By Kieran Loughney
Isolation. Lockdown. Seclusion. Words now part of my daily conversation bring me back to a time when these terms had a different context. I return in my mind to a place where another invisible enemy was confronted. A place where there were strict limits on personal freedom and no assurance of a positive outcome.
On a frigid February night 25 years ago, as a psychiatric aide at a small hospital in Carbondale, Pennsylvania, I began my usual rounds. Flashlight in hand, I silently entered each room. Medicated patients slept in narrow beds which doubled as couches during the day. Snores and body odor greeted me. This tranquil scene suggested that the night might pass peacefully. The staff would often spend time reading, drawing, or chatting between checks on patients. But the dullness of routine invited complacency, danger’s loyal ally. One could easily forget during periods of calm that at any moment a crisis might ignite.
At the start of the shift, my coworker, a nurse, and I learned that among the new patients in the unit was a 24-year-old homeless woman diagnosed with paranoid schizophrenia. Confined to the security room, Angel was separated from the other patients for safety concerns.
The security room is the last place anyone would choose to spend time. With a steel-framed bed bolted to the floor, a single window covered with a metal grate, and a heavy door with an industrial lock, the room is designed for one purpose: to isolate and control the patient. If needed, leather straps are fastened to the bed frame. Attached to the straps are padded cuffs which can be adjusted to fit wrists and ankles and then locked in place, making the patient immobile and safe from harming herself or others.
I continued down the hall to the locked door of the security room and aimed my torch through the small diamond-wired window. The beam picked up a glint of metal in Angel’s small fist. I heard the click of a lighter, saw the spark, and then the flame. I switched on the light and quickly unlocked the door with a large key. Angel’s pale blue eyes flashed in dark orbits. Her face was ruddy from exposure to the elements. She wore a backless hospital gown. Her twig-like legs dangled from the bed. I approached her as she quickly put the lighter behind her back, slipping it into her panties.
When patients are admitted, they are first read a list of rights. They are then required to strip down to their underwear and are checked for any contraband such as sharp objects, drugs, or matches or lighters. The body check is a critically important step in ensuring safety on the unit. Somehow, Angel’s lighter had escaped the attention of the staff.
Backing out of the room, I looked for the nurse. No one was at the nurses’ station. My only coworker had taken a bathroom break. That was the moment Angel chose to set fire to the bedsheets on her right and behind her. I turned toward her as she lit a fire on her left. Flames on three sides of her rose a foot high and smoke billowed toward the ceiling. Angel remained motionless. I grabbed the lighter from her hand while carefully lowering her body to the floor. Crouching behind her, I gave her a firm push and slid her across the floor and out of the room. I then gathered the bedding in upon itself, quickly extinguishing the fire. Angel sat quietly on the hallway floor, expressionless and remarkably unscathed by the episode. The nurse, now back from her break, was astonished. Before she could speak, I held out my hand and said, “I’ve got her lighter.”
I felt good about what I had done that night. Angel was safe. I had taken charge of a dangerous situation. Control here changed hands without warning, though. To keep the control in staff hands, choices were made. Choices which either protected patients and staff or put everyone at risk.
On another night shift here, George, who had a history of manic depression was locked in the security room and held in four-point restraints. A 260-pound former football linebacker, he had spent years in a state mental hospital and was placed on a powerful drug to manage his psychotic and sometimes violent behavior. The doctor treating him at my facility opted to discontinue his medication.
George had been bound to the bed all day. He was now shouting, cursing, demanding to use the bathroom. For a patient to be released, the unit policy was clear. A doctor would be contacted by phone and asked to issue the order. Two security guards would then be summoned to the unit. Only then could the patient be unshackled. On this night, however, a co-worker took pity on George. She released him from the restraints and the security room without authorization, violating policy.
As staff we often faced a choice between strictly following protocol or granting patients a bit of freedom and dignity by bending the rules. A small liberty could be granted as a reward or to build trust. Some staff, however, imposed harsh limits or denied rights. The worst of these workers inflicted physical abuse. They might twist an arm or punch a patient to subdue or control them. It sickened and angered me to witness this. Even more troubling was that, when informed of abuse, management turned a blind eye.
The aide walked George to the nearby bathroom. When he was finished I saw him exit and quickly joined them. Our mission now was to persuade him to return to his confined space. His protest began immediately. A massive immovable force, George stood in the hall determined to remain there. He was nearly twice my size. We knew of his attacks on staff members. He had seriously injured two workers at a state hospital. Getting confrontational with this man was not an option for me. I chose an “I’m on your side” approach. Calmly, almost apologetically, I tried to get him to cooperate. I kept my hands down, lowered my voice and tried to reassure him that he’d be allowed to join the other patients in the morning. But George, unlike many patients who had responded well to this approach in the past, was having none of it. “I know it’s awful in there,” I told him empathetically. George knew “awful” didn’t come close to describing being bound to a bed in a locked room for hours. Unable to do as much as scratch an itch or raise his head more than a few inches, he faced further humiliation by having to ask permission to use the bathroom. He had spent the last several hours enduring deprivation and suffering that very few of us will ever know.
As an exercise while training for my staff position I’d been locked briefly in those cuffs myself, in that same room. Those few minutes, while uncomfortable, revealed only a flicker of the helplessness a patient must feel. With no way for one to estimate how long confinement might last, a gnawing desperation to be freed must surely have intensified as each minute passed.
George paused for a moment, considering his next move. His eyes narrowed as he glared at me, his face reddening. He lunged toward me. In an instant his beefy hands clutched my ribcage. Lifting me completely off the floor, he propelled me toward the safety glass of the nearby nurses’ station window. The nurse inside called for help. Uniformed security guards arrived seconds later. George continued in a rage until he was wrestled back into restraints and subdued with the injection of a powerful sedative.
In the moment George came toward me, control of the situation was his. My role was caregiver and protector. But now, suddenly, my own safety was jeopardized. While I had extinguished the small fire Angel had set, I underestimated the burning intensity of George’s anger and frustration. I worked in this setting for years, seeing hundreds of patients with a wide variety of psychiatric challenges. When this crisis hit, I overlooked one essential truth. By boldly claiming to empathize with George’s situation, I was complicit in his outburst. This troubled man saw me act as if I knew who he was and what he had been through. That must have been particularly upsetting for him. At the time, I saw his attack as the culmination of bad choices made by others. It’s clear now, 25 years later, that my actions were misguided too. To claim to know George’s pain was pure fiction, and fiction certainly had no place in this setting. In this situation, in this dark place, it’s hard enough for anyone, staff or patient, to see the light of sanity.
As Covid-19 has claimed more lives with no clear end in sight, weeks of restriction and isolation have turned into months. I appreciate now, as never before, the terrible weight of mental illness. It gives me pause now to consider those lives controlled by unseen forces as, in a small way, mine is today. And in that pause, a glimmer of hope emerges. In a sense, we have all been confined to the security room now. Surely, when the restraints come off we will have been changed by the experience.