Psychiatry: The Uncertain Science
Page Three of Twelve

As recently as 1956 there were 335 patients in public mental hospitals for every 100,000 people in the USA. By 1962 there were 283 per 100,000, and today there are only 238. At the end of World War II there were 4,000 American psychiatrists. Today there are 22,000. Equally significant, a Joint Commission on Mental Illness, created by Congress and organised by the A.P.A. and the American Medical Association, has formally defined the goal of' treatment of' major mental illness as keeping the patient out of' a hospital and in his community as much as possible. Following the Commission's recommendations, Congress has appropriated $23 million for the construction and staffing of community mental-health centres, a concept which psychiatric organizations have endorsed with a unity unmatched in U.S. psychiatric history.

To qualify, an institution must plan to coordinate at least five basic, community-oriented services: (1) inpatient, or full-time hospitalisation; (2) outpatient services; (3) a day-care program of part time hospitalisation; (4) emergency services around the clock; and (5) a program for consultation with and education of local agencies and doctors. As of last April, 276 centres, covering 44 million people in 48 states and territories, had received construction and staffing grants totalling $146 million.

Yet for all its growth and its increased contacts with the community, psychiatry has really achieved only token integration. Most Americans still can't distinguish between psychiatrists and psychoanalysts, which is like thinking of all journalists as sports writers. Out of 16,000 members of the A.P.A., only 1,600 are psychoanalysts, and many of those use analysis in treating only a minority of their patients. In terms of appeal to public sympathy, mental illness itself still ranks far down - behind polio, tuberculosis, cancer, heart disease, crippled children, cerebral palsy and muscular dystrophy. Yet social attitudes often determine treatment. Dr. Menninger recently gave a succinct explanation for the strides his profession has made in recent years. "In my student days," he said, "they weren't supposed to get well."

Until very recently there was a strong tendency, in almost all psychiatry's approaches, toward treating mental patients as though they existed in a void. Since the mentally ill did not behave in normal ways, society removed them from the normal world. Once in an institution, the normal world ceased actually to be much of a factor in the patient's life, and he was treated without reference to it - if he was treated at all. If he recovered, he was replaced in the normal world and cut off from all contact with his asylum.

The Freudian model, on which most modern psychiatry is based, strengthened this isolating approach. Freud saw the adult as having an established mental system, which followed certain constant laws of its own. While he conceded the importance of current stresses in aggravating weak spots in this system, he concentrated his treatment on the weak spot itself, and never regarded the current stresses as something he could properly treat in analysis.

All the major developments in psychiatry in recent years have moved away from this approach, and they have come with the growth of the profession.

"We're a relatively new profession," says Dr. Francis Braceland, past president of the A.P.A. and current editor of its American Journal of Psychiatry. "It was only in the 'Thirties that there were any private psychiatrists. Before that, they were all behind walls."

"I was practicing here prior to World War ll," says Dr. Ralph Greenson, of Los Angeles, "and I would guess that there were only five or six psychiatrists of all kinds in all of Los Angeles. There were less than two hundred analysts in the United States. Analysis was considered shameful.
In the early days of the war, if a man broke down in combat and couldn't fly any more, he was tried for lack of moral fibre. Then, in the Eighth Air Force in England, it was found that even the most heroic men, after a certain number of missions, would get nervous convulsions and shakes and get drunk every night. With the realization that even the bravest man had a breaking point it even became fashionable to have combat fatigue."
More than half of all U.S. World War II casualties were mental, and by the end of the war millions of people had altered their concept of mental illness. Psychiatrists, seeing combat breakdowns rectified in 24 hours, had begun to re-evaluate the role of immediate stress in mental illness. A nation determined to take care of its veterans gave large amounts of money to the Veterans Hospitals. At the same time, society at large was deciding to attack all its problems, including mental illness, on a large scale. Federal expenses for mental-illness research shot from $1.5 million in 1950 (when the Federal Government spent $30 million for research on hoof-and-mouth disease) to $220 million this year.

Meanwhile English psychiatrists were getting good results with more liberal treatment of hospitalised mental patients. When locked wards were opened and the patients were given both more help and more responsibility, many stopped soiling themselves and destructiveness declined.

"One of the things we've learned is that there is a greater destructiveness in a pathological environment than in the illness itself," says Barney Stone, formerly head social worker at Colorado's Fort Logan Mental Health Centre.

"People developed asylum lunacy; they became hospital habituated. We found that if a patient got out of a hospital within one year, he had a 90 percent chance of staying out. After that first year, his chances were cut in half. After the second year, he was almost sure to be permanent."
The last and most critical factor in this dehospitalisation process was the new mind drugs of the 'Fifties, which calmed the most disordered patients and made them treatable by other means. One third to one half of all prescriptions written today are for mind drugs.

"With the drugs we have now, there should not be any more madhouses," says Dr. Sidney Cohen, who is associated with the Brentwood (California) Veterans Hospital. "We used to spend more damn money up at Brentwood repairing broken windows and stuffed toilets and broken light bulbs than I bet we spend on drugs now. Today's young psychiatrists, they just can't realize what it was like."

Today some hospitals still lock up all new patients, and most hospitals have some locked wards, but some, like Colorado's Fort Logan, do not lock any wards at any time. Furthermore, many more people than ever before are receiving psychiatric treatment while continuing to work, raise families, or otherwise partake of normal life outside a hospital - and much of this is thanks to the drugs. Just 20 years ago, a hospitalised mental patient named Lara Jefferson wrote in her diary: "Here I sit - mad as the hatter - with nothing to do but either become madder and madder - or else recover enough of my sanity to be allowed to go back to the life which drove me mad." If Lara Jefferson were a mental-hospital patient in certain states today, at the time of discharge she would be told to visit her local mental-health clinic, which would be advised she was leaving the hospital. She would be given a five-day supply of psychoactive drugs and a prescription for more, and if she didn't show up at the clinic with her prescription after five days, a public-health nurse would go to her home to find out why.

Even in the face of great obstacles, hospitals have managed to reduce their patient load. In 1963, when Dr. Charles Meredith became superintendent, the large and isolated Colorado State Hospital in Pueblo was revamping its program. In four years, with the help of a new state program, Dr. Meredith reduced the patient population from 4,000 to 2,100, and the average stay from 5 months to 3 months. Seventeen hundred geriatric patients have been sent home. "The whole trend has been reversed," he says, "and we have knocked five buildings down." Incoming patients are now sent to a building designated for their part of the state, and the building's staff members know the area's judges, doctors, and social agencies. To reach people in remote areas, the hospital uses private psychiatrists who make their rounds by plane and are known as "flychiatrists." In the children's division, 16 children are living in small cottages with undergraduate psychology majors from South Colorado State College as counsellors. During the day the children and counsellors go to school and college in town, and in mid-afternoon they all return to the cottage. The experiment hopes to show that intensive therapy in a nearly normal selling can enable disturbed children to go to regular schools. "If it works," Dr. Meredith says, "the same system can be applied out in the hills, without any hospital plant at all."

Many psychiatrists are also working with doctors and ministers to enable them to take care of patients who are only mildly disturbed. A small, county-sponsored mental-health centre in Grand Rapids, Michigan, has found that the cost of actually seeing a family is 10 times greater than the cost of merely advising the family doctor, and most of the time the results are no better. Today 8 of every 10 families it deals with stay in the care of a local doctor or agency.

As a theoretical accompaniment to these changes, the profession has modified its thinking about what constitutes normality and to the point that many psychiatrists now question whether either word has any real meaning.

Psychiatrists have long noted that mental illness never seems to be total. Freud wrote that even patients with severe hallucinations later reported that "in some corner of their minds. As they express it, there was a normal person hidden who watched the hubbub of the illness go past like a disinterested spectator." Recent experience has convinced most psychiatrists that mental health is also never total, and that the amount of health varies from time to time. One remarkable study of 175,000 people in New York City, excluding all those under 20 or over 59 and Negroes and Puerto Ricans, has suggested that the general level of illness is much higher than most people would like to think. The study found that 36.3 percent of the subjects had "mild" symptoms of mental illness, 21.8 percent had "moderate symptoms, 13.2 percent had "marked" symptoms, 7.5 percent had "severe" symptoms, and 2.7 percent were so disturbed that they were virtually incapacitated. Only 18.5 percent showed no signs of mental illness at all.

Such observations have convinced many psychiatrists that their proper study is not specific diseases like schizophrenia but the "whole" man who has developed a harmful way of reacting to his life and himself, and this view has led psychiatry to expand its area of concern. The Menninger Foundation's Division of Industrial Mental Health, under psychologist Harry Levinson, gives seminars to doctors and businessmen, and advises organizations on specific problems. In San Mateo County, California, about half the people sentenced to jail go to one of two "honour camps" run by the sheriff with the help of the county mental-health centre.
Psychiatry's rapid expansion, however, has given it some growing pains. The demand for psychiatrists is increasing even more rapidly than the supply thanks in part to the profession's efforts to convince the public that mental illness is curable and not shameful. Reducing the number of patients in a hospital moreover, often brings a cut in the hospital's funds. California's Governor Ronald Reagan, who once sent his dog to a psychologist ($245 for six sessions of therapy), cut $17 million from California's mental-health budget last year on the grounds that a reduction in the number of patients enabled the state to do without 3,700 mental-health workers.

More ominously, some hospitals have already built up a backlog of chronic patients who, in the standard phrase, "are unable to benefit from our treatment," and more custodial facilities may be needed for them. Some psychiatrists also think that the zeal for building new centres, in the words of Dr. David Vail of Minnesota, "is like hoping to cure illiteracy by building more libraries," and the community psychiatry movement has been accused of noisily overselling itself.

Whether or not this is true, many sections of the community have been slow to welcome psychiatry into their midst. The current relations between psychiatry and the clergy are generally uneasy. Fewer than 9,000 clergymen, or four percent of the country's total, have ever taken a course in clinical pastoral counselling, and the Academy of Religion and Mental Health, which was founded to bridge the gap between the two professions, estimates that fewer than seven percent of all clergymen have even an adequate knowledge of psychiatry.