“How many people do you find dead in the alleys?” he demanded, wiping the tears from his eyes. “How many people die because you won’t hospitalize them?”
I felt my heart thumping against my chest. I said nothing.
“I know this isn’t your fault,” he recanted, wiping his nose on his sleeve, “but this is like losing my son.”
“I understand your frustration—”
“—no, I don’t think you understand,” he coldly interrupted. “He isn’t your son.”
I took a deep breath. “Let me rephrase that,” I replied. “You’re right—I don’t completely understand, but I’ve had to speak with many other families about situations that are very similar to this one.”
He looked away, the tears continuing to trickle down his face.
“He’s not going to accept any help—he thinks that the secret messages from the textbooks will save him. How much worse does he have to get before he’ll get care? He can’t go home tonight—I don’t know what he’s going to do. The law in this state grants too much freedom to people; it’s gone too far.”
My heart continued to thump in my chest.
His son was reclining on a gurney a mere two rooms away, his fingers intertwined with each other and serving as a humble pillow for his head. His right ankle was crossed over his left and his light brown eyes peered at the ceiling tiles. The hunter green polo shirt, overlaying a thin, white tee-shirt, complemented his smooth, cocoa skin. His jeans, purposely tattered at the heels, barely hinted at the shape of his lean legs. A metal watch with a large, orange face adorned his left wrist and a single ring of silver was on his right thumb.
“I know it sounds weird when I say it,” the son said, a self-conscious smile appearing on his face. He was handsome; his smile radiated warmth and playfulness. He ran his right hand through his shaggy brown hair, the thumb ring glinting from the overhead lights. “The case law not only provides information about how society has organized itself in the past, but also contains the collective wisdom of all the people who have lived before us. We cannot change the future if we do not understand the past. There’s the content of the papers; then there’s the actual messages contained within. Everyone can read the messages, but few people pay attention.”
It was his first year of law school. He had stopped attending classes a few weeks prior because he believed that he needed time to recollect himself. He was receiving too much information.
“The messages are everywhere—it’s almost like I need to assemble the information to make it coherent. This responsibility is daunting—but I’m learning so much about the genesis of morality. There are other ways of living; ancient peoples had codes of conduct that were superior to our current way of living. This information is accessible; it leaps out of the books in a different print—it’s like it’s between the lines, or the words really mean something else, or it’s a code. I don’t know why I have been selected by these past societies to transmit this information to the present time, but we could benefit so much from learning about this untainted information. It is a boon to our culture.”
He had borrowed over four hundred books from the law library; about half of them were overdue. They were stacked throughout the space of his loft, creating small towers of knowledge upon which rested numerous sheets of notebook paper, each covered with sentences that contained few commas and even less periods.
“I choose not to use the computer anymore,” the law student continued. “The radiation from the electromagnetic fields of the television and computer interfere with the messages sent from the past. I find that if I focus my mind on texts only, the messages travel with greater ease from the collective consciousness into my brain. Everything else is just noise, a distraction—and I can’t waste time. There are still probably close to a thousand books that I need to read to complete my edification of correct morality. Once I can capture all of these ideas and transform them into a succinct paper, then I can disseminate it to the public to resolve the world’s problems.”
Security officers had to escort him out of the library four times the previous week and police officers found him loitering outside of the city’s public library at dawn, forehead pressed against the glass, eyes closed, and kneeling in quiet repose, on three consecutive mornings.
“I can’t tell my dad about all of this; when I say ‘collective consciousness’ and talk about the interfering radiation, he thinks I’m messed up in the head. That’s not what I actually mean,” the son said, flashing that beautiful smile while coyly looking away. “It’s just a different way of communicating.”
“He’s psychotic,” I murmured to my colleague. “He’s totally psychotic and it’s probably going to get worse unless he receives treatment. He’s bright, though, and has enough cognitive reserve to pull it together. He’s declining inpatient hospitalization, or outpatient care, or any mental health intervention, really—he says he just wants to go home and read more tonight before going to bed, so he’s at least sharing a reasonable, safe plan—and we have absolutely nothing to offer the mental health professionals to get him detained. His dad is understandably freaking out.”
“Don’t worry,” the law student said, sitting up on the gurney, twisting his thumb ring. “I’m just trying to figure all of this stuff out; I’m not going to hurt myself or anyone else. I’m just trying to help humanity.”
“He’s telling me that he doesn’t need to eat as much anymore because knowledge is his primary sustenance now!” his father bitterly said. “He started yelling in the car about the absence of morality in my soul and hoped that the collective consciousness would blot my mind out because I am not facilitating the transfer of messages from the past to the present! My son—my son!—thinks that when he dies, the collection of knowledge that he has accumulated in his brain from these ’studies’ will spread throughout the world through the sixty-fourth dimension! This is not my son! And you’re telling me that he can’t get hospitalized?!”
I took a deep breath—I knew he was not going to like what I was about to say.
“In the state of Washington,” I began, “psychiatrists—physicians—do not have the power to involuntarily detain people for mental health reasons due to concerns about civil liberties. The only people who have that power are individuals known as “mental health professionals“, who are agents of the county. There are only two states in America that use this system. The reason why this system was put in place was that physicians could unjustly violate the rights of others—for example, if I didn’t like someone, I could get him detained for illegitimate reasons. This dual agency is problematic, right? Thus, a third party—a mental health professional—is called in to assess the situation and order detention, if he deems it appropriate. Mental health professionals, or ‘MHPs’, are generally social workers and psychologists who are familiar with both psychiatric conditions and the law.”
The father nodded.
“MHPs will only detain people if two broad conditions are met: The patient has to be an ‘imminent’ danger to himself, an ‘imminent’ danger to others, or gravely disabled—that is, unable to care for one’s own safety and health. These prior conditions must be due to a mental condition. These are the criteria that the MHPs look for when interviewing patients.”
I swallowed.
“MHPs need evidence that the patient is a danger to self or others or is gravely disabled. ‘Evidence’ means reports from witnesses who heard the patient make threats, police reports, things like that. This evidence is submitted to court in the form of an affidavit and the person who wrote the affidavit may have to testify.”
I took another deep breath.
“Your son would benefit from inpatient hospitalization to prevent further worsening of his symptoms. However, he is unwilling to be hospitalized at this point and we don’t have any evidence that he is trying to hurt himself or someone else… and he’s clearly still taking care of himself right now. Thus, it is highly unlikely that the MHPs would detain him.”
“So you’re saying that he has to get worse before he could get treatment?” the father sputtered. “What kind of law is that? I understand the concerns about freedom and whatnot, but this is my son and I don’t know what’s going to happen to him if he keeps on doing this stuff! What if someone assaults him outside of the library? What if someone beats him up because he’s going on and on about ‘the genesis of morality’ and ‘transmission from the past’ and ‘the collective consciousness’? I can’t take him home this evening—he doesn’t trust me—and he needs help. He’s not going to follow up at that appointment you’ve scheduled for him—he thinks that only the textbooks can save him—and so he’s just going to get worse?”
I felt my heart thumping against my chest. I said nothing.
His father put his hands over his face and began bawling, his hoarse voice breaking into sobs.
His son was kneeling on the floor in quiet repose, eyes closed, forehead pressed against the folded sheets of paper that were on the floor.
22 Apr 2007 |
I think a lot of people have a hard time understanding how deranged someone’s thinking can be and still not require psychiatric admission.
Comment by Greg P | 22 Apr 2007 @ 3:41pm
Very powerful entry. You make the patient, the father, and yourself, with all your intersecting and conflicting interests, equally sympathetic. I’m glad their are people with such all-encompassing compassion going into psychiatry.
Comment by LadyGrey | 22 Apr 2007 @ 7:28pm
Oh, the horror! The horror! Watching men cry is the worst thing in the world! It’s so heartbreaking.
Comment by tscd | 23 Apr 2007 @ 12:31am
*nods*
Thanks for that. Have been pondering “first episode psychosis” today before I read this. Our health system (Aus) is great at dealing with crises, but not so good at preventing them (ie. early identification and intervention) or dealing with the aftermath of them (ie. “you’re no longer floridly psychotic, you can go home. Ciao!”).
I hadn’t considered this side of the issue.
Comment by yay | 23 Apr 2007 @ 2:18am
I was THERE, in that scene you describe, as you wrote . . . your writing, well . . . I was so . . . in the story with you, as you were conveying it . . . such a well expressed experience, I felt the yank of a fisherman’s hook within my soul as the father began to sob . . . .
In other words, you brought the experience to life.
Wow. What a powerful experience and relation of it. If I had been standing, I would have reached out for support physically, unaware I was doing so; if it had been on my mp3 player, I would have stumbled or mis-stepped.
Comment by sarebear | 23 Apr 2007 @ 3:29am
In my opinion, studying/creating/researching is just as demanding as hard manual labor, or trying to survive a natural disaster, but in different ways. The mind can go on some sort of a marathon of its own and neglect the needs of the body for hydration, nourishment, sleep and socialization. The person studying and creating binges on it, isolating himself/herself in order to avoid interrupting his/her “productivity” or thought process. We all need a support system of family, friends, mentors, health care specialists and spiritual programs/guides to maintain our mental/physical/spiritual health. I believe this person is trying to separate from his father and grow into a calling of his own. He needs individuals other than his father to gently remind him how to pace himself. I hope our society’s safety net is adequate in this case. That’s my 2-cents.
Carol
Comstock Park, MI
Comment by Carol | 23 Apr 2007 @ 8:43am
Please consider submitting this to the NYTimes or the Washington Post as an Op-Ed. You did a magnificent job of explaining the limits and dilemmas of involuntary treatment.
I have been blogging, albeit not nearly as eloquently as you, about the possibility of applying universal criteria and standards of care and practice in determining the use of subsituted judgment. Just as a person who has dementia and refuses to eat, to bathe and to dress is provided with all of those - whether or not he or she consents, someone who does the same as a result of symptoms of mental illness should also be protected and provided with needed care.
There is no stigma when we put up siderails, refuse to allow patients to ambulate, and bathe them if they are too confused to consent as a result of physical illness or injury. Likewise, we need to protect patients who are unable to do so as a result of symptoms of mental illness, and we must make it the same straightforward process so that no stigma is attached to it.
Thank you for writing this post. It is incredibly powerful!
Comment by N=1 | 23 Apr 2007 @ 10:27am
Carol:
I’ll be interested to see what Maria might have to say, but this is not a description of the workings of a rational mind trying to figure out some personal dilemma. It’s not a job for counseling.
Comment by Greg P | 24 Apr 2007 @ 6:07am
I’d like to echo N=1, this is one of the most powerful posts I’ve read since I started following your blog several months ago. The frustration and despair of the father is truly heart-breaking, and I can feel how you have no choice but to deploy the force-field of professionalism in front of you to deal with the unimaginable desperation of this poor father.
Is there some way you can lure the patient into the hospital with piles of books to keep him busy? Though it seems that he is too intelligent to be easily persuaded by such a simple ploy. Though I can’t imagine myself being a psychiatrist (I’m a medical student), these kinds of situations remind me of the crippling burden of mental disease and how much the world needs thoughtful, understanding psychiatrists.
Comment by Michael B | 24 Apr 2007 @ 6:18pm
The person described in this post reminded me of one of my friends. No matter how ungrounded he was, because he was gentle and could “cover” well, he was never committed. It took a full-on episode before he actually was.
I go back and forth on the issue. On one hand if the person is not a danger to himself or others, why should he or she be committed against their will? However, the other side of it is the lack of insight that often comes with the strange behaviors (although yours seemed to realize on some level that some people might construe his thinking as odd), and if there is a lack of insight of course the person would not recognize the need for treatment.
It must be frustrating to be in situations like these.
Comment by catherine | 24 Apr 2007 @ 6:55pm
I am not good at rebuttal and hesitate to clutter the comments. I am not schooled in psychiatry. I am a just a layperson (not in the clergical sense) and parent of a college-age adult. Maria’s post is very provocative in conjunction with the recent Virginia Tech massacre. It conjures up all sorts of frightening scenarios in addition to the one the father fears. One of the scenarios I was imagining was that the patient couldn’t meet his father’s expectations to become a lawyer, and both father and son were in some sort of denial. If the father were to “let go” of his son because of his inability to carry him any further, his son might have to face his limitations, drop out of school (which he effectively already has), and learn how to support himself some other way. Is it possible for him to do this if he is psychotic? Has he been kicked out of his loft? Is he already homeless? Is his peer group capable of talking him into treatment? Can the street people do it? All of our hearts are thumping in our chests as we wait to find out.
Carol
Comstock Park, MI
Comment by Carol | 25 Apr 2007 @ 12:41am
I think this is one of the saddest things I’ve ever read. Powerful is understating it.
I also want to reiterate something I tried to say before on a previous post, but did so badly.
I have never been floridly psychotic. At least as far as I thought. But I have been committed against my will. People were shocked. I was holding it together pretty well, and once someone started asking the right questions and the thoughts in my head were revealed to be as dangerous and disconnected from reality as they were, it was determined that emergency in-patient care was required. I knew that people saw me as strange, as not right. And that was part of my shame. Still is, some days.
This young man is clearly much further along the path than I was. Should he be committed? As Carol said, this post is particularly poignant in the light of the shooting at VTech. I don’t mean to keep coming back to myself, but it is the only position from which I can honestly speak the truth. The rest is supposition and hearsay. From examining my family and personal history, left alone, mental illness does not usually just spontaneously “heal” itself. There is a reasonable expectation that things will over time deteriorate. The unknown is how quickly and in what direction. And is for that reason, that unknown, that some hesitate to help this young man see the world as it is rather than how he has constructed it for reasons that only make sense to him (and believe me, they do make perfect sense to him).
The anguish of the father hurts me the most. All I can see when I read that is the face of my husband as he rushed into the psych ward to see me, scared and alone and unable to walk out the door with him to the safety and security of my home. Whenever I start to think I can get along without my medication, that look of loss and pain on his face floats before me and I rethink things.
I can only hope the father gets his son the help he truly needs.
Comment by bp_hockey_chick | 25 Apr 2007 @ 11:22am
As I had opined in the actual piece, the patient was “totally psychotic”—and, indeed, people can be “totally psychotic” AND pleasant, charming, and demure. Popular media often portrays “totally psychotic” people as dangerous, violent individuals whom we should all fear—this is an inaccurate statement. One need not be “totally psychotic” to be dangerous and violent.
Our imaginations may insert reasons into scenarios that we do not understand; our brains drive us to make sense of things that seem confusing. Those of us who are more “rational” (a subjective term!) may conjure up more “rational” explanations for the behaviors of others, though these reasons may be completely incongruent with those of the individual in question. We can ultimately only comment on the behaviors and speech of others, not their reasons (because we can’t read minds—though we can generate hypotheses).
The principles of this story are true; the actual story is not. I will say, however, that the patient ultimately accepted mental health treatment, much to everyone’s relief.
Comment by Maria | 25 Apr 2007 @ 7:59pm
I’ve been in those shoes — dealing with a patient in need of services but unwilling to accept them, and not disabled enough to compel. It’s a tough sitation; a catch-22.
First psychotic breaks are terrible. They are life-changing and horrifying, and tragic.
Beautifully written.
Comment by shadowfax | 26 Apr 2007 @ 9:32pm
Just great writing… up to par with CAG-CAG-CAG..
You should do a “Best of”…
Comment by Marc | 1 May 2007 @ 12:18am
[…] three times,” she commented, referring to the sole agents in the state of Washington who have the power to involuntarily hospitalize people for psychiatric reasons. “They told me all three times that he’s unwell, but he’s not unwell enough. They […]
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