Wednesday, November 28, 2007

Blink and ya missed it

This past summer, traveling along Route 50 between Lake Tahoe and Sacramento, we passed the town of Kyburz, CA. I suppose you can call it a town, I mean it is on the map.

A few indicators of how small this municipality is:

It was named after the postmaster (Mr. Kyburz, I presume).

To get from Kyburz Drive to Kyburz Drive, you take Hillbilly Lane.

But the best sign of how small the place is, well, a sign. A single sign on a store on Route 50 proclaimed:



Tuesday, November 13, 2007

Thoughts on psychosis

Some details have been changed to protect the confidentiality of protected patient information (Thanks Ariel for the consult).

Leaving the hospital right after my session with a remarkably insightful young man who some time ago, in a psychotic and drug-intoxicated state, shot and wounded several police officers, I heard a report on the radio about the developing case of Khiel Coppin. I'm sure news reports will be more comprehensive by the time you read this, but for now you can check out the story here (be sure to read the transcript of the 911 call) and here.

Basically, Khiel, an 18-year-old living in Brooklyn, was killed in a confrontation with police. He had stopped taking his anti-psychotic meds and decompensated. His mother called 911 because of his threatening behavior. He can be heard in the background saying he had a gun. The police responded and Kyle ignored their orders to stand down and surrender. He threatened them with a knife and then brandished something from under his shirt. It was a hairbrush.

People will blame the police for firing 20 shots at him (10 hit their mark). I don't blame the police. I don't blame Khiel. I don't blame his mother. It's just so sad when this happens. No one is directly responsible. There are only victims: the ill, the police, or in the case of other patients on my ward, a father perceived to be a robot sent by the CIA, a great-aunt who was believed to be turning into a witch.

I work with people who've committed horrific, violent crimes with incomprehensible intensity and purpose. Were these people not psychotic, they would be tried, vilified, and incarcerated. Thankfully, the law recognizes their impairments and commits them (usually) under Article 330.20 of the Criminal Procedure Law (CPL), otherwise known as "not responsible by reason of mental disease or defect."

In the short time I've served on my externship, I've come to understand two major concepts:

First, when you encounter in the news someone who is arrested after committing or attempting an exceptionally violent act (like this recent case), you can usually count on reading the words "motive unknown." You can also expect that person to fade from the media's eyes. But he (or she, though usually he) doesn't disappear. He gets swept under the rug. I work at that rug. They appear on the news radar when their actions are salient and shocking, but they often get better with medication and therapy. I often encounter incredulity when I relate the story of a given patient who committed any given -cide, who is doing really well and is heading towards discharge.

Which leads me to my second discovery. These are regular people, though ill. They are not hell-spawn or terrorists and they are not sociopaths
(usually, though some of our patients are). They see and hear and experience as real things we only encounter in horror movies, and worse. When psychotic, they can feel terrified, entirely overwhelmed, with no one to turn to, and especially, no one to trust. If I were seeing demons all around me, my grandmother were the devil and angels were telling me to kill her to save my life and the world, why wouldn't I follow through?

When they are treated and come out from within the delusions and hallucinations, they can realize what they've done and they express a remorse that can be existential and eternal. One patient is reconciling with his mother for killing her mother. He is working to stay healthy and lead a productive and fulfilling life in the community. He says, "I realize what I've done. I'm horrified at what I did, I'm angry at myself, and I pray for her soul everyday. I have two choices- I can kill myself or try to move forward with my life. I choose to live. I don't want that ever to happen again and I'll never go off my meds." And he means it.

When talking about the kind of people I work with, I'm often asked
whether we rehabilitate them to the point that they can then begin serving the appropriate jail time. That would be a terrible thing. The law recognizes that their crimes were not committed with an intact mind and thankfully does not punish them for being sick; it tries to ensure they are helped to heal and to cease being a danger to themselves and others. When a person like that becomes well, he is not the same person who committed the crime and doesn't deserve to suffer the criminal consequences of the act.

It is important to know that a very small percentage of people with psychosis are violent or act violently, but when I work with these cases or hear about them on the news (and I feel like I've been hearing more and more of them), it makes me so sad.

UPDATE: A follow up post on another tragic case.

Sunday, November 04, 2007

Just another day on the road

I've never experienced another human being willfully and intentionally try to cause me grave physical harm and quite possibly death. Until last Wednesday.

I was doing one of my usual commutes (school, externship, and research take me different places every day) that morning and was driving over the bridge at 9:45, in the right-most lane. Because of construction, the lane was closed ahead of me and I had to merge left. I was running out of road, but found space in front of the blue dump truck to my left. I signaled and merged in, and he HONKED. He had been going pretty fast and was right on my tail, so I jerked back into the right lane. I sped up to make some more clearance, and merged in again. He sped up. I brake-checked him to slow him down (until about 20 seconds later, I thought one of the scariest things was to have an 11-ton dump truck bearing down on you), and he got mad.

The lane to the right had opened up again, and he passed me- dangerously. I had to brake hard to avoid him smashing the front passenger side of my car. So now I'm behind him in the middle lane and starting to realize that he's a little nuts. I went into the left lane and tried to pass him, but as I sped up, he jerked his wheel into my lane. I had to slam on the brakes to avoid being crushed into the concrete divider or flipping over it into oncoming traffic.

Like a faucet opening full throat, adrenaline carried a primal, existential fear to every cell of my body. Thankfully, I've been driving long enough that I'm able to hold my own in tight situations and remained (behaviorally) calm. He had slowed down to antagonize me and I had a patient to see at the clinic, so I didn't want to trail off behind him. He was watching me intently in his driver's-side mirror, so I picked up my cell phone and pantomimed a phone call to the police, hoping to maybe intimidate him enough that he would back off. I should have actually called. He picked up his phone and I didn't want him to see my license plate, so I moved behind him again, in the middle lane.

I followed him this way off the bridge and onto the expressway, waiting for an opportunity. After another mile or so, the road curved sharply to the left, and there was no one in the left lane. I put my accelerator to the floor and passed him on the inside of the turn- barely. Again he tried to slam me into the divider. I got by with my car 1/4 in the left lane and 3/4 on a rough, narrow shoulder, riding up right against the divider.

I zoomed ahead, keeping sight of him in my rearview mirror and scanning the side of the road ahead for police or highway patrol. Where are they when you need them? I got off at my exit and was stopped at a light with a view of the expressway behind me. I saw him coming and got a quick glimpse of the side his truck as he passed:

8 9 3 9 3 0 8

I had dealt successfully with the situation, or at least survived, but only afterwards when the thought crossed my mind, "He tried to kill me!" did I get really shaken. I was glad my patient didn't show up, because it would have been very difficult for me to function in that session (though not as difficult as the session I had with a patient 30 seconds after receiving a call that a friend died unexpectedly of a brain aneurysm), and I was also mad at the patient for an additional no-show/no-call. I had left earlier and had to deal with this dump truck to see him and he didn't even meet his commitment.

I searched online, trying to find the company that operates that truck, but came up with nothing. PLEASE CONTACT ME IF YOU CAN PROVIDE MORE INFORMATION.

By the end of the day, the memory seemed so surreal that it provided a functional emotional remove, for the time being. On Friday, I went to my local police precinct to inquire about the utility of filing a report. The desk agent told me it was just road rage and there was nothing to do unless our vehicles had made contact. When I told her that this isn't about a motor vehicle accident, but that this person should not be allowed on the road, she said that he might say the same about me.

In the eyes of the law, this was a benign, everyday occurrence. I now have a greater appreciation of all the "unreported" incidents that qualify statistical presentations. In my eyes, I chanced to meet a psychopath (and I know- I work with his type and worse at the psychiatric hospital) who clearly had no concern for causing a serious accident, and apparently not much more concern for causing my death.

This story is not the truth, it is my defended representation of what happened that day. I know that I played a role in provoking this person and I don't hide from that, at least within myself. But I can also be honest with myself and realize that his reactions were unconscionable and disproportionate.

Attempting to file a police report was one step towards finding closure. This post is another. But the one that affected me most profoundly and unexpectedly was in shul this past Shabbos morning, when I recited the bracha of gomel.

In the times of the בית המקדש, those who survived peril offered a sacrifice, a קרבן תודה, in thanksgiving to HaShem. In our time, we cannot offer korbanot and instead recite this blessing before a minyan (preferably including two wise men, as it is written, וירוממוהו בקהל-עם ובמושב זקנים יהללוהו):

ברוך אתה ה' אל-נו מלך העולם
הגומל לחייבים טובות
שגמלני כל טוב

Blessed are You, O Lord, our God, King of the Universe,
who remunerates the culpable with good,
so You have repaid me with all good.

I thought I had been doing better three days after the incident, but as I stood before the whole shul and clearly recited the bracha, I was swept up in the emotions again. A couple people were sensitive enough to notice that I was not discharging my obligation after flying back from overseas, and they asked me about it.

Ultimately, processing the experience with others (repeatedly) has been a boon to my getting back on track. Thank you, everyone.

Addendum: As you may have discovered in the gomel document linked above that only someone who was in a serious, life-threatening accident makes the bracha. Someone who was almost in an accident does not make the bracha (with 'שם ה).

As Rav Bick [sick [sic]] told someone who came to him asking if he should make the bracha after a large tree branch fell right where he had been standing a minute before, "This morning my wife ironed my pants. If I had been in them..." Ergo, I should not have bentched gomel with God's name. I did so based on my interpretation of an otherwise murky threshold of danger the bracha requires.