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By donning the medical waistcoat again, psychiatry also hopes to shed what Asimus calls its "freaky" image. As he explains it, even doctors have traditionally regarded their psychiatric colleagues as "a strange breed of people" who picked the specialty to work out their own hang-ups as much as those of their patients. Public misconceptions about psychiatry are still worse, including the cartoonist's idea that almost all psychiatry, rather than just traditional analysis, is done on a couch. For years psychiatrists have also been regarded as medicine's robber barons. In fact, as medical specialists go, they rank relatively low on the pay scale (average annual income: $47,565), far behind surgeons, $73,245, and only slightly above GPs $47,438.
More rankling still is the recent perception of male psychiatrists as sexual exploiters of their women patients. Though such behavior is clearly a violation of the Freudian ethic, which forbids any social contact between patient and doctor, to say nothing of the Hippocratic oath, there is clearly some fire behind the smoke. In Florida alone, nine psychiatrists last year were charged with sexual misconduct during therapy; in a recent poll of 500 psychiatrists, a medical journal found that a surprising 19% said that they approved of doctor-patient sex under some circumstances. The intimate relationships in therapy obviously make both patient and doctor more sexually vulnerable than in other professional relationships, but such deplorable indiscretions are found in all branches of medicine.
If psychiatry is trying to change its slightly tarnished image, it is also changing its attitudes. One of its favorite projects of the 1960s was the community mental-health movement. That plan to bring psychiatric services to the deprived went hand in hand with a consensus among psychiatrists that state hospitals should be emptied of all but the most intractable and dangerous hard-core patients. The hospitals were jammed and poorly funded in most states. The idea was compelling: since psychiatric hospitals could presumably do little more than store patients, those who responded to the new antipsychotic medication could be released to their families and treated as outpatients. Under the Community Mental Health Center Act of 1963, 647 local centers have been set up to treat such "deinstitutionalized" patients, and also to bring low-cost care to the rest of the public, particularly the poor.
While the scheme had successful aspects, it also brought new problems. Says Robert Michels: "Thirty years ago, 75% of all psychiatric treatment was conducted in hospitals. Today, 75% takes place in an outpatient setting. That's progress." Still psychiatric patients fill 40% of all hospital beds in the nation, and the number of mental patients in nursing homes, prisons and single-room occupancy residences is up. Says Payne Whitney's John Talbott: "We've merely shifted the mentally ill population, not decreased it."