Psychiatric Annals

INTRODUCTION

Francis J Braceland, MD

Abstract

The articles that follow were written by experienced observers who comment on aspects of the psychiatric scene that they know best; en route, they note the hopes and fears of each segment of the discipline and mark the directions that they think psychiatric institutions and practices seem to be taking.

Unfortunately, while the pictures they paint cannot be encouraging, they are fair representations of the present state of our art, which (like its sister medical specialties) is operating in times of economic and cultural confusion and conflict. In fact, the writers use admirable restraint, when one considers the present-day pressures and the still more complicated possibilities as various disturbing noises emanate from Congressional halls hinting at National Health Insurance and one knows not what else.

Throughout this issue, however, the thesis remains constant: that psychiatry's mission is to take scientific and humane care of emotionally distraught and mentally ill patients, no matter what their circumstances or where they are found. This is psychiatry's reason for being, and all else is accessory before or after the fact. Psychiatry recognizes that it has not been popular and that its patients have been history's stepchildren, treated contumeliously in each generation. The laws concerning them have gone through various gyrations, from hanging them as witches to simply neglecting them, to the present-day upheaval when many of them are being legislated out of hospitals, away from the protective care that they badly need, and tossed out to the mercy of community ventures that are usually ill prepared to care for them.

The writers are exquisitely fair and give only hints of the unbelievable pressures that are brought to bear, especially upon those who work in institutions. To mention but a few of the dilemmas the hospital psychiatrist faces, we have the recently enunciated patient's right to treatment and the patient's right to refuse treatment, both perfectly justifiable. If the patient refuses treatment, however, he cannot be discharged from the hospital for that reason. If a patient is confined in a hospital, the law says he must have adequate treatment; but then if you treat him against his wishes, this is "assault." If he says he was confined illegally, even 10 or 15 years ago, he can enter suit against you. You get the idea!

Impressively, Dr. Brill states: "Never in their long history of attacks and exposés have the state hospitals faced so uncertain a future as they do today, and never has planning for that future been so difficult or contained so many conflicting influences." New antipsychiatric attitudes are present in various forms, as is "a renewed antihospital dialectic." Dr. Houck observes that his excellent private psychiatric hospital is regularly inspected by 15 regulatory bodies, as well as investigators for 17 professional training programs. He concludes that no one can properly enumerate the varied visiting bodies, for new ones are constantly being added, but an unbelievable number of "assorted government and professional bodies jostle for position behind the shoulders of the director." This is a disgrace. Gulliver was not the only one so tied up that he could not function.

Psychiatry, as the younger sister of medicine, has always had its troubles, but hardly as many as now exist. Milton Greenblatt calls the discipline the battered child of medicine, feared by the public, scorned by its sister specialties, and throughout its history dependent upon handouts from public agencies. Apparently people fear the specialty because it treats of an illness that they dread perhaps worse than death. Unfortunately, at present the psychiatric discipline is in a bit of a shambles, and the profession is divided…

The articles that follow were written by experienced observers who comment on aspects of the psychiatric scene that they know best; en route, they note the hopes and fears of each segment of the discipline and mark the directions that they think psychiatric institutions and practices seem to be taking.

Unfortunately, while the pictures they paint cannot be encouraging, they are fair representations of the present state of our art, which (like its sister medical specialties) is operating in times of economic and cultural confusion and conflict. In fact, the writers use admirable restraint, when one considers the present-day pressures and the still more complicated possibilities as various disturbing noises emanate from Congressional halls hinting at National Health Insurance and one knows not what else.

Throughout this issue, however, the thesis remains constant: that psychiatry's mission is to take scientific and humane care of emotionally distraught and mentally ill patients, no matter what their circumstances or where they are found. This is psychiatry's reason for being, and all else is accessory before or after the fact. Psychiatry recognizes that it has not been popular and that its patients have been history's stepchildren, treated contumeliously in each generation. The laws concerning them have gone through various gyrations, from hanging them as witches to simply neglecting them, to the present-day upheaval when many of them are being legislated out of hospitals, away from the protective care that they badly need, and tossed out to the mercy of community ventures that are usually ill prepared to care for them.

The writers are exquisitely fair and give only hints of the unbelievable pressures that are brought to bear, especially upon those who work in institutions. To mention but a few of the dilemmas the hospital psychiatrist faces, we have the recently enunciated patient's right to treatment and the patient's right to refuse treatment, both perfectly justifiable. If the patient refuses treatment, however, he cannot be discharged from the hospital for that reason. If a patient is confined in a hospital, the law says he must have adequate treatment; but then if you treat him against his wishes, this is "assault." If he says he was confined illegally, even 10 or 15 years ago, he can enter suit against you. You get the idea!

Impressively, Dr. Brill states: "Never in their long history of attacks and exposés have the state hospitals faced so uncertain a future as they do today, and never has planning for that future been so difficult or contained so many conflicting influences." New antipsychiatric attitudes are present in various forms, as is "a renewed antihospital dialectic." Dr. Houck observes that his excellent private psychiatric hospital is regularly inspected by 15 regulatory bodies, as well as investigators for 17 professional training programs. He concludes that no one can properly enumerate the varied visiting bodies, for new ones are constantly being added, but an unbelievable number of "assorted government and professional bodies jostle for position behind the shoulders of the director." This is a disgrace. Gulliver was not the only one so tied up that he could not function.

Psychiatry, as the younger sister of medicine, has always had its troubles, but hardly as many as now exist. Milton Greenblatt calls the discipline the battered child of medicine, feared by the public, scorned by its sister specialties, and throughout its history dependent upon handouts from public agencies. Apparently people fear the specialty because it treats of an illness that they dread perhaps worse than death. Unfortunately, at present the psychiatric discipline is in a bit of a shambles, and the profession is divided within itself. The older clinicians seem to favor remaining close to general medicine, which early on nurtured it; a few of the younger psychiatrists, however, appear to be leaning more towards a sociologie approach to the treatment of patients with mental illness, and although the thought is admirable, very few have really been trained for the serious racial, economic, and cultural problems that they encounter in communities.

But the story is not one of despair, for there are currently visible signs of a return to a broad-gauged, dedicated care of the whole person - psyche and soma and in relation to his environment. Out of the present upset I believe that a new psychiatry will arise, like the phoenix - a discipline that is much better equipped scientifically and based on a more solid foundation. Recently there have been remarkable advances in the basic understanding of some of the mental illnesses, as psychopharmacology, chemistry, and endocrinology have yielded some of their secrets. We are now on our second go-round with psychosomatic medicine and are surely on a more secure foundation for our understanding of it. In the 1930s we were taken to a high hill, shown all the illnesses that had emotional components, and told that we were to play an important part in medical efforts to cure them. But our interpretation of disease processes was premature, and we did not yet know the best ways of collaborating with our colleagues, so we failed.

All of this points to the direction that psychiatry will eventually take - a return to medicine, retaining mastery of the psychotherapeutic techniques and all the useful psychologic and somatic therapies that we have learned in our sojourn outside the fold. Private practice, general hospitals, and private and state hospitals all have important functions to perform, for unfortunately the world is still full of sick people and many of them are clamoring for help.

10.3928/0048-5713-19750901-03

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