Cathy R. Schen, MD

Voices of Hope for Mental Illness: Not Against, With

by Jackie Goldstein; Charlston, SC: CreateSpace Independent Publishing Platform, 2015
233 pages • $14.99 (softcover)[[{"type":"media","view_mode":"media_crop","fid":"51553","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_8596003269665","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6518","media_crop_rotate":"0","media_crop_scale_h":"227","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; height: 189px; width: 125px; float: right;","title":" ","typeof":"foaf:Image"}}]]

 champions community recovery programs for persons with severe mental illness. The author, a former psychology professor at Samford University in Birmingham, Alabama, tells the stories of exemplary community treatment programs. She begins by describing one such program in Geel, Belgium, founded during the Middle Ages and active today.

She then introduces the reader to 15 community programs across the US, including the Village, run by Mark Ragins; Broadway Community Housing, founded by Ellen Baxter; and Gould Farm, established in 1913 and located in Monterey, Massachusetts. These programs focus on healing through human relationships, meaningful work, and a sense of community. Most are affordable to all, because Goldstein recognizes the connection between mental illness, poverty, and homelessness.

 I was, like Goldstein, struck by the integration of its “guests” with the staff and their families who worked there. Living and working alongside people with mental illness represents the kind of community integration that Goldstein searches for and believes essential to providing a healthy environment that reduces stigma and promotes recovery.

Mental illness is part of our human existence, she suggests, and we must help communities “live with the fact, not fear, of mental illness in their midst.” While hospitals, psychopharmacology, and therapy are important and often necessary, Goldstein finds evidence that these are not enough to support a person with mental illness to live a meaningful life.

We must help communities “live with the fact, not fear, of mental illness in their midst.

While a psychiatry resident, I valued Courtenay Harding, Joseph Zubin, and John Strauss’s important paper on schizophrenia outcomes.

 The authors reviewed the longitudinal course of persons with schizophrenia and looked at clinical biases that led to falsely low prognoses of outcome. They examined iatrogenic factors and concluded, “The substantial list of psychosocial artifacts that create chronicity, over and above illness factors, has contributed a large segment of patients for whom chronicity could have been avoided.”

The book supports the activist mission of Harding and colleagues.

 As a humanist, Goldstein wrote her book because parents and their adult children with schizophrenia struggled to find the resources and support they need. Hers is a book of grassroots endeavors and the individuals who passionately, and often at great sacrifice, work to build community-based programs for people with psychiatric illnesses.

One compelling chapter in the book centers on the work of Ellen Baxter, founder of Broadway Housing Communities in New York City. As an undergraduate at Bowdoin College, Baxter feigned symptoms of mental illness to get herself admitted to the Augusta State Hospital to investigate conditions there. Baxter later spent a year in Geel, Belgium, on a Watson fellowship and returned to the US determined to develop community programs inspired by the family care model she discovered in Geel. This model of psychiatric care in a family home contrasted starkly with the inhumane treatment she experienced first-hand in the Maine state mental institution.

Goldstein also describes the work of psychiatrist Mark Ragins, who in 1990 headed up the Village in Long Beach, California, a support service for community integration and member recovery. Ragins was inspired by Boston University psychiatrist William Anthony who spearheaded the recovery movement for mental illness. Ragins found that treating the whole person and providing integrated services for people with severe mental illness-many of whom also struggle with substance abuse and homelessness-could turn their lives around.

Goldstein concludes her book with the story of her own effort to start a community program. She helped found a local Compeer agency. Compeer was established in Rochester, New York, first as a program called “Adopt-a-Patient” that matched community members with persons with mental illness leaving state institutions from 1970 to 1986. Its name was changed to “Compeer” to emphasize the peer aspect of the relationship of a person with mental illness and community-matched “friend.”

Compeer agencies sprouted up throughout the country. When Goldstein invited a small group of interested people to meet in her home and brainstorm the opening of a local chapter of Compeer, she did not anticipate how much work and how many obstacles the group would encounter. She recounts the efforts of applying for non-profit status, establishing a board, and getting funding and donations. Her agency lasted for 10 years before funding, staffing, and recruitment challenges led to its closing.

,” describes a patient with schizophrenia who asks him, “What do you want from me? Just tell me what you want and I’ll do it.”

 Ragins thinks for a moment and replies, “I want you to hope: I want you to hope there can be more to life than staying out of the hospital. I want you to hope that you can use medication to relieve some of your suffering. I want you to hope that your self hasn’t been swallowed up by your illness and you can recover the things that make you special.”

The expectation of parity has not been met in this country. Hope for parity was born with the passage, in 2008, of the Mental Health Parity and Addiction Equity Act. This hope grew when the Patient Protection and Affordable Care Act was passed in 2010. Despite these 2 pieces of legislation, federal funding for mental health care has experienced big cuts. The 2015

 Institute of Medicine Psychosocial Report

 documented the large gap that exists between what is known to be effective psychosocial treatments for mental illness and what is currently practiced.

 Their report calls for establishing standards for psychosocial interventions.

The NIMH Recovery After an Initial Schizophrenia Episode

, launched in 2008, has now reported that recovery-oriented treatment programs that include psychosocial supports improve outcome in persons with a first episode psychotic illness.

 As Goldstein so well demonstrates, we need legislation, federal funding, and individuals who take action. We also need research that provides evidence of the importance of building comprehensive and integrated systems of mental health care.

 is an important resource for families and their loved ones suffering from severe mental illness; for people looking for inspiration and guidance to establish community programs; and for mental health professionals who can benefit from reminders to address the basic human needs of their patients.

This article was originally posted on 9/7/2016 and has since been updated.

Dr Schen is Assistant Clinical Professor in the department of psychiatry at Harvard Medical School, Cambridge, Mass. She reports that she has no conflicts of interest concerning the subject matter of this article.

http://www.psychiatrictimes.com/depression/farming-and-doctoring

 Harding CM, Zubin J, Strauss JS. Chronicity in schizophrenia: fact, partial fact, or artifact? 

Exploring Recovery: The Collected Village Writings of Mark Ragins

http://static1.1.sqspcdn.com/static/f/1084149/15458164/1323114583167/03HopeandSchizophrenia.pdf

 Institute of Medicine. Psychosocial Interventions for Mental and Substance Use Disorders. July 2015. 

www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2015/Psychosocial-Report-in-Brief.pdf

 National Institute of Mental Health. Recovery After an Initial Schizophrenia Episode (RAISE). 

http://www.nimh.nih.gov/health/topics/schizophrenia/raise/index.shtml

Articles

Making the Case for Community-Based Programs

We psychiatrists talk about “seeing” patients, but the seeing involves primarily an inward gaze-at least in psychotherapy-along the parameters of listening, empathy, and association. That may be one reason why, after many years seeing patients, I began to work on a farm. I needed to learn to see outward again, the way being in nature demands, to see instead of think, to be instead of analyze. I needed to be physical at work, in the way farming requires. I left my office and joined the crew one day a week at 

 in Lincoln, Massachusetts. Every Tuesday at 7:30 AM, we gathered in the barn to divide up the morning tasks and then paired off for the harvest.

If on an autumn morning, you walk down a field of collard greens to find each broad leaf delicately dipped in a glaze of ice, row upon row, your eyes open. When your task is to harvest 84 bunches of those leaves, 15 leaves to a bunch, you become immersed in the smell of earth, in the snap of each stem, in the fresh, clean flavor as you break off a taste. Periodically, you stand up and shift your gaze from its focused task to the horizon, to watch a hawk circle overhead, to see the mountain in the distance that separates sky from field. The day heats up, the ice melts, your back aches, and you feel you 

 sky, that hawk, that veined palm of collard.

Scandinavia and the Netherlands have “care farms” that 

 for troubled youth, depressed adults, the elderly, and others in need of healing.

 In the US, the oldest therapeutic farm is 

, founded in 1913 by William Gould and his wife, Agnes. I visited Gould Farm to learn more about the restorative aspects of farming. The Goulds purchased 650 acres of undeveloped land in the rural village of Monterey, Massachusetts, to found a farming community that would promote emotional healing through hard work on the land and service to others. The Goulds were inspired by the work of William Tuke, a Quaker merchant from Liverpool, England, who in 1792 developed the first retreat asylum, and by Dorothea Dix, who went to England in 1836 to recuperate from symptoms of depression and discovered Tuke’s ideas. When Dix returned to the US, she brought back these ideas and used them to champion improved conditions for people with mental illness in this country.

The work program supervisor, a lean and wiry man wearing a soft-brimmed hat, took me on a tour of Gould Farm. We walked past fields and barns, while he told me about the farm’s philosophy. Patients who come to stay at Gould Farm are called “guests” and live in several residences on the farm. Staff members live here with their families also, in order to foster a tight-knit community of people living and working together. “I hope you don’t mind that I don’t introduce you as a doctor,” he said, calling me “Cathy” to staff and guests. I considered that the outward similarity in dress of guest and staff and their shared work came from a philosophical stance of equality and an effort to overcome the stigma of mental illness.

The relaxed and easygoing atmosphere of Gould Farm reminded me of walking with patients on the grounds of Metropolitan State Hospital, in Belmont, Massachusetts, when I was a psychiatry resident. The importance of making a connection with patients who often feel deeply humiliated by their illness was one of the first lessons I learned as a psychiatrist in training. One of my patients insisted that she was a psychiatrist working the night shift at Massachusetts General Hospital. The reason she was so tired during our morning meetings, she explained, was because she had been up all night treating patients at this prestigious Boston hospital. The medical director of the hospital helped me understand my patient’s delusion. “It’s like this,” he commented, reaching over his desk to pick up a drawing made by one of his patients. The drawing showed a tall stool next to a very small footstool. “You are up here,” he gestured to the tall stool in the picture. “And your patient feels like she’s down there,” he said, pointing to the little footstool. My patient’s imaginary work was intended to raise her self-esteem and place her on a more equal footing with her doctor.

One difference between Metropolitan State Hospital and Gould Farm is that patients have real and tangible work to do at the latter institution. We visited the industrial kitchen to meet the head chef, a rotund, energetic, and direct man. Right away he asked me why I had come to visit. I told him that I was a psychiatrist interested in therapeutic farming.

His face lit up. He gave me an articulate vision of the importance of work. “Guests are motivated by making a meaningful contribution to the community and knowing that they are accountable,” he told me. “If someone doesn’t show up for work, it affects others. The bread isn’t made; the cows aren’t milked. Everyone can see the results of their labors. And in return, guests get something back. Most people who come here are young and for various reasons missed out on those crucial years in their late teens and early 20s, when young people get “practice” working-summer jobs, that kind of thing. So here, they get that practice. We give them that. Also, they get to learn in a hands-on way what kinds of accommodations they will need in the regular working world. We can accommodate them here. But out there it’s different. So they learn about themselves and know that, for example, when their boss tells them what they need to do, they can say to their boss something like, ‘It would help me follow through on these instructions if you could put them in writing.’ I think our guests find that they get back a lot.”

I asked the chef if guests were paid for their work here. “No,” he answered. “The work is the therapy. Sometimes we 

 have guests start to tell us, ‘Now wait a minute. I’m working really hard here and I could earn real money doing this as a paying job.’ If someone is saying that, it indicates to us that this person may be getting ready to take the next step and transition to the outside world. We are always looking to challenge our guests while at the same time offering them a place for recovery. We have our farm stand out on Route 23 that serves the public. That’s no easy job, let me tell you, and so guests who are getting ready to leave Gould Farm often work there, interfacing with the public, as they get ready to leave us.”

The effort on the part of Gould Farm to balance healing and sanctuary with challenge and rehabilitation is not easy to achieve. A community can tip too far into a utopia isolated and cut off from the “real world.” Just as quickly, a community can develop agendas like improving the profitability of the farm or conducting clinical research that puts a strain on its therapeutic mission.

The executive director of Gould Farm at the time of my visit told me how he and the staff were working to make changes that keep up with the demands of the modern world while preserving a feeling of sanctuary. Dressed in a lavender oxford shirt and khaki pants, he stood out from the rest of us in his business attire. He had had a successful career in the corporate world before coming here. He was taking a careful look at the therapeutic components of the farm. “Guests and their family members come these days expecting more than just a therapeutic work environment,” he told me. “They are looking for psychotherapy and psychopharmacology as part of the treatment. Gould Farm now offers these therapeutic modalities. It initiated research on patient satisfaction and outcome. You should talk with Laurie Heatherington,” he said. “She is spearheading the research.”

Respecting the privacy of the guests at Gould Farm was essential, which meant that I did not talk with any patients during my visit. I hoped that Dr Heatherington, Professor of Psychology at Williams College in Williamstown, Massachusetts, might give me a sense of the experience of the patients and whether they thought farming played a role in their recovery. Petite and freckled, with red-brown hair framing a heart-shaped face, Laurie told me she first visited Gould Farm 15 years ago. Laurie had grown up in farming country in Indiana and had gotten to know patients with serious mental illness as a teenager when she started working at the state psychiatric hospital nearby. This experience was pivotal in her career development. She became a psychologist passionate about helping people with chronic mental illness. A large photograph of 

 greets visitors to her office. This hospital was a field trip destination for her students until it closed in the 1990s. After she visited Gould Farm, she headed up its long-term outcome study.

It is difficult for clinical research to measure objective changes in symptoms and overall function while also capturing qualitative subjective experience. 

 demonstrated improvement in symptoms and supported the role of psychosocial rehabilitation. But it did not reveal-and was not intended to study-whether there was something particular about 

that contributed to the positive change seen in guests. Would a sheltered workshop be a qualitatively different experience? What about a computer training program? Was there something about working the land, growing and harvesting the food you eat, that promoted healing for some people in ways that other modalities wouldn’t? Does working on a farm create community and friends in a way that other kinds of work do not?

Working on a therapeutic farm for returning veterans in California, a Gulf War veteran at 

 “It’s a different feeling of accomplishment when you’re watching something grow with life out of your own hands and not die from your trigger finger.”

I don’t have the answer to these questions. I can draw from my own experience, however. When I come home from a day working at my local farm, I am exhausted and hungry, but I also feel physically restored and mentally content. I’ve just pulled 270 edamame plants with a couple of crew members. I’ve tugged and hacked away at 90 celeriac roots and piled them into the truck in the southwest field-on my own at first, then joined by a member doing her required work hours. The labor is hard, but I enjoy it. It is a “farming high.” A hundred years ago, we were a nation of people trying to find ways to escape the kind of relentless, backbreaking labor that farming demands. Farming is physically rigorous, often tedious, and monotonous. It is sweaty and dirty. But it also leaves indelible impressions that are like childhood memories, of the leaves rustling overhead as you wash the lettuce heads in the basin, of white buckets filled with red tomatoes creaking in each hand, of rows of magenta amaranth, of taking off your shoes and going barefoot in the fragrant earth.

 Iancu SC, Zweekhorst MB, Veltman DJ, et al. Mental health recovery on care farms and day centres: a qualitative comparative study of users’ perspectives. 

http://www.ncbi.nlm.nih.gov/pubmed/23802137

Voice for the Mad: The Life of Dorothea Dix

 Heatherington L, Bonner B, Linsley J, Loder C. Measuring the milieu: outcomes of a unique residential treatment for major mental illness. Poster presented at the 2011 North American Society for Psychotherapy Research Conference, Banff, Canada. Abstract: 

http://www.psychotherapyresearch.org/associations/6344/files/events/banff/naspr2011_boa.pdf

. Accessed July 29, 2013.
4. Brett B. Veterans Administration pulls funding from therapeutic farm program. 

http://www.huffingtonpost.com/brigid-brett/veterans-administration-p_b_531976.html

Therapeutic farms that offer psychotherapy and psychopharmacology give patients an opportunity to learn about themselves.

Cathy R. Schen, MD

Articles

Making the Case for Community-Based Programs

Farming and Doctoring