Thomas L. Chiu FROM THE COUCH TO THE JUNGLE
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Chapter 7
The Mobile Crisis Unit (MCU) In the "East Village" (1985-91)


My "outreach fever" led me to obtain a position, in 1984, with Gouverneur Hospital in Manhattan, Department of Psychiatry, working on the Mobile Crisis Unit (MCU)-a most unusual psychiatric home-service, akin to a crisis center on wheels! I was to be part of a three-person team that included a psychiatric nurse and a psychiatric social worker. Our assigned territory was the Lower East Side of Manhattan, often called the "East Village," densely populated by the full panoply of "hyphenated Americans": Asian, Hispanic, African, Italian, and Jewish, among many others. Our primary role required that, while roaming the streets in the MCU, we would answer emergency calls for help in patients' households, and provide follow-up care for patients with whom we had already established contact. I knew the tempo of my work would be faster than it was with the with GMHP and the general climate more dramatic.

Asian Bicultural Clinic. In addition to working on the MCU, my new position required that I occasionally see patients at Gouverneur's Asian Bicultural Clinic (ABC). The ABC was established as part of the expanded outpatient services to meet the needs of the growing Asian-American population, especially the Chinese in New York City. The Clinic was staffed with an interdisciplinary team of bilingual, bicultural professionals to provide a comprehensive and culturally sensitive approach to Asian-Americans, who had been underutilizing mental health services due to language and cultural barriers. In addition to the conventional clinical services offered-including psychiatric consultation and evaluation, psychological testing, psychotherapy, counseling, and pharmacotherapy-the ABC offered acupuncture, the traditional Chinese practice to treat stress-related psychosomatic and psychophysiological disorders.

A Brief Background of the MCU
With the de-institutionalization of thousands of psychiatric patients in the 1960s, there emerged public outcries for more services-including more innovative services-to deal with this group. The outcries were particularly vociferous in New York City, where such formerly institutionalized patients tended to congregate in large numbers. Many were homeless, and had neither adequate follow-up nor a place to seek help.

As a result of these public outcries in the 1960s, many community mental health centers and expanded outpatient clinics were established, in both New York and other major American cities; nonetheless, thousands of individuals remained "left out," so to speak, from the traditional psychiatric care delivery system.

This situation gave rise, in 1967, to the concept of the Mobile Crisis Unit (MCU) in New York City. At Gouverneur Hospital, the MCU was designed as an outreach program, created to serve a particular patient population-including children, adolescents, adults, and the elderly-residing South of 14th Street on the East Side; East of Bowery and 4th Avenue; and South of Canal Street to Battery Park.

Using the MCU, psychiatric professionals were to serve patient populations primarily composed of those who could not go out, were afraid to go out, or who otherwise could not arrange for clinical, hospital, or private psychiatric care outside the domicile. On rare occasion, the MCU was also to serve individuals living on the streets, i.e., the homeless. Such individuals tended to have (and still have) a higher rate of mental illness, especially psychosis, than non-homeless individuals.

Goals of the MCU
The goals of the MCU were to provide a rapid response in the attempt to prevent patients from being hospitalized; to help patients maintain functioning through the availability of home visits; to help individuals and families become aware of available resources in the community; and to help coordinate care among families and agencies in the community. During crisis, we usually made one of three decisions: to hospitalize a patient; to do nothing temporarily, such as when the patient refused to be seen or the family said "wait;" or to treat the patient at home until he or she was ready to go to the clinic for follow-up.

The MCU Team
I worked on the MCU as part of a team, as mentioned, with a registered psychiatric nurse and a psychiatric social worker. Our team operated as a unit but was characterized by a distinct division of labor, with each member drawing the knowledge from his or her own experience and training in a discipline that is helpful in assessing and treating each patient.

Division of Labor Among Team Members. While the team operated as a unit, each member drew from his or her own experience and training the knowledge helpful in assessing and treating each patient. For example, the nurse took vital signs, made comments about nutrition, and gave injections; the social worker explained ways family members could obtain welfare benefits; and I, the psychiatrist, offered information on diagnosis and medication.

Ways We Treated Patients
In my work on the MCU for seven years, until 1991, we treated patients in a variety of ways:

1. Visits to Psychiatric Patients in Their Homes. We arranged home visits when psychiatric or physical impairments prevented patients from coming to Gouverneur Hospital initially. A patient may have been treated with psychotherapy, pharmacotherapy, or other services necessary to resolve the crisis until the patient could attend appropriate appointments in a hospital, clinic or other non-household therapeutic setting. In the household, families were included in the treatment and, at times, referred for treatment during or after resolution of the crisis.
2. Role Within Gouverneur Hospital. The MCU team was sometimes asked to make a home visit assessment by a department of Gouverneur Hospital or another psychiatric clinic. This often occurred when the patient failed to return to a clinic for a scheduled visit or a report was made that there was a crisis or problem at the patient's home.
3. Relationship With Other Agencies. The MCU team had an active relationship with other community agencies, informing them of the service capacity of the unit and other units within the department at Gouverneur. The MCU team also coordinated the services relating to crises of patients serviced by other community clinics and agencies.
4. Role in Hospitalization. Hospitalization was arranged by the MCU team when indicated. This especially occurred when the patient was judged too dangerous to either self or others. This also occurred when crisis intervention efforts at home had not been successful and the structure of the hospital environment was necessary for resolution of the crisis. When hospitalization was required and arranged by the MCU team, contact with either the patient, hospital staff, or both was often maintained. Reentry of the patient into the community after discharge was often facilitated by the MCU team.

The Trend of Following-Up Patients
While we saw and evaluated many patients after one or two visits, there were some who, for one reason or other, remained regular follow-up patients. The trend of seeing and following patients after crisis came about gradually. A few who seemed determined to remain home-bound began to be seen, after repeated attempts to stabilize them.

It took time to stabilize most patients, because of chronicity and the nature of their illnesses. By the time stabilization occurred, some bonding between the patient and the MCU team had developed. It therefore became even more difficult to transfer or refer these patients elsewhere. A few who were referred elsewhere decompensated soon after stabilization and needed to be re-engaged.

This phenomenon of "holding on" by the patient was contributed to by the resistance of the police to bring patients to the hospital. They did this only when there was gross evidence of violent or destructive behavior, including a suicide or homicide attempt. Moreover, many hospitals did not admit such patients. Often they were observed briefly, treated on the spot, and sent home, the same day. Families were seldom given opportunities to explain or elaborate on the circumstances of patients' behaviors. These practices were common in many city hospitals' emergency rooms: a seemingly docile patient was often sent home with little advice given either to him or family members.

Our Approach to Patients and Frequency of Contact
If the patient could wait for service, we set up an appointment; if not, we got there as quickly as possible. The treatment could involve only talk or such medication as Haldol or Prolixin (prescribed by me), especially for floridly psychotic individuals.

The average home visit took about an hour. Once contact had been made, patients would be treated at home or the hospital clinic. Hospitalization was arranged only when intensive efforts at outpatient treatment had failed. Even after hospitalization, our MCU team usually maintained contact with the patient or treating staff for several weeks or months, and often coordinated the patient's reentry into the community.

In most cases, we saw the same patients repeatedly, some for several years. After the first call, we would go to each patient's home on our own and assess their progress, but our main goal was to keep patients equilibrated ("cooled out") rather than to cure them. At times, we referred patients to an appropriate agency; when they could not be referred, we saw them indefinitely.

Stages in the Process of Stabilizing Patients
Stabilizing manic or other distressed patients was, of course, a major function of the MCU team. From years of observation and experience, I noted that there were four stages in the process of patient stabilization: a building of trust and confidence between the MCU team and the patient/family; therapeutic alliance; acceptance and compliance; and resolution of the process.

1. Building Trust and Confidence. This involved not only the patient but also the other members of the family. While there appeared to be a diffusion of attention, especially in the beginning of our encounters with patients, it became clear that the identified patient became the focus of our attention. Subsequently, the rest of the family tacitly agreed to this approach. On many occasions, medicine had been brought to the patient by our team, or transportation has been provided for the family to pick up the medicine in our clinic, so the patient could begin early chemotherapy. Indeed many of our patients were started on medication as soon as indicated, in order to break either the psychosis or the family turbulence. To achieve this, the team had, at times, administered the medicine to the patient on a daily basis.

It cannot be overstated that this was one of the most vital of our early approaches. Not only was the patient shown urgency and concern by the team but, also, a message was given to the family about our seriousness and determination to pursue the problem. Access to the whole family in its own environment provided and facilitated evaluation. Furthermore, there were times when patients themselves were brought by our team to the clinic and, after obtaining their medication, they were brought back to their homes.

These services we provided would be difficult, if not impossible, for patients to obtain elsewhere. We thought they provided an important first important step in engaging the patients.
2. Therapeutic Alliance. After the initial encounter, the stage was set for a closer linkage with the patient. We also encouraged other family members to provide information on a continuing basis.
3. Acceptance and Compliance. For stabilization to occur, the patient had to accept and comply with our treatment, which required the presence of three factors.

First, there had to be a recognition of roles. Designation of who the patient is and is not requires some understanding of family dynamics. It was the responsibility of the MCU team members to recognize the complexity of this dynamic and clarify the situation for all concerned. To accomplish this, the MCU team members often had to closely examine the roles of each family member.

Second, there had to be recognition of illness. This may be difficult to achieve unless both the patient and family are insightful. Often this is accomplished by discussing specific problems, for example, breaking furniture, unemployment, truancy, or fighting among family members.

Third, there had to be recognition of need for treatment. This usually followed acceptance of the above two processes, although there were times when the patient was given medication at the outset, in the hope that he or she recovered early enough for further engagement and compliance.
4. Resolution. This stage varied, too, from patient to patient. There was sometimes an impasse. The team, after noting stabilization in the patient's illness, may have continued to visit the family until the family was ready to care for the patient effectively, including such complex tasks as being aware of signs and symptoms of imminent decompensation. The patient may have decided to leave his or her home and go to the clinic for further treatment or counselling. In this case, we fully supported, encouraged, and facilitated the patient's intentions and activities. In these instances, the family also may have decided to go to the clinic for counselling.

How We Learned About Patients
Most often we learned about patients who needed crisis intervention from phone calls to our Mobile Unit made by patients' family members, neighbors, or clergymen, after they sought assistance at Gouverneur Hospital. Between 1984 and 1991, we treated various types of individuals in the home setting. Those we most commonly served, based on referrals, are shown in the table below.

Table 3
Types of Patients Referred to the Mobile Crisis Unit
1 Patients discharged from (a) States Hospitals, (b) the Psychiatric Units of general hospitals, and (c) Private doctors/institutes
 
2 Patients with substance/alcohol abuse problems
3 Patients from another state or borough
4 Patients from women's/men's shelters
 
5 Patients referred by families, neighbors, clergy, housing management, police, etc.
6 Patients from Nursing Homes
7 Patients from Social/Welfare agencies
8 Patients from Gouverneur Hospital


The Team Approach and Its Problems
As I gained experience on the MCU, I became aware that, no matter how much I valued the team approach to treatment, linkage with the patient could be clouded by the very existence of a team. In particular, during the initial phase of contact, the patient (as well as family members) often had difficulty addressing the members of the team at the same time. To minimize this potential problem, our team tried to function as one unit, complementing one another throughout, from gathering information to identifying problems to eventually intervening.

Our Unorthodox Way of Working
Because of the unique nature of our work, the mode of operation of the Mobile Crisis Unit team could rightfully be described as "unorthodox." There was no strict code or rule that we followed; rather, we were flexible, ever-sensitive and respectful of the differing needs of the various ethnic groups we treated.

On many occasions, the MCU team, for expediency, offered a variety of miscellaneous concrete services to facilitate rapport and early treatment, e.g., providing car service to and from the clinic for medical appointments and medication; giving medication (injection) in the MCU van when necessary; making regular visits in the parks when it was thought this was more convenient for the patients and for the staff; and visiting patients' neighbors in their homes on many occasions, sometimes on a regular basis, when the patients themselves refused to be seen or were unable to be seen. The rationale for these visits was both to alleviate the neighbors' anxiety and enable the MCU team to obtain ongoing information about the patients.

The MCU team also had the role of advocating on behalf of patients to prevent eviction by landlords. We did this by directly intervening in the process through letters, phone conversations, or face-to-face contact with the aggrieved parties. Many patients and their families had responded positively, consequently, to the MCU team's approach, and thus became more willing to accept therapy if indicated. In addition, the MCU team often brought food to patients, sometimes on an ongoing basis, until the patients received food stamps or money from public assistance programs.

In certain instances, when we did not have enough history on a patient prior to a home visit, we would approach the patient with caution, although one could never quite predict what would ensue. Sometimes we requested assistance from the neighborhood police, with interviews and evaluations, medication, or hospitalization.

The MCU team, when confronted with ambivalence by either the patient or a family member, would act in a way we considered therapeutic at that particular moment. When treating a psychotic individual, for example, who was undecided about hospitalization, we would make the decision for the patient, and follow-up with the subsequent plans. This invariably minimized tension, relieved further anxiety, and hastened therapeutic alliance.

The MCU team also consulted for agencies that cared for patients, providing general guidelines and principles for the handling of patients, including setting limits, firmness in approach, and appropriateness of social contact and community living. We saw both the patients and the staff, sometimes together and sometimes separately, but always with maximum regularity and consistency.

Because of the essential nature of our work-visiting patients in households Ñ we often encountered potential psychiatric patients in families. For example, a 50 year old Jewish man who was caring for his mother was noted to be increasingly depressed, angry and suicidal. He therefore was eventually engaged in therapy with the team during and after the death of his mother. Each ethnic group we saw, while unique and distinct, appreciated the flexible kind of assistance we provided. One day we might be sharing coffee with a patient in a diner and the next week be giving him an injection in his apartment.

The Multicultural Population Our MCU Team Treated:
Some Case Studies

On the Lower East Side, the mix of citizens and recent immigrants we treated from diverse heritages-Italian, Chinese, Jewish, Puerto Rican, and African, among others-presented an awesome professional challenge, and was also an unprecedented learning experience in multicultural psychiatry. Many individuals and families had lived there for years but they seldom made full use of the neighborhood clinic. More often, concerned citizens called our Mobile Team, either for early resolution of a particular problem or because they wanted a little privacy for patient evaluations or consultations with the MCU team in their own homes. I learned that families had various ways of being helpful to the patients after receiving the Mobile Team's guidance and, in some cases, direct instructions.

Who, exactly, were the patients we treated? What kinds of problems did they have? What did we do for them? The answers to these questions are in the following case studies of some patients I treated, along with my team members, on the Lower East Side of Manhattan between 1984 and 1991. Collectively, they importantly show how patients' socio-cultural backgrounds interact with their mental and emotional illness to produce, among other things, different behavioral manifestations of the same underlying psychopathologies, self-definitions of health and illness, and reactions to health care providers and medication. These examples also show what I had to be aware of-and what I believe every mental health professional working in multicultural setting-needs to be aware of when treating patients from different national, ethnic, racial, and religious groups.

A White Southern Patient
Our work on the MCU sometimes was inherently dangerous, as in the case of a 50 year-old Caucasian woman, formerly a farmer from a southern state. She was reported to us for evaluation because of her irrational behavior. Alerted to her violent temper, we asked the police to escort us to her apartment. She was completely covered with a white sheet, seemingly immobile. When the sheet was gingerly lifted by the police, her face and extremities were all darkened by dye. She sat up and, with a pocket knife in her hand, attacked the policeman. At this point, the other police officers subdued her and escorted her to the hospital. Later I learned that she used to shoot with a rifle-a fact that all the more raised fears in me.

An English Patient
From the Sherwood Forest in England, a twenty-five year-old man who walked around the neighborhood with a footlong barbecue fork was referred to our Mobile Team by his mother, an only relative. Before we arrived at his apartment, he had pushed his mother out the door, bolted it and demanded an audience and interview with a television crew inside his apartment. The negotiation, among the police negotiator, the patient, and myself took almost the whole day (the television crew and management agreed to talk to him-but only if he came out of his apartment). By dusk, when we thought it was futile to continue, the police decided to enter the apartment. The Englishman was brought to the hospital, eventually.

The MCU and the Police. This case illustrates something of the relationship between we, on the MCU, and the police on the Lower East Side. While there was relative ease in our many attempts to seek police assistance in bringing patients to the hospital, there were many other times our team was met with opposition, confrontation, and even outright challenge to our clinical judgment from the police themselves. One time, for example, after the police refused to bring a patient to the hospital, we on the MCU organized a sit-in with a family. In the end, the police gave in, succumbing to our pleas. Indeed, we experienced many moments of a war of nerves with the police. I am sure there were other avenues we could have explored or resorted to, but at times, expediency overruled and dominated our approach.

Having no guiding principles to arm ourselves with, we relied mostly on our own tenacity and convictions, ever mindful of our position and role. Playing heroes could have been an invitation to disaster. Thank God that no one on our team ever faced ignominious insults or incidents.

Chinese Patients
Most of the Chinese seen by the MCU team spoke Cantonese, having emigrated from either Canton province or Hong Kong. As with most groups in Chinese culture, the family ties were strong, the extended family system was prevalent, and the attitude towards mental illness was one of indifference or denial.

While there has traditionally been widespread stigmata attached to mental illness among the Chinese, the MCU team had noted a general increasing awareness among the Chinese community of the need to do something about treating mental illness through Western methods. For example, some Chinese, with the assistance of social agencies, had come to use psychiatric services in addition to getting benefits in the form of monies and housing improvements.

A designated or declared psychiatrically disabled individual would receive financial benefit and not be obligated to seek employment. This would ultimately diminish or reduce many family burdens. Seeking psychiatric intervention thus became more palatable. In addition, it somehow minimized the label of mental illness in the family.

The gravity of a situation often times prompted a family to seek outside help. A patient who refused to eat or who stayed in bed all day may not have been referred until he or she made the rest of the household angry or extremely frustrated, e. g., by throwing food away, using dirty bed sheets, or wandering in the streets with inadequate clothing during winter.

Such behavior, which embarrassed a family in the eyes of the neighbors, may also have hastened referral to the team. An individual who screamed in the hallway of an apartment building for example, may have gotten the attention of other tenants, which in turn, may have prompted the latter to report the incident to the superintendent or, worse still, to the police. This undoubtedly created a sense of shame.

Mrs. M: These general characteristics, typifying the Chinese on the Lower East Side, may be seen in the case of Mrs. M. When we first saw her, she was 62 years of age, married and living with her husband, age 67, and two adolescent children in a tiny three-room apartment. She was referred to us because she was covering her mouth with a cloth tape (the kind used by engineers for taping wires and equipment), and was refusing food prepared by her husband. In the middle of the night when no one appeared to be watching, however, we learned that she would take food from the refrigerator. She also stayed in bed most of the time, remaining uncommunicative. While never violent, Mrs. M-in keeping with the role of the traditional Chinese woman-was obstreperous when asked to participate in minor household chores. She had a history of psychiatric illness for 10 years, and previously had been to the hospital.

When we first saw her, she was totally covered under a blanket, making little movement or response. After we began speaking to her, she removed the tape from her mouth and emerged from under the blanket. We saw that she was dressed much like the stereotype of the Chinese woman, in black trousers and a kimono-like blouse top that looked like a short robe. Her only words were "nothing is wrong. He [referring to her husband] needs a doctor." She then turned her back on us. Mrs. M. did not speak in English, but, rather, in Chinese, as did her husband.

Speaking Chinese, I was able to communicate with her, and explained, "We came here to help the family." I went on to say that we wanted to improve her living arrangements, by helping them move to a bigger housing unit; and that we also wanted to help her daughter-who was unemployed and had a diagnosis of schizophrenic disorder. I told her that she was not well and needed medicine so that she could go out again and help her children. I purposely avoided mentioning her husband in the early contacts, knowing her profound displeasure with him.

Accepting an injection of medication, she agreed for us to make subsequent visits until about three months later, when she decided to attend the clinic. Meanwhile, she began to take part in other activities, such as her applying for her psychiatric disability and changing to better housing. Both she and her husband agreed to go to the clinic for conjoint therapy.

As noted by her age, Mrs. M. was an Old World individual, and she was not a citizen of the United States. In her homeland, mainland China, mental illness has long been viewed as either a political problem, for example, a sign of "incorrect thinking," or as caused by natural forces and treatable mainly by herbal remedies or acupuncture. Mrs. M. responded initially to us out of a sense of responsibility to her daughter: she got the idea that if she became well, she could then help her daughter to get well and get a job and her own residence. If that occurred, then her daughter would be able to move out of Mrs. M's household, in which there were six people living. Mrs. M was compliant; she went along with authority, following our instructions. She also respected the authority of her husband over her, following traditional Chinese hierarchy in which the wife is subordinate, but she was angry at her husband-and so taped her mouth shut and covered herself rather than show the anger and violate the Chinese norm.

The case of Mrs. M provides a graphic example of how socio-cultural background and psychosis interact to produce a manifestation of the mental disorder. The case of Mrs. M also illustrates an Old World sense of responsibility to the daughter, and how this played a part in her positive acceptance of the MCU team and the proscribed treatment. Also, typical of Chinese patients on the Lower East Side, Mrs. M did not seek care early in the course of her illness but, rather, waited a long time, until the last possible minute before getting help.

Mrs. K: Mrs. K. was 45 years of age, unemployed, separated, with two sons, one of whom was adopted by a family friend. The adoption had been arranged by a Chinese adoption service agency. The other son was attending college. He came home to visit his mother, Mrs. K, during school breaks. He spoke like an American, unlike his mother who was not born here, but in mainland China, and was not a citizen of the U. S. When we first saw Mrs. K, she was dressed like Mrs. M, in black trousers and with a kimono-like top that looked like a short robe. Mrs. K was referred initially to us for psychiatric evaluation by a neighborhood agency with hopes that she would qualify for monetary benefits and not be asked to seek employment.

Two years earlier I had seen Mrs. K, and she walked away whenever I went to talk to her. This time, on our first visit, it was clear that she was paranoid and much overwhelmed by our presence. Her one-and-a-half rooms were very cluttered. She resisted divulging information, especially regarding financial matters. She was noted to talk to herself, and we were told that she wandered aimlessly, often in the streets. She denied any illness and would not accept any treatment.

However, when we reassured her that if she cooperated with treatment it would be good for her sons as well as herself, she soon agreed to further psychiatric involvement. Her son agreed to monitor the medication. Three months later, she came to the clinic on her own for regular therapy.

Again we see on the part of a Chinese patient with an Old World background that a sense of responsibility to a family member, this time a son, provided motivation for cooperation with treatment. A mother's sense of duty to her son is a deeply embedded part of Chinese culture.

Mr. W: Mr. W, age 50, was unemployed, separated from his wife and son, and living in a two room apartment with his mother, 80 years old, who was still working in a factory. Mr. W was referred to us by his mother because he was wandering in the streets, opening all the windows in the apartment during the winter months, and refusing to accept assistance for financial benefits. The mother had difficulty making ends meet.

When we first saw Mr. W, he was hostile -in contrast to Mrs. M-and denied any illness. I diagnosed him as having paranoid schizophrenia. All he wanted was to be an American citizen, because he had a sense of responsibility to his mother; he believed he could care for her better if he were a citizen. He was told that he would be helped in becoming a citizen if he cooperated and accepted medication. He agreed and, thereafter, attended a neighborhood clinic. He subsequently obtained citizenship.

Like Mrs. M, who's sense of responsibility to her daughter played a part in her positive acceptance of the MCU team and the proscribed treatment, Mr. W showed a great sense of responsibility to a family member, his mother, which he linked with citizenship. This provided him with motivation to accept treatment.

Mrs. B: Grossly psychotic, Mrs. B, 64, came to our attention through her husband's concern. He did not want the Mobile Team to send her to the hospital. She was violent, creating havoc for him and the rest of the family. We decided to give her an injection. The family was in total accord with our plan. Knowing she would refuse the injection, we all (including the husband and family) planned in detail as to which room to use for the administration of the medication, and who would assist the Mobile Team in the event she resisted or struggled. Up until the last few seconds before the injection, I noticed mounting anxiety and desperation among the family members. I wondered if they had ambivalent feelings, even in those critical moments, about whether to give or not to give the injection.

We on the Mobile Team had, indeed, met several instances where any idea of interventions frightened the family. The Mobile Team in such situations had made the decisions for them in attempts to ease the agony long endured. In hindsight, these decision-making processes were bold attempts to save time and break the gnawing uncertainties that befell many such occasions. I finally gave Mrs. B the injection, and a week later, the she started attending the psychiatric clinic with her husband.

Ms. N, Mr. G, and Ms. S: This case involves three Chinese siblings who had severe mental illness. Ms. N was a Cantonese woman, age 40, whom I first saw following what appeared to be a psychotic episode. At that time, she had jumped from her apartment to the street, four stories below. Several home visits were made in attempts to control her illness with medication. After some improvement, she was treated subsequently by a neighborhood mental health clinic. Now, five years later, Ms. N was again referred to the MCU team. This time she was catatonic, withdrawn and autistic, so we became more involved with the other members of the family. I noted that her mother was doting and self-sacrificing, and she infantilized Ms. N. She also tried to hide from us that Ms. N. had poured boiling tea on her (the mother) only a few days before the visit. With medication, Ms. N gradually improved and began attending the clinic, seeing the team on a regular basis, and participating in a Day Program.

Ms. N had an older brother, age 50, Mr. G, who lived with his sister and their mother. He was recommended for evaluation because of violent behavior against Ms. N, as well as experiencing auditory hallucination. Accepting therapy, Mr. G began being seen by the team at the clinic.

Not long after these involvements, another sister, Ms. S, age 45, was referred to us because of persecutory delusions. She lived elsewhere with another sister. Ms. S agreed to our visits and accepted medication. She found employment subsequently and continued to be seen by the team.

During that time, we made regular contacts with other family members about the sick siblings. The most reliable and resourceful well family member was a sister, who reported on the progress of her three siblings and the well being of everyone in the family. She indeed was the family's lifeline to the caretakers. This case shows that mental illness can certainly be prevalent within a family, but that not everyone in the family has to necessarily manifest the illness.

Hispanic Patients
Hispanic people composed the largest of the ethnic populations on the Lower East Side. The majority of the Hispanics came from the island of Puerto Rico. The others came from the Dominican Republic and South America. In the Hispanic group there was reluctance to rely on the MCU team unless a crisis of gargantuan proportion had occurred or was about to occur, e.g., physical violence or the carrying of a dangerous weapon.

Among Hispanic families there was a strong tendency to attribute psychiatric illness to something medically oriented; thus one often heard of general body weakness or poor appetite or something called padese de el celebro (weakness of the mind). Within Hispanic culture, there are general ways of thinking and behaving that result in different manifestations of psychiatric disorder than among the Chinese.

Mr. V: These differences, along with certain similarities that will be pointed out, may be seen in the case of Mr. V, a 40 year old unemployed Puerto Rican who was living with his father, age 78, and mother, age 75. He was referred by his father because Mr. V. was "abusive" to him, not so much physically as verbally. It was learned that the son said a terrible thing to his father that shattered the latter's image of himself. Abusive verbalization from child to a parent, it may be noted here, is much more common among Hispanics than among the Chinese; so is a reaction from the abused parent, who in this case called for psychiatric help. Because he called for the help only after the act of verbal abuse, however, I surmised that it was the abuse that motivated him to seek the help and not his son's psychosis per se.

The history of Mr. V, as narrated by the father, involved a long psychiatric illness dating to age 16, when Mr. V saw his younger brother die in a car accident and had since withdrawn to his own world. He had previously been admitted to psychiatric institutions for violent behavior. While individual members of any ethnic, racial, or religious group may exhibit violence, of course, expression of physical violence is generally more typical of Hispanic culture than of Chinese culture, deriving from the state of mind usually referred to as "machismo."

For the past fifteen years, Mr. V had toned down somewhat, and settled in his own room. He often walked naked, slept in the bathtub, and used the toilet for hours at a time, which caused inconvenience to his parents. He accepted food, and this acceptance provided the only bridge of communication between Mr. V and his parents.

On our first visit, Mr. V was seen very briefly in the bathroom but refused all manner of contact. We visited him a few days later and, again, he resisted our entreaty, slamming the door on us, and exhibiting his tendency towards violence in the form of physical behavior.

Three days later he complained of a headache. Among Hispanics, it is generally more acceptable to complain about physical than emotional problems, which indicate weakness and "unmanly" behavior. We were called and, to our surprise, he accepted our recommendation for medication and a neuroleptic injection. There was no apparent reason for the inconsistency in behavior.

A week later, Mr. V began wearing pajamas and speaking to us about sports and current world events. He agreed to our regular visits. Meanwhile other members of the family were contacted to assist the elderly parents.

Mr. A: Another Hispanic patient Mr. A, was from the Dominican Republic. When we saw him, he was 30 years old, single, unemployed, and living with his mother and two brothers. He was referred by a psychiatric clinic in the neighborhood because of non-compliance with follow-up appointments. He accepted, however, taking medication at home. This was essentially like a "bribe" on the part of the clinic, i.e., "Take the medicine at home or go to the clinic!"

On our initial visit, Mr. A was well groomed and alert, but he exhibited heightened suspicion in our presence. He questioned our visit, declaring that nothing was wrong with him. This tendency to deny having a psychiatric problem was also evidenced among the Chinese and other patients we served, and, in fact, is characteristic of most psychotics.

Despite his denial, midway through the session he boomed at us, "Give me the prescription and leave!" To prevent ambivalence on his part, we gave him the prescription and offered to see him again in a week. Subsequent visits were less stressful for everyone, as he was more accepting and had been taking the medication at the insistence of his mother, who had assumed the role of the monitoring agent.

It appeared that without medication, Mr. A would become agitated and fight with his younger brother, again illustrating the tendency of Hispanic males to display physicality. His mother gave in to him often, to the frustration and consternation of the brother. Given the mother's involvement with the brothers, the team tried to clarify the mother's role and the younger brother was encouraged to pursue interests outside the household.

In this case, as in others discussed in this book, we can see that the family unit is involved in the treatment, not only the psychiatric patient. A family member may report the illness, monitor the medication, act as a communication bridge between the patient and other individuals, or liaison with neighborhood agencies, among other functions.

Thus, in addition to medication, the total treatment approach by mental health professionals in a multicultural environment should consider the roles of other family members in the situation of the patient, and the mental health professionals should do what they can to minimize stresses that may exist in the household of the patient among family members.

Mrs. G: A 35 year old Hispanic mother of three, Mrs. G was married to a 32 year old Hispanic man with Schizophrenic Disorder, Paranoid Type. She initially presented to us with a complaint over the telephone-six months before our visit Ñ that she had anxiety and was afraid of going out. These complaints were punctuated by increasing depression and anger towards her husband, who began to exhibit destructive and violent behavior at Mrs. G and their daughter, aged eleven. Mrs. G was fearful that outside interference would provoke her husband further, hence the lapse which preceded our involvement.

Mrs. G was not only anxious and phobic, she was heavy-set and felt trapped. While the three children appeared well cared for, the eldest was noted to be timid and retiring. The husband joined us in only one session. He was indeed someone who exuded fears in others. Visits to the family continued, and she was taking medication we had prescribed.

While she was our initial focus, we were cognizant of the tension which consumed everyone in the household. The husband began to drink, turned more violent, and deteriorated to the point of eviction by court order to his mother's residence.

Meanwhile, Mrs. G slowly took over the reigns of her life, and began to leave her apartment to manage basic necessities; her symptoms improved, and her weight gradually diminished, to her amazement. She continued to raise her children, accepted the additional care of a foster boy, and even began working as a home attendant for an elderly woman.

Three years after first seeing Mrs. G, I felt that she was ready to decide for herself whether there was need for our continued visits. She decided to try to go it alone, even though she expected to experience crises from time to time, especially from the emerging preadolescent turmoil of her oldest daughter. We discussed that she could always call on our MCU team or the clinic for help if the need arose.

Jewish Patients
There were basically two groups of Jews on the Lower East Side often seen by the team. One, the major group, had no ritualistic or strict discipline as far as religious practice was concerned. The other was the Orthodox group, with well defined religious practices. The latter group seemed to draw more attention in general because of an active rabbinical order and an established social agency under the aegis of a wider Metropolitan Jewish Service Agency. There was a rabbi who made home visits to oversee members of the congregation. Thus problems, be they medical or psychiatric, were reported right away to respective clinics.

Patients in both groups were often reported to us by neighbors, landlords, or superintendents of the apartments in which the patients resided. Often, the reason for the referral would be poor hygiene (of the patient or of the patient's apartment), which undermined the values of other tenants. Non-payment of rent was also a very frequent reason for referral. I noted that the relatively small household size of the Jewish patients we saw generally reflected the smaller household size of Jewish Americans compared to other ethnic groups in the society.

Mr. S: A 57 year old man, he was single, unemployed, and an Orthodox Jew who was referred by the rabbi of his synagogue. The rabbi reported that the patient was not eating, was extremely depressed, and would not leave his apartment.

During the initial visit, Mr. S presented with paranoid ideation and vegetative signs of depression. The suddenness of the onset of illness coincided with the anniversary of the death of his brother of heart attack, in the same synagogue he now attended.

Mr. S at first refused any kind of medication, and the MCU team and the rabbi tried to persuade him to change his mind. The rabbi spoke directly to him in Yiddish, and we basically pointed out to Mr. S that the congregation needed him; this was apparently the key statement for gaining his compliance, and he finally accepted an injection of a neuroleptic.

Mr. S improved in a few days, and he started attending the synagogue and coming to our clinic for follow-up. The next year, sometime during Passover Ñ an important Jewish holiday in which families typically congregate in households Ñ Mr. S relapsed into a similar psychotic state. The rabbi again contacted us and tried to communicate with Mr. S. A neuroleptic and an antidepressant were instituted. Two days later, we were hastened back to Mr. S's apartment, and were made aware of a problem involving the 50 mg. antidepressant pill I prescribed. Both the rabbi and the patient stated-with confirmation from a Hebrew pharmaceutical book-that the 50 mg. pill was not kosher because of the way it was prepared (with wheat or barley), but that the 25 mg. pill was acceptable. It appeared that during Passover, the preparation of the 50 mg. pill was not in keeping with the Jewish Law. "Everyone" agreed with this, the patient told us. We complied with the patient's wish. Improvement was gradual and progressive.

This problem of the 50 mg. pill not being kosher provides an extremely clear example of the effect of socio-cultural background on patient behavior, in this case involving the relationship to a prescribed medication. It may also be noted in this case that each time we were called to see Mr. S followed a religiously heightened time for the patient: in the first instance, it will be recalled, the onset of illness coincided with the anniversary of the death of his brother of heart attack in the same synagogue the patient attended; and in the second instance, the onset of illness occurred during Passover.

This case also suggests that mental health professionals should pay greater attention to susceptible patients during emotionally heightened times, which can be stimulated by religious or other socio-cultural events, especially those involving such basic realities as family, God, and "roots."

Mr. P: Another unmarried man, Mr. P was 52 years of age, lived alone, and had a Bachelor's degree in Accounting. At the time of our visit, he was unemployed. Mr. P.'s mother-a retired social worker 85 years of age who cleaned his apartment twice a month-provided him with sundry monies, and he also received a comfortable disability remuneration. In general, Mrs. P doted on her son and, in this regard, fit the cultural stereotype of the "smothering Jewish mother."

Mr. P, who had been ill since age 19, was referred to us by his superintendent because he was leaving his apartment door unlocked whenever he went out and asking for minor things from other tenants in the building. We also learned that he occasionally took things from the neighborhood supermarket without paying.

On our first visit, Mr. P appeared floridly psychotic, although he accepted medication. As he gradually improved, he felt that he could pursue some graduate courses in business and continue treatment in our clinic. Simultaneously, we also periodically saw Mrs. P, because we felt it would be good for Mr. P to do more things for himself, and for Mrs. P., consequently, to be less of a "smothering mother." We attempted, in other words, to diffuse her involvement with Mr. P while retaining the sense of bonding they deeply shared.

African-American Patients
Many African-American individuals on the Lower East Side live in housing projects that are either exclusively Black or are integrated with, among others, Hispanic, Chinese, and Polish individuals and families. Compared to other socio-cultural groups in the area, African-Americans have fewer intact families and less of an extended family structure. In addition, they have relatively few community helping organizations rooted in African-American heritage designed to care for individuals with mental or emotional problems. For these reasons, Blacks were more likely than members of other neighborhood groups to seek assistance from the local clinics and hospitals in cases involving emergencies, including matters involving the police. Thus, we frequently saw Black patients in their homes.

Mrs. L: The case of Mrs. L was typical, in many respects, of the African- American patients we saw. Age 50, Mrs. L was separated and living with her two grown sons as well as home attendants, who resided with her 24 hours a day because she was confined to a wheelchair, as a result of having had post status CVA (Cerebral Vascular Accident, or "stroke"). We quickly learned that her younger son, who was 20 years of age, was suffering from Chronic Schizophrenic Disorder. It may be noted that Mrs. L.'s familial household composition-a mother only and her children-is more typical of the African-American family in America than of any other socio-cultural group.

During our initial visit, Mrs. L presented with myriad problems, including auditory hallucinations, poor impulse control (e.g., screaming and leaving if not seen right away), and difficulty comprehending mailings, mainly bills, she received from various social agencies, such as the phone company, which had discontinued her service for lack of payment. Mrs. L also, we noticed, suffered from bronchial asthma, which was very much related to stressors within the family. These included her schizophrenic son's frequent need for psychiatric admissions; her eldest son's inappropriate social contacts, especially women he brought to the household for the purpose of having sex, in a separate room where he could secure privacy; and a third son's frequent visits to the household when he was having trouble with his wife. This son was also psychotic.

Although we noticed that Mrs. L rarely yelled at her sons, she was frequently in a state of rage over the "incompetence" of the home attendants sent to care for her, who were Caucasian. She often justified this conviction after "testing" them. For example, she would ask, "What would you give me if I had a seizure?" While she appeared mildly depressed, she viewed expressing suicidal ideation as a "challenge."

Mrs. L accepted medication and regular visits by the team, and she started coming to our clinic. At the same time, the MCU team monitored the younger son's psychiatric follow-up at another clinic and directed the older son to gainful employment. Over time, her hallucinations disappeared, she came to realize that her anger at the home attendants was related to her decreasing omnipotence and loss of independence, and she gradually accepted the role of the home attendants. Her inner strengths propelled Mrs. L. to consider outside occupational activities.

Mr. S: Twenty-three years of age, Mr. S was single, unemployed, and living with his parents when we first saw him. He was referred by his mother, the apparent power in the household, who was once an active community worker in the neighborhood.

On our initial visit, Mr. S appeared alert and generally responded appropriately. He reported a morbid fear of leaving home, however, because he thought that people could look through him and read his mind. He thus stayed at home and never went outside.

Without much difficulty, Mr. S agreed to accept medication and the MCU team's regular visit. Four months later, he ventured out during twilight on his bicycle, "So I can come home right away in the early evening hours," he explained; soon he was riding during the day time.

A year following our initial home visit, Mr. S felt comfortable seeking employment as a courier, using his own bicycleÑa relatively common occupation in New York City for a young Black man without much formal education. The MCU team encouraged him to pursue his interest. Six months after working, Mr. S began to socialize and, to his surprise, he found a lady friend. The romance continued and, another six months later, he announced his marriage to her. Mr. S maintained contact with the MCU team and requested formal transfer to another clinic for follow-up when he moved. The MCU As A Wise Teacher: Some Lessons Learned About Multicultural Psychiatry
From my experience on the MCU between 1984 and 1991, I came to deeply appreciate that socio-cultural background factors of patients influence how they act out or behaviorally express the same underlying psychiatric disorder. I also came to appreciate deeply that socio-cultural factors influence how patients think about their mental illness, relate to medication, treat mental health professionals, and follow-through on treatment modalities, including visits to clinics and hospitals in their neighborhoods.

For example, Mrs. M, the Chinese patient, taped her mouth shut so as to contain verbal violence against her husband, which would have violated cultural norms from the "Old Country," mainland China. She was also conservative about her physical appearance, remaining dressed at all times, and in Old World clothing. In contrast, Mr. V., the Hispanic patient, was verbally abusive to his father, caused inconveniences to other family members, and frequently walked around naked. His cultural background including "machismo" was noticeable in his behavior. Mr. S, the Jewish patient, clearly showed how socio-cultural background factors affect behavioral expressions of mental illness when he, for example, refused to take the 50 mg. pill, which he claimed was not kosher. He also did not exhibit violent behaviors, which are less typical of Jewish individuals than members of some other ethnic groups. Finally, Mrs. L gave indications of how her socio-cultural background affected her behaviors by showing rage at and "testing" the Caucasian attendants, but not exhibiting such abusive behaviors toward her own sons, whom she tolerated despite their often aberrant behaviors.

In these examples and other aspects of the case studies presented, it may be noted that much of the behavioral differences expressed by patients is evidenced in interaction with other family members, or other individuals involved with the welfare of the patient, such as the home care attendants and the rabbi. In addition to being an object of communication for the patient, a family member or other caretaker may report the illness, monitor the medication, act as a communication bridge between the patient and other individuals, or liaison with neighborhood agencies, among other functions. Thus, in addition to medication, the total treatment approach should consider the roles of family members and other caretakers in the situation of the patient, and mental health professionals should do what they can to minimize stresses that may exist in the household of the patient.

Because of socio-cultural differences among patients, treatment strategies must inevitably vary from one ethnic group to another. The Chinese group for example, to a greater extent than any of the other socio-cultural groups discussed in this book, more readily accepted a treatment approach that began and ended at home. This may have been because, among the Chinese, the hospital has traditionally been viewed as something akin to the "end of the road," where patients were believed to have, at best, only a 50-50 chance of recovery. Jewish patients, on the other hand, in my experience, welcomed early hospitalization, viewing home treatments as dragging on, uncertain, and often painful.

In addition, from my experience on the MCU, I came to conclude that psychiatrists and other mental health professionals must be aware of how socio-cultural factors affect reception of the medication prescribed. In the case of the Orthodox Jewish patient discussed above, Mr. S., for example, it will be recalled how he would not take the 50 mg. pill because it was not prepared in keeping with the kosher laws, but he would take two 25 mg. pills.

My experiences with multicultural patient populations has also led me to form the impression-an hypothesis really-that behavioral differences between individuals of the same class, education, etc. in the various normal socio- cultural groups, e.g., Hispanic and Chinese, are greater than they are among the psychotic members of the respective groups. In other words, I believe that psychosis tends to minimize socio-cultural differences among individuals from different backgrounds because the disease itself tends to manifest uniform characteristics in all individuals. This "homogenizing" influence competes with the distinguishing influence of socio-cultural variables. The net effect of these two forces working togetherÑthe "homogenizing effect" (of the psychosis) and the "interactive effect" (of socio-cultural differences and the psychosis)Ñis a lessening of the way socio-cultural characteristics distinguish behaviors of individuals in normal populations.

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