the only catch was Catch-22

I’ve written about this before, so maybe this is just part of the greatest hits. I don’t know.

We are living in an era in which we have ostensibly seen improvements in the visibility of people living with mental illness and in public understanding and support for them. From my limited vantage the average American seems more aware of specific disorders and the symptoms associated with them than they were in my youth. We are, at least, less likely to be confronted with overt stigmas against having a mental illness and more inclined to understand that many millions of Americans suffer from one.

It has not all been progress. There is a weird sense in which the effort to destigmatize mental illness has led some people to sort of sunnily ignore the myriad negative aspects of having one. I have been frequently confused by people who, having learned of my mental illness, react by essentially expressing the attitude that my illness must not impact my behavior or otherwise threaten my grip on life. This is well-meaning, I guess, to think that mental illness is so normal as to be unworthy of mention. But it is the opposite of what those with mental illnesses need, which is precisely an understanding that mental illness alters behavior – that the mentally ill are not the camera-ready crazy dreamers the movies have sold to you, but regular human beings who are flawed in all the normal ways and have the added problem of reduced impulse control, delusions about the current reality, and compromised cognitive functioning.

At an extreme you have the new and bizarre ritual of people insisting after a mass shooting that a shooter could not possibly be mentally ill, as mental illness never compels people to violence. (To say otherwise would be to promote stigma.) But some mentally ill people, a minority but some, most certainly are inclined to violence when symptomatic, and it only hurts their interests to pretend otherwise.

(This question is not the same as the question about whether people who suffer from mental illness are responsible for their behaviors while symptomatic. I am, personally, but that’s a far different conversation than I want to have.)

I suspect that in fact recent woke norms about mental illness have contributed to one of the most casually destructive attitudes one can have: the sense that the only real expression of mental illness is in psychosis. Mental illness is normal, so it becomes relevant only in those cases where someone is so far gone that the facade of normalcy crumbles. But mental health symptoms are spectral, not binary, and in fact most people become symptomatic gradually, with no clear break between a lucid reality and a delusional mindset. And in these stages, these grey pre-psychotic areas, help can potentially be most effective: it can save people a great deal of problems by intervening before they hit someone, before they spend all their money, before they make paranoid threats, before they commit the behaviors that they then have to account for when they are in recovery and thus in their most vulnerable state.

The problem is that the system seems set up to make getting help in these stages impossible.

My experience in 2017 seems typical. My bipolar cycle is exceptionally slow, depression and mania building in turn over the course of months. I certainly don’t envy people with rapid cycling bipolar disorder, but the alternative offers its own challenges. For me it is a perfect example of the classic trope of the boiling frog: my cycles descend on me so slowly and gradually that I don’t notice them until they are at such an acute stage that they become unmistakable. In a depressive phase this is tricky because depression makes things like getting to see a psychiatrist for meds and securing a therapist seem like an impossible mountain to climb. In a manic phase the condition is worse, as the paranoia makes me view treatment with suspicion and thus anyone who suggests it as a potential enemy who is working towards nefarious ends.

Events and my own bad behavior made treatment impossible to avoid, though I was able to stave it off long enough to inflict permanent injury to my own life and to treat others inexcusably. I was forced into care. Most importantly, my brother got involved and came up to New York to get me into treatment, without which I think it would have required arrest before I would have entered into any kind of program.

We first went to a facility that has a dedicated psychiatric emergency room, which seemed like the place where my problems were most likely to be taken seriously. And yet when I got worked up there the doctor did not take me seriously. I was ambulatory, I was communicative, I was unrestrained, and these facts alone seemed to signal to him that I was not a candidate for emergency psychiatric care. This despite my loudly stated and deeply sincere belief that there was a conspiracy working against me and that they would soon turn to violent means to hurt me. He asked me about my first break when I was younger, an event which certainly qualifies as full-blown psychosis and ended with me shot up with Haldol. He seemed unimpressed.

Eventually it became clear that we were doing a dance that, I have to believe, happens all the time: the admitting psychiatrist would only entertain admission if I indicated I was a danger to myself and to others – that is, if I was willing to say the magic words that can trigger involuntary commitment. But giving up control over my life and being forced to placate shadowy authority figures to get it back was utterly against the desires of my paranoid mind. I was facing a far-too typical dilemma: how I could get admitted without being committed. How could I prove the severity of my problem without triggering the potentially devastating consequences of involuntary commitment?

This is the terrible bind people with mental illness sometimes find themselves in: the sense among loved ones and even medical professionals that people lucid enough to know they need help are therefore too lucid to need help. That is the Catch-22, the bind. And experience suggest to me that it represents a clear impediment to care. How many people with a deep need for care have declined to seek professional help for fear of ending up in involuntary commitment, giving up their personal autonomy in the most basic sense?

I’m sure some would question whether someone who was lucid enough to attempt to avoid involuntary commitment was really experiencing a psychotic episode. Well, first, for me specifically, it makes sense: my manic states are characterized by extreme paranoia more than anything else. I see enemies everywhere. Knowing that the intervention of medical personnel invites risk of catching an involuntary commitment changes my paranoid behavior and gives me a very convenient excuse to avoid treatment. More to the point, it seems to me that progress will come precisely when we stop seeing manic states in binary terms of psychotic and minor. Too many people in the mental health community seem not able to understand that for many, there are periods in which the need for help becomes obvious to the conscious mind even while the perceptions of that mind become more and more distorted.

Leaving that hospital in Staten Island was one of the most brutal “what the fuck do I do now?” moments of my life. Ultimately sheer pragmatism pushed me in the direction of outpatient care: while there were surely private facilities that would have taken me on as an admitted patient, navigating the thicket of America’s health insurance system made inpatient care seem impossible. It took days more, and some deeply unpleasant medical misadventures while in a manic state, but I was able to connect with a doctor who got me on a short-term antipsychotic that made possible my adherence to a full treatment regimen, including long-term oral antipsychotics. I got lucky. I had the right friends and the support of family and enough money on hand to pay out of pocket. Many people don’t have those things.

I recognize that inpatient care is not appropriate for all patients or in all cases. I understand that in New York at least there is a city-wide effort to steer more patients away from costly hospital stays and towards outpatient care. I even broadly agree with that effort. And some would say that my experience demonstrates the system working, that outpatient care has worked and that pursuing it was more appropriate than being admitted for days or weeks. I don’t know, maybe they’re right.

I do know, though, that the conversation with me and that ER psychiatrist was a deeply unhealthy, disordered thing, both of us stalking around a legal definition that would compel him to act in a way that I found untenable. I am certain that this dynamic plays out all the time. I recognize that the life of an ER psychiatrist is likely difficult and that, given how often they experience psychosis, anything less than a full-blown case might seem like a waste of time. But there has to be a space between involuntary commitment on one hand and sedatives and the street on the other. One of the most basic needs of someone seeking psychiatric care is to have their problems reaffirmed as real problems, and yet bureaucratic and legal entanglements push doctors to see patients first as potential vectors for liability. It’s just not healthy for either side of the equation.

Triage is a fact of life in medicine. But the triage nurse should not be a formidable barrier to care, and too often, I have reason to believe, they are. If I fall out of a tree and tell my doctor that I think I broke my leg, that belief does not somehow complicate his or her diagnosis of whether I in fact did. And if I, now 17 years removed from my first diagnosis, am capable of acknowledging to medical personnel that I have descended again into manic hell, that should not confuse anyone into thinking that my condition is therefore not dire. If we are to dismantle stigma, let’s dismantle this one while we’re at it: the pernicious and false notion that people who can perceive their own illness aren’t really ill.