It’s 1 Patient, 1 Vote in Center for Mental Health

The president of the hospital ward called the meeting to order at 9:15 a.m. First on the agenda was a woman who wanted an increase in personal privileges.

“I haven’t been yelling and screaming,” she said. “I keep my bed made and I take care of myself.”

The patients and medical staff took some time discussing her case.

“You’re very polite and you get along with everyone,” said one woman. “You attended an activity yesterday and were real helpful,” added another.

In the end, they approved her request unanimously.

The next case was more difficult: A patient who had been there two weeks wanted the freedom to leave the ward unaccompanied. “I’ve been attending all the meetings,” he said. “I was fighting the system; now I’m not.”

But some thought he might be bluffing. So before voting to approve his request, 17 to 2, they made him promise not to leave the ward while feeling suicidal. “I’m still concerned about whether what I’m hearing is a lot of BS,” a fellow patient said.

Like other live-in mental health wards, the 18-bed facility on the third floor of Long Beach Community Hospital treats a variety of people for a variety of psychological problems. Unlike most, the hospital’s Center for Mental Health allows its patients to determine aspects of their own treatment through democracy.

Idea Not New

The idea isn’t new, psychiatrists say. Developed after World War II by an English psychiatrist named Maxwell Jones, the “therapeutic community” method of treatment was quite common for a time in the United States.

Then things changed. Tranquilizers and other medication became widely used for treatment of depression and mental illness. And because government agencies became less willing to subsidize long hospital stays, psychiatric hospitalizations that once lasted up to a year began averaging only a few weeks.

As a result, according to Sam Rapport, medical director of the psychiatric department at Memorial Medical Center of Long Beach, democratic approaches to psychiatric treatment fell out of vogue. “Expecting patients to be familiar enough with (each other) to make responsible decisions after only a few days could be irresponsible,” he said.

For that reason and to avoid costly lawsuits alleging breach of responsibility for patients’ well-being, his and many other medical institutions abandoned the approach altogether.

“We feel that it is not relevant or practical for our patients,” Rapport said. While some therapeutic communities still exist, he said, he is not aware of any in Southern California other than the one at Long Beach Community. “I question the efficacy of such an approach during a short stay,” he said.

Anthony Rosenthal, clinical director of adult mental health at St. John’s Hospital in Santa Monica, said: “We would never have a patient voting on whether another patient should have a pass. You don’t have a lot of Edsels driving around, either.”

New Context for Concept

But psychiatrist Ronald Silverstein, medical director at the Center for Mental Health, is undeterred by such views. He said his methods provide a welcome relief from the widely used authoritarian approaches to mental health. Giving patients a chance to interact and accept responsibility for themselves and others, even on a short-term basis, he said, helps prepare them for life in the real world. And by resurrecting the old concept in a new context, he said, he has broadened the range of options available to area patients.

“It is extremely effective for patients to see that they can get some response” from other patients, he said. “It improves their self-respect and self-esteem.”

Though he maintains veto power over all community decisions, the psychiatrist said, he has not once had to exercise it in the seven months since the program began. “We really treat the whole (ward) community,” said Silverstein. “Everyone is part of the whole.”

Under the program--which costs an average of $450 a day, usually covered by medical insurance--each patient is assigned one of five status levels denoting a specific set of rights and responsibilities.

All patients are restricted to the unit for the first 24 hours of their stay, then are permitted to leave the ward in the company of a staff member. After that, according to Silverstein, all promotions in status must be discussed and approved by regularly scheduled community gatherings at which each participant--whether patient or staffer--has one vote.

Patients Given Responsibilities

While some patients are allowed to leave the unit only during regular visiting hours in the company of a relative or approved visitor, others can leave by themselves for up to one hour. Those at the highest level, Silverstein said, are permitted not only to leave by themselves but to accept the responsibility for accompanying lower-level patients off the ward.

“There’s an awful lot of peer pressure to advance,” Silverstein said.

In addition to deciding matters of individual status, community meetings regularly bring election of officers to preside over patient business. Patients also attend daily group-therapy sessions and individual consultations with therapists, as well as weekly field trips and classes in occupational therapy.

Although some medications are prescribed by individual therapists, Silverstein said, activities rather than drugs form the crux of the program. A high level of participation in those activities, in fact, is a favorable factor when patients debate a request for status changes. Such requests are “definitely (not) . . . a popularity contest,” he said.

Operating near capacity, the center has treated about 150 patients since May, mostly for anxiety or stress-related ailments. While some are referred by psychiatrists, Silverstein said, others come directly from hospital emergency rooms or are referred by a mental health hot line maintained by the center.

So far, he said, the approach seems to be working.

“It’s gotten me to think of myself as a person again,” said Robert Burton, who had been on the ward just over a week. Deeply depressed by long-term unemployment, Burton, 32, had taken pills in an unsuccessful suicide attempt that he says landed him in the hospital’s emergency room and then in its mental health center.

“At first I couldn’t accept it,” he said of the treatment he had received there. “I always thought a mental institution was like on TV--being locked in with guards and wearing little gray uniforms. This surprised me; I’m glad I came.”

Pounded on Walls

Denis Pasica, 42, said he had admitted himself eight days earlier, after a noisy wall-pounding altercation with some neighbors. “It’s an emotional problem,” said Pasica, adding that he had been hospitalized for stress-related problems several times before. “I get lonely, (I get) feelings of isolation. This has helped a lot. It has helped me show myself how easy it is to be friendly to other people.”

Silverstein says there is no objective way to measure the success of an institution like the Center for Mental Health. Most patients, he believes, walk out feeling better than when they came in. And apparently the hospital feels positively enough about the project to have already approved plans for an expansion later this year that will double its capacity.

“We feel it’s a very good program and one that is needed in the community,” said Paul Viviano, the hospital’s chief executive officer. Located in a ward that was previously “under-utilized,” he said, the mental health center is one of several factors contributing to an overall 20% increase in admissions over the past year at the hospital, where charges for psychiatric care are slightly lower than St. John’s and roughly comparable to Memorial’s.

“It’s working out very, very well,” Viviano said. “We’re pleased with the progress we’ve made.”

Back at the community meeting, meanwhile, the essence of what Silverstein calls therapy was taking place as patient Burton received the unanimous nod of his peers to serve as the ward’s elected activity director, responsible for planning weekend and evening leisure activities with a recreational therapist and the nursing staff.

“I’ve never been elected to anything in my life,” said the man who less than two weeks before had tried to commit suicide. “Now I hold an office and people are going to ask me what I think. I’ve never felt better.”