Forty thousand people used to live on the grounds of Creedmoor State Hospital. It is a sprawling and imposing complex in the middle of Long Island, just at the outer edge of Queens, New York.
There is a single large building, the hospital proper, which follows the same floor plan as every other state psychiatric hospital. The efforts of the WPA built these structures. The government used the same plans for every state hospital to save money. The Surroundings were also hulking structures. A retinue of older, more baroque, and less industrial buildings stood ready. These were built with rough stones that we remember in black-and-white pictures. Many such buildings make up the complex on the grounds of Creedmoor Hospital. Some of these are not empty; some have been converted into housing for patients discharged from the hospital. One of the buildings, close to the compound's center, houses the mental health court. In this courtroom, Queens County pleadings are adjudicated every week. These are among the more literal prayers for relief of all legal questions—those regarding involuntary admission to a psychiatric hospital. These litigants can’t leave without a judge saying so. They are unfree.
I was in my second year of psychiatric residency, and I had to come to witness the hearing for one of my patients, for whom we had come to seek a court order for “medication over objection.” This was before the end of October 2012. The air had begun its annual crispiness in earnest; the grass was dying. Most of the leaves had fallen, absent some sickly obsessive stragglers who hung on for reasons understandable to none but the wind. There was a pervasive autumnal quality to both buildings and season. The ADA accessibility of the court building was not foremost in the minds of the original architects. The ramp was an afterthought. The stairs were steeper than reasonable these days. I entered the building, walking a few steps behind Dr. Alan Mendelowitz. The ceiling height was vaulted and would be considered absurd in any building built these days. The courtroom is at the end of the hall, and it looks like any other courtroom—tables for defense, the state, and rows of Spartan benches, on which conflicting prayers were doubtless offered.
“You probably won't have to say anything,” Dr. Mendelowitz said in his low, calming voice. He noticed how nervous I was…perhaps because he’s an excellent psychiatrist. New York State has draconian involuntary commitment standards compared to other parts of the United States. For example, on the say-so of one emergency medicine physician and another doctor the next day, you can be held against your will for up to 15 days. The situation needs to be dire; this is called an emergency admission.
Similarly, if the situation is less life-threatening, but there is an applicant--this can be a nursing administrator or family member--as well as two licensed physicians and a board-certified or board-eligible psychiatrist at the receiving facility, you can be held against your will for up to 60 days. This is called a “two PC”—short for two physician certification. It is where the term "certifiable" comes from when we are discussing insanity.
None of our ability to admit patients to a hospital against their will gives those physicians the right to force medication into the bodies of others. Only a judge can order medication over objection. Most of the work for involuntary admissions, which was not trivial, is about persuasion. It's a coercive interaction: if you take the drug, maybe you can get out quicker. Some patients take the deal, but others hold out, and it was for one of those individuals that we found ourselves in court that day.
The case before my patient's case had a moment of absurdity, at least to me. I looked up from my notes; I heard the judge exclaiming:
“ I'm not granting this; psychiatrists are all a bunch of Nazis.”
That patient had his petition to be administered medication over his objection denied. It made more sense why we only utilize this as a last resort. This judge, at least, was a fan of personal freedom, even when it meant freedom from treatment for a psychiatric condition.
There was a problem, both for our patient and for our case. We had gone to court to request medication over objection. But there is a practical issue: you can't force a pill down someone's throat. Maybe you can once or twice, but none of us want to. We were unwilling to take the steps necessary to force someone to swallow a pill every day. In the case of injectable medicine, especially one that only needs to be given once every couple of weeks or maybe even once a month? Well, that's something where you can get the team on board with using physical force, plus the force of law, to get medicine into somebody’s body. But the patient we had to care for? Their illness didn't have an easy answer that came in an injectable format. So we were going to argue in front of a judge to obtain a court order to force somebody to take medicine. We also knew that this order would not be enough to force the doctors and nurses to do something so coercive. The necessary medicine only came in the form of an oral pill. The only medicines we could inject wouldn't be very helpful for this individual’s condition.
It was a court order for the impossible. We were unwilling to be as coercive as necessary to enforce that court order. I'm not going to shove a pill down someone's throat. No matter how much I think it's necessary. Neither was anybody else. The whole thing was unfortunate. This was a chess move— the court order, we hoped, would be the thing that allowed persuasion to work. We essentially were asking for a court order that allowed us to say… “C’mon!…take it already!”
I learned in the course of that morning that judges are not psychiatric professionals. They are not making medical decisions about what happens. They're looking at the legal issues in front of them and making some gut check about what to do that boils down to "Is the person before me completely crazy?”
The individuals who held it together in the courtroom seemed to win pretty frequently, no matter what the medical history indicated. Winning meant they got to leave the hospital and not be forced to take medication—we would usually discharge patients who won the right not to take any medicine. So even for them, winning ended up being losing in their life, at least from the perspective of the psychiatrists. Some of the people petitioning the court acted, frankly, crazy. There would be yelling and screaming in the courtroom. There was sometimes flailing on the floor. In those cases, the judge, no matter what his feelings about the medical discipline of psychiatry, would rule in favor of medication over objection or involuntary psychiatric hospitalization’s ongoing role.
This seemed like a crazy system—crazier, by far, than the delusions or mania or depression that we came to litigate solutions to. There was expertise in the room. There were strong feelings. But the final call came down to somebody with no medical expertise, only expertise in the law, and his judgment was based on years of experience. Did the person before him seem like they could hold it together?
If they seemed anything other than completely crazy, they got to leave the coercive setting of the hospital and return to whatever state of dangerous unwellness that led to their involuntary psychiatric admission in the first place.
The difference, to me, is that this absurdist use of legal systems for coercive “c’mon, the judge said so!” conversations later, the lack of medical expertise in charge, and its apparent unwillingness to meet anyone where they and their illness were at? These insanities were all concocted and carried out by people who were not, at the moment, adjudicated to be crazy themselves. It was a crazy system created by the “sound of mind,” which made even less sense to any astute observer than responding to voices inside your head. The patients heard voices telling them to scream out about a conspiracy—the judges and doctors had no such excuse.