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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The hospital was originally designed for fewer than fifty patients. But it wasn’t long before problems began cropping up. Within five years of the hospital’s inauguration, the superintendent was moved to complain, “The asylum at present seems crowded to its limits of accommodation.” According to one historian, five years after that, a new superintendent, appalled by some of the practices he saw, “abolished as much as possible all modes of restraint and punishment, such as…iron handcuffs.” And in 1894 another superintendent wrote a description of asylum life that sounds eerily like the present: “In the commodious…parks of all modern asylums will be seen hundreds of lunatics sitting day in and day out in idleness and misery, watched by attendants who take little interest in them.”
For nearly a century the state’s main response to the problems of the asylums was to build more of them. As late as the 1950’s, when Governor Allan Shivers went on the one passionate crusade of his political life—a campaign to improve conditions in the state hospitals—his chief solution was to build the eighth and last, in Kerrville. In addition, the Legislature consistently found money for expansion of the existing hospitals. By 1965 the Austin State Hospital was a sprawling 117-building campus that held about 3250 patients. Statewide, more than 15,000 people were committed in mental hospitals.
And how did those 15,000 people live? They lived horribly. The humanitarian impulse that had informed the asylum movement was long forgotten, as mental hospitals all across the country evolved into warehouses. Hospitals were grossly understaffed; in the fifties the 3000 plus patients at the Austin State Hospital were served by only ten doctors and four nurses. What staff there was relied on straitjackets and cages to control the more-violent patients; even the tamer ones were almost never allowed to do much more than sit in a crowded, foul ward and stare at the four walls. The tales of outright abuse were legion. Over the years muckrakers documented the sadistic use of electric shock treatment as punishment, the regular beatings and occasional death of patients at the hands of staff, and after the first psychotropic drug became available in the early sixties, the overmedication of patients as the chief means of keeping them “calm.”
Those conditions led to the second grass-roots movement on behalf of the mentally ill: the deinstitutionalization movement, which is the dominant ideology today. Deinstitutionalization was a classic sixties crusade, propelled by a sense of humanity and outrage at injustice, and more than a little naiveté. Whereas the asylum movement had held that the mentally ill had the right to be protected from society, the new movement believed just the opposite: that they had the right to be a part of society. Thanks to the introduction of drugs like Thorazine, it was widely believed that many—nay, most—mentally ill people could learn to live productively. In any case, proponents of deinstitutionalization believed that the mentally ill should have the legal right to live in the “least-restrictive environment”—a phrase that implied someplace other than a mental hospital. The new movement quickly gained the same kind of moral suasion that the asylum movement once had; by 1963 its tenets were federal law.
No one can doubt that deinstitutionalization has done a lot of good. Many who didn’t need to be there were languishing in mental hospitals; their lives have been immeasurably improved. In 1970 alone, the Austin State Hospital’s population dropped from 3400 to 1800, and almost all the releases were easy cases. But if deinstitutionalization has done some unquestioned good, it has also had its share of unintended consequences. Look around downtown Houston, where as many as 2000 mentally ill people, “freed” from the state hospital, wander the streets like modern-day paupers, and you quickly realize how far the promise of deinstitutionalization is from the reality. The miracle drugs that were going to “cure” the mentally ill have turned out to be not so miraculous after all—helpful, yes, but not miraculous. The extensive network of community programs and halfway houses that were expected to absorb the thousands of mentally ill streaming out of state hospitals never developed—especially not in Texas, where the state hospitals still pull in nearly 80 per cent of all the mental health money even as their populations have been reduced by more than two thirds. A patient’s right under the law to be released from a state hospital commitment after ninety days has been largely responsible for the so-called revolving door syndrome, in which patients spend their lives shuttling back and forth from the hospital to the community. The right to live in the least restrictive environment has meant that thousands of mentally ill people, not sick enough to be confined to a hospital ward but still desperately in need of care, live in the least restrictive environment imaginable: the streets.
And yet the pressure on the state hospitals to “get the census down” remains as inexorable as ever. It comes from state and federal law and from a society still unwilling to admit that deinstitutionalization has not worked the way it was supposed to. And it also comes from Judge Sanders. The judge’s mental health monitors—the people overseeing the hospital system on his behalf—deny that de-population is their intent, but they cannot deny the result. Their goal is purely to improve conditions at the state hospital, with little thought given to how the judge’s orders will affect the rest of the system. Several years ago, when Judge Sanders, acting on the masters’ recommendations, ordered that the staff-to-patient ratio be significantly lowered, his aim was to make each ward a less dangerous place. But since the hospitals didn’t have the money to hire the hundreds of staff members needed to comply with the order, they reacted—predictably—not by adding staff but by increasing medication dosages for the patients, to get them out more quickly. The hospitals can say—and do say, all the time—that they are only doing their job while complying with a court order. The judge can say that he is doing his job. (The population in Austin today is around 550.) And meanwhile, a few thousand more mentally ill people are released to the streets, where they find…nothing.
Well, not exactly nothing. Houston, for example, does have some outpatient clinics, some apartments for mentally ill people, and one small halfway house to serve the thousands of mentally ill people who live in the city. The halfway house is Tarry Hall, on a residential street in Montrose. It has 27 beds. It is the reality of deinstitutionalization in Houston. As it happens, Tarry Hall was where Cathy Nottebart was trying to persuade Fred Thomas to live.
“I’m Not Rubbish”
There was no way Cathy could force Fred to go to Tarry Hall against his will. His legal right to refuse treatment—a right originally aimed at preventing overmedication and unnecessary electric shock treatment—meant that he didn’t have to accept any community placement he didn’t want, even if he wound up on the streets. But Fred knew his mother would never let that happen, and most of Fred’s social workers over the years knew it too. That was why most of them had never bothered to try to place Fred in a halfway house; they knew Liz Thomas would take him back, even when she said she didn’t want to. Social workers saw it all the time: a parent’s initial resolve to force the hospital to find placement weakened as the memories of psychotic behavior were replaced by natural feelings of guilt and love—and the slender hope that this time it might be different.
But Liz was not wilting. In the past she had visited the hospital regularly, bringing Fred money and clothes. She enjoyed those trips. Now she stayed away, telling Fred over the phone, “It’s time for you to start acting like a man.” In conversations with both Cathy and Fred, she made it plain that she thought he would be better off in a halfway house. Cathy agreed. Clearly, there was something about the dynamic between mother and son that caused Fred to regress every time he went home.
Cathy made a point of mentioning Tarry Hall whenever she saw Fred, which was almost every day. Sometimes it took, and he would talk about how he might find a job once he got there. He knew about the halfway house because he had lived there for three months in 1980, at a time when he was much less psychotic. His memories, though, were not happy ones. Fred had bridled at all the rules and the chores, and as a result Cathy’s suggestions were just as often met with a stern rebuff (“I ain’t going to no damn Tarry Hall!”) or some incoherent mumbling. Still, by May Cathy felt she had made enough progress to set up an appointment for Fred the next time the Tarry Hall screening committee came to Austin. The interview was scheduled for the morning of May 16, a Thursday.
On Wednesday, May 8, near the halfway point of his ninety-day commitment, Fred had his second meeting with Dr. Cabada. After the usual cursory examination, Cabada decided to increase Fred’s Haldol to 45 milligrams a day, up from the initial 30 milligrams. A week later, on the day before the Tarry Hall screening, the doctor saw Fred for the third time. Cabada increased Fred’s Haldol to 80 milligrams a day. In the short span of three weeks he had put Fred on four times more medication than he had ever been on in his life.
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