Marcia A. Murphy has published articles, essays, and works of creative nonfiction in professional psychiatric journals, four anthologies, and elsewhere. She is also the author of a memoir which is the story of her life, experience with mental illness, and recovery, titled Voices in the Rain: Meaning in Psychosis.
By Marcia A. Murphy
Enter, ye, who have no hope.
Thus, the unwritten sign posted above the entrance way of the psych unit. Invisible to most, but not to me. As a former psychiatric inpatient I can honestly say that I have been there—to Hell and back. Not that the unit, itself, is Hell. No, in my own mind and heart I’ve been desperately without hope and have sunk into despair. It was the psych ward that caught me in free fall and because of this I am alive today.
As you already know, humans are often victims of evil as well as perpetrators of it and these things can profoundly influence mental health. The world in which we live produces casualties every day. The impact of trauma upon the lives who’ve experienced war, domestic turmoil, and other violent situations has received more attention in recent years. In addition to these devastating relational and environmental factors, the biological and genetic aspects of mental illness are also well known. People involved in working to help the mentally ill have ranged from kind and compassionate human beings, to callous and condemning.
Society has always struggled with how to care for the mentally ill. For example, in the early 1900’s the mentally ill were abandoned and warehoused in institutions that consisted of old dirty buildings where the patients were barely fed or clothed. Chronically understaffed, these facilities did not provide any kind of stimulation for the heart or mind. Patients would be forced to sit for many hours on long wooden benches in crowded day rooms and they were put (sometimes strapped) in filthy bug infested beds at night. It was not uncommon for patients to be brutally beaten—and sometimes, killed—by cruel attendants. There were few medical treatments and also few recoveries.
Things began to improve in 1946 with the instigation of the Mental Health Hygiene Program which became the National Mental Health Foundation. This, in turn, led to new medications and deinstitutionalization. However, now a large number of the mentally ill are behind bars and homeless.
To give some idea of what a modern day psychiatrist might say if asked about his/her choice to enter the field and of the subsequent experience while practicing, I will describe a hypothetical interview with fictional Dr. B, a composite character of real-life responses to my project questionnaire. Though many may think this field presents many challenges, this composite has turned out to be a physician who realizes the depth of this serious medical and social problem and who, at the same time, has used whatever creative intelligence and ingenuity needed to search for possible solutions.
I walked into Dr. B’s office and he motioned for me to take a chair. On his desk, books and papers were neatly stacked. There was a wooden table to his left with a small waterfall trickling over pebbles. A bronze floor lamp in the corner lit up the room.
“What can I help you with?” Dr. B asked as he quickly glanced at his pager.
“As I mentioned in my email, I’m considering the field of psychiatry for my life’s work but wanted to ask you some questions to get a better idea of what that might entail.”
“Sure—no problem. Go right ahead.”
“I would like to start by asking why you became a psychiatrist. What inspired you to do this? What attracted you to this field?”
After a moment of silence, Dr. B began.
“I decided to become a psychiatrist during my senior year in medical school. I had been considering the specialties of psychiatry, obstetrics and gynecology, even internal medicine. That year I had a six-week rotation on the psychiatry service. To me, the mental disorders were of uncommon interest. I was fascinated with the patients and intrigued with the lack of understanding on the causes of mental illnesses and their treatment. Problems of a psychiatric nature presented an intellectual challenge that appealed to me and I recognized in me a feeling for, an empathy if you like, for people so afflicted.”
“Did you ask anyone for advice?”
“Yes, I did. As I was considering my choice I went to speak with the chair of the psychiatry department. He cautioned me saying, ‘The mentally ill–most of them–have chronic conditions that you can do little to change.’ He said, ‘They tend to be difficult people and they won’t thank you.’ He said little that was encouraging. As it turned out, I found that a lot of what this man had told me was true. But that was in 1959, and the field of psychiatry has changed a great deal in more than 50 years.”
“Oh, really? In what way do you mean?” I asked.
“For example, new treatments have been developed or discovered that have changed peoples lives for which they have been grateful. These were treatments such as lithium for bipolar disorder (manic depressive illness), imipramine for panic disorder, and chlomipramine for obsessive-compulsive disorder. Cognitive and behavioral therapies were found to be effective for a wide variety of disorders. When I began my career there was no means of altering the long-term course of bipolar disorder–no mood stabilizers, obsessive-compulsive disorder was a disabling and untreatable condition, and there were no effective treatments for panic disorder (the diagnosis was not made until 1980). It was gratifying for me not only to see, but to participate in, these developments and see people respond to these new treatments. I believe that psychiatry is one of the more effective specialties, and important developments in treatment, and now prevention, are continuing to take place.”
“Were there any other reasons you had for choosing psychiatry?”
“Yes, another reason was the need for psychiatrists. It seemed to me that I would always have a job, and this practical consideration entered in. But something else that I may not have appreciated was the variety of career opportunities available. During my residency training I developed an interest in clinical research and scholarly endeavor and was very fortunate to have an opportunity to pursue an academic career.”
“Is there a variety of settings in which a psychiatrist may practice? And what are some of the subspecialty areas?”
“Yes, psychiatrists work in state hospitals, mental health centers, private practice, military service, academic settings and other places. In addition to child and geriatric psychiatry, there are now addiction psychiatry, forensic psychiatry, psychosomatic medicine, and administrative psychiatry. Fellowship training and board certification are available in these areas. Residencies in internal medicine-psychiatry and family practice-psychiatry provide training for work with patients having combined medical and psychiatric problems now referred to as psychosomatic medicine. It’s the subspecialty which seeks to bridge medicine and psychiatry. For some, it’s the urge to blend both that sort of fuels a desire to understand people in a way which emphasizes the fundamental indivisibility of mind and body. A colleague of mine was a lab technologist early in his career, and when he was not in the lab, he drew blood specimens from patients on the wards. He told me that every patient he saw was afflicted with both mental and physical illness. He said that he wanted to learn more about how to help patients than just by looking at their tissue specimens. After he entered medical school, the patients he saw on almost every clinical rotation in his junior year suffered from both bodily disease and mental suffering. My friend told me he wanted to learn as much as he could in his role as a physician about how to best understand and help these people. He also had a great mentor who was very influential.”
“I’m sure working with the mentally ill has been difficult but has it also gratifying?”
“Yes, even though it has been a challenge, it has also been gratifying. I am grateful for the opportunity I have had to see them improve and benefit from treatments. Many are people who have not only had the misfortune to develop a mental illness but have also been stigmatized on this account. I have felt privileged to respect these people and to extend them a helping hand.
“Persons with mental illnesses are human beings who have a biological illness that affects the brain, thus, causing symptoms. I strongly feel that they need medical help just as someone with any other illness. Their illness is not related to anything that they did or did not do. Finding the most effective treatment for a patient with a mental illness has been as I said, a challenge, but I enjoy a challenge.”
“What are some of the things psychiatry offers?”
“That’s a good question and I’ve often thought about it. What I value the most is that it has given me the opportunity to develop deep and lasting relationships with people. In the course of treatment they reveal intimate details of their lives, and the relationship that develops is special and rewarding to the doctor as well as the patient. Of course, the psychiatrist deals with serious matters–especially suicide–and the practice tests him or her at times. It has shown me things about myself, some of them positive, others less so.”
“Tell me some more about your work.”
“Mine has been an academic career that has included research, teaching and service. I was fortunate to have the time, financial support and encouragement to engage in clinical research. An intellectual curiosity and scholarly tendency were traits I was able to apply to good effect.”
“It looks like the field of psychiatry was broad enough that you were able to find your niche.”
“Exactly. Everyone needs to find the right fit for themselves and to do this a person needs to consider his or her own weaknesses and strengths. It is also important to consider the philosophical approach a department takes to teaching and areas of knowledge. For example, what are the particular perspectives and characteristics that define the program. Along with this it is helpful to consider the ethos and values of a department and whether they are compatible with one’s own.
“Throughout my career, I worked on a succession of research projects that I found of great interest and that produced some useful findings. My teaching was, over the years, done mostly on the psychiatric consultation service.”
“Can you explain that?”
“It’s where I had the opportunity to instruct residents on a clinical service as they evaluated patients referred from other medical services. It was in this setting that I developed interviewing skills and experience that proved valuable for teaching. Here again, I found a niche and work that was stimulating, challenging and rewarding. The field of psychiatry is all of these.”
“Did you ever regret your choice to go into psychiatry?”
Doctor B stood and took a step over to a shelf. He pulled off two books, one thin and the other, less so. He handed them to me.
“Here, take a look at these. When you are done, you can return them to my secretary. They will give you an idea of what conditions were like in the early 1940’s. We’ve come a long way since then.”
“I know we just allotted twenty minutes for today but I still have some questions. Could we set up another meeting?”
“Sure. No problem. We can meet next week: same day and time.”
I thanked Dr. B and left. His phone rang as I closed the door behind me.
That night, I began reading the books and to say I was shocked is an understatement. Here was the state of psychiatry:
The year was 1942. The need for mental hospital personnel was overwhelming. The staffs of mental hospitals were decimated by the onset of World War II as hospital employees moved on to better paying jobs in the new war economy. Mental hospital staffs were notoriously ill paid. In 1941 Philadelphia State Hospital had 1,000 employees. By October 1942 only 200 remained. Designed for 2,500 patients, the hospital held 6,000. There was one attendant for 300 patients. The work was hard and long; most men logged at least 72 hours per week and sometimes as much as 100 hours. There were 100 to 175 patients on the violent ward with only one attendant responsible for their care. There was also a ward for incontinent patients where 350 people lived with almost no care at all, some naked, and all filthy and ill-fed.
Also in the early 1940’s, at Hudson River State Hospital an attempt was made to keep about 30 of the most destructive and incontinent patients in one of the small day rooms. Because of a lack of [staff] help it was impossible to keep the room clean, so most times feces and urine puddles were in evidence. Much clothing was destroyed and soiled so that much of the time the disturbed patients in the small day room were entirely naked. Only custodial care was given. Proper personal attention to any single patient or a small group of patients was out of the question.*
I didn’t find the situation much better in the other book which also documented conditions of psychiatric institutions in the United States in the early 1940’s:
With inadequate buildings, which are poorly planned and poorly equipped, mental patients are crowded together in such a way that adequate treatment and attention are impossible…Treatments that might cure sick minds are not used as often as they should be, and sick bodies, too, are often seriously neglected. Not even a minimum of food, clothing, shelter and cleanliness is always available to mental patients. And these unfortunate, pitiful human beings are still being locked up, beaten, punished, annoyed, offended—even killed—for no greater crime than simply becoming sick and showing the expected symptoms of their sickness.
Understaffing: State mental hospitals, on the average, had one doctor (many of them not psychiatrists) for every 251 patients, and one nurse or attendant to care for every 28 patients (for 3 shifts).
Poverty: State mental hospitals, on the average, operated on a budget of 82.1 cents per patient per day to buy all food, clothing and supplies, and to provide all medical care and personnel.
Based on innumerable surveys it was plainly evident that deplorable conditions existed generally throughout the country, in many different hospitals. In 1941, Edith M. Stern wrote: “…state [mental] hospitals are dotted with notations like ‘falling plaster,’ ‘toilet leaking through the ceiling from the floor above,’ ‘fire hazards,’ and ‘floors so rotten they are dangerous’…In too many states, still, the mentally ill are treated not like sick people but like criminals.”**
With umbrella dripping at my side, I once again dropped into the chair across from Dr. B’s desk. Normally he was a man of few words so I was glad I had been able to coax him out of his usual reserved state.
I cut to the chase.
“I have been reading those books you gave me. How tragic. The conditions in the first half of the 20th century and I’m sure, before, were awful. People with mental illnesses back then had no dignity whatsoever as human beings. How has it improved since then?”
“For one thing, the ratio of doctor/patients has improved significantly in psychiatric facilities. At our hospital for the adult psychiatry units, there are 5 attending staff doctors for 58 patients. The number of residents vary but there are usually 7-8 residents assigned to these patients. As far as the number of RNs and nursing assistants I can only speak for the one unit where I’ve had experience and there are 3 RNs and 3-4 nursing assistants on days and evenings for the 22 patients.
“In our modern times, psychiatric units are generally kept very clean and orderly. The units have a television, a computer with internet access, and telephones. The patients can shower in their own rooms with soap and shampoo, and they have clean towels. Many years ago, this was not the case. Now patients also have three balanced meals a day and they are not rushed through mealtimes.”
“There was once a time when the mentally ill were housed in rudimentary buildings without heat in the winter, and in the summer the buildings were suffocatingly hot with little or no ventilation,” I said. “People assumed that the ‘mad lunatics’ were not aware of their surroundings and didn’t know what was going on.”
“I strongly disagree with that view,” Dr. B said. “We now know that psychiatric patients are very much aware of their environment and what is going on around and to them. In fact, I have found that most of my own patients have proven to be exceptionally sensitive in nature. To say that psychiatric patients don’t know what is happening to them or around them is absolutely false.
“Two of this hospital’s adult psych units have a clothing storage area where clean clothes are kept for lower-income patients who may have little in the way of family support or who have traveled long distances to come to the hospital sometimes wearing only the shirt on their backs.”
“The books you loaned to me describe how mental institutions had little or no activity therapy or recreation back then,” I said. “But I know that now the psych units have plenty of books, magazines, crossword puzzles, and other items which will help to improve cognitive abilities and ward off boredom. The department also has activity therapists who regularly provide outings which are sometimes to other parts of the hospital or outdoors, game activities, and arts and crafts. These activities encourage socializing, team effort, and may help the patients focus on something outside of themselves. The arts and crafts are not only a creative outlet but can bring about therapeutic healing. In addition, the hospital’s Patients’ Library will deliver movie DVD’s, music CD’s and players, and radios. All these things are a welcome diversion from the stress of being ill and being on a busy psychiatric unit. I think there have been great gains in treating the psychiatric patient with respect and restoring their sense of dignity. They now have every opportunity to get well and to move forward with their lives.”
My eyes wandered to some things above Dr. B on the wall behind him.
“What are those plaques on the wall above you?” I asked.
Turning around in his seat he said, “Oh, those are some things I keep around as reminders.”
Doctor B stood, took the plaques from the wall and handed them to me. They were gold inscriptions on matching blocks of wood. The first read:
“While the ward physician is not directly responsible for the ward routine which is carried on by the nursing and attendant personnel, yet his attitude toward his patients will determine more than any other factor the attitude of the nursing personnel toward the patient.” ~George W. Morrow, M.D., Superintendent, Kankakee State Hospital, Illinois
And the second:
No thrill is comparable to the restoration of a disintegrating personality to a good level of behavior. ~anonymous psychiatric healthcare provider
“Those are very nice,” I said, handing the plaques back to Dr. B.
He put them down on his desk.
“It has been very meaningful for me to see a patient respond well to treatment and to be able to function in the capacity they want. In my work I have tried to use all available resources to get their symptoms under the best possible control so that they can live productive lives.”
“I’m struck by your dedication and compassion for the ill,” I said.
“Well, I believe that any sick human being deserves help and relief from suffering. My colleague, the one I mentioned earlier, told me once that the mentally ill deserve to be helped because their sorrow diminishes the light in every corner of society every day their sorrow is ignored or misunderstood. He said that, ironically, sometimes the way the psychiatric patients look at the world adds to his own perspective, giving it a little extra texture and enriching the color.”
“I’d say there are some physicians who see working with individuals with mental illness as more of a calling than a thought out decision,” I said. “Then there is the problem of stigma and false stereotypes. Just the other day someone said to me: “Oh, those psychiatrists! They have more mental problems than anybody else and they just go into the field to solve their own!”
“That stereotype has been around a long time! It’s almost a cliché,” said Dr. B. “You are exactly right—it is false, absolutely false! Quite the contrary, it really takes a level head and strong character to help people with mental illnesses. And I might add, maybe also a gutsy, adventurous type!”
I stirred in my chair and jotted down a note.
“Could you tell me more about what you have found meaningful in your work as a psychiatrist? What is it about psychiatry that has given you a sense of meaning and purpose?” I asked.
“I’d say that the most meaningful part of my work as a psychiatrist has been learning over and over again the importance of listening to peoples’ stories about themselves, the people they love or hate, and the world in which they live. They have taught me more than I have, them, and I treasure wisdom wherever I find it. A physician first needs to earn the patients’ trust. And, unfortunately, psychiatric patients don’t always receive the best medical treatment so I have tried to advocate for better care for them.”
“I hope you don’t mind a change of subject,” I said. “I’d like to know when, as a psychiatrist, you have felt frustrated or disappointed, what is it that kept you going? What set of principles have guided you? And what has given you strength and motivation to keep going forward?”
Doctor B became very still and looked thoughtful; then he responded in a low voice.
“I have to say that in the past I remember thinking: It is frustrating when a patient who is doing well chooses to terminate treatment as I know that they will not do as well in the future. If I feel that I have done the best that I can to help the person, I will still be frustrated but, at the same time, will know that I gave them the best I had to offer and this keeps me going.
“And, I have thought: Although it’s hard to remember sometimes that my life has a span, it’s recalling that I won’t live forever that brings me out of the blues that I occasionally experience. The funny thing is that I first learned this many decades ago from reading the books of a man nowadays dismissed as a fraud because he probably did pass off simple and beautiful fiction illustrating principles about how to live one’s life… as cultural anthropology. His protagonist, an Indian medicine man, always insisted that ‘Death is an advisor.’ I don’t have time to wallow in self-pity—for long anyway.”
Doctor B smiled.
“Throughout your career, have you felt that you have made a difference in the lives of your patients?” I asked. “If so, in what way?”
“The knowledge that I’ve helped patients (and learners) is one of the main reasons I keep trying to hone my skills as a listener and a learner myself. Over the years, my students have been learning from my example and so I have felt the need to stay sharp and be aware of what I say and do because I am a role model. I don’t fix people because by and large most of us aren’t broken. I frequently asked hospitalized patients who attempted and survived suicide to call me to let me know how they were doing after I did what I could to connect and assess their readiness to leave the hospital. Almost none of them called me and yet I never dropped this part of my assessment. It is rare that they did call me, but when they did, they let me know how important it was to them.
“I also feel that my care has provided patients with their best chance of success. I have seen many of my patients have an improvement in their social, education and/or occupational functioning.”
“What rewards, if any, have you experienced in your work with the mentally ill?” I asked.
“You know, some professors in the department have to leave their positions in academia (briefly to private practice) and as a clinical psychiatrist to realize what the greatest rewards of their work are. They miss teaching the next generation of doctors and listening to the terrible, funny, and fascinating stories of all the patients.
“Also, seeing very ill patients improve under my care, allowing them to develop better relationships with people around them, and increase their overall functioning is very rewarding. To have a patient or family members acknowledge that my care improved their lives has been fulfilling.”
I wrote something down, then continued.
“What are some insights you’ve gained in your work with the mentally ill?”
“Although I haven’t learned it nearly well enough yet, I believe I need to shut up and listen mostly. I’ve been a teacher and early on in my career, I talked way too much. Gradually I got over some of that and was finally able to hear not only the insights my patients have about their own travail but about the world in general. In sorrow there is wisdom.
“But, most importantly, I have found that there is only so much I as an individual can do. I’ve needed to rely on other mental health professionals to best help my patients. Patients need to want to get better and work on getting better. I have not made choices for patients, they’ve needed to be involved in decisions and I’ve needed to be okay with it if they chose something that I did not feel was best.”
“When set within the entire historical context of the field of psychiatry,” I said, “if you had the freedom and power to exact change in the field of psychiatry, in what direction would you lead the field in the area of research and treatments for the ill?”
“I would want to increase funding for research. There is much we do not know about the etiology of mental illnesses and our treatments are still inadequate. Hopefully, with increased research funding we can learn more about the causes of mental illnesses and improve treatments and patient outcomes.
“And we clearly need more funding for psychiatric services. There continues to be a shortage of mental health professionals and needed services. In certain areas of the state and country patients have to wait unacceptable lengths of time before they can be seen leading to increased suffering and at times mortality.
“I would add that the psychiatric professionals need to spend more time with the patients and get better life histories or biographies so they will not end up stereotyping or resort to generalizations. The more details you know about a person the more you are able to know how to help them. I would also try to spread accountability for all patients with both medical and psychiatric illness amongst all those who are stakeholders, including the internists and intensivists, nurses on general medical units, pharmacists, neuropsychologists, and psychiatrists. Using this approach, I would envision someday providing the highest quality medical care to patients. I would like that to be as commonplace as washing your hands.”
I made a final note as Dr. B glanced once again at his pager. Then checking out my watch I saw that I had just enough time to buy a cup of coffee at the kiosk before heading down to third floor for my next appointment.
“I guess I’ll go now. I can’t thank you enough for all your help. I’m very grateful that you took the time to meet with me,” I said, standing.
“It was my pleasure. I wish you the very best with your endeavors!” Dr. B answered from behind his desk.
Enter, ye, who have no hope?
Modern day psychiatric professionals have the opportunity and abilities to possibly change all that. Many years ago and up to the present time, I have received treatment from physicians who possessed the characteristics of empathy, compassion, and a desire to help others—all essential traits in medicine. I know in my own case if it weren’t for them, I wouldn’t be as functional as I am today.
*The CPS Story: An Illustrated History of Civilian Public Service
by Albert N. Keim Copyright 1990
** Out of Sight, Out of Mind
by Frank L.Wright, Jr. Copyright 1947 [Based on more than 2,000 eye-witness reports]