The Bureaucratic Destruction of Patients' Faith in Their Doctors: Public Psychiatry's Negative Lessons for General...

The doctor-patient relationship, so important in all of medical practice, has been destroyed in much of American public psychiatry. That destruction should serve as an important negative lesson for a medical care system facing reorganization. The desirability of having the same psychiatrist caring for a patient both in the mental hospital and after discharge-continuity of care-should have been obvious, but its significance was not defined explicitly, to this author's knowledge, until about 1979. White's demonstration that the therapeutic relationship's positive impact seems to "account for about half of the benefits" associated with medical and similar ministrations underlines its importance. Continuity of competent public psychiatric care, and its therapeutic effectiveness, have been impeded by the harmful attitudes and actions of American psychiatry and the care-fragmenting acts of public officials. Soon after the continuity concept was informally presented in 1979, official American psychiatry, increasingly influenced by drug companies, began denying the importance of a physician's continuing care by redefining "continuity" as though public mental health care had to be fragmented. Specific policy decisions by officials are also largely responsible for the destruction of good public psychiatric care. This in turn has produced gross overuse of medications and the near disappearance of competent public psychiatric leadership and effective therapeutic relationships. An example from the federal Health Care Finance Administration shows how comparably harmful bureaucratic decisions concerning health care can also be made on the federal level. If similar decisions are made under the proposed reorganization of general medical care, that care, like American public psychiatry, may become harmful to its patients.