Scream Dement

Arizona is supposedly booming, a happening place. But for some seriously ill people, all that's happening is the abuse and neglect they're suffering from the people charged with taking care of them.

Beci Johnson is 21 years old. She's been having anxiety attacks since she was 16. Symptoms include agoraphobia, claustrophobia and a fear she can't identify. This year has been her worst. She's often unable to leave her apartment, and sometimes she can't bring herself to take a shower. The latter, she admits with an embarrassed laugh, can last for as long as a week.

She's a qualified auto mechanic, but her illness makes it impossible for her to do the job she trained for. "I try to go for interviews and I can't. Nothing seems real. I don't know what I'm afraid of."

Instead she keeps a roof over her head by working from home as what she euphemistically calls "a telephone actress." The job pays little more than her rent--her phone has just been cut off, so she's working out of a friend's house.

Around the middle of last month, a friend became so concerned about Johnson's inability to cope that she advised her to get help. "I didn't realize how bad she was until I gave her a ride to a job interview. We weren't even two blocks from her apartment before she had a panic attack. She kept saying, 'It's so bright and so open.' Her whole body was trembling and she was hyperventilating. I realized that she couldn't go outside during the day."

The friend gave her the number of ComCare, the agency responsible for care of the mentally ill in Maricopa County. Johnson called the number and explained what was wrong with her. She didn't get much in the way of comfort.

"The lady who answered stressed me out. She seemed like she was in a big rush. She asked me weird questions, like did I like to cook. She almost made me have an anxiety attack. She said they'd call me in July to give me an appointment."

What's she supposed to do until then?
She shakes her head. She doesn't know the answer to that.
ComCare is in financial crisis. The agency's ineptitude has left it more than $7 million over its budget. It has responded by cutting services to 13,000 of its 40,000 clients, and it looks likely that some of its 1,200 staff members will be laid off this summer.

But it would be erroneous to suggest that a crisis at ComCare is the same thing as a crisis among those unfortunate enough to be its clients. In this county, mentally ill people with low or no income live in a perpetual state of crisis.

Compared with others in the same system, Beci Johnson is lucky. She's not actually suicidal, and she's not violent. She has friends, and will probably find a way to survive the next few weeks.

Brian Stevens (not his real name) has been a client of ComCare since May 1991. His mental problems go back further than that--he was diagnosed schizophrenic while still in high school. When he approached ComCare, the agency wouldn't treat him at first.

"They said they were waiting for my SSI to go through--it was just about money," he says. "They had a sliding scale, but I didn't have the money to pay for it."

He finally qualified for treatment eight months later. He says it took ComCare about a year to diagnose him, even though he told the agency about his diagnosis in high school. Before diagnosing him, ComCare tried to get rid of him.

"They wanted to discontinue me as a client because they thought I was malingering. They thought I was overreporting psychotic symptoms--they thought nobody could be that crazy. I had visual and auditory hallucinations, severe mood swings and social phobia. I would spout nonsense and wouldn't be able to stop. I suffered from paranoid idealization--I thought the TV and the government were watching me.

"I requested a change of doctor. They had to go through due process to get rid of me. During that time, I wasn't getting medication--it cost about $500 a month, and SSI only gave me $480, which I needed for food. I went to four different doctors, and finally got diagnosed. Now that I had a diagnosis, they got money from the county to pay for my medication."

But, before diagnosing him, ComCare was willing to prescribe Prozac and Haldol as long as Stevens could pay for it.

Like Johnson, Stevens, now 23, once made a crisis call to ComCare. Unlike Johnson, he felt both suicidal and violent. Like her, however, he was told he couldn't have an appointment until a month later.

"Another time, I went there extremely agitated, cursing and screaming. The receptionists there are cold and unsympathetic--they treat the clients like little kids or idiots. They told me to calm down and stop acting like a child. Finally, a doctor came out, and they just called a taxi and sent me home."

He adds that the receptionists' attitude is the same at every appointment.
Some of Stevens' claims would be comical if they weren't so disturbing. "They made me see a psychiatrist who was working for them for free as part of his community service for drunk driving. He'd show up for our meetings reeking of beer . . .

"When I asked to see my medical records, they refused. They said it was their own private business. I threatened them with the Freedom of Information Act, and they got scared and agreed to give me some but not all. When they gave it to me, they'd blanked out parts of a report written by an outside psychologist they'd sent me to. When I requested the rest of my records, they said I had it all, even though they'd already admitted that I didn't."

Things are better for him now. But he attributes that to his medicine--"Zoloft has worked wonders," he says--rather than to any improvement in ComCare's behavior. "Things have been fine over the past year or so, except that about half of my appointments get canceled because doctors are sick or on vacation or whatever."

When listening to people who are, by their own admission, delusional, you have to allow for exaggeration, or outright fabrication. But it's not just the clients who have horror stories to tell--professionals working in the field paint a similar picture of ComCare as a vicious bureaucratic jungle.

Michael Balch is a social worker and clinical specialist who works with homeless people who are mentally ill. He says that, even prior to the much-publicized cuts in services, it was almost impossible to get ComCare to treat his clients. ComCare apparently doesn't like the inconvenience of dealing with those who are less than functional citizens.

"My clients are usually not on SSI when they come to me, and ComCare won't take them if they're not on SSI. We're supposed to stabilize them, and then pass them on to ComCare--who won't take them if they're stable! What're we supposed to do--take them off their medication?

"Then when they do get accepted, it can take four to six weeks for them to be seen."

Balch wonders how severe a person's illness has to be before ComCare will consider him to be an emergency.

"I had a guy threatening to cut his jugular vein . . . He soaked himself in oil and threatened to set himself on fire . . . And ComCare said he didn't need psychiatric treatment."

The client he's referring to is Angelo White. After 12 years in the mental-health system, White understands that the mentally ill are regarded as second-class patients.

"Medicare will pay for only 190 days of [mental health] treatment in a lifetime," says White. "If you have cancer, or any other physical illness, you get forever. When your Medicare runs out, you resort to the county, whose resources are limited.

"Psychiatrists aren't held to the same standards as other physicians. Doctors can't open you up and then just leave you that way, but psychiatrists can just drop you when the money runs out.

"The American public is being defrauded," White says. "They're paying for services that aren't being rendered. The authorities think they can subcontract their way out of all responsibility."

Lloyd Vacovsky, a case manager for Central Arizona Shelter Services, expresses admiration for some of the individuals who work for ComCare.

"There are good people there," Vacovsky says. "They send an intake worker to our shelter every week, and she's one of the best I've seen. She's very caring." But his view of the agency as a whole is considerably less positive. "The system means that the clients get screwed."

New Times has reported the death of Donald Ellison, a homeless and mentally ill Vietnam veteran who succumbed to heat prostration on the street. Many people believe ComCare's incompetence and neglect contributed to Ellison's death. Ellison was Vacovsky's client.

"After that, I swore I'd never lose another client to ComCare," he says. "He had attempted suicide, and they did nothing. They said suicide attempts weren't enough. What do they want, blood?

"They want good little SMIs [seriously mentally ill] who do what they're supposed to," says Vacovsky. "But mentally ill people, by definition, don't do what they're supposed to do.

"You have to tell ComCare what they want to hear--yes, I'm crazy, no, I haven't used alcohol . . . Sad to say, a mentally ill person is better off coming to the shelter and letting us case-manage them. Accessing ComCare direct is a scary thing, even for us."

But the shelter is for homeless people. Those with a place to live must face ComCare's abuses on their own.

I asked Annette Morrison, ComCare communications officer, about the criticisms leveled by clients and those who care for them. She seemed willing to talk at first.

"Well, what are the criticisms?" she asked me.
When I asked her about the waiting time for crisis calls, her tone became belligerent. Apparently unable to offer defense or justification, she said, "ComCare does not comment to the New Times."

Before I could point out that she was already talking to me, she hung up.
Outrageous though Morrison's behavior is, there's no question that she's in the right job. In her attitude, she personifies the organization she works for--too stupid to avoid being caught in deceit, and too arrogant and mean-spirited to feel the need to explain or apologize.

To understand why even social workers find ComCare "scary," you need only to pay a visit to its emergency provider, the Southwest Behavioral Health Urgent Care Center.

If you call the people at ComCare's crisis line, and manage to be incoherent enough for them to think you're crazy while being articulate enough for them to worry that you might be aware of your rights and able to make a nuisance of yourself if they just blow you off, this is where they refer you.

It's on Thomas Road in Phoenix, and if your taste in entertainment inclines toward gothic horror, it's well worth a visit. The waiting room provides scenes more appropriate to a 19th-century asylum. A man curses and yells while a woman stands in front of the TV, rocking back and forth, moaning and drooling on herself. The show on the screen is Roseanne.

An old woman sits with her family. She seems demented, and doesn't know where she is. The family wants to have her committed, to have her cared for 24 hours a day, but is told that because the woman can't understand what's going on around her, she can't give her consent to it, so there's nothing to be done.

People in so much emotional pain that it seems physical are seen by a nurse, then left to wait, then seen by a counselor, then left to wait some more, then seen by a psychiatrist.

It's not really the waiting time that makes it so heinous--that's the norm in just about any emergency room--it's the attitudes of the staff members. They don't bother to conceal their distaste for the patients.

One nurse, a man, was so aggressive that he frightened people. A young woman thought he might be the psychiatrist she was waiting to see, and was terrified. She sat there like a little kid, nervous and eager to please, her eyes wide behind her glasses. The frames of the glasses were broken, but her clothes were clean and she didn't smell and she wasn't obviously demented, which set her apart from many of the people waiting to be seen. She told the counselor, "There's a man out there being really mean to people. Is he the psychiatrist?" She was told that he wasn't the psychiatrist, but the counselor didn't deny that the guy was mean. As I listened to her tell the story to the friend who was taking care of her, the friend didn't say anything. I wouldn't have known what to say either.

It's easy to defend the behavior of the staff members by saying that their job is stressful. There's no doubt that many of the people they deal with are so sick that they're repulsive. It's hard to imagine anybody wanting to be near such people.

The most revolting thing about them is that you're scared of being like them. When you know that a quarter of the people in this country suffer from mental illness during their lifetimes, and when you know that more than 51 million Americans have a mental disorder in a single year, then you also know it could be you.

You know that if you didn't manage to get up, wash yourself, use the toilet properly, go to work, remember to pay your bills, then you could be there in the waiting room for more than journalistic reasons. There have been times in my life when my behavior probably wasn't much less crazy than that of anybody mentioned in this article. So you don't want to be around those people--you want to go and be normal and sane with your normal, sane friends and colleagues.

But, although you can't blame staffers for disliking the clients, you can and should blame them for making that dislike so obvious. It's a miserable job, but nobody's forcing them to do it.

Some years ago, I told my Buddhist teacher that I felt guilty because I was repulsed by the homeless and mentally ill people I was working with. He said I shouldn't worry. "Compassion is in your actions, not your feelings or thoughts," he told me. "If people need help, it's not important how you feel about them. What's important is what you do to help them. Be repulsed by them--just don't treat them as though they're repulsive."

If people working with the mentally ill can't contain their revulsion and manufacture some compassion and respect, then they shouldn't be in the job.

How did a situation like this--such vulnerable people being so abused--come to be? Starting with $165 million to spend, how did ComCare end up in such a mess? Michael Balch's answer is simple and horrifying. "I could give you story after story of the shameful, disgusting way they throw lives away. $165 million can buy a lot of health care. They chose to pay top dollars to the upper management and hire untrained staff, pay them terrible wages and give them massive case loads they are not prepared to serve."

If you have no money of your own and you suffer from mental problems such as separation anxiety, inappropriate aggression or a tendency to throw yourself out of windows, there is a place in Phoenix where you will be taken seriously and treated with care and respect.

Trouble is, you have to be a dog. At Canine Behavior Services, Trisha Harper works with dogs and their owners to identify and treat behavioral problems. Sometimes she'll prescribe drugs for the dog--antidepressants, antipsychotics, antianxiety--but this is relatively rare. But, after listening to Harper's reasoned, thoughtful ideas as to why dogs have more problems now than they used to, it's clear that this is a county where middle-class dogs receive better treatment than mentally ill people without funds.

--Graham

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