THE INSTITUTION

by Chris R. Morgan

greystone

To: Commissioner, State Department of Health
Re: Progress Report

Dear Commissioner:

I have served as the Administrative Director of [REDACTED] State Hospital for the Psychiatrically Afflicted for a period of a little over three months. In that time I have taken great care to familiarize myself with the various contours of this institution and those who people it. I have walked through its grounds and its hallways and seen the life and culture that abounds it day and night. Perhaps you will disagree, but I am confident that after that time I have come to a general, if not altogether complete, understanding as to the character of this institution. Some of my conclusions—or rather conclusion—are worth noting, if you’ll pardon the indulgence.

Correct me if I’m wrong, but I believe one of the main factors behind your hiring me for this position was that I possessed few, or really any, illusions about the purpose of this arm of our healthcare system. I believe you appreciate that we are not in the business of saving an entire mass of our state from some collective malady of conscience, or whatever the reformist true believers want to call it. I am more earthbound than that. We exist to assure that those who need treatment, who are beyond self-help, get the best possible treatment; and moreover, that they do not hinder the morale, safety, and good health of society at large. It is, I admit, a task far too modest for some, and too little compassionate still for others, but it is crucial in maintaining society in the most broadly desired state of order.

It is with no small dismay to admit that this institution fails even that task.

In my three months I have been able to take stock in the following: the state of the art of our tools, the competency of the staff who use them, the technical knowledge (and sometimes the ethical intent) of the physicians who guide them, the overall aura of the facilities themselves, and the morale of the patients subject to all of the above. From gauging these characteristics, I can’t say with any certainty that this institution has any therapeutic value. Indeed, I can say definitively that it does not.

For the past several weeks I have been going back and forth with the institution’s head physicians, asking them forthrightly, but respectfully, to produce one—just one—example of a patient who has been successfully treated; who has been able to live at least a manageable life outside of these walls with minimal assistance from and minimal disruption to others. This has proved a difficult task. The paperwork is endless, and yet there are no outpatient records or progress reports. One patient in the women’s wing was said to be discharged but seems to have returned within weeks, and in a reduced state no less, inadequately clothed and largely in a seclusion that people seem to think is self-imposed. The numbers are telling. The patient population is expanding; it is not contracting let alone leveling off. We are beyond capacity and beyond supply. There is one patient I hear of who wanders freely throughout the facilities. All that stands out about him is that he does not speak a word of English. It took an orderly to tell me that it was Turkish and that he had “gotten lost” somewhere.

What seems to be contracting, however, is the staff. I cannot say for certain that the nurses, orderlies, and other mid-to-low level employees would recognize me, or even know positively that I exist. I do my best, however, to at least understand broadly the circumstances by which they make their living. I think it varies from person to person whether we pay them too little in proportion to their tasks or too much, but it is strange that I’ll see an orderly during the day shift looking bored and agitated, and then see the same one again after the day shift looking just agitated.

The doctors are another matter. Setting aside the fact that they seem to inhabit the polar extremes of the moral motive spectrum, and that some of them seem to lack precise training in psychiatry or find psychiatry in total to be suspect, I simply cannot relieve this institution of them or their influence. They seem attached to this place, sometimes physically, given that one wheels himself from wing to wing on his swivel chair. The squeal of his coming echoes throughout the halls and unnerves patients and staff to a notable but unspoken degree. My authority, such as it is, goes unheeded. Perhaps it is because they have persisted longer than I have, and that my judgment is suspect; but I get the feeling that three months or three years will have little effect. My dictates seem to fall outside the calling of the dictates they choose to follow. From what source they emanate, I can’t quite say.

All of this has led me to determine that providing even basic healthcare, if that purpose existed at all, does not exist as a function here. In addressing this I see two options:

(1) Take action to reform the workings of this institution to provide what its very name makes clear to provide. Assess the broad needs of the patient population and how it can be manageably reduced. Determine the efficiency and functionality of treatment methods, particularly against new and emerging treatment methods that no present physician has heard of or cares to hear of. Unburden and expand present staff needs. Fix the plumbing. And so on.

(2) Discard the pretense of providing care and reopen the institution as a public storage facility for the state’s damaged goods.

I am dispirited, pardon me. But if you opt for the former, which I am hopeful and confident you will, I need more than your word to propel its implementation, more even than your basic trust that it can get done against present constraints. [REDACTED], in its present state, is undirectable. If it functions it does so in spite of me, it does so out of what I’m simply going to call force of habit, a series of motions and stereotyped patterns combined into one overbearing entity, born out of decisions the intents of which have since become perverted, for reasons long ago forgotten. Doing nothing, not even the latter option, however, will have adverse effects on everybody, not least of all the patients, who are betrayed by such inaction. Their options are bad ones, which I can either accelerate or delay for them at present, but not avoid or soften.

I hope, in any case, that you will consider all of these options—not limited, of course, to simply removing me from this position. Know that I will respect and abide by whatever direction you give.

Sincerely,

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