Archives: Xmas on the Locked Ward

By October 29, 2010Articles - Archives

Paul McHugh comments:

The meaning of Christmas gets reduced to basics on the locked mental health ward of a veteran’s hospital. A day spent there during the holiday season a number of years back still resonates. Sometimes, the rather unhinged don’t seem all that much different from you and me. They have many of the same issues, but they burn with a much greater intensity.

Holiday on the Flight Deck

It’s one of the places we put crazy people: Ward 5C4, in the Veteran’s Administration Hospital in the otherwise tony burg of Palo Alto, California. This ward’s official title is, “Psychiatric Intensive Care Unit.” But in a burst of the gallows humor that docs and cops often use to drain off tension, the Stanford medical students and staff here commonly call it, “The Flight Deck.”

Dr. John Rork wears a Formica nametag identifying him as a Resident in Psychiatry. He’s 32 years old, in his third year of post-graduate work at Stanford, and just 18 months away from his board exams. As he leads me up a dank, echoing stairwell toward the fifth floor of the VA, Rork cautions me that the Christmas Season is usually a time of high disturbance among denizens of locked psychiatric wards.

That’s when they feel most keenly the wide gulf that yawns between them and people on the Outside.
Consequently, holidays present a time of extra stress and danger. Staff must pay extra attention to procedures that keep the patients from doing harm to themselves, or to others.

I accompany Rork in part because, as a former student of psychology, I am entertaining the idea of entering the field for a career. But beyond that, I have a simple, much more existential motive. I just want to see how much like me, and unlike me, these confined folks are.

We move down a hall with its faint, stale redolence of medicine, paint, bedpans and disinfectant, and walk toward a big metal door with a tiny square of wired glass in its center. I start to feel a bit apprehensive. Author Ken Kesey did his research for “One Flew Over the Cuckoo’s Nest” at the locked wards of a related hospital, the VA in nearby Menlo Park.

Although Kesey’s novel and the movie derived from it are by-now-dated works of fiction, scenes from the book still drift through my mind.
Two surreal details before me at the moment are the cardboard Santa waving a cheery mittened hand, taped to that steel door, and a tired tinsel wreath. Somehow, these nods to the holiday spirit fail to reassure.

Rork tugs a bundle of keys from his pocket, unlocks the door, and leans his body into its mass as he shoves it open.
The good doctor is greeted enthusiastically by a slender black man in a rumpled jump suit and snappy blue hat. Patient, or staff? I wonder.

It’s not immediately easy to pick out staff from the small crowd I see milling around in the entry and common room. No one acts in manner notably bizarre. But after a few minutes, I do catch on. Since patients are not permitted to wear belts, their clothing remains in mild disarray. Also, they seem to have an air of grim, silent struggle, the sort of aura one often perceives hovering about impoverished drifters, or the urban homeless.

The staff, in addition to a neater appearance, also tend to be garbed in lab coats – which I’d initially mistaken as a variation on hospital gowns. In contrast to the mood of the patients, they also seem to broadcast an intentionally upbeat demeanor, as if they seek to communicate optimism to the patients by contagion.

In the common room, men lounge on couches and watch TV. An adjoining room with large glass windows permits observation of the patients. Down the hall is a small commissary, and dorm rooms where beds and steel lockers are arranged in orderly rows. Further along are the office rooms used by the resident doctors, and finally, those famed, tiled seclusion rooms, equipped with padded restraints, to consign patients who go into violent phases – episodes that are rather antiseptically dubbed, “decompensation.”

A senior nurse summons Rork into the glass observation room to tell him what’s gone down in this ward over the 32 hours since he was last on duty.
A day earlier, sponsored by a local Elks Lodge, Santa and his elves had come to 5C4. A small tree had been elaborately trimmed in anticipation. The jolly saint arrived, there was joy, even hilarity, small gifts and useful toiletries were distributed (all razors confiscated immediately afterward, of course).

Then, all too soon, this icon of the holidays vanished, and the ward sank back into a deeper gloom.
Rork and the nurse stand before a plastic board listing the names of all 20 patients in the ward, followed by a letter code that indicated status.

“A” means a patient must wear pajamas and stay confined to the ward. “B” and “C” patients can take escorted trips off the ward to the hospital’s gym or canteen. “D” is a full-privilege status, meaning a patient can spend up to six hours a day off the ward, even engaging in unsupervised activities.

The nurse’s update to Rork is full of shorthand, slang, and the same kind of humor that christened this place as The Flight Deck. She points to a name and says, “Now, this little man is very busy in his head. Really schizing away.”
“He still talking word salad?” Rork asks.
“Maybe. Didn’t hear. He stayed glued to his bed all day. Like he had Elmer’s Glue all over him.” She points again. “Now, Dale left to spend a day with his folks, but a few hours later he came right back to the ward. I don’t know yet exactly what happened. . .”

And so on, until they clear the board. Then there is a call for, “Medication!” and the top half of a dutch door is swung open. Patients line up, and their doses of anti-psychotics and anti-depressants are passed out in paper cups that contain pills, capsules and various colored liquids.

One patient, a short, muscular chap wearing a bruise that encircles one eye, sees me watching him as I sip away at my coffee. He raises his cup, filled with a solution of lithium salts, says, “Cheers,” and splashes it off his tonsils.
I return his toast, and swallow the dregs from my Styrofoam cup. We smile at each other. Evidently, humor about this situation is not solely the province of the medical staff.

Time for Rork’s first consultation with a patient. He brings me into his small, barren office to witness the encounter. The room’s sole furnishings are made of thick steel layered with multiple coats of paint. Rork tells me this is the décor of mental wards across the globe. The monotony of the walls have been somewhat relieved by pastoral scenes cut from calendar photos.

Rork sees me glaze at the pictures.
“Interesting thing,” he says, grinning. “A patient pointed this out to me. I put up three pictures of bridges, right next to each other, without even thinking about it!”
I wonder how many other psychiatrists got a kick out of hearing patients reveal patterns in the doctor’s thinking.

His first patient of the day is a pudgy blond man, Dale, who jetted back into the ward after spending just a few hours with his family.
Slumped in one of the thick steel chairs, staring intensely at Rork, Dale says, “I’d like to love my parents. But something down there just isn’t right. I cried when I left the house, because I was still a kid. Meanwhile, everybody else is acting like an adult! And I’m the oldest. I feel left out.”

Rork uses gentle, insistent questions to navigate between Dale’s statements, drawing lines between the man’s expressions of consternation or anger, and some of its potential causes. This process is slow, but fascinating.

“My dad always made me sit on the bench in baseball. It was the start in my life of the way it was gonna go. But I don’t want that! I want to have a couple of at-bats. I’ve never been an engine, doc. I’ve always been a caboose. I figured I could be an engine, until I went in the service. All my walls started tumbling in then.”

The feelings Dale is describing must be common to many, I think. Wherein lies his madness? Why must he be confined here? Then, as Rork continues to probe, I start to see what sets Dale apart.

“Air seemed different. We’re talking both here and in Greece, now. In Greece, everyone was getting back by cab, and it seemed a nuclear war was happening. ‘Cos I’ve always thought of a nuclear war as dark, and it was plenty dark in Greece. People were looking at me funny. I felt they were talking about me. And now, I feel the people in the hospital are talking about me. But I want to get well! I don’t want to get angry. But by the same token, I don’t want to kill anybody, either.”

“You lost me.”

“I sort of lost it too, doc. I was in the military when it first broke me down. Now, I can’t even make it in civilian life. That’s real scary. I don’t want to go back to war, no way! See, I’m not a crazy person. I don’t talk about myself, I talk about what’s going to happen. And I know I’m not Jesus, even though I’ve got a head. I can speak to you clearly. I’m not that bad. I’ve got God in my head. But I won’t tell you the other one, because then I know you’ll get the secret.”

“You’ve got a god, and a devil?”

“No,” Dale answers craftily. “A fly.”

By the session’s end, Rork has brought the man’s meandering verbal flight back to earth, and they calmly discuss Dale’s prognosis. Rork suggests that, if things go well, in a week or two, maybe Dale can leave 5C4 for an open ward, and start taking occupational therapy. Such positive steps depend, however, on Dale remembering to take his meds.

Dale needs anti-psychotic drugs to make his thought disorder more manageable. He had been on the Outside before, but elected to stop his maintenance doses. That brought on his third nervous breakdown and involuntary return to 5C4. Refusal to medicate is a common cause or ward recidivism, Rork tells me later.

“The patients who come to 5C4 can just about be evenly divided into the three main groups of severe mental illness that modern psychiatry recognizes,” Rork says. “About a third have thought disorders, or schizophrenia, like Dale. Their connection with consensual reality is impaired. So, it manifests as a cognitive disease. Hallucinations and delusions impair goal-directed behavior, and judgment, and reasoning. Our research suggests that most forms of schizophrenia have some sort of genetic base.

“Another third have affective disorders, which are long, substantial deviations in mood. The most common forms are severe depression, and manic-depression – which involves swings from the depressed state to a giddy, manic high. When not at the ends of that spectrum, these people can seem pretty natural, fairly normal.

“Then, there’s personality disorders. These are the people who can’t fit in, no matter what. They have their personality structured in maladapted ways. Their only role in society is that of the oddball, or ‘real character’.”

Rork says a root symptom in most cases, especially with the first two groups, is an imbalance in neurotransmitters, the brain chemicals that act as vehicles for transmission of impulses, from nerve to nerve, across the synaptic bridge. High stress aggravates weaknesses in a person’s genetically-ordained nervous system, and trigger an onset of mental illness.

Look upon the brain as a fuse box, and folks with a genetic predisposition to madness could be seen as those with an excess of exposed wiring. Stress that a normal person could experience as a half-hour of mild anxiety will turn a manic-depressive’s fuse box into a three-alarm fire. Anti-psychotic and anti-depressant drugs are like rolls of plastic electrical tape that a doctor can use to wrap around some of the bare wires, reducing the intensity of the blaze.

Since the 1950s, when Thorazine was discovered, some 15 anti-psychotic drugs have been found (by the mid-1980s – author’s note), with five in common use. These range from Thorazine, considered the weakest but possessing desirable sedative effects, through Navane (mid-range) to Haloperidol, or Haldol, the “elephant gun” of anti-psychotics. There is also lithium, a carbonated salt thought to resemble salts naturally occurring in the brain, and a class of anti-depressants called Tri-cyclics.

“If someone acts psychotic enough to come here to the Flight Deck,” Rork says, “they are usually put on hefty doses of medication until they calm down. Then we set about finding their minimum daily dose. These drugs aren’t entirely benign. They can produce negative side effects, like involuntary tremors, or sometimes shaking feet and a tendency to pace that’s called the Thorazine Shuffle.

“Before I began doing practical psychiatry, I used to think that psychotropic medications were horrible,” Rork adds. “But once you’re around real schizophrenia and you see how miserable these people are, and that a significant percentage gets real help with drugs, it becomes more difficult to maintain that naïve stance.

“Because of these drugs, the number of mental patients at public health institutions is one-tenth of what it was. I wish we had even finer tools, medications that more clearly address the target systems. These are still much too blunt.

“But used carefully, these drugs achieve an amazing purpose in allowing people to live outside institutions. Most of my patients would much rather be out in the world; institutionalization is what they hate. Their biggest fear is that will end up without an independent existence – because independence is at the core of self-esteem for people in this culture. Drugs are in fact a kind of dependency, but nothing like being confined in an institution.”

That innate drive to independence is on full display when all patients gather in the communal room for their daily meeting. A pretty, brunette Psychology Intern opens the floor for business, and Terry, the muscular patient with the bruise around his eye, dives right in with a defiant statement.

“I want a discharge right now! And if I can’t have it, I want ‘D’-level status or ‘D-B’ at worst!”

A chorus of other patients clamor for an improved status on the ward. It’s as though the status board were a ladder to sanity and freedom, and each grade a rung. Enhancing mobility to the Outside stays the primary order of business, until it’s announced that Dr. Rork has finished his residency, and will depart from the ward in a few days.

This is a double-whammy. Not only are the patients losing a friend, but Rork’s free, outward bound trajectory illustrates a kind of mobility about which they can only dream.

An elderly patient launches an abrupt tirade against the night staff. “They ordered a strip search and wouldn’t tell me why! It’s part and parcel of the jailer mentality of this place! You staff take a great delight in acting like cops!” He levels a bony finger at Rork. “You can go back to Stanford and get down in the scum with Reagan and Nixon and Billy Graham and all the other capitalist swine. I don’t really care.”

John nods calmly. “And what about Nina and Karen?” he asks. These women are an intern and a resident, both of whom are also leaving. They sit beside the old man as he rants.

He sneers, “I wouldn’t mind if a Mack truck ran over them.”

This launches a wave of other comments that are less personally directed, but just as critical of staff arrogance and assertive of the patients’ inalienable rights. Esprit de corps unites the patients as they dump their grievances. Many of them give each other winks and high signs during this group display.
But the thing that impresses me most is that Nina and Karen look as if their feelings have been genuinely hurt by the raging old man.

They have spent a lot of therapeutic time with him. This tells me that these women made themselves available for genuine interactions, did not utterly armor themselves, or withdraw behind the shield of their identity as staff.
As I mention this impression with Rork, later, he stares at me as if I am reporting I had just struck gold in his back yard.

“That’s right!” he says. “If patients get the idea that you regard them as some form of dangerous alien, that only makes your work harder. So, you’ve got to let them touch you. You’ve got to hold yourself somewhat vulnerable to them.”

Then the staff holds a meeting about the meeting. They agree that the patients had to express anger about the departure of Rork, Karen and Nina.

“The clue,” Rork says, “is that the anger was directed at the staff in general. They generalize as a form of avoidance. But it’s important not to fall for that, because it’s not a therapeutic form of release. Most of the public running around out there on the street does that too. They all project affect away, instead of owning up to what it actually is.”

Since so much energy was released in the group meeting, the staff predict the rest of the day will be fairly quiet. It is, allowing me to wander around the common room, hanging out and talking to the guys. As I do so, I wonder about a question that all of Rork’s comments have posed. Can it be true that the very crazy are not all that different from you and me? That they simply have many of the problems of normalcy writ exceptionally large, etched into their minds and lives by the Kafka-esque machine of their own aberrant biology?

Sometimes, the similarities may seem hard to track, as in the case of Elliott, who sits by himself in a corner, woofing down cigarette after cigarette. He wears his hair in a high, greasy pompadour, sits on the edge of his seat with charm school poise, and talks like Blanche DuBois. He’s one of several Vietnam veterans present. I seek to use that as a conversational opener, and ask him about his experiences there.

All Elliott will say is, “Ah was loved in Vietnam. I was very deeply loved, in fact, from bootcamp right on through Vietnam.”

Then he gracefully rises and minces across the room to light another cigarette from the tiny electric coil set into one wall.
Even though I can only speculate about what Elliott’s inner reality is like, parts of him are congruous, they make a certain kind of sense – and it’s the same for the others. In fact, the wildest, most incohernet babbler in the place is not any patient, but the big color TV that alternately blathers and croons from its niche in the corner.

I make additional contact with Terry, the bruised manic-depressive who had come to the ward after getting himself into a barroom brawl in Monterey. I can sense his chagrin at finding himself back on the Flight Deck. I share some of my own past with him, and it turns out we have in common a Catholic boyhood.

He says he maintains a deep regard for the Franciscan brothers who taught him. But these days, he tends more toward the free-lance mysticism of Krishnamurti.
“You can discover states of mystical consciousness that are just absolutely blinding in their purity, and the sweeping vastness of your perception. . .” Terry pauses, and gives me a sidelong glance. “So I bet you think, that sounds pretty close to a description of a manic state, huh?”

I ruefully nod, and Terry bursts out laughing.

“Well, I have to admit,” he says, “there’s probably more than a little similarity between the two!”

We finish by trading back and forth some altar boy responses from the old Latin mass, and I sang him some Gregorian chant. It is a humor-filled, friendly and even poetic encounter that would seem valuable in any setting, but is particularly poignant here.

Just under half the men in the ward are actual combat bets. But all are veterans of a war waged for years behind their eyes. The shock, the weariness of that, stays evident. Achieving any sort of ceasefire is just the start of making their way toward a peaceable, promised land. Even if that storm of inner chaos can be subdued, other obstacles and hurdles loom.

“The VA system is kind of a ‘borderline’ mother,” Rork says. “One who is overwhelmed by the nurture needs of her children, and conveys that by falling short in a couple of key areas. But at the same time, if the children start to pull away, she threatens to cut off even the scant support she does provide.

“See, as it’s currently set up, the VA pays people to stay crazy. A one-hundred-percent, service-connected, disabled vet gets thousands of dollars per year, tax-free – much more than most could ever hope to make free and clear on the Outside. The trick is to look and sound sick enough to get all that money, but seem well enough so they can stay on the street and spend it. You have to be clever to maintain such a fine line.

“So the guys who want to achieve real independence have a much tougher row to hoe. They have to desperately want to wean themselves off that support, in order to even have a chance of doing so.”

Heroism was not one of the things I expected to find on the ward, but I’m starting to learn how to see it. Rork has two more consultations that day.
One is with a young man who retreated into a fantasy realm after being sexually brutalized in his early teens. But over the past three years, he has moved out from the Flight Deck and on to self-sufficiency on the street. He has a romantic relationship, and he has just won a raise at his job. Returns to 5C4 now solely as an outpatient.

He and Rork discuss his medley of anxieties and strategies for coping like two experienced players dissecting a game of chess.
That sort of graduate status is what Malcolm, Rork’s final interview of the day, seeks to achieve.

Malcolm is a tall, dark, bearded and slender man who has just advanced to ‘D’ status and is looking next for a discharge. The flesh on Malcom’s lips and fingers are stained like old ivory by all the cigarettes he’s smoked during his confinement. His hands and feet shake from dyskinesia – tremors that are a common side effect of anti-psychotic drugs.

But he speaks calmly and clearly, and has an aristocratic, faintly sardonic air about him that I like.
Malcolm pulls out some recent crayon drawings to show Rork. The first illustrates a rabbit by means of concentric lines of vibrant, clashing color. It’s a classic example of schizophrenic art. At the moment, it reminds me of Huichol Indian yarn drawings, which I mention to Malcolm.

“Really? Interesting,” Malcolm says. “I’m trying to portray a bunny who’s recuperating after three weeks on Navane.”

We pore through other drawings, with Rork asking questions about symbolism and meaning. Malcolm sometimes answers, sometimes fends him off. I simply assess them as art. I particularly admire one titled, “MARCOS!” that mourns the assassination of Benigno Aquino. And I like a drawing of a rhinoceros that suggests that near-sighted animal’s suspicious, wary soul.

Pleased by my interest, Malcolm uses his new privileges to invite me out to the VA hospital canteen for a cup of coffee. The big steel door that closes off the ward is unlocked for us, and we head downstairs and then out into a cool, blustery, December afternoon.

It’s a huge relief to be leave behind the stagnant, medicinal, smoky are of the Flight Deck. We stride along, kicking through drifts of sere leaves scattered by the most recent winter storm.

“The rough edge of mind changes people who get close to it,” Malcolm volunteers cryptically.
I ask him what he means.

“It’s hard to explain. You’re either a virgin, or you’re not. You’re either exposed to that, and it changes you forever – or it’s hard to know what it’s all about, whether you’re a patient or a doctor. No matter what a person is like before he’s in the system, once he’s expressed himself in a hostile way, taken the drugs, been bobbled around the system for a while, he’s then different from that point on.

“So, this rough edge of mind which changes him, is that part which is confusing, which is destroying, which is unholy. Which is, ultimately, irrelevant.”

Outside the entry to the canteen, Malcolm pauses. Some sort of half-crippled insect has landed on his boot, and he stops, stares at it. I look, too. The bug has tattered wings, and appears to close to the end of its life-cycle, prepared to die after the exhaustion of mating. Malcolm tenderly plucks it off his boot and deposits it on the sidewalk.

“Well, I guess he’s on his own now,” Malcolm says. “I don’t think there’s anything we can do.”

Inside the canteen and sipping our dark, bitter brew, Malcolm tells me more about life on the ward.
“You get to see a lot in this system. Big moments come through for people. A lot of big suffering. Bursts of joy, too. Both can occur in the same person, I think, because of mercy. In retrospect, one is always thankful for feeling healed in the new moment. When a clear space comes, you can look at the past, talk about it, and it doesn’t really mean anything. But when you are inside the suffering, everything only hurts, and that’s why they give you the drugs. To relieve pain, and give you a chance to get your mind together.

“That’s their theory, anyhow, and the practice is pretty close to that. You’ve got to make allowances, because we’re all the same, and we’re all different, too. It’s like any other classroom situation. Some people get the message, some don’t. Some already know it, but can’t put it into practice.”

Watching Malcolm speak, I think of how weary he looks, so aged beyond his years. Yet, there’s also the glow of an inner grit and determination in him. He resembles some early frontiersman, who has recently crossed the Great Basin desert, alone and on foot.

Malcolm tells me of his plans for the future. He’s located some broken medical equipment stored at the hospital, and wants to start a business repairing and returning it to use.

“There’s no restrictions on me. I’m a dischargeable patient. The only thing stopping me is a lack of housing. I get disability from the military, and I have the chance of work here. I don’t to find a salaried job, though someday I’d like a chance to try that. I know that there will be hindrances. But as far as I can see, the next six months look bright. If I can just keep practicing in the same way. Still, I know there will be many decisions ahead of me, about things that may not be so easily accomplished.”

Malcolm places both of his stained and shaking hands together, palms upward, and shrugs. He looks like someone uncertain, lost in a quandary.

But since it’s Christmas, I prefer to think that he looks like someone about to receive a gift. Perhaps a universal, endlessly recyclable gift, something he gives to himself, something given to him by Dr. Rork, and the staff, and his friends on the Flight Deck. Perhaps it’s something I am giving to him now, and he is giving it to me also, by taking me out to coffee and offering to explain things about the ward.

There’s an amazing mental achievement most of us accomplish steadily – without even needing to think about it, if we are fortunate. Call it sanity, call it normalcy. But we should never take for granted the small, healing touches of friendship and nurture, given and received, that collectively help us to make sanity occur.

Note: To protect privacy, all names were altered and identities concealed in the story above.