Unintended Consequences

Rena Pederson

What does a humane city do with those who are not mentally capable of caring for themselves?

It’s an old question. We get our word bedlam from the old London hospital St. Mary of Bethlehem – condensed to Bedlam. It was where the demented were kept so the name has come to mean any noisy, confused place. In the U.S. back in 1841, social reformer Dorothea Dix was horrified when she entered the East Cambridge Jail. She had volunteered to teach a Sunday School class for women inmates. Upon entering the jail, she witnessed such horrible images, that her life was forever changed. She observed prostitutes, drunks, criminals, retarded individuals and the mentally ill all housed together in unheated, unfurnished and foul-smelling quarters. When asked why the jail was in these conditions, she was told, “the insane do not feel heat or cold.”

She took the matter to the courts and after a series of battles finally won. Soon her investigation took her across the entire state of Massachusetts. She made careful notes and delivered results to the Massachusetts Legislature. As a result, funds were set aside for the expansion of the Worcester State Hospital. Her views about the treatment of the mentally ill were radical at the time. The popular belief was that the insane would never be cured. However, Dorothea Dix showed, just by bettering the conditions of the inmates, that mental illness could be cured, improved or alleviated. She eventually took her crusade across the country, visiting every state east of the Mississippi. She played a major role in the founding of 32 mental hospitals and 15 schools for the feeble-minded, as it was known then. Today she is mentioned in only 10 percent of general history books. She refused to have her name placed on the hospitals she created, so she is largely anonymous today.

A century and a half later, we are still struggling with the question of what to do with those who are mentally unstable?

It’s an issue with particular resonance for me. Back in the early 1970s, I started work at The Dallas Morning News as a reporter, covering the federal beat. One of the lawsuits I covered was filed on behalf of a patient at Terrell State Hospital, the primary state mental hospital for North Texas, because he was so abused while under state care, his parents alleged, that his mental and physical condition dramatically deteriorated. There were other allegations in other suits alleging mental patients had been raped, beaten with brooms, neglected. I decided that the only way to weigh the allegations was to go see for myself. So for several months in 1974, I posed as a volunteer at Terrell State Hospital using my married name. I wrote a series of articles for The News called “Out of Sight, Out of Mind.” If I may be so bold, I would like to read some excerpts for you now:

“Terrell, Texas – At first I thought I must be crazy myself to pose as a volunteer at Terrell State Hospital. Now I’m glad because I learned two very important things while searching for the “inside” story”:

* The public should be more concerned with humanizing its state mental hospitals – if for no other reason than as insurance. Because some unlucky, unhappy day, it could be you or your wife or your ailing father or your retarded child who is abandoned to the sorrow, the boredom, the horror of a mental institution, overcrowded and understaffed.

At Terrell I met a former fashion model … an engineer from General Motors … an insurance executive … teen-agers confused by drug and family problems …. plus mentally retarded children who had been more of an embarrassment or a bother to their parents than a danger.

What most of the patients had in common was that they were all from families, rich or poor, who probably never dreamed they would one day give their relatives over to the state. (But many do, because they cannot handle the erratic behavior or cannot afford private care.)

* The staff members at the hospital are working in a heartbreaking situation for paltry pay. But the thing they want most is understanding from the community. First they need help and cooperation, and then, maybe, they can get more money from the Legislature.

I don’t think it ever occurred to the volunteer office staff that I might be a reporter because they were so desperate, so eager for volunteers.

I was assigned to work Tuesdays in the geriatrics ward with Mrs. Jeanetta Smithers, a recreation therapist overloaded with 250 old persons to rehabilitate as best she could with arts and crafts and games.

The first thing I noticed was the smell. Urine, feces, stale vomit, medicine. The effect is nearly nauseating for the newcomer. The odor exists because old people often lose control of their body functions, especially if they are sedated or locked in seclusion rooms (for long periods of time, as they often were).

Sometimes the use of seclusion is to the advantage of the staffers, who cannot oversee a rambunctious, roving ward of patients all the time. The staff is hard pressed to check patients frequently about their bathroom needs or to promptly clean up all their “accidents.”

When asked about the smell, the staff – from attendant to doctor to director – reply, as if by rote, “well, you know old people.”

A few patients in each ward sat around naked in bare chairs, staring at a lost world, while other patients stared robot-like at old black and white television sets.

“Why doesn’t that woman have any clothes?” an attendant was asked.

“Oh, she just takes them off,” was the unconcerned reply.

Some patients – who seemed docile enough on one of my visits – would disappear later in seclusion rooms or be seen sitting disheveled and unresponsive in a chair against the wall.

“Isn’t Mrs. Smith coming to Bingo today?” I would ask when the missing person was a particular favorite.

“No, she’s been making some trouble,” or “She doesn’t feel like it today” were the answers.

The fine line between sanity and insanity appeared to have become a numbing fact of life for the hospital workers. Generally, they were a hard-working, dedicated crew, but a bit callous.

That the attendants stay on year after year at $397 tops a month is either a testimonial to economic necessity or a sincere dedication to helping people.

There has been testimony in hearings about hospital conditions to the effect that attendants deny patients privileges, punish them for petty offenses, even herd them with brooms to the bathrooms. Such abuses may exist, but I saw nothing of that order in the time I observed at Terrell. But – many of the staffers, who labor, certainly, in less than positive circumstances, have let their attitudes deteriorate, if not into negativism, at least into dullness. They don’t seem to notice the smell anymore. Or the naked patients. Or the bare ugly wards.

There were good days (like the days when patient responded to encouragement and improved enough to return to a family). There were days when the old people just flat broke my heart – petting my hair with tenderness, showing me their handcrafts with pride.

And to be honest, there were times when they repulsed me with their animal noises and smells, the open sores and ragged clothing.

Sometimes they even scared me – talking gibberish, coughing up tobacco, bolting for the door. One man ripped Mrs. Smithers’ beads off one day, threw her against the wall and ran by me down the hall.

I was usually thankful that I could leave, go back to The News and not have to see such sights for another week. But I kept coming back, not just to observe, but to help.

I was less horrified than depressed by the scenes at Terrell. Such scenes are the reason we have let our mental hospitals become mere warehouses for the mentally ill: out of sight, out of mind. No one, not me, not anyone, really likes to see “crazy” people because it is messy, tacky, sad. And a reminder that it could happen to you.

But after seeing them, I learned to care about the patients at Terrell. They deserve better, future patients deserve better.”

So here were are three decades later. And as we examine what makes a humane city, we have to ask ourselves, is the care for the mentally ill in our community better? I think not.

I don’t have to drive the 40 minutes to Terrell to see the mentally ill. I drive by them every day on my way to work. They are on our downtown streets by the hundreds. We call them the homeless now. Some are merely out of work temporarily or down on their luck or passing through. But many are mentally ill. For lack of more appropriate care, many end up in our jails.

This summer, The Morning News published a news series that reported mentally ill prisoners in Dallas County only receive minimal psychiatric exams and often go without the anti-psychotic drugs needed to control their behavior.

One 36-year-old woman with bipolar disorder swallowed her own feces and toxic amounts of ground coffee. She was found in her cell with no pulse. In another case, a 32-year-old severely depressed inmate swallowed 133 plastic spoons handles and was kept in a chilly isolation cell – often naked – for nearly a month because doctors thought he was faking mental illness, despite six suicide attempts.

During one two-week period this summer, a mentally ill inmate hanged himself in his cell and another pulled his eye out during a psychotic episode. Both men had long histories of mental illness.

In June, more than 1,300 of the 7,000 prisoners in Dallas County jail were receiving some kind of psychiatric care. That means about one-fifth were diagnosed as mentally ill and many others probably should have been. Most of those on medication have received diagnoses of or say they suffer from depression, bipolar disorder or schizophrenia. The number of mentally ill inmates is higher than in 1997, when a task force of prominent psychiatrists recommended that commissioners add more staff to a jail that de facto has become the largest mental illness facility in North Texas. Dr. Joel Feiner, who co-authored the 1997 study, said it’s apparent that many of the recommended changes never went into effect or were set aside.

In effect, we have ended up with a worse situation that I observed in 1974. It is a situation that looks very much like the inhuman incarceration that Dorothea Dix protested in the 1800s. How did we go so terribly wrong?

This may well be a classic tragedy of unintended consequences. Back in the 1970s, the federal courts ruled in the class action cases filed against its state mental hospitals, that state must deinstitutionalize its mentally ill – turn them out of big box warehouse-like institutions – so they can be treated closer to home in smaller, community-based treatment centers.

Yet a truly adequate system of care has never really materialized. As a drive through our downtown streets will show you, there are more mentally marginal people living on our streets than ever before. And when they get drunk, overdose, act up, steal and make trouble, they end up in our jails and prisons. This is a statewide problem, not just a Dallas problem. The Texas Criminal Justice Policy Council has found that at least 29,000 state prison inmates, 106,000 adults and juveniles on probation and 15,000 county and city jail prisoners have had some contact with the public mental health system. That’s at least 150,000 people.

Compare that to the load that used to be considered too large at state mental hospitals. Terrell State Hospital was once the largest mental hospital west of the Mississippi River. Its population peaked at 2,828 in 1948 and dwindled to less than 300 in recent years.

When it opened in 1885, it was called the North Texas Lunatic Asylum. Later it became the North Texas Hospital and then Terrell State Hospital. Ironically, the patient population is on the upswing at Terrell because of managed care. That’s because low-income people who used to be sent at public expense to private psychiatric hospitals near their homes are being sent by managed care plans to Terrell, where they usually do not stay as long, which in turn saves money. But it means they are back – you guessed it, on the street.

Dallas and Texas are not alone in having this problem.

In New York just last week officials at state psychiatric hospitals ordered social workers to stop sending discharged patients to locked units in private nursing homes. The move ends a 6-year-old practice that was supposed to help scale back the state’s costly psychiatric system, but has raised civil rights concerns. That’s because the state has allowed a dozen nursing homes to keep discharged psychiatric patients locked away in the units where they are prohibited from going outside on their own, have almost no contact with others and have little ability to contest their confinement. The residents had not been deemed a danger to themselves and therefore did not meet the legal standard used to keep someone in a locked hospital psychiatric ward. They are not guaranteed the right to a layer or to a hearing to contest having their freedom taken away.

In California, some 50,000 severely mentally ill homeless people roam the streets, rummaging through trash bins, doing battle with interior demons and sometimes inflicting harm on themselves and others. The Los Angeles Times campaigned for change in state law last year so that state officials can compel the homeless to take their psychiatric medicines. It’s a tough civil liberties question: can the government force you be “sane”?

California’s current dilemma is instructive – the mental health catastrophe began in 1957 when California passed a measure known as Short-Doyle Act. It was one of the first in a series of state and national measures that emptied public mental hospitals, leading to a drop from 550,000 institutionalized patients in 1955 to 60,000 today. The idea was to get patients out of “snake pits” and onto medication. But often on the streets, it was illegal drugs that were easier to get than the prescription kind. As result, the state spends more than $500 million a year to house mentally ill prisoners.

Los Angeles County has a model program called the Village that should be widely replicated. It is headquartered in a three-story building near the heart of Long Beach. There’s a laundry in the basement, a deli, catering business and drop-in center at street level, and counselors on the top floor. The Village offers menus of housing, employment and social activities to members who span the spectrum of society’s wounded. That menu might include “Wisdom House,” where a patient could come to learn how his or her mood swings are related to a biological cause – bipolar disorder – which contributed to problems with drug addiction. A counselor might help that patient find an apartment. Another might help him find a job as a maintenance worker. When the client relapsed, as many do, he would have a safety net at the Village, to put him back on course.

In Dallas, some help may be on the way. But it must be reinforced with much stronger leadership from the medical community, Dallas County and the public.

The first development is that the Dallas County Commissioners Court has voted to contract with the University of Texas Medical Branch at Galveston to administer mental health services at the Dallas County jails. The contract should stipulate:

 

  • That inmates receive an adequate mental health screening within 24 hours of intake.
  • That a psychiatrist give inmates a mental health screening within seven days.
  • That inmates receive treatment and medicine immediately upon intake if they suffer from acute mental problems.
  • That inmates receive medication within 24 hours of prescription.

 

An outside panel of mental health experts also should be given access to the county patients on a regular basis to determine the quality of care. That panel should regularly review the UTMB work. We have recommended at The News that a special ombudsperson be appointed to specifically monitor the UTMB performance.

The second development is that Mayor Laura Miller also is convening a Nov. 1 summit on the homeless issue. The issue has been forced by the need to find a better place to provide meals and day shelter for the homeless other than in the midst of the civic square including the library, where many children have to pass through a gauntlet of disheveled, often disoriented persons. I commend Mayor Miller for taking on the homeless issue. If she can find a more effective way to deal with the homeless, she will follow in the great tradition of Annette Strauss who helped start the shelter for the homeless downtown.

But in truth, providing health care for the indigent is a county responsibility, according to the Texas Constitution. Dallas County historically has done an inadequate, patchwork job of mental health care, leaving the burden to the psychiatric intake unit at Parkland Hospital and the jails. We must urge our county leaders to do better. Jailers are not trained to deal with deranged inmates. We must have a better diversion program so the seriously mentally ill are not locked up without proper medication or supervision. That’s not coddling. That’s human decency. And it actually will cost less money in the long run. It is cheaper to create a system where the mentally ill get medication instead of incarceration. By some estimates, it costs up to $600 to house a mentally ill inmate overnight. It costs many thousands more to process a mentally ill person through the emergency room every week, which is often the case.

It is estimated that contracting the jail psychiatric service out to the Galveston Medical School will save Dallas County $600,000 a year. That money supposedly will be used for new generation medication and it should.

It is no great mystery how to care for the mentally ill homeless – we know the best practices – like the Village. We just need to rethink our community care models. A first step would be a more effective diversion system. The system in Dallas has been improved – police officers are better trained now to spot the mentally ill and take them to Parkland for stabilization. If they need be placed in holding areas for treatment or further stabilization, the mentally ill are taken to Terrell or specialty providers like ABC or Adapt, where they get some therapy, some job training, some relocation assistance. Thanks to the new Northstar, HMO style program, such placements are possible for the indigent mentally ill. But, again, the quality and scope of the programs are questionable.

Cities like Miami – which had a larger homeless population and fewer resources – are developing much more effective diversion programs to see that the mentally ill are not locked in jail to begin with. We should learn from them. Eli Lilly drug company has provided some small grant money for Dallas mental health authorities to improve such services, but it’s not much money and not much is happening yet.

It is going to taken more effort at all levels of government – city, county and state – to improve the problem with the homeless on the streets. Texas currently is 47th in the nation in its funding for mental health services. At a time when the state has a $5 billion budget shortfall – and pressing needs for education and welfare – expending large sums for a decent system is not at all likely. But I think we all have to start building coalitions – on behalf of those who cannot advocate for themselves because they are compelled to eat plastic forks or coffee grounds and those who have been erased by Alzheimer’s or those who were born feeble-minded. We can encourage the church community in Dallas – which has been rolling up its sleeves to build homes in neglected areas of the southern sector and west Dallas – to build more humane triage centers.

We have to be persistent and we also have to be creative in getting funds. For example, we might suggest a tax on alcoholic beverages, specifically beer, which gets a free ride in Texas because of the powerful beer lobby. Since alcohol contributes so significantly to the social and health problems in this state as a gateway drug, I think a good case could be made for a tax that is dedicated to treatment for the mentally ill – and send a subtle message in the process.

I hope I can do my part as an editor at The News to continue to bring the story about the mentally ill to the public. Please join me. As has been said, “The test of every civilization is the point below which the weakest and most unfortunate are not allowed to fall.” Dallas will be a more humane city when we care for the mentally ill who are now on our streets, not just because it’s annoying for the new residents downtown and not just because it will be more cost-effective than jail care, but because the people on the streets are part of our family.

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