Canadian Psychiatric Association Journal Vol. 20

OUawa, Canada, November 1975

No.7

Presidential Address THREE CHALLENGES*

COLIN MCPHERSON SMITH, M.D.1

"Les hommes qui ont une foi excessive dans leurs theories ou dans leurs idees sont non seulement mal disposes pour fa ire des decouvertes, mail ilsfont aussi de tres mauvaises observations . . . L' esprit vraiment scientifique devrait done nous rendre modestes et bienveillants. Nous savons tous bien peu de chose en realite, et nous sommes tous fallibles en face des difficultes immenses que nous offre l'investigation dans les phenomenes naturels. Nous n' aurions done rien de mieux a faire que de reunir nos efforts au lieu de les diviser et de les neutraliser par les disputes personnelles,' , Claude Bernard (7) •'Il n'y a point de doctrine plus propre iI l' homme que celie Iii: qui l'instruit de sa double capacite de recevoir et de perdre la grace, a cause du double peril ou il est toujours expose de desespoir ou d' orgueil." B. Pascal (63) Our meeting this year is especially memorable because it is our silver anniversary and is being held in Banff, the beautiful site of our first major scientific meeting in 1952. The intervening years have been kind to us. They have seen a tremendous growth in the Association, from a mere handful of members to the current figure of about 2,200, of whom, 1,300 are active members. Concurrently, there have been impressive changes in our specialty. The number of psychiatrists and other professionals has greatly increased, along with the volume of services delivered. The number of patients in mental hospitals has dramatically declined in Saskatchewan there were over 4,000 patients in 1951; now, there are only 350 (82, 83). There has been increased emphasis on community • Presidential Address, Canadian Psychiatric Association, Silver Anniversary Meeting, Banff, Alberta, September 1975. 1, Clinical Professor of Psychiatry, University of Saskatchewan, Executive Director, Psychiatric Services Branch, Saskatchewan Department of Health, Regina, Saskatchewan. Can. Psychiatr. Assoc. J. Vol. 20 (1975)

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care, but when hospitalization is necessary, staff/patient ratios are far better now. Institutions which were little more than warehouses for discarded personalities have virtually disappeared. Many psychiatric hospitals have become accredited by the Canadian Council on Hospital Accreditation. There has been much emphasis on an interdisciplinary or team-work approach to mental illness problems, New medical schools with psychiatric departments have been founded. There is also some evidence of at least modest improvement in public attitudes towards mental illness (3, 4, 16). Psychiatric literature has grown enormously both in depth and in range. Current texts, such as the Comprehensive Textbook of Psychiatry (27) and the American Handbook of Psychiatry (2) bear eloquent testimony to this. We may wonder with Montaigne (57) whether

" . . . je trouve bien plus rare de voir convenir nos humeurs et nos desseins. Et ne jut jamais au monde deux opinions pareilles, non plus que deux poils ou deux grains. Leur plus universelle qualite, c' est la diversite,' , Certainly, our postgraduate students find the problem of mastering this expanding knowledge increasingly difficult. Indeed, it has been said with some truth that the major problem facing psychiatry is not adversity but diversity. \ Meanwhile, the demand for the services of psychiatrists continues to increase and is limited chiefly by problems of health care financing. Yet the future is not entirely unclouded, and many papers, speeches and books attest to the criticisms being levelled against psychiatry (13, 14, 23, 24, 29, 87-91). In some cases the criticisms have been frankly iconoclastic, in others reasonable and constructive; but in either case the evidence should be examined on its own basis to avoid an argumentum ad hominem. Some psychiatrists have been unduly disturbed by the problems confronting our profession today, and Dr. John Spiegel in his recent thoughtful Presidential Address to the American Psychiatric Association (87) even referred to the four 'Cs' facing psychiatry - crisis, criticism, controversy, and contempt. I would prefer to conceptualize the problems of psychiatry in terms of three major challenges which have yet to be fully engaged, for the problems are not mere threats but provide exciting and unrivalled opportunities for growth and development. First, what are the proper limits of our specialty and how can our scarce resources be allocated more effectively? Second, has as much as possible been done to help those people whom

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society has defined as life's losers? Third, what are the proper standards which should govern the whole psychiatric enterprise? It is to be hoped that the courage, the determination, and the strength will be found to meet these three challenges as successfully as Great Heart in the charming old Indian tale of the three tests (50, 86).

Psychoethics Ethical and scientific issues are deeply intertwined in the answers to these questions. These issues are too seldom discussed and one looks in vain for any examination of psychoethics in most texts. The term 'psychoethics' implies that in the investigation of the good life or personality, the different dimensions of man's nature must be kept in mind (8). Patients, therapists and society must operate under some conception of what the nature of the therapeutic endeavours should be. In fact, there is significant evidence of staff and patient conflict in the perception of the helping process (53, 54). Psychiatrists have tended to be somewhat uneasy about the application of ethical and scientific concepts to their specialty. For many, it was sufficient to feel that the patient was being helped according to subjective judgment. Some were perturbed when Torrey (90) suggested that cultural factors might be crucial in the helping relationship, and that witch doctors might be very effective within their particular cultural context. Torrey's (90) data are inconclusive as were Eysenck's (20) before him, but such studies highlight the requirement of a firm evaluative basis, using objective, shareable and reliable data, in terms of which specific hypotheses regarding treatment modalities may be soundly assessed. The aims of the enterprise must be defined in ethical terms and assessed in scientific ones. This is not easy - patients are complex human beings. Wittgenstein has expressed part of the problem: "The difficulty, is not to say what one does not know." It is possible to build up concepts which are not securely anchored to facts, and to make elaborate statements which do not convey information at all. It was the Vienna circle which introduced the saying that, "The meaning of a statement is the method of its verification." Their approach was useful in helping to clarify statements of fact but was incomplete as a theory of meaning itself. For the difficulty is surely greater than this and lies in going beyond the facts to the world of ideas, without substituting obscurity of expression for the expression of obscurity. Sir Karl Popper's (68, 69) concept of the three worlds is useful in

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clarifying ethical and scientific problems. He distinguishes between the world of material objects (world 1), a subjective world of minds (world 2) and finally, a world of ideas, science, art, language, ethics, institutions, and so on, (world 3). Although all world 3 entities are products of the human mind, they may exist independently of any knowing subject. He says: "Man has created new worlds of language, of music, of poetry, of science; and the most important of these is the world of the moral demands, for equality, for freedom, and for helping the weak. " (67) Norms or standards such as 'Thou Shalt not Steal' are not facts and cannot be derived from them. Popper comments: "The view that norms are man-made is also strangely enough contested by those who see in this attitude an attack on religion. It must be admitted, of course, that this view is an attack on certain forms of religion, namely, on the religion of blind authority, on magic and tabooism. But I do not think that it is in any way opposed to a religion based upon the idea of personal responsibility and freedom of choice." (67) Such opinions are not incompatible with the view that ethical laws are given to us by God. But neither do they presuppose it. For it is we who are responsible for accepting or rejecting them. It seems that Sartre is overly pessimistic when he tells us:

"pense qu'il est tres genant que Dieu n' existe pas, car avec lui disparait toute possibilite de trouver des valeurs dans un ciel intelligible." (76) The view taken here is that norms are fundamental and irreducible, not in the sense of being a priori valid as Kant, for example, supposed, but that they arise from the necessity of imposing a regularity or order to the world in which we live. Like scientific concepts, they are psychologically a priori, rather than a priori valid. They are just as essential to psychological well being as vitamins are to physical health.

The Doctor's Dilemma or the Challenge of Limits and Priorities The first challenge is perhaps best introduced by a statement of a past president of the American Psychiatric Association that: " ... actually no less than the entire world is a proper catchment area for present-day psychiatry, and

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psychiatry need not be appalled at the magnitude of the task." (74) The statement is staggering in its implications, particularly when taken in conjunction with findings of surveys such as the Midtown Manhattan and Stirling County Studies which suggested that only about 20 percent of the population could be considered well or symptom-free. If the whole world is our catchment area, where do we begin? Who shall be first? What are the most important problems to be tackled? This is the essence of the challenge oflimits and priorities. It was Jules Romains' Dr. Knock (73) who said, "Les gens bien portants sont des malades qui s' ignorent." The population surveys have been criticized for almost eliminating the existence of health, but this is unfair. If all minor forms of physical ill-health were included, perhaps indeed about 100 percent of people surveyed would illustrate some minor disability. The problem in psychiatry goes deeper than this; there is considerable disagreement about who should be selected for treatment. For example, Henry, Sims and Spray (35) found in their study of 4,300 psychotherapists that 5 to 22 percent of the patients treated were "relatively healthy", while most of the therapists had little experience with blacks, low-income groups, children, the aged, alcoholics and addicts. If, indeed, the "whole world" is the catchment area, what are the principles which should govern the allocation of care, given the relative scarcity of professional personnel? The gap between the few who are receiving psychiatric care and the needs of millions is one of the great credibility gaps of psychiatry today. Also it is often the least sick who seem to get the best care. Moreover, there is a serious problem of mal-distribution of professionals, with high concentrations in the great metropolitan centres. Even on Freedma~'s conservative estimate of 10 percent of people who are psychiatrically ill (26), how can existing specialized resources provide adequate care? The data from most studies of general practice suggest that if only the care of what might be called the 'classical' psychiatric conditions (psychoses and neuroses) were undertaken there would still be a flood of cases. Some think that psychiatrists should concern themselves only with such disorders. Certainly, the further away the psychiatrist goes from conditions in which there is a firm medical basis for diagnosis or treatment, the lesser becomes his expertise and authority. However, even in the traditional psychiatric domain, it will

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be advantageous if the psychiatrist can also act as a consultant to general practitioners and others. In Saskatchewan patients with psychiatric labels, diagnosed by physicians, tended to cost (under Medicare) three or four times as much as sample controls (11), but most of these extra costs were for non-psychiatric services. When regular consultative services to general practitioners were provided it was surprising how much more effective and comfortable they became with their 'psychiatric' patients (49, 83, 85). The example is a simple one, but it is the paradigm of others. Surely the psychiatrist must teach his methods to other helping persons if large-scale problems of human anguish are to be tackled successfully, and the work of KiiblerRoss (45) illustrates this. Every dying person does not need a psychiatrist, but a psychiatrist is particularly well placed to make a contribution to the understanding of the problems of the dying by virtue of broad training in the medical and psychosocial fields. Such contributions will flow from the psychiatrist to other front-line workers who deal with troubled people. He must become more of a consultant, as well as concentrating on the more severe cases in which medical, psychological and social factors are closely interlinked. Our care-giving responsibilities must be shared with other professionals as well as with non-professionals, such as indigenous workers. There are many controversial areas to which psychiatrists must make a contribution. In such cases they should proceed cautiously, evaluate carefully, and avoid flaunting a non-existent authority. It would be wrong to turn away from such challenges; psychiatrists have a role to play, but it should be on the basis of scientific enquiry and careful assessment. For example, recent work supports the relevance of biological and genetic factors in some types of psychopathy and criminality (21, 27, 38, 79), but contributions in such areas are usually best made in a research setting, unless there is an association with clearly established clinical entities. No subject is more clearly beyond the frontiers than mental health. For years the euphemism 'mental health' was used when 'mental illness' was really meant. So many foolish things were said in the name of 'mental health' (91) that many psychiatrists have retreated in alarm from the whole subject. This is an over-reaction. Many workers in the field have had important things to say about positive mental health as opposed to the mere absence of mental illness. These include Fromm, Allport,

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and Maslow (1, 30, 31, 51), as well as earlier workers such as William McDougall (48). Piaget (64, 65) and Kohlberg (43, 44) have made important contributions regarding the development of moral character. Rokeach (72) has pioneered in the experimentai study of values. There has been increased interest in the subjects of religion, moral character, ethics and deviant behaviour, mainly from a more experimental frame of reference (10, 18,92). Much of this work receives curiously little attention in these massive psychiatric textbooks which threaten to crush us by their sheer weight; yet many of the problems affecting people today appear to be characterized by a lack of meaningfulness in their lives, rather than something which can be labeled an illness in the classical sense - thus, the suggestion by Rollo May that we are in an age of apathy or disordered will (52). Certainly, there is a rise in the frequency of cultism, violence, crime, vandalism, dropouts, faddism, alienation, and dependence on drugs and alcohol. Psychiatrists must seek a greater understanding of the conditions which bring about a rise and fall in such phenomena and their relationship to biological, social and psychological variables, but we must enter this area as pioneers rather than as pundits, and as researchers rather than social reformers. Dr. Christopher Evans (19) in a thoughtful and sympathetic review of the newer sciencefiction religions writes: "The gap between the discoveries at the frontiers of science and their assimilation into some useful cosmological theory is already immense, and there is a danger that it may grow wider still. . .. In their heart of hearts people still want some fairly simple; reasonably logical answers to the questions that human beings have always asked answers which will ease the chill which we have all felt when, in the small hours of morning, we wonder about life and death, time and space, creation and destruction. "These gaps, we will all have to agree, are increasing. And if science and present-day philosophy currently obsessed with semantics and linguistics - are unprepared to offer help, while the great world religions offer only outworn, outdated and implausible concepts, then the field is ripe as never before for stop-gap systems, pseudoscientific philosophies, quasi-technological cults and new Messiahs to emerge. " There is much to be said for John Fowles' (25)

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argument that a major problem of our time is the fear of insignificance or nothingness which he calls the 'nemo' , He writes: "The nemo is a man's sense of his own futility and ephemerality, of his relativity, his comparativeness; of his virtual nothingness. " The limitation of knowledge in the field of positive mental health must be faced but its importance must not be denied. Man cannot live by bread alone, but needs to create some picture of his role in the moral and cosmological spheres. The words of Immanuel Kant (41) are still valid in the final analysis: "Two things fill the mind with ever new and increasing admiration and awe, the oftener and more steadily we reflect on them: the starry heavens above and the moral law within. " It may be objected that the wonder accorded to the starry heavens belongs today to astrology rather than to astronomy, and that moral chaos, rather than order, reigns. But both phenomena are products of man's desperate search for meaning and order within a universe of dizzily accelerating change; a need which is as deep-seated and inherent as the dependence of the body on an essential foodstuff. Modern psychiatry in its preoccupation with technology has had little to say about the moral or spiritual needs of man. Freud (28) could write that: "The impression forces itself on one that men measure by false standards, that everyone seeks power, success or riches for himself and admires others who attain them, while undervaluing the truly precious things of life." But Freud's own theory was basically psychopathological and did not really enhance our understanding of why there should be 'truly precious' things of life at all. We badly need more research into the subject of mental illness, but even more do we need enhanced understanding of mental health. Yet at this time the federal government has failed abysmally and deplorably to provide the leadership it should, dissolving its mental health division and cutting back on research funding. At a time when the mental health of the country has probably never been worse, this strikes a new low in terms of political responsiveness to the needs of the people. We all know about the rising costs of Medicare and the problems created. To a large extent the

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politicans brought these problems upon themselves. They must be solved by reason, not by running away. It seems probable that a promising approach to both mental health and mental illness lies in an attempt to persuade people to change their life styles. The contrast in mortality between Utah and Nevada, for example, does seem to strikingly illustrate the effect of life styles (32). And Brenner's (9) work provides an interesting link between admissions for mental illness (and other social and health indicators) on the one hand, and the state of the economy, for example, the unemployment rate, on the other. Such work in the mental health field remains in its infancy and will so remain unless actively supported through governmental funding. There are no easy solutions to these topics. They are at the frontiers of knowledge. Psychiatrists have to approach them with humility and work with others towards their solution. The key is to determine how we can best use our resources in the interests of the individual and of society. People may be helped directly or through others, or they may be enabled to help themselves; all three modalities are important. It is vital that the Canadian Psychiatric Association provide real leadership in resolving the 'identity problems' (36) of modern psychiatry and also that it help define goals and objectives for the profession, which are idealistic but also feasible and realistic, and dedicated to the needs of the people. Priorities must be set and reasonable limits defined, and we must be careful neither to claim too much nor to dare too little.

Life's Losers If a visitor from Mars were to come to this planet to review our services to the mentally ill, he would probably expect to find a concentration of the most capable professionals where the most intractable human problems exist - in mental hospitals, jails, and slums. He would find, instead, that it is precisely in such settings that it is most difficult to obtain the services of psychiatrists. He might be quite perturbed to find that existing evidence suggests that psychiatrists (and other therapists) are most comfortable with people of their own social class and background. A few years, ago, Schofield (78) described the YAVIS syndrome - the tendency of therapists to select people who were young, attractive, verbal, intelligent, successful and, usually, female. The Nader study group (13) took this up again in their recent attack on the Community

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Mental Health Centres in the United States. Fuller Torrey has raised much the same kind of issue in his cross-cultural review (90, 91). Indeed, if our visitor were a classical scholar, he might be excused for wondering whether Plato's (66) contrast between the physician of the slave and that of the free-man had yet been fully resolved. Certainly, there is evidence from studies in the United States that if a psychiatric patient is well educated and has a good income, he is more likely to receive some form of insight therapy. If poor, his treatment is more likely to be of a short-term, supportive nature, or to include some form of physical treatment. There is also evidence that lower-class patients stop treatment sooner than middle-class ones, and that even when financial barriers are removed, patients of lower socioeconomic class are less likely to be accepted in psychotherapy. Paradoxically, psychiatrists tend to see more sickness in the lower classes, and there has been some suggestion that the high degree of pathology found in the lower socioeconomic strata in studies such as those in Midtown Manhattan and Stirling County is in part at least the product of viewing the lower classes through the looking glass of a middle-class set of values (22, 37, 53, 54,71,75). Some recent books have indicated that the problem of life's losers continues to exist. For example, Henry et at. (35) in Public and Private Lives ofPsychotherapists have this to say: "With regard to the patient's emotional suitability for psychotherapy, the practitioners in our sample apparently find the degree of fit between the therapists and patient's religiocultural affinity to be the best screening device .... Since religiocultural congruence is a basic factor in the selective matching of therapists and patients we can only conclude that psychotherapy is primarily an affective rather than an intellectual venture. Perhaps that is why psychotherapists rely so heavily upon their own personalized, idiosyncratic set of beliefs and practices to conduct such relationships." They continue: "In the everyday social world 'birds of a feather flock together', presumably in part because they talk the same language and hence feel comfortable not only with the terminology used but with the trend and flow of the conversation and with the cognitive and intellectual processes used in deriving conclusions. Since psychotherapists

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specialize in the performance of verbal therapy it is not surprising that they prefer patients who can talk their own language. " These are serious shortcomings of current practices. If psychotherapists are unable to understand those who do not speak their own language, perhaps they should become multilingual and learn the language of the poor, the oppressed and the downtrodden (33). Better training in sociolinguistics, sociology, anthropology and psychology are surely required. But also perhaps the spirit of the great lung's (40) words should be taken seriously: "Anyone who wants to know the human psyche will learn next to nothing from experimental psychology. He would be better advised to put away his scholar's gown, bid farewell to his study, and wander with human heart through the world. There, in the horrors of prisons, lunatic asylums and hospitals, in drab surburban pubs, in brothels and gambling-hells, in the salons of the elegant, the Stock Exchanges, Socialist meetings, churches, revivalist gatherings and ecstatic sects, through love and hate, through the experience of passion in every form in his own body, he would reap richer stores of knowledge than text-books a foot thick could give him, and he will know how to doctor the sick with real knowledge of the human soul.' , Psychiatrists need to be aware of the wide variation in human values within their own culture and that of others. It is good that the Canadian Psychiatric Association has shown a real sensitivity to this need. Thus, our present program contains an important series of papers on Canadian Native peoples' mental health and also a valuable group of presentations on transcultural psychiatry. Many of our members deserve great credit for their pioneering efforts in these areas. For one thing is certain: we must never allow the progress of psychotherapy to be turned back at the frontier of religiocultural congruence. And we must be sensitive as a profession to the needs of the aged, the underprivileged, minority groups and any other section defined by society as life's losers. The Search for New Standards For years, psychiatry has been bedevilled by low standards. In the past, mental hospitals were overcrowded and understaffed, both in quality and quantity. Recently, with reduced patient population, conditions have improved, but the burden has shifted from hospital to community,

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where there have been difficulties in providing reasonable care to former patients (3, 58, 81, 82). Meanwhile, the custom lingers on of adopting different standards of medical licensing for institutions as opposed to normal community practice; this should be no longer tolerated by the profession. Educational standards must be revised and upgraded. The fact that the second edition of the Comprehensive Textbook of Psychiatry (1975) had to be completely rewritten and is double the size of the first edition (1967) is but one indication of the rapidity of expansion of our field. Psychiatric training must be intensified to meet these standards, and new techniques of evaluation must be developed which are continuous, objective, and reliable (59). Psychiatric residents must be better prepared in the social and psychological fields than in the past and they should be better prepared to evaluate new knowledge, for much of their present training will soon be obsolete. In this respect, statistics, philosophy of science, and research design and evaluation deserve special emphasis. After graduation, the psychiatrist should continue his education throughout life through peer review techniques and participation in regular continuing education courses. While the present use of peer review techniques has been criticized (47), their effective use will ensure that high treatment standards are maintained. But their application in psychiatry is difficult and much work remains to be done in improving the methodology. It must always be remembered that medicine is an exact science: human lives depend on it and psychiatry is no exception in that respect. There is a great need for better methods of finding out (to put it crudely) what things work. Psychiatry and the social sciences have suffered from a kind of methodological essentialism in which too much time and attention is paid to such questions as what is schizophrenia, or what is the medical model, and too little to how people behave under carefully defined conditions. Even today, the text-books are full of vague systems and jargon that impede rather than help the understanding of people, and many writers in our field seek to persuade through literary rather than scientific means. There is, to be sure, a sense in which literary forms of communication offer more than scientific prose. In Simone de Beauvoir's words:

"seul le roman permettra d' evoquer dans sa realite complete, singuliere, temporelle, la jaillissement originel de l' existence." (6)

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But the use of the imagination must be followed by a test of the validity of the hypothesis generated. The appeal to selfevidence simply will not do. It was once thought self-evident that some women are witches, that the earth is flat, and that unbaptized infants were damned (80). In testing remedies on people, it is desirable to proceed by making measurements along a number of dimensions, one of which should be the patient's self-report (46,53,54,84). Too little use has been made of this in the past; yet the criterion of the' satisfied customer', while not by any means a complete criterion of success, is certainly an important ingredient of it. The subject of geographical standards is rarely discussed, save in frequent references to 'mal-distribution' of psychiatrists, with high concentration in the larger cities; yet physical distance influences utilization rates and also the type of client (14, 15, 42). Socioeconomic variables are important here and deserve to be more thoroughly studied. The problem of striking a reasonable balance between consumer needs and professional preferences is not an easy one, but it would seem that unless we professionals tackle it seriously and make positive proposals, it will fall to government by default. Positive incentives which encourage a more equitable distribution of professionals must be found so that human needs may be more adequately met. The Primacy of Ethical Standards It is perhaps the whole question of ethical standards which most requires the attention of psychiatrists at the present time. The very success of our field has opened the door to serious criticisms of our aims and achievements. We already have many powerful drugs and other treatment modalities with a profound capacity to influence the human mind. Soon we shall have still more potent ones. Perhaps we may have drugs which will render whole populations aggressive or passive at will. One shudders to think of possible state abuses: already one reads of shocking misuse of LSD by the CIA. But even on an individual basis difficult questions will arise. It is a profound responsibility to give to a man, even with his consent, a substance which may produce considerable personality change (no doubt with concomitant risks). Then again, maybe in a few years we really shall have a truth drug. How will it be regulated? The use of more effective behaviour therapy techniques is also fraught with the same kind of ethical issue. New types of brain surgery will no doubt be

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developed. There will be many a struggle between the desire for confidentiality on the one hand, and rapid access to information on the other. The criticisms of Thomas Szasz (88, 89) are essentially moral ones. In general, his answers are unsatisfactory. His oversimplified dichotomy of the 'problems of living' and 'brain diseases' represents a nostalgic attempt to return to the past when it was easier to separate mind and body. Perhaps it signifies a Rousseau-like longing for" la simplicite des premiers temps. " Such concepts have no place in a world in which rats succumb to pleasure and starve themselves for a little electricity in the right place, where we are beginning to find out about the neural pathways involved when we acquire new information (6 I, 62), or where genetic factors in antisocial behaviour are being uncovered (21, 27, 38, 79). But if Szasz can be dismissed lightly on scientific grounds, the ethical questions which he raises must be seriously considered by all psychiatrists. On the whole, it is extraordinary how little attention has been paid to the formulation of a detailed code of psychiatric ethics on the one hand, or a philosophy of the morality of the whole treatment enterprise, on the other. For one thing, there are inherent risks (39). Moreover, whether we act or withdraw in a treatment situation, our action (or failure to act) may profoundly influence the outcome. In practice, it has usually been implied that removal of the patient's psychopathology enables him to grow and develop into a more 'mature' way or one in accordance with his own 'true potentialities'. But the language of psychiatry is one of psychopathology, and psychiatrists have few clearly articulated principles to enable them to guide patients towards a goal of positive mental health. Certainly, psychiatry has as one aim the relief of unnecessary suffering, but were the total abolition of anguish to be adopted as the primary aim we might be faced with the chilling and nightmarish spectacle of whole populations rendered chemically tranquil - and surely in the process less distinctively human. In developing a framework of psychoethics, both the rights and the responsibilities of patients, of therapists and of society as a whole, must receive due consideration. How are these to be balanced in a way that is truly just? Rosenblatt (75) raises the interesting question of whether patients have the right to choose not to become independent, self-supporting members of society. However that may be, they clearly have certain duties as well as rights (93). The resolution of such

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problems in an explicitly formulated ethical system is one of our major tasks. In regard to treatment, it should be of particular concern that free and informed consent be given by the patient or by those acting in his best interests. In general, we should be cautious about treating people against their will. Certainly, there are some absolute indications for doing so, but safeguards must be built in to protect patient rights. Most emphatically, we must reject the role of jailers for those unfortunate people who are thought to be socially or politically undersirable. There is no place in psychiatry for terms such as the 'disease of dissent' or of 'delusions of social reform' which have occurred in the U.S.S.R. (55). Psychiatrists must never become mere agents of the social system. It is to out shame that we have not spoken out strongly against the apparent abuse of psychiatry in the Soviet Union. The World Psychiatric Association has failed to come to grips with this problem, but we ignore it at our risk and discredit. Here again, we are presented with a problem which is basically a moral one, and we have to take a stand rather than take cover. Fortunately, such abuses do not exist in this country but, even here, we have some problems and we must be alert to those and the possibility of others. An example would be persons detained under the 'pleasure' of the Lieutenant-Governor for long periods after having been found 'unfit to plead' or 'not guilty because of insanity'. Worse still are those transferred from prison, while on a determinate sentence, to a mental hospital where they are detained by Order-in-Council on an indeterminate basis. These unfortunates are virtually political prisoners and are likely to receive custodial detention rather than genuine treatment. The newer Review Boards should help to improve this situation, but it is highly unsatisfactory that the final decision to release or detain such 'sick' persons in psychiatric hospitals should rest with politicians rather than with psychiatrists. In general, we have to take a stronger position on social issues which affect our specialty. One example is therapeutic abortion. We should push for a clear statement in law, rather than justify therapeutic abortions on vague grounds of possible mental ill health. The basic issues are: who has control over a woman's body? What are the legitimate interests of society? What rights should be accorded the fetus? These questions are simply being evaded by politicians, and the responsibility transferred to physicians who are

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given no clear guidance as to how their judgment should be exercised. In the past, our profession has been troubled by feelings of ineffectiveness; now we are burdened with the awful weight of responsibility which derives from having too many powerful remedies (5). During the next few years the Canadian Psychiatric Association will have to apply itself more to ethical issues. A good indication of our concern for human values has been the recent formation of, and intense interest in, our Section on Religion and Psychiatry. However, the ethical issues must not be irretrievably linked with a religious doctrine but must be pursued with urgency and vigour on their own account. Role of the Canadian Psychiatric Association Despite attacks on psychiatry there has been tremendous progress during the past two decades. The psychiatrist, by virtue of his unique training in the biological and psychosocial fields, has a role to play which cannot be taken by any other specialist. However, the rapid advances in our field, together with the growing demand of society, have presented us with many problems as to how psychiatric services can be distributed most effectively and equitably. There are problems in serving the poor, aged, underprivileged and minority groups. There is a need to evaluate the diversity of our treatments more effectively. There are major ethical problems in the application of our very powerful remedies, and also in defining the goals of the therapeutic enterprise. The rights and duties of patients, therapists and society need to be clarified. The need to develop new understanding of the field of mental health and the growth of moral, cultural and esthetic values is paramount. These tasks will challenge our ability to produce well-trained psychiatrists. But psychiatry is too important for anything less than a well-trained psychiatrist. The Association has a vital part to play in future developments. Better public understanding of the role of the psychiatrist is of fundamental importance. Such understanding must include an appreciation of our limits as well as our accomplishments. We have a duty to speak out more clearly and effectively on social issues which are of direct concern to psychiatry, but we should be cautious with regard to matters which lie far away from the consulting room. We may indeed help bring about a better understanding of why men go to

war or commit crimes, but psychiatry is in no position to claim to abolish either. Our Association should make proposals which would help promote better health care in this country for all of its citizens. We must be concerned that the skills of psychiatrists are utilized appropriately, effectively and economically, and that they are reasonably available to all who need them. There must be no class, racial or cultural barriers to good care. Psychiatry is a scientific and ethical discipline, not an affective venture based on an ability to help only those who are like ourselves. We need to develop our own plans, and not simply react to these massive, wearisome, repetitious, highly theoretical reports of the philosopher kings of the health field (12, 17,23,24,34,60,70,77). Above all, we must show that it is the public interest, and not just our own interest, we have at heart. And we must demonstrate that idealism is not dead in Canada, despite the deplorable examples shown by some of society's leaders. I would like to end by referring to the four 'Cs' of which I spoke at the beginning. I suggest that, as far as the future is concerned, we re-define them to stand for 'courage', 'confidence' , 'cheerfulness', and 'compassion'. These qualities, together with our skill and knowledge, will enable us to care for and cure our patients more effectively. And if we do that, we have absolutely nothing to fear. References 1. Allport, G. W.: Pattern and Growth in

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Personality. New York, N. Y., Holt, Rinehart and Winston, 1961. Arieti, S.: (Editor-in-chief) American Handbook of Psychiatry, 2nd Ed. Vols. I-III (1974), Vols. IV-VI (in press), New York, N. Y., Basic Books. Aviram, W. and Segal, S. P.: Exclusion of the mentally ill. Arch. Gen. Psychiatry, 29, 126-131,1973. Badgley, R. F., Smith, Colin M. and McKerracher, D. G.: Study of mental illness. Part 1: The public, In 'Trends in Psychiatric Care'. Royal Commission on Health Services, Ottawa, 1966. Bazelon, D.: The perils of wizardry. Am. J. Psychiatry, 131, 1317-1322,1974. Beavoir, S. de: Cited in French Thought Since 1600. Potts D. C. and Charlton, D. G., London, Methuen, 1974. Bernard, C.: lndroduction II l'etude de la medecin experimentale. Garnier - Flammarion, Paris, 1966 (orig. published 1865).

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8. Bertocci,P. A. and Millard, R. M.: Personality and the Good. New York, N.Y., McKay, 1963. 9. Brenner, M., Harvey: Mental Illness and the Economy, Cambridge, Mass., Harvard University Press, 1973. 10. Brown, L. B.: (Ed.) Psychology and Religion. London, Penguin, 1973. 11. Cassell, W. A., Ramsay, J. D., Penman, D., and Rankin, M. G.: The development of a comprehensive computerized medical and statistical linking system. Can. J. Public Health, 61,203-209,1970. 12. Castonguay, C. (Chairman 1967-70), and Nepveu, G. (Chairman 1970- ): Commission of Inquiry on Health and Social Welfare. Quebec official publisher. Various volumes French and English 1967 13. Chu, F., and Trotter, S.: The Madness Establishment New York, Grossman, 1974. 14. Clarkson, J. G. and M. D. T. Associates: Mental Health and Retardation Services in Manitoba. Manitoba Dept. of Health and Social Development, 1973. 15. Cohen, J.: The effect of distance on use of out-patient services in a rural mental health centre. Hosp. and Community Psychiatry, 23, 79-80, 1972. 16. D'Arcy, C. and Brockman, J.: Public rejection of the ex-mental patient: are attitudes changing? Submitted for publication. 17. Dowie, Ian R. (Chairman): Committee on the Healing Arts, 13 Vols. Toronto, Queen's Printer, 1970. 18. Downie, R. S.: Roles and Values: An Introduction to Social Ethics. London, Methuen, 1971. 19. Evans, C.: Cults of Unreason. Hertfordshire, England, Panther Books, 1974. 20. Eysenck, H. J.: The effects of psychotherapy. Int. J. Psychiatry, 1, 99-142,1965. 21. Eysenck, H. J.: Crime and Personality. Hertfordshire, England, Paladin Books, 1970. 22. Finney, J. C. (Eds): Culture Change, Mental Health and Poverty. New York, N. Y., Simon and Schuster, 1970. 23. Foulkes, R. G.: Health Security for British Columbians, 2 Vols. Report to Minister of Health, B.C., 1973. 24. Foulkes, R. G.: Health Security for British Columbians. Special Report: Psychiatry at the Crossroads. B.C., 1974. 25. Fowles, J.: The Aristos. New York, N.Y., New American Library, 1970.

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26. Freedman, A. M.: Critical psychiatry: A new and necessary school. Hosp. CommunityPsychiatry, 24, 819-824,1974. 27. Freedman, A. M., Kaplan, H. 1. and Sadock, B. J.: Comprehensive Textbook of Psychiatry ll, 2 Vols. Baltimore, Williams and Wilkins, 1975. 28. Freud, S.: Civilization and Its Discontents. London, Hogarth Press, 1949. 29. Friedberg, J.: Electroshock therapy: let's stop blasting the brain. Psychology To-day, 9, 18, 1975. 30. Fromm, E.: Man for Himself. New York, N.Y., Holt, Rinehart and Winston, 1947. 31. Fromm, E.: The Anatomy of Human Destructiveness. New York, Holt, Rinehart and Winston, 1973. 32. Fusch, V. R.: Who Shall Live? New York, N.Y., Basic Books, 1974. 33. Giglioni, P. P.: (Ed.) Language and Social Context. London, Penguin Books, 1972. 34. Hastings, J. F.: (Chairman) The Community Health Centre in Canada. Ottawa, Information Canada, 1972. 35. Henry, W. E., Sims, J. H. and Spray, S. L.: Public and Private Lives of Psychotherapists. Washington, D. C., Jossey Bass, 1973. 36. Hirsch, S.: Observations on the identity problems of psychiatrists. C.M.A.!., 109, 1090-1094, 1973. 37. Hollingshead, A. B. and Redlich, F. C.: Social Class and Mental Illness. New York, N.Y., John Wiley, 1958. 38. Hutchings, B. and Mednick, S. A.: Registered criminality in the adoptive and biological parents of registered male adoptees. In Genetic Research in Psychiatry, Fieve, R. R., Brill, H. and Rosenthal, D., New York, N. Y., University Press, 1974. 39. Illich, 1.: Medical Nemesis. Toronto, McClelland and Stewart, 1975. 40. Jung, C. G.: Two Essays in Analytical Psychology, Appendix 1. New Paths in Psychology, Collected Works, Vol. 7, London, Routledge and Kegan Paul. 2nd Edition, 1966. 41. Kant, 1.: Critique of Practical Reason, Conclusion. Trans. Thomas Kingsmill Abbott. Britannica Books. (Originally published 1788.) 42. Klein, D. C.: The community and mental health: an attempt at a conceptual framework. Community Ment. Health: J., 301-308,1965. 43. Kohlberg, L.: Moral Development and Identification. In Stevenson, H. E. (Ed.)

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60. Mustard, J. F. (Chairman): Report of the Health Planning Task Force. Province of Ontario, 1974. 61. Olds, J.: Ten milliseconds into the brain. Psychology Today, 8,45-48,1975. 62. Olds, J.: Brain Mechanisms of Reinforcement Learning. In Pleasure, Reward, Preference, Eds. Berlyne, D. E. and Madsen, K. B., New York, N.Y., Academic Press, 1973. 63. Pascal, B.: Pascal's Pensees with notes by H. F. Stewart. New York, N.Y., Pantheon Books, 1950. 64. Piaget, J.: The Moral Judgement of the Child. London, Routedge and Kegan Paul, 1932. 65. Piaget, J.: Six Psychological Studies. New York, N.Y., Random House, 1967. 66. Plato: The Laws. Trans. Jowett, Chicago, Britannica Great Books, 1952. 67. Popper, Sir Karl R.: The Open Society and Its Enemies, (2 vols.). London, Routledge and Kegan Paul, 5th Ed., 1966. 68. Popper, Sir Karl R.: The Logic of Scientific Discovery. London, Hutchison, 3rd Ed., 1972. 69. Popper, Sir Karl R.: Objective Knowledge: An Evolutionary Approach. Oxford University Press, Toronto, 1973. 70. Province of Manitoba: Guidelines for the Seventies. 3 Vols., Winnipeg, 1973. 71. Riessman, F., Cohen, J. and Pearl, A.: (Eds.) Mental Health of the Poor. New York, N. Y., Free Press, 1946. 72. Romains, Jules: Knock: ou Le triomphe de La Medecine , Ed. Menut and Chapman, New York, N.Y., Century, 1927. 74. Rome, H. P.: Psychiatry and foreign affairs: The expanding competence of psychiatry. Am. J. Psychiatry, 125, 725-30, 1968. 75. Rosenblatt, A.: Providing custodial care for mental patients: an affirmative view. Psychiatr. Q., 48,14-25,1974. 76. Sartre, J. P.: Cited in French Thought Since 1600, D. C. Potts and D. G. Charlton. London, Methuen, 1974. 77. Science Council of Canada: Report no. 22 Science for Health Services. Ottawa, Information Canada, 1974. 78. Schofield, W.: The Purchase ofFriendship. New Jersey, Prentice Hall, 1964. 79. Schulzinger, F.: Psychopathy: heredity and environment. Int. J. Ment. Health, 1, 190-206,1972. 80. Smith, Colin M.: The unscientific bases of psychiatry. J. Neuropsychiatry, 3, 67-74, 1961.

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81. Smith, Colin M.: Measuring some effects of mental illness on the family. Can. Psychiatr. Assoc. J., 14,97-104,1969. 82. Smith, Colin M.: Crisis and aftermath: Community psychiatry in Saskatchewan 1963-69. Can. Psychiatr. Assoc. J., 16, 65-76,1971. 83. Smith, Colin M: Mental Health Services in Canada - System or Non-System. Unpublished Report, 1974. 84. Smith, Colin M. And Levey, A. B.: The follow-up in psychiatry. Dis. Nerv. Syst., 27,595-599,1966. 85. Smith, Colin M. and McKerracher, D. G.: The Family Doctor in a Program of Comprehensive Psychiatric Care, In New Aspects of the Mental Health Services, Ed. Freeman and Farndale, New York, N.Y., Pergamon, 1967.

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86. Spence, Lewis: The Myths of the North American Indians. London, Harrap, 1922. 87. Spiegel, John P.: Psychiatry - A high risk profession. Am. J. Psychiatry 132, 693-697, 1975. 88. Szasz, T.: The Myth ofMental Illness. New York, N.Y., Harper and Row, 1961. 89. Szasz, T.: Law, Liberty and Psychiatry. New York, N.Y., MacMillan, 1963. 90. Torrey, E. F.: The Mind Game: Witchdoctors and Psychiatrists. New York, N.Y., Bantam, 1973. 91. Torrey, E. F.: The Death of Psychiatry. Radnor, Pennsylvania, Chilton Book Co., 1974. 92. Wright, Derek: The Psychology of Moral Behaviour. London, Pelican Books, 1972. 93. Parsons, Talcott: Social Structure and Personality. New York, N.Y., Free Press, 1964.

Government and co-operation are in all things the laws oflife; anarchy and competition the laws ofdeath. John Ruskin 1819-1900