Anosognosia

I frequently experience thoughts of suicide. They are rarely actionable and they are rarely fantasies about actually ending my life- these seem to only emerge in my darkest moments. Instead, these they are little snippets of conversation that I imagine occurring between people I know in which they discuss my passing by my own hand. I think this stems from the embarrassment I feel at the state of my life, and a sense that this would be a thing that would put my feelings in the proper context for people, that it would be a full expression of the desperation I feel at the slow drag-along-the-ground that I am experiencing and that I fear will be interminable. 

In my most desperate periods of fear and agitation I have taken myself to the emergency room, towards what purpose I no longer understand, but one must be very careful in these environments. Talk of suicide can get you institutionalized. Ideally, when you visit the emergency room you get a little bit of valium instead of a trip to an institution. 

And an institution is a place to be avoided. Statistically, one is much more likely to commit suicide after release from a mental institution. This is paradoxical at first glance, but makes more sense if one is familiar with the mental health system. A mental hospital is not a place of healing. It is simply a legal obligation on the part of the state to warehouse people with inconvenient or unpleasant thoughts, feelings and behaviors- they don’t provide you with talk therapy, or healing touch, or meaningful assistance with the material problems of your life. While there are pretensions of providing trauma-informed care in most hospitals, it is often the care itself that is traumatizing. Therefor, I am very careful with my statements to the myriad of healthcare professionals with whom I interact in my thus-far futile efforts to turn back into a functional adult person. I don’t talk about these specters of suicidality, lest I end up hospitalized and emerge sicker and more medicated.

It is a strange experience visiting a psychiatric facility for work when I feel so off myself. Certainly, I am doing a bit better than the majority of people committed here, at least on the outside, but not two years ago I was in a partial hospitalization program at this very same facility . They slapped a number of new diagnoses on me related to substance use, drug-tested me and had me participate in a bunch of useless, insulting ‘life skills’ groups. I discharged myself from the program after they played Sweet Home Alabama in music therapy. I can take pointless breathing exercises and stress management worksheets, but I draw the line at singing along to segregationist anthems. I am lucky that I had the choice to discharge- many others do not. 

The patients on the top floor of the hospital are those that are considered the most ill. I don’t know if this is a spatial arrangement that holds true in other facilities. This is the only one I’ve ever been to, excluding the ones that I was committed to as an adolescent, and those are too far in my past to remember. All I really recall of those experiences is the sense of confinement and the fact that the ceilings were covered in pats of butter launched from spoons by bored patients.

Patients on this unit are not infrequently forensic cases, which means they have been committed in lieu of going to a correctional facility if they are found to have been insane at the time that they committed a criminal act. Everyone on the unit is involuntary, and while there are many people at the facility who are being held for emergency evaluations that typically last three days, this is not that type of involuntary. These are people that the state has decided they are going to apply to treat involuntarily, which generally means at least a three month stay. It is rare that I know the particulars of why someone is in the hospital, but occasionally a patient will tell me, will even show me their court paperwork. 

Very rarely, the person in charge of advocacy at the hospital will provide me with some insight into their case and I have generally perceived this to be in the service of biasing me against the patient in some way. There is only one occasion that I can recall in which this was not the case, and it was a passing comment in which she implied that she thought a particular patient did not belong on this top floor unit. Then she hedged and said something about the patient believing she had pinworms, which still doesn’t mean she’s a threat to herself or anyone else (other than being a potential vector for pinworms). 

This unit is the only place in the facility where the staff are friendly to me. I don’t know why this is, and I never asked for fear of changing the dynamic. The degree to which this is helpful in navigating the floor is profound- I can ask who is new, who is having a bad day, and who might want to talk. This is purely for my own convenience. I’ve been burned out on this job since I began- it has never been easy for me to walk up to a stranger who is legally confined and ask if I can help them while knowing that I definitively, absolutely can’t. My role is strictly window-dressing to make the system seem more humane. The things I most frequently do with patients are refer them to their lawyers, refer them to another advocacy organization, or help them fill out the hospital’s own complaint forms, which are frequently ignored (though this is ostensibly illegal) and when they’re not, are responded to with a great deal of victim-blaming and dissembling. The people who generally want to speak with me are too psychotic to realize that I’m useless to them. 

On this occasion though, every staff person I encountered pointed me towards the woman who the patient advocate had mentioned. They said she didn’t belong, that it was a mistake that she was in the hospital to begin with. This is a strong statement considering the sources. My colleagues don’t hold the floor staff in high regard, comparing them to cops and prison guards. I have a hard time lumping them all in like this- certainly some of them are brutal and some of them are dicks but on the whole they are just working class people, and the hospital is a stop along the way to somewhere else. With that being said, there are few of them that would question the logic of involuntary commitment and it is exceedingly rare that they question the premise under which someone is hospitalized.  

After being directed by several staff to intercede on behalf of this person I headed back to the low stimulation area, which is a misnomer. This is a segregated area of the floor where they put all the newly arrived patients and all the people who are loud enough that they’ll disrupt the flow of the unit. It’s a hell of a place to put someone fresh out of the emergency room. There was a young woman crying on one of the impossibly heavy, unthrowable chairs that they furnish the units with. Obviously this was her, the woman that didn’t belong on the unit. I introduced myself and she said what everyone says, which is that she didn’t belong there and that I needed to help her get out. She said that they were already discussing seeking an order to treat involuntarily- to my shame I scarcely understand the process of involuntary commitment, though I have tried at many junctures to get a grasp on how it works, however in my limited understanding, the wheels are already in motion from the moment you arrive in the hospital and they plan on keeping you past a three day observation. 

She’d arrived in the hospital after witnessing her fiance commit suicide with a handgun. She told me very little of this event, just the bare details- that the police had shown up at their house for reasons that weren’t clear to me and that he had walked outside and shot himself in the head. Understandably, her reaction to this trauma was some sort of meltdown, the specifics of which I do not know, and this had somehow landed her on the top floor of the hospital. 

She seemed distressed but lucid- she wanted to get back to her house, she was bereft that she had missed her partner’s funeral, and she was awakening to the fact that she was in a total and austere institution that was not interested in helping her but in holding her. She said she had a job at a nursery to get back to and a cat that might very well be starving to death in her absence. 

I offered to speak with her and her psychiatrist. This never helps, but sometimes it makes people feel like they’re being listened to. I asked her psychiatrist to meet with us and had to explain my role to him. Then he stated bluntly that it was his opinion that she was suffering from drug-induced psychosis. When she tried to ask clarifying questions he accused her of being hostile towards him and stated that he would leave if she interrupted him again. I asked him if he had considered the significant trauma she had experienced in his diagnosis. He told me he didn’t have any more time to talk to us and walked out of the room without excusing himself.  

I sat with the patient in silence for a moment, and then I said that I thought that her psychiatrist was very much an asshole. She agreed. Psychiatrists rotate through this unit every two months because the tiny, rural state this facility is in can’t retain them permanently. Some of them are decent (for psychiatrists), some of them are bad and some of them are worse. This man ranked among the worst. I expressed this to the employees in the low stimulation area and they agreed sincerely. 

On my way to the unit clerk to pick up complaint forms the woman’s social worker pulled me aside. This is always a bad thing. It means either that I am going to be asked to break someone’s confidentiality or that the social worker herself is going to break confidentiality. In this instance it was the latter. She wanted to tell me that though the patient presented well that she was a heroin user and that she was using other drugs- that she had been told by the woman’s sister that she used ecstasy, which according to the social worker was a type of speed that causes psychosis, and that her dead fiance was a well-known heroin dealer in the little town that they were from. I nodded my head through all of this nonsense. 

It was unclear to me what the social worker’s intent was. I doubt that she was unaware of my relative lack of power in the grand scheme of things, so concern that I would get the patient released was an unlikely motive. Sometimes treatment teams interpret advocacy efforts as harmful to the patient’s recovery, as if it somehow perpetuates delusions. Or perhaps she was embarrassed by this particular commitment and wanted to mitigate my judgement of her, her colleagues and the institution as a whole. Either way, I ignored her and  assisted the woman with a complaint in which she requested a new psychiatrist based upon his rude and dismissive behavior, and then we called her attorney to request a preliminary hearing to contest her commitment. 

I visited the unit a few days later. The woman I had worked with was in good spirits- she was braiding the long, tangled hair of one of the other patients and had picked flowers in the courtyard garden and arranged them in styrofoam cups on tables. Her legal aid attorney had secured her a hearing and the hospital was releasing her rather than taking her to court. It is at this point that I made the observation, not for the first time in my life, that relief is better than pleasure, and that there is nothing finer than deliverance from fear- not that it lasts, not that it sustains, but that it is like the finest analgesic regardless. Her release from the hospital would not wash away the image of a loved one killing himself, or relieve her of whatever other struggles would surely plague her the second her medicaid cab ride started driving her towards home, but they were momentarily forgotten with the promise of freedom.

I have tasted this myself at times. Sadly, most of the time the relief doesn’t last and the near miss turns out to have hit you dead on. Sometimes waking from a nightmare is not enough, and the preconditions that gave rise to it don’t just haunt you, they possess you entirely. I would be surprised if this were not the case for this woman, but still, I am glad that she wasn’t robbed of months of her life, that she got to smell flowers rather than disinfectant for the remainder of the short northern summer and that she wasn’t shot full of antipsychotics against her will. I hope she got to visit the grave of her lover and come to some sort of peace with that, although I have my doubts about peace and its presence in our lives. 

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