My daughter Jessye, who’s graduating from college, tells me she wants to go to work in community mental health. She’s excited by many aspects of the field, particularly case management with women and children. As a 25-year veteran of the struggles of community mental health, I listen to my daughter and think unworthy thoughts on the order of “Get an MBA!” At the same time, I admire my daughter’s sense of purpose, and I instinctively understand her passion.
Jessye will make her own career choice, of course, but her selection process is prompting me to reflect on mine. After a quarter-century in the field, would I still recommend community mental health as a career? Part of me believes that no reasonable person would choose this work, especially not now. Beset by chronic budgetary constraints, invasive regulations, heavy caseloads, frequent crises, and insufficient respect from society at large, community mental health today seems like a Sisyphean career choice. At the very least, it qualifies as what Michael White called a “problem-saturated narrative.”
It didn’t start out that way. Officially launched in 1963 when President John F. Kennedy signed into law the Community Mental Health Act, the CMH movement was born of equal parts idealism, political will, and commonsense thinking. The plan was to build 2,000 mental health centers throughout the country, most located in low-income communities. Each center would offer a soup-to-nuts menu of services, from inpatient and outpatient treatment, to 24/7 emergency services, to drug and alcohol treatment, to day programs and more. The dream that drove the plan was to make high-quality, comprehensive mental health services accessible to everyone who needed them, especially poor people who’d previously gone without care or whose “treatment” had consisted of hard time in state mental hospitals. There was excitement in the air, a sense of agency and optimism about making meaningful social change through empowering clients and communities.
Almost from the start, psychotherapists saw in CMH work the chance to develop therapeutic approaches that would address the multilevel, interwoven troubles of families, rather than merely treating the symptoms of individuals. Salvador Minuchin developed structural family therapy from his work with “families of the slums” in West Philadelphia, and through the 1970s, family therapy was virtually identified with community mental health.
I wasn’t part of the movement yet—I wasn’t even a therapist yet—but it got plenty of media attention, and I found myself intrigued. The early community mental health movement seemed to me genuinely visionary and democratic, a concept that attracted therapists who sought to meld political ideals of equality with grass-roots work with troubled people. The personal was the political. Now that was an idea.
At the time, I was caught in the intersection of the political and the personal in a different way, as a political organizer and consultant in New York City. I’d experienced the exhilaration of triumph in battles for good causes, including a stint with the Puerto Rican Legal Defense and Education Fund when it successfully sued New York City in 1981 to stop the mayoral and city council election due to redistricting that was discriminatory to Hispanics. I’d also experienced failure, plenty of it. Unequipped to manage, or even identify, the interpersonal animosities, implicit power struggles, and hidden coalitions that seemed to torpedo so many of my organization’s efforts, I began to feel increasingly frustrated. Clearly, I needed to learn more about human behavior. I was also in my own therapy, and had begun to value the process of change involved in exploring the internal, as well as the external, world. So, I enrolled in graduate school in clinical social work.
Some of my political-organizing colleagues thought this was a bad idea. When I told them I might go into counseling, they dismissed it as a “band-aid,” work that offered people temporary relief, but took place too far downstream from fundamentally unjust social and economic realities to have any major impact. I didn’t disagree, but I still felt a pull toward counseling. Maybe it was for the greater intimacy of contact I’d experienced in my own therapy, the mix of interpersonal honesty and accountability that was often missing in political discourse. In my former job, I’d spent plenty of time talking about “the people,” but what did I really know? Whom did I really know?
Listening for Systems
My first placement, in 1982, was in an inpatient setting in East Harlem as part of a Hispanic outreach unit. Many of our severely mentally ill patients were being “deinstitutionalized” with no viable discharge plan; they were simply returned to the street. So the placement coincided with the beginnings of the homelessness crisis in New York. Our mission was to follow these patients into the community and help them find the supportive services they needed to live securely.
My supervisor, a dedicated, imposing Puerto Rican woman whom we called “La Profesora,” made clear that our primary function was to carry hope to our clients. I tried to remember this when I was assigned to a man on the unit who had no I.D. and, therefore, no known name. He spent his hours and days in the corner of the large common room, shouting names and numbers at passersby. “I’m not Governor Carey!” he’d yell. “I’m not Mayor Koch!” Then he’d let loose with a volley of numbers: “Eight four eight two nine seven five six four one!”
I’d never encountered psychosis before, and had no idea how to help this distraught man. But La Profesora instructed me to continue to approach him, introduce myself, offer to help, and then wait. Wait and listen. As I kept vigil with this man one morning, I began to notice a pattern in his shouted numbers. The first three sounded like a New Jersey area code. Then a whole phone number emerged, and when I dialed it, the man’s aunt answered. She told me that her nephew was a Vietnam War veteran and a PTSD survivor. This phone conversation led to a reconnection between nephew and aunt, which, in turn, made possible a real discharge plan.
I was stunned, and thrilled, by this outcome. In graduate school, I’d been learning about the importance of context, about listening for the systemic background music in a client’s story. Even so, this man was clearly psychotic, making no sense at all to me, and if it hadn’t been for La Profesora—”keep paying attention, keep paying attention”—I’d have probably written off his shouted pleas as mere ravings and concluded that we needed to up his meds. Now I’d experienced the power of systems thinking, firsthand. This man, who appeared to be so utterly alone, did have a family, wanted his family, and had communicated that to me as best he could.
Even as I was being introduced to this work, a seismic shift in the community mental health system was under way. Early in his first term, President Reagan oversaw the repeal of the Mental Health Systems Act, thereby ensuring that a nationwide network of federally funded, fully staffed, multiservice clinics would be dismantled. Instead, funding would be sent to states as block grants, to be distributed to local social service agencies, which would then compete for scarce resources, like undernourished siblings. The only reliable source of federal funding that remained was Medicaid, which meant that mental health services would move from a community based, public health model to an individually-based, medical treatment model.
The good thing about a government bureaucracy is that after it announces bad news, it generally takes a long time to act on it. So, for a few more years, community mental health remained a vital enterprise. What strikes me now about my early days in this field was the environment of creative spaciousness and intellectual freedom in which we worked.
At my next placement, a child-guidance clinic in Queens, we had the time and resources for weekly, individual supervision, as well as meetings with consultants on a rich smorgasbord of therapeutic approaches. My learning curve accelerated as I discovered family therapy and its bold array of strategies. I wrote paradoxical letters to fathers who missed sessions, congratulating them on their ability to maintain detachment in the face of family crisis. I tried out Peggy Papp’s Greek Chorus approach, enlisting my colleagues to support client resistance and the unlikelihood of change. I asked parents and children to switch seats. I employed circular questioning.
It’s hard to describe adequately the camaraderie and sense of shared quest I experienced during that period. I was a member of a rich, fertile learning laboratory, wherein curiosity was valued, questions flew, unorthodox ideas were floated, and a young therapist could grow. Perhaps most important, I was allowed—practically encouraged—to make mistakes.
I remember working with Hector, a charming, sweet boy, who had no interest in school. It turned out that his attention was focused elsewhere: at age 12, he was the man of the house, trying his best to protect his single mother and numerous siblings and to live up to his family nickname, “Macho.” I talked with his mother, Angela, about her parenting practices, including the implications of Hector’s nickname, and coached her on more effective child-rearing strategies.
Meanwhile, my own wife was about to give birth, and one day I informed Angela that I’d be out of the office for a month, explaining why. “Oh,” she said, nodding knowledgeably. “How many children is this?”
“My first,” I said proudly.
“Your first?!” she repeated, flabbergasted. Then she laughed. “Why, you don’t know anything!”
Indeed. I was embarrassed. But when I shared this story in our next supervision meeting, my colleagues chuckled sympathetically and then asked what I’d learned in that experience of “not-knowing.” They were genuinely interested. It didn’t occur to me that I was immersed in a rare and precious moment in time, and that the value placed on not-knowing would soon go the way of the typewriter and the rotary phone. In CMH settings today, therapists are pressured to display expertise, accomplish a great deal in a short time, and apply the same “correct” intervention on clients of widely divergent histories, cultural backgrounds, and temperaments.
Still, that early permission to “not know” and to simply remain curious has stayed with me. At odd times and in odd places—waiting at the tail end of a grocery line, or greeting a challenging client as he slouches into my office, or conversing with my daughter over lunch—I find myself reveling in the complexity that swirls around me. What might be actually happening here? So little, really, is certain. And the less certainty, the more possibilities one can entertain.
The Pinocchio Moment
In the late 1980s, I became the director of a community mental health center in suburban Philadelphia. During my first years there, we worked much as I had in Queens, with adequate supervision, productive treatment team meetings, and reasonable caseloads. We spent a full year developing and producing a play with clients and staff.
It was an adaptation of the real story of Pinocchio—Carlo Collodi’s subversive, satirical, 1883 tale, not the sugarcoated Disney version. The story had palpable meaning for clients and staff alike. Some identified with Pinocchio’s struggle to be “real.” Others related to his impulsivity, poor judgment, and penchant for doing what wasn’t in his best interest. Still others connected to it as a story about the value of loyalty and love, or the capacity for self-sacrifice in the service of a goal.
From the beginning of this collaborative effort, client creativity trumped that of the staff. Many clients took the lead in designing sets, creating costumes, painting the scenery, and writing the music. They made the most original contributions to the script, and some of their acting was inspired. Gepetto was played by a middle-aged woman outfitted in a moustache and suspenders, who imbued her character with a rakishness and wit that only her therapist had been privy to before.
The performances garnered standing ovations and local press coverage. The cast was jubilant. But what moved me most was the experience of watching clients dive into places in themselves—creative, capable, joyful places—that they’d scarcely known existed. (We’d later learn that audience members couldn’t consistently distinguish staff from clients.)
Many of our clients had spent years in mental hospitals, where they’d learned to define themselves by their pathology. The community mental health model gave us, and them, the freedom to try out vastly new roles, to experience genuine collaboration, and to utilize our imaginations in ways that would have been all but impossible in a traditional therapy setting. Some of these clients continued to inhabit their new sense of agency and creativity, and were able to build bridges to healthier lives.
What Really Matters
Looking back, that joyful collaboration on Pinocchio marked the end of an era. By now, managed care had carved its initials into the walls of community mental health. At first, I’d been enthusiastic about this new system of health delivery, as it promised greater efficiency of resources, more thoughtful case management and continuums of services, and an investment in preventive services. But managed care and other regulatory agencies, with their increasing demands for consistency, predictability, and accountability, began to transform the creative work of running a CMH center into drudgery. We were deluged with red tape—audit after audit, forms heaped upon forms. The behavioral paradigm—by its nature formulaic, easily reproduced, and predictable—came to dominate the community mental health ecosystem, like a species with no natural predators.
Working in a neighborhood clinic, I sometimes felt as if the walls were closing in on me. But I wasn’t feeling just the squeeze of managed care; by now, the whole social infrastructure within which I worked was collapsing. Public schools were dangerous, prisons were overcrowded, the child welfare system was overwhelmed, and there wasn’t nearly enough housing for people recovering from mental illness and addiction. It was all I could do to focus on one client, one family, at a time.
In 2001, I worked with Jamal, an 11-year-old boy who was acting up in school and not in the least interested in talking about it. I brought in his mother, father, and grandmother, who had differing expectations of the boy, but my attempts at structural family therapy went nowhere. Jamal continued to get into trouble with teachers and other kids, often landing in the principal’s office. I worried that he was headed for suspension.
One afternoon, he came into session and just sat there, rolling a gum wrapper in his fingers. After a while he mumbled, “I wish I was in school.” (Was therapy that bad, I wondered.) I asked why, and he replied that if he were in school, he could throw the gum wrapper at the back of someone’s head.
“Why not throw it at me?” I asked.
“Because then I couldn’t blame it on someone else,” he said.
Jamal and I looked at each other. We both knew that something important had just happened: he’d caught a view of himself from the outside. It was the birth of an observing ego, a significant developmental moment that I hadn’t anticipated or prepared for, or even especially contributed to, except to offer a space where reflection and insight might occur.
A few weeks later, he came in for another session. “I’m done acting up in school,” he said, and he was. I was glad for him. During the next few sessions we worked together, Jamal continued to take responsibility for his behavior and to develop interests beyond irritating his teachers. I thought of his therapy as a success story.
That was seven years ago. Earlier this year, I got a call from his family. Jamal, now 18, had been arrested and imprisoned for a felony. I was shocked. I visited him in prison. Prisoners and their visitors huddled together throughout the room. Occasionally a handcuffed man came in and was put behind a pane of glass for his visit. I wondered how Jamal was coping. We talked about his strategies for getting through his time.
He said he was attending Bible classes and studying for his GED while awaiting trial. He hoped that the letter I’d written on his behalf, in combination with good behavior, might help him get off with time served. I hoped for that, too.
Seeing Jamal in prison reminded me, yet again, of the injustice of systems: how our society offers black men so few legitimate options. I thought about the stunning reality that more African American men are now in prison than in college (reversing the trend of 1980, when black men in college outnumbered those in prison three to one). I wondered what kind of odds Jamal faced. What kinds of cultural images of himself was he wrestling with? Therapy seemed to me a tiny island in the midst of some rough seas that young people, especially young people of color, were forced to navigate.
Jamal’s plight gnawed at me. I thought of him sitting in his cell, and I worried for his future. Seeking some direction, I reread and reflected on W. E. B. DuBois’s concept of double consciousness, described in his 1903 book, The Souls of Black Folk. DuBois wrote about African Americans’ experience of looking at themselves through the eyes of The Other, the dominant white culture that projects relentlessly negative images onto them. But he also described a second kind of consciousness: a nascent, internal consciousness, which provides a source of resistance to the images imposed by the external culture.
I found this concept useful in thinking about Jamal and other marginalized people who enter the mental health system. Through this lens, I thought, therapy could be seen as an effort to identify and support clients’ double consciousness, which, in turn, could help them develop their voices and sense of agency. This was the original vision of community mental health, wasn’t it: to utilize therapy as a force for intertwined personal and social change? CMH work could be political not only at the macro level of overhauling systems, but also at the micro level of listening for the vital, fighting spirit in each client.
At his trial, Jamal received a seven-year sentence.
A Community Effort
These days, the field is struggling mightily. At most agencies, “quality management” has mushroomed from a line on a job description to multiple-employee departments, and time for supervision and clinical learning continues to shrink. Nonetheless, the community mental health field refuses to be stomped or stereotyped into obsolescence. The City of Philadelphia, for example, has recently committed itself to a transformational mental health initiative based on the values of the recovery movement, which places consumers at the center of their own care, rather than making passive recipients of treatment.
Under the umbrella of this initiative, and with the additional support of the city’s Department of Human Services, I’m working on a substance-abuse treatment project with three African American women who are graduates of residential treatment and aftercare. I’m training these women to conduct qualitative research on effective treatment for women and children by interviewing other women recovering from drug addiction, analyzing the findings, and presenting them to the leadership of the city’s Child Welfare and Behavioral Health systems. Originally, I included these women because I thought the research process would be more effective if interviewees could identify with their interviewers. But these women, two of whom haven’t yet finished high school, have performed beyond my expectations.
Jamila, who has seven children, is highly organized and breathtakingly intuitive, often completing my thoughts (accurately) as I begin to share them. Cynthia has taken on the responsibility of explaining the project to interviewees and has changed our format to make it more inclusive. Dawn has now gotten herself a job in the field, largely because she’s been such an effective advocate for her own child. She brings a sense of professionalism and an incisive, questioning attitude to everything we do.
It’s deeply satisfying to watch these women gain expertise and seize new opportunities. Somehow it seems to be the core of community mental health: this process of opening doors for people in the neighborhoods, sharing tools and skills, and allowing the lines to blur between professionals and “ordinary” people who turn out, quite often, to be extraordinary. I listen as Jamila, Cynthia, and Dawn learn to talk as researchers, publicly sharing their impressions of what other women have told them. I watch them present their findings, locally and at a conference in San Francisco; two of them had never flown before. I pay attention as they report on important discoveries they’ve made about effective treatment entry points for women, about the nature of relationships between recovering female addicts and staff, and about the social factors that help women stay clean and sober. My hope is that I’m passing on to Jamila, Cynthia, and Dawn a bit of the legacy of the CMH movement, especially the importance of staying curious and daring to not-know.
My daughter recently shared with me a journal she wrote as part of her internship at a shelter for women and children escaping domestic violence. In the process, Jessye discovered Camus’s essay, “The Myth of Sisyphus,” and found there a metaphor for understanding her own relationship to the work:
I imagine Sisyphus watching his boulder roll down once again, to the bottom of the hill, watch him wipe his sweat as I wave goodbye to women who return to abusers when their PFAs expire, when their custody order comes in and reads “joint.” Women who cannot get housing because landlords do not want eight children on their property, because SSI is not enough for an apartment in a safe neighborhood. . . . Women whose intakes report death threats by kitchen knives as their children knelt behind them in prayer. . . .Young case managers and older janitors, exhausted by the needs of clients, humbled and angry by their inability to do everything.
I imagine walking back down the trail of his boulder (for “the rock is his thing”), contemplating the heavy tracks of his calloused feet in the dirt, the noise he makes as he positions himself behind his rock, inhales, then exhales and pushes. And like Camus, I must, I must, imagine Sisyphus happy. I know that something pulls me into this world, this world where I genuinely want to live, this world that makes me happy.
I’m, frankly, inspired by my daughter. I regret that Jessye will probably not have the experience I’ve had—the spaciousness, the creativity, the diversity—in the field of community mental health. I worry that the danger of burning out looms much larger today, and that the ability to make a decent living is much harder. I feel there’s a real danger that community mental health could become increasingly marginal, as shrinking economic resources continue to savage the safety net of the poor. Would I prefer that Jessye become a software developer? Fluent in Chinese?
Not really. After all these years, I’ve come to think that those of us in community mental health don’t so much choose the work—it chooses us. Perhaps this is what distinguishes a calling from a job. I do know that, however impractical our career choice, however frustrating the work, and however unlikely it is that we’ll achieve the kind of material success our society venerates, we feel truly alive and engaged only when we’re in the thick of this impossible profession. This is a good thing, because more than ever, the community mental health field needs people with vision, energy, and a gut-level love for this work.
Jessye, I wish you well.
David Dan, L.C.S.W., has consulted and served as clinical director to a number of agencies in Philadelphia. He also consults to the City’s Department of Human Services and maintains a small private practice. Contact: email@example.com.