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My Brother's Battle -- and Mine

By Asra Q. Nomani
Sunday, April 29, 2007

MORGANTOWN, W.Va.

"I'll take a knife and cut up your uterus," said the voice on the other end of the line. I shuddered, but got off the phone gently, because the speaker was someone I love very much. My brother spoke those chilling words to me last October, but the recent suicide-massacre at Virginia Tech brought back the anguish of that day.

Like so many, I mourn for the victims and their families and friends. But strange as it may sound, I also connect with the killer and his immigrant family, and my sadness extends to them. Since the early 1980s, my brother has been bravely battling an incurable illness called schizoaffective disorder that hit him on the threshold of adulthood. It's a brain disease related to schizophrenia, characterized by mood swings, thought disorder, psychosis and bursts of violence. When he's being treated, my brother is kind, thoughtful, loving, a genius in world history and brilliant at soccer, a sport he had hoped to play professionally.

The day he threatened me last year, he had refused to go to the hospital for a regular dose of a new injectable antipsychotic drug his physicians were trying. I had urged him to take his medicine, prompting the outburst. In the preceding months, he had been "decompensating," psychiatric jargon for melting down, as the new medicine wasn't working well. We'd been there before. Over the years, my family had been on the firing line because of my brother's illness. Once, he punched me in the head. He has kicked, scratched, hit and spat on our parents. Earlier last year, he had broken down our mother's bedroom door and pummeled her. But we always knew it was his illness speaking, and we always loved him. And we knew that he was suffering.

This wasn't the American dream that our parents -- like the parents of the Virginia Tech killer -- were chasing. They had immigrated to the United States in the 1960s in search of better lives than our native India could offer. My brother and I joined them in 1969, when I was 4 and he was 6. Like Seung Hui Cho and his sister, who were born in South Korea, my brother and I are part of the "1.5 generation," who come to the United States as children.

Now psychiatrists are learning something about this generation. A study published in the Schizophrenia Bulletin last year found "compelling evidence" that immigrants have an elevated risk of developing schizophrenia and other types of psychotic disorders. A 2005 Journal of Psychiatry article reported that "social defeat," or the "chronic stressful experience of outsider status," can make migration an "important risk factor" for schizophrenia. While my brother deteriorated, I went out, like Cho's sister, and became the supposed immigrant success story, privately in anguish all the while.

Away from home in those early years of my brother's disease, before cellphones, I thought about getting a pager so my mother could reach me if my brother beat her up. I have lived in dread ever since that I'd get a phone call saying that my brother, who lived at home, had killed our parents. When he threatened me last fall, my family and I made a heart-wrenching decision for the sake of everyone's safety: We had him committed to a psychiatric hospital.

We were one of the lucky families. We live in a state where such an act is possible, because the legislature wrote new laws in recent years that allow mental health commissioners to examine medical histories, among other things, when judging whether people are likely to seriously harm themselves or others. Too many states do not allow the consideration of medical histories.

As someone who has spent 25 years painstakingly navigating mental health laws to protect my family, my brother and society from violence, I believe that future massacres like the one at Virginia Tech and others can be avoided. But it will take much-needed reform of outdated state laws based on the concept, dating to 1972, that people must be of "imminent danger" to themselves or others before a court can order them into treatment.

On the books, in part due to the lobbying of the Arlington, Va.-based Treatment Advocacy Center, most states have departed from the "imminent danger" standard. In recent years, 23 states have lowered the bar to include a "need for treatment" standard to determine whether someone should get court-ordered treatment, either outpatient or inpatient. New standards in North Dakota, for instance, consider whether there has been a "substantial deterioration in mental health."

But an attitude requiring dangerousness prevails, not allowing mental illnesses to be treated as the medical conditions they are. Pennsylvania requires a person to be of "clear and present danger," and Virginia has retained the "imminent danger" standard. That was what handcuffed Virginia Tech police when an English professor warned them about Cho's disturbing classroom behavior. Tragically, in January, the Virginia General Assembly passed up an opportunity to broaden the criteria, tabling proposed reforms in favor of waiting for a commission report -- due in 2009.

Every week, our national mental health crisis comes to life for me when I drive a little more than an hour on I-79 South to a place called Weston, W.Va. Heading through town, I pass a sprawling building of native blue sandstone that was opened in 1858 as the Trans-Allegheny Asylum for the Insane. It's closed now, replaced by a state mental hospital up the road from the Mystik Mountaineer Mart.

At the new hospital, behind the locked doors of the G-1 unit, my brother has been treated for the past six months, slowly getting better. It's not the institution of exposés past. Last weekend, a nurse gave my 4-year-old son and me a tour of the rec room, the indoor swimming pool area, the neatly stocked library and the cafeteria.

But it's also not pretty. Not long ago, my brother was punched in the jaw by another patient. A male nurse dislocated two fingers while pulling them apart. As I visited my brother last week in a locked room for visitors, the assailant waved to me through the glass window, his earlier violence apparently forgotten.

My brother is due for a mental health commission hearing this week to determine whether he should be hospitalized for another six months. "I'm scared," he told my mother and me, and I knew he was getting better. It's rational to be afraid of being committed to a psychiatric unit.

Because of West Virginia's new legislation, he probably will be discharged soon for a six-month "temporary observation period" that orders him back to the hospital if he doesn't take his medicine. The bar will not be violence.

As a psychiatric nurse let me out of G-1, we stood for a moment at the door beside a sign that read, "Caution. Elopement Risk." "We wouldn't leave someone bleeding on the streets because they didn't want to go into the hospital after a hit-and-run," the nurse said to me. "Why abandon the mentally ill?"

As the nurse went back into G-1, I caught my brother's eye through the sliver-of-glass window on the door. My heart ached, but I knew that he wouldn't be a threat to others as he received the treatment he critically needs. Then the door clicked shut.

asra@asranomani.com

Asra Q. Nomani is the author of "Standing Alone: An American Woman's Struggle for the Soul of Islam."

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