Monday, May 26, 2008

Not Guilty by Reason of Insanity ... Sounds Good, Doesn't It?

"What happens to our bodies when we die? Inside a dusty room in a decaying outbuilding on the grounds of a state-run psychiatric hospital are simple pine shelves lined three-deep with thousands of copper canisters. The canisters hold the cremated remains of mental patients who died at the hospital from 1883 (the year the hospital was opened, when it was known as the Oregon State Insane Asylum) to the 1970's, and whose bodies remained unclaimed by their families. The copper canisters have a handmade quality; they are at turns burnished or dull; corrosion blooms wildly from the seams of many of the cans...The intensely hued colors of the blooming minerals, the etching of the surface of the copper, the denting of the metal, and in some cases, the vestiges of paper labels with the names of the dead, all combine to individuate the canisters, and to imbue each with a remarkable singularity..."

-- From The Library of Dust

I work as a forensic psychologist, in a mental hospital. Oh, sorry ... I know that I am not supposed to say that. I mean that I work in an institution that is there to empower forensically committed individuals to lead happy, productive lives and to reach their fullest human potential.

Funny ... It feels like I work in a mental hospital. From the ugly linoleum to the Seclusion and Restraint Room to the dorm rooms that cram four people into a bare room to the razor wire. From count to chow to canteen ... it is much like a prison ... filled with people with mental illness. Not as bad as One Flew Over the Cuckoo's Nest, but on some days, we kind of get there.

It is not a nice place to live, a mental hospital. I will talk more about that another day, perhaps. What has been on my mind a lot is the concept of Not Guilty by Reason of Insanity, as a legal entity. On the one hand, I think in a civilized society, there should be an understanding that sometimes people should not be held completely to blame for their actions. The person who really believes, as much as I believe that I am sitting in my living room with my laptop, that the world is coming to an end and that they have to stop it by committing a crime, should not get the same level of accountability as the person who shoots their drug dealer because they got stiffed.

On the other hand, it just feels like another way that the mentally ill get the proverbial short end of the stick.

In California, one is deemed to be Guilty, but not Guilty by Reason of Insanity for a crime, (NGRI). So, you did the crime and are guilty, but the legal system recognizes that you were not responsible for your actions because of a mental illness that interfered with your ability to discern reality . And if you don't judge reality correctly, you are not legally responsible for your actions.

Some examples would be that you were hearing voices that told you that someone specific was going to harm you or you believed that the world was coming to an end and you were trying to prevent the apocalypse or you thought that your neighbor was sending messages through the telephone to you that were slowly irradiating you and would not stop.

The idea is, that if you knew what was real and what wasn't, you would make a different decision.

All of this is well and good, and necessary. However, in some ways, it is an example of how mentally ill people are well and truly screwed by the system. The idea is that a person will receive treatment for their mental illness and will then be released into the community. They have to take the maximum time for their crime to get an NGRI. So, if your crime ordinarily got seven years to life as a sentence, you would have to take a life sentence to get the NGRI. Which means that the state has a hold on you for the rest of your life. As long as you have a current sentence, the state has absolute control over your life.

So, let's see this in action. John is a 19 year old gang-banger with an extensive criminal history beginning with Grand Theft Auto at the age of 11. He is out with his homeboys and and a fellow 18th street gang member comes running down the street saying that he was jumped by a rival gang. They all run back and get involved in a fight with the rival gang. John pulls out a gun and shoots randomly into the crowd. He does not intend to specifically kill someone but ends up wounding someone, who later dies. Let's say, for the sake of argument (I don't know the laws well enough to know how accurate I would be here), that he gets eight years to life for manslaughter or second degree murder or something. This means that he can come up for parole, and if the Parole Board agrees, he can go out, serve his parole, and live his life from the age of 26, hopefully a wiser man.

Now let's talk about Joe. Joe has schizophrenia and has been hearing voices that tell him that his mother has been killed and replaced by a robot. He does not believe this at first, but the voices are compelling and become increasingly believable. At the age of 19, based on what the voices say, he attacks his mother with a kitchen knife, believing that the robot is evil and is part of a plot to take over the Earth, one person at a time. His mother thankfully survives, but he gets a plea of NGRI and also gets seven years to life.

However, he gets the life sentence, because he has to get the maximum sentence to not just be sentenced to prison and rave for seven years. He finally gets sent off to the state mental hospital, where he is treated for symptoms of his mental illness and responds really well to treatment. Within a year, his psychosis abates. He will live in the mental hospital for at least the next five or six years, because pretty much no one gets a recommendation for supervised outpatient treatment in less than five or six years after getting to the hospital, because you have to demonstrate a period of stability.

Okay, so now he has demonstrated a period of stability, having had no symptoms for six years. He takes his medication faithfully. He has completed a "detailed, viable relapse prevention plan", he has identified the stressors that could trigger his illness. He knows the warning signs of his illness. He has attended hours and hours and hours of mental health treatment. He has never been in a fight. He has put up with the rigid rules of the hospital. He has been able to tolerate an environment that makes you both passive and dependent -- one that not only demands that you be meek and subservient, but punishes you for any sign of independence or rebellion.

He is fortunate enough to get approved for possible release into the community in six months, should he continue to maintain his progress. One morning, a new staff member gets him up on a Saturday for morning medication, not knowing that he does not have to go to early medication. He informs her that he doesn't have to go. She writes him up for refusing, partly to cover up her own ignorance, presenting it as his being noncompliant with unit rules. (The patients call this getting "chart whipped" or "pencil whipped".)

This sets him back another six months, because the CONREP evaluator will not even consider looking at you with a recent write up. So, he sucks it up like a good patient and remembers that he is not to ever, ever talk back to staff. He finally gets his recommendation for outpatient treatment. Six months later, CONREP comes out to evaluate him and decides that he is not suitable for outpatient treatment, for whatever reason. Maybe they sent out the wrong evaluator. Maybe the evaluator evaluated him in about 15 minutes and he did not say the right words. Maybe the evaluator saw that he got written up eight months ago.

So he waits another six months at the minimum. CONREP is supposed to see people every six months, but does not, because they are woefully understaffed. But Joe is very lucky, because he is seen in six months and CONREP approves him for outpatient release. It has now been seven years. it takes about four or five months for the paperwork to get through the system. The court approves him for conditional release (which just means that he is released, but with conditions -- kind of like parole, but much, much, much stricter).

But there are no beds in the community. CONREP has very few beds and you must live where CONREP says. So he has to wait -- maybe six months, maybe nine months, maybe a year. And during this time, he has to maintain a pristine record. Never late for meds, never late for chow, never responding to provocation.

So, he gets a bed in the community, in a board and care facility. Usually in a pretty ratty board and care. Here is our young man -- less than thirty years old, who has spent much of his young adulthood in a mental hospital. He has been groomed to live a marginal existence.

He will have to live in a board and care, usually in a pretty bad part of town. Drug dealers and prostitutes will hang outside of the local liquor store on the corner. He will not be allowed to get a car or work, because he will have to be in treatment. A lot of treatment. He will have a curfew and very little free time. He will be forced to live on SSI, despite the fact that he is healthy and eager to work. CONREP will take most of his SSI to pay for his treatment. He will get less than 50 or whatever amount it is a month to live on. His food and board and medication will be paid for, but that is it. He will have to make the 50 dollars stretch to cover all of the other living expenses. CONREP will tell him when he can get a job or go to school. If he is very, very lucky, he may be able to move into independent living in about a year. He will endure random searches and drug screens as long as he is on conditional release.

Once you are on CONREP, you will continue to be supervised until ... well ... they say so. You can be on CONREP for the rest of your life, because when you get out into the community, the clock stops on your commitment. Let's say that Joe has a year left on his commitment when he left the hospital. CONREP can keep him indefinitely -- until they say that he is restored to sanity.

And the thing about CONREP, is that they can revoke you at any time, for anything. You can be revoked and sent back to the hospital for anything ... anything. With no recourse, because the court will always side with them. So you come back to the hospital and the whole thing starts all over again, but it is worse, because CONREP even less willing to take you back if you have been revoked.

Let's just say that it is pretty much impossible to be restored to sanity once you are on CONREP -- because they can always point to your history and say that, due to a mental illness, you are dangerous. And they do. Because you are considered to be dangerous to the community because you have a mental illness. Not because you have a long-standing history of criminal behavior, not because you have a drug problem, but simply and solely because you have a mental illness.

Everyone else in society has a right to be a criminal -- you will hopefully pay the consequences, but you have that right. If you have a mental illness, you lose that right. John, at 26, will leave for parole and as long as he serves it, he will be done. He can live where he wants, work where he wants (pretty much) and as long as he abides by the conditions of parole, he can live his life as he pleases.

Joe will live in a crappy board and care -- usually sharing a room with someone who may or may not have a mental illness, or who may be a parolee, or a mentally disordered offender (more on that later) or be gravely disabled -- but for whatever reason, his roomie will not generally be able to care for themselves. And they may steal his stuff. With a board and care operator who views him with suspicion because he is a criminal. Riding the bus to get to his day treatment program. Working if he is allowed to, at a job that is approved by CONREP. He can maybe get an apartment if CONREP says so. He can only have so much money. If he wants to make a large purchase, he has to ask permission. If he wants to go to school, he has to ask permission. If he wants to buy a computer, he has to ask permission. If he wants to go to his sister's wedding, he has to ask permission. If he asks permission and doesn't get it in writing, his counselor can say that he did not ask permission and he will be violated. I knew a guy that this happened to. His counselor was new and said that he could leave the county to attend a family function and did not follow the proper procedure and the individual was revoked. He spent the next four years in the hospital, getting treatment for I-don't-know-what. Failure to get it in writing?

Anyway. It just seems odd that the person who commits a crime due to a mental illness is considered to be more of a threat to society than the person who just doesn't care about the rules. Why are we more afraid of a person with a mental illness than a person who has no regard for the rest of us?

It truly sucks to be mentally ill.

Wednesday, May 14, 2008

Just a first post

I have been wanting to get this started for some time. I have been waiting and waiting for the proper way to introduce talking about what it is like to work as a forensic psychologist, but I just can't seem to get myself together. So, in true blog-style, I am just going to jump on in and tell you about my day today.

Not all about it, because that would be long and boring and repetitious. But I will talk about a relapse prevention plan and why I think I am weird sometimes.

I am working with a young man who has persistent symptoms of a mental illness. They are mild, but can slip into moderate if he is not careful. We have been talking a lot about relapse prevention -- the idea that you can be minding your own business, living your life, and then you can have a flare up of symptoms of your mental illness.

I work with people with severe mental illness -- schizophrenia, schizoaffective disorder, bipolar disorder ... those types of things. I will explain more later, I think. But when a person has a severe mental illness, it is helpful to have them put together a plan for how they will cope with it if they start to get sick.

Because the really awful, pernicious, lousy thing about mental illness is that when you are sick, often it feels just like reality. The line is not clear cut for some people. I was talking to a guy the other day, and he said that when he was "going through my changes" (i.e. being psychotic), he did not talk about it, just as we weren't talking about the table in front of us ... because it just is.

So, when a person is sick, what they feel is very real. So, you have to catch the symptoms when they are manageable and small enough to contain. My patient and I have noticed that he is pretty much always struggling with mild symptoms of his illness -- some paranoia, mostly. For him, he will have a thought that will trigger feelings of anxiety and then he will go down this spiral of negative thinking that can lead to depression. He has been getting better and better at recognizing the thoughts when they were small and using some tools that we have identified to combat the thought.

The whole idea is to see what thoughts are hot buttons for him, and he has done well, generally speaking, to isolate a triggering thought. But last week, he got all bunched up in a really scary thought. He was not buying anything that I was saying and was insisting that his paranoid thoughts were real -- not just that they felt real, but that because he felt them so strongly, they were reality.

So, today we talked about what was happening last week, what his thoughts and feelings were and how we could stop those thoughts before they got out of control and became full-fledged paranoia. He said that he could recognize that he will have a disturbing thought, and then the thought would lead to a feeling and the feeling would lead to a mood. In a depressed, paranoid, hopeless mood, he literally cannot think his way out of the situation -- the emotions are just overwhelming.

So, I was saying that we would generate a series of steps to rein in the early, more manageable aspects of the thoughts -- so when he had one, he could try the strategies out, one by one, and see what works the best, but that he had to have a number of ideas at his fingertips for such occasions.

We were standing in the hall of the mental hospital where I work, him leaning on the wall, and me standing out in the hallway a little. We both have our arms crossed, but not in a defensive posture -- is it just comfortable. I notice how we are mirroring each other little. This man is often in motion, jiggling from foot to foot, shifting restlessly -- anxious, but now, he is slouched comfortably. No one else is walking down the hallway, which makes it easier to work. I should take him into a treatment room, but I am afraid that we will miss count, and that would be a drag. I don't want the situation where other staff members are running around looking for us, so we are in plain sight of the nurse's station.

So, I was saying that he needed to know his mild symptoms really well, and have some tools to manage them. The idea is that if those strategies don't work, and the symptoms persist or get worse, he needs to know that there is a specific moment when he will ask for help. Because without that, mild may turn into moderate without him really being aware of it. And moderate symptoms will interfere with his functioning in a significant way, and will make help even more difficult to ask for or accept if it is offered. Moderate symptoms are likely to feel so real that he will not listen to anyone when they try to help. He needs to know when other people may be better able to see the situation and the solution, and to be able to accept it.

I said to him that it is like The Cat in the Hat Comes Back, when the Cat realizes ... I notice that he is looking at me quizzically. "You have read The Cat in the Hat Comes Back, haven't you?"He shakes his head at me, eyebrows lifted interrogatively.

So, I have to give a brief synopsis of the story, how the Cat left a pink ring in the bathtub that they tried to clean it up with Mother's new dress and how it got splashed all over the house and then it got outside and all over the snow, turning it pink. I am aware of my patient's amusement and the fact that he is politely waiting for the point of the whole story. I could tell him about Dad's ten dollar shoes ... and the fact that the dress has dots ... and the Cat was eating cake in the tub ... but I refrain.

It would have been easier if he had just known the dratted story.

So I explain that the snow is all pink and that there is no way to get pink out of the snow, because ... well ... it is just hard to get pink out of snow. And the Cat in the Hat realizes that it is just too much for him to do alone, so he lifts his hat to reveal ... Little Cat A. And Little Cat A realizes that the job is too big for him and reveals Little Cat B, and then C and so on and so on until Little Cat Z.

My patient is looking at me, listening, and I can see the point where he starts to get it, because he says "Ohhhh".

I tell him that Little Cat Z does not have another cat in his hat, but he has VOOM and that is the thing that really works to get the pink out of the snow.

He is laughing a little at me, and I say to him ... I want you to be like the Cat in the Hat who knew when the job was too much for him and tried each Little Cat and went all the way to Little Cat Z, who uses VOOM to clean up the snow. I want you to have Plan A and then Plan B and then Plan L, M, and N. And I want you to know that there is a place when you cannot take care of it any more, when you have to turn to the Cat with the VOOM!

My patient is shaking his head at me, but not in an exasperated way, but in a kind way, I think. He is used to my odd conceptualizations ... I can't help it that I know more about Dr. Seuss than Dr. Freud. He gets what I mean, that sometimes your symptoms get the better of you, and you need a whole hat full of little cats. Because when you have done everything that you can think of, maybe it is up to someone else to help, because even the Cat had to have a little faith ...

"Voom is so hard to get,
You never saw anything
Like it, I bet.
Why, Voom cleans up anything
Clean as can be!"

Then he yelled,
"Take your hat off now,
Little Cat Z!
Take the Voom off your head!
Make it clean up the snow!
Hurry! You Little Cat!
One! Two! Three! GO!"

Then the Voom...
It went VOOM!
And, oh boy! What a VOOM!

Now, don't ask me what Voom is.
I never will know.
But, boy! Let me tell you
It DOES clean up snow!"