I was thinking about Psychiatry today and the problems of deinstitutionalization. The best source for the latter is “My brother Ron,” by Clayton Cramer.
My book review of this book is here.
I was a medical student in 1962 when I got a summer job working in a VA psychiatric hospital doing routine physicals on the inmates. They were all men and some had been there for years. They were all “chronic hospital cases,” as described in this excellent history. Mr. Cramer gives a very thorough history of psychiatry leading up to the introduction of psychiatric drugs that actually worked and the social upheavals of the 60s that led to the emptying of the state mental hospitals. At the time I had my personal experience with the chronic schizophrenic, the deinstitutionalization movement was just getting started. My own days with these patients were similar in many respects to Mr Cramer’s experiences with his brother, Ron. Fortunately, none were my relatives and I could go home every night and leave their troubles behind. Still, the experience of talking to them all day was exhausting. My job was to do annual physicals since the psychiatry residents did not want to do so.
This was the height of the psychoanalysis influence on psychiatry. Fortunately, the chief of the service where I was working was a former analyst who realized that Freud had nothing to offer the psychotic patient. He taught me to talk to the sane part of the patient and ignore the “crazy” part. The early drugs, like chlorpromazine (Thorazine), allowed much better interaction with these chronic schizophrenics. Some of them explained what it was like to be “crazy,” their preferred term. I witnessed Electroconvulsive treatment (ECT) and saw the “lucid interval” that often followed the session. The patients usually lapsed into psychosis again after a few hours but the desire was to try to prolong the effect and this led to repeat sessions.
The author does a great job with the history and goes into far more detail on the legal aspects than I did in the chapter on psychiatry in my own book, A Brief History of Disease, Science and Medicine. He writes about “The fever treatment” that won a Nobel Prize for Wagner-Jauregg, the advocate, in the 1920s. This was a result of success with syphilis using fever when the drugs were inadequate and toxic. The legal history is important as the legal maneuvers of anti-psychiatry forces were the proximate cause of the disaster that followed. The homeless problem appeared in the 70s as the mental hospitals emptied and the former patients found nothing to replace them. The Community Mental Health Centers, as the author so well describes, were intended to take the place of the state hospitals but were never adequate, especially in the era of “talk therapy,” where a single psychiatrist could only see eight to ten patients a day.
I teach medical students and take them to the homeless shelters in Los Angeles every year so they can see where their County Hospital patients come from, and return to after hospitalization. They are able to see the futility of prescribing medicines when the patient has no clock or refrigerator to time the dose or preserve the drug between doses. The author relates the incidence of mental illness among the street population. The managers of the shelters tell me and my students that 60% of the homeless are psychotic and 60% are drug and alcohol addicts. Half of each group is both. For the first few years, we had an amazing guide, a former homeless man now working for the city. He would regale us with stories of his ten years on the street addicted to crack cocaine. He took us to shelters and to homeless hideouts where he warned us not to go there without him.
This book is a source for anyone who wants to know how things got so bad and why the families of psychotic patients are so frustrated with the “advocates” who block treatment or commitment of those unable to care for themselves. One of my students’ patients was a man with a severe leg infection that threatened amputation. He lived on the sidewalk in front of a Pasadena church. He refused parishioners’ offers of housing, telling them he was waiting for the perfect apartment. He barely kept his leg with intense treatment. After treatment, he returned to the street. This is a national tragedy and the reasons are well explained in this book. I can’t recommend it highly enough.
My experience described above was with George Harrington MD, the most impressive man I have ever met in Medicine. His obituary:
Born in Independence, Missouri, Dr. Harrington attended the University of Kansas, where he received his medical degree in 1941. He also played football for the university. He then interned in Chicago, and during World War II served in the Pacific theater as a Navy flight surgeon. He was the recipient of a Personal Citation, Distinguished Flying Cross, and four Air Medals as a result of his service. In 1946, Dr. Harrington began his residency training in psychiatry at the Menninger Foundation of Psychiatry, and became a faculty member at the Menninger School of Psychiatry. He also served as chief of professional services at the Winter VA Hospital in Topeka, Kansas and was a member of the American Psychiatric Association. In 1955, he moved with his family to Pacific Palisades, where he began private practice. He was also a clinical professor of psychiatry at UCLA and head of psychiatric services at Brentwood VA Hospital until 1965.
After he served as staff psychiatrist in charge of a research project on chronic mental illness at the Brentwood VA Hospital, his work culminated in the 1965 book, “Reality Therapy,” written by William Glasser. The book, offering a new approach to psychiatric treatment, was dedicated to Dr. Harrington. He counted many noted writers and entertainers among his patients, many of whom dedicated works to him. The playwright George Furth dedicated his Broadway play, “Company,” to Dr. Harrington, who was an avid sailor and continued this activity until his death.
Harrington was a big rugged looking guy who walked with a limp from a femur fracture incurred in an auto accident soon after he finished his residency at Menninger Clinic. He told me his father had been a minister who became a lay psychoanalyst and spent time in Vienna with Sigmund Freud. In fact, he told me that he had sat on Freud’s knee as a child. From the time he was 17 he wanted to be an analyst. His father was at Menninger hence his MD from U of Kansas. After the war, he began his residency at Menninger and found that analysis had little or nothing to offer psychotic patients. He told me that every summer, the staff psychiatrists would leave the state hospital on vacation, leaving the medical students to take over. It didn’t take long for him to realize that he was getting nowhere with psychotics using analysis. He was a funny guy with a great sense of humor and an ability to mimic.
He became a clinical professor of Psychiatry at UCLA and took over a ward at the Sawtelle VA hospital sometime before 1962 when I met him. He told me that staff at the VA were very skeptical of his new ideas on therapy so, early in his tenure, they lined up a “hard case” for him to demonstrate this new “talk therapy. ” The new drugs had made things much easier to deal with schizophrenics and he wanted to go beyond with some sort of behavioral therapy. He said the patient was a typical schizophrenic little guy. Harrington asked him how things were and the patient responded with a long stream of typical crazy talk. Harrington listened to all this, then responded that something very similar had happened to him. He then repeated almost verbatim the same stream of crazy talk the patient had related. Half way through, the patient he said began to laugh. He was no longer psychotic, if he had ever been so. He liked having a bed and three square meals a day. He had memorized enough crazy talk to keep everyone convinced that he belonged there. Harrington cautioned me that anybody who wanted to live in a nut house was not normal. Still, the guy was just not that psychotic. He convinced the ward staff that there was something to his ideas. After that, everybody on the staff was part of the treatment team. Even the guy who ran the floor polisher was invited to the Wednesday staff meeting.
What Harrington did was to set up a program of rules that taught these psychotic patients that we knew they were crazy and we were not about to throw them out into a world that scared them so badly. We also, me especially, talked to them and focused on the part that was not crazy. It could be exhausting to do so but patients would respond. One of them told me as I was leaving at at the end of the summer to go back to school that talking to me allowed more of his mind to come out of the psychosis. Of course, he didn’t put it that way but that is what it sounded like to me. It was an intense summer and George Harrington was someone I will never forget.
Most of my job was to do annual physicals on these man, many of whom had not been examined in years. It was an interesting experience to do prostate exams on these psychotic men. It turned out to be no big deal as they all appreciated someone looking after them. I even found a prostate cancer that summer. Psychiatry was still in the grip of analysis then and the residents from UCLA did not want to touch patients.
After returning to medical school, I met some academic psychiatrists and lost interest in the specialty. Harrington was almost unique although Glasser’s book, which explains much of Harrington’s methods, had a wide popularity and is still in print.