I fell in love twice in my life: at 19, in 1942, as a Harvard College senior, with the lovely girl to whom I have been happily married for nearly 70 years; and, at 21, as an Albany Medical College junior, with psychiatry. That love has been somewhat less successful or satisfying.
Starting in psychiatry
I have always been rather optimistic, and sometimes overly so. My interest in psychiatry began as a third year medical student when I found that psychiatric ward patients often cheered up significantly when I spoke with them. During my first residency year, at Bellevue in 1947-48, this faulty optimism got me into difficulty from failing to take into account the lack of social supports for a young man there whose depression diminished greatly after we spoke together, and who I therefore mistakenly thought might be ready for release. My error was corrected by more experienced superiors. But I also found at Bellevue how much my approach to patients determined their responses to me. I saw how my usual frank and open attitude evoked more humanity from patients, and less evidence of illness (psychopathology) than when I took the “neutral,” supposedly “non-judgmental,” approaches we were taught as standard; this I called “the wooden Indian school of psychiatry.”
Since I had gone through medical school during the war in the army specialized training program (ASTP), I spent 1949-50 in Kansas as psychiatrist to a basic training unit.
In September, 1950, with psychoanalysis riding high in psychiatry, I began both a psychiatric residency at psychoanalytically-oriented Hillside Hospital and a three-year, two-evenings-a-week course toward certification as a psychoanalyst.
In retrospect, I had considerable difficulty with Hillside’s psychoanalytically-oriented approach. The Freudian technique of unstructured free association, as opposed to conscious focus on specific problems, seemed to make treatment almost endless. Its emphasis on childhood traumas as key determinants of today’s difficulties, rather than on current issues, seemed wrong from the start; I later found that for only about a tenth of my patients were such childhood difficulties relevant; for the others, the problems needing solution arose in the present and recent past. And seeing patients in isolation, without next of kin, seemed tailor-made for causing trouble; in those days, each member of a couple seeking psychoanalysis would be sent to a different analyst! Soon after starting practice, I began to insist on seeing every patient’s spouse, to understand the relationship between them, and to help improve it if necessary. Only gradually, and over the years, did I come to realize the importance of defining and strengthening the social structure of which the patient is an integral part - his family - and which, in turn, represents a fundamental support of his or her life.
Nevertheless, I very much liked the Hillside program, and learned more there than from any other part of my residency. But I soon became concerned that we were keeping patients hospitalized too long. That was because psychotherapy was provided only within the hospital; there was none after release, when it is actually most needed. I took my protest against over-retention to, and beyond, the Hospital Director. My anticipated two year residency was then terminated, altho I was allowed to finish one year. Ten years later, I wrote a paper based on, among other things, Hillside’s own published statistics, which showed that across different diagnoses and different facilities, the longer a patient was hospitalized, the greater were his chances of needing subsequent readmission. That’s because overly-long hospitalization can infantilize patients. Over the subsequent years, psychiatric hospitalization has changed considerably - often going from too long to too short: from frying pan into fire.
After Hillside, I took a position at Creedmoor State Hospital, a State Office of Mental Health facility just down the road. A few months later, by virtue of my four years of psychiatric training/experience and a civil service examination, I was appointed “supervising psychiatrist” - chief of the female admissions service. There, to combat the pessimism so often pervading psychiatry, I saw each patient her afternoon of admission and told her our job was to help her calm down so she could return home to normal living. I had a superb chief nurse, two or three fine psychiatric residents and we did a good job. Almost all of our patients recovered and left the hospital without returning; very few were sent on to “continued treatment” wards.
Psychoanalysis and me
My view of psychoanalysis, of which I had always been critical because of its conservative political outlook, changed during my two Army years. (Freud himself, although persecuted as a Jew, had expressed admiration for Benito Mussolini.) I saw that Roy Whitman, M.D., a psychiatrist on the base with the same limited psychiatric background as I, but with some exposure during it to psychoanalytic therapy, was able to help patients much better than I. That’s when I decided that I also needed psychoanalytic training.
Although my cousin Philip R. Lehrman, M.D., was a past-president of the New York Psychoanalytic Society, I was too critical of classical Freudianism to go there. I enrolled instead in the New York Medical College-Flower and Fifth Avenue Hospital’s Comprehensive (evenings) Course in Psychoanalysis, where I would get supervision from both “classical” and “culturalist” analysts. As part of my training, I also spent four years on the couch: the first two with a cold fish who then gave up office practice to open a private psychiatric hospital (a business long since gone) and the last two with an analyst of whom I was very fond, but whose main contribution to me was loosening some sexual inhibitions.
When we finished the course, we had a graduation play, which I wrote. Its title was “The Birds and the Bees at the Flower” and I had the lead role. It described a boy (me) and a girl, who, unable to consummate sexually, therefore sought psychoanalytic help: from Freudian and culturalist analysts respectively. At the play’s end, the pair, having been successfully analyzed, still cannot consummate - but they are happy because they now know why!
Private practice in Great Neck, L.I.
In 1953, after two years at Creedmoor, and a small, part-time practice in Manhattan, I opened a full-time psychotherapeutic practice in Great Neck, L.I. I did very well and in 1954 my wife and I were able to buy a home in Roslyn. But five years later, when well-organized reactionary groups attacked public education throughout Nassau County, I became involved in vigorous defense of the Roslyn schools, which my children attended. I was then subjected to a multitude of simultaneous attacks from many directions. It is worth noting here that Adolf Hitler, in Mein Kampf, described the specific tactic of attacking an enemy from several directions simultaneously in order to “break their nerves.” It is even more worth noting that individuals complaining nowadays of such simultaneous attacks tend to be written off as “paranoid.”
Mistakenly, I fought back all the attacks. Doing so made me increasingly hypersensitive - paranoid - and I began misinterpreting trivial annoyances as deliberate attacks. The recognition by my family and friends that some of the supposed attacks were baseless led to the conclusion by professionals and others that they were all false; this left me high, dry and, for four years, increasingly agitated.
In this situation, my professional psychiatric colleagues were of no use whatsoever. My life was saved, however, by a cousin, Louis J. Soffer, M.D., an attending endocrinologist at New York’s Mt. Sinai Hospital, who took command and had me admitted to its psychiatric ward. I spent three months there, recovering completely because of (1) its protected environment, (2) the discontinuation of medication (which, for the two weeks I took it, had made me a zombie) (3) my running a mile each day in the hospital gym, and (4) my starting a research project in the nearby New York Academy of Medicine Library. That hospitalization got me better; the psychiatrists caring for me, who systematically ignored the immediate experiences which made my hospitalization necessary, and focused instead irrelevantly on my childhood, were totally unrelated to my recovery.
After several successful home visits, I was released from hospital and then faced the problem of making a living. Although I had graduated from a psychoanalytic training program, was Board certified in psychiatry, knew many professional colleagues and had presented important scientific papers at major psychiatric meetings, I could not find a job. Finally, however, I was given a position at Kings Park State Hospital and, two years later, I transferred to Bronx State Hospital, which was affiliated with the Albert Einstein College of Medicine (on whose faculty I had been long but inactive). In 1973, having passed a civil service examination, I was appointed Clinical Director at Kingsboro Psychiatric Center (Brooklyn State Hospital), where I then served for 5 1/2 years. In 1978, at 55, with 20 years of state pension credit, I retired.
True continuity of care: a psychiatric vision
Ross Mitchell, M.D., the Deputy Director of Fulbourne (public psychiatric) Hospital in Cambridge, England, had visited Bronx State when I was there, and also at my home. When I retired, my wife and I visited him and his hospital in England. My transformative experience there I compare to St. Paul’s on the road to Damascus.
Unlike anything I had ever seen in the United States, each Cambridge patient had the same psychiatrist both in the hospital and after it. Each psychiatrist therefore spent half his time in the hospital, and the rest at outlying clinics, close to the patients’ homes. This is what is properly called “continuity of care.” When I compared Cambridge’s costs with those in New York State, I found, because of their lack of duplicated services, that they needed less that 40% as much staff, and funding, as we.
Before retiring as Kingsboro’s Clinical Director, I had obtained a 2/5 time clinic position at Creedmoor Psychiatric Center, treating patients just released from inpatient status into aftercare. Using my experience and training, and expecting that patients could change maladaptive patterns after they came to recognize them, I vigorously addressed with them their current problems - both in their heads and with those closest to them. I also reduced their medications step by small step. My results were excellent and, to report them, I organized a panel for the American Psychiatric Association’s 1980 Annual Meeting.
The importance of true “continuity of care” - having each patient cared for by one psychiatrist (as in England) rather than having him or her shifted among several - was central to my presentation. For my A.P.A. panel, I then recruited psychiatrists experienced in treating hospital populations from all over the country. One was John A. Talbott, M.D., of Cornell, who then suggested I also invite Leona Bachrach, Ph.D., from the University of Maryland, which I did. She was an academic sociologist, involved with theory, NOT a clinical social worker primarily involved with patient care.
Sabotaging “continuity of care” by officially redefining it
The continuity of the care I provided represented the heart of my paper, “Effective Psychotherapy in Chronic Schizophrenia.” If any patient needed rehospitalization, I continued seeing him on the ward. But Dr. Bachrach’s paper, “Continuity of care - a conceptual analysis,” defined that “continuity” in a strikingly discontinuous way - as “the orderly, uninterrupted and unlimited movement of patients among the diverse elements of the service delivery system,” including its many doctors. This so-called “continuity” is based on making sure papers are not lost as patients change physicians.
Her care-fragmenting paper was then published as the lead article in the American Journal of Psychiatry, the specialty’s most important publication, and she was invited to present her discontinuous definition of continuity at medical school grand rounds all over the country . She expanded on these views in two subsequent papers. My paper, rejected by the A.J.P., appeared in the little-read American Journal of Psychoanalysis (which requested it); I then received a total of two reprint requests. There have been, to my knowledge, no further efforts to systematically reduce the number of psychiatrists sequentially treating an individual patient.
The catastrophic results of care fragmentation
This fragmentation of care, which still continues throughout the public mental health care system, has produced many tragedies like that of Sylvia Frumkin, which Susan Sheehan described in her 1978 book, “Is there no place on earth for me.” In a Jan. 24, 2014 New York Times column, “For the mentally ill, it’s worse,” Joe Nocera recalled this case “Over an 18 year period, Sylvia was treated in 45 different NYC settings. The cost of her treatment was conservatively estimated at $636,000, more than if she had been confined to a state hospital for that entire period.”
Nocera called it “appalling to see what she goes thru as a mental patient: the hospitals that overmedicate; the misdiagnoses by doctors after the briefest of examinations; the lack of any kind of safety net when she is not hospitalized. But here’s the worst part: even though the story Sheehan tells is more than 30 years old, there is only one real difference between then and now for the mentally ill: it’s worse today.”
Nocera continues: “I remember thinking when Sheehan’s articles first came out that some day we would look back in horror at the way our society treats the mentally ill. Thirty-three years later, that day still hasn’t come.” Let me remind you that was written this past January 24.
Equally horrendous was the story of 19 year old Judith Singer, as presented in a February, 1982, official report of the New York State Commission on the Quality of Care for the Mentally Disabled, and the February 19, 1982 New York Times. Ms. Singer was in good physical health when involuntarily admitted to South Beach Psychiatric Center in 1981 for a manic episode. Thirteen physicians treated her, one after another, in four different wards. Since they could not persuade her to take oral medications, they gave her 34 injections of seven different major psychopharmaceuticals. She was tied down in restraints for most of her six days in hospital and lost 23 pounds. Then she died. Blame was then placed on the last physician who saw her, rather than on the administrators - local and State - directly responsible for her fragmented and incompetent care, and for her death.
Between 1979 and 1984, 17 patients in New York State psychiatric hospitals died as Judith Singer did: in connection with being tied down. A Select Commission on the Future of the State-Local Mental Health System was then appointed and chaired by the executive vice-president of the Jewish Board of Family and Children’s Services, a social worker; its vice-chairman was the bishop heading Catholic Charities.
Immediately after the Commission’s appointment, I sent the chairman material demonstrating the value and importance of true continuity of care, and asking to testify before it as soon as possible. Not until the committee was preparing its final report, and I had appeared on local television, was I finally asked to testify. Despite the material I had sent, not one of the Commission members had ever heard of “continuity of care”!!
Its changes worsened matters, although well-publicized deaths seemed fewer: continuity was fragmented even further by shifting aftercare services from state hospital clinics to private agencies - including those headed by the co-chairmen. To help patients negotiate this newly created administrative labyrinth, “case managers” were then appointed.
This bureaucratic undercutting of the continuity of care principle occurred at the federal level also. In 1986, I took a 2-day training course given by the Health Care Finance Administration in Kansas City for prospective inspectors of psychiatric facilities. Most of the students were high-level psychiatrists, including two former state commissioners and one deputy commissioner, whereas the faculty was almost entirely nonmedical. They told us that our inspections were limited to issues of staffing and records. Recalling what happened in New York, I asked what we should do as inspectors if, on re-examining a facility, we found that administrative changes - increased fragmentation of care, for example - had impaired treatment. I was told the question was outside our purview as inspectors and a few weeks later was notified that my services as an inspector would not be needed.
And as recently as April 19 in the New York Times, T.M. Luhrmann, Stanford professor of anthropology, describes our public mental health system as “a crazy quilt of uncoordinated agencies whose missions shift depending on who gives them money and for what - [and which] can be hideously difficult to navigate even for someone who is not hearing hallucinated voices.” Desperate in this age of science, and reluctant to define specifically the utter failure of American psychiatry, she proposes instead that major new roles in mental health care be taken over by our churches!
Nevertheless, publications recognizing the importance of true continuity of care have continued to appear outside the United States. In 1997, A. Avery and others pointed out how, in England, “continuity of care with aftercare services following a psychiatric inpatient discharge is an important factor in enhancing the stability and tenure of community ling.” They described continuity’s effectiveness in reducing post-hospital homelessness among those with only one pre-hospitalization shelter system use, but not among those who had used that system repeatedly.
In 2009, A. Wierdsma and others, in the Netherlands, wrote (J Health Serv Res Policy) that “continuity of mental health care is a key issue in the organization and evaluation of services for patients with disabling chronic conditions,” and that “achieving continuity of care is hindered by the lack of standard measures and administrative data appropriate to assessing continuity.”
A 2014 study by N. Hoertel and others of the entire French National Health Insurance (NHI) reimbursement database concluded that “improving longitudinal (long-term) continuity of care in mental health care may contribute to substantially decrease mortality.” These authors point out that “the association is plausible as a stable therapeutic relationship between a practitioner and [his/her] patients can lead to a better understanding of patients’ psychiatric disorders and may underpin a better management of mental disorders to reduce suicidal risk, as well as enhance a better holistic monitoring of these patients to decrease the risk of death due to physical health risk factors.”
The strength and importance of social supports
An obvious, but little recognized, aspect of psychiatry is on spectacular display here at the Amsterdam: the key role of the community’s social, mental and emotional supports in keeping its residents alive and well. Psychiatry, often preoccupied with patients’ painful thoughts - their distorted thoughts especially - often overlooks the powerful positive effects such supportive relationships can play.
An example: the death of a long-term spouse creates a tremendous new emptiness in a survivor’s social/emotional support system. After the funeral and formal mourning period, the survivor living alone is often minimally inclined to do anything. With nobody physically present urging him or her to continue living, the days can become empty, emotional deterioration can follow, with death soon thereafter. To prevent this, mourners living alone must actively make and maintain social contacts. In sharpest contrast is the situation at the Amsterdam, where communal living provides hundreds of neighbors who stand eager to help in any way they can.
This continuing availability of positive relationships helps explain the rather remarkable infrequency of death among the recently bereaved at the Amsterdam: At last look, 14 married residents - ten men and four women - have died here since it opened in the autumn of 2009. Of their surviving spouses, 13 remain in independent living, and the fourteenth is thriving in our assisted living program. Not one surviving spouse has died!
Comparing support systems for the bereaved, like that which emerged at the Amsterdam, with psychiatry’s professional handling of mourners, allows us to recognize serious faults in the latter. These arise from (1) the profession’s failure to recognize that its usual way of addressing an individual’s difficulties - focusing primarily on what hurts - can unwittingly aggravate that pain, and (2) that doing so with just the sufferer alone ignores a most important aspect of helping the patient most effectively: rapidly engaging the closest kin.
Preparing this talk suggested to me the desirability of re-examining psychiatry’s customary way of dealing with troubled mourners. Like all physicians, we ask about a patient’s difficulties. But we may overlook how we do this, and the impact of our doing so. A psychiatrist’s search for psychopathology, especially on a patient’s initial visit, can aggravate that psychopathology, thus significantly undermining the patient’s self-confidence.
Someone seeking psychiatric help may have unusual subjective experiences, such as hearing their thoughts as external voices. If, as we usually do, we openly ask about hearing voices, and then press him or her about them, when an affirmative answer finally comes, the affirmant’s self-picture can suffer: does acknowledging the experiencing of some kind of craziness mean that that individual may indeed be crazy?
If, however, someone is gently asked whether at times his or her thoughts seem so real that they are almost heard - thus excluding the self-esteem-lowering notion that someone is hallucinating - such increased self-doubts will be less likely to occur.
Most people live in relationships with others. In those relationships which continue, the positive elements tend to outweigh the negative, despite any ambivalences. “Accentuate the positive and eliminate the negative” means that focus on the positive alone may make it unnecessary to pay much attention to the negative - which is so often the focus of psychotherapy. Indeed, the building of positive relationships - and correction of problems within existing ones - should be as much a part of psychotherapy as understanding a patient’s views of his or her world. This creation of, or re-emphasis on, existing social supports can thus greatly reduce the need for individual psychotherapy.
Summary
Psychiatry has long been a major source of harm to many of its patients. Undoing that harm will require immense changes in the organization and provision of public mental health care.
A patient’s relationship with his or her psychiatrist (or other professional therapist) is central to his or her ability to recover. That relationship should be long-lasting - continuing especially when the patient moves from hospital to clinic or home. This continuity also makes the psychiatrist/therapist accountable, which is far from universal today.
The importance of making and keeping positive relationships should be emphasized to patients, as they and those closest to them are assisted in solving their joint problems. Getting patients to understand how and why they broke down, and how they might have handled matters differently, can help prevent future breakdowns.
