Resistance is Futile

Despite new state and federal regulations, mentally ill Texans are still dying while being restrained by the very people they turn to for help

When Macie Stafford was admitted to Terrell State Hospital in November 1999, he spoke about the inner desperation consuming him. Today, his words read like an eerie premonition of the violent end he would soon meet.

During his intake interview, Stafford lamented that he was broke. He had no job, no sex drive. "And I'm back here," he added, referring to Terrell, where months earlier he had been a patient. "Ain't no way I'm getting out of here alive."

The doctor described Stafford's speech as "fluent and coherent" and observed that his physical health was good. His thought process was "organized," though the doctor noted he "exhibited a poverty of thought" and was at times "oppositional." He assessed Stafford as suffering from "melancholic type depression with nihilistic delusions" and switched his antidepressant prescription. Stafford was admitted to the hospital's K-2 acute care unit, where he was to remain for 90 days under a court order, which his daughter Katherlyn LaGale Walker had previously sought.

Macie Stafford is just one of at least 12 Texans who have died while being restrained in various state institutions since 1999.
Macie Stafford is just one of at least 12 Texans who have died while being restrained in various state institutions since 1999.
New laws are designed to publicly document restraint-related deaths, but Katherlyn LaGale Walker says she has to sue the state of Texas to get the truth behind her father's death.
Mark Graham
New laws are designed to publicly document restraint-related deaths, but Katherlyn LaGale Walker says she has to sue the state of Texas to get the truth behind her father's death.
Attorney Laurance Priddy says no one should die just because he loses touch with reality.
Mark Garham
Attorney Laurance Priddy says no one should die just because he loses touch with reality.

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If Stafford was suicidal then, his demeanor had changed four weeks later when he placed three collect calls to Walker, asking her each time to come get him. It was his last call, on Thursday, December 9, that still haunts Walker.

"He said, 'I want to come home. They're trying to kill me,'" Walker recalls. "I said, 'Be patient. We'll be down there Saturday.'"

At the time, Walker says she couldn't get her 51-year-old father to explain what was wrong. Indeed, nothing out of the ordinary appears to have happened that day, according to the daily progress note staff entered in Stafford's file at 8 that night. "Client remains depressed; has been keeping to himself," it states. "No behavioral or management problems noted."

Shortly after 11 p.m., however, Stafford awoke in his bedroom and turned on his light. A nurse suggested he sit in the lobby if he couldn't sleep. Stafford sat in the lobby without incident for some time between 11:30 and midnight but eventually went back to his room and turned the light on again. He was told to turn it off. He walked back and forth between the lobby and his room, repeatedly turning on the light. Stafford was becoming combative.

The mental health workers at Terrell are trained to diffuse these situations so they don't have to physically restrain patients--using various body holds and, if necessary, tranquilizers, straps and seclusion--to prevent them from hurting themselves or others. The details of what happened to Stafford next are sketchy, but one thing is clear: The training didn't work.

Stafford began yelling. At one point, he lunged at or grabbed a staff member. They put Stafford in a two-man "basket hold," securing his arms behind his back. Stafford began kicking his legs, so they forced him facedown on the floor into a "prone" hold. More staff members (it's not clear how many) arrived and held his arms and feet down. Stafford began banging his head on the floor, prompting staff to grab his head. It is unknown how long Stafford was kept in this position, but at some point he was injected with two rounds of sedatives. Stafford went still.

When staff members rolled him over to check his breathing, they noticed a "faint smell of feces"--a common indication of asphyxiation. If the staff were adequately trained and equipped to resuscitate Stafford, by then it may have been too late: Stafford was likely dead. Some 45 minutes later he was brought by ambulance to a local hospital. His pupils were fixed and dilated, he had no vital signs, and his abdomen was "grossly" distended--he was dead on arrival.

That night, the telephone rang in Walker's Dallas home. "They called me and told me they thought he was having a heart attack," Walker says. The next day, Walker went to Terrell to get a detailed account of her father's death. She never got one. Instead, she left believing he died of a heart attack brought on by natural causes.

"They didn't tell me how he died, what's the cause of death, none of that," Walker says. "They never told us they had to restrain him."

Laurance Priddy, a staff attorney at the Dallas branch of Advocacy, Inc., a federally funded nonprofit watchdog empowered to investigate cases like this, does not believe there was any criminal intent behind Stafford's death. It was an accident, he thinks, but one that should have never happened. Trouble is, deaths like Stafford's are all too common. That's why Advocacy, Inc. is now suing the Texas Department of Mental Health and Mental Retardation (TDMHMR), the state agency that regulates Terrell hospital, hoping to force changes that will prevent deaths like Stafford's.

The litigation is part of an ongoing national campaign led by advocates of the mentally ill who argue that the use of physical restraints is a "medieval" practice that, while sometimes necessary, is relied on as a substitute for effective care, resulting in unnecessary death and injury of society's most vulnerable citizens. Worse, they say, the restraints are still used to discipline difficult patients or simply out of convenience--despite new laws strictly prohibiting that.

Two weeks after Stafford's funeral, a representative from Advocacy, Inc. contacted Walker. The representative gave Walker a portion of her father's medical records, including the autopsy report, which concluded that Stafford died of asphyxiation during a takedown, ruling his death an accident.

Walker had her first glimpse into the real circumstances behind her father's death. She was infuriated. Worse, she was left with unanswered questions about how her father died: Did he really die because he wanted his bedroom light on? What made him believe his life was in danger? Why didn't they get off him before it was too late? Most important, how could he have died at the hands of the very people Walker trusted to help him?

"The way [Advocacy] talked, he was fighting for his life," Walker says. "There's some lying going on."


Mental health advocates had complained about deadly restraints for years, but it wasn't until 1998 that their use became publicly scrutinized. That year, The Hartford Courant published a series of groundbreaking articles that uncovered 142 U.S. deaths in 10 years. The articles estimated the real number of restraint-related deaths each year to be much higher--anywhere from 50 to 150 people--but said that the actual number is untraceable because institutions weren't required to report them and privacy laws stymied outside investigative efforts.

The articles, however, confirmed many of the advocates' complaints, blaming many of the deaths on a lack of regulations governing how and when restraints should be used, as well as an absence of training requirements that emphasize "de-escalation" techniques proven to calm patients down before they need to be restrained.

The newspaper series led to the passage of new federal laws that recognize a patient's right to be free from unnecessary restraints and created public reporting requirements designed to document the problem. The legislation, which took effect in 1999 and 2000, established new rules prohibiting the use of restraints except during emergencies in federally funded institutions. In Texas, the state agencies that regulate those facilities have recently revised their own sets of rules, which mirror the federal standards and began to take effect last year.

Although mental health advocates welcome changes, they argue that the facilities still aren't doing enough to decrease the use of restraints, and as a result unnecessary deaths and injuries are still too common. Stafford's death, for example, is one of a dozen restraint-related deaths that Advocacy, Inc. has recorded in Texas since 1999.

"If [Terrell] had followed their own rules, this shouldn't have happened," Priddy says, adding the case goes beyond questions about rules and encompasses broader treatment practices used in state hospitals. "There is an atmosphere of animosity that does not contribute to a therapeutic alliance between the clients and the staff. Instead, it exacerbates the conflict, despite the rules."

Others who care for the mentally ill say the new regulations aren't an effective tool to prevent deaths and injury. Various professional medical lobbies complain that the regulations are so specific they strip doctors of their ability to exercise individual judgment while bogging them down with paperwork. Others worry the new public reporting requirements will lead to an increase in lawsuits, which will only drive up costs in a system that virtually everyone agrees is under-funded and already unable to keep good employees on the job.

Katie Stavinoha, a TDMHMR spokeswoman, says she can't comment on the Stafford lawsuit (nor would officials at the Texas Attorney General's Office, which is handling the litigation). Generally, Stavinoha and other state officials say they effectively regulate the use of restraints. They also say they had been training their employees in de-escalation techniques long before the law required it.

Indeed, there is no shortage of rules pertaining to how restraints are used. In addition to the federal regulations, each state regulatory agency in Texas now has numerous, complex rules. They cover virtually every aspect of restraints, from how long patients can be held to the exact amount of time a facility has to call a doctor and fill out all the appropriate paperwork.

What the rules don't do is effectively address what employees should do to prevent the use of restraints--beyond requiring them to receive training in what caregivers call de-escalation, says Nestor Presas, a staff investigator at the Dallas branch of Advocacy, Inc. The organization is the designated agency in Texas under the national Protection & Advocacy system, which Congress created in 1975 to guard the interests of physically and mentally disabled people.

"We have techniques and technology to bring down a wild elephant without stress, yet when a fellow human being has lost touch with reality, we still think the best way of dealing with that person is to have six burly guys jump on him," Presas says. "We know what causes aggression. We don't seem to have an updated response to those situations. Instead, we keep addressing them in a way that is basically medieval."

The situation is not the result of a lack of good alternative options, says David Mandt, a Richardson businessman who created the "The Mandt System," an internationally recognized training program that focuses on de-escalation techniques. When he developed the system in the 1970s, Mandt says he based it on the principle that every patient has a right to be treated with dignity and respect.

"I thought, 'If my child was mentally retarded or had a developmental disability, how would I want him treated?'" Mandt says.

To Mandt, the problem with many of today's training programs is that while they may claim to address de-escalation techniques, they put too much emphasis on takedowns and cling to the idea that pain is a reasonable tool to use on unruly patients.

"We don't teach pain compliance. We don't teach takedowns," Mandt says. "The patient's natural reaction to that is to resist, and that's where most people get hurt. Once you're on the ground, everybody piles on."

In his experience, Mandt says, few patients are intent on causing injury when they become aggressive. But because of their illnesses, they can't effectively communicate their problems with mental health workers. So they act out.

"All behavior has meaning," Mandt says. "What we have to do is figure out what that behavior means."

To do that, Mandt says the first thing mental health workers must learn how to do is control their own behavior when tensions rise. Then, they need to learn how to stay relaxed so they can keep their patients relaxed. Everything they do, from their body posture to the tone of their voice, is an important part of the process.

Say, for example, a patient doesn't want to eat his dinner because it's hamburger and he doesn't like hamburger. Instead of asking why the patient isn't eating, workers will too often exert their authority over the patient, ordering him to eat or depriving him of dessert as punishment. It becomes a battle over who has control, and violence ensues.

"When do we empower people and allow them to make some of their own decisions?" Mandt says. "We're telling them when to get up, when to go to bed. The way we treat people sometimes, I don't know, it's just weird. People die over stupid stuff."

Peggy Perry is the assistant director of state mental health facilities at the Texas Department of Mental Health and Mental Retardation. She could not speak about Macie Stafford's case because of the litigation, but says the restraint-training program the state created in 1980 works well, though it has required some tinkering over the years.

"Early on there was some criticism that when people got through with training they were ready to go out and take somebody down," Perry says. "In recent years, there's been a lot more emphasis on prevention."

Today, all state employees who deal with patients have to complete annual "competency based" training, meaning that instead of just completing an exam they have to demonstrate that they can handle an emergency situation. When restraints are used for real, Perry says, the employees involved, their supervisor and the patients themselves together discuss what happened and how the situation can be avoided in the future.

Perry says the steps are working. In the first quarter of 1997, for example, the department recorded 5.75 seclusions per 1,000 bed dates. In the first quarter of 2001, that number had dropped to 1.4 per 1,000 bed dates. The number of restraints the agency recorded in the same time period also dropped, from 4.26 to 3.31.

For her part, Perry agrees that the unit rules at places like Terrell are sometimes restrictive, but she says the state has become more enlightened about the importance of relaxing them.

"In the past it was like, 'Take your meds!' Now it's like, 'OK, you don't have to do that right now,'" Perry says.

Advocacy's Presas, who spends much of his time interviewing clients at Terrell, says he has seen a decrease in the number of restraint-related injuries there, but he says Stafford's case shows the state still has a long way to go.

"They tell you when to get up, when to eat, when you can smoke, when you can watch TV. The atmosphere is very punitive. I have clients there that have enough money for a cell phone and not once have they been able to keep it--staff always finds a reason to take it away," Presas says. "The fact that a death like Mr. Stafford's happens is a clear indication that something drastic has to be done. It's a total betrayal of trust that people have in this state agency. It shouldn't happen. One dead is just too many."


Deaths as the result of restraints occur at all types of facilities, from state hospitals and group homes for the mentally retarded to nursing homes, but Laurel Ridge Hospital in San Antonio keeps finding itself at the center of the controversy.

Laurel Ridge is a subsidiary of The Brown Schools, a Nashville-based corporation that was founded in Texas in 1940. Today, The Brown Schools is one of the largest privately run companies in the nation providing mental health care services for youths. Laurel Ridge is a long-term residential treatment center that accepts kids from all over the country and relies on Medicaid to pay for their care.

Located on an open campus just outside the city, Laurel Ridge has the appearance of a state-of-the-art home for troubled youths. The main building boasts stucco walls and smooth arched doorways, while a gracious red tile roof completes the Spanish look. Set beneath a dense collection of shade trees, the place looks like a Southwestern oasis.

It was behind that neat exterior where 16-year-old Roshelle Clayborne died four years ago. Officially, Clayborne died of natural causes, the medical examiner pointing to a bad heart she had inherited from her father. But there was nothing natural about the way Clayborne died.

Known to be a "hell-raiser" who was routinely restrained, Clayborne was put facedown in a prone hold after she attacked staff with a pencil on August 18, 1997. Clayborne complained she couldn't breathe, but staff ignored her and shot her full of Thorazine. They stood around and watched as Clayborne lost control of her bowels and grew still, blood trickling from her mouth. Later, they rolled her onto a blanket and dragged her into an 8-by-10-foot seclusion room, where she died alone.

Clayborne's death, exposed in The Hartford Courantseries, was investigated by the Texas Department of Protective and Regulatory Services (TDPRS), the state agency that regulates treatment centers for mentally ill youths and that for years has sent children who become wards of the state to Laurel Ridge for care. The department cited the facility for numerous rules infractions, concluding that the restraint used on Clayborne was improper and carried out by mental health care workers who were inadequately trained and supervised.

Instead of shutting the place down, the department placed Laurel Ridge on a year's probation after it promised to make improvements. The facility successfully completed probation in December 1998 and is currently licensed, though TDPRS no longer sends its own kids there for care.

Today, Laurel Ridge is under new management and claims that it has stepped up its training programs and drastically reduced the need for emergency interventions, says Sherry Thornton, the chief operating officer of The Brown Schools.

"We really focus on de-escalation techniques. In the two and a half years I've been with the company, it's been our main focus," Thornton says, adding that the use of seclusions in particular has declined. "We have some facilities that are totally seclusion free. We don't use it at all."

Thornton, however, declined to release any specific information documenting how much the corporation's use of restraints and seclusions has declined. When asked what specific procedures Laurel Ridge has changed since Clayborne's death, Thornton says she doesn't know because she was not around at the time. "I've only been with the company for a couple of years," she says.

San Antonio attorney Tim Maloney doesn't believe Laurel Ridge has changed the way it treats its kids because 9-year-old Randy Steele died there just last year--after he was restrained in the same manner as Clayborne. Maloney is representing Leonard and Holly Steele, Randy's parents, who sued Laurel Ridge for gross negligence last fall.

Laurel Ridge representatives refused to discuss the case, except to note that Steele's death was ruled to be a result of natural causes and that state investigators have already cleared the facility of any wrongdoing after they investigated the matter.

Whether Laurel Ridge is negligent in Steele's death is a question a jury may soon weigh; the case is set to go to trial in February. Still, Steele's death illustrates that the treatment of the mentally ill hasn't advanced very far. It suggests that, despite new regulations, some patients--particularly children--are still regularly restrained, sometimes on a daily basis.


Randy Steele had always been a very sick boy.

His mental illness emerged at age 2, when he was diagnosed with attention deficit hyperactivity disorder and put on medication. As he grew older, his condition worsened. He set fires and threatened to kill himself. He hit his parents. He hit other children. His teachers couldn't control him. Neither could his parents. He rolled in and out of various treatment programs, where he was only given more drugs.

Randy didn't want to stay at Laurel Ridge, a point he communicated by repeatedly kicking his father on the day he arrived in January 2000. By then, the boy was taking four medications, including lithium and Thorazine, and his behavior was uncontrollable.

The past efforts to medicate Randy's illness into submission were clearly not working. The Steeles put Randy in Laurel Ridge, hoping they would find some other way to help their son.

Despite its name, Laurel Ridge is not a hospital. In fact, it does not pay to keep a single medical doctor on site. Instead, mental health workers who are not required to have any medical training run all but one of its dormitory-like units, to which patients are assigned depending on their age, sex and the level of care they need.

Randy Steele was assigned to the San Saba unit, a so-called "medical model" unit, unique on campus because it is the only unit in which there are nurses on duty 24 hours a day. It is reserved for kids like Randy whose conditions are acute.

Randy's behavior didn't change while he was at San Saba. Day after day he got into fights with other students, and he constantly broke the rules. One day he was restrained twice--once for throwing a chair and twice because he became "aggressive" after he refused to eat his lunch and was denied dessert. He wet his pants so often his alternative set of clothes was constantly being washed. At one point, Randy's lithium was increased so much it went outside the normal limits and had to be reduced.

From their notes, which Maloney discovered as part of his lawsuit, the staff didn't know what to do with Randy--beyond altering his medications, physically restraining him and placing him in locked seclusion.

During his first 10 days at the unit, Randy was restrained almost every day--a routine that continued unabated throughout his stay at Laurel Ridge, according to the testimony of Dr. Robert Demski, Randy's attending physician who was deposed as part of the lawsuit. Demski has worked on a contract basis as one of Laurel Ridge's primary psychiatrists since the facility opened in the late 1980s. During the deposition, Maloney asked him whether the frequency with which Randy was restrained was unusual for the kids on that unit.

"No," Demski responded.

"What does that tell you?" Maloney asked.

"We've got a lot of sick kids."

"What's that tell you about the individual kid in terms of therapy, treatment?" Maloney pressed.

"Well, it tells me that I need to keep working on the medications, changing them or giving them more time to kick in."

Demski periodically met with Randy during his stay at Laurel Ridge, but he testified that he didn't give Randy any individualized psychiatric counseling and he mostly relied on the nurses and mental health workers to keep him apprised of his progress. He did the same for all the kids under his wing at Laurel Ridge.

"I did not do therapy," said Demski, who resigned not long after Steele's death. "I simply prescribed medications, evaluated diagnoses to make sure they were correct and evaluated the results of the medication."

Because it is a medical model unit, San Saba is more expensive to run than the other units at Laurel Ridge. Typically, Medicaid only authorizes children to stay there for up to 28 days. If a child's status is still acute when those days are up, however, the facility can appeal to Medicaid with a request to keep the child there. On February 4, 2000, Randy's 28 days were up, and he was promptly transferred to a "stepped-down" unit--a decision Maloney says cost him his life.

On the very day Randy was transferred, he was physically restrained and given a shot of Thorazine to calm him down. Despite the behavior, the facility made no attempt to keep Randy at San Saba. In his deposition, Maloney asked Demski why. "Didn't feel it was necessary," Demski said. "The appeals take weeks, if you get it." When asked directly if the decision to transfer Randy was a financial one, Demski pointedly told Maloney he should ask the Medicaid office.

During the deposition, Demski didn't try to mask his disdain for the various rules and regulations he had to comply with at Laurel Ridge. At one point, he was asked why the San Saba unit had nurses on it but the other units didn't.

"The patients themselves were not that different in many ways, but you have a morass of regulations put out by the federal government, by the state, by other agencies that you have to comply with. It's a very difficult thing," Demski said. "So in doing that we would cover all the bases, make sure that we had the proper people in place, and a lot was to satisfy the demands, be they reasonable or not, by various agencies which sent us these patients."

The rules and regulations didn't require Laurel Ridge to keep a medical doctor on site. Nor did they require nurses to be always present on the San Gabriel unit, where Randy was transferred. If they had been there, Randy might still be alive today: The nurses at San Saba restrained Randy some 25 times in 28 days, but he was never once injured. Once in the hands of San Gabriel's mental health workers, however, Randy survived just two days.

Sometime on the afternoon of February 6, Randy had to be physically restrained, during which he was given a shot of Thorazine. It was in the aftermath of that restraint that he suffered his final takedown. It happened around 3 p.m., just as the second-shift workers were clocking onto the job. One of the oncoming workers, Cathy Rodriguez, noticed that Randy had wet his pants again and told him to go change his clothes. Randy didn't because he had no clean clothes. Rodriguez ordered him to take a shower, telling him she'd bring him some clothes.

On his way back to his room, with Rodriguez on his tail, Randy went into the group room and began running around. Again Rodriguez ordered him to his room. He started throwing books and toys. When Rodriguez tried to "escort" Randy to his room, he lashed out.

Rodriguez put him in a basket hold, forcing him to sit on the ground. Later, her colleague David Spicer came in and held Randy's feet. Together, they flipped the wriggling boy onto his stomach and held him facedown on the floor. That's the prone position, the same one used on Clayborne and which became illegal under new laws just months later. Randy began to hyperventilate. At one point he screamed out, "I can't breathe."

"We sat him up, checked him," Spicer said in his deposition. "He was breathing, talking, yelling, cursing. OK, he's breathing, you know, back down he went."

They held him there for more than 20 minutes, at which point they heard him gasp. Rodriguez lifted Randy to his feet.

"I noticed some liquid coming out of the corner of his mouth," Spicer said. "Cathy then called out his name, 'Randy.' He was unresponsive. She laid him back down on his back, and she checked for a pulse, and we had a pulse, but we had no breathing."

Apparently, Randy had vomited. Rodriguez swept Randy's mouth with her fingers to check his air passage and began slapping his back. She then attempted CPR, blowing into his mouth and pushing on his chest. Spicer, meanwhile, had no idea if what Rodriguez was doing was correct. "I'd never seen anybody perform CPR before."

Worse, according to Maloney, Rodriguez had never performed CPR before. As a result, Maloney contends, Rodriguez and Spicer were totally unprepared to determine whether or not they were putting Randy's life in jeopardy.

"It is utterly and completely indefensible from a moral or legal standpoint not to provide nursing care for each unit around the clock," Maloney says. "To suggest that a mental health care worker is capable of assessing the physical health of a child is reprehensible."

Randy was taken by ambulance to a local hospital where he was pronounced dead.

When asked whether Laurel Ridge should employ a doctor to be on site 24 hours a day, The Brown Schools COO Thornton pointed out that rules governing staffing don't require it. Besides, she doesn't see the point.

"The patients are not there for medical problems. To have an internist or something there wouldn't be needed," Thornton says, adding, "We're not a medical hospital."

Like Roshelle Clayborne, Randy Steele's death was ruled to be the result of a heart attack brought on by natural causes. As far as Laurel Ridge is concerned, Randy's death was an "act of God," according to the answer the facility's lawyer filed to Maloney's lawsuit. Alternatively, the facility is arguing, Randy's death is his own fault. The injuries he sustained, they say, are the result of "pre-existing medical or psychological conditions or disabilities that are in no way the responsibility of" Laurel Ridge.


As in the Clayborne case, attorney Maloney says a lack of adequately trained workers contributed to Steele's death. Specifically, Maloney says Laurel Ridge follows a morally bankrupt treatment program in which it relies on entry-level workers, instead of doctors and nurses, to care for children who are so sick they can't function in mainstream society.

But Maloney is not an advocate for more rules. "This industry already is regulated to death. Staffing is the scandal of these places."

Maloney's arguments echo what most mental health advocates, including health care providers, say is the root of the problems relating to restraints: Facilities can't or won't keep enough quality workers on the job. Instead of treating its patients' illnesses, they simply medicate and warehouse them.

Peggy Perry, the woman who oversees the state's adult psychiatric facilities, won't dispute that she has trouble with staffing. At TDMHMR, Perry says she is constantly battling high turnover rates--particularly among nurses, who in the past five years have left the agency at an average rate of 36 percent a year.

While Laurel Ridge is a for-profit corporation, TDMHMR is dependent on state lawmakers for money, and, historically, they haven't given enough of it to help people like Perry offer competitive salaries. The problem has been exacerbated as the state's economy boomed and workers were in short supply. State lawmakers did provide some rare relief when they recently voted to give all state employees a raise; they even increased the salary rates for their mental health workers. Still, the pay for an entry-level mental health aide at TDMHMR is just $1,423 a month.

"It had gotten to the point that in most areas folks could go to McDonald's or Taco Bell and almost make more money working there," Perry says.

Fort Worth Senator Mike Moncrief, one of the mentally ill's best advocates in Austin, has been trying for years to pass restraint-related legislation, among other efforts on behalf of the disabled, but his efforts never seem to get past the Finance Committee. Today Moncrief fears his colleagues have missed their window of opportunity: They failed to pass more funding for social services programs when times were good. Now that the economy has turned south, Moncrief is dreading what'll happen next session.

"We have painted ourselves into a corner. We have not kept up with the growth of the state and the demand that places on our social services," Moncrief says. "We need more eyes and ears telling us what's going on in these facilities, not less. We need to pay those providers a commensurate rate of reimbursement for their services. We need to pay our doctors on time. It's a huge financial issue."

The end result, Perry concedes, is patients really don't get any effective treatment--especially at places like Terrell, where they are simply kept until their medications kick in and they no longer appear to be a threat to themselves or others. Then they are sent away.

"The most effective thing we do is psychoactive medications," Perry says. "That's probably the most important treatment intervention we have."

Medication is about all Macie Stafford got when he wound up back at Terrell in November 1999.

Stafford had been there once before, committed in December 1998 and released the following May. While he was there, he was diagnosed with neurosyphilis, a disease that had reached its heyday before World War II when it filled the nation's mental hospitals with victims. They commonly died in a state of dementia after the disease robbed them of their ability to remember and left them sinking in despair.

In between his commitments, Stafford occasionally stayed with his daughter, Katherlyn LaGale Walker. She thought he had "syphilis," the early stage of neurosyphilis, and says she never really understood what was wrong with her dad. When he was acting OK, he'd spend his time fixing cars at various garages, where he would also sleep. When it got cold, he came home.

"I was trying to make sure he was taking his pills and stuff," says Walker, who also took him to and from the local MHMR facility where he got his medications. "They would ask him a couple of questions, refill his medications and send him off."

That fall, Stafford started acting like he wasn't OK. Walker knew he was really off when he failed to fix her car. He was becoming increasingly disoriented. He didn't know what year it was. One day he was cooking spaghetti and cornbread together. Then he started leaving home for days at a time. Invariably he'd call Walker and she would bring him home. Walker would probe him to see if he was still taking his medications.

"He'd say, 'I ain't no child,'" Walker says. "I'd have to tell him to take a bath. I'd tell him to change his clothes. He'd get mad. He didn't think about nothing like that. All he thought about was fixing cars."

Then one day Stafford asked Walker if she would drive him somewhere. It was cold out and Walker said no, told him he should stay at home. He left. Walker didn't go after him. After all, he was a grown man.

Dallas paramedics later found him lying on a street, claiming to be "non-existent." They took him to Parkland hospital, and from there he went back to Terrell. When Stafford got there, the doctor asked him if he felt like killing himself. "Why not?" Stafford replied. "I'm dead anyway."

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