IT'S NOT A RIGHT, IT'S A PRIVILEGE: Four Days in a Psychiatric Ward

Part II

I felt quite protective of the women on the ward. I knew that many had been in abusive relationships, some all of their lives, and many were depressed like me. Women are often the saddest victims in the mental health system. The groups of women I was with in those four days generally could be described as middle-aged mothers in dysfunctional families. In each life story, there was an element of enslavement to their significant other, often leading to pernicious results. The men were more likely to be victims of drug and alcohol abuse and the women victims of other people, although by no means are these statements generalizable.

For example, there was Pat, a crack addict whose only contributions to discussion were hilarious comments said with straight-faced mordancy. She weighed about 90 pounds and had the body of an adolescent. She could have been any age; the drugs had certainly aged her and her face told the story better than I ever could. She said to me, "honey, I used to smoke six eight-balls a day." After she'd kicked the last of the withdrawal, she was a bit more amiable but still far from unadulterated felicity. She and Don were both headed for a half-way house after their stay at Noble.

It seemed to me, that on my ward of 20 inpatients, the men still had that willingness and doggedness to fight their personal enemies; the women had already capitulated.

On the second day, I also requested to see exactly what I had signed during my admission. There was nothing about the loss of my rights, such as smoking, leaving the grounds, or drinking caffeinated drinks. It did state it was with the "discretion of the Superintendent," i.e. Dr. Allen, that I remain for three days after a request for discharge. That night I spent anxiously worrying that I would not be allowed to leave on Saturday, that I would be sectioned, committed against my will. This thought produced enough anguish and despair that my depression completely disappeared. All I longed for was freedom. I even welcomed my boring job back. As I had already been threatened with a section prior to my admission into Noble Hospital, the possibility was not unlikely, and the certainty of it loomed larger and darker in my mind with every passing minute. Had I actually gone so far as to get myself into this imbroglio without a door back into normality? Would I spend months "recovering" and everyday wait until the next damned cigarette break?

These thoughts contributed to my real insomnia and increasing levels of anxiety. If I had been depressed upon coming to Noble, I was in the opposite state by the end of the first day there. No one believed me. I had never been seriously suicidal when I had asked to be hospitalized. My intention was to break the depressive downward cycle before getting to the state of actually killing myself. I told this to everyone, and yet all of my records state "Suicidality: Very High Risk." Why was this? Once I realized that every counselor, case manager, and psychiatrist thought I was going to blow my head off with my gun anytime (the putative confiscation of which is another complete story), I began trying to unravel the misinterpretation. It had begun with my own psychiatrist, Dr. Shelley, that Tuesday morning I had had an appointment with her. Had I inadvertently exaggerated my case, worried that she would refuse to hospitalize me? It was possible. Usually, no one believes me initially, and it could be that in an effort to get help I presented myself as an out-of-control suicide risk. Of course, it could be that since she had only seen me once before, she had her own self-interests and license to protect and rather than risk it, she overstated my case. I clearly remember telling her that Tuesday morning that I "am not going to kill myself today, tomorrow or the next day."

Having myself been trained in assessing suicidality, a gun in the room plus living alone increased the likelihood of suicide certainly. Nevertheless, I did not have a plan, time or day to this presumed suicide, and more importantly, I could have been committed against my will based on misinformation and bad judgement. A law willing to err favorably on the side of the mental health clinician and unfavorably on the side of the patient is unjust, capricious, and dangerous. To be institutionalized is a living nightmare, a complete Hell on Earth.

When the other patients would discuss the benefits of our psychiatric ward, I only felt disgust. Had they so lost their own will and become so myopic that giving up their freedom meant nothing to them? A staffperson once lit our cigarettes up two minutes early, and a patient said so and so "is really nice to do that for us." I looked at the person who had spoke with disbelief. I remembered then Victor Frankl's description of the resignation of Nazi camp prisoners to their own death which he describes in Man's Search For Meaning. The inpatients I met reminded one of those prisoners in that they accepted their powerlessness, had given up asking for better or for more, and had without a fight given up the only autonomous part of themselves, their self-respect and freedom. Instead of demanding to be taken outside to walk or to smoke, they instead thanked their oppressors for the "privileges" they received. I had even found myself groveling obsequiously before my psychiatrist when he had refused to discharge me that first day. How pathetic these pleas must have seemed to him! How many before me had begged and pleaded for mercy with no possibility of atonement?

The staffperson running group A heard me snort several times when members of the group complimented the ward for such fine treatment, and I finally blurted out, "I don't like my freedoms being stripped." The staffperson looked at me and said "well, of course, if you only look at it from that perspective you won't accomplish anything, but if you're willing to work..." Again, I was stunned. 'What do you mean?' I thought. Is freedom so insignificant that it can be dismissed in a sentence? Is this some fantastical Orwellian world where people have lost their individuality and where words mean the opposite of their definitions?

The brochure of Patient's Rights and Responsibilities, given to me during my intake, is a masterpiece of civil rights. It is a beacon for us to look to if we want to advance the oppression inherent in institutions like the psychiatric ward at Noble Hospital. It states (and I will only quote a few of the items listed under "patient's responsibilities:"

"1. Smoking is a privilege [author's italics] to be used responsibly.... We discourage habitual smoking and will assist you [author's italics] in cutting down on smoking while here."

There is no mention of the actual time limitation on smoking, and an in-coming patient would not know this until after the intake process and the signing of all papers. It is possible that the most scrupulous of patients might actually read the brochure before signing the voluntary agreement, which would be a miracle considering the miserable state in which most of us are in when we get there and the rushed manner in which the intake is done by the staff. I would also argue that the word assist as stated in the brochure would be better replaced and be far more accurate if substituted with the word forced.

"11. The staff may search patients or their rooms if warranted to protect against any items that may be of danger to patients. Patients will be notified in advance of any searches and will be in attendance if their rooms are checked."

This particular rule is seen everywhere in mental health residences or programs, but it was used as a threat on our ward. The night before I left and after dinner, one of the staff came into the lounge while we were smoking and asked us if anyone knew about a missing spoon. She was a heavyset woman with blonde hair that was pulled out of her face in a severe ponytail. They counted the silverware after every meal to ensure that no one was surreptitiously sharpening it into a knife or other weapon. We all mumbled "no" and took up the conversation again. After a few seconds, she said menacingly standing in the doorway, "well, I guess I'll have to do room searches!" and proceeded to slam the door behind her. I looked at the person next to me and said, "she'd better get our consent first and have us in the room or I'll raise holy hell." Everyone seemed quite indifferent about the whole thing but me. I had a reason to worry. One of my visitors had, at my request, snuck in a diet coke for me, and there was an empty glass bottle in my bag. I was afraid I would be reprimanded for my flagrant nonobservance of the no caffeine rule (see below) in addition to having glass, which was strictly verboten. They never did search our rooms, and I never found out what happened to the missing spoon.

"12. Because of the ill effects of caffeine, this is a caffeine free unit. Please inform your visitors to bring only caffeine free beverages."

This 'responsibility' on my part was particularly difficult to maintain since I was a bonafide caffeine addict. Before coming to Fowler, I drank the equivalent of four to five cups of coffee per day. I had severe caffeine withdrawal in the form of a hellish migraine-like headache 24 hours after my last caffeinated beverage. The nurses gave me a rubber glove that I filled with ice, and I managed with that until they finally took pity on me, and Dr. Allen okayed two cups of regular coffee per day, at breakfast and at lunch. This was in addition to the contraband diet coke I was getting from the outside. It was amazing how criminal I felt when appropriating diet coke.

On the third day, I was asked to complete an MMPI (Minnesota Multiphasic Personality Inventory), and I obliged happily. I had completed one before during college, and I knew it would kill a couple of hours (I was always looking for something to do because I had so much time to waste). Besides, I was familiar with the scoring, and it amused me to know I was a biased subject. The psychologist on the unit had directed staff to give it to me. I wasn't even sure who the staff psychologist was. I think I saw a glimpse of him on my first day when I accidentally walked in to a staff meeting. Nevertheless, I completed the questionnaire (which depressed me by the way) and asked staff when I would get the results. No one knew what to tell me. I was finally directed to write a note to Dr. Wheeler about it, but it was certain he would not have time to score it before I was discharged, which was the next morning. I never saw him or heard from him before I left, and it was during my meeting with Dr. Allen that I learned it was the insurance company that had requested it in the first place.

That day's meeting with Allen was especially frustrating. After my first meeting with him, I didn't realize that he frequently got into power plays with his patients, but we all quickly figured out just what a control freak this man really was. That morning I told him that I wanted a copy of my records before I left. His reaction was quite unexpected. He said I couldn't just have a copy and that I'd "have to get a lawyer" if I really wanted my records. I grew very indignant, telling him repeatedly that it "was my legal right" to see my chart. I asked him if I could read the crisis evaluator's summary, and he said no, that she had sent it to him not me. He then tried a different tactic, saying I "wouldn't want them anyway, that "there's nothing to see," "they cost a dollar a page" and so on. He asked me why I wanted them. I said because there was maybe something staff observes that I don't see in myself, and besides it is my legal right. I don't remember how it ended. I just knew that now more than ever, I was going to obtain my records.

Another putatively important person in my treatment, who was also a part of my "treatment team" included my primary counselor, Jennifer. I met with her on the first day, and she explained to me her role and answered questions I had about the program at Fowler. She told me that on the next day she would talk to me and give me some materials on depression on which I could work. The second day came and went with promises that she would still meet with me "later." I never met with her either that day or the next though she worked the evening shift both nights. I never mentioned our conversation. The only words I did have with her was to ask her if she would sign as a "witness" on my release of information form so that I could obtain my own records.

"No," Jennifer responds, "I won't sign this until I've talked to the doctor."

"It's my legal right to get them."

"I know," she says peevishly, "but we usually get the doctor's approval first, and unless you've already talked to him..."

"I have, and he discouraged me from getting my records," I said.

"Well, then definitely I want to talk to him first." We are both standing eye to eye and although I think I'm sounding effectively intimidating, she is too. Besides, she has the control. Did I really expect to win?

"Well, I would appreciate it if you could get back to me on this issue ASAP," and I turn around and walk off toward the lounge.

"I will get to it," she says emphatically, "as soon as I can."

I looked over my shoulder at her when she said this, and I could tell she was pissed off that a patient was demanding she do anything. Asking for my records, however, can hardly be considered an unreasonable request.

Ten minutes later, after I had just gotten off the phone with a therapist I had set up an appointment to see, I went back to the nurses' station and asked someone for another release of information form. I guess I hadn't learned yet that you can't win against people who know they know better than you.

"What do you want it for?" I was asked by a staffperson.

"I need to send my records to..."

"Look, you've already talked to both Jennifer and Trisha about this, and you will just have to wait for the doctor...," interrupted a nurse. She was sitting behind the man I was talking to. I looked over to her; what the hell? I thought. She must have seen...

"I am not talking about that," I snapped at her, "I need to have my records sent to a therapist that Trisha referred me to." I turn back to the staffperson. Looking directly at me, he says,

"No. Talk to your primary counselor about it."

I was extremely irritated by now. After having been denied Jennifer's signature, I had sought out my treatment coordinator, Trisha, a wonderful woman who I knew I could rely on for help. Earlier that morning, she had let me read the crisis evaluator's report that Allen had refused to let me see. I had explained to her that Jennifer had refused to sign a release for me to obtain my own records, and saying "I have no problem with that," she signed as a witness. The nurse in the background, who I hadn't noticed, obviously saw the whole thing.

It was definitely obvious that Fowler was understaffed, and the staff who were there were under a lot of stress and had too much work. If not, how can I explain their indifference toward their patients? I am not yet willing to completely attribute it to the known effects of institutionalization, but there was definitely a general diffusion of apathy which infected both staff and patients. Staff also would use the control and power they were granted to coerce patients into compliance, and when you are in a locked ward, you have no choice but to comply or lose your "privileges." Most of the patients were anyway incapable of asserting themselves, and there was no one, not even the "patient representative," who could effectively voice the inhumanity and injustice we all felt while locked in there.

I asked some of our smoking group if they didn't also feel like they were being treated like, in my words, "five-year olds." All nodded and mumbled agreement, and some of them began telling us how Fowler was far superior to other places, like Cooley Dickinson Hospital in Northampton (where I could have gone) and the VA Hospitals. However, as much as they were glad to be in a place which was comparatively better than other facilities, I had no comparison to make and was unable to appreciate the benefits of Noble Hospital's psychiatric ward. In fact, incarcerated seemed more apt a term than hospitalization. I hated Fowler Wing and everybody running it for patronizing me and treating us all like we were demanding too much or wasting their time. It was the worst experience of my life, and I vowed it would never happen again.

On the eve of my discharge, because of the events of the day, I had my first completely identifiable anxiety attack. I could hardly eat all day, but this time it was not due to depression. I again felt that depersonalization that feels like everything is surreal, reality having long ago disappeared. As I shuffled down the corridor in my slippers, I thought about how I could never adequately explain this to anyone, and when I did, I felt that catch-22 feeling that they wouldn't believe me anyway, that what I said was overexaggerated for effect or because of my illness. How can I describe how it feels to be trapped, shuffling around like a zombie with nothing to do and waiting patiently for the next smoking break?

Solzhenitsyn in the Gulag Archipelago gives incoming zeks good advice on surviving imprisonment. He said you had to forget about your former life, your family, your home. You must forget everything from before; if you do not, you will not survive. A few times during my institutionalization, I did manage to forget where I was, like when we all watched the movie First Blood, the first Sylvester Stalone Rambo flick. The only times I laughed were during those rare moments. However, many times I failed to forget and when I would read some of the short stories in the Norton Anthology, I found myself wishing I could be that character because at least he or she was living in the real world. I think Solzhenitsyn is right; if you dwell on the past, it's all the more painful in the present. I yearned for my bed, my own room, the freedom to drive anywhere I wanted. I was helpless.

Somewhere in my chart was written "high bolt risk." I, of course, examined the windows and fantasized about escape, but I wasn't that desperate yet. I was putting faith in my Saturday discharge. What were they thinking? For what reason did someone somewhere decided I was a high bolt risk? I'd never been hospitalized in a locked ward before, and I had no previous 'escape attempts.' I'd never had anywhere to escape from. Of course, it is quite like me to run, hitchhike to Amherst, go home and wait for the police to take me back. Or maybe they were worried I'd find a gun shop, buy one, and do the deed before they had a chance to nab me. So little of the whole experience made sense.

I attained the most important "privilege" on the third day, group walks. In a moment of kindness, Allen had granted me this privilege. I went outside for the first time in 3 days. It was wet, rainy and cold, but I was so happy I almost began crying. The walk itself was about five minutes in length, enough to smoke one cigarette. I was amazed to realize the hospital was small, no bigger than my high-school. We walked into the hospital through the main entrance, past admission, beyond surgery around the corner to the Fowler Wing. On the door to the wing was a sign saying "BOLT RISK." I laughed silently, thinking that's what that meant in my chart!

By the third day, my self-imposed isolation in my room with my books had taken its toll, and I was eager to tell my story to anyone who would listen. I had also discovered that one of my diagnoses, other than major depression, was "borderline tendencies." I was shocked. I couldn't stand borderlines, people diagnosed with borderline personality disorder, and I disliked having to work with them. They are manipulative, needy, and attention-seeking. They are the ones who in relationships will threaten to kill themselves if their boy/girlfriend breaks up with them. They are in my mind, the most irritating clients with which to work. Trisha explained that having borderline tendencies is not the same thing as having the diagnosis of borderline personality disorder.

"Oh yeah?" I ask. "Then explain to me why that is written there!"

"You tend to get close then distant, close then distant. You dropped hints rather than explaining who you are and then you refuse to elaborate."

"Okay, what else?" I demanded.

"You're impulsive, and that's a major characteristic of borderline behavior."

I was silent. With what had I to argue? I'd left my Diagnostic and Statistical Manual at home. I brooded on this all that day, the next, and the next. I was afraid that this label would stick, and everyone I would see who could help me would be biased, see "borderline" traits coming out everywhere in my behavior. I agree that I'm impulsive. However, it's only the actual timing of an act that's impulsive. I don't know what day I plan to do something, although I've usually thought about it all out long before then. I had thought about getting a tattoo years before I actually got one. I'd thought about piercing my nose for months before I did it. Now that I had this impulsive label, I began to understand why everyone thought that I was a "high bolt risk." However, what I guess they didn't also know is that I was much too much a control freak to ever act without careful consideration.

On the morning of my discharge and after I'd taken a shower, packed and brought my things to the nurse's station, I learned that Allen was not expected until 1 pm. The day before, I had told him my discharge was at 11 am, and he had asked me if I could move the time back until one o'clock.

"Why, do you want to sleep late?" I had asked him sarcastically.

"I have things to do," he answered, obviously oblivious that I too, had a life to get back to. I agreed to be discharged at one.

The person picking me up had to go to work immediately afterwards, and when I learned he wasn't even going to be at Fowler before one, I was in a rage. I didn't show it of course. In no way was I going to delay my discharge. The nurse refused to call him at home and explain that I had to leave at one, and I just walked around holding back the tears and hoping to god he came early. I watched MTV for awhile in the lounge. On the weekends the TV can stay on all day, yet another privilege for which we must be thankful! I went out on my second group walk, this time to the store. Of course, I had forgotten to bring money, and this blackened my mood even more. I snapped at everyone to hurry up while ringing my hands because of the cold, and I walked on ahead, worrying about the time and smoking as many cigarettes as I could.

Dr. Allen came in a little after noon. I was relieved. He took me into his office, and we both sat down.

"How are you doing?" he asked.

"Fine," I answered.

"You don't look fine. You look depressed."

"I just want to go home."

"Are you suicidal?
"No," I said, wondering if he thinks I'm lying just so he'll let me leave.

"Okay good. Well, what are you doing about follow-up treatment?"

"I'm seeing a therapist on Tuesday, one that Trisha referred me to."

"Oh, good. Well, I just need to do some paperwork which will take 15 to 20 minutes, and if your ride gets here, then you maybe you can leave early."

"Great. Thanks," and with that farewell I walked out ready than ever to leave. I thought I would have been elated. I wasn't. I didn't wanted to stay there, of course, but the day had gone so wrong. The staff once again had been intransigent in granting my requests, and I felt helpless again. Feeling helpless is as bad as feeling hopeless.

There was more than one instance when a staffperson or nurse who had angered me was close enough that I thought about hitting them, which indicates how upset I was. I rarely fantasize about violence toward other people. Take for instance the nurse who refused to call the doctor earlier that day. She didn't just refuse. She talked to me like I was an insistent child who just couldn't take no for an answer. In the discussion groups, we had talked about how we needed to speak up if we wanted something, how we had to be assertive in getting our needs met. Yet, every time I or someone else did, staff would assume a sententious air and respond to you with impatience. It was enough to demoralize me. I just couldn't be happy even though I knew I would be leaving soon.

Even at the time, it was obvious to me that hospitalization had hardly helped my depression. I had to expend most of my energy on salvaging my human dignity. I had rebelled. I brought in caffeinated drinks, used my own lighter that they didn't realize I had, organized a petition to change the smoking times. But it was still useless. That part of me that had been convinced I could do anything, confident that I controlled my world, had left, and I was felt like I was drifting without knowing where I should be or go or what I should do. I had been a rat in a learned helplessness experiment; I no longer cared if I got shocked because I knew there was no escape. I had, like many others before me, been squeezed through the mental health system. This manuscript is testament to that experience, and I dedicate it to the patients at Noble Hospital and to everyone who has ever been institutionalized. I hope it helps.