“What are you saying, Alen? You’re making this sound hopeless. What do you mean ‘there’s not much out there’? How do we know what’s supposed to work?”
“Well, unfortunately, for many families and kids it’s trial and error. The insurance companies have made this nearly impossible. But be sure that you find a place with an emphasis on therapy, on CBT [cognitive behavioral therapy]. And make sure there’s a good pharmacologist on staff who knows what he or she’s doing.”
I felt my fragile lifeboat leaking. Alen Salerian, the one person I trusted to guide me through this horrific morass, had exhausted all of his remedies. We were in the midst of a high-wire act working without a net.
Our nation’s mental health care system is obstinate, capricious, and obscenely inhumane. Managed care fought to limit Will’s hospital stay to ten days. We did not want him released without a residential treatment program in place.
And Will was a mess by then, deeply depressed and suspicious of our intentions. He argued fiercely against going to a residential treatment program. He wanted to come home and insisted we give him a chance to recover with family and friends. Bob was spending as much time as he could manage away from his job on the West Coast to be with Will and help us find a solution. At PIW, Bob and I argued the same ground over and over with Will: “You need to be with other depressed kids; you need to be in a safe place; you need long-term help.” The conversations went nowhere. To me, Will looked like a caged animal waiting to be released so he could throw himself under a car.
April 1, 2001, the start of Will’s third week in the hospital: Bob was heading back to California Sunday evening. Will, Jack, Bob, and I sat at a dilapidated card table in the common room on Will’s unit. The TV blared basketball in one corner and a handful of patients, unlucky enough to be inside and not out “on pass,” slumped on couches watching the game.
We had been at it for over an hour. Bob was distraught and torn. He didn’t want to leave town without the “next step” in play. I was in tears. Will only reluctantly met my gaze.
“I can’t have you living at home, Will. I can’t do that until you get serious help.” Will looked away, his jaw set, signaling quiet rage.
Bob reiterated, “For us, Will, ‘help’ has got to be a residential program.”
All of the adults in Will’s life agreed—nothing short of a therapeutic inpatient program would do.
“If you were home now, Will, do you realize what that would do to us—and to you? We would be so terrified for you, you’d have no freedom, no life—and neither would we.”
I flooded the plastic tabletop with tears and continued, “I love you—we love you—more than you can imagine, but we won’t take a risk with your life.”
Will’s expression had hardened into something made of wood. He stared intently at his father and me for several minutes. He didn’t say a word. I began to wonder if he was in there—had his mind vaporized? Anger? Exhaustion? Hatred? What? No response.
Bob caught his flight back to California at 5:00 PM.
The phone rang at 8:30 PM. It was Will calling from the hospital: he wanted to strike a bargain.
“If I agree to go to a program, will you get me out of here tomorrow?”
“Absolutely,” I assured him.
Discharge Summary
Patient Name: Xxxxx, William
Hospital Number: 000000
Date of Admission: 03/13/01
Date of Discharge: 04/02/01
I. INITIAL ASSESSMENT:
The patient is a 17 year old Caucasian male, who on 03/11/01, took a massive overdose of Remeron after writing a suicidal letter thanking his parents for their love, and asking for their forgiveness. The patient remained in a coma at George Washington University ICU for 48 hours, was medically stabilized, and transferred to PIW. This was the patient’s first suicide attempt.
Past Psychiatric History: PIW in 02/01 for depression. Outpatient, Dr. Salerian in 12/00 to present.
Current Medications: Remeron 45 mg q.d., Prozac 80 mg q.d., Concerta 36 mg q.d.
Psychosocial/Family: Paternal aunt, depression; mother, depression.
Suicidal/Homicidal Ideation: Massive overdose with a suicidal letter on 03/11/01. Denies homicidal ideation.
Mental Status on Admission: A mental status examination was performed on admission. Mental status was normal other than depressed mood with blunted affect. No psychosis was noted. Due to the patient’s suicide attempt, the patient was considered a high risk for self-harm.
II. INITIAL DIAGNOSIS:
AXIS I [psychiatric disorders]: Major Depression, Recurrent.
AXIS II [personality disorders]: None.
AXIS III [medical conditions]: Status Post Overdose.
AXIS IV [level of stress; environmental factors]: Severe: Social, Environmental.
AXIS V [global assessment of functioning; scale is 0–90]: 20
CONSULTATION AND LABORATORY DATA:
The patient was medically cleared at George Washington University Hospital. Medical records accompanied patient.
MEDICAL PROBLEMS:
As above.
CLINICAL COURSE:
The patient was admitted to the APS unit as a transfer from George Washington University Hospital, monitored for safety, seen daily in individual and group therapies. Prozac 60 mg q.d., [daily; Remeron 30 mg increasing to 45 mg h.s at night]; Concerta 36 mg q.d., increasing to 54 mg q.d., Lithobid 600 mg h.s., Zantac 150 mg b.i.d. was prescribed.
Initially, the patient presented as depressed, but stating he was glad to be alive and had no thoughts of taking another overdose. The patient was considered to remain high risk, needing educational, supportive, pharmacotherapy, as well as gaining insight into his actions and the consequences of his impulsive behaviors. A family meeting was held with the purpose of educating family and the patient on illness, reaffirming family support and exploring discharge options. The patient did attend the educational groups, and was compliant with taking medications, gradually with noted mood stabilization. The patient was agreeing to follow up with outpatient care.
Discharge planning included returning home to live with family, attend a therapeutic educational program. Outpatient psychological testing with Alison Howard. Outpatient medication management, Dr. Salerian. Outpatient therapy, Dr. Ainsworth. The patient was denying suicidal/homicidal ideation, and was discharged on 04/02/01.
In a journal entry in April 2001, Will sums up what he sees as his many failings. He talks about missing “Gene,” the elderly schizophrenic patient he met during his first hospitalization at PIW. Their brief encounter, which he describes in an earlier journal entry, becomes larger than life in his memory. I get the impression that the fleeting connection he made to Gene, comforting her and imploring her not to cry, represents a bond that he feels unable to secure with the rest of the world.
April 2001:
Recently I’ve found myself in some strange places. I noticed it maybe a year ago. I don’t remember where or why or how, but I distinctly remember coming to a full stop at whatever I was doing and saying to myself, “Will…How the fuck do you get yourself into these situations?” It’s a very clear memory amidst several cloudy years of my life. It’s almost creepy, to me at least, that I remember so little of what happened in the months or even years around this. Thoughts pass in and out of my head and are instantly forgotten, but not this one. It’s strange, but it’s true. And it’s not something I’m terribly happy about (as I’ve recently come to realize).
For a while I thought it was funny, just another way to make myself laugh. But I don’t really know anymore. When I think back about the times where this thought actually applied, I realize that I laugh at my own pain more than anything. It’s my own private slapstick comedy. Getting caught in my friend’s car naked with a girl. Being locked in a mental hospital eating cereal and laughing at crazy people’s jokes. Going to bed after taking two bottles of sleeping pills. Waking up two days later with my hands tied down and a tube in
my penis. Strange situations, potentially funny, not nearly as funny when it happens to you.
I used to look back and laugh, but it’s been hard lately. I try not to take myself too seriously; I’ve always tried not to. But then one day it wasn’t as funny (not as funny to me…I can still turn it into a pretty funny story). I want to be good. I want to be in a position where I can’t fail, not for my own sake (I am in no way a perfectionist), but for others. I left school to relieve myself of the burden of academic failure (thus letting down parents, teachers, interested relatives). I wanted to move out of the house, buy my own car, make my own rules. Slowly untangle myself from the life I lived with my family. Disconnect myself to completely rule out the possibility of failing them. I would set up my life, structure it, so that I couldn’t fail. Get a low rent apartment, buy a modest car; get an easy job, something I know I could do. Something that pays, but leaves no room for me to fuck up. I love my family, but if I had the chance to leave, leave everyone I’ve ever known, move somewhere where they’d never find me and start over with my own life, my custom-made infallible life, I don’t know what I would say. I can’t say for sure if I would take it or not, but that in itself scares me. It’s as if I’m in the same place thinking the same things as before this whole mess started.
I miss Gene. I don’t know if I’ve ever cared as much about anyone as I did Gene. To know that I will never see her again breaks my heart. Maybe it’s just the warped negative thinking of my depression, but I miss her a lot and I’m worried that the farther I move from the time I last saw her, I will slowly forget her.
Memo
To: Friends and colleagues
Date: April 9, 2001
Subject: Thanks to all
I wouldn’t normally write a blanket thank you note like this, but I have been so overwhelmed by the kindness you all have shown during these past few weeks as I have struggled to come to terms with Will’s depression and suicide attempt. I have appreciated everything you have done—the well wishes, the notes, the prayers—and the huge basket of foodstuffs delivered to the house after Will was hospitalized. You have been good friends to me and I cherish these relationships.
We are in the throes of trying to determine next steps for Will. I will be in and out of the office for the next several weeks until this is resolved, but know that I take great comfort in your support.
Gail
Will was released from the psychiatric hospital on Monday, April 2, 2001. Once Will was back at home, we pieced together a complicated schedule, so he was never left alone; Jack would take a shift so I could run out for groceries or make phone calls investigating resources for potential inpatient treatment. Will wasn’t allowed to leave the house in the company of friends, only his parents. We limited his phone calls and visits with friends who came to the house. We insisted that communications with Megan be kept at a minimum (an edict her parents also issued). He was tethered to us and he resented it. He might as well have been four years old instead of seventeen. I became overprotective and fearful. Several times a night I looked in on him, just to make sure he was still breathing. I wanted to climb into bed with him and rock him as if he were a small child.
I don’t think Will understood that the independence he sought when he dropped out of high school in February became untenable in our minds after his suicide attempt. He did not see himself in danger or at risk of another attempt—he claimed he had “learned his lesson.” He was embarrassed whenever the trauma was mentioned and regarded our insistence on residential treatment as “a punishment.”
Jane came home from Charleston for Easter break. It was the first time they were reunited since his suicide attempt. “I don’t get it,” he told Jane. “I do this one bad thing—this one little thing, and they’re all over my case. They won’t cut me any slack.”
“‘One little thing,’—that one thing?!” Jane shouted. She was incredulous. “Will, that one little thing you did—that was sooooo much worse than anything the rest of us have ever done. Will, you tried to kill yourself! Nothing, nothing is as bad as that!” Will was stung. He loved Jane. Clearly she didn’t see the situation from his point of view.
Jack and I worked feverishly at this end of the continent, while Bob and Melissa scoured the West Coast to dredge up treatment facilities specifically for depressed teens. We kept striking out. Querying medical institutions over the phone often left me tangled in voice mail hell; no one seemed to offer a suitable program. Several programs we considered were not willing to take Will because of the severity and recentness of his suicide attempt. Others insisted on short-term, outpatient programs as a precondition to admission, but there were no local outpatient programs that met our needs. We were in a trick box.
After a frustrating few weeks, Jack suggested we enlist the services of a local psychiatric social worker with an advanced degree in education, who had been helpful in steering us to the appropriate educational resources for Jane when she ran into academic and emotional difficulties during her sophomore year of high school. Susan Dranitzke had been an educational consultant at one time, but by 2001 she had cut back her practice. Nonetheless, she agreed to help us.
Oftentimes the fastest route to a reputable therapeutic school is by referral from an educational consultant. In fact, many schools nowadays only admit children who have been “vetted” by an educational consultant. In the past few years educational consulting has become a growth industry, and many individuals offer their services for a fee. Many advertise in the Yellow Pages or on the Internet. By all means seek out their help, but always check credentials; ask about the types of programs they favor and expect to pay for their services just as you would pay a therapist.
Susan Dranitzke was both compassionate and effective and steered us through a complicated process requiring yet another series of sessions, more diagnostic workups for Will, reviewing reams of materials about possible therapeutic programs and filing applications to the ones we thought best matched Will’s needs. Her services alone ran over a thousand dollars, and no insurance provider I knew reimbursed families for educational consultants. Likewise, none of the residential treatment options we were considering were covered by insurance.
We were shocked to discover that most private therapeutic or residential treatment programs for adolescents cost several thousand dollars a month. I despair for families and children who have no possibility of meeting the financial challenges to pay for the requisite care for their kids. They are relegated to the dregs of the mental health system—poorly managed and poorly maintained state-run facilities. Their children suffer, their families suffer—and we all pay for this heinous failure to provide adequate treatment for every young person who needs it.
Sitting in Susan Dranitzke’s office following his first meeting with her, Will provided the following writing sample, at her request:
One experience which I value happened on a Friday after school last year. I was waiting for the bus on Van Ness Street; it was sunny; I was out for the weekend—all that good stuff that typically makes someone happy. So, as I waited I was looking across the street, watching people as they crossed when the light turned green and I noticed an old man. He was an old black man, probably about seventy-five years old or so, wearing a brown suit and hat, and carrying a cane. As he got closer, I heard him singing. He was singing quite loudly but I had only noticed it now because the traffic had drowned him out when he was further. I don’t remember what he was singing but it was very happy and upbeat, which was reflected in his walk. He walked slowly, as if he loved being in the middle of the street and swung his cane as if that’s what he had it for (carefree swinging). I wondered if he needed the cane at all. When he walked by me he didn’t stop singing, walking or swinging the cane. He winked at me and kept moving.
Now, I don’t know if I knew it immediately, but that old man is my hero. He does what makes him happy. I’m more envious of him than of anybody else in the entire world. I would love to have no inhibitions and be able to do what
I wanted, but I think that’s a right we reserve for old people and I’ll have to wait.
7
LOST HORIZON RANCH
Search for the words “troubled teens” on the Internet and a single search engine, Google, will return over six hundred thousand entries. “Boot Camps for Troubled Teens” “Military School for Troubled Youth” “Wilderness Therapy” “private guidance” “permanent solution” “programs for defiant and unruly teens” “tough love alternatives” “Christian Mission therapy” “life-changing, high-impact, residential treatment for girls”—the sheer volume of resources positing solutions is enough to propel a worried parent into orbit. The growth of the Internet has boosted humankind’s ability to access information on any topic, but what does it say about our society that “troubled teens” pulls up over half a million entries?
Our goal seemed simple: we needed to find a therapeutic residential treatment program for depressed adolescents. We investigated dozens and visited three. They were all out of our area. Chestnut Lodge, a well-regarded residential treatment program in Maryland, had just closed its doors. Like many other treatment programs for the mentally ill, Chestnut Lodge had become prohibitively expensive to operate. Dominion Hospital in northern Virginia offered a short-term hospital stay and follow-up, outpatient treatment. We had already tried that. We abandoned hope of finding the right fit for Will close to home and turned our attention to residential treatment programs out of the area. On the recommendation of our educational consultant, we applied to the Cascade School near Redding, California (which closed its doors in 2004), but were turned down because Will’s suicide attempt was so recent. We considered McLean in Boston, the Grove in Connecticut, Mills Peninsula in California, and six or seven more. None was an exact fit for Will. We had applications pending at Island View in Utah, and Montana Academy.
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