Falling Down (6)

“Just living is not enough.  One must have sunshine, freedom, and a little flower.”
– Hans Christian Anderson

First Person

+178:23

This story is true.  Everything happened.  To me.  All the events listed occurred.  All the opinions about them are my own.

Institutional mental health is a mess.  There is no better way, no softer, gentler way to put that.  And I say that with absolute respect and gratitude to the men and women of the staff who worked with me, who work every day with difficult patients under difficult circumstances, in the facility in which I stayed and in all the others.

Why did I get 5150’ed?  I suffer from chronic depression, and for a variety of reasons it had become severe.  I went to a psychiatrist and before our meeting I filled out a form.  On it I indicated that I had frequent suicidal thoughts, and at the beginning of our conversation I indicated that I had a plan.  That was all that was necessary for me to be hospitalized.

Did I want to be 5150’ed?  No.  I knew it might happen, but what I wanted was voluntary treatment.  I had a plan, but I did not have intent.  I wanted help, not death.  Had I wanted to kill myself, the last place I would have gone was to a psychiatrist.  Had I wanted to kill myself I would have attempted to kill myself.  However, from the point of view of my psychologist, I had crossed a line.  Even the potential for me to be a danger to myself was enough to trigger this response.  There were, I believe, two reasons for this.  The first was that the moment I had walked into the office, the psychiatrist had a duty of care for me – they became responsible, in part, for my current and future well-being.  This is part of the cost of being a doctor.  Because suicide is final for the victim, and a potential threat to individuals nearby when it happens, one must tread very carefully when it comes up.  The potential for harm is great, and the response must be proportional.  The second reason is that we live in a very litigious society.  The potential for the psychiatrist to become embroiled in lawsuits were I to do damage to myself or others after reporting my issues was certainly significant, and could ruin their life and career.  To protect themselves, they needed to act decisively and with an eye towards even a small risk of big litigation.  This is the way the world works.  Nevertheless it is sad that a decision that has such powerful and lasting effects on a patient should be made, even partially, with the well-being of the doctor in mind.

I don’t necessarily disagree with the decision to 5150 me.  What I disagree with is the results of that decision, the care I was given, and the operation of the facility I was put into.  Before I go anywhere further with that thought I want to say again what I have said several times – flaws in my care were for the most part not the fault of the staff who worked with me.  They were dedicated, empathetic, and worked hard at their jobs.  They truly seemed to care for the people under their charge – both their safety and their care.  But for some reason people far above their pay grade had made decisions that were inappropriate with optimum care and treatment of the people in the facility, and that largely robbed my time there of potential value.

To their credit, they got my blood sugar under control.  I do not underestimate this as a good thing.  It was important, and I am thankful that they did it.  They also brought my blood pressure down somewhat, which is also important.  However, these are physical issues, and while they certainly impact on mental health they are by no means the sort of problems that require one to be put into a locked mental health facility and have their right to freedom or decisions about the length or scope of their treatment taken away.  A day or two in the hospital would have had the same effect from a health viewpoint.

What they did not offer was any non-chemical treatment for my depression, or any opportunity (save one) to discuss the root causes of it or find any options that might improve it.  From that perspective the stay in the hospital was a near complete waste of time, useful only in that I spent so much time worrying about how to get out that the issues that had made me depressed went to the back of my mind.  The environment was not in any way gentle or conducive to my wellness – between bed checks and charting my blood oxygen monitor there was someone walking into my room approximately every five minutes for the whole of the night, and even waking me up if I had rolled into a position where my monitor was under the covers or face-down.  Coupled with the noises made by other patients, the light level being high, and the overall difficulty of getting to sleep in a strange place with strange noises, it was impossible to get the sort of sleep that doctors actually recommend for good mental health.  I never got more than 4 hours of sleep on any of the nights I was there, and the restfulness of even that was questionable.

Why was I 5250’ed?  Honestly I have no idea.  I have theories, but they would be nothing more than speculation without any facts to back them up.  Should I have been 5250’ed?  Absolutely not.  The law is crystal clear on the matter – a person can be 5250ed as gravely disabled ONLY if they have no support structure in the outside world.  A five-minute phone conversation with my wife would have revealed that this was the case, and she was listed on all my paperwork as a contact.  The only way that the hospital, that my doctor, could not have known this was that they failed to make even a cursory examination of my circumstances or history before filling out the paperwork.  But without examining my circumstances, how could anyone make the determination that I was gravely disabled?

The effect was devastating and will have long-term consequences for me.  The fact that I was 5250’ed after the doctor implied that I would be released, for reasons that were not even brought up in our short meeting beforehand, and that flatly did not apply to me – which could have been easily confirmed – functionally destroyed any faith I had in the doctor-patient relationship at the hospital, and damaged my faith in the doctor-patient relationship in general.  Admittedly it was only for a single day, and from the moment I found out until the moment I found I would be released was only 19 hours, but that was enough.  Nineteen hours of wondering what the hell happened and why, and facing up to fourteen days of additional involuntary hospitalization without any control over the matter, was terrifying, and the fact that the reasons listed on the paperwork seemed to be at odds with everything we discussed in our brief meeting made the whole institution feel suddenly like a sham – a ponzi scheme for the mentally ill.  Had there been treatment, and had I stayed longer, I think it would have taken some time for trust to be rebuilt, if it could be rebuilt at all.

And therapy cannot proceed without trust.  Trust between the therapist and the patient is one of the foundation principles of therapy.  Now that it has been lost, it will take time and effort for me to feel it again.  Subsequent to my release I met with a psychiatrist and a therapist.  I didn’t, couldn’t, fully trust either.

The same issue also flows from the patient side in a locked institution like the ward.  The institution rewards patients who give positive statements about their mental health, but lacks the resources to explore whether or not those statements are true.  If you say you are doing well  you get access to the cafeteria, for example, with its sugar and caffeinated coffee and portion control and access to brief visits outside the walls.  If it isn’t true, if you say you aren’t feeling positive, if you are sleep deprived and depressed and frightened, you don’t get to go to the cafeteria.  You lose the perks.  And for many the chance to get off the ward, to take some control over a portion of their lives – if only what they have for lunch and how much – and to get a few minutes standing in sunshine and breathing fresh air are the most therapeutic things that the institution can offer them that day.  The people who need these the most – the crushed and broken – are the ones least likely to receive them because these perks, which should be seen as therapy to help them, have instead been turned into a reward for appropriate behavior and response.

Truth and trust seem to be very tenuous in a locked facility.

The patient advocate, on the other hand, stands as one of the best and most inspiring parts of my stay.  This is a person who works day after day for the rights of people who come in dazed, confused, and likely neither knowing or in many cases caring about their rights as patients.  The patient advocate stands between these people and the institution, making sure that everyone’s rights are protected, and making sure that everyone knows what their rights are.  Her job was speaking truth to power each day on behalf of some of the most powerless people in our society.  I cannot but think that it must be a very thankless job working every day against the organization that signs your paychecks.  Her dedication was amazing.  I will never forget her.  I wish I could have shaken her hand.

Issues of mental health are difficult and convoluted in our society.  Much stigma remains towards those who are mentally ill or mentally disabled.  There are no easy solutions.   As I said before, it’s a mess.  But there is progress.  We have moved past the days of Bedlam Asylum.  We now have doctors and nurses and staff and real facilities.  Gone is the emphasis on warehousing the mentally disabled, at least in theory, though budget often constrains the sorts of treatments that are available.  There are lots of good people who spend their professional lives trying to make a difference, and despite the failings of the institutions they work for, they should be honored for that.

I would like to thank and honor my wife for her unflagging support during this troubled time in my life.  Though it was an hour’s drive each way to the facility in which I stayed, she never missed a visit, even in the face of terrible traffic.  Support of friends and family is a critical component in dealing with mental health issues, and from what I saw far too few of the patients who shared the ward with me got enough of it.  I was never made aware of the specifics of most of their cases, and I pass no judgement on their family and friends.  Because beds in mental health facilities are few and far between, patients are sometimes transported long distances for treatment – distances that may make regular visits from their support network impractical.  I am very lucky that this was not the case for me, and very grateful that my wife availed herself of every opportunity to be actively involved with me during my time in the hospital.  She is a fantastic person.

I would also like to thank and honor all the friends who pitched in during our time of need to bring to both myself and my wife much needed support.  A network is important at times like this.  Not everyone can be or should be the person who comes for visits in the hospital every day – for one thing visiting hours are just too short for that, and the number of people allowed at any one time too limited.  But rest assured I got all the messages you sent in support and was very grateful and humbled by the sheer volume of them.  I am also grateful for all the support you gave to my wife during a time when she was also alone, confused, and having to bear up under considerable pressure and stress.  All of you helped the situation immeasurably.

To the staff of the facility where I stayed – thank you.  You were wonderful.  You work hard at a difficult job, and your dedication makes a difference.

Finally, to those who shared the ward with me, thank you.  Being put in a locked ward cannot help but be a frightening experience for anyone.  Nevertheless, you took the time and energy apart from your own struggles to help support me when I was at my lowest ebb ever.  I will remember you all with gratitude for the rest of my life, and I hope that you are well and recovering.

End

Back to Falling Down (5)

Falling Down (2)

“Our treatments are designed to allow our patients to move toward a more independent future.”

– from the facility mission statement

The Ward

+19:15

From the back of the ambulance, the building looked dark and forbidding.  Ground floor windows were all treated with tinted, reflective glass, and there was no sign anywhere near the sliding front doors to indicate whether this was a hospital, office complex, dental hygienist college, or abattoir of unusual design.  The ambulance crew conferred by telephone with someone inside.  “We need to wheel him out to the front door,” one said.  “They’ll unlock once they see us there.”

Unlock, he thought.  This place locks its doors.

Out of the ambulance, through the rain, up to the front door which unlocked with a click, and into a pristine and sterile lobby, where the ambulance crew talked with several nurses and handed over paperwork while he lay still secured to the gurney.  He as embarrassed, lying there in his paper scrubs with straps holding him down.  He had been told they were safety belts.  But of course they weren’t, though they performed that function too – they were bindings, there to hold him on the gurney until such time as someone was ready to set him free.

After some conferencing, a nurse opened a set of double doors and the ambulance crew wheeled him in.  The doors closed and the nurse locked them and just like that there he was.

Locked ward.

It was quiet.  There was no one there but staff and one woman pushing a walker down the hall, muttering.  He was glad – he was going to have to live with people in this ward, and didn’t want them to see him rolled in on a gurney.  Of course they had all come in that way, but it was 5:30 am and he wasn’t really thinking about that.  But he felt acutely embarrassed and vulnerable, tied up and immobile and waiting at the pleasure of others to give him some limited freedom once again.

Jesus, he thought, all I did was fill out a form.  It isn’t as though I tried to jump off the bridge or take the pills or anything like that.  I went in because I was having thoughts, and I didn’t want the thoughts, and I needed help. 

I hope this is help.

He was starting to have his doubts.

After what seemed like a long time but really wasn’t, he got unstrapped from the gurney and led into an interview room.  There was paperwork.  (There is always paperwork).  The iPhone was taken away from him, dropped in a plastic bag, and sealed away.  He had to put up a fuss to retain it long enough to text his wife with his location.  Aside from his glasses, his wedding ring, one pair of underwear, and one pair of socks – all of which he had to sign liability waivers for (“the hospital bears no responsibility if these items are lost, stolen, or damaged”) he now had no possessions of his own.  They even took away his green scrubs and replaced them with blue paper pants and a blue tee shirt – what he would come to think of as “ward chic”.  They assigned him a bed, took a blood sample, gave him an injection, and he was officially finished with intake.

The ward had 16 beds – 13 occupied, including his.  It consisted of a single long corridor with rooms off to either side (some of them with two beds, some with three) and a glass “emergency exit” door at the end.  Through the exit door, if one stood just right, one could see a cherry tree in bloom.  At the other end of the corridor was the nurse’s station/staff area where records, equipment, drugs, and the phone were kept.  There was a vaguely seen room with a door like a walk-in freezer and a large window off the nursing station.  It was labeled “Observation”.  It was ominous.

Just off the corridor to one side of the nurse’s station was the day room.  This was the social center of the ward.  It had tables and chairs and a couch with stiff vinyl cushions.  There was a television behind a thick Plexiglas window.  There were crayons and felt pens and a few word puzzles.  Books included the AAA Guide to Spain, a travel guide to scenic Tuscany, and Wine and Food:  Pairings Made Easy.  There was art – apparently made by former patients – on the walls and partly covering the window, obscuring the view of a parking lot and the blank wall of the building next door.

Almost everything of any importance to the daily functioning of the ward went on in the day room.  Meals were served here.  Group sessions on topics ranging from anger management to personal hygiene and art therapy happened here.  Announcements about things happening on the ward and reminders about the rules were made here.  Blood pressure tests and blood glucose tests were made here (yes, there was blood work being done in the same place that patients ate and congregated.  Some of the patients didn’t like it, and when it was time for his blood draws he would frequently try to convince the nurses to do it somewhere else, but was often unsuccessful).  Snacks were distributed here.

The ward had a converted feel to it, as though it had originally been used for some other purpose.  Rooms were not uniform in size or shape.  There was a locked stairwell leading to the second floor.  There were areas where the walls were marked by signs that had since been removed.  It wasn’t a bad place (as such places go he had imagined far worse – a veritable bedlam of cages and damp basements) but it showed some age and hard use.

His room, which he shared with a glassy-eyed schizophrenic who said little, didn’t snore, and was in all ways about the best roommate that anyone could hope for – contained two beds, each with no sheet and a single blanket and a single pillow.  There was a writing desk and chair, which he couldn’t for the life of him figure out a use for given that they were allowed no pens or pencils, and crayons & felt pens were limited to use in the day room.  There were two individual lockers with padlocks for which the staff had the keys, which again he could not figure the use for given that practically everything he owned had been taken from him and locked away.  There was a window that looked out onto the same parking lot and blank wall as the window in the day room.  It got no direct sun.  There was a bathroom with no door but a shower curtain, a toilet that sounded like a jet engine when flushed (he soon learned the basic ward etiquette – don’t flush after lights out unless it’s a #2), a small sink, and a small shower stall with no shower head and a water control button that you had to push approximately once every 30 seconds to keep the water on.  There was toilet paper, some towels, and some soap available in the room.  Additional amenities such as shampoo, conditioner, toothbrush, toothpaste, a comb, and antiperspirant had to be requested from one of the nurses.

This was where he would be living, until others decided to let him go free.

Since he finished his paperwork about the time that everyone got up for breakfast, he had no real opportunity for sleep.  He ate a bland but filling breakfast (eggs, toast, bacon, and farina) but missed the coffee (which turned out to be decaf anyway).  He did what most people would do under similar circumstances – kept his head down, kept quiet, observed the others on the ward, and tried to figure out what the group and individual dynamics were.  He attended a group session, spoke a little to others, avoided snacking, and tried to put on his game face for the staff to show that he was feeling better and not the sort of person who would do terrible, terrible things that might get him put into a locked ward as a threat to self, threat to others, or profoundly disabled.  When he was not doing something else he tried to nap to catch up on his sleep, but unsurprisingly found it difficult in a strange bed in a strange environment surrounded by strangers.  He had his blood glucose tested four times, his blood pressure taken twice. and received his meds for both diabetes and blood pressure.  The hospital did not carry the type of insulin that his doctor had prescribed, he was informed, to he was getting a substitute.  They would be using a sliding scale to determine his dosage several times a day based on his blood glucose results.  They were very concerned that his blood glucose level stay healthy.

For dinner they served him pasta and cake.

That was how the day passed.

His wife and two friends came for a visit.  He was pathetically grateful to see them, fighting to hold back tears.  The three of them could only visit two at a time.  They had to be searched before being let into the ward.  He felt simultaneously ashamed that they saw him like this (disheveled, wild-haired, in paper pants inside a locked ward) and profoundly moved that they would go to the trouble of coming to see him, an hour drive away each direction. There was not really all that much to talk about – conversations about being 5150ed and life in a locked psychiatric ward were by mutual consent off the table – but the companionship was wonderful, like a breath of clean air in the midst of poisonous haze.  His wife promised to bring him some books to read (since Wine and Food, Pairings Made Easy held little allure and there were no plans to go to Tuscany), and at the end of visiting hours he watched his wife exit the locked door through which he could not pass.

At 10:00 pm the tv was turned off and it was time for everyone to go to bed.  This is when he was informed about the monitor he was to wear.  Because he had been diagnosed with sleep apnea, they intended to monitor his blood oxygen levels with the aid of a device that looked like a large sports watch attached by a wire to something that looked a lot like a clothes pin.  The watch went on his wrist and the clothespin went over one finger.  It monitored his heart rate, and shone a light through his finger to determine his blood oxygen level.  They were very concerned about making sure that his blood oxygen level stayed high, so a staff member would check on him and get a blood oxygen reading from the device once every ten minutes throughout the night.  If by chance he happened to have rolled over, tucked himself under his blanket, or had shifted his arm and the monitor so it could not be read, the staff would wake him up to get him to move so they could get their reading.  He was admonished to simply keep the arm with the monitor outside the covers with the monitor facing up so he could avoid having the staff disturb his sleep.

He pondered how he could do that while asleep, but could find no simple answer.  It turned out that for most of the night it wasn’t an issue though.  The woman across the hall, who had glossolalia, would talk or sing or clap and keep him awake, or someone elsewhere in the ward would conduct a conversation with things unseen, or the bathroom light – which could not be turned off – would bother him, or his own fear and anxiety would pull him away from slumber,  So the checks for his blood oxygen every ten minutes didn’t bother him much.  The bed checks ever ten minutes didn’t bother him either though they were not run concurrently with the blood oxygen checks which meant that someone was literally coming into his room every five minutes throughout the night.

In it’s own way it’s clever, he thought.  If you never get to sleep, you can’t suffer from sleep apnea.

The blood oxygen monitor also monitored heart rate.  His was in the low 90’s.  He spent a couple of hours trying to voluntarily lower it through meditation and directed breathing. while watching the monitor for positive or negative feedback.  Eventually he got it down to the high 60’s.

It was the closest thing he had to a video game.

A little after 3:00 am he dropped off to sleep.

It had been 41 hours.  No one had yet asked him why he was depressed.

Continued in “Falling Down” (3)

Return to “Falling Down” (1)

Falling Down (1)

Section 5150 is a section of the California Welfare and Institutions Code (WIC) (in particular, the Lanterman–Petris–Short Act or “LPS”) which authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes them a danger to themselves, a danger to others, and/or gravely disabled. A qualified officer, which includes any California peace officer, as well as any specifically-designated county clinician, can request the confinement after signing a written declaration stating the psychiatric diagnosis that the diagnosing medical professional believes to be the cause or reason why they believe the patient to be “a danger to themselves or others” or the psychiatric disorder that has rendered the patient incapable of making their own medical treatment decisions.

 – Description of the 5150 Involuntary Psychiatric Hold

Intake

+00:02

He sat in what they referred to as the “security room” – a room with three chairs and nothing more.  There was a guard at the door.  The room didn’t offer any sense of security, safety, calm, peace, relaxation, or surcease of unease.  It looked and felt like a very small unused office or a place where copy machines or supplies might be kept.  It lacked even motivational posters on the walls to provide a visual break from the bland paint and stark corners.

Thirty-five minute ago he had met with his psychiatrist.  Forty-five minutes ago he had filled out a one-page form rating various aspects of his mental state on a scale from 0-3.  He was depressed.  He was struggling.  He needed help.  That’s why he was meeting with his psychiatrist.  To get help.

“I don’t think I have a choice,” she had told him.

He had thought, had feared that this might happen.

His wife joined him in the security room.  They sat and waited and said little.  Time passed.   The security guard joked with other security guards and greeted staff members as they went back and forth in the corridor.  The room did not become more comforting.

Eventually two paramedics showed up with a gurney.

I can walk, he thought.  “I can walk”, he told them.  They smiled and nodded, clearly familiar with the routine and prepared for their reply.  “It’s just policy,” they said.  They started strapping him down as one guard briefed another “Just walk him as far as the elevator.  Once there meet with building security and make sure he gets into the elevator.  Once he’s in, he’s not our responsibility anymore.”

The last of the straps clicked into place and the paramedics wheeled him out.  His wife headed for their car to meet them at the hospital.  He was alone with two strangers, tied to a board.  They took him down in a freight elevator and wheeled him out the back of the building to a waiting ambulance for the short ride to the hospital emergency room.

At the emergency room he traded his real-person cloths for a set of green paper scrubs and was examined for physical problems.  He had to be healthy before he could be transferred because he wasn’t going to a medical hospital, and the facility didn’t want any surprise physical problems to deal with.  It seemed crazy, taking up a bed in the emergency room – he didn’t feel like an emergency.  Certainly not like the other patients there.  The ER staff did their examination, declared his blood sugar high (not surprising) and his blood pressure high (certainly not surprising) and then pretty much left him alone, except for his wife and a guard.  Time continued to pass.  Eventually it started getting late.  Eventually he was informed that he would be spending the night in the ER.  Eventually he was informed that they were having a hard time finding him a bed.  Eventually his wife had to go home.  She took with her almost all of his real-people possessions – clothes, shoes, wallet, keys – leaving only his iPhone, which was threatening to die.  He hadn’t brought the charger because even though he had some concerns in his heart he had thought it would only be a half-hour appointment.

There was nothing to do.

The guards changed shifts around once an hour.  From what he overheard guarding him was considered to be tedious and boring duty and nobody wanted to do it for very long.  There were frequent discussions of swapping duties over the radio.  One guard, however, started a conversation, and discovered he was from Oroville.  The guard became enthusiastic and animated.  Oroville, he said, was a place that he badly wanted to visit.  Oroville had something that he was very interested in.  Oroville had a Shakeys Pizza – the closest Shakey’s Pizza to the Bay Area as it turned out, and the guard really wanted to try Shakey’s.

Looking it up on his iPhone, he discovered that it was true – the town where he grew up did, in fact, contain the Shakey’s closest to the Bay Area – the only Shakey’s in Northern California.  The Shakey’s he had been in many times growing up, and was not far from his childhood home.  The incident was so bizarre that it made him, for the first time that day, actually question his sanity.  What were the chances of meeting a security guard in an emergency room who had a dream of driving to your home town and eating at a restaurant you went to all the time as a teen?  It just seemed to defy belief – like seeing angels or ghosts.

Sleeping in the Emergency Room was impossible.  He was lying on a glorified gurney with one thin blanket.  Just outside the area where he was being – what?  Housed?  Secured?  Stored?  – the ER continued about it’s business.  As the night grew later and turned into very early morning, there was a constant stream of patients into the ER – accident victims, a drug overdose, a woman moaning continuously from some abdominal distress, a man found unconscious and naked in a parking lot.  All during this time he continued to take up a spot in the ER, and the guard continued to wait just outside the door.

The guard also had to follow him to the bathroom when he peed, which he had to do a lot because they kept giving him fluids.  Some guards were circumspect about it, and simply admonished him to keep the door unlocked when he peed.  Others insisted on standing in the doorway, though they turned their backs (which was understandable – there are few who actually enjoy watching people pee).

A nurse took pity on him and charged his iPhone in the staff break room, and he whiled away a bit of time sending messages to some people and forwarding the occasional Facebook funny.

Then two more paramedics showed up with another gurney.  The hospital had located a bed at a mental health facility that was an hour away.  Again he was strapped down and carried towards a waiting ambulance.  But the hospital doors leading to the ambulance parking jammed and no one seemed to know how to open them, so eventually he had to be wheeled out through the waiting room, past family and friends of the other ER patients, waiting for news about their loved ones.

It had been eighteen hours.  Aside from a very brief explanation to his psychiatrist that amounted to no more than a general outline, no one had yet asked him why he was depressed.

Continued in “Falling Down” (2)