Perhaps I Touched the Minaret, or How Patient-Centered Care Remains a Dream.

Abstract

Keep true to the dreams of thy youth.—Herman Melville Recently in Psychiatric Services I looked back at the 55 years I have spent as a psychiatrist, in which I observed that resources needed for patient care have quietly disappeared in America (1). The promise that psychiatry would mature to serve persons with severe mental illness in communities has withered and died. So, too, has the principle of caring for patients as persons rather than as diagnoses. Psychiatrists now focus on criteria for various disorders and write prescriptions for medications that do not necessarily improve the well-being of their patients. This morning I awoke at 3 a.m. frankly anxious. I realized I was worried about two unexpected, colliding forces. How well had I met my responsibilities in the situations that constituted my career? What are today’s implications of my past activities as a physician and psychiatrist? Memories had disrupted not only my sleep, but also the complacency of my retirement. The evening before, at a social gathering, a friend whose adult son has a severe mental illness asked me to meet with our local Utah county authorities. She wanted to address the lack of services available to her son and others with severe mental illness. She had learned of my work aimed to reorient the care that psychiatrists provide to these patients. Her request was entirely reasonable, and I agreed to the meeting. Hours later, as I slept, darker concerns wakened me unexpectedly. These concerned on what grounds I had to considermyselfeffectivewithpatientsoverthispasthalf-century, In my first postresidency position in Texas, I published an evaluation of a rehabilitation program I developed for chronically hospitalized persons with mental illnesses. While developing this program, I remember thinking to myself, “If I can create this level of resources here at a bureaucratic U.S. government public health service hospital, then what a pleasure it will be,after completing my Selective Service commitments, to return to Yale and all the resources in Connecticut.”Thesedreams were never tobefulfilled, not at Yale, and not thereafter. In all following years, in spite of my successes besting, on many occasions, circumstances hostile to the interests of those with severe mental illness, I could never match the successes we had in Texas.