Wednesday, June 20, 2012

Sectioned- On The Road to Redemption

This old man and his four sons.
April 12th 2012: Today is an anniversary of sorts, five years on from April 12th 2007. By the fate of the calendar’s cycle it’s the same day of the week too, it’s Thursday.
The day I was sectioned for the first and only time, in my thirty two year experience with this profound dis-ease know as bipolar disorder.
Confined within an acute care ward and then released with profuse apologies a week later.

The experience speaks volumes about our subjective states of mind, and the reality of mental health diagnosis. On that Thursday afternoon I’d sat opposite a young psychiatrist, as guilty of projecting a subjective state of mind onto immediate reality, as I was. I’d seen his involuntary reaction the previous Thursday while watching him read a young psych grad’s evaluation notes. Watched a whole body shift as his posture suddenly stiffened, and a pronounced look of concern transformed his face. His mind seemed to become fixated from that moment on, “this man is unstable and needs medication.” Over two brief sessions he repeated the same mantra some half a dozen times, “your in a hypo-manic state and without medication you will become hyper-manic.“

‘I’m coming out of the hyper-phase now, I’ve been in the hyper state for a couple of weeks.’

My explanations of emotional context and relevant developmental issues, like childhood trauma did not register at all with him. My twenty seven year history of bipolar only confirmed a rigid mindset, “unstable - medication.” I might as well have been experiencing my first episode of psychosis, same procedural approach, same firm belief in a disease of the brain. Discussing emotional context was counterproductive in his view, “loss of insight is a standard feature of this illness,” was his most empathic response during our first meeting.

We didn’t connect at all in the here and now reality of those face to face moments, divided by unconscious defensive reactions into which we each projected our subjective perception. His a brain disease of acute care need, of locked doors, sedating medications and strict policy procedures. A tough love perception of unfortunate souls, becoming increasingly defensive due to the rise in violence, from drug induced psychosis. All my training in the art of emotional healing, meant nothing to a paradigm of perception which views overt emotional expression as proof of a disease. His reactive judgment the same as in 1980 when I’d steamed open an M.D. referral letter to read, “exhibits schizophrenia like symptoms,” and been diagnosed schizophrenic within fifteen minutes, of my first contact with a psychiatrist.

‘Jesus! It can’t be that subjective surely, isn’t it just like a cancer or diabetes, don‘t they send you for some tests and get conformation of the disease?’ A good friend recently asked, in perfect illustration of normal assumptions about the mental illness experience.

‘You’d assume so wouldn’t you, but maybe that’s the problem with our famous “I think therefore I am” cognition, it has no idea about its own stimulus,’ I’d replied.

‘Here we go, the mysterious black box of unconscious motivation, I thought we’d left all that Freudian crap behind us now - let me analyze your dreams Master-Bates.’

‘Yeah yeah, tell an old joke an lighten the mood, fully aware of why and how you do that? - Harry Homeostasis.’

‘Homeostasis! That’s just one of those big words you intellectual dickheads use to feel superior and I don’t care what it means, only fools take life to seriously while the rest of us just get on with it.’

Clearly my tone had upset him somewhat and we moved quickly to more comfortable topics, although I couldn’t help comparing his reaction to a young psych grad writing up her notes. “You’re a psychology graduate, aren’t you the least bit interested in the psychology of mania?” “No, no. This is what you people do, you twist things around.” Time presses, life demands and we just get on with it, taking our experience for granted with no inquiry into what really makes us tick?

I remember driving towards the hospital, wondering if I should keep the appointment or give it a miss. Three days after my acting out in the churchyard, I was back to near normal functioning with good foreground focus and attention. I’d managed a full days work for the first time in two weeks, and really felt the manic energy begin to subside. I was feeling a bit emotionally raw of coarse, and looking forward to meeting new friends at the Baha’i Temple the following Sunday. Yet in these weeks of openly embracing the psychosis experience, I’d put my family, friends and particularly my oldest son through a worrisome period and wanted to appease their concerns. “Keep the appointment and go on to show you don’t need the medication,” was the thought which swayed my choice that day. Like in the movie “Sliding Doors,” it now seems like one of those “butterfly effect,” moments still reverberating its consequences today.

"How have you been Mr Bates?” Another young psych grad asked, with twenty standard questions clipboard in her hand. Forgetting the average adults wary suspicion about what others will think, I should have only volunteered the right answers. Said I was feeling much better, sleep better, appetite better, ideation returning to normal. Instead I openly explained how the news of the séance had fired a manic excitement for a while. I told her about feeling angry and frustrated with my sons response and how I’d gone for a very long walk the next day to dissipate the energy. Where did I think I was? In a therapy session with someone interested in psychology? Why didn’t I just limit my conversation to the rest and relaxation I'd taken the previous day, and how I’d managed a full days work already? Did she even hear me when I said that, and what did she say to the Doctor? And No! I didn‘t mention a word about the churchyard, I don‘t loose that much insight?

‘Please wait here Mr Bates.’ Five minutes later she was back.

‘Doctor would like a few words before you go, please follow me.’ What happened in the following hour felt as surreal as some of the events at the height of psychosis. For decades I’d always been cooperative in these situations, never abusive or defiant, never arrested and always a model patient when I’d voluntarily gone to hospital in the past.

‘You’ve been feeling agitated and emotional Mr Bates,’ was the good Doctor’s response to my, “hi, how are you?”

‘I was a bit emotional with my son yes, although nothing more than a few words before I walked out.’

‘You didn’t sleep that night though, just walked around the city?’

‘Yes, I was upset and disappointed that people turn away so much, that they don’t want to know, even my own family.’

‘Or you don’t want know that you have an illness.’

‘I’ve explained that I accepted the diagnosis in the past, yet have started to believe its an emotional development issue.’

‘Yet your behavior is hypo-manic.’

‘No, I was hyper-manic, and that energy is fading rapidly now.’

‘I think your hypo-manic and without medications you’ll become hyper-manic.’

At which point he the picked up the phone and spoke with someone. For a long time we just sat in silence looking at each other, it was bizarre and I couldn’t understand what was happening. After a few minutes a man entered the room and my good Doctor reached into his desk drawer and produced some papers. Having never been through anything like this before I still wasn’t sure what was going on until he said.

‘Can you sign the ????? For this patient please.’ I was stunned.

‘What are you doing?’ I asked.

‘Unless your medicated you’ll become hyper-manic, you need to stay in hospital.’

At times like this I always become supremely calm, maybe its circumstances which call for a complete surrender to gut instinct? I remember being involved in car accident years ago when my second boy was a only a baby, glass from shattered windows had covered his crib on the back seat. In the ambulance a medic had noticed a piece of glass on his bottom eyelid and was to scared to remove it. “Wait till we get to the hospital,“ he’d said, yet I was terrified my baby would rub it into his eye. Taking a deep breath I calmly reached down and slowly removed the glass with my thumb, in that bizarre state of mind that‘s like watching someone else act in slow motion. In the consultation room I calmly watched the M.D. as he reached for his glasses and asked about patient diagnosis.

‘Bipolar 1, hypo-manic symptoms,’ the good psychiatrist replied.

‘When I walked into the room I knew the long walk thing had stirred you up,’ I said.

‘Are you reading my mind Mr Bates?’

I shook my head at his adolescent response and his steadfast refusal of any open and honest communication. We’d been locked in this Mexican stand off since the first words we’d spoken to each other. Or rather I’d spoken and he’d just sat there with his pre-determined judgment.

‘Do I look hyper-manic to you?’ I asked the middle aged M.D., who just shrugged his shoulders in that classic self-preservation response of the employable institutionalized. I closed my eyes thinking, “no sense of in the moment responsibility, just follow the staff preservation rules and cover your ass regulations,” then I reached for my cell phone and called my son.

‘Believe it or not I’m being sectioned for the first time in my life, this is just amazing.’

He said he’d call the psychiatrist and come by as soon as he could. It was unthinkable what was happening before my eyes, not one question had been asked about my current circumstances. How I’d arrived at the hospital, my work situation or my finances, which were not good at that time. I was already at least a week behind schedule on the house I was renovating and needed to catch up fast.

‘Do you guys really believe I’d sit calmly through this assault on my liberty if I was truly becoming hyper-manic?’ I asked. Again there was the same blank refusal of any kind of man to man communication, I guess in their eyes I was just a mental, worthy only of suspicion, and pitiful concern? I had the briefest impulse to get up and try to leave, but there was no way I was going to provide the satisfaction of having me physically restrained. Within a few minutes I was walking beside my jailer towards the psychiatric ward.

‘What is it? Did I insult your ego?’ I asked him as he pressed the security buzzer beside the gray painted double doors.

‘My ego’s not insulted, this is about health care,’ he replied as a nurses face appeared in a door’s little window.

‘This is really ridiculous,’ I said as he gestured I should follow the nurse, a satisfied smile his only response, as if we’d played a game and he‘d won.

I stepped over the threshold and into a large square shaped recreation room, four steps behind Larry the male psych nurse, greeted by the scene of half a dozen patients sitting around in various states of zombie like agitation, all staring vacantly at a TV, “welcome to side effect alley” I said to myself. Larry marched towards the far wall and a large hallway running of to the left, there was about twenty single rooms, patient bathrooms, toilets and that one special room with its padded walls. “This will be your room” Larry told me about halfway along the grey painted hallway, its dark grey door looking more like the entrance to a prison cell than a hospital room, “shit, I hate these places.” There was a standard single bed, single chair and freestanding single wardrobe for clothes which probably looked ok, to anyone not suffering a state of shock. After taking possession of personal items like my cell phone and bagging them, Larry asked me to remove my belt and take of my shoes.

‘Sorry I have to take the belt and shoelaces, but you’ll get them back when you go onto the normal ward.’

‘The normal ward?’ I asked.

‘You’ll get transferred over there later,’ Larry told me as he hurriedly unpicked my shoelaces before making his retreat. I just sat there still in shock at the detached nature of it all, and the speed with which I’d suddenly found myself locked up, “this is just unbelievable“ I kept saying to myself.

I did swallow the medication pill offered that night, yet would refuse it the following day as this ridiculous episode unfolded. That Friday the 13th, I spent the day making phone calls to my sons and trying to remain calm while deeply concerned that I should have been working. In the late afternoon I was visited by two more hospital psychiatrists who raised my hopes when they told me they’d come to do a further assessment. I expressed my new belief in an emotional development problem possibly caused by childhood trauma, and how after twenty seven years experience, mostly self managed, I thought this sectioning was inappropriate. At that time I had no idea what wheels had been set in motion by the signing of certain documents, or that this assessment was part of a standard procedure I was yet to comprehend.

I was advised that it was probably for the best that I stay over the weekend for observation and a review could be made the following Monday. I sat in my room for a long time after that visit, thinking about when I’d tossed my keys to my son and said he could take me to hospital. It was impulsive and the thought had been about showing him the subjective nature of diagnosis, and healing the damage it had caused my family. Sectioned, this was the last thing I'd expected, surely I hadn’t given sufficient reason for such drastic action? Now what should I do? The same as in the past and be the compliant patient, just accepting opinions I didn’t agree with? In all conscience I couldn’t place another pill in my mouth and swallow it, not with such a long history of medication intolerance, I needed to follow through with my convictions.

About 8pm a female nurse came to offer me the prescribed pill and I explained my decision. We talked about it for while and she advised me I could be restrained and given medication by injection. I acknowledged the procedural issue for the nursing staff and told her I would not resist such action, but on principle I could not place a pill in my mouth and swallow it. She accepted that was I sincere, even commenting that I was surprisingly calm about the issue and left to prepare an injection needle. Fifteen minutes later she returned with three others, two male and another female nurse and asked me to lay face down on the bed. After the talk we’d had I thought it was a typical example of the assumptive and suspicious nature of the mental health environment, rules, regulations, procedures and no trust in personal judgment about another human being.

I complied with all instructions and was complimented on my reasonable demeanor, soon to become the only acute patient on friendly conversational terms with most of the nursing staff. The next day I started to comprehend the difference in an aspect of mental health I never seen before, the bare minimum environment of acute care. It started with talking to one of the male nurses from the previous night, when I teased him about needing four people to administer one injection.

‘You just don’t know what will happen these days, especially on an acute ward,’ he said. Explaining that there had been a ten fold increase in assaults on hospital staff in the previous few years.

‘Is that why your all barricaded behind locked doors and a plate glass window?’

‘Only for this side, its not like this on the normal ward.’

‘So were all these people sectioned too?’ I asked, gesturing around the recreation room at the half dozen or so patients. He looked up from his clipboard assessment sheet, and glanced around the room.

‘Afraid so, most I’ve seen in here before, people who go off their meds and become the revolving doors.’

‘Non-compliant like me huh?’ He just smiled and gestured that he needed to complete his assessment duty.

It was a tough day, another when I should have been working and I tried to be productive by reading a book, “Family Therapy in Clinical Practice,” by Murrray Bowen. Bowen’s seminal ideas about the family emotional system, and the generational transmission of emotionality, had been a big influence on my belief in emotional development issues. Ideas that a certain young psychiatrist obviously didn’t give much credence to. I remember watching the nursing staff do their assessment trips into the ward, sitting off to one side observing, ticking boxes and writing a few comments. It made the place feel more like a zoo than a hospital ward, with people making field trips to observe the specimens. It was bizarre considering that most patients sat around and watched TV all day, or chain smoked out in the courtyard.

‘Wouldn’t it be better to talk to people, to find out how their doing?’ I asked one female nurse, “best not to antagonize” was her curt response, a thin smile of contempt reminding me that there is always at least one power junkie on a ward. She was true to form a few days later too, when I watched a young female forced into the isolation room. The girl had become hysterical when her room was searched just after a friends visit, presumably on suspicion of drugs.

‘YOU FUCKING BITCH! YOU FUCKING BITCH! YOU FUCKING….’ She’d screamed as three people dragged her out of her room, and it was so obvious they hadn‘t found a thing.

‘Those two have previous,’ a fellow patient advised as we watched the upturned nose of nurse “Ratchet,” depart the ward.

“Saturday night and your still hanging around …..,” I silently sang after John the psych nurse asked me about taking a pill, and had gone off to prepare another injection.

‘It won’t go down well with the General and his Lieutenant’s you know, they’ll just see it as a deluded defiance and proof of diagnosis,’ he’d told me. We’d had a really good chat about the Sydney Lifeline Crisis telephone center, where we’d both worked as counselors, and he was interested in the Gestalt Therapy training I’d just started.

‘You know, the rat’s and stat’s brigade, who wouldn’t know empathic approach if was staring them in the face.’ The ratio’s and statistics brigade was an old counseling joke about psychologist’s and psychiatrist’s, and their penchant for categorizing people.

‘I’m just a foot soldier in here, I might as well have trained as a security guard or a warehouse store man, as done my psych nursing,’ he complained earlier, as we‘d talked about the atmosphere on the ward and the strange detached ritual of patient observations. Shit! Saturday night, and I’m sat waiting for John to return, reflecting on the dizzy heights of spiritual euphoria, madness and mania, “is it just a disease process?” As he came back into my room I smiled, “at least one person trusts his own judgment and isn’t dependent on rules, regulations and institutional procedures.”

‘You know the drill,’ he said, showing me the tray with the needle.

‘Time for Captain Jack,’ I quipped, as I lay down and lowered my not so tie dyed jeans below my butt. “Take me to my special island. Just a little push …” “Love Billy Joel,” I’m thinking.

‘You pulling a double shift tonight? Shining your light through the door window?’ I asked John as he prepared to leave.

‘Yep, every hour on the hour, after 11pm, never miss the safety check.’

 ‘So tell me HAL, will I dream?’

‘Of coarse you will Dave,’ he responded with a laugh.

‘2001 - A Space Odyssey, right? - Oblique reference to the dream like quality of your euphoric state, yes?’

‘Or word salad, and you should definitely do a counseling degree, and a masters. - The rat’s and stat’s brigade would get no where near that kind of understanding.’

‘Keep it real man,’ he said as he left the room.

As I drifted of to sleep, George Orwell's 1984 came to mind and the dangers of the 20th centuries left-brained, mechanically minded man. All cause and effect, in his learned presumptions, with no felt depth of awareness.


'Yes HAL.'

'Will I dream?'

I spent Sunday doing much the same, counseling some of the other patients and feeling trapped and angry at the stupidity that was preventing me from returning to the Baha’i Temple. John was absent from the ward after his double shift, and three grown men came to give me a needle that night, the next day I met the General (head of psychiatry at the hospital).

‘Look, if you want to get out here, just take the medication,’ was his first reaction to my pleading for understanding. Exactly the same mantra had been pronounced about a certainty that I was hypo-manic and would become hyper without medications. I explained my belief about an emotional development issue, with a possibility that post traumatic stress disorder was involved somehow.

‘That’s gobbledygook really, you have a serious mental illness that can be successfully treated with medications like any other illness.’

‘You really believe its similar to having cancer?’ I asked him.

‘Yes, and you need to accept the illness and work with the experts to sort out the medications that will work for you.’

‘So your prognosis is that without any medications my condition will worsen?’ I asked, and of coarse he agreed.

‘Then stop the injections and just monitor me,’ I demanded. At first he dismissed the suggestion as plainly ridiculous and a symptom of my illness, a loss of insight and a denial. We went over my behavior in refusing medication and I asked him to consider that I’d acted responsibly towards staff needs, while upholding my own conscience. He agreed to discontinue the medications, for now, he said, although neither he or any other psychiatrist had explained what would be happening within two days. Shortly after my meeting with the head of psychiatry there was a mandatory visit from a social worker, Monday was her part in this procedural play.

‘You will go before a magistrate (judge) on Wednesday, a hearing that will seek a statutory two week detention order,’ she explained.

‘So four days after I’m arbitrarily detained, it’s the social workers job to explain to me what is actually going on here,’ I replied with an added comment about mental illness and cancer patients.

‘You’ll have a legal aid to represent you and can make a statement if you wish.’

I spent that night thinking about arguing my case for wrongful detention, my long experience, no threat to myself or others, and one of the estimated thirty percent of sufferers who receive no ongoing benefit from medication treatments. The next day I was visited by a legal aid solicitor who listened patiently to my story, before explaining that the hearing was effectively a rubber stamp procedure. She was surprised by my explanation of such a high percentage of medication intolerance though, and intrigued that a psychiatrist had agreed to stop mine.

‘I’ve been doing this pro-bono work for a while now and never heard of this before, difficult people who for one reason or another refuse treatment, is generally the way cases are presented, be interesting to see what the magistrate thinks,’ she told me, although she doubted it would make any difference.

‘Frankly, I’ve haven’t seen or heard of an application being refused.’ I spent much of that night drafting a statement for the magistrate, which outlined the subjective nature of assessment and detailed my respectful cooperation with the hospital staff. I pointed out my long experience with the illness and concern at being sectioned for the first time with no evidence of likely harm to either myself or others. I also pointed out that the result of an extended stay in hospital would be severe financial stress and possible legal action from a current client for breach of contract. As it was my legal representative read the statement and advised me the magistrate would not be interested.

‘Your best hope is to let me point out the anomalies in treatment here and ask for a second opinion,’ she told me. She started her presentation and questioning of the hospital’s representative by pointing out a suspected hypo-manic condition in the sectioning order and the grounds for the hearing.

‘Doctor do you still maintain that my client is in a hypo-manic condition and will become hyper-manic without appropriate medications?’ She asked the junior psychiatrist assigned to the hearing.

‘That is the assessment of Mr Bates current condition, yes.’

‘Can you explain on what evidence such an assessment is made Doctor.’

‘On the evidence of presenting symptoms, and also the records of Mr Bates long history of Bipolar Disorder.’

‘Can you confirm that my client is not currently receiving any medications, Doctor?’

‘That is correct.’

‘Can you also confirm that a decision was made to discontinue medications, three days after my clients involuntary admission to the hospitals acute care ward, apparently in a hypo-manic state,’ she asked, drawing a perplexed look from the magistrate.

‘It was agreed to discontinue medication at Mr Bates request, yes.’

‘With all due respect, it seems a rather strange health care decision considering my clients condition is expected to deteriorate without medication.’

‘Treatment of mental illness can be a complex process.’

‘I’m reliably informed of evidence that up to thirty percent of mental illness sufferers are known to be medication intolerant, and receive little benefit from ongoing medication use. Was this a factor in the decision to discontinue medication, Doctor?’ At which point the magistrate asked for clarification of what he’d just heard, turning to the psychiatrist with a look of bemusement.

‘There are some studies that suggest up to forty percent medication intolerance, yes.’ An answer which seemed to alarm the magistrate somewhat as he straightened his posture and became far more formal and considered in his choice of words.

‘I have not been made aware of such information before this time and will take it into consideration,’ he said, before asking my legal counsel to proceed.

‘My client informs me that he presented a different understanding of his condition during the consultation in which it was agreed to cease medication, can you confirm this Doctor?’

‘Mr Bates has a view of an emotional development disorder, for which there is no compelling evidence.’

‘My client also holds a view that there is no empirical evidence of a disease process in mental illness either. Is he perhaps delusional in his view Doctor? A symptom of his hypo-manic state perhaps?’

‘Its very difficult to gain empirical evidence from an organ of the body as complex as the brain, yet there is reliable evidence of symptom expression and effective treatment with medications.’

‘And yet by your own admission Doctor, up to forty percent of medication treatment may not be effective and you actually discontinued my clients medication, I’m becoming a little confused here.’

‘I’ve heard enough submission here, Mr Bates I recommend you seek a second opinion and I will only order a maximum stay of five days,’ the magistrate announced and quickly brought proceedings to a close.

‘You won, I’ve never seen a mandatory two week order rejected like that,’ my happy legal counsel announced as we walked towards the recreation room.

‘Its hardly justice, you didn’t even mention the idiot who arbitrarily sectioned me,’ I told her, feeling disappointed that I was still incarcerated.

Within fifteen minutes of the hearing I was ushered onto the normal ward, advised that I was being allowed a break from acute care. I spent that evening mingling with other patients in the kind of scenes that I had been familiar with, art work therapy and bright yellow walls a stark contrast to the acute care ward. Although I remember feeling further dismayed at the whole medical view of the mental illness experience as I watched a beautiful young woman sitting with her parents, who were speaking with her Doctor.

It was painful to see the pleading look in their eyes, as they looked for signs of hope and recovery in their precious child. An only daughter who’d been overcome by this strange and mysterious affliction while in her final year of a law degree at university. She looked on with those familiar vacant eyes and I noted her right leg doing the side effect shuffle as she tried to contain the desperate fear and confusion of this first episode experience. “Maybe she’ll get lucky with medication, find her way to a wise therapist,” I remember thinking, although fearful for her future in this public health system.

As I lay in bed that night thinking about my options and the fastest way to secure my release, the second opinion of a private practice psychiatrist was an obvious choice. I went over and over every gesture and uttered word spoken during the legal hearing. How the young psychiatrist had been caught off-guard by unexpected questions, in a normally routine and rubber stamped procedure. The genuine shock of the magistrate when what might have been an irrelevant comment by my legal counsel was confirmed and even compounded by the mental health expert.

“Surely what was said and admitted to was evidence of inappropriate detention,” I mused. I rehashed the psychiatrist’s responses over and over, “On the evidence of presenting symptoms, and also the records of Mr Bates long history of Bipolar Disorder.” “What records? All they have is the current assessment notes,” I suddenly realized, wondering if the psychiatrist had actually perjured himself with this lazy intimation during a legal hearing? I resolved that in the morning I would go on the attack by pointing this out, and demanding to be assed by a private psychiatrist.

‘It was just a figure of speech, your son told us of your medical history.’

‘A slip of the tongue which gave the impression that your assessment was based on the solid foundation of written records about my past episodes, and spoken under oath?’

Within an hour I was released with an apology and fervent wish that I would not have to be hospitalized again. And so began my five year road to redemption through dedicated reading research and my heart felt unfolding of "psychosis." And why I’ve acted out online and recorded three full term psychosis since this one and only sectioning in 2007.

Story continues in The Atmosphere of Moments