After receiving a Lifetime Achievement award in the 2006 Lilly Reintegration Awards, Behavioral Healthcare asked me to reflect on my experiences in mental healthcare. Below I describe how I discovered and grew in this field.
1941-1964: Growing up in the Snake Pit
My first memories are of being cared for by Dorothy, a patient at Worcester State Hospital in Massachusetts at the beginning of World War II. My father was the clinical director and my mother was a social worker, and child care was in the hands of patients. As the war progressed, patients assumed other jobs, as staff were drafted for the war effort. Patients were employed as ward attendants, artisans (plumbers, electricians), farmers, and so on.
Among my other memories of the time, however, are the sounds of more than 1,000 patients screaming 24 hours a day, seven days a week, as this was before psychotropic medications were introduced. With the war's end, staff returned and patients I had known, like Johnny, disappeared back into locked wards. During this time, I saw the movie The Snake Pit, which accurately portrayed the horrors of mental hospital conditions during that period.
During summers in the mid-1950s, I worked as a ward attendant at Westborough State Hospital in Massachusetts, and I witnessed the miraculous switch from chaos to almost total silence with the introduction of Thorazine. I learned much from Bill and the other six patients on one ward, each of whom claimed to be the son of God. Each thought the others were “crazy,” but they also were friends. From them I learned that patients could treat each other with unconditional sensitivity.
And there was Zoltan, a Hungarian freedom fighter who spoke no English and was perceived as suffering from schizophrenia. He was there because the medical doctor was Hungarian, but the doctor never saw Zoltan because he wasn't a medical case. Zoltan got into fights until a student from International House in Boston was brought in to interpret. Zoltan was discharged within six months.
During college, I volunteered at Connecticut Valley State Hospital, where I met Helen, an elderly lady who wouldn't speak. As we worked together on jigsaw puzzles, she began talking and soon was transferred to a nursing home. Following graduate school, I worked at the Judge Baker Child Guidance Center in Boston until I was drafted into the Army.
1964-1988: The Formative Years
Upon discharge, I sought a job in the mental health field and discovered Fountain House in New York City. I was hired as what now is called a “job coach” to work with a group of discharged patients at a car wash. For Bill, Marty, Sal, Cheryl, and the others, this was their first job after long years of hospitalization. I learned how important even a menial job can be and that it can lead to other jobs. Under the mentorship of John Beard, then Fountain House's executive director, I solidified the vision of hope and a positive future for members (the clubhouse term for “consumers”) through the development of relationships and hard work.
Three years later, I moved on to program evaluation as research director. Working with members Maria, Richard, and Thorne, among others, we completed two controlled research studies that documented the long-term reduction in length of rehospitalization for those having utilized Fountain House's services. We also documented the expansion of employment opportunities and a significant increase in full-time employment rates over a 40-month follow-up period. Furthermore, under federal sponsorship, we helped develop a clubhouse in Pakistan. Rashid Chaudhry, MD, the director, taught me that our work with the mentally ill is a humanitarian service at a societal and cross-cultural level.
1988-2006: The Mature Years
In 1988, I became Fountain House's program director and, later, associate director. I witnessed the further expansion of opportunities for members. With the help of members Mark and Ray, training efforts led to clubhouse replication, currently in 34 states and 13 countries. Within Fountain House, program expansion included the significant development of member education programs, housing expansion for the homeless, reach-out to city shelters, and increased advocacy efforts to impact public policy.
Another initiative was developed with Ralph Aquila, MD, to strengthen the interface between psychiatric rehabilitation and both mental health and primary care services. Contracting with a local hospital led to the establishment of a storefront facility, in proximity to Fountain House, where clinical services are easily accessible. These services include Weight Watchers, smoking cessation, and Double Trouble groups for those with mental illnesses and substance abuse issues, as well as more formal primary care and psychiatric services. With the advent of newer medications and the subsequent reduction of cognitive impairments, the focus is directed toward such comorbidities as hypertension, diabetes, obesity, and other metabolic problems, which have reached near epidemic proportions for this population. Bob and George, among other members, have helped to develop new ways to address these issues.
The interaction between doctors and their patients historically has been seen as a key to the successful treatment of illness and an important factor in social-vocational rehabilitation. The “therapeutic” alliance, however, often has been insufficient in meeting the needs of persons with serious and persistent mental illness—medication noncompliance being a major factor, as documented in the recent CATIE studies.
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