Reflections of a Cynical Clinical Psychologist

Max Heinrich

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9780367336400
• eBook ISBN: 9781000026436
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Presenting first-hand accounts from the 'front line', Reflections of a Cynical Clinical Psychologist provides the reader with a participant experience of the daily ups and downs of a US mental health professional. Vividly describing actual clinical events ranging from tragic to comedic, this book calls attention to the human realities of the system's dysfunction.

Illustrated throughout by anecdotes based on the author's 50 years of experience and observations in the field, the book focuses on 'the system' as the problem, identifying the limitations in current mental health policy with the emphasis misplaced onto profit rather than optimal patient care. These anecdotes are organized by themes such as the harsh treatment of patients by staff; loss in the workplace; anomalous staff behavior; problems with the legal system; and clinically unexpected and bizarre episodes.

The value of humor as a stress reducer, social leveler and a means to make incisive points is highlighted throughout. This is important reading for mental health professionals, policy makers and those interested in humanizing social policy.

Part I

Institutions

Chapter 1

Graduate school

Prologue to hypocrisy

Graduate school was my first introduction to the arbitrary treatment of the mentally ill. I recall a rather hefty, bull-necked professor of psychology who frequently punctuated his lectures with pejorative remarks about psychiatry and clinical psychology. Referring to these disciplines as “fraudulent”, he would rail on and on, continually deriding the clinically applied disciplines of the behavioral sciences.

One fall afternoon this professor walked into class and taught what seemed to be all of the rest of the semester’s work. Then he walked out without another word.

A day or so later, while sitting in the student union cafeteria, I chanced upon a newspaper article of local interest: A woman had been caught speeding on a highway near campus. She was pulled over by the police but when asked for her license, she immediately sped off. The police followed in hot pursuit. The driver was clocked at speeds well over 100 miles per hour and was finally apprehended at a roadblock in town. The police ordered the driver out of the car whereupon out stepped my statistics professor wearing a dress and wig. He was jailed overnight and released on the stipulation that he obtain psychiatric treatment. Despite my attempts, as well as those of other graduate students, to point out that having what was then considered a psychiatric disorder should not automatically be a basis for dismissal from a faculty position, especially in the psychology department, our professor was nevertheless forced to resign from the university. Apparently he was not alone within the department in his contempt for the value of psychotherapeutic treatment.

Sadly this professor was not the last mental health professional I would witness being summarily terminated as a result of a behavioral disorder. This was prologue to the hypocrisy I would eventually come to recognize as pervasive in the mental health field.

Clinical encounters

In the 1960s, people with mild intellectual impairment were technically (and unsympathetically) dismissed as “Morons”. Moderately impaired individuals were labeled Imbeciles, and those with severe mental retardation were classified as Idiots. These labels were all based on specific standardized IQ ranges. Perhaps this moralistically tinged nomenclature was a reflection of the poor technical understanding of these disorders at that time.

One of my assignments as a graduate student was to travel to what was then called a state training school where the ‘mentally retarded’ were tucked away from public view. My task was to administer the legally required annual routine intelligence tests to confirm the inmates’ low IQ scores for the purpose of justifying their continued, essentially involuntary inpatient status. A more accurate designation for this institution might have been state ‘maintenance’ school as the residents remained there indefinitely and, despite the reference to ‘training’, none was evident.

On one ward there were rooms filled with net-covered cribs, essentially cages, inside of which were human beings of all sizes, with all manner of deformities. Most had abnormally small or large heads, and fixed stares and were lying in more or less frozen positions. On the ceiling was a flashing, revolving yellow light and when I asked a nurse what that was, her answer was very unsettling: “Oh, that’s their entertainment!”

On another ward I examined a young woman in her 20s. Her test results indicated she was of low average intelligence with many behaviors more consistent with a diagnosis of schizophrenia than mental retardation. When I presented my findings to my supervisor, along with the suggestion that she be appropriately transferred, he gently told me that given the comparative quality of life in her current setting versus the state hospital to which she would inevitably be sent, it was probably in her best interest to leave her where she was. This admired and trusted supervisor was making the most humane judgment he could in the face of an overall inhumane system.

An embarrassing incident occurred when a group of us were traveling by bus to this institution. During the ride an intern colleague and I had made several mental retardation ‘jokes’, to the apparent delight of our fellow students and, as we pulled up to the parking area, we were all smiles. As we began to disembark, however, one of the women in our party ever so casually, but perhaps with an edge of hostility, mentioned that while she was here she would be visiting her sister, a resident. In retrospect I realized she had not been laughing at our ‘jokes’.

A hard lesson was thus learned about sensitivity concerning this very real kind of tragedy and its impact on the family, as well as the need to practice better discretion around those you don’t know well.

Chapter 2

The city hospital

Training wreck

Any remaining expectation of humanistic or even rational treatment for defenseless human beings, in this case psychiatric patients, was swept away by the various training experiences I was now being paid for.

In the city hospital where I interned, as well as the other settings in which my training took place, most of the patients came from impoverished and disorganized communities. They languished on locked wards for varying periods of time, dressed only in standard issue hospital gowns of uniform pattern and color, open at the back. The physicians who treated them were well dressed and preoccupied primarily with going on to (or were already attending) psychoanalytic institutes so eventually they could treat wealthy individuals in their private practices. The administration of maximal amounts of medication along with minimal amounts of humanity was their apparent treatment philosophy.

The doors to these wards were kept locked and the keys were of substantial size and weight. The furniture was heavy Mission Oak, the kind only the strongest patients could throw at you. The only eating utensils provided were spoons. And, as if patients were not humiliated enough by the admission and evaluation procedures, their belts and shoelaces were immediately confiscated so they would not be able to hang themselves, never mind that sheets and towels were always handy for this method of escape. Is it really possible to hang yourself with shoelaces? (“Breakaway” shoelaces and “breakaway belts”, possibly even edible, providing late night snacks when the staff was asleep, might become a big seller if anyone cared to do the research, development and subsequent marketing. The sales pitch could be: “Better laced than never!”)

The chief psychologist at this city hospital, a particularly brilliant man, was rumored to have such a clear view of reality that he was chronically depressed as a result. He would often conduct interviews with patients, usually ones with severe diagnoses such as schizophrenia, in the presence of the entire psychology department, ostensibly for teaching purposes. Invariably he would conclude these examinations with a series of increasingly complex proverbs, the patients struggling to discern the meaning while growing more and more uncomfortable and confounded by the sheer abstruseness of these aphorisms. An example: If you’re going to sup with the devil, bring a long spoon.

After the patients were taken away, this chief would turn to us and declare that the progressive bafflement evidenced by the patients was consistent with a thought disorder, one associated with their particular psychiatric diagnosis. The staff kept it secret from the chief that often these same proverbs baffled us!

What follows are three scenarios (true enough) to capture the overall anomic essence of the city hospital in the early 1960s.

Scene 1 – A bare hospital room containing four beds, each with its own dented, sharp edged metal bedside stand painted white. The enameled beds with their iron pipe-like foot- and headboards are also painted white. The sheets and blankets are white. The plaster walls are covered with thick layers of fissured white paint. The nurses, doctors and orderlies all wear white. The complexions of the bedded patients range from pale to very pale. (The hospital staff doesn’t look much better.) The surfaces are hard. Noises are distant and muffled. Light, filtered by uneven layers of dust and grime, comes from two sources: through large un-curtained windows and also radiating from globes suspended from the high ceilings, casting unpleasant shadows. Every surface, animate and inanimate, reflects this light. It is as if all color and sound have been drained from the world. The patients lie still, flat on their backs, their breathing barely discernible. Their only possible entertainment, rarely interrupted by hospital staff or procedures, is the view of endless designs in the myriad cracks and shadows on the walls and ceiling. There are no TV’s, no radios, few visitors, no volunteers bringing good cheer, companionship, books or magazines. This was a charity ward for the elderly mentally ill at a time when they were referred to as the ‘aged’. It was truly an ancient city hospital, often the final resting place before the final resting place.

One patient, with a great view of the ceiling, is lying especially still in his bed. An orderly, at that time a position requiring very little training, enters the room and immediately recognizes the patient is dead because there are two untouched glasses of orange juice on his bedside table! One can imagine the doctor coming in to pronounce him “unjuiced”!

Scene 2 – An escort has been called to the emergency department where a nurse orders him to transport a critically ill patient to the Intensive Care Unit (ICU). The escort wheels the patient on a gurney toward the elevator and, after the requisite patience-challenging wait, the elevator eventually comes and they enter. The doors close, the floor button is pushed, and the patient dies. Despite the apparent death, the escort delivers the body to the ICU where a nurse takes one look and asks the escort, “Where do you think you’re going with ‘that’?” The escort makes an attempt to explain but as he opens his mouth, the nurse curtly orders him out of the ICU stating, “We don’t accept dead bodies here!” The escort heads back to the emergency department to return the body. When he greets the original nurse with the news, without even verifying the accuracy of the escort’s statement, the nurse immediately orders him out of the ER with the body. “He was alive when he left here, and that’s all I know,” she says. Intimidated by her hyper-authority, the escort retreats with the body.

A few days later a security guard finds it on a sun porch.

Scene 3 – The hospital pharmacy, long lines of people waiting to have prescriptions filled. There is no separate window for staff at this institution; they just cut right to the front. On this day, however, no pharmacist is behind the window. Assuming he or she has gone to retrieve a medication for the next person in line, an intern waits, five minutes, ten minutes, before finally stepping over to the other window and making the obvious inquiry as to the whereabouts of the first pharmacist. Clarification is finally achieved: “Oh, he went to lunch.” No announcement, no sign. No problem. Just many ‘insignificant’ people left standing there for the entirety of the pharmacist’s lunch hour.

Case conferences

The conduct of interdisciplinary case conferences on one of the locked inpatient units provides insight into the dehumanizing ambience in the hospital. Picture the staff, seated around three sides of a rectangular oak table leaving the fourth side empty. Wearing the typical hospital gown, open at the back (thus exposing his or her posterior), the patient is then ushered in and told to stand at the vacant end. A series of very personal questions is asked by one of the doctors, along with comments from the staff, almost as if the intent is to humiliate the patient: “So, Mr. S, are you still involved with those farm animals?” Okay, an exaggeration, after all we were in the city!

Prior to these case conferences, the psychology interns were allotted a mere 15 minutes during which to examine the patient and collect sufficient information to present a preliminary psychological overview. A psychological assessment generally takes a few hours before a reasonably accurate diagnostic impression can be arrived at yet, oddly enough given the intense focus required during these seemingly surreal exams, more often than not the necessary complete follow-up examination confirmed we had indeed captured the essence of the patient’s dysfunctional behavior in those few minutes. Certainly the value of paying very close attention was driven home and, in this instance, at very high speed.

Clinical rotations

During my internship, I rotated through five different services, each experience lasting ten weeks. I always worked under supervision yet it was clear there would be heavy reliance on my assessments and recommendations. For example, on a medical unit I evaluated a male patient in his early 40s with a diagnosis of severe stomach ulceration. What distinguished this patient from the usual diagnostic referrals I saw was the utterly profound impact my clinical judgment would have: If I determined this patient could follow a very strict and somewhat complicated diet, he would avoid having to undergo major abdominal surgery for removal of his stomach. From their appraisal of the patient’s mental status, the surgeons suspected he lacked sufficient intelligence to sustain compliance with the more conservative dietary treatment approach, but their ultimate decision would be based on my definitive recommendation after examination. Dutifully I conducted the exam, carefully evaluated the data and prudently made the painful judgment. The patient’s stomach was removed. This experience amplified the reality of my work.

During my rotation to the Prison Ward, what today would be called the Forensic Unit, the first patient I saw was a man who had killed another man for making a homosexual pass at him in a public bathroom. My task, under supervision, was to determine if this prisoner could comprehend the nature of the charge against him and assist counsel in his defense. If he could not, as turned out to be the case, he would be transferred to the state hospital for the criminally insane for ‘treatment’ until he was capable of defending himself in court, a rare outcome.

Another inmate recently admitted to this Prison Ward was a slightly effeminate black male in his 30s, charged with mugging another man. His modus operandi was to dress up as a woman and lure unsuspecting ‘johns’ into what they thought was going to be a sexual moment and then attack them. His intake interview was conducted by a psychiatrist and yielded some surprises: The prisoner explained that he occasionally supplemented his income by allowing men to have anal intercourse with him. Interested in the clinical implications of this new information, the psychiatrist inquired whether the prisoner ever performed anal intercourse on these ‘johns’. “What, are you ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• Introduction
• Part I Institutions
• Part II Challenging clinical circumstances
• Part III A challenging system
• Afterword
• Appundix