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.


  1. Chani E.8:10 PM

    You have eloquently spoken about a number of “hot topics” and I am touched by your gift to relate to a reality that many of us are frightened of. You have told a truly human story; it makes me wonder how much I would listen to the words of demons if I thought I could save the world…….

    Thank you for sharing your insights into this world and providing me with the opportunity to remember those who are so often forgotten.

  2. Anonymous8:06 PM

    Thank you for sharing that news report, as well as your blog. I agree with your thoughts regarding the case, and the fact that no one can be blamed for the outcome, however tragic it may be. Kyle's story reminds me of the case you told me about where a woman died at the airport under police custody, en route to rehab. It is so unfortunate that the only psychiatric patients to make it on the news are those that are
    violent or threaten violence even though this is not representative of the population we work with. No wonder there is such a stigma with the label "mentally ill". Do you think the outcome might be different if police received psychoeducation?

    Firsthand encounters with patients suffering from psychosis has been
    truly eye-opening this year. I feel like I have a (slightly) better
    sense of just how much they must be suffering and it really is
    heartbreaking. We get a glimpse into the nightmare they live within. How lonely, terrifying, and hopeless it must feel. I can't even imagine. I guess we in the mental health profession have to hold onto the hope that patients stay medication compliant and have supportive, attentive people surrounding them.

    Thanks again for sharing.