Directed by Raymond Depardon (2017)
At the Museum of Fine Arts, Boston, Annual French Film Festival, July 13 & 14
Special to the Boston City Paper by Joseph Spilsbury
This beautifully captured documentary film by Raymond Depardon was truly sad to watch. I felt a deep empathic emptiness, a sense of hopelessness and helplessness, like how I imagine the patients must feel as they take their turns sitting before the judge, again and again, accompanied by lawyers, and getting shut down each time. Not one is released, and many have been locked up for months or years. I felt more striking sadness watching this film than I do on a daily basis working as a therapist at an inpatient psychiatric hospital. Having worked at one of the only remaining Massachusetts state hospitals for one year, as well as two private acute inpatient psychiatric hospitals since, there is much to compare between how things are dealt with clinically and legally.
For one, the patients in the film are locked up for 12 days (that is a long initial time frame) before they even have the right to see a judge and present their case; and as the film portrays, they seemingly are always kept for further evaluation and treatment. The judge already knows the verdict, though still asks the patients, and their lawyers, for their thoughts, before deliberating the conclusions that the psychiatrists have already made beforehand. In the film, not one patient is released during this court-like process. The torment is palpable.
Here in Boston, and in the State of Massachusetts, almost all patients are brought to inpatient hospitals on a Section 12, which can be done by a police officer, social worker, or psychiatrist. This section implies that the person is a danger to themselves or others: that they have likely attempted suicide, had an overdose, threatened to take their life to a family member, or maybe discussed the idea or a plan with a therapist; or simply stated it at the wrong time and place, oftentimes under the influence. A Section 12 is basically one of two things, suicidal ideation or homicidal ideation, and it is usually in the hands of the police to make the judgement call and get the person to an ER for a clinical evaluation.
Under a Section 12, once a person gets to the psychiatric hospital, they have three days (one quarter of the length of time shown in the French hospital in the film) before they have to sign a “conditional voluntary,” stating they will work with the treatment team, comply with medications, go to group therapy, and meet with their social worker to figure out a plan for discharge. This can be an extremely complicated process, and messy. The majority of patients retaliate against treatment and sign a “three-day notice,” because they do not want to be kept locked up; they often want to leave immediately. The patients have the option to “rescind” their three-day notice and sign the conditional voluntary; but if they don’t, then the psychiatrist is bound by law to take them to a court commitment hearing, which if they lose (oftentimes the case), they are legally bound to the hospital for up to six months—and if they don’t get discharged before that allotted time, they are sent to a state hospital.
12 days is a long time to wait before hearing any judgment on an individual’s case. The average total length of stay at my hospital is about two weeks. Some come in and out in a few days or a week, some a few more weeks, and occasionally we have a treatment-resistant person who ends up living in our walls for months on end. In the three years I have worked at my current hospital, I have seen only three patients stay the entire six months and get transferred to a state hospital.
With the demographic I work with, racially and ethnically diverse, though a generally low socio-economic status, many people come from very complex traumatic backgrounds, have experienced physical and sexual abuse from a young age, grew up in gangs or with violence on the streets, and in many cases, have significant criminal backgrounds. Though we are not a licensed “dual diagnosis” unit, still 80–90 percent of all patients I encounter are addicts, and many are poly-substance abusers. A decent percentage are homeless, with no roof over their heads on the outside, with nowhere to go, which makes the job of the social workers challenging.
We try to set up a safe discharge plan and get them out of the hospital as soon as they are stable and can care for themselves. This is the ideal, but it is not sustainable. Mental illness is chronic, and unless individuals are aware and in full acceptance of their condition, they will likely be noncompliant with treatment as soon as they are released. We try our best from a multidisciplinary team approach, with the medications and the therapy; and the social workers often set up further “step-down” treatment options, at various types of outpatient programs, clinics, and rehabilitation centers, in which the patients can attend groups and have structure during the day, continue with their medication regiment, but be free in the evenings. Sadly, too often, we can’t get an outpatient program to accept a patient, or vice-versa (the patient won’t comply, or quits after a few days), and many people unfortunately go straight to homeless shelters; basically back where they came from.
In more than three years at one hospital, I have seen countless faces return—three, four, five times, in some cases more, and that is just on my unit, one of six. Sometimes these individuals walk out the door and are back in a few days or weeks. I look into every patient’s record that I work with, and some have had 40, 50, 60 “episodes,” or inpatient stays, just at my hospital alone. We call it the “revolving door.” These patients are “in the system” for life. They are even sometimes referred to as “professional patients.”
So, while the legality and structure of the hospital care in the United States, or in Massachusetts, is different from France’s system, it is not necessarily better or worse. We try our best to get patients stable, so they can leave, but the support system and safety net is not systemically strong enough yet, and it often feels hopeless and helpless in the same way the film portrayed patients being locked up.
One noticeable difference, from a humanitarian perspective, was the sterility of the hospital in the French documentary—almost as if no life existed between the walls and behind closed doors. It looked and felt like a prison, a holding cell. Where were the patients? Where were the groups? The treatment? The doctors? Or is it just a holding cell? At my hospital, it is a bustling ecosystem, with 24 patients on a single unit, sometimes 6, 8, or 10 attending each of my four therapy groups per day. They go downstairs as a unit for three meals a day (unless unit restricted), and they go outside to the courtyard as a group twice a day. We have music therapy, art therapy, occupational therapy, and activity groups, as well as a front day-room with a kitchen, and a back day-room, and two TVs (turned off during group therapy), and a sensory room, and a quiet room. Not that this presents a “normal” or “free life” for them, but in contrast, the film portrayed no life inside the walls of the Edouard Herriott Hospital. It was slightly disturbing. I’ll say it again, it gave me a feeling of deep emptiness, a striking sadness, that these poor patients have nothing to live for and keep getting shot down every single time they go before the judge. It’s like a sadistic joke by the end of the film. At least in my experience working inpatient, I have seen many (even if a small percentage) beat the psychiatrist in their court commitment hearings. I am sometimes secretly rooting for them, even though I am on the same treatment team as the doctor. Sometimes the system inevitably feels sick.
Joseph Spilsbury is a clinical mental health counselor and music therapist and works as a group therapist at an inpatient psychiatric hospital. He is a multi-instrumentalist and composer, as well as the co-founder and guitarist of the local Boston band, Miele (Mielemusic.com). He is on the board of the Massachusetts Music Therapy Alliance (MMTA).