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.
(Page 5 of 9)
By the next morning, when Fred was scheduled to see the Tarry Hall people, it was obvious that the new dosage was taking its toll. He looked like a walking zombie. His eyes were red and nearly shut. His mouth hung open. The act of walking from one end of the dayroom to the other seemed to take every bit of energy he could muster. An attendant handed him a comb so he could clean up for the screening. He took the comb and slowly began making his way to a mirror. Halfway to the mirror he dropped the comb, but he had so little feeling in his fingers that it took him several seconds to realize the comb was no longer in his hand. He went back to pick it up and walked numbly around with it some more. He dropped it again. He picked it up a second time and finally reached the mirror, where he stood and stared. The morning game shows had begun, so Fred moved a few steps sideways until he stood almost directly under the television that was attached to the wall. He started blankly at the $25,000 Pyramid. A staff person opened the bedrooms so they could be cleaned. Fred sneaked in and went back to sleep.
It was nine-thirty by the time Fred was taken in to see the people from Harris County. They all sat around a conference table; Cathy sat across from Fred. One his right sat Dr. Irving Belz, the director of medical service for the Mental Health and Mental Retardation Authority of Harris County. Next to Belz sat Judith Mitchell, a big, gregariously friendly woman who was the assistant director of Tarry Hall. Mitchell recognized Fred from his previous stay at the halfway house. “Do you remember me, Fred?” she asked, smiling. “Yuh,” grunted Fred.
The session did not go well. Fred’s speech was scattered and slurred, often veering off into gibberish. When Belz asked him what happened when he first started getting sick, he said, “Everything went jibbity, jibbity, jibbity.” When the doctor asked if he had a history of drug abuse, Fred said, “Olive oil.” The interview ended when Belz asked Fred how he would handle not living with his mother, and Fred replied that he was a billygoat.
When Fred left the room, Cathy asked the doctor what he thought. “His thoughts are scattered,” replied Belz, “but it’s hard to tell if that’s from his medication or because that’s how he handles stress.” In looking over Fred’s chart, Belz and the others had been surprised at the sharp, sudden increases in his medication. After some more discussion, the screening committee decided to talk to Fred again the next day, but before he had his morning meds. Their hope was that if they saw him before he became groggy from the Haldol, they might get a clearer reading of him. But the next day, Fred was not perceptibly better.
“Do you want to talk seriously about what your plans are when you get to Houston?” Belz began.
Fred shrugged. “I’m not rubbish you can wrap up and send off,” he said. “She thinks I’m rubbish, man.”
“Who thinks you’re rubbish?”
“My mother, man.” There was a long pause. “This is crazy, doc,” Fred said finally. “I don’t want to go to Tarry Hall ‘cause they don’t have no energy.”
“Energy?”
“A generator, man. Degenerate.” There were those scattered thoughts again. But after another uncomfortably long pause, Fred said something everyone in the room understood. “Who cares?” he asked despondently. “Nobody cares. Send me to St. Joseph’s, man.” St. Joseph’s is a private psychiatric hospital in Houston.
“You’ve been there before too,” Belz pointed out.
“Been to Tarry Hall too,” replied Fred bitterly. “I’m not gonna sit here and fool with this anymore.” And with that, he stood up and stalked from the room. Cathy jumped up to chase after him.
It didn’t take long for the Tarry Hall screeners to make up their minds. Fred was a long way from being ready for Tarry Hall. Aside from his unwillingness to go there, he was simply too sick for a halfway house. There was hope, though. The screening team would be back in less than a month, and they would talk to Fred then. As they put aside Fred’s chart, Belz had one last thought. “I imagine they’re going to have to back off that dosage,” he said.
End Run
A few days after the screening, Dr. Cabada took a week’s vacation to attend the American Psychiatric Association’s annual convention in Dallas. That meant that Wards A and B were without a doctor for a week. But then, so were four other wards, where the doctors had resigned and had not been replaced yet. For the time being all of those wards were being covered by one man, the Harris K unit director, a psychiatrist named Len Dan Kerr. In juggling all the admissions, evaluations, patient requests, emergencies, and everything else for the two hundred or so patients in these wards, Kerr was impossibly stretched. He couldn’t have been happier.
Although Kerr had been at Austin for only six months, he had already made a deep impression on the Harris K staff. It wasn’t just his immense capacity for work that was so impressive; it was also his unfailing good humor, and his clinical judgment, which was a ray of sunshine in this haze of psychiatric mediocrity. Kerr was a rare bird at the state hospital; a native Texan who had studied medicine at UT-Galveston, he worked in the state hospital system not because he couldn’t find anything else but because the system was where he genuinely wanted to be. It was where he thought he could do the most good. He had been with one state hospital or another since 1977, and though he had made his peace with the system, he was neither cynical nor burned out. He was fifty years old, a short man with an unruly head of hair and a gray beard. He made $70,000 a year.
Cabada’s vacation gave Cathy Nottebart the perfect excuse to have Kerr examine Fred Thomas. Earlier in the week she had seen Fred sitting by himself in a corner of the dayroom. His eyes were closed tightly, his arms wrapped across his chest, and his head pulled back as far as it could go. Suddenly he began rocking back and forth, and as he did Cathy could see that he was shaking. He began to moan softly. It was a sad and scary moment, for Fred’s pain was as visible at that instant as it would ever be.
Under ordinary circumstances, doing an end run around the regular doctor might have entailed some bureaucratic risk for Cathy. Cabada would probably be furious when he found out about what she had done. But since Cabada was heading for Miami in a few weeks, it didn’t much matter how angry he got.
And that’s why, on the afternoon of May 24—two thirds of the way through his stay, yet sicker than the day he walked in the door—Fred Thomas found himself sitting across a table from Len Dan Kerr. With Kerr, however, Fred was more alert than he had been in days. He smirked and grimaced his way through the session, and he rudely whistled old Motown tunes whenever Kerr began to talk. Still, his speech was very loose and almost painfully slow.
“I’m going to Tarry Hall today,” Fred told Kerr. He laughed scornfully and tapped his toes to a beat only he could hear. “I’ve got a beautiful record, man. No taxation. No bribery. I know you don’t care, but I’m going home, man.”
“I thought you were going to Tarry Hall,” said Kerr.
“If I have to use a disguise, I’m going home, man.”
Although he was too politic to say so directly, Kerr realized that Fred was overmedicated. He quickly wrote an order cutting the Haldol back to 45 milligrams. “It’s not in his best interest to cut off the Haldol altogether,” he said later. But he was also convinced that there was more to Fred’s problem than just overmedication. “When I was in medical school,” Kerr said, “we were always taught that a psychotic person was schizophrenic until proven otherwise.” But after working in state hospitals, he had come to believe that many of the delusional patients he saw were not afflicted solely with schizophrenia or solely with manic depression, but rather with some combination of the two. “Schizoaffective disorder,” he called it; the Chinese, he was fond of pointing out, had been diagnosing that for centuries. In Fred’s case, where I had seen his slow and halting speech, Kerr had seen something else entirely—a patient whose thoughts were so hyperactive he could barely keep up with them. That, to him, was evidence of mania, for which Fred had never been diagnosed. Kerr leafed through Fred’s chart, noting all the times he had been diagnosed as schizophrenic. “I’m going to assume some doctors made some easy choices along the way,” Kerr said. He wrote up a second order for Fred: Tegretol, 200 milligrams, three times a day. Originally marketed as an antiseizure medicine for epileptics, Tegretol had more recently been found to work well for manic depression. It was the hot psychotropic drug of the moment, and Kerr had been using it extensively for over a year. He closed Fred’s chart. “There is nothing empirical about this,” he said finally. “All you can do is bring your experience and your training.” He headed for the door; there were other wards that needed him as badly as Ward B, and he didn’t have time to dawdle. “This is what I get paid for,” he remarked cheerily, closing the door behind him.
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