Inpatient Treatment · Issues within mental health

The institutionalisation trap

I was 20 the first time I was admitted to a psychiatric ward. I was the youngest by maybe 10, 15 years. After eyeing me up, the older patients- the women who had been in and out for years, said to me, ‘don’t make this your life wee girl’. Terrified, I nodded vigorously- I wasn’t planning to.

Not too long ago, people with mental illnesses went into hospitals and never came out; in 2014/15, 5.7% (or just over 100,000) of the people in contact with mental health services in England were hospitalised. In recent years, a shift from hospital to community based care and a reduction in numbers of inpatient beds due to funding has seen the deinsitutionalisation of the mentally ill- something I don’t necessarily think is a bad thing.

It was a matter of days before I got used to the ward- fell into the comfortable routine of shuffling from bed to dining room to clinical room to TV room to dining room to clinical room to bed. A matter of days to get used to the idea of having staff available 24/7 if I was struggling and needed a chat. A matter of days to get used to the idea that on the ward, little was expected of me- no essay deadlines or lectures or work or social events I had to plaster a smile on my face for; depending what nurses were on, I wasn’t even expected to shower or dress. Psychiatric wards are not real life; it is a safe, protective little bubble and you are shielded and excused from everyday life. It was a matter of days before I realised just how very dangerous that was- just how very easy it would be to fall into the trap of becoming institutionalised, reliant on the system, a revolving door patient.

Institutionalisation is when ‘individuals living in institutions may be deprived (whether unintentionally or not) of independence and of responsibility, to the point that once they return to “outside life” they are often unable to manage many of its demands’. It is becoming comfortable with, and totally dependant on the routine and structure of a ward setting and the safety of staff. It is my biggest fear.

During my last admission, I had a conversation with a nurse. We were talking about the bipolar diagnosis, and she asked me if I was scared. When I nodded, she asked me what of. ‘Being in and out of here forever’. It was something I’d talked about with staff before, but this was admission number six, and the bipolar diagnosis made me fear that this was the kind of life I could come to expect. The nurse tells me to take control of my illness, to not let it control me, and it won’t be.

But it’s got me thinking: throughout each admission, I’ve met people I was in with that first time. I see the same faces each time I am admitted or on the occasions I’ve visited a friend on the ward, or hear that the same people are back in. Every time I bump into someone I’ve met in hospital, we ask each other ‘you been back in since?’ The last time I was sent to a ward out of area, there was a woman who was still there from when I first was, two years previously- and even then, she’d been in for years. And I think it highlights a few of things- that acute wards in particular aren’t equipped to adequately help patients with long term illnesses, that hospital aftercare isn’t doing enough to prevent readmissions, that lengthy admissions can create a dependance on the hospital environment and lead to rapid relapse in the community, that once you’re ‘in the system’/cycle of hospital admissions it can be hard to get out of it, that really and truly, hospital probably isn’t an ideal environment for giving people the tools to manage their illnesses- on the basis of the fact it is an artificial environment.

And it’s a tough one, because hospital has given me invaluable tools for managing my condition. I’ve had hugely helpful advice from lots of lovely nurses, opened up about things that have been bothering me for years, received a diagnosis, and lots of support with coming to terms with it, been started on appropriate medication, have been kept safe at times when I couldn’t do it myself and have had my moods stabilised when they became out of control and unmanageable. And I know for lots of other people, inpatient treatment has saved their life, provided them with huge amounts of support, has been entirely necessary and beneficial. For all the people I’ve met coming in and out of the wards, there have been dozens more that haven’t come back at all, and while I’ve seen patients struggle for months or years, their condition unchanged, I’ve also seen HUGE transformations in people after a few days or weeks- something that probably wouldn’t have been the case for them had they not been admitted.

Anyone who’s been a psychiatric inpatient will probably know that discharge isn’t always the welcome relief you’d expect it to be. That actually, for days or weeks (or months) afterwards, there’s an adjustment period. It takes time to adjust to life back home, to switching from round the clock support to hour long appointments once or twice a week, being able to sleep at night without gossiping nurses in the corridor, or being woken by alarms or the flashlight during checks. Takes time to ease back into things like going out, seeing friends, or starting back at school or work. Takes time to gain back the responsibility and independence that was taken from you on admission. For days or weeks, you feel a little wobbly, uneasy, panicked- because after days or weeks or months or years in hospital, you do become used to things, you do become reliant on the ward routine, familiar with the rules, the staff, what’s expected of you. You do start to feel a little comfortable, safe, scared of the ‘real world’, despite how demoralising and traumatising life on the ward can be.

And I think the longer you’ve been in, the younger you are, the fewer obligations you have (in terms of children, a job, bills to pay etc), the more likely it is to become institutionalised. If you grow up in hospital, or spend months or years on a ward, or have little sense of a life or responsibilities back home, I think hospital can become all you know and something that is strangely comforting. When each day you are living a life confined by hospital walls and the structure of life within them, it is easy then to forget how to live on the outside. When the coping skills you are taught are applied only in a hospital setting, it is difficult to try an implement them at home. When the most important people in your recovery are left behind on discharge, it is a struggle to cope without them. I think when you’re hospitalised, taken away from the things that ordinarily might help ground you, or give you a sense of purpose in life, it is easy to give up hope.

In my own experience, I was readmitted a few months after my longest admission. I’d struggled on discharge and continued to struggle- with adjusting back to ‘real life’ /responsibilities, with feeling stigmatised, with the fact my friends and extended family now ‘knew’ I was mentally ill. I went back to uni, a hundred miles from home and saw my CPN maybe once every 2 weeks. Now ‘in the system’, my CPN started suggesting readmission maybe 3 weeks after discharge, and continued to do so for the following three months until I was.  I was 20 when I was first admitted, 17 when I was first given a ‘choice’ to go in. Knowing what I know now, I was right to say no to that admission at 17, because rather than ‘fixing’ me sooner, I think it would have fuelled things- had I been sent miles from home, away from the things that have since proved to help my recovery (school, family, friends), I would have lost sight of my reasons to live. And when admitted just before exams, just before a nursing interview, while at work- I’ve had reason to fight to get the hell out of hospital sooner.

I’ve struggled writing this post- and I’m not sure where I’m going with it, or what it is I want to say. I’m just wary. I see lots of teenagers and young people online who seem ‘comfortable’ (a term I use loosely, as really and truly, comfortable as one might be in hospital, it’s not something many truly want for themselves) with a life in hospital, who seem to have grown too attached to the wards they grew up in to see that there is a life beyond the walls of a psychiatric hospital. And I am so, so worried that I will become like them, like the women I see each time I go back to the ward. I have been in and out of the revolving door of Elm ward for two years now, and I am so aware that very little stands between me and institutionalisation- that it doesn’t take much to lose control, lose insight, lose the sense of purpose, the desire to live, that keeps me out of those places. Every time I leave, I vow never to go back- and yet five more times I have found myself in those same dormitories, with the same purple lino, same yellow walls, the same nurses who chirp ‘well, yer back!’

I don’t want it to be my life. And I am scared, every day, that it could be.


3 thoughts on “The institutionalisation trap

  1. Great post. You talked about getting comfortable in the ward. For me, when I was hospitalized last year, it took a few days to get comfortable. When I realized how comfortable I’d become, it kind of scared me and motivated me to get out. I probably left too soon, but I didn’t want to be comfortable there. Like you said, it wasn’t real life.


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