It has become increasing apparent in our
society that mental health treatments must be improved. One step towards
progress can be shown in the emergence of mental health facilities, but the
methods of treating patients are far from being perfected. This is evident in
the case of emergency psychiatric care. Because I lack prior knowledge in emergency
psychiatry, I assumed that an emergency unit catering to metal health patients
would function similarity to a general emergency health unit. Therefore, I
acknowledged the pressures associated with having vacant beds available to help
patients; however, according to the APU’s conduct, this pressure to have
available beds for patients turned out to be essentially the only driving force
in dealing with patients. As a result, psychiatric patients were assessed not
by what type of treatment they required, but by how readily they could be
discharged or transferred. Lorna Rhodes juggles the notion of quality versus
quantity, which is translated into efficiency versus effectiveness, in the
light of the functioning emergency psychiatric unit. Both quality and quantity
is what is ideal, but reality does not often align with the ideal. Therefore,
Lorna Rhodes analyzes the decisions and actions the APU takes to provide care
for the patients. She does not justify the psychiatric unit’s controversial
actions but concludes that alternative approaches would result in the same
rebuke because either way, significant factors are being sacrificed for the
sake of other significant factors. There is so much pressure involved in the
unit that it is not easy and clear cut. The overarching theme and discovery of
Rhodes’ research is that the mental health community receive an incomplete,
largely lacking care in society, and one representation of this can be seen in
the functioning of the Acute Psychiatric Unit.
Emptying
Beds: The Work of an Emergency Psychiatric Unit, is an ethnography written by Lorna Rhodes
that dissects the functions of an Acute Psychiatric Unit (APU). Lorna Rhodes
role in this case study was to understand the functions of the unit in an
attempt to find solutions to improve aftercare of patients admitted to the APU.
Although her research did not result in a solution to outpatient care, it
explained why the circumstances rendered the task too difficult. Lorna Rhodes’
compilation of thoughts, recorded dialogues, observations, and illustrations
revealed the complexities that challenged the moral principles of all aspects
of patient care. Her research gave a holistic view into how the emergency unit
operated under high demand when the there was inadequate funding. There were
more patients than there were available beds; therefore, a fixation on vacant
beds became the defining figure of success. The emergency unit would
momentarily hold patients while relocating others so that constant influxes of
people were coming and going. It was like a revolving door. Because patients
were not effectively treated, they kept coming back. “Over one-fourth of the
patients who were admitted to the APU were returning to the unit (Rhodes 1991:117).”
It was a flawed system that centered on transferring patients from one location
to the next, so patients were not provided the necessary attention or care they
needed to actually get better. If patients were not given adequate treatment,
why would they keep coming back? Because individuals suffering from mental
illnesses are social outcasts, they have nowhere else to go. From prior
knowledge, I knew that equality among different social groups within a
community existed. For example, gender, economic status, etc., is associated
with different social perceptions, likewise, in health, I found that mental
health illnesses and biological diseases have different social perceptions. This
ethnography highlights the low standards of patient care for mental health
patients.
The Acute Psychiatric Unit operated under
serious violation of ethical issues ranging from the most basic humane
treatment of its patients to the manipulation of regulations. Although the
purpose of the APU’s existence was to provide emergency assistance to patients,
it seemed as if the unit functioned with little regard for the actual patient. The
unit referenced a patient to be “defined as the offal—the piece of shit in the
game of hot potato, or hot shit, among parts of the system. Whoever got stuck
with him would be the person who take care of the shit” (Rhodes 1991:75).
Individuals who were either mandated by court or abnormal (did not fit into the
societal standard) were outcasts even within a system that was designed for
their needs. Patients were referenced in such a demeaning way; even the
patients that were viewed in a positive light were referenced as a “pet”
(Rhodes). It was infuriating to see professionals with that mentality. There
are also prevalent issues of manipulation of power and data to elicit specific
results. For example, the staff of the APU had access to
medications that could dictate a patient’s behavior, and it was strategically
distributed in the interests of the staff, not primary for the patient. “I’ll
just keep her crazy… so she’ll be sent to State Hospital today” (Rhodes
1991:68). With the mounting pressure to toss patients out when vacant beds were
limited, the emergency unit responded by changing information in the charts of
patients so that they could be quickly discharged thereafter. “The staff also
had occasion to conceal or omit information that might make a patient unacceptable
to a particular placement” (Rhodes 1991:69). And after a patient was
transferred, the complications and difficulties with the patient that followed were
referred to as “it’s their problem now.” There was no sense of accountability.
There was a lack of commitment and responsibility between the interacting
figures (nurses, social workers, mental health workers, residents, students
etc.) within the unit that mirrored the relationships between the patient and
caregiver. These cases reminded me of global health interventions like the Play
Pump Campaign for clean water in Africa. This project was designed with good
intentions, but one of the evident problems that arose from the project was
that the sponsors failed to communicate with the local community. Therefore,
play pumps were installed in communities that could not operate it. This shows
that without communication, there is a clear limitation to the effectiveness of
the purpose.
At first, the work enraged me. I could not
comprehend the logic of the emergency psychiatric unit’s methods and I
questioned under what authority this unit was approved to conduct its work. I
thought that this unit had lost the mentality of caring for patients who needed
help. I thought that this psychiatric unit was corrupt because ethical issues
were so deeply intertwined in ever relationship between the staff and the
patients. Although any audience would identify the functionality of the unit as
unethical and wrong, it was difficult if not impossible to come up with an
alternative approach to dealing with situations. “A desire for omnipotence, a
fantasy of providing for the patient that is likely to have no end. The lesson
is contradictory: helping the patient will help you see how helpless you are.
Trying to help is exposed as not what it seems” (Rhodes 1991:167). Ideal does
not exist in this setting. There are limitations in treating patients because there
is no easy cure. Some symptoms can be reduced and some behavior can be
controlled, but understanding mental illness is an ongoing struggle. “These
jobs are closely related to our rescue fantasies, wanting to help people. As
children we see ourselves as autonomous; later we realize we have to work in
concert with other people. Things intrude on this fantasy—like impossible patients—and
intrude on our capacity to do the work” (Rhodes 1991:56). It made sense. In an
emergency situation, the goal was to stabilize the patient so that he/she could
be fully treated elsewhere. The emergency unit was not in charge of treating
chronic cases, those cases had to be transferred. The basic layout of the unit
made sense, but when it all came together under the circumstances, it was all
unethical and wrong because real people were put into the mix. “We are doing
just what you’d expect [under these circumstances]. When the patient comes in
you make a quick decision and make your plans. We don’t get into their
intrapsychic life; our goal is to reduce their anxiety” (Rhodes 1991:58). However,
it is unfair to say that because the system is so complex, the methods and
mentality of the staff are acceptable when dealing with patients. The reality
of the circumstance uncovers the reasoning as to why the staff behaves in a
certain way; nevertheless it did not change my stance on disapproving the Acute
Psychiatric Unit’s code of conduct and its mentality.
Global health encompasses health problems,
issues, and concerns that transcend national boundaries, and it is often associated
with epidemics that exhibit visible signs or biological abnormalities that
cause symptoms of intense discomfort and physical deterioration. Therefore,
mental health is often shadowed by other more apparent health problems. It is
rarely mentioned as a global health issue because some regions do not acknowledge
its legitimacy because much of mental health is largely unknown. Incomplete
knowledge results in incomplete cures, which results in incomplete treatment. Regardless,
mental health is undoubtedly a global health issue. Patients that showed up on
the front doors of the emergency psychiatric unit ranged from individuals that
experienced suicidal thoughts, violent outbursts, delusions, hallucinations,
etc., or presented threat or threatened society’s standards (patients admitted
involuntarily by court order) (Rhodes). An illness does not have meaning
without being placed within a social context and then being acknowledged as a
sickness. Society and culture influence health. This is supported by an excerpt
from the ethnography, which clearly illustrates the relationship between health
and society’s influence on health. “The psychiatric emergency does not exist
until it is placed within in a social setting. For example, suicidal ideation
not brought to the attention of others… is never identified as an emergency.
Once the elements of a patient’s stress or danger are brought into the social
system, however, the evaluation and disposition process grind on until the
stress and danger are reduced or eliminated” (Rhodes 1991:37). Mental health is
defined within a society, and only carries meaning after it is defined. Other
topics from the ethnography that directly align with the topics we have
discussed in class are ethics and medicalization of conditions. Diagnosing
mental health was mentioned by using the Diagnostic and Statistical Manual
(DSM).
I think what Lorna Rhodes did impeccably well
was derive the meaning of every personal account made by the staff. An outsider
has no understanding of the true difficulties of patient care and in an environment
like the APU. An initial negative reaction from an outsider is anticipated, but
she was not bias; she presented the research as it stood. She did not pick a
side (the position of the patient or the position of the medical staff), but
she showed complexities of both sides to story by referencing limitations of
the situation. Where I believe the ethnography lacked was from the perspective
of the community surrounding the emergency psychiatric unit. Lorna Rhodes
accurately portrayed multiple perspectives of staff and patients, but there was
no account of an outside perspective. She muted the outside world in which the
unit functioned within.
Funneling patients in and out of the system
quickly was the priority. The system got so preoccupied in “emptying beds” that
the patients who needed help were just locked up and isolated until they calmed
down on drugs and was discharged. Efficiency was accomplished but the lack of
effectiveness of the method was blatantly clear. But in what standards is
effectiveness measured? There is no opposition when stated that the APU is not
effective in their treatment of patients. However, if the controversy of ethics
is disregarded for a moment, it can be acknowledged that the unit is effective
in its specific role to provide a temporary place of safety while arrangements
are made for a more permanent replacement. Lorna Rhodes research revealed the
starkness of the mental health facility that was previously invisible to the
general public. Therefore, this ethnography can be used as the mediator to gain
insight into the patient care conditions of mental health patients. This will
ideally serve to initiate change within the community’s perception of mental
health and seek to improve its conditions.
Rhodes,
L. A. (1991). Emptying beds : the work of an emergency psychiatric unit.
Berkeley, University of California Press.
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