J o u r n a l of Religion a n d Health, Vol. 17, No. 3, 1978
Psychiatry in a Restless World BERTRAM S. BROWN During the last decade, through the miracles of the mass communications media, we have watched the industrial powers of the world and m a n y developing countries mount massive initiatives to increase their scientific bodies of knowledge and technical capabilities. As this scientific revolution gained momentum, many of the peoples of the world for the first time caught a glimpse of the inequities in the existing social order and s o u g h t , through spirited movements for social change, to achieve some sort of equity. Needless to say, much of the restlessness in the world today is a symptom of these movements. During the past few years, organized mental health professionals and supporters worldwide have sought to evaluate and monitor the impact of these movements on mental health. Studies of the relationship of racism, sexism, migration, housing, and urbanization to mental health are just a few examples. If successful, such efforts will in part answer not only why but also what kinds of mental health services are important. The mental health establishment in the United States is no exception in this process. We, too, in recent years have had to take a much closer look at and, in fact, become much more sensitive to the issue of h u m a n rights and the rights of h u m a n subjects. In my view, our thrust and our accomplishments in this area arose primarily from the anti-poverty and civil rights movements of the 1950s and 1960s. Those movements made us all more sensitive to the intricate network of overt and covert political, social, and moral processes that offend h u m a n dignity and constrain h u m a n freedom. Civil rights, of course, have meanings mure varied than simply the improvement of race relations. Throughout the world the mentally ill have been identified as an oppressed and mistreated group, with the growing knowledge-and insistence--that the mentally ill have rights far beyond those they had been accorded for so many years. In the context of a restless, changing world, the question before us is, "Why do mental health services remain important?" Traditional answers would clearly focus on the scientific advances in diagnosis and treatment. Administrators and program leaders responsible for research programs as well as services have developed the ability not only to describe clearly the art Dr. Brown was Director of the National Institute of Mental Health a t the time this article was prepared. On J a n u a r y 3, 1978, h e was appointed Senior Assistant Surgeon General, U.S. Public H e a l t h Service, and is currently on assignment at the Woodrow Wilson International Center for Scholars in Washington, D.C. 192 0022-4197/78/0700-0192$00.95
Institutes of Religio~and Health
Psychiatry in a Restless World
of basic research but also to translate its implications into clinical application. No matter that science often moves slowly; the appetites of both advocates and adversaries are insatiable for the most recent word on the latest advances. But science and technology are not the complete answer to the question. They are necessary b u t not sufficient. There are other more subtle reasons why mental health services remain important. While the subtlety m a y be lost in the budget hearing room and gets little play in the headlines, it is nevertheless present and fundamental to all else that we do. What I am referring to can be described as the moral dimension of mental health services--the values that underpin our efforts. Values permeate our lives, from the dealings of nation with nation through the interpersonal relationships between the members of families as well as between individuals. Among these values we can count many that have more or less importance in our lives--religion, race, sex, politics, occupation, economic status, and on and on. An individual m a y accord primacy to the values associated with any number of personal or institutional identities in his or her life. Ultimately, however, a common thread must link them all, lest our lives as well as our institutions become chaotic, our goals fragmented. Against this line of reasoning, I suggest that mental health services remain important because of a specific humanitarian value that is widely shared by all mankind. It is a value that states that society is measured by the manner in which it treats and responds to its most unfortunate members. This value is often used for a specific condition, symptom, or group: the mentally retarded, the aged, the ill, prisoners, and so forth. My point is that the system that serves the largest collection of this diverse, oppressed, and needful group is mental health. Mental health services, through the roles we have assigned them in contemporary society, increasingly represent the court of last resort for the poor, the ill, the underprivileged, and the disenfranchised. In this changing and restless world, how adequately is the moral dynamic of the mental health effort expressed, and how can it be measured?
A tripartite view of scientific decision making and moral measurement The contributing factors to this moral m e a s u r e m e n t of mental health are science, politics, and values--all equally weighted. The interrelationships of the three have not always been clear. I would like to share briefly some personal experiences that serve as the base for the concepts and ideas presented in this paper. For many years I was appropriately occupied with the relation between science and values. In medical school I was most concerned with the conflicting values that emphasized the individual on the one hand, and doing the greatest good for the greatest number on the other. This value conflict continues to confuse the field of mental health. My own solution was to take formal training in psychiatry and public health. While I was still in medical school, I prepared a paper in which I attempted
Journal of Religion and Health
to address this issue in a practical way, focusing on the biological, psychological, and sociocultural needs of the mentally retarded. Through circumstance, that paper came to the attention of the Kennedy family and ultimately served as the mechanism through which I came to work in the White House in 1960 under President Kennedy as an assistant for mental retardation. It was in the White House that I was introduced to the realities of a second critical d i a d - - t h a t of science and politics. The interplay of this diad was most visible in the annual budget review, then a new experience for me. The director of the budget office requested that a subject be presented to him in two parts: first, the merits of the issue, the scientific substance, and, second, the politics of the issue. During those years and later, in the mid-1960s, when I started working with the National Institute of Mental Health and was involved in setting up the community mental health center program, I became more appreciative of a third crucial diad--politics and values. The skepticism that we see today in the motives and the promise of the political process was not prevalent then. There was a mood in our country and throughout the world that has been described as a "revolution of rising expectation." The revolution was popular, but its keenest leaders were our political representatives in the executive branch, the Congress, and the courts. Sights were set on social goals, and the political process provided the vehicle, its values the fuel. It was also during those years of rising expectation and early achievements that I learned in a practical sense that the three factors I have described are tightly interwoven and must be utilized simultaneously and at the same levels of significance. Specifically, I realized that mechanisms and systems for dealing with ethics and values issues must be brought into the traditional institutional diad of science and politics that I was familiar with. I held to this view of a tripartite decision-making structure through the subsequent revolution of falling expectations, when social turmoil wrested our sights from the grand goals we had set for ourselves. I became convinced when I saw the chaotic anomie that follows from the discongruity between our deepest held values and our science and our politics. My conviction seems finally to have brought me full circle. A paper I recently prepared on this particular subject came to the attention of another Kennedysponsored activity--the Center for Bioethics of the Joseph and Rose Kennedy Institute for the Study of H u m a n Reproduction and Bioethics, in Washington. The Center is also interested in the tripolar system I have described. In the words of Sargent Shriver, chairman of the Institute's international advisory board, the Institute is concerned with the interrelationships of the '~Gown," that is, the academic, university complex and all that implies; the ~'Bench," or the sciences represented in the National Institutes of Health; and the "Hill," meaning the political powers and processes of both the executive and legislative parts of our government. The development of new institutional forms where the philosopher and ethicist work in productive partnership with the scientist and the politician is a major challenge of our times.
P s y c h i a t r y in a Restless W o r l d
The challenge suggests two associations: one a famous nursery rhyme undoubtedly stemming from what the psychoanalysts would call primary process, the Kraepelinian Clang association. Rub-a-dub-dub, Three men in a tub. They must stay together If things will get better, But the creation of this new institutional form, this social instrument, reminds one of the difficulty of crafting a violin. Those who would create it must put themselves in the place of Stradivarius, for the creation of a great violin is a marvel. The master makers knew how it would sound but never lived to hear it, since the violin did not reach its peak and power until it h a d aged several hundred years. We must create a new social instrument now to deal with the issues two and three centuries into the future.
The politics of panic and the scientific revolution The need for this new tripolar view--the need for the creation of a new threestringed social instrument--stems from a number of events; dominant among them are the scientific revolution and the rate of social change. Also relevant are the economics of maintaining a health research/delivery program, urgent social and political causes, and the need to determine who, most appropriately, should participate in health/science decisions. Consider first the economics of a national mental health program. Psychiatric research and the delivery of mental health services by trained professionals are an expensive proposition. As our knowledge base continues to expand, the scientific issues become more subtle and the approaches to answering them more complex. Thus we see schizophrenia fruitfully studied through such a large-scale effort as the NIMH-World Health Organization nine-nation collaborative project. In the United States, in the summer of 1977, the NIMH initiated the second phase of a major collaborative project on depression. This is a multi-pronged effort involving the participation of nearly a dozen major research centers. The first phase dealt with biological underpinnings of the disorder; this newest effort focuses down on clinical and psychosocial aspects of depression. The point is that only the public sector can afford to underwrite much of the necessary research. And when research yields clinical applications, the public sector again is expected to take a lead role in facilitating utilization of the yield. But with public financing comes public responsibility and, more importantly, public voice in the direction and goals---or, in other words, the value base--of mental health research and services. This should be so; ideally, the process represents participatory politics in science at its best. On the other hand, the role and ramifications of the public's participation
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have come to be viewed by some as impinging on an area of scientific prerogative. At one end of the controversy stand the public and its representatives, who hold that their financial support of the scientific and health services efforts entitles them to direct the focus of various programs and projects. At the other end stand scientists who perceive their historical powers of selfdetermination as well as their professionalism as being undermined. Participatory politics in science easily becomes the politicizing of science, and politicized research is not always viewed by the scientific community as being in the public's best interest. Both positions are seductively correct. When health and mental health programs are implemented on a national scale, the public in the broadest sense stands to savor the benefits of those programs--and to suffer the risks, or at least the inadequacies. Then again, much ~targeted" research is mandated and conducted in response to hazily defined but immediate social needs. A public beset by an urgent problem and its political representatives who are genuinely interested in responding to that problem with the best answers possible are apt to accept the first answer feasible. Two dangers exist. The first is that research results will be translated too hastily into policy and practice without giving necessary consideration to ethics and value questions that underlie either the premise under which the policy was formulated or the population toward whom it was directed. The second danger is that in the absence of recognized and legitimate forums for weighing the concerns of science, politics, and ethics, a vocal minority may block developments that would indeed prove to be in the public good. Among the many areas of biomedical science and health care that are currently deeply affected by this complex web of issues, mental health is highly visible. The major reason derives from the dual nature of the mental health movement and its component disciplines. Within the federal biomedical system in our country, NIMH alone clearly straddles the artificial boundary that separates the biomedical/biological sphere from the behavioral sphere with its compelling links to society's problems and potentials. In the past ten years NIMH has been called upon to carry out research programs and give policy advice on controversial issues including marijuana and health, television violence and behavior, psychosurgery, and behavior modification, to mention only a few. The major reports to the Congress, to the President, and to the public have led to a careful thinking through of the components of science, politics, and values. However, the very broadness, diversity, diffuseness, and difficulty of this type of issue, which the field of mental health has been called upon to deal with, have led many leaders in the field of mental health to call for a refocusing. The field of psychiatry, particularly, has seen many of its leaders call for new priorities on major mental illnesses such as schizophrenia and depression. I can fully understand the desire of some psychiatrists to channel the profession back into the medical mainstream. The rationale is that resources are getting scarcer and the competition for them getting stiffer. Therefore, they say, we ought to focus our efforts on the discretely defined and severe mental illnesses. That rationale is sound, as far as it goes. I feel, however, that by
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doing this we would jeopardize the unique nature of our contribution, the blending of science with humanism. To focus so sharply we will become a nucleus without a cytoplasm, a ship without an ocean, a star without a sky, a body without a soul, a present without a future. I feel that our mission is not only to produce the best science but also, through our best values, to insure the political action necessary for bringing our product to individuals most in need, now and in the future.
Maintaining the moral dynamic So far I have focused orl striving toward the positive, toward realization of our best values. One final thought deals with resisting negative values that may be expressed in society. Mental health deals not only with troubled behavior b u t also with troubling behavior and deviant behavior. We are aware that we will continue to contend with misuses of the mental health system by the political system as it continues to put away people who m a y not be troubled b u t who are troubling to the political system. We must address these problems. I would conclude by proposing four tests that we ought to submit to ourselves and the field. 1. Do mental health services make the best use of the existing scientific base? I call this the quality issue, vis-a-vis our science and technology. 2. Are mental health services available to all, and are we providing a oneclass system of care? I call this the access, availability issue. 3. Do our services deal with the underlying issues of racism/poverty, malnutrition, etc., and how well do they do it? 4. Are our services misused by the political system for purposes of control and social order, rather than for the alleviation of h u m a n suffering? If we pass the test, it should be obvious that mental health services are important.
Mental health services: The shadow on the wall (conclusion) The importance of the tripolar structure now becomes clearer. Through our active involvement in the decisions involving science, ethics, and politics, we as scientists and as citizens stand to gain a deeper understanding of the political process. This understanding is crucial, because mental health continues to serve the broadest arena of society's oppressed: victims of racism, poverty, sexism, colonialism, and other social inequalities. Mental health services become the operational a r m by which we measure how successfully we have expended the resources made available to us through the political process. Let me put it another way, by borrowing from Plato's analogy of the cave: Mental health services are the shadow on the wall that is cast by the light of the moral dynamic, the values, generated in the tripolar forum.
We have presented the mental health service system as the practical real-
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life measuring rod of our morality and humanity. Is it not enough that the overburdened system must in theory care for the seriously ill--the psychotic--deal with disturbing and disabling behavior and feelings? Is it fair, just, correct to burden further the mental health service system with a new and awesome task of moral judge? Yes. It is the very nature of the function of the mental health system dealing with the casualties of biological determinism and rapid social change, dealing essentially with disturbed and disturbing behavior, that makes the mental health service system the moral measuring red. It is important because it spans the range from basic science to human misery. Mental health is a worldwide social movement that starts from the dire necessity of dealing with the mentally ill and aspiring clearly toward the highest quality of life. As long as society does continue to care for its least fortunate, mental health services will remain not only important but also a measure of how well we carry out that vital function that measures our humanity.
This article deals with the critical history of German and Japanese psychiatrists who dreamed of a 'German world' that would cross borders. It analyses their discourse, not only by looking at their biographical backgrounds, but also by examining them
In the present work, we investigate the hypothesis that failures of task-related executive control that occur during episodes of mind wandering are associated with an increase in extraneous movements (fidgeting). In 2 studies, we assessed mind wander
This paper examines the relationship between 'world citizenship' and the new psychiatric research paradigm established by the World Health Organization in the early post-World War II period. Endorsing the humanitarian ideological concept of 'world ci
The 100th anniversary of the outbreak of World War 1 could be viewed as a tempting opportunity to acknowledge the origins of military psychiatry and the start of a journey from psychological ignorance to enlightenment. However, the psychiatric legacy
Polish psychiatry was since its origin deeply influenced by German (Austrian) and Russian psychiatry. After the German assault Polish psychiatric patients were the first victims of mass executions, and the first to be killed by new developed "gassing