Urban Confrontation; 48; The Trauma: Mental Life and City Life

He's been a National Information Network his. Sides are higher for a hundred thousand population than rural areas and the tend to congregate in cities and the suicide rate I reach is a little peak in late adolescence and then tapers off and then begins to gradually climb so that the higher the suicide rate is particular to among males. This week on YOUR HEALTH CARE OF MENTAL HEALTH in Massachusetts and Dr. Jack thank you of Massachusetts Mental Health Center program. The. Mental life and city much. Here is your host Joseph. Are there. Mental Illnesses affected or will affect virtually every American at some time in their lives either personally or with a family member or friend.

Questions where can people in our cities who are afflicted with this health problem turn for help. How can our cities prevent and cure mental illness. Are city areas faced with mental problems that suburban and rural areas do not face. Well gentlemen this is a city series and let's take a look at these city oriented questions first one where can City people with emotional or mental problems find the best help. Almost every large city across the country in a number of the small ones there is mental health care available not in their mouth needed perhaps the best place to contact these either the local Mental Health Association the local General Hospital a lot of them have psychiatric units within them. The other place would be if they can't find their right to their state commissioner of Mental Health who will know about each city and he's area yet you admit that this care is not available in the amount needed. Why. Where we failed. Could I add the following thing that when a person is in trouble he very likely will turn to his family and there is some help to be gotten from the families that you know understanding family

member and an older person the wiser person. If they don't get help there or even if they do they may turn to friends. This is a natural thing and friends are a tremendous help. We all go to friends for understanding if they don't make it there they may go to their general practitioner. Many general practitioners write in arrested in helping in this way and can help and some of them are become increasingly sophisticated in psychiatric methods. In recent years the new crop of medical students are coming out of the medical schools are violent. I know a great deal more much much more about mental health mental problems and the older practitioners so they'll go through that gamut before they go to a psychiatrist or an outpatient or General Hospital. Now you ask how come we don't have enough to help. Well the problem is so extensive so vast. We've been unable to deliver the services supply the professionals all the facilities to do the job. The problems of two for one is a tremendous need. And second the great shortage of

trained personnel. Why are the problems so extensive so vast you call them 25 percent of our population afflicted with some sort of mental disorder. What does this say about our society. Or don't we have a monopoly on this problem. Well we don't have a monopoly and I don't think we have any more than any other nation in the world we may count it more than some nations and less than some others. But there isn't any reason to think there are more problems in one nation in another. Is there any reason to believe gentlemen that city areas are faced with mental health problems that suburban or rural areas do not face. Well there's reason to believe that this study has more that the prevalence is higher in the city than in the rural area according to the studies that have been done. And the question is why. Well when you pack people into a city and you increase the temple of life and you do a lot of other things that the city does in the way of poverty and housing problems of unemployment and so on. Apparently you increase the risk of a

mental illness in animals it's been shown that if you pack them together in small areas their behavior gets completely this dirt. This might be the answer but really the causes are probably multiple And the answer is not simple. That's what the city does to make it personal. Well I think there's also a sort of a skew factor in it that the people in lower socioeconomic groups are a high risk group for all kinds of illness and disease including mental illness and disease. And they tend to gravitate end of the cities. All are people are a high risk group for all kinds of disease including mental disease and they tend to gravitate into the core areas of the cities. So you have to if you like to call them geographic factors of poverty and AIDS that tend to have high numbers of these wherever they are but they tend to gravitate into the core areas. So you have more trouble and more illness and higher morbidity Another thing is when you're in the country in a rural area if you're a bit different.

Difference doesn't affect the other person quite so much as a not so many people to react to it in the city. It may be noticed a lot more the temp of the city I think is higher and in order to get along in the city you kind of have to master more behavioral patterns to get along get your work done and your recreation and all the rest of it. 85 percent of our people I believe the statistic is 85 percent of our people are pressed together into two and a half three percent of our nation's land. That's about right. In the old days of course we were primarily a rural population were essentially urban population a lot enough is just a guy who used to be 85 percent rural right. This means it has been a fabulous migration as well as you know. Population due to births but a fabulous migration over quite a few years people into the city is now what we know is that any migrant people get sick and then the more stable people. If you migrate you've got to make a heck of a lot more adaptation to get mentally and physically more sick. Maybe the illness is in part due to

that. Is there any reason to believe that our migration from this soil from the rural areas to the city is accompanied by any higher incidence of mental problem in North America than any movement in the history of mankind. The farmers movement of any major migration that has been carefully studied has always shown that you know people will get sick they drop out of the migrating group and the people who finally get to the destination of quite a fewer number than the ones that started out as in the survival of the fittest concept than it applies here are the stresses bring out the weaknesses in the disease control. What we don't have two good figures actually about the most reliable data we have are World Health Organization studies of newly emerging nations where the people come out of the bush if you like or the small farms and began to move into the industrialized areas of the cities

as the economic level of the country rises and in almost every instance study there's been an increase in alcoholism increase in broken families. And the increase in certain particular more social mental disorders. Let me shift the questioning gentleman to whether there is perhaps more suicides per 100000. What is the incidence of suicide in our city areas. Is it on the increase. No it's not on the increase but City area suicides are higher per hundred thousand population than rural areas. But I think this can readily be explained by my earlier statement is that the poor and the old tend to congregate in cities and the suicide rate I reach is a little peak in late adolescence and then tapers off and then begins to gradually climb so the older the higher the suicide rate.

What about suicide rates among the young affluent. Well as you all has said amongst the young it is one of the big causes of death. If you want to talk about attempts I remember one study in California that some 4 percent of the population have made an attempt sometime in their life so that. There's a lot of depressive feeling in a lot of attempts now amongst the young people. The girls attempt more than the boys but the boy succeed more than the girls. It's a very important problem and as they said because of distress in the units of the colleges what programs can not only colleges but city governments Institute to cut down the suicide rate which as you pointed out Dr. Rhee what is higher in cities than in rural areas. Well I think the availability of emergency services psychiatric services the so-called suicide prevention centers they originate actually in California I believe it to pretty much across the country now where there's a number

in the phone book like the fire department the police department and they can call in some knowledgeable person is on the other end that they can talk to that can somebody they can reach out to verbal and contact. Sometimes those people can help the person sometimes they can refer them the person uses their own judgment and I think of all the possible constructive steps this is the one it's probably most useful is singling out a single thing. What about problems of the elderly are their problems more acute in urban areas where they often are separated from family and old friends. I would make a guess that it is more acute in the urban area right in our culture you know. We do tend to reject the older person much more than other cultures do. Vision you know of the Chinese who respect the elderly more and they have more of a place for them in their life so they flourished there compared to here. Perhaps that's one of the big things that the Medicare Medicaid program has done and it is done something especially for the

elderly many of whom would have been absolutely without funds or resources no Medicaid gives them and they have self-esteem they can get some kid with it depending on their children. So the elderly and population don't age too happily if they don't have a lot of resources and exactly the right kind of family. Let me pause at this point in the program gentlemen to remind those around the country who may have just tuned in tell them that they're listening to the urban confrontation series we're talking with Commissioner Milton Green blot and Dr. Jackie Walt experts on mental health problems from Massachusetts and talking about the problems of mental health in the American city. Gentlemen I'd like to shift the questioning here in the second half of the program to an article that I read before coming over here to your offices. The article indicated that state hospitals one built many years ago were meant as custom audio facilities in other words they were built in out of the way places remote from the urban areas that they were intended to serve. Question that comes to

mind is has this changed throughout the country. Much is being done to try to convert the state hospitals from these remote isolated institutions to more community related and relevant institutions of that sort. The populations in the hospitals have gone down partly because of the drugs partly because of increased staff partly because of better community acceptance of the program and the hospitals have try to push towards the community by having outpatient clinics and Day services and night services and emergency services and consultation and education in the community now. Have they been successful. Yes some hospitals have been remarkably successful in doing those things especially those hospitals that are in or near urban centers. Those hospitals are remote have a tougher job. Well how do you implement the success of patient care. Yes just mention what we call transitional arrangements a day unit so that patients can step from the hospital to the day unit and then into the community or if they get sick and go into the day unit instead of into the hospital halfway houses night

activities or work rehabilitation activities apartment dwelling people have invented all kinds of ways to make the state hospital more relevant to the community and in some places they succeeded admirably. Another thing that happened is to give the state hospitals a catchment area that they can call their own of the find. Catchment area and charge them with looking after the people in this area inventing ways to give help outside. So that has been happening now. This alone is not enough. In addition small hospitals are being built which are called mental health centers like this one. This is one of the great prototypes that Massachusetts Mental health centers. Much of what's going on in the country today is due to this example and the work of the Joint Commission which our good friend Dr. He will the executive officer in their recommendations to the federal government to a large extent have been implemented across the nation to produce literally hundreds of small community mental health centers of a

comprehensive type where the people are giving the service to the people instead of the bringing the sick patient to a remote hospital as in the old days bring the hospital and it was there with his right to the door of the sick patient if you can. I think a great deal has been. What about converting the traditional physical health hospital converting sections of it to use for mental problems hospitals in the cities for the most part treat only the physically ill know what's being done to expand this treatment for emotionally disturbed people. Well you know the the American Hospital Association the American medical the American Psychiatric of all foster deformation of General Hospital units for a number of years. This is gone on to the point that now for first admission to a hospital for mental trouble more than half go to a general hospital first. A large proportion of those are treated there and then go home so I think large numbers of the LART particularly the larger hospitals in municipal areas have psychiatric

services. One of the advantages Jelen to having a psychiatric section the mental health section as part of the traditional physical health evaluation in the first place the patient usually comes earlier in his illness there's less reluctance to send a patient to a psychiatric ward at the Mass General it's let's say than there is to let's say the Metropolitan State Hospital we're talking about stigma earlier and I think this is thank one very simple. Economic thing is that most third party payments like Blue Cross will pay the hospital bill if he goes into the psychiatric ward at the Mass General but if he goes into say the metropolitan state or a small private mental hospital insurance doesn't cover him. So this is another economic advantage. Another point isn't related to that is if you go into a general hospital psychiatric unit the cost per Deum will be a great deal more than if you go into a state hospital. This is because of its depth the staff there is

at the level of the staffing in the other units. What about treatment at home. Home visits by physical health doctors are decreasing. That's well known but apparently home visits by psychiatry's are in great you know what are the advantages of treating a patient in a zone where you can bring the treatment to the patient in his home you don't disrupt the patient from his family don't tear him away from his family don't turn away from his job or his loved ones from his normal habitat. You don't put them away in a remote institution with a lot of other people who are sick. That may frighten him. And this would seem to be a reason he was never putting a person in an in any way to have a let's face it you can only treat certain kinds of patients in the home and for that type of patients I think it's a tremendous use by it. It is only one of many kinds of services that you need just as Dr. Green got much ahead of that part time care of one so it would indeed be very desirable if we could do it for everybody.

But we simply can't. Well it is true though that the trauma of being confined to a mental hospital as unfortunately all too often been like imprisonment for a patient. It tends perhaps to increase the patients anxiety and probably a little extra because the public hasn't provided adequate facilities so that the only reason people are locked up in mental hospitals in the few they still are is where you have one poor nurse or an aide trying to take care of a couple of hundred people and you know if you have cows that many with one cowboy you have to lock them up tool. And also what you say of course depends on the kind of hospital they go to. If they go to a mental hospital where they get good care waiting lists for those hospitals can be very large indeed but if they go to a hospital with a poor reputation because of inadequate staffing they just don't want to go. What about the halfway house concept. How does that work what is the purpose of a halfway house halfway house is a small residential facility. Let's say for a 10 12 or 15 or

20 patients where you have a quote mother and father a surrogate mother and father you might say that looking after the House and the patient learn to live together as a group and to get absorbed into the community. Often times they work and end and the halfway house represents a stage in their rehabilitation halfway. Quite a way of requited way between the hospital and independent community living. It's a supervised rooming house where the hospital staff and physicians sort of take some responsibility for continuing care of the patient. You mentioned the problem of financing the fact that so often if being confined to a mental institution is a traumatic experience for a patient then the blame for that should be left not necessarily on the institution's doorstep but on the taxpayers or step. How do you finance and staff a halfway house. Many a community can support this halfway house all by themselves raise the money find the

house and find the staff. The vast vast majority have been developed by the citizenry. The professionals have gone around talking up the idea. Only a relatively few of them have got any kind of state support. Now the halfway house concept a citizen can understand immediately. Yes this is it this is the kind of thing a patient sickie ought to have a place close to home. He can't maybe make it at home this particular patient and he'll be near us. Also the financial needs are such that as they say a good little active community can support a halfway house. I think we'll see a lot of development of the halfway house not only for the mentally ill but also for the alcoholic for the drug case the delinquent. Some types of retired dates as well and even geriatric patients. It's got vast use now the whole press of modern philosophy is as we say to get into the community to work very closely with the patient and work in small groups with the patients we don't want them by the hundreds or they have been in the large hospitals.

The concept of a self-supporting grassroots institution I think is imbedded very deeply in the United States historic approach to problem solution. And the idea of a volunteer program is perhaps and vetted even more deeply on the concept of the volunteer program apparently has started out again here in Massachusetts a program in which a volunteer is instructed by psychiatric social workers and then assigned to get to know to be friend a patient. And help them toward his eventual release from the hospital and back into society now. How successful has that program I dreamed that actually when he was on the staff here was instrumental in starting a lot of this and I think it's partially started with the Phillips Brooks students at Harvard working in this hospital and some of the others. And they brought up some old houses and they want to hire as many of five of these in the students run these places themselves and the patients come in there and the patients work and pay what they can they've been

tremendously successful. It's sort of a little variant of a halfway house like Oh I think you're alluding also to the case aid approach where a volunteer supervised by a social worker will be assigned a patient to form a friendship relationship and to try to help that patient use the hospital more and to get out and find a place to live and then follow them up there now. You asked how successful has that been. One study they found that 30 percent or more of our very chronic group chronically hospitalized group got out of the hospital and stayed out for a year or more. The duration of the follow up. After they'd been handled in this particular way so that the volunteer can be very very effective. How else can other interested Americans concerned with mental illness problems help to solve these problems. Their activity can be at all levels they can join a Mental Health Association they can educate themselves or they can be of more use to their friends or relatives if they become ill. They can

petition their legislators they can serve on boards of trustees they can serve area boards or citizen boards or county boards having to do with this problem. They can become a volunteer type mention where they work directly with the patient. Literally there are dozens of ways that they can get into the picture and be of help. And I might say this that we're going to be increasingly dependent on the volunteer movement to help us out because yes the state government is giving more money yes the federal government giving more money but. We don't anywhere near have enough money or men pala to do it all so I'm in PA will have to do more and more of training and supervising and helping volunteers to help the patient other volunteer pool men. That's really really great to say one final hopeful thing. The American citizen has got a big tradition of volunteering and they're pretty much open hearted and very generous about doing this kind of thing. If they

are given an opportunity and if they help to see what they can do and get some kind of supervision so that they won't be at sea and doing the volunteering we are very near the end. And with that in mind I'm going to give both of you gentlemen a barrage of questions which will enable you to give some indication of how hopeful you are with regard to the solution of mental health problems in the rest of the 20th century first is the United States meeting health problems adequately and if there is a lie of how serious is it how much research is being done to seek new cures and treatments for mental illness who supports it. And lastly can you compare the amount of money being spent on Mental Illness research to say cancer research or heart research and that's quite a list as well as shoes as you will. The services certainly are not adequate I don't think our mental health services are. As adequate to the population as a whole is our general health services although there may be gaps in that particularly general medical services to older people

is seriously lacking as well. I think we can't deny the fact that the research in mental health has been rather generously supported at the federal level although I must say the current administration seems to be chopping it down a bit. And as compared to heart and cancer I think it has been supported on a fair level. The voluntary hospital support and the private funds in the mental health programs however has been much below that. There are very few private nonprofit mental hospitals are there are a small number. The public at large is look to the state and county governments for this kind of support. Unless you're agreeable I'd like to say that we got bit by the tail you know. We've got a problem solver requiring so much money and personnel etc that we can expect results right away. Research has been generously supportive for a long time and we hope that after Vietnam will get back to a generous support. We hope that the Powers That Be will give out enormous amounts of funds will

recognise that basic research as well as applied research is important. There's always a tendency. Political mind to say what am I going to get out of this tomorrow. Some of us feel that basic research is really the way to plan for tomorrow and a very long tomorrow. It was basic research that developed most of the great advances that we have I think again that our research will be probably one of the great ways out of the dilemma because as we look at it today we don't see how we can put together a successful equation to take care of all our mentally ill. But research gives us the hope that something new will be discovered which will give us a shortcut to success for exactly well seconds remaining. Yeah right. The thing I want to make certain that the public understand that when we speak of the larger numbers of mentally ill in the poorer sections of town I am not talking about the militants. Those are trying to break out of this. I think rather there the healthy ones in that community and it's the

passive ones are put up with the wrath and the poverty of the sick minds. I would not like it to be understood that these rather vociferous and at times a big nuisance people are mentally ill I think they're the healthy ones and reacting in a healthy way to an oppressive situation when a fellow has his foot on your neck. Healthy response is the challenge I have and bite his foot try to get them off. Gentlemen a realistic and yet an optimistic assessment of the possibilities of getting some money to do they all important research needed to solve mental health problems here in the United States and a very informative program. Two very articulate experts on mental health. Thank you very much. Robert. Thank you for her health and really glad her mental health matters. And Dr. Jack has a mental health day

program from a mental life and city law. The views and opinions expressed on the seating program. As the saying goes. I'm working from university for this question that will moderate presenting many sides of today's house your home videos of our director in part because this week's program was produced by Hugh little less reckoned by George Romero who by Peter stand executive producer for behind his ribbon confrontation if you want to get the numbers back home in a cage in a large private Northeastern University. Requests for a tape recorder popping up in a program may be addressed in the confrontation. Northeastern University has a higher ground. This is the national educational radio network.