The revolving door is a metaphor we most often associate with prisons. Prisoners create networks of criminals and sometimes turn those convicted of petty crimes into career criminals on release. Prison also creates dependency. The process of being institutionalised by serving time in prison is one similar to being institutionalised through long-stays in psych wards or frequent readmissions.
If there is a revolving door to the wards with readmission, there is also a revolving door for those who present to hospitals but are turned away. In Emergency Departments (also known as ED, A&E, ER or just ‘Emergency’), some doctors and managers even label those with frequent mental health issues who come there as ‘frequent presenters’ or even ‘frequent flyers’. Special plans and projects are formulated to divert these patients with frequent severe distress away from hospitals including sometimes denying any form of medication or talk therapy completely.
Turning patients away is justified as ‘not having enough beds’ or ‘avoiding dependence on the ward’ which is often a reasonable excuse. It is also a mechanism for shifting the blame back to community services and the usually untrained family, partners and friends who have to look after their loved ones after up to 30 hours waiting in stressful clinical environments to be told they can’t be helped. This process is common and with many tragic consequences including suicide, homicide and much more frequently further deterioration of mental health to the point where hospital will be needed and a longer stay is needed because symptoms were allowed to become so much worse.
Architecture and interior design in psych wards that create the impression of modern and comfortable care but still largely resemble a prison in many other ways. Just as a Central Tower was placed in Bentham and Foucault’s Panopticon – a design of a prison with total surveillance of every cell – security cameras and a central Perspex nursing station monitor the patients of most modern psych wards. Often you don’t know you are being watched – but you are always vulnerable and often visible. Even where cameras are not allowed inside a room or even inside a ward, nursing staff may be on their way for their rounds including often shining a flashlight/torch in at night to check you are breathing.
The high rise asylum involves a different tower and mechanism of control. The high rise prison in Chicago uses a triangular floor plan to make it easier for the guards to have a clear line of sight to every prisoner. Similarly, the Perspex nursing station usually allows this sort of surveillance in the modern asylum while creating a physical barrier but more problematically also allowing nurses and other clinicians to distance themselves from patients. Patients are deliberately ignored with excuses that clinicians are too busy completing documentation or having important meetings like handover. Prioritising documentation and long meetings over patient care is rarely justifiable but totally legitimised by these institutions and professional standards required for accreditation or membership.
Psych wards in the developed world still vary from those run for many decades on the same sites as the original tortuous asylums. Inpatient psych wards usually include a mix of government-operated (public) and non-government-operated (nonprofit or corporate) residential mental health services. The buildings that house these wards include large hospitals with many other wards treating physical health conditions, hospitals just with mental health and addiction treatment or standalone mental health facilities. Each of these ways to package and physically present psychiatric care to the outside world comes with an element of creating the impression that mental illness is just like any other illness. Equating mental illness with physical illness can reduce stigma but it can also prioritise physical care well above emotional care.
Monitoring for physical illness makes sense for those who have harmed themselves, been harmed by others or impacted by side effects or co-existing conditions. Taking blood pressure, temperature and checks of signs of breathing at night can all make sense but represent the model of hospital care in the rest of the hospital rather than actually checking in on changes in mood and distress. When patients leave the hospital and discharge back home or to new group homes, their vital signs are not regularly checked so it seems rather unjustified to constantly check them in the hospital. Many nurses who I have observed do blood pressure and temperature two or three times a day fail to ask about mood, distress, side effects or even just polite small talk.
The buildings and the medically-justified busywork are merely window dressing. These unhealthy systems are overly coercive and traumatic for inpatients and lack proper follow up for patients back in community.
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