For-Profit Inpatient Psychiatric Standards of Care: Setting the Bar Low
I have not studied the history of psychiatry in depth. But it doesn’t really take doing so to surmise that psychiatry’s reputation, which I likely need not explain, is based on the realities of what is probably a long, dark, history. Many are working towards shifting the course of that history, but it’s going to be long road. There are so many problems across the board, but here, I’ll focus on for-profit inpatient standards of care which have seemingly set the bar for all.
Psychiatric patients are subjected to abuse, neglect, and egregiously low standards of care on a routine basis. Because they have psychiatric illnesses. The presence of psychiatric illness means for them that they are less likely to be believed when reporting misdeeds of caregivers or others charged with their protection. And because others are uncomfortable with what may be viewed as odd, socially unacceptable behaviors, they are viewed as “less than” and as a result “less deserving” than those viewed as “normal” by societal standards. This is true from even within the profession itself.
How is it that it has been decided that by and large the standard of care for psychiatric inpatients is to be locked in a facility with hardly any staff, minimal interaction with psychiatrists, and lack of access to meaningful therapy? Who is responsible for making this the acceptable standard of care? Our largest providers of for-profit psychiatric care in the United States have visible reputations related to abuse, neglect, and fraud, and yet they remain in business. As a nurse, what I realized is that staff often don’t know any better. Many nurses come into psychiatric nursing because it’s the only place they are able to find a job. I have seen this with associate level registered nurses who have been excluded from more traditional medical settings due to lack of a higher degree. A bare bones model of care is seen as the norm because it’s all they know. One nurse said to me “I’m like an abused child. I don’t know any better” when I asked why they kept their position for so long. Others told me they did as they were told when engaging in conduct they knew was wrong because they needed to keep their jobs. The need to maintain income is valid. Not everyone can speak up.
It is imperative that we demand better for those in need of or receiving psychiatric care. Psychiatric patients need more time, more attention, and more care than most. Getting to the roots of feelings, emotions, perceptions, and understanding unique circumstances and their impact on psychiatric illness or well-being takes great effort. Getting it right takes time. Patients deserve more than five minutes with a psychiatrist who blows through a unit seeing twenty patients as an attending, followed by seeing a schedule of patients in an outpatient practice. At one job, I had to line adolescents up outside a consult room where they went in one at a time for three to five minutes with the psychiatrist. Groups happened at most twice per day and were mostly worksheets. Other time was spent watching vine videos and even episodes of cartoons like The Cleveland Show. The government and insurance companies paid good money for this “service.”
Many nurses will confirm that staffing on psychiatric units is abysmal and they have untrained support staff. The model of care in for-profit is to require a high school diploma to come in and work as a psychiatric technician – whatever that is. Many staff are wonderful people, but that doesn’t mean they have appropriate training. In the first couple of places I worked – for-profit – the only training I had was new hospital orientation and our de-escalation training. No training on psychiatric illness or otherwise. Once I even had an argument with a nurse manager that they’d have to appropriately train me on lab collection if they wanted me to do that. I was told that was my problem. For those reading, reputable hospitals train you properly and keep track of the training. In fact, you cannot do certain nursing or other procedures until you have been signed off in many cases. But not most for-profit psychiatric hospitals. And I say “most” because one company I worked for operates more than any other.
It is absolutely the case that there are those working in the profession who are undeserving of doing so. They are perhaps even welcoming of the opportunity to take advantage of circumstances that allow them to easily commit fraud. These people exist at the corporate level, and at the provider level. We need to be rid of them.
But, as I mentioned, many clinical staff and even administrative staff don’t know any better. One thing I noticed is that many who work for these for-profits have no other experience, either clinical or administrative. They routinely hire people with little to no experience. This likely serves as a gateway to permitting bad corporate behaviors. Because when administration is instructed by higher ups to do things a certain way, they haven’t the experience to know it’s wrong. And for those going from one for-profit to another for-profit psychiatric facility, they assume it’s all status quo.
I have to think the same is not true for psychiatrists though with respect to knowing better. But I hope I am wrong. They often complete their training at academic medical centers that provide better care than the majority of for-profit hospitals. They probably know that seeing many inpatients a day plus additional patients in the outpatient setting is bad practice. So why do they do it then? And why do their peers appear to accept this? I have yet to see a significant number of those in medicine speak out against this specific aspect of for-profit inpatient psychiatry, or any other aspect of it for that matter. Given how bad the for-profit environment is, there should be many speaking out. A few have blown the whistle, but many remain silent.
Story after story of misuse of hospital holds for profit, denial of care for those who most need it, abuse and neglect of patients, including children, and yet it’s business as usual for these facilities. This is because it is psychiatry where patients often have trouble speaking up and being heard and the standard has been set so low by these corporations the staff are “used to it.” The worst part is that I worry that those capable of actually extinguishing these behaviors simply don’t care about those needing psychiatric service
If you look closely, you will see that places striving to provide good care often operate at a loss, struggling to stay afloat. While somehow these for-profit places manage to turn a hefty profit. At what cost? We need more funding for the good places. And more accountability for the bad. Because increased funding for those committing nefarious deeds only serves to further line their pockets if we do nothing significant about it. Financial wrist slaps simply aren’t enough. The fines need to be large enough to feel like legitimate punishment capable of correcting bad conduct (akin to the nature of punitive damages). But first, we need enough people in the right places to care about what’s happening in these facilities. Only then can it be changed.