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The Heller School for Social Policy and Management at Brandeis University

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November 28, 2016

VA officials promise action in response to PhD student’s findings of shameful quality of inpatient psychiatric care

By Bethany Romano 

In 1955, approximately 560,000 people throughout the U.S. lived in inpatient psychiatric facilities. These huge institutions, often referred to as asylums, were immortalized in books and films like One Flew Over the Cuckoo’s Nest. Reports of abuse and neglect in these hospitals were common, as were serious concerns over the general quality of care and treatment. In the 60s and 70s a wave of deinstitutionalization took hold, driven by the advent of more effective drug therapies and a social-political movement to reduce unnecessary and often involuntary confinement of people in long-term hospital settings.

Over the course of 50 years, the asylum population dropped precipitously from 340 psychiatric hospital beds per 100,000 U.S. citizens to just 17. In Massachusetts alone, at least 30 state hospitals, sanitariums and state schools closed. Most of them were demolished or remain abandoned to this day.

image of Westborough State Hospital, now closed
Image of a shuttered building on the campus of the now-closed Westborough State Hospital in Westborough, Massachusetts.

Today, the inpatient psychiatric facilities of decades past are often considered with the disdain of hindsight and the superiority of a hard won fight. Mass institutionalization is now widely considered a morally reprehensible episode in our nation’s history.

Yet psychiatric facilities continue to exist, though today they primarily serve as stabilization hubs and Band-Aids within a system that failed to create robust community supports following deinstitutionalization. What is the experience like for the thousands who receive treatment in these facilities?

We know very little, it turns out. But what we do know is deeply troubling.

Morgan Shields, a PhD student at the Heller School for Social Policy and Management at Brandeis University, has begun to piece together data about inpatient psychiatric care from a variety of sources, but part of the problem is there’s very little to analyze.

“There is no national surveillance system of inpatient psychiatric facilities,” says Shields.” Despite how vulnerable consumers in inpatient psychiatric facilities are, we have no idea how many people die in these facilities, at the most extreme, how many are physically harmed or neglected, we don’t know about interpersonal relationships between staff and consumers, what the consumer experience is, and we know nothing about emotional harm and re-traumatization. It is disturbing how little we know because it inhibits our ability to improve care, appropriately regulate facilities, and ensure the safety and wellbeing of consumers.”

To get an overview, Shields conducted a media analysis of harm and mortality in inpatient psychiatric facilities. “Outside of interviewing a large number of individuals, news articles are actually our best source of data on incidences of consumer harm, given the lack of a systematic tracking system. A media analysis can give us a broad idea of the worst cases—the ones that made it into the news.”

The examples include harrowing accounts of oppression, abuse and neglect. In Jackson, Miss., individuals were admitted without admission screenings and kept there for years. In Pembroke Pines, Fla., youth were restrained physically and chemically for being annoying to staff, were sexually assaulted by staff and were overmedicated. In Houston, a man diagnosed with bipolar was tasered, shot and handcuffed by security guards in response to non-violent, manic behavior. The list goes on. And on.

Among them were several accounts of scandal at Veterans’ Affairs (VA) inpatient psychiatric facilities. “The Tomah VA hospital—nicknamed ‘Candyland,’—was administering painkillers to the inpatient psych consumers in very large amounts, which resulted in at least three deaths,” says Shields. “A clinical psychologist on staff blew the whistle along with a few other coworkers and he was promptly fired. This psychologist then committed suicide.” Indeed, this retaliation against VA whistleblowers is not an isolated event nor are whistleblowing reports a rare occurrence.

Many of the cases in Shields’ media analysis were brought forward by whistleblowers. The federal Office of Special Counsel, which protects whistleblowers and processes their complaints, receives more cases from the VA than any other office—by a landslide. In 2015 the OSC received 2,165 VA cases, which is 800 more than the agency with the next highest total, the Department of Defense.  

image of Morgan Shields
Morgan Shields, first year PhD student at the Heller School for Social Policy and Management at Brandeis University.

The closest thing to national standardized data collection for inpatient psychiatric facilities is a set of seven measures collected by The Joint Commission (TJC), the federal accrediting body for hospitals in the U.S. However, these measures are not without problems. For example, the TJC asks facilities to report the percentage of patients discharged with a continuing care plan, but includes no parameters or guidelines on the quality or structure of that plan. 

Shields’ analysis showed that according to the 2014 TJC data, VA hospitals perform poorly when compared to for-profit, nonprofit, and other government facilities. For example, TJC asks for the percent of patients that received an admission screening. The national average was 90 percent, but at VA hospitals it’s just 61 percent. The national average for appropriately justifying patients discharged on multiple antipsychotic medications is 53 percent, but for the VA it’s just 39 percent. Only 56 percent of VA patients received a continuing care plan upon discharge, compared to 88 percent nationally.

“These are very basic quality measures,” says Shields. “Every facility should be doing great on these, and even if they are, that still would not mean that they are providing high-quality care. That’s how basic these measures are. And for hospitals that perform poorly on these measures? Yikes.”

Top leaders from the VA headquarters in Washington, D.C. read the TJC data study and contacted Shields and her coauthor Meredith Rosenthal to discuss their findings. “They told us they’ve taken swift action, and that they’re looking into ways to improve quality and measurement,” says Shields. “They think it’s possible that there were measurement errors, and said the integrated nature of the VA treatment model may make them appear worse than they actually are. I am invited to spend time with them in D.C. to look at their internal data. ” Shields and Rosenthal were thrilled to know that their work has already had an impact.

In addition to working with media coverage and TJC data, Shields has pursued more individual-level exploratory research, having conducted interviews and administered surveys to consumers of inpatient psychiatric care. From those surveys Shields learned that improving care in inpatient psychiatric facilities shouldn’t focus exclusively on reducing explicit harms, such as physical abuse and death. Rather, these initiatives must be supplemented by efforts to reduce rates of re-traumatization and increase individuals’ trust in the mental healthcare system.

Shields’ interviews revealed several negative themes that align with her other findings, including staff apathy, offensive language and dehumanization toward consumers, and a lack of de-escalation, information sharing, and consumer agency. One of the individuals Shields interviewed said, “To have that excruciating, searing, indescribable emotional pain and then on top of that being mistreated or disrespected or ignored or whatever...it's very bad. I try to avoid going to the hospital as much as possible, even when I might need it." Another said, “I've never been in a prison but it felt exactly like a prison.”

Some of the individuals she interviewed described positive experiences. Shields notes that it is helpful to hear these stories as they allow her to better understand what consumers find effective, or at least compassionate, care. However, Shields says, “while the participants in my study did report some positive and helpful experiences, the negative ones were much more common.”

sillouette image of person with their head in their hands

Sadly, the atrocious care that Shields heard about in her research is rarely discussed in research and policy circles. Moreover, she says, “the lack of surveillance monitoring inhibits our ability to really understand the true prevalence of these experiences and the factors that enable their occurrence.” Part of Shields’ motivation to do this research is to provoke a national conversation about quality of inpatient psychiatric care. “People are dying, people are being abused and sexually assaulted, especially youth, and I don’t hear anyone really talking about it,” says Shields. “This is actually a huge problem. I hear lots of people complaining about access to care, arguing for more beds, saying we have to get people off the streets. Why do I only hear people saying we need more beds? That’s not a deep way of thinking about the problem at all, and I don’t think it would solve it. Fixing this is not as simple as adding some beds.”

Shields also cites the common misperception that mental illness is connected to violence risk. “Whenever there are high-profile incidents of violence, especially gun violence, some people use these events as a scare tactic to argue for expanded involuntary and inpatient treatment, despite the fact that individuals diagnosed with a mental illness are more likely to be victims of crime than perpetrators. Moreover, I would argue that you cannot make an informed decision about expanding access when you have no idea what is going on inside the facilities themselves.”

“If, after you learn about the harm and the potential for re-traumatization within some of these facilities, you still advocate to expand inpatient psychiatric care, then you’re effectively saying that your main motivation is to get ‘these people’ out of sight, regardless of how it may harm them. Mental health touches so many different lives. It crosses all identities—socioeconomic status, race and ethnicity, gender and sexuality—it cuts across them all. Improving quality, monitoring and regulation of mental healthcare is something that everyone should get behind.”

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