Washington Baltimore Center for Psychoanalysis

Beyond the COuch

A Grand Experiment in Community Mental Health: The DC Institute for Mental Hygiene

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By Patricia Demont, PhD

After graduating from Catholic University, I inquired where people went to get the best training in psychodynamic/psychoanalytic theory and practice. The Washington School of Psychiatry and the DC Institute for Mental Hygiene were named repeatedly.  

I knew nothing about the Institute’s stellar history when I began working in one of the three branches of what was typically called DCIMH.  I am only now fully aware of its incredible backstory.  Dr. Harold Eist was appointed the Medical Director of the tiny Institute in 1969 with a handful of staff members seeing less than a total of twenty patients. Harold was the genius behind creating the Institute’s mission which set it apart from all other community mental health centers.  The mission was two-fold: first, to provide the same kind of quality mental health care to the poor that the affluent could receive; and second, to offer the best psychoanalytic training to volunteers so that they would flock to the Institute, gladly trading their time and service for the opportunity to learn psychoanalytic theory and practice treating this population.  This mission drove its success.

The Institute grew into hundreds of staff members at three different locations treating thousands of patients each year.  In 1979, the Institute received the Gold Award for “ Best Community Mental Health Center” in the country from the American Psychiatric Association. That same year, Dr. Eist was recognized as a Washingtonian of the Year for extending outpatient mental health. Additionally, The Frieda Fromm-Reichmann award was given to Dr. Eist for bringing psychoanalytic psychotherapy to the underserved in the Washington, DC area.  By 1975, the Institute began offering annual symposiums to widely attended audiences.  In short, DC Institute was unique among community mental health clinics and wildly successful.  But I knew none of this at the time I began as a volunteer in Anacostia.

A Snapshot of my Experience:

On a fall morning in 1986, I walked towards the medical building which housed Anacostia’s branch of the DC Institute for Mental Hygiene.  Soon, I saw the familiar face of a patient of mine who was waiting for my arrival.  “L” smiled the unmistakable smile of someone with tardive dyskinesia.  His face lit up seeing me and he said what had become a familiar welcome: “take a wing!” while offering his bent arm to escort me into the building.  I happily accepted.  We entered together.  I saw L, who was living with chronic schizophrenia, three times a week for one dollar per session.  Although his session with me would not occur for three hours, he simply enjoyed being at our clinic and treated it as if it were a day treatment center.  In fact, the waiting room was full of people including some without an appointment that day.  My initial fear of being in the inner city known as “the murder capital of the world” was dispelled.  So was my worry about whether I, a middle-class white woman from the suburbs, would be accepted by the poor Black individuals who came to see us.  I had a lot to learn, but each patient was a unique teacher and the connections we made transcended race and socioeconomic status.

Later that day, my case load included a grandmother who took three buses to come to see me.  Her daughter was on crack cocaine, and she had become the primary caregiver to her grandchildren.  On that occasion, she brought me a homemade sweet potato pie.  At the Washington School of Psychiatry where I was participating in a certificate training program simultaneous to my work in the inner city, I learned not to accept gifts from patients.  In Anacostia, I understood that to refuse this kindness would be a mistake.  What justified the difference?  To some we saw in Anacostia, we became an extension of their family.  The parameters of traditional psychoanalytic therapy were modified to include this understanding.

Once, a mother recently assigned to me came bereft from the recent shooting of her son.  When she asked me to walk with her to the place where he was killed, I didn’t think twice about saying yes.  Being a witness to the senseless murder of her young son and experiencing this mother’s unbearable grief was an important early step in forming a connection.  She needed to know I could accompany her to the depth of her horror and sorrow without shielding myself.  Our work in the inner city did require us to stretch and grow and to tap into inner wellsprings of strength we hadn’t known existed.  It was sacred, privileged service.

We were able to provide care to the population we served because our clinic was the epitome of Winnicott’s “holding environment” from the top down.  Dr. John Love (Jack to us) was the psychiatrist at our clinic and his experience working with severe mental illness gave us courage to do the same. He literally fed us with bagels and cream cheese when we gathered for study groups.  To those of us fortunate enough to work in Anacostia, we privately called our branch “the Love Clinic.”   The next line of defense was the experienced supervisors Jack met with weekly to discuss any issues or questions they had in supervising the rest of us.  We received a free hour of supervision for every five clinical hours we provided.  On Fridays, everyone gathered for a day of training.  Didactic training was led by senior staff.  A formal case presentation was given, and a discussant responded.  I would be remiss if I didn’t mention the importance of our staff lounge as part of the holding environment.  I learned to “never be alone with a difficult case,” and invariably found members on break ready to listen and provide comfort when needed.  We supported each other.

I learned a great deal about working with psychosis from Jack.  It wasn’t unusual to see him sitting in the stairwell beside a frightened patient who was not yet ready to enter our space.  He also knew that despite the voices and hallucinations a new patient might experience, writing a prescription for medication before establishing a connection would not work.  Often, he’d learn what interested that person, get them engaged in conversation, and suggest they drop by tomorrow to say hello. Most did.  I came to understand that ingesting medication felt equivalent to ingesting the prescriber himself. For some, their projections interfered with conversation.  Jack had a ready supply of books from which to read aloud to interrupt the silence.  Jack would assess what the individual could tolerate and titrate his dosage of expression of interest appropriately.  “You can’t take a starving man to a banquet,” he once explained.  A jar of jellybeans was always on his desk, a concrete manifestation of the many ways Jack fed the hungry.  I remember learning one year that Jack intended to work on Christmas Eve.  He simply explained that Santa had to come.

There was much to love and be proud of working at DC Institute for Mental Hygiene. For me, one of my highlights occurred quietly with “L,” my patient with chronic schizophrenia.  We had worked together for several years.  He looked across the room at me and quietly quoted words I recognized:

          “For I was hungry, and you fed me.

            I was thirsty, and you gave me water.

           I was naked, and you clothed me.

           I was sick, and you visited me.”

I have never been thanked so eloquently before or after. This was a moment I will always remember from my work providing community mental health in the inner city.

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