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Poor Bastards

Way back when I was dating the university’s president’s daughter I scored an internship at a psychiatric hospital in a rough neighborhood of Philly. Flagrant nepotism but incidentally I knew psych, I was helpful during my stint and could empathize with the patients better and get them to comply with their medicines.

None of the med students wanted to pursue psych as a career, they were just doing their rounds so that they could practice some other type of medicine, and had no emotional stake in doing a good job.

When someone goes crazy enough to provoke someone to call 911 and the cops dump the guy in our lap, we usually have just seventy two hours to repair the patient’s brain. That’s crazy.

First we have to sedate the patient with a major tranquilizer. Then that has to wear off. Then we have to diagnose the patient. This is difficult, especially in a rough neighborhood where drugs, namely PCP (Phencyclidine, aka Angel Dust), are prevalent, as we have to determine if the patient is psychotic because he has such a drug in his system that is making him appear psychotic and most likely schizophrenic, or if he is indeed schizophrenic, or if he is both schizophrenic and also experiencing the effects of PCP as a lot of those folks do PCP.

What also takes time is coming up with the right diagnosis. A lot of patients to observe, not much staff, and again, not much time. There are many different mental diseases that present with similar symptoms with only subtle differences, and it is important to get the right diagnosis as it may call for a completely different form of chemical and psychotherapeutic treatment.

Note, these patients generally want to remain crazy and don’t appreciate being incarcerated, compounded by the fact that most of them are black and all the doctors and students I worked with were white. And many of the patients already had had a negative experience with the hospital.

So there’s no trust and very little cooperation. Instead of trust, just a lot of involuntary injections of Haldol (a chemical restraint, a major tranquilizer that can be ingested intramuscularly) and a lot of strapping the patients to their beds and threatening them with taking away their smoking privileges if they don’t submit. Try talking a patient into taking his meds when his legs and torso are strapped tightly to a bed in a crummy  psych hospital while jonesing for a cigarette.

Once a wild guess of a diagnosis is determined (called a “working diagnosis”), then it’s time to prescribe some drugs. Then if during our daily five minute interviews and watching them wander around and scream we determine we misdiagnosed, we have to start over.

Some drugs kick in in twenty minutes, Thorazine for example, and they are effective in nuking the crazy out of the patient. Problem is, most antipsychotics like that not only stop a patient from feeling so high that he thinks he’s Jesus (messianic delusions are usually fun), they carry very strong and undesirable side effects, and permanent health risks that some of the patients who aren’t illiterate find out about (diabetes, impotence, no sex drive, weight gain, hair loss, the “Thorazine Shuffle”), and then tell the other patients.

Patients become good at “lipping” their meds (we watch them take the drugs to make sure they’re swallowing, but they dupe us).

Other drugs that would have the potential to treat a manic depressive successfully to the point that he could function in society with tolerable or zero side effects can take a week to engage, and then months to modify the dose and introduce other drugs to combat any side effects until the perfect “cocktail” is achieved.

Back to the seventy two hours: We had our own court in the hospital, judge and everything, in which the patients we want to keep longer than 72 hours (basically all of them) can challenge us, and most of the time, unless we can make a very compelling case of threats of violence and suicide, the judge lets the patient go.

A patient can also be released on a technicality: One lady we had suffered from AIDS, but was so obviously schizophrenic. Her pro bono lawyer successfully argued that because AIDS, a somatic or organic condition and not a mysterious mental imbalance, can induce psychosis, therefore we have no right to keep the patient against her will. That woman needed our help, and we might have been able to keep her if she didn’t have AIDS on top of schizophrenia. Blew my mind to witness that.

Some patients were released from prison and given directly to us. That actually gave us an advantage, histories of criminal violence (including recent incidents in the prison – one man spent eleven straight months in the hole), as we could use it as leverage with the judge to keep the patient longer.

Not only that, when we discharge a patient, we can only give them prescriptions and beg them to go to CVS and fill them, we cannot give them a few bottles to take home. We could inject a drug like Haldol into their muscle involuntarily which would slowly release and treat them for a month, but that doesn’t sit well with the ACLU.

Mental hospitals that are understaffed and treat patients who don’t have money and good family to help (family is key and I don’t recall one family member coming to visit), patients with nothing to lose, are really a waste of space whose only effective function is keeping crazies off the street for a little while.

The deck is stacked against the mentally ill in the best of circumstances, and in these circumstances the deck has already crushed them. I read somewhere that the largest group of patients occupying all hospital beds in the world are schizophrenic. Half the homeless are schizophrenic.

That was in 2002 I think. By now I’d wager most of the patients I got close to are dead. Man, I saw some sad shit.

Doug Simmons

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