The Long, Lonesome Road
Fred Thomas is schizophrenic. Seven years ago he entered a state mental hospital. Ever since, his life has been a jumble of doctors and drugs, hospitals and halfway houses. But like so many others in Texas’ abysmal mental health system, he is not one bit better today.
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Don Peterson seems quite comfortable living in Ward B. And why not? His life on the outside is unrelievedly sad. His elderly father refuses to have anything to do with him. The mental health system barely knows he exists. He sleeps in a sickeningly ramshackle house in a Houston ghetto with a dozen other mentally ill people. For human companionship, he hangs out at the Star of Hope Mission in downtown Houston, where he is prey for thugs.
In the hospital, on the other hand, his living conditions are dramatically improved, he knows the ropes, and he can play the hunter instead of the prey. Soon after John Collins arrived, for instance, Peterson sidled up to him on a bench with a can of Coke in his hand and asked with a smirk, “Do you think I can kill you with this?” Peterson also, from time to time, initiates sex with other men in the ward. This is not uncommon among the patients; even Fred was once caught trading a sexual act for cigarettes. There are a lot of things Fred has done in the hospital that pain Liz Thomas—she remembers especially the time he sold an expensive winter coat for two cigarettes—but nothing compares with the hurt of knowing about that incident.
After Sue Dennison gives Peterson his medicine, he quickly walks away—a little too quickly, in Dennison’s opinion. She believes Peterson has been “cheeking his meds” lately—that is, only pretending to take his medication until he can get to the bathroom and spit it out. She thinks this because he has begun talking about how John Kennedy and Martin Luther King have deputized him “to be with white women.” The mental health workers stop Peterson before he can get to the bathroom. He glares at them for a few seconds, but finally he swallows.
After Fred takes his morning medication and has breakfast in the ward cafeteria, he gets his two-cigarette allotment from the ward’s “point store” (patients trade “points” they have earned in return for cigarettes or candy or coffee). As he walks to the nurse’s station for a match, he notices that his social worker, Cathy Nottebart, has come into the dayroom. She is a tall, friendly woman in her early thirties, six months pregnant with her second child. For three years she has been a social worker at the state hospital, a job that primarily entails finding placement for the patients once they are released. It’s frustrating work, filled with more than the usual quota of institutional hypocrisy, inasmuch as a social worker’s written description of placement for a soon-to-be released patient—a description required by Judge Sanders—is often at considerable odds with the harsh realities of life in the community. It’s particularly frustrating for the social workers in the Harris K unit because they are handling Houston patients, and Houston has the fewest resources of just about any big city in the country. “Placing” people at the Star of Hope Mission—which isn’t much better than releasing the mentally ill into the streets of Houston—is not uncommon.
“Cathy,” Fred begins after spotting her, “I’m not retarded. I’m ready to go home. I’m doing well.” Fred, however, does not look well at all. His eyes are glazed, and his eyelids are nearly closed.
“Frederick,” replies Cathy sweetly, “what about a halfway house? Yesterday you said you wanted to go there.” Ever since Fred’s arrival, Cathy has been trying to warm him up to the idea of going to a halfway house. As she speaks she brushes away some cigarette smoke Fred has blown in her direction.
“Do I stink?” Fred asks defensively. “Do I smell?”
“No, Frederick,” she says gently.
“What can I tell my mother? That I’m going to a halfway house?”
“How do you feel about it today?”
“Scared. I want to go home. What’s wrong with home?”
“The problem is that you and your mother argue a lot,” Cathy says.
“I don’t think that’s any of your business,” Fred replies angrily. Then he asks meekly, “Are you mad at me, Cathy?”
What happened to Fred in the past month offers a short course in the vagaries of patient care at the state hospital. His commitment began on March 26, when he was admitted to Ward B as an “acute” patient, a status that legally limits his stay to a maximum of ninety days. He told the admissions staff glumly, “This is where I belong.”
The doctor for Wards A and B (A is one of the female wards) was a kindly, Egyptian-born psychiatrist whose command of English was tentative at best, and who had a reputation for being cautious—too cautious, in fact, for the bureaucracy, which felt that he was gumming up the works by not releasing patients quickly enough. After about twenty minutes with Fred, the doctor diagnosed his illness as “schizophrenia undifferentiated chronic”—very much in line with previous diagnoses—and prescribed Prolixin, a safe choice that also reflected Fred’s history.
A month later Fred’s first doctor left the hospital; he was replaced by a Cuban-born psychiatrist named Heriberto Cabada. Brusque and garrulous, Cabada was almost the complete opposite in temperament from his predecessor, with whom he shared only one apparent trait: heavily accented English. (Like most state hospitals, Austin is full of foreign-born and trained psychiatrists.) A large man with a pronounced girth who favored guayabera shirts and a three-day growth of beard, Cabada was the shortest of short-timers. In little more than a month he would finish his three-year residency at the hospital and move to Miami to begin what he hoped would be a lucrative private practice. Wards A and B were about the last place on earth he wanted to be. “This is a first-year resident’s rotation,” he groused to anyone within earshot. But he knew why he had been brought in.
In his three years at the hospital, Cabada had learned how to play the game, and he had become fairly cynical about it. He knew how to keep his head down whenever there was trouble; he had learned that lesson when one of his patients committed suicide while he was on vacation, and he nearly lost his residency as a result. Although he bridled at the paperwork (“It’s a wonder we have time to see any patients at all”), he knew the importance of leaving a paper trail to keep the court and the bureaucracy satisfied. He knew he was there to prescribe drugs and not to administer psychotherapy. “This is a place to stabilize people and get them out,” he said bluntly. And when he got to Wards A and B, he immediately understood what was expected of him. Within a week, Cabada had released enough patients that the census on Ward B had dropped from 24 to 18. “I love that Cabada,” said one of the workers on the ward.
And when Cabada saw Fred Thomas for the first time—for fifteen minutes on the morning of May 2—he knew what was expected of him there too. Prolixin, which the previous doctor had prescribed, was popular in community outpatient clinics because it was the only drug at the time that could be given by injection with long-lasting (up to two weeks) effect. But the imperative at the state hospital makes Prolixin much less ideal because it is so slow-acting compared with most other psychotropic drugs. As Cabada noted in Fred’s chart, the patient “is progressing slowly, although he is not at the point where he should be.” To speed things along, Cabada decided to switch Fred to Haldol, a potent, fast-acting, highly sedating drug. Haldol is as popular inside the hospital as Prolixin is outside. At an initial dose of thirty milligrams a day, Fred was more drugged, and more sedated, and feeling more side effects than he ever had in his life.
Late one afternoon, a few days after the change, I got an inkling of how the Haldol was affecting Fred. The patients were out on the patio; Fred was sitting in a chair he had pulled out from the ward. He was in a bad way. His lips were tight and trembled slightly, and he constantly touched them. He scratched his legs until they were white with scratch marks, and he was very groggy. Peterson came up to Fred and started screaming at him; Fred barely noticed. Instead he began talking to himself softly: “Rolling bowling green.”
A woman walked by, and Fred asked her for a cigarette. She gave him one. “I love you,” she said. “I want to have your child. Do you love me?” Fred stared at the ground. “I’m a fortune teller,” she said. “Do you want a beer?”
“A beer,” replied Fred dreamily. “I want a beer.”
“You have to come with me,” the woman said.
Fred stood up. But instead of walking off with the woman, he headed in the opposite direction, toward a picnic table in the middle of the patio. It was a hot day. Other patients were talking or throwing around a football. Fred seemed oblivious. He lay down on a bench and curled himself up. He took one last glance around and said, to no one in particular, “You keep your hands off my girl.” Then he lay back down and, his head never actually touching the bench, fell fast asleep.
The Revolving Door
Like many of the nation’s older mental institutions, the Austin State Hospital is a product of the first grass-roots movement on behalf of the mentally ill: the asylum movement. Begun in the 1840’s in Worcester, Massachusetts, the movement held that the mentally ill had the right to “asylum”—that is, to a place where they could live in relative peace. Because the nation’s lunatics, as they were called, lived in poorhouses or jails, the asylum movement had a powerful moral suasion, and it quickly spread beyond the East Coast. In 1861 the State Lunatic Asylum (renamed the Austin State Hospital in 1915) took in its first patients.
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