By Jeff Balke
By Aaron Reiss
By Angelica Leicht
By Dianna Wray
By Aaron Reiss
By Camilo Smith
By Craig Malisow
By Jeff Balke
At the time, the public mental health system was, in effect, going public: People who had been shut away in state hospitals were being encouraged, sometimes forced, to live among the rest of us. To ease the transition, federally funded treatment centers opened around the country, offering medication, housing, job training and psychotherapy. An incorrigible idealist, Mitchell was pursuing a sociology degree while working for the phone company when he quit his job and, at half the pay, went to work for the Mental Health and Mental Retardation Authority of Harris County.
In 1973 Mitchell was pulling graveyard shifts at Terry Hall, a residential halfway house in Montrose, where he met a young man with schizophrenia named Darnell Anderson. The hope for Darnell and others like him was that with medication and a little guidance, they could control the symptoms of their disease -- the voices, hallucinations and paranoia -- and, someday, be able to care for themselves.
No one knew yet that such a humble wish was itself a delusion.
Darnell was raised poor in the West End. But by age 20, his frame of reference in life had become Rusk State Hospital, where nothing asked is nothing gained. Darnell built his reputation at Terry Hall around a question, "Will you do me one small favor?" His needs were rarely unreasonable -- a pair of shoes, a ride someplace, "soda water" or a bag of chips. But until Darnell got what he wanted, his requests would escalate into relentless demands. If they could, other people, even some of the Terry Hall staff, avoided him.
On the late shift, Tom Mitchell often found himself alone with Darnell. After midnight, while others slept, Darnell seemed more tranquil and lucid. He told funny stories about his family and his life before it was devastated by the chemical imbalance in his brain.
In the three decades since they first became acquainted, Mitchell and Darnell have traveled separate but parallel roads through the public mental health system. Mitchell got a master's degree and became a licensed social worker. He made his way up the clinical ranks at MHMRA of Harris County until 1987, when he left to become director of community-support programs at the Tri-County mental health authority in Conroe. Mitchell ran Tri-County's Fairweather Lodge, which helped groups of mentally ill people set up a home together. They cared for each other and supported themselves by developing a small business, such as a janitorial service.
Harris County had its own Fairweather Lodge, but it wasn't much help to Darnell. Darnell, it seemed, couldn't be relied upon to take his medication or, on the other hand, not to ingest a week's worth of the drugs at once. More often than not, Darnell was in Rusk State Hospital or the Harris County Psychiatric Center.
Sometimes he was off his meds and psychotic. Sometimes he was just being Darnell, in need of a favor.
"Darnell's job is to be Darnell," Tom Mitchell says. It's mid-morning on a weekday in January. The city is veiled in a storm-driven gloom. Pelting rain and a cold wind slap Mitchell's sport utility vehicle as he exits U.S. 59 in north Houston.
"When people have been as sick as Darnell has," he says, "for as long as he has, and with the system the way it is, he just considers it his job to be Darnell. It's his purpose."
Mitchell pulls into a strip mall on Stuebner-Airline and parks in front of a sign that reads, "The Caring Place Adult Daycare and Beauty Salon." He double-times it through a steady downpour and goes inside.
A wiry 53-year-old Houston native with a trim, graying beard and hair the color of wet sand, Mitchell returned to MHMRA of Harris County in 1993 to help the agency launch something called Assertive Community Treatment. ACT was developed in the early 1970s, but it took 20 years before anyone outside Wisconsin and Michigan really tried it. Texas adopted it earlier than most states and, in 1996, made ACT mandatory at all county and local mental health agencies.
There are two types of patients in the public mental health system: those who use the clinics, and those who use the hospitals. The two groups are almost mutually exclusive; people who use the clinics avoid the hospital. They also tend to have fuller and more stable lives. ACT addresses what science and advocacy have long understood but most everyone else ignores: Public mental health clinics can do little for some people who suffer chronically from illnesses like schizophrenia and bipolar disease.
To make it on their own, these patients need unfettered access to medical care, as well as the full range of social-welfare services. Without constant support, the worst symptoms of their diseases return, and they start showing up regularly in emergency rooms, or are admitted to the hospital over and over again for anywhere from a few days to a few years. It's also true that most homeless people and, according to the U.S. Department of Justice, at least 16 percent of the nation's prison population have a serious mental illness.
Harris County's ACT program started in March 1996 with 40 patients, who were assigned to a ten-member treatment team consisting of a psychiatrist, a nurse, an employment specialist, rehab counselors and social workers. There are now three ACT teams in Harris County and, at last count, 295 patients, who are referred to as clients. By design, ACT anticipates that all of them will need the program indefinitely, if not for the rest of their lives.
"These are the sickest people in the system," says Mitchell, who became the director of Harris County's program in 1999. "The goal is to get them an apartment, maybe a job, or somehow situated in as normal a life as possible. Some get there, after years. Some never get there."
A handful of Mitchell's clients have jobs. Most of them are poor and rely on some form of public assistance. One in four have been in jail, some repeatedly, for crimes attributable to their illness. About a half-dozen were court-ordered into the program, either as probationers or, in the case of those found mentally incompetent or not guilty by reason of insanity, upon release from a state hospital.
In the 28 years since it was founded in Madison, Wisconsin, ACT has been the subject of no fewer than 25 controlled studies comparing the program to clinic-based services. A soon-to-be-published review of that research found that ACT never failed to reduce hospital admission rates -- by as much as 78 percent in some groups -- and cut the overall cost of treating serious mental illness.
Yet as recently as 1990, only seven states reported using ACT. In 1996 the National Alliance for the Mentally Ill, an influential advocacy group, began promoting ACT, with the goal of establishing the program in all 50 states by 2002. Some 36 states have adopted ACT, though most of them have embraced it rather halfheartedly; only about a dozen have treatment teams in more than half their community mental health centers.
ACT's basic blueprint, which Texas adheres to as a matter of policy, calls for one ten-person team for every 100 of the most chronic cases. However, that equation can be manipulated to take in a wider range of mental patients. Those whose symptoms make employment impossible, for example, can be assigned to a more intensive ACT team that emphasizes "illness management." Those who are more independent -- who may have a job, live on their own or with a supportive family -- can be "stepped down" to a team that doesn't offer such ever-present support.
The latest use for ACT, and one of the most promising, is helping mentally ill people stay out of jail. Since 1998 four ACT teams have been working out of the Cook County Jail in Chicago. The results of a two-year study of 13 cases, soon to be published by Loyola University, are impressive: total arrests -- down from 116 before ACT to 13; days incarcerated -- down from 1,546 to 213; and inpatient days -- reduced from a total of 990 to 175 after two years.
The researchers calculated that the net savings to Cook County taxpayers for those 13 cases was $455,800.
There is some confusion inside The Caring Place Adult Daycare and Beauty Salon when Mitchell learns that Darnell isn't here. On his cell phone, he dials ACT headquarters at Northwest Community Service Center, on Dacoma Street. A moment later a caseworker tells Mitchell that Darnell is only five minutes away, at a therapeutic day program off the North Freeway. He's sitting in the lobby when Mitchell arrives.
Darnell, now 49, is a big man, well over six feet tall and at least 250 pounds, with a full head of hair that's graying softly around the ears. He has a Fu Manchu moustache and long sideburns. He's wearing jeans, tennis shoes and a black warm-up jacket and sweatshirt. Darnell greets Mitchell shyly, but he's obviously glad to see him.
Mitchell rarely crossed paths with Darnell during his six years with the Tri-County agency. But by the time Harris County's ACT program opened for business, Mitchell says, Darnell had become "a legend" in local mental health circles. Mitchell made him a charter client of the program.
"When Darnell wanted something, he wouldn't give in. He would just pester people and go on and on," he says. "Then he'd get angry....Darnell is the only guy I know who could talk the police into buying him cigarettes. He used HPD like a taxi service to the hospital."
All the time, apparently. By the mid-1990s Darnell was spending as many as 300 days a year in the hospital. "The community" didn't represent freedom and normalcy to Darnell, only loneliness and terror. Too much community, or any at all, can be overwhelming for people with mental illness. A few of Harris County's ACT clients are so emotionally fragile they can't visit the program's offices without risking a psychotic episode.
Moreover, there are no longer any Fairweather Lodges and far fewer halfway houses like Terry Hall in Harris County. The housing void was filled by a network of personal-care homes and unlicensed boarding houses. Too few to meet demand, such establishments frequently exercise their right to be arbitrary. People with mental illness lose their room and board when they're hospitalized. Or their symptoms, including alcoholism and drug abuse in half the cases, make them undesirable tenants.
Mitchell poked around the city's neighborhoods for eight hours one night, looking for a place that would take Darnell. "A lot of these places knew him, and they about slammed the door in my face," recalls Mitchell, who reports the seedier personal-care homes to the state health department. He has succeeded in having several shut down, but unfortunately, he says, most of them just move to another part of town under a new name.
"We try to make sure they're at least semiclean, but it's getting harder and harder," Mitchell says. "The nicer ones are getting to be expensive, and most of our clients only get about $500 a month in social security."
Rusk State Hospital and the Harris County Psychiatric Center are sanctuaries for the mentally ill -- clean surroundings, a bed, three meals a day. And patients usually find the company more to their liking. "When he felt like he was alone and just hanging out there, that's when Darnell would start calling the hospitals," Mitchell says. "We've tried to transfer that dependence onto us."
By any standard, they've succeeded. Darnell can't drive or navigate public transportation. So for much of his tenure in the program, ACT team members have had to visit Darnell daily, sometimes twice daily, to personally hand him his medications -- making sure he doesn't "cheek" the pills -- and to chauffeur him to doctor's appointments and weekly therapy sessions.
Darnell has lived at more than a dozen locations in the last five years, from his brother's camper parked in the West End to boarding-house rooms so small they hardly contained him. About six months ago the ACT team was able to move Darnell into a good personal-care home. The owner has agreed to make sure he takes his medication every day and to provide transportation to and from the day program.
That arrangement has worked out well: Someone from ACT (it's often Tom Mitchell) visits Darnell only once or twice a week now, and he never misses his group sessions. But most important, Darnell has been admitted to the hospital just once in the last two years. For the first time since he was a child, perhaps, he has a relatively stable life -- for now, anyway.
"Medication makes me feel good," Darnell says in a smooth basso growl. "Without it, I feel lousy -- lousiest in the world. Like 16 dump trucks lettin' out sand."
Darnell is seated at a card table, across from Mitchell. He reaches back and pulls a battered brown cowhide billfold from his pocket. At times, it appears that Darnell is doing all he can to keep his heavily featured face from sliding off his head -- an unfortunate side effect of his medication. His eyes are downcast, under heavy lids. His cheeks sag, and his mouth is slack and thick-tongued. But Darnell loves company, and clearly he likes to talk. Typically, he doesn't wait long for an invitation.
"My mama's dead, my daddy's in a wheelchair, and my brother don't have good sense," he announces. "I was born in Jeff Davis Hospital, five pounds, 11 ounces. I went to Doris Miller Elementary, R.G. Lockett Junior High School. I was in special education, because I was a slow learner. Old J. Will Jones High School, at Holman and Chenevert."
As he speaks, Darnell is constructing, from the contents of his wallet, a small mountain of haphazardly folded and wadded pieces of paper. "All the places I been," he explains. The skin around the rocklike knuckles of Darnell's enormous hands is cracked from dryness. He pulls out an official State of Texas ID card, then carefully unravels what turns out to be a sulfate warning from a hospital cafeteria. Next, a receipt from yesterday's visit to the emergency room. It says Darnell had come in complaining of athlete's foot; the attending physician had added, in parentheses, the abbreviation "schizo."
"You've got to stop doing that," Mitchell says.
"I don't do that too much," Darnell replies. "I been to Rusk 34 times, been to HCPC too many times. I want to stay out of those places. They experiment on me."
ACT is often called a "hospital without walls," which explains why someone like Darnell responds so well to it. But many people with mental illness have scrupulously avoided the public mental health system for years, and they see no reason to change just because someone -- a psychiatrist, a social worker, a judge -- has put an ACT team on their case.
Right now Harris County's ACT clients are all present and accounted for -- if not all completely on board -- but this could change at any time. It's not unusual for them to disappear. "Then," Mitchell says, "we have to be detectives." Team members check with family, if there is one. They canvass hospitals and homeless shelters and log on to the Justice Information Management System, a criminal courts database.
Sometimes they get outside help. ACT clients, who are given special identification cards, have turned up at a Washington state hospital and in the protective custody of police in Boston. A few years ago Mitchell received a phone call from McAllen -- an ACT client had stripped off her clothes and climbed onto the hood of an 18-wheeler on the Mexican border.
"Part of it is them testing us," Mitchell says. "People come and go in their lives for years, and they want to see if we'll stick it out. But we don't take no for an answer."
Harris County's ACT team members are licensed and experienced, with no shortage of employment opportunities, including private practice. To be sure, they could find work elsewhere in the public system -- at a state hospital, for example, or at a community clinic where the patients come to them. But ACT team members seem uniformly repelled by the idea of sitting behind a desk eight hours a day, doling out 15 minutes of chat therapy to an endless stream of patients.
Indeed, ACT is the antithesis of the community-clinic system. Eighty percent of a team's interaction with a client takes place on the client's turf. This can represent an interesting challenge. Although more mentally ill people are living in the community than ever before, they are almost invisible just the same. Socially isolated by nature, they typically live in poor, crime-ridden neighborhoods where room and board are cheapest.
Team members soon learn that they have little to fear from their clients. However, that's not always true of the people with whom their clients associate. The extent to which the job is dangerous depends on how team members handle themselves, says Mitchell, who has been "belted" once in six years. "If you go in and your emotions are all out in the open, that tends to set things off," he says. "We need people who can at least appear to be calm."
ACT clients with substance abuse problems often end up living with other addicts in close proximity to shooting galleries and crack houses. Addiction is highly prevalent in people with mental illness -- "self-medication" is the term -- and rehab counselors are integral members of the treatment teams.
Bill Munday, a small, energetic Irishman, fills that role in Harris County. Munday spends most mornings driving to the far reaches of Harris County and back to pick up ACT clients for the afternoon group sessions -- which, in Munday's hands, isn't how one might imagine therapy to be. Lately he's been teaching ACT clients how to play chess. A musician, he'll lead the group in a sing-along with his guitar. A couple of weeks ago he tapped the petty cash drawer and took them to the zoo.
"Many of these people here are so desperate, their reality is so ugly and depressing, that it makes sense to step out of it any way they can," Munday says. "We just try to replace it with something else. If we had the budget and the resources, we could do some things that would make your eyes light up."
Being an ACT team member is certainly not for everyone. Recently, a caseworker prospect lasted less than two days, shocked into quitting a job that often looks impossible. "To be good at ACT, you can't be a real rigid person," says Karen Dorrier, an ACT team case manager. "Because you can never predict what's going to happen."
Every morning, Harris County's three ACT teams meet separately to review the status of each client. There is little structure to these gatherings; team leaders simply call a name, and whichever team member saw the client most recently offers a brief assessment. Last month Nancy Gold began one meeting of her team by asking about Elizabeth.
"I saw her yesterday," a caseworker replied. "We need to pick up a new prescription at the pharmacy."
"She has to go to HPD. She says she was assaulted by a man who stole her car."
"He's talking about Indian tribes and migrations. I'm afraid he might be off his medications."
"I was with her yesterday. She's been sober two and a half years, but she still has cravings."
Donald Thomasson, the program's director of clinical care, points out that Jennifer is on probation. "She goes back in [jail] if she starts using again," he says. "I'll increase her Zyprexa and put her on an antidepressant."
It's difficult to say if ACT attracts better clinicians or just a different breed of them. Team members have a luxury that is largely denied community-clinic workers, who see so many patients and have so few resources that their jobs have become an exercise in Medicaid-billing techniques, the most effective of which is moving patients along as quickly as possible. ACT team members have far lower rates of burnout than clinic workers.
The difference is time. Clinics never have enough; for ACT teams, it's sometimes all there is. Team members are only as good as the relationships they form with their clients; everything else is a crapshoot. ACT teams have no authority, legal or otherwise, to compel a client to do anything. If he refuses to take his medication or attend therapy, the ACT team gets "assertive" and spends more face-to-face time with him, wherever he may go. If she breaks down but won't go to the hospital, the ACT team gets a commitment order. If a client is using drugs, the ACT team tries to steer him to treatment, hoping he doesn't get arrested first. If he's put in jail, the team is there when he gets out.
"We are involved in these people's lives so closely, they will run you dry," says Gold, a clinical therapist who's been with ACT about a year. "Some people love the attention, and others just want us out of their business."
For about 20 years now Edward Carter has had a reputation in certain circles that rivals Darnell Anderson's. Edward (his name has been changed) often could be found hanging around the old HPD headquarters at 61 Riesner, which could be why he's been arrested so often for urinating in public.
"He likes the police station," Mitchell says. "He stands out front and talks to himself."
Mitchell says that coincidentally he and Edward both graduated from San Jacinto High School, several years apart. Edward has a "phenomenal" memory, Mitchell says, and occasionally the two men trade stories about the teachers they had in common. Edward likes Party on the Plaza, but the police won't let him in unaccompanied. A couple of years ago Mitchell escorted him to the Thursday-night event, which Edward calmly enjoyed.
"He's not taking his meds now," Mitchell explains, "but he's not in the hospital as much as he used to be, either. We've been able to head that off because we know him. We can predict his day-to-day behavior. We're not afraid of him like some people are."
Edward lives in a boarding house in a far-east-Houston subdivision of rotting, low-slung tract housing. The boarding house is an old single-story apartment complex, all harsh lines, craggy brick and dirty windows. Mitchell points out a drug haven a few doors down. He says he once proposed, only half jokingly, that ACT team members wear T-shirts that announce, "I Am Not a Narc."
A half-dozen anxious-looking men and women are standing next to the parking lot. Up close, a few appear to be medicated, but Mitchell seems not to recognize any ACT clients among them. He asks for Edward and is pointed that-a-way, where, on the concrete slab just outside an open doorway, a woman in a lawn chair is smoking a cigarette next to an old console television blaring the .38 Special hit "Hold On Loosely."
The woman smiles at Mitchell and hitches her thumb toward the open door. Her teeth are black nubs peeking out from pale gums, possibly a side effect associated with an older generation of antipsychotics. Drugs like haloperidol, used to treat schizophrenia, cause dental rot or, in some cases, tardive dyskinesia, involuntary spasms that can breed permanent neurological damage. Newer medications, or "atypicals," are much kinder and considered more effective, especially in older patients.
But for a drug to work, one has to take it, and Edward hasn't been taking his for about a year now. His boarding-house room is about eight feet by ten feet, space enough for twin beds, a nightstand and a small dresser. The linoleum-tiled floor emits a damp chill. Edward is laid out on a bed along the far wall, atop a loose blue sheet; his clothed body is half-covered by a tattered beige blanket. He looks to be about 50, tall, large-bellied and thick across the chest, with gray hair and an unkempt silver beard.
"How ya doing, Edward," Mitchell says.
"Well, Tom," Edward replies slowly in a voice that reverberates off the Sheetrock walls. "I just don't know why I'm so sleepy."
"Because you've been up all night," Mitchell says with gentle reproach.
"Why aren't you taking your medicine, Edward?"
"Well, Tom, I just don't think I'm mentally ill. I really don't think I am, Tom."
Mitchell visits with Edward for 20 minutes, trying to interest him, once again, in taking his medication. But Edward keeps repeating how sleepy he is. At one point, he manages to ask Mitchell about his social security check, which goes directly to the ACT team; Edward gets about $80 after the team has paid for his housing, such as it is, and a few other obligations.
Before Mitchell leaves, Edward releases a torrent of words, unintelligible except for seemingly random references to George W. Bush and Glen McCarthy, the Houston oilman who built the late Shamrock Hotel. "When he starts going like this," Mitchell says sadly, over the accelerated babble, "there's nothing you can do but wait for it to stop."
For centuries the mystery of why some minds work better than others has been so impenetrable that the public's response to mental illness has ranged from ignorance to cruelty. In the 1950s the notion was widely held that schizophrenia was caused by poor parenting. Before that theory was discredited, an entire generation of mental health professionals was fishing with the wrong bait.
The '90s were referred to as the Decade of the Brain, but science is really just learning what makes people like Edward Carter and Darnell Anderson so different. In recent years scientists have identified genes that may be linked to schizophrenia. Of the three million Americans with the disease -- about 1.5 percent of the population -- 300,000 had a parent who suffered from it, too. Mood disorders, such as major depression and bipolar disease, also "clearly run in families," according to the first ever U.S. surgeon general's report on mental illness, released in December 1999.
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."
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.
When he wasn't in the hospital, Devon was put in MHMRA's outpatient program. But he invariably missed his appointments, whereby the agency would close his file. "I am wondering why Devon is not in the ACT Program. [He] needs medication, treatment and monitoring," his mother wrote. "I believe with these, he can lead a fairly normal life. Without treatment, I believe that [Devon] could snap and start killing, beginning with his family or kill himself.
"Please let this letter serve to inform you and those that are responsible for treating [Devon] that, as of today, I hold you professionally responsible for the treatment that my son does not receive from the system that is there to do just that."
Following yet another commitment to Rusk, Devon was finally admitted to the ACT program in early January. Mitchell says he also has accepted a client just released from state prison. "He called me the morning he was released and said, 'I want back in,' " Mitchell says. "Luckily we had room."
But not for long. The state capped Harris County's ACT program at 300 clients last summer, leaving Mitchell with only a handful of open spaces. They probably will be reserved for people who are referred by criminal court judges to mental health outpatient care, he says. As for clients "graduating" to free up slots, no one's quite ready for that. "We've got a few people who are pretty doggone close, but even they need support to stay where they're at," Mitchell says.
According to MHMRA, another 600 to 800 patients who have fallen through cracks in the community-clinic system could really use ACT. But the program is expensive -- per-patient costs range from $7,500 to $10,000 per year. At those prices, meeting the need for ACT would require another $4 million to $8 million in state funding. Mitchell has talked with Rose Childs, MHMRA's director of clinical programs, about setting up an "assertive outreach" program that would offer ACT-like services to certain high-risk clinic patients. But there is no money available for that, either.
Apparently it's a matter of priorities. Since 1996, the state's budget for prescription drugs for the mentally ill has more than doubled, to $148 million, while funding to the community-clinic system has remained flat. In 1999 lawmakers scraped together $50 million for two years' worth of the new-generation antipsychotics, to be distributed by community clinics.
"It's a philosophy that you can treat everything with a pill," Mitchell says. "Don't get me wrong -- the new medications are great. But it's kinda like that movie Awakenings, where you wake up and you have no recollection of certain years. Then what?"
Indeed, Harris County appears headed for a rude awakening in the form of a mental health crisis. Grossly underfunded -- MHMRA receives less than $12 in state mental health funding per resident, compared to a national per capita average of $27 -- the agency's clinic system is in shambles. Last fall MHMRA eliminated 29 case-management positions, in effect telling patients to look after their own affairs. The clinics are so backlogged that all but the severest cases must wait three to four months for an appointment, which serves only to create more of the severest cases: Emergency-room visits by the mentally ill in Harris County have skyrocketed, no doubt hastening the downward drift of some of those patients.
Most of MHMRA's $120 million budget has been diverted to treating insured patients. Meanwhile, care has been rationed to the indigent, who are having to make do with prescription services. But even that effort has been a disaster: MHMRA recently had to forfeit $5 million of the $7.6 million in new-drug money it received from legislators two years ago because the agency's clinics couldn't get the medications to enough patients (see "Catch Us If You Can," by Brian Wallstin and Margaret Downing, November 9).
Unfortunately, the state has never shown much interest in providing adequate resources for the community-clinic system that was pressed on it 30 years ago by the federal government. During this legislative session, moreover, lawmakers are faced with a $350 million shortfall in statewide health-care funding. Almost every elected official solemnly vowed to fully fund the Children's Health Insurance Program. No one made a similar commitment to people with mental illness.
From the available evidence, ACT has done what was long thought impossible: It has provided the mentally ill with the necessary wherewithal -- sometimes in big ways, mostly in little ones -- that allows them to have as much of a normal life as they can handle.
Last year the state released an outcomes survey of 1,235 ACT clients around the state. In the 12-month period that ended in June 1998, state hospital costs were cut by more than $5.4 million, and total inpatient days decreased 56 percent. The before-and-after numbers for the Harris County ACT program were even better: The 52 clients surveyed spent an average of nine days in the hospital, compared to 48 days the previous year -- an 81 percent reduction. ACT saved Harris County taxpayers an estimated $286,000 that year, and that doesn't include savings from fewer bed days at the county psychiatric center.
During this legislative session, mental health officials from around the state will lean on lawmakers to start reversing their dismal record on mental health. Should additional funds become available, it's hard to know how much the state's ACT program would expand. An oft-repeated knock on ACT is that it breeds dependency -- although as Tom Mitchell points out, "We're all dependent to some degree" -- and besides, there are plenty of new medications on the market that might make everyone feel better.
More worrisome, from the perspective of Mitchell and his 30-odd ACT team members, is that ACT appears primed to become just another business. A California company with a less-than-reassuring name, Telecare Corp., has taken over two ACT teams in San Antonio and one in Fort Worth. For the past year, Telecare has been trying to make inroads to Harris County, but for now at least, the company hasn't gained much traction.
"They're sending me a lot of propaganda, trying to get me on their side," Mitchell says. "But so far, I'm told, we don't have anything to worry about."
Telecare would probably want to hire Mitchell and most of his crew, with better pay. However, it's hard to imagine a private company taking the time to discuss with the Edward Carters of the world whether or not they fit the definition of someone with mental illness. Much easier, perhaps, to concede that they do not and move along to someone more amenable. Then again, it may not be good for the bottom line to drop in on people like Darnell Anderson, just to ask him how he's doing.
Toward the end of a recent visit from Mitchell, Darnell finally got around to that small favor he always seems to need. Slumping a bit in his chair, a trifle embarrassed, he asked, "Hey, Tom, can you get me a comb and some socks?"
And Tom Mitchell replied, "I'll have somebody bring 'em by tomorrow, Darnell."