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Crossposted on the frontpages of My Left Wing and Smirking Chimp

I am now working with a specialized private program providing community based treatment to adults with chronic mental illness.

Among many of my duties is the assessment and diagnostic impression of people newly admitted to the program. Many are folks who have been in prison, the homeless people you see, or in institutions because they have serious mental illnesses that, despite surface appearances, have not been really "treated".

Please believe me when I tell you I hear a lot of stories.

I just met a fascinating individual and I think you should know his story.

The names and certain events are altered, of course, to maintain confidentiality.

Neglected, Deprived, Shunned
I insist on making appointments with the folks referred to the program. Many of the people discharged from jail or the state hospitals get placed in home called "transitional homes". I don’t really understand the regulations behind them, but there can’t be many. They are often appalling but nobody seems in charge of telling people how to deal with things. The home managers at places like these will tell me to "come on anytime, they don’t do nothing". It is an active example of the poor regard that persons with mental illness have in this country.

So my soon-to-be new client was waiting at the arranged time at the care home in which he now stays. His care home provider is a good man with 3 decades of public service; the care home is sort of his "taking it easy" job, yet he is STILL helping people. He accepts the setting of an appointment.

I drive up and have the critical eye because of the things I have seen already – the place needs some landscaping and yard work. A couple people are milling around in back. It's an typical brick house for that area.

I ring the doorbell and the house manager answers. We have talked on the phone a couple times and he lets me in without asking for ID. (Which is good because I washed mine and ruined it and we don’t have the new nice badges yet.)

The home is nice and quiet in side. Jeremy, my new client, is sitting one the couch, looking at the floor.

I introduce myself and we shake hands. I notice a wedding band – unusual for the lot I am working with. He is wearing a shirt from a  local greasy spoon restaurant – a Denny’s or an IHOP, something like that – and I could see the outline of a pack of cigarettes in the pocket. It was a button down shirt with logos and a pocket. he was wearing Dockers, or something similar.

When he spoke his voice had a quality I haven’t really heard in a long time. When I used to live in Indiana I worked around a lot of "country folk" (Wait.. I was one!) Sometime the men who drank a lot of coffee and smoked a lot of cigarettes got a resonant deep baritone quality to their speaking voice. They sound very manly when they talk. Sort of like Johnny Cash.

I sat across from him at an angle so I could first explain the paperwork and then get signatures.

I have never been to school.
After a cursory social introductions, I told him that over the years I had learned that it was best to ask up front if people can read, rather then to make them more and more uncomfortable. He glances down and says "I never learned to read. I never went to school".

I was taken a bit off guard by his statement and pressed for a little elaboration and asked "what do you mean you never went to school"?

He changed position in his chair and looked intently at the floor and said "Sir, I’ll be straight with you..." There was a real tension in his way of saying this and the baritone in his voice sort of had my attention.

"When I was born, I had brain damage. The teachers in first or second grade said I couldn’t be in school  and should go to this place, an institution. I never went, mom didn’t let it happen. I just never went back to school. I can't read."

I thanked him for sharing that with me as I was doing an assessment and that is valuable and pertinent information. I pressed on.

Jeremy would not have been referred to my program if there was not already a sufficient mental illness diagnosis, so I asked about his medication. "I don’t know the name of it sir...It’s a little pill".

"Does it work for you, sir" Does it treat you right"?

Yes sir he replies. But I have been out of it for over a month now."

"What happens without your medication?" I asked.

"I think a lot, I don't eat well. I think about all the bad things in the past..." Jeremy essentially describes major depression without saying those exact words.

I don't want to talk about my father
I ask about his childhood and upbringing, or try to.

He talks about mother and a couple brothers. He just went to the funeral of his older sister, just before Christmas. We’ll talk more about that in a bit. I learn that mother has passed away.

I ask about his father and the sudden shift of posture and the tension in the voice return.

"Sir, I do not want to talk about my father" he said with a subtle force that resonated in that baritone. It didn't take a Psychiatrist to grasp this was a major sore point.

I told him that was just fine and that if there is anything that I ask that he doesn’t want to answer or deal with, it’s cool. He doesn't know me and this is our first meeting. Just tell me.

Command hallucinations and a suicide attempt
I change the topic.

I ask about the treatment for his illness over the years and learn that he has been in a couple a large state hospitals for a combined period of over 2 decades.

I asked if he heard voices.

He made a rather disturbed look in my direction and made eye contact "Yup" and he closed his eyes.

"What did they say, sir", I asked "Bad things"? He shook his head and opened his eyes and said "yeah".

His mental illness seems to have set in in his late teenage years. "The voices were so bad I cut my wrists and took an overdose of pills". "Did the voices tell you to do this?" I asked "Yes, sir, they did" he confirmed.

He was accused of a robbery, of sorts, probably 25 years ago and he turned himself in. He was found NGRI: not guilty by reason of insanity. Alcohol was involved and I have been given some sketchy detail of other people being involved. Jeremy would be the classic 'fall guy' – the 'slower guy' who would hang around and do like the others, then get left holding the bag while everybody else skates. He still turned himself in. Jeremy says he never drank again after that incident.

Burnt out on treatment attempts
I asked about the wedding ring. "You’re married" I said" "At some point, something was going right, wasn't it"?

Nope.

"My wife and I aren’t together and I don’t want to talk about that either".

So now we have discovered 3 or 4 issues he doesn't want to talk about and his initial reaction to this is to adopt a subtly threatening demeanor.

As the conversation went on it was very obvious this man is tired of being prodded for his personal information. I cannot imagine and he cannot remember the number of times he’s been asked the same crap over and over.

He never actually complained about the interview or the impending influx of the treatment team. It was the way he cooperated that said it. It vibrated off of him.

I am always trying to be sensitive to this when I interview people because I know these folks have been through it many times. I have had plenty of people be threatening and abusive and difficult, and outright psychotic. But this man has to the MOST tired of clinical assessment I have ever experienced.

Removing a Barrier
At one point he postured and told me he’s "slow" and he doesn’t understand everything. It was a defensive gesture. He was frustrated and also intimidated by my presence.

I experience this a lot: people who are poorly educated often show "deference" when addressing me at first because of the position I have and all the implied "smartness and education". People often do call me "doctor" because of the work I do. (I does me best to discourage this, but to little avail.)

To make matters worse,this day I am actually wearing a white collar shirt. The whole "white collar professional thing". That and being in a position of him having to talk to me so I can "help him" because I am somehow better or more together or something clearly interfere with the interaction necessary to get useful, accurate information about this gentleman. I have to cut through this barrier if he is going to be able to relate to me.

So I gently confront this. I ask him to please not judge me by my shirt or my speech. I point to my long hair (tied in a ponytail) and say, I’m a guitar player and I really like that. And that I really like doing what I am doing here with him. I am not here to judge him.

So many times, mental health "staff" are simply sealed off and "above" the clients in their care. Not always, by a long shot, but far too often in the past and I still see incompetence and a lack of regard flourishing with privatized mental health care.

He responds to that in a snap "Thank you. I don’t need no more judgin’."

I advise him the program he is entering wants to keep him OUT of the hospital and to help him become more independent. "Nobody wants you back in the hospital" I advise.

Then I said, "you are a hurt man." He said "Yes sir, I am a very hurt man".

As I had treated him with respect, and as evidence my work on removing the barrier was actually successful, Jeremy did an about-face and let me know his main issue with his father: that his father molested his sister. He apparently had witnessed this on a couple of occasions and he still fills with rage for not being able to do anything about it. He looks at the floor.

A Funeral for Christmas
He tells me he had a couple brothers and his older sister. His court worker advised me that Jeremy’s father was a predatory molester who abused his mother and molested everybody in the family, including Jeremy.

His older sister just died, right before this past Christmas. He went to her funeral.

He told me that although his family live about 25 minutes away he’s not talked with them in years though he has a brother who would call him once in a while. .

After he was sentenced to the State Hospital it seems that his family washed their hands of him. The proverbial last straw. This sort of institutionalization was what had been recommended to them years ago. They fought it back then, but, apparently, the rape charge and sentence to the State Hospital was just too much. His immediate family of birth had just let him go.

At the funeral he says he stood off to the side. He saw his family there but they did not talk to him or include him in the burial of his sibling – their sibling. If that does not say "He is not part of them anymore", I am unsure what would. He did say than an uncle had come over to him to say hello and was nice to him. But he was not part of his own family as they buried his only sister.  

That had to just hurt like hell. Before you blame the family though, remember this story unfolded generations ago and Jeremy shows the long-term effects of complete mistreatment, but the Family was never supported either. Given the background info supplied to me I am rather certain Jermey's status as "mentally retarded" was normally dealt with by hiding or institutionalization. Families often fought this and that lead t the de-institutionalization movement. But public misapprehension and misunderstanding about the particulars of mental health contribute quite significantly to stressing a family and making proper care more difficult or even socially frowned upon.

Hope and Potential
He tells me without his medication he spends long hours staring at the ground dwelling on what has happened and what could have been. "My life is pretty much over now. But I still have to go on".

Near the end of the interview Jeremy looked at me and then smiled a big, big grin. Absolutely goofy-looking. I did not anticipate the smile, but I did expect the following question: "Will I be seeing you again?" he asks. I explain my position as program coordinator and how a team will be coming to work with him and left the office number as he requested. I had made solid contact.

Jeremy is sort of a poster child for Major Depressive illness (though I believe the new MD I send him to might also tack on PTSD - the man's been through the wringer). He is also a living metaphor for how America treats – or wants to treat – people with severe mental illness: hidden, neglected, deprived.  And he has cost them a lot of money that I argue has been completely wasted if he is as unable to socially function without significant structure. He has been in the system for 3 years and is unable to function socially without considerable structure.

I believe that a lot of the time he was in state hospitals he was not helped as clearly evidenced by this institutionalization, a peculiar set of stereotyped habits and social maladjustment one sees in people who have been in institutions for a long time.

Diagnosis and Treatment

AXIS I - Major Depression, recurrent, severe, without psychotic features 296.33 - - - -  R/O PTSD 309.81  
AXIS II - R/O Borderline intellectual functioning
AXIS III - Smokes Tobacco, High Cholesterol, History of seizure activity
AXIS IV - Severe: Childhood sexual abuse,educational neglect/deprivation, chronic mental illness, long-term institutionalization, recent death of family member, ostracized from family.
AXIS V - 35

I will have the treatment team work first with establishing a respectful relationship with Jeremy before they try to get to work on his issues. He will look for any reason to withdraw from these interactions and there will be a load of work helping him acclimate to free society in a way he has never done. They will ensure that he doesn't run out of medication, that he will get effective vocation rehabilitation attention. He's already in adult literacy classes and we will work to support that. We will work on social skills, mental illness education and we will see about a rather non-scientific idea that I believe in:

That it's never too late to have a happy childhood.

As we look at establishing proper healthcare for all, I would like to see the abject mistreatment of mental illness rectified.

I am seeing a lot of people with schizophrenia, bipolar disorders, and major depression. Many of these folks have been your homeless people. They are suffering from neglect, malnutrition, serious drug abuse – alcohol, tobacco and crack is the usual thing, with some pot here and there – and long term untreated psychosis: hearing things, suicide attempts and so forth. The entire time you and I have been out of high school, trying to get our lives on track and succeeding, these people have been having those experiences.

We can rather easily prevent people from having to go through much of what Jeremy has endured. And it won't cost as much as blowing up foreign countries.

We can do  lot better, but we have to remove that barrier.

Originally posted to Toking Points Memo on Sat Jan 10, 2009 at 08:20 AM PST.

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