American Medicine

THE OPEN MIND
Host: Richard D. Heffner
Guest: Robert Michels, M.D.
VTR: 6/25/75

Hello, I’m Richard Heffner, your host in THE OPEN MIND and my guest today is Dr. Robert Michels. Dr. Michels is Professor and Chairman of the Department of Psychiatry at the Cornell University Medical College, and is Psychiatrist-in-Chief at New York Hospital. Dr, Michels, I’d like to begin the program by referring to another program in a sense. Many months ago THE OPEN MIND did a program on health care in America, and the distinguished medical men who faced me at that point, graced that discussion with the question of whether the need to serve larger and larger numbers of Americans, medically speaking health care for the millions—for 200 millions Americans—whether that needs threatened or promised to change the very quality of medicine in this country, and our discussion seemed to focus on the question: mustn’t there be a trade-off somewhere of quality for quantity, perhaps. I wonder whether that formulation relates in your own thinking to psychiatry, as well as to medicine in general.

MICHELS: I think in some ways it’s probably an even more critical question for psychiatry because there’s a less clear consensus about what optimal or adequate care is, psychiatrically. I think there are a great many people in the medical progression who would think that we ought to be able to provide something fairly close to optimal professional care for all of our citizens, and that’s an economically plausible goal that we should aim at, with the recognition en route that we might have to make transient compromises, but we can reach it, that we can train the number of professionals we need, we can have the number of hospital facilities and other health facilities, and we can even—if we ever solve the problem of how to do it—we can even distribute them appropriately. The problem in psychiatry is the definition of optimal care isn’t clear, because psychiatrists not only treat people with clearly defined diseases and bring them back to some normal level, they’re also involved in helping people to handle problems more effectively than they would otherwise. There’s a kind of optimizing function as well as a normalizing function, and it’s very hard to define when that has reached its limit. If we think that we’re going to psychoanalyze every member of the population, we couldn’t possibly train the number of psychoanalysts we’d need to do it. So that we need some sort of decisions about what the appropriate limits of psychiatric care are for the population, and then secondarily but very importantly, whether those would be the same for every member, whether we want a society where some people have access to more care than others, and how we make those decisions.

HEFFNER: At the medical school—at Cornell University Medical College—what are your answers to the very questions you’ve just raised?

MICHELS: Well, I think that being a—my notion of an academic institution, our job is to raise those question to articulate alternatives, to examine the implications that they would have, and to urge our students to formulate their answers—we don’t have much alternative because they’re going to do that anyway. I think that the most—the highest priority most of us feel should go to those that are must in need, the sickest, the ones that have the most severe mental disturbances, the ones that are in the greatest need of care. Those are people for the most part with major psychoses, and that group of patients is for the most part fairly similar in the kinds of health delivery problems they provide to patients with other chronic illnesses in medicine or in other fields of medicine. And I think that a reasonable goal for our society would be fairly optimal care for people with major psychiatric illness that impair their total life functioning.

HEFFNER: Why?

MICHELS: Well, that’s a hard question. I’ll give you a few answers to it.

HEFFNER: Okay.

MICHELS: One is because that’s the kind of society we want to live in. We want to live in a society where people who are in terrible trouble to get help, and get good help. That’s why we want to take care of people that are dying, even if we can’t prolong their lives, to make them comfortable and happy, and to make that part of their life. So that’s one answer. The second answer is a cost benefit kind of economic answer. We have pretty good treatment for these answers. And if we’re able to deliver it, in a long run we’ll do better economically and we’ll get more yield for our efforts than if we don’t treat it. At patient with a psychosis that’s treated offers more to society than the cost of the treatment. I guess another answer, in a sense, is that these are the most disadvantaged people that there are, in many ways—the chronic mentally ill—and there’s a sort of, I guess a value ethic that many of us will subscribe to, that we ought to go out of our way to do something for the ones who are worst off.

HEFFNER: Do you find among your students the feeling, perhaps, that that’s the wrong approach to take, that indeed what it does is level everything off, and perhaps not help is raise the quality of life for most people, most younger people rather than the older and the more chronically ill?

MICHELS: Certainly there’s a trade-off between helping the people who are worst of and helping those where a single unit of help can do the most—can make the most change in someone’s life. That’s a trade-off throughout medicine. I think ideals we live in a system where we had enough resources, enough care-takers, enough medical facilities, so that we wouldn’t have to ask that question, but we don’t. We certainly don’t in psychiatry. I guess that we should do both in some kind of balanced way. I don’t think that we should spend all of our resources in providing support for the chronically, and perhaps incurably, ill, nor do I think that we should ignore them and devote all of our resources to those people for whom a unit of health can produce the greatest change in their lives.

HEFFNER: In the psychiatric field, is there a way of making a decision, is there a consensus, is there a national policy in terms of whom we help, and how can we balance the help we give to different groups?

MICHELS: I think that there’s probably more of a practice than a policy—a policy implies that it’s been carefully though through, rationally decided upon by the profession or some other group, and then done that way—I don’t think there is. I think there are patterns of practice that have emerged, often in response to other factors—economic factors, traditional factors—then lead to a policy that’s implicit and that has to be discovered. For example, the patterns of the economic support for heath care delivery encourage the treatment of acute illness and discourage the treatment of chronic illness. Many insurance policies say they’ll pay for X days of treatment and no more than that. They encourage in many situations treatment of people who either are poor and therefore can apply for government-supported treatments from Medicaid or similar programs, or are rich, that discourage the treatment of people in the middle. They often, unfortunately, terribly unfortunately, are biased against the treatment of children.

HEFFNER: Is there any sign that there can be a change in that concept of cost benefit analysis.

MICHELS: Well, one of the problems that the progression has faced in this area is that psychiatry is much more a public area of medicine. It’s the most socialized area of medicine. More psychiatrists work for governmental organizations or large public institutions. They spend less of their time in private practice than most other medical specialties.

HEFFNER: That’s not the picture, it seems to me, that the public has of psychiatrists.

MICHELS: Well, the public picture is based on a stereotype that has to do with magazine cartoons of psychoanalysts sitting behind couches. In fact, when surveys are done, psychiatrists spend more of their time in employment and less in private practice than any other medical specialty that has direct patient care. Also, psychiatry is very much—if it’s going to be effective in out-patient form of medicine, treating people who aren’t yet hospitalized. The training programs are not geared in their financial support to these facts. In the past the federal government and some state governments have provided major fiscal support for psychiatric training programs, which were symmetrical, since the products of those programs went back to work for those governments. The governments are short of money these days, as you know. They’ve been cutting back on that support, and when the support for training programs is thrown into the non-governmental sphere, psychiatry is in terrible trouble. There are people who know what the problem is. It’s been clearly and succinctly formulated by leaders of the profession. The solution has not yet appeared.

HEFFNER: The solution, you seem to feel, is a fiscal matter?

MICHELS: That’s a component of it. I think that would reflect the solution in terms of there being true policy-making, rather than the practices reflecting practical solutions to practical problems that don’t have to do with health care. Look at it this way—the health care budget of our country is over $100 billion a year. The amount that’s spent on research, development, and training, as a percentage of that, is miniscule. When you compare it to an industry like the automobile industry we ran our health care system as a sort of cottage industry with lots of little organizations in business for themselves, an no one spending the appropriate amount of emphasis on education, research, and centralized, or at least comprehensive, planning. These problems have been articulated, they’ll be expensive to solve. I think the limiting factor in solving them this month, or this year, is the commitment of the funds required to solve them. But I think that we probably will move in that direction. I guess there’s a basic optimism, we’re a rational species, and we’ll move in the direction of rational solutions.

HEFFNER: Is that your assumption, as a psychiatrist, that we’re rational?

MICHELS: Not as a psychiatrist, but as a citizen.

HEFFNER: And as a psychiatrist? Seriously.

MICHELS: As a psychiatrist, we’re both—I guess, as a psychiatrist, my primary interest is in the irrational, and with the assumption that everything that anyone does is important and vital irrational components, in its motivation in its being, in its conduct—but those are components. And I think it’s the overenthusiastic or naïve believer of the theory who says that that’s all there is to it, that somebody picks up the telephone to call a friend, he may be involved in all kinds of important unconscious, aggressive or sexual behaviors, but he’s also calling his friend.

HEFFNER: When you use the word “behaviors”—and we met at a conference on behavior control or behavior modification, and I’ve wondered since that time whether, in your professional role as Chairman of the Department of Psychiatry at Cornell Medical College, and as the Chief of Psychiatry at New York Hospital—whether your concern is essentially with the behavior of the patients you reach directly and through your many students and through the doctors who report to you—are you concerned essentially with what they do in society or with their inner beings? Now, I’m sure the answer isn’t going to be one or the other, but I wondered if you’d discuss that?

MICHELS: Certainly the answer is both. In a way, the problem is a very serious one, as emerged at that conference. It’s almost least important with psychiatry patients that we generally treat in psychiatry. The vast majority of patients come for help saying: I don’t like the way I behave and the way I feel. Please help me to change. And therefore, their concern with their overt patters of behavior in society and their inner feelings is the same concern. And the request for change comes for the vast majority, not from society’s disapproval of their behavior but from their unhappiness with their own behavior. The problem gets more complex with that smaller group of patients who say: I’m fine. But someone else says: Change him. Or with non-patients of whom the same thing is true. People who can be seen on the one hand as being sick, or take an extreme turn, and on the other hand as being naughty or socially undesirably or deviant. Psychiatrists, and myself included, get very nervous in such situations. I think we are most happy when we can find an area where our client, or patient, wants to be changed and seeks our assistance. I think the only situation where we’d be inclined to go beyond that is where there is overwhelming evidence that his true interest are to be changed—his true personal interests—and he’s denying those interests because of some confusion or some mental illness, somebody who in a moment of panic says: Please end my life. Somebody who in a toxic delirium or confusion says: Let me out of here. Somebody who’s retarded and doesn’t know enough to seek what’s best for himself. When we reach question of social values, and someone says: I like the way I am; and someone else says: He really ought to be different. It would be better for society; we’re no longer talking about psychiatry, we’re talking about social engineering and the whole—psychiatry as a branch of medicine has no important role to play in that—

HEFFNER: It doesn’t? –that’s a—

MICHELS: It shouldn’t.

HEFFNER: That’s something different, isn’t it?

MICHELS: Yes.

HEFFNER: It shouldn’t, but it does, because if I remember the conference that we attended together, certainly there were enough representatives from your profession who were at least interested in going on in society in terms of behavior modification. You say it shouldn’t. Why shouldn’t it, if there are patterns of behavior that in your judgment as a professional as well as a citizen should be changed, why isn’t it part of the function of psychiatry to participate in the modification of that behavior?

MICHELS: As a citizen, I feel I’ve a right to have values about how people should act, and I Have a vote to help express those values, and I think there are situations where the society has the right to engage professionals to help modify people’s behavior. But as a professional psychiatrist, I think I should be extremely careful to keep those citizen values out of my function, and to say that my—the one value that I represent as a physician and a psychiatrist is health. And unless someone’s deviant behavior falls in that rather narrow category of deviants we call sickness, that I shouldn’t offer my professional skills as a physician to help change it, unless the client wants the change.

HEFFNER: You said a moment ago that there are perhaps some areas though, perhaps, where it might be appropriate. What are those areas—of criminals.?

MICHELS: I think that there are areas where society might find it appropriate, on certain forms of criminal behavior, certain forms of stupidity, of dumb behavior. Let’s take the typical example. Society has always felt that it’s appropriate to modify the behavior of young children, with the thought that adults know more about what’s good for them than children do themselves. The most startlingly successful form of behavior control that’s been learned over the generations is toilet training, where every child’s wishes are places second to society’s interests and parental interests. I’m not against toilet training. I don’t have a professional view that that’s bad. But I think that we have to be careful to limit the situations where we impose the dominant wishes of the larger group on the individual to those [CAN’T READ] a very, very, very strong social consensus that the individual is better off as a result.

HEFFNER: But, isn’t that in a sense begging the question, because isn’t that exactly what we do all the time, isn’t the process of socialization—you talk about toilet training, but don’t we teach each other what it is to be a human being in so many, many, many ways. School, where we learn more than the A’s and B’s and C’s, where we learn more than the reading and writing and arithmetic, where we learn how to behave, what it means to be a human being. Isn’t it in a sense copping out when you say we shouldn’t do this, when you say we shouldn’t do this, when in fact we seem to do it all the time?

MICHELS: Sure, we do it all the time. And we should do that. That’s apart of the value of our species being a social organism. What’s I’m saying that shouldn’t be done in some particularly powerful tools of shaping other people, that are traditionally associated with the medical profession and psychiatry, perhaps—tools like drugs, tools perhaps even like surgery, tools like some forms of very intensive psychotherapy, should be preserved for situations where the—that are more limited than normal socialization. One of the nice things about the kind of socialization you’re talking about—what goes on in the school, what foes on in peer groups—is that its results are not that predictable, that it’s not that overwhelmingly powerful, and that there are so many competing socializing factors, that the individual has some role in determining his own fate. He isn’t a victim.

HEFFNER: [Two words unintelligible] wonder then, and I appreciate what you just said, and I certainly see the wisdom in it. But I’m also thinking about those who would say: Dr. Michels, what you’ve said is that we can use tools as long as they’re not too powerful, as long as they’re not too powerful, as long as they’re not really that successful. But if we do want to bring about change, if we have some sense of what the good society can be, should be, must be, why don’t we use the more and more powerful tools? Why beat around the bush and say well, let’s use tools that aren’t that powerful, aren’t that effective.

MICHELS: I think you hear me clearly. And I think there may be powerful and aren’t that effective, and the reason is that I at least do not have an absolute certainly about what the good society should be. I think there’s an advantage to maintaining a pluralistic society, an advantage to allowing for the fact that we may be wrong, and therefore using methods of persuasion that are short of coercion. If we’re in this discussion, and you’re right and I’m wrong, I’d rather you talked me into your view than hypnotized me or operated on my brain, because I’m never quite that sure that you’re right and I’m wrong, and I wouldn’t mind your effectiveness being such that ten percent of the people you talk to ended up being unpersuaded by your arguments.

HEFFNER: And fifteen percent? Or twenty? Or fifty percent? –at what point would you be willing—and perhaps the point is never—to use the more coercive techniques or tools of persuasion.

MICHELS: The limiting edge question is one we’re not near at the moment, and so I can comfortably cop out. I would sayh at this point it seems clear to me that in dealing with out patients, with people who are ill, with people who are suffering from definably mental illnesses or syndromes, the problem is that our tools aren’t powerful enough. In dealing with the general members of our society, where our knowledge of what’s good in not that clear, the danger is that our tools may be used too widely and too generally without paying attention to their undesirable or side effects.

HEFFNER: My feeling is—my strong feeling is that there are many people who are not as deeply devoted as I believe you are, to the democratic tradition, to the tradition of choice, to the tradition of the absence of coercive instruments, who want in their understanding and their determination that they understand what’s right, what’s good, what must be, to use more and more powerful tools, and that in a sense your profession has been perfecting those tools, brain surgery, perhaps, the psychopharmacological approach, and others. So at the very moment you say that you don’t want to use those totally coercive, the irreversible perhaps, devices, it is your profession that is creating the ability for society to be even more coercive than it is.

MICHELS: The answer—to comment on one of your earlier parts of that—I’ve known a great many people who want to use more coercive tools. I know very few who want more coercive tools used on them, and I take that to have some meaning. I think it would probably be a little bit more honest to say that it’s my progression that’s trying to develop such powerful tools, we’ve not been that overwhelmingly successful, and out best tools are still crude. I think the problem is more is more a problem of our anticipated success in the coming years. We are close to certain kinds of success in the coming years. We are close to certain kinds of success, and society ought to deal with the problems that we are going to create with those successes. I think the successes are inevitable. I don’t think it’s practically possible to legislate against the knowledge or the technique. I also think they’re desirable. There are many useful ways in which our knowledge of how to shape other people’s behavior can enrich society and help people that need and should have help. I think the problem is to develop at the same time or in advance of developing the technical tools for modifying people’s behavior, the social instruments for controlling those tools, and that’s a task that we’re really just beginning to address.

HEFFNER: Now, would it be unfair of me to ask you whether, quite honestly, you would anticipate that we will develop those tools of social control of our ability to control others, that we’ll develop the capacity—the moral capacity—not to use all the power that we create, or when you fear, as a good many people do that we are opening up more and more of Pandora’s box, that science, which we don’t want to stop, still is creating the ability to do the many things that you fear, without creating the moral climate in which these instruments should be considered before they’re used. What’s your bet.

MICHELS: I said I was an optimist as a citizen before, and I guess I remain an optimist. I think the problem will be a painful one. I w think there’ll be many treacherous stops along the way. I suspect that in a long run we will reach some kind of reasonable solution of it. I’m sure that when that first man rolled that log over on its side and discovered the wheel some of us, sufficiently farsighted if we were present, would have worried about the air pollution that would result form the internal combustion engines that would be designed to fit on top of those wheels and said, better stop now. In the long run, the air pollution’s a problem, the traffic’s a problem, but it’s a better society with the wheel than it would have been without it.

HEFFNER: As a psychiatrist, you were going to put society down or American society down on this table, on this couch before us, then what would your assumption be, not as an optimist or a pessimist, but thinking in terms of the functioning of groups of individuals, given the quantum jumps that have been made in our capacity to control our environment in the last several decades, where’s your bet them? Seriously, I don’t mean to bait you on that.

MICHELS: I think that our capacity to influence our environment and each other has increased and is going to increase even more. I think also the sophistication of our citizens, of our average citizen, about the potential powers of science and the limits of dangers of science, also increased. And I think that that may serve as a very valuable balance. I think that the era when science meant some kind of arcane, mysterious, powerful method of doing something that couldn’t be understood, that had to be feared, and that had to be supported, is ending. I think we’re beginning to make more intelligent social decisions about science, and I think I’ll bet on that side winning.

HEFFNER: You mean you stay—you remain the..

MICHELS: I’ll remain the optimist.

HEFFNER: The optimist. Thank you very, very much, Dr. Robert Michels, for joining us today. I must admit that we’ve got to come back and discuss this further and further because there are still so many questions at hand. But thank you for joining us, and thanks, too, to you in the audience. I hope that you’ll join us again on THE OPEN MIND. Meanwhile, as an old friend used to say, “Good night, and good luck.”