Dangerously Unaware

When I started working on an inpatient psychiatric unit as a social work intern for the New York state's Office of Mental Health in 1996, my supervisor told me, "No one here is mentally ill." She was never part of the anti-psychiatry group who believe that mental illness doesn't exist. By stating this, she meant that many of these patients didn't believe that they were ill.

Psychiatric emergency services work can be akin to watching a train wreck without any ability to prevent the wreck from happening. When will the next tragedy involving serious injury or loss of life due to untreated serious mental illness occur? Governments are reactive.

The severe shortage of inpatient psychiatric beds along with overly restrictive inpatient commitment criteria often result in only the sickest of the sick getting admitted to inpatient units. For people with psychosis who lack awareness of being psychotic, brain deterioration often occurs long before sufficient psychiatric treatment is obtained. Early psychosis programs are completely voluntary, thus marginalize those who refuse to engage in treatment because they don't believe that they are ill.

I go to a psychotic woman's apartment with an outpatient worker because she stopped eating. She stopped eating because of her belief that people are poisoning her food. Because she believes that poisonous gas is coming out of her heating vents, she covers these. Because she believes that poisonous gas is coming out of her faucets, she keeps the water running continuously. She believes that running the water blocks the gas. As we are standing in water inches deep, she tells me that she is not mentally ill. Therefore, from her perspective there's no need to take any medication. The police are called and an ambulance transports her to the hospital emergency department. The emergency medical doctor calls and tells me that because she is well groomed, speaking clearly, not suicidal, and not homicidal, she is being discharged back to her home. Everything I report to them is disregarded. I'm just a social worker. Would she be moved on to inpatient if I am a psychiatrist or medical director of an agency? Would she be moved on to inpatient if she has a family member to advocate for her? Weeks later, she is evicted from her apartment with nowhere to sleep except for the streets.

A psychotic man got discharged from Bridgewater state "hospital," really managed by the Department of Correction, earlier that week. He was there because he was eating his feces and cutting himself to remove what he believed was the devil from his body while incarcerated. He yells out his fears of the devil when I evaluate him at the state-funded respite unit. He tells me that he got sentenced to prison because he pointed a loaded gun toward a stranger. I inquire about what made him do this. He says that the devil told him to do it. He doesn't believe that he is mentally ill.

Emergency medical doctors are more likely to discharge to the streets a dangerous patient who is not wanting any treatment, than a dangerous patient who is wanting treatment. They are more likely to move on to inpatient the malingerer who doesn't need treatment, than a psychotic patient who can "pull it together," and cover up symptoms.