My month in a psych ward

I checked myself in to the inpatient psych unit of a major NYC hospital on January 23, where I would stay for nearly a month. I’m still sorting out what my next steps should be, but I thought people might be interested in some of the things I noticed.

  • The care I received was excellent and the staff were very courteous and professional. I would recommend hospitalization to anyone who is in crisis, especially if outpatient care isn’t working.
  • I received electroshock therapy and it worked like magic. There’s too much stigma surrounding this low-risk treatment that helps countless people live decent lives.
  • Hospital food sucks, as per its reputation. For some reason they put me on the Hasidic menu and never corrected it (I’m not Jewish). Then again, I never complained, largely because I developed a taste for gefilte.
  • Hospital life is hard. You’re not allowed to have pens or shoelaces. Somebody opens your door every 15 minutes to make sure you’re still alive. My roommate spoke in tongues and once tried to exorcise me. It was all worth it.
  • Nearly all the patients there were people of color– which makes me think our system is failing. Too many POC don’t benefit from decent outpatient treatment and are forced to rely on hospitalization, the most extreme treatment option. At least that’s my interpretation.

Have you ever been hospitalized? Does this shed any light on the treatment system? Let me know in the comments.

The secret history of mandated treatment

Mandated treatment is about society’s needs, not the mentally ills’.

On the evening of January 3, 1999 Kendra Webdale stepped onto the platform of the uptown R train at the West 23rd St station in Manhattan. She was 32, blonde and had a reputation for being kind to a fault, so it must have been typical for her to exchange words with the man beside her.

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Kendra Webdale

Then the man pushed her in front of an oncoming train, decapitating Webdale.

The man, Andrew Goldstein, had a history of hospitalizations for schizophrenia. When asked why he killed Webdale he later said he “just had the urge to push her.”

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Andrew Goldstein

In response to what he did that evening state lawmakers would pass Kendra’s Law, far-reaching legislation that lets judges mandate mental health treatment. But like any ambitious mental health program Kendra’s Law says as much about society’s fears as it does the needs of the mentally ill.

To understand what mandated treatment is really about, we need to understand those fears.

Kendra’s Law is a marketing tool designed to assure affluent white people that the problem of dangerous, crazed loners is under control.

Kendra’s Law is sweeping. It lets judges require people to submit to mandated treatment for up to a year at a time if they’re judged not to be safe without supervision and establishes teams of workers to provide services and monitor compliance. Though often justified with the rhetoric of public safety, a person doesn’t need to have a history of violence to be mandated under the law.

The law was used more than 8,700 times by mid-2007, with more then 5,600 of those people seeing their mandated services extended. Most people affected by the law (70%) are in New York City; many upstate counties don’t use the law at all.

That’s the law. Understanding the law’s purpose requires knowing a bit about New York – and Kendra Webdale herself.

Webdale was in many ways the prototypical New Yorker. An aspiring screenwriter from Fredonia, NY, she was drawn to the city by its parks and museums.

She wasn’t the first person to die on the subway tracks. Subway crime was down in 1999, but according to the New York Post, “even in safe times, a common fear haunt[ed] riders standing on a crowded platform. It’s of being shoved in front of a speeding train by a crazed attacker.” People remembered Renee Katz, who lost a hand in a similar attack, and several other people not named in the article (a 63-year-old grandmother, a Staten Island chemist, a 20-year-old mother described as having “cheap costume jewelry”).

Why did Webdale’s death merit a response from then-mayor Rudy Giuliani and eventually lead to a landmark state law while these other victims have been forgotten?

The numbers tell the story – a story of race, money and politics.

In the 1970s New York City was in trouble. Plagued by crime and a bad economy, white people and families fled in record numbers, to the point where whites were nearly a minority group. In the 1980s the population started to rebound, but the increase was driven by immigrants, who made up for a continuing exodus of white people. Crime was still rampant, and
the city’s image was reflected in the unstable loner Travis Bickle, Robert Dinero’s character in Taxi Driver. It wasn’t until the 1990s, the decade that Webdale moved to New York, that the city’s population really began to take off, growing by nearly 1%. By now the bleak image painted by Taxi Driver was being supplanted by Seinfeld and Friends – images of a kinder, more liveable city.

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I love New York!

However, crime still scared both current and potential New Yorkers. And even then a quarter of the city lived in poverty, up from previous years.

When a white woman who moved to the city in pursuit of her dreams was murdered by an unstable New Yorker, then, it must have been the worst publicity imaginable for city leaders.

They sprang into action.

After Webdale’s death Elliot Spitzer, then state attorney general and a city native, proposed legislation requiring mandated treatment, and the New York Times editorialized that such a law would be good for both people with mental illness and the city as a whole. Powerful New York State Assembly Speaker Sheldon Silver, who represented a Manhattan district, introduced the bill that would become known as Kendra’s Law. Silver was clear that “the specific incident that inspired ‘Kendra’s Law’ accurately depicts this as a public safety issue” while noting that his bill would also benefit those with mental illness.

Kendra’s Law passed. But like other public safety initiatives it wasn’t applied evenly.

In 2005 New York Lawyers for the Public Interest condemned Kendra’s Law, stating that only 15% of people mandated to treatment under its provisions had a history of violence. NYLPI accused those implementing the law of bias – citing figures from the New York State government, they said black people were nearly five times more likely than whites to be subjected to Kendra’s Law orders (others would say this is because black people are less likely to receive appropriate treatment). They also noted a regional bias, stating New York City accounted for 76% of orders despite having only 42% of the state’s population – exactly what one would expect if the law was created to make the city seem safer.

The marketing seems to have worked. By 2007 the number of people moving to New York City from other parts of the country surpassed the number leaving, a “new pattern,” and immigrants from within the United States went from representing half of the inflow at the turn of the millenium to two-thirds by 2011. Incomes rose too, with the median household income going from $31,591 in 1990 to $54,310 in 2014 when adjusted for inflation.

New York City became wealthier, whiter and more appealing to people from other states after Kendra’s Law passed. The law wasn’t solely responsible, of course, but it was one of the policies that made the New York success story possible.

What does this all mean? Many conclusions can be drawn. Here’s mine: Kendra’s Law is a marketing tool designed to assure affluent white people – inside and outside of the city – that the problem of dangerous, crazed loners is under control. When a mentally ill man murdered an attractive white woman from the suburbs city leaders feared Taxi Driver New York was killing Friends New York. They sprang into action, successfully lobbying for a law that’s used almost exclusively against poor black city residents.

None of this is to deny that Kendra’s Law has been effective. Studies by Duke University and the New York State Office of Mental Health have found the law reduces hospitalizations as well as suicide attempts, homelessness and other problems associated with untreated mental illness. Supporters of the law say it’s helping people who are mandated to services and saving the city money by reducing the need for inpatient care.

Mandated treatment is clearly a complicated issue that defies easy answers. But when we debate its wisdom we should consider all of its pros and cons, including some that are often overlooked by its supporters.

For example, any discussion of Kendra’s Law should consider:

The increased burden on mental health clinics that are required to treat mandated clients;

The impact of stringent rules clinics impose to manage mandated clients, such as policies to drop clients if they miss appointments;

The waiting lists clinics create to accommodate increases in demand;

The potential clients who give up on counseling because they’ve been placed on waiting lists;

The stress experienced by therapists and social workers who must work with mandated clients;

The impact this stress has on their work;

The good things providers could be doing with voluntary clients but aren’t because they’re working with mandated clients instead;

The things that could be done with money currently spent on mandated clients;

The pain clients experience after losing autonomy.

I’ve worked in agencies that serve mandated clients and I can truly say their being mandated changes everything. They stop being clients at all; instead they are treated like difficult, ungrateful children. When a clinician constantly assumes an unwilling client won’t show up or won’t be interested in material, it’s hard to overestimate the damage that causes to the therapeutic relationship. In a 2009 study of Kendra’s Law, case managers rated 54% of participants as not being “positively engaged” a full year after services began.

The above points demonstrate an odd fact: while Kendra’s Law has made treatment more available for mandated clients, the result has been that treatment has become more scarce for voluntary clients – the ones who are most likely to benefit from treatment. Every time a client is mandated waiting lists grow longer, clinicians become less available and clinic policies become more rigid. NYLPI says that this “right to treatment” for mandated clients even leads some people who want treatment to intentionally become mandated so they can get the help they need.

A stunning 41% of New Yorkers with severe mental illnesses report they needed help in the past year but weren’t able to get it. Does that mean we should have more mandated treatment? Maybe – but this treatment gap makes me question the wisdom of forcing scarce mental health resources on those who don’t want it.

I don’t know whether Kendra’s Law should be changed or repealed. But let’s be real about our reasons for mandating treatment. Let’s own the harm and benefits of it – all considerable and all very real.

In other words, let’s honor Kendra Webdale, Andrew Goldstein and the 20 year old mother in costume jewelry the New York Post didn’t bother to name.

Blood

My bosses were oddly sympathetic – they didn’t just want to know why I kept coming in late for work but why I was having so much trouble sleeping at night. I didn’t know, so I just looked at the floor, feeling my cheeks flush.

Which is why I’m on medical leave now. Timetable? “Open-ended.”

This time I ask the question, and once again a room falls silent. After a moment the guy leading the support group leans towards me and says, softly, “You know, a lot of us have nightmares.”

Something connects inside me. Nightmares. Goddamn right.

Like when I woke up that morning to a guy climbing into my bed, getting ready to punch me. I sat up and in a moment he was gone, taking the fear with him.

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Courtesy of Matthew Hall, The Noun Project

Some nightmares are imaginary and some nightmares are real.

A year earlier I was a social worker in the Bronx. I’m in the lobby of an apartment building waiting to meet with a family I work with. A teenage girl comes in, then a guy. The guy corners the girl. She tells the guy to leave her alone. “It sounds like you’d better go,” I say. “Mind your fucking business,” the guy says. I’m between them. The guy has his fist cocked back but all I see in his eyes is fear. “Move or I’ll punch you.”

I make him to be about 16.

I’m on the floor. Blood is pouring out of a busted lip. There’s something so wrong about the feeling of a busted lip.

I must have blacked out. My head hurt. The girl was still there. The guy was gone.

These are the things I remember, usually at night. Fear is such a funny thing. The memories come at night, the fear comes in the day.

I remember a teenage girl on a bench near a park in the Bronx, two other teenagers above her, raining down on her with their fists. There’s so much blood. You can’t pull the two girls off, they’re like magnets, but they run when a cop shows up. The cop just shrugs when I offer to give a statement so I leave; I’m late to see a family.

I remember a cop talking about how the neighborhood used to be when white people lived there; he’s nostalgic. I’m thinking, you racist bastard.

I remember a guy hitting a cop with a two-by-four, two blocks from my office.

A funny thing. Sometimes you’re afraid when you shouldn’t be and sometimes you’re not afraid when you should be.

I remember standing outside my office smoking a cigarette when my phone rings. It’s my boss calling from inside the office – “Get inside. Now.” I’m pissed about her tone until I realize someone got shot right across the street, at the dollar slice pizza parlor where I eat most days. We can’t see the body through the office windows, just blood pooling from behind the bus shelter that obscures our view. The police and paramedics take a long time to arrive. When they load him into an ambulance we realize the guy isn’t dead because they have to push him into the stretcher; and he yells, “Matelo.” “Kill him,” a coworker translates. The police don’t react; they stay in a tight-knit circle, talking to each other. A Hispanic guy comes out of the pizza place and uses a hose to wash away the blood. The guy who was barking out prices for stockings returns to his stool by the fire hydrant. A minute later the street is full again. A year later I’m still numb.

I often miss that job – even the bad parts. The late nights. The shelters and the projects. The stories of abuse. The bruises on a kid’s arm. I especially miss the bad parts because I could do something about them; or failing that, I could at least bear witness.

But I don’t miss the blood. I never want to see blood again.

When I started the job kids would tell me about blood – classmates’, strangers’, parents’, their own. The blood was often their excuse for misbehaving. I didn’t always believe them – it was my job to be skeptical. That was before I knew about blood.

That was before I got off elevators carefully, checking sight lines to make sure no one was waiting for me.

Before I started wondering, every time I met someone, whether I could hurt them or they could hurt me.

Before this anger that has no name.

They say the Bronx is getting more violent – more violence, more killings, more blood. It hardly matters. You only need to see blood once for it to get in you, change you. Make your future open-ended.

Trust me on this.

I see it in my dreams.

The Toolkit: 9 Essential Resources I Wish I Had As A Beginning Therapist

By nature counseling is an overwhelming job. These tools can get you up to speed quickly

Counseling is one of the hardest jobs on the planet. If you’re anything like me you regularly deal with unreasonable supervisors, out of control paperwork and clients who never seem satisfied. Worst of all, interns and beginning workers are often thrown into situations where they feel over their heads.

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Photo courtesy of pixabay.com

I can’t change any of that. But I can tell you some good news – the internet has changed every step of practice, from engagement to termination.

So let me take the load off a bit. Here are nine essential tools for any smart clinician’s toolbox.

Would you read a SocialWorked newsletter? If enough people sign up I’ll start writing. Click here to join the SocialWorked mailing list. I promise not to share your information.

Clinical Resources

Your supervisor introduces you to a new client and takes you aside to say, “He has insomnia. Use whatever treatment is best for that.” And you say, “Insomnia is what Pacino had in that movie, right?”

You’re in a bind – and ideally, you should seek training and supervision to help you understand your client’s issues. But in the meantime, the Social Psychology Network has a truly remarkable library of websites and articles organized by disorder. If you have 15 minutes to learn about an illness, this is the place to go.

15 minutes later…

OK, you know a bit about the client’s disorder, and you’re ready to think about treatment.

My all-time favorite online resource is Psychology Tools, an impressive and user-friendly database of free worksheets and handouts for clients. If you have a rudimentary understanding of cognitive behavioral therapy, for example, the tools here will bring it to life.  I highly recommend taking 10 minutes now to explore the site – I can almost guarantee you’ll come away with a new skill.

The Centre for Clinical Interventions in Australia also has a top-notch directory of free handouts for clients as well as detailed treatment manuals for clinicians. Combined with clinical skills and training, both of these websites have resources that can go a long way towards a successful therapeutic journey.

Would you read a SocialWorked newsletter? I’ll start one if people say they’re interested – let me know by finishing this quick survey.

Referrals

You’ve successfully treated your client – congratulations! – and she’s ready to leave your program. But she needs a referral. Now what?

Trust the government on this. SAMHSA has created an incredibly detailed database of mental health, substance abuse and VA providers that you can search by treatment orientation, insurance accepted, and more. 

You can also try a crisis referral line. Call the National Suicide Prevention Lifeline to be automatically routed to a crisis line in your area (800-273-TALK). Lifeline Crisis Chat also has a list of crisis lines for specific populations, including veterans, people with eating disorders and more. All of these lines serve consumers, but most will also be happy to help providers find the best resource.

Education

You’ve treated all your clients and referred them to the appropriate programs – a little friendly humor there – and you find yourself with some downtime. Why not use it to get up to speed on the latest developments in mental health?

The American Medical Association makes some articles from its prestigious Journal of the American Medical Association available online for free – its psychiatry articles are here. The American Psychiatric Association also puts out truly informative updates on clinical issues, as well as developments in politics and the mental health system.

I also highly recommend finding a news aggregator that helps you subscribe to your favorite websites and blogs. I personally love Feedly, which is available on Android, iPhone and the web.

You should throw a subscription to The Onion in there, too – life is short, and you’ve earned a laugh.

Will any of these tools help you in your work? Did I miss anything? Let me know in the comments and I’ll include updates in a future post!

Would you read a SocialWorked newsletter? I’ll start one if people say they’re interested – let me know here.

Second opinion

Warning: Adult language and themes; triggering content.

“I think it’s time you consider a higher level of care.”

The psychiatrist’s words hit me like buckshot.

A beat passed in his office on the Upper East Side. Between us there was a marble table. In the bathroom there were four kinds of soap.

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Illustration by Sven Gabriel for The Noun Project

I play it cool. Inside I’m screaming. “Like a five-day-a-week program? ,” I say. “Would the idea be to get my meds sorted out?”

The psychiatrist leans back in his chair as if I’d asked for the meaning of life. He paws through my intake form, which had been blank 30 minutes ago.

Calculating route. Calculating route.

“It would be an opportunity to get your medications sorted out.” He points to a page of the intake form. “And you’ve told me that you’re experiencing significant pain, to the detriment of your ability to function; and that you’ve had significant thoughts about suicide in the last couple of weeks.”

When you drink all you need to do to fix your life is stop drinking. When you quit you’re left with what’s left – yourself.

I tell him I’m not worried about the thoughts of suicide. I can handle the thoughts of suicide. They’d always been there, like a loyal friend.

The depression and anxiety suck, and I’ve been working on them forever, I tell him. My therapist and doctor know about every thought, every symptom, I say.

I’m seeing him because I can’t seem to wake up in the morning, as if the meds I’m taking have a gross weight that holds my body to the matress. I’m seeing him for a second opinion. I sure got one.

“I need some insight,” I say. “I need your opinion about whether my medications are working for me. Right now that would help me more than a referral to a program.”

“You can come back if you like, but I’m not saying I’ve taken you on as a patient,” he says.

“I understand,” I say. “You’re worried something bad might happen.”

Calculating route. Calculating route.

He points at my intake form, now full of scribbled notes. Somewhere in there is my sister, dead by suicide at 20; my abusive grandparents; my estranged alcoholic aunt; my ex-wife and the pills she swallowed one fall afternoon in a church courtyard.

“I’m only worried this isn’t the proper treatment setting for you,” he says. “I think you need a higher level of care. You’re experiencing significant pain, to the detriment of your ability to function; and you’ve had thoughts about suicide in the last couple of weeks.”

You’re worried you’ll be liable if I swallow a bottle of pills, so fuck you.

Earlier I’d told him where I’m employed as a social worker. Will he ever refer people there again? Will he tell everyone about the messed up counselor he met from [Mental Health Inc]?

Earlier still I’d told him I’m one year and three weeks sober. Congratulations, he’d said. It doesn’t feel like congratulations are in order. When you drink you’re a badass – you’re Don Draper or McNulty from The Wire. When you quit you’re just some depressed anxious dude. When you drink all you need to do to fix your life is stop drinking. When you quit you’re left with what’s left – yourself.

We shake hands and I leave. The receptionist is confused about my insurance. I’m panicking: are they buying time while the psychiatrist calls 911? This is exactly how they’d do it.

We sort out the insurance and I leave. I light a cigarette, then another. I catch my reflection in a window. Fuck you. The psychiatrist will tell all his colleagues about the messed up social worker from [Mental Health Inc]; don’t refer people there, they’ll hire anybody.

What right do I have to be a social worker, being in the condition I’m in? I’ve spoken with rape victims and domestic violence survivors. I’ve spoken with people who were suicidal while being suicidal myself. I’ve spoken with people who had the knife in their hand, the pills in their belly. I haven’t lost a person yet. I haven’t made a person feel as scared and powerless as I felt just now.

I think of the psychiatrist; of that quality of empathy. I think: I’ll never refer anyone to him.

I think, Fuck you.