Schizophrenics and Responsibility : Private Pilot Program Helps Mentally Ill Help Themselves

When mental-health counselor Jean Kramer stepped inside Ted’s Santa Monica apartment, the place looked as though it hadn’t been cleaned in weeks. Ted’s sleeping mat lay unmade in one corner; dirty clothes were strewn across the unswept floor. Such indolence was characteristic of chronic schizophrenics like Ted, Kramer knew. But she also knew that was no excuse.

“Which would you like to do first: Straighten the apartment or do the laundry?” Kramer asked.

Ted waited awhile before answering. “Awww, I don’t want to do laundry today. Let’s go the beach instead.”

“I know it’s not fun, but everyone has to do their laundry,” Kramer said. “Who wants to walk around in smelly clothes?”

“All right,” Ted said reluctantly. “But . . . I don’t have any change for the machines.”

“I do,” Kramer shot back.

Outmaneuvered, the 25-year-old mental patient began to stuff his soiled clothes into a laundry sack.

Ted’s behavior was typical of schizophrenics, the counselor said later. “So often, they’ll sit around in clothes that smell bad or don’t even match, and they’ll wait for someone else to take care of it for them,” Kramer said. “Instead of letting Ted avoid responsibility by behaving like a sick person, we’ve tried to communicate the idea that normal, healthy people don’t rely on others that way. They take responsibility for themselves.”

Based in Santa Monica

For 15 people enrolled in (Re-)Socialization Skills Inc., a private, Santa Monica-based pilot program for the chronically mentally ill, that simple message seems to be coming across. Founded in 1979 by Bart Ellis, a licensed clinical social worker, (Re-)Socialization Skills has pursued a “mainstreaming” approach to psychiatric therapy by taking patients out of tax-supported institutions and placing them in their own apartments. With the help of counselors (Ellis calls them “special friends”) who are available on a one-to-one basis, the patients (or clients) learn how to cook, shop, clean house, balance a checkbook, take a driver’s test and, ultimately, look for a job.

(Re-)Socialization Skills has worked with about 60 clients, their problems ranging from adolescent adjustment difficulties to learning disorders.

One client is Richard, 37, whose developmental disabilities have left him with the emotional age of a pre-adolescent. Before the program, Richard was not able to live on his own or work. After three years in Ellis’ program, he is living on his own and working part time.

After years of delusion and dependence, those in Ellis’ program are learning to face reality. Like Ted, about a third of them suffer from chronic schizophrenia, a mental illness marked by disordered thinking patterns, hallucinations and bizarre behavior. While the illness generally is considered to be incurable, schizophrenics often can quell their symptoms with major tranquilizers. Believing themselves well enough to stop taking the drugs, many then become trapped in a hopeless “revolving door,” bounced from brief periods in the street to a state mental hospital to a minimal board-and-care facility; in time, the cycle begins again.

“The medical establishment thinks little can be done for schizophrenics outside of medication and institutionalization, so there are few efforts to integrate them into the larger community,” said Ellis, 46. “We think a great deal can be done, but different approaches are needed. The entire system needs major surgery. Long-term patients have spent 15 to 20 years learning how to be good mental patients. Because psychiatrists, parents and friends treat them like they’re made of Dresden china, that’s the way they act. Their craziness--the voices they hear--attract attention, so there’s incentive for the crazy behavior to continue.

“Science shows that chronic schizophrenics probably have a biochemical imbalance, but there’s also very much a learned, manipulative component to the illness that people don’t realize,” Ellis said. “Most of the clients we work with prefer to remain babies, for instance; they’re allergic to work. With mainstreaming, we say to the client, ‘Wait a minute. You’re not an invalid. You’re not helpless. And we don’t want to hear about your voices. What did you do today? You cooked an egg and washed your hair? Good for you! You’re getting stronger every day.’ ”

Some Don’t Improve

Because of the nature of the illness, however, not all in Ellis’ program get stronger. Such was the case with Randy, a quiet, Los Angeles-born college student who first “snapped” on Thanksgiving Day, 1980, after overindulging in marijuana and alcohol.

“Randy was chanting, ‘I’m the devil’ and talking crazy about President Reagan and the Russians,” his sister said. “When he ripped the turkey apart and threw Mom across the room, we drove him to the hospital.”

Diagnosed as a paranoid schizophrenic, Randy signed up with (Re-)Socialization Skills and showed improvement for more than two years. Assisted by program counselors from 24 hours a day in the beginning to 15 hours a week, he learned how to box, coached Little League baseball, took dog-grooming lessons and worked part time at a fast-food restaurant. Then, two summers ago, he told Ellis: “I don’t want to grow up. It’s scaring the hell out of me.” Within weeks he stopped taking his medication, drank a bottle of cologne and was picked up by police for sleeping alongside the San Diego Freeway.

Thrown out of (Re-)Socialization Skills for that behavior, he is now confined to the state hospital in Camarillo, where he was transferred last spring after assaulting two psychiatric technicians at the Chatsworth Health and Rehabilitation Medical Center. And he’s having second thoughts about giving up on Ellis’ program.

“I didn’t know what to do with myself (in the summer of ‘83), so I chose to party a lot,” Randy said softly, his hands shaking as he sipped a cup of lemonade. “Now I know I have to work on my self-motivation. I had a job cleaning up the rehabilitation office at Chatsworth, but I lost it because I forgot to go to work the second day.

“I’d rather be back with Bart.”

Before that can happen, Ellis said, Randy must prove that he is serious about accepting responsibility. “We’re letting him see what happens to people who don’t take care of themselves: They lose their freedom,” Ellis said. “I think the reality is starting to hit Randy now. But I won’t take him back until he’s ready to take his medication regularly and hold a job. He absolutely won’t manipulate me.”

A willingness to cooperate is the first requirement for entering his program, Ellis said. “I’ll take anyone who wants to try, whether their prognosis for success is good or poor. In the past, we have been able to turn around some people who had a very poor prognosis. But I won’t take anyone who doesn’t want to put forth the effort.”

Modeled after a similar program in Madison, Wis., (Re-)Socialization Skills represents an alternative to therapies offered by the psychiatric Establishment.

Program Criticized

“Anything that anyone can do to help schizophrenics is commendable, and this program is probably doing a lot of good,” said Dr. Evelyn Crumpton, senior associate chief of psychology service at the VA Medical Center--West L.A., and a clinical professor of psychology at UCLA. “But while I am wholeheartedly in favor of the mainstreaming approach, it seems to me that some parts of the (Re-)Socialization program could be more sophisticated.

“For example, I consider their underlying attitude that schizophrenics are lazy, manipulative babies who don’t want to work to be very countertherapeutic,” said Crumpton, who’s spent her career working with schizophrenia and a range of other psychopathologies. “Moreover, I believe that the best role model for a schizophrenic is another schizophrenic. On our supervised outings in groups at the medical center, one patient will inevitably come up with an extra bit of knowledge or be able to do a thing that the others cannot do. If we can help them in this way to focus on what they can do, by having success and good role models and carefully supervised training, many will move in a positive direction to make better lives for themselves.”

Typical fees in the (Re-)Socialization program range from $2,400 to $6,000 a month, including living expenses. Fees in state and private mental hospitals can run to $5,000 and $14,000 a month respectively. Because insurance companies don’t pay for mainstreaming therapies, families must bear the costs alone. Ellis recently received federal tax-exempt status as a charitable public agency, hoping eventually to attract the sort of corporate funding that would make the treatment more accessible.

Additionally, Ellis has asked the state for $332,000 to fund a year-long pilot program that would mainstream 24 of Santa Monica’s homeless mentally ill. Ellis’ concept was called “one that appears to offer enormous potential at a rather low cost” by Assemblyman Bruce Bronzan (D-Fresno). The chairman of the Assembly Select Committee on Mental Health, Bronzan is also the author of a new law that will provide some $20 million in state funds to support local programs for the homeless mentally ill.

So far clients have remained with (Re-)Socialization Skills an average of one year, Ellis said. Most often, he said, their participation has ended because of finances or because of the families’ impatience for a more rapid recovery--especially the families of schizophrenics.

What is Ellis’ success rate with schizophrenics?

“Every one of them has been successful in the program in the sense that they have stayed out of the hospital for a time and learned to live more productively in the community,” he said.

“If you take a person who’s only showered once a month and persuade him to shower every other day, that’s a success. Or someone who’s survived on nothing but junk food and teach him how to open a can of soup and heat it up, that’s a success, too. Mainstreaming is a continual process, however, and most clients need some kind of support system for the rest of their lives.

“Unfortunately, the schizophrenic life style--and the system itself--make it difficult for many to re-enter the mainstream.”

Progress Is Slow

Ted is a case in point. Treated by psychiatrists since he was 4, Ted entered Ellis’ program a year ago. His progress since then has been slow and often tortured, a hint of which could be seen during a meal with Ellis at a pizza parlor.

Unshaven and unfocused, the young man found it hard to keep up the simplest conversation. When Ellis suggested that he get his “butt to the store and buy some food for the refrigerator,” Ted just nodded blankly and looked away.

A few months later, he was dropped from the program.

“As long as Ted got his SSI (Supplementary Security Income) check for $500 every month, he had no real incentive to make progress,” Ellis said. “In a sense he was saying, ‘Why should I go to work when it’s so much easier to stay a bum?’

“That’s why success has to be judged differently with mainstreaming,” Ellis said. “When a client prepares a dinner or doesn’t throw a tantrum or maintains a part-time job--those are major, successful breakthroughs. Because recovery is a long process.”