Response to the Presidential Address: Psychiatry's Unfinished Business in the 20th Century

At the APA's 114th annual meeting in California 26 years ago this week, Harry C Solomon, the 70th President, called our large mental hospitals "antiquated, outmoded, and. . . obsolete." He concluded that they were "bankrupt beyond remedy" (1). He also noted that a recent reduction in the census of such facilities had been coupled with a rise in the number of psychiatric wards in general hospitals, outpatient clinics, halfway houses, home care services, and day hospital and night hospital facilities. Dr. Solomon cautioned that "liberalization of insurance plans" might encourage increased use of the new facilities by acutely ill patients rather than the chronically ill—necessitating the formation of homes or colonies for the chronically ill who were "less readily recoverable." Nevertheless, he urged us to "liquidate our large mental hospitals as rapidly as can be done in an orderly and progressive fashion" and to move toward a two-tiered system of "community-oriented intensive treatment" for the acutely ill and moderate-sized homes or colonies for the chronically disabled.

Now, in 1984, with the end of the century staring us in the face, we seem no closer to this Solomon's dream than he was. Our public facilities are deteriorating physically, clinically, and economically; our chronically ill are either "transinstitutionalized" to nursing homes or deinstitutionalized to our cities' streets, lost in the vast army of the homeless; and our "liberal" insurance plans are mostly a thing of the past.

Psychiatry, so full of promise, so expectant of cure, so flush with excitement just 26 years ago, now seems mired in a multiplicity of problems. It is these problems, which constitute our unfinished business for the remainder of the 20th century, that I will address.

The fate of the public mental health system

Harry Solomon's call for an end to the antiquated large mental hospital was not made in isolation—the World Health Organization, the Joint Commission on Mental Illness and Health, and lay and professional leaders throughout this nation made similar suggestions. Ironically, while we have experienced the deemphasis of the large state hospitals he anticipated, we have seen neither any provision for funding the homes or colonies for "the less readily recoverable" chronically ill that Solomon called for nor any widespread implementation of an integrated community care system for the more readily recoverable. In addition, while crippled and cracked, our state hospitals have not withered and blown away.

It is time we called for a reappraisal of the policy of depopulation of state hospitals without the concomitant provision of comprehensive treatment and care for the many who can return to the community and humane asylum and care for the few who cannot. It is time to face the facts that we currently have no cure for debilitating psychotic illnesses, that not all persons suffering from schizophrenia are amenable to our current therapeutic armamentarium, that no community in America has an adequate number or array of psychiatric services, and that no fiscal legerdemain in the world can make our "system" cost effective so long as 297 state and county mental hospitals continue to consume the lion's share of money spent by our states nationwide.

Reimbursement for psychiatric services

Solomon noted in 1958 the beginning liberalization of insurance plans to fund care for the mentally ill; currently over 98% of Americans are covered by either government or private health insurance plans. However, as we all know only too well, there are gigantic blotches in this seemingly rosy picture: Coverage for the treatment of mental illness has always been less ample than that for other medical illnesses, and fears of increasing health costs have prompted both government and business to suggest drastic measures for cutting costs.

From an economic standpoint, the list of measures enacted or proposed reads like a bureaucrat's nightmare: cost-containment measures, such as caps on Medicaid, prospective payment mechanisms, and mandatory assignment of Medicare patients; decreased insurance protection through increased copayment and deductibles and outright elimination of benefits; business coalitions formed with the express purpose of devising strategies to reduce health care costs of employees; and reduction of benefits through increased claims review, demands for documentation, and administrative harassment.

From a regulatory standpoint, the increased constraints are similarly restrictive: attention by the Joint Commission on Accreditation of Hospitals and other accrediting bodies to quantitative rather than qualitative or outcome measures; strangling regulation by an incredible number of government and "voluntary" agencies, which in New York State number 164; and a zealous effort by professional standards review organizations and their competitors to disallow or "carve out" patient days.

In addition, the practice of medicine is undergoing a radical shift, largely powered by the following economic forces: movement from solo to group or organized practice settings; competition from allied mental health professionals seeking parity of reimbursement, admitting privileges, and licensure; competition from other medical specialists seeking payment for "cognitive" treatment; introduction of "new" forms of practice, such as health maintenance organizations (HMOs), individual practice associations (IPAs), and preferred provider organizations (PPOs), designed to provide less expensive packages of health care; and increasing numbers of investor-owned psychiatric facilities.

Our response to these radical changes in the way we practice is more often characterized by anger at the bearer of the bad news or instrument of change than action aimed at correcting discrimination, poor-quality care, or economically unsound proposals. When Margaret Heckler, Secretary of Health and Human Services, said in Los Angeles 8 months ago that 10% of hospitals would close by the year 1990 and 5% of physicians would be out of work, and when Governor Richard Lamm of Colorado suggested at the APA's State Legislative Seminar 6 months ago that America's reindustrialization depended on reducing medicine's share of the economic pie, we can appreciate that the problem is bigger than that of psychiatry alone.

It is self-defeating to complain and bemoan the loss of the good old days, to blame the bearer of the bad news, or to act as if there were no abuses, problems, or substance to the charges of overspending. If we are to ensure our patients' future, we must lay aside our misguided notions that benign legislators will do what we want merely because of our medical degrees, that the public on their own will fight for mental health benefits, and that the introduction of money, advocacy efforts, and old-fashioned politics is unbecoming to scientist-physicians. We must spend time getting to know our state and federal legislators, being available to their staffs to discuss pending legislation, journeying to our capitals to testify on bills, and agreeing to appear on television or speak on the record to representatives of the print media. Large war chests, like the psychologists are wont to use, are but a partial solution. We are this profession's most precious resource, and we must be willing to spend a sizable amount of our professional time in what I call legislative lobbying overhead if we are to survive and if our patients are to receive the care that they so desperately need.

The destigmatization of mental illness

Since time immemorial the mentally ill have been ridiculed, discriminated against, and stigmatized. While alcoholism is now accepted as a medical disease and mental retardation as a physical affliction, the mentally ill are still considered by many to be responsible for their illnesses and are penalized for them. Efforts have been made over the years to destigmatize mental illness, but in my opinion these have been grossly amateurish.

What we need is a serious, concerted, and professional effort to educate the public about the prevalence of serious and chronic mental illnesses; the necessity of funding research into the epidemiology, etiology, prevention, and treatment of these illnesses; and the limitations and efficacy of psychosocial and biological treatments. It would certainly help to have a prominent public figure, like Jerry Lewis or Will Rogers, take the lead. In addition, we need the support and advocacy of relatives of the mentally ill who, for too long a time, have been blamed by us for the afflictions of their family members. Finally, and most difficult, we need the support of articulate patients and ex-patients, just as kidney-transplant surgeons and burn-unit physicians have.

As a coda, let me suggest that our inability to look anything but ridiculous in the celebrated courtroom battles of the experts over the existence of mental illness or lack of it in criminal suspects makes the process of destigmatization of our patients all the more difficult. This Association must find some way to protect the seriously ill from being punished for acts they committed when incomprehensibly psychotic, while eliminating the spectacles that occur all too frequently between our so-called forensic experts and that tarnish all of us and our patients.

Reexamining our exploitative treatment of foreign medical graduates

For years, public mental hospitals and substandard residency programs have utilized foreign medical graduates (FMGs) because they could not attract qualified U.S. medical graduates. The psychiatric training, cultural education, language preparation, and professional socialization of most FMGs has been substandard; in addition, they perform more clinical service than they are rewarded for educationally. Although over one-third of the candidates for the American Board of Psychiatry and Neurology's examination are FMGs, their failure rate is eight times that of U.S. medical graduates; although one-fourth of APN's members are FMGs, only a few serve on committees, in the Assembly, or on the Board; and although our President himself is a foreign medical graduate, he is the first in the 140 years of this Association.

We can no longer continue to encourage the importation of FMGs as cheap labor for the public facilities, we can no longer continue to offer those now in the country such substandard cultural, linguistic, and didactic experiences, and we can no longer countenance the gap between those graduate psychiatrists who are foreign born and those who are not.

Determining and ensuring the most effective care for each patient

Throughout psychiatry's relatively short history, enthusiasm and personal conviction have frequently determined what patient received which treatment in what setting. Only recently have we begun to look at differential therapeutics with a scientific eye. To some extent, our current research on treatment outcome is prompted by the same cost considerations I enumerated earlier, but as a profession we must investigate these questions primarily out of a commitment to provide the most appropriate treatment, of the highest quality, for each person.

While we await the results of all the important investigations into the etiology of mental illnesses, the critical research questions that should occupy us for the remainder of this century include the following: What treatment works for which patients in what settings? What is the best system of care for the mentally ill? How do we ensure the provision of the most appropriate treatment and care for each individual?

Unification of psychiatry as a medical specialty

In a related vein, as we all know only too well, psychiatrists have grown not only in numbers but in the diversity of the treatment modalities they employ and the settings in which they work. This growth and diversity represent a significant component of both our strength and our weakness. For while the multiplicity of orientations, subspecialties, and treatment settings has, as Dr. Tarjan pointed out in his presidental address, given us a rich dynamic mosaic, the feelings of competition, antagonism, and perceived favoritism that arise hinder the solid sense of identity as psychiatrists that we all should feel, first and foremost.

As I have traveled around the country, I have been concerned that almost every subgroup of psychiatrists feels underrepresented and underappreciated by official psychiatry or underpaid in relation to some other subgroup. The list is long and includes state commissioners of mental health, psychoanalysts, psychoanalytically oriented psychotherapists, family therapists, child psychiatrists, FMGs, blacks, women, gays, Hispanics, psychosocially oriented researchers, psychiatric administrators, and psychiatrists working in general hospitals, Veterans Administration hospitals, state hospitals, community mental health centers, health maintenance organizations, and the military. I have been sensitized to the pervasive sense of uneasiness of many of our members that, as our scientific frontiers expand so rapidly in exciting directions, they will become distant from and irrelevant to our clinical core. This concern is not merely about a split between those interested in biological versus those interested in psychological etiologies and treatments. Rather, it is expressed as a hope that we continue to be able to integrate all parts of our rapidly moving field into the central core of our thinking and practice. This is one of the most intriguing challenges we face in the next 15 years.

Let me reemphasize that our relationship to the rest of medicine and organized medicine is at a critical phase. Through the hard work of thousands of our members at national, state, and local levels, we are once again being seen as "real doctors" who are interested not only in our own specialty and subspecialties but in the problems, challenges, and actions of all of our medical colleagues. Thus our continuing reintegration into medicine must proceed vigorously.

Organized psychiatry as a guild

Finally, I would like to focus on our very real concerns as members of a profession on those issues commonly referred to as guild issues, defined in Webster's dictionary as issues of mutual aid and protection.

Psychiatry, along with the rest of medicine, can thrive only so long as it maintains the public's trust. That trust, in our case, is frequently shaped by events and developments we may have little or no control over, but some over which we do. Whether we like it or not, our social status, income level, and public image as an ethical profession depend less on our therapeutic effectiveness, individual integrity, and scientific knowledge than on publicly visible problems such as deinstitutionalization, homelessness, sexual abuse of patients, criminal acts by patients, and the psychiatric underservice of the poor, minorities, and severely and chronically ill.

Make no mistake. The APA and its elected officers can advocate for the members' economic and professional well-being only if we are willing to take on and attempt to redress these public concerns. In addition, we will have credibility with the public only if our primary concern is the well-being of our patients, not ourselves. To that end our need, indeed our dependence, on healing the schism between ourselves and the relatives of the mentally ill is critical. No longer will an insurance company or a mental health program adequately fund or reimburse services on the basis of our word alone; we need allies, coalitions, and friends.

The focus on the patient

My primary goal as President will be to focus attention on the patients we have the responsibility for treating. It is my conviction that whether we are talking about public policy decisions (such as deinstitutionalization or the insanity defense), clinical decisions (such as when and how long to treat persons in outpatient or inpatient care), research questions (such as etiology, treatment, and rehabilitation), or training issues (such as the optimal balance between experience in long-term psychotherapy and in psychopharmacology or the amount of time to spend in a psychiatric versus general hospital versus community program), we will be able to address the issues appropriately only if we start with the patient and then derive our research questions, educational curricula, clinical strategies, regulatory processes, and public policy initiatives.

If we start with the patient, that is where we will also end up. As a means of emphasizing this focus, I have decided that the theme of the 1985 annual meeting in Dallas will be "Our Patients." For the remainder of this week, I look forward to illuminating myself in the reflected light of the great dynamic mosaic George Tarjan has described. For the next 15 years I expect that we as a profession will try to settle the issues I have discussed. As a starting point, for the next year I hope that you and I will concentrate our attention on the ultimate purpose of all our work, whether clinical, administrative, research, or teaching—our patients.

This article was originally published in the American Journal of Psychiatry in 1984, pages 927-930.