A Different View of Mental Health Advocacy

11-24-14  On Friday, I posted a speech that D.J. Jaffe had given at the New York State National Alliance on Mental Illness convention that highlighted the difference that he sees between being a Mental Health Advocate and Mental Illness Advocate. Larry Drain, the Depression and Bipolar Support Alliance’s legislative liaison for state affairs in Tennessee, responds in the blog below with a different point of view. Drain recently gained attention in the media after he and his wife of 33 years were forced to separate so they could keep her health insurance. Tennessee did not expand Medicaid and Drain has been protesting by writing a letter every day to that state’s governor. 

MENTAL HEALTH vs MENTAL ILLNESS: WHERE D.J. JAFFE GETS IT WRONG

BY LARRY DRAIN 

  If you have not read D.J. Jaffe’s speech, nothing I say will make much sense but I read it and here is my response. Jaffe’s basic argument is, as I understand it, really simple. drainWe spend far too much money on people with less serious mental health issues and far too little on people with serious mental illness. That spending has been fueled by the people who have a vested interest in that kind of allocation of resources, and the result has been a tragedy of immense social and personal dimensions. Jaffe cites the number of people in jail with mental illness and the number of homeless and says this has been the direct consequence of this misapplication of resources. His solution is the Murphy Bill. Provide increased funding for psychiatric hospitalization and increase the use of Assisted Outpatient Treatment being the specific remedies largely proposed by the bill.

The most important part of Mr. Jaffe’s speech is not what he says but what he doesn’t say.

At least 5 billion dollars in spending have been cut from state mental health budgets in recent years. In my view that is the most important single fact about the mental health system in the last several years. Systems that were at maximum basically skeletal are now down to less than bones. In Tennessee the first proposal for the budget for next year is due out on Monday. Early indications are there will be a 7% cut proposed.

One casualty will probably be the network of 46 peer support centers. Peer support centers in Tennessee serve about 3500 people a day. The people served by the peer support centers are largely those diagnosed with severe mental illness. Data indicates that they reduce hospitalization for those who attend by 90%. It costs the state about $3 a day for someone to attend a peer support center.

That is a real problem. The problem is not misallocation. It is the lack of resources to allocate. To not even note that or discuss that is a curious omission. I don’t understand how it can be missed or ignored. And I question how accurate any description of the issues can be that ignores it. I can’t say I have lot of knowledge about other states but I do know Tennessee and having services to access to is a major issue for everyone seeking help.

In Tennessee another major issue is access. Due to lack of Medicaid expansion over 82,000 people with mental health diagnoses and over 32,000 people with diagnosis of severe mental illness, lack the insurance they need to access any services. In almost half the states in this country the same issue is real. Mr. Jaffe does not see this as even a relevant issue from what I can tell, but it is worth noting that Rep. Murphy who preaches about serving the seriously mentally ill has voted numerous times to repeal the law that would give them access to any of the services he says they need. Mr. Jaffe ends one paragraph like this, “360,000 are behind bars, and 200,000 homeless because we are now focused on improving mental health, rather than treating serious mental illness.” My first question would be does he have any proof of this other than his assumption that it is true? But there is an even more basic question. What does he really mean by this?

What is the distinction between focusing on mental health as versus mental illness? What is the translation, the code, to what sounds like on the surface a meaningless distinction? I believe that when you take away the fancy words what Jaffe is saying is that moving away from long term psychiatric hospitalization towards community services has resulted in 360,000 people being put in jail and 200,000 being homeless. Basically, most people with serious mental illness suffer from a deficiency or psychiatric hospitalization.

If I am to any degree accurate Jaffe’s statement is remarkably naive. He substitutes emotional rhetoric for good sense. He ignores the steady emaciation of the mental health system in virtually every state. I seriously question whether any experts in the field of homelessness or criminal justice would buy his idea that criminality or homelessness is simply a symptom of mental illness. Ignoring poverty, drugs, trauma, gangs, racism, unemployment, social pressures and experiences and a host of other factors as causative agents just don’t make any sense. I don’t know of anyone other than someone who has a personal investment in the Murphy Bill who seriously believes that psychiatric hospitalization in and of itself prevents crime or homelessness.

A side note on numbers since I will return to that issue throughout this post. Mr. Jaffe quotes the figure 360,000 people with mental illness in jail and 200,000 homeless people with mental illness. Perhaps there is evidence that these people meet Mr. Jaffe’s criteria of seriously mentally ill and that they have a history of ineffective treatment or even no treatment. Perhaps there is. I just don’t know what it is. Personally this sounds like another over-generalization.

Mr. Jaffe says, “I admit the boundary between mental health and mental illness, is debatable….”

That is the most accurate statement in his entire talk. I can’t think of one professional voice I know of, other than those who have a personal stake in the Murphy Bill or in the Treatment Advocacy Center that would buy it. The idea that if you don’t need to be in a psychiatric hospital that your issues are not important, serious and deserving of help is nonsense.

Again no, I repeat no professional I know of would take this as a statement deserving serious consideration. The notion of “worried well” is akin to telling one starving person that his biggest problem in life is that another starving person eats too much. This is Mr. Jaffe assuming that advocating for the seriously mentally and advocating for the vision of the Treatment Advocacy Center are one and the same thing. I really question that, as do most of the people I know.

Mr. Jaffe’s next argument is that many people lack insight into the fact they need treatment. Many people lack insight including doctors and mental health advocates, but he goes further than that. Many of the seriously mentally ill have brain damage he says that prevents them from having insight into their problems and that according to him is a proven scientific fact. They have anosognosia, a concept borrowed from studies of stroke victims. The concept of anosognosia is a sacred item of faith for Mr. Jaffe. It is a core concept in justifying the necessity of coercive treatment so dear to Mr. Jaffe’s heart. There are some problems though. I don’t think there are any independent studies that substantiate the notion. Any doctor who looks at a brain scan from a stroke victim can tell if that person has anosognosia. There are no widely accepted notions of what a brain scan from someone with mental illness looks like to the best of my knowledge.

Perhaps I am a little cynical but I seems that anyone who says that anyone disagreeing with psychiatric opinion must have brain damage hasn’t dealt with many psychiatrists. Another side note on numbers. Most of the time the notion of anosognosia is used someone will tell you that 50% of the seriously mentally ill have anosognosia. Using Tennessee as an example let’s do the math. Tennessee has about 6,500,000 people. According “to studies” that means 156,000 Tennesseans have a serious mental illness. According to Mr. Jaffe that means that 78,000 of them have anosognosia. That means they have a mental illness they don’t recognize with impactful symptoms that probably disrupt daily life in a serious way.

Where are they?

By definition they are probably not being served in the mental health system. They don’t recognize they have a problem. Tennessee has about 12,000 committals a year to psychiatric hospitals. There are 21,000 people in prison. Even assuming that all the committals have anosognosia (which seems far fetched to me and given that 12000 committals are not 12000 people) and that all 21,000 people in prison have a severe mental illness and don’t recognize it (which is not true and no one believes) there are still enough people missing to fill a good sized Tennessee town. Do the math in any state and the numbers will be the same. No one is really missing.

The 50% of severely mentally ill is closer to religious belief than scientific fact. Saying that some people at some time in their life lack insight, acknowledgement or even honesty about what is going on in their life seems to me to be a pretty good description of virtually everyone I know. Saying that blindness can be so bad it can be incapacitating again seems common sense. Anyone trying to follow national politics can attest to that. Saying that it can be scarily rigid and resistant to help seems common sense to me. But to say it is all the result of brain damage that only affects people with severe mental illness seems to be a convenient fiction with little or no basis in fact.

Jaffe says, “Historically, people with serious mental illness were a priority because our budget was spent on the hospitalized, but mental health advocates have changed our focus….” He needs to revisit history again. My first job in a psychiatric hospital was in 1974. I asked one of the first patients I met how long he had been there. He stopped and seemed to do the math in his head. “About 45 years….” I asked him why he was there. He stopped again. “I don’t remember. I would be glad to ask someone though if you need to know…”

Psychiatric hospitals closed because they were warehouses that wasted human life after human life. They did not prepare people for life. They stole it.

The evidence is overwhelming. To say that caring for serious mental illness is the same as housing those people with a serious mental illness in a psychiatric hospital as a substitute for any kind of real life is neither caring or a statement of fact. Psychiatric hospitals role in the mental health system changed because people discovered that what happened there was frequently not very ethical or honest and really not very effective. I think Mr. Jaffe believes psychiatric hospitalization is an evidence-based practice. I don’t know of anyone else that thinks that. Aside from perhaps crisis stabilization, I don’t know of any evidence it works at all. Insurance companies stopped paying for it because it was way too little bang for way too many bucks.

Psychiatric hospitalization as the primary mode of treatment basically self destructed as the truth about it became more widely known. The claim that mental health advocates stole it away somehow is simply silly. A word about reality again using Tennessee as an example. A state psychiatric bed can cost as much as 345,000 dollars a year for more intensive care. Peer support centers that deal with many people with histories of chronic hospitalization and largely keep people out of the hospital cost $3 a day. The 7% budget cut will probably eliminate peer support centers. That budget is about 4.5 million dollars a year. It serves about 3,500 people a day…. About the price it would take to hospitalize 12 people a year.

Regardless of polemics like Mr. Jaffe, or how many times he is in the paper or interviewed on TV or how fervently Rep Murphy tries to seize on every tragedy to toot his horn what do you really believe Tennessee is going to choose to do? The ship of psychiatric hospitalization sailed long ago and Mr. Jaffe missed the boat. Mr. Jaffe claims “all mental illness is not serious.”

This is one of his most interesting statements.

I don’t know if he realizes that this is a challenge to the bulk of mainstream psychiatry which certainly doesn’t share that opinion. If he does, he will find out that many mental health advocates share the feeling that the mental health system has ensnared way too many people and medical-ized way too much of ordinary human life and suffering. Again a lot of it is in the translation. If he is saying people often have an amazing ability to cope with the distress in their life and an incredible resiliency in the face of hard times, I agree with him. If he is saying that even people in difficult times can maintain their ability to manage and make good decisions, I agree with that. If he is saying that things are not serious until life gets totally out of control, I think that is nonsense.

If he thinks he knows the secret of how to measure the seriousness and reality of one person’s pain against that of another he is deluding himself both about his importance and his insight. Obviously all things come in degrees and if all he means is that some people need more help than others — that seems more an obvious platitude than a great insight. His claim that we are helping those that need less help at the expense of those who need help more is simply not true. Most state legislatures are trying hard to make sure everyone is helped less! Jaffe says lot of important things and I have not attempted to deal with most of them.

But I want to close with a thought about Assistant Outpatient Treatment. I want to point out in closing the major paradox of what Jaffe, Torrey, and Murphy say about AOT. They spend a lot of time tearing the mental health system to shreds. They say it is insufficient to the needs of the seriously mentally ill and is polluted by its allegiance to the notion of mental health. Yet, they also proclaim loudly the value of AOT. This is basically saying that forced participation in a system that is no good is good. Perhaps I haven’t explained it very well but it sounds a lot like trying to have your cake and eat it too. How can committal to something that is no good be good? It seems a curious notion to me.

Mr. Jaffe is right about one thing though and very right. Although many improvements have been made, much of what happens in the mental health system is lacking and even shameful. The treatment of people with mental health issues, especially those with serious issues, in the correctional system of this country is a national disgrace. The continued amputation of needed services and programs in state after state is a national disgrace. But so is the continued reliance on approaches that don’t work and even hurt the people they claim to help. And so is the continued effort of so many to advance their ideas or positions at the expense of a simple question. Regardless of who’s turf or status is affected what really works? I still remember listening to Robert Whitaker wonder if an honest mental health system will ever be possible.

I still wonder.

Larry Drain is the current Legislative Liaison on state affairs for DBSA Tennessee.  He has been the past chairman of consumer advisory board, a member of TMHCA board of directors, involved with Tennessee Health Care Campaign,  the Tennessee Suicide Prevention Network as well as several other causes.  He is currently president of NAMI Maryville and a member of the NAMI policy council.  He writes a blog “Hopeworks Community” (http://hopeworkscommunity.wordpress.com) that has international readership.  

Mental Health Advocate vs Mental Illness Advocate : You Decide

11-21-14  D. J. Jaffe is a mental health gadfly, defined as “one who provokes others into action by criticism” and much like his friend and mentor, Dr. E. Fuller Torrey, his views often inspire some and anger others.

height.200.no_border.width.200Earlier this month in a speech at the New York State convention of the National Alliance on Mental Illness, Jaffe claimed there was a difference between being a mental health advocate and a mental illness advocate. Here is an edited version of his talk.

By D J Jaffe

Exec. Dir. Mental Illness Policy Org.

I want to make clear that like most of you, I am not a mental health advocate. I am a mental illness advocate.  I think we need less mental health spending and more mental illness spending.  It is the most seriously ill not the worried-well, who disproportionately become homeless, commit crime, become violent, get arrested incarcerated or hospitalized. 360,000 are behind bars and 200,000 homeless because we are now focused on improving mental health, rather than treating serious mental illness.

My number one message is that we have to stop ignoring the most seriously ill. Send them to the front of the line for services rather than jails shelters prisons and morgues.  I’ll talk (now) about how mental health advocates ignore the seriously ill.

I admit the boundary between mental health and mental illness is debatable, but the extremities are clear. 100% of the population can have their mental health improved. 20% have some sort of illness that can be found in DSM, mainly minor illnesses like anxiety. And most of the illnesses in DSM are minor. But only 4.2% have a serious mental illness like schizophrenia, treatment resistant bipolar, major severe depression or another illness that prevents them from functioning.

Historically, people with serious mental illness were a priority because our budget was spent on the hospitalized. But mental health advocates have changed our focus. The federal government spends $130 billion mental health dollars, much on improving the mental health of all Americans-or as former NYS OMH Commissioner Michael Hogan argued, “to create hope filled environments where people can grow.”

I say we stop ignoring the seriously mentally ill.

That distinction between mental health and mental illness is the main debate going on today … NAMI/NYS is one of the few groups doing both.  They have always done a stellar job at trying to improve the mental health of the 20% and they also advocate for the 4%. So if someone asks me, “Where do I stand?” — it is with NAMI/NYS. Although I should add, my comments today are mine, not theirs.

Let me talk about how mental health advocates drive care away from the most seriously ill.

Mental “health” advocates claim everyone is well enough to volunteer for treatment. That is simply not true. As Congressman Murphy-who is also a psychologist, mentioned last night, some have anosognosia: They are so sick, they don’t know they are sick because the brain is impaired so insight is lacking. When you see someone walking down the street screaming they are the Messiah it is not because they think they are the Messiah. They know it. Their illness tells them it is so.

We have to stop ignoring the seriously ill .

Other mental “health” advocates claim mental illness affects everyone and claim all mental illness is serious. They are wrong. All mental illness is not serious. Many people I worked with including myself, have had or have depression, anxiety, have trouble sleeping, take Zoloft or Prozac, or nothing and do quite well.  We don’t need funds diverted from the seriously ill to the highest functioning.

Mental “health” advocates claim everyone recovers. That is False. Some do not. They actually hide those who don’t recover. You won’t see the homeless and psychotic in their Mental Health Awareness Week PSAs because they want everyone to believe all mentally ill are high functioning. Trying to gain sympathy for mental illness by only showing the high functioning is like trying to end hunger in Africa, by only showing the well-fed.

We have to stop ignoring the seriously ill.

There are two trade associations here in Albany that do some good work for the high functioning, but claim to speak for those with serious mental illness. They want OMH to close hospitals that serve the seriously ill and turn the money over to them.  That would be wrong. 

We are short 95,000 hospital beds, nationwide and 4,000 in NY, even if we had perfect community services.  When hospitals go down incarceration goes up. There are so few hospitals, today it’s harder to get into Bellevue than Harvard and once in you’ll be discharged sicker and quicker. Here in Albany last week Desmond Wyatt was released from the Capital District Psychiatric Center and killed his mother the next day.  His brother told police Desmond was hearing voices but that didn’t stop the hospital from releasing him.

We have to stop ignoring the seriously ill.

Mental health advocates work to convince the public that violence is not associated with mental illness. That may be true for the high functioning but  violence is clearly associated with untreated serious mental illness. To convince the public mentally ill are not more violent, mental health advocates quote studies of the treated. Those studies prove treatment works, not that the untreated are not more violent than others. Or they quote studies of the 20% with any mental illness not the 4% with serious mental illness. Their studies are of those in the community and therefore exclude the violent: those in jails, in prisons, involuntarily committed, or have completed suicide.

They argue that even talking about violence causes stigma. Talking about violence is a prerequisite to reducing it. It is violence by the small minority that tars the non-violent majority. Their failure to admit to violence is preventing us from implementing policies to reduce it.

We have to stop ignoring the seriously ill.

Current laws prevent people from getting treatment until after they become danger to self or others. That’s ludicrous. Laws should prevent violence not require it. Think seatbelts. But mental “health” advocates want civil commitment to be even more difficult. They argue involuntary treatment is bad without recognizing jail and prison are worse. They argue against medications and restraint and as the NY Times pointed out on Monday that is causing hospitals to become dangerous places. Patients can’t be restrained so hospitals call police. Mental health advocacy is causing seriously mentally ill patients into prisoners.

We have to stop ignoring the seriously ill.

Mental Health Advocates are working to stop Assisted Outpatient Treatment (Kendra’s Law). AOT is the most successful treatment for the small group of the most seriously ill who already accumulated multiple incidents of violence, arrest, incarceration, or needless hospitalization because of their refusal, actually their inability, to be well enough to volunteer for treatment. Kendra’s allows courts to order six months of mandated and monitored community treatment.  It is less restrictive than the alternatives: inpatient commitment and incarceration. It reduces arrest, suicide, hospitalization and violence among people with serious mental illness over 70% each and cut costs in half creating more funds for services for all.

Peer support may do something. But it is not proven to do anything like what Kendra’s Law does. But mental health advocates want to replace Kendra’s Law with peer support.

We have to stop ignoring the seriously ill.

Mental “health”  advocates encourage government to spend more on prediction and prevention. As we heard in multiple sessions yesterday, we don’t know how to predict or prevent serious mental illness because we don’t know what causes it.  They argue we should focus our spending on children because half of all mental illness begins before age 14.  But the statement is only true if you include substance abuse. The study the claim is based on actually EXCLUDED serious mental illnesses like schizophrenia and bipolar. Serious mental illness begins in late teens and early twenties and continues after that. That’s where we have to focus our attention.

Mental “health” advocates argue mental illness is associated with bad grades, poverty, single parent households, and their latest cause, bullying and cyberbullying so we should divert funds meant to help the seriously ill to improve grades, end poverty, improve marriages and address cyberbullying.  Those are worthy social services issues but are not mental illnesses. Spending mental health funds on those diverts attention from mental illness.   Mental “health” advocates claim trauma is a mental illness. Trauma is not a mental illness. PTSD is. It can be extreme or mild.

Stop Diverting the Money!

Mental  “health” advocates blame police when something goes wrong, and want more CIT training as do I. But police only step in when one condition has been met: The mental health system failed. And mental health advocates fail to recognize that as their diverting funds to the tangential rather than the consequential is largely responsible for the system failing. As mental ‘health” advocates abandoned advocating for the seriously ill, criminal justice has stepped up: Largely thanks to Chief Biasotti, the International and NYS Associations of Chiefs of Police, Dept. of Justice, National Sheriffs Association, and others have become the leading voices on how to improve care for the seriously ill.

Now I’d like to turn to how this debate between mental health and serious mental illness is playing out in New York and Washington.

What is interesting to me, is that generally it is Republicans, not Democrats who are helping the seriously ill.  I am a left wing Democrat so it pains me to say, but my party is generally oblivious to the fact that throwing more money at mental health does not improve treatment for people with serious mental illness. Democrats have been captured by mental health advocates and therefore ignore unpleasant truths like not everyone recovers, sometimes hospitals are needed; and left untreated a small subset of the most seriously ill do become violent.

For example, in NY, when Governor Cuomo said he was going to pass legislation requiring therapists to report potentially dangerous mentally ill to criminal justice so they could be banned from owning firearms, there was no way to stop it. But Republicans inserted provisions requiring the reports to go through county mental health directors rather than directly from therapist to criminal justice. Why? Because that was a way to force county mental health departments to become aware of seriously mentally ill who live in their counties. The hope was they would offer treatment not just take guns away.  Directors fought the provision, preferring to keep their heads in the sand.  They called it an ‘unfunded mandate’. Helping the seriously ill is not an unfunded mandate, it is their mandate…

To improve care for people with serious mental illness money is not missing, leadership is. We have to stop listening to mental health advocates and start listening to mental illness advocates. We need to replace mission creep with mission control. As Police Chief Biasotti, testified to Congress:

We have two mental health systems today, serving two mutually exclusive populations: Community programs serve those who seek and accept treatment. Those who refuse, or are too sick to seek treatment voluntarily, become a law enforcement responsibility. …(M)ental health officials seem unwilling to recognize or take responsibility for this second more symptomatic group.”

We have to stop ignoring the seriously ill.

Feel differently? Send a response to [email protected] for possible posting on my webpage.

Spreading the Word: TV Interviews on NBC Washington D.C. & In Boise

11-18-14 My son, Kevin, and I were interviewed last night by our NBC station here in Washington D.C.. The affiliate has broadcast several segments about mental illness as part of a well-received series entitled Changing Minds. We’re grateful to reporter Mark Seagraves for helping us share our story.

In early October, Marcia Franklin, broadcast an interview that she did with me on her popular Idaho Public Television program, Dialogue. Marcia has done several powerful and groundbreaking documentaries in Idaho about mental illness. I was in Boise at the invitation of the National Alliance on Mental Illness Idaho chapter to speak to state legislators about the importance of supporting mental health funding.

His “Crime” Is Autism: Man Gets Another Year In Hell After Being Trapped In Our Criminal Justice System

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11-17-14  WARNING: This story should make you angry!

Washington Post editorial writer, Ruth Marcus, has taken-up the cause of a 22 year-old Virginia man who has autism and has been kept in solitary confinement most of the last year under conditions that are worsening his mental and physical health.

Unfortunately, Reginald “Neli” Latson’s plight is not an isolated happening, given that our jails and prisons have become our nation’s new asylums for individuals with serious mental illnesses and, all too often, those with intellectual disabilities.

Latson’s case is especially egregious.

On May 24, 2010, Latson was nineteen years old and waiting for a public library near an elementary school in Stafford, Virginia, to open so he could return a book. A woman at the school next door called the Stafford County Sheriff’s Office because she thought he looked “suspicious” loitering on the grass.

Latson, who has an IQ of 69, is African American and was wearing a hoodie.

The sheriff’s office sent Tom Calverly, a deputy assigned to the school, to investigate. When Latson refused to tell the officer his name and tried to leave, a scuffle broke out. Calverly shot Latson with pepper spray. Latson reacted by taking the spray away from the deputy and using it on him. Calverly suffered a head laceration, abrasions and a broken ankle.

Latson was charged with assault on a law enforcement officer, wounding an officer in commission of a felony, disarming a police officer and obstruction of justice. A jury found him guilty and recommended that he be sent to prison for  10-and-a-half years.  Deputy Calverly, a 30-year officer, ended his career on disability.

Latson had no previous criminal record.

Autism and mental health groups complained. Judge Charles Sharp told Latson that he had to serve two years in jail, but the judge suspended the other 8 1/2 years.

Sadly, Latson’s problems were only beginning.

Because of his autism and low IQ,  jail officials feared he wouldn’t do well in the general inmate  population so they housed him in a solitary cell used for punishment. He was confined there 24 hours a day with minimal human contact. Not surprisingly, his mental health suffered. He began urinating on the floor and licking it up.

When he became suicidal, he was moved to an even more restrictive “crisis cell” —  an empty room with no bed and a hole in the floor for a toilet. Latson reportedly became more violent. He struck a guard, was shot with a Taser and charged with assault.

Eventually, he was moved into a group home where in March, he got involved in another tussle with a police officer. His probation was immediately revoked and he was returned to jail.

Stafford Commonwealth Attorney Eric Olsen asked Judge Sharp to reimpose Latson’s original ten year prison sentence, claiming that Latson was now prone to frequent violent outbursts, especially when he was approached by police officers.

Latson’s lawyer, Price Koch, called several expert witnesses who testified that imposing Latson’s original prison term would only make his anger, resentment  and mental condition worse. One witness described Latson as “a little boy trapped in a man’s body” with limited understanding of what had happened to him or why.

Judge Sharp, who handled both of the assault cases against Latson, did not force Latson to serve the remainder of his original sentence. Instead, he added an additional year to Latson’s two year term.

Latson is currently back in solitary confinement. Not surprisingly his mental condition has worsen. He has lost fifty pounds.

In her well-reasoned column, editorial writer Marcus noted that most teenagers would have considered it a “harassing annoyance” to be questioned by a school deputy while waiting to return a library book. But “given the rigid thinking and ‘fight or flight’ instincts characteristic of those with autism” it was not surprising that Latson refused to tell the officer his name and tried to run — setting the stage for a still unfolding tragedy.

This is not the first time that a man with an intellectual disability has gotten involved in an encounter that should have been insignificant but became tragic. In January 2013, Robert Saylor was choked to death by officers in Frederick, Maryland, when he refused to leave his seat in a movie theater after the movie ended. He wanted to watch it a second time. Three officers wrestled him to the floor and put a choke hold on him.

In her editorial, Marcus  wrote that Latson was “less a criminal than a victim of his disability” and urged Virginia Governor Terry McAuliffe to transfer him to a locked Florida facility that specializes in handling prisoners with mental illnesses and intellectual disabilities. Marcus wrote:  “The public would be safe and Latson would receive treatment, not futile punishment.”

The case provides us with an all too common example of what can happen when someone with a mental illness or intellectual disability is confronted by law enforcement and ends up in a criminal justice system ill prepared for them.

Police, deputies, guards, prosecutors and judges need to become better informed about mental illness and intellectual disabilities. Crisis Intervention Team training is an important first step.

We need jail diversion programs and specialized dockets for persons whose crimes are clearly the result of mental impairments.

We  need appropriate facilities for individuals who have severe mental illnesses and intellectual disabilities who are violent where they can receive treatment and help. All of us know that a majority of persons with mental illnesses are more likely to be the victims of violence than the perpetrators, but a small percent are violent and we should not ignore the danger that they present nor the need for locked facilities to protect them from themselves and others while they receive meaningful treatment.  (A recent editorial in The New York Times contains shocking statistics about how often psychiatrists and social workers are assaulted by clients who they are trying to help.)

Most all of all, we should end the sadistic practice of confining prisoners with mental illnesses and intellectual disabilities in segregation cells used for punishment. It is wrong and worsens their mental health.

Marcus wrote:

“Solitary confinement can be torture, with serious psychological consequences. For those already suffering from disabilities, the impact can be far more devastating.”

Virginia Gov. McAuliffe should listen to Marcus and immediately remove Latson from the solitary hell where he now is being punished for the  “crime” of having autism.

 

My Favorite World War Two Veteran: My Father

My father on Veterans Day with two of his grandchildren: Kathy and Kevin

My father, Elmer Earley, was in church on December 7, 1941 when Pearl Harbor was attacked, and he and his buddies in his church’s men’s group immediately decided they would enlist. My dad had just turned 21. He tried the Air Force but it wouldn’t take him because he had chronic asthma. The Navy turned him down next. But by that point,  he knew what answers the military doctors wanted to hear so he bypassed the local recruiting stations and drove to Philadelphia where there were no records of his earlier attempts. The Coast Guard took him.

Last month, he turned 94 and although dementia has robbed him of nearly all of his memories and confused his thoughts, when I visited him today at the memory care unit where he lives, he remembered the war and that he had served in the Coast Guard.

It was a reminder to me about how complicated our brains are. My father thinks his siblings are still alive (all have passed) and he can’t tell you what day or year it is. Often his words come out jumbled and it is difficult for him to complete a thought. But he remembered being in the service during the war and how much he loves our country.

Thanks for your service Dad, and thanks to all of the men and women in our military who have and are serving our nation.

The Power of Sharing Our Personal Stories: Josh’s Death and Creigh Deeds

Photo by Matt McClain/The Washington Post

Photo by Matt McClain/The Washington Post

11-7-14 The letter that Anne Francisco wrote to me this week about her son’s suicide has become the second most read blog that I’ve posted, being read by 43,000 on my Facebook page alone and nearly that number on my author’s webpage.

Her letter about Josh’s preventable death is a poignant reminder of how the telling of our personal stories can touch the lives of others.  This week, The Washington Post, published another dramatic example of this that I want to share with you.

A FATHER’S SCARS: FOR VA.’S CREIGH DEEDS, TRAGEDY BRINGS UNENDING QUESTIONS

By Stephanie McCrummen

The Washington Post: 11-1-2014

HE WAKES UP, and even before he opens his eyes, he can see his beautiful, delusional son.

Gus, Creigh Deeds thinks.

He lies in bed a few minutes more, trying to conjure specific images. Gus dancing. Gus playing the banjo. Gus with the puppies. Any images of Gus other than the final ones he has of his 24-year-old, mentally ill son attacking him and then walking away to kill himself, images that intrude on his days and nights along with the questions that he will begin asking himself soon, but not yet. A few minutes more. Gus fishing. Gus looking at him. Gus smiling at him. Time to start the day.

HE GETS OUT OF BED, where a piece of the shotgun he had taken apart in those last days of his son’s life is still hidden under the mattress. He goes outside to feed the animals, first the chickens in the yard and then the horses in the red-sided barn. He leads the blind thoroughbred outside with a bucket of feed, the same bucket he was holding when he saw Gus walking toward him — “Morning, Bud,” he said; “Morning,” Gus said, and began stabbing him — and then he goes back inside.

Breakfast, shower, shave, mirror. Almost a year. He is 56 now. He looks at the scars across his face, around his ear, along his upper chest and right arm. He gets dressed and goes outside to his truck, and there’s the fence that he somehow managed to climb even though he was bleeding, and there’s the field he staggered across to a rutted road where he was found.

This is how most days begin for Creigh Deeds, a father who had a son with mental illness, who struggled to understand him, tried to get help for him, and was ultimately left alone to deal with him, and who now looks over at the barn where he had so suddenly dropped the feed bucket. “I lost a tooth over there somewhere, a gold tooth,” he says, shaking his head a little, and then he goes to work.

HE TURNS ON THE MUSIC. It’s always on as he drives through western Virginia, and he turns it on as soon as he arrives at his office. He’s still a state senator, as he was on the day of the attack, and he is still a lawyer with a two-room office in Hot Springs, where the music stays on even when he’s on the phone.

“I don’t blame you for wanting to appeal, but I don’t think there’s much chance of that working,” he says to a client as Van Morrison is singing.

His longtime secretary, Rhonda, asks him about an invitation to speak at a convention on mental illness.

“Columbus, Ohio?” she calls out over more Van Morrison, who was often playing in the Deeds household when Gus and his three sisters were little.

“I’m not going to Columbus,” Deeds calls back. “Tell them I appreciate the invitation, but no, I can’t go to Columbus, Ohio.”

When he came back to work a week or so after leaving the hospital, he would walk past Rhonda, shut his office door and turn the music on. She would protect him from all the phone calls pouring in, although one time a call came when she was gone and Deeds answered it.

It was a woman who wanted to tell him, like so many wanted to tell him, that she understood how he felt, because she had a son with mental illness.

“I’m sorry,” he recalls saying as he interrupted her. “Did your son stab you in the face?”

“No, but — ” he remembers her saying.

“And did your son kill himself?” he remembers asking.

“No, but — ”

“Then you don’t know anything about how I feel,” Deeds told her, and hung up.

Sometimes, he would read letters.

“I am honored and thankful to have crossed paths with Gus. He was brilliant and kindhearted,” wrote a young man who knew Gus from college.

“We are all reluctant to be a sacrifice but there are times God chooses us, ” wrote a fellow legislator.

“Dear Creigh,” wrote Bill Clinton. “I’m so sorry.”

“Dear Creigh,” wrote Deeds’s long-ago elementary school teacher who recalled explaining the word “inchoate” to Deeds’s class, and who went on to say that he had seen Deeds on TV pressing for changes in the mental-health-care system and that he was so proud to see him turning a tragedy into something positive.

“Nothing can make a more complete and fulfilled life than creating good from evil,” the teacher wrote. “You may now remove ‘inchoate’ from your vocabulary.”

It was one of the few letters to which he felt compelled to respond.

“I’m not complete,” Deeds wrote back.

* * *

HE’S GOING TO LUNCH. He smears prescription-strength silicone sunscreen over the scars. Then he takes out a tube of SPF 60, closes his eyes, and smears that on top of the silicone and all over his face.

“The doctor wants me to keep this on,” he says, eyes closed, rubbing it in a bit impatiently, so that there’s still a film of white when he walks out of his office into the bright noon sun of western Virginia, the place where he grew up and raised four kids, and which he has represented in the state legislature since 1992.

He walks fast.

“Hey, Creigh,” a man says through the rolled-down window of his truck.

Deeds nods his head and keeps walking, crossing Main Street in Hot Springs.

“Hey, Creigh,” say two men working on a car. He waves but keeps moving, finally ducking into Lindsay’s Roost Bar, a dark dive where he sits and puts on his glasses, glancing over the menu.

Before the attack, he mentions, his prescription was 1.75, and after, the doctor told him he needed 2.75s. He takes his glasses off and points to one of his scars.

“This one got my eye socket,” he says.

He reaches behind him to find another scar.

“The first two times I was stabbed in the back,” he says. “He punctured a lung. I think it was back there, probably on the lower left side, the lower part of the lung.”

He touches his dress shirt and tie.

“Then he got me multiple times in front here, across the collarbone,” he says. “The face is what most people see. I don’t take my shirt off.”

He stretches out his right arm and touches those scars.

“I’ve lost some feeling here,” he says.

“I’ve got no feeling in the right side of my face,” he says, touching his right cheek, lip and gum.

“My right ear was pretty much cut off,” he says, touching his ear.

“This was the longer slash over here,” he says, pointing to the left side.

“I don’t know what happened, but a chunk of my tongue is gone,” he says. “There is enough damage to the inside of my mouth that it could have been cut off.”

He feels for the spot in his mouth where he lost the gold tooth. He’s not sure how that happened, either. He was in shock, he explains. There are only some things about that morning he can remember.

He remembers saying into a cellphone to Siobhan, his second wife, whom he’d married in 2012, “I’ve been stabbed.” He remembers limping away, and all the blood, and being found on the road. He remembers the ambulance coming, then the helicopter, then a voice on a radio saying the words “second victim,” and the crowd of nurses and doctors meeting him at the hospital.

He remembers waking up after surgery, and the tube that was in his mouth. He couldn’t speak. He remembers the nurses hurrying to remove it, and he remembers what he said, the first question, looking at Siobhan and holding out his arms.

“I just said, ‘Gus? Gus?’ ” he says, holding out his arms again.

* * *

HE IS DRIVING, window down, arm out in the warm passing air. He can count most days on having some time alone in the car, winding through the Appalachian Mountains that Gus loved.

“Whatcha gonna do,” Van Morrison sings in the truck.

“ ‘Whatcha gonna do,’ is right,” Deeds says back.

He passes the church where Gus was baptized, the river Gus fished, a camp where Gus learned music, the schools where Gus excelled, and the green football field where Gus played in the band, and now, on a clear fall afternoon, he sees the band out there practicing.

“Probably someone is playing one of Gus’s trombones,” he says.

He gave them away. He decided before he left the hospital that he didn’t want physical reminders of his son. He would have the memories he chose to have. So he asked his family to clear out Gus’s room at home, where he had been living, and they hauled off his clothes to Goodwill, his pants and shirts that had become increasingly colorful and large as Gus had gotten sicker, heavier and more delusional.

They gave his electric drum kit, an electric organ and his two trombones to the Bath County High School band. His acoustic guitars, his squeezebox, harmonicas, a left-handed fiddle and a banjo Gus made out of a bucket and wood were sent to Nature Camp, where he had been a counselor.

Deeds still has one banjo he’s not sure what to do with. The day before the attack, he had become so worried about Gus’s behavior that he obtained an emergency custody order to have him taken to the hospital for a psychiatric evaluation, and Gus had been playing the banjo on the front porch when the sheriff arrived. He had seemed calmer when he was playing.

He has most of his son’s books, also — encyclopedias he’d read at night when he was a kid, and so many novels, histories, books about Gaelic mythology and anything Irish.

“I’m not sure I’ve met anybody like him,” Deeds says. “He was all the things I wanted to be. I’m not smart, not good at anything, not coordinated, can’t sing, no musical-instrument ability, no gift for languages, and he had all that. I don’t have any of the confidence he displayed at every moment.”

All of which made it more difficult for him to understand his son as he became sicker, Deeds says, driving along.

“What did I miss?” he asks, and here come more questions, the questions of a father wondering when he should have begun to see his son as a person who was becoming ill. “What was there that should have tipped me off? What should I have seen?”

There was Gus’s first year at the College of William and Mary, when he was serious about a young woman from Colombia, went to visit her there and came home dramatically heartbroken. Was that unbridled love, Deeds wonders, or the beginning of his unraveling?

He was making the dean’s list, and seemed proud of that. He took a semester off in the fall of his junior year to campaign all over the state with his dad when he ran for governor, playing banjo along the way, and had seemed happy doing so. Was he not as happy as he seemed? Was the illness already taking effect?

After Deeds lost the campaign, he and Gus’s mother split up and Gus took off on a road trip across the country, writing bad checks along the way and later saying he was baptized on the Oregon coast. Was that delusional behavior or a youthful search for meaning?

“I thought it was strange but not that unusual,” Deeds says.

He took another semester off in the spring of 2010 to work in Gary, Ind., coming home at one point with a young woman, and coming home at another point but leaving his clothes and banjo in Gary, and coming home for good to live with his mother when Indiana did not work out. Was that Gus being eccentric or erratic or both?

Finally it was too much to ignore, and Gus’s mother had him evaluated. Gus was given a diagnosis of bipolar disorder, and at some point that Deeds cannot remember, he was told about it. His son had a mental illness.

“I never wanted to believe that about my son,” Deeds says. “I just wanted to get him back.”

He kept trying to get him back. He helped Gus get a job washing dishes at the Homestead, a sprawling mountain resort in Hot Springs, because surely the structure of a job would help, but then Gus got fired after some sort of fight Gus never explained, and in June of 2011 he moved in with his father, the two of them together in the old white wooden house in Millboro.

Deeds would go to work. Gus would garden all day, planting vegetables by hand, and then go out hunting coyotes at night. He had always been interested in weapons as a kid growing up in the country, but now he had a closet full of homemade knives, bows and arrows. Once Deeds came home and Gus was sitting at the table in shorts, no shirt and bare feet, holding a homemade spear. He started burning things in the outside furnace, old yearbooks, photos, one of his banjos. At that point, he was all skin, muscle and bones.

“I said, ‘Gus, what’s going on?’ ” Deeds says.

“He was having delusions, and I was under the illusion that things would work out. I’m optimistic. Sometimes I’d say to Gus, ‘Come on, pull yourself up.’ For a period of months, he had this book, ‘Confederacy of Dunces,’ and I said, ‘You’re like the hero in the book,’ ” he says, referring to the brilliant, eccentric, philosophical but also slothful main character. “I said, ‘Come on, Bud, you’ve got to do better than this.’ I said, ‘Gus, what’s the plan?’ ”

He shakes his head at how he reacted.

“I just didn’t know what to do,” he says.

He had no information. Gus was an adult, and so his medical records were private.

“When I’d ask him about it he’d just say, ‘That’s a private matter, Dad.’ ” The one psychologist who did talk to Deeds said Gus’s bipolar disorder was not typical, that he would eventually get off his medications, and Deeds believed that.

“I believed in Gus,” he says. “I believed he would snap out of it.”

Then Gus started talking about suicide. “He’d say, ‘I just feel like I’m going to end it,’ ” Deeds says. “He’d say, ‘Dad, I feel like I want to die.’ ” Deeds obtained a court order to have him committed to a hospital, which is possible if someone is deemed a danger to himself or others. Was that the right decision?

He thought so, remembering what Gus had told him in the hospital — “He said, ‘Dad, this is where I need to be,’ ” Deeds says — but a few months later, when Gus was talking about suicide again, and Deeds had him committed again, Gus resented it.

“But he was back on his medications,” Deeds says, reassuring himself. “He went back to school.”

He went back to school until the fall of last year, when Deeds started tracking his son’s Facebook page and saw that he was becoming paranoid, writing that professors were ganging up on him.

“I messaged him and said, ‘Is there anything I can do, Bud?’ ” he says.

Gus said he wanted to leave school again. But now Deeds was afraid for him to come home, for a variety of reasons: His son’s symptoms were getting worse. Deeds and Siobhan had a trip coming up to Ireland to bury her mother. He was worried about Gus being alone.

Gus’s mom dropped him off near midnight at the house in Millboro. It was clear he was off his medications. His appetite had become ravenous, and he’d gained a huge amount of weight. He would barely engage in conversation, giving one-word answers. He would look past his father and laugh at nothing in the distance.

“I panicked,” Deeds says, and soon he is circling back to the beginning, trying to figure out how things reached that point.

“He was just a sensitive little boy, a very sweet child,” he says. “No sign of what would happen.”

* * *

HE IS HAVING DINNER. It is just him and Siobhan. They are at a house Siobhan owns in Lexington where Deeds came after he left the hospital.

Over there is the couch where he spent so many days reading. Siobhan took all the phone calls coming in, and he read one book after another to focus his mind — “How the Irish Saved Civilization”; a biography of Robert F. Kennedy. He recited the Serenity Prayer over and over. Eventually, he started reading a journal that Gus had been keeping, page after page in which his son re-imagined his childhood, saying he was beaten and starved for 24 years. Deeds understood the journal entries were a manifestation of his son’s delusional thinking, but they bothered him all the same, and now not a day goes by that he doesn’t need to look at old photos of Gus to remind himself that his son was happy before he became sick.

He has not talked about any of this with a counselor, as some people have urged him to do, although he did talk to a priest. He says he wanted clarification on Gus’s hereafter, and he had some other questions, too.

Mostly, he talks to Siobhan, as he is doing over dinner when he puts his head in his hands and says, “I could have done more,” and Siobhan says, “You did everything you could do.”

He is shaking his head and saying that he didn’t realize how sick Gus had become, didn’t imagine that his son could be violent.

“I should have known,” he says, his head still down.

Siobhan has her hand on his back.

“I probably did know,” he says.

* * *

HE DRIVES TO RICHMOND. He walks into Senate Room B, Siobhan holding his hand. He sits at a long dais and bangs a gavel, facing a room full of mental-health workers, state officials and families assembled for the first meeting of the Joint Subcommittee to Study Mental Health Services in the 21st Century.

“I’m Creigh Deeds,” he says after the other legislators introduce themselves. “I represent the 25th District. You know who I am.”

Before everything happened, his legislative work revolved around economic development, cleaning up a Superfund site, transportation, electoral law and public safety. He supported changes to the mental-health-care system after the 2007 Virginia Tech massacre, but it wasn’t until the day before Gus attacked him that Deeds fully grasped how dysfunctional the mental-health system could be.

That was the day he obtained an emergency custody order for Gus once again. But at the hospital, the legal time limit to find a psychiatric bed for someone deemed to be in need of commitment — at the time, six hours in Virginia —was reached before a bed could be found, at which point Gus was sent home with his worried father.

Then came January, two months after the attack, when Deeds returned to the state legislature, his scars still raw, his eyes red from crying, knowing, he says, that “it would be damn difficult” for legislators to say no to his requests, which they didn’t. Now, because of Deeds, the legal time limit to find a bed is up to 12 hours, and if no bed can be found, the state psychiatric hospital must provide one.

There were other changes, too, but not enough, Deeds says, and so now he is chairing the subcommittee to study Virginia’s mental-health system.

He introduces an official from the state attorney general’s office to talk about Virginia’s involuntary-commitment laws. He welcomes the new mental-health commissioner, Debra Ferguson, who talks about a system that emphasizes community-based treatment, early intervention and recovery.

“As you can imagine,” she says at one point, “there are tragic consequences if someone needs services that can’t be provided.”

Deeds smiles and looks down at his notes.

He calls on an advocate who says that the mental-health system neglects the small percentage of people with the most serious mental illnesses. He says that such people often need 180 days to get medications to work properly, and that the average psychiatric hospitalization is five days, after which families are usually on their own to deal with a medical condition that can be as complex as cancer.

Deeds calls a few others signed up to speak.

“We had a family member with schizophrenia and spent $10,000 trying to help her,” begins the first woman, adding, “She’s stayed in nine different places. . . . She can’t stay with us, because we are afraid she will poison our food.”

He folds and unfolds his arms. He bites the end of his reading glasses.

“My brother has been diagnosed with schizophrenia since he was 16, and he’s now 33, and we can’t make him take his medications,” begins another woman, explaining that her brother has had three psychiatric commitments in the past six months and there’s nowhere for him to go except jail, where he is now.

People come up to him in hallways with such stories. People write letters and e-mails. One man left a message on Deeds’s official voice mail, crying, saying he was going to kill himself and had already said goodbye to his children.

“This is the story of Sam,” began an e-mail about a 46-year-old man whose body was found in the James River a few days after he told a relative he was delusional, then went to a hospital to get help but was released without any family being contacted.

“Jeff was bipolar,” began another. “A very bright, good looking, well liked and loved, talented in many endeavors, funny man who loved his family dearly, who . . . chose, for only God knows what reason, to take his own life.”

“Kyle was a brilliant and talented man,” began a memorial-service bulletin that arrived with a letter from the young man’s father, a Nebraska doctor who said that his son had killed himself and that he was writing “to ask for suggestions, if you have some, for what I might do here in Omaha.”

“Would you please consider changing the current laws that block parents from knowing what is going on as far as treatment for bi-polar?” wrote a woman who included a photo of her son winking into the camera, the words “a needless death” written underneath.

“My daughter was accosted to the ground and pepper sprayed in her

eyes . . .”

“My son, Joseph . . .”

“My daughter Teresa . . .”

“My brother’s suicide by starvation . . .”

“There were no beds available for

Matt . . .”

“The police arrived and were absolutely clueless . . .”

“You did not fail your son the system did.”

His legislative aide, Tracy, has indexed and filed the mail in boxes stacked in his district office in Charlottesville for him to read, not that he does. Instead, when he goes there for meetings, as he does a few weeks after the Richmond panel, he turns on his music, which is playing at a medium volume through his computer speakers as people arrive for appointments.

“Creigh Deeds,” he says over the singing, holding out his numb right arm to shake hands with two women who run a free mental-health clinic.

“What can I do?” he says to a psychiatrist who wants to participate in reform efforts.

“That’s what I was going to ask you,” the psychiatrist says, glancing at the speakers. “Is this a good time?”

“It’s as good a time as any,” Deeds says, and the psychiatrist talks over the music for a few minutes about problems with emergency psychiatric care. Deeds presses a pen into his cheek and massages his forehead. The psychiatrist finishes. Deeds says nothing.

“So?” the doctor says. “Any questions about what I’m doing?”

“I’ve got lots of questions,” Deeds says.

* * *

HE IS GETTING READY for a parade. It is a hot bright Labor Day in Covington, and he is smearing the sunscreen over his scars.

“Did you put the silicone on?” asks Siobhan, who is dropping him off at the staging area.

“I did,” he says and rubs in another layer, gets out of the car and takes his place near the silver-buttoned Allegheny High School band tuning up in the sharp sun.

“Mr. Deeds,” says a young man, showing him to his spot. “How are you, sir?”

“Just got to keep going,” Deeds says.

“You got a lot of support here,” says a man in a union T-shirt.

“I got a lot of things to do,” Deeds says, and soon the parade starts, stretching out of the parking lot, first the band, then a trailer hauling Little Miss Bath County, then the little-league football team, then a jeep flying an American flag, then Sen. Mark Warner, who says “Hey, everybody!” and now him. Here he goes.

“I’m Creigh Deeds,” he says to a woman on a grassy corner as he heads out into the streets of the factory town, where most everyone seems to know him.

“Hey, Creigh. How you doing, man?” says a man on the sidewalk.

He nods, shakes a hand and keeps moving.

“Creigh!” says a man under a tree.

“Hey, Creigh,” says the woman next to the man.

He waves and keep moving, zagging across the street to a man in a John Deere hat — “How you doing, Creigh?” — to the people in front of the craft shop — “Creigh!” — to the parents and strollers on along North Monroe, where a man in a black bandanna yells out “Hey, Creigh!” and a woman, seeing Deeds, says nothing and holds out her arms and hugs him tightly until he says “Gotta keep going” and jogs to the other side of the street.

“How you doing, brother? Been thinking about you!” a man calls to him, and Deeds runs to the other side, almost tripping on a baby stroller, sweating.

“Hey, Creigh!” says a woman with two friends.

“Hey, Julia,” he says.

“How you doing, Creigh?” says a man with her.

“All right,” he says, running ahead, dress shirt drenched, face red and dripping.

Handshake, handshake, nod, wave, run.

“Hey, Creigh!” a man yells. “Good to see you!”

Deeds waves and he zags to the other side of the street, runs in front of a cluster of bagpipers and Little Miss Covington and a group of Warner supporters who stop their chanting for Warner while a man with the microphone says, “Ladies and gentlemen, Creigh Deeds!” and the supporters start chanting “Deeds Not Words! Deeds Not Words!” and Deeds keeps running.

He is out of breath. He shakes hands with a man in a wheelchair.

“I haven’t seen you to say I’m sorry about your situation. I really am,” the man begins, and Deeds says thank you and hurries on, back past the bagpipers to the other side, where a woman yells “Creigh!” and now he is falling behind his spot in the parade, and he is trying to catch up when the same woman calls out again.

“Creigh!” she yells, and starts running after him, a skinny boy jogging alongside her.

“Creigh!” she yells, and Deeds is still running ahead, and she and the boy are weaving through the people, chasing after him.

“Creigh!” she yells louder, and he turns around, and she is waving her arms, and she and the little boy catch up to him, and the three of them stand there a moment as the parade goes on, all of them out of breath, and now the woman is trying not to cry.

“I want you to meet my nephew,” she says, trying to contain herself.

She whispers something to Deeds, and he looks at the boy, and the boy stands straight, smiles sweetly and holds out his hand, and Deeds hugs him, pulls him close, lays his cheek on the boy’s head, and then turns and keeps running on North Lexington.

“Bless you, Senator!” yells a woman.

“Hey, how are you?” yells a man.

“Hey, Creigh!”

“Hey, Creigh! Looking good!”

He runs past the Good News Christian Fellowship church and Halsey’s repair shop. One more block.

“Creigh Deeds,” says a woman on West Pine. “You coming along all right?”

Siobhan grabs his hand and takes him to the car, where he drinks a bottle of water as they drive. He turns on music.

“Robin introduced me to her nephew,” he says after a while. “He’s got Gus’s trombone now. Take a left here.”

They are winding through thick woods and a sparkling river with smooth rocks where people are swimming.

“I couldn’t take it when she brought that little boy to meet me,” he says.

He looks out the window, takes off his glasses and starts massaging his eyes. He changes the music to a singer Gus listened to often, a singer who committed suicide, a singer he says he listens to when he is trying to understand how his son must have felt.

He is still massaging his eyes. He opens his hand and covers his face. He slides the hand into his hair and starts pulling it as they drive along the river.

* * *

HE IS THINKING ABOUT GUS.

He is thinking about Gus because he is always thinking about Gus. When he drives, when he works, when he’s having dinner, when he’s in a parade, when he wakes up and goes to sleep and closes his eyes. He’s always circling back, always with questions.

He is thinking now about Saturday morning, the attack three days away, when he had just gotten back from the Ireland trip and was reading all the mail Gus hadn’t opened about all the psychiatric appointments he had missed.

“What if I’d been able to put off the Ireland trip?” Deeds says. “We tried to have Grandma check on him, his other friends. Everything just fell apart.”

He is thinking about that evening, seeing Gus take a soda out of the refrigerator, guzzle it down and throw it in the trash. He is hearing himself say to his son, “Bud, you know we recycle in this house,” and hearing Gus say in a voice that frightens him, “You have no right to talk to me like that.”

“I didn’t know what to think,” he says.

He is thinking about reading his son’s journal — this was Saturday or Sunday — where Gus had described himself as godlike, referred to his father as his “dog,” and indicated that he found the two guns in the house. He is remembering how he took the shotgun apart into three pieces, taking one piece to work, leaving one in a drawer and tucking one under his mattress, and how he didn’t worry about the other gun, because it had no ammunition.

“I couldn’t find it to buy,” he says. “I don’t know how Gus got ammo for that gun.”

He is thinking about Monday, the attack one day away, when he got the emergency custody order, and he can still see Gus pacing back and forth in the hospital. He is thinking about how his stomach turned when he was told no bed could be found, and how quiet Gus was on the way home.

“I know he felt I betrayed him when I went and got the order,” Deeds says. “I don’t feel I had a choice. I did what I did to try to save him.”

He is thinking about that night, and the text message he got from Siobhan, who was staying in Lexington. “She said, ‘Get out of that house,’ ” he says. “I said, ‘No, I’m going to stay with my son.’ ” He is thinking about when he went to bed and, for the first time ever, locked the bedroom door, and heard Gus rattling it, trying to get in.

“I never thought he would try to kill me,” he says.

He is thinking about Tuesday morning, and showering first so he would be ready when Gus woke up, and then going to feed the animals. He can feel the bucket in his hand, and he can see Gus walking toward him, and now he is thinking about how Gus seemed to be aiming for his eyes, and he is hearing Gus grunt with effort, and hearing what he said to his son in that very moment.

“I said, ‘I love you so much,’ ” Deeds says.

And then it is Wednesday, and Thursday, and every day since, and the questions are starting and spiraling into the hardest question of all, one he returns to over and over.

Why did Gus stop?

Because that’s what happened. He stopped and walked away without saying a word.

Why did he walk away? Why did he not say anything?

Why did he stop?

He is remembering something his daughter Susannah said to him.

“That once he heard ‘I love you,’ he softened up,” he says, “that he just wanted to prevent me from interfering with him killing himself.”

He is finishing lunch one day.

“Maybe he figured he did the damage he needed to do to kill me,” he says. “Maybe he’d seen enough blood.”

He is in his office in Hot Springs.

“If he had bullets he could have shot me across the yard,” he says. “He could have. Gus was a good shot. He wanted me to suffer.”

He is with Siobhan.

“You said ‘I love you,’ ” she is reminding him.

He is home in Millboro, where he asked the priest to come and bless the house after everything happened, where he scattered Gus’s ashes by an oak tree, by a river and on a mountain his son used to run when he was healthy, one he can see from his yard.

“If you read what he wrote in his journal,” he says, focusing on a passage he read later, where Gus wrote that he would ascend to heaven after he killed his father, “it’s hard to think anything other than he intended to kill me.”

He is getting into his truck.

“I like to believe what Susannah said,” he says, going back to his daughter’s theory. “That when I said ‘I love you,’ that broke through. That he was still delusional, but that did break through, and the old Gus heard that. Not the old Gus — Gus. That those things that had taken over Gus were defeated.”

He is shaking his head.

“I’ll have these questions for the rest of my life,” he says, and begins asking them again. Did Gus want to kill him? Did he know his father loved him? Did he hear him? Is that why he stopped? The questions keep coming, even though by now he has realized the inescapable answer.

“I’m never really going to know,” he says, and once more he is driving, music on, window down, and winding through the woods.