Diagnosis: Insanity

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“Don’t take me out of jail,” Alan begged Ruth O’Sullivan. “Don’t put me in a shelter.”

Alan (not his real name) is an IV drug user and paranoid schizophrenic from Puerto Rico. His wife is dead, and his two kids are living away from him. People who know him say he’s gentle, nice, smart. But when he decompensates–that is, when his illness spins out of control–he starts hearing voices. When he hears voices, he self-medicates with drugs. And when the drugs don’t muffle the voices out, he hurts himself. Once he even drove a household tool into his head.

“This guy’s breaking my heart,” says O’Sullivan, Alan’s case manager with Treatment Alternatives to Street Crime (TASC), a jail-diversion program under contract with the city. O’Sullivan tried for more than six months to find a place for Alan to live that can give him enough care to keep him from relapsing and heading back to prison. “He has good insight,” she says. “He knows how to take care of his illness. His goal is to get out and get to his children. But he’s also had several very, very serious suicide attempts.”

It sounds counterintuitive, but compared with what he’d experience on the outside, life at Rikers Island has at least been more structured for Alan. He sees a psychiatrist once a week, more often if he needs to. He has access to a social worker and a discharge planner, whose main job is to check in on mentally ill prisoners and explain that they have to take their pills. Of course, it’s still jail. “They can be beaten,” says one source who, until this past December, was the psychologist in charge of a mental observation unit at Rikers. “They can be abused.” And that’s just the other inmates. “I’ve seen a lot of patients who complain to me about the conduct of a lot of officers”-everything from brutal treatment to being ignored during a conflict with another inmate.

O’Sullivan first met Alan last August in Rikers, where he was being held for drug possession. Like all of TASC’s 450 clients, he was offered the chance to participate in the program by a district attorney–if he copped a plea. He agreed. In return, the judge sentenced him to two years with the program, including a warning that if he violated its terms he’d be sent away for three or four years. Alan agreed to those stipulations, too, and O’Sullivan started looking for a place for him to live.

But since then, he’s been caught in a mind-boggling bureaucratic black hole. They can’t find a bed for him. His ticket out of jail is a letter of approval from the city Human Resources Administration, which specifies that he requires 24-hour supervision. Since Alan has never been homeless, he doesn’t qualify for NY/NY-supervised housing for homeless and mentally ill chemical abusers. There are supportive housing programs besides NY/NY that could provide the oversight he needs, but they generally will not interview prospective residents while they’re still behind bars.

O’Sullivan has convinced Rikers officials to send Alan to the Brooklyn courthouse, where he can be interviewed in the pen. “But a lot of residences won’t even do that,” she says sadly. “I’ve even told them he can do a video conference from jail, and they’ve said no.”

Over the winter, a housing program on Wards Island had agreed to visit Alan at the courthouse. He had an interview that went well. “He’d be out there right now if he took it,” says O’Sullivan. But the housing program is located near a place where he used to get high. “He learned where it was–he knew people in the area–and he learned he’d have some independence. And he said no. He’s smart. But because he’s smart, he’s still in jail.”

Finally, in March, in order to help get him more interviews, O’Sullivan found him a spot in a shelter that is its own sort of prison-24-hour supervision, with no way to leave the building. If O’Sullivan can’t place him within about a month, back to Rikers he goes. The clock is ticking.

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As astounding as the city’s drop in crime has been, we have yet to figure out what to do with people like Alan–the volatile mentally ill who, in our darkest fears, might one day go on the attack. The public’s dominant image of a disturbed street person remains Andrew Goldstein, who in 1999 shoved Kendra Webdale in front of a subway after years of revolving in and out of hospitals and jails. But since that tragedy, little about how government addresses the needs of the mentally ill has changed. People like Alan are jailed before they’re treated, and get some of their most consistent treatment while behind bars.

Now, as altered police priorities after September 11 leave sidewalks a visible home for disturbed people once again, New Yorkers are reminded every day that this is also one of the fronts on which the quality-of-life war is far from won.

Mental illness, so fluid and elusive and unpredictable, isn’t easy for bureaucratic systems to address. Catering to the needs of people like Alan has rarely been less politically popular. And so jails have remained the destination for mentally ill New Yorkers who run afoul of the law, thousands annually, from petty drug offenders to homicidal Goldsteins.

For years now, Rikers Island has rivaled L.A. County’s prison system as the largest de facto mental health facility in the United States, with approximately 800 beds ready to receive inmates who are diagnosed as mentally ill. The nation’s largest mobile crisis team dealing with mentally ill street people is run not by a hospital, and not by a university, but (by default) by the NYPD. If someone like Alan commits a violent crime or other felony, his next stop after Rikers is most likely a state prison. But for those who aren’t violent–who commit misdemeanors like drug possession, or shoplifting–Rikers is the destination, for a stay that could last anywhere from a few days to a few years. Turnstile-jumping, to take one common offense, has a maximum sentence of one year–longer than the infraction might demand, but adequate to keep a dangerous–seeming person off the streets, to make them someone else’s problem.

If what happens to the mentally ill on their way into prison is tragic, the experience is repeated as farce upon their release. Once they’re done doing time, inmates are dropped in Queens Plaza in the middle of the night with nothing but a $3 MetroCard. The city has resisted demands to allow mentally ill inmates to apply for public aid while behind bars, leaving them temporarily without access to medication, food stamps or Social Security benefits. They receive little to no direction to social services or health care. Not surprisingly, many wind up becoming a police problem again in no time.

The problem did not begin with Rudy. The revolving door between jail and the streets first started spinning in the 1980s and early 1990s, when the closings of state mental hospitals–not necessarily hospitable places for treatment themselves–created a generation of homeless people plagued by delusions and hallucinations.

They seemed impervious to care. Most had problems with alcohol or drugs. The city gave them a name–MICAs, or mentally ill chemical abusers–and paid to put some of them in supportive housing. But no neighborhood was particularly interested in hosting new homes for such people. Overburdened, politically vulnerable nonprofit housing developers weren’t much more interested in taking on the most volatile of the population–not when so many other people needed the beds. The stage was set for the police to become the city’s first and practically only line of response to the needs of the severely mentally ill.

The poster patient for the revolving-door phenomenon is Brad H., the lead plaintiff in a potentially groundbreaking lawsuit against the city. Filed by lawyers from the Urban Justice Center, New York Lawyers for the Public Interest, and Debevoise and Plimpton, the suit demands services, or “discharge planning,” for mentally ill people leaving Rikers. As Mayor Bloomberg took office, the judge in the case, Richard Braun, was pushing city lawyers to settle; the discussions continue.

But at the same time, the city is also fighting a motion for contempt, which charges that in the two years since Judge Braun issued a preliminary injunction in the case, it has failed to comply with the court’s order to help mentally ill inmates find care–including Medicaid, food stamps, and other basic resources–once they’re out of jail. The suit names five agencies: the Department of Mental Health and Department of Health (soon to be merged into the new Department of Public Health), the Health and Hospitals Corporation, the Human Resources Administration, the Department of Correction, and the jails’ private health care provider, Prison Health Services. As City Limits went to press, arguments were set to conclude in April.

Slow and serpentine as the litigation has been, it’s nothing compared with Brad’s own saga. Brad first came to Creedmoor Psychiatric Center when he was 9; his lawyers have been unable to find out exactly why, though Brad himself seems to remember his mother abandoning him at the hospital. “I think he feels that she took him there because she didn’t want him,” says one of his lawyers. After nine years of shock therapy, he ran away when he was 18, became homeless and alcoholic shortly thereafter, and then embarked on what’s become a 29-year cycle in and out of Rikers Island, all for nonviolent offenses. He also went to state prisons four times. Only the maximum-security prisons, it turns out, offer a high level of mental health care. In his deposition in the lawsuit, Brad said he spent most of his time in Attica in his cell, fearing for his life.

In 1998, Brad left state prison with two weeks of medication and instructions to go to Woodhull Hospital if he needed mental health services. Left on his own, he drifted to the Atlantic Avenue Shelter, long considered the worst in the city, and promptly lost his false teeth and eyeglasses on a sink near a toilet. He spent nine months toothless and without sight, a homeless man living in subway stations with no psychiatric help, until one day he was arrested for fare-beating and wound up back at Rikers.

In 1999, an NYU psychiatrist interviewed Brad in jail and declared that once he was released, he’d need to keep taking antipsychotic medication, an antidepressant, and a sedative, and see a psychiatrist regularly who would give him a Breathalyzer. Needless to say, none of that came to pass. In and out he went, from the streets to the jails. In 2001, Brad was released from a state prison and went to the 30th Street Men’s Shelter, the central intake center for homeless men. The revolving door kept spinning.

Hank Steadman, the head of the GAIN Center, a national group that runs jail-diversion programs for the mentally ill, once called the Brad H. lawsuit the most important court case in the last 25 years for the rights of people with mental illness. Attorney Heather Barr of the Urban Justice Center is flattered, but part of her can’t stand that the discharge planning gap has taken so long to be filled. “I’d like to be working on something a little more radical,” she says. “I look back and I say, ‘I can’t believe I’ve spent six years on this.’ It’s like filing a big lawsuit saying ice cream is good. And then you have to actually argue that ice cream is good.”

The truth is that she and the other lawyers are operating largely on their own. When it comes to demanding an adequate government response to a public health crisis, “the AIDS community has done a much better job than the mental health community,” Barr notes. “They’ve been able to get over a stigma–they did a phenomenal job of organizing and radicalizing and enlisting politicians. In a way, the mental health community hasn’t been advocates for themselves. They’re uncomfortable with the idea of demonstration, much less throwing blood in cathedrals.” The very nature of the mental health cause poses a conundrum: If demonstrators act too crazy, wouldn’t that defeat their very point?

Their battle won’t end, either, even with sincere commitments from government authorities to address the psychiatric needs of the severely mentally ill. How is a cop supposed to know the difference between someone who’s a danger to himself, and someone who could be a danger to others?

The missing piece, of course, is a place for these people to live. We criminalize the mentally ill not simply because we fear them. We criminalize them because the resources aren’t there to give them anything else–a third way that could keep them safe from themselves and from the public. (It’s now widely understood that this would save money, too. A year in supportive housing costs $12,000 to $14,000. At Rikers, it’s $65,000.)

But as it stands now, Barr is battling in court to get her clients a simple application for Medicaid. “People actually go to Rikers Island now for their mental health services,” she marvels. “Taxpayers are paying an extraordinary amount of money to deal with the fact that we don’t have a health care system.”

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It doesn’t matter if you were caught jumping a turnstile or throwing a brick. On Rikers Island, every offender is pretty much created equal.

The quality of your medical care depends less on your sanity and more on where in the prison facility you happen to land, and what time of day you get there. Everyone who is sent to Rikers Island goes through a medical check, but not everyone has a psychiatric screening.

Only two mental health units on the island, called C71 and C95, are staffed 24 hours a day with psychiatrists and social workers. If you come in any other part of Rikers at the wrong time, you go unnoticed for a few days until something happens.

What could happen? You might get into a fight. You might decompensate and start having a breakdown. The drugs you’ve been taking might wear off, and you might start acting in a different way. Kanie Foster sat untreated for days on end before getting help. “The last time I was in Rikers, I didn’t see a psychiatrist for a week,” says Foster, a 46-year-old with Hepatitis C, a 30-year history of drug and alcohol abuse, and a problem with depression that has driven him to lay himself down on train tracks.

Foster has been in and out of Rikers four times; each time it’s taken days to diagnose his various illnesses. After a while in a holding pen, with no methadone or psychiatric medication, he says he lost track of reality. “I thought an atomic bomb had fallen and I was in a bomb shelter. I thought people around me were robots come to life. They say I was talking gibberish at nighttime, playing cards with no cards.”

When anything unusual happens, officers on duty have a psychiatric checklist to fill out. If they see certain behavior, they check that on the form and refer the inmate to a mental health unit for a psychiatric assessment. But according to the psychologist who formerly ran an observation unit at Rikers, more than half the people who get referred to the mental health units don’t stay there.

Often, this is because they’re not mentally ill. Services of any kind are so scarce at Rikers that mental health has become like one-stop shopping for any type of problem. Even a complaint that someone is threatening an inmate triggers a visit to mental health. “Mental health is so over-used in the system that they get overloaded,” says the psychologist, who spent 12 years at Rikers, leaving this past winter (and would like to go unnamed, since he still does some work there through an outside agency). “They’re so overwhelmed because they see everyone, basically.”

So, often you won’t end up in the mental health unit for long because, with medication, you’ll be deemed able of functioning among the general population. You’ll have access to a therapist once a week, and a daily trip to the mental health unit to take your meds. “I would say a good 45 percent are inside the mental units, and we have a good 55 percent outside,” says the psychologist. For the mentally ill left with the general population, things sometimes get dicey. Pearl Neal, 27, spent two-and-a-half months in Rikers for shoving a police officer, before TASC picked her up. She’s openly hostile about her time there, and it’s apparent that whatever anger got her into jail wasn’t tempered much once she got there. “It’s just disgusting,” she says of Rikers. “It’s really horrible. They just keep piling you up like sardines. You’ve got low-life girls trying to pick fights with you.”

Things aren’t that much better inside the mental health units, where you are often one of 40 or 50 people, sleeping on a cot in a large room with no walls or curtains, because the half-dozen medical staff members are watching you at all times. Not that you have much one-on-one contact with them–maybe once a day. They’re too busy tending to the 10 or so beds in the far end of the room, the ones set aside for people on suicide watch.

This kind of neglect is demoralizing at best; while some people are stabilized there, it’s hard to imagine anyone at Rikers getting better. “Incarceration, in my view, makes people’s problems even worse,” says the psychologist. “Incarceration is stressful. You get a lot of psychological problems: insomnia, anger, aggression.” The diagnosis they give it at Rikers is adjustment disorder with depressed mood. “The stress of the system is so great. It’s unsanitary, really.”

Most of a typical Rikers psychologist’s time is spent dealing with crises. An inmate hears that her mother is dead; another inmate is terrified for his safety. By the time he got to see the psychiatrist, recalls Foster, the psychiatrist “was overloaded, burnt out.”

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All of which helps explain how a lifetime of prison visits can take their toll. The University of Rochester Medical Center has pioneered a program, called Project Link, to keep track of some of that city’s mentally ill people as they cycle in and out of the jails. One of the men they track, whom we’ll call Cal, left a group home recently to hit the bottle and was picked up for loitering. It took three days for a guard at the cell block to report he was talking to himself at night and disturbing everyone’s sleep. One of his fellow inmates threatened to beat him silly if he didn’t quiet down. Finally, Cal was diagnosed with paranoid schizophrenia and auditory hallucinations.

He couldn’t tell them what meds he used to take, so they gave him an antipsychotic pill, distributed through the bars by a nurse. But it wasn’t clear whether he took it, because she had such a long list of people to serve.

Two days later, the same cell guard was told that Cal was still talking during the night. They realized Cal was perhaps noncompliant. So six or seven days out, he finally got observed taking pills. “This is the good scenario,” says Dr. Rob Weissman, who runs the program.

Once Project Link tracked down Cal in jail, Weissman and his colleagues waited for his release and returned him to his old residential group home. But why did he leave the group home in the first place? Weissman believes it’s partly because “home” simply isn’t part of Cal’s vocabulary. He’s spent more than 17 years of his life in jail; walking into the revolving door is second nature. Once Cal relapsed, “jail in a way was more predictable for him than being in the outside world,” Weissman says. “Some of my clients tell me that in jails they at least know where their next meal is and where their bed is. We call it ‘institutional transference.’ When they find support and thrive as we would with our family in our own home, it’s their version of home. When they’re released to the community they don’t have the skills. They become anxious and turn to drinking or drugs.”

When mentally ill people adapt to prison life, it can hurt them in the long haul. A 1998 study by the Bronx Psychiatric Center suggested that mentally ill inmates “learn institutional behaviors” so they can cope in jail-behavior that trips them up on the outside. Sometimes they train themselves to be too passive to deal with the real world. Other times they become aggressive, manipulative or closed off to any offers of assistance. Any of those problems make them harder to treat.

Psychiatrist Steven Lamberti, who developed Project Link, has identified three problems created by the revolving door. There are the ravages of fragmented medical care: “You see a person who cycles through the system so rapidly that it’s almost impossible for health care providers to catch up.” You could call this the Andrew Goldstein problem.

Then there’s the way that being in jail prevents formerly incarcerated people from getting the Medicaid or food stamp or Social Security benefits that could have kept them from decompensating in the first place. “When mentally ill people are incarcerated, their benefits are typically suspended until their release,” Lamberti notes. Navigating and accessing the safety net is hard enough for a sane person. For many, it’s just easier to look for drugs than it is to find a place to apply for benefits that take, under the best circumstances, 45 days to kick in.

Finally, there’s the obvious loss of morale. “Many lose hope that they’ll be able to break free and able to accomplish their personal goals,” he says. “Such individuals are an increased risk for suicide, and many do that while incarcerated.”

Jesus Garcia, 48, is HIV-positive and suffers from acute depression. He’s been to Rikers more than five times in the last 10 years, always for drug possession; his last visit lasted two-and-a-half years. “All the time, I stay alone,” Garcia says in broken English. “No friends, no nothing. You make a friend, you turn your back, they do something to you.” A psychiatrist offered help every two weeks or so, but beyond that he was on his own. What hope does a depressive who spends all his time alone for years on end have? “Maybe the reason I get so depressed,” he says, “is I was so alone.”

Garcia currently lives in a residence hotel on Lexington Avenue while TASC finds him a long-term residence with on-site therapy. His life outside of jail isn’t terribly different from the time he spends in jail. “Any place I go, I try to be by myself, not bother anybody,” he says.

He has a program to go to during the day, and some more people to talk to, but admits to being locked in his own psychic institution: “In jail I try to make as much like home as possible. I try not to bother anybody. I’m by myself, nobody bothers me.”

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Every borough has a program like TASC, funded by the city’s Department of Mental Health to work with discharge planners inside Rikers Island to make sure people get help on the outside. Staff test former prisoners for drugs, in compliance with the court agreements all of the clients have signed in order to come here. But more importantly, the caseworkers function as a gateway to the resources each will need to survive, including housing and medical services.

Getting to TASC isn’t easy, even after a judge has agreed to allow an ex-inmate into the program. While some get bused almost door-to-door, prisoners released at Queens Plaza more typically have to find their own way to TASC’s stuffy offices on Court Street in downtown Brooklyn. “We can help someone, but only if they come to us,” says Ruth O’Sullivan. “If they’re out on a Friday at 3 a.m., by Monday morning when we’d see them, they’ll be high.”

These programs appear to be underutilized. Dr. Jack Carney of the New York City Federation of Mental Health, Mental Retardation and Alcoholism Services was curious to see whether TASC and the other programs, known collectively as LINK, were getting more or fewer referrals since the Brad H. case heated up. He conducted a brief phone survey and learned that they received fewer than half of the prison referrals they expected to get-a scary statistic, considering that the capacity of these programs dwarfs by a long shot the estimated number of mentally ill people in the jails.

Prison Health Services, the private health care provider at Rikers, isn’t completely ignorant of the fact that a mentally ill person needs more attention than the average inmate. Rikers is staffed with discharge planners who are supposed to keep tabs on anyone who is disturbed, make sure they’re taking their meds, and serve as a contact to outside agencies that might help them once they’re released. The problem isn’t just that these discharge planners are overwhelmed, which they most certainly are. It’s that the jail’s walls keep all other help out.

Last fall, the judge in the Brad H. case asked the city to prove it had adequate discharge planning. Since then, the city has claimed in court, there’s been more attention paid to tracking mentally ill people in the system. Some sources say there are more discharge planners working now than ever before. (The city won’t comment, refusing even to testify at a March City Council hearing on discharge planning, ostensibly because of the Brad H. litigation.) But there’s still no mechanism within the prison to make sure inmates have essential services in place once they get out. “At one point, the city had planned to help inmates apply for Medicaid, food stamps and public assistance benefits while in jail,” Heather Barr says. “But then they abandoned that. Now the plan only refers to Medicaid.”

The linchpin of the city’s plan is the state’s Medication Grants Program, authorized by Kendra’s Law, which sent $6 million to the city specifically to supply psychiatric medication to uninsured mentally ill inmates released from prison. But from October 2000 through October 2001, the program enrolled only 639 inmates, and just 20 of them actually got the benefits. O’Sullivan and other workers say that since the Brad H. court order last fall, more inmates are getting seamless access to Medicaid. Barr and others who testified at the City Council hearing say they haven’t seen an improvement.

Brad H., for one, not only continues to struggle to get health benefits, but also continues to cycle through the system. He spent a good part of last year bouncing between jails and the streets. “He was a great poster child when we filed the lawsuit,” says Barr. “And the experiences he’s had since then continue to be very typical ones.”

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So where does the revolving door stop? At home, in theory–except that there’s still nowhere for most mentally ill people to go once they’re out of jail. “One of the things we’ve learned so clearly from our work on Brad H. is you could have the best discharge planning in the world, but you still wouldn’t have any housing,” says Barr.

Looking to create housing and services that will be tailored for mentally ill people coming out of jail, Barr is helping the Center for Alternative Sentencing and Employment Services (CASES) plan the Clayton Williams Residence, a new 65-bed transitional home in the Bronx. The state’s Homeless Housing Assistance Program has just committed $3.3 million for its construction.

There have been other efforts to house the mentally ill, of course. Ed Koch’s 10-year capital investment plan included supportive housing. That led to the New York/New York agreement, the city-state pact between David Dinkins and Mario Cuomo to build nearly 5,000 units of supportive housing for the mentally ill. That was the peak of locally sponsored production. In 1997, the city’s Department of Mental Health issued a report declaring a need for 10,000 more units; two years later, Mayor Giuliani and George Pataki agreed to build 1,500.

The city currently approves about 1,500 applications for supportive housing every year, but there are only about 300 vacancies. The odds are particularly heavy against former prisoners; why take in a disturbed addict ex-con when there’s inevitably someone less imposing you can bring into your program? “Lack of supply does allow for some cherry-picking,” admits Maureen Friar, executive director of the Supportive Housing Network. “It’s permanent housing, so they can pick whoever they want. If they have five applications for one bed, they’ll pick the best one.”

Some groups are also working on keeping the mentally ill out of jail in the first place. Two years ago, CASES set up the Nathaniel Project, which gives options to judges who are dealing with defendants who could benefit from treatment rather than a jail sentence. These are felony offenders, sometimes violent, who have cycled in and out of the system for years. At first, some of the people involved were worried that judges wouldn’t want to put them into a program instead of prison. But the courts loved it.

One Brooklyn night court judge, Morton Karopkin, has become a one-man diversion program. He found studies that show that more than one out every five defendants at night arraignments have a mental illness. These people are four times as likely as typical defendants to be arrested in brushes on the street with police, and five times as likely to be substance abusers. He’s hired a psychologist to to work on alternatives to incarceration.

And Karopkin’s not the only one trying to keep people out of Rikers. Two mental health courts are being planned–one in Brooklyn, another in the Bronx–that will sentence offenders to treatment as an alternative to incarceration [see “Getting Judgmental,” March 2002].

But no one’s kidding themselves. In the absence of a well-supervised path to safety, severely mentally ill people will always apply their own impaired logic to an irrational set of circumstances–with results that are painfully predictable.

In her work on Brad H., Heather Barr is in regular contact with a host of troubled convicts. One client, whom we’ll call Jim, is deaf, mentally ill, homeless, and suffering from AIDS. He’s released one day from a courthouse without any I.D. All his stuff is still at Rikers. He goes straight to the city’s Division of AIDS Services. They tell him they can’t help him because he doesn’t have I.D. But they do pay to put him up in a hotel for five days while he searches for his belongings. Which brings him to a critical juncture: Jim is alone in a hotel with no idea how to get to Rikers (do you?). He’s sick. He’s got no meds. He’s lonely, and he’s hungry-he has no money. So he decides to rob a bank. This will either get him some money, or get him to Rikers. It’s a no-lose situation.

The robbery is something out of Take the Money and Run. He ambles into a bank and slips the teller a note. The teller gives him $5,000. He ambles out and goes to the deli next door and gets a bagel and cup of coffee. He sits and eats it. No police come. He stands up and heads out the door. Still no police. So he walks down the street and buys $100 worth of clothes. “If you’re arrested in summer and come out in winter,” Barr says, “it’s not like Rikers Island gives you new clothes.”

Finally, Jim starts to feel bad. He robbed a bank. He’s still lonely. So he walks into a precinct, hands the police $4,900 and surrenders. “So they send him to Rikers Island,” Barr says. The revolving door keeps spinning.

Robert Kolker is a contributing editor at New York magazine.