Francine Cournos is a fixer. She fixes patients. She fixes mistakes made by
student interns. She fixes errors in the studies she reviews for 14
psychiatric journals. And now, as interim director of the New York State
Psychiatric Institute, Cournos, 58, is trying to fix both the acute and
chronic problems that plague one of the country’s largest psychiatric
institutes, or the “PI” as Cournos likes to call it.

“Everything that is wrong I think I have to fix,” Cournos said one afternoon
as she stared out of her sixth floor office window at the PI’s main building
in Washington Heights. She paused, furrowing her dark eyebrows. “I mean,
something might have been a problem for 15 years but I have that urge to fix
it,” she said. “I actually think it is a detriment in the sense that it’s
sometimes hard for me to step back and see the larger picture.”

At the PI, that larger picture is a bureaucratic nightmare. There are 27
major research departments, an additional 20 sub-departments and eight
clinical service centers, including a 22-bed inpatient unit and two
outpatient clinics.
Although the PI was originally named the Pathological Institute when it opened on Ward’s Island in 1896, it later moved to 1051 Riverside Drive in Manhattan, where it is now linked to Columbia-Presbyterian Medical Center both academically and via a pedway that connects the facility to the hospital. The PI, Cournos said, is no greater than its smaller parts. Medical health inspectors concurred, and in February they made sure those smaller parts didn’t need fixing.

Cournos remained characteristically calm as “they” infiltrated the PI—“they”
being bigwig medical surveyors representing the Joint Commission on
Accreditation of Healthcare Organizations. The surveyors spread out quickly,
carefully evaluating whether the PI had complied with nationally established
accreditation standards. “Everything, everything,” must be in order,
obsessed Cournos during the first day of inspections, from patient medical
records to safety reports to the orderliness of the grounds.

The inspection commenced first thing on a Monday morning. In her office,
Cournos hosted a paper party for surveyors, offering proof of compliance
with standards and plans promising to correct deficiencies. Her assistant,
Johanne, then, danced around the copy room, happily avoiding a messy breakup with the (once again) reliable photocopier. Her team of psychiatrists
shuffled in and out of small conference rooms littered with inspectors
conducting compliance interviews.

Meanwhile, patients, hospital visitors and new student interns wiped sleep from their eyes. By late Tuesday afternoon, workers at both hospital and behavioral service centers were exhausted from onsite inspections and from listening to surveyor recommendations. The final diagnosis was soon delivered: “Accreditation with full standards compliance.” The PI was given a clean bill of health. So then was Cournos.

Cournos said she only knows “what to do when something is wrong—when it’s
grounded—rather than trying to figure out how to keep things together so
that they just work better.” But inspection results refuted that assertion.
In the spring of 2002, when John Oldham vacated the position as the PI’s
director, there was a rocky period of 18 months marked by drastic state
budget cuts.
Interim director, Timothy Walsh, staved off damaging layoffs
and ensured that the institute continued its research and service delivery.
Walsh’s term ended, however, around the same time that the state implemented a freeze in funding. A hiring committee quickly formed to find the PI’s new leader and members were looking for someone who could improve psychiatric services without spending another penny. Last October, they offered Cournos the job.

“I really think Fran’s done the best one can do with limited resources in
providing very good care to a population that’s underserved,” said David
Lowenthal, an attending psychiatrist who oversees the PI’s inpatient unit.
While passing by a group of acutely ill patients (the unit mostly serves
local lower class immigrants from the Dominican Republic), Lowenthal pointed
to a Spanish-speaking psychologist leading a group therapy session.

He noted that as soon as Cournos was appointed interim director, she ensured that all Spanish-speaking patients received therapeutic care in their native
language. Instead of spending extra money on interpreters, Cournos divvied
up patient caseloads and shuffled around bilingual psychiatrists and nurses
so they could serve both populations. She also brought in bilingual medical
interns to facilitate day program activities. “Fran’s very creative—in a
concrete way—in how she manages to build a service that works well for
people who can’t afford medical care,” Lowenthal said.

Although the PI’s hiring committee is still searching for a permanent
director, Cournos agreed to leave her former position as director of the
Washington Heights Community Service (WHCS, one of the PI’s outpatient units
where she had been director since 1978) and moved into a spacious office in
the PI’s main building.

But like a child uprooted from her family, she misses her first home and has made it clear that the move will only be temporary. “I’m really much more into serving public mental health,” she explained one afternoon after delivering an HIV/AIDS lecture via videoconference. “That’s where my heart is.”

In fact, Cournos is so attached to the WHCS that she outright rejected an invitation to apply for the permanent director position: “My main disqualification for this job would be that I don’t have a vision of a place the institute could go or think it could go,” she said. “For a research institute you’d like to have vision,
and my vision is one of survival.”

Unlike psychiatrists sprung from upper class nuclear families, Cournos can
wholly empathize with patients who grew up in New York City’s foster care
system and, like her, survived in a world devoid of familial stability. She
was, after all, only three years old when her father unexpectedly died of an
undiagnosed brain tumor. Two years later her grandfather hemorrhaged from a
peptic ulcer and passed away. Soon after that her mother developed breast
cancer, which metastasized and caused her death when Cournos was only 11.

“I was feeling very confused about what was going on when I was a child,”
Cournos said in March at a conference for the National Membership Committee
on Psychoanalysis in Clinical Social Work. In front of a crowded room of 300
therapists, she said, “My family wasn’t working the way I thought it should
work. I wanted to fix it.” Cournos’ speech, titled “Psychoanalysis and
Traumatic Childhood Loss,” included readings from her memoir, City of One,
and practical suggestions for therapists helping patients overcome familial
death. When Cournos’ 45 minutes in front of the microphone had passed and
she began rushing to finish her speech, therapists shouted out in
objection—they wanted the longer story of her childhood and were willing to
be late for the conference’s next sessions.

The longer story is that by 13, Cournos and her sister had been abandoned by
their aunts, uncles and grandmother and thrown into a home with an
emotionally cold foster mother. Resistant, Cournos shut out the world and
obsessed over the one constant in her life—school. She developed an
addiction to books, excelled academically and garnered much-needed adult
praise and admiration before tackling City College, where she mastered
chemistry at the cost of $37 a semester.

Cournos eventually pushed her way to an M.D. from New York University’s School of Medicine after bombing her Cornell Medical School interview (when she was asked, hypothetically, how she would balance being both a doctor and a parent she responded by firing the question back at the male interviewer).

Admittedly headstrong and at times abrupt, Cournos burned through four years of medical school, a yearlong internship and another year of residency before specializing in psychiatry and falling in love with her husband-to-be, Nicholas Bakalar. She soon gave birth to a daughter, Elizabeth, but sank into depression, fearing she would somehow abandon her child much like her own mother had abandoned her: “I just assumed that women really had to get things done and move on,” she said. “They weren’t meant to take care of things.” Cournos, who had been in and out of therapy for much of her life but avoided speaking directly about her mother’s death, tried counseling again and finally dealt with the loss of her mother. “Finally,” she said, “after a million years” in
psychoanalysis (18 years actually), Cournos said she felt herself “fixed.”

Still, she has a backup plan just in case she ever develops a full-blown
psychiatric illness.

“When I was young and I got mental health care in a public setting, I didn’t
always like everything that happened to me,” she said. “I wanted to create a
program where I myself would be willing to use it.” And would she? “I have
various people lined up to take care of me if I am ever diagnosed with
schizophrenia. If I need social services—like if I wind up in a nursing care
facility—I have a social worker whose perfect at the WHCS.”

Each year more than 1,000 people with serious mental illnesses—many
diagnosed with schizophrenia—filter through the WHCS inpatient and
outpatient clinics hoping to be “fixed.” Most aren’t. Some temporarily
escape delusions and hallucinations only to relapse a few months later.
Others stabilize with heavy medication until they experience a psychotic
break and the dosage needs to be upped. A few even refuse treatment, losing
touch with reality altogether.
Cournos, who will “most likely” resume her as position as director of the WHCS after a permanent director is found for the PI, “is very much for patient rights,” said Lucia Capitelli, a WHCS nurse who recently attended a lecture Cournos developed on practicing psychiatry with cultural sensitivity. “I’ve seen her go out and buy a mattress for a patient to sleep on—that’s going above and beyond what’s required,” Capitelli said.

Cournos said her role as director of the WHCS was solely administrative—checking reports, collecting research funding and hiring psychiatrists. But Laverne Evans, WHCS’ receptionist and assistant social worker, observed that while “a lot of Fran’s responsibilities were not directly working with patients day-to-day, she still came out to visit. She wasn’t locked away in her ivory tower.”

Stephanie LeMelle, assistant director of the WHCS, attested Cournos’ role
was much more direct. So much, in fact, that LeMelle said, “I think we’re
all a little ‘hypo-manic’ because of her.” Minutes after arriving at her
office one morning, LeMelle was on the phone talking to a prison officer.
She was told that one of her patients had inappropriately groped someone in
public after consuming alcohol along with antipsychotic medication.

LeMelle managed to convince the officer to transfer her patient to a special cell,
stressing that he might act out violently if locked with other inmates. The
officer cooperated and the patient avoided a psychotic break. Smiling,
LeMelle hung up the phone and said, “One thing that I learned from Fran was
that if a problem can be fixed now, fix it.”

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