The Selling of Clinical Psychiatry in America
Marcio V. Pinheiro, M.D.
I have never been in hospitals where patients
are not welcomed, as is the case today
in America.
In 1958, after finishing medical school in Brazil, I came to this country for postgraduate training. In 1974, after becoming a psychiatrist here, I went back to Brazil, and for 13 years I brought to my hometown of Belo Horizonte much of what I had learned about American dynamic psychiatry. In 1987 I returned to this country and was shocked by the changes-all for the worse-that I found in American psychiatry (1).
In 1986, while still working in Belo Horizonte, I visited a private hospital on the U.S. East Coast. As I talked with the hospital's clinical director about the changes taking place in psychiatry, this competent psychiatrist told me that he would like to have one representative of his hospital in every American business. That idea startled me and brought to mind a nagging question: how far can American psychiatry go in accommodating the needs of business without jeopardizing its mission to treat all patients adequately and equally?
This question has become more important as I have grown more aware of how American clinical psychiatry is bending to the interests of government, businesses, insurance companies, and even organizations of patients' families, to the detriment of patient care. In this paper I examine the ethical issues arising from psy-chiatry's accommodation of these in-terests, and the limits of such an accommodation.
Public psychiatry
When I returned to America in 1987, I chose to work in a public hospital,
hoping I would not feel the pressures from insurance companies that I was
told were present in the private sector. Besides, due to their poor working
conditions, public hos-pitals have always been open to cheap foreign labor.
But as soon as I walked into my new job, I realized that pub-lic psychiatry
in this country was also changing.
During the sixties, I had worked briefly in a state hospital for the men-tally retarded. I have good memories of that experience, despite the fact that I dealt with patients who didn't have much going for them in terms of ever being able to live indepen-dently in the community. But at that time, the state was clearly committed to supporting the hospital, which provided shelter, protection, and treatment for its needy population.
Today that is obviously not the case. A few months ago I went back to
that hospital; 30 years had passed. I was heartbroken to see buildings
with boarded windows and doors. I sensed clearly the lack of public support
for that dying institution.
While in Brazil, I corresponded with the hospital superintendent, Dr.
T. Glyne Williams, a kind and competent psychiatrist. He wrote me about
his distress with the changes taking place in American psychiatry. Being
far away, I didn't realize the
extent of the changes. Only after my return did I fully understand
his con-cerns and the turn that psychiatry has taken here in the past 20
years.
I wonder where all the patients have gone. How are they managing without that protective environment they once had? Even if community programs are good places for some, they are not good for all. The community can be a dreadful and dangerous place for disabled people who need the protection that only a psy-chiatric hospital can offer.
Recently I read in the press about how poorly one community program was caring for its mentally retarded residents. I also read about an increase in the numbers of people who are homeless or in jail. Could there be a connection between the two? If there is, then can we say that while American public psychiatric hospitals are decreasing their census, dis-charged patients are creating more tensions in the larger society?
My biggest surprise was hearing a public sector psychiatrist-administrator say that because it is cheaper to keep patients in jails or on the streets than in hospitals, it is desirable to do so. That may make sense from an economic point of view, but not from a clinical perspective.
Unfortunately, as people climb the bureaucracy of the state mental health system, they become more concerned with saving money than with clinical care. The question then is, How far can the state go in saving taxpayers' money before crossing an ethical line beyond which minimally acceptable treatment for psychiatrically disabled persons is not available?
The prevailing ideology among public administrators today is that a decrease in the census or even the closing of state hospitals is a desirable goal. There is a convenient belief that psychiatry, with its "modern" treatments, is making it possible to meet such goals. What is worse, success in public psychiatry is measured more by the number of patients discharged than by the clinical care they receive.
The same psychiatrist-administrator who found keeping patients out of the hospital to be economically advantageous also pointed out that a revolving-door policy was good because it kept the census down. But how about the clinical casualties of such a system? I have never been in hospitals where patients are not welcomed, as is the case today in America. Patients are learning fast that to receive the care they need, they must become dangerous to themselves or others, as is evident from the statistics on escalating violence in state hospitals.
How have American public psychiatrists allowed these changes to occur? By conforming to them, are they not selling themselves to the state's interests at the expense of patient care?
The private sector
In the private sector the situation is worse. A battle is raging between
clinicians and insurers about what constitutes proper care. As government
transfers to business the care of the mentally ill, economic interests
dictate what constitutes proper care. Usually it is the least expensive
treatment, sold as "quality, cost-efficient care." This battle between
clinicians and insurers is making the practice of psychiatry impossible.
I have seen many good, experienced clinicians leaving the field to avoid
dealing with pressures from insurance companies.
In 1974, when I went back to practice in Brazil, there were some hints in the U.S. about the coming need for accountability to third party payers. Payers were already finding ways to deny services to subscribers. Things have now gone too far. Insurance companies are, in very clever ways, manipulating clinicians into making decisions that fit the insurers' interests, not the patients'. How they have been able to accomplish this is a tribute to their ingenuity, but clinical psychiatry -to the extent that it has accommodated such manipulations-has played right along with them.
Back in the sixties, insurance companies started refusing payment for milieu therapy in the hospitals. Today it is impossible to collect for the staffs time and effort to create a therapeutic milieu, even though clinicians know very well the importance of the milieu in a hospital treatment. The other day, the same psychiatrist-administrator I have spoken of was explaining to me that because the patients in his hospital had no therapy on the weekends, it was right for third-party payers to refuse payment for those days. I observed that the way things are going, sooner or later, third-party payers will also refuse payment for the time patients spend sleeping at night, eating their meals, or going to the bathroom. To deny treatment, insurance companies have adopted the concept of medical necessity. This concept doesn't take into consideration that many psychiatric patients do not show medical necessity-that is, symptoms during hospitalization. It does not recognize that medical necessity often is not evident until patients are placed in the community without the support they need.
Endless documentation is now the main activity of clinicians. They are
working more for third-party payers than for their patients. It is bizarre
to see professionals in a psychiatric ward writing in the charts while
leaving the patients unattended.
What is more scary is seeing psychiatrists selling themselves to third-party
payers, helping them to "scien-tifically" justify denials of care. In this
context, lucrative health maintenance organizations, preferred provider
organizations, and managed care organizations have multiplied. I don't
think anything would be wrong in having these organizations disclose their
economic profiles and inform subscribers where the money goes and what
treatments they offer in exchange for it. Instead, the subscribers are
told only that they will receive "state-of-the-art, quality care" if they
show "medical necessity." The most serious problem with the various types
of managed care plans, however, is that their profits depend on their denial
of care.
In the mental health field, it is difficult to measure the quality of therapeutic interventions. The psychiatric profession must draw a line beyond which it will not go in compromising clinical care; failure to do so will mean that business will continue to devise clever ways to manipulate clinicians to work for them instead of for patients.
Research
In 1990 the American Psychiatric Association dedicated its annual meeting
to the theme "The Research Alliance." After all, clinical psychiatry depends
on research to find better treatments for patients. But research can also
interfere with clinical practice and may even cross an ethical line beyond
which clinical psychiatry will not be serving patients well.
For example, recently a group of state hospital psychiatrists were given a data collection form to be completed for a research project. While they spent time on the form, clinical care that was already less than desirable deteriorated still further. But even worse, by becoming agents of research, the clinicians lost the freedom and spontaneity that were once very important ingredients of their therapy. This alliance between research and clinical work, particularly in psychiatry, can backfire in terms of therapeutic results. By bending too far to research interests, clinical psychiatry can limit its scope and creativity because research can only deal with a very limited number of variables.
In addition, it is important to remember that research is usually funded by government or foundations that can indeed be very biased in their priorities. We all know how ideologies affect scientific inquiry. One doesn't have to reach far into history to recall how totalitarian governments have channeled research in directions that were syntonic to their political aims, not necessarily to people's needs.
In America today, a strong "ideology of the brain" has moved research away from the social, interpersonal, and intrapsychic fields as they relate to mental disorders. This focus on the hard sciences, although it is legitimate, serves powerful economic interests, including drug manufac-turers, insurance companies, and the government. The ideology that holds chemical imbalances in the brain as being solely responsible for mental disorders is used by families, and sometimes by professionals and patients, in an opportunistic or defensive way that undermines adequate clinical care. When a depressed mental patient discloses that, for instance, his father was depressed, the patient's depression is immediately labeled as genetically linked, and he will not have the chance to work through his experiences growing up with such a father. As a consequence, American psychiatric patients no longer have histories but only target symptoms, disconnected from their past and from the social context of their lives, to be treated with medication.
By selling itself to research, clinical psychiatry is abandoning its mission to respond, above all, to its pa-tients' clinical needs.
The National Alliance for the Mentally Ill
A close partnership has been forged between psychiatry and the National
Alliance for the Mentally Ill. Of course, psychiatry should welcome an
organization that helps to fund research and improve treatment of the mentally
ill. But at the same time, psychiatry must preserve its autonomy when deciding
on areas of scientific investigation. It should not forget all that has
been learned about individual, marital, family, and social dynamics as
they relate to the etiology and treatment of mental disorders.
A blind alliance with an organization of families of the mentally ill may lessen psychiatrists' autonomy to investigate the causes of and treatments for mental disorders. The conflict becomes acute when families are unduly defensive about their unwitting participation in the development of a relative's disturbance and their role in treatment. This defensiveness leads to focusing on the brain as the only source of the disturbance, to the exclusion of individual, family, and social dynamics. It also leads to an ideological patrol that blocks research in directions other than on the brain. Families might be comforted by the thought that the patient has a brain disorder for which biologic research will someday find a cause and cure, but the result will be a therapeutic impasse.
By becoming allied with an organization of families and abiding by their biological ideology, clinical psychiatry is again selling itself to interests other than patient care. This affiliation will not help patients or, in the long run, their families.
Conclusions
Today clinical psychiatry in America is under pressure from employers,
insurance companies, and government to compromise patient care. That such
a conflict is inherent in our work should not surprise us. Administrators
of public and private funds are charged with seeing that resources are
well spent. What is alarming is the extent to which clinical psychiatry
is bending to these interests to the detriment of patients' needs.
There is no room in America today for research into areas other than the brain. A new generation of psychiatrists are being trained to focus on the brain. Americans are enthralled with computers and data bases, and because computers simplify the task of collecting information about mental disorders in families, the "genetic load" has become the preferred etiological explanation for mental disorders. Such an explanation eliminates the need for the slow, more difficult, and frequently painful task of collecting data that permits examination of the meaning and impact of these dis-orders in the context of the patient's psychosocial history.
As businesses in America become more efficient and lucrative, employees are placed under greater stress. When stress-reducing techniques fail, people turn to the health delivery system. When the health system fails, they crowd the jails or become homeless. Those concerned about the rising cost of health care in this country fail to see a connection between health care costs and the increasing stress experienced by Americans as corporations compete for profit.
An ideology of the brain's central role in mental disorders, coming from the alliance of psychiatry, government, businesses, research, and families of patients, is dominating the field of American psychiatry and pushing psychiatric patients into the medical model, to be treated by bio-chemical alterations when talking therapies may be more effective. The approaches used by Freud, Sullivan, Adolf Meyer, Frieda Fromm-Reich-mann, and many others that involved looking for meaning in patients' speech are now being suppressed in the name of quality care and scientif-ic progress.
In America the pendulum always swings back. I hope it will swing back so that the needs of patients and their families are considered in the social context in which they live. But such a change should occur quickly because mental patients in America are suffering. American clinical psychiatry has the responsibility to see that clinical needs are met and that psychiatry does not sell itself to other interests, to the detriment of pa-tients.
Reference
1. Pinheiro MV: USA 13 years later. Psychi-atry 52:469-1174, 1989
February 1992 Vol. 43 No. 2
Hospital and Community Psychiatry
February 1992 Vol. 43 No. 2
Dr. Pinheiro is clinical assistant professor of psychiatry at the University of Maryland School of Medicine in Baltimore and director of inpatient services for the Catonsville unit of the Walter P. Carter Center. Address correspondence to him at 6214 Oak Hill Drive, Sykesville, Maryland 21784. Steven S. Sharfstein, M.D., is editor of this column.