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Columns   |    
Personal Accounts: Stepping Into a Crosswalk
Aaron Needle
Psychiatric Services 2012; doi: 10.1176/appi.ps.20120p734
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Mr. Needle is a lifelong resident of the Greater Boston area (e-mail: aaron.needle@gmail.com). Jeffrey L. Geller, M.D., M.P.H., is editor of this column.

Copyright © 2012 by the American Psychiatric Association.

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Stepping into a crosswalk hand in hand, a couple begins crossing a street. By law all motor traffic must halt to allow them safely across. But with the couple already two steps into the crosswalk, a motorist chatting on a cell phone cruises through, oblivious to them. Four steps in and a large pickup truck with a tinted windshield rumbles by. Only when the couple reaches the middle of the road does the traffic halt.

The crosswalk is an analogy for the boundaries existing in treatment programs for people with mental illness. Just as a crosswalk is intended to provide a safe, respected passageway, a mental health program can be as well. But in the spectrum of programs that I've attended, the staff has a propensity to interrupt and disrupt the normal, vital interactions and relationships happening within them. The title of the book Girl, Interrupted is no misnomer.

I've really struggled with the way people with mental illnesses have been categorized and “communitized.” I've wondered aloud if it's appropriate to lump together such a diverse group of unique individuals with unique mental challenges and then justify it by generically labeling them all as clients, patients, or consumers; I wonder sometimes if it is for some grand ulterior purpose. But as long as we are to be grouped together, I feel very strongly that as people with mental illness make their way through the mental health system, the interactions and relationships in which they partake warrant greater acknowledgment and respect.

The clinicians and counselors commonly referred to as “staff people” are academically trained to psychologically evaluate people. When I sense that I am being evaluated, I become guarded, reticent, or just plain silent. It is the opposite behavior as observed during the “in-between times”—a term that psychiatrist Bruno Bettelheim used to describe the free and normal activity of troubled kids he observed during recess, which he contrasted with their behavior observed during class time. It's best illustrated by a funny scene in Monty Python's film The Life of Brian, in which two plebian men are engaged in an animated, very erudite conversation until a Roman Centurion barges in upon them and they revert to mere grunts and gestures.

At age 21, I received a diagnosis of paranoid schizophrenia. By my mid-thirties, through determination, hard work, and good self-care, I had recovered to the degree that I was able to work full-time while attending college. But at 30 I was stricken with tardive dystonia and became so disabled that I was forced to withdraw from both endeavors, as well as from the world in general. These major setbacks, plus the physical suffering I experienced, led to behaviors that landed me in a state hospital. After being locked up for five months, I requested and won a hearing to determine my readiness to return to the community.

But being safely at home wasn't the end of my ordeal. I was beset by fears that the behavior that had gotten me hospitalized, as well as the record of being in a state hospital, would always be held against me by society, and I had lost all hope of ever having a decent job. Shaken and dejected, I began attending a Fountain House-model clubhouse in Waltham, Massachusetts, specifically designed to place people with mental illness into meaningful jobs. I soon received a transitional employment placement in the mailroom of a local large insurance company and began to build my self-esteem and confidence. But internalized stigma—a lingering aftereffect of my experience in the hospital—made it difficult for me to communicate with my coworkers and feel accepted as an equal.

I overcame this barrier by attending a coffee gathering every morning at a community day center in Belmont, Massachusetts. I found out about this particular day center when I inquired if anyone knew of a local program offering peer counseling. Through it I regained social confidence and self-respect. After completing my transitional employment assignment, it was a truly happy moment for me when my manager hired me as a permanent employee. I continued to work at this insurance company for six more years.

Unlike many programs, I found the staff at the community day center to be very respectful of my space and my interpersonal interactions with other members. They allowed our conversations to continue undeterred, and there weren't any mandatory groups or work to disrupt me there. Not known to me, the community day center had been designed to be an “intentional community.” Its main purpose was to unobtrusively nurture and facilitate the development of a real-life community atmosphere among its members.

Before the onset of my illness, I had been a fine arts major in college. Since that time, I hadn't done much with my talents. The community day center had a dynamic occupational therapist running a group that created greeting cards. I joined the group, and with the therapist's guidance and encouragement, I once again immersed myself in making art. I conceived of a unique style of cards that combines elements of early graphics, such as those found in old trading cards and book covers, with borders that I design with fine, handmade marbled papers. [An example is available online as a data supplement to this column.] I've recently publicly exhibited my collages at a local bookstore and at a local cable TV outlet.

In most day treatment programs I've attended, the staff members are not allowed to share anything about their personal lives. For example, in one program a woman on the staff refused to answer a client's question about whether her new baby was a boy or a girl. The client reported to me that the staff person's refusal made her feel “less than human.” In stark contrast, the staff members at the community day center spoke very openly about their own lives. After experiencing the oppressive atmosphere in day treatment, hearing these staff members talk was like music to my ears.

Whatever the clinical rationale is for such extreme boundaries between staff and clients, they have a negative impact that should not be disregarded. In addition to making clients feel dehumanized, these boundaries hinder healthy role modeling. In fact, they contribute to clinical condescension, and I believe they are the reason so many people are stuck in day treatment for large portions of their lives. In his book The Theory and Practice of Group Psychotherapy, Irvin D. Yalom (with Molyn Leszcz) cites healthy interpersonal relationships as a principal “curative factor” in recovery from mental illness. In many day treatment programs there is a stilted version of normal relationships which therefore provide a limited, if any, degree of recovery. And just as patients aren't allowed to really know their clinicians, their clinicians don't really get to know them in their full humanity. Instead, clinicians view clients through a haze of jargon and labels. Even after being in a day treatment program for many years, it was my experience that the staff didn't really know me.

Peer counselors embrace the idea of being role models. They are so effective at it because they can convey the insights and approaches that earned them their time-tested recovery. To return to the crosswalk analogy, peer counselors are like crossing guards who, having made it themselves, return to escort other people safely toward recovery. They are the guideposts that illuminate the way through the often Kafkaesque mental health system and the murkiness of mental illness.

The combination of the resources, respect, and support I received from the clubhouse and from the community day center helped me to develop into a valued, contributing member of society. These two programs were instrumental in my being able to fully integrate back into, and thrive, in the workplace, in my community, and with my family after a very debilitating and rather degrading hospitalization.

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