It is good to seek admission to the psychiatric ward (Psych Ward) of a suitable hospital if you are in danger of harming yourself or others, for containment until you are stable enough to leave. Sometimes we do not have the insight to make that decision and may be brought into hospital against our will, or if initially in hospital voluntarily, if we lack the insight to see the need to stay for the sake of safety, we may be made involuntary. In the bad old days, this could and was used against people who should not have been kept against their wills. This abuse of the system is now extremely hard to to. Psych Ward is about containment, not about healing.
Psych Ward is About Containment, not Healing
Many people I talk to who have been admitted to the Psychiatric Ward of a Hospital (Psych Ward) complain that they didn’t get better while there. I think their expectation is that they would get a good diagnosis, good medication, good group therapy, good individual therapy and be able to leave as a healed contributing member of society. That is not the purpose of Psych Ward. That is the what mental health therapy in the community is about.
People who go to Psych Ward have exceeded the care ability of the mental health services in the community (home). Most commonly, a person admits themselves to Psych Ward when they feel like they are unable to keep themself safe in some significant way, or perhaps keep others safe from themselves. This can include significant deliberate self-harm that could be life threatening or permanent, suicide, or risk of harming another person. Even so, it is hard to be admitted. Most psychiatric units are full or close to full. Frequently the assessing team need to work out not only if you fit the criteria for admission, but if your situation is worse than the least risky person currently in the ward. Mostly this is due to poor funding for mental health, especially for hospitals.
You may not have the insight to recognise that your actions are unsafe. We’ll delve into this a bit later. The point for this is, someone else has determined that you are a risk to yourself or someone else, and so you have been admitted on your behalf.
The goal of the Psych Ward is to get you safe enough that you can be discharged. Sometimes, that means a better diagnosis and better medication. Sometimes that means filling in some necessary blanks in your knowledge of how to manage so that you are able to be safer or better self-managed. Once you are safe enough to discharge, then you can go on to mental health services that aren’t part of the ward. While they are helping you reach that target, they will do their best to contain the risk portion of why you couldn’t be helped in the community.
That is, the goal of Psych Ward is containment until you are safe, then release – it isn’t to heal you.
Psych Ward is Generally Neurodivergent Unfriendly
Autism, ADHD and BPD are not part of the general qualifications for psychologists, social workers or psychiatrists. Most people who qualify with these degrees and become therapist certified did not learn about these conditions. Most of what they know are the pop-psych stereotypes. What that means is, unless you look much like the most stereotypical presentation of the relevant condition, they will most likely misdiagnose you and thus their treatment plans will be wrong and likely ill fitting; and even if they do recognise the condition that you have (or you have been pre-diagnosed), they still won’t know how to give a positive treatment plan for your condition.
Personally, this is a tragedy. Most of the people in Psych Ward are neurodivergent, with many Autistic and ADHD people who haven’t been property diagnosed, or aren’t being treated in a friendly way. Most people who are in Psych Ward for containment and are Autistic and or ADHD will likely be given a diagnosis of BPD. In our BPD page, we make the case that this is not a good diagnosis for anyone, however the particular pattern of behaviour that led to this diagnosis can be good to note.
BPD is considered anathema to Psych Ward, and should be you be diagnosed with it, they’ll implement the unwritten policy of “patch em up, get em out”. While that sounds callous, it is actually the best thing they can do for both you and them. If you are diagnosed with BPD, the longer you stay in Psych Ward, the worse you’ll get, and the higher the risk of harm.
You’ll like be Prescribed an Antipsychotic
The most common medication given in Psych Ward is antipsychotics. This has the benefit of nullifying the more common mind altering recreational drugs that cause psychotic presentations, treats half of the people who are schizophrenic, and pacifies most of the people who are agitated with its sedative qualities. This pacifying aspect makes sense when you realise that most people admitted to Psych Ward are agitated and the goal of Psych Ward is to contain you until you are safe to discharge. People who are at risk become far less so once they have been given an antipsychotic, and the risk to health is very low for short term use.
However, Antipsychotic medication is not compatible with most people diagnosed with ADHD and Autism, and minimally useful for BPD, Anxiety and Depression. As noted above, Psych Ward often doesn’t recognise that your actual condition is Autism or ADHD, and often misdiagnoses people with the
ADHD is a common hereditary congenital neurological condition (around 5-10% of the population, it runs in families, you are born with it, it is a difference in neurology) that leads to problems using Dopamine in the prefrontal cortex (the bit of brain just behind your forehead). This can be a problem creating sufficient Dopamine to use to think with, or getting enough Dopamine in the synapses to register a synapse signal (simplistically, insufficient to flip the communication switch). The key aspect of this is that sufficient dopamine molecules need to fill the synaptic gap to key into the Dopamine Receptors to pass the signal from one neuron to the next. There are 5 types of Dopamine Receptor, and each will manage a different aspect of higher order executive thinking. Antipsychotic medications works by blocking Dopamine Receptors in the brain, which make ADHD symptoms worse and effectively block ADHD medication from working.
Atypical Antipsychotics work the same way as typical antipsychotics, but won’t block all 5 of the Dopamine Receptors. This can allow targeting the Dopamine Receptor that is connected to the faulty brain mechanism that is causing odd behaviour in someone with schizophrenia (mostly the D2 neurotransmitter), without knocking out the other executive functions that the other Dopamine Receptors manage. For ADHDers, this it is often better to take an atypical antipsychotic than a typical one, but even then, it is hard to get your brain working again when your ADHD symptoms have been exacerbated.
The more up to date medical science indicates that the overlap between Autism and ADHD is around between 22% to 83% (Aspect “Autism and ADHD (AuDHD) Fact Sheet”) (ASD and ADHD Comorbidity: What Are We Talking About?), and I argue that it is closer to 100%. What this means at the least is that many Autistic people won’t benefit from being prescribed antipsychotic medication in the long term.
As we will see, part of being able to be discharged is demonstrating competence and safety. This is very hard to do when your executive function has been compromised.
Involuntary Psych Ward
If your cognitive process is compromised, you will struggle to understand what is going on. You may think you know, but you don’t, and for your own sake, you need to be contained.
We make decisions on four key aspects:
- How we feel about something
- Insight into the consequence of our, and thus why events around us may be due to ourselves
- Judgement about what is good for ourselves and our community
- Sufficient memory to be able to review the past, recognise the present and recall our decisions and reasoning later
Once we make a decision, we then enact that via our actions. How we do those actions is a large part of our behaviours. If we lose track of why we are doing something, or our values for insight and judgement become distorted, are we just don’t remember what we decided, our behaviours become erratic.
A person may be in the community and due to concerns about their ability to make rational decisions, they may be taken under a mental health law (in Western Australia, the Mental Health Act 2014, a Referral for examination at authorised hospital [Section 36]), or if already a voluntary inpatient because their decisions have become dangerous (in WA, the Mental Health Act 2014, an Inpatient Treatment Order, Section 55]). Someone won’t be sectioned unless they fit certain criteria under the law. Once they do (or seem to), a psychiatrist needs to examine the patient (a psychiatrist is a medical doctor who has specialised in psychiatric conditions) who must then determine, as guided by the law, that the individual meets the criteria to be kept involuntarily in the Psychiatric Ward. That psychiatrist cannot be the one who proposed the person be involuntary.