When the Bough Breaks

The mental-health system was itself a challenge to the Fabers, who found themselves stymied at every turn in their attempts to find a program in which their ã
daughter could be treated, against her will if necessary. But since 1969, when California put into effect the provisions of the Lanterman-Petris-Short Act, the standards for involuntary commitment -- that a person demonstrate "danger to self or others" or be deemed "gravely disabled" -- have been so tough to meet that scarcely anyone qualifies. In the three decades since its enactment, the number of patients in California's state mental hospitals has been reduced by 89.8 percent.

As a result, many people with severe mental illness have ended up on the streets or in jail -- some 33 percent of Los Angeles' homeless have been diagnosed with severe mental illness, as have an estimated 10 percent to 20 percent of the state prison population. Like Elizabeth, many of them demonstrated their dangerousness to others only by commiting a violent crime. By the time Elizabeth proved her need for commitment, her baby was dead.

"YOU HEAR EXAMPLES OF THIS KIND OF THING EVERY DAY," Carla Jacobs told me at a NAMI meeting one Tuesday night in November 1998. During the meeting, which had been called expressly to discuss ways of reforming the system, family members and mental-health workers offered reports of the latest atrocities -- a son who came home from school and stabbed his father, a woman who assaulted her elderly mother -- tragedies many family members believe could have been prevented if the civil rights of the mentally ill were not valued over their well-being. "Mental illness robs you of your free will," Jacobs explained. She then read aloud to the group a description of manic-depression written in 1994 by consumer Dru Ann McCain. "For a depressive, every choice is a conscious one, and no less energy is required in deciding to brush one's teeth than for making a multimillion-dollar decision," McCain wrote. In a manic episode, on the other hand, "free will is accelerated . . . it becomes easy to make choices because thought of the consequences of one's acts is passed over too quickly or altogether removed."

"Two years after she wrote that document," Jacobs told the group, "Dru Ann McCain completed a 'successful' suicide."

The question of whether a person with mental illness is able to judge for herself whether she is able to make sound decisions about her well-being is the question on which battle lines are drawn between the mentally ill and their relatives. Family members want safety for their loved ones; consumers, says Sally Zinman, "want to know [their] spirits will be taken care of, too." Stories such as McCain's and Faber's notwithstanding, it is not an easy balance to strike, and NAMI's ideas for solving the mental-health crisis are by no means universally accepted. And by some, even their examples are disputed.

"You're picking a story that's convenient for their argument," Zinman objects. "You're just going to play into the myth of violence they're using to push their agenda." Zinman, who has been diagnosed in the past as paranoid schizophrenic, speaks from long experience with the system. She co-founded a drop-in center for peer support in Berkeley, and strongly believes that the best people to make decisions about the mentally ill are the clients themselves. "A client-sensitive mental-health system deals with the whole human being," she says, "housing needs, the need to work, self-image. What about those of us who voluntarily choose to look for services and they aren't available? It's not going to help to just commit more of us."

She is not alone in her opinion. When Mark Ragins, the affable and opinionated medical director of Village Integrated Services Agency, a mental-health facility in Long Beach, hears about cases like Elizabeth Faber's, he sees not an argument for more involuntary holds, but a deep need for continuity in a patient's care. "It takes a number of years to stop using street drugs and start using psychiatric medications regularly," Ragins says. "But we never stick with anybody for a number of years. And then, when there's a crisis, if some emergency happens, the person who's ill sees a total stranger. The huge majority of 72-hour holds are written by people who are absolute strangers, and our most common response to a crisis is to have a total stranger tie somebody up and give them a shot of Haldol," which is exactly what happened to Elizabeth at Ingleside. "It's hard to imagine that's very healing."

Ragins would like to see alternatives that might include providing a means for a psychiatric patient to develop an ongoing relationship with a single mental-health worker, or a group of several, so that someone educated and compassionate could keep track of ebbs and flows in the patient's well-being over time. That was a relationship that Elizabeth Faber, for her entire history of psychiatric treatment, was glaringly without.

TWO MONTHS AFTER HER RELEASE from Ingleside, Elizabeth called her mom, crying. "I just need to get back on my feet," she said. Kathy agreed to send her an airline ticket, provided that she'd consent to psychiatric treatment. Once off the plane in Baltimore, however, she decided she didn't need a doctor, just a job. And so she got one, at a record store in the city, and tried on her own to sort through her muddle of moods. But in April, Kathy got a phone call from one of Elizabeth's co-workers telling her that Elizabeth would be fired the next day. "She told me Lynn's behavior was very strange, that she was saying things to customers like, if they couldn't find a certain CD, it was because they hadn't prayed. She was saying that people were trying to kill her. She would write 'Elizabeth' on a label and put it on her forehead."