xxAACP Newsletter, Volume 12,
Number 3, Summer 1998
Editor's Column: Psychiatry and Personal Growth
in an Era of Uncertainty
Perhaps closer to home, the papers in Pittsburgh have been reporting on the financial crisis of Allegheney Health, Education, and Research Foundation (AHERF), owner of several hospitals here in Pittsburgh and Philadelphia and of the Allegheny University of the Health Sciences (formerly Hahneman Medical School and the Medical College of Pennsylvania). All the non-tenured faculty, some 800 physicians, have been required to submit letters of resignation. Some will be rehired, but some will be let go. I am non-tenured. I work for a large academic health system here in Pennyslvania. What makes my situation potentially any different from the AHERF faculty in Philly?
Reflecting the growth of the electronic media, I have recently become a participant in a listserv organized by the American Psychiatric Association. Called Member to Member (M2M), the listserv is a forum for APA members to vent about managed care and other issues. And vent they do, almost entirely about managed care. A litany of protests against restricted formularies, denial of payment, and other practices of managed care pour out. Some members are proposing soultions - a return to fee for service practice, a boycott of managed care, a call for a Canadian style national health system. Everyone sounds threatened and everyone calls for the mobilization of the profession. But none of the solutions seem very likely, either because they have already been rejected as part of the problem , or require changes that the powers that be refuse to consider. Where will this go? Who will pay us, how, for what?
The New York Times has recorded the fact that we live in booming economic times. (Its the primary reason I have so much to lose in my retirement account if the Y3K problem is not solved.) But it has also noted that many Americans have a deep sense of uncertainty about the future. We may be making money now, contributing to the economy and society, but we have little faith that this will persist. No doubt this reflects the turmoil in this growing and shifting economy. A fear of downsizing and obsolescence haunts our imaginations, especially in health care. It is an era of uncertainly. We do not know how to remain tethered to a rapidly changing social ecology.
The approaching millennium both captures and symbolizes this on many levels, including an ironic one. No one can say with certainty that when the millennium will actually occur - January 1, 2000 or January 1, 2001. It is a matter of semantics and definitions and whose approach to dating one decides to accept. So even the date of the millennium is uncertain. The meaning of the millennium is up for grabs too. Some see it as an approaching point of biblical significance. Others dismiss it as just another day in a long line of days. Still others note that the reaction to the millennium will not start unitil it becomes clear that nothing predicted has happened and then those who had been waiting will become despondent en masse.
Perhaps an apt metaphor for our era, generated at this time of year, is that our society is blindfolded and walking out on a plank (or is it a diving board?) of unknown length over water of uncertain depth. Will we sink or swim? And when? (The Titanic looms large in the popular culture.)
What does psychiatry have to say about this state of uncertainty? I am not sure that we have really focused on it recently. We tend to want to resolve anxiety, to move beyond ambivalence, to use reason and to find a diagnosis, a cure, a brain that concretely explains the mind and its distressing symptoms. We do not talk much about how we might help people manage or live with the uncertainty engulfing us. Yet we ourselves live with uncertainty all the time - every time we see a patient and try to decide if they will be safe or what medicine to use or contemplate a new theory of the etiology of schizophrenia or consider the Y2K problem. We are truly certain of none of these things, even if sometimes we think we are.
Of course we continue to search of answers, for certainty, for reason. Clearly, this is a good strategy for finding answers. Even if it were not, it greatly reduces anxiety to believe and answer is attainable. But we must know by now that certainty will elude us. It is trite but true to observe that every answer seems to create new uncertainties. Besides merely seeking answers then, how else might we proceed?
One source of possibilities might be to look at the recovery movement (see Wes Sower's editorial in the previous edition of this newsletter [Vol. 12-2]). It is clear that some recognition of the certainty of uncertainty is a key component of all recovery, as is the sense that we are all in it together, communicated by mutual aid and empathy. Pragmatic support and partial solutions, in lieu of a cure, are also critical elements. Often a spiritual sense of transcendence and unity and even magic seems to provide solace. There is belief that examined, exrapolated experience is a teacher and a guide worthy of attention.
I admit I am uncertain about the future of psychiatry, just as I am uncertain how to end this piece. Maybe that it the first step in beginning to learn how to live without certainty. Time to take a dip.
Ken Thompson, MD
Webmaster
Web Editor's Note, June 13, 2003 -- Today the Hahneman and Medical College of Pennsylvania schools are no longer under AHERF, and AHERF itself has gone bankrupt. The two schools are now merged into one school called "MCP Hahneman". It is operated by Drexel University. For more information, visit Drexel's merger announcement website.
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