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5 Things I've Learned Working at a State Psychiatric Hospital


Two years ago, I began working at a large state psychiatric facility. While I am not new to the field of mental health, I had never worked in a hospital setting. I’ve worked in community agencies, drug treatment centers and in private practice. Now, I go through seven locked doors to get to my office.

Like anyone, I had some preconceived notions about psychiatric hospitals. I predicted constant danger and a siege mentality from the staff. But that’s just not the case. In fact, when I share my experiences, people are surprised to learn I love it despite the challenges. Here are five things I’d like you to know:

1. It’s not at all what you think.

State psychiatric hospitals have a bad reputation. While they have evolved over the past 150 years, courts still have the authority to send people there. Roughly half of the patients I work with have pending charges for ghastly crimes. Charges of rape, murder and kidnapping are common.

It’s easy to dismiss some of these people as lost causes. You can read a patient’s chart and, based on what they’ve done, assume it’s not worth your time to help them. But your attitude changes when you start working with them. Most patients were struggling deeply with developmental and mental disorders when they committed their crimes. For some, once they find a medication and dosage that works for them, it’s hard to believe they committed those crimes in the first place.

Most of my patients are cool. They have goals, dreams and families. What often sets them apart is untreated mental illness, substance use disorders and trauma. It is easy, by the way, to be successful in life if you don’t have to contend with those things. I have learned not to judge the actions of others.

The hospital is not what you might think, either. It is old and beautiful, orderly and safe. Sometimes bad things happen. One time a patient died by suicide. Fights happen from time to time. Sometimes I hear shouting. I work throughout the hospital, and never do I walk onto a floor worried I might be attacked. In fact, what happens most often is that the patients ask you about your day and invite you to play cards. Most of the patients are grateful for the treatment. Most of the staff are compassionate and dedicated. Don’t believe the silly depictions you see in movies and on TV.

2. Mental illness can be a factor in some crimes.

I have several patients whom you would have no problem inviting into your home. They are intelligent, polite, empathetic and kind. The disconnect between who they are and the crimes they committed is profound. In fact, they only make sense if you look at the underlying mental illness.

The more I work with this population, the more I see the degree to which mental illness plays a role in criminality.

I am not suggesting that all or even most people who live with mental illnesses commit crimes. That is simply falseIn general, people who experience psychosis do not become violent. But where I work, psychotic symptoms seem to be characteristic of almost every patient accused of a violent crime. For example, I work with a woman who shot her neighbor because she thought he was part of a government conspiracy. I work with another who strangled his aunt during a psychotic episode.

Those are egregious examples, but others are far more common. One of my patients did time for grand larceny because he stole a TV to pay for his crack habit. Out of desperation, he swiped money from a register in full view of all the customers and clerks in the store.

This is what I mean when I say mental illness is a factor in criminal behavior. Addiction compromises our ability to think and behave rationally. This guy would never have committed that crime if he was sober.

The solution to this is not to incarcerate the mentally ill, though that’s exactly what we do. Prisons are full of people with mood and psychotic disorders who would never have committed crimes if not for their mental illness. The country is in dire need of a paradigm shift about criminals and the crimes they commit. Treatment works in most cases and is far less expensive than long term incarceration. Where would you rather your tax dollars go?

3. The mental health system is broken and absurd.

One of the huge problems though is the disconnect between what “the system” prescribes as treatment and what people actually need. A great example of this are so-called 28-day Drug and Alcohol Treatment Programs. There is nothing special about 28 days. It’s not like patients are sick on day 27 and cured on day 29. Four weeks is a standardized amount of time that makes sense to insurance companies and Medicaid. It has zero to do with a patient’s needs. It has zero to do with actual recovery.

If treatment was the priority, length of stay would be determined by medical professionals, not accountants. But we are less concerned with outcomes and more concerned with budgets. These problems cost the United States hundreds of billions of dollars every year. So not only are we focused on the wrong things, but we’re going about them in magnificently wrong ways.

Despite the nonsense, the professional staff with whom I work do an excellent job. But resources are scarce in the community, so it takes a long time to discharge patients. The hospital where I work is supposed to be for acute need, but many patients languish away for months or years because we have nowhere to send them. Where I work, it costs something like $1,000 a day to treat a patient at a psychiatric hospital. If you have 300 patients, that’s $110 million a year. Wouldn’t it make sense to provide less-expensive treatment options in the community?

4. Family support is everything.

Ultimately, you can’t rely on the government. Psychiatric hospitals and outpatient treatment centers are only temporary solutions. Even though the services can be excellent, it’s all for naught without social support and accountability.

Support from family and friends is the single biggest predictor of long-term recovery from substance use disorders and mental illness. This is one of the reasons why Alcoholics Anonymous enjoys so much success with its members. They don’t prescribe medication. They don’t offer counseling. They won’t solve your problems. What they do is offer social support and accountability. It’s hard to overstate the importance of those things.

The same basic thing is true with a person’s social support system (i.e., their friends and family). If your family is a judgmental and reactionary, recovery may well be impossible. But anything is possible in a home full of love and support.

This is especially true with children. Our adolescent unit often sees the same children admitted over and over again. The reason this happens is that they keep being discharged to toxic parents who keep toxic homes. I’m talking about parents who farm their children out to sex traffickers. I’m talking about families with an overt record of physical and sexual abuse. These are not good people.

Family can prop us up, but it can also tear us to pieces. I don’t know of a solution for this problem, but we do need to talk more about the dangers of toxic families. When it comes to the safety of children, no topic should be off-limits.

5. People can (and do) recover.

Despite these problems, I witness miracles all the time. When people make the choice to work on their recovery, extraordinary things happen. While of course, some people need high levels of support for the rest of their lives, it is also not the norm. In my experience, the norm is recovery. The norm is that people get better. Some of them still face serious legal problems when they discharge, but most get credit for time served.

I chair three 12-step meetings at the hospital. The patients attend them voluntarily. They read the literature and share their troubles and support one another. When they share, they do so with the intention of helping others. Despite all they have been through, many leap at the chance to offer encouragement and support. It is quite a sight to behold. This is what happens when you afford people quality care. I see it happen every day. The successes far outnumber the failures.

Over the past two years I’ve seen people struggling in ways you cannot image. Profound paranoid ideation. Substance-induced psychosis. Auditory and visual hallucinations. Compulsive self-harm. I’ve seen teenagers who survived horrific sexual abuse and I’ve seen adults who perpetrated it.

But I’ve also seen people make full recoveries when nobody thought they could. I’ve seen my assumptions challenged. I’ve seen hard work pay off. I’ve seen people make full recoveries when nobody thought they could. I see miracles happen all the time. It has done nothing but enrich my career and deepen my love for the field of mental health. While the system is broken, the human spirit remains strong.

Follow this journey on the author’s blog.

Getty image via sudok1