Interview with Ronald C. Young, M.D. Interviewed May 25,1979
Interviewed for the Minnesota Psychiatric Society Interviewed by Marvin Sukov, M.D.
Ronald Young - RY Marvin Sukov - MS
MS: Doctor Ronald Young is being interviewed. Doctor Young will identify himself and tell you a little about himself in the course of this conversation.
Doctor Young, as a preliminary, where were you born?
RY: I was born in La Moure, North Dakota, a small town in southeastern North Dakota. [break in the interview]
MS: So you were born in a small town in South Dakota. RY: North Dakota.
MS: Oh, North Dakota. That makes it a little better. [chuckles]
MS: Were you reared in that community?
RY: I lived in La Moure until I was about eighteen. Then, I went into the Navy during the last year of World War II. I spent a year and a half in the Navy and came out and attended a junior college in [Lamoni] Iowa called Graceland College for two years. I used the G.!. Bill. I got married after I left Graceland College and then moved to Minneapolis, where I finished my undergraduate work at the University [of Minnesota]. By that time, we had two children, and lots of debt. So I worked for about four years, and, then, went to back to medical school, finished medical school at the University, and took my psychiatric residency at Hennepin County General [Hospital], at the University [Hospital] and at the VA [Veterans Administration Hospital] in Minneapolis.
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MS: Interesting. You were really, then, reared in the small town where you had your grade school and high school.
RY: Right.
MS: Do you have brothers, sisters?
RY: I have two sisters, one older and one younger. One lives in North Dakota and one in California.
MS: Now, you settled in Minneapolis .. .1 should rather say in Minnesota because of the position you hold in the state government.
RY: Yes.
MS: At what point in your schooling did you decide on psychiatry?
RY: I thought about that. It's a little hard to pinpoint, but during medical school, I was interested in psychology. I had some of my undergraduate work in psychology. But I think it was in the internship when I realized what a high percentage of general practice cases-I was intending to go into general practice when I took my internship; it was a rotating internship at Bethesda Hospital in Saint Paul-how many patients, basically, have psychiatric problems and I decided that I should go and specialize in psychiatry. MS: May I comment? In the practice here in the office, we'll say ... Of course, I do only psychotherapy. I don't do electric shock. The reverse does not seem to be the case; that is, the usual run of patient's anxiety and mild depression and somewhat we call psychopathy. You don't get them to have a great deal of somatic complaints. Now, the reverse may be true. Those who come with somatic complaints prove to be psychogenic, or at least have a psychological basis. But over here-you should be interviewing me on this-another thing that has impressed me with all these patients with anxiety coming in ... "I'm nervous, Doctor." You would expect a great deal of hypertension.
RY: Yes.
MS: But my patients go in and they get checked out, at least their blood pressure is ordinary. Well, so much for that. I just thought I would comment.
RY: I think this crossover is interesting though. You have psychiatric patients in general medicine that come in misidentified-at least, perhaps, in their own mind or in the referral process. And there are psychiatric patients presenting with medical problems. I suppose there must be some of the other, that psychiatric patients who are basically medical problems, that they're psychiatric symptoms are tied closely to organic disorders of one kind or another.
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The reason I'm interested in this is one of my new interests is in the promotion of healthy lifestyle. I think with the Health Maintenance Organizations [HMO] so prominent and popular in Minnesota today, they're asked to deal with a whole range of disorders and to not only treat people but to contain costs and the public, in addition, is pushing to go to a health facility that helps them achieve good health, maximum health, not normal health or absence of pathology, but they want to maximize their health and their potential. So I'm currently putting together a proposal for one of the Health Maintenance Organizations to see how this whole concept of maximizing good health and, maybe, treating the psychosomatic or the somatopsychic disorders in the appropriate places within that Health Maintenance Organization.
MS: I hope it takes. It's very interesting. Years ago, I first came across the term holistic psychiatry.
RY: Yes.
MS: I first heard it from [Franz] Alexander, maybe ... Alexander [Hungarian-American psychoanalyst who pioneered psychosomatic theory] was the first to use it. Now, I hear the term used holistic medicine, which is all right, you know, at least technically. The doctors have done a lot of talking about it, treating the patient, but, actually, they're so busy or at least their training is such that they treat the immediate symptomology and let the patient fend for himself.
RY: This is interesting. On my way over here today, I was thinking about this subject and wondering what your recollection was of holistic medicine. I was sure-well, I know in my reading over the years-that many good physicians in the past have talked about holistic medicine, diet, and exercise, and whatever. It just hasn't been practiced face to face with patients. If you look at a patient, you tend to look for disease and pathology and stop there, instead of thinking what is that person's potential to be healthier, to bring down the heart rate or to lower the [blood] pressure even though it's not pathological. What is that person's potential for good physical fitness? We stop short of that.
MS: Activating ... We used to talk ... treat the patient as a whole. RY: Yes.
MS: It's a great bit of an initiative. Truly, it ought to be done.
RY: I think the public is demanding it now, too. A certain segment is saying, "This is what we want from our healthcare system." And doctors are going to have to either do it themselves or fit into it; otherwise, other people will take over-and they already are. MS: They already are and well they might, you know. People want it; now they get it. There are a lot of books written on it, too, aren't there? More and more books are coming
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out on maintaining your health. They're more diet conscious now than they ever were and more athletic conscious ... a great deal.
RY: I got into my car at the University to come over here and I stopped for a couple of minutes enjoying the sunshine on River Road there. There must have been at least fifty joggers that went by. About three or four years ago, you might see one jogger in an
afternoon. Now, within five minutes, there were fifty joggers that went by.
MS: At any rate, you went directly from medical school into your psychiatry residency? RY: Right.
MS: May I ask you something that's of general interest? As you look back now, and you think of all the hours, of course, you spent in anatomy and physiology and so forth, can you envisage any shortcut, assuming that you knew, and a great many people do know ... They say, "I'm going to psychiatry." They have to go through medical school to become a psychiatrist. Can you envisage a medical school embarking on any shorter approach either emphasizing psychiatry, psychology during the student's medical school years, possibly eliminating some work, which he finds later--quote-useless? Now, it may not be so, but have you thought of it as part of the curriculum? Say, if a man goes in today and he says, "I know I want to be a psychiatrist". .. What are there, something like over 20,000 in the American Psychiatric Association [APA], so it's quite a group.
RY: Yes.
MS: Perhaps, it will grow; perhaps not. Would there be any way of improving his medical school education aimed at psychiatry instead of aimed as it is now in organic medicine?
RY: I have conflicting thoughts about that. As I look back on my own training, there were subjects that I have never used, because I went directly into psychiatry. I can think of all the hours we spent trying to understand porphyrin metabolism, because we had a prominent internist [Cecil Watson] as head of the department who developed porphyrin metabolism. I can think of some things in radiology and anatomy that were very highly specialized because the head of the department had an interest. I haven't used much of that information. I think probably they could trim some of that.
The other side of my conflicted thinking is that I feel it's important for a psychiatrist to not only see himself as a doctor but to a substantial extent be able to think and to be proficient at being a doctor. I don't know of any shortcut way to do that, except to be a doctor. There's something unique about understanding human beings, and illnesses, and wellness, and so forth, that makes the psychiatrist a special person in the healthcare field. If I had to trade off, I guess it's probably obvious that I would maintain that identity of being a physician. I think that's something special.
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MS: Possibly, too, these specialties, these super specialties that you alluded to that some of your professors had, also teach us something about methodology and about research and maybe take you a little bit into the future.
RY: The Harvard [University] curriculum I noticed the other day was being changed for the undergraduates. Instead of a lot of survey courses for undergraduates, they are taking focused, in depth courses relating to special eras of history or subjects for the reason that you're saying. People should know how to think and to analyze, to research, and be proficient in depth. I think this is a current trend right now.
MS: Very interesting.
I'd like to focus a bit on your residency here at the General Hospital, if you want to speak to it, both on some of the personalities you met and the general curriculum, how it impressed you as a resident at the time. Was it a good residency or poor residency, whatever?
MS: At that time, the University had total residency identification and you were a University resident and spent some time in Hennepin County [General Hospital] and time at other places. So it was a University residency.
I suppose I mention Hennepin County first, because that was the most dramatic part of my training. The most spectacular and challenging and unusual kinds of emergencies and cases went through Hennepin County General. It certainly wasn't controlled. I recall when I was on the in-patient service as a resident at Hennepin County General, we had only one or two staff psychiatrists and maybe two or three social workers, two psychologists, as I recall-these numbers may not be exact, but it was a very small staff-and a thousand admissions to the in-patient service a year. This was about twenty-five in-patient beds that were locked and another eighteen beds that were open part of the time. I had, as a resident, responsibility for probably 20 in-patients at any given time or all the time, and I think about 120 out-patients. So we would see, in addition to our in-patient cases, twenty or thirty out-in-patients in an afternoon, most of them just drug maintenance and crisis intervention kinds of things. It was a hectic, interesting service with not a lot of supervision. The staff psychiatrists were very good and they were available and helpful, but when you have that kind of a workload, you just try to keep from drowning.
MS: Yes.
RY: The University [Hospital] was a much more measured pace. We had only a few in-patients and had time to study them in depth and discuss them and have supervision. I thought the residency as a whole was quite good. Personally, I'm not a critical type of person. I tend to see the better side of things, more so than to be critical, which I'll have to keep in mind in my remarks. I felt that the residents who left there had a very
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practical, usable experience, that they could go out and practice psychiatry III the
community in a variety of settings and be reasonably competent.
The didactic work... In fact, as I recall, you gave some lectures on the history of psychiatry that I still remember ...
MS: Well, thank you. I did. [chuckles]
RY: ... going back to early Greek and Roman experience. The didactic work, I thought was good. It was eclectic, not particularly weighted in any direction. We had some psychoanalytic courses and some on drug management, and a little bit on community psychiatry.
[break in the interview]
RY: One of the things that we didn't have was much exposure to the chronic and severely disabled psychiatric patient. We didn't rotate through state hospitals. That's still the case, and, now that I'm in my present position as medical director for the State Department of Welfare, I have a vested interest in improving those programs by making it part of training experiences. I think the students who are going to practice psychiatry really need to see long term, severely disabled patients in state hospitals, and we didn't have that. We saw some of them as they came out of the state hospitals back to Hennepin County General Hospital for their follow up care.
MS: That would be an innovation here, wouldn't it? They ought to see the regressed schizophrenic, what can happen to one of them. Of course, they probably see very little of geriatric patients here at the General. It would be well for them to see them.
RY: At the University, Doctor [Floyd] Garetz now has a program in psychiatry, out-patient, for geriatric evaluation. I think there's more interest nationally, and with the [Jimmy Carter's] Presidential Commission on Mental Health [1978], they have placed the chronic mental patient as the first priority in the mental health system in the United States. I would expect that for a few years at least, there will be more resources, more attention given to that group of people.
MS: What do you feel about the facilities for continuing education for the psychiatrist here in Minnesota? What are the opportunities? Say the man has graduated and he has his residency and has practiced three years or five years, where can you learn ... ? Where can you continue with psychiatry? Do the hospitals provide any of that?
RY: I think most of the hospitals do now; although, since psychiatry is a specialty, private hospitals, perhaps, don't have that many programs. The University certainly has a number of continuing education seminars, grand rounds, going on every week. The department has a Wednesday noon grand rounds where speakers from around the country, as well as this area, talk on a specific topic in psychiatry. The adult in-patient service has grand rounds. Child Psychiatry has grand rounds. Doctor [Faruk] Abuzzahab
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has had psychopharmacology grand rounds once a week. In fact, we use a telephone hookup with the state hospitals to bring the Wednesday seminars to the state hospitals now for the doctors there to meet their continuing education requirements.
MS: That's interesting. I have attended a number of these Wednesday noon seminars. They're very good. Incidentally, very few men from [private] practice appear there. They're generally attended by students and staff and so forth. Well, it comes at noon, and I imagine they can't very well cut into their day's work.
RY: It's disappointing. They're often fifteen or less people there.
MS: Yes. And they've been good; they're good seminars. I think if one were to attend regularly every Wednesday, he'd be pretty much on top of the goings on in the field. RY: One of my other interests for a number of years. .. I used to fly up to the Canadian border, up to Thief River Falls, Minnesota, once a week for two days. I helped to start a unit in a general hospital there for psychiatric patients. It was very obvious that we need to use telecommunication capability, two-way television. We have satellites now. One is parked over the Canadian border that's usable. It's got a footprint that covers much of the Upper Midwest and can be used as a relay station to bring programs from the University to those areas. But, even in direct consultation, there are the University of Nebraska studies, pilot projects that show that you could do things like neurological consultations and psychiatric interviews, many things by two-way television. I think with the gas shortage that's looming on the horizon and costs increasing very soon we will see telecommunications become a chief medium for continuing education and to make it unnecessary for consultants, like myself in those days, to travel all over the state. I spent hours traveling. Even flying, it took me an hour and a half to get to Thief River Falls. MS: Apparently it is feasible cost-wise? Would it be less expensive say to obtain a consultation through telecasts than it would be to have someone go up there and see the patient?
RY: The cost so far has been high. The maintenance costs of the system have been high; although, the government has these satellites with time available on them. The costs are not that great for these pilot projects. But, until transportation becomes so expensive, people don't think about it.
There's another interesting thing about that. Even with telecommunications available, people still like to meet face-to-face. I heard of a project in Missouri where they already had telecommunication linkage and they wanted to talk about how to use it. Instead of using the telecommunication linkage for that meeting, they got together someplace in between and met face-to-face. So there's some magic about meeting face-to-face that's still there.
MS: Interesting. And you do see them. It isn't like the telephone where you don't even see the patient. In this instance, you see them before you.
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RY: Right. The cameras can be controlled remotely by both sides so that you can focus up close on... In fact, if you want to see the pupil for a neurologic exam, you can focus the camera closely enough to get the pupil so it fills the entire screen.
MS: As we were talking earlier, this thing [interview] will not be listened to for another twenty-five years. Possibly, twenty-five years from now, this method of consultation might be in common use.
RY: It will be very interesting to see at that time. I would hope so or, perhaps, some things we haven't even thought of will be used by then.
MS: Other ones. All right. [break in the interview]
MS: Doctor Young, how long have you been the medical director in the Department of Public Welfare?
RY: Seven years.
MS: That's a fairly good cut of time. Have there been any changes in that period either through the general dynamics or, perhaps, some innovations of yours? Perhaps, you'll tell us about them.
RY: I think one of the major changes in the last seven years has been the shift to federal funds, Medicaid and Medicare, for the support of patients in the state hospitals. The [mentally] retarded now are covered under Medicaid funds, and the mentally ill to a much less extent. The federal government has been reluctant to take over the burden from states for supporting the chronic mentally ill in hospitals or in any mental illness facility. The shift in funding from a state-funded mental health in-patient service to federal funding is having a profound effect. Now, people have options whether they go into a state hospital or they get their care in the community. They have these options. It's changing the characteristics of the types of services delivered.
For instance, in state hospitals, we no longer try to provide comprehensive medical care to mentally ill, mentally retarded, and chemically dependent people. We focus more specifically on treating those disorders with the necessary medical expertise to do that, but if there's a major medical problem, they might be sent, for instance, for an acute appendicitis or medical illness, to the community hospital and treated there for that illness and, then, returned back to the state hospital. In the old days, the state hospital was the total community and you tried to provide every service to everyone. We've gotten away from that, to a large extent. We realized that we can't keep up with the tremendous advances in medical specialties. We can't keep up in all of those areas and we can provide better care by having them treated elsewhere in the community for those problems. So that certainly is changing the complexion of things.
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The big shift of people out of state hospitals into the community had pretty much occurred by the time I became medical director; although, that's continued over these seven years. The large numbers of older patients who were transferred into nursing [homes ...
[break in the interview] MS: Please, continue.
RY: The state hospital population in Minnesota has been reduced from about 15,000 in the early 1960s to around 5,500 at the present time. Now that was a mixed blessing as everybody knows. There are some chronic patients who probably are better served in state hospitals. They adjust more easily and so forth in state hospitals. But some of them were discharged, too, as you know, into the community. Some went into nursing homes, which didn't provide the comprehensive care as in state hospitals. So having reduced those populations, now we're faced with the question of providing better care for people in the community.
Talking about what I have been involved in and thinking about, we have put together a state plan for the Department of Public Welfare that was done by a taskforce of people from a variety of backgrounds and interests. One of the things in that state plan emphasized the needs of the chronic mental patients, as well as other sub groups, such as adolescents, ethnic minorities, the geriatric patients. There are several groups that need special attention. As a result of that, we've gotten some legislation during this session to provide additional funds for the chronic mentally ill in the community to give them services where they live. Many mental patients, even though they're living in what we would think of as a ghetto in the city, still prefer this to a state hospital. It's hard for me when I see the idyllic state hospital setting out in the country by a lake; I think this would be a nice place to live. Patients still like the idea of being able to decide what they're going to do and how they're going to live their life. I guess that's the trend of the times. MS: Do you think that they get more visits when they're close to the city than they would in some state hospital fifty miles away?
RY: Most of the people who end up in state hospitals have very few contacts with family and friends. It seems by that time, for whatever reasons, they have lost touch with much of their social network. I'm not convinced that it makes that much difference whether they're next to the city or out away from the city.
MS: It's probably just the onus of calling it a state hospital, you know. "They sent her to a state hospital" probably still carries a lot of punch with most people; whereas, if they can be locally ...
R Y: There's still that stigma.
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MS: Oh, yes.
RY: In fact, we're talking now about changing the names of state hospitals to something else, for two reasons. State hospitals are multipurpose campuses. They have programs for the retarded that are basically educational programs. They have programs for the chemically dependent, which are in the education/rehabilitation spectrum, for the most part. We have programs for the acute mentally ill and rehabilitation programs for the chronic mentally ill. So hospital is not really the appropriate label anymore for a state hospital.
MS: It's my guess that if the next hospitals built were called an institute, a multipurpose institute, and put it to the public in that way, it would gain a lot of popularity.
RY: That's my preference ... that word, institute. MS: Oh, is that so? [chuckles]
RY: It really is. [The new name became "Regional Treatment Center.]
MS: It would give them a feeling, a thinking going on there that there's possibly experimentation and use of the latest. Maybe it would be reflected in turn.
Well, in these last few years, the population has been cut to a third. I have the figure here that you just gave me from 15,000 to about 5,500.
RY: Yes.
MS: Have any of the state hospitals been closed down?
RY: About two and a half years ago, we closed Hastings State Hospital, mainly because it had reached a size where it was no longer cost efficient to run it. The total number of patients ... there were about fifty chemically dependent, probably a little over a hundred mentally ill, and a very small program for the mentally retarded. With the large campus at Hastings, it was just not cost efficient to continue running it. Those patients from Ramsey and Washington Counties now go to Anoka and Rochester State Hospitals. MS: I see. Then, I presume-this is only a guess-that some units have been shut down whether in Anoka or Rochester. Some units within the hospital systems have been shut down rather than closing down the entire hospital as you did in Hastings.
RY: We have a different standard today than we had before. Some of the hospitals, like Saint Peter State Hospital, had 2,000 patients. Today, that same campus has less than 400. As you remember visiting state hospitals twenty, twenty-five years ago, the beds were so close together that you could hardly get between them. [The patients] They had no place for their own clothing. The conditions ... looking back, you wonder how we could allow that to happen. Now the standards are such for the Health Department, the
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Joint Commission on Accreditation of Hospitals, the federal standards for Medicaid and Medicare funds that we have to have a certain number of square feet of living space for each person. We have to have lockers. We have to have adequate ventilation. We have to provide money for the patients to spend in whatever way they want to spend it. We have to have recreation areas. So that campus that was accommodating thousands of patients now accommodates hundreds and with still no room to spare, because we have a different standard entirely for what is acceptable. This has been hard for the legislators to grasp. They feel with the big reduction in patients that we should have excess room and excess staff. Here again, we would staff, years ago, with one staff person for five or six patients. That was clearly inadequate for the type of severely disordered people we had. Now, the ratios are about one to one, one staff person for every patient. That's over-all staffing. Even at that, it doesn't really equal what kinds of staffing you see in private facilities. The state hospitals are not yet at the level where private hospitals are. There's some excellent programs, fine people, some very specialized things going on in state hospitals, but. ..
For instance, the [1973] court case Welsch v. Likins was a class action court case by parents of a retarded girl at Cambridge State Hospital, and after several weeks of court trial, the judge [Federal Judge Earl R. Larson] set standards [by Consent Decree] for state hospitals caring for the retarded. We are not yet at those levels. I don't think the standards were unrealistic or excessively rich, but the Legislature has reacted negatively for two reasons: one, they feel the courts are taking away the decision-making power as to how many resources Minnesota is going to put into the state hospitals, and, secondly, they believe that we don't need that many staff to take care of these people. I think they still believe the state hospitals should be bargain-basement places. That double standard is not as saleable today as it used to be, where you could put people away for years and forget about them. Now state hospitals have to comply with the same standards as anybody else.
MS: Back in the old days-I'm leading into something-most of our work on the farm ... We had 700 acres ofland on our state hospital in Iowa. All the work was done by patients and much of housekeeping was done by patients. Of course, if we could find a patient who could type, I believe she was pretty certain to remain longer in the hospital than one who could not type. [chuckles] Haven't some of these things changed now where you may not use patients as you might an employee? You've got to pay them now. Am I correct?
RY: It's changed drastically. We can't ask a patient to do any work other than to tidy up around his own bedroom, unless we pay him for it. The federal government laws about minimum wages apply to state hospitals as well as other places. We can prorate it based on the kind of productivity the person is capable of, but we have to pay patients a wage if we ask them to work, which is fine.
We phased the farms out and that may be a cyclical thing. Now, we're through with the farms, but people are talking nostalgically about getting back to the land and having gardens and so forth.
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MS: Yes.
RY: Some programs are being started around the country in the same way we started state hospitals, out in a beautiful setting in the country. [ chuckles] So that may just be another cycle.
MS: Now, Ron, we began talking about state hospitals. It shows at least my prejudice. But I know full well that your purview, your responsibility as director in the Department of Health, extends beyond just the state hospitals. Would you tell us a little more and, also, I believe you have some new program, something like a day hospital or day care. Would you, please, tell us about that?
RY: The Department of Public Welfare, in addition to directly administering the nine state hospitals-there were ten before Hastings closed-has two 400-bed nursing homes, one in northern Minnesota and one outside the metropolitan area. We also provide money to the community mental health centers that the Legislature appropriates and on a matching fifty/fifty basis, the local communities have started twenty-six mental health centers around the state. We are responsible for setting standards or monitoring the staffing and the programs at those mental health centers. That's going to change this year because the Legislature has gone to a new philosophy of appropriating money on a block grant basis to the counties. So instead of money coming to the Department of Welfare to be apportioned out to the twenty-six mental health centers, the money will go to the county government, the county commissioners, and they will decide locally in those eighty-seven counties how they want to spend the money. There will be some guidelines and restrictions, but they will decide what they want locally. Now, that's a whole new philosophy about money. It's hard to predict what will happen, whether mental health will be lost in that shuffle or whether it will emerge as a clear priority for each county. You were mentioning about day hospitals. My first job after I graduated from the residency at the University was as a psychiatrist at the Hennepin County Medical Center. I was in charge of one of the in-patient units. I guess the Russians started the first day hospital back in the 1930s, because they had too few hospital beds. Menninger [Clinic-at the time in Topeka, Kansas], had had a day hospital and there's one in Canada.
[break in the interview]
RY: So I decided that we should try to establish a day hospital where the patients came in for an intensive program during the day, but slept at home. We'd use our staff and our resources to provide intensive programming rather than spreading it out over a twenty-four hour period and watch people sleep, is what it amounted to. We took a closed ward, carefully planned to discharge all the patients on that ward, and the next day, we'd have a day hospital. Well, we discharged them. The patients, as they left, some of them weren't too happy about it and made statements like, "I came here because I attempted suicide. I don't feel very happy going home like this, and I hope I'm here tomorrow morning," which raised the anxiety of the staff. I suppose if there had been a suicide, we wouldn't
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have had a day hospital program the next day. But, as it turned out, everybody came back, and we had one of the first day hospitals in the country at Hennepin County General Hospital.
That idea smoldered along and there were federal government attempts to get more day hospitals, because most people can be cared for in day hospitals rather than in in-patient services. But there were no pressures to do that.
MS: May I interrupt you? Would you tell us just a little more what the patient does? When does he report? Where does he get his meals? Where does he get his rest during the day? How does a day hospital function?
RY: Usually, they operate from about eight or nine in the morning until four or five in the afternoon. Here-it depends on who is organizing the program-there are a variety of activities and treatments available and quite a bit of group therapy, but individual therapy, work evaluation programs, family group therapy. We did some of the first family groups, with several families getting together as groups, in group therapy. Hopefully, it's tailored to the individual patient rather than putting all the patients through the same programs. Being a small town boy, the phenomenon of the sheep dip, it occurs to me that running the sheep through the sheep dip whether they needed it or not... I think in psychiatry we, sometimes, do that. We give everybody the same program whether they need it or not. So, hopefully it's an individualized program during the day depending on what the patient's problems are and what he needs by way of treatment. Then there are evening programs, too, for those that can't be at home for whatever reason.
MS: It appears that you would need more staff, more immediate staff for a day program than you would for a full time program. It seems like you've got to provide activity for these patients here if somebody comes to the hospital at nine in the morning. He's going to be there until five or six. He must be doing something or maybe he can sit back and rest. Whereas, if that same patient were in an in-hospital care unit, you so stretch it out. He's safe. He's on the sidelines.
RY: That's right. It probably takes about as much staff for a day hospital as a twenty-four-hour program if you do a good job, and you can't get away with some of the inefficient or low key things, like having them sit around for most of the day. If they're a patient in a hospital, you can put them in pajamas and society says, "That's all right. They're a patient. We don't need expect them to do anything. They're just there and they're going to get well." In a day hospital when they're going home every night, the spouse will say, "What did you do today?" "Well, I sat around for four hours," or "I knitted my fourth blanket," or something. They say, "What the hell is going on here? The family is low on money. We need your help and you're going to a day hospital and not doing anything. Why do you have to do that?" As a result, day hospitals get more reality oriented and more efficient because they're tied into the community. They are people going in and out all the time.
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[break in the interview]
MS: Doctor, we've had a reduction of 10,000 patients in the state hospital service in the past decade or, perhaps, over a decade. What has happened? Can we be optimistic enough to think that with the mental health units functioning and, perhaps, with some private work going on that many of these patients are really kept away from the state hospitals or might we think that with the newer drug therapy that these patients are then either recovered or improved sufficiently to go home and are earning members of the community? I really wonder whether you have any figures to indicate the discrepancy between 5,000 now-5,500 you said-in the state hospital system and 15,000 some years ago. What happens to these people?
RY: I know that they're not all cured, that we have many former state hospital patients who are either living in the community and getting services from psychiatric units, private psychiatrists, other facilities ... Many of them are in nursing homes. For instance, a survey about three years ago of all nursing home patients in the State of Minnesota by physicians on teams determined that there were at least 10,000 patients in nursing homes who had a psychiatric diagnosis. Now, that includes those with chronic brain syndromes and senile dementi as and so forth. But there are also many former state hospital patients in nursing homes. We know that there are many people living marginal kinds of lives particularly in the cities, in the Twin Cities. The readmission rates in state hospitals have gone back up. We decreased the populations for a few years. The admission rates were low. Now, the readmission rates are much higher in state hospitals across the country. So there's this revolving door phenomenon going on in the state hospitals. Now, some of that is all right. You treat a person in their acute episodes, stabilize them, and send them back to the community, but the community doesn't always agree with this. They'd rather that this unattractive state hospital person who has bad habits and is a nuisance would be taken out of the community and put someplace else. We have to have a very well organized support system to keep them functioning in the community. We're only now recognizing that as a real priority in the state. We don't have the problems that they do in California and New York and some other places, but we do have many former mental patients who are under-served, who need additional help that used to be in state hospitals. MS: When you mention priority, would you explain a bit what you mean? Do you mean a priority of services to these patients?
RY: Talking now about state government and the Legislature, they have not put a high priority on the chronic mental patient, although the budget is big in Minnesota. The budget for state hospitals is around a hundred million dollars. It still has not included much money for community support projects. We've started a few of those now.
[break in the interview]
MS: Doctor, when we talk about state hospital patients, as you've already indicated, it includes your chronic schizophrenics, your manic or repeat manic, and, of course, there's a high incidence of organic, geriatric patients, all of those. Has there been anything in the
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last few years .. .I know there's a lot of research going on in what we might call neurophysiology or neurochemistry? Can you see help coming to these people soon? It seems that the geriatric population has been going up and up. Of course. They're living longer and longer and longer. We're able to maintain them longer and longer. Is there any help on the way to help these people who are all right except that they're memory has been wiped out, as they say, or are all right, except that, we'll say, their arteries have been closed down. In what area do you feel is the most helpful line of research? Where is it? It's such a broad question that really I don't know how you can answer it. But you've probably thought about some of it.
RY: As far as state hospitals are concerned, we tend to get those patients that can't be helped any other place. Everything that's known has been tried. I think in Minnesota, particularly, we provide good medical services. We use the latest methods in private hospitals and private practices. People that can be helped are helped. The ones that don't respond end up in state hospitals for two reasons: if there's no money available to maintain them in the community in a private nursing home or facility or if they're such a bother to the community, or so obnoxious or dangerous. The state hospitals still serve that function. That's the group that we end up with. As you said, it's a conglomeration of all different sorts of problems that just are not understood and we have no treatment that seems to work.
I'm not a researcher and don't know the details of neurophysiological research, but it just seems to me that we're still a fair distance away from having conceptual categories to understand these patients and what's going on. We need ways to think about them and their problems and, then, find some kind of treatment.
To give you an example... At the AP A meeting in Chicago last week, there was an exhibit done by some researchers at the University of Tennessee. They have constructed a model of three levels of the brain based on the-I'm trying to think of the word here-developmental models of the brain from the primitive brain to the more advanced brain, the frontal lobes and so forth. Their whole model looks at different levels of the brain and the pharmacological interventions that might affect each of these levels differently. It's an interacting system.
I think we've got to have some kind of conceptual breakthroughs before we're able to really deal with these complicated problems. It's not just trying new medicines, but it's understanding the interactions of primitive functions versus more advanced civilized kinds of functions that people are able to perform, plus having specific therapies for specific disorders. Behavior therapy, relaxation techniques, family therapy .. .I think all of these interventions are appropriate for certain segments of the population. As we learn which ones work for which people, we're going to see some changes.
[break in the interview]
MS: Doctor Young, our time is up now. Unless you want to squeeze in a few more comments-it's been a most interesting interview-we can close it down now.
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RY: I thank you for this chance to be interviewed, and I hope we can get together and listen to it twenty-five years from now.
MS: I'm quite sure you will and I won't. [chuckles]
MS: Anyway, good luck. RY: Thank you.
[End of the Interview]
Transcribed by Beverly Hermes
Hermes Transcribing & Research Service
12617 F airgreen Avenue, S t. Paul, Minnesota, 55124 952-953-0730 bhermcs I
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