Psychiatry: The Uncertain Science
Page Four of Twelve

Few doctors have had any training in psychiatry, and many are sceptical about its effectiveness.

"You have to treat doctors as gingerly as you treat a patient," says Mrs. Morton Golden, who administers her psychiatrist husband's seminar series for doctors in Brooklyn Heights, N.Y. "The young doctors are too busy getting going to come to us, and it also seems to take about twenty years, for the doctor to realize that there are patients he's not having success dealing with. When you first approach a general practitioner, you're dealing with a layman."

Community psychiatry has even had its frustrations with psychiatrists. In a study of psychiatric agencies several years ago, Dr. John Curning and Dr. Claire Rudolph found that the agencies with the best-trained workers concentrated almost completely on mildly disturbed patients, and saw only a small percentage of severely disturbed people. Similarly, the agencies with the least-trained workers treated the most people and most of the severely disturbed. There are fewer members of the A.P.A. working in public hospitals today than there were when the organization had only 4,000 members.

"At least half psychiatry's energy today is going to people for whom treatment is essentially palliative," says San Mateo's Dr. Joseph Downing.
"This means people who probably wouldn't be much different if they weren't treated at all. One of our big problems is the dog-in-the-manger attitude of most professionals, that even though they're overworked and can't do a job, nobody else can do it because they're not professionals."
Finally, of course, many of the places where the most ill are treated are unsuited to community psychiatry, which was a major reason for the creation of the community mental-health centre concept in the first place.

The average U.S. mental hospital has 1,440 beds, compared to the non-psychiatric hospital average of 139. Some 452,000 Americans are being treated in 284 state and County mental hospitals, most of which are at least 45 years old; about 40 percent of these patients have been hospitalised for more than 10 years, and almost 30 percent of them are over 65 years old. The country's 259 private mental hospitals have 80,000 patients and five times as many staff members per patient as the public hospitals, and the average stay in them is two months. Many of these private hospitals, like Menninger's, in Topeka, Kansas, and the Institute of Living, in Hartford, Connecticut, have supplied the profession's leaders, but many of the more conservative, less community-oriented voices in the profession also come from such hospitals. Today, still, there are 13 states with no private mental hospitals at all.

The most community-oriented of all hospitals are probably the 1,005 general hospitals that have psychiatric units. General hospitals today actually treat more mental patients than do the state and county hospitals, and more of them have applied to become community mental-health centres than any other class of hospital. Nonetheless, even the general hospitals are a long way from the minimum standards laid down by the National Institute of Mental Health. Only a third of them have any social workers (the average mental-health centre has seven), and only a third offer any form of part-time hospitalisation.

One vivid example of how far psychiatry has come in recent years, and of how far it still has to go, is an old, remote, unglamorous hospital in Orofino, Idaho, which serves the entire northern half of the state.
In the summer of' 1939 a young premed student from California went up to Orofino's State Hospital North to work as an attendant. "It was a dumping ground," he recalled recently. "The big therapy was to push big blocks with carpeting on them, back and forth, to polish the floor. The place was staffed by bughousers - a floating population, like circus roustabouts - who worked in mental institutions. You've read the horrors about patients getting beaten up? - Well, the simple fact was, it worked. The other patients complain that they can't sleep because some guy is yelling, so you went in and beat him up for five minutes. You got a dry towel, never a wet one, and knotted it and beat him. If anybody came along later, there were no marks - maybe a skin rash, nothing else. There was one male nurse who was a sadist. He went in and beat up a patient badly with a towel. I went in and complained to the doctor. I remember he was sitting in the dark, listening to Jack Benny. Nothing ever happened."

Ten years later, after a series of newspaper exposes about State Hospital North, the legislature appropriated money for two new buildings, but by 1956 conditions had still not improved much. That year, a psychiatrist named Dr. Myrick W. Pullen Jr., who was in private practice in Salt Lake City, heard from his father, a doctor in Boise, that State Hospital North was looking for a superintendent, so he went up to take a look.
"The needs just stood out all over," he recalls. "And I knew I could run a place better than that." With no fancier mandate than that, Dr. Pullen became superintendent. "It was fantastic," he says. "The patients were working twelve hours a day, seven days a week. A lot of people were being held here just because they were good workers. People would say, 'You can't let Charlie go home for Christmas. Who'd collect the garbage?' Lock 'em up, keep 'em quiet, and work 'em was the treatment plan, by and large."

Dr. Pullen is a quiet, unprepossessing father of six who favours pale sports jackets and keeps a Methodist hymnal on the upright piano in his parlour. He does not write papers, and he is not known to the leaders of his profession. Nonetheless, thanks to Dr. Pullen, northern Idaho has a very different hospital today. State Hospital North now has 278 patients instead of 435, and 108 of those were admitted before Dr. Pullen arrived. New patients generally get out in a little over a month, and can start trial home visits within two weeks. A family-care program places patients without relatives in a sponsor's home, and discharged patients are provided medicine at cost. Two thirds of the wards are open, and there are two sunny and cheerful self-management wards. There is a well-equipped new laboratory; a room with a see-through mirror and tape recorder, for group therapy; a lively recreational therapy shop.

Two thousand feet up in the mountains, 17 miles from the hospital grounds, patients and staff members are building four A-frame houses as a self-sustaining camp for the hospital's most needy cases, its long-time patients. "We have some of the recreational advantages the rest of the country is crying for, and it would be nice to use them," says Bernard Sargent, the young public health specialist who supervised the camp's founding. "If we can give these chronic patients a group identity, and set up a retreat that is realistic, not escapist, we may help some of them."
State Hospital North is still not a model hospital. Orofino is set dramatically alongside the Clearwater River at the bottom of a deep, narrow, inaccessible valley, and it is hard to get psychiatrists and doctors to work there. Dr. and Mrs. Pullen have had two weeks vacation in 10 years, and Dr. Pullen uses his spare time travelling to professional meetings, to keep informed. "Many patients who come here could be treated in their communities," Mrs. Pullen says, "but there are no facilities.

State Hospital North also carries the burden of its past. The old men's ward has a large sitting area furnished with a semicircle of' chairs. Every day, 43 old men in overalls sit there, crying, muttering, gesturing to themselves, sucking toothless gums, and their meaningless jabber creates a susurrating noise like the fluttering of hundreds of moths. Some are incontinent, but they are always cleaned up right away. One old man sings over and over again, "I'm gonna quit, I'm gonna quit, I'm gonna quit."

"These are a lot easier to take care of than most patients," says the old men's nurse, a short, energetic woman. "They're not nearly so demanding. They're all capable of feeding themselves. I like these little old men - there's something about them. This little guy is paretic. He's had syphilis of the central nervous system. He thinks he's God's gift to women. He has a girlfriend - he sits out with her and holds hands. This little guy who's singing, every once in a while I go tell him to be quiet or he'll wake the baby. I got a bunch of characters in here. It's more fun than a barrel of monkeys."

Speaking of a patient in the old women's ward across the hall, Mrs, Pullen says, "I sat, down next to Pearl the other day and said, 'Pearl, how long have you been here?' and she said, 'Thirty-four years.'"
Psychiatry has dramatically improved the way it treats its patients, in the years since Pearl went in, but Pearl is still there. Such patients are no longer considered hopeless, but their hope now lies not in humane treatment but in intensive therapy. The hard problem still facing the profession is this problem of therapy: what specifically to do to help the mentally ill shake off their invisible chains and thus, as Freud put it, return them to the common unhappiness.

Of all the choices presented to psychiatrists in treating the mentally ill, one of the most basic is whether to deal with the patient individually or as a social being, in his surroundings - roughly, a choice between the classic medical approach and what is called the "problem of living" model, With its move out of isolation, psychiatry has also moved away from the medical model toward the social one.

One of the ripe paradoxes of this paradoxical profession is that, in the teeth of this shift, psychiatry's most important single treatment is still psychoanalysis, which is medically oriented, resolutely individual, and has changed hardly at all for 50 years.
Psychoanalysis is by all odds the most complex, cumbersome, limited and time-consuming psychiatric treatment ever devised. Psychoanalytic treatment takes three or four years to complete, the patient must visit his analyst three to five times every week, and full treatment may cost as much as $30,000. But analysis has had little success with the severely disturbed, and many analysts use it on only a few of their patients.
The few studies that have been made indicate that analysis, even with its selected clientele, succeeds only two thirds of the time, a rate not distinguishable from spontaneous recovery rates after no treatment at all. Analysis has therefore come under heavy attack from those who want to treat mental illness on a large scale or within a brief amount of time.