Published Date: 2012-06-27
We were on something like the 15th round of rummy, and my father was winning decisively. He cracked a wide, toothy grin as he laid his cards on the table. “That’s 321 for BaBa, and 227 for String Bean,” he said, tallying the ledger we were keeping on a piece of scrap paper.
Before he finished writing the numbers, he began a rapid succession of anecdotes about his first car. And his second. And his third. He reached for a magazine to show me the vintage Mustang he said he was planning to buy my mother for their 45th wedding anniversary, which, he reminded me, was just six months away. Then he began speaking Sicilian, instructing me to repeat after him: “Napeladan mangia pane!” (“People from Naples eat bread.”) “Calabrese testa dura!” (“People from Calabria have thick heads.”) My father has the most amazing blue eyes, and right then they were wide and eager, like an overexcited child’s. He was rambling, and the inflections of his voice betrayed sheer manic joy. It was a mood completely incongruous with our setting.
We were playing our card game at the Psychiatric Emergency Screening Services, or PESS, a small locked-down unit in the community hospital near my parents’ apartment in Somerville, N.J. Harsh fluorescent lighting fell on cracked and faded yellow walls. A disheveled, rail-thin woman paced and wept in the room across the way. Down the hall, a police officer guarded locked double doors.
It was early December 2010. That August, my father, who was 69, became abruptly and deeply paranoid. Convinced that nameless people were trying to kill him, he slept no more than an hour or two a night and started drinking after five years of sobriety. When his suspicions grew to include his immediate family, he became violent and threatened suicide. At one point, he tried to jump out of the car as my mother was driving down the highway on the way to the doctor’s office. On another day, he poured motor oil over her windshield as she was pulling out of the garage. More than once, he hit her. More than once, he threatened to burn the house down.
In rare moments of lucidity, he would cry and apologize, confessing that he was terrified. He didn’t know what was happening to him. But we did. He was given a diagnosis of bipolar syndrome in 2005, during a similarly disturbing period. He rode out much of that episode in a state psychiatric hospital, and having him admitted again seemed the best way to keep him and my mother safe. His lucid moments would pass quickly. Once his switch flipped back to manic, he would refuse to even discuss the possibility that something was wrong, let alone consent to seeing a psychiatrist.
The police had been to the house a couple of times, but there was not much they could do. In order for them to take him to PESS, or for the psychiatric screeners at PESS to commit him involuntarily, he had to be an imminent danger to himself or others. Domestic violence and verbal threats met that standard, in theory. But in practice, it seemed to mean that he had to be standing on the ledge of a building, or holding a knife to someone’s throat at the very moment the police arrived.
And so for weeks, we had been locked in a game of chicken: waiting for my father to do something clearly dangerous; praying like hell that it would not be his suicide or accidental death or the death of someone else. In the meantime, my mother had all but stopped sleeping and had started hiding the car keys and the checkbook. She would tiptoe around their one-bedroom apartment at night, waiting for him to doze off, then call my sister or me to unload her despair in a flurry of whispers.
Finally one December afternoon, he fell down in a neighborhood convenience store. The medics saw that he was disoriented. He thought the store owner was his son. He did not recognize my mother, who had rushed to the store when the owner called her at home. He said that he hurt all over and that people were trying to kill him. In the emergency room, he grew belligerent, shoving a doctor and nearly punching an orderly. That’s when he was injected with Haldol and sent to PESS.
As dismal as the place was, I felt relieved to be there. Finally he would be forced to talk to a psychiatrist, who I was sure would see right away that he was manic and dangerous and needed help.
While we waited for the doctor to evaluate him, my father did what mental health professionals refer to as double-bookkeeping. He remembered most of what transpired earlier in the day but still believed he was in the hospital to have his pacemaker checked. Even as we laughed together, I knew what would come: the psychiatrist would ask him about his behavior, and my father would deny all the paranoia, delusions and violence. He would curse and yell and try to walk out of the room. When the police officer stopped him, he would become enraged. And when I confirmed for the doctor that he had indeed done these things, and that we, his family, were asking that he be hospitalized, he would stop calling me String Bean. He would stop speaking to me at all.
Until the late 19th century, mentally ill people were locked in prisons or left to wander the streets. Reformers, seeking a more humane response, created a vast system of state-run psychiatric hospitals. By the 1960s, however, the overcrowded, often disturbing conditions in those facilities had come to light. At the same time, new psychiatric medicines were being developed, all of which gave rise to a new reform effort. Deinstitutionalization, the systematic closure of state psychiatric hospitals, was codified by the Community Mental Health Centers Act of 1963 and supported by patients’ rights laws secured state by state. Chief among those laws were strict new standards: only people who posed an imminent danger to themselves or someone else could be committed to a psychiatric hospital or treated against their will. By treating the rest in the least-restrictive settings possible, the thinking went, we would protect the civil liberties of the mentally ill and hasten their recoveries. Surely community life was better for mental health than a cold, unfeeling institution.
But in the decades since, the sickest patients have begun turning up in jails and homeless shelters with a frequency that mirrors that of the late 1800s. “We’re protecting civil liberties at the expense of health and safety,” says Doris A. Fuller, the executive director of the Treatment Advocacy Center, a nonprofit group that lobbies for broader involuntary commitment standards. “Deinstitutionalization has gone way too far.” According to Fuller’s group, there was one public psychiatric bed for every 300 Americans in 1955; by 2012, that number was one for every 7,000. That’s less than a third of what is needed, the organization asserts. The recession has made matters worse: since late 2008, more than $1.5 billion has been cut from state mental health budgets across the country. In the past two years alone, 12 state hospitals with a total of nearly 4,000 beds have either closed or are in danger of closing.
Already patients in crisis can spend several days in an emergency room waiting for a psychiatric bed to become available. In New Jersey, it can take as long as five days; in Vermont — where, as Bloomberg News recently reported, there are virtually no state psychiatric beds left — severely mentally ill patients have been handcuffed to emergency-room beds. For lack of other options, many patients who clearly meet the imminent-danger standard are released. “The lack of resources has triggered a devolution of the standard,” says Robert Davison, executive director of the Mental Health Association of Essex County, a nonprofit group that connects patients to services in northern New Jersey. “Twenty years ago, ‘imminent danger’ meant what most people think it means. But now there’s this systemic push to divert people away from inpatient care, no matter how sick they are, because we know there’s no place to send them.”
When I asked Davison for specific examples, he rattled several off the top of his head. A man who was convinced that aliens were on the roof and that bugs were coming out of the walls and who would not sit on furniture but only lie on the floor was not committable. Neither was the man who refused medication and mutilated his own testicles. Nor the woman who wouldn’t eat because she believed the C.I.A. was trying to poison her. “It is unbelievable the condition of people who are found not to meet the standard,” Davison says.
Despite agreement that more services are urgently needed, families, doctors and policy makers are divided over what kind of services. Those concerned about civil liberties and state budgets want to close state psychiatric hospitals and divert more patients to community-based programs and short-term-care facilities. But others argue that not every patient can thrive in a community setting or recover in just a few weeks’ time. Meanwhile, outpatient commitment laws — which would enable some patients to live in the community, provided they adhere to a treatment plan — confront the same opposition as inpatient commitment: namely the concern that they violate civil liberties or are too expensive to implement or both. “We say a better system would cost too much,” says Marvin Swartz, a researcher at Duke University who has studied mental health systems for the past two decades. “But we’re spending more money ignoring the problem than we would have to spend to address it.”
During the three months in which my father cycled through the system, he racked up five emergency room visits, four arrests, four court appearances, three trips to PESS and too many police confrontations to remember. He spent 25 (nonconsecutive) days in a psychiatric hospital and 40 in a county jail. The medical expenses alone — not including the police hours, jail time or court costs — ran upward of $250,000. These were costly months indeed — to the institutions forced to deal with him and, in more ways than one, to our family.
The first thing my father, Joseph Frank Interlandi Sr., would tell you about himself is that he was born and raised in Brooklyn. Not today’s gentrified Brooklyn, but Bensonhurst of the 1940s and ’50s. His neighborhood was a backdrop to Jackie Gleason in “The Honeymooners” and later to John Travolta in “Saturday Night Fever.” As a younger man, my father even looked a bit like Travolta’s character: he was six feet tall and lanky, with black, pomaded hair. He is a first-generation American, a full-blooded Sicilian, the youngest of 10 children and the son and sibling of garment workers. He met and married my mother, Patricia, a half-Sicilian hairdresser from New Jersey, when he was 25 and she was 22.
My mother lost nine pregnancies (including twins) before my parents went all the way to Colombia to adopt my siblings and me from an orphanage there. My twin brother and I were born significantly premature, and my parents spent four months in Medellín, nursing us to health and praying over our incubators.
They raised my sister, brother and me on fantastic, over-the-top stories about their courtship (he proposed on the first date!), their honeymoon in Italy (they stayed for two months!) and the elaborate parties they gave before we were born. (They once converted an aboveground pool into an in-ground one by digging a huge pit in the backyard; they roasted a pig and the men put on my mother’s wigs and gowns and danced the cancan.) It was not enough that they survived a fire, a flood and a robbery in their first years of marriage: the flood was Noah’s second coming, the fire nothing short of apocalyptic and the robbery so malicious that the cops worried the perpetrators might belong to some sort of cult and called in the F.B.I.
My father, a self-described man’s man, spent 35 years cutting fabric in a factory in Jersey City. When he was past 50, the work went overseas and the factory closed. My siblings and I were still teenagers; my father took any job he could find — stocking produce at A.&P., painting kitchens for cash, baking pies at Costco — so that we could at least finish high school before the bank took the house.
I once wondered if those indignities are what triggered his first bouts of mania. But for as long as I can remember, he was bubbling over or oozing out, as if his own skin could not quite contain him. In winter, he would cover every last edge of our two-story home in blinking, multicolored and musical Christmas decorations. In summer, he kept a large vegetable garden and carried baskets of tomatoes and zucchini to our neighbors. He was never still. On the Fourth of July, he would sometimes fill a trash can with fireworks, drag it into the middle of our street and set them off in a quickening crescendo, trying to dare our neighbors into a friendly competition, while my mother fumed in the kitchen.
Occasionally his excess of personality would tip over into something darker. For decades before his diagnosis, we ascribed those turbulent moods to “too much Scotch.” Psychiatric medications were becoming commonplace; indeed, a new way of thinking about mental illness — one based more on biology and less on individual blame — was gaining prominence. But that growing awareness had not penetrated his circle. Men like my father were expected to drink and to be voluble and volatile. They did not see psychiatrists. They did not necessarily believe in a thing like bipolar disorder.
During his previous manic episode, in 2005, my father was committed to Hagedorn Psychiatric Hospital, a state facility, where he stayed for more than a month. But five years later, that hospital was closing, and the others seemed to be overflowing. The state would replace that 310-bed hospital with 71 short-term-care beds. Short-term-care facilities were smaller and cheaper to run than state hospitals. But as their name suggested, they offered only temporary care. And by many accounts, the net loss of beds was already creating congestion.
It took five days for my father to be transferred from the PESS unit to a psychiatric facility that would hold him for only two or three weeks. That, in our experience, would not be long enough to stabilize him.
We wanted him to go to a state hospital, where he could be cared for until he came around to taking his medication or until his mania subsided on its own (which is not uncommon in people with bipolar syndrome). But getting him committed to one would be difficult. We would have to persuade a civil court that he met the imminent-danger standard, and there was no telling which information the judge would weigh most heavily — the doctors’ assessments, our description of his recent conduct or merely the way my father presented himself in court. Our best bet would be to make sure the staff at the psychiatric facility knew about his bipolar diagnosis and his previous commitment so that they could work with us to keep him hospitalized.
It took a week just to get the social worker assigned to his case on the phone. Although I had been sitting right next to my father at PESS when he was told where he would be transferred, privacy laws prohibited the nurses at the new facility from even confirming, without his written consent, that he had been admitted. I asked if someone could tell him we called and have him sign a consent form so that we could speak with his doctor or social worker.
Yes, I was told, he would be given a consent form — if he was there, which again they would not confirm or deny.
Eventually one nurse took pity and told us that he had indeed filled out the form but had granted access only to Barack Obama and Duke Ellington. The staff took this as proof of his illness. But I saw it differently. When my father was manic, I felt as if an evil alien had invaded his mind and taken over his body. I blamed the alien for hitting my mother; my actual father would never do that. But mocking an important medical document? That was definitely Joe Interlandi. He was in there somewhere, I told myself, trying to make jokes.
With the nurse serving as mediator, we brokered a deal: we brought him notebooks, playing cards and cigarettes, in exchange for permission to talk to his doctors. But as we soon discovered, there was not much to communicate about. The psychiatrist assigned to his case did not see him at all during the first week (nor did he return our calls). The social worker told us that his treatment consisted mostly of group therapy sessions, which my father would either try to lead (by talking over the staff member in charge) or refuse to participate in at all. He spent most of his time drawing pictures for his grandchildren, playing cards with the other patients and writing hundreds of pages in his journal about the indignity of being told what to do and the certainty that he had been betrayed and abandoned by the people he loved most.
He wanted to go home. But he was unwilling to take any of the steps that we were laying out for him to get there. He insisted that nothing was wrong with him and refused to take mood-stabilizing medication. He agreed to a family meeting, but when we arrived, he would not speak to us. He called home periodically to scream and threaten us. He was obstinate and unreasonable, and my siblings and I had to keep reminding one another that he wasn’t deliberately tormenting us, that he was sick.
The social worker advised us that telephone threats would be enough to secure a restraining order. That order would help the doctor and the social worker to persuade a judge that he was a danger and should be sent to a state hospital. On this logic, and with my prodding, my mother went to the police station three days after Christmas.
It was not an easy decision. Barring our father from his own home at a time when he seemed to most need our help felt cruel, and we didn’t all agree on it. My brother hated the idea, but he deferred to my mother and sister, who seemed genuinely frightened at the prospect of his homecoming. They would have to deal with the brunt of his unpredictable behavior. I lived an hour’s train ride from Somerville and didn’t feel personally threatened. But I wanted the order for its strategic value: if he wasn’t committed to a psychiatric hospital, he would surely violate the restraining order, and the police would be able to take him to jail. That meant if all else failed, he would still be warm, dry and supervised — and my mother would be safe.
We quickly found ourselves navigating an entirely different system, one created for victims of domestic violence. There was a court hearing, where my mom had to recount every remotely menacing thing my father had done or said in the past several months. There was talk of safe houses and emergency hot lines and free do-it-yourself divorce workshops. And there were lots of brochures and plenty of unsolicited advice. Most of it seemed beside the point. My father was not really violent, I wanted to explain. He was just having a bipolar episode, and we wanted to keep him from wandering the streets.
My parents’ journals reveal that throughout this separation they remained united, if only by a shared sense of abandonment. Both kept a precise tally of days that passed since they had seen or spoken to each other; both noted that in 45 years, they had never spent Christmas — or New Year’s or Valentine’s Day — apart. My father wrote winding recollections of their early years. My mother carried a framed photo of him around the house, from the kitchen to the living room to the bedroom. She called me once at 2 a.m. to ask if I knew who was washing his clothes. Did I think he had enough underwear? When her doctor suggested she leave him, she found a new doctor. Divorce was not something she considered, even for a second. They would swim or sink together, as they always had.
The commitment hearing, which took place on Dec. 30, 2010, in Union County Superior Court, was a tragedy of errors. His doctor did not show up. The substitute doctor maintained that my father was not ready to go home, but when pressed by the judge, she could not explain why. “This patient is not really mine,” she said. “So I’m covering now.”
My father yelled at the social worker, who was present, and talked over the judge and lied about his psychiatric history. He presented his journals as documentation of the injustices he had suffered. He asked to read from them, a request the judge denied. “I came from Brooklyn, New York,” he said. “I fell off a bike, and now I’m in prison.” And then, “This is nuts.”
I didn’t witness any of this. I read it in the court transcript. I could not screw up the nerve to go to the hearing myself. Talking to his social worker on the phone, or to my mother and siblings in private, about the urgent need for longer-term hospitalization was one thing. But speaking against him in court would feel like a betrayal. I couldn’t bear to see his face as I told the judge that we were afraid of him and wanted him put away in a state facility. Nor could I bear to hear the evil alien’s vicious retorts. So I told myself it was better to let the doctors handle the situation.
It was a decision I came to regret. Without his doctor or immediate family present, there was no one to describe the events leading up to his hospitalization or to explain the nature of his diagnosis. Instead, the argument hinged on a single line in a letter that my father wrote my mother from the hospital: “I will haunt you for all the rest of your life.”
“ ‘Haunt’ is a bad word?” my father asked. “It’s on the television every day.”
Noting his annoyance at the doctor’s absence, and declaring the entire session a “circus,” the judge said that a single threatening letter did not meet the standard of imminent danger. “He’s an extreme, somewhat combative” man, the judge said, and “his credibility is not of the highest, in my opinion. However, I have to tell you that with the standard involved . . . in spite of everything I’ve heard, and those things that I have not heard, in terms of having the case prepared properly through the hospital. . . .” He would have to be released.
The social worker called us after the hearing. My father would be discharged in the next day or so, she said. He would need someone to pick him up or at least give him money for a cab.
We considered our options. We could lift the restraining order and bring him home. But if he spun out of control, we would have no way to protect our mother. Friends and relatives suggested that we offer no assistance and let him “hit rock bottom.” But it was now early January, and we could not bring ourselves to leave him with nothing in the biting cold. So we fashioned something of a compromise. We kept the restraining order but dropped off some money and a suitcase full of clean clothes at the front desk of the short-term facility. We crossed our fingers and waited.
Of all the stories my parents tell, this is my favorite: My brother and I were just shy of 4 months old and finally well enough to make the flight from Colombia to New Jersey. But the night before we were supposed to leave, I fell violently ill: diarrhea, vomiting, fever. It was late; the ground was still reverberating with aftershocks from an earthquake earlier in the day. And our doctor was tending to some other sick baby in some other neighborhood. As my mother tells it, my father ran through the darkened streets, knocking on strangers’ doors, speaking a frantic blend of Italian and Spanish, asking everyone whose path he crossed for help for a baby he barely knew but already loved, fiercely, as his own.
“Por favor! Mi bambina está enferma!”
Eventually he found a woman who spoke English and had antibiotics. By morning, I was fine.
In the week that followed his release, my father wandered. He hopped a bus to North Carolina to visit his brother. He came back to New Jersey and spent a few nights at a hotel near my parents’ apartment. Eventually he made his way back to the emergency room complaining of chest pains. His heart was fine, but a doctor noticed that he was “scattered” and “delusional” and referred him to PESS. Before they could transfer him to the locked unit, he fled the building with an IV sticking out of his arm. When the police found him and brought him back, he threatened to “blow up the hospital like the World Trade Center.” This unlikely threat landed him back in the same psychiatric facility that released him just seven days earlier.
The absurdity of the situation wore on us. How was anyone with a diagnosed mental illness supposed to recover through a revolving door of emergency rooms, short-term psych wards and jail
In reporting this article, I found scores of families trapped in the same fractured system, crawling through whatever loopholes they could find in an effort to prevent what seemed like certain tragedy. They described programs that were underfinanced and overcrowded, not to mention involuntary commitment laws that were only haphazardly enforced. Most of them seemed as lost as we were.
When a judge told Jennay Ghowrwal that her mother — who was convinced that the C.I.A. was plotting to destroy her and had once tried to set the house on fire — would have to be in danger of starving or freezing to death on the street to meet Maryland’s commitment standard, members of her support group suggested that Ghowrwal and her brother withdraw financial support. “The idea was that if we stopped paying her mortgage and buying her food, she might become homeless, and then maybe the courts would hospitalize her,” Ghowrwal told me. “But she’s in her mid-60s. We just couldn’t.”
Teresa Clark, who lived in Flagstaff, Ariz., was told that her son, who had schizophrenia, could be committed only if he threatened or hurt someone. Not until after he killed a police officer (who he believed was an alien in disguise) did she find out that in Arizona anyone can file an application to detain someone for 72 hours of psychiatric observation. She could have done it. The police could have done it. But none of the hospitals she called or officers she spoke to told her that.
A California law requires mental health professionals to consider information supplied by family members during a commitment evaluation, but Candy DeWitt, who lives in Alameda, told me that some screeners would consider only her son’s behavior at the time of evaluation. “I’d fill out the form, listing all the dangerous things he’d done, and my husband would bring it down to the hospital,” she said. “One lady would completely ignore it and go just by what she saw in her 15-minute evaluation. And he’d be released. The next week he’d end up back in, and a different lady would look at the same form, with the same information, and send him to a hospital.” DeWitt saw her son, who was diagnosed with schizophrenia, through five years’ worth of hospitalizations. This past February, he was charged with killing a man, just weeks after being released from a short-term-care facility against his parents’ pleading. In March, he was deemed unfit to stand trial and sent to a state hospital, where he is now being medicated. “It’s one of the most upsetting parts,” DeWitt said. “They wouldn’t treat him against his will before this happened, even though we begged them to. But now they will. Now that it’s too late.”
Joe Bruce’s story is particularly haunting. In 2005, his son William, who had schizophrenia, was discharged from a mental health facility, even though he had recently threatened two people with a gun. Bruce remembers begging the facility to reconsider. “I said: ‘In all likelihood, he is going to kill someone. And in all likelihood, that someone is going to be her.’ And I pointed to my wife and asked them: ‘Do you understand? Do. You. Understand?’ And they let him out anyway.” One year later, William killed his mother with a hatchet.
In most of the stories I heard, hospitalizations and incarcerations quickly became indistinguishable. Neither offered a path to recovery, each only a brief respite from constant worry. “You spend all your time thinking about where they are and if they’re O.K., and what’s going to happen next,” Candy DeWitt said. “And when you get the call that they’ve been arrested or that they’ve been sentenced to jail, that terror that you felt is replaced with this overwhelming sadness.”
My father’s second stay at the short-term hospital, in mid-January 2011, was a bust. The doctor discharged him after a week, without even requesting another commitment hearing. The social worker said that he was really no better than when he was first admitted in December. But he was refusing all treatment, she said. And based on how the previous commitment hearing had gone, it seemed highly unlikely that we would get him into a state hospital anyway.
It felt pointless to bring him more cash and clean clothes knowing that he would only repeat the same cycle. But bringing him home, where he could possibly hurt our mother, felt equally unacceptable. So we called the police again and reported another restraining-order violation: a single phone call he made from the hospital to the apartment. The police took him back to jail.
Ten days passed. Our resolve waned. While jail was probably safer than the streets, it hardly seemed like the right place for a 69-year-old man with a pacemaker and a mood disorder. Besides, it had been nearly two months since his first visit to PESS. Maybe his mania was subsiding; maybe we could rehabilitate him ourselves. We decided to bail him out. He would stay with my brother, who lives just one town over. We would set clear and strict rules: he would have to take his medicine and see a psychiatrist weekly. If he complied and got better, he could go home to our mother. If he became even remotely violent, we would send him back to PESS.
My brother went to the jail to present him with our conditions, while my sister and I tried to weave some sort of fast safety net. We needed a social worker, I thought, and maybe a home health aide who, if needed, could restrain a 250-pound man without hurting him. I called the Office on Aging, which referred me to Adult Protective Services. Upon hearing the words “alcohol” and “restraining order,” the woman on the line suggested a combination of Alcoholics Anonymous and battered-women’s counseling. I tried making a psychiatric appointment for him. But the few psychiatrists who took his insurance were not accepting new patients, and the earliest opening at the community mental health center was two months away.
Our safety net was full of holes. Five days after we bailed him out, my father fled my brother’s apartment in a rage.
He called my mother an hour later, in full thrall to his mania, saying he was on the top floor of a vacant building and wanted to jump. He rambled on somewhat incoherently about the darker moments of their long life together: the lost babies, the lost jobs, the lost house. All of them had bled together and been compressed in time.
My mother and sister kept him on the phone while my brother and the police from two towns searched for him. I paced my apartment floor, inhaling cigarettes as I ran through a list of maybes. Maybe we shouldn’t have bailed him out. Or maybe we shouldn’t have gotten a restraining order in the first place. Maybe it wasn’t his illness that pushed him over the edge; maybe it was the pain of being separated from the people he loved most. He rescued me from the oblivion of orphanhood. Bought me my first typewriter. Taught me to grow my own vegetables. And now I had locked him out of our lives. And this was how it was going to end
Por favor! Mi BaBa está enfermo! Por favor. Por favor. Por favor.
An hour passed. The police found him, shaking and confused, in the janitor’s closet of a church basement. They took him back to PESS. The screeners asked him if he still wanted to kill himself. He said no. So they released him. Because he had violated the restraining order by calling my mother with his suicide threat, the police took him back to jail.
I could feel everyone getting tired. The emergency-screening service kept sending the same patient to the psychiatric hospital, only to see him again the following week. The hospital had to baby-sit for a man who refused to comply with treatment. I made dozens of phone calls and was getting nowhere. The only people who hadn’t succumbed to fatigue were my mother, though her fingers were cramped from praying so many rosaries, and the local police, who had no choice in the matter. The same roster of officers responded to each call, shepherding my father from the street to the emergency room to PESS to jail, and periodically driving past my mother’s house to make sure things were calm. I worried that before long they, too, would give up and release my father, on his own recognizance, to the street.
And then what
I imagined him circling a drain, the pull of love and obligation dragging my mother and siblings and me behind him.
Here’s what I thought should have happened: My father should have been hospitalized against his protestations until his mania subsided. Once it did, he should have been released under supervision and under the condition that he abstain from drinking, which can exacerbate the symptoms of bipolar syndrome, and adhere to a treatment plan involving some combination of talk therapy and medication. I imagined something like probation, but run by a mental health office instead of a criminal court.
As it turned out, New Jersey’s mental health community was debating that very idea. Gregory’s Law, an involuntary outpatient commitment statute named after an 11-year-old boy who was killed by a man with untreated schizophrenia, had been passed by the state legislature in 2009. But in 2011, as my father was shuffling between jail and the emergency room, it had yet to be implemented.
The law was being fiercely resisted on a number of grounds. Patients’ rights groups said that any form of involuntary treatment — even outpatient — would violate civil liberties and that Gregory’s Law was tantamount to the forcible medicating of the mentally ill that predated the civil rights era. The New Jersey Department of Human Services argued that the state could not afford to track and monitor patients and that implementing Gregory’s Law would divert resources from existing voluntary outpatient programs. Even some would-be supporters said that heaping more mandates on an already overburdened system would do more harm than good — unless there was money sufficient to finance those mandates.
One state psychiatric hospital, meanwhile, was in the process of closing, even though another was so overcrowded that the Department of Justice had initiated an investigation. “They are closing down the hospitals to save money,” says Mary Zdanowicz, whose sister was a patient at Hagedorn and whose brother has been a patient in Massachusetts’ mental health system. “The problem is they are not replacing them with anything suitable for someone like my sister, who’s really ill and needs 24-hour care.”
Families of patients and victims have spent the past decade pushing for change. They want a more flexible definition of imminent danger that takes into account a person’s recent behavior, not just behavior at the moment of evaluation. They also want more states to adhere to a grave-disability standard, by which mentally ill people who are too impaired to care for themselves can be committed even if they are not dangerous. They are lobbying to prevent more psychiatric hospitals from closing and also fighting to establish outpatient programs that would treat some patients involuntarily in the community.
Like Gregory’s Law in New Jersey, many of the outpatient commitment laws bear the names of the victims who inspired them; there’s Kendra’s Law in New York, named after a young woman who was pushed in front of a train by a man with schizophrenia who had been turned away from several psychiatric hospitals; there’s Laura’s Law in California, for a 19-year-old shot and killed by a mentally ill man who refused treatment. There’s Nicola’s Law in Louisiana and Kevin’s Law in Michigan.
Opponents of these laws point out that such sensational violence is the exception, not the rule. The threats have been trumped up, they argue, in a deliberate effort to stir public fear. “When they tried to get legislative support for involuntary outpatient programs, nobody much cared,” says Virginia Aldigé Hiday, a researcher at North Carolina State University who focuses on mental health and civil liberties. “It wasn’t until they started focusing on the violence, safety and criminal justice angle that they got a response.”
Indeed a vast majority of people with serious mental illness are not violent at all. Even among patients who present a danger, only a tiny fraction will ever become extremely violent in the way that most families fear. And you cannot possibly predict whether any given patient will be in that tiny fraction. For every case like Joe Bruce’s, there are dozens more in which parents thought their child might kill them but didn’t. Given the remoteness of that risk, some argue, protection of liberty should weigh more heavily than public safety. And given the dearth of resources, voluntary programs — for people who actually want help — should take precedence over involuntary ones.
But extreme violence is not the only thing families like mine worry about. We worry that our loved ones will themselves fall victim to violent crimes, or accidental disasters, if they are left out in the streets while they are sick and delusional. We also worry that without involuntary treatment, they might not recover.
“Sometimes the worst thing that can happen is nothing — no tipping point, no treatment, no recovery,” says Ghowrwal, whose mother has become a shut-in. “What good are civil liberties if the person we’re protecting has zero quality of life?” There is no doubt that involuntary commitment — inpatient and outpatient — impinges on individual freedom. Even as I tried to have my father committed, I fretted over the irrevocability of the process. But it also works. And yes, state hospitals and involuntary outpatient programs are expensive, but evidence suggests that in the long run, they save money. Studies show that, when financed properly, these programs reduce hospitalizations and incarcerations. They also improve treatment compliance and reduce the likelihood that a person suffering from mental illness will either be criminally victimized or will victimize someone else.
On Jan. 8, 2011, Jared Loughner a 22-year-old man with paranoid schizophrenia, opened fire at an Arizona shopping center, killing six people and injuring 14 more, Representative Gabrielle Giffords among them. In the months that followed, he would be deemed unfit to stand trial and then medicated. It was around that time, says Davison in Essex County, that New Jersey officials finally agreed to begin implementing — and financing — the state’s outpatient commitment law.
After his third trip to PESS, my father would stay in the county jail for a month and a half — waiting for his hearing on the restraining-order violations. If the judge found him guilty, he could be sentenced to as many as 90 days, though it was more likely he would get probation or even be released with time served.
I wrote a letter to the judge, detailing my father’s psychiatric history and emphasizing that my father needed medical treatment, not jail time. The judge ordered a psychiatric evaluation. It concluded that even though his behavior had been enough to secure a restraining order, and to land him in PESS and then jail, he still did not meet the imminent-danger standard for involuntary hospitalization.
We didn’t know it yet, but my father’s mania was beginning to subside on its own. He had started asking for my mother, telling the guards and other inmates how much he missed her and that he had to get home in time for her birthday. To that end, he finally agreed to let the jail social worker share information with me.
Seeing in this gesture that he was groping toward sanity, we hired a lawyer. We wanted to lift the restraining order and take him home, we explained. But we needed some help caring for him. He needed psychiatric therapy, but it had to be court-ordered so that he couldn’t simply refuse to comply once released. The lawyer spoke to my father — and the prosecutor and the judge — and helped draft the following agreement: My father would have to see a probation officer every week for a year and complete six months of therapy at the community mental health center. If he complied, he could live at home with my mother; if he didn’t, the judge would send him back to jail.
It was this legal agreement, brokered by a defense attorney in a criminal court, that finally cleared the path for my father’s long-term psychiatric care. With a referral from the probation office, the community mental health center made room for him right away. With the threat of jail, my father kept every appointment. And with therapy and medication, the final traces of his mania finally dissolved. He was back to himself just in time for my mother’s birthday in early March.
A year later, he and I were playing cards again, this time at the dining-room table, as my mother cooked in the kitchen. I asked him what he remembered about the whole ordeal. He lamented the time lost with his family. “Those are days I will never get back,” he said.
The events that had precipitated his first trip to PESS were fuzzy. He was not himself, was all he could really say. He felt like some other being had possessed him for a time. And he hoped that whatever it was, it was gone for good. My mother echoed those sentiments, shouting from the kitchen that it was the only part of their marriage that she wished to forget. Both of them seemed perfectly happy to ignore the fact that bipolar disorder is considered to be a lifelong condition. They would bury this alongside their other shared tragedies until, eventually, it became just another story they told. Already, my father had dropped the larger subject in favor of funny tales about the people he met at the hospital and in jail, and the jokes he played on them to pass the time. We laughed. And apologized to each other. And then, as best we could, we let it go.
Jeneen Interlandi is a 2013 Nieman fellow. Her last article for the magazine was about patients waking from minimal consciousness