One In, One Out

“Here, everyone is an inappropriate admission. I don’t admit patients. I discharge them” – Psychiatrist, quoted in Rhodes, Emptying Beds.

Before I had even met my treating psychiatrist, they were talking about my discharge. Someone from downstairs—that is, the part of the hospital that isn’t a locked psychiatric ward—came to tell me that I would be discharged into a program for “Dialectical Behavioral Therapy” (no, the “Dialectical” part isn’t a Marxism reference). Technically, everything outside the hospital is “voluntary”, but she didn’t make the twelve-week program sound like it: “This is your life. You life depends on doing DBT.”

A few minutes later, the hospital social worker came for a visit. I was still clinging to the idea of a quick recovery and returning to my apartment in New York. I wanted to know if it was really going to be twelve weeks. “Yes, ideally, DBT lasts twelve weeks,” she told me, “But it really depends on your insurance company. It could be six weeks… it could be two.”

Our lives are to be turned around in 10-day doses, with subsequent redemption pursuant to a further authorization. Our illness must be in a sweet spot, by which we’re doing well enough to show that the program is worth the investment, but not so well that we couldn’t survive with care that costs less. And so, we are working every day, practicing and tracking our skills in “emotion regulation” and “distress tolerance”, on a long, life-changing “DBT journey” that could be cut off at any time.

Last Friday, one of my best friends came into our afternoon “check-out” crying: “They won’t pay for it anymore.” No one sick enough to be here can afford a few hundred dollars a day out of pocket, and so she’ll be gone by Monday. The therapist tries to console her, “You can practice on your own.” Your life depends on going through the worksheets and checking off skills. On your own.

When I walked out of the hospital, I got a few blocks down Shattuck before I heard someone crying out. A disheveled man stumbles out of a bank. A security guard follows him, delivering a punch and a kick. The man falls down. The man is brandishing a dollar bill like a shield; his feet are bare and his jacket open, revealing an otherwise naked torso in 40-degree weather. I try to help him up. He doesn’t make it.

A cop arrives. He snaps on some rubber gloves; his demeanor is cold; he’s seen this before. Absurdly, he asks the man, writhing on the ground, if he wants to press charges. He garbles out a “no.” I stick around, wondering if they’ll need a witness and figuring cops behave better when white people are watching them. They pat him down, looking for identification, asking if he needs help.

Another cop arrives, and sees me lingering. “We’re taking him to the hospital” he assures me. “He’ll get medical care but first, uhh, he’ll go to psychiatry.” The man is shouting, “no hospital, no hospital.” The weird thing about psychiatric hospitals in the U.S. is that the people who can get in generally don’t want to be there, and those who want in are too sick to get in. In any case, everyone knows he’ll be back on the streets in a week.

When I was in France, there was a real debate about the merits of the mental health system. The government bureaucrats I talked to complained that the system cost too much; the patients opined that they were stuck in the hospitals too long; the young psychiatrists worried that they were falling behind in the pharmaceutical arms-race. But there were also people who stood by it, who spoke with pride about public clinics. “We heal, and we heal well,” more than one psychiatrist insisted to me.

No one thinks the system in the U.S. works. The psychiatrists hate being consigned to mechanically writing dozens of prescriptions a day; the cops are sick of seeing the same people treated-and-released with no solution in sight; the administrators have lost patience for explaining to faceless insurance companies why people need care; the bureaucrats at the insurance companies actually have faces and hate cutting off peoples’ cares. I’ve conducted scores of interviews, and not one tells me, “We have a long way to go, but I think we’re on the right track.” Everyone knows the system is broken.

I continue on to the post office, and mail off the first few payments for my hospitalization. Someone, after all, has to keep the system going.

One in, one out.

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