the 401 paradox

how did you lose your mind

Every state has different laws regarding involuntary commitment. The infamous fifty-one fifty in California is the 401 in Tennessee. The common knowledge myth that the skid row nightmare out west exploded when Reagan shut down the state mental hospitals is only half true. It’s also become increasingly difficult to involuntarily commit a patient in California, due in part to evermore murky definitions of danger and self-harm plus endlessly more progressive concessions made to protect the rights of the mentally ill to free speech and the pursuit of happiness. If you choose to express yourself in San Francisco by shitting on the sidewalk while wearing a chicken bucket on your head, then blissfully smoke yourself into a fentanyl coma, that is free speech. That is your god given human right to chase your happy place unhindered by the man. Or so the logic goes.

But it remains easy as cake to 401 somebody in the state of Tennessee. Happens every day, hundreds of times per day. It requires the scribbled signatures of two qualified healthcare professionals. Nurse, cop, doctor, therapist or social worker. If drunk patient X is sitting in an ER waiting area for hours waiting to have a non life-threatening laceration stitched up, and finally loses his or her shit and screams, I’m gonna kill myself if somebody doesn’t get me some painkillers right the fuck now then boom, one signature. If patient Y is a homeless junkie who wants to get off the street because he owes the dope boys money and needs to lay low until the first of the month when his disability check comes in, he can walk up to the nearest police car and say I’m thinking about blowing up the mayor’s office. Boom. If patient Z is the wife in a domestic violence situation and says to her therapist sometimes I want to kill him in his sleep, and the therapist doesn’t care to split hyperbolic hairs, well. Boom. And if patient zero is just emerging from a three-day blackout with a kitchen knife in hand when the police arrive for a welfare check, boom. If any of the above land in the lobby of a Memphis psych hospital agitated and combative, the process moves along very quickly, provided they have some form of insurance. If not they will be transferred elsewhere. Meanwhile the chicken bucket guy in Memphis would be hit with that first signature before he pulled up his pants. If you are sleeping outside and aggressively panhandling in most of the south, you are considered a danger to yourself.

And once you have the first signature, you are pretty much guaranteed to get the second. Because no doctor or social worker wants to pass on a second sig only to see that patient on the news 24 hours later walk into a church or an Ikea with a long gun. Because this is America, baby. That shit is on the news every night of the week. Don’t get me wrong. It’s relatively simple to be admitted to a psych facility as a voluntary patient, too. If a non combative detoxing patient with private insurance enters a facility seeking help he or she will surely get it. Though they may first be sent to a nearby ER for med clearance if their vital signs are cruising at stroke altitude. Psych hospital admin hate it like poison when anybody dies on campus. If you’re working one unit and hear a code blue called on the overhead for another, your first thought is somebody is getting fired. And anyone having a psychotic break who walks through the front doors under their own power and asks for help dealing with the voices or the shadow forces haunting their corner of the realm, they too will be admitted without fail, provided they have insurance. If not, the for-profit hospitals will tie themselves into bureaucratic gordian knots in the effort to get that patient transferred elsewhere. 

But never fear. The majority of homeless and section eight patients are covered by TNCare, which typically provides for seven days of reboot time, or just long enough to stabilize on their meds. They discharge and come back again and again. If the incoming patient is actively seeking treatment and has no history of violence and makes no statements suicidal or homicidal, and remains calm, they will be tagged voluntary for the time being. All well and good but not necessarily from the staff’s point of view. Because if that patient is allowed to walk onto the psych ward floor with voluntary status intact, staff are technically not allowed to put hands on them or medicate against their will until they freak out and attack someone. The voluntary psychotic patient may see the color orange or hear the word subdivision or see their grandmother’s face in a trick of light on a dead TV screen and proceed to flip the fuck out by strangling whoever is standing behind them. And one doesn’t necessarily have to attack someone to create a dangerous situation. Hours of screaming like a dopesick demon tends to make the other patients uneasy and may trigger sympathetic mayhem. 

The ultimate 401 paradox sinks in a few days later when the voluntary patient decides the food sucks or the repetitive group therapy sessions are stupid or simply says fuck it I’m craving my drug of choice. If that patient asks calm and cool to be discharged AMA, against medical advice, he or she will then be required to sit down and wait up to twelve hours for an external psych assessor to arrive and then convince that assessor they present no danger to themselves or others. If the voluntary patient breathes even an ironic aside about self-harm or seeing lizard people or just cops to the very real itch to head down to the row to score some fentanyl, or starts raising hell because the secondary assessor is slow to arrive, they generally find themselves 401’d heartbeat quick. Boom. Look what you did. Now you’re involuntary. Because you apparently don’t have your own best interests at heart. Or because you might walk across the street and buy a gun. All psych hospital employees have the tangled concepts of legal and medical liability and plausible deniability tattooed onto the undercarriage of their skulls. And above all because the hospital is in the business of keeping beds filled. Throw in the various legit scientific and philosophical arguments that free will is an illusion and the concepts voluntary and involuntary rapidly lose all meaning. 

A common recurring nightmare among psych staff who spend any real time on the floor and in the soup is the Alice in Wonderland scenario. Walk through the wrong doorway or lean too close to the wrong mirror and find yourself on the other side, wearing paper scrubs and shoes with no laces. No phone no keys no identification nothing to separate you from the other patients. My personal favorite existential fuck me moment is the Kubrick bathroom dream. Find myself sleep-deprived in one of the lobby restrooms washing my face with no memory of how or when I walked in there and a voice in my head muttering uh no Jack you’ve always been the caretaker here. But that speaks to an altogether different sort of fear that lives deep in the bone marrow and is neither here nor there. 

On the dystopian flipside. If an addict or alcoholic is on day seven or fourteen of voluntary detox and actually wants to stay for the full thirty days and they want to be sure their private insurance continues to pay $1500 per night for ongoing access to that rubber mattress, they must lie to their doctor. To claim suicidal ideation, to voice urges to harm. Over the years I’ve advised dozens of patients it was in their best interest to deceive, to insist they were still suicidal and even if they were not. The implications are absurd. After a few days of gingerly edging back to reality and truthfully reporting that you’re suffering no tremors, no hallucinations, no active thoughts of self-harm, if you admit that you’re improving, the more ruthless insurance companies will cut bait and discharge you. To some sort of halfway house if you’re lucky, to the street if you aren’t. And when it comes time to discharge an involuntary patient, the final step is to convince them to sign a document consenting to psychiatric care, thereby converting them to voluntary status on their way out the door.

The fundamental trouble with psychiatry is that no one person perceives reality the same as anyone else. Reality is spun up and defined by each individual consciousness and its accompanying soundtrack or internal narrative, which is by definition nonlinear, nonsensical, and maybe half verbal in composition. The other half being an endlessly shifting ethereal undefinable mashup of assorted sensory input and flashes of memory, fragments of downloaded imagery real and imagined. Patterns of light and shadow cast on the cave wall and blurred chaotic and muddy. Quantum mechanics and neuroscience have next to zero explanation for how consciousness actually works, so the business of diagnosing psych patients and medicating them for being out of contact with said reality becomes a dodgy prospect at best. Dangerous and negligent and potentially abusive at worst. Meanwhile anyone who has taken a long hard gander at high def 3D brain scans and renders of neurons at work and not been reminded of those long range Hubble photos of the post bang universe is surely not paying attention. Dislocation from time and space is the unholy common ground of psychotics, depressives, addicts and drunks.

Drift back to the here and now on the smoke patio and wonder how long I’ve been sitting alone in the dark. How did you lose your mind. Gradually then all at once. But time is not just a direction or construct. Time is elemental. Time is how we navigate our minds. Time exists in memory as a series of loops and locked rooms and local pockets of complexity. How much time we spend in those locked rooms is subject to operator discretion and further aggravated by drugs and trauma. But how much control does any of us have over these unseen zero mass dark energy bits and bobs, these shards of light, these zero mass neutrinos and god particles that form our conscious thoughts and memories, our subconscious cutscenes and menu screens. Those straylight shards keep on keeping on with or without our voluntary involvement. The brain freebases dopamine and serotonin, adrenaline and our own internal DMT source code to merrily construct the three and four dimensional worlds of our dreams and our memories whether we’re conscious of it happening or not. The laws of thermodynamics are all about ever increasing entropy and disorder. Meanwhile the external algorithm spoonfeeds each of us our own personally tailored reality stream and even the most well-adjusted normies and mentally fit among us live and die closer to the edge than they realize and ultimately we are all adrift, alone in our own internal westworld dreamscape funzone habitat where free will is the final illusion. If there is no spoon how the fuck does it bend.

*postscript. I lived in California for a dozen years before migrating back to TN and sometimes I explored my dark side. To put it mildly. And I took comfort in the knowledge that it was harder to be committed involuntarily out there. But now when I lay my head down at night I’m aware that between the various hospital psych wards, drug rehabs, and jailhouse psych pods, the city of Memphis has maybe a thousand involuntary commitment beds that are occupied every night. A thousand patients who might otherwise be wandering the streets contemplating our extraordinarily relaxed gun laws.