The first time that I was struck full force with the artificial nature of much of the mental health system was when I received a distressed call from a former patient several years after we were no longer working together. He was living in a supportive housing program and, as far as I had known at the time, was doing reasonably well managing a psychotic disorder on an outpatient basis. That is, he had not had to return to the hospital even once in the over 15 years since we had first starting working together, this following a tempestuous first 10-12 years of illness which had begun (or at least first appeared to be psychosis) in his last year of college. Frank psychotic symptoms, including hallucinations and paranoid delusions, had apparently erupted when he was rejected from the only medical school to which he had applied, and the first 10-12 years thereafter involved multiple hospital stays, with homeless meanderings across the country interposed in between. I met him when he landed in the city and at the mental health center where I was working, and had been able to maintain a useful relationship with him for a 7 or so year period, until I left the mental health center.
In the 8 or so years since then, I had heard from him occasionally, mostly with updates on his many accomplishments, including taking on volunteer positions and then part-time jobs, having girlfriends, and moving into, and maintaining, his own apartment, with minimal staff support. I also heard from him when his parents died and whenever one of his friends would get into trouble, either with the law or, more often, with the mental health system. This time was one of the few when he appeared to be in real distress, reminiscent of the ‘old days' when I would get crisis calls on a fairly frequent basis.
This time, he had called because he had been told-so he said-that he was going to be kicked out of the supportive housing program he was in and-again according to him-would thereby lose his apartment. When I asked him the cause of his impending evictions, he told me that the staff were complaining that he did not attend enough of their therapy groups and that his missing a group that afternoon had been the precipitant for his expulsion-the last straw that broke this particular camel's back. I asked him what group it was that he had missed and why, especially if he had known that this had become an issue for the staff. His matter of fact reply was: "It was a self-esteem group and I missed it because it was held at the same time as the college course I'm taking. I thought that going to college was more important for my self-esteem than sitting in a group talking about how I don't have any."
This smallish story fortunately had a happy ending. My former patient was not kicked out of his supportive housing program for attending college and, with encouragement, the staff renegotiated what services he was expected to use based on their mutual agreement that the services might be beneficial for him. His apartment had actually never been in danger, as he held his own lease and could have remained in the apartment even if he had been discharged from the program. This had not been clear to him, however, and his previous experiences with mental health services had led him to anticipate punishment for his ‘non-compliance'. He eventually graduated from the program, as the continued pressure and demands from the staff came to outweigh whatever benefits he felt he received from the program. He has since lived on his own in the same apartment and continued to attend college.
The slipcover phenomenon illustrated by this story, however, has yet to disappear from the mental health system. By referring to such instances of giving artificial settings and activities primacy over naturally occurring ones as examples of a "slipcover phenomenon," I draw on my own experiences growing up in a stereotypic New York-Jewish family in the 1960's. Like many other middleclass families of the time, my grandparents viewed the living room in their house as off limits to food, beverages, children, and, of course-god forbid-pets. When my siblings or I pressed my mother about why our grandparents had a room-and it was by far the biggest room in the house-that we weren't allowed to use, she would explain that that room "was just for company." And just in case any of the contraband was to make it past the invisible barriers, the stylish and mint-condition living room furniture that absolutely had to be kept clean was doubly protected by plastic slipcovers.
Now being the father of three children, and having two dogs, I can well appreciate the allure and function of plastic slipcovers, as well as the wish to preserve some section of our home as presentable to visitors. The problem with my grandparents' use of slipcovers-and I have since come to understand the problem with many other people's use of slipcovers as well-is that they never once had company that, in Seinfeld terms, was considered "slipcover worthy." That is, we never once saw our grandparents take the slipcovers off of the furniture, no matter who came to visit or for how long. Perhaps they never had visitors who were distinguished enough to warrant removal of the slipcovers, but this would have included all of the adults in our world, including their friends, other relatives, members of various clubs and societies to which they belonged, television repair men, and, eventually, real estate agents. Who else would have to come to the house for the slipcovers to be removed? I had the distinct impression that if our grandparents had anticipated the governor, the president, or even the rabbi dropping by, rather than being a reason to remove the slipcovers from the living room furniture, this would have served instead as an impetus for slipcovers being put on all of the furniture in the rest of the rooms in the house.
So perhaps I have a sore spot when it comes to slipcovers. Besides being awfully uncomfortable, they give the person who has to sit on them (or who is not even allowed to sit on them) the impression that he or she is not important enough, or perhaps not yet ready, for real life. Only an artificial life, life at a safe if antiseptic distance, is possible for me. Real life is for other people. And even if no such other people actually exist, even if the slipcovers are never taken off, what is abundantly clear is that I am not the one for whom they will be taken off. Like the Platonic forms, real life, the real couch with the soft and luxurious upholstery, is always somewhere else.
In our efforts to provide various forms of rehabilitation, we have unfortunately and unwittingly given this same message to many people with serious mental illnesses. They cannot be expected to enhance their self-esteem in the same ways or through the same processes that other people do, such as deriving a sense of mastery through accomplishing tasks (e.g., going to class) or succeeding in meaningful endeavors (e.g.. graduating from college), or deriving a sense of value through helping others. For them, self-esteem is to come through therapeutic means, just as are insight, coping skills, and emotional regulation. Life is in the housing program, or in the clubhouse or social club, not in the real world. One of the very first mental health consumer advocates I ever met pointedly asked me why my love of music was considered admirable while she was seen as needing "music therapy," and why I could own and love a dog while she had to be provided with "pet therapy." I had no good answer for her over 20 years ago, and I still do not today. Recovery, as she had suggested, is to be found beyond the slipcovers.