A Mother Relies on Her “Connections” to Navigate the Complexities of In-Patient Hospitalization for a Child in Crisis. But What If Those Connections Did Not Exist?
December 17, 2018
December 17, 2018
Note: In this essay, the author uses “They” pronouns when describing “Mia.”
The text came in late in the afternoon. I anticipated a message much like any other that my eldest child sends from time to time, as they navigate studies and life as a young adult on the other side of the country. We’d been exchanging musical recommendations just a few days earlier…and I vaguely remember wondering what the latest ‘must listen to’ song would be as the text came in. Once I read through the message though, everything came to a standstill.
“Mama I’m going to the psych ward today w voluntary admission I’m on the phone with my therapist, but I’ve been hitting up the suicide hotlines like yesterday and today, so I have to go.”
Mia had been seeing a therapist for at least a year for depression and other mental health issues that they had identified in their sessions together. As Mia approached adulthood, there were occasions when they shared that “everything was too much” and that some days they wished they could sleep and “never wake up again.” Reflecting on these statements now, I feel shame that I hadn’t recognized these for what they were: suicide ideation, what psychologists define as contemplation of suicide, which can range from fleeting thoughts to more organized plans. After all, I’m a behavioral health services researcher and should have noticed. Although I’m not a psychologist, I work with a number of colleagues who are and that have considerable expertise in this area. Regardless, the text landed like a punch in the gut.
In my work with family members in Florida and across the country, narratives about the realization that an adolescent or young adult child has a mental illness is often characterized as one that brings shock and confusion, despite clues that seem clear to parents in hindsight. Once I put the phone down and texted my husband to discuss the logistics of flying out as quickly as possible, my mind focused on one key question. What do I do next to best help my child? To be sure, there were other (darker) questions that I could have entertained right then. However, focusing on concrete steps helped me to stay as calm and as clear as one can be in such moments. I thought about Mia and the fact that they had the strength to hold on for two days, despite an impulse urging them not to. Then I began contacting people that knew much more than I did about such events.
A senior colleague who maintained professional connections in California asked me a few questions after I texted him to get a better sense of what sort of professionals to look for and reach out to. One question and then, my response to it, still gives me pause.
“Does depression run in your family or [their] dad’s?” Pretty straightforward question…but my response was telling.
“Not sure about dad’s family. But my family is pretty typical Latino…avoid MH at all costs.”
Of course, this is a gross over-generalization. However, when I thought about my extended family and the ways that we have responded to crises, I could probably count on one hand the number of us that had been to a mental health professional. Most aren’t even open to discussing challenges in this regard. That’s not to say that we haven’t experienced serious issues…it’s just that going to a doctor to address them didn’t ever seem like an option for one to take or even, to suggest to a loved one. Mental health stigma in Latinx communities is broadly recognized by researchers as a considerable barrier to help-seeking in times of mental illness, especially among first- and second-generation immigrants. Young people who are conversant in the ways of their peers and this country, however, can be more willing to seek help when they know where to go. This was the case with Mia, who was informed by several friends about their own crises and their experiences seeking help. As a result of this support, Mia prepared by identifying a trusted friend to connect with me once they were admitted for hospitalization and learned when they could use the phone to call family and friends, once admitted. Therefore, I received a quick phone call shortly after I arrived in state to inform me about visiting hours (one hour each afternoon on weekdays), as well as an update on how Mia was feeling eight hours after admission.
As many people find, the process of a psychiatric hold can be a disorienting one that seems designed to curtail any sense of urgency on the part of the person experiencing a crisis. I write this knowing full well that the policies used by psychiatric units are meant to ensure well-being and reduce threats of harm to self or others on the part of individuals who have expressly stated such intent. Following admission, all of Mia’s belongings were taken from them. However, clothes brought to them by a friend and by me were lost for most of their stay. During this time, Mia was heavily medicated for a number of suspected conditions, resulting in prescriptions for three drugs and a sleeping pill based solely on intake information gathered. (This cocktail, we would learn, was highly damaging to Mia’s stomach and brought on a series of symptoms associated with a previous gastrointestinal diagnosis less than a week later.) Further, as we approached what we thought was the end of Mia’s 72-hour stay —the typical length of stay for a voluntary admission— we learned that Mia might not be able to leave at that time, after all.
The day before their originally projected discharge date, Mia was told that they were required to have a documented appointment with a psychiatrist to provide follow-up care before they would be discharged. There were a few challenges associated with this requirement. First, a large packet with information on local providers was given to Mia late in the day on a Friday, when most medical offices would be closing. Making any calls would have required them to miss visitation with family due to limited access to unit telephones. Also, they would have had to make these calls without their insurance card and other information they might need when making medical appointments. When I arrived for visitation that afternoon, Mia asked me to accompany them to speak with the nurse. During this meeting, I noted that it seemed unrealistic to expect patients to schedule these appointments as a condition of release when many had only recently experienced a crisis and were heavily medicated. I also noted that the logistics of making these calls on top of this fact, made this requirement seem like a challenging task for most. The nurse said that she understood my points but stressed that the requirement was based on policies to ensure patient-led care. She told me, however, that she would discuss our concerns with the psychiatrist.
The following day, which would have been Mia’s date of release, we also learned that at some point during their stay, Mia had been asked to sign a form acknowledging and agreeing to a recommendation for an additional stay (with no clear indication as to length of stay or treatment protocol). Effectively Mia’s stay changed from a voluntary one to an involuntary one once they signed this form. During what had become our regular morning call, Mia asked if I’d speak to the psychiatrist about what they thought was a misunderstanding. They told me they were ready to go home and find a new psychiatrist and psychologist to address the issues that led to the crisis in the first place and that they wanted my help in doing so. To be quite honest, I wasn’t sure what the best course of action would be at that point. I wondered if an extended stay was warranted. However, Mia sounded and looked well every time we saw each other and assured me that staying in the hospital for additional days would not help in furthering their recovery. They told me that working to find new providers at home and which I could help them vet would be best for them. Despite my hesitance, which I explained to Mia, I agreed to talk with the psychiatrist, who called me a few hours later while I was waiting for visiting hours to begin. He said only that it was important for me to speak with him about Mia, and I told him that I was already on the hospital grounds and could talk with him as soon as he was available.
Truth be told, I was nervous about this meeting. In the first place, although Mia and I have what I would characterize as a very close relationship, I wasn’t sure if there was more to the story than I could see with my own eyes at visitation. After all, hadn’t I missed signs of distress earlier? I also worried that this doctor might only want to meet with me as a courtesy. However, Mia had had the insight (and trust in me) to sign a consent form allowing the care team to consult with me in all matters. In addition, once I told the psychiatrist that I conduct behavioral health services research, he seemed to relax his initially guarded demeanor. He then explained some of the decision-making that went into the medications provided to Mia, patiently explained each one of them and some of their potential side effects, gave me some advice on signs of renewed distress to look out for, and asked if I felt equipped to help Mia make follow-up appointments and re-adjust to daily life after hospitalization. It wasn’t long after this meeting that Mia and I left the hospital.
Mia’s recovery continues, and thankfully, three months later there have been no signs of distress that might lead to another crisis. Despite some challenges, reflecting on this time in our lives has led me to consider the ways in which our story might have varied had a few of our circumstances differed just slightly. Had I not had professional knowledge of or personal experience with mental health services, I might have advised my child to avoid hospitalization at any cost upon receiving that urgent text message. Worse, I might have taken the opportunity to minimize Mia’s cry for help in a way that could have resulted in a very different and likely, tragic outcome. And yet…although our experience has been a positive one, very few of my family members know that I flew out to California with less than 8 hours’ notice in September to support Mia. Mia decided early on in their recovery journey that they didn’t want to hear from well-meaning grandparents and other relatives with wrong-headed advice or platitudes. (No pienses así, niña. What does someone your age have to worry about?) I continue to respect Mia’s decision about who to tell about this experience. However, I wonder whether keeping quiet about this situation doesn’t help to strengthen existing stigma in my family. After all, direct experience with difficult life situations can teach us new ways of knowing, new beliefs.
Beyond the cultural considerations of mental illness and help-seeking within my own family, I think about where we’d be without the trusted colleagues who connected me and guided me before I arrived in California. Would we have had the good fortune to find the well-regarded providers that Mia is now seeing without my connection to the local county mental health services director? I may never know. Aside from his recommendations, what I appreciated most was his honest counsel on what to expect with regard to long waiting lists for many local providers, some of whom don’t accept insurance of any kind.
Despite some initial concern, I’m privileged to have fairly good health care coverage, and most of the recommended providers were available to us. Yes, Mia did have long wait times for appointments. For one doctor, the wait time for getting on the wait list was eight weeks; for the other clinician, it was only four. However, we were able to secure spots for eventual appointments five days after Mia’s discharge. What of other families with no social capital (e.g., “connections”) to prepare them and help them navigate the local mental health care system? In addition, my experience with the psychiatrist that gave authorization for Mia’s discharge might have been much different had I not had the sense to give him my credentials, known what to ask, and clarify next steps with him. To be fair, this man is by all accounts, a compassionate professional that is easy to talk to and genuinely cares about the people in his care. Yet, I have to wonder if he and/or the mental health director would have taken as much time as they did with me had I not had the connections and knowledge that I relied on so heavily throughout this trip.
It’s also not lost on me that my cultural capital (that is, the knowledge that we use to make our way in the world, particularly institutions such as our service systems) has been transferred to Mia, to some degree. Mia chose to go to one of the best local hospitals with a well-regarded behavioral health unit. Throughout their life, they have been fortunate enough to have good insurance coverage, access to quality medical services, and some familiarity with the process of identifying medical providers. Despite some of the challenges they experienced, Mia knew to leverage the information their friends gave them about their own stays in a way that helped them to learn quickly about hospital rules and policies, as well as to place stock in the care and treatment that they were being given. This might not have been the case had they learned to fear or distrust health systems at a young age.
While we’ve been fortunate throughout this experience, I’m also fairly certain that we are, unfortunately, not the norm. This is especially the case among families with limited or no insurance coverage, who live in communities with few quality providers, and/or who’ve had previous negative experiences with local mental health systems. As a result, I’ve gained a renewed sense of commitment toward working to support young adults and their families—especially those from communities with high rates of unmet mental health needs. Raising awareness about signs that we should pay attention to is critical; after all, even with my training, I overlooked some of Mia’s early symptoms. However if we are to ensure that more young people get to the services and supports that they need and deserve, then we must all push for systems that go beyond treatment and service delivery. While evidence-based interventions and medications are important, what made the difference for us were the people who took the time to explain things in terms that were easily understandable, and who were also willing to listen to our concerns and respond to them in a respectful manner. Sadly, for many people that don’t have the social and cultural capital that I do, such human connection in our service systems, while vital, is often limited or non-existent. We must do more if we are to truly ensure that our mental health systems address the needs of all young people.
Linda M. Callejas is a socio-cultural anthropologist with expertise in qualitative methodologies and community-engaged research. As an Assistant Professor at the University of South Florida, she conducts research and evaluation in the areas of behavioral health disparities, innovative practices/interventions designed to increase engagement among critically underserved populations, and collaborative community initiatives designed to improve health and well-being. Dr. Callejas is especially interested in understanding how aspects of the social environment in urban neighborhoods affect residents’ mental health and well-being, particularly in cities experiencing large-scale redevelopment. She has also done extensive work studying how community residents work within their neighborhoods to provide support and assistance to their neighbors in marginalized communities.