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The Making of a Hellhole

Mental Health in a Sorry State: Henry Horner Children's Center, opened with such enthusiasm 16 years ago, stands today as a case study on the devastating impact politics can have on the ability of state-run institutions to operate therapeutically.



Life has never been easy for Scott. The Chicago teenager has long suffered from periods of deep depression and fits of uncontrollable rage. His working-class parents couldn't afford private care for him. So when Scott needed hospitalization last year, he ended up at Henry Horner Children's Center, at 4201 N. Oak Park, the largest public mental-health facility for children and adolescents in the state, and a hospice of last resort for the poor, the parentless, and the underinsured. Scott spent nearly a year there, and his memories of Horner are like open wounds.

During his first two months of treatment Scott saw his individual therapist only twice, and throughout his stay he received no family therapy whatsoever. He and the other boys on his unit were taken on occasional outings to the local shopping mall or to the gym on the grounds, but otherwise they had little to do all day but "sit around, watch TV, and get fat."

Whenever Scott's temper got out of hand, the nurses on the unit would stuff him with Thorazine, a medication used to control unruly behavior. If he resisted, he would either be forcibly injected or clapped into leather restraints. Scott remembers once being so doped up on Thorazine that he fell backward out of a bathroom stall, hitting his head on the floor. "I lay in the bathroom for about five minutes. They didn't even know I was in there."

Scott saw children languishing in restraints for hours on end. He recalls security guards sandwiching a patient between the box spring and mattress of his bed and then lying on top of him--after they had him strapped down. He says a male nurse on the unit once grabbed a friend by the hair and slammed his head into the bedroom lockers. He also recalls seeing a patient in the restraint room--strapped down and unattended--being sexually molested by another boy on the unit.

The food at Horner, Scott says, was often greasy and occasionally seasoned with dead fruit flies or human hairs. Crumbs and crushed milk cartons littered the dayroom, and the bathrooms stank of urine. Feces smeared on the bathroom walls would sometimes remain there for days.

Children ran away from Horner regularly, even though they lived on locked units. "It was so easy," Scott says. They would either pour out of an open window or pull the fire alarm and escape when the doors automatically swung open. Or they would take off while a group was being walked to classes in a separate building on the grounds. The only thing standing between them and freedom was a six-foot-high chain-link fence. They would run because they were bored or, like Scott, because they just couldn't take it anymore. "I don't think that place should even exist," he says. "They just misuse everybody."

Scott's delivery is rapid-fire, a little jumpy, and your first impulse is not to believe him. He is a teenager, after all, and a deeply troubled one. But according to Benjamin Wolf, the American Civil Liberties Union's advocate for institutionalized children and adults in Illinois, Scott's story is far from unique. "I've interviewed maybe 50 kids at Horner over the last four years, and they've all told me the same thing," he says. "When you have that many kids reporting incidents of violence and sexual assault and staff misconduct, that in itself is evidence of serious problems--even if every particular story isn't true."

Wolf has been keeping close tabs on Horner since December 1986, when the ACLU filed a class-action suit against the facility on behalf of its residents. The suit alleges, in part, that severe overcrowding and understaffing have created a virtual therapeutic vacuum in which patients' rights are abused with alarming frequency.

Much has changed in the four years since the suit was filed--funding has been increased, long-vacant positions have been filled, new programs have been added, and the administration has become better at monitoring quality of care and weeding out patient abuse. But, says Wolf, conversations with patients and reviews of internal documents reveal that the worst of the conditions persist.

In many ways Horner itself is a victim of abuse and neglect. The facility--opened with such optimism 16 years ago--stands today as a case history of the devastating impact of politics on the ability of a state-run hospital to operate therapeutically. Encoded in that history is a blueprint for reform of the way the mentally ill are treated in Illinois. Because in the final analysis, Horner is just the tip of the iceberg. Many consider the facility and its problems to be only the most blatant example of the systematic dismantling of the state mental-health-care system under the 14-year stewardship of Governor Jim Thompson.

"The political football game that has been played with Henry Horner Children's Center is a prime example of the way the current administration has run mental health into the ground," says Wolf. "With its periodic arbitrary slashing of staff, its occasional efforts at reform that are then subverted, and its cosmetic changes in the face of litigation, I think Henry Horner serves as an archetype for these problems."

The ACLU suit, which could come to trial this winter, will be one of the first items on the new governor's agenda. Yet neither Republican Jim Edgar nor Democrat Neil Hartigan has plans for Horner that he is willing to discuss publicly, though on the campaign trail both have expressed a commitment to efficient, competent care for the mentally ill. Still, there is a striking difference between their overall approaches to reform and between the policy advisers who have helped them define those approaches.

Edgar, the cautious technocrat, is calling for incremental change. His counselor on mental-health issues is Michael Belletire, a no-nonsense administrative troubleshooter brought in by Governor Thompson in 1982 to clean up the state's Department of Mental Health and Developmental Disabilities (DMH), of which Horner is a part.

Hartigan, the high-minded reformer, favors a more cataclysmic approach. The principal architect of Hartigan's mental-health platform is Dr. Ronald Davidson, a firebrand former civil rights activist who was hired by Belletire in 1985 to whip Horner into shape.

Both Davidson and Belletire were tenacious in their pursuit of reform. But they approached it in vastly different ways, which would seem to indicate differences in how Hartigan and Edgar would deal with a mental-health-care system in crisis.

Davidson sees his candidate as the only real hope for the resurrection of DMH--as does Belletire. Davidson contends that Edgar's cautiousness is part and parcel of a "say nothing, do nothing" campaign that masks a lack of commitment to real reform. And Belletire argues that Hartigan's visionary talk is nothing more than "lip service" designed to win votes from special-interest groups.

Whichever candidate wins, one can only hope that the criticism leveled against him is mere campaign rhetoric. For the well-being of our state's most vulnerable children hangs in the balance. They come to Horner overagitated, self-destructive, severely depressed, and out of control. They have heard voices, set fires, jumped in front of cars, and killed their siblings. They have been betrayed by their biochemistry and undone by their environment. Their parents are alcoholic, abusive, or simply unable to cope. Mental-health professionals disagree on the best way to reach these kids. But all will concede that before any real therapy can take place, they need a consistent, nurturing environment peopled by reliable care givers--from the governor on down.

Horner was built in 1974 as a remedy for the problems that now afflict it. Until that time most of the children and adolescents in the area were housed in a decaying building of the old Chicago State Hospital, a vast and largely vacant facility bordered by Irving Park, Narragansett, Montrose, and Oak Park. The units were poorly staffed, physical conditions were abominable, and community agencies and family groups were clamoring for change. So a new facility was built on ten acres on the grounds of old Chicago State. "Our goal was to provide a state-of-the-art facility for children and adolescents," says Dr. Prakash Desai, director of DMH's Chicago region from 1973 to 1979. "In the process, we hoped to create an environment that would be attractive to the highest quality professionals. In the beginning at least, I think we were quite successful."

In design Horner is more like a summer camp than a psychiatric hospital. One cluster of oversized cottages houses eight inpatient treatment units. Other buildings contain a swimming pool, a gym, classrooms, activity rooms, and administrative offices. The bedrooms on the units are designed for communal sleeping, and the nurse's stations are tucked discreetly away from the hubs of patient activity.

The original direct-care staff-to-patient ratio of 2 to 1 is well above today's standard (1.6 to 1 is now considered an absolute minimum). Each unit had a chief administrator, a psychiatrist, a pair of psychologists, a half-time pediatrician, two social workers, a pair of activity therapists, nurses, psychiatric technicians, and a psychiatric specialist.

A cadre of administrators oversaw the activities of each professional discipline. These "discipline chiefs" recruited, supervised, and evaluated staff, and coordinated regular in-service training sessions. They also monitored a steady flow of interns from the local professional schools, which increased the level of patient care while creating a ready supply of new recruits.

Each inpatient unit at Horner contained no more than 20 beds, and the facility's service area extended only from Lake Michigan to the Chicago city limits and from Roosevelt Road to the near north suburbs. The facility had an open house each year and regularly presented seminars on different aspects of its work. "It was a very exciting, very vital place," says a Horner employee from that time. Like most of the dozen or so current and former DMH employees who agreed to be interviewed for this story, this staff member insisted on anonymity out of fear of retaliation. "We were getting the staff we needed because people saw it as an opportunity, and we were getting the involvement of professional schools because of the reputation of our programs."

This golden age was cut short in 1977. Under steadily mounting pressure from the Thompson administration and the state legislature to reduce spending at state facilities, the Department of Mental Health began lopping staff positions at Horner and closing other children and adolescent units in the area. The shuttering of such units at the Elgin Mental Health Center in 1977 added most of Lake County to the Horner service area.

A DMH task-force report from 1978 revealed a dozen staff vacancies and overcrowding on all but two of the inpatient units. Staff morale was low and the turnover rate was high, according to the report. And the patients saw Horner more as a "place to live" than a source of treatment.

By 1980 Horner's service area had been expanded north to the Wisconsin border, west into Du Page County, and south to Indiana. In 1982 DMH was forced to cut more than 2,000 jobs, and Horner was particularly hard hit. Of the facility's 272 employees, 125 either lost their jobs or quit, leaving 175 approved positions and 18 vacancies. An appeal the next year for an additional 53 positions was rebuffed--and then more were cut. By June 1984 Horner had 162 approved positions and 22 vacancies; the direct-care staff-to-patient ratio had dropped to slightly more than 1 to 1.

Most of the cuts took place at the administrative and professional levels. The cadre of discipline chiefs was eliminated, and with it went any hope of assuring quality. And without the overseers, the local social-work and psychology schools stopped sending trainees. Many of the remaining professionals who could find jobs elsewhere took them.

The nursing and technical staff was gutted in a different way. Since they held civil-service jobs, and since positions throughout the department were being cut, many of these staffers were "bumped" by employees with greater seniority from facilities for the adult mentally retarded. According to staff at the time, these replacements had neither the skill nor the sensitivity to deal with the children at Horner. "We took a lot of people who had no background in mental illness, and we stuck them with conduct-disordered, severely disturbed adolescents," a former Horner employee recalls. "A strong-arm mentality took over. They didn't see the kids as victims of abuse and neglect, they saw them as spoiled brats. Many of these [employees] could have been salvaged when they were ingested into the system if somebody had tried to do some training." Unfortunately, nobody did.

Over time, three of Horner's eight units were closed and their populations were shoehorned into the remaining five. As pressures on the staff mounted, morale deteriorated--along with the physical condition of the facility.

A site assessment conducted by the department in early 1984 labeled one unit a "disaster," pointing to broken furniture and equipment, a burned-out activity area, and filthy walls. A review conducted later that year to determine the causes of Horner's mounting runaway problem cited "an overall climate of neglect and carelessness." Lockers and walls bore huge gang insignias, and doorknobs were missing. One staff member reported that a stretch of floor on one of the units hadn't been cleaned in more than two years. The facilities had the "appearance of pervasive disorganization, a lack of discipline and a structureless program," according to the assessment. "Staff members were angry, frustrated, felt intimidated to the point where they felt they could not perform in a satisfactory manner."

Worse yet, patient abuse was on the rise. A 1983 investigation of Horner conducted by the Guardianship and Advocacy Commission, a state-funded watchdog group, found that residents were being prescribed medication without the consent of their parents or guardians. A system-wide investigation conducted in 1984 uncovered one instance in which a Horner resident was placed in solitary confinement "for nearly half his waking hours for over a month." A staff report that same year revealed that a nurse at Horner had slapped one of her patients so hard across the face that she drew blood. The patient was in restraints at the time.

Horner's communal bedrooms and recessed nursing stations made monitoring patients virtually impossible in the absence of adequate staff. "What happens when you can't keep an eye on these kids is that they intimidate one another, they physically harm one another, they sexually assault one another," a former employee says. "It's a nightmare what happens to these kids when they're left to their own devices."

By the mid-80s the facility had descended into chaos. A DMH internal memo from early 1985 noted that in one six-month period children at Horner had racked up a staggering 246 incidents, including fights, sex acts, self-inflicted wounds, and running away. A staff report from the same time indicates that one of the mentally ill boys at Horner had been coaxed into performing oral sex on a trio of fellow residents on several occasions. In a heartbreaking letter written to Ben Wolf a couple of days after he filed the ACLU suit, the mother of a former Horner patient described how her son had been raped by two other patients within six days of his arrival. "One held his mouth shut so he couldn't speak while the other raped him," she wrote, "and then they switched."

By far the worst of the problems at Horner were being caused by transferees from the Illinois Department of Corrections (DOC). Some of these transferees were truly in desperate need of hospitalization; one had mutilated himself on nine occasions in a three-month period. But a DOC memorandum from 1985 indicates that Horner was being used by perfectly sane inmates as a perverse sort of underground railroad. It stated that El Rukn gang members who entered the DOC system would feign lunacy to win a transfer to Horner, where a security guard with ties to the gang would help them escape. Another popular means of escape, according to a Horner staff report from the same period, was to start a fire, wait for the fire alarm to go off and the exit door to swing open, and then run into the night.

Perhaps the most influential internal document ever written against Horner came from the pen of Ronald Davidson. Davidson was doing consulting work at Horner while directing children and adolescent services at the Illinois State Psychiatric Institute. At the time, ISPI was one of the few state-run mental-health facilities with a reputation for something other than overcrowding and patient abuse.

Davidson had been called out to Horner in December 1984 to help the distraught staff deal with the fact that a group of adolescent boys had run amok the day before. The patients had taken hostages, barricaded themselves in a bedroom, and set fire to a mattress. Chicago fire fighters had to hack open the door with axes.

"I got there the morning after to find out what went on. Some truly amazing things emerged and some truly scary things," Davidson says. "I remember one guy saying, 'Well Doc, what ya gotta understand is this ain't ISPI, this is Horner. When you work in a place like this, there's a certain acceptable level of violence that goes on that you can't do anything about. You don't have the resources, and you don't have the power to change it--so you just kinda accept it.' I'm looking around the room as he's saying this, and people are nodding their heads in agreement."

Shortly after, when a colleague who was being considered for director of Horner asked Davidson for his advice, he responded with a blistering 12-page assault on conditions at the facility. The memo fell into the hands of DMH director Belletire, and in March 1985 Davidson was sent to clean up Horner. "I wanted someone with bluster and presence--I felt that was important--and I wanted someone who was driven. That's part of the reason I ended up relying on Ron," Belletire says. "And I wanted someone with professional credentials, because I didn't want that person to be demeaned by other professionals."

Davidson was made acting director of the Institute for Juvenile Research, which at the time had direct responsibility for all children and adolescent services in the Chicago area. Davidson's first inclination was to wipe Horner off the map, but there weren't enough vacant units in other area facilities to pick up its patients. So he turned his attention to damage control.

The only way to get a handle on the worst cases at Horner, he reasoned, was to remove them from the facility altogether. So he retrained the staff on the most troubled Horner units and rounded up the DOC transferees and other problem cases, put them on a bus, and shipped them over to ISPI.

If Horner resembles a summer camp, ISPI looks for all the world like a prison. It is stacked 11 stories high on the edge of the University of Illinois at Chicago campus. Its two exits are guarded constantly, and its outdoor-activity area is surrounded by a 12-foot-high cyclone fence. Its nurses' stations have clean sight lines down long halls flanked by 15 single bedrooms.

But ISPI has long been a model for the level of care that Horner was able to muster only briefly. By 1985 ISPI had twice Horner's ratio of nurses to patients and triple its ratio of professionals to patients, according to calculations done by Davidson. And that didn't take into account the half dozen trainees, interns, and residents that swarmed over each ISPI unit. The patients at ISPI received individual counseling as often as once a day and family therapy at least once a week. And when they weren't in school, they were engaged from dawn to dusk in one form of therapeutic activity or other.

ISPI houses both adult and children's units and was designed as a teaching and research facility with an emphasis on long-term care. Before the transfer of the Horner patients, ISPI had two children's units: one of them served a small dirt-poor area on the city's near southwest side, and the other, known as the Tri-Agency Program, took the worst cases from DOC, DCFS, and other DMH facilities. "Our Tri-Agency patients made the [Horner] DOC kids look like pussycats," Davidson recalls.

ISPI has had its share of critics. Some contend that its programs are far too structured, even rigid; others complain that children are kept there far too long. But the facility has long had a reputation for getting the job done. It was the only local state psychiatric hospital listed in The Best Medicine, a book written in 1986 that ranked hospitals with medical specialties across the nation. That same year the Tri-Agency Program was cited in "Exemplary and Innovative Health Department Programs for Service Delivery to Adolescents," a report published by George Washington University.

The facility's reputation wasn't lost on local pols. Davidson remembers regularly receiving calls from legislators asking him to place the child of a politically connected family at ISPI, even though the family lived in the Horner or Madden Mental Health Center service areas.

The Tri-Agency unit was established, in essence, to treat patients that everybody else had given up on. According to Davidson, many of these supposedly unmanageable kids were in fact victims of bad therapy.

He recalls one case in which a boy was sent from Horner after spending the previous three days propositioning every male staff member and patient in sight. After a change in medication and a few days of treatment, all traces of the behavior disappeared and the patient was able to admit that he had been raped while at Horner, an experience that more than likely triggered his acting out. "As soon as you can get him out of that environment and can properly assess, treat, and protect him, the crazy behavior stops--and the problem simply becomes a troubled kid who needs some treatment," Davidson says.

Davidson was banking on ISPI having the same calming effect on the bus load of kids he shipped out of Horner after he arrived. According to Davidson, the transformation was nothing short of miraculous. He wrote in a memo to one of his superiors, "The following figures for the first month speak for themselves: 0 fires, 0 successful runaways, 0 attempted runaways, 0 aggressive acting out incidents, 0 (unusual) incidents of any type."

One of the more incorrigible DOC patients eventually did set a fire at ISPI and made a run for it in the confusion that followed. But before he could make it out the door, the other boys jumped him and started beating him up. "When we were processing [the incident] with the kids the next day, they were real apologetic because some of them knew it was going to happen and they hadn't told anybody," Davidson recalls. "Back at Horner they would have been out the door with him. Meanwhile, the staff is feeling bad because they couldn't predict it or stop it, and I'm sitting there feeling great and smiling. They're all wondering 'What's wrong with him?' So I tell them, "You don't understand. We got a program here, guys."

The flip side of Davidson's strategy was considerably more challenging: to export the ISPI model to Horner. But within several months the entire Horner staff had gone through two weeks of intensive retraining, which consisted of a week of seminars and brainstorming sessions at ISPI, followed by a week of work with a counterpart on the ISPI staff. "I knew the process was starting to jell when one of the nurses in the training group decided spontaneously to organize a day of activities based on her experience at ISPI," Davidson says. "When she came in Monday morning, she was floating six inches off the ground. She said 'I've worked at Henry Horner for ten years, and I've just had the best day of my life.'"

Davidson also began culling out the bad apples. One staff member was forced to retire after refusing to intervene in a fight between patients, and another was let go for negligence that resulted in a fire on one of the units. Yet another was discharged for verbally and physically abusing patients. Davidson fired or forced out a half dozen Horner staff members and was building cases on a half dozen others. Several formally challenged Davidson's actions, but all challenges were turned back. One charge of racial discrimination was brought against Davidson in federal court. But it was summarily dismissed by the judge, who wrote in his decision that the plaintiff "has not shown that he was treated unfavorably for racially discriminatory reasons. At most, plaintiff has shown that Davidson wanted to make an example of [him] as a means of ending abuse that Davidson believed was prevalent at Horner."

By mid-October 1985 the Guardianship and Advocacy Commission closed its case against the facility, crediting Davidson with making "major changes" that brought about a "sufficient resolution" of its concerns about patient abuse and neglect. By December Davidson was able to report a 90 percent reduction in runaways and violent incidents.

But the progress that Davidson was able to make was being undercut from the start. Within three months of his arrival, Davidson says, the state general assembly proposed a $700,000 DMH budget cut that would have had a devastating impact on the facility. As fate would have it, however, one of his patients set a mattress ablaze shortly after the cuts were announced. The patient escaped, his bedroom lay in ruins, and a boy sleeping in the next room almost died of smoke inhalation.

Davidson leaked the story of the fire to Hanke Gratteau, then the mental-health reporter for the Chicago Tribune. Within days of the appearance of Gratteau's story, the proposed cuts were withdrawn. "To this day there are some people in the department who think that I set that fire," Davidson says with a laugh.

But Davidson had less success battling Thompson's patronage machine. An advertisement he ran for nurses, social workers, and psychologists drew "more vitas than the system had seen in years," he says. "I remember sending all those applications down to Springfield, and then waiting months and not getting anything. I didn't realize that I had taken all those applications and flushed them down the toilet."

The state's application-review process had been bogged down for years by a hiring freeze, which many in the department saw as a cover for the Thompson administration's patronage operations. During the freeze, every department was assigned a "field liaison" who reviewed each request to fill a vacant position. According to Dr. Charles Harris, a former DMH regional administrator, the field liaisons were de facto patronage officers for the governor who sat on requests for "freeze exceptions" until a Republican became available.

"The process is well-known to nearly all state employees," Harris wrote in a letter to the editor of the Southern Illinoisan newspaper in late 1986. "It affects virtually all hiring, from the lowest paid worker to the highest paid administrator. And since the majority of staff hired are those who have direct contact with patients, this has a direct impact upon the quality of service."

Davidson remembers waiting so long for positions at Horner to be filled that at one point he ran out of nurses to dispense medication on one of his units. He says that one of his administrative aides was able to trace his emergency request for a nurse to the desk of the DMH field liaison, where it had been languishing for days.

Shortly after charging one of his employees with patient abuse, Davidson began receiving phone calls from the field-liaison office. The liaison simply inquired into the status of the case, Davidson says, but the intent was clear. "No one ever said to me, 'Don't fuck with this Republican,' but when the patronage officer for the department calls you and asks what's going on with so and so, you know what he means."

Davidson's anger grew as the calls regarding the employee continued. When they followed him to a convention in Fort Lauderdale, he called an aide in the governor's office. "I basically told her to kindly get the governor's patronage people off my back, because I was going to fire this guy and put him in jail for child abuse if I could--and I didn't think [the governor] wanted the embarrassment of seeing this issue in the papers with his name associated with it."

The calls stopped, Davidson says, but two months later Belletire eliminated the position Davidson had occupied that allowed him to supervise Horner and offered him the opportunity to return to ISPI. Davidson accepted.

Davidson went on to become the scourge of DMH, testifying before the legislature about problems within the system and regularly leaking stories to the local media. When the department moved to gut the ISPI budget in 1986, for example, Davidson orchestrated an all-out media counteroffensive that forced the withdrawal of cuts within weeks. That fall Davidson was featured prominently in "System of Shame," a three-part investigative series on DMH produced by Channel Two.

In November 1986 Davidson penned a 62-page single-spaced memo on patient abuse and neglect at DMH facilities that received wide distribution within the department. The memo was also leaked to the press, and a story about it appeared in the Tribune on the same day as an article about the ACLU lawsuit against Horner. Though Davidson vigorously denies releasing the memo, he does admit to having played a role in creating the suit.

Davidson had heard from a colleague that the ACLU was preparing to take Horner to court. And when news of renewed violence and declining staff morale there began filtering back to him, Davidson picked up the phone and called Ben Wolf. "Most of the information we get on children [in institutional settings] comes from employees within the system," says Wolf. "But it's not very often that you find a former facility director who is so forthcoming."

Unlike Davidson, who wasn't afraid to air DMH's dirty laundry, Belletire was the consummate team player who preferred to work from within. That difference in style is reflected in the ways they came to DMH. Davidson spent three years in the civil rights movement--getting "shot at, beat up, and thrown in jail"--before earning a PhD in psychology from the University of California. Belletire worked his way up through the bureaucratic ranks, holding key positions in the Bureau of the Budget during the Walker administration and the Department of Public Aid during the early Thompson years before being invited into the governor's inner circle to do administrative troubleshooting with departmental management.

Thompson made Belletire director of DMH in 1982, the same year Davidson was hired to head one of the children-and-adolescent units at ISPI. At the time, according to Belletire, Thompson considered the department his "biggest management problem of all."

Belletire says, "I was brought in to try to identify administrative and directional problems, and to reestablish communications with some of the interest groups and staff members who had become disaffected with upper leadership. I was brought in to try to identify the talent within the organization and to try to set an agenda for correction."

According to Davidson, Belletire made some remarkable strides. "I think Mike was incredibly good at pulling the department together in a very organized manner. I frankly wish that he had stayed on as director for a couple more years to kick the shit out of the central office and get them operating in a more rational fashion."

Belletire says he left the department because he had made progress toward his goals and it was time to pass the baton. But one gets the impression that he also felt stymied by the administration. He says part of his reason for leaving was "a general sense that whether it was me or anybody else, if there wasn't some kind of specific support beyond the department, those things wouldn't be achieved anyway. I've never been one to stay if I don't believe I can make contributions."

Though Belletire and Davidson grudgingly admire each other, their differing approaches have long been a source of friction. In Belletire's estimation, Davidson's habit of going public with departmental problems bordered on recklessness. "I have some regard for Ron, but I will also tell you that he is like a bull in a china shop. I'm not going to suggest that he hasn't made contributions, but I'll tell you quite frankly he did some things that I felt were damaging to mental health's long-term interest and to actual reform within the system."

According to Davidson, Belletire wasn't reckless enough. "I think Mike's tragic flaw was that he pulled his punches. I think he worked for a governor who was heartless at the core and who tried to balance the budget on the backs of the poor and helpless. I think Mike knew that it was wrong, and I think he fought it as long as he could. But in the end he caved in, and I find that terribly sad."

Both Davidson and Belletire managed to step out of the pressure cooker before the ACLU turned up the heat. Belletire left the department for a job in the private sector a couple of months after Davidson switched back to ISPI. Horner reportedly became a pet project of Belletire's successor, Ann Kiley, who held the director's post until early this year, when she died of cancer. Though many praised Kiley for her commitment to mending what she once called "the shreds of a system," others felt that her strongest qualification for the post was her marriage to Thompson insider James Kiley.

In July 1986 Ann Kiley installed Horner's first full-time director in more than two years. James Erickson, a social worker by training, has now served for four years as head of the embattled facility. While supporters of the department point to the hiring of Erickson as evidence that the will to improve existed before the lawsuit was filed, the pace of change has quickened considerably since. Within days of the filing, the entire facility was repainted. Scores of smoke detectors were installed, new furniture was brought in, and mattresses were replaced with a less flammable variety. "It was just incredible," Wolf recalls.

The facility's budget, which had been tailing off, climbed from $3.7 million in fiscal year 1987 to $5.2 million in 1990. Long-vacant staff positions have been filled, and many new ones have been added. The number of activity therapists, which had dwindled to two, now stands at nine, and the facility recently hired a fresh batch of psychiatrists.

The staff at Horner has been reorganized into multidisciplinary teams that are responsible for developing and executing a treatment plan for each patient at Horner. In addition, a point system has been instituted that bestows privileges on patients who meet behavioral criteria. "There has been a lot of progress in terms of putting programs into place and getting staff organized in a specific way," says Dr. Lee Combrinck-Graham, who recently stepped down from the reinstated position of director of the Institute for Juvenile Research.

Outsiders have begun to notice the changes. The staff at Kaleidoscope, a Chicago-based child-welfare agency that occasionally sends children to Horner, has seen a marked improvement in the services provided by Horner, according to Karl Dennis, the director of the agency. Dora Barichello, a board member of the Alliance for the Mentally Ill of Greater Chicago who conducts site visits at Horner and regularly attends a community forum sponsored by the administration, has detected a greater spirit of openness at the facility. "Within the last two years, I think the rapport between the people at Horner and the people in the community has become much better," she says. "There's much more of a give and take."

Because of the pending ACLU lawsuit DMH employees have been barred from officially commenting on conditions at Horner--even regarding changes for the better. But the impression that emerges, from off-the-record comments and observations by outsiders, is of a greatly improved facility. "It's not perfect," says a source within DMH, "but it's definitely not a hellhole anymore."

But according to Wolf, none of these improvements have eliminated the worst problems at Horner. In recent interviews with patients he discovered that as recently as late last year, gang initiation meetings of 15 to 20 boys were being held on one of the adolescent units. The midnight gatherings involved ritual beatings, and children who refused to join were harassed and attacked. He also was informed that one of the more aggressive kids on the unit had turned one of the more passive kids into his "slave," ordering him to fetch things and to perform sexual favors.

Wolf's own informal tally indicates that as many as 100 patients ran away from Horner last year alone. "Our experts would say that the runaways are an indication of inadequate facilities and the absence of supervision." And, he adds, "that many kids would not run away from a place that treated them decently."

Wolf and cocounsel David Graham, a partner with the law firm of Sidley & Austin, contend that the patients at Horner continue to operate in a therapeutic vacuum. And they say that evidence for that contention can be found in the treatment plans that the new multidisciplinary teams are generating. "A typical treatment plan at Henry Horner deals solely with symptoms, and the cure is to remove those symptoms," says Graham, who is working with the ACLU on a pro bono basis. "If a child has been setting fires, the treatment plan will read, 'Have the child stop fire-setting behavior.' Then three months later you can show on your charts, 'Well, the child hasn't set any fires.' You end up having measurable objectives that have nothing to do with the internal life of the child and what's causing the problem to begin with. And unless therapy is directed toward the root causes, your efforts are going to be in vain."

Even Governor Thompson's most vocal critics acknowledge that the problems at Horner and in the department in general are not all his fault. DMH hospitals were overcrowded and understaffed when he took over in 1977, and the community-mental-health movement was underfunded and fractious. The state budget was badly out of whack, and the federal government was one presidential administration away from dramatic cuts in support for the mentally ill.

What critics do accuse the Thompson administration of is an appalling lack of leadership that led to the crippling of an already hobbled system. In his first decade as governor, two out of every five jobs in the department were eliminated and one out of every three state hospital beds was emptied. There was no equivalent shift in resources to community mental health. From 1976 to 1986 an already emaciated DMH budget doubled while health-care costs tripled. When federal funds were available, the Thompson administration was particularly bad at chasing down Illinois' fair share.

"While it's fair to say that, from the broadest historical perspective, not all the blame lies with the Thompson administration," says Ann Boisclair, director of public policy for the Mental Health Association of Greater Chicago, "he has presided over 14 years of decay in a delicate system that was badly in need of growth and that serves some of our most vulnerable people."

Most critics of the system agree that no real change is possible without a massive infusion of funds. In fact, in December 1989 the governor's own Commission to Revise the Mental Health Code of Illinois noted that "an adequate system of care may require more than a doubling of current expenditures."

While both gubernatorial candidates have promised to more aggressively pursue federal dollars, neither has committed himself to increasing state funding to anywhere near the level suggested by the commission's report. But their approaches to fixing things on a shoestring budget are a study in contrasts.

Jim Edgar has promised to map out a ten-year strategy of measured growth and reform. "It's not going to happen in one or two years," he assured an audience of 350 mental-health professionals and advocates at a May candidates' forum. "But through a decade, I hope that we will see a much better mental-health program in Illinois."

Belletire, who is on leave from an administrative position with the state board of education to work on Edgar's campaign, defends his candidate's approach as fiscally responsible. "If Jim Edgar has been tempered in his commitment to any parts of government, it's because he's trying to maintain a sense of realism and not place expectation so far ahead of the potential to deliver."

Neil Hartigan plans to tear DMH apart immediately and rebuild it from scratch. "Give me access to the $25 billion [state budget] and the 80,000 [state] employees, and we'll develop a mental-health system that'll work in this state," he assured the May candidates' forum. "And anybody that stands in the way won't be working for this state."

Davidson, who left the Hartigan campaign when he became director of public policy for the Mental Health Association in Illinois, rankles at any suggestion that his candidate's passion is manufactured. "I've seen the man's face get red, and I've seen him pound the table with rage over problems in the system. And I think it's going to take that kind of affect in a political leader to really change things."

In the end the new governor's plans for reform may be dictated by the outcome of the ACLU lawsuit. According to Wolf, Horner's needs are simple enough: a lower patient population, more clinical staff, training that focuses on addressing the real problems. But those reforms carry a hefty price tag.

The official capacity of the units at Horner now ranges from 22 to 30. The actual population of a given unit on a particularly bad day can climb above 40. But according to one DMH clinician, even 20 children is far too many for the staff to handle. "I really think that the ideal number is 15. Even five more children, and you have a hard time providing a desirable treatment program." To maintain a lower population during peak months, Horner would have to either reopen the four units it has shuttered or contract out to private psychiatric hospitals, where there is an abundance of empty beds.

The type of extensive in-service training that Wolf is requesting would be feasible only with additional administrative staff. A return to the system of discipline chiefs would also allow Horner to once again court trainees from the local professional schools.

But these improvements alone would easily double Horner's $5.2 million budget. And that doesn't begin to account for the cost of beefing up the community-based services that would keep children out of Horner in the first place--and prevent those who must go there from returning once they were discharged. "The main problem is that there aren't enough services for children in the Chicago area. And pouring money into Horner isn't going to solve that," says Joan Costello of the Chapin Hall Center for Children at the University of Chicago. "They are getting children as the end point of a system that's inadequate--and there's no place else for them to go."

It can take weeks to get an appointment at the local community mental-health center, and most of them aren't equipped to handle the seriously mentally ill. Many residential treatment centers in Illinois have been driven out of business by the state's miserly medicaid reimbursement practices, and out-of-state facilities often refuse to take children from Illinois for the same reason.

The Department of Children and Family Services has only a fraction of the resources it needs to keep wards of the state out of Horner. And even the children of working-class families are denied adequate treatment by an insurance industry that consistently underfunds inpatient care and often refuses to cover outpatient treatment.

If you look at Horner as a metaphor for the entire state mental-health system, doubling the DMH budget seems like a modest proposal. And you can bet that the ACLU is thinking metaphorically on this matter. "Our efforts right now are focused primarily on Henry Horner Children's Center and not the Department of Mental Health as a whole," says Wolf's cocounsel, David Graham. "The implications of this suit are sufficient, however, that if the relief we seek is obtained, the department would be foolish if it did not voluntarily implement those steps at other institutions."

Barring an unforeseen settlement, a status hearing scheduled for the day before the election could prove decisive. According to Wolf, if the final stages of pretrial activity are wrapped up by then, the judge could see fit to set a trial date as early as December.

Even if the case comes to trial before the inauguration, Wolf says, the governor-elect will have plenty of time to influence the course of the case. "If there's any indication that the new governor has a different view than Mr. Thompson, we would open the door to serious talks. We certainly hope that the new governor will think about these problems, and sit down and do something constructive with us."

The ACLU fully expects to win. But if it doesn't, it's not about to give up. There are always the state courts. And failing that, the ACLU will take the case to the streets. "We would organize," Wolf says. "We would pressure the legislature, inform our members, get people active, bring in other advocacy groups. The political process to date has not been very good to our clients in this field. And if it became clear that the courts could no longer be relied on as the ultimate protector of rights, I think the public might."

Art accompanying story in printed newspaper (not available in this archive): photos/Lloyd DeGrane.

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