SOME P R O B L E M S W I T H I N S A N E I N S T I T U T I O N S N o r m a n Morse

Professor D. L. Rosenhan's (1973) article "On Being Sane in Insane Places" has received wide circulation. The a t t e n d a n t publicity bespeaks its wide interest and wide-ranging implications. For those of us with a work background in inpatient psychiatric settings, the report does not really say a n y t h i n g new, or t h a t has not been known before. On the other hand, it is i m p o r t a n t t h a t it is being said again at this time and t h a t we examine its implications. While the report contains numerous technical deficiencies as pointed out in other commentaries, it does, however, present a vivid picture of two of the major problems facing the mental health field today. These two problems are the lack of a conceptual basis for approaches to health/mental health care, and inadequacies in the t r e a t m e n t models currently being employed to deliver mental h e a l t h care.

Conceptual Basis For Approaches to M e n t a l Health Care By a conceptual basis, I m e a n an organized system of ideas--a theory. Theory is something the m e n t a l health clinician read in school but, all too frequently, neglects in practice. This reflects a failure on the p a r t of academia to d e m o n s t r a t e the inseparability of theory and technique. As a result, the clinician emphasizes the 'how-to' and ignores the 'why,' populating the field with a lot of high-priced technicians who don't know w h a t they are doing. There are m a n y theories. There is a theory of evolution; the theory of the expanding universe; the germ theory of disease; and there are psychological theories. Such theories are meaningful and useful insofar as they reflect man's current state of knowledge and his attempt to explain, through a reasonable a r r a n g e m e n t of ideas, various p h e n o m e n a which currently lack explanation. For instance, the theory of evolution attempts to explain the origins of man. This theory is an a r r a n g e m e n t of ideas into an organized system which attempts to 291

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explain h o w m a n came to be w h a t he is t o d a y . T h i s t h e o r y sets forth v a r i o u s p o s t u l a t e s (as do all theories), in this case to explain m a n ' s v a r i o u s d e v e l o p m e n t a l stages. S o m e of t h e p o s t u l a t e s are verifiable; some are y e t to be verified. Yet, t h e p e r s i s t e n c e of this t h e o r y is attributable to its potential verifiability a n d its logical n a t u r e in relation to m a n ' s current store of knowledge. A t h e o r y is sustained as long as n o t h i n g b e t t e r s u p p l a n t s it. When its p o s t u l a t e s become k n o w n to be true t h r o u g h verification, the theory g a i n s strength. If all p o s t u l a t e s b e c o m e verified, it is no longer a theory. Likewise, the p o s t u l a t e s m u s t at l e a s t h a v e the potential for verification at some point in time. If the p o s t u l a t e s are abstract c o n c e p t s without the potential for verification, it is not a useful theory for potential application in the real world. T h i s is the case with the so-called F r e u d i a n Theory. All of our operations, a n d in this i n s t a n c e let us confine ourselves to the m e n t a l h e a l t h field, are b a s e d in theory. W h e n we do a mental s t a t u s e x a m i n a t i o n , take a psycho-social history, c o n d u c t group therapy, or a s k a n open-ended question, we operate, p e r h a p s unaware, from s o m e theoretical base. T h e s e operations, or techniques, are all b a s e d in one or a n o t h e r psychological or g r o u p b e h a v i o r theory. T h e theoretical b a s e s for the u n d e r s t a n d i n g of m a n in h e a l t h / mental h e a l t h care are not currently b a s e d on an o r g a n i z a t i o n of holistic concepts. M a n y theories h a v e d e v e l o p e d t h a t are concerned with the p a r t s o f m a n . In general, t h e s e c a n be categorized as physical, physiological, psychological, or sociological theories. N o n e of these reflect all of the aspects of m a n , n o r his holistic n a t u r e as a living s y s t e m in a n interdependent a n d i n t e r a c t i n g r e l a t i o n s h i p with his e n v i r o n m e n t . As a result we h a v e been i n u n d a t e d b y t h e era of specialization. We h a v e specialists for each p a r t of m a n as identified by the a b o v e theories a n d then for the p a r t s of the parts. A psychological theory is b y definition limited in its scope. It does n o t e v e n a t t e m p t to explain h u m a n behavior; it does, at best, a t t e m p t to explain the psychological, or s o m e t i m e s psycho-social, motivations to behavior. However, this is o n l y a p a r t w h e n we are actually d e a l i n g with whole man. Thus, w h e n we o p e r a t e only from a base of p s y c h o l o g i c a l theory, we a r e s e v e r e l y limiting our perception of p a t i e n t s a n d problems, as well as t h e r a n g e of a l t e r n a t i v e s available to us in developing a therapeutic p l a n of action. C u r r e n t knowledge is too s i g n i f i c a n t a n d too v a s t for us to continue in this m a n n e r . Specialization m u s t give w a y to a n o t h e r level of theoretical formulation, generalizaton. T h e o r i s t s m u s t t a k e the multiple a n d p a r t i c u l a t e theories of m a n t h a t w e n o w h a v e a n d formulate holistic theories. We must reorganize w h a t we h a v e learned during

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the intensive years of specialization, incorporate new knowledge, and move to another level of conceptualization. Early examples of this trend are already evident in the m o v e m e n t toward a type of family practitioner in medicine and nursing and toward a new type of generic social worker. In the mental health field, we lack theories t h a t are based on a holistic concept of man. A few a t t e m p t s h a v e been m a d e to expand a psychological theory into a psycho-social theory, but two parts have not proven to be much better t h a n one. Some clinicians profess to operate from an eclectic approach, but this is a mythical explanation to cover the fact that what they are doing is pure guess-work. Few theorists to date have tackled the problem of constructing a holistic model. Two outstanding exceptions are Ludwig von Bertalanffy (1968, 1972) and Martha Rogers (1970). Bertalanffy formulated a general systems theory, one of the first attempts in the health field to transcend existing theoretical models, rather t h a n just rearrange them. Rogers h a s developed a conceptual s y s t e m which defines man as a whole, more than the sum of his parts, and continually evolving - - a theory of becoming. Practice Model The second major problem so vividly documented b y R o s e n h a n is the lack o f a theoretically-based practice or t r e a t m e n t model for the delivery of comprehensive mental health care in an institutional setting. While holistic theories m a y eventually obviate the "bits and pieces" type of mental health care as we now know it, such changes are not imminent. In the meantime, we can only work to improve existing care models. The m o s t prevalent model is the traditional or medical model, which is designed for sick care, as opposed to health care. There are also private practice models which are limited by the preparation of the individual practitioner a n d which tend to emphasize therapeutic techniques, as opposed to using the techniques as a m e a n s to achieve a conceptually-based goal. There is also the casework method, but this is essentially an individual or private practice model. We simply lack a model for mental health care delivery systems. This deficiency can be directly related to the deficiencies in our current conceptual systems. The medical model is a disease model. It is designed for the treatment of disease in an individual patient b y a physician. The same model which is used in private practice is used in an institution. It is only the complexity of the type of medical practice a n d the number of

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assistants which are noticeable c h a n g e s from the private office to the institution. This model is based in disease theory. It is basically a sick care model, not a health care model. It attempts to cure or control disease, not promote and strengthen health. The model currently utilized in psychiatric institutions is the medical model, or some euphemism for the same thing. The physician-patient relationship is the core; the physician directs the relationship in his effort to control or cure "mental disease." The problem with such a model is clear. The model evolved to deal with physical and physiological problems within the individual. It cannot have successful application where the process is not, by consensus at least, a disease; where there is no agreement as to a theoretical basis; where the process is already demonstrably socially related; where psychiatry, as well as any other single profession, lacks the scope and preparation to deal with the process through the medical model; and where concepts of health seem to be intrinsically involved. On the other hand, is there another model which is a n y better? The therapeutic community model as described by Jones (1953) and the problem-solving model (Weed, 1969; Bjorn, 1970; Hurst, 1972) are both attempts to improve upon the traditional medical model. However, both basically remain a medical model. The therapeutic community employs group d y n a m i c theory in the t r e a t m e n t process, but the therapeutic plan is still essentially determined in the traditional manner. The problem-solving method is basically a disease model; it attempts to resolve (cure) problems and is not designed to promote health. The so-called team approach is generally applied within the medical model. Other professionals contribute information t h a t is utilized by the physician in the diagnostic a n d treatment p l a n n i n g process. Other information that such professionals m a y have, offer, or view as essential to the promotion and m a i n t e n a n c e of health does not fall within the scope of medical practice. Consequently, where such a team situation exists and the medical model is the mode for delivery of services--as in psychiatric institutions--various forms of conflict arise. E a c h of us has experienced this type of conflict in one way or another. For example, a ward nursing staff became increasingly demoralized as the director of p s y c h i a t r y for the hospital maintained t h a t the lack of toilet seats and doors on the bathroom stalls of the patients' single communal bathroom was in no way related to patient illness and treatment. Or consider the social worker who was encouraged to develop as m a n y ward group activities a n d programs as he was able, but whose plans a n d observations surrounding these activities were not viewed by the physician as being significant in the

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development and implementation of a t r e a t m e n t plan. Or, by way of contrast, consider the physician who feels t h a t an admission is warranted because of his evaluation of potential homicide but who is harangued the next morning by all of the ward staff for m a k i n g an inappropriate admission. Such examples are endless. It is not surprising that the participants in R o s e n h a n ' s project met with the situations they did. When you are placed in an institution t h a t delivers services which lack a sound theoretical or scientific basis and a model is used which is essentially designed for private and institutional medical care, the various depersonalizing experiences can hardly be avoided. Staffing patterns are designed on the basis of guesswork and not on a theoretical basis for the delivery of our best knowledge of mental health care. Existing staffing patterns are also inappropriate to the application of the medical model. With the size of the inpatient populations t h a t currently exist, m a n y more psychiatrists would be needed to correctly employ the model. However, the appropriateness of the medical model and resultant need for more psychiatrists is clearly questionable and one which cannot be resolved easily.

One Alternative: The Managerial System The managerial system is the most popular of the newer approaches to the delivery of health or mental health care in institutions. In this system, professional administrators assume ultimate operational authority and responsibilty for delivery of services rather than the medical director. This system is common throughout the business world. The leader m a y be expected to possess a background in public or business administration, law, finance, or something closely related. This leader, director, president, or whatever title is used, is assisted by subordinates who are specialists in finance, operations, supplies, and other individuals whose areas of specialization reflect the n a t u r e of the organization. In hospitals, the executive director would be assisted by the medical director and the directors of nursing a n d perhaps social work, depending upon the size of the department. The key members in the hospital system would be the medical director for overall clinical policy, the controller for finances, and the assistant directors who coordinate all daily operations. The role of the leader is t h a t of ultimate authority, which is exercised through subordinates. His power in decision-making rests mainly with his or her ability to seek appropriate information from the various subdivisions and formulate operational decisions based upon this information. For instance, a decision on w h e t h e r or not to

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grant a request from the program director of the pediatric clinic for more staff will be made only after review of available and projected finances by the controller; evaluation by the medical director of the soundness of the clinical program; and presentation of utilization statistics and information by the assistant administrators for the program area. There are several advantages to the m a n a g e r i a l system over the more traditional structure where a physician was always the director. Unfortunately, this latter structure was never more t h a n an enlarged medical model. However, this was functional as long as the charity concept suported general hospital care. With the more recent evolution of the medical-industrial complex, a more business-oriented approach became essential to the survival of all hospital systems. There can be little question that the increased emphasis upon the application of sound business principles has been of benefit to m a n y in the hospital system by making higher wages and more personnel possible. Another a d v a n t a g e is t h a t the medical model is not the operational base for the professional administrator. Medical opinion becomes a contributing voice in decision-making and not necessarily the rule. Other professional opinions* also contribute but have limitations where medical authority has become institutionalized into "law," and where the nonmedical professional's experience in the politics of power remains naive from so m a n y years of yes-doctor. The operational base for the managerial system includes knowledge of the exercise of authority, power relationships, leadership and interpersonal relationships, economics and finance, and other areas depending upon the field of specialization. This background is generally obtained at the masters degree level. The m a n a g e r i a l system clearly has the potential for the implementation of true team approaches. The professional administrator does not s h a r e the professional identity, biases, a n d self-serving interests t h a t we clinicians are limited to by the nature of our preparation. Each clinical group is thereby called upon to substantiate its position and m a y b e negotiate this position with other clinical groups, rather t h a n just being able to blame physicians for the failure to implement its ideas. In mental health care systems, where we lack consistent or comprehensive conceptual bases for the n a t u r e and delivery of care, the managerial system affords the opportunity for a lot of cross-professional education. While this m a y be a more democratic approach, there is still no basis to suggest t h a t this approach would be an improvement over the authoritarian medical model. Perhaps one of the greatest criticisms of the m a n a g e r i a l system

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is that, while the system m a y greatly enhance the operational efficiency of an existing organization, it can make no claim to improving the quality of care in and of itself. The success of the managerial system in health care becomes almost entirely dependent upon the abilities of the top administrator. The m a n a g e r i a l system is at best a technical solution to a technical problem--production. The m a n a g e r i a l system has evolved to provide efficiency and promote expansion in production systems. Quality becomes a timelimited concept, translatable into such an idea as planned obsolescence. Production systems are geared toward improving the efficiency of production output, regulating the material quality, and measuring success in expansion a n d dividends. However, transferring this system into h u m a n services organizations presents the same conceptual problems for the administrator as I outlined for mental health care in general. The m a n a g e r i a l system is designed to direct mechanical systems and not h u m a n systems. Its focus is upon input (money) and output (quantification of treatment services). Quality of care is so difficult, if not impossible, to quantify t h a t it is virtually ignored. Likewise, professional administrators lack preparation in the n a t u r e of m a n and this can result in inappropriate application of m e c h a n i c a l (closed system) concepts to h u m a n services. There is too much emphasis on the "how" and too little respect for the "why." On the other hand, I have worked in all of the above systems and would definitely opt for the m a n a g e r i a l system until something better comes along. It seems to me that, in spite of the disadvantages of this system, it presents us with the best opportunity at this time to try some alternative approaches to existing treatment methods and for all clinicians to learn a great deal more about their own viewpoints, as well as t h a t of their fellow professionals. It also forces each of us as individuals to operate from a conceptual basis t h a t is defensible, to formulate delivery models from such theory, and to demonstrate t h a t both the theory and practice are effective toward achieving our goals. The medical model has not afforded us, the physician included, this opportunity. It would appear, therefore, t h a t we are fast approaching a crossroads in health and mental h e a l t h care. Reports such as those by Rosenhan will m a g n i f y public pressure for reform. High costs of care are rapidly forcing changes, as demonstrated by the widespread use of the m a n a g e r i a l system. Comprehensive theories are already being developed t h a t will require c h a n g e s in thinking a n d models for delivery systems. Frankly, I think we are moving into a n exciting future.

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REFERENCES Bertalanffy, L. von. General system theory. New York: George Braziller, 1968. Bertalanff-y, L. von. The history and status of general systems theory. In G. J. Klir, Trends in general systems theory. New York: Wiley-Interscience, John Wiley & Sons, 1972. Bjorn, J., & Cross, H. The problem-oriented practice of private medicine. Chicago: Modern Hospital Press, McGraw-Hill, 1970. Hurst, J., & Walker, H. (Eds.). The problem-oriented system. New York: Medcom Press, 1972. Rogers, M. E. An introduction to the theoretical basis of nursing. Philadelphia: F. A. Davis, 1970. Rosenhan, D. L. On being sane in insane places. Science. 1973, 179(4070), 250-258. Weed, L. L. Medical records, medical education and patient care. Cleveland: Press of Case Western Reserve University, 1969. P. O. Box 337 Riverhead, New York 11901

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