There are no hard and fast rules on how to treat the mental problems of the poor.
Most of the public mental health clinics in Washington and across the United States rely on a brief, pragmatic approach that focuses on the problems that poor people bring in. If an angry patient wants to talk about his landlord, the therapist will usually ask questions about the landlord--not the patient's mother.
"We fix what's broken but no more than that. It really isn't necessary to reconstruct the house from the ground up." says Dr. Robert Nichols, a psychiatrist in charge of mental health clinics in Fairfax County.
At the private, nonprofit D.C. Institute of Mental Hygiene, however, patients are urged to stick around for years and talk. Many patients spend hundreds of hours rehashing their childhoods. Almost everyone ends up talking about his or her mother.
"There is nothing sneaky about me. I want people to stay around . . . If you get someone on the hook and don't let them off the hook, it reduces the chances of suicides and murders." says Dr. Jack Love, a psychiatrist in charge at the institute's Anacostia office, where the caseload is 94 percent black and almost uniformly poor.
Impassioned claims and counterclaims about the value of different schools of psychotherapy are endemic to psychiatry, which, of all the branches of medicine, probably offers the fewest definitive answers about the causes and cures of the diseases it treats.
"To try to determine by scientific analysis how much better or worse (one form of psychotherapy is compared with another) is in many ways equivalent to attempting to determine by the same means the relative merits of Cole Porter and Richard Rodgers," according to Dr. Jerome D. Frank, a professor of psychiatry at Johns Hopkins.
Research indicates almost all kinds of psychotherapy do some good. For some patients, psychotherapy combined with drug treatment is more effective than either treatment alone. For other, severely ill patients, particularly schizophrenics, most research suggests that insight therapy combined with drug treatment (which is the way schizophrenics are treated at the D.C. Institute) is no more effective than drug treatment alone. Love and Dr. Harold Eist, the institute's medical director, dispute the second finding and say their clinical experience shows otherwise.
Many clinic directors cite experience and research showing that many poor and lower class patients have a low tolerance for frustration, tend to drop out of therapy prematurely, try to solve problems by action rather than thought and are not adept at using words to describe their inner life.
"Long-term talk therapy quickly reaches a point of limited returns with the people we treat. Many of them just can't wait. They are looking for therapy that is as short-term as possible," says Alan Orenstein, deputy director for the Area D Mental Health Center in Anacostia.
"These people can be assisted in a more speedy way," says John DeFee, director of the Woodburn Mental Health Clinic in Northern Virginia. "A good many of the people we see are not psychologically-minded, not that sophisticated."
The D.C. Institute rejects such arguments.
"To say that poor blacks are less amenable to talking cures is not true," says Eist. "It strikes us as one of the most pernicious racist notions promulgated within the field of psychiatry that the laws of human behavior do not apply equally to minorities . . .
The psychoanalyst argues that those who don't believe Freudian techniques are effective with poor people "have not worked with the patients or found a way to relate to them."
Psychiatry in Washington and across the country is an overwhelmingly white profession. Of the 38,545 psychiatrists in the country, only 588 (1.5 percent) are black. In Washington, about 40 of the 1,200 psychiatrists (3.3 percent) are black.
"The numbers just aren't there. We won't produce enough black psychiatrists in our generation. So we must rely on whites," says Dr. James L. Collins, a black psychiatrist and chairman of the psychiatry department at Howard University Hospital. "Whites can effectively treat blacks if they understand the cultures they work with."
Collins says that that understanding is far more important than any particular brand of therapy. The D.C. Institute, he says, may not be the most efficient clinic and it may not be suitable for everyone but it does help many poor, relatively unsophisticated people.
In Washington, an estimated 80,000 people a year use some kind of mental health service. Despite the area's 1,100 psychiatrists (and 1,200 psychologists), local experts say psychiatric care for the poor, especially in the District, is bad.
"The basic investment of psychiatry in this country, and in Washington, is to give long-term care to the people who can afford it," said Dr. Thomas Reynolds, former director of a division of St. Elizabeths Hospital and a former staff psychiatrist at the institute. "There is a small minority of those (therapists) who are dedicated to the poor."
In the District, the D.C. Institute of Mental Hygiene is by far the largest, most successful private attempt by that minority to deliver to the poor treatment normally reserved for the middle class. With its sliding fee schedule, it collects less than $14 an hour to treat more than half of the 1,200 patients a year who crowd its corridors. The same care would cost about $65 an hour from a private psychiatrist.
Compared with the District's two underfunded and understaffed public mental health centers, which one expert at NIMH calls "one of the most troubled efforts in the country," the institute is a well-run clinic that "treats poor people with dignity," says Gail Marker, a psychiatric social worker with the Mental Health Law Project.
The American Psychiatric Association four years ago gave the clinic its "gold award" as the best outpatient clinic in the country. Dr. Roger Peele, chief of psychiatry at St. Elizabeths Hospital, says that without the clinic "we would see more people in public hospitals in Washing- ton. We would see more deaths."
It is the institute's commitment to the poor, however, not its Freudian techniques, that leads many mental health authorities to praise it and refer patients to it.
"I virtually never give any thought to their theoretical orientation when I refer someone there," says Len Allen, a local psychologist and president-elect of the District of Columbia Psychological Association. Allen, who doubts the usefulness of long-term therapy for his own patients, refers people to the clinic because "I know they will receive concerned, knowing care."
"I think these same therapists could use another approach and make it work," says Evelyn Ireland, a psychologist and chairman of the institute's board of directors. "If we were in a more experimental area of the country, like California, we probably would have a less conservative approach than the one we use."
But the institute is in Washington, long considered one of the nation's most conservative, psychoanalytically oriented cities. There are two psychoanalytic institutes here, and the area's 235 psychonanalysts comprise the largest, most influential like- minded segment of the area's psychiatric community.
Whatever the significance of the theoretical bent of the institute to its patients, it is an important staff recruiting tool among the analytically inclined therapists who are abundant in Washington.
"I don't think Harold Eist is above exploiting our labor, but it is for a good reason," says Susan Roth, a psychiatric social worker who has been with the clinic for eight years. The "good reason," Roth and others say, includes the opportunity to use their analytic training with troubled patients while being super40 ofvised by experienced psychiatrists. The clinic allows therapists--most of whom are white women, many of them with young children-- to set their own hours. Finally, as Roth says, there's "Harold's teaching."
The clinic staff has grown from 14 to 109 in spite of its abysmal pay scale. For the first six months at the clinic, everyone works for nothing. After that, psychologists and social workers make between $13,750 and $14,900 a year. At public clinics in the District and its suburbs, they could make between $20,000 and $30,000 a year.
"The only way I can run this clinic is with those six- month volunteers," says Eist. "We are also tapped into a sea of professional women (most of whom are married and not financially dependent on the clinic) in the area who get experience and some money. The male therapists don't stay with us too long. It is very difficult, if not impossible, to make a living at the clinic."
Although the institute has been successful in providing psychotherapy to needy and underserved poor patients in the District, mental health experts say it is too small and its services are too limited to be anything more than one piece of an adequate, municipal mental health system.
In the District, the other pieces are lacking. Private psychiatrists and psychologists, for the most part, are uninvolved with poor, very sick patients. At city clinics, according to a recent court- ordered study of care for de- institutionalized patients, clients who need intensive care "are being harmed and will continue to be harmed" until better service is available.
Limited though it may be, the D.C. Institute, with its Freudian methods that many consider inappropriate for the clientele it serves, is one agency thaoffers continuing --and apparently effective-- care to mentally ill poor peo
Without the clinic, says Dr. Steven S. Sharfstein, deputy dire of the American Psychiatric Association and a national expert on communit mental health, many poor people in the city "would probably get nothing."