An erudite encounter with: Sir David Goldberg

Having obtained degrees in experimental psychology and medicine from Oxford University, and subsequently trained at St Thomas’ Hospital in London and the Maudsley Hospital, David Goldberg produced the ‘General Health Questionnaire’, and the ‘Clinical Interview Schedule’, both of which have been widely adopted and have impacted psychiatric practice deeply. After completing his training, he worked for nearly a quarter of a century in Manchester, where he became Head of the Department of Psychiatry and Behavioural Science. In 1993, he returned to the Maudsley as Professor of Psychiatry and Director of Research and Development. David spent two periods of his life in the United States where he conducted research in primary care. Throughout his life, he has worked for the World Health Organization (WHO) as a consultant, and has trained psychiatrists worldwide.

When, as a medical student in Manchester under David’s tutelage, I sought his counsel regarding a career in psychiatry, his advice was, ‘Get some general medical experience first and then come back to me when you know what fascinates you most’. Having dutifully done as instructed, my next encounter with David occurred when he was ‘Professor of Professors’ at the Institute of Psychiatry in London where, after he had grilled all those present in the Grand Rounds he was conducting, he remarked on the mental state of a post-psychosurgery patient, ‘I simply cannot believe the brain can be cut without unwanted consequences’. This prescient comment, borne out by subsequent research (Dalgleish et al., 2004; Happé et al., 2001), illustrates David’s perspicacity and vision. Traits that are also reflected by the pathways to psychiatric care model posited by him and Peter Huxley in 1980 (Goldberg and Huxley, 1980) that provided a framework of levels and filters to conceptualize the experiences of patients as they course through the veins of health care systems, transitioning from one space to another; an early form of clinical staging.

• What drives you? At different stages of my life different things have driven me. Up to the age of 59, my department in Manchester had major responsibilities for both undergraduate and postgraduate education. My teaching was informed by an interest in why many doctors fail to notice psychological disorders in their patients, and this expressed itself as a determination to modify the way in which the medical interview progresses. After my return to the Institute of Psychiatry, I no longer had responsibility for medical students, and my main interest became modifying the way both the Institute and its associated hospitals functioned. My aim was to improve collaboration between the various departments in the former, and to greatly improve the services for care in the community in the latter.

• What advice would you give your younger self? Arrange your personal timetable so that whole days are devoted to writing up your research. I learned to do this during a visit to Michael Gelder’s department at Oxford during my early 50s, and afterwards, I very much wished that I had done this much earlier. After my visit, I used to strike off one day a week for this purpose, but the pressure of events was such that every month I would lose at least two of these to urgent matters at either my university or department, so in practice I got about 2 days every 4 weeks to sit at home and write. This was an enormous change for me, as previously my writing had to be done in the small hours.

• As a psychiatrist what have you learnt about the human condition? That people will tell you about themselves if you allow them to do so. The interviewer’s behaviour is critical, and determines what, and how much, the patient tells them.

• Research is fundamental to psychiatry because … There is a convent near St Louis where the following slogan is printed on the walls of the library: ‘Research is to Teaching as Sin is to Confession’. If you don’t do any of the first, there is really very little to teach about in the second. Unless a young psychiatrist has done their own research, they will never really understand how knowledge advances, and how new claims can be best tested.

• The most important topic in psychiatry is… This has to be how Primary Care Physicians across the world are taught to interview their patients, and how they gain skills in dealing with psychological disorders. About 25 years ago, I assisted the WHO in producing a classification of psychological disorders that are most common in primary care settings, and accompanying each disorder with advice about its best management. In my retirement, I have assisted the WHO in revising this classification, together with its management guidelines. The present enthusiasm among psychiatrists for believing that individual mental disorders are separate from one another, and that when more than one is present they should pronounce the presence of ‘co-morbidity’, is not helpful in primary care settings, where the only really important form of co-morbidity is that between chronic physical disorders and psychological disorder.

• What is the future of psychiatry? This varies between different parts of the world, depending on how services for mental disorders are funded. In most countries, there is a service for severely ill people paid for out of public funds, but the amounts of support vary enormously between countries. The demand for publicly funded services commonly exceeds the supply, so that in many parts of the world those receiving such help commonly receive a sub-optimal service. Enabling lay people to assist in the care of those with severe illnesses is an important component of care, not only for the severely ill, but also for those dealt with by primary care services.

The large discrepancies in wealth between rich and poor people will ensure that in most countries psychiatry for the well off will have a future, dispensing one-to-one care for those able to pay for it. Even here, the availability of effective psychological treatments in addition to drug treatments is likely to modify the way such treatments are given.

The greatest changes in the future are likely to come from preventive actions taken by others not connected to the medical system. Among these, the increasing recognition that sexual and physical abuse of children is responsible for many of the common mental disorders, and the important work of the WHO in improving the care given by both nurses and trained lay people, are both likely to result in better management of the burden of mental disorders.

The heroine of Middlemarch ¹ said that making prophecies about the future was ‘the most gratuitous form of error’. However, there are some predictions that are completely safe. Wherever poverty, violence, drug dependence, religious intolerance and bigotry are still found, there will always be people needing psychological care. Since these problems are all likely to remain fairly common, unfortunately psychiatry has a future which is completely secure.