In August of last year, I was held for three weeks in Psychiatric Intensive Care at the Royal Jubilee Hospital in Victoria, British Columbia. While there, I witnessed another patient violently smashing her head into the wall. Security was called and as the troubled young woman was put into restraints, the nurse said to her, “I know you’re angry but don’t hurt yourself — use your words.”
Even in my madness, I could recognize this as powerful advice and have been gathering my words ever since.
I have an episodic, sometimes debilitating, serious mental illness and have been under the care of an Assertive Community Treatment (ACT) team for six years, often on Extended Leave from the hospital. On Extended Leave, a patient is still committed under British Columbia’s Mental Health Act (MHA) but resides at home under a variety of conditions, e.g. having her medication witnessed or meeting with her psychiatrist regularly, to name just two of many possibilities.
If she fails to meet her obligations, the ACT team has the power to have a Warrant issued, the police come to arrest her and she is returned to hospital. Extended Leave lasts indefinitely, with the psychiatrist deciding at regular intervals whether or not a client will have her civil rights reinstated. As a result of my most recent episode of illness and subsequent hospitalization (which I voluntarily agreed to, as I was keenly aware that I was in urgent need of psychiatric care), I find myself yet again an involuntary patient embarked on yet another Extended Leave.
Being on Extended Leave intermittently over the last several years has been extremely unpleasant. Favourable responses to some requests that I have made (such as having injections administered only by a female nurse) have been a long time coming; other similarly reasonable requests continue to be ignored. Choosing to return to hospital rather than continue to suffer the indignities of Extended Leave is not possible, given that there are far, far more patients in Victoria on Extended Leave than there are available hospital beds. My ACT team alone serves 80 clients, the vast majority of whom are involuntary.
Since most patients cannot afford legal fees for a court application (and this is not covered by Legal Aid), the only possible route back to voluntary status — besides simply waiting an Extended Leave out — is to appear before a Mental Health Review Panel, the system’s purported safeguard from psychiatric overreach. The three-person panel, comprised of a lawyer, a doctor and a member of the public, hears evidence from both the patient and her doctor and decides whether Extended Leave should be continued.
Review Panels tend to be stressful affairs and rarely work in a patient’s favour — only one in eight succeeds. Evidence is used against us that would never be allowed in court, and the onus seems to be on the patient to prove that she’s not insane, rather than on the psychiatrist to prove that she is.
At my last Review Panel hearing, my psychiatrist took more than an hour to read from my medical records, which contain gross inaccuracies. He then left abruptly, so I had no opportunity to correct the errors. When it was finally my turn, I wasn’t permitted to present my position verbally but merely allowed to submit the written notes I had made in preparation for the hearing. The Review Panel chair behaved in a biased and highly unprofessional manner, questioning me in a belittling, contemptuous fashion and repeatedly rolling his eyes at my responses.
Review Panels are clearly not a sufficient safeguard, and nothing short of a court adjudication would be. Currently, extreme circumstances such as someone being a danger to himself or others are not nearly required for forced hospitalization or, worse, the diabolical Extended Leave.
Shortly after my recent discharge — which I engineered by flattering my ACT team leader, knowing that a word from him to the hospital staff would be sufficient to secure my release — I made a serious error when a different ACT team member showed up at my home with medication a couple of days later. I believe the exact words I yelled at him were, “Why don’t you do something more respectable for a living like deal crystal meth?”
The next day, as a result of this unseemly outburst, I was offered the choice of attending the hospital for assessment “voluntarily” or being arrested by the Victoria City Police and taken there. So I duly chose to present myself at the hospital, where I waited for six hours to see a physician. I exercised much self control (which is really all it takes to disguise mental illness), spoke calmly and slowly, displayed a passable rendition of sanity and, at 11:00 p.m., received a free taxi voucher to get home. I was grateful for the taxi voucher. I would be even more grateful for an apology from my doctor but none has been forthcoming.
The ACT team member who had driven this whole process informed me a couple of weeks later that she had treated me “respectfully” (I guess referring to the fact that she had spoken softly to me as she threatened arrest), while I submit that coercive psychiatric treatment is, by its very nature, the ultimate in disrespect — towards our minds, bodies and souls. Furthermore, the hypocrisy the ACT team displays in calling my decision to return to hospital “voluntary” in these circumstances is astonishing.
I have since come to realize that all I have to do is pretend to be rational and respectful in the presence of power. The ACT team members, by themselves, do not have power — they just trigger the mechanism that exposes me to power. I can be truculent up to the point where I’m in the presence of Psychiatric Emergency Services staff, doctors (any doctor, not just a psychiatrist) or the police.
This preserves my “freedom,” in that I’m not held at Psychiatric Emergency Services and injected with drugs by a (usually male) nurse, but does nothing to improve the conditions I’m forced to endure outside of the hospital. Being required under threat of arrest to be polite to people who are coercing you is not, I think, what policy makers had in mind when crafting the Extended Leave provisions of the MHA.
Without doubt, Extended Leave profoundly curtails one’s freedoms and rights, and the threshold for what is deemed “unacceptable” behaviour is invariably lowered. Please keep in mind that at the time of the contretemps described above, I had recently been deemed fit to leave the hospital, was taking massive doses of medication as prescribed (three antipsychotics, a mood stabilizer and a sedative) and was doing a competent job of taking care of myself. My only crime was being offensive towards an ACT team member. It seems that the goal I am now reduced to fighting for is merely the right to be rude in my own home.
The Extended Leave provisions of our MHA are often abused by psychiatrists, and in any event, they’re not even required; rather, we need drastic expansion of voluntary in-patient facilities. And I mean truly voluntary, not the all-too-common pseudo-voluntary mechanism I experienced in August. BC’s mental health care system is long overdue for an overhaul, as many anti-psychiatrists have been saying for years.
The most vocal proponents of Extended Leave or Assisted Outpatient Treatment (as it is termed in the US) make several questionable claims, the most pernicious being that the seriously mentally ill usually suffer anosognosia (lack of insight) into their conditions and consequent need for psychiatric treatment. Although anosognosia is indeed an actual phenomenon that occurs, for example, in stroke victims, there is no sound basis for believing it similarly occurs in most of the seriously mentally ill.
As with all mental illnesses, there is no brain scan, blood test or any other physical test which can confirm or deny the presence of anosognosia. Therefore, in practice, it can easily be — and often is — diagnosed in patients simply for daring to disagree with their doctors. Stating that you are not mentally ill almost always works against you, as it will generally be interpreted to mean that you must be mentally ill in order to make such a claim. As Phil Hickey asks: “Can you imagine a criminal justice system where pleading not guilty is routinely taken to be evidence of guilt?”
Despite this lack of objectivity, we are expected to take it on faith that a patient has this insurmountable neurological barrier to insight, rendering her incompetent to direct her own care. As somebody who has been diagnosed variously with anxiety, psychotic depression, schizophrenia, panic disorder, schizoaffective disorder, major depressive disorder, borderline personality disorder and, finally, bipolar disorder (my sole accurate diagnosis), I’m skeptical that disagreement with my psychiatrist as to the presence or absence of any particular mental illness necessarily indicates neurological disease. I think it’s also fair to say that objectivity is not psychiatry’s strong suit.
In any event, insight can be learned, and most of the mentally ill are aware that they are suffering great distress. A journal entry made shortly before my most recent hospitalization reads: “You’re not thinking clearly — be careful.”
I have long felt that community mental health care has been an unmitigated disaster. We need to abolish Extended Leave and, instead, vastly increase the number of voluntary hospital beds, reserving involuntary treatment for rare and extraordinary circumstances. During mental health crises, sedation is often required (sometimes considerable sedation), but it need not invariably be involuntary. For instance, I myself now recognize the need for medication when I am acutely ill, not because there is evidence that these drugs somehow delicately rebalance my neurochemistry, but simply because my experience is that I feel better when I take them.
The seriously mentally ill (especially those of us concurrently abusing alcohol or street drugs, and many of us do) can be violent. I am both middle-aged and middle-class, generally well-behaved, minding my own business and living in a quiet suburb of Victoria, yet I have a criminal record that includes an assault conviction. This arose from a time when the hospital declined to treat me, when I and everybody around me knew that I desperately needed psychiatric care. In frustration, regrettably, I threw a lukewarm cup of coffee at a Psychiatric Emergency Services nurse and then slammed a swinging door against her leg.
(As an aside, I also received a criminal harassment conviction for dialing 9-1-1 repeatedly to ask for assistance and to report that wild pigs were roaming in my backyard, and I received mischief convictions for (a) emptying the salt and pepper shakers at a pub; (b) stuffing a coffee shop’s toilet with newspaper; and (c) rearranging merchandise on a drugstore’s shelves.)
As devastating to my employment and travel prospects as these convictions have been, I do keep in mind that it was only through the criminal justice system that I finally had access to competent psychiatric care (one of the terms of my probation was to receive psychiatric care). Surely we can pave a less harrowing road to mental health care than the one I was forced to travel.
It was generally a chaotic time for me: I threw many of my apartment’s contents out the window, turned over my fridge, destroyed my treasured photographs, screamed incomprehensibly, burned food, frequently got drunk, embarrassed myself on the internet, disturbed my neighbours, wasted police resources, scared the shit out of my parents, destroyed what was left of my long-distance marriage and alienated most of my friends. I knew I was mad and I knew I desperately needed care but none was forthcoming, so the issue of voluntary versus involuntary treatment was moot. It often is.
Provide the beds, offer three square meals and as much sedation as patients want and most of the mentally ill, including the drug addicted living on our streets, will receive the treatment they require. Most involuntary treatment is utterly unnecessary — substantially expanded and run properly, psychiatric hospitals would have little need of force. With the current power structure dismantled, hospital procedures would have to be designed to be inviting, humane and mindful of patients’ rights.
Many people such as myself who acknowledge the presence of a serious mental illness would avail themselves of voluntary hospital services when need be. And street people who may not identify as mentally ill but who surely know that they are tired, poor, hungry and scared, would also flock to safety. The only real problem with this solution, in my view, is that voluntary psychiatric hospitals would be simply overrun, unable to provide for all those seeking sanctuary.
In the meantime, we are left with our current system which is in shambles. People are unable to access mental health care until there’s a crisis which sees them hospitalized, patched up with sedation and then released on Extended Leave.
Extended Leave is a form of social control, not health care, as it’s primarily designed to curb undesirable behaviour. I am no longer allowed to be a harmless, occasionally rude person struggling with a serious mental illness on my own terms and in my own home, even as that home is being regularly invaded by unwelcome guests, coercively medicating me under threat of arrest.
It’s time to phase out Extended Leave. If I’m ill, by all means, hospitalize me (involuntarily if so required); when I am well, let me go and leave me alone.
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.