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Breakdown: Difficult decisions in a void

This story is the fifth in a series about mental health care in North Carolina. To read the previous stories in the series, go to www.carrborocitizen.com

By Taylor Sisk
Staff Writer

The decision to institutionalize or forcibly medicate a loved one suffering from mental illness is clearly very difficult. Balancing the desire to protect that person from harm against the wish to respect his or her free will is a delicate, imprecise calculation, particularly when the loved one is an adult. Opting for involuntary commitment or forced medication requires faith that sustained, comprehensive care will be available.

But families in North Carolina are losing faith. Because beds and services for long-term care are all but nonexistent, those most critically in need are increasingly becoming the most neglected.

“The hospitals are too busy,” says Carol VanderZwaag, a psychiatrist at XDS Inc., a nonprofit mental health care provider in Chapel Hill. “The stays have gotten ridiculously short, and the rehabilitation beds – which are the longer-term beds – are essentially shut down right now.”

Area mental health care providers say that getting a patient in for more than a week stay is all but impossible – even in situations when such patients may pose a threat to others or to themselves.

Anita and Larry Shirley of Carrboro know this all too well. Their struggle to come to grips with how much pressure they could exert on a family member to continue seeking treatment was a struggle made immeasurably worse by North Carolina’s post-reform mental health care system.

David Shirley was diagnosed with bipolar disorder in 1996, at age 11. Over the course of the next few years, “he muddled through,” says his mother, Anita. But in 2002, his school work began to deteriorate and he seemed to be suffering more frequently from depression and from the side effects of the drugs he was taking for his disorder.

In 2003, David began having rages in which he would throw things and break windows and get into altercations with his younger brother, Chris.

David asked to be admitted to an institution. What ensued over the next couple of years was what his father, Larry, calls “this in-and-out thing” – in and out of state institutions, a couple of private hospitals and a wilderness program.

“Basically, the care that he got [at the state institutions] was just to stabilize,” Larry Shirley says. “As long as he stopped being violent, then it was just trying to get him out as quickly as possible.”

At one institution, Shirley says, the chief psychiatrist actually laughed in his face when he asked if his son was going to receive therapy.

“He said, ‘Therapy? Therapy? Are you kidding me? This is not about therapy. This is just about getting to a point where we can get him out of here and hopefully he won’t kill himself or anyone else.’”

David had a few brushes with the law. One high-speed joy ride, with the police in pursuit, ended when David returned home, sat down and waited to be arrested. He had violent altercations with his mother. His parents involuntarily committed him several times, though his hospital stays generally lasted just a few days at most.

David very much wanted to go to college. When he was accepted at Warren Wilson near Asheville, though, he lasted only a couple of months. He was smoking marijuana and, his parents believe, doing other drugs as well.

One day he was found in his dorm room with the word “Help” carved into his forearm. His mother picked him up and David flew into a rage on the drive home, resulting in a call to the police and a trip to UNC Hospitals.

“I think that he was just really upset that it was all crumbling before his eyes,” his mother says. “Because he really wanted [to be in college], but he just couldn’t control himself.”

David was now 19 and, says his mother, to meet him at that time, “Your impression would have been of a young man, kind of sad, a little depressed, not a lot of self-confidence. But you could talk to him. There would be no reason you would think this kid … has a problem.”

But there was a very serious problem, and nothing was working.

“Outpatient treatment wasn’t working,” Larry Shirley says. “Visiting the psychiatrist for 15 minutes or 30 minutes of medicine management wasn’t working. He was a danger to himself and a danger to others, but nobody would take him. There was nothing. A complete void.”

No one offered any guidance, or a way out.

“Basically, nobody had a plan for what happens after you stabilize him,” says Anita Shirley. “What are we going to do with him? They kept on wanting to discharge him. But discharge him to what? What is he going to be doing?”

The Shirleys were advised by mental health professionals that they couldn’t keep rescuing David; they should let him “deal with it.”

His father says: “He was giving signals that ‘I’m in trouble. I need help.’ But at that point we were out of options. We didn’t know what to do.”

The turning point

The point at which society says we’ve crossed the line and violated a person’s free will in the interest of protecting them is, says Clay Whitehead, a Chapel Hill-based psychiatrist “a moving target.” Societal norms change.

But certain stipulations should always be prerequisite.

If a person is to be forcibly medicated, will an inpatient bed and comprehensive care be provided to see through the effects of that drug and to plot the next stage of treatment?

And if medication isn’t the preferable option, what is, and who’s going to provide it?

If we can’t answer these questions, says Clay Whitehead, “we’re all complicit.” In not demanding that these options be made available, regardless of the cost, he says, “We’re just not doing a very good job as citizens.”

The consequences can be tragic.

In late 2005, after attempting suicide by taking a month’s medication and walking off into the woods alongside the Warren Wilson College campus, David was transferred to Broughton Hospital in Morganton. There, his diagnosis was changed from bipolar to borderline personality disorder, and he was told that he no longer needed to be on medication, that it wouldn’t help him.

There’s no question that David’s condition was complex, says his father, “that it wasn’t a pure diagnosis in any one area. There’s no question that it was a really difficult case in that regard.

“But to make that kind of statement to him was just devastating in terms of getting any future treatment for him.”

David was an adult, so the law allowed him to make his own decisions. Having been shuttled in and out of too many facilities on too many occasions, he’d utterly lost faith in the public mental health care system. And he felt that private care was a waste of his parents’ money.

“He felt bad,” his mother says. “It was like, ‘You guys shouldn’t spend this money. I’m not going to get better. It’s just wasting money.’”

David again took an overdose of his medication. He tried school again, at Western Carolina, but was kicked out for being drunk and disorderly in his dorm.

One night in February 2006, he went on a drinking binge. His mother says that he was extremely sad, that he had been jilted by a girl, “and it was just one of those horrible, horrible, horrible nights that you can have when you want to be with a girl and she’s with another guy, and it just sucks.”

After being up all that night, he went the next morning to see his closest friend from high school, a student at UNC who lived in Craige dormitory.

His friend wasn’t home. David walked across the street to Morrison dorm, which was then closed for renovations. He climbed over the barriers and up the building to the top, the 10th floor. He called his brother and told him that this wasn’t about him, that it was just something he had to do. Then he jumped.

David somehow survived the fall and was conscious when he was found by construction workers. He was still conscious when he arrived at the hospital, but was then sedated due to his massive injuries. He died a week later, on March 1.

“What we had wished for,” says Anita Shirley, “was that there was a place where we could have taken him where he could have been safe, away from drugs, away from alcohol, a safe environment, for like a month or two, so that they could establish the right medication for him. But that place didn’t exist.”

Worse still is the fact that David’s parents believe the longest, and nearly the last, inpatient treatment he did receive was disastrous.

“Somehow I wish I could have intervened to keep him from going to Broughton Hospital,” his father now says. “That was such a negative thing overall and such a turning point.

“To have gotten him anywhere else at that point – whether it would have saved his life, I don’t know. But it would have given him a better chance.” Having been told there that he no longer required medication, “he was much more resistant to care, treatment and hope.

“I think it took away his hope.”

Next in the series: Finding solutions

5 Responses

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  1. I see clients on an outpt basis that are as ill as David. That means they get THERAPY—-something that the psychiatrist, as per the article, did not believe was possible. When one ponders ‘just what is the use of therapy for someone this ill’, it’s the sanctity of the relationship and the trust that is built into such a relationship that can make the difference between moving towards a stable life or throwing oneself off a building.
    However, as David was under Smoky Mountain Center (SMC) LME catchment area while at Western Carolina U., there would have been no therapy except under the Student Counseling Center which is not geared to deal w/ the severity of David’s illness. IF SMC LME had Basic Level Services, which includes only outpt therapy and medication f/u, he might have found a professional mental health provider who could have been a great help to him. But they don’t. Western Highlands Network LME does, but SMC LME, in an apparent attempt to protect their clinical spin-off, Meridian Behavioral Health Services, contracted w/ SMC LME to provide mental health services for state funded clients. This has created a barrier for all other professional mental health providers in the largest of the LME’s in NC, SMC LME.
    Marsha V. Hammond, PhD: Clinical Psychologist
    NC Mental Health Reform blogspot: http://madame-defarge.blogspot.com/

  2. Nicholas Stratas

    Great series! Personal, poignant and telling especially at a time at the major media have gone to sleep again on MH.

  3. Vivian Phillips

    I am so sorry for the Shirleys’ loss. I commend them for their public sharing of such a personal pain.

    It was all the more sad to read placed next to the article on whether or not to spend $5 million on sidewalks. How much mental health care treatment might that buy?

    When are we going to take care of our most vulnerable citizens?

  4. Julie

    What a sad story.

    It might be the case that the latter diagnosis was correct. People are often told they have Bipolar 2 when they really have BPD (if one is willing to accept the endless and not always helpful lables of the DSM).

    BPD requires significant long-term therapy (e.g. DBT). It requires a commitment from a good therapist, and also, it must be said, a commitment from the mental health consumer.

    Medication is (mostly) wasted on the condition.

  5. Traci

    If you research mental disorders, you will learn that Borderline Personality Disorder (BPD) and Bipolar II are often co-morbid conditions. Treatment for Bipolar II (such as Lamictal) can often help the patient with his/her underlying depression and mood swings, thus making therapy for BPD more effective.

    It doesn’t have to be one diagnosis or the other. In fact, these patients often also have co-morbid substance abuse problems with drugs or alcohol, and therefore may need treatment for those addictions as well at the same time as for BPD and Bipolar II.

    Keep in mind that there ARE reputable treatment clinics in the U.S. for these conditions. However, they may not be covered by your insurance. If I had a family member with BPD plus substance abuse plus self-injury, I would spend whatever it would take to get them the right treatment. Suicide is not uncommon in these people.