The Greatest Casualty
It’s 10:00 PM and I’m sitting in the day room of the psych unit writing my patient notes. Because the hospital’s somewhat antediluvian, I have to scribble them out by hand. Unfortunately a Medicare auditor recently complained she couldn’t read my chicken scratch so my boss advised me improve my penmanship. Abandoning the cursive scrawl of my youth, I slowly print words like disorganized, delusional, and confabulating with the care of a medieval monk transcribing an illuminated manuscript. Well, you can almost read it.
After half an hour of writing the arthritis in wrist suddenly flares up. As I massage it I look around the unit. Half the patients are watching television and the other half are zonked out in their rooms. We have a fairly mixed group of patients this evening – schizophrenics, depressives, two really far out bi-polars, a demented old woman and someone the docs haven’t figured out yet. Most of our clients are “frequent flyers” which means I see them over and over again.
“Can I talk to you?” a voice behind me says.
I turn around. It’s Gustavo, a paranoid schizophrenic we admitted three days ago. “Sure Gustavo,” I say. “What’s up?”
“They’re watching me you know. I’m worried all the time.”
“Who is watching you?”
“Them,” he says pointing to the ceiling. “There’s cameras everywhere.”
Gustavo is absolutely right. With the exception of the patients’ rooms and the showers, the entire unit is blanketed with CCTV cameras. We’ve made no effort to hide them.
“The cameras are there for your safety and mine,” I say.
Occasionally a patient tries tearing the unit apart. If there isn’t time to reach a panic button or call for help, the theory is the security guys will see the fracas on their screens and come running. But the reality is the cameras are there to watch me. Assaults, neglect and sexual abuse perpetuated by staff are not unknown in the mental health world.
“But my phone’s tapped,” Gustavo says. “The government is watching me through the television. They got drones, man. Robots! They watch me from the sky.”
When I started working psych twenty-four years ago everything Gustavo’s saying would be patently ridiculous. Now it’s not. Governments monitor our emails, listen to our phone calls, use drones to look for terrorists and have the ability to watch us surreptitiously though our computer’s camera. The police scan our license plates with high speed readers, track us down through our cell phones and use Google Earth when planning a raid on a crackhouse. It’s not paranoid to think Big Brother is watching you when he is watching you.
This has ramifications for dealing with the clinically paranoid. You can’t say, “It’s all in your head, now take your meds.” Mentally ill does not mean stupid. My patients read the papers. They see how privacy is being eroded in our hyper connected world. Paranoia is a “thought process heavily influenced by fear and anxiety, often to the point of irrationality and delusion.” Well, how many of your “sane” friends spin conspiracy theories about how the government is using the Internet to watch our every move? How many times have you heard a parent worry about their kid doing something stupid online that will be digitally archived forever and scare off potential mates or employers? Twenty years ago such thoughts were for the tin-foil hat crowd. Now we’re all thinking them. We’ve entered the era of Paranoia 2.0. So instead of bullshitting my patients, I’m straight with them.
“Yes, Gustavo,” I say. “We live in a world where a lot of what we do can be recorded and analyzed. The police use drones and the CIA can tap people’s phones. You’re totally right and there’s a lot of debate about it. But let me ask you, why do you think they’re after you personally?”
“I don’t know.”
“You up to something? Planning to overthrow the government?”
“No man, I’m straight up American. I tried to join the Army.”
If you’re not doing anything illegal I doubt they’re looking at you.”
“But they’re everywhere.”
“I worry about that stuff too,” I say. “But when worrying about it screws up your life, when you start yelling at people and don’t trust anybody, not even your own mother, then something’s wrong.”
“But my Mom called the cops on me!” Gustavo says. “She’s in on it!”
“She’s looking out for you, man,” I say. “She doesn’t want you to get hurt. Listen, when you take your meds do you have paranoid thoughts?”
“Not as much.”
“You keep taking those meds and you’ll be outta here in no time,” I say. “Just relax. You’re safe with us. Okay?”
Gustavo shuffles off, not looking convinced. He’s only been here a few days and the drugs we’re giving him haven’t fully kicked in yet. But I fear the increasing omniscience of modern technology is just exacerbating the suspiciousness Gustavo’s illness inflicts on him.
I’ve written previously about how uneasy our brave new world makes me. Just the other day a college kid told me how she submits her term papers through a system called Turnitin, a computer system designed to sniff out plagiarism. But when she told me how her school’s “Office of Academic Integrity” occasionally suspended innocent students tripped up by the system’s unfeeling algorithms, I thought of Orwell’s Winston Smith toiling away at the Ministry of Truth. I also watched this kid happily use free services like Twitter and Facebook on her phone, blissfully unaware that nothing’s free and the data stream she’s producing is being sold for profit.
My shift finished, I go home to find the baby sleeping in her crib and Annie passed out with her iPad glowing softly in her lap. Feeling uneasy I pour a finger of Scotch into a tumbler and flop down on the living room couch. As I feel the liquor burn a path down my throat I turn on the television, but the jabbering talking heads disgust me and I switch it off. Thumbing on my smartphone, I check my email. My mother has sent me some disturbing news. A mentally ill homeless guy stabbed a man to death in my old hometown.
The daughter of the man who was killed was a friend of my sister-in-law. Scanning the news reports I read a sad and familiar story. The homeless man’s territory was a strip mall. He slept in a restaurant and washed his clothes at the neighboring Laundromat. Clean and presentable he never caused any trouble. Then the restaurant closed and he was forced to live in a boarding home in a bad part of town. He deteriorated after that. Probably went off his meds. Now a man is dead, one month before his was to meet his first grandchild.
I think of Gustavo. Most mentally ill people don’t commit acts of violence, but when they’re off their meds and actively hallucinating bad things can happen. I know this because patients have sent me to the ER more times than I care to remember. Untreated, Gustavo could end up preyed upon or commit violence himself. And when he’s discharged he’ll probably end up in a boarding home just like that assailant.
The reason so many of my patients are frequent flyers is that they don’t have a decent place to live. Families are often unable to cope with them so discharged patients go to boarding homes, halfway houses and shelters. Some of these programs are good, but many of them are run by lazy incompetents more interested in profiting from government contracts than providing care and supervision. Assaults and abuse are common. Patients have their medications stolen and sold on the streets.
Deinstitutionalization, the closing of mental hospitals nationwide and moving the patients into the “community” has been a disaster. In 1955 the U.S. had 300 hospital beds for every 100,000 people. Now the national average is around 15, with some states barely having 5. As a result the penal system has become the largest provider of psychiatric services in the country and deadly encounters between the police and mentally ill are daily news. When I was on my honeymoon in San Diego I was stunned by the legions of homeless psych cases wandering the streets. They all didn’t need to be locked up but a large number of them required constant care. We need to be building mental hospitals not closing them.
But let’s face it, as a nation we’ve thrown these people away. They’re shadows – modern versions of untouchables. Who care what happens to them? If you watch television commercials you’ll see where our priorities now lie. We’re constantly enticed by young and shiny people to enthusiastically embrace the promise of the Digital Age, Have you ever seen that commercial for American Express? A well dressed hipster in a coffee shop buys an expensive bauble online and gets a fraud alert on her phone. After confirming her purchase was legit, she leans back in her chair with a smug blissed out look on her face while the announcer proclaims, “This is what membership is. This is what membership does.” Hey, I don’t like people ripping me off either, but Amex is using the same systems that allow governments and corporations to hoover up every byte of information about us they can find. Don’t believe me? Apply for life insurance. The underwriters know all about you. We’re in danger of becoming just ones and zeros. Data. A commodity. A product observed, dissected and quantified with inhuman precision. The problem is that commodities are used up and thrown away. Just like the mentally ill. Just like Gustavo.
Technology has given us many gifts but it has now enabled Orwell’s dark vision to threaten us in ways even he couldn’t have imagined. The interconnectedness of human beings is being replaced with a pale digital imitation – to the detriment of empathy and compassion and to the advantage of those who exploit us. We are being forced into digital cocoons that foster self-interest and consumption. People like Gustavo have no chance in this world. If we’re not careful we’ll create a new breed of people like him.
I finish my drink. Maybe I’ve been working around paranoid people too long. but dealing with the mentally ill has made me feel their pain in my gut. A veteran co-worker always tells the new recruits, “Imagine what it’s like to be them. No one likes them. No one wants to sit with them, take them to dinner or let them into their homes. They’re passed on the streets like they’re nothing everyday.” The answer is to take care of them, to protect the least among us. That’s what membership in the human race means. That’s what membership does. But we’re not doing it. Worrying about the world my daughter will inherit I realize why I feel uneasy.
The greatest casualty of 1984 was human love.