Pilgrim’s Progress, or The Tortuous Road to Mental Health Zigmond
M. Lebensohn
P
SYCHIATRISTS are a curious breed. Perhaps more than any other medical specialists they tend to insulate themselves from the difficulties their clients experience in obtaining prompt, effective psychiatric treatment, especially treatment geared to the person’s specific needs. Lulled by the fact that somehow or other his patients were able to get to him, the individual psychiatrist has given little thought to the time-consuming, tortuous, and frustrating path many Americans must follow to get some semblance of psychiatric care. In his quest to regain his own mental health, the troubled patient often encounters many obstacles before he achieves his goal. Even before he sees a psychiatrist he may run into formidable administrative, jurisdictional, or economic roadblocks. Assuming that he is well motivated and remains undaunted by his experience, he eventually finds himself in the presence of the psychiatrist. But his troubles may still not be over. If the psychiatrist happens to be overspecialized, a true believer in the universal application of his overspecialty, and vigorously opposed to all other methods, and should his highly specialized treatment approach be singularly unsuited to the patient’s problems, then months and sometimes years may be wasted in futile attempts to force the patient’s illness to respond to a preconceived treatment pattern. In some ways the path of the modern seeker for personal mental health resembles that followed by Christian, the central character in Pilgrim’s Progress. John Bunyan, who published this remarkable allegory in 1678, describes the incredible trials and tribulations encountered by the pilgrim Christian on his way to reach the Celestial City. He has to go through the City of Destruction, the Slough of Despond, the Valley of the Shadow of Death, Doubting Castle, and the town of Vanity Fair before he reaches his goal. He has to overcome the evil counsel of characters such as Obstinate and Pliable and endure the false witness of acquaintances such as Envy, Superstition, and Pickthank (Flatterer). He is sustained on his journey by friends named Faithful and Hopeful and finally reaches his goal. It shall be my purpose to trace the course of the modern pilgrim in search of his Celestial City of Mental Health. 1 shall describe his usual route, which I have called the Linear Path Downward. I hope to discuss some of the roadblocks he encounters along the way, with special emphasis on those obstacles such as the Ogre of Catchmenting Basin, the Swamp of Rigid System, and the Valley of Chronicity, which we as psychiatrists inadvertently place in the path of our pilFrom the Departments o/Psgchialry. Georgetown University School oJMedicine and Sihlev Memorial Hospital. Washingron, D.C. Zigmond M. Lebensohn, M.D.: Clinical Professor of P.ywhiafry. Georgefown Universirv School o/ Medicine, and ChieJ Department of Psychiatry, Sibley Memorial Hospital. Washingron. D.C This paper is a modified version oJa lecture delivered Nov. 20. 1974, at Norrhwestern Unir,er.vit\, Institute oJPsvchiatrv. as one in its series of Distinguished Guesl Lecrures. K 1975 hv Grune & Stratton. Inc. Comprehensive Psychiatry, Vol. 16. No. 5 (September/October).
1975
415
416
ZIGMOND
M. LEBENSOHN
grim patient’s progress. I shall mention a few of the characters he encounters along the way, such as Dr. Sectarian and Dr. One-Note. Finally, I plan to suggest some remedies for this deplorable situation that we as psychiatrists should be able to offer. THE LINEAR
PATH DOWNWARD
The “pilgrim’s progress” of the average person who develops a mental illness has been generally conceived by both the lay and medical public as a linear model with a dangerous propensity for progressing inexorably “downward” from its very inception. Let us see how it works (Fig. 1). The illness is usually first noted at home or at work. If the prospective pilgrim perceives his symptoms as a “problem in living,” he may consult a counselor, a clergyman, a clinical psychologist, or a social worker, or go to a community mental health center. If, on the other hand, the prospective pilgrim patient perceives his symptoms as an “illness”, he frequently consults his family physician. Here he may receive a wide variety of attention, good, bad, or indifferent, often with heavy emphasis on chemotherapy and direct advice. In some instances such intervention is sufficient, and the patient may recover. Just how often this occurs would be most difficult to estimate with any degree of accuracy, but it would be a worthy subject for future investigation. In many instances, however, the family physician begins to recognize that the patient is either failing to respond or is beginning to develop alarming symptoms, and he refers the patient to a psychiatrist. At this point the path has many branches-perhaps far too many branches. As a result, the pilgrim, the medical man, and the public at large often become confused as to which is the best branch to take. I will mention only three of the more commonly encountered branches.
1.
HOME OR OFFICE
2.
3.
PSYCHIATRIST
I 4. PSYCHIATRIC
UNIT GENERAL
HOSPITAL
I 5.
6.
PRIVATE
PSYCHIATRIC
HOSPITAL
STATE HOSPITAL
(Lasciate ogni speranza, voi the entrate!)
Fig. 1. Pilgrim’s progress, or the line path downward.
PILGRIM’S
PROGRESS
417
If our pilgrim consults a biologically oriented psychiatrist, he will most likely receive chemotherapy, together with some supportive psychotherapy. If, on the other hand, he is referred to a psychoanalyst, a course of analysis may be recommended, and it is most unlikely (depending, of course, on the orthodoxy or unorthodoxy of the analyst) that he will be given any medication at all. If by chance he should fall into the hands of a general psychiatrist, he will be treated with a combination of methods and referred for analysis only if that appears to be the most promising course for the patient. Our pilgrim patient may, of course, recover completely due to the ministrations of any one of the above-mentioned gentlemen. But let us assume for the purposes of our discussion that in spite of all this attention, he becomes much worse and clearly requires treatment in a hospital. At this point the analyst, who often has no hospital connections (although I am happy to report the picture is rapidly changing in this regard), does one of several things: (1) He may refer the patient to one of his colleagues with hospital privileges, for admission to the psychiatric unit of a general hospital; (2) He may refer the patient to a private psychiatric hospital directly; (3) He may throw up his hands. The biologically oriented psychiatrist and the general psychiatrist usually have hospital privileges and can arrange for hospitalization directly. Our pilgrim has now arrived on the psychiatric unit of the general hospital where he finds himself under the care of a second or third physician since his illness began or under the care of a “team,” that highly touted organization cleverly designed to elude clinical responsibility and weekend duty. In most instances our pilgrim will be greatly helped on his way, often within a matter of weeks. Let us assume, however, that our patient’s problems are very stubborn and most resistant to treatment. Let us also assume that the unit has a maximum limit of stay, which the patient is rapidly approaching, or that the Utilization Committee is breathing down the neck of the attending psychiatrist. At this point, if the patient or his family are still solvent and/or are blessed with wonderful health insurance, the patient may be transferred to a private psychiatric hospital, often at some distance from the patient’s home. Being treated in a private psychiatric hospital at some distance from the patient’s home is not always a disadvantage. I have seen many instances of patients who have made brilliant recoveries after entering or being transferred to such private psychiatric hospitals. Be that as it may, let us once again assume that our hapless pilgrim has a most stubborn illness or that his family runs out of funds to pay for further private hospital care. At this point a number of conferences take place, more serious perhaps than any that have occurred until now, and the recommendation is Finally made that the patient be transferred to the neighboring state hospital. At this point, and at the risk of mixing my metaphors, let me jump from John Bunyan’s Pilgrim’s Progress to Jacobowsky and the Colonel. You may remember the delightful Broadway play of that name in which Jacobowsky tells the story of “the two possibilities” to illustrate the unquenchable optimism of the Jew in the face of certain disaster. According to one version of the story, Jacobowsky meets Yankel, his anxious fellow Jew who is faced with induction into the army. The following dialogue takes place:
418
ZIGMOND
M. LEBENSOHN
Jacobowsky (to his friend Yankel): Don’t worry. There are always two possibilities. Either you are inducted or you’re not. If you’re not inducted, you have nothing to worry about. Y ankel: But what if I am inducted? Jacobowsky: There are still two possibilities. You can be assigned to combat duty or non-combat duty. If you get non-combat duty you have nothing to worry about. Yankel: But what if I get combat duty? Jacobowsky: Well, there are still two possibilities. Either you get wounded or you don’t get wounded. If you don’t get wounded, you have nothing to worry about. Yankel: But suppose I get wounded? Jacobowsky: Well, there are still two possibilities. Either your wound is fatal or it’s non-fatal. If it’s non-fatal you will be invalided out of the service so you will have nothing to worry about. Yankel: But suppose it’s fatal. Jacobowsky: Well, even here, there are still two possibilities. Either you can be buried in sacred ground or not. If you are buried in sacred ground then your soul will go straight to Paradise and you will have nothing to worry about. Yankel: But suppose I’m not buried in sacred ground? Jacobowsky: Then, my good friend, you’re in one hell of a mess! Our pilgrim patient (or Yankel, if you wish) has now reached the state hospital. But he is not necessarily in “one hell of a mess.” Nonetheless, to this day the very mention of the name of the state hospital often strikes dread into the hearts of nearby residents. Moved by fear, ignorance, or superstition, many might be reminded of Dante’s famous inscription on the portals of hell, “Lasciate ogni speranza, voi the entrate.” Yet, it is well known to any experienced psychiatrist that the recovery rate for most state hospitals, considering their niggardly support by state legislatures, has been remarkably good and compares favorably with other better endowed institutions. Many patients who have failed to make headway in other treatment facilities have gone on to full recovery following treatment in a state hospital. Let us now retrace the steps of our troubled pilgrim and list at least a few of the perils he has encountered along the way. THE OGRE OF CATCHMENTING
BASIN
The Ogre of Catchmenting Basin confronts only the pilgrim who has been headed in the direction of a community mental health center (CMHC). Our pilgrim patient, after conquering his doubts, fears, and misgivings, arrives at CMHC A only to learn from the receptionist that he is not eligible for treatment there but really belongs to the CMHC B catchment area. Can you imagine the discouragement and resentment of our pilgrim patient? No matter that CMHC A is nearer his residence or place of work than CMHC B. No matter that he has been referred to center A by a friend or relative who has received excellent treatment there and is now favorably disposed to the staff of center A. No matter that he has come to center A with built-up expectations and at considerable sacrifice of time and energy. The rules say he must go to center B, and off to center B he is sent packing.
PILGRIM’S
PROGRESS
419
The tendency of intake personnel at some CMHCs to place excessive stress on residency and eligibility gives the patient the feeling that the personnel are more interested in shifting him to another center than in learning about his problem and doing whatever possible to help. Patients tell me that they were met with delight when it was discovered that they did not “belong” to the CMHC being visited and with resignation when they discovered that they did belong. The mere fact that the patient arrives at a CMHC asking for help and is still warm to the touch should be enough to mobilize a treatment effort. There is, of course, very little incentive to add still one more patient to the treatment load. CMHC personnel are all on salary. They are not paid on the basis of how many people they serve. Their incentives are promotions on the basis of the quality of their work and the satisfaction of having done a good job. Perhaps the incentives need revision. COMMUNITY-REAL OR ILLUSORY? Perhaps a comment about the word community in the community mental health center movement is in order at this point. In most American cities the word community has become a kind of empty shibboleth, devoid of any real meaning. Most of us tend to use it with reckless abangon, often without bothering to see if the community really exists outside the walls of the center. It is almost as if we were trying to bring about the existence of the community in some kind of magical way by constantly repeating its name. Richard Goodwin, in his recent book The American Condition, has made a number of observations on the term community that are highly relevant to our subject. The brief excerpts that follow give the gist of his thinking. Today
some speak of the community
of Christian souls
munity
such abstractions enlarged.
the concept
The modern base from works
reflect
which
deprives
mon human
with young
healthy. Within
Americans
of our growing
pate unplanned women housing
meetings have
little
asserting burden
suburbs
The suburb components
are sterilized while college
or commitment
without
virtually
tions. citizens’
groups
or community
environment
are incarcerated
a
A man where of com-
in institu-
and city “pads”
love among
the young
are and
pleasure.
no place where neighbors Only
can antici-
disastrous
for those
small towns and lower income
laundromat
It is true that there are thousands
and leagues for recreation.
is merely
or companionship
store or park. This lack is especially
playground
can meet with some regularity.
or city block
campuses
the value of love. meaning
there is often
where women
of people who share a common
At best.
of the living reminders
the senile and retarded
to spend much of their lives at home.
a common
decline).
of social existence.
else. finds pleasure
His streets
for the elderly,
-no pub or corner
who are compelled projects
shops somewhere
projects
people passionately
of free men, and even the com-
a severe population
a lot of people are in the same boat. So
of community.
The aged and decrepit,
or in housing
the love that involves many
to believe that
none of these places.
responsibility:
from
reaches out to the scattered
in one place, sleeps in another,
tlons or hospitals
the community
is destroyed
most
the individual
he can and cares about
tilled
a vague inclination
of community
world
of nations.
(a once lively place now suffering
But they are not a substitute
-some
physical
setting
of clubs and associafor the regular
contact
and its concerns.’
Are we in psychiatry assuming a sense of community that does not exist? Are we attempting to create something in our small centers that can only be achieved by the sociopolitical process over a long period? Dr. Peter Randolph, the director of an East Coast mental health center, recently addressed himself to this very problem when he wrote:
420
ZIGMOND
One basic tenet of community
psychiatry,
that patients receive better care in their own commu-
nities close to home, is based on the assumption there are all kinds of communities
M. LEBENSOHN
that such communities
with greater
exist. Yet we all know that
or lesser degrees of coherence
and integration
and
greater or lesser capacity to deal with deviant behavior. We also know that in many of our cities there are a multitude
of different
communities.
Certainly
in a city such as Boston, it is not unreasonable
to
expect that many of the chronically
dependent and multiple handicapped
large part of our patient population
will tend to drift into the areas of the city which are least well in-
tegrated
and where
predictable
the sense of community
is characterized
that some of these patients will end up wandering
people who make up such a
by transience
and anomie.
It is
around public spaces in large public
buildings, which are not equipped to handle them. The danger involved here is clear enough. We will soon arrive at the situation in New York
State; the public will begin to feel that we are not doing our
job and the outcry raised will seriously impair our efforts to bring patients out of institutions and into more humane
settings. The opportunity
the very things that community education,
consultation
inherent in this situation is equally clear. There is a need for
psychiatry
has added to the mental health armamentarium:
and the provision of readily available
backup
public
services. We must be able to
provide these services to groups we had not previously thought of as being in need. By so doing, we can seize the opportunity
of participating
in the development
of better integrated
and more supportive
communities.2
Whether Dr. Randolph’s noble plans can ever be achieved by psychiatry alone or by the community mental health center movement, even with fullest possible support, is highly doubtful. The very question itself-whether psychiatry can play a role in the enhancement or revival of a sense of community-may be considered presumptuous by some and idealistic by others. Nonetheless, these questions must be faced honestly and openly if we are to arrive at a sensible solution or if we are to continue getting the support without which we shall certainly perish. SWAMP
THE
OF RIGID
SYSTEM
Whether he comes from a community or a “noncommunity,” our unsuspecting pilgrim patient who reaches out for help frequently finds himself ensnared in a system ostensibly designed to give service, but which often ends up as a rigid system dealing in nonservice. Many of the mental health delivery systems in operation throughout the country seem to be ingeniously designed to put as many obstacles as possible in the path of the patient seeking help, particularly if the patient is very sick, psychotic, or an emergency in need of hospitalization. A recent example from a large eastern city will illustrate the system in all its lurid dimensions. A 42-year-old
white male widower was brought to the emergency
bulance at 7:40 A.M.
His wife had died 6 months earlier,
room of a general hospital by am-
and since then he had become withdrawn,
isolated, and deeply depressed. The depression was intensified by alcohol, and he became preoccupied with suicide. He was seen immediately also examined that
by the night physician of the emergency
by the regular emergency-room
the patient
needed psychiatric
resident was called; he examined mended immediate hospital,
consultation
the patient,
hospitalization.
physician, this time a psychiatrist and recommendations the local community
and immediate
hospitalization.
there were no psychiatric
in the emergency
on the staff of the hospital.
and instructed
thereafter
he was
The psychiatric
made the diagnosis of psychotic depression, and recom-
Unfortunately,
and the patient was kept temporarily
room. Shortly
physician who had just reported for duty. Both agreed
the emergency-room
beds available
at that
room until he was seen by a fourth
He agreed with the previous diagnosis
nurse to arrange for a routine transfer to
hospital.
The nurse, who was very experienced ments for his transfer.
in such matters,
She first called the headquarters
was totally unsuccessful in making arrangeof the local CMHC.
She was then referred
to
PILGRIM’S
421
PROGRESS
the community
psychiatric
hospital
in another
part of the city. From there she was referred
back to
headquarters of CMHC. This time she was referred to an Outreach program located in a church in the patient’s catchment area. Completely frustrated by this time. she called the staff psychiatrist who told her he would try to arrange for the patient’s immediate hospitalization. The psychiatrist was as unsuccessful as the emergency-room nurse. He made four telephone calls. each time attempting to speak with a physician who might be able to approve the patient’s admission. The last call was to a woman who identified herself only as a person who could approve emergency admissions. Success at last! Or so it seemed. But then she wanted to have still another extensive history and examination of the patient. This material would then have to be reviewed and approved by some sort of it committee. Only then might the patient be approved for admission. This struck the psychiatrist as being not only totally unworkable but as coming straight from never-never land. Since she seemed unwilling to accept the unanimous recommendation of four physicians, the psychiatrist suggested that she examine the patient herself. She said she would not see the patient in the emergency room. Although she realized that the patient would have to be transferred to her via ambulance. that was the only way she could evaluate the patient for admission. At this point everyone gave up. Four hours and innumerable telephone calls later, a frustrated, embittered. and exhausted staff arranged for the sick man’s transfer to a less suitable facility.*
Unfortunately, this is not an isolated example. Psychiatrists and all mental health professionals must redouble their efforts to eliminate the rigidities in our systems so that they can really be of service to those in need. THE
VALLEY
OF CHRONICITY
Chronicity may be defined as any condition that is of long duration and fails to respond to treatment. To be sure, some disorders, by their very nature, tend to be chronic. Such disorders, however, are not the primary concern of our present discussion, but even these cases deserve periodic reevaluation, reassessment, and therapeutic trials to be sure that the chronicity is real and not induced, Our chief concern (and the concern of our pilgrim patient) is that psychiatrists and the mental health service system may be contributing to chronicity (unintentionally, of course) in cases which need not be chronic at all. It has been the custom to heap most of the blame for chronicity on the iarge public mental hospital.The sad truth is that every segment of psychiatry, every step in the Linear Path Downward, has had its share in producing chronicity. The general practitioner contributes to chronicity by keeping an emotionally disturbed patient unnecessarily and for long period of time on sedatives or tranquilizers, or by ordering a host of unnecessary x-rays and laboratory tests, thus conveying the impression that the problem is somatic, or by delaying referral to a psychiatrist. The psychiatrist and the psychoanalyst contribute to chronicity by inadvertently fostering excessive dependency on therapy. Either they do not make sufficient effort to wean the patient from this kind of dependency or fail to consider the possibility that the patient may be helped by other modalities such as chemotherapy. The case of the 40-year-old biochemist with a long history of bipolar manicdepressive illness will illustrate my point. He had been hospitalized on at least four separate occasions for manic episodes and had made one serious suicidal at-
*I am grateful
to Steven Steury,
M.D., for the details of this case.
422
ZIGMOND
M. LEBENSOHN
tempt. He was referred to an analyst in another city when he changed jobs. The analyst saw him four times a week, but in spite of this intensive therapy he had two more manic episodes and one severe depression in a 2-year period, each requiring hospitalization. During one of the hospitalizations his analyst went on vacation and turned the case over to a psychiatrist who placed the patient on lithium carbonate. Since then 7 years have elapsed without any recurrence of symptoms requiring hospitalization. He is seen once every month or two for brief sessions and for checks on his blood lithium level and has remained in excellent health. The psychiatric unit of the general hospital is usually not conducive to chronicity, because most of them are designed for short-term treatment, and many have a maximum limit of stay. But if the unit is in the practice of indiscriminately applying only one treatment modality (electroshock for example) without adequate use of chemotherapy or psychotherapy, chronicity may also result. Private psychiatric hospitals contribute to chronicity when they refuse to use psychoactive drugs, specialize in only one modality of treatment, and insist, somewhat unrealistically, that the patient achieve a very high level of adjustment before returning to the community. Public mental hospitals contribute to chronicity when they fail to provide specific treatment that could cut short hospital stay. Electroshock therapy is a case in point. A whole generation of young psychiatrists are being trained without any experience in this valuable treatment method, which in spite of all the brouhaha to the contrary remains a most remarkable, effective, and often life-saving treatment method when properly used. THE
RADIAL
CONCEPT
OF PSYCHIATRIC
SERVICES
We have, I believe, tarried overlong in the Valley of Chronicity, and it is time we search for a way out. You may remember that one of the ways our pilgrim patient got into this mess was by getting caught in the concept of the Linear Path Downward. What I propose to counteract the potential perils of linear descent is the Poly-Belted Radial Concept of psychiatric services (Fig. 2). In this scheme, the patient, instead of being a helpless object pulled by gravity to ever lower levels, is conceptualized as being in the center of a circular pattern, free to avail
_
PATIENT-
PSYCHIATRIC UNIT GENERAL HOSPITAL
PSYCHIATRIST
Fig. 2. Poly-belted radial concept of mental health services.
PILGRIM’S
423
PROGRESS
himself of the services of a wide variety of psychiatric outpatient and inpatient treatments based on what is best for him at a particular point in his illness. The various treatment modalities are thus not seen in a hierarchical order with any one method considered intrinsically better than the one below it, but rather as a wide range of modalities, any one of which may be just right for that patient at that time. But, as Shakespeare put it, there’s the rub. It is difficult, indeed, to determine what is best for a particular patient at a given time. But therein also lies the art and skill of the psychiatrist. This specific art and skill has never been sufficiently stressed in psychiatric training or in practice. Thus many psychiatrists emerge from training with a shockingly constricted overview of the rich assortment of treatment modalities available even in their own communities. One way to remedy this deficiency, aside from the obvious device of familiarizing each resident with all psychiatric modalities available in the area, is to place the psychiatrist in the very front line in a kind of “triage” position. I know that this is contrary to established tradition, which insists that the patient struggle first past a clerk, than an intake social worker, and than a clinical psychologist. Finally, after all the paperwork has been done, the psychiatrist, at the top of the pecking order, becomes involved with the case. This does not necessarily mean that he actually sees or talks to the patient. In many cases it may mean only that the psychiatrist presides over an impressive conference in which impressive reports are read and following which an impressive treatment plan is drawn up. The report, no matter how excellent, can never substitute for the live patient seen by the psychiatrist early in the illness when the symptoms are still fresh. What I suggest, wherever possible, is to reverse the order and arrange for the psychiatrist to be the first to interview the patient. After all, this is the procedure followed with great effectiveness in the private-practice sector, and surprising as it may seem, with a much lower average cost per treatment hour* than in the CMHCs. The experience of triage will certainly sharpen the psychiatrist’s clinical skills even though it may not bolster his ego as much as presiding over diagnostic and treatment conferences. Perhaps he can arrange to do both. The radial concept, with the patient surrounded by a ring of psychiatric services, means that he does not have to use these services in any particular order. I can conceive, for example, of situations in which it might be most appropriate for the patient to seek admission first to a state hospital where he could obtain the most effective available treatment for his particular disorder at that time. In another instance it may be best to start with a day-care center or a group therapist. Any one of the treatment modalities on the circle can be abused or used inappropriately and thus lead to chronicity. We now live in an age that considers hospitals “bad” and outpatient services “good.” There are neither bad nor good services in psychiatry; there are only appropriate or inappropriate treatments. For example, a 40-year-old government secretary was treated for 20 months in a day-care center for a stubborn depression, first without drugs and later, at her husband’s insistence, with them. When she became worse she was finally
*APA Practice
Task
Force No. 6, The Present and Future
in the Delivery
D.C.. June 1973.
of Mental
Health
Importance
Services. American
of Patterns
Psychiatric
of Private Psychiatric
Association.
Washington.
424
ZIGMOND
M. LEBENSOHN
transferred to the psychiatric unit of a general hospital where she received a small number of ECTs, with rapid recovery. In retrospect, it was clearly apparent that her case was totally unsuited for treatment in a day-care center or by group therapy-a judgment that could have been made within the first few weeks of treatment. SUMMARY
We have reviewed the tortuous path of our modern pilgrim on his way to mental health and have been dismayed by the number of obstacles that we as psychiatrists have inadvertently put in his way. What can we do to help clear the obstacles and speed our pilgrim toward his goal? To begin with, we should give him a new road map. Neither he nor we should be forced to use the outdated concept of the Linear Path Downward. Thinking in terms of the radial concept of psychiatric services should do much to offer the patient and his psychiatrist quick availability to a wide variety of treatment methods, one of which should be best suited to the patient’s needs. Psychiatrists need more training in all the accepted methods of treatment and should become familiar with all the resources of their community. Psychiatric services should rid themselves of their superfluous rigidities, so that our pilgrim need never again fear the Ogre of Catchmenting Basin. Psychiatrists must redouble their efforts to convince administrators and legislators that systems were designed to serve people; people were not designed to serve systems. Since people by their very nature are not rigid, they cannot be treated by rigid systems. By all the means at our command we should do everything possible to keep our pilgrim from the Valley of Chronicity. In doing so we must also remember that there are always some conditions that are resistant to cure. We should be guided by the old medical maxim that wisely states that we should always try to cure. If we cannot cure we should at least try to ameliorate. If we cannot ameliorate, at least we should do no harm. A word of caution is in order. In our great zeal to avoid chronicity, I am afraid that psychiatrists, goaded not too gently by our fiscal and legal brethren, have succumbed to the current mania for mass deinstitutionalization. We have deluded ourselves into believing that discharge from the hospital, even though premature, is tantamount to recovery. We have told our legislators and fiscal experts that extramural treatment in the community is less costly and more effective than treatment in a hospital. We have told our lawyer friends, “See, we are on your side. We don’t want to keep anyone in the hospital against his will either.” What we have been doing by the senseless large-scale discharges of sick patients (not only in New York State but in other states as well) is to produce a form of dangerous extramural chronicity that does incalculable harm to the patient, to society, and to psychiatry itself. Many of these patients are totally unsuited for outpatient therapy, and even if they were, our present outpatient facilities are totally incapable of coping with this crushing load. Furthermore, there is increasing evidence that good extramural treatment costs more, rather than less, than hospital treatment. We must now address ourselves to this serious problem with all the zeal and ingenuity we possess. We must elevate the level of
PILGRIM’S
PROGRESS
425
treatment in all our large mental hospitals to such a degree that most of our patients will elect voluntary or informal admission. We must learn to be comfortable with patients who can and do leave the hospital if they feel they are not receiving adequate treatment. Determination of the length of stay in the hospital should return to being primarily a clinical decision for the benefit of the patient and not a fiscal or legal determination made by well-intentioned but misguided zealots. But we must also put our own house in order. To help eliminate chronicity in the future, I make the following ten recommendations: 1. A psychiatrist should never be satisfied with any case that continues for too long a time. Periodic review of all long-term patients should be mandatory. Much of this will come about by peer review organizations whose task, although necessary, is awesome in its implications. 2. Become familiar with all possible treatment alternatives. Avoid overspecialization. Specialization is here to stay, but some psychiatrists and some hospitals are so overspecialized in one and only one method of treatment that I am moved to make a musical analogy: I do not object to psychiatrists specializing in the use of one instrument; they often become quite skilled at it. But I do object strenuously when they specialize in playing only one note on that one instrument. The results are boring in the extreme, and the audience is either numbed into submission or incited to revolt. Do not be a one-note psychiatrist. 3. Avoid sectarianism and parochialism. We psychiatrists have become the victims of our own overly rigid training programs. We have institutionalized our own prejudices to the point of becoming sectarian and parochial to an alarming degree. 4. Seek constantly for the specific diagnosis, elusive as it may be. There is always a better chance for rational treatment when a specific diagnosis can be made. Nothing, as Seymour Kety has stated, has done more damage to the concept of mental illness than the ambiguous attitude toward psychiatric diagnosis.” 5. Be imaginative and ever-questioning. Ask yourself, “Is there any method that has not been tried that might offer some help?” 6. Pick the treatment that fits the patient--not the patient who fits the treatment. Match the best available treatment method with the specific disorder of the individual. 7. Never hesitate to ask for consultation. 8. Review your incentives. When a patient and his psychiatrist settle down to a mutually comfortable relationship there is often precious little incentive to terminate. Chronic dependency may result. We must seek for appropriate incentives that will reward effectiveness of treatment as opposed to length of treatment. 9. Be constantly aware of economic factors. Third-party, state, or federal payments do not affect the individual’s pocketbook as does fee for service. Hence the patient goes on blithely assuming that “someone else” is paying for his therapy. When he starts paying the bills himself he is often jolted into reality. It is curious to note the frequency with which many patients begin to make rapid progress just at this point. 10. Reexamine the potentially harmful effects of compensation. In the past
426
ZIGMOND
M. LEBENSOHN
many state and federal programs were justly accused of fostering chronicity by rewarding patients for remaining ill. More recent trends properly emphasize rehabilitation and treatment instead of compensation, but much more needs to be done in this area. Just as there is no single cause for mental illness, so is there no single treatment method. There is no justification to be smug about any one approach in psychiatry. The medical model, that most ancient, honorable, and useful model, has come under heavy attack in recent years, particularly from those who do not really understand it. Although other models may be useful from time to time and in certain instances, no other model can be as broad or all-inclusive and as subject to scientific scrutiny as the medical model. As Kety recently put it: The medical model of an illness is a process that moves from the recognition and palliation of symptoms to the characterization of a specific disease in which the etiology and pathogenesis are known and the treatment is rational and specific. That progress depends upon the acquisition of knowledge and may often take many years or centuries. Numerous medical disorders and one or two mental illnesses have moved to the final stages of understanding, but many are still at various points along the way. After the recognition of symptoms, there comes the realization that some symptoms occur in fairly regular clusters, which are then described as syndromes. These may ultimately turn out to represent one or several etiological and pathogenetic components, the nature of which may be obscure at earlier stages of knowledge. The evolution of a medical model from symptoms through syndromes to diseases with specific pathology and, ultimately, with definitive etiologies and rational treatment is an excellent example of the scientific method applied to the alleviation of human suffering. It involves careful observation and study, the generation, sharpening, and testing of hypotheses, and the elucidation of underlying mechanisms, all pointing toward prevention and effective treatment. In many instances throughout medicine, this process has been successful, and there is justifiable concern that the fruits of this knowledge
are not available
to all the po$rlation.3
If psychiatrists of the future can be trained to understand and use the medical model in psychiatry as Kety suggests, our pilgrim will have no cause for worry. He will always be able to opt for the better of the “two possibilities.” REFERENCES I. Goodwin
RN:
The
American
Condition.
New York, Doubleday, 1974, pp 77-82 2. Randolph PB: Editorial. Mass J Mental
Health Vol4, No 3, Spring 1974 3. Kety SS: From rationalization Am J Psychiatry 131:959, 1974
to reason.
M. Lebensohn
P
SYCHIATRISTS are a curious breed. Perhaps more than any other medical specialists they tend to insulate themselves from the difficulties their clients experience in obtaining prompt, effective psychiatric treatment, especially treatment geared to the person’s specific needs. Lulled by the fact that somehow or other his patients were able to get to him, the individual psychiatrist has given little thought to the time-consuming, tortuous, and frustrating path many Americans must follow to get some semblance of psychiatric care. In his quest to regain his own mental health, the troubled patient often encounters many obstacles before he achieves his goal. Even before he sees a psychiatrist he may run into formidable administrative, jurisdictional, or economic roadblocks. Assuming that he is well motivated and remains undaunted by his experience, he eventually finds himself in the presence of the psychiatrist. But his troubles may still not be over. If the psychiatrist happens to be overspecialized, a true believer in the universal application of his overspecialty, and vigorously opposed to all other methods, and should his highly specialized treatment approach be singularly unsuited to the patient’s problems, then months and sometimes years may be wasted in futile attempts to force the patient’s illness to respond to a preconceived treatment pattern. In some ways the path of the modern seeker for personal mental health resembles that followed by Christian, the central character in Pilgrim’s Progress. John Bunyan, who published this remarkable allegory in 1678, describes the incredible trials and tribulations encountered by the pilgrim Christian on his way to reach the Celestial City. He has to go through the City of Destruction, the Slough of Despond, the Valley of the Shadow of Death, Doubting Castle, and the town of Vanity Fair before he reaches his goal. He has to overcome the evil counsel of characters such as Obstinate and Pliable and endure the false witness of acquaintances such as Envy, Superstition, and Pickthank (Flatterer). He is sustained on his journey by friends named Faithful and Hopeful and finally reaches his goal. It shall be my purpose to trace the course of the modern pilgrim in search of his Celestial City of Mental Health. 1 shall describe his usual route, which I have called the Linear Path Downward. I hope to discuss some of the roadblocks he encounters along the way, with special emphasis on those obstacles such as the Ogre of Catchmenting Basin, the Swamp of Rigid System, and the Valley of Chronicity, which we as psychiatrists inadvertently place in the path of our pilFrom the Departments o/Psgchialry. Georgetown University School oJMedicine and Sihlev Memorial Hospital. Washingron, D.C. Zigmond M. Lebensohn, M.D.: Clinical Professor of P.ywhiafry. Georgefown Universirv School o/ Medicine, and ChieJ Department of Psychiatry, Sibley Memorial Hospital. Washingron. D.C This paper is a modified version oJa lecture delivered Nov. 20. 1974, at Norrhwestern Unir,er.vit\, Institute oJPsvchiatrv. as one in its series of Distinguished Guesl Lecrures. K 1975 hv Grune & Stratton. Inc. Comprehensive Psychiatry, Vol. 16. No. 5 (September/October).
1975
415
416
ZIGMOND
M. LEBENSOHN
grim patient’s progress. I shall mention a few of the characters he encounters along the way, such as Dr. Sectarian and Dr. One-Note. Finally, I plan to suggest some remedies for this deplorable situation that we as psychiatrists should be able to offer. THE LINEAR
PATH DOWNWARD
The “pilgrim’s progress” of the average person who develops a mental illness has been generally conceived by both the lay and medical public as a linear model with a dangerous propensity for progressing inexorably “downward” from its very inception. Let us see how it works (Fig. 1). The illness is usually first noted at home or at work. If the prospective pilgrim perceives his symptoms as a “problem in living,” he may consult a counselor, a clergyman, a clinical psychologist, or a social worker, or go to a community mental health center. If, on the other hand, the prospective pilgrim patient perceives his symptoms as an “illness”, he frequently consults his family physician. Here he may receive a wide variety of attention, good, bad, or indifferent, often with heavy emphasis on chemotherapy and direct advice. In some instances such intervention is sufficient, and the patient may recover. Just how often this occurs would be most difficult to estimate with any degree of accuracy, but it would be a worthy subject for future investigation. In many instances, however, the family physician begins to recognize that the patient is either failing to respond or is beginning to develop alarming symptoms, and he refers the patient to a psychiatrist. At this point the path has many branches-perhaps far too many branches. As a result, the pilgrim, the medical man, and the public at large often become confused as to which is the best branch to take. I will mention only three of the more commonly encountered branches.
1.
HOME OR OFFICE
2.
3.
PSYCHIATRIST
I 4. PSYCHIATRIC
UNIT GENERAL
HOSPITAL
I 5.
6.
PRIVATE
PSYCHIATRIC
HOSPITAL
STATE HOSPITAL
(Lasciate ogni speranza, voi the entrate!)
Fig. 1. Pilgrim’s progress, or the line path downward.
PILGRIM’S
PROGRESS
417
If our pilgrim consults a biologically oriented psychiatrist, he will most likely receive chemotherapy, together with some supportive psychotherapy. If, on the other hand, he is referred to a psychoanalyst, a course of analysis may be recommended, and it is most unlikely (depending, of course, on the orthodoxy or unorthodoxy of the analyst) that he will be given any medication at all. If by chance he should fall into the hands of a general psychiatrist, he will be treated with a combination of methods and referred for analysis only if that appears to be the most promising course for the patient. Our pilgrim patient may, of course, recover completely due to the ministrations of any one of the above-mentioned gentlemen. But let us assume for the purposes of our discussion that in spite of all this attention, he becomes much worse and clearly requires treatment in a hospital. At this point the analyst, who often has no hospital connections (although I am happy to report the picture is rapidly changing in this regard), does one of several things: (1) He may refer the patient to one of his colleagues with hospital privileges, for admission to the psychiatric unit of a general hospital; (2) He may refer the patient to a private psychiatric hospital directly; (3) He may throw up his hands. The biologically oriented psychiatrist and the general psychiatrist usually have hospital privileges and can arrange for hospitalization directly. Our pilgrim has now arrived on the psychiatric unit of the general hospital where he finds himself under the care of a second or third physician since his illness began or under the care of a “team,” that highly touted organization cleverly designed to elude clinical responsibility and weekend duty. In most instances our pilgrim will be greatly helped on his way, often within a matter of weeks. Let us assume, however, that our patient’s problems are very stubborn and most resistant to treatment. Let us also assume that the unit has a maximum limit of stay, which the patient is rapidly approaching, or that the Utilization Committee is breathing down the neck of the attending psychiatrist. At this point, if the patient or his family are still solvent and/or are blessed with wonderful health insurance, the patient may be transferred to a private psychiatric hospital, often at some distance from the patient’s home. Being treated in a private psychiatric hospital at some distance from the patient’s home is not always a disadvantage. I have seen many instances of patients who have made brilliant recoveries after entering or being transferred to such private psychiatric hospitals. Be that as it may, let us once again assume that our hapless pilgrim has a most stubborn illness or that his family runs out of funds to pay for further private hospital care. At this point a number of conferences take place, more serious perhaps than any that have occurred until now, and the recommendation is Finally made that the patient be transferred to the neighboring state hospital. At this point, and at the risk of mixing my metaphors, let me jump from John Bunyan’s Pilgrim’s Progress to Jacobowsky and the Colonel. You may remember the delightful Broadway play of that name in which Jacobowsky tells the story of “the two possibilities” to illustrate the unquenchable optimism of the Jew in the face of certain disaster. According to one version of the story, Jacobowsky meets Yankel, his anxious fellow Jew who is faced with induction into the army. The following dialogue takes place:
418
ZIGMOND
M. LEBENSOHN
Jacobowsky (to his friend Yankel): Don’t worry. There are always two possibilities. Either you are inducted or you’re not. If you’re not inducted, you have nothing to worry about. Y ankel: But what if I am inducted? Jacobowsky: There are still two possibilities. You can be assigned to combat duty or non-combat duty. If you get non-combat duty you have nothing to worry about. Yankel: But what if I get combat duty? Jacobowsky: Well, there are still two possibilities. Either you get wounded or you don’t get wounded. If you don’t get wounded, you have nothing to worry about. Yankel: But suppose I get wounded? Jacobowsky: Well, there are still two possibilities. Either your wound is fatal or it’s non-fatal. If it’s non-fatal you will be invalided out of the service so you will have nothing to worry about. Yankel: But suppose it’s fatal. Jacobowsky: Well, even here, there are still two possibilities. Either you can be buried in sacred ground or not. If you are buried in sacred ground then your soul will go straight to Paradise and you will have nothing to worry about. Yankel: But suppose I’m not buried in sacred ground? Jacobowsky: Then, my good friend, you’re in one hell of a mess! Our pilgrim patient (or Yankel, if you wish) has now reached the state hospital. But he is not necessarily in “one hell of a mess.” Nonetheless, to this day the very mention of the name of the state hospital often strikes dread into the hearts of nearby residents. Moved by fear, ignorance, or superstition, many might be reminded of Dante’s famous inscription on the portals of hell, “Lasciate ogni speranza, voi the entrate.” Yet, it is well known to any experienced psychiatrist that the recovery rate for most state hospitals, considering their niggardly support by state legislatures, has been remarkably good and compares favorably with other better endowed institutions. Many patients who have failed to make headway in other treatment facilities have gone on to full recovery following treatment in a state hospital. Let us now retrace the steps of our troubled pilgrim and list at least a few of the perils he has encountered along the way. THE OGRE OF CATCHMENTING
BASIN
The Ogre of Catchmenting Basin confronts only the pilgrim who has been headed in the direction of a community mental health center (CMHC). Our pilgrim patient, after conquering his doubts, fears, and misgivings, arrives at CMHC A only to learn from the receptionist that he is not eligible for treatment there but really belongs to the CMHC B catchment area. Can you imagine the discouragement and resentment of our pilgrim patient? No matter that CMHC A is nearer his residence or place of work than CMHC B. No matter that he has been referred to center A by a friend or relative who has received excellent treatment there and is now favorably disposed to the staff of center A. No matter that he has come to center A with built-up expectations and at considerable sacrifice of time and energy. The rules say he must go to center B, and off to center B he is sent packing.
PILGRIM’S
PROGRESS
419
The tendency of intake personnel at some CMHCs to place excessive stress on residency and eligibility gives the patient the feeling that the personnel are more interested in shifting him to another center than in learning about his problem and doing whatever possible to help. Patients tell me that they were met with delight when it was discovered that they did not “belong” to the CMHC being visited and with resignation when they discovered that they did belong. The mere fact that the patient arrives at a CMHC asking for help and is still warm to the touch should be enough to mobilize a treatment effort. There is, of course, very little incentive to add still one more patient to the treatment load. CMHC personnel are all on salary. They are not paid on the basis of how many people they serve. Their incentives are promotions on the basis of the quality of their work and the satisfaction of having done a good job. Perhaps the incentives need revision. COMMUNITY-REAL OR ILLUSORY? Perhaps a comment about the word community in the community mental health center movement is in order at this point. In most American cities the word community has become a kind of empty shibboleth, devoid of any real meaning. Most of us tend to use it with reckless abangon, often without bothering to see if the community really exists outside the walls of the center. It is almost as if we were trying to bring about the existence of the community in some kind of magical way by constantly repeating its name. Richard Goodwin, in his recent book The American Condition, has made a number of observations on the term community that are highly relevant to our subject. The brief excerpts that follow give the gist of his thinking. Today
some speak of the community
of Christian souls
munity
such abstractions enlarged.
the concept
The modern base from works
reflect
which
deprives
mon human
with young
healthy. Within
Americans
of our growing
pate unplanned women housing
meetings have
little
asserting burden
suburbs
The suburb components
are sterilized while college
or commitment
without
virtually
tions. citizens’
groups
or community
environment
are incarcerated
a
A man where of com-
in institu-
and city “pads”
love among
the young
are and
pleasure.
no place where neighbors Only
can antici-
disastrous
for those
small towns and lower income
laundromat
It is true that there are thousands
and leagues for recreation.
is merely
or companionship
store or park. This lack is especially
playground
can meet with some regularity.
or city block
campuses
the value of love. meaning
there is often
where women
of people who share a common
At best.
of the living reminders
the senile and retarded
to spend much of their lives at home.
a common
decline).
of social existence.
else. finds pleasure
His streets
for the elderly,
-no pub or corner
who are compelled projects
shops somewhere
projects
people passionately
of free men, and even the com-
a severe population
a lot of people are in the same boat. So
of community.
The aged and decrepit,
or in housing
the love that involves many
to believe that
none of these places.
responsibility:
from
reaches out to the scattered
in one place, sleeps in another,
tlons or hospitals
the community
is destroyed
most
the individual
he can and cares about
tilled
a vague inclination
of community
world
of nations.
(a once lively place now suffering
But they are not a substitute
-some
physical
setting
of clubs and associafor the regular
contact
and its concerns.’
Are we in psychiatry assuming a sense of community that does not exist? Are we attempting to create something in our small centers that can only be achieved by the sociopolitical process over a long period? Dr. Peter Randolph, the director of an East Coast mental health center, recently addressed himself to this very problem when he wrote:
420
ZIGMOND
One basic tenet of community
psychiatry,
that patients receive better care in their own commu-
nities close to home, is based on the assumption there are all kinds of communities
M. LEBENSOHN
that such communities
with greater
exist. Yet we all know that
or lesser degrees of coherence
and integration
and
greater or lesser capacity to deal with deviant behavior. We also know that in many of our cities there are a multitude
of different
communities.
Certainly
in a city such as Boston, it is not unreasonable
to
expect that many of the chronically
dependent and multiple handicapped
large part of our patient population
will tend to drift into the areas of the city which are least well in-
tegrated
and where
predictable
the sense of community
is characterized
that some of these patients will end up wandering
people who make up such a
by transience
and anomie.
It is
around public spaces in large public
buildings, which are not equipped to handle them. The danger involved here is clear enough. We will soon arrive at the situation in New York
State; the public will begin to feel that we are not doing our
job and the outcry raised will seriously impair our efforts to bring patients out of institutions and into more humane
settings. The opportunity
the very things that community education,
consultation
inherent in this situation is equally clear. There is a need for
psychiatry
has added to the mental health armamentarium:
and the provision of readily available
backup
public
services. We must be able to
provide these services to groups we had not previously thought of as being in need. By so doing, we can seize the opportunity
of participating
in the development
of better integrated
and more supportive
communities.2
Whether Dr. Randolph’s noble plans can ever be achieved by psychiatry alone or by the community mental health center movement, even with fullest possible support, is highly doubtful. The very question itself-whether psychiatry can play a role in the enhancement or revival of a sense of community-may be considered presumptuous by some and idealistic by others. Nonetheless, these questions must be faced honestly and openly if we are to arrive at a sensible solution or if we are to continue getting the support without which we shall certainly perish. SWAMP
THE
OF RIGID
SYSTEM
Whether he comes from a community or a “noncommunity,” our unsuspecting pilgrim patient who reaches out for help frequently finds himself ensnared in a system ostensibly designed to give service, but which often ends up as a rigid system dealing in nonservice. Many of the mental health delivery systems in operation throughout the country seem to be ingeniously designed to put as many obstacles as possible in the path of the patient seeking help, particularly if the patient is very sick, psychotic, or an emergency in need of hospitalization. A recent example from a large eastern city will illustrate the system in all its lurid dimensions. A 42-year-old
white male widower was brought to the emergency
bulance at 7:40 A.M.
His wife had died 6 months earlier,
room of a general hospital by am-
and since then he had become withdrawn,
isolated, and deeply depressed. The depression was intensified by alcohol, and he became preoccupied with suicide. He was seen immediately also examined that
by the night physician of the emergency
by the regular emergency-room
the patient
needed psychiatric
resident was called; he examined mended immediate hospital,
consultation
the patient,
hospitalization.
physician, this time a psychiatrist and recommendations the local community
and immediate
hospitalization.
there were no psychiatric
in the emergency
on the staff of the hospital.
and instructed
thereafter
he was
The psychiatric
made the diagnosis of psychotic depression, and recom-
Unfortunately,
and the patient was kept temporarily
room. Shortly
physician who had just reported for duty. Both agreed
the emergency-room
beds available
at that
room until he was seen by a fourth
He agreed with the previous diagnosis
nurse to arrange for a routine transfer to
hospital.
The nurse, who was very experienced ments for his transfer.
in such matters,
She first called the headquarters
was totally unsuccessful in making arrangeof the local CMHC.
She was then referred
to
PILGRIM’S
421
PROGRESS
the community
psychiatric
hospital
in another
part of the city. From there she was referred
back to
headquarters of CMHC. This time she was referred to an Outreach program located in a church in the patient’s catchment area. Completely frustrated by this time. she called the staff psychiatrist who told her he would try to arrange for the patient’s immediate hospitalization. The psychiatrist was as unsuccessful as the emergency-room nurse. He made four telephone calls. each time attempting to speak with a physician who might be able to approve the patient’s admission. The last call was to a woman who identified herself only as a person who could approve emergency admissions. Success at last! Or so it seemed. But then she wanted to have still another extensive history and examination of the patient. This material would then have to be reviewed and approved by some sort of it committee. Only then might the patient be approved for admission. This struck the psychiatrist as being not only totally unworkable but as coming straight from never-never land. Since she seemed unwilling to accept the unanimous recommendation of four physicians, the psychiatrist suggested that she examine the patient herself. She said she would not see the patient in the emergency room. Although she realized that the patient would have to be transferred to her via ambulance. that was the only way she could evaluate the patient for admission. At this point everyone gave up. Four hours and innumerable telephone calls later, a frustrated, embittered. and exhausted staff arranged for the sick man’s transfer to a less suitable facility.*
Unfortunately, this is not an isolated example. Psychiatrists and all mental health professionals must redouble their efforts to eliminate the rigidities in our systems so that they can really be of service to those in need. THE
VALLEY
OF CHRONICITY
Chronicity may be defined as any condition that is of long duration and fails to respond to treatment. To be sure, some disorders, by their very nature, tend to be chronic. Such disorders, however, are not the primary concern of our present discussion, but even these cases deserve periodic reevaluation, reassessment, and therapeutic trials to be sure that the chronicity is real and not induced, Our chief concern (and the concern of our pilgrim patient) is that psychiatrists and the mental health service system may be contributing to chronicity (unintentionally, of course) in cases which need not be chronic at all. It has been the custom to heap most of the blame for chronicity on the iarge public mental hospital.The sad truth is that every segment of psychiatry, every step in the Linear Path Downward, has had its share in producing chronicity. The general practitioner contributes to chronicity by keeping an emotionally disturbed patient unnecessarily and for long period of time on sedatives or tranquilizers, or by ordering a host of unnecessary x-rays and laboratory tests, thus conveying the impression that the problem is somatic, or by delaying referral to a psychiatrist. The psychiatrist and the psychoanalyst contribute to chronicity by inadvertently fostering excessive dependency on therapy. Either they do not make sufficient effort to wean the patient from this kind of dependency or fail to consider the possibility that the patient may be helped by other modalities such as chemotherapy. The case of the 40-year-old biochemist with a long history of bipolar manicdepressive illness will illustrate my point. He had been hospitalized on at least four separate occasions for manic episodes and had made one serious suicidal at-
*I am grateful
to Steven Steury,
M.D., for the details of this case.
422
ZIGMOND
M. LEBENSOHN
tempt. He was referred to an analyst in another city when he changed jobs. The analyst saw him four times a week, but in spite of this intensive therapy he had two more manic episodes and one severe depression in a 2-year period, each requiring hospitalization. During one of the hospitalizations his analyst went on vacation and turned the case over to a psychiatrist who placed the patient on lithium carbonate. Since then 7 years have elapsed without any recurrence of symptoms requiring hospitalization. He is seen once every month or two for brief sessions and for checks on his blood lithium level and has remained in excellent health. The psychiatric unit of the general hospital is usually not conducive to chronicity, because most of them are designed for short-term treatment, and many have a maximum limit of stay. But if the unit is in the practice of indiscriminately applying only one treatment modality (electroshock for example) without adequate use of chemotherapy or psychotherapy, chronicity may also result. Private psychiatric hospitals contribute to chronicity when they refuse to use psychoactive drugs, specialize in only one modality of treatment, and insist, somewhat unrealistically, that the patient achieve a very high level of adjustment before returning to the community. Public mental hospitals contribute to chronicity when they fail to provide specific treatment that could cut short hospital stay. Electroshock therapy is a case in point. A whole generation of young psychiatrists are being trained without any experience in this valuable treatment method, which in spite of all the brouhaha to the contrary remains a most remarkable, effective, and often life-saving treatment method when properly used. THE
RADIAL
CONCEPT
OF PSYCHIATRIC
SERVICES
We have, I believe, tarried overlong in the Valley of Chronicity, and it is time we search for a way out. You may remember that one of the ways our pilgrim patient got into this mess was by getting caught in the concept of the Linear Path Downward. What I propose to counteract the potential perils of linear descent is the Poly-Belted Radial Concept of psychiatric services (Fig. 2). In this scheme, the patient, instead of being a helpless object pulled by gravity to ever lower levels, is conceptualized as being in the center of a circular pattern, free to avail
_
PATIENT-
PSYCHIATRIC UNIT GENERAL HOSPITAL
PSYCHIATRIST
Fig. 2. Poly-belted radial concept of mental health services.
PILGRIM’S
423
PROGRESS
himself of the services of a wide variety of psychiatric outpatient and inpatient treatments based on what is best for him at a particular point in his illness. The various treatment modalities are thus not seen in a hierarchical order with any one method considered intrinsically better than the one below it, but rather as a wide range of modalities, any one of which may be just right for that patient at that time. But, as Shakespeare put it, there’s the rub. It is difficult, indeed, to determine what is best for a particular patient at a given time. But therein also lies the art and skill of the psychiatrist. This specific art and skill has never been sufficiently stressed in psychiatric training or in practice. Thus many psychiatrists emerge from training with a shockingly constricted overview of the rich assortment of treatment modalities available even in their own communities. One way to remedy this deficiency, aside from the obvious device of familiarizing each resident with all psychiatric modalities available in the area, is to place the psychiatrist in the very front line in a kind of “triage” position. I know that this is contrary to established tradition, which insists that the patient struggle first past a clerk, than an intake social worker, and than a clinical psychologist. Finally, after all the paperwork has been done, the psychiatrist, at the top of the pecking order, becomes involved with the case. This does not necessarily mean that he actually sees or talks to the patient. In many cases it may mean only that the psychiatrist presides over an impressive conference in which impressive reports are read and following which an impressive treatment plan is drawn up. The report, no matter how excellent, can never substitute for the live patient seen by the psychiatrist early in the illness when the symptoms are still fresh. What I suggest, wherever possible, is to reverse the order and arrange for the psychiatrist to be the first to interview the patient. After all, this is the procedure followed with great effectiveness in the private-practice sector, and surprising as it may seem, with a much lower average cost per treatment hour* than in the CMHCs. The experience of triage will certainly sharpen the psychiatrist’s clinical skills even though it may not bolster his ego as much as presiding over diagnostic and treatment conferences. Perhaps he can arrange to do both. The radial concept, with the patient surrounded by a ring of psychiatric services, means that he does not have to use these services in any particular order. I can conceive, for example, of situations in which it might be most appropriate for the patient to seek admission first to a state hospital where he could obtain the most effective available treatment for his particular disorder at that time. In another instance it may be best to start with a day-care center or a group therapist. Any one of the treatment modalities on the circle can be abused or used inappropriately and thus lead to chronicity. We now live in an age that considers hospitals “bad” and outpatient services “good.” There are neither bad nor good services in psychiatry; there are only appropriate or inappropriate treatments. For example, a 40-year-old government secretary was treated for 20 months in a day-care center for a stubborn depression, first without drugs and later, at her husband’s insistence, with them. When she became worse she was finally
*APA Practice
Task
Force No. 6, The Present and Future
in the Delivery
D.C.. June 1973.
of Mental
Health
Importance
Services. American
of Patterns
Psychiatric
of Private Psychiatric
Association.
Washington.
424
ZIGMOND
M. LEBENSOHN
transferred to the psychiatric unit of a general hospital where she received a small number of ECTs, with rapid recovery. In retrospect, it was clearly apparent that her case was totally unsuited for treatment in a day-care center or by group therapy-a judgment that could have been made within the first few weeks of treatment. SUMMARY
We have reviewed the tortuous path of our modern pilgrim on his way to mental health and have been dismayed by the number of obstacles that we as psychiatrists have inadvertently put in his way. What can we do to help clear the obstacles and speed our pilgrim toward his goal? To begin with, we should give him a new road map. Neither he nor we should be forced to use the outdated concept of the Linear Path Downward. Thinking in terms of the radial concept of psychiatric services should do much to offer the patient and his psychiatrist quick availability to a wide variety of treatment methods, one of which should be best suited to the patient’s needs. Psychiatrists need more training in all the accepted methods of treatment and should become familiar with all the resources of their community. Psychiatric services should rid themselves of their superfluous rigidities, so that our pilgrim need never again fear the Ogre of Catchmenting Basin. Psychiatrists must redouble their efforts to convince administrators and legislators that systems were designed to serve people; people were not designed to serve systems. Since people by their very nature are not rigid, they cannot be treated by rigid systems. By all the means at our command we should do everything possible to keep our pilgrim from the Valley of Chronicity. In doing so we must also remember that there are always some conditions that are resistant to cure. We should be guided by the old medical maxim that wisely states that we should always try to cure. If we cannot cure we should at least try to ameliorate. If we cannot ameliorate, at least we should do no harm. A word of caution is in order. In our great zeal to avoid chronicity, I am afraid that psychiatrists, goaded not too gently by our fiscal and legal brethren, have succumbed to the current mania for mass deinstitutionalization. We have deluded ourselves into believing that discharge from the hospital, even though premature, is tantamount to recovery. We have told our legislators and fiscal experts that extramural treatment in the community is less costly and more effective than treatment in a hospital. We have told our lawyer friends, “See, we are on your side. We don’t want to keep anyone in the hospital against his will either.” What we have been doing by the senseless large-scale discharges of sick patients (not only in New York State but in other states as well) is to produce a form of dangerous extramural chronicity that does incalculable harm to the patient, to society, and to psychiatry itself. Many of these patients are totally unsuited for outpatient therapy, and even if they were, our present outpatient facilities are totally incapable of coping with this crushing load. Furthermore, there is increasing evidence that good extramural treatment costs more, rather than less, than hospital treatment. We must now address ourselves to this serious problem with all the zeal and ingenuity we possess. We must elevate the level of
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treatment in all our large mental hospitals to such a degree that most of our patients will elect voluntary or informal admission. We must learn to be comfortable with patients who can and do leave the hospital if they feel they are not receiving adequate treatment. Determination of the length of stay in the hospital should return to being primarily a clinical decision for the benefit of the patient and not a fiscal or legal determination made by well-intentioned but misguided zealots. But we must also put our own house in order. To help eliminate chronicity in the future, I make the following ten recommendations: 1. A psychiatrist should never be satisfied with any case that continues for too long a time. Periodic review of all long-term patients should be mandatory. Much of this will come about by peer review organizations whose task, although necessary, is awesome in its implications. 2. Become familiar with all possible treatment alternatives. Avoid overspecialization. Specialization is here to stay, but some psychiatrists and some hospitals are so overspecialized in one and only one method of treatment that I am moved to make a musical analogy: I do not object to psychiatrists specializing in the use of one instrument; they often become quite skilled at it. But I do object strenuously when they specialize in playing only one note on that one instrument. The results are boring in the extreme, and the audience is either numbed into submission or incited to revolt. Do not be a one-note psychiatrist. 3. Avoid sectarianism and parochialism. We psychiatrists have become the victims of our own overly rigid training programs. We have institutionalized our own prejudices to the point of becoming sectarian and parochial to an alarming degree. 4. Seek constantly for the specific diagnosis, elusive as it may be. There is always a better chance for rational treatment when a specific diagnosis can be made. Nothing, as Seymour Kety has stated, has done more damage to the concept of mental illness than the ambiguous attitude toward psychiatric diagnosis.” 5. Be imaginative and ever-questioning. Ask yourself, “Is there any method that has not been tried that might offer some help?” 6. Pick the treatment that fits the patient--not the patient who fits the treatment. Match the best available treatment method with the specific disorder of the individual. 7. Never hesitate to ask for consultation. 8. Review your incentives. When a patient and his psychiatrist settle down to a mutually comfortable relationship there is often precious little incentive to terminate. Chronic dependency may result. We must seek for appropriate incentives that will reward effectiveness of treatment as opposed to length of treatment. 9. Be constantly aware of economic factors. Third-party, state, or federal payments do not affect the individual’s pocketbook as does fee for service. Hence the patient goes on blithely assuming that “someone else” is paying for his therapy. When he starts paying the bills himself he is often jolted into reality. It is curious to note the frequency with which many patients begin to make rapid progress just at this point. 10. Reexamine the potentially harmful effects of compensation. In the past
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many state and federal programs were justly accused of fostering chronicity by rewarding patients for remaining ill. More recent trends properly emphasize rehabilitation and treatment instead of compensation, but much more needs to be done in this area. Just as there is no single cause for mental illness, so is there no single treatment method. There is no justification to be smug about any one approach in psychiatry. The medical model, that most ancient, honorable, and useful model, has come under heavy attack in recent years, particularly from those who do not really understand it. Although other models may be useful from time to time and in certain instances, no other model can be as broad or all-inclusive and as subject to scientific scrutiny as the medical model. As Kety recently put it: The medical model of an illness is a process that moves from the recognition and palliation of symptoms to the characterization of a specific disease in which the etiology and pathogenesis are known and the treatment is rational and specific. That progress depends upon the acquisition of knowledge and may often take many years or centuries. Numerous medical disorders and one or two mental illnesses have moved to the final stages of understanding, but many are still at various points along the way. After the recognition of symptoms, there comes the realization that some symptoms occur in fairly regular clusters, which are then described as syndromes. These may ultimately turn out to represent one or several etiological and pathogenetic components, the nature of which may be obscure at earlier stages of knowledge. The evolution of a medical model from symptoms through syndromes to diseases with specific pathology and, ultimately, with definitive etiologies and rational treatment is an excellent example of the scientific method applied to the alleviation of human suffering. It involves careful observation and study, the generation, sharpening, and testing of hypotheses, and the elucidation of underlying mechanisms, all pointing toward prevention and effective treatment. In many instances throughout medicine, this process has been successful, and there is justifiable concern that the fruits of this knowledge
are not available
to all the po$rlation.3
If psychiatrists of the future can be trained to understand and use the medical model in psychiatry as Kety suggests, our pilgrim will have no cause for worry. He will always be able to opt for the better of the “two possibilities.” REFERENCES I. Goodwin
RN:
The
American
Condition.
New York, Doubleday, 1974, pp 77-82 2. Randolph PB: Editorial. Mass J Mental
Health Vol4, No 3, Spring 1974 3. Kety SS: From rationalization Am J Psychiatry 131:959, 1974
to reason.
