Psychiatry: The Uncertain Science
Page Ten of Twelve
This apparently simple procedure is thoroughly grounded
in psychiatric theory, and Dr. Levy was influenced in setting it
up by the teachings of many different doctors, among them Dr. Stuart
Asch and Dr. Edward Joseph of the New York Psychoanalytic Institute.
"These two men taught me that psychotherapy is not an intellectual
exercise but a question of getting people to express feelings, often
at the most basic level, Dr. Levy says. "And some of my ideas
came from Ralph Kaufman, director of psychiatry at Mt. Sinai. I
was with him one morning when he passed the room of a man who was
suffering from severe ulcerative colitis. The man was depressed,
and he saw only a lousy life ahead. He wasn't eating at all. Kaufman
walked in with a cigar in his mouth and said, 'Hey, if you don't
eat you're going to die.' He began to eat.
'"We have found that you can get just about anybody
in the state of Maine to come to this place. Within two weeks of
the time we started, we were snowed. We often had to say, 'Go home
and get sicker, we can't treat you now.' What we've been able to
establish here is a system of priorities. At Kings County Hospital,
in New York City, the time from reporting through waiting list and
treatment was two and a half years. We have no waiting list.
"Yesterday we got a forty-eight-year-old woman
in the emergency ward at the hospital. The cops had found her with
her head in the oven. She was hysterical when they brought her here,
and now they've given her tranquillisers and put her in a security
room. She has a logical discouragement. Number one, she has cancer.
She started radium and cobalt treatment a while ago.
They thought they had it stopped, and then she got a
return of the symptoms. Number two, her husband walked out three
weeks ago without warning. She hasn't heard from him since. Three,
her children are grown, and they don't get along well. They hate
each other's guts, to put it bluntly. She herself has been an alcoholic,
and she talks about one of the sons with hatred. I hope to get her
home in two days."
Occasional programs like Portland's notwithstanding,
one of psychiatry's greatest failures is its poor overall record
in handling psychiatric emergencies. One death in 100 in this country
is listed as suicide, but the official figures are probably much
too low because of the pressures to list death as accidental in
all doubtful cases. One authority says that there are probably 50,000
to 60,000 suicides a year, which would mean a death rate higher
than that from auto accidents (many of which probably conceal a
suicide); another study has concluded that there are about 250,000
suicide attempts in this country every year.
Yet neither doctors nor psychiatrists are adequately
trained to handle these cases. Non-psychiatric interns are often
assigned to the emergency wards in hospitals, and their qualifications
for assessing mental disturbance are slim. One study of a New York
hospital's emergency ward showed that only 144 out of 3,268 patients
were referred by the admitting doctor to the psychiatric resident
on duty. When 84 patients who had not been referred were studied
later, 52 were found to have obvious psychiatric troubles, and 18
more showed probable psychiatric symptoms. A recent A.P.A. study
concluded that psychiatrists themselves were no better qualified
by training and temperament to deal with emergencies than many other
professionals, and could probably learn a good deal from psychiatric
nurses and experienced policemen.
Emergency facilities are also in short supply. More
than half the country's general hospitals are prevented by their
charters from accepting mental patients who come their way; if a
man has slashed his wrists, he will simply be patched up and sent
home, without psychiatric evaluation. If a patient is physically
healthy but clearly disturbed, the only facility in many places
is jail.
Psychiatry's record with many chronic illnesses is no
better. There are an estimated four and a half million emotionally
disturbed children in the country, about one percent of whom have
an opportunity to get treatment. (Treatment can easily cost $10,000
a year, and there are only some I,500 child psychiatrists.) There
are about 5.5 million mentally retarded Americans, of whom only
180,000 are in institutions. It is estimated that at least 25 out
of every 30 retarded people could, with proper training, lead almost
independent lives, but there are not enough psychiatric workers.
The National Council on Alcoholism estimates that there are six
million U.S. alcoholics, but there is no consensus on the proper
psychiatric approach to alcoholism (many psychiatrists recommend
Alcoholics Anonymous), and alcoholics and psychiatrists have little
mutual attraction.
"They've had very little success in the psychiatric
division with people we've sent there,." says Lester Bellwood,
an ordained minister who heads Fort Logan's alcoholism division.
"One group of patients feels, 'We may be nuts, but at least
we're not drunk.' Another says, ''We may be drunk, but at least
we're not nuts.'" Psychiatry has done even less work with criminals,
yet when 608 convicts at Sing Sing were examined, 60 percent were
found to be feeble minded, mentally ill, or psychopathic.
Recently there have been a few promising attempts to
find specific approaches. A hospital in Cooperstown, N.Y., has developed
a computerised typewriter which has greatly improved schizophrenic
children. In a quiet, pleasant voice, it gives the child a word
to type. If he punches the wrong key, nothing happens. If he punches
the right one, the letter is printed. The machine thus removes pressure
on the child by making mistakes impossible.
Two doctors at the Jefferson Medical College in Philadelphia
have reported success with alcoholics by allowing the patient to
drink, inviting him to talk about his life, then filming the discussion.
Later the sober patient and the psychiatrist look at and discuss
the film, and the sessions are said to make the patient aware of
self-deluding aspects of his behaviour. LSD has also been used with
some striking effects in treating alcoholics. The dose is large,
the aim being to achieve a profound experience which, by temporarily
changing habitual ways of responding reveals their inappropriateness
and encourages relearning.
Psychiatry is even working with some criminals who are not legally
"insane"
The staff of the Kansas State Reception and Diagnostic
Centre examine each convicted criminal to determine how much security
is required and what treatment will probably be most effective.
Of the first group of criminals examined, 423 were sent to the state
penitentiary; 480 were sent to an industrial reformatory with detailed
recommendations for treatment; 34 went to a state hospital for mentally
ill convicts; and 15 were sent to a state hospital outside the prison
system.
The proliferation of experimental treatments of all
kinds makes psychiatry an energetic profession, but so far it has
had almost no success converting its energy into a scientific body
of information. As a result, psychiatrists are now in the unique
position of helping the mentally ill in many ways and disagreeing
among themselves about all of them. But Dr. Paul Wilson is conducting
a four-year National. Institute of Mental Health program that may
be the first step in bringing order out of this confusion.
A computerized national clearing house for mental health
information has been set up. There is a coordinating index to facilitate
cross-checking of similar experiments, and there may possibly be
patient data, so that if a man from New York has an emergency in
California, a doctor there can get precise information about him.
So far, some 90,000 technical and scientific documents have been
programmed into the computer.
"National registration of patients is probably
necessary for good research, although there will have to be very
stringent safeguards," Dr. Wilson says." "We hope
that accumulating a large body of information about a large number
of patients will increase agreement among psychiatrists. Technically
this hasn't been possible until recently. Now it's possible for
many doctors to be exposed to the same patients and get the same
sensory perceptions,
"Whether it's possible to get rid of the political ' things
underneath the disagreements - that's something else."
Almost in unison the psychiatrists came to their feet
across the crowded ballroom. It was the banquet of the annual convention
of the American Psychiatric Association; the day had been filled
with debates about "Unravelling the Phobic Defence," "Socrates
and Psychotherapy," and "Information Exchange Modelled
in the Time Domain," and now Guy Lombardo, who always plays
at the banquet, was inaugurating the dancing with King of the Road.
From the four corners of the room they came, sweeping onto the dance
floor; in a moment the floor was jammed with bouncing psychiatrists
- past presidents of the A.P.A., analysts from Massachusetts and
Texas, family therapists from Oregon and Illinois, millieu therapists
from Florida, all fox-trotting and smiling together. Every once
in a while a head would go bobbing by - Dr. Whosis, originator of
the multilinear discombobulation theory, or Dr. Whatis, head of
the great Centerville Clinic - and then quickly disappear again
into the happy throng.
The Guy Lombardo rite takes place at every annual banquet,
and it is probably the only time when a large group of psychiatrists
can be seen in one place, smiling. For reasons best left to psychiatrists
to figure out, Guy Lombardo is just their cup of tea, and the banquet
itself is the one light spot in five days of intense cerebration.
The next morning they will return to "Transvestites' Women"
and "The Clinical Approach to the Problem of Nothingness"
and "Attitudes to Body Products." They will listen to
papers and appraisals of papers', At panel sessions they will stand
up and say, I will try not to make a speech but to ask a question,"
and then make a speech, and they will accuse each other of trying
to demonstrate masculinity. But for these few banquet hours, once
a year, the psychiatrists of America seem as naturally congenial
as a group of hat manufacturers.
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