Why Am I Here

My enemies weren’t human like me; they took the form of a large cockroach having antennae on the front of its head with a metal, shiny scale like skin. The insect also had wings like a wasp. I was sure it could communicate, and feel vibrations.

The cockroaches took off my clothes. They then hosed me down in a brick cubicle. They dressed me in pyjamas, the wrong way around with the buttons at the back. I was taken to a cage like cell. There was a mattress on the floor, nothing else, except for the fly on the wall.

     ‘It’s okay I won’t hurt you,’ said the fly.

My legs felt numb. I ran on the spot to try and alleviate the cramps and my pain.

What’s wrong with me. Am I insane. 

‘You won’t get better with just physical exercise,’ said the fly.

     ‘I am going to die, aren’t I,’ I said to the fly.

‘They just have theories and text book jargon. They don’t understand,’ said the fly.

There was a small square window situated near the top of the door. I pressed my face against the pane. I was angry.

‘I am not an animal; you can’t torture me and dissect my mind. I am not just another one of your experiments. I am not a guinea pig. Let me out of here.’

Am I being punished? Why have they locked me up. Are my thoughts bad, is my brain diseased. I am not hearing voices or having hallucinations. 

‘You’re all bastards,’ I said.

I noticed how hard it was to vocalise my words. I was finding it difficult to talk. I realised I was stammering.

‘You can’t even talk now,’ said the fly.

I could feel my body rattling and trembling. I could see blood pulsing on the back of my hand, under my vein like Skin. I kept on screaming.

‘Do you think you are right, to lock me up.’

‘You can’t come out, so stop screaming,’ said one of the sentry guards.

‘They will keep on giving you more medication if you continue to scream like that,’ said the fly. ‘They have sedatives and your thoughts will be lost. The medication is like a chemical lobotomy, its biochemical. They think your anger is a sign of psychosis, of madness. What ever you do, they will always see you as being mentally ill. No wonder you’re scared. You have to prove to them that you do not have an illness, that you are normal like them. Stop the medication and all this will go away, you will be free,’ said the fly.

Suddenly I heard footsteps, there was someone outside. I saw the bolted latch turn and the door slowly open. I saw my enemy again.

What good are they, these cockroaches. Don’t they cause diseases, like typhoid or polio. They are ugly, scary things and they can reproduce quickly like rabbits. Could they take over the world?

The insect came into my cell. He was carrying with his claw like appendages, a bottle of pills.

‘You have to take these tablets and I won’t move from here until I see you swallow them all.’

I began making worm like movements with my tongue. I couldn’t help it. My facial muscles were contorting. I felt my face; it was numb, mask like. I could feel my lips and they were swollen.

I noticed too that I wasn’t blinking. I couldn’t move my eyes. I knew that the prison guards, the cockroaches could look into my eyes, and know if I was insane or not.

I took the tablets even though they were difficult to swallow.

‘Don’t do it again. Understand why you are here,’ said the cockroach and then it locked the door and walked away.

‘What did I do to be in a high security ward. I ran away from hospital and went home. Is that why. I know this is a padded cell and that cockroaches like to kill all living things. 

     ‘Do you enjoy putting people through hell,’ I screamed.

Do they think I will hurt them. Are they waiting for me to change because I am not good enough, not like them. 

‘The tablets are making you feel sick,’ said the fly. ‘If your wound is left to the open air, it can heal in the sunshine. If the infection is not treated, it will only get worse. If you are without light, warmth, care and understanding isn’t it probable, that your mind will get worse.’

The fly has made a good point because it’s not just about the mind or the body and medications having side effects. It’s about treatment, and living with respect.

I felt like my muscles had seized up and my head suddenly bent sideways and I could not move it. Being frightened was an understatement. I had to scream at them.

‘My head is going to fall off.’

It was some time before the prison cockroaches came to help me. I saw one of them holding a needle. They made me undress and injected the apparatus into my bottom. I heard the word Cogentin used. Is this happening because I am mad. ‘Am I crazy?’ My head then returned to normal and I was horrified because the possibility of it happening again, terrified me.

‘I know you are in pain,’ said the fly. ‘They can’t help you, but soon you will have wings. You are going to be a butterfly and you will be able to fly and to be free.’

I will have rainbow wings and they will be like beautiful flowers, with colours never seen before. But they will cut my wings and they have already put electrodes on my head. They strapped me down so I could not move. 

‘I don’t think you should say anymore,’ said the fly. ‘They will only judge you. I have been here for millions of years, and I am of huge ecological and human importance. Don’t they know that I pollinate flowers second only to the bee. I have been responsible for the first plant pollination in the Triassic age. My larvae are used for medicine to clean wounds. They only see me as spreading food-borne illnesses.’

These cockroaches have caused plagues. I don’t have a choice and I don’t have a voice. 

‘All life forms have a different genetic code,’ said the fly. ‘You are made up of the essential elements of the earth, like everything else with hydrogen, carbon, nitrogen, oxygen. Your brain cells will develop again, duplicate, multiply. You have within you the beginnings of the world, your blueprint is written in your psyche.

You have multicellular nuclear reactors within you, charging like volcanoes and spewing forth hot tumultuous streams of gas. You are energy, a powerhouse, and the mitochondria of all cells. You can change, divide and conquer all at the same time. You have a purpose and you need to mature and breed,’ said the fly.

I tried to understand the fly and its philosophy, but the ideas were complex. I could only try to cope in this present moment.

At different times I was allowed to come out to go to the toilet. I had a shuffling walk with slow movements of my legs and arms. They felt stiff and my arms did not swing. My hands were trembling. I had a stooped posture and felt fragile with a loss of balance and control. I couldn’t coordinate my body. I felt dizzy. I was quite literally a zombie.

At meal times I was allowed to come out to the dining room to eat. I sat in a small room with three tables. There were two other human beings sitting next to me. One believed himself to be some sort of bee and kept on making buzzing noises in my ear. The other man, who did seem quite coherent, did not have any hands.

Every time I ate I would go to the toilet and be violently sick. I was getting thinner by the minute and other necessary functions of the body were not working. I suffered constipation and had to have regular enemas. I had fluid retention and had difficulty in urinating. Prior to this imprisonment when I was in the open ward, I had to have a catheter.

I knew I hated myself. I was disgusted by my circumstances; I was ashamed of my state, my mind. I expected other people to see me as worthless. My abnormality had been drummed into me, it was a core belief in my system now and I had to continually tell myself that I was a worthwhile human being.

I don’t have the courage or stamina to tell them I am okay and that I don’t need their help. I will be all right, won’t I. I know I can not beat them so I will join them, perhaps then I will get some peace.

‘I am sorry I have been bad. I won’t scream anymore. I will do anything you want, but please don’t hurt me.’

I think they recognised my acceptance of my illness or their treatment of me. The only likely way I was to survive was to agree with them. Tell them that I do hear voices.

This eventual agreement with their ideas, my acknowledgement that what they were doing was right, changed my situation. The cockroaches stopped questioning me like the Spanish inquisition. I could return to the open ward, but I knew I could not leave. I was left in peace to an extent. I was trying to be good, to listen to them and by all standards comply with their measures.

The fly had told me that cockroaches weren’t all bad. That they were an important part of the food chain and were a source of food for different organisms, like birds and mammals. They also played an important role in breaking down plant material.

None the less, my brain felt like a festering sore or an ulcer, and it was gradually growing, eating my flesh.

I am fighting an enemy I can’t see. I feel like I am pushing a wheelbarrow that is heavy with infectious flesh to the top of a hill but having the barrow continually sliding back. I have to lift its arms again and again, like continually having to walk through a revolving door.

I was sitting on the mattress trying to understand time.

Is it morning or night and how many hours and days have passed.

As I was trying to understand my plight, a sentry cockroach came to the door. He pushed back the bolt.

‘You have to see the doctor now.’ I knew that doctors could change your life, and how important it was to try and keep ones sanity. The alternative was too frightening to contemplate.

I sat and waited in a room that had a desk and chair situated near the window. I saw a glass plane, and I knew it was a mirror, for others behind it, to see through. They wanted to inspect and observe my behaviour and responses.

It was not long before a very large cockroach entered the room.

‘How are you today,’ it said.

‘Oh wonderful, I am really liking it here.’

     Is that a good response.

     You have had a very long admission,’ it said.

     ‘Yes but I would really like to go home.’

     ‘That’s the problem. You just can’t run off like that when you are detained.’

     So is that the answer, to be locked up. Animals are treated better. But then cockroaches are not treated very well either.

     ‘Am I psychotic.’

     ‘Yes your mental state has been impaired and treatment with medication has been unsuccessful. We have tried major tranquillisers and antidepressants such as imipramine, fluphenazine and haloperidol. Even shock treatment has had little effect.’

‘I want to leave.’

I could hear my voice and I was talking in a very slow manner.

I got up and walked to the door.

‘I want to leave,’ I repeated.

I tried not to make eye contact with the cockroach, because it could see in my eyes, the possibility of insanity.

‘There is no where to go, come back and sit down.’ I had to obey orders, because the consequences could be terrifying if I did not.

‘I can see a bird outside the window and I feel down in the dumps. I think I am going to die. I am swallowing my tongue and there is smoke coming out of my ears.’

I saw the cockroach writing down notes.

‘I am hearing voices in both ears saying ‘hello’ and I am hearing a voice saying that I am dead and that I have to put my hat on.’

‘What do you hear when the television is on. Are the messages only for you.

I thought about that question.

     Don’t all people hear voices coming from the television. It isn’t specifically talking to me, or is it. 

I went back to my cell. I knew that I had delusional thoughts. I was intelligent, or had some insight to understand my circumstances.

I was discharged soon after, to go back to the open ward. Life was not easy living in a public mental health facility. All I could do was to refrain from any communication. I did not want to incite further action. Restraints could be used, with medication and tranquillizers and also the possibility of detention. This behaviour to not talk made my life worse. The cockroaches saw my silence as evidence of a psychosis. I was given more medication.

I didn’t talk to the fly anymore. I had always wanted to go home, to leave the institution, the sad and cruel treatment. I did slowly get better, leaving the institution and living in a normalised environment at home.

I had a second chance at life. I could leave the past behind, but unfortunately my world was impregnated with fear. I had anxiety issues that would not go away. I believed I was not like others and if I did anything wrong I would be thrown to the wolves again.

My psychosis was real but wasn’t it a logical reaction to the environment I was living in. Wasn’t it understandable to be paranoid, to live with the fact I may be locked up again, to continually be traumatized.

Treatment and Progress

Initially Alice Footer was fully orientated in person and place but not date. She had impaired insight and rapport was difficult because of her blunted affect, thought disorder and perplexity. Physical examination was normal except for Parkinsonism symptoms and enlarged pupils which are side effects of the medication.

Alice appeared quite depressed and distressed, but this aspect of her mental state seemed to improve with time, until at the time of discharge her affect although labile was most fairly normal.

Eventually lithium was added and she became more obviously affected by the side effects of haloperidol. This was changed to perphenazine and over the next few months she improved somewhat, although she remained thought disordered with rather grandiose delusions and a few angry outbursts up until the time of her discharge.

She was having regular long weekends at home and eventually came to resist being returned to the ward. Arrangements were made for her to be discharged into the care of her mother on the understanding that she can be returned for admission or for respite for her mother as necessary.

Investigations

Complete blood picture normal. CT head scan normal. EEG showed an excess of low voltage fast activity which is non specific or maybe related to medication. The EEG was otherwise in all respects normal.

Medication on discharge

Temazepam at night

Prothiaden at night

Lithium morning and at night

Senokot to relieve constipation

Benztropine morning and night

Lorazepam prn (when requested.)

Perphenazine morning and night and prn

To see doctor regularly in outpatients.

The National Mental Health Care Organization has a position statement, wanting to end seclusion and restraint in Australian Mental Health Services.

Seclusion is the confinement of the consumer at any time of the day or night alone in a room or area from which free exit is prevented.

There are three distinct types of restraint – physical (e.g. manual, handcuffs, harnesses, straps, chemical (e.g. sedative medication) and emotional e.g. fear of expressing views.

The key factor that differentiates seclusion and restraint from other forms of care or medical treatment is intent. Seclusion and restraint are often used to restrict the movement or behaviour of a person because of a failure to provide proper mental health care. Seclusion and restraint are being used on a daily basis, despite the evidence they can contribute to negative health outcomes.

Seclusion and restraint is used at unacceptably high levels. It can be an avoidable and preventable practice. The treatment of those who suffer is commonly associated with human rights abuse. It is not an evidence-based therapeutic intervention. It causes short and long term emotional damage. Such therapy is an inhibitor of developing trust and respect between consumers, carers and clinical staff.

The trauma of seclusion and restraint contributes to consumers’ fear of treatments and they are much less likely to seek help again if subjected to seclusion and/or restraint. Similarly families and/or carers may feel reluctant to seek treatment for a consumer.

Unless alternative locations for care and services are established, people requiring mental health care will be forced to attend psychiatric units which are notorious for their use of seclusion and restraint – not as a measure of last resort, but as the default means of keeping order.

Consensual treatment is the ideal form of therapeutic care. By allowing patients to make decisions, enhances the psychiatrist-patient relationship and patients gain greater trust and confidence in the treating psychiatrist. It increases motivation for rehabilitation, as patients are said to respond to better treatment if they are explicitly involved and internally motivated to comply with treatment as opposed to being externally coerced.

Attracting and maintaining a dedicated mental health workforce will be hindered if the care provided continues to be associated with patient harm rather than positive health outcomes.