In this essay, Rick Hermann, M.D., describes his feelings of thankfulness and sadness as he comes to the end of his training. Describing the rapid changes and dislocations currently shaping the practice of psychiatry, Dr. Hermann explores the effect of these changes on our relationship to our teachers, to our patients, and to the practice of psychiatry. He captures the spirit of anticipation and elegy that many residents experience during their training.

Dr. Hermann is a staff psychiatrist at McLean Hospital. This year he will complete a fellowship in mental health services research at the Harvard School of Public Health. His research focuses on the variation in and appropriateness of psychiatric treatment, and the impact of health system change on the quality of psychiatric care. Dr. Hermann can be reached at rhermann@warren.med.harvard.edu.

I encourage all residents to VOTE in APA's 1997 election. We are a significant percentage of APA, and our voice and vote make a difference.

Please feel free to reach me at hegger@psych.mc.duke.edu or call me at (919) 416-7223.

Helen Egger, M.D.
Member-in-Training Trustee

By Richard C. Hermann, M.D.

When I was graduating from college, I was acutely aware that I wanted to say something before I left. I wrote an occasional column for the college newspaper, so it was not as though I needed to find a venue to express my thoughts. But two long papers remained to be written before graduation, and I had only so much resolve. I stuffed the thought to the back of my mind, and before I knew it, I was down the aisle and on to other things.

Fortunately, as I near the end of four years of residency and two years of fellowship, similar thoughts arise. After much time on both sides of a therapeutic dyad, perhaps I am better at listening to my thoughts and less given to suppressing them. I have a deep feeling of gratitude and a desire to express appreciation to my gifted and kind teachers, the researchers who have mentored me, and the patients who have taught me about trusting and trying. As I would have put it when I graduated from college, I wanted to thank my teachers for filling my mind so my ears wouldn't whistle in the wind when I walked.

I came to residency at a transitional time. The hospital's psychotherapy community had neither fought off nor been vanquished by the growing presence of psychopharmacologists and biologic researchers. Indeed, there was still a dynamic tension between the communities. In my first month of training, an analytically oriented supervisor consulted on one of my inpatients. The patient, a young man, was educated, sensitive, and deeply wounded. He was also paralyzed with depression and reflexively intent on killing himself. The attending psychiatrist, biologically oriented, had suggested electroconvulsive therapy. New to psychiatric treatments, I reacted with visceral inhibition to this reasonable suggestion. My reaction was reinforced by the consulting analyst, who asked, "What! You going to fry his brain?" Over the years, it has been through hearing different perspectives, trying different things, and learning from the outcomes that I've been able to synthesize my own understanding of mental health and psychiatric treatment. It is for these experiences, learning, and relationships that I am grateful.

I wish that this needed to be only a short observance and thanks. However, simultaneous with my own development as a psychiatrist, psychiatric treatment has devolved. As the psychotherapists and pharmacologists alternated between bickering and collaborating, they were blindsided by the managers and the money men. Grand and esteemed psychiatric hospitals, centuries old, are failing. A psychotherapeutic tradition of connection, support, and shared understanding is beset by economic and administrative pressures. Training programs that taught an integrated model of assessment and treatment are scrambling to reconfigure and survive.

I don't mean to suggest that amid all of this deterioration and loss there is no hope. To the contrary, the emerging health care system may come to achieve some of its stated goals and not to realize our worst fears. An integrated, consolidated, well-managed system may fulfill a vision of using limited health care resources rationally for the greatest social good. Some day the teaching and practice of dynamic therapy may be reintegrated into the mainstream of training, funding, and patient care.

So while it is with anticipation and even optimism that I set forth, it is also with mourning. Change in mental health care is requiring destruction, and part of what is being lost is precious. For the past couple of years, the following quotation has sat above my desk. The words are those of John Elder, a professor of environmental studies who teaches in Vermont and makes cedar canoes (New York Times Magazine, October 29, 1995). He describes the relationship of environmentalists to the environment in the face of destructive change, but his message could just as well apply to psychiatrists and our relationship to our hospitals, our profession, and the traditions my teachers taught from:

"To a degree, the work of intellectuals in our time is the work of grieving, but it's not just lamentations. I call it 'creative grieving.' We've come to a moment when we can think about loss, can absorb the extent of the damage done, and perhaps engage in real action." (Psychiatric News, February 7, 1997)