A life diminished by the province's care

Simon Stubbs tapped open Instacart one day in late September. A bottle of extra strength acetaminophen sat in his cart from a previous visit. He added some groceries, completed the order, and then waited for the delivery in the reception area of the Royal Jubilee Hospital adult mental-health unit known as One South, or 1S. At 5:18pm, a staff member on the unit opened the door, allowing a delivery driver to hand a bag containing an over-the-counter pharmaceutical to a psychiatric patient with a history of suicide attempts.

Simon took the bag back to his room. He expected a nurse or mental health care worker to appear at any moment, search the bag, and confiscate the pills. When it became clear that a search wasn’t going to happen, he began swallowing the pills by the handful.

He was sick of hospital life. He’d been stuck at Royal Jubilee for the better part of three and a half years. Other 21-year-olds were getting jobs and moving into their own apartments. He was losing hope that he’d ever hit those milestones, and living with his family wasn’t an option. Simon had a history of self-harm and required high levels of supervision and support—too much for his mother and stepfather, who had full-time jobs.

When Simon was 18 and still at home, he’d frequently end up in the emergency room—for insulin overdoses, catatonic panic attacks, and mysterious non-epileptic seizures. The living-at-home arrangement came to a halt after Simon confessed that a persistent voice inside his head was urging him to poke his younger brother with insulin.

At 19, he became a client of Community Living BC (CLBC), a crown corporation that works to keep people with developmental disabilities in the community and to connect them to funded services. CLBC has been trying to find Simon suitable supportive housing ever since.

A biracial transgender man with Type 1 diabetes, developmental delays, and mental-health struggles, Simon sometimes thinks of himself as a square peg that the province is trying to force into round holes.

There have been several false starts: in a home share (with a chronically ill caregiver), a group home (with staffing problems and nonverbal, elderly residents), and, most recently, an independent living facility (augmented by services from contracted support workers). None was specifically designed for youth with complex-care needs; all failed disastrously. A perfect solution doesn’t seem to exist, and the province—despite its piecemeal tinkering—has failed to find even a workable one.

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Last summer, a spot opened up at Comerford, an independent living facility in Esquimalt for people who have persistent mental-health challenges, substance-use issues, or both. Residents live in their own apartments, with access to 24-hour onsite staffing and mental-health check-ins. The Island Health facility, however, isn’t set up to provide medical care. Nor is it equipped for residents with developmental disabilities.

Simon’s advocates, family, and care providers knew Simon wasn’t ready for independent living. But the choice was between trying to make Comerford work or having him remain indefinitely in the hospital.

As Simon eased into Comerford on overnight passes, the hospital kept a bed for him in case he needed to return.

To give the placement a chance to succeed, CLBC contracted with a not-for-profit health-care agency to provide in-home support for three hours per day—to help Simon build independent living skills, such as grocery shopping, budgeting, and meal preparation—and arranged for him to have an hour of dialectical behaviour therapy every week.  The support workers, however, didn’t always show up. Worse, the onsite medication management at Comerford excluded insulin, a drug Simon was known to abuse. From a safety standpoint, it made zero sense for Simon to keep insulin in his living space, but at Comerford there was no other choice.

Predictably, he overdosed repeatedly—both on over-the-counter pain medication and, once—accidentally, he says—on insulin. Simon’s medical records note that a psychiatrist spoke with him after the insulin overdose, telling him that his behaviour “in the past 10 days, of overdosing with nonlethal amounts of over-the-counter substances, and being seen daily in emergency, was not conducive to Comerford housing long-term.”

Less than two weeks after he’d relinquished his bed at Royal Jubilee, Simon was readmitted to 1S.

A psychiatrist at the hospital wrote in Simon’s file, “Patient feels safe in institutional care and consciously or unconsciously behaves in ways in order to ensure ongoing admission to medical units.”

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Despite feeling safe in institutional care, Simon longed to be independent. With Comerford a bust, he was demoralized.

He settled back into hospital life but was quickly exhausted by the familiar routine. Insulin injections throughout the day; finger poke after finger poke. A seemingly  ever-changing cast of psychiatrists and throw-everything-at-the wall diagnoses: psychosis, borderline personality disorder, factitious disorder, somatic symptom disorder.

The spots of joy—daily visits with his granny or mother; weekly outings to study with his long-time vocal coach—were what kept him going.

Sept. 30 was a particularly rough day. During an appointment with an endocrinologist, Simon sensed a lack of compassion. The words morbidly obese landed like a scold.

Afterward, Simon refused to submit to a glucose check and was observed by staff punching his bed and crying.

He wanted to get outside, go for a walk, and burn off some energy. Staff wouldn’t allow it. He tried to impress upon them how desperately he needed to get out, how tired he was of the diabetes routine. The message he heard in return— Get used to it; this is life— felt unbearable.

He opened Instacart and saw the bottle of acetaminophen in his cart. He then selected groceries—yogurt, granola bars, ginger ale, cheese sticks, potato crisps—to provide cover.

Simon says he didn’t want to die. He’d just wanted the “gigantic emotions” to stop.

After swallowing the pills, he felt sick to his stomach. He handed the bottle to a nurse and told her what he’d done. It was missing 63 pills.

Simon was quickly given a mixture of activated charcoal and water to drink, to reduce the drug’s absorption. Afterward, he vomited about a litre of black fluid, and then spent several days being treated intravenously with an antidote to prevent liver injury. “It took weeks until I started to feel normal again,” he says.

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Simon’s mother, Jennifer Stubbs, was livid when she heard the news. How could a psychiatric patient obtain—let alone overdose on—an over-the-counter drug in the hospital?

An email from Stubbs appeared in my inbox a couple of months later, in early December. I had previously written about Simon’s search for supportive housing (before he began his gender transition), about how his particular housing needs had stumped the province, despite the efforts of his dedicated family and team of fierce advocates from multiple provincial agencies. The search had begun in 2019. That it was still happening at the end of 2022 was, in Stubbs’s eyes, both devastating for her child and a mark of shame on the province.

The Ministry of Mental Health and Addictions is well aware of the gaps in the system for people like Simon. In 2021, the province estimated that 2,200 people lacked complex-care housing services. In response, it created a complex-care housing program, aiming to serve 500 people over the course of three years with $164 million in funding. The ministry calls the program “a ground-breaking approach” to address the needs of people with overlapping “mental health, substance use, and other complex health challenges who are often left to experience homelessness or are at risk of eviction.”

As of April 1, only 184 people in the province were receiving complex-care housing services; 17 of them in Victoria.

The email Stubbs sent me was familiar in its end-of-the-year delivery of bad news (another December with Simon stuck in the hospital), but remarkable in its desperation. “SS has 0 quality of life!” she wrote.

Following Simon’s overdose, Island Health had transferred him to the hospital's psychiatric intensive care unit (1N), where he was being held involuntarily under the Mental Health Act.

On the less restrictive unit of 1S, he’d at least managed to create a life within the confines of the hospital that allowed for creative nourishment, study, and family. The life came with limitations, and it wasn’t all he wanted, but he’d been able to regularly spend time outside the hospital setting for voice lessons and to attend a course on medical terminology at Camosun College. He also left the hospital to help his grandmother grocery shop, to work out, and to assist with the sound for a live production of The Rocky Horror Show at the McPherson Playhouse.

Now, he could no longer do any of those things. He wasn’t allowed out of the hospital, even with supervision. He could take in fresh air but only in small doses, and only while standing on a small, viewless patio. Access to it was through the visiting room and was denied any time a patient on the unit was threatening to escape, which happened “very often,” according to Simon.

The new situation burdened Simon’s connection to his family. With his cell phone taken away for his own safety, he couldn’t call his family at will. Visits had to be planned in advance, were confined to a visiting room, and were limited to one hour. Minors weren’t allowed on the unit, a rule that kept him from seeing his 15-year-old brother.

Simon’s freedoms were so restricted that Stubbs thought of him as being in “psychiatric jail.”

And there was no end in sight.

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I accompanied Stubbs on a visit to Simon a few days after receiving her email.  A staff member greeted us at the door to the psychiatric ICU and then led us down a hallway and into a cheerless room with low ceilings and fluorescent lighting. A white board hung over a couch. A piano, pushed up against the same wall, was missing a bench.

The staff member locked our bags in a low cabinet under an interior window that allowed staff members in the hallway to see inside.

Simon was waiting for us at a small game table with a checkerboard top. He wore a hospital-issued pyjama shirt, its champagne-yellow colour an almost exact match to the wall behind him.

As we joined him at the table, Stubbs handed him a stuffed toy lamb he’d owned since he was an infant, and a stuffed toy giraffe that had been the conduit through which he’d revealed his suicidal thoughts to her several years earlier. He clutched them to his chest, hugging them tightly, eyes closed, savouring the moment.

The stuffed animals could make only brief visits. Other tools he’d long relied on to soothe himself—a weighted blanket, Netflix—were completely off-limits in psychiatric intensive care.

“They won't let me back onto an open unit because they think I'm too much of a safety hazard,” he told me. “But that means all of my coping skills basically get taken away.”

He looked down as he spoke, twirling a loose thread from his sleeve around a finger. He’d been injecting testosterone for about six months and was starting to grow facial hair. His voice was deepening.

Stubbs was still getting used to the changes—and to calling him by the name he’d chosen for himself as a nod to a Kinky Boots character whose fearless embrace of his authentic self Simon found inspiring. Simon had been diagnosed with gender dysphoria and cleared for testosterone treatment and top surgery after two hours of video sessions with a doctor from an outside clinic in the Comox Valley, despite the concerns of a Royal Jubilee psychiatrist directly caring for Simon. That psychiatrist had suggested that Simon wait to start on testosterone until after he settled into community housing, an idea that made more sense to Stubbs. She couldn’t believe a psychiatric patient—especially one who’d been diagnosed with factitious disorder, a condition in which a patient fabricates physical or psychiatric symptoms—had been considered of sound enough mind to start a gender transition.

At times Stubbs thought Simon seemed dazed on visits.

“Have you been put on more meds?” she asked.

Simon was clearly alert, but his lack of eye contact was disturbing. He said he had been put on “a lot more” medication since arriving in psychiatric intensive care. He rattled off the names of nine he said he took daily:  “And they keep trying different antipsychotics, but they don't work, because I'm not in psychosis.”

I asked Simon how he passed the time. “Once the doctor comes, I basically have no real sense of purpose for the rest of the day,” he said. He was sleeping more than usual and spending long hours alone in his room, a space without art or personal effects—a space with “throw-up green” walls.

Beyond Zoom lessons with his vocal coach and an hour of dialectical behaviour therapy once a week, there wasn’t much to do. He had no social outlets, and few opportunities to bond with other patients. They tended not to stick around for long after they were stabilized, and he was wary of most of them anyway.

Everyone on the unit had been certified under the Mental Health Act. The average stay was between 16 and 20 days. Simon had been there for more than 68.

His family worried about the consequences of a prolonged stretch in such a restrictive environment. His grandmother noticed that he was growing restless and frustrated from a lack of activity and seclusion. His mother described him as withering away. His stepfather, too, believed that Simon’s condition was now worse than it was three years ago, when Simon had first sought help for his mental-health struggles, and that Simon “deserves a better life than this.”

And it wasn’t just his family that was concerned.

“I have even heard the nurses saying that me being in here is sort of like me deteriorating,” Simon told me. “And that's never something you want to hear.”

When our hour was up, Simon reluctantly returned his stuffed animals to his mother.

“Can I get some more hugs?” she asked.

After they embraced, Simon walked over to the locked door that would take him back to his room. Stubbs had been allowed onto all of Simon’s other hospital units, seen his living conditions, talked to the nursing staff—access from which she’d derived comfort. Now, she watched apprehensively as Simon waited to be let back into the living quarters. “I have no idea what’s on the other side of that door,” she said.

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Stubbs was adamant that Simon didn’t need to be in psychiatric intensive care, though she acknowledged the logic of it, given his overdose on the less restrictive unit.

“It’s an obvious attempt at risk mitigation and liability control, and I get it,” she said. But the move had seemed knee-jerk to her. Simon didn’t meet the profile of someone she expected to be admitted into 1N: he wasn’t delusional; he wasn’t in psychosis. To her, it seemed he was being punished because hospital staff “fell asleep at the wheel.” Weren’t there solutions, short of psychiatric jail, that the hospital could employ to keep Simon safe?

“When Simon is on a medical unit, they have round-the-clock health-care aides at the door,” she said. “Simon is never unobserved. But when they’re moved back to psychiatric units, they remove that service. Why wouldn't you just put an HCA [Health Care Assistant] at the door?”

Stubbs also believed Simon needed intensive therapy. “We’re trying to unwind 20 years of maladaptive behaviours, and that sure as hell [is] not going to happen in PIC,” she said.

But the truth was, intensive therapy hadn’t happened in any of the less-restrictive units Simon had been in, either.

Those were wasted years, according to Stubbs: “If you really can't allow therapy to happen in an acute care environment, why isn't the government finding a solution where therapy can happen?” Without it, she said, “We've just created new behaviours, new traumas, and now institutionalization.”

The inability to find a solution for Simon had not only been hard on him, it’d been hard on the whole family. “This is the conversation that dominates every family meal, every conversation,” Stubbs said. “I have no relationship with my mother other than to talk about Simon. It's stolen the last four years of our life.”

Nobody who loves or advocates for Simon ever thought prolonged institutionalization would be good for him. For years Simon’s family and advocates—various people from the Representative of Children and Youth; Inclusion BC; Community Living Victoria; and, at times, the Office of the Advocate for Service Quality—have been meeting with CLBC and Royal Jubilee staff in an effort to get Simon out of the hospital and into supportive housing.

After a failed home-share arrangement lasted only 17 days in early 2021, a doctor readmitting Simon to Royal Jubilee noted in Simon’s file that a “lengthy hospital stay” would not “serve to encourage autonomy and independent coping strategies.”

Why then, two years later, was Simon still hospitalized, having had only brief respites in the community?

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Royal Jubilee Hospital. Photo: Jimmy Thomson / Capital Daily

For about a hundred years dating from the late 1800s, norms dictated the warehousing of people with mental illness and developmental and intellectual disabilities. Institutionalization fell out of favour in BC, and elsewhere, in the 1970s and ’80s. With the rise of the disability rights movement, and activists promoting inclusion rather than social isolation and placing disability issues in the context of human rights, the province began moving toward building smaller-scale residential options in the community and bulking up local support networks.

In 1996, with the shuttering of Woodlands hospital (created as an asylum for “lunatics and the feebleminded”), BC became the first province to close all of its large residential institutions for people with intellectual disabilities. Evidence later emerged that residents of Woodlands were subjected to sexual, physical, and emotional abuse, and that the abuse had been systemic.

Today it’s widely understood that people tend to have a better quality of life in the community than they do in residential institutional care. Despite this knowledge and the shift in resources toward community-based care models, harmful institutionalization still happens in Canada.

In 2019, the Nova Scotia Human Rights Commission heard a case concerning three people languishing in a locked unit of a psychiatric hospital. One had spent 15 years there with no medical justification.

The commission’s board of inquiry ruled that the province had discriminated against the three complainants—one of whom died during the proceedings—by keeping them in a custodial setting “against all advice,” when they no longer needed the acute care service the institution was “purposed to provide” and it was no longer in their best interest to be there.

In 2021, Nova Scotia’s Court of Appeal went a step further, ruling that the discrimination was systemic. It increased the amount of damages awarded to the two remaining complainants from $100,000 to $200,000 and $300,000. But 12 days before that decision was released, another complainant died.

For all its obvious faults as a long-term accommodation, Royal Jubilee Hospital should at least have been able to provide Simon with a safe environment.

His propensity for self-harm was hardly a secret. His care team was well aware of his history of insulin abuse and overdosing on over-the-counter medication. According to Simon’s medical records, shortly before he got his hands on the bottle of acetaminophen, a psychiatrist noted that Simon was having “vague passive thoughts of over-the-counter overdose.”

How did Royal Jubilee fail to keep him safe?

I reached out to Island Health. Citing privacy legislation, a spokesperson declined to comment on the particulars of Simon’s situation. The spokesperson did, however, say in an email that while there was no specific policy regarding deliveries to patients, “All new items brought on to the unit are to be searched by a nurse or mental health worker” and that prohibited items include weapons, lighters, and drugs not included in a patient’s treatment plan.

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Before Simon’s long years of institutionalization, he seemed to be on a trajectory toward independence. He graduated with honours from a private school for children with learning disabilities, worked a part-time job at Thrifty Foods, took college courses, performed in musicals, and advocated for himself and other kids with diabetes through the Rick Hansen Foundation.

His family and advocates believe institutionalization has taken a toll.

“It’s hard to comprehend how somebody who was, relatively speaking, high functioning before this three-and-a-half year window, has spiralled into the most restrictive arm of the health sector,” said Cary Chiu, the advocate for service quality in the Office of the Advocate for Service Quality, an independent agency that reports to the minister of Social Development and Poverty Reduction. “I mean, you can't get more restrictive than being involuntarily committed.”

Chiu’s office looks into complaints concerning CLBC clients, ranging from funding issues to quality of care. Based on its findings, it can make recommendations to CLBC, which aren’t public and which CLBC is free to ignore. But the office can draw attention to individual cases and experiences in its annual reports, and Chiu is anonymizing Simon’s experience for the next one, which he expects to publish in mid-May.

Stubbs first alerted the office to Simon’s situation in 2021. It closed the file after CLBC found what seemed a viable option in a group home and then reopened it last fall after she reached back out to say that Simon’s situation had grown worse.

CLBC does not keep track of the number of its clients who spend more than six months in acute care waiting for appropriate supportive housing. But as of March, Chiu says, Royal Jubilee had four residents in acute care who were in situations analogous to Simon’s, in which their multiple care needs could not be met by the current system and who were in the hospital only because there was no alternative housing option.

Chiu suspects that number is the tip of the iceberg. “For every Simon that we see or hear about at this office, we're pretty sure there are dozens of individuals across the province who we don't even hear about,” he said.

BC’s 2023 budget includes $169 million to build hundreds of complex-care housing units. It also includes $97 million for enhanced health supports at those and existing locations. “Every person in British Columbia deserves a home – somewhere they can feel safe and live with dignity,” a spokesperson for the Ministry of Mental Health and Addictions wrote to me in an email.

Simon’s case seemed to be going nowhere, but not for lack of attention. It was on the radar of all the right people. As someone who’d worked for more than two and a half decades in BC public service, Stubbs knew her way around the provincial government. “Jenn's quite sophisticated, and bless her, she’s so, so committed to advocating,” Chiu said. “It's definitely not the average family member in terms of knowledge or sophistication.”

With Simon in psychiatric intensive care, there was now an unprecedented sense of urgency among his advocates, CLBC, and Island Health to come up with a housing solution. “They totally understand that this is not acceptable,” Chiu said. “This is tantamount to incarceration. And Simon is being incarcerated right now, for no reason other than the proper supports and resources don't exist.”

He added, “It’s only been under that type of egregious kind of a backdrop that the more heavy duty conversations are happening at the agencies now—they can't really fall back on, ‘Oh, we're doing what we can.’”

During a case conference in December, tertiary care was raised as a possibility. Island Health operates two inpatient tertiary care programs on Vancouver Island. Together they offer 67 adult beds and 21 senior beds, and provide residents with individualized treatment and “psychosocial rehabilitation,” with the goal of achieving “maximum independence,” according to Island Health’s website. The programs are staffed by multidisciplinary teams, including psychiatrists, registered nurses and psychiatric nurses, social workers, dieticians, licensed practical nurses, and therapists.

But in order to be accepted into tertiary care, Stubbs learned, Simon would first need to spend 90 days at CLBC’s Pacific Assessment Centre (PAC) in Vancouver so he could receive a “care plan.” Stubbs said CLBC rightly rejected the idea. “The waiting list for PAC is typically six months to a year,” she said, adding that even if Simon went to PAC, there would be no guarantee that a tertiary care bed would be available to him after he got the care plan. If a requirement of tertiary care was having a care plan, she wondered, why couldn’t Island Health just create one for Simon at Royal Jubilee, an Island Health facility?

A few days before Christmas, Simon was transferred out of psychiatric intensive care and back to 1S, the open adult mental health unit on which he’d overdosed on acetaminophen.

“At this time I’m unclear of the treatment plan, disposition and where our responsibility of care ends,” a Royal Jubilee psychiatrist wrote in a progress note on Dec. 28. “Hospital has clearly made things worse.”

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Simon's room on 1S. Photo: Submitted

Four months later, Simon remains hospitalized on 1S—it’s still not where he wants to be, but compared to psychiatric jail, it’s a welcome relief.

He can leave the hospital on three- and four-hour passes, unsupervised. And he’s found outlets for creative expression. He recently gave a sultry performance in a youth queer cabaret, belting out a crowd-pleasing musical theatre medley. He’s also helping out with sound for a new production at McPherson.

His family and advocates have mapped out his support needs, believing that any successful placement in the community would have to at least include medical care for diabetes management, trauma-informed counselling, psychological support for deinstitutionalization and rehabilitation, gender-affirming care, and support to help Simon acquire basic living skills and safely increase his independence.

Shortly after Simon was readmitted to 1S, Stubbs, frustrated that nothing was on offer from the province, looked into private residential treatment options. She found a promising one in Tucson, Arizona. According to its informational material, the facility addresses “co-occurring issues” with comprehensive evidenced-based treatment, custom fit to each resident. There was no way the family could afford the hefty tuition, but Stubbs thought that since the province, in some cases, subsidizes private residential treatment for people with substance-use issues—for example, it funds beds at Edgewood Treatment Centre in Nanaimo—it might be willing to do the same for youth whose complex-care needs it hasn’t been able to meet.

The exploration didn’t get far. In January, a psychiatrist at Royal Jubilee stunned Simon’s family and advocates when he announced that he’d winnowed down Simon’s diagnoses. Only one stuck, he said: borderline personality disorder.

With the scrapping of diagnoses came the understanding that Royal Jubilee had nothing more to offer Simon. An acute-care setting was not where personality disorders were treated.

“When the advocates were told of the new diagnosis, there was a collective gasp,” said Chiu. “The preliminary feeling was that that kind of treatment is going to be the responsibility of the family to arrange. Island Health can potentially facilitate with referrals, but at the end of the day, it's really the family's proactive responsibility.”

Stubbs was gobsmacked. From her perspective, Island Health was washing its hands of Simon after subjecting him to several years of soul-sucking hospitalization. “This has just been trauma on trauma on trauma,” she said. “We’ve institutionalized someone for three-and-a-half years, primarily in acute care wards, who needs therapeutic intervention and hasn’t had any.”

A discussion with Simon’s psychiatrist didn’t go well, she said: “I have been told now that I should just expect that Simon is going to go out in the community, and Simon is going to hurt themselves, and Simon will have to deal with the consequences of that—up to and including death.”

Simon isn’t sure he agrees with the new, singular diagnosis. “There's been a conversation between me and my psychiatrist about whether or not the whole gender bit is because of the borderline personality disorder or if it's true gender dysphoria,” he said recently. “Part of borderline is being flip-floppy with who you are and not really knowing who you are as a person. But I make the argument that I do know who I am as a person, and that it’s just changing so that my body and my brain feel connected.”

Because of the re-evaluated diagnosis, Simon has been taken off most of his medications. He says he feels great as a result.

Chiu says CLBC has indicated that the plan is to send Simon back to Comerford as soon as there’s a vacancy—probably sometime in the next three months—only this time with more supports in place.

The stakes for a successful community placement are higher than ever, since Royal Jubilee doesn't offer beds to people for the treatment of personality disorders.

In mid-April, Stubbs said Island Health and CLBC seemed to be collaborating at the “executive level,” which she’d never seen before. “Part of the problem last time with Comerford is it was set up with extra services coming in from CLBC, and then those extra services didn't show up,” she said. The Island Health staff at Comerford “didn't know when [the support workers] were supposed to come, didn't know who they were, didn't have any authority over the contract to say, ‘Where are you?’” Stubbs said. “They left it with Simon to manage.”

The new plan, she said, was for CLBC to pay Island Health, rather than an outside agency, to provide extra support staff for Simon. But a couple of weeks later, Stubbs told me the funding was still being worked out, and that now a cost-sharing arrangement between CLBC and Island Health was being negotiated.

“Every time someone with complex needs needs services from multiple agencies, they have to reinvent the wheel,” she said. “Policies, procedures, shared budgets, and a cross-agency navigator that would allow for effective and efficient collaboration between agencies don’t exist.”

Regardless of the funding arrangement, without a plan for Simon’s insulin to be stored safely out of his reach, it’s hard to think of Comerford as a viable option. “Comerford staff cannot store, monitor, or administer insulin,” Stubbs points out.

On 1S, Simon has been administering his own insulin and testosterone under supervision, and he says he’s matured since his last attempt to live in the community. Still, he acknowledges, “I'm not ready to have months worth of medications at a time in my apartment.”

And so he waits for a new housing plan to take shape, living life on a psychiatric ward, as he’s accustomed to doing.