Psychiatry: The Uncertain Science
Page One of Twelve
Of all man's disorders, the most infuriating to both
sufferer and observer are those that seem to have no cause, If the
disorder is physical, it has at least a passable respectability.
If it is something other than physical, it is irritating, unattractive
and, worst, not understandable. Even the most sympathetic people
will tend to feel, in some far corner of their hearts, that if the
sufferer would just show a little more willpower or self-control,
the trouble would go away. The sufferer himself will probably try
that. If it doesn't work, he may well take to drink, or pills, or
sex, or change jobs. If none of those efforts work he is likely
to go to his minister, or his family doctor.
If none of them is able to help, and the disorder is
still bad enough, he finally goes to a man known as a psychiatrist.
What this man does, and what he is supposed to do, are subjects
of great confusion among laymen, ministers, doctors and even psychiatrists
themselves, but in broad terms his assignment is clear. He is supposed
to ascertain, the cause of a disorder that appears to have none,
and then somehow get rid of it.
There are many unnecessary causes for the confusion
surrounding this peculiar profession, including many laymen's mistrust
and fear of psychiatrists, and many psychiatrists' reciprocal mistrust
of laymen, but most of the confusion is both justified and appropriate.
Psychiatry is a very young and imprecise science, and it has never
found a workable definition of itself. On top of that, it has recently
been expanding so rapidly that it has burst what were once regarded
as its seams.
Since World War 11, the number of American psychiatrists
has quintupled. Since 1955 the number of Americans admitted to mental
hospitals has risen four times faster than the population. But today's
psychiatrists are experimenting on a scale and with a vigour unmatched
in the history of mental treatment, and they have drugs that early
psychiatrists only dreamed of. As a result, the average length of
stay in mental hospitals has been cut in half, and there are now
one fifth as many patients in those hospitals as there were in 1955.
And as part and parcel of these developments, the profession of
psychiatry itself has been edging out of the unnatural confinement
in which it has traditionally been kept and is trying, with uneven
success, to join the mainstream of American life.
It is not surprising, then, that the profession's attempts to define
itself are today even less satisfactory than they used to be. Psychiatry
is usually called "a medical speciality treating disorders
of the mind," while psychology is "the study of the mind,"
and in many ways these definitions are meaningless.
To begin with, psychiatry is not really a "speciality,"
but a broad field, and it is no more possible to specify what sort
of treatment a patient will get from a psychiatrist than it is to
say what will happen when he goes to a doctor.
Furthermore, all of psychiatry will not even fit under
the heading "medical." Psychiatrists are medically trained,
while psychologists aren't, but some psychiatrists do not even define
the disorders they treat as illnesses, and much psychiatric treatment
is becoming less medically oriented all the time. Finally, some
psychiatrists even object to defining the disorders they treat as
"disorders of the mind." They say the disorders are emotional,
or behavioural - or, as some drug therapists believe, physical.
The most basic characteristic of psychiatry is that,
far from being a medical speciality, it is intrinsically uncontainable
and spills over into every area of human endeavour, including philosophy,
sociology, physics, chemistry, religion, government and art. This
untidiness is innate, for the simple reason that all psychiatric
theory must start by defining man and his nature, and psychiatry
has not one but many definitions of man. Sigmund Freud's is the
only doctrine that has any wide acceptance in psychiatry today,
but it is also widely challenged and even more widely modified.
The Freudian psychiatrist sees man as having an unconscious,
which influences and sometimes dominates his actions, ~and which
contains a number ~t of repressed sexual !and aggressive drives.
Followers of Alfred Adler see man as dominated by his aggressive
instincts, and believe that he can be understood only in terms of
the goals he sets himself and his movement toward them. Carl Jung
declared that beneath man's individual unconscious there is a racial
unconscious, and below that a universal unconscious mystically shared
by all men of all time. Existential psychiatrists belittle searches
for the causes of disorder, and concentrate on studying the disorder
itself.
From these contradictory beginnings, psychiatry has
developed a wide variety of equally contradictory ways of treating
its patients. People are being treated today with as few as six
treatments and for as long as 10 years. Treatment is given by psychiatrists,
psychoanalysts, psychologists, social workers, psychiatric nurses,
psychiatric technicians, trained housewives, general practitioners,
and all combinations thereof. Patients are being treated in remote
hospitals, community mental-health centres, hospitals to which they
go only by day' hospitals to which they go only by night, in private
offices and homes, and they are paying anywhere from nothing to
$30,000 a year. They are being treated singly and in groups, as
families and in groups of families ' and they are being given psychoanalysis,
drugs, electric shocks, hypnosis - or simply advice and reassurance.
The variety of psychiatric experience today, therefore,
is enormous.
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At a clinic in Portland, Maine, a girl pays her 'first visit
to a psychiatrist. She is young, pretty, intelligent, has four
children, and has recently been deserted by her husband. Now
she is depressed, anxious and frightened of herself. "I'm
afraid to spank the kids," she says. "I'm afraid that
I'll hurt them. They don't seem to please me. I came close to
trying suicide, but I realised I'd only be hurting myself."
The psychiatrist says he is sure his clinic can help her, gives
her two prescriptions, and arranges to have a social agency
"homemaker" help her at home. After 40 minutes she
is launched on a six-treatment program with limited goals and
a very high rate of success. This clinic has treated 500 critically
ill people in 14 months, and 493 of them have been able to stay
out of a hospital and keep functioning at home.
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In New York City a 24-year-old man visits a psychoanalyst.
He has lost his job. He is emotionally crippled with depression,
anxiety, tension, work inhibition, social and sexual inhibitions,
facial tics, a peptic ulcer, fear of aeroplane travel, fear
of blacking out while driving, fear of horses, fear of losing
his temper and killing somebody. For three years he undergoes
analysis three or four times a week. He becomes aware of various
unconscious parental dominations, and frees himself of them.
His ulcer disappears; he gains confidence. For five more years
he makes intermittent visits to the analyst about specific problems.
After eight years of treatment he speaks with quiet assurance
and animation, is happily married, owns and operates a thriving
export-import business.
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In Orofino, Idaho, State Hospital North applies to the National
Institute of Mental Health for funds to build a new camp in
the mountains as an experiment in rehabilitating chronic patients
who have grown dependent on the hospital environment. The camp
will be largely self-sufficient, and the patients will be asked
to exercise responsibility. If they do well, they will go to
a self-management ward in the hospital, then to trial visits
outside it. Among the therapeutic instruments the hospital requests
are two power saws, three picks, six shovels, four wheelbarrows,
six rakes, two brush hooks, a wrecking bar, four axes and two
sledgehammers.
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In Topeka, Kansas, the prestigious and private Menninger Foundation
worries that its staff may not be participating enough in the
community. It takes a survey and finds that 44 of its doctors
are advising some 55 organisations, including the Topeka schools,
Leavenworth prison, the Topeka Police Department, the Kansas
Council of Churches, the Campfire Girls and the Strategic Air
Command.
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In Pueblo, Colorado, a state-hospital employee unlocks the
door to a ward housing the sickest and oldest patients. In a
large, bare room, a thin, birdlike old lady, who years ago murdered
her husband, sits with her feet twisted awkwardly through the
rungs of a chair. "They took out my eyes and gave me new
eyes," she announces. "If I hadn't married that Robert,
nothing would have happened." A few feet away, a large
Negro sits at a table, smiling vaguely. He has one leg and wears
four hats, one on top of another. A tall woman walks by. "I
used to be very rich, and they tortured me," she says pleasantly.
"I was terribly rich. But I'm not on the state. Thirty-five
dollars a month I pay here. My daughter has the receipts."
Outside ' the employee says, "Five years ago those patients
would have been sitting in their own vomit. Now those people
are bombed. Without their medicine, they'd be taking the paint
off the walls. If today's conditions pertained when they were
admitted, they'd be out now.
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