The Observation Room – Mad In America

I had an appointment with a doctor I had been seeing for a sleeping disorder at an outpatient clinic in a large psychiatric hospital in Montreal. My insomnia had begun a few years prior, when I stopped taking Risperdal for tics caused by Tourette’s Syndrome. I thought the insomnia was part of my withdrawal from Risperdal, yet it continued. I could not sleep without medication.

The doctor had told me that we would discuss a problem I had with a neighbour who would begin yelling whenever I entered my home. I had complained to my landlord but nothing was done. A few minutes after my appointment with my psychiatrist had begun, I was given a ‘choice’: I could either bring myself to the hospital’s ER or I could be brought there by security.

I would learn later after obtaining my medical records that I had been diagnosed with having auditory hallucinations. I was, according to doctors, schizo-affective.

After the bedlam of the ER, the calm and order of ward 408, where new patients were quarantined, was eerie.

In the room opposite the nurses’ office was a bed fixed to the floor. It is fitted with restraints that can be fastened around a patient’s ankles and wrists, enabling limbs to be strapped down by nurses while security immobilizes the patient. The ‘observation room’ — on its far wall is an unbreakable window through which little can be seen.

For the new patient, the observation room is the source of intermittent yelling and anguished screams. These, he learns, end with the administering of a PRN. The room is as cold as a meat locker. Inmates are refused a blanket, the cold a valued feature for staff and part of the observation room’s chilling effect. The observation room is staff’s trump card. For a patient like myself who contests his hospitalization, containment inside its walls is an inexorable given. The only question is when.

Inmates in sanitariums were once routinely chained to walls. Medicine, we are told, has progressed since then. But a patient in ward 408 is soon disabused of this notion. Chains and other such simple and crude technologies figure still in the practice of psychiatry. The threat of their use is palpable. The fear it instills creates a bond between staff and patient, the therapeutic value of which can only be unique in medicine.

In many ways the quiet and seeming tranquility of ward 408 are a byproduct of the omnipresent fear caused by the threat of being taken to the observation room. A palpable physical presence, it hangs like a pallor over ward 408. Only the most obstinate and obtuse do not learn to fear confinement inside its featureless walls.

A new patient tells himself that only the most aggressive and violent patients are taken there. But then, of course, the full therapeutic benefit and effect of the observation room are not fully realized or exploited.

The room is unique in a legal sense. To be taken there is the same as committing a violent act. The caregiver becomes a witness for the prosecution to the patient’s crime. To escape prosecution for such crimes, committed or otherwise, is to accept unquestionably your diagnosis, whatever its clinical basis, and take your medicine, whatever the medical benefit.

Under this rough justice, perverse and sadistic staff, the guard dogs of clinico-medical privilege, are prized and protected by administrators. They, in return, may act with an impunity unknown outside the clinical environment. They are a law unto themselves.

The observation room, as a therapeutic technology or instrument, is, of course, based on sound scientific if not medical principles.

Behaviourists early on understood that punishment, when given arbitrarily and randomly, invariably induces helplessness. Indeed, if nothing you can do helps you to avoid punishment, you not only feel helpless but for all practical purposes you are helpless. For patients in ward 408, this was a familiar feeling and reinforced further the ‘therapeutic’ bond with caregivers.

A few days after my arrival in ward 408, Nurse C, my nurse for the day, told me that I looked stressed. I was preparing for a hearing in the afternoon. The hospital was seeking a court order to prolong my commitment. I declined her offer of something to relax me and returned to my writing. Nurse C left my room only to return with two security guards. I was now given another “choice.” I could go under my own power to the observation room or be forcibly taken there by security. I “chose” not to resist and walked quietly to the observation room.

The observation room quickly filled with nurses. What I now felt, though not clinically a kind of distress and better described in legal terms as a form of duress, only increased as Nurse C insisted that I open my mouth, say Ah, and swallow the medication that would be my ticket out of the observation room. As was my right under law, I continued to refuse the ‘medication’ Nurse C insisted on giving me. Finally, she put the small paper cup with the pills in front of my face. I pushed it away. I had now ‘acted out’ and ‘assaulted’ a staff member.

I was then tied by restraints to the bed. My pants were lowered and I was injected, according to the nurses’ notes, with “2 milligrams of Ativan and 5 milligrams of Haldol.”

My hearing was postponed until the next day. My reputed assault of a caregiver was entered as evidence of my dangerousness and grounds for my continued forced hospitalization.

A few weeks later I was still in ward 408. Another nurse, Nurse M, came to my room. He asked me to sit and talk with him. He told me, “The people here just want to help you.” I bolted up in my chair. The back of the chair broke a small piece of wood from the window frame above the heater.

The next morning two women came to my room with a camera. They were indignant and chastised me for my violent and destructive behavior. I told them Nurse M could support my claim that it was an accident. Despite the nurses’ report claiming that I had torn a two-by-four of wood a meter long out of the window frame, the chip in the wood was quite small.

The next morning, the window frame was repaired. The smell of the glue sickened me and I refused to stay in my room. My nurse, Nurse B, wrote in her notes that the windows were opened and that I was ordered to stay in my room. The windows in psychiatric wards, however, only open a few inches. Nonetheless I was told the room had been aired out. I told Nurse B. that I would not stay in my room. This was viewed as impertinent. Security was called and I was again injected with Haldol and Ativan in the observation room.

The Haldol induced extrapyramidal syndrome in me. My tremors were noted, and my inability to sit still and need to pace back and forth in the small confines of the observation room also appear in the nurses’ notes. The notes for that day are very detailed. After three pages, the letters EPS appear.

Acute akathisia is a symptom of extrapyramidal syndrome and a side effect of Haldol. The sufferer’s skin literally crawls. Waves of anxiety go up and down his body. He has restless leg syndrome. When he gets up and paces to try to calm the anxiety, he wants to lie down and relax. When he lies down, he wants to get up and pace. My EPS would continue for three horrific days.

The day I was transferred to ward 208, I had my first evaluation by Dr. P. For the first five minutes he refused to identify himself. It did not matter who he was, he told me. I had been diagnosed by four psychiatrists. He would extend my hospital stay, he told me.

He then began to yell. “You had to be restrained! You were administered repeated PRNs!”

For the next eight months, Dr. P’s yelling at me histrionically that I had to be taken to the observation room and restrained would be the sum total of our therapeutic relationship.

When my hearing in Superior Court finally came up after months of delaying by the hospital, Dr. P returned to this theme. Haldol is a molecule widely recognized for its effects on cases of extreme agitation like that I presented, he told the court. Akathisia is very rare with a first injection and the dosage of Haldol I was injected with was very small, he said, but it was possible, he conceded, that I had extrapyramidal effects like tremors or nausea. I was agitated and broke things and, in such instances, Haldol is administered and has a very quick effect, he explained.

Though Dr. P had not been in ward 408 on the two occasions that I was taken to the observation room, the judge accepted Dr. P’s claims without question and might as well have been in the observation room when the drugs were administered. In fact, I had imagined a judge, in his robes, signing the court order to inject me as nurses tightened the restraints around my ankles and wrists and Nurse B stuck the needle into my backside.

In the former Soviet Union, akathisia-inducing drugs were allegedly used as a form of torture. Haldol was used to induce intense restlessness and Parkinson’s-type symptoms in prisoners. This of course does not happen in Canada.

The question of Canada returns in my medical file.

The first time I was diagnosed with paranoia was in 2017. The doctor wrote: “Mr. Nolin denies being paranoid — he has documented crimes by Canadian governments.” (All translations from the original French are by the author.)

Four years later, Dr. P, in his ‘expert report’ presented at my hearing on forcible injection, said the same thing. “[Mr. Nolin],” he wrote, “denies being paranoid but claims to have documented crimes by the Canadian government.”

In paragraph eight of its grounds for forcible injection, the hospital gave the court my diagnosis: paranoid psychosis with a paranoid type delirium and paranoid personality. The supporting facts included a report by Dr. T, the psychiatrist I had seen at the outpatient clinic for a sleeping disorder. In the eight years I saw her, never did she mention paranoia but there it was on page twelve in the hospital’s report:

Mr. Nolin denies being paranoid. He says that he has documented crimes by the Canadian Government. He rejects attempts to restructure his thinking.

We include in our supporting documents a manuscript of 127 pages that had been provided us by Mr. Nolin. It implicates the Canadian Government in a plan to destabilize Cambodia that was responsible for many deaths.

The October 2017 evaluation says that I contacted the minister responsible for foreign affairs about my research on Canada and Cambodia and that he did not respond. The honourable minister did, however, deign to reply. He said he acknowledged my concerns, but no further action was taken.

The idea that my writing was grounds to forcibly inject me was nonetheless new to me. I had only first seen my medical file from October 2017 after an Access to Information request in March 2021. But there it was in black and white: I had had the temerity to accuse the government of being implicated in war crimes. But what indeed were the symptoms of my growing disease? I had maxed out my credit cards buying 800 pages of internal communications archived by Canadian foreign affairs on Cambodia in the 1980s. These included Ottawa explicitly agreeing to ‘sanitize’ the Pol Pot rump government-in-exile.

I shared the files with Cambodia specialists. In 2020, I shared my writing with the Norwegian embassy. Norway was seeking a seat on the UN Security Council, as was Canada. A former Quebec premier, Jean Charest, had visited New York to solicit votes. The Canadian Prime Minister, Justin Trudeau, visited Africa to this same end. Canada’s bid for a seat on the Security Council was rejected.

I do not know if my research influenced the UN Security Council vote against Canada. Perhaps not. But what I do know is that I was effectively tortured in an attempt “to restructure my thinking.” As Dr. T and Dr. P testified in Superior Court, the fact that I persisted in my research is attributed to my age. “Delusional disorders,” like my reputed ailment, the court was told, are not as susceptible to treatment as the hallucinations of schizophrenics. This is because I reputedly suffered from a certain ‘rigidity’ and the mistaken belief that forcible injection was “an affront to my autonomy.”

The day before my hearing in Superior Court, a pharmacist in ward 408 came to my room. I told her about my doubts about the panoply of drugs that the hospital was looking to inject in me. She explained how Abilify would correct all this. Holding out her fists, she said that they were like synapses that were too far apart. This resulted in negative associations. Abilify would bring the fists together and better associations would result. I was making inappropriate associations. Like Polygrip, Abilify would fill the gap between my synapses. I would be smiling again.

The idea that such crude methods and technologies as forced drugging and the observation room can “restructure” someone’s thinking is not new. As Critical Psychiatry has exposed elsewhere, class war between the haves and have nots is nowhere more evident than in a psychiatric ward, whether it is in the former Soviet Union or in the United States and Canada. The very identity and personhood of those who question the underpinnings of society are crushed and broken in the observation room. It is an instrument of an untenable status quo. Dissidence becomes both a disease and a crime where cure is indistinguishable from punishment. A hospital becomes an adjunct of the penal system where those guilty of crimes without victims — crimes of thought — are committed and imprisoned.

Incredibly, the doctors in my case stated explicitly and in no uncertain terms what they were doing. But was my treatment an anomaly? Are such abuses systemic? How many others have had their spirit broken by such means but have left no record?

For a psychiatric patient like myself, to ask such questions is to tempt fate. The observation room is where those who ask uncomfortable questions receive their answers — in no uncertain terms — and are isolated and silenced. To be taken there is to understand a terrible truth about a brutal society and its ‘caregivers’ — that the new order is imposed by the same means as the old; and that to question this order is indeed ‘insanity.’

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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