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Published On September 14, 2017

POLICY

The Unwelcome and Unwell

An excerpt from a new memoir by Elizabeth Ford, who reflects on nearly two decades of treating patients in New York City’s correctional system.

On any given day, the New York City jail system, with its hub on Rikers Island, manages more than 9,500 inmates. About 1,000 of them have serious mental illnesses, a number higher than the total capacity of all inpatient psychiatric units in the city.

Elizabeth Ford serves as chief of psychiatry for New York City Health + Hospitals' Correctional Health Services. On the 19th floor of Bellevue Hospital, in a maximum-security inpatient psychiatric unit, she has for 17 years assessed and offered treatment to patients who may be violent and are often in need of more care than they are likely to receive. “The mental health care system has often failed them, and now the correctional system is supposed to step in,” she says.

When the experience began to wear on her, she started to write. She recently released a memoir, Sometimes Amazing Things Happen. “Sharing my experience and evolution was my chance to allow people to see the patients as I do,” she says. “These are men who are struggling to survive against overwhelming pressures: poverty, abuse, homelessness, lack of education, serious mental illness, drug use and public opinion.”

Ford treated many patients with schizophrenia, bipolar disorder and other challenging conditions. She also encountered mental problems that her patients didn’t arrive with, but were the product of prison itself. “There is constant anxiety, stress, fear, disordered sleep-wake cycle—many people will sleep in the day and be awake at night—separation from support networks, exposure to trauma and lack of autonomy. All of these are profoundly toxic to emotional well-being.”

And some of the patients she saw defied neat classifications. In this excerpt from Sometimes Wonderful Things Happen, Ford describes Peter, a troubled inmate, and how his lack of clear diagnosis keeps him from receiving the long-term observation and care that would improve his chances at recovery.

I hear Peter before I see him.

“Hey, you over there, shut up so I can think!” he yells loudly from his intake cell. I can also faintly hear another patient rapping about sex with aliens. He must be the target of Peter’s vitriol.

“Can’t you get him to shut up?” Peter whines. I’ve made it to Gate 3, just before the hallway that leads to 19 South, the forensic medical-surgical service. The individual intake pens for all the “psychs” look out on this hallway. I can see Peter’s ESU officers leaning against the hallway wall with their arms crossed, shaking their heads dismis¬sively at Peter’s complaining. They don’t see me just yet.

Three years after I first met Peter in this same holding area, he is now perhaps the most difficult and well-known patient incarcerated at Rikers Island. He has been in and out of the jail for more than half of his thirty-one years.

Peter has become infamous during his time in the box. He has racked up more than 800 days of punitive segregation, mostly for as¬saults, but also for serious acts of self-injury, like cutting his wrists with loose screws from door hinges and swallowing forks and batteries. He is like a caged animal when he gets out for his one hour of exercise—all of his pent-up frustration and rage lets loose on whichever unlucky officer escorts him outside. In the twisted world of jail, where there isn’t much to be proud of, Peter contends for the honor of most feared inmate.

Rikers Island sends Peter to Bellevue every so often so that the jail staff can get a break from him. He is definitely sick, but he doesn’t fall neatly into any diagnostic category. It is hard to figure out where he be¬longs in the system. The jail thinks he is too “behaviorally dysregulated” and suicidal to stay there; the doctors at the hospital usually think that he is too manipulative and aggressive to be here.

During an admission to 19 West, about six months before, he apparently made it a few days before he was found with a shank under his mattress. He used it to cut his arms, and threatened to kill himself if his doctor sent him back to Rikers Island. Even that wasn’t enough to keep him in the hospital. The discharge summary read, “He has been evaluated and admitted multiple times, and his behavior has never been seen to be a function of a major mental illness.” This is code language for “We don’t understand him, so we can’t treat him.”

Psychiatric hospital admissions are a largely subjective endeavor in New York State, especially when the patient is in jail. The legal paper¬work that can force someone in against his will mentions “alleged men¬tal illness” and “likelihood to result in serious harm.” Patients who want to be in the hospital, and can sign in voluntarily, need to have a “mental illness for which care and treatment in a hospital are appropriate.” None of these terms is clearly defined in the accompanying statutes, so local hospital customs dictate who gets in and out.

Patients who present with clear and classic “major mental illness”— schizophrenia, bipolar disorder, major depression—typically get ad¬mitted and stay until their acute symptoms subside, about two to four weeks. Some patients stay longer because we are worried about what might happen to them when they go back to Rikers Island. It’s not the same discharge plan as leaving a regular hospital unit and heading home to your family. Patients without classic mental-illness patterns, patients who are a complicated mix of pathology and learned behavior, patients who are aggressive for reasons that are not easily obvious (like paranoia)—all are hard to treat. There are no medication algorithms, no behavioral plans, no quick fixes. Doctors don’t like to fail, and they don’t like to feel helpless. So someone like Peter, who can make even the most dedicated doctor eventually feel like a helpless failure, is rarely welcome on an inpatient unit.

The scariest thing about Peter is that he is fearless. “No one can do anything to me that would make my life any more miserable than it already is,” he told me the last time I saw him. 

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