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Towards a unified psychiatry
J.
Behav.
Thcr.
& Exp.
Prychiat.
Vol.
I. pp.
241-242.
TOWARDS
Prrgamon
Press. 1970.
Printed
A UNIFIED
in Great
Brrtain
PSYCHIATRY
NEIL B. EDWARDS Department
of Psychiatry, Temple.University
WORKI.GG in Temple’s community health center and participating in the Midwest Professors’ ConfertBnce in Philadelphia, I have found myself becoming increasingly aware of an abhorrent state of affairs in American psychiatry. This I shall s,>mewhat euphemistically designate as polarity. There is no doubt that a patient who is well-to-do and well-educated receives one form of treatment while the poverty-stricken, uneducated patient receives another. Whether or not the form received by the higher socioeconomic groups is in fact a “higher” form of treatment is a moot point. I would venture to say, however, that one-to-one psychotherapy is implicitly agreed upon as the “best” psychotherapeutic mode: and this is the type of treatment by and large that the more highly socioeconomically placed patient receives. On the other hand, the patient who is treated in the community mental health center receives other forms of psychotherapy such as group therapy and “supervised” psychotherapy by mental health assistants. Supervision by psychiatrists is often minimal because of one glaring reality-there are not enough psychiatrists working in commu;lity mental health to provide adequate supervi4on. 1 have often heard from avid proponents of the existing community mental health system that this really does not matter, that the mental health assistant can do just as well with the patients he must deal with as a psychiatrist can because, having been drawn from the community he is closer to his patient’s needs and consequently understands them better. This again is a moot point. I have found for the most part that our mental health assistants are intelligent and dedicated, but I think that agree-
Health Sciences Center
ment would be quite high that the person best qualified to do psychotherapy is a person with extensive training in psychotherapy, e.g. a psychiatrist. It is quite clear, therefore, that a polarity does exist and that patients in community psychiatry may well be getting shortchanged. Having recognized this, what do we do about it? This question raises several others which must first be answered. I. Are all people entitled to the “same level” of psychiatric care? 2. Even if psychiatric care of the highest possible order is an inalienable right, must we in psychiatry cancel-n ourselves with implementing the delivery of thll; care? 3. If we 3re to concern ourselves with the delivery of high order psychiatric care to all people, will the psychiatrists’ role change drastically from spending most of his time on ogre-to.one psychotherapy (which even in shortterm forms is often highly uneconomical), to acting largely as an advisor and supervisor? The answer to the first of these questions. in my mind, is an unqualified “Yse”. More significant than my personal belief, however, is the fact that most Americans seem to be voicing the same opinion; and we are iinding ourselves faced with demands from several fronts to provide the highest possible level of psychiatric care to all. But must we do anything about it? Again my answer would be an unqualified “Yes”. If wc’ in psychiatry do not concern otirselves with the delivery of care, it will be done for us and HC will then find ourselves with the unsavory ta
242
NEIL
B. EDWARDS
function much more as advisor, supervisor and administrator, and much less in the actual practice of psychotherapy. Such uneconomical practices as long-term one-to-one, intensive psychotherapy may well be forced largely into oblivion and much more attention paid to shorter therapies and group methods. Having answered these preliminary questions, I would like to attempt the basic question, riz. “What do we do about this state of affairs?” We must first admit that the highest possible level of psychiatric care is an inalienable right. If this be so, then do we attempt to bring the psychiatric care of the lower socioeconomic groups up to “our level” or do we accept an entirely new system of psychiatric care which will provide to all people the same psychiatric care? Community mental health centers represent an attempt to implement the former policy. This approach, in my opinion, has failed miserably. It would appear more practicable to attack the problem from the latter stance, i.e. to accept the responsibility for revamping psychiatry entirely
(Rrceived
so that all people can receive the same level of psychiatric care. The implications of this are far-reaching. Many psychiatrists would have to give up the much-coveted practice of “doing their own thing” since in many cases these pet activities are not beneficial to enough people either therapeutically or from a research standpoint to justify their continued existence. A great deal more effort must be expended in research in both psychotherapies and organic therapies to find what will do the most good for the most people in the shortest period of time with the least expenditure of money and effort. Training of residents would then of necessity, concentrate much more on how to supervise and administrate, on the teaching of the shorter term, more efficient methods, how to administrate their implementation by others, and how to do research. Most significantly, however, the double standard of psychiatric care would be abandoned. The present community mental care system would be given up as a bad job, and afl people would be treated on the same principle.
30 June 1970)
Behav.
Thcr.
& Exp.
Prychiat.
Vol.
I. pp.
241-242.
TOWARDS
Prrgamon
Press. 1970.
Printed
A UNIFIED
in Great
Brrtain
PSYCHIATRY
NEIL B. EDWARDS Department
of Psychiatry, Temple.University
WORKI.GG in Temple’s community health center and participating in the Midwest Professors’ ConfertBnce in Philadelphia, I have found myself becoming increasingly aware of an abhorrent state of affairs in American psychiatry. This I shall s,>mewhat euphemistically designate as polarity. There is no doubt that a patient who is well-to-do and well-educated receives one form of treatment while the poverty-stricken, uneducated patient receives another. Whether or not the form received by the higher socioeconomic groups is in fact a “higher” form of treatment is a moot point. I would venture to say, however, that one-to-one psychotherapy is implicitly agreed upon as the “best” psychotherapeutic mode: and this is the type of treatment by and large that the more highly socioeconomically placed patient receives. On the other hand, the patient who is treated in the community mental health center receives other forms of psychotherapy such as group therapy and “supervised” psychotherapy by mental health assistants. Supervision by psychiatrists is often minimal because of one glaring reality-there are not enough psychiatrists working in commu;lity mental health to provide adequate supervi4on. 1 have often heard from avid proponents of the existing community mental health system that this really does not matter, that the mental health assistant can do just as well with the patients he must deal with as a psychiatrist can because, having been drawn from the community he is closer to his patient’s needs and consequently understands them better. This again is a moot point. I have found for the most part that our mental health assistants are intelligent and dedicated, but I think that agree-
Health Sciences Center
ment would be quite high that the person best qualified to do psychotherapy is a person with extensive training in psychotherapy, e.g. a psychiatrist. It is quite clear, therefore, that a polarity does exist and that patients in community psychiatry may well be getting shortchanged. Having recognized this, what do we do about it? This question raises several others which must first be answered. I. Are all people entitled to the “same level” of psychiatric care? 2. Even if psychiatric care of the highest possible order is an inalienable right, must we in psychiatry cancel-n ourselves with implementing the delivery of thll; care? 3. If we 3re to concern ourselves with the delivery of high order psychiatric care to all people, will the psychiatrists’ role change drastically from spending most of his time on ogre-to.one psychotherapy (which even in shortterm forms is often highly uneconomical), to acting largely as an advisor and supervisor? The answer to the first of these questions. in my mind, is an unqualified “Yse”. More significant than my personal belief, however, is the fact that most Americans seem to be voicing the same opinion; and we are iinding ourselves faced with demands from several fronts to provide the highest possible level of psychiatric care to all. But must we do anything about it? Again my answer would be an unqualified “Yes”. If wc’ in psychiatry do not concern otirselves with the delivery of care, it will be done for us and HC will then find ourselves with the unsavory ta
242
NEIL
B. EDWARDS
function much more as advisor, supervisor and administrator, and much less in the actual practice of psychotherapy. Such uneconomical practices as long-term one-to-one, intensive psychotherapy may well be forced largely into oblivion and much more attention paid to shorter therapies and group methods. Having answered these preliminary questions, I would like to attempt the basic question, riz. “What do we do about this state of affairs?” We must first admit that the highest possible level of psychiatric care is an inalienable right. If this be so, then do we attempt to bring the psychiatric care of the lower socioeconomic groups up to “our level” or do we accept an entirely new system of psychiatric care which will provide to all people the same psychiatric care? Community mental health centers represent an attempt to implement the former policy. This approach, in my opinion, has failed miserably. It would appear more practicable to attack the problem from the latter stance, i.e. to accept the responsibility for revamping psychiatry entirely
(Rrceived
so that all people can receive the same level of psychiatric care. The implications of this are far-reaching. Many psychiatrists would have to give up the much-coveted practice of “doing their own thing” since in many cases these pet activities are not beneficial to enough people either therapeutically or from a research standpoint to justify their continued existence. A great deal more effort must be expended in research in both psychotherapies and organic therapies to find what will do the most good for the most people in the shortest period of time with the least expenditure of money and effort. Training of residents would then of necessity, concentrate much more on how to supervise and administrate, on the teaching of the shorter term, more efficient methods, how to administrate their implementation by others, and how to do research. Most significantly, however, the double standard of psychiatric care would be abandoned. The present community mental care system would be given up as a bad job, and afl people would be treated on the same principle.
30 June 1970)