Yet after enduring so many irritations in her hospital unit—patients who wouldn’t stop talking, or who touched her, or sat in her favorite chair, or made noise in the middle of the night—she didn’t mind having time alone. New Yorker
“God Knows Where I Am” would have you believe that the government, through misguided activism, has extended too many rights to the mentally ill. They can no longer be locked up, as easily, against their will. As a result, people like Linda Bishop end up wandering the streets alone in the middle of winter and then starving to death in an abandoned farmhouse instead of wisely accepting the custodial guardianship of her sister, Joan.
They are not completely wrong. There is a problem. But I was disturbed by how quickly and easily these advocates slipped into the idea that it should be easy for a relative or guardian to take over an individual’s right to decide, for herself, where she wants to be. That’s one issue: her safety and health. But what may have really pissed off the staff at the New Hampshire Hospital was her continued refusal to recognize that they were right and she was wrong. I am sure they did not distinguish, in their own minds, between their concern for her well-being and their concern for their own status as gatekeepers. But one of the reasons for her continued incarceration, rather than the actual symptoms of schizophrenia, was that she refused to admit that they had justly appropriated her autonomy. That she had no right to decide whether she was competent or not.
…psychiatry is stuck in a kind of moral impasse. It is the only field in which refusal of treatment is commonly viewed as a manifestation of illness rather than as an authentic wish.
They are not, as I said, completely wrong. There are cases– Linda Bishop is probably one–in which it might be necessary for the state to step in to ensure that a patient does not cause herself or others harm. But there is one enormous flaw in this process and it should not be run roughshod over by those eager to save someone from themselves. It is this: we may very well use that custodial arrangement to lock somebody up in a hell-hole from which they have no chance– ever– of escaping.
Not one of the advocates for stronger measures for guardianship gave even a little credence to the possibility that the care that will be given to the secured patient will be inadequate, or incorrect, or downright negligent. Or worse. The New Hampshire Hospital, where she was institutionalized, seems like a fine, adequately funded operation. At least, for the much smaller numbers of patients they harbour today than they used to. But they didn’t acknowledge that, in the past, people with mental disturbances have been warehoused under brutal conditions. They could be beaten, assaulted, sexually abused, neglected, and abandoned, by an institution deliberately underfunded by an uncaring government unwilling to ask voters for more money to do a better job.
One of the untold reasons that the mentally ill were moved out of institutions in the first place was not really to free them but to save money.
Patients spent so many years in the hospital that they no longer knew how to leave it. (The institution has two graveyards for people who died in its care.)
Think about that.
It could mean they can’t find the exit. It could also mean that they don’t understand the paperwork required. It could also mean that after a certain amount of time spent in an institution the desire to leave, in and of itself, can be regarded as a symptom of mental incompetence. In Linda Bishop’s case, that is at least partly true.
It is possible that Linda Bishop might have received excellent care somewhere. It is possible that she was receiving excellent care at the New Hampshire Hospital in Concord where she was held for three years. But it is possible that the money would run out eventually and she would be moved to a cheaper, state-run institution that needed to save money by cutting staff and buying cheaper food and drugging most patients into oblivion so they wander aimlessly in the common areas to be watched by minimal staff.
During her first, voluntary, incarceration, Linda cried constantly for four days, feeling betrayed by those who had persuaded her to go in. Finally, she acknowledged she was suffering from delusions. From the accounts of the staff there, it’s not clear that they make any distinction between a real acknowledgement and the more obvious fact that she gave up trying to convince them that she really was sane and decided to play along so she could be released. If that’s what she wanted, it worked: she got a prescription. And a release.
One interviewee argues that one would never allow a patient with a bleeding wound from the chest to just walk out of a hospital, so why would you allow a patient with bipolar disorder do it? Well, one reason is this: one doctor thought she was bipolar, but another psychiatrist thought she was schizo-affective. So one doctor thinks the patient needs stitches to a wound in the heart and another doctor thinks he needs a cast on his leg. And perhaps the surgeon puts in a catheter.
Let’s think further about it: what patient, after getting treatment for a bleeding wound, would intentionally rip out the stitches? Yet patient after patient who is on medication for a mental illness stops taking their medications. The medications make them feel less alive, drugged, indifferent. They feel less creative. Or they start to feel great but they don’t really seem to believe that the drugs are responsible.
And let’s take note of something else: there is well-known experiment in which a group of perfectly sane psychology students posed as schizophrenics to get themselves admitted to psychiatric institutions. Once inside, they all behaved exactly as normal, and requested a reassessment and release. I don’t believe a single one of them was diagnosed as sane and released. Not one. Not one. When a resentful psychiatrist dared them to try his hospital, they announced that they would. A few months later, that psychiatrist had identified a fair number of “fakes”. The problem is, that none of them were: no attempt was made to infiltrate that hospital.
At one point, again, Linda was offered access to a funded apartment for people in transition. But to get it, she had to sign a document which essentially forced her to admit that she was mentally ill. She refused. Logic, here, somebody, anybody? A woman refuses housing intended to help the mentally ill because you want to force her to admit that the diagnosticians are right and she is wrong and, more significantly, she is not competent to determine for herself whether she is sane or not. And if she doesn’t sign– in other words, if she really is mentally ill– or she really is not mentally ill– it doesn’t matter– she doesn’t get the help intended for …. the mentally ill.
What she needed was a Hogeweyk: the Dutch institution for patients with dementia who want to be free, and wander the community, and shop, and go to school. The Dutch solution: build a “school”, a “store”, a “community”, staff it with mental health professionals, and let them “free”. Everyone’s safe. Everyone’s happy. It’s a marvel of common sense and practicality.
When Saks was a law student at Yale, she was restrained and medicated against her wishes; she calls it one of the most degrading experiences of her life.
I really believe there should be a constitutional amendment that says this: if the state is going to deprive an individual of the freedom to come and go as he or she pleases, it is required to provide the kind of quality of care that an objective observer would characterize as “excellent”, including good quality food, adequate staff, and opportunities for exercise, activities, relaxation, and privacy.
And it absolutely should include facilities like Hogeweyk.
If not. If it cannot guarantee that level of care, then the forced institutionalization of individuals with mental problems is nothing more or less than imprisonment and even toture.
Right now, if the government, fails to provide enough funding to make these individuals comfortable, our elected representatives are not subject to any serious consequences. Only the inmates bear consequences, in the form of neglect, restraint, harassment, lack of privacy, and abuse.
Incidentally, is the belief that there is not such thing as global warming really, in substance, all that different from the belief that “they are spying on me” and “they are out to get me”? They are both equally fictional.