The first time I saw Sassy Lewis, she was holding a nurse and two psychiatric attendants at bay with an upheld chair and a torrent of obscenity. She was 14 years old, very dark-skinned, a little chubby and short, but as intimidating as a wounded bear. It took a little fast talk and several minutes of listening for her to calm down. It was the beginning of a rich 6-month relationship.
She really shouldn't have been on our adult unit, but the adolescent units at the state hospital had found her unmanageable, with an adult-sized temper. She was one of the world's many, many orphans; kept here, shipped there, dropped off somewhere else for all of her life. I don't remember just what had brought her to the hospital to begin with, but she hadn't been able to handle the demands of school very well, and when she was really upset she could present a very odd and unsettling appearance: sort of whirling in place like a little tornado, screaming, and looking -- well-- "crazy." She could also hit people and break things.
She aroused a lot of dislike, and the instinctive responses were the old standbys: threats, lectures, confinement and drugs. The first three tended to trigger more belligerence, and while enough heavy tranquilizers could reduce her to the stuporous shuffle enacted by countless paper shoes down countless hospital corridors, doses short of that seemed only to make her rages less intelligible. She seemed downright incurable -- which ended up making me feel pretty smart, for awhile. Being a highly trained non-MD (psychologist) in a big hospital is sort of like being a civilian in the military. No one knows exactly how important you are, or just what you should be doing. I had used that ambiguity to shape a role for myself as a sort of psychotherapeutic trouble-shooter, taking on the unit's hairier cases and sometimes having good luck. I was asked rather desperately to try to work with her, at least until a transfer to a prison unit somewhere could be arranged.
Sassy was actually pretty easy to deal with. If you could manage to not get set off by the big chip on her shoulder, but see the injuries inside, and listen to her with some patient, protective attention, the bad stuff melted. Give her honest attention (like all hurt kids, she could smell phony or merely professional attention in a second) and her heart opened up like a day lily to the morning, and her face spread to a smile as big as the sky. Actually, I was not the best at this for her. Better than me was Mrs. Johnson, an attendant on her ward, who saw through Sassy immediately and dealt with her like a good mother-substitute: firm, warm, stern and patient. She knew more about where Sassy came from than I did, and spoke her language better. Johnson and I quickly became a team, and managed her treatment.
You must remember that this was a medical institution, grounded in science, and treating gen-yoo-wine psychiatric diseases. It is difficult in such a setting to think clearly of treatment in such terms as honest attention, affection, loyalty and understanding, even though many who work there know deep down that these are the most curative things. It feels more tangible and hard-nosed to put chemicals into the patient's bloodstream, or shape chunks of behavior with rewards and punishments. To satisfy protocol I became Sassy's "treatment manager" and Johnson was my "technician." I also consulted on the pharmacological treatment. Johnson and I and Sassy did agree on a little package of constructive things and especially noxious things she did, and coaxed her some on increasing the former and decreasing the latter, and spelled out some of the self-talk that got her especially desperate, and I consulted the drugs to a place where the stupor was gone. For the most part, though, we just gave her some reliable, caring attention. She was one of those pure, clear but injured souls, who have somehow retained a capacity to respond to reliability and care, even though they have never known those things. Because we'd come past her belligerence, five minutes a day of "how are things going?" followed by some honest listening from Johnson and me was generally enough to get the smile, and see the fear and anger steam away. Sassy started attending school, and reading, and Johnson and I got to feel like Ann Sullivan and Sigmund Freud. She would tell us sad stories from the past until they became too sad, and she became a bright presence on the gray old loony ward.
One day something that happened to her made me the angriest I ever got in that setting. Before Sassy had come to our unit, on one bright day in a blind quest for love she went into the woods with a male patient and emerged later, chigger-eaten and inseminated. When the pregnancy was discovered, she decided to have an abortion, but with anguish. The tiny, invisible fetus was as real to her as her hand, and more loved. We talked a long time with her about how the things she was doing now were preparing her to able to really care for the children she would have later, after she kept going along the good road she had gotten on. With tears and those somewhat consoling thoughts, a few days after her 15th birthday she got into the car to take her to another hospital for the abortion. A few days later, I got word that Sassy had come back and was pitching a fit. I found her enraged, confused, talking to people I couldn't see, and crying. She had just learned that while under anesthesia but just before passing out, the surgeon had given her a form to sign consenting to a hysterectomy. She didn't remember signing it, but when she grasped the consequences later, she freaked. Some scuttlebutt had already spread through the nursing staff from some of those who had been working in the OR, that Sassy had clearly been too groggy to know what she was signing, and that this had happened before, to other patients.
The surgeon -- I don't remember his name, call him Dr. Eugene Icks -- apparently had a philosophy of protecting society from future dregs by nipping them in the bud, so to speak. I called his office in a fury, got no response, and went on to make many more calls, all up and down the system. After a couple of weeks it was clear I was up against an impenetrable wall. No one who had been in the OR would formally report the thing, and the word of a 15-year old, illegitimately pregnant nut was worth as much as you would think. And, I was told, I was very close to causing my own career irreparable damage, and "anyway it couldn't be changed now." Icks never answered my calls, except through a very arch attorney, so I never even got to tell him my opinion of him. Perhaps the fuss slowed his knife a bit the next time, but I'd make no bets. Through it all I knew Sassy better, because I understood helplessness better.
Sassy rallied, and after a couple more months on our unit transferred to an "in-between" unit, designed for well-functioning patients who had no supports outside the hospital, while some sort of placement was worked out. There she had to function with a lot of autonomy and self-control. She stayed in school, and read more books than she had ever seen in her life. She missed Johnson and the other friends she had made, but made some new ones. With me she made do with two "check-ins" a week. I would stop by her unit at the appointed time, and we chatted for 15 or 20 minutes about things, her head full of heartbreak, excitement, silliness and details, like most 15 year old girls. Her new staff was optimistic about a halfway-house placement that was in the works. We could begin to see the person that Sassy could become: an enthusiastic, cheerful soul, bright and clear as a sunbeam. There were bits of irony and nuance, her mind emerging. She was beginning to discern trustworthiness and its absence.
Our last meeting didn't happen. She knew I was leaving the hospital for another job. It was very rare for her to not show up as agreed, but I should have known it would be so. It was too sad a goodbye. I had to wish good luck to the scruffy little stuffed bear that a nurse had given to her. I could only hug a round-faced image in my memory.
The next time I heard about her was 2 years later. A small article in the paper said that a young woman named Sassy Lewis had hanged herself to death during the night at the county jail.
What had happened? I never found out too much. She had only lasted a few months at the half-way house. The place was busy and understaffed, but especially, there had been no one there who thought to make the little inner act of adoption that Sassy needed to have a floor under her feet. Her weekly therapy session at the mental health center had been quickly changed to a monthly med-check with a man who didn't remember her name. Her temper came back, she became crazy and unruly, lost her job, skipped school. Then the streets. To learn more I would have had to ask other street kids, and I didn't know any of them to ask just then. I never found out what had happened in the jail that night.
Most people who are as injured as Sassy are not as easily helped. The walls are bigger, the hopelessness deeper, the paths away from connection more twisted and thorny. Sassy's was mostly a disease of neglect. She had gotten what mental-health bureaucracy would see as the appropriate treatment -- a good placement, a case manager, state of the art psychotropic meds -- yet not the reliable investment of someone's real energy, stern and forgiving, that she needed to stay straight and keep growing.
All of this was many years ago, at a time workers in mental health are now astonished to look back on as "the good old days." We knew that the hospitals were inadequate, but they were staffed mostly with dedicated, struggling people who worked hard to invent improvements. Psychological treatment – human treatment – of psychotic people was better understood as a result of a couple of decades of creative innovation on the part of many people.
The dawning vision of Community Mental Health was glowing brightly on the horizon, and it seemed that community-based treatment would flourish, supplementing the deep, hard work hospitals did, and things would really improve for the mentally and emotionally ill. Then legislators worked their mysterious ways, presumably speaking for a largely indifferent and stingy public. Laws intended to protect the rights of the mentally ill were framed so naively that their main effect was to make it impossible for hospitals to give sustained, serious treatment to the very sick, because they could not be kept against their say-so, no matter how crazy. Rather than refine the laws, this apparently seemed a terrific justification to cut funding to hospitals. This allowed states to put down the financial burden of treatment and pass it on to the federal government, which would not subsidize state hospitals, but would pay for some treatment and placement of individuals in the community through Medicaid and Medicare.
The drug companies and the biological wing of psychiatry (now almost totally dominant in mental health treatment), were perpetually dependent on the illusion of having just found the "magic bullet." They oversold and oversimplified the benefits of meds: another justification to close wards and send money to wherever businessmen wanted it. The burdens of treatment were shifted to community agencies at the same moment that state funding was also taken away from them.
This cynical dis-investment in our weak and sick continues and accelerates today. At the time Sassy swung from her belt, one might have said with tasteless irony that she "fell through the cracks." Now the cracks widen daily, and sometimes we can hardly find the boards. We wonder where "the Homeless" come from. In the clear winter night, the homeless mad quarrel with the demons in the sky, and shake with cold.