Sticking It Out As Case-Aides, PBH Volunteers Prove Themselves

Roy M. Kahn, Director of Psy chological Research for the Children's Unit at Metropolitan State Hospital and also for the state Department of Mental Health, has supervised Phillips Brooks House case-aide programs for three years. Groups of Harvard and Radclifle students in this program go out to various hospitals, including Met State, once a week to see individual patients. The group discusses their visits with a professional consultant.

In a recent interview, Dr. Kahn spoke--as a PBH consultant--about the motivations and learning processes of students who participate in the program.

I DON'T know the motivations for people getting into case-aide work. I imagine that these students are not exactly a representative sample of Harvard, because in almost every instance there has been some kind of family problem, either between the case-aide worker and his parents, who are possibly highly placed and overly busy, or who have had separations, divorces, deaths in the family, and other things. In a way it is possible that, in seeking to work with people with problems, they are also seeking to find some way to come to grips with their own problems.

A lot of case-aide workers are probably not altruistic, but selfish, in the sense that they are very eager to prove something about themselves. But this effort to prove themselves is also an effort to grow and should not be seen in any other light than that. It isn't really selfishness. I guess, to want to grow, but it isn't altruism. They're not going in masochistically.

A number of case-aides, on their own elect to go into individual therapy. Not a lot of them, and not because they think they're going to go insane but because they get confronted with things that they think they need help with. They probably could resolve these things on their own, in some other fashion, over the next five or ten years. But it might be much more difficult.

Testing Reality

I think that the concerns of case-aides about their emotional security are no more and no less than the concerns of any other people of the same age. The way they approach their problems may be a little different. They may seek to test reality by going to see what very disturbed people are like. They may seek opportunities to apply their knowledge or experience or theories -- they're tired of being students.

They may have family members who have been ill and be attempting to atone for unconscious guilt or something. But these are not the basic motivations. I don't know what the basic motivations are. They relate to efforts to establish their own value, their own work, their own capacity, their own ability, and to somehow grow from wherever they are to some other place they want to get to.

The role that they fill for the patients may help them do that, and the judgments that they have to make may help them do that. And I think that their outrage at the realities of life in mental hospitals may help them do that. The knowledge that intentions are not enough, that action is also required--and in this generation you see that knowledge more and more especially politically--is also important.

Different students join the program for different reasons, mostly because they come equipped rather differently for the work that they're going to do. A fairly consistent thing develops in case-aide work, and that is, through the year, a kind of group feeling or group coherence which grows up among the case workers in any given group. It comes from the discussions. Each group has a day leader--he's a student--and a [professional] supervisor. The frequency with which they meet with the professional person--advisor (I guess everyone's a professional person)-- varies very much from group to group. The kind of group that forms also varies with the frequency.

Classic Pattern

What you get, then, eventually, in a good working case-aide group, is a kind of group process--normal group process, not group therapy. This is definitely not group therapy. You get a normal group process, provided that the membership doesn't flit in and out and provided that they do bring a certain amount of dedication to their work.

We have an almost classic pattern in these groups. The sooner the population of the group coheres, the sooner the effects of the group set in. Students won't express themselves in the group until they feel comfortable, so you have to have a stable population. The first two or three weeks, it's frightening, it's exciting, it's exploratory.

It is then crucial that the supervision not become group therapy. But personality changes in the case-aides do occur. Students who are aware of their own problems actually do change in their relationships with their families. The girls start out talking about "Daddy," but by the end of the year they're talking about "my father." This is just a little bit different. The boys, some of them, become aware of their relationships with their brother, and so forth, but none of this is discussed in the group. This is something they do internally. This is not Soc Rel 120.

What it is is that in the course of exploring how other people feel, how meaningful they themselves can be to other people, and how little things mean something to them and to others when there is an interaction between the patient and the case-aide worker, they begin to discover that actually, they have a lot of feelings that they didn't know about. The group may point it out to them or the patient may point it out to them by refusing to see them one week after they've missed a session, and they hadn't thought they were that important.

AND THEN also, very importantly, the case-aide worker has to be the adult in the situation. You go to college and you have a moratorium, you live in a protected world whether you like it or not, you're not worried about food or clothing necessarily, your tuition is paid, your big head-aches occur in two sets of three weeks during the year--it's all pretty easy.

And suddenly you come to a situation where what you do or what you say is apparently important to someone else, and you must make the judgments. The rules are not there as to how you should behave or what you can rebel against. You suddenly become the adult instead of the one being taken care of, and you find it's not that easy. This enables you to take another look, to review your relationships with other people. And changes do occur without therapy, without any such thing--as a normal process of growth.

At the end of about six weeks, you begin to get a puzzlement in the group. The case-aide brings the best of intentions. Harvard students -- people in that age bracket, generally--bring a sense of omnipotence to their work: it is as a result of their good intentions that the patient will get well. It is as a result of somebody paying a little attention to him. Sometimes this actually works.

But intentions are not enough, and this is what I've learned, if anything, in case-aide work. Some knowledge is important, but people with psychology or soc rel backgrounds generally do not make the best case-aide workers . . . they're anxious to apply their theories where theoretical knowledge is almost an impediment. Total naivete is worse, however. Some students start working from voyeuristic interest, but that quickly drops out. Adequate supervision stops that. I'm talking about the kind of person who feels that if this patient could only realize it's silly to keep banging his head against the wall, he'd stop. We had had some like that, and they do pose a major problem, but eventually, through group pressure, they are ready to become case-aide workers.

Patients Are People

But the ones who have a smattering of theoretical knowledge get hung up on interpretations instead of listening to the patient and relating to him as a person. Successful case-aides react naturally to a patient and bring things back to the group to find out what they're about. Frequently they are being therapeutic without doing therapy. They try to figure out the patients, but as people, not as cases.

After six weeks, then, the patient isn't getting well. He is still sitting behind a newspaper during the hour. He still says, "Aah, I can't see you because I'm gonna play poker." You go see him after five weeks of visits, after having brought him a little gift, and he's in bed and he just doesn't want to see you. And this has to be understood--as a rejection, or as a fear of closeness, or as an invitation to get into bed too.

You have to come to grips with this, and the case-aide's intentions are no longer the meaningful variable in dealing with the patient's experience of the situation. They are meaningful in terms of keeping the case-aide working with the patient, and they are meaningful to the patient, I guess, in terms of the fact that the case-aide keeps working in spite of the rejection, but in terms of curing someone, the inner conviction, by God, I'm going to help this person, itself is not enough.

So, at the end of six weeks, we begin to hit a puzzlement, a wondering at the loss of omnipotence, and maybe you begin to get a flaking out. Some people begin to drop from the group; they get discouraged. Three weeks in a row the patient hasn't wanted to see them. They decide the case is incurable, this is a lousy deal, and they drop out.

Realizations

This is not necessarily true. Cases may be incurable--in fact I don't think we cure anybody, we get them well enough to manage in the world. Nevertheless, you struggle through that, and the group begins to need support from the advisor and the day leader. Up comes exams about this time or a few weeks later; there is an interruption, and unless the case-aides keep contact with their patients, you find that the patients do reject the case-aides.

At this point the case-aides need to have explained to them that they are important, that the patients have been rejecting them, lying to them, or whatever. And about this time a depressed mood settles over the group. They have discovered that they're not going to fix the patients in 12 or 16 or 18 visits once a week. Here the group really comes to grips with itself. Is it going to be a group? Is it going to survive this realization, this destruction? How meaningful is it? Why did they get into this thing? It's a difficult job, it's hard work, and so forth.

They work this through, and begin to feel better about what they're doing because now they've finally gotten to know their patients and what this stuff means--not analytically, but in terms of interpersonal relationships. And then it's almost time to stop. We have to work through the termination, and we get a genuine depression in each member of the group, as well as in the over-all group. They have to realize that it is up to the patient to retain whatever they've done.

He may keep two per cent or 90 per cent of the good, the growth, the change. The whole year may have been spent just in getting to know the patient. That patient is not going to walk out of the hospital this year. Are they going to volunteer next year? This is the point at which the girls start speaking about "my father" instead of "Daddy." They become more realistic about the difficulties involved.

IN GROUP discussions, they bring up their own feelings, something different from their own problems. I only recall one instance when we got into some individual past history. This one episode related to dealing with feelings about death, and this brought up a piece of personal history which was very useful because it caused the other group members to express their feelings freely. But we got right back on to the patients.

Questions keep coming up in the groups. "My patient wants to double date. What should I do?" We had one funny incident with a charming girl, a good case-aide, whose patient, a lady, told her that her son would not allowed her to see her husband. For 20 years, supposedly, her son had not allowed her to see her husband, who had just had, supposedly, his second coronary up in New Hampshire. The case-aide was all set to take this patient in a car to New Hampshire to see her husband.

Before she could go, it came to my attention--fortunately, because first, we don't even know if there is a husband; second, we don't know if he is in New Hampshire, and if she crosses a state line, she can say. "Out! Bve!" Third suppose that there is a husband and he's had his second corpary and he hasn't seen his wife in 20 years and she's been in a mental hospital and looks all disheveled. When she walks in he's going to have his third coronary, and that'll be fatal.

Jealousy

Sometimes the case-aide worker becomes possessive of his patient and resents any "interference" by the hospital--sometimes appropriately. Quite correctly at times students feel that the system helps perpetuate an illness and impedes the patient's discharge.

Three years ago, people would go out and comment on how horrible the hospitals were; now they come out and say. "I thought it would be worse." I don't know whether the hospitals have changed that much or whether the case-aides have gotten feedback--they'd been told how horrible the hospitals are and see that they aren't so bad.

Three years ago they'd come out ready to teach the hospitals how to run things. Now they are a little more worried about whether they can handle it. Fortunately, they also bring lots of energy and imagination. They are not musclebound with knowledge, and as a result they bring iniative; they do things with the children, for example, that are perfectly marvelous and that the professional staff is too old, and too tired, and too beaten down by the system, even to try. Similarly, with the adults, case-aides can invest in an individual in a situation where normally one doctor, with 300 patients, gets to see them once every Gow-knows-when. This is not the doctor's fault, he is overburdened and just can't.

What the patients have done is to alienate the world. They've withdrawn from it and they've force dit not to want them around, either. The case-aide must mediate between the patient and the community and get them to accept each other more, without doing fancy intra-psychic work--which only the patient can really do. In therapy you don't cure patients. You open doors and try to let the patient go through if he wants.

Getting Out

Of those case-aides who have come back for two, three, or four years, many have been able to get their patients out of the hospital. It involves meeting their families, getting them an apartment, going out and getting them a job, or getting them to get a job, telling them they look lousy, they're not going to get a job without a necktie on, dragging them around in a car to these jobs--supporting them at all points. It isn't just on a once-a-week basis that you get these people out of the hospital.

Nobody leaves as a result of case-aide work. They leave as a result of getting some help in leaving. They might not have gotten this without case-aide simply because they're lost in a mob of 300 people. The patient has to get himself to the point of leaying, but frequently he cannot do this on his own. At least five out of the about 25 adult patients who have been seen by case-aide workers in the past three years have gone to halfway houses, or gotten out and gotten jobs. This is usually the result of two or three, not one, year's work.

If the case-aide is not coming back, this is made clear. It is unfortunate, as is any break in a relationship, or a friendship. It is guilt-inducing, but the realities are that Harvard students go off places come sommertime. Those that have stayed have tended to get involved in the summer program, and have gone out to see their patients--usually without supervision. They don't just sit on the ward and talk to patients. If the weather's nice they take them out. If they have cars, they might take them to Harvard Square or something. They do all kinds of things that are perfectly marvelous to reintroduce the patients to the community.

They have a lack of fear about doing things with the patients that the staff doesn't have the time or the inclination to do. A girl runs up a hill with a little boy and he loves it and he's laughing--I don't have the energy to do it. Students get down on the floor and play with the kids.

In the course of case-aide work, a certain amount of judgment is called for. The exercise of this judgment prevents the exercise of pure rebellion by the case-aide against a system that has become top-heavy, monolithic, under-financed and therefore incapable of dealing with the problems that are involved in getting patients out. The new Commissioner of Mental Health, Dr. Greenblatt, is and has been very supportive of case-aide work. He really is moving this group, attempting to get patients out into the community and to get community people to work with the patients, to get them placed, and so forth. The case-aide program has been anticipating these efforts for several years.

I'M A BIT of a martinet in this regard: You do make a contract with your patient, and you have a sem-i professional relationship, insofar as you have a commitment. I also very much believe in activism--in getting the case-aide and patient to talk to the doctors, in discussing getting medication lowered if the patient thinks it's too high; in relating to the ward personnel, the nurses and attendants, and trying to learn from them even if one does not take everything they say at face value.

Rivalries

Rivalries among case-aides are not overt rivalries. Nobody hates anybody in the groups. What does sometimes happen is that the roles of the day leader and the professional advisor have to be clarified between them. They have to work together so that the advisor doesn't feel usurped by the day leader and the day leader doesn't feel put down or put himself down to the supervisor. If not, the group will split and form loyalties. This is where professionalism comes in--here, and in answering questions like "What is the effect of electroshock?" or "What does this drug do?" or "I want to get my patient out; who should I contact?"

If the day leader and the supervisor get together frequently enough, the group will cohere. If there is any competition among group members, it spurs them to try different ways of helping their patients. Problems do come up when one member tries to dominate the group by endlessly bringing up his patient.

Other problems come up when one member unknowingly tries to turn the session into group therapy by saying that the supervisor is lousy or that the day leader isn't doing his job or that the whole philosophy of the group is wrong--raising the anxiety of the group in order to get attention for himself. At that point, rather delicate handling of the situation is needed to keep it from becoming group therapy, or to keep the one from being clobbered by the rest of the group.

Brute Honesty

No formal ethic evolves, but of course you do not lie to patients, you do keep your problems, you do keep your appointments. Furthermore, since patients are very sensitive to their own feelings--not so much to yours--they do not necessarily respond to your wishes but they do sense immediately whether you are telling the truth and whether you are afraid. If they feel this, they immediately withdraw.

On the other hand, brute honesty is not particularly indicated; this is not an Ibsen's Wild Duck situation. You listen to something and you try to respond more or less the way you feel, within the bounds of judgment. You don't tell the patient, "We won't talk about that because I'm scared." What you might say is, "That's kind of a frightening idea." He may be frightened of it too.

One girl we had finally learned to say no. She couldn't stand to hurt anybody's feelings, but the patient kept asking to kiss her and she spent almost a whole year just learning to say no. For her to learn that was a very important part of her growing up.

Sex has not been any problem in any of the groups I've had, because it's very simple--you handle it matter-of-factly. The patients are not that intersted in sex, anyway. It's not the issue. The issue is fear, and terror, and sickness, and trembling unto death, a la Kierkegaard.

Patients are very much like children sometimes. They sense things without understanding them. They are sometimes frightened of what they sense, so it is occasionally appropriate for the case-aide to be aware of what he is feeling so he can explain something about the topic or problem in a way that the patient can understand too.

"WHEN AM I going to get out of here?" Possible answers: "Ask your doctor." "Do you want to get out of here?" "When do you think you're going to get out?" "You'll get out of here just as soon as you show them that you aren't going to go around hitting people." "You get off the bottle." "You can get out of here any time you want to, but you have to have a job first."

Honesty is basic, but you can only be honest about what you know about yourself. You cannot equate honesty with brutality. In Hannah Green's book, the doctor was not brutal with the child. She did finally say, "I never promised you a rose garden." But it was only whenthe patient was ready to hear it, and had discovered that the world wasn't going to be a rose garden.

I discourage the reading of any records until after they've known the patient for at least six months. When finally they see the records, inevitably they say the record doesn't help one bit. Actually, the record is very useful to a professional, but for accomplishing what you're trying to accomplish as a case-aide, the record may be useful for finding out that the patient doesn't really have a sister, or didn't really kill his child, or has in fact held good jobs, but what is the good of knowing about the truth of a sibling when the patient was a year old? To a professional it may be helpful, but for working with the patient or getting him out of the hospital, it isn't very helpful.

I THINK the voyeurism you originally asked me about comes in in wanting to see the record, but it is also the child of insecurity in the role: there must be some answer to this case, and it must be hidden in the record. Father must have the answer. This leads to a whole series of unspoken assumptions that something has been denied. The doctors are deliberately not curing this person. The answer is somewhere in the record. They won't let me see the record. Therefore they don't want to cure this person.

"The nurses and attendants are nasty, vicious people." This is not true! And when case-aides see a nurse say to a patient, "Damn it, get up! Get out of here!" they protest, but it may be exactly what that patient needs, and they may find themselves saying the same thing four months later