THE BRIDGE BETWEEN CRISES

THE BRIDGE BETWEEN CRISES
'Turning Understanding into Care'
Written by Dr. Todd Brown

On a January day in 2017, Calvin Clark stood on the interstate bridge over the Columbia River, 140 feet above winter water. He was not more than a headline or a case number. He was a son, a friend, a young man trying to survive an illness that made survival feel impossible. Days earlier, police had found him wandering in traffic—scared, disoriented, talking about setting himself on fire or letting a car end it. There were no psychiatric beds. A five-day hold came and went. He was discharged to an Uber, dropped off at a shelter, and soon walked to that bridge. He jumped—and then he swam, because in a brief, stubborn flash his body remembered how to live. He was rescued. Two years later, after short stabilizations and breaks in medication, Calvin died after another jump, this time from a hotel roof. He was 23.

If you’ve read Robert Kolker’s Hidden Valley Road, you recognize the shape of this story even if the details differ. The Galvin family’s twelve children included six sons who developed schizophrenia, an illness that arrived not as a neat diagnosis but as confusion, fear, and pain. Their parents lived through eras when psychiatry blamed mothers, when treatments were scarce or punishing, and when even the best help meant years of vigilance, relapse, and repair. Kolker’s book isn’t a “gotcha” on the past. It records what happens when an illness that many cannot see is treated as a moral failing, a phase, or a private tragedy. The lesson is simple but difficult. People do not suffer alone. Families do not fight alone. Communities do not avoid the bill.

One word binds Calvin’s story to the Galvins’ and to thousands of families today: anosognosia. It isn’t denial in the pop-psych sense. It is a neurologic inability to perceive one’s own illness. When insight is absent, “choose treatment” is not a plan, it’s a slogan. That’s why so many loved ones describe the same revolving door:

     street → brief hospital stay → discharge → jail → street

We can honor liberty, but we also need to admit that the absence of care is not freedom. Psychiatrist Darold Treffert captured the cruelty of our rules as “dying with their rights on.” People are left to deteriorate until they meet a catastrophic threshold of “imminent danger.” No one wins in that system, least of all the person who is ill.

Policy choices built this maze. Over the last half-century, we closed large state hospitals (often for good reasons) and promised robust community care that never arrived at scale. The result: fewer long-term beds, narrow commitment standards, and outpatient systems that depend on insight many people can’t muster when they most need it. Families are told to “come back if it gets worse,” which too often means “come back after a knife, a bridge, or a fire is involved.”
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Clinicians do courageous work inside rules that force them to stabilize and release. Advocates push to widen civil-commitment criteria or create court-ordered care pathways. In New York’s assisted outpatient treatment program, hospital admissions decreased by about 25% during the first six months following a court order compared with the pre-order period (Swartz et al., 2010). Critics remind us that without step-down housing, case management, and continuity, more commitment only means more discharges into nothing. Everyone is right, and people are still falling.

And yet there is real progress through science—refusing the old blame and locating illness in biology, not character. In large genetic studies, researchers have identified rare, high-impact variants that increase schizophrenia risk, including genes involved in chromatin organization and inhibitory signaling (for example, SLC6A1, which affects GABA transmission). The point isn’t a single “schizophrenia gene.” It’s the accumulating map. We must understand that this is the brain, not willpower. It is synaptic, not sin. Hidden Valley Road also shows how the Galvins’ participation in research helped drive that turn away from parents-as-pathology and toward neurodevelopmental pathways we can measure, model, and—given enough persistence—treat more precisely.

So, what does understanding and helping look like in practice?
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• Earlier, steadier intervention. We should stop mistaking short holds for care. When insight is absent, help must be measured in continuity: weeks to months of treatment that include medication, therapy, peer support, and rehabilitation, followed by warm handoffs and persistent follow-up. Assertive Community Treatment can be lifesaving, but it only works when teams are resourced and, crucially, when there is somewhere safe to sleep.

• A true “middle space.” Not jail. Not a 72-hour stopover. Not an unlocked clinic visit a month from now. We need dignified, longer-term residential options—small, therapeutic homes where people can live, work part-time, learn skills, rebuild trust, and step down gradually. This is where outcomes improve. This is where families can exhale.

• Families as partners. When anosognosia is present, loved ones are often the only historians, the only safety net. With consent and safeguards, systems should default to including families—teaching what to watch for, whom to call, how to navigate benefits, and how to endure. Families should not have to choose between privacy and safety, or between love and boundaries.

• Policy that follows the person. Debates about commitment standards and federal funding rules matter, but they must be linked to beds, staff, and housing. If we expand authority to treat, we must also expand the places and people who can provide that treatment, which makes recovery sustainable. States can combine flexible Medicaid dollars with federal support for community mental-health clinics and housing vouchers to build the step-down “middle space” that keeps care continuous. Parity is not poetry. It is budgets, training slots, mobile teams, respite beds, and leases.

• Language that refuses stigma. We don’t say a person “is cancer.” We say they “have cancer.” The same dignity should be automatic for schizophrenia, bipolar disorder, and severe depression. Words will change budgets, votes, and whether a neighbor calls 911 to punish or to protect. Person-first language is not cosmetic. It is the difference between an open door and a locked one.

​Calvin was not a set of symptoms. He surfed. He debated. He noticed when others needed encouragement. The Galvin children in Hidden Valley Road were not case studies. They were brothers and sisters whose lives were shaped (and sometimes shattered) by an illness the world struggled to admit was real. People living with serious mental illness deserve what anyone with a life-threatening condition deserves: timely care, a safe place to recover, continuity, and respect.

The importance of understanding and helping is not abstract. It is whether a mother is told, “Come back when he’s dangerous,” or “We have a plan and a bed.” It is whether science continues to march toward treatments that fit the brain in front of us. It is whether we can say, with a straight face, that the richest nation on earth offers something more than a bridge between crises.

Rights mean little at 140 feet above winter water. Let them mean a bed, a plan, and people who hold on, not jump off. ∎