What Exactly Does it Mean to “Check In” for Mental Health Care?
Is it a locked, windowless room, or a spa? A psychiatrist explains.
"We all need to take time for a little 'me time,'" Britney Spears posted to her 21.7 million followers on Instagram on April 3. In the weeks since, rather than being hidden away, she has been seen getting her hair done and spending Easter with her boyfriend. Then came the wild speculation that Britney was being held against her will and, according to the hashtag that sprung up, needed to be "freed." In response, Spears herself spoke out in an Instagram video encouraging fans to "not believe everything you read and hear." "I'm trying to take a moment for myself," she said, kindly asking for time and privacy "to deal with all the hard things that life is throwing my way."
Her initial post was a vague and simple call for self-care, and the controversy that has followed has only confused what we presumed to know about the situation. According to the LA Times and Variety, Britney Spears' social media hiatus and "me time" coincided with her "checking herself in" to a "mental health facility" for 30 days.
This is not the first time that "checking in" for mental health care was used to describe a celebrity's decision to seek treatment, or just disappear for a little while. For example, in October, Selena Gomez reportedly checked in for treatment following an "emotional breakdown." Demi Lovato has checked in to treatment many times, most recently following her reported overdose in mid-2018.
But, what exactly does it mean to "check in" for treatment — and is it something non-celebrities do? If your idea of in-patient treatment is based on TV narratives or movies like Girl, Interrupted, you're probably off-base. Perhaps you're wondering if it's a locked, windowless-room situation, or more like a spa. The short answer is: neither. The long answer is, it depends on the patient and the facility. While I cannot make any assumptions based on individual celebrity cases, or anyone I haven't evaluated, as a psychiatrist, I do have experience with what it means to "check in" for treatment, whether you're rich and famous or not.
Why Do People Check in for Treatment?
I like to think about hospitalization as the safest place you can go when you are too sick to be at home. If you had a cold, you might be able to tough it out or see your doctor for a quick visit, but if you had debilitating pneumonia, you'd need more intensive care. This is the same for mental illness. Many people have symptoms that can be managed with occasional or even regular outpatient care with a therapist and a psychiatrist, but when your symptoms do not respond to this treatment, or worsen and become incapacitating, you need to go into a hospital or residential treatment program.
People go into 24-7 treatment for a few reasons: The main one is to receive focused, intensive care provided by therapists and psychiatrists who are experts in a specific illness. There are specialized programs for everything from drug and alcohol dependency to disordered eating, bipolar disorder, OCD, trauma, depression, and psychosis.
Other reasons to go into treatment include the need for immediate safety: in the hospital, a patient won't have access to ways to harm themselves or others; or the need for medical monitoring, for example tracking blood pressure, heart rate, or lab tests while detoxing. It can also be a place for someone who's suffered with disordered eating to begin eating safely again with guidance. In this kind of setting, patients are cared for by a large, multidisciplinary staff of providers, including psychiatrists, social workers, nurses, and medical doctors, which makes it possible to track side effects and quickly adjust treatment plans as needed.
Where do people go for this kind of treatment?
There are two main types of inpatient psychiatric treatment facilities: a hospital and a residential program. The hospital programs often occupy a floor or area within the same place you'd go to the ER. This often surprises people, that while you're getting your broken arm set in a cast, elsewhere in the building patients are locked in for round-the-clock monitoring. This is where the more urgent cases go: people who may hurt themselves, or those with psychosis or mania off of medication. This is often where people go when they did not voluntarily agree to treatment (more on that in a minute).
A residential program is separate from the hospital, often on expansive grounds dedicated purely to psychiatric treatment, which lasts for a prescribed amount of time (like 28 to 30 days). This setting can feel less sterile than the hospital, and offers a bit more freedom. Patients here have to be sick enough to not be doing well with outpatient therapy, but not so sick that they should be in the confines of a locked psychiatric ward.
Then there are the quote-unquote "treatment centers," which are really just fancy, full-time spas for rest, relaxation and a break from paparazzi. Here, a person might be juice cleansing and doing yoga. While this is nice for self-care, it would not actually treat any serious mental-health condition.
What Is Inpatient Treatment Like?
Patients often ask the same questions about inpatient care: Does someone follow me around everywhere I go? Am I allowed to leave? Can I still talk to my friends and family? Each answer is, it depends.
Day-to-day differs immensely between an inpatient hospital and a residential facility. The bland room with mainly just a bed and some furniture that's purposefully heavy so people can't throw it? That is in an inpatient locked ward. There, you are regularly monitored (every 15 minutes up to every hour) and the doors to leave are actually locked. This may feel restrictive, but, again, it is for the people most at-risk.
Treatment in this kind of hospital setting can be voluntary or involuntary. Involuntary treatment, which fans were concerned Britney Spears was undergoing, is governed by state laws, but typically occurs when someone is thought to be a danger to themselves or others, or unable to take care of themselves due to psychiatric reasons. But it's not as if one doctor (or relative) says "lock her up!" and off you go. Patients do have the opportunity to challenge a physician's determination that they require this kind of care, and a judge will decide. The other way that "someone" decides whether a patient should be under supervision is a "conservatorship," which some believe Spears to have in place. This is a longer term loss of decision-making power in which a court appoints someone else, like a family member, to make decisions about a patient's care. Again: Britney Spears has not said this herself, and has simply asked for her fans to respect her taking time away for much-needed care.
Residential treatment is almost entirely voluntary, except in cases of conservatorship. That said, checking in usually means agreeing to stay the required length of time. Even if you are voluntarily there, you typically cannot just walk out.
In my experience, celebrities "checking in" are referring to residential stays, which can feel a bit like going to college or a nice sleepaway camp. The facilities look and feel like a place you want to go, instead of a place you have to or need to, with trees, ponds, and nature all around. There's a campus, and patients sleep in dorms. Patients are typically separated by gender, and bathrooms might be en suite or more communal (just like college!). There may be shared rooms, but in some private hospitals, you can buy your way out of that. One huge difference from dorm life is that hooking up is strictly prohibited — sex interferes with almost any kind of recovery.
When you arrive in any type of treatment facility, its staff will look through whatever you've brought with you, and you'll be limited in what you can bring in. Often items like belts (which are a suicide hazard), outside food (which can contain drugs), and smartphones are not allowed. Each facility has its own rules, and hospital settings are the most restrictive. Electronics often make the "not allowed" list, because they can interfere with your treatment, and with others' privacy (if you felt the urge to snap a photo of your potentially famous suite-mate, for example). There's usually a common room with computers, phones, and TV to use during down time.
In treatment, your day is meticulously planned by the hour, with the majority of the day spent in group therapy. Groups focus on specific skills (e.g. how to handle distress, recognizing and naming emotions, mindfulness), but they can also be occupational therapy, music or art therapy, or education about your disorder. No one, not even a celebrity, would be exempt from sharing and participating in group, and like all treatment, what goes on there is confidential. Outside of groups, there's individual therapy and personalized psychiatric appointments. There is typically time outside of therapy to socialize with each other, exercise, or have visitors, some of whom may be asked to come participate in care.
After some time in treatment, patients can earn the privilege of going off campus. So, it would not be shocking to see that Britney Spears went to get her hair done or spent Easter with her boyfriend. She had probably been in her program long enough to earn the time off. In a hospital setting, however, the "privilege" might be something like less frequent checks by a nurse, or being allowed time in the enclosed outside space that is part of the hospital unit — no leaving the premises.
Even in a residential setting, someone like Spears getting to leave doesn't mean she can just come and go as she pleases. Patients have to sign in and out, can only be gone during specific times and for short amounts of time, and would have their belongings searched when they return. They may be drug tested upon checking back in, if there was any concern they used while off the premises. There are often chaperoned group outings to add a bit of fun on weekends. I have seen people in residential therapy do everything from equine therapy to going to a baseball game to visiting a museum, all contributing to that summer-camp feeling.
How Much Does All of This Cost?
Simply put, residential treatment stays are expensive and the cost varies by how long you are there and any testing you need done (labs, medications, brain imaging are all extra). You are also paying for the food, a place to stay, and the staff of nurses, social workers, and physicians. It adds up, and quickly.
Some programs accept insurance, but that likely won't pay for all of it. Hospital settings are much more likely to be paid for by insurance than residential settings, because at that point of severity, insurance companies are more easily convinced a patient has no other options for treatment. Many residential programs are strictly out-of-pocket. One private hospital charges from $37,100 to 70,000 for 28 days in treatment. Costs in other programs seem to vary from $10,000 to $60,000 a month.
While the cost wouldn't be a concern for Britney Spears, for example, it does make this kind of treatment out of reach for many. Usually, if we have a patient who can't pay for needed treatment, we will first try to appeal to their insurance company. If we are denied again, which happens often, we will try to get the patient into the highest level of care that will be covered; this may end up being an intensive outpatient program where they receive full days of treatment but don't stay overnight. Sometimes, we have to wait for a patient to get "sick enough" to qualify for involuntary treatment — and then, insurance will cover it. It's unfair, and hard to watch as a provider, and certainly not a vacation once they finally get the care they need.
VIDEO: Britney Spears Breaks Her Silence Amid Rumors About Her Well-Being
But Back to Britney Spears
Who knows exactly what Britney meant by "me time" or why the care she's getting keeps being referred to as "wellness treatment." We can't know what level of treatment she is getting, whether it is a month at the spa or at a residential program where she had to earn her afternoons off, but, as she said in her Instagram post, she is "doing what's best at this moment."
I do not know the specifics of her case, but I do know that if someone really needs help, getting help is a positive, brave, and important thing to do. We should never talk about mental-health treatment as something a person needs to be freed from. People get it for a reason, and completing treatment is just as important as starting it in the first place. Perhaps #SupportBritney would be a less stigmatizing hashtag option — or we could use the old standby and, as she asked in her latest post, #LeaveBritneyAlone.
Jessi Gold, M.D., M.S., is a psychiatrist specializing in college mental health.