Upon admission to this facility, one finds conditions of care more akin to those of a prison rather than a provider of key and needed mental health services. Indeed, prisons provide valuable access to mental health care relative to the labyrinthian system that the general public is forced to navigate, often when they are at their worst. While it is common practice in psychiatric facilities to do a body map of a patient’s scars, bruises, tattoos, and other markings so as to be able to identify the appearance of new such markings and injuries over the course of one’s hospitalization, at Hartgrove they conduct it far more like a prison strip search, having patients remove all clothes, squat, and cough, a particularly high level of invasiveness (and particularly stressful for those with trauma histories, as many of their patients, especially among the women, do).
Next, patients are asked to pick their poison if they get out of control, ranking from 1st to 4th choice medication, isolation, physical hold, or restraints (note that no options are technically off-limits). Patients then find themselves surrounded by often rude caretakers more intent on constraining rights rather than expanding horizons. Individuals are refused access to their relatives (even their children) during hours outside of regular phone call times, at times following being on hold for as much as half an hour. Ironically, one fairly standard rule that the facility does not impose is a prohibition against patients touching one another, though one might imagine such a rule might be warranted here. The conditions of the searches and potential restraints strike at something particularly crucial, which is that depression eats at one’s sense of self-worth, and the treatment at these stages only validate those cognitive distortions of low esteem, potentially even “deserving it.”
One young woman, 18 years old, just old enough to be separated from her friend and ex-boyfriend of 17, who thus is in the adolescent unit – stares wistfully out of her semi-private bedroom window, watching as women in the salon across the street get their hair and nails done, looking happily at their done-up complexions as she herself covers the scars and scratches that she has inflicted upon herself when the voices in her head become more vocal. Another patient asks for the fourth time for his legally-provided paperwork entitling him to discharge on his fifth day of stay provided that he is not a danger to himself or others, and after repeated denials of this request within his legal rights, is granted the form only after threatening publicly to call the patient advocacy line with which patients are all equipped but that too few of them actually use, perhaps because they have come to believe that they do not deserve better, or perhaps because they have not yet had the chance to know better, to be treated with human dignity. Another woman enters her fifth day of requesting her book of phone numbers from her purse being held in security, so that she can notify her family and dog-sitter of her location and status. A nurse who could aptly be characterized as a modern-day Nurse Ratchett flatly denies the request on account of “being busy” while openly discussing details of a patient’s case in the nursing station in a loud tone, with other staffers and patients well within earshot.
“She was in the ICU and intubated,” she calls out to a fellow staffer managing a new patient’s intake as a handful of patients congregate near the nurse’s station awaiting their receipt of medications. There are many other such “confidentialish” discussions about patient information, raising questions as to their understanding of compliance with HIPAA patient protections and a need for a private room in which to discuss case information that is away from patient access. The same patient seeking her family members’ phone numbers had a neurologist-approved medication withheld from her without discussion with her psychiatrist or social worker, with subsequent refusal to engage in discussion with the patient regarding the matter.
“Is it always this acrimonious?” the new admit asks.
“The desk manager unabashedly answers “yes,” which is a rare piece of truth that one finds among those running the unit. Some are seasoned and dedicated but overworked and understaffed and thus unable to maintain what might have been a prior sense of competence. Others are clearly of the view that with this patient community, one must impose the most restrictive rights, draw the brightest lines, impose the strictest of terms, allow the least freedom. For example, only two incoming and two outgoing calls per person are allowed (typically not consecutively and only within narrow time windows), there are no doors but rather curtains in front of the bathrooms (again, with bedroom doors not permitted to be closed, thus leaving virtually no privacy), patients may not stand in front of the red line approximately six feet in front of the nursing station without express permission, patients are not allowed to walk the halls for the most marginal degree of exercise to burn off some of their all fried foods (deemed “worse than prison food,” according to an ex-offender), between 9pm curfew and 8am breakfast patients are required to be in their rooms, occasionally scolded for getting up in the middle of the night to obtain more pain or sleep medication. Checks throughout the night are often conducted by way of holding flashlights in front of the faces of patients, purportedly to check that they are in bed and breathing, but also maintaining the dictatorial attitude according to which this “mellower” unit is run. And while patients in the "mellower" unit 2 South are no doubt glad not to be in the acute care unit of 2 North, the judgment with which the staff speak of the "crazy" patients in 2 North is stark.
Other staffers are young and perhaps well-meaning, but appear more intent on bonding with the patients than facilitating patients’ recovery and have yet to build the skill set necessary to be effective purveyors of care with respect to simple request such as retrieving phone numbers from personal belongings. The latter request is particularly ironic for a field of health build so centrally on the value of including a support system and making them integral to a patient’s recovery. Hartgrove has missed that memo, and perhaps instead taken a trip “back to the future” of dismal conditions that prey upon the often vulnerable mentally ill populations unable to advocate adequately for themselves. Such populations should truly get the most care (and in context of civil rights and the Equal Protection Clause, vulnerable populations are afforded higher levels of judicial scrutiny in the evaluation of constitutional rights) and yet sadly from an administrative standpoint, the red tape looms large and patients fall through the cracks, a phenomenon seen quite ubiquitously in this particular context.
This is not to say that the staff and psychiatric care is universally sub-par. There are exceptions, to be sure, with some quite dedicated and highly competent. But the fact that there is such a wide variance in degree of care when it makes such an immense difference in length of stay, medication management, and after-care is an issue of grave concern. Whether you are cared for well and released in 5 days versus ignored and left for 10 days should be determined not by assignment to a particular doctor but by the patient’s individual condition and progress. Consistently, adherence to rules regarding things such as phone calls is left to the discretion of individual staff members, some of whom are accommodating and many of whom are not. Moreover, not all staffers appear to be well-versed in the nature of psychiatric illness, with one seemingly well-meaning staff member asking an academically accomplished patient, “Damn, girl, what you got to be depressed about?” The comment, though made in jest, marginalizes the real struggles, both biological and circumstantial that land patients in such facilities. When the patient acknowledges that her admission followed a suicide attempt by way of overdose, the staffer asks whether it was because of a boyfriend. Such was the inquiry of the patient by multiple (male) staffers at Hartgrove, another of whom mocked a patient about the effectiveness of her method of suicide attempt.
A common standard of care, at least in top hospitals, is to meet daily with members of the treatment team (a psychiatrist and social worker), often both but in some cases alternate days with respect to the psychiatrist, with more limited care available on weekends except with respect to new admissions or an acute issue requiring immediate treatment. Hartgrove is notoriously understaffed and overcrowded, leading to what the DCFS to consider the facility to be dangerous conditions for children in this 150-bed facility. Such was the decision rendered at affiliated hospitals owned by Universal Health Services, including Garfield Park Hospital, an 88-bed facility where patients reported being injured during restraints by staff members and assaults on the units were frequent occurrences. Investigations into Hartgrove revealed approximately 100 incidents of violence and abuse between December 2010 and summer 2011, including the breaking of a child's arm during an improper restraint by staff members and the failure to to provide the child with medical treatment until the next day. One patient at Hartgrove had to wait 72 hours before being seen by her psychiatrist for the first time, and in six days had only seen the psychiatrist twice and her social worker once. Multiple requests to meet with social workers were rebuffed with “we’ll see,” or “we’ll track her down eventually,” but needless to say, eventually never came for a day or two, leaving patients with often poorly-organized groups (some better suited to prisoner re-entry than mental health treatment) that according to one staffer “sometimes meet, sometimes don’t,” and sometimes consist of little other than games such as Pictionary or sharing stories (technically anonymously) about prior patients. To the extent that an individual therapy session might have been afforded, it was held sitting on the floor of the hallway within earshot of other patients and staff, and thus not at all protective of patient privacy under HIPAA.
The staff are keen on using profanity among one another and with patients, which reflects a general casualness rather than level of professionalism that one should reasonably be able to expect, and many activities on the schedule do not ultimately occur (for example, exercise). Despite having a dietitian with whom patients meet, accommodations are rarely if ever made, even for religious reasons (e.g., kosher) and thus bringing Free Exercise Clause issues into play. If individual therapy sessions are able to be obtained, it is not uncommon for them to be held sitting on the hallway floor, in the presence of others staffers, as opposed to a private consultation room, again bringing into question issues of patients’ health privacy.
There are no secrets as to the shortage of mental health services in most of the country, but the casual acceptance of their own laxness in care provision is stark. There are no books available to patients, nor information on psychiatric disorders or medications, only two board games, limited art supplies, only one puzzle with a third of the pieces missing. In turn, there are limited ways other than watching TV to occupy time before 9 p.m. curfew, at which point patients are not allowed out of their rooms, scolded at times for even looking into the hallway from their doorways, and must keep their doors open (though at least one staff member was found having fallen asleep during his night shift). Thus, the provision of patient care at this facility, where staffers go by Mister or Miss to further reinforce the hierarchy vis-à-vis the patients, appears to deemphasize constantly the operative word “care.”
There are mixed findings as to the systematic effectiveness of psychotropic medications, and the consensus is that treatment in this domain is at least as much about art as it is about science when it comes to treating a particular patient. The findings of the beneficial effects of therapy – whether psychodynamic or cognitive behavioral – are more widely substantiated (despite obvious limitations of publication biases toward positive findings). While inpatient facilities are meant primarily for crisis stabilization in acute states, surely more group-based programs such as those at New York Presbyterian and Johns Hopkins and others should be encouraged if not required so as to ensure patients with some basic equipment (e.g., dialectical behavioral therapy) with valuable coping mechanisms before returning to the outside world with varied access to patient care (and thus reducing mental health recidivism, or “frequent flyers”). It would not be hard to envision a study of the patients whose particularly bad experiences in psychiatric facilities had not simply null effects on their progress but actually had induced setbacks in therapy progress.
Hartgrove Psychiatric Hospital is owned by Universal Health Services (UHS), the provider of 20% of all inpatient behavioral health care in the United States, and which is emblematic of poor cookie cutter solutions to mental health that may ultimately do more harm than good. Founded in 1983, UHS is the largest provider of facility-based behavioral health care in the nation, operating 216 centers in 37 states, Washington DC, and Puerto Rico, the US Virgin Islands, as well as the United Kingdom. Over the years, UHS has been caught in a number of scandals, from Medicare and Medicaid fraud to poor patient care. In March 2012, the organization and two of its subsidiaries paid $6.85 million to settle allegations that they were providing sub-standard care in Virginia and engaging in false claims under the False Claims Act. In August 2012, it settled for $4.25 a suit by parents alleging that they falsely billed for instruction of inpatient children and adolescents while actually just warehousing them. The institution has been alleged to have terminated whistleblowers across the nation, with employees raising issues such as patient neglect and sexual assaults against patients. Safety violations were found in 13 of the 26 UHS facilities in Texas, where among other violations, male nurses were held to have stripped naked a sex abuse victim and left her in solitary confinement, and elsewhere to have dropped off at a bus stop a suicidal patient who committed suicide the next day. Most recently, UHS lost in its False Claims Act case at the Supreme Court in Universal Health Services v. United States ex rel Escobar (2016) with respect to the UHS facility Arbour Counseling Services in Massachusetts.
The UHS-owned behavioral health centers of Chicago have been caught in a number of scandals over the recent yeas, with the Illinois Department of Children and Family Services not only deciding in 2011 to no longer send children and adolescents to Hartrgrove Psychiatric Hospital but also in 2013 opting not to send them to Garfield Park Hospital due to hundreds of alleged violent attacks and sexual assaults against patients. Riveredge Hospital, also now barred from receiving patients through DCFS, has also had allegations of sexual assaults of patients, and in 2013 a patient there committed suicide by hanging herself on the unit. It is not difficult to conceive of how experiencing, or even witnessing, such events while seeking acute psychiatric care would be traumatizing (or re-traumatizing) to a patient already in a vulnerable state. These are not isolated incidents, but rather systemic problems that deserve not just piecemeal Department of Justice investigations into specific patient complaints, but rather a large-scale evaluation of the institution’s mismanagement of such a huge share of the nation’s mental health care services.
One solution is better funding, allowing for more staffing and thus more flexibility with respect to patient requests and meeting patients’ basic needs. Currently, Hartgrove staff receive only approximately 6 paid holidays per year, which is below most employment standards (and not surprisingly, the staff are not unionized). However, it is unclear whether the culture itself needs a cleansing independent of the degree of staffing that they might hope to obtain.
We speak at times of the “prison industrial complex,” with some corporations reaping marked financial profits from prison overcrowding amid the expansion of the inmate populations in private prisons. That UHS manages approximately 20% of inpatient care is a figure that actually exceeds the numbers with respect to private prisons, which manage the incarceration of 6% of state prisoners and 16% of federal prisoners. The company overall, which manages an immense share of the national mental health care, reports large profit margins despite the struggles of many non-profit hospitals, though given the number of Department of Justice investigations that their facilities are undergoing for alleged fraud and patient abuse, it does not appear to be driven by the quality of patient care.
UHS declares that in 2015, they treated 2.5 million patients, with a citation of 400,000 patients per year within the domain of behavioral health. While UHS v. United States Ex Rel Escobar (2016) emphasized the False Claims Act, inherent in the determination of whether fraudulent claims were made was a discussion of the nature of patient care, and the substandard nature with which the hospital was going about its business. The federal government has a financial interest in Medicare and Medicaid claims being submitted in good faith with respect to patient care delivered as promised. But it also has an interest in the health and welfare of its citizens. Absent effective and safe care, they are more likely to face hospital readmission, disability or otherwise have reduced productivity, and poverty in future years. Hartgrove Psychiatric Hospital in Illinois and Arbour Counseling Services in Massachusetts are but two examples of the substandard care to which Universal Health Services patients are being subjected. The federal and state governments both have social, financial, and moral obligations to take action with respect to the risks to which UHS is subjecting its patients, and the deleterious health and economic impact of this substandard care being implemented across the United States upon patients’ admission to their facilities.