Dr. Esber Yazicioglu, a psychiatrist, came to the September 1986 meeting at St. Elizabeths Hospital convinced he had only one choice: The man seated before him -- 73-year-old Oscar Holt -- might have recovered from his chronic alcoholism, but that didn't matter. Holt was feeble and old, and whatever one labeled Holt's condition, Yazicioglu felt that his obligation was to keep his patient safe, which meant keeping him at St. Elizabeths.
If Holt were released from the hospital, in whose custody he had been for 18 years, he might start drinking again, or become a homeless person. Holt had diabetes, was hard of hearing, had trouble seeing and could not remember from one minute to the next anything he heard.
Holt squirmed in his chair. "I am not forgetful," he finally interrupted, glaring at his doctor. "I remember everything you tell me . . . . "
He pulled himself up. "I am not a prisoner. I have committed no crime. I want out of this hospital."
The question of what to do about Holt, one of 1,470 patients at St. Elizabeths, will become the District's responsibility this week when it takes over the hospital from the federal government. City officials already have announced plans to release about 600 patients into community settings in the next four years, in response to court orders and the overall reorganization of the District mental health system.
About 150 of these patients are elderly and no longer have the severe mental illness that resulted in their commitment, according to officials and lawyers. But although they no longer need psychiatric care or confinement to a mental institution, they have nowhere to go and have languished at St. Elizabeths for years.On the Borderline
Holt, born in Graham, N.C., found work in the District as a painter, truck driver and parking lot attendant. He had physical problems -- diabetes, syphilis, seizures, an ulcerous foot -- and at the time of his 1969 admission to St. Elizabeths, he was drinking up to a fifth of whiskey per day, his wife told doctors.
"He was quite confused and disoriented and unable to care for his basic needs," recalled Dr. John Lowe. A judge committed Holt for "alcoholic dementia."
By the early 1970s, Holt was considered ready to return to the community. However, his wife had disappeared, and he had great difficulty adjusting in foster homes, in large part because he resumed his drinking, records show.
When the hospital tried to send Holt to Hope Village, a private agency that houses criminal offenders, Holt refused, saying he was afraid of the "young hoodlums."
He also refused to enter a nursing home, which he said was for patients who needed "rolling chairs," his term for wheelchairs.
In many ways, Holt is the prototypical case that deinstitutionalization was supposed to help, the borderline patient who could, with adequate support, survive in the community.
The federal court here already has ruled that Holt and 300 other patients were entitled to court reviews of their hospital commitments, and at a hearing this year a judge may grant Holt the freedom his doctors refuse to give him.
But even so, the dilemma of where Holt will go persists. Until adequate community facilities are developed, his doctors say, the best way to safeguard his health is by sacrificing some of his independence.
"He wants to go to an apartment and live on his own," said Dr. Bernard Arons, the hospital's chief clinical adviser in 1986, "even though there is a clear feeling on the staff's part that if he were to do that it would be risking his death . . . . They see the dilemma as freedom versus preservation of life."
The result has been a standoff, with Holt demanding freedom on his terms -- he wants to use about $13,000 in accumulated Social Security payments to rent an apartment -- and Yazicioglu blocking an unconditional release on the basis that Holt does not appreciate the extent of his disabilities.
"What would be his quality of life?" Yazicioglu said. "He's better off here."
Mental health lawyers and city officials agree that an ideal situation for patients like Holt would be the creation of small neighborhood group homes, or shared apartments, where a nurse could visit periodically and administer medication. While that is "something we will strive to have," said Robert Washington, who will officially become the city's new mental health commissioner Thursday, "it is expensive and has to be weighed against everything else the city has to do for the mentally ill."
Elizabeth Jones, a staff member with the Mental Health Law Project, which represents Holt and most other St. Elizabeths patients, said hospital officials constantly tell her: "Well, these people all need nursing homes. They've been here too long. They can't live on the outside."
Said Jones: "The only difference in terms of Oscar is that Oscar is able to speak out for himself, and if there's any hope at all, it's that he's articulate enough that people have been captivated by his situation. There are people there that are probably the ones to worry about more in the long run, the ones who have nobody speaking out for them, and have no voice left of their own."
The September 1986 meeting involving Holt and Yazicioglu was a dramatic confrontation on a ward where few patients are able to articulate their concerns and desires.
Joanne M. Jones, the lawyer appointed by the court to serve as Holt's conservator, said: "He should be able to do whatever he wants to do, and if that's to drink himself to death then that's what he should be able to do . . . . That's a personal decision." A Narrow World
Holt's home is the Haydon Building, which is composed of about 20 wards each holding 20 to 30 geriatric patients. Many with psychotic symptoms spend their time talking incoherently in a large day room on the ward; other patients are impassive, seemingly lost in their own worlds. Holt tries to avoid this setting, preferring to sit in the hallway near the elevators, just outside the ward door. There, he sits alone and smokes for hours.
During the 1970s, Holt was one of the many patients covered by the Dixon case, a landmark court ruling that said patients should be held in the least restrictive setting possible, which set the stage for deinstitutionalization in the District.
Holt's longest stay in a foster home was from December 1974 to January 1977. He had to return to the hospital after a seizure (which doctors said resulted from his failure to take medication), and again after the home's operator claimed that Holt was drinking excessively and had threatened to buy a gun to kill her.
Between his foster home placements, Holt participated in the hospital's industrial therapy program, eagerly accepting housekeeping chores on the grounds, for which he was paid the minimum wage.
"He was very proud at having that job," said social worker Maria Owen. "You got out, you got to mix with the regular people, you were treated like an employe. What he doesn't tell you is that he showed up drunk half the time and finally had to be terminated because of his drinking."
After losing his job and his chance at living in a foster home, Holt's emotional state deteriorated. He was angry at the hospital's request that he go to a nursing home, angrier still when the hospital began billing him for his stay.
Holt has refused to pay.
On the ward, Holt kept to himself and refused to engage in activities such as basket weaving and arts and crafts, calling them "child's stuff" or for "crazy people." When he learned that other patients were being transferred from the ward, he complained to social worker Owen, "You let these crazy people go. What do you still have me here for?"
Fond of Holt, Owen tried to cushion the harsh institutional life. "He's a joy to be with. He could be my grandfather," she said.
She took him to a nearby men's store to purchase slacks, shoes and shirts; to the Safeway to buy toothpaste and other toiletries; to the bank to deposit his Social Security checks. Even after he was restricted to the ward, she continued to take his clothes to the dry cleaners.
"He wanted to be well dressed. It distressed him when he could not be," Owen said.
The loss of grounds privileges made Holt despondent. It happened once after he returned to the ward drunk. But another time it occurred after a seemingly minor incident on the ward.
Holt had returned from a walk and a nurse asked to search him. Holt, who already had handed over his cigarettes, said, "I refuse to be searched. I am not a prisoner."
He was searched anyway and told he could not leave the building.
Holt said in a recent interview, "I don't like to be hemmed up in here. It's like jail. I can't get nothing but just look at the walls and come downstairs and get a soda. And go back. And that's all."
Yazicioglu acknowledges that Holt often expresses anger at him. "He sees me as the butcher, the despot, you know."
Holt's world was further narrowed last month when a set of different doctors and nurses ordered him confined inside the ward, not allowing him even to go to the elevator lobby to smoke.
Holt complained to public defender Harry Fulton, who asked the nurses to overturn the rule.
They complained to Fulton that Holt might burn himself sitting alone and that his safety was more important than his freedom.
As Fulton recalls the conversation, the nurses essentially said, "You're asking us to let this man sit outside . . . to have that kind of pleasure, to have his spirits up . . . when we're telling you his condition is deteriorating and he could hurt himself with a cigarette . . . . We think it has to go back the other way. We think our concern over his physical well-being has to take precedence over his being out for a couple of hours a day."
At Fulton's insistence, though, Holt was allowed to return to his favorite spot.
A Question of Survival
On Nov. 14, Dr. Arons sat with Holt in the lobby and asked him to read a sign posted over the elevator, a good 10 feet away.
"Ain't no sign over there," Holt said. He was not wearing his glasses that day.
Arons went to the sign and touched it. "Do you see something over here?" he asked.
"Yeah, that's brown. And blue. Yellow," said Holt, saying the distance caused him problems. "The more it come in, the more I can see."
"The doctors and nurses are worried about you . . . ," Arons said. He asked whether Holt would be able to see a red light when crossing the street.
"Oh, I can see anything like that," Holt insisted.
Holt's denial of any problem bothered Arons the most.
Owen believes that freedom may never come for Holt -- and other patients like him -- no matter where he ends up.
"He holds out this dream, that he is finally going to get somewhere," she said.
"He's always going to be a prisoner, wherever he goes. They can call it a small home. They can call it a large home. They can call it a nursing home. They can call it St. Elizabeths. It isn't the roof over Mr. Holt's head that is a restriction. It's the restriction on his liberties, which he will have to have in order to survive."