Why do people behave the way they do? This was the question that led me from being a philosophy major as an undergrad at the University of Pennsylvania, 60 years ago, to the field of psychiatry, which was considered almost a non-entity in medical school. CMS at that time was in a very old, somewhat shoddy, building across the street from the historic Cook County Hospital. There was only one female in my class of 65 students and no such thing as a computer. I was the only student in my class initially interested in psychiatry and the only one interested at the time of graduation. The typical reason pre-med students at that time gave for applying to medical school was their ostensible interest in helping people and this ideal also applied to those applying for a residency in psychiatry.
As a graduate of CMS I was quite fortunate to be accepted to a superior residency in psychiatry at Michael Reese Hospital (Psychiatric and Psychosomatic Institute) which was noted for its psychoanalytic orientation due to the director who had been analyzed by Sigmund Freud himself.
Although the “helping of patients” turned out to be a product of my years in practice, it was my original interest in the etiology of behavior which supplied the energy, the persistence and the determination to study, to sacrifice the time and other social opportunities and to focus on the pursuit of understanding and knowledge about my patients and incidentally many others. It also provided a pathway to discover much about myself, which has been useful at times.
The first seventeen years of my practice included a teaching position at Northwestern Medical School and a staff position at their Memorial Hospital and two smaller hospitals. I proceeded to build a full time psychotherapy practice providing individual and group therapy for mostly well-functioning people, occasionally seeing them as in-patients when needed. I learned early on that my interest was predominantly in patients that were able to relate in an intelligible manner despite their serious concerns, emotional pain, anxiety and/or depression. I did not feel as interested in those who were overtly psychotic and non-functioning so referred them to other specialists.
Rarely using medications I was more intent on encouraging my patients to ventilate, to express their feelings and to say whatever came to their minds, i.e. “a free association of ideas”. The uncovering of their unconscious and the etiology of their behavior would be our ultimate goal. Thus, with the proficiency I developed in my training as a resident I was able to assist the patients in gaining insight into their behavior and encourage them to use this therapeutic opportunity to openly express their feelings and consider modifying their behavior for a better future. As this analytic technique proved to be very successful my patients became more insightful and more in control of their lives and I grew more confident in my ability to provide what they needed. Feedback from the patients as to their mental progress and relief from symptoms verified the validity of my work with them.
As my practice grew in size there developed the additional opportunity to create groups for another form of psychotherapy which I had learned during my residency. Group therapy excited me because of the additional elements available in this form of psychiatric treatment, referred to by Irvin D. Yalom, M.D as “curative factors”. Of the 13 factors he described there were such aspects as “helping others and thereby gaining self-respect”, and “learning that I’m not the only one…”
Selection of eight of my patients, from those in individual treatment, to meet weekly with me and a co-therapist as a group afforded us all the chance to interact with each other and not only gain the intellectual insight into each person’s psyche, but to have the very practical advantage of seeing everyone’s interpersonal behavior in action which became “grist for the mill”. For me this was such a psycho-dynamically fascinating and productive experience that I eventually created a total of 5 groups each meeting for many years with natural turnover of patients as the years went by.
Creating groups from my individual patients required a special sense of who would work well together in enhancing their mutual ability to participate and expose what was usually kept very secretive. There also were requirements imposed on the group members by me for those patients to make at least a six month commitment to the process and to maintain confidentiality within the group members.
For me my groups represented a living experience with reality as opposed to just the intellectual psychotherapeutic experience with them as individuals. It was humanity and the human experience in the flesh.
During my residency in psychiatry I was required to create a research project and write a report about it. Because of my childhood interest in prison movies and my current courses in group therapy I conceived of the idea of doing group therapy in a prison. With the Director of the Residency’s permission I proceeded to the Illinois Department of Corrections for their agreement to go forward with this project and it was granted. This led to my eventually working at Stateville Prison in Joliet for 5 years where I created several groups and treated dozen of inmates. It was a fascinating experience in itself, as well as my first time being a therapist outside of the training program. My research paper was reflective of the intellectual joy I had in being privy to this population and the thinking of the criminal mind. My research paper on this experience won a first place prize.
While conducting the groups at the prison, amongst other things I learned of the critical importance of their discharge and transition to the outside world. This knowledge brought me into contact with the parole board, a very enlightening and challenging experience. I went on to create a group in which all the members could be discharged at the same time so they could continue their therapy together outside of the prison. Additional innovations included some sessions which allowed each member to bring in a friend or relative to help establish a supportive relationship which could continue after the inmate was discharged from prison.
My participation in this prison research project unexpectedly became the precursor of two of the most important aspects of my future professional practice. Initially, I gained experience not only as a therapist but fortunately developed some early expertise as a group therapist which carried over to a major portion of my therapeutic practice. Secondly, my prison project came to be known by some of the attorneys in the Chicago area. Thus, once I opened my private practice I began to receive calls to consult with some of the attorneys in criminal legal cases and my life as a forensic psychiatrist was born.
I knew of no training programs at that time for this specialty so I learned on the job, read journals and was eventually invited to join organizations of others practicing forensic psychiatry. I traveled near and far to go to professional meetings, listen to presentations, wrote papers which I presented and developed a whole new professional group of associates. I was able to expand my work from criminal to civil cases and was spending about 10 -15 % of my time doing forensic evaluations, writing reports and testifying at depositions and in trials, all of which I found extremely stimulating and productive.
An especially unique opportunity presented itself when I was engaged to consult on the case of a “mass murderer”, the most prolific in American history. When interviewed by the FBI I re-named this behavior and referred to the killer as a “serial murderer” (of 32 young men) and this term has become extremely common today. My association with this high-profile case resulted in more forensic referrals as well as further insights into the thinking of this most baffling if not inscrutable segment of the population. In fact, soon after my involvement with that case I had several other high profile cases referred to me and was called to different States to consult on them.
After 17 years of practicing in Chicago I moved to San Diego in order to have a warmer and brighter environment. I was immediately able to gain a position on the faculty of the University of California San Diego (UCSD) as an Associate Clinical Professor of Psychiatry. However, I was not ready to start a treatment practice so soon after having separated from the many patient- relationships I had just left in Chicago. It was a risky move to a city over-crowded with psychiatrists who shunned any additional competition so I began anew by gaining a position on a court panel of psychiatrists. I received referrals from the courts and then from private practicing attorneys and quickly built a forensic–only full time practice, a somewhat rare and fortunate development for me.
Ten years after my rejuvenation in California I applied for and was given another opportunity; that of becoming a lecturer on cruise ships. I created a number of lectures which were initially of general psychological interest to guests on luxury liners and later I provided more formal lectures involving forensic subjects (due to high interest in CSI programs on television). Consequently, I have enjoyed 23 cruises to every corner of the world and to almost every continent in the capacity as guest lecturer. My attraction to cruising and my own travels to foreign sites all emanates from my interest in sightseeing and exploring places which are new to me as well as my fascination with people, their behavior and thinking.
My position as lecturer also gave me the travel experience to ports I would not likely have sought on my own. These ventures were enlightening and rewarding intellectually especially meeting people from all over the world, conversing with them, going into their living environments (such as the dung houses in Africa or the homes of Arabs in the Middle East) and learning first-hand about their culture, their values and their distinctive ideas, customs and thinking. That’s where I started and where I have found a most meaningful perspective, in knowing why people behave the way they do.
When I decided to go to medical school, just so I could become a psychiatrist, I had no idea of the great variety and richness of experiences which I would encounter or how my professional life would lead me into unimaginable intellectual and enriching endeavors. My own innate curiosity and creative thinking was largely responsible for that variation. Each new venture inspired pursuits into associated areas which then became new foci for a practical development. Some things did not work but there were those that did, yet I never hesitated to pursue an idea because I feared it would not work.
For example, back in the early seventies and my first years of practice, ATT had developed a picture phone and was trying to promote it in Chicago. I came up with ideas for several uses of that instrument in psychiatry and forensics and asked ATT to work with me on them. I was asked to write a grant proposal with my ideas, which I did, but before it went to completion, ATT decided to end their interest in the picture phone. However, today we have SCIPE and much more.
Today’s medical students have the advantage of a highly technical world which is unbelievably fast paced and moving forward in the medical field with applications to medical research and individualized medical care. Being immersed in a scholarly life the student will be witness to new opportunities any of which, if pursued, can lead to great satisfaction and unexpected achievement. Those who are proficient in some area of medicine will have the nidus of potential for enlarging their spectrum of knowledge and medical practice particularly if they are also creative, enterprising and uninhibited motivationally.
Eric Topol, MD an authority on the Genome, wrote a book entitled “The Constructive Destruction of Medicine,” which will give all students numerous ideas on the future of medicine and technology. At the same time this technological medical world will result in more physical distance between patient and physician. Thus, it will be incumbent on the medical schools to provide newly designed courses to enhance the personal relationships between doctor and patient. It will be their task to increase the sensitivity of those physicians and spark their empathy and compassion for the human beings for whom they will be caring.
Richard G. Rappaport, M.D
Associate Clinical Professor of Psychiatry
University of California San Diego
Chicago Medical School, Class of 1963