The College motto is ‘Let Wisdom Guide’: but what is wisdom?

Wisdom is a recognizable attribute of human beings, reflected in their thoughts, words and actions, derived through intuition and through individual contemplation of ideas, knowledge and experience of all kinds. The definition is conventional, and says something. But what is wisdom?

A game of chess, a novel and a career all have in common a beginning, a middle and an end. And there is usually a postscript or a post-mortem to round it off: this is, for me at the moment, the first of these.

It is clear that, at least in recent years, American psychiatry has been on the move. The past decade has seen dramatic shifts in emphasis away from the complicated, empirically derived and little validated theories of the Post-Freudians. A new, aggressive medical specialty is challenging analytical departments in medical schools and postgraduate teaching hospitals. This is most apparent on the Eastern seaboard, in States which have traditionally been more orientated to European views.

It was fully anticipated that the Mental Health Act Commission would take special interest in psychosurgery, and Section 57 is clearly intended to supervise this form of therapy. The Chairman of the Commission, Lord Colville, considerately arranged a visit to our Unit shortly after the implementation of the Act, and this proved to be a most useful meeting. Obviously we were ready to give any help or advice needed, based on our experience of over 1,100 operations carried out over about 20 years. Our world-unique unit has eight beds specifically for the assessment and treatment of patients referred for psychosurgery, although intensive antidepressant medication is sometimes used successfully in order to avoid psychosurgery.

The gradual transition from unqualified attendant to the trained psychiatric nurse of the present day was described in detail by Walk. A key turning point in this story occurred at the Quarterly Meeting of the Medico-Psychological Association in Edinburgh on 16 November 1883, when Dr A. Campbell Clark, Medical Superintendent of the Glasgow District Asylum, read a paper entitled ‘The special training of asylum attendants'. This paper was published in the Journal of Mental Science in January 1884. Whilst attention had been given by many other asylum doctors to the training of attendants, Clark's experience of organizing attendant training courses and his firm recommendations opened the way to practical steps which set training on a new footing. Clark acknowledged the work of Dr T. S. Clouston, Physician Superintendent of the Royal Edinburgh Asylum, who read a paper to the annual meeting of the Association in 1876 entitled ‘On the question of getting, training, and retaining the services of good asylum attendants'. This paper aroused a good deal of interest amongst members of the Association, and a small committee was formed to report ‘on the advisability of the formation of an association or registry of attendants in connection with this Association and the best manner of carrying it into effect’. However, there is no record of any report by this committee.

Brian Barraclough interviewed Sir William Trethowan at his home on 23 August 1983.

In these remarks I want to concentrate on services for mentally ill people, though many of my comments are relevant to the other two parts of that unhappy triumvirate of neglected services, mental handicap and old age. Though finances appear even more ‘restrained’ now, with the latest expenditure White Paper projecting a real drop of 2 per cent in personal social services spending between 1985 and 1988, we should avoid an excess of political emotion over reason. There has been progress over the last ten years in promoting mental health. What the figures I will quote show, however, is how painfully slow and erratic these developments have been.

In October 1982 Council discussed a paper by me with the above title in which I posed a number of questions. The document was then widely debated within the College, and on the basis of responses received I presented a report to Council in October 1983. Council endorsed a number of recommendations and these are now embodied in this paper.

The following is the second part of Brian Barraclough's interview with Sir William Trethowan. Part I appeared in the February Bulletin.

When, and for what reasons, do doctors decide to specialize in psychiatry? Having committed themselves, how adequate do they find their training? Is the general level of their training improving as a result of the efforts of the Royal College of Psychiatrists and of the Joint Committee on Higher Psychiatric Training (JCHPT)? These were the questions asked of consultants in general psychiatry newly appointed between 1 October 1978 and 30 September 1981.

As announced in 1983, the Department of Transport has issued new procedures for dealing with drinking and driving offenders deemed ‘high risk’, being those disqualified for the second time in 10 years for driving with a blood alcohol concentration over 2 ½ times the legal limit (i.e. 200 mg per cent) or failing to provide a specimen. The Driver and Vehicle Licensing Centre at Swansea will notify such an individual that when he applies for his licence on the expiry of the second period of disqualification (usually three years or more) ‘consideration will be given to whether these convictions indicate a medical disability and, if so, whether he has managed to get his drinking problem under control’. He will be advised to seek help from an alcohol counselling agency and will be given a list of such agencies.

The mental handicap scene is changing but not as quickly as some would like. A constant stream of letters, consultative documents and booklets remind us of the various ways in which we can work together to create a service where the health care component is rationalized and the large hospitals are reduced in size. The services are changing, but there is variation in the pace of change and in the commitment to the joint planning process involved in such change.

In 1977 a number of considerations prompted a review of the facilities for the mentally ill of ‘no fixed abode’ in St Brendan's Hospital, Dublin. At that time the hospital had three clinical teams who serviced three geographically distinct catchment areas within the city and attended to the needs of patients with ‘no fixed abode’ on a rotational basis. There were complaints from community care agencies concerned with the care of the homeless which alleged that patients were discharged without adequate preparation or follow-up. However, this view was not shared by hospital staff, who instanced occasions when patients sought help in what seemed to be a psychiatric or social emergency, and then abused the service by discharging themselves shortly afterwards. The truth perhaps lay somewhere in between. Another complaint was that no single medical practitioner was clearly responsible for these disadvantaged individuals, thereby making it difficult for community care agencies to liaise with the hospital staff.

While not claiming any record, the Tribunal held on 4 November 1983 at Springfield Hospital to hear an appeal against detention under Section 2 of the 1983 Mental Health Act must have been among the first. The case is instructive as it illustrates the difficulties which may arise in obtaining the full facts for presentation in the short time which is available under the new legislation.

The working party was set up in November 1981 to review current senior registrar training in alcoholism and drug dependence, and to make recommendations for the future. It sought the views of all known consultants in alcoholism and drug dependence, and their present and past senior registrars. Attention to this question is justified for the following reasons. First, the Manpower Working Party's report, Medical Manpower in the Psychiatric Specialties (Royal College of Psychiatrists, 1982), has recommended that the average District (i.e. a population of 200,000) should allocate about four consultant sessions to the ‘dependencies', such sessions being provided by general psychiatrists with a special interest in alcohol or drug dependence or both. Secondly, appropriately trained applicants are needed for vacancies which occur in the existing regional and sub-regional alcoholism treatment units and drug dependence clinics. Thirdly, the Treatment and Rehabilitation Working Group of the government's Advisory Council on the Misuse of Drugs is likely to recommend an increase in the number of consultants specializing in drug dependence.