I am fond of telling medical students that psychiatry is the only specialty of medicine that concerns itself with all levels of organization, ranging from molecular biology to social interactions. Indeed, few, if any, other branches of medicine, or science for that matter, embrace such a wide spectrum of levels of organization. For the clinician, this means that a wide array of therapeutic interventions ranging from psychopharmacology to social engineering, in varying proportions according to the clinical problem, must be considered in order to administer optimum treatment and gain optimum results. This month's issue on family psychiatry, edited by John G. Howells, MD, underscores this truth.
Dr. Howells, in his introduction and description of his "Profile of Family Interactions," sets the tone for a focus on important interactions within the family of upbringing as a basis for an individual's degree of health or pathology. He makes a case for identifying patterns of transactions both inside and outside the family through this method of identifying all the individual's significant interactions as a basis for understanding life experience.
Melvin R. Lansky, MD, in his contribution, "Family Genesis of Aggression," emphasizes the importance of family dynamics and the manner in which shame is handled in violent families, resulting in lowered self-esteem and violence proneness in these individuals who are already predisposed by other vulnerabilities.
The contribution entitled "The Role of the Family in Major Depressive Illness," by Gabor Keitner, MD, Ivan Miller, PhD, and Christine Ryan, PhD, provides an excellent review of evidence suggesting that the social environment in which a depressive episode evolves has a significant impact on the onset, duration, course, outcome, relapse potential, and response to treatment of the illness. Furthermore, therapeutic attention to family dynamics undermining social support for the patient may demonstrably improve both outcome and course for the patient.
In their contribution, "Alcoholism as a Family Dysfunction," Brian L. Cook, DO, and George Winokur, MD, review data addressing the genetic transmission of risks for alcoholism as well as the role of familial psychopathology in the expression of alcoholism.
W-W. Meissner, MD, discusses the importance of psychological factors on the course of cancer while citing recent evidence supporting the notion that psychosocial interventions may prolong survival rates. He discusses various theories of family dynamics as a potential buffering system supporting coping mechanisms or, alternatively, as a mechanism for intensifying stress and maladaptation to this disturbing event.
Taken together, this issue presenting various viewpoints in the context of a number of clinical situations reminds us of specific dynamics and opportunities for intervention from the perspective of the family.
Two major factors conspire to focus our clinical attention too narrowly in the practice of psychiatry. The first is the explosion of technical knowledge along such a broad spectrum of disciplines - the intellectual diversity that makes psychiatry so potentially interesting in the first place. Because of the amount of knowledge to be mastered, we are pressured to overspecialize in order to become expert in one aspect of our own field. This tends to make us withdraw our interests from other vital perspectives and developments that we may need to know about to provide the best care possible for individual patients.
Second, economic pressures to achieve rapid improvement in our patients may overfocus our attention, resulting in treatment that is too narrowly focused. While it may be necessary and advantageous for us to specialize our interests, and while we certainly have to take into account the economic realities of today in our practice of medicine, it is important that we do not withdraw interest from the spectrum of factors that might contribute to the treatment of our individual patients.
An example that certainly concerns the family is the current issue of child abuse as a cause of psychiatric disturbance. No matter what our specialty interests may be, it is incumbent on us to address this problem and be aware of the clinical importance of this factor as well as the extremes to which it is being carried as an explanation for psychopathology.
It is hoped that through this and future issues, Psychiatric Annals will help the clinician to maintain a balance of information across a range of new developments and theories that are relevant and sometimes essential elements of the clinical approach tailored to individual patients. Hopefully, by covering a wide range of thinking applicable to a variety of clinical situations, the tendency toward a "one treatment fits all" approach, which seems to be dictated by the pressures of expanding knowledge and economic demands, can be broadened and differentiated to encourage individual treatment plans for our patients.