Canadian Journal of Psychiatry Vol. 24
Ottawa, Canada, December 1979
No.8
Presidential Address IN FAVOUR OF PSYCHIATRY* HARRY PROSEN,
M.D.'
Introduction
When the President-Elect introduces the President on this occasion he is already considering what he will say when his own turn comes in a year's time. Discussions with my predecessors indicated that they, like me, searched, asked opinions from others and gathered materials in quest of important themes to present to the membership. Most read what other Presidents of both the Canadian and American Psychiatric Associations have said and with this preparation, an appreciation grows that many issues are not new and have been well examined before. Our Association has benefited from a variety of presidential addresses ranging from great declamations to humble and personal statements of considerable value to us, such as that made by Dr. Douglas McLean last year. (I) In conducting this review some similarities of pattern were found in the problems and promises of Psychiatry. American Psychiatric Association Presidents have recently had their own special theme, discussing the important events that have happened during their term of office, and demonstrating an increasing interest and contribution to international Psychiatry. This has also provided similar interesting opportunities and impetus for us in Canada. We have all tried to deal with specific psychiatric political issues in terms of our own hopes and beliefs. 'Presented at the Canadian Psychiatric Association Annual Meeting, Vancouver, B.C., September, 1979. 'Professor and Head, Department of Psychiatry, University of Manitoba; Chairman, Specialty Committee in Psychiatry, Royal College of Physicians and Surgeons; Psychiatrist-inChief, Health Sciences Centre. University of Manitoba, Winnipeg. Can. J. Psychiatry Vol. 24 (1979)
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Our Canadian Presidents have tended much less to follow a regular pattern or style. As well as making a personal statement to the membership they have nearly all offered to serve at least a little as a psychiatric oracle. We have also generally attempted to define and deal pragmatically with our own Canadian problems. This is likely because our Presidents have visited each province by the time they give their presidential address and thus are able to present various provincial interests along with the national concerns of Canadian Psychiatry. It is true in this country, and perhaps elsewhere as well, that the same matters are usually of concern in at least several provinces at the same time, whether they are proposed changes in mental health legislation, or concerns about confiden-
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tiality. Although I will discuss what I consider to be some of the matters that are most important to our profession, I may not appear to always separate these from what are important only to me and maybe to a few others. I must nevertheless mention my own concerns. Anti-Psychiatry It is not possible now, if ever it was, to simply practise Psychiatry to the best of our ability and be content. Not only must we be aware of the burgeoning knowledge in areas such as biochemistry, psychopharmacology and neuropsychology, we must also pay attention to the diagnoses made by others about us as well as our own diagnostic formulation of our current state of professional and institutional health.
The issue of Time magazine which featured "Psychiatry's Depression" (3) presented Psychiatry's complaint as "overwork, loss of confidence and inability to get provable results". The diagnosis of our condition was that of "standard conflictual anxiety and maturational variations, complicated by acute depression ... Identity crisis accompanied by compensatory delusions of grandeur and a declining ability to cope . . . Patient averse to therapeutic alliance and shows incipient overreliance on drugs". The prognosis was considered problematic. As usual the article smacked of anti-psychiatry and factual distortion in its early pages, but as the discussion continued the picture improved and our usefulness was positively determined. If one had to interpret the reason for this article and search similar articles for a common theme, that theme seems to be a fear of psychiatrists and what is projected as Psychiatry's power - its power in terms of understanding and thereby in some way controlling the mind and what is then alleged by some as a wish to control the individual. Although there is truth in our desire to understand the psyche and human behaviour, our grandiosity is generally well tempered by extensive and prolonged studies in medical school of the nature and application of scientific objectivity; and in
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our psychiatric training it is hoped that we have learned to deal with aspects of our own grandiose countertransference. The irony is that our detractors accuse us of corrupting power and control when we often feel helpless in effecting useful environmental changes for our patients. As well, our medical training is envied and demeaned by our more hostile detractors who themselves wish to possess its growthgiving character through short courses in Medicine while we ourselves talk of returning to Medicine as though we were the prodigal child. Most of us have never left Medicine or our pride in our medical training and the depth of understanding it has given us, and this is the real origin of whatever power we possess. It is true that there are assiduous questions as to our viability as a profession and attempts are made to dismantle piecemeal our range of skills into various components, some of which can also be ably represented by other groups of specialists. We now often face criticisms about being anti libertarian and more interested in arresting and locking up the individual's soul rather than liberating it from psychic conflict and disease, which is the commitment that the majority of us have made.
Sources of Power Sometimes, I think that it is the lawyers who are the dangerous ones. It is they who in one way or another influence our political and judicial processes. Such an influence and governance inevitably makes regulation and control dominant over homeostasis and health. We of course accept that civilization requires regulation, policing and judgement. With our innate ambivalence about freedom and its expression, society's security seems to demand that the legal process rather than the medical process dominates. Antithesis often results when it should not. The psychiatric medical process has as its goal health and not an unethical life or society. The legal process seeks truth and must inevitably attribute blame and seek guilt. It is this necessary legal process that contains all real power in
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society. The reading of judicial opinions on many matters of health and physiology, such as sexual expression, will cause one to recognize that the judicial process defines states of normality more than does common experience. Normality as accepted by the law may not be the normality of common and frequent human behaviour. Only a step removed from the legal processes that govern a civilization are the political processes. These processes infiltrate everywhere and in order to maintain our profession some of us must be involved in politics. Indeed, I suspect that some psychiatrists love politics even more than Psychiatry. The politics, as with all politics, can be very complex. They involve our relationship to Medicine, to government and its agents in determining health care priorities, to governments and universities in determining educational goals and priorities and to competition from other groups within the mental health system. We then of course face that large group of critics, not all enemies, that we loosely call the anti-psychiatry movement. As I see it, the most serious danger is the anti-psychiatry within Psychiatry. This anti-psychiatry is too often worked out through subtle political processes that we use in our attempts to work together. Sometimes when we cannot compromise on our diverse orientations through scientific and clinical discourse, we attempt to gather electorates about us, as though possessing a particular orientation is the same as having a set of political beliefs. We are generally clever enough as a group to cover up this politicization quite well. Some are foolish enough to let their belief system be used in the service of anti-psychiatry groups who have their own cultic needs to absorb and capture followers. Orientation and Diagnosis
Although we must recognize our current limitations in successfully treating all of the major psychiatric disorders, particularly schizophrenia; and as we continue our excitement at new discoveries-while balancing their appeal as personal against scientific - the combination of perceived
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limitation and bias of therapeutic approach does tend to put us into competition with each other. Too often we choose competing and contradictory positions instead of continuously synthesizing in our clinical approach. Also, as we all know, Psychiatry goes through phases, in which many practitioners turn about face to new views, too easily forgetting whatever is of value in an abandoned position; while others can always find fundamental reasons for clinging to their original theoretical position and never changing. We are really no different than any group of specialists in this, although we seem to make more of a romance out of our dogmas and positions than many other groups. That is part of the problem and also part of the joy of being a psychiatrist. What great fun, what great drama, what great tragedy, what terribly important lives we lead. But the advantage is ours as long as we retain that value which should be intrinsic to Psychiatry, the analysis and understanding of our particular position and a continuing attempt to objectify our interpretations. We and others continuously question our role as commentators on the human condition when it is evident that civilization is threatened and the environment has been sadly abused. In fact we have a background and propensity that causes us to enjoy philosophization about the human condition, sometimes without enough concern as to when our philosophy is personal and when it is useful. But we are not so different from others in Medicine and the behavioural sciences who refer to Karl Popper and the nature of science in their common discussions. If it is permissible and even encouraged that we philosophize about science, why not about the human condition? The answer is that as citizens we should indeed be involved in responsible discussions of the human condition, its problems and its best future. We must also be aware that we oversell and fragment the self of Psychiatry when we leave its basis of knowledge in these discussions or overinterpret events using our identity as psychiatrists as the key to such understanding. There seems to be general agreement
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that eclecticism is now more necessary than ever. I can agree with this if the eclecticism represents a com bination of strengths, an openmindedness to all areas of knowledge within Psychiatry, and particularly an understanding of the different theories and researches into behaviour, cognition and affect and the potential utility of the array of therapeutic approaches now available. I tried hard to escape from my own early eclecticism which then meant to me inadequate understanding. As we continue to value and teach eclecticism to our residents, it should not be at the peril of eliminating splendid teachers with particular orientations who may try to capture the imagination and talents of their students. The mistake would only be if there were not subsequent forums for balanced discussions of the thoughts of the charismatic teacher and his beliefs against the need of maintaining an open system with its constant, but necessary, level of anxiety. Such an anxiety should lead to creative review and searching on a continuous basis and it is different from the anxiety of having to defend a firmly fixed and closed position. We now fully realize that Psychiatry must have much to do with its progenitor, Medicine. We should stop defining Psychiatry by the theory and practice of psychoanalysis, or biochemistry, or neuropsychology, or learning theory, or sociology. None of these was ever endorsed by all of Psychiatry, even though the advent of some as predominant doctrines of their times were referred to as revolutions. Several positions, such as that of Social Psychiatry, have been in some measure abandoned even before being fully explored, and others have been generally rejected as being nonmedical, non biological and sometimes as even ignorant. Too much time is wasted in arguing against previous positions, and in using limited research findings (because so much of our research methodology is still very elementary and uncertain) to prove that certain psychiatric belief systems have finally been dis proven, beyond a shadow of a doubt. It is these various splits that constitute our own antipsychiatry.
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Psychiatric Diagnosis Psychiatric diagnosis is difficult enough in its own right, without adding concerns about confidentiality and labelling. We hear somewhat less about labelling now, possibly because we recognize that being a physician must involve making a diagnosis and probably also because the specialty examination system in Canada places emphasis on the ability to conduct a sophisticated diagnostic formulation. It is hard to predict whether new diagnostic systems such as DSM III will aid us in our diagnostic considerations or not. DS M III has severalgoals; among them is the attempt to combine phenomenological and psychodynamic issues and to provide a bridge between them. During several visits to provincial psychiatric associations I heard heated discussions about the utility of DS M III and how much of this Americandesigned system we will use in Canada. Particular concern has been expressed that the Royal College endorse a diagnostic system so that certification examination candidates can prepare themselves with some certainty for questions about diagnosis. I have also heard discussions in many provinces, particularly in Ontario, about the wisdom of entering a diagnosis indicating a more serious psychiatric illness on a medicare card when there is suspicion that such diagnoses can be bled out of a computerized health care data system. This concern becomes part of a double bind as our provincial colleges of physicians and surgeons require us to maintain adequate and complete diagnostic and treatment records. These are issues of current debate in our association and they will require our continuing attention. Although we are obliged to acknowledge the inaccuracy of federal government statistics about psychiatric illness, we should be clear about the importance of maintaining accurate diagnostic criteria and standards in our own practices and teaching. As mentioned, there is evidence that health insurance data entered into a computerized provincial health system can be leaked, including psychiatric diagnoses. Psychia-
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trists have found various ways of dealing with this concern so as to minimize damage to their patients. For instance, some diagnose all patients as adjustment reactions, while others choose to diagnose the majority of their patients as having a personality disorder or a depression, depending upon which diagnosis that psychiatrist sees as least damaging. Data gathering a bout mental health statistics is inadequate and these data are then fed into a statistical system that varies in its manpower and whose ability to gather accurate statistics also depends upon the amount of money available for staffing and research. I have been told that there has just recently been a serious cutback in the number of personnel involved in the federal government's mental health statistics keeping system. When such is the case, we must regard national statistics about psychiatric illness with great mistrust and realize it is virtually impossible to do other than localized research projects with any expectation of accuracy. Community Psychiatry and Interdisciplinary Relationships
Even those who strongly believe that Psychiatry needs to maintain a firm medical identity recognize that interdisciplinary relationships are necessary to our work, particularly when this work is conducted in a hospital or community setting. Our interdisciplinary involvement has been one of our strengths and should not be threatened by the recent anxieties about competition with other mental health groups. There has been a backlash in Psychiatry against what was thought to be the excess socialization and communitization of our specialty, even though as a whole we probably never really did develop an adequate community model. There are of course some notable exceptions. The reason for this failure remains uncertain. It may be partly because the community mental health movement proved too costly and vague a model or because the very essence of the term community psychiatry distracted us from those areas of firm foothold that come out of our hospital origins. The most cogent reason is
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that it has not been sufficiently viable or realistic in the very nature of its orientation, that is, it is not a psychopathological and treatment model. It now seems unlikely that we will ever see a community mental health model in Canada supported by health insurance because of this vagueness of definition and the magnitude of the model's charge. Even so, it was surely not a mistake for us to be concerned about community mental health, but it may have been a mistake to participate as actively as we did in the community mental health movement. We generously offered a partnership that unfortunately allowed the issues of finance and hierarchical order to interfere with the development of the model. Thus, although the community mental health movement may continue in a modified form, it is more likely that Psychiatry's participation will be largely hospital based and from the hospital base may come consultation to the community. This will allow us at all times to retain our medical centrality. We thus became simultaneously involved in two major cycles of development, and although each cycle in its own right has been difficult enough, the fact that the cycles often clashed has not helped in the clarification of the issues. One cycle involves our interdisciplinary relationships and the question of who can be a primary patient therapist and more than that, whether there is a medical definition of psychotherapy and all that that means. The second cycle of development has been focused around our own discussions in which we continuously compare the values of our various technologies, particularly psychotherapy and psychopharmacology, with each other. Fortunately, we seem to be accommodating ourselves to this last predicament so that we mostly choose to be trained in a variety of approaches and recognize the need to have the expertise to deal therapeutically with a range of technological possi bilities. It is possible to train a technologist in a much shorter time than the four years required to train a medical specialist and it is possible for a technologist to give a cer-
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tain kind of care fairly cheaply in comparison to the cost of specialist care. It is necessary, however, for some one group of professionals to be so well trained and competent that they can make an adequate diagnosis and then possibly refer to the appropriate technologist. In many situations the treatment issues are so complex in terms ofthe biological knowledge demands that only a psychiatrist can adequately treat the patient. These complex issues necessitate a general theoretical understanding of matters psychological, sociological, and biological as well as the ability to judge their relative balance so as to manage and adjust the treatment accordingly. The treatment conducted in such situations, including the psychotherapy, is psychiatric treatment. There are also psychotherapies which do not have these determinants and involve more straightforward human transactions and where the expertise can be shared by a number of disciplines including Psychiatry. Regardless of our preference in patient management, we must agree on the necessity of being able to deal with patients psychotherapeutically. This ability is based upon the early development of comprehensive interviewing skills and learning to elicit information in a sensitive way as well as being able to formulate such information in a frame of reference that is diagnostically and therapeutically useful. The maintenance of this basic skill may save us from the perils of automation and a computerized inhumane Psychiatry. It is unfortunate that Psychology and Psychiatry in particular have pulled apart in such a devastating way in many places. We now have predictions of a prolonged period of confrontation and conflict between the two professions, not only over the rightful possession of psychotherapy but as well, over such issues as diagnostic and treatment responsibilities in hospitals. There are fortunately still settings where a good collaboration and relationship continues between the two professions. The Canadian Psychiatric Association is aware of these issues and is attending to them. We cannot avoid participating in proper inter-
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disciplinary efforts and discussions, for that would be irresponsible. We must not only be able to work together with a firm sense of our own identity but to also insist that the various mental health professions ask rigorous questions about their professional identity. The problem may be less in the primary socialization or initial training in a professional faculty than in the secondary socialization which comes from working together in the field and where the community mental health movement and the primary therapist pursuit has led to a blurring of professional boundaries to the point where, in some situations, it is not only difficult to determine why a psychiatrist is needed, but also why a psychologist or social worker or any other professional is required. Once having tasted the power that comes from managing the mental health team and being the primary caregiver, how can we expect the professionals in the other mental health disciplines to easily give up this quest for privileges and self-esteem, or to give up what they see as more possible than ever, a higher income. In some sense, those concerns are not our problems, but in being vigilant to the motivations of the arguments that will be used in discussions with us and around us, we must always be aware of them. If adequate reason could be established for the disappearance of Psychiatry, much of the same reason would hold true for the disappearance of Psychology and possibly Social Work most of all. Its identity and strength has really sagged in many places. Noone profession can find its identity by rewriting the definition of another. Some of us would rewrite the definition of the role of clinical psychologists so that they would all again willingly do psychological testing and ofsocial workers so that they would again willingly do counselling and homefinding. They will not likely resume these activities as their role or major focuses very readily, if ever again. The enemies without then are sometimes the other mental health professions, those agents who use anti-psychiatry for their own purposes often convincing and taking
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with them large social groups into their belief system (and who frequently ha.ve charismatic leaders, as did early Psychiatry). But of even more danger is the antipsychiatry within ourselves. T?is. is not simply represented by our conflicting sy~ tems of understanding and therapeutic approach but also by our doubts, our competitiveness and sometimes our laziness in not attending to the work and anxiety that goes with gaining new knowledge and trying new experiences. Even if we all clearly agree that we are the medical specialists of Psychiatry and would like to give up other of our alleged roles, we will still find ourselves locked in by the requirements of those politicians and social systems who, immediately after attacking us, will still turn to us for an opinion. They like to keep us around and in fact, even if Psychiatry were to be rationally discredited, I submit that we would soon be re-invented. The Dependent Society I n preparing for this paper, I also reviewed some of what was written earlier in my career when I was firmly committed to an interdisciplinary model, as I still am though perhaps now more realistically. One of these papers was on the subject of "Psychiatry and the Poor" (2). One of my earliest work assignments was to organize a Psychiatry outpatient department which mainly treated severely and often chronically ill patients as well as a large group of persons with both social and sociological problems. The hospital was in the city core and it was readily accessible and frequently visited by many patients complaining of a life crisis. Much has been written about both kinds of patients, those who are severely and chronically ill and who we maintain as well as we can, and the other large group of patients suffering major and immediate conflict, often having experienced some disruption and trauma in their life and wanting a direct and immediate solution to their specific problem. One group kept coming back periodically and the other group would visit only once or twice and then disappear. Since the chronically ill often also lived in the core of the
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city and not infrequently in the lower social class families, the issues of the two were frequently confused together. I noted in that paper my concern about the dangers involved in "the blossoming welfare system". This was in the early days of national health insurance and the paper said, "As medical treatment in general and psychiatric treatment specifically becomes more freely available to the population, there will be increased demands for psychiatric services. There has been concern for some time with the present pressure that is faced by our local psychiatric outpatient departments. These units tend to see a great many people with insufficient personnel and may tend to do inadequate initial assessments." I was concerned then about the problems and resistances to making adequate diagnoses and it seemed to me that institutionalization of patients could occur through the very act of their coming to a hospital outpatient department and having a psychiatric chart started for them. I then feared that the ultimate result of our early welfare system would be the facilitation of a hospital system that produced chronic psychiatric patients, even in those cases where there may not have been a specific psychiatric illness at the outset. Indeed, some of this has really happened and. part of our current straightening out must be to make the differential diagnoses that we should have been making years ago. The problem is complicated further by the expectation of universal health care, related to unclear definitions of illness, and encouraged by an array of professionals who need to see emotional disturbances and illness for their own verification. This earlier paper predicted, as did many others, that pure economic and social need would be decreasingly regarded as the personal responsibility of the individual and as social welfare services increased, the presence of inadequate educational ~?d other early environmental opportumtres would contribute to less adequate functioning and little ability to provide selfsupport among some individuals. I stated,
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"we will soon have to cope with a new kind of psychosomatic symptomatology and possibly a new kind of hypochondriasis that will result in life-long dependency for some of our population". I suggested that certain techniques and safeguards be used to ensure that those people who lived on some form of welfare remain self-respecting and self-sufficient. I realize as the years have passed that this prognosis was not completely accurate but also that some of the problems predicted really did become manifest. They developed in such a complicated way that they often contaminated the diagnostic picture further, making it even more difficult to obtain a clear definition of psychopathology and psychiatric illness. We have now fully inherited these patients and with them those existential problems of living that come out of ordinary life and an aging population, adding to our requirements for knowledge and treatment expertise. Thus, on the one hand we need to define our field more narrowly to develop more specific treatment approaches for those whom we can realistically treat. On the other hand, we cannot do realistic work without a broad system's view which attempts to include and integrate the wide range of possibilities of understanding of the individual and the family and the social influences over which we have little direct control. Understanding in Psychiatry
This wide range of understanding is necessary because a definition of Psychiatry can no longer be honestly related by individual clinicians to the theory and practice of psychoanalysis, or to learning theory, or social issues, or even biochemistry and pharmacology alone. To read any of our literature adequately, we must have a complex understanding. It may be equally intimidating to read a review article about the significance and relationship of the various neurotransmitters, a discussion of genetics or of the newer discussions of narcissism and self-psychology. The most earnest disbeliever must be fascinated by the biochemical and pharmacological research
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and suffer some uncertainty when it is not well comprehended. F or many years after Freud, psychoanalysis offered great promise to many but failed in the treatment of severe psychosis. Ultimately we saw the development of new approaches and most recently that of selfpsychology. There was a time when psychoanalysis dominated much of the psychiatric training because of its intense body of theory which offered a dynamic explanation for human behaviour and psychopathology. In the 1950's powerful new drugs became available and we were introduced to chlorpromazine in Canada by our colleague Dr. Heinz Lehmann of Montreal. We were tremendously enthusiastic, but even though research continues and variations of existing drugs continue to appear, there really has been nothing radically new since lithium carbonate arrived some years ago. We are now also aware of the significant side effects of drugs and their limitations. Moreover, we now know that anything that can help can also' harm. Psychiatric Education
We have defined the role of the psychiatrist as medical many times in this discussion, but clearly, theories, understandings, technical treatment approaches and technicians can all be used-in pursuit of this role, but none of them can individually define the role. Dr. Vivian Rakoff has written that "the role of the physician and specifically of the psychiatrist is to operate in the domain of judgement and uncertainty in response to human suffering. Paradoxically the moment that the uncertainty of a given area disappears; that is as soon as a predictable and specifically mechanical therapy is discovered, the role ofthe physician is diminished. Prescription can then be done by rote, or procedures can be accomplished by people who work in narrowly defined areas" (4). This is not necessrily bad because simple therapies are economical and advantageous to the patient and indeed, there is cost effectiveness in training people to predictably and efficiently handle a certain problem with an
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effective technique. But again, only the psychiatric physician is equipped to assume the entire mantle. Such a mantle must not be worn grandiosely. We can ill afford as a collective and entire profession to follow either a conservative psychoanalytic orthodoxy or a naive organicism. We must use all information from all sides of the question. One of our concerns is a quest for certainty and that is part of the reason why we pursue different models at different times. It is essential to be certain that we are not returning to the medical model for political and economic reasons, but rather because man is a biological person and because of our desire to recognize the importance of our medical attitudes and training in opening the door to very ill patients. Sooner or later, we will have to do this; it should be done now. We still need a comprehensive view of man just as we need a breakthrough in the treatment of schizophrenia. Such a view, or as near as we can come to it, must start with the education of psychiatrists. Psychiatrists require more than ever a systematic training in the behavioural sciences as well as in Medicine. This means not only the biology of the nervous system and the mind, which of course includes the brain, but as well, the information that is derived from sociology, learning theory, developmental theory, ethology, and even anthropology. Our training must be thorough and include all things psychological and somatic. This is necessary for the definition of a psychiatrist as a total caregiver. Being a total caregiver also means being able as a group to give care to patients of all kinds, and of all social and economic backgrounds. This does not necessarily mean that each of us must be a total specialist, but we should consider coming as close to this ideal as possible as a profession and certainly we should all agree that we support fully within Psychiatry some idea of totality such as I have just mentioned. Psychiatry then is continuously evolving. We acknowledge our growth and development and should also acknowledge
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that it is normal for each developmental stage to have its tasks and crises. Conflict may occur at any stage of development and as in a family, the same conflicts may occur in family members at different ages which although similar in nature, are unrecognized as such. 1n fact, conflicts that are not resolved in the earlier developmental stages of life may manifest themselves later on and result particularly in difficulties in aging. Families in such conflict often fail to recognize that they are working on the same issues and come to the conclusion that they must split up or disintegrate rather than work out a mutual solution. That is ultimately a matter of personal choice, and mutual solutions do involve compromise. The danger of not achieving compromise in the psychiatric family is to not achieve the strength that comes from continuing within the developmental process and possibly succumbing to mid-life crisis with its loss of idealism and either a giving up or burn-out, boredom and sometimes even hopelessness with Psychiatry; or a seeking impulsively for new esoteric adventures and approaches. Some of us prefer to narrow our views and choose the safety of conservatism and traditionalism and this certainly can often get one through, and not with a bad reputation either. Because of the limitations of our knowledge and perhaps because of the middle age of Psychiatry, some of us become very angry and disgruntled and destructive to ourselves and others. We are impatient with our inability to satisfy our idealism and many of us can no longer tolerate the health care demands of our patients and turn away to work in a relatively isolated and narrow clinical fashion. The course is difficult and requires the taming of our own grandiosity and a willingness to compromise with limited knowledge, a large reliance on ourselves, the need for continuous upgrading and to struggle for new knowledge and self-improvement continuously. Too many psychiatrists become depressed themselves and are afraid to share their depression with others and work it through. It is difficult not to transfer personal issues to the institutional environment of
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Psychiatry and particularly its bureaucratic system. Many tend to over-romanticize Psychiatry and because of the strong emotional commitment to our work and our patients and because we have been trained to deal empathically and sensitively with people, we fail to recognize quite often in our dealings with government and other bureaucratic systems that our concerns must be expressed in data that are measurable and translatable, particularly nowadays, in economically viable terms. When we fail to do this, we leave our objective Psychiatry behind and enter politics, for which we are not usually well trained and indeed, we suffer too much in such political activity and often get hurt. One of the next stages of development for Psychiatry, particularly in its hospital and academic relationships, must be the interpretation of our experience through data. This must be done to defend Psychiatry, our hospitals, our practices and our academic systems against our competitors as well as to demonstrate clearly our need for increased resources. To summarize: we need to educate and upgrade ourselves in biology and psychology, in systems theory and social theory, in semiotics and the philosophy of science. We need to treat the severely ill and the chronically ill, but not foresake the neurotic and character disorder. We must work with a cross-section of patients and as a profession, be able to use a variety of techniques. We should as individuals, as well as in the Canadian Psychiatric Association, work with the Canadian Mental Health Association to advocate the cause of our patients, particularly with governments. In this country we especially need a federal presence in Psychiatry and a much more adequate provincial voice in the organization of health services. Weare beginning to keep an eye on federallegislation and although we are still too small an Association to organizea lobby, that may be an eventual goal. In the meantime, we are strengthening as rapidly as we can our ties to the Canadian Medical Association and as a sign of our maturation we are dis-
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cussing whether we should approach the Royal College of Physicians and Surgeons of Canada with a request that we be considered a Separate Division. The Canadian Psychiatric Association is an active and vigorous young body. It is no longer frightened of studying important issues and making position statements, even though sometimes controversial. Its future will be to continue to study and comment on important issues such as manpower, peer review, confidentiality, standards of practice, role conflicts, continuing medical education, and the ethics of psychiatric practice, both nationally and internationally - the latter particularly with reference to any abuse of Psychiatry. The Canadian Psychiatric Association should urge a national flow and interest of psychiatrists, should urge improvement and upgrading of its members, make new information easily available to its membership and not fear studying controversial areas and expressing opinions about them. To be politically active is no longer a question. To become more sophisticated in this activity and to seek astute advice and support is increasingly necessary. Conclusion
Bertrand Russell has stated what he considers to be the requisite conditions for doing adequate work. His comments also reflect the need for each of us to not only work together within our national organization, but individually to commit ourselves to creativity and freedom. Russell said, "The teacher, like the artist, the philosopher, and the man of letters, can only perform his work adequately if he feels himself to be an individual directed by an inner creative impulse, not dominated and fettered by an outside authority. It is very difficult in this modern world to find a place for the individual. He can subsist at the top as a dictator in a totalitarian state or a plutocratic magnate in a country of large industrial enterprises, but in the realm of the mind it is becoming more and more difficult to preserve independence of the great organized forces that control the
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livelihoods of men and women. If the world is not to lose the benefit to be derived from its best minds, it will have to find some method of allowing them scope and liberty in spite of organization. This involves a deliberate restraint on the part of those who have power, and a conscious realization that there are men to whom free scope must be afforded. Renaissance Popes could feel in this way towards Renaissance artists, but the powerful men of our day seem to have more difficulty in feeling respect for exceptional genius. The turbulence of our times is inimical to the fine flower of culture. The man in the street is full of fear, and therefore unwilling to tolerate freedoms for which he sees no need. Perhaps we must wait for quieter times before the claims of civilization can again override the claims of party spirit. Mean-
while, it IS Important that some at least should continue to realize the limitations of what can be done by organization. Every system should allow loopholes and exceptions, for if it does not it will in the end crush all that is best in man" (5). References I. McLean, J.D.: Presidential Address -
2.
3. 4. 5.
Rights, rituals and the political process. Can Psychiatr Assoc J, 23(8): 513-18, 1978. Prosen, H.: Psychiatry and the poor. Manitoba Medical Review, Feb. 1967. "Psychiatry's Depression." Time Magazine, April 2, 1979, pp. 44-52. Rakoff, V.: Personal Communication. Russell, B.:"The Functions of a Teacher," in The Basic Writings of Bertrand Russel/.
R.E. Enger and L.E. Denonn (eds). New York: Simon and Schuster, p. 442.
Ottawa, Canada, December 1979
No.8
Presidential Address IN FAVOUR OF PSYCHIATRY* HARRY PROSEN,
M.D.'
Introduction
When the President-Elect introduces the President on this occasion he is already considering what he will say when his own turn comes in a year's time. Discussions with my predecessors indicated that they, like me, searched, asked opinions from others and gathered materials in quest of important themes to present to the membership. Most read what other Presidents of both the Canadian and American Psychiatric Associations have said and with this preparation, an appreciation grows that many issues are not new and have been well examined before. Our Association has benefited from a variety of presidential addresses ranging from great declamations to humble and personal statements of considerable value to us, such as that made by Dr. Douglas McLean last year. (I) In conducting this review some similarities of pattern were found in the problems and promises of Psychiatry. American Psychiatric Association Presidents have recently had their own special theme, discussing the important events that have happened during their term of office, and demonstrating an increasing interest and contribution to international Psychiatry. This has also provided similar interesting opportunities and impetus for us in Canada. We have all tried to deal with specific psychiatric political issues in terms of our own hopes and beliefs. 'Presented at the Canadian Psychiatric Association Annual Meeting, Vancouver, B.C., September, 1979. 'Professor and Head, Department of Psychiatry, University of Manitoba; Chairman, Specialty Committee in Psychiatry, Royal College of Physicians and Surgeons; Psychiatrist-inChief, Health Sciences Centre. University of Manitoba, Winnipeg. Can. J. Psychiatry Vol. 24 (1979)
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Our Canadian Presidents have tended much less to follow a regular pattern or style. As well as making a personal statement to the membership they have nearly all offered to serve at least a little as a psychiatric oracle. We have also generally attempted to define and deal pragmatically with our own Canadian problems. This is likely because our Presidents have visited each province by the time they give their presidential address and thus are able to present various provincial interests along with the national concerns of Canadian Psychiatry. It is true in this country, and perhaps elsewhere as well, that the same matters are usually of concern in at least several provinces at the same time, whether they are proposed changes in mental health legislation, or concerns about confiden-
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tiality. Although I will discuss what I consider to be some of the matters that are most important to our profession, I may not appear to always separate these from what are important only to me and maybe to a few others. I must nevertheless mention my own concerns. Anti-Psychiatry It is not possible now, if ever it was, to simply practise Psychiatry to the best of our ability and be content. Not only must we be aware of the burgeoning knowledge in areas such as biochemistry, psychopharmacology and neuropsychology, we must also pay attention to the diagnoses made by others about us as well as our own diagnostic formulation of our current state of professional and institutional health.
The issue of Time magazine which featured "Psychiatry's Depression" (3) presented Psychiatry's complaint as "overwork, loss of confidence and inability to get provable results". The diagnosis of our condition was that of "standard conflictual anxiety and maturational variations, complicated by acute depression ... Identity crisis accompanied by compensatory delusions of grandeur and a declining ability to cope . . . Patient averse to therapeutic alliance and shows incipient overreliance on drugs". The prognosis was considered problematic. As usual the article smacked of anti-psychiatry and factual distortion in its early pages, but as the discussion continued the picture improved and our usefulness was positively determined. If one had to interpret the reason for this article and search similar articles for a common theme, that theme seems to be a fear of psychiatrists and what is projected as Psychiatry's power - its power in terms of understanding and thereby in some way controlling the mind and what is then alleged by some as a wish to control the individual. Although there is truth in our desire to understand the psyche and human behaviour, our grandiosity is generally well tempered by extensive and prolonged studies in medical school of the nature and application of scientific objectivity; and in
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our psychiatric training it is hoped that we have learned to deal with aspects of our own grandiose countertransference. The irony is that our detractors accuse us of corrupting power and control when we often feel helpless in effecting useful environmental changes for our patients. As well, our medical training is envied and demeaned by our more hostile detractors who themselves wish to possess its growthgiving character through short courses in Medicine while we ourselves talk of returning to Medicine as though we were the prodigal child. Most of us have never left Medicine or our pride in our medical training and the depth of understanding it has given us, and this is the real origin of whatever power we possess. It is true that there are assiduous questions as to our viability as a profession and attempts are made to dismantle piecemeal our range of skills into various components, some of which can also be ably represented by other groups of specialists. We now often face criticisms about being anti libertarian and more interested in arresting and locking up the individual's soul rather than liberating it from psychic conflict and disease, which is the commitment that the majority of us have made.
Sources of Power Sometimes, I think that it is the lawyers who are the dangerous ones. It is they who in one way or another influence our political and judicial processes. Such an influence and governance inevitably makes regulation and control dominant over homeostasis and health. We of course accept that civilization requires regulation, policing and judgement. With our innate ambivalence about freedom and its expression, society's security seems to demand that the legal process rather than the medical process dominates. Antithesis often results when it should not. The psychiatric medical process has as its goal health and not an unethical life or society. The legal process seeks truth and must inevitably attribute blame and seek guilt. It is this necessary legal process that contains all real power in
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society. The reading of judicial opinions on many matters of health and physiology, such as sexual expression, will cause one to recognize that the judicial process defines states of normality more than does common experience. Normality as accepted by the law may not be the normality of common and frequent human behaviour. Only a step removed from the legal processes that govern a civilization are the political processes. These processes infiltrate everywhere and in order to maintain our profession some of us must be involved in politics. Indeed, I suspect that some psychiatrists love politics even more than Psychiatry. The politics, as with all politics, can be very complex. They involve our relationship to Medicine, to government and its agents in determining health care priorities, to governments and universities in determining educational goals and priorities and to competition from other groups within the mental health system. We then of course face that large group of critics, not all enemies, that we loosely call the anti-psychiatry movement. As I see it, the most serious danger is the anti-psychiatry within Psychiatry. This anti-psychiatry is too often worked out through subtle political processes that we use in our attempts to work together. Sometimes when we cannot compromise on our diverse orientations through scientific and clinical discourse, we attempt to gather electorates about us, as though possessing a particular orientation is the same as having a set of political beliefs. We are generally clever enough as a group to cover up this politicization quite well. Some are foolish enough to let their belief system be used in the service of anti-psychiatry groups who have their own cultic needs to absorb and capture followers. Orientation and Diagnosis
Although we must recognize our current limitations in successfully treating all of the major psychiatric disorders, particularly schizophrenia; and as we continue our excitement at new discoveries-while balancing their appeal as personal against scientific - the combination of perceived
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limitation and bias of therapeutic approach does tend to put us into competition with each other. Too often we choose competing and contradictory positions instead of continuously synthesizing in our clinical approach. Also, as we all know, Psychiatry goes through phases, in which many practitioners turn about face to new views, too easily forgetting whatever is of value in an abandoned position; while others can always find fundamental reasons for clinging to their original theoretical position and never changing. We are really no different than any group of specialists in this, although we seem to make more of a romance out of our dogmas and positions than many other groups. That is part of the problem and also part of the joy of being a psychiatrist. What great fun, what great drama, what great tragedy, what terribly important lives we lead. But the advantage is ours as long as we retain that value which should be intrinsic to Psychiatry, the analysis and understanding of our particular position and a continuing attempt to objectify our interpretations. We and others continuously question our role as commentators on the human condition when it is evident that civilization is threatened and the environment has been sadly abused. In fact we have a background and propensity that causes us to enjoy philosophization about the human condition, sometimes without enough concern as to when our philosophy is personal and when it is useful. But we are not so different from others in Medicine and the behavioural sciences who refer to Karl Popper and the nature of science in their common discussions. If it is permissible and even encouraged that we philosophize about science, why not about the human condition? The answer is that as citizens we should indeed be involved in responsible discussions of the human condition, its problems and its best future. We must also be aware that we oversell and fragment the self of Psychiatry when we leave its basis of knowledge in these discussions or overinterpret events using our identity as psychiatrists as the key to such understanding. There seems to be general agreement
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that eclecticism is now more necessary than ever. I can agree with this if the eclecticism represents a com bination of strengths, an openmindedness to all areas of knowledge within Psychiatry, and particularly an understanding of the different theories and researches into behaviour, cognition and affect and the potential utility of the array of therapeutic approaches now available. I tried hard to escape from my own early eclecticism which then meant to me inadequate understanding. As we continue to value and teach eclecticism to our residents, it should not be at the peril of eliminating splendid teachers with particular orientations who may try to capture the imagination and talents of their students. The mistake would only be if there were not subsequent forums for balanced discussions of the thoughts of the charismatic teacher and his beliefs against the need of maintaining an open system with its constant, but necessary, level of anxiety. Such an anxiety should lead to creative review and searching on a continuous basis and it is different from the anxiety of having to defend a firmly fixed and closed position. We now fully realize that Psychiatry must have much to do with its progenitor, Medicine. We should stop defining Psychiatry by the theory and practice of psychoanalysis, or biochemistry, or neuropsychology, or learning theory, or sociology. None of these was ever endorsed by all of Psychiatry, even though the advent of some as predominant doctrines of their times were referred to as revolutions. Several positions, such as that of Social Psychiatry, have been in some measure abandoned even before being fully explored, and others have been generally rejected as being nonmedical, non biological and sometimes as even ignorant. Too much time is wasted in arguing against previous positions, and in using limited research findings (because so much of our research methodology is still very elementary and uncertain) to prove that certain psychiatric belief systems have finally been dis proven, beyond a shadow of a doubt. It is these various splits that constitute our own antipsychiatry.
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Psychiatric Diagnosis Psychiatric diagnosis is difficult enough in its own right, without adding concerns about confidentiality and labelling. We hear somewhat less about labelling now, possibly because we recognize that being a physician must involve making a diagnosis and probably also because the specialty examination system in Canada places emphasis on the ability to conduct a sophisticated diagnostic formulation. It is hard to predict whether new diagnostic systems such as DSM III will aid us in our diagnostic considerations or not. DS M III has severalgoals; among them is the attempt to combine phenomenological and psychodynamic issues and to provide a bridge between them. During several visits to provincial psychiatric associations I heard heated discussions about the utility of DS M III and how much of this Americandesigned system we will use in Canada. Particular concern has been expressed that the Royal College endorse a diagnostic system so that certification examination candidates can prepare themselves with some certainty for questions about diagnosis. I have also heard discussions in many provinces, particularly in Ontario, about the wisdom of entering a diagnosis indicating a more serious psychiatric illness on a medicare card when there is suspicion that such diagnoses can be bled out of a computerized health care data system. This concern becomes part of a double bind as our provincial colleges of physicians and surgeons require us to maintain adequate and complete diagnostic and treatment records. These are issues of current debate in our association and they will require our continuing attention. Although we are obliged to acknowledge the inaccuracy of federal government statistics about psychiatric illness, we should be clear about the importance of maintaining accurate diagnostic criteria and standards in our own practices and teaching. As mentioned, there is evidence that health insurance data entered into a computerized provincial health system can be leaked, including psychiatric diagnoses. Psychia-
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trists have found various ways of dealing with this concern so as to minimize damage to their patients. For instance, some diagnose all patients as adjustment reactions, while others choose to diagnose the majority of their patients as having a personality disorder or a depression, depending upon which diagnosis that psychiatrist sees as least damaging. Data gathering a bout mental health statistics is inadequate and these data are then fed into a statistical system that varies in its manpower and whose ability to gather accurate statistics also depends upon the amount of money available for staffing and research. I have been told that there has just recently been a serious cutback in the number of personnel involved in the federal government's mental health statistics keeping system. When such is the case, we must regard national statistics about psychiatric illness with great mistrust and realize it is virtually impossible to do other than localized research projects with any expectation of accuracy. Community Psychiatry and Interdisciplinary Relationships
Even those who strongly believe that Psychiatry needs to maintain a firm medical identity recognize that interdisciplinary relationships are necessary to our work, particularly when this work is conducted in a hospital or community setting. Our interdisciplinary involvement has been one of our strengths and should not be threatened by the recent anxieties about competition with other mental health groups. There has been a backlash in Psychiatry against what was thought to be the excess socialization and communitization of our specialty, even though as a whole we probably never really did develop an adequate community model. There are of course some notable exceptions. The reason for this failure remains uncertain. It may be partly because the community mental health movement proved too costly and vague a model or because the very essence of the term community psychiatry distracted us from those areas of firm foothold that come out of our hospital origins. The most cogent reason is
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that it has not been sufficiently viable or realistic in the very nature of its orientation, that is, it is not a psychopathological and treatment model. It now seems unlikely that we will ever see a community mental health model in Canada supported by health insurance because of this vagueness of definition and the magnitude of the model's charge. Even so, it was surely not a mistake for us to be concerned about community mental health, but it may have been a mistake to participate as actively as we did in the community mental health movement. We generously offered a partnership that unfortunately allowed the issues of finance and hierarchical order to interfere with the development of the model. Thus, although the community mental health movement may continue in a modified form, it is more likely that Psychiatry's participation will be largely hospital based and from the hospital base may come consultation to the community. This will allow us at all times to retain our medical centrality. We thus became simultaneously involved in two major cycles of development, and although each cycle in its own right has been difficult enough, the fact that the cycles often clashed has not helped in the clarification of the issues. One cycle involves our interdisciplinary relationships and the question of who can be a primary patient therapist and more than that, whether there is a medical definition of psychotherapy and all that that means. The second cycle of development has been focused around our own discussions in which we continuously compare the values of our various technologies, particularly psychotherapy and psychopharmacology, with each other. Fortunately, we seem to be accommodating ourselves to this last predicament so that we mostly choose to be trained in a variety of approaches and recognize the need to have the expertise to deal therapeutically with a range of technological possi bilities. It is possible to train a technologist in a much shorter time than the four years required to train a medical specialist and it is possible for a technologist to give a cer-
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tain kind of care fairly cheaply in comparison to the cost of specialist care. It is necessary, however, for some one group of professionals to be so well trained and competent that they can make an adequate diagnosis and then possibly refer to the appropriate technologist. In many situations the treatment issues are so complex in terms ofthe biological knowledge demands that only a psychiatrist can adequately treat the patient. These complex issues necessitate a general theoretical understanding of matters psychological, sociological, and biological as well as the ability to judge their relative balance so as to manage and adjust the treatment accordingly. The treatment conducted in such situations, including the psychotherapy, is psychiatric treatment. There are also psychotherapies which do not have these determinants and involve more straightforward human transactions and where the expertise can be shared by a number of disciplines including Psychiatry. Regardless of our preference in patient management, we must agree on the necessity of being able to deal with patients psychotherapeutically. This ability is based upon the early development of comprehensive interviewing skills and learning to elicit information in a sensitive way as well as being able to formulate such information in a frame of reference that is diagnostically and therapeutically useful. The maintenance of this basic skill may save us from the perils of automation and a computerized inhumane Psychiatry. It is unfortunate that Psychology and Psychiatry in particular have pulled apart in such a devastating way in many places. We now have predictions of a prolonged period of confrontation and conflict between the two professions, not only over the rightful possession of psychotherapy but as well, over such issues as diagnostic and treatment responsibilities in hospitals. There are fortunately still settings where a good collaboration and relationship continues between the two professions. The Canadian Psychiatric Association is aware of these issues and is attending to them. We cannot avoid participating in proper inter-
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disciplinary efforts and discussions, for that would be irresponsible. We must not only be able to work together with a firm sense of our own identity but to also insist that the various mental health professions ask rigorous questions about their professional identity. The problem may be less in the primary socialization or initial training in a professional faculty than in the secondary socialization which comes from working together in the field and where the community mental health movement and the primary therapist pursuit has led to a blurring of professional boundaries to the point where, in some situations, it is not only difficult to determine why a psychiatrist is needed, but also why a psychologist or social worker or any other professional is required. Once having tasted the power that comes from managing the mental health team and being the primary caregiver, how can we expect the professionals in the other mental health disciplines to easily give up this quest for privileges and self-esteem, or to give up what they see as more possible than ever, a higher income. In some sense, those concerns are not our problems, but in being vigilant to the motivations of the arguments that will be used in discussions with us and around us, we must always be aware of them. If adequate reason could be established for the disappearance of Psychiatry, much of the same reason would hold true for the disappearance of Psychology and possibly Social Work most of all. Its identity and strength has really sagged in many places. Noone profession can find its identity by rewriting the definition of another. Some of us would rewrite the definition of the role of clinical psychologists so that they would all again willingly do psychological testing and ofsocial workers so that they would again willingly do counselling and homefinding. They will not likely resume these activities as their role or major focuses very readily, if ever again. The enemies without then are sometimes the other mental health professions, those agents who use anti-psychiatry for their own purposes often convincing and taking
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with them large social groups into their belief system (and who frequently ha.ve charismatic leaders, as did early Psychiatry). But of even more danger is the antipsychiatry within ourselves. T?is. is not simply represented by our conflicting sy~ tems of understanding and therapeutic approach but also by our doubts, our competitiveness and sometimes our laziness in not attending to the work and anxiety that goes with gaining new knowledge and trying new experiences. Even if we all clearly agree that we are the medical specialists of Psychiatry and would like to give up other of our alleged roles, we will still find ourselves locked in by the requirements of those politicians and social systems who, immediately after attacking us, will still turn to us for an opinion. They like to keep us around and in fact, even if Psychiatry were to be rationally discredited, I submit that we would soon be re-invented. The Dependent Society I n preparing for this paper, I also reviewed some of what was written earlier in my career when I was firmly committed to an interdisciplinary model, as I still am though perhaps now more realistically. One of these papers was on the subject of "Psychiatry and the Poor" (2). One of my earliest work assignments was to organize a Psychiatry outpatient department which mainly treated severely and often chronically ill patients as well as a large group of persons with both social and sociological problems. The hospital was in the city core and it was readily accessible and frequently visited by many patients complaining of a life crisis. Much has been written about both kinds of patients, those who are severely and chronically ill and who we maintain as well as we can, and the other large group of patients suffering major and immediate conflict, often having experienced some disruption and trauma in their life and wanting a direct and immediate solution to their specific problem. One group kept coming back periodically and the other group would visit only once or twice and then disappear. Since the chronically ill often also lived in the core of the
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city and not infrequently in the lower social class families, the issues of the two were frequently confused together. I noted in that paper my concern about the dangers involved in "the blossoming welfare system". This was in the early days of national health insurance and the paper said, "As medical treatment in general and psychiatric treatment specifically becomes more freely available to the population, there will be increased demands for psychiatric services. There has been concern for some time with the present pressure that is faced by our local psychiatric outpatient departments. These units tend to see a great many people with insufficient personnel and may tend to do inadequate initial assessments." I was concerned then about the problems and resistances to making adequate diagnoses and it seemed to me that institutionalization of patients could occur through the very act of their coming to a hospital outpatient department and having a psychiatric chart started for them. I then feared that the ultimate result of our early welfare system would be the facilitation of a hospital system that produced chronic psychiatric patients, even in those cases where there may not have been a specific psychiatric illness at the outset. Indeed, some of this has really happened and. part of our current straightening out must be to make the differential diagnoses that we should have been making years ago. The problem is complicated further by the expectation of universal health care, related to unclear definitions of illness, and encouraged by an array of professionals who need to see emotional disturbances and illness for their own verification. This earlier paper predicted, as did many others, that pure economic and social need would be decreasingly regarded as the personal responsibility of the individual and as social welfare services increased, the presence of inadequate educational ~?d other early environmental opportumtres would contribute to less adequate functioning and little ability to provide selfsupport among some individuals. I stated,
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"we will soon have to cope with a new kind of psychosomatic symptomatology and possibly a new kind of hypochondriasis that will result in life-long dependency for some of our population". I suggested that certain techniques and safeguards be used to ensure that those people who lived on some form of welfare remain self-respecting and self-sufficient. I realize as the years have passed that this prognosis was not completely accurate but also that some of the problems predicted really did become manifest. They developed in such a complicated way that they often contaminated the diagnostic picture further, making it even more difficult to obtain a clear definition of psychopathology and psychiatric illness. We have now fully inherited these patients and with them those existential problems of living that come out of ordinary life and an aging population, adding to our requirements for knowledge and treatment expertise. Thus, on the one hand we need to define our field more narrowly to develop more specific treatment approaches for those whom we can realistically treat. On the other hand, we cannot do realistic work without a broad system's view which attempts to include and integrate the wide range of possibilities of understanding of the individual and the family and the social influences over which we have little direct control. Understanding in Psychiatry
This wide range of understanding is necessary because a definition of Psychiatry can no longer be honestly related by individual clinicians to the theory and practice of psychoanalysis, or to learning theory, or social issues, or even biochemistry and pharmacology alone. To read any of our literature adequately, we must have a complex understanding. It may be equally intimidating to read a review article about the significance and relationship of the various neurotransmitters, a discussion of genetics or of the newer discussions of narcissism and self-psychology. The most earnest disbeliever must be fascinated by the biochemical and pharmacological research
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and suffer some uncertainty when it is not well comprehended. F or many years after Freud, psychoanalysis offered great promise to many but failed in the treatment of severe psychosis. Ultimately we saw the development of new approaches and most recently that of selfpsychology. There was a time when psychoanalysis dominated much of the psychiatric training because of its intense body of theory which offered a dynamic explanation for human behaviour and psychopathology. In the 1950's powerful new drugs became available and we were introduced to chlorpromazine in Canada by our colleague Dr. Heinz Lehmann of Montreal. We were tremendously enthusiastic, but even though research continues and variations of existing drugs continue to appear, there really has been nothing radically new since lithium carbonate arrived some years ago. We are now also aware of the significant side effects of drugs and their limitations. Moreover, we now know that anything that can help can also' harm. Psychiatric Education
We have defined the role of the psychiatrist as medical many times in this discussion, but clearly, theories, understandings, technical treatment approaches and technicians can all be used-in pursuit of this role, but none of them can individually define the role. Dr. Vivian Rakoff has written that "the role of the physician and specifically of the psychiatrist is to operate in the domain of judgement and uncertainty in response to human suffering. Paradoxically the moment that the uncertainty of a given area disappears; that is as soon as a predictable and specifically mechanical therapy is discovered, the role ofthe physician is diminished. Prescription can then be done by rote, or procedures can be accomplished by people who work in narrowly defined areas" (4). This is not necessrily bad because simple therapies are economical and advantageous to the patient and indeed, there is cost effectiveness in training people to predictably and efficiently handle a certain problem with an
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effective technique. But again, only the psychiatric physician is equipped to assume the entire mantle. Such a mantle must not be worn grandiosely. We can ill afford as a collective and entire profession to follow either a conservative psychoanalytic orthodoxy or a naive organicism. We must use all information from all sides of the question. One of our concerns is a quest for certainty and that is part of the reason why we pursue different models at different times. It is essential to be certain that we are not returning to the medical model for political and economic reasons, but rather because man is a biological person and because of our desire to recognize the importance of our medical attitudes and training in opening the door to very ill patients. Sooner or later, we will have to do this; it should be done now. We still need a comprehensive view of man just as we need a breakthrough in the treatment of schizophrenia. Such a view, or as near as we can come to it, must start with the education of psychiatrists. Psychiatrists require more than ever a systematic training in the behavioural sciences as well as in Medicine. This means not only the biology of the nervous system and the mind, which of course includes the brain, but as well, the information that is derived from sociology, learning theory, developmental theory, ethology, and even anthropology. Our training must be thorough and include all things psychological and somatic. This is necessary for the definition of a psychiatrist as a total caregiver. Being a total caregiver also means being able as a group to give care to patients of all kinds, and of all social and economic backgrounds. This does not necessarily mean that each of us must be a total specialist, but we should consider coming as close to this ideal as possible as a profession and certainly we should all agree that we support fully within Psychiatry some idea of totality such as I have just mentioned. Psychiatry then is continuously evolving. We acknowledge our growth and development and should also acknowledge
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that it is normal for each developmental stage to have its tasks and crises. Conflict may occur at any stage of development and as in a family, the same conflicts may occur in family members at different ages which although similar in nature, are unrecognized as such. 1n fact, conflicts that are not resolved in the earlier developmental stages of life may manifest themselves later on and result particularly in difficulties in aging. Families in such conflict often fail to recognize that they are working on the same issues and come to the conclusion that they must split up or disintegrate rather than work out a mutual solution. That is ultimately a matter of personal choice, and mutual solutions do involve compromise. The danger of not achieving compromise in the psychiatric family is to not achieve the strength that comes from continuing within the developmental process and possibly succumbing to mid-life crisis with its loss of idealism and either a giving up or burn-out, boredom and sometimes even hopelessness with Psychiatry; or a seeking impulsively for new esoteric adventures and approaches. Some of us prefer to narrow our views and choose the safety of conservatism and traditionalism and this certainly can often get one through, and not with a bad reputation either. Because of the limitations of our knowledge and perhaps because of the middle age of Psychiatry, some of us become very angry and disgruntled and destructive to ourselves and others. We are impatient with our inability to satisfy our idealism and many of us can no longer tolerate the health care demands of our patients and turn away to work in a relatively isolated and narrow clinical fashion. The course is difficult and requires the taming of our own grandiosity and a willingness to compromise with limited knowledge, a large reliance on ourselves, the need for continuous upgrading and to struggle for new knowledge and self-improvement continuously. Too many psychiatrists become depressed themselves and are afraid to share their depression with others and work it through. It is difficult not to transfer personal issues to the institutional environment of
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Psychiatry and particularly its bureaucratic system. Many tend to over-romanticize Psychiatry and because of the strong emotional commitment to our work and our patients and because we have been trained to deal empathically and sensitively with people, we fail to recognize quite often in our dealings with government and other bureaucratic systems that our concerns must be expressed in data that are measurable and translatable, particularly nowadays, in economically viable terms. When we fail to do this, we leave our objective Psychiatry behind and enter politics, for which we are not usually well trained and indeed, we suffer too much in such political activity and often get hurt. One of the next stages of development for Psychiatry, particularly in its hospital and academic relationships, must be the interpretation of our experience through data. This must be done to defend Psychiatry, our hospitals, our practices and our academic systems against our competitors as well as to demonstrate clearly our need for increased resources. To summarize: we need to educate and upgrade ourselves in biology and psychology, in systems theory and social theory, in semiotics and the philosophy of science. We need to treat the severely ill and the chronically ill, but not foresake the neurotic and character disorder. We must work with a cross-section of patients and as a profession, be able to use a variety of techniques. We should as individuals, as well as in the Canadian Psychiatric Association, work with the Canadian Mental Health Association to advocate the cause of our patients, particularly with governments. In this country we especially need a federal presence in Psychiatry and a much more adequate provincial voice in the organization of health services. Weare beginning to keep an eye on federallegislation and although we are still too small an Association to organizea lobby, that may be an eventual goal. In the meantime, we are strengthening as rapidly as we can our ties to the Canadian Medical Association and as a sign of our maturation we are dis-
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cussing whether we should approach the Royal College of Physicians and Surgeons of Canada with a request that we be considered a Separate Division. The Canadian Psychiatric Association is an active and vigorous young body. It is no longer frightened of studying important issues and making position statements, even though sometimes controversial. Its future will be to continue to study and comment on important issues such as manpower, peer review, confidentiality, standards of practice, role conflicts, continuing medical education, and the ethics of psychiatric practice, both nationally and internationally - the latter particularly with reference to any abuse of Psychiatry. The Canadian Psychiatric Association should urge a national flow and interest of psychiatrists, should urge improvement and upgrading of its members, make new information easily available to its membership and not fear studying controversial areas and expressing opinions about them. To be politically active is no longer a question. To become more sophisticated in this activity and to seek astute advice and support is increasingly necessary. Conclusion
Bertrand Russell has stated what he considers to be the requisite conditions for doing adequate work. His comments also reflect the need for each of us to not only work together within our national organization, but individually to commit ourselves to creativity and freedom. Russell said, "The teacher, like the artist, the philosopher, and the man of letters, can only perform his work adequately if he feels himself to be an individual directed by an inner creative impulse, not dominated and fettered by an outside authority. It is very difficult in this modern world to find a place for the individual. He can subsist at the top as a dictator in a totalitarian state or a plutocratic magnate in a country of large industrial enterprises, but in the realm of the mind it is becoming more and more difficult to preserve independence of the great organized forces that control the
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livelihoods of men and women. If the world is not to lose the benefit to be derived from its best minds, it will have to find some method of allowing them scope and liberty in spite of organization. This involves a deliberate restraint on the part of those who have power, and a conscious realization that there are men to whom free scope must be afforded. Renaissance Popes could feel in this way towards Renaissance artists, but the powerful men of our day seem to have more difficulty in feeling respect for exceptional genius. The turbulence of our times is inimical to the fine flower of culture. The man in the street is full of fear, and therefore unwilling to tolerate freedoms for which he sees no need. Perhaps we must wait for quieter times before the claims of civilization can again override the claims of party spirit. Mean-
while, it IS Important that some at least should continue to realize the limitations of what can be done by organization. Every system should allow loopholes and exceptions, for if it does not it will in the end crush all that is best in man" (5). References I. McLean, J.D.: Presidential Address -
2.
3. 4. 5.
Rights, rituals and the political process. Can Psychiatr Assoc J, 23(8): 513-18, 1978. Prosen, H.: Psychiatry and the poor. Manitoba Medical Review, Feb. 1967. "Psychiatry's Depression." Time Magazine, April 2, 1979, pp. 44-52. Rakoff, V.: Personal Communication. Russell, B.:"The Functions of a Teacher," in The Basic Writings of Bertrand Russel/.
R.E. Enger and L.E. Denonn (eds). New York: Simon and Schuster, p. 442.
