Friday, September 30, 2011

Mental patients are more often prey then predator.

                The popular media version of the mental patient is the crazed killer who is a danger to the community. In my experience, it is more likely that people with serious psychiatric illness are preyed upon by bad people. Living in poverty in unsafe housing and marginal neighborhoods, the few belongings they have are always at risk. Many times, when people are hospitalized, their belongings are lost and stolen and when they are released they have to start from scratch. The risk of physical harm is also great. Those with psychiatric illness are not viewed as reliable reporters of crime. They can be victimized not only by the people who prey upon them, but by law enforcement and a criminal justice system that has difficulty understanding their needs.

The Story

Gil was the sort of guy that when you met him, you couldn’t help smiling. This happened as a reflection of his smile, almost a permanent fixture on his face. It was genuine and welcoming and slightly amused as if he had a private joke he was about to share with only you. The tobacco stains on his teeth and mustache didn’t deter you from smiling back. Nor did his torn jeans and flannel shirt. Part of the joy that Gil relished was his secret knowledge that he was of royal blood. This idea had come to him when he was a second year student at Cornell. Having spent a good part of the year as a history major studying European history, he’d realized that the reach of the Hapsburgs went far and wide. They had many offspring and branches that entered every royal house in Europe. During winter break, visiting his parents in Delaware, he’d quizzed them extensively on their lineage. His father’s father had come from Germany as a child in the late 1890’s. A family story was told about his great grandfather working in the Kaiser’s kitchen. In the following spring semester Gil proclaimed during a seminar that he was of royal blood, most likely a prince. The professor ignored him until he became very insistent and disruptive. Gil’s roommate could only ignore him until a chair on a platform, decorated in red velvet, appeared in room they shared. Gil sat upon it dressed in a gold bathrobe with a crown made from wire coat hangers. The other students on the floor were more frightened than amused and when campus security came, Gil meekly agreed to go to the hospital. Gil’s dad, who had an uncle and several cousins with schizophrenia, wasn’t surprised by the call, just saddened that his only son had joined what he’d viewed as a family curse.
At the time, in the middle 1970’s, claims of royal blood combined with upsetting behavior could land you in the state hospital. Gil was a model patient, cooperating with all treatments, helping other patients and participating in groups and vocational programs. Unfortunately, he never gained “insight” into his illness and it took him several years to understand that there are some things that you just need to keep to yourself.
When Gil got out of the hospital, he found living in Ithaca more pleasing than his parent’s home in rural Delaware and stayed on. During his decades here, he thought of himself as an “alternative” sort of guy and Ithaca suited him fine. Much of the time he spent here was on our downtown pedestrian mall or “commons” as we call it. Summer or winter, he’d hang out with friends, sometimes playing his guitar or joining in a chess match. His apartment was nearby and well maintained, primarily through his caseworker, Helen.
Helen was very upset when she came into my office on a Monday morning. She plopped down in a chair and said, “The McCabe brothers have moved in on Gil.” Unfortunately, I knew exactly what that meant. The McCabe brothers were a real problem. Their primary occupation was to prey on the elderly and the disabled. The local cops had trouble deciding who was a bigger troublemaker, Danny or Davey. Danny was an alcoholic and substance abuser who would drink, smoke, snort or shoot anything he could get his hands on. He was a liar and a thief and worst of all, he was a bully. He always found someone weak and frightened to threaten and intimidate. At age 42, he was a little less than six feet tall with thin blond hair, cracked, broken and missing teeth, and a pitted lined face. His arms and legs were filled with bad ink from jail. He had a mean streak that could lead him to hitting and hurting anyone who didn’t give him what he wanted.
Davey was a runt. At a little over five feet tall, he was prone to wearing cowboy boots with lifts in them, except when he was working and then he wore Converse All Star sneakers. His work was stealing, and he maintained a specialty. He stole women’s purses off the backs of chairs and floors in bars and restaurants. He was good at it. I once went into a college bar at about 11:00pm and at least a dozen women were lined up to give statements to the uniformed cop. The purses were discovered the next day floating in a creek two blocks away. Money, credit cards and all other valuables had been removed.
Bar owners and bouncers knew Davey and what he did. But he somehow managed to get past them and ply his craft. Occasionally, he was caught, but the charges never gave him more than a month in the county lockup.
When I got to the apartment, Gil answered the door. “It’s not a good time.” He half whispered. “I need to talk to you,” I replied as I entered the room. Davey was lying on the couch smoking a cigarette. Danny was asleep in Gil’s bed. A pillow and blanket were on the floor where Gil had spent the night. I banged on the bedroom door. “Danny! Danny! Hey! Rise and shine. I have to talk to you.“ I heard him curse under his breath as he pulled on his jeans and got out of bed. “What’s the problem?” “Look Danny, you know the deal. Gil has an agreement with us and the landlord that he won’t have overnight guests. If you guys crash here, he’s going to get evicted.” “He asked us to stay,” Davey said from behind me. “Yeah, I know. Gil is a really good guy. He’s always ready to help somebody out,” I said.
Fifteen minutes later the McCabe’s were gone. “Terry, I’m sorry that I got Helen so upset. I was out on the street last night and those guys didn’t have a place to stay and we got a twelve pack and I told them they could crash here.” He was smiling that winning smile. “You know those guys,” I said. “They act like your friends, but they just use people. Did you give them money?“ “Just twenty bucks. But Danny said it was a loan, he’d pay me back.” “How long have they really been here?” I asked. “About a week,” he replied.
I received a call from Helen just before the work day ended. Gil had shown up at her office in tears. He reported that a watch his grandfather had given him and a coin collection (that was hidden in his closet) were gone.
The next day I was joined by a police officer and we found the McCabes hanging out in front of the Department of Social Services. “Look guys, there’s some stuff missing from Gil’s apartment. We’re not saying you took it but you may know where it is. It might be best if it was returned,” I said. Davey replied, “Hey, there were a lot of people in and out of that place. Anybody could have taken that stuff.” “It would be really good if Gil got his grandfather’s watch back,” I strongly suggested.
The next day Helen called to tell me Gil had found his watch. “He said he misplaced it,” she said.
Over the next several months Helen called multiple times to tell me about the McCabes and Gil. She took over managing Gil’s finances and transferred the lease from his name to his elderly parents. She got their power of attorney, in an attempt to control the apartment. She and I tracked down the McCabes one Friday afternoon and Helen gave them a written notice stating that they were not allowed in Gil’s apartment under any circumstances. The next Monday Gil showed up at Helen’s office with stomach pains. When Helen pursued the cause of his distress he lifted his shirt to show multiple bruises all around his mid-section. She called me, and an officer and I met with Gil to get his story. The McCabes had shown up late Friday night and gave Gil a beating. They stayed at his apartment all week-end, having a party that got so big that the police had been called with a noise complaint.
Gil went to the police station and wrote out a statement to file charges against the McCabes. We met with an Assistant District Attorney and reviewed the charges. Trespassing was an easy one because of the documentation, including the police report from the noise complaint. Aggravated harassment was as high as they could be charged for the beating. “It’s a ‘his word against theirs’ kind of thing,” the ADA advised us. Beat cops brought the McCabes in later that day and they were both taken to the county jail, neither having bail money.
Helen called me to her office later that week. “Gil’s staying at the shelter in Rochester and they’re going to get him an apartment up there. He says that the McCabes will kill him when they get out.”
A year later, Danny’s body was found in an abandoned house.  He'd died of natural causes but nobody missed him for a week. Last month I saw Davey in a bar I frequent. When he saw me staring at him he made a quick exit. I never saw Gil again.
The Stories
The stories are my remembrances. Each of them is based on a true event in my work for Tompkins County Mental Health. I have changed the names and identifying information of every client, patient and co-worker except for Beau Saul, of the Ithaca Police Department, who I was fortunate enough to have as a partner. When confidentiality demanded it, I have changed details. The dialogue is my reconstruction of what was said at the time.   I have felt honored to be let into the lives of so many individuals over the years. Their stories are a gift I have been given.  Please enjoy them in the spirit with which they were written; to educate and inform.

Wednesday, September 21, 2011

We all seek community, some more successfully than others.

        Many people with serious psychiatric illness live in isolation.  Their behaviors can drive away family and friends. When they are symptomatic, many of their actions are misunderstood. Because of the perception of the mentally ill as dangerous, the way they conduct themselves may be viewed as threatening or menacing.  Landlords, neighbors and acquaintances fear that interactions may bring on negative consequences. When they are stable, the person with mental illness may have little understanding as to why they are shunned by those around them. In seeking companionship, they may compound the fear their behavior has created.  Most of us want to be part of a community, either the geographic community we reside in or the community of interest that makes our lives fuller. My experience suggests that even those with the most serious illness are well intentioned in their hope to make their lives better.

The Story

                     I stood behind a column, peeking around it at the café that occupied the public space between stores.  A short woman with dark hair in her late forties was moving from table to table, a coffee pot in her right hand and a large pad of paper in her left hand.  She reached over and around patrons, pouring coffee in cups, bowls and glasses.  Behind her an elderly woman began to rise from her chair, pushing herself away from her finished meal.  “Sit down! You sit down!” the younger woman screamed as she turned, facing the tables behind her.  “Don’t get up until I tell you to get up.  Do you understand me?”  The elderly woman regained her seat, clutching her purse in her lap. It was late morning.  The café’s twenty tables were only half full.  The rest were set for lunch. I could see two cooks and two waitresses crowded together in the small kitchen.  They had closed the kitchen door and were staring at me from behind the pass through, one cook clutching a large knife. 
Directly across from me and down the hallway, a police officer gave me a thumbs up.  I held my hand up motioning him to wait and walked slowly toward the woman with the coffee pot.  She put it down as I approached and turned to fully face me.  “Rosa,” I said. “What’s going on?”  “So they called you?  Why is it that every time I get things straight in my head, every time I get my life together you show up?”  She was an unattractive woman with a big nose, bulging eyes peering through large black framed glasses and hair that had not seen a comb in months. She had on a flowered knee length skirt with a dungaree shirt jammed into it. Over this she had a bright vest that someone had bought at a tourist shop in Central America.  A backpack rested on her back, a paisley bag on her left shoulder, a waist pack cinched around her stout middle.  A pair of torn black hightop sneakers without socks completed her outfit.  “Why don’t you go away?  Why don’t you just mind your own damn business and get the hell out of here?” she screamed.  “Somebody called me.  They were worried about you.  When they call I have to come, you know that.  Why don’t we go someplace else to talk?  Everybody doesn’t need to know your business.”  I could sense movement behind me as people began to leave their tables.  “I hope you’re happy?”  Rosa said as she leaned on the table closest to her, palms down, her notebook under her arm.
I looked over my shoulder to find the police officer escorting people down the hall.  When I turned back, a mass of cheese, avocado and sprouts on toast exploded in my face, the small fat hand rubbing it into my nose and eyes.  Moments later, Rosa was on the ground screaming at the cop wrestling her one cuffed hand behind her to join under the backpack with the other hand waving in front of his face.
I’d known Rosa for many years.  I’d first met her in the 1970’s, when I coordinated programs for mental health patients being discharged from Willard Psychiatric Center during the late stages of deinstitutionalization.  Rosa was a revolving door patient who would become briefly stable and discharged and never keep appointments or follow up with treatment.  As she got older, she cooperated with treatment more often, but still had periods of bothersome bi-polar symptoms.  Several months earlier Rosa had visited the psychiatrist in our office stating that she no longer needed medication.  ‘I’ve been doing some research”, she had told the doctor, “And I believe that I have aged out of my illness.”  She then presented copies of journal articles to support her proposition.  She had a master’s degree in city planning and was able to use her academic background to articulate her case.  What she presented was her decision.  It was not open to discussion.  When the doctor had me join them, she said, “He may be in charge here, but he is not the boss of me.”
The calls started to come in shortly thereafter: her grown daughter pleading “Isn’t there anything you can do?  Can I sign a paper?  Do we have to go through this all again?  We know what’s going to happen.  I’m the one who has to clean up her mess.”  Her ex-husband stating, “If she shows up again I’m going to press charges.  I don’t care how crazy she is, she can’t just show up at my house threatening my new wife.  If she goes to jail, so be it.”
Rosa owned a beautiful home in a neighborhood of small ranch houses on a hill overlooking the city.  I’d been there in the previous year to drop off a prescription that the doctor had forgotten to give her.  The small inheritance she’d used to buy the house had also been spent on some nice antiques that she had restored.  At the time she’d asked me in to take a tour and be dazzled by the views of Cornell and the valley below.  “What do you think?” she’d asked, smiling.  “I’m jealous,” I replied.  Having seen Rosa years earlier stripped to her bra and panties on a foam pad in the isolation room at Willard, screaming and banging on a concrete wall, I was pleased to see the life she made for herself.
I visited again, after the calls began.  When she opened the door, it appeared that a giant had picked up the house and shaken it like a snow globe.  The rug was bunched up, the furniture overturned.  Books pulled from bookcases, dishes dirty everywhere.  “It took me a while, but I found it.”  In her hand was a binder containing her master’s thesis.  “Look at this,” she said guiding me to the kitchen table where a large piece of poster paper was unrolled.  Books were piled on one corner; duct tape held the other three.  A slide rule, protractor and plastic ruler, educational instruments long abandoned by academics, were at the bottom of the drawing. Her work showed a crude illustration of the valley as seen from her window.  Near the top were wavy lines indicating the multiple rivers, streams and creeks flowing down the hills and into the lake.  Each of them was well marked.  At right angles to these lines were broad strokes made by magic markers that seemed to enter buildings erected on the top of the hill.  “Well!  What do you think?” she asked.  “I don’t know what I’m looking at,” I replied.  “Are you stupid?  It’s the valley.  See these?” she said indicating the wavy lines. “This is all water and water is power.  You move the water from the streams and rivers, through the pipes and into the generator buildings.  The wheels spin and the water falls downhill into the lake.  The people who first lived here understood that.  That is why they settled here.  For the last 100 years we’ve ignored it.  I’m the only one who understands it.”  She walked over to the picture window.  “Look at that!  Ithaca doesn’t need to have one once of electricity come from the outside.  I’ve solved it.  That smelly coal plant up the lake can be torn down.  It’s time for old to be new again.” She began to sing and dance. “It’s time for old to be new again; it’s time for old to be new again.”
“Rosa?  Rosa, I need to talk to you.  Your daughter called and…?”  “Get out!” she yelled, not touching me, but moving me toward the door. “That little bitch is an ingrate.  Her father raised her to hate me.  He has always been jealous of my success and he can’t wait to see me fail.  When people see what I’ve accomplished, what I’ve given back to this community, then he’ll have to apologize. Now get out and don’t come back and don’t tell anyone about my plan.  I want to have an unveiling at City Hall when it’s all complete.  If you tell anyone, anyone at all, I’ll sue you.  Don’t think I won’t.  The house shook when the door slammed.
Two days later I was at the city engineer’s office, a police officer at my side.  “I’m going, I’m going.” Rosa said, gathering her things. “But you haven’t heard the last of me.”  That afternoon, her ancient Volvo wagon was spotted parked sideways at the food co-op.  Later, when I’d responded to the convenience store at the edge of town, the woman behind the counter said, “I don’t know what her problem is, but she better not bring it in here again.”  Eventually I got a call from the woman who owned the café.  She’d called just before Rosa had taken over her restaurant. “I don’t want her to get in trouble,” she’d said.
I sat across from Rosa at her hospital discharge meeting nearly a month later. “Sorry”, she said. “I know you’re trying to help.  But sometimes you’re really a pain in the ass.”
The Stories
The stories are my remembrances. Each of them is based on a true event in my work for Tompkins County Mental Health. I have changed the names and identifying information of every client, patient and co-worker except for Beau Saul, of the Ithaca Police Department, who I was fortunate enough to have as a partner. When confidentiality demanded it, I have changed details. The dialogue is my reconstruction of what was said at the time.   I have felt honored to be let into the lives of so many individuals over the years. Their stories are a gift I have been given.  Please enjoy them in the spirit with which they were written; to educate and inform.

Wednesday, September 7, 2011

Fifty years from now, we will look back in shame! How could we let the mentally ill be treated like this?

                History will judge our actions harshly.  We closed the hospitals and placed the impossibly high burden of “danger to self or others” as our treatment criteria.  Meanwhile millions who are seriously ill either live on the streets or are incarcerated.  It is estimated that there are as many mentally ill in jails and prisons now as there were in hospitals at the beginning of deinstitutionalization; almost 500,000.  We have protected their rights:  the right to be ill without treatment, the right to live in poverty or in a cage.  We have returned to a time before the asylum movement where the serious mentally ill were left to fend for themselves until their behavior interfered with our lives.  Shame on us and the choices we have made.

The Story

                He was standing next to our billing administrator screaming, “My brame, my brame. Turn that off, it is hurting my brame.”  His left hand was banging on the computer screen on her desk; his right hand was pressed against his head above his ear.  “Stephan!” I called.  “Stephan, what’s the matter?”  He turned toward me, his narrow face contorted with pain, his eyes moist.  His eastern European accent was thick.  “The computer!  It is hurting my brame!  Ronald Reagan first put the radioactive isotopes in my skull and now he is trying to control me with this computer.”
                “Karen, could you shut the computer down and I’ll get Stephan downstairs?”  The frightened woman had already shut it off and was grabbing her purse from under her desk moving toward another office.  I led Stephan to the elevator and we went down a few floors to my office. Colleagues stationed themselves near my door as I directed the yelling man to a chair. A nurse mimed a call to the police as we passed her. I shook my head no, but left the door open.
                Stephan was the strongest person I’ve ever met. He wasn’t tall, less than six feet. But he was so broad he had to turn sideways to walk through most doors. When he’d emigrated from the Ukraine twenty years earlier he’d gotten a job on the loading dock at a local factory. When the fork lift broke, he loaded barrels by hand.  I once watched him pick up the back of a small American car.  He was psychotic most of the time. The only time I saw him stable was after an extended hospitalization. Even then, he was symptomatic but not agitated.  He drank and smoked pot and most likely used other substances.  He also screamed and yelled and frightened almost everyone he met, including me.  He’d recently grabbed his file from a nurse who was treating him and ran out the door into the street.  I’d needed the police to get the file back.
                However, there was a sweetness about him that would emerge when he realized how fearful he made people.  “Ok, ok! Don’t worry,” he said smiling. “Maybe the computer is only to get money for mental health.  That lady was a nice lady. She wouldn’t hurt me.  But Ronald Reagan did put isotopes in my brame!”   In the clinic, we held his prescription for an anti-psychotic medication that had a sedating effect. I offered it to him. He swallowed two and said, “I need some beer.”   Then he got up and left.
                Waiting for him in our reception area was Jane, his girlfriend.  She was a tall, thin woman with stringy black hair.  She’d met Stephan in the state hospital when they were there on a long term admission.  She’d found him exotic and interesting and had attached herself to him.  Ten years later she still followed him around, helping and supporting him and cleaning up his messes.  One of her main roles in the relationship was to find apartments.  Landlords would never rent to Stephan, but when Jane went to rent a place, she was neat, clean, pleasant and cooperative.  She’d never had a problem finding a place.
Jane’s first hospitalization was at age 17.  Voices told her that her father was evil so she’d attacked him.  She’d been taken directly to the state hospital where she spent several years.  As a consequence she’d taken medication most of her adult life. Every few years she would stop taking medication and become catatonic, entering a world that only she knew. Unfortunately, she would stop eating and taking care of herself and eventually agree that she needed to be hospitalized. Even when she was stable, she still was psychotic in a quiet, internal way that, for the most part, gave her pleasure. She called it “active dreaming”.  She created a world in her mind where many millions of people lived.  She controlled them consciously, but they lived in what she described as a “wide awake dream state.”
                Jane would work with her caseworker to secure an apartment, pretending that she would live there by herself.  The caseworker would join in the fiction, imploring Jane to keep Stephan out.  Jane would agree, but within hours of moving in, Stephan would be there.  He was a presence.  Even in his most stable moments he was three times louder than any other person.  He occupied space with constant movement, walking to and fro; arms flailing with a lit cigarette dropping ash.  Soon after moving in, the apartment was a mess, with empty beer cans and liquor bottles strewn about.  Fast food containers would fill the trash cans and burn marks would appear on the furniture and rugs.
                The first complaints would come from neighbors, those unfortunate enough to share walls, ceilings or floors with Jane and Stephan.  Often, the inexpensive housing was occupied by graduate students who would tap on the door requesting that Stephan please quiet down.  Drunk or sober Stephan would explain that he had been made into a nuclear weapon by Ronald Reagan. Once I was called by a student’s roommate and went to the apartment to find Stephan sitting on a coffee table yelling at his frightened neighbor trapped on the couch in front of him.  Stephan was wildly gesticulating, bits of ash and trails of smoke everywhere.  “Look in my eyes!” he yelled at the young man. “See the bits of gold?  They always use gold when they place the isotopes.”  The student nodded in agreement.  “Terry, my friend! Tell him this is true!  I’m not lying about this,” he said, turning towards me and standing up.  I replied, “Stephan, you’ve certainly had some very difficult and frightening things happen to you.  But I need to talk to you.  Is it okay if this guy leaves?”  The student was out the door before Stephan turned around.
                “This is a nice place,” I said looking around. “You and Jane can make this work for you if you settle down. “  Jane came out of the kitchen where she had been reading a book. “Don’t worry, we won’t screw it up.  Stephan promised to stay away when he gets drunk. That should help.”   “A few drinks is not drunk,” he said.  He then proceeded to touch his nose, stand on one foot and walk a straight line, replicating a police field sobriety test.
                Jane’s caseworker came to my office the next day.  “Other tenants are already threatening to leave if Stephan keeps coming around. Just thought I’d let you know.”   When I stopped at the police station later that morning I was presented with three separate complaints about noise from Jane’s apartment. One included a question about domestic violence with the officer concerned about Jane’s safety.  It was something I often wondered about, but the only time I had seen Stephan get physical with Jane was out on the street in front of the mental health building.  He had grabbed her head and put her ear next to his ear.  He’d been screaming, “Hear them, they are cursing me.  They are laughing at me. They are trying to kill me.”  When Jane agreed that she’d heard the voices, he let her go.
                The eviction notice came the next week.  The caseworker tried to get them someplace else, wanting to stay on good terms with the landlord.  Weeks and then months passed as the eviction proceeded, and no living alternative presented itself.  Stephan’s drinking got worse and he spent most days on the street downtown, yelling at passers by.  When the police told him to stop or move on, he quieted down and left. I had numerous conversations with the psychiatrists and nurses and social workers I worked with to try to figure out a way to resolve the situation. I met with the Commissioner of Mental Health and the head of the hospital psychiatric unit.  Although Stephan put himself at risk by yelling at people and menacing them, he did not meet the criteria for “danger to self or others”.  Finally, the day arrived when they had to leave.
                Jane came to my office with her few possessions in a garbage bag. “I stopped taking my meds three weeks ago.” she said. “I want to go in the hospital.  I’m having difficulty knowing what’s real and what’s not.”  With Jane in the hospital, Stephan became a bigger problem.  He began living outside, staying in the parks and gorges that are plentiful in Ithaca.  His caseworker prevailed upon a shelter in a nearby city to help.  Stephan only had the clothes on his back when he left.
                The Ithaca police department Deputy Chief called me at my office several months later.  “Stephan was shot and killed last night.  The duty officer in ____, found out he was originally from here and called me. They wanted information to justify the shooting. Apparently, he’d had a small fire in his apartment, probably from unsafe smoking.  When the fire department came, he wouldn’t let them in.  When officers arrived to assist, he jumped out of a window and ran down the street.  When they finally cornered him he had a kitchen knife.  He wouldn’t put it down so they pepper-sprayed him, and then shot him with a bean bag round.  You know Stephan, that would only piss him off.  In the end, he came at them with the knife and they put four rounds in him.  Sorry to be the bearer of bad news.”
                I go to the library every week.  Each time I visit, Jane is in a comfortable chair reading a book.
The Stories
The stories are my remembrances. Each of them is based on a true event in my work for Tompkins County Mental Health. I have changed the names and identifying information of every client, patient and co-worker except for Beau Saul, of the Ithaca Police Department, who I was fortunate enough to have as a partner. When confidentiality demanded it, I have changed details. The dialogue is my reconstruction of what was said at the time.   I have felt honored to be let into the lives of so many individuals over the years. Their stories are a gift I have been given.  Please enjoy them in the spirit with which they were written; to educate and inform.