Lost, found and lost again…
Lost in America, lost in the mind
“What kind of mother would I be if I left my son here and went home?” Reba asked me this with tears in her eyes. In the midst of a busy shift in the emergency room, it was a question I could not answer. Her son Jacob, in his twenties, was schizophrenic. He had wandered to Oconee county over hundreds of miles. His mother thought he was dead, since he had been missing for months. The police notified her that he was in custody for some minor offense, so she came cross-country by bus to nearby Anderson, SC, then by taxi to our hospital in Seneca. She tried to pick Jacob up when he was released. He refused to go with her, but came to the hospital in a police car. I suppose he came to me because she asked him to, or because the police officers suggested it.
“He needs help,” his mother said. “He needs to be committed and get help!” I talked to him. He was calm, not suicidal, not violent. I don’t even think he was hallucinating. I spoke with the mental health case worker on call. South Carolina is a state with little money for mental health patients who are dangerous, much less those who aren’t. The case worker said that Jacob didn’t meet the criteria for hospitalization. He couldn’t be forced to stay if he weren’t an obvious danger to himself. There weren’t enough beds for patients who were in peril, much less those who weren’t.
I told his mother and she rolled her eyes, then fell back into her chair. “What am I supposed to do? I have to go back to work. I’ll lose my job! I can’t leave him here!” I tried to explain that I couldn’t force him to stay. The law was just as rigid about that fact as anything else. “Well, he needs to get on the bus and go back home with me. That’s it.”
We discussed this with Jacob. He laughed and looked up and down. He stared into his hands. Every time that she asked him to go with her, he said no. She pleaded. She tried to speak gently. She tried to be rational. She tried to be firm. She cried.
In the end, we released him. I talked to her about outpatient mental health care. I was going through the motions. It was all pointless, really. Unless she would succeed. Unless he would get in the taxi that we called, ride the 40 minutes to the bus station, and go home with his mother.
The driver came. Reba begged her son over and over. She pulled on his arm. She tried to force him into the cab. She failed. There was nothing we could do. Physicians, nurses and deputies with years of experience intervening in lives, and we were powerless. Jacob walked into the night with no money, no ID, no home and only the clothes on his back.
His mother shook with sobs as she left. She knew that it might be the last time she would ever see her baby. He would wander the land homeless and frequently confused. The next phone call might be the worst of all. Homeless schizophrenics get pneumonia, die of exposure, are murdered, walk in front of cars, develop HIV. The list goes on. His mother wasn’t a physician, but she didn’t need to be. She knew the score.
I’ve thought a lot about them since that night. I wonder if I’ll see Jacob again. I wonder if he has moved on, east toward the coast or up to North Carolina. Maybe off to the labyrinth of Atlanta which, like New York City, could hide someone for a lifetime. I hope and pray he survives. For his sake and his mother’s.
It all illustrates a difficult point in medicine and society at large. For all of our good intentions, we have limited capacity to fix lives. We can treat diseases. We can cure some of them. We can treat lives; we can cure very few.
At an unfortunate nexus of medicine, law and economics there is a blind spot, where some are simply outside of our collective reach. It’s a reality that takes years to absorb, but it’s the hard truth. Some people will just wander away no matter how much we want to help. And all we can do is whisper a prayer as they go.
Not too many years ago these people were hospitalized and at least kept safe from themselves and others. Somebody decided it was their “right” to wander the face of the earth, being victimized, cold, sick and starving so they made it impossible to hospitalize these folks and closed all the mental hospitals so there’d be no place for them to go even if they could be admitted. No doubt the architects of this mess thought they were doing the compassionate thing, but the results have been horrific. Some people just can’t be and shouldn’t be in the general population.
Edwin,
This is an amazing post. I recently left my job working for a psychiatrist in private practice. The emotional ride I went on everyday was hard. I saw patients like this often….have even had to call police officers to our office because the patient was threatening to kill his dad. Basically, the police take him to NPC (at Ben Taub) and fortunately he was admitted to a neighboring hospital that happened to have a bed available. I have seen many patients who need to be hospitalized but the parents think they can care for them at home. They can’t. They would call our office and tell us that their grown child was walking around outside completely naked…asking what they should do. Our response was always “take him back to the hospital”.
It also frustrates me that insurance companies will cover many things…but, not mental health. They will cover the cost for a counselor or therapist…but, not a mental health professional (MD). The people that need to see a psychiatrist needs meds…something that a counselor cannot provide.
There just has to be a better way. I don’t have an answer for this and I have experienced the same frustrations. The depressed patient who is not endorsing suicidal ideation. The schizophrenic patient who is unable to keep a job, or keep it together to pay bills, but is not violent, psychotic, or hallucinating. We have to wait for them to get “bad enough”. I have even seen patients who are requesting hospitalization denied, due to lack of beds. I think to myself, “Will they stand strong against the illness, or get bad enough we can bring them to the front of the line and get them in?”
Mental health care is a mess, fromt the limited number of inpatient beds, to the inadequate insurance coverage, to the lack of transitional and supervisory options to the acute care hospital.
Mental health is an issue that the South Carolina Hospital Association is making a top advocacy effort beginning this upcoming legislative session. It is an issue that effects everyone. According to the National Institute of Mental Health, 1 in 4 adults are diagnosed with a mental disorder each year.
We are hoping that with the help of individuals and families, things can change. We are also hoping that through our efforts we can help dispel myths and the stigma around mental health.
I realize that it’s a difficult problem. There’s insufficient funding and staff all around! It’s just more terrifying at night, in the emergency department of a small hospital, when there are no psychiatrists available, no one at a state facility to even talk with about the patient, not even so much as a ‘telepsych’ consultant to use and yet a person with very real psychiatric needs. But I as an emergency physician have to navigate it all until morning when ‘real’ doctors and resources are well rested and have had their coffee. A friend of mine was once called onto the carpet by the state medical board, who asked him why he felt qualified to evaluate psychiatric disorders. ‘Because I have to!’ he told them.