680
CORRESPONDENCE
suffered from mental illness (using a definition of mental illness which excludes personality disorder). thus, this appears to be a case in which an individual was found to be legally insane while being medically normal. And thus, it was no surprise when the Mental Health Review Tribunal, being orientated towards health and rehabilitation rather than law and punishment, made the reported finding and recommendation. However, the Attorney-General has announced that the State Government has rejected the recommendation of the Tribunal. The unsatisfactory, temporary end of the matter is that the State Government has rejected the advice of a body, which it (the State Government) established, to give it (the State Government) advice. Subsequently, a front page report in The Mercury newspaper announced that the Psychiatrist member had resigned from the Mental Health Review Tribunal, “in frustration over the State Government’s refusal to free one of Tasmania’s most notorious killers”. This was followed by public statements by Tasmania’s Women’s Action Group who cheered the State Government’s decision, and criticised “the system” which could make release possible. These problems have arisen because of attempts to combine medicine and the law. Re-occurrences can only be prevented by overhauling the legislation. The removal of the insanity plea and a special post-verdict, pre-judgment, in camera mental health assessment mechanism is highly recommended. This would allow the guilty individual to be managed appropriately and simply, using either the legal or medical system. It would also put an end to the unproductive public contests between prosecution and defence medical practitioners arguing legal concepts.
The changing nature of psychiatry J P Parkinson, Castle Hill, New South Wales: Professor Gavin Andrews’ provocative address [ 11 has already drawn a healthy response [Z-51.I can add only a few points. His argument that much direct patient care will have to be done by non-psychiatrists will not please medical chauvinists. However, his estimate of community need is convincing. Not surprisingly he does not digress to remind us that the recruitment and training of “lay” analysts was one of Freud’s pioneering innovations [6]. The wheel has turned and the most valued part of my own training in psychotherapy was
supervision by psychoanalysts who, as it happened, were not medically qualified. It is the section “Which treatment?” and the conclusions based on it that are not merely controversial but arguably mischievous. Broadly, Andrews dismisses all evidence for the success of psychodynamic therapies on the grounds that the studies he quotes do not show their superiority to what he calls the placebo of %on-specific” good clinical care. Although he cites Frank, “The placebo is therapy” [7] and although he acknowledges that a recent NIMH study [8] “showed just how powerful one non-specific placebo condition, informed clinical care, could be,” he does not seem to have taken the point. this point was well made by Isla L o n i e , w h o c r i t i c i s e d t h e a s s u m p t i o n that psychotherapy should contain some specific factor “which can be isolated from other complex factors in the interaction ... a relationship with a specific patient” [91. The issue seems to be that Andrews (like others in the field) uses the word “specific” in a way that is clinically and philosophically unsound. The refinement of diagnostic categories and the quest for causes and specific treatments have won enviable success in general medicine and in some areas of psychiatry. However, in other areas it is relevant to understand that logically a diagnosis cannot be specific. On the contrary, it is an attempt to form a generalisation, or a universal, from a particular set of symptoms and signs in a specific individual. While accepting that without the capacity for abstraction human though would scarcely be possible, I will nonetheless play Aristotle to Andrew’s Plato and point out that universals are not real. They have reality only in the particular - in this case in the multidetermined complexities of the individual mind. This is the only specific. The transactions which Andrews dismisses as non-specific kindly advice, good care - may be very specific to the needs of the person involved. Andrews rightly points out that psychotherapy can cause harm. Psychoanalytic theory and technique are not monolithic, any more than cognitive/behavioural therapy or biological psychiatry. All clinicians are at times consulted by rejects and refugees from other practitioners and schools of thought. Technical issues in psychotherapy. such as whether, when and how to interpret a hostile transference, are important. Moreover, what Meares and Hobson have written of The Persecutory Therapist [ 101can in a sense apply to the whole spectrum of psychiatry - the toxic effect of
Downloaded from anp.sagepub.com at NANYANG TECH UNIV LIBRARY on May 27, 2015
QUEENSLAND HEALTH Specialist Psychiatrists QueenslandHealthis currently seekingspecialist psychiatriststo work in our non-metropolitanpublic sector mental health services. Mental Health is a priority area for the Queensland government and over $22 million is currently being spent on new mental health facilities throughoutthe State. Additional psychiatristsare being actively sought to staff these new services. The recent opening of Community Psychiatry Services in Bundaberg and Mackay has completed a statewide network of community services which operate in close co-ordinationwith inpatient facilities. Queensland is a subtropical state with a delightful climate and relaxed lifestyle. It offers excellent educational and recreationalfacilities. Vacancies exist in Cairns, Townsville, Mackay, Sunshine Coast, Gold Coast and Toowoomba. These positions range from Staff Psychiatristto Director level. Attractive packagesfor specialist psychiatristsare now available. The current salary range is from $69,574 (M01-1) - $87,798 (M01-7). Specialist psychiatrists are able to choose from: Option A which is a 22.5 per cent payment in lieu of private practice in non-metropolitan areas which carries total remuneration for psychiatrists to $85,228 - $1 07,552. Option B which is rights of private practice up to 50 per cent of M01-7 salary (i.e. $43,899) per year. Other benefits include 5 weeks annual leave, Director’s allowance (if applicable), on call allowance, superannuation,sick leave, long service leave, annual conference leave, and study leave (13 weeks on full pay with expenses and round world air ticket every 5 years or pro rata after 2 years). Some Regional Health Authorities will provide accommodation or generous rental subsidies. Relocation expenses are also negotiable. For further information please contact Dr Brett Emmerson, Chief Psychiatrist, Mental Health Branch, Queensland Health, GPO Box 48, Brisbane Q 4001, telephone (07)234 0677.
-
-= /y=
QUEENSLAND HEALTH PENINSULA AND TORRES STRAIT REGION CAIRNS BASE HOSPITAL Director of Psychiatry
This position offers an exciting opportunity to practice psychiatry in a multicultural, multidisciplinary environment as the team leader of the Cairns Base Hospital inpatient psychiatric unit. The unit is a 26 bed acute facility providing services for the Peninsula and Torres Strait Region with a population of 200,000. The acute unit works in close liaison with Community Mental Health Services to provide a continuum of patient care. The successful appointee would have the opportunity to work both in an inpatient and community setting. Mental Health Services in Far North Queensland are currently undergoing review and are being developed to meet the needs of the rapidly developing Cairns community and the varied needs of the Peninsula and Torres Strait Health Region. The region has been chosen to participate in an International World Health Organisation Initiative to study support services for people with a mental disability. Applicants must be registrable as a specialist psychiatrist in Queensland and should have had a wide range of experience in psychiatric practice as well as some administrative experience. The current salary range is $A78,270 - 82,406 however this is currently under review. Specialist psychiatrists are able to choose from Option A which is a 22.5 per cent payment in lieu of private practice in non-metropolitan areas. Option B which is the right of private practice up to 50 per cent of M01-7 salary which is equivalent to $A43,899 per year. Other benefits include 5 weeks annual leave, on call allowance, superannuation, sick leave, long service leave, annual conference leave and study leave (13 weeks on full pay with expenses and around the world air ticket every 5 years or pro rata after 2 years). Accommodation is available and assistance will be given with relocation expenses. Further information and application kits are available from: Dr Jill Newland, Deputy Medical Superintendent, Cairns Base Hospital, PO Box 902, CAIRNS QLD 4870, Phone (070) 50 6357
Downloaded from anp.sagepub.com at NANYANG TECH UNIV LIBRARY on May 27, 2015
682
CORRESPONDENCE
acting from an apriori position rather than responding to the present need of the patient. Those who throw the stones which Masson [ 1 I] has provided against the psychoanalytic establishment should beware of his friend Breggin, whose To,uic Psychiatry is an indictment of psychiatric practice in general. Of interest for this discussion is Breggin’s description of the Harvard-Radcliffe Mental Hospital Volunteer Program, in which untrained but supervised college students sustained great success over a number of years in helping backward patients achieve discharge. “Make him feel that he is important to you, the worker” [ 121. This is the most general of noble precepts but one which requires sensitive specific application and sincerity more than technical training. The mischief at the end of Andrews’ address is that he recommends reducing the emphasis on dynamic psychotherapy in the training of psychiatrists. The implication is that psychotherapy supervision, a hallmark of Australian training, might be dropped. This is perplexing in that he has just acknowledged of the dynamic psychotherapies that “perhaps one of their greatest strengths is that they train doctors to have the patience and the theoretical interest in working with a disturbed patient year after years, using the factors common to all successful therapies (crisis resolution, empathy, support, non-possessive warmth and kindly advice) to encourage healthy behaviours and minimise damage.” Incidentally, this is an impressive list of placebos to encounter “while waiting for natural remission to occur”. I suspect that the methodology has not yet been developed to discriminate all these factors, though I would not doubt somk protocols aim in that direction. Likewise those on waiting lists for treatment do not live in a vacuum. A refined methodology would scan for such contaminants as fortunate marriages, caring homosexual partners, tolerant prison warders and motherly sergeant-majors. Despite the irony, I take my hat off to the industry of colleagues labouring to devise scientific methods appropriate to this uniquely complex subject matter. For some years yet, however, I think it will remain the way of realism to view psychotherapy as a difficult art whose practitioners have had some training in science.
References 1. Andrews G. The changing nature of psychiatry. Australian and
New Zealand Journal of Psychiatry 1991; 25:453-459. 2. Stanley OT. Correspondence.Australian and New Zealand Journal of Psychiatry 1992; 26: 125-126.
3. Gaughwin P. Correspondence.Australian and New Zealand Journal of Psychiatry 1992; 26:132-134. 4. Morris PLP. Correspondence.Australian and New Zealand Journal of Psychiatry 1992; 26:322-323. 5 . Blom GE. Correspondence.Australian and New Zealand Journal of Psychiatry 1992; 26:323-326. 6. Freud S. The question of lay analysis ( 1926).In: The Pelican Freud Library Volume IS. London: Penguin, 1986:279-353. 7. Frank JD. The placebo in psychotherapy. Behavioural and Brain Sciences 1983; 6:292-292. 8. Elkin I, Shea T, Watkins JTet nl. National Institute of Mental Health treatment of depression collaborative research program. General effectiveness of treatments. Archives of General Psychiatry 1989: 46:97 1-982. 9. Lonie I. The battle of the couches and the rats. Medical Journal of Australia 1991; 155:843-845. 10. Meares R, Hobson R. The persecutory therapist. British Journal of Medical Psychology 1977; 50:349-359. 11. Masson J. Against therapy. London: Fontana, 1990. 12. Breggin PR. Toxic psychiatry. New York: St Martin’s Press, 1991:380.
Ethics and patient-therapistsexual contact Chris Ryan, Westmead,New South Wales: While agreeing with the thrust and many of the recommendations of Dr Quadrio’s exhaustive review of patient-therapist sexual contact (PTSC), I was disappointed with the poverty of ethical debate presented [ 11. I was disappointed because, while I believe PTSC is unethical, it is likely that 5 - 10% of the readers of this Journal do not [2]. A proportion of these dissenters will have examined their consciences and will genuinely believe they are doing nothing wrong. It is to these people that this letter is primarily directed. In fact the primary argument supporting PTSC as ethically acceptable is much stronger than is usually acknowledged. It rests on the principle of autonomy and states that two mentally unimpaired adults should be allowed to do what ever they wish, so long as they don’t harm anyone else. Many dissenters defend their actions with the principle of autonomy and criticise established views as paternalistic. The statement that “consent is simply not relevant” [3] is unlikely to holdmuch sway among this minority. They will argue that consent is central. Adult human beings can make up their own minds. Defenders of the established view often argue that the special nature of the therapeutic relationship invalidates consent. Transference in the relationship renders it equivalent to the father-daughter relationship. PTSC is, therefore, like incest. This is a powerful argument if you agree with the premise, but many do not and without it. it simply collapses. Arguments
Downloaded from anp.sagepub.com at NANYANG TECH UNIV LIBRARY on May 27, 2015
CORRESPONDENCE
suffered from mental illness (using a definition of mental illness which excludes personality disorder). thus, this appears to be a case in which an individual was found to be legally insane while being medically normal. And thus, it was no surprise when the Mental Health Review Tribunal, being orientated towards health and rehabilitation rather than law and punishment, made the reported finding and recommendation. However, the Attorney-General has announced that the State Government has rejected the recommendation of the Tribunal. The unsatisfactory, temporary end of the matter is that the State Government has rejected the advice of a body, which it (the State Government) established, to give it (the State Government) advice. Subsequently, a front page report in The Mercury newspaper announced that the Psychiatrist member had resigned from the Mental Health Review Tribunal, “in frustration over the State Government’s refusal to free one of Tasmania’s most notorious killers”. This was followed by public statements by Tasmania’s Women’s Action Group who cheered the State Government’s decision, and criticised “the system” which could make release possible. These problems have arisen because of attempts to combine medicine and the law. Re-occurrences can only be prevented by overhauling the legislation. The removal of the insanity plea and a special post-verdict, pre-judgment, in camera mental health assessment mechanism is highly recommended. This would allow the guilty individual to be managed appropriately and simply, using either the legal or medical system. It would also put an end to the unproductive public contests between prosecution and defence medical practitioners arguing legal concepts.
The changing nature of psychiatry J P Parkinson, Castle Hill, New South Wales: Professor Gavin Andrews’ provocative address [ 11 has already drawn a healthy response [Z-51.I can add only a few points. His argument that much direct patient care will have to be done by non-psychiatrists will not please medical chauvinists. However, his estimate of community need is convincing. Not surprisingly he does not digress to remind us that the recruitment and training of “lay” analysts was one of Freud’s pioneering innovations [6]. The wheel has turned and the most valued part of my own training in psychotherapy was
supervision by psychoanalysts who, as it happened, were not medically qualified. It is the section “Which treatment?” and the conclusions based on it that are not merely controversial but arguably mischievous. Broadly, Andrews dismisses all evidence for the success of psychodynamic therapies on the grounds that the studies he quotes do not show their superiority to what he calls the placebo of %on-specific” good clinical care. Although he cites Frank, “The placebo is therapy” [7] and although he acknowledges that a recent NIMH study [8] “showed just how powerful one non-specific placebo condition, informed clinical care, could be,” he does not seem to have taken the point. this point was well made by Isla L o n i e , w h o c r i t i c i s e d t h e a s s u m p t i o n that psychotherapy should contain some specific factor “which can be isolated from other complex factors in the interaction ... a relationship with a specific patient” [91. The issue seems to be that Andrews (like others in the field) uses the word “specific” in a way that is clinically and philosophically unsound. The refinement of diagnostic categories and the quest for causes and specific treatments have won enviable success in general medicine and in some areas of psychiatry. However, in other areas it is relevant to understand that logically a diagnosis cannot be specific. On the contrary, it is an attempt to form a generalisation, or a universal, from a particular set of symptoms and signs in a specific individual. While accepting that without the capacity for abstraction human though would scarcely be possible, I will nonetheless play Aristotle to Andrew’s Plato and point out that universals are not real. They have reality only in the particular - in this case in the multidetermined complexities of the individual mind. This is the only specific. The transactions which Andrews dismisses as non-specific kindly advice, good care - may be very specific to the needs of the person involved. Andrews rightly points out that psychotherapy can cause harm. Psychoanalytic theory and technique are not monolithic, any more than cognitive/behavioural therapy or biological psychiatry. All clinicians are at times consulted by rejects and refugees from other practitioners and schools of thought. Technical issues in psychotherapy. such as whether, when and how to interpret a hostile transference, are important. Moreover, what Meares and Hobson have written of The Persecutory Therapist [ 101can in a sense apply to the whole spectrum of psychiatry - the toxic effect of
Downloaded from anp.sagepub.com at NANYANG TECH UNIV LIBRARY on May 27, 2015
QUEENSLAND HEALTH Specialist Psychiatrists QueenslandHealthis currently seekingspecialist psychiatriststo work in our non-metropolitanpublic sector mental health services. Mental Health is a priority area for the Queensland government and over $22 million is currently being spent on new mental health facilities throughoutthe State. Additional psychiatristsare being actively sought to staff these new services. The recent opening of Community Psychiatry Services in Bundaberg and Mackay has completed a statewide network of community services which operate in close co-ordinationwith inpatient facilities. Queensland is a subtropical state with a delightful climate and relaxed lifestyle. It offers excellent educational and recreationalfacilities. Vacancies exist in Cairns, Townsville, Mackay, Sunshine Coast, Gold Coast and Toowoomba. These positions range from Staff Psychiatristto Director level. Attractive packagesfor specialist psychiatristsare now available. The current salary range is from $69,574 (M01-1) - $87,798 (M01-7). Specialist psychiatrists are able to choose from: Option A which is a 22.5 per cent payment in lieu of private practice in non-metropolitan areas which carries total remuneration for psychiatrists to $85,228 - $1 07,552. Option B which is rights of private practice up to 50 per cent of M01-7 salary (i.e. $43,899) per year. Other benefits include 5 weeks annual leave, Director’s allowance (if applicable), on call allowance, superannuation,sick leave, long service leave, annual conference leave, and study leave (13 weeks on full pay with expenses and round world air ticket every 5 years or pro rata after 2 years). Some Regional Health Authorities will provide accommodation or generous rental subsidies. Relocation expenses are also negotiable. For further information please contact Dr Brett Emmerson, Chief Psychiatrist, Mental Health Branch, Queensland Health, GPO Box 48, Brisbane Q 4001, telephone (07)234 0677.
-
-= /y=
QUEENSLAND HEALTH PENINSULA AND TORRES STRAIT REGION CAIRNS BASE HOSPITAL Director of Psychiatry
This position offers an exciting opportunity to practice psychiatry in a multicultural, multidisciplinary environment as the team leader of the Cairns Base Hospital inpatient psychiatric unit. The unit is a 26 bed acute facility providing services for the Peninsula and Torres Strait Region with a population of 200,000. The acute unit works in close liaison with Community Mental Health Services to provide a continuum of patient care. The successful appointee would have the opportunity to work both in an inpatient and community setting. Mental Health Services in Far North Queensland are currently undergoing review and are being developed to meet the needs of the rapidly developing Cairns community and the varied needs of the Peninsula and Torres Strait Health Region. The region has been chosen to participate in an International World Health Organisation Initiative to study support services for people with a mental disability. Applicants must be registrable as a specialist psychiatrist in Queensland and should have had a wide range of experience in psychiatric practice as well as some administrative experience. The current salary range is $A78,270 - 82,406 however this is currently under review. Specialist psychiatrists are able to choose from Option A which is a 22.5 per cent payment in lieu of private practice in non-metropolitan areas. Option B which is the right of private practice up to 50 per cent of M01-7 salary which is equivalent to $A43,899 per year. Other benefits include 5 weeks annual leave, on call allowance, superannuation, sick leave, long service leave, annual conference leave and study leave (13 weeks on full pay with expenses and around the world air ticket every 5 years or pro rata after 2 years). Accommodation is available and assistance will be given with relocation expenses. Further information and application kits are available from: Dr Jill Newland, Deputy Medical Superintendent, Cairns Base Hospital, PO Box 902, CAIRNS QLD 4870, Phone (070) 50 6357
Downloaded from anp.sagepub.com at NANYANG TECH UNIV LIBRARY on May 27, 2015
682
CORRESPONDENCE
acting from an apriori position rather than responding to the present need of the patient. Those who throw the stones which Masson [ 1 I] has provided against the psychoanalytic establishment should beware of his friend Breggin, whose To,uic Psychiatry is an indictment of psychiatric practice in general. Of interest for this discussion is Breggin’s description of the Harvard-Radcliffe Mental Hospital Volunteer Program, in which untrained but supervised college students sustained great success over a number of years in helping backward patients achieve discharge. “Make him feel that he is important to you, the worker” [ 121. This is the most general of noble precepts but one which requires sensitive specific application and sincerity more than technical training. The mischief at the end of Andrews’ address is that he recommends reducing the emphasis on dynamic psychotherapy in the training of psychiatrists. The implication is that psychotherapy supervision, a hallmark of Australian training, might be dropped. This is perplexing in that he has just acknowledged of the dynamic psychotherapies that “perhaps one of their greatest strengths is that they train doctors to have the patience and the theoretical interest in working with a disturbed patient year after years, using the factors common to all successful therapies (crisis resolution, empathy, support, non-possessive warmth and kindly advice) to encourage healthy behaviours and minimise damage.” Incidentally, this is an impressive list of placebos to encounter “while waiting for natural remission to occur”. I suspect that the methodology has not yet been developed to discriminate all these factors, though I would not doubt somk protocols aim in that direction. Likewise those on waiting lists for treatment do not live in a vacuum. A refined methodology would scan for such contaminants as fortunate marriages, caring homosexual partners, tolerant prison warders and motherly sergeant-majors. Despite the irony, I take my hat off to the industry of colleagues labouring to devise scientific methods appropriate to this uniquely complex subject matter. For some years yet, however, I think it will remain the way of realism to view psychotherapy as a difficult art whose practitioners have had some training in science.
References 1. Andrews G. The changing nature of psychiatry. Australian and
New Zealand Journal of Psychiatry 1991; 25:453-459. 2. Stanley OT. Correspondence.Australian and New Zealand Journal of Psychiatry 1992; 26: 125-126.
3. Gaughwin P. Correspondence.Australian and New Zealand Journal of Psychiatry 1992; 26:132-134. 4. Morris PLP. Correspondence.Australian and New Zealand Journal of Psychiatry 1992; 26:322-323. 5 . Blom GE. Correspondence.Australian and New Zealand Journal of Psychiatry 1992; 26:323-326. 6. Freud S. The question of lay analysis ( 1926).In: The Pelican Freud Library Volume IS. London: Penguin, 1986:279-353. 7. Frank JD. The placebo in psychotherapy. Behavioural and Brain Sciences 1983; 6:292-292. 8. Elkin I, Shea T, Watkins JTet nl. National Institute of Mental Health treatment of depression collaborative research program. General effectiveness of treatments. Archives of General Psychiatry 1989: 46:97 1-982. 9. Lonie I. The battle of the couches and the rats. Medical Journal of Australia 1991; 155:843-845. 10. Meares R, Hobson R. The persecutory therapist. British Journal of Medical Psychology 1977; 50:349-359. 11. Masson J. Against therapy. London: Fontana, 1990. 12. Breggin PR. Toxic psychiatry. New York: St Martin’s Press, 1991:380.
Ethics and patient-therapistsexual contact Chris Ryan, Westmead,New South Wales: While agreeing with the thrust and many of the recommendations of Dr Quadrio’s exhaustive review of patient-therapist sexual contact (PTSC), I was disappointed with the poverty of ethical debate presented [ 11. I was disappointed because, while I believe PTSC is unethical, it is likely that 5 - 10% of the readers of this Journal do not [2]. A proportion of these dissenters will have examined their consciences and will genuinely believe they are doing nothing wrong. It is to these people that this letter is primarily directed. In fact the primary argument supporting PTSC as ethically acceptable is much stronger than is usually acknowledged. It rests on the principle of autonomy and states that two mentally unimpaired adults should be allowed to do what ever they wish, so long as they don’t harm anyone else. Many dissenters defend their actions with the principle of autonomy and criticise established views as paternalistic. The statement that “consent is simply not relevant” [3] is unlikely to holdmuch sway among this minority. They will argue that consent is central. Adult human beings can make up their own minds. Defenders of the established view often argue that the special nature of the therapeutic relationship invalidates consent. Transference in the relationship renders it equivalent to the father-daughter relationship. PTSC is, therefore, like incest. This is a powerful argument if you agree with the premise, but many do not and without it. it simply collapses. Arguments
Downloaded from anp.sagepub.com at NANYANG TECH UNIV LIBRARY on May 27, 2015
