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How Psychiatric Hospitals Reinforce Negative Behaviors

Another hospital practice that further dilutes the attention that is provided to all patients truly in need is the assigning of one to one staff per patient when individual patients "act out" in a self destructive manner.

When some types of patients see how easy it is to have a staff member be at their "beckon call", the idea apparently becomes very appealing to the "starved for control" Borderline Patient, (also known as BPD for Borderline Personality Disorder). Although not all BPD patients fit into this category, these patients are more notorious for this type of behavior than are patients with other psychiatric labels.  The borderline patient commonly needs to be continuously  reinforced with attention to allay feelings of inferiority. It is also very common for this behavior to  generate into the need to control others. So you might be wondering, how does a hospital reinforce this need?

When a patient states that he intends to harm himself he gets assigned a staff member to continuous observation. Usually this patient has a staff member follow him everywhere. That means that the patient says where he wants to sit, when he wants to move, when he wants to go outside and smoke, when he desires to use the phone, and so on. The staff must follow the patient, usually at arms length, so as to prevent the patient from making a sudden self damaging movement.

This kind of power is (commonly) very appealing to the Borderline Patient. It gives the patient a false notion of being in control. This is a type of behavour a BPD patient will frequently use to compansate for a lack of self esteem.

The problem with the hospital assigning staff members to 1:1 observation is that it reinforces the behavior that it is trying to prevent! If a patient uses maladaptive behaviors to seek attention, that is probably the characteristic that landed him in the Psych Hospital in the first place. So let’s take a look at the chain of events; first the patient makes a suicide attempt or the threat of a suicide attempt to get put in the hospital in the first place. Then when the patient becomes adjusted to the psych ward, usually within two days, he or she learns that other patients have staff following them everywhere, talking to them and usually entertaining them, the adjusted patient then wonders, what do I have to do to get that kind of attention? Then the patient figures out all they have to do is cry, lay on the floor, get in fetal position, say that they want to die and they "feel in danger". And within an hour they have their very own shadow following them everywhere. A staff will be assigned 1:1 with the patient. And if the staff turns his or her head even for a moment and the patient manages to scratch him/herself, the staff will be disciplined if not fired. Many patients openly state that this is their very intention! The patients do this with regularity as a game of control.

Even though the supervisors are aware that the patients intentionally try to get the staff reprimanded for not giving them their undivided attention, the supervisors will still punish the staff instead of the patient! I believe that this is because if there were consequences to the patient for this type of manipulative behavior, the patient would choose another hospital to get Baker Acted into the next time that he/she decides to attempt suicide! That's about $500 a day that the Hospital would lose!

This type of practice doesn’t sound very therapeutic, so why is it practiced? Because it’s policy! It’s the way things are done in Florida! It’s the Status Quo. When a patient states that they desire to kill herself, the threat cannot be taken lightly. If it is ignored, the patient will usually act out and scratch herself just to show that she means business. The act will not be an actual attempt to do real harm, but it will be a game of See- I told you so! This act again is done with the tradition of getting the staff member that ignored the patient’s threat in deep shit. And as policy dictates, so it will be.

I discussed this policy with the supervising nurse and asked her why don’t we make 1:1 Observation a little less rewarding by, for example, requiring the patient to be kept in one room without the privileges of smoking, watching TV and the freedom to walk around with the staff continuously following her? The supervising nurse replied that we weren’t permitted to make that kind of restriction on the suicidal patient, without the DR’s approval.

Again one may ask the question of why, what exactly is the intention of the psychiatric hospital? After you see how things operate in the hospital environment, the answer becomes obvious. The soul purpose of the Psych Hospital is the same purpose of every other business in the world. And that is to make money.

Repeat Customers

Having a low census can have the effect of reducing hospital profits. Hospitals nowadays have a need to compete with each other just as other businesses do. This applies to psychiatric wards as well. If mental illness was all cured once and for all, a lot of people would lose a lot of money. There is profit in mental illness. And your local Baker Act Facility has figured out how to capitalize on it. This concept can be summed up the same way other business sum up their business; A happy customer is a return customer.

By now you might be thinking that it is a little unethical to give psychiatric patients incentive to return to the psych ward? Actually this depends on the school of thought you subscribe to. Some believe that the mentally ill are in need of nurturing and should be given the attention that they have been so consistently deprived of. The other school of thought would say that if a behavior is rewarded it will have a tendency to increase the likelihood of that behavior in the future.

The fact of the matter is in the psychiatric facility that I work in, there are many patients, sometimes up to 50% of them that come in regularly and spend a large portion of their lives in this hospital. They even request to be taken to this hospital, even when there are other psychiatric facilities that are closer to where they live.


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