Psychiatry: The Uncertain Science
Page Two of Twelve

Given the wide range of psychiatry's activities, it is useless to try to find a definition to cover them all. It is more profitable to describe psychiatry generally handles those it treats. When a person with a physical complaint goes to a doctor, he will get one of many available treatments, and the selection is made on medical grounds. The treatment meted out to a psychiatric patient today is usually determined by what's available where he lives, what he can afford, and what kind of psychiatrist or psychiatric facility he chooses. The patients come from all ranks and stations, some have obvious, immediate problems and some don't, some act crazy but many don't, some are functioning successfully in the world and some aren't.

Whatever their troubles, almost all these people come to treatment with the patient's natural expectation that he has something fairly definite wrong which a doctor can fix up, but the characteristic common to the largest number of psychiatric treatments is that they are not specific. Psychiatrists do not locate and remove mental gallstones or even diagnose and cure specific emotional infections. (The only psychiatric treatments that produce definite, predetermined results are drugs and other physical treatments, and there are strong differences about how and when they should be used.) In analysis, sudden insight sometimes brings quick improvement, but that probably takes place in fewer than five percent of analysed patients - a small minority of all psychiatric patients - and it rarely occurs unless the trouble was caused by a specific, buried, traumatic experience. Psychiatric recovery is generally a slow and invisible process.

There are seven principal ways in which psychiatrists help people today:

1. They give, or enable a patient to attain new insight into his mind and emotions.

2. They give guidance, by intervening in the patient's ineffective ways of acting.

3. They foster relearning, or different ways of reacting to stress.

4. They prescribe drugs.

5. They give other physical treatments, primarily electric shock.

6. They offer support and reassurance.

7. They offer and rest and relaxation, usually in a hospital.

In various combinations, these several ingredients constitute the five primary psychiatric treatment in use today:

Psychoanalysis is aimed at enabling the patient to achieve insight into his unconscious mind. and classical analysis strenuously avoids all other methods of psychiatric relief. It is the only major form of therapy which has clearly established ground rules, though in practice the rules have to be played by ear. The patient lies on a couch and reports his feelings through free association, while the psychiatrist relies on interpretation to bring the patient to an awareness of these feelings.

A widow in New York becomes paralysed when a gentleman caller arrives at her door. During, analysis she discovers that the paralysis sprang from feelings ' of guilt over suppressed sexual desire, and the paralysis disappears. She then rediscovers a buried memory: As a girl, she had been seduced by a cousin, and her aunt and uncle, who had been raising her, called her a streetwalker and threw her out of the house. Her paralysis had symbolically and literally prevented street-walking. Understanding these suppressed feelings, she loses her guilt over them.

Psychotherapy is individual treatment using techniques other than or in addition to those of analysis. Psychotherapists may use drugs; they give less insight, more guidance and support, and always play an active role. The patient usually faces the psychiatrist and treatment takes from six to 15 visits.
A college student in New York has obsessive thoughts about doing away with himself and can't get to college for fear of driving off a bridge on the way. He is a strict Catholic in love for the first time, has considerable buried aggressiveness toward his domineering mother and his church, and feels guilty about sexual desire for his girl friend. Without trying to reshape his underlying psychic structure, the psychiatrist reassures him that his feelings are not unusual, and that there is a great difference between having feelings and acting on them. He tells the boy not to fear his impulses and to express his feelings more. The boy starts expressing himself more in classes and even occasionally yelling back at his mother,and his symptoms go away.

Chemotherapy is treatment by means of drugs. Insight never plays a part; guidance and support play secondary roles. (Some psychiatrists rely primarily on drugs, and psychoanalysis is the only treatment that does not use drugs at all.) A woman in New York has a recurring, incapacitating depression.
She has spent several years in and felt it helped until the depression came back as strong as ever. The psychiatrist gave her an anti-depressant, and her depression disappears.
Thereafter she is given the drug whenever she feels a deep depression coming on, and is taken off it over the course of several months. She is able successfully to resume a good job in publishing.

Milieu Therapy helps a patient to recover through manipulation of his environment in a hospital. Insight generally plays a minor role; rest, relaxation, support, relearning and guidance play major roles. Most hospitals, while trying to provide healthy surroundings, do not use milieu therapy in any formal sense.

Group Therapy is a treatment in which the patient is also a therapist to his fellow patients. Under a psychiatrist's unobtrusive supervision, a group of patients discuss their troubles and feelings, and both give and get support, reassurance, relearning and guidance. Group therapy is seldorn the sole treatment given, and is most commonly used in hospitals or, with outpatients.

It is a startling fact that nobody can say how well any of these treatments work. Evaluation is difficult because there are no cures in the strict sense, while improvement and recovery are matters of subjective judgment. Research comparing treatments has been very skimpy, and psychiatry today has no sizable body of statistical proof to verify the effectiveness of any of its methods.

Furthermore, psychiatrists as individuals are prickly and prone to disagreement. "There's almost nothing I can say that in ' any of my colleagues won't disagree with," Dr. Lawrence Kubie, of Baltimore's Sheppard-Pratt Hospital, said recently, and that statement is one of the few that most of his colleagues could agree with. Psychiatrists today do not even speak a common language; leaders of various schools will refine their lingos to the point where they baffle each other. "I give you the assurance," Dr. Karl,Menninger has said, "that I don't understand a good deal of what my colleagues are talking about."

Instead of working to break down these differences, psychiatrists of different persuasions are apt to be segregated from one another. Confidence is recognized as an essential element for therapists as well as patients, and, whether by design or inclination, psychiatrists tend to work and associate with others who share their beliefs so that informational exchanges are erratic. As a result, psychiatry in many ways today is like a large medieval country with a number of isolated fortresses. The inhabitants of one fortress may express admiration for the strength and ability of an opposing army. They may, between battles, meet and talk and even break bread. But to a great extent they are isolated and in a state that either is, or looks an awful lot like, war.

It isn't surprising that a profession in such shape should put off many who have come into contact with it. Some informed people consider it all bunk. Many more consider most of it bunk. (The psychiatrist is sometimes defined as "a Jewish doctor who can't stand the sight of blood. Another underground definition holds that psychiatry is "an unidentified technique applied to unspecified problems with unpredictable results, for which rigorous training is recommended.") But there are three factors which, as Dr. Robert J. Campbell, chief of the community mental health division at St. Vincent's Hospital in New York, has written, argue against "dumping the whole bit on the rubbish heap." One is the fact that psychiatric disagreements sometimes appear more intense than in practice they really are. The second is that all forms of psychiatry probably affect patients, whether for the better or not, and many therapies have demonstrably worked. The third, and most important, is that despite its wrangling and its lack of established methodology, psychiatry in the past decade has more in the treatment of mental illness this decade than during any decade min its history.

In short, psychiatry today is a remarkable profession: wracked by dissension, lacking established rules or practices, unsure of its proper role in society and flourishing anyway.

The profession of psychiatry today is not only radically different from what most people think it is, it is also radically different from what it was a dozen years ago and in another dozen years it will be radically different from what it is today.

At any given time about 600,000 Americans are patients in mental hospitals, about 500,000 are attending outpatient clinics, and almost one million are visiting private psychiatrists. The country's mental hospitals, less than 10 percent of all its hospitals, house half its hospitalised patients. The American Psychiatric Association estimates that these hospitals still have only 57 percent of the number psychiatrists they should have, and 23 percent of the nurses. Two thirds of the patients in state mental hospitals are getting virtually no treatment at all. These patients, however, are mostly leftovers from psychiatry's past, people who got sick too long ago to benefit from recent advances.

Today, the man who suffers a severe mental illness has a far better chance of living outside a hospital than he would have had even a dozen years ago.