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How to get out of a mental institution

Introduction

Mental institutions provide intensive mental care which may be very helpful to some. However, many oppose such treatment. Some oppose the techniques which are used in such institutions, such as forced medication and ECT. However, the objection of ashers is usually more fundamental. Not all suicidal people have any mental disease, however, some mental health practitioners will equate suicidal tendencies to mental disease. In such cases, involuntary hospitalization can be viewed as a form of political coercion which has little to do with mental health. On top of this, the decision to hospitalize, or to release suicidal patients from hospital, is difficult for therapists to make, since they may be liable if suicide occurs. Therefore, their judgment tends to be on the safe side. This leads to hospitalization and treatment which may be unnecessary and even harmful.

Ashers may face the risk of being put into a mental institution without their consent. This may occur in the progress of treatment with a therapist, or if friends or family members feel that the individual is at risk of suicide. Even if you have gone to an institution voluntarily, you may find that it is not what you had hoped. The intention of this guide is to help you get out if you so desire.

However, this article is not suited for anybody who wishes to exit from a mental institution. If you are hospitalized because of some specific psychiatric diagnosis, then you might be confined to the hospital until you are "cured" from whatever the doctors think you have. In this case, determining whether you are "cured" depends on what you have been diagnosed with. A document aimed at helping you convince the staff that you are "cured" would have to address each mental disease separately. This is beyond the scope of this article.

This article is intended for those who are to be hospitalized based on their attempt to commit suicide, or because somebody thought they are about to commit suicide. Thus we assume that in order to exit the hospital, all one needs to do is convince the staff that you are no longer at risk of committing suicide.

Treatment Alternatives

To get out of hospital you should first know what are the possible alternatives you are striving for. This will also depend on what programs and institutions are available in your area.

Obviously, the best alternative to hospital is not getting there in the first place. It may be that you are first referred to a therapist for initial crisis intervention efforts. The ultimate goal of any crisis intervention is to convert a crisis ( in this case, impending suicide ) to a manageable situation that may or may not require longer term psychotherapy. Most of the guidelines which appear at the end of this article are suitable for handling such treatment in order to avoid winding up in hospital.

Hospitalization is the most intensive and intrusive form of treatment. There are other options for treatment, and you may strive for those which offer greater freedom. Partial hospitalization programs (day hospitals) are almost like hospitalization, but the patient sleeps at home. In outpatient treatment the patient receives individual medical care while not hospital-confined. Group therapy is another alternative, which may not be hospital-confined.

Outpatient treatment is the most commonly chosen alternative to hospitalization for individuals at risk for suicide. The rest of this section compares the advantages and disadvantages of hospitalization versus outpatient treatment, from the point of view of the therapist. A patient can utilize this by presenting his case such that the disadvantages of hospitalization, and the advantages of outpatient treatment are emphasized. In turn this may convince the therapist that outpatient treatment would be more beneficial.

The advantages of hospitalization for patients with suicide risk are:

Relative degree of safety from suicidal behavior inherent in the close observation available with hospitalization. This sort of protective custody may stop self-destructive impulses.
Provides the hospitalized patient a time-delay mechanism which is especially important for patients who are viewed as impulsive.
There is the possibility of lowered mortality.
Intensive, 24-hour therapy which is tailored to the patient's problem.
Treatment is provided such that the diseased is minimized in terms of duration, severity, etc. For example, the total duration of illness can be minimized

The disadvantages of hospitalization are:

Removal of the individual from the suicidogenic life circumstances may hinder treatment. When an individual is hospitalized, the immediacy of life stresses is minimized. As a result it is difficult to bring into day-to-day treatment the importance of these circumstances. So important psychological work involving these factors is postponed until the individual is returned to more normal living conditions.
Hospitalization offers a degree of gratification for the patient's dependency yearning This gratification is especially important in individuals who experience a great deal of conflict between autonomy and dependency. The gratification of dependency in the case of dependency conflict removes the very issues that are central to restoration of the individual to health.
Nursing personnel attest to the fact that everyone regresses to a certain extent when hospitalized.

Advantages of outpatient therapy for individuals with suicide risk are:

Treatment stresses responsibility placed on the suicidal individual for self-determination (in contrast to dependency gratification and tendency to regression in hospitals). It restores the individual as a responsible, functioning adult.
Minimizes disruption in personal life. Occupational and educational responsibilities can be met. Situations and interpersonal contacts continue and can be brought immediately into the therapy situation.
Minimizes stigma attached to mental illness which is amplified by hospitalization. Stigma may extend through family dynamics to neighborhood, or educational/ occupational workplace.
May mobilize support resources that otherwise may not be utilized.

The disadvantages of outpatient therapy are:

Increased burden on family and member of support system, for example, in the form of anxiety.
For the therapist, Added burden of uncertainty about about welfare of suicidal individual.
Increased dangerousness due to self-harm.

How Clinicians Assess Suicide Risk

Psychiatric Interviews play a crucial role in determining your fate. These interviews can be held to decide if you are to be committed in the first place, or, if you are already inside the hospital, to determine the duration of your stay.

Based on the patient's psychiatric history, and on psychiatric interviews, clinicians assess the degree of suicide risk by focusing on the following points[1][2]:

Therapeutic Alliance: The individual's ability and willingness to accept help and personal motivation for change with respect to suicide risk, The individual and intervener should be on the same side.
Patient's Judgment: Patient's own judgment of the level of intentionality and of subsequent short-term risk, plus the professional judgment of the reliability of that individual's account.
Supporting Resources: supporting resources both within the personality and in the external world, that work to counteract suicide by offering affirmation and admiration[1] . Since the loss of these resources may trigger suicide, the clinician can try to detect such lost resources, and restore or replace them by providing encouragement, support and (for permanent lost resources) mourning. An important part of the assessment is the assessment of the availability of support resources outside the hospital.
Patient Characteristics: Traits which may contribute to vulnerability of suicide, such as impulsiveness, denial, emotional stresses, depression, hopelessness, pessimism, lack of future orientation, capacity for reality testing (under normal conditions and during times of stress), the stability of their identity, and their characteristic mechanisms of defense and functional effectiveness. For example, how realistic are the patients assessments of the worth and availability of the sustaining resources that remain accessible to them.
History: The patient's past responses to emotional stresses, particularly losses. These losses may be either part the normal process of life, such as the movement towards adolescence away from the parents, or they can be unexpected such as the death of a loved one. The patient is examined for capacity to deal with separation, grief, disappointment or failure, and the capacity to mourn and ultimately accept these losses.
Formal risk factors for suicide: For example, unemployment, living alone, significant medical illnesses, and marital status of separation, divorce, or widowhood. Statistically, people with such traits are more likely to commit suicide.
Assessment of the patients vulnerability to three varieties of affect closely associated with suicide: aloneness, self-hatred, and murderous rage. In addition assessment of factors that may help patients to cope with these, without turning to suicide.
Assessment of the emergence and emotional importance of death fantasies.

Your job is to affect as many factors as possible, in order to leave the impression that you are not at risk of suicide.

Supporting Resources

Support resources include other people, work, and positive aspects of self ( such as physical prowess or intellectual capacities). Suicide-vulnerable persons may depend on others to support their self-esteem. Other patients may depend on a highly valued career.

Such resources of self-soothing and self-worth, must be restored. Exterior sustaining resources may be seen as replacing what the patients cannot provide for themselves. However, when external supports are to be relied on, the therapist is obliged to informing and rally the appropriate individuals. This requires first, the consent of that individual for the outreach efforts. If the individual at risk is unwilling for these contacts to be made, the need for hospitalization may seem greater.[2]

Note that even if there may seem to be available support resources, it may be the case, for example, that the family is not prepared to accept the burden of relating with and caring for a family member at risk for suicide, or that the employer, the school, or the neighborhood are not willing or able to provide needed support [2].

Personal Characteristics

Patient impulsivity is the enemy of the therapist. Without impulsivity, even if the situation of the patient is bad, the clinician is at least consoled with the certainty of the situation, which provides a sound basis for action. But when impulsivity is added to the picture, the therapist may find it impossible to realistically assess the risk of the suicide. In such a case, the judgment is likely to be on the safe side, i.e., hospitalization.

Impulsivity is usually evaluated by checking whether the history of the patient displays impulsive behavior. To evaluate impulsivity the therapist may also ask questions such as: "What do you think you are going to do?", "Do you think you are going to be safe over the next several weeks?", "In your judgment are you able to resist these impulses?".

Another characteristic of importance is the degree of denial of the suicide risk. When the degree of turbulence in the life is denied, and the seriousness of suicide ideation, threat or attempt is minimized, the need for hospitalization may be considered greater [3].

The degree of hopelessness, pessimism, and lack of future orientation are also key issues during assessment of risk[4]. With their existence the need for hospitalization may be considered greater.

Other indications which may increase the chance of being hospitalized are: agitation or anxiety at the level of panic, social isolation, substance abuse, situational stress, a history of suicide attempts, a family history of suicide attempts, having left a suicide note, and alcoholism.

Basis for Hospitalization

Hospitalization is likely when there is failure of response to crises intervention efforts, as applied by a therapist. Failure can occur for one of two reasons, either it has not been possible to establish a reasonable treatment alliance with an individual at risk, or if despite the existence of such an alliance, the patient continues to express overwhelming immediate intent to suicide. One or two hours in session with an individual is sufficient to discourage most therapists, who then resort to hospitalization.

Another reasonable basis for hospitalization for patients with suicide intent is when there is a diagnosis of a disorder that optimally is treated with hospitalization, regardless of whether suicide risk exists. Such is the case, for example, for major depression, manic-depressive disorder, and psychotic presentations.

Finally, hospitalization is likely when it is judged that for the particular case the advantages outweigh the disadvantages (also, see above)[2].

Guidelines

The basic strategy is to play along. Do not start fighting back or argue with the staff. They will not let you out, if you are "treatment resistant". Try to express hope and optimism. Do not deny that you are/were at risk of suicide and that this is a serious problem.

The following are points for behavior and communication with the staff in general, and psychiatric interviews in particular.

Body Language

Make good eye contact, this is the first thing they check.
Make sure your expression matches your mood.
You must avoid seeming smug, cynical or superior, as this may indicate that you are not on the same side as your therapists.

Reality Testing

Be prepared to answer questions like the date, the name of the president, your age, etc. You may also be asked to do some basic math problems or interpret some common sayings.
Do not exaggerate when praising the treatment, your therapists, or other support.

Establishing Alliance with Doctors

Express seeing treatment itself as a source of hope.
Present yourself as truly fighting to be alive.
Appraise the therapy realistically as a potential, but not magical source of support.
Ask the examining doctor if it is possible to feel better again, this means you are hopeful and interested in recovery.
Tell the shrinks you like them, that they are helping you and you want their help, that the drugs are helping, that everything is fine, that you really appreciate their intervention.
When discussing your failed attempt you should look ashamed, say how sad you are and weep, express regret and say you cannot believe you did such a thing.
When you are asked if you have any plans to harm yourself, look stunned and say something like. "I cannot even imagine what I would do. I certainly would never do attempt suicide again."
Make sure you say something like "I cannot believe I stopped looking for help." or something that expresses you know there are alternatives to suicide.

Lowering Perceived Impulsivity

You may be tempted to act as if there is nothing wrong with you neither now nor in your past, and therefore you should be released from hospital. However, assuming that you were hospitalized due to an attempt, this may convince your doctors that your attempt was impulsive, so they will not release you quickly. A different approach might be to admit to a problem in the past which caused your attempt. This will give the therapist some motivation for suicide, and reduce the reason to explain your attempt using impulsivity. All that remains is to convince your doctor that you have gotten over the problem, or at least are beginning to see a way out of it.
Do you have a history of being impulsive? If so and if it is possible, do not disclose this. Otherwise, if it is mentioned try to gloss it over.
Be prepared to answer questions such as: "What do you think you are going to do?", "Do you think you are going to be safe over the next several weeks?", "In your judgment are you able to resist these impulses?".

History

Since an attempt might be viewed as a response to a crisis, you might be asked for how you dealt with crisis in the past. These crisis may be due to normal development or due to tragedy. If you have experienced losses, you should be try to be perceived as having "mourned over" yet ultimately accepted the new situation.

Plan for the Future

Planning for long term future shows that you are not planning to commit suicide. Your plans may be about eliminating what therapists might consider as risk factors. If you are single, you can plan to date and eventually get married. If you are unemployed you can plan to get a job. If you have some physical illness you can plan to treat yourself as best as possible. If you are lonely you can plan to start going out with friends. If you are alcoholic, you can ask for referral to an appropriate support group. You do not have to follow your plans, but planning may calm your therapists.

Tactics for getting out of Hospital

You may choose to present the reasons for your suicidalness laying solely outside the hospital. Since you do not come in contact with the outside world while inside the hospital, you are feeling great, so there is not much more that can be done for you inside the hospital. Further treatment must continue outside, in order to deal with what ever is bothering you outside the hospital.
An opposite approach is to present hospitalization as very harmful to your life since you cannot live up to your responsibilities at work, school, etc. This worries you and distracts you from efforts to get better.
Mention possible support resources outside the hospital such as friends, family, work, or the ability to express parts of you which provide comfort, outside the hospital. You can portray the lack of these supports as depressing and thus harmful to your recovery. Note that you must accept the possibility that your doctor may want to contact some people which you consider supportive. If you disagree, this may prolong your stay in the hospital.
Ask the doctor if they have a social worker who can help set you up with an outpatient shrink.

What Not to do

Do not express idealization or fantasies about death.
Do not disclose self-hatred, rage, and aloneness.
If possible, do not disclose previous suicide attempts, or suicide incidents in your family.

USA specific information

Buy health insurance that does not pay for very much, if any, mental health treatment. If the institution is not getting paid, they will let you go.
If you are under involuntary outpatient commitment (IOC), that is, living out in the community but being forced to take drugs/treatment, just move to another state. Then they cannot do anything. While you are moving, perhaps it is worth to go to a state without IOC. Maine has the least restrictive mental health laws.

Conclusion

As you have seen, there are many guidelines for helping one exit a hospital. Some of the recommendations are contradictory. The choice of how to present your case and what guidelines to use depends on the circumstances of your particular case.

If you are required to lie, it is a good idea to base your story upon events in your real life. This will give your story authenticity so you will not need to brush up your acting skills.

If you manage to get "into character", you might get a quick release from hospital and return to your (very supportive) family and friends. And according to plan, you get married and find a great job. You just might find the whole experience very worthwhile. :-)

REFERENCES

[1] Cristopher G. Lovett and John T. Maltsberger, "Psychodynamic Approaches to the Assessment and Management of Suicide", In "Suicide: guidelines for assessment, management and treatment", edited by Bruce Bongar, 1992.

[2] Betsy S. Comstock, "Decision to Hospitalize and Alternatives to Hospitalization", In "Suicide: guidelines for assessment, management and treatment", edited by Bruce Bongar, 1992.

[3] Kiev, A. "Cluster analysis profiles of suicide attempters", American Journal of Psychiatry, Vol. 133, 1976.

[4] Beck A. T., Steer R. A., et al, "Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation", American Journal of Psychiatry, Vol. 142, 1985.