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Conversation with Sheila Blume

2005; Wiley; Volume: 101; Issue: 1 Linguagem: Inglês

10.1111/j.1360-0443.2005.01261.x

1360-0443

Sheila B. Blume,

Substance Abuse Treatment and Outcomes

AddictionVolume 101, Issue 1 p. 31-39 Free Access Conversation with Sheila Blume First published: 21 November 2005 https://doi.org/10.1111/j.1360-0443.2005.01261.xCitations: 4AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Figure 1Open in figure viewerPowerPoint In this occasional series we record the views and personal experience of people who have especially contributed to the evolution of ideas in the journal's field of interest. Sheila Blume has been widely influential in the substance misuse field in the United States of America and more widely at many different levels. She has, in addition, played an important role in enhancing professional interest in pathological gambling, its measurement and its treatment. EARLY YEARS Addiction (A): Your career has been a rich and accomplished one. You have been an important mentor to many in the field of addiction medicine and are one of its pioneers. Please tell me a little about how it began and where you grew up. Sheila Blume (SB): I was born in Brooklyn, New York. My father was an engineer and a self-made man who had grown up in poverty. My mother had also come from the slums of New York and they were very interested in education and opportunity. I had a brother 3 years older who followed my father's footsteps as an engineer. I as a woman had the good luck of choosing my own path. I went to public schools in Brooklyn. I graduated from Abraham Lincoln High School, a very good public high school, where I met my husband, Marty. He was the captain of the math team when I joined as a ‘rookie’, but he was older and graduated before me, and we did not get together again until graduate school. A: Where did you go to school after that? SB: I attended Cornell mainly because my brother did. I never finished and never got my bachelor's degree. I applied to medical school after 3 years, which was unusual. My challenge in college was to decide on a career. I spent a summer at Woods Hole Marine Biological Laboratory after my sophomore year, where I got to study invertebrate biology and see what a laboratory was like. During that summer, I decided that I would go into medicine. I found the biological research of the 1950s too slowly paced for me. A: Was that unusual for a woman in the 1950s to apply to medical school, especially after only 3 years of college? SB: Yes. I was influenced by a professor named Marcus Singer, bless his heart, who had come to Cornell from Harvard Medical School. By then, I was auditing graduate classes. I had started doing that as a sophomore—embryology, neuroanatomy—because these subjects interested me. I was auditing his course in neuroanatomy and he was asked to interview me for medical school. He was aware of my interest and motivation, and he talked me into going to Harvard. A: By that time, you had decided that research was not the career for you because it took too long to get results—correct? SB: Yes, well, pure research. Medical research was OK. I still was not sure because I did not know what medicine was like but I knew I wanted action! [Chuckles] That's the psychodramatist in me speaking! I was the youngest member of my medical school class. A: The youngest and one of only a few women. What was that like? SB: We were the tenth year of a 10-year experiment. The first year they took women at Harvard Medical School, in 1944, was very late, given the times. They were forced into it by World War II. The medical school had been admitting boys right out of high school while refusing women from the best colleges, so they decided that for 10 years they would accept women and see how it worked out. We were the tenth class—the class of 1958, about 5% of the class. We were most unwelcome. A: How did you know you were not welcome? SB: How would you like to be sitting in a giant lecture room and have a professor show slides of nude women in compromising positions, as a joke? I did not find it funny. They made jokes about women constantly. You know, old-fashioned women jokes about how stupid, and grasping women are, how all women want is a new refrigerator. Then, when I got to obstetrics, I never delivered a baby. We were supposed to deliver 10—then graduate, but the obstetrics instructor arranged it so that I never had the opportunity. Anyway, I graduated with honors, as did most of the women. That was not unexpected because in order to be admitted a woman had to be not only smart but assertive and self-possessed, so the women were on top of the class, and we were resented for that, too. ‘They made jokes about women constantly. You know, old-fashioned women jokes about how stupid, and grasping women are, how all women want is a new refrigerator.’ WANTING OUT OF BOSTON A: What got you through those times? SB: Ahh . . . true love! In the fall of my first year, I met Marty again and we were married at the end of the school year. And we fell in love right away and we stayed that way. We will be celebrating our 50th anniversary in June of 2005. When we needed to relax, we had our favorite places. One was a Japanese garden in the Boston Museum of Art. That was a calm and beautiful place. That is how we came to be interested in Japanese art. When I finally completed my internship at Childrens’ Medical Center, and he gained his PhD in physics, we wanted out of Boston. I did not want to climb the corporate (academic) ladder, which for women was so hard anyway. It was just banging your head against a wall. There were few women in high positions. We met only one female professor in our whole 4 years at Harvard, a professor of public health (I think her name was Harriet Hardy) who gave us one lecture. Marty and I wanted to go as far away as we could, so we applied for Fulbright grants in Japan and we got them (‘his and hers’). My internship ended in July and we left in September, so I studied Japanese from a book over the summer. Marty and I decided to go around the world on the surface—no flying. We wanted to see how big the world was and were gone for 3 years. We went west on the 20th Century Limited to Chicago, and then we went across country on the Great Northern Railroad. Then we crossed the Pacific in a Japanese ship, the Hikawa Maru, from Seattle to Yokohama. There were a lot of Fulbrighters on the ship—Japanese coming home and Americans going over. I then discovered that although I had mastered the 12 lessons in my Teach Yourself Japanese book, as I had never heard it spoken, I could not understand the language. But to my pleasure and amazement, I think it was about 4 or 5 weeks later, suddenly I felt a switch in my head go ‘click’ and I could speak and understand Japanese—of course, not too well, but I could use everything I had learned. I opened my mouth and Japanese came out! Marty and I started to learn to read Japanese. I could eventually read signs and the headlines in the newspaper. That was pretty good. A: What did you work on while in Japan? SB: I did a study on hair color in phenylketonuria in Japan. I had gone there to look for the disease, as it had never been described in Japan, but a group of geneticists had just completed that study before my arrival. I used their cases to study hair pigmentation in probands and families and was able to show a heterozygous state. It was a lot of fun and I got to travel all over the country. A: What was it like being a woman in Japan at that time? SB: It was weird. First of all, the Japanese language has various forms and there is no appropriate form for a western woman, so western women use a modified male speech. There were some words that I could not use as a woman. A: Interesting! SB: Very complex. [Chuckles] A: What were the attitudes toward professional women—women in academia? SB: The graduate students, who were our friends and Marty's colleagues, were fascinated because they were still in arranged marriages. Love matches were rare. Having a career and marriage and children—I had a baby while I was there—was almost unknown. People were very curious about how it would work. They were curious about the United States anyway. Very few US civilians had been there in the 1950s, and I was asked loads of questions. I taught conversational English classes at night. We did a lot of traveling, met a lot of people and stayed a little extra time before we went to England. We traveled to England on a German passenger-freighter. A: What happened in England? SB: We lived in rural England for 2 years in a thatched cottage with no heat, and had a second child. That is another story. A: So you had finished your internship in pediatrics and completed a Fulbright. How did your career path move toward psychiatry? SB: Pediatrics as practised in the 1950s blamed parents for their children's illnesses. I knew, first of all, that this could not be true, and even if it were true, telling the parents this was not helpful. I saw role model pediatricians, these exalted professors, saying to parents, ‘You’re responsible for your child's illness.’ I thought if I studied some psychiatry, I would learn what makes people emotionally healthy and more about parent–child relationships. At the time, most pediatric work was well baby work. I wanted to do that but I wanted to be a good pediatrician and understand psychiatry at the same time. At Childrens’ Medical Center, in the 1950s, the parents were the enemy. The nurses would complain that the parents would visit and the children would cry when they left. Well what did you expect them to do—dance? Ugh! PSYCHIATRIC TRAINING A: Where did you decide to study psychiatry? SB: I went to a large state hospital—Central Islip State Hospital—because Marty was working on Long Island. We took a map and drew circles to find out which hospital would be close enough to apply for residency. My career took a turn the first day of residency training, 9 September 1962. Everyone else started 1 July, but we had just returned from England and we needed to find a house. When I got to the hospital, I found they had been assigning me patients since 1 July! The other residents were taking care of them, but they were Dr Blume's patients. It was a substantial list—I cannot tell you how many. I spent my first day interviewing all of these women—it was a women's admission service. I had been taught nothing practical in medical school about psychiatry. Psychoanalysis ruled in those days. Our training at the Boston Psychopathic Hospital consisted of sitting for an hour with lobotomized schizophrenics and trying to analyze what they were saying. It had nothing to do with real life. So I interviewed my patients and found a museum of mental illness—every possible disorder. ‘I had been taught nothing practical in medical school about psychiatry. Psychoanalysis ruled in those days. Our training at the Boston Psychopathic Hospital consisted of sitting for an hour with lobotomized schizophrenics and trying to analyze what they were saying.’ A: And what did you do next? SB: What I decided to do was to pick the woman who was the most sick and the woman who was the least sick and spend a lot of time with them to learn. I would treat and follow the other patients as my colleagues did. In my total ignorance, the woman who I thought was most sick was acutely psychotic, while the woman who I thought was least sick was an alcoholic teacher with six kids. She had been sleeping in her car in the school parking lot. Somehow her husband had had her committed. So those were my two intensive cases. The psychotic woman got well on thorazine. The hospital was just what she needed. She did beautifully and we had a great relationship. We stayed in touch for months and she would come out to see me on visiting day. I still have a string of pearls that she gave me. She wore the same ones. It was great! So you would think that I would go into schizophrenia treatment, but no. A: The alcoholic woman? SB: The alcoholic woman was the real challenge. She was desperate to stop drinking. There was nothing therapeutic in the hospital for her except that it protected her from access to alcohol. She had only our sessions together. So she and I set out like two babes in the woods to try to figure out what to do. After a couple of weeks, I went to the chief of service and said I needed some help, and he started me on my career with his two-word answer, ‘Why bother!’. That was the attitude in 1962. ‘You can’t help alcoholics anyway. You’re wasting your time. Also, if you’re going to spend your time with somebody, pick someone who is really sick—not one of those drunken bums.’ In fact, in the state system at that time, we were supposed to diagnose alcoholic patients as ‘without mental disorder’ and discharge them. I was also attending the New York School of Psychiatry, a school that was part of the residency training. We were being introduced to group therapy, so I started a group for alcoholic women. We would trade patients—one schizophrenic for one alcoholic—the other trainees were only too happy to do that. I ran the group for a year. That is how I learned about alcoholism—it was always a woman's disease to me. My patients taught me. The only help I got was from Marty Mann's book, The New Primer on Alcoholism[1], which we happened to have in our hospital library. I learned about Alcoholics Anonymous (AA) because there was a male AA group in the hospital. I integrated it—I got them to allow women to attend. But every time I went away for a week, the women were thrown out again. But that experience also made the fellowship more valuable to the women. They had to fight their way in. AA was not shoved down their throats. That was just my first year of training. GETTING INTO ALCOHOLISM A: And what happened during the rest of your residency? SB: Then I went to child psychiatry for my second year at Central Islip. But fate stepped in. Unbeknownst to me, New York State decided to start the first in-patient alcohol rehabilitation unit in the state at Central Islip because we had an established AA meeting. We were one of the few hospitals that cared enough about alcoholics to have one—that was how bad it was. The Bowery (New York City's Skid Row) was in our catchment area so we had a lot of alcoholics. The rehabilitation unit was started in 1962. I did not even know it was there. In 1964, I got a call from the director. The secretary said ‘He wants to see you immediately.’[Laughs] Frankly, I thought I had killed somebody. It was a big place—10 000 patients. It was too far to walk so I got in my car and I drove to his office trying to think about what I might have done. Well, the psychiatrist who ran the alcohol unit had asked for a month's leave of absence. Of the over 100 psychiatrists on staff, nobody would go there as a substitute. Somebody remembered there was a resident, by then I was second-year, who ‘liked those people’. So he asked if I would do it and I agreed. That is where I met my first alcoholic man. I had asked the head nurse to find the most typical alcoholic on the unit. She picked a patient who had been slipping and sliding and failing, who also turned out to be a neighbor of mine. I asked him if he would talk to me whenever I had spare time. I just sat and listened to him talk and asked questions. I am glad to report that he never relapsed again after that stay and we became friends. His wife would come to visit and introduced me to Al-Anon. She took me to meetings. I loved it for that month. A: At the end of the month? SB: At the end of the month, I was called back to see the director. The doctor who had taken a leave of absence decided not to come back. The directorship of the unit was open—it was a position three levels up from residency. He was offering me the job, complete with the salary, but I did not take the job right away. I said something that made his jaw drop. I said I would take the job on one condition. Here I was, this lowly creature, making conditions! The condition was that we develop a unit for women. Women were not getting the proper treatment. He said, ‘Yes, I agree with you but we don’t have the money for it. Let's get together and put in a grant proposal.’ So we did and received money from NIMH (National Institute of Mental Health). It was before there was NIAAA (National Institute of Alcoholism and Alcohol Abuse). In 1966, we started the first women's unit in New York state. At first we had separate male and female units that were about half a mile apart, but you could not get lost because the men and women had carved a path in the grass between the two buildings. We eventually integrated the units. A: One of your many interests is in psychodrama. How did that interest start? SB: I started a psychodrama program very early when I first took over the rehabilitation unit. I had gone with a friend, another resident, to see Dr Jacob L. Moreno in his theater in New York City. He gave public performances—it seems so strange to me now. We all went on a date. It was interesting and I filed it away in my head as something that had potential. When I took over the male alcoholism unit, we needed more activity. There were therapy groups and AA but we needed more, so I started what I called ‘Situations’, role-playing. I worked my way into psychodrama by reading more about it. The unit was all male so I started bussing the women over rather than having two separate groups, and that is where I had the idea that we really had to have one co-educational unit. I found that in running same-sex groups—which I did for a long time—the sexes tended to scapegoat one another: ‘men are all alike, all they’re after is sex . . .’; ‘the women just want your money . . .’. In a mixed group, you cannot get away with that. I found that I preferred a mixed unit, although romances would develop. A: What did you do about detoxification in those early days? SB: Actually we also had the first detoxification unit in the state hospital system. Patients were being detoxified on the admission units anyway, so I thought we might as well do it properly and bring all of the patients together. That way we had a group of patients we could learn from, instead of each doctor conducting the detoxification differently. So I ran a detoxification unit, a rehabilitation unit, a little quarter-way house and a day hospital. The day hospital was great. My idea was that the day program would be for the down-and-outers—people who were no longer employable but were motivated to stay sober. We acquired a van and driver. I found out that I was wrong about who would benefit from this group. There were actually two sectors: the male old-timers, and housewives with children! The women could not come to the in-patient rehabilitation unit because they had children at home. They just loved coming to the day hospital, however, never missed a day, and most got well. So that was nice. STATE RESPONSIBILITY A: It sounds as if you really loved your work. How did your career evolve into becoming Commissioner of Alcoholism and Alcohol Abuse for the state of New York? SB: Our governor, Hugh Carey, was running for a second term. One of the planks of his platform was that he was going to re-organize the Department of Mental Hygiene, the largest department in government. He thought it was a good time to remove the responsibility for alcohol programs from the department because alcoholism just was not getting much attention. He formed a task force of 10 people, of which I was one, to rewrite the law as part of his initiative in going for another term. That was something new to me. I discovered the power of a word written in law. For example, my job on the task force was to re-write the treatment part of the alcohol side of the new law. The old law said the purpose of the agency was to provide services for the alcoholic. We added two words—‘and family.’ With those two words, we enlarged the scope of what we could do. Treatment of children of alcoholics started under my leadership. Family work was not part of our job before. I wish I had been smart enough to add treatment for gambling problems as well. ‘I discovered the power of a word written in law . . . The old law said the purpose of the agency was to provide services for the alcoholic. We added two words—“and family”.’ A: Was the law passed? SB: The governor was re-elected and the law was passed. However, he ran into some trouble. He had fired some commissioners and everyone was mad at him. He needed someone to go up to Albany in a hurry—someone who was well-known, well-liked and who could bring the field back together. And that task fell to me. I had no wish to leave Long Island, but thinking it over, Marty and I figured it would be fun and I would just do it for a short time until everything calmed down. As it turned out, I had a 4-year stint. It was very interesting. A: What did you accomplish as commissioner that you are most proud of? SB: I did a lot that I wanted to do: for example, changing the social services law. Previously, the definition of child neglect contained phraseology that if a parent was a habitual user of alcohol or drugs, he or she was by definition a child neglecter. That meant that a woman or a man (it was usually a woman) who had no family and needed in-patient care for addiction, and had to get public help with child care, might not get her children back. The parent was guilty by law of child neglect. So we changed the wording—I composed the wording myself. It was written to say that if the parent was in a program of recovery, purposely stated that way so that AA could be included, that there had to be specific evidence of child neglect in order to accuse the parent of neglect. Social service people did not oppose it. It became a model law. The Children of Alcoholics Foundation wrote a booklet about it in order to change the law in other states. Is that not amazing? You can do that in government. But you also waste a lot of time. I figured about one-third of my time was devoted to substantial work. A: Other initiatives? SB: Another thing that we did was raise the purchasing age for alcohol from 18 to 19 years old. That was one of the few bills in the history of New York state that was actually passed in a form that was designed to allow a pre- and post-test. In other words, there was a research piece in the bill. It did not take effect for 6 months after passage so that we could collect baseline data. One year after the age change began, we would know if what we predicted was correct, whether we actually saved lives. With that information, we could raise the age from 19 to 21 years old. New York's purchasing age for alcohol had been 18 since the repeal of Prohibition. We measured single car crashes and found a drop among drivers between ages 18 and 19, but not for other ages. I remember saying ‘picture a baseball team of boys—we are going to save their lives with this bill’. Nothing is ever done that way in government. Usually if a program gets studied at all, it is studied years later. A: Another focus of yours has been pregnancy and addiction. How did that interest evolve? SB: I was always interested in women because their problems were routinely overlooked. Research would discuss this and that in alcoholics but the studies were only conducted in the male population. Sometimes they did not even mention the sex of the subjects—it was just assumed to be male. From these studies, broad generalizations about alcoholism were made and women were left out. All the treatments were developed based on men, and women were squeezed into the mold. I was always interested in programming for women. When I got to Albany, fetal alcohol syndrome (FAS) was just beginning to be described. Most doctors, including obstetricians, had never heard of it or thought that they would never see it. People in the alcohol field barely knew what it was and the public thought it meant drunk babies. So one of my first initiatives was forming a task force of people from around the state with varying areas of expertise—mental retardation, obstetrics and so on. The group developed a report and a public education initiative. So that is how my name got associated with FAS. A copy of a paper on FAS and referral information was sent to every Obstetrics and Gynecology unit in the state. I once gave a talk about FAS at the New York Academy of Medicine, typed up my talk and submitted it for publication in the Journal of the New York State Medical Society. The editor returned it with a note that said, ‘Sheila, are you kidding?’ This response was typical of the way FAS was greeted by the medical establishment. They did not believe in it. They thought if this existed we would already know about it. But they did not know about it! I wrote back that I was not kidding and referred to the review article that was just published in Science[2]. My article was then published [3]. We had our job to do and I am afraid it is still not completed. A: After 4 years in Albany, what happened? SB: I went to the National Council on Alcoholism (NCA). After about 6 months, they could no longer afford a full-time medical director. Around that time, the New York State Medical Society was starting the Committee on Physicians’ Health, so I began to work for them writing the manuals. I had known what was needed from my work with the Medical Society committee. Unfortunately, the executive director at the time was not supportive of this program. So I left. That is when I went to South Oaks Hospital, in 1984. THE MOVE TO SOUTH OAKS HOSPITAL A: How did the opportunity at South Oaks come about? SB: South Oaks was a privately owned psychiatric hospital on Long Island established in 1882. It was owned by a group of families. The director was very interested in alcoholism and drug dependence and he began treatment services at the hospital for those disorders. He also developed a training program for addiction counselors called the South Oaks Institute. He was looking for a new director with both the psychiatric and administrative experience. I became director of the alcoholism, chemical dependency and compulsive gambling services (as well as director of the Institute), and I was given the freedom to do what I wanted. [I loved working in the private sector. I could try things out and if they did not work that was OK, whereas in government you cannot say something does not work because if you do, you lose funding]. I developed all kinds of programs. At its height, I had 129 beds that included detoxification services for alcohol and drugs, and a compulsive gambling program that had started just before I got to South Oaks. It gave me the opportunity to develop my long-standing interest in gambling problems. It was perfect for me. I had a great staff and did a great deal of training. I resumed directing psychodrama. I had a deputy, Bob Cahill MSW, who was already a psychodramatist. I developed a closed unit for those who could not maintain themselves drug free on an open unit. Patients worked their way to greater privileges. It really was an effective approach for some people. We had a dual diagnosis unit—even back then. We also had out-patient and intensive out-patient services. ‘I loved working in the private sector. I could try things out and if they did not work that was OK, whereas in government you cannot say something does not work because if you do, you lose funding.’ A: How did you become interested in gambling addiction? SB: As always, through a patient. I came to know him in the late 1960s. He was part of my study of Jewish alcoholics. After leaving the alcohol unit, he switched addictions and became a pathological gambler. He came back to the unit to ‘hide out’ because people were looking for him. I agreed to let him stay if he agreed to work on his gambling problem. So he and I got started, just as I did with the first alcoholic woman I treated. I looked in the phone book and luckily there was listed a number for Gamblers’ Anonymous (GA). I called it and met a man from GA who talked to my patient and to the psychiatric residents. At that time, I was also running the resident training program at Central Islip. A: South Oaks is the namesake for the pathological gambling scale that you developed. Tell me how that evolved. SB: When I arrived, South Oaks had just made arrangements with a professor at St John's University named Henry Lesieur PhD to do research on gambling. He felt quite rightly that there was a need for a screening tool, and I worked with him on developing one. We needed a name. We wanted a four-letter acronym like the MAST (Michigan Alcohol Screening Test). We also thought it would be nice for South Oaks to be in the name because their foundation funded the research. We finally decided on SOGS (South Oaks Gambling Screen) [4]. The SOGS is now available in 35 languages—most recently Estonian. A: I know that you have been involved in helping to develop addiction programs around the world. I recently learned that the Caribbean was one of those places. Tell me more about that experience. SB: The NIAAA was formed by federal law in the 1970s. They had a lot of money to give away for treatment—what later became the block grants. Some money went to the Virgin Islands and they had no organized treatment. They decided to use the first year's money to invite experts down from the continent