With painful clarity, Liz Thomas remembers when she first knew her only child was mentally ill. It was September 1979. Frederick, her son, was a seventeen-year-old senior at Houston’s Kashmere High. He had always been a good kid, a B student, and interested in the usual things: music and movies and girls. He got into the occasional scrape, but not often, for it was not in Fred Thomas’ nature to cause trouble.
The previous spring, Fred had begun to undergo a dramatic personality change. He started skipping school. He spent days in his bedroom, where he sat on his bed and stared at the walls, his door closed, his radio blaring. At night he wandered around his Fifth Ward neighborhood, smoking pot and drinking beer, and sometimes harassing the neighbors. He made lewd comments to women who walked by his house and became brusque and cold toward his mother. Whenever Liz tried to get Fred to come out of his room, her once-polite son would lash out at her with curses and threats, and push her out the door.
Liz Thomas has a younger sister who has schizophrenia, the most commonly diagnosed form of serious mental illness in this country. But Liz could not bring herself to contemplate the awful thought that her son was showing symptoms of the same disease. At first she ascribed Fred’s behavior to “a teenage thing.” Then in July, after a frightening outburst in which Fred ripped his bedroom door off the wall, Liz took him to Harris County Psychiatric Hospital, a forty-bed hospital—at the time, the county’s only short-term facility for the mentally ill—located on the third floor of one wing of Jefferson Davis Hospital. He was released after a few days of observation; the doctor told Liz that Fred simply wasn’t sick enough to be hospitalized. Although the doctor prescribed Navane, one of the array of so-called psychotropic drugs that are used to treat schizophrenia, his words greatly comforted Liz Thomas because they allowed her to cling to her most fervent hope for her son—that he was not mentally ill. “I guess you don’t want to accept stuff about your own child,” she says now. But then came that September day when Fred’s teacher at Kashmere High called Liz to say that her son was doing something scary and strange in class. He was barking like a dog, and the teacher had not been able to get him to stop. And that’s when Liz Thomas knew.
Liz also knew what she had to do. She had seen her own mother do it for her sister many times. She took Fred back to Jeff Davis and told the Harris County mental health authorities that her son needed to be committed. If a probate judge agreed with her assessment, Fred would be sent nearly two hundred miles away, to the Austin State Hospital, since the most populous county in Texas had no long-term facility of its own. Liz Thomas also knew she would have to sign legal documents alleging that her son, who until six months before had been her greatest source of hope and pride and joy, was “a danger to himself and others.” She read over the papers, occasionally wiping a tear from her eye. Then she signed them and went home, and let the tears pour out.
If Liz Thomas thought the Austin State Hospital was going to solve her son’s problem, she was wrong. In the time between Fred’s first commitment and when I met him six years later, he had been in the hospital five times. He had also been a client of out-patient clinics near his home; spent three months as a resident at a halfway house in Houston; been prescribed half a dozen drugs; and been seen by about forty doctors. Young schizophrenics are difficult to help under the best of circumstances, their conditions exacerbated by years of using dope and alcohol. But it’s fair to say that Fred’s experience with the Texas mental health system between 1979 and 1985, rather than making things better, had only made them worse. Fred continued to get sicker, more haunted by his private demons with every passing year.
The fact is, a real mental health system does not exist in Texas. Instead, a group of independent fiefdoms and power bases all operate under the loose rubric of the Texas Department of Mental Health and Mental Retardation (MHMR). State hospitals are one power base, and local mental health authorities are another. Probate judges try to get mentally ill people into state hospitals, while hospital social workers try just as hard to get them out. There is even a federal judge involved in running the state hospital. As a result of a class-action suit brought a dozen years ago on the behalf of patients, federal district judge Barefoot Sanders is immersed in every aspect of hospital life, and although his intimidating presence has made the hospitals marginally better, the improvements have come at the expense of the local authorities. Part of the reason that everyone seems to be working at cross-purposes is that there is honest disagreement about how best to treat the mentally ill. But the chaos that reigns in the Texas mental health system also results from some of the worst reasons imaginable: bureaucratic infighting and turf battles, and a preference for the status quo over innovation or change.
Fred Thomas is in many ways typical of the people who populate that system. He is black. He is poor. He is unquestionably a tough case, partly because of the severity of his illness, but also because, as I discovered in the five months I spent with him a year ago, he lacks the motivation to try to make something of his life. Though instilling such motivation is perhaps the most fundamental goal of the modern mental health movement, the Texas system has seemed utterly helpless to change Fred. Instead, the system has been content to process him into the state hospital and process him out—always sending him back to his mother’s house, where inevitably and tragically he would revert to his old ways. Although Texas’ mental health hospitals are no longer hellholes, they are still little more than benign jails. One former social worker used to tell patients about to be released: “If you can survive in this place, you can survive anything.” When I first met Fred Thomas, he had learned to survive in the hospital. The question confronting him was whether he could survive beyond its walls.
“A Worse Fix”
On a bright April day, in a large outdoor area of the Austin State Hospital, Fred Thomas sat down across from me at a picnic table. In hospital jargon, he was in the Harris K patio—the Harris K unit being the drab, one-story, pentagon-shaped building that surrounds the patio. The men of Fred’s ward were outdoors for an hour of “exercise”—thus satisfying one of Judge Sanders’ requirements for structured daily activities. As far as I could see, only two men were actually exercising: a member of the ward staff and a patient were shooting baskets through a worn, bent rim. A few other patients were walking, somewhat frantically, along a cement pathway. The rest were either sitting in chairs or sprawling out under one of the pecan trees, fast asleep. At least half of them were smoking—and constantly fending off requests for a drag or a “short,” hospital lingo for a nearly finished cigarette. Almost all the patients wore dirty, ill-fitting clothes. Most of them looked harmless enough, except for one, a black, middle-aged schizophrenic with a Fu Manchu moustache who was standing in the center of the patio screaming about the CIA and the KGB. I would later learn that he was Donald Peterson.
Before coming over to the table, Fred had been among those trying to get someone to give him a cigarette. He was wearing a grimy sweatshirt, slightly tattered green jogging pants, and old-fashioned high-top sneakers without socks. Upon reaching the table, Fred sat down across from me, but at first he ignored me, concentrating instead on the cigarette he had scored. He lighted the cigarette and inhaled with excruciating slowness, savoring each puff as if it might be his last. Before his first admission, Fred had never smoked. But because cigarettes are so integral to life in a state hospital—even to the extent that they are used as carrots in Austin’s behavior modification program—he now smoked so much that his fingers had permanent tobacco stains. When his cigarette was finished, he looked up and began talking.
Fred’s speech was characterized by what psychiatrists call “loose association” or “tangential thought”—that is, skipping rapidly from one topic to the next, usually with a tenuous thread linking each new thought to the one before it. When I introduced myself, he said, “Joe. Where you gonna go, Joe? Joe Willie Namath.” And that led him to a brief discussion of Namath’s bad knees, and on to trees and bees, and then to the birds and the bees, and then to honey, which led to girls, and finally to a recently released patient whom he claimed had been his girlfriend. Although the lines are sometimes fuzzy between schizophrenia and manic depression, that sort of loose association is usually considered a symptom of schizophrenia. Fred was also awash in petty paranoia; whenever there was the slightest lull in the conversation, he would ask, “Are you mad at me, man?” Such paranoia is another symptom of schizophrenia.
Despite his illness, Fred Thomas was easy to like. He was nearly six feet tall and had a gentle voice, a sly, funny smile, and a soft, almost delicate face. He was 23 years old and looked it; his chin was half-hidden by some facial hairs struggling to be a beard. His laugh, which came frequently (sometimes for good reason and sometimes not), was infectious. There was nothing at all threatening about him, and it later became clear that only in the presence of his mother did that side of him come out. Though he had a noticeable paunch, he was otherwise thin and even gangly. His eyelids drooped a little; that was from one of the side effects of his psychotropic medication—it made him drowsy. Other side effects were equally obvious. His skin and mouth were dry. There was numbness in his touch. His arms and legs always felt stiff, so he tended to shuffle. These side effects were experienced by almost all the patients to one degree or another; they could, and often did, lead to a twitching syndrome called tardive dyskinesia, which bears a resemblance to Parkinson’s disease.
We talked for a while longer about things that interested him—Prince’s latest record, a Richard Pryor concert he had seen in Houston, the black actress in The Facts of Life television show. Fred had an astonishing memory for the most arcane details about the lives of pop music stars and television personalities. Then, completely out of the blue, he said, “I know I’m a mental patient, man. I know it. I don’t like it. It’s a stigma, man.” He sighed. But a minute later he was off again on Joe Willie Namath and the birds and the bees, his moment of lucid sadness fleeting memory.
That April marked the beginning of Fred’s fifth stay at the Austin State Hospital. After his initial admission in 1979, he had managed to stay out of the hospital for four years. But between March 1984 and March 1985, he had been in three times. Upon Fred’s most recent release—on March 6, 1985, after a 43-day stay—Liz took her mother along to pick him up. When they arrived, Fred’s grandmother took one look at him and said, “Liz, this child’s in a worse fix than before. You get him right back in there, and you keep sending him back until they do something for him!” Liz held off for two days. Then Fred came after her with a broom, and she knew her mother was right. She called the authorities a few hours later to have her son recommitted to Austin. She had to wait a week for a temporary bed to open up at the Harris County Psychiatric Hospital. But finally two men from the county came to her house to pick up Fred. And after they left, Liz Thomas broke down and cried, just as she had in 1979. It hadn’t gotten any easier.
“Do You Think I Can Kill You With This?”
It’s 8 a.m. on a Thursday in early May: time for the “morning meds” in Ward B, one of the four male wards in the Harris K unit (there are two female wards). Ward B has been Fred Thomas’ home for more than a month.
The heart of an Austin State Hospital ward is the central dayroom, no larger than a bank president’s office; it is filled with beat-up chairs, a few card tables, and a television set that is constantly on. Plexiglas windows and locked doors separate the dayroom and a nurse’s station, from which the ward staff keeps watch over its charges. There are some 25 men in the Ward B dayroom this morning, at least 7 more than the ward was intended to hold. During the time I spent at Harris K, the dayroom was constantly overcrowded, which greatly increased the level of agitation and even danger. Fred, however, does not seem agitated. He is wearing a clean pair of short pants, a new T-shirt, and his ever-present basketball sneakers, unlaced. He is standing in front of a full-length mirror, mumbling to himself. No one seems to notice.
The two mental health workers sitting in the nurse’s station don’t notice Fred because, by their lights, he is being good. To such nonprofessionals, who make less than a good grocery clerk, a patient’s goodness is measured entirely on the basis of how little trouble he causes. Fred may be incoherent, but at least he’s not starting a fight. Besides, they are busy with their morning ration of paperwork, which is voluminous, as usual.
The other patients don’t take any special note of Fred because most of them are equally absorbed in their own private worlds. Very little is known about what causes mental illness; this is one reason why psychiatrists—and society—still can only guess at how best to treat mentally ill people. We also cannot even begin to comprehend their pain. Some schizophrenics hear voices commanding them to do things; others suffer from hallucinations, delusions, paranoia, or a combination of all three. Earlier this year, in an anonymous New York Times article, a woman who suffers from schizophrenia described her torment as “the fierce battle that goes on in my head.” She went on: “My mind can divide on a subject, and those two parts subdivide over and over until my mind feels like it is in pieces….At other times, I feel like I am trapped inside my head, banging against its wall, trying desperately to escape.”
You can get a small glimpse of that private torment in the dayroom this morning—or any morning. Three or four men are sitting stonily in chairs, grumbling angrily at the walls. Another man erupts into loud, incomprehensible laughter. A new patient tries to flick something off his shoulder, a motion he repeats again and again; there is nothing there. In the bathroom an extremely delusional, muscular man stuffs magazines down a toilet. The man’s parents conceived him (so the story goes) while both were patients at Rusk State Hospital. He has been flushing magazines down the toilet every morning for over a week, ever since someone sent dozens of old copies of the New Yorker to Ward B.
Although all the patients were roused out of bed two hours ago, the only things they have been required to do so far are brush their teeth, comb their hair, and make their beds, activities that exhaust no more than five minutes apiece. Thus the rest of their time has been spent doing what they’re doing now—milling about. When you’re confined to a state hospital ward, you’re forced to spend a lot of time with your thoughts, however terrifying they might be. This cruel fact cannot possibly help anyone get better, but that’s the way it is. Other than the television, there are very few distractions. Milling about is the basic activity in the ward.
In the middle of the low-level chaos, a nurse holding a carton containing the morning medication walks into the nurse’s station. Her name is Sue Dennison. “Okay,” she announces in a tone that is both firm and pleasant, “get in line for your morning meds.” The two mental health workers go into the dayroom to help the patients form a scraggly line. One by one the patients step up to the nurse’s station to receive their medication. The psychotropic drugs they take—with names like Thorazine, Navane, Prolixin, Mellaril, and Haldol—are the primary, indeed, the only, form of real treatment they will receive in the hospital. And while there is no doubt that most of the people in this dayroom need the drugs desperately, there is considerable doubt as to whether some of them might not also benefit from other forms of help—from therapy, for instance. The issue of alternative treatments, which is the subject of a fierce national debate, does not get addressed in Austin. It is drugs that can prop people up the fastest, and get them out the quickest, and soak up the least amount of money. So drugs are what is used.
The first person Sue Dennison sees on this Thursday morning is a short, shy, soft-spoken man who looks about fifty years old. He is a murderer. In June 1980, six weeks after being released from the state hospital, he shot his next-door neighbor. He had heard voices telling him the neighbor was about to shoot him. Every time the doctors think he is well enough to stand trial, he is sent to prison. But as soon as he gets to prison, he regresses and has to be returned to the state hospital.
“How are you feeling today?” Dennison asks him. A few days before, the man had asked a ward staffer if the attendant was going to kill him soon. “Oh, just fine,” he says meekly.
Next, a young black man steps up to the window. He has a little goatee and wears a baseball cap turned backward. When he sees Dennison, he puts his chin on the window ledge and stares at her salaciously. “Come on, Michael,” she says, “I can’t give you your medicine if you’re doing that.” He keeps staring.
Michael is retarded. He was committed by a probate judge in Harris County, thus making him Austin’s problem instead of Houston’s. Harris County washed its hands of him not long after he arrived by sending a letter to the hospital stating that Michael could not be returned to Houston because the city lacked an “appropriate placement.” But Austin doesn’t have any place for him either. He belongs in a state school for the mentally retarded, but he can’t get into one; the waiting period is about two years. Judge Sanders’ monitors have raised the issue of retarded people languishing in the state hospitals. But what can the staff on Ward B do? All they can do is wait.
Next in line is John Collins (not his real name), a tall, gaunt, 25-year-old with curly black hair and a terrible stutter. He is much better dressed than the others and much more scared: this is his first admission to the state hospital. After John comes a young Hispanic from the Valley who has serious brain damage, the result of sniffing glue. His face is pocked from self-inflicted acid wounds. And next is a tall, sardonic man who is suffering from manic depression.
Bringing up the end of the line is Donald Peterson (not his real name). He is the toughest patient on the ward; he has lived at least half of his adult life in an institution—either a mental hospital or Huntsville State Prison (for armed robbery). The other patients are afraid of him. The staff prefers to keep its distance too. Peterson, who looks old beyond his 44 years, hasn’t shaved or bathed in days. He smells of stale cigarettes and rancid sweat, and the other patients have been complaining about him. Eventually, staff will have to force Peterson to take a shower, but they’re not in any hurry. The last time they tried to make Peterson clean up—it happened about a week ago—one of the mental health workers wound up with torn ligaments in his thumb.
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.
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.
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.”
“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.
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.
“They’re Trying To Railroad Me!”
On Friday, May 31, Fred’s sixty-third day at the hospital, Cathy Nottebart called Liz Thomas and put Fred on the phone. In recent days Fred had been rejecting all of Cathy’s overtures about Tarry Hall; with the clock ticking on his commitment, Fred was betting that his mother would break down and take him back. Cathy had made the phone call to convince Fred otherwise. It didn’t. Instead, Fred blew up at his mother. “Why are you doing this to me?” he spat into the phone. “I’ve got plenty of other places to go! I can go live at the Holiday Inn!” Afterward in the dayroom, Fred remained livid. “They’re like a locomotive, and they’ve tied me on the tracks,” he said. “They’re trying to railroad me.” Liz Thomas was also upset by the phone call. The next morning she bought a bus ticket for Austin.
By one o’clock Sunday, Liz was sitting in the Ward B visitors’ lobby, two of her sisters in tow, waiting to see Fred. It was a lovely afternoon, a perfect day for a picnic. For the past several years, Liz had been working behind the deli counter at a Kroger supermarket, and she bought two large ice chests filled with things from the deli: sandwiches, cookies, chips, and cold soda. Recently Kroger had cut back her hours, and money was tight. So although she also brought Fred some new clothes, they were mostly T-shirts and short pants, and not the expensive items she used to bring him.
When Fred strolled into the visitors’ lobby, Liz leapt out of her seat and gave her son a long, loving hug. “You’re looking good, baby,” she said after looking him up and down. It was true; in less than a week, the change Kerr had ordered in Fred’s medication had done wonders for him. Then Liz patted the bulge in Fred’s waistline. “You’ve been gaining some weight!” she added with a broad grin. Fred grinned back sheepishly.
Liz Thomas was a good eight inches shorter than her son, and notwithstanding his paunch, a good deal plumper. Fred had been born when she was 22, and she had never married his father, a jazz musician whom Fred had met only two or three times in his life. Liz was 45 now, but the weight was fairly recent; Judith Mitchell remembered her from Fred’s earlier stay at Tarry Hall as something of a man-killer. That was easy to picture. Liz has a very pretty face, and as she and Fred sat next to each other in the lobby, you saw at once where he got his delicate features.
After Fred hugged both his aunts, he and Liz immediately lapsed into a mother-and-son routine that was clearly second nature. Liz likes to keep the conversation flowing, and Fred doesn’t, so she would pepper him with questions and remarks while he grunted monosyllables in response. Most of her comments concerned his appearance, which in her opinion had been in steady decline since he entered the hospital. “Fred,” she said with a pained smile, “here’s a comb. Your hair is a mess!” Fred grumbled as he took the comb and made a few halfhearted stabs at his hair. Dissatisfied, Liz grabbed the comb back and began working it vigorously through his hair. “We gotta get you to Supercuts,” she said in dismay. Then she added, almost as if it were an afterthought, “You’re going to that halfway house, aren’t you?”
“Yes, ma’am,” replied Fred, staring gloomily at the ground.
“When you’re doing better you can come home.”
“Can you get this wet so I can comb your hair?”
The Thomas family went outside. They sat at a picnic table on the lush, sprawling grounds behind Harris K, and Liz handed out sandwiches and soda. A huge live oak provided shade.
“Fred,” said Liz after everyone had eaten, “you’re not talking much for someone who has visitors from out of town. Tell us some of the Richard Pryor jokes you used to tell.”
“I don’t know no Richard Pryor jokes,” he answered sullenly. There was a lull in the conversation, and Fred broke it by asking his mother if she watched Charlie’s Angels. She sighed at the question and didn’t reply. Fred could read her mind. “You think I’m crazy, don’t you?”
“You’re not crazy!” Liz replied heatedly. “You got a lot of sense. Why are you saying you’re crazy?”
Again the conversation stopped. This time Liz broke the silence. “You need to get some glasses, baby,” she said. Although no one at the hospital had noticed, Fred was nearsighted. “I’ll have to ask Cathy about getting you glasses,” Liz continued. “You can ask her too, Fred. You’re a man now. Will you see Cathy tomorrow?”
“Are you gonna tell her you’re going to Tarry Hall?”
“Got a girlfriend?”
“Yes, ma’am,” said Fred, though this was untrue. The idea of a girlfriend seemed to perk him up, however. He laughed happily as he described this figment of his imagination to his mother, and she laughed too, not knowing if he was telling the truth but not caring either. She was just happy to hear him talk. Then Liz realized something she hadn’t noticed before. “Fred,” she said in amazement, “you’re not asking us if we’re mad at you.”
After Liz’s visit Fred accepted the inevitable. When the Tarry Hall screeners saw him a few weeks later, he no longer said he would not go there, and when Cathy told him that he had been accepted into the halfway house, he did not protest. If he still felt railroaded, his new attitude was that there was nothing he could do except lay across the tracks. And so, early in the morning of June 19—the eighty-fifth day of his commitment—while the other patients went to the cafeteria to eat breakfast, Fred remained in the dayroom, awaiting the hospital van that would take him to Houston. Waiting with him was Don Peterson, who had also improved dramatically after Kerr prescribed Tegretol.
They made an odd pair. Like so many patients released from Harris K, Peterson was returning, essentially, to the streets of Houston. Yet he seemed thrilled to be going back there. Wearing four layers of dirty clothes and a muddy red bandanna around his neck, Peterson was cackling and jabbering and rolling tobacco. “I’m going back to the Rev,” he kept saying. “The Rev’s gonna to take care of me.” “The Rev” was a man named Alvin Armstrong, who rented a series of run-down houses deep in a Houston ghetto to as many as fifteen mentally ill people. Peterson had lived in the Armstrong house on and off for six years.
By the standards of the system, it was Fred and not Peterson who should have been thrilled. After all, Fred had won a spot in the only publicly funded halfway house in the city. He was being given the rare chance to stop the revolving door. But while Peterson continued his excited talk, Fred sat morosely in front of the television. June 19 was, of course, Juneteenth, and that was a special day for Fred: his grandmother, whom he revered, always threw a big family barbecue at her home in Kashmere Gardens. The thought that he would be so close to the barbecue yet unable to attend made him miserable. “I wish you were happier about leaving,” the Ward B nurse remarked.
“I am,” Fred replied glumly. “I’m ecstatic.”
It rained most of Juneteenth. At Fred’s grandmother’s house, the rain forced the party into the small wooden house where Liz’s mother lives with her mentally ill daughter, Leola, and Leola’s two children. Late in the afternoon the rain finally gave way to sun and blue skies, and the house quickly emptied. Liz stayed inside, however, slicing brisket, piling on the coleslaw, and pressing seconds on anyone whose plate was less than completely full. She was the first of eight children, with the oldest child’s sense of responsibility; except for one three-month stretch, for instance, she had never been on welfare in her life. The family saw her more as a second mother than a sister. At affairs like this, Liz Thomas always seemed to be in the kitchen working.
As usual, Liz kept up a steady stream of small talk as she ladled out the food. But you could see that her heart wasn’t in it; she was preoccupied with thoughts of her son. It had taken a supreme act of will for Liz to stay away from Austin; now that Fred was at Tarry Hall, just a few miles away, it would be even harder. But she knew that she had to try to keep some distance.
Five years before, when Fred left Tarry Hall after only three months, Liz was blamed for his departure. She had visited her son frequently, picking up Fred’s laundry almost every day and keeping him supplied in cigarettes and money. Part of the point of a place like Tarry Hall is that the residents are supposed to learn to do their own laundry, and they are also supposed to earn their money and cigarettes by participating in the programs. Liz’s visits became a source of irritation to the staff, who felt that they stripped Fred of any motivation to do things for himself. They also believed that for deep psychological reasons of her own, Liz encouraged Fred’s dependency. When Fred left, the Tarry Hall staff was quick to write it off as a case of parental “sabotage.”
At first Liz deeply resented the accusation, but more recently she too had come to see Fred’s continued dependence on her as a problem. As she got older, Fred’s behavior and his needs were wearing her down. She was tired—tired in the way only the parent of a mentally ill person can be tired.
Still, as long as Fred was living close by, Liz would always be struggling between her motherly desire to see her child and her knowledge that the Tarry Hall staff wanted her to stay away. And on this Juneteenth, motherly desire was winning out. Late that afternoon she called Tarry Hall and asked, ever so timidly, if it would be okay for her to bring a plate of barbecue for Fred. There were tears in her eyes when the answer was yes.
Around six o’clock, with the party winding down, Liz Thomas made her first trip to Tarry Hall in five years. Along with the barbecue, she brought a carton of cigarettes and $5. When she arrived, she pulled one pack out of the carton and handed the rest to a Tarry Hall aide; she remembered the routine from the last time. Then she found her son, and after much hugging and kissing and fussing with his hair, they retired to a small room where they could talk in relative privacy. She handed him the cigarettes and the plate of barbecue, which he promptly began to devour.
“What did you do today?” she asked.
“Went for a walk.”
“What are you going to do tomorrow?”
Fred stared at his now-empty plate, but did not reply. “You’re not being very nice, Fred,” Liz said. “Talk to me.” She was pleading. “Are you glad to be back in Houston?” Fred nodded yes, but he still said nothing. “I’m glad you decided to come to Tarry Hall.”
At that, Fred looked up at his mother. There were daggers in his eyes. “Mommie Dearest,” he said in a tone dripping with sarcasm. But instantly the tone softened. “Mommie Dearest. Did you like that movie? Better than The Exorcist. I think I’ll be content living here.” He smiled at her. “I used to have two Richard Pryor albums.”
She smiled back. “You’re looking good, baby. They got any pretty women in here?”
“You’re pretty, Mama,” replied Fred. “Nobody’s prettier than you.”
The Trials of Tarry Hall
“Hygiene and room check are now beginning.”
It was 9:15 a.m. the next day, and the voice booming over the intercom belonged to Dennis Milam, a bearded, sandaled social worker who is third in command at Tarry Hall. By this time, the residents (as Tarry Hall calls its clientele) had been awake for nearly three hours, and theoretically they should have finished their hygiene and room chores. Instead, most were in the same position as Fred. They hadn’t even started.
Tarry Hall is a deceptively large house built in the shape of a square doughnut. Its central feature is an outdoor courtyard surrounded by four wide corridors. In the front of the building is a pool room, and in the back, a den. Because it has a TV and a stereo, the den serves much the same function as the dayroom in Austin; it is where the residents can usually be found when they have nothing else to do. It was where Talvin Paul—a 25-year-old graduate of Grambling who was Fred’s caseworker—now found his new charge.
“Have you taken a shower yet, Fred?” asked Talvin.
“Too early for that, man.” Fred stared straight ahead while Talvin spoke. “One of the expectations around here is that everybody takes a shower,” Talvin said. Still, Fred didn’t move. It was 9:25. Over the intercom Dennis said, “Fred Thomas, you are needed in your room.” Fred crushed his cigarette butt into the floor—ignoring Talvin’s admonition to put it in an ashtray—and shuffled off to his room.
The purpose of the hygiene and room chores is to instill a sense of responsibility in the residents, and those who accomplish their daily tasks are rewarded with access to their money and cigarettes and with the accumulation of free time—time they can spend away from the halfway house. Fred and his new roommate, another recent arrival from Austin, listened impassively as Dennis explained what was expected of them each morning: besides making their beds and putting their clothes away, they were supposed to sweep, mop, and dust their rooms. In addition, each would soon be given a household chore (Fred was eventually assigned a bathroom to keep clean). “Do you understand?” asked Dennis. Fred nodded and began picking up his sheets. But as soon as Dennis left, Fred dropped the sheets, wandered back into the den, and turned on the stereo. It was 9:35.
Fifteen minutes later, Dennis found him. “In the morning,” he said, “we don’t have the stereo or TV on.” He flicked the music off. “Your roommate is sweeping the room right now, so why don’t you get the mop?” Annoyed by that, Fred nonetheless got a mop and dragged it behind him toward his bedroom. When he got there he gave the floor a few halfhearted passes. But as soon as the coast was clear, Fred started to walk back to the den. Talvin spotted him. “Fred,” he shouted, “you need to be in your room!”
That was more than Fred could bear. He stalked past Talvin into the den and again turned on the stereo. When Talvin caught up with him, Fred glared. “Why are you trying to punish me, man?” he asked. It was 10:15.
Today hygiene and room check took nearly two hours. Up until a few months ago, it had taken a half-hour. Back then, the staff had encouraged residents to look for work, and the residents themselves had run a meeting every Friday to decided how much free time each person had earned. Now the staff was spending its time encouraging residents to comb their hair, and the Friday meeting was run by staff members, who had already decided how much time each resident had earned. Things were different because the residents were different; the mentally ill people whom Tarry Hall once treated had been much less sick than the ones it treated now.
The era had only recently ended, yet it was already viewed nostalgically by the Tarry Hall staff. It had been more fun to work with higher functioning residents: they were more motivated to succeed and easier to reach, and the psychic rewards for the staff were much more immediate. Tarry Hall had enjoyed a great deal of independence in the old days. Stripped of that independence, Tarry Hall was bitter.
For most of its eight-year existence, the halfway house had successfully resisted efforts to make it a port of entry for released state hospital patients. Never mind that Tarry Hall was the only county-funded halfway house in the city and that there were mentally ill people in the streets of Houston who needed the kind of help Tarry Hall could offer. For years Tarry Hall administrators refused to admit that those two facts were connected.
Early in 1985, however, in its never-ending effort to reduce hospital populations, MHMR began dangling money in front of local mental health agencies as an inducement to treat more mentally ill people. Each agency would receive $35.50 per patient per day that the census was reduced in Austin. Gradually, the Harris County mental health authorities began making changes aimed at keeping more people out of the hospital. For instance, they assigned caseworkers to monitor the progress of recently released state hospital patients. They also began scrambling for more placement possibilities; inevitably, they saw Tarry Hall as a luxury they could no longer afford. In late March 1985 Tarry Hall had begun accepting its first handful of residents from Austin.
The change from without imposed on Tarry Hall also brought changes from within. Tarry Hall used to have a library; now the library was being converted to a point store. The former clientele had attended current-events classes; the new clientele took walks in the neighborhood. In general, sights were lowered. Among the staff members, who had agreed to the changes only because they had no other choice, morale was very weak.
The question that remained unanswered was whether the new Tarry Hall was equipped to help its new residents. For years the staff had done a good job with the people it chose to work with. Now, though the residents were different, the staff was the same. Could the staff teach residents to comb their hair and take a shower as well as they had once taught current events? Could Tarry Hall motivate the truly unmotivated? As Fred had shown, it would be no easy trick.
On his third day at Tarry Hall, just after lunch, Fred Thomas walked home. It took him all afternoon. He got into the house by crawling through an unlocked window; when Liz got home from work she thought at first she had been robbed. But then she poked her head in Fred’s old room and saw her son there, sleeping off a bottle of wine.
In her heart of hearts, Liz knew she should probably drive him right back. But she couldn’t bring herself to do it. Instead she made him dinner, and afterward they talked, mostly about how Fred didn’t want to go back. At about ten-thirty, Liz handed him all the money she could spare—$2—and drove him to Tarry Hall.
At the halfway house Fred’s departure did not create much of a stir. It was only after Liz brought him back that several mental alarm bells went off among the staff—and the source of the concern was not Fred but his mother. “The minute she walked in the door, she had that look on her face I remembered from last time,” Judith Mitchell said later. “And the first thing she wanted to know was whether Fred had enough cigarettes.” To Judith, that was the first sign of parental sabotage. “I think I’m going to have a talk to her,” she added. But she never did.
A week later Liz screwed up her courage and called Talvin to ask if Fred could come home for a Fourth of July barbecue. She knew that such a request left her open to accusations of sabotage, but she couldn’t help herself; she was a mother who wanted to do something nice for her son. She also half-expected Talvin to say no to her request, but to her surprise that was not the case.
In the short time Fred had been at Tarry Hall, he had not responded to the program at all. His behavior was starting to exasperate the staff. Compared with a number of other residents, Fred was quite bright; at times, when Talvin spoke to him about what he might get out of Tarry Hall, he seemed, after the usual hemming and hawing, to truly understand the point of it all. Fred would talk about wanting to live on his own and find a job, and when pushed he would admit that he had a long way to go before he was ready. “I need to do my hygiene,” he would say. “I gotta get some discipline.” He even had insight into his lack of motivation. “My mother spoiled me,” he would complain. “She never pushed me.” He liked to compare himself with Michael Jackson the singer. Joe Jackson, Michael’s father, had pushed his children to become singers, forcing them to practice every day even when they didn’t want to, Fred would say. As a result, the Jacksons had become “professionals.”
Yet, despite his insight, Fred Thomas simply would not lift a finger on his own behalf. His teeth went unbrushed and his hair uncombed. His room was disheveled. The bathroom he had been assigned to clean was so foul that the other residents wouldn’t use it. When asked about the bathroom, Fred would snap, “I ain’t no janitor, man,” and walk away.
When Liz made her request about the Fourth of July, it gave Talvin an idea. Maybe, he thought, Fred’s mother could provide the incentive he had been unable to. Talvin explained to Liz that he would like to use the visit home as a motivational tool, something Fred could earn by doing his hygiene and morning chores. Liz agreed. After he got off the phone, Talvin told Fred about the deal he had struck with Liz. Fred listened silently.
Later, however, after Talvin had left for the day, the Fourth of July was much on Fred’s mind. “There’s gonna be a barbecue at my grandma’s house!” Fred said excitedly. “If I keep my hygiene up and participate more, they’ll let me home for the Fourth. That’s what Talvin said.” Just then, a Tarry Hall aide announced that she needed help planting flowers. Fred quickly volunteered, grabbed a shovel and, along with a handful of others, went outside to the garden. But once he got there, he put down the shovel, and while the others dug up dirt and planted flowers and chatted amiably, Fred just watched.
The Dirty Little Secret
One morning in early July I decided to see how the other half lived—the mentally ill people in Houston who do not have one of the 27 beds in Tarry Hall or access to the other facilities available to the lucky few. I went looking for Don Peterson.
I started at the Armstrong house where Peterson lived and talked my way inside for a quick glance around. I didn’t find Peterson, but what I did find left me reeling. Peterson’s tiny bedroom, which he shared with two other people, was particularly gruesome. A spoon on his bureau had been there for so long that whatever food it once held had turned moldy and black and so hard that it appeared glued to the surface. I saw a black woman walking around naked. I tried to talk to her, but two young white “attendants” shooed me away. The attendants would be fired a few weeks later when Armstrong found them “misusing one of the girls,” as he phrased it, though not sexually, he quickly added. Before I left, one of the tenants told me that Peterson usually hung out at the Star of Hope Mission during the day.
That’s where I found Peterson, sitting in a lower downtown parking lot across the street from the mission, a large, two-story building that can accommodate as many as five hundred homeless every night. Next to him was a white teenager, a runaway. Despite the heat, Peterson wore his usual four shirts, a vest, a jacket, and a pair of new tan cowboy boots. Sweat was dripping from the end of his moustache, and a dirty winter coat lay on the sidewalk next to him. He held a Burger King bag that contained a bottle of Thunderbird wine, which he had bought from someone at the mission for 13 cents.
Every day Peterson got up before dawn and took a bus downtown in order to be at the mission in time for breakfast, which began at 5 a.m. He usually stayed through the dinner hour. I thought at first that he came because the food was better, but he quickly disabused me. “Rev’s food’s about the same.” So why did he do it? “Dunno,” he said. “Guess it’s ‘cause this is where all my friends are.” He pointed in the direction of the runaway. I asked him what his friend’s name was. He didn’t know.
The real reason for Peterson’s routine was that the Star of Hope Mission came the closest to approximating life in an institution. He was used to the barter economy of the state hospital; that also existed among the transient population. He was used to standing in line for his food. He was even used to the danger. The runaway told me, somewhat nervously, that in the last week there had been four stabbings outside the mission. From reading the newspaper you can get the impression that mentally ill people commit an inordinate number of violent crimes. At a place like the Star of Hope Mission, you quickly see that the opposite is true: their sickness makes them easy targets.
By midmorning the sun was blazing down on the parking lot, and Peterson, dizzy from the heat and the wine, decided to walk across the street to the mission. He went into a small, fenced-in yard that was covered by a tin roof, which offered a small reprieve from the sun. I could immediately see its appeal too: it had the feel of a hospital dayroom, only much dirtier. Men who were wearing everything they owned sat and stared into space. Others slept on the asphalt, urine trickling down their legs. A hustler walked through the area selling cigarettes, 10 cents each or three for a quarter.
Peterson was in a talkative mood. He began jabbering and laughing and touching me in an eerie way. Out of the hospital less than a month, he was already regressing. I asked if he was still taking his medicine; yes, he said sharply. Then I pointed to his new boots and asked about them. “Rev bought ‘em for me,” he said proudly.
You didn’t have to spend much time in Houston mental health circles to hear the allegations about the Reverend Alvin Armstrong. They were rampant. There were allegations of sexual abuse at his house, of serious untreated illness, and more. From time to time, someone in the bureaucracy would poke around, but the investigations were always halfhearted at best. The system’s dirty little secret is that it needs Armstrong, desperately, to provide his wretched shelter. However many mentally ill people are wandering the streets of Houston, there would be hundreds more without the Alvin Armstrongs of the world. Mentally ill street people shame the society that lets them live as they do. In Armstrong’s house, tucked away in the ghetto, they are out of sight and out of mind.
Everyone in the system knew how bad his house was; everyone felt helpless to do anything. The existence of places like Armstrong’s was seen as a fact of life in the mental health business—one of the awful, unintended consequences of deinstitutionalization. A social worker who refers patients to Armstrong told me that she couldn’t bring herself to visit his house. “I don’t want to see it,” she said. “I don’t want to know where I’m sending them.” That Armstrong saw himself as a doer of good, not evil, only made things more pathetic. His case for himself contained a large measure of sad, undeniable truth. “I take care of the people no one else will touch,” he said. “Tell me what would be better,” he added when I asked him about the things I had heard, “that they live here, or outside in garbage cans?” He went on. “I don’t see you white people down here helping me.” His voice rose in indignation. “If I’m so terrible, why do people keep coming back to me?”
Certainly that was true for Peterson, who had been coming back ever since his father handed him over to Armstrong in 1979. When I asked Peterson how much he got each month from the federal government, he replied, “Dunno. Rev takes care of that. The Rev gives me whatever I need.” The modern mental health movement, with its emphasis on letting people out of institutions, does not admit that there are people who don’t know how to be anything but wards. Peterson was a ward. With the state unwilling to provide for him and his father unwilling, where else could he go but to the Rev’s?
Back at the Star of Hope Mission, it was time for lunch. Peterson dutifully got in line, his overcoat under his arm. Several hundred men were in front of him. When he finally got into the cafeteria, he picked up the day’s servings—bologna on white bread, Kool-Aid, and a prefab tart—and sat in a corner where he could eat by himself. After lunch, he went to the bathroom, where he found a dirty shirt and an even dirtier vest lying on the floor. He took off his jacket, his vest, and his four shirts, put them on the ground, and tried on the clothes he had just found. He looked at himself admiringly in the mirror; the clothes were too big, but he liked them anyway. He picked up his overcoat—leaving the rest of his clothes behind for the next person—and walked out of the mission. Then he headed up the street, to see what the rest of the day had to offer.
A Mother’s Love
Fred Thomas never got to go home on the Fourth of July. Even the chance to spend a day at home could not arouse him from his lethargy.
It was not that Fred hadn’t improved since arriving from Austin; in some ways he was vastly better. One of the premises of deinstitutionalization is that in a less stressful setting, the need for medication is reduced. That premise was clearly borne out at Tarry Hall. In Fred’s case, the doctor at the halfway house had taken him off all drugs for nearly a week in order to get a truer reading of his illness, and you couldn’t tell the difference. The doctor then cut his daily intake of Haldol by more than two thirds. On the new dosage Fred actually seemed better.
But on the thing that mattered most at Tarry Hall—Fred’s attitude—there was no improvement at all. By the end of July his daily routine consisted mostly of begging for cigarettes, listening to the stereo, watching television, sneaking off to a nearby convenience store for beer—and avoiding Dennis and Talvin. The staff had settled into a routine too. They prodded Fred when they saw him, and they took away his free time. But they no longer bothered tracking him down to get him to do his hygiene and chores, and they stopped confronting him every time he violated a house rule. Fred’s lack of interest was causing the staff to lose interest in him. After all, there were so many other residents who were responding.
If anything, the obvious progress of other residents made Fred’s behavior more painful to watch. Most of the residents at Tarry Hall were people I had seen in Austin. Many had been at least as sick as Fred, and yet they now seemed genuinely improved. I remember in particular a young man from Pasadena, about the same age as Fred, who had spent nearly three months at the state hospital without saying more than a dozen words a day. Soon after he arrived at Tarry Hall, I overheard him screaming to his father over the phone: “I hope you’re proud of yourself. You’re letting me rot in here!” But slowly his resistance had broken down. He had begun talking to people and doing his chores and participating in the classes; you could see a spark taking hold. Soon the staff began speculating about when he might be ready to move on. Why had the spark taken hold in him and not in Fred? I could never answer that question, and perhaps there wasn’t a good answer. But it bothered me that the Tarry Hall staff had no more idea than I did about how to awaken Fred to life’s possibilities.
The staff members had their own answer: Liz Thomas was once again sabotaging her son’s treatment. But that struck me as a bit too convenient. Yes, it was true that Liz visited Fred and gave him a few bucks and a pack of cigarettes. But they were gone within hours, which put Fred in the same position he’d been in before she showed up: either he had to beg for his cigarettes or he had to earn them. He chose the former every time.
More important, if Liz really was sabotaging her son’s treatment, then the Tarry Hall staff should have done a better job of telling her so. A professional halfway house should know how to deal with a mother’s love. For her part, Liz believed that the problem lay not with her but with Tarry Hall. “They told me in Austin this was such a great place,” she said bitterly, “but I don’t see what good they’re doing for Fred. You got to push Fred. If you don’t push him, he’s gonna sleep all day.”
Near the middle of August Fred began doing things that made it obvious he was getting worse. His lapses into crazy talk started to rise. He was caught eating out of a garbage can. He had always been sullen, but now he became contemptuous, flouting the rules. His sexual remarks, which had been mostly self-pitying, turned ugly. He began telling some of the nurses that he wanted to rape them.
With Fred deteriorating, Judith and Talvin concluded that Tarry Hall could no longer keep him. Judith had just returned from a round of screenings at Austin and had seen how many patients were waiting to get into the halfway house. The pressure to free up beds was unrelenting; if a resident showed no signs of improvement after two months, Tarry Hall had to let him go. “Mr. Thomas,” Talvin wrote grimly in Fred’s chart, “does not choose to make any changes in his life at this time.”
Still, nobody wanted to send Fred back to his mother; his track record practically guaranteed that he would wind up back in Austin before long. The point of it all—the $35.50, the transformation of Tarry Hall—was to keep people like Fred out of Austin. So Judith decided to try to place Fred in a state-run nursing home. By late August the paperwork had begun. Such homes, called personal care homes, were not like traditional nursing homes, Judith explained. They took mostly younger people, and there were some programs. She tried to sound upbeat. “Maybe this experience will jar something in him. Sometimes something clicks after they leave.” But her expression betrayed her words.
“You’re My Backbone, Mama”
Liz Thomas sat in her living room, her hand resting on the phone. It was a Friday morning in late September, and though Liz had been up for three hours she was still in her bathrobe. She had been drinking coffee, pacing the floor, and trying to decide whether to call Tarry Hall and cancel a meeting scheduled for one-thirty that afternoon. The meeting was about whether the halfway house would take Fred back. She picked up the receiver, took a deep breath, hesitated—and then put the receiver back down. One more time she went over the pros and cons. “I just don’t know what to do,” she said finally.
Liz had first thought about withdrawing Fred from Tarry Hall when she heard about the nursing home. The news frightened her terribly; she had visions of Fred living in a home full of elderly people, where he would be neglected or worse. Then Liz took her mother to visit Fred, and the older woman had come away unimpressed. “He’s just stinkin’ and sleepin’,” she said. “These people ain’t doin’ him no good!” That clinched it. One Monday, September 22, for the first time in six months, Liz brought her son home.
Monday evening had gone well; when Liz went to bed, Fred was quietly watching the football game. She was pleased, confident she had made the right decision. But around three in the morning she got a call from her mother, who said that Fred had come by her house and was now wandering the streets. By the time Liz left for work the next morning, Fred still had not come home. She panicked. As soon as she got to work, she called Talvin, told him she had made a terrible mistake, and begged him to take Fred back. After speaking to Judith, Talvin agreed Freed could return, provided that Liz and Fred met with the staff. That meeting was the one she was thinking about canceling.
In the interim, however, Fred had returned home only to behave better than he had in years. That made Liz wonder whether her initial panic had been misplaced. “I know I can take care of him if he stays like this,” she kept saying. Then again, what guarantee did she have that he would stay like this?
At about ten Fred got up and joined his mother in the living room. His transformation was remarkable. He was, of course, smoking a cigarette, but he was alert and lucid—more so than I had ever seen him. Liz quickly launched into the subject at hand. “Do you want to go back to Tarry Hall?” she asked Fred.
“No, man. I just got out of there.” He got up and walked into his bedroom. Liz followed him in, pointing out his unmade bed. Amazingly, he made his bed without complaint. Then he walked into the kitchen and asked about breakfast. Liz poured him some apple juice and began making eggs. “If you go to Tarry Hall,” she asked, “will you behave yourself?”
“I cleaned the house every day!” Fred said angrily. “I’m not going to Tarry Hall.”
“If you stay here,” she replied, “you have to go to a day program. You can’t sleep your life away.”
“I’m gonna be a lawyer. Neat. Clean. I don’t have to go to Tarry Hall. I can be independent here. I can get a job. I can be a janitor.” Suddenly his mood turned sour. “You know they’ll take me back at Tarry Hall. ‘Cause I’m a mental case.”
As soon as he spoke those words, Liz’s eyes narrowed and her jaw stiffened. At that moment her mind was made up. “Lots of mental patients work,” she said softly. “They hold jobs. You can learn how to do that too, Fred. But not here.”
Between the Tuesday that the Tarry Hall staff decided to take him back and the Friday meeting, the staff had at long last devised a strategy for, as they put it, “breaking the dependency.” Liz’s visits and phone calls would be limited to two a month, and even those two would depend on how often Fred did his chores and hygiene. When Liz did visit, she would not be allowed to give him so much as a dime. And if Fred ran home, Liz could not even let him in the house. She had to tell him to return to Tarry Hall on his own. The plan was tough, but Fred had shown he needed something tough. Indeed, the new plan struck me as so sensible that I later asked Judith why the staff hadn’t tried it months ago, before they decided to shunt Fred off to a nursing home. She said she didn’t know.
But when Liz faced the Tarry Hall staff she did not hear the outline of this new strategy, explained to her one adult to another. Instead, as Talvin and Judith and others sat in a circle facing Liz, she heard that she had sabotaged Fred’s treatment with her visits. She heard that she had taken away Fred’s incentives by supplying him with money and cigarettes. She heard that she secretly wanted to “create a dependency.” Talvin read aloud a contract he had drawn up, which Liz and Fred had to sign, spelling out the terms under which Fred would be allowed back. From everything that was said, it was made clear to Liz that the staff was unwilling to accept one iota of responsibility for Fred’s failure in the three months he had been at the halfway house. The entire burden was being placed at Liz’s feet.
Liz Thomas wept openly at the meeting. She sobbed as she signed the contract, and after Fred had been brought into the room, she dabbed at her eyes when, at Talvin’s insistence, she looked at her son squarely and said, “Fred, you can’t go home. You have to stay in the program.”
“But you’re my backbone, Mama,” Fred replied, making one last, desperate plea to change her mind.
“You’re an adult now, Fred,” said Talvin. “It’s time to start acting like one.”
Then the meeting was over, and Liz was getting ready to go, and her only son was asking her for a dollar. Without thinking, she began to rummage through her purse. She pulled out a five-dollar bill; with a nervous glance around the room, she handed the money to Talvin. Then there was another nervous glance. “Does he need any cigarettes?” she asked.