Evenson stops first at the canteen to get Sally's usual: coffee with two creams and two sugars and the biggest glazed doughnut in the case. Juggling two of everything because Sally hates to eat alone, he buzzes the locked door of Ward H, the "social learning" ward where 26 of the most severely impaired, lowest-functioning patients live.
Sally's waiting for him at the reception desk, wearing soft black shoes, open at the top; hot-pink sweatpants; and a red sweatshirt appliqued with satin poinsettias. She's pretty, her hair still dark and glossy, her broken-toothed smile younger than any other 45-year-old's. Her cheeks turn as pink as the sweatpants when Evenson swoops her into a hug.
"I saw Tom walking around the canteen," he tells her when they're settled in a visiting room. "How come he has all those privileges, and can go to the gym or the courtyard on his own, and you still can't?"
"I guess he's moved up a level and I haven't," she says, shrugging. "I don't want to leave Level 1. I'm afraid" -- she leans forward and stabs with her index finger, pointing between her legs. They both know that since her commitment, she's had sex with at least two other patients, at least one of them HIV-positive, right on the grounds of the hospital -- and the less supervision, the likelier such encounters.
"I didn't have too much of a happy life," she says a minute later. "My dad, when I was a baby, he kind of had intercourse with me, you know?" Evenson nods, remembering how, at 9, Sally told doctors she didn't have a father or mother, that she "came from the moon."
Later, Evenson asks whether she has any happy memories of her mom, and Sally starts to rock back and forth: "I don't think I remember that far back. I guess she was so-so; that's all I can say about that." She does volunteer a memory of a foster father who, when his wife went to open the door for her, said, "You going to let that bitch in?" She doesn't remember any of the foster parents' being kind -- but then she's not sure, and she looks to Evenson, her only friend for 27 years now: "Do you remember if any of them were kind?"
Helplessly he shrugs, and she turns back.
"It really wasn't a good thing for a young child," she says firmly.
Glancing through the room's window, he asks how she likes the new staff (turnover, especially for nurses, is high) and Sally tilts her hand left, then right; they're "so-so." She talks about the doctors and nurses back at the domed building with the nostalgia other people reserve for the happiest days of their childhood. "They know more about me, I guess, than a lot of these people do," she explains. "These people are new towards me, and I'm new towards them."
Later, watching the elaborate negotiations needed to bring her a soda from a vending machine outside the locked ward, she remarks, "It's kind of hard to do things here." She sits down, clutching the cola gratefully -- and immediately an elderly woman taps on the door, gesturing that she wants a sip. Sally sighs. "No, don't worry about it," she says to an offer for another soda expedition. "I'll give her this." She pours half the soda in a spare cup, goes to the door and whispers, "Go in that room to drink it; you're going to get me in trouble." Then she returns, explaining, "We're not supposed to give them things. It's against the program."
Later a nurse, seeing rare visitors, comes up, squeezes Sally's shoulder and announces, "She's been doing great!" Behind the spectacles, Evenson's bright eyes narrow. "She's still on Level 1, isn't she?" he retorts. Sally smiles but doesn't say anything, just leads the way into another empty classroom. "They have "shaping class' in here," she says over her shoulder. "It's like arithmetic, maybe a little bit of reading, and they give 'em candy. If one of 'em does good, they will give him three pieces of candy."
She speaks often in the third person ("Santa comes -- they do buy presents for the clients"), and she lives for the chance of a conversation with a staff member or the ward psychiatrist. The other clients make her nervous, she confides, some walking up and down really fast and "talking to nobody, or acting like I'm in their head." Sally prefers quiet people. In shaping class, she gets in trouble because all the clients are supposed to sit around the central table, and she likes to stay off to one side.
Her only hope of moving beyond Level 1 lies in participating in the program, showing up for the day's full roster of group meetings, obeying all the rules. "If you do the program right, you can do just about anything, even go outside," she says cheerfully. Then her face clouds. "They say I'm doing so well, but I just don't see it." She avoids the groups whenever she can, penalties be damned.
"I sleep more than I do anything else," she remarks. "I think it's got something to do with my sadness."
Evenson first saw Sally in 1973. She was sitting on the floor in front of a record player, moving back and forth like a rocking chair somebody pushed too hard. Her long, shiny black hair swung as she rocked, grazing the soles of bare feet mottled with grime and sores.
He stepped back quietly and went in search of a nurse: Why weren't this girl's feet washed? Get them clean, get some salve to heal them and then get some shoes on her before these filthy floors give her gangrene!
She wouldn't wear shoes, the nurse explained wearily. Nobody knew why. She'd been taken from her grandparents when she was 6, spun through eight different foster homes, sent to St. Louis State Hospital at age 9. Two years later she'd come across her mother, also a patient, in a hallway, and that chance encounter had haunted her for years. Now she was 18, and she'd just been transferred to the adult ward.
Evenson poured a cup of the ward's bitter coffee, found a corner where the patients' random yells were muffled and started to read the thick medical file for Sally (a pseudonym). At 6 she'd masturbated unstoppably, chewed her nails until they bled, split her attention into 100 pieces. At 9, she'd insisted she came from the moon.
Sally's mother had been institutionalized for paranoid schizophrenia, and her father was described in an old file as having "organic brain syndrome with psychosis" (an obsolete diagnosis suggesting that some unknown physical problem hindered brain function). All five of their children had some degree of mental retardation, and Sally had grown up alternating angry, frustrated outbursts with apathy, wrist-slashing, window-breaking and relentless attention-seeking. Mild mental retardation had been diagnosed, and everyone agreed there was a further problem -- either an "organic brain disorder" (possibly caused by rheumatic fever) or childhood-onset schizophrenia. She'd been treated with Thorazine, Dilantin, Librium, chloral hydrate, sodium amytal, Serentil, Haldol and Stelazine -- "the classic pharmacopoeia of the times," notes Dr. John Csernansky, Washington University psychiatry professor and medical director of the Metropolitan St. Louis Psychiatric Center. "When you see a menu like that, it suggests that nothing was working."
Evenson had become a psychologist midcareer, after a stint as a hotshot advertising copywriter in Chicago, and his agile, irreverent mind now sorted the crazy-profound wordplay of men and women with schizophrenia. His first clinical post had been at Elgin State Hospital in Illinois, helping a group of young Turks disperse the custodial "back wards" where the worst patients rocked and screamed, their miswired brains rotting with boredom and a death-row sort of despair. In 1972 he'd joined the faculty of the Missouri Institute of Psychiatry, a research center established by the University of Missouri-St. Louis on the grounds of St. Louis State Hospital.
Early in 1973, Evenson visited Sally's ward to help adjust the "token economy," a newly popular gamelike system for motivating and controlling long-term patients' behavior. As Evenson reminded the staff, reinforcement only kicked in when patients spent their tokens and received pleasurable rewards. The tightly budgeted ward wasn't offering many temptations, so the savvier patients were hoarding their tokens, triggering "inflation." Evenson suggested the staff wipe the slate clean, print new token currency and arrange a few church-supper outings and other low-cost incentives. Then he took the two "wealthiest" patients out for a white-tablecloth steak dinner and let them pay him with lots of old tokens.
As he tweaked the system, he thought about Sally. She wasn't the only one, the ward doctor told him; they had a handful of girls who'd pretty much grown up at State Hospital and would probably stay the rest of their lives. In those days, once the key turned in the lock, it seldom reversed -- unless people had family who would care for them. These girls' families weren't around much, the parents ill themselves, absent or dead. Nearly all the girls regularly cut themselves -- or smashed their own reflections in glass windows and mirrors -- to get attention.
Enlisting a motherly nurse named Ruby Graves, Evenson started a family-model therapy group for the girls, paying close attention to their backgrounds and individual needs, showering them with praise and encouragement. He met with them in his office at MIP, raising the eyebrows of his research colleagues, and he urged his secretary, Pat Chamberlain, to let the girls come in for a chat and a cup of coffee whenever they liked. "His idea was that it was the only time they were really treated as normal people," she recalls. "The Institute director told me if I wanted to refuse, he'd back me up, but those visits were the greatest pleasure of my job."
Over months of chitchat, Chamberlain began to unlock the mysteries of Sally's sadness. One day, for example, Sally announced that she felt like giving God the finger. Stifling a response (Dr. E. had warned Chamberlain, a devout Methodist, not to preach to the girls, making them feel guilty about acts that were more likely to be symptoms than sins), Chamberlain simply asked why. "Well, you always talk about your daughter and your son," said Sally, "and I just feel like somehow I've been cheated."
According to Evenson's records, Sally went from 30 wrist-cuttings and window-smashings in 1973 to four in the first two months of 1974, and none thereafter. Her apathy changed to uninhibited demands -- she used to bang on his office door and call out cheerfully, "Open the fucking door!" One day, another employee came over to commiserate with Chamberlain, telling her it was a shame she had to endure these girls' foul mouths. Just then the banging started, and Chamberlain grinned at her prim friend: "Guess I better go open the fucking door."
With Evenson, the girls ventured outside State Hospital for the first time in years. They went to McDonald's, where Sally learned not to cuss out loud, and they went shopping, and to the library, and on a picnic at a nearby park. "They were terrified to go on that picnic -- they thought people would recognize them as "state-hospital girls,'" says Evenson. "They were so relieved when nobody even noticed them!"
Sally loved talk radio, and "she was interested in things that, for her IQ, would be considered intellectual," says Evenson. Soon she started working at a sheltered workshop, and with her first paycheck she bought the first dress of her life -- an elegant floor-length satin gown from a resale shop. "She wore it to the group meeting the next day," he recalls. "She beamed, and so did everyone else." By November 1975, he was urging that she receive sewing lessons and sex education (the latter having been promised repeatedly for all the girls) so she could be readied for life in the world. "The hospital may currently be doing her more harm than good," he noted in a report. "She is ready to bloom."
In March of 1976, Sally was discharged. Three years earlier, no one had thought she'd ever leave. But she'd made some progress, and the timing was right -- community mental health was the new mandate, and legal and political pressures were building, prompting institutions to release patients as quickly as possible.
The "community" wasn't exactly ready, though, and nobody at the hospitals knew how to make the transition gradual, manageable and safe for patients who hadn't seen the world in years. Sudden freedom overwhelmed Sally, and she slammed through a series of halfway houses, boardinghouses and apartments like a pinball, alternating eager questions ("Why does it rain?" "Why do people get fat?") with anxious outbursts of temper. She was feeling her way into a world she hadn't lived in since she was 6, and there was nobody waiting to catch her. Evenson watched with a sick feeling in his stomach, wondering where all the newly touted "community support" was.
Finally, in August 1979, Sally landed in a Places for People apartment where she received steady, companionable help from volunteer Jean Jonet. Jonet soon realized the root problem: Sally was terrified. She was afraid to use the bathtub, afraid to be alone, afraid strange men were going to climb up the drainpipe at night.
With Jonet's guidance, Sally fought her anxiety down. She still panicked easily, but she was learning to do her own shopping, cooking, laundry and housekeeping. She already knew how to take the bus: Dr. Evenson had taught her what she called the "cross-the-street trick," to make sure she took the return bus home. She started going to classes, and she managed on her own for five months, improving steadily. Tickled pink, Evenson brought his wife and sons to visit, and they all went out for ice cream.
Then, that January, Sally's father turned up. She went to live with him readily -- even though she'd told people at State Hospital that he had sexually abused her and her sister when they were very young and, in the '70s, staff had noticed him making gestures so overt that they discontinued home visits. "I guess I thought he was a different man," explains Sally. "When he visited, he used to bring me sandwiches and hot coffee in a jar, made-at-home coffee, and we'd smoke cigarettes together."
According to Evenson's notes, her "grooming and social skills markedly deteriorated" when she moved in with her dad, and "she seldom left the small, dingy apartment" -- except for periods when she wandered the streets. By March 1983 she was back in State Hospital, her early progress erased by chaos.
In November of 1984, they released her again. There were 100 hands pushing the door open: The federal Community Mental Health Act had insisted that people live in the least restrictive environment, and all the state funding was being channeled into community placements. The census at State Hospital -- 2,634 when Sally was first admitted two decades earlier -- had dropped to 488, and releases now outstripped admissions.
Evenson says he first learned of Sally's discharge when he saw her in the hallway, clutching a plastic bag that held all her belongings. Startled, he asked whether she had a place to stay. She fibbed. He later learned that she slept in an empty garage, then went to live with a male hospital employee, who had sex with her. Soon she was back on the streets, living off and on with her dad or in boardinghouses. The clouds in her mind gathered and darkened, blowing up storms so disorienting she stopped taking her medicine. On Jan. 5, 1987, she showed up at Evenson's office completely unraveled, desperate to return to the only home she'd ever known. She disrupted the entire institute, a pin-drop-quiet sort of place, on her way in, and soon two guards were sent. Ignoring Chamberlain's whispered "Please don't interrupt, she's talking to him now," they banged through Evenson's closed office door and -- after subduing the enraged psychologist -- removed her. (Later, Chamberlain asked the nicer of the guards why they'd done such a thing. "Because she was going around acting crazy," he replied, and Chamberlain snapped, "Well, she is crazy!" The guard thought about this for a minute before countering, "Then why did the superintendent order me to remove her?" Chamberlain couldn't resist: "Maybe he's crazy?")
Evenson, meanwhile, was dictating a terse letter to State Hospital's admitting room, describing Sally's "state of despair and psychological disorganization" and the voices that were telling her to cut her wrist and hurt her father. Doctors still refused to admit her, saying she didn't meet their criteria, which had tightened to the old standard for involuntary commitment: "a danger to oneself or others." Exasperated, Evenson drove Sally over to Malcolm Bliss Mental Hospital, which was in the process of taking over all acute hospital admissions and already having trouble recruiting enough doctors. They, too, refused. Their emergency room was packed daily with people who'd been discharged in the early '80s and were psychotic, suicidal, screwed up by a toxic mix of their drugs and the street's or homeless and looking for shelter. Most could not, by virtue of the new laws protecting their dignity, be admitted. Many wound up committing crimes "by reason of insanity" and returning to State Hospital the only way they could, as forensic admissions.
Sally grew increasingly agitated and intractable, sometimes refusing treatment and sometimes begging for medication, continually trying to get back into the hospital. On April 11, 1988, she went to the Bliss outpatient clinic, complaining yet again of voices. She was given a shot of Prolixin, an anti-psychotic, and sent back to the boardinghouse where she was living. Three days later, mad in every sense of the word, she set fire to a robe in the closet she shared with two other residents. Then she lay back down on her bed. By the time anybody noticed, the woman on the other side of the paper-thin closet wall had died of smoke inhalation.
Sally was charged with Murder 1 and first-degree arson. She was sent to Biggs Forensic Center in Fulton, Mo., for psychiatric evaluation, and when Evenson read that staff's reports, he exploded. The "history" -- which would follow Sally for the rest of her life -- said she had been married twice, was currently divorced and "often gets pregnant when placed in the community." "She has never been married," he exclaims (and a search of marriage records in St. Louis confirms it). "She's had one child -- this "often gets pregnant' stuff is bullshit. Fulton couldn't find their buttocks with both hands." He scans a chronology of alleged violent outbursts (including a time Sally was talking to a man who wanted to kill himself and said, "OK then, I'll help you") and rolls his eyes: "Psychiatric records. They're full of inaccuracies and crazy talk, and over the years it all gets magnified because you pick up everything from before, and eventually it's gospel. That's not to say that (Sally) is an angel. But you tar with the brush of old misdemeanors, and nobody ever verifies anything.
"Did you ever do any little thing you were ashamed of?" he asks suddenly. "How would you feel if someone wrote it down and referred to it constantly for years? "Whoa-ho! I see here that you ...' That's how that stuff follows you in your psychiatric records," he ends more quietly, "and if you weren't crazy already, it would drive you crazy."
As for the crime itself, he continues, most of the information came from a highly stressful interview by police officers with no psychiatric expertise. They said Sally admitted starting the fire on purpose to kill a woman who'd made her angry. But when they told her she'd killed the wrong woman, she said, "Well, that's OK, too." Later she said she was sorry because she'd liked the woman who died -- but that she'd do the same again, because the place "was dirty and had roaches and greasy dishes." She also said, according to the forensic reports, that she set the fire because she "didn't like that place, I wanted to get kicked out of there"; and that the judge should put her to death "by breaking my neck in an electric chair."
Evenson doesn't believe Sally intended to kill anyone -- except maybe, in a bleary, random way, herself. She's easily confused, he notes, and intensely suggestible, eager to please anyone by telling a person what he or she seems to want to hear. The report emphasizes that she was still hearing voices, saying they "struck her on the back of the head," but Evenson points out that "she'd been talking about all sorts of voices for months." He slows his usual rush of words to the pace of a kindergarten teacher's: "She was trying to get back into the hospital, which was the only real home she'd ever known. And it was hard for her to understand why they wouldn't take her back."
Sally found her way back -- permanently. "They should have let her plead guilty to involuntary manslaughter," says Evenson. "She'd have been out five or six years ago." Instead, she was found not guilty by reason of insanity and, in September 1988, committed indefinitely to the state's custody with security restrictions befitting a first-degree murderer.
"I messed up again," Sally blurts the next Tuesday. "Slept all day yesterday, and now I can't smoke. I'm pretty sure I did it on purpose." In the hall, a tall, loose-jointed man knocks along the top of the glass window like a carpenter looking for beams, then slowly outlines each pane with his long, thin fingers, searching for something. She ignores him. From the neatly stacked canvas totebag she carries everywhere, she pulls a slim pile of rubberbanded tokens, then rummages for a notepad where she tracks when she can smoke and how many fines she has. "Seems like they are always taking it away from me," she sighs. "The only way I can get a cigarette, if I'm lucky, is to get a light from somebody and take it into the bathroom."
Administrators say fines are so common -- and there are so many ways to earn tokens back -- that the clients don't take the penalties seriously. But Sally, a bundle of contradictions, gets upset every time she's fined and announces her token losses with ritual formality. Evenson resents these small deprivations even more than she does: "They took away the radio I gave her, the pots for planting seed, all the little things that make life more than being an animal," he says. "In my opinion, a good token economy does not take anything away. When you have fines for every little thing, you're set back for every step forward."
Not one to mince words with the bureaucracy (his framed motto reads Non illegitimati carborandum [sic], "Don't let the bastards grind you down"), Evenson views Ward H as a cosmeticized back ward, redeemed only by better drugs and hygiene, and busywork in pods instead of a row of creaking rockers. He's still furious about the months in 1996 when Sally showed up for appointments with him in leg shackles, automatically branded a high security risk despite an evaluation showing no high-risk factors, because, he says, "State Hospital lives by crisis control" and was locking the barn door after a series of escapes.
Evenson's not even convinced Sally has schizophrenia -- he says she "carries that diagnosis because once you have been in a state hospital for longer than five years, you will have that diagnosis, period." For 12 years, he's dogged clinicians with questions about Sally's medications and repeated requests for treatment reports, fussed at them for dawdling on her dental work and nagged until they got her spectacles. His file of clinical observations includes jotted reminders to bring her whitening toothpaste, more C batteries for the tiny radio he bought her, a jar of instant creamer. He's enjoyed the doughnut visits as much as she has, treasuring the freshness of her blunt honesty.
"What I want for (Sally) is so simple," he sighs, "just to get her back where she was before all this junk happened with her father and the criminal proceedings. She was functioning really well in the community, and there is no reason she can't again. People should be able to bounce back to the hospital whenever they need to, but you don't just keep them like they are firewood you are stacking up someplace. Hospitals are not good for people; they have certain iatrogenic effects."
There's a new urgency in his voice: He's retiring to Arkansas, and Sally will have no one nearby to look out for her. Still, he's stubborn enough to keep hoping that a pro bono lawyer will turn up and somehow wring a new version of justice from the system. Sally brings up the prospect almost automatically; any real hope flattened into habit years ago, and if a pro bono lawyer showed up and handed her the ward key, she just might hand it back. She gets a funny feeling in her stomach at the thought of even leaving the ward, and she describes her future as "oh, I guess being here forever, that's about all I know." Then she asks impulsively: "How is the world out there now -- is it good, or like you see on TV?"
Sally guesses she could still do the cross-the-street trick and reminisces about the apartment on Nebraska Street, which, she says, was "really nice. It had three rooms and a bathroom, a pantry where I could keep dry cereal, and an icebox. I could eat whenever I wanted to, watch TV maybe, sit outside on a nice day." She can't sit outside now, she adds, because she's ""supervised.' But I'm not much of an outdoor person anyway. I stay mostly inside."
Curious to hear what Sally thinks about Evenson's dream of springing her, I go alone to see her the next week. She arranges with an aide to unlock an empty classroom so we can visit privately, then briskly wheels a babbling woman's chair away from the door, reassuring her gently. By the time Sally returns, a man's lying on his side in front of the doorway, staring into the depths of a clear-plastic trash bag stretched over a cart. "Some of the clients are sicker than me," she volunteers, making sure the door's locked "so we don't get our tea snatched." Paranoia, I wonder? Five minutes later, a skinny guy in a blue hood appears from nowhere and rattles the handle.
Gulping tea, Sally says she's not sure why she participated so fully in Evenson's token program but won't get involved in this one. Was the other program better? "Well, yeah, it kind of got me out of here." She's changed a lot since then, she adds: "I used to be real sweet -- I never used vulgar language on anybody. I used to think that people would like me. I kinda got the idea now that they don't."
Sally admits shielding Evenson from her darkest moments, the way you'd shield an older parent who loves you too much to bear your failures. There are still days when her illness talks to her, she confides, goading her to "end my life and the hell with it, because I've been hurt and I don't need to live anymore. It even talks to me about God, telling me the hell with what God says about it, if he puts you in hell, fuck him." She says she tries to ignore the voice, remembering the doctors and nurses who pointed out, years ago, that her illness doesn't like her very much. "I guess you could say I'm a little afraid of dying," she offers.
Over the years, she's cobbled together a theology, dubbing God "a pretty nice man; he had a son who died and forgave me for any crime I did." She looks around, afraid to say the next part out loud. "I think God wants everybody in heaven with him no matter what," she ventures. "But it seems to me God tries to make life a little harder. When you try to do something right, God makes you mess up." She rocks faster and faster. "He puts a lot of problems on your back and makes you wonder if he's there." She falls silent for a second, then blurts, "I don't see how you can depend on God.
"I could picture my illness with a mouth," she offers a minute later. "I'll be imagining the illness having a head and a face -- a long nose, big eyes, a head with no hair on it. Bald-headed." Giggling, she reproves herself: "Bald. That's a terrible thing to say about somebody's illness."
The next week, she's not waiting at the desk when I arrive. "What sofa does (Sally) sleep on?" the receptionist calls, and "Billy" is pressed to go find her. He lopes toward a room where Sally is curled up on the seat of a wide chair, huddled under a dark coat, and pulls it off with a chef's flourish: Voilà! Cranky at first, Sally tries to hunker back down, but then she remembers my visit, comes out and graciously turns away any apology. "Don't worry about it," she says gently. And then, with eagerness, "Did you bring the doughnuts?"
She rips through four packs, three of them meant for later, then burps and, aghast, excuses herself. Her manners are delicate, and she insists she learned them at home: "I guess my parents were kind of strict about us kids' using manners: "Say your prayers and thank God for the food and chew with your mouth shut.' Most moms are picky about that stuff." She looks down at a Rorschach of powdered sugar: "Here, let me get something to wipe this table off with."
As she glides the paper towel fastidiously over the vinyl-topped table, she says she thinks about her mom all the time: "Orlando and Dawn sing this song -- they don't play it much on the radio anymore." She's blanking on the title. "Tie a Yellow Ribbon?" I suggest. "Yeah, that's it!" I'm coming home, I've done my time ... Do you still want me? "It's more about lovers, I guess," she murmurs. "But it makes me think of my mother."
Table spotless, she glances through the window at a passing nurse. "That's Kay -- she's nice; she has two daughters." She cranes her neck toward the receptionist desk. "Come here. See that woman with the glasses? She seems like a mom to me. And that woman sitting there with a blue cap at the desk? She's like a sister to me."
Sally asks about Evenson's sons every visit, remembers the names, sexes and ages of every nurse's family members and talks often about her own children, sometimes claiming as many as 11 and grandchildren to boot. (There's evidence of only one, a daughter given up for adoption years ago.) She says she remembers a dog that had five puppies: "I put them in diapers and fed them out of baby bottles, rocked them, tapped them on the head, gave them some loving. She (the mother dog) wouldn't have anything to do with them; she disowned them. So I put a soft quilt down, and cooled their milk because it was summer. "Open your mouth, little fella,' I'd say, and tell them a little story, like, "That's your mama's titties,' because I didn't want to hurt their feelings, make them think their mom disowned them. And they would stop crying and go right to sleep."
In the maelstrom of Sally's mental retardation, her illness, her early and late traumas and her near-lifelong institutionalization, it's hard to see answers. She's obviously fearful -- how much is paranoia, and how much is justified, given that the safest place she's ever lived is the lowest ward of a forensic institution? Can she distinguish between a "voice" and an intense disturbing thought? Has she learned to please clinicians who want her to hear voices? Has her early eagerness to join the world been "institutionalized" out of her or sapped by her illness? Is she genuinely bored with the groups and the games of the token economy, or is she filled with a single, burning ambition: to sabotage her own progress so she can stay safe? And if it's sabotage, is there any harm in it?
Whether or not she has schizophrenia is a moot point, according to Dr. Lori DeRosear, the medical director of SLPRC. The meds target psychotic symptoms, not specific diagnoses, so even if Evenson were right about Sally's not having schizophrenia, her treatment wouldn't change one bit. Sally has improved in the 12 years, insists DeRosear, and though she still gets frustrated and mad, she has far fewer violent outbursts. As for sabotaging her progress, DeRosear says, "They all do it, especially when they're getting close to discharge. We're aware."
Sally's nowhere close to discharge, though; she's warding off far smaller freedoms, saying she's afraid to leave the ward because she might run away, and she's afraid to walk alone to the canteen or the courtyard because someone might want to have sex with her. She's in a system that rewards increasing freedom, and she's playing it backward.
"I can't imagine that it really is fearful for her," says DeRosear. "I don't think she cares that much about getting past Level 1. She's getting all her needs met, she gets to do whatever she wants to do, she doesn't have to fight the snow and ice. What (Sally) says is clouded by so many different factors. The important thing is, she eats good, she sleeps good, she seems happy. The best alternative she could hope for is a nursing home, where the only care is custodial."
Evenson doesn't want Sally stuck in a nursing home or sitting, as DeRosear mimes, all alone in an apartment with her hands folded, jolted by every noise, scared of every shadow. He's envisioning support, lots of it. But right now the only place for someone without money to receive 24-hour supervision and therapy is SLPRC, and the only surefire way to get a bed there is to commit a crime.
When Sally went to State Hospital as a 9-year-old, the Youth Center had only been open one year, housed in a back building east of the power plant. There were bars on the domed building's windows and drugs that either put you to sleep or made you feel as if your skin was crawling off your body. Dr. Alfonso Menotti, who did a psychology internship there in 1960 and stayed to become director of psychology, remembers 3,700 clients at the peak, wards so crowded doctors practically had to climb over the beds to reach their patients; people soiling themselves and no one having time to clean them; frozen sheets and tubs of icy water for the agitated; catatonic patients standing rigid as marble statues in the hallways.
The changes that followed made those harrowing early years worthwhile, he says. Medicines improved dramatically; the general philosophy became less coercive, less of a power struggle between client and staff; use of restraints dropped below the national average; they introduced the concept of rehabilitation. "The key word now is hope," says Menotti. "There is a light at the end of the tunnel." That light's grown so bright, he put off retiring two years ago so he could watch the reforms of the mid-'90s, which got people out of bed and into classes and jobs, take hold. He saw a man who used to sleep until 4 p.m. every day working long hours in the commissary. Clients who'd never thought they could function again were calling out to him in the hall, "Dr. Menotti! I start a new job on Monday!"
More than 75 percent of the clients now work, either within the institution or in the community, and most move pretty freely around the facility. Sally begged for a job on the ward years ago but now she says she doesn't want one. Staff members talk openly in the new groups about sexual intercourse, teaching lessons of boundaries and safety -- but sex has brought Sally so much trouble, it doesn't even interest her anymore. Clients without her restrictions regularly go shopping, to the zoo, on camping trips -- but she's not interested in any of that, either. She saw enough of the streets when she had no choice.
Sally describes her life at SLPRC as "so-so," adding with a shrug, "That's all I know." All told, she's lived there more than 35 years. SLPRC's average length of stay has dropped, however, to seven years, and the overarching goal is to make every client as independent as possible. Discharges are handled far differently now, with entire classes devoted to gradually acquainting clients with the community and its challenges. The staff holds showers to get people set up comfortably in their new apartments, and, ideally, the minute a client falters or misses a few doses of medication, he or she is brought back for extra guidance. "We do a much, much better job of transitioning people out," sums up Alan Blake, chief of clinical services. "Before, they would just patch you up and stick you out there."
Sally has noticed the changes, but she's still dubious. "They kind of changed it around, put people in different places," she says. "Sometimes I wonder if they know what they're doing themselves. What's the sense in putting a person out when you know they will not be able to stay out there?"
She doesn't say such things to Evenson, because she doesn't want to hurt his feelings. He's like a father to her. And what he wants for her is freedom.
What she wants is the safety of a family.
Before I leave, she gives me a present: a Salvation Army pamphlet cover, reprinting Giovanni Battista Salvi's painting of the Madonna with the baby Jesus on her lap. "She's not holding onto him too good, is she?" Sally asks nervously. Then she stands -- her goodbyes are always abrupt. "Tell your husband and your mother I said hi." She peers out the classroom window at the darkening, icy parking lot. "Be careful out there."