Psychiatry: The Uncertain Science
Page Nine of Twelve

The day at Fort Logan begins with a cottage report on the previous day, written and read by one of the patients ("Albert slept for two hours before midnight. There was a complaint about popcorn on the floor"). Afterward there is a brief meeting of the staff team and then group therapy, with nine patients and three team members.

In the group-therapy period, after a long awkward silence, a heavy blond woman begins to talk. Haltingly, but with growing eagerness, she tells about her disastrous honeymoon, her hysterectomy, an attempt at suicide, and the inattention of her husband. The great, unbroken flood of grievances and failures ends, there is another pause, and then several people question whether the fault is all on the husband's side.

A nervous, sharp-featured woman named Ethel says that the blond woman should try being more responsive, and several people berate Ethel for being too critical of everybody. Then an energetic Negro woman tells a silent, timid little woman beside her that she is entirely too passive and ought to be more positive about things. The little woman thinks a moment, then says uncertainly, "What would you suggest, Martha' and the group breaks up, laughing.

Afterward there is another staff-team meeting. The talk is inconclusive and interspersed with long stretches when no one says anything:
"I wonder if we're going through a phase where we have to get back on the feel level."
"Ethel got openly angry at the group, and the group got angry at her." '
"Yesterday was terrible. The whole damn hospital was bad."

Next, five members of the staff team go to practice psychodrama. In psychodrama each team member or patient plays himself or another member of the team or another patient, trying to express the way they think that person feels. The director is a beautiful, cool, red-haired former actress, and she starts with a short lecture: "If you know the group is destructive, I would not hold the psychodrama. I am not going to let anybody get up there and expose themselves and be torn to bits." Then a single chair is placed on the small stage, and after a little hesitation, a social worker goes up on the stage beside the chair.
I am putting the staff in the chair, at a team meeting," she explains. To the staff in the chair, she says, "I am sorry that I have let Ethel drive me away." She describes at length her impatience with Ethel, who is often cantankerous. "I can't work with her any more until I can work out my feelings," the social worker concludes unhappily.

A Negro technician gets up and says he will talk to Ethel on the phone. "Ethel, I don't know how much you can ask of the staff," he says. "They give, give, give, and I think it's about time you did something."
"Respond as Ethel," the director says, and when he does, she says, "You don't sound as though you mean it."
After lunch in the cafeteria, most of the group watch a movie about alcoholism, and the discussion that follows goes far afield, A large, slow boy on day care says he has been drugged many times and resents it, then turns to a pretty young nurse and says, "Why don't you talk about your problems?" She covers her face in embarrassment. "I'm a nurse," she squeals.
"Psychiatrists are nuts," somebody says.

There is another staff-team meeting that afternoon, about an ex-patient who has been doing well in family care, about another who is being re-admitted, and about a 15-year-old boy, ready to go home, whose parents have manufactured a story about his being away which could put a strain on him.

That evening, while the patients watch TV or play games, two nurses from the team go to a group session of 16 outpatients, during which a lonely old woman starts to cry while telling about a nice girl next door who once brought her a slice of cake. Afterward the nurses distribute handfuls of drugs, about half a dozen bottles per patient. "The system at Fort Logan is so unstructured, it took me two years to get comfortable," one nurse says later. "Now I love it. It isn't dull. You're on your own. You can take initiative. . . ."

It is hard to catch people in the act of getting better at Fort Logan, but they do. "I had been in private treatment," says the heavy blond woman, , and when I first came here I couldn't believe I could discuss my problems with a group, and that people would be interested." "I get up every morning," the boy on day care says "and all I can think about is getting to Fort Logan."

"There are three elements in treatment here," Dr. Kraft has said. "One, the removal of the patient from the immediate area of pressure. He can rest, think and recuperate. That's very important, not to be underestimated. Two, the drugs. Three, the living-learning situation, the school for living.

"We're becoming adept at treating certain kinds of patients, but there are dozens we don't know a damn thing about. But there's willingness to question, in psychiatry, that hasn't been around before. Gerald Caplan of Harvard can conceive of a psychiatrist who never sees a patient but works entirely through the police, educators, and so on. The mentally ill are one among many disadvantaged groups, the elderly, racial minorities, and the political atmosphere of our country is stimulating scientific advances in these things. There's a new pizazz."

One of the most dramatic products of psychiatry's new pizazz has been the number of programs which drastically shorten hospital time or treat patients briefly without any hospitalisation at all. (As radical as Fort Logan's program is, its patients spend an average of 145 days in treatment, 35 of these as residents, the remainder in day and outpatient care.) Because of the shortage of psychiatrists, brief psychotherapy is often justified as the only alternative to no therapy, but several recent surveys have strongly suggested that it is at least as effective as long stays in hospitals, and is much preferred by patients and their relatives. Many psychotherapists are convinced that changes also continue long after the treatment stops, and that brief therapy can promote basic changes in character.

In California, San Mateo County's hospitalisation rate is 148 people out of 100,000. This compares with a national rate of 238 and a rate of 264 in neighbouring San Francisco County. The San Mateo Community Mental Health Centre program consists on the average of six days in the hospital followed by several months of day and. outpatient care. "We're simply finding that it's not advisable to keep psychotic people in the hospital more than seven days, because if they stay longer. They begin to adopt the hospital atmosphere, ', says Dr. Joseph Downing, the director. "The chief of our inpatient services came here five years ago, feeling strongly that we were sending people out too soon. Now he's completely changed his mind and we're sending them out even faster than we were when he came."

An important factor in San Mateo's low hospitalisation rate is the mental health centre's home evaluations of patients for whom commitment has been asked. As a result of these evaluations, half the patients involved have been able to stay outside the hospital altogether. "I make one visit, it can run a couple of hours trying to figure out what has upset the apple cart," says Dr. Gerald Lutovich, a private psychiatrist who makes many of the evaluations. "If I can't make a decision, I come back two, three, even five times. These are mainly the hard core, who deny completely that they're sick, and many of them won't get much better or much worse. I tell them, 'I'm really here to get your side of the story.' Diagnosis is not the most important thing; the question is whether they can function without being a danger to society or themselves.

"The danger is that in our enthusiasm to treat outside the hospital, we may be keeping out people who could be treated better inside. Sometimes we put too much of a strain on a family that's already pretty weak. Sometimes a decisive, dramatic gesture does more for the family. But very few of these people are a danger to themselves or others. The axiom used to be, 'If in doubt, hospitalise.' We're kind of working on the theory, 'If in doubt, don't hospitalise.',"

An even more dramatic anti-hospitalisation program has been set up in Portland, Maine, by Dr. Richard A. Levy, a tall, dark, briskly informal young psychiatrist, born in New York and trained at Mt. Sinai. Dr. Levy has a private office in Portland, where he keeps a portable heater at the foot of the couch for the convenience of patients who want to take off their shoes. The Portland clinic, where he is now an adviser, is equally down to earth. The clinic is the only public psychiatric facility in the city; as such, it treats only the most severely ill and tries to keep them functioning outside the state hospital in Augusta. The entire treatment program consists of six visits over three or four months, and it relies on rapid diagnosis, reassurance, drugs, and the help of visiting nurses, homemakers, employers and especially members of the patient's family. The clinic treated 500 people during its first 14 months, and only seven of them went on to the state hospital.

"I used to worry a lot during the first fourteen months," Dr. Levy once said. "Would we have a suicide or a homicide- I send a lot of rocky people home. But acute illnesses are usually related to specific events. At the beginning you explore the immediate crisis and give the person reassurance; he's not the only one who ever felt that way, and there's a big difference between having bizarre thoughts and acting on them. When you've sat with depressed patient after depressed patient, you get a feeling for the intensity of the depression. If I do my job fairly well, and don't accuse them of being murderers in the first five minutes, they'll generally relax.
"Our patients are suffering from severe anxiety, or panic, or depression to the point of suicide, or complete psychosis, with complete loss of control. The odds are favourable that you will find out the true cause of the trouble in six visits.
Probably most psychiatrists would find it difficult to believe that so much could be accomplished in so short a time. I myself felt that way at one time. And I've been astonished at the low number of returnees. In five years only 27 have made a return visit, and we've never had to give a complete second series of treatments to anybody.

The clinic's program is precise and efficient. While Dr. Levy is getting the patient's history and prescribing medication, a social worker interviews the family and enlists its aid. In subsequent visits Dr. Levy explores the crisis further, helps the patient to recognize the characteristic and inappropriate way in which he reacts to problems, and, at the last visit, assures him that he may come in again if he feels the need.