Getting Out

Sandy and Jennifer were made to eat on the floor like dogs.

The sisters, seven and eight, are on the floor of the trailer, the newspaper spread before them. They've got their eyes out for roaches.

Grandpa is sitting quietly at the nearby table while Grandma prepares the meal. She sets Grandpa's plate on the table, then turns back to the girls' plates. She mixes the food together in one big clump and puts the plates down on the newspaper.

Sandy and Jennifer (not their real names) look at each other. Who's gonna get it this time? they think. Please don't let it be me.

By the time Grandma reaches the table, the girls are devouring the food. They've got to eat fast. For some reason, Jennifer usually does better. She can handle eating that much that fast, as proved by her pudgy frame. She eats so well that Grandma makes her eat everyone's leftovers but Sandy's.

Sandy, she can hardly eat. During meals, she sometimes breaks out in hives. The food makes her nervous, eating fast makes her nervous, the roaches scurrying across the newspaper make her nervous. It's too much for her tiny stomach; the kid is skin and bones to start with.

Sandy looks at her sister, watches her lift a spoonful of mush to her lips, force it in her mouth, swallow and reach down for a refill.

It's all too much. Sandy begins to gag. Grandma hears the retching sound, turns to look. Sandy vomits onto her plate.

Grandma won't have this. She slides her chair back, stands up and walks to Sandy.

"Eat it," she says.

Sandy looks at the mess on her plate, to Jennifer, then back up to Grandma.

The other night, Sandy blamed God for making her have to eat.

She opens her mouth and closes her eyes.

When she opens them, 20-some years later, she fixes them to the TV. On the screen, a judge is banging her gavel and restoring order to the court. Sandy is in her favorite chair, wrapped in a blanket. This is how it is, day in, day out. Her children go to school, come home, play with the few toys she could afford to buy. Her boyfriend works, drinks, hits her, sleeps.

She figures it's safer inside. Outside are the What Ifs. The What Ifs will get you. Like this thing she saw on the news. A woman driving her car got creamed by a chunk of concrete falling from an overpass. So Sandy doesn't drive. Because what if? You never know -- you're just driving along, and the next thing you know, you have no head.

She doesn't leave the house, which is the way her boyfriend and mother want it anyway. There's no way she can seek help. So she's stayed inside for two years. She doesn't eat, because maybe one day she'll just disappear.

And then, she sees this thing on the news. A mother suffocates her child. The broadcasters mention something called the Harris County Mental Health and Mental Retardation Authority. She calls the number and tells the voice on the other end that she wants help, but there's no way she can leave her house.

It's okay, the voice says. We can come to you.

And in the office of Houston's new Mobile Crisis Outreach Team (MCOT), Sandy's name is written in black marker on a dry-erase board, right by 40 others.

The names on the board are a chart of color-coded tragedy.

Members of the city's year-old crisis outreach team sit facing the board, as Dr. Tracie Dejarnette-Holly runs through the patients' statuses: There's the 16-year-old boy with a six-month-old baby whose parents found the teen hanging, still alive. There's the man who grieves for his dead wife and kids, though they never existed. There's the young woman who's been suicidal ever since surgeons removed her brain tumor.

The team's nerve center is a relatively small office space on the first floor of the NeuroPsychiatric Center (NPC), next to Ben Taub Hospital. It's an extremely dull-looking room. The eye can't help but gloss over the smattering of desks and file cabinets and go straight to the names on the wall.

These are the people you hear about when someone says "they fell through the cracks." Except that's not really true. If they truly fell through the cracks, they'd disappear, and they wouldn't stumble into emergency rooms at 2 a.m. screaming about invisible demons trying to butcher them. Taxpayers wouldn't have to cover their jail time and hospital stays.

That's where the mobile crisis team comes in, thanks to a $1.9 million grant from Harris County Commissioners Court. The first of its kind in Texas, the team links the mentally ill and substance abusers to clinics, counseling and residential facilities. The idea is that a little money spent up front will save a fortune in the future.  

The approach is similar to MHMRA's Assertive Community Treatment program, but cranked up to hyperspeed. Developed in the 1990s, ACT provides long-term outpatient care for the mentally ill. The program is still successful; it was just never designed for crisis care. The program is also bound by MHMRA regulations to work only with people diagnosed with schizophrenia, schizoaffective disorder, major depression and bipolar disorder.

MCOT is not restricted to these specific diagnoses. And since the team is funded by the county and not billing Medicaid, they can spend as much time as necessary with a client. Still, staffers try to close cases within one to three months.

Team director Tom Mitchell was the head of ACT for seven years. He and other ACT staffers made the jump to the new crisis team last February.

"Part of it was just [I was] ready for a change," Mitchell says. "I've been in the system 26 years. Things go through cycles, and we're in one of our low ebbs now, as far as community services, because of all the cutbacks. And this seemed to be the way, I thought, [to] have the greatest impact on as many people as possible."

Simply put, the difference between MCOT and ACT is, in Mitchell's words: "It's more of a marines-on-the-beach type [of] mentality as opposed to the troops in Iraq, who are there for long hauls."

According to MHMRA, 80 of the crisis team's first 100 clients were linked to outpatient services and four were admitted to the Harris County Psychiatric Center. Sixteen either refused service, were jailed or just disappeared.

MHMRA estimates that 55 of those clients would have been hospitalized or jailed, at a cost of $2.3 million a year. If those numbers are accurate, the county has saved about $400,000, after subtracting MCOT's budget.

Other states implemented this approach years ago.

California's state-funded mobile crisis units cover about two-thirds of the state's population, according to Dr. Steve Mayberg, director of the California Department of Mental Health. While some units were created 15 years ago, that state only recently formed units to deal exclusively with the homeless mentally ill.

In 1999, the year California's homeless mentally ill program started, crisis teams oversaw 4,900 people, according to a department spokesperson. In four years, psychiatric hospitalization of that group dropped 56 percent, incarceration dropped 72 percent, and the number of days spent homeless dropped 67 percent.

Moreover, the number of days of full-time employment increased by 65 percent, and the number of days of part-time employment increased 53 percent.

Wisconsin, which has mobile units in 34 counties, has seen a 20 to 30 percent reduction in hospitalization in the 15 years since its program started, according to George Hulick, clinical consultant for the Wisconsin Bureau of Community Mental Health.

Dr. Hunter McQuistion, chief medical officer for New York City's Division of Mental Hygiene, has no hard numbers, but says his city's 20-odd mobile units have considerably cut down emergency hospitalizations and jail time.

And now, in Houston, the team's 20-person staff of doctors, social workers, psych techs and nurses covers the entire county, 40 people at a time. (As of January, the team's staff expanded to 28 and their caseload grew to 60.) They work in shifts from 7 a.m. to 11 p.m. during the week and from 9 a.m. to 9 p.m. on the weekends. Clients come through the hot line and via referrals from law enforcement, family members, schools, apartment managers, hospitals and homeless shelters. They never run out of names. As soon as one is erased, there's another to take its place.

Psychiatrist Dejarnette-Holly, whom everyone calls Dr. D.J., is the team's medical director. Tall in heels, bespectacled and solemn-faced, Dr. D.J. is the consummate professional. She's seldom solving fewer than five problems at once. She can maintain the same unfettered expression whether she's driving a manic, babbling client in one of the team's white vans, taking a crisis call on the hot line, or ordering a Whopper.

Dr. D.J. leads the staff through the daily afternoon rounds, the only time all the staffers are in the office together.

Today, she brings up Mark and Warren (not their real names), two men who are at the Star of Hope men's shelter, who were MIA yesterday, Wednesday, when staffers conduct assessments there. Mark is back and has taken a turn for the worse -- he's talking to Satan. This is what is called decompensation, the process of retreating from reality.

Warren turned up at the Star of Hope late last night, after the staffers left, on a tip from R&B singer Luther Vandross. Warren's out a lot of money from a barbershop burglary, and Vandross advised him the culprits were at the shelter. Warren disrupted a church service in his quest for the missing cash, insisting there'd be hell to pay when Vandross showed up.  

Dr. D.J. also says to keep an ear out for the elusive Voodoo Man, who's been calling the police complaining about the misalignment of his neck. Unbeknownst to Dr. D.J., Voodoo Man called MCOT the previous night, hanging up before giving his name or location. All he could say was that his neck was "to the left," and he suspected an ex-girlfriend of dabbling in black magic. Helping him may be as difficult as helping the man who called the hot line expressing paranoid delusions of people in white vans coming to get him. How, then, to drive a white crisis van to that guy's house?

By 3:30, rounds are over, and the office is mostly empty. None of the staff likes to be inside. Paperwork is saved for the end of the shift. The real work is conducted outside, face to face.

Sandy is standing outside her small brick home smoking a cigarette when the van pulls into the driveway. That she's already outdoors is a minor miracle. Dr. D.J. and nurse Annabel Elsner have been working with her for the past two and a half months, and she's made it out of the house only a few times.

Sandy's baggy sweatshirt and jeans only exaggerate her frailty: 99 pounds on a five-foot-two frame. She beams at the sight of the van, crushes her cigarette and slides into the backseat. Her thin, shoulder-length hair is gathered in a pony tail. She smells of cigarettes.

It's 11 a.m. on a weekday. These meetings are timed for when Sandy's boyfriend is at work and the kids are in school. Right away, she starts talking to Dr. D.J., who's behind the wheel, and Elsner, riding shotgun.

She lets loose with a stream-of- consciousness state of the union, describing the latest exploits of her children and letting the women know that her boyfriend hasn't acted up recently. She refers to her boyfriend, the father of her children, as her husband. She sounds anxious, like a kid who's not sure if she's going to AstroWorld or the dentist.

Dr. D.J. and Elsner are taking Sandy to a follow-up at a nearby MHMRA clinic. Depending on the outcome, this may be the last day they see Sandy professionally.

Their first visit was awkward. Sandy was guarded; she still didn't know if she was doing the right thing. By reaching out for help, she was going behind the backs of her boyfriend and mother. They were the ones who encouraged her to stay home when she lost her accounting job after 9/11. Her family has never been a source of support.

Her parents split when she was little. Sandy and Jennifer spent weekends at their father's house, sitting in a room by themselves while he and his girlfriend shot up heroin. When Sandy's mother remarried, she brought into her home a man who started raping Sandy. Sandy told her mother about it. Her mother told Sandy to put up or shut up. Throughout all of this, Sandy kept telling herself a bit of folklore she heard somewhere: Only special souls pick families like these.

Upon meeting Sandy, Elsner thought, We've got a lot of work to do here. But she also saw Sandy's potential. Later on, she saw a bruise. It took Sandy a month to tell Dr. D.J. and Elsner that her boyfriend hit her. She was too embarrassed.

Sandy "could do so much more," Elsner says in a friendly, down-home drawl. "She's capable of total recovery."

After a few visits, Dr. D.J. and Elsner convinced Sandy to go grocery shopping with them. In the store, she couldn't breathe. There were too many people, too many lights. She clutched the cart to keep from shaking.

But eventually, they paired her up with a psychiatrist at a nearby clinic. She got on antidepressants, mood stabilizers, anti-anxiety meds. They took her to get food stamps and to apply for jobs through the Texas Workforce Commission.

"You gotta realize, I never met nice people before," Sandy says. "They gave me hope, which is really a gift."

As the van winds past a playground and a series of buildings, Sandy points out the window.

"That's the school I got pregnant at," she says. "Well, I wasn't at school…"

Sandy was an 18-year-old high school senior when she had her first child. She worked two jobs to support the child, her boyfriend and herself -- and she also graduated. Sandy loves talking about her kids and her old job, about how she felt validated leafing through invoices.  

That validation meant a lot to someone whose earliest thought was I was born to get beaten and abused.

This belief could be the root of one of Sandy's most unnerving mannerisms: the ability to discuss abuse in the tone of voice a person would use to describe the inconvenience of a late fee at Blockbuster.

It's like part of Sandy believes that getting beaten with a broomstick for not fetching beer is a woman's lot in life. She can actually make herself laugh when she remembers one night her boyfriend came home after an especially prodigious bender.

"He was tossing me around like a rag doll," she says. "He punched me, but I just stood there like an idiot 'cause I just couldn't believe that that man punched me. I mean, I could see him slapping me…" She starts to laugh.

She ran outside after that, and her boyfriend followed, ripping her clothes as he tackled her into an antpile. He sat on top of her and told her to calm down, while angry ants bit her exposed flesh. She told him to get off her because of the ants. Not because he punched her.

"I was ate up by those ants," she says with a laugh.

"We're getting ripped off," Mitchell says.

When it comes to how the state legislature treats the mentally ill, the MCOT director is outspoken. It's an admirable quality, a refreshing change of pace from the paranoia that pervades MHMRA. A recent wave of layoffs and clinic closures has many within the system worried about their future. Lower-level employees prefer to keep their criticism off the record.

"I think with some of them," Mitchell says of the legislators, "it's flat not caring"; the mentally ill are "just 'crazy people.' "

Texas consistently ranks low in state spending on mental health, according to the National Association of State Mental Health Program Directors. In fiscal year 2001, the most recent data available, the state spent $797 million on mental health care, the fifth-highest amount in the country. But that translated into just $38 per person, placing Texas at 46th in per-capita spending.

But Texas, like other states, is facing serious budget woes. In order to make up for a $9.9 billion shortfall, Texas -- like 28 other states, according to the National Alliance for the Mentally Ill -- has had to cut mental health expenses.

MHMRA hopes to trim $4 million to $5 million, starting with the closure of clinics in north Houston, Humble and Baytown last year. The clinics served about 1,900 adults and 240 children. MHMRA also laid off more than 100 employees in the last year. Funding a new crisis unit was out of the question.

The closures could leave many without consistent care. Mitchell says the team has been especially busy in the north end, responding to people who suddenly found themselves without their doctors. Many are already starting to decompensate, he says, putting mental health resources into red-alert mode.

"Unfortunately, we're geared for crises now," Mitchell says of MHMRA, "because we don't have the services to maintain people…If that's the tack you have to take, then MCOT seems to be the best way to go, 'cause at least you're out there on the streets with the people."

Rise (pronounced "Ree-sa") Collins and Rashaan Harris are driving to the Star of Hope. Harris, 31 and wiry, is behind the wheel. He was a psych tech for years before joining the team in April. He plays soprano and tenor sax because he likes to. He works with the mentally ill because God wants him to.

Collins, riding shotgun, is a licensed clinical social worker who's been with the team since its February inception. She has a flair for the dramatic and is elusive about her past. She has a seen-it-all attitude that makes her especially cut out for this kind of work.

Before they reach the Star of Hope, they make a quick stop in the Third Ward to check on a female client, a 37-year-old recovering cocaine addict married to an octogenarian. Harris waits in the car while Collins talks to the woman on the sidewalk outside the house. She wants to make sure the woman's been to MHMRA's Eligibility Center to check on her benefits. She also wants to see if the woman is looking for a job.

Afterward, it's on to the Star of Hope, where they plan to check up on Mark and Warren, who've been talking to the devil and Luther Vandross.  

They walk through the shelter's check-in point, where a few clients are sitting with their legs extended and backs to the wall. A man turns to look at Collins, out of place because of her gender and her loud red hat.

"Are you a counselor?" he asks.

"I'm a social worker," she says.

He's not sure what to make of it, but he perks up, thinking he may be in the market for a social worker.

"What do…," he starts.

"What do you need to do to see me?" she finishes. "You need to have a mental illness."

The man quickly folds his arms and presses his back closer to the wall.

"Yes, ma'am -- I mean, no, ma'am."

Collins and Harris continue through the check-in and head to the office of Louis Durden, a shelter manager. Durden has a good working relationship with MCOT, always letting them know of clients who need their help.

It turns out Warren has slipped away, so Collins and Harris won't be able to do their assessment. But Durden wants them to speak with Charles (not his real name), who has returned to the shelter after a brief stay at his mother's house. Charles is saying that woman isn't really his mother -- she's an impostor who tried to kill him while he was in the shower. The only other family Charles mentioned were his kids -- R&B divas TLC, former child rappers Kriss Kross and Philadelphia 76ers guard Allen Iverson.

Durden leads Collins and Harris to one of the shelter's small intake rooms, where they wait for Charles.

After a few minutes, a tall man with caramel-colored skin and a tangle of curly black hair piled on an unusually large head shuffles stoop-shouldered into the room. He plops into a chair opposite the desk from Collins.

Collins starts by asking him the basics: Why does he think he's here?

"I get out of mind," Charles says through clenched teeth. He tugs absentmindedly at his wispy mustache and chin hair.

Charles says he spent 12 years in the pen for aggravated assault with a deadly weapon. He's stayed periodically at his mom's house, but he recently discovered that the woman in the house is an impostor. She's trying to kill him in order to get her hands on the $48 billion in his bank account.

He's been off and on meds for schizophrenia and off and on marijuana dipped in formaldehyde. Mostly on. It's known as wet, fry and amp, and it's a common drug among schizophrenics. Collins says it's called fry because that's what it does to your brain.

She asks to see his meds, and he produces from his blue jeans pocket a bottle of mismatched pills. Collins lifts her glasses and squints at the washed-out label. What he's been popping for the last month is anyone's guess. This is a common problem. Clients who can't get to the clinic or miss appointments with their social workers can wind up without medication. In Charles's case, he's illiterate and can't remember the names of his meds, so if he can't get in to see his regular doctor or nurse practitioner, he might wind up with someone new who prescribes a different type of medicine.

But now, Collins continues through her standard list of intake questions.

"Who loves you and cares about you?" she asks.

He says his real mom and dad love him. He communicates with his dad telepathically through what he calls a sensor. The sensor also allows him to talk to his old prison buddies.

When Collins asks about his real mother, Charles become agitated. He's told the impostor story a million times, and all he wants is for someone to call the FBI and have that woman arrested.

Collins speaks calmly, as if to a child, but Charles becomes more frustrated. Harris quietly gets out of his chair and leaves the room. He says later that he was bothered by the way Collins kept asking about Charles's mom. He says he would've left it alone.

But Collins carries on.

She asks: What's the best thing that's ever happened to you?

Getting out of the pen, he says.

She asks: Do you ever get messages from the television?

"No," he says. "I'm not crazy."

Four years ago, the MHMRA lured Dr. Avrim Fishkind from Washington, D.C., where he basically overhauled the district's emergency psychiatric program. Tall, heavy-set, with a bushy gray goatee, Fishkind is the president-elect for the American Association for Emergency Psychiatry.  

MCOT is his baby. After seeing how mobile units worked elsewhere, he was eager to build one in Houston.

Mobile crisis teams have historically worked closely with law enforcement, whose hands are tied unless individuals with mental illness present immediate threats to themselves or others. Instead of having to wait until a person reaches their breaking point, officers can call upon mobile crisis units to assess the individual. Such is the relationship between Houston law enforcement and the new crisis team, Fishkind says.

Mobile crisis units are also one of the only ways to reach an otherwise hidden population.

"One of the great unidentified mental health populations are people who are just quietly mentally ill," Fishkind says. "They predominantly stay in their homes…they may come out just to do simple shopping. [They] are often grossly delusional, often disorganized, but…never rise to the level of dangerousness, so never come to anyone's attention."

Without realizing it, he's just described Sandy. And he says there are thousands in Harris County.

But, like Mitchell and others tied to the new team, Fishkind is prepared to make a financial argument in favor of the program in case compassion fails.

"Let's say somebody says, 'I don't want any of my tax dollars to go to taking care of that homeless mentally ill [man] on the corner…but I want you to get rid of him,' " he says. "Well, let's look at what that means."

A homeless mentally ill person is typically hospitalized 40 days a year, Fishkind says. At $500 a day, that's $20,000 just for a bed. That doesn't include emergency room care, medication or outpatient care. It doesn't include the cost of the usual police or EMS calls. And it doesn't even account for how many days that person might have spent in jail.

"So if you think you're doing nothing for a homeless chronically mentally ill person -- you're not spending a penny and you're not gonna -- that's absurd," he says.

According to Fishkind, some states have figured out that they can house, clothe, feed and medically treat a chronically mentally ill person at a starting cost of about $28,000. In succeeding years -- as that person stabilizes -- the cost declines.

"In a lot of places they've figured out that actually doing something actually saves the taxpayers money," he says. "Doing nothing costs the taxpayers a lot of money."

Harris County Commissioners Court agreed.

When presented with Fishkind's funding proposal, the court was eager to accommodate, says County Judge Robert Eckels. Besides funding the new team, Commissioners Court also funded MHMRA's new 18-bed respite center on Caroline Street, gave additional funding to the emergency room and has added six beds to the ten-bed voluntary stabilization unit at NPC.

"We looked at this as a way to diffuse a mental health crisis," Eckels says of MCOT. "It's a smart use of tax dollars, and it's a service that's desperately needed in the community."

The next budget-planning session starts in March, and Eckels says there is support to continue the funding.

Sandy has this dream where, for some reason, she's running toward a helicopter. The engine's on, the blades are spinning, and she's just feet from the door. All of a sudden, the devil appears, pulls out a knife and slits her throat.

"I don't know what it means or anything, but it's not the best dream in the world," she says.

Recently, Sandy has formulated a plan to get her kids and herself away from her boyfriend. Devising this plan, and applying for jobs, were necessary in order for Dr. D.J. and Elsner to close the case in good conscience. They're tight-lipped about the plan, and for good reason. No one wants her boyfriend to find out.

Dr. D.J. and Elsner officially closed Sandy's case a week earlier, but they saw her again on a weekend trip to the movies. The MCOT workers wanted to commemorate their relationship with a fun outing, a trip outside that didn't have to do with doctors or job applications. They suggested seeing a movie of Sandy's choice. Inexplicably, she chose Gothika, a horror movie about a woman trapped in a draconian insane asylum. She says she loved it. It was the first time in ages she wore a dress and fixed her hair.

Today, Elsner has stopped by Sandy's house to give her a bag of presents the staffers bought for her daughter's birthday. If the escape plan works, this will probably be the last time Elsner sees her.

When Elsner comes to the front door, Sandy's in her pajamas, smoking, sitting in her favorite chair in front of the large-screen TV. These are totems of the part of her life she wants to put away.  

Sandy is jubilant about the presents. The staffers had all pitched in for a child's birthday before, and Sandy was hoping they would again, but she didn't want to get too excited.

Elsner sits down as Sandy eagerly picks through two bags of gifts. Elsner says her daughter, who's the same age as Sandy's, helped pick out the gifts. There's a makeup kit, some Barbie accessories and a stuffed bear.

Most intriguing to Sandy is the Magic 8-Ball, something she says she's never seen before. She asks what it does. Elsner explains: You ask it a question, shake it, and look at the bottom for an answer that reveals itself in what resembles a pool of bubbly blue amniotic fluid.

Ask a question, Elsner says.

Sandy thinks. Foremost on her mind is the accounting job she applied for, all the way on the other side of the city. It'd be a cruel commute, but it'd be worth it.

She takes the 8-Ball in her hand and asks, "Am I gonna get a job?"

She shakes it, flips it over for the answer.

Cannot predict now.

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