Counselors Help Mental Patients Cope With Daily Life on the Edge

It was only 8 a.m. and Bill Peck was already sweating. He had just dialed the home phone number of a woman he had hoped to check into a psychiatric ward by nightfall.

“No one is answering. That’s not a good sign,” said the Los Angeles County social worker.

In a previous visit, Peck had noticed that the young woman had begun chattering about the devil again. She was incontinent. Both were ominous signs for a woman with a history of trying to hurt herself with hot water, cigarette lighters and stove burners.

By nightfall, Peck had located and counseled her. But in between there were several other mentally ill clients that day needing his attention: there was the delusional man in love with singer Joni Mitchell, a volatile young mother whose baby had been taken away and a frightened middle-aged man locked in a mental ward.

New Ways of Helping

They are among the San Fernando Valley’s most severely mentally ill--those who will never completely escape their difficulties. But the county is providing a new way of helping them lead their lives as independently as possible.

A year ago, the county’s Department of Mental Health kicked off a pilot project in the Valley to identify and give extra attention to the heaviest users of its services. Four veteran mental health workers crisscross the Valley most days to visit with 80 or so clients in the program. They serve as confidants and go-betweens with landlords, doctors, bill collectors and others in the outside world.

The program’s average 20-person caseload for its social workers is far lighter than that of their colleagues, who must keep track of as many as 60 to 80 clients.

“We’re their mother, their father, their friend,” explained Peck, who makes his rounds in an aging orange Volkswagen bug with a leaky roof.

The intensive case management program, as it is called, is the first of its kind in Southern California. For county officials, it serves a dual purpose. Officials hope that the added investment in this select group of the neediest mentally ill not only will improve their lives but will save money and hospital bed space.

Mental health administrators had grown concerned that a small percentage of troubled individuals had been costing the county millions of dollars, primarily for hospital stays. For many of these people, the return rate to state and county hospitals--their second homes--was dizzying. Before entering the pilot program, one former short-order cook in his 30s had been hospitalized 39 times.

The experiment so far has lived up to expectations, county administrators said in recent interviews.

“The whole idea of the program is to see if there isn’t a better way to serve this population. It seems it is certainly working,” said Ken Miya, the program’s project director. He attributed the success to the clients knowing that people who care about them are willing to help however they can.

Hospitalization Figures

His yardstick is the latest set of figures on the number of days the program’s enrollees are spending in hospitals. Before the program’s start, 71 future participants had stayed a total of 4,383 days in county or state mental wards during the 1986-87 fiscal year. During the experiment’s first 10 months, however, the same group spent just 687 days in a hospital.

That decrease meant the county paid $120,000 for hospital stays during the program’s first 10 months, compared to $635,000 paid for hospitalization during the 1986-87 fiscal year, Miya said.

Several of the clients said during recent interviews that they are deeply appreciative of the extra attention the program’s social workers provide.

One of those was John, whose deep depression is such a constant in his life that his social worker cannot even classify it as recurrent.

“I feel it is the best thing the county has done,” said the middle-aged man, on the verge of tears. “I don’t feel lonely. I feel the county is protecting me. I need that. I need that very badly.”

County Prototype

The experiment has served as a prototype for the countywide mental health system. But with funds for the county’s mental health network evaporating, the program’s future remains clouded.

The fate of every program is “up in the air,” said Roberto Quiroz, the director of the county’s mental health department. But he said, “When the dust clears, I think case management with the focus on the severely chronically mentally ill is the way we’ve got to go.”

The experiment began when a county computer was enlisted to identify the Valley’s most dependent mentally ill clients. The criterion: those who had generated the biggest mental-health care bills in 1986-87.

The computer extracted a pool of 1,530 from the Valley, Glendale and Eagle Rock who had used county mental health services the most. From that list, caseworkers started contacting the top 100 or so individuals to see if they would be interested in participating.

Compiling the list turned out to be simple. Finding those on the printout and then persuading them to participate was trickier. Some didn’t have permanent addresses--a few lived in cars, parks or on the streets. The social workers located some when police dropped them off at emergency rooms after they had caused public disturbances during psychotic episodes.

The responses of some who were approached, recalled Linda Graul, the project’s supervisor, was: “Who the hell are you? Get out of my face.”

The typical participant is white, between ages 26 and 45, and living with family or in a residence. About half are males, half females.

A small, idealistic staff started what they call their “missionary work” last April. Since then, the county’s financial woes cut the program’s staff in half to four caseworkers. Later, the full-time psychiatrist was reassigned elsewhere three days a week. After that happened late last year, the clients’ rate of hospitalizations in state institutions jumped almost 400% during a period of four months.

But despite the setbacks, the staff members said they remain committed to their clients, who oftentimes are estranged from family and friends whose patience dried up years ago.

“I go home at night and I’m exhausted. It’s like having 20 children,” said Lenore Lewis, a county social worker. “The rewards are small, but you get very excited when someone makes even some little progress.”

Just the week before, one of Lewis’ clients, who thought she was Joan of Arc, took one of those small steps forward. Lewis kept a close eye on the woman until she could arrange for the staff psychiatrist to see her. The woman called Lewis two hours after she saw the psychiatrist and received new medicine.

“She was so excited; the voices had lessened,” Lewis said. “She could deal with her own thoughts.”

Psychiatrist in Charge

The psychiatrist who takes care of the group’s medical needs is Dr. Paul Joseph, 35, who looks more like a Hollywood screenwriter than a doctor. The bearded physician, who wears a blue-jean jacket, a Swatch watch and fabric bracelets, quit his private practice to work with the homeless on the Santa Monica beaches a few years ago. He is apparently the only county psychiatrist who makes house calls, Graul said.

The caseworkers have relied heavily upon Joseph to prescribe drugs because almost all their clients require medication. Most are taking six to eight drugs, and the wrong mix can be disastrous.

Suzy, for instance, entered the program with a set of prescriptions she had received at a hospital, but her behavior remained bizarre. Twenty times a day she was calling her caseworker, Sue Melton, telling her she was fired and then rehired.

Joseph was summoned, and he prescribed a better combination of medications. Suzy’s calls stopped, and he gradually weaned her off all medication. Today, Suzy is working at a yogurt shop and doing volunteer work.

Salvaged Furnishings

The small staff meets frequently in their North Hollywood office, which is furnished with salvaged furniture and just two filing cabinets. Together, they provide moral support and brainstorm. Creative solutions are sought for the endless string of “what now?” dilemmas that come with the job.

Some of caseworkers’ approaches seem surprisingly simple. What for instance, can be done to prevent the deeply depressed person from trying to overdose with the medication in his bathroom cabinet? One tactic that has been tried is asking the client to sign a suicide contract promising not to kill himself before the next counseling appointment. So far it has worked.

Vangie Montalvo, a bilingual caseworker, once resorted to an Old World “cure” to help one of her deeply troubled clients. The client, a 19-year-old woman who hears voices, would frighten her family by uncontrollably twisting her body in grotesque ways, Montalvo said. Complicating matters, the teen-ager had developed an adverse reaction to drugs that might have helped--something that normally doesn’t develop for 30 or 40 years.

The Latino family believed that the teen-ager was the victim of a curse placed by one of her mother’s co-workers. Montalvo didn’t try to argue with the parents, and her suggestions for the daughter’s care were largely spurned.

Family Counseled

So Montalvo turned to a social worker at Metropolitan State Hospital in Norwalk who works with the superstitions of recent immigrants. He counseled the family using mainstream therapy methods, but also performed an exorcism, which seemed to improve the girl’s condition, if only slightly.

His advice to the family, Montalvo said, was “the same things I was telling them for months and other therapists have told them for years.” “They were able to hear it from him and accept it from him much more readily.”

Bill Peck had his own challenges awaiting him the day that began with his telephone call to the potentially suicidal woman who had delusions about talking to the devil.

One of those challenges was curled up in a chair and chain-smoking when he reached the door of her townhouse in Van Nuys. Like most of the clients, Claire, a bright young woman, cannot work because of her disability. Her infant child was taken away seven months earlier after social workers feared that the baby might be harmed.

Claire had been in a fury the night before, after her first day of classes at Pierce College. She thought the strangers in her class didn’t like her and were trying to humiliate her.

Questions About Child

She became subdued when Peck asked about her baby.

“Do you know what you want to do with Joey?”

“I don’t know.”

“How do you feel about him not being here?”

“I don’t know. I don’t want to give him up because I don’t know.”

In one of her more candid moments, Claire, who had been struggling with whether to give up the baby to adoption, said: “I have no mothering skills. I feel awkward around him.”

When Peck started to go, Claire bummed a dollar from him for gas for her car, showing him a coin purse that held only 78 cents. With no money, she said, she had been “ripping Ralphs off on a regular basis” with bad checks.

She did say, however, that she hoped things would improve when her husband got his next paycheck more than a week later.

Peck’s next stop, the mental health staffers agree, was one of the program’s shining successes. Before Peter joined the program, he would wander away from the various board-and-care homes where he lived, only to return hours later, sunburned with feet that were bloodied, apparently from walking miles barefoot.

Frequent Hospitalizations

Peter’s greatest wish was to get his own apartment. But his 39 hospitalizations and compulsive spending had made that unlikely, Peck said.

Peck eventually arranged for the move to an apartment, however, and visited Peter every day for months to make sure things went smoothly. Peter has remained out of the hospital and in his immaculately kept studio apartment in Van Nuys for almost a year.

“When Bill comes by we have a little thing going,” said Peter, who had become more paranoid in recent days. “When Bill’s in my house, it turns into a psychiatric unit.”

It was harder for Peck to be optimistic about the next client he visited at Glendale Adventist Medical Center. John, a newcomer to the program, had no friends or family and often talked about starting his life over again--his code words for suicide. He was scared that he would be trapped in the hospital forever.

“My worst worry at this point, I have to be honest with you . . . is they aren’t planning to let me go,” John, clad in pajamas and slippers, told Peck.

Peck assures John that he is wrong. And in a soft voice he tries to cheer him up. He tells him that he looks better since he lost some weight and that his hospital room is much nicer than those at the state mental hospital in Camarillo. Peck leaves, reassuring John that he will let his landlord know where he is.

When he walks out of the hospital, Peck resumes thinking about the suicidal woman he needs to find tonight. And he remarks, “Well, you’ve seen a typical day.”