For 26-year-old Frank K., going back to the community has meant trading a locked ward in Maryland's largest state mental hospital for a windowless cell in a suburban jail.
For the past three years, Frank has shuttled between Springfield Hospital Center and the Montgomery County jail. Court officials have sent him to Springfield because they suspect that mental illness is the reason he commits crimes such as selling his prescribed narcotics. Doctors at Springfield have shipped him back to jail, saying that while he may be schizophrenic, he is legally competent and responsible for his actions.
"Nobody knows what to do with him," said Paul DeWolfe, his public defender lawyer. "He commits petty crimes, goes to jail, gets crazy and gets better, and he's been doing that for years."
Halfway houses won't accept Frank because he has a drug habit and pending criminal charges. Drug programs don't want him because he has been diagnosed as schizophrenic. Springfield won't keep him because he isn't sick enough. His family won't take him back because he is too disruptive. So he spends his days in jail sleeping and watching his favorite cartoon: "Voltron: Defender of the Universe."
A generation ago "young adult chronics" like Frank were hospitalized for years, discharged when they were older, more compliant and much less mobile. Today they are hospitalized briefly and released as fast as possible in the belief that it is more humane and effective to treat people outside, not inside, institutions.
What usually awaits them is a byzantine maze of bureaucratic regulations, inadequate or inappropriate programs, indifferent administrators or, in some cases, nothing at all. More than any other factor, the lack of programs to ease the wrenching transition from hospital to outside world has led critics of deinstitutionalization to contend that many mental patients are better off staying in places like Springfield.
"There are people like him everywhere," said Neal S. Brown, director of community support programs for the National Institute of Mental Health. "What they need is a comprehensive array of programs and a system that follows people and knows where they are. The hardest part is not designing a program, it's getting local governments to agree to make the investment and getting professionals willing to work and trained to deal with these people."
The 2 million chronically mentally ill Americans who suffer from schizophrenia, manic depression or severe depression need four basic services, according to mental health experts: housing; a rehabilitative day program that could lead to a job; outpatient therapy, and a skilled case manager. Few have had the benefits of any, let alone all, of these services.
Of the four former Springfield patients whose cases were examined in detail by The Washington Post, only one, Sandy W., received adequate discharge and follow-up care when he returned to Montgomery County after 27 years in the hospital.
For Frank K. and Michael Wayne Allen, encounters with social service agencies have been frustrating and ultimately fruitless. In Christine Muzyk Disher's case, it was primarily her own gritty resolve -- not community services -- that enabled her to rebuild her life. High Expectations, Little Support
Their burden, shared by thousands of former patients, is the expectation that from the remote confines of state hospitals, in precarious condition, with little help and less money, they will manage to reestablish their lives in communities that provide little support. Not surprisingly, most fail.
Once patients leave the hospital, Springfield officials have no way of knowing what happens to them unless -- as happens frequently -- they are readmitted. After they are discharged, the responsibility for their care theoretically shifts to local jurisdictions, often with confusing results.
"We are dealing with a human being almost by definition at the most fragile time of life coming from an institution where all decisions have been made," said Maryland Attorney General Stephen H. Sachs, an outspoken critic of Maryland's mental health system. "And what do we do? We give 'em a bus ticket and the phone number of social services and then have 13 different agencies picking at them."
Montgomery County operates a sophisticated network of public services and spends $3 million annually in county funds, an unusually large amount in Maryland, to care for 4,000 chronically mentally ill residents. However, Charles L. Short, director of the Department of Family Resources, the agency assigned to coordinate the county's deinstitutionalization effort, acknowledges there are major problems in providing services.
"The community thing is that Springfield has released someone prematurely," said Short. "I'm not sure that's the case. I think they've released someone to a community that can't provide the services that person needs."
There are only 100 places in supervised houses in the county. St. Lukes House Inc., the largest halfway house, has more than 200 names on its waiting list. There are 200 slots in day rehabilitation programs. Montgomery House, the primary day program, is so understaffed that one counselor is assigned to work with as many as 20 ex-patients, most of whom need considerable individual attention.
County mental health clinics are swamped. They do no outreach, have little walk-in service, have no weekend hours and make only limited attempts to track patients, usually by sending letters to those who miss appointments. The busiest clinic, in Silver Spring, has six full-time staff and a caseload of 603 patients, most of whom do not receive individual therapy.
Resources are so scarce that one branch of the health department routinely refers ex-patients to an informal network of unlicensed boarding houses that another section of the same department is supposed to shut down. The county's personnel system is so hamstrung by red tape that the Gaithersburg clinic went without a full-time psychiatrist for nearly a year. 'There's No Place Else to Put Him'
For Frank K., the lack of facilities has meant seven trips to Springfield since 1979 and more than a year in jail, most of it awaiting trial. Currently there are as many as 45 inmates with serious mental illnesses in the Montgomery County Detention Center, according to corrections director Gary Blake. A decade ago there were only a few.
"I don't think Frank belongs in here, but there's no place else to put him," said Blake. "We can't do anything for him except try and protect him." What Frank and his counterparts need, mental health experts say, is supportive housing and intensive counseling for mental illness and substance abuse, not narrowly defined treatment geared to only one problem.
Everyone agrees Frank is mentally ill, but doctors say he is usually not sick enough to be hospitalized. He routinely drops out of court-ordered psychiatric treatment and says he has no desire to stay off the narcotics that control his physical illness and make him high enough to forget his problems.
In March 1984, a month after doctors at Springfield certified that he was competent to stand trial, Frank was convicted by Montgomery County Circuit Court Judge James McAuliffe of attempting to sell $160 worth of opium to an undercover police officer. The opium had been prescribed to control the chronic diarrhea he has had since age 14, when Crohn's disease forced the removal of much of his small intestine.
Instead of sending him back to jail, McAuliffe sentenced him to five years' intensive probation and ordered him to stay off opium, attend therapy and report regularly to his probation officer.
After three months Frank stopped following the judge's orders. "I didn't have a car, I got tired of going and I wanted to work," said Frank, who sporadically worked for his father, a used-car dealer. He was also back on opium, which he obtained legally by doctor-hopping.
Five months ago he was arrested for violating his probation and taken back to jail. In early March his lawyer, concerned by his passivity and incoherence, asked McAuliffe to send Frank to Springfield as a voluntary patient. Frank agreed to stay for as long as doctors deemed necessary. He said later he made the promise because he preferred Springfield to jail and thought he could go home on weekends.
Within minutes of his arrival at the Lane Building, however, he told Dr. Stephen Siebert, his psychiatrist, that he had no intention of staying longer than three days, the minimum for a voluntary patient.
"All he was doing was trying to manipulate his way out of jail," said Siebert. "I would have loved to keep him as a patient, but he basically thumbed his nose at the judge and me . . . . Schizophrenia was not an issue when he was here." According to Siebert, Frank was not dangerous, so he could not be kept against his will. "It was a frustrating experience," he said.
Siebert notified McAuliffe, and the judge ordered Frank back to jail.
By early June, when his next hearing is scheduled, Frank will have spent six months in the Montgomery County Detention Center on a charge of probation violation. A New Life On the Streets
There is no place Michael Allen, 32, calls home. Since July 1982, when he ran away from Springfield after a five-week stay, he has lived mostly on the streets.
He spent five months last year living outside the National Museum of Natural History, scrounging through Smithsonian Institution trash cans for scraps of food because he disliked begging for money. Last winter he made the rounds of soup kitchens and shelters in Montgomery County, where he grew up.
At Shepherd's Table, a Silver Spring soup kitchen, he confessed his problems to Dan Kloper, a 20-year-old student volunteer. "He would sit there every day and tell me this really far-out stuff, like I was his mother from another lifetime," Kloper recalled. "It was really hard to listen to, but I felt very bad for him because it seemed like I was the only person he talked to."
Kloper suggested that Allen apply for the county's "workfare" program and set up an appointment for him. Allen went to social services but said he was told he could not qualify for the $126 monthly check because he had no fixed address.
"If he couldn't convince us to our satisfaction that he lived in Montgomery County, then it is very possible we told him that," said Doreen Getsinger, entitlement chief for the county's Department of Social Services.
Allen said he saw a counselor at a mental health clinic once. "I just didn't follow through," said Allen, who said he never returned after he was told there was no guarantee he would continue seeing the same therapist. "I just don't want start over and over again. It gets very annoying."
What he needed, according to Liz Farrell, a social worker who specializes in chronically mentally ill clients, is a case manager skilled in guiding ex-patients through the bureaucracy. Such services, especially critical in the days after discharge, are in short supply. "I can't even figure the system out, it's so complicated," said Farrell, who met Allen at the soup kitchen. "With someone like Mike . . . you have to walk him through everything."
He has developed certain routines. Every week he walks to his mother's office and she gives him about $8. Periodically he spends the night at his parents' house.
"He comes home every so often, and we feed him and clothe him and clean him up and give him some money," said his father. "I care," he said, reflecting the emotional toll that eight years of dealing with his son's illness has taken, "but I had to give up on [him]. . . . "
Allen's favorite way to spend the day is to walk to the National Institutes of Health. "They have comfortable chairs and they don't ask you to leave," said Allen, who carries a toothbrush and small tube of toothpaste in his shirt pocket.
Several months ago, Allen said, he shaved off his eyebrows because "they were driving me crazy." He said he does not think he is mentally ill and that he believes that it is evil demons that cause him to stand on street corners shrieking at strangers.
"I used to be a normal human being sometime in my life," he said softly, "and I would like to be again." Unlearning the Role of Patient
Sandy W., 45, neither looks nor acts "normal." But his current life is much more normal than the one he led at Springfield, and his experience illustrates the difference an effective community program can make, even for the most chronic patient. Simple things such as taking the bus by himself and shopping alone are skills hospital staff never dreamed he would master.
After 27 years at Springfield, mostly spent smoking and watching TV on a back ward, Sandy was discharged last December to Chadwick House, a supervised group home in a Rockville subdivision.
The staff saw just how rocky his transition would be the night after he moved in. At dinnertime he went next door, politely asked to borrow a jar of pickles, sat down on the doorstep and devoured the whole thing.
"We told him if we were going to stay here, it was important not to disturb the neighbors," recalled Martha Bramhall, a social worker for Threshold Services, the private group that operates Chadwick.
Unlike other programs in Montgomery County, known in hospital parlance as as "grow and go" -- temporary transitional housing -- Chadwick is permanent. Its eight residents need round-the-clock care indefinitely.
"The idea is to create a family, not a therapeutic community," said Bramhall. Chadwick residents are expected to learn to take the bus, attend a day program where it is hoped they will acquire simple skills that could lead to a job, and perform simple housekeeping chores.
After more than a year, six of the original eight ex-patients are still there. The $24,000 a year it costs to keep Sandy at Chadwick, half the cost of a year at Springfield, is paid by a state program supplemented by Sandy's monthly $514 disability check.
Unlearning the role of mental patient has been difficult for Sandy, who spent two-thirds of his life in the hospital. "He has no innate fear of going up to anybody," said Chadwick House director Harry Schwarz, who fears that Sandy's innocent friendliness could be misinterpreted, especially if it involves children.
His return to Montgomery County, where his widowed father still lives, has required family adjustments. He no longer calls his father four times a day, as he did at first when he was delighted by unaccustomed access to a telephone.
One recent afternoon he walked away from his day program and took the bus to Bethesda, arriving at his father's house minutes before dinner guests. His father, who visits him every week as he did during the 28 years Sandy was hospitalized, was not pleased.
"I told him I would call a cab but he had to leave," his father recalled, looking pained, "and he looked at me with these sad eyes and said, 'Isn't this my house, aren't you my father anymore?' "
A week later Sandy called from a dentist's office near Chadwick and told the staff that he had gotten off the bus because it was too crowded and he wanted a ride. Schwarz told Sandy to wait for another bus or walk.
When Sandy arrived home, Schwarz summoned him to the staff office, slammed the door and began yelling. "It was mostly a ploy, but sweet-talking him hadn't worked, reasoning hadn't worked and my impact was to make him think," Schwarz said. "This wasn't a game, this was serious and that if he didn't want to go back to the hospital there were certain things that were expected." Ferocious Determination To Make It
When Christy Disher left Springfield on Valentine's Day 1980, doctors were unsure how long she would stay out. She was 30, an overweight schizophrenic with a drinking problem who had washed out of two halfway houses. In addition, she was plagued by obsessive fears and compulsive behavior that is very hard to treat. But Disher's ferocious determination and the support she received literally helped her change her life. Her life, once a series of repeated failures, became the kind of triumph the architects of deinstitutionalization envisioned 30 years ago.
"I decided I just didn't want to go back to Springfield again," said Disher, who had been at Springfield for a total of nearly two years since 1971.
Shortly after she was discharged she found a roommate and a secretarial job. Like Michael Allen, she went to a county clinic only once. "This doctor looked at the clock because I was 10 minutes late and he was not sympathetic at all," she recalled. "It was, 'Oh, yeah, another one of them.' "
Desperate for support, she joined Alcoholics Anonymous, sometimes attending three meetings a day. She also began weekly sessions with a private psychiatrist.
As sick as she had been, Disher had more assets than many other ex-patients. She had graduated from college and lived on her own. She had money and her family was supportive. Medication controlled her illness. She functioned well enough and looked "normal" enough to get a job.
Most of all, she was determined. "She amazes us," said her mother, Evelyn Muzyk. "She has a wonderful gritty ability to struggle through."
Dr. Jonathan Tuerk, her psychiatrist, agrees. "I don't know if this is what did it . . . but in general people can get better if they want to get better badly enough and there are people around them who can help them stay connected. That's a very important kind of ingredient."
Three years ago her mother and father, a retired Army colonel, joined the Montgomery County chapter of the Alliance for the Mentally Ill, a rapidly growing family support group.
Involvement in a group, after nearly 20 years of feeling ostracized by the schizophrenia of Chris and her oldest brother, had a profound impact. "Our philosophy is acceptance and detachment," said Evelyn Muzyk. "We've finally accepted the fact that there is such a thing as mental illness and these two children of ours are mentally ill."
Disher made her own enormous changes. She stopped drinking, lost weight and, at a meeting two years ago, met Brian Disher, also a former patient, whom she eventually married.
With the help of a similar group in Baltimore, they founded On Our Own, a support group for ex-patients. Last year Christy Disher persuaded Montgomery County officials to donate rent-free a Rockville bungalow for use as a drop-in center and lobbied Maryland officials to appropriate $37,000 in start-up costs. Disher hopes that the center, which is open evenings and weekends when traditional services are unavailable, will eventually serve 200 people annually.
Disher's life is not problem-free. Sometimes she feels overwhelmed, but she has learned to pace herself and is proud of her accomplishments. Most of the credit, she said, belongs to her psychiatrist, her family and herself. "I haven't really worked for years," she said, "and here I walk in and start this drop-in center, which would be a challenge for a 'normal' person."
She still returns to Springfield, this time as a member of the hospital's Human Rights Advisory Committee. "My life has just changed dramatically," she said. "I've learned so much. I had 10 solid years of pain and bad times, but I know I never have to go back there again.