Notes from a Secure Psychiatric Facility in a Poor Red State

Our Freedom Can’t Wait by Lawrence Lemaoana

The patient did not have a schizoid disorder—he’d flipped out in jail after smoking flocka. A bad trip had landed him here, and yet he got monthly injections of Haldol. I went to my supervisor with my discovery. Really? she said. Despite being the patient’s assigned social worker, she had not been aware of his diagnosis or lack thereof. In my naïve student-intern role, I figured that there’d been a simple-yet-awful mistake: he had gotten prescribed this heavy-hitting, tremor-inducing, first-generation antipsychotic while in psychosis and, busy humans that they are, the psychiatrists forgot to take him off his medication once he stabilized. I ask if I can speak with Dr. White. Stay in your lane, my supervisor responds. You do your job and let Psychiatry do theirs.

Dumbass that I am, I recite the National Association of Social Workers Code of Ethics to my supervisor. My duty is to pursue social change on behalf of vulnerable and oppressed individuals. It is to respect the inherent dignity and worth of the person. To promote ethical practices on the part of the organizations of which I am affiliated. As a social worker, isn’t my job to advocate for the patient?

No, my supervisor is not amused. My supervisor, a Black woman in her fifties who has a reputation for making interns cry, has worked at the hospital for half her life. In our department, she holds the second-to-top position. She (along with the handful of others who have been here decades) is nonplussed by the stark difference between our mushy professional code and reality. Your job is to assist the state in evaluations and stabilization so these guys can return to jail, she reminds me.

I continue pressing my supervisor on the dodginess of injecting somebody with Haldol when he does not have a psychotic disorder, and eventually my supervisor tells me that I can talk with the patient’s nurse. (My supervisor has five hours left of records to complete and two hours to complete them: she needs me to stop badgering.)

Over her scrubs, the nurse wears a sweatshirt printed with an image of MTV’s Daria and the sarcastic words I’M OVERCOME WITH EMOTION. She resembles Daria—the same affectless line for lips—in the guise of a buxom Southern woman.

For his mild cognitive deficits, the nurse replies when I ask for the logic behind the patient’s prescribed medication. He was going too fast. Sometimes, people with cognitive deficits need something to slow them down.

But I just talked with him the other day. He reads. He talks. He didn’t seem to be particularly cognitively…deficient.

Oh, he is.

So he needs Haldol?

It’s an off-label use.

I’m still confused. But I’m getting a strong vibe that in asking questions, I am the dumb one who is missing something. Before I skedaddle, I’ve just one more query: Do you see anything…ethically…weird…about his prescription?

She does not.

* * *

Our facility houses men suspected of serious mental illness and charged with serious violent crime. Each of these words, crime and illness, have ample wiggle-room with regards to what falls under their jurisdiction. Their qualifiers—mental and violent, as well as that wiggliest word, serious—are not much help. We’ve got someone in here accused of stealing a cell phone; in the same unit, someone has been charged for a gruesome murder. We’ve got men who spend their days conversing with “unseen others”; others are totally lucid but “antisocial.”

These men come from jails all over the state. They have not been convicted of any crimes. They’ve been charged, but have not yet gone to trial. In jail, they exhibited signs of severe psychosis. Maybe they attempted to gouge out their eyes with a spoon, maybe they attacked a guard, maybe they’re talking nonsense, or they won’t quit with the attempted suicides. They became too great of a liability for the jail, and so the judge ordered them to come to our hospital. Here, we house the men until they stabilize enough to return to jail. That is, if they become stable enough to return to jail. Many of our men do not stabilize.

* * *

A tech escorts a patient into the conference room. The patient wears his state-issued sweatpants inside out—the sweats are fluffy and matted like the coat of a stuffed lamb who has been through the washer too many times. It is a poignant expression of individuality in a place that won’t let him hold a pen. The patient is seated, and the social worker fiddles with a monitor. All eyes look up at the mounted, oversized HD-TV. A psychiatrist—let’s call him Dr. White #2—appears on screen. As for the aptronym: the psychiatrist and I are white, while the other folks in the room are Black. This breakdown mirrors the facility’s racial composition as a whole: approximately ninety-five percent of the patients are Black. The forensic techs are also all Black. They have the hardest job of all: they are on the unit to maintain peace (break up fights), hold “safety watches” (make sure that guys do not self-harm), and perform impromptu therapy with the patients (laugh, chat, be human)—all for a measly pay of $9.75 per hour. The rest of the staff—social workers, nurses, administratives, police officers—are pretty evenly split, Black and white. A notable exception to this pattern is our Psychiatry Department, which is all white, save for one South Asian man.

All but one of the psychiatrists went remote during the Covid shutdown, and word in the ward is that they are not planning on coming back. In a few years (another social worker predicts), this place will only house the patients and a barebone number of techs and RNs to break up fights, dispense meds, and assist with the occasional Zoom. Dr. White #2 is seated on a leather sofa, ankles crossed, sipping a mug of coffee. Behind him looms an innocuous Abstract Expressionist-style painting. Mr. Jones, he says. Can you tell me why you’re here? I shouldn’t be here. What is your diagnosis? I’m not supposed to be here, Doc! Can you list your medications?

These questions resemble the ones that a team of psychologists will ask each patient during their every-90-days-for-the-first-year forensic evaluation. To prep the patients, staff ask each patient the questions during their monthly treatment team meeting to measure the patient’s progress. Of course, by progress, I mean the patient’s willingness/ability to answer the questions to the staff’s liking. A successful patient will accept his diagnosis (schizophrenia or schizoaffective disorder in the vast majority of cases) and talk, without aggression or confusion, about how he has come to our facility to receive treatment in order that he’ll be fit to stand trial. If the patient does not accept his diagnosis—or starts bemoaning his situation—then he is likely labeled aggressive, delusional, and/or incompetent: still mentally ill.

If, in his first year, the patient fails his three forensic evals, then his status is changed from Pretrial to Unrestorable. This classification circumvents the patient’s chance to stand trial. As an Unrestorable, the patient becomes a ward of the state. He will have his freedom stripped from him and be mandated to transfer to a “less restrictive environment”: a state group home for the mentally ill. In the group home, there’ll be about 20 men, while our hospital holds a total of 140. At the group home, the guys will have a shared kitchen, and staff will escort them on weekly trips to the Winn-Dixie for food. Here, patients don’t even go to a cafeteria for a change of scenery: their styrofoam-plated meals are brought to them in the unit, the same big room in which they eat, sleep, and shit. Once a week, the guys in the group home may go on a chaperoned trip to a local bowling alley. The biggest plus—in the group home, there’ll be a yard that the men can access freely. At the hospital, patients rarely step outside. (There is a courtyard that the men tended pre-Covid, but during the pandemic, access to this open-air space was mysteriously shut off.)

That’s about as “less restrictive” as it gets. In the group home, the patient will not be free to leave or to get a job or to stop taking his meds or to bring guests into his “home.” And he has all this to look forward to only when he finally gets transferred to the group home. Chances are, he’ll remain here, in the secure psychiatric hospital, for several more years as he waits for one of their beds to open up.

Of all that is wrong with the hospital, the “Unrestorable” designation is one that bugs me most. Not everyone at the hospital becomes “Unrestorable”: of the guys who have been here over a year, some return to jail, enter a plea deal of Not Guilty By Reason of Insanity (NGRI), and then return to the hospital to await placement in a less restrictive environment. The men who are NGRI are in essentially the same situation as those who have been classified as Unrestorable: both become adult wards of the state awaiting transfer to a group home. But at least NGRI folks had a chance to communicate with their lawyer and to put in a plea. A man who is “Unrestorable” was never even granted this façade of justice. He simply waited in the hospital and did not progress. A group of psychologists skimmed his files, met with the man for less than three hours over the course of an entire year, and then proclaimed that the man would never become better. They stamped him as Unrestorable and sealed his fate.

* * *

My mother tries to get me to look on the bright side. The group home sounds better than being homeless, which a lot of people with schizophrenia are. At least in the group home they’re guaranteed a warm bed and meals.

Sure, my mother has a point—but that’s assuming that the facility’s diagnoses are correct, and that all the “Unrestorables” actually do have serious mental illness. I do not trust the staff here. I do not believe that our staff can accurately determine whether or not a person can be restored to sanity.

It’s not ideal, my supervisor answers when I ask if it is illegal for the state to take control of a person’s life even though he never had a chance to stand trial. Later, I ask a psychologist from our state’s Department of Mental Health the same question. Oh, totally, she says. Of course, we are violating their constitutional and human rights! (Duh! Had I forgotten where I live?!)

* * *

Back in the conference room, Mr. Jones grows frustrated. (Or aggressive, in our facility’s lingo.) The tech escorts him back to the unit. The psychiatrist grins at us like we’re all in on a private joke. Before we x out of the meeting, I ask Dr. White #2 how he makes his diagnoses. I am curious because I know that not everybody who experiences psychosis has a schizoid disorder. The human psyche is breakable, but with care, it can heal. Sure, all the patients were transferred here because, while in jail, they became psychotic—but why does that mean that they all have schizophrenia? From what I’ve witnessed (and, granted, I have not been at the facility long), many patients here do not fit the criteria necessary for a diagnosis of schizophrenia or schizoaffective disorder as prescribed by the DSM-V. Am I missing something?

Oh, no, I do not bother with the DSM-V. Again, that smile. I have developed my own criteria.

* * *

Patient: But I don’t want to go to the group home. I want to go home.

Supervisor: If you don’t want to go to the group home, you can stay here. Do you want to stay here?

I shadow my supervisor as she does “interventions” with her patients. The intervention is the heart of each patient’s “individualized treatment plan”—once a week, for 30 minutes, the social worker meets one-on-one with her patient to work on his “individualized” “goal.” When I first learned that I’d be doing interventions, my heart glowed fuzzy: I imagined bringing in a Dialectical Behavioral Therapy Skills Workbook, teaching these guys all the hacks that I learned in my multi-thousand-dollar, 60-day stint at an in-patient rehab. Of course, I’m somewhat bummed when I learn that these interventions must take place in the unit’s common area, while seated at the tables bolted to the ground in the Behavioral Health Solutions Suicide Resistant® Armless Chairs, as the nurses surveil us from inside the unbreakable nursing station and as the officers surveil us from the unbreakable police station and amidst 44 other men pacing or slumped or cracking jokes or standing as close as is physically possible to the TV as they ogle G-string-clad asses jiggling juicy and incessant. I am more bummed when I learn that these interventions only last 30 minutes per week. I am straight-up disheartened once I realize that, once a patient has been here for 60 days, the social worker must cut down her visitation time with him to 30 minutes per month.

Patient: You can’t hold me here, against my will, forever.

Legal-wise, the patient is right. In this state, the law says that a person cannot be held without trial for longer than six months. But the law is…pliable.

Supervisor: We’re not holding you here against your will. It is your choice. You can stay here, or you can go to the group home. You are free to make a choice.

I’m still trying to glean a therapeutic takeaway as I learn my trade. There’s something CBT-esque about the interaction, right? If Cognitive Behavioral Therapy is all about getting an individual to reframe their cognitions about their situation, then what my supervisor is doing counts as therapy. Right? Showing this boy that his state of illegal imprisonment is, in fact, a choice he has made with his own free will?

I am bipolar, the boy is losing steam. The psychiatrist told me that I have bipolar. I am not crazy. But if I stay here much longer, this place is going to drive me insane.

* * *

At the end of the third week of my internship, I spill my beans. I tell my supervisor that there’d been a time in my life in which I had been unwell, and if this facility had gotten their hands on me, I may well have been labeled psychotic. At the time, I was so unwell that the idea of sanity—of walking down the street without sobbing, of laughing, of holding a conversation, of doing all those beautiful, mundane things that people do—seemed out of the realm of possibility. After I broke down sobbing in a grocery store because I was certain that I had shat my pants and I was confused because when I fished my fingers around my butthole, I could not feel any shit and yet I could smell the shit exuding from me and my flesh, I believed that I would never again be able to enter a store.

I mention this shitshow only because smelling things that others do not smell can be a sign of psychosis. I would not label my experience as psychotic, but others may. Here, labels are slapped on sloppily. Just as the legal system tends to presume guilt before innocence, workers at the secure hospital presume sickness before health. For example, one (mildly) intellectually disabled patient never had a psychotic episode in his first year at the hospital. However, at his annual assessment, he mentioned to his assessor that he had once seen a shadowy figure standing by a doorway. The assessor checked a box stating that the patient experienced Hallucinations.

Listen—I do not want to suggest that I was anywhere near as sick as many of the guys are when they arrive at our hospital. But in recalling my past, what I want to remember is this: when you’re broken, believing that you are capable of becoming well can feel impossible. At the time, I was prescribed lithium and Abilify, and while the medications allowed me to rest (to lie in bed for months on end, only getting up to pee or scream at my mother or scream at my father or eat), the medication had not healed me. Even after that acute episode dissipated, the sick feeling lurked within me, always threatening to seep from my pores, grab my hair from behind, yank me back down into crazyworld. For several years thereafter, I still believed that at my core I was a sick, bad person. I only postured sanity by blotting out this true me with some careful (and, eventually, uncareful) substance-based rituals.

What eventually healed me was opening myself up to the possibility that I was not a sick and evil person. In rehab, with cognitive behavioral therapy, I learned to challenge my core beliefs—those unhelpful beliefs that I held about myself and the world, “absolute truths” that in turn shaped my behavior in any given situation. It was not easy to distance myself from them. As ugly as those beliefs had been, they’d become my identity; when I began CBT, when those beliefs that had grounded me for so long began to crumble but I had nothing yet to replace them and no substances to propel me forward, I felt like a hungry ghost.

In rehab, all I fucking wanted to do was to lie in bed and to scream and sob and scream and sob and scream and sob. I wanted to pound my fists into objects, myself, other people—since facing reality felt horrible. But I couldn’t. I did not have time to. In rehab, my time was constantly scheduled: I had to carry myself to breakfast by 8am each morning. Then, for the rest of the day, I’d have group and individual therapy, therapeutic recreational activities (hikes, mainly), an AA or NA meeting at night. By the time the schedule ended—9pm—I’d be wiped. I hated this scheduling, but I understand it: the schedule forced me to push through from one minute to the next; it prevented me from constantly breaking down.

And when I did break down, I got a hug. An actual full-bodied embrace from a staff member. That was another wonderful thing about the rehab: many of the staff were in sobriety, and would talk openly about their own struggles with addiction and the long, ongoing process of recovery. It was inspiring to see people who were “like me” and doing okay. But, more importantly, having staff in recovery helped me to get over my shame—and to trust my caregivers. Admitting that you need help is deeply embarrassing—so much so that it is way easier to lie to yourself, to tell yourself that you don’t actually need any help, to backtrack. You become suspicious of everyone. You think everyone is out to get you, or is judging you, hates you, feels superior. Knowing that staff had been through the same thing allowed me to open myself up to them, and allowed me to be receptive to therapy.

But here? We do jackshit to help these guys heal. Structure is a joke. Legally, the hospital must provide each patient with 20 hours of programming per week. The programming that we do provide is lame—for “Music Therapy,” the guys crowd around a boombox to listen to rap; for “Group Fitness,” they walk laps around the unit. But at least it’s something—the hospital is currently missing its legally-mandated 20-hour-per-week mark. Many of the guys only have scheduled activities for a few hours per week. The rest of the time, they’re on the unit, watching TV or napping. Most of the guys don’t complain. They’re sleepy, thanks to their monthly injections of Haldol plus whatever other psychiatric cocktails they’re on. And whenever they do “act out” (be it cussing at a nurse or slamming a fist against the nursing station window), we teach them lessons in How to Relieve Psychic Pain via Intravenous Drugs: in addition to injecting the guys with their scheduled antipsychotics, the nurses regularly stick the patients’ thighs with bonus “take as needed” shots of Haldol and Benadryl.

As for support, we certainly do not treat our patients like they are good people with unfortunate learned behaviors or like they are people who might one day be capable of living a fulfilling life. Case in point: my supervisor, while running her Symptom Management class, asks the patients, Is schizophrenia curable? The patients remain silent. No, schizophrenia is NOT curable. You will always have schizophrenia. My supervisor may be correct, but she fails to add the key point: that it is possible to manage the symptoms of schizophrenia, and it is possible for a person with schizophrenia to live a fulfilling life.

Case in point: in that Symptom Management class, when I write up the Group Notes of the Electronic Health Records, on some days, when I think one of the guys has demonstrated progress, I’ll check: Moderate. But when my supervisor returns the edits to me, Moderate is slashed out, Minimum is circled. “Why’d you put Moderate?” she’ll ask, not listening for a response. “These guys—the way they are, they are never going to progress. It is always going to be minimal progress for them. Remember: always circle Minimum. Even at the end.”

* * *

Here’s a tip: don’t tell your supervisor that you have been possibly psychotic and in rehab and are genetically predisposed to serious mental illness. After my confession, I lay low for a few weeks—her follow-up questions led me to realize that she was not interested in the point that I was trying to make (that some of these guys are getting worse because we make them believe themselves to be sick, bad, incurable), but that she was assessing my stability. But I can’t stay quiet too long: I am confused. One of my patients keeps bringing up the fact that he was raped in jail. Also, his mother committed suicide. I’m wondering: could he have PTSD? I’d been doing some outside reading, and I’d found that PTSD can lead to psychosis—so can Major Depressive Disorder—and researchers have documented folks with PTSD getting misdiagnosed with schizophrenia and—

Claudia, my supervisor cuts me off. You are individualizing these guys too much. Don’t spend so much time thinking about them. You’ll never last if you do.

I’m fine. I want to scream.

You are projecting your experience with mental illness onto these men, she says. Just because you got better you think that they can, too. I’m not denying that your patient has PTSD—and he probably was raped in jail. But that’s not our job to hear it. Do you remember what I told you? Do you remember what your job is?

Yeah, it’s to help stabilize these guys, but how—

Exactly. Your job isn’t to address their trauma. All you do is assist the state in stabilization and evaluation.

Maybe she’s right, and the men are much sicker than I understand, and even the bougiest cognitive behavioral therapy couldn’t heal them. I’m sure this is the case with some of the guys—but many of them, I’m still convinced, are getting diagnosed with a serious brain disease that they do not have. Black men are 2.4 times more likely than whites to get diagnosed with schizophrenia. After working here, the statistic makes way too much sense. How much simpler and cheaper it is for the white doctor in our racist state to call the poor Black dude schizophrenic rather than look into his complex PTSD. It’s an easy disease to spot when you’re on the lookout for delusional behavior of the paranoid or grandiose sort, as well as aggression and rapid speech. (Hallucinations are not required for a schizophrenia diagnosis.) But—even for the guys who have schizophrenia: they would benefit from getting their trauma treated. Schizophrenia and PTSD often go hand-in-hand: trauma history can trigger genes that predispose people for schizophrenia. And it is commonly understood that for people with schizophrenia and PTSD, untreated PTSD hurts their chances of recovery from psychosis: they are unlikely to stabilize if their PTSD is ignored. In the meantime, the days tick by, and the guys become Unrestorable.

* * *

There are currently 122 130 142 155 men on our waiting list and only 140 beds in our facility. 155 men waiting in jail for treatment. Once the judge orders a man to come to our hospital for treatment, the man will have to wait in the jail for another year or two (or three or four or…) until one of our beds open up. The bottleneck is unsurprising: we’ve got so many Unrestorables here in the facility waiting around for a bed to open up in the state group homes. Our state’s response to the bottleneck is also unsurprising: to build another secure facility while keeping staff salaries ridiculously low. As a result of our shitass wages, the whole facility is facing a crisis-level staffing shortage. In the meantime, what is there to do? Haldol and Benadryl, Haldol and Benadryl: injections in the thigh.

* * *

The psychologist and disability rights advocate Pat Deegan, who herself has a diagnosis of schizophrenia, has stated that “recovery refers to the lived experience of people as they accept and overcome the challenge of the disability.” In this model of recovery, people with schizophrenia “experience themselves as recovering a new sense of self and of purpose within and beyond the limits of the disability.” Today, person-centered recovery is considered a best practice for treating people with schizophrenia. And this model of recovery does not equate to making patients symptom-free. In schizophrenia, full recovery is rare. Rather, person-centered recovery focuses on the individual’s ability to make positive meaning for themselves in light of their disorder. In this model, hope, meaning making, and the development of an identity beyond one’s mental illness are all key.

The good news is that hope, the ability to create meaning, and multifaceted identities exist free of charge. It need not cost tax-payers any more money to provide wards of the state with these gifts. The patients already contain hope, the meaning-making apparatus, and rich identities within them. I witness their humanity every day. I bring cupcakes to Symptom Management, and one young man covered in face tattoos smears vanilla icing on his nose. Another time, a patient begins wailing Bob Marley songs when I ask him, Can you tell me your diagnosis? I am cheered whenever I witness the patients joking around with the techs: rapping, chuckling.

The crappy news is that that damned word Unrestorable does nothing to inspire hope or meaning or complex identities. The more we insist on labeling the guys as such—thus training the patients to align themselves with that cruel phrase—the harder it becomes for any of us to see hope.

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