The Help We Need

by Greer Williams

THE idea of using lay volunteers to give mental patients friendship and hope dates back at least as far as the Quaker, William Tuke, who in 1792 started the York Retreat in England. The Quakers then brought this “moral treatment” approach to America when they started the Friends’ Asylum in Philadelphia in 1817. Tuke and his Friends had no quarrel with doctors, but they did prove that dedicated laymen could work with the insane as imperturbably, kindly, and skillfully as their bettereducated medical friends.

The idea got lost in the rise of professionalism; even a trained nurse may look down on lay helpers. But here and there a hospital attendant or occupational therapist was observed to have a wonderful way of pulling a patient back to the real world and along the road to recovery. Action for Mental Health, the report made to Congress in 1961 by the Joint Commission on Mental Illness and Health, seized on the volunteer worker as a way of getting understaffed, overcrowded state hospitals off the dead center of despair and futility, and of arousing a community interest in these isolated institutions.

Certainly good-hearted volunteers were no answer to the fact that these hospitals need twice as many psychiatrists as they have and no answer to the chronic need for more money to pay staff doctors salaries halfway competitive with private practice. The use of volunteers, even if laymen would venture into “loony bins,” could not by itself break the manpower bottleneck. On the other hand, it might help.

The question of whether volunteers would and could come in and work with chronic psychotic patients on the back wards was settled for all time after 1952, when Dr. Harry C. Solomon and Dr. Milton Greenblatt, of the “Try anything that won’t hurt and may help the patient” school of psychiatry, gave J. Lawrence Dohan, then a Harvard junior, a job as a volunteer attendant at Boston Psychopathic Hospital. Two years later, Dohan led a band of two hundred Harvard and Radcliffe students into Metropolitan State Hospital, near Boston, to work a half day a week as ward helpers or, as some preferred, case aides. Inspired by the enthusiasm of these young men and women, aged eighteen to twenty-two, a psychiatric social worker, David Kantor, took them under his wing.

What has happened in the college student volunteer program in the last twelve years constitutes, beyond a doubt, one of the most hopeful developments in the care of the mentally ill of America during the last hundred and fifty years. The Harvard and Radcliffe students, sometimes joined by students from Brandeis and Boston University, have returned year after year to Metropolitan State, two or three hundred strong, as self-selected volunteers who begin anxiously but gain confidence and undertake tasks of their own choosing — anything from hanging curtains and helping the regular attendants clean up the wards to trying to talk with patients who have been in the hospital ten or fifteen years and have lost all social graces.

From the start, the students had the big idea that they would help patients get better and leave the hospital. This they have done, as manpower expanders of the regular staff. According to a report in the American journal of Psychiatry on a series of a hundred and twenty patients with whom students worked individually, thirty-seven, or 31 percent, left, the hospital, and twenty-eight of these had remained in the community for an average of 3.4 years at the time of the study. The nine who relapsed stayed out an average of 1.2 years. Most of the patients were schizophrenic; the majority were single. The average age was 43.5, and they had averaged 4.7 years in the hospital.

As any psychiatrist will tell you, getting and keeping a schizophrenic out of a state hospital after the first year once was thought to be quite impractical. He is likely to have no home or job to return to and may not have heard from his relatives. The new process probably is more correctly described as rehabilitation than as therapy. The first problem is to induce the patient to want to face the world again, and then, when he agrees, to help him find a place to live and a job. In the absence of sufficient hospital staff for this purpose, the college students do this kind of casework and, most important, follow through. The student says, “Here’s my phone number in case you need me.” Occasionally he may have to intercede and explain to the boss or the landlady if there is some little question of the patient’s odd behavior or difficulty in communicating.

The Harvard-Radcliffe group became so well organized in their efforts, for which they receive college credit, that they started their own “halfway house" for patients halfway, as it were, between the back ward and the open street. It is called Wellmet. Here students and ex-mental-patients dwell together. When the house burned (without harm to anyone) the students put on a fund-raising drive and rebuilt the place. Such is the energy that is needed for the fight against mental illness.

Bringing youth into the mental hospitals has been a great idea for patients, like raising a curtain to let in sunlight; and also for mental health manpower, since many college student volunteers elect to go into professional mental health work; and for the students themselves, because youth has a need for going places, for adventure in strange places, for feeling useful and important. One test of a great idea is that it grows, and this one meets the test. College student volunteers in mental hospitals now come from eighty or more colleges throughout the country.

IT IS impossible to recite here more than a brief example of the great variety of mental health volunteer work going on in different places. Boston State Hospital, for instance, has 125 volunteer organizations, ranging from an M.I.T. fraternity to some businessmen who call themselves PROP (Patient Rehabilitation and Occupational Program). The enthusiasm has been so infectious that even members of the professional staff have volunteered for after-hours work with patients.

One of Boston State’s prize cases was a thirtyone-year-old man who had been locked up in various mental hospitals since he was in high school. He never had held a job. The staff had been looking at him for eight years and, as Dr. Green blatt remarked, “voted him least likely to succeed.” Two years ago a Harvard student elected to work with him and presently got him out of the hospital and into Wellmet. He later found the patient a room at the Y and lined up a $60-a-week job for him as a maintenance worker. By April 1 5 of the next year, this previously hopeless individual, a public charge, was paying $500 in federal income tax. The former patient is now trying to train himself for a still better job.

As another example, Indiana has a large and well-established program for volunteers of all ages — some 3000 uniformed Gold Ladies, Gold Men, and Gold Teens who work in the state hospitals on a regular schedule, doing everything from gathering Christmas presents for patients to teaching them arithmetic. Some 4200 other volunteers take part in an adopt-a-patient program, each volunteer taking the responsibility of being a friend to some otherwise forgotten mental patient.

Indiana uses its mental health volunteers to do something for patients, to recruit other volunteers, and to help pressure the legislature to vote larger funds for the state’s mental hospitals. Paradoxically, in the beginning of the volunteer program, ten years ago, it was the mental hospital superintendents who resisted it most strongly. Now, thanks to substantial increases in public funds for improved treatment programs, the hospitals have been able to discharge twice as many patients.

Indiana is a good example of what has been going on elsewhere. On the whole, consistent gains have been made by state hospitals in reducing the average daily patient population, which has dropped nationally from the all-time peak of 559,000 in 1955 to 516,000 at the end of 1962, a rather remarkable improvement considering that the admissions to these mental hospitals increased from 186,000 in 1955 to 271,000 in 1962. The net gain was in releases, up from 145,000 in 1955 to 231,000 in 1962.

The rising tide of patients reflects population growth. The capacity of state hospitals to get more patients out is attributed to a combination of factors — the advent of the tranquilizing drugs.

more personnel to care for patients, and a little more money to work with. State hospitals now spend an average of $6 per patient per day compared with $4 eight years ago. (This is a pittance compared, for instance, with a daily charge of $53 per patient at the fully staffed Menninger psychiatric hospital in Topeka.)

Thanks mainly to grants from Congress and the National Institute of Mental Health, some gains have been made in the manpower problem. From 1 950 to 1963, the number of psychiatrists, psychologists, social workers, and nurses working in the mental health field increased from 23,000 to 51,000. The percentage of doctors in psychiatry, meanwhile, has increased from 3 to 7 percent of all medical specialists. The professional staffs in public mental hospitals increased from 2.8 to 4.5 workers per hundred patients from 1956 to 1962. These are gains, just as every drop in a bucket is a gain. The typical general hospital in this country has more doctors, nurses, technicians, and social workers than it has patients.

President Kennedy, in his special message to Congress in February, 1 963, called for a broad new mental health and mental retardation program in which “it will be possible within a decade or two to reduce the number of patients now under custodial care by 50 per cent or more.” In a new approach which proposed “to use federal resources to stimulate state, local, and private action,” President Kennedy embraced the theme of Action for Mental Health — shifting the treatment scene from mental hospitals into community mental health centers, through a whole range of outpatient services for children and adults.

The eventuality was not so hopeful, in what Congress did to the President’s proposed legislation not long before he died. He submitted a bill to Congress asking for $850 million to spend over a five-year period, mainly for constructing and staffing community centers for care of the mentally ill and mentally retarded. In “action for mental health” terms, the crucial section was a provision of $427 million in grants to help finance the staffing of community mental health centers.

The request was unprecedented, for never before had federal-aid money been spent for the care of mental patients: for research, yes; for training, yes; but for salaries of persons who worked with patients, no. Action for Mental Health had made the case: “Federal aid will be needed, in large sums. It is self-evident that the States for the most part have defaulted on adequate care for the mentally ill, and have consistently done so for a century. It is likewise evident that the States cannot afford the kind of money needed to catch up on modern standards of care without revolutionary changes in their tax structure.”

In the Senate, there was no problem. Senator Lister Hill, Alabama Democrat, long had furnished leadership in mental health legislation, and he threw his full weight behind the Kennedy bill. The Senate passed it, 72 to 1, with Senator Carl T. Curtis, Nebraska Republican, alone in the minority.

There was no such leadership in the House and, indeed, no one with the stomach to make a fight for the bill against the opposition that emerged. The bill went to the Committee on Interstate Commerce, under the chairmanship of Representative Oren Harris, Arkansas Democrat, and then into a subcommittee chaired by Representative Kenneth Roberts, Alabama Democrat. The subcommittee twice voted for the staffing provision, in reduced amounts. But the House Republican Policy Committee and the House of Delegates of the American Medical Association declared their opposition to any money for staffing — for bricks and mortar maybe, but for the care of human beings, nothing.

The Harris committee cut out the $427 million staff provision entirely and left $238 million for building construction. The crucial vote in committee found three Democrats joining twelve Republicans to outvote twelve Democrats and defeat this pivotal recommendation of Action for Mental Health, a report which cost the taxpayers $1,410,600. Five Democrats and one Republican absented themselves from the vote. The House passed the remnant, 335 to 18. Eventually, House and Senate compromised on a $329 million act, omitting all money for personnel.

Neither Harris nor Roberts nor anyone else made an effort on the floor of the House to save the Kennedy bill. Some close observers hold these two ultimately responsible for the bill’s failure. Why did they let down the mentally ill? In sum, the answer is simple enough. Where there is divided opinion, a politician is responsive to those who exert the most pressure on him. The National Association for Mental Health and its state chapters made an effort to bring citizen pressure on the House but only succeeded in demonstrating weakness in this quarter. Observers said, “It was too little too late.” In contrast, organized medicine’s lobby quietly applied a technique in which it was schooled some years ago by the California public relations experts Whitaker & Baxter. Key congressmen heard from “their doctors” and were told that what they were about to do was “not right.”

As demonstrated in the defeat of the Kennedy program, further help for disturbed Americans will depend on the development of a strong, vocal citizens’ movement that will hammer away at all those who oppose improving the shameful way the mentally ill are treated. Despite good intentions and some good beginnings, the mental health movement has so far been too weak and too inept.