Fred Bemak [Director of Counseling Psychology, Antioch New England]: An Interview about Problems in Mental Institutions

I worked in the mental health field as an administrator of three different programs. At various times mental health programs to mental health programs and one upper bound project with an anti-poverty program. And also worked as a clinical director of an organization called the Western Massachusetts training consortium which was based at the university master's medical school. And did some national working in mental health and with training consulting. So you have sort of a broad range of experience in the mental health field it's not just that you are a counselor. Right right. Today I just as I told you want to talk about deinstitutionalization and I guess before we talk about deinstitutionalization maybe we should talk about the state of mental health institutions and what is institutionalization. Now it's an interesting and very important question. And I think of the places where I've worked and consulted. And think of some of the situations that I've seen. And maybe that's the best way to talk about some of

what institutionalization is. Recently in. I was asked to come in and consult for a state institution in a state which I will not name but I think it probably parallels many of the other institutions in many other states. And I was asked to talk about the treatment program and how to help the clinicians do better work in how to help the power professionals and nurses and do better work just to look at the entire system. And what I found very quickly that didn't seem to be a concern to anyone there was that there weren't sheets and towels. So when I don't find sheets and towels I can't talk about treatment. I don't think that's so different than other facilities that I see. It's more 1984 now in the United States which is considered a pretty progressive and technological society yet we can't get sheets and towels to the mentally ill.

Why were there no seats in towels. Is it a fear of strangulation or something. No it was pure bureaucracy. And finances and priorities and just those kinds of things being overlooked which says it all about what treatment isn't instead of. And it's very hard for someone that begin to feel good about themselves when they don't have a towel to dry themselves with. When we talk about the mentally ill we're talking about. I mean that's a very broad term and it sort of goes everything from people who have neuroses to to somebody who has things that maybe are physically induced. Am I correct about that. I mean I'm thinking that people who who can't make logical decisions for their lives to people who like me maybe are real stressed out sometimes get headaches. My understanding is all of that is is under the category of some sort of mental illness of some sort. But yet not all of those people are put into institutions.

That's correct and they are. What the criteria is now generally is that someone must be a danger to themselves or others so that if you had headaches and felt suicidal because you had headaches. There would be a greater chance that you might be put in a institution if you were just having headaches no one is going to drag you often and lock you up. Or if you were threatening to hurt other people and you were considered a harm it's very difficult in some states right now though to prove that in some states in fact we are looking at statistics to keep people out of institutions so that some people fall through the cracks and it creates great political havoc. One thing that I wanted to clarify before I went on was the term committing somebody to an institution can I if I felt that I was harmful to other people would I just be able to go to a mental hospital and check myself in. Or is it is it really the

sort of stereotype that I have that somebody and their lawyer come and sign you in for a life to Bellevue or bedlam or someplace like that. Or is it somewhere in between somewhere in between. Psychiatry is are the people right now that can commit. Individuals the hospitals so that it has to be through a psychiatric evaluation. Although there's tremendous pressure politically on psychiatrists in certain areas of the country to not allow patients into the people into the hospitals. So I don't think it's pure clinical work anymore as much as it's clinical work in conjunction with politics. When we talk about politics we talk about rights and things like that as a person in a mental hospital have legal rights or is it psychiatry. He's acting in local Prentiss. How does that work. In theory in practice I talk about both OK. In theory every patient has rights. In practice it's

very difficult to have any sense of power and this is these are part of the problems that are inherent in institutionalization. It's very hard for an individual to have any sense of power or self control over their own lives. Empowerment staff in turn oftentimes who feel. Devalued do not easily give up their own sense of control or power to the patients. In turn you have a devalued system. I'm generalizing now that simplify it quite a bit but I think that's one of the themes that I see quite often. So in a sense then the portrait the that I'm getting now out of view of a mental institution is someplace that I like businesses in the society has to worry about how it how it's financing itself who's paying for what and so they make Budget and Policy Priorities with their money sheets and health may not be a priority for some institutions a place that that's an institute that's a big place that's not dealing with

people always on a one to one level. You know I I would say it a little different and I think it is a priority when it's pointed out but I think because of the patterns and the norms that are stylish institutions people overlook those basic things. It's also difficult to work within the bureaucracy to begin to purchase something like the change of budget to say oh yeah we do need 100 towels. Where is the money and how do you change line items and how do you figure that and how do you get that signed off. Four's is sometimes as I've seen it quite difficult. Are we talking about public institutions right now or is this sort of mental hospitals. I'm talking about just public statements already OK. That's what I thought it's going to clarify that. So when you look at this and you you were saying earlier you went to look at at this hospital and were stopped by this first. This first thing that had been overlooked the sheets and towels I guess you can't really generalize but how do you how would you feel then you looking at it

about maybe the kind of care that people are getting are or are people getting cured of their mental illness for lack of a better term in state institutions right now. Is that the best way to help people who are mentally ill. It's very difficult. I don't think so. But there's tremendous controversy and I'm sure depending on on someone's philosophy and orientation I think that it's important for people to be out of institutions and gain a sense of self dignity and begin to move more into the workforce and a capacity that they are capable of. Begin to relate to family systems again and to work through some of the stigmatization that are coupled with people who are institutionalize a very hard to overcome those. So now we're talking about the institutionalization starting to starting to well what maybe I have you define deinstitutionalization I mean you

get a glimmering that's taking people out of institutions but to where. It depends on the state to where. For some places I've seen it takes people into the streets where they hang out and don't have any services and they have medication checks once a week. Obviously for someone who is in tremendous chaos internally and confused about where they are what they're doing who they are that's not enough. For other places I've seen it takes people into and I think ideally this is more what it should do is it takes people into a comprehensive service system in the community so that if somebody is capable of living independently with some supports that they may in fact have the opportunity to move into apartment but have staff who work with them and gradually decrease their contact with those staff members for other people that might need more of a small group home kind of facility could because they are not capable of taking care of themselves

taking care of their personal hygiene having any kind of social relationships. Then they would need in fact more staffing what happens is the staffing begins to reach place. The number of staff begin to in theory should replace the restrictive missive Alok saying. So you would have maybe five people working in a home with maybe almost a nice one on one. I'm sure that never happens but you know you know say there were 10 people in a home and you had maybe three people who were there working all the time. That might be thumping. A little less independent than somebody living in the apartment. Is that a ratio three to five or three to ten. No the aim right now in many states is more to have a very small group homes. And then when the numbers start reaching 10 what happens is that oftentimes duplicates many institutions and so you have the institutional patterns begin to erupt in the community which is not helpful nor healthy for the clients. So what are we

talking about exactly. The Pens on the level of function the client has kind of may range from 1 to 3 as a staffing ratio and so I've seen that number silly or 1 to 6. So are these regular houses in the community. It's like a group home. I've seen group homes for the developmentally disabled. Would it be something like that similar or what's happening quite often our apartments are being set up as well either single or double apartment settings is to with a staff person living there you know with a staff person recently for example I was evaluating a comprehensive community mental health program and. They had a series of apartments throughout a particular city but they had staff who had an apartment in one particular location that was their base and that would travel between the apartments so normalisation would say that the staff don't live in the apartments but that the clients own the house

and own ownership of the of the territory and the psychological and emotional territory of the house and it's theirs and they would have a certain spot where they knew they could contact somebody if they needed help or they would get checked on regularly by somebody. Yes I guess when you start thinking about it you've given me all these levels of you know who can do what and how independent somebody can be. And I'm sure that that that there's we have to talk in generalities because I'm sure that's different. I mean every person is different right. It's an individual judgement but in rough terms what would you be looking for in somebody that that would allow them that you with a psychologist or. Or me as a psychologist could say Oh I think you know Mary would do really well in an apartment by herself. You know I think she she's capable of it what kinds of things might she have. What kinds of symptoms mushy display I guess.

It would require for a Mary to do this. For her one is to have the motivation to do that. That is a very scary to take on the responsibility and all that comes along with that. For some individuals to be independent. Secondly is is Mary would need to know that she would have enough support if she does have problems that she isn't left abandoned. And third is just basic kinds of functional skills like being able to cook being able to shop being able to count money see numbers of clients who have been left alone who would go into stores but didn't know how to. Count the change. And that's very difficult very scary So how does that manifest itself in terms of behaviors it manifests itself. Where the client would go into the store and have outbursts before they got to the counter and start screaming and be dragged out by staff and never got to the real root of the issue about the fear of going up to the checkout counter and paying the money. Also personal

hygiene is very important. Those individuals that have medical problems need to know how to contact doctors take transportation to get around. Other people need to know how to get transportation to get to appointments those kinds of things. So if our Mary our hypothetical Mary or anybody else was in a large institution and and there was a possibility that she would be in de institutionalize or that there was going to be a program like that started which would be more likely than on a one by one I would imagine in terms of a program in the community if she did not have those skills. I'm sort of confused about about the range of the mentally ill I guess is their training for independence in a in an institution so that somebody can go out and become more independent. Is there are there like daily survival skills classes or lessons that somebody could have for those. Is that an idea that would be good. It's a great idea.

It doesn't it doesn't always happen and it doesn't always happen. For a number of reasons. One is that. Academic institutions that trained professionals in psychology in psychiatry and social work don't necessarily train people about how to work with advanced institutionalized chronic mental health population. Many many many folks will learn a great deal about theory but not about practice. I. In one institution I consulted for I went in and found in the system that all the professionals would meet once a week for a three hour diagnosis meeting and they would talk about the diagnosis of the clients and have the client come in and talk to the client have a client leave very traditional kind of approach and then argue for the next two hours about the diagnosis. When the other staff would come in and say OK great so you've decided on the diagnosis of manic depressive. What do we do.

And the meeting would immediately end not and my sense always was that people didn't know how to talk about what to do that professionals aren't taught what to do is someone who's delusional. What do you say how do you approach those delusions. Another example is recently I did a training for para professionals in a state institution and although some of the people there had been working 20 years they did not know how to define psychosis. And all they see are people who are many many of the people that they see or are psychotic or labeled psychotic they did not know how to prevent or or identify suicidal risks. It's very very important questions with people with suicidal risks or coming through their unit every week. When they get on no I'm understanding you I'm just thousands of questions pop into my head as you talk. I guess when I think about it in terms of people with delusions and people who. Are a social who

won't talk to you or or who are very frustrated and get angry easily when they are out in the world. I know a lot of people get finally end up in institutions because of all those problems that they have dealing in society and so are you telling me that that those things never go away in terms of being dealt with. I mean if somebody who is belligerent for example or who who's frustrated with the incapability to do whatever it is can't change or take a bus if they need to take a bus. But those aren't really being dealt with those kinds of things. Those problems are always going to exist. What are the doctors treating in the institution. Your question ties in with labeling and labeling of patients. It's interesting the moment of diagnosis for mental health patient is a life time. It sets the precedent for a lifetime so sometimes I meet people mostly

hi who are you what do you do. And and I cough on my role to them and they say oh I'm a manic depressive and it's a label that's very very important I remember once as an administrator of a program or as working with the most difficult adolescent population mental or mental health or adolescent population that had been through 10 programs plus. And no one else could treat so there was a program set up in the western half of Massachusetts which I was directing and one client pestered me. For over a year for her diagnosis. It was critical to her to know her identity and that diagnosis. And we went back and forth about the importance of it and why I know it and what does it mean and who are you without a diagnosis and those kinds of questions are extremely important. So once we have a manic depressive or a schizo phrenic the thing I don't know very many labels but you know those are the labels then are the doctors and the paraprofessionals treating.

Treating. The symptoms of those labels I mean that I don't I'm not quite a lady and the label tells us nothing about the functional level of the person. OK nor does it tell us anything about why what precipitated any kind of crisis that brought them into an institution. The label does tell us what kind of medications we should use. Pretty traditional medical model kind of orientation but it doesn't tell us how to treat somebody or if they're hallucinating or not hallucinating or how they're feeling or what's going on with them. So it seems like if if you wanted to to set up a program of homes or apartments or group homes for people who had some of these problems or your illnesses that that's the way that they're defined it would be really difficult to sort of sort out who could go and who who couldn't with a label so I mean is that a hang up in terms of who can get out of the institution and go out. I mean are there labels

like well we don't let's gets a phrenic Sco or we will lead a manic depressive go. You know you fall into that label or are people looked at as individual cases. They're looked at as individual cases. The community mental health system is not quite in sync with the institutional system in the places that I've seen. And so there is more of a medical model and institutions and a non-medical model in the communities which begins to look at the person although I see the stigma as carry being carried with the people quite often so that when I see what you call before a belligerent client or an aggressive client big problems in our community mental health I might go in and if I'm asked to do a clinical and I do book clinical an organizational consultation soem of them asked to do clinical consultation going and say OK let's talk about this person. When was the last aggressive incident. More often than not I hear that it was five years ago but the person still aggressive. So

what are we really talking about when we talk about treatment and the change of an individual someone who is labelled manic depressive five years ago they're still manic depressive they're always manic depressive I received a doctorate I'm always a doctor. They received a manic depressive label they're always a manic depressive and that's worrisome to me because it does not allow or permit change in that kind of structure. You talk about the problems that the patients face in the community one of them I would imagine is the community itself. Accepting it. I was talking earlier to another person who works here and she was saying well you know she's live in Ithaca New York and they wanted to put a group home for mentally ill in a very chic part of town and the citizens the residents there really were very opposed to it and then eventually blocked that building block the whole the whole idea of a group in their neighborhood we don't want that in our neighborhood. But there's it seems like discrimination.

I mean what kinds of How could how do you and I get I want to talk about from the mental patients point of view but what has been the reaction in different communities that you've seen to the group home idea or that the independent living idea. I've seen a great deal of resistance. This is this tremendous fear about the mental health patient there's a stigma attached that's been carried through with patients for years as a matter of fact. There was research done on the locations of state institutions and they found that many state institutions are located in places where there's been some horrible situation before so they know of one institution in Massachusetts where there was a hanging years ago an institution was built around the grounds where the hanging happened and that's not so uncommon. Those things have been carried for years. What I found in the communities I've also seen houses burnt down in communities that potentially mental health programs are

going to move into great resistance it's a factor that I've seen mobilized communities very quickly. The other side of it is what I've found is that when people begin to see that mental health clients are in fact human and want to begin to have face to face contact with people and they begin to break down some of the myths and the barriers. That has broken through a great deal of the kind of fear and concern that's that people have had I know of one program recently that just had a community day. And in the apartment complex where they were living the Mental Health Department programs cleaned up first of all had a day where they cleaned up the entire car apartment complex had a number of officials from the city in town come in and had a barbecue for over 300 people. And it was a great day. It mobilized that community in a way that no one had ever done that apartment complex in ways that no one else had ever done. They're very of course you can imagine they're very much accepted into that particular area.

One last comment about it too isn't it. Studies have shown that the mental health population is less aggressive. As a population than the population. The portion of the to the population at whole as a whole I can imagine that. I'm wondering if people who are go out and live on their own in an apartment complex or whatever the structure is in that particular community is the contact with the so called normal population is that a source of frustration or is that A is that an inducement to function better in the society. How do you see it for the client for the client themselves. I would need to preface that with being hard to make the contact. That program that I just described with community days is an exception that it's very hard for quote normal folks to know how to meet new

people and to begin to establish relationships let alone somebody that's had a history of internalizing a deviant image and feeling a lack of self-worth and lack of self-confidence a lack of How to notice. Knowing how to socialize. I think when people have integrated in the community and in community functions I think it's been a tremendous asset. It's helped people a great deal. There's no prescription for that one though. Oftentimes we have staff who don't know how to do it so how can they begin to teach the clients would that be an ultimate goal though in your mind integrating different kinds of people. I mean you know yes I and I see all kinds of interest I see all kinds of barriers for that for example I see I saw a fishing place once on the west coast that had handicapped rails for people who are handicapped who were using wheelchairs to all fish at the site but well how did how did they set those

up to set them up in a roll of about six so that of course the what's underlying that is anyone who's in a wheelchair would all they would all want to fish at the same time on the same day in the same place and they can and they can all go together. So it's not individualized and it keeps people segregated and that that kind of attitude permeates very strong in a number of kinds of activities that happen in in the in the programs and in the community for the programs.