Lost, Found and Lost again

A tale of psychosis

Marijuana and Methamphetamine notoriously produce psychosis. Psychosis in general, schizophrenia in particular, are difficult diagnoses to manage on a good day. Particularly when we have limited resources to do so.

As I thought about this, I remembered a story from earlier in my career.

“What kind of mother would I be if I left my son here and went home?” Reba asked me this with tears in her eyes. In the midst of a busy shift in the emergency room, it was a question I could not answer. Her son Jacob, in his twenties, was schizophrenic. He had wandered to our rural South Carolina county over hundreds of miles. His mother thought he was dead since he had been missing for months.

The police notified her that he was in custody for some minor offense, so she came cross-country by bus to a nearby city, then by taxi to our hospital . She tried to pick Jacob up when he was released. He refused to go with her, but came to the hospital in a police car. I suppose he came to me because she asked him to, or because the police officers suggested it.

“He needs help,” his mother said. “He needs to be committed and get help!” I talked to him. He was calm, not suicidal, not violent. I don’t even think he was hallucinating. I spoke with the mental health case worker on call. South Carolina had (and has) little money for mental health patients who are dangerous, much less those who aren’t. The case worker said that Jacob didn’t meet the criteria for hospitalization. He couldn’t be forced to stay if he weren’t an obvious danger to himself or others.

In a kind of dark irony, it would have been much better for everyone if he were.

I told his mother the score and she rolled her eyes, then fell back into her chair. “What am I supposed to do? I have to go back to work. I’ll lose my job! I can’t leave him here!” I tried to explain that I couldn’t force him to stay. The law was just as rigid about that fact as anything else. It’s a fine line. We don’t want it to be too easy to commit patients against their will.

At the notorious Trans-Allegheny Asylum in WV, in the 1800s, men could simply drop off their wives and children and assert that their women were insane. They were trapped. The hillside across from that sorrow haunted building is filled with unmarked graves of those who were, or were not, in need of confinement.

This sort of thing has happened too much down the years. So yes, there are rigid safeguards.

Maybe too rigid.

Jacob’s mother was firm: “Well, he needs to get on the bus and go back home with me. That’s it.”

We discussed this with Jacob. He laughed and looked up and down. He stared into his hands. He stared into whatever space, whatever reality was ‘real’ to his wandering mind.

Every time that she asked him to go with her, he said no. She pleaded. She tried to speak gently. She tried to be rational. She tried to be firm.

She cried.

In the end, we released him. I talked to her about outpatient mental health care. I was going through the motions. It was all pointless, really. Unless she would succeed in her attempts to convince her wandering child. Unless he would get in the taxi that we called, ride the 40 minutes to the bus station and go home with his mother.

The taxi driver came. Reba begged her son again, over and over. She pulled on his arm. She tried to force him into the cab. She failed. There was nothing we could do.

Physicians, nurses and deputies with years of experience intervening in lives, and we were powerless. Jacob walked into the night with no ID, no home and only the clothes on his back.

His mother shook with sobs as she left. She knew that it might be the last time she would ever see her baby. He would wander the land homeless and frequently confused. The next phone call might be the worst of all. Homeless schizophrenics get pneumonia, die of exposure, are murdered, walk in front of cars, develop HIV. The list goes on.

His mother wasn’t a physician, but she didn’t need to be. She knew the score.

I’ve thought a lot about them since that night. I wonder if I’ll see Jacob again. I wonder if he has moved on, east toward the coast or up to North Carolina. Maybe off to the labyrinth of Atlanta which, like New York City, could hide someone for a lifetime. I hope and pray he survives. For his sake and his mother’s.

It all illustrates a difficult point in medicine and society at large. For all of our good intentions, we have limited capacity to fix lives. We can treat diseases. We can cure some of them. We can treat lives; we can cure very few.

The swirling cyclone which spins together drugs, mental illness, crime, homelessness and substance abuse is a storm that did not blow by, but parked atop our nation. And for decades, that cyclone has rained suffering and chaos.

At an unfortunate nexus of medicine, law, ethics and economics there is a blind spot, where some are simply outside of our collective reach. It’s a reality that takes years to absorb, but it’s the hard truth. Some people will just wander away no matter how much we want to help.

For all of our science and good intentions, all we can do is whisper a prayer as they go.