A Tragic Mistake

Written 03.04.08

Am I too naive to think that the principal aim of a hospital should be to help its patients? Well, apparently I am, because during the last two years that I have been working at one of the nation’s top psychiatric hospitals, I’ve seen very few examples that would back up this idea. The overwhelming majority of people and procedures employed by the psych hospital have very different objectives, ranging from maximizing the profit to minimizing the effort, and culminating in an all-consuming urge to cover one’s ass. Among the people who genuinely tried to struggle with the system and help the patients, during these two years some have been fired, and some have “gotten used to it”, but no one lasted long. As a matter of fact, I am fairly close to losing my job right now, after an argument with a charge nurse yesterday, during which she tried to din into me that the most important thing for her was not to lose her license. Not that I cared too much, because I had already given the termination notice anyway.

Too many people assume uncritically that if they go to a psychiatric hospital they will get help; even more believe that their children/parents/spouses will be helped if they send them there. This is what all the propaganda is about. But it is a lie. A mental hospital in this day and age is not an institution of help - it is an institution of confinement, much like a jail. It is a place in which kept are people who have not committed a crime but have nonetheless made their relatives or friends very uncomfortable with their being around. This point is so obvious that it doesn’t even need to be proved; just look at all the door locks and security guards in any mental hospital. If this institution was helpful, people would want to be there, and none of this would be needed.

Really, think about all the homeless people, all the battered spouses, all the terrified youngsters going through a psychotic episode, all the misunderstood children and suicidal adults longing for understanding or at least for a pacific place to curl up in the corner and sleep it over. Think about everyone who needs to get away from their environment for a while. If the proclamations of the psychiatric industry had some truth in them, if there really existed a place where they could relax and get help, those people would line up to get into this kind of institution! Obviously, a psychiatric hospital is not such a place, because most of the patients hate it there and struggle to break out. Until, of course, they lose their life drive and become dependent on the system.

Now, this is of course not to imply that the mental hospitals are completely worthless. There are people, and many, out there who are either morbidly stupid or completely out of their minds. They cannot survive in a demanding environment of a today’s city and therefore need to be confined and cared for. But to assume that the same mental hospital is a helpful place for all the able people just going through a difficult time, is a tragic mistake.

People who send their relatives to a psychiatric hospital never find out what actually happens there. Parents are told all kinds of stories about how helpful the place is and how much therapy their children receive. They don’t know that the therapy is heartless and superficial, or that the place is extremely boring and unfriendly. They never see their kids crying and begging a nurse for a breath of fresh air after being indoors for days and weeks, or being dragged to their room on the floor by uncaring strangers. They never observe their kids’ free spirit being broken into submission; if they did, they would not forgive themselves.

If there is only one thing to be remembered out of this whole journal, it is this. Please, don’t put your children and loved ones in a psychiatric hospital for help. Put them there because you want to confine them, get rid of them, forget about them! Put them there because you don’t care, or because you hate them - but not because you love them. Don’t fool yourself thinking that you are doing them good. Because nothing can be farther from the truth.

Defying the Statistics

- What is the chance that you meet a dragon on the street?
- Fifty per cent.
- ???
- Well, either I meet him, or I don't!
A joke

Statistics plays a large part in psychiatry, as in the rest of medicine, because it helps clinicians to make decisions about what is likely to be beneficial or harmful to their patients. Most of the guidelines for physicians are based on the statistically significant conclusions from the clinical trials. The argument goes like this: It has been found that, say 70% of the patients with a certain diagnosis and a particular set of other characteristics (age, race, height, weight, etc.) get better on a medication. Therefore, if you have a patient Ivan Johnson who fits all these characteristics, his chance of benefiting from this medication is seventy per cent, which means he should take it.

Here at the American Medical Informatics Association conference I constantly witness conclusions like this being drawn. They have become basis of medical expert systems and much of medical informatics in general. Yet, I am going to show with one simple example, that this logic is erroneous. It is a case of scientific confusion between the probability of an event observed in many previous experiments, and the ability to correctly predict the result of one next experiment.

Let's not go as far as medical predictions. Let us take the simplest model of probability - a tossed coin. The probability of the heads is 50% - everybody knows that. Indeed, if we toss a coin a billion times, we will probably observe the heads in something very close to 50% of the cases. But that is all it means! You can't go any further in your conclusions! In your ability to predict what the coin will fall next, in your one-billion-and-first experiment, you are as helpless as you were when you'd thrown it for the first time. You simply don't know what it will be - all you can say is that it will be either one or the other.

It is not because the probability is 50% that you don't know. Take an experiment with the chance of outcome A being 90% and the outcome B being 10%. What is the probability of the outcome A in the next experiment? Nine out of ten, very well. But what outcome will the next experiment have? You can't ask this. You don't know. It will be either one or the other.

So what does this nuance mean for the system of psychiatry and health care in general? Not much, because the system operates on statistics, it deals with patients en masse, and therefore the results of multiple experiments correlate well with the predictions based on probability. But it means the world for an individual patient; for you and me.

Even if we forget for a minute that the experiments in which the probability is calculated were not actually done on you and me, but on some other people; even if we forget that the medical outcomes are not binary but multidimensional and unpredictable by their very nature - even then predicting an outcome for a particular patient will be impossible because of the effect I've just described. If 99.99% of the patients like you die in a month without an operation, it doesn't mean that you will also die in a month. The probability of it is high; whether it happens is not known.

I admit of course that with a chance like that you might want to strongly consider the operation; I would probably do the same. However, the majority of psychiatric statistics operates with numbers quite remote from the extremes. People talk about reducing risks from twenty-five to fifteen per cent, of improving the outcome in sixty per cent of the patients versus forty. For the hospital and the insurance company these numbers are big business; for you and me, they are simply meaningless.

Taking Medication Is Voluntary

Taking a psychiatric medication is a voluntary act. Unless you are brought to a psychiatric hospital by ambulance, or suspected of being a possible danger to yourself or others, or not obeying the directions of hospital personnel, or hallucinating, or not agreeing to take the drugs voluntarily for too long when the doctor deems it necessary, you cannot be given a medication against your will.

No Test Required

Another interesting point that Mr. Jeff Griffin makes in the interview I mentioned yesterday is that psychiatrists do not have to use any objective medical tests in order to make a diagnosis or prescribe a medication.

Some tests have been developed, and are even used in clinic and in research. All these tests consist of questions and answers. They are not, strictly speaking, objective. What they provide is a quantative scale. The result of such a test is usually a number, that the researchers can compare with other numbers received from other research. Yet, this number still depends on the subject's ability to understand the question, willingness to answer it truthfully, as well as the interviewer's manner of gathering the information.

So, these tests are subjective, if convenient for comparative measuring. Yet, even they are not required in clinical practice. A subjective judgment of a psychiatrist alone is still enough to detain someone in a psychiatric hospital, label him with a diagnosis and give him medications agains his will. Strange as it is, this is the law.