Hello I Want to Die Please Fix Me

by Anna Mehler Paperny

  Mario Cappelli studied the incident. “You could not have publicized those two deaths any more than they were publicized and we had no increase in suicides. Media…talking about suicide keeps mental health at the forefront, right? And that’s not a bad thing.” 17

  Sensationalistic reporting is always irresponsible; if you can’t report on something empathically, compassionately, contextually, you shouldn’t be a reporter. Are there irresponsible ways to talk openly about suicide? Of course. Valorizing, glorifying, referring to “successful” suicides versus “failed” ones; talking about someone’s bravery in killing themselves—none of that shit helps. Don’t do it. It should be common sense not to rhapsodize a tragic death resulting from a debilitating disorder. And, for all the suicide reporting guidelines out there, there are legitimate ongoing concerns about what constitutes responsible coverage. Some news orgs provide contact information for crisis lines and similar at the end of their suicide-related stories, which strikes me as a good and useful idea but it’s no substitute for good journalism.

  Madelyn Gould believes the key is to approach suicidal ideation as a treatable symptom of mental illness rather than a way to solve a problem or the reasonable, inevitable resolution of a shitty situation. “I definitely wouldn’t want to see it on the front page. And I wouldn’t want to see extensive coverage.” Here is where we differ: I believe it’s possible to responsibly put suicide on A1 and to portray it, as Gould suggests, as a failure of treatment rather than a glamourized or sensationalized end. (She also thinks stories on the front page should be about hope and recovery. Maybe we need more of that. But bad news is still news; it’s our job to make sense of it.)

  What galls me is the way contagion freak-outs infantilize human beings with agency. The urge to kill oneself arises from deep-seated despair that goes beyond any blip in public discourse or news cycle obsession. Andrew Solomon in The Noonday Demon likens suicide contagion to a hungry person seeing a restaurant and going inside.18 With all due respect, this makes no sense to me: even if the hungry person doesn’t see the restaurant the hunger persists; and if it persists she will probably feel impelled to sate it. Pretending she isn’t hungry, acting as though this hunger will go away on its own as long as no one acknowledges its existence, does no one any favours. For no other public health crisis in the world would you suggest that ignoring its toll would make everything better. But for a long time, that’s how the media approached suicide.

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  HOW PREVALENT IS the stone-in-your-gut feeling, the nonplussed sense of loss, of having someone you care about kill themselves? I’ll never forget the wonderful woman at Pfizer’s switchboard who answered one of my first requests for an interview with the big pharma company, and who sounded as if she was all ready to pass me on to someone who would shoot down said request, but stopped as soon as I told her what I’d be asking about.

  “This is a really, really, really important and great topic. I had a friend who killed himself a couple years ago and I’m always trying to figure it out. It touches everybody, so I’m always interested in what kind of insights people can come up with. Because, to me, I’m still left with the idea that he didn’t mean to, you know? I mean, he was just overwhelmed, and that’s sort of what happened.

  “So. I’m going to redirect your call.”

  26

  Certifiable

  Picture in your mind a mental hospital, a psychiatric ward, an asylum for the insane. If you grew up in North America in the mid-to late-twentieth century, One Flew Over the Cuckoo’s Nest probably comes to mind first. Maybe you also think of the film Girl, Interrupted. (Remember when Angelina Jolie, as edgy fascinating pseudo-sociopath, was still something of an unknown quantity?) Maybe you read Janet Frame’s chillingly good stories, based on her own psychiatric incarceration, of New Zealand madhouses, or Life magazine’s depiction in “Bedlam 1946” of torturous conditions in American mental hospitals—men and women beaten to death by staff, half-starved, crowded into under-resourced institutions. Maybe you were struck by nineteenth-century woodcuts of people naked, chattering, wild-eyed, chained to the wall and wallowing in their own filth.

  The imprinting of those images on the collective psyche drove decades of deinstitutionalization—an en-masse emptying of those long-term facilities for disordered minds. It also drove trans-institutionalization, as legions of people with mental illness were discharged to the street and, without necessary care, were arrested and ended up filling prisons instead.

  The idea was to replace that inpatient treatment with outpatient community resources to get people care before they got seriously ill enough to need inpatient treatment. At the time, advances in psychiatric medicine seemed guaranteed, population-level prevention of mental illness a real possibility. It didn’t work out that way: in 1960s America, legislation intended to drastically draw down (state-funded) psych hospitals and establish (federally funded) community mental health centres resulted in much more of the former than the latter. Community resources couldn’t meet the needs of severely ill people who were now, in many cases, left on their own; where the needed resources existed, the links between hospitals and outpatient facilities did not.1

  More than half a century later this remains the case. And now the pendulum’s swung the other way. It’s become fashionable for many clinicians and public health experts to decry society’s aversion to housing crazy people in places that’ll keep them safe from society and—more to the point—society safe from them. The latter argument has been emphasized by doctors like E. Fuller Torrey, whose book American Psychosis laments the lack of institutions, bolstering its argument with a parade of anecdotes and statistics of the grisly crimes committed by violent crazies. (Yes, as discussed, these individuals comprise a minuscule minority of people with mental illness, who are far more likely to be victims of crime than its perpetrators. But don’t mess with the narrative.)

  Meantime, many jurisdictions, including Canada and the United Kingdom, are coercively treating people at a much greater rate than they did a decade ago, when most of the people filling Ontario’s psychiatric hospital beds were there of their own volition. That’s no longer true: between 2008 and 2016 involuntary admissions rose 82 percent. Between March and December of 2016, a thousand people a month were hospitalized against their will because of a mental illness.2 There are different flavours of coercive care and each one is increasing.

  Time for some stats. Deep breath: this is important. In Ontario the number of people put on a Form 1 (the seventy-two-hour hold I was put on after my first attempt) jumped 62 percent in eight years. The number of people put on a Form 3, the two-week forcible stay I was put on, increased 63 percent. Month-long forced stays, Form 4, more than doubled during that time. The number of admissions per patient also rose, which means more people are being hospitalized against their will multiple times a year. Overwhelmingly, they’re there because they pose a danger to themselves or are deemed unable to care for themselves—not because they pose a danger to others. The use of involuntary hospitalization is rising most steeply among the young.3

  You still have rights when hospitalized against your will—you have a right to a lawyer to help you challenge your committal, for one thing. You still have the right to refuse treatment, although that can be formally taken away. And the percentage of psychiatric inpatients being forcibly treated has also risen: its share of admissions increased about 15 percent over eight years. But coercion in one domain bleeds into others: part of the reason I agreed to start taking antidepressants despite my—admittedly irrational—misgivings was because I knew my release from hospital, my return to work was contingent in no small part on my good behaviour, on my impressing upon my captors that I was truly trying to get well. I know I’m not the only person who’s made that calculated, pressured choice.

  These are big increases. And a big deal if the rights to freedom of movement and integrity of the person matter at all.

  The trend holds true in B
ritish Columbia, where involuntary hospitalization jumped 54 percent in seven years and went from representing the minority to the majority of all psych inpatients. Here, too, they rose most among young girls.4 It’s true in Alberta, Saskatchewan, Manitoba and Nova Scotia. It’s true in England, where compulsory hospitalization increased 64 percent in two decades.5 It’s true in Germany, France, Austria and Finland.6

  As compulsion rises, it discriminates: people involuntarily hospitalized are more likely to be poor, unemployed, less educated;7 they’re more likely to live in poor areas;8 they’re more likely to be persons of colour. Black people in England are almost three times more likely to be involuntarily hospitalized than white.9 In Ontario, Black people are also over-represented among people placed on Community Treatment Orders, which impose mandatory conditions on your discharge from hospital, requiring you to take your meds, attend appointments and follow doctor’s orders or be committed.10 This disparity could be because people with crappy access to care to begin with are more likely to deteriorate to the point at which coercion becomes necessary. It could be because we more readily rob of autonomy people who are marginalized to begin with. Could be both. It does certainly raise questions about quality of care, equality of care and possible violations of human rights.11

  What’s going on with the increase?

  It’s not entirely clear. But we can see that in some jurisdictions the number of coerced psychiatric hospitalizations is rising as the number of psychiatric hospital beds drops.12 The flipped ratio between voluntary and involuntary admissions is fairly intuitive—when you have fewer beds they’re going to go to the most acute cases, and those are often going to be the ones that need or are seen to need hospitalization against their will. People may be trying to get into hospital voluntarily only to be turned away. But the absolute number of psych inpatient admissions has gone up, too. People are being hospitalized more often: involuntary visits per patient are up. And more people are deteriorating to the point where they won’t seek treatment even if they desperately need it.

  In a fee-for-service model of care, there’s also a financial incentive: physicians in Ontario get $105 for filling out a Form 1. I’m loath to think doctors are depriving people of their freedom to make a buck, but hospital-level anomalies suggest the question has to be asked.13

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  ANITA SZIGETI’S NAME strikes fear in the hearts of people who commit people for a living. The Toronto lawyer and staunch civil liberties advocate agrees insufficient beds and other treatment resources are at issue but her solution is less compulsion, not more. Her job is to fight for her clients’ rights and autonomy against those who would hospitalize or treat them against their will for their own good. She challenges committals at Ontario’s Consent and Capacity Board, seeking to emphasize her clients’ civil liberties ahead of the state’s responsibility to help people who can’t help themselves. She’s notorious enough among Toronto-area shrinks that when my psychiatrist saw her name on a book I was reading (A Guide to Consent and Capacity Law in Ontario is no beach read, but is very thorough), his eyebrows rose. She is busy. But she is not popular. Where psychiatrists see a necessary, underutilized way to improve the lives and prognoses of people who don’t know their lives need improvement, Anita Szigeti sees a set-up stacked against the most vulnerable patients who, no matter how severe their illness, still have rights that are all too easily ignored.

  She contends in our chat that most of her clients shouldn’t be committed to begin with. Many are held for reasons outside their control and outside the elements of their illness—they don’t have housing to go home to, for example, or can’t access intensive outpatient treatment that could keep them out of hospital. And anything more than a few days’ institutionalization can make you lose the supports you had when you were out, making it even riskier to discharge you: you can lose social assistance, lose your apartment, lose your job, lose touch with whatever social connections you had on the outside. “I don’t blame the doctors; they’re clinical caregivers. They want their patient-client to get better. They think they can help them.”14

  Psych wards are no longer Bedlam caricatures or Nellie Bly’s madhouse. Inpatients have rights and, more importantly, provisions are in place for maintaining them. (Whether those provisions are followed to the letter is another story.) There are protocols for the ways you’re treated and what you’re treated with and, overwhelmingly, the people who work in those wards—in my limited experience and from what I’ve heard of others’—are decent and compassionate individuals. But in some ways the places we put the insane still fit Ken Kesey’s stereotype. The longer-term ward I stayed in featured putty-coloured floors and walls and ceilings, doors that didn’t close and windows that didn’t open but were crosshatched with metal mesh nonetheless. There was a common area with tables for eating or playing board games and a smaller alcove with a TV mounted near the ceiling whose channels were the purview of the tall. Windows fitted in the doors to patients’ rooms and outside light switches made it easy for nurses to check on you at odd hours of the night, cutting short whatever scrap of sleep you could summon. The mandatory activities were self-parodies, as were weekly meetings where patient-inmates sat in a circle and discussed living conditions. Years later the hospital built a new lounge with money from a generous donor—games, better couches, books, Ping-Pong. Ping-Pong! I cannot adequately express my happiness that this exists.

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  HOW DO you decide when someone’s too crazy to make decisions?

  My most naked personal bias in this regard is decidedly libertarian. I want to throw open auto-locking psych-ward doors and cry, “Go free, crazy people!” But I’ve spoken with enough disconsolate relatives and health care workers, and seen enough devastating sequelae of treatment foregone, to understand why this is a bad idea.

  So how do you make that assessment? Take, as an example, the state of Arkansas, which requires past non-compliance with treatment in order to involuntarily hospitalize someone who poses a danger to himself or others, or whose inability to treat herself and impaired understanding of the need for treatment puts her in danger of deterioration. Colorado adds the possibility that a person “cannot manage resources or conduct social relations,” or that they’re losing a caregiver. (If having trouble socializing was enough to get a person forcibly hospitalized, I doubt there’d be many people walking free.) Hawaii includes people in danger of inflicting “substantial emotional injury to others.” (Um, who isn’t?) In New York State, involuntary hospitalization requires a person pose a danger to himself or others, require “essential” treatment AND be unable to fully grasp why.15 It’s hardly a hospitalize-the-crazies extravaganza, although I know plenty of online commenters who think it should be.

  Depriving someone of some rights means you have to be even more vigilant about protecting the rights they still have. But clinicians do sometimes fail in that regard. A March, 2019 report from British Columbia’s ombudsperson found the province’s hospitals were ignoring the rights of people involuntarily hospitalized. Legally required forms were missing, late or improperly completed. Sometimes physicians failed to explain why the person met the criteria for involuntary admission. Most involuntary patients got no rights advice form, and many had no chance to consent to their treatment.16

  A slip as simple as failing to fill out paperwork properly can trap you. In my second time through the psych ward post-suicide, the statutory countdown to my freedom should have started on my admittance to hospital. No one filled out that paperwork. The countdown on my Form 1 only started a day later, as I got settled in my curtained-off psych-ward abode. The prospect of another seventy-two hours without natural light or fresh air, after having spent the previous twenty-four hours hospitalized and the forty-eight before that holed up in my apartment (“Yes, but whose fault was that, Anna?” “Not helpful, Mom.”) was too much to countenance. Seventy-two hours is an eternity. And no, it isn’t the same as spending an e
ntire weekend in your apartment because going outdoors is too much effort: in your apartment you’re left to your own devices and you feel like you’re there by choice, even if the choice is pathological. And, in your apartment, there’s a motherfucking window. In theory I could have appealed my committal to the staff psychiatrist. But it was a Saturday afternoon, and I felt badly about it—I knew enough to know that the psych on call over the weekend is usually swamped.

  Late Sunday afternoon I lucked out, as someone persuaded the harried on-call individual to come visit the ward’s whiny patient-inmate. I promised not to run away or dash into traffic, to stay as a voluntary patient for as long as my doctor(s) felt necessary, if he would just take me off that Form. He acquiesced. I can’t overstate how validating that felt. I was still a crazy person housed in a modern-day loony bin, talking to nurses and social workers about my Thoughts and Feelings and answering daily suicidality questionnaires. But now I could wear pants. I could come and go at will, as long as I informed my keepers where I was headed and when I’d be back, checked in at shift change and didn’t abscond for more than a couple of hours at a time. More than that, I regained a sense of agency: I was a competent adult making my own decisions about my health care. If this comes across as semantic nitpicking, you’ve never had your autonomy snatched or curtailed because you’re too nuts to be trusted. Later I asked my psychiatrist why I wasn’t offered that same voluntary inpatient status after my first suicide attempt. He said I’d have been a bad candidate for it: I’d made clear I wanted to leave and was at too high a risk of killing myself to be taken off the Form. He then astonished me by saying he probably wouldn’t have taken me off the Form the second time around, either, for the same reasons. Yes, I had said I wanted to stay, but I had just made a serious suicide attempt and had a history of similar. It wasn’t that he didn’t trust me, he said: he didn’t trust the mood disorder. The news that my psychiatrist would have kept me locked up came as a blow. It also made me all the more grateful to that doctor who’d made the risky but, for me, enormously life-ameliorating call to set me free.