Personal Accounts: Community Psychiatry in the 1960s: A History Lesson

I began the decade of the 1960s as clinical director of a statewide alcoholism program consisting of five outpatient clinics in major cities and a 40-bed inpatient facility. The inpatient facility operated as a therapeutic community in which all employees were encouraged and trained to think of themselves as part of the treatment team, with every patient contact having therapeutic potential.

Staff members, both professional and lay, were chosen for their ability to conform to this model. Morale was high, and we considered ourselves one of the four best programs in the country. Professional staff included two social workers, one psychologist, and an occupational and recreational therapist, as well as nurses, nursing technicians, and alcoholism counselors. There were daily didactic groups with an orientation suggestive of modern cognitive-behavioral therapy. Small psychodynamically oriented groups were held three times a week, and there was a weekly "town meeting" in which concerns of the community, from either staff or patient, were discussed and an attempt made at resolution. Patients were admitted Monday through Friday, and the mandatory patient stay was 30 days. I hoped this treatment modality would provide an economically realistic and effective alternative to prohibitively expensive psychoanalysis and inexpensive somatic therapies, which had dominated my training.

Although I was already a board-certified psychiatrist, this program was the most educational experience of my entire career. It was made more so by a collegial relationship with the administrator, a brilliant clergyman-turned-administrator who discouraged a hierarchical relationship.

On the other hand, the job was made more stressful by the head of a non-clinical department who told me that he intended to get the administrator fired in order to move into his job and that I might be fired as a result, although he had nothing against me. His conflict with the administrator lasted more than a year. He eventually lost. To his credit, years later he went out of his way to find me and apologize.

The job afforded ample opportunity to attend professional meetings and to associate with leading figures in the field. Maxwell Jones, M.D., pioneer of the therapeutic community, visited the facility. He was complimentary, saying he was impressed with what we accomplished with an unsophisticated staff. (His staff at the Maudsley were nearly all graduates of psychoanalytic training.)

My wife had a different experience. The facility was located in a small southern town where newly arrived "yankees" were accepted only grudgingly. She was tied down with three young children and unable to join me on all of my travels. She felt lonely and depressed. At the same time a change in politics threatened the budgetary support of the program. It was time to leave. A job search led me to Massachusetts and Minnesota, where offers were extended but none were attractive enough to warrant a move.

Life as a community psychiatrist

At a meeting of state agency heads in 1963, I became aware of a small rural community where a convergence of forces had created an opportunity. The state board of health, responsible at the time for outpatient clinic services, wanted experience with mental health services in a community smaller than any previously served. Law enforcement officials, in the wake of two tragic incidents in which officers had been killed by individuals with mental illness, felt that help was needed in dealing with disturbed individuals. It was the beginning of the era of integration of mental health services into general hospitals, and the local general hospital wanted to open a psychiatric ward. Together they had created an attractive package. After some negotiation we agreed that I would provide a rather loosely defined package of community services and be allowed a limited private practice. The contract was unwritten and consisted of nothing more than a handshake, but all parties were honest and well intentioned—it worked. I was now a community psychiatrist, and like the fellow in a familiar joke, "last week I could not even spell it and now I were one!" It was up to me to define my duties.

I visited several community programs but found them to be of little help, given that each had far more resources than my situation afforded. I was provided with a three-room office (across the hall from the venereal disease investigator) furnished with desks, chairs, and a filing cabinet. From my $12,000 annual stipend and whatever I might earn from private practice, I provided the phone, a used copy machine, a used typewriter, and the salary for the secretary I employed. The office was shared with the county mental health worker, a position filled shortly after my arrival by a nurse with whom I had worked during my years at the previous location. We were a good team with similar views of the goals and methods we adopted. In some ways my opposite, she liked the excitement of emergencies, loved to work crisis situations with police, and tended to be bored with the routine that I preferred. Together with a very caring and competent secretary, we were the mental health resource for the next ten years. We were responsible for a county larger than the state of Rhode Island with a population approaching 100,000. The private practice catchment area included four adjacent counties and part of a fifth—a radius of more than 50 miles.

It was obvious that I could not provide direct therapeutic services to such a large population. I therefore decided to adapt the method used in the therapeutic community from which I had come—to use the already existing caretaker and helping agencies of the community and to work with and through them in a consultative role. The mental health worker—"Annie" (not her real name)—and I spent many hours visiting and establishing working relationships with the many agencies with which we would be involved and established regular schedules for group consultations. These included law enforcement, courts, juvenile and adult probation and parole officers, corrections facilities, welfare workers, public health nurses, and practicing physicians, to name but a few. These agencies also served as referral sources for those individual problems that could not be resolved through consultation. Patients seen individually were charged a private fee ranging downward from $20 per 50-minute hour (standard at the time) to $.50 per hour, with fees carefully graduated to avoid causing hardship. After the first year the income from this source approximately equaled the stipend. This arrangement appeared to be quite effective, considering the small resources involved.

I was also given the use of a ward at the local hospital. Generally the space assigned was space that had been rendered obsolete by a change in hospital technology or policies. We moved from a former black obstetrical ward (abandoned when the hospital integregated obstetrics) to a cardiac step-down unit that had been replaced by a larger unit assigned to that purpose, back to the old nursery, and out again when it was decided to remodel the space into offices.

The hospital provided space and staff even though the unit seldom paid its own expenses given that many psychiatric patients were chronically ill, disabled, uninsured, and unable to pay for their care. When it became known that there was to be a special ward for my patients, a young nurse with no specific psychiatric training asked to be assigned. She turned out to be a warm and caring individual, anxious to learn, with good intuitive judgment, and she was head nurse on the unit throughout its years. I was given reasonable control over assignment of hospital personnel to the unit, and we developed a close-knit group who liked working with psychiatric patients and who were generally well liked by the patients. During one phase of hospital reconstruction all visitors to the hospital passed through the center of our day room. This did little for privacy and confidentiality but had an unexpected positive effect. It appeared to reduce stigmatization of psychiatric patients as the public became aware that our patients were not so different from other patients in the hospital.

Nurse Annie and I were responsible for the distribution of psychotropic medications for follow-up of patients discharged from the state hospital. The local pharmacists objected to the distribution of these medications by a nurse and wanted it done by a pharmacist—until they discovered that there was no fee paid for the service. "Miss Annie" (as she became known in the community) sought out patients who failed to make it to their appointments and administered their medication at home.

Throughout the 1960s I was the only psychiatrist in the area. With today's standards this would have been an intolerable load, but at the time I could occasionally skip hospital rounds on Sunday if the ward was quiet. If I wanted to take a vacation, the patients' own personal primary physicians would cover while I was gone.

At the time training in psychiatry did not include any preparation for practice in a small town where privacy was at best relative. I was surprised that many of my patients did not seem to protect their privacy as much as I did. For example, it was not unusual to be greeted across the room in a public place by a patient reporting on his or her response to a medication.

The above arrangements persisted into the early 1970s, when a fully staffed community mental health center came into being. I gradually transitioned to full-time private practice.

A pioneer in simpler times

Although I did not realize it at the time, in a sense I was a pioneer. I practiced interdisciplinary psychiatry and advocacy for mental health causes before such was common. I performed short-term limited-goal psychotherapy before we had manual-driven short-term goal-directed therapies. As a yankee boy in a deeply southern town in the midst of the trauma of desegregation, I performed transcultural psychiatry. I had a close cooperation with Alcoholics Anonymous and with Al-Anon and assisted in the formation of a Recovery Incorporated group. It was in the 1960s that I stopped writing prescriptions with directions in Latin symbols, started labeling prescriptions and writing instructions in plain English, and began to discuss probable side effects with patients. (It now seems absurd that such practice was not always standard.) I seized every opportunity to speak to any group where I might raise awareness of mental health issues.

If indeed I was a pioneer it was the result of necessity, not of genius. It was an exciting time when I dared to do what was right for the benefit of the patient, without looking over my shoulder to see if a trial lawyer was watching and without first seeking authorization from a care "manager"—patients were responsible for their own bills if they had funds, and if they truly did not, the hospital would not pressure me to discharge them. This freedom from artificial restrictions was a key ingredient in success with little staff and low funding.

My career has spanned the transition from the era of psychoanalysis and psychosurgery to that of cognitive-behavioral therapy, selective serotonin reuptake inhibitors, and atypical neuroleptics; from hospital "warehouses" to homelessness, and jails as hospitals; and from paternalism to self-determination. Exactly which part of this evolution took place during the decade of the 1960s I do not exactly remember—but it has been an exciting life!