The End of an Era in Psychiatric Research

CAMARILLO —  There is little left of the clinical research unit at Camarillo State Hospital that reshaped the world of psychiatric care.

Nothing that hints at the work that propelled the treatment of mental illness out of the dark ages of asylums and lobotomies into an era of wonder drugs for schizophrenia and other disorders.

Nothing that gives a clue of the research that went beyond drugs to radical new behavior therapies--incredibly simple but effective breakthroughs such as humming to quiet hallucinatory voices.

In fact, only stacks of spare furniture, old psychiatric textbooks and a collection of black and white portraits are reminders of the giants of mental health who worked in Unit 45 and who boosted the state hospital to worldwide prominence.

They include Dr. Philip R. A. May, whose research in the 1950s and 1960s led to the widespread acceptance of the generation of drugs now used to treat schizophrenia.

And Dr. Robert P. Liberman, who pushed the boundaries of psychiatric care, pioneering treatments now used around the globe that focus on managing incurable mental illness.

Liberman, a UCLA professor of psychiatry who took over as head of the unit in 1970 when the university became an equal partner in the hospital’s research, devoted his life’s work to battling the demons of mental illness.

He insisted that each member of his staff spend at least one 24-hour period as a patient on the unit to gain empathy for those in institutional care. He celebrated New Year’s Eve and other holidays on the ward, often delighting patients with his talent as a concert violinist.

Together, he and his team plumbed the depths of mental illness, publishing hundreds of articles while traveling around the world to teach others about the latest breakthroughs in mental health research.

But with the state hospital scheduled to close by July 1, the research unit will soon come to an end--although many of the researchers will transfer to the Veterans Affairs Hospital in West Los Angeles. Citing rising costs and a shrinking patient population, Gov. Pete Wilson ordered the shuttering of the facility early last year. And efforts are underway to transform the sprawling hospital campus into Ventura County’s first public university.

The loss of the research unit is immeasurable, hospital officials say. To be sure, it is a blow to Camarillo patients. But it is also a blow to patients everywhere who were tough to treat and often written off as lost causes, those who most stood to gain from this marriage of university resources and state hospital needs.

“It’s very, very sad for me to see it close,” Liberman said. “They are closing what is generally acknowledged as the premier institution in the world for the developmentally disabled and the mentally ill. And it’s going to take some hard lessons before people realize that this retrenchment and lowering of priorities for the mentally ill was a very serious blunder.”

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Since the 1950s, Camarillo and the state’s other mental hospitals have periodically found themselves tangled in controversy, first for the warehousing of patients, later as they emptied their populations into surrounding communities.

But through it all, with little public fanfare, Camarillo’s clinical research unit grew to be one of the most important in the world.

It was at Camarillo, under May’s guidance, where researchers first proved the superiority of the class of drugs known as phenothiazine in battling schizophrenia, conducting studies with hundreds of patients over a span of more than a decade.

By the time Liberman arrived in 1970, however, no serious advances had been made on that work, leaving the door wide open for renewed exploration.

Liberman and his team blended the use of the latest drugs with new social-skills training aimed at teaching patients how to control their illnesses and function more independently.

The emphasis was on determining what part of the illness responded best to medication and what was best handled by social therapy, he said. And the goal was to ready as many patients as possible to leave the hospital for a place in the real world.

Although most of the work centered around mental illness, the research branched out over the years to include the treatment of autism and other developmental disabilities.

Liberman remembers one autistic patient in the early 1970s who was shipped to Camarillo from a state hospital in Michigan. He was in his mid-20s and could care for basic needs such as eating and getting dressed.

But he was often aggressive, kicking and cursing and spitting at those around him. He would fight with staff and, when fully enraged, would toss furniture around the room. As a result he spent a lot of time secluded and restrained.

Researchers set out to find ways to motivate change.

As it turned out, the key in this case was a dollar bill. Realizing that money was extremely important to him, a program was set up that allowed him to earn a dollar a day as long as he behaved. On the flip side, he lost a dime each time he lost his cool and lashed out.

That incentive was combined with a social skills program designed to teach him how to properly communicate his needs, medical and otherwise, to people around him.

As a result, Liberman said, his abusive behavior virtually disappeared within three or four months and he was discharged to a board-and-care home, where he has lived for more than two decades.

That story reflects the experience of many of those who spent time on the 11-bed research unit, Liberman said. Patients were hand-picked for the ward, depending on the research needs at the time.

The vast majority of research patients--perhaps more than 500 over the years--came from other units at Camarillo and other state hospitals.

About half of those who came to the unit were able to leave the hospital at the end of their treatment, Liberman said.

“These were people who were really going to live out their entire lives in what we call the back wards of state hospitals,” Liberman said. “We treated the most severely disabled of the most severely disabled. They are the ones who need the research the most but who are no longer going to have it available to them.”

None of the work came cheap. There were 18 staff members for the ward’s 11 patients, by far the highest staff-to-patient ratio at the hospital. It cost about $1 million a year to operate the unit, perhaps two or three times the cost of other units.

Some of those costs were offset by the fact that the program was a joint venture with UCLA, which supplied five staff members and other resources. The unit also attracted about $2 million a year in federal and pharmaceutical company grants, which helped ease the financial burden and fueled the research efforts.

“For 20 years, we have taken the most difficult patients the hospital has and rendered them superb treatment that could be gotten nowhere else in the world,” said Dr. Barringer Marshall, the unit’s medical director. “I’m really sorry to see the opportunity to continue to do that go down the drain.”

That sentiment, however, is not universally embraced.

Some mental health advocates argue that there is no shortage of research centers nationwide, and that there will be little or no impact when Camarillo’s shuts down.

Furthermore, they argue that since researchers are transferring to the veterans hospital in Los Angeles, there will still be plenty of opportunity for researchers to continue their work.

Steven J. Taylor, coordinator of disability studies and director of the Center on Human Policy at Syracuse University, said it made sense to have research programs in state hospitals when they were providing the bulk of the care for the mentally ill and retarded.

But just as that care has shifted over the years away from institutions and toward community care programs, research efforts must shift as well.

“They can celebrate the work and the history and the past, but times have changed and it’s time to move on,” Taylor said. “I think the bottom line is you don’t keep people in institutions just to make it convenient for research.”

But Liberman said it is hard to argue with the results achieved at Camarillo over the years.

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Thousands of workers all over the globe have been trained to use the treatment techniques developed at Unit 45. Education programs, which can teach entire families how to better cope with mental illness, have also been widely replicated.

Training programs to teach independent living skills--such as teaching patients how to manage their own medication--have been translated into a dozen languages, put on videotapes and distributed worldwide.

The future of those efforts remains in doubt, however. The unit actually closed last year on Halloween, with the bulk of the research team boxing up their belongings and transferring to the VA Hospital in Los Angeles.

Liberman is uncertain whether the same forces will ever again be assembled to create a unit as effective as the one at Camarillo. And if that doesn’t happen, he worries what that will mean to patients who stood to benefit most from continued research.

“There will be a proportionate share of these individuals who will not be able to succeed when they leave here,” Liberman said.

“These people are going to be lined up in our emergency rooms, they’re going to wind up in our jails,” he said. “It means there’s going to be much more vagrancy. And it means there’s going to be an extraordinary increase in the burden on families. It means we’re going back to the 19th century, before we had state hospitals.”