Tuesday, May 24, 2005

Leave all this? What are you, crazy?

“Orr was crazy and could be grounded. All he had to do was ask; and as soon as he did, he would no longer be crazy and would have to fly more missions. Orr would be crazy to fly more missions and sane if he didn't, but if he was sane he had to fly them. If he flew them he was crazy and didn't have to; but if he didn't want to he was sane and had to .”

-- Joseph Heller


If you came to visit the locked ward where I work, you’d likely be surprised by the number of patients who don’t want to leave—who, in fact, refuse to leave, and must almost be pried out with a crow-bar. Are they crazy? I don’t know. It’s really not such a bad place, here. It’s bright and clean, and someone else does the cleaning. The food is hot and good (so they tell me—I’m not allowed to eat it. I bring cold, bad food from home.) Lots of varied activities and outings. Instantaneous medical care, even for trivial problems. Superbowl parties, World Series parties, birthday parties, dances, concerts, and magic shows. Compare this to the “real world” many of my patients experience when they leave: Crappy apartments in bad, crime-riddled neighborhoods. Neighbors who taunt them because of their illnesses. Days or weeks of waiting to see a doctor when they have health problems (yep, same as you and me). Limited transportation. Only whatever meals they prepare for themselves. No birthday parties. And so forth. So, you can see how people who value comfort, security, and sociability over personal liberty and self-determination may be reluctant to walk out the door. And that description fits a large chunk of humanity.

Every week, I am compelled by the Administration to submit a list of my patients, indicating which have met the criteria of “clinical readiness for discharge” and remain hospitalized only because they are homeless. “Readiness for discharge” is essentially the absence of the things that precipitate hospitalization: dangerousness to self, others, or inability to care for oneself. So every week I struggle with this question: If someone is behaving appropriately, eating fine, sleeping well, pleasant with others, going on trips to Wal-Mart and mini-golf, taking her medications, not threatening suicide or homicide, and generally appearing to be a model citizen—BUT tears up every housing application or rental assistance form I put in front of her, and refuses permission for us to talk to landlords or outpatient agencies—should that person be classified as “ready to go, but unwilling”, or is that person, by definition, still crazy? Is the desire to remain, unnecessarily, in a mental hospital a priori reason that someone is not mentally well? Or could it be that, under the circumstances, wishing to stay in the hospital is the most sane and rational decision— and, as such, evidence that a person is ready to go?

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