Here’s a prescription for how to approach treatment of people with schizophrenia: “mental illness can be alleviated if the person is treated in a considerate manner, if he has the opportunity to talk about his trouble, if his interest is stimulated and if he is kept actively involved in life.” What may surprise you is that this prescription was written in 1806 by Phillipe Pinel, the founder of the moral treatment movement in France. What Pinel prescribed, before the advent of Freudian psychology, our modern understanding of the biological underpinnings of serious mental illness, and today’s focus on active recovery, was revolutionary at a time when mental illness was thought to be a matter of religious possession. In defining mental illness as a medical condition and prescribing consideration, supportive verbal therapy, and active engagement in life, Pinel, and his followers laid the foundation for the evolution of mental health policy in America.
Pinel conceptualized the asylum as the place where his moral treatment would be carried out, where “patients” (a revolutionary concept in contrast to the “possessed”) would live and work in a therapeutic environment. In the 1840s and 50s, the crusaders in the United States (notably Dorothea Dix) successfully advocated state-by-state for the establishment of asylums that evolved into the State hospitals that dominated the system for 100 years. Sadly, the vision of moral treatment was short-lived in the United States where the state hospitals evolved into the custodial, largely non-therapeutic institutions of the 20th century.
By the 1950s, the New York State psychiatric hospital system had an astonishing 93,000 patients. The cost of the system and the patient-care scandals that regularly rocked and embarrassed professionals and legislators alike, combined with the nascent community mental health movement that envisioned ending the institutional isolation of the mentally ill in favor of community-based care, set the stage for reforms to come. 1954 was the year that New York enacted historic community mental health legislation and Thorazine was introduced as the first effective anti-psychotic medication.
It was also the year that The Bridge, the community-based mental health agency in New York City that provides services to more than 1,600 men and women with serious mental health conditions, was founded. The history of The Bridge reflects the evolution and revolutions that have occurred in the mental health system over the past 55 years. It’s an instructive history, charting the system’s path to recovery.
Given the undeveloped state of community mental health in 1954 it is not surprising that it was a group of patients who had been together in a psychiatric hospital and who were discharged with medication prescriptions in-hand and appointment slips for follow-up clinic visits, who joined together to form their own support program, giving birth to The Bridge.
For the next 15 years, The Bridge was a kind of self-help psychosocial club. The “members” (a term still used by many today), supported by a group of volunteers who raised money to lease space and provide other necessities, participated together in social and mutual-aid activities. The primary value of the group was non-institutionalism, staying out of the hospital. The agency served as a place of friendship, there was no professional staff and the role of the members was to socialize and provide mutual support.
By 1969 the policy of deinstitutionalization was in full swing. Thousands of patients were discharged from the five State psychiatric hospitals that served New York City. The Upper Westside of Manhattan, with its abundance of inexpensive single-room occupancy hotels, was a magnet for those discharged and, with few program options, both the quality of life of those discharged and the neighborhood were seriously impacted. It was then that The Bridge, located on the Upper Westside, was sought out by the State Office of Mental Health and offered its first government contract that combined State, City and agency matching funds.
The first order of business was to hire the agency’s first professional Executive Director who was a social worker, psychoanalyst and group psychotherapist. The first thing he brought to the task was the theory of the origin of schizophrenia that was widely accepted at the time: the schizophrenegenic family. According to this theory, the cause of schizophrenia could be traced directly to deviant and harmful family interactions. His response to this theoretical proposition was to create in The Bridge “a second chance family” in which the new family, comprised of staff, would offer a corrective family relationship based on caring and nurturing. When combined with the second major idea he brought from social work, the importance of addressing basic living needs such as food, clothing, safety, income and medical benefits, decent housing, and daily structure, the agency quickly became focused around a paternalistic paradigm in which the staff assumed the role of parents with the clients viewed as children to be taken care of indefinitely.
This paradigm flowered in the 1970s and well into the 80s, as the agency added a number of programs, at the heart of which was a 12-hour-a-day Continuing Day treatment Program that operated 365 day-a-year. In 1979, in response to the poor living conditions that many clients endured, the agency offered its first housing programs.
In the late 1980s a crucial change process began, and significantly it was initiated by the agency’s clients. In a confirmation of Abraham Maslow’s concept of the hierarchy of human needs, the clients acknowledged that they were indeed being well cared for – with 365 days of program, quality housing, their entitlements in place and medication therapy all under one roof. The clients then asked what the agency had to address their growing desire to do more? When asked what they wanted, their response was: work. Following the clients’ lead, in the late 80s The Bridge started offering vocational services (job training and experience, placement in competitive employment) funded by both the State Office of Mental Health and, later, by what is today’s City Department of Health and Mental Hygiene.
It was the advent of vocational services and the goal directed clients who eagerly participated in them that began the agency shift to rehabilitation. In addition, advances in the science of understanding schizophrenia had a major impact on the agency. With the schizophrenogenic family theory repudiated and discarded and with new understanding of the biological underpinnings of the disorder, “the second chance family” paradigm was challenged. The client role was shifting from passive recipient of services to active pursuer of individual life goals; the agency function was shifting from nurturing to rehabilitation.
The new paradigm certainly challenged staff whose role was being redefined from parent to facilitator/teacher. This shift not only required acquiring the new technologies of rehabilitation, but also entailed embracing a new set of values, which agency leadership promoted but which were met with understandable resistance. In this new paradigm, which required individualized services, staff’s role was to encourage clients to define their own goals, a revolutionary idea.
In 1998 the seminal PORT Study (Schizophrenia Bulletin 24(1):1-10, 1998 NIMH) was published with its 30 consensus recommendations of practices that improve outcome for persons with schizophrenia. Twenty-one of the thirty recommendations related to medication practices; seven to other psychosocial rehabilitation services, including the provision of skills training to address the deficits in persons with schizophrenia, creating opportunities for positive family involvement in treatment and support, providing vocational services including supported employment programs for those who express interest and the appropriate use of intensive case management and ACT Programs. These recommended practices and other evidence-based practices that have emerged over the last decade now form the core of services at The Bridge.
Borrowing from the world of substance abuse, recovery has also emerged as a core concept in the last decade. The articulate and inspiring Patricia Deegan defines recovery, not as a cure, but as “try[ing] to stay in the driver’s seat of my life. I don’t let my illness run me.” (Social Work in Mental Health: Trends and Issues ed. Uri Aviram. Vol. 25, No. 3, 1997, pp. 11-24). This vision, combined with a new emphasis on peer empowerment and responsibility, has had a major impact on reshaping services. Today at The Bridge many programs include peer workers on the staff and the Peer-to-Peer Program offers clients the opportunity to learn and practice the skills of effective advocacy both inside and outside the agency.
In some senses the evolution of the mental health system over the past 55 years has brought The Bridge full circle. Today’s clients provide mutual aid and support and, along with staff, they share the knowledge and skills they have developed to empower others. It is an exhilarating experience to witness the fruition of Phillipe Pinel’s prescription more than 200 years ago: persons with mental illness claiming the consideration that is their right and being actively engaged in life.