For those of us living with severe mental illness, the world is full of cages. (An excerpt from Esmé Wang's The Collected Schizophrenias .)

With Level One privileges at the psychiatric hospital where I was involuntarily committed in 2002, the patient was allowed off the ward for breakfast. Because I spent my first half day hidden in my room’s wardrobe, sobbing, no one knew that I was not a danger to myself or others, and so I ate the first breakfast without any designation, stowed away near the nurses’ station at a round plastic table. I chose raisin bran from a selection of preschool-sized boxes. I ate the cereal under supervision with a plastic spoon. I drank apple juice, which came in a plastic container with a foil top and a straw. There were patients who had been there longer, were well behaved, and yet also ate breakfast on the ward; signs hung on the doors of their rooms indicated that they received electro-convulsive therapy, and thus could not eat before their morning treatments.

The nurse who checked my vitals on the second morning informed me that I’d been elevated to Level One status, which I took as a good sign. I sat by the television for a while with some of the other patients, all of whom were groggy from psychotropic side effects and uncommunicative. Eventually Level One patients began to hang around the ward exit, as though it were a gate at an airport terminal, and we were all eager to nab overhead bin space. A handful of nurses followed, laughing among themselves and teasing: “You say that to me again, I dare you.” “Yeah, I’ll say that to you again.” One nurse used her key card to scan us out of the ward — the double doors swung slowly open — and we went down in pairs in the elevator, which required another key card, to the cafeteria. The room was a smaller version of the school cafeterias I’ve known all my life, with a line for hot food and a few circular tables. The other patients muttered and jostled, jittery in this foreign space. We did not serve ourselves. Instead, we told the servers what we wanted. I asked for eggs and home fries, and could tell straightaway that the scoop of yellow dropped on my plate was reconstituted. My stomach lurched at the sight, but I was hungry, having barely eaten in weeks. Where to sit? I had a sense of which patients to avoid and which would let me be, but I also saw a few sitting with the nurses, who attracted me with their normalcy. I took a risk and sat at an empty table, where I attended to the food before me. I used my spork first to sample the eggs, which were nearly tasteless, and lacked the near-sulfurous attributes that make them disgusting to those who hate eggs — but their tastelessness was its own challenge. I almost choked on the first bite before abandoning the rest. The home fries were warm and slicked my tongue with grease. I ate them all. I finished my plastic container of apple juice and looked around: the glass door and windows showed the bright blue sky we couldn’t reach; the nurses ate and chatted as if we could be anywhere. An “asylum” is a “place of haran or safety” (The Oxford English Dictionary), though the antiquated word, when applied to psychiatric hospitals, is now used to conjure fear. In the book Haunted Asylums: Stories of the Damned: Inside the Haunted Prisons, Wards, and Crazy Houses, paranormal enthusiast Roger P. Mills claims that mental hospitals “are among the most haunted places on the planet.” The second season of the FX horror series American Horror Story, called “Asylum,” places a mishmash of murderers, a secret Nazi, rape, and grotesque scientific experiments within the walls of its fictional sanitarium, Briarcliff Manor. The Elizabeth Arkham Asylum for the Criminally Insane confines, at least temporarily, the worst villains of Batman lore. The word “asylum” triggers cultural associations, à la One Flew Over the Cuckoo’s Nest, with frightening and brutal treatment of psychiatric patients. And yet I suspect that what’s truly scary about the word has more to do with the inefficacy of psychiatric treatment from that era, which did little to rein in its patients’ most disturbing behaviors, including those that were inexplicable, dangerous, or violent. “[The patients] were being driven to a prison, through no fault of their own, in all probability for life. In comparison, how much easier it would be to walk to the gallows than to this tomb of living humans!” writes investigative journalist Nellie Bly in her 1887 exposé, Ten Days in a Mad-House, which gives readers a revelatory view into a New York City “lunatic asylum.” Bly gained access to the hospital by pretending to be insane herself. After her admittance, Bly recounts asking for her notebook and pencil. The attending nurse, Miss Grady, tells her that she brought only a book, and no pencil. “I was provoked,” Bly says, “and insisted that I had, whereupon I was advised to fight against the imaginations of my brain.” In another part of Ten Days, she says, “I always made a point of telling the doctors I was sane and asking to be released, but the more I endeavored to assure them of my sanity the more they doubted it.”

During my second hospitalization, which occurred in the same location as my first, I passed a nurse. “How are you doing?” she asked. “Okay,” I said, which was true. My mania and subsequent depression seemed to have been exorcised by the overdose I’d taken immediately prior to being hospitalized, and other than being frustrated by my return to the WS2 ward, life no longer felt like an intolerable sentence. The nurse smiled. “But how are you really doing?” “I’m really doing okay.” The notes I’ve acquired from Yale Psychiatric Institute read, among other things, “Patient shows lack of insight.”

As Bly’s anecdotes, and my own, indicate, a primary feature of the experience of staying in a psychiatric hospital is that you will not be believed about anything. A corollary to this feature: Things will be believed about you that are not at all true. My third hospitalization occurred in rural Louisiana. I told the doctor that I was a writer and had studied psychology at Yale and Stanford, which was about as believable as my saying that I was an astronaut and an identical twin born to a Russian ambassador. I later trounced the other patients in a mandatory group therapy word game, not allowing anyone else to score a point; to do so was childish, but I was tired of being treated as though I were stupid. I do not know how my behavior in this session reflected on me from the nurses’ and doctor’s perspectives. It may have indicated that I was intelligent, or at least book-smart, two characteristics that are of dubious value in a psychiatric hospital. It almost certainly indicated that I can be a stubborn asshole. The doctor told me in one of our rare meetings that I’d said, upon emergency room intake, that I believed in “a conspiracy of people” who were determined to hurt me. “I didn’t say that,” I said. “I said that I was feeling unsafe.” But “feeling unsafe”— as in, feeling terror about everything and nothing in particular — was an unfortunate phrase for me to use during the intake. “Unsafe” is a psychiatric code word for “suicidal,” which I was not, although I was many other things. I hadn’t said anything about a conspiracy. “Unsafe” might have triggered the hospital’s belief — its own delusion — that I felt unsafe due to a paranoid belief: a conspiracy of people out to do me harm. The hospital maintained for the remainder of my stay that I had come in feeling “unsafe,” with delusions of persecution. Because “unsafe” doubled as “suicidal,” I was considered a danger to myself. Even though I had voluntarily walked into the ER for help, “unsafe” meant that I was considered to be “involuntarily hospitalized,” which also meant that I was locked down in the rural Louisianan hospital, on the north shore of Lake Pontchartrain, until the doctor gave me permission to leave. I did not know how long that would be.

Things had gone wrong prior to that stay during the time I spent alone in the Metairie hotel room. I’d had problems with hotel rooms that year. Once, C. brought me with him to Reno on a business trip and left me in our room while he attended a conference. In his absence, a wild fear came over me. I covered the mirrors with towels; when that wasn’t enough to soothe me, I hid in the tiny closet. C. came back. He saw the towels on the mirrors, and he began to call my name. Eventually he tried to open the closet door, where I was still hiding, and I emitted a small scream. “Don’t open the door,” I whimpered. Recounting this anecdote without providing a porthole to my inner workings makes it sound like a prototypical tale of a lunatic, and I don’t dispute that I was insane in Reno. I did, however, possess insight into my own situation. I’d brought my laptop into the closet with me, and was coherently messaging a friend about how I’d wound up there. I’d covered the mirrors because the sight of my own face terrified me. No story accompanied the fear — no hallucinations about torn and rotting flesh, no delusions about losing my soul to the reflection. As was the case months later in Louisiana, I was overwhelmed with a sense of free-floating terror that spread like blood and congealed around vulnerable targets such as my face, the patterns in the carpet and on the bedspread, the view of dry and dusty Reno from our window. The only tenable solution was to fold myself into a small, dark place: the closet. Typing on my laptop, I tried to explain to my friend what was happening. Perhaps I was attempting to provide evidence for my side of the story, or trying to make sense of a situation that was confusing even to me, using tools that I found acceptable. The small chat window was not frightening in the same way that a face-to-face interaction would have been. C. just came back, I typed. I’m scared. Eventually, I emerged. I was calmer, but fragile. The smallest pressure would crush me. We had no warnings of what those pressures were. When we returned to San Francisco, I went back to work. From 10 a.m. to 6 p.m., Monday through Friday, I went to stand-up meetings and gave presentations and sat at my computer and covertly swigged from the liquor in the office pantry. I did my job. I said nothing about the horror show that was still sinking its teeth into me. Sometimes I saw things darting here and there, but I ignored them. I considered myself lucky to have hallucinations that I could ignore. My psychotic symptoms were barely under control, but C. and I had an upcoming trip to his parents’ home in New Orleans. We discussed canceling and staying in San Francisco. We wondered if being around family during the holidays would, instead of providing more stress, actually be the best thing for both of us. After all, C. had been my primary caretaker during this long crisis, and I suspected that spreading the responsibility among a stable group, particularly one that was loving, would ease the strain. So we flew south, watching the olive-hued swampland grow in the airplane’s window, and stayed in a motel near his parents’ suburban home. We fell with relief into the arms of our welcoming family.

On one of those nights, when the air was damp and cold, C. left to watch a football game at the Superdome with his father, and I was once again alone in an unfamiliar room. I’d encouraged him to go — I was glad that he had the opportunity to do something fun without me. But his absence undid something that needed to be fastened shut, and the terror was glad to sweep in. I started gathering towels. The coherence of reality threatened to desert me. Soon my mind was a black hole, and that dead star insisted on snatching every wisp and scrap of sense; it tore at the edges of the world. After struggling with the decision to reach out, I called my mother-in-law. I told her as calmly as I could that I thought I might need to be in a hospital. “All right,” she said. A former nurse, Ms. Gail has a soothing demeanor in times of crisis. “Let’s go ahead and get you sorted.” Though nearly all the statements a psychiatric patient can make are not believed, proclamations of insanity are the exception to the rule. “I want to kill myself ” generally holds water, and a therapist who hears those words is legally required to disclose them to prevent client self-harm. In a study hypothesizing that sane people could easily be hospitalized under certain conditions, researcher David Rosenhan and his associates claimed to have auditory hallucinations, and were consequently held in different psychiatric facilities for an average of nineteen days — this, despite being neurotypical and exhibiting no symptoms while hospitalized. All but one of the pseudopatients were released with diagnoses of schizophrenia, and were released only on the condition that they agree to take antipsychotic prescriptions. If not for Rosenhan’s credibility as a scientist and the ensuing publication of his 1973 paper “On Being Sane in Insane Places,” those diagnoses could have dogged Rosenhan and his compatriots for life. Unlike me, Rosenhan ultimately proved to the doctors he had duped that he was, really and truly, a Stanford researcher.

In the Louisiana hospital I stood in a slow cafeteria line. While waiting to reach the workers who would deliver the morning’s hot and greasy victuals, I realized that Mara, my roommate, who stood in front of me, was wearing my coat — a well-made, beloved tweed garment that I’d owned for years. I asked, “Are you wearing my coat?” She didn’t respond at first. I’d noticed that Mara had the slowed-down disposition of someone who was either locked in a severe depression or burned-out on psychotropics. She turned her head, not making eye contact, and began to take off my coat in slow motion. “It’s okay,” I assured her. “You can keep it on during breakfast, but I’d like it back when we go upstairs.” Despite this, she finished removing my coat and handed it to me without saying a word. The next morning, I awoke to something unexpected: a nurse in our room, dropped to a crouch by my roommate’s bed. She said, gently, “I see you have three pillows there. Do you have an extra pillow, Mara?” I sat up, turned, and saw the single pillow on my bed. Mara had taken one of my pillows while I was asleep. I said, “I’m missing one of mine.” When the nurse brought me back the pillow Mara had pilfered during the night, I mentioned the incident with my coat as well. I wasn’t trying to get Mara in trouble — the thefts were so bizarre, and Mara so absent of malice, that it seemed impossible she would be punished for them — but I did want someone in authority to know that they were happening. The nurse replied, her voice low, “Mara doesn’t mean to do it. She can’t help it. But I would recommend that you keep anything important or valuable with the nurses’ desk.” There was one important thing that I would have been devastated to have anyone take: my green notebook with a textured cover like alligator skin. I’d been able to keep it at all times because it was perfect-bound, with no spiral wire that could be used as a weapon to harm myself or others. I was so wedded to my notebook that one of the other patients was convinced that I was an undercover journalist, and nicknamed me Lois Lane; Lois Lane, and not Nellie Bly, whose asylum exposé instigated a $850,000 increase in the budget of the New York City Department of Public Charities and Correction. I never learned the diagnosis of the young man who called me Lois, and he claimed that he had no idea why he was in the hospital. I couldn’t tell if there was anything wrong with him. In Ten Days, Bly writes: “The insane asylum on Blackwell’s Island is a human rat-trap. It is easy to get in, but once there it is impossible to get out.”

Both David Rosenhan and Nellie Bly knew during their institutionalizations that they would never be caught in their rat-traps beyond what they could endure. Having been hospitalized through trickery, they would only have to reveal those trickeries to escape. I doubt they ever felt the absolute terror that coincides with not knowing when, or if, you will get out of such a place.

In a psychiatric hospital, getting out is known as “discharge,” which is a sacred word. Rumors circulate among the patients about who will be discharged soon and when; morning group therapy sessions note and celebrate whoever will be discharged that day; rare visits from psychiatrists, or, in some cases, a single psychiatrist for the entire ward, revolve around the patient’s potential discharge date. Though discharge might not be on the table for several days, the question of when it will happen hovers over everything as soon as a patient walks in. The obsession with discharge is most prominent among those who are involuntarily hospitalized, as I have been, because those who’ve checked themselves in are permitted to leave at any time. I’ve watched people who seemed no more or less sane than I did decide, perhaps, that they’d had enough of being watched over and told what to do and think, where and when to sleep, or simply that they were feeling better, and those people checked themselves out as easily as leaving a hotel while the rest of us continued to count the interminable hours, the interminable days.

In the winter of 2003, because I had technically taken an overdose of anticonvulsants — although such a minor overdose that there was no need for charcoal, or for pumping my stomach — I was put in two-point restraints while waiting in the ER for an ambulance. The restraints were leather, and kept one wrist and one ankle shackled to the bed while I lay and listened to the calls of people in pain, and the response of the harried people trying to help them. At one point during the hours of waiting, I grew bored and tried to wriggle my hand out of its cuff. It worked because I have fine-boned hands with delicate, strong wrists — piano hands. When a nurse realized I’d turned my two-point restraints into a one-point restraint, he tightly fastened my hand back into the cuff. Before he walked away, he threatened to put me in four-point restraints if I didn’t behave.

For schizophrenia, second-generation antipsychotics are considered the first line of attack (or defense, depending on your perspective), and include Abilify, Saphris, Rexulti, Vraylar, Clorazil, Fanapt, Latuda, Zyprexa, Invega, Seroquel, Risperdal, and Geodon. Less preferable are the first-generation antipsychotics — chlorpromazine, fluphenazine, haloperidol, and perphenazine — which are infamous for their neurological side effects. Most notably, first-generation antipsychotics can cause involuntary jerking motions of the face and limbs, known as tardive dyskinesia (TD); once activated, TD may remain as a side effect even after you quit taking the medication that caused it. A person who is hospitalized with schizophrenia will inevitably be put on some type of second-generation antipsychotic. Zyprexa, for example, is known to put the brakes on manic activity. Hospitalization is generally reserved for times of psychiatric crisis, and so Zyprexa, or a drug like it, may shut down the most violent behaviors. But medication is only one part of the ideal treatment plan. According to the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Schizophrenia, second edition, that plan has three major components: “1) [to] reduce or eliminate symptoms, 2) [to] maximize quality of life and adaptive functioning, and 3) [to] promote and maintain recovery from the debilitating effects of illness to the maximum extent possible.” All of this should be done swiftly; according to a 2012 study, the average stay in a psychiatric hospital is ten days — the exact length of time I was institutionalized during each of my three hospital visits. The contemporary psychiatric hospital is intended to stabilize its patients, and then to set them up for recovery in the outside world.

State mental hospitals — the type referred to as asylums, and of which Nellie Bly wrote in her landmark book — were long seen as terrible, frightening places that were nevertheless essential for a society with mentally ill and developmentally disabled people in it. Despite this, the publication of Albert Q. Maisel’s exposé “Bedlam 1946: Most U.S. Mental Hospitals Are a Shame and a Disgrace,” in Life magazine, awoke Americans to the gruesome nature of such asylums as nothing had before, breathlessly announcing that “state after state has allowed its institutions for the care and the cure of the mentally sick to degenerate into little more than concentration camps on the Belsen pattern.” Advocates such as Dr. Robert H. Felix, who became the first director of the National Institute of Mental Health in the 1950s, followed suit; Felix believed that state mental hospitals could and should be replaced by federally funded community health centers, which were not only believed to be more humane, but which also paved the way for the recovery model of mental health treatment. The decision to do away with state mental hospitals remains a controversial one, and is blamed by some for everything from homelessness to murder. In his book American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System, E. Fuller Torrey rails against the nationwide closing of state mental hospitals that occurred under President John F. Kennedy: Unfortunately, the mental health centers legislation passed by Congress was fatally flawed. It encouraged the closing of state mental hospitals without any realistic plan regarding what would happen to the discharged patients, especially those who refused to take the medication they needed to remain well. It included no plan for the future funding of the [community] mental health centers. It focused resources on prevention when nobody understood enough about mental illnesses to know how to prevent them. And by bypassing the states, it guaranteed that future services would not be coordinated. Torrey, a psychiatrist who helped found the Treatment Advocacy Center, is a vigorous proponent of involuntary treatment, including hospitalization. He has publicly criticized the recovery movement for giving false hope to the severely ill; in turn, recovery and survivor-based movements criticize Torrey for his emphasis on drugging them and locking them up. There are solid reasons behind the existence of involuntary hospitalization laws — primarily, that there are circumstances in which a person with severe mental illness becomes unable to make good choices for themselves. The National Alliance on Mental Illness (NAMI) states in its policy platform that “with adequate professional consultation, every person with a serious mental illness who has the capacity and competence to do so should be entitled to manage his or her own treatment,” but that “when an individual lacks capacity and competence because of his or her serious mental illness . . . the substitute judgment of others . . . may be justified in determining treatment and possible hospitalization.” Regarding involuntary commitment, NAMI makes a point of mentioning that people “with serious mental illnesses such as schizophrenia and bipolar disorder” may “at times, due to their illness, lack insight or good judgment about their need for medical treatment.” As a woman with schizoaffective disorder, the psychiatric disorder that combines the two, I consider myself called. Involuntary commitment may sometimes be warranted, but it has never felt useful to me.

Section 5150 of the California Welfare and Institutions Code states that “a person, as a result of a mental health disorder, [who] is a danger to others, or to himself or herself, or gravely disabled” is allowed to be taken “into custody for a period of up to 72 hours for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment in a facility designated by the county for evaluation and treatment and approved by the State Department of Health Care Services.” Although all states have some form of this law, “5150” has slipped into the cultural vernacular as a catch-all term for involuntary psychiatric hospitalization. A friend of mine, a veteran of the mental health care system, once confessed to me that his ATM card’s PIN code was 5150. We both laughed, uneasily. According to section (g)(1) of Section 5150, a person taken under custody due to the law must be provided the following information, either orally or in writing: My name is———. I am a [peace officer/mental health professional] with [name of agency]. You are not under criminal arrest, but I am taking you for an examination by mental health professionals at [name of facility]. You will be told your rights by the mental health staff. If the person is taken under custody while at their home, the following must also be provided: You may bring a few personal items with you, which I will have to approve. Please inform me if you need assistance turning off any appliance or water. You may make a phone call and leave a note to tell your friends or family where you have been taken. Though I’ve lived in California for most of my life, I’ve never been 5150’d. I do find that this final paragraph echoes the wording of kidnapping narratives — “leave a note to tell your friends or family where you have been taken.” What do these notes, written under duress, look like? How much time is a person given in order to concoct such a message? I once interviewed a young woman, whom I will call Kate, about her 5150 experience. Kate tells me that she was 5150’d in 2012, after confessing suicidal ideation to a social worker at a welfare office in Oakland, California. She was facing eviction, and, she admits, was not handling it well. The social worker offered to have Kate speak to the counselor on duty; Kate agreed, relieved to be offered help. However, once it became clear that the counselor wasn’t on duty, the social worker had Kate 5150’d instead. Kate doesn’t remember hearing anything like the Section 5150 (g)(1) script, though she also recalls that nobody, including the police, said much until she got to the hospital. “I don’t know how anyone gets better in [that place],” she says. “They put me in the big crazy intake room. Most people seemed to be homeless people that needed a few days off the street to catch up on sleep and get some proper meals. Some people were the rambling or screaming type. Some seemed to be regulars. There was no care. I just sat there with the nurses and begged them to let me go.” Her experience influenced the way she responds to other people in psychiatric crisis. “Now,” she says, “I do everything I can to keep people from being involuntarily taken and offer to drive them to the ER myself. . . . I’m a nobody and I know how to calm someone down long enough to get them to consent [to hospitalization voluntarily].” Though the experience of being 5150’d is not the same as being arrested (“You are not under criminal arrest”), there are inevitable parallels between involuntary hospitalization and incarceration. In both circumstances, a confined person’s ability to control their lives and their bodies is dramatically reduced; they are at the mercy of those in control; they must behave in prescribed ways to acquire privileges and eventually, perhaps, to be released. And then there is the wide swath of people for whom mental illness and imprisonment overlap: according to the Department of Justice, “nearly 1.3 million people with mental illness are incarcerated in state and federal jails and prisons.”

For those of us living with severe mental illness, the world is full of cages where we can be locked in. My hope is that I’ll stay out of those cages for the rest of my life, although I allow myself the option of checking into a psychiatric ward if suicide feels like the only other option. I maintain, years later, that not one of my three involuntary hospitalizations helped me. I believe that being held in a psychiatric ward against my will remains among the most scarring of my traumas. I am no longer friends with the man who told me his pin code was 5150, but when we were kin I spent countless hours trying to convince him not to kill himself. On the dark nights when it seemed particularly likely that he would end his life, I’d attempt to coax him into voluntary hospitalization; if he were in a hospital, so I reasoned, I’d know that someone was keeping an eye on him. Once, during a particularly bad spell, I told him that I was going to call the police. He laughed and said he’d get the cops to shoot him before he’d let them bring him to yet another psychiatric facility. He was tired of hospitals, and he was tired of living, but I never had to ask him why he was so resistant to the idea of hospitalization. I think we both knew that I, too, feared being on a ward again. ●

Copyright © 2019 by Esmé Weijun Wang. From The Collected Schizophrenias by Esmé Weijun Wang (Graywolf Press, February 5, 2019). Illustrations by Jeremy Leung for BuzzFeed News.



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