Farewell Thoughts

By Barry Blackwell

   As I approach the end of a long career at age 89 the discipline I learned and chose to practice, Psychopharmacology, seems close to extinction. Farewell Thoughts explores and seeks to explain this alarming outcome based on the dual aspects of my life’s work. First, earning a living during a clinical career as an administrator, teacher, researcher, Chair of two new Academic Departments as Professor of Psychiatry, Pharmacology and Medicine (1968-2008). This was followed by pro bono work (2008- present), invited by Tom Ban, first as an assistant editor for the Oral History of Psychopharmacology (OHP), then as an essayist, editor and historian for the International Network for the History of Neuropsychopharmacology (inhn.org), which provided added insights and perspectives to my early clinical experiences and the evolving national scene.  

   The history of modern Psychopharmacology developed as I began my training, first in preclinical studies at Cambridge University, then as a medical student at Guy’s Hospital, followed by a year of neurology and finally as a junior resident at the Maudsley Hospital and London Institute of Psychiatry. 

   My three years at beautiful Queens’ College, Cambridge on the banks of the river Cam was devoted more to social life, playing rugby for the University second team, rowing at college and carousing with teammates at the adjacent Anchor Pub, oblivious to the birth of my future discipline. The only significant or relevant academic event was that I failed Organic Chemistry for the second time, the first was in High School. It was “three times and you’re out.” Organic chemistry was the most likely hurdle to prevent a medical student from progressing. I visited my college tutor for permission to return for a third time during the summer vacation. He welcomed me kindly, invited me to sit down and informed me that “although I had failed the second time my name had been mistakenly published in the Pass List.” He felt I would make a good doctor so proposed to do nothing.  

   I eventually achieved a second-class degree in Natural Science and moved on to Guy’s Hospital in London where I became Captain of the oldest rugby club in the world. Contact with live patients kindled a passion for medicine that included an interest in research and writing scientific articles that began with Munchausen’s Syndrome as evidenced by vagrants with a strong desire to be cared for seeking admission for bogus complaints by repeated visits to the Emergency Room. Obviously, a psychiatric condition but not what committed me to life as a psychiatrist. That came on the Obstetric rotation when I was assigned to care for a pregnant woman who could not understand how she became pregnant and feared the delivery. I suggested a psychiatric consultation. The Chief of Obstetrics declined. Next, I enquired about a Caesarian Section which was ignored. Instead, he forced my patient into labor with an intravenous drip; I sat by her bedside throughout the night while she screamed and eventually delivered. That week the Lancet published an editorial by the Chief of Obstetrics at another London teaching Hospital with the title, “Human Relationships in Obstetrics.”  

   I wrote a passionate Letter to the Editor detailing my concerns about the kind of problem I had encountered which they chose to publish as the first letter by “Barry Blackwell, Guy’s Hospital.”  

    Several months later my time as a student was over and I returned to Cambridge for my graduation exams. All went well and I passed every subject except Obstetrics. The obstetrician who examined me had made me perform a vaginal exam, had ridiculed my attempts to put size 7 gloves on my size 8 hands and chose to exert his right to fail me overall, not just in obstetrics. So, I spent six months doing obstetrics at another hospital before returning to Guy’s as a House Officer.  

    When I rotated to the Emergency Room, I was surprised to find that although the National Health Service had been initiated and everyone now had a family doctor, patients still chose to come to the hospital. The Chief shared my concern and allowed me to conduct a study asking patients about their reasons. Not surprisingly they viewed Guys as a superior source of wisdom and preferred it to a crowded doctor’s evening office. I submitted the article to the Lancet and was surprised and delighted they published it. I imagined they might have been influenced by the previous letter about obstetrics, a supposition I would find supported when I later began my psychiatric residency. 

   When I completed my internship, I took a yearlong position at a nearby Neurology hospital to increase my chances of gaining a position at the Maudsley where Sir Aubrey Lewis preferred to have residents who had completed a three-year Board Certification in Internal Medicine. 

    A significant number of our patients had made a suicidal attempt with an overdose of drugs. Although the first minor tranquillizer, Meprobamate, was now on the market, the most common drug used by patients was a barbiturate. So, I developed a technique to reverse its effects using a brain stem stimulant which was quite successful. For this I won the Hospital’s Annual Research Award. Another fortunate aspect was that I learned something from the registrar who supervised my work in neurology.  He had cared for a patient who was taking a new monoamine oxidase inhibitor, tranylcypromine, Parnate, and who had suffered a subarachnoid hemorrhage, so he insisted I always take a history from anyone admitted who had been prescribed this drug. Nothing happened but I took the knowledge with me to the Maudsley Hospital.  

   Residents admitted to the Maudsley were assigned to either an A or B stream. Those with Membership in the Royal College were assigned to the A stream and were located at the Elephant and Castle in the City, also affiliated with London University and King’s College Hospital. Those in the B stream were assigned to the Bethlem Royal Hospital, (formerly Bedlam), a 45-minute drive away in the countryside. 

   Founded in 1915 the Maudsley was transformed into the leading center for psychiatric education and research during the tenure of Aubrey Lewis.  In 1946, after the hospital came under the auspices of the University of London, he became Professor and Chair shortly before the founding of the National Health Service. Lewis is credited with establishing the institute’s international reputation and attracting the best and brightest faculty and students from Britain and around the world. Under his leadership, the stature of psychiatry as a scientific discipline increased significantly and graduates from the program went on to distinguished academic careers and Chairmanships of departments in Britain, Canada, America and Australia. For this he received a knighthood from the Queen and retired in 1966, the year I graduated. 

   As a person, Sir Aubrey was short, with a shiny bald pate, a rim of black hair and piercing eyes framed by old-fashioned spectacles. An austere demeanor and critical mind concealed a kind and humorous persona known only to his family and a few intimates. The climate he created was intellectually challenging and industrious; an ideal environment in which to mature, supported by a talented multidisciplinary faculty. 

    These were the days when Saturday was still considered part of the work week, and on that morning, every trainee and faculty member attended a Professorial Conference at headquarters. Each week, residents took turns to present a clinical case of their own choosing. It was a competitive forum where we went to significant lengths to impress Sir Aubrey by selecting unusual or interesting topics we had studied in great depth and detail. He was our probing but benevolent inquisitor.  

    When my turn came, I chose to present a rare case of myoclonus epilepsy, misdiagnosed as hysteria and sent to us for a second opinion. I persuaded the hospital’s audiovisual technician to make an 8 mm film of the patient’s bizarre and explosive movements. At the conclusion of my presentation, I waited for Sir Aubrey’s inevitable probing question. “Had I by any chance read the recent Japanese accounts of this disorder?” No, I had not. A week later I stopped by Sir Aubrey’s office and spoke to Miss Marshall, the guardian at his gate. I learned Sir Aubrey had taken the Japanese Journal out on loan from the library and only just returned it. Checkmate?  

    My Australian friend, George, also a B stream resident, who spoke fluent German, had been a member of a South Pole research team and was a world champion wrestler had also visited the Burgholzi Hospital in Zurich and met with Manfred Bleuler, one of Europe’s leading psychiatrists. George presented an account of the hospital, now celebrating its Centennial Anniversary. During the presentation he attributed an opinion to Bleuler. Sir Aubrey pounced. How could George possibly know what Bleuler thought? My friend was so anxious that the odor of his sweat permeated the conference room. With hardly a pause, he explained he had flown to Zurich at his own expense to conduct a personal interview in German. Even Sir Aubrey seemed impressed. Later, George, who had an inferiority complex about his writing skills, invited me to co-author his paper, “The Burholzi Centennial,” which was published in the Journal of Medical History.   

   In the fall of 1962, a few months after I began my psychiatric training, a change occurred that altered the course of my professional life. While I was eating lunch in the cafeteria, I heard residents at an adjacent table talking about a young woman who had just suffered a severe hemorrhage. My ears picked up. I asked my colleagues if their patient was taking any drugs and learned she was taking Parnate! I went to the library to look through recent issues of the Lancet and there were six letters in the last 20 months describing an association between taking Parnate and experiencing headache and severe hypertension. And, at about that time, I ran into my family doctor and when I told him what I was interested in, he explained he’d been called out twice in the previous weeks to see patients suffering the same symptoms. 

 So, I wrote my own letter to the Lancet suggesting that this side effect might be much more common and serious than previously thought. It was published in January 1963. A week or so later I received a letter from a hospital pharmacist in Nottingham who went to the public library to read medical journals. He described two episodes of sudden severe headache his wife had suffered while taking Parnate after eating cheese and described this in detail: “No effects are caused by butter or milk. If cheese was indeed the factor, could it perhaps explain the sporadic nature of the side effect? I hope my comments will be of some use to you in your investigations.” Signed G.E.F. ROWE. 

    I was naïve enough to find this letter amusing and shared it with my fellow residents. A week later, I also showed it to the local representative of Smith Kline and French who manufactured Parnate. He had heard of similar cases as well as a death at a research unit where they had been studying the combination of MAO inhibitors with amino acids.  He suggested I take the letter seriously and investigate the composition of cheese. 

    The first thing to do was to see If we could find out what our own patient had eaten; she was a vegetarian and the hospital menu before her hemorrhage had been a cheese pie. The next obvious but foolish thing to do was to see if I could provoke the side effect myself. So, with one of my fellow residents, a woman, we took Parnate for a week, bought some cheddar cheese from the cafeteria and sat down to see what would happen to our blood pressure. Nothing! We were disappointed but lucky. 

    The cheese idea was beginning to attract ridicule from my fellow residents when a coincidence stepped in to play a part. As a cash strapped resident with a wife and two (soon to be three) children, I supplemented my income by serving as a medical officer in an Army field ambulance whose commanding officer was also a family practitioner, for whom I moonlighted on weekends. One evening I was called by the husband of a patient whose wife was suffering from a severe headache. She had recently been prescribed an antidepressant and had just eaten a cheese sandwich for supper. I jumped into my car and did a home visit to find she was suffering a severe hypertensive crisis from which she made a rapid and complete recovery.  So, I thought maybe people with depression were vulnerable while my colleague and I had been immune from the effects of cheese. Then I persuaded myself it would be ethical to repeat the experiment in another patient.

I approached a woman on my ward who was already taking Parnate and after explaining my plan to both the patient and her husband I bought a piece of cheese from the cafeteria and watched her eat it. For two hours I sat by her bedside monitoring her pulse and blood pressure while nothing happened. I left the ward but within minutes was paged by a nurse to “prescribe the patient an aspirin for headache.” When I arrived at her bedside the patient was in the throes of a hypertensive crisis but an hour later her blood pressure was normal and her headache gone. Now evidence was mounting to support the connection with cheese and one further coincidence confirmed it. I was working late at the hospital one evening when the registrar on duty passed me in the corridor enroute to see two patients who had both been taking Parnate and who were sleeping in adjacent beds. Both were suffering from severe headaches and both had just returned to the ward after eating cheese in the cafeteria where it made its weekly appearance on the menu. I experienced what could be called “The Eureka Syndrome.”  

     In the nine months after my letter to the Lancet I collected 12 cases of hypertensive crisis of which 8 had eaten cheese.  That data was published in the Lancet in October 1963 in an article entitled “Hypertensive Crisis Due to Monoamine Oxidase Inhibitors.” There were immediate responses in the correspondence column. A patient wrote to say she’d known of the association for several months but “doctors laughed at the idea.” The Medical Director of the Pharmaceutical Company said my findings were “unscientific and premature.”  Another physician had “treated hundreds of patients with Parnate and never seen a headache,” even though the data show that headache occurs at least once weekly in a third of the population.        

     These doubts were proved wrong and disappeared a few weeks later when a team at another London teaching hospital discovered the causative component in cheese to be tyramine and published their findings in the Lancet. Tyramine is derived from the amino acid tyrosine during the maturation of cheese. Both tyrosine and tyramine were discovered in cheese centuries ago and named after the Greek word, tyros for cheese.  

     My discovery would evoke changes that helped define my career. I was immediately promoted to the A stream and assigned to Sir Aubrey’s team at the Maudsley and required to wear a white coat.  After watching me closely for several months Aubrey offered me the opportunity of a two-year fellowship in pharmacology under the direction of Professor Ted Marley. Situated in an army Nissan hut on the edges of the campus, my research on rats would be designed to explain the details of the MAOI-tyramine interaction and earned a Doctoral Degree in medicine from Cambridge University. Sir Aubrey, a Greek scholar, informed me that Hippocrates considered cheese to be a “bad article of food” and provided me the reference that became the title of my dissertation. 

    I completed the task of graduating from Maudsley by working with Michael Shepherd, the senior faculty member, and producing two publications as the first author (again in the Lancet). One was an early study on an antidepressant that failed for several technical reasons and the other a critical evaluation of an early Scandinavian study on Lithium with the unusual and provocative claim that it had a prophylactic action, stifling future bipolar episodes. This controversy prevailed in various forms throughout my career in America.  

   Unknown to the faculty and my fellow residents I had also been recruited by the Deputy Editor of the Lancet to write anonymous editorials and annotations on psychiatric topics of interest to the journal. My relationship with the Lancet editorial staff began towards the end of medical school at Guy’s, continued throughout residency training and lasted into my mid-career in America. 

   While at the Maudsley the deputy editor would take me to lunch quarterly at the elite Athenium Club in London where on several occasions we would walk to the dining room, silently past Aubrey Lewis reading the London Times in front of the fireplace. Aubrey never acknowledged, inquired or commented on what I might be doing. 

    Graduation from the Maudsley was marked by London University with a diploma in Psychiatric Medicine (DPM). Sometime after Aubrey’s retirement this was retrospectively changed to a master’s degree in philosophy, which I still hold.  

    As graduation approached Aubrey never enquired about my career aspirations nor did I ask for advice. I was ambivalent, uncertain whether my fate lay in medicine or psychiatry. Certainly not in animal pharmacology. Despite my success in the laboratory, I was clumsy, breaking delicate glass pipettes used for injections and blurring the smoked drums that recorded the rat’s blood pressure. 

    In the end I compromised. My friend and Commanding Officer of the field ambulance I served in on weekends was a successful family doctor in South London and was seeking a partner. The salary was satisfactory and the work congenial. Coincidentally, I agreed to collaborate with a fellow resident at the Maudsley who had designed a study and rating scale to record the prevalence and natural history of mild to moderate psychiatric illness in primary care. At the same time industry was producing novel medications to treat anxiety and depression. We published two papers in the British Medical Journal documenting our results. 

     My friend, fellow resident and co- author, David Goldberg, made a worldwide success of the rating scale and eventually became Aubrey’s successor as the Department Head of the Maudsley, including a knighthood bestowed by Queen Elizabeth. 

    When my year in family practice had reached its end, I heard by chance of a former colleague and resident at the Maudsley who had returned after a year touring America during which he had visited academic programs and pharmaceutical companies. The Merrill Company in Cincinnati had an opening for a Director of Psychotropic Drug Research to take advantage of all the new drug developments. Was I interested? The salary and timing seemed appropriate. It was 1968, the war was over, and morale in America was high; the optimistic years of the Eisenhower Presidency in America created a land of opportunity, a time of upward social mobility and the expectation children could surpass their parents on the economic ladder. However, I quickly learned all was not well at the company I had joined.

Merrell had marketed the drug Thalidomide as a safe compound to treat insomnia, only to find that it caused fetal abnormalities in the children of pregnant women – phocomelia, deformed limbs. Congress responded by passing the Harris-Kefauver Act mandating approval of all drugs to ensure they were “safe and effective.” An FDA physician, Frances Kelsey, had detected the flaws in Merrill’s new drug application and some Merrell scientists were under criminal indictment for fabricating data. As a result, the company had lawyered-up and all its marketed products were under scrutiny.

Among them was a compound named Frenquel with the advertising claim it alleviated hallucinations. Hearing voices and seeing visions are epiphenomena of a variety of psychiatric disorders and the claim was widespread. The drug was available in an oral and intravenous form, with the bizarre claim that the intravenous dose was larger than the oral one. The sales were barely sufficient to cover the cost of production but when Merrell announced they would withdraw the drug, which seemed a no-brainer, there was a substantial response from patients and providers complaining there were no alternatives and they were desperate to obtain it. The FDA was firm; testimonials were not evidence. This was among the first challenges I was assigned as their new Medical Director, was it possible to find humanistic exceptions? 

    I decided to visit one of these vocal supplicants. The office where the cab let me off in Greenwich Village was next to a homeless Drop-in Center. The doorbell was answered by a polite, casually dressed, older physician who greeted me and ushered me into a room in the basement furnished more like a family doctor’s office than a psychiatrist’s den. In the center of the room stood an examining table rather than a reclining couch with an attached shiny aluminum tray on which lay a large syringe containing a colorless liquid I assumed wasFrenquel.     

Sitting on the table, legs dangling and wearing a bright colored, mildly revealing, dress was an attractive young woman. Almost before I could take in the scene, she leapt to the floor, faced me, and began to shout, “so you’re the f-- ing drug company man who’s going to ruin my life!” The doctor moved quickly to take her arm, guided her back to the table, and did his best to calm her. She settled down and lay back, still eyeing me furiously, pulling up the sleeve of her dress to expose the veins in the hollow of her arm. This was obviously a well-practiced routine, which the doctor performed often. He inserted the needle and gently pushed the plunger as the patient closed her eyes and appeared to drift into a light sleep. Visibly relieved, the doctor removed the needle, laid down the syringe and leaned towards her. “It’s all right, Martha, you can get up now.” Eyes open, she smiled at us and thanked me for coming so far out of my way to help her.

Another surprise awaited me; the doctor suggested the three of us have lunch together. We walked to a nearby bistro and, over a meal paid for by Merrill, I spent an hour in the company of two friendly, apparently normal, people. The doctor explained that the alcohol and detox clinic adjoining the Homeless Center used Frenquel often to help bring down people in drug withdrawal. On my flight back to Cincinnati I wrote up my trip report explaining I had found two “off label” novel uses of Frenquel, to calm someone who most likely had a borderline personality and to facilitate drug or alcohol detoxification. I didn’t suggest Merrell pursue research into these potential new indications but perhaps I was wrong, new uses for old drugs are often discovered by chance, looking for one thing and finding another. It’s called serendipity. On the other hand, it seemed more likely that everything attributed to Frenquel might be due to suggestion, the placebo response or spontaneous remission. 

It was hardly the best time to become an industry physician but there were pragmatic and professional benefits. Professionally there was an aura of stigma that made me feel subtly ashamed. But there were also compensatory influences. My contract with Merrell allowed me to spend one day a week at the University of Cincinnati Departments of Psychiatry and Pharmacology, teaching medical students and psychiatric residents about the new drugs available to treat mental illness. Merrill had also obtained one of the country’s leading psychopharmacologists as a consultant, available to me as a mentor.

Frank Ayd was a devout Catholic and father of 12 children who had lived at the Vatican for two years as an adviser to the Pope and Vatican on ethical and mental illness matters. At his private practice in Baltimore Frank had also been one of the first psychiatrists in the world to study and report on the benefits of Thorazine in schizophrenia and he was a founding member of the American College of Neuropsychopharmacology (ACNP).  Frank took me under his wing and introduced me to all the leading psychopharmacologists in America and sponsored me as a member of the ACNP in 1970.  Many years later, in 2008, I had the honor of writing my friend and mentor’s obituary for the ACNP archive. 

We did research together, wrote scientific articles and made joint presentations at the Annual Meetings of the ACNP in sunny Puerto Rico. Both Frank and I were involved in teaching our new discipline to public and professional audiences. Out of this came the idea of bringing together the 15 scientists from Europe and America who had made all the original discoveries in the field. The conference took place in Baltimore sponsored by the hospital where Frank worked and the proceedings were published in 1970 in a book we co-edited, Discoveries in Biological Psychiatry. It was among the very first books published on this topic and is still in print today.  Its contents are listed below: 

Blackwell: The Process of Discovery 

Joel Elkes: Psychopharmacology, a New Science 

Irvine Page: Neurochemistry 

Lother Kalinowski: Treatments Preceding Drugs 

Chauncey Leake: The Long Road for a Drug from Idea to Use  

Tracey Putnam: Anti-convulsants 

Albert Hoffman: Hallucinogens 

John Krantz: Indoklon a Convulsant

Frank Berger: Anxiety, Meprobamate and Tranquilizers

Irvin Cohen: Benzodiazepines  

Pierre Deniker: Neuroleptics 

Paul Janssen:  Butyrophenones 

Jorgen Ravn: Thioxanthene’s 

Nate Klein: MAO inhibitors 

Roland Kuhn: Imipramine 

John Cade: Lithium 

Frank Ayd: Biological Psychiatry  

 I had enjoyed and benefited from my time in industry but felt uneasy about my role. Given the competing priorities of industry and science I knew I would be better placed as a consultant and not as an employee. My self-esteem was tied to education and research rather than product development and commerce. 

After just over 18 months in my dual industry-academic life I was offered an opportunity to reverse roles; to become a full time Professor of Psychiatry and Pharmacology at the University of Cincinnati, with one day a week consulting to Merrill. This would help to support my academic salary and allow me to resume treating patients under the university umbrella without seeking formal licensure. 

American psychiatry had begun to change rapidly. Almost all academic programs had a psychoanalytic Chair; the majority of faculty were analysts and most residents were in analysis with a faculty member. If a resident showed an undue interest in medications it was interpreted as a defense to escape verbal intimacy and punish the patient. 

When I joined the Cincinnati Department the Chair, Maury Levine, who had written a book on psychiatry and family practice, was wise enough to put me in charge of the Psychosomatic Unit which had a distinguished past. This did not sit well with the entire faculty, some of whom warned residents that a rotation under my direction would “ruin their careers.” This advice provoked me to challenge one leading analyst to a public debate and some of the best and most inquiring minds among the residents elected to join me. Three went on to become the Chairman of leading academic departments.  

The Psychosomatic Unit had a distinguished past under the direction of George Engel, an internist who was psychoanalytically trained and internationally recognized for broadening the narrow scope of medicine with a “biopsychosocial” model which emphasized the integration of its three components in understanding illness and disease. When I took over as the junior faculty member, Engel’s views were superimposed on those of Hans Selye who coined the term “stress” studying its effects on the psyche and soma in animals and humans, producing a prodigious body of knowledge in 1,700 publications and seven popular books before his death in 1982. 

The stress model of Psychosomatic disorders was modified by the psychoanalysts in their customary manner; attempting to link personality traits in selected individuals with specific medical diagnoses. For example, they speculated that peptic ulcer was due to unmet dependency needs and hypertension to stifled aggression. Such stereotypes, drawn from a few highly selected individuals were largely mythic, a fact that became painfully obvious when peptic ulcer was shown to be a bacterial infection caused by helicobacter. In 1970 the views of Selye, Engel and the analysts were dominant and popular with both faculty and residents. When I joined Ward 2 West, the psychosomatic unit, the head nurse was assisted by a creative and talented cognitive-behavioral psychologist, whose father pioneered the first heart-lung machine. This began a collaboration that lasted five years, spawning a new and different way of thinking about psychosomatic disorders. 

Our theoretical framework evolved from the work of a social scientist at the University of Wisconsin in Madison and turned the view of psychosomatic medicine on its head. Instead of looking for specific character flaws in patients, it focused on the behaviors that psychosomatic patients displayed in common, independent of the medical diagnosis. It defined the wood rather than the trees. This view was popular with the nursing staff who daily witnessed the common behaviors among groups of patients on an inpatient ward, which physicians or therapists, treating single patients for short periods in outpatient offices, missed or overlooked. This approach made an important distinction between a person’s “disease” (physical symptoms and signs) and their “illness” (how the disease was experienced and responded to behaviorally).

This difference is easily recognizable: take 100 people with the common cold and same rate of runny nose. Some stay home to be cared for by a loved one, others go to work and give it to everybody else. At the severe end of the disease spectrum, consider the onset of crushing chest pain. Some people walk up and down stairs to make sure it’s real; others call for the life squad immediately. A week later in intensive care, some people are demanding to go home while others are reluctant to get out of bed. 

What accounts for these individual differences? Another psychologist developed a “health beliefs” model to explain the way in which response to the signs and symptoms of disease differ from one person to another depending on a host of variables, including their upbringing, life stress and experiences, mood states, social support, attitudes and beliefs. 

Based on these two models, applied to our inpatient experience, we defined illness behavior in patients as characterized by “disability disproportionate to detectable disease” and set out to identify and describe its characteristics. It is this discrepancy between detectable disease and patient behavior that drives some doctors to despair. Unable to make a diagnosis or produce a cure, they resort to rejection and labeling such people as “hypochondriacs” or “crocs.” Unfortunately, illness behavior is often in the eye of the beholder diagnosis. Some physicians are not empathic or constitutionally inclined to prefer patients who are stoical and uncomplaining. Some settings are conducive to a dismissive response such as prisons, the army or doctors in primary care, operating under unreasonable time constraints. 

It was incumbent on us to not only define this behavior but to evolve a convincing explanation for its cause and its management. Identifying the outward manifestations of illness behavior does not identify the cause any more than pain or fever reveals the underlying source, leading to correct treatment. For example, fever may be due to a virus or bacteria but only the second responds to antibiotics. So, we need to know why a person is behaving sick. A helpful, indeed essential, axiom is that nobody behaves sick if they know how to behave healthily.

There are two basic reasons a person may have adopted a sick instead of a healthy role and both are usually present in varying degrees. First, the person is trapped in an existential predicament where they are unable to meet the demands and expectations of a healthy role. They lack the necessary skills or fear failure and are trapped in a situation from which they cannot escape. Perhaps they have been promoted beyond their ability and have a harsh boss. Maybe they are overwhelmed by parenting, lack of skills or have an abusive, demanding spouse. There are an infinite number of such situations often concealed by shame and secrecy. It’s often elaborated by low self-esteem, depression, lack of energy, social phobias or learning disability. Illness becomes a safe harbor or shield. The first set of variables are called “avoidance behavior” by cognitive behavioral psychologists or “primary gain” by psychoanalysts.

The second set of forces to be reckoned with are the factors that reward or reinforce the sick role. This is called “positive reinforcement” by psychologists and “secondary gain” by psychoanalysts. It includes monetary incentives, litigation, entitlement programs, compensation and, more commonly, sympathy, caretaking, help or status as a special or complex patient. Almost always, both kinds of factors coexist in a push-pull combination of primary and secondary gain. 

Treatment follows logically, increasing a person’s capacity for healthy behavior and decreasing or removing the rewards for illness behavior. This is much more easily said than done. It requires time, sophistication, empathy and competent knowledge about both mind and body. The model demands many different points of attack. It must begin with a thorough physical evaluation and review of medical records, which reassures the patient their concerns are taken seriously. If there are existing or impending financial rewards, treatment is unlikely to succeed and this needs to be frankly discussed with the patient.  

Family and caretakers need to be involved and agree to encourage the patient’s increasing attempts at independence while reducing or removing their own oversolicitous caretaking. Many have their own unmet needs to care for others. Physical rehabilitation is often called for and patients are encouraged to set their own goals. It is reasonable to suggest that talking about pain or disability often makes it worse. 

Existing physical and emotional problems must be adequately but conservatively treated, especially comorbid psychiatric disorders which are seldom openly acknowledged. The commonest form of illness behavior is a chronic pain condition in which nine out of 10 patients have depression, manifest poor motivation, lack of energy and pessimism, all barriers to rehabilitation.  

We studied this treatment approach and its successful outcomes for more than two years and published our results in a leading medical journal, but it is seldom used today. We had the luxury of extended inpatient stays and reasonable insurance coverage in the days before managed care. People with psychosomatic disorders have preexisting conditions, high deductibles and expensive co-pays. Those who complain of pain often end up addicted to analgesics. Some things have changed, and some stay the same. Psychosomatic Medicine is now a term seldom used, largely replaced by Behavioral Medicine. To illustrate wisdom over adversity what follows is a single case study and a brief prose poem on the subtlety of the pain experience. 

It Only Hurts When I Cry 

Lucinda did not look like a clown. She was short, skinny and sad. At her outpatient evaluation the staff was preoccupied with Lucinda’s many pains, wheezy chest and ailing heart. Her hobbies hardly seemed significant. After she was admitted to the pain unit, Lucinda’s cardiac condition was stable, her pain was chronic and she remained sad. Lucinda grudgingly agreed there was nothing fatal or malignant that caused her suffering, yet she was unable to give up her aches or their audience, until she glimpsed solace elsewhere. 

Lucinda’s slow progress ended abruptly soon after she told us that four generations of her family were clowns, including men and women, grandparents to grandchildren. Each clown created his or her unique face; either white, the provocative French Mime, Auguste, the boisterous German boy, or Tramp, a downtrodden American bum. Lucinda was too old to be Mime and too slender to be Tramp. She chose Auguste, a jovial extrovert who jostled the other clowns. 

One day Lucinda brought her clown regalia to the hospital and painted on her face to entertain the other pain patients. It was a metamorphosis as dramatic as caterpillar to butterfly. Lucinda’s crescent lips curved upwards into a smile that spread as far as the crow’s feet around her eyes. As she went into a routine Lucinda shed the limp, her shoulders lifted and her voice lost its weary timbre.  

Once clowns are attired, they adopt etiquette. Profanity, smoking and drinking are forbidden. If children rush up to tweak their bulbous nose or tread on their oversized feet, clowns are enjoined to banter back. Irritability and anger are outlawed. Lucinda played the role to such perfection that her aches were no longer obvious. Nobody knew for sure if they still existed. Talking about pain makes it worse, so in social situations staff and patients are instructed not to inquire. But in the morning rounds, when we wear our white coats, we are allowed to ask. Lucinda told us that the pain was hardly present when she clowned. She sounded surprised, although it was something she had noticed years before but had ignored. Instead, the worse the pain the less she had performed, so that even the clowns in her alley left her alone. 

Once Lucinda learned she could control the pain everything else came quickly. She mastered biofeedback, reached her exercise quotas and slept soundly. When we asked her later what helped the most, she talked about learning to be assertive with her family and no longer letting the kids take advantage. She learned to set limits on their demands and to get her own needs met without needing to suffer or be sick.  

Our time on the pain unit ran out together. My monthly stint as attending position was over the day Lucinda was discharged. At morning rounds the patients sit in the day room waiting for us to see each of them in turn. As I looked up, I saw Lucinda in the wings, ready to walk on stage. She smiled and sat down. The rehearsal was over, the performance was about to begin. I asked her how she would make it in the real world without grease paint. Lucinda laughed and said she thought she could: “Now I can be a clown without letting the kids walk all over me.” 

Light Touch 

Tickles are a curiously dilute form of pain; they travel the same path through the body to the brain. Both sensations are enhanced by the presence of another person. Biologically it makes perfect sense. Suffering and pleasure were meant to be shared, nourished by comfort or communication. Talking amplifies pain, inviting solace. Tickling is for two. When nobody is there, the sensations diminish or disappear.

In my practice I often see chronic pain. Intractable but benign, it ruins life rather than ending it. I witness its contortions and attend to its sighs. Seduced by its symptoms, I become the significant other. Only when we can discover some new pleasure in a patient’s life am I emancipated from charts as thick and heavy as tombstones. Often, we cannot. Bad thoughts, scant sleep and poor coping collude with the pain. To break the cycle, I am sometimes tempted to prescribe. Drugs named antidepressants block rumination, induce sleep and restore coping. When that happens, I wield my pen lightly. It feels like a feather. 

At the time I migrated to America Herbert Benson published his book The Relaxation Response suggesting that this was an effective treatment for many of his patients with psychosomatic ailments at Harvard Medical School. His faculty mentors disagreed and expressed the view that only surgery and medications were adequate treatments and required Benson to obtain the funding to support his research and publish the findings in a first rank Journal. This was not accomplished for several decades. 

While this was happening, I had moved from industry to academia and once I had secured my position and research goals for the psychosomatic unit at the University of Cincinnati, I was ready to also focus on my psychopharmacology interests. 

The first two studies I completed tended to validate Benson’s hypothesis. The Relaxation Response evoked comparison with both ancient forms of mindfulness meditation as well as contemporary Transcendental Meditation. My first study was on the effects of Transcendental Meditation in the management of high blood pressure. These were positive, but variable between individuals and the results were published by the Lancet. 

The second study focused on the placebo response as a likely constituent to the benefits of Mindfulness. I was teaching a pharmacology course for first year medical students. Together with a pharmacologist, fellow faculty members and a statistician we designed a study and used the students as subjects in the classroom. It was described as a double-blind comparison between a stimulant and a sedative drug, but both were placebos.   Students were randomly assigned to receive one or two red or blue capsules and later in the class completed a rating scale to record their responses on mood and side effects. They also worked in pairs to measure blood pressure and pulse rates.  

Based on the existing placebo research in the literature we predicted the nature, size and frequency of the treatment responses obtained by the students which we sealed in an envelope to be opened at the next lecture after we had tabulated the nature, size and frequency of the student’s responses. Every prediction in the literature was confirmed. A third of the students reported changes in mood and some had side effects. Red capsules had more stimulant effects, including increases in blood pressure and pulse rate while blue capsules produced sedative responses. Two capsules produce more effects than one! Even we were surprised and so were the students. The Lancet published the study, but I don’t believe it has ever been replicated. 

When the experiment was over the Chair of the Pharmacology Department expressed ethical concerns about the deceit. But the students saw the point and approved. When the course ended, they awarded me their Golden Apple as Teacher of the Year. Half a century later it still sits on my desktop. 

By the 1970s the perspective on all the new psychotropic drugs for each of the major disorders had consolidated regarding efficacy and side effects, mostly in a positive direction with one startling exception. In that same time period from 1964 to 1972 the use of anti-anxiety drugs had increased from 25 million to more than 70 million prescriptions at a cost of $200 million, due entirely to one drug, Valium, prescribed by 97% of Internists and General Practitioners. An essay I published speculated about the reasons from an historical perspective. 

Twice in a While 

     In every age there are medicines of the moment that divide doctors and patients down the middle. In the 18^th century it was opium; in the 19^th, bromides and in the early 20^th century, barbiturates. The 1960s ushered in the benzodiazepines like Valium in an era of John Kennedy’s Camelot. By George Orwell’s 1984 it was clear that some people were more equal than others and that these drugs were prescribed unequally often to women, the indigent, the elderly and the maimed. 

These new drugs were so safe they could be used more often but for less reason, raising hackles on segments of the public. Were mind tampering drugs being used to correct a social or chemical imbalance? Were doctors dabbling in existential predicaments beyond their bailiwick? Was the medicine for mothers-in-law or a pharmacologic lid to Pandora’s box? 

These are all appropriate questions to be asked in an age that amplified anxiety and invented safer tranquilizers to treat it. But the problem is broader and older than that. It has existed as long as there have been panaceas, a physician to prescribe them and a public eager to seek comfort. Even if the correct agenda is caretaking and not chemicals, the drugs often help in uncertain ways. Which drug it is doesn’t really matter but how it happens does.  It could be and has been, various tonics, liver extract, vitamin B12 shots, iron tablets or thyroid pills. They are given to patients who visit doctors when life events have loaded up on them. Often these are symptom-sensitive people, with the amplifier turned up on their autonomic arousal. They voice distress in body language and invite doctors to collude with diagnosis and prescriptions. After they leave the office, life subsides or the pills placate them. A cycle is set. Next time a spouse leaves, a job ends or a child is sick they return expectantly for more. “Those pills you gave me really helped,” they say. 

Doctors disagree about all this. Prescribers are “Chemophilic Hedonists” say the withholders. Withholders are “Pharmacologic Calvinists” say the prescribers. My partner and I sit in friendly disagreement on opposite sides of this rhetorical fence. She is younger and knows where the benzodiazepine receptors are in the brain. When her patients see me, we talk briefly about their troubles. Some, in a minor way, seem more tranquil.  Others sense the skepticism with which I write their refills. Once in a while isn’t wrong, they ask? Perhaps twice in a while I reply. 

In the mid-1970s, in my late time at Cincinnati, I became aware of the fact that of all the “non-drug factors” that influence treatment outcome, none is more important or more overlooked than when the drug is not taken at all or not in the manner intended.  

Neglect of this topic is curious; ever since Eve ate the forbidden fruit it has been obvious people sometimes fail to follow directions. Hippocrates warned of this in his quotation, “Keep a watch on the faults of the patients which often make them lie about things prescribed.” This warning was largely ignored and the word “compliance” did not appear in the medical literature until 1975 when it replaced the term “medical dropout.” 

Several factors explained the late interest in this important topic. First, although Hippocrates laid the blame on the patient, research has shown that physicians seriously underestimate the size of the problem with their own patients. Secondly, when most drugs were panaceas or placebos, not taking them hardly mattered and failed to alter the course of the disease. It was not until the mid-20^th century and the discovery of modern pharmaceuticals, including antibiotics, analgesics, steroids and psychotropic drugs that the failure to take the medication became a life and death matter. Thirdly, the arrival of modern medicines contributed to the patient’s rights movement and the demand for a more active role in treatment decisions. Lastly, added impetus due to the involvement of additional disciplines in the prescribing process including, pharmacists, psychologists, optometrists and nurse practitioners. 

My interest in the topic of compliance originated amid this ferment. I published my first article on the topic in 1972 and the following year was invited to write a second titled “Drug Therapy: Patient Compliance” for The NewEngland Journal of Medicine. Shortly after that I participated in and presented papers at the first two International Conferences on Compliance held at McMaster University in 1974 and 1977. This jumpstarted research in the field with which I remained involved for a quarter century, culminating in editing my own book, Treatment Compliance and the Therapeutic Alliance, published in 1997, towards the end of my clinical career. 

In the quarter century, 1972 to 1997 more than 12,000 articles were published on the topic involving 50 different conditions of which Pediatrics, Psychiatry and several chronic disorders were the major topics, including asthma, diabetes, glaucoma and hypertension. Seat belts and smoking cessation were late comers in the field. Despite the volume of research, quality and consensus were lacking.

Compliance is not an easy subject to study because the problem tends to disappear under scrutiny and covert observations without the patient’s knowledge raise ethical concerns. Consequently, more than half the studies failed to yield any conclusions. The positive results were kaleidoscopic and varied, often involving attitudes and beliefs that are both difficult to measure reliably or to influence predictably. Nevertheless, some generalizations emerge: the extent of non-compliance, complete or partial, involved about a quarter of inpatients and half of outpatients.

Factors associated with good compliance are when patient expectations of treatment are met, if they are satisfied or supervised, if the disease is serious and the patient feels susceptible. Involved family members, friends and care providers often make a positive contribution. Poor compliance is associated with chronic diseases and prolonged treatment, such as lithium prophylaxis, complicated regimens that require lifestyle change, asymptomatic diseases such as glaucoma hypertension and diabetes, significant side effects, stress, isolation and alcoholism. 

Most of my writing and teaching about compliance was conceptual and based on reviews of the research literature. The semantics of the compliance problem is resolved when it is viewed as a treatment alliance between two individuals who need to negotiate and reconcile their different roles, knowledge, attitudes, beliefs and goals. Doctors are trained to portray knowledge, certainty and confidence. They are often quick to inform and slow to inquire. Patients, on the other hand, are often anxious, intimidated or subdued during the encounter and reluctant to be assertive.  

Two New Medical Schools 

By the mid-1970s my interests and ambitions aspired to the Chairmanship of my own department with a broader educational mission. The Federal Government had established a nationwide program of 30 new medical schools located in community settings, away from the academic Ivory tower and directed towards graduating physicians as Primary Care Providers willing to work in underserved urban and rural locations. Ohio had already two such programs and a third was planned for Dayton at Wright State University. I applied, was appointed and began to commute and recruited a psychoanalyst as my Vice chair and a cognitive behavioral psychologist as Director of Medical Student Education.    

I relocated in 1974 and began developing the four-year curriculum for graduation in 1980. To understand both the challenge I found and the lessons I learned I will compare two abstracts from published papers. 

The first, published in 1977, in the Alpha Omega Journal was titled “Old stresses and New directions.” It describes my aspirations and frustrations three years into the task at Wright State. The second published in 1985 in General Hospital, five years after graduation, describes the lessons learned with the title “Medical Education and Modest Expectations.” 

Despite rigorous medical school admission procedures, designed to select the brightest and best qualified applicants, the demands of medical education tax the coping capacity of most students and overwhelm the few. About 40% of students experienced significant stress and 8% dropped out. Half of those who experienced stress seek help, two-thirds of these have symptoms of anxiety or depression and a third report personal or sexual difficulties. In a class of 200 two or three students may have a psychotic break. The educational process that produces these stresses is equally open to question.

During the past decade, two major concerns have surfaced. The amount of information to be transmitted has increased dramatically. Medical knowledge now has a half-life of five years and is predicted that three quarters of the knowledge useful to a practicing physician will have to be acquired through continuing medical education. Secondly, imparting this information within the Flexner tradition has created physicians who have come to regard themselves as technical specialists and who have been segregated from the needs of people and communities. This process has produced a social and political backlash, with a demand for more emphasis in medical education on producing physicians interested in primary care in community settings. Given these facts, let us examine the current system to see how it imposes stress and molds its educational product and second, examine the changes proposed in the newest medical schools, to see how they are likely to impact on the problems of student stress and the educational process. 

The Student Experience 

Joan Priestly, a journalist who entered medical school in the fall of 1974 has written eloquently about her experiences and I shall quote her in some detail. She begins as follows: “There they were, 201 excited and anxious people, mostly white or mostly male, nervously fingering their introductory packets, listening to the Deans saying that now they were part of a special community. The import of what I was doing with my life by entering Medical School never really struck home until I walked in the door for the first day of class. I approached medical school from an essentially fear based perspective, fraught with overwhelming awe for the seemingly superhuman intellect and endurance necessary to become a physician. And, of course, the counterpart to that was the continuously gnawing doubt and fear that I lacked those traits and would not make it through.”

Recently, members of the graduating class at Southern Illinois University completed an unpublished review of their experiences in medical school entitled “Going through the Change.”  They found the most common and major sources of concern by far to be information overload, performance anxiety and problematic relationships with the faculty. While these may be identical in any graduate program, social and personal expectations accentuate them in medicine. “Saving lives” implies the need to know it all and to apply it perfectly.

Priestly writes, “throughout our entire daily education we examined and described the human body. Its physical components, processes and malfunctions. Hopefully, this narrow focus gives us the background and insight necessary to exercise control over people’s desires to take medication, to reproduce or abort children, to understand their sexuality, to cling to life, or willfully terminate their existence. No other professional school makes even a pretense of training students for such awesome and complete power over people’s lives. But before reaching this goal, the student must assimilate a vast knowledge, one expanding exponentially; one that cannot even be acquired until a vocabulary of more than 13,000 new words has been mastered. He also has a comforting awareness that the art of applying this information is not found between hard covers. So, students turned to the faculty for an allocation of learning priorities and for physician role models. Such expectations are easily frustrated and can manifest themselves (sometimes appropriately) in concerns about unfair grading procedures, ineffectual teachers, irrelevant lecturers, or the arbitrary application of faculty power over student affairs.” 

The Faculty Experience

From the Hippocratic ideal to the Marcus Welby image, the stereotype of the physician is of one who is always available, constantly kind and inherently wise. How to best educate physicians to fulfill this exacting role is an old and difficult problem. Neither society nor the profession has been modest in their expectations of meeting these ideals.  

Medical educators have voiced their concern for more than 50 years. In an address to Harvard medical students in 1927, Francis Peabody, a distinguished internist, complained that “young graduates have been taught a great deal about the mechanism of disease but very little about the practice of Medicine, or to put it bluntly, they are too scientific and do not know how to take care of patients.”

In 1978 George Engel, my predecessor at the psychosomatic unit in Cincinnati and a distinguished internist, proposed a new biopsychosocial model of medicine and commented that “medical education has grown increasingly proficient in conveying to physicians sophisticated scientific knowledge and technical skills about the body and its aberrations. Yet at the same time it has failed to give corresponding attention to the scientific understanding of human behavior and the social and psychological aspects of illness and patient care.” 

In the 50 years between these almost identical admonitions, the faculty and curriculum of medical schools have expanded prodigiously: the amount of time devoted to teaching the Behavioral Sciences and Psychiatry has increased from 26 to 362 hours during the four-year interval between admission and graduation. The extent of the experimentation can be gaged from the observation that 43 different disciplines or departments are involved teaching these topics and that as many as seven different programs collaborate in some schools.  

The fact these concerns persist and the pluralism of attempts to address them indicate the absence of an ideal answer. If anything, modern medical terminology has further eroded this possibility. The competent generalist has given away to the highly trained subspecialist and the art of practice has been eclipsed by science. Doctors have clustered around City Medical Centers and shunned rural communities. As the technical competence of the profession has increased its availability and humanity has been called into question. 

By the mid-1970s my time in Cincinnati had broadened the scope of my interest in the social and psychological aspects of Medicine coupled with my existing knowledge of the biological components. My chairman Murray Levine was stricken with late onset acute leukemia and sent me one of his renowned “Memos from Maury” offering to initiate a novel kind of conference for each of us to combine psychoanalytic with biological perspectives. But Maury died and I decided to move on.

I took with me to Wright State, a Vice Chair who was a psychoanalyst and a Director of Medical Student Education who was a cognitive behavioral psychologist. Like most of the new medical schools founded by the Kennedy Administration, the Dean at Wright State had added an Ethics and Humanism program. Many of the new faculty were eager to experiment with the curriculum and the admissions committee was flexible and innovative in accepting a wide variety of applicants. The charter class included a helicopter pilot, a housewife with several children, a classics major and an African American psychotherapist. 

Efforts were made to design “a benign behavioral science course.” The failure of one such experiment with which I was involved could probably serve as a stereotype. Concerns are voiced about the Medical Model which originates from the time when Christian Orthodoxy permitted dissection of the human body provided that a strict segregation was preserved between the physician’s province of the body and the church’s domain of the mind and spirit. This dichotomy fostered an attitude in which life is stripped of its social and psychological complexity and reduced to a technology reliant on physical phenomena. In medical school, this dualistic approach is fostered by the psychological defenses that students mobilize to cope with the stress of exposure to the dead body. So, we designed an experience to heighten the student’s awareness of this situation and its relevance to future practice.

Faculty from the departments of Anatomy, Pathology, Psychiatry and Humanities met with students on the first day of class to discuss their feelings and formally share in the introduction to their cadaver. That evening the students wrote a fictional biography of the cadaver and the next day shared this and the experience of their first dissection with the faculty. This experiment in humanizing the student encounter was originally popular but failed to survive for reasons that are intrinsic to the problems of changing medical education. In order to create a summer break, the task of dissecting the entire human body was condensed from two semesters to one.

The founding faculty who designed the class left and were replaced by more skeptical faculty who had not shared in the planning. The class size expanded and contained fewer idealists and more traditional students. After three years the polarization between staff and students was such that, the experiment was dropped. Philosophy confronted logistics and lost. The paradox is that the very scientific advances that create the need for humanism simultaneously crowded out of the curriculum. Our failure was symbolized when a student who participated in this experiment cut the penis off his cadaver and flashed it on campus. 

We may be looking at this problem through the wrong end of the telescope. The greatest anxieties of medicine come in practice and not in the preparation for it. Our own study of residents in training found that the main stresses of adopting the physician role are acting in unexpected emergencies, dealing with ambiguous situations and making decisions without adequate data.

The strategies that residents adopt to cope with their anxieties include appearing more certain than they feel, assuming absolute control in emergencies and adopting a set approach to complicated problems. Thus, the essential tasks of the physician role arouse anxieties and coping strategies that may initiate a process of alienation from the patient. They breed arrogance, uncertainty and insensitivity that provoke inevitable responses from the patient.

Some patients adopt passive dependence, others react angrily to this paternalism and only a few can meet the physician’s needs for information or control in an effectively assertive way. This basic dynamic of the physician-patient encounter needs to be more clearly enunciated and better understood. Physicians often discover this themselves when they relax after years of practice and find that their encounters are enhanced if they can share their own and their patients’ beliefs and uncertainties. The arrogance that becomes a reflex to deal with life-threatening emergencies during hospital training mellows with time and the tempo of office practice to become an occasional and necessary tool for taking control in ambiguous situations.

The degree to which this process of humanization can be accelerated is questionable. Attempts to do so in pre-graduate training occur at the time when they are least relevant and compete poorly in an overcrowded curriculum. During internship and residency, the goals of humanization are subordinate to the more pressing tasks of role adoption. 

There is no Holy Grail; like Canute I learned that the tides of medical education cannot be turned. If changes come about as the result of the new medical schools, it will be because they flooded the marketplace with physicians. The laws of supply and demand are operating to fill the less popular, least paid and unpopulated places. Those who practice there will find the limited degree to which education abbreviates experience and the greater extent to which time tempers science with the art of Medicine. 

In return for more modest expectations about what medical education can accomplish, the profession may feel less frustrated, the public less disappointed and individual practitioners less prone to impairment. 

A Second Medical School 

Lessons learned from my first experience in a new medical school did not deter me from undertaking a second task offering new challenges. I moved from Dayton to Milwaukee in 1980 after the charter class of medical students at Wright State graduated. It was already clear that the goal of producing primary care physicians for under-served areas would fail. Selecting a Surgeon as Founding Dean did not help, especially an aggressive and ambitious individual whose primary goal was to create the post of Vice President for Health Affairs and take over the school of nursing. The feminist faculty was proud and protected its professional independence, a position I openly supported and which ultimately led to resigning my Chair in the school of Medicine. 

Although the birthplace of the Wright Brothers and aviation, Dayton was an undistinguished, dwindling city, halfway between Columbus and Cincinnati. So, I was glad to be recruited by the University of Wisconsin School of Medicine in Madison to participate in a new venture, the adverse of the Wright State experiment.

This well-established medical school was seeking to create an urban campus in Milwaukee, the largest city in Wisconsin, to provide teaching access to a medically underserved inner city patient population with a high incidence of chronic and severe medical, obstetric and psychiatric disorders. Mount Sinai, the downtown Jewish hospital, was facing an urban flight to the suburbs and having problems filling its beds. Perhaps an academic affiliation with a well credentialed faculty might stem the tide and attract better insured patients. 

This became a “marriage of convenience” between Madison and Mount Sinai; the hospital would gain prestige and paying patients, the medical school would have access to pathology for teaching with space and support for faculty salaries, paid for from hospital revenue. So, in the summer of 1980 I was attracted to this scenario. In my recruitment I quizzed the Dean about the economic integrity of the deal and was assured it was “As safe as Fort Knox.” Events proved otherwise.  

My educational and administrative task was to create an Academic Department of Psychiatry and this was completed with the recruitment of faculty, accreditation of the program, development of curriculum and filling our residency slots with a mix of American and foreign graduates. But the timing for this was terrible as the cost of health care and insurance were increasing exponentially.  And on the horizon, the government and insurance industry were about to address over-utilization of inpatient services. Medicare and Medicaid introduced statistical norms for lengths of hospital stays by diagnosis (the DRG), while the insurance industry introduced “Managed Care” by which hospital stays were pre-authorized and monitored for appropriateness, duration of stay and outcome. Not surprisingly the hospital census declined and revenue dwindled. 

In 1980 there were five inner city hospitals but over the next decade, bankruptcies, closures and mergers took place. The Lutheran Hospital merged with the Catholic Deaconess Hospital to become Good Samaritan. Samaritan merged with Mount Sinai to become Sinai Samaritan and the psychiatry department moved its offices to the Samaritan Campus. 

These interdenominational mergers created culture clashes that were difficult to manage and within two years, by 1990, a new dynamic was emerging. The surviving institutions coalesced into three large, allegedly not for profit, Healthcare Corporations. The largest, and most aggressive of these, was named Aurora. Inevitably, Aurora acquired Sinai Samaritan and renamed it Aurora Sinai. It was now the only remaining inner city hospital, still the Milwaukee campus of the Madison Medical School, but now bearing the entire burden of the inner city indigent and Medicaid population, good for teaching, bad for revenue. 

Faculty were now exposed to a new breed of aggressive hospital administrator, armed with novel mottos learned in business school: “No Margin, No Mission” and “Every Bucket Must Carry its Own Water.” The meaning was clear, make a profit or else, and nobody is going to bail you out, even a more affluent institution in the same corporation. 

The writing was on the wall: specialties like psychiatry and primary care, based on personal care not on remunerative technical procedures, were doomed. The Dean fled back to Madison and within two years Aurora pulled the plug on the psychiatry department and its residency training program. Internal medicine and family practice lasted a little longer until Aurora issued an edict that faculty were no longer to treat underfunded Medicaid patients. Those who refused were asked to resign or were fired. Those who submitted became Aurora doctors but no longer faculty; there was no one to teach and no patients to teach on.  But the former Chair of Family Medicine became the CEO of Aurora, and eventually, a millionaire. In May of 1994, JAMA published my story under the title “No Margin; No Mission.”  

I remained Chair of a dwindling and discouraged department but still with one interesting and challenging issue that involved a large homeless population, many with mental illness and substance abuse, an epidemic of AIDS, unemployed Veterans from the latest war and surges of “not in my backyard” public sentiment. Homelessness was again on the rise. We were entering a Recession, President Reagan was trimming the welfare rolls, gentrification of the inner city was underway, more Vietnam War veterans were jobless and outpatient mental health services were squeezed by managed care protocols and Healthcare Corporations with their mantra of no margin, no mission.

Nobody deserves what they couldn’t afford and, if you were homeless, that was not much. The main purpose in establishing a Milwaukee campus was to enlarge student access to the wide spectrum of urban healthcare and its problems. Milwaukee already had an enviable reputation for meal sites and shelters serving the homeless backed by local churches or hospitals and staffed by volunteer citizens and professionals. Soon after I joined the campus, I volunteered as the first psychiatrist at Saint Ben’s Healthcare Clinic and meal site, a short walk from my office at Mount Sinai in downtown Milwaukee. I became familiar with the problems of homelessness at the time Congress had turned its back on the problem while a series of studies by the Institute of Medicine and others were reporting the reciprocal relationship between Physical illness, mental illness, aids, poverty and homelessness. 

Alerted by these reports, in 1983 the Robert Wood Johnson and Pew Foundation funded a four-year demonstration project on homelessness to be implemented in 19 cities selected from the 51 largest urban areas in America. The project was administered by an advisory committee which included five city mayors, chaired by Henry Maier, Mayor of Milwaukee. In 1985, $25 million was awarded to 19 of the 45 cities that submitted applications. Milwaukee was included and I became involved. The data was collected over a two-year period from 1995 to 1997 and it included 63,000 homeless clients seen in 17 of the cities. 

The results of the study provided the first national database on the prevalence and problems associated with homelessness. They were published in a 1990 book entitled Under the Safety Net co-edited by Philip W. Brickner, Linda Keen Scharer and Barbara A. Conanan . I was invited by the editors to coordinate and write the chapter on psychiatric and mental health services. This was a collaborative effort among six contributors: representatives’ coworkers, clients and patients in four cities, Albuquerque, Baltimore, Milwaukee and San Francisco. I was appointed the main author for the article combining the experiences of homelessness in these four major cities. I began the report with a quotation I had discovered from Sigmund Freud written in 1918. 

   “One may reasonably expect that some time or other the conscience of the community will awake and admonish it that the poor man has just as much right to help for his mind. The task will then arise for us to adapt our techniques to the new conditions. Possibly we may often be able to achieve something if we combine aid to the mind with material support.” 

--Sigmund Freud, 5^th International Psychiatric Conference, Budapest, 1918. 

What follows is a synopsis of why people with mental illness are homeless derived from the four cities contributing to the article.   

Homelessness is multiply determined, contributed to by both socioeconomic and clinical factors. The former includes social problems such as increasing poverty, reduced stability, availability of low-income housing and lack of affordable healthcare that are not unique to the mentally ill but that may affect them as a vulnerable population. Some socio-economic factors have a more specific impact upon the mentally ill; they include stringent eligibility rules or long waits or poor disability benefits and neighborhood resistance to group homes. 

Particular to people with mental illness has been several effects of deinstitutionalization. Its impact has been debated, but in one state hospital 35% of patients released became homeless within three months. However, by no means have all the mentally ill among the homeless been institutionalized and some have had no contact with the mental health system. 

Widespread closure of mental hospital beds reduced hospitals’ capacity to provide asylum to the disabled, with both good and bad connotations. At the same time, the provision of adequate community support has been limited by the failure of community Mental Health Centers to attend to the needs of the chronic population, by failures to shift resources from institutions into the community, by failure to develop new support programs and by absence of attention to linkages between agencies. The lack of community residential facilities has also been clearly defined. 

From a clinical viewpoint it is possible to see how individuals with psychiatric illnesses might have difficulties obtaining support when both societal and medical resources are inadequate and poorly integrated. As a population they display poor social skills, thinking and judgment clouded by psychosis or substance abuse, behaviors that often appear bizarre and impulses that may be poorly controlled. Not only do these difficulties diminish the capability to garner scarce resources, but they also invite discrimination and stereotyping. 

Finally, the plight of the homeless who have mental illness has been unwittingly worsened in some states by commitment laws that discourage involuntary treatment until violence is imminent or has occurred. It is easier to arrest those who behave bizarrely than to get them into psychiatric care. Coupled with the lack of mental health services, this has contributed to criminalization of the chronic mentally ill.

In Albuquerque, a survey comparing the mentally ill homeless with other homeless individuals found that the mentally ill homeless had more often been in jail (80% versus 64%). They also had been the victims of crime (77% versus 58%). Whatever difficulties mental illness imposes or compounds, its presence is neither a necessary nor a sufficient cause for homelessness. Many homeless persons do not have mental illness and only a minority of those with mental illness are homeless. 

The process of becoming homeless involves disconnection from family or friends. Not surprisingly, a common characteristic commented on by those who work with homeless individuals is the problem of alienation or difficulty with affiliation, evident in interpersonal relationships and in relationships with social agencies. This problem is contributed to by an overwhelmed social service system which often exposes the homeless to frustrating and dehumanizing experiences, by stigmatization, and the social circumstances of the homeless, by psychiatric illness and perhaps by psychological difficulties based on earlier mental trauma. 

Homeless people are often easy to identify because of their poverty, the fact they frequently must carry all their possessions with them and because of the difficulty they face in maintaining personal hygiene as the result of the lack of facilities. Time, visibility and low socioeconomic position isolate them and invite discrimination or stigmatization, manifested by being banned from public places or simply objectified and avoided by the public and passersby. 

Homeless persons are vulnerable to the dangers of crime and victimization, they often express fears of being beaten, attacked, robbed or raped. This leads them to be careful of whom they talk with or where they stay. In some cities women prefer shelters to hotels because of the crime rate and isolation in the latter. Even in the relatively safe environment of a stable San Francisco shelter, women who have seen each other for months or even years avoid speaking to each other. Although not peculiar to those who are mentally ill, an inability to affiliate is sometimes a component or product of psychiatric disorders.

Psychotic conditions complicate family dynamics in the community and certain personality types such as borderline, antisocial, paranoid or schizoid occur relatively frequently among the homeless and are characterized by difficulties with attachment. This often results in loss of affiliated support through family rifts and unemployment. In Detroit, 70% of those who were homeless on admission to a State Hospital had become so at the time of family breakup, rejection or crisis. 

Problems of affiliation among the homeless may have a developmental origin in some cases. One study of the early experiences of homeless men found a high frequency of separation and delinquency during childhood. A case control comparison among women found that those who became homeless had been physically abused eight times more often than housed women, 42% versus 5%. Another survey found that 18% of homeless women in Albuquerque had histories of sexual abuse.  

Here is an example of a homeless individual. 

Mike H was referred to the outreach team by a waitress from a coffee shop on the outskirts of the city. When he was first seen, his appearance was rough and dirty, his clothes were disheveled and he admitted a foul body odor. Mike explained that he had been on the streets for almost 12 years and that he was trapped there by “evil spirits and demons” that made up the “masonry of the universe.” They kept him from leaving the boundaries of a full block area within which he slept in a sleeping bag on the steps of a local church. 

The outreach team visited him two or three times weekly, taking food and candy, often buying him coffee. They sat with him on the sidewalk, listening, offering advice and coaxing him to venture in their van outside his area. On one occasion a team member shared the food Mike had retrieved from a dumpster. Little by little, over many months, team members gained his trust; he became more comfortable with them and seemed to look forward to their visits. The team’s next step was to obtain Social Security benefits. A field representative met Mike at the coffee shop and completed the paperwork. Next the team found a psychiatrist willing to conduct an evaluation outside his office. Attracted by the possibility of obtaining income, Michael agreed, and they met on a downtown street corner within Mike’s safe zone.

The psychiatrist confirmed the diagnosis of paranoid schizophrenia. Among other things Mike told him, “I see eyeballs and stuff; heads and eyeballs just hanging there. Groups tell me the bodies are controlled by computers, just sad soul-destroying things. The bodies are pre-engineered.” As Mike’s trust in the team grew, he ventured outside the boundaries of his domain and agreed to accept a community support program as his payee after Social Security was awarded. Once in the program, he agreed to take medication and he’s now stabilized and living in housing. The street outreach team continues to see him weekly and finds that he has now made friends whom he visits regularly. 

The Robert Wood Johnson-Pew demonstration project had important outcomes; it aroused public interest and concern and stimulated political involvement. Congress passed the Stuart B. McKinney Homeless Assistance act, which was signed into law by President Reagan in July 1987. Between 1987 and 1989 Congress appropriated $75 million for health care services and established an Interagency Council on Homelessness that coordinated six Federal agencies and 15 programs that provided shelter, housing and other services to the homeless population. My experience working among homeless people had made me a candidate for the position of Staff Director of this Interagency Council. Not surprisingly, when invited to fill this position, I agreed. In October 1990 I began to commute twice weekly to Washington DC while the bureaucracy worked out details of an interagency personnel agreement. 

Inside the NIMH 

Wisconsin Psychiatrist 1992 

 An academic invited to spend time at the NIMH might well feel like a Holy man asked to visit Mecca. My sabbatical was overdue, seven years had stretched past 10 and I felt burned out by the warfare of urban psychiatry. Our new residency training program had just been fully accredited but shortly would have to be discontinued and abandoned. 

Representation on the new task force reflected a well-recognized need for coordination within the Federal Government between HUD, HCFA, SSA, the Department of Labor, the White House, the Veterans Administration and NIMH. Who should Chair the Task Force was less clear. The decision that this be the director of NIMH conflicted with the HUD opinion that homelessness was primarily a housing problem and the fact that their representative to the task force was an Assistant Secretary who outranked the Director of NIMH in the Federal hierarchy. 

This tension made the basis for a contentious first meeting with open confrontation that was resolved when the director of NIMH, an academic, quit his position a week later to return to his home university. The Deputy director who replaced him was a career bureaucrat eager to become the first psychologist to head NIMH, who went to great lengths to avoid conflict and sought consensus amongst the more powerful members of the task force. 

However laudable the intention and composition of this task force, its purpose was hampered from the start by major political constraints. Its charter required the appointment of a National Advisory Committee. There was lengthy rumination about how to select 16 individuals who would represent every form of expertise but also reflect ethnic, geographic and gender diversity. 

More arduous still was the problem of how to keep the balance of power in Federal hands to protect against intemperate advocacy interests and potential minority reports. The appointment process proved to be so protracted that the problem solved itself. It took six months for the process to be completed during which time the Federal representatives had met frequently enough to determine direction. This left less than nine months for the Advisory Committee to respond and for a final report to be written. 

It was during this interval, prior to the appointment of the Advisory Committee, that I served as Staff Director while the task force attempted to define the scope of the problem and the appropriate issues to address. I was located at the NIMH in the office of Programs on Homelessness and Severe Mental Illness, one of two programs directly attached to the Director’s Office, the other was AIDS. 

The NIMH is in Maryland, northwest of Washington, outside the district but inside the Beltway. It is housed in a vast glass and steel rectangular building. Its functional and minimalist architecture conceals endless windowless corridors opening into crowded cubicles. Parking is hopelessly inadequate. Newcomers must carpool or scramble for lots adjacent to local shops. I was lucky to find space behind a nearby Chinese laundry at $50 a month.  That was the good news; the bad news was that I had no office, telephone or secretary. For three months I squatted in temporary space, moving from one location to another. After two months a telephone line was installed. Its number, 0000, seemed symbolic – I was beginning to feel like the biggest zero at the institute.  

Meanwhile we worked our way through several temporary secretaries with semi-literate skills. This threadbare infrastructure and support system is reflective both of inadequate Federal salary scales and an administration preoccupied with outside political appearances but neglectful of morale and organizational issues under its roof. Looking good was an obsession. What another agency, a senator or congressman might think was preemptive. All of it supported by bureaucratic procedures of Byzantine dimensions and an organizational style characterized by malignant compulsivity.  

All outside correspondence from significant sources became controlled, passing through weeks of review while answers were sanitized. The smallest matters were repeatedly scrutinized; plans made and remade, doing and undoing in a search for safe perfection. The interaction between this political paranoia, bureaucratic system and inadequate infrastructure was stultifying. 

One of my tasks as Staff Director was to prepare speaking points and minutes for meetings. A memo that had taken my temporary secretary an hour to type was returned with dozens of picayune corrections. Frustrated, I protested the need to distinguish style from substance. The trouble I was told is “that you write like an Englishman.”  

Another of my tasks was to develop background papers on significant issues of relevant to homelessness and severe mental illness. One of the areas identified was legal and civil rights, obviously a sensitive and politically charged topic involving state commitment laws. At first, we planned a conference with experts inside and outside the NIMH. Concerned about controversy, we canceled it. Next, we searched for an outside expert who could be relied upon not to upset the various advocacy groups. Nobody seemed safe so I undertook a discreet telephone survey of alleged experts, most of whom didn’t want to commit themselves by telephone on such complicated and contentious topics. Finally, frustrated, I wrote a position paper on my own. Nobody commented. 

This seemed to me a signal of futility and I decided to return to Milwaukee where I felt more needed and useful. My departure less than halfway through the projected sabbatical coincided with the first meeting between the Task Force and the Advisory committee. This report was due to be issued early in 1992. Buried in the mandate was a massive paradox of major political proportions: how to address the needs of a vulnerable minority without tackling the prohibitively expensive social and political issues that affect the entire homeless population. 

I was fortunate to be able to escape but was left wondering to what extent I was undone by my own naivete and narcissism. Tact and diplomacy were never my long suit. The underdog comes before the organization. First Amendment rights made more sense to me than the government they protect us from. With hindsight, perhaps an accurate job description or an honest interview could have deterred me from making this trip to Mecca. Yet there are good things to remember, friends I did make; mostly the little people and those from the less powerful agencies, an insider’s look at government and a respite from the healthcare Holocaust back home.   

Two months after I returned to Milwaukee the mail brought an impressive document. It was the “Administrators Award for Meritorious Achievement” signed by the Director of NIMH and the Administrator of ADAMHA. A band aid for my wounded narcissism? A bid to buy my silence? Or just a nice touch? Who will ever know?  Perhaps a friend summed it up best when she noted, “Experience is what you get when you don’t get what you want!”  

Back in the office during the early to mid-1990s the economic and political situation continued to deteriorate. Public and professional outrage towards managed care had escalated. People were enraged that access to specialists was blocked by gatekeepers or needed prior authorization. Worse still, it might be a pre-existing condition in which case you were on your own, perhaps facing bankruptcy.

My belief, based in part of my experience as a young psychiatrist and family doctor in England, is that health care is a basic human necessity that must be provided by the government because it cannot be equitably, or cost effectively managed by market forces or commercial competition. The reason is simple: nobody wants to die, so everybody wants the best available medical care, irrespective of cost. This is true even if you believe in heaven and hope to go there. Even so, nobody is in a hurry. Healthcare is not like clothes or a car where people settle for what they can afford: a suit or blue jeans, a Ford or Lexus? We know this is true because the largest share of Medicare is spent on the last six months of life, usually to no avail. Nobody buys a BMW on their deathbed. But bankruptcy due to terminal illness was increasing. 

Affordable care for everybody means nobody can have everything; rationing, a choice guided by best practices, is inevitable. Again, the facts are certain: in America’s unregulated marketplace we spend more of our GDP on health care for worse results than any other civilized nation. This is not because the rest of the world is socialist but because they are fair-minded and cost conscious. The cynical political claim “we have the best care in the world” is true only for millionaires who can afford it or for people who believe that an early death is a just penalty for poverty. 

Believing these things, my remaining days were spent on these issues to educate others by my writings. With our chief psychologist, we studied the impact of case review on the quantity of care provided: does rationing reduce care? It didn’t, we published our results in the American Journal of Psychiatry. With my vice chairman, we published an article on the educational implications of managed health care which was also published.  

These educational research efforts coincided with the waning stages of my career. In 1996 I stepped down as Chair, handed the department over to my Vice Chair and remained on the faculty for another two years, bolstering my practice income by working as a consultant to Blue Cross and Blue Shield. 

Once it became clear that the fate of the academic program was sealed, closure was economically and politically inevitable. I resigned and accepted a position as Medical Director of a small managed care company in Milwaukee for the same salary I earned as a department chair. There I tried to practice what I preached as a fair-minded adjudicator of the quantity and quality of care provided to patients by my colleagues. I did this for two years before taking down my shingle in 1998 at age 64.  

When I told people I was retiring, I quickly became weary of the inevitable response, “What are you going to do now.” I didn’t have a clue and felt inclined to say “nothing.” Like most compulsives, I imagined there was relief in letting go and I was certainly determined to quit medicine. If it was true, that “nature abhors vacuum” all I had to do was to wait. My deepening involvement with my wife’s church, the Catholic Church, shaped the outcome.

Early in adult life, a blend of hubris and atheism made me look down on those who espoused religious or spiritual convictions. I viewed them as self-deluded folks, lacking intellectual vigor or easily misled. As a young psychiatrist, I seldom inquired about a patient’s faith life.

By the time I retired, I was wiser; I envied those who claimed a spiritual dimension and wondered what I might be missing. As the century drew to a close, I decided to seek an answer to that question. Saint Francis Seminary was a short distance from the Archdiocese headquarters that I was already familiar with, looking towards Lake Michigan and nestled in several acres of woodland. It offered a variety of educational opportunities for laity in addition to priestly vocations. I was ready to give up medicine but not sex! Two of these programs were master’s Degrees; one a Master of Pastoral Studies (MAPS), and a more rigorous, traditional Master of Divinity (M.Div.). But first there were hurdles to cross: two interviews with former graduates to assess my capability and suitability for the seminary, next an essay for the Dean describing my purpose and finally an interview with a psychologist to screen out emotionally troubled or immature individuals, including potential pedophiles. 

I was accepted and enrolled in the easier of the two programs, (MAPS) and was required to take a prerequisite course in 101 philosophy and religion. Classes were small and intimate, usually six to 12 individuals including young seminarians, all male, and lay students like me, mostly women seeking second careers as educators or lay administrators in local parishes, helping to cope with the priest shortage. 

Faculty were outstanding, many with doctoral degrees earned in Rome, so the academic standards were demanding, including oral and written exams at the end of each course. Essays had to be formatted and footnoted to meet precise requirements. In class I took meticulous notes and condensed them onto 4x6-inch index cards, which I kept on my person to memorize. Competitive as ever, I was determined to maintain an A average, not an insignificant goal alongside seminarians 40 years my junior.

As important, if not more so, was the social environment and sense of community. The Seminary is approached through an avenue of tall trees, arching protectively over a long driveway leading to a statue of Saint Francis and the entrance way. Inside, the hushed corridors lead to a solemn chapel; the wall behind its altar adorned with a large crimson and gold painting of Jesus as Rabbi and teacher. The students, seminarians and faculty mingled over meals at common tables in the refractory, worshiped together in the chapel and shared a rich variety of extracurricular lectures and seminars.  

I became involved in all these activities, was elected to the Student Council and helped lobby for more attention to women’s issues on campus, a plea the Catholic Church was not yet ready to hear. In class, I asked the probing questions many were reticent to raise and received open and honest answers. A sense of the depth and quality of disputation was illustrated in a term paper I wrote for the course on “Catholic faith and Doctrine.” In addition to classroom dialog, the faculty kept office hours for private discourse and queries.

As an added door to my inner self, I was assigned a spiritual director, a delightful nun I met with monthly in the comfort of her sister House, adjacent to the seminary. I kept my workload to a modest 6 to 8 credit hours each week and, other than domestic chores, had only one additional commitment. The year I retired, the Governor of Wisconsin appointed me to the State Mental Health Council for an initial three-year term, followed by a second term during which I served as Chair. This was a pragmatic counterpoint to my spiritual quest but also an opportunity for “good works.” 

Wisconsin is well-known for a commitment to innovative mental health policy; it pioneered the Case Management model of community care in the mid-1960s to unite fragmented agencies or services and prevent the recurrent hospitalization of those with severe and recurrent mental illness. During the time I served on the Council the State also made a major commitment to another Wisconsin innovation, the so called “Procovery Movement.” This sought to empower people with mental illness to capitalize on their own intellectual, emotional and spiritual strength in order to play a larger role in their own rehabilitation even when full recovery or cure was unattainable. Funds were allocated to support this concept at the community level and several leaders in the movement were appointed to the council. 

The existence of the Health Council was mandated by the Federal government as part of the legislation covering block grants that channeled millions of dollars annually into each State’s coffers. The council’s purpose was to ensure citizen oversight of the distribution and appropriate use of the funds at the community level. Compliance with this mandate was overseen by the NIMH. This requirement was not honored in the breach; I knew from my time at the NIMH that the State council’s reports were filed in a closet and seldom or never read! 

My contacts on the council with pro recovery advocates led to invitations to speak about mental illness to congregations at different religious denominations coupled with requests to help develop a program that we named Faith in Recovery. Devoted to the pro-recovery ideal I wrote, submitted and obtained, a not-for-profit 501©3 application and successfully raised funds to support the project still mainly focused on Catholic parishes. This success was contrary to some events that were occurring at the State Council where there was an inevitable conflict between the Governor who appointed council members on the advice of recommendations by the bureaucracy and some members of the council, me included, who felt that empowerment ought to include the right of persons with mental illness to nominate their own representatives. At stake was control over millions of block grant dollars. 

Matters came to a head when the time came to vote for a new council member, chosen by the bureau and approved by the governor and another candidate supported by the Pro recovery advocates and myself. Paper ballots were distributed, collected and counted by a staff member to the council. The result was announced; the officially preferred candidate won by a single vote. As Chair I requested the ballots, recounted them and discovered “a mistake,” the reverse was true, the pro-recovery candidate had won. Hurt and wounded by the conflict and subsequent debate, the candidate declined to serve and I subsequently resigned from the council. 

Back at the seminary, during my monthly visit to my spiritual director, I came to the realization that I still only had what could be called at best a puny spirituality. Routinely, at the beginning of our meetings she asked, “Barry where has God been in your life this month?” I could never answer that question and decided that I was indeed “spiritually handicapped” and perhaps afflicted with what the Catholics call the Pelagian Heresy.

Pelagius was a British monk around 315 to 420 AD who migrated to Rome where he taught in public the merit of “good works and free will” while at the same time denying Augustine’s doctrine of “original sin.” At first, he was praised by Augustine for ascetism and for being a “saintly” man but who eventually was declared a heretic by the Council of Carthage in 418 and vanquished from Rome.  Some theologians believe Pelagius was closer to Jesus’s moral teaching and that Augustin’s sexual mores may have laid the groundwork for Catholic misogyny. 

In the late stages of my days at the seminary I also became aware of the mental health services offered by Catholic Charities for people with little or no mental health insurance benefits and I began to explore the possibility of becoming the first psychiatrist to work in the clinics. 

This confluence of events led to the realization that I already had the requisite medical degree to answer a call to resume providing mental health services to those in need and it would be alright to abandon the quest for a theological credential that had served its purpose and which I neither needed nor merited. 

In the seminary tensions were also developing. The Liberal Archbishop has reached retirement age and his mandated letter of resignation was accepted by a Pope moving in a more conservative direction. Meanwhile the Archdiocese was struggling to cope with the pedophile crisis. (I served on the Bishop’s Committee that allocated and financed the victims’ therapy). The new conservative Archbishop was confronting the likelihood of bankruptcy, the need to sell property and refigure which programs and facilities would survive. Part of the hierarchy’s response to the shame and chaos was a return to more rigid and traditional liturgical practices, including a reversion to its paternalistic and misogynist roots. Both the seminarians and the late students picked up the scent.  

Once again, my inclinations were towards the losing side. Saint Francis has a magnificent bell tower, looking out on the lake and reached by an elevator that lets you out into a cozy, intimate space for small group meetings. The group I belonged to gathered here weekly to discuss spiritual matters, made up entirely of women many of whom longed to be pastors. Our final get together was a celebration of the Eucharist complete with wine and wafers led by a woman with the frustrated Vatican 2 desire to be ordained. It was a defiant act, worthy of excommunication but I found it exhilarating. 

At the same time the last lecture series I attended was on Feminist Theology taught by a woman theologian from Marquette University. It was spurned by all the male seminarians, fearful of the new Archbishop’s displeasure, so I was the only male among 20 women! 

Recent events in the seminary fed the realization that I already had the requisite medical degree to answer a compelling call to resume providing mental health services to those in need and it would be alright to abandon the quest for a theological credential that had served its purpose, but which I neither needed nor merited. In these late stages of my days in the seminary I also became aware of the mental health services offered by Catholic charities for people with little or no mental health insurance benefits and began to explore the possibility of becoming the first psychiatrist to work in their clinics. 

I volunteered to become involved but waited in vain for a response, despite repeated reminders. Professions are often competitive and reluctant to collaborate and bureaucrats procrastinate because decisions incur risk. After two years or more, I insisted on an answer and threatened to withdraw. I was invited to meet the staff during their summer retreat and was quizzed about my attitudes, beliefs, practice style and relationships with other disciplines. They were clearly interested so I offered to staff all four clinics on a regular basis for less than a third of my former salary and to absorb the time and cost of weekly travel which was more than 100 miles. If the Church was unable to collect insurance or fees to cover my salary, I would accept a lower rate. The clinics had a sliding fee scale, as little as $5 a visit for those without insurance. It soon became clear that the Church’s accounting capabilities were too chaotic to calculate the balance of cash flow to cost so our arrangement remained in place throughout my tenure. It felt good to be back in the saddle in a situation that I enjoyed. 

The people I served were often impoverished minorities in dire financial straits, uninsured or unable to find a psychiatrist willing to accept Medicaid. There were two problems. Between a third and a half of the patients failed to show up for their appointments, which is not unusual in a population where finding a babysitter or a ride to the clinic was problematic. It was not unusual for a young single mother and her child to sit in my office while the child played with toys and I engaged the mother. This was an opportunity to observe their interaction; earlier in family practice, I had learned that a common presentation of depression in young mothers was “I’m irritable with my kids and feel guilty afterwards.” 

The second problem was that the availability of a free psychiatrist, willing to prescribe, attracted the kind of client the therapists were unused to treating. Therapists were trained to do therapy with patients who were insightful, verbally adept, and came regularly to talk over their problems and issues. For a while, I felt this might sabotage my involvement but was grateful to discover that the ability to share our opinions and titrate the interaction of medication and therapy was mutually satisfying, although this was not something for which insurance paid.

The therapists were interesting people and most were excellent at their jobs. One social worker spent her days off cleaning other people’s houses; she made more money and the work satisfied her compulsive personality! For those patients with no insurance or unable to pay for medication, I was able to obtain free samples or help to enroll them in drug assistance programs provided by the pharmaceutical companies, a positive feature of the industry.

 I was also fortunate to have a boss who was supportive and knowledgeable; it was unusual for an experienced psychiatrist to report to a social worker family therapist! About three years into my tenure, the head of Catholic Charities, a much respected and long serving social worker, retired. The Archdiocese was now in serious financial trouble with bankruptcy looming ever closer. This may account for the Board of Trustees’ strange decision to appoint a female attorney as the new Head of Catholic charities, someone with no formal training in mental health services. In addition, she lacked administrative skills and had an abrasive and unfriendly demeanor. Her office was adjacent to mine at one of the clinics, yet she never spoke a word. It soon became clear that the attorney’s mandate was to cut staff and costs. She introduced unpopular productivity ratios for the therapists and quickly got rid of anyone who challenged her authority. I decided it was time to move on and concentrate on nurturing my Faith in Recovery program. 

My decision was complicated by the difficulty of finding a psychiatrist willing to take over my caseload, so I set a departure date months ahead and began to work with clients and therapists to transfer care. I knew something was brewing when someone in Human resources asked me why are you taking so long to leave? Some weeks later, on the eve of a vacation, I received a phone call demanding I go immediately to meet the Head of Human Resources. No explanation was forthcoming, and I was ordered to comply. When I declined due to the inconvenience of an impending vacation, I was told “to come now, submit your resignation in writing or be fired.”     I immediately called my supervisor and was surprised to hear that he was uninformed as I was.  He called the Head of Human Resources and was brushed off. 

I returned to my office, wrote my resignation and included a list of the 100 patients who were left without a psychiatrist. Over the next several weeks I wrote to the board of Trustees, including the archbishop, requesting an explanation but received none, although he thanked me for my services. So, I called a spiritual friend who told me he knew nothing of the problem and felt it would be inappropriate to intervene. 

A short time afterwards my boss was also fired following many years of service and without any job prospects. I agreed to write him a reference and, at a second meeting some months later, he found an excellent new job, better suited to his skill and temperament.  

Now I turned my attention and energy back to Faith in Recovery. The 501©3 I wrote was approved by the Internal Revenue service on its first submission and our mission began to prosper due largely to a remarkable nun, who suffered from a bipolar disorder, well controlled by medication. She was responsible for setting up the first homeless health clinic in Milwaukee, and for over more than 30 years, had been an involved advocate for almost every initiative in the inner city devoted to meeting the housing and mental health needs of its citizens. Her brother designed and monitored our Internet website which contained a toolkit and other helpful material and contacts for existing programs. Sister used her own contacts to obtain free office space, a telephone and computer in a Senior Service Center that raised money to support its programs from bingo sessions. My daughter-in-law designed a faith in recovery logo for our toolkit and the website.

In our new quarters we set up a steering committee made up of folks with mental illness and family members. Sister followed me as its chairperson. This freed me up to write grant applications and we obtained more than $10,000 from two foundations supportive of mental health issues. This was used to support annual meetings to increase public awareness of Faith in Recovery, expand the number of affiliate programs from different faith traditions and allowed us to host monthly half-day get-togethers at the senior center for representatives of the more than 20 affiliates we had now acquired. Each of these programs was encouraged to offer twice-annual day-long seminars for the whole faith community in mental illness and mental health awareness months, May and October, to spread the word and stimulate recruitment to their support groups. 

So far, so good. But serious problems began to emerge. The most significant challenged the fundamental premise of the recovery concept on which Faith in Recovery was based; that is the extent to which people suffering from severe and persistent mental illness can manage and sustain the affairs of this kind organization. Some psychiatrists had already challenged this concept, pointing out that the most serious disorders like schizophrenia, often erode thought processes and motivation despite the best that medication can do, corrupting a person’s capacity and skills for independent living. 

It was true that the most active members of Faith in Recovery were those with either less severe forms of mental illness or well controlled by medication. It was difficult to find members with sustained energy and ability to plan, manage a budget, organize or run meetings and raise funds. When attendance and enthusiasm at monthly meetings began to dwindle, we recognized that members were primarily committed to running the support groups and the programs in their own faith communities with little time or energy left to devote to the organization. Even at the individual church level there were significant problems in recruiting new members. National data indicate that at least one in five of the of the population has firsthand personal knowledge of mental illness either as a patient or a family member, but most groups that we had started had less than a dozen participants even in faith communities where there were several hundred members, this was despite the support of the priests. New members came and went but they seldom stayed. 

Behind this reluctance lay at least three major factors:  the stigma of mental illness, fear of discrimination and concerns about confidentiality. Even in a faith-based community, many people prefer to remain in the closet. Second is the problem of defining faith or spirituality; one expert likened the diversity to that of blind men groping different parts of an elephant in the room. How might spirituality best be nurtured in a group setting? Expert or personal testimony, Bible readings and exegesis Jesus, prayer, meditation, or support and advice? No systematic effort was made to enquire and identify why some people dropped out. What had they failed to get that they were seeking?  

Finally, were issues concerning group leadership. We had taken a position that this should be decided among group members rather than recruiting trained therapists from in or outside the faith community. This idealistic criterion failed to accommodate several concerns. How to deal with individuals who dominated a group or others who failed to speak up? What to do if someone was psychotic or suicidal?  How to follow up when someone stopped coming?  Was it all right to have patients and family members attend the same group? Our philosophy was to turn these issues back onto the assumed wisdom of the group. Perhaps this was asking too much?  But where was the energy to identify, train and support successful leadership?  

By now, I felt overwhelmed myself like “Horatio on the Bridge, when all but he had fled.” The nun’s term as chair of the organizing committee ended and nobody was eager to inherit the job.  Somebody did so reluctantly but after I took a leave of absence, everything collapsed.  There was just enough energy and leadership remaining to wind up the 501©3 and distribute the remaining funds to kindred organizations. Once again, I was reminded of the dictum, “Experience is what you get when you don’t get what you want.” 

The ghost of our website haunts the Internet, but nobody answers the phone. A few of the Faith in Recovery programs may still exist, but I have not inquired. In the end the sources of failure remain ambiguous as Robert Browning says, “Fail I alone in words or deeds?  Why, all men strive and who succeeds?”

Being fired from Catholic Charities and the collapse of Faith in Recovery coincided with my son’s entry to medical school. Strategically, he applied for early admission and was accepted. What specialty he might choose was undecided; he was blessed with manual dexterity, (God knows from where), benevolence and equanimity so the field was open. I had secret hopes he might opt for family practice but knew that in today’s world, medical students graduated with massive debts, up to a quarter of $1,000,000, which would seduce them into lucrative procedure-oriented specialties. Having funded his first education, we could hardly afford to subsidize another. 

Then fate intervened, fed up with Catholic misogyny and pedophilia my wife had transferred her faith affiliation to the next best tradition, the Episcopal Church. We became friends with an individual who was an associate pastor, a Jesuit, a PhD psychologist as well as the head of psychology in the state’s prison correctional system. He persuaded me to consider working as a psychiatrist in the prison system. It was far from an economic sacrifice; in one 10-hour day I could earn enough to pay my son’s medical school tuition of $38,000 a year, increasing the chance my son would feel free to choose whatever field of practice he desired including the low paid talking specialties: family practice, pediatrics or psychiatry.  The next opening available was in the women’s minimum-security prison in Waupun, a 65 mile commute each way. I accepted, committing myself to a13 hour day each week for the next four years, until my son graduated in May 2011. 

Half the prison population of up to 250 women had a mental illness. As the only psychiatrist, I was therefore responsible for up to 125 inmates, depending on the census, amounting to 15-20 patient visits a day. My main responsibility was medication management and I worked with a very experienced and collaborative psychologist. I was situated in the health services unit with a small staff of nurses, none of whom were psychiatrically trained. There was no night duty; call was provided by the psychology staff. 

This proved to be one of the most rewarding and educational experiences of my career. In America, prison has always been a venue for those with mental illness, particularly since the mid-1960s after closure of the mental asylums and failure to transfer funds into community care.

I began with the belief that the stereotypical inmate with mental illness was incarcerated for one of several reasons. They suffered from a lifelong major mental illness and had never had health insurance or adequate care and so they treated their symptoms with drugs or alcohol, eventually encountering the law. Other common scenarios were repeat driving offenses due to alcohol abuse, including rare instances of vehicular homicide and retaliatory violence related to spousal abuse. Most inmates had suffered from emotional, physical or sexual abuse as children and many had post-traumatic stress. 

Compared to life in the community, prison offered a safe and predictable environment, free of domestic stress, abuse, or responsibilities as well as the absence of access to drugs or alcohol. In a minimum-security prison, inmates also had the possibility of paid employment either in prison for only cents an hour, or outside in the community, where they were employed in factories, farms or the Humane Society for at least the minimum wage and often considerably more. Food in the prison was surprisingly good, many women worked in the kitchens; staff ate the same food in the same dining hall. There was an excellent library, to which I contributed books, and a well-equipped gym. What was lacking was any chapel, meditation or quiet space although there was good access to television and regular movies.

Most women shared a cell and upper or lower bunk with another inmate; cellmates were not always compatible or considerate and “special” (sexual) relationships were strictly forbidden. Makeup was also restricted. Infringement of these regulations resulted in a variety of penalties including the hole, a period of days or weeks in solitary confinement at the Wisconsin woman’s’ maximum security prison in Taycheedah. Security was maintained by two levels of guards: sergeants or “blue shirts” and two supervisory captains or “white shirts.”

I was impressed with the caliber of the correctional staff; the two captains were especially impressive in their ability to maintain firm discipline in a fair predictable and open-handed manner. Inevitably there were a few blue shirts with mildly sadistic traits, but this was very much the exception. The Warden was a woman, and like the captains, I was impressed with her demeanor and relationship with the inmates, who had access to her when requested. 

The correctional system has a culture of its own and my adaptation to it was not all plain sailing. The prison had a restricted formulary, partly to prevent abuse or addiction but also for financial reasons. The parent women’s institution had been under court orders for several years following lawsuits brought by both the ACLU and the Federal government for inadequate care. Prescribing practices differed from those in the community, mainly in relation to the use of sedative drugs like the benzodiazepines for anxiety and sleep disorders and stimulant drugs like amphetamine for attention deficit disorder. These conditions were treated instead with off-label use of non-addictive compounds like antihistamines, antidepressants and beta-blockers.

Initially, I was criticized for occasionally not complying with these stipulations and complaints were made behind my back to the medical director. This was handled by setting up a monthly staff meeting attended by the nurses, the warden, the captains and the psychologist. This resolved the problem and became the foundation of a collegial working relationship. I was greatly helped by the advice and mentoring of my psychology colleague who understood the nuances of the Correctional environment and how to negotiate them. Another area of difficulty was the mildly sadistic attitude of one or two nurses who were inclined to assume inmates were malingering or manipulating the system. My background in psychosomatic medicine and family practice helped deal with this after I made the point that “everyone dies of something” and it was wise to take complaints seriously. After I found some problems that they had missed this became less of an issue. 

Probably my biggest problem and likely source of the nurses and attitudes was my opposite number in medicine. This was a former pathologist turned internist who delighted in discontinuing all the medicines he considered unnecessary prescribed to inmates before transfer from Taycheedah to minimum security. This man was gay and boasted about the number of lawsuits filed against him by women inmates. He clearly was a misogynist who was eventually transferred to another male prison. 

I was happiest seeing the women. My main job was medication management and I only saw each patient on average every six weeks, but I always took time to establish a personal relationship and deal with their psychological and personal as well as medical issues. Each week, I spent some time with my psychologist colleague and we exchanged ideas about our shared patients. Although from different disciplines, our viewpoints were usually compatible. People who had an acute problem and needed to be seen more often filled out a “blue slip” and were seen at the next visit. I was required to dictate a record after every session but also kept meticulous written chart notes with more personal information that linked one visit to another. 

Every three months, I went to Madison for a meeting with the 30 or more psychiatrists who worked in the correctional system throughout the state. Two of us were members of the ACNP and probably a third of all of them had held a faculty position in one of the two state medical schools. However, there was little evidence of any systematic attempt at quality improvement and during my four years, there was never a single visit by a supervisor to oversee my work. Nor was there any resolution of the issues surrounding the appropriate treatment of insomnia among inmates.  

I made my last visit to the prison two weeks after my son graduated from medical school, almost 50 years to the day since I myself became a physician. I hosted a carry-in lunch for the nursing, medical and correctional staff; the warden thanked me for my work and said that the women had liked and would miss me, especially my English accent when I called them to my office by the overhead announcement system. 

As I watched my son training to become a family doctor, I did indeed hope that Harry Truman was right when he said, “Deeds grow into destiny.” 

Working with Tom Ban 

The almost 20 years I worked with Tom were a delight and a dramatic change. The work was pro bono, but interesting, important and rewarding. Tom, a modest human being, was probably the most influential and widely published member of our profession. He died suddenly of a stroke in February 2022 and is badly missed. My poem below, In Gratitude spells out characteristics he was endowed with that made him a beloved friend and colleague.  

In Gratitude 

Here was a particular, singular, 

Hungarian man. 

Who shed the toil and shackles 

Of World War Two, 

Fled them, shunning turmoil. 

Leaving Fascism, Communism, Antisemitism behind, 

pursuing gentler prospects of the mind. 

A philosophy blind to prejudice and hypocrisy 

tuned to more poetic parameters. 

Blending wise ideas of others with his own, 

all voices heard, nothing smothered, absurd or weird, 

yielding wise and generous compromise. 

Tom’s productivity was profound,  

never loudly displayed or pompously displayed. 

Early in my career as a prison psychiatrist I had already determined what I would do next. My days as an educator, administrator, clinician, professor and research worker were behind me. What lay ahead was a pro bono career as an untitled editor, amateur historian and occasional author. 

Modern psychopharmacology began with the discovery of chlorpromazine, followed by the discovery of drugs for each major diagnostic category; by midcentury neuropsychopharmacology, the understanding of how drugs worked, had also evolved. The need for clinicians and basic scientists to collaborate was clear, leading to the first international organization, the Collegium Internationale Neuropsychopharmacologicum (CINP) in 1947, and the American ACNP in 1961. 

Tom Ban began training in psychiatry in his native Hungary but escaped from the Communist Regime by migrating to Canada in 1957, before joining Heinz Lehman as his resident. Together they developed one of the first NIMH funded Early Clinical Drug Evaluation Units (ECDEU) which became the most productive and leading organization in clinical psychopharmacology research.  

By 1976 this NIMH program began termination as drug studies were picked up by industry. Lehman retired and Tom became Head of Clinical Psychopharmacology at Vanderbilt University in Tennessee. He had joined the ACNP in 1966 and had become aware that by the 1990s many of the pioneers had died or retired and the ACNP had concerns about the history of the field. To prevent this “silent erosion of history” the ACNP had established an “International Archive of Neuropsychopharmacology” at Vanderbilt and began making videotaped oral interviews of pioneers conducted by colleagues. Tom himself had been interviewed by Leo Hollister in 1996 and their conversation records their agreement on the importance and significance of the project. 

Altogether 238 interviews were completed with plans to publish them in a 10-volume series to celebrate the 50^th anniversary of the ACNP in 2011.  

My own interview was by Don Robinson at the 2007 annual meeting of the ACNP at Boca Raton in Florida. Following the interview Tom Ban socialized with me and I was invited to join him as co-editor of the series, which I agreed to.  

This began a 16-year experience of working alongside Tom, the first four years completing the 10 volume Oral History of which I was co-editor of three volumes: Volume 4 Psychopharmacology (after Jerry Levine retired), Volume 7 (Special Areas) and Volume 9 (Update). I also completed many of the brief interviews (Dramatis Personae) that provided a framework of understanding each scientists’ individual achievements. 

Once this task was completed in 2011 Tom began to work on his new goal of developing the International Network for the History of Neuropsychopharmacology and its website, inhn.org. He invited me to join him as an editor, and amateur historian, beginning in 2013, responsible for detailed biographies of leading contributors to the field, major discoveries as well as conflicts in the field, controversies and book reviews. I would talk to Tom by phone weekly or more often and I visited him in Toronto on several occasions.  

In 2020, with Tom’s encouragement I turned my 36 contributions to the website into my own final book, Treating the Brain: An Odyssey. It provides a history of the modern era of psychopharmacology divided into two dramatically different time periods. 

1949-1980, “An innovative three decades when all the first drugs were discovered for all the major disorders contrasted with 1981-present characterized by dwindling innovation, corporate corruption in the pharmaceutical industry, professional and academic complicity in a climate of avarice, political malfeasance.” 

The book has a Foreword by Edward Shorter, America’s leading psychiatric historian, “It is a triumph of historical scholarship and of a mature reflection on the past by someone now in his 80s looking back on a history of triumph and tragedy.” 

Treating the Brain: An Odyssey is published by INHN and all proceeds contribute to perpetuation of the website founded by Tom Ban. 

Mine has been a productive career in both pleasant and trying times. It draws to an end at a moment when some of my last book reviews for INHN reveal an optimistic and encouraging note in our field of enquiry.  The treatment of mental disorders is becoming directed more to the electrical than the chemical functions of the brain, focusing on the role of trauma in the etiology of these conditions, more on novel therapies for the mind, perhaps less on prescribing medications. I hope further discoveries in neuroscience will follow and wish you well in their implementation.

July 27, 2023