Psychiatric Hospitalization
Questions and Answers
As a professional Psychologist, I work with many mental health issues. There have been times in my practice when hospitalization has been a needed step.
Hospitalization happens in a:
psychiatric inpatient ward (within a general hospital)
stand-alone psychiatric hospital
Locked rehabilitation centers
Why are people hospitalized?
The Figure above is the rate of inpatient stays for mental disorders from 2016-2018 per 100,000 persons (AHRQ). This rate is before COVID which has skewed hospitalization stays making it difficult to disentangle what is COVID from Non-COVID related admissions. Statistics underscore the high rate of Depressive Disorders, although this may be that Depression is a common default diagnosis for most hospitals and providers. Either way, the absolute numbers per 100,000 people are very low.
For those who have experienced a severe and acute mental health episode (or incident) like an out-of-control addiction, it might seem obvious. Those who have not encountered such an issue might wonder when psychiatric hospitalization is needed. Some may wonder how any mental health “hospitalization” can be helpful. Say, admitting a person to a “locked” facility that is against the person’s will.
Once in a while, a client will ask me, Dr. Hill, If I tell you I’ve been thinking lately about killing myself, Will you send me to a psychiatric hospital?
Some might view mental health hospitalization as evidence of a setback. Others might see it as a “last hope.”
Hospitalization in my practice is rare. When it happens, clients feel benefitted.
Some might eschew mental health hospitalization as something they would be ashamed to experience. Some might believe admission to a hospital for mental health reasons is only for those who are “insane” and should not be part of society.
This raises a question.
What is insanity? and How is insanity different from sanity?
Defined (Cambridge Dictionary): Insanity is:…1: a very stupid, unreasonable, or dangerous action or situation; 2: the condition of being very annoyed, angry, upset, or excited, often so that you cannot think or behave normally. 3. a word for the condition of being seriously mentally ill, which was used by doctors in the past and is still sometimes used in law but can be considered offensive in other situations.
The Cambridge three-part definition of insanity highlights the word’s complexity.
The first two definitions are colloquial. Definition #3 is serious.
The numerical order of the definition follows the most common use of the word. Definition #1 grew out of the stereotyping of Definition #3.
INSANITY in the “American Psychological Association Dictionary, 11/15/2023 is:
n. in law, a condition of the mind that renders a person incapable of being responsible for their criminal acts. Defendants who are found to be not guilty by reason of insanity therefore lack criminal responsibility for their conduct…
The American Psychological Association does not define “Mental Illness.” I find this surprising.
“Mental Illness” has currency for hospitalization.
Defined (Cambridge Dictionary): Mental Illness 1. An illness that affects the mind.
This is accurate but substandard.
The World Health Organization's mental illness definition, reframed by WHO as “mental disorder,” is:
A mental disorder [illness] is characterized by a clinically significant disturbance in an individual’s cognition, emotional regulation, or [behavior]…associated with distress or impairment in important areas of functioning…Mental disorders may also be referred to as mental health conditions. The latter is a broader term covering mental disorders, psychosocial disabilities, and (other) mental states associated with significant distress…In 2019, 1 in every 8 people (or 970 million people] around the world were living with a mental disorder…
What is the difference?
The difference between mental illness and insanity is that mental illness is a broader term; insanity is a legal term for severe mental disorders.
I focus my entry on hospitalization as a treatment for a specific severe mental disorder, even though people are also hospitalized for reasons of insanity.
What is the difference?
Hospitalization is “short-term” (usually a week or less) and usually for a specific condition. Institutionalization is “long-term” (months, years) due to a “permanent disabling mental illness.” This is referred to as “institutional commitment.”
A Nursing Home for persons with Dementia would fit “institutionalization.”
The history of short-term stay psychiatric hospitalization is clouded with stories - mainly by the media - sometimes confusing it with permanent institutionalization.
Why do Psychiatric Hospitals exist?
What happens during a Psychiatric Hospitalization?
What is the usual outcome of an inpatient Psychiatric Hospital stay?
Why do Psychiatric Hospitals Exist?
The #1 reason is to provide “safe” and “structured” temporary care for people in a “severe” mental illness “episode.”
What happens during a Psychiatric Hospitalization?
People don’t call, make an appointment, and admit themselves to a psychiatric hospital.
Admitting Steps:
You'll need a referral from a licensed mental health or medical practitioner.
An intake with someone who evaluates your case to determine appropriateness.
A: A signed order from a mental health or medical practitioner who has (hospital privileges). This means a licensed health professional has rights granted by the specific hospital to admit patients to that hospital for treatment. When a client is admitted, the professional transfers responsibility for care to the hospital.
Outside (or non-hospital-employed) professionals can have three privileges:
Admitting Privilege — Allows an outside doctor to admit a patient to the hospital.
Courtesy Privilege—The physician can occasionally treat or admit an individual to the hospital. Usually, the hospital assigns this health professional for follow-up care.
Surgical Privilege — Allows the physician to perform outpatient or operating room surgeries.
As a licensed psychologist, I can only admit clients to hospitals where I have this privilege. Otherwise, I need to contact that hospital, speak with someone who does have privileges and admit the client through that person.
Once in a hospital, client status turns to “patient.” The patient is assigned to a “Ward” (a psychiatric ward or a behavioral health ward) and to a “bed” with a room #. Beds versus Rooms are the byword in a hospital, although people are always in rooms.
The admitted is treated like a medical patient. This includes vitals, blood tests, and being assigned a nursing staff member to examine the patient. Clothes are changed to hospital garb (for easy treatment). In some stand-alone highly specialized behavioral health or psychiatric hospitals normal clothes might be worn. Still, it is standard for psychiatric wards in general hospitals.
Your primary health provider (now a psychiatrist, MD) is switching from the provider you’ve seen outside the hospital. This inpatient provider might see many patients per day, so time will be limited and rushed.
Treatment and Outcome in a Hospital Setting
Treatment in a hospital varies. If admitted for a severe mental disorder episode (Depression), it will be different than an out-of-control alcohol addiction. If you are in a significant psychotic break with self-harm, you might be assigned to an “Isolation Room.”
What is an Isolation Room?
Isolation rooms are specialized hospital spaces that temporarily keep patients separate from other people, provide maximum self-harm protection, and low stimulation while the patient receives acute care.
These are meant for very short stays, usually less than 48 hours, designed for the patient’s safety. They might include behavioral control, but more often, they are a maximum time-out space for the patient and the patient’s provider to manage an out-of-control psychiatric state.
I like the wording of the UK Mental Health Act of 1983 (Code of Practice): "…the supervised confinement of a patient in a room, which may be locked. Its sole aim is to contain severely disturbed behavior likely to cause harm to others…."
Hospital treatment is standardized; don’t expect tailored care based on your preferences. That’s not why you are in the Hospital. The reason you are admitted is “Your safety and secondarily safety for others.”
Hospital Treatment Protocol (priority in this order):
Safety: Evaluation of suicidality risk (patients at high risk for suicide are treated differently than patients at low risk - constant or intermittent observation). Evaluate factors that put a patient at risk in the hospital (patient combativeness, patient coherence). Conducted by a Nursing Professional.
Assessment: This involves: 1. A Psychiatric Interview (Establish rapport, gather information, formulate a diagnosis, create a treatment plan)
Medication: Directed by a Psychiatrist (a medical practitioner, always MD, specializing in diagnosing and treating mental illness). 1. A hospital stay might be to wean a person off one psychoactive drug onto another. 2. The side effects of this process can be substantial. OR Evaluating a problematic drug regimen (someone who has been over-prescribed).
Therapy: Several types: 1. Expressive (art therapy, reminiscent therapy), 2. Individual (Cognitive Behavioral Therapy, Behavioral Therapies, Humanistic Therapies), 3. Group (to ensure interpersonal interaction with other patients), and 4. Family (for discharge planning except in eating disorders).
Activities: Discussion Groups, Limited Exercise, Education, Reading, Television Watching. No cell phones in a hospital for patients.
Discharge Plan: 1. Contact with a provider outside the hospital. 2. Contact with family. 3. The patient has a place to live outside the hospital. 4. Coordinating care plans from the hospital with the treatment outside the hospital and establishing a social support network outside the hospital. 5. Patient medication after leaving and has a method for refilling medication.
Family participation is a component of the discharge plan. Still, it is also a separate one that 1. educates the family, 2. connects the family back to the patient, and 3. plans with the family for re-admission if needed.
This has been a long and dense entry. I’ve worked as a psychologist in inpatient hospital settings for about two years, so I understand its value and the challenge of this option in our free and independent society.
Do people get better as a consequence of hospitalization?
A difficult question to answer and much more complex than administering a patient satisfaction questionnaire before and after the stay. Many people might say they are “worse” when they are actually “better” with “better” is defined as still alive. Also, a hospitalization is a paradigm shift. Your whole world changes as you enter.
The outside world, still there, emotionally goes away as you focus on the hospital experience. Sometimes, post-paradigm-shift, people get better - much better. But, this is not the purpose of hospitalization.
Hospitalization is to make sure you are SAFE until you feel you are SAFE. This, I believe, is what it means to get better, post-hospitalization.
Hospitalization is not frequently used in my day-to-day psychotherapy. Still, it is a component of client awareness of mental health treatment, and it is useful to provide some limited education on the topic.