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    Standardizing Care for the Forgotten

    May 18 2022

    Central State Hospital (CSH) opened in 1870 in Petersburg, Va., and was the first state hospital in the United States exclusively for African Americans. Rather than integrate its two existing asylums, Virginia’s governor signed legislation to house all “insane” Black people in a former Confederate hospital. The hospital remained segregated until 1968 when federal law required integration of health care facilities.

    Throughout its history, the underfunded hospital's staff, patients, and their families often did not receive the care or respect they deserved. Dr. Olivia Garland was one of the first directors of the hospital to make significant improvements to change that. On this episode, she joins us to talk about that journey.

    Olivia Garland, Ph.D., served as Director of CSH from 1985 to 1991. During her tenure, the facility regained its accreditation, secured funding to have all patient living areas air-conditioned, and established a residency program with Virginia Commonwealth University/Medical College of Virginia.

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    Transcript for Audio

    Deena Gorland: Hello, and welcome to Mentally Healthy Nation, a podcast from the American Psychiatric Association Foundation. I'm today's host, Deena Gorland.

    Deena Gorland: The Central State Hospital was the first standalone mental hospital in the United States for African Americans, which opened in Virginia in 1870, and remained segregated until the passage of the Civil Rights Act of 1964. Today, Central State Hospital continues to support the wellness of individuals, serve the community and employ thousands of Virginians throughout the Commonwealth. Please join my conversation with Dr. Olivia Garland to learn how she transformed the care for the patients and the hospital environment for the staff.

    Deena Gorland: Today, I have the pleasure of speaking with Dr. Olivia Garland. Dr. Garland was named Director of Central State Hospital in 1985 as the first full-time permanent African American director since Dr. JD Harris in 1869. And during her time at Central State Hospital, she promoted and advocated for a more robust system where patients received aggressive inpatient treatment and equal outpatient services to support and sustain a productive life in the community. Welcome, Dr. Garland. I'm so pleased that you're able to talk to me today. I would like just to start out finding a little bit more about your background and early career and work experience, before we sort of dive into your time at Central State Hospital.

    Dr. Olivia Garland: Well, first of all, thanks Deena. I'm very pleased to be here. I was born and raised in Richmond, but specifically Henrico County, and Henrico County is a rural county that surrounds Richmond on three sides. I had my early education there, my high school education in Henrico until I went to college at Hampton University. My parents were formally uneducated people. That is neither of them finished high school, but they were both absolutely brilliant. So my mother worked in a factory environment at Nabisco, a cookie company, and my dad worked at American Tobacco Company. He was the first African American to be promoted to a managerial position back in the 60s.

    Deena Gorland: That's impressive.

    Dr. Olivia Garland: I was very fortunate to grow up with such wonderful parents. First of all, my mother had me reading books at three and four years old. So when I went to the first grade, I was reading at a fourth-grade level because of the work she had done so I felt very fortunate. And they both told me I was smart and I was going to be prepared to be in a new world, a world very different from theirs. And my dad had this saying when I was a young girl, about 10 or 11, he used to say, "Olivia, Henrico County is not the world. Richmond is not the world. Virginia is not the world. The United States is not the world. There is a big world out there with lots of countries and different people. And you're going to be a part of that world." And I always remembered that. In fact, when I went to Hampton University, one of the reasons I went was because they had a foreign exchange program, and I was able to study abroad in Spain at the University of Valencia during my junior year.

    Dr. Olivia Garland: And that also proved to me what my dad had said, that the world was much bigger than where I grew up. I actually had an English education major. And so when I left Hampton, I started my career as an 11th grade English teacher in the Richmond public schools, where I taught for 3 years before I started making changes in my career. I went on to get my master's and my doctorate degree from Virginia Commonwealth University. My career has not been very linear. I thoroughly enjoy teaching. I had honors students, very bright kids, all of them became doctors and lawyers. I'm so proud of those kids that I had in those days. But I wanted to do more for perhaps the unfortunate. So I ended up actually after teaching, working for the Department of Corrections, where I worked as a rehabilitation counselor at the state penitentiary for men. And I stayed in that department, and six years later, I became the first female warden of a men's prison. It was called Stanton Correctional Center where we offered programs in substance abuse and some other programs there.

    Deena Gorland: And how long were you the warden there?

    Dr. Olivia Garland: Well, I was assistant warden at Powhatan Correctional Center for three years. And I was the warden at Stanton Correctional Center for three and a half years. And it was at that point that I was contacted by some people from the Department of Behavioral Health and Developmental Services.

    Deena Gorland: Oh, and so that's sort of what led you then to go over to Central State Hospital? Is that ...

    Dr. Olivia Garland: Yes. I came in contact with them because I was trying to bring more mental health care to the prison where I was working. I did my own personal study of the prison system and realized that about 20% of my population had mental health problems. So I made contact with the Department of Behavioral Health and asked their advice on the types of people to hire, what kind of programs were good for people with mental illness, as well as people with substance abuse. And so they got to know me by me being interested in getting programs at my prison. And one day I had one of them to call and say, we have this position opened at the psych hospital at Central State, and we'd like for you to apply. And I kind of said, "Well, I'm not a physician or a psychiatrist or a psychologist. I'm an administrator." And they said, "Well, that's okay. There are plenty of clinicians at the hospital. We need an administrator. We need somebody who knows how to run a complex organization." So we interacted for two or three months and then I accepted the position.

    Deena Gorland: I'd love really to dive into your time as the Hospital Director at Central State. So you were hired in 1985?

    Dr. Olivia Garland: Yes.

    Deena Gorland: And you were the first African American director since JD Harris, that's over 115 years. Was it a lot of pressure on you when you accepted the position? And I guess, did you have concerns or were you apprehensive, I guess, is what I would say about accepting the position?

    Dr. Olivia Garland: I certainly was because I knew, unlike the prison system, I had a physician, I had a couple of nurses, but then I knew if I took this job, the whole hospital was filled with clinicians. So I wasn't sure how I would be accepted, and I wasn't sure at the time, what the actual issues were at that hospital. I knew that there was a reputational problem going on there and I knew they hadn't been able to maintain a director. So I was apprehensive in that sense, yeah.

    Deena Gorland: And during the time you were hired, who was the Virginia Commissioner?

    Dr. Olivia Garland: Well, his name was Joseph Bevilacqua. He was phenomenal. He probably was the one that was instrumental in making me feel comfortable. He, I think, had a couple of objectives for hiring me. I think he wanted someone who understood organizations and how to run an organization. He wanted someone, I think, who was maybe a minority, because what I found once I got to Central was 70% of the direct care staff were minorities, even though the patient population was 50-50. And I think because Central State was the only facility out of the nine that had a formal forensics unit, which was a highly secure unit, he knew because I came from the prison system that I would not be uncomfortable managing a more secure environment. But all of the previous directors had been a clinician, either a psychiatrist, physician, psychologist, nurse, or social worker. I'm pretty sure I was the first person who did not have a clinical background.

    Deena Gorland: I guess the first day of the job when you got onto the facility, what was your plan of attack so to speak? I mean, I know that there's a step -by-by step process that you have to take and having sort of an administrative background within moving in these healthcare systems, both private and public, were you initially sort of shocked and during your initial review, I guess I would say, and the assessment of the overall facility?

    Dr. Olivia Garland: I kind of use ... I have my own way of doing an assessment so that I can feel comfortable that I understand the environment I'm in. So I did sort of lay out my normal plan of attack. The first is always to get to know the people, the patients, the staff. I needed to have a feel for what they thought of where they were. What did the patients think about the care and treatment they were getting there? What did the staff think about working there? And so I spent the first two or three months, really almost living at the facility. I went on every shift and I just talked to people, very informally, introduced myself, talked with them one on one, asked them many questions about how they felt, what they know, what they didn't know, what they expected of me as the new director. So I spent some time getting a feel for the people there.

    Dr. Olivia Garland: And then I usually, after listening to them, I went back and I accumulated all of the data I could find about the hospital because there is a quality improvement committee at hospitals and they collect data every day or every week or every month. And so I got those reports and I reviewed them to see what the reports were saying about injuries at the hospital, about the quality of care, about seclusion and restraints. There were just a couple of dozen things that I looked at that time.

    Deena Gorland: Right. When you first set eyes on the facility, was this facility different from other facilities that maybe you had visited or that you had seen, or even comparing to ... I guess you can't necessarily compare it to being warden in a correctional facility.

    Dr. Olivia Garland: I did. I did have an initial impression because the facility is a campus. So it's set on really 2 or 300 acres of land and the place was manicured well, but there were, oh, a half dozen dilapidated buildings that had been there, you could tell for years, and they were boarded up. The campus in that sense did not look appealing to work in. There was a little section in the center of the campus where buildings had been built in the maybe late 60s, early 70s for patients. And they looked out a place to the rest of the campus. But even they, when you went inside, were not that conducive to me for treatment. And Central State shared the campus with another facility, two facilities actually, one was a training center for people with intellectual disabilities. And the other was a small physical hospital and just the whole campus was not an appealing place to look at.

    Deena Gorland: I mean, obviously there was disparities between what was there on the campus comparative to other hospitals. And it seems though there wasn't a lot of attention to this particular facility.

    Dr. Olivia Garland: Yes. Well, when I had been warden, I was actually, for the prison I ran, was very close to another behavioral health hospital called Western State. And I had visited Western State, and I saw their grounds and I saw their buildings. And I could say that they look a heck of a lot better than the ones that I saw at Central. But once I started working at Central, I quickly visited almost all of the other facilities. Aside from maybe one other hospital, I saw quite a difference in obviously the resources that Central didn't have.

    Deena Gorland: Right.

    Dr. Olivia Garland: I did my assessment probably in three months, maybe four, mostly because I wanted to be able to, first of all, feel that this was a place where I could make a difference. And then secondly, I wanted to be able to tell the commissioner, Dr. Bevilacqua what I thought, which I did. And I did talk to him about the physical plant, that I found these crumbling buildings there, a distraction on the campus. I talked about the disparity I saw between our hospital and the other hospitals. I talked to him about the budget because I looked at the budgets at the other hospitals as well. And I could see some difference in the budget that Central had versus some of the others. I talked about the fact that Central was overcrowded and had a number of patients there from other hospitals.

    Dr. Olivia Garland: And so when I looked at the injury rate at Central, it was higher than the injury rate at the other hospitals. But as I got to know more about the hospital, over that two to three to four months, I realized that the other hospitals were sending their most difficult and challenging patients to Central. And yet Central wasn't getting additional staffing for that, and it resulted in a lot of injuries to patients and staff.

    Deena Gorland: Wow. I do remember you mentioning that the staff just overall at the facility sort of felt, as you said, a stepchild of the system and like a dumping ground for all those that couldn't be taken care of elsewhere. And I mean, that adds so much stress, not just to you as a hospital administrator, but also to the clinicians there. So during your time, was there also like a sort of a changeover in staff, and how you went about the way that patients were cared for overall? I mean, you were advocating for them too, the staff and the patients, but ...

    Dr. Olivia Garland: Absolutely. Well, the first thing I realized after doing my assessment, besides the negative things that I noticed, the good thing was that I had really quite a competent staff. The clinical staff had great credentials. I thought that the direct care staff probably needed more training, but they were all very dedicated to the facility. And even though they felt like a stepchild in the system, they pulled together very well to make things work for the patients. So I thought that was a positive. I saw enough there, when you have the staff all working together in a positive way, that's half the battle. And so I thought we could make some things happen there.

    Dr. Olivia Garland: So the first thing that I did was to talk to the staff and say, the hospital had lost its accreditation several years before I got there. And I said, "The first thing we're going to do is to get accredited. We can't call ourselves a hospital. We can't be credible in the system unless we meet national standards like any hospital." So that became the cry at the hospital. Everybody knew that's what we were going after. They all had to learn the standards, and we had to function within those standards. And it wasn't just for the clinical staff. It was right down to the housekeeper so that I could walk anywhere on the campus and stop an employee, and ask them about their jobs and how did that fit into the standards. And they could tell me because it became the most important thing at the hospital.

    Deena Gorland: Wow. That's impressive. Because to get accredited is a long process and the dedication of the staff, but I get a feeling that your caregiving abilities made staff probably even as well as the patients feel comfortable, as well as feel like things are going to move forward, and your plans after the assessment were going to make changes in the hospital. I also see too, that you established an affiliation with the Department of psychiatry at VCU. was that after then you were accredited and how would ...

    Dr. Olivia Garland: Yes. I was doing that probably around the same time. I mean, when you're trying to get the hospital up to par, there are a number of things you put in motion, and that was one of them. And at that time, Dr. King Davis was called the Galt Scholar. And his role was to bridge a relationship between the universities, the teaching universities in Virginia, with the Department of Behavioral Health. And VCU, Virginia Commonwealth University, was 25 miles up the road from Central State. So I got to know the chairman of the department of psychiatry. And he, along with Dr. Davis and myself, developed this agreement that all third-year residents would rotate at Central. And it was really a fabulous time, all of these young docs coming in with their new ideas and meeting patients that they would never have seen in the university because Central had a number of people with chronic mental illness who were in and out of treatment over years. Whereas the young docs frequently dealt with people for four or five weeks, and then they were out of there. We used to call them the Wounded Well.

    Dr. Olivia Garland: And so they came to Central, they met with our staff who were very experienced clinicians, and they really meld well together. So this program was very, very effective. They provided training. Our clinicians could go to VCU to grand rounds and take courses there. Some of our docs, our experienced docs were asked to be on the faculty as adjunct faculty. So it was really a terrific relationship. At the same time, we were all getting ready for the joint commission, and we actually achieved accreditation 18 months after I started.

    Deena Gorland: Wow. That's quick. So you really did make a difference. And I think just reading a little bit too, about your background and history there, you brought in more equity just among the facilities, you helped with the funding and the staff and the big responsibility. Like there's no air conditioning in the patients' buildings. This is 1985. What's happening?

    Dr. Olivia Garland: Yes, I think that was the most surprising thing when I went to the patient buildings and Richmond, Virginia is 95 degrees in the summertime.

    Deena Gorland: It's the swamp.

    Dr. Olivia Garland: And all of these fans were blowing. I mean, there were like 8 or 10 fans running constantly. I thought this is crazy. So that became another, that was another one of those projects that we asked for funding to put in air conditioning in the patient buildings, which was approved. And I think they all got put in within two years and we had four patient buildings where we needed that done.

    Deena Gorland: I mean, just the basic necessities. I mean, here you have patients that are dealing with chemical imbalances. And that is just a basic living condition. So crucial just to be able to sleep. And so after all of your assessments, your reviews, things started sort of moving forward, then you invited legislators to the hospital to say these are the things that have been done.

    Dr. Olivia Garland: There were a couple of other things that had to happen. One was to deal with this whole issue of overcrowding and injuries. And so when I realized, with the staff's help, that they were accepting anyone, that another hospital would call and say, "Hey, I have a patient that just hurt two of my staff and we can't handle them and they're coming to Central." And we also had some of that coming from the private psych units as well. So I said to staff, "We have no obligation to say yes to all of this. Why are we doing this?" Let's set up a process for how we accept other facilities' patients, or let's have a team that could go out to those facilities to help train them on how to handle the more difficult, challenging, and sometimes aggressive and dangerous patients. And so we also then slowed down the admission of some of these patients from other facilities. I wasn't necessarily liked by some of the other directors for doing that, but I realized that no one had been advocating for Central.

    Dr. Olivia Garland: And when we started doing this, then we saw the injury levels go down to the same percentage as other facilities. So yes, we did, I asked the commissioner for more resources, for more staff. Because we had a forensics unit separate from the civil side of the hospital, that we needed additional staff to man the units. And we did receive that. And so once we got the facility sort of in hand and I kind of understood what was happening, I contacted the legislators, the local legislators. I wanted them to become more of a part of Central, to advocate for us at the general assembly whenever there were requests for more funding for the department. And they were slow at first because Central had had this reputation and they didn't want to be asked any questions by the media about what was happening at Central. But once things began to move, we became accredited, we had this program with Virginia Commonwealth University, then the legislators were very supportive and we had a great relationship.

    Deena Gorland: Yeah. I think it's like, you have to sort of put the systems in place. And to have it be thorough and make sense in order for people to understand what the next direction would be. Because it seems as though when you got there, it was a bit chaotic, not just the facility itself and it being run down and there was a high rate of injuries of staff, but the system itself, the healthcare system itself was a bit flawed, shall we say?

    Dr. Olivia Garland: Yes.

    Deena Gorland: And so you were there for six years.

    Dr. Olivia Garland: Yes.

    Deena Gorland: And so I guess, what would you say was a highlight for you when the job was over and went on to your next position?

    Dr. Olivia Garland: Well, I think I've talked a little bit about the things that changed, but I'll tell you what really personally made me feel good. I think the staff felt respected during my time there. And I'll tell you a little story. When I was walking on the unit one night, a lady wanted to talk to me and she wanted to talk and talk. And I told her, "Why don't you come over tomorrow, make an appointment with my admin and come over and talk to me? And I can set aside 30, 40 minutes." Well, she did ultimately make an appointment, but when she came to the building, she didn't walk in my office. She stood at the door and I said, "Oh yeah, there you are. Come in." And she kind of hesitated. And I said, "What's wrong?" And she said, "We weren't allowed in this building, let alone coming into the director's office. And we just can't believe that you are here, a black woman, running this hospital."

    Dr. Olivia Garland: That was a profound moment for me, and I realized at that point, how important me being at that facility was to the people there. And so that probably had more of an impact on me, and I felt when I left there, the staff felt like they were a part of the department. We had committees at the central office and frequently those committees wanted someone from Central to lead the group. There was a whole different attitude about Central, I think at the end of my tenure.

    Deena Gorland: Yeah. I think that is a wonderful story. And I'm sure you have other sentimental stories such as that. And I think just you as a woman, but also as an African American woman probably had such an impact on everyone there. And I think that's just a wonderful highlight to remember. And just being there at Central State, your presence probably was more than you even probably know. So I think that's a wonderful experience in your life to carry on. And you have 35 years of healthcare experience in both the public and private sectors. And so I'd really like to kind of know what your thoughts are on the sort of mental health landscape in general with providers or even stigma, treatment today, but most particularly for black and indigenous people of color.

    Dr. Olivia Garland: Well, I think the first thing I want to say is that I'm really hardened to see the stigma, the walls falling. I think the fact that you can go on your phone now and find an app to help you with anxiety.

    Deena Gorland: Oh yes.

    Dr. Olivia Garland: Or you can have telehealth where you can talk to a provider on your computer or on your phone. I think that's saying a lot and it's one of the things that I'm very pleased that's happening because I know people of color, especially African Americans, have really probably avoided getting help that they sometimes need because of the stigma. And now they're seeing that they don't have to be ashamed or concerned. When I see athletes talking openly about their mental illness, I think it's a wonderful thing, and it's a change that I hope will continue. I think in hospitals, whether it's a public or a private hospital, having families more engaged with the treatment teams is a good thing because it wasn't always that way. I think having peers serve as members of a patient's treatment team are really good things, and that's the way I hope the mental health world continues from my perspective.

    Deena Gorland: Yes, definitely. I agree with you. I think over time, the stigma of having a mental illness has changed. I mean, obviously there's always more work to be done. And I do think that mentioning about families being involved is really important because it takes a team to really help those in need. And one of the things that I think is so important that we need to realize as a society, that mental illness doesn't define who you are.

    Dr. Olivia Garland: Exactly.

    Deena Gorland: And we have to maybe educate more people to understand this. It shouldn't define who you are, and there's treatment and even more so now than ever. And as we move into the future, there's a lot more treatment options than there were. And behavioral health is a very important part of the makeup of a person. And hopefully over our lifetime, we'll see more acceptance, and better treatment, and also more of a collaborative care system I think is also quite important.

    Dr. Olivia Garland: Exactly. I totally agree with that. One of the things that I know that I can say was difficult to do at first when I went to Central was, and I think it was true in the whole department and the department had to make some changes as well. And that is that the hospital is not a place to live in. It's a place where you go and get aggressive treatment so that you can go back out and live a productive and satisfying life. And so having family members engaged, having community mental health professionals all engaged with the individual for a short while in the hospital is fine. But really you are working toward that person living happily in the community. And so that also became one of my mantras. This is not a place where people live. This is the place where people get treated and go back out into the world.

    Deena Gorland: And I think too, just more care and thought needs to be pushed in that direction. And change is slow, but I definitely think it will happen. And it is happening. I want to really thank you so much for speaking with me today, about your time as Hospital Director at Central State Hospital in Central Virginia. And I'm excited to see the new hospital and the new facility, which I think is very much needed.

    Dr. Olivia Garland: I am very excited about it. I think about the fact that was the last thing I said to Dr. Bevilacqua is there needs to be a new hospital here. That was in 1991. And now they're going to finally get one in 2023, 2024, that's focused on treatment. And it's very exciting. I've seen the drawings, I've seen how they plan to operate. It's really going to be wonderful.

    Deena Gorland: Yeah. I think it's important, the future of patient care and perhaps the new Central State Hospital could be the blueprint of other facilities around the nation. Thank you so much, Dr. Garland for taking your time today to speak with me. I appreciate it.

    Dr. Olivia Garland: Thank you, Deena. I enjoyed it.

    Deena Gorland: Thank you for joining us for this special episode of Mentally Healthy Nation. I want to encourage you to check out the free resources from the APA Foundation at apafdn.org. And if you want to learn more about the library and archives, please visit legacy.psychiatry.org.

    Speaker 3: The views and opinions expressed in this podcast are those of the individual speakers in their personal capacity only, and do not necessarily represent the views of the American Psychiatric Association Foundation or the views, official policy or position of the institutions and organizations with which the speakers are affiliated. The content of this podcast is provided for general information purposes only, and does not offer medical or any other type of professional advice. If you are having a medical emergency, please contact your local emergency response number.