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Psychiatry
Sometimes Amazing Things Happen
Heartbreak and Hope on the Bellevue Hospital Psychiatric Prison Ward
Posted June 3, 2017
Sometimes Amazing Things Happen: Heartbreak and Hope on the Bellevue Hospital Psychiatric Prison Ward
By Elizabeth Ford, MD
Reviewed by Lloyd I Sederer, MD
The sad truth about serious mental illnesses, like clinical depression, bipolar disorder, PTSD, the addictions and schizophrenia, is that no group of people is spared – whether they be young or old, of any color or race, and those who have been charged or convicted of crimes.
Throughout this country when men and women, from teenagers to adults, are arrested and arraigned for an alleged crime they are transported in shackles to a local jail. Some of them wait in jail to go to trial or have their charges dropped. Those who are convicted serve out their sentences either in the jail or if a judge renders a lengthy period of incarceration, they wait in jail until moved to a state prison.
An estimated 15% of these incarcerated men and women will have a serious mental illness, and approximately 50% have an active substance use disorder, or both. Some will be incompetent to stand trial and need psychiatric treatment to restore capacity. Others will be actively psychotic, suicidal, self-destructive or aggressive because of their mental condition. They are ill and have the legal right to be treated, just as they would if they had diabetes, heart disease or asthma. Where does that treatment happen?
For some, medications as well as limited counseling and group therapy are provided in the jail (or prison). But for those incarcerated whose illness is acute, severe and often life-threatening they need a hospital.
The second largest jail system in the US is centered on Rikers Island (since there also are 3 jails off the island), serving New York City, and housing about 60,000 people annually, about 9,500 on any given day (the turnover is staggering, many staying a week while others weeks or months). And when an incarcerated person with a mental illness is too ill to be cared for at Rikers they go, the men that is, to the "prison ward" on the 19th floor of New York's storied Bellevue Hospital, where they remain in custody while doctors, nurses, social workers and counselors treat them, under the watchful eyes of correctional officers, until they are well enough to return to jail.
In this quite extraordinary book, by Dr. Elizabeth Ford, a quite extraordinary psychiatrist, we enter the doors of the Bellevue prison ward and the lives of its patients, clinicians, correctional officers, and most intimately the thoughts and feelings of Dr. Ford. That's because above all this book is her memoir, and an early one at that, not only an analysis of the sociology of jails, prisons and those incarcerated and their caretakers.
Elizabeth Ford is a forensic psychiatrist, which means that after medical school she took a four-year residency in psychiatry and then an additional year as a forensic fellow, all at NYU in Manhattan, stretching from 28th to 31st streets and facing the East River. A few months after her residency she became the lead psychiatrist on one of the Bellevue forensic units, treating men relocated from Rikers for the treatment they needed, whether they sought it or not. In other words, a helluva job.
In "Sometimes Amazing Things Happen", Dr. Ford's elegant and evocative memoir begins in her days as a medical student and proceeds on through her residency and fellowship. Her compassion for patients is strong, strong enough early on to get her into trouble for vocally advocating for them. That was not lost on her supervisors and, as has been said, she was quickly promoted for "no good deed goes unpunished".
As a memoir, this book is both heartbreaking and inspiring. The gravity of the trauma and suffering in these incarcerated men that we read about is enormous, which means that properly treating them, putting one's heart into their care, calls for an exceptional degree of purpose, commitment, stamina and mission.
This is a book of beautifully written stories about selected men who depict a life of hardship and illness, and who often are dangerous to others and themselves. And it is the story of Dr. Ford's evolution as a psychiatrist and leader, as well as a wife and mother. The prison ward work in time gets to her, especially after the birth of her second child, a girl, and she leaves the job - 'stepping down' to work in the Bellevue psychiatric emergency service. But two years later she is back, taking on the director job, which means not only the two Bellevue wards but two clinics and the outpatient commitment service as well. She is the first woman and mother to occupy this pretty formidable job. Yet to read her tell about it is to see the pain and illness that abounds and that cries out for the help that can make a difference.
One amazing story, among others, happened in November of 2012 when Hurricane Sandy hit NYC. The basement at Bellevue was flooded from the East River surge, which was where the fuel tanks for the entire hospital were located. With no source of power for the generators Bellevue had to be evacuated, which was a huge undertaking. But no other hospital would receive the prisoners from the 19th floor. Days without power, food, showers and non-functioning toilets tested everyone's mettle but able leadership, including the boss (Dr. Ford), kept everyone from rioting.
Finally, patients were transferred to forensic state hospitals in upstate NY and in NYC (I am the chief medical officer for the NYS mental health system and proud of what we did) where they remained for as long as a few months before Bellevue was again operational. To serve the 30 new patients a week at Rikers who required psychiatric treatment the Bellevue staff transplanted themselves to the jail and set up shop there. If you want to create a situation of high stress and human challenge, for ill patients and staff alike, have a massive hurricane hit a hospital.
One sentence by Dr. Ford, in particular, portrays the world of forensic psychiatry that she lives in: "...the many states of being that separate us - patient and doctor, man and woman, black and white, mentally ill and healthy, incarcerated and free" (p.235). Yet amazing things do happen and, like in everyday life, they are small, incremental yet transformative.
Otherwise there would be no recovery in the patients, which happens a lot, and no sustaining the hearts and minds of the staff who serve them.
For all the candor about her experience that Dr. Ford offers it remains a bit of a mystery to me how she would find her calling in this off the charts type of work. She speaks about her purpose, about the privilege of caring for patients, and the camaraderie of other staff. But she did not grow up poor, traumatized, of color, or with little prospect for the future - as did about all her patients. Yet she knew early on that caring for incarcerated people with serious mental illness was what she needed to do. Bless her.
The book ends with Dr. Ford taking on an even harder job. She is offered the position of Chief of Psychiatry for Correctional Health Services at Rikers Island, the epicenter of action in NYC for forensic psychiatry. Amazing things can happen there too. Who knows where she will go from there?
***
Dr. Lloyd Sederer is a psychiatrist and public health doctor. The opinions offered here are entirely his own.
His latest books are Improving Mental Health; Four Secrets in Plain Sight (2017) and Controversies in Mental Health and the Addictions (2017). His book on drugs in America will be published by Scribner (Simon & Schuster) in the spring of 2018.
@askdrlloyd
