The Most Restrictive Environment

The psych ward. The nut house. The loony bin.  The asylum.  Whatever you call it, it is not the place most of us want to be, yet it often becomes the dump site for the stigmatized. Although we are trending toward more blended medical-psychiatric and gero-psychiatric inpatient units that allow more medical management to take place concurrently, the ideal environment for mental health management is in the outpatient setting.

I believe in the principle of least restrictive environment for mental health care.  Some providers are confused and feel psychiatric floors should be the depository for issues they do not want to deal with or are not interesting enough for medicine. Certainly, chronic mental illness is an issue of management rather than cure, and acute-care physical health providers are often intimidated by conditions that cannot be eliminated by pharmacological or surgical interventions. Many would prefer to pass people off rather than deal with complex matters of mind-body interaction. Perhaps if some of them visited a psych unit, they might get a fresh perspective. Let's review what happens when a person is admitted to a psychiatric ward versus a medical ward:

We take your clothes
We search your belongings and lock them up
We lock the doors and windows to the unit so you cannot get out
We take your phone, e-reader, laptop, music player, and electronics
We restrict when and who can visit you
We tell you when you can and cannot talk on a common, public phone
We tell you when you get up and when to go to bed
We put you in a room with 1-3 other people in beds that do not adjust
We tell you what you can and cannot watch and when on a common TV
We take away your right to smoke
We take away  your food choices and deny outside delivery
We take away your right to breath fresh air
We label you as a "psych patient" for life with all the privileges of stigma therein

In short, we take away your constitutional liberties.  So why do we do that?

Sometimes, it is because it is the only way to keep a person safe. Psychosis, suicidality, homicidality, mania - these are viable reasons to put someone in this most restrictive environment with the intent and hope of finding the right treatment plan as quickly as possible to get this person stable and back in the community. Sometimes we do it when the person really feels it is in their best interest because they feel unsafe or unstable and want to prevent escalation of symptoms.  These are the two scenarios where admission is the right thing to do.

However, not everyone who has delusions, suicidality, or mania needs to be admitted.  Just because it is in the brain, does not mean it needs to be managed by psych. For example, seizures are seizures - whether from epilepsy, alcohol withdrawal, or psychosomatic origins, they need to be monitored by the medical team.  Keeping the old Maslow's Hierarchy of Needs care theory becomes particularly useful in holistic, individualized treatment planning for patients with complex and co-morbid disorders.

These days, to be in a hospital for more than an outpatient procedure, you better be sick. This goes for physical and mental illness. Unfortunately, many providers take a cavalier attitude when it comes to dispositioning someone on a locked psychiatric ward and use a DSM diagnosis as a basis to gloss over a through medical assessment and justify an inappropriate admission to a psychiatric unit. Two areas that seem to be ripe for controversy are dementia and substance abuse.

Being confused is not justification for taking you freedom. If it were, half the hospital staff would qualify by Thursday afternoon. This confusion about the confused occurs frequently with the elderly, who will often manifest altered mental symptoms as a result of multiple drug interactions, any number of physical condition, or just plain physical neurodegenerative changes related to a specific disorder or the normal aging process.  When medicine tries to label all hallucinations as psych in origin, I harken back to a high school biology class where we discussed the how visual and tactile hallucinations were linked with everything from UTIs to syphilis.  This was repeated and detailed multiple times through the course of my nursing education in the family practice and mental health specialties. Plus, I have seen Trainspotting at least 5 times. See it if you haven't.

Needing to dry out from a bender is also inappropriate not only from the aspect of liberty, but competent care for withdrawal symptoms. Most psychiatric facilities and wards have restrictions on medical interventions or devices. IVs, catheters, ports or lines, telemetry monitoring, uncontrolled seizures, and unstable vital signs are just some common limitations that warrant the patient seeking a medical rather than psychiatric management, no matter what their state of mind. When medical teams refuse to medically detox a patient "because they are psych," I get miffed.

They may have psych issues. They are not themselves psych.  They are people who need placement in the least restrictive environment possible to provide positive outcomes for long-term management.