Travels with Lizbeth

by Lars Eighner

  I had been an attendant at the state asylum in Austin for seven years, five of which I worked in the admissions office, and before that I had worked in a walk-in crisis center. I could recognize most of the chronic lunatics in the Austin area and I met many of them on the streets. A few of them recognized me, but for want of the proper context they rarely knew where they had met me before.

  Moreover after some ten years’ experience in the mental-health field, I could detect the symptoms of mental illness in many homeless people of whose histories I had no direct knowledge. The state asylum in Austin is a large institution that draws patients from a vast area. Often when patients are released they do not return whence they came. Austin is a liberal town and as good a place as any to be insane.

  Most patients now are released from the state institution very quickly, but not because a rapid recovery has been effected.

  In the 1970s a new strategy for dealing with the mentally ill was developed. It was thought that patients could be treated more efficiently, and more humanely, in their own communities. This seemed feasible because the most serious and the most common forms of mental illness responded well to drugs that were developed in the 1950s and the 1960s. The plan was to reduce the large central institutions and to establish many small clinics in the communities.

  Whether this plan would have worked or not we will never know, for only half of it was implemented. The powers and resources of the central institutions were drastically reduced. But the community clinics were established in only a few places, and where they were established they were inadequate. Many communities did not want mental-health facilities right next door, although their being right next door, in touch with the neighborhoods, was a key aspect of the plan for the clinics. Breaking up the large institutions meant that economies of scale would have to be sacrificed, and neither the legislature nor the communities were willing to fund the clinics at a level that would have offered some chance for success.

  To make matters worse, there were problems with the wonder drugs. They were so good in treating the disorders for which they were appropriate that they were often tried where they were inappropriate—in much the same way that penicillin was once prescribed for viral disorders against which it could not possibly be effective. If a little of the drug did not produce the desired result, physicians often increased the dosage. Inappropriate use of the drugs often ended badly. But even when the drugs were prescribed appropriately, they produced some undesirable side effects. Patients won the right to refuse to take the drugs. Patients who did not raise the issue of their rights often simply discontinued taking them.

  Anyone who has had to take a medication for a chronic disorder will recognize the resentment one feels at having to do this thing that other people need not do. Mental patients feel this resentment as much as anyone, and they as much as anyone can deny they have the disorder and refuse to take the medication or can conveniently forget to take it. In addition, I have always suspected that it feels good to be a little bit crazy. At least one person has told me he tries to reduce his medication so that he can get the good feeling of being a little bit crazy. Unfortunately, just a little bit crazy is just crazy enough for him to believe he can do without the medication altogether, which he cannot.

  I do not believe that patients who discontinue their medications often do so for fear of the side effects. But the side effects, though relatively minor, are real and are sometimes irreversible. A reasonable person might conclude that the risk of the side effects outweighed the benefits of the drug—or so thought the courts in deciding that mental patients ought to be able to refuse the drugs.

  But the idea of the community clinics was that patients would take the drugs and would report to the clinics on an outpatient basis for minor adjustments of dosage and such. The clinics were supposed to have, at most, a few inpatients who would be stabilized quickly and returned to their homes, families, and neighborhoods.

  When the plan went smash, the central institutions no longer had the capacity to handle large numbers of patients. As a result, subacute mental patients must be discharged to the streets until they are again sufficiently ill to be readmitted to the central institutions. Unfortunately there is no solution so simple as refunding the central institutions. Many of the evils of the central institutions persist; abusive and neglectful habits are still inculcated in the staffs of such institutions. But the power to compel treatment, whereby the central institutions occasionally and haphazardly did some good, is gone. Moreover, while acute psychosis is a vivid and unmistakable phenomenon that presents a need for hospitalization, even involuntary hospitalization, that few observers would deny, the more common symptoms of mental illness are matters of degree and definition that in the question of involuntary hospitalization try the limits of human wisdom and justice.

  Matilda Temple was a crazy woman who occupied very much the same territory that Lizbeth and I frequented. She was from a well-to-do family in a large Texas city. She came to Austin not as a mental patient, but as a student. Many schizophrenic disorders first manifest themselves in late adolescence or early adulthood. And so it was with Matilda. Her illness was a great shock for the family, but at first they were very supportive. They put her in the best private institutions, and whenever she was released the family would set her up anew with a nice apartment and a vehicle. But Matilda would not take her medication. After so many cycles of treatment and relapse, the family washed their hands of her.

  As an admissions attendant I saw Matilda many times. Most often she was brought to admissions by law-enforcement officers—then she would be floridly psychotic and violent. Rarely she appeared voluntarily, when the weather was especially cold or her food stamps had run out—then she was less violent but just as psychotic.

  In my latter years at the hospital I worked on a women’s ward and had the opportunity of seeing Matilda when she was medicated. When medicated, she seemed as sane as anyone. She was an intelligent and strong-willed woman, with enough of a mean streak that it was clear to me that she was not drugged into a zombie-like state, but was for the nonce in her right mind. And she would say as much herself.

  Of course, when I saw her on the streets again she was nuts. She talked nonsense constantly—anyone who has ridden a New York subway or the Hollywood bus in Los Angeles is likely to have heard this sort of talk, which mental-health workers call word salad. Fortunately, Matilda only rarely remembered that I had been her attendant, but it hardly mattered when she did, because she could not hold a thought for more than a few seconds. She usually carried a red sleeping bag with her and went from store to store begging for cigarettes.

  Matilda slept on stoops and porches and sometimes on the pew at Ramblin’ Red’s—she got very upset with me when Lizbeth and I stayed too late on the pew. At night she screamed and shouted at imaginary people and monsters, and her threats to them were so graphic that she often alarmed people who did not know her.

  Matilda received, at general delivery, an SSI check on the first of each month. Her allotment was not so generous as Dan Archer’s, but with it she might have got a small apartment, and in the apartment she might have received food stamps. But she disposed of her check quickly. Sometimes she literally threw money away. Other times she gave it away. She would get four large carry-out pizzas or a gross of doughnuts, eat a little, and leave the rest on the ground to be claimed by the fire ants. She was a crazy woman and she did crazy things with money. In any event, the money would be gone by the third.

  I describe Matilda’s case in some detail because I know the most about it and because it is typical of the mental patients I encountered on the streets. (In particular, her sex is typical. In discussing alcohol I deliberately referred to men. I never saw a single woman in one of these groups. Very rarely a woman attended as the companion of a man in the group, and then she most often sat away from the circle. On the other hand, I seldom recognized insane men on the streets. A man as threatening and verbally abusive as Matilda would have
been taken to jail. And I would guess some men kept themselves medicated with alcohol and camouflaged themselves among the drinking groups. Matilda sometimes drank a beer, but in general, the crazy women I saw did not drink. I cannot explain the difference.)

  What should society do with Matilda?

  By the time I saw her on the streets, she was no longer violent, although she could be threatening and verbally abusive. She had been through the state asylum so many times that they would not accept her as a voluntary patient. Yet, unless she was immediately dangerous to herself or others, she could not be committed involuntarily. When she was committed involuntarily she could be compelled to take her medication so long as she was violent, but precisely because the medications worked so well in her case she would cease to be violent almost as soon as she received her first dose. But then, because she would not take her medicine once she was allowed to refuse it, and her bed was needed for someone else, she would be discharged to the streets. She was obviously very unhappy on the streets, whereas when I had seen her medicated she had claimed to be quite content.

  What may in justice be done for a person without his or her consent is a question treated in Platonic dialogues, yet for all the centuries passed since Socrates sought wisdom, it is a question I cannot answer.

  Dr. Velasquez and Dr. Stalin did not mean to do me harm, but quite the contrary—or so I think when I am in a generous mood. Dr. Velasquez did not know whether I was mentally ill or not, and I do not think he believed he knew. What he did believe, that I know not to be so, was that the state asylum was a good place, that they would sort out my disorder if I had one, and that I would be better off for going there. He may also have known that by committing me to the state asylum, he could assure that the state would pay the costs of the treatment of my phlebitis. At any rate, I do not think he was wise enough to decide for me, and so I do not think I am wise enough to decide for Matilda.

  I have heard psychiatrists say that anyone who is homeless is ipso facto a chronic schizophrenic unless there is some more evident diagnosis. By one school of thought it is a form of mental illness to be so much at variance with the commonly accepted values of one’s society, and it was to this school the Soviets applied when they committed their political dissidents to mental institutions. By the criteria of homelessness and deviance, I was no doubt mentally ill.

  But given my values I thought I was about as rational and consistent as anyone could claim to be. I was moody. But in my material situation I think it no wonder that I was sometimes depressed. The wonder was that much of the time I managed to buoy up my spirits.

  On the streets, one day very quickly blurs into the rest, and without the checkpoints of ordinary conversation I sometimes found my mind had wandered far from the path of sound judgment. I counted myself as sane as I could be in my circumstances, but I am in no position to argue if this account leads anyone to another conclusion.

  ELEVEN

  On Institutional Parasitism

  Strictly for my own amusement I began to compose a novel I called Hoebecker’s Diary.

  One of the winos had come by the pew one evening with a well-dressed drinking companion who told me he lived by going from hospital to hospital, masquerading as a doctor. I knew from my years of working at the state lunatic asylum that such a career was entirely feasible, and this occupation—I called it “institutional parasitism”—was to be one of the themes of my work of fiction.

  My antecedents were Ellison’s Invisible Man and Richard Wright’s very similar short story “The Man Who Lived Underground.” I suppose The Phantom of the Opera would be one too, but I didn’t think of it at the time. At any rate, I thought a person might discover a niche in a large institution and survive there for a long time without coming to the notice of those who had legitimate places there.

  I had seen malingerers at the asylum who very blatantly put the resources of the institution to their own purposes, and so did many of my coworkers—this was government work, after all. Hoebecker would sleep in unused wards. He would eat by ordering meals for inmates that did not exist and by pilfering food from the inmates’ kitchen. He would do his laundry in the facilities provided for the inmates, and he would get new clothes when he needed them from stocks provided for inmates.

  None of Hoebecker’s misappropriations was anything out of the ordinary. Each was something I had seen attendants at the state asylum do; ordering extra meal trays to save the expense of lunch was especially common. Hoebecker would differ only in degree. He would obtain everything he needed from the asylum. Before the end he would not even bother to cash his paychecks. He would be a parasite.

  Hoebecker, like the attendants he was modeled on and the malingerers, would begin with an official and legitimate role at the institution. Yet as I wrote I became more interested in the idea of an utter impostor—someone with no official connection to the institution—who might from the excess resources of the institution provide himself with all the necessities of life and even a few of the luxuries.

  As the novel developed in my mind I wished I could have another interview with the impostor who had first planted the seed of the idea. Alas, he never returned.

  I often sat up late at the pew, lost in the novel, and in the weeks I was absorbed with it I met Don.

  I met Don through Alex, who had been my penultimate roommate in the little shack on Avenue B. Alex bore a grudge against me from that time, and he had walked by the pew with Don several times before he deigned to introduce us. In spite of the company he kept, I somehow formed the impression that Don was Burmese and a professor at the university, albeit an eccentric one.

  Don was a squat, middle-aged, brown-skinned man. He seemed not entirely at home in English, but I could not detect a foreign accent—or perhaps he had a slight one I could not identify. He was very quiet when other people were present, seeming to devote all his concentration to observing the others. Between the two of us he was usually very talkative with occasional long lapses that I took for periods of profound thought.

  I supposed Don was an academic of the field of social work and that Alex, whose situation was better than mine because he had attached himself to the social welfare system by virtue of being on probation for several offenses, was the subject of some practical experiment. Other times I suspected Don was a social anthropologist and I was his key native informant. Mistaken as my impressions proved to be, Don contributed to them by speaking of “cases” and “case histories.” Alex certainly was Don’s main case.

  When Don had me to himself he would tell me in the manner of a shaggy-dog story all the minutiae of Alex’s latest escapade. Escapade is too good a word. Don’s stories simply recounted events as if approaching but never reaching a point: Alex borrowed five dollars from someone but did not repay the lender when he was able to do so; Alex said one evening he was going to look for a job the next day and he circled a number of help-wanted ads in the newspaper, but the following day he slept until noon and threw out the newspaper; someone came to the apartment and offered Alex a job, but he got drunk and overslept; Alex made some stuff of egg yolk and sage that he sold as hashish.

  Don seemed to expect me to comment on stories of this kind, but I could never think of anything except to ask, “What did you expect?”

  Most of Don’s stories had less point than these. Perhaps he thought that having once allowed Alex to room with me I had some enduring interest in him and I would be pleased to hear of any news, however mundane, pertaining to him. Once he began, Don seldom spent less than an hour telling me of Alex. But after some weeks, Don did begin to talk to me a little of his other subject.

  Don’s other subject was his poetry.

  I belabored my incapacity as a critic with the blessed result that I was only twice confronted with the wretched stuff. Perhaps Don’s poetry was no worse than average; I am no judge. At any rate, had Don wanted criticism he could have got it from his little poetry group, a superficially civilized kind of literary snake pit. Since Don s
till spoke warmly of the group without expecting any member, I gathered none of them had taken him seriously enough to critique his poetry.

  Don wanted his poetry to be published and he had heard I knew something of the writing business. In particular he wanted to know how much he should expect to pay to have his work published. I am always surprised at the number of people who believe that writers ought to pay publishers.

  I explained publishing to Don as clearly as I could. He seemed never to understand what I was telling him. In many meetings with him I re-covered the same ground; I stressed that a promising work in a popular form might expect a vicissitudinous career, but the odds against poetry were very long indeed.

  Don brought me a small ad he had torn from a magazine. The ad announced a poetry contest. The first three winners were to receive small cash prizes and the honorable-mention winners were to have their poems published in a beautifully bound book. Don proposed to enter the contest.

  I pointed out the line in the ad that said winners might be required to purchase a copy of the book in order to have their poems published in it. Don saw this as no objection. He certainly would want to buy the book if his poem was printed in it.

  I told him he would win an honorable mention. Unless it contained language likely to shock the other subscribers, any poem entered in the contest would win an honorable mention. I said the society that placed the ad, contrary to what its name suggested, was not a philanthropic enterprise, but was a printing business that would print anything for money. Don sent for the brochure nonetheless.

  The volumes depicted in the brochure did look impressive. They had leatherlike covers and gilt-edged pages. So far as I could tell from the brochure, the signatures were saddle-sewn. The endpapers were marbled. I marveled at this at first, but as Don got deeper into the scheme I understood it better. The books were not cheap; they were nearly forty dollars apiece. And they were fully subscribed before they went to press. Little wonder the printer could make both handsome books and handsome profits. The beauty of the books was the genius of it.