THE PROLOGUE

 

         According to the NIH, one in five American adults live with a mental illness. That number is surely on the rise, in large part due to the trove of distraction that like a slobbering demon dog from some Freudian confounded future sits on pixelated haunches, ready to be acknowledged, pet, played with, let out of its cage, its restingplace, where it whiles away inside the apps that populate our phones and computer screens. 

    A report from the Treatment Advocacy Center meanwhile indicates that American jails and prisons housed an estimated 356,268 inmates suffering from a severe mental illness (circa 2012). Ethics aside, this is a staggeringly high number which, if nothing else, lends credence to the ongoing narrative regarding the rampant misunderstanding surrounding mental illness in America. Its impact. Its prevalence. And the widespread mishandling of those whose symptomatic expression has blossomed into prison time rather than, and far more appropriately, diagnostic endeavors followed by a bonafide, tried-and-true treatment path. 

    I should mention: I am not looking to assign blame in any form or fashion. That is not the purpose of this document. No. I want to say, this problem surrounding mental health is tricky. I, myself, a patient and, in this instance, the protagonist of the story, am guilty of holding onto and revering as truth a host of inaccurate assumptions about the magnitude and very make of the mental health epidemic rounding the bends of America’s institutionalized healthcare racetracks. 

    For instance…

For thirty years, I believed depression was like the flu: a person caught it, was hobbled briefly by it, and then eventually managed to recover from it after being inoculated with a smattering of some of modern medicine’s more titillating varietals. Of course, my youthful ignorance also led me to champion more conventional treatment plans used by old-timers as well: chiefest, a wad of mud rubbed, scrubbed and scratched deeply into one’s scalp. Grit, I was told, can go a long way. No matter whether it be applied on the gridiron or in the space between the ears.

         Perhaps, the first sign that I myself was depressed was the suicide note I wrote at age fifteen. My mom found it in the trash, impossibly. I had torn it to shreds after reevaluating the accusations I’d hocked, rather recklessly, towards my family, and thrown it out. My mom, unbeknownst to me, pieced the note back together (she didn’t reveal this to me until shortly before I started writing this) and kept it secreted underneath some clothes stacked inside of a bedroom drawer. 

Where the depression really intensified for me however was in the workplace. At age twenty-three, I worked in the corner cubicle of a healthcare system’s administration office. The mundanity, the repetition, the lack of physical movement, and the glare of the computer screen were things I never anticipated having to deal with while enrolled in university. Summed squarely, the lack of stimuli made me feel like a disemboweled original generation iPod in 2010: empty, and devoid of any novelty since the introduction of newer, sleeker models.

         Today, I’m thirty-one. I live at home. Debt collectors hound my phone line like telematics-crazed bounty hunters. Not but two months ago, prior to undergoing an ECT procedure meant to help me get a grip on my depression, my medications gave me tremors and boiled me alive with raw, unfettered anxiety. I am currently jobless, and dependent upon food stamps for sustenance, and resemble an owl pellet, in the sense that my insides, emotionally speaking, seem to be visible to onlookers. Alas, that’s the price I pay…

A year ago, almost exactly, I was diagnosed as Bipolar II, with a side of Major Depressive Disorder. I had tried to commit suicide by drinking a concoction consisting of ground Benadryl (some sixty pills-worth) and hydrogen peroxide. The concoction was not well blended and had a gluey, oozy texture to it. It was abysmal tasting and did not work like it was supposed to.

Let me rewind the tape a bit. 

I had been experiencing intense delusions and other withdrawal symptoms, along with delirium tremens. Seeing as I was a former pharmaceutical advertising account rep, I understood these symptoms fell within the schizophrenia canon. This frightened me. Worse than those symptoms was the fact that (or so I believed) the frog man news anchor on Fox… Sean Hannity… was speaking to me directly, following my every move with those beady buckshot eyes of his as I paced the living room. I spoke to him, and the director of his broadcast, and the both of them graciously felt inclined to rebut. Together, we improvised. In the intervening intervals, television commercials urged me to run to Target for CoQ10 and blueberries, and then punished me when I didn’t obey their orders. The State of the Union Address, Joe Biden’s redemption monologue, was my brainchild. The air ventilation duct in my mother’s family room, along with Vladimir Putin, became my mortal enemies. 

         

    On the night of my overdose attempt, I had attended an Account Managers’ team dinner at one of the swankier restaurants in the Chicagoland area: RPM Seafood.

We started out with drinks. I ceremoniously went with my usual old fashioned. The rest of the group at the table, all ladies, meanwhile, hauled in martinis and aperol spritzers and other seasonal creations from the tuxedo-clad bartender shaking his tush for his audience on the main floor.

    We ordered everything. Seafood towers. Lobster. Truffle fries. Fish bearing names of four syllables, or longer. But something, inexplicably, felt off. Amidst this magnificent meal, my attention turned towards the outdoors. It was a pleasant spring night. Humid and warm for the Midwest in the month of March. In the distance, I spotted a building, lit from top to bottom in yellow and blue. The colors of the Ukrainian flag. Suddenly, the banter turned toxic. Hyper-precise but veiled orbs of verbal venom were flung at me from left and right. My head began to spin, simultaneously in awe of and panicked by the velocity at which this disjointed conversation flooded our corner table and penetrated my psychological vulnerabilities. Before we had a chance to order dessert, I stood and announced my imminent departure. It was a brief and surprising gesture. I gathered my backpack and ballcap and smoked my way out of that restaurant faster than a controlled blaze moving across dead prairie.   

    At this juncture, I can assure you that I was seriously freaked. The Zelenskyy dilemma already had me feeling geeked and confused. And the fact that this bizarre battle with foes visible and invisible, henchman of the television, had inched its way into my waking, workplace reality left me stunned.

    So, I bought a fifth of Jim Beam and a couple packets of Benadryl, dodging the inquisitive eyes of the checkout clerk. Then, I looked around for my killing field. The first place I frequented, feeling wily and giddy with moxie, imbued seemingly with a sense of cosmic serendipity, was The Wit. What a funny place to die, that, I had thought. 

    “No vacancies,” replied the fellow at the front desk when I asked for a room.

    I trundled on over to The Renaissance. Another equally worthwhile name given my well-known affinity for The Arts.

    “No vacancies,” replied the fellow at the front desk, again.

    Next, I tried the Virgin Hotels Chicago. It had, after all, been months and months since I had been laid.

    “No vacancies.”

    I took to the River Walk, surprised as a spectator at a gender reveal party, wondering what I had done to anger the God of Chance, or the Nymph of Universal Fortune, or the Cherub of Curious Blunders. Who could say, really. And so, left with no other choice, I ordered an Uber back to my mom’s, who I knew was occupied in Marcos Island, FL, her second home, and prepared myself for the end there. 

*

Following my admission to the Emergency Room, and subsequent hand-off to the psych ward, I was deposed to twelve months of Hell on Institutional Earth. A form of Hell, I should say, that was served up with a side of laughter, tears, incompetence, confusion, fear, shame, negligence, and unexpected patronage and support.

         I learned firsthand an awful lot about the healthcare system and insurance, CPAP machines and pharmaceutical and behavioral therapies, breathing exercises and plastic silverware. I had a front row seat to the scariest shitshow in America; the only front row seat I’d ever turn down again if given the chance. I doubt this is politically correct, but the food in those places still makes me constipated if I think about it for too long.

         In any case, I’ve thought hard about the act of undressing this system, and myself, and in particular, my mind, in word form like this. I’ve thought about the blowback I may receive from neighbors with obnoxiously loud snowblowers, all the therapists and psychiatry majors I may offend. Ultimately, sharing my perspective, my experience, is worth it if it helps just one person. It is worth it if these words, however impossibly, are delivered and then read and digested. There are people among us—who knows?—maybe you’re one of them—who are suffering—suffering a torturous, unjust, unrepentant and unnecessary fate at the behest of an inept and infantile mental health system.

         This, what you’re reading, constitutes the ‘allow me to move you’ portion of this overview. In the section succeeding this one, the bulk of this effort, I identify solutions for problems I encountered personally. Indeed, the dramatics above and below are borne of a restitution pursuant to only the noblest of ends. Welcome to the world as I’ve known it. If you just so happen to smirk or shudder now, then I have done the first part of my job well enough.

         Over the course of my tenured madness, I have been committed to six inpatient units, one substance use rehabilitation center, one behavioral health residential program, two sober living houses, and a handful of partial hospitalization and intensive outpatient programs. My flight path as a patient, owing to a lack of cohesion between destinations, has been virtually nonexistent. At every level of care, I witnessed—no, I felt—the clunkiness of a system at the dawn of its scientific prerogative. I was mis-diagnosed, mis-treated, mis-prescribed. Contradictory counseling around voluntary and involuntary admittance, and the ethical implications of both, which fringe upon questionable human rights legislation, was the norm.  

I slept beside people who screamed, farted, fretted, and devised military complex operations at night. Outside of the residential setting, I have never seen the same psychiatrist three times in a row. I have been forced into eating nothing but grits and toast for breakfast. I have slept on the sidewalk. I have sat and listened and shared my defeats and wins alike at scores of AA meetings. What I know now, more than ever before, is that things need to change and that these changes must be rampant and swift, and executed in an intelligent and organized fashion if we are to call ourselves an advanced society of humanitarians.

There is no excuse for removing human dignity from the recovery equation. There is nothing redeemable about treating mental illness as a lesser condition than a physical tear or strain. Or practicing a policy of “sedate and wait” and calling it “improvement”. That, I say, is wicked and corrupt. The lack of cooperation that occurs between medical providers and insurance providers does nothing but sow chaos and confusion for patients, insurers, clinical caregivers, and other administrative fellows. And please take note: this is just the tip of the iceberg. For one, I am not a clinical researcher, or a medical provider. I have only a small and incomplete sightline into what sort of gores and gaps we ought to be interrogating on a systemic level when it comes to evaluating the efficacy of clinical practices within the mental health field. I am aware of this stuff only to the extent that I have been through the psych ward ringer six times and have been exposed to more than a few care outcomes at the bottom end of the care funnel, too. 

         With that all said, there are some things that are working in their current form. The practical optimist inside of me (which is a title I just invented) can confirm that it’s not all doom and gloom:

• The people in the healthcare field, by and large, care and care competently.

• Insurance companies are incentivized, in most cases, to promote health and wellness. If you, the patient, have proper insurance, you’re in luck—the entire system centers around people like you who are insured. If, however, you, the patient, are without insurance—gird thy loins, my friend. Your pockets are about to take an absolute beating, and your care options will be vastly inferior and more limited. 

• Clinical researchers are rock stars lacking a national stage. Integrating new research into our institutions with any sort of expediency, however, leaves much to be desired. 

• Mental health expresses differently for every individual. There are plenty of therapeutic options out there, if one knows where to look. And a substantial dose of patience and fortitude can make all the difference in the world—for not every therapy is going to work the first time. 

From a systemic point of view, there are five levels of care in mental health / behavioral health. Ranging from most to least intensive: inpatient care (think One Flew Over the Cuckoo’s Next), residential (think summer camp with counselors), partial hospitalization programs (think classroom learning + detention), intensive outpatient programs (think classroom learning) and therapy / advocacy groups (self-explanatory).

While anecdotal in nature, and thus, flawed, I hope my personal gripes about each do not come across as whiny, but as helpful. Often, as a society, we adopt an idealistic view of things when it comes to solutioning and planning for success. The truth of the matter is that the patient, not the administrator, sits at ground zero. It is the patient, not the doctor, who must take the medications as prescribed and deal with the side effects. It is the patient, not the clinical researcher, who must become a self-advocate and face mental health stigma head-on, bravely, while retaining some semblance of pride and decency. The patient ought to have a say in the patient experience. Now, is that so revolutionary a thought?

 

SECTION 1: INPATIENT CARE

 

CHAPTER 1: THE PSYCH WARD

 

The lump sum of patients are wheeled into the psych ward, or inpatient unit, on a gurney, accompanied by police officers or EMTs. And that alone sets the mood for the entire experience–like a badly sung national anthem before a rodeo. In my case, I found each of my six stays to be quietly disorienting and borderline insane. Unlike the uniform nature of a game of baseball, which consists of nine innings, one mound, four bases, and an outfield, the rules and circumstances of every inpatient unit varied wildly.

In one facility, I was allowed to sleep as much as I wanted to. Another facility meanwhile locked all bedroom doors at 8:00a sharp and did not permit access again until 9:00p. A third, finally, found me fending off hordes of bed bugs at night and sleeping in chairs during the day.

Classes generally were taught to us, the pajama-rankled and the begowned, using a shuffled deck version of Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT) and mindfulness, with each of the six respective institutions selecting for itself the components it favored most, while banishing the rest to the Island of Lost Coping Techniques. Lesson plans taught at the inpatient level tended to trickle down into lower levels of care. At face value, this information-reinforcement-tactic may sound like it’s coming from an evidence-backed dictum written back in the 60s proselytizing the positive effects of repetition in learning. In reality, the redundancy almost drove me to the brink of a certain special breed of crazy. The sort of crazy that whispers in a humorless tone such absurdities as, ‘I’ll sleep 60 out of the next 72 hours and pound Ativan by the milligram in order to avoid another cope-ahead class’, or, ‘if I have to walk this god-forsaken corridor one more time I am going to punch a hole through the wall and spank a nurse so that I am restrained in a bed’.

In all, I received six championship rings. By which I mean, I attended six different inpatient units. Six different psych wards on six different, drool-splattered halls. 

In-bathroom suites featured lidless toilets, automatic lights, showers without shower heads. Because there were cameras in the corners of many of the bedrooms, bathrooms were endowed with a protective, escape artist’s aura. Sitting on the toilet became my solitary reprieve, my refuge from the watchful eye of the command center: the nurses’ station. For those suffering from paranoia such as myself, and for other anxious patients, the technological vigilance triggered additional stress and sowed distrust between the patients on the unit and the professional resources who were trying to keep us safe. 

The diagnostic component of the inpatient experience, however, was the most abused aspect of the healthcare package. I, for instance, had been diagnosed with schizophrenia, schizoaffective disorder, bipolar, psychosis, major depressive disorder (MDD), and substance-induced psychosis on separate trips to the inpatient ward. Well, doctor, which is it? Imagine suffering from MDD yet receiving a schizophrenia diagnosis. That’s the equivalent of ordering steak at a steakhouse and being served a gruffly-fileted shiitake mushroom in its place. 

One doctor, without talking to me, without inspecting me, without looking at me, proclaimed as much. Then, he prescribed to me a months’ supply of antipsychotics with the nonchalance of a parolee picking up roadside trash, a clinical swing-of-the-litter-pick-up-stick that was meant to rectify the apparent chemical imbalances of my clear and rather brash expression of schizophrenia. All told, these encounters boasted a degree of negligence I would deem criminal. Criminal, and I mean it. 

So what went right?

• The unit succeeded in keeping me safe–thereby achieving its primary goal. The cost of keeping me safe was significant, however: increased depression. And increased anxiety. And a newfound dependence upon medication. And the shame, guilt, and embarrassment of being in an inpatient setting, period. 

• The staff: psychiatrists aside, most counselors did a nice job of trying to convert dry, ineffective material into something engaging. Social workers were hit or miss. Some played their power cards ruthlessly. Others collaborated, asked questions, and the best of the bunch proactively crafted after-care plans that held promise, even if they did buck conventional procedure by meeting with me daily.

• The very existence of a curriculum is a win unto itself. Perhaps this may seem like a low bar, but I find it encouraging that professionals at inpatient facilities are paid to minister not just clinically to patients, but also holistically. As much as I like to rag on DBT and CBT and mindfulness–for there is an irrefutable and almost laughable dorkiness to how these largely eastern-principled disciplines are recapitulated for our spiritually-thirsty American ranks–I can’t deny that a good many of my institutionalized cronies benefitted from their techniques, at least on paper. In this instance, I lay my sword with the minority. Only a few of the coping strategies did I find to be effective. Those: exercise, deep breathing, stretching, visualization practices, brain teasers, goal-setting, and gratitude journaling. My mother, the queen of aromatherapy, which I also now enjoy, would be pleased to know that lemongrass and citrus essences are my favorite combination (for me, aromatherapy is a bit like ingesting a *healthy* soda… there is a nice endorphin-injected pop! that accompanies each sip, or whiff). This is all to say: coping strategies are a dime-a-dozen and preferentially distinct to each individual. Inpatient institutions that expose patients to a multitude of these strategies (and do not hammer patients over the head with them) are doing right by their patients. 

    All in all, inpatient units are mostly effective. However, they are also tremendously depressing and insulting places to be committed to. For people suffering from mental health issues, living on a sad corridor alongside a bunch of other sad folks breeds further sadness. Pharma rules, and rules absolutely, inside the hallowed halls of the psych ward. Diagnoses meanwhile are handed out like air horns at a monster truck event, devoid of discernment. Access to sunshine is restricted to the normies who live “on the outside” sans active suicidal ideation. Thus, Vitamin D levels are exceedingly low, and it shows. The air on the inside meanwhile is bone dry, while the outfits are positively heinous. 

    So what can be done? Well, I have some ideas. The goal of this level of care ought to remain the same: keep the patient safe, and improve their symptoms. But, dropping a teaser, what if we separated patients into a ‘stabilized and compliant’ grouping and an ‘unstable and noncompliant’ grouping? Each, garnering privileges, rules, and regulations consistent with what will promote the most personal growth for that grouping, without forfeiting safety considerations. 

    The hand-offs between inpatient units and other institutions and care programs, on a final note, were nearly always awkward. Orchestrated by social workers, patients must rely upon the effort of their assigned social worker for aftercare planning. My social workers, in discordance with what their title typifies, were some of the greatest, most difficult-to-socialize-with, hide-and-seekers I’ve ever played against. Have a question about the logistical qualities of small-town living without a vehicle? Poof. Your social worker will return with an answer in no less than four business days. Is there paperwork to sign? Paperwork you didn’t know existed until a fellow patient wearing upside down sandals informed you? Good luck finding your social worker to request it.

    I’ve had psych ward personnel forget to have me sign five-days* and ROIs to secure EMR transfers. I’ve been relied upon, exclusively, to generate my own aftercare plans. I’ve had inpatient units forget to order medications on my behalf, or check my insurance information to ascertain whether a certain medication may be out of my price range. All in all, the hand-off portion of the care experience at this level of care will endure in my mind as nothing short of a wholesale systemic failure. Harsh words. But, also, honest words.

 

CHAPTER 2: THE RESIDENTIAL TREATMENT CENTER 

 

    The next step down from inpatient care is called residential care. In residential, patients are admitted to a facility, generally via referral, and live in a sweepingly surveilled common area / university dormitory format. 

    Depending upon your insurer, this level of care may or may not be covered. For severe cases, it is worth it. For mild and potentially moderate cases, it probably isn’t worth it. If you are functionally independent–meaning you work at a job, and your place is not an absolute pigsty–a residency program will not address your issues adequately.

Meals were consumed in a cafeteria, off-unit. The facility employed licensed behavioral therapists, nurses, psychiatrists, licensed recreational therapists, and ward techs. The curriculum was significantly looser than it was in the inpatient setting, strangely. This is not a bad thing. Personally, I treasured it. Patients were granted ample down time, which effectively forced us to create healthy diversions that, in the most useful of cases, honed or contributed to growth in a desired domain. The facility boasted an extensive bookshelf, art supply stock, and games and puzzles galore. 

The hand-off from inpatient to the residential facility was, thankfully, smooth (rounding out the hand-off success rate to 1 in 6). I didn’t have to, for the first time upon entering a new care scenario, relate the backstory of how I ended up there. The intake specialist had my EMR handy. My assigned therapist played equal parts advocate and hardball–encouraging me to face my illness with a verve I would not and could not have mustered if left to my own devices. The psychiatrist was simultaneously understanding of my situation and also skeptical of my diagnosis. She investigated and analyzed my mental defects with an open mind, afterwards making mostly sensible medication changes. The recreational therapists (art and physical) oversaw well-devised games and lesson plans that managed, serviceably so, to connect to the CBT and DBT curricula that reigned supreme, wall-to-wall. 

    From a privileges perspective, our freedoms were intentionally limited. Phone time for example was restricted to four hours at night (a good but frustrating mandate, no doubt). Exercise time was supervised and constrained to one hour at 8:00p at night. During the week, considering it was wintertime in Wisconsin, I hardly left the unit. The staff provided us an opportunity to stretch our legs and get some air four times per day, for fifteen-minute increments. On the weekends, we were allowed to leave campus for a couple of hours, together, under supervision, and scurry about a mall, or walk a path beside Lake Michigan, or peruse a crystal shop on the outskirts of town.

    We also held night-in activities on the unit on the weekends. These were quite memorable. In particular, I enjoyed the Kazoo! trivia in which we faced off against our overlords, the ward techs. After a couple of weeks of fair and just intellectual judo, a couple of rogue inmates–I mean, patients–hijacked a personal quiz containing facts circumventing a user named “Jason”. The group of us, slinging answers into our smartphones, feigned familiarity with this virtual Jason, whom none of us actually knew. Then, the fibs began to circulate. One patient claimed him as a cousin. Another remarked a wrinkle in time in which he and Jason had gone to the petting zoo. I, meanwhile, looked on spellbound. Impossibly, against all odds, I was having fun.

    You know what wasn’t fun?

• I gained twenty-three unflattering pounds during my stay. Thank you, Latuda and Resperdal.

• Much like inpatient, the lot of us were infantilized and endowed with such little responsibility that, and this I believe in my heart (it is not a data point that has a neat and nifty statistic), the odds of relapse in the real world were amplified.

• Despite having stockpiled a stout and mutable armory of resources, this facility did not do a great job of proactively sharing tangible ways to reintegrate into society with us. I think they were under the impression that an entity in a lower part of the mental health care funnel would handle it.

Compared to the psych ward setting, the residential setting provided much more freedom to its patient yield. This instilled in me a greater sense of hope. Hope, I came to discover, was the single most underrated aspect of the entire behavioral / mental health care experience. When I had hope, I made gains. When I didn’t have hope, I got lost in thought loops, became complacent, relapsed, and isolated myself. Counterintuitive though it may seem, the act of providing more freedom, or extra leash, as it were, boosted my sense of safety, hope and self-worth. I didn’t feel like a prisoner anymore. Instead, I felt like somebody who had made a mistake, and who now had the opportunity, rather than the order, to get better. In fact, I started to want to get better. Once willpower and motivation entered the fold, my depression began to dissipate. The mania I channeled through a series of side quests: paintings, ironic PowerPoint presentations, fictional short stories, comedic comic book excerpts, piano melodies. 

There exists a fine line between having too much freedom and having not enough freedom. Residency nailed the ratio, in my mind. The psych ward, meanwhile, corrupted this line by turning people against one another (patients vs. medical staff) and by treating us as less than human.

    So, who is best served for treatment in the residential care setting? I consider it a secure reservation for the more extreme cases. For people such as myself, recovering from an intense psychotic episode. For those with hard and taxing mental health diagnoses, who may be experiencing abnormal or heavy loads of symptomatic expression. This level of care is sensible for the person who has had the mental breakdown and who can’t bring their kids to school without having their nerves unravel into a thousand spools of fine, white thread. 

Around fifty percent of the patients I lived with in the facility I was admitted to ought to have been siphoned directly into a PHP program. The other fifty percent received an effective and worthwhile treatment offering. 

CHAPTER 3:THE  PARTIAL HOSPITALIZATION PROGRAM PT. 1

 

Partial hospitalization programs likely vary considerably across state lines and by organization. Even more so depending upon whether the patient is living on premise or merely commuting for a half-day of in-classroom activities. In my case, I had the distinct “privilege” of encountering both situations, and I have strong feelings about which worked, and which didn’t—and why. 

The first partial hospitalization program I attended was an extension of the residential program that I had been enrolled in. My year of rootless nomadic adventures would find me living in another clinical-adjacent environment, after all. After being discharged from the residential facility, I was shepherded up to a remote part of snowy Wisconsin where I took my stay in a place that looked like a Canadian lodge. Or a place that Harriet Beecher Stowe might have holed up inside of to write a book. The interior of the space was magnificent, a hunter’s dream. It had enough beds to sleep about fourteen people. The main floor consisted of a cozy communal space set underneath a vaulted atrium consisting of massive, treated logs stacked one atop the other, and also featured two flyaway corridors where the bedrooms were tucked away.

Clearly outrigged for fostering connection amongst residents, the open concept design of the building featured a long Viking’s table that ran adjacent to a massive marble top island which served to separate the kitchen from the dining room. At the far end of the communal area, a television was fixed squarely above an electric fireplace that was surrounded by comfortable couches and sitting chairs. The bedrooms were, again, shared. I roomed with an outgoing and all-around affable gentleman named Leonard. Leonard, I figured, had enough charisma to fill an actor’s studio. In the basement of the lodge was sequestered a pool table, a fitness room, and an additional television area for residents to take advantage of.

Not too shabby, huh.  

I spent most of my time indoors during my stay at this partial hospitalization program—winters in Wisconsin are bitter and can be spirit-breaking. My days were generally split 50/50 between classroom learning and free time. Up the hill, a chilly two-minute walk from the living quarters, stood a gorgeous master lodge establishment. Inside were several shared work spaces for children, private areas for blood draws and psych appointments, and classrooms for adults enrolled in PHP and IOP programs. I spent much of my time with a counselor named Eric. Nice as can-be, calm, and a great listener, Eric ran the classroom like a maestro, the way a conductor simultaneously handles his brass and wood sections in a concerto hall. I enjoyed going to class every day, despite the CBT and DBT material which, for the nth time, a trained professional tried to shove into my cranium with the negligence of a brain surgeon gone rogue. 

The in-classroom portion of the inpatient PHP experience functioned like a dynamic high school class. Eric, a licensed professional who looked more like an offensive tackle for the Green Bay Packers than a sniffly clog-clad teacher, stood at the front of the class and leveraged a book filled with common source material to organize discussions. We chatted through coping mechanisms, the minutiae of our waking days, if/then scenarios, substance use troubleshooting, and much more.  

While we did not manage to resolve all my problems, of course, I did glean a whole lot of value out of listening to others explain what had them peeved or rankled, exhausted or stumbling round the proverbial watering hole at their wit’s end. I realized quickly that my problems paled in comparison to some classmates—those who had kids to worry about, spouses to appease or make up with, jail time to contend with, a record and bills, eviction notices. Whereas care at the psych ward and the residential levels primarily focused on walking through hypothetical and agnosticized problems and solutions, at PHP we dug into our individual issues with greater rigor. Conversations revolved around, say, Jen’s failing relationship. Or Michael’s inability to quit smoking. Leonard’s antsy predisposition. I found these discussions to be refreshing and insightful and revealing. I was allowed to chip in with advice, opinions, personal anecdotes, all while gaining insight into a host of issues that I may not yet have confronted, or which I may never confront, or which future me may ultimately have to face. This exercise in empathy, patience, and scenario-planning effectively parked its usefulness within the benefit log of perspective-building. Instead of talking about the Fertile Crescent, integers, or the proper application of an adverb, I possessed for the first time the opportunity to truly open up in a classroom setting and share my personal vault of trauma, doubt, and malcontent. To do so in front of a room full of people who, like I, were dogged in their determination to reconcile their pain with peace was the icing on the cake.

With mornings reserved for classroom time, I had the early afternoon and the whole of every evening to myself. I and many others took advantage of this time by lifting weights and journaling, though some, to be fair, built blanket forts and lazed like Netflix-hungry hogs before the televisions. The downtime, accompanied by the lack of exposure to the anxieties of my ‘real life’, encouraged me to form certain heartening, adulting-templated habits, such as cooking for myself. Twice a week, we were ferried to and from local grocery stores and department outlets to shop for food and other necessities. If a patient had the money to dole out for delivery food, he or she was entitled to do so. I didn’t have the means. And so, a surprising relationship between myself and a simple stovetop formed, the give-and-take of which, cooking, transformed into no small sanctuary for me. The dining table meanwhile provided a landing spot to store the childish ends of my creative whims, my messy canvases, on which I would paint and draw. 

I felt at ease in this environment. There was nothing competitive or judgmental about the folks who I lived with. We were all wounded birds, in a way, supportive of one another, and generally speaking, conscionable enough to know how to flex socially in order to avoid conflict. 

The live-in partial hospitalization program situation enabled me in all the right ways. Foremost, I felt less like a patient, and more like a human. This newfound sovereignty instilled confidence in my ability to carry out normal, everyday tasks. I no longer had to line up for food at a counter. Meds were not served to me at a specified medication window. It was my responsibility to take care of myself and attend to my personal needs. 

At this point in the care funnel, I felt the goals being extended to residents were both appropriate and warranted. After months of being infantilized in psych wards, rehabs, and residential treatment centers, I finally had been given an opportunity and some leash to carry out the functional nodes of living a normal life. Understandably, the mental / behavioral health system is designed as such that a patient must prove and earn his or her autonomy. Had I known at the outset that this was the case, I think I might have been able to relax more at the psych ward and in rehab and at the residential treatment center. I wasn’t aware, upon entering the system, that there was a ’pathway’ for patients. Also, it sure didn’t feel like I was being ushered through a ‘pathway’, either. It felt disorganized. It felt like we were making things up as we went. It felt like I was merely lucky that I was the beneficiary of great insurance (I was). Where was the connective tissue that provided me with a sightline? I would have been relieved to know that there was a plan, and that that plan would wind up with me attending to the daily strokes in a safe place like a live-in PHP. 

One final note. Those who lived on-premise at this facility, I found, made more meaningful strides than those who commuted in for a half day. I think the act of detaching completely from one’s life is still an important piece of the recovery puzzle at the PHP level. While I understand it may not seem like everybody has that sort of luxury, I think PHPs ought to be remanded to demand that a patient must become a resident. A week or two away from home, from the paying job, from the frivolous and the arcane alike, is so extremely helpful. We ought to reserve commute-ins for IOP. PHP is a time for patients to focus their healing energy on themselves. It is a long-term investment that will pay dividends over the slog of the months and years ahead. Let PHP be the place where things, where life, slows down and is stripped of the extraneous. Let PHP be the time where one reorients oneself around what the rhythms of a stress-free day resemble. Let it be a place to unwind, to take a break, and to learn and to connect with others and to do some self-exploration. We are not machines. We are humans, and humankind is, above all, kind. We feel. We must be kind to ourselves and we must remember that work and the kids and the dogs and daycare and cleaning the house and folding laundry and mowing the grass and shoveling the driveway—that these are important responsibilities—but responsibilities that mean nothing if we do not have our health. 

 

SECTION 2: OUTPATIENT CARE

    

 

CHAPTER 4: THE PARTIAL HOSPITALIZATION PROGRAM PT. 2

 

We started our days off with a meditation reading–which I found to be a useful exercise in the sense that it allowed me to close my groggy, Trazodone-punched eyes. Then, the fun part: five hours of Pro/Con listicles–for which we were depended upon for participation. The primary therapeutic topic changed every day, but that did little to supplant the monotony which stalked the room like a thousand-year-old white noise enthusiast. The material was dull, droll, and dumb. For those ten weeks of outpatient PHP, I majored in Common Sense and The Psychology of Duh!

    A very lightly dramatized version of a classroom discussion, below:

Counselor: “When you’re feeling tired, what should you do?

Class: “Sleep.”

Counselor: “What else could you do?”

Class: “Nap.”

Counselor: “Anything else? No? Well, you missed one. How could you miss this one? Anyway, well, the one you missed, you can try to close your eyes, and not nap, and not fall asleep, and…”

 

Honestly, it felt like somebody was pranking me. When I’d arrive in the morning, the first thing I’d do is look out the window to see if maybe, just maybe, a friend or foe might be standing below holding a huge sign, adorned with a big, old, “Gotcha!” Because that would have made more sense. The outpatient PHP curriculum was similar to the inpatient PHP curriculum, but because outpatient classes were flooded with people who were estranged to one another, the sense of camaraderie and peer-to-peer support observed in the inpatient program was nonexistent. In my mind, the more generalized outpatient curriculum could logically have also been renamed to, “How to Be a Human, for Non-Humans, the Pre-101 Course.” Or, alternatively, “How to Waste Time and Money: What Your Healthcare Insurer Doesn’t Know.”

If only it really was a joke.

Days started at 9:00a and ended at 2:15p. I couldn’t believe people were taking time away from their jobs and families for something so obtuse. I heard stories about companies stepping up, championing an individual, and footing the bill, despite policy. A new mother whom I befriended spoke to me about her postpartum depression. She cried in her chair nearly every day. In the drive-through line at the local coffee shop, however, she and I had a field day lighting up the program. This seemed more appropriate–the rib-rubbing, that is. Indeed, it seemed to me most of the people who showed up wanted PHP to work, and so they played the part of the enthused, happy-to-be-alive student in the classroom. Nevertheless, the truth was different. And the truth was that seldom few found the program useful. 

Now, for a few other personal gripes:

• To address another classmate’s comment, we first had to say, “My name is X. My pronouns are Y. And I’d like to validate Z for ZZZ.” How inclusively exhausting.

• Art therapy happened only once a week for an hour. It was far and away the most helpful ‘mindfulness’ seminar the program ran, in that… one could actually practice how to be mindful rather than merely talk about what it takes to be mindful.

• Medication management–there was an opportunity to drive patient adherence by making us legitimately accountable. Medications, topically, were only discussed with our psychiatrist. Odd, considering the circumstances and the crowd.

• Goal-tracking was sporadic and unenforced. The counselors in the PHP setting didn’t quite seem to know how to help. In my case, I received only a meager portion of career guidance. If anything, to me, I had anticipated that most of my time would be spent with counselors; the lot of us collaborating on reintegration plans. 

    At this point in my mental health journey, I was completely burnt out. Overnights, plus inpatient and residential stints had compounded to crush my psychological endurance. By the time I had entered the outpatient PHP circuit, I was a wreck, but a wreck who very well could have been teaching the classes. This created a woeful dynamic. I felt agitated, subdued, and unavoidably jittery whilst the therapist at the head of the class regurgitated lesson plans written further upstream (psych ward, residential). I grew slightly sour, surly, and rebellious in light of the repeat material. My attitude, which already hoisted an air of apathy, negativity, and perturbation, seemed to slip and slide from one polar instinct to the other. Over time, I became unstable–hellbent on drawing up plans to carry out some sort of personal vendetta against the concept of boredom and against the brackish backwaters of redundancy. Boredom inevitably led to the creation of some pretty ugly thoughts. And those pretty ugly thoughts inevitably led to a mental health relapse. 

 

CHAPTER 5: THE INTENSIVE OUTPATIENT PROGRAM

 

    There is almost no difference between a PHP and an IOP from a level of care, curriculum, and commitment standpoint, outside of the fact that an IOP is considered a step down (classes run three versus five hours). The majority of attendees work an intensive outpatient program while also managing their standard day-to-day. I have heard of a great number of programs which take place virtually, or from 5:00-8:00p, or later, in order to capture the working person. 

    Frankly, IOP was a waste of time. By and large, the care offering felt goalless and a bit like what you’d encounter at the DMV–meaning, it was a crusty program propped up out of necessity, whose agenda revolved more around observing a set of rules than helping people to thrive. Perhaps others may disagree, but in my opinion almost nothing novel appeared in the IOP curriculum when compared to what appeared in the PHP curriculum, or above PHP. A lot of what was taught was Google-able. And making “friends” was actively discouraged (though, it happened… and that turned out to be more helpful than anything else. In fact, I’m messaging one fellow attendee now as I write this). 

    Having passed through inpatient, residential, and two PHPs prior to entering an IOP, I expected to engage with resources that would help me acclimate more quickly to a work-life situation. I anticipated more conversations circumventing real, tangible ways to maintain balance in my desired life. I expected to be given ample opportunity to research the job landscape, and to speak existentially and candidly about my career aspirations with a counselor. I hoped to break ground and start to try to wrap my head around specific relationships, the dating world, my social groups, the prospect of ascribing to a defined routine–the practical stuff. Instead, I was forced to learn, again, coping techniques, as imagined in an abstract vacuum. IOP didn’t seem to understand its place within the hierarchy of care. It felt merely like an extension of PHP rather than a care level that was geared towards the wants and needs of its patient pool.

 

CHAPTER 6: OUTPATIENT THERAPY / GROUPS

 

    The amorphous fifth level of care–consisting of outpatient therapy and organizational groupthink–arguably functions within a sphere of influence that rests outside the jurisprudence of the traditional coordinated care hierarchy. I decided to include them here however because I believe strongly that they are important components of the treatment algorithm, as prescribed by doctors, counselors, spiritual advisors, and others. Licensed therapists and groups like AA, NAMI, SAMHSA, and many more sit at the bottom of the care funnel. Yet, they have the most intimate and untampered access to the patient’s thoughts and feelings. If something breaks at the top of the funnel, say, an incorrect medication is prescribed at an inpatient facility, the therapist is the person who must deal with and sort through the consequences of that mistake. 

    Therapists have vital real-world insight into what sort of gaps may exist at the patient level. So, if we were to rejigger the system, therapists would be a good place to start. “Play to your strengths,” it’s often said.  Indeed, by starting at the bottom of the funnel, rather than at the top, we capture the greater majority of mental and behavioral health cases in America. In a sense, this allows us to not only play to our strengths, but also to do the most good, too.

Therapists often function doubly as care providers and care coordinators. My attempts at navigating the system proved extremely challenging without a helping hand. Had I been diligent about establishing a relationship with a therapist, and had I maintained that relationship over the duration of my care experience, I’m certain I could have avoided a lot of headaches, mistakes, and time ill-spent.

    Finding more ways to partner with and enhance and empower therapists, sponsors, and counselors seems like an easy way to recalibrate a system that is built top-down, rather than ground-up. The unfortunate truth is that, as current, therapists, as a collective, function in silos. As a disjointed entity, they are a dollar, or a billion dollars, short of the requisite connective tissue demanded by the rest of the system. 

As a standalone service, vital personal health information, care history information, and provider insights are lost to oblivion. Integrating outpatient services, like therapy, and other programs, like NAMI, into the larger system seems like a no-brainer. We stand to see next to nil in the way of risk and/or downside. And the reward potential is staggering: information sharing will likely improve, preventative medical action will more often than not be taken sooner, crises can be mitigated quicker, and more people in the system will be engaged in services promoting socialization, honesty, and conflict-resolution.

 

SECTION 3: SUBSTANCE USE