“The essential point here is that the thinking which mental health practitioners call delusional is simply an extreme case of a completely normal phenomenon – namely, the ability of human beings to construct thought patterns which serve our needs, and to consistently screen out information which threatens these patterns.”
“Case Note: ‘John Doe’ # 246765; Inmate seen today. No data on family, resources or history. He appears to be in his 30’s, odd manner of dress and hair style, mood is euthymic, speech WNL, memory poor or withholding information (?), presence of “delusional” content, possible abuse in cell (bruising) denies emotional/medical problems, court date (?), pub def (?) charge;602PC. Plan; Nursing consult. Obtain psycho social data, contact P.D.”
— True case from the Los Angeles Correctional System
One cannot be with other individuals without encountering their belief systems at some point. My work with individuals in locked in patient units, mental health clinics and the Los Angeles Jails has brought me into close contact with people who had diverse belief systems, some of which were cultural and life-long, others were trauma-induced or influenced by drugs and alcohol. These experiences taught me to approach belief systems without prejudice and with open receptivity to their meaning and importance to the person.
The development of a resilient sense of self, with a belief system that is protective, congruent with social mores and motivating is the ultimate task of maturation. For the vulnerable, marginalized person; the individual living in poverty surrounded by instability and conflict , victimized by abuse and indifference, the pathway to developing a functional sense of self is a minefield. The journey from childhood to adulthood often presents obstacles – not opportunities for self-realization, harmony and emotional balance. Harsh adverse experiences create depression, anxiety, and belief systems that make sense of a nonsensical world; belief systems that are not based upon “known” evidence. Known is the key word here, for many “delusional” thoughts and the emotions attached to them make remarkable sense when seen in the context of the person’s lived experiences.
In the jail system, an individual with “delusions” is at extremely high risk for abuse, as the following case illustrates. The environment is hostile and punitive, often mirroring the individual’s life experiences with abuse and dehumanization. The inmates and deputies are bored, angry and retaliatory. Within this environment symptoms of emotional distress become worse and these symptoms often provoke attacks upon persons who are defenseless.
The last time that I saw “john Doe # 246765 he was strapped down to a gurney on his way to Atascadero State Hospital. He was disheveled, dirty and thin as a rail. I was close to tears as he was wheeled out. He was frightened and pale, for the first time recognizing that this “release” was not going to be back to his “home” in the streets. I knew that a patient at the State Hospital had been murdered the week before and that this man would become a target – as he had been in the jail – with no one to look out for him. His delusions would make some people angry, others would use him because he was a gentle soul, and I hoped my case notes and documentation could shield him in some way.
John Doe (Mickey, as I found out later) was an inmate in Men’s Central Jail in downtown Los Angeles, and he was a frequent inhabitant of the correctional system. I met him when I joined the jail’s mental health staff as the first clinician on the JMET Team (Jail Mental Evaluation Team) that was a partnership between a deputy and a clinician who were tasked with identifying the “mentally ill” inmates in the jail. The cells were overflowing with inmates in Men’s Central; 12 men to an 8X12 foot cell meant for 4 adults. Each row of cells had 12 cells filled to capacity with “general population” inmates whose crimes ranged from trespassing to armed robbery and assault with a deadly weapon. Screening for emotional problems at the intake level was superficial and inmates who were in acute states of emotional distress were thrown in with the others if they were able to say they had no history of illness.
Mickey, when I first encountered him, was in the back of a filthy cell squatting against the wall as the other 11 men played cards and wrote letters. The cell was buzzing with the black flies that were everywhere and the smells of urine and stale food made breathing difficult. The only data that I had to go on was his “rap sheet” listing 15 incarcerations for trespassing, breaking and entering, loitering, failure to obey a police officer, possession of marijuana, and receiving stolen property. This was the usual list for many of the “mentally ill” incarcerated who are picked up by the police and taken to jail when they are not flagrantly out of control – and the jail was full of such individuals. My job was to find them and have them evaluated by a psychiatrist and possibly sent to “Twin Towers,” the mental health jail.
There was no private space in which to speak to Mickey, and when I called him over to the bars he kept close to the walls, his hands clasped as though he were handcuffed. Aside from telling me that he was called “Mickey” he told me that he was in jail by mistake because the police did not know that he was the owner of the house in Hancock Park where he was found, nor were they aware that he owned multiple homes and other property in Los Angeles. He was, by his account, a millionaire who “helped” people on the streets who needed money or places to live. He had “friends” but no family, and he couldn’t tell me where he was born, raised, or went to school.
Mickey seemed to be a pleasant, gentle fellow although when he started talking about his property his voice became louder and his speech was rapid and pressured. He sketched beautiful pictures for me upon envelopes and called me “Miss Margie.“ He consistently denied any contact with mental health in his past, and insisted that he was OK . I noticed bruises on his arms and a cut on his cheek. He said that he had banged into the walls and the cut was his “badge of honor” for having fought through many wars. In the background I could hear the other inmates joking about what he was saying, and one of the deputies habitually called him a “ding” (their word for “crazy”).
After this first encounter I meet with Mickey daily. He was evaluated and prescribed Haldol and Cogentin, but not moved due to problems at Twin Towers. Mickey became attached to me and welcomed visits throughout his 4-month stay, but he became progressively more lethargic with the medications. He seemed distracted and withdrawn and was less able to defend himself verbally or behaviorally. His delusions persisted and I had him seen by a nurse who uncovered multiple bruises on his chest and back; he was being assaulted in the jail. My contact with his public defender was disastrous; he had too many cases, he was busy, and my pleas for getting Mickey out of the cell – either to a hospital in-patient unit or to Twin Towers – were to no avail. With his increasing lethargy, followed by tremors and drooling, he was more vulnerable than ever, and I finally had him moved to a cell usually reserved for elderly inmates where he was a bit safer. Due to the 3-Strikes Law, the judge who finally heard the case sentenced him to State Prison because of his multiple misdemeanors, several of which had been upgraded to felonies. He would languish in prison for years given the lack of available family and his increasingly passive, withdrawn emotional state. This was work that I brought home with me, along with his sketches, and I think about him often.
Mickey was not the only delusional inmate that I encountered. Perhaps the saddest was a 76-year-old man who, several months after his wife’s death stripped himself naked and presented himself to a woman from his Church saying that she was his wife. He demanded entrance, became agitated, and when the police arrived and tried to handcuff him they found him to be “combative.” When they called emergency rooms they were informed that there was a long wait for evaluations so they booked him into jail. This elderly man was cleaned up by the nurses and sent back to the cell on medication. It took weeks before he was able to give me the names of family members who eventually came to his rescue. According to his cousin, he had been delusional for months after his wife died, saying that she was alive and that he had to find her. He had refused help but had been cooperative in every other way so that they left him alone and hoped he would “come to his senses.”
There is no positive ending to this narrative, but the way forward is to inform and educate more people about the meaning and the risks of “delusional” thinking. Context and resources (family and a safe environment) are of utmost importance in these situations. When they are unavailable the person is at high risk for unimaginable abuse.
My job has been to listen to Mickey, and many others. I have come to see “delusions” as nothing other than the expression of unmet needs – needs which if you were to listen long enough become utterly and completely understandable to anyone listening with a compassionate ear. Needs such as a safe place to live, or hope for the restoration of a lost – or future – love can take increasingly tortured forms when hope fades. What others view as delusional comes to seem, when we listen from our hearts, like the increasingly strident – and occasionally bizarre – expression of hearts as they break, or are broken. This is something we can all understand. As any one of us is really only a few short steps from being in that place ourselves, we are obliged to learn to listen. We all belong to a society that benefits some at the expense of others: we must honor our debt to those who find themselves – as we all might and probably will at some time – under the tail at the other end of the bell curve.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.