' t New Yori, (Continued) P ~I, FR l D A Y , · A U G U ST 9, - - - - - B y Albert Deutsch------.-----------------, New Federa1 Mental Health Program Gets Off to. a Good tart The groundwork for a co-ordinated, nation-wide Th~ Advisory Council will hold its first meeting <lrive against mental disease-America's health Aug. 15 in Washington. problem No. 1-is being laid rapidly, following Congressional passage of the National Mental In charge of the over-all program is Dr. Robert Health Act. Just before adjournment, Congress H. Felix, chief of the Public Health Service's appropriated $5,200,000 to the U.S. Public Healt? mental hygiene division, who has experienced a Service to get the Federal program started. Of this rather meteoric rise to a top psychiatric post. amount, $850,000 is earmarked to begin constmc­ Chubby, genial and earnest, Felix was' born in tion on a National ~lental Health Institute at Beth­ esda, Md., which will serve as a center of psychia­ Downs, Kan., 42 years ago. His grandfather was tric research and training. The building of the a physician; so was his father. Felix describes the Institute ½'ill ultimately cost $7,500,000, it is esti­ latter as a "saddle-horse doctor who graduated into mated. It will include a 200-bed hospital for the the horse-and-buggy class." ;study of nervous and mental ills. The rest of the initial Congressional appropriation will be spent in Felix got his M.D. degree at the Colorado Uni­ financing psyclfiatric research and training projects versity Medical School and later got a· master's and in Federal grants to states to stimulate estab­ degree in public health at ..the Johns Hopkins lishment of more mental hygiene clinics through­ S9hool of Hygiene. He was awarded psychiatric out the land. It is hoped that 100 of these clinics research and training fellowships from the Com­ will be organized during the next year. monwealth Fund and the Rockefeller FoW1dation. In 1933 he entered the Public Health Service, Surgeon General Thomas Parran, moving swiftly rising to clinical director at the Medical Center upon Congress's favorable action, has appointed for Federal Prisoners at Springfield, :t-.fo., and later a six-man National Mental Health Advisory Coun­ serving as clinical director of the Federal Narcotic cil consisting of outstanding psychiatrists. Their Farm at Lexington, Ky. At the latter institution, 1 job, as defined in the Act, is to help plan and he completed several research projects on the per­ develop the mental health program and to rec­ sonality of dmg addicts. ommend research projects. Surgeon General Parran ran into the young TI1e Council includes: . psychiatrist in 1940 during a visit to the Lexington , 1 Dr. David M. Levy, distinguished child psy­ narcotic farm, and was favorably impressed by his chiatrist of New York City. unusual grasp of administrative detail. When Dr. 1 Dr. William C. Menninger of the famed Men­ Lawrence Kolb retired as head of the Service's mental hygiene division in 1944, Dr, Parran named ninger Clinic in Topeka, Kan., who was chief of the U. S, Army's neuropsychiatric division, with the Felix to the post. Felix is a diplomate of the Na­ rank of brigadier-general, until his return to civil­ tional Board of Neurology and Psychiatry, and is ian life last month. considered a progressive eclectic in his specialty. 1 Dr. John Romano, professor of psychiatry at He is completely wrapped up in the job of organiz­ the Rochester University Medical School. ing a national mental health program, regarding it as a God-given duty. He is married, has an eight­ 1 Dr. George S. Stevenson, medical director of month old daughter, and collects classic-music the National Committee for Mental Hygiene. records and reads philosophy in his off-hours. 1 Dr. Edward A. Strecker, chief of service at Don't expect any sensational results from this the Pennsylvania Hospital's Mental Hygiene In­ new Federal set-up for some years to come. The stitute in Philadelphia and ex-president of the organizing job, in the face of c;ritical shortages of American Phychiab·ic Association. psychiatric personnel and facilities, is a tremendous , ~ Dr. Frank F. Tallman, Ohio State Mental one. But the program is off to a good start, under Hygiene Commissioner, who has played an out­ splendid auspices. In time, I am confident, it will 1 standing role in bringing to public attention the serve as an effective spearhead in the war against shocking conditions in many of our state mental mental disease and the promotion of sound mental •hospitals. health. , · UR PROFESSOR ATTENDS EET: Dr. John Romano, professor of . •psychiatry at the University of Rochester School of Medicine and Dentistry, i.s in ·washin,gton at­ tending the first meeting of the National Mental Health Advisory Council, appointed by Surgeon , General Thomas Parron. 1 , Dr. Romano is one o! six out~ ·standing p.sychiatriata named by the surgeon general to carry on the work of a co-ordinated, nation­ wide drive against mental disease. Groundwork rfor the program was laid with the recent Congressional 'appropriation of $5,200,000 for the U. S. Public Health Service to get the federal program started. Of that amount, $850,000 is earmarked to be used to start construction of a National Mental Health In- ,stitute at Bethesda, Md., which · ultima,tely will cost $7,500,000. Dr. Romano, who Mrved as visit~. ing neuro-psychiatric consultant for the Eighth Service Command and psychiatric consultant to the Army in- the European theater in World War II, will head the $3,000,000 new psychiatric clinic, the Riva., Clinic, being built at ; the UR. -/J u:.,1, I~ I Hi, 1 lf'ocheslen AUGUST 16, 1946 -----By Albert Deutsch----------------..;.__ Atomic Pile seen as Nucleus I Of D".S. Health and Medical Center .; WASHINGTON, Aug. 16.-Surgeon General they pass through the human system. · ':;Thomas Parran, of the U.S. Public Health Service Dr, Parran observes that the development of yesterday revealed plans for the creation of a these isotopic tracers may prove to be ''the great­ : ¥'three•pronged research project to apply at atomic ·est aid to medical research since the invention . energy "for the greater health and welfare" of ·, of the microscope." the civilian population. The · The proposed atomic pile research center at i plan, which ·· has not yet gone Bethesda would be operated jointly by. the U. S. beyond the "scientific· discus­ Bureau of Standards and the Public Health serv-. ' sion" stage centers around '. an ice. The project already has won the arproval of atomic pile that would be Secretary of Commerce Henry A. Wallace and '. located at the Public Health Federal Security Administrator Watson Miller. ' · Service's research headquarters in Dr. R. E. Dyer, director of the National Health Bethesda; 'Md., just outside of . Institute, estimates that the center would cost Washington. ( An atomic energy about $15,000,000. Final approval would have to pile consists of normal uranium be obtained from the Congressional Committee and· a graphite-like material on Atomic Emffgy before it could be launched. which slows down neutrons, thus The plan was announced at the first meeting , Dr. Parran permitting the normal uranium of the newly-created National Advisory Mental ·. to produce a chain-reacting sys- Health Council, a six-man board appointed by tem without being processed into U-235. or plu- Dr. Parran to help develop policy and supervise­ tonium.) · research under the National Mental Health Act On side of the proposed atomic pile would passed last month by Congress. Dr. Parran, who . be a center for atomic research from the presided over the meeting, was outlining plans physical science; on the other would be for a new health and medical center at Bethesda a research center for the application of atomic -including research hospitals for cancer, -tuber­ .energy in the biological sciences, including medi- culosis and mental disease-when he slipped into cine. · a discussion of the atomic pile project. third building erected around the atomic The Mental Health Council consists of Doc­ would house· research scientists, such as tors \Villiam C. Menninger, John Romano, George ch,em:ists, whose investigations would be perti­ S. Stevenson, Edward A. Strecker, Frank F. Tall­ nent to the physical and biological sciences. man and David M. Levy-all outstanding psychia­ The proposed research center oriented around trists. Dr. Parran announced the appointment of the atomic pile would be connected with the four consultants to 'the council-Dr. F. Alan National Institute of Health, operated by the Chalmers of Minneapolis, Dr. Frank Fremont­ Public Health Service at Bethesda. One of its Smith of New York Dr. Nolan b. C. Lewis of ·primary goals would be the application of atomic New York and Dr. \Villiam Malamud, of Boston. energy to the cure, and perhaps the prevention, In an earlier column, I stated erroneously that of cancer and other human diseases. The atomic Congress had appropriated $5,200,000 to the pile would permit extensive research into the Public Health Service for the administration of inner life of the human body, in health and in the National :Mental Health Act. I learn that this illness, through the use of isotopic hacers which, sum was stricken out of the act at the last mo­ by irradiation, make it possible to follow the ment, leaving the set-up without fonds at least ~~~~~_of ~<~!?-cl1-c ,hlood and other substances as until next January, when Congress reconvenes. \ , r Illnesses for People Over 65 Predicted ·A prediction that mental illnesses J oh1/ Romano, University of Roch- Security Agency~ Council members among Americans 65 years and over ester;, George S. Stevenson, medi- and guests were introduced by Dr. will double .in the next· 40, years cal director of the National Com- Thomas Parran. Surgeon General was maqe yesterday at the first mittee for Mental Hygiene; and of the United States Public Health meeting '·of the· National Advisory Frank F. Tallmarf, Ohio State Service. Mental Health Council. · . Commissioner of Mental Diseases. Other speakers were Mrs. Albert In a statement issued at a meet- All attended yesterday's opening D. Lasker, secretary of the National ing of the c~uncil, :Vhose six expert session with. the exception of Dr. Committee for Mental Hygiene; Dr. members wlll . assist the Surgeon Levy. · Robert Felix chief of the Public General,of the U. S. Public Health_ . The welcoming address was given Health Servi~e division of rriental Service in administering the Na- by, Miss. Mary E. Switzer, assistant hygiene, and Dr. Dale Cameron,: tional Mental;cHe.alth A9t, the PHS to the administrator '. of , Federal assistant chief of the division. declared: ' . . . ~•An increase of cases out of pro- · portion to ·the increase of ·total population •is forecast sinGe the . incidence of mental disease rises · with age,. and the n.uD1ber . of Americans. ·aged 65 and over is ex- · pected to · double in the next 40 · years." · The statement estimated that eight million Americans now suffer from some form· of mental or nerv- · ous disease; said that·. the . "blue,. print" for · a broad drive against such afflictions is provided in the · . new law, and added: · · "Through the investment of our wealth in human resources as ' authorized. under this law, we can , make this a·· happier and healthier nation, h,old together homes that . would be broken because· of mental illness,· return many of· those suf- fering trom these· diseases to pro~ ductive citizenship, and protect our ENQUIRER AUGUST 30, 1946 Friel younger generatio,:i in their right to grow up as healthy, happy, use- ful human beings." · Congress has authorized, but not i yet appropriated, $7,500,000·· for · Former UC Teacher a construction of a national institu­ tion of mental health. for research and the training of technicians, : and . has authorized, but . not' yet To ental Hygiene Dr, John Romano, Rochester, appropriated, 10 million dollars an­ N. Y., former professor of psychia­ nually for grants-in-aid to States for attacks on the problem of men­ try at the College of Medicine, Uni­ tal illness. versity of Cincinnati, , and Dr. The_ ·.two-day meeting of the ad­ Frank F. Tallman, Columbus, Di­ visory council will end this after­ rector of Mental Hygiene for Ohio, noon with PH$ and Federal Se­ 1 have been named members of a curity Agency officials analyzing six-man commission to assist Dr. the law and• disc'!lssing proposed Thomas Parran, Surgeon General policies with the council. · of the U. S. Public Health Serv- At ' yesterday's session, Repre­ ' ice, in administration of the Na­ sentative J. Brown (R., Ohio),, said , tional Mental Health Act, it was that· ,Congress, in passing the :learned yesterday. measure, did not intend that the Bleecker Marquette, ExecutJve States' obligations in caring· for i Secretary of the Cincinnati Public DR, ROMANO. DR, TALLMAN, mental patients be removed. Health Federation, said thnt the . The acat, he declared, is designed federation gave active support to of $10,000,000 over the present to promote Federal initiative in re­ the measure, which was passed by $20,000,000 available annually for search and training of cqmpetent Congress this summer. grants to states for the establish~ personnel · so .that all the States "Ohio will be entitled to a sub- ment and maintenance of public may benefit. '. 1 stantial allocation under the terms health services. Dr. Edward A. Strecker, head of Iof this act, which provides for "Money is also made available psychiatry at the University of , resc::,rch, for mental hygiene edu- for the training of personnel. This 1 Pennsylvania and a member of the . c~tion and for the training of per- is one of the greatest of all needs, newly - formed council, praised 1 , sonnel, all of which are vitally Nearly 2,000,000 men were rejected needed," Marquette said. from military service for psychi- ICongress for its progressiveness "The act authorizes two appro- atric reasons. Most of them could ', and courage in, enacti~g the Iegis­ priations. One of them is for benefit by treatment. At· present, ;lation. $4,500,000 to erect and equip a hos• there are not _anything like enough Other members of the council, pital and laboratory building in trained psychiatrists, psychologists all psychiatrists,,are Drs. _David M. Levy, Columbia University; Wil­ l Vlashington, to be known as the and psychiatric social workers to National Institute of Men ta 1 treat returned veterans and others liam C. Menninger. T.opeka, Kan.; Health. The other is an increase who need care." Columns PM, WEDNESDAY, JANUARY 29, 1947 .,XU • ~ '''r=•N,__. .,.,~ _ __,.,_ ...~,-~,~.-,, . -1111111,11111111111111111..11111111,m... By Albert Deutscl1111mmmru111111mt111tHIIIIIIIIIIIIIUUIIUllllllllllllllldlllllJIUlll;iffllUIIIIIIHIIIIIIIIIIIIIII--E Exper,ts ·Chllrt Federal Program i; ~ To Help Combat Mental Disease § ! a Plans for a Federal attack on· the Nation's the care, treatment and prevention of mental ill- , Number One· Health Problem, mental disease, ness. The Council approved, as a starter, grants were drafted last week in vVashington by a group in aid to medical schools and centers for the train­ of high-ranking psychiatric experts called together ing of 150 psychiatrists, 150 psychologists, 150 for the purpose by the U. S. Public Health Service. ' psychiatric nurses and 150 psychiatric social The plans include Fed~ral aid v/orkers. ~ to help break the. criticaif bottle­ Community Services: The National Mental !1ecks in psychiatric research, He,;1.lth Act authorizes the Public Health Service trained personnel and mental to make grants to the. States on a matching basis­ health facilities. If Congress two Federal dollars for every state dollar-to be comes across with the appropria­ used mainly in setting up mental health clinics. No tions i1eeded to put these plans Federal money is to be used for operating mc!1tal into effect, it would make pos­ hospitals, which is considered to be a state or local sible the greatest single advance responsibility. President Truman has asked for of our generation in American $3,000,000 for this purpose and for setting up mehtal hygiene. Federal-financed demonstration projects in stra­ · Last Summer, Congress passed tegic areas. Part of the $3,000,000 ean be used to the National Mental Health Act; prepare publications on mental health for the pro­ authorizing an annual appropria-" fessional and lay public. tion not exceeding $10,000,000 to the Public There isn't a state in the Union which isn't Health Service for waging a Federal campaign terribly short of mental health clinics, where people . against mental disease. Unfortunately, no app1~0- with emotional or mental disturbances can obtain priation was made. at the time. President Truman, psychiatric· advice or treatment without being in his recent budget message to Congress, recorn­ hospitalized. Experts tell us that at least one such mended a total of about $6,000,000 for next year's · clinic is needed for every 100,000 'people. Many administration of the Mental Health Act. The states haven't a single fully staffed mental clinic. 1 National Mental Health Advisory Council, con­ The Federal program seeks to help set up about sisting of six topnotch psychiatris.ts, m.ct last Fri­ 100 clinics during the next year. While local public day and approved a three-pronged offensive for and private non-profit psychiatric pr9jccts can be the first year, conditioned on favorable budgetary supported by Federal funds, they are eligible only action by Congress. · when submitted by an ·authorized state ager.cy as · Here's how the Federal, plan shapes up for the part of a state plan. In other words, the local next year: . r agency in each ·instance must submit its request Research:· $500,000 is set· aside ( if Congress for financial aid t-0 the appropriate state authority, makes the money available) for Federal grants to not directly to the Public Health Service. non-profit institutions and agencies, public and · The National Mental Health Advisory Council, private, to stimulate and conduct scientific studies appointed by Surgeon General Parran to shape on the nature, cause and treatment of mental ills. policy and approve projects, includes Drs. Edward The Advisory Council, at its meeting, considered A. Strecker, William C. Menninger, John Romano, 32 research projects that had been submitted in Frank F:Tallman, George S. Stevenson and David anticipation of Federal grants. The Council gave M. Levy. Dr. Robert H. Felix, head of the Public outright approval to nine projects, costing $100,- Health Service's mental hygiene division, admin­ 000, rejected 15 and deferred the rest for further iste1·s the program set up by the National Mental investigation. The Council's recommendations must Health Act. go to Surgeon General Thomas Parran of the Pub­ Citizens interested in the Federal mental health lic Health Service for :final approval. program might write their Congressmen and/or Training: $2,000,000 has been requested of 'Rep. John Taber, chairman of the House Appro­ Congress for Federal grants to aid in the training priations Committee, in support of P1:esident Tru­ of i;:lesperately needed psychiatric personnel for man's budget recornm~ndations. FEDERAL SECURITY AGENCY U.S. PUBLIC HEALTH SERVICE WASHINGTON 25, D. C. IN REPLYING ADDRESS THE SURGEON GENERAL. U.S. PUBLIC HEALTH SERVICE April 3, 1947 MEMORANDUM TO: Members of the National Advisory Mente.l Health Council SUBJECT: Appropriations Bill as Fessed by the House, March 25, 1947 for Fiscel Yeur 1948. I am sure you will be ir.terested in knowing the results to date of the 1948 Appropriations for rnentd health. $4,000,000 was appropriated by the House for these activi­ ties exclusive of grants to st&tes. The budget included cm estimate of $5,108,000 to carry out provisions of the National Mentel Health Act. The House, however, appropriated $1,108,000 less than the Budget requested, beceuse it felt that since the progre.m is a new one it would be wise to proceed on a modere.te ba.sis during the first yee..r. In this $4,000,000 is to be included the maintenance of hos­ pittls at Fort Worth, Tex~s, and Lexington, Ky., resecrch training, 1 and administration. It will now be necessc:.ry to review and critically appraise the appropriations for resea.rch grants so that those with the greatest potentialities will be awarded the aid. Besides the $4,000,000 eppropriated, the Committee has specificelly earmarked $3,000,000 in grants to Stc..tes to be used sole.ly for mental-heal th activities. It will be e source of gratification to you to know t}J.at the Report of the House Committee contains the following stetement: "The Committee is mindful of the great good to be derived from this program e~nd expects to make ade4uate provision therefor". The appropriation must next be acted upon by the Senate. ~~ / Surgeon General COI C Federal Security Agency U. s. Public Health Service National Institute of Health Bethesda 14, Maryland January 8, 1947 Dr. William C. Menninger General Secretary The Menninger Foundation Topeka, Kansas ne·ar Doctor Menninger: I should like to acknowledge receipt of your. application for a grant in aid in the amount of $18,130 submitted in behalf of Doctor George S. Klein's proposed research on "A Clinical Study of the Personality and Psychiatric Diagnostic Correlates of Certain Perceptual Effects .. " This application is being prepared for presentation at the next scheduled meeting of the National Mental Health Council, January 24, 1947, and notification of the action taken by the Council will be forwarded immediately thereafter. · It is noted that the proposed budget includes two items which are usually disapproved by the National Advisory Councils in making grants-in-aid. It is the policy of the Councils that principal investigators with tenure shall not receive salary reimbursements from grant funds~ It is also contrary to policy to grant', funds for indefinite items such as your request for $800 for "Mis­ cellaneous (to provide for price changes and other unforeseen equipment needs). 11 We would suggest that, if this item cannot be deleted, some definite type of equipment should be specified. Clarification of the questions raised, and your authorization for the Research Grants Division to amend your application to make any necessary changes, will facilitate the processing of the application for presentation to the Council. Sincerely yours, Ernest M. Allen Assistant Chief Research Grants Division cc: Dr. Georges. Klein Dr. Kolb (2) COPY January 13, 1947 Dr. Lawrence Kolb U.S. Public Health Service Washington 25, D. C. Dear Doctor Kolb: Thank you for your suggestions in our phone conyersation today. It was my intention to indicate to you over the phone that where we have listed a half-time salary as the co-director of the three research projects which we submitted we did so on the basis that someone would have to be employed to do the clinical work which .these persons are now doing. In other words, in contrast to. a state institution or university and despite the fact that we are a Foundation our chief source of income has been and must continue to be from ,clinical work. Therefore, if. we relieve someone from cli.nical work to do this research we must of necessity either forego that in­ come or, as is our intention, employ someone else to do the work. Consequently., it is my feeling that this particular situation, which I assume would apply in other private institutions, involves a prin­ ciple for which some policy should be considered by the Research Committee. It was my understanding that you had encountered the same situation in some other requests and that a policy would have to be worked out to cover such situations. It is implied in paxagraph II, A 1 of the Agenda for the meeting. Since Doctor Rapaport will be present at the meeting you felt it was not essential to revise our statement but as I indicated I do not want to put Doctor Rapaport on the spot in defense of our own particular requests. Therefore;we will be sending a slightly revis~d first page of our requests, indicating that the amount of money requested for the Directo~ or the co-director does not accrue to the salary of the worker and will be used to employ a substitute to carry on the clinical work now being carried by the person designated. If there is anything further we should do about this please let me know. We are grateful to you and to Docotr Ellis and to Doctor Felix for including these projects in the Agenda and hope that this slight conflict can,be cleared up. Sincerely.yours, William c. Menninger, M. D. WCM-n THE .MENNINGER FOUNDATION FOR PSYCHIATRIC EDUCATION TOPEKA,KANSAS . . . . . . . . . . . . . . . . . . . . . . AND RESEARCH January 15, 1947 Dr. John Romano University of Rochester Medical School Rochester, New York Dea.r John: I want to apprise you of the situation we encountered when submitting three projects for consideration to the Research Grants Di­ vision of the Public Health Service. The enclosed copy of the letter from Dr. E. M. Allen is a sample of the lt::tters I received in wake of our submitting the projects. To Gather some infonnation I telephoned Dr. Lawrence Kolb. The copy of my letter of January 13, which I also enclose here, records his ~mcgestion for coping with the situation. It is also in keeping with the policy recommendation that appears on the first page of agenda of the Committee on Research of which you am the chairman under II, A, 1. In another letter to Dr. Kolb accompanyinrr a revision of our budeet sheet I wrote, 11 the footnotes we incorporated on these pages are meant to explain that these people (that is, the direc­ tors of the projects) have been engaged in performing clinical duties and the amounts requested are to pay for substitutes to do their clini­ cal work and not to supplewmt their salaries". I believe that many institutions, and certainly all private institutions which want to do research and want to make sacrifices for it, will be faced with the following situation: (a) They 1vill devote the time of some of their best men to research, giving up the income-producing, teaching, and administrative time of these men which is of crucial importance to the institution. This will be tho case in all those institutions where endowed research positions are not extant ( and I want you to count on your .fingers how many institutions the re arc who re crnch positions do oxi:Jt). (b) If thcso institutJons will b(: supported to Lhn extent that at least the salaries of men whose services they give up for the Dr. John Romano, January 15, 1947 - Pae:e 2 sake of research will be paid so that some kind of substitutes can be hired to carry on the routine work, these institutions will be encour­ aged to make the sacrifices for research described under (a). I feel that a policy-making board should seriously consider this situation. I regret only that I have to bring up the problem in connection with the institution with which I am associated. I trust that you, who can see the situation in several other institutions, will be in the position to put this issue in general terms. As for me, I feel that the policy we choose to follow in this respect may make the difference whether mature men steeped in clinical work 'Nill do research or whether all the mature talent vrill be absorbed in routine and admin­ ist·rative work and the research will be done (under more or less super­ vision from these mature men) by "beginners". At least this is how the situation looks to me. I hope you will be able to give consideration to these matters before the meeting of the Committee. Sincerely, ~ William C. Menninger, M.D. General Director WCM:el FOR PSYCHIATRIC EDUCATION THE MENNINGER FOUNDATION TOPEKA,KANSAS . . . . . . . . . .. . . . . . . . . . . . AND RESEARCH January 15, 191-~7 Dr. John Romano University of Rochoster Jfodical School Rochester, New York Dea·r John: I just finished vrriting you a letter vrhon it occurred to me that it mizht be well to bring to your attention another policy problem which might well deserve your consideration before the meet­ ing. I think your Committee on He search might com3ide r not only grants for research projects but also issuoc of training for research. It goes without saying that no regular training of psychiatrists, grad­ uate or postgraduate, amounts to a training in research and that such traininf, can be accompli~:;hed only by apprenticeship in research insti­ tutions. I therefore wonder whether or not your Cor:ar.1ittee should con­ sider the establishment of research training fellovrships and junior re­ search fellovrships and the 'Nays and means provided for such fellowships ·within the framework of the pre sent lecislation. Looking forvvard to seeing you soon, Sincerely, ~ William C. Menninger, M.D. General Secretary WCM:el THE MENNINGER FOUNDATION FOR PSYCHIATRIC EDUCATION TO PE KA, KAN SAS . . . . . . . . . . . . . . . . . . . . . . AND RESEARCH March 5, 1947 Dr. John Romano Uni ve rsi ty of Rochester School of Medicine 260 Crittenden Boulevard Rochester 7, New York Dear John: Like yourself, I too was deeply shaken by the passing of Dr. Kurt Lewin. Particularly those of us who knew his broadminded, non-partisan character experienced his passing as a very great loss. Even though this certainly is outside of what I consider my respon­ sibilities on the Advisory Council, I could not help but give some thought to what losing him will mean to your Committee. I thought you would not mind if I dropped you a note on the ideas I had. Psychologists like psychiatrists are a sectarian lot; they have many factions. Levdn somehow stood above these factions and had the respect of all. I imagine you would want to find somebody in his place who could fill this bill to some extent. In rummaging through my memories and in talking to a few people, two names stand out: one of them is Dr. Gardner Murphy, the head of the Psychology Department of City College. He is a past-president of the American Psychological Association and a man of high ideals, integrity, and general recogni­ tion. The other is a younger man, Dr. Robert White of the Harvard Psy­ chological Clinic, who happily unites an academic background and clin­ ical interest. These are my ideas; take them for what they are worth. William C. Menninger, M.D. W'CM:el I I ~------, ;/ I . .. ' FEDERAL SECURITY AGENCY U. S. PUBLIC HEALTH SERVICE ', WASHINGTON 25, D. C. IN Rlt,-L.YIN<ll May 20, 1947 ADDRESS THE SUl'ilOKON GllNEAAL U. Ill, PUBLIC HEAL.TH •ERVIClt Dear Doctor Romano: I have read with much interest your thoughtful letter of May 14th concerning policies to be followed in giving grants for training. I agree fully with your point of view that training grants should be given to as large a number of qualified institutions as possible even though no one institu- tio~ during this first year will have an adequate amount. Our Committee on Psychiatric Training was working under tremendous pressure and in my opinion were seeking to apply an ex.act measurement to the problem which was not susceptible. of such measurement. I am sure Dr. Felix has sent or will send to you sugges­ tions wl1ich were developed after the Council meeting which had for their objectives a more satisfactory appraisal of the several training projects. If we should have the good fortune of getting additional funds for training as.a reuult of the action of the Sen~te in increasing our mental hygiene appropriation by $500,000 it should be possible to spread much more widely our grants for this purpose during the next year. I assume that Doctor Felix will be discussing the matter ---·----··--------- _ ---~~tl.th~01L:this_week....a.t_the.-A.m@.ci--Ca:a.-1?.s.y:Gh-i-et--tF-ie---mee--t-iflg-.----------------- With kind regards, I am yours, ~ ~ Lu:rgeon General Dr. John Romano Professor of Psychiatry The University of Rochester 260 Crittenden Boulevard Rochester 7, New York cc Members National Advisory Mental Health Council Dr. Felix FEDERAL SECURITY AGENCY U.S. PUBLIC HEALTH SERVICE WASHINGTON 25, D. C. IN REPLYING ADDRESS THE SURGEON GENERAL U.S. f'UOLIC II CALTH SCRVICC ·Dr.. Thomas Parrnn Surgeon General. Uuited. States Public ,,,_,1:,....,w,,... Service Va11hln«'on 2,5 • D• .C. If' you remember, I had to lieavo before the end of businEHHl lato l:/edn&sday nfte:rnoon • April .23. I loft during the final deliberations of the Council with you at:a to actions which the Council we.a to take on tho report of the Training Committee• and. more la.rly,. on tlle grants for clinical :psyclrl.atric tmini~. ·,.,-~--·- I was sooewha.t con- cerned bY' this report ·of the Training Oom:ii tt~e. ".g'J!>'!l'"hil!n.,,@ vaa ~ we were tryi~ r.nl!m~:u:tft of """"'""'__.., into too ..,_,........, ~nt. of t1m8. th."':h.t there may have to be nome typ~ of priority the cot~ittee in order to deter;n1ne elif;ibilities urgencies of certain tn.in1.ng a.reo.s. I was not clear as to all of the criteria of priority. nor tUliformly the criteria. 'We~e used for final jn~~.entn. Rn.vine h';t.d. the opportu.nity in the past fourteen years to have worked :in a mt.~ber of clinics 1n various of eountry- anc\' to' 111 somewhat surprise~ at Un1ver1l1t7,o:t C1ne1nn.at1mmber 23. are diet1nctly '?raining Council .and pertinence of any project. Further, our final decision. ,r .It certain schools cu.eh au Cincinnati nothing at Bll u.."'lder th>S appropriation, a oonsiderAble a."i'lount of u;;~n~f!;c will have been <lone. It is poedble there my be an inference that the department d.id not measure up tot he standards of others. This could not fail to react against a department when it attcir:rpts to raise money locally or obtain ~oney throur,)l found..~tions. One cannot 00 ,~ 0 ~, 0 the fact the Com1ttee on Tra1n1ng 0 by' the fact that 1 t "1111 to nor.e end not to , u:nfortu.I:k"ltely the power to produce the impresoion t..l:le.t there are two of departrnents-acceptable • In view o'£ ··this ....,,.."'·' """""' I think 1 t tfuould exceedingly careful to see that f'irat-rate get a grnnt. no mattor how small. ~en an b;r the committee that eome schools vhieh deserve gl"t\nts did get ,,'{,li~ited. montQ" W:ill :not.counterbalance g.,.,i.~,v of 4J,F,. ~?l"t:1n:r>et1 J,l'~.l.. ,.centers. ··· · · I should like to ta.t.."'8 a definite stand ai n I,'!6I1oe:r of' the Council tho.t schools really good ,,.._,....,,.#1>,_,...t.,.. be ~1ven a £ra."l t no mtter hov small. the s1tuatit)n of th•0a schoola--even degree far Dr. Thomas Parran -2- 14, 1947 An obJection m;:, be th1s may prtnei~le are given money @hould be enCl'U.gh "' 1 "''1",m."!l'J"' to benaf1 t them. about the necessity of wcll a policy. So aa I knowi all ot the fir,t 1ixteen are to be to centers mental premine is t~~t the money at present that they ca.."l prorluce the ~eater nu.mber of ..,..........,., . . . :people so urgently needed. believe that we,ar1ng wishing capo. Enren thoueh they roo,y be f1tuffed v1th bank notea, is going to solve tho problen of nn inadequate numb~r of skilled and trained people. I can 1 t see how al.locating money to inferior ".,.~;~v~•~ ia eoi:rie to n1f'ica.ntcy, particu.larly ·when tbii is done in preference to I use the example of Cincinnati as have al.so had occasion to knov exuerience p and of others tr.trO"'J,f)l vioita MY in C1noinnat1 1 a exoellcnt. They have a group -well-trained yolme :psy- ehiatrtst e rw:~ra. by RMenbnu...r,; they hn.ve good worJ:ing relationships in cine and in podiatries; a grou? of tor-notch investiea,tors a. long-time :produetiva ralntionnhip with tho health and social C¾f~,,;;,,.,......., . ty. . In addi t1on, they i:k'1-V8. begun n tio-trp vi th Unitad J?u.blio Lextttgton. I hope that thie liaison will a.a I &"!i sure it can beD.efic1al. I have told you on previous occasions, I ~ .........,-.;.,. in doing ~hatever I CM to help you the -othero e.dminiBtar a very portant progravn of national mento.l hoalth.. I nm thankful for your brond vir.iion and for your whdom, an.cl hope sincerely that you will find it :possible to be w1 th us in l1ew York at the tine of the meotine:. --,,-.,;; FEDERAL SECURITY AGENCY U.S. PUBLIC HEALTH SERVICE WASHINGTON 25, D. C. IN REPLYING ADDRESS THE SURGEON GENERAL U.S. PUBLIC HEALTH SERVICE . \~f,~ihJ{{$;:, Th6mas F;rran :,.,• : , U. s. :Public Health Service Wsshington ~15, D. C. Thank you for sending me a copy of Dr.· $trecker•s letter. As I have ht!d · · a obance · tto think: of the first work of the Ad:vhoey Council there are some genera:i thinga thet I :feel should be taken into secount. ' l'i'irzt of nll it seemed to me tho.t the work of the three comm1ttest has :proceeded too independently 11 .f:'lnd in view of· thf1t I would Hka •:.itomodify the yie.,.':Point ex:pressid by D:r. Strecker in his laiat paragraph to the :point that the decisions of the Oorra-nittea shouJ.cl ~ti1nd. It seems to me tha:;,t it is the job of the Council to see that the deatsions of the Committees dovetail .v1th ee.ch ~ther in order that they r.1ay ~oe mutually su:pport ing. ! believe. the ultimate test of the effectiveness of this .A.ct will not 1Je the number of research :projects turned out or the number of psyehfa,trhh trr-dned. but tht\ ,,amount, of. good work thn.t is done t~>"' the ;people ,of ~he United Stntea who are in :need of' i?entaJ. heal th services.' · If this is true, then, the grant-in-aid progrt1m, coupled with the independent activities tl1roughout the country, should. give thi,,, le~'.id to both training and research. It should sho-w \;her& training is needed, what kind of ' training,, and·a.1so where o\tr ·researchhgai,s are. I must ad:i.lit that vhilo acting e.s a member of the Council this waa 'not quite so. llear to me as it ii nov-, end t the other members of the Co\Ulcil have had mu.ch less opportunity to secure .this over-all :perspective in their de.Uy work than havo I,. lfost o!, tht.?m art) ,•.,.., aca.demicrilly focused r:n i think in terms of e..cMemio stren.ghtening. 1 At our very first meeting, for exsun:ple, it was pointed out that we . .,~ .~~·~ he,.ve a shotttnge of training facilitieo and tha.t eve'I:'J effort sho·uld be JnFLde to utilize VhE:t ,,,e have E:nd. to focus training in such a wny as to e.ugment ou.:r tra.ining focilities. In the c~llocBtion of funds. however, there wns no effort to clarify the critic~l poi».ts ot ehortage of p0rsonna1. P.nd I am atr·aid . thet the "fla;/ g:rs..nts were made is almost certain to t le u:o ·the fund2 in s'l.Ach a we::, that changes in ellocn.tion will be difficult to bring t:tbout. As a reanlt thers are training centers to which no attention ha.a been paid e.nd whi~h are likely to go unused ~hiltethe inexperienced centers are being strengthened. Th.are tJra some thirty vacu:1.neies for :psychiatrists in the children I s field. which ic more than anything else the field represented by the grante-in­ ,\;aid~ Unless these vr:tc-Dnc1es are filled the whole grant-in-aid program is threatened with the use of inferior personnel. In eompansetion for this I · have been able to secure $16.000 this :,ear from the Commonweal th Fund, contraey . · ·to,their,decidon .more than two years ago that the7 would not make grants for ... - 2 - June 23, 194? stipends for the first ye~.,r • 8 t.cr.i:o.ing in child l)Sychia.try, Thh will make 1.t pouible for. ua to "save" the above mentioned experienced center$. but I believe· in the future the Council should truce seriously the fact that 1:t & job over and ebova end \ sometime1 c:ontracy to the.t of the individual commi Uees. I believe that the Council should in the futttre the t:rpe of help thi~.t it wants from the committees t:ind not allow them to move nlong independently. For examJ)le, it ILiight nsk the corr,mittees to review the country with the J>Ossibility of building u:p nree,s in ~w1hich there no center o:f psychiatric teaching. It might e,sk them. on the other hand, to build u:p :four or five top ranking pls.ces in which our future professors eould be trained. It might esk them to build up centers for training child psyahia.tri or for tr1a:utU)6 personnel for re;er:rch, depending what happens to be the need from to t1me. I feel most comfort&ble tha,t you hnvf.:t put Dr. J;_lan Gregg on thG Council for his work- hos brought him into the brander :perspoct ive. s/ George • June 24, 1947 Dr. Thoma11 Pa,rran Surgeon General, United States Public Health Service Weshington 25, D. o. Dear Dr. Parran: Thank you for sending men copy of Dr. Strecker•s reoent letter to you, in which he indicrited his ree.ctions to the :points I preunted in my earlier letter to~You and to the discussion which took place in the Council meeting in New York Oity. You a,ak if it would be agreeable to the writers if this and other COJFHpondenee dee.ling with Council matters should be sent to the entire group. Not' only do I ha.vs no objection,· but I· think it en excellent idea. You will remember ,tb..at my earlier letter to you was in the ns.ture of unfinished business~ as I ha.d to lee.ve tl:e Council meeting in mid-afternc.on end was esked by you to send my tho1.\,~hts on the discussion which had to do with the lt1st order of business,· namely, the Report of the Tre.ining Committee. As I left, it l!8S my understanding th1.it the Council he.d s,r.1proved the Report of the Training Committee but that. if there were to be t::.ny changes the amount of money to be expended by the '!'raining Committee, the existing order of J?riority &.:ld a.uignment of stipend would be o:pen to rav1~. I leRrned that the latter ,uu1, the cAse Ond thet there waa to be a. change in the amount money available for the Trfllining Committee. l presented my sugge9tions to you end in the Mew York meeting :presented them to the Council tus e, group. Essentially my 1notive in riresenting the points was the following. I believe 'sincerely that Americo.n psychiatry is in urgent need of skilled lenders and trae.chers. ; ·Therefore. I feel that the wisest :plan would be to see to it those schools and institutes which currently are the best prepared to teach because' of men and f~ilities should be underwritten to insure the training of as !118111' skilled persons as :pouible. I chose to s:peak of the of Cinoinna'li, :particularly because of nr:, intima.te k:nowledgt of the men the faoil1ties'',1n tl1is school. In instances like this I prefer to speak of partioul!irt so thr,t I :mey 111ustrnte and defend my :point of view rather tha.n deal in ebatriictions. At the meeting it was the Oouncil Is cleoidon that we rete.in the original n:pproval of tile committee report. Noturally, a; s. member of the Council, I accepted this majority decision• . However, as I read Dr. Streaker's letter, I sense that there is another mtttter which b :perhaps ruore fundamental thf1n the specific instance of which he spoke iind of which I have just written. It has to do tdth the zone of res:pondbility of the Council. :Perh,'9.ps it will be :possible a.t ouj{ next meeting to pla.oe thi1 mn-tter e.nd two others ,, hioh follow on the a.gende.• so that we may discuss them. in detail. The first question is what is the fundamental :responsibility of the Cou.r1cil? Is it essentially a Council which should accept without comment the varioua co1nmittee reports, or is it invested with the responsibility end privilege of exp~essing opinions, offering suggestions and criticism on the report, ~hioh . June 24, 1947 .are submitted to it by each of the committee chairmen? In other words, is it proper for mo or for aJlY other me1nber of the Council to quEui_tion, ofter auggeetions, or criticize a committee report? I must confess that this has been~ under­ standing. If 1 am in;.error I would e.ppreoiate your telling me, ao that I mq kno11 the ~act.a oorreatly• 1 . .A second t:ll!i.tter crmcerns the time inte:rvnl betw·een the prepr:J.:rrition of the com­ mittee reports rnd the review of the committee re:porh by the Coun<'J11. In the times thnt we lw.ve met the Council has met on the third day of a three-day session. , The f irat twodey;a tnd two nights for the cotun1 ttee ehairn1en t1.re filled with the major responsibility of directing the oommittee ' & wo1"k and~ of prepa,ring a report to be preaented to the Counoil on the third de,y-. !Cech of U$ who i• a committee,, chairman. therefore, is so engrossed in the ;preperation of his own report and. 1,U pr,esenting it,,Je> the Council that he has little tbie .to atudy end.. diga.st the reports of the other comm'lttee ch.airmen. My question h this--would it be ~dviseble to hr-ive e. period of time elapse bit'"leen the work of the in<lividu.F-tl committees tt:nd the meeting of the Council? As I 1.md.erstand. it• this is the way in which the other Councils operate. It would eive the Council an opportunity to atudy end digest more thoroughly the work of the committees, so that it mny ·oe in a better• J)OSition to give .an opinion. I believe we ha..v e discussed this before. and there ~·'.• may be me.ny reasons why it has been arranged in the way 1 t b.ac. Certainl.7 one -~:,..1,:;,: reason has been the tremend.cru., pressure of time an.d of multiple dema.nda made on those ot us vho, sarva on the Counoil. The :present method si1ve$ time. I believe a second rea.•on veis the :matter ·or expanae1 for travel and· of 'l'tdministra.tion of the meeting. There m.ny be other reasons. A third question ~hich I should like to have the Council discUBs at the next meeting is the matter o:f h.!!,v:lng members of the Council t?ct es chairmen of the eollU!littees, l. d.o:n •t know if thb :procedure is follo11ed in the other Councils, nor the re~son.s for its opere..tion in our Council. .ls it now stands, th1'ee members .of the Oounc1l ere chairmen of the commit tees a.nd the remaining three are members of one or the, other com.mittee. Actually. then, .when e. chairm.'!ll nresents the. oom- 'mittee 'report' to· the Council. he is e.ctu.~,lly present inf.;. it to fo~u.• members Md not to dx. Would it be proper to discuss this matter at our next matting, namely. the ,double a.sdgnment of Council member,? I look forward es.gerly to meeting with you e.nd the members of the Council at the next meeting. I. hope "'1'e shall have an opportunity a.t tha.t time to discuss these matters in detail. Sincerely yours, S/ John Romrno John Romano, H.D. Dr~ ThomD,n Parran Surgeon Gen~rel • U. S. Public Ra:llth Service Wa~hington 25, D,. C. Dear Dr. Parran: I read \1i th sincere regret the nnnounct3mont o:f your retirement, I hn.v~ looked :forward eagerly to the ueo tings of the Mental Heal th Council in \fa.Ghi:ngton for a number of' rerrnonn. One very important reason was the opportu.ni ty of m~t1ting and sh..:.'1.ring with you the rcspon.si"bilitien of long-term planning in tho • field of mental health. Althour)l I have :known you. a verJ shor't time •. I have been sincerely impreased "With your q11al:tties ~s a leader and as a. creative thinker. I have been impressed by your eou:ra~, intelligence, ann wisdom in dealing vith others. Your record in the past twelve years is concrete evi­ dence of your courage in fncing and your ability in planning for the real and urgent health.needs of our ru:.ition. Cordially y o u r ~ JR/HS FEDERAL SECURITY AGENCY U.S. PUBLIC HEALTH SERVICE OFFICE OP' Quarantine Station MEDICAL. OFFICER IN CHARGE Miami Beach., Fla. March 2., 194-8 Dear Doctor Romano: Your kind lotter has been forwarded to ino here., where Mrs• Parran and I are gottin g a brief vacation,. I want you to know how deeply I ap­ preciate the kind se11timents which you expross. It has been a great pleasure to l01ow you during those last two yen.rs ar1d particularly to seo the way your mind works. Some tine a.e;o, a lending .American educator ·was telling me how much he ad­ mired Generr,l IJarshs.11 e He said, "Of all the men ·who1:i I have lrnown, General IJarshall., more thDJJ any o thor., 11...as the ability., in dm:i.liDt; with a coE1plex sit­ uation., to defino the important variables and to keep them constru1tly in equation." 0110 of my pleasant tasks has been to participate in tho sessions of our several councils. Thero are s01ne of the best medical end scientific minds hi the country. May I tell you that in my judge­ ment you havo the S8Jne quality of m:i.nd as that which my .friend has attributed to General Marshall? FEDERAL SECURITY AGENCY U.S. PUBLIC HEALTH SERVICE OFFICE OF J!CAL OmCER 1H CHARGE 2 I hope our paths vdll cross often in the days ahead. With all good ·wishes, I run., Cordially, I John Ro1:iano, :.I. De Psychiatrist-in-Chief The 1Jni vorsi -bJ of Rochester 260 Crittendon Boulevard Rochester 7, N. Y. • ,,-';,•"d' C c: p y ;I,.,#'!, ,,. " ,, ~E MENNINGER FOUNDATION TOPEKA, KANSAS April 26, 1948. Dr. Robert H. Felix Room 3018 Railroad Retirement Bldg. 4th & D, S. W. Washington, D. C. SUBJECT: Comments on the Reports of the Sub-committees for the Mental Health Advisory Council. Dear Bob: It is with a great deal of regret that I cannot possibly be with you on May 14 and 15 because as I indicated in previous letters these dates conflict with the American Psychoanalytic Association meets of which I am president. The Council Meeting and Committee on Standards and Training meet on the 14th with the standing committees meeting that evening and the first day of the Association meeting is on the 15th. May I make a plea that we do not conflict with any national psychiatric meetings hereafter as dates set for the Council. I am aware of the fact that this saves two days for most of the rest of the members but with. a six man Board it seems to me rather important that a date be chosen in which at least at the time that it is chosen it is acceptable to all members of the Board. 1. General Comments A. Sub-committee meetings. The Board, I think should consider ways and means of advising you as to how the Sub-committee meetings can be less intense, less strenuous and demand far less of those persons whom we ask to assist us. I have only the Training Committee meeting on which to judge but it was far, far too strenuous to expect people to continue with such service. This may be an administrative matter but it seems to me it is of primary importance. ½e cannot expect people to work until two or three o'clock in the morning on this job. It is highly commendable that we do but something is just cockeyed in the system. Therefore, I recommend: (1) That ways and means be devised to prevent excessive demands on our consultants. (2) That official thanks go from the Council to every member of every Advisory Committee expressing our recognition of the tremendous effort they have invested and our deep apprecia­ tion to their guidance and counsel to us as the Council. I think we should indicate that we could not possibly function without their help and are taking steps to make this demand less intense upon them. 2.. Recommendations from Consultants: I am convinced that if we give people an opportunity to express their opinions we could learn a great deal. Therefore, I would recommend that the Council adopt a policy of asking every consultant on everyone of these three general advisory committees to give us their opinion and advice as to how we can do the job better, how we can make their work less strenuous and yet just as effective and any other suggestions they would have to us as the Council. I think it would be well worthwhile to point out to them our responsibility and why we want their advice. Dr. Robert H. Felix - 2 April 26, 1948 3 •. Integration: I am not at all convinced that we have as yet begun to achieve the desirable integration between the committees on training or between the three areas o~ training, research and community service. Specifically, this letter is dictated on April 26. The meeting of the Council is two weeks hence. I have no idea whatever, as a Council member, of what is recommended from research or from community service. I appreciate that this may be an administrative problem within your own division and yet I don't see how we can act intelligently without throught­ fully considering these three areas and our responsibility for allotting money between the three. Integration within the Committee on Training seems t,o me to still be lacking the ideal. ½bile we have the various disciplines represented on the Nursing, Psychology and Social Work Committees, we have not as yet had those disciplines represented in the Psychiatric Committee. We can go on giving lip service to this business of 11 The teamn but I am quite certain that the committee for instance on Psychiatry has no really adequate conception of what went on in the other ttlree divisions. I believe this is an administrative problem and I don't know how to solve it but I certainly want to emphasize and point out that we are not as yet meeting our responsibility. For instance, I am sure that we ought to be favoring those institutions that have a sufficiently adequate psychiatric program to conduct, for instance, an adequate psychiatric nursing program. We do have two psychiatrists on the Psychiatric Nursing section but I don't know whether they even have the data as to what kind of a psychiatric training program is currently going on in the institution nor what the Public Health Service, through this :Mental Health Act, is providing in funds to augment it. I think one could duplicate this throughout. It doesn't make any sense at all to me to make a terrific grant in one area, say psychiatric nursing, if we have a weak psychiatric department in the school where we are making a grant. How can we integrate that? Isn't that our responsibility? Shouldn't this be done at the time we are making the grant? 4. Money Available: At the moment I dictate this I have no idea and I presume you don't either of how much money is to be granted. I am impressed at least in the psychiatric committee of how we whittled grants right and left. Again and again I was impressed, as an on-looker, of the number of grants from very superior institutions in which we whittled off twenty percent, fifty percent, seventy-five percent in a hasty sort of a fashion. If there is enought money I hope that these will all be reconsidered. In fact, as a member of the Council, ,I insist from my single vote that they must be reconsidered. I make this re­ commendation because in my testimony before Jlfir. 0'Keefe's committee he asked whether we were going far enough and fast enough. I regretfully admit that I couldn't answer that or didn't answer i-t adequately but I wrote him subsequently to the effect that I thought we were not going fast enough or far enough whenever we had to cut down the grants from excellent training institutions to one-half or one-third or even one-fourth of what they requested. A. Comments on preliminary report of the Sub-committee on Psychiatric Social Work: This committee ought to be commended on its report. I think it is excellent. Again, obviously they have had to try to create a minimum and optimum grant and I would so hope that we can have the money to make the optimum grant. I don't know whether it is the Council's job to review ~hese applications Dr. Robert H. Felix - 3 April 26, 191+8 "rejected" and I wonder about the advisability of having somebody from this c.ornmittee present to explain these details if and when the Council meets. This committee discusses the point of support from USPHS funds to maintain in-service training progra.ms within clinical field work facilities. They specifica.lly cite the situation at the Menninger :Foundation, recommending a grant for the coming year but none hereafter. Although personally involved, I want to raise the question as to what is the institution providing field work to do about administrative problems in rela­ tion to managing this field work facility'? I think the Council ought to specifical­ ly instruct the Social Work Committee, that if we follow their recommendation then the institutions who are to supply the students should include in their grant such administrative funds as are necessary for the field work facilitF to carry out the training. In simpler terms, I wonder what their thinking is as to who is going to pay the bills for kee1->ing the records, for t,he office space, for the stenographic work. This becomes somewhat personal in my illustration but five of us fromt'the .Menninger Foundation went back to Pittsburgh to sit with them at their faculty meeting in Iviarch and while the University, I believe, paid the expenses of four of the five it nevertheless cut out considerable time, effort and work in the Foundation. i~one of that is paid for by merely paying railroad expenses. Field agencies can't carry on this work unless they are remunerated and it is not clear from this report how they will be. What are we going to do about the professional coordination at the federal level, between the requests and the functions of the training program and the Community Services program of the Mental Hygiene Division? I ask this hoping that the Council will give it earnest consideration. B. Sub-committee on Psychiatric Nursing: Quite frankly this report somewhat distresses me. Seventeen of nineteen applications were approved in contrast to at least ten, fifteen or perhaps twenty psychiatric training grants which were disapproved (I don't know what percentage of the whole number)j only fourteen of the sub-committee on clinical psychology out of approximately forty-two were approved and eleven out of thirty-seven of the social work were disapproved. In other words, the very high percentage of acceptance for approval of the Psychiatric Nursing Committee makes me wonder about their standards. Review of the recommended grants for nursing seem totally out of line to me, based on the experience in the psychiatric training plan. I personally , just cannot conceive on the basis of the psychiatric training how the Council can approve grants of eighty-nine thousand, fifty-five thousand, sixty-seven thousand, seventy-eight thousand, fifty-one thousand, fifty-three thousand and many other sums over thirty thousand to training in nursing when we have given none in psychiatry, to my recollection (I do not have the figures in front of me) of over forty or fifty thousand. Something is totally out of line in this and I thinl<: it is the Council I s responsibility to find out where and how. I personally cannot approve of these enormous grants for the training in nursing when I have no indication as to what the coordinated programs are in psychiatry, clinical psychology and psychiatric social work. If the latter three are weak, then it doesn't make any sense whatever to me to give an enormous gra...rrc in nursing. · Dr. Hobert H. F'elix - 4 April 26, 191.+8 Personally, may I make myself clear that I am extremely sympathetic with psychiatric nursing and I recognize a great need for it. Their grants, however, are totally out of line with everything else in the amount of money, and I would feel it a very great responsibility of the Council to check these as to the coordinated programs in psychiatry. I would urge detailed investigation to find out how much psychiatric guidance is given to the course in psychiatric nursing at Columbia University which is supposedly recommended for eighty-nine thousand dollars, at the University of Minnesota where it is recommended that we give seventy-eight thousand dollars, at the Catholic University for fifty-three thousand dollars, at the University of ~"~ashington in Seattle for fifty thousand dollars where I know we don't even have a Professor of Psychiatry appointed. C. Heport of the Sub-committee on Training in Clinical Psychology: This seems to me a very excellent report. I have no suggestions or criticisms. I do feel thai if we have the money that by all means we should give the "desirable grant • 11 I think also we should give the "desirable number of stipends • 11 This report impresses me with its great care but this care is obviously emphasizing the importance of scaling down the amount available to meet the minimum needs. If we are going to do the job, then I would hope that the Council gives, if at all possible, the "desirable grant" and if not at least the "minimum grant." This report illustrates again the- fact that we don't have anywhere near enough money to do our job and must curtail the program proportionately in every area because we don't have available funds. D. He search Grants: I have no data on this subject and have not had a report from this Committee so I have no comments. I caution our Council on the necessity to integrate the work of this committee -with Training and with Community Services. E. Community Grants: Again I have not the slightest idea nor have I even seen a report from the Public Health Service as to how nmch money has been given for community grants under this general category. I feel· at a loss as to my responsibility on the Council because, except for the state of Kansas, which I happen to know incidentally, I do not know· what this Act has provided in the way of help to states in terms of money. Perhaps this information has been sent me and I just have not seen it. There is no way I can judge without such information. This long memorandum is in lieu of my inability to attend the Council Meeting. I hope it may be helpful and I do feel adeep sense of responsibility for our actions as an advisor to the Surgeon General. Sincerely, WCM/lf William C. Menninger, M. D. dfs THE UNIVERSITY OF ROCHESTER School of Medicine and Dentistry and Strong Memorial Hospital 260 CRITTENDEN BOULEVARD ROCHESTER, NEW YORK 14642 JOHN ROMANO, M.D. Distinguished University Professor of Psychiatry March 25, 1977 (716) 275-3047 Eli A.. Rubinstein, Ph.D., Scientific Director Brookdale International Institute P.O. Box 801 Stony Brook, N. Y. 11790 Dear Eli: I had copies made of the enclosed two prints. The Fellow­ ship Grant Committee photograph is completely legended. It was the last year that I chaired the Comm.ittee (1960-1961). The other picture is that of the National Advisory Mental Health Board. It is the 3rd year of the Board's existence. Carlyle Jacobson, Karl Bowman, Alan Gregg and Leo Bartemeier have replaced Frank F. Tallman, George S. Stevenson, David M. Levy, and Edward A. Strecker. This is the 191+8- 191+9 year. You may keep these. I hope you may find them of some JR: Encs .. l I l\ TI H • Tc~ H · ! 1 i n g o f P ~) <' h i a l r _, io q c d i ca I ~; I u d, ·n I ~: Pa~L P1T~t·nt. ~ar,d l•'ut,u-c HY ,JUI!\ 1(0'\l \ '\O, \I. H. The author. o!ra 1101 i11g rrihutl' to th(' /011· "c rn :1, l k I h· r I I\ir r y , J 11111 I .v; 1n s , < and l1l c. chic{ of'(/!(' .\'/,\!// tmi11i11g hr(l!ll'li, tfr­ ln tl1,: t1r\t t1t.·c1 \T:trs, i\bri1l11 Durfee, Jules scrihc.1 JJc111 111:d < 1111,·;;f ; 1.1rc-/1iutric cd111'<1· W:1ll11cr. !{ill Sli:1n:d1:1n. :rnd Phil Franklin tin11. ,,/11/()ll_' 1/;1· 111/l!l/l 1Uir>!/S lie hdic\('I 1 i, \Iii'.,, I !I\. esrchiat1,i- h::·. n1ndc ru 111< tlio1! <'d11, urion B11t tl1· 11.: wcr1.' othns. John Hcnj;1rnin w;1s ore irs c11?/'l,.·',i1 011 n11•.1h11Js n/ oh.1c1 ,·or/1J!I frr•,l1h :1:1i1,l'd !'10111 /11rich :ind from his and on rh1· f'<T.1·011(1//11·. 111:1!1•1.1 ;1•:,111.·1;1!i1111 111lh th,: Hlculcrs :111d 1,ith Frnilc ll11\1·er1·r. ! ,/i1·1,·.1 <'111r<·,1r ; 1 111hiur1ic' /;, 1 ( )h1.·1 ii, 1 !/1..·1. I It.- ,h:1r,·d ,, ith us his int<.:11._'Sl tn1i11in_r: h111 u1 1,, r,·J < n11r1ih11rinn1 /r,1u; ;ind Lr1111•, kil:•1,_: ol 11s\ch,1;rn;:lysis :rnd the !Ii<' hiu!,1,::1, iii '•t /, 11, n 1:nd /11:/1 /,1 ,,,_,11;- F.1ir •.1·!1:11. li I k c,p1>k(' t1i uc: ()1· co1,niti,·c di\- J>frtt'/r /'('( ( ,· r/1r· {llljl()/'((!!/1',' ()I ('1/- '"<' tu1!,.1rk1'•, <it· s,,·!ii,,11plircnic patients ;111d tirc file <'\, ft· !11· 0!1,1 11111·11<'.1 n·c11Jt ;d , < >t 1I t 11i • l' 1.· r1l · r :1I le' 11 qi n 11 f cont inc n t ; 1l clwngcs /;1111 · ,/1, u! '1 hu, ,/ ,·!uri, 11/0. ['"' 1·h i I l r 1 l ii Hi!l111/ l1 :d jw;t L1unchcd, with the r,·r1i·r1q1•, !1 ·11 1 11 1 tl1c IZ()d.c'.c:llcr Fo11t1<h a 1\\l i11 h, :11" rl11l'.,'fl l<• 1•i\t' ff()',t)i'.! I) t 1, I Ii:· 1, k'. I 1c;1 I [h\Tlii:it ric li:1 i son pr()· fl thc I i 1 "t \ , ,. l , · r I' 1, r r ~ :\ 1c r l l< l r i :1I I IT t Im· .n:1111 i'l th,· (()l1)r;1t!() Crn,i·:il fl<l.spit;1l :1r1t! pk:1:,,·,.l 1,, !11 :1l1l•· t111':1, 1111!1li1· 1r1l11:li 1 > 1 I 11:i' < ·11, .11 t·11s :1r1d !\Latin I m,lc1 c;II11L· t1p ;1 f'ril·r1d ;111,.! ,,,lk.1·'11.· cd 111.111, .\l':1r·, \\,· l1i1:11 <,:l·.1•,,:n11: P:1\i<l.\<lll :rnd (1cc from met in l),11s.,·r i1 1 J 1 l\(, "\'c"i,·· w:1', 111,· fi1-.1 l ·,,,,>11,hk 1i1it1·h C<1l11fl1hi.1: l':1ul \\'olk:1nd o f' ~1 "l' r 1, '" ( 1I !' :1h I 1, · l k ;i I l Ii Ser , i cc I' l 1, " 1- utli,.·r-; !111111 !Ii, .\Lile liu'.,f•it:il in Pueblo c i:lfVi "c n ! I 1 1 ( , , I(q·: 1 d1 1 h , \ \ ;ii t 1. r T r c :1ii 11 ; 1 -.. .t\t 1l 1 :1! l11:, tl1, rr 1,crc onh· ;: limited n11111- ;111d \\;IS \ll\.it..'•'(kd h1 ltl:'lf h, r ,1! r,·-,i1k11t pr, 1i·r:11lls ir1 the nation, :111d \' <l)'C I, ;ind th:,t 1111',' 1!1:· 1111111hn of' u:; w:1,'s \lll'<_, . ..,·1ir. I :1,,11'!1,·1· f,1ilh !he :1d ,, ; 1,. ; 1 111 1 >I le 1· l1 . It • " " h11r1· , l /' c n o u s t l u n .L' 1 n 11 111111is11,1t111.· 11ll1c,·r.., 11 1 till· ( 1il,1r.1ili, ! 1 ,\ 1111· i ,q111 •>·-rl1l1r1 iii !>!(''-' ril fl' .1dc11( p1>1111Lt 1 rh1111 :1!li1c· l!n-..1111 1 1 ,,c ic· I 1:11,I Ji11 I l 1 :11::·l1. t1,,r 1 . \ \ l11!:- 111.· rii:1y l1:1n' dr:rnn togcl!iu ('li;t1ln H:,11,1·1. :111d ( l:i1L H.1111:1,!1 ll1t· l,>1 iliilt r,·11! 1c 1',1>n\, one 111111,irLint rc:1scln Cu11111ll1n,,T:1l1!1 l 111Hl l rllc1\\\ i11,·l:11kd \ \;I ,, f i l ·.' Tl 1 I 1 I I Ii ll i ! \ 11 )f /'f; Id .1; \[ C ,<; I II d y i fl I J:1rk h,;ilt. I l1 r1r\ Hru:,i11. Pliill'I' l lt-1·1 tk I 1, · I,! < ii < 11r11,_ , : I I\ s·' . _. Ii i ;1 t r > i n a rI i: 1 inr 11r1i\cr:,1t, dt.·r1;1rtrnr11t, housed in a psycho­ R c;1d ;J\ t IH' Sn 111, 1 111· \ nt, I Ill !r f ,\ 1l'f1i(\I i.1 I r ('( r Ill,· I I lJ \' N, I I I II r I, I I ( 1. I ii 1 · I I 11: \ k I 1I .I I l fl. I I I h ·" I \ ;1 [':1thi1· lici·,1 1 1l,1l, \\()\'Cll irll<l tlic Lihric or ;1 Tr:1rn1i:r, :111d )', '·' .1" 1>. \\ ,:· h111··1,,::. I l C . .' ,, 1· 1 1,, 1 111,1!i,:1I •cl1,1c1l, v,it!i tlw tlH·n r;irc suppur( 7'>. l'><,'i I )1 I< /\111.lfli\ I, ! ',t !I' 'Ill l1 ti ill'' ,1 ',!! \ I''"'' ": 11! nf [i·ll1•''- ,fi11• \lip< 11d<; r111iik:·,I ;1,; lilt.'\' I\1:1\' p1,,cli1.1t, 1 :111,I , Ii 11, ,,: ,·, ,!,·1·.11 I 11,, .. 1: , •I ,, .. ,, !,,.::: 1·, ~-<.'1111 1~:)(I!) ;1 r111q1tli) to us 111 our ;!lllucnt l 11111 ,,jJ \ "' I'',, I I '•' i,,,"I ! \ l I:, I"< .111, I I\, 'I I 1 I J 1 f('' i'l\l t,•.tr\_ .1111! !'',\1_!11 ,:, 1 l t 1 , 1, 1...,l!i1: 1 ·,11•1111111 ii 111 p1Lil, :1(,1) ( I 1l\1 ;·, 1, I! I\I<. ,; 1:,,, i,, •,!,:. y J l/, '!I 1\\ l-'.cdi1·1t I 1·li\(•i) h:1·, poi11lcd out, \\hik r II M IIIN(i l'SYClli,\!fZY \0 Mf DICA!. S(ill i NTS the llLIJ<lr tli111"l ol the pro/'r:1111 was <'tit who sc1vcd principally ·as h:1ndnwidc,, ,. It c..bily en1::1 1 n11rnt in the :;tudy, c;irc, :ind 1 w:1s ;1 l:1r cry from tk' rich and profi. :tide treat rncn ( nf 1 :t t icn ts, Un u1: 11 and others 1 intncl1;in 1,c. that exists today in most c;' the made pns-.ihlc our i11volvcrnc11t in hc:1lth univer:;ity dq,artrncnts. services, not ()nly to our p:1tirnts and th\.'ir This was the settinr to which Vest) and families. but :d"o to th: comrnt111ity in \\liich J.ucillL: :incl their son, Huddy 1 came in i<J36. we niskd :ind which we sern·d. \Ve were 1\ltliourd1 his earlier life in Illinois and f owa exposed tn :111d in\'olvcd in rnedicil kµ:tl should have prcrarcd him for Li11dk·kcd issues. occ;1sinr1:1lly with clr:1111:\tic cli111:1\; Cnl()r;ido, he missed the sea and ship· :111d in c o 11 s u I f; !l i v c s c n· ic r s t n c n t n t s a n d s l i:d <) (tigs :111d krric'., with which he w;1,., \'lr­ agcnc1c'< in dc111nnstration child ;111rl :1rlult rot1ndcd at lllis lsland, from which hr l1ad c 1i n i c" i 11 ( ; r n: ley, Ft. Co I !i n s, ; tr1 d (; r; t 11 d _j Lt St CPllll'.. Juncti()!1: in di:q 11ostic :rncl trc:1t111rnt sn­ 1 \'csty told me often how import·n1t the vices to ;1 nc:nhy institution f'<,r dclinqurnt inflt1cr1cc c,r San1 \\'ortis and P;1ul F1.·dern boys: in thr,·,·- to r()lJI-Jl1()11tli assi1:n111l.'!l(S h:id hcc11 to hi111 in the Ellis Island a"'--ign­ to the st:1tc hospit:il in Puchlu: in nurncrous mc 111 • hll t h c re I t t hC (' 0 JO r a cf O C Xpc r j :_' !1 CC public cd11c:1tinn:1l lectures to p:1rent-tc:1ch­ nrnq i11!1uc11tial. J>crh:1ps this was be1.' 1usc cr ;ind Liv oq':ini1:1l inns in Denver :rnd or the i11fnr1n:ility, intrnsity, and ir1tir:·,:1cy . j thrnu;'l]()u! the st:1ll'. ol rn1r m)1·k lof~c'tlier. ;\s young men, we There \\;ts little or no forn1al instructiun. dr1..':1rncd yoI1ng rncn's dreams. Ilow,:vcr, as w c k n n w th is to d: 1y, in t h c ro rm of tut o­ I dut1ht if ;rny of' 11s, even the most prcsc'irnt, r ia Is. s c m in :11 s, co 11 fer enc cs, ;t n d le ct u r c: s L'. - cot1ld !JdVC predicted the changes that have rics. \\'e t;111t~ht ;rnd le:irncd frnrn c;1ch other: Liken pl:icc :ind more particularly the rate and ;it ti111cs long ;rnd hc:1ted \\'ere our <k­ ;1! which the ch:rngcs have occurred. We batcs ;1h<lut the qucly, unckrst:indi11r. :ind Illll'-.l !l()t delude our~ch·cs by forgc!.ting most :1r'1 1 ropri;1tc c:irc for our p:1tiL:nts. \\'c or 111ini111i1i11g the major political, s<,,:ial, \.' j Cd \ \ j ( Ji e; l Ch O l her ro r :1 S S j ,E fl 111 C fl Is i 11 ( h C :ind ec<,nrnnic forces that. played an irnpor­ t C ,l C Ji i 11 ):' () f' Ill Cd i C: ti q ll Ck 11 ( S , ;!fl d i fl k r C S l j ll L\llt p:irt i11 the overall dcvclormcnt cf 1:1cn­ and Ct 1 1h.:nn ,1 li( 1 11 t t c ;1c hi llf. \\ cre crilLrn,·t·d t;il hc:il t Ii cd tlf..: :t ti on, research, and sen ices by the l;iLt th:lt Lhaueh ;rnd l~ymcr m:rc in in om n;ition; yet there arc and there ha\'c the midst of' their surn:y nf psych1:1tric been I hose who played a significant ro k in . curriculurn content in ;1 ntirnhcr of ,\rncric;111 initi:itinL',, ··cn:ihling, and imrlcrncr1ting mcclicil sclwol'-.(J). ;\s I rcmc111hcr it, there th n:; c c I 1:1n t: cs. V cs t y w; 1s on c of tho s c I I e \Vas Ii t l k ro fll u I in\' Cs t i g; l t i \ C \\' ()( k, ;il - was ;111 irnport:rnt member of that group of though ;1 r111mhcr of us did hcco111e i11\'(1ln·d men ;ind women brought togctl,er by in cc1L1in cli11ic:il case studies, i11clt1di11g Tho11i;1s !\1rran and Robert Felix in tile· rc­ prognoqic studies in schil(lphrenia. \\'c mar k ;1hlc venture 0f our federal govcrn1 1cnt 1 were imnl\'(:d in the cnthusi;1srns of'thc time in the licld or lllCTltal hc,1lth. --with doli('rschla/: insulin. the use of the /\ftcr Vc<;ty lcf't Colorado he was ncd Kettering hy11ertherm in the treatment of' to Ln i 11 1 ! on. where he tool-.: part in a n ll m­ 1 -------------:-------;f"),"'tr.i-;.c-;,11..-c-s--,-,,\~j'r 1s}p h ii Is' ;1 s \\(' II as \\'It Ii th C bcr or 1 in11cn cpidcmiolof.>.ic studies. JIc 1 more traditl(lnal pS\'cliothcr;1prntic tech­ rct11rncd t(l the l J. S. Marine IIospiL I ;it niques or the day. Sull':1 h:1d :11Il\'Cd h11t 11cn­ 1 lli~; hl:1nd in 1939, where he became chief icilli11 ,1:1:-- vl'l to come, ;ind w,· would w:1it or the ncu1opwchi:1tric ,.;crvicc; he rc111:1incd another 20 yc:1rs bdorT chlorpro111;1.1i1h· there until JlJ.t~. Robert llcwitt served with was ;1\·:1iL1hk. Later in our stay r--1c1r;11ol Vcsty ;it 1.llis IsL1nd. Jamb Arlow a11d fohn was l ricd and I CT was lHl the lwri1nn. Tr:1in were residents, ,rnd Paul Fcckrn and \Ve Sl.'l'l11 t<l 11:1,·c h:1d an endless nt1rnhcr S:1111 \Vnrfis were m;1jor consultants. of ;1u1ll'I\ d1,,t111lll·d 11:1ticnts, ;111d \\T \\'()llld I n I () -I '1 V c, t y was a:, sir. n e d to t Ii, I ; . S. H'"[1t111d t<l tl1(·11 l'lllCI/ 1 <·11cv llr<'d,;, !1,1•cll1(·1 1'11hl1,, I l<-:iltli :~c1 \'il'l' I Tmpital ;1t It.\\ ill th, with <111r 11111,,1·s ;111d ;1ltc11<Lrnt·< ,,11l1 tlH· T1..·\;1'; \\'illi:1rn .Jrnk111:, writes of' this pc: iud: pro11q1f (it'\'(l( i<lll;1nd )'ll\{() f)r sc:t\()flCd fir1.· "Vc<.tv 1.':1111c thc1c :1s executive offiic1 ;rnd linr'.,l"·, l .\cl1td<1,'.'\' ;11HI snci;il w<11k \\T!1.'. d11nlt11 n[ l1:1i11ini'. wlicri Dr. G1ovcr f\(111pf 1 rcpll''·1·1111·d Ii>· rnlly a fnv v:tl1:111t :-.n11h, \\ :t \ 11 \(' d I 1 ; I I () (liL· t'I' j 11 l' Ii ;I r f C aII d !{ < ' li ,: f ( [ JOO] A 11/t'r. I l'.1rtl11u [. J26 :8' Fchruun· I l)7{) . I I I lnvitt \V:1'; cli11ic:1l di11 \ \r\J S,11lll' <ii tl1t· pl.'oplc u11 tl1r "1:ill tll\·11. :111d :1111,·111!' !11J111 ()l11"\, :rnt! p11hli1: lic:dlli :1.', \\cil :1\ with th<: I J I/ I 1:11I I I11111.1I d 1•. <_ 111 I i11 n. I le c 11; lll Ipi 1111 L' d 11 H' i1k:1 111' h:1\i1.· \('l<.'ll\.T dq, 11l111t·1its or licl1:1v­ ti111l: t(l tir11,· ,,i1l1 "<)1111· 111 Ill) t'\1 1 ,·r1t·11, 1' 111 psychi:\\1y, 1111.·\11(ktl l,11i."lit i\ldrnli, < 111tis i,1r ;11 '>I li'll<'\.''>. S() 11 t 1i; 11 d . \ \ i11 1111 I·'. m: 1111 dl, TI l( 111 i: 1s I ) , )11. 1: I l1n ,1,,·;1k nf l1is m()dcstv :111d ahsrncc l\Llritrn R1,·l1111t 11tl. l{:1lph ('()lth:1111. Bill 1 u I p I r k 11c,i1111. 11 I I II s 11 c· \'Cr ;1s,;11 Ill i 11 g a p 11 <., • L cw is. I() t1 i', <;() t h c 11. 1I k . I ):1, id I c < ; 1 :1n ii . tt1rc rwl rc1111im:ly his (ll\ll. T;iey !,pc;1k ul' Ted lk,·kn, I u:·,:11t.· Ni11111:·n, .l,1l111 N:ndi11i, 11 i " I 1, ; 1I 1 , t () t Ii L' Pt I h I i c I le; 1 I l h Sc r \' icc, to < and others. \'nty t;1w:ht :111d c:1rricd out a \\hi,·h he 1•:1,·c f,'Jh:rrn1sh ol lii111s,·!L ;\ nu111- 1n:1j1)r C\l'Cllli1,: !'1111c111111 i11 the ()1,n:ili()n nr h,:r dr,·,, ;1tt~·11ti 1 111 tn th· cL1ilv lunch meet the l10spit:1l. I k t·ncn111:1. 1-·d thr ,rn1111• '->Lllr 11 i111", h1·ld 111,ht <)!"tl-11 in hi,; (1 !licL~ ;1ttcndcd to lc;1rn ;rnd hi \ ::1,·11. ,,.1,il..h 111:1111 did." 1 h\ H\ih h·l1\ ..Jim I 1m1y, .Jolin Lhcrkirdt, I 11 I 9 4 ~ li c· ,,. :1" t.': 1I b I h\' I\. (1 h n t I \.'. I i \ t n .Im· B11hlii1, \lilt \\'11it111:111, Buh Stuhhlc­ llCC\llllC rhi1:r \)r tilt.'. tr;ii11illf'. h1:1111·l1 nl licld. Pli1! S:q,ir . .l\llin CLlusL:11, Bill Jenkins, N I l\ 111. ! le \\ ;l s t h l'. li I c; I Chi l' r O 11 iC n i 11 t Iii s B1) h 11 ,, " i It, I, c n I itt k. h; t Ii c r (,arr is on, di\'ision, ;1:--. in the· 11r,'l..,·di11:.' 1,criod ( J<).H1--l/--'.J !<Ii R11h111,,kin, R,1,· l·,:ldrn:111, and many Lawrence C. ~(llh li:1d ,vr,ed ;1:, :1d111i11istr;1- () \ h l'1' s' Hi l l .le Ilk lI1 :- , \\' r i l Cs () r this: "s() m c­ t in: n 11 ic er ! 11 h 1 ) l Ii 1Ii 1_: 11..· ",: :1r c 11 ;ll1 d t 1: 1i 11 i 11 !: t i 111, · <., th1.: t;1lk \\:1s ;i\,()t1\ the \\1)rk, but often pr())-'LllllS lt \\;!', 111\ rn11ik! l' i11 t\1,· 11nt 1 tl1n1· \\;1s 1 11t1d 11:1t11rl.'d juc,hi11!'- ;rnd l11111wr 1 11 yc1rs t() n1-·~·t (1 ltl·11 \\ itli \'est, ;is\\,' 1,:11- ;11111 \'r1h:1I c1)11111ctiti,c111.·c,", ;111d \'est; ticip;1tcd i11 the ;i!Li11,, 1d the (.()t1r1,·1l, in th1.· \,;is 1)!\\'11 ;1 crntr:il li;•.1111.: in tlic give ;1nd 111cl'lillfS \lr tlH· ll'<-1.':lrl·h ;111d tr;11nillt'. sn·-­ l:1k,· ,.d tlin,· s,·ssinn'->. \\hicli lie liked \'l'IY t in 11 s ;rn ti I: 11 1..: 1 i11 t lw" l' o I tli 1..· ( · ;11 L' n I 11 n: s - 11111,·!1 ·· ·1 his. \\;ts \',:"t>·'s V1ll:tgc (irecn, ;i tir;1tor Sl:kl·\i1):l ( 1rn11nitll'c \\'l1ik Ill\ pl:i, \' :111il ;\ ti 111C 1·()!' the ll1CCling or friends mc'll10ril.'s nl tl1c·'-l' 11H•,'ti11;'" :1rc !till ;111d :111d \.'() \\r11kl'I\. lh1t 111.: h:1d ;11wthcr Vi!L1rc \'i\'id, tlll'> )1;11.1· h1-c11 r1:i11!1l1u·d ;ind n­ (;1,·,·11. 1,11c tli:1t C\tc11lkd 1:ir hc:yorHl lkthcs­ t CI 1( k d h \ \ h: I c' 111: 11 k ', () I ;I ft.·\\' (l f \,\.''-I >, S d:1 :H t11:1lh frnrn cr1;1st to co 1st m;idc up j ll t l I11; I\ CS, t I l \ \ h I l I 11 I \ \ I (J \l' ;l11 d Ll \ k L' d. ol the l:1~1il11c:--. \ll nm 11nivnsiti1..:s. He visited Their Jl>1~1\ll'-1·s, i1111n1_·d1;1tl' ;ind \\:1r111. ;11·, ;111il !'t1idri! :lllil c11111f'111tcd :111(1 stimuhtcd i Il th I._' I l ]<; (' 1'. \' Co l k; I I l.' \ I (km: C () r t li C 11 i !' 1i \'; I\ Ji I l I I I :-, j 11 Ii i S \I fl'-,\\ l' I ', i 11 f' CI 1 111 ll lit Ill U1 t t 0 cstec111 :111!1 1k1·1) ;ilru·tion L':1ch ti:1d ltir 11111i1111tc, 1w111i,.h. ;1r1d strn1gtl1c11 our cd11c:1- Ves1v: IZ1iht·1t I cli\, I ;1\\'rrn,.__·c C. K<ilh, S. t i 1 ) I1: l I I' r , 1 ! ' I; l Ill S. ;\ 11 d Ji C d Id ;ti \ 0 f t Ji\.:<.,,; Bern.;ml \ \ ·(1rt i s ( \\ i t Ii ,, h() 111 I LIi k cd t hc d :1v tl1in_i s \\JIil li111itcd :1sc,isL111cc. It is in this 1 bc1·()1c hL' diL·dl. \\ illi:1111 .kr1k1r1". l<td1n\ r,·:·:1rd tli:1t lir li;1s l11.:cn c;1lkd 1.~cncratin·. Stu h li 1c 11 c I I I. .f I l "c· H tr cl Ii I l) 11, ;ll1 d IZ: 1y 111 () nd ;111 :1dnic:1!t.', ;1 clJ;1111pio11, :ind an enabler. h:ld111a11. Tlinc C(·lllld h:t\C l1 l'.Cll a lC)'IUll nr This is \\line ()flC s:1w the dimensions or others cquiill_, :is rnti11i:1t,', ;is Vcsty's li!'c !1is rich p:11cnLil qu:1litics. and carl'r.:r t()tklinl 111:111\·. \' l'\I \. likl.' I]l()S t () r \IS, had his rroblcms. l k \'.l';1!l1r1l·d '->llL-roslully ;rnd with gr;1cc ;in Porlr.iit 111' a \l:111 (_' 1l <I 1l.' ', s 11 ll I I ii Ii.. I () r ;I d 111 inis t r ;l t i V C er i s C s r C Lt t i11,, I11 I 11111 I 11w ,rn d t , ) , c rs, 1n 11 cl. I I c ,v tt >; l i S r c l 11 ;I r k·: 1i'>IT'trn-:•;---·crr[Tc;-T~1C-TTt·--~rmt-farH·-r-----'-'-'-,e_:..:.__'-'-----'------'-.:c...__-'-'-'-'-:-'-..:,__---:L..:_..:,__:__~___.:_..;:...:._:______:__ _ _ _ _ _--1l. d i s; l I) 11 () I11 k d I() \\' i \ Ill. '-, <., \ Ii l'. ', i.' \.' Il1 i fl /2 l y pl' t t '' ful is the 11 nrt1:1il \11 tll\' 111:111 d1;11\J1 Ii,· L':1•,li ; 111 d l ·Iii Irl I II.\' "p I IL, t 11; 1t o lT 11 :r c d in s c \'Cr; 1l or our C<llk:1_!'lll.'S. } J():1\ tlici1 \ :1r1Ll) l'tli11\s 1,-,-_1__'111:111:11\tic in\litutcs. ;111d he rn:1dc sc,·- 1 ,: thcy spl:;1k li1c,t ()I l1is !'L'illk11ns. l-.111,lnL:\,, . · 1 I r1 · t c1;il c·ll(l!h !(1·:11111r():Jc!i 111il1\idu:ils about ;Jll( I 1!1 1C)'ll: 1 ;1 11 ( ;1 \ l l ()1 1I\ C\ !;l\)I\ 11 II :.try ability tosn· the f'()()(I in rw()pk. :1tt·,·11q,ts tn 1cs,1l\'c the sd1isrns. JJ1__: C()t1- Thcy s1w:1k nr his; 1k1oti()fl (() his ;1-:sir11- ti!l\J<._'d t() h:linc th:11 sd1,,11ls of puhh: mcnt and liis r,·111:11k:1hk r:q,:1citv, tllrntt/•h lirc1lth u 1t1ld do 1rn1cli 111orc to innucncc p11l1- his n:1111111". \() ()li\:1i11 tlw 11\11,n<.,1 c!lnrtc, lir lic.1ltl1 !c:1ll1i11r in Ilic 11,edic:tl schnnls. of tJi,1,,,. , .illt \\li1l111 l1,· \\:1c, ;1s 1 i:1\l'tl, i11 1: ( ) , \\ h:11 c,1·,·111·: c\t1:1n1d11i:11y i.s tl1c 1·;1ct th;1t ;1l- cl11d111!' h,1tl1 1)11li,·:.c,i,1J1:il :111d ,n·rct.111:1! tl1,1111·l1 \'1 ... 1,·.., ;11111:il 111-r'>()ri:1! r\pcri,·1111'. sL1fls. I le ,1.;1., 1111111\·:iti\,' ;111d ir1i;q•:11;1t1n: ;i<; :1k;11111.-1 \\:1'-i qt11t1: l1111it,·d, lie was able tu in corll't'I\ i11" :rnd l.11111,·hi11!' 111;1m· rH·\\ ,·ii 111Hk1 ·.\ 111d :111d I() p1n111nt1:, in their es<;c11c 1 ·, u c: 1t i rn i;, I q· 11111 rT ,, \, 11l 1 '.,,·I 1, ) 1 ii s u I 1:1 ,v, I I w c d11l ·, 111 1\I 1:1I 11 1 () ,!' 1:i 11 1c, i n 11 1; 1n \' d is c i pI i n 1• ., , r 101 1 111 S ·11 M IIIN<i l'SY< 1111\ll(Y 10 i!l:DICAI. ~fll'>INTS and lie '<t'l·1n<·tl. 1)crli;q)\ i11tuil1\cly, to scll'>l' to l1ciiin the his!nry or psychiatric edu, :11ion the h;1<-.1,: IH'l'ri n! !lie llfli\'('JSi(\ to lw rrt:t' in Bril:1111 is in l7_'-i1, \'.'lien the govcrn,·1s of free {<l C\pltlfT tl1c 1111kn<l\\fl ;1;1d (() he i1111r, ~.; t. I ti k e 's I I o ·) pi t; ti , London , ;i u t I,, q i I cd v a l i '- l' I I i., r < ii c \ q s ;1s ;1n (·11 ; ii 1l er ;1r1d o fl l'. \ \, j l l l ; I 111 fL l ! I j C, j) !J )' S 1C j ; In t O th C IJ n: f1 j l ;i I, \vlin did not h,,'c1,111c inlrt1'.,i,·( i11 the :IfLii,s t o LI kc pt Ip i Is. I t i·" t rt I c t h :1 t this pc r rn ,"s ion or the lllli\,·rsitv. f k \\;\S ;1hk to dis;tifl!'lll\li,qs rL'',(i11dcd _'i() yc:1rs later, but it w;1s a bc(\\('l'll cr;tft..,;1,;1rblii11 ;l11d prur·c'-.Sl()f; ;111d str:1w in the wiPd. Bv the time tile t· 1 Jvcr­ rccnrni1,,:d ll1:1t the l;iltn 111u,t :1llcI11pt ;1l­ nors of St. Luke's in.lfq3 ~1utlwri1c(l :1 re­ w;1ys l<) use'. intclli!'l'lll'c' in new \\'d_Vs. I k sumption of tc:1chinf~. others h:1d iw,t1!utcd r l' S p() l1d C d l () 1Ii C j I11 111 L' 11 SC C I1:1 1k H', C n f l h c SO!lH'lliit1i! (\r the kind n;1rnely ;\le, :nilcr J Lisk ;rnd !'ll'\\ \\itli Iii" np1..:rit.·ricc. , l\1orisllfl in hlrnht1r1·h (1823) ;ind lulin Corrnnlly :1t ll:1rnn-ll (l8-l2). In 18,rn B llilc­ hc111 ;1d111itkd ;1 le,,. pupils, and fru111 1848 ffc ,•.lio is clioscr1 t(, ~.1ve the Vestcrrn:trk 1 nn,,·;1rd there were r,·: t1Ltr coursc·s. l:1sting 1 Mernori:1I l,ccture on m;1ttcrs rcl:lling (() 101 !liur monthc; ;rnd held twin~ ;1 \·ear. psychi;1lric cduc:1ti()n h:is a wide rcpnlury The first ch;1ir of psychiatry dcsir11;1tcd from \\hicli In choose, as Vcsty's ciren as such \\'as that occupied by IIcirm\th in touclH·d 111;111:' disciplirh'S. I h:l\l' cll0sc11 lo l,ci1)1ig in 181 l. sr,c:1k 011 !lie 1":tc·liin.~'. or 1)s>chi:iti)· ltl 111 c•d- 1\111crit;:111 ps)chiatric teaching h:til its ical slt1drnts sinL·c I :till f'lllly ;m;irc or Vcsty's orif'in i11 the work or Benjamin Rt1.'-h(2). susL1ifll•d :1fld \1r()rnt1s s 11 pp\,rl n!thc url(kr- In 18'1 !{11sh p11hlislicd his Afrdicul /n- gr:1dt1;1k 1)rn.1:r:i111 in medicine. J Ic cl1.:; 11 !)· quiri<'s ot1d Oh.,oTatinns Uf)()!I the /)fs,·ascs unclc1st()()(I the str;1tq.1-ir iriq)m{;rncc nf' t!it: of' the ,\finr/(14). which was the first /\!11eri- . C( !llC:l(J(lfl () r· t l1C )) Il~Sll'l;ll1 . . . l1H l()fll(Hf\l\\. C:111 !'l'fll'r:tl . trc;1tisc nn the sub_1'ect or ll!Cfl- r'>e g; If ( ll CS S () r· l11·S C \ l' 11 ( ti ;t I Sp Ce I·:I I Si--.1 ·11 · I S, 111- Lil dic;c:1ses. B:1sed on his JO years' ob'-,:rva- · (er CS [ S, ; l fl ( 1 ( l lT l 11); ! fl()!) S, ( 1) C p I] y <;JC · J;· lfl r C - t inn s or rn en t a 1 11; 1t irn t s at t h c Pc n n s,_1, h :i nia mains :1 niriL·:1111 <..(1ci:1l iw,trurnrnl in r,r·o- llosr~i1:1l, for many decades this rem;1incd a motinr-' 1m·11t:il hc:1!1h :It \;1riot1'-. Jn·cl~; nf' prirn:1ry textbook for American students hc:1lth sen ice" llirn11; lwu1 the n:itit,n. 1 or mcnt;tl disc:ises. ft was the only tnt of' Wh:tl I sl1:1ll li:1n· t() s:1y ;1h<)lll the tc;ich- its kine! llntil 1883, when William Ifa1111i10lld ing of f)S)chi:itry to flll'dicil studrnts will he (7) :rnd F. C. Spitzb(16) published !c'Xt- bascd i 11 !' rc:1 t 1):1 rt tlll pc rsnn:1 l n 1~crirncn hooh ()!l in s;rn i ty, loll owed hy E C. f\ Linn I s l1:1 II rHll prcsc·nt :111 c\ l i:111'.t 1vc · '>llrn·y <1 r· ( l(l). l l<1,v,·,·c·1·, -- tl1cr·t', w·,1s· ,'l pr·L'.\','11·1·111<.-1. ir1c.11·1·- the n:ln:rnt litn:ltt1rc. i\.1ost ul' the time in f'crcncc to the subject or mental Jisonkr'> in the p:1st .15 yt::1rs in five of the six rncdictl all hut :1 !'cw or the medical schools in this schools with which J h:t\'C hcL'r1 associ:1tcd country. I have been c11g:1gcd rull-tirnc in tc:1cliing, Pliny Larlc ,v:1s :ippointcd v1s1t1ng phy- raticnt cu-c, clinicil invcstig:1lion, and :id- sician to the New York Asylum in !853; "'· m in i st r: 1t ion . d 11 r i n g t Ii is ye a r h c dcl i vc r c d h is fI rs t co ur s c ~ - - - - - - - - - ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - n r o lcct 11 res 011 111 ci1 ta I d; sc;1 scs at the Co I lcge or Ph\·sici;in<; :tnd Surrcons. Liter Ill' w:1s aprmintcd ))rnf'cssor ol 111;1tcria mcdio ,trH.I I t is h c Ii n· c d t Ii ;1t m c d ic; ti sch o o ls c x i st c d psycl1()lll/'.ic:il rncdici11,· in the Bn~\hirc in conrH·dion ,vitli the lempks or :incil·nt l\lcdil':11 l11slitutc ;it f'ittsliclcl, f'vbss. rc­ Egypt. ·1 here is firmer evidl'!lcc tk1t 111cd1c;il f'JTtflllh· a short lived institution l atcr cduc1lio11 to()K 1)!;1cc i11 v:11ious rorr11s in dcn·l"p111rnts occ'urrcd in New Yo1 k City, .incirnt Cirrek rncdic!llc ;rnd later in ,,\1;1hic Phil:l(klplii;1, Boston. Albany, and Halti­ medicine_ i\1\lre systc111:1tic li.':1cl1i111 \v;is he 1 n1orc. But it cin he s:iid th;1t until the 1870s !',till in the c:111\ 1\liddk 1\_1 .,·s in S;1lnrw ;111d 1 c\·c11 ()(·,·;isi()JLi! kl·t11rcrs on 11,c11t:1l ;l!ld /'!('\\' 11111lin dt111 1·• 1'1,- l{('1i:11'-'>:11l\ t' 11()\\ ll<'l\'<1t1•, di\c;1..,n, nnl l() spc;1k of sysl<'1,1:1tic n·n, tlir ll':1t'11111· <'I 1)syclii;1tr\· to 111l'd1c·,1l cm I r s c .s, \ vc r c r ;1r i t i es i r1 o u r 111 cd ica I c() I I,: 1:-'. cs. stud1.·nh ,,·;1" ir11k1.·rl ;1 1:i!l('I cLI\ ;11<·<,111- Tltc ;1pp:1llir11• Lick of' psychiatric 111,,l111c­ pli..,li11H.·11f. Sir I.c\,is(S) n:111i1Hh 1\t1htl'Y tion \,;is lorr11:illy rccnrni1cd in 1871. when us tli;1t !lie rnosr coJ1\'l'flic11t d,tlt' ;1t \\hi(l1 t Ii c 1\ ,; .., r , c i ;1t ion of ~ 1c d ic: ii Su pc r i 11 t rn d(' 11 ts r 1021 ,1l111cr. .I, f'sychiat /_Yi:8, Fchru11r1 1r170 r JOIIN H<l~lM✓ ll 11 l!J 0f ;\ 111 er i c; lll I 11 \ t it lit I() I l\ rm l he I n \; I fl C ;I\ ol t Ii csc conk re nccs ;111d pa rt il:i p;1 IL'd act i vc-- its :inn u:1 l llll't.'t i II," ;1i! 1 )j l( \'.d ;\ \L' rics., or ft'.',() Ill·· 1v i 11 t l1ci r lk'.,l)'.11 ;1 IHI cxcc11t i1.;n. The·- W or Id . tions \'iEnro11:-,lv rL·cn111111L·11tling the nerd l'<>r l-lc,iltli 01p;111i1:1tion in 1%2(18) submitted •·· 1cct ur1.:s' ;u1d c" Ii 11 iL·;il n pcric nee-;. Su hs.,up1cn t an :1dd1tior;;il report on the tc:1ching of psy­ statcmenh \\nc 111:1dc ;1t the end ol'thc JCJth chi:11 n, ;ind the most recent conference w:1s century ;rnd 1r1to the 2f)1!1. held ir1 !<)(17(17); the workini~ p,1pers h;1n: hcTll distrih11lcd, :rnd I liclievc: the rcpnrt is :'\lt·,c-r\, l11fl111·11<T t () ;1pp c; 1r s n < ll 1. h ir t hc I <) (1 7 con k r c 11 \ ,· Tlwrn:1s \Vchster prcp:trl:d :1 most usdul Perh;1ps 110t stdliciL·nt tribute h;1s been :ind dcL1ilcd sL1tcmc11t ;1bout psychiatr) :1t1d paid to i\d()ll. \lc-yer \\ llO. more than ;111) k Ii ;1" i or; 1I sci L' rK c cur r i (.' u Iu rn Ii oms in U. '.-,'. other pcrs<)Tl. p<.:rsi.--,!L'd in pointin~' _ out s c Ii o o ls oI' 111 c d i l' i ri c ;1nd us t cop at h y ( I 9), l le dcficicnciL'S :ind till· t11 : cnt nc,'d [() <k,·clop 1 1,tiintnl out sig11ific1nt trcnd.s in the incre;isc a S VS t C I11 :I t j C C t II r j Cl! l ll , ;1 () / r~ S \'Ch j ; I t I} j Tl t hC in hch:1,,ior;tl sciences durill_(: the first two me-died schools. I 11 ] ()()CJ the Council ()!1 ve;1rs rd· 111ed1cal school. tlw illcrcase in clcc­ J\.kdical hlt1c:1tinn 01 the i\meric:lll l\'kdi­ ti\'c curric11ll1m hours, and in interdepart­ cal ;\ssoci;1ti()11 11 11lilishcd a model rncdic:ll t11L'llL1l tc:1chine. curriculu111 th;1t i11L·ludcd a toLil JO hours ()r \\'liilc the ;1,111ount of psychiatry and bc­ for psychi:tlr:, :111 in the fourth yc;1r. 111 h:1\ ioral science te:lL'hing in lJ. S. mcdic:il 1912 the 1\S\()L'i:1(i1lll (1r i\rnnic:111 l\kdic;il sl'hcinls h:1s licrn i11c1 e;1c;in;', for over 50 Cnllu:cs SL't ;1 111i11111111111 st;1nd;1rd of 20 \c;1rs, tlic 1'.1c:1tcst devcluprncnth:1s occurred hnurs' or [)\\ chi;1tr,· (e;1chi11r in rnediL·:d ~i lll'L' the ~-1Hl of Wor Id \Var I 1. There arc schonls. l.;11'.'L'h tl1rnui h 1\d(ilf' l\1nn's 1 11111m·r<)11s rdncnces tu this in the rrofcs­ eff()rts a 1111inh~:r ol ~,i:ncys \\l'IC 111Hl<.:r­ si() ILI I I it CI;!( ti r l'' 1\1 ()st Or \Is a ck n () w ledge takc11: in l 1)1-1 ll\ (,r;t\\.'S(~). in ]<)3 1 h~ tli:1t t1ie·si1wk 1110s! imporLrnt dctcrrninant NO h le ( l ~). ;l I) d t 11· l, '-, I 11\ l' \ Ii_\ L h: I 11 ~ h ;lil d 1 ol clian!•.c ii'1 the tkpartmrnts of psychiatry Rymer in ]().J~ r,·ln1cd l\l (';nlin. . These sunns \\l'!l.'. f'o!l()\\L:d by co1dc1- in the lJnili.'d St:1tcs since the end or World \\':ir II rcst1ltL·d l'rnm the cn;1ctmcnt or thl~ cnccs su P!'<H tl'd h\ l lie N ;1 l io11;il Cu Ill 111 i l t ~-l· N;1tio11:tl i\1c11t;II Ilcallh Act, passed by fur !\knt;tl lh: i,-1ll' Iii(: lirsl \\;1sc:1lkd !fl 1 the· 7<)t Ii Com'.r-css in 1946, which rn ;1dc J<)JJ to l'{)ll·S;dl'l th<.: !or111;1tinn ()r thl'. ;\ rncric;i n B( ,;ml of h_, L·li i:1 t 1\' ;111d N cu rn 1- pus:,ihk the :illnc;llion or f1111cls .ror cd11ca­ {in 11 ;rnd 1-c:-,L';11c h. () lher d ct er Ill In ;rn ts that 0l!V: the scc\11HI. in ]()1 L discussed the 11 sy­ kl\c hrnuL•.ht ,d)()u( ch:1ngcs in the tt:aching cl1;;1tric c1111irnll1t11 1<)1· p•,\clii:1tric tc:1ch­ int1.: thL: thi1d. 111 lil-1\ di ... ,11ssd J1l-,\l'lii;1tn· ()r 1,s.,\'clii:;tn {() mcdic:1! stu~lcnts included tl1<.· nt;1hli:,l11m:11t of p'-.ych1alr1c scrv1LTS :1r~d ped1:1t1ics: tlil· l(1urtli, i11 ]<JV1. di..,cusscd i11 1 c11cr;tl li(l:;pit:1k It is irn1)ort;1nt lo rc:1l­ 1 the 111etl1od.., nl ll':1clii111 ps\'l_·l1i:1l1\. The1 i;c0tli:11 <nTr 80 percent of' existing gcncr:tl Common,\c;1ltl1 l-t111d '>llJ 1 iHl11L'd one con­ Ii o" pit; 1I" w i th psych i; ll ric u nit s h :1 v c op enc cl lcrcncc, \\ liicli lo1)k pL1cc dming I he w;1r 1!1L·i1 doors sir1cc 11),!7. Oilier l:1ctors i11clu1k ( h· h rt1 a r y I <) I Sl. t Ii t' n I1; Ill s i() 11 ;11 1d l i Ii,: r ;ti i/; 1t i o n o f h c, ti t !1 Tile t \\'<l It '1;1(·;1 Con kr L'11ccs \\'nc S j 11. ll if i l'; l 11 Cl' O I t Ji l' \ t' t \\ <l C{) ll k I l' 11 I'<..' S i' [H()\idvd k1k1:il 111.1lrlii11; r1111ds 1 \\TII kll(l\\Il \\ li;1l1.·,l_·1 '-.lll'CO'> l1;1s l<ill(n,cd !it11l\l111;• <)I ps\chi:1tric· sn\'ices in fCllcr:il the Itli:1c;1 Co11IL·rc1llTS dc11c1Hkd in rrc:1t lws11it:1k part on wh:tl li;1d p1,·ce1kd l_lH·111_, lwt there Ilicrc h:1ve also licrn sir11dic1nt ch~1npcs was one d ill'crcncc th :it d I st I fl/' 111shcd t lie m frorn prcvin11 s ,·en l II re~;. Tli(' I l l1;1c;1 Cnn kr-­ i11 tl,c pncL·ption or tile lrnspit;il by the pul,­ lic. ;1s C\l'lllplifil'd hy the rrowing USC ul' cnccs ;111d tl11..· rL·co1111m·rHL1tio11-; lk1t c11'-.1u·d f 1 <l 111 t h l' Ill , , (' rt· !, <• 1H · r <\ 11s h Iwt 11 i'- Ii c d h\' ;11nht1l:1lm~ snviu:c;, jl;1rtict1l:1rly the hospi­ 1 l'cdcr;1l l1111tl'-. :1nil;1hk ltir tli1.· dnL-lti1)111rr1t t; I t' 11 l<' I )' \' 11,·\ l ( H l I 11 , ;i S ; l 11 I i Ill ; l l )' SO l I ITC J of h()!li !l';1tli 111Hkr_!'l;1tll1;11\' ;111d 1•1;1il11:1lt' (ll 111cd11·:1I t·;11r ·1 liL· ps)clii:1tric service i'l ing ['r<1rr;1111'-.. Sn l;1r ;is I k1H1,,·: this l1;1d Iltl t Ii l' I' rn n; 1 I I1()"pit; ii I1; 1s rn; 1d c poss i h I e t Ii c p1crcdc11t V,",l\ sc1,\·d ;1'> tl1L' l1:11s.,t1r1 \lll1n·1 s111d\ :l!ld r;i 1c of p:1t ir11l popu l:1tio11:--., lrn,11 tlic l 1. S l)11hl1t I k;1lth Sn\'1n: lu L';1, li \\ l1il 11, i11 ;1dd1t i(ltl to persons sutrcrill[! lrn111 11/1/cr . .I. l'.1r,!11nr /.'(, S, I ,hmon 1r;70 [IOI! I I .10 11,\( lllt<<i l'\Y< 111·\ll,Y 10 r--11 l>IC/\l Sf\11)1 Nf'S tradition;il 111cnl:1I illnt·ss. i11clt1dc· <itlicrs irinc, 11rnrnlogy, an;1t()rny, physiolory, ph:tr• ·. not ordi11:1rily seen or c;1rcd for hv 1,sychia­ r11;1cnlo)'y, ~rnd lhc dean's o!Ticc in term· of· trists. I lm,cvcr. tli1..· prncr;tl hospiL1l move­ student selection and ;i,:sessmcnl. The s,1ci­ ment ;1lsn hrnt1ght with it restrictions in tile olnµist has become a familiar figure, :ind care or the chrnnic rsychotic patient, the there arc overtures f'rom political scier cc, · mcnt;illy rct;trdcd. the delinquent, the ccononiics, education, :1i1d history. It is ;dso · alcoholic. th1..'. ;1ddict, :tnd the psychotic ck:tr tli;1t psyclwan;ilytic, psychology has child. It is hoped that the cornmunity rncn­ had a f!re:1tcr irnp;1ct on psychiatry and rcn­ t a I hca Ith cc 11 t n rn o ,, 1..· 111 c 11 t • ,.,,. it h its con - cral medical education in !he United St 1les ccrn ;ihuul co11ti11uity or c1re and the de­ than in other countries. Not only h;ts \his livery 01· h1..:;1l1li scn·icL·s to ;ill rn1r citi1cns, 11rovickd ;1 set or notions concerning tile na­ may he II) c11rrcct th is ddicicrwy. ture of' mcnt:il ill11ess and or treatment pro­ The ohil'l'(i\'l'S in the t1..•;1chinr or p.sy­ ccd11res to correct illness. hut it has ,tlso 1110- ) cbi;ltry t\l 111cdic;tl students ,,ere ck;1rly \'ided ,In opportu11ity to learn more athHll .l outlinL·d in till: ftrst lth;ic;1 Confnrncc ;ind norm:11 behavior and tn ;iccunrnlatc <iata since then h:1vc been st;1tcd b>· :t ~rnmhcr or Inward a f!cncral hurn:111 psychology. us. I sh,ill nnl a\ this time outline in dct;1il all of tlic ohiel'livcs. hut I wo1ild like to Point 111!1 tlLtt th\: oh.i'cct h;is 110! hn:n ex­ Psyclii:ttry has heen nne of the si1l11ificr1nt clusin·l> (() p1c11:1rc tlW\L' who ,viii Ill'.· lca\'l'lliP/ ;1;•rnts in bringing about ;1 grc tier 1 , cornc pswlii:ttri...,h, m cvcri tu pninl cspl· intini;tc\ hctwei.:n the rnnlical school and the cially to the L1111ily dol'tor of to111orro\\' to u11ivcr~,ity-at-l;irge. This, or course, :llso the e,clusinn of the surr.con, internist, radi- includes the liaison established with hiol­ ologist, ;111d ol hers. ogy, chc,nistry, physics, biostatistics. ;ind TmL1y. in rn:tny \Vestern countries tlic with the recent uncan11y development of doctor h:1s ;111 11nusual <ln[)(1rtunit_\' t<i uh- ' mech;rni;cd i11tclligencc. Psychiatry has ;ilso tain sound scil'11tific tr;1i11int!, to dnelup hcen ;1n ill1porLtnt agent in bringing ;1hout att it udcs or cl i11ic;11 11,:rce11t i\·cness, and to a gre;1tcr intimacy bct\\'cen the medical become inf11r111cd. Ilis h:1'-iic rnedic;1I edu- school :rnd the comnwnity in the rc,'.ion cation ,illo,,s lii111 to hrin~: to the p;1tirnt- in whiL'h it exists. M,rny university psy- physici:rn rrLlti()Jl'-,hi1 1 ' 111 ;ittitudc ol· ;ilfrc- chi:1tric dcp:trtmcnts survived their early t i v e a n d 1110 r ;1I n e u t r; ii i t y, l )si r1_~; hi s k 11 o w I- ye; 1rs principally through funds provided hy cd1.:.c ;111d s~ill ;is \\'ell ;1s liis insitd1t :111d sy111-- , ' · Community Chest ;1nd public tax ,ourccs 11 at Ii et i c u 11 d er st: 1n d i n .P , Ii i s ro k i s t () st u d -v !'or tIi c co11 ti 1m inµ services of the depart 111 en t and h1..·lp his p;1ticnt ,,itlwut hcco111in1~ ;1 111c111hns to the community.This w:is the censor or .·1ud_!'.C. \Ve h;tVl' k;1rlll·d th:1t ii' he - c:tse in Cincinnati whrn I went there in 1942 is to dcscr\'l'. this pusition in society and ii' ;ind in Rochester in 1946. Much of this he is to f'ull'ill these responsibilities. he must has "growcd like Topsy." Much of it, too, have th1..: r1rcparation :1ppropri;1te to his work, Ir he pcrpctu;1tcs the dichotomy of has bcrn cornmunity crisis oriented. 11.nre­ Litcd or isoL1tcd from other health sen·ices ·---------------------U-J:-r:-,i-!+LJ.:u.:Ji.cJ__~t.u-tL--pr-a.c.t~ct;___ j_r:i__1-1-.iciJ~<:ir.1.1.c:-----i--1-l'------------------------- h e tries to deal systen1;1ticilly ;ind sciL·ntif'-• and subject tn the whims and vagaries of' pcr- ically with the body hut rern;1ins contrnt to sonal interests ,rnd disinterests and sl1ort- hc intuitin: and :1rtistic in de:tlint! with the li\'ed. hudf Ctary commitments. Only re- 1 mind and emotions he will he found ccntly h;1s there been clearer awareness or wanting. the need for more systematic knowlcd_i'c of The drp:irl111c11t or psychiatry h:1s ken tl1c COllllllllllity in tcrlllS or health r:1cil1ties the princip:11 ~1gcnt responsible for the intro- ;rnd plans f'or the extension and coordina- ductinn int11 tile 111cdic:il sclwnl 01· the he- ti()!l or ...,i.:rviL·cs tD ,ill citi1.ens in the n1111- h:1vio1:il Sl il'lll't•~,. This i~; 1nost clc;1rly 111:lll- 1111111itv or !('/'inn, ikst w11l1 tlir rrnwtli or P:->l'lwl(l)'>'· rwl In Ilic followi11u scclio11 I have si:kded 0nly within the dcp;11tmrnt or 1,sychi:1trv cert;1in ;1rc:is of concern th;tt I bclie\'l: li;1vc b II t ! Ji r <ll I/' IH ll It t Ii C Ill t' d j C: ti S d l U t ,I ifl I ii L'. Jc d l o IC'; I l CO n t ri \ill t j O 11 ,; I() the Cd ll C; I I i 11 Of (I dcp:1rtr11c11ts ol pl'di:1trics. prnl'ntivc med- to1111irrow's physirian. [101] 11111a. J. l'.ly<'hiut. 126:8, Fchmorr I 970 l(lllN l!O~L,\NO 1121 i11ti111;1n is ;1 r1c·n·ssary IJ11t not ;, sul!icicnt r()11di1i,,11. It 11111\t he :1daptcd lo spt'.cilie ', · ,,. · First, and pcrh:tps rnost ir1111orfa11t, is 11cc·d~.. lfc 11~11st k:1rn a new rnk, constit11t­ ··,, · co1'i'cl'111 with 111cllrnds ()I' ()lisL·1\·;1tirlll. \\'r· i11!1 ;1 111L·:111s l() ;rn l'IHI, not :rn end 111 its<.:lf'. It ·-::, arc indebted tn lbvid Sl1:d,1l\\( IS) for ck:1rl_v is.;1 rnk th:1t rcq11irvs interest in arid capacity ;klincatirH! till: disIim.ti1111s hd\\l'.l'll olljcc­ !'or i11vllhc'llH'11t ,,1th self and otlit'.rs. Also tivc obsc~-\'~1ti()11, p;1rticip:lllt ,1hscrvatir111, suhjcctivc ohsc1 ,·,1Iio11, ;111d self ()!i"cn·:1ti1lll. lll'('('S\;Jr\' is the· cunscious ,\W,Hl'rlCSS the or i111plici1 ·,nutu:11 C\j)l'CL1tio11s ;111d crnotior1:il h<;rn thl'. stt1dt'11t·s t1;1di1in11:il 1..·,pnic11cc in ;ittitudc:-. of the cli11ician ,111d his p;!ticnt. The his study of llil· 1)liysic:il and hiolo~)icli rc,k 11111st he k:irricd lhrnu!~h L'.x.;implc and sciences, he h:1s lH·uJ111c L1mili:1r \,ith ohjL·c­ ptL'CcT1l. The cliniL·i:in must ;1cquirc com­ tivc ohscrvati(lll. l·rn111 the s,H.'.i:tl .\cicnccs p:1 ss ior1;1 le ohjccl ivi ty in order to observe and the lrnrn:111itil:s :111d in p:utic11l:1r as a clc:1rlv ,111d rcli::hlv ;ind to rccurd accu­ sen t i c n t h u m :rn h,: i11 ~'. . t Ii e st u d c 11 t h :1 s s o in c r:tleh·. so th:11 tile i,;rcrcnccs from his obscr­ a,,arcness (hut k:---s sys!c111:1tic \.,nr,wlcd.~1:c) vati(;ll.._ nLI\' he nlid :rnd his dcci:-.ions wise. of particip:111t. subin·Ii,·c. :rnd sc'll-ohscrv;1- I hl:licrc ·th:1t during the gr(rnth of the tio11. The \\(Hid ul thill!'S is 111t1ch rnnrc 111cdil:al st11dcnt tlicrr: is a critic:il period - a order Iv than th,· ,.,·orld ()r 11 crsons. point in ti111e \\hen the lc;1rni112. Lisk 11111st he I! 11:1s hcl·n prii1ci1 1 ::lh ll1rnu1-'I. the tc:1ch- j n i 11 e ti . \, Ill· n 1i; 1s i L: p: 1t t c r n s ;1r c s d down t h at i ll ~l ()f p Sy C 1, i :1! I \ l IJ ;I t I Ii e St ll d l'11 l Ji ;l S l Ii C ·dctn1ni11L· !lie l11l11rc modL: :ind course or ()pp or I u 11 it y t u k, ! 111 li <1" t () c \';I I u; 1t c· Iii Ill co I ! d l H' t r, JI t / 1C St l I ( k 11 t p Ii_\ S i Ci :l f1 f h CJ i CV l'. sclr as ;1 11:1rticq1:111t i11 ;1 rrnup :rnd t() 111;1\.,c it t;1Lcs pl:1cc in the sl11tknt's initi;tl L:ngag,c­ cv;ilu;1tio11s Sl·1•:11;ik lrorn those currnn:tcd rnrnts \\ill! Iii:-- p:iticnts in the ll':1L.·hi11g hos­ wit Ii p; n tic i p; 1l i,) !1 i 11 the i' roll f': hc le; 1rn s pit:1ls during his student clinic;tl yc:irs and how to undc1 SLl 11<1 t lie rn· Ii fl)'\ or li is p;\­ intn11sliip. t ien ts ;1hout th·111t-.L'l\'l'S ;1nd !he· ir11rl;t\.'t or ill11css 011 tlic111 :11id ()fl their i':1111ilil·'< lie . II d C r-. t a ll d j II g O f P(' I'~ 0 ll .I Ij I Y also ;1cq11ircs ;1 L·:q1:1l·ity l°()J' sL·ll-ohsn\';\- 1io11 ;ind rn;i\ hn!i11 to 11rnkr'.;t;111d so111c­ ;\ 11()( lln :irl' :1 () r c, 1nccrn is t liL: genera I no­ lhi111' or his (mn ln:li1E S ;1s he j.:; invohcd 1 t inn or pnso11:tlitv ;rnd the h:1sic principles with,- others. \\.ith thi·..__ he heco111rs ;1c- tlr:I t11Hkrlil: tl1e 1111Clcrstanding or pcrson­ qu:1intcd \\i!l1 tl1c· l'tllnf)IC\ity ;ind dillil·tilty t1l1;_\. I !ere :1rai11 ,.,l: :ire gr:1tdul to Shakow in ,·;ilid:1ti11!' his ()h\cJ\:llinns, ;111d hl: is !or Iii s l' k,1r rnicw( I'.)). Students come tn deeply i1111~1c-;"cd "ith the rc111:irk;1hlc tile 111l·dil·:il sd1()()l today 11111ch better in- v;1ri.illility or 1111111;111 (,'()lldt1cl. 101111 t'< I t Ii ;111 Il1ci r l)tl·dnTssors, ll ndo11 lit cd ly This C(-)llCl'.ffl \\ 1th 111ctliods (\r uh-;crv;1tir1n due to the 111:tj()r 1111provcmc11ts that have is n:ntr;il to tl1c· 1111dcrsl;1ndinf or thl· p:1- t:1kcn pl:1ce in- the urnlcrgr:1du;1tc teaching tirnt-physici:111 1 cL1tic,nship. I helil·vc this of p:,\Tl1ology, liio!ogv, and the social to he a phasc-s1 1 ,·~itie l;1sk and th:1t lc:1rni11r. sciences ;111d pcrh:1ps also d11e tn the per­ this role is dependent upon ;rnd crncr-r~cs \'asin: :lll1hicnn: ol' psycliology in our time. fro111 the student ·s h;1sic c1 l;icit v !"or hu m:rn B:1sic 1)rinciplcs of personality include con- in t i rn a c y. I t is !' l' n r r; 1II y :1r r c e d t h :1t l Ii is sic l'r:1t1t111 o rc111c ;111< ontogcne!1c actors c;q,:1cily' d()l'S !Hll :q)1w:1r fully for111cd, 11m in rrowtli, dcn·lnp111rnt, :ind decline; the is it ever rn1111)ktely :1chil:vcd. lndi,·idu:il rcco1•11i1io11 ol 1r11ronscinus ;111(I preconscious successes :ind l":1ilurcs ;1s infants. children, L1ct,~1s :is dctcr111iri:1nts or heli:1vior: the and .idolcscc11ts i11 our i11tn;1ctio11:-i \\'ilh !l()(i()n or drivl·-,kr i,·;1tive behavior; the idea p;ircnts, family, rrit:nds. tc:1chcrs Lirrcly tli;1t tile pcrson;1lity is intcpal ;u1d indi-visi­ determine our h;1sic c:1p:1city fur interest hk: ;11Hl Ilic P'-}Tlio-soci:il principle that in and invohellll'll! with ourselves :llld rccnp11i1cs th:,t 111,1n is a social :inin1al and others. \Vhrn \\l' h:t\'l' :1cq11ircd this c;1p:ll_·it\', that· tl1c crnl·r1'i111 st:1gcs or the life cycle 1 lllll\l iil' lllldnslond in tn111s or 1hc cruci:d we ;ire c:1p:1lik 11! i111l'1pnso11:il i11ti111;1n. \ V c c: l r1 ;1, niii Ii n ·, 1, 11 i Iq, 1-, 1 , Lil r ii , 1r Il lT di 11 ! • cn111 di 1u I i1111 hrt \\Ten t lie dcvt·lnpi11g 111-­ to (k!iu111;1r1i1c ()tlr 1rl:1ti1i11-. with others lic­ div1d 11 :1 I ;ind hi'., \Uci;il rnvironrne11t. e ;i 11 s c , ii l'c M o I h L' i 11:, 111 j 111c- d or d n l r uy L' < I. Tl1is concern with the prinliplcs that For the clinici:11i, this c:1p:1cit_,. !or hu111:111 underlie u11<krst:1ndi11g of personality has A111a . .I. /'.,rcl/11/f l.'(1 S. lcl 1rt1111T /<J70 [1051 1122 111\( 111r . ,, l'SY< 111,\fl~Y f() l\ll l>l('i\( Sllll)I ::1s also kd lo a clearer concept of hc,dt h ;111d rn11I rih11ti iris, I h:lkvc .it has b 1:c1I P'-V­ disease. rvkdic;tl sttl(knts hcco111c ;m;1rc or cli(1l(),n, 11:1rtic11Lirly as it has bc('o111c 111-• ' ' . the speciousness ol' the single c;I1Isc and ti111;1ll'ly i·1tcrw()\•cn into thL: fabric c,r I!ic '• more cogni1;1nl or multiple c111sc.s ,rnd dc1):trllllc: I. of psychi;1try, that has ;1ssi, ul 1 effects, or open rather th;1n closed biological us more li:in :1I1y other discipline. \Vl ;1t­ 1 systems. ;1nd or dyn;1111ic slei1dy st;1ks r;1tltcr c\'cr succ, ss h;1s been m:1de co i!d not h \l.'c than fi,L·d, i11111n1t:1hlc equilihri:1. /\s Li k rn pL1l·c ,vit lir t,t the inti 111:1k r<'ci1~rn .::1 l 1 clinici;111s. sttHknls learn tl1:1l their 111;1tcrial C()11trihut1\i11s or rL:sc:1rch and cli11ic;1l s,::-­ is that or the \\hole or livin~, org;111i1ation. vin: assigr1mc11ts. And in the traditic11 of They hccnmc :m:Irt: or their Tov,:cr or Bahe! A 111nica11 lllcdici1H:, our residents rrom ! he and as~ how su flici c 11 t is I he Li ni.~ u ;1f1e lc,1 rn cd beginning have ;1ssurncd important n·sp<in­ or the hudy ;is ,1 rn;1chinc, of' the Lrngu;1ge sihilities in the teaching or our medi:;ll or sm ;ii I p:1rt s k,1 med by Ill icrosrnpy, cl st udcnts. th C la 11 /2 l 1; l ~2 C () f ph,Y S j CS ; \fl d Che 111 i st r y, 0 f t h C lanp1a,!_'.C ur the llll'lll,il appar;1tus, or the lan­ gu:q1,C or soci;il S\S!crns. Students hcc1.)111c awarL' th:1t \\C l1;1vc yet to acquire the rull Thc1c n1:Iy h:1\'c hL·e11 successes, hut there and proper l,inr.u;irc that dcscribi:s the is lllllch still to he done. There h:tvc lwcn whole or livin~! org;1ni1ation-- -that is, a satis­ a rc;1s or n cg lcct. I wi 11 d r:1 w attention to \lne factory hasic sckncc ()fhum:rn biology. of' t!H·se ;rnd sr1 cak to two ,treas that rcqt:irc The [l'k\':tllCC or this to psyeh()p;1tl10l()gy furthn n1~lor:11io11 ;111d to cerL1in curr,:I1t is apparent Students k:1rn th:11 psycho­ trrnds in currirnl11m pLrnning in medic:il ratholory survives :rnd rcr1:rctf't1lly 1~rospers cduc:1tio11, with p;1rticul:1r reference to the under m;rny lbgs. They learn to recogni1c leacl1i111: ()r psychi:1try. the rnullipk determinants or the behavior I he I IC\'(.' that we h;1vc neglected to i 11 .:I 11dc 1 of ernotio11ally ;ind mentally sid persons. rek\'ant contrihutio11s from the biological They l1.:;1rn, tnn, th:1t the distress or their sciences in our teaching program. /\t lc: 1 st, patients 111;1y lie 111anif'cstcd in rhysic:il, psy­ thL' te,1ching in this ~1rca has been uneven :rnd choloµic:11. or social symptoms, or in ;111 usu;illy unin-.,piring. As John Nurnbergcr(l3) infinite number or co111hin;1tio1h or these. h,1.s nnt c<l. th is would include !Jch ;1vima ! /\II this, ;1s I h:1\'e :ilrc:1dy IJUtcd, requires genetics, lune! ion;tl ncuro:111:itomy, nrn r() mastery or :1ppropriate methods or obser­ hu 11101;tl and hornwn;d chemistry. :,nd vation. It ;tlso requires learning more about heh a \·ior:1 l neurophysiology. Nu rn ber1'cr the 1.ones of healthy and sick behavior in points out thc1! in spite of the substantive our society ;ind the inrormation necessary advances; in these areas, contributions rrom to disti11t2,ui-.,h among norm:tl, neurotic, these fields arc generally neglected in the rsychopathic, psychotic, ;ind intellectually tc;1chinr of our students. I le believes the defective heh a vior. St udcn ts learn that th c biological roots of behavior arc sunk as clinician is no longer an isolate. I k shares decrly and explored as fully as arc the with nu rsc s, p rec Ii n ica I scientists. 1rn:d ic;1 I soci:il scirncc roots hut still do not com- specialists, rsyclwlogists, social scientists, 111;11HI their :1ppropriatc place in a tc:1ehing socia I ,,·rH k crs, ad 111 in ist rat ors, ;111d ol hers pro~? r:1111 :ind cu rricu I u 111. \Vhilc relati()n­ in the pren:ntion or illness and in the study sh I ps have been cstabf,sncd between ana­ and care of the sick person. Studrnts learn, lytic;1lly trained psychiatrists and :,rn·ial too, that those who care for the sick fillll that scil·ntists, he notes the lack or such rcl,1ti/)n­ ships hct\\'ce11 psychiatrists and biolorical they arc concerned not only with dise;1se but sci mt isl s. increasin[!ly with the raticnt and his disabil­ This h;1s been a matter of concern to us ity, with the members oft ht: p;1ticnt's family, for some years, and in our depart mcnt and with the co111mu11ity to which they be­ Robert Ader(!) is offering opportunities long. to first- and sccond-yc;1r medical student:-; to These, then, arc the areas or concern in 1111dcrt;1k c short-term ;1ni ma I research p1 nj­ which I believe th,11 psychiatry has pL1ycd a cch as part of their preclinical work in p:,y­ signific;rnt p;Irt. While our sister disciplines clli:.t ry. The im111cdi:1tc goal is to dc11111n­ in the medical school have shared in these str;lle the influence or n:pcricntial L1ct1irs I 10(1J ,,, 111cr. .I. 1'.lycl,iat. I~16:8. Fchruari· I <J 7() ...,,.,. f>i NTS JOI IN IWi\lANn en psy- 1111c in­ in the dcvL·ln111111-.·11t and bch;1vior of' the vidt1al's d;1ily ;1ct1v1ty cycle): or that a bio of lhc ' organism ;111d 011 its susccptihil1ty to Jorie predisposition is not ncccssarilv suffi assisted . • org,111ic disc:1sc. I ft: believes. ;Is do I, th:1t f'or cit:nt in itself to result in manifest ~liscasc '• a stud c n t to ohs n ve d i r cc l I v t he c/Tc ct s o f his Whal­ (the intnaction between plasma rcrsinogc11 ot have Tll a 11 j p U l :t t i n g l Ii C C .\ r Cr j Cr{ l i :I l Ji i St Ory O f a Incl and tht: sevt:rity of the "stress situa-­ ~iprocal living animal is a r:1r more effective tc:1ching Iio11"). :a I ser­ device th:111 ,111y nurnhcr of' didactic or read­ \Vith Ader I bclie\'e the active participa­ it ion of I ing assig11111e11ts. /\dcr writes: tion or the student in tht.: type of short-term ·om the -~ Such ;1n 1..·,ncis,: \\<Hild help to ;1ccomrlish two experiments referred to may assist him tn other !!O:ils in µcncr:il medical cducition (;1nd in obt;1in ;1 heller undcrstandint~ or the relation­ rcspon­ mcdical I rsychi:1Iri..: tr:iinin;' in p:1rticular). 1-ir'>t. the stu­ ship hct\\'ccn biology and bcl;avior. dent Wotild i,;i1til·ir,;itc in thl.'. rornwl:1tio11 or ;1 There is one other area that requires mc:rninµf'ul problem or q11L'.\lio11 in a f'o1111 which further cxplor;1tion. The reading of ;1 is a111rn:1hl1.: [() nr)1.:rimcntal :m:1hsis. Second, cril ical review( 11) or a r<.:ccntly published such an ncrcisc could foster ,!fl :q~prcciation or tcxt(I)) on the human lif'c cycle reinforced my ut there the n:ilurc ur the rcl;1tio11shir hel\\Cl'tl hiolot:r i Ill pre S Si On Of Ill a 11 )' )'ear S that \\,'hat 111 \) S l vc been and heha, ior. It has been s;1id that to speak ·<;I' biolo~y ,tnd behavior is lo be rcdund;rnt. for the of" us have been trying to teach in this rc­ n to one gitrd is far !'rum satisf'actory. comrlcte lJ mkr'>l:tlld in;• (lr one 111 ll q l'flCO Ill pass require the other. The kli;1, iur or man is nol qu:tlit;1tivcly cu rrcn t I Ill port all<'<' of Lif<· Cy,·1<· difTnent lr(i111 lh:11 ol nthcr or;'a11isllls. hut rep­ medical resents thr rc-.ult nf' :111 c,·olutinn:1r_'., prnccss an-d lo the While we have added Erikson and Piaget should thcrcf"url' he sl11died i11 thi-; contnt. This is not to :id,·l)Ctlc ;1 rcductioni<;tic philosophy. On to Fret 1d and havt.: included co~nitivc and include the contr;n:-. it semis c, idcnt th:1t thcic is no onc- physical sequences of dcvclopn;cnt in our )logical to-one rcl:1ti1ir1.._1Jip h1..·t,,·1..·rn rhy.siolol ic:tl or hio- 1 con..,ider;1tion of human infancy and chilcl­ ,t least. chemical .'-Lttc-; :ind ;1 i.•ivcn hch:1,·ior. p-,\'clioso- hond, our tre:1t111cnt of the human life cycle vcn and matic 111cdici11c. for cxa111plc, ,,hich m:iny still in its tot;1lity is foreshortened, or, as the re­ •gcr(l3) think or as a st11d: of' the effects or the 111i.nd on viewer c;ll led it, truncated. Perhaps because iavioral the body, h:ts hcl:01111..· tr:1nsl;1tcd into the studv or of the influence of psychoanalytic psychology the inter:1ctic 11 hct,,cL'll psycholoricil :ind 11h._ysi­ 1 with its c111ph;1.sis on early life and on the ncuro- ologica I pI Ol'L'sses: in short, to u ndcrs t and t hi.: he- hurnan dy:1d, pcrli;1ps because we have been y, a nd ha\'ing indi, 1dt1,1l [p:1lil·11t]. onL' 111u<;1 u11dcrsL111d lllore concerned with intrapsychic th~rn with ·1bcrgcr that his hch;l\ inr is, the result or rn1nplc, i11tcr- interpersonal c\'ents, pcrhars because our ;tantive action or hiolot'.ictl processes, rrnic :rnd npcri- 1s from cnli:tl history. :111d tile cultur:tl :ind social cnvi- interest in the ;1fkclivc life has diminished tn the :-onrnent in \\hiclt his hclu, ior t:1kcs place. our concern with cognitive and physic;il as­ -1cs the Work in /\dcr's lahor;1tor:v ;ind in tli()sc pects, or perhaps ror other reasons we arc unk as . of others shows that individ11al diffcrcnci..:s apt to resort to stereotyped patterns and to ire the can he lr:1ccd (() the biological and cxpcri- nq!lect significant aspects of the learning proccs~;, or the inlluencc or multiple fan1ily t com- ential hi\tory or the orranisrn. It can be ~aching 1 ,,r d c 111 on st rat c cl t h at pre n at a l or early l i re members ,111d of social class and ethnic :fa tion- ex pericnccs a re ca pa hi c of inn uc nci n.L:- di ffcrcnces a nJ cu rrcn t belief sys! e rn s -1 :-=--n::.. . . . :~:::cH:..:. l'=-d_-- - - - - - 1 - 1 -------'l.o..,Ie"-·\'-'' l-"'o+J'-'-1.,_,n~erlt a I pr <)Cc ss cs ( ma1LLULLLcHL__of <.:"-'' of social morality. l'v1ost of us seem t:_::o___:_:h-=-c_ _ _ _--1►- social hcha\'ior:ll :rnd physiological rhythllls); be- c xha u st c d by t hc t i ni c w c have d ca It \\ i th childhood and adokscence and arc apt :lation- havioral (pnccptual ;me.I learning perform- to i:~ive short shrift to young, middle, and dogical ance, crnot ion:1 I reactivity); physiologic Lite adult life, to occupational choice. fu net ion (;1d rrnornrtica I activity); ,rnd sus­ ·1 to us parenthood, and retirement. Perhaps ()Ur ccpt ihi li ty to a v,iriely of disease processes t r;tdit ion;tl and pervasivt: concern with rt mcnt (gastric erosions. tII111ors, allox:1n diabetes, unities morbidity- that is, with illness, loss, ;rnd vi r a I d i sc; 1sc· ) . ;\ de r h:1s show 11 t ha t t h c pr c­ disability has dulled our means to rccog- en ts to v ail inf P';:,l'lrn11liysiologictl st;1tc or the or­ 11i1c the strcL·csses, l'rccdoms, and gratifica- Ii pro1- g:1nisrn \\ill dcIn111i11c its response to the tion'> or r11iddlc ;1nd Lite life. in psy­ su pcri 1111)osi t ion or pa thogcnic agents (su s­ St udics or pat icnts recovering from serious lcmon- ceptihi Iity to i111mohili1,1tion induced injury, sucli as those conducted by David 1·act ors gastric erosl()ns ;is a !'unction or the i11di- I la111hurr((1) of severely burned patients, r1• /970 A111cr. .I. l'.11·,/,iur. I -.!<,.8, l<'hmorr /<Ji() [107] I , 11 \( 111~,li ('\~( 111\,1(' 1 MIDIC,\l. Sl\ll)ltHS n1:1v l1l'li' 11s !(\ d1sli11rt11:---li lwl\\c<·n l·1,1'i11_1• cd t1\·:1 I inn f'nr new , < .r· para medical \ Jtid: th~· t1 adiltnn:tl ltll'11l:d 111cc!1;1n1,111s ur p1 uk,..,:,11111:ils. tkCcniL'\ "('01,ill'.'r" is ;1n old \\(1rtl th:1l 1s Our unique cnntril 1 as:, univcrsitv is fll,l\ !I· ,, t,·, I, \ ,1 ''("', . ,1, l ., . bCirJf:,,j:titt<i lh'\\ d\~. . l~flrt1g·<l0v1ct-\, unlike to und:rt 111--c ~) stn~1.: J (.',l tl\\icf of a__broad t!tt !\ ~ ~i:i it l\i'n irr. 't'kfc\\~l; i '., /1~ ::10,h ;_1 n ism\: . ;ire n1orc :ip\ \0 he dH1sc1oubhan tl!H.'\)!lSCIOll~, 1~;111!~c of health snvrc tlhjcctiry issues rel~Hil'::'t·! 1q~d ic,d needs, but 1'1;1t may clartfy and n~~i\ 1 1 1 1 .i n1 ~:1Y1~·H1;·ll:\qh:\n i'nt /·:\p~'rsnn:1I, rn~)re l'H)t to :,dcipt. wiHir: 1 i·: (.)Cl1unwittingly, a rn:·s~\\) 1 \)i~h sh:\1_1,~c \th~\11 :~v,it,h gll:lt. l'hl'.j' priori coi1rnnitnh~nt..., •, , 1iitrl i<:uJµr solutions. '\\'S ,r,nn,tc 1 iuturc-n,r1¢ntcd :rnd jrc inform a~ ;\' s mu s1 he evident. 1' : , matter :is centrally l rrn1\; 1.] 1· P,!; /)1 l' ri 11.~_'., ··,.· r:1 tli U',;. ·.r l.i!i 11' i 11 !W.r d1:it i Dtl- 1. 1 "., 11 , , , .·• 1 . 1 • 1 • t·"L1tcd to lhc com11n:J1it1 n1cntal health c.~n­ rGcJucing. \\'e_ 1(1()~ to _oq1; p\>·chologist 11nd ter movement ;ind t,1 /i·;· attempt to become A~)\}(1->:r\)~~.is~' colk;i.t\l)d t() ;1'ss'ist us\ inf'orrn n:sponsihk l'or sv::, .11,1 1 :1~ :-;tudios of health u tor-re~~ our· )~'r~scnt short-sir,,htcdnc.ss, 1 01 c;11T and cklivery n1 :, '·' vict;s to all of uur ~{1;(1\;Ud t()' (lllf 'ut1dc'r~( :111cHr1'r! 1)!'~ IJOl h psy- citi,cns. It rcL1tcs, :.i,i; t· the nt;ed to become :~,h'<i l<)g\: :a/i,d p~yl·lidp~1th ology.~- , 1 ' rcspon:-.ihk 'for th,. ,;tw1v and ·care of many -~:0n'q~,l1~;r ;1rci1 :dr'~i1d~'k:i,d~ l1Xf1 1orcd'i'-: the ~l who have b<.:rn i, ·,·.c i .:.:ted-thc chronic ·r.ut\1i·e dcsiL:11 <.~f th'c \1!11\Tr'sllV 111cdic·,c1l°ccntcr. rs1chotic:. the nd/1}. l :'ilG)uding the alco~ 1 !, cit'}s 1~1\:/!1c..tcd th;1tilh~~ cchttr ,,ill hecornc a '\1]·11 !) : I , l hol ic), the de I inq .1,:11t: · he aged, and the 1 1~/?,Inl1lllnity h~:dt11 ccntcr'a11d in 'so doing psychotic :tnd hr;fr •,d :1 .• '.ged child.· 1)"'\ll :t)c9ln,1e'i11,ti11,1:11cly intertwined into tlie fabdc o!' · rcc.i()n;d 11c:dth scrvic<.'s. As a ~\A~i1)1'0,l oj'thl:.-,l,1ni\·,c1:sl,,ty. ();u,rL:t;1,1t,_t,:1_l objective '; Ii : I' Currcnt trend.., ::1 · ,1r1rkrgraduatc medical i •, , , , 1.s' t,l..l.l' _ctlu,c:1t, Jo,n ,: 11 f., 1(H)1~.)rf()\\1"~ phy~icians. 1 1 I \\.e · know t 1at we C\rnm)t ~1c1L'1)111pli"h this c<lllcali11n inclt;d1.;1;t,li.:\~ ,ction in the time of ,, · · , 1 · h;1sic r, re ;1ssi.r· 11' 1. i1h; an increase in the in' the sense 'o! a rr'of'c's~ion' ll!llcss \V(.~ re- '· · . • ,· · · , time !m c kctivc in -1111ln 11.:nts; a prolircration tain the frcccfom to' pu rshc 'rkw f.-: now ledge, wherever it may take tis., \\'c also krw,v 1 or irHcrdisclplin?r\< ,i;r.i~:ises; provision for car·ly commit rncnt s' of s\ udents with special that medicine is not a spectator sport and that the student learns how to study and interests, with thccstablishment of multiple tracks of curriculu 111; and active particip~ition care for the sick by doing so--in the prop- by students in determining individual choice er setting and with regard to social needs. of curricular pattern. Are there hazards asso­ For centuries the hospital has been the ciatcd with requiring early commitment and environment in which the medical student thus reducing options early in the intellectual has lea rncd----t h rou_gh - cxa m !)le and J)rccc1)t and prokssional life of the student, making and through a series of graduated assign- more difficult the possibility of intelligent , i mcnts of personal rcsponsibility---how to choice from the wide range of opportunities ! apply the basic information he has acquired throughout the undergraduate period? It in physics, chemistry, biology, psychology, is a rich and varied menu. Arc there ha,ards and sociology to the tasks of the physician. for the students who do not choose the psy- _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____!__!lt'----'-'is~c.~lt ~th'!.:e~l~)C::.:(~Is,_._.ci ~Ie"'.__·~•~rn~d~i~n_t::h:;c~c_;_ili~n~ic~ti__;.h~a~t_ _:c_:__:h:;.;i~1t~r:._:ic:__::.-tr:. :a=-::c. k ? W i11 th cy be short-ch an g ed the medical student learns to discipline his 111 their exposu-(c-ro-r11-c in1pactc:rrp-sychimry------- capacity for human intimacy in his encounter on all of medicine? Will the department of with his patient and the patient's family. It psychiatry continue to consider one of its is here where he learns of those events of major responsibilities helping prepare all human interaction that are specific to the medical graduates, regardless of their even- tual destinies, to become informed of the doctor's .1·ob. But the new generation of basic emotional and cognitive aspects of students also must learn, as we must learn, human interaction and of the significance how to provide health care to the patient and of the effects or psychosocial events as these his family before he comes to the hospital innucnce the lives and health of patients and and arter he leaves it. There will inevitnbly their families? We believe that equally in~- bc changes in our curriculum to meet these porLint to any contribution we may make needs. i\t the same time the teaching hospital to the education of' the psychiatrist of to- will he responsible for designing patterns of morrow is the contribution we make to all [ 108] Amer. J. l'sychiat. 126:fi, Fehrnar.r /970 ·-··· L •r, J()IIN IWr--1\N<I 1125 physici:111s, wlH·llin <)I IHll tlwir 111:1j()1 co11 C('S, :111<! tlH· '11111i;111ities. N<)r must we 11I1I11- ccrn later i11 l1k is in p:llirnt care. 111i1e lllL· sig11i/ic:111t effect of the imp1 uvc- \Ve li:1,·<· ll<)t hr('ll i,i1p1t·s\1·d with :111v con I1H·rit i11 st'<'<111d:11\' <'rit1<·;1tinn. •I ~ii y is tr:1st i11 tl1L' i11tL'tt:s! i11 psyclic1srn·i:tl 111;1llcT; l11!cll111c·111 :ltld sc11sitivc udmissions t·o111- :1 liro:1d lwtwrc11 •,l11tk11t•; wh() dt, :111d tli<lS\' \\'l1n dll 111ilt1·<·~; :11<· 110w :1hk lo idrntil'y dilfrrt·11t:es la1ifya11d not wisl1 to l)l·L:0111e psychiat1isls. 111 our aI11011g students and to rt~spcct such differ- ;ii needs, h11 t sa 111 pk s () r 111 l' cl i L': l 1 s ( t I( k 11 t s ;1ll d Ill l' di C: ii rn ('Vs' f\ fr dk; ii r: I('lJ l I i Cs n IT 11 () \V j n a p() s j l i() I\ wittir}!'ly, :t school :q111lic;111ts, we SL:c L1rgc 1111111hc·1s of to provide variations on the theme of trarli- 1r solutions. young men and women who lt;1vc given tio11;1I courses to meet more approrri;ttcly is ccn lra Ily serious ;1ttc11tion to social and hcliavior;il the interests and needs of the student at the I hl!al th cen- sciences in thL'.ir collegiate experience, w]l() kvcl ( ) r sophistic:iti()ll with which he comes 1 to become h:1vc Lr;ivclcd, eng;1ged in ;1 wide Ltll?C of lo medical school. Furthermore, cxperi- .:s of health 1i fc a cl iv i ti cs , a r c sc n sit iv c t o t h c ,1cu tc prn h-- rn c 11 t s i n in nova t ivc ch an g es m c r a rn pant , all of our lems of our world and its people, ;111d ;ire for in medical schools, particularly in providing ,l to become frorn the stereotype image or the narrow generous chunks of elective time. This has .re of many biologic scientist who secs little beyond his gone so far that we must make sure that he chronic test tube or counter. For many of our stu- the notion of the elective docs not become : the alco­ dents we sec the ps~/chiatric education we a s;1ucd cow., alld we must be on the alert d, and the give them ,1s providing some basic rn1-1ccpts to examine the effects of some of these de- id. and tools with which they can :1pply the pJrturcs rrorn traditional curricula. I be- human sensitivity and awareness or life prob- licve there will be experiments by many of !ems that they alre,Hly have to their work us to introduce the student early in his 1tc medical with 11atients. Pcrh,1ps the alternate track career to certain types of clinical cxpcri- thc time of for medical students 111,\y turn out rnt~dical cncc. But from our limited experience l do case i n the st u cl en ts 111 or c i 11 f'o r 111 c d i n psych i:1t r y I Ii :1n is not con sid c r t h is an ca sy task. W hi le it roliferation currently possible in rn:.rny c;iscs. is relatively easy for preclinical students ovision for Givi..'.n ,1 student with a clear, 11rm dcci- to assume objective observational I oles vith special sion to become a psychiatrist, my tci1ckncy (that or spectators of human behavior), it is of multiple would be to encourage him to obt;1in as more diflicult for them to become partici- ,irticipation broad an experience as possible in tcncral pant observers in the professional role be- dual choice medicine before entering the field. More- cause of their still limited tool kit of infor- •1.ards asso- over, I would be concerned ,ibout what is rnation ,ll1d knowledge and because they ,itmcnt and lost fnr the student who docs not t:ikc the lwvc not h;1d sufficient experience to prcp,irc i 11 t Cl lc Ct ll a I t r a Ck i [l p s)'Ch i 'I ( ry. I \V () II Id ;t !s() Ih: C() 11- ( Ii C l 1l r I1l () ( i() 11 'ii l y ro r t 11 C t; ls k . nt, making ccrncd ,1bout the potential charn~c of One rundamcntal issue that each school intelligent in tcrcst and in vest m cnt of the dcp:i rt men t Ill u st !'ace cl car ly and honestly is what is to iportunitics faculty in working with elite and nonelitc be considered basic and fundamental in the period? It groups of st udcnts. W c have s11 ilicicnt med ic;il curricu ! um ror tile preparation or tl1c ,:re hazards experience to indicate that even as much undilTcrenliatcd physician. There may be sq, th c p S•>Y.:'. _,-_ _____:__•·~~~----~c-=d-=u~c~;1.:::.1i:. .:.o:. . :,.r~1~a.:::.s_(~H~I1..:..·~!i..:..r_:_st:__--;-'"-11.. :. .H'-'--l-:-;-'-s-'-c-;-c_n_c__n~d--;--.:-·'~c~a~r-~;1~11~(!. p r<2l1,\ l)! y ~<J.rn11LcLb.c_)__.\"a.ciation$-.as.-..lo- -,\-r:cff~1il g cc courses in psychiatry and a limited four- how this may be defined. But given this basic psychiatry week psychi,1tric clerkship ;ire in;1dccp1:llc to or core c11nirnl11m, 1 believe m;1ny of us will ;artmcnt of ,. -'., prep;11c a pliysici:in fully for the psyclii:1tric provide a l;irge range of elective opportuni- onc of its hackgrou11d he needs in his 11rofc'-:sional tics f'nr om studrnts within the mc<lic:il ircparc all work, wh;1tever his eventual c1rccr choice. school, in the univcrsity-at-l;1rgc, and in the • their even- Would we· not agree that tocL1y's mcdic;tl cnrnrriunity. I al:-;o believe that with propa 1 1cd of the curricul11111 is becoming quite !ibcr:ili1cd? guidance through !acuity tutorial supcrvi- aspccts of It is nwch more ncxiblc than it ever was sion, some of these electives may be framul i1:n t ' ific;1ncc p IT\' ·I() I I sIy. ;l ll ( ! 11 ll IC 1I () r· I Il C rI·/',Id · i (y () I· ( Ill'. t ()\\';I rd sp CC if i C C11 (Is' ·l ·1 l Cs C may 11 () I. ll t 11s ;1s tl1csc · convn\ sy:;tc111 li:ts hL:cn di111inishc·<I. Prep !()\\';11d 111olcc11l:ir hiolo1•.v or the psycl10- .iticnls ;ind arali<lil !'or nicdicinc is 111ucll ktrn tn- soci:tl scl. ;\s you c;rn sec, I am nol of tl1c tjUallv 1 ill~· da"1 tli;in it \Va'.; 25 1\'C;1rs ;p_,.o 1. 11nt <111l_y in 01li11ion th:11 the rncdic;1l school as a pro- 1nay 1nakc · rist of to-• rnat!tc,11:11 ics, physics, biology, ~11Jd clic1nis lcs\io11,tl school is cquivaknt to a traditiun:d iakc to all try, hut also in psychology, the social sci<'ll.. f r;1duatc scliool. l think there arc certain irn~ hr11ar_r /970 Ama. .1. 1\yclnar. /26:S. Fclmwn· /970 l 109] 1 I 2(i 11 M Illl''ri 1'SYCIIIATRY TO MEI.JICAL STUDENTS pcrativcs in the prorcssional s1 li\Jol th;11 ,1. h·l1.\, I( 11.: The Prcpara11on of a Cornmunit', are ncccss:1rily J1()t prl'SCnt in the ;'.rad11;1tc Orirntcd Pswhi:itrist, Ame,. J. Psychiat. I i2: 11111,· suppl. 2-7, 1%6. schools. 011c should also rcn1crnbcr th:11 5. (;r;1vcs, W. W.: Some Fuctors Tending Toward many sch on I,c; Ii ;1 vc cond ucl cd f'a i r ly Ii hcr:il 1\<kq11;11<' lnstrnctin11 in Nnvous and Mental progr:1ms. l11 our own school, approxi,n:itcly l>i~<·:1•;cs. .I. A. (VI. A. (d:1707-1713, 1914. ten to 70 students in one year use one-year 6. lla111ht11g, D. !\ .. Hamburg, B., and dcGo,rn, fellowship periods to work in the several S.: Adaptive Problems and Mechanisllls in Severely l3urncd Patients, Psychiatry 16:1-20, departments of the rnedicc1! school, and well 1953. over 75 percent of the student body is cur­ 7. I! am 111ond, W. !\.: Treatise on Insanity and Its rently involved in summer fellowships or one Medical ReLitions. New York: Appleton-Ccn­ type or another. Up to the rrescnt these t11ry-Crnrts. 188.1. have not been called electives and arc dealt 8. l.cwis, /\.: "Psychiatric Education," in Davis, D. L., and Shepherd, M., eds,: Background and ..1 with out side or the tradition a I school year. I listory. London: Pitman Medical Publishing The traditional instrnmcnl to effect change Co., I%4, pp. 6-25. in the preparation of tomorrow's profession­ 9. lid1. T.: The Person. New York: Basic Books, al person is the: curriculum. However, one 1%8. 10. Mann, E. C.: ;\ Manual of Psychological Medi­ must remember that it is <Ill instrument, a cine ,rnd Allied Ni:rvous Diseases ... with a Care­ means to an end, not. an end in itself. And ru!ly Prepared Digest of the Lunacy Laws in like theoretical beliefs or notions, it should the Various States Relating to the Care, Custody, command loyalty only as long as it is u<;cful :rnd Responsibility of the rnsane. Philadelphia: and germ in al-- that is, capable of leading P. Blakiston, Son & Co., 1883. 11. Ncugartcn, B. L.: /\ Truncated View of the Life one to use intelligence in new ,vays. Cycle, Co11trn1por,1ry Psychology 14:409-411, 1969, The burden of' our task as teachers is to 12. N ohlc, R. /\.: Psychiatry in Medical Education. create the proper instrument and use it New York: National Committee for Mental '1 !I ygirnc, I <J3J. wisely, to constantly test its usefulness and i appropriateness to the times, and lo IJ. Nurnher~cr, J. I.: "The Brief for the [nclusion of' Rclcv:tnt Contrihutions from the Basic Biolog.. venture courageously toward new and ical Sciences Within the Broad Spectrum of De­ better vvays. havioral Sciences," in Teaching Psychiatry in But there arc certain matters quite inde­ l\1cdical Schools: Working Papers of the Con­ pendent of curriculum, course schedules, ;ind f'L:rcncc on Psychiatry and Medical Education, 1%7. Washington. D. C.: J\111crican Psychiatric content 1h,1t constitute the e:;scncc of the ;\ssoci;1tion, 1%9, pp. 440-445. educational process. ·These arc v,ilues tlwt l,I l~t1,li, B.: l\1cdical Inquiries and Observations Vcsty unclnstood, respected, ;ind held l 111011 tile DiscaSL'S of tile Mind. Philadelphia: dear. They ;ire the tr,1ditions of our irnli\'id- Kimber ;111d Richardson, 1812. ual sch1l0l,c;; the skill ,111d dC\'otion nf sen­ 1'i. Sli:1k{)\v, D.: "Connnents on Study of Bchaviorai 'j Scirnu· in l\frdici11c," in Cope, 0., ed.: Man, Mind, ,i ior and junior teachers; the insistence on and Medicine. Philadelphia: J. B. Lippincott Co., integrity -~111cl on the mainten:rnce of stan- 1968, pp. 123-133. dards of conduct; the ever-present curiosity 16. Spi11ka, I:. C.: Insanity: Its Classification, Diagno­ and rest lcssness ,ihout existing belief's ;ind sis, and Treatment. New York: Bermingham and Co. 188'1. practice~; and the pursuit of new knowlcdre, l 7. Tc,iching Psychiatry in Medical Schools: Work in -----~--r-,----;....------even-foTc-th"C-srrkr-o"f:;tiTc---:;cnTh; - th c nru tu a I P,qwrs on·1ic Conference on Psychiatry and MccJ .. rcsrcct or a co1111111111ity of scholars; and Ilic ic:tl hl11cation, 1967. Wasltin;~ton, D. C.: Arncri­ compassionate objectivity of the clinician c;rn Psychiatric Association, 1%9. 18. The lJndcrrraduatc Teaching of Psychiatry and in his c1rc ol' the sick ;rnd the family of' tl1c l\.lrntal I lc,1llh Promotion. Ninth Report of ihc sick in the communities in which they live. Fxpcrl Committee on Mental Health, World" I lealth Organi1ation, Technical R~port Series REFERENCES No. 208, Geneva. 1%1. ,,' J. Ader. I{.: personal communication. 19. Webster, T. Ci.: "Psychiatry and Behavioral Science 2. Fha111•li, F. Ci: Tlw l listnry of Psychiatric hl11c1 C,11 ri<.·1!111111 I lours in United States Schools of tion in the I lnil\'d Stale~ frrn11 'l8•1-1 J<),1,1, ;\111n. l\frcli<i1ll· ;111d Osteop:1thy," in Teaching Psy- J 1':.1< lii:11 100: I', I lid, l'>•l-1 <lii:1t1\ i11 l\frdiv:tl Scltnols: W,irking Papers of the 3. IJi:1t11·li, I·. (i, and IZy111cr, C. A.: l'syclu;111y in ( ·011lcrc11cc on Psycl1i,1try and Medical Education, l\1ed1,il hl11c;1tion. New York: The Co11irno11 .. l<)(,7 Washin1!!nn, D. C.: /\rncrican Psychiatric wc\11li I und, l'J·P ;\s\oci:tlinn, 1<J(1<), pp. 2'.>9-288. [l lOJ Amer. .!. Psychiat. 126:8. FebruarJ' /970 l tlllt' l\l6G JOHN H(}MANO 7 i('u- ,idering what roles professionals may play Since all psychiatrists do not accept this v\·cr and beyond that of delivnillg tra­ view-in fact, since there is a rather sharp of .litiona I direct services and toward enrich­ division in point of view-is it not the ,ng and supplementing traditional com­ a obligation of all of us to take thoughtful to nunity mental health programs. and searching look into training and re­ , itc- Pwchiatrists who are developing these training procedures for. ourselves and for ic, :raining programs do not have an easy those who will follow us? Those now in ind ;:ask. As I have said, some of our colleagues training and who will enter training in the ·ies !nave been critical of the introduction of an next few years will be the leaders and con­ , 0 . (idditional area of training into an already sultants for challenging new comprehen­ . of Ilwcrc-ro-,vded professional • training curricu- sive community mental health centers, with the !'tim. They believe that such a program all that they promise for the future. Out ,he ;?ushcs the psychiatric resident into areas of devotion to the best interests of the . rn. jrhat are not the true province of the special- mentally ill who are our primary respon­ 1 tcs :y. sibility, and out of regard and concern for ·nt 1_ I firmly believe that residents properly our psychiatric colleagues of tomorrow as ll"e i1elected in the first place and sufficiently well as of today, it seems to me \Ve have ;rounded in well-planned psychotherapeu­ no choice but to examine and experiment :,~C- :ic exJ_)ericnccs will mature r)ersonally and_ with our psychiatric curricula. of ;1rofcssionally more rapidly with the adcli- This field of medicine which is our , -r- .:ional training and experience in commu­ special trust, this psychiatry which we try : i~- ,nity roles. to understand and to apply, is so impor­ w 1 These are questions that must be re- tant to the physical, social and psycho­ 11.\. mlvcd, but to me it seems logical that logical welfare of mankind that our best a \tuclcnts of psychiatry who receive this efforts and our most statesman-like thinking ,-~. training would be better prepared to prac- and planning are the minimum we can 1. ·ice-whatever their roles-after having ex­ offer. ,·l. •)erienced this orientation to the commu- 1 ]..,_ ·1ity. This attitude of mine no doubt springs REFERENCES 1 /i n part from my training and background, 1. The Psychiatrist, His Training and Devel­ i1. md, I think, is in the Ebaugh tradition. opment. Report of the 1952 Conference 1 :(. The 1lll'll whu are <levdupi11g these cur­ on Psychiatric Education. Washington, i it ricula arc convinced that, in the face of D. C. : . American Psychiatric Association, ,ii ·he psychiatric and mental health needs 195.3. ,!t· :hat exist and in anticipation of the roles 2. Training the Psychiatrist to Meet Chang­ 11 , in which psychiatrists will and should be ing Needs. Report of the Conference on \ functioning in the future, training in com­ Graduate Psychiatric Education. Washing­ j\ :nunity psychiatry should be required in ton, D. C, : American Psychiatric Associa­ the residency curriculum. tion, 196.3. TWENTY-FIVE YEARS OF UNIVERSITY DEPARTMENT CHAIRMANSHIP JOHN ROMANO, M.D. An advertisement in the N e10 York Times events of the second third of the 20th cen­ framatically ca1ls our attention to the tury, which is now drawing to a close. It is claimed that more basic and far-reaching changes have taken place during the last Dr. Romano is Professor and Chairman, Depart­ 30 years than in the 300 preceding them. nent of Psychiatry, University of Rochester Historians may call it "The Age of Change," ichool of Medicine and· Dentistry and Psychiatrist­ :n-Chief, Strong IVfemorial Hospital, Hochester, not only because there have been many \'.. Y. 14G20. changes, but because the rate of change 8 UNIVEHSITY DEPARTMENT CHAIRMANSHIP [JU1i itself has accelerated faster than men have schools, to the number of students in . ever dreamed possible. class. Research activities on the part of Ol' The advertisement enumerates the major faculties and increasingly on the part o and publicly visible events of the past our students have expanded. We face tc three decades-the Great Depression, the day many problems-the subsidy of medica Second VVorld War, Korea and now Viet education and of medical research, t}1- Nam, the rise of new nations, the struggle costs of patient care, the growing relation for power, the spread of affluence, the tech­ between the medical school and commu 1 nological revolutions in making and build­ nity, the increasing dependence of tlt ing and distributing, and vividly at this medical school on state and federal gov moment the serious attempts in our own ernment support. nation to ensure full measure of civil rights Faculties of our medical schools are en• and living opportunities for all of our citi­ gaged in studies of the preparation of stu­ zens. dents for medicine and of the selection From demographic and statistical studies, procedures for admission to medical we learn that today about one out of every sc:hools. rviedical school faculty commit• 25 human beings who ever lived is alive. tees throughout the nation are studying And 90 percent of all the scientists who the curriculum, particularly as it relates ever lived are alive. The rate of the world's to the integration between the teaching o! population increase has doubled in this disciplines. There is interest in studies ol center third of the 20th century. There has the assessment of students in operational been the most enormous knowledge ex­ as well as in traditional examination pro- j 1 plosion in history. Four times as much is known now as in 1935, and in the next 15 years scientists will learn as much more as cc<lures. There are studies into teaching practice.1 and into the characteristics of successful l I in all previous history. As many scientific and unsuccessful teachers. There have been I papers have been published since 1950 a few bold persons who have tried to mea­ alone as we1;e published in all the centuries sure the success or failure of the medical before ( 10) . schools in learning what it is that the physi­ Small wonder, then, that there have oc­ cian docs-vvhen, where and how dfectivelv curred in the past 25 years and, more he does it. \Ve have become aware of th~· particularly, since the end of \Vorld \Var differences in the physician's work, section­ II, immense changes in our nation's health ally, within a nation, as well as the differ­ services, including, of course, the conduct ences which exist between nations. We an of affairs in university medical centers. In learning that political and social attitudes my view, the changes have been greater inevitably and significantly influence the and more dramatic in the past 20 years model or image of a physician in a soci­ than they were in the two decades which ety( 13). followed the publi~ati()n of A,braharnJTlex- That changes have ocicffrrcd Is evident in .ncrs <':Bullefiii No. 4 of the Carnegie Insti­ the medical schools and their teaching hos­ tute for the Advancement of Teaching," pitals, in their relations to their parent uni• published in 1910, which played such a versities, to their communities and to the tremendous part in effecting changes in nation at large. medical education and indirectly, but to a Changes have also taken place in the lesser extent, changes in the health services departments which constitute the univer· of our nation. sity medical center, including the operating Multiple determinants since the end of functions of the department chairman. It is \Vorld \Var II have intensified interest m to these last two points that I wish to draw medical education. Many, if not most, of your attention. I intend to select certain our medical schools, both public and pri­ experiences which I have encountered as a vate, are in the midst of active expansion in university department chairman over the space and structure as well as in function. past 25 years, something less than five year~ \Ve have added materially to the number in Cincinnati, something more than 20 years of full-time faculty members and, in some in Rochester. [ June _19_6_'6__;_1_ _ _ _ _ _ _._ _ _ _ _ _ _--'cJ:__O_l_IN_-_I_~(_>l\_·r_A_N_·o_ _ _ _ _ _ _ _ _ _ _ __ -----'=-"--- ,uber of students in a Notwithstanding the hazards of personal To what extent the experiences I recount •:ities on the part of our selective history, it may be likened to a are representative of follow chairmen in tsingly on the part of window through which one may look out other schools, I do not know. expanded. \Ve face to- upon our concerns and responsibilities. And Let me add another reservation : this is ---the subsidy of medical, like the special windows with which we not meant to be an evaluation of our suc­ medical research, the equip our clinics and laboratories, it may cesses or of our failures, of what we believe ,,, the growing relations also enable us to look in upon ourselves, on we've done well or \\'hat we believe we've al school and commu• who we are and what we may become. It done poorly or, for that matter, what others i<r dependence of the may help us to examine the basic patterns believe we've done well or poorly. This is ';tate and federal gov- of current organization of the department altogether another matter, which ccrtainlv 1 land of the medical school an~ hospita_l. deserves separate treatment fully and I tnedical schools are en- Have our current patterns outlived their frankly. It should be done, perhaps togeth­ the preparation of stu· f1sefulness? Must we consider new and dif­ er, by a number of us \vho have shared in , and of the selection 11ferent patterns, hopefully more appropriate the common venture, but if not, then in­ tdmission to medical 1] and useful to the tasks which lie before us? dependently by each of us. It should be ;chool faculty commit• 1 As you will learn, this is not a:1 exhaustive done, too, by external, interested, informed c nation are studying 1treatment or survey of the issues noted persons from their stance of neutrality and :rticularly as it relates tor a systematic documentation of the rele­ objectivity. ictween the teaching of jvant literature. It is not based on any con­ One great weakness of my argurnent is ;s interest in studies of jsensus. o~ 11:1y colleagues or fell_ow_ c~1air­ that I do not have a very clear or informed students in operational 1men. It 1s Just what I have smd 1t 1s, a baseline from which to make comparisons. tional examination pro- ;jpersonal selective history of the changes in Before my appointment as department jthe form and function of the university chairman in Cincinnati in November 1941, 1 , into teaching practices clinical _d~l?~rtment of psychiatry and _of the I did have certain preconceptions of the lcteristics of successful respons1b1hhes of the department cha1nnan. role of a department chairman and of the 1chers. There have been J \Yho have tried to meaM l failure of the medical I FIGURE 1 what it is that the physi~ ]100 Full-Time Faculty in Six Departments of Psychiatry l1ere and how effectively J .'e become aware of the J 90 ,Jiysician's work, section• j •n, as well as the differ• i 80 Jctween nations. We are J :cal and social attitudes 1 uificantly influence thcj 70 6,5 65 F a physician in a soci~ ·~ -······+60. ve occurred is evident in J ; and their teaching hos~ }50 , ions to their parent uni* <i :ommunities and to th<· j 40 l dso taken place in tlw ,j 30 1 constitute the univer* f , including th~ operatin.g 20 J partment chairman. It is # )ints that I wish to draw I intend to select certain i IO I. have encountered as a j 1 ent chairman over the : 0 1 42 65 1 1 46 65 1 thing less than five year'\ i CINCINNATI ROCHESTER thing more than 20 yeau 1 [ June UNIYEHSITY DEPAHT!vlENT CHAIHMANSIIIP i91:: ----------------------------------~ - form and function of a department. At individual investigative work; for the ger• Th( Marquette, Yale, Colorado and Harvard, I mination of new and hopefully creatiw fy. j knew, had studied and worked with a ideas ; for responsibility in the selectirni number of part- and full-time professors and promotion of faculty and career resi• and department chairmen in anatomy, bio­ dents; for the opportunity of continuing chemistry, medicine, neurology and psy­ clinical experience; and, above all, for tlit chiatry and knew something less about sur­ parental or generative responsibility of prtr gery, pediatrics and obstetrics. fessional leadership in the conduct of tli As for 30 years ago, we must remember department. that only a few schools had any full-time To what extent this was illusory and clinical faculty, that many department wishful, based on insufficient informatioo chairmen were sometime or part-time par­ as is a child's view of his father's work and !O t ticipants ( 5). Most deans were part-time Jife, I cannot tell. I do know that soon afltt dl(' officer's, many with considerable laboratory my initiation as a department chairman ii ,ca1 or clinical assignments. However, from the Cincinnati, many matters requiring decisirt W.3t samples available to me, I gathered an action were brought forcibly and vivid1y !ell( image of the role of a full-time professor to my attention-matters about which ! l'nit and chairman, at least as it appeared to had little previous awareness, much lt'.11 ?ital me, and from conversations with my peers, preparation. Since then, these matters harr 14.•n·; as they, too, thought it would be. It was not not only increased in number but in com­ tim( a very clear image, but it did contain gen­ plexity and significance. 'X) ( erous portions of time and leisure for think­ In the following I outline briefly wMf :wo ing, reading and writing; for scholarly pur­ I consider to be areas of significant changr md suits; for the education of the young; for in the form and function of a department ~HT. ,om, ij_'f\ I FIGURE 2 Volunteer and Part-Time Faculty in Six Departments of Psychiatry 100 00-· 100 90-l _j i ! 80·-1 -j 70 60 50 40 -l 3o-l 101 10 _j ol JOHN HO.MANO 11 ·• 1• work; fo y are not ordered in imp0rtance. Final­ consultant to the hospital but sa\v about 1d hopcfulJ, shall make certain general remarks. eight to ten psychiatric patients daily in litv in the consultation. Today there is a full-fledged ·ulty and psychiatric service. irtunity o is perhaps the most visible change. In the period 1939-1942, while my ap­ .rnd, abovt 1, 2 and 3 show quite graphically pointment was in medicine, I served as i, responsih changes over the years in numbers of psychiatrist and neurologist at the Peter iu the cone part-time and resident and fellow Bent Brigham Hospital. I compared the . :ttoc1omtmen1ts in five university departments roster in 19.39 with the present one at the this was illusory which I have been associated. Peter Bent Brigham Hospital, where there 1sufficient "'f'~l'fo~S..1.u~•,.:_,'1.- the changes in Yale from 1934 never has been established a separate in­ i his father's work the present ; in Colorado from 1937 to patient psychiatric service. In Cincinnati, io know that soou present. ( I chose 1937-1938, the third 1942 is compared \vith the present and in ·partment chairman of fellowship in Denver.) During Hochester, 1946 with the present. 1 tcrs rcq uiring ,,,Nu•-.Lc.•vv while I was serving as a Hocke­ Tables 1 and 2 show the increase in fac­ 1 forcibly and Fellow in neurology at the Harvard ulty appointments in Rochester at five-year :1.tters about v;hich in Neurology at the Boston City Hos­ intervals over the past 20 years, including awareness, much there was no established psychiatric those with academic tenure. 1 en, these matters As you will see, there were no full­ n number but in faculty appointments in psychiatry, These appointments include psychiatrists, ICC, designated psychiatric house officers, psychologists, social caseworkers, nurses, l outline briefly ,, part-time appointments of psychiatrists social scientists, statisticians and colleagues 'i of significant chIWil:!'.W:': one of a clinical psychologist. How~ from our fellow clinical disciplines. r ·tion of a departrm."1°%1 the "nerve resident" always had had There are comparable increases in the type of psychiatric training and number of nonacademic professional, tech­ not only as a neurologic house officer nical, secretarial, clerical and administra- FIGURE 3 House Officers, Residents and Fellows in Six Departments of Psychiatry 53 55 48 14 0 37 65 38 65 39 65 42 65 '46 65 i NNATI YALE COLORADO HARVARD HARVARD CINCINNATI ROCHESTER BOSTON CITY) /PETER BENT) ( HOSPITAL \ BRIGHAM 12_' _ __________U_N_I_VE_•l_{S_'I_T_Y_D_E_P_A_H_T_:i\_II_•:N_T•_r_C_I_IA_IR_:i\_f_A_J',;"_S_H_II_'_ _ _ _ _ _ _ _ [Jt_llH" I11966 J_ TABLE 1 Full-Time Faculty Members at the University of Rochester Medical Center l------ Department of Psychiatry, by Year PSYCHIATRY PSYCHOLOGY YEAR TENURE TOTAL TENURE TOTAL OTHERS* TOT!t 1946-47 1 3 0 0 0 l 1YEAR 1951-52 3 13 0 1 0 J.« f 1928 1956-57 5 17 0 2 0 19 f 1929 1961-62 7 21 1 10 5 36 1930 1965-66 10 1931 29 4 11 9 49 1 11932 * Social casework, nursing school, sociology, statistics and biochemistry. f 1933 f 1934 TABLE 2 11935 Part-Time Faculty and Residents and Fellows at the University of il936 Rochester Medical Center Department of Psychiatry, by Year l1937 l1933 PART-TIME FACULTY \ RESIDENTS AND FELLOWS }1939 SOCIAL 11940 YEAR PSYCHIATRY PSYCHOLOGY CASEWORK TOTAL PSYCHIATRY PSYCHOLOGY TOT~ j 1941 1946-47 7 2 0 9 4 0 4 11942 1951-52 12 4 0 16 16 0 16 l 1943 1956-57 24 6 0 20 20 0 ?O '1944 1961-62 34 5 1 40 32 1 3J 1945 1965-66 36 9 5 50 36 3 39 1946 -_ _.______ ... FIGURE 4 tive perso11 Total Membership of the American Psychiatric Association for the Years 1928-1965 Inclusive number is Nursing 15,000 Technica Houseku 14,000 Dietary 13,000 Grounds 12,000 All this Ji, · with it i~,·· 11,000 Jrunding, n : 1 ition for sl, 10,000 V) lthe design 0 z V) 9,000 Ideal with t1 l cc .,..__ I..LJ ___ part Topgy" CL a:,ooo LL Consider. 0 7,000 al personnel 6,000 f Tablcs 3, 4 jship of the 5,000 ~tion for l l1 Jsive(4). !\I 4,000 1has indicate 3,000 •1· of growth a of the Amci 2,000 physician JH ISUS. 1,000 28 3} 32 34 36 38 40 42 LI-I 46 YEAR 48 50 52 54 56 58 a} 62 fH l In the p( , psychiatric rbout 3000 j inc 1966 JOHN ROMANO 13 TABLE 3 Membership of the American Psychiatric Association for the Years 1928-1965 Inclusive PERCENT PERCENT OT.Al TOTAL YEARLY TOTAL YEARLY YEAR MEMBERSHIP INCREASE YEAR MEMBERSHIP INCREASE 3 14 1928 1302 1947 4341 8.3 19 !929 1325 1.8 1948 4678 7.8 36 1930 1346 1.6 1949 5276 12.8 49 1931 1393 3.5 1950 5856 11.0 1932 1416 1.6 1951 6581 12.4 1933 1517 7.1 1952 7125 8.3 1934 1604 5.7 1953 7608 6.8 1935 1676 4.5 1954 8149 7.1 1936 1749 4.4 1955 8673 6.4 1937 1889 8.0 1956 9247 6.6 - 1938 2053 8.7 1957 9801 6.0 1939 2235 8.9 1958 10420 6.3 1940 2423 8.4 1959 11037 5.9 OTAL 1941 2667 10.1 1960 11637 5.4 4 1942 2913 9.2 1961 12161 4.5 16 1943 3125 7.3 1962 13001 6.9 20 1944 3387 8.4 1963 13396 3.0 33 1945 3634 7.3 1964 13853 3.4 39 1946 4010 10.3 1965 14341 3.5 . -----···-------~---- tive persons. Currently in 1965-1966, this the total number of social welfare person­ number is 17.5 persons. nel. It is stated that between 1950 and Nursing personnel 59 1960, the four core mental health profes­ Technical, secretarial, clerical 92 sions ( psychiatrists, psychologists, social Housekeeping 15 caseworkers, nurses) increased far more Dietary 7 rapidly than all health professions and this Grounds men 2 trend is expected to continue ( 8). All this has quite understandably brought FINANCES with it issues of recruitment, selection, funding, evaluatiim, promotion and compet­ Quite predictably, increases in operating ition for skills and experience. However, costs of the university department are com­ the design of organization to meet and parable to increases in personnel. Table 6 deal with the issues has been for the most part Topsy-like, "\Ve just growed." TABLE 4 Consider, too, the growth of profession­ American Psychiatric Association Membership Compared al personnel in national terms. Figure 4 and to Physician Population for .Selected Years Tables 3, 4 and 5 show the total member­ APA PERCENTAGE ship of the American Psychiatric Associa­ PHYSICIANS MEMBERS .APA MEMBERS tion for the years 1928 to 1965 inclu­ PER MILLION PER MILLION IN PHYSICIAN YEAR U.S. POPULATION U.S. POPULATION POPULATION sive( 4). My colleague, Charles Odoroff, has indicated in Tables 3, 4 and 5 the rates 1931 1260 11.2 0.9 of growth and comparisons of membership 1940 1326 18.3 1.4 of the American Psychiatric Association to 1949 1349 35.2 2.6 physician population and the national cen­ 1955 1319 52.3 4.0 sus. 1957 1324 56.9 4.3 1959 1334 62.1 4.7 In the period 1950-1960, the number of 1960 1326 64.4 4.8 psychiatric social caseworkers rose from 1962 1324 69.6 5.3 .about 3000 to 7200-far more rapidly than 14 UNIVERSITY DEPARTMENT CHAIH!-.fANSHIP [ ] Ullt' 1966 TABLE 5 Growth Characteristics of American Psychiatric Association Membership Compared to the Population of the United States f YEAR APA MEMBERSHIP AVERAGE ANNUAL GROWTH RATE PRECEDING DECADE (PERCENT) UNITED STATES POPULATION AVERAGE ANNUAL GROWTH RATE PRECEDING DECADE CORRECTED FOR APA MEMBERS PER POPULATION GROWTH MILLION POPULATION (PERCENT) II FISCAL 194c 1961 1965 1930 1,346 123,100,000 10.9 1940 2,423 6.1 132,600,000 18.3 5.3 I 1950 5,856 9.2 152,300,000 38.5 7.7 fI labor:1 1960 11,637 7.1 180,700,000 64.4 5.2 expcrii 1965 14,341 194,000,000 73.9 clinary 1970 17,700 * 4.3 * 206,000,000 t 85.9 * 2.9 * and c1 1970 19,400 ** 5.1 ** 206,000,000 t 94.2 ** 3.9 ** expans * Estimated from 5 years 1961-1965. servic(' ** .Estimated from 10 years 1956-1965. facilitit t Projected using smallest expected growth rate. univen In ti shows changes in the budget in Hochester of Mental Health. On other occasions confrn for the medical center as a whole and in have indicated that the single most impor­ league., the salary budget of the Department of tant determinant of change in the depart• istrati,, Psychiatry. mcnts of psychiatry in the United States There are separate and multiple accounts resulted from the ei1achnent of the Nation­ for research, education and clinical ser­ al Mental Health Act, passed by the 79th Some In vices ; for contractual agreements with local, Congress in 1946, which made possible the Total state and national agencies, with pri­ allocation of funds for research, teaching -----·- - - - .. vate foundations, corporations and individ­ and certain community services. Tables 7, RANK ual donors, with local and national 8, 9, 10 and 11 indicate the amount and (OUT OF 71 insurance companies. In Rochester in 1946, changes in federal funds for National In­ the Department of Psychiatry had four ac­ counts ; in 1965 there are 84. The time spent in learning about avail­ stitute of Mental Health training grants in the period 1948-1965( 6). I i able· funds for which one is eligible to PLANNING AND BUILDING I- t I apply, not to speak of preparing, defending Much time has been spent on planning. and resubmitting grant proposals, is con­ dravving, stiperv1smg, constructing and siderable. A business manager has been equipping hospital floors, clinics, emergency appointed to which much of this has been units, clay and night care facilities. Pro\'i­ SomeM::,;'. delegated but, quite properly, the major de­ sions have been made for offices, conference c:isi()11s and the ~t1l)~t;111tiy~ n1atcria.I sub~ and · interviewing rooms, patient · activity 1962 RM, · mitted come from the professional staff and centers, special electronic sound, visual. (OUT 01 the chairman. The major source of external photographic and data processing fa. fonds, of course, is the National Institute 8 cilities and for animal quarters as well as JO 15 TABLE 6 TABLE 7 23 University of Rochester Medical School and Number and Amount of Mental Health Training Grants 29 Department Budgets Awarded and Average Amount per Grant 1963 RANI TOTAL BUDGET OF DEPARTMENT OF NUMBER (OUT OF AVERAGE MEDICAL SCHOOL PSYCHIATRY FISCAL OF AMOUNT YEAR AND HOSPITAL SALARY BUDGET YEAR GRANTS TOTAL AWARDS PER GRANT 10 ---~-·-·- ·-··-····-----·----- -- -- ··-·-·-··------··- 12 1946-47 $ 4,000,000 $ 35,894 1948 62 $ 1,140,079 $18,388 18 (approx.) 1961 907 28,423,534 31,338 24 1965-66 30,265,000 1,303,083 1965 1,816 75,523,250 41,588 33 • ·~ c1955] JOHN HOMANO 15 TABLE 8 Graduate Mental Health Trainee Stipends Awarded, Average Number of Stipends per Grant and Average Amount of Stipend AVUAU NUMBER Of STIPENDS AWARDED AMOUNT OF STIPENDS AWARDED UOW1111 UU flSCAL YEAR TOTAL AVERAGE PER GRANT TOTAL AVERAGE PER STIPEND PU.CtOlttil. CO~ltltTUI 1948 219 3.5 $ 401,268 $1,832 fER POPUUTIOlre 1961 3,372 4.7 13,021,466 3,862 \f!OH (l'UtUn, 1965 7,548 5.7 32,809,595 4,347 5,3 laboratories for both animal and human has also necessitated deciphering and even­ 7.7 experimentation. It has been an extraor­ tually submitting endless forms, question­ 5.2 dinary time of expansion, both exciting naires and proposals about such buildings and enervating an<l, as is well known, the to local, state and national planning and expansion has been not only for clinical funding bodies. The significant assistance services but for educational and research of the Hill-Burton Act making possible facilities, both desperately needed in the matching funds for the building of psy­ _university hospital. chiatric services in general hospitals ante­ In turn, all of this has meant numerous dated the recently enacted provisions for other occasiom, conferences and discussions with one's col­ community mental health centers. single most leagues in other departments, with admin­ Our experience in building actually elates u1ge in the ~trative ofRc,:ers, architects and builders. It back to the late war years ( 1944-1946) , the United when plans were being made for a univer­ ncnt of the TABLE 9 sity-affiliated psychiatric service at the Jc,,v­ Some Institutions Receiving More Than $500,000 in ish Hospital in Cincinnati. From 1946 to passed by the Total Mental Health Training Awards During the 1948 in Rochester we obtained as much l 1 made possihll• Period 1948-1961 information as we could about buildings research, services. Tablt>s • RANK TOTAL before we built our own, and some of tl;e tc the amount ,uT OF 71) TRAINING INSTITUTION AWARDS most imaginative and helpful ideas came ·,ls for National 4 Yale $3,204,132 from modern hotel rather than hospital h training granh 8 Harvard 2,733,392 personnel. vVe were one of the first to use \ !• 13 Cincinnati 2,031,257 studio beds, wallpaper, individual toilets in 15 Colorado 1,958,697 rooms, combination desks and chests and 22 Rochester 1,675,213 other innovations in a psychiatric unit 1 spent on TABLE 11 constructing TABLE 1O ,:;, clinics, emergem·y Some Institutions Receiving More Than $250,000 in Some Institutions Receiving More Than $500,000 in ·are facilities. PnH, i• Mental Health Training Awards During the Mental Health Training Awards During the Years 1962 and 1963 Years 1964 and 1965 (JrofRces,conferem~ ··~·================== _,_ _____ 1ns, patient 1962 RANK TOTAL 1964 RANK TOTAL (OUT OF 40) TRAINING INSTITUTION AWARDS (OUT OF 36) TRAINING INSTITUTION AWARDS 1 onic soun<l, 8 Yale $721,834 11 Yale $964,820 10 Harvard 693,770 12 Harvard 935,046 15 Rochester 566,806 18 Rochester 767,811 7 23 Cincinnati 435,777 22 Cincinnati 713,296 ,tal Health Training Gr.tf$ti ; 29 Colorado (Medical Center) 370,670 28 Colorado (Medical Center) 604,146 Amount per Grant -================= 1963 RANK TOTAL 1965 RANK TOTAL '; (OUT Of 58) TRAINING INSTITUTION AWARDS (OUT OF 39) TRAINING INSTITUTION AWARDS AVERA.ti . -----·- --·-·----·------- AMOUWf $822,748 17 10 Yale Rochester $823,563 f AL AWARDS PER Ci!UJff 12 Harvard 795,517 18 Yale 823,387 1,, 140,079 $18,35$ 18 Rocllester 596,863 24 Cincinnati 709,979 '8,423,534 31.33.! 24 Cincinnati 506,321 26 Harvard 673,834 1 5,523,250 41.SS,i 33 Colorado (Medical Center) 438,565 29 Colorado (Medical Center) 649,758 _1_6___________l_J_N_I\_'l_.~I_,S_'I_'l_'Y_D_l'_:P_A_H_'l_'l\_1_E_N_T_C_H_A_1_H_l\_1.A_N_SI_I_ll_~_ _ _ _ _ _ __..o[J_~11H' 1966 in a university teaching hospital. \Ve made volvcd and engaged in services to our com• making the initial decision to weave the psychiatric munity. Our 24-hour emergency service }u-, in acaclcr unit intimately into the fabric of the whole grovm tremendously and currently we ha\ may find university hospital and medical center. The about 4,000 patient visits a year. A small colleagm·! alternative was to build a separate, auton­ percentage are true emergencies in the tra• generatioi omous unit. Although we met and have ditional sense. Most are social and personal ical ednc,i dealt with the inevitable issues which re­ crises requiring and responding to imrncdi• awareness sult from the introduction of psychiatric ate attention and care. This has become an matters 1 services into a traditional set previously important service to the community. It ha, talents Im without any established service, there is enhanced our teaching and research pro· it that I little question that the decision was wise. grams. It has also introduced new prob­ daily ink: \Ve have had the unusual privilege of be­ lems in terms of staffing and intcrrelatini..:: in the p11 ing within bareheaded distance of our col­ the service with our colleagues in our \i,­ rounds \\'I leagues, providing intimate interrelations ter clinical disciplines. continuirni for our students, staff, faculty and patients. door pol/~ DEPAHTMENT OHGANIZATION timately iu PATIENT CARE Departments have grown with an incr('aw years. I c~1 Earlier and separately, I considered in in their component divisions. \Ve have di\i• impressed some detail the changes which have taken sions of inpatient care, outpatient cans, edge ands place and continue to occur in the nature emergency s<Tvice, children's service, liai• I have , of the care and study of psychiatric pa­ son services ( medicine, pediatrics and oh. the modcn tients ( 16). I drew attention to the current stetrics), preventive psychiatry, stude11t again that social movement with its objectives of health, clinical and experimental psychol­ the chairrn reducing the size of public mental hospital ogy, social casc,vork, nursing service and parental g< services, of increasing general hospital ser­ education and activities program. Eada the qualit) vices and of promoting greater community has a division head to whom arc delegated becoming participation in preventive, reconstructivc proper responsibilities. Competition and ri­ timal sitmt and rehabilitative measures. I commented, valry abound for funds; for professional, would ha\·( too, upon the truly prodigious increase in technical and secretarial personnel : for The ch:i the number of psychiatric units in general space and equipment needs; for assigwd capacity f<, hospitals and of outpatient clinics and the time in the undergraduate and grad11ak obvious cii increasing attention paid to emergency ser­ curricu.la ; for research projects ; for home . his departi 1 vices, to first aid and to helping patients officer and follow assignments; for studc11I It is his r<'SJ at points of crisis. follows; and for traveffunds. to initiate. Liberalization of insurance, increasing Ivluch of this is vital, vigorous, healthy. special int( numbers of psychiatrists in the general as well as inevitable. However, at tirn1·, other, more practice of psychiatry, the very consider­ parochial and selfish interests and personal the citizen"! able successes of milieu and other psycho­ ambitions restrict one's viC\vs, leading lo which he i thcrapcntie modes, of ECT and of the use initiate, en: ~onHid, . c11vy, .. jecll()usy ,~1:1d .. r?ctty int()!('r• of psychotropic dnrgs have cohthhtffc'd lo a1ice. Frequent and regular department staff- schMI ,i changes in length of stay and in general meetings, executive councils, ad hoc and not help 1i procedures. Currently, there is need for standing intradepartmental committees. an mediately. I avalanche of memos, white papers, hhw sacrifices. "[\ I scrutiny of the operational identities of the roles of professional and paraprofessional papers ( dittoed, thcrmofaxecl and xeroxed) ulties in a groups in the study and care of the psy­ and occasional cries of alarm do not com­ federations chiatric patient. I also expressed concern pletely solve the problem of ensuring pri• Obviously ;1 that the social objectives cannot become mary loyalty to the departrnent as a wholt' grow unh·s,, exclusively service oriented and that there and sharing responsibilities for its O\Tr•all faculty for t should be a foll rneasure of support for ohjcctivcs. whole. continuing researches at basic as well as One learns that the chairman's role may EDUCATIOJ\ Al applied levels in the field. he a lonely one, not only because of th, Since the inception of this dcpartrncnt 20 incviLlhlc and rn·ccssary lo11clincss of tlw As indic;i l years ago, we have been intimately in- parental figure cutrnstccl with decision· with an inert JOHN ROMANO 17 , to ou ,- rmu­ making but also because of this moment that is, from two or three residents per year \. Sl'f\' i (:(' h.• .. in academic history. Those who follow us to 12, exclusive of liaison, child and re­ ntly ,vt-' h,tH' · may find, among their fellow chairmen, search fellows. Herc again it is important \ ear. A sm.all colleagues more informed than those of our to project this onto the changes \vhich have it·s in tlw tr.,. generation because of the changes in med­ occurred nationally. George Mixtcr of the and penon.11 ical education and because of the growing Council on Medical Education of the Amer­ 1 '..!; to izn11u"t.l1- · awareness and acquisition of knowledge of ican Medical Association and Robert Lock­ ' ; 1. s bee<> HJ(' a,. matters psychological. My interests and man of the Manpower Department of the nunitv. It h.u talents being what they are, I have seen to American Psychiatric Association have gen­ rcsea~ch pro­ it that I continue to take an active part erously submitted information about this . d nevv proh· daily in teaching, in the care of the sick and (6, 11) . 1 intcrrdatin~ in the pursuit of new knowledge. Daily Briefly and in general terms, one finds ,('S in our ~1"' rounds with students and house officers, there are four times as many programs in continuing care of the sick and an open psychiatry in 1965 ( 328) as there were in door policy have enabled me to be in­ 1927 ( 80), more than twice as many in timately involved in these matters for many 1965 (328) as there were in 1946 (155). In years. I can assure you that this has clearly terms of numbers of residencies offered, , ith an in(:n•a.~~· impressed me with the limits of our knowl­ ·there arc 13 times as many residencies \\'c ha,;c dt\l• edge and skills. offered today (4,627) as in 1928 ( 360) and :t patient (\UT, I have commented on chairmanship in about six times as many as were offered ,. service, h.o• the modern medical school( 12). :May I say in 1946 ( 758). At the present time, of the .itrics nnd oh• again that if he is to succeed, even survive, 3?.,8 programs, 86 are child programs. The ;itrv, studt·ut the chairman must have some capacity for total number of residents for the year HJG,1- ,(·11t:11 p,ydml• parental gcnerativity. That is, he must have 1965 is 3,624. This is 78 percent of the ,,1 ser\'"iC(' aml the quality of feeling rewarded ( without total number of residencies offcred-4,627. --1~)g;ram. Ead• becoming masochistic) in providing op­ There are the problems of selection. For , arc dckgat.-tl timal situations for others to do what he example, each year we have about 1.30 in­ i H'tition ~rnd ri- IVould have liked to have done himself. quiries, about 60 of these candidates arc r profession.it The chairman should also have some considered seriously by us, 40 arc inter­ , ){'rSOilllcl; f OI capacity for bipolar citizenship. His more viewed and we choose 12. · : for assig:n~·,1 obvious citizenship is as protagonist of vVe have chosen not to adopt any formal and gr.ichiah" his department in over-all school matters. or systematic type of psychologic question­ ds; for hmt\i · It is his responsibility to explain, to defend, naire for purposes of selection. \Ve do ob­ its; for ~tudc1tt to initiate, to stimulate and to support the tain information, with the candidate's special interests of his department. The knowledge and approval, about his college .;)r()llS, h(·;1hh'?, ,. other, more difficult to come by, is that of and medical school records, and internship ever. at thnr"' !he citizenship of the school as a whole in performance when available, from persons 1 s; and pcrsot.al which he may have to support, at times \~ho . ½I1?\\T ~il11 intir11~t('.ly and \Vjth \V}l()Jn \\ ~. kadin_g_ to initiate, certain ventures for th:e hc:,11.c~fif of · he has wo~-1::ed:vVe in.sfat on personal intcr­ 1 pcttv into1n · ilie school as a \vhole, even though it may vicv,'s during which time he visits us and '.1_•part;1wnt ~1~,tf not help his department directly or im­ meets with three or four senior members of !\, ad hoc uml mediately. It may even cause it to make our faculty and at least one member of the committC<'~ . •,n iacrifices. Medical faculties, like other fac- psychiatric house staff. , . papers, him· 1ilties in a university, are apt to be con- From the beginning, we have taken part d and ·xcroxe,I \ 1ederations of mo1e or less hostile states. in the Gentlemen's Agreement Plan and . 'n do not com· •)f ('nsuring pd·· Obviously a school can neither prosper nor have pledged our participation in the Hcsi­ ncnt as a whol«· p·ow unless support is obtained from its dency Matching Program which may lw for its ovcr•all faculty for the objectives of the school as a initiated in the next year. a'hole. There are problems of financial support, ; man's role m;l~ of assignment, of supervision, of evaluation, aJUCATIONAL PROGRAM: GHADUATE LEVEL of participation in ongoing or independent because of tra , )!lcliness of tJw As indicated earlier, we are now dealing researches, of providing individual thera­ with dcc:isioo., with an increase in the nurnber of residents, peutic, economic and intellectual assistance u_N_1v_E_,.1_~s_1_T_Y_D_E_P_A_H_T_M_F_,N_1_,_c_:H_A_1_n_~_1A_N_S_H_ll_'- - - - - - - ~ [ l~11w l_8_ __________ 1966 I and guidance. Pedagogic patterns, tradi­ standing and have maintained the chid munity in tionally preceptoral and apprentice-like, resident position in the third year for si,, program u have become more formal and systematic, month blocks of time on the inpatient and on what ai with an increase in the number of courses outpatient divisions, the emergency <hi• responsibili and seminars and with the increasing par­ sion and more latterly in assignments lo sity deparh ticipation of psychologists, biologists, social community psychiatry. Tbese are assign• teaching (1 scientists and statisticians as well as clin­ ments with considerable responsibility and ate) to the ical psychiatrists. with opportunity for initiative and lcadt•r, clinical ser, And what of substance, of the content of ship. edge, to the our educ·ational. program? I have chosen to \Vhilc ,ve have maintained adequate tu• ly with per.• show you the following table ( Table 12) torial and supervisory relations with om and objecti which indicates the major headings of cur­ residents, we try in many ways to pro\'idr scientists an rent research activities of the National an optimal climate both intellectually and In my vie Institute of Mental Health ( 23). emotiona11y for them to assume rcspon• department I drav.r your attention to it to point out sibility. This is particularly so in their Iating to tli that each subject mentioned satisfies cer­ signments to the teaching of medical !'>!Ii· edge and sl, tain criteria of relevance for our educa­ dents and their fellow residents. Can·ir fixed at thi.\ tional program. Obviously over the years teacher feliows and others are given man:, department the content has been expanded. It includes opportunities to learn at firsthand ha,ir university, Ii many areas not dealt with earlier in our principles of pedagogy and to gain cxperi• of the unin careers. Whether all indivicli1al departments cnce in the teaching of medical studcn!\, less in its si can expect to do justice to all of these residents and others. Our stipends hau· ceptualizati< areas and, if so, how they are to do so arc been set at U. S. Public Health Scn-h., concerned. l matters for serious consideration by all of levels. \Ve have not had the advantage, empiric. us. some vvho have added considerably to tht·,~ At the san We have attempted to avoid fragmenta­ stipends with obvious recruiting attrat• empirically tion and discontinuity in our teaching pro­ tions. useful in tli( grams. \Ve have not adopted an extended It may he of historical interest to realiu management colonial pattern of short-term assignments that professional medical education in tiw responsible. to many areas beyond the university hos­ United States provides for greater indi,id, what hash pital. vVe have tried to remain intimately ual variations from school to school th;m vclopmcnt <, involved in our teaching programs ,vith our does medical education in a number One is seci1; residents, and our senior faculty have de­ other nations. At least this is my vie\\' afti1 business sch, voted much time, thought and energy to visiting and examining a number of that is, the (', ical schools and graduate institutes in \:u, ceptor rnetlw the teaching-learning processes in our work ions parts of the world. Perhaps the fot'l basic knowk, with our residents. \Ve have also made that half of the medical schools in tht derlie that , possible an intimate exchange between res­ United States arc in part supported pri\'ah mulated cmp idents of first-, second- and third-year ly,the . . otherha]f ..through tax famds, (·on~ . \Ve do no+ tributes to a greater degree of freedom choanalytic r TABLE 12 exploring ne,v ,vays of doing things period, nor (I Research Activities of the National Institute of not necessarily being committed to a n.,. ticipatc in ;1, Mental Health, December 1964 tional stereotype. Therefore, one would the departrn, Biological factors in mental health and illness .ticipate that there will continue to he in· relevant to Ji: Drugs and the treatment of mental illness dividual variations in all phases of medic.d community, ; Psychophysiology and psychosomatic illness education, including graduate teaching and the medi( Neural mechanisms and behavior clinical psychiatry. lo no neglect Developmental factors in mental health and illness Psychological and interpersonal factors in mental health These variations will depend upon the 1u, Those mcmb( · and illness turc of the physical facilities; npon the din, invited to r, Effects of social change and cultural deprivation ical services, hoth obligatory and elccth(· ments beyond The community and its mental health resources upon the faculties recruited, their to pursue l' Surveys of mentally ill populations and treatment facilities tcllectual interests and objectives; and (Kt· been assisted 1 International research programs haps on other matters relating to the c:rim, Tandem ]) [J urn· ---------·····-·· __ ___________________________________ H966 j_;___ JOHN HOMANO HJ i ned the chief munity in which the university graduate brought with it, unlike any other discipline, -d year for six• program exists. Much would depend, too, issues of time away from university duties, 1' inpatient and on what are the basic perceptions of the need for special £nancial support, varying rnergency divi~ responsibilities of the conduct of a univer- relations and agreements with psychoan­ assignments to ,sity department in its multiple functions of alytic institutes and competing loyalties , •se are assi~n· ,teaching (both undergraduate and gradu­ with the primary university assignment. :; ponsibility and ate) to the teaching of ancillary persons, to Earlier and separately in my discussion in i ve and leader• clinical services, to pursuit of new knowl­ the proceedings of the first and second edge, to the opportunities to work intimate- Onchiota Conferences, I have considered •d adequate tu* :Jy with persons with different backgrounds past, present and future relations of univer­ 1 tions with our :and objectives such as biochemists, social sity programs with psychoanalytic insti­ \\ a ys to provi<fr scientists and mathematicians. tutes ( 14). ,tcllectually and In my view, the objectives of a university I believe it is generally understood and :tssume respon· department cannot be fixed at a point re­ accepted that in many, if not most, of the so in their as• lating to the current usefulness of knowl­ university graduate teaching programs in of medical stu· edge and skill. Certainly, it should not be clinical psychiatry at this time in our nation, •sidents. Can:er fixed at this point exclusively. Rather, the certain basic psychoanalytic ideas and no­ :trc given manr department in a professional school of the tions have been incorporated and utilized firsthand basic university, like departments in all branches in the general body subsumed by clinical to gain expcn· of the university, must constantly be rest­ psychiatry and also, I believe, in much of "'clical students. less in its search for higher levels of con­ what is called general psychology. I speak stipends ha n· ceptualization of the data with which it is of ideas of psychic determinism ; of the dy­ l Iealth Sen·itT concerned. It cannot remain content to be namic unconscious mind; of individual dif­ ", advantag<·s of empiric. ferences among persons explicable in terms dcrably to thew At the same time, it cannot give up skills, of ontogenetic growth and development: cruiting attrm:• empirically arrived at, \vhich are currently of the multiple person set; of the ideas of useful in the practical understanding and critical phases of such development ; of the i tcrcst to rcalizi· management of the sick for whom one is recent reintroduction of epigenetic con­ ducation in th,· responsible. Isn't this actually a reflection of cepts (Erikson) as determined by la\vs of ureatcr individ· IVhat has happened in the historical de­ individual development and laws of social ~o school tlurn velopment of all professional education ? organization. 11 a numlwr One is seeing this in engineering and in More controversial, I believe, is the evi­ \s my view afkr ousiness schools, perhaps in law schools­ dence for a drive-derivative hypothesis nunher of nu·d· tl1at is, the emergence from apprentice pre­ including concepts of conflict, anxiety and i nstitutcs in var· eeptor methods of instruction to search for symptom formation. Less clear, too, is the )crhaps the fad basic knowledge and techniques which un­ evidence for specificity of past life experi­ schools in tht• uerlie that which earlier had been accu­ ence in predictive terms of specific neuro­ pported pr_i~~~~t~· mul~t~der11piric:c1Jly. ses, psychosomatic illnesses and psychoses. tax funds, con­ '" We cfo not provide opportunities for psy- In this regard I believe that there is ur­ ·(' of freedom :hoanalytic training during the residency gent and imperative need for the arduous r)ing things ?eriod, nor do we permit residents to par­ collection of empiric data to support or 1rnitted to a ticipate in any professional work outside refute the inferences about human behav­ i' one would an· :he department unless the assignment is ior heretofore reached on what are limited , itinue to hC' in· relevant to his scholarship, needed by the primary data. hases of nwdi<..,il ,zommunity, approved by the department Furthermore, in the field of psychother­ :,ate teaching md the medical center as a whole and leads apy, there has been an acceptance of many :0 no neglect of his primary responsibility. of the general issues relating to human ('nd upon the m,.. fhose members of the department who are interaction, of knowledge of the affective ·" ; 11pcm the cHn· 'nvited to remain with faculty appoint­ life of the patient and his family and of the ,ry and electin· nents beyond the residency and who wish matters of transference and countertrans­ :iitcd, their in· ':o imrsue psychoanalytic training have fercnce. That there is need here, too, to ('ctives; and per· ieen assisted materially by the department. examine the effectiveness of various thera­ ding to the com· Tandem psychoanalytic training ha:: peutic approaches to patients' needs, in- r 20 UNIVERSITY DEPAHTM:::t c::~~,:~:s::,:rapeutic I Jmw J::::l:ly two eluding the approaches of formal psycho- analytic treatment, and to compare the effectiveness of various approaches with energy and money over many years h:n, skills aequind with the necessary expenditure of tin11 . J I would have u something like each other is again, in my view, urgent and not been found to be as effective as \\ .:i., JMedical Scien imperative. once hoped may contribute further to the J Over the ye I believe there is need for a more explicit decrease in numbers. 1true to our b; statement of the basic issnes which are cur- There is also evidence that in many oi fof psychiatry. rently utilized and incorporated from psy- the current university psychiatric rcsidc1K\ 'I partment of p choanalysis into the general body of clin- programs there is ample opportunity to iar biology, rn ical psychiatry. Is there a true consensus? learn basic techniques of psychotlll'rap'., I department o 1 Furthermore, there will be a need for us which have been found to be useful and 1.' lectic point ol to examine pedagogically not only the sub- stance but the methods used by us to teach others. ·what are the values of the evidence, too, that the general practiu· of psychiatry has reached a higher dcgn·t· nf l effective in the care of the sick. Thne h land to look f. from physi.cal genetics, fron supervisory or tutorial system to the young maturity in many communities, and it ii. . branches, fro psychiatrist treating his patients? \iVhat arc found hy many of the newly graduatr'\i I the use of nw the values of the small group seminar or residents to he intellectually, cmohonalh I as from our n the larger lecture hall? \Vhat are the values and financially attractive to them. ] tions as physi< of demonstrating through certain expcri- The long period of apprenticeship in J What is pi mcnts the validity of the basic issues : for psychoanalytic training may prevent yo1m:: j our work as c example, hypnosis in terms of unconscious physicians interested in clinical in\'estigath c h:iplinc our ca 1 rncntation or the collection of empirical work from engaging in such work hct,Hl¾t ·1 to apply it in observations concerning short- or long-term of the considerable demand on thl'ir tinv i i.nteraction b1 separation of children from significant par- and energy. This has made more diffic,ili families .and ( ·•.ff cntal figures? their participation as teachers and dini• I believe there is not only need for ex- cal investigators in university departnwnh •Ii EDUCATIONAL perirnents in teaching the substance of psy- and has made more hazardous their futmr •. ~IEDICAL snm choanalytic ideas and notions but also need as academicians. Furthermore, young 1wr· l A major co for experiments in the learning process of sons find more attractive the traditional \1 ~ Jover 25 yc, 11 technique. Should we remain content to of the university in its community of schnl. Ii undergra<lu,i l accept the traditional pattern of psycho- arship and in the broader market plau· oi years, we hn analytic training for those who wish to ideas. In the university there is apt to ti◄ ,lmental acti\< become psychoanalysts in terms of the cs- less of an investment in the status quo an!, Jand physioh tablished institute pattern of personal anal- of belief systems. Perhaps also there is .,. Jtion and th<' yscs of so many years' duration, of seminar greater opportunity to be stimulated h~· J)!I 1- i fellow clinic and control supervision of so many years' sons whose belief systems differ from their~ tventivc mcdi duration? Can we not experiment to learn l believe also that the psychoanal~h fs~rgery. Ne·\ ,vtmrcanhega1nedhythecandidatehoth p1·c1c,;titig_ncr\\1 ill}ess1i½ely 1:e ~r1.t·:,;p(d• 1 tional_ depa_1 in terms of substance and technique from mentalist. I have the irnpression tliat hf· - fe..c;t_ahhshcdu shorter ( that is, six months', nine months', may one day become more useful ai, ,t:1 !dnatry oftci 12 months', 13 months') participation in experimental subject. \Vise, s('asonn.! )In our prccL personal psychoanalysis together with par- skilled psychoanalytic practitioners h:n, 1work towar( · allel didactic and supervisory experiences? acquired certain types of data proC('\\ir,:: iscience of hi I believe the days of the independent in- operations which in themselves may b,- J We are a\' stitutes arc numbered. There appears to highly relevant and significant to cxaminJ Jthe whole oi he evidence that the number of applicants tion hy others. _Jhow suffici(; to these institutes is reduced. There is also \Vil] the basic design, ohjediYes ;mJ Fu~lge lcarrn some f cc Img. 1 y o f tl· 1c can- tl1a t tl· 1c qua I't opera t·ions o f• tl w trac1·1t10na · I moepcn< · 1 lrnt 1· chme ' ofI 1 . Iates luts d· 1mm1s · · · lwe.1 I t may l)C t Imt t l1c I 1 · · · · · I I1 1 iv ' cI1c psyc 1oana ytlc trammg .__ . mstitutes c 1a11~, 1f tlearncc . t -l 1e 1nen ·t principal motivation for many applicants in with serious attempts to make of them r, · Jsocial or(;ai. the past has been that of acquiring tlwr- st'arch institutes? I have questioned whdh )that \VC ] 1;, \ apcutic skills with less attention to the er or not this can take place outsick th, 1proper Jan,'.' furtherance of critical scholarship. The university scene except perhaps for 01w 1114 }of living OIT j I 21 skills acquir<'d possibly two research institutes which In our teaching, major consideration has ,,nditurc of time, would have to assume the proportions of been directed to concepts of health and many years have something like the Rockefeller Institute for disease, concepts of growth and devel­ ·; effective as v,a\ Medical Science if they wen~ to snrvivc. oprn.ent, concepts of the social matrix of ,nte further to the Over the years, we have tried to remain the .patient and his family and concepts true to our basic identity as a department basic to the idiosyncratic human interac­ ,, that in many of psychiatry. We have not become a de­ tion between patient and physician and ,·chiatric residem:y partment of psychoanalysis nor of molecu­ to the disciplined capacity for human in­ le opportunity to lar biology, nor do we intend to become a timacy basic to the physician's role. Beyond of psychotherapr department of social psychiatry. Our ec­ this, our students have ample opportunity to be useful and lectic point of view permits us to examine for intimate and responsible engagement the sick. There l\ and to look for new knowledge and skills with patients on hospital floors, in the clin­ :;cneral practice of from physical-chemical biology, including ics and emergency division and through higher degree of genetics, from psychology and its various them with social and health agencies of nnnities, and it i\ branches, from the social sciences, from the community. Each student has the op­ newly graduated the use of mechanized intelligence, as '.vell portunity to become engaged with the more r ually, emotionally as from our more traditional clinical opera­ significant and representative types of Im­ to them. tions as physicians and psychiatrists. man psychopathology in the patients as­ apprenticeship in What is primary and not derivative in signed to thern. ,nay prevent young our work as clinicians is our ability to dis­ For many years we have made provi­ linical investigatiw cipline our capacity for human intimacy and sions for summer student assignments, both ·;uch work bccamt• to apply it in obtaining the data of human research and clinical. This past summer ;and on their tirm• interaction between us, our patients, their we had 13 students, one from abroad, one 1ade more difficult families and our coworkers. from another school and 11 from our school. :cachers and clini­ EDUCATIONAL PROGRAM : UNDERGRADUATE Summer fellowships, like other student as­ \Trsity departmenti HEDICAL STUDENTS signments, carry with them problems of 'ardous their futlm• selection, fonding, supervision, special as­ •rrnore, young per, A major concern and interest of our work signments and evaluation. The nature of ;, the traditional sd over 2.5 years has been the teaching of our school permits us and our students to ommunity of schol­ undergraduate medical students, Over the know each other well. The size of the class, lcr market place of years, we have had increasing interdepart­ the setting and our traditional informality there is apt to ht· mental activity with biology, biochemistry contribute to this. Our considerable suc­ the status quo anh· and physiology, with psychology, educa­ cesses in the liaison programs between ,a ps also there is tion and the social sciences and with our us and medicine, obstetrics and more re­ e stimulated by 1wr* fellow clinical disciplines-medicine, pre­ cently with pediatrics reinforces this re­ ,is cliffer from theirs, ventive medicine, pediatrics, obstetrics and lationship. An experimental two-year in­ the psychoanalytic mrgery. New courses transcending tradi­ ternship ( 19.59-1961) \Vhich provided for ; kc ly .. be .an cxpcd• tional department boundaries have been scr:vice assignments in .. medicine, surgery, impression that lw -e~5faEiishi~d in 1.vhi.cb. fhe de1)iti=tmeiif of psy­ pediatrics, obstetrics and psychiatry also more useful as an chiatry often has played a germinal role. contributed to productive interrelationships \Vise,. seasoned. In our preclinical teaching, we continue to between the clinical disciplines ( 1.5). practitioners havr work towards the establishment of a basic My colleague, Hilliard Jason, has pre­ of data processin~ science of human biology. pared a table ( Table 13) from his study 1hernselves may lw \Ve are aware that our material is that of of our medical school graduates who arc ;ni:Rcant to examinH• the whole of living organization and we ask choosing psychiatry as a career which illus­ how sufficient for our purpose is the lan­ trates certain changes over the years. guage learned by us of the body as a ma­ ign, objectives aml Department members have been active chine, of the language of small parts li tional independent learned by microscopy, of the language of and have shared generously in the process _i~ institutes chan~t• the mental apparatus, of the language of of selection of students admitted to this to make of them rew mcial organization. vVc are keenly aware school. In our own work we have paid par­ (' questioned wheth­ that we have yet to acquire the full and ticular attention to the evaluation of stu­ c place outside tht• proper language that describes the whole dents assigned to us, particularly in the t perhaps for one or of living organization. clinical setting, and han' made many 22__________ __ U_N_IV_E_R_S_l_T_Y_D_E_P_A_H_'1_'1v_1_E_N_T_C_H_A_I_R_1'_'1A_N_Sl_I_IP_ _ _ _ _ _ _ _ [ ) ll!w 1966 TABLE 13 view wit! Survey of University of Rochester Medical School Graduates to rnaint; DECADE OF GRADUATION purpose 1929-38 1939-48 1949-58 students, CATEGORY NUMBER PERCENT NUM~ER PERCENT NUMBER PEIIU 111 have had Those taking first or first and second 276 562 673 ic COllrSl': residency have attc Those in above group taking one or other 11 3.9 31 5.5 48 u systcmati, ·in psychiatry vant and Full-time academics 18 92 131 the inn.' Full-time academics with training in 0 0 4 4.3 16 122 tempted psychiatry and quc.<.;i Part-time academics 73 160 163 afforded Part-time academics with training in 2 2.7 13 8.1 16 9.8 and to Li psychiatry Those reporting specialty practice as a 164 350 361 clinical i major professional activity tratcs th,· Those reporting psychiatry as their 9 5.5 28 8.0 34 by the rn specialty year int< 194(-3-1 I experiments using different types of exam­ ber and amount of research grants is madr 1951-J! inations. RESEARCH more understandable when one examinn, the increase in the number and armnmt of research grants made by the National In" l- 1956-1 1961-1' II '11LITAm There has been a truly amazing change stitute of Mental Health for the natio11 at in the research activities of the university large in the period 1948-1965(17, 22) (~n:· Since department. Currently in our department Table 14). \Vorl<l \ there are about 50 major and minor re­ In addition to funds from the Nation:ii COI1C(T11( search projects covering a wide array of Institute of Mental Health, we haw h;id J O.S.H.D. subject matter and using an equally great assistance principally from the Common, sultant l number of techniques. Robert Morison in wealth, Hockefeller and Ford Foundatiom, l• consult;,i his recent critique reminds us of the con­ and from individual donors, for which "r i to Vck: tributions of the Rockefeller Foundation in are most grateful. Some of this has madr coming the period before the establishment of the possible the exploratory research activitir1< f staff to National Institute of Mental Health(7). He of students and of residents. Health : points out how small the amount of money Career investigators have been supported in the attempt to create scholars and s-<·i• 1 of 1 lent 1 1: present was: cntists in the field of clinical psychiatry t draw fo . . . alittle over $16,00Q,QQQ jn 20 years for Psychiatry and related disciplines. i'ne refo.ted Considerable time is devoted to corrcdi11~ and editfr1g rn:.111tiscfif)ts; . supervisin~ thr .l service. disciplines (Neurology, Neurophysiology, Neu­ conduct of research and submitting re• l1 VISIT()Wi roanatomy, Neurochemistry and Psychology) ports. Increase in technical, secretaria·I am! absorbed nearly two-thirds of the funds. f Duri1i clerical assistance has followed, as has th,· · 74 visit, Virtually all of the research supported <luring this period was in the related disciplines and need for additional space, equipment and I came 11 not in Psychiatry per se. Help to Psychiatry, supporting funds. J for a h itself, went largely for the development of Although there have been difference, of f our ad full-time teaching departments in medical schools, with smaller portions to training fel­ lowships and some experiments in the applica­ tion of Psvchiatry as i11 mental health and child TABLE 14 National Institute of Mental Health Research Gmll :I. f service.', specifi(· includ{ · guidance ·clinics.' Emphasis in the teaching de­ partments was on bringing this specialty more fully into the mainstream of Medicine. FISCAL YEAR 1948 NUMBER Of GRANTS 38 AMOU!il $ 373.??£ .• I 'f , tionaJ l additirn a few 1 1961 1,286 30.492.~ 1 1 scholar The magnitude of the change in the num- 1965 1,770 60,176.12'; -----·-·-···--·- -•--.,--- - ----·---·--- -- --·-· .. -----·--·-·· -·-------- ,. lectl1n•' W66 i . --•··-----··--···· JOHN HO:t\JANO --------"---------------------- 23 \'icw within the department, we have tried sure and profit in being host to our visitors to maintain a fairly informal set for the is apparent; however, the time and effort purpose of research training among our of meeting, of arranging travel schedules, 194t-511 students, residents and special fellows. \Ve conferences and lectures, housing, enter­ NUMBER i>[KC~ : have had a minimum of formal systemat­ tainment and avoiding conflicts with other ic courses in research methods. Rather, we lecturers in the school at times present qnite 673 have attempted to introduce material in a a problem. 48 7J systematic fashion when it appeared rele­ vant and timely to the special pursuit of MEDICAL SCHOOL, HOSPITAL AND UNIVERSITY 131 the investigator. Above all, we have at­ SERVICE 16 12 2 tempted to establish a climate of curiosity As indicated earlier, the ferment of : and questioning in our daily ,vork and have change is apparent in all the departments 163 · afforded the young opportunities to know of the medical school and hospital. As a 16 9S and to be exposed intimately to models of department chairman, one is not only an clinical investigators. The following illus­ active member of the major policy and 361 trates the number of scientific publications operating standing committees of the school 34 9t by the members of the department at five­ and hospital but may be called upon to year intervals over the past 20 years : lead and serve on many ad hoc committees, 1946-1951 44 committees on tenure, on interdisciplinary 1951-19.56 89 studies, on faculty salary scales, on faculty .·h grants is m,1tk­ 1956-1961 130 rank and organization, on the curriculum, .r·n one cxarnin~·i,. 1961-1965 ( four years) 179 on planning and building, on bed utiliza­ · T and amount ut tion and patient care, on promotion and the National fo. UILITARY on the search for new chairmen of other for the nation .it departments. D65( 17, 22) ( M·,· Since the Draft Act of 1940, through Hegardless of how the dean's office may World \Var II and since, we have been be expanded, the department chairmen are .1 om the Nation~I concerned and involved with the military. called upon to give fully and generously of 1 ! h, we ha v<· had O.S.R.D. researches during the war, con­ sultant posts to the Army here and abroad, their time, effort and skill to the affairs of >rn the Comnuiu• the medical school and its teaching hos­ 'orcl Foun<latiom, consultant and dean's committee programs to Veterans Administration hospitals, the pitals. Similarly, the medical school has irs, for which \\(" become more intimately involved with the of this has mad•· coming and going of junior and resident university at large. Membership in the ,·esearch activiti~-~ staff to the armed forces, U. S. Public senate of the faculty, campaign fund com­ ls. Health Service and the National Institute mittee, honorary degrees committee or .'(' been supportrll of Mental Health clearly attest to this. The presidential search committee may be illus­ scholars and M-;. 'present Viet Nam crisis will undoubtedly trative of these engagements. 'i nical psych fa tr">. draw further upon us for needed military l~eprt~se11tativ(~, J90, _ _ of tbejn.crgasi11g in~ ·oted to correetit~­ 'Service; timacy and involvement of the department . supervising th,· VISITOHS of psychiatry with university departments d submitting n··· outside the medical school are our associa­ d, secretarial umJ During the past academic year we had tions with biology, psychology, the social i lowed, as has tlw 74 visitors to the department, 24 of whom ,, equipment nntl came from abroad. Most remained with us sciences, education, statistics and with the for a few days to learn something about ever-burgeoning growth of data processing ,t•cn differentT5 of ·our activities in teaching and in clinical facilities. services or were particularly interested in COMMUNITY LIAISON speciBc research programs. This did not lealth Research Gruti include about ten site visitors from the Na­ As I indicated earlier in this report, our tional Instittite of Mental Health or ten department of psychiatry, like many, has additional persons invited by us to spend traditionally been more extramural and re­ $ 373,n·t a few days in the department as visiting lated to various community services than 30,492,()!i scholars and scientists to present formal many of its fellow clinical departments. 60,176,1;} lectures and engage in seminars. The plea- For reasons outlined earlier, we anticipate 1 10(3(; 2_·4_ _ _ _ _ _ _ _ _ _ _ u_N_l\_'I_m_s_I_T_Y_D_E_P_A_H_T_M_E_·~N_'l_'_C_I_IA_I_H_~_1_A_N_S_H_n_,- - - - - - - - - - - " - - " [J_~~lll~ ( an increase in the demand from the com­ munity for direct clinical services, for con­ There is little question that more of us will be taking part in various internatiollal stud­ ' less 1t ancl sultant posts to agencies, courts, schools and for participation in community service planning. It is evident that with increasing size and complexity of communities, health ies from which cornparative data will be ob­ tained about morbidity, health services, epidemiology, treatment procedures, etc. l Regr yet l ,j cidcn f f natio service planning is no longer elective. Plan­ ning has become obligatory in order to GENEHAL HEMAHKS Thirty years ago a number of us, now in l chan,t "t-.h avoid unnecessary duplication of services this room, met in this university hospital as SC' and to establish proper regional distribution and worked together as fellow students. what of such to serve the needs of all persons. ,,Vhile we may have been drawn here for sen tat different teasons, I believe <1n important for us NATIONAL AND INTEHNATIONAL ACTIVITIES one was the opportunity for graduate study occur, My personal experiences, I believe, may in the field of clinical psychiatry in a major whic+ university department in a modern medical prope; be quite representative of my generation of department chairmen. A number of us school with the then rare support of fellow• gional have bee.n seriously engaged in national ship stipends, modest as they may seem to haps i planning for health services in our field. us in our affluent present. some Over the succeeding three decades, as studic·, The burden of our assignments has led some of us to consider ourselves an expend­ friends and as colleagues, we have touched Chain able generation in terms of our individual each other's lives through our student), Perhm scholarship. our scientific work and membership on vari­ f reprcs; ous national, scientific and professional ! McntH I had the privilege of participating in the beginnings of the National Institute of groups. ,ve have been seriously engaged in j of th, J and I\, Mental Health. In 1946 I served as a mem­ the common venture of the growth and de• ~ plan ii ber of the original Council and as chairman velopment of clinical psychiatry. More par• of the first research study section. For the ticu1arly, we have participated in the truly f future. amazing growth of the university depart· ; Can succeeding 1.5 years, I served on various National Institute of Mental Health com­ ment in its educational, clinical service and ! same r mittees, including the Career Investigator research functions. ' i years, ( Selection Committee. In addition, I have As young men, we dreamed young men'\ i the S served on various advisory groups to the dreams. I doubt, however, if any of us I stabic Ford Foundation assigned the task of allo­ dreamed, much less could have predicted. i for fm t ! cating funds for research programs in psy­ the changes \vhich have taken place, and j ogy(9) chiatry and related disciplines both here more particularly, the rate at which the l to be, ii and abroad. changes have occurred. There is sufficient f what \\ Other assignments have included service evidence, I believe, that we have been 'j be dcp, on editorial boards of scientific journals. participant observers, not spectators, of the i mand.s 1 Other . . . rne1nbers of our department. have human comedy in this middltJ third of tlw ·j we exi~;t served on National Institute of Mental century. It would i;1deed be gratifying tu i kow ha,, Health committees and have acted as site believe that our efforts contributed signifi­ J profcssi, visitors and consultants. All of this has re­ cantly to these, changes in our field. \\'e must not delude ourselves hy forgetting or t arc soci quired time, effort and study to do full jus­ tice to this truly remarkable venture of our minimizing the major political, social and i values. ~­ federal government in the field of men­ economic forces which played an impor• J role an(l 1 tal health. tant part in the over-all development of or groui A generous fellowship from the Com­ monvvcalth Fund made possible for me a mental health services in our nation. \\"c must also note that some, but not all, of 1 pendent I ing the 1' year of sabbatkaI study ( 1959-1960) in our problems appear to be the problems of • In th;, which I made comparative observations of success. like all 1 teaching, research and clinical services in I find that we may have been success• namic, iJ the United Kingdom, continental Europe, ful in some matters. However, there arr moreov( 1 the Soviet Union and the 1'1idcllc East. other matters with which we have been which it 11 ■1 I 3 Al 11 11-dlll . _____l~J,ll(' 1966 l JOHN HOMANO 2.S 1 re of us will less engaged: for example, in the study cemed with the design of the organization iational stud, and care of the chronic psychotic patient. of our university departments? ta will be ob, Regretfully, so far as I know, our efforts as Eric Trist and other social system theor­ ,, lth service\, yet have not appreciably modified the in­ ists inform us that : dures, etc, cidence or prevalence of madness in our A main problem in the study of organizational nation or elsewhere. change is that the environmental contexts in My major thesis has been to point out which organizations exist are themselves chang­ changes in department form and function ing-at an increasing rate, under the impact ,Jf us, no·w in as seen by one department chairman. If of technological change. This means that they ,·sity hospit.11 what I have seen and experienced is repre­ demand consideration for their own sake. . . . ( )W studcnh, This requires an extension of systems theory. sentative, then it may be wise and useful i.vvn here for The first steps in systems theory were taken in for us to pause and consider our future. It tn important connection vvith the analysis of internal pro­ occurs to me that many of the matters to , aduate study cesses in organisms, or organizations, which in­ which I have drawn attention could quite ry in a major volved relating parts to the whole. 1\fost of properly and profitably be discussed by re­ dcrn mcdic-:1! these problems could be dealt with througl1 gional groups of department chairmen. Per­ closed system models. The next steps were ort of fellow• haps even more appropriate would he for taken when wholes had to be related to their n-1.ay seem to some of these matters to be discussed and environments. This led to open system models, studied by the National Association of .such as that introduced by Bertalanffy, in­ decades, .a\ Chairmen of Departments of Psychiatry. volving a general transport equation. Though 1ave touched this enables exchange processes between the · Perhaps we could invite to our meetings : i 1r stu<lenh, representatives of the National Institute of organism, or organization, and elements in its ;ship on v~td· environment to be dealt with, it does not Mental Health, of residency review boards, profession.ii deal with those processes in the environment .of the American Board of Psychiatry v engaged in itself, which are the determining conditions of ,and Neurology, so that together we could Jwth and d«·· the exchanges. To analyze these, an additional ,plan intelligently and constructively for the concept-the causal texture of the environment y. !\fore par• · future. 1· in the trul} ~is needed ( 1). Can we expect continuing growth at the rsity depart• I believe v,:e could apply these notions same rate it has occurred in the past 20 l service u1al properly and usefully to a number of our years, or are we to expect a leveling off of the S curve of growth towards a more concerns, including that of psychotherapy. young mcn"i To apply these notions to our organization­ f any of u, stable form, as predicted by John Platt al problems, we would first have to ex­ ,T pre<lictnl for further changes in science and teclmol­ amine the internal system of the depart­ il place, am! ogy( 9) ? Whatever the rate may continue ment, its component part and its intcr­ , t which th,~ to be, it must be clear that what we do and clcpenclencies. It appears to me that psy­ is sufHcknt what we may become will, in great part, chiatry covers a much wider array of have bc~·u be dependent upon the nature and de­ substantive mattcrs-physicochcmical, bio­ ; a tors, of th,, mands of the social organization in which logical, medical, psychosocial--llia11 do its third of ttw we exist now and tomorrow. As David Sha­ fellow clinical disciplines, at least in their tr,ratifying to kow has said, "In the end, the functions of more traditional views. We are, perhaps, ;utecl siguifi, professions and the functions of disciplines not only more heterogeneous, but as yet we ur field. Wr· are social, and the values must be social have not resolved satisfactorily the con­ l'orgetting Of siderable dissonance among us in our basic values. Society decides what should be the social and j, belief and value systems. There remain role and function of a particular profession (r' an im1><Jf, among us both biophobes and psycho­ clopment of or group. rl11e final test, of course, is de- phobes. We should listen to the caution ol t pendent upon what the persons represent­ nation. W<' Herbert, the 17th century poet, who said, :t not all, of ing the profession have to contribute" ( 18). "\i\loe be to him who reads hut one book.'' problem~ of In the ideal world, social organization, Our internal system as a department is ·like all viable living things, must be dy­ in constant exchange with its environments. 1 ·en suc't·e1~• namic, informed, germinal, adaptive and, Our most immediate environment is our r, there un· moreover, useful to the central purpose parental home, the medical school, its have hee:u \\'hich it serves. Should we not be con- teaching hospitals and the university at 26 UNIVEHSlTY DEPAHTi\1ENT CHAIHMA:['-;SHIP ------------------------------------~ [ Jl!!!f' 1966 I large. Space and financial needs, competi­ mcnt transcending the medical school not wittingly or um\ tion for faculty and curricular time, the hospital and relating directly to the pan·Hl decisions concerning explosion of knowledge and of techniques, university, in this way facilitating workin~ adequate and proper the uncanny development of mechanized relations with many clcpai'tments in the uni• \Vhitchcacl remind intelligence-these are some of the' matters vcrsity at large? Should universities n· unlike a craft, cannol about which we are in constant exchange tablish schools or divisions for applied tornary procedures. with our, colleagues in the medical school, social studies in order to eliminate the un• search for means to < hospital and university. It appears that we necessary duplication of personnel engaged ligence in new way:• are able to reach reasonable concordance in in survey research or in ad hoc rcspon,_e, a search may help 1. that which ,vc share most commonly, name­ to emergency inquiries and studies hasrd design of our uni, 1 ly, in the teaching of undergraduate medi­ upon community needs ? ganization, appropri: cal students and in the study and care of But we must rememher ,ve have cn\'iron• purpose and to the t the sick. rncnts other than the medical school, ho,• society. \Vith other matters, in our research and pital and university. These, too, are L'm·irnn,, HEFEl in certain aspects of our teaching program, mcnts on which ,ve arc dependent and with which we are in constant exchange. I 1. Emery, F. E., and there is apt to be greater deviation among al Texture of On us. Earlier, I spoke of the very considerable speak now of the environment of the com· Human Relations ferment and change which is taking place rnunity in both local and national tm1i1. 2. Keeney, B. : ()uot throughout the medical school and hospi­ where changes arc taking place at acu·l• January 16, 186(;, tal. vVith the changes, actual and imminent, eratcd rates. The social movement allu(!t-d .'3. Kubie, L. A. : A can we ancl our colleagues chart a course to earlier will be characterized hy mort' Medicine Within safely between the exclusive extremes of a not less, demand on the lmiversity nl('diral ical School ancl l community clinical service station and of a center. Health is no longer considcrnl ,'39:476-480, 1D6,J, restricted research institute and yet drav.r privilege. It is now dcmancled as a right. 4. Lockman, H. F. ( properly on each in order to preserve our Recent laws relating to hospitalization partment, Amcri, lion) : personal primary obligation to education? procedures and Medicare are parallckd 196.S. Has the subject matter entrusted to us, new and additional insurance coverage fm ,5. \1edical Educati11 or that thrust upon us, become too broad to professional and psychiatric servic.cs in J.A.i\1.A. 194:7•1.'1 he encompassed within a clinical depart­ offices and in clinics, as well as for inpatil'nl 6. Mixter, C., fr. ( 1\ ment ? Should our preclinical teaching be care in psychiatric hospitals. The estahli\li­ cil on ivf edi~'al Ed woven into a department of behavioral sci­ ment of regional medical complexes will ical Association) : ences in order to share it more fully with certainly affect the medical school, it, 7. Morison, H. S. : 1 psychology, social science, pediatrics, pre­ teaching hospitals and its constituent clr­ Health, J. i\led. !<, ventive medicine, biology, to mention a partrnents. The burden of this last point i, 8. New Directions i\1ental Health, Bl fc,v? Should we encourage the establish­ the need for us to realize that the c11ang1, no ..3, July-Septen ment of independent departments of psy­ which are occurring in our cnviromncn!" 9. Platt, J. H. : Tli, chology and social science in the medical arc rapid and significant. In great part, tlw: 149:607-61.3, H)(j, school? Should child psychiatry be woven will determine ,vho we arc and what \\1 10. Reflections on t l 1 into the fabric of pediatrics and child may become. York Times, AugL hi~ami ?:Shmikl fliere he estal>lishec.l a r1c;w \Vith Bal'11aby Ke(~11(')', lTim· awarP ohtw Residents in Psr< department of preventive health services hazards incurred when universities turn power Bulletin '\ encompassing much of what is done now themselves into instruments of social a,. D. C. : Americ;rn in preventive medicine, epidemiology, so­ tion ( 2). In a recent address Keeney issurd 12. Homano, J. : Crn, · I\ledical Educatirn cial psychiatry, pediatric family practice a Yvarning against both cxtrcrncs-acti\'i~m HJ61. and well baby clinics, birth control and well and detachment. There is little question l,'3. Romano, J. : Cow woman clinics ? that, as participant observers of the ln1m;m the Teaching of J Has the traditional departmental organi­ comedy and as clinical activists, we art' and zation outlived its usefulness? Or should must continue to be engaged in servic(' tn we more boldly consider the establishment our communities. HowcYcr, in some man• of a school of psychological medicine as ncr or other, we must protect and contiuw proposed by Kubie ( 3) and others in the to nourish the very basic obligation of th1. past? Should the department of psychi­ university to contemporary society, to ex• atry be established as a university depart- amine objectively the issues hcfore us am! ___________ I__ Jt 1Ill' 1966] JOHN ROMANO 27 , lical school and not wittingly or unwittingly adopt a priori uate Medical Students, Perspect. BioL dy to the pan•,,: decisions concerning social reform without 1'fod. 5:.519-.526, 1962. i1itating workim~ adequate and proper study. 14. Homano, J. : in Proceedings of the Confer­ mcnts in the uni• Whitehead reminds us that a profession, ence on Integration of Psychoanalysis with Universities and/or Medical Schools, On­ universities e,­ unlike a craft, cannot be satisfied with cus­ chiota Conference Center, February 1961 ·>ns for applied tomary procedures. \Ve must constantly and June 1962. ·liminatc tlH· un• search for means to organize and use intel-: 15. 7 Romano, J.: Study of Two-) ear Rotating . rsonnel cngag,·d ligence in new ways(25). Hopefully, such Internship, J.A.M.A. 189:283-289, 1964. .d hoc n•spon,t·i a search may help us to take part in the 16. Romano, J. : Psychiatry, the University, ,id studies ha~t'd design of our university department or­ and the Community, Arch. Gen. Psychiat. ganization, appropriate and useful to our 1,3:395-402, 1965. 1.n~ have cm·inm• purpose and to the changing needs of our 17. Sapir, P. ( Chief, Research Grants and Fel­ ,ica] school, ho,., society. lowships Branch, NIMH) : personal com­ munication. too are environ· REFERENCES 18. Shakow, D. : Quoted in Kaufman, M. H., de{)endcnt aml 1. Emery, F. E., and Trist, E. L. : The Caus­ ed. : The Psychiatric Unit in a General tant exchange. I Hospital. New York : International Univer­ al Texture of Organization Environment, icnt of the ccm~· Human Relations 18:21-.32, 1965. sities Press, 1965, p. 102. l national term, 2. Keeney, B. : Quoted in New York Times, 19. U. S. Dept. of Health, Education and Wel­ place at acn•J. January 16, 1966. fare : National Institute of Mental Health , ,,cnwnt alluded 3. Kubie, L. A. : A School of -Psychological Training Grant Program Fiscal Years 1948- 'rized hy 1non\ Medicine \Vithin a Framework of a !\fod­ 1961, Public Health Service Publication , i vcrsity rncdie,ll ical School and University, J. Med. Educ. No. 966. 20. U. S. Dept. of Health, Education and Wel­ er considC'red *' .39:476-480, 1964. 4. Lockman, H. F. ( Director, J\fanpower De­ fare : National Institute of Mental Health li•d as a right. partment, American Psychiatric Associa­ Training Grant Program Fiscal Year 1962, ) hospitalization Public Health Service Publication No. tion) : personal communication, October :re paralleled hy 1965. 1075. ,ice coverage for 5. rvfedical Education in the United States, 21. U. S. Dept. of liealt-h, Education and Wel­ i ric services iu J.A.M.A. 194:74.3-752, 196.S. fare: National Institute of Mental Health ! l as for inpatient 6. J\1ixter, G., Jr. ( Assistant Secretary, Coun­ Training Grant Program Fiscal Year 19G.3, !s. The establish• cil on Medical Education, American Med­ Public Health Service Publication 'i\o. complexes will ical Association) : personal communication. 1272. lical school, ih 7. Morison, R. S. : Some Illnesses of Mental 22. U. S. Dept. of Health, Education and Wel­ Health, J. Med. Educ..39:985-999, 1964. fare : A Summary of the Research · Grant constituent ck• 8. New Directions Towards Communitv Program of the National Institute of ~1en­ this last point i, i hat the change,. Mental Health, Blue Cross Reports, vol. II, tal Health, 1948-19CH. Bethesda, !\Id. : no. 3, July-September 1964. National Institute of Mental Health, March ·, ir environnwnt.;; 1, 1962. 9. Platt, J. H. : The Step to Man, Science , , great part, tlwy 149:607-613, 1965. 2,3. U. S. Dept. of Health, Education and Wel­ 1c and what vn 1 10. Reflections on the Age of Change, New fare : Research Activities of the National York Timef;, Augu:;t 5, 1065. Institute uf Mental Health, Uecember, am aware of tfw 11. Residents in Psychiatry, Psychiatric ~fan­ 1964, Public Health Service Publication miversitics tum power Bu11etin No. 7, 1965. \Vashington, No. 1291. ,ts of social ac· D. C. : American Psychiatric Assn., 196.5. 24. Van Matre, H. M. : personal communica­ <s Keeney issued l2. Homano, J. : Comparative Observations of tion on National Institute of Mental Health Medical Education, J.A.}.1.A. 178:741-747, training grant programs for fiscal vears trcmcs-acti\·bm 1961. HW4 and 196.5. . •; little question 13. Homano, J. : Comparative Observations on 25. \Vhitehead, A. N. : Adventures of Ideas. ·rs of the lrnniau the Teaching of Psychiatry to Undergrad- London : Pelican Books, 1948 . . \·ists, we are and :eel in servin' to ,·. in some maH· {'d and continur ·)hligation of tiw society, to c,> ·.s; before us and REQUIEM OR REVEILLE: PSYCHIATRY'S CHOICE John Romano, MD Distinguished University Professor of Psychiatry University of Rochester School of Medicine & Dentistry Strong Memorial Hospital Rochester, New York 14642 Read in part as the Thomas William Salmon Lecture The Salmon Committee on Psychiatry and Mental Hygiene The New York Academy of Medicine 2 East 103rd Street New York, N. Y. 10029 Thursday, December 2, 1976 1 INTRODUCTION What follows is selective history, the hazard of which was made clear some years ago in reading this note from the Times of London: Then there was a schoolmaster setting essays on Alfred the Great. 11 He urged upon his pupils no mention of the cake-burning episode as being irrelevant to the main thread of our rough island story. The resultant offerings included one which ran: Alfred fought a big battle against the Danes. He lost. He then ran into a wood, where he found a woman living in a hut. He went inside. What went on afterwards, I 1 m not to mention. 11 It is said that we are dead, or at least dying, and that our days are past. Faulkner told us that the past is never dead, that it isn't even past. But what may be pa.st or passing is the more limited professional role which we served earlier in the century. We are more nmnerous, more diverse in function, and are called upon by our society to serve many needs, for some of which we are not prepared. It is said that we deal with myths, that mental disorders are myths imposed and nourished by a harsh society. Obviously, one of the most human of our characteristics is that of variability, and even within reasonably homogeneous groups, there may be a wide distribution of behavior patterns. Yet, within each group certain patterns emerge which are interpreted and identi­ fied by the members of the group as illnesses. Jane Murphy 1 s recent report, in which she presents systematic data from Eskimo and Yoruba groups and infor­ mation from several other cultural areas, calls the labeling theory into q_uestion. She concludes: nRather than being simply violations of the social norms of particular groups, as labeling theories suggest, symptoms of mental illness are manifestations of a type of affliction shared by virtually all (1) mankind." But of course there are myths. There have always been and probably always will be myths about health and sickness, and for obvious reasons particularly about mental illness. How many in this, our age of enlightenment, could have predicted the popular interest in 11 The Exorcist 11 and its sanction by the clergy'? 2 There is one matter which I do believe is more substance than shadow. It is the concern of the modern psychiatrist about his professional role. This concern is clearly illustrated by the following selection of titles and comments taken from papers recently published in our professional jou;rnals: Heaven protect the patient from any therapist who has a political position and a single form of treatment. Psychiatric therapy often reflects the bias of the therapist and not the needs of the patient. We have lost our boundaries. We are over-regulated and over-managed. There is an anti-intellectual movement promoting craftsmanship at the cost of scholarship through truncating the undergraduate medical curriculum, eliminating the internship, and reducing the residency. Somebody has· to put the whole person together again. Psychiatrists are found deficient in knowledge of psychotropic drugs. There is a false egalitarianism obscuring and den;ying the differences in education, knowledge, skill, and responsibility between professionals and paraprofessionals in the interdisciplinary care of psychiatric patients. Psychiatrists see their specialty returning to the mainstream of medicine. The law doesn't trust psychiatry. Patients are dying with their rights on • .A.re you a psychiatrist or a real doctor? Is liaison psychiatry the answer to medical dualism? The death of psychiatry. The life of psychiatry. Muddled models. Labeling effects in psychiatric hospitalization. The psychotherapy jungle--a guide for the perplexed. Breaking through the boarding house blues. Social policy in mental illness. Shopping for the right therapy. 3 Is psychiatry a white middle-class invention? It's all in your head. The future of psychoanalysis and its institutes. The great megavitamin flap. Much of what has been cited touches on the professional role of the psychiatrist. To obtain a more immediate sampling, I asked sixty of rrry psychiatric colleagues, together with twelve psychologists, social workers, social scientists, and biologists, to list for me the three most urgent problems they believe confront the psychiatric profession at this time. Here, as in the list of titles read, the central and pervasive concern of the psychiatric group, in con­ trast to the non-psychiatrists, was the definition of their professional role. These psychiatrists, full-time, part-time, hospital and office practice, town 11 and gown, junior and senior, would ask, ~1ho am I? What is the knowledge, which are the skills I shall need in my professional work? Who are to be my patients, and with whom do I share the responsibility for the care of the sick?" Many also sought clarification of their professional role, not only within the medical profession, for example, 11 Am I a real doctor?", but also within the mental health team (psychologist, social worker, nurse, social scientist, mental health coun.selor, and others), nWhat is it I do, and what is it the others do? 11 No one has described our predicament more succinctly than our esteemed colleague, Leon Eisenberg, who said, nDoes psychiatry have a future as a medical specialty? ••• There are those who argue that mental disorders are simply forms of social deviance and that psychiatry- is nothing more than a covert penal system, designed to maintain law and order. Others contend that mental ailments are problems of living and that people from his neighborhood are better able to treat the patient than doctors distant from him in status, education, and social class. Psycholo­ gists tell us that psychiatrists study medicine, which they do not practice, and (2) practice psychology, which they have not studied.n 4 Whether our concerns are different in kind or in number from those of our predecessors in other times and in other places, will be determined eventually by tomorrow's historians. Silas Weir Mitchell's critique of the psychiatric profession in 1894 pointed to some of the deficiencies in the study and care of institutionalized patients at that time. While certain matters of which he spoke are still relevant in our day, we live in a different time and have, for the most part, quite different problems. Several of our colleagues have commented that identity confusion has been recognized as a problem to psychiatrists at.least since World War II, if not before, and there is similar i confusion in the psychiatric professions of other nations. It is said that each generation is apt to over-estimate its contribution to its society, and perhaps for the same reasons over-estimate the seriousness of its problems. But what has happened to us? Is our concern appropriate? What has con­ tributed to this confusion about our professional role? It seems unlikely that whatever confusion we may have could be due, certainly not to any serious degree, to the inherent ambiguities of our material, human nature in distress. There is, as yet, no satisfactory unitary concept which encompasses human behavior in biologic, psychologic, and social terms. We have yet to acquire the full and proper language that deals with the whole of man in his society. We have with­ drawn into secluded apartments in the Tower of Babel and at times speak to each other only in tongues. But this has been so since the beginning, and I would expect it to be so for some time to come. Our colleagues in medicine and not surgery are less concerned with this matter as they are/with the seemingly infinite variations of human behavior in manners and morals. Thus, lmlike most of our medical colleagues, we carry a heavier burden of doubt, of conceptual uncertainty, of ambiguity. More likely, I believe that whatever confusion we have has been determined by certain changes in the aims, scope, and operations of our professional work. 5 These changes are not only of considerable magnitude, but have occurred at an unprecedented rate of change in these past thirty years. As we are intimately intertwined in the society in which we exist and in which we serve, the changes which have occurred in our field and in all of medicine are obviously part of a larger fabric. It is claimed that more basic and far-reaching changes have (3) occurred in the middle third of our century than in the 300 years preceding it. The Great Depression, the Second World War, Korea, Vietnam, the rise of new nations, the struggle for power, the spread of affluence, the technological revolutions in making and building and distributing, the increase in world population, the explosion of knowledge, the serious attempts to insure full measure of civil rights and living opportunities for all of our citizens-- these and others have significantly and materially affected our way of life. In addition, in the past decade of discord and discontent, we have witnessed a movement toward unreason and mysticism which appears to be nourished in an ambience of mistrust of authority figures and of the establishment. One is aware of this in attitudes towards government, the law, the church, and education, as well as towards medicine. That the best educated and most sophis­ ticated generation of young Americans in history should be seriously interested in astrology, palmistry, numerology, even witchcraft, is certainly an enigma, 11 a major paradox, of our time. It is as if Shaw's caution, Every profession is a conspiracy against society, 11 has been taken quite seriously. But there is little question that in the long run it is society which determines the professions it chooses to serve it. I am aware that change is not always for the better, and that in my lifetime several developments, for example, the psychopathic hospital and the general hospital psychiatric unit, as well as the psychoanalytic movement, have not fulfilled our expectations. We have awakened to a number of false dawns, but there is little question that change has certainly influenced our present professional status. 6 I have chosen to consider those changes relating to the remarkable increase in our number; to the changing character of the psychiatric patient, together with the exponential expansion of psychotherapeutic modes; to our renewed interest in the study, care, and treatment of the psychotic patient; and to the beginning development of scientific research. INCREASE IN NUMBER OF PSYCHIATRISTS Again, to point out how intimately we are woven into the fabric of our society, I believe the National Mental Health Law, passed by our 79th Congress in 1946, was perhaps the single most influential factor in producing change. The law made possible generous financial support, both for education and for research. Certainly, the law had immense influence in effecting the greatest change in our profession, namely, the increase in our number. In 1934, when I began my resident training in psychiatry at Yale, the total membership of the American Psychiatric Association was 1604. In 1939, when I assumed my first faculty appointment as an instructor at Harvard, it was 2235. It was 2913 when I went to Cincinnati in 1942 to chair the department, and 4010 in 1946, when I came to Rochester. Bertram Brown recently has updated the figures and states that today there are 27,000 psychiatrists in the United States, which must include those who are not members of the APA. Further, he estimates that by 1980, there will be 30,000. Brown estimated that the United States (4) has between 1/4 and 1/3 of the world's psychiatrists. If this is so, there must have been a comparable increase in psychiatrists in many- other nations. Thus, in my professional lifetime there has been, in the United States, an increase of psychiatrists from less than 2 per 100,000 of population, to currently about 12 per 100,000, and Brown predicts 17.8 per 100,000 by 1980. All of this is quite dry stick unless one has lived and worked and been accou.ritable during the entire period. I grew up in Milwaukee and went to medical school at .Marquette, finishing in 1933. With the exception of one psychiatrist in ,the Child Guidance Clinic and two psychiatrists engaged 7 principally in forensic work, the only other psychiatrists to be found were in two small private psychiatric hospitals and two large county mental hospitals, the total number of psychiatrists being less than eight for the urban population, about 400,000. Today there are 94 who serve the same area with only doubling the population. Similar growths took place in Cincinnati and in Rochester. Neurotic patients, when identified and respected as such, were seen and cared for by general practitioners, internists, and neurologists. I have no idea how often the alienist saw court cases, nor how many children were seen in the guidance clinic. Psychotic patients, when identified, were sent to psychiatric hospitals. And so, unlike 40 years ago, when the few psychiatrists who did exist served almost exclusively in public and private mental hospitals, today's psychiatrists are found principally in community, private, and group practices, in clinics and general hospital settings, including those for children and adolescents, in schools, courts, and agencies, on the faculties of.our medical schools, schools of social work, and at the NIMH. The principal areas of neglect remain those of the continuing care of the chronic psychotic patient, the alcoholic, the drug addict, the criminal, the retarded, the aged-­ particularly when they are poor and/or black. The profession has become a house of many mansions, with considerable diversity among us as to whom we see and care for, what methods we use, and what beliefs underlie our practices. Small wonder, then, that increasing numbers of patients are seen, estimated to be about five million, more than 2.5% of the population. But the story of this extraordinary increase is incomplete without mentioning the parallel increase in the numbers of our professional colleagues in the mental health field as well as a growing cadre of paraprofessional counselors. This, too, is in marked contrast with my experience as a resident 8 when psychology and social work were represented by a fe-w· valiant souls who served principally as handmaidens. Nurses there were, and I learned much from them, and there were attendants in the large public hospitals. But now there are considerable numbers of psychologists, social workers, nurses, nurse­ clinicians, nursing assistants, mental health counselors, and still others, who take part with the psychiatrist in the care of his patient, not only on the inpatient services but in outpatient and office practices and in neighbor­ hood outposts. Many assume duties initially fulfilled exclusively by psychi~trists. Obviously, there is confusion about this, and much of it stems from the lack of clear definitions of the roles of the non-medical professional and paraprofessional persons who are engaged in interdisciplinar"J involvements with psychiatric physicians. In this we are not alone. In October 1975 it is alleged an ecumenical service was held in London by the Royal College of Psychiatrists, the Royal College of General Practitioners, the Association of Directors of Social Services, and the Department of Health and Social Security. The order of service was initiated by a reading from the Old Testament: "In the Beginning, God made a psychiatric service and the psychiatrist ruled therein. And Lo~ a psychiatric social worker was fashioned even from the psychiatrist's ovm rib. And they lived and worked happily together. Then there came a serpent and said to the woman: 1 ·w1ierefore dost thou slave for this man? Social work should be generic. Behold, I bring thee a report which, if thou readest, will give thee greater wisdom and better conditions of service.' A.nd the woman did read and straightway she ran away to join others of her kind, Welfare workers, and Child workers, and Blind workers, and Old People's workers, each after her own kind. Then the psychiatrist was wroth and rent his raiment, and would not be comforted, except by a College.!! (5) And the confusion extends beyond the members of' the mental health team. If you listen carefully, you may hear a chorus of voices, often plaintive, some­ 11 times :petulant, but quite persistent, Who is my doctor? 11 THE PATIENT PJT.D PSYCHOTH.2RAYi Who is our patient? What do we understand to be the nature of his distress? Is his trouble to be considered disease or discontent'? What can we do to help him'? These are not trivial questions. The Parsonian model of the sick role, designed for those who are acutely physically ill, is not useful when applied to the psychiatric patient, or, for (6) that matter, to patients with chronic illness. .Most studies indicate that the extent of societal agreement about admission to the sick role decreases as the social and psychological aspects of the condition increase. Obvious differ­ ences include the notions of individual responsibility for incapacity; the hazard, as well as the reward, for seeking technical professional help; the dependent-passive-submissive vs. independent-active-self-directed interactions (7) with the professional person. In our lifetime the physically sick model has been applied to two great public mental health scourges, now happily reduced, if not eliminated, namely the psychoses associated with neurosyphilis and with pellagra. The traditional sick model is also applied without much difficulty to the organic psychoses, as these may be determined by genetic factors, infection, trauma, neoplasm, metabolic disorder, aging, etc., and more recently, because of the vigorous interest in genetics and neurochemistry and the successful use of the psychotropic drugs and other biochemical agents, greater emphasis is given to biological factors in explaining the onset, course, and treatment of the schizophrenic patient, the manic-depressive, and to many other forms of affective disorder. There has also been a more critical view of the exclusively psychological explanation of certain of the neuroses, including the historical paradigm of (8) hysteria. In our modern day the principal thrust of the theory of psycho- logical motivation emerged from Freud's study of neurotic patients, which draws attention to the conflict of competing needs and drives for expression 9r compromise solution of these needs. The counter theory, more traditional 10 "',:i th medicine, is the neurobiological concept 1·,hich attempts to explain behavior in terms of deficit, impaired capacities, release or loss of controlled behavior, and the lowering of the orga.YJ.izational level. Each has had its past in the mists of antig_uity. We can find allegations that disease or sickness may be related to fear, to shame, to guilt, or to feelings of having done wrong; on the other hand, we can trace our neurobiological concept of brain pathology back at least to Hippocrates. On other occasions I have drawn atten­ tion to the uniquely significant impact of psychoanalysis on American (as contrasted with European) psychiatry, which, in turn, led to a wider polarization (9) of belief systems among us, as compared with our European colleagues. We have championed the psychosocial model at times to the detriment of the genetic biological model of behavior, and it has led us quite predictably to respond to a considerably broader repertory of persons in distress. Many engaged in private psychotherapeutic practices were concerned principally with neurotic middle-class patients; however, the nature of the neurotic distress treated changed from that of symptom distress--that is, symptom neurosis--to that of character neurosis. And this, in turn again quite naturally expanded to responding to the needs of those who are unhappy, troubled, alienated, lonely, and afflicted with the malaise and anomie of our time. Small wonder, then, that we have wandered far from our original aim, the art of treating mental disorders. Now we are concerned not only with the relief of distress, but with the achievement of positive mental health, and so the range of problems has expanded. Psychotherapy, as it was influenced by psychoanalytic psychology, was most concerned with the internal unconscious conflicts of the individual, but now it attempts to change or modify inter­ personal, family, and other social systems in which the patient is a member. Our students at times appear to be puzzled about the psychiatrist having been Mr. Inside and now as beiri..g Mr. Outside. In my professional life, believing ' that man 1 s problems have always been inside and outside, I am somewhat dismayed 11 at the exclusive commitment of some of our colleagues to one pole or to the other. I say, a plague on both their houses. There is little question in rrry mind that dynamic psychotherapy, as influenced by psychoanalytic psychology, has had a tremendous humanizing i~luence on all of Medicine. It has helped inestimably in understanding each other and our patients and has made possible a beginning systematic approach to the study of the interaction between patient and physician. Our increasing concern with the human family, as well as the human community, has also added immeasurably to our understanding of the human condition. Psychotherapy, formerly the province of psychiatrists and psychoanalysts, now includes the clinical psychologist, social worker, nurse, clergyman, and a large group of paraprofessionals. There a.re also former patients whose credentials as psychotherapists are that they have experienced the distress similar to that experienced by those for whom they care, particularly drug abusers, alcoholics, delinquents, and criminals. We are told that at the moment there are 130 different psychotherapeutic modes. Parloff, in a splendid popular presentation, has classified the four major schools: (1) analytically­ oriented therapy; (2) behavior therapy; (3) humanistic therapy; and (4) trans­ personal therapy. Others may be classified as pantheoretical, like many group and community-oriented therapies, and still others, defy classification, (10) such as primal therapy. The first two of the major schools, namely, analytically-oriented therapy and behavior therapy, hardly need explanation. The humanistic therapy is represented by a broad spectrum of self-actualizing techniques. The transpersonalists a.re not content with the aims of self-actualization. Their goal is to transcend the limits of ordinary waking consciousness and to become at one with the universe. I did not realize how extensively certain of 12 these methods were used until I read a report in the New York Times on 18 November, 1976, which reported in brief the results of a recent Gallup Poll. A sampling of 1553 adults, 18 or older, in the period from August 27-30, 1976, were given a card with the listing of various disciplines, were asked, "Which, if any, of these are you involved in, or do you practice?" The list included mysticism, Oriental religions, Yoga, Transcendental Meditation, and the Charismatic renewal, a Christian movement that emphasizes the 11 gifts 11 of the spirit, such as healing, and "speaking in tongues." Transcendental Medi­ tation registered the greatest following, 4% of those sampled, or an estimated six million of the general population. Next was Yoga, which gained 3% response or a projected total of five million. Both the Charismatic renewal and mysticism gained 2°/o of the responses, an estimated three million apiece. One per cent of the sample, or a projected total of two million, indicated an association with Eastern religions. The report indicated that those who practiced Transcendental Meditation and Yoga tended to be young adults, 18-24, those in college, or who are generally non-religious in the traditional sense. 11 These findings are attributed to two social trends, ••• one is the apparent desire by many Americans to find ways of calming the tensions of modern life, the other is that the new wave represents a revolt against the scientific (11) rationalistic view that has created a profoundly secular climate." Obviously, today's psychiatrist is not the only professional, paraprofessional, or lay person engaged in these matters. But there is little question that there have been considerable changes in the aims, the scope, the population served, of patients today as compared with 30-40 years ago. Most of us would accept the evidence that almost all forms of psychotherapy are effective, with about two-thirds of their non-psychotic patients, that is, regardless of method, and that those patients who are treated do show more improvement in mood, thought, and behavior than do comparable samples of untreated patients. 13 It is said that behavior modification appears to be particularly useful in some specific types of phobias; there is, as yet, no convincing evidence of the relief from biofeedback, and I know of no critical studies of the effectiveness of the many humanistic and trans personal therapeutic modes. With the increase in our numbers and the parallel increase in nonmedical and paraprofessional groups, and with the increasing breadth of human problems brought to our attention, it is not surprising that there is confusion about the designation of those who seek help. Traditionally, in the medical sense, it is the patient, he who suffers. But, increasingly, those who come for help, regardless of to whom they go, are also called client, a term which initially meant a dependent, and customarily used by those who are served by a social agency or one who consults a legal advisor. And when one considers some of the objectives of the tr ans personalists and the humanists, one wonders whether those who seek such help should be called penitents. There is so much more for us, as psychiatrists, to learn about this incredibly important and influential phenomenon--that which takes place between the patient (he who suffers)and the physician (he who wishes to heal). It has been the thread of continuity, the means of survival, of the physician through the centuries, regardless of how informed or uninformed, how helpful or harmful he has been to those who have sought his aid.• Perhaps Jerome F-~ank is right in proposing that the following 6 features (12) are common to all psychotherapies: 1. "An intense emotionally-charged confiding relationship with a helping person, often with the participation of a group. 2. A rationale or myth, which includes an explanation of the cause of the patient's distress and a method for relieving it. 3. Provision of new information concerning the nature and sources of the patient's problems, and possible alternative ways of dealing with them. 14 4. Strengthening the patient 1 s ex.pectations of help through the personal qualities of the therapist, enhanced by his status in society and the setting in which he works. 5. Provision of success experiences which further heighten the patient's hopes and also enhance his sense of mastery, inter­ personal competence, or capability. 6. The sixth shared feature of all psychotherapies in facilitation of emotional arousal, which seems to be a prerequisite to attitudinal and behavioral changes." Obviously, one of the major areas of unfinished business is the search for that which is basic and essential to the psychotherapeutic encounter. Psychiatrists, with their colleagues in psychology, biology, and the social sciences, must pursue with increasing vigor those studies which one day may enable us to act less blindly and to prescribe the appropriate method to help our patients. PSYCHOTIC PATIENT Certainly one of the more dramatic changes in the past 30 years has been the renewed interest in the care and treatment of the psychotic patient. Our professional journal reports attest to the reduction of the resident state and county mental hospital populations, the decline in average length of stay per patient, and the shift towards care in the psychiatric units of the general hospitaJ. and beyond, to the OPD and to the office. Undoubtedly there were several determinants, but most of us would agree that the changes stemmed principally from the introduction of the psychotropic drugs and the re-emergence f'rom the past of the moral treatment of our mad. While we are aware of the limitations of each of these factors, it is a remarkable change from my salad days, when we were involved in the psychiatric hospitals of our day with long­ stay patients. We used to the full the therapeutic enthusiasms of our day, with dauerschlaf and insulin, with pentavelent arsenicals and the Kettering hypertherm. We used chloral and bromides and the barbiturates as wisely as we knew how, and we practiced the various ty-pes of insight and supportive psycho­ therapies known to us at that time. Sulpha had just arrived, penicillin was yet to come, and we would wait twenty years before chlorpromazine was available. 15 Later in our stay, metrazol was used and ECT was on the horizon. We seer:ied to have had an endless number of acutely disturbed patients, and we would respond to their emergency needs, together with our nurses and attendants, with the gusto of seasoned firehorses. We did initiate certain limited commu...11ity services; for example, we helped to establish outpost clinics in western Colorado for purposes of triage, diagnostic study, first aid treatment, and referral. Although the psychotropic drugs have altered materially the course and recurrence of psychotic episodes, they are, in themselves, no full solution to madness and often cause toxic reactions even when prescribed appropriately. As for the community mental health movement, I look upon it in principle as a vanguard movement of what will be taking place in all of Medicine. It reflects our increasing concern ·with the delivery of health services, with the aware­ ness of our current deficiencies in the continuity of care of our patients, and with the pervasive problems of the much-neglected chronically ill patient. Regrettably, the initial phases of this movement were launched without adequate systematic experiment and trial. As a result, many chronic psychotic patients, long institutionalized, with either absent or long-lost social skills, were catapulted into the community without adequate means for their care. Chronic illness is another non-myth. It cannot be removed by sweeping it under the rug of ill-prepared community facilities. While these two movements, in concert, have brought about the dramatic change in the care of the psychotic patient, they have, in themselves, also led to quite divergent goals. The introduction of the drugs and their daily use by the practicing psychiatrist has returned the psychiatrist to his biological heritage and has drawn attention to the neurobiological model as well as the motivational model, as a determinant of illness. It has led to a more balanced view of psycho­ pathology, explicable not only in terms of the paradigm of psychologic conflict, 16 but also that of deficit. The daily use of medication has required physical as well as psychological screening of patients, and the psychiatrist has had to become familiar with certain laboratory methods to help him gauge drug dosage and to avoid complications. This trend has been called neo-Kraepelinian, with its serious consideration of genetic factors, greater precision in noting signs and symptoms of disease, •by the charting of the natural course of illness, and by follow-up studies of the effects of intervention on prognosis. In short, the psychiatrist is returning to being a doctor. But, alas, in all of this our o~m colleagues on the American Board of Psychiatry and Neurology decided in 1970 to eliminate the one-year internship requirement for certification in psychiatry and neurology. For those of us who have devoted the major portion of our professional lives to strengthening the relations between psychiatry and medicine, this decision (13) was considered regressive. I am heartened to learn that there are movements to correct this error in judgment, at least in part. But, the community health movement has pointed in another direction. It has led some to insist that our major objectives must be those of primary prevention, that is, for the psychiatrist to become informed and socially and politically active in reducing poverty, population, racial discrimination, and in improving education, employment, and housing. This is a major departure from our traditional engagement with the individual patient. It points towards a collective public health-social engineering role for the psychiatrist and I believe makes demands of him which he cannot fulfill because of his lack of expertness in social and political science. Regrettably, this is clearly illustrated in several instances of our bmnbling political intervention in community mental health ventures. From an educational point of view, I believe it is this dilemma which causes the most confusion in our young residents. We have, as yet, no clear-cut definitions of the public health, social, and political roles to guide us in the preparation of those who may assume these new responsibilities. 17 And it is i:1 this regard that ·we have erred in promising not one, r:iany rose gardens in responding to society's insistent demands that we cio something to reduce crime, delinquency, drug abuse, and alcoholism. RESEARCH And now, a word about the growth of research in our field. With Lewis Thomas, I believe the most urgent problem of the day is to insure the continued and vigorous support of research in all the fields relevant to our professional (14) work. With him, I also believe that one must support particularly those inquiries that may lead to basic or fundamental knowledge, and not only to those which may have immediate applicability for personal and social change. vie must insure fellowship support and adequate facilities for the pursuit of new fu--}OW- ledge, including that which may seem useless at the moment. We must remember that we have just begun. Sigerist reminded us that the physician was a priest in Babylonia, a craftsman in Ancient Greece, a cleric in the early and a scholar in the later Middle Ages. He became a scientist with the rise of the natural sciences barely a century ago. We are just at the beginning. During my- intern, resident, and fellowship assignments in New Haven, Denver, and Boston there was no formal investigative work taking place, although several of us did become involved in clinical case histories and follow-up studies. In fact, there were few models of scientific investigators available to us. At that time psychiatry had no Rockefeller Institute to help groom its young professors, as was the case in medicine and psysiology. We had to wait aJ..Jnost fifteen years before Nil'1H became a reality. Our models were the clinician­ teacher-scholar and later the psychoanalytic psychotherapist-practitioner. It was not until the early 50's that the Career Investigator Fellowship Program was established, with the hope of several of us that a new model of psychiatrist­ scientific investigator would be created and fostered. 18 Robert Morison, more than a decade ago, in his critique of our field, reminded us of the contributions of the Rockefeller Foundation in the period before the establisrm1ent of the National Institute of Mental Health. He points out how small the amo'Jllt of money was: " •.• a little over $16,000,000 in twenty years for Psychiatry and related disciplines. The related disciplines (Neurology, Neuro­ physiology, Neuroanatomy, Neurochemistry, and Psychology) absorbed nearly two-thirds of the fu..-ri~s. Virtually all of the research supported during this period was in the related disciplines and not in Psychiatry per se. Help to Psychiatry, itself, went largely for the development of full-time teaching departments in medical schools, with smaller portions to training fellowships and some experiments in the application of Psychiatr'IJ as in mental health and child guidance clinics. Emphasis in the teaching departments was on bringing this specialty more fully into the mainstream of Medicine." (15) More recently, Brown summarized a two-year report of the Research Task Force that involved three hundred people and one million dollars to review one billion dollars worth of research in the United States, supported by NLvlli and others. The number of research projects supported annually by Nil,IH has grown from 38, in 1948, when the first appropriations were made under the National Mental Health Act of 1946 (at which time I was privileged to serve as chairman of the First Research Study Section), to nearly 1,500 in 1975. The report indicates that over the last twenty years the ratio of the amount of Nilfili-supported biomedical research to psychosocial research was reversed. Twenty years ago the ratio of biomedical research to psychosocial research was 2-1; in 1972 it was 1-2. This change reflects the broadening of NIMH's commitments in the late 1960 s into social problem areas, such as 1 (4) crime and delinquency. In my recent return to clinical research, after many intervening years of department chairmanship, I noted certain overall impressions of clinical (16) investigation in our field at this t:i.me. One impression is of the lL~ited number of clinical psychiatrists engaged in basic or applied clinical research. In a quick review of the twenty ongoing research programs in the 19 United States engaged in the search for the antecedents of schizophrenia, I four1d only 7 had psychiatrists as principal investigators, the rest being psychologists. In no way disparaging the considerable contributions made by our psychologist colleagues, I found it somewhat of a personal disappoint­ ment that not more psychiatrists are engaged full-time in research, particu­ larly after the aspirations of those who initiated the USPHS Career Investigator Program more than twenty years ago. I gather, from what Bro~.m has written, that my sa.~ple may be valid for the nation as a whole. He said: nPsychiatry has been a major service-providing instrument of that vital and nourishing enterpris_e we call mental health research. The psychiatrist has played a significant but smaller role in the actual conduct of research. Only a few psychiatrists--numbering in the hundreds--are full-time researchers.n (4) I have begun to understand better the separate domains of the clinician and the investigator, and at times how difficult it may be for one to understand the other. The investigator defines in clear, operational tenns, the variables he wishes to test. It is apt to be a circumscribed or atomic view, as con­ trasted with the molar, full sweep of the clinician. The investigator points towards behavior of members of a class, the nomothetic position, while the clinician has been traditionally idiographic. The investigator, perforce, because of the circumscribed sample, is ahistoric, while the hallmark of the clinician has been his allegiance to the historic method. And finally, there is the therapeutic intent of the clinician, which demarcates him from his investigator colleaguets basic curiosity. Many years ago, I drew attention to other factors which may have contributed to the lag in psychiatric research, (17) as compared with the pursuit of new knowledge in other medical fields. Other impressions are that few senior professional persons have direct contact with the research subject or patient; the limits of usefulness, of record research, and the lamentable habit of recording data in terms of inferred psychodyna.mics rather than at the phenotypic levels of behavior; the temptation to use methods familiar, available, and reliable, but inappropriate 20 to test what it is we wish to learn; confusion between the investigative purposes of hypothesis generation and hypothesis testing; an awesome regard of the all-inclusive and seemingly infinite capacities of the computer. Of the utmost importance to our university departments of psychiatry should be the existence and support of adequate role models who are significantly and seriously engaged in research, and opportunities should be made for college students, medical students, psychology and social science students, biology students, and particularly for our psychiatric residents to be exposed to the lives and interests and work of the research scientists. And every attempt should be made to identi~J the special talents of the young and to nourish them with fellowship assistance. CONCLUSION It is quite fashionable today to be concerned with death and dying. Even after applying our new and more precise tests, I see no need to call for a special mass to be chanted for the repose of our soul. On the contrary, I see much reason to sound reveille, as it is time to rise to meet and fulfill more effectively our professional responsibilities. We have become diverse, not quite as much as our older brothers, the internists and surgeons, but more so than the pediatricians and obstetricians, whom we now outnumber. In essence, our diversity is a function of our numbers but is further qualified by increasing fragmentation of functions formerly performed by those of us who have been generalists. There has been an exponential increase of full-time psychiatric faculty in our medical schools, exceeded only by those in Internal Medicine, although the actual number of psychiatrists engaged full-time in research is small in comparison. There has been a continuing demand for our consultative services from health, welfare, and legal agencies, both public and private. The explosive multiplication of psychotherapeutic modes has further fragmented us, although many, if not most, of the newer techniques have been initiated by non-psychiatrists 21 who assume the greater share of behavior, h"t.1.>nanistic, and transpersonal therapeutic approaches, particularly in group sessions. But, I am heartened by our renewed interest in the psychotic patient and his family, an interest nourished by the use of the psychotropic drugs and their serendipitous impact on neurochemical research, and by the moral treatment of our day, w"ith its compassionate concern for the forgotten and neglected chronic psychotic patient. We have learned that psychopathology survives and prospers under many flags and that behavior can be explicable in the paradigm of deficit as well as that of conflict. One of our greatest achievements has been the education of our medical students, that is, all physicians, whether or not their major concern in later life is in patient care. Consider how significant this is and may become should there be continued development of Family Medicine and Primary Care Physician Programs. Earlier, I mentioned the im:perative need for the :pursuit of new knowledge in order that one day we may understand better the essence of :psycho:pathology and of psychotherapy. 11 At times, I am reminded of those immortal words of Pogo, We have met the enemy and he is us.n Obviously, we erred in our uncritical, naive, and passive obeisance to political pressure w"ithout adequate and systematic trial before we embarked on our community mental health ventures. And peremptory was our decision to eliminate the free-standing internship for professional training, thus putting at hazard our biological heritage. We must clarify our role and the roles of others, both professional and paraprofessional, who share with us the study, care, and treatment of the sick and their families. The present deceptive egalitarianism has led to confusion worse confounded and in practice to the lowest common denominator of skill. We must stop acting blindly as self-appointed social engineer saviors and learn from experiment and trial if and how our skills and knowledge are 22 applicable to social issues. We should examine carefully our relations to the law, to the courts, and to the criminal. We may have promised more than we were able to give, but there is little question that we have added considerably to the hu."'Ilanizing of criminal justice in our search for the psychological antecedents of deviant behavior. In the present ambience of mistrust, we must do all we can to earn the confidence of our patients and their families to insure privacy, and above all, to do no harm. But,· we should not be intimidated by the strident ~bstractions of those who would prevent us and our patients from knowing more, a right as fundamental as the right to live. We are overdirected, overma.YJ.aged, overburdened, almost overcome by a militant corps of congressmen, lawyers, judges, philosophers, clergymen, ethicists, as well as paraprofessional do-gooders who are unrestrained in their zeal to tell us whom we are to see, what medication we are to prescribe, before or after meals, whom we should admit to hospitals, how long should they stay, which questions we should ask--unprecedented intrusion. But in an historical sense quite interesting. For decades our patients and ·we have been unsung, unloved, and unheard of, usually swept under the rug of our collective shame and guilt, and now we stagger unsteadily through a forest of committees intent on insuring that we are dependable and responsible and accountable. Personally, I continue to prefer as my guides the moral dicta of an earlier day, taught us by Hippocrates and Maimonides. I would commend to you the clarity and vigor of the statement made (18) recently by Jonas R. Rappeport: n ••• declare a type of independence from the law, that we declare our individuality, that we declare the rationality of our treatment programs, the rationality of our need to commit some patients to hospitals, that we declare that commitment laws fit the needs of patients, not abstract concepts--and our right to treat patients at the best possible facilities and in the best manner, according to our professional judgment, without costly and wasteful legal trappings. 11 23 On another anniversary occasion, three years ago, when several of us took part in the Bicentennary Celebration of the First Public Mental Hospital in the Colonies, at Williamsburg, Virginia, I said: "The major function of the psychiatrist, and one unique to him, is that he serves as a crucial bridge between genetics, biology, clinical medicine, on one hand, and the behavioral sciences on the other. The psychologist, the social worker, and the social scientist lack knowledge of the body, the biologist that of the mind, and up to the present, the nurse has had insufficient scholarship in either field to serve the purpose of a bridge. Further, I believe that if we are to serve this function properly, we must become expert in both biologic and psychosocial systems. Only then will we be able to interrelate effectively the knowledge from these basic sources in our unique role and contribution as clinician and scientist. To neglect scholarship at either pole would be to diminish our useful­ ness for tomorrow.u (9) While we may derive information and knowledge from these two poles, we must also contribute to them, and I believe we can do so best in our historic and, I believe, our essential role as psychiatric clinician. Let us hope that those who conduct the educational programs for those ·who succeed us will keep this point foremost, and that also they will constantly be dissatisfied with customary procedures of craftsmanship in their search for means to organize and use intelligence in new ways. Such a search may help us to learn that which is basic and essential to our task, that which may be found appropriate and useful to our purpose and to the changing needs of our society. There is so much to learn, so very much yet to be discovered. Lacking a bugle to sound reveille, I have drawn upon the following, taken from the verses of Sir Rabindrath Tagore, the late Indian author and poet: 11 Listen to the rumbling of the clouds, 0 heart of mine, Be brave, break through, and leave for the unknmm. 11 REFERENCES 1. .Murphy, J1:I: Psychiatric Labeling in Cross-cultural Perspective. Science, 191:1019-1028, March 12, 1976. 2. Eisenberg, L: The Future of Psychiatry. Lancet, 1371-1375, Dec. 15, 1973. 3. Romano, J: Twenty-Five Years of University Department Chairmanship. Supplement, Amer. J. of Psychiat., 122:7-27, June 1966. 4. Brown, BS: The Life of Psychiatry. Amer. J. of Psychiat., 133:489-495, May 1976. 5. Birley, JLT: Ecumenism in Action. Brit. J. of Psychiat., Vol. 129, News and Notes, pp. 7-8, Oct. 1976. 6. Parsons, T: The Social System. The Free Press, Glencoe, Ill., 1951. 7. Segall, A: The Sick Role Concept: Understanding Illness Behavior. J. of Health and Social Behavior, 17:162-169, June 1976. 8. Ludwig, AM: Hysteria, a Neurobiological Theory. Arch. Gen. Psychiat, 27: 771-777, Dec. 1972. 9. Romano, J: American Psychiatry: Past, Present, and Future. In book of same title, edited by Kriegman, G, Gardner, RD, and Abse, DW. University Press of Virginia, Charlottesville, 1975. 10. Parloff, MB: Shopping for the Right Therapy. Saturday Review, pp. 14-20, Feb. 21, 1976. 11. New York TL~es, Thursday, Nov.- 18, 1976. 12. Frank, JD: Common Features of Psychotherapy. Australian, New Zealand J. of Psychiatry, 6:34-40, Mar. 1972. 13. Romano, J: The Elimination of the Internship--~.n Act of Regression. Am. J. of Psychiat., 126:1565-1576, May 1970. 14. Thomas, L: Q,uoted by Wykert, J, Psychiatric News, Vol XI, pp. 8-9, Aug. 6, 1976. 15. Morison, RS: Some Illnesses of Mental Health. J. of Med. Educ., 39: 985-999, 1964. l6. Romano, J: The Central Core or Hac1.viess. To be published. in Proceedings of the Second Rochester International Conference on Schizophrenia, John Wiley & Sons, New York, 1977. l7. Romano, J: Discussion of paper by Brosin, HW, on Discovery and Experiment in Psychiat~J, Arn. J. of Psychiat., 111:570-572, Feb. 1955. 18. Rappeport, JR: The Belegaled Profession. Roche Report, Frontiers of Psychiatry, 6:1,5, Nov. 15, 1976. THE CENTRAL CORE OF MADNESS John Romano, M.D. Distinguished University Professor of Psychiatry University of Rochester School of Medicine & Dentistry Rochester, New York 14642 · Presented at the Second Rochester International Conference on Schizophrenia Rochester, New York May 3, 1976 It happened over 40 years ago. The patient, a young man, recently admitted, was frightened, perplexed, and hallucinated. As he wouldn't eat, he had to be tube-fed daily. On each occasion he had to be tube-fed twice, not once, because after the first trial he would vomit what he had been fed. After the second feeding it would stay down. In answer to my question, "Why do you vomit?u the patient said, "Because I have no stomach," to which I replied, "Well, the second time I f'ed you the food stayed down. Where did it go if' you have no stomach?" Almost immediately the patient answered, "It goes to the upper peninsula." This took place when I was a house officer with Eugen Kahn at Yale. I tried as best I could to trace this idea to its source, to look for related ideas through detailed review with@the patient and his family of' his past and present life history, through the use of' projective tests, through his infrequent spontaneous remarks, and even through pondering over fragments of' occasional dreams he recounted to me; but to no avail. It remained enigmatic, strange, nonunderstandable. I learned later of the emphasi_s placed by Jaspers (1) on the signifi­ cance of understandability as a criterion of schizophrenic symptomatology. Whether a given symptom can be understood or not Jaspers believed is determined by feeling oneself' into the situ.atio~ of' the patient and assessing whether the symptom can be understood logica.11:y or emotionally as arising from the patient's af'f'ective state, his previous personality, or the current situation. But, as many have noted, this approach is somewhat vague and subjective. I have learned that it depends in great part on how much time you spend with a patient, how informed you are of' his past and present lif'e, and on the nature of' the trust established between you and the patient. Whatever its significance, the nonunderstandability, together with the characteristic hallucinations, the thought disorders, the passivity experiences and their delusional interpretations-­ all occurring in a state of wakeful consciousness--these have constituted a 2 mosaic, a cluster, of signs and symptoms which have demarcated this type of madness from others.(2) Through the mists of antiquity the notion of paranoia emerged, and long before it acquired its modern denotative persecu­ tory or projective meanings, it meant more simply, beyond understanding, and was used to describe the essence of madness. Perceptive, seasoned clinicians, beginning with Thomas Willis in the 17th century, and others through the 18th and 19th centuries, differentiated what today we call schizophrenia. from melancholia., from mania due to fever and that due to wine, from the enfeeblement of the aged, and from those who suffered brain damage in war. Although schizophrenia had many names-­ stupidity, foolishness, vesania, idiocy, monomania, paranoia., and others-­ these earlier clinicians described the characteristics of family origin, endogenous cause, early onset, remitting or regressive course, bizarre ideas, dissociation of thought and emotion, and social withdrawal. These were written long before the more precise contributions of Morel, Hecker, Kahlbaum, Kraepelin, and Bleul.er and the designations of dementia. praecox and schizo­ phrenia..(3) Then, as now, other types of madness, like melancholia, mania with elation and that due to fever, the enfeeblement of the aged, these seemed more capable of empathic understanding--more consonant with human psychological experience. Then, a.snow, this special type of madness which today we call schizophrenia. appeared to be the central core of madness or unreason. On the occasion of the First Rochester International Conference on Schizophrenia. nine yea.rs ago, we drew attention to the magnitude of the preva­ lence of schizophrenia., the lack of agreement about its diagnosis and course, and the multiple conjectures about its origins--aJ.J. attesting to the fact that it constitutes modern psychiatry's greatest challenge.(4) It appeared then, nine years ago, as it does now, that the need for continuing studies would contribute not only to the understanding of schizophrenia, but also to 3 our knowledge of perception, thought, memory, and emotion, to human growth and development, and to the continued events o:f human interaction within the family and in other social groups. One of the objectives of the First Conference was to stimulate us, and we hoped others, to examine more critically what it is we know, or believe we know, and more particularly to seek new knowledge in all the areas relevant to our task. We are encouraged to learn that in the past decade there appears to be an increased world-wide interest in and support of the investigation of the schizophrenic patient and his family. This is attested to by the number of published scientific papers and monographs, the establishment of special journals, the international studies of diagnosis and course, the development o:f new methods of biologic research, and the frequent convening of interested groups in assemblies and conferences such as the one in which we a.re now engaged. Following our First Conf'erence, and stimulated in great part by Norman Garmezy' s seminar on vulnerability to psychopathology (1969), we initiated a pilot study, supported generously by the Scottish Rite Foundation and the Margo Cleveland Research Fund, in which Ha.routun Babigian, Arthur Orgel, and Irving Weiner took major responsibilities and were joined later by Alfred and Clara Baldwin, then at Cornell, and now, happily for us, at Rochester. With the appointment o:f Lyman Wynne as department chairman (1971), we were able, under his leadership, to design and launch the University of Rochester Child and Family Study, whose objectives a.re: (1) to identify children who genetically a.re at high vs. low risk for schizophrenia; (2) to examine these groups through three classes o:f predictor variables: (a) diagnostic assess­ ments o:f the biological parents, with the implication of differing genetic loadings :for the "high riskn children o:f a schizophrenic parent vs. the "low risk" children of parents who have had other kinds o:f psychiatric 4 disorders, (b) the diverse patterns of psychosocial competence, adaptation and biological functioning of the children, themselves, and (c) a constel­ lation of factors in the family and school environments which may differentiate the high from the low risk children; and then (3) to follow these families prospectively and determine whether or not the initial differences were maintained in developmental trends. It has been my privilege in the past five years to return, after many intervening years, to active participation in clinical research as a part of the University of Rochester Child and Family Study. Together with my associate, Robert Geertsma, and our research technician, Sandra Squires Trieshmann, our assignment in the overall program has been to conduct investi­ gations which aim at the identification of those characteristics of parents which are associated with vulnerability or invulnerability of children at high risk for schizophrenia.. Identification here refers to: l. the documentation of pa.rental characteristics and the nature of the caretaking patterns of behavior from videotaped interviews, 2. the characterization of parental object relations through adjective checklist studies, and 3. the analysis of clinical diagnosis; past and present, through current videotaped interviews of patient and spouse and through careful review of past hospital records. Our particular project in the overall program has been supported by the Scottish Rite Foundation and the Margo Cleveland Research Fund. Most briefly, I should like to present one diagnostic datum from our studies in progress and share with you several personal impressions of clinical research in this field. Since the start of the study, we have seen 105 families. Of the first 97 families studied, 50 were diagnosed as schizophrenic during their inpatient 5 hospital period of study. Following our review of the hospital records, together with our current clinical diagnostic interviews with the former patient and spouse, we disagreed in 5<Y/o of the instances with the initial hospital diagnosis of schizophrenia (26 of 50 patients); 47 patients had the hospital diagnosis of non-schizophrenia, and here our agreement was 95%. Our clinical diagnoses, both retrospective and current, are then compared with those reached by John Strauss and his associates, who review past records a.nd use standardized questionnaire interviews currently. In 80% of the families studied thus far, there was agreement between John Strauss' s and our group in the diagnosis of the patient during his inpatient hospital sta.y. Obviously, diagnosis remains an urgent and central problem of concern. Equally obvious is that most of us in the United States have tended to diagnose schizophrenia less rigorously than most of our European colleagues. And rarely did I find patients described as hebephrenic or a.s catatonic. I believe, too, tha.t the adjective, pa.ra.noid, is used too loosely, and chronic undifferentiated schizophrenia now seems to occupy the center of the stage. I am heartened by evidence of a national movement in clinical practice for greater precision in diagnosis. :From a practical point of view, it has now become necessary to discriminate carefully among schizo­ phrenia, mania., the several types of depression, and other psychotic behavior in order to prescribe the appropriate medication. The inter­ national studies, both the United States-United Kingdom a.nd the World Hea.lth Organization Studies, attest to this greater interest and concern.(5) One impression which we sha.lJ. have to check later is that we a.re dealing with a particular type of schizophrenic patient, selected by us by design. Ra.rely has illness been initiated in childhood or adolescence. M'ost frequently, particularly in women patients, it seems associated with the problems of young adulthood, including courtship, marriage, pregnancy and 6 labor, parenthood, house-moving, employment, economic stress, relation to parents, and with mental illness in the families of origin. Most of our patients' illnesses have been short-term, a number with remitting course, with improvement assisted principally by medication, hospital care, and family rally. While over one-half of the patients still receive some type of medi­ cation, either the major or minor tranquilizers, we found three-quarters of our patients to be currently asymptomatic. By design, the schizophrenic population under study is exclusively white, predominantly middle-class, continuously married, with intact family, and having male children ages 4, 7, and 10 before, during, or after the psychotic illness. While our population may be representative of the population of patie,{lts admitted to the psychiatric unit of a university teaching general hospital, it certainly is not representative of populations frequently studied; namely, those of long-term, lower social class patients continuously hospitalized since early life, with little acquisition of social competence, unmarried or divorced, and with limited or no parenting behavior. The need for those of us engaged in clinical surveys to define clearly and fully the populations under study is evident. The possibility of biased conclusions from uneven selection of patients is obvious a.nd a constant hazard. Another impression is the recognition of the limits of usefulness, not to speak of validity or reliability, of record research. Even in reasonably well-conducted clinical households, one often finds that the data one wishes are not available and that records, when legible, vary considerably in recording primary data of patient behavior. The fullest, most useful records are those prepared by our third-year medical students during their clinicaJ. assignment to our floors. Most observers prefer to record data in terms of inferred psychodynamics rather than at the phenotypic level of behavior. 7 Terms such as "regression in the service of the ego," "introjection of hostile wishes," "homosexual panic," a.nd even more simply, "cognitive slippage," "patient is depressed, or hal.lucinated, or paranoid," a.re commonly used without giving any specific evidence of the behavior which led to the inference. I have also become disenchanted with traditionaJ. psychologicaJ. and Rorschach reports, as they, too, may allow you to hear the grass grow but provide no primary data, and consist essentially of inferential statements arrived at artistically. Incidentally, the more recent the record, the more complete the charting of family genetic trees. And rare, indeed, does one find a report of the physical description of the person--dress, mannerisms, posture, gait, expression, height, weight, movement, etc. On another occasion I have noted, "In psychiatry we have been so fascinated by what we hear that we have neglected to look. We can well respond to the wisdom of that Dean of Malapropisms, Yogi Berra, when he said, 'You can observe a lot just by watching.' "(6) Another impression is of the limited number of clinical psychiatrists engaged in these high risk studies. In a quick review of the 20 ongoing research programs in the United States engaged in the search for the antecedents of schizophrenia, I found only 7 had psychiatrists as principal investigators, the rest being psychologists.(7) Whether this ratio is representative of .American psychiatrists engaged in clinical investigative work is not lmown, and in no Wa;/ disparaging the considerable contributions made by our psychologist colleagues, I find it is somewhat of a personal disappointment that not more psychiatrists a.re engaged f'ull-time in researches of this type, particularly after the aspirations of those of us who initiated the USPHS Career Investigator Program many years a.go. Furthermore, on my return to clinical investigative work, I am surprised to find that in many of these programs, including our own, few senior professional persons have direct contact with the research subject or patient, such contact being made principally by technicians and in some instances by pre- and postdoctoral psychology students, who obtain the primary data. 8 The basic problem with this is again the crucial necessity to obtain a.n informed, sensitive and precise appraisal of the subjects who will provide the primary data. Without such subject identification, the generalization of results and their comparison with results of other studies·, becomes indeterminate. I have learned something about the hazards of research programs dealing with an almost infinite number of variables. There is, quite understandably, the compelling temptation to use methods familiar, available, and reliable, to test what it is we wish to learn. How appropriate they may be to our task is another matter. John Dollard cautioned us years ago, "The first loyalty of a scientist is to his material; he mu.st seek it where it can be found and grasp it as it permits. If he doesn't do this, he is likely to find himself an aimless imitator of others, of better methods not applicable to his field. "(8) I have also learned that we are apt to confuse two investigative purposes: that of hypothesis generation and that of hypothesis testing. One is concerned with d?-scovery, the other with proof. I would predict that in large studies like ours, that more will emerge as discovery, less, as proof. Because the computer can now handle thousands of variables, this has removed from the investigator's shoulders the necessity for him to select those variables which he wishes to test. This, in turn, tends to produce more variables rather than proving relationships. One is reminded of Edith Wharton's remark of getting into the thick of thin things. What has been most impressive to me is the old-fashioned altruism of the families who have participated in our studies, however one chooses to define altruism. In our study, even though a full explanation of the project was given at the time the subjects filled out appropriate consent forms, more than 2/3 appeared to retain little of what they had heard or read when I asked them about this in our interview, which usually takes place at the end of the study. 9 Almost invariably, while they are not clear as to the purpose of the study, they appear to have enjoyed participating in it, have been impressed with the interest and kindness of those with whom they have met, even though at times they were somewhat puzzled as to why an endless number of silly questions was 11 asked. Most often we hear: We're really not sure what this is all about, but we and the children have enjoyed doing it. We wanted to take part in it to express our appreciation for having been helped in the past, and perhaps one day, while the information you are getting may not be useful. to us, it may be to someone else." I wish sincerely that some of our militant philosophers, theologians, and ethicists, whose instant omniscience in matters of privacy and informed consent appears to be matched only by their overweening arrogance, could hear some of these remarks, and learn from them of the need of the patient to give something of himself and to recognize that among one's fundamental rights is the right to know, and one hopes to know more, about the disturbance which affects his life. May I now add my word of welcome to those spoken by Chancellor Wallis and Dean Orbison. It is a great personal pleasure to see old friends and colleagues, to greet our distinguished visitors from abroad, and to welcome many new acquaintances. We look forward eagerly to the work of the next several days, expecting to learn more about how we may better understand and help the schizophrenic patient and his family. While we may not be able to reach the shores of the upper peninsula, perhaps we can be pointed in the right direction. REFERENCES l. Jaspers, K.: General psychopathology. University of Chicago Press, 1963. 2. Fish, F.J.: Schizophrenia. Bristol, John Wright & Sons, Ltd., 1962. 3. Wender, P.H.: Dementia praecox: the development of the concept. Am. J. Psychiat. 119:1143-1151, June 1963. 4. Romano, J.: Introduction, p. 3. The origins of schizophrenia. Excerpta Medica Foundation, Amsterdam, 1967. 5. Carpenter, W.T., Strauss, J.S., Bartko, J.J.: Flexible system for the diagnosis of schizophrenia. Report from the WHO international. pilot study of schizophrenia. Science 182:1275-1278, Dec. 21, 1973. 6. Romano, J.: On those from whom we learn. California Medicine lJ.7:72-75, October 1972. 7. Ga.rmezy, N.: Children at risk: the search for the antecedents of schizophrenia.. Part II: ongoing research programs, issues and interventions. Schizophrenia Bull., Issue 9, pp. 55-125, Summer 1974. 8. Dollard, J.: Caste and class in a southern town. Second Ed., Harper Bros., New York, 1949. Boothe, Bert E., Rosenfeld, Anne H., and Walker, E~ward.L. Toward a Science of Psychiatry. Monterey, California: Brooks/Cole Publishing Co., 1974, pp. v-vi. John Romano For some time before his death, Bert E. Boothe had planned ., Belmont, to write a report describing the design and progress of the Research De­ ry be repro­ velopment Program of the National Institute of Mcnta1 lica1th. Edward ,1 or by any L. \Valker and Anne II. Rosenfeld h~n-c completed his project; Tmvard othern·ise­ a Science of Psychiatry describes the success of the Research Development ;lCo1e Pub­ Program in effecting a significant chauge in the number and quality of -rth Publish- psychiatrists and others in tcrcstcd and engaged in sustained investigative work in psychiatry. Certain chapters of this book have special historical value-such as Chapter 4 on psychoanalysis, which, although born in Europe, flourished as a particularly American experience. Other chapters give a clear account of the development of ickas and hypotheses from tlic several belief systems that contribute today to the understanding of the mentally sick person, his family. and his community. The final chapter and the appendices will be useful to present and future historians in re­ cording the growth and clc\·clopment of psychiatric research in the past 25 years. · During the mid-19-f0s, those of us associated with the Research Study Section of Nlt\III s0011 became aware of the scarcity of young men and \Vomcn cw:;agcd significantly in psychiatric research. [t hecrn1c clear that the field needed a 11C\\' type of psychiatrist-namely, the research scientist, as coutrastccl with the teacher-clinician, the practicing psychi:1- trist. the psychothcr;:ipist, or tlte administrati\·c officer. Unlike our col­ leagues in medicine ~md physiolog~-. we i11 psychi;1try did !lot h~l\'C a l\ lassachu- Rockefeller institute to help prepare young men and women for pro- ~on, l\fassa- John Romano. ~1. D .. is Di~tini:;uisltccl Uni\'crsity Professor of Psychiatr:· ;1t the University of Rochester School of ~lcdicinc and Dentistry. Rochester, New York. ...,....,.,JJ.,_ •·t-4·,._• ,, .... ,.-l~. J ·'- ' vi Foreword fessorial posts and research careers. Before 1946, when few persons were engaged in imTstigati\-C work, appropriate models for tlie young to enrn1atc were rarely found. Earlier in the century, whatever research had been con­ ducted \vas done under pri\·atc auspices or in a few Lngc state mental hospitals. Support subsequently came from state fnncls through the clc\'cl­ opment of the Psycl10p:1tliic I Iospital 1110\ cmcnt in A1111 :\rhor, Iowa Citv. Denver, and Boston. Contributions were made by the Rockefeller Founda­ tion, the Scottish Rite, and the Connnonwealth Fund. Given this background, one can understand the excitement and promise of the Congressional action that established the National Mental Health Lnv in 1946. By the bte l 9--fOs. we were fortnIJate that two re­ cently created programs for supporting research scieutists-The t\Iarklc Scholarship in Medicine, founded in 1948, and the American Heart Asso­ ciation's Lifetime Career J\\\'ard-met needs similar to ours. \Ve used these two as models to guide us in drafting proposals for the Career Investigator Grant Awards in psychiatry. For about 10 years before he came to NI~ III in 1957, Bert and I had corresponded. principally exchanging information about candidates for the :Menninger School of Psychiatry: a number of these candidates had been my students at Harvard, Cincinnati, and Rochester. Bert and I subsequently had an opportunity to work together \\'lien he succeeded Philip Sapir as the Executive Sccretar\' of the Mental Ilcalth Career In­ vestigator Selection Committee at NI\Il-I. In his derntion and commit­ ment to this position, he was extraordinarily useful i11 helping the Com­ mittee make important judgments about the selection of promising young scientists in our field. f le joined us at ;\rden House at the first meeting of the young investigators and was the principal plauncr and engineer of subscqucn t annual meetings. ( Incidentally, we arc again indebted to the Markle Scholarship Plan for the idea of convening our investigators. The ~farkk group had done this successfully for a number of years before our first meeting.) Over the years, Bert became a truly charismatic figure to those young men and womeu who had been recipients of Career Investigator and Research Career Development awards. They, fouucl him to be an able, intelligent, thoughtful, and always helpful person. They recognized th:1t his interest in them was genuine aml sustained, and he was both fatherly and motherly in doiug much to help them in their Liter careers. I le was modest, e\·en shy at times, gentle, and most generous of himself and iu his work with others. I am sure tlut the success of this report stems from the thought­ ful candor of the m:my rcsponclcnts quoted throughout it. The cpdity and extent of this respollsC is a function of the awardecs' respect, ad­ miration, and affection for Bert Boothe. fu