Jean-Francois Dreyfus: My early years in psychiatry 1968-1973
David S. Janowsky’s comment
I very much enjoyed Dr. Dreyfus’s essay on his experiences as a young psychiatrist between 1968 and 1973 (Dreyfus 2021). I was especially intrigued by his comments centering on the “antipsychiatry” ward with which he was affiliated. I had a somewhat similar experiences, although not nearly as dramatic or “radical” (or as much fun and exciting), as Dr. Dreyfus apparently experienced.
I would like to add to Dr. Dreyfus’s comments with the following: At least in the USA, in the second half of the 1960s and the early to mid-1970s, ward’s such as Dr. Dreyfus’s were to a large extent consistent with the philosophy and politics of the “revolutionary" and “youth culture” of the times. Characteristics of this point of view included being against the Vietnam war, an antiestablishment orientation and humanistically, idealistically, utopian and experientially oriented rather than traditionally oriented. It was in this context that an “antipsychiatry “unit might have found fertile ground in which to grow.
My own experiences were in developing and directing what I then referred to as “participatory democracies.” These occurred while I was a faculty member at Vanderbilt University and then the University of California at San Diego in the early to mid-1970s. What follows are my impressions of the nature of these units.
As described previously in my response (Janowsky 2018) to Dr. Edwin Fann’s essay (Fann 2018) on the Tennessee Neuropsychiatric Institute, during my psychiatric residency at UCLA, I had had the pleasure of spending my first year (1965-1966) on a milieu psychiatry inpatient ward, under the direction of Dr. Roderic Gorney, This unit was designed in many ways to be a “therapeutic community.” Because of that experience and my enthusiasm for it, I had applied and was accepted by the U.S. Public Health Service (USPHS) to come to the NIMH in Bethesda Maryland in 1967-1969 as a Clinical Associate. My role was to run an open, basically equalitarian, inpatient psychiatric unit, a “therapeutic community.” This unit was to be carefully compared for outcome with a more conventionally structured psychiatric unit. However, the career USPHS scientist who planned the study and was in charge of it and to whom I was to be assigned was reassigned several weeks before my arrival. I was reassigned to Dr. William Bunney’s psychobiologic research unit, that focused on the study of affect disorders. Although I tried, I had little success in converting that research unit into a “therapeutic community.” However, while there I met and became good friends with Dr. John Davis, a highly significant and fortuitous turn of luck for me.
In the summer of 1969 I completed my USPHS obligation (which also counted as my military obligation) and my last year of residency and returned to California to start a psychiatric crisis emergency room service at Harbor General Hospital in Torrance, Harbor General Hospital being an affiliate of the UCLA school of medicine. After about a year, John Davis, called me and told me about a leadership job he was about to take in Nashville Tennessee at Vanderbilt University’s Department of Psychiatry. He asked if I would be interested in joining him in developing a clinical research unit at Nashville’s Vanderbilt affiliated Central State Hospital, working under the auspices of Vanderbilt’s departments of pharmacology and psychiatry in an institute called the Tennessee Neuropsychiatric Institute. I agreed and moved with my family to Nashville in the fall of 1970.
I requested and John Davis agreed that the 11-bed research unit I was to administer could be structured as a “therapeutic community” or as I called it at the time a “participatory democracy.” My role at Central State Hospital was to be the clinical leader working under the leadership of Dr. Davis of an as yet to be developed clinical research unit. I would be running the unit day to day and facilitating the clinical care of patients transferred from the general psychiatric inpatient units of Central State Hospital for research purposes.
Over a period of several months we hired a group of enthusiastic, college educated young people, some being college dropouts, some being college graduates. They were hired mostly based on their ability to relate with compassion and empathy, their flexibility and their interest in caring for the very sick mentally ill patients, mostly long term psychiatric inpatients. They were basically people with good hearts. These days, they would be said to have high emotional intelligence. These new hires, highly enthused, joined a small cadre of professional psychiatric nurses and psychiatric technicians assigned from the units of Central State Hospital. These “professionals” generally were used to a more pyramidal unit organization. Some liked the more open system, while others did not and most of these ultimately left.
Once staff was hired, we recruited patients from the inpatient units of Central State Hospital. Their diagnoses consisted primarily of bipolar disorder and schizophrenia, and most were long term inpatients. We rapidly developed a unit where patients had much more autonomy than they had on the other units. For example, they voted with some authority on whether the ward door would be locked on a given day and had input into the issuance of each other’s passes. Nevertheless, staff did maintain veto power over decisions made by consensus, although this occurred only occasionally. The patients openly discussed ward policies in group therapy and discussed which drugs they were receiving in their group and individual therapy. There was an equalitarian ethic in which nursing staff and trainees, including residents and psychologists, were treated more or less as equals. Staff addressed each other on a first name basis, wore street clothes including jeans. No one wore white coats, common on academic psychiatric inpatient units. In community meetings, staff opinions were considered mostly based on logic and reasonableness rather than based on professional training or rank or credentials. We tried to inculcate an ethic in which treatment and research were to be emphasized equally. We tried to offer good care through group therapy, frequent community meetings and individual interactions, and to offer a humanistic offset for the patients participating in predominantly psychobiologic research. We tried to overcome the attitude that the patients, chronic as they often were, could not be helped very much and tried to emphasize their creative, unique and positive qualities as people. As above, credentials mattered very little, which was liberating to some staff and threatening to others. At the time, and probably subsequently, the unit I am describing was the antithesis of the usual accepted more formal pyramidal structure of most psychiatric units in the South, and for that matter throughout the USA. However, our colleagues at Vanderbilt and at Central State Hospital, although often skeptical, were relatively tolerant of our endeavors.
In 1973, after three years of living in Nashville and working at the Tennessee Neuropsychiatric Institute/ Central State Hospital, John Davis left to work at the University of Illinois in Chicago. I returned to the West Coast to work in the University of California San Diego (UCSD) Department of Psychiatry, then co-chaired by Dr. Lewis Judd and Dr. Arnold Mandell. After a year running the UCSD VA liaison consultation service I was asked to run ward 8 East, a mostly acute relatively short term 18-bed inpatient unit at the Downtown UCSD hospital. I was the unit chief of that unit from July 1974 until 1976. With permission from Dr. Judd I attempted to convert the unit into a “therapeutic community-participatory democracy,” very much like the Vanderbilt unit described above.
During one of the years that I directed this unit, the unit Chief Resident was Dr. J Hamp Atkinson, now a professor of psychiatry at UCSD. He and I wrote a paper detailing the nature of the unit which we published in the International Journal of Therapeutic Communities (4). The paper described some of the advantages, problems and pitfalls of using democratic principles to set policy and guide treatment for nursing personnel, psychiatric residents and patients.
As with the Vanderbilt unit, the major administrative principals underlying the personnel -administrative system were as follows and as described in our paper:
1. that for administrative or policy decisions, the opinions of all staff members were open to consideration, based on the merits of an individual’s logic, rather than on credentials;
2. with respect to treatment planning, an employee’s common sense and experience were at least as important as credentials;
3. that group decisions based on consensual validation are more often correct than individually made decisions;
4. and that nursing staff are more likely to treat paints humanely and appropriately if they feel they are in control of and responsible for their own vocational destinies.
In practice, the administrative functions of the unit centered around a 1.5 hour weekly staff meeting. This was attended by myself as the unit director, the psychiatric residents, the social workers and nursing personnel. Major policy decisions were considered by all staff members present and resolution was decided by general consensus or majority vote. However, I, as unit director, maintained the right to have veto power, which I cannot remember actually ever using. Some issues considered in these staff meetings included hiring of personnel; defining roles of personnel; decisions about employee job mobility, promotion and reward of staff members for outstanding work; discussion of inadequate performing personnel; structuring; assignment of working hours; use of educational funds; and consideration of staff roles on the unit.
Such decision making was also applied to patient care in the context of a system of a daily team meeting and community meetings. In these, physicians, nurses and patients met to plan treatments. Decisions were usually made by consensus with the patient’s primary therapist, with patients themselves having major input. Decisions concerning discharge and passes, and even medications were often made in these meetings. Furthermore, nursing reports often occurred the with patients present, assuming they wanted to be there and patients had access to their charts.
In our International Journal of Therapeutic Communities article, Dr. J Hamp Atkinson and I attempted to outline the positives and negatives of our “participatory democracy.” On the negative side, our training of first-year residents was reported as a mixed experience. Some fully embraced the administrative democracy. Others, while usually acknowledging that they had learned much, felt that the nurses and nursing assistants were too powerful, too assertive and too informal. Many felt that being in a less powerful, more diffuse role than usually occurred for young doctors was threatening. Thus the obvious decrease in medical authority was disturbing to some and not to others. Overall, “administrative democracy” had as negatives the disadvantages of increased chaos, slowness of decision making, the stress of role diffusion and the negative of less confidentiality.
On the positive side, overall, morale was high among staff on the unit, and turnover of nursing and other personnel decreased significantly compared to before the unit was converted to a “participatory democracy.” However, this stability developed over time and initially some staff didn’t like the open system and sought work elsewhere. Staff self-esteem increased and staff reported that they felt more creative and energetic, especially those staff members who were low on the totem pole. Nurses who stayed generally felt more spontaneous and relieved to some degree of the burdens of individual responsibility. Overall, creativity, initiative, self-esteem and morale increased. Projection of responsibility to “authority figures” rather than to self decreased remarkably. Backbiting and passive aggressive coping also decreased. Psychiatric residents overall felt their time on the unit had been meaningful and informative and they had learned much about themselves, their patients and how an inpatient system really works. Overall, very few complaints were made by patients, especially once a stable professional staff had evolved.
Finally, I want to say that I look back upon my “participatory democracy” experiences with some degree of amazement and awe. I had not read the Janowsky-Atkinson paper for decades and it was somewhat startling to me to see and remember what we had attempted. What was described seems very far removed from contemporary psychiatric treatment and the political directions of our country. Indeed, once I left the units and new psychiatrists were appointed as directors, the units rapidly became more conventional and pyramidal in structure. In my opinion, what was done as described reflected the “revolutionary” times as such, as well as the nature of the mores and beliefs of at least one segment of society, a segment which might be called the “hippie” or “youth” culture, and of which I would have considered myself at most a mild participant at the time. In any case, it was a heady experience and great fun at the time, with pros and cons as any treatment system will have.
References:
Dreyfus JF. Jean-François Dreyfus: My Early Years in Psychiatry: 1968-1973. inhn.org. biographies. July 22, 2021.
Fann EW. W. Edwin Fann: A History of the Tennessee Neuropsychiatric Institute, inhn.org.perspectives. March 1, 2018.
Janowsky DS. Comment: My Time at the Tennessee Neuropsychiatric Institute (1970-1973). inhn.org.perspectives. July 19, 2018.
Janowsky DS, Atkinson JH. Administrative democracy on the psychiatric ward: nursing and psychiatric resident issues. International Journal of Therapeutic Communities, 1982;3(3):126-35.
September 16, 2021