The International Journal of Psychosocial Rehabilitation


Management of the Mental Hospital 


Dr Hitesh C Sheth
Superintendent and Psychiatrist
Hospital for Mental Health
Vikas Gruh Road
Jamnagar, Gujarat, India


Citation:

Sheth, HC (2013). Management of the Mental Hospital International Journal of Psychosocial Rehabilitation. Vol 17(2)  69-73



Correspondence:     
 Dr Hitesh Chandrakant Sheth
Superintendent and Psychiatrist
 Hospital for Mental Health 
Vikas Gruh Road
Jamnagar,India
hiteshcsheth@rediffmail.com          




Abstract
There are multiple challenges; one comes across when one manages the facilities that house mentally ill patients. The challenges include maintenance of physical infrastructure, including water and drainage systems; to protect the human rights of mentally ill patients admitted in such facilities and the management of the staff working in the institution. These challenges are going to exacerbate in future because mentally ill patients are increasing day by day, while the facilities that can house them and treat them, are not increasing in the same proportion. We need novel approaches and active government interventions, both physically as well as financially, to avert this impending humanitarian crisis.

Keywords: Mental Hospitals, Management, Deinstitutionalization, Traninstitutionalization, Human Rights


Introduction

The management according to oxford dictionary can be defined as, ‘The processes of dealing with or controlling things or people.’  So if we accept this definition of management for a practical purpose then, a management has two elements, first is to deal with people and to control them and second is to deal with things and to control them. 

Here when, we say that the dealing with people, it essentially means, the dealing with peoples’ minds, which have different temperaments, varied characters and different points of views, while looking at the same situation and the same goals. The problem of management assumes a different dimension, when we realized that institution is not an inert thing, but has a mind of its own and that is a sum total of the minds of people working in the institution and the minds of people availing services from the institution. The management becomes a tad difficult here, because when you are managing a mental institution, you are managing the minds, which are thinking, perceiving and reacting in a different manner than normal people do.  Herein below, I have tried to discuss the challenges that one faces while managing the institutes that house mentally ill patients.

Maintenance of Physical Infrastructure:
It is always difficult to maintain the infrastructure of public utilities and the problem become more pronounced in the institutions that house mentally ill persons, who many a times are admitted in the institutions with complaints of breaking household things and violent behavior towards self and others. 

In the times of recession, with the over stretched financial budgets, most of the governments over the world are already tightening a screw to maintain the fiscal discipline. In USA, representatives from some of the most important parts of the health-care sector met with the president and pledged to take aggressive steps to cut the currently projected growth rate of national health-care spending by an average of 1.5 percentage points in each of the next 10 years.[1] Many other governments  are thinking on similar lines.

In such hard times, it is very difficult to replace the same damaged things day in and day out. The full time people like plumbers, masons, tailors, carpenters, electricians, etc; are needed for day to day maintenance of such institutions, which are sadly not available in many of these institutions.

The recurrent need of new linens, clothes, beds, bed sheets and furniture, takes toll on already overburdened budget of the institutions. It is not uncommon to see a one disruptive patient tearing down all the bed sheets in a single day, which then need urgent replacement, which anyhow is needed frequently because soiling of them by the patients, who sometimes pass urine or stool on them.
The appointment of skilled labors on a contract bases may solve these problems without adding extra financial burden on a hospital budget.
 
Maintenance of Water and Drainage system:
Frequently it has been seen that the patient of schizophrenia often loss toilet training. They frequently pass stool at inappropriate places or eat their own stool
(corporphagia).After passing of stool, they often forget to turn on the tap which often leads to clogging of drainage system or sometimes if they turn on the tap then they forget to turn off the tape, which leads to emptying of the water storage tanks. But replacing the ordinary taps with push button type of taps is not a solution because many patients rarely push the button or flush the toilet, which again leads to clogging of the drainage system.

To deal with this type of problems, the institution needs many more attendants and sweepers, which are rarely available in many of the institutions. The old drainage lines, if replaced with wide bored drainage pipes, can help in reducing these problems. The new type of toilets, having pressure sensors to sense the weight of human being, may help to tackle this kind of problems.

Management of the Overcrowding at the Hospitals:    
 As we all know, we are still fumbling in a dark for a sure shot treatment of schizophrenia. Though outcome seems to have improved, the criteria that denote good outcomes are not as ambitious as it should be and we have accepted a little improvement in certain sets of symptoms as a good outcome. For instance, the recent consensus definition of remission for schizophrenia developed by an American Psychiatric Association working group does not even include a requirement of improved functioning, which many patients and families view as the essence of recovery. [2]

Neuroleptics, both conventional and atypical antipsychotics, reduce psychotic symptoms but may not treat the cognitive deficits or negative symptoms of schizophrenia. [3] Therefore, a large number of patients still require indoor hospital treatment

Owning to budgetary constraints and due to other reasons, the governments all over the world is implementing a deinstitutionalization policy. In the United States, policy decisions about deinstitutionalization have been made for a range of reasons, related to the well-being of service recipients, litigation, funding, and political considerations. [4] This policy has lead to closure of many hospitals, though in reality, increase in world population requires a proportionate increase in a number of mental hospitals. Therefore, increasing number of patients need to be accommodate in a same number of the hospitals, which in turns leads to overcrowding in the hospitals. Patients’ relatives are reluctant to house the patients at home due to social, economic, or family reasons or due to stigma associated with mental illness. [5]  

In India, a recent survey conducted by ICMR (Indian Council of Medical Research), found that 8-10% people suffer from psychiatric illnesses like depression, anxiety, and schizophrenia, among others. [6] Out of which at least one percent requires indoor treatment. Therefore, in India, there are at least ten million people, with severe mental illness. The world has 1.69 psychiatric beds 10,000 population compare to which India has only 0.25 beds per 10,000 populations. [7] .So a large number of patients are required to be accommodated in limited number of beds.

The other option advocated is to treat a patient in the community itself. While exercising this second option and treating the patient in the community itself, one expects that in community, parents are going to take care of the patient. But, when caretaker parents become old, one question always arises, that whether the old parents are going to take care of a mentally ill patient or a mentally ill patient is going to take care of the aging and perhaps infirm parents. And in today’s world when people are refusing to take care of their healthy siblings, it is preposterous to think that they would take care of a mentally ill and perhaps a dependant patient. Therefore, this approach of treating the patient in community itself leads to undesirable consequences like; utter neglect of the patient by his relatives, frequent contact with criminal justice system and more people in beggar homes, shelters and streets and jails instead of mental hospitals. Thus, net result is transinstitutionalization instead of deinstitutionalization, and because of that, patients die with their rights on, making a process of deinstitutionalization less palatable. We just switched places that results in mentally ill patients being in jail instead of hospital. According to jail official at Ohio, the whole system is topsy-turvy and the last person served is the mentally ill person. [8]
         
To tackle the problems many more institutions are needed, not just to treat the increasing number of mentally ill patients but also to train the future psychiatrists, so to lessen the load on existing institutions and workforce.

 Management of Hospital Staff:
There is a well-known Murphy’s Law according to which, if anything can go wrong, it will. And if this law is true for any place then it is more likely to be true for a mental hospital, because there are certain sets of problems, which, one is more likely to witness in mental hospitals than in any other hospitals. The reasons are, the other hospitals are under direct vigil of public, which make hospital staff and authorities alert to patients problems. Second is, in other hospitals, patient themselves are alert for their rights, which makes staff and administration sensitive to patients’ requirements, while in case of mentally ill patients they are completely at mercy of hospital staff. 

The other problem one frequently witnessed in the mental hospitals, is caretaker staff that take care of mentally ill patients, in order to maintain equilibrium in their relationship with patients, often start to think in a different manner, while dealing with them. The result of this interaction is burnt out of staff members and poor patient-staff interaction. Here, the defense mechanism-projective identification comes into play. Projective identification is a self-fulfilling prophecy, in first stage, the contents of patients’ minds are projected on staff members. In second stage the staff members introject, store and process the content and in third stage, it is reintroduced into the patients. The patient may think that the whole society including the staff members is unfair to them, and they may project the same contents on staff members. The staff members may identify with the projected contents unknowingly, and processes them. And in last stage, they may behave in an improper manner with the patient, fulfilling his preconceived false notions. Thus, staff members and patient act in unison, vitiating the hospital atmosphere. This process generally happens outside the awareness of both parties involved. [9] 

As in all other institutions, Pareto’s principle of work may also apply to the institutions that house mentally ill patients. [10] And as per this principle, it is not uncommon to see, the twenty percent of staff doing eighty percent of work of the institution. So one needs to devote a little more energy to motivate and manage the staffs that are little less efficient than their counterparts are.
The institutions can avoid these problems by rotating the staff members at regular intervals. The sensitization of staff members can go a long way to avoid these problems arising from poor staff-patients interactions.

Management of Human Rights of Mentally Ills:
The bodies that watch for the humans rights of mentally ill patients often rightly direct that there should not be an overcrowding at hospitals, as the overcrowding in a limited space leads to violation of basic human rights of the patients. However, the other choice to send partially improved patient to his relative’s home, who is unwilling to take care of him, also leads to violation of patient’s human right at home. Not many people working in the mental hospitals would disagree with the fact that their large amount of time is spent in explaining the reluctant relatives of the patient, the benefits and necessity of treating and keeping a mentally ill patient at home.

In some situation, one has to choose between a devil of human right violation and a deep sea of utter neglect. It is true that the overcrowding in a limited space is a human right violation, but the other option is equally appalling, to live in the unlimited space- a euphemism for living on the streets. Sometimes, one faces a dilemma, whether to feed a one person with the food sufficient for him alone and keep him alive or to feed three persons with the same amount of food and keep three persons alive. And sometimes second option seems far more appealing because it keeps three instead of one person alive. Frequently, persons with a soft conscience may choose a second type of option, though it can be always debated, whether a second option is better than the first or not.
 ‘Mercy bookings’, by police who are trying to protect the mentally ill are also surprisingly common. This is especially true for women, who are easily victimized, even raped, on the streets. A sheriff in Arizona admitted that the police officers ‘will find something to charge the person with and bring her to jail.’ A  conscientious jail official in West Virginia, after describing how the local state psychiatric hospital routinely discharged severely disabled patients to the streets, said, "If the mental institutions will not hold them, I will."[8] 

To solve these problems, government needs to build more number of institutions that treats mentally ill people. China has already taken the commendable steps in this direction. The Chinese government will reform and expand 550 psychiatric hospitals across the country within the next two years in an attempt to boost recovery rates and prevent patients from causing harm to society. [11] In a present situation, until governments build more treatment and housing facilities for mentally ill patients, it seems more prudent to overlook a problem of little overcrowding, so that the patients are not left on streets to die.
   
Conclusion:
The management of the institutions, which housed mentally ill patients, is a tad difficult. Therefore, we required novel physical as well as mental solutions, to solve these problems. Nowadays, many governments across the worlds are cutting the spending in the social sectors. This shortsighted approach may exacerbate the problem in future, Therefore, the governments should up the social sectors spending and create many more facilities to treat the mentally ill patients. The governments should also create facilities to generate and train the workforce, so to treat the mentally ill patients, who belong to us and are one of us. 



References
1)    Orszag Peter R. Health Costs are the real deficit threat. The Wall Street Journal 15th May 2009;A13. [http://online.wsj.com/article/SB124234365947221489.html]

2)    Andreasen NC, Carpenter WT, Kane JM, Lasser RA, Marder SR, Weinberger DR. Remission in schizophrenia: proposed criteria and rationale for consensus. Am J Psychiatr 2005; 162: 441-449
.
3)    Hyman S, Fenton W. Medicine. What are the right targets for psychopharmacology? Science 2003; 299: 350-351.

4)    Roger J. Stancliffe, K. Charlie Lakin, John R. Shea, Robert W. Prouty, and Kathryn Coucouvanis. Excerpts from The Economics of  Deinstitutionalization. 2004.

5)    Sheth, H.C.  Common Problems in Psychosocial Rehabilitation.  International Journal of Psychosocial Rehabilitation. 2005;10(1):53-60.

6)    Times of India, Delhi Edition, date 24/01/2011.   [http://timesofindia.indiatimes.com/articleshow/7349447.cms]

7)     WHO-aims report on mental health system in Uttarkhand, India.2006. ISBN 978-92-9022-309-2  [http://www.searo.who.int/LinkFiles/Mental_Health_Resources_WHO-
      AIMS_Report_MHS_Ind.pdf]

8)    Torrey, E. F., Stieber, J., Ezekiel, J., Wolfe, S. M., Sharfstein, J., Noble, J. H., "Flynn, L. M. Criminalizing the seriously mentally ill. Washington, DC  National Alliance for the Mentally Ill and Public Citizen Health Research Group.199;43

9)  [http://en.wikipedia.org/wiki/Projective_identification]

10) [http://en.wikipedia.org/wiki/Pareto_principle]
    
 11)  [http://www.china.org.cn/china/2010-06/21/content_20308720.htm]



   

 


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