Psychiatry and the “deinstitutionalism” movement.

There is a piece in the City Journal this quarter about the New York state experience with psychotic citizens and the prison system. Years ago, I wrote a book about my experiences in medical school and still have some thoughts of publishing it as an e-baook. Chapter One included my own experience working in a psychiatric hospital before the changes took place that put the mentally ill on the streets.

In June of 1962 I was released from active duty. A place in the 1962 first year medical school class had been held for me, but I needed a job for the summer until classes resumed in September. I came across an ad in a Los Angeles paper for medical students to work at the Veteran’s Administration Hospital in West Los Angeles. I was a medical student, albeit one with only a month of medical school under my belt, and I responded to the ad. I got the job, which consisted of performing annual physical examinations on patients in the closed psychiatric ward of the VA Hospital in West Los Angeles. My first experience with patients then was with chronic schizophrenics in a VA hospital.

As I entered upon my new duties at the VA hospital I had more experience than one would expect of a one-month medical student because I had been a corpsman for three years (only one on active duty). Nonetheless, performing annual physicals on 200 psychotic adult men was a daunting task. The psychiatry attending staff and residents decided that they would not do these required physicals because they thought physical contact would interfere with their relationship with the patients. These were the days of Psychoanalysis in psychiatry and examining or even touching patients was considered harmful. They chose medical students to do the task, and I was hired along with a few others. I reported to Building 206 on the Sawtelle Veteran’s Administration Hospital campus about the 15th of June to start my job. Building 206 housed 200 patients, all but a few of whom were chronic schizophrenics. There was one elderly black gentleman who suffered from tertiary syphilis (also called “General Paresis of the Insane” in the old days) contracted during the First World War. He had been a Veteran’s Administration Hospital patient since about 1928. The remainder was from World War II and Korea. The second floor of the building was a locked ward where patients were not allowed out on the grounds without being accompanied by a staff member. There was even a locked room on that floor where patients were confined in strait jackets if they were too agitated to be free on the locked ward. The first floor patients were in an “open ward” where they were allowed to go to the canteen and to go about the grounds of the hospital but were not allowed off the hospital grounds without a pass. If someone left without a pass he had “eloped.” There was one building on the hospital campus with a higher level of security than Building 206, but these patients of mine were chronically psychotic and not allowed to wander about freely except when they were on pass. It was an interesting experience for a first year medical student.

The VA Psych hospital was called The Sawtelle Veterans Home at one time.

The VA Psych hospital was north of Wilshire and evidence of the psych hospital is not easy to find.

This area, containing former hospital and apartment buildings and the historical veteran’s home, and now converted to research and office space, is mostly north of Wilshire Boulevard. Since 1977, this area has formally included the Veterans Affairs (VA) Wadsworth Medical Center (now the West Los Angeles Medical Center),[4] which is south of Wilshire Boulevard from the former veteran’s home site (see illustration above).

The medical director of the unit was George Harrington M.D., one of the most colorful and impressive men I have met in medicine. He was a private practice psychiatrist and a Clinical Professor of Psychiatry at UCLA School of Medicine. Several years before I met him he had been placed in charge of this chronic unit, at least in part, to prove his theories about treating chronic psychotics. Harrington had originally trained as a classical psychoanalyst, and his father, originally a Baptist minister, was a lay analyst trained in Vienna by Sigmund Freud. In Europe, unlike the U.S, analysts were not required to have medical degrees. He told me that he literally had sat on Sigmund Freud’s knee as a small child. He attended the University of Kansas Medical School and trained in psychiatry at the Menninger Clinic in Kansas, where his father was practicing, either at Menninger or nearby. Doctor Harrington had developed considerable skepticism about Freudian psychoanalytic methods and, in particular, he did not think much of the psychoanalytic theory of psychosis, especially schizophrenia, which he thought was an organic disease. At one point he told me that he thought schizophrenia probably would turn out to be caused by an unknown vitamin deficiency. This was in 1962 and some of his ideas have turned out to be pretty close to modern concepts about schizophrenia.

In 1962 the psychoanalytic model for schizophrenia was still widely accepted. There was the “schizophrenogenic mother,” a demanding, fickle mother who drove her sons crazy. The fact that schizophrenia has been shown to be partially hereditary (50% of identical twins will both be affected if one is) meant that some mothers were burdened with the accusation that they had caused more than one son’s illness. There is a male predominance of about 2 to 1 and females seem to develop the disease in later life (peak at age 15 for males, age 25 for females) so the psychoanalytic model was a heavy burden for mothers. The son was often still at home at the onset of the illness while the daughter had left the home for some time before the symptoms began. Now we know much more about the disease and mothers have been absolved of responsibility. There is definite evidence of an organic cause and heredity, while significant, is not the whole story. If one twin is schizophrenic the other has a 50% chance of being affected if they are identical but only about 18% if they are fraternal. If one parent is schizophrenic, the risk of a schizophrenic child is about 12%; if both parents have the disease, the risk is about 37%. The risk in the general population varies from about 1 per thousand (0.1%) to as high as 7 per thousand in some countries. It is now known that being adopted into a family with one schizophrenic parent does not increase the risk so the poor mother should finally be excused from responsibility.

Schizophrenia is a mental disease characterized by problems with thinking. All psychoses share that characteristic but schizophrenia is different because the disorganization of thinking is global. There are four types of “positive symptoms;” delusions, hallucinations, disorganized speech and disorganized behavior (the most severe example being catatonia in which the patient remains still and mute). Delusions are beliefs that are not based on reality, often paranoid in content. Hallucinations in schizophrenia are always auditory; the patient hears voices. Visual hallucinations are almost always due to organic brain problems, like the hallucinations of delirium tremens due to alcohol withdrawal. Speech disorders may include “word salad” in which the speech is very disorganized and does not make any sense. Behavior problems include constant pacing and odd posture or actions. There are also “negative symptoms,” which include withdrawal, very common in which the patient stops interacting with others, “anhedonia”-which means an inability to have pleasure, anergia- reduced ability to act and carry on daily routine. Affective flattening is very common and means an absence of any show of emotion by facial expression or tone of voice. Not all schizophrenics show all of these symptoms but affective flattening and hallucinations are very common. Thought disorder may not be apparent unless one spends some time talking to the patient and then symptoms like incoherence, loose associations and poverty of speech may appear. An excellent way to bring out these symptoms is to ask the patient to interpret proverbs, of which more a little later. The results can be quite startling although there is a strong cultural component to things like proverbs.

Biological causes can be further studied using autopsy and various modern brain imaging techniques. The prefrontal region of the brain, along with several of the basal ganglia, seems to be the most affected. This prefrontal area is associated with attention, planning and decision-making, functions affected by schizophrenia. Decreased blood flow, glucose metabolism and even reduced absolute volume are noted in schizophrenic brains. In identical twins the affected twin has these changes but the unaffected twin has normal brain anatomy and function. There is a group of “patient advocates” who deny the existence of schizophrenia as a disease and blame the whole thing on a plot against people who are “different.” The book and movie “One Flew Over the Cuckoo’s Nest” has promoted this view. They allege that the brain changes in schizophrenia are a consequence of the drug therapy “forced” on these individuals. Unfortunately for their theory, a number of studies of never-medicated schizophrenics have shown the same changes in the brain.
There is an argument that schizophrenia is a “new disease” and that it did not exist until modern times, suggesting that it is a “social construct” rather than a disease. In colonial times there were accounts of crazy family members confined in appalling conditions and Dorothea Dix, later famous for nursing in the Civil War, was an early reformer. I have more about this, of anyone is interested, in my history of medicine book. The early saints may have included some schizophrenics, as well as some of the early witches.

The patients of building 206 were a fairly typical group of chronic schizophrenics. They were of course all male, although there was also a female ward at the VA Hospital. They were treated with Thorazine (chlorpromazine) and Stelazine, which had come out in the 1950s as the first effective anti-psychotic medications. Because these drugs had fairly severe side effects, they had not proved to be the panacea that initially was expected. Chlorpromazine, a derivative of anti-histamines, was discovered to have antipsychotic effects in 1951 and became available in the U.S. in 1953. Because it is a dopamine blocker (dopamine is a chemical with neuro-transmission functions as well as being an intermediate stage in adrenaline metabolism) it supports the dopamine-excess theory of schizophrenia but the dopamine blocking effect also leads to the side effects, similar to the symptoms of Parkinson’s Disease, which is caused by dopamine deficiency. Doctor Harrington told me of his first experience with the new anti-psychotic drugs. He had finished his residency and, just as he was getting ready to open a practice, he was in a serious auto accident. He suffered a fractured femur and was laid up in traction for several months. As he lay there frustrated with his immobility and his desire to get started, he read about the new “miracle drugs.” He thought to himself, “My God, I’ve just gone through 10 years of training to treat psychiatric illness and someone has invented a pill which cures it.” Soon after he returned to practice he witnessed the side effects of Thorazine and realized that he had not been made superfluous after all. His description of this incident was given with his typical storytelling skill and hilarious mimicry of a poor patient drooling with the extrapyramidal side effects of Thorazine. The other effect of his accident was more long lasting as the femur fracture left him with a pronounced limp. He was a large, handsome man with rugged features and this, combined with the limp, had interesting psychological effects on his patients.

During my first week on the ward, I was introduced to the staff, including the chief nurse and a number of orderlies. In Harrington’s concept of treatment, every employee on the ward, including the man who polished the linoleum floor, was part of the treatment team. Every Wednesday morning he would have a conference with the entire staff, including the maintenance workers, and specific patients would be discussed. Sometimes he would have a patient come in for an interview and then demonstrate his concepts and methods to the staff. One of Harrington’s stories described a patient who was brought in for an interview not long after he became the medical director of the ward. There was a good deal of skepticism on the part of the full-time VA staff about his methods and someone on the nursing staff chose this particular patient as the “toughest nut to crack.” This could have been an attempt to show up Harrington as a bit of an amateur, but it gave him the opportunity to demonstrate that he really knew what he was talking about. The patient was a little disheveled-looking fellow who, typical of most of the patients, shuffled the hallways for hours during the day and said very little. What he did say was usually a mixture of delusions and gibberish. When he was brought in before the entire staff in the conference room, Harrington, with his muscular-looking physique and pronounced limp from the old leg injury, made quite a contrast with the patient. He sat the fellow down and asked him how things were going. The patient proceeded to recite a lengthy example of his usual “word salad” conversation, including a lot of delusional stories and some pretty wild images. It would take a recording of one of these patients to convey the impression but the effect was one of complete psychosis. Harrington sat there for a long time listening to this and then finally interrupted him to say, well, he could certainly understand what the patient was talking about because something similar had happened to himself. Whereupon, he proceeded to recite, almost verbatim, the same crazy conversation that the patient had just delivered. About halfway through this, the patient started laughing and it quickly became apparent to everybody that he had been copying stuff he heard from other patients on the ward and deceiving everyone about his mental status. He had recovered from whatever psychiatric problem that brought him there years before but was contented with a clean bed, regular meals, a cigarette allowance, and nobody hassling him. He kept to himself and, when someone in the staff would talk to him, he would recite enough gibberish to convince them that he still belonged in the psychiatric unit and they left him alone the rest of the time. That patient was one of the first of Harrington’s successes, and was moved out of the closed ward into a halfway house not long afterward. He was now functioning independently in the outside world. Certainly anyone with a desire to remain in a closed psychiatric ward is not a normal individual, but this fellow was not nearly as crazy as he had led everyone to believe.

Here George Harrington taught me how to talk to psychotic patients.

The first couple of weeks on the ward gave me a crash course in Harrington’s methods of dealing with psychotics. He thought that psychotics, particularly schizophrenics, have a problem with interpreting reality. They, for whatever reason, are unable to pick up the usual cues and messages of interpersonal relationships like normal people do. Autism and Asberger’s Syndrome have some similar characteristics, which lead to current theories that they are related. The patients are constantly getting into trouble with the normal society and react to cues and messages that are invisible to normal people around them. This creates a lot of anxiety and this anxiety is responsible for a lot of the bizarre behavior. In addition, the anxiety leads to hallucinations, which in psychiatric illness are auditory hallucinations. Visual hallucinations are generally indicative of toxic encephalopathies from drug reactions or toxic chemicals. One theory, popular at the time, was that sensory deprivation could mimic psychosis. If a volunteer is immersed in a body temperature pool with no light or sound, hallucinations develop fairly rapidly. The relevance of this was a theory that schizophrenia could be a sensory input problem and schizophrenics are experiencing sensory deprivation. There are a number of drugs, like LSD and methamphetamine, that can mimic some symptoms of schizophrenia but they do not produce all the findings and the disease appears to be more complex than one mechanism could explain.

The way to deal with psychotics according to Harrington was to listen to the things they said that made sense and ignore the nonsense. This required an enormous amount of concentration on the part of the listener if you were dealing with a patient who was actively psychotic. The effectiveness of the method, however, was dramatic in some of these patients and they quickly realized that I could understand what they were trying to say and that I was ignoring what the patients themselves called “the crazy stuff.” The treatment, in addition to therapy with chlorpromazine, was to give them an artificial set of rules of life, which would reduce their conflict with normal society and by doing so would relieve a lot of their anxiety. They couldn’t understand why they were always getting into trouble because they could not pick up all the subtle cues of normal social behavior. A simple example is the inability of schizophrenics to interpret proverbs. A typical part of the psychiatric exam might be asking a patient to explain what “A bird in the hand is worth two in the bush” means. A schizophrenic will get lost in talking about birds and will be unable to extrapolate the concrete example to a general statement about possession and anticipation of possession being different things.

I recently had one of my students try this with a patient on a “psychosomatic” ward where patients are admitted with psychiatric problems in addition to medical illness. He told me he suspected psychosis so I demonstrated the effect of asking a psychotic to interpret a proverb. A half hour later the patient was still going on a flight of wild ideas that had nothing to do with birds and bushes. Harrington had a whole set of artificial rules which allowed these people to function and to get by with a minimum of conflict with the rational world. Patients were given details to perform on the ward. One patient’s daily chore might be to clean out the drinking fountains twice a day, and if he performed that satisfactorily, it was a sign that, first of all, he was getting the message and, secondly, he was able to control his illness to the point where he could follow instructions and perform a task. The reinforcement that the patient got from performing the task satisfactorily helped to reassure him that he was doing the right thing, that people were not angry with him, and that he was functioning. This was a self-reinforcing situation and, as patients performed one simple task adequately, they were given a slow progression of more complicated tasks. If they showed signs of regression such as increasing crazy talk or misbehavior, they were brought back to the beginning. In some instances this meant taking them to the locked ward or even in a few extreme cases, putting them in a straitjacket and restraining them completely for a few days until they calmed down. Then they could resume this step-by-step pathway to functional existence. They still couldn’t interpret proverbs but they could get along.

In a halfway house, they were given a list of duties like brushing their teeth and bathing and shaving every day. If they began to feel anxiety, they might stop doing these simple tasks and the resident monitor was trained to note such changes in behavior. Sometimes a talk about responsibility was enough to reassure the patient that we all knew he was still crazy but, at times, a return trip to the hospital was needed and they would calm down. If nobody noticed, they would progress to more crazy behavior until somebody noticed. That was harmful and recovery would take longer. Now, with no hospitals, the consequences of deinstitutionalization are everywhere on the streets.

The second floor locked ward was a pretty bizarre place. There was a large dayroom with two or three television sets going 24 hours a day. There was always a large audience intently concentrating on these TV programs and the staff assured me that most of the attentive patients believed they were receiving instructions from the TV sets and fully incorporated the programs into their psychotic thinking. This certainly ensured a quiet audience. Several rooms were locked within the locked ward itself and were used for patients who were “acting out” and having a lot of trouble controlling their physical activity. There were even a couple of rooms where patients were confined in straitjackets. The patients themselves understood what was going on and, contrary to myths perpetuated by movies like “The Snakepit” and “One Flew Over the Cuckoo’s Nest,” the patient in a straitjacket almost invariably, at least in my own experience, calmed right down and was reassured by the restraint. Harrington’s explanation of this was that we were proving to them that we understood that they were crazy and that they were unable to cope with the outside world. The anxiety that a lot of these patients felt was brought about by their belief that they were about to be tossed out into a cold, cruel, uncaring world that did not understand they were crazy and unable to deal with it. When they were convinced that the VA staff knew they were crazy and were going to protect them from the outside world, they calmed right down. Patients who had failed their routine tasks in their ward details settled down right away when they were brought back to a more basic level and frequently were able then to progress more rapidly in the treatment program. They had been reassured that even though they were improving, they were not yet ready for the outside world. Before deciding that I am a Neanderthal about the treatment of mental illness, remember that the drugs we had were still primitive and the side effects were similar to severe Parkinson’s disease.

Needless to say, performing complete physical exams on these patients was a bit of a challenge. They were middle-aged males and a prostate exam was part of the physical. I had some apprehension as to how this was going to be received by these psychotic men early on but found that it was not a problem at all. As I got a little better at the psychiatric method and could communicate with these folks, I found that they were very understanding. They were happy to have me there, probably because I represented another person who cared about them and was paying attention to them. There was one fellow, “Roy,” who had been a VA psychiatric patient since the Anzio beachhead battle, in Italy in 1943. He had come ashore at Anzio in the Italian campaign and was subjected to severe artillery bombardment which left him shell shocked. He never recovered. When I saw him, he had been a psychiatric patient in the Veteran’s Administration for 19 years. He was still on the closed ward and, in fact, spent part of the time on the locked ward. His conversation was pretty bizarre but I thought I detected some parts that made sense and answered those parts. It was exhausting to talk to him, but I found that I sometimes understood what he said, and at one point a long description of the Sun spinning around and lights flashing in the sky turned out to be his welcoming me and telling me that he was happy that I was there. A month or so later I found that Roy’s situation was more complicated. Two nights a week, in spite of his severe psychosis, he had a pass and could walk down to Wilshire Boulevard, which passed through the VA medical campus, to catch a bus to UCLA, about half a mile east of us. There, Roy was attending night school and getting a master’s degree in mathematics. I would love to have been a fly on the wall of the classroom to see what his behavior was like in class. I simply could not put the two people together; one, the word salad spouting chronic psychotic and the other, a graduate student in mathematics.

Another patient, who I will call “Luke,” (most of these names I have forgotten over the years and I would not use real names anyway for confidentiality reasons) was a man of about 45 who apparently had a fairly comfortable middle class life with a wife and a couple of children until one morning he came down to the breakfast table wearing one of his wife’s dresses. He informed his children that he was their mother and their mother was actually their father. Needless to say, he wound up in a VA psychiatric unit shortly after and had been there for several years when I met him. He was able to talk to me quite candidly about that experience and described himself as “really crazy” at the time. He was not nearly so crazy now, he said, but he did not feel that he was ready to go back to the outside world any time soon. He was able to carry on a pretty rational conversation and, until you got into some of his delusions, he sounded like a normal middle-aged man. A few signs of his illness present all the time, however, were his constant pacing of the halls and his inability to sit down and concentrate at any task like reading or working at any sort of hobby. He also believed, at times, that he was Jesus Christ. At other times he told me that he really didn’t believe that but it seemed real when the moment came.

Two of our patients had long-term incestuous relationships with their mothers and, as bizarre as this sounds, the mothers would take the patients out on weekend passes and, according to the staff, the two patients and the two mothers would “double date” and go off somewhere for the weekend. I was told a number of times by the staff that some of the families were crazier than the patients and the only reason that the patients were where they were was because they were veterans and were entitled to the Veteran’s Administration care. Some of the families were brought in for treatment conferences and, on occasion, these conferences were more of an attempt at group therapy of the family members than of the patient. There was a darker side to some of these families. When a veteran is confined in this fashion the family, depending on the status of the veteran (Some, like Roy, were service connected), may be collecting an allotment. This is similar to the allotment paid to the dependents of an active duty member of the military. So long as the veteran is confined, the family collects the allotment from the VA. If he is released as cured, or even improved so that his condition no longer requires hospitalization, the allotment does not increase and the family now has another mouth to feed. This system resulted in some resistance from the families to discharge planning for the veteran. Staff members told me that they believed that the allotment system was responsible for the prolonged hospital stays in some patients who might have been successfully treated as outpatients.

The deinstitutionalization movement began with the movie One Flew over the Cuckoo’s Nest. Randle Patrick McMurphy is a free-spirited, small-time convict who fakes being crazy so he can get transferred from the state penitentiary to a more comfortable state mental hospital.

The point is made that mental hospitals are horrible paces where even sane inmates are driven crazy or lobotomized.

As the summer went by, I gradually worked my way through the patient population doing my physical exams and even found a few diseases. I picked up a cancer of the prostate on one patient. When I started I had never done a digital rectal exam and Harrington himself showed me what to feel for. He made a fist and told me that the prostate felt like the muscles between the thumb and index finger when the fist was clenched. He demonstrated by tightly pressing his thumb against the first knuckle (rather than actually clenching the fist) and told me that if it did not feel like the tensed muscle, or if I felt any lumps in it, I had better let somebody know. This is pretty basic physical diagnosis education and my students would cringe at the teaching method but I guess it worked. The normal prostate does feel rubbery, like that muscle. Sure enough, one of the patients had a lump in his prostate and it turned out to be a prostate cancer when he was worked up over at the medical portion of the VA complex. I have learned over the years that the key to finding disease is to look. As Woody Allen once said, “Half of success in life is just showing up.” More than half of the diagnosis of prostate cancer is just doing a rectal exam, even if it is done by a first year medical student.

On another occasion, one of my patients, whom I had gotten to know pretty well, spent the day looking different to me. He was very quiet and was not pacing as much as he usually did. He did not say much but had a look of distress on his face. Schizophrenics have a “flattened affect”, meaning they have poker faces. Even a slight change of expression is unusual. Finally I got him to come in and lie down on the examination table and sure enough he seemed to be tender in his right lower quadrant. I sent him over to the emergency department with what I thought might be appendicitis. Again, I was right, he did have acute appendicitis and I had made the second of my diagnoses that summer. Who knows how many diseases I missed but, as far as those patients were concerned, I was it. I have since read that as many as 10% of all patients who die in long-term psychiatric hospitals have brain tumors. I don’t know if I missed any of those.

While I was working in Building 206, I was able to attend some of the staff conferences in the other parts of the psychiatric complex and I met some of the psychiatry residents who were training in the VA program. One of them was a radiologist who had completed a residency in radiology at UCLA and then, after a short period in radiology practice, decided that he might like psychiatry better. He was a really nice guy but was now having some doubts about his decision. He told me about an experience on the women’s ward. The residents were experimenting with different methods of relating to patients and this particular day he was trying physical contact. Specifically, while he was talking to this psychotic woman patient, he was brushing her hair. She enjoyed this and their conversation continued while he sat there, apparently quite close to her, and brushed her hair out. Eventually, the pleasure part of the experience got too much for her and she peed on him, soaking his trouser leg. This completely disconcerted him. That and a few other similar experiences had put some question in his mind about his choice when he switched to psychiatry.

On a couple of occasions, I went over to the shock therapy suite while patients of mine were undergoing electroconvulsive, or shock, therapy. There are two kinds of shock therapy that were in use at that time. One was electrical which involved discharge of electrodes over the patients scalp with other electrodes, as I recall, on their arms and legs. Patients were sedated and given some muscle relaxants and may well have been completely anesthetized, I cannot recall. They were then subjected to an electric shock that caused a convulsion. The muscle relaxants were intended to prevent fractures during the convulsion. A few years later there was a great outcry against this method of treatment and it was largely discontinued. My own extremely limited experience with it was interesting. Several of the patients, who I knew were grossly psychotic, had a lucid interval that lasted a matter of hours to a few days after the shock therapy. During this period the psychosis appeared to be completely resolved. Unfortunately, it always recurred but repeated shock therapy treatments were given in an attempt to induce a prolonged remission from the psychotic thought processes. The other method of shock therapy was called insulin shock because the patient was given an injection of insulin until he became hypoglycemic (low blood sugar) and sometimes had a convulsion as a result of the hypoglycemia. This I thought was more harmful because the brain can be injured by very low blood sugar levels and I could not seen any difference in the effect between the few cases of insulin coma therapy that I saw and the electroconvulsive therapy. Shock therapy did appear to be a useful form of treatment in days when the anti-psychotic drugs were pretty primitive. It was also used in depression but I had no experience with this application. I have since done more reading about insulin shock therapy and my impression that it was harmful was probably incorrect.

Insulin Shock Therapies have a terrible reputation.

As the summer drew to a close, I managed to finish my 200 physicals. I hope I didn’t miss too many important diagnoses, because if I missed them, no one else would find them. Most of these patients had not had a physical examination in years and mine was probably the only one they would receive for years to come. I got lot of practice listening to hearts and feeling abdominal organs and hope that I did them some good. I would come home every day mentally exhausted from the effort of talking to patients who were grossly psychotic yet who were trying to communicate. If I responded to the lucid portions of their conversation, they would gradually increase the amount that was rational. During the last week before I left to start medical school again, Roy came up to say goodbye. He told me (in his own oblique way) that most of his day was spent with other patients who were also psychotic and there was little use in attempting to carry on a rational conversation with someone who was not rational himself. The rest of the staff was busy enough with the basic medical care and “hotel functions”(feeding and changing linen) of the ward so they did not spend much time talking with the patients. I had been there now for three months and had spent more time talking to these men than anybody else had for some time and Roy tried to explain the effect on him. He told me that his mind (he didn’t use that exact term) was like an iceberg, only a small portion of which could rise above the surface of the water. I interpreted the water to mean his psychosis. As he talked to me, more of the iceberg would rise out of the water. He was sorry that I was leaving and he would miss our conversations. This was a dramatic expression of feeling that I have never forgotten. I don’t know what happened to these men after I left but it has now been over 50 years and I remember them very well and with a great deal of fondness.

I do wonder what happened to them after they were thrown on the street by well meaning “activists.”


One Response to “Psychiatry and the “deinstitutionalism” movement.”

  1. Brett says:

    Especially interesting since psychology was my major in college although I never studied it beyond a bachelor degree. Also, I grew up and lived most of my life within 5 miles of the VA Hospital in West L.A. It was always a mystery to me what went on there at that expansive campus. I did cut through the campus while trying to skirt traffic a time or too. I did attend a musical program, “Stomp” at the Wadsworth Theater in the mid 90’s when I was about 30 years old. That is the extent of my personal experience there though. Thanks for another interesting post. On a side note, that entire campus has become some very expensive real estate. I’m amazed it hasn’t been plowed over and turned into homes by now.