"One should practice morality urgently, as if the god of death had seized one by the hair."
--paraphrase of Sanskrit by Daniel Herwitz, director, University of Michigan's Institute for the Humanities
By the time you read this column, we will have had our annual American Psychiatric Association meeting, where we often try to highlight much of the best of psychiatry. In contrast to foolish psychiatry--which I discussed in my column last month--I do hope this one becomes an annual May column in celebration of the meeting.
What to celebrate, though? The answer and inspiration first came to me while on a trip my wife and I signed up for last year called 'A Sublime Journey: The Art and Architecture of Northern India." I then wondered, If sublime can apply to art, could it apply to psychiatry? After all, weren't we all taught the "art" of medicine?
I'd seen the word sublime used as an adjective in many contexts recently: sublime apple pie, the sublime poetry of John Milton, Mozart's sublime clarinet concerto, and sublime love. But I was not able to find any reference to sublime psychiatry. Was I on the wrong track?
Since this is an ethics column, I considered the American Medical Association's ethical principles. Some may think these principles themselves are sublime. But our APA must not. After all, as I mentioned last month, the task force charged with revising our ethical principals is looking at whether the notion of maintaining appropriate boundaries is outdated ("Sex and the Psychiatric Clinician," Clinical Psychiatry News, April 2008 p. 62).
What about the individual principles? The ethical expectations are quite modest; none expect the sublime. For example, ethical treatment only needs to be "competent," not ideal. But this shouldn't stop us. Most of us usually strive for the best, whether working in patient care, or on presentations or publications. Perhaps our work could be considered sublime whenever it reaches those heights.
Given my limited and biased perspective, I decided to ask colleagues for possible examples. (I cite them hereafter with their permission.) To define sublime for this request, I looked in my Oxford English Dictionary, which gave the primary definition as: "of such excellence or beauty as to inspire great admiration or awe."
In the beginning of a running discussion I had with Dr. Chuck Joy, he noted the difficulty of holding "sublime" and "psychiatry" in the same thought. Art, yes, and possibly the use of arts in psychiatry, such as art therapy, music therapy, or movie therapy. But what about everyday psychiatry?
Dr. Joy, a psychiatrist and poet, went on to wonder whether feeling awe and wonder might indicate a counter transference problem needing consultation. Uh-oh, I thought. This notion might take me right back to the issues discussed in last month's column on foolish psychiatry. Did our winner feel awe and wonder as his attempts to treat a colleague ended up in an intimate relationship? Would I just be doing another column on foolish ways under the guise of the sublime? As our discussion progressed, Dr. Joy and I got to some possibly sublime intellectual concepts in psychiatry, such as Dr. Donald Winnicott's idea of the "good-enough mother." We were getting closer.
Recovery Is Sublime
One intellectually sublime concept that can be translated into clinical practice is the recovery movement. The issue that seems to push the recovery movement beyond the usual to the sublime is that at its essence, the move-ment has revised the expectations upward for how treatment should be approached for those with so-called serious mental illness. When able to do so completely, psychiatrists often have been left with a sense of awe at what can be accomplished, in contrast with the limited expectations--and even pessimism--associated with treatment as usual.
The recovery movement has been slowly gaining momentum. In fact, the landmark articles of CM. Harding and others from 20 years ago evoked awe and wonder in the field by suggesting that many more patients seem to recover from schizophrenia than we had assumed (Hosp. Community Psychiatry 1987:38;477-86). At that time, I was astounded to learn that up to two-thirds of those with "chronic schizophrenia" got much better over long periods of time, even at times without psychiatric medication, provided they had the right social supports.
As is not so unusual with such research findings, it has taken the last 20 years to begin to understand better what constitutes the right social supports. Recovery ties those ideas together. In the early 1990s, Dr. William Anthony introduced the concept of a recovery-oriented system (Psychosocial Rehabilitation Journal 1993;16:120-3). Such a system would provide treatment, case management, wellness, self-help, and other services--all geared to attaining the individual quality of life desired by the patient (or, as many prefer to be called, the consumer).
At its best, such an approach exemplifies the bioethical principle of autonomy. That is, the recipient of services is the driving force for what is needed, not what the system determines is needed for the recipient. At the essence of this approach, as my colleague Dr. Joel S. Feiner wrote in an e-mail message, "[are] human rights and social justice, doing everything we have at our disposal to bring another marginalized group into the mainstream."
Perhaps the best model for such a recovery system is the Mental Health Asso-nation's (MHA) Village in Long Beach, Calif. Started in 1990, the village provides "whatever it takes," with an emphasis on choice, along with equality of staff and recipients. Teams of mental health professionals and paraprofessionals provide services that help those in recovery with issues such as employment, money management, and community involvement. Some of the staff members are themselves in recovery from mental illness.
The founding MHA Village psychiatrist, Dr. Mark Ragins, has distilled the four stages of recovery into hope, empowerment, self-responsibility, and a meaningful role of life. Although the MHA Village model tries to do whatever it takes, Dr. Ragins emphasizes that it does not assume that "anything goes."
However, given the absence of rigid rules at the MHA Village, Dr. Ragins thinks more attention must be paid to ethics in recovery, including no tolerance for exploitation or aggression, and an insistence on mutual safety.
As a clinician, he thinks it's satisfying to make a correct diagnosis but sublime when the patient says, "Now I can never again say that no one understands me." It's satisfying to have medication help, but sublime when the recipient says, "These pills have helped me find myself again, releasing me from the prison in my head."
Ironically, as impressive as the MHA Village might be, one factor that makes it sublime has been the difficulty of replicating it. Once its successes become, one hopes, more standard in our field, it will no longer be sublime.
We now have some tools to assist our organizations and ourselves to see how far along we are with recovery. An organizational readiness checklist is available from Marianne Farkas, Sc.D., of the Center for Psychiatric Rehabilitation of Boston University. Lori Ashcraft, Ph.D., of Recovery Innovations in Phoenix, has designed a recovery self-assessment for clinicians.
A particularly interesting aspect of Recovery Innovations is that it is funded and managed by the for-profit managed care company, Value Options. This program incorporates recovery principles throughout and uses various hospital alternatives.. Half of the workforce is peer specialists. So not only does it seem good, it must be cost-effective. Sublime indeed!
Volunteering Is Sublime
Responding to a disaster almost always means time away from usual work and family life in order to serve patient and societal needs. Called a "disaster" by some, the war in Iraq has presented a unique opportunity to volunteer beyond the usual call of duty. For physicians who are serving, the war also has inherently provided preparedness for disaster.
After--and because of--Sept. 11, 2001, Dr. Michael McBride volunteered to serve as a psychiatrist in the military. Dr. McBride, who has a family and had a successful private practice, was called up twice to Germany with his U.S. Army Reserve combat stress company. He has now been called to Iraq. More and more I fear for him, and feel some survival guilt about being home.
In e-mail messages, Dr. McBride has described the ethical dilemma that can occur when the needs of the patient conflict with those of the U.S. government: a patient's need to recover versus the military's need for more soldiers to carry on the fight. Perhaps his sublime sense of service is best illustrated by the strawberry milk shakes he bought to make his patients suffering from posttraumatic stress disorder more comfortable when they came to see him.
This sublime work reflects the bioethical principle of beneficence. Dr. McBride did whatever he could to voluntarily provide benefits to those in need.
He is due home about the time this column comes out. Welcome home, Mike!
Mental Health Reform Is Sublime
It seems that all psychiatrists agree that our system(s) for providing mental health care are in general inadequate, fragmented, and spotty in quality. We might disagree on the solution--some might want a return to the "good old days" of indemnity-supported private practice and others might call for new pilot projects--but we agree on the need for change.
One psychiatrist, Dr. Leslie Hartley Gise, has worked relentlessly to advocate for change of a certain kind. Because she agrees that the single-payer system promulgated by Physicians for a National Health Program (PNHP) is the way to go, she provides constant reminders and information to everyone on her Listserv. Her ability to call up a wealth of timely information, seemingly at the drop of a hat, is awe-inspiring. She is the voice of psychiatry for PNHP.
The PNHP plan is modeled after the Canadian system, in which accounts suggest that patients generally receive competent care and psychiatrists are much more satisfied.
The struggle for equitable mental health care meets the bioethical principle of justice. Social justice under this model would be a fair distribution of competent psychiatric services.
Psychiatry Is Sublime
I did not expect to find that some psychiatrists think that the field itself could be sublime. But Dr. Linda G. Gochfeld did. When I asked her about this, she replied that just being able to work as a psychiatrist, particularly as a community psychiatrist, was sublime.
Do you also feel psychiatry is sublime? Do you know of other examples of sublime psychiatry, including sublime moments? If you do, please let me know for possible publication as a letter or for possible inclusion in next year's column.
Dr. MOFFIC is a professor of psychiatry and behavioral medicine, as well as family and community medicine, at the Medical College of Wisconsin, Milwaukee. He can be reached at email@example.com.…