THE
AMERICAN
JOURNAL
OF
PSYCHIATRY
The Life of Psychiatry BY BERTRAM
S. BROWN.
M.D.
Focusing on the definition, scope, androle of psychiatry today, the author discusses whether psychiatry is primarily medical, whether it is overstepping its boundaries in attempting to treat problems ofliving, and whether it is too involved with social questions. On the basis ofan examination of the current scientific base ofpsvchiatrv he predicts that psychiatry t’ill continue to grow in size and diversity, that it will refocus substantial/v on biological issues, that it will become more humble about what it can do with regard to social problems, and that it will continue to yield new therapeutic measures and techniques. ,
PERSPECTIVE on the life of psychiatry is both personal and professional, drawing on both my evolving self-concept as a psychiatrist and my role as director of the National Institute of Mental Health. Although I will focus on psychiatry. many of my comments apply to the broad field of mental health. To write a truly comprehensive and current paper on this field is difficult. Therefore. I will discuss briefly or omit several important areas, such as the potential impact of national health insurance, the role of Professional Standards Review Organizations (PSROs), the new health planning legislation (Public Law 93-641). and other critical areas. Rather. I will attempt to focus on some of the potentials and limits of psychiatry at a time when the resiliency of the profession is being tested by calls for both expansion and contraction. The simple fact that many of these calls originate within the profession will make the proof of the test all the more crucial. THIS
Revised version the American 1975.
of a paper Psychiatric
presented Association.
Dr. Brown is Director. National Drug Abuse, and Mental Health Rockville. Md. 20852.
at the 128th Anaheim,
annual Calif..
meeting of May 5-9.
Institute of Mental Health. Alcohol. Administration. 5600 Fishers Lane. This
I would like to highlight a particular evolution that has taken place. Twenty-five years ago, when our predecessors spoke of psychiatry they were also speaking of the broader field of mental health. What they and their coniemporaries termed “mental health” some leaders today term ‘human services. Many of these leaders are psychiatrists, but the issue of how much psychiatry represents mental health and how much mental health represents human services is at the heart of the great debate concerning the role, definition, scope, and boundaries of psychiatry. The same issue applies to NIMH. There is a “strict constructionist” view of the mission of NIMH that emphasizes health sciences; there is also a broad view that emphasizes human services and other social missions. What is the role of psychiatry? Does it even have a role, or is it, as some would have it, dead or dying? Is it perhaps gathering strength? What is the nature of its identity crisis? What are its prospects? ‘
COMPARISONS
WITH
‘ ‘
GENERAL
MEDICINE
Measured by the sheer number of practitioners,’ psychiatry has had an astonishing growth since 1939. In that year there were about 3,000 psychiatrists (2.3 per 100,000 of the population of the United States). Most of them were called “alienists.” In 1948, when NIMH was founded, there were 4,700. In 1950 there were 7,100 (4.7 per 100,000). By 1960 this number had almost doubled to 14,000 (7.7 per 100,000). During the decade of the 1960s the number of psychiatrists increased by 65% to 23,200 in 1970 (11.3 per 100,000). Today there are 27,000 psychiatrists in the United
‘Data on the number of psychiatrists before 1960 were compiled from records on APA membership and filled psychiatric residencies. Data on psychiatrists and other physicians for 1960 to 1973 are based on Distribution of Physicians in the United States (1). 1 have estimated the projection (or 1980, taking into consideration the number, production. and attrition of practicing psychiatrists today.
Ons
Am
J Psychiatry
133:5,
May
1976
489
THE
LIFE
OF
PSYCHIATRY
States.2 Estimating according to the number of potential psychiatrists in the educational system now, there will be 30.000 by 1980 (17.8 per 100,000). Thus the number of psychiatrists has increased by 16% in the past 5 years and 45% in the past 10 years. Since the founding of NIMH it has increased more than fivefold. How does this compare with general medicine? In the decade from 1963 to 1973 the total number of nonpsychiatrist physicians increased by 81,422, from 259,894 in 1963 to 341,316 in 1973, an increase of 31.3%. During the same decade the number of psychiatrists increased by 8,482, from 16,581 to 25,063, an increase of 51.2%. Additionally, the proportion of psychiatrists in the total number of physicians increased by 0.8%, from 6.0% to 6.8%. A comparison with other specialty groups shows that psychiatry’s growth during 1963 through 1973 was the third largest. It was surpassed only by internal medicine, which increased by 2.7%, and by radiology, which increased by 1%. However, the number of psychiatric residents in the United States today has reached a plateau. According to data from APA and the American Medical Association (AMA), the number ofresidents in training in 1972 was 4,699, in 1973 it was 4,739, and in 1974 it was 4,802. Approximately I ,000 American medical school graduates were in the first year of psychiatric residency in September 1972, representing 10.5% of the graduating class. In September 1974, there were again about 1,000 graduates who were in the first year of psychiatric residency. However, these residents represented only about 8.9% of a larger graduating class. Although the number remained approximately the same, the proportion of medical school graduates entering psychiatric residency dropped by approximately 15% between 1972 and 1974. One feature of medicine in general that applies dramatically to the statistics on the number of psychiatrists is the role of foreign medical graduates. According to data from APA and AMA, foreign medical graduates constituted 32% of all psychiatric residents in 1974. They now comprise more than 50% of the psychiatrists in practice in many state institutions; in a few states their proportion in these hospitals nears 100%. Activities in Congress, in the states, and in professional organizations that may limit the immigration or the ability to practice of foreign medical graduates will have an immediate and severe impact on patient care. The issue of the willingness of other psychiatrists to work in state institutions will stand out clearly if foreign medical graduates are excluded from these jobs. About 1,500 psychiatrists in the United States complete their residency training each year, and about 850
2Although there are no hard data on the number of psychiatrists in the world today, information from the World Health Organization and the World Psychiatric Association indicate that the figure is between 75,000 and 100.000. Thus the United States has between onequarter and one-third of the world’s psychiatrists.
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1976
leave active practice. Thus about 750 psychiatrists are annually added to the national total. It is generally estimated (2) that about halfofall psychiatrists active today are in general psychiatry, 13% deal with adults, 10.5% specialize in psychoanalysis, and just over 9% are in child psychiatry. Somewhat more than 4% work in community or social psychiatry, and only 0.5% report specializing in geriatric psychiatry. Another aspect of these numbers and proportions is extremely interesting. A 1972 NIMH survey of psychiatrists (3) showed that the percentages of psychiatrists from minority groups were relatively small-1.4% were black, 1 .5% were Spanish-American, and 1.3% were from other minority groups. Although earlier figures are not readily available for comparison, the proportion of minority psychiatrists is apparently growing, albeit slowly. For yet another perspective on the issue of numbers, consider the distribution of psychiatrists per 100,000 population in this country (2). Eleven states, including South Dakota, Wyoming, and Alabama, haie less than 5 psychiatrists for every 100,000 people. Twenty states, including Alaska, Maine, Minnesota, and Virginia, have more than 5 but less than 8 psychiatrists per 100,000. In 8 states the ratio is at least 12 psychiatrists per 100,000. New York State has 25, Massachusetts has 22, Connecticut has 20, Maryland has 19, Vermont and California have 17 each, Colorado has 15, and Hawaii has 13. The average number of psychiatrists per 100,000 population for the entire United States is 11.9. The District of Columbia stands head and shoulders above the other states in terms of number of psychiatrists. Its ratio is 58 psychiatrists per 100,000 peoplemore than double that of New York State and more than quadruple the average. The numbers do not include the more than 2,200 psychiatrists who work for the federal government in the District of Columbia. The wide variation in number of psychiatrists per 100,000 people among the states is important. The figures range from 5 to more than 50; i.e., one state has more than 10 times as many psychiatrists per 100,000 people as another. When rural areas are distinguished from metropolitan areas and those in between in each state, one finds that some areas have 20 to 30 times as many psychiatrists per 100,000 people as other areas. These ranges underlie the issues pressing at health and mental health manpower legislation. The term now most commonly used to describe this situation is “maldistribution.”
PSYCHIATRIC
TRAINING
The recent policy shifts in psychiatric training have been among the most dramatic in the history of all professional training. Several years ago the various professional associations engaged in vigorous debate over the requirement of a medical internship for medical
BERTRAM
school graduates planning to enter psychiatry. Two polarities of opinion emerged. One group held that dropping the internship would be a dreadful mistake, and the other felt that most of a medical internship was irrelevant to psychiatric practice and should be dropped. The latter position ultimately won, and the American Board of Psychiatry and Neurology dropped the internship requirement. During the next year or so we will undoubtedly see a reversal of this policy and a reinstitution of the internship or an internship-like experience as either a prerequisite to or the initial part of psychiatric residency training. It is important to note that the experience of caring for a variety of patients with serious physical illnesses rather than the loss ofa year called an “internship” has been the missing ingredient. In a practical sense, the movement of psychiatry back into the health arena is more than a conceptual issue. It is a descriptive issue on the current educational scene. Along with the increase in the number of psychiatrists there has been an increase in the number of residency programs (4). There were 270 residency programs in the United States in 1973, representing positions for4,992 residents; 4,131 ofthese positions (86%) were filled. The residency programs ranged from those which were highly clinically oriented to those which worked with chronic patients in state institutions to those which were psychodynamically oriented university programs. Moreover, these programs of psychiatric training and education were not limited to psychiatrists. Training in psychiatry and behavioral sciences has been provided to nonpsychiatric physicians, particularly those providing primary care, and to other mental health professionals. Of even greater importance is the provision of psychiatric, behavioral, and social science training for medical students. Every medical school now has a department of psychiatry. In the future, programs in psychiatry and behavioral and social sciences will be provided and emphasized in all of the stages in the education of medical students.
THE
PATIENT
S.
BROWN
U.S. population) had some contact with the mental health care system (5). By the mid-1960s this number had increased to 2.6 million (1 .4% of the population). Our most recent figure (for 1971) is more than 4 million (2.4% of the population). These figures represent all patient care episodes and include some duplication. A conservative estimate for 1975 would be 5 million to 6 million people in contact with the mental health care system. The diagnostic categories of those who were receiving some kind of treatment in 1971 (6) included schizoph%renia (22.5%), depressive disorder (15.4%), alcohol disorder (8.8%), organic brain syndrome (5.4%), mental retardation (3.1%), drug disorder (2.9%), and psychosis other than schizophrenia and depression (1.5%). All other diagnoses totaled 32.4%, and 8% of the patients were undiagnosed (see figure 1). The national utilization rate, the percentage of the population that in a given year comes to the attention of the formal mental health care system, was about 2% or 2.5% in 1971 (5). These contacts may be as brief as 10 minutes in the emergency room of a hospital or as long as the entire year in an inpatient unit. The range of utilization rates in different parts of the United States is somewhat similar to the distribution of psychiatrists. The utilization rate in rural parts of
FIGURE 1 Distribution of Diagnoses of More Than 4 Million Patients Contact with the Mental Health Care System in 1971 (6)
Who Had
POPULATION
The heart and the end point of the issues of scope and definition are in psychiatry’s interaction with patients and other people. The context of the following patient population statistics is traditional, including the services of state and Veterans Administration hospitals, outpatient clinics, and community mental health centers. The numbers of patients are somewhat understated because they do not include those seen by psychiatrists in private practice and by other mental health professionals. Also not included are family service agencies or what I call “fringe groups,” the plethora of sensitivity training groups, experimental programs, and other encounter sessions and seminars. In 1955, about 1.7 million people (1% of the total
1:
Schizophrenia
(22.5%)
2:
Depressive
3:
Alcohol
disorder
4:
Undiagnosed
disorder
5:
Organic
syndrome
disorder
brain
(15.4%)
(8.8%)
Am
6:
Mental
7:
Drug disorder
8:
Psychosis
(8.0%) (5.4#{176}/o)
J Psychiatry
retardation
9:
All other
133:5,
(2.9%)
other
or depression
than schizophrenia
(1.5%)
disorders
May
(3. 1 %)
(32.4%)
1976
491
THE
LIFE
OF
PSYCHIATRY
the
country, which have about 5 psychiatrists per people, is 0.5% to 0.75%. The utilization rate of such urban areas as San Mateo County, midtown Manhattan, and the suburbs of Washington, D.C., is about 7% or 8%. This disparity is behind the demands ofboth liberals and conservatives to improve access to mental health care and to meet the criterion of equity. Looking at this situation most conservatively, i.e., projecting a 1% increase in the national utilization rate, continued support for training at no less than the present level, and no fewer entrants into the profession, we can predict a shortage ofnearly 10,000 psychiatrists by 1981. The forces behind the increased utilization rates are related to the purchasing power that is now available through third-party financing. The rates will increase even more with the passage of some form of national health insurance in the near future. They are also related to the fact that seeking psychiatric assistance has less of a stigma attached to it today. 100,000
theory, he concentrates on an office practice; although he may hospitalize his patients occasionally, he usually transfers patients needing hospitalization to a colleague. The frequency ofthis type ofpsychiatrist is 1evcling off. The psychoanalyst, type 3, has taken full psychoanalytic training and practices psychoanalysis predominantly. He may have 5 to 15 patients and may allocate a small proportion of his time to consultation or other outside activities. Because this type of psychiatrist was dominant, from 1945 to 1955 it was nearly impossible for a nonpsychoanalyst to become chairman of a department or professor of psychiatry. Today the number of psychoanalysts is dwindling, and an exclusively psychoanalytic psychiatrist is rarely found at the head of a department of psychiatry. Type 4, the biological psychiatrist, includes some of the brightest young people in the country. Skilled in the psychobiological sciences, this cadre is changing the profession as a whole and influencing society. My type 5 is the child psychiatrist. Many child psychiatrists
A LOOK
AT
THE
PROFESSION
I want to emphasize that there are different types of psychiatrists, that their training experiences are diverse, and that the types of patients they see are also diverse. This is another reflection of the issues of scope, definition, and role. I believe that psychiatry faces less danger from adversity than it does from diversity. Although diversity is a danger, it is much more a sign of growth and cxperimentation, a developmental process that relates clearly to the history of our evolving specialty and the state of our scientific knowledge. A healthy and sound aspect of diversity is that it results in a focusing and narrowing of our skills.Each type of psychiatry may treat the very persons who need and benefit from that special focus of experience and approach. The following seven types of psychiatrists comprise a loose, non-mutually-exclusive typology: Type 1, the neuropsychiatrist, is rapidly becoming a vanishing breed. This is the pragmatic clinical practitioner who is as comfortable with neurology as with psychiatry. His patients range from the simply troubled to the severely ill, and he may see patients for brief counseling or hospitalize them. He may use convulsive therapy; he may prescribe drugs. I recently checked on the number of people who took Board examinations in both neurology and psychiatry in 1973 and 1974. According to data from APA, several hundred took one or the other and passed; the number who took both in 1974 can be counted on one hand. Two or three decades ago, however, the majority of psychiatrists took both examinations. My type 2 psychiatrist-the psychodynamically oriented psychotherapist-seemed on the path to dominance only a short time ago. This psychiatrist may see patients one to three times a week over a period of 6 months to 2 years or more. Steeped in psychoanalytic
492
Am
J Psychiatry
133:5,
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1976
were
pediatricians
before
turning
to psychia-
try. The growth of child psychiatry as a specialty has been phenomenal. According to data from AMA, there were 751 child psychiatrists in the United States in 1963; in 1973 there were 2,362. This represents a growth rate of 200%. General psychiatry’s growth rate was
46%
during
the
same
period.
I would classify type 6 as the social psychiatristthe program administrator or the director of a mental health center or a new alcoholism or drug abuse endeavor. His work is at the interface of troubled behavior
and
social
Finally, tal”
systems.
there
or “fringe”
is type
7, which
group.
This
I call the “experimen-
psychiatrist
uses
a variety
of techniques and is often found in unusual places doing unusual things. This is a critically important group because when the fads filter out and the charlatans and phonies take their leave, type 7 promises to be the wave of the future. If we look carefully at the history
been that
erally
KEY
The
of psychiatry
elements have
we
in the
had
more
recognized
find
fringe
influence
that
and
there
have
experimental
ultimately
than
always
groups was
gen-
at the time.
ISSUES
major
the definition, cal subissues
issues
I have focused on have to do with scope, and role of psychiatry. The critiare whether psychiatry is primarily medi-
cal and therefore concerned with taking care of the seriously clinically sick, whether psychiatry is overdoing its task in attempting to treat those with transient or less severe clinical problems, and whether psychiatry is too involved in social questions. Thus the issues center around three categories of people-the very sick and psychotic patients, those who are greatly handicapped by emotional and psychological disturbances, and those who are experiencing
BERTRAM
problems of living, for whom the desired quality of life has proved elusive. It is around these groups that the tensions in our field are being generated; two points of view seem to predominate. There are those who believe that psychiatry has clearly bitten off more than it can chew and ought to get back to treating serious mental illness, and there are those who feel that unless we work to change social systems we shall inevitably have a continuing flow of sick and troubled people. I realize that people at both ends of this spectrum are keenly aware that the intermediate zone is one of great diagnostic difficulty. It takes skill and knowledge to ascertain what might be a life problem and what might be the earliest signs of an oncoming depression or other mental illness. Such diagnostic requirements demand that we take an extensive look at our clinical and scientific base and what we do or do not know about prevention.
THE
SCIENTIFIC
BASE
It is one thing to have a value base for what we think we should do, but it is quite another to have a scientific base-an objective set of measures about whether what we do is effectively achieving what we set out to do. Psychiatry has been a major service-providing instrument of that vital and nourishing enterprise we call mental health research. Psychiatry has played a significant but smaller role in the actual conduct of research. Only a few psychiatrists-numbering in the hundreds-are full-time researchers. This is a vital area ofdebate as we deliberate over the nature of financial support policies in research in general and psychiatry in particular. In their roles as conceptual, clinical, and program leaders, psychiatrists have played a leading role in stimulating and supporting research endeavors by other mental health professionals and behavioral and social scientists. At NIMH we have just finished a 2-year effort by a research task force that involved 300 people and $1 million to review $1 billion worth of research in the United States supported by NIMH and others. The report (7) shows that the number of research projects supported annually by NIMH has grown from 38 in 1948, when the first appropriations were made under the National Mental Health Act of 1946, to nearly 1,500 in 1975. About 30% of the total NIMH research budget has been devoted to research in the biomedical and behavioral sciences, including studies designed to identify physiological, psychological, social, and cultural factors that shape human behavior. Out of this effort has emerged work of enormous relevance, not only for enlarging our understanding of human behavior but for productive clinical research as well. The task force report will vitalize debates now under way as to the nature and scope of the psychiatric research enterprise, including such issues as balance and priorities. To some degree, these are but other ways of
5.
BROWN
looking at the scope and definition of psychiatry itself. A brief example will suffice: over the last 20 years we have seen the ratio of the amount of NIMH-supported biomedical research to psychosocial research reversed; 20 years ago the ratio ofbiomedical research to psychosocial research was 2 to I ; in 1975 it was I to 2. This dramatic shift reflects the broadening of NIMH’s mission in the late l960s into social problem areas such as crime and delinquency. Within the mental illness sphere of the NIMH program, biomedically oriented research continues to be predominant but with an increasingly fine line ofdistinction between the two approches. The Subjective
Approach
One of the ways I have approached chiatry’s scientific base is to return Forexample, when I really wonderabout wisdom of my opinion or judgment tion, I ask what I want for myself, my my parents. Some of the answers me follow:
the issue of psyto the subjective. the depth and on a given situawife, my children, that emerged for
1 I would much rather have a mid-life depression today than 20 years ago (assuming my present age both now and then) because of the current advances in the treatment of depression and acute depression, the understanding of its biology, and the availability of drugs. .
2. I think I would rather one of my children have an acute schizophrenic break now than 20 years ago. I will not go farther because I know the complexities surrounding schizophrenia, and I do not say this with quite the certainty that I use in discussing mid-life depression. However, I think we have made enough advances in the treatment of acute schizophrenia that the scientific base is ahead of that of 20 years ago. 3. Suppose my marriage were in serious trouble, with agony, misery, sleeplessness, concern, trouble with the children, and job trouble. Would I be any better off being treated by a psychiatrist today than I would have 20 years ago? I think not. The best possible source for help for me in this situation would be a mature, wise psychiatrist. There has been an increment of knowledge in the area of marital and family therapy, but that increment is small compared with what is known or needs to be known. The critical variable today is the same as it was 20 years ago-the maturity and wisdom of the helping person. The research task force (7) found that research investments in the area of helping the practitioner deal with troubled people have not yielded a cornucopia of techniques or programs. To realize our hopes and expectations in this area we must reassess what we have been doing, decide what we have been doing incorrectly’ and ascertain what we can do better. The relatively low yield in social research may be due to many factors. It may be that we are just now Am
J Psychiatry
133:5,
May
1976
493
THE
LIFE
OF
PSYCHIATRY
building the base in the next decade
It may
be that
swers
in the
in this complex field or so may provide
the methodologies area
of
social
What
so that workers useful answers.
necessary problems
to get an-
are
so
complex
that we have yet to develop effective tools. There are those who would have us abandon this area altogether. This I cannot support. To do it better-perhaps even to make use of some of the resources from more promising
areas-makes
both
unprofessional
A Look
sense,
and
but
to
do
nothing
seems
unwise.
at Possibilities
Let me now move from my subjective position to a more general frame of reference: I My answer to the question of whether psychiatry .
is up to the
and
task
whether
ically, fectly,
of dealing with serious mental illness the job has to be yes. EmphatI must add that we are not doing it perwe doing enough ofit, given our knowl-
it is doing
however, nor are
edge base. In spite of our advances in knowledge and the addition of chemotherapy to our armamentarium, we must still wait for research to uncover some basic unknowns. Even so, we could do it better if we made the best use of what we know now, particularly about community treatment and care. 2. My answer to whether psychiatry is dealing effectively with that 5% or 10% ofthe population who are not psychotic but who are very troubled, whose functioning is disturbed, or who are on the verge of becoming disturbed also has to be yes. However, I must add that the gains gains
in this
in the
ophrenia 3.
best
been
area
answer
regarding
ated, years
have
and psychotic
My
base
area
biological
was
psychiatry’s
ofthe
and the troubled has is that it has increased
economic then,
ask
perhaps more
for
scientific
unhappy,
increased in very little.
the alienthe
past
20
are
these
those who lost their jobs in of course, with unemploysocial benefits, the outlook
is considerably people
better
better
what psychiatry has to offer? Many more people who develop toms
the
schiz-
are people who have been laid off from
recovery but
than
against
depression.
work better off today than the 1930s? In one sense, ment insurance and other
for
significant
struggle
to whether
the treatment
For example,
less
in the
help
today
than
off
than
in terms
troubling
asked
for
it of
symp-
it in the
1930s,
for no other reason than that it is so much
available.
However,
knowledge has ability to care
only
a minimal
accumulated-beyond for the mentally
or
amount
of
our increased emotionally dis-
abled-to strengthen our capacity for dealing with the unemployment problem as it affects the emotional well-being of the individual. When it comes to the question of whether psychiatry should treat people with problems of living, one of the most powerful dynamics is the great influence of the dollar. If the troubled are willing to pay, and the psychiatrist is willing to accept, the question becomes
moot. 494
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J Psychiatry
133:5.
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1976
Lies
Ahead?
On the basis of the research task force report (7) and the knowledge my colleagues and others in the field have gained, I predict in complete confidence that psychiatry There
will continue is no sign
growth
in the size
to grow in size at present that
of psychiatry
its services ing in size,
is decreasing. that is having
on
that
it, and
grams, niques
types is not
has
Any more
such
or that
the demand
profession and more
a diversity
of practitioners, a dying profession.
and diversity. there is a lack
and
of
for
that is growdemands put
in training therapeutic
protech-
By reason of the nature of psychiatry’s scientific base and its cultural connection to medicine, I also predict that the profession will refocus to a significant cxtent on clinical-and particularly biological-psychiatry,
that
it will
become
more
humble
about
what
it can
do in regard to social problems and issues, and that it will continue to yield new experimental therapeutic measures and techniques. Most ofthese will fall by the wayside, but a few should lead to more effective treatment. For the rest of this century and probably well into the next, treating the hard core of mental illness-the schizophrenias and the depressions-and dealing with troubled behavior that is or threatens to become incapacitating will continue to be vital activities in the thriving
profession
of psychiatry.
The psychiatrist will continue to be called on to help with problems of living that are less serious but more widespread. However, so will the psychologist, the social worker, the psychiatric nurse, the educator, the clinical sociologist, the clergyman, and others who for years have been working in this area. In other words, psychiatry can expect to find itself in collegial competition with other professions and, perhaps, with paraprofessionals in the treatment of people whose problems in living are not associated with serious clinical illness. From the standpoint of the patient, or the client, there may be two strong reasons for going to a skilled problems-of-living psychiatrist rather than to another mental health professional. One is to enjoy whatever protection can be assumed to lie in the M.D. the ethics and the traditions associated with for thousands of years. The other is to benefit greater diagnostic acumen that the psychiatrist
degreemedicine from the has, or
should have, in case of an underlying biological condition requiring attention. When there is no such condition, the wise pastoral counselor, the humanistic psychologist, and the warmhearted psychiatrist may be equally effective; the results depend more on the quality and less on the type of training of the human beings who serve as therapists or counselors. In the final analysis, the patient, the consumer, will make the final judgment. In 1949 I had the privilege of hearing David Wechsicr, who developed the Wechsler Adult Intelligence Scale, give a lecture on the future of psychology. He
BERTRAM
discussed gists
tance would ciation
the then
could
do
red-hot
issue
psychotherapy.
of psychiatrists. not be settled meeting
of whether He
the
or at an American
but the
most
although
Psychological
‘in the American question of who relatively
as in
pro-
this
Asso-
marketplace.” will deal with
‘
minor,
ofour
the men-
tal health problems will be decided in the marketplace. Ifthe nonmedical worker proves as acceptable and efficacious as the physician as well as less expensive, psychiatry can be expected to play less ofa role in treating the so-called problems ofliving. In the treatment of serious mental illness, however, psychiatry is likely to remain dominant.
CONCLUSIONS
Psychiatry
is growing
relation
to general
duction
point
expect 1980s.
of view
psychiatry
Psychiatry
in size,
medicine. will
is growing
it has
continue
absolutely
as well
Although passed
from
its
peak
to grow
in diversity.
Parts
into
the
of the
paper
to be
as accountable
I can,
cism.
There
pro-
place, but we must realize er; the fight is on behalf
we are not battling each othof the mentally ill and in the
pursuit
all.
fession are returning to basic biological and medical foundations; parts are undistinguishable in practice from other mental health professions; parts are under attack, and the outcome is unclear-particularly in social psychiatry. A critical area is the future of child psychiatry-or general psychiatry’s role in dealing with families and children. Psychiatry is undergoing severe criticism from within and without, but the demand for psychiatric services has shown no concomitant diminution and none is in sight. In my opinion the test of the marketplace, both in the quality of the product and people’s willingness to pay, is such that it would be unwise to limit psychiatry’s services only to the mentally ill, although its responsibility and strength in this area are clear. It would be unwise and grandiose for psychiatry to claim a monopoly on treating the unhappinesses of the human condition, but it will be a challenge to see if the profession is worth its higher fees in this area. The interface between psychiatry and social systems is an area in which psychiatry has in some ways overpromised. This interface is the site of hope for in-
battles
to be won
of happiness
for
dissent
my
mid-
are
to welcome
to state
and
I
to continue
as
view,
growth,
the
BROWN
tegrating prevention efforts with social concerns, for integrating scientific knowledge with humanistic concerns, and, in my opinion, it is a proper domain of psychiatry. Finally, let me describe a more personal conclusion. I have been practicing something that has been loosely called “political psychiatry.” Without bombast, this concerns my having been an administrator dealing with executive, legislative,judicial, and other affairsserving as deputy director or director of NIMH for a decade. I think the issue of my accountability within these affairs should be brought out. I have pondered over the fact that two of the groups now under the most severe attack from the public are politicians and psychiatrists. I think what these two groups have in common is the breakdown in trust on the part of their constituents and patients. The issue of trust is basic not only to psychiatry and developmental psychology, but also to the nature of government and governance. Thus it has been my purpose in writing
resis-
He also predicted that the issue at an American Psychiatric Asso-
ciation meeting I believe that pervasive,
psycholo-
predicted
S.
or lost
and
in the
criti-
market-
REFERENCES I
.
Roback 1973.
GA:
Distribution
Chicago,
2. Arnhoff Survey.
of Physicians
American
FN, Kumbar Washington,
Medical
in the
Association,
United
States,
1974
AH: The Nation’s Psychiatrists-1970 DC, American Psychiatric Association,
1973
3. Follow-up 1948-1968. Manpower published 4.
American dencies
5. Taube sodes
survey of NIMH-supported trainees and fellows, Rockville, Md, National Institute of Mental Health and Analytic Studies Branch, December 1973 (unreport) Medical 1974-1975.
Association: Chicago,
AMA,
Directory 1975
of
Approved
CA, Redick RW: Provisional Data on Patient in Mental Health Facilities in 1973. Statistical
Rockville,
Md,
National
Institute
of Mental
Health
Resi-
Care Note
Epi127.
Division
of
Biometry (in press) 6. Redick RW: Patient Care Episodes in Psychiatric Services, United States, 1971. Statistical Note 92. Rockville, Md, National Institute of Mental Health Division of Biometry, 1973 7. Segal J, Boomer DS, Bouthilet L (eds) Research in the Service of Mental Health: Report tional Institute of Mental
Education, NIMH,
and
Welfare
of the Research Health. US
Publication
Task Force Department
75-236.
of the Naof Health,
Rockville,
Md,
1976
495
1975
Am
J Psychiatry
133:5,
May
AMERICAN
JOURNAL
OF
PSYCHIATRY
The Life of Psychiatry BY BERTRAM
S. BROWN.
M.D.
Focusing on the definition, scope, androle of psychiatry today, the author discusses whether psychiatry is primarily medical, whether it is overstepping its boundaries in attempting to treat problems ofliving, and whether it is too involved with social questions. On the basis ofan examination of the current scientific base ofpsvchiatrv he predicts that psychiatry t’ill continue to grow in size and diversity, that it will refocus substantial/v on biological issues, that it will become more humble about what it can do with regard to social problems, and that it will continue to yield new therapeutic measures and techniques. ,
PERSPECTIVE on the life of psychiatry is both personal and professional, drawing on both my evolving self-concept as a psychiatrist and my role as director of the National Institute of Mental Health. Although I will focus on psychiatry. many of my comments apply to the broad field of mental health. To write a truly comprehensive and current paper on this field is difficult. Therefore. I will discuss briefly or omit several important areas, such as the potential impact of national health insurance, the role of Professional Standards Review Organizations (PSROs), the new health planning legislation (Public Law 93-641). and other critical areas. Rather. I will attempt to focus on some of the potentials and limits of psychiatry at a time when the resiliency of the profession is being tested by calls for both expansion and contraction. The simple fact that many of these calls originate within the profession will make the proof of the test all the more crucial. THIS
Revised version the American 1975.
of a paper Psychiatric
presented Association.
Dr. Brown is Director. National Drug Abuse, and Mental Health Rockville. Md. 20852.
at the 128th Anaheim,
annual Calif..
meeting of May 5-9.
Institute of Mental Health. Alcohol. Administration. 5600 Fishers Lane. This
I would like to highlight a particular evolution that has taken place. Twenty-five years ago, when our predecessors spoke of psychiatry they were also speaking of the broader field of mental health. What they and their coniemporaries termed “mental health” some leaders today term ‘human services. Many of these leaders are psychiatrists, but the issue of how much psychiatry represents mental health and how much mental health represents human services is at the heart of the great debate concerning the role, definition, scope, and boundaries of psychiatry. The same issue applies to NIMH. There is a “strict constructionist” view of the mission of NIMH that emphasizes health sciences; there is also a broad view that emphasizes human services and other social missions. What is the role of psychiatry? Does it even have a role, or is it, as some would have it, dead or dying? Is it perhaps gathering strength? What is the nature of its identity crisis? What are its prospects? ‘
COMPARISONS
WITH
‘ ‘
GENERAL
MEDICINE
Measured by the sheer number of practitioners,’ psychiatry has had an astonishing growth since 1939. In that year there were about 3,000 psychiatrists (2.3 per 100,000 of the population of the United States). Most of them were called “alienists.” In 1948, when NIMH was founded, there were 4,700. In 1950 there were 7,100 (4.7 per 100,000). By 1960 this number had almost doubled to 14,000 (7.7 per 100,000). During the decade of the 1960s the number of psychiatrists increased by 65% to 23,200 in 1970 (11.3 per 100,000). Today there are 27,000 psychiatrists in the United
‘Data on the number of psychiatrists before 1960 were compiled from records on APA membership and filled psychiatric residencies. Data on psychiatrists and other physicians for 1960 to 1973 are based on Distribution of Physicians in the United States (1). 1 have estimated the projection (or 1980, taking into consideration the number, production. and attrition of practicing psychiatrists today.
Ons
Am
J Psychiatry
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May
1976
489
THE
LIFE
OF
PSYCHIATRY
States.2 Estimating according to the number of potential psychiatrists in the educational system now, there will be 30.000 by 1980 (17.8 per 100,000). Thus the number of psychiatrists has increased by 16% in the past 5 years and 45% in the past 10 years. Since the founding of NIMH it has increased more than fivefold. How does this compare with general medicine? In the decade from 1963 to 1973 the total number of nonpsychiatrist physicians increased by 81,422, from 259,894 in 1963 to 341,316 in 1973, an increase of 31.3%. During the same decade the number of psychiatrists increased by 8,482, from 16,581 to 25,063, an increase of 51.2%. Additionally, the proportion of psychiatrists in the total number of physicians increased by 0.8%, from 6.0% to 6.8%. A comparison with other specialty groups shows that psychiatry’s growth during 1963 through 1973 was the third largest. It was surpassed only by internal medicine, which increased by 2.7%, and by radiology, which increased by 1%. However, the number of psychiatric residents in the United States today has reached a plateau. According to data from APA and the American Medical Association (AMA), the number ofresidents in training in 1972 was 4,699, in 1973 it was 4,739, and in 1974 it was 4,802. Approximately I ,000 American medical school graduates were in the first year of psychiatric residency in September 1972, representing 10.5% of the graduating class. In September 1974, there were again about 1,000 graduates who were in the first year of psychiatric residency. However, these residents represented only about 8.9% of a larger graduating class. Although the number remained approximately the same, the proportion of medical school graduates entering psychiatric residency dropped by approximately 15% between 1972 and 1974. One feature of medicine in general that applies dramatically to the statistics on the number of psychiatrists is the role of foreign medical graduates. According to data from APA and AMA, foreign medical graduates constituted 32% of all psychiatric residents in 1974. They now comprise more than 50% of the psychiatrists in practice in many state institutions; in a few states their proportion in these hospitals nears 100%. Activities in Congress, in the states, and in professional organizations that may limit the immigration or the ability to practice of foreign medical graduates will have an immediate and severe impact on patient care. The issue of the willingness of other psychiatrists to work in state institutions will stand out clearly if foreign medical graduates are excluded from these jobs. About 1,500 psychiatrists in the United States complete their residency training each year, and about 850
2Although there are no hard data on the number of psychiatrists in the world today, information from the World Health Organization and the World Psychiatric Association indicate that the figure is between 75,000 and 100.000. Thus the United States has between onequarter and one-third of the world’s psychiatrists.
490
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1976
leave active practice. Thus about 750 psychiatrists are annually added to the national total. It is generally estimated (2) that about halfofall psychiatrists active today are in general psychiatry, 13% deal with adults, 10.5% specialize in psychoanalysis, and just over 9% are in child psychiatry. Somewhat more than 4% work in community or social psychiatry, and only 0.5% report specializing in geriatric psychiatry. Another aspect of these numbers and proportions is extremely interesting. A 1972 NIMH survey of psychiatrists (3) showed that the percentages of psychiatrists from minority groups were relatively small-1.4% were black, 1 .5% were Spanish-American, and 1.3% were from other minority groups. Although earlier figures are not readily available for comparison, the proportion of minority psychiatrists is apparently growing, albeit slowly. For yet another perspective on the issue of numbers, consider the distribution of psychiatrists per 100,000 population in this country (2). Eleven states, including South Dakota, Wyoming, and Alabama, haie less than 5 psychiatrists for every 100,000 people. Twenty states, including Alaska, Maine, Minnesota, and Virginia, have more than 5 but less than 8 psychiatrists per 100,000. In 8 states the ratio is at least 12 psychiatrists per 100,000. New York State has 25, Massachusetts has 22, Connecticut has 20, Maryland has 19, Vermont and California have 17 each, Colorado has 15, and Hawaii has 13. The average number of psychiatrists per 100,000 population for the entire United States is 11.9. The District of Columbia stands head and shoulders above the other states in terms of number of psychiatrists. Its ratio is 58 psychiatrists per 100,000 peoplemore than double that of New York State and more than quadruple the average. The numbers do not include the more than 2,200 psychiatrists who work for the federal government in the District of Columbia. The wide variation in number of psychiatrists per 100,000 people among the states is important. The figures range from 5 to more than 50; i.e., one state has more than 10 times as many psychiatrists per 100,000 people as another. When rural areas are distinguished from metropolitan areas and those in between in each state, one finds that some areas have 20 to 30 times as many psychiatrists per 100,000 people as other areas. These ranges underlie the issues pressing at health and mental health manpower legislation. The term now most commonly used to describe this situation is “maldistribution.”
PSYCHIATRIC
TRAINING
The recent policy shifts in psychiatric training have been among the most dramatic in the history of all professional training. Several years ago the various professional associations engaged in vigorous debate over the requirement of a medical internship for medical
BERTRAM
school graduates planning to enter psychiatry. Two polarities of opinion emerged. One group held that dropping the internship would be a dreadful mistake, and the other felt that most of a medical internship was irrelevant to psychiatric practice and should be dropped. The latter position ultimately won, and the American Board of Psychiatry and Neurology dropped the internship requirement. During the next year or so we will undoubtedly see a reversal of this policy and a reinstitution of the internship or an internship-like experience as either a prerequisite to or the initial part of psychiatric residency training. It is important to note that the experience of caring for a variety of patients with serious physical illnesses rather than the loss ofa year called an “internship” has been the missing ingredient. In a practical sense, the movement of psychiatry back into the health arena is more than a conceptual issue. It is a descriptive issue on the current educational scene. Along with the increase in the number of psychiatrists there has been an increase in the number of residency programs (4). There were 270 residency programs in the United States in 1973, representing positions for4,992 residents; 4,131 ofthese positions (86%) were filled. The residency programs ranged from those which were highly clinically oriented to those which worked with chronic patients in state institutions to those which were psychodynamically oriented university programs. Moreover, these programs of psychiatric training and education were not limited to psychiatrists. Training in psychiatry and behavioral sciences has been provided to nonpsychiatric physicians, particularly those providing primary care, and to other mental health professionals. Of even greater importance is the provision of psychiatric, behavioral, and social science training for medical students. Every medical school now has a department of psychiatry. In the future, programs in psychiatry and behavioral and social sciences will be provided and emphasized in all of the stages in the education of medical students.
THE
PATIENT
S.
BROWN
U.S. population) had some contact with the mental health care system (5). By the mid-1960s this number had increased to 2.6 million (1 .4% of the population). Our most recent figure (for 1971) is more than 4 million (2.4% of the population). These figures represent all patient care episodes and include some duplication. A conservative estimate for 1975 would be 5 million to 6 million people in contact with the mental health care system. The diagnostic categories of those who were receiving some kind of treatment in 1971 (6) included schizoph%renia (22.5%), depressive disorder (15.4%), alcohol disorder (8.8%), organic brain syndrome (5.4%), mental retardation (3.1%), drug disorder (2.9%), and psychosis other than schizophrenia and depression (1.5%). All other diagnoses totaled 32.4%, and 8% of the patients were undiagnosed (see figure 1). The national utilization rate, the percentage of the population that in a given year comes to the attention of the formal mental health care system, was about 2% or 2.5% in 1971 (5). These contacts may be as brief as 10 minutes in the emergency room of a hospital or as long as the entire year in an inpatient unit. The range of utilization rates in different parts of the United States is somewhat similar to the distribution of psychiatrists. The utilization rate in rural parts of
FIGURE 1 Distribution of Diagnoses of More Than 4 Million Patients Contact with the Mental Health Care System in 1971 (6)
Who Had
POPULATION
The heart and the end point of the issues of scope and definition are in psychiatry’s interaction with patients and other people. The context of the following patient population statistics is traditional, including the services of state and Veterans Administration hospitals, outpatient clinics, and community mental health centers. The numbers of patients are somewhat understated because they do not include those seen by psychiatrists in private practice and by other mental health professionals. Also not included are family service agencies or what I call “fringe groups,” the plethora of sensitivity training groups, experimental programs, and other encounter sessions and seminars. In 1955, about 1.7 million people (1% of the total
1:
Schizophrenia
(22.5%)
2:
Depressive
3:
Alcohol
disorder
4:
Undiagnosed
disorder
5:
Organic
syndrome
disorder
brain
(15.4%)
(8.8%)
Am
6:
Mental
7:
Drug disorder
8:
Psychosis
(8.0%) (5.4#{176}/o)
J Psychiatry
retardation
9:
All other
133:5,
(2.9%)
other
or depression
than schizophrenia
(1.5%)
disorders
May
(3. 1 %)
(32.4%)
1976
491
THE
LIFE
OF
PSYCHIATRY
the
country, which have about 5 psychiatrists per people, is 0.5% to 0.75%. The utilization rate of such urban areas as San Mateo County, midtown Manhattan, and the suburbs of Washington, D.C., is about 7% or 8%. This disparity is behind the demands ofboth liberals and conservatives to improve access to mental health care and to meet the criterion of equity. Looking at this situation most conservatively, i.e., projecting a 1% increase in the national utilization rate, continued support for training at no less than the present level, and no fewer entrants into the profession, we can predict a shortage ofnearly 10,000 psychiatrists by 1981. The forces behind the increased utilization rates are related to the purchasing power that is now available through third-party financing. The rates will increase even more with the passage of some form of national health insurance in the near future. They are also related to the fact that seeking psychiatric assistance has less of a stigma attached to it today. 100,000
theory, he concentrates on an office practice; although he may hospitalize his patients occasionally, he usually transfers patients needing hospitalization to a colleague. The frequency ofthis type ofpsychiatrist is 1evcling off. The psychoanalyst, type 3, has taken full psychoanalytic training and practices psychoanalysis predominantly. He may have 5 to 15 patients and may allocate a small proportion of his time to consultation or other outside activities. Because this type of psychiatrist was dominant, from 1945 to 1955 it was nearly impossible for a nonpsychoanalyst to become chairman of a department or professor of psychiatry. Today the number of psychoanalysts is dwindling, and an exclusively psychoanalytic psychiatrist is rarely found at the head of a department of psychiatry. Type 4, the biological psychiatrist, includes some of the brightest young people in the country. Skilled in the psychobiological sciences, this cadre is changing the profession as a whole and influencing society. My type 5 is the child psychiatrist. Many child psychiatrists
A LOOK
AT
THE
PROFESSION
I want to emphasize that there are different types of psychiatrists, that their training experiences are diverse, and that the types of patients they see are also diverse. This is another reflection of the issues of scope, definition, and role. I believe that psychiatry faces less danger from adversity than it does from diversity. Although diversity is a danger, it is much more a sign of growth and cxperimentation, a developmental process that relates clearly to the history of our evolving specialty and the state of our scientific knowledge. A healthy and sound aspect of diversity is that it results in a focusing and narrowing of our skills.Each type of psychiatry may treat the very persons who need and benefit from that special focus of experience and approach. The following seven types of psychiatrists comprise a loose, non-mutually-exclusive typology: Type 1, the neuropsychiatrist, is rapidly becoming a vanishing breed. This is the pragmatic clinical practitioner who is as comfortable with neurology as with psychiatry. His patients range from the simply troubled to the severely ill, and he may see patients for brief counseling or hospitalize them. He may use convulsive therapy; he may prescribe drugs. I recently checked on the number of people who took Board examinations in both neurology and psychiatry in 1973 and 1974. According to data from APA, several hundred took one or the other and passed; the number who took both in 1974 can be counted on one hand. Two or three decades ago, however, the majority of psychiatrists took both examinations. My type 2 psychiatrist-the psychodynamically oriented psychotherapist-seemed on the path to dominance only a short time ago. This psychiatrist may see patients one to three times a week over a period of 6 months to 2 years or more. Steeped in psychoanalytic
492
Am
J Psychiatry
133:5,
May
1976
were
pediatricians
before
turning
to psychia-
try. The growth of child psychiatry as a specialty has been phenomenal. According to data from AMA, there were 751 child psychiatrists in the United States in 1963; in 1973 there were 2,362. This represents a growth rate of 200%. General psychiatry’s growth rate was
46%
during
the
same
period.
I would classify type 6 as the social psychiatristthe program administrator or the director of a mental health center or a new alcoholism or drug abuse endeavor. His work is at the interface of troubled behavior
and
social
Finally, tal”
systems.
there
or “fringe”
is type
7, which
group.
This
I call the “experimen-
psychiatrist
uses
a variety
of techniques and is often found in unusual places doing unusual things. This is a critically important group because when the fads filter out and the charlatans and phonies take their leave, type 7 promises to be the wave of the future. If we look carefully at the history
been that
erally
KEY
The
of psychiatry
elements have
we
in the
had
more
recognized
find
fringe
influence
that
and
there
have
experimental
ultimately
than
always
groups was
gen-
at the time.
ISSUES
major
the definition, cal subissues
issues
I have focused on have to do with scope, and role of psychiatry. The critiare whether psychiatry is primarily medi-
cal and therefore concerned with taking care of the seriously clinically sick, whether psychiatry is overdoing its task in attempting to treat those with transient or less severe clinical problems, and whether psychiatry is too involved in social questions. Thus the issues center around three categories of people-the very sick and psychotic patients, those who are greatly handicapped by emotional and psychological disturbances, and those who are experiencing
BERTRAM
problems of living, for whom the desired quality of life has proved elusive. It is around these groups that the tensions in our field are being generated; two points of view seem to predominate. There are those who believe that psychiatry has clearly bitten off more than it can chew and ought to get back to treating serious mental illness, and there are those who feel that unless we work to change social systems we shall inevitably have a continuing flow of sick and troubled people. I realize that people at both ends of this spectrum are keenly aware that the intermediate zone is one of great diagnostic difficulty. It takes skill and knowledge to ascertain what might be a life problem and what might be the earliest signs of an oncoming depression or other mental illness. Such diagnostic requirements demand that we take an extensive look at our clinical and scientific base and what we do or do not know about prevention.
THE
SCIENTIFIC
BASE
It is one thing to have a value base for what we think we should do, but it is quite another to have a scientific base-an objective set of measures about whether what we do is effectively achieving what we set out to do. Psychiatry has been a major service-providing instrument of that vital and nourishing enterprise we call mental health research. Psychiatry has played a significant but smaller role in the actual conduct of research. Only a few psychiatrists-numbering in the hundreds-are full-time researchers. This is a vital area ofdebate as we deliberate over the nature of financial support policies in research in general and psychiatry in particular. In their roles as conceptual, clinical, and program leaders, psychiatrists have played a leading role in stimulating and supporting research endeavors by other mental health professionals and behavioral and social scientists. At NIMH we have just finished a 2-year effort by a research task force that involved 300 people and $1 million to review $1 billion worth of research in the United States supported by NIMH and others. The report (7) shows that the number of research projects supported annually by NIMH has grown from 38 in 1948, when the first appropriations were made under the National Mental Health Act of 1946, to nearly 1,500 in 1975. About 30% of the total NIMH research budget has been devoted to research in the biomedical and behavioral sciences, including studies designed to identify physiological, psychological, social, and cultural factors that shape human behavior. Out of this effort has emerged work of enormous relevance, not only for enlarging our understanding of human behavior but for productive clinical research as well. The task force report will vitalize debates now under way as to the nature and scope of the psychiatric research enterprise, including such issues as balance and priorities. To some degree, these are but other ways of
5.
BROWN
looking at the scope and definition of psychiatry itself. A brief example will suffice: over the last 20 years we have seen the ratio of the amount of NIMH-supported biomedical research to psychosocial research reversed; 20 years ago the ratio ofbiomedical research to psychosocial research was 2 to I ; in 1975 it was I to 2. This dramatic shift reflects the broadening of NIMH’s mission in the late l960s into social problem areas such as crime and delinquency. Within the mental illness sphere of the NIMH program, biomedically oriented research continues to be predominant but with an increasingly fine line ofdistinction between the two approches. The Subjective
Approach
One of the ways I have approached chiatry’s scientific base is to return Forexample, when I really wonderabout wisdom of my opinion or judgment tion, I ask what I want for myself, my my parents. Some of the answers me follow:
the issue of psyto the subjective. the depth and on a given situawife, my children, that emerged for
1 I would much rather have a mid-life depression today than 20 years ago (assuming my present age both now and then) because of the current advances in the treatment of depression and acute depression, the understanding of its biology, and the availability of drugs. .
2. I think I would rather one of my children have an acute schizophrenic break now than 20 years ago. I will not go farther because I know the complexities surrounding schizophrenia, and I do not say this with quite the certainty that I use in discussing mid-life depression. However, I think we have made enough advances in the treatment of acute schizophrenia that the scientific base is ahead of that of 20 years ago. 3. Suppose my marriage were in serious trouble, with agony, misery, sleeplessness, concern, trouble with the children, and job trouble. Would I be any better off being treated by a psychiatrist today than I would have 20 years ago? I think not. The best possible source for help for me in this situation would be a mature, wise psychiatrist. There has been an increment of knowledge in the area of marital and family therapy, but that increment is small compared with what is known or needs to be known. The critical variable today is the same as it was 20 years ago-the maturity and wisdom of the helping person. The research task force (7) found that research investments in the area of helping the practitioner deal with troubled people have not yielded a cornucopia of techniques or programs. To realize our hopes and expectations in this area we must reassess what we have been doing, decide what we have been doing incorrectly’ and ascertain what we can do better. The relatively low yield in social research may be due to many factors. It may be that we are just now Am
J Psychiatry
133:5,
May
1976
493
THE
LIFE
OF
PSYCHIATRY
building the base in the next decade
It may
be that
swers
in the
in this complex field or so may provide
the methodologies area
of
social
What
so that workers useful answers.
necessary problems
to get an-
are
so
complex
that we have yet to develop effective tools. There are those who would have us abandon this area altogether. This I cannot support. To do it better-perhaps even to make use of some of the resources from more promising
areas-makes
both
unprofessional
A Look
sense,
and
but
to
do
nothing
seems
unwise.
at Possibilities
Let me now move from my subjective position to a more general frame of reference: I My answer to the question of whether psychiatry .
is up to the
and
task
whether
ically, fectly,
of dealing with serious mental illness the job has to be yes. EmphatI must add that we are not doing it perwe doing enough ofit, given our knowl-
it is doing
however, nor are
edge base. In spite of our advances in knowledge and the addition of chemotherapy to our armamentarium, we must still wait for research to uncover some basic unknowns. Even so, we could do it better if we made the best use of what we know now, particularly about community treatment and care. 2. My answer to whether psychiatry is dealing effectively with that 5% or 10% ofthe population who are not psychotic but who are very troubled, whose functioning is disturbed, or who are on the verge of becoming disturbed also has to be yes. However, I must add that the gains gains
in this
in the
ophrenia 3.
best
been
area
answer
regarding
ated, years
have
and psychotic
My
base
area
biological
was
psychiatry’s
ofthe
and the troubled has is that it has increased
economic then,
ask
perhaps more
for
scientific
unhappy,
increased in very little.
the alienthe
past
20
are
these
those who lost their jobs in of course, with unemploysocial benefits, the outlook
is considerably people
better
better
what psychiatry has to offer? Many more people who develop toms
the
schiz-
are people who have been laid off from
recovery but
than
against
depression.
work better off today than the 1930s? In one sense, ment insurance and other
for
significant
struggle
to whether
the treatment
For example,
less
in the
help
today
than
off
than
in terms
troubling
asked
for
it of
symp-
it in the
1930s,
for no other reason than that it is so much
available.
However,
knowledge has ability to care
only
a minimal
accumulated-beyond for the mentally
or
amount
of
our increased emotionally dis-
abled-to strengthen our capacity for dealing with the unemployment problem as it affects the emotional well-being of the individual. When it comes to the question of whether psychiatry should treat people with problems of living, one of the most powerful dynamics is the great influence of the dollar. If the troubled are willing to pay, and the psychiatrist is willing to accept, the question becomes
moot. 494
Am
J Psychiatry
133:5.
May
1976
Lies
Ahead?
On the basis of the research task force report (7) and the knowledge my colleagues and others in the field have gained, I predict in complete confidence that psychiatry There
will continue is no sign
growth
in the size
to grow in size at present that
of psychiatry
its services ing in size,
is decreasing. that is having
on
that
it, and
grams, niques
types is not
has
Any more
such
or that
the demand
profession and more
a diversity
of practitioners, a dying profession.
and diversity. there is a lack
and
of
for
that is growdemands put
in training therapeutic
protech-
By reason of the nature of psychiatry’s scientific base and its cultural connection to medicine, I also predict that the profession will refocus to a significant cxtent on clinical-and particularly biological-psychiatry,
that
it will
become
more
humble
about
what
it can
do in regard to social problems and issues, and that it will continue to yield new experimental therapeutic measures and techniques. Most ofthese will fall by the wayside, but a few should lead to more effective treatment. For the rest of this century and probably well into the next, treating the hard core of mental illness-the schizophrenias and the depressions-and dealing with troubled behavior that is or threatens to become incapacitating will continue to be vital activities in the thriving
profession
of psychiatry.
The psychiatrist will continue to be called on to help with problems of living that are less serious but more widespread. However, so will the psychologist, the social worker, the psychiatric nurse, the educator, the clinical sociologist, the clergyman, and others who for years have been working in this area. In other words, psychiatry can expect to find itself in collegial competition with other professions and, perhaps, with paraprofessionals in the treatment of people whose problems in living are not associated with serious clinical illness. From the standpoint of the patient, or the client, there may be two strong reasons for going to a skilled problems-of-living psychiatrist rather than to another mental health professional. One is to enjoy whatever protection can be assumed to lie in the M.D. the ethics and the traditions associated with for thousands of years. The other is to benefit greater diagnostic acumen that the psychiatrist
degreemedicine from the has, or
should have, in case of an underlying biological condition requiring attention. When there is no such condition, the wise pastoral counselor, the humanistic psychologist, and the warmhearted psychiatrist may be equally effective; the results depend more on the quality and less on the type of training of the human beings who serve as therapists or counselors. In the final analysis, the patient, the consumer, will make the final judgment. In 1949 I had the privilege of hearing David Wechsicr, who developed the Wechsler Adult Intelligence Scale, give a lecture on the future of psychology. He
BERTRAM
discussed gists
tance would ciation
the then
could
do
red-hot
issue
psychotherapy.
of psychiatrists. not be settled meeting
of whether He
the
or at an American
but the
most
although
Psychological
‘in the American question of who relatively
as in
pro-
this
Asso-
marketplace.” will deal with
‘
minor,
ofour
the men-
tal health problems will be decided in the marketplace. Ifthe nonmedical worker proves as acceptable and efficacious as the physician as well as less expensive, psychiatry can be expected to play less ofa role in treating the so-called problems ofliving. In the treatment of serious mental illness, however, psychiatry is likely to remain dominant.
CONCLUSIONS
Psychiatry
is growing
relation
to general
duction
point
expect 1980s.
of view
psychiatry
Psychiatry
in size,
medicine. will
is growing
it has
continue
absolutely
as well
Although passed
from
its
peak
to grow
in diversity.
Parts
into
the
of the
paper
to be
as accountable
I can,
cism.
There
pro-
place, but we must realize er; the fight is on behalf
we are not battling each othof the mentally ill and in the
pursuit
all.
fession are returning to basic biological and medical foundations; parts are undistinguishable in practice from other mental health professions; parts are under attack, and the outcome is unclear-particularly in social psychiatry. A critical area is the future of child psychiatry-or general psychiatry’s role in dealing with families and children. Psychiatry is undergoing severe criticism from within and without, but the demand for psychiatric services has shown no concomitant diminution and none is in sight. In my opinion the test of the marketplace, both in the quality of the product and people’s willingness to pay, is such that it would be unwise to limit psychiatry’s services only to the mentally ill, although its responsibility and strength in this area are clear. It would be unwise and grandiose for psychiatry to claim a monopoly on treating the unhappinesses of the human condition, but it will be a challenge to see if the profession is worth its higher fees in this area. The interface between psychiatry and social systems is an area in which psychiatry has in some ways overpromised. This interface is the site of hope for in-
battles
to be won
of happiness
for
dissent
my
mid-
are
to welcome
to state
and
I
to continue
as
view,
growth,
the
BROWN
tegrating prevention efforts with social concerns, for integrating scientific knowledge with humanistic concerns, and, in my opinion, it is a proper domain of psychiatry. Finally, let me describe a more personal conclusion. I have been practicing something that has been loosely called “political psychiatry.” Without bombast, this concerns my having been an administrator dealing with executive, legislative,judicial, and other affairsserving as deputy director or director of NIMH for a decade. I think the issue of my accountability within these affairs should be brought out. I have pondered over the fact that two of the groups now under the most severe attack from the public are politicians and psychiatrists. I think what these two groups have in common is the breakdown in trust on the part of their constituents and patients. The issue of trust is basic not only to psychiatry and developmental psychology, but also to the nature of government and governance. Thus it has been my purpose in writing
resis-
He also predicted that the issue at an American Psychiatric Asso-
ciation meeting I believe that pervasive,
psycholo-
predicted
S.
or lost
and
in the
criti-
market-
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.
Roback 1973.
GA:
Distribution
Chicago,
2. Arnhoff Survey.
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American
FN, Kumbar Washington,
Medical
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Association,
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States,
1974
AH: The Nation’s Psychiatrists-1970 DC, American Psychiatric Association,
1973
3. Follow-up 1948-1968. Manpower published 4.
American dencies
5. Taube sodes
survey of NIMH-supported trainees and fellows, Rockville, Md, National Institute of Mental Health and Analytic Studies Branch, December 1973 (unreport) Medical 1974-1975.
Association: Chicago,
AMA,
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Approved
CA, Redick RW: Provisional Data on Patient in Mental Health Facilities in 1973. Statistical
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Care Note
Epi127.
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