The Long View

It is always hard in the midst of events to maintain perspective and take a longer view. Given all our daily activities, or any year’s APA events, an accurate perspective on our field—how people think about mental health or mental illness—can be hard to achieve. At a time of substantive developments in neuroscience, genetics, and health care reform, doing so is important for our field and APA if we are to stay focused on the activities that will most benefit patients and families over the long term.

Rapid developments in science or society are particularly hard to assess in the moment. I recently read a column by NYU Professor Clay Shirky on the current transformation of print journalism in an environment of intense pressure from digital media (March 2009). He noted how much the world had changed with Gutenberg’s invention in the 15th century of the printing press and movable type and how hard it was at the time to understand their significance. Noting that the transition was chaotic, he cited the historian Elizabeth Eisenstein and her book The Printing Press as an Agent of Change. As Shirky wrote:

She was able to find many descriptions of life in the early 1400s, the era before movable type. Literacy was limited, the Catholic Church was the pan-European political force, Mass was in Latin, and the average book was the Bible. She was also able to find endless descriptions of life in the late 1500s, after Gutenberg’s invention had started to spread. Literacy was on the rise, as were books written in contemporary languages, Copernicus had published his epochal work on astronomy, and Martin Luther’s use of the press to reform the Church was upending both religious and political stability.

So immersed are we in an era of both great and at times overwhelming technological and scientific change that we can be easily forgiven if we can’t see clearly what these changes mean for our views of human nature, our understanding of the brain and mental functioning, and our definition of mental illness. If the discovery of the neuron by Ramón y Cajal in 1888 was a major contributor to the rise of neuroscience in the early 20th century and influenced Freud’s pre-psychoanalytic neurobiologic theorizing, how much more will our perspective be upended by the flood of work currently under way?

At the same time, much doesn’t appear to change. Mental illness affects, as ever, the most human and intimate of our capacities. It impacts our ability to understand the world around and in us and to define our sense of self and can place us in emotional and cognitive confusion.

Likewise, the discrimination that patients with mental disorders encounter seems to lessen slowly, if at all, especially when we monitor these circumstances day to day. At times our patients and even we are subject to disparagement and harsh criticism. And while these experiences aren’t pleasant, maintaining perspective here as well is important. We may disagree strongly with those who are skeptical of, or hostile to, the reality of psychiatric illness. Spend even a few days in any emergency room or care for a patient with severe catatonia who, bedridden and requiring feeding support, gets dramatically better with ECT and the reality and impact of mental illness is quite clear. Spend time in any prison and it is clear that our system has failed to care for those who are ill and instead incarcerates them.

While it is, in general, wise to avoid applying psychological interpretations to credible intellectual disputes, one is nevertheless left with the nagging sense that the intensity of the critical response to psychiatry may in part be due to the importance of behavior and psychological life to human beings, especially in modern culture. Just as we shouldn’t medicalize the sufferings of everyday life, we also can’t and must not ignore the reality of psychiatric illness. In the heat of engagement or battle, we can be rightly discouraged with the slow pace of change or progress in any of these areas. Stepping back, one can see not just the growing improvement in the care we are providing, but a much more open and honest public discussion of the impact of these illnesses and how far we have to go to achieve true equity. The bravery of those who have confronted the stigma associated with mental illness, regardless of personal risk, and have spoken openly about their lives and experiences is remarkable to witness.

The work in which we and APA have been engaged, whether to achieve parity or advance science, remains essential. If there is anything I have learned over this last year, it is that mental illness does not respect person, class, religion, or political persuasion, and people throughout the United States—patients and families—are passionately committed to better care and cures. So while the effort is challenging and progress may seem painfully slow when looked at close up, we need to take the long view and remain sharply focused on our solving the scientific and policy issues that will relieve the burden of mental illness. ■