Frustration!
When someone says they are ready and there is no place for them to go.
When I decided to work in mental health, I knew that there would be heartbreak and frustration. I knew that there would be people who did not follow through, patients who were not ready to heal, and illnesses I could not help. What I was not aware of was that I would have people who wanted and needed treatment to stay alive who would have few options of places with beds available. Even worse, there would be beds available in places that could harm rather than help.
It is a weekly, at minimum, and sometimes daily conversation…so and so needs inpatient/residential/detox, what options do we have? After several phone calls we find ourselves considering how we can keep someone safe when we are an outpatient setting. We simply do not have the resources needed. Ask anyone working in mental health about this and they will all agree, but despite this, things are not changing.
North Carolina, where I work, is not known to have good access for those needing mental health care. There are waitlists for psychiatric providers and therapists, there are no beds available in inpatient settings and there are treatment facilities where people who are already in crisis experience inhumane treatment. A few months ago, I needed to have a patient admitted to keep her safe. She stayed in an ER for more than 24 hours. She was asked to wear paper scrubs. Her parents were told not to visit. She was sedated. She was discharged home by the on-call staff with no communication to me, her outpatient provider, despite numerous phone calls and a treatment plan that had been arranged for her post discharge. Another facility made headline news when several patients on the adolescent unit eloped and were missing for over 24 hours and in yet another facility, staff preyed on female patients taking advantage of those already vulnerable.
Outpatient clinics are not equipped to manage crisis cases. There are limited slots on schedules, no access to onsite medications, crowded waiting rooms without security. All too often the providers in outpatient clinics are faced with impossible decisions. The decision to see the crisis patient outpatient or risk they don’t seek care at all. The decision to send a patient home placing responsibility on their family rather than admitting to a dangerous facility. The decision about which medicine to use to most quickly stabilize a person because it’s safer than admission. The decision to detox a person using substances at home because treatment centers are often either full or cash pay with expensive price tags that are not affordable to many.
And here is the thing about being faced with these decisions in the outpatient world…
Because we care about our patients and want the best for them, we make these decisions. We spend hours calling inpatient facilities and investigating new facilities to see if there is a better choice. We calculate the risk versus benefits and ask our peers what they suggest. BUT, every hour we are on the phone looking for a bed, or having an extended visit with someone in crisis, or even allowing some recently discharged from a poor inpatient experience we are away from other patients. We are away from patients who are still early in their mental health journey that could avoid needing inpatient treatment if they had early intervention. We are not taking new patients desperate for help off our waiting lists. We are not researching new medications or getting more education. And all if these things perpetuate the cycle of poor access to care and a lack of beds for patients who need a higher level of care.
