Zack is a 38-year-old man who had no mental health history into his early adulthood. He was an occasional user of marijuana and a weekend drinker, and he experimented with cocaine and amphetamines, but never used these latter drugs regularly. At age 26, he was in a low-speed motorcycle accident, resulting in a brief (less than an hour) period of unconsciousness, and no obvious problems in the immediate aftermath of the accident other than a broken arm.
During the next several years, Zack began to engage in more risky behaviors, including heavier drug use and speeding on his motorcycle. When he was 29, working on a construction site, he fell about three stories, sustaining a much more severe traumatic brain injury (TBI). On this occasion, Zack was in a coma for over two weeks, and required many months of rehabilitation and therapy before he could walk independently.
Over the years since the second brain injury, Zack was noted to be very impulsive, frequently engaging in fights with family, strangers, and the police. He was found to be eligible for state-funded services for people with adult-onset TBIs. However, after a year in a placement in which he was doing well, Zack decided he no longer wanted the services, preferring to live independently, against the advice of his treatment providers. He resumed his use of alcohol and drugs when not in a restricted environment. Eventually, he was charged with disorderly conduct, failing to obey an order, and resisting arrest.
Upon review, the court deferred trying the case, recommending that Zack return to a treatment or rehabilitation program. Instead, Zack stayed for a few weeks with his brother, but his behavior became too frightening to his brother and his brother's family. He became homeless, and missed a review hearing. When he did finally appear back in court, he was convicted of the charges. However, the court and his public defender were concerned that he would not do well in jail or prison, given his difficulties stemming from his TBI, and sentencing was deferred, again with a recommendation that he seek care.
During the next year, he again became homeless again. Finally, misbehaving in public again, the police decided not to arrest him but instead brought him to a local emergency room. He was found to be intoxicated and psychotic, and over several days in the ER, he stabilized and returned to his current baseline, which included impulsivity and poor frustration tolerance, but a rather friendly demeanor overall.
The hospital's psychiatry unit declined to admit him, as his symptoms related to a brain injury and not a psychiatric illness. The neurology and medical units refused him, as his presentation after stabilization did not represent an acute illness but rather his long-term TBI-related problems. He remained in the ER for over two weeks, until the court (remember, he still had an open case) ordered him admitted to the state psychiatric unit for a competency evaluation.
On admission, it was evident that Zack was not receiving the sorts of treatment, rehabilitation, or management that he required. The state hospital staff learned that the only way to access TBI services was to arrange for his admission to a TBI unit at a publicly funded rehabilitation hospital. Time was of the essence—his Medicaid would be terminated if he remained in the state psychiatric hospital for more than 30 days under a court-commitment. If that happened, the only way he could again become Medicaid eligible would be to have his court commitment resolved. Of course, as you recall, the way the court wanted to resolve the case was to get him into a treatment program. A real Catch 22, right?
As it happened, we at the state hospital were able to collaborate with the state's TBI program to orchestrate a rapid transfer from the psychiatric hospital to the TBI unit at the rehabilitation facility. This took many hours of work, but with the collaborative approach on the part of staff at both hospitals, at the state's TBI program, and the support of the state's psychiatric and medical administrators, as well as the Court and counsel, Zack was transferred to the TBI unit last week.
The next steps include ensuring that he has long-term care Medicaid and then identifying the proper program for his ongoing treatment and rehabilitation.
Had it not been for a judge interested in doing the right thing, rather than the easy thing, Zack would likely have ended up in jail or prison, where he would likely not do well given his impulsivity and poor frustration tolerance. Many readers will be aware of the recent attention to TBI in professional sports. We can expect many many more, given the numbers of war veterans returning with TBI's.
How many Zack's are there in jails and prisons? How can society get them needed care, treatment, and rehabilitation in order to avoid these terrible outcomes?
Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene.
Photo by jugbo via Flickr.