What makes Sammy run?

Huge and helpless, schizophrenic and hypertensive, Sammy Allen has fallen between the administrative cracks of a local mental health system that can't seem to get its ACT together

Sammy Allen stands meekly and hopefully outside the screen door of his family's house in South Dallas, calling out, "Daddy! Daddy! It's Sammy, Daddy!" Sammy's 11-year-old nephew comes to the door. "Hey, it's Sammy Tee," he tells the boy, trying to come across as a treasured relative, one who sets nieces and nephews to jumping up and down and squealing "Uncle Sammy's here!" But Sammy's nephew just ignores him, unlocking the door and walking away to get his grandfather, Sammy's father.

Sammy is allowed to come in only a few feet past the front door, his father mindful of his son's 26-year documented history of being tear-gassed by police on the house's front stoop, setting fires in the home, and threatening murder. Twenty-six years of Sammy accusing his father of trying to kill him and steal his money. Twenty-six years of Sammy phoning from prisons and psychiatric emergency rooms demanding and begging his family to take him back.

Sammy and his father exchange a few words, and then his father hands him the mail that he's come to pick up. Time for Sammy to leave.

Two weeks later, at the end of April, Sammy Allen is being thrown out of his latest boarding home. Members of the Dallas Mental Health and Mental Retardation Assertive Community Treatment team (ACT), a specialized unit that provides intensive outpatient care for the mentally ill, take him to a room at the Flora Motel, located just off Fort Worth Avenue, in an area lined with $80-a-week motels whose lobbies feature "No Prostitution" signs, the kind of places where guests must leave an ID at the front desk.

"I'm on my own. I don't have anything now. I'm on my own," Sammy says, repeating "I'm on my own now" over and over until he non sequiturs into a story about chains and handcuffs and mistreatment in the county jail, an incident from many years ago.

Sammy claims that he called every number in his "Patient Rights" book in an effort to report the ACT team for neglect, but couldn't get hold of anyone. He adds that he went to MHMR's Westmoreland Clinic in Oak Cliff, but that they just gave him an injection of the anti-psychotic drug Haldol and a ride back to the motel. The next night, he says, he called an ambulance, begging to be taken to Parkland Memorial Hospital's psychiatric emergency room.

He's stuttering badly now. He thinks people are coming to get him: "I'm tensed up. I'm scared to death. I'm not safe out here. I need to be in a protected environment." He says that he's lonely and hungry, that he needs to be taken care of, that he's a cripple. "Please have pity on me," he pleads desperately with equal parts demand and complaint, a telling one-line summary of the way in which Allen has related to the world for the past 26 years.

Now 48 years old, Samuel Tunson Allen Jr.--a 355-pound black man hobbled by degenerative joint disease of the knees, suffering from hypertension and incontinence, wearing someone else's prescription eyeglasses--has been intimately and regularly involved with the local mental health system since 1971, existing almost exclusively under some sort of case management. He's been in and out of state psychiatric facilities that serve Dallas County 46 separate times, 41 of those under an involuntary court order. In 1996 alone, he had 18 separate admissions to either a psychiatric emergency room or a psychiatric intensive care unit.

His most recent "presumptive" diagnosis is schizoaffective disorder bipolar type, which is, according to Starla Harrison, who serves as a psychiatric nurse for the ACT team, "a combination of both schizophrenia, which is more straightly delusional and includes hallucinations, and a mood disorder. People who have schizoaffective disorder, if they're not treated, have psychotic symptoms all the time, in addition to these mood swings that go up from mania all the way down to depression."

Allen also has been diagnosed with "personality disorder not otherwise specified," a combination of elements of several personality disorders; these include antisocial (primarily a lack of conscience), narcissistic (lack of empathy for others), and dependent (excessive need to be taken care of) personalities.

Sammy Allen represents a nagging problem that has vexed the mental health system since the nationwide advent of deinstitutionalization some 35 years ago, when patients were gradually moved out of psychiatric hospitals and into supported housing in the community. He is the chronic mentally ill recidivist who's not psychotic enough to remain in a state hospital; who hasn't done anything that would justify locking him up in a prison or a psychiatric hospital for any significant length of time; and who can't or doesn't choose to function well in the community.

His family support is extremely limited, and economic constraints keep him in substandard housing. His attitude and behavior sabotage most of his rehabilitation opportunities, and caregivers question whether he is really mentally ill, suggesting that he's merely an antisocial malingerer taking advantage of the system.

ACT is the agency within MHMR that deals with the estimated 600 people in Dallas County who fit Sammy Allen's profile. A 1996 fiscal study done by the local ACT team on its own program states, "The effectiveness of a program can be evaluated by the reduction of crisis services and hospitalization [for a consumer]." The most recent data available from Texas Mental Health and Mental Retardation (TXMHMR) indicates that one year before being serviced by the Dallas County ACT team, a consumer (industry lingo for "patient" or "client") had an annual average of 33 days in a state hospital; after a year in ACT, that average dropped to 10 days.

"Every time one of these consumers is positively impacted by this team...the community (city, county, and state) is saving significant tax dollars," states an ACT team report. "We know that ACT is effective because of the reduced hospital stays and quality-of-life indicators," contends Melody Olsen, coordinator of ACT/supported housing for TXMHMR.

However, according to Sue Burek, who collects and analyzes data on ACT teams across the state for TXMHMR, the only data that actually exists right now to judge the effectiveness of Dallas County ACT is the team's ability to keep people out of state hospitals.

Part of the outpatient care ACT provides is described in the agency's literature on specific job tasks for its case managers: "Actively reaches out to each assigned consumer to establish a relationship...provides advocacy which is sensitive to bureaucratic barriers...supportive, friendly conversation related to daily living problems the person is experiencing." It's difficult to make definitive evaluations of this type of service because the quality of something such as "reaching out" depends on the attitude, skills, and interest of each individual case manager. And it's further complicated by the difficulty in determining where a consumer's resistance to treatment ends and a case manager's lack of effort begins.

Based on repeated observations of Sammy Allen interacting with the Dallas County ACT team, conversations with both case managers and Allen, and regular monitoring of Allen's life since he was discharged from Terrell State Hospital, it seems apparent that, despite the expenditure of considerable manpower monitoring Allen and retrieving him from repeated admissions to Parkland Hospital's psychiatric emergency room, the ACT team did not know--or if they did know, did nothing about it--how Allen spends his days, how he ended up in Parkland's psychiatric ER, and whether he actually committed the violent acts he was accused of. Additionally, Dallas County ACT seemed ignorant of the facts that Allen was living in a room where people were smoking crack, that he didn't have a belt to hold up his pants or clean clothes to wear, and that he was sleeping on urine-soaked sheets for nearly a month.

Allen's main case manager on the ACT team did not even know what medication his patient was taking.

Allen was first admitted to Terrell State Psychiatric Hospital in Kaufman County on March 3, 1971, and was committed for three months. According to Terrell State records, he was brought into the hospital on a stretcher, bound in a straitjacket and handcuffs.

He was diagnosed with schizophrenia. Sixty-seven days and 13 rounds of electric shock therapy later, he was discharged to outpatient services with prescriptions for the antipsychotic Thorazine and for Akineton, a medication that addresses some of the possible side effects from antipsychotics (pacing, shaking legs, involuntary movements of the tongue and mouth).

In records scattered among a number of state and local mental health agencies--many of them made difficult to access as a result of Allen's reluctance to comply with anything, including putting his signature on a consent form--are a quarter-century's worth of documents, thousands of pages detailing how a disturbed, obese black man has been picked up on mental-illness warrants, court-ordered to outpatient services, and escorted into and out of boarding homes, motel rooms, psychiatric emergency rooms, psychiatric intensive-care units, and correctional facilities.

He's had his motel door kicked in by constables. He's been restrained and secluded countless times. He's been given thousands of milligrams of Haldol, Thorazine, Lithium, Prolixin, Mellaril, Olanzapine, Atavin, and other drugs. He's threatened to injure or kill children, doctors, mental health technicians, psychiatrists, caseworkers, and fellow consumers. His criminal history includes at least 46 arrests on various misdemeanor charges--everything from refusing to leave a McDonald's to bringing a starter's pistol into a psychiatric ER demanding admission--and six felony charges for crimes such as "unlawful carrying of a weapon" in a tavern (he was in a bar with a pair of martial-arts nunchuks shoved in his pants), and "aggravated robbery" (he chuckles about it today, noting that he was out of his mind at the time, when he stood in front of an information booth at a Greyhound bus terminal holding a knife).

In each felony case, he was found incompetent to stand trial and was sent to a psychiatric hospital until it was determined he had regained competency. Afterward, either his case would be dismissed and he would be released, or he would be sent for a short time to a correctional facility.

He's been repeatedly evaluated as homicidal, violent, and dangerous--an Yberpsychotic. "He's required so much medication that if we were to give it to one of us, it probably would kill us," one psychiatrist testified at a long-ago Allen competency hearing. "But to him it's just enough to sort of calm him down a little bit."

According to Dr. W. Miller Logan, the ACT team psychiatrist, there are no more than two or three places in the entire state that would be appropriate for someone such as Allen--facilities that offer long-term supportive housing for a mentally ill person who has never worked and therefore isn't eligible for disability benefits, and who has no private medical insurance. (Allen says he currently receives $485 a month in Social Security benefits. He has been on Medicaid in the past, but he is not drawing it currently.)

Hospitality House, a 65-bed licensed nursing and residential care facility located in Mount Pleasant, about 135 miles east of Dallas, is one such place. When contacted, Kristi Graves, a social worker at the facility, said that Hospitality House is now, for the most part, focused on rehabilitating people to reenter mainstream society rather than providing a place for a person to live out his life while being cared for. Graves added that Dallas County MHMR has to refer an individual to Hospitality House and must pick up a significant portion of the bill, which she estimated to be about $200 a day.

Allen has been under court-ordered outpatient treatment countless times, but the tool to enforce compliance is the threat of being sent to a state hospital--in reality more of an economic problem for the state than a disincentive to someone such as Allen. According to a 1996 report by the Performance Review Division of the state Comptroller's office, which analyzes cost-cutting measures in government agencies, the average daily cost to provide what is loosely called "supported housing" (housing in the community with an attending case manager) for a Texas consumer is $22, compared to $185 a day at a state hospital.

The report goes on to state that the mentally ill "historically have been served in state institutions. Such views, however, have changed significantly in the last several decades. Services that integrate consumers into their communities have proven to be not only effective, but also cost-efficient."

Of Allen's 46 stays in state mental hospitals since 1971, most were for only two to three months. Some lasted only two weeks. Consumers like Allen now spend most of their time living in low-cost motels, in boarding homes, in shelters, and in apartment complexes, where case managers visit periodically to check up on the consumer's status.

According to Sharon Killen, systems manager for DMHMR Adult Mental Health, people are discharged into Dallas County from state hospitals approximately 1,000 times a year; DMHMR's Liaison Services coordinates the outpatient care for these persons. From September 1, 1996, through March 31, 1997, the time period for which the most recent data is available, DMHMR served 12,009 consumers on an outpatient basis. Of that number, 1,367 received intensive case management, meaning that rather than the consumer just coming into a local clinic for medication, a case manager regularly monitored the person in the community.

"Every day I get asked or get a phone call saying, 'Hey, can you provide services for this consumer?' And I have to say, 'I'm sorry, I can't, I don't have the manpower,'" says Jesse Valdez, coordinator of DMHMR's ACT team.

In essence, ACT teams serve as mental health clinics on wheels, offering intensive outpatient services to what DMHMR terms "level III consumers": people who haven't cooperated in taking their medication; people who have moved through the mental health system's revolving doors (psychiatric emergency rooms, psychiatric intensive care units, jails, state hospitals, shelters, and boarding homes); people like Sammy Allen.

Originally conceived in Wisconsin in the late 1960s, ACT teams were developed as a way to monitor patients discharged from psychiatric hospitals, intervening before a patient got to the point where he or she had to be readmitted. The local ACT team has been a part of Dallas County MHMR since 1994, but wasn't officially mandated by Texas MHMR until 1995. Its purpose is to deal with people who weren't being helped by standard case management. The team consists of a registered nurse, a master clinician, five case managers, two community integration specialists (all full-time), and a half-time psychiatrist.

The clinician performs some counseling, initiates commitment procedures for consumers, and develops treatment plans. The case managers work in the field to develop close relationships with consumers and provide one-stop mental health care: crisis intervention, support with medication, and assistance with housing, basically seeing to it that the consumers are functioning well. The community integration specialists perform the more hands-on tasks, such as teaching consumers to prepare meals or do laundry.

The ACT team's goal is to provide an average of two hours per week to each of the 60 consumers on its rolls. Tony DeFreece, an ACT case manager and "point man" for Sammy Allen, had a caseload of 12 consumers: three in boarding homes, two in jail, one on the streets, and one about to be evicted from his apartment; the other five live with family or in apartments. (DeFreece has since left ACT.)

"We're about the only other option there is," notes ACT psychiatrist Logan. "If we can't do it with Sammy, there's nothing in Dallas County that can."

On March 20 of this year, after a more-than-40-day stay at Terrell State Hospital, Allen was released on a 30-day furlough to ACT. Later that same day, he sits on a couch at the DMHMR Westmoreland clinic, surrounded by several white garbage bags filled with his possessions, a wheelchair by his side. His body odor is overpowering. He rants, loudly and steadily.

Logan meets briefly with Allen, explaining his medications. He mentions that Allen will have to come by the clinic for Haldol injections every two weeks. Sammy says he'll walk away right now if a needle comes near him. Logan hands him a brown paper bag containing four pill bottles, one each of Klonopin (anti-anxiety), Cogentin (to prevent side effects from the Haldol), Procardia (for high blood pressure), and Dyazide (a diuretic).

At this point DeFreece comes over to prepare to transport Allen to Jefferson House, the boarding home at which ACT has arranged for him to stay. According to ACT's Valdez, DMHMR policy doesn't allow his agency to refer a consumer to any of the estimated 50 to 100 legal boarding homes in the Dallas area, most of which house the mentally ill. ACT can only show a client a sheet with a listing of boarding houses, and then let the consumer choose. With Allen, however, this doesn't happen. DeFreece had already chosen a boarding house for Allen while Sammy was in Terrell.

Every step from the clinic couch to the ACT van waiting outside is fraught with tension. When Allen learns that a flight of stairs leads up to Jefferson House, he complains that he can't walk up stairs. DeFreece is skeptical and attempts to placate Allen, who, in turn, rages in proportion to the placating tones. Eventually he's screaming, horrified: "I don't want to be captive! I want to be able to go out, to do things, feed the pigeons, watch traffic!"

DeFreece hurries him along, assuring him that everything will be fine, which prompts Sammy to scold his caseworker, telling DeFreece that he's supposed to be a trained mental health professional--he's supposed to be patient. An argument ensues over who will carry Allen's bags. Sammy repeatedly insists that he's handicapped, that he's sick, that he's slow, that he's old. DeFreece finally relents, agreeing to carry the bags, and the situation cools down. After a moment, Allen says, half to himself, "I'll carry my Bible."

DeFreece responds, gotcha-like: "Oh, if you can carry the Bible, then you can carry the bags."

Allen screams, "Why are you so stupid?"
"Guess it just comes naturally, Sammy."
Allen's fists are clenched, teeth gritted, body shaking. He's about to explode with anger and frustration. "Where are my servants?" he demands. "I'm a king. Where are my servants?"

"You don't have any servants here, Sammy."

Sammy Allen's own account of his past and present mixes outright delusion with hazy autobiographical fragments, all of which is obscured by his anger, his mistrust, and his indifference to the accuracy of information that comes from a lifetime of trafficking in a world in which accurate information has little value for him.

He was the fourth of eight children born to a mother who worked as a maid and a father who worked in the Dallas public school system as a school aide. Sammy was born in South Dallas, but in 1961, when he was 13, the Allens moved to an area in Oak Cliff, the first black family in an all-white neighborhood.

Today the neighborhood is predominantly black. Sammy frequently refers--with both pride and amusement--to living his whole life in the "ghetto." His 76-year-old father, Samuel Allen Sr., still lives in Oak Cliff, along with several members of his extended family, in a home on a quiet street with well-kept houses. His wife, Cornell, died in 1981 of heart trouble.

Allen Sr., a soft-spoken man with a gentle disposition, says that all his children grew up in a religious household (he's a minister who has his own church). One of his other children was admitted to Terrell several times over the years, he allows, but now is fine. Several of his kids are college graduates with stable jobs and families. He remembers nothing remarkable about Sammy as a child, pointing out that he didn't communicate much with his son because he was always working. He refers to Sammy's illness as--literally--an evil spirit or demon, and remains unclear as to when Sammy's problems began, speculating that his son was in his late teens when "he went out of his mind or something." The police, he recalls, picked up Sammy off the streets and took him to the county jail, where he was stripped naked and put in a cell. Eventually he was sent to Terrell.

Sammy himself remembers it differently, claiming that when he was 17, his mother called the police on him because of some dispute. He was taken to jail for the first time, where he remembers shaking and hallucinating. He adds that there were grown men there and that he was just a kid, that the other prisoners harassed him. He describes it as the worst experience of his life.

In a 1977 note in Allen's file, a caseworker described Sammy's mother as screaming at the top of her lungs and refusing permission for a caseworker to visit Sammy at home. "His mother is an agitate to her son," reads the entry. "As I talked to Sammy and tried to help him remember his appt. time and date, his mother taunted him in the background. She was saying he's a mental patient, he needs mental medication."

"My mother loved me," Sammy says now. "She said some things she didn't mean."

"He would do all right as long as he stayed on the medicine that the folks gave him, all that dope that they give him," his father remembers. "Then when he stopped using the dope, he started going back off. And that's been on and on for I don't know how long now...He's been in and out of institutions and jails, that's about the whole story."

Allen Sr. says that Sammy calls from time to time to report his whereabouts, and that he's allowed to come to the house occasionally to pick up his mail.

But for the most part, he acknowledges that Sammy is separated from the family. "I believe he wants to come back here to stay, but I won't permit that," Allen Sr. explains. "Not long ago, my granddaughter was telling me where some mental guy was trying to attack his mother or something and killed his father. I'm not taking no chance on no mental patient staying with me. Mental folk, when they go crazy and act up and kill somebody, all they [authorities] say is [imitates mockingly], 'A mental patient killed his father,' and carry him down to Terrell, keep him two, three weeks, then put him back on the streets. That's what happens with mental people. My son ain't gonna live with me no more."

Given the choice, Sammy says he would spend the rest of his life at Terrell State Hospital. He speaks about the place wistfully, describing it as rural and peaceful. He has friends there, he contends, and groups there to help him control his anger. It is, he notes, a place where he can eat cookies and ice cream. A place for sex, too. Allen talks about the "one-dollar hole" he met in Terrell, a female patient with whom he had sex in the bushes behind the hospital's family center. (A psychiatrist at Terrell State wrote in a recent evaluation of Allen, "This [Terrell State] is probably the closest thing that this patient has to a home.")

The attitude of some in the mental health community toward Allen has been a mixture of resentment, resignation, and skepticism as to whether he has a legitimate psychiatric problem. A number of his clinicians and caseworkers appear to be unclear as to where Allen's psychiatric problems end and his behavioral problems begin. Larry Sadberry, a DMHMR case manager, worked with Sammy from 1993 to 1996 when Allen was living in various apartments in South Dallas--the only period in his history during which he was not admitted to a state hospital. Sadberry states that he was involved in "difficult case conferences" during which doctors were convinced that Allen was faking his mental illness, and that Sammy was a malingerer who should go to jail for his behavior rather than exist as a ward of the mental health system.

A 1985 caseworker report on Sammy Allen reads: "This patient has a very difficult time adjusting outside of the hospital and mainly has only one interest in life and that is being taken care of with regular meals and a roof over his head...He especially enjoys staying in bed, lounging around, and just taking it easy."

From a 1996 psychiatric evaluation: "One thing is for sure. He does know how to manipulate the mental health and legal systems to get what he wants...I would also recommend that the Treatment Team work with Sammy to help him understand that the hospital is not his personal Club Med or refuge from all the problems of the world."

"I actually believe he is not as mentally ill as he acts," Sammy's father says. "At times he talks sensible, he knows the scripture, he talks to you with good common sense, he knows how to handle his own money like a normal person. He has a problem, but I think he's actually using that problem to take advantage of the system and of the police force, because they all know him and aren't gonna hurt him. I ain't never heard him be beat up or nothing like that. I believe he's not as sick in mind as he pretends he is."

But when Sammy shows up at a local psychiatric emergency room and announces, "I'm sick, take care of me," he can't be readily dismissed or moved on as homeless and a behavioral problem, because he's been officially diagnosed as being mentally ill. And he has a 26-year paper trail of commitment papers to prove it. So, usually, the ER keeps him overnight, administers medication, and sends him back out into the community.

"I think part of what it's about is Sammy just becomes so frustrating that it's somewhat human nature that people tend to hold on to the part of him that they can say he's milking the system," theorizes Logan, who does believe Allen suffers from a legitimate mental illness. "On the other hand, there's still that sense of 'Gosh I'll throw whatever [medication] I can at him just to see if it'll keep him out of the hospital long enough next time.'"

Jefferson House is a plain brick two-story building located on a retail strip of Oak Cliff filled with pawn shops and rent-to-own stores. A glass door opens to a 20-step flight of stairs, which Sammy labors to ascend.

At the top of the stairs, a worker sits behind a desk in what serves as the Jefferson House lobby. Nearby stands a filing cabinet that has been affixed with a crudely lettered sign that proclaims "NO ONE GETS MEDS"--the rest has been ripped off. Tony DeFreece hands the desk clerk Allen's medications, and she puts them in the filing cabinet, which holds approximately 15 additional paper sacks of medication.

Sammy is assigned to an eight-bed room approximately 30 feet long by 10 feet wide, with each of the beds spaced a few feet apart. The mattresses and sheets are stained. A ceiling panel over the room's two fluorescent lights is missing. Two of the three ceiling fans don't work. The doorknob is falling off. A few broken-down bureaus are scattered around the room. The bathroom consists of a shower the size of a large telephone booth and two toilets, both missing their stall doors. For this Allen pays $340 a month. (DeFreece acknowledges that boarding homes can be unappealing places to live, but he points out that no one else will take the population with whom ACT works.)

Jefferson House has 11 rooms and 58 beds. Its population fluctuates, but recently 54 men and women lived there, 28 of whom were DMHMR clients. It provides three meals daily, plus it posts someone--usually an ex-DMHMR consumer--at the front desk. Curfew is at 10 p.m., and no one is allowed out of his room after 11 p.m.

Sammy spends much of his time watching television, either sitting in the day room or in his room, surrounded by his garbage bags filled with soiled and foul-smelling clothes, some of which are starting to mildew. He urinates in his bed, and the sheets are not changed. He is constantly harassed by residents and the desk clerks to wash, to lower his voice, and to stop his ranting.

At different times a resident tries to sell Sammy cufflinks, a belt with "Ellis Unit Death Row" stamped on its buckle, a lighter, two cans of soda, an umbrella, and the over-the-counter antihistamine Benadryl. Allen weighs each offer seriously and occasionally makes a deal. In the television room, a resident offers Sammy a three-quarters-full lighter in exchange for some of his soda. Allen lets him keep the lighter and pours him a cup. Another resident picks through the ashtrays looking for stubbed-out cigarettes to smoke. One man sits in a chair in the day room, points to different residents, and says, "See that guy over there? He's crazy."

Formerly a flophouse for alcoholics, Jefferson House is a privately owned boarding house (or residential hotel) that only recently started taking in the mentally ill because they were easier to control and were less of a problem, according to a manager there.

The environment blends peer support (a resident looking for crack money will do the laundry of an elderly resident who receives a disability check) with a jailhouse mentality (homemade tattoos, gimme-a-cigarette demands to show who's in control, a lot of verbal violence and threats).

"This is a dumping ground," shrugs a Jefferson House manager. "They opened up the institutions, and people had nowhere to go. MHMR wants them in the community. These people in here are the lucky ones."

Allen alternately rages against the boarding home and worries that the "boss man" will throw him out. He makes futile efforts to clean and organize his area, but gets confused, distracted, and forgetful in the process. Nothing gets accomplished but a bit of shifting around. He flip-flops on whether he will take his medications and, from time to time, goes to the desk to ask the on-duty clerk for them.

"I'm not supposed to be dispensing, really," one of the desk clerks confides. "We can't really keep their medication for them, but we tell them it's for security. I'm probably not supposed to be giving it to him [Allen], but I don't think they'll [MHMR] mind."

The Texas Administrative Code governing the use of medications for patients receiving community-based mental health services states that to be qualified even to supervise the self-administration of medications, a person must receive a training course taught by a physician, registered nurse, or pharmacist that includes education on the effect a medication will have on a patient and what symptoms a medication is intended to address; on recognizing, managing, reporting, and documenting side effects, adverse reactions, and medication errors; and on the potential toxicity of medications. (None of the Jefferson House desk clerks has any such mental health training, admits a manager at the boarding home.)

According to Charline Stowers, manager of information services Long Term Care Regulatory, the division of the Texas Department of Human Services that licenses personal-care facilities (which are the more expensive step up from boarding homes), workers in boarding homes are not allowed to render any personal care beyond providing room, board, and laundry. "They [residents] can even be sick, as long as no one is caring for them."

She adds that a boarding house is not allowed to keep someone's medication for them and control access to it, dispense medication, or keep records of who takes what and when. Jefferson House does all of these things.

"There's some consumers that really can't handle their own medications, and somebody's got to do it," explains ACT team coordinator Jesse Valdez. "I don't know if it's legal or not, I'll be honest. There's no regulations to govern those boarding homes. We have no control over that, and I don't know of anyone who does. If they don't [dispense meds], then what happens? Does the client not take the medication? Does the medication get stolen? Do the medications get misused by either the consumer himself or other consumers?"

But even in this supposedly benign skirting of bureaucracy, the system breaks down. Desk clerks often fail to dispense medication when they're supposed to, and some workers will ask the consumer which medication he or she has to take (Allen identifies his by color). For instance, a Jefferson House desk clerk holds up one of Allen's pill bottles and announces, "This medication right here, we make sure he gets this medication. He can't miss this. This is what keeps him from getting out of control."

It's a diuretic.

On March 23, three days after he has been released from Terrell, Sammy is admitted to the Parkland psychiatric emergency room for the first time. Parkland records indicate that he was brought in by police on an APPOW (apprehension by a peace officer without a warrant). Allen claims he fell asleep on a bus and missed the 10 p.m. curfew at Jefferson House; as a result, transit police took him to Parkland. The hospital kept him overnight, judged him "not acutely dangerous to self or others," and in the morning gave him a voucher to take a taxi back to Jefferson House. Two days later he was admitted again, with Parkland records noting, "48 yr. old BM in on APPOW. Was found outside a store 'talking nonsense' and disturbing others."

When asked how Allen got into Parkland's ER the second time, Valdez notes that a hospital liaison person told him that Sammy "got into an argument at the boarding home. I guess they called the police, and they took him to Parkland. Sammy does not like to be told what to do. They were trying to tell Sammy what to do. Sammy started losing his cool, and it got to the point of almost being physical. That's when the police got called in."

Valdez adds that Parkland got its information regarding Allen from the police who brought in Sammy, and that the cops got their information from the boarding house. Also, Valdez continues, the Parkland liaison told him that Sammy had to be put in a "strapjacket" and placed in seclusion. And yet hospital records included in the case file that DMHMR maintains on Allen (referred to as his "chart") do not indicate that this occurred. Additionally, according to police records, no 911 calls were made from Jefferson House from March 24 to March 26.

The afternoon after Sammy's second Parkland visit, DeFreece and another member of the ACT team drive to the hospital ER to pick him up. In the psych ER, Allen smells worse than usual, his clothes are stained, and he seems heavily sedated. The ER doctor tells DeFreece that Allen was "pooping on himself." According to Parkland records, he dropped his pants and urinated on the floor; was "hypersexual and hyperreligious"; demanded to leave, yelling "I have rights, and you can't keep me" as he beat on a door. Because of his behavior, he was given 35 milligrams of Haldol at least four separate times over 14 hours, as well as Ativan, an anti-anxiety medication. The Haldol, which takes effect in about 20 minutes, is supposed to help alleviate psychotic symptoms, most commonly audio hallucinations and delusions. It also acts as a sedative.

(For his part, Allen says he hates taking psychotropic medication, that it never makes him feel better, and that he doesn't need it. "Haldol makes you go crazy, makes you a zombie," he contends. "Medication crippled me.")

DeFreece tells the ER staff to call if Allen shows up in the future so that the ACT team can come to retrieve him.

On March 31, Allen is admitted yet again to Parkland's psych ER. Hospital records state that he was brought in on an APPOW from the boarding house and that he "was out of control...and throwing things [furniture] about at boarding home." He was administered Haldol and Ativan once again, and received surgery on his right eye, which, according to hospital records, was apparently infected with gonorrhea. Doctors indicated he could possibly lose the eye if he didn't get proper treatment.

But Sammy tells a somewhat different story regarding how he wound up at the Parkland psych ER that third time: On the night of March 31, he says, he was harassed by a man who sleeps in his room at Jefferson House, a man he has repeatedly described as a killer. Allen also has difficulty sleeping at night. He claims he left his room to enter the smoking area. The worker at the desk told him to get back in his bed, because it was after 11 p.m.--he couldn't remain in the lobby. Sammy didn't want to go back into his room, and didn't move. The desk clerk called 911, and the police transported Allen to Parkland. (According to police statistics, from April 1, 1996, to April 1, 1997, there were 65 911 calls made from Jefferson House, either by staff or residents. Five of those calls were reports of attempted suicides--some involving medication--and one was to retrieve the dead body of a resident.)

The Dallas police officer stationed at Parkland explains that any time a person is brought in on an APPOW, one copy of the APPOW report (describing specifically what the person was doing and why the police officer saw him as a danger to himself or others) is added to the patient's chart. None of these APPOW reports has been included in Allen's chart material sent from Parkland to DMHMR, and Parkland refuses to comment on whether the reports even exist. So it remains somewhat unclear whether Allen's APPOW admissions are properly documented.

The larger point is that there are times when Allen is being admitted to a psychiatric emergency room, involuntarily medicated, and classified as violent based on the word of a boarding house desk clerk who may not have liked the fact that Allen disobeyed one of the house rules. This is typical of Sammy's existence within the local mental health system. He has left in his wake a paper trail filled with misinformation and hearsay, a collection of providers who can't keep track of the details of his life, and the overriding assumption that because he's so antisocial, he's probably in the wrong anyway.

And yet despite 26 years of orders of protective custody, involuntary commitments, and psychiatrists testifying to the fact that Allen is dangerous and violent, no documented evidence exists that he has ever physically harmed anyone.

"I don't disagree with removing him from the community when he is even perceived as dangerous, either to himself or to other people," observes Larry Sadberry. "But I know personally that there's been times when he's just told me to go away and don't come back, and don't 'f' with him--and I did that. And then the next time I heard it, he ran after me with a knife and threatened to kill me, and basically things got really blown up out of proportion."

"I'm not dangerous," Allen says. "I'm an old man. Who am I gonna hurt?"

On the night of March 31, after Allen has been released from the Parkland ER, he sits by himself in a bus shelter a block away from Jefferson House. He wears plastic, rose-colored glasses given to him by the hospital. Behind the glasses, his eye is dripping and encrusted with pus.

Earlier he had been in a thrift store located near Jefferson House, when he felt the need to urinate. Because he didn't want to embarrass himself by relieving himself in the store, he hurried outside, where he urinated on himself. Now he's waiting for his pants to dry so he won't get yelled at by the people at the boarding home. He believes the urination problem is caused by his medication, although he doesn't know which medication.

One week later, on April 6, Allen is at Jefferson House, flush with money from his SSI check, a melted chocolate bar in his pocket. He's being yelled at repeatedly by the desk clerk to be quiet, to lower his voice. Sammy rages back arrogantly. When a resident asks no one in particular for a cigarette, Allen goes on a rampage, calling the resident a bum, accusing him of never working in his life, and mockingly repeating "Gimme a cigarette, gimme a cigarette." The resident cowers and goes away.

On April 9, he sits in his room, commenting that he's trapped. The seat of his pants is split completely apart, he's not wearing underwear, and the smell is terrible. Allen notes that Richard Smith, the ACT team master clinician, and another ACT member have just left, and that they gave him a cigar (he likes cigars). When asked why he didn't tell the ACT members about his pants, he says he doesn't know why--says he's too weak-minded.

He puts on a dirty trench coat and walks to a local thrift shop, screaming and cursing at the passing cars that make it difficult for him to cross the street. (Allen says that sometimes buses won't stop for him because some of the drivers know him, and he's too much of a burden to have on the bus.) In the store he's confused, belligerent, and nasty, sometimes screaming violently. After considerable effort, he manages to buy a pair of pants. On the walk back to Jefferson House, he says, "I didn't mean to...Um, I didn't mean nothing by..." He fumbles for words, trying to form an apology, and finally winds up quoting scripture to suggest how people should respond to him: "Soft words turn away wrath."

On April 15, Allen is thrown out of Jefferson House. The way Sammy Allen tells it, it was his decision to move. But a manager at the boarding home claims that Allen was "too loud and obnoxious."

For the 26 days Allen lived at Jefferson House, he slept on the same urine-soaked sheets. For 26 days he wore filthy, foul-smelling clothes, and his laundry was never done. Untrained boarding house desk clerks dispensed his medication. And he failed to show up at Parkland for follow-up care on his infected eye because he depended on a desk clerk to coordinate his appointment, which didn't happen. Three weeks later, he still had not been to the eye doctor.

On even the most basic level, there was not even a scheduled time for an ACT team member to meet with Allen at the boarding home. ACT members came by whenever they could and hoped that Sammy would be there. Allen never had any idea when they would be stopping by, and if he really cared about seeing them--which he didn't--he would have had to sit in the boarding home all day until they showed up.

This April 2 entry in an ACT consumer activity log typifies the care Allen received during the time he lived at the boarding house: "Went to see Sammy to monitor progress. He stated that he does not like living @ THE BH [BOARDING HOME] AND WOULD LIKE TO GO TO TERRELL AND REVOKE HIS FURLOUGH. I STATED THAT OUR JOB WAS TO KEEP HIM OUT OF THE HOSPITAL. HE GOT BELLIGERENT AND STATED THAT HE DIDN'T WANT TO SPEAK TO ME ANYMORE. I LEFT AT THIS TIME AND INFORMED HIS CM [CASE MANAGER] OF THE SITUATION."

ACT'S VALDEZ SAYS THAT HIS AGENCY IS LIMITED IN WHAT THEY CAN DO IN A BOARDING HOUSE SITUATION, BECAUSE THEY DO NOT WANT TO INTERFERE WITH ITS DAILY OPERATION. "WE NEED TO BE CAREFUL NOT TO INFRINGE ON TAKING TOO MUCH OF A ROLE," HE EXPLAINS. "OTHERWISE WE TEND TO ALIENATE THE BOARDING HOME PEOPLE. IF WE PUSH A BOARDING HOME OWNER TOO FAR, WE WON'T EVEN BE ABLE TO GET IN THE DARN DOOR."

ALLEN LASTED ABOUT A WEEK AT THE FLORA MOTEL BEFORE BEING THROWN OUT FOR BEING TOO LOUD, ACCORDING TO DEFREECE. FOR APPROXIMATELY THREE WEEKS, HE BOUNCED FROM A SALVATION ARMY SHELTER NEAR PARKLAND MEMORIAL HOSPITAL TO DMHMR RESPITE BEDS (WHICH THE AGENCY MAINTAINS TO PLACE PEOPLE TEMPORARILY DURING CRISES) TO THE STREETS. IN MID-MAY, SAMMY MOVED TO A RUNDOWN SOUTH DALLAS APARTMENT COMPLEX THAT HE FOUND FOR HIMSELF. HE PAID $325 A MONTH, INCLUDING ALL UTILITIES, FOR A SMALL ONE-BEDROOM.

ON A RECENT VISIT, MOST OF THE FLOORS WERE COVERED WITH CIGARETTE ASHES, A BOTTLE OF THUNDERBIRD AND TWO BOTTLES OF WHISKEY WERE IN THE CABINET, AND TWO BARE MATTRESSES WERE PILED ON TOP OF EACH OTHER. ALLEN SMELLED BAD, THE ONE CHAIR IN HIS APARTMENT REEKED, AND HE SAID THAT HE'D BEEN FORCED TO WASH HIS BOTTOM WITH WATER FROM THE TOILET BECAUSE HE HAD NO TOILET PAPER.

SITTING IN HIS WHEELCHAIR, EYES ROLLED BACK IN HIS HEAD FROM EITHER FATIGUE OR ALCOHOL, SAMMY ALLOWED THAT HE HADN'T BEEN TAKING HIS MEDICATIONS AND SAID THAT HE WOULDN'T AGREE TO ANY INJECTIONS. HE SEEMED AMUSED AT THE MERE MENTION OF ACT, CLAIMING HE HAD NO IDEA WHEN THEY MIGHT COME BY, OR EVEN IF THEY MIGHT COME BY. AND HE COULDN'T IMAGINE WHAT THEY COULD DO FOR HIM ANYWAY, BESIDES GIVE HIM A RIDE SOMEPLACE. WHEN PRESSED, HE ADMITTED HE COULD USE SOMEBODY TO TALK TO.

HIS DAILY ACTIVITY CONSISTED OF SITTING OUTSIDE WATCHING THE TRAFFIC GO BY, SMOKING, AND MEDITATING. AND HE STILL WISHED HE COULD LIVE AT TERRELL STATE HOSPITAL. "I WENT TO PARKLAND A ZILLION TIMES," HE SAID WITH A TIRED, RESIGNED LAUGH. "THEY WON'T LET ME [GO TO TERRELL]."

TWENTY-SIX YEARS OF CASE NOTES DESCRIBE SAMMY ALLEN WANDERING THROUGH THE MENTAL HEALTH SYSTEMo threatening, obnoxious, noncompliant, and malingering. What doesn't get recorded is the same Sammy Allen sitting idly at his latest boarding house, garbage bags packed in anticipation of the moment when he'd be thrown out. "I pray to God I stay out of trouble," he muttered, mostly to himself. "I pray for God's mercy that I don't screw up.

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