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The Fourth Experience

After this training, in 1968, I chose employment as a psychiatrist in an environment where the emphasis was truly on psychiatry as a helping profession: offering assistance to people who voluntarily sought it, with as broad a variety of treatment options as possible. The idea was that voluntary treatment in an early as possible stage would help prevent demotivation and the necessity of involuntary commitment at a later stage. In this way, psychiatry would become a healing and emancipating medical specialty.

I chose a kind of employment that until then barely existed in those days: in an outpatient clinic affiliated with a mental hospital. The expectation was that such clinics would develop into centers for multidisciplinary outpatient treatment on a voluntary basis. We would provide pre- and post-hospitalizational care to persons who would therefore not have to be hospitalized or re-hospitalized. We would also offer our services to people who had never had any contact with psychiatry yet, and for whom no hospitalization was being considered. In addition to psychiatrists, the team of helping professionals would consist of clinical psychologists, nurses specialized in social psychiatry, psychotherapists, psychomotor therapists and creative therapists. The treatments were to include foremost all forms of psychotherapy: individual psychoanalytical psychotherapy; client-centered and behavior therapy; group therapy, marriage counseling, and family counseling. Secondly we would provide psychoactive drugs, supportive guidance, socio-psychiatric intervention, and non-verbal forms of therapy.

It was agreed that coercive measures would not be possible at the outpatient clinic. In my view these new treatment centers were to not frighten off people who would otherwise fear being subjected to involuntary commitment. Also, after my first two experiences, I did not wish to risk being in a position that I would be required to write medical statements for the purpose of effecting an involuntary commitment.

“My” outpatient clinic grew rapidly. Particularly family physicians were very much interested in the courses we gave on conversing with patients, as well as in our adequate and speedy reporting on the patients they referred to us. This provided doctors with a solution for their more problematic patients.
In no time we were faced with the necessity of expanding the staff to be able to continue treating the increasing numbers of patients. This expansion was hindered by all sorts of administrative, bureaucratic, financial, and political objections. Waiting lists were instated. The goal we had in mind retreated farther away. For years this was a constant source of tensions. We never succeeded in responding adequately to the waxing stream of patients. To complicate matters, suspicion was cast onto outpatient clinics by other institutions who resented what they felt was competition.

In those days the field of ambulatory psychiatric services was dominated almost totally by two parties:
  • The Social-Psychiatric Services which provided pre- and post hospitalizational care; medical statements to effectuate involuntary commitments; and home visits; but could not prescribe drugs, and
  • Private psychiatrists who were often affiliated with a general hospital.
Both of these parties perceived the new outpatient clinics as competition and felt threatened by them, which is astonishing, as they themselves were also overwhelmed by the growing demand for their services which they could not meet. Some politicians accused psychiatric hospitals of using the outpatient clinics to recruit patients to fill their beds. These allegations were all the more surprising in view of the outpatient clinics’ policy which was clearly and explicitly aimed at preventing hospitalization. Also, admittance wards at psychiatric hospitals were always full. There was no need to recruit patients.
So the ideal – offering humane, effective, and early psychiatric intervention on a voluntary basis – turned out to be only partly realizable. It also became clear that hospitalization could not always be avoided, although thanks to intensive and motivation-enhancing guidance involuntary commitment was almost never necessary.
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