Memoir

The problem of living

Dispatches from deep psychiatry

The period of the wildest weeping, the fiercest delusion, is over.
The women rest their tired half-healed hearts; they are almost well...
Everything will be splendid: the grandmother will not drink habitually.
The fruit salad will bloom on the plate like a bouquet
And the garden produce the blue-ribbon aquilegia.
The cats will be glad; the fathers feel justified; the mothers relieved.
The sons and husbands will no longer need to pay the bills.
Childhoods will be put away, the obscene nightmare abated. 

Louise Bogan, ‘Evening in the Sanitarium’

 

THE PSYCHIATRIC WARD is gravely ill. The psychiatric ward doesn’t want you to know this. The psychiatric ward is in deep denial. Heads down, thumbs up. The psychiatric ward holds the Guinness World Record for Most Ominous Linoleum Flooring. The psychiatric ward is a suburban community theatre production of Waiting for Godot in which Godot is played by a disinterested registrar. The psychiatric ward is ‘porridge and more porridge, and they make you feel like Oliver Twist when you ask for more’.[i] The psychiatric ward is an experimental art installation entitled Dignity Is Overrated. The psychiatric ward is a ‘net that encircled my mind as well as my body, that always seemed to stretch just a little farther than I could think’.[ii] The psychiatric ward is a shrine to Jatz crackers and The Ellen DeGeneres Show.

The psychiatric ward is full of tricks. Just after midnight, my friend Linh and I creep over to the nurses’ station to ask for a few spare blankets and a bottle of water. As we step into the common area, we are met by a wall of heat. Linh is baffled. Our rooms are so cold that we fall asleep with our teeth clenched, wrapped in every piece of clothing we can scrounge up. Hospital gowns on top of jeans on top of stockings. Linh often goes to bed wearing her iridescent Nikes, her ankles extended just a few centimetres past the edge of the mattress so as not to get the sheets dirty. Sometimes she manages to stay in that pose for more than eight hours, like a stylish cadaver.

Outside the nurses’ station, it must be at least 30 degrees. Apparently they do this on purpose, to discourage us from talking in the lounge room after 9 pm. The security guard let it slip on the night I was brought in – he was sweating bullets through his uniform. ‘I think this kind of thing is called “hostile architecture”,’ I tell Linh. ‘Like those “anti-loitering” spikes you see on windowsills and public benches.’

‘We need more of that around here,’ Linh says, ‘so that the pigeons don’t come in and shit on the carpet during lunch.’ Her iridescent Nikes clap against the floor as we walk back to our beds with our blankets and water. Her shoelaces have been confiscated, as have everyone’s. Above her bedside table, Linh has set up a Blu-tacked arrangement of photos of her baby boy – pink-cheeked at the beach, eating noodles at the kitchen table – that inevitably slip away from the concrete during the night. Each morning she methodically sticks them back into place – her own minor struggle against the ward’s hostility.

 

TO THE CHRONIC patient, psychiatry is a cityscape of hostile architecture. The bones of the asylum system were never completely dismantled, but hastily patched over with bad drugs and big promises – a house flip executed by money-grubbing cowboys. Mercifully, some of psychiatry’s more draconian practices have been phased out, but the well-meaning deinstitutionalisation movement of the late twentieth century – intended to reintegrate long-term patients back into society – has achieved questionable results. As Australian institutions shut down, the push for ongoing community care was soon stymied by inadequate funding and overwhelming policy failure, enabling the proliferation and eventual supremacy of quick pharmaceutical solutions. Legions of patients, many of them non-white and working class, have been lost to suicide, homelessness and incarceration as a result of our government’s continued refusal to materially or socially support the proposed psychiatric revolution. Others, like me, have witnessed the strain that this period has exacted on overstretched mental health workers and unpaid family carers, who have been forced to pick up the pieces on
their own.

In the public imagination, psychiatry’s old ways may have conveniently disappeared as its network of institutions did, a narrative buoyed by mental health awareness campaigns that, understandably, seek to promote the image of a fully evolved and benevolent system. Yet underneath the spin, psychiatry seems to wrestle with the very same tensions that have flourished throughout its history. Person, patient. Consumer, consumed. Safety, surveillance. Science, guesswork. Care, coercion. Means, ends.

I am twenty-three years old, and I’d estimate that I’ve been on fifteen different medications over the span of seven years. Some were prescribed by clinicians I knew, some were prescribed by relative strangers in hospitals, some were prescribed to mitigate the side effects of others. Currently, I take four medications – twelve pills all up – and our mental healthcare system’s allegiance to pharmacotherapy is only getting stronger. Consultations with GPs and psychiatrists, who overwhelmingly focus on treating mental illness with medication, are either bulk-billed or subsidised by unlimited rebates, while Medicare offers only ten annual rebates for talk or practical therapy sessions. It is inevitable, then, that the seriously ill will swiftly find themselves over-medicated and under-supported.

Sometimes, the distinction between the psychiatric past and present feels entirely semantic. During a recent stint in hospital, I sat beside an elderly woman as the staff completed their hourly rounds. She was on edge, kneading the vinyl sofa with her hands, nails splayed, like a cat. When the nurse arrived, it all came out. ‘I’ve been institutionalised!’ she yelled, drawing the attention of the afternoon visitors. ‘Oh, of course you haven’t Susan, don’t say that,’ the nurse said, extending her hand. Susan pulled away, hissing. ‘What I mean, then, is that I’ve been admitted to hospital ten times in three years. Do those words make more sense to you?’

 

I AM STRUCK by English historian Barbara Taylor’s comments on the complex myth of psychiatric progress. In her 2014 memoir, The Last Asylum: A Memoir of Madness in Our Times, Taylor writes that while ‘the mental health system I entered in the 1980s was deeply flawed…at least it recognised needs – for ongoing care, for asylum, for someone to rely on when self-reliance is no option’. The current system operates as though these needs no longer exist, offering only acute fixes and ‘individualist pieties’ that make ‘a mockery of people’s sufferings’.

Taylor was a long-term patient of Friern Hospital in London, leaving just before its official closure in 1993. The fourteen-acre complex used to be home to the longest corridor in Europe – apparently it took over two hours to walk the full length of the asylum, ward to ward. The building has since been gutted and divided up into luxury apartments, four of which were later occupied by the boys from One Direction.

To the average consumer in need of brief counsel or a simple prescription, psychiatry’s facade may have scrubbed up similarly. But for a patient like me, what was once an endless corridor – dubbed by Taylor as ‘the very emblem of despair’ – is now a labyrinth of disparate services, devoid of guidance or continuity or fellow feeling. This substructure is what I would term ‘deep’ psychiatry – the further you travel, the darker your path, the harder it is to find your way out.

 

I DON’T REMEMBER very much about my first admission. I was sixteen; I travelled in an ambulance; I laughed and cried at all the wrong times. There weren’t any beds for adolescents, so I was admitted to the adult ward. It was my first encounter with any kind of psychiatry, and it swiftly revealed the public system in all its glory – the leery men, the powdered eggs, the constant wailing of the first-time mothers, the stuffy doctors, the stoic regulars, the reckless distribution of mystery drugs. Within a couple of days I’d seen more naked bodies than I had in my entire lifetime. My roommate liked to burst out of the bathroom topless, pendulous breasts flying, to frighten the nurses on the morning shift. At least two of them had to hustle her back into our room as she shouted ‘Pervs! Pervs! Leave me alone!’ For whatever reason I wasn’t too shaken. I met a lot of people I liked.

The two psychiatrists on the ward were ice cold. At each meeting they scrutinised my motives – as if a teenager might enter an adult psychiatric ward for a lark, or free teabags – while also pushing drugs at a rate that implied I was a terminal case. I didn’t get it. A few years later, I would come to find out that many of the medications I was prescribed around that time carry ‘black box’ warnings in the US, indicating that they are associated with an increased risk of suicidal behaviour in adolescents. Either out of ignorance or in the face of a system with few other accessible treatment options, doctors continue to hand them out like lollies. At the time, I certainly got the sense that rejecting the drugs for any reason – fact or feeling – would only confirm my status as a suspicious figure. So I took them, out of fear and hope. And still the interrogation continued, each question like a blade. Was I upset over a boy? Had I thought about how much I was disappointing my teachers, terrifying my parents, alienating my schoolmates?

It was during my first admission, too, that I learnt the customary psychiatric goodbye. Historically, close friendships between inpatients have been supervised and even broken up by hospital workers to prevent the emergence of inappropriate bonds or uprisings. Sandra, a muralist in her thirties, had her phone confiscated when she asked me for my number on the day of her discharge. In its place she offered a few words and a contraband hug. ‘Bye girl, good luck with it all… I really hope I never have to see
you again.’

I see Sandra in hospital the following summer, gaunt and sporting a pixie cut. She doesn’t seem to remember me.

 

AFTER MY FIRST admission, in the wake of a handful of bad episodes, I quickly learnt how to drop out of life and into hospital as quietly as possible, cloaked in euphemism. These days, I disappear into the system the way an old family pet disappears to a ‘farm’ for a good long rest. Sometimes I play the well-intentioned mother, cooking up and palming off the optimistic lie. I’m well! My doctors are just being weirdly cautious while I change my medication. In private, of course, I take more naturally to the role of the dead dog.

This is sometimes part of the allure of hospitalisation – its proximity to death. I have met a couple of patients who agree that the psychiatric ward feels like an afterlife simulation, all blank walls and spectral echoes and panels of fluorescent light. This is a useful function, and one that is easily exploited, as it affords voluntary patients a reprieve from the unique pain of experiencing illness in the real world – a reprieve from their aliveness. In this case, the doctors are just a peripheral challenge, though I often wonder if they’ve caught on – that entry into hospital doesn’t always represent a heel turn from suicide, that sometimes it might feel more like a parallel channel.

To enter the psychiatric ward is to externalise the internal, I once wrote during a particularly gruelling stay. Despite my occasional ability to tap into a blank-walled afterlife, this idea usually provokes more pain than it does relief. Inside the ward, my anxieties about my outsider status are suddenly confirmed by a succession of locked doors. I see my fragility in the plastic cutlery. My morbidity in the safety faucets. My panic in the red duress alarms. My worst fears, quite literally, are made concrete.

The culture of deep psychiatry and the disordered brain often work in this kind of neat symbiosis, organically convincing the patient of her own deficiencies. In the psychiatric ward, sociologist Erving Goffman says, ‘the patient is firmly instructed that the restrictions and deprivations he encounters are not due to such blind forces as tradition or economy – and hence dissociable from self – but are intentional parts of his treatment, part of his needs at the time, and therefore an expression of the state that his self has fallen to.’ By my second or third admission, I had already developed a kind of Stockholm syndrome, internalising the idea that I needed to separate myself from the outside world during periods of illness. If it wasn’t wrong for me to participate in public life, I reasoned, why would isolation feature as such an integral – and increasingly attractive – part of the psychiatric regime?

These beliefs spiralled out of control each time I was discharged into the community, still in the throes of illness. I couldn’t sit with my family at dinner time; I was a stranger in my own suburb. I’d baulk at parties and retreat to the host’s bedroom, finding it hard to trust myself around others. I willingly subscribed to the cult of exile, believing it was for the best.

 

THE HOSPITAL HAS granted me an hour of unsupervised leave, so I power walk to the local park, trying to beat the rain. I’ve just come out of a meeting with Dr Wilson, a kind psychiatrist with whom I’ve consulted for about three years, on and off. His uniform has stayed the same: silver glasses, a Casio calculator watch and a blue shirt with a sauce stain that seems to steadily metastasise between breakfast and dinner. Our point of discussion hasn’t changed either. We are tracking my progress with Cymbalta, a medication that I’ve been attempting to discontinue for as long as I’ve known him.

The drug’s clinical trials were wracked with controversy – one young woman hanged herself in an Eli Lilly testing lab after her dose was altered, forcing the company to disclose the earlier suicides of at least four other trial participants. Reportedly, since Cymbalta’s release in 2004, thousands of patients have developed severe chemical dependencies, a consequence of which users are generally unaware until they attempt to wean themselves off the drug. I wasn’t alert to any of this until I found myself sweating and clawing at my arms a couple of days after my last dose, wracked with paranoia. I was admitted to hospital, where I asked the staff to reinstate the drug immediately.

By the time I get to the park it’s pouring, and I cut across the oval to shelter under the awning of the public toilets as families pack up their picnic rugs and cricket sets. A few metres away, an exasperated woman crouches beneath a tree, trying to coax her son down from one of the low branches. The child is too hysterical to budge. ‘Why? Why’d you let me climb up here if you knew it’d be so hard to get down?’

 

ONCE UPON A time, I might have derived comfort in the transient, restorative vision of psychiatry that Louise Bogan presents in her wry poem ‘Evening in the Sanitarium’:

To the suburban railway station you will return, return, / To meet forever Jim home on the 5:35. / You will again be as normal and selfish and heartless as anybody else. Now, I fear that the attrition of treatment has dissolved my personality and recast my flaws, that I am selfish and heartless in ways that could only be taught to me by a series of medical dead ends. To the suburban railway station I return, return, to stare into the middle distance, to remember how I used to be. Forever Jim on the 5.35 is probably just a greasy pharmaceutical representative with a bag of free stationery.

In 2017, after a big break-up – a blunt reminder of the way that my illness had tarnished the things closest to me – even a brief return to the real world felt too painful. I didn’t know how to tally the losses. In 2018, after finally qualifying for the Disability Support Pension – a privilege I required to live out of home – I packed up and moved away from my family and friends, ostensibly to start a university degree. Privately, my reasons were more complex. I was mortified by my inability to live. As Jennifer Dawson’s character Josephine, a disillusioned inpatient, comments in the novel The Ha-Ha, ‘I wanted the knack of existing. I did not know the rules.’ I would come back when I knew them. Somehow, I would recover.

 

ONLY IN THE past year have I truly woken up to the sheer lunacy of this plan – that I’d best regain social connection through a strict regime of isolation; that I would not return to ‘real’ life until I had independently proven myself through a certifiable display of stoicism, of ‘health’. It is logic so bizarre that it could only be lifted from a single place – the psychiatric doctrine.

I now think of Susan’s outcry – I’ve been institutionalised – and our nurse’s quick dismissal, knowing full well that institutionalisation doesn’t merely rest upon a system of constant physical confinement, as in the stereotype of mid-century asylums, but also upon a system of social and chemical confinement – a system of being – that will serve the patient just as well in the outside world.

This is the specific knack of a branch of medicine that can justifiably claim every part of you, pathologising your life and selfhood in its entirety. Deep psychiatry assumes that a boundless problem – the problem of living – is best solved by a boundless institution, with full custody of your success and sorrow. It is impossible to see yourself in a way that is untainted by the dominant psychiatric idea of you. Ruby, sixteen, laughs and cries at all the wrong times.

Yet mainstream campaigns still proffer the same reductive slogans: that your illness doesn’t – shouldn’t – define you, that you are so much more than your disorder. This kind of individualist rhetoric dominates twenty-first century psychiatry, effectively shifting the blame from the service to the service user. It’s up to the patient to cling to their identity in a context engineered to break it.

I’m reminded of an inspirational magnet that sat above my old psychiatrist’s desk: You are what you repeatedly do. Excellence, then, is not an act, but a habit. I would stare at this fucking thing as I repeatedly attended appointments and trialled new medications – honing my habits, fumbling my excellence, retracing the labyrinth. It sat next to a bright red poster to which my psychiatrist possessed a matching mug: Keep calm and carry on.

 

OF COURSE, A patient with a compromised identity does nothing if not reliably generate a profit. After illness snatches away the trophies of modern life, pharmaceutical companies pledge to return them – at an undisclosed price. Like so many before me, I have faithfully surrendered my mind, body, money and time in the hope that one day, surely, I’ll find the package on my doorstep. Clearly, I am still moved by the fantasy of it all.

The weight of this sacrifice is rarely acknowledged, as it is decidedly more offensive to engage with society unrecovered than it is to be unhappily married to a cluster of sedatives or a cycle of inpatient stays. Those with complex mental illnesses are often expected to tolerate drugs that carry even greater risks, like the metabolic and movement disorders associated with the long-term use of antipsychotics. A good patient, it seems, must be willing to make every prescribed effort to salvage their status as a person, despite the fact that these prescribed efforts can shift us even further away from the norms of personhood.

Only a few weeks ago, Dr Wilson urged me to stay in hospital to undergo electroconvulsive therapy, a lengthy treatment that carries the risk of significant cognitive side effects, such as memory loss. I reminded him, perhaps for the tenth time, that I wanted to continue with university – I had fought for years to access it – and work on this essay. I needed to write, I repeated. It made me happy. He paused for a moment or two, fiddling with his pen. ‘Well, why’s the essay so important? What’s it about, anyway?’

‘Oh, this and that.’

Porridge. Dead dogs. Ellen DeGeneres.

 

ONE OF MY favourite fellow patients, Chen, is set to leave hospital in a few days. He is known as the man who single-handedly organised the hospital’s weekend table tennis tournament and the man who single-handedly dominated it. We are busy eating jelly and watching the MasterChef semi-final when he leans over and quietly confesses that his children believe that their dad’s on a ‘long holiday’, that his wife doesn’t want them to ask any difficult questions. Chen worries that he’ll never be able to retreat from the charade, so we spend the ad breaks comparing the relative merits of absent father figures – jetsetter dickheads versus manic depressives.

Chen and I often share the best nurse, Joanna, a Polish woman who comes into work wearing a suite of gold heart-shaped jewellery. Each time she checks in on her patients, she will leave them with a Joannaism – an aphorism lost in translation, a customised fortune, a telling-off – delivered in a stage whisper: The life is a bitch. We try to get on with it. You will get up now. Take or leave what they tell you. You are the most special. Sometimes they emerge more spontaneously: Most husbands are shits. Some doctors are shits. Your ego is swollen. In these moments she is the walking, swearing antithesis of a trite psychiatric magnet, and I couldn’t love her more for it.

Chen taunts me in the dinner line, joking that he just received you are the most special, despite the fact that it was bestowed upon me fewer than three hours ago. I tell him that he can claim it for the day in light of his impending discharge. I heard him crying earlier in the morning after he got the news, begging the nurses to let him stay another week – he wanted ‘more time with his brothers and sisters’.

 

PERHAPS I SHOULD have come clean to Dr Wilson about this essay. In the moment, I genuinely think I wanted to protect his feelings. At a different hospital, about eighteen months earlier, a friendly outpatient psychiatrist had introduced himself by asking about the book I’d been reading as I waited in the crowded vestibule outside his office. It happened to be Taylor’s memoir, The Last Asylum, and he murmured in interest. As we wound our way through a throng of patients, I paraphrased a few of her arguments about the current psychiatric landscape. He interrupted: ‘I guess I’ll mention now that I think it’s inappropriate – it’s…unhelpful – for you to arrive with those kinds of negative beliefs.’

For the duration of our appointment – as we discussed Cymbalta, no less – he looked vaguely nauseous, as if he’d just caught me conducting an extramarital affair while our kids were in the next room. But had psychiatry always been faithful to me? At that point I was well aware of its own – extended – flirtations: with capitalism, with murky science, with covert and overt violence, with industry-sponsored clinical trials, with death. I was sick, but I wasn’t stupid.

Patients with complex mental health issues know this brand of defensive positivity all too well. Their experience of treatment is largely built upon – and thwarted by – a series of utopian assumptions: that deinstitutionalisation is a universal success story; that isolation and its associated conditioning died as asylums did; that drug therapy has rightfully earned its hegemony over other forms of treatment or social support; that pharmaceutical companies have our best interests at heart; that change invariably amounts to progress. These fabrications, whether or not our government can recognise them as such, lie at the core of the system’s dysfunction. Before we can conceive of any kind of functional psychiatric revolution, we must first honour
the truth.

 

THERE IS A minor crisis on the morning of Chen’s discharge. Ana, the old woman in room seven, climbs out of bed at 3 am to do what she normally does at 3 pm – pace the building while chanting Portuguese folk songs at an unearthly volume. For two hours, her whoops and claps travel down the hallway and nest in every crevice of my bedroom. At 5 am I give up on the idea of sleep and head out to the dining area. Almost everyone is crowded around the table, eyes bleary, clutching polystyrene cups. Sienna, who is new and looks about sixteen, is trawling Portuguese news outlets to see if they’ve elected a new prime minister or won some sort of world cup.

‘She better be doing all this for a good reason.’

I pull up a chair beside Linh, who asks me if she smells bad after sitting under the hot recycled air for an hour, and soon we can’t stop laughing, delirious from sleep deprivation and hostile architecture and foreign ballads. Normally, in moments like this, patients have access to the great psychiatric icebreaker – the television set – but the remote is locked up until 8 am, and besides, all three of the night nurses are busy dealing with Ana.

At once, we are unanimously alert to this rare moment of privacy – so unexpected, so unpsychiatric – that we are almost cautious to approach it. Kate, who prefers to keep her hands occupied at all times, shyly suggests that she could comb the kitchenette for packets of salt and pepper to arrange into mandalas on the floor. Patrick might play the keyboard, given that everyone’s awake anyway. I tell Linh that she should stand on the table in the courtyard as the sun comes up, cursing at any pigeons who look as though they might be conspiring to break in and shit on the carpet. Chen and I will sit on the sofa, perhaps for the last time, to discuss the problem of living, to prepare for our psychiatric goodbye. Where would we start? Perhaps with a few simple truths:

The life is a bitch.

Take or leave what they tell you. 

We try to get on with it.

 

REFERENCES

[i] Heseltine, H., 1990. Left, Right Or Centre? Psychiatry And The Status Quo. 1st ed. Canberra: Australian Defence Force Academy Department of English.

[ii] Dawson, J., 1961. The Ha-Ha. London: Virago Press, p.20.

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