Acceptance of the role of social factors in psychiatry gradually gained momentum during the 1960s. As one might conclude from the previous text, antipsychiatrists have made every effort to emphasize the dominant influence of the negative side of the family and society, both in etiopathogenesis and in the repression and discrimination of individuals afflicted with mental illness. Some, like Szasz, even claimed that mental illness is completely a social construct and as such stands for a “canary” who is the messenger of a disturbed society, not a sick individual. If we leave aside such considerations, which I wrote about in more detail in the above-mentioned text on antipsychiatry and turn to the positive side of the role of society in the functioning of the individual, then a more balanced attitude can be achieved, which forms the basis for the development of sociotherapy.
Sociotherapy
I first became familiar with sociotherapy while I was studying medicine at the psychiatric institution “Avala.” Later, during my residency training at the Institute of Mental Health, and while I was working at the Vršac Neuropsychiatric Hospital, my exposure and experience multiplied. All forms of sociotherapy were carried out in those days. There were small and large groups, a therapeutic community, occupational and rehabilitation therapy, a day hospital, and a patient club. I had the opportunity not only to be a quiet observer but also to be an active participant and facilitator, especially in group therapy. It was a valuable experience for my psychiatric training and skill development which later enabled me to use group therapy as an important treatment method for patients I also treated individually. I think it was a one-of-a-kind experience for me and for the patients. Many of them remembered this period with nostalgia and considered it the most important for their recovery. Obviously, it is relevant for our minds to experience the connection with other people, especially if an atmosphere of safety and confidence is created. Under these circumstances, we are able to discard the usual defensive mechanisms and remove the mask behind which we hide our true faces. We are prepared to immerse ourselves in an energy domain where relationships with others create a matrix of connection, forming a new entity, a group with a common purpose.
My theoretical knowledge of social psychiatry is connected with the name of Dušan Kecmanović and his book. * The book describes the historical roots, the most significant representatives, the definition, the field of action, as well as related disciplines such as anthropology, sociology, and social psychology. The primary purpose of social psychiatry is to contribute to a better understanding of individuals' interactions with their social and cultural environment, and the impact of these interactions on the clinical occurrence, treatment and prevention of mental disorders. The application of the principles of social psychiatry in the treatment of the mentally ill began to dominate the world in the second half of the last century. This has also given rise to psychiatric tendencies in Yugoslavia. In 1963, a group of psychiatrists in Belgrade created the Institute of Mental Health, the first social psychiatric institution in Yugoslavia and the Balkans. The work of this institution was entirely arranged for the application of social and psychological methods in treating psychiatric disorders. I ended up in this facility 20 years later during my training in neuropsychiatry. At that time, the Institute had a reputation as the best-organized mental health facility in the country.
Tomislav Sedmak
My mentor and supervisor at the Institute was Tomislav Sedmak, a psychiatrist who significantly influenced the formation of my psychiatric sculpture during these early years. His style of behavior was not polished and politically correct. While he was exceedingly smart and well-read, he had no impressive title behind his name. He was the head of the psychosis department at the day hospital. He led a small and a large group. I saw him at work in the most challenging situations. He was like a skillful conductor capable of handling the cacophony of the voices of psychotic patients and creating a coherent whole with purpose and meaning, intuitively following the flow of energy in the room, without pause. I was often astounded to witness this extraordinary scene, the psychotherapeutic approach to treating schizophrenia. Later, in his office, he offered a theoretical explanation of his interventions, accompanied by quoting world leaders in the field, such as Harry Stuck Sullivan, Otto Will, and Silvano Arieti.
Dr. Sedmak allowed me to go with him to the clinic where he saw individual patients in the late afternoon. Many of them had “easier” diagnoses than schizophrenia. I was there to observe the breadth of his skills and the application of different treatment methods to those I was accustomed to in the day hospital. He displayed extraordinary patience in working with patients, with an enormous capacity for empathy for their ailments. He was the type of physician, devoted to his job, and in possession of enviable knowledge and talent. At the same time, he had no “hair on his tongue” and tolerance for the arrogance and ignorance of colleagues and trainees. Because of this, he caused a split in opinion. You either adored him (like me) or feared and avoided him. He was an exceptional lecturer. He did not use slides or notes. Usually, he entered the room carrying a pile of books that he used to prepare lectures. Then he would deliver his presentation, as if in a frenzy, from the top of his head. In addition, he published articles in the Institute's journal, so I was once again convinced of his genius in that written way. I wanted to be like him so I often quoted him in conversations with others.
Educational group
One day I had the opportunity to get to know him even better. Dr. Sedmak told me that he was planning an educational group to which he invited several residents and younger psychiatrists. He asked me if I was interested. My answer was of course positive. I felt honored that I was included in this group of chosen ones. And so began my three-year journey in his educational group sprinkled with the elements of therapy. We met once a week in the evening when everything was quiet at the Institute and when the daily work was over. Sedmak was always ready with almost inexhaustible energy to speak on a variety of subjects. This was the educational component. The second, less defined, component was experiential, associated with belonging to a social organization, a group. There we were, confined in a particular time and space where each of us brought our past and future orientations to the present situation. Hence, we filled that room with “loads of people”, some present in person, and some virtual, ghosts of the past or projects of the imagined future. Group, in the psychological sense, is regarded as a symbol of a mother, and the leader of the group, a symbol of a father. This created, in our group, an unconscious dynamic that affected the group's functioning and resulted in intermittent tension. But on the whole, the focus of the group on present reality, characterized by the principle “here and now”, dominated.
Our group had intrinsic cohesion because of our profession, age, and work experience. Despite this, there were differences among us regarding the degree of socialization and the strength of the affiliative drive. Adaptation to a group norm in which individuality was diminished and individuals encouraged to abandon obsessive preoccupation with self or psychological isolation had not always been easy to follow. But little by little, for all of us, there had been an identification with the “peer group” and development of social maturation, which improved our handling of the social reality of the group and more importantly the wider community. This process was especially beneficial for me because of my introverted personality structure and social inhibition. Therefore, I became more open and willing to take risks by speaking up without being afraid of being rejected or ridiculed. Of course, Sedmak noticed my pattern, so he facilitated this transformation of my social behavior through his encouragement.
Sedmak taught us to relate to the emotional states of the patient by recognizing them within ourselves and thus better understanding our own emotional being as well as the emotional being of the patient. He told us to avoid moralistic or aesthetic evaluation of patients (beautiful-ugly, pleasant-unpleasant, neat-dirty, etc.) but to remain neutral. In a nutshell, to accept the patient as he or she is. Sedmak stated that the basic rule of a good psychiatrist is to trust the patient and take up any information we receive from him as true. If we call the patient a case or a diagnosis, what it really means is that we have rejected the patient as a subject and as a participant in treatment. Then our interest in him comes from professional curiosity rather than human connection and understanding. Sedmak emphasized that curiosity must not be applied in working with the patient, but in acquiring knowledge from books and in education. The patient must not become a tool for the inquisitive psychiatrist.
Each decision and understanding with regard to the patient must not be definitive, for then we cast it, pierce it with a spinel like a dead butterfly that we put on the wall as a trophy for our ability. Essentially, when we make up our minds, we stop thinking about the patient. It is far more appropriate to regard our present decision as temporary and leave enough mental space to modify it if we're compelled to do so by new information we continuously gather with an open mind. Sedmak declared that a psychiatrist should never lose the presence of the mind and carry out any decision out of desperation. I remember well Sedmak's “manifesto” that remained with me until this day. It goes roughly like this: “I can help the patient as much as he allows me, as much as the institution where I work allows me, and as much as the society in which I live allows me. For every patient, I make sure that I invest the optimal amount of effort.” This approach serves as a reminder not to be more ambitious than the patient himself, but to focus on understanding the patient's expectations for treatment as well as his investment in the same. Also, it speaks about the importance of clearly understanding the culture of the institution and society as a whole and adapting the work according to Sedmak's wise counsel.
Broader topics
Sedmak sometimes waddled through philosophical waters. One of the things he spoke about was the interaction between theory, ideology, and practice. A theory is easily transformed into an ideology. Ideology then attempts to subordinate totality of the reality to fit into an imposed theory. But, ideology and theory, by their very nature, constitute only a part of reality. On the other hand, practice is more diversified than any theory. In order to defend ideology and validate the theory, dogmatic psychiatrists use selection bias and choose only patients who can be “adapted” to a certain theory. According to Sedmak, practice is the only truth and has only one time: the present. Theoretical explanation is a secondary process (a product of the human mind) we use for organizing information, providing order and security, a sense of control (governance), and prediction. Without the illusion of control and predictability, we would face uncertainty, which is the source of anxiety. And it is a well-known fact that it is in human nature to avoid the unpleasant state of anxiety.
Prognosis is an integral part of the medical model by which medicine tries to be a science. By accepting the medical model, psychiatry expresses its ambition to be accepted as medical science. Behind science lies the psychological need to rule, predict the future, reduce uncertainty, and ultimately reduce the fear of death (finiteness). Sedmak believes that the acceptance of the medical model is a mistake on the part of psychiatrists because most psychiatric phenomena are more easily explained by social interactions than by biochemical reactions. If we accept that psychiatry is more skill and less science, the question becomes, are psychiatrists entitled to make predictions (prognoses)? This question has been asked, and the answer is not easy and straightforward.
I also learned from Sedmak the meaning of intuition. He explains the concepts of knowledge, experience, and intuition. He states that knowledge is the conscious accumulation of information, and that experience is knowledge through action, which is practice. Education is all about gaining knowledge and experience. Intuition does not belong to that model. It is pre-verbal, pre-logical thinking, integration of information on the basis of which an insufficiently substantiated conclusion is reached. Intuition coupled with experience is a skill that illuminates practice. Knowledge can be in conflict with practice, while intuition and experience are not. Intuition is the automatic association of information with the possibility of unconscious selection of useful information. When applied in psychiatry, intuition is the unconscious capacity to understand the condition of the patient before his verbal report. When approaching the patient, the acquired knowledge can be completely useless if it does not include intuition and experience. Experience gradually assumes some elements of intuition because the amount of information needed to arrive at a conclusion is reduced. Real experience is gained by gradually linking knowledge and intuition while nourishing the continuing uncertainty towards the patient so that the openness of the system to receive new information from the patient remains preserved. Of course, this is not easy to realize, because a theory is a law and order, and practice is chaos and anarchy. Psychiatrists, who have an anxious predisposition, have little tolerance for this approach. Because I was also in that group, Sedmak's teaching on intuition has been one of the most important lessons I have taken to heart and found a happy compromise that has guided my work.
Therapeutic community
Let me now briefly address the significance of the therapeutic community to my “sculpting” of a psychiatrist project. I experienced this important form of sociotherapy in the best possible way while working in the drug addiction department at the Vršac hospital. There, I witnessed and participated in the application of the basic principles of the therapeutic community. The most essential principle was establishing equality among everyone present, whether it was the patients or the staff of the department. The leveling of the hierarchical pyramid served as the ideal guide for democratic governance. Regular meetings for all took place where the events of the preceding 24 hours were discussed and analyzed. I spent a year in the department led by Dr. Dragica Stanojlović. With iron will and determination, she made an enormous effort to modernize addiction treatment using the therapeutic community model that had been circulating around the world for the previous two decades. With her assistance, I learned to balance different aspects of the doctor's role in the work of the therapeutic community. This model was in contrast to the paternalistic behavior widespread among the medical personnel at the time, especially in psychiatric institutions such as the Vršac Hospital. Stanojlović fostered informal meetings and conversations with patients in order for the physician to lose the omniscient aura of authority, so present in the traditional models of care.
Dr. Stanojlović used personal examples to modify the behavior of both patients and staff, accustomed to authoritative “rules.” She constantly tried to stimulate the active participation of everybody. But sometimes it seemed as if her department existed as an isolated island separated from the mainland of the hospital environment, which operated according to different rules. I was fortunate enough to be there to witness how the atmosphere of the community becomes a decisive contributing factor that determines the effectiveness of the treatment. I had a similar experience five years later in the United States, during my specialization, working in a veterans’ administration hospital as a member of the substance abuse treatment program. Thanks to my Vršac training, I fit seamlessly into the work of the therapeutic community in this new environment, to the satisfaction of my supervisors who were not accustomed to seeing trainees able to use this sociotherapeutic model of treatment with ease, I was demonstrating.
Dr. Stanojević has had additional importance on my formation as a psychiatrist. For the purpose of my applying for specialization in America, she drafted a recommendation in which she described me as a secure and reliable leader in a sociotherapy group. She wrote: “Dr. Jocić (my former last name) understood group dynamics, conscious and unconscious resistance of patients and was able to control and create therapeutic situations with ease. His personality, especially calmness and patience, enabled him to adequately represent social reality to patients. Patients easily accepted and respected him. He helped and motivated patients to understand their inner world. The sociotherapist's task is to find new ways and new solutions when the patient is in crisis. In this task, Dr. Jocić was an original and inspiring instructor for patients. Due to the aforementioned characteristics, I highly recommend him as a gifted professional with great capacity and interest in psychiatry.” With such a recommendation, it was easy to secure a place among other applicants for a psychiatry residency training program in the United States.
* Socijalna psihijatrija sa psihijatriskom socijologijom, Dušan Kecmanović, Svjetlost, 1978.
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