A KING FROM the Middle Ages, whose custom it was to surround himself with all the best healers in his realm, would be very much at home with the contemporary mental health profession in America. The affluent and educated elite are surrounded by first-class healers, while the masses must make do with whatever second-class services are left over. It is a two-class profession.
The distribution of psychiatrists has long been known to be grossly inequitable, but recent data has clarified the dimensions of this inequity. Wealthy Westport, Conn., has one psychiatrist per 1,000 inhabitants, whereas blue-collar suburbs of Chicago (e.g. Gary, Hammond, East Chicago) have one per 100,000. In two buildings on New York's fashionable upper East Side there are offices for 65 psychiatrists, more than exist in any one of 16 states. In Washington, where there are more than 1,100 psychiatrists, only seven have private offices in the poorer Northeast and Southeast sections where more than half the population lives.
A 1978 survey of psychologists and clinical social workers, published in Psychology Today, confirmed that these two professions are just as inequitably concentrated in affluent urban areas and university towns.
What kinds of patients do most of these mental health professionals see? A study in Boston found that only 20 percent of patients seen by private mental health professionals could be classified as seriously ill. The remainder had various combinations of problems that were interfering with their ability to work, play or live with others.
These problems of living are real and disabling, to be sure, but what kind of a system is it that allocates most of its resources to help the unamiable affluent while it ignores the truly mentally ill?
The really sick people in our mental health system are in the state hospitals, community institutions designed to keep them out of sight and out of mind. The professional staff for these institutions usually consists of rejects from the king's court (one state hospital director complained publicly that the only American professionals he had been able to recruit were alcholics, drug addicts and mentally distrubed) and an assortment of foreign medical graduates.
A 1976 National Institute of Mental Health report makes clear the dimensions of our dependence on those graduates. Of all physicians employed full-time in state mental hospitals, 58 percent are products of foreign medical schools. In 11 states, the figure is more than 70 percent, and these include not only smaller states (West Virginia, South Dakota) but some of the largest and wealthiest states (ohio, Illinois).
Many foreign medical graduates provide excellent services; there is no doubt that many others do not. The NIMH report details how 42 percent of these individuals in state hospitals are not fully licensed, but rather practice on a restricted license specially issued by the state.
Training in foreign medical schools varies widely from excellent to pay-a-thousand-and-buy-your-degree; in light of this, it is not surprising that horror stories from the "asylum" make the professional rounds in the politest of mental health circles.
One psychologist who recently left the Illinois state hospital system in disgust told of having to work with a psychiatrist in charge of prescribing drugs who did not know that 0.8 and 0.80 were the same number. And the American Medical Association cites four foreign medical graduates who had each failed state licensing board exams at least 13 times and, at last report, were still trying.
The directors of public mental institutions are usually between a rock and a hard place, given the fact that most American mental health professionals are not available for public service. The directors can either fall back onto foreign medical graduates to fill the empty positions, or they can leave them empty and provide not even the facade of services. Washington, with a higher concentration of psychiatrists and psychologists than anywhere in the world, illustrates the latter alternative.
The solution to all this is rather simple. Most mental health professionals are trained with large amounts of public funds. Doesn't it seem reasonable to expect such individuals to pay this back with a period of public service before they gallop off to Westport to join the king's court?
If this is not done, we can expect to continue a two-class system of care. And this, for most people, is distinctly second class.