The Profitable Business of Holding Patients Against Their Will
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A Times investigation into a leading chain of psychiatric hospitals in the U.S. reveals a world where profits trump medical needs and patients are detained against their will. Today, my colleague Jessica Silva-Greenberg on the story of one woman trapped inside. It's Thursday, September 26th.

So, Jessica, earlier this year, you started looking into abuses in the mental health care sector. What made you dig into this one major chain of psychiatric hospitals? Well, I'm an investigative reporter on the business desk, and I look at how big businesses collide with ordinary Americans and basically how those companies affect their lives. So last year, my reporting partner, Katie Thomas, and I, while working on another series of stories about health care, got a tip.

It was more of a whisper. It was something like, you guys should take a look at a company called Acadia Healthcare. At the time, that honestly didn't mean that much to us. We had no idea what Acadia was, certainly not a household name.

But when we started digging in, we got actually really interested because it turns out that Acadia is one of America's largest chains of psychiatric hospitals. I mean, I have never heard of Acadia. So what's the story of this company? So the story of Acadia is really a broader story of how Americans today receive mental health care. So Acadia gets its start in 2005. And it's...

Entering this new niche because mental health care used to be provided by essentially two big groups, nonprofit hospital systems or the government. But, you know, over the past decade or so, as costs have risen and demand has increased, those players are stepping back and they're closing psych wards. And Acadia is one of the for-profit players that's stepping into that gulf.

And Acadia grew slowly at first, but in 2011, the company goes public, and the timing couldn't have been better. ♪

At the time, Obamacare is being rolled out. And Obamacare requires insurers to cover mental health. And that coverage brings in billions of dollars into the market. And Acadia gets a boost from all of that money. They are now so big and they've had so much growth, including through the pandemic, that today they're valued at $7 billion. And they are everywhere.

You know, they are in 19 states and chances are if you as a patient need mental health care, you might very well encounter an Acadia hospital. Jessica, so far, all of this sounds kind of like a win-win, honestly. More money to cover mental health and a corporate success story.

So what did you actually learn when you started to look into those whispers you mentioned that something was going on at Acadia? Well, even though Acadia is this enormous publicly traded company, it wasn't that easy at first to get a window into its operations.

So what we started doing was we started putting in freedom of information requests. We requested all manner of things. Health inspections, complaints to the attorneys general in every state where Acadia does business, every state where they have inpatient psychiatric hospitals.

And once those documents started coming back, we started to hear similar stories again and again that started to give us a window into how this really profitable company was making decisions around how to provide care to this very vulnerable group, people who are really in crisis. And maybe the best way to understand this dynamic is to look at the case of one woman.

Yes, I am Kathy McKenzie. I'm 51 years old. Named Kathy McKenzie. And I live in Wesley Chapel, Florida. She's a school social worker. From a very young age.

It just made me happy to help other people and see them accomplish their goals. And throughout her life, since her 20s, she has struggled with bipolar disorder. And her first episode was when she was in her 20s. And at the time, she was playing volleyball pretty intensely. The pressure of it was a new team for me.

became overwhelming. Her commitment, her excitement about volleyball morphed into a kind of mania for her. She started having these notions of grandeur. I was saying to my mom over the phone, I'm jumping higher than the other kids. I'm hitting harder. I'm thinking that I'm far surpassing my other teammates when that wasn't true at all.

And when the reality of her situation kind of began to intrude, when she started to grapple with how she had these very grandiose elevated thoughts, but those weren't really consistent with reality, she crashed. And my mind is like so dark. And I remember my father picking me up from Richmond to get me up to D.C. to a hospital.

And I even said, I just want to go to heaven. I just want to be with my grandfather. Just let me go. Let me go, daddy.

I just literally collapsed at the doors of the hospital. And I remember him screaming and yelling and asking for help. And at that time, she's briefly medicated. She realizes this is something that she's going to live with. I really want to study it. I wanted to understand it. So she harnesses it. And I think that really also drove me towards social work even more. Being sympathetic to something that you personally struggle with.

And ultimately, I try to overcome. And so rather than be a hindrance, it's actually something that fuels her conviction and her commitment to her passion, which is her career as a social worker. And things are going well. I have a really good plan of action to take my medication. I don't miss anything. I don't get confused by it.

If I feel that I need somebody to talk to, I have a group of girlfriends and a support group. Then fast forward to 2020. I had so much excitement surrounding this job. She gets this great job and she moves to Florida to be closer to her mom. I have a very tight connection with her. The two are very, very bonded. Always have, and I've always felt calmer about it.

Yeah, that felt great. But like we all know, moving is stressful. It's one of the biggest stresses in a lot of people's lives. And this move is particularly tough. She moves, she doesn't immediately have a doctor, so her care is a little bit fragmented. And her mom notices that

That she's sleeping less. I had a slight elevation in mood. She's talking really quickly. They were picking it up on a little bit of rapid speech. Which is typically a red flag for her family. A little bit of excitement, you know, maybe a little bit above the normal. And her mom and her sister decide that she should probably go see a doctor. I didn't.

want to go. I didn't feel a need to go. But again, you do what your family feels is best sometimes. And what they want is they want a physician to assess her bipolar medications and see if they need to be tweaked or adjusted given her new situation. I mean, I actually drove myself to the hospital. My mom went with me. You know, it's the middle of the pandemic. So we're firmly in 2020. It's the summer, August of 2020. And

No one is allowed to go in with her to that emergency room. You know, I went in with my water bottle, my phone and my medicines and a little note from my mother and just kind of like, OK, I expected to be in and out of there quickly. So at this point, no one has any reason to believe anything has gone awry. But when Kathy ultimately sees the doctor in the emergency room, that doctor wants to send her to another hospital to have her get a psychiatric evaluation.

And is that normal? Increasingly, it is. Since the pandemic, emergency departments like the one that Kathy went to have been overrun with people who are seeking some kind of mental health care. They can be in crisis. They could be seeking like Kathy was to get, you know, medication evaluations. And so those emergency departments, because it's not really their area of expertise, are outsourcing that care to hospitals like Acadia. And then...

A couple young gentlemen showed up with a gurney, and then they said, you have to do this to get transported to have the evaluation. So she's sent to another hospital for a psychiatric evaluation. And so I wasn't strapped in or anything like that. They just asked me to get on, and I did. The hospital she's sent to is North Tampa Behavioral Health. I believe I arrived about 1 a.m. It was dark and just totally uninviting and scary.

Very scary. And, you know, they let me just walk in. I had my purse. I had my phone. They take her to a small room and the intake person there starts asking her very standard questions as part of this psychiatric evaluation. Are you feeling, having like thoughts of harming yourself? So she's asked whether she has any suicidal thoughts or

And plans to harm herself, to which she answers no, and that's reflected in her medical records. Do you take medications? Do you have a medical diagnosis? And she's also asked whether or not she is homicidal, whether or not she has any imminent plans to harm others, to which she also answers no. It was a fairly brief interview. I felt that I answered questions very appropriately.

And the young lady said that I did. They're trying to evaluate whether a patient is a danger to themselves or is an imminent danger to others. If patients meet either of those, they can be held against their will under what are called involuntary commitment laws for up to 72 hours. As a social worker, Kathy is pretty familiar with this process.

And she thinks she answers the intake questions pretty well. But still, there's something about the whole episode. She's there in the early hours of the morning and something in her, some spidey sense kicks in. At that point, I had pretty much kind of figured this out. And she thinks this evaluation is strange and maybe it isn't going as well as she'd thought. My suspicion is...

went off and I thought, oh my gosh, they really are going to hold me. So Kathy decides that she's going to kind of test how they treat her. I wanted to test the waters, so I asked to go to the restroom. The staff at North Tampa Behavioral agree to let her use the bathroom. But when she leaves the interview room, she ends up in another room with 10 other people. This is not a bathroom. This is not a bathroom.

There was a woman with a blanket and there was like one window and there was literally only like one or two chairs and there had to have been 10 of us maybe. I think the moment that is especially chilling for Kathy is when that door closes, they lock the door behind her. Could you hear the door lock? Yes. And I screamed and I yelled and I screamed.

I want to see my paperwork. I want to see my paperwork. This isn't, you've got this totally wrong. So Kathy is basically institutionalized against her will in North Tampa behavioral. That's right. She's been held against her will. She is trapped. It's the worst claustrophobic feeling and lack of control on steroids ever.

It makes you instantaneously think your life is a turn towards something that you never, ever thought. I've never been arrested. I've never had any level of involvement in any negative way with law enforcement. I thought, oh my gosh, my career is done. So what happens to her?

So she's first placed in a room with another woman and that other patient was on suicide watch. And that's her first night there. Yeah, they took everything from me. They gave me one sheet where I quickly jot down phone numbers that I wanted. And, you know, I wanted to call them and tell them that I was physically okay at that point. But I was not allowed to do that.

And I just had to sit there for the whole night. So over the next couple of days, she falls into a kind of routine. There would be breakfast, lunch, dinner. You would have to walk military style to the dining hall.

I was constantly going to the nurse's desk and said, I want my rights. Like, I want my records. I want to talk to my family. I want to make a phone call. And then they'd say stuff like, oh, you're a hot one or you're a wired one or you're going to cause some trouble. On the television, there are television screens. And for whatever reason, Kathy remembers that the movie Jumanji was on the screen the whole time on a kind of Groundhog Day loop. Oh, God, it's terrible.

I don't know. They looped that movie over and over. Can you ever watch Jumanji again? No, I don't want to ever see that movie again. And then there was some significant amount of time where you just sat for hours waiting for the next activity. So I would just walk down to the nurse's station and look at the clock. And there was just a very slow passing of time. It all felt...

It felt like a movie. It felt so surreal. And does she get any treatment for this supposed episode that they're keeping her in for? Her medical records indicate that she's not getting what any of us would consider care. She's not getting...

one-on-one therapy. She's basically in a holding pattern. I was able to get phone calls in with my sister. I never... She does eventually call her sister, who's both a lawyer and her medical proxy. I did talk to her. She would just say, honey, you have to stay calm.

You have to. They're trying their hardest to come up with a plan to get her out, which involves a couple of things. One is Kathy, you know, has to be a model citizen. She can't show any kind of emotion that would give the facility any other reason to hold her. And I think having that communication when I was able to made all the difference.

And so she develops these coping mechanisms like saying the serenity prayer over and over again. There was a particular like sort of seats where I could pull my knees up to my chest to give myself a little bit of comfort. Just trying to sort of say prayers that would help me hold it together mentally and emotionally. And it took two days at least to get a pen ready.

And a journal. I begged for that. I needed something to write where I could write my prayers, I could write my thoughts. Another thing she does that really helped her and gave her a sense, however feeble, of control in this situation is she gets her hands on a journal. And she starts taking notes. I would shower with it. I'd go to the bathroom with it. Like, I was so scared of them taking anything and everything from me. And...

She shared a copy of her journal with me and I was just blown away by it. She wrote at one point, "God, please connect me back to my mom ASAP." And she also said, and the grammar on this is a little off and I find it actually more moving, she wrote, "Every time the locked door open and slam, I feel a quick feeling of fear."

I was trying to get as much down about the place. Like, I felt like I was this little detective. I'm like, I'm inside this nightmare. For her, it was all a way to keep her mind focused. And the days are ticking by. I'm going to get as much information out of it because, God willing, I'm going to get out someday. We'll be right back.

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So Jessica, Kathy's story is really a kind of nightmare scenario for anyone seeking mental health care to be kept against your will in a closed institution. And you said her story was just one of many you found in your reporting. But what was Acadia's motive here? We found again and again that Acadia was making decisions in the interest of maximizing its profits, even if that meant sacrificing patient care.

And to really understand what was happening, we called hundreds of people. And we ultimately got 55 current and former employees. And that's a mix of staff, executives of the various hospitals all across the country to talk to us. And they outlined this pretty elaborate system at Acadia to get as many patients in the door as

And then keep those patients, especially the ones with insurance, in Acadia facilities for as long as possible. I mean, that's really dark. Explain the system to me. How do they actually do this?

Well, it starts with the way Acadia finds and recruits patients. So they first market directly to potential customers. They run advertisements that tell people, skip the ER, come to us. The company also cultivates relationships with people who are more likely to encounter

patients in the throes of some kind of mental crisis. So police officers, emergency responders. And the hope there is that those individuals will bring patients to Acadia. And I imagine that's a pretty attractive offer, given how overrun emergency rooms are these days.

Right. And we found that Acadia actually directly markets to those ERs. Business development teams show up at ERs bearing donuts and coffee, and they say, look, we have the expertise, we have the skills to quickly evaluate and stabilize these patients, and we can treat them.

That's really appealing. It means that Acadia is willing to take some of the most difficult patients off the hands of these emergency departments. And it's all about filling beds because every patient they get into a bed, especially if that person comes with private insurance, is money in the door for Acadia. And some of Acadia's strategies to attract patients

patients, I would say take the normal kind of sales relationship a little bit further. So in some states, Acadia has actually dispatched teams to these overwhelmed ERs to help those emergency rooms determine whether patients need to be hospitalized. These employees are known as assessors, and they're supposed to be providing an objective evaluation as to whether someone is

at an emergency room needs a further psychiatric evaluation and whether that patient needs to be hospitalized. But they're paid by Acadia to do this in ERs. Exactly. So that's where it gets a little muddy. Several Acadia assessors who we spoke to

said that when they didn't send patients to Acadia, when they opted to send them home because they determined that they didn't need that level of care, they didn't need to be hospitalized, or when they sent them to other facilities, they would be scolded by their superiors. One assessor that we spoke to, a woman named Gwyneth Shanks, said it felt deeply unethical to her because she thought all of the pressure actually clouded the judgments of assessors.

Okay, so that's how they get the patients into the door. But what happens once these patients are on the premises? Well, they typically keep them there for as long as they can. And we found that in case after case, they do this by exploiting a fundamental information imbalance. As we've talked about, patients can only be held against their will for a relatively short amount of time.

But patients don't always know that. And Acadia is kind of capitalizing on that confusion to keep patients there as long as possible. And Acadia deploys a lot of different strategies that we identified in our reporting to convince insurers to pay for those extra days.

So sometimes staff exaggerate patient symptoms. They write patients up and call them out, branding them as uncooperative if they don't finish a meal. They argue that they're not well enough to leave.

In one case in Redding, Pennsylvania, we found that actually inspectors called an Acadia hospital out for this because in 2022, state health inspectors found that workers had been instructed to avoid adjectives like calm and compliant in a patient's chart.

And remember how I said we filed just like these voluminous records requests? Those started yielding similar things in other states. So that same year in 2022, we found in records that Acadia employees in hospitals in Ohio and Michigan complained to their state regulators that doctors had written false statements in patients' medical charts to justify their continued stays. Yeah.

And these strategies ultimately led to patients spending more days there than medically necessary. Sometimes it was between three and five days. Sometimes it was longer. We found that Acadia often holds patients until that insurance money runs out.

And how much money are we talking about here? We don't know in every case. But for Kathy, for example, we saw that for every day she was held, Acadia was charging her insurance $2,200. That's a lot of money, especially if you're held in there for a long time. But as you said, there are legal limits to keeping people in hospital against their will. So how does Acadia get around these rules?

So the mechanics of this are pretty interesting. In Florida, as we've talked about, the limit for holding patients like Kathy McKenzie against their will is 72 hours. Right. And in order to extend that time, hospitals like North Tampa Behavioral, where Kathy was, have to go to court to get approval.

And the way they do that is they file a petition that says, this patient needs to be held longer than that 72-hour period. Now, here's where things get really interesting. Simply filing that petition, whatever the prospect of it succeeding in the end...

allows the hospital to legally hold the patients and, more importantly, bill their insurance until the court date, which can be several days after the petition is filed. So they've effectively identified this loophole. Yeah, in our reporting, we found that North Tampa filed thousands of petitions to extend patients' involuntary stays between 2019 and 2023.

Of those, and this is when my jaw really hit the floor when we got this data back, judges granted only 54 of more than 4,500 of North Tampa Behavioral's petitions. So that's about 1% of the total. That's crazy. So 99% of these patients had their confinement prolonged by several days.

With petitions that were never really expected to be granted, they were simply a delaying tactic, it seems, a tactic to maximize the daily insurance payouts. That's absolutely right. And that's according to current and former employees that we interviewed. And judges in this case agreed. Wow. But Jessica, how did the company actually implement the strategy sort of on the ground?

Was there an internal policy? Like, were there written guidelines to keep patients in for as long as possible? I mean, how do you get a whole hospital staff in?

to fall into line with this strategy? So it's a really good question. And it's one that I tried to use to guide my reporting as well as like, how is this put into practice? And what we found is that there was nothing in writing. There were no instructions. Like, here is how you convince insurance companies to hold patients as long as possible. But

When we spoke to those 55 current and former employees, and that group included psychiatrists who worked at these facilities, they said it was subtle pressure from their bosses. And the pressure manifested in different ways. Sometimes it was, don't you think this patient could, you know, benefit from a couple of more days inside? You know, don't you think that

They said they weren't suicidal, but maybe they're behaving a little erratically. Could we describe them as combative? And so these people at least said that was a real problem for them and that

It all comes back to a company that was run more by the business side than by the clinical side. I mean, one thing that consistently came up is that every patient first was identified by how many insurance days they had left, not their constellation of symptoms.

I mean, that pretty much says it all. Identifying patients by the potential profit gains they bring, basically how valuable they are to the company's bottom line. So is this ultimately just what happens when for-profit companies move into a space that used to be occupied by governments and not-for-profits? I mean, we definitely found that in our reporting. And it's been something of a consistent theme that as healthcare becomes more

more monetized and more for-profit companies move into this space. It's the patients who really suffer. And in this story about Acadia,

I think both Katie and I found it particularly stark because these patients are particularly vulnerable. They are in the midst of some kind of mental health crisis. And so sometimes they're not believed. They're easy to dismiss, to not listen to. So it makes what's happening all the more...

upsetting and harmful because as these patients are being commoditized, they are also being ignored and kind of brushed aside. And have you confronted Acadia with all of these findings, you know, these different layers of abuse they're accused of? Yes, absolutely. So the Acadia spokesman wouldn't comment on individual patients. And he said the reason was patient privacy laws, which is pretty standard.

And the spokesman also said, and he really emphasized this, that quality care and medical necessity does drive every patient-related decision at Acadia. He said that the patient examples we cited, people like Kathy McKenzie, were not representative of the many patients who did have positive experiences at Acadia. But what has really struck me is actually what has happened since the story published.

So Katie and I have just been overwhelmed with reader emails, with reader comments on the story. And what people are saying is that they have experienced very similar things to what Kathy experienced in the story. And some of the ones that are particularly kind of harrowing to me are people who say,

My family member, my loved one, is stuck inside an Acadia hospital right now. And the only thing we can say to them is, if you need help, you should contact an advocate in your state. So there are these groups called protection and advocacy agencies, and they're funded by the government, and they're essentially watchdogs for these mental health institutions. But that's really all we can do.

And that, I think, has been the most stunning thing to me, is just the number of people who are dealing with parallel situations to those of Kathy's, but in real time, right now. And Jess, do these agencies have any real authority? Are there likely to be any real consequences here? I mean, I...

I'm skeptical that there will be any real responses because as we found when we requested all these public records, people have been raising red flags, raising the alarms for years. And so far, very little has happened. It's pretty shocking that something like this can happen on this scale without any real consequences. And it does make me wonder,

You know, what does that do to people like Kathy who have been a victim of the system? So Kathy's mom and sister worked together to find and then hire a lawyer. And they do get her out. But for Kathy, she doesn't really know any of this as she's waiting inside that locked psychiatric hospital. And she felt so alone.

It was almost like that outside world had really ceased to exist. She was in the upside down. I've never been like in the military or something, but I could only imagine being almost like in a war zone where you're just scared for your life and you have nobody to protect you. And then I walk out into the lobby and my mother's there. It was surreal. It was like something that felt like it'd taken months and it was almost exactly a week.

Kathy ends up staying at Acadia for about a week. They release her right before a judge could issue a decision to have her released. So they release her on the day of her hearing. And so this nightmarish ordeal that happened to Kathy, it's finally over. And what did her life look like after she was released? I came out very quickly diagnosed with PTSD. She...

was traumatized. She was really traumatized. I mean, it's the only way I can think to describe it. We had night terrors, severe nightmares. They definitely had to do with being locked up again and not having freedoms. Had to readjust and just start totally fresh with medication and kind of just even rejuvenate

Going to the grocery store, going to do normal basic things. If I would see a cop car, I would get extremely agitated and paranoid that they were coming after me. I was living with my mom again and, you know, there were nights where I would just race across the house and just have to lay with her just to calm myself down.

When she went into that hospital in August of 2020, she was in a relatively good place. She had a fair amount of faith in the mental health care system. And when she left that Acadia facility six days later, all of that faith was gone. I have a very clear plan, and it will never be to go to an emergency room ever again. Thank you, Jessica. Thank you for having me on. I really appreciate it.

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