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Chapter 6
Geriatric Mental Health Program,
New York State (1971-1984)
In 1971, I received an offer
from a new mental health
program established by New
York State in 1970-the
Geriatric Mental Health Program, to which I had applied. Although it represented
a radically different clinical enterprise for me, it seemed to offer the opportunity
to practice community psychiatry. I did not know whether the program would be
interested in me when I applied, since I had no special experience with the aged; I
did, however, have outreach experience, which the organization viewed as
valuable. When I found myself accepting the position, I knew this experience was
going to be a "rocky road" for me-figuring out how to deal with the aged and
their mental illnesses. I had no idea, however, how deeply I soon would become
immersed in multicultural psychiatry!
Around the time I finalized my new employment position as the psychiatrist
for the Geriatric Mental Health Program, I established a residence in the Bronx,
near Yonkers, below my brother in the same building. I was to stay there until
1973 (when I moved to Hartsdale, NY, where I have lived since).
From reading and talks with others, I soon learned that the Geriatric Mental
Health Program (GMHP) was founded by the New York State Department of
Mental Hygiene, as one of two similar "pilot programs" in New York. It was an
attempt by the Department of Psychiatry of the Brooklyn-Cumberland Medical
Center to meet the needs of the elderly with mental or emotional problems who
lived in Brooklyn, in the Cumberland Hospital ambulance area-including Fort
Greene, Brooklyn Heights and the Williamsburg sections of Brooklyn. The patient
populations in Forte Green and the Williamsburg sections were primarily Black,
Hispanic, and Jewish, including many Hasidic Jews, while the population of
Brooklyn Heights was primarily White and more affluent than the other sections.
Nonetheless, even in Brooklyn Heights there were significant numbers of poor,
and even homeless, people, including those from various ethnic groups.
The need for the GMHP was spurred on when, in 1968, the New York State
Department of Mental Hygiene changed its admission policy-and virtually
ruled out the State Hospital as an alternative for the aged psychiatric patient.
Clearly, this decision had merit in that the custodial care formerly provided by the
State could now potentially be provided, more appropriately, in the local
communities. However, the reality of the situation at the end of the 1960s was
that there were no services available to provide for care of these elderly citizens,
even though they were now released into the community.
Within this context, in 1970 the New York State Department of Mental
Hygiene funded the Mental Health Services to develop a Geriatric Mental Health
Program. The mandate was to develop a model for service and operationalize it.
At that time, there were more than a million New Yorkers 65 years of age or older
Ñ 13 percent of the population. Many of them had mental or emotional problems
related to physical ailments or poor social conditions involving the environment
and interpersonal relationships. In our catchment area, these problems of the
elderly were exacerbated by their generally low income. In an attempt to alleviate
some of these problems, the GMHP provided various services.
The staff of the GMHP consisted of a psychiatrist (me), an internist, social
workers, and mental health workers. Each elderly person served by the program
was visited in his or her residence by a mental health worker. The evaluation of
each patient by me and the internist also were done in the home, if the patient was
unable to travel to the hospital. When all the evaluations were completed, the staff
met to arrive at recommendations, based on our understanding of the older
person's psychiatric, social, and medical situation.
After the evaluations were done and recommendations were made, the work of
the GMHP did not end. Often, the elderly persons were not able to carry out
plans by themselves, and they did not have close relatives to help them. Team
members, therefore, continued to make themselves available to the elderly. Their
help could include, among other things, administering psychiatric medication,
arranging for housekeeping services, planning for the move to a foster home or
nursing home, or counseling, to help the elderly person and his or her family make
a better adjustment to the harsh realities of old age.
In addition, because a program aimed at the elderly with emotional problems
could not simply sit back waiting for applicants, the GMHP actively sought out
elderly people who came to the emergency room of Cumberland Hospital. The
staff made telephone calls to encourage reluctant patients to accept assistance.
They provided transportation and escort services to those who could not come to
appointments by themselves. In these ways, elderly people were encouraged to
get the help that could prevent their future confinement in institutions.
Generally, the elderly also could arrange for help by contacting the program.
Or, the initial contact could be made by relatives of friends. We were also glad to
accept referral from physicians, clergymen, social service workers, or other
concerned persons. Since so many elderly people were alone back then, as they
are today, and unable to seek help, it was important for others to take an interest
in their condition.
Given the philosophy and programmatic development of the Geriatric
Program, the GMHP developed linkages with various agencies, including two
general hospitals, two nursing homes and one health-related facility, Senior
Centers, Settlement Houses, churches, the Jewish Association of Services to the
Aged, and social service agencies, such as the Heights and Hill Community
Council.
While I was adjusting to my new position at the GMHP and becoming
involved with the lives of my elderly patients, my mind still was very involved
with the Sarawak data and my article on Latah. The fact was, the data drama had
become very serious, at least to Karl Schmidt, who was concerned that the whole
project could be in jeopardy, for multiple reasons described to me in a letter dated
October 23, 1971.
Tom, you realise, I am sure that we are in serious trouble over the
clinical data: unless you can find the key or the assessment sheets
we are sunk. There are other problems. The numbers of computer
cards which John brought along does not correspond to the
numbers of cases detected. There are at least 40 missing, of the
Iban, I believe. What are the exact numbers of cases found in each
group?
I will be going to the Vth World Congress to read a paper on
Mexico-although in view of the above points, I hardly dare to
show my face. . . . Would it be possible for you and me to meet in
New York to try to establish the key? This would be around the 25th
Nov and I will send details later. You would need to bring the listing
of the items and the assessment sheet. I feel that between you and
me we might be able to set this key up. . . . By the time I will leave
England for New York and Mexico, I hope to have news of the
Research Fellowship; but I feel unless we can sort the clinical data
out, it seems hardly worthwhile accepting it. Karl.
Although danger loomed on the data front, good news finally came regarding
my Latah article, now coauthored with Tong and Schmidt. In 1972, it was
published in Psychological Medicine under the title "A Clinical and Survey Study
of Latah in Sarawak, Malaysia." One of the rewards flowing from publication was
being contacted by people who found the article valuable for their own work. A
graduate student at the University of Chicago, for example, wrote to me, in a letter
postmarked February 8, 1972:
Dear Dr. Chiu: Having read the abstract of your paper. . . I am
very interested in examining the original paper. My primary
interests are centered upon culture-bound mental disorders. For my
Master's paper, I intend to examine Latah-type syndromes and
culture change. My tentative hypothesis is that with increasing
urbanization the incidence of latah will decrease.
Yap in 1952 states: "Latah occurs almost always in people of
poor education and enlightenment, and with increasing education
such as for instance goes hand-in-hand with the process of
`urbanizing' peasant communities its incidence undoubtedly
decreases." The information in the abstract appears to be in direct
contradiction with this. I also find it fascinating that the subjects
mentioned dreams of such direct sexual content.
The reports on the Ainu disorder "Imu" also present
information on very explicit sexual content in dreams of Imu
sufferers. If at all possible could you please send to me a copy of
your paper. I am well aware that I can get a copy from
Transcultural Psychiatric Research, but as a typical graduate study
my financial resources are marginal. Sincerely, David Katz.
I was now on a bit of a "roll" when it came to good luck, for soon after
publication of the article, I learned from Schmidt that the data drama was partly
resolved-and I stress "partly"-in a letter dated June 27, 1972, sent to me
from Noumea, New Caledonia. Karl wrote:
Dear Tom: Believe it or not, the assessment sheets have arrived.
Many thanks. We can now go ahead. I will take them with me to
American Samoa and discuss analyses at the Computer Centre
there. . . . You have, I suppose, had no inspiration what the figures
in red mean and how they are related to the punch cards. Also, I
suppose the missing 20 Iban cards and assessment sheets remain
as a problem. I suppose we will have to cook this up to 120. Karl.
About five weeks later, I learned that some more data problems had been
resolved, but that others still remained, in a letter from Schmidt dated August 2:
Dear Tom: As far as the Case-Assessments go, everything appears
clear now with key, printouts, card sheets all in hand. Our
statistician here and I, we have done an analysis of the case
numbers plus subsamples and he comes out with a simply beautiful
curve of significance. However, to be more specific, can you
remember or find (or estimate) the number of respondents from the
subsamples. . . .
Am on my way to Pago-Pago (American Samoa) (via a week in
Tahiti, and then on to Western Samoa and directly to Sydney,
Twelfth World Rehabilitation Congress) where I hope to get the
analysis of the cases done for which I have written a program.
Have you any idea why our interviewers only found 19% of the
Chinese cases who were treated at some time by the central health
service, only 34% of the Malay cases and only .5% of the Iban
cases. One explanation is a difference in mobility, in and out of the
sample areas. Would you think that to be the answer. . . Any
comments are most welcome. Best wishes, Sincerely yours, Karl.
Gradually my mental involvement in the Sarawak data drama subsided, as I
became more integrated into the GMHP. (I could not have known it at the time,
but the data drama was to continue into the early 1980s, before the final analyses
were run on the computer). Our program was expanding and experiments in
service delivery were being conducted regularly. In 1973, for example, based on an
evaluation of the program to date, the executive staff decided to deliver services
from an "Out Station" in the Atlantic Avenue Brooklyn area. The Out Station was
manned by two staff members who were reassigned two days a week to work out
of the space, which was provided by a senior center in the target area; and social
work interns were introduced into this setting to supplement the program's staff.
After nearly four years at GMHP, I felt the work I was doing was interesting
and important-a conviction reinforced by my friend, Frederich H. Lowy, M.D.,
Professor and Chairman of the Department of Psychiatry at the University of
Toronto. "It is good to hear about your activities," he wrote in a letter dated
January 16, 1975.
I know of no more socially significant field in psychiatry than
geriatrics and nursing home consultations. And I am glad that someone of your
experience and ability has an interest in that field.
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Living in Hartsdale, New York, and working at the GMHP, I had not been
seeing too much of Karl Schmidt recently, who was spending most of his time in
England, when he was not traveling to one exotic spot or another, usually for a
psychiatric convention. Perhaps this relative lack of personal contact was why I
decided one day, in 1976, to send him and his wife, Una, who were living in
Somerset, England, a photograph of my house, along with a scarf for Una. Shortly
thereafter, I received a letter from Karl, dated May 31, 1976, who obviously got
carried away with the "household" idea, and started imagining all kinds of
domestic scenarios for me.
Dear Tom: . . . Many thanks for the delightful photo of your house.
Am so glad that you are so nicely settled. I think you need a woman
there. Will send you the address of the very attractive sister of one
of my Sarawak nurses-a strongly Methodist family-who works
in an ICU in Dallas; if I can get hold of her address: A very sincere
person who would be just right for you. . . .
Then Karl turned his attention to the academic and intellectual matters that
were always at the forefront of his consciousness. He said:
On the whole I am quite glad to be out of the rat-race-though I
will read a paper on "The Significance of Transcultural Psychiatry
to Primary Prevention of Psychiatric Disorders" to the
International Congress of Psychiatry at Bradford University in
July. Had the visit here for 4 days of Prof. H. B. M. Murphy who
urges further analysis of the Sarawak data. Will meet him at
Bradford again. I will probably chair a session at the VI World
Congress in Honolulu next year. Karl.
Some Observations of the Aged at the GMHP
"Based on my ongoing work at the GMHP, I wrote a report called "Continuing
Education of the Aging Population," in 1976. It involved my observations of the
elderly on trips we took. I introduced the report as "an informal, unstructured
inquiry into the functioning capacities of the elderly in organized tours," and
added, "The author attempts to `demystify' the commonly accepted fact that the
elderly are useless and incapable of many activities." The group I reported on
included 15 men and 25 women, all Caucasian, between 50-73 years of age.
Twenty-five percent of the women and 75% of the men were still working.
My impressions of the group members were that they adapted well to
changing, shifting situations with insignificant or no discomfort; they pursued the
unknown, in a manner reminiscent of youth; they exhibited a remarkable sense of
perseverance to attain or reach objectives (such as when 95% of the group
members climbed to Mont St. Michel); they accepted their limitations; and they
tolerated inconvenience and abided by rules and regulations, especially the older
age group, involving such things as seating arrangements and getting luggage in
transfer. In addition, I noted that only one member noticeably was forgetful, only
one couple drank excessively, and only one individual was disliked by some of the
others, though he was accepted by most.
From my observations of these group members, I drew a general conclusion in
my report about the elderly in our society: "The elderly can be a vital force in
today's society. While this group is very much a viable, important part of the
population it needs continued sustenance, stimulation, and excitation to go on." I
believe that more strongly than ever today.
From working with elderly patients, I began to realize the need to explore and
learn their conceptions and wisdom as well as appreciate the fear, concerns and
even dilemmas of growing old. They "tuned me in" to the many intricacies one has
to face in old age, when so many previously simple tasks become hurdles to
overcome.
***************************************************************
Keeping Connected to Karl
Karl continued to write to me on a regular basis, from his base in Somersert,
England, and never failed to invite me to come over and stay a while, if not
"forever," with him and Una in their beloved locale. Extolling Somerset's beauty
and quietude, he wrote in a letter dated "Good Friday," 1977, "Think of how
awful it must be to go to concerts in London by underground, when here we have
everything-and much more than one could possibly go to-in most pleasant
settings."
In this letter, he also informed me that he would soon be going to Hawaii to
the 6th World Conference to chair a session on Transcendental Meditation (TM).
"Have just completed a 3 month (twice weekly evenings) course on SCI (the
Science of Creative Intelligence)," he wrote. "I find the TM technique of which
SCI is the theoretical basis very useful in my daily life." He also referred to the
Amok paper he had been writing, saying it "is now finally coming out in the
International Journal of Social Psychiatry. I have just received the proofs."
The letters kept coming from Karl, with that same combination of homey
invitation and scholarly concern. His interests overlapped with mine when it came
to the elderly, as indicated in this letter dated March 22, 1978, describing that he
was about to go "off to Barcelona to read 3 papers to the 2nd World Congress of
Biological Psychiatry in August." One of the papers was titled "Biological
Changes in the Elderly Brain and Social Isolation." Of this paper, he said,"
I need your help if you can help. . . . From the title alone you will get
the idea. Have you any data to support this claim or should I only
suggest research to establish or refute this as a question? Any
references would be useful.
Karl's primary concern with and insight about the elderly and social isolation
was even more cogently indicated in a letter I received from him only a week later,
dated April 1. After he first stated that the resume of the paper was already
accepted and he was still working on the paper itself, he asked if I could provide
any research
to support the thesis, i.e., does Social Isolation cause biological
changes. Though it may not cause Alzheimer's plaques it probably
does slow down synaptic pathways by atrophy of the neurons.
There may however also be work on actual cellular degeneration
or cell-particle degeneration (nucleus or cell body) as well as
changes in the cell or enzyme systems of which I do not know.
We know from animal experiments that in cats (young) if they
are presented with vertical stimuli only, they will not jump on a
chair for instance because they cannot perceive the horizontal seat.
Similarly if babies are not loved or cared for ("stroked") they
appear not to grow physically, neurologically and emotionally. By
analogy I feel that I am justified that there is a good chance that
biological changes are developing or at least developing faster (?
greater rate of cell fall-out) if the elderly are not "stroked", do not
partake, i.e., are not communicated with significantly.
Karl's desire for me to transplant to England seemed to be escalating with the
months, for in a letter dated September 24, 1978, he actually implied that I should
trade my position at the GMHP for one in England-with less pay and a lower
status! He said:
In case you are interested-though I am not sure you are
immediately permanently registered here-there is always a job
for you here as Senior Hospital Medical Officer or Medical
Assistant, but that is probably not what you would want. . . . Our
salaries are of course quite low by your standards but one can live
(the above appointments are of course not junior ones but
immediately below the consultant grade and carry interesting
responsibility.
No, but thanks for the thought, Karl. I was satisfied where I was. Karl also
would not let me forget our "data drama" involving the Sarawak study! Here it
was, now 1980, and the analyses were not yet completed. Worse (though not
unexpected), problems still existed, as indicated in this letter from Karl dated
April 8th, 1980.
Dear Tom: . . . I have found a computer-science teacher (husband
of an ex-patient of mine) who is willing to help with the survey data
analysis and who has a computer at his disposal. I have therefore
asked John [Tong] to send the cards. . . .
I have found another expert on computers (Mr. Stewart Spray)
also a patient's husband, and who also has a computer at his
disposal and will help with the clinical data analysis. I need your
help: can you give me a list of the "Leading symptoms" and
"Leading signs" and which numbers we assigned to each? It
should of course, if you no longer possess this information, be
possible to set this up from the data as contained in the Assessment
Sheets themselves.
It was possible, and eventually the data were analyzed to everyone's relative
satisfaction. And I once thought, in some far distant past, that you simply collect
data, analyze it, and that's that, in scientific studies! Heaven forbid if all survey
studies have this level of difficulty and drama in getting statistics from answers
given to questions in the field!
Visiting the Aged At Home
Part of my work at the GMHP involved consulting at the two nursing homes
in Forte Greene. At first, this work involved seeing only the patients. (Nursing
home visits were only in Forte Greene, and no Hasidic Jews were seen in nursing
homes, only in their own homes.) Later on, however, as the nursing staff became
more confident and comfortable in coping with the patients, my consultancy in
the nursing homes was confined to biweekly sessions with the nursing staff.
In addition, we visited men and women at senior citizen centers. Those
merciful havens for many elderly had given me ample opportunities to reminisce
with them. While some came for companionship, many came to lend support to
others. The centers were chalices of hope for many who now lived alone, literally
in the shadow of death.
More typically during my years at the GMHP I visited patients in their own
homes, where I and my staff offered counsel and psychotherapeutic treatment,
among other services. These visits were described by Ronald Sullivan, in an article
in the New York Times dated Sunday January 2, 1983, under the large headline,
"Psychiatrist Ministers to Elderly Poor at Their Homes." Underneath the headline
was a photograph of yours truly, seated on a chair, between two women. The
caption read: "Dr. Thomas Chiu and Robin Strauss, a social worker, visiting a
woman at the Walt Whitman Houses in Brooklyn." The article began:
Dr. Thomas Chiu makes psychiatric house calls on the elderly in
Brooklyn. He interrupts their loneliness in apartments in city
housing projects to listen to their complaints and fears. He talks to
homeless and alienated women loaded down with shopping bags at
the entrances to subway stations and offers them care on the spot.
And if an elderly person is willing, Dr. Chiu will include him in
geriatric group-therapy sessions that tend to revolve around such
issues as love and death. Dr. Chiu . . . runs Cumberland Hospital's
geriatric clinic at 285 Myrtle Street in the Fort Greene section of
Brooklyn. Operating out of a small center on the first floor of Walt
Whitman Houses, the 47-year-old Dr. Chiu goes to poor elderly
patients who are too afraid or frail to come to him.
The article then went on to explain that, while many psychiatric programs
sought cures for their patients, the one I "ran" did not. (Actually, I did not "run"
the program in an administrative sense, as reported in the Times article; rather, I
was the sole psychiatrist in the program). Cures in our program were rare because
so many of our patients were either too senile or lacked the money or physical
and mental strength to change. "Instead," the article continued,
Dr. Chiu and his staff of social workers try to keep their patients
out of hospitals and nursing homes by making them as comfortable
and secure as possible in their homes, even if home is a dingy
rooming house or a subway entrance.
For us, success was measured by reductions in despondency and anxiety
among our mainly old and lonely patients, who tended to be disabled, forgetful
and depressed. In many cases they had been abandoned by relatives.
The article concluded by describing a group-therapy session attended by four
women who had weathered the rain that day. With my coaching "they slowly
began to talk about what was bothering them, besides their illnesses and poverty.
They talked about failing eyesight and arthritis, rising prices, old times and,
finally, romance."
The group therapy was, in many instances, most important for each and every
member. This fact is poignantly illustrated in the case of "Mr. Robinson." He
was referred by a priest in Green Point to our Mobile Geriatric Program, which
was established in the early seventies. The priest pointed out that Mr. Robinson
was a fifty-five year old, despondent man, who seemed like he should be
hospitalized. Mr. Robinson was to stay on with the Program the next three years.
Enquiries revealed that Mr. Robinson was recently widowed, had no children, and
was living by himself in an apartment within a huge complex in the Green Point
section of Brooklyn. The area appeared besieged, forlorn, unkind, and empty.
His apartment was on the fourteenth floor. It was well kept and adequately
furnished, though there was no memorabilia. He spoke of his wife, who had died
several months earlier, after a lingering illness. Their marriage was a happy and
comfortable one, spanning almost thirty years. Now there was a vacuum that left
Mr. Robinson feeling oppressively closed in. Life for him had come to an end, and
he wanted an exit-the window! It was as if the air that sustained him had
suddenly gotten sparse. Mr. Robinson had a little savings and was receiving a
small pension. With no immediate family around him, he was desolate.
After our initial contact with him, he agreed to come to our office. He
appeared to us to be a man with great resilience and imagination. Born and raised
in Manchester, England, he wanted to see other places in his teens. America, a
new world for him then, became a reality when he jumped from a merchant marine
ship. Procuring a job after a brief hiatus, he was able to secure and anchor himself
with certainty. Marriage further welded his position to stability.
Through medicine, supportive counseling and, later, group therapy, his
confidence in himself increased. A brighter side to his life dawned. His spirits
soared gradually. The group, which was to be with him for the next three years,
had provided him with another vision-a vision with which to search for his
past. The group helped him locate his two sisters, one in England, the other in
South Africa. Immediately upon finding an old address in England, he composed
his very first letter in thirty years. There was trepidation. The group held its
breath. One day, months later, when hope was thought non-existent, Mr.
Robinson
came to announce the news, very good news, indeed. "You must go now, Jay," the
group urged in unison.
"Is it possible, after all these years?" he queried.
Summoning another round of determination, similar to his earlier feat of leaving
his country, he decided to visit his sister.
"I am scared," he said a few times in the group.
"You will make it."
The sweetness of being home, long lost, and the many ambiguities of his
feelings of giving up an adopted country, made him all the more perplexed and
frightened. The group helped him overcome these negative feelings. With a warm
send-off, he left.
Then there was no news. Days, weeks, and months passed. Not even a post
card. Summer went by slowly, until towards its end, when Mr. Robinson
suddenly trotted in, beaming.
With joys of seeing him back, the group hungered for what he had to relate.
Foregoing his tales of meeting with his family, he reported what would be a
turning point in his life.
"I was on a public phone one day near where my sister lived, when I heard
this vaguely familiar voice, `Is that you, Jay?' behind me. I was awe struck. There
in front of me stood Sheilagh, now all silvery but unmistakably she, my one
enchanting lass! What separated us and brought us back together was a miracle.
Needless to say, we promised to write each other and to pick up the thousand
pieces of our lives we'd left to the winds."
Since then, the group had become consumed with "The Lost Affair Regained."
Mr. Robinson, after coming back to the group, began to read all his
correspondence to the members.
Excitement mounted each week, as he unfolded the innermost thoughts of the
letters. The group was not only listening to them, but was also becoming part of
the "soap opera." The members would volunteer ideas for Mr. Robinson to write
in his letters. The tenacity of the group was obvious, in wanting to unite the two.
The fresh outlook on both Jay and Sheilagh favored the final union, but not
without nights of soul-searching on Jay's part. He would be saying goodbye to
America now, with a heavy heart. The group, by this time, had become his family.
He was overwhelmed by their
love for him. The group also, with its munificence, appreciated his willingness
to open his heart to them.
The circles were complete, at last. A triumph of the spirit fostered by his
peers helped Jay to shape his next adventure back across the Atlantic, as if to say,
"Listen, Jay, go now to your Sheilagh, go to your land now and cherish them."
Williamsburg and the Hasidic Jews
An altogether unique venture during my tenure at the GMHP took me to the
Williamsburg section of Brooklyn. The residents in this area had been mostly
Hasidic Jews, and most of those we saw came from Eastern Europe. This group
was unusual not only in appearance, but also in lifestyle and philosophy. In order
to understand them well, I had to do much reading and even soul-searching.
One Hasidic patient I saw, for example, came from Poland originally. She had
been complaining of "Kalt" all the time on every part of her body. In exasperation,
her husband, who also was from Poland, asked the case worker and our team for
assistance. The caseworker was herself a concentration camp survivor and
Hasidic Jew from Czechoslovakia, who was employed by the Jewish Association
for Services to the Aged (JASA). After talking with the patient, we related her
constant complaint to the fact that, during the Second World War, for about three
years she was hidden in a closet in the unheated basement of a hospital and
received only little scraps of food. Now she apparently was directing all her
energy towards this complaint. With our help, however, she began to realize what
she was doing-trying to get her husband's attention.
Another example of the Hasidic patients we saw involved two brothers from
Hungary, both in their fifties. They started coming to our clinic after their mother,
our former client, died. One of the brothers, "Mr. R.," reported frequent
gastrointestinal symptoms. The other, "Mr. L.," just wanted "to talk." Both had
been interned in different concentration camps during WWII. After the War, Mr.
L. was further incarcerated in a Russian camp while Mr. R. left with his mother
for America.
Mr. R. seemed to languish in his somatic distress, clinging to it for years. He
never accepted the connection between his depression, which we had diagnosed,
and the G. I. symptoms. His brother, Mr. L., who was employed, also came to
the clinic regularly (at different sessions from his brother), to talk about his
exploits during the War. He was asymptomatic, presenting no gross psychiatric
disorder.
The two brothers must have shared many pains for a long, long time. Pains, no
doubt, from losses of family and property. They had supported each other
emotionally, and thus were able to sustain themselves over the years. Our role, it
appears in retrospect, was to continually let the brothers know that we
appreciated their view of life and their indomitable strengths, which our team
reinforced.
There was much more to the monthly visits we made in Williamsburg, but
suffice it to say here that my mind was kept jarred by the thoughts on this
extraordinary culture. It was extremely important, I thought, that we attempted to
understand the origin, the meaning of, and the reasons for each of the complaints
brought forth. Some patients were forward in verbalizing their complaints, but
there were many instances where families tried to shield their own or another
patient's suffering.
These Old World men and women made me deeply feel the need to cut
through layers and layers of social-ethnocultural factors in order to be able to
reach and help them. I was not sure if I would come out of my experience with the
Hasidic Jews richer or poorer, but I did know that I felt the need to understand the
symbolism, the mysticism, and above all, the pain that many of them carried, and
which was only now being exposed as emotional illness.
Treatment in Transient Hotels
We also regularly saw patients in hotels, including the single elderly living in
transient hotels. Many represented everything that spoke of dread, danger, and
dirt. Seeing them in their lonely rooms often made me ask which problem should
be resolved first-the mental disorders of the tenants or the grotesque, darkened
rooms that engulfed them. Our tasks involving these patients were often limited,
and time was fleeting, but as I look back on our points of our contact with those
patients-a vigil almost-I think it was they who gave us hope each day, not
our ministries.
The case of one patient in a transient hotel, Mr. K, was especially fascinating,
not only because of the human aspect of our relationship, but also because it
revealed a rarely documented side effect-or what most certainly appeared to be
a direct side effect-of an antidepressant drug commonly prescribed back then,
Desipramine Hydrochloride.
When we first saw Mr. K, a single male Caucasian, 53, who had been a
pharmacist, he was living in a single room occupancy hotel, where he had been
placed after eviction from his apartment for apparent nonpayment of rent. His
only contact with the outside world was accepting two meals brought in daily
through a Meals-on-Wheels program, which he consumed at one time. Mr. K's
checks were handled by the neighborhood parish. All visitors came to his hotel
room, including us.
Physically, Mr. K was thin and wore only a T-shirt and boxer short, which he
never changed. He did not wear shoes or slippers. His hair was long and matted.
His toe nails needed hygienic care. In answer to direct questions, he spoke
coherently, with no more than a few words, but his speech was a monotone and
sounded agonized and nonspontaneous. During our weekly visits with Mr. K
over a period of months, he gave us a cohesive chronology of his life's events. He
had no previous psychiatric history, though now he was extremely depressed.
However, he denied hopelessness or despondency. He had no suicidal or
homicidal ideation. His memory for recent and remote events was adequate. His
orientation to the three spheres was unimpaired. His intelligence appeared within
normal range. His judgement was fairly good. He did not show signs of gross
thought disorder. His insight was minimal.
-Although his room was never cleaned, there was orderliness, with everything
having a place. Any disturbance of this order that might have resulted from our
visits would be corrected by the following week.
We visited Mr. K weekly for five years. While he accepted us, he refused
medication and hospitalization. He showed no gross changes during this whole
period of contact.
Then one day, after the fifth year, he accepted 50 mg of Desipramine HCL, a
common medication then for depression, on a daily basis. A week later, he agreed
to have his toe nails cut by visiting student nurses. The next week he went
downstairs in the hotel lobby for a haircut. Shortly thereafter, Mr. K disappeared
from us. He was reported to be serenading a neighbor with an harmonica. He took
off to a resort 50 miles from the hotel, and was going to send a limousine for us to
join him. He announced he was getting married.
Then signs of mania in him became prominent. Soon he was hospitalized for
surgery of a rectal cancer, from which he died subsequently. That the triggering
factor for mania was Desipramine HCL is difficult to ascertain, although it is
known that antidepressants are associated with precipitating mania. There was no
significant relationship between life events and mania in this case, except for the
five-year supportive therapy we provided.
Could it be that Mr. K's age and vulnerability to mania had been responsible
for the manic effect we noted? Could his cancer have played a role in the mania?
There was no way we could know the answers to these questions, of course, but
it seemed, on the face of it, that the Desipramine HCL caused the mania. How this
could be or why it should have happened to Mr. K have also remained mysteries
to me, to this day.
Goodbye, GMHP
I possibly might have continued on at the GMHP to the present day, but the
enthusiasm and funds for the Program were withdrawn, and the Program was
made redundant in 1984, after about 15 years of existence. I saw its demise as
tantamount to a testament to the nearsightedness of the institution's
administrators.
Now, once again, I had to seek new employment. Where would I go? What did
I want to do? I could not say exactly at that time, but I do know that I was
wanted to continue treating patients from diverse social, cultural, religious, ethnic,
and racial backgrounds. In short, I was "hooked," I believe, on what today would
be called "multicultural psychiatry."
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