Thursday, July 28, 2011

Depression/ Not Depression

Depression is an illness, a series of symptoms, not your life.  The worst cases of depression I saw were people who had bi-polar disorder that was mainly expressed in depressive rather than manic states.  The few episodes of mania they experienced were rare and often brought chaos and then regret into their lives.  Mostly, they lived with depression. “Like a giant hand is holding me down,” said one client.
One of the ways to look at depression is a very simple behavioral approach I refer to as, depression/not depression.  This is a concept I got from trainings with Bill O’Hanlon (, a great speaker and trainer.  In this approach we look at the way a person spends the day as if we were observing it on a video.  We then describe the activities in terms of depression or not depression.  This is an example of a patient I saw for many years:
Depression - “I wake up and get a cup of coffee and sit on the couch.  I turn on the TV, light up a smoke and proceed to watch Today, Regis, The View and intersperse it with CNN and whatever else is on.  I’ll eat cereal or a bagel, not get dressed, not get washed and have my jammies on when the midday local news show comes on.”
Not depression - “When I wake up I get into the shower, and then brush my teeth.  If I have to have coffee, I have it while I’m getting dressed.  I leave the house.  Even if it’s for a walk around the block, I get outside.  I try to have an activity for the afternoon.  I try to plan meals and have good food in the house.  I make sure I talk to someone every single day.”
For a depressed person, not depression is difficult.  However, even those with the worst depression can do something, one thing different every day.  What I am suggesting is not meant to replace medication or other talk therapy.  It is meant to add a way to maintain success with small measurable goals.  The outcome can be significant.  Read the story.

The Story
                She set down the shoebox on the table between us and rifled through some photographs, “I don’t think you believe me, so I brought some pictures.  Here, look at this,” she said handing me a cracked color photo of a group of women with big hair wearing mid-seventies vintage clothing.  In the center of this group of five women holding their drinks up toasting the camera, I recognized a thinner, younger Hanna Berg.  “I was something, a real hell raiser, and I made good money too.”  In another image she sits on a barstool, her back to the bar, legs neatly crossed, her hands folded in her lap, the beginning a of a smile on her face.
                I’d been seeing Hanna for over five years.  Her bi-polar disorder was diagnosed shortly after these pictures were taken.  “I covered the area from Syracuse to Albany.  In the springtime I was always on the road,” she continued, describing her work taking and selling school pictures.  “We did class pictures and individual pictures and all the stuff that went in the yearbook.”  Although I’d heard this all before, Hanna felt the need to display proof of her normalcy.  The manic episodes, worsened by self-medication with alcohol and drugs, made her young life a shambles.  There were a series of episodes that saw her arrested, and then hospitalized.  After a high speed car chase and crash, she was sent to the State hospital and been one of the last long term patients before it closed.  She’d fought the mania with medication and as she got older she found that the manic episodes were few and far between.  She mourned her mania like the death of a loved one and had no choice but to accept the depression that overwhelmed her like dark grey clouds filling the sky for months or even years at a time.  Anti-depressants gave some relief, but not much. Early on she’d had electro convulsive therapy, known as ECT or shock treatment.  She said of it, “You know, it made me feel better, but my short term memory was shot.  Then I’d get anxious that I’d forgot something important and that would make me feel depressed.”  At times, she had great trouble getting out of bed, not because she was tired, but as if a giant hand were holding her down.  When I first met her she used to cry a great deal, but later she seemed to have less emotion attached to her illness.  Her diet had gotten worse and she sometimes would eat a month’s worth of groceries in a week.  She was now a pale, overweight woman in her late fifties with a halo of dyed blonde hair framing a puffy pale face.  Her occasional smile could brighten a room and I could imagine how she’d been a heartbreaker as well as a hell raiser.
                Hanna was always at a high level of lethality for suicide and we’d been through at least seven attempts in our time together.  “Look at my crappy life.  Is there really a reason to go on?” she’d said to me in the emergency room after she’d slit her wrists and been found by her boyfriend.  “Bill is a jerk.  He doesn’t love me and is only my boyfriend because it gives him a free place to stay when his mom gets sick of him.  He also knows I’ll feed him.  If I died he’d have to find a job.”
                When her elderly mother became ill, Hanna moved her into an apartment in Hanna’s building and cared for her or arranged for her care until her mother died.  Hanna also, somehow, found money to help her disabled sister who lived in a group home.  She almost always made an effort to see her sister on Sunday afternoons.  Other residents of her complex depended on her daily phone contacts even when she was in the hospital.  Few days passed when she did not have advice or a kind word for someone.
                A good friend of hers called me and asked me to go to Hanna’s apartment after not hearing from her for a few days.  She tried calling and had even knocked on her door without getting a response.  She’d tried to contact Bill, but he did not return her call.  No one came to the door for me either, so I called the landlord who came over and let me in.  Hanna was lying on the sofa, her features flat, the person gone.  Above her head was a white poster board taped to the wall.  In magic marker, it said: “Do not resuscitate.”
                Several hundred people attended her funeral service.  Many said they didn’t know what they’d do without her.

Thursday, July 21, 2011

Lives Interrupted! Photos by Emil Ghinger

I worked at Meadow House, a day treatment program in Ithaca, NY from 1975-1979.  The mission of  the agency was to reintroduce people to the community who had been institutionalized for years. My friend Emil Ghinger, a portrait photographer, took pictures of some of the clients in 1976. This is a sample of some of the work that Mr. Ghinger produced. I am very pleased to share them.

The hard lessons learned from two deaths.

This front page article in the New York Times fairly describes the work I did with Beau Saul from the Ithaca Police Department.  There are many other aspects of our work that are not covered, including our founding and co-leading a regional hostage negotiation team.  I will post stories about those events in the future.  The title of this feature is based on a series of articles that studied 100 rampage killers in the United States over 50 years. Many of those killings were carried out by people who were mentally ill. This story is a response to letters that asked, "What is being done?"

New York Times
September 6, 2000               
 Trying to Prevent the Next Killer Rampage
          [I] THACA, N.Y. — It was nearly four years ago when the police climbed the creaky stairs to  Deborah Stagg's apartment in  response to calls from neighbors who  had heard her screaming and  raving alone in there. Ms.Stagg was known around town as a woman so disturbed that she had once  delivered her own baby by cutting her womb open with a  penknife.                 
          This time, a steak knife in hand, Ms. Stagg bolted from her barricaded bathroom and stabbed  Inspector Michael A.Padula in the neck, a fatal wound. The police opened fire,  killing Ms. Stagg.        
          The double deaths were a pivotal trauma in Ithaca, where Inspector Padula was the first police officer  killed in the line of duty. In the grim  aftermath, the police blamed the mental health department, and  mental health advocates blamed the  police.
          In the midst of the mourning and  finger-pointing, a policeman and a mental health clinic  supervisor who were distant acquaintances got together over beer to talk about whether they could  prevent such occurrences, jotting down ideas on bar napkins. Out of it grew a collaboration between the Ithaca police and mental health departments that some policing experts say is unmatched anywhere in the country because of its focus on pre-empting problems in addition to responding to crises.
          Now, when the police department receives a call that someone is behaving bizarrely, making threats or talking of suicide, it is usually the two men who brainstormed in the bar — Lt. John Beau Saul of the police department and Terry Garahan, the mental health clinic supervisor — who drive to the scene together in a worn police van to assess the situation. They have paved the way for other police officers or county sheriffs and mental health workers to go out regularly on calls together. They intervene when the case is potentially dangerous, as when a young man threatened to kill the staff at a temporary-employment agency and then kill himself. But they also  intervene when the case might appear frivolous, as when a woman called to report Martians invading through her ceiling.
          "We go out and find these people and try to get them to get the help they need,"  Lieutenant Saul said,   steering the van down a leafy street to visit an elderly man who had called the police to report a jar of   peanut butter stolen from his bed.
          "If you go to other places," he said, "people like this are avoided like the plague. We actually go out of  our way to find these people and engage them."
          Mr. Garahan said, "The theory is, you solve problems even when they're not problems. "The unlikely team, one a clean- cut cop, the other a long-haired social worker, uses a carrot-and- stick approach, sometimes cajoling a person into mental health treatment or
contact with other social services, and sometimes, where criminal behavior is  involved, using the threat of arrest or imprisonment.
The result is that even Ithaca police officers who were initially cynical about the approach now say they have seen a steep decline in the number of chronic phone callers tying up  police lines and time, and fewer untreated mentally ill people out on the streets. In several cases, they succeeded in defusing emotionally disturbed people who were armed and threatening violence, prodding them into psychiatric care rather than prison.
          In a study of rampage killers conducted earlier this year by The New York Times, family, friends, and  neighbors of killers repeatedly said in interviews afterward that they had observed the killers behaving strangely or making threats before the crime, and had tried to alert the police or mental health officials, to no avail. The police often say that they can intervene only after the person has demonstrated a danger to himself or others. Mental health services and hospitals in most places are stretched so thin that they too are not equipped to respond.
          The city of Ithaca has dared to move beyond this "hands are tied" response. A maverick university town, the home of Cornell, in upstate New York at the southern tip of Cayuga Lake, Ithaca has committed the resources of its police and mental health departments to respond even when there is no immediate crisis. It allows the sharing of information between the departments about past criminal and mental health histories, treading close to a line that could raise the hackles of civil libertarians and advocates for mental health patients.
          Approaching the Mentally Ill
          The approach in Ithaca goes beyond that of other cities in which police departments have begun programs for dealing with the mentally ill. The model most commonly copied is from Memphis, where a specially trained police unit responds to crisis calls about emotionally disturbed people, referred to by the police as EDP's. Other cities, like Los Angeles and Birmingham, Ala., have paired social workers with police officers who respond to crises involving the mentally ill, said several experts who study policing.
          What is unusual in Ithaca is the emphasis on prevention, and the decision to devote police resources to following up on people with chronic problems who do not always want to  accept help. Over the course of the summer, Mr. Saul and Mr. Garahan revisited several  cases, including those of a mentally ill crack addict who was resisting drug treatment, an  angry schizophrenic who had threatened his ex-wife and was making harassing phone calls to public officials at their homes, and a paranoid factory worker who wanted the police  to investigate "mind intrusion machines" that he insisted were planted in his home and workplace.
          By August, Mr. Saul and Mr. Garahan had succeeded in steering two of those inddividuals into  treatment and were still making weekly visits to persuade the crack-addicted man to enter a drug detoxification program.
          "That's pretty unique. I haven't heard of that type of follow-up before," said Melissa M. Reuland, a  research associate at the Police Executive Research Forum, a Washington nonprofit group whose  members include chiefs from the nation's larger police departments.
          "This really is problem-solving in action, identifying hot spots and partnering with service providers in your community who have expertise where you don't. If we could subject this to a really critical legal  and ethical analysis, I think it's got some promise." But such aggressive police involvement has a  risk, said Henry J. Steadman, the president of  Policy Research Associates, which studies mental disorders and the criminal justice system.  "There is a potential invasiveness there for individuals who would feel coerced into mental  health services because the police are still checking up on them in the role of police  officers," Mr. Steadman said. "If the person is simply seen as in need of treatment, then  why should the police be hanging around forcing the person into treatment?"  Ron Honberg, director of legal affairs at the National Alliance for the Mentally Ill, said,
          "I think it's great that Ithaca cares enough to do something creative. I just worry that if  it's done the wrong way it conjures up images of Big Brother at its worst."
          The police are often on the front lines of mental health care in this country, like it or not. For instance, the Ithaca Police Department was called on Aug. 26, 1999, when the managers at Stafkings, a temporary-employment agency, arrived at work to hear two chilling messages on their answering machine from an unemployed man who said he was frustrated that he had not been offered a job.
          "I'll kill all y'all up in there. I ain't playing, man," he said, spitting out his words in the recorded message. "The day that I kill all you I'll probably kill myself because I'm upset enough."
In many smaller police departments that have not been trained in threat assessment, the routine response would be to document the complaint and leave it at that. In Ithaca, the  police department contacted Mr. Garahan, who, as supervisor of the county outpatient mental  health clinic, knew the man who had left the message. Jason James, who is 21, suffered from psychotic episodes and had received a diagnosis of schizoaffective disorder at the  clinic, but had quit treatment. The phone threats indicated he had reached a critical stage.
          Found at his house, Mr. James was charged with aggravated harassment but was told that he could avoid jail by committing to a program of counseling and psychiatric medication. Mr. James, accompanied by Mr. Garahan, appeared in court before Judge Judith A. Rossiter, who often works closely with Mr. Garahan and Mr. Saul to devise alternatives to prison for emotionally disturbed people. Judge Rossiter dropped the charge on the condition that Mr. James resumed treatment.  One day last month, Mr. James rode his bicycle to Ithaca's mental health clinic, which he  does daily to receive his daily medication.  Soft-spoken and serious, Mr. James said that now that the voices had faded, he knew he needed the treatment. He said he still  struggled, however, to explain his illness to his family and friends.
          "They just wave their hands and say, `He's sick,' `He's crazy.' I want people to see that I am getting treatment, that I am living a better life," he said, before riding off to a  job interview.
          Emphasizing Persistent Vigilance
          Often, however, people are far less compliant, even when facing arrest. All summer, Mr.  Garahan and Mr. Saul worked on the case of Nicholas Celia, a 44-year-old man with a  record of convictions for assaults on civilians and police officers, and a history
of alcohol and drug abuse as well as psychiatric problems and hospitalizations —  the three factors that experts say indicate a potential for future violence. Recent studies  have found that the mentally ill are no more violent than other people, except when they  are off their medications or have been abusing drugs or alcohol.  Looking like a pirate in a blue bandanna and hoop earring, Mr. Celia wandered the Ithaca  Commons, the city's open-air street mall, sometimes mellow and bumming cigarettes, sometimes screaming and menacing. He was repeatedly arrested on charges of harassment and assault, once on Mr. Garahan, who got an order of protection against Mr. Celia and began to carry pepper spray. Even some of Mr. Celia's friends at the regular Wednesday night  dinner of the local mental health advocacy group said in interviews that Mr. Celia was starting to scare them and needed help.
          Mr. Garahan and Mr. Saul decided to use the newest, most aggressive tool they had to  compel Mr. Celia into treatment: Kendra's Law, named for Kendra Webdale, who died after being  pushed in front of a New York City subway train by a mentally ill man. They filed a  petition asking a judge to order Mr. Celia into outpatient drug treatment and counseling.
          At his hearing, Mr. Celia interrupted a psychiatrist testifying that he had examined  Mr. Celia and diagnosed bipolar disorder, or manic-depression.
          "I would just like to say, Your Honor, I am getting a little upset hearing these lies and  innuendo, and this is what happens when I am under stress and this is a farce to me," Mr.   Celia said, speaking loud and fast.
          The judge ordered Mr. Celia to report to the outpatient clinic for injections of Haldol.
          In his police car after the hearing, Lieutenant Saul volunteered that he was uneasy at the idea of forcing psychiatric drugs on someone.
          "I have a miniature soul-search about it, but then maybe if Deborah Stagg had been forced to  take medication, Mike would still be alive," said Mr. Saul, who wears a small pin on his  uniform in honor of Michael Padula, the dead policeman.
          Mr. Celia's response was to flee. He went to New York City, checked in to Bellevue Hospital's psychiatric ward, returned to Ithaca, was arrested, hospitalized again and  released, returned to New York City, was arrested and sent again to Bellevue before
 being transferred to a county hospital for long-term treatment.  In a telephone interview from Bellevue in August, Mr. Celia, now more subdued, insisted  he needed no treatment, saying, "What's  happening to me is an injustice."
          An Appreciated if Unenvied Job
          Even in this politically liberal college town, however, it is hard to find a civil libertarian or mental health consumer who objects to the work of Mr. Garahan and Mr.  Saul. Some do oppose the law stemming from the Kendra Webdale killing, but all said in  interviews that they were glad there were officials with mental health experience to call in emergencies.
          Much of Mr. Garahan and Mr. Saul's work boils down to protecting emotionally disturbed people from hurting themselves or from being victimized by others. After months in which they tried to convince the woman obsessed with Martians to seek treatment, she set a fire in  her apartment to exorcise the extraterrestrials. She walked to the police station and was hospitalized.  And when Mr. Garahan and Mr. Saul responded to the elderly man who had reported a jar of  peanut butter missing, they found him living in a basement apartment swarming with flies,  with feces tracked across the floor and a bare light bulb that had burned through a lampshade. They called building inspectors, who condemned the place. They called an ambulance for the man, in keeping with their approach that "medicalizing" a mental illness  is less threatening for the person.
          "I know it doesn't look like compassion, but it is for his best, and for the neighborhood's best," Mr. Saul said to neighbors curious about the ambulance. The landlord has since renovated the apartment, Mr. Garahan said.
          As to whether they have ever stopped a rampage killer, Mr. Garahan said: "You do this stuff and you don't know whether you prevented something or not. But I do know that the ability of the two disciplines, police and mental health, to work together has a
tremendous effect on a lot of people's lives."

                Copyright 2000 The New York Times Company

Thursday, July 14, 2011

A few people with mental illness are very dangerous. There are better ways to keep us all safe.

Why did Jared Loughner, a dangerous mentally ill man never get treatment?  Teachers, friends, family members and others not only knew he was disturbed, his actions and words caused them to fear him.  In my experience providing crisis counseling to people with mental illness who are dangerous, most people are afraid of becoming the target of aggression.  I had become a target on a number of occasions over my twenty plus years in crisis work.  I understand why others won’t want their names attached to a complaint. The question for many becomes who to call?  In the end the police have to be involved.  Had a mental health professional been contacted, he would have had to involve the police to facilitate the evaluation.  Mr. Loughner created such fear that when the campus police went to his home to tell him he would no longer be able to attend college, they requested backup. 
The police are the primary providers of mental health services in the United States.  They deal with the mentally ill at all times of day and in both private and public settings.  At a time when the police are also being judged with regard to their actions in Tucson prior to the shootings, it is important to state that the actions taken by law enforcement regarding Jared Loughner were appropriate to the circumstances and consistent with actions taken by law enforcement agencies throughout the country.  The consequence of those actions will be that Mr. Loughner will enter the prison system, joining the approximately 320,000 other mentally ill individuals currently incarcerated.  If you add the 100,000 currently in mental hospitals, the result is almost the same number as those in state hospitals prior to deinstitutionalization.  It is also important to state that most interactions the police have with the mentally ill are ineffective because the police are not part of the mental health system and have no regular access to it.  When the call is finished and the records are written and the shift ends, nothing happens.  The only way to resolve this and to create effective interventions that can stop incidents like what happened in Tucson is to have mental health professionals attached to police departments.  One of the clients in the clinic I ran killed a police officer in 1996.  As a result, I worked with police to form a partnership that would link mental health services with local law enforcement.  Sharing information was a crucial aspect of our work within the limits of confidentiality.  I opened cases that were appropriate mental health cases and transferred primary responsibility from law enforcement to mental health, often using mandated treatment with the cooperation of local judges.  While many of our cases were driven by police reports, I would also open cases based on reports of family, friends, coworkers and landlords.  Sadly, many went nowhere, because the person was not dangerous.  The concept of dangerousness needs to be replaced by need for care.  Anosognosia, the inability of the person to recognize illness in himself, made it impossible to help many very ill people.
Crises take place on a continuum.  Mister Loughner had multiple negative contacts with police, teachers, family and friends.  At those times, if he had then been connected to mental health services, there could have been interventions.
                In this brief window between outrage and despair, there is a chance for action.  Congress can begin by appropriating funds to have police agencies throughout the nation hire mental health social workers or caseworkers to attach to departments and precincts to move people with serious psychiatric problems from the criminal justice to the mental health system.  Mental health courts could help facilitate this process.

The Story

            Mr. Jones was handsome and charming and extraordinarily dangerous.  His good looks and charm got him pretty far along.  Preppy was the term we used to describe him, which in a town with an Ivy League University is not a negative.  Wavy black hair, soft blue eyes and a 100 watt smile gave him more second looks then he deserved.  Women who should have known better suspended their judgment when they met him and would at least take the opportunity to know him better.  I never met one who did not regret it.  He never really participated in treatment, but my interactions with him, all of them in my role as crisis counselor, would lead me to believe he had schizoaffective disorder.  This diagnosis combines the elements of a mood disorder like bi-polar with elements of a thought disorder like schizophrenia.  What it produced in him was a manic mood that was like someone after 20 cups of coffee. Once started, he did not stop.  That mood was wrapped around thoughts that were very disturbing; like he was the smartest man in the United States and the government was after him, torturing and punishing him because of his genius.  Unfortunately, his actions played out these thoughts and moods in frightening and dangerous ways.

                He lived in a rooming house downtown occupied by students and recent graduates.  It was a building where there were shared spaces like kitchen and bathroom.  He ate people’s food, he banged on the bathroom door, and he entered other people’s rooms and sat on their beds while they were sleeping, then waking them to tell them something.  It was at that point that the winning smile became the frightening grin.  If they disagreed with him, he would yell at them and curse them.  I got a call from the police department one morning asking me to come see him.  He was in a holding cell at the back of the station.  “They locked up the wrong person!  They screwed up!  Get me out of here!”  When I tried to ask what happened, he was out of control.  “She’s the criminal, not me!”   The overnight shift had gone home, so I read the report.  At about 4 in the morning he had arrived at the police station with a young woman.  Her hands were tied behind her back and she had packing tape over her mouth.  He pushed her against the bullet proof window and shouted, “This is a citizen’s arrest.”  The desk officer responded by putting him in cuffs and taking him to a holding cell.
                The woman reported he’d come in after the bars had closed and had been crashing around the kitchen and bathroom.  He then had gone from door to door asking if anyone had cigarettes.  She had been sleeping for a while before he came home and since it was a weekday she had school in the morning.  She’d begun to yell at him and when she'd had enough of his antics she got very personal in her language.   He grabbed her and put her face down on the bed and yanked out the phone line to bind her hands.  When she’d screamed he pushed her face in the pillow, yelling at her to “Shut up!” The packing tape was put on before he pulled her down the hall.  In her nightgown and bare feet he pushed, pulled and dragged her the four blocks to the police station.  He wanted her charged with aggravated harassment for cursing at him and calling him names.

                I tried to speak with him, to calm him down.  He had no idea what he had done to be treated this way and as he stated to me many times, “I’m not crazy.”  A few hours later when he got in front of the female judge, he was calm and charming, but the judge would have none of it.  Before his arraignment the court officer had run his “sheet”, a list of previous charges and crimes.  At the time, the computer paper was on a roll.  His sheet was 14 feet long.  I was in the court and the judge asked me if he would get mental health treatment in jail.  “We’ll try,” I replied.  “If I send him to the hospital there’s no guarantee they’ll keep him, is there? “  she asked, already knowing the answer.  He went to jail and the student got an order of protection.

                A few months later I got a call from an officer I knew quite well. “Terry, I’m in my car on Green Street and Mr. Jones is walking down the street pushing a shopping cart with a rifle in it.  Is there any reason he should have a rifle?”  A chill went through me, “No, absolutely not!”  I did a short hand of mental hygiene law in my head.  “Take him into custody, I’ll sign the papers.  And please be careful.”
                Minutes later I met her at the police station with him in an interview room.  I sat across from him at a desk and asked what the gun was for.  He smiled smugly and said, “None of your business.  I’m not crazy and I don’t have to talk to you.”  An investigator went to the K-Mart where Mr. Jones had bought the rifle and nearly 1000 rounds of ammunition.  There was no background check at that time and if there had been it would not have included psychiatric hospitalizations.  On the form where it asked if the person purchasing the weapon had ever been committed to a mental hospital against their will, Mr. Jones had checked “No”.  When asked about this, Mr. Jones had replied, “All of those hospitalizations were illegal, I don’t recognize them.”`
                Hours on the phone trying to get the Feds through the ATF (Alcohol, Tobacco and Firearms) to file felony charges for lying on their form were wasted.  The local District Attorney’s office finally came up with the misdemeanor charge of filing a false instrument.  We noted that Mr. Jones at the time was heading in the direction of the colleges.  He never told anyone what the gun was for.  He left town shortly after that, telling me and my police partner Beau Saul, “I can’t do anything here, I’m leaving.”  Months later I got a call from a Sergeant in a police force in a nearby city.  “I picked up this crazy guy with a shotgun.  What can you tell me about him?”  I replied, “Look at his sheet.”

Sunday, July 10, 2011

Important change in addiction treatment

The New York times has published an article that looks at changes in the way addiction is viewed. It has important implications for those with serious mental illness. The Link is below:

Rethinking Addiction’s Roots, and Its Treatment

Wednesday, July 6, 2011

Doing better can create danger!

Intense Insight

While many people with serious mental illness have no idea that they are ill, it can still be difficult for them to deny the evidence of their illness. Surrounded by poverty, ill health, repeated incarcerations and hospitalizations it is impossible to not know that something is wrong.  There can be moments of extraordinary clarity that can be as frightening and dangerous as the worst symptoms.  Getting the right kind of help during this time is a challenge for the patient and the helper.

The Story

I stood there in the harsh light of the morgue, walking around the body staring at the face.  It looked somewhat familiar, but distorted in ways that made it difficult to discern.  He had jumped from one of the higher bridges, almost 17 stories, nearly 170 feet into the gorge.  When he’d landed, he’d  hit his head, and the bruising, swelling and missing teeth combined with almost 24 hours in the water had altered his appearance in nightmarish ways. He looked shockingly like a Halloween pumpkin ready for display.   He’d jumped in the early evening and only one person had seen him.  If not for her, we may have never known what happened. He might have gone over the falls and into the lake without anyone knowing. As it was, he’d ended up in a small deep pool a half mile downstream.  A uniformed cop with a long pole had found him.
  “Could you help me roll him,” the investigator asked, “I want to see if there is anything in his back pockets.”   I could feel the cold through the rubber gloves.  I grabbed a belt loop on the jeans with my right hand and pushed hard with my left on his shoulders.  We tipped him on his side and the second investigator carefully searched the pockets. We returned the body to its prone position and started to remove the clothing and bag it.  It was driving me crazy! Who was it! I knew I knew him!  He was a Southeast Asian or Hispanic male, early thirties to early forties without a damn bit of ID on him.  When he was naked I left the room.  Someone knew this man, loved this man, and he was dead and they didn’t know it.  
I went back to the clinic and talked to my colleagues.  They were stumped.  I went to the records department to try and jar my memory. Our records room was a big square room with tall metal shelves filled with three ring binders with names on the side. I started with the A’s going from top to bottom, left to right, walking slowly along the shelves.  By the time I got to the end of the open cases, I was sure we weren’t currently treating him. I began to look at the names of the closed case binders and got to the second shelf and realized I’d found my answer. I pulled out the binder and started reading the notes.
Doug was his Americanized name.  He wasn’t born in the US, but had been raised here.  His parents had attended Cornell as grad students and separated when he was about seven. His dad returned to Asia and his mom stayed, starting a small home based business that thrived. She and Doug moved in with a widowed man who also had a son a few years younger than Doug. The family was happy until Doug started to have psychotic symptoms just after high school graduation.  Mostly he heard voices that called him names or cursed at him. He’d respond to the voices by yelling and cursing back.   Sometimes he would break things in the house or imagine his step- brother was against him and make vocal threats against him.  His actions made it impossible to stay in the family home, so he moved through a series of crummy apartments and rooms.  He’d work washing dishes or shoveling snow or cutting grass.  His threatening statements caused a string of hospitalizations that would be followed by periods of calm. Then he would stop taking medications, start smoking pot and the process would begin again.
Each time he was hospitalized, he would be referred to our clinic for outpatient treatment upon discharge.  He had little insight as to his illness, but he hated to be hospitalized and often the focus of treatment was our encouraging him to take the medication to avoid the hospital.  Another consequence of his becoming stable was the onset of depression.   His depression was the result of this clear, unobstructed view of his life, at least as he saw it.  He was a loser, almost thirty and nothing good happening.  He’d tell the psychiatrist, “Everybody I know has a better life than I do.  Everybody I went to school with is a success. They have good jobs, wives and kids, houses and cars and I’ve got shit.”  The doctor, of course explained that it was not true, not “everybody” he went to high school with was doing great.  In fact we knew some, both personally and professionally, that were not doing well at all.
Eighteen months earlier Doug’s father had come from Pakistan and after consulting with Doug’s mom took him home with him.  We closed his case and went on treating the other five hundred and sixty patients.  Doug had returned with his dad six weeks ago.  His father had made an appointment with the doctor for a consultation.   Although not uncommon, a parent requesting a doctor visit without the son, who was the patient, made me wonder, so I decided to sit in.  “For almost a year now, I have been treating him.”  Doug’s father began.  “My cousin is a doctor and he has prescribed the very same medicines he was given here in the United States.  Each day I have crushed up this medicine and placed it in his food. I have never seen him doing better.  If you would just continue to prescribe this medicine, his mother has agreed to continue to put it in his food.”  “Does he know he is taking the medication?” the doctor asked.  The father replied, “Of course not, he would stop taking it like he always does. This is working so much better and all we need is the prescriptions and we’ll take full responsibility.”   He left our office sad and dejected and not fully understanding why we could not and would not participate in his plan of deception.  He went back to Pakistan telling his wife he would send the medications.
Doug’s mom had called about a month ago, after the dad left.  “I understand why you couldn’t do it, but his dad is a stubborn guy.   Doug is really doing great.  He’s applied to community college and says he will make an appointment with you guys.  He’s got some money from his granddad and has rented an apartment in college town. I’ll give you the address.”   I went to see him at one of the newer apartment houses, filled with Cornell students.  “Nice place,” I remarked as I entered his apartment.  It was easily the nicest apartment he’d lived in since he’d left home. It was neat and well cared for. He looked good; clean clothes, nice haircut. He said, “I thought since I was going to college, even community college, I’d try to live the part.”  We talked for a little while and I set up an appointment for him and left.  He never kept the appointment and when I returned he was not there or did not answer the door.   I’d spoken briefly to his mom and she said he was still doing Ok, but seemed stressed. “I’ll try to get him to see you.”
I put the binder back and walked over to the police department. When I got to investigations I looked at the pictures from the morgue. I knew the answer, but had to confirm my suspicions.  It was him!  I went with the investigator to Doug’s apartment and we got the landlord to let us in.  The smell of rotting food in styrofoam greeted us. The place was a mess. No note or indication of his thoughts.  I called his mom. “Have you seen Doug?”  I asked.  “No we haven’t seen him for a week.  He had dinner with us Sunday and he was really depressed.  Being around all those successful kids wasn’t a good idea. He just kept saying, I’ll never catch up.”  I took a deep breath and said, “Are you going to be home for a while, I want to stop by and talk to you?”
The Lieutenant and I went to see her.  He told her there were other means of identification they were pursuing; that the remains were unpleasant to view.  “No mother should have to see their child like that,” he said to me as she entered the morgue.

Sunday, July 3, 2011

Is this a good Idea?

Cuts in services and programs! No food, no housing ; but at least they can get guns.  If you have a few minutes read this from today's NYTimes. The link is below.

Some With Histories of Mental Illness Petition to Get Their Gun Rights Back

Now they mandate treatment!

This is from last weeks Washingtonpost.  It is followed by a link from today's New York Times.  I will write about violence, guns and the mentally ill in weeks to come. Unfortunately I have more stories than I want to remember. It is important to know that even among the most serious mentally ill there are only a small number who are prone to violence.