Confronting Mental Illness Around the Globe

At a clinic in Harlem, approximately 50 people sit along a rectangle composed of metal folding tables. Dr. Martin Gittelman, a tall man in his late 60s, is conducting his weekly seminar, striding back and forth as he interacts with the group. His navy blue business suit and authoritative tone are tempered with a feeling of warm solidarity with his audience, most of whom are afflicted with schizophrenia. He shakes hands with each individual in the room.

Gittelman is a psychologist and Clinical Professor in the Department of Psychiatry at New York University School of Medicine. He is one of a handful of world-renowned experts in the field of community mental health – a specialization that combines public health and psychiatry. Rather than analyzing the individual psyche, its proponents focus on planning and building a mental health infrastructure, which links local healthcare professionals and recruits patients and their families as partners in care.

Gittelman developed his own strong community-oriented perspective early on. Born and raised in Washington Heights – a mixed, largely working-class neighborhood just north of Harlem – Marty Gittelman was a tough, streetwise kid who fought in the Golden Gloves, a competition sponsored by the New York Daily News, until he was so badly beaten that his mother put her foot down. There was more to life than winning a fight, she insisted, and the bright young man came to see things her way. He applied himself as never before to his studies and graduated from high school with honors.

At Brooklyn College in the early 1950s, Gittelman became interested in psychology and chose it as his major. He recalls engaging in lively debates with his colleagues, many of whom aspired to careers as psychotherapists. "A friend lent me a copy of Freud's Totem and Taboo," he says. "Although I could see its philosophical and literary merit, it seemed like 19th-century stuff. This is New York City, I'd argue. What relevance does traditional psychoanalysis have for a truck driver whose kid is having problems at school?"

Education and Inspiration

After completing his PhD in clinical psychology at Columbia University Teachers College, Gittelman took a succession of fellowships and training at the National Institute of Mental Health, the Alfred Adler Institute, and the US Department of Health, Education and Welfare, among others. He says that his experiences as a mental health worker in the South, during the Freedom Summer of 1964, were personally transformational.

"In the early and mid-1960s, young people from all over the country were going south to register voters and support civil rights," he says. "I was an instructor in psychiatry at Albert Einstein College of Medicine at the time, and a group of us decided to go to Mississippi to help. As doctors and mental health professionals, we believed our presence would have a calming effect on the situation. The impact we made surpassed our wildest expectations."

The young psychologist brought his street smarts to the training he carried out with African-Americans caught up in the struggle as well as with their young supporters from across the country. "If the sheriff stops you, look him in the eye and keep your hands still," he'd say. "Then, look sideways and use your body language to reduce your persona." These strategies exemplify psychosocial skills – the set of culturally mediated behaviors people need for daily survival. Gittelman began to suspect that the same kind of training could be therapeutic for those with mental disorders.

The French Connection

In 1965, Gittelman accepted a fellowship with the Sector Psychiatry Program in Paris. In France, patients with serious mental disorders routinely receive psychosocial skills rehabilitation. The French system also stresses family education, medication, and a highly effective mode of organization called sectorization – a pyramid-like structure that allows psychiatric expertise to be diffused beyond the hospital and throughout the community. Vital to the entire effort are patients and their families, all of whom are trained to monitor symptoms and micro-manage medication. Says Gittelman, "It's a community-based approach that can be applied to many situations and cultures."

Tailoring the Strategy

Since the late 1980s, as a consultant for the World Health Organization (WHO), Gittelman has worked with ministries of health to establish community mental health programs in more than 20 developing countries. WHO studies have shown community-based programs can reduce relapse rates among patients with schizophrenia from as high as 70% to 20%.

"Each country is different," says Gittelman, "but in a wide range of circumstances, you can construct an effective mental health infrastructure via 'deskilling,' which means training non-professionals as medical assistants all the way down the hierarchy. Our goal is always, where possible, to help the mentally ill live and work in their own communities. That's where psychosocial skills rehab comes in."

The specific content of psychosocial skills training is radically different in countries where the overarching issue is basic survival. In China, Gittelman and his team may instruct patients in the fine points of hunting rabbits. In Zimbabwe, people with schizophrenia are taught how to get seeds, grow food, and raise animals. In Korea, they're trained to work at part-time manufacturing jobs in sheltered workshops for the disabled, which are similar to those established for disabled workers in Denmark and Sweden.

There are numerous cultural differences in how schizophrenia is perceived. In parts of Africa, for example, it may be seen as a curse. "In a village in Mali," recalls Gittelman, "people told me that one guy had it because his uncle was buried in the wrong position and felt uncomfortable in his grave. The nephew's condition was considered a direct expression of his deceased uncle's anger."

Looking back, the psychologist says the program he helped set up in China has been the most successful of all. The WHO provided entrée to Gittelman's team and supported their activities over a period of years, which helped enormously. A relative abundance of highly qualified medical personnel also made a difference, including the so-called barefoot doctors – rural paramedics trained to monitor symptoms and administer basic primary care. "When I insisted that these indigenous health workers be paid, I was called an American capitalist," he says. "Then I explained that the system wouldn't last if it depended on all-volunteer labor, to which they responded, 'Now you're thinking like a Chinese!'"

However, the same approach has been less successful in Latin America. Gittelman points to Mexico with its powerful anti-hospital movement and emphasis on private care, both of which work against the building of a well-organized mental health infrastructure. But giving up isn't in Gittelman's nature. "We'll get there," he says. "It'll take time, but we'll get there."

From Macro to Micro

Colleague Maurice Green, MD, describes Gittelman as a "dynamo." "Marty's the one who lays it all out and puts these programs together," he says. "It also doesn't hurt that he's a polyglot. Besides being fluent in French, Spanish, and Greek, he has the uncanny ability to pick up languages as easily as donning a hat."

Beyond his activities as an academic, clinician, and consultant, Gittelman has served as president of the World Association for Psychosocial Rehabilitation and of Psychologue Sans Frontières (Mental Health Workers Without Borders). He also is founder and editor-in-chief of the International Journal of Mental Health and a frequent contributor to such respected publications as Archives of General Psychiatry and the American Journal of Public Health. On many fronts – from the classroom to the clinic and from research to field work – he continues to confront mental illness around the globe with the same resolve that motivated him as an idealistic student nearly 40 years ago.

But even with all his travels and myriad responsibilities, Gittelman stays committed to his own community. Every Tuesday morning, he comes to the Harlem-based New York State Mental Health Office clinic to provide psychosocial skills training to patients with schizophrenia. "We urge them to quit smoking, eat nutritious meals, avoid drugs and alcohol, and visit the dentist," he says. "We also remind them to wear a warm jacket when the weather turns cold. Above all, we encourage them to make friends. Every week, we try to reinforce what they've already learned and add new skills into the mix. All this may sound a little like nagging, but it works."

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