My gran'ther's rule was safer' ? 'tis to crow: Don't never prophesy - onless ye know.
James Russell Lowell
(The Bigelow Papers, Series II)
When I was invited to contribute to this issue devoted to psychiatric crystal gazing, I felt highly honored but somewhat troubled. I hesitated a bit before accepting, not because of any built-in bias against this art form but largely because of the common-sense warning against prophesy so colorfully stated above by the well-known American poet. I was heartened, however, by the words of another poet. Lord Byron this time, who said, "The best of prophets of the future is the past." At last I felt qualified. With 40 years in psychiatry, the bulk of which has been devoted to full-time private practice, I decided that this was a sufficient past on which to base a future prediction.
STUDIES OF PRIVATE PRACTICE
It is a curious irony that the private-practice sector of psychiatry, which has made such major contributions to the efficient delivery of mental health care in this country, should have had such little attention from organized psychiatry until quite recently. Not until 1973 did the American Psychiatric Association publish its first formal statement on the private practice of psychiatry.1 Some of the possible causes for the relative neglect and tardy recognition of such a large segment of its membership, over 66 per cent of whom are in full- or parttime practice, are given in the introduction. While acknowledging that "some dedicated full-time practitioners have played an active role ... in the formulation of the Association's programs and policies," the report explains that the average private practitioner
"cannot afford the time entailed in such service since his income is solely dependent on his practice, the number of patients he sees and the number of days he works. Also, his first responsibility and his first love is for his patients. He typically has a distaste for administrative and political issues, including professional politics and bureaucratic red tape. They are, in short, among the busiest workers in our culture and about 90% of their time is spent in treating and attempting to keep their patients functioning in home and community. They thus tend to be ineffective spokesmen for themselves in a political sense and this statement is intended to delineate the size and nature of their contribution to the delivery of psychiatric services in our country."1
Among the conclusions arrived at by the task force is that
"the private practice sector of psychiatry comprises a most essential element in the delivery of mental health services in our country, and one which cannot be replaced at this time. . . . In general, the average American, when he is sick, prefers to see a physician of his choice and is willing to pay for his services in the knowledge that once chosen, the physician is his doctor, that anything that is revealed in their relationship will be private and confidential, that the doctor will be available to him in a crisis, and that the doctor will have access to a wide range of hospital facilities . . . adding up to a comprehensive care system that provides for continuity of treatment and management. . . . Admittedly the private practice model will not meet all of the health needs of the American people. It must be supplemented by a wide range of public services. But the end product should be a balanced mix of both, each reinforcing the other. Our political and economic system and our present day culture contraindícate the development of a single unitary model for the delivery of health services."1
THE J.I.S. SURVEY
Task Force Report No. 6 was based largely on data derived from the American Hospital Association, the 1972 Survey of Mental Health Need in Kentucky, and various NIMH, A.M. A., and A.P.A. sources, material that has been interpreted differently by other authors.2 For the past two years the Joint Information Service 0. 1. S.) has been working on a "Survey of Private Practice Psychiatrists and Their Patients" and, using a sophisticated questionnaire and sampling system, has collected a mass of highly relevant data, much of it supporting and strengthening many of the conclusions of A.P.A. Task Force Report No. 6. As any professional surveyor knows, it is notoriously difficult to get valid data on the nature of medical practice. This is particularly true of efforts to find out what actually goes on in the private practice of psychiatry. Some of the critical questions that must be raised in any such survey have to do with who is being treated and how many, diagnostic categories, age, sex, types of therapies used, average duration of treatment per episode, hourly fees, frequency of sessions, etc. Psychiatrists are traditionally loath to answer questionnaires, particularly the lengthy ones needed in any kind of comprehensive survey. Hence, the extraordinarily high response rate (73 per cent of those polled) not only is an eloquent commentary on the good design of the questionnaire but also suggests that psychiatrists in private practice have finally become sufficiently concerned about their own future to take time out to answer such questionnaires. The J.I.S. report is due to be published later this year and will be eagerly awaited by all those interested in both the present and the future of the private practice of psychiatry in America.
American psychiatry is deeply concerned about what is in store for it in the foreseeable future. Every psychiatrist is now being deluged with material on the various alphabet-soup combinations: HMOs (Health Maintenance Organizations), PSROs (Professional Standards Review Organizations), and NHI (National Health Insurance), to mention only the leading few. Each movement has its vigorous advocates and equally vigorous opponents. The HMO movement seems to have stalled for the moment. An actual decline in the number of HMOs in the United States has been reported.5 In spite of their possible theoretical value, neither psychiatrists nor their patients have shown much interest in them. PSROs are gathering momentum in many quarters in an effort to establish acceptable standards and to cut the costs of treatment, especially to the third-party carriers. Even this movement, laudable and necessary though it may be, carries with it a number of threats to the private practice of psychiatry. One of the most serious is, of course, the erosion of patient-doctor confidentiality. Another, which may be equally serious, is the Procrustean tendency of such organizations to force highly individual and complex clinical situations into a standard mold. This could well stifle the development of innovative treatment methods and encourage mediocrity, to the detriment of the nation's health.
Generally speaking, psychiatrists in private practice seem to take a nonalarmist attitude towards the possible advent of National Health Insurance. Perhaps they are lulled by the fact that most of them have excellent and close relations with their patients and their patients' families, who seem to be satisfied with their services. This may account for the results of a 1973 Harris poll showing that although confidence in all institutions was declining, the American public still had a higher degree of confidence in medicine as a profession than in such institutions as higher education and the military. All this suggests that the American people (at least those polled) do trust their own doctors and may not be so dissatisfied with the present system of medical care as is often reported.
Although many private practitioners of psychiatry may be isolated from the fountainheads of political ferment, it is my impression that the greatest proportion of them are sophisticated and intuitive and have come to agree with Eli Ginzberg's statement that
". . . the shortcomings and defects of the health care system are not likely to be cured by national action alone. The problems of access, availability, and quality of care are not likely to be solved through national legislation and administrative action because of the tremendous variability in the distribution of resources among and within regions and smaller areas of the country. The only way a national solution might work is if the entire system were under total governmental control - doctors, hospitals, patients. Yet even in Yugoslavia and Bulgaria, which have such systems, I have found that access, availability, and quality are a long way from being assured to the entire population."5
Unless there is a radical and unforeseen change in our democratic form of government, it is unlikely that medical care will be placed under total governmental control in America. However, a quick look at what has happened in other countries may give us some clue as to what the future may hold for us.
EXPERIENCE IN OTHER COUNTRIES
The British have had a National Health Service since 1948. Although there have been problems from time to time, most Britons would agree that it is there to stay. Under the British system, private practice was not outlawed and many psychiatrists care for the patients assigned to them under the National Health Plan as well as conduct a part-time private practice. Citizens who have the means to consult a private psychiatrist are able to obtain treatment more quickly and have greater latitude in choosing a psychiatrist. Although this practice is periodically attacked by the Labour Party and unions on the grounds that it is manifestly unfair, that the right to good health should never be affected by the power of one's pocketbook, private practice in Britain has continued to exist. "Many top surgeons and other specialists (including psychiatrists who have both types of practice) relish their private practice not for the money it provides, which is small beer except for a handful in Harley Street, so much as for the professional stimulus it provides - the extra clinical freedom that would be missing in a totally state controlled service."8
In the Soviet Union I expected to find a system of medical care "under total governmental control,"5 but I was due for some surprises. On my last trip to Leningrad, my Intourist guide was a schoolteacher in her 40s who worked as a guide during school vacations. Towards the end of our visit and after touring several psychiatric institutions, she confided to me that she had consulted a psychiatrist herself and had benefited greatly from his help. I asked if she had seen this psychiatrist at the local dispensary in her neighborhood. She replied, quite emphatically and somewhat proudly, "Oh, no! I go to see him privately at his home!"
One is reminded of the episode in Solzhenitsyn's Cancer Ward in which Dr. Lyudmila Dontsova, the radiologist, who believes somewhat naively but deeply in the Soviet medical system of total governmental control, develops symptoms of cancer herself. She is terror-stricken at the possible consequences and, instead of consulting her colleagues at the clinic, goes as a private patient to her former professor, Dr. Oreshchenkov, an older man now retired, who is still permitted to conduct a small private practice. The dialogue between Dr. Dontsova, the firm believer in statecontrolled medicine, and Dr. Oreshchenkov, the saddened but wise old exponent of private practice and personalized service, brings out the strengths and weaknesses of both systems, with the private-practice model emerging as the superior and more humanistic system of ministering to the sick.
The few reports available concerning the practice of psychiatry in the People's Republic of China7 indicate that their entire health system is under much more rigid and total governmental control than is the case in the Soviet Union. It is doubtful, for example, that any private practice exists there today. Some observers have commented whimsically that the reduction or elimination of prostitution, drug addiction, unemployment, abject poverty, starvation, venereal disease, and crime, and the general improvement in public health that has occurred since the ascendancy of Chairman Mao, has done more for the mental health of 800 million Chinese than the efforts of all the world's psychiatrists and mental hygiene movements put together. Perhaps so, but most of those who live in the Western democracies would consider the absolute and total conformity to a monolithic political system too high a price to pay. The example of China, however, points up the truism that shapes the future form of the practice of medicine in any country - namely, that any system of medicine exists at the pleasure of the society it serves. Society giveth and Society taketh away. Political systems such as ours, which permit a diversity of medical practice, may be more inefficient at times, but their great strength lies in the freedom given to the human mind to develop new and better methods to serve the sick. In this lie both the warning and the challenge to the private practice of any profession, including psychiatry.
WILL THE MEDICAL MODEL SURVIVE IN PSYCHIATRY?8
In recent years the entire field of psychiatry has been seriously fragmented by major forces from both within and outside the profession. Roy Grinker, Sr., has aptly characterized psychiatry as "riding madly in all directions." Today we have reached the point where, if a patient says "I'm seeing a psychiatrist," we have almost no idea of what is actually going on. Is he in individual therapy or group therapy? Is he in analysis? If so, which of several brands? Is he receiving chemotherapy or has he received electroshock therapy? Is he receiving supportive psychotherapy, reality therapy, behavior therapy, conditioning therapy, family therapy, marital therapy, "Primal Scream" therapy - or what? If he is in group therapy, is he in an orthodox group, a nude group, or a "feel" group? Is it a weekend marathon group, a confrontation group, or a "T" group? Is he into Zen, existentialism, or yoga?
What are the causes of such confusion and fragmentation? One could point to the complexity of psychiatry and the human condition, the imprecise nature of the healing process, the tensions of modern society, the overtolerant attitude of American psychiatry to unproven innovations, the enormous suggestibility of the emotionally unstable and the lonely, and many other areas. But one of the factors not sufficiently emphasized has been the tendency for a substantial segment of American psychiatry to abandon the medical model. This is not to say that the psychiatrist should not also be familiar with the social, psychoanalytic, and family-interaction models. But each year the teaching of psychiatry in our medical schools seems to drift further and further away from the biologic and clinical approaches to mental illness. The psychiatric resident may often know all about group dynamics but may not know how to cope with a disturbed patient. He may know the theoretical implications of the analerotic character but may be lost in prescribing an effective psychoactive drug for a seriously depressed patient. Such continued alienation from medicine places the whole future of psychiatry in jeopardy, especially in respect to projected health care legislation. The psychiatrist of the future may be described bitterly as "any person who practices psychotherapy without a Ph.D. degree."
What is obviously needed in our medical schools is a rapid return to the medical model, with a greater emphasis on developing general psychiatrists who are trained to treat sick people. Such training must maintain a careful balance beteen the psychologic, social, and biologic roots of psychiatry. The modern psychiatrist must be well versed in all three. Research is now giving growing support to the biologic causes of mental disorders, and this crucial area must never again be neglected.
If general psychiatrists could be produced in sufficient number, they could staff our community mental health centers, the psychiatric units of our general hospitals, and the consulting rooms of our country, thus reversing the trend away from the medical model. Conceivably, they might even help clear up the confusion about the current fragmentation of psychiatry.
PREDICTIONS FOR THE FUTURE
Will private practice survive? The private practice of psychiatry in the United States will not only survive but continue to flourish. I foresee its continuing influence on the practice of medicine, especially general practice, which will pattern itself more and more on concepts and techniques developed in the private practice of psychiatry. Fewer psychiatrists will be going into solo practice, probably because of its special stresses, and more psychiatrists will be entering some form of group practice. People with emotional problems will continue to reach out for the confidentiality, prompt attention, personalized service, and lack of bureaucratic red tape that is the hallmark of private practice. Incomes will be proportionately somewhat less, but psychiatrists' schedules will continue to be filled and they will be able to live comfortably while pursuing their chosen field.
Changes in psychiatric education. The medical schools and the psychiatric residency training programs will slowly but surely begin to pay more and more attention to training their residents for the general practice of psychiatry. This means placing a greater emphasis on the medical model and the biologic roots of psychiatry. Dr. Gerald Merman9 listed the current hierarchy of psychiatric therapies in descending order as follows: (1) insight therapy, (2) supportive therapy, and (3) pharmacotherapy. He then added that "the degree of involvement of the profession in these three therapies is in inverse proportion to the evidence of their effectiveness." It is now high time that the profession, particularly the psychiatric residency training programs, recognize this important fact and revise the curriculum accordingly. I believe it is inevitable that they will do so.
Development of new drugs. The great advances in psychopharmacology will continue - but at a much slower pace, owing largely to the many restrictions being placed on research. These will probably continue for quite some time. The dramatic effectiveness of psychoactive drugs in properly selected cases is now beginning to penetrate all levels of psychiatry, including psychoanalysis. As a result of this trend, the psychiatrist of the future will have a much firmer grounding in the use of psychoactive drugs and somatic therapies than he has today. The psychiatrist in private practice will be much more sophisticated in the use of psychopharmaceuticals, and their use will increase, not decrease. New and rapid methods of determining blood levels of psychoactive agents will become generally available and will permit greater scientific accuracy and control in chemotherapy.
Psychoanalysis. It would be the height of temerity for a nonanalyst to make any predictions in this regard. However, one of my British colleagues recently proclaimed, "Psychoanalysis cannot be expected to survive the 20th century any more than the chaise longue." A past president of the American Psychoanalytic Association takes, understandably enough, a somewhat different view, concluding his presidential remarks with the statement that "there is still life in psychoanalysis despite the scare headlines."10 Nonetheless, it is incontestible that classical psychoanalysis (five times a week, on the couch, etc.) has become a rara avis. It is almost as if Freud's own prophetic assessment of psychoanalysis in his famous article for the Encyclopaedia Britannica had come true. In that article Freud stated that "the future will probably attribute far greater importance to psychoanalysis as the science of the unconscious than as a therapeutic procedure." According to the recent J. I. S. survey, the current tendency of American psychoanalysts to devote more and more of their practice to nonanalytic patients and for the group of psychiatrists surveyed (both analysts and nonanalysts) to average approximately 50 sessions a year would strongly suggest that once-a-week therapy can be effective and that coverage of this sort by National Health Insurance is certainly feasible.
Psychoanalysis, which has already made such enormous contributions to psychiatry (most of which have already been incorporated into the body of general psychiatry) will continue to be influenced more and more by developments in American psychiatry. I anticipate a product emerging from this union that may be more effective than either of its parents.
Patients. The number of patients seeking help is likely to increase. The incidence of the major psychoses will remain the same, but anxieties, depressions, and personality disorders will increase in frequency, owing to overpopulation, crowding, and the stress of urban technologic society.
Electroconvulsive therapy (ECT). The current wave of legislative and judicial sentiment seriously restricting the use of electroconvulsive therapy will eventually subside. The techniques, safeguards, indications, and contraindications for the use of ECT will be spelled out in greater detail by hospitals and psychiatric societies. Fully informed consent will be the rule. Eventually, ECT will once again take its place as a valuable and often dramatically effective form of treatment.
Group therapy. I anticipate a sharp increase in the use of group therapy under private auspices. The indications and contraindications for this specialized approach will be sharpened, and new techniques will be developed. The group therapy movement will become more solidly entrenched in American psychiatry, and some of the "far-out" methods will fade into oblivion. The reasons for the phenomenal growth of group therapy in the last decade are complex, but certainly the economics of reaching larger numbers with limited personnel is one of them. Aside from that, group therapy will continue to fill a very real need in the lives of thousands of unhappy, lonely people living in our overcrowded urban centers. For these maladjusted people who have had so much difficulty in establishing satisfying interpersonal relationships, group therapy will continue to be the treatment of choice.
Social psychiatry versus the medical model. Psychiatry, frustrated by its flirtation with sociology, will return firmly to the medical model from which it should never have strayed. The medical model, that most ancient and useful of all models, has served man well ever since the first primitive man became sick and another ministered to his illness in the role of healer. The medical model is broad enough to include the psychologic, social, and biologic factors that may be present in any illness, and the future will see its re-emergence. The general practice of psychiatry of the future will serve as a bridge in building ever closer ties with medicine. Only in this way can the various fragments of our profession be brought together as a unified whole for the greater benefit of the people we treat - our patients.
1. A.P.A, Task Force Report No. 6. The Present and Future Importance of Patterns of Private Psychiatric Practice in the Delivery of Mental Health Services. Washington, D.C.: American Psychiatric Association, June, 1973.
2. Sharfstein, S.S.. Taube. CA., and Goldberg, I.D. Private psychiatry and accountability: A response to the A.P.A. Task Force Report on private practice. Am. J. Psychiatry 132:1 (1975), 43-47.
3. J. LS. Report. Psychiatrists and Their Patients: A National Study of Private Practice, Joint Information Service, 1975.
4. Study suggests revision of law. American Medical News (April 21, 1975). 8.
5. Ginzberg, E. The young physician - Inevitable change ahead. The Pharos of ASiA, January, 1975.
6. Private beds at issue in Britain. American Medical News (Jan. 13, 1975), 9.
7. Walls. P.D.. Walls, L.H., and Langsley, D.G. Psychiatric training and practice in the People's Republic of China. Am. J. Psychiatry 732:2(1975), 121-128.
8. This section has been modified from an editorial, "Psychiatry: Fragmented Specialty," by the author, in Med. Ann. D.C. 42:2 (1973), 3.
9. Klerman, G. Ethical Issues in Pharmacotherapy (lecture).
10. Joseph, E. D. Perspectives on psychoanalytic education. Bull. Menninger Clin. 39:2 (1975), 144.
11. Freud, S. Psychoanalysis: Freudian school. Encyclopaedia Britannica, 14th Edition, p. 673.