Ghetto psychiatric clinics treat and work with people who are particularly vulnerable to changes in milieu. As a result, the characteristics of the services offered, the nature of the clinical program, frequently undergoes change. For example, in the 1950s and early 1960s a large proportion of patients utilizing the Harlem Hospital Center Adult Psychiatric Clinic had spent much time in state hospitals and came to be hospitalized. With changes in duration of hospitalization and development of mental health centers, patients rarely come to be hospitalized but for "treatment."
Changes in the social system reflected in changes in welfare and employment also made for changes in the nautre of patient population and the services expected. In what follows we will attempt to describe our clinic as it is today, that is, where we are in the process of undergoing change as we move to improve the quality of our services.
A major factor in the pathology of our community is related to drug addiction. The problem is so massive that it is handled by separate units of the hospital and by other units in the community. These vary as the needs of the addict population change and have included inpatient, residential, and ambulatory units.
Before discussing the rationale for our system, I think a brief description of what happens in the procedures of our clinic will be helpful.
The patient comes into the emergency room or the clinic, is first registered and then screened by a paraprofessional on our staff or by one of the college students who are part of the intake team of that day. (These students are on field assignment from their schools and usually consist of students who have grown up in the ghetto and are seniors in sociology.) The patient is then described to a clinician (psychiatrist, social worker or psycologist) in charge of that team, who decides which clinician in the team will see the patient immediately. A diagnosis and socio-psychodynamic evaluation and treatment plan are determined. Unless the patient requires a treatment not conducted by members of that team, responsibility for the conduct of that patient's treatment rests with the members of that team. There are five teams, one for each day of the week. In all cases, a psychiatrist of the team is expected to see the patient as part of the intake procedure.
Extra-team facilities for the clinic include a vestibule group, several ongoing process groups in which medication may be administered, several "medication groups" which meet primarily to dispense medication on a monthly basis, and a long-term system of medication and supportive therapy involving individual visits of 20 minutes with variable intervals between visits. Long-term psychotherapy is available to a limited number of patients.
Therefore, the majority of new patients are involved in brief psychotherapy, crisis intervention or intervention with the milieu. A small number of patients are hospitalized at intake.
One way of seeing this would be a dynamic one. That is to say that the high risk of object loss at vulnerable ages, the reality of exposure to violence from an early age on, the impairments to self-esteem related to rejection by the majority culture and the crippling effects of poverty lead to fundamental difficulties in separation-individuation, major problems with passivity and dependency, rigidity of defenses in relationship particularly to aggression, and major difficulties around selfesteem. Add to this the necessity for surviving in an environment where survival is not guaranteed, and one can see the difficulties in performing the tasks of development which have confronted our patients. It is to the credit of the people in our community that so few emerge seriously disturbed. Paradoxically what we observe with our patient population is the great flexibility of adaptation to the milieu together with rigidity of the psychic defenses. One should not be mislead into assuming that our patients are without ego strengths. The mere fact of survival attests to this and in the community as a whole there is a great deal of creativity and most people experience deep and satisfying relationships.
In this context, a developmental approach dominates our thinking and our arriving at current procedures.
Ideally, what is required is relief of acute symptoms, aid in dealing with a social milieu which presents unconscionable burdens to the disadvantaged, and a long-term psychotherapeutic relationship which would enable patients to cope more effectively with the relationships in which they ordinarily fail. In such a program, effective crisis psychotherapy, intelligent use of medication, and appropriate intervention with social agencies are within the means of our clinic. Long-term medication is also available, with the possibility that patients who are in such programs may have access to the crisis therapy of intervention programs when crises develop. We have found that active process groups can be utilized by many of our patients who might otherwise be treated in a desultory fashion. Long-term individual psychotherapy is available to a limited number of patients.
The problem we face, and which I suspect is one we share with other inner city hospital clinics, is that of desultory treatment. It is our experience that great dangers reside in categorizing patients in such a way that therapeutic "unambition" is encouraged. We have seen that patients who are referred to as "chronic schizophrenics," "medication patients," "burned out schizophrenics," may get short shrift from clinic staff. It often requires a major crisis and an institution of more intensive treatment before such staff becomes aware of the potentials for strength and growth which these patients possess.
This may reflect a failure of our diagnostic categories and the failure to recognize the specific relevance of a malignant social milieu which has confronted these patients during their developmental periods. For example, patients who grow up in the ghetto are confronted in reality with extreme exposure to violence both towards themselves and to others. The distortions in development which result lead to characteristic difficulties in management of their own feelings and their relationships to others. The tendency toward effective isolation is thus very prevalent. Failure of the more advanced defenses in the face of adaptational stress makes regression to primitive defenses more frequent, but the significance of the appearance of such defenses in the form of symptoms such as hallucinations is quite different in such a patient than it is in others in which the family and social milieu during development were more optimal. Herein lies the importance of an enthusiastic and optimistic but sophisticated clinic staff. Our staff has learned that dementia praecox is not synonymous with chronic psychosis; that anti-social behavior perhaps is often related to severe depression, or to be more exact, that it substitutes for depression.
Implicitly derived from these assumptions is the following program: That a patient coming to us for help be engaged quickly in a treatment program tailored to what is perceived as his needs, both by patient and clinician. The clinician's task initially is to evaluate the meaning of the current crisis in terms that relate the crisis to the patient's underlying conflicts. This requires development of skills as an ongoing responsibility of the clinician as part of the service to the patient. Whenever possible the objective is rapid relief of symptomatology and, when appropriate, discharge of the patient with an open-ended invitation to return.
The importance of clinician factors in the success of this program is obvious, and we prefer to assume responsibility for treatment failure than to ascribe it to the patient's lack of motivation. This does not belie our recognition that we are often used manipulatively or that we are the means to help many patients.
Implied in what I am saying is a high regard for the difficulties presented to the patient by reality experiences.* Much investment is made in dealing with reality problems. Programs like this are now quite common.
Rarely, however, does a clinic start out with a clean slate. This program has been established in a clinic in which the majority of staff time had been devoted to long-term patients, most of whom were receiving medication either individually or in groups. With this large population, we have come to examine their potential for change. Approximately one-half of the patients who were seen in "medication groups" still receive medication, but the groups now involve therapeutic process, and these patients have shown capacity to develop more flexible adaptive techniques in these programs. Many of the patients considered perpetual medication patients have shown an ability to change as demonstrated by increased success in achieving social goals as well as by increasing subjective self-esteem when worked with more intensively.
It would be nice if the clinics existed in a vacuum or at least in a milieu in which the agenda of the clinic, of the department, of the hospital and of the community were all synchronized. This has not been the case here nor is it that of any municipal medical center I know of. Thus, while these changes have been going on, intake of the patients has increased, and changes in welfare procedures and in employment have created more stress for our community. Nevertheless, the staff of the clinic, slightly augmented by new personnel, has responded as they have in the past with greater output of work both in quantity and quality.
This has made possible the integration of the emergency room with the clinic so that now we exist as a combined emergency service, walk-in clinic and formal appointment clinic. The emergency room had been previously functioning as a separate unit with a separate psychiatrist in the classical model. In any inner city hospital, the emergency room must be recognized as being at least as important as any other facility within the institution. Patients at such hospitals usually seek help when they are already seriously ill. Preventive services are generally meager whether they be in the form of neighborhood health clinics or neighborhood general practitioners. Added to this is the attitude of most patients in our community that one does not go to a hospital early since to do so may be a sign of "emotional weakness." This is true of all services but is particularly true of psychiatric patients who present with severe illness rather than neurotic difficulties. Many patients are brought to the psychiatric emergency room by relatives or the authorities in acute stages of decompensation, often after performing a bizarre act. Such a patient is entitled to receive compassion and understanding, not simply administrative management.
As is the case with such clinics, we are chronically disturbed by an inadequate system of self-evaluation. We can count the number of patients we see, but it is difficult for us to have more than a clinical impression of the impact of this experience on our clients. Hence, information which could lead to self-correcting measures is lacking. I can only suggest that other clinics seeking to learn from our experience build evaluative techniques which would be directed toward evaluation of the quality of outcome rather than for cost accounting purposes.
Two final notes: As mentioned above, much of the clinic work is performed by paraprofessional and nonprofessional staff under the direction of professionals (two-thirds professional, one-third paraprofessional). Both groups have learned from each other, but as a whole this hierarchial system has worked well for us. Secondly, we have found constant vigilance required in order to see that staff is always alert to the possibility of use of other modalities ol treatment and other resources available either in the department or in the community. There appears to be a basic tendency to ignore the usefulness of medication for psychotherapy patients and the usefulness of inpatient experiences for patients treated in an ambulatory setting. Unless one is alert to the importance of rehabilitation and occupational services, many patients are deprived of experiences which increase self-esteem and a sense of confidence. We are fortunate at Harlem in having such services available to us, and we are constantly working with them to the patient's benefit.