Hands On

When the sickest of Harris County's mentally ill break down, an ACT team is there to pick up the pieces and put them back together again

Dr. Joel Steinberg, attending physician at the Harris County Psychiatric Center, has been experimenting with advanced imaging techniques that record nerve-cell activity in the brain. Steinberg's research is focusing on the prefrontal cortex, which is responsible for cognitive functions such as short-term memory. His findings suggest that the level of "neuronal firing" in the prefrontal cortex of schizophrenics is weaker, hindering their ability to organize the sequence of events needed to carry out simple tasks.

"People without that working memory may not be able to hold on to things in their memories, and they will forget what they are doing," Steinberg says. "It is difficult for people with this illness to reach out. The illness keeps them from following through."

Steinberg says "it would be great" if researchers could predict outcomes for people with schizophrenia or bipolar disease. However, prognosis is ultimately determined by complex factors such as individual biological and psychological traits, socioeconomic status and cultural background. "Some people respond quite well and have normal lives and families," he says. "Others deteriorate no matter what."

Director Tom Mitchell worries that ACT could be privatized.
Deron Neblett
Director Tom Mitchell worries that ACT could be privatized.

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In 1987 the American Journal of Psychiatry published the results of a 30-year study of schizophrenics from the "back wards" of Vermont's mental hospitals, who in the 1950s were released into a rehabilitation program that offered housing assistance, job training and other services. More than half the patients "significantly recovered," compared to little improvement among patients in Maine who were released into the community without similar support.

Between 1965 and 1975 more than 400,000 people were discharged from the nation's mental hospitals -- 80 percent of the institutionalized population. One reason for the exodus was Medicaid, which didn't cover the cost of care in state mental hospitals. Instead, the federal government built the community mental health network, which has itself behaved rather neurotically. Early on, there was an emphasis on transitional programs, like halfway houses; then an almost religious faith in pharmaceuticals; followed by the belief that medication should be joined by social-welfare services; and back again to a devotion to drugs.

The year the Vermont study was published, Tom Mitchell took over Tri-County's community-support programs, which, in light of that research, gave great hope to mental patients and their advocates. But by the early '90s, policymakers had begun dismantling those programs, including Fairweather Lodge, and were investing heavily in the "new generation" of antipsychotic medications.

While the right treatment, or combination of treatments, eluded almost everyone, people like Darnell and Edward were helpless to stop the progression of their diseases. They went years without setting foot in a clinic, suffering repeated psychotic breakdowns and spending weeks and months at a time in the hospital. Meanwhile, they likely suffered from what's known as downward drift, the steady and permanent decline of their functional abilities.

"It's something we see in older patients in particular," says Thomasson, ACT's director of clinical care. "With each psychotic episode, you don't bounce back."

While ACT may, perhaps, preclude younger patients from the kind of suffering experienced by Darnell and Edward, some things are harder to change. In colonial times, the mentally ill were the family's responsibility. In the 19th century, urbanization spawned asylums that separated "lunatics" from the general public. Two centuries later, the asylums have been emptied -- some people still think it was a bad idea -- but treating the mind and treating the body remain completely separate endeavors. Meanwhile, the chasm between the sickest and the sane continues to grow.

"There are some of us who just like these people, and after you meet them you'd like them, too," says Munday. "They try your patience, they piss on the front seat of your car, but hey -- people on the street are afraid? It's not like that at all. These people are the ones running scared."


Last April a woman wrote a letter to Dr. Roy Varner, the medical director of the Harris County Psychiatric Center, and sent certified copies to, among others, MHMRA Executive Director Steven Schnee, state Representative Garnet Coleman and County Commissioner El Franco Lee.

The letter was prompted by a three-part series in The New York Times called "The Well-Marked Roads to Homicidal Rage." The woman described her 31-year-old son -- call him Devon -- as a fairly average young man until he jumped or fell from a moving vehicle and suffered a serious head injury. About six months later, the letter said, "his life and his family's life became a living hell."

Devon told friends he was going to kill his mother because she was poisoning his food. When his mother started sleeping behind a locked door with her daughters and a loaded gun, Devon told her they'd be defenseless if he decided to drive his van through the bedroom wall. Devon was diagnosed as paranoid schizophrenic, but he thought his medication was evil. While he sometimes agreed to take it -- often enough to have learned a trade -- he always stopped.

Off the drugs, Devon became violent. He once attacked his stepfather and, twice, his father. In 1994 he had an armed standoff with HPD's SWAT team. Fortunately no one was hurt, but the police later found five more guns in Devon's room. Devon's parents have had him involuntarily committed to HCPC 16 times, to Rusk State Hospital five times and twice to private hospitals.

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