1 Boring Old Man

A Memory: My first faculty job after Residency involved running the CIS [Crisis Intervention Service]. That’s what we called the Psychiatric Emergency Room at Grady Hospital in Atlanta. It was the mid 1970s, when the Community Mental Health Movement was running out of juice [and money], but still the paradigm du jour. I was asked to give a few lectures about Community Mental Health to the First Year Residents, so I went to the Library [the musty kind we had before the Internet], and read and read. I read about how the idea of Crisis Intervention arose out of the military’s experience in World War II. And I read about Kennedy’s Mental Health Act and the liberation of mental patients into a system of Mental Health Centers that would maintain them in the Community [What I didn’t read about was Nixon’s defunding of the whole system or about its demise, because that hadn’t been written quite yet]. As I was collating the information for my coming [way over-prepared] lectures, it occurred to me that there was something missing – Thorazine. The thing that closed our gigantic Mental Hospitals was the discovery of Thorazine, not the lofty rhetoric of the Community Mental Health Movement. I added that into the lecture at the end. I moved on to become Residency Training Director after a year, but the fate of the Chronically Mentally Ill stayed on the front burner of my mind.

It was obvious that the resources were evaporating in front of our eyes, and that we were approaching the point where we didn’t have enough hospital beds to treat our client load. So I did a study in my spare time – kind of a hobby. At times when the hospital was not full [so discharge was predicated on the condition of the patient and scheduled aftercare] there were two distinct populations. A fast group who were admitted, rapidly stabilized, and returned to their lives. There was a second slower group, patients with more chronic psychosis who took a while to get in shape to live in the world. I could show these populations mathematically, with p values that were impressive [<0.001]. For periods when the hospital was full, there was only one population – the fast track [p<0.001]. That fit what the Residents said. When the hospital was full, discharge was forced to make room for the throng.

Another Memory: After I resigned from the Psychiatry Department, I stayed on for a year while I figured out what to do with myself. I  had tenure, so that was my prerogative. I say resigned, but I would surely have been asked to leave had I not, though I didn’t quite know that at the time. It was fine. I didn’t fit, nor wanted to fit, with the changes. But that didn’t mean I was at war with our new Chairman. We were very different, but we still talked. I liked him. I think he liked me but saw me as dangerous or something like that. I taught the Medical School Course for a year until he found a replacement for the former Director who also didn’t fit [they were at war].

One day, the Chairman and I were talking, and I said [provocatively] that I saw Psychiatry as the medical specialty that dealt with what was ambiguous in medicine. My example was Brain Syphilis. Those patients Kraeplin studied back in the end of the nineteenth century [Schizophrenia and Manic Depressive Illness] were way in the minority in Mental Hospitals. The main population were people with Tertiary Syphilis. When treatment became available for Syphilis, they disappeared [I’ve seen only one such case in my lifetime]. I claimed that as soon as any mental illness came along that was genuinely treatable, it would disappear from the Psychiatric domain. I was going to go on to say that the antipsychotics were not close to a cure for Schizophrenia, so that illness was with us still [that was actually my point in the first place].

Yet another Memory: After being waved off by the Hospital Superintendent [first memory], I talked to a guy who was occupying the position of Vice Chairman in the Department. He’d been in State Government in Mental Health and either left or was removed, so he was hanging around looking for his next big move – later to be a Chairman then Dean at a smaller school. I [naively] told him about my hobby study. Before I could finish, he tightened up and said, "There’s never been any evidence that long term hospitalization helps Schizophrenia!"

Recalling those encounters, I think I come off as being a perverse figure, misanthropic. I don’t recall being that way at the time. But I think I was extremely naive. I knew that my psychoanalytic-ness was a problem, but none of these things above had to do with that credential. They had to do with my perception about what was happening in response to the introduction of antipsychotic medications. I had even created a computer model and gone to some trouble to gather real numbers to plug into it. It took the rate of new patients with Schizophrenia, the relapse rates of Chronic Schizophrenics in the best Mental Health Center we had, and the length of stay curves when the hospital wasn’t stressed, and computed the number of hospital beds that would be required to manage the patients. It was a least-case scenario. We’d already fallen below that number and were still on the way down. I was afraid the patients would be homeless, dead, or in a prison setting [that’s exactly what did happen to a lot of them].

It wasn’t until I started thinking back on those days writing this series that it occurred to me that it wasn’t the fact that I was a candidate in the Psychoanalytic Institute that made me such a pariah all of a sudden. It didn’t help, but it wasn’t the center of it. It was two other things. I was not going to compromise on the outpatient placements of the residents where we taught psychotherapy. But I think the biggest was this hobby study of mine about keeping the hospital beds for the treatment of the chronically ill at a level that would support the Community Mental Health Movement [that I thought we all agreed with]. Ironically, after I left, those outpatient placements survived [the residents  and other faculty insisted]. That Mental Hospital, however, is now a field of weeds and debris where homeless people often sleep – paradoxically, the place that used to care for them.

All of this happened in the early days of the evidence-based medicine movement that I’ve been talking about. I realize that I was naive and only looking at one side of things. The people above me were looking at the fact that it was the Reagan years and the plight of the mentally ill was way on the back burner – some liberal bleeding heart issue. The Fed and the States had gotten over taking care of the chronically afflicted. Likewise, the antipsychotic medication really did change treatment in a substantial way. But the denial about the downside and the limitations of the miracle medications was widespread and set in stone. The medicine worked. It just had to work. So things were just not close to as rosy as the managers of the purse strings had wished. The promise of better medications for Mental Illness was alluring, but any fool could see that they were throwing out the babies with the bath water in hopes of something that just wasn’t going to happen [I guess I was just any fool].