U.S.A., 13 Years Later
M arcio Vasconcellos Pinheiro
IN OCTOBER 1974, after living in Baltimore for 16 years, I went back
to my home town, Belo Horizonte, in the State of Minas Gerais, Brazil.
By then I was a citizen of the United States and a Board Certified Psychiatrist,
and I wanted to bring back there some of what I had learned here. In 1987
I returned to the United States, and I want to set down my impressions
of what has happened here since I left.
When I first arrived in the U.S., in 1958, I was a young physician looking for post-graduate training. I went through a rotating internship and a residency in psychiatry after a brief passage in internal medicine. I was coming from a country where psychiatry was mainly biological in the best European tradition and where psychoanalysis, quite divorced from psychiatry, had a very strong Kleinian bent. After a residency at the Psychiatric Institute of the University of Maryland, I completed my personal analysis and then worked at Sheppard and Enoch Pratt Hospital and in private practice for 7 years. I learned the "dynamic American psychiatry" of the 50s and 60s, inspired by psychoanalytic principles and heavily anchored in the social sciences.
It was this kind of psychiatry that I decided to bring to my home town when I went back in 1974. To some extent, I think I was able to do that. In Belo Horizonte I founded the first psychiatric day hospital, I started the first psychiatric inpatient unit that- like the day hospital -functioned on a psychosocial model, and I completed my psychoanalytic training with the Circulo Psicanalitico de Minas Gerais.
After 13 years in Belo Horizonte I decided to return to Baltimore. Now, for the second time, I am going through the experience of entering this culture, one that had been familiar to me but that has changed a great deal during my absence. It is about this experience that I want to write, while it is still fresh in my mind and before I get so immersed in the American way of life that I lose the perspective that I now have.
First I will comment on Baltimore and its people. Then I will say something
about contemporary psychiatry in the United States, and finally I will
make some remarks on being a psychiatrist in America today.
BALTIMORE, 1987
In the last 13 years Baltimore has changed a lot. The first time I
went downtown after my return I realized that everything was different.
The old and decaying Baltimore of the 60s had been rebuilt to become a
very pleasant and lively city: a tourist attraction. I am not only speaking
of the Inner Harbor, with its shops and restaurants, the National Aquarium,
the Science Center and the other attractions in that area. I am including
the whole downtown area. There is a new Convention Center.
The Civic Center has been renovated. There is a new Symphony Hall with
one of the best orchestras in the country. The Lyric Theater has been modernized.
The Center Stage, which struggled so much in the past, has moved to a new
and better location. Baltimore, no doubt, lost some of its provincial flavor
of the past in the process of becoming a more modern city.
Thirteen years ago Baltimoreans didn't have much motivation to go downtown. Tourists passed directly through the Harbor Tunnel without taking a look at the town. Today, things are quite different.
Side by side with the new, some of the old remains. The Memorial Stadium
with the Orioles (the Colts have gone) is still
there. I understand that Maryland is planning to spend considerable
money on a new sports complex. Johns Hopkins
University and the professional schools of the University of Maryland
have both ex-panded. The Enoch Pratt Free Library remains a landmark. That
fine natural resource the Chesapeake Bay is as beautiful as ever.
I can't help but be impressed by the wealth of this country and by the money that is being invested to rebuild American towns, opening new opportunities for business.
Baltimore, no doubt, has changed for the better.
BALTIMOREANS, 1987
Baltimoreans are more restless and competitive than ever. The population
has increased. The traffic is heavier. The speed of life is faster. Americans
have al-ways been a very fast-moving people when compared to Brazilians,
but I am now perplexed by the fact that American life is even faster than
it was. It is difficult for me to conceive of a society more individualistic
and competitive than this one. People now have not one but two jobs. Husband
and wife are working outside the home, and day care for children
has become institutionalized as an important dimension of childrearing.
Technology has made great progress. Computers are everywhere. They are storing data and giving instant answers to all questions. They are shaping Ameri-can life with hard data and endless statis-tics. They facilitate the life of scientists in every field. Even the American language is gradually being molded by computers, so that Americans are learning how to talk in a way that computers understand.
Living in such a technological and eco-nomically conservative society, Ameri-cans hope, through the hard sciences, to resolve all human ills and imperfections, making everything and everybody func-tion at their highest level of efficiency. This aim connects with a greater intolerance for people's limitations, disabilities, mistakes and failures. There is no place in America today for poor performance. There is a great intolerance toward people with chronic disabilities who need continuing care. Everybody must be a success.
Americans are now used to throwing away defective products. Nothing
is worth repairing. What doesn't function properly is rapidly replaced.
This attitude may be expanding toward people in gener-al. The replacement
of faulty human organs, for instance, is considered great progress, but
continuing assistance for the chronically ill is considered much less worth
doing,
even an undesirable endeav-or, a wasteful use of the GNP The front
pages of the newspapers are full of head-lines on organ transplants and
the accompanying technology, while little attention is paid to the needs
of the chronically disabled mental patients.
The conservative philosophy is at its peak. Free enterprise is the official
creed. "Privatization" is the main theme. There is no room in this country
today for any kind of liberal, collective or socialist thinking. Such thinking
is immediately equated with anti-Americanism even though we know that the
United States trails behind in social programs when compared with the other
industrialized countries in the free world. The main notion is that each
one must fend for himself, and the expectation is that everyone is able
to join the work force and become self-supporting.
PSYCHIATRY, U.S.A., 1987
Psychiatry reflects what goes on in the larger society. In the last
13 years psychi-atry in America has also changed. Following the present
social trend, American psychiatry became simple, fast, exact and, above
all, economic (nobody wants to foot the bill).
While in Brazil I followed the psychiatric developments here. I knew about the DSM-III (now the DSM-III-R) and the efforts made by the American Psychiatric Association to improve communication between clinicians and researchers through this highly objective classification of mental disorders. The DSM-III-R indeed reflects contemporary American life: it is short, pragmatic, objective, measurable and ready to enter computers to become statistics.
The progress notes on patients records are now written in a stereotyped, problem-oriented way: the Individualized Treatment Plan. This ITP, which I understand came from the National Institute of Mental Health- that is, from Washington - has become the psychiatric language of the country. It took away from the psychiatrists the freedom they once had to desscribe their patient's responses to treatment. But what is more dangerous, it took away from humans their most important asset: their subjective world. Insight, once.considered the one fringe benefit for a psychiatric patient, is no longer considered an important therapeutic goal simply because it can't be measured in a language that computers understand. Complex variables are being reduced to measurable items, forcing psychiatrists to think computer language instead of their own.
It was quite an experience to be part, for the first time, of a treatment team try-ing to work within the constraints of an ITP. It felt like working in an assembly line where emphasis was placed on fixing parts of observable behavior at the expense of the patient's inner life. This tedious, repetitious, futile attempt to reduce human beings to problems to be resolved is now a nationwide procedure that has no credibility in terms of reflecting what really goes on in a patient's treatment. Has American psychiatry become an exact science? Have American psychiatrists become mere bureaucrats?
American psychiatry is also importing a new language from the business
world. This is understandable in a country where business is the greatest
model for personal success. Some new words in the psychiatric scenario
include "quality control;' "utilization review" and "risk management,"
They seem more applicable to industry than to clinical work. I recently
went
to a conference on quality control in a local hospital, and I was amazed
to see the degree of sophistication, time, money
and talent that were being spent in this endeavor. I left the place
wondering about the limits of what these practices could
really measure despite all the meticulously collected recorded data.
I also knew, while I was away, about the rising costs of medical care
in the United States. It seems that in the last 10 years numerous efforts
have been made to reduce these costs, but so far no consensus has been
reached on what kind of care
should be available to the American people. There has been an enormous
push toward quick, economic and profitable interventions by the private
sector, but at the same time, there is a nagging awareness that an increasing
segment of the population depends on the public sector for the continuing
care they need. At the same time the public sector has been
moving toward deinstitutionalization, privatization and deprofessionalization.
The main goal is also obviously economic
In order to justify this movement the concept of "chronic patients"
is being replaced by the notion of "treatment resistant patients," the
implication being that everybody, if properly treated by "modern psychiatry,"
can be an autonomous, self-supporting, hardworking citizen. Public money
that otherwise would be allocated for the long-term care of this
population is being spent in other, more "patriotic" endeavors. It
is also worth mentioning in this context that as the
government implements these plans, the number of homeless, psychiatrically
disturbed Americans is on the increase.
But the change that has grabbed my attention the most since I have returned
is the turn that American psychiatry has
taken in the direction of the brain. The hard sciences are now in the
forefront of the research efforts, and the soft social sciences, including
psychoanalysis, are being pushed to a very distant corner. To-day, the
hopes of patients, families and professionals are being placed on biological
research and what this could bring about in terms of more effectively (less
costly and time-consuming) preventing and treating mental disorders. Psychosocial
factors, once so popular, now seem almost forgotten.
This emphasis on the brain, legitimate as it may be, is being misused
defensively by patients, families and professionals alike. One patient
recently said to me: "I am upset today because of my brain chemistry. Would
you please adjust my medication?"
A mother recently said to me about her schizophrenic son: "Poor son;
we just hope that someday you doctors will find a way
to fix his brain chemistry." Even professionals are defensively focusing
on the psychopharmacological dimensions of treatment
to the exclusion of all others. The tendency to consider mental illness
as a chemical imbalance is so strong that it is becoming difficult to invite
patients, families, professionals and society to look at their participation
in the development and treatment of mental disorders. Once a patient is
defined as sick in his brain, the understanding of what is wrong is fixated
on the medical model and nobody is interested in what may be going on in
his or her mind. American patients don't have a personal history
any longer, their relationships with significant others are not a major
concern, and their subjective world is of no interest. They simply have
problems. American psychiatry forgot what it learned from people like Adolf
Meyer, Harry Stack Sullivan or Frieda Fromm-Reichmann, to mention just
a few who contributed toward the understanding of severe mental disorders
and to the development of what has been known worldwide as American dynamic
psychiatry.
Another interesting related change is the current practice of American psychiatrists in labeling more people as suffering from mood disorders. I understand this is happening for good reasons, and I am aware that even before I left in 1974, British psychiatrists seemed to be diagnosing more mood disorders than their American colleagues. But maybe one of the reasons for the change is the better prognosis and quicker treatment of mood disorders since the advent of lithium. Many "schizophrenic" patients are now being diagnosed as having mood disorders and are being treated with lithium.
There also have been other drastic changes in the way people are being diagnosed. In the past we used to arrive at one major diagnosis- that is, the diagnosis that would best fit a given patient even if the patient showed traits of other diag-nostic categories. For instance, we would label a patient with certain symptoms as schizophrenic even if he showed some antisocial acting out and alcohol abuse at a given stage of the illness. Today, such a patient would be diagnosed as suffering from schizophrenia, antisocial personality and alcohol abuse. This fragmentation of diagnosis is leading to fragmentation of treatment, and patients are frequently being placed in competing therapeutic programs. Such a schizophrenic patient, for instance, would receive antipsychotic medication while at the same time partici-pating in group interventions designed for the treatment of antisocial personalities and alcohol abusers or dependents. I am not sure if this multiple therapeutic approach constitutes good clinical practice. I am treating a borderline patient who shows some masochistic, self-mutilating tendencies; because of her multiple symptoms, she is now in outpatient treatment both in a sexual disorders program and a community mental health clinic, requiring an enormous amount of communication among the professionals involved.
The relationship between doctors and patients has also changed. Doctors are more defensive. This is related to the increasing number of lawsuits against them- a part of the prevailing cultural trend of demanding perfection from every -one, which is accompanied by the feeling that one is always due compensation when things go wrong.
Also clear today is the influence of third-party payers in psychiatric practice. Government advisory groups and insurance companies are now determining what constitutes good clinical practice although their major interest, dictated by economic concerns, is not always related to the patient's well being. Americans are refusing to accept certain costs inherent to living in a society. The ideology of "autonomy regardless of circumstances" is undermining any attempt to improve public psychiatry.
Available funds are now the main deter-minants of treatments. It is distressing to see how patients are being shipped from program to program in order to comply with funding. This is interfering with adequate therapeutic planning, particularly for patients who need continuing long-term care. Anyone who observes the readmission rate in psychiatric hospitals realizes what some patients are now going through. Third-party payers are also demanding an enormous amount of paper work as a condition for payment. As a consequence, records become more important than patients. A colleague recently said to me: "In this hospital, if you lose a patient, that is bad. But if you lose a patient's records, you must be prepared to leave town."
Finally, I want to say a few words about the role of the psychiatrists
in the mental health team. By becoming psychobiologists who are experts
in psychopharmacology, psychiatrists have lost their traditional role as
leaders in the mental health field. Such a psychiatrist is now instead
just another member of the team -a team that can be led by a social worker,
a psychologist, a nurse or even a lay administrator. He is also losing
his identity as a psychotherapist as he holds on to his image as a prescribing
physician. It is difficult to predict how the mental health team will evolve
in the future and what the role of the psychiatrist will be upon it.
WHY THE U S.A.?
Perhaps, to a large extent, the United States still remains a land
of opportunities. But I certainly don't feel that way when I compare this
country today with the one I left in 1974. Things have changed drastically,
and I am puzzled by the enormous paradox of a country that has improved
so much materially and yet seems to provide so much less care for its people,
particularly the less fortunate ones.
Last winter, I was walking with a Brazilian physician along the beautiful
Inner Harbor in Baltimore. It was about 6 o'clock
in the evening. I was proud of what I was showing my friend of American
life. The place was all dressed up for Christmas. Lights everywhere made
it look warm and friendly. We passed through Santa Claus's highly decorated
glass house. Outside,
a line of happy-looking children were waiting their turn to take the
traditional picture with the kind man. We crossed the street to enter a
new shopping center, bursting with holiday decorations. At the door, a
tall, miserable, disheveled black man was shouting disconnected statements
in a desperate and agitated way. For a moment I was embarrassed until these
thoughts
came to my mind:
Problem: Shouting continuously in front of a shopping center.
Goals: Decrease shouting to three times a week.
Intervention: Prolixin Decanoate, 1 cc (25 mg) IM.
That is all.
How far can this country continue to move in the direction it is going
before people realize that they are missing something?
Since I returned to the U.S.A. I have come across a whole new generation
of psychiatrists, coming from the best medical schools, who are unable
to pay attention to their patients' subjective worlds. They have been trained
to look at people's outsides: behavior is what counts, in the best American,
mechanistic, pragmatic tradition. In my opinion, American psychiatry, while
considering itself more scientific, has returned to unfortunate attitudes
of the pre-Freudian days. In some respects has changed for the worse in
terms of patient care.
I have spent some time trying to understand these changes. I believe that they have a lot to do with shifting priorities in this country. The question seems to be where to spend the country's wealth. As more money is shifted to protect big business and defense contracts, less is left for vulnerable citizens who have no influence in the political power structure, among them the sick, the disabled, the elderly and the minorities. The pendulum has swung too far to the right. Could there be a relationship between the political right and the emphasis on biological psychiatry?
My hope is that, sooner or later, the distortions that I perceive will be corrected and priorities will again be set placing people as the main consideration. This is not an unfounded hope. After all, despite the many imperfections of the socioeconomic system of the United States, it has been able to function under one and the same Constitution since its beginnings. The system has remained viable because of its flexibility in allowing changes that the people wanted. This country has always searched for answers without falling prey to radical beliefs. The possibility of changes, along with the freedom to work for them, makes it still exciting to be part of the U.S.A.
PSYCHIATRY, Vol. 52, November 1989
Marcio Vasconcellos Pinheiro graduated from the School of Medicine, University of Minas Gerais in Belo Horizonte, Brazil, and completed his residency in psychiatry at the Psychiatric Institute of the University of Maryland and his psychoanalytic training at the Circulo Psicanalitico of Minas Gerais, Brazil. He has worked both in the United States and in Brazil, and he is Staff Psychiatrist at the Southeastern Community Mental Health Clinic in Baltimore County and at Springfield Hospital Center. Sykesville. MD 21784.
The author is thankful to Dr. Bruce Hershfield, Superintendent of Springfield Hospital Center. for revising the manuscript, and to Elderburg's branch of the Carroll County Public Library for introducing him to word processing.