oodhull Hospital serves two of Brooklyn’s poorest communities, Bushwick and Bedford-Stuyvesant, where nearly half the residents have incomes below the federal poverty level. Woodhull is one of the city’s 11 public hospitals,operated by the Health and Hospitals Corporation, an agency that isincreasingly responsible for treating the city’s uninsured poor. In 1996, HHC treated 46 percent of all psychiatric inpatients in the city.
I wasn’t suicidal when I entered Woodhull’s emergency room. I went in as a reporter. The purpose of going undercover was to evaluate New York City’s system for providing crisis-level mental health services to low-income people.
This is a story that doesn’t lend itself well to conventional reporting. A journalist is limited by confidentiality issues, access to facilities and logistics--you can’t sit in on a psychiatrist’s interview with a patient in crisis and take notes. What’s more, many psychiatry professionals are either dismissive or ambivalent about patients’ criticism of their treatment on hospital psych wards. In the course of reporting this article, I interviewed Dr. Spencer Eth, clinical director of the Department of Psychiatry at St. Vincents Hospital in Manhattan and a frequently quoted expert on mental health issues. I listed a series of complaints about treatment on psychiatric wards.
His response: “Patients who have been hospitalized often have incomplete and inaccurate recollections of the process because almost by definition they are disturbed and upset at the time.... It’s a stressful, upsetting time. Many of the patients we see are intoxicated at the time, some are psychotic, some are demented. Often you’re explaining issues to patients who are not really getting it.”
He added, by way of analogy, “Y’know, you talk to some people and they describe police brutality, you talk to other people and they don’t. What’s the truth? Well, who’s to say? Both are the truth? Neither is the truth?”
Former patients may not always be the most reliable critics of the psychiatric system. But this point of fact can easily lapse into over generalization. Darby Penney, special assistant to the commissioner for the New York State Office of Mental Health--and herself a former psychiatric patient--talks about how this perspective is often used to discount patients’ criticism. “It’s like, ‘They’re mental patients so they’re probably not telling the truth or they thought it up, they imagined it, they hallucinated it and it’s not really happening,’” she says. “People just dismiss it because they figure, ‘Well, they’re crazy, so what they say is suspect.’”
I didn’t tell Eth the origins of my list of complaints, but they all concerned situations I personally witnessed as a psychiatric inpatient at Woodhull.
The discussion of psychiatric care becomes particularly complicated where social and mental health issues intersect. Numerous studies cite poverty as a significant factor that places people at increased risk for psychiatric illnesses. Recently, a 1997 New England Journal of Medicine article linked “sustained economic hardship” with depression.
But there’s also a parallel body of literature which argues that the diagnostic process sometimes misidentifies social problems as psychiatric disorders, especially among low-income populations. A 1997 article in Community Mental Health Journal analyzed the overdiagnosis of major depression in homeless individuals and the difficulties clinicians have in distinguishing “state-dependent distress” (misery, demoralization) from actual psychopathology.
What happens when someone with no family, no money, no job, no social support, shows up at a public hospital in the middle of the night and says: I’m depressed, I’m suicidal, I don’t want to live like this anymore? Will social and economic problems be pathologized? Will psychiatric problems be dismissed as just part of the poverty package? How is a person actually treated? To find out, I followed myself through the system.
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