Nut houses are crazy.
“Oh, no, Mr. Hansen."
"We prefer to use the term 'psychiatric institutions'.”
The people who run them are crazy.
The psychiatrists are crazy.
The doctors are crazy.
The staff members are crazy.
Some of the patients are crazy.
“I'm crazy.”
“Oh, no, no, no, Mr. Hansen."
"We prefer to use the term 'mentally ill'.”
Some of the patients are not crazy.
What's a crazy person? To you, crazy probably means anyone who doesn't act like you do. Crazy, huh? But too true.
Psychiatry uses a gazillion words and code numbers to classify mental illness (and justify bills.) Mental illness can mean a lot of things. Things like being nervous. Or inattentive. Disobedient. Selfish. Uncaring. Hallucinating. Manic. Depressed. Drunk. And a whole lot more.
Crazy.
I feel sorry for you and your diminished quality of life if you think crazy people are bad people who mean to act weird and won't try to get better.
I feel sorry for your children who will probably have your ignorance and intolerance passed on down to the next generation for yet another round of harmful fear.
Psychiatry today is enlightened.
A psychiatric problem can be caused by a tiny imbalance of just one little brain chemical.
Or because Grampa was crazy and you got his defective genes.
Or because your son saw you kill his mother.
Or because you abused your daughter emotionally, physically, sexually, or all three.
Crazy people aren't bad people who mean to act weird or don't try to get better. They're just born into a crazy world like you are. And you can become crazy, too, if you aren't already crazy.
The best thing for ourselves, our afflicted family members, our friends and our neighbors is to get to a safe place like a psychiatric institution.
Psychiatric institutions lift patients out of their isolation and misery by inserting them into a safe place. A place that's secure, peaceful, warm and dry. A place with plenty of nutritious food. A place where a fully functional non-judgmental community environment meets all their individual needs so they can benefit from an inherent stabilizing process.
Psychiatric patients are sick and need help just like medical patients do.
There are no “cures” in psychiatry.
Positive mutually beneficial therapeutic relationships with experienced, skilled care providers seem like magic, but they're not. It's simply a matter of patience, listening and responding to a patient with respect, kindness and non-judgmental understanding.
Patients can be admitted to psychiatric institutions only after they have been evaluated, stabilized by and safely transferred from a doctor's office or hospital by ambulance. Maybe the occasional police car.
Psychiatric patients are classified as either voluntary or involuntary. The difference is that the former can leave any time they want, and the latter can't.
When you get admitted, your possessions are thoroughly searched for weapons and cigarettes. When you left they'd give you your knife back, but your cigarettes would have mysteriously disappeared.
Hint: If I want to find your drugs, I look in your shoes. That's where your drugs are always hidden. Always.
The first thing you hear from me when you come to stay on my floor is:
“You're responsible for the consequences of your own actions. Please don't act up. Don't ever lie to me. You shine me on, I'm gone. You're straight with me, I'll give you everything I possibly can. I don't make promises. No deals. Don't threaten me. I don't negotiate with terrorists. I've never lost. Do you understand? Good. Thank you. If you ever need anything from me, just ask someone on the staff to get me and I'll come to you as soon as I can. Is there anything I can do for you right now? Thanks. Oh. Watch out for the crazy doctors.”
So you're in.
Your drinking buddy tries to call you at the psychiatric institution. A friendly, sincere, polite and professional discussion follows between him and the institution's operator.
“Hi, I'm Fred Smith's brother.”
(Lie. “I'm his drug dealer.”)
“Oh, Mr. Smith, I'm glad you called.”
(Lie. “Leave me alone. I'm busy with my crosswords.”)
“We're really tight.”
(Lie. “He owes me a lot of money.”)
“I'd like to talk to him.”
(Lie. “I want to break his legs.”)
“Could you hold while I see if he's here?”
(Lie. “Go away.”)
“I'd be glad to.” The operator paints her fingernails.
(Lie. “Hurry the hell up.”)
“Mr. Smith? Thank you for holding.”
(Lie. “I hoped you got tired of waiting and hung up.”)
“No problem.”
(Lie. “It's a big problem to me.”)
“Oh, I'm so sorry. He's not registered here.”
(Lie. “He's here.”)
“Thanks. It's okay. I'll just go check with Mom.”
(Lie. “I’ll kidnap and hold his dog for ransom.”)
“Thank you for calling.”
(Lie. “Don't ever call me again, loser.”)
“I hope you have a good night.”
(Lie. “I hope you die a slow and painful death.”)
“Good night to you, too.”
(Lie. “I'm gonna get your butt fired.”)
Crazy.
The mission of psychiatric institutions is to evaluate your problem(s), stabilize you with medications and improve your state of mind with therapy. Two out of three's not bad. Psychiatric institutions do their best these days to get you in and out as fast as possible, send out a bill, and pass the therapy part on to community services that are not there. Most people who have visited me came back many times to do the whole thing all over again for that reason.
There are many other reasons why my psychiatric patients became destabilized.
They got thrown back into the same dysfunctional families that made them crazy in the first place.
They got thrown back into their old unsafe neighborhoods.
They didn't get enough of the right medications.
They didn't understand or believe their diagnoses.
85% of psychiatric patients have more than one diagnosis.
85% of psychiatric patients self-medicate. They spend their monthly checks on cigarettes, alcohol and drugs. Dealers give crazy people credit because they know about the monthly checks and they show up the day the mail arrives on the first day of the month to collect. The cycle repeats itself every month.
If the crazy person is lucky, they ended up with us, one way or another. They ended up in the hands of the crazy police. They ended up with our crazy doctors.
Doctors in funny farms don't wear white these days. They wear street clothing so they appear less authoritarian. But crazy people aren't stupid. They can spot doctors and psychiatrists from a mile away. How do they do that? They see a person walking down the middle of a hall for protection. Doctor. Patients walk near a wall for protection. You need to always be alert to protect yourself from crazy doctors and crazy patients.
The patient's day is tightly regimented. Wake up, go to the bathroom, go out for a cigarette, get and take your psychiatric medications, then follow the herd to breakfast. Go out for a cigarette. Watch TV. Get seen by a few shrink types for 5 minutes or so. That's your “psychiatric therapy” for the day.
Follow the herd to lunch. Go out for a cigarette. Watch TV. Follow the herd to dinner. Go out for a cigarette. Wander the halls for three hours. Get and take your psychiatric medications. Go out for a cigarette.
If you can tolerate some stranger watching you shower without a shower curtain while maintaining your dignity, you can stay clean. If you don't want to, you're free to let your body get as filthy as you like.
At the end of the day you're herded into your room to go to sleep. That's if your craziness will let you.
If you acted up, I put you down and you stayed down.
Old-days white straight jackets are no longer used for restraint. Straight jackets make people crazy. Chemical restraints are much kinder and safer. They make people sleepy. The only reason the crazy doctors had me (a medical and psychiatric physician assistant) in nut houses overnight while they slept was that I am licensed by the DEA to prescribe drugs. I knocked out patients who had become dangerously unsafe and aggressive with my blowgun and jungle-juice-coated darts while I hid behind a nurse.
I'd have a nurse shoot you up with an injection of the potent anti-psychotic drug, Haldol, even if you weren't psychotic. It was just the strongest stuff we had to stop you in your tracks.
2 mg if I wanted to calm you down.
5 mg if I wanted to drop you to the floor.
10 mg if I wanted to definitively take you out.
Four minutes later you'd be drooling, babbling nursery rhymes and on your merry way to a nice long sleepy-bye face down on the floor.
Mr. Nice Guy, I'd add 1 mg of make-your-nerves-happy Cogentin to the shot so when you finally managed to gather your senses hours later your body wouldn't be aching and painfully stiff. That's unless the staff fell (read thumped) on you when you were on your way down to hit the deck. Staff isn't allowed to hit patients, but they sometimes “fall” on patients during a struggle.
My practice was “good cop, bad cop.”
If I had a nurse shoot you up, she or he instantly became the enforcer. Talking back was a very bad decision. If you had a needle stuck in you just once, you'd do exactly what you were told during the rest of your stay, or you'd pay with your freedom.
I didn't stick needles into my patients or physically restrain them. I was their friend and gave them goodies like happy pills, smoking passes and outdoor recreation privileges. I'm not a shrink but many of my patients would ask to see me so they could talk.
Many psychiatric patients smoke tobacco. Nicotine is a good drug that makes the brain feel happier. Taking away smoking privileges is like taking away freedom, which it is. Many, many nights one of my patients would pop out of the toaster and have to be physically restrained. I'd wade into the fight.
“Please. Leave so I can talk to my patient alone.”
The combative patient instantly stopped being crazy. They knew why they were acting up. I knew why they were acting up. They wanted to smoke.
Even though most loony bins today have banned smoking on “campus”, I broke the prohibition every time. I took patients outside, unsupervised, to smoke together, shuddering under light institutional jackets (no zippers, no cords, no hoods) struggling to resist the night chill, lying on a rolling green grass bank of a lazy, wide, New England-type river, on our backs looking up at the stars and talking softly. Brucify 'em. Good, effective therapy.
Besides performing routine tasks such as dispensing medications, staff spent the night putting out the fires of unacceptable behavior, which was also routine. Routine like five unacceptable behavior dangerous incidents a night. Dangerous to both patients and staff.
Institutionalized psychiatric patients have the right to make their own choices. When I approached an aggressive patient, my offer of choices was of the same thing, only stated differently so the patient felt they were making their own choices. In the end, they did what I wanted.
Loud, firm, steady and commanding voice with searing eye contact:
“I'm only going to say this once. You will not talk back to me. You have two choices. We can take you right to your room for a “Time Out”, or you can go in there on your own and rest until you tell us you feel better. You can earn your way out with good behavior. You have to decide right now.”
What's unacceptable behavior? Unacceptable behavior means doing bad things like smuggling, relentlessly attempting to use the telephone, calling 911, refusing a staff order, throwing temper tantrums, spitting, swearing loudly, yelling, screaming, kicking, threatening other patients or staff, throwing objects, food or feces, destroying furniture, urinating on the floor, head-banging, and my personal favorite phony attempt-to-get-attention gesture, attempting suicide.
Staff members do a Suicide Watch every 15 minutes, 24 hours a day. They walk down the halls looking into your room until they see you breathing.
Magazines are not allowed in psychiatric institutions so a patient can't remove the staples and harm themselves or someone else.
Tap water temperature is tepid so patients can't harm themselves or someone else.
Some places don't even allow patients to have straws.
At one snake pit where I worked, a patient with a history of good behavior could earn the privilege of freely walking around the grounds unsupervised. They were given an international-safety-orange knit watch cap to wear on their walk. Sometimes a patient would keep walking and run away.
Call the cops.
The cops always found the escapee in one of two places. Hiding in the bushes (with their heads up) or at the local 7-11 buying coffee, soda, chips and cigarettes. They were easy to find. They were wearing easy-to-spot international-safety-orange knit watch caps.
A patient displaying bad behavior could earn a “Time Out”, just like you do with your children when you send them to their rooms to calm down for a while.
If a patient's unsafe unacceptable behavior suggested that the patient might harm themselves, they got a “Supervised Time Out.” A designated staff member would sit directly in front of your open door or in your room to keep an eye on you. The staffer was not allowed to read during the many-hour open-ended vigil.
Staff intervention against a patient's aggressive or unsafe unacceptable behavior occasionally required a “Show of Force.” For example, Mary stands in the doorway of her room, screaming obscenities. Loudspeakers throughout the floor declare:
“Show of Force, Room 17.”
All available staff members quickly assemble in a group (maybe about 10 people) directly in front of the patient, two paces away. Nobody's arms are folded, body language that the patient could interpret (correctly) as suggesting negativity and threat. The staff member closest to the patient (her “friend”) steps away (not advancing) from the group, states:
“Mary, your behavior is unacceptable. Do you want to take a Time Out?”
If the patient says “No”, the confrontation continues.
“Mary, take a Time Out in your room.”
If the patient refuses, the confrontation escalates.
“If you don't go back to your room, we'll have to take you back there to protect your own safety.”
If the patient still continues to refuse, the staff advances one pace, tightening the 10 people-circular-wall and causing most patients to panic. I know I'd certainly panic if I was surrounded by a closing ring of threat. Your perception of threat is directly related to your psychiatric disorder.
However, my professional experience has shown me that most crazy people are not crazy.
Patients that are not crazy do unsafe inappropriate things, then explode in resistance to the inevitable (desired) struggle to end up getting flattened and pinned to the floor.
Patients that are crazy do unsafe inappropriate things, too. But when they're confronted, they'd curl up, sobbing uncontrollably, and try to hide in a corner if you just raise your voice to them. I controlled alcoholics in the ER by yelling at them, too. Easy.
“Mary, go to your room, now.”
If the patient does not comply with the direct order, the staff advances another pace and surrounds the aggressive patient. No patient retreat? No problem. Twenty hands grab body parts for a “Take-down” and pin the patient gently to the floor. One staff member cradles her head to protect it, four restrain her arms and legs, and one grabs her belt, to be used as a handle. The rest grab pieces of clothing. Nobody speaks. Leader:
”Mary, please go to your room.”
Any resistance will result in Mary being carried bodily back into her room, followed by her “friend.”
It's hard to not be affected by all this craziness. If a patient confronted me with inappropriate behavior, I would not respond so I wouldn't get sucked up into their game of manipulation as free cheap thrills entertainment. I had to disengage myself immediately before my own craziness bubbled up. I have only raised my voice to a patient once, and it will haunt me for the rest of my life.
“I hate you! I hate you! Why won't you let me do what I want? Why won't you answer me?”
“Because you're not capable of understanding what I'm saying!”
Medical school drills into you the difference between sympathy and empathy, warning of the destructive effect of the provider having sympathy for the patient. Sympathy is experiencing a patient's emotions and feelings. Empathy is the imagining of a patient's emotions and feelings.
I know how important it is to be empathetic in order to maintain the psychical distance required to shield myself from my patients' feelings in order to work effectively. Dispassionately.
I know how dangerous it is to be sympathetic, feeling the same feelings as my patient does.
I know the difference, but I feel sympathetic. It has always been my undoing. Taking care of patients while not taking care of myself. Hugs for patients, none for me. Sure, I get too wrapped up in my patient's pain, but how could I possibly claim to understand what it feels like to live in a nut house?
I was a patient in a nut house.
