SURELY IT’S POSSIBLE for involuntary status to be rendered moot because the patient decides to stay of their own accord. You just need to win them over.
How do you persuade?
Making hospitals less awful would be a start, Andrew Lustig says. Better programming, a comfortable environment, the ability to get fresh air. Some facilities actually have fenced-off green space of some kind where people can go but where they can’t run away. (The balcony in my longer-stay psych ward would have made an enormous difference in my quality of life, if only it had been open for more than five minutes a day, or whenever we could prevail on the nurses to let us breathe). Talk to the patient like they’re a human being. Like you’re on the same side. Try to establish a degree of trust. Explain to them why you want to take whatever interventions you think are necessary, and what you hope that will accomplish. It’s not enough to say, “This will make you better.” What is better? How will this intervention get you there? In other words, “being empathic—listening, hearing what they have to say, taking an interest in their lives. Not just walking in and saying, ‘Here, you need this medication,’ but clearly communicating to them you want to help them get better and having them believe that.”
Clinical compassion is more crucial here, arguably, than it is in any other field of medicine. Lacking insight into your illness puts you and your doctor at odds from the beginning. “If someone breaks their leg, there’s generally agreement between the orthopedic surgeon and the patient that the leg is broken, right? But if somebody has schizophrenia, oftentimes the physician’s view is, ‘You have schizophrenia.’ And the patient’s view is, ‘I don’t have schizophrenia, but people are following me and they want to harm me.’”
That doesn’t mean you have to force the patient into things. “The most helpful thing to do,” Lustig concludes, “is, I think, to find something where you—the doctor and the patient—can agree on what the problem is. So maybe you can’t agree that the diagnosis is schizophrenia, but maybe you can both agree the person is under a lot of stress and that taking this medication will help alleviate the stress.”
* * *
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“DO YOU WANT to spend a few days in hospital?”
It was the first time he’d asked me that. My doctor. In five and a half years of treatment, during which I’d confessed—with 100 percent honesty, I swear—every need for death at my own hand, no matter how fleeting or interminable or nightmare-compelling, whether during insomniac nights or a sudden midday emotional blow to the chest.
We had a deal. One he’d initiated, not me. He’d promised not to commit me. There are few therapeutic gifts more valuable, engendering more trust. Maybe none. It makes it possible, even natural, even therapeutic to tell someone about your desire to kill yourself when you trust them and when they take you seriously and when you know your honesty won’t be punished. It made it possible for me not only to tell him I’d stocked up on Aspirin with the intention of overdosing but to pull out the bottle of pills to show him.
So now I was telling him about intense suicidality that commandeered my nights and intruded on my days and my commute and my work, a telescoping anxiety that paralyzed me and convinced me I was in the midst of a psychotic break. (He said I wasn’t. So there.) And now he was asking about, offering, an inpatient stay. Because, he said, he figured I wouldn’t ask for it myself if I wanted it. Which was true but also maybe overly optimistic on his part: I couldn’t imagine a return to the short-stay psych unit with my nurse friends who remembered me better than I remembered them. I couldn’t conceptualize that as anything but a surrender to misery or, if I was unspeakably lucky, a chance to will myself into endless catatonia—the next best thing, I figured, to total obliteration. Even when the possibility of surrender seemed a relief, the prospect of re-entering the real world after even a short, even a voluntary stay, took so much out of me I could not imagine mustering the wherewithal to do it.
Transitioning from psych ward to real world as an attempted facsimile of a normal person is, for me, like racing to climb onto a train hurtling at full speed. Many people I’ve spoken with say they checked themselves into hospital because they didn’t trust themselves with themselves. It was such a relief, they said, to give this responsibility to someone else. At the very least it offered respite from that oppressive impossible weight. Maybe a chance to recover. And I get that. And I’m so jealous. A respite I understand. But how do I bounce back? I couldn’t. I can’t.
So I didn’t go. And his offer, his question, both petrified and comforted me. Petrified because it was without precedent and because of that it seemed to indicate an unprecedented fear on his part.
“Oh shit. Did I alarm you?”
“Do I look alarmed?”
But if he were not, why would he have suggested I check myself in before I wreck myself?
Comforted, though, because it was such a respectful way to ask a scary thing. He didn’t tell me. He didn’t even say he thought I should. He just asked. This, again, was its own invaluable gift.
A doctor’s orders needn’t come across as orders.
“I think, as a profession, psychiatry has probably lost a lot of its ability to just talk to the clients,” Anita Szigeti tells me. “And I think we’re definitely seeing force and forced medication where we don’t need to, if a doctor had better skills at just therapy and communication.”
* * *
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ABBY’S FIRST-EVER PSYCHIATRIC session ended with her being hospitalized against her will. She then spent a decade cycling through involuntary hospitalization and involuntary outpatient treatment. I call her Abby; she didn’t want any part of her real name used for this project. She’d be discharged, often into homeless shelters, arrested after a burst of rage or erratic behaviour, Formed and hospitalized again. She felt scared and disrespected—as though nobody was listening to her or cared to try. Like a nightmare where you talk, yell, and no sound comes out. The swift loss of agency, the forcible treatment, the physical and pharmacological restraints, left lasting psychic scars. Made her vacuum sense of isolation worse. Poisoned any future therapeutic relationship. Talking to me a dozen years later, Abby acknowledged she had issues with mental illness, anger management. She had breakdowns, would “flip out” and kick walls or mirrors, wave a knife, try to slap doctors away or kick her mom off her hospital bed. She finally got out of hospital for good when she signed—coercively, she argues: What choice did she have?—a Community Treatment Order agreeing to semi-weekly injections that went on for years until finally her doctor said she’d been doing so well he would let her off the treatment order if she agreed to take a low dose of an antipsychotic (olanzapine, the same one I was on a couple of times) voluntarily. She kicks herself in hindsight for not realizing earlier that her relationship with clinicians could have been collaborative rather than coercive.
She wishes someone had made clear this was an option.
Psych wards can save lives. They can provide a safe place to stabilize and, as they did for me, an on-ramp to longer-term outpatient care. Sometimes some people need to be hospitalized even if they don’t want to be. But our use of coercion is increasing and it isn’t benign; it’s the kind of thing whose consequences you’d want to think twice about.
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Trust Issues
You can have an awful doctor in any sphere and it can fuck with your trust for life. Surgery sucks. Intubation is awful. Chemotherapy is harrowing. But why is mental illness the only sphere of medicine characterized by a deep mistrust of caregivers and caregivers’ profession? Cancer foundations are multi-billion-dollar industries yet it’s depression—the world’s leading cause of years lost to disability, which boasts no ice-bucket-challenge or money-making marathon, which gets fewer public dollars, and whose practitioners make less than the average medical specialist—that’s derided as a marketing-driven capitalist fiction.
LANEY
Trapped in a suicidal morass, Laney’s son did the supposedly res
ponsible thing. He told his mom to take him to hospital. She did. He checked himself into a psych ward. As the son of a social worker in Virginia he knew what he needed and what he did not. But then everything went wrong, his mom says. The staff was domineering, locked him in seclusion for asking, jokingly, if a grumpy-looking staff member needed a hug. Eventually he unlocked the door with his credit card, walked out and asked to speak with the head nurse—and for a copy of his rights. They tried to grab him; he ran; they took him down, put him in restraints, forcibly injected him with an antipsychotic. He was committed the next day. His parents attended the commitment hearing, begging for him to be let go. No dice.
His mother still can’t quite wrap her head around it. “They beat the shit out of someone who was feeling suicidal and wanted to go someplace safe.”1 The committal still haunts her son, she says. He can’t own a gun. An IT and computer systems specialist, he was turned down for a federal job (he was working on contract and trying to jump to a full-time gig) because the committal came up on a background search. He hasn’t accepted medication since. He hasn’t forgiven her. Refused to talk to her for eight years, then relented and let her visit once a year, on Christmas Day. He has a son now, named after her father. Laney (not her real name) has met her grandson twice. “I guess he felt betrayed. And he thought it was my fault.” She doesn’t know if he’s ever tried to kill himself. If he’s ever wanted to. “He basically said, ‘I’m never going to tell you again if I feel suicidal.’” She asked me to change her name and not to name him for fear of upsetting him.
She hasn’t forgiven herself. “Frankly, I don’t blame him for feeling like I had led him into the lion’s den. As much as it breaks my heart, I don’t blame him. I wish I hadn’t done it. I wish I had said to him, ‘Let’s keep you at home and I’ll keep you safe at all costs.’ It would have kept his dignity. It would have kept his humanity and his self-determination. It would have accepted who he is as a person.”
She certainly hasn’t forgiven the health structure that did that to him. “And what happened to my son is nothing compared to other people. Nothing.” She knows. She started out as a social worker in what she calls a “mental health ghetto”—an area where people were discharged from psychiatric wards into an abyss, sans supports: single-room occupancy units or group homes or the streets. Now her advocacy for the most vulnerable mentally disordered individuals runs counter to a system she sees failing, abusing and infantilizing them in ways that border on criminal.
During a placement for her master’s degree in social work, she says, she got an “eye-opening” look at the gap between the advocacy work that interested her and the care-provision that was the status quo: “The ‘I know best for you; I know what you need better than you do.’…I was confused about how to make it a more empowering experience for such a damaged population.”
She became a shit-disturbing crusader, “muckraking with hospitals,” pushing for better community care and going after what she saw as systemic screw-ups in the state mental health systems where she’d gotten her start. She briefly headed Virginia’s chapter of the advocacy-oriented but largely institution-friendly National Alliance on Mental Illness, but moved on to work at the more radically psychiatry-skeptic National Coalition for Mental Health Recovery.
What Laney preaches is itself not so different from what many public health advocates want to see: more robust community-based outpatient care. “We believe in intervening before it’s too late.”
But she’s sick of seeing mental health budgets swell and ebb like tides pulled by the force of political moons. She’s sick of the merry-go-round of one-off funding infusions that never last long enough to change much. She’s sick of coercive care, and to her, now, all psychiatric hospitals are inherently coercive. “They just are, under the best of circumstances….I am opposed to inpatient care. I think there’s no way to fix it.” She’s sick of clinician attitudes to people deemed mentally ill. “I despair at the mindset of other mental health professionals—particularly in inpatient settings. And I think that, you know, coercion and ‘You will do what I say’ and ‘I know better than you do’ and ‘You’re behaving badly so I’m going to punish you for it,’ I think it’s really nearly impossible to get rid of that mindset.” For this reason more than the myriad shortcomings and side effects of the best-intended treatments, “survivors don’t want anything to do with psychiatric services.” She’s sick of families supporting laws expanding involuntary hospitalization or treatment because they see no other hope for their loved ones (or themselves). “Families have been so completely failed by the mental health system that they have concluded that forced treatment is the only way to help their family members get better. I don’t think family members understand what actually happens” when people are committed. “They have no idea the nightmare has just started for their loved ones.” And she’s sick of people calling psychic suffering a sickness. Sees it as one more thing pushing coercion: “If you’re sick, you can’t take care of yourself. You’re a helpless person. I don’t call them illnesses. I would call them conditions.”
I’ve encountered this argument before. I understand the sentiment but now disagree with the conclusion: calling something an illness forces you to take it seriously, to devote resources to it. An illness can be outside a person’s control without that person being out of control—therefore untrustworthy, unfit for autonomy—as a result. But when the illness outside your control is a mental one, the crucial differentiation is often blurred.
Much as you might disagree with Laney’s conclusions and her indictment of the entire field, it’s tough to argue with her mantra for fixing mental health care. “Make it voluntary. Make it attractive. Make it effective. Make it humane.”
* * *
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IT’S NOT UNUSUAL to find extreme psychiatry-skeptics. The Ontario Institute for Studies in Education (OISE) at the University of Toronto, the biggest post-secondary institution in Canada, now has an antipsychiatry scholarship. “Given the overwhelmingly and disproportionate availability of ‘regular’ scholarships for studying issues related to psychiatry,” the scholarship’s website reads, “equity and academic freedom themselves require that antipsychiatry scholars, including exceptional ones, have more equitable access to scholarship support.”2
I know a lot of serious-minded people who think this is a deeply harmful idea. Bonnie Burstow, the author-activist who endowed that scholarship, is not looking for their approval. She wants to see electroconvulsive therapy criminalized, antidepressants and other psychotropic drugs banned, and psychiatry as a field extinguished. The things we call “mental illnesses” are not illnesses, she says, but “problems living.” (I can confirm they are most definitely that.) Antidepressants and electroconvulsive therapy are so damaging, she claims, that “if they told you the truth, no one would take the treatment. What psychiatrists do with depression…is not only not meaningful, it should be a crime against humanity. Because it takes healthy people and seriously brain damages them for life.”3
It’s understandable for people who’ve dedicated their lives to caring for those with depression to be less than tolerant of such maddening misconceptions. But strident smackdowns aren’t helping. When Charles Kellner at Mount Sinai in New York dismisses people worried about losing memories to electroconvulsive therapy as being silly at best or Scientology stooges at worst, that doesn’t win anyone over.
There are reasons why mental illness is a sphere of medicine so characterized by mistrust.
Antidepressants, for example, have a bad rap in large part because clinician, researcher, marketer pronouncements about the way they worked overstated their certainty, simplicity and efficacy.
“I think sometimes, to explain things to people, we have maybe oversimplified things…using ‘chemical imbalance’ to explain things to people, using the analogy of not having enough insulin, etcetera,” Husseini Manji, Janssen Pharma’s global head of Neuroscience Therapeutic Area and the man behind Janssen’s
ketamine experiments, admits to me. “I think some of the oversimplification was done with good intent. And I’m guilty of it. Because with things like depression, often people seem to think, ‘If I only tried harder. What’s wrong with me?’ And you almost want to say, ‘No! It’s not you.’”4
No one’s known much about depression treatment in the history of treating depression. So once researchers and clinicians found something that appeared to effectively treat depression, they explained it and sold it to governments and the public (and perhaps to themselves) on a reverse-engineered mechanistic explanation that made sense at the time but hasn’t held up to scrutiny.
This overstatement of psychiatric certainty when it comes to understanding the way depression works has become one of anti-psychiatry’s most effective weapons. Gary Greenberg, author of Manufacturing Depression and coiner of the delicious Blakeian phrase “what’s dark and Satanic about the depression mills,” 5 isn’t afraid to wield it. But when you press him he’s cool with the idea of depression as an illness, as long as you don’t insist on bringing biology into it. “I actually think an illness, a disease, is better understood as a rhetorical device than as a biological category. It provides us with a way to decide how to allocate social resources: a disease is a kind of suffering that deserves social resources, and social resources can include research, drugs, compassion, money. Is depression a legitimate disease by that definition? Absolutely.” 6
Most psychiatric researchers and clinicians—certainly everyone who specializes in the neurology and neurochemistry of depression—would understandably refuse to abandon the idea of depression as a medical disease with an identifiable (even if as-yet unidentified) pathophysiology, especially as neuroplasticity and neurocircuitry appear to offer potentially illuminating avenues of inquiry. But at the patient level, does it matter? Does it do anyone any good to argue with a patient over the pathogenesis of their illness if your common goal of remission doesn’t require anywhere near that unanimity? I talk to my doctor and follow his advice because I trust him, not because he has or claims to have all the answers as to where depression comes from or how it works or even how these drugs work. Arguably he’s a better psychiatrist because he’s so straight up about his profession’s uncertainty.
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