Nothing Has Changed in Psychiatry

I know people who have been locked up in a psychiatric institution. Not voluntarily. Not because they wanted to be. Because a doctor decided they had to be.

I won't go into who, or where, or why. This isn't about one person. It's about a system.

One Flew Over the Cuckoo's Nest

Ken Kesey's novel came out in 1962. Miloš Forman's film in 1975. Half a century ago.

What strikes you when you see a locked ward from the inside today: almost nothing has changed. The hallways are cleaner. The furniture is newer. The medication has different names. But the shape of it is the same. People in crisis are placed in a building with other people in crisis. Uniforms change every shift. Procedures take priority over conversations. And if you don't fall in line with the routine, you are the problem.

McMurphy sat among people who didn't know him and didn't want to change anything about him. Today it still works exactly the same way.

How it actually goes

Pills get prescribed by people who haven't spoken to you. Not once. Not for five minutes. The information comes from a nurse who heard it from a colleague who heard it from a night shift, who heard you say something while you were trying to sleep. On that basis, someone decides what ends up in your body.

Patient rights exist on paper. In practice they're theoretical. You have the right to a patient advocate, but they'll come tomorrow, or the day after. You have the right to a second opinion, but you're here now. You have the right to your phone, your clothes, your contact with the outside world, until restricting it becomes convenient.

And if you protest, the protest becomes a symptom.

What happens is plausible

People don't get better. People get worse.

That isn't an opinion. On a ward like that, I watched someone try to take their own life. In a place that was supposed to prevent exactly that. It wasn't abstract. It was a regular weekday.

Trauma in psychiatric care isn't rare. It's structural. A ward where strangers wake you up at night to take your blood pressure, where you don't know which face will be on shift tomorrow, where the routine decides and you follow: that doesn't heal anyone who came in already unraveled. It unravels them further.

What does work

What people in crisis need is no mystery.

Rest. Quiet. Routine. People you know. People who love you. A place where the same face that came in yesterday comes in again tomorrow.

It's a simple recipe. And it's exactly what the system doesn't deliver. The system delivers the opposite: rotating shifts, strangers, procedures, unpredictability. And then it acts surprised when the patient doesn't calm down.

Open source as a small step

Someone has to start.

I've built a platform where people who've been in psychiatric care can share their experience anonymously. It's called Patiëntenstem ("Patient Voice" in Dutch). It's on GitHub under an MIT license: github.com/JoostBoer/patientenstem.

It's not a startup. Not a product. Not something I want to host or make money from. It's code. For anyone. Pick it up. Build on it. Host it. Copy it. Do whatever you want with it.

If you work in mental health care and you recognize this story: take it. If you're a developer and you want to build something that matters: fork it. If you're a lawyer, journalist, policymaker, peer expert: use what comes in.

This doesn't fix everything. One platform doesn't change a system. But silence isn't an option anymore, and waiting for the minister isn't a plan.

Last thing

This isn't about me. It's about the people who are in there right now. At this moment. While you read this. In a building where the fluorescents are on, the routine is in charge, and the faces will be different tomorrow.

The system has to change. Not in ten years. Now.

And if the institutions won't do it themselves, we'll do it without them.