Our crazy mental health system

A crusading journalist with a bipolar son says jails have become warehouses for the mad -- and argues for forced commitment.


Marissa Kantor
April 11, 2006 2:12PM (UTC)

Pete Earley never thought he'd be writing this book. No parent would. Spurred on by his son Mike's journey through diagnosis and treatment for bipolar disorder, Earley, a former Washington Post reporter and the author of several acclaimed nonfiction books, begins "Crazy: A Father's Search Through America's Mental Health Madness" in the midst of personal crisis. But though "Crazy" starts as a chronicle of his family's journey, Earley's instincts as an investigative reporter soon take over. While his son shuttles through the hands of doctors and lawyers, Earley undertakes a larger examination of America's labyrinthine mental health system, culminating in an investigation of daily life within the psychiatric ward of the Miami-Dade County Jail. By weaving together both narratives, Earley creates a work of advocacy journalism that is not only a record of one man's struggle with his child's uncertain prognosis but also a look at the ways in which mental illness -- given the legal barriers to care and the inadequacy of the current system -- can devastate any American family.

Earley's work is grounded in two simple premises. The first is that mental illness can happen to anyone at any time and it is never the affected person's fault. The second is that jails and prisons have become our new state asylums, where we hide rather than rehabilitate people. During his year in Miami, Earley is granted complete access to the primary psychiatric unit, sometimes called "the forgotten floor," on the ninth floor of the jail. There he finds "hidden prisoners" with severe mental illness -- who have committed crimes ranging from felonies to petty misdemeanors -- on suicide watch, while psychiatrists try to force mumbling, confused patients to take medication so they will be stable enough to stand trial.

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But Earley's solution to America's mental health crisis is nothing if not controversial: He advocates for a reinstitution of the old state hospital system, for places outside the jail system that can house people with severe mental illnesses who have nowhere else to go. After sitting in an emergency room cradling his psychotic son for hours, only to see him denied care because the state of Virginia's strict interpretation of the imminent danger clause determined he was not an immediate threat to himself and others, Earley is moved to reach out to other parents to let them know that they are not alone. That same experience also convinces Earley that a reconsideration of forced commitment -- a move that would certainly require a serious national debate about civil rights and when to suspend them -- is a reform that mental health advocates should not dismiss out of hand. In the end, "Crazy" is as much a call to arms as it is a portrait of a hidden population.

Salon spoke with Earley by phone about his experiences as a parent of a child with bipolar disorder, the need for more police training about mental illness, and how America might begin to repair its broken mental health system.

The words "crazy" and "madness" are two very loaded terms in the mental health community. Why did you decide to use them in the title of your book?

Well, just your asking that shows that you know more about the mental health system than I did when [my publisher and I] made that choice. Actually, originally we were going to call the book "The Ninth Floor," but my editor felt that was too obtuse. So we came up with "Crazy" -- and the whole point was this idea that the system is crazy, it's broken, it's a mess. Since then, though, I've thought, Gee, it wasn't probably the best choice-- because some people find it offensive and don't look beyond that word, don't see that we're talking about the system.

Partly I'm a newcomer to this, and I didn't realize that some people find the term "the mentally ill" insulting, that it should be people with mental illnesses. But basically, I feel like I've spent three years of my life on this and my motives are pure. I have a son who is [in the mental health system] and this is an issue I care passionately about.

You make a point of repeating that mental illness can happen to anyone. Do you think people's fear of disease is responsible for some of the stigmatizing of people with severe mental illness that goes on in America?

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Mental illnesses are so frightening and there's so much ignorance about them that I think it comforts people to think, Oh, well, it happens to these people because they deserve it. I've heard a lot of people, including prosecutors, say, Oh, that person's mentally ill but they got [that way] by taking drugs -- even though the National Institute of Mental Health says that's impossible. Those are the same rationalizations that have been used throughout history, from the time we first started recognizing that some people act differently. We want to blame the individual because we don't want to think it can happen to us. We want to think that the person who's ranting and raving on a street corner and living on the street somehow wants to be that way. That way we can justify walking by them and not caring and reaching out. A lot of what we do helps us cover up our own guilt, but I also think it covers up the fear.

It does seem like severe mental illnesses are largely ignored until a sensational crime takes place -- like someone with schizophrenia pushing someone in front of a subway train. Why do you think those are the only times people take notice?

When people who have mental illnesses start being a threat, by pushing someone in front of a subway, or chopping off someone's arms, or drowning their children in a bathtub, then all of a sudden that frightens people and people want to do something about it. The people who are really pushing to stop people with mental illnesses from being put in jails and prisons are sheriffs, police and correctional officers because they know they don't belong there.

But what I explain in my book is that you can describe the conditions that the mentally ill face, you can talk about how jails and prisons have become our new asylums, you can talk about how there are no services there. But talking doesn't get people to act. So it's kind of a double-edged sword -- we don't want to stigmatize the mentally ill as being dangerous, because the majority of them are not, but by the same token, that seems to be the only way that people will sit up and take notice that conditions are lousy and that we need to reexamine the whole system.

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What are some of the dangers and pitfalls of trying to understand and navigate a system as a journalist that you've become so tied to as a father?

I tried to be objective when I was in Miami, but was I? Probably not. Because when I went through the ninth floor, every time I looked at someone who was screaming and throwing feces, or being beaten up by the staff, I thought about my son. I guess what you have to do then is say that upfront, say, "Look, I'm going to tell you right upfront that I am a parent and I'm also a journalist."

I think that the real difference is not so much that you lose your objectivity, because I tried [to maintain a balance]. I talked to civil rights advocates. I talked to the police. I talked to correctional officials. I talked to psychiatrists, psychologists. I did everything a reporter would do who didn't have a son with a mental illness. The difference is that you find yourself becoming impassioned. You feel a tremendous drive to scream, yell, to do anything to call attention to what's going on. You become an advocate. But I think that's what good journalism is about. I'm sorry. I think that some of the greatest muckrakers and some of the greatest investigative journalists of all time had strong feelings about civil rights. There is a role for the journalist-advocate. And as long as you play your cards on the table, I think that's a role that we should allow.

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You suggest the revival of the asylum system might be a way to provide safe places for people with mental illnesses, places that allow them to escape the streets and jails and hospitals. Do you think that's really possible?

I think it's actually happening right now, but in a negative way. In Miami, for instance, there is an activist, well-meaning judge who is looking at the jails and prisons and seeing horrid conditions. So the prisons are under heat and they say, "OK, we'll create special units just for persons with mental illnesses where they can be safe while they're locked up." But the point is they're still in jail, they're still in prison and they shouldn't be there. What we're really doing is we're re-creating old state asylums in jails. You follow me?

What makes me angry is that we decided the old asylums were horrible places, so we shut them down in favor of community treatment centers. And, unfortunately, even though that sounds good, community-based treatment centers are not equipped to take care of people with severe mental illnesses. So what's happened? Well, we're dumping people in nursing homes, we've dumped them in rest homes, we've dumped them in awful assisted living facilities.

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There are 647 [assisted living facilities] in Miami and 400 of them don't even pass minimal standards. I've walked through them. A typical one has 40 or 50 people crowded in it, is an old, beat-up house where the landlord is making as much money as he can off of them. The landlord has hired an undocumented worker to run the place who doesn't speak the same language as the people in it. Pills are sitting on the table with no one handing them out. There is no one who knows how to dispense them. The people are fed rice and beans every meal and completely unsupervised in the sense that they can wander the streets, and many of them are confused. How is that an improvement? I'm not saying that the old asylums were good, because they weren't, but the point is, have we really helped or changed these people's lives? We haven't. We've simply hidden them better.

I worked for 10 years in a psychosocial club for adults with severe mental illness, where the ultimate goal was reintegration into society. What troubles me is that many of the people I met there had experienced forced restraint, over-medication and other abusive effects of the hospital system. Given the precarious state of Medicaid and Social Security, what makes you think we could get asylums right the second time around?

That's an excellent question. It's hard, because it's also about money. It costs an average of $500 a night to keep someone in a psychiatric bed. It costs $89 in the jail. But I want to be real clear about something. I'm not suggesting that we create the old hospital network. I'm not suggesting that we pull people out of communities. In the book I do try to give examples of programs that work. But the reason they work is because they have somebody running it who's compassionate, who's concerned, who cares and wants to get people with mental illnesses back into our society.

In those same chapters, though, I talk about picking a day at random to go to the courthouse, and seeing cases involving people with severe mental illness whom the courts have literally no idea how to place. Alice Ann is one example. She was a hardcore person who's had mental illness, who was deinstitutionalized, who was dumped on the street. She pushed an elderly person at a bus stop and for three years she was sent back and forth on a bus between the state hospital and the courts. Why? Because they didn't know what to do with her.

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I guess what I'm trying to say is that we need a system that has several levels. We shouldn't have to make people with mental illnesses into criminals. We need a place outside the jail system in the community where they can receive treatment and services. But to just say that we can't build those kinds of asylums because they are going to be mental hospitals, I think is short-sighted -- I think it's the stigma of the old system.

In your investigation you came across a number of fatalities involving police officers and people with mental illnesses that might have been prevented if the officers had gone through a specialized training program like Crisis Intervention Team.

I think CIT training should be [mandatory] in every community. It's not as sexy as SWAT, it's not as sexy as hostage rescue teams, but the police need it.

The problem in this country is that people in the mental health community don't want to talk about commitment. It's the idea that everyone is scared of. And that's where I blame civil rights' attorneys. And I know that seems harsh. Because civil rights attorneys are out there trying to protect the mentally ill, people who need to be protected. But by the same token, it doesn't do society or a person with mental illness any good to let them walk out the door untreated.

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The question is how do you change that? And I think we need to reexamine our commitment laws. We need to reexamine the imminent danger clause that states use to determine treatment, based strictly on whether or not a person seems to be an immediate risk to himself or others. Because I think a lot of that [legislation] was passed in the '80s when we had horrible institutions. It was passed when people thought that mental illness was a choice.

These are issues that are very much in contention within the mental health community.

Yes, in my short venture into the mental health community I've seen a lot of infighting. When the truth is, we all should be going after the same thing, which is to help these people. And if you have a person who's been on and off their medication 40 or 50 times, who has a long history of decompensating -- why in the world would we let that person get to the stage where basically we've written them off?

I had to come at this as a parent. And I've got to tell you it's almost impossible to describe what it's like to have a sick child and not be able to get them help. And to watch them go further and further and further into this abyss and not be able to pull them out. And as a parent, that's what drives me, and what makes me so [focused on the issue of] civil rights. Yes, I want [my son's] civil rights protected -- but when everyone in the room knows he has a serious mental illness but lets a person walk out the door and get into trouble, how does that help them?

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But isn't the civil rights issue a very slippery slope? How do we decide who gets them and who gets them taken away?

It's absolutely a slippery slope. Certainly we need to build safeguards into the system. For instance, you need a panel that includes a guardian or a doctor and a lawyer, someone who can advocate for the person with mental illness.

Will there be mistakes made? Yes. But right now it's treated exactly as a criminal procedure, so the parents are cut out, the doctors are basically cut out -- it's all a matter of legality and whether a person is about to harm themselves or someone else. The courts have gone so far as to rule that a guy eating his own feces is not considered in imminent danger. To me that signals that the pendulum needs to swing back. For instance, what if a guy is in jail and not eating? We saying it's horrible to violate his civil rights, but when he gets to the point where he's about to die then we rush in -- and his civil rights don't matter anymore. But why wait until that point?

The turning point for you as an author and a father seems to be the scene when you leave the courtroom and realize that the woman who prosecuted your son for breaking into her house during a psychotic episode is not to be hated. Instead she becomes the target of your book, the person with whom you want to share all you've learned.

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That was a very hard because I had gotten to the point where I hated her, because Mike's my son. And then I literally had to stop and I had to think how I'd react if I'd walked into my house and found this person I didn't recognize tearing up my possessions -- would I have sympathy? It was a humbling experience on my part, because I realized that I was operating now on knowledge that I had gained about mental illness that she didn't have.

The other issue that, quite frankly, I haven't come to terms with yet, is how as a parent to step back. For instance, there is one tragic case in my book -- April, who is living on the streets, has been gang raped, and is clearly psychotic, but her parents can't do anything. I don't know how you do that. If Mike were to go off his meds, if he becomes so despondent that I can't help him, how do I go on as a parent? I don't know how to answer that.

You end the book with three truths: that nothing in life is guaranteed or fair, that mental illness is a cruel disease with no known cure, and that it lasts forever. What message do you hope to send parents who are in a situation similar to yours?

The first is that this disease is no fault of theirs. As parents for a long time we have been relegated and blamed. But the one thing that never changes is that the parent is there; the loved one is there as long as they possibly can stand it. You're the one left to pick up the pieces and often you just feel helpless. I guess I'm just trying to say I don't think that's right, that I've been there, and I want to do something about it.

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I hope people will be educated. I would love for this book to spur conversations about the imminent danger clause. Because a parent shouldn't take a psychotic child to a hospital and be turned away. I just don't believe that that should happen. I think that's why I put my own son's face and put my face in this book. I want people to see that this is what happens, and it's happening every day in this country. And I want them to see it on a personal, personified level -- not just through statistics. Nobody wants to dump people in state hospitals like throwaways. But can we learn from the past? That's the question.

Is your definition of hope the same as when you started out?

No. I naively thought everybody could be saved, that it was just a chemical problem so if we could just get the chemicals right he'd be fine. Then I thought, well, maybe assisted outpatient treatment would work, let's just get these people up off the streets, let's give them drugs, and they'll be fine. Eventually I guess what doing the book taught me was that it's the whole system. It's not only a matter of trying to keep people out of jail, out of prisons, it's a matter of having follow-up, it's a matter of having case managers, it's a matter of housing. All these things are linked together and very hard to be hopeful about.

You say that you first went down to Florida to find a success story. But after witnessing such horrible cases, did your goals for your son have to change?

Absolutely. The fact is, Mike was on probation for two years. And he took his medicine every day for two years. Then six months after he went off probation we discovered he had gone off his meds. And I couldn't believe it. I wanted to grab him, I wanted to shake him. But I think deep down, in his case, he feels that taking the meds is an admission to him that he has a mental illness -- and I think that's terribly hard for him to accept. My wife convinced him to go back on his meds, but right now we're not sure if he's on them or not.

So I guess that's what's weird about this book is that usually you write your book, you end your story and you move on. And this is not the end of my story.


Marissa Kantor

Marissa Kantor is a freelance writer in New York.

MORE FROM Marissa Kantor

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