THE BUREAUCRATIC DESTRUCTION OF PATIENTS FAITH IN THEIR DOCTORS - PUBLIC PSYCHIATRY NEGATIVE LESSONS FOR GENERAL MEDICINE

The doctor-patient relationship, so important in all of medical practi ce, has been destroyed in much of American public psychiatry. That des truction should serve as an important negative lesson for a medical ca re system facing reorganization. The desirability of having the same p sychiatrist caring for a patient both in the mental hospital and after discharge-continuity of care-should have been obvious, but its signif icance was not defined explicitly, to this author's knowledge, until a bout 1979. White's demonstration that the therapeutic relationship's p ositive impact seems to ''account for about half of the benefits'' ass ociated with medical and similar ministrations underlines its importan ce. Continuity of competent public psychiatric care, and its therapeut ic effectiveness, have been impeded by the harmful attitudes and actio ns of American psychiatry and the care-fragmenting acts of public offi cials. Soon after the continuity concept was informally presented in 1 979, official American psychiatry, increasingly influenced by drug com panies, began denying the importance of a physician's continuing care by redefining ''continuity'' as though public mental health care had t o be fragmented. Specific policy decisions by officials are also large ly responsible for the destruction of good public psychiatric care. Th is in turn has produced gross overuse of medications and the near disa ppearance of competent public psychiatric leadership and effective the rapeutic relationships. An example from the federal Health Care Financ e Administration shows how comparably harmful bureaucratic decisions c oncerning health care can also be made on the federal level. If simila r decisions are made under the proposed reorganization of general medi cal care, that care, like American public psychiatry, may become harmf ul to its patients.