Donahue: Inadequate care is ultimate mental health stigma

Editor’s note: This op-ed is by Rep. Anne Donahue, R-Northfield, co-chair of the House Mental Health Oversight Committee.

Gov. Peter Shumlin ripped into the news media last week for reporting quotes from hospitals describing the dangerous situations arising as a result of admitting dozens of psychiatric patients who can no longer be cared for at the flooded-out Vermont State Hospital.

Shumlin said they were stigmatizing an illness that could affect anyone – young or old, large or small – through descriptions of large, frightening patients who were putting other more vulnerable patients at risk.

Stigma is defined as an application of social disgrace to all those who share a specific “distinguishing mark.” It is utterly inappropriate to use an illness as such a “mark.” Suggesting that mental illness creates a higher risk of violence is untrue, yet also reflects a longstanding stigma.

Is it stigma if individuals are truthfully described without assigning social disgrace?

Shumlin and others involved in addressing the psychiatric hospital bed shortage have failed to identify why the state cares for some persons in a mental health crisis, but not others.

Having symptoms of a mental illness places a person in a unique status under the law.

Society asserts the right to lock up a person if the illness is believed to create a risk to the person or others, and there is no lesser way to ensure safety.

We assert the state’s interest in the value of life in assuming the right to take persons into custody if they are suicidal and not willing to accept help.

We assert the state’s interest in protection of the public in assuming the right to take persons into custody if they might potentially become violent and are not willing to accept help. It is the only time that the state can lock up someone who has not committed a crime, but is only predicted to be a risk to commit a violent act.

Because we are using the powers of the state to restrain people against their will, there are legal protections required to protect the constitutional right to freedom.

Because the state is asserting the need to hospitalize these individuals against their will, it has a direct responsibility to provide appropriate hospital care.

About 3,360 persons per year are admitted to hospitals in Vermont for acute episodes of a mental illness. Of that number, about 10 percent are admitted under the state’s power to take involuntary custody. What that 10 percent have in common is that they do not have a choice over having the state’s version of necessary treatment imposed upon them.

Whether or not one agrees philosophically that the state should have this power, it is fair to recognize that these are people who do not want to be in the hospital, would leave if they could, and are likely to be more challenging to engage as patients.

The majority of persons who are held against their will are treated in our general hospitals when their safety and the safety of other patients can still be met, and they are willing to follow mandated treatment planning.

Vermont State Hospital has continued to exist because general hospitals do not have the separate space and the specialized expertise to work with the remainder of them.
It has also existed for individuals who have been charged with a crime and are being evaluated for competence to stand trial, or who have been found not competent and in need of hospital treatment. Most of these are not violent crimes, but some are.

In total, those admitted to VSH have been about 3 percent of all admissions. This tiny percentage used a third of all inpatient beds in the state because of much longer hospitalizations.

In losing VSH to Irene, the state’s care for these patients has been flung upon general hospitals, a crisis because the statewide inpatient system was already full, but more so because the beds lost were those being used for this limited but high-security group of patients.

It is not just about space, as Shumlin claimed in his press conference. It is about an inappropriate mix of different levels of patient need, a mix that puts those who want to be there together with persons who are angry about being held against their will.

Since space must be made for those the state is requiring to be hospitalized, they must be held in the emergency room until a bed in the over-extended system can be located.

That’s unfair to those patients, and no Vermont emergency department is equipped to keep that a safe environment for them or for other emergency department patients.

Before the crisis precipitated by Irene, the outdated Vermont State Hospital was already recognized as an antiquated and unfit setting for patient care.

Gov. Shumlin has now decided that the state should not restore this former status quo while its replacement planning continues.

Instead, we create a new status quo for many months longer into an indefinite future: inadequate care for most patients served in psychiatric units any given day in Vermont, safety issues in emergency rooms across the state, and too few beds for people seeking care.

Saying that this is a dangerous medical crisis that pits anger and occasions of aggression against other vulnerable and ill persons is not perpetuating a stigma against persons with mental illness. It is reflecting a reality created by our laws to lock up a small number of persons who have been diagnosed with a mental illness.

The administration chose the political opportunity to be the one to declare VSH permanently closed, but did nothing in its place to provide additional hospital beds, and in particular, hospital beds that are safe and secure.

Lashing out at the media and passionately crying prejudice for accurate descriptions of this crisis is a way to divert attention from the urgency of addressing the needs of patients in the state’s involuntary care and custody.

The ultimate stigma is unequal access to care.

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  • Jan Santor

    The Governor cannot control the media. To chastise them for reporting what legitimate sources (mental health professionals)have told them; is unconscionable. This attempt to curtail the press and freedom of speech is an egregious over-stepping of his authority as Governor. This state needs a facility for the criminally insane and a facility for those severely and profoundly affected by mental illness, but; who do not have a propensity for criminal activity. The ACLU will have a field day with this one. The people have a right to know the honest opinions of professionals in any situation and the media has the right to report those opinions. This breeches the cornerstone of constitutional rights. How dare he!!
    DISCLAIMER: I am not an ACLU member or a subscriber to all of their endeavors and doctrines, just a citizen who does not want our freedom of the press curtailed by an authority figure who serves his own agenda by attempting to do so.

  • Dave Salathe

    Is it possible for the state hospital patients to be housed at the governor’s house, or maybe at his travel company? They won’t be a bother to him and it’s all good and safe. Mr. Spaulding has a pretty big place too I think. He would want to help too.

  • Alexandra Forbes

    I agree with Anne Donahue that there is a special urgency for the needs of people in this kind of crisis and for the hospitals that don’t have the right facilities.
    The Governor and the Department of Mental health must create or find the adaquate site and staffing for this particular population as soon as possible. The needs here should take top priority.

    Alexandra Forbes
    legislative Chair
    Vermont Psychological Association

  • Heather Cobden

    I am an RN on the psychiatric unit at FAHC. This article is PRECISELY what I’ve been saying all along, ever since the flood when my coworkers would fret that policy-makers would decide that this was their chance to close VSH permanently.

    Vermont politicians and decision-makers have NO CLUE as to the reality of this situation. The patients at VSH were a very specific population and they don’t belong in the general hospitals. We are not set up for them. Our staff is not accustomed to or trained for the increased acuity.

    The patients who have historically been admitted to a general hospital–suicidal, bipolar and experiencing the manic part of the manic-depression cycle, etc.–are put at a disadvantage because they fear the ones who are very acute and prone to violence(and for good reason, we have found). They hole themselves up in their rooms, they don’t socialize, they don’t go to groups. How is this current situation therapeutic for ANYONE??

  • ruth kaufmann

    Thanks to Ms. Donahue for this piece. I wonder how many individuals will be reluctant to accept inpatient treatment out of fear of the increased acuity on inpatient units. Just as it’s unreasonable to suggest that all mentally ill individuals are violent, It’s also unreasonable to suggest that no mentally ill individuals are violent. Without an acute care facility, I fear Vermont may opt to treat aggressive/assaultive mentally ill individuals as many other states do – by placing them in the corrections system.

    • Heather Cobden

      Ruth is right and it’s happening already.

  • Robert Duncan

    Ms. Donahue has completely and accurately described the issues and the Governor’s dissembling. This is a crisis for the State and for the individuals who work and are patients in the other hospitals,a neglect of responsibilities by the State.
    I wonder if she has ideas about how to reframe the debate and alter the outcome?