Dim Cap? Or Dull Bulb?

• diminished capacity
• psychosis
• pre-trial detainee
• jail
• medication toxicity

I wrote “DIMINISHED CAPACITY” in small, capital letters on a valuable piece of paper with the three-inch plastic refill that served as my pen. Somewhere deep in the recesses filled with thick glue that had become my cognitive processing, I was familiar with this concept. I couldn’t place it, despite being a board-certified forensic psychiatrist. My attorney said this was the route to go.

It was fall, gray, and damp in the far reaches of the Pacific Northwest. I was in solitary confinement in a small, rural American jail. I wore a boot cast, having been stepped on by one of the arresting sheriffs. I was devastated because I would never see my children again. At best, every day I received an hour out of my cell. Using the jail phone in the dayroom was beyond me and could only be used to make collect calls to landlines.

Decades earlier I spent many years inside the King County Correctional Facility (KCCF) in Seattle, WA. Originally, I arranged electives at the jail because my outpatients from the local community mental health center were repeatedly incarcerated. Later, in my work as the Medical Director of Psychiatric Services at the KCCF, accompanied by clinical research,^1,2 I found ongoing meaning in providing direct clinical care to jail detainees.

I had also spent time in Washington state prisons. I joined a collaborative, multidisciplinary team through the University of Washington Department of Psychiatry; we provided direct case consultation, wrote scholarly papers based on jail and prison program outcomes for those with mental illness,^3,–,5 and advocated for legislative funding for programs for those released from prison.

Decades had passed since those early days in my career. My emphasis had shifted to those within the involuntary treatment system, and I had leveraged my role as the Chief of Psychiatric Services at the local community hospital to influence legislation and local care standards.

None of that mattered when I was in solitary confinement. I was terrified and unable to fathom why I was going to be thrown away. I had no idea how long I had been in the hole. I had been hit by Wings (one of the other women). I didn’t retaliate, despite wearing the boot cast and having my second-degree black belt in Tae Kwon Do. Even though Wings instigated the event, I refused to file charges. The morning after being hit, I was back in solitary. So was Wings, but that didn’t provide any comfort.

Legal proceedings swirled around me. I didn’t understand the terms of the extraordinarily high cash bail that had been set. I couldn’t understand when I was going to court, or why. Unbeknownst to me, the court had ordered a mental health examination. While I was surprised to be taken to a competency evaluation conducted by a former colleague, I was determined to use the opportunity to beg for help.

Meeting with the court evaluator was an exercise in cooperation, frustration tolerance, and bewilderment. We knew each other professionally. I had read his opinion concerning many people I had the honor of treating at the KCCF. We had taught in the same lecture series for forensic psychology fellows through the Western State Hospital graduate program. There was no bridging the gap that had come between us over the years. I was hungry, cold, and terrified. Probably a week had gone by since I had more than a sentence or two exchange with another human. He was distant, focused on the well-rehearsed task at hand, and wouldn’t make eye contact with me.

I mindfully let the court evaluator lead the interview, but became agitated when it was clear he could not grasp the significance of what I was saying and asking of him. Wanting to be helpful, and with his permission, I wrote notes alongside his interview. Multitasking, I answered his questions in a goal-oriented way, but simultaneously provided my own written narrative of what was really happening in my neighborhood, and in our nation.

The formal mental status exam was noteworthy. I was grateful that my children’s math teacher had shed light on how to successfully complete subtracting serial sevens from a random two-digit number. I objected when asked for the last four or five U.S. Presidents. I had been raised in Canada, and arguably was under a great deal of stress, so the question wasn’t cricket, or fair, at all. I suggested that it was a cultural-bound question being used to assess my fund of knowledge, and that perhaps it would be far better to ask me the names of the last four or five Canadian Prime Ministers. I didn’t get a response. But I was rewarded with a small smile, as one might give a child, when I produced the answers that he sought.

In a similar vein, I was struck by the three objects given to assess my short-term memory. “Penny, table, green,” he told me. As instructed, I repeated the three objects. I started to write them down, but was stopped. As a practicing psychiatrist, I hadn’t had a patient try to write the objects down and was pretty sure it wasn’t allowed. I couldn’t recall specifically being told or reading that, but followed the evaluator’s directions without comment. We then proceeded with an unrelated topic.

I mentally followed the evaluator and thought about the three objects. I knew that 67 percent of the test was simply my memory of money and furniture. Or, in other words, financial resources I couldn’t access, and the table, which was literally the object between us. I wondered about the wisdom of giving a detainee symbols of stability and status to remember, when the concern was primarily neutral short-term memory.

I had behaved in unusual ways in front of the video camera used to project the detainees’ presence in court. I argued with the court over my name. I was not Miss Harris. The court had added that inaccurate prefix and I wasn’t so much offended or superior as I was determined to slow my pending transfer to Guantanamo Bay. I believed that by insisting my identity was more accurately Dr. Harris, enough confusion would reign that I would have time to contact my children. Role confusion then seemed to take over. My own public defender objected to my insistent, constant interruptions and corrections. I objected to his objections, and the corrections officers (COs) dragged me away.

Not only had I argued with the judge over my name, I had appeared with “§2254” written on both of my palms, and insisted on showing them to the court through the video camera. Someone had posted the information from the American Civil Liberties Union (ACLU) on the cinderblock wall with toothpaste, and I thought it was specifically for me. 28 USC 2254, the federally protected rights of all jail detainees and prison inmates, as explained in the notice, seemed to apply. I needed someone to write a writ of habeas corpus to the court because I clearly should not be transferred to Guantanamo Bay. No matter what I had done, I reasoned, it couldn’t possibly have been bad enough to be sent there. I had dual citizenship with Canada and carried passports to both countries, but surely the United States criminal justice system would not allow me to be sent to Guantanamo Bay and tortured. I am a citizen of the United States, and we don’t send our own people there, do we?!!?

“Put your hands down.” The judge calmly but resolutely repeated herself. The other detainees sitting on the wooden bench that lined the camera court all wore orange scrubs, and made a solid hue behind me reminiscent of a pumpkin patch on a fall morning. I became aware every time I raised my hands to show my palms to the court, I had the undivided attention of all the gathered detainees and the three COs that crowded the tiny video interview room.

The video presence during my court hearings struck me as unfair and unethical. While clearly done as a safety and cost-saving measure, spectators in the court could see the detainees on camera, but the reverse was not true. Despite not being charged with any crime, I was repeatedly paraded forth for what felt like the entertainment value of those in person in the gallery. The spectators in the court were afforded privacy, but I wasn’t.

In solitary, even without books, paper, or pens, I managed to stay busy. I behaved in ways that guaranteed I would finally be seen by a psychiatric provider. I had long, loud, animated conversations with myself, offering all sides of various debates centered on political discourse. I did martial arts rolls on the concrete floor while wearing my boot cast, and spent my hour out of my cell examining the invisible grouting between the cinderblocks of the walls, with fear that an overdue earthquake would strike and the jail walls would crumble. I had discussions with national newscasters broadcast thru satellite TV. My disorganized, psychotic behavior was seen by officers on a variety of shifts and reported up the chain of command. I was taken to see a psychiatric provider who was on a computer screen.

Fortunately, my brain was able to register the person on the computer screen was real. And I registered his opinion that I was delusional. And that he believed the causative agent was a prescribed medication that I had been taking for approximately 15 years. He reminded me that particular medication was one that is typically not used in people my age (… my age!!…. Since when did almost 60 years become old?!). As he told me his recommended treatment plan to address the medication toxicity that had rendered me psychotic, I again slipped away from reality.

While I had decades of experience treating patients as they slowly made their way back from psychosis, I lacked personal experience. I had been delirious for the better part of a year from a medication toxicity that set in after years of successfully taking the prescription. It had progressed to psychosis and affected every waking moment of my life. I had suddenly developed auditory, visual, and tactile hallucinations that supported the developing delusional system I had concerning an ex-girlfriend, an ex-therapist, my neighbors, and my community. I was sleeping at odd hours of the day, couldn’t organize sequential behaviors beyond two-steps, and thought those around me to be “doppelgangers,” or replacements for real people that I knew.

My belief system, that the people had been taken away because they were predators waiting to be formally charged, caused my behavior that ran afoul of the law. As I was collecting their mail from the office to take it back to the post office, I was on video camera. My actions which supported the charges of mail theft and voter fraud (there were primary ballots in the mail I had collected) were clear. The video was later used in a state news story about voter fraud that I happened to catch one night while preparing dinner.⁶

In reality, I was not only wrong about the activities of my neighbors, I was wrong about those who were no longer around. Those that had left were snowbirds, moving to warmer climes in winter. As I became more ill, their absence and the dwindling neighborhood population were incorporated into my psychotic belief system, and I became more confused and frightened.

National political events also became ensnared in my ever-expanding delusional system. I could not understand why, nor did I want such fame. But I eventually came to believe myself a national whistler-blower in the judicial hearings around the possible impeachment of our (then) President. And it was directly tied to the predatory behavior of my neighbors.

Returning to reality in jail was not linear. There were encouraging events around me; I finally had a private attorney. I had been let out of solitary and was allowed back into the women’s cellblock milieu. I acted emergently as a physician during two fentanyl overdoses, and had to endure searches afterward because the drugs were still around. But I was with people again. Importantly, I had extra food and clothing because I had convinced the Superintendent to allow me access to my cash that was held across the street in the Sheriff’s Department. And I was no longer worried about personal safety in the cellblock. Wings had been neutralized and was in a different area because she was involved with the drugs. My stories of being a physician who became ill on prescribed medications were heard with amazement, and my newfound clothing and commissary guaranteed friendly respect from the other women. Life was definitely looking up.

I remained focused on recovery. I discovered I was significantly cognitively impaired. Numbers made sense again, but I had lost my ability to manipulate them with ease in my mind. I couldn’t learn new information, and was unable to integrate pieces with knowledge that I had, or should have had. It made for social challenges. I had trouble learning card games and the social hierarchy and rules. Newspapers and magazines were long out of date, but I had insufficient attention to complete an article. I couldn’t learn the complicated telephone tree to call my cherished friend even though I could now remember her landline number and knew that I was wrong about the predator ring. I was remarkably blasé. I knew I had a high cash bail ($100,000 without allegations of harming a person or property), but could not discern the charges. Despite all unknowns, including the status of my beloved dog, cognitive recovery was a high priority.

I developed for myself the best inpatient psychiatric program that I could. I knew the importance of structure, flexibility, creativity, and reinforcement. I knew that compassion, humor, and persistence were needed, and I would have to supply the bulk of these qualities. I wrote and followed a daily schedule. I would have to replace it twice until I learned where to hide it because posting anything was forbidden. I included time for my “After Action Plan” from the previous day, social time, religious study and spiritual practice, physical exercise, and several de-stimulation periods throughout the day because I found the milieu overwhelming.

Of importance was returning to my mainstream religious practices, once I was well enough. I took advantage of yard time in the early morning when no one else in the small jail wanted access. I used one blanket as a skirt to keep away the morning frost. The other was my tallit, as I walked, chanted, was mindfully thankful, and greeted the day. I carefully drew two lit candles on one side of a paper to mark the start of the seventh day of the week. The candles I drew on the other side of my paper were entwined and extinguished, symbolizing Havdalah or the return of the workweek. I used the package of crystalized red sugar and Vitamin C with warm water for wine, and saved the predictable sweet bread from Friday lunch. As the sun set on Friday afternoons, seemingly early because the windows were so high on the walls, I used ritual to find solace and peace, and imagined community that spanned continents and generations. Even in jail, or perhaps because I was incarcerated, it was crucial to separate the sacred from the mundane, as many across the world do every Friday at sunset.

My approach to cognitive retraining was simple. I started with paragraphs from the newspaper. I read, reviewed, wrote notes, and reviewed in my mind again. Over and over, I repeated this, until I could learn new pieces of information. I then advanced the complexity, in terms of content and length. Because I had been in solitary, the only group I was allowed to attend was Bible study, so I had buddies bring back magazines and fresh newspapers from the classes they were allowed to attend. My day started at 0410 with a loud metal bang as the cellblock door slid open for med call and the lights went on. My day ended at 10 pm when I had already been locked in my cell for an hour, and the lights went out. It was exhausting work.

When the reality of the evaluator’s incompetence findings sank in, I became more desperate to make bail. I vaguely and intermittently remembered a landmark case finding from Washington state, that extensive pretrial detention pending competency restoration was a violation of the defendant’s Constitutional rights.^7,8 It would be almost a year until I could focus enough to research my inklings about the landmark case. That didn’t matter much because I was desperate to avoid going to the state hospital. I had not only taught there with the court evaluator, I had also conducted research there as a psychiatric resident.⁹ I knew it to be under-staffed. It was thought to be a place of both over-medication and danger to patients and staff.¹⁰ My attorney offered that it had to be better than jail, and that perhaps I would be sent back earlier than the “… up to 45 days ….” usually ordered.

I disagreed with my attorney’s fundamental offer of hope that perhaps they would send me back earlier. I understood healthcare systems and workflow concerns. I knew the largest body of work required by staff was at admission and discharge. In between is routine work. There is a workload disincentive for staff to discharge patients early because there will simply be another new patient (with the incumbent heavy workload) waiting for the bed. I could see the research design that would easily refute my hypothesis, but said nothing. Best to avoid the place altogether, if I could.

My attorney tried unsuccessfully to have bail lowered or converted to a bond. My older sister passed away the summer I was ill. Only one of my brothers was able to accept collect phone calls. Arranging business was virtually impossible because I did not have an active Durable Power of Attorney for Financial Matters. While I was fortunate that the psychiatric provider had just assumed competence for healthcare decisions, my initial attempts to sell my tiny houses for cash were stopped because of questions concerning contractual competence. In the meantime, I learned how to manage my commissary and protect my space. I had labeled all my religious work: “Legal Work for Victoria Harris,” so it wouldn’t be destroyed in the next drug search.

I was stunned when I was finally released. Women in both cellblocks cheered as I was escorted down the hall. I jumped at the sounds and the CO gently said “… that’s for you ….” I knew they were also cheering for themselves. For hope of release and reentry. And hoping that maybe, they didn’t belong. Whatever the reasons, I was surprised.

Being homeless, on bail, and in uncertain legal territory was frightening. I was concerned with medications, having been released with only two weeks supply, at my cost and insistence. While fortunate that I had resources I could access once released, bewilderment persisted as I attended to basics of food and housing security for both myself and my beloved dog. I could follow the chronology of what had unfolded, and could easily understand how a medication toxicity could unfold in that manner. What I couldn’t understand was my inability to get help before I ended up in the criminal justice system.

I knew that I had been a tad socially isolated, but was fully transparent in therapy as I decompensated. My brothers knew pieces of my world, but had developed their own diagnosis and management plan that missed the underlying etiology. I was embarrassingly public on social media as to my beliefs and fears. I experienced mild aphasia, had seen my primary care provider and had an MRI with angiography that was normal in anticipation of a pending neurology appointment. Even in jail, I called the ACLU and was told they couldn’t help. I was howling in panic one night in solitary, convinced that my transfer to Guantanamo Bay was imminent and I would never see my children again. No one responded to my desperate cries for help. During my hour out, I called every private defense attorney that had their card pasted on the cinderblock wall. I called them twice over about a week. When I started with the third round of calls a month later, my newly hired attorney told me that others knew I could not engage an attorney beyond the public defender that I had been assigned.

Once released from jail, I was vulnerable, worried that I would become sick again and repeat my failures at getting help. I was terrified I would be returned to jail. When the charges were finally filed, I was horrified and ashamed to discover the number of serious allegations. By that time, however, I was familiar again with the concept of mens rea. I could see that both my behavior and the reasoning behind it fit the M’Naughten Standard for an insanity defense.

As I cleared in jail, I also vaguely remembered that my fundamental due process rights had been ignored. I spoke for a good 30 minutes during the ride to jail because I wasn’t Mirandized until I said “… don’t you have to read me my rights or something?”

Earlier, I wasn’t shown the search warrant for my home, despite asking for it. I remember a deputy waving his cell phone at me as his giant frame dwarfed the entry to my tiny house when he barged in. He said “…. It’s right here!! And now you! …. Turn around!!” And the cuffs came out. It was also a typical rural town legal system with prosecution and the arresting deputy being married, and hosting Thanksgiving dinner for others in town, including my private defense attorney.

Leaving out how I felt about where he ate Thanksgiving dinner, I spoke with my attorney about my concerns. I didn’t want to plead guilty to anything. I believed that doing so would trample the rights of others, regardless of whether they had a mental health condition. When I gently broached how I had been treated by his old high school buddy, the arresting deputy, my attorney bristled. I was told if I insisted on going to trial, pleading Not Guilty by Reason of Insanity, I would need a new lawyer. Did I need a new lawyer?

As a compromise between pleading guilty to any charge or insisting on going to trial, I supported a series of conditions for dismissal of all charges. My neighbors testified as to the chaos I had caused and the psychological damage they experienced. I felt terrible. Never in my life would I have imagined that I would so transgress against others. I was also confused. This was not a sentencing hearing; why were victim impact statements being read? Despite the challenges to listening, I paid careful attention. I had plans to offer reasonable repair. Beyond my private, specific plans, and the apology I offered to the court, to the community, and my neighbors, maybe there was more I could do. No one spoke of their desire for PTSD therapy, or requested other treatment modalities they were interested in, but perhaps couldn’t access.

The conditions were punitive, requiring my physician to report me to the court and allowing for my rearrest should I become ill again. In no way was adherence or severity factored in, nor was I to be allowed to find (or helped to find) psychiatric hospitalization. I was to be rearrested if I became ill again.

Many of my experiences while ill and part of the criminal justice system have left an indelible mark. Moving forward with my life, the sum of my personal and professional experiences help frame several main areas for my new roles in advocacy and education.

• © 2024 American Academy of Psychiatry and the Law