An Institute of Living

I

I HAD come to the place with lines of Jeffers beating in my memory: —

It is likely enough that lions and scorpions
Guard the end: life never was bonded to be
endurable nor the act of dying
Unpainful. . . .

My friend and I had chosen a bench near a group of elms and maples in that corner of the grounds between the conservatories and an outlying area of flower beds. We had chosen the bench because of its view of a border of red cannas and salvia. They reminded us of a university campus we had both known.

More than bright borders recalled the campus. Over the thirty-five grasscovered acres, surprisingly preserved while a century of the drive and unrest of a growing city pressed in on them; over the park with its scattered cottages framed in magnificent tree groups, spread that atmosphere of tranquillity which marked the campus. Familiar pigeons plied between the gables of the older central hospital building, near the truckand car-traveled street, and the distant cottage roofs. Gray squirrel families were busy with the trees. And a woman, perhaps in her fifties, was picking red salvia from the border near us.

‘ She is picking the flowers,’ I said.

‘That’s what they’re for.’

There seemed to be nothing unusual about her. It was pleasant to me to see her own pleasure in this action of selecting her bouquet. Then she left the salvia for a stand of dahlia bushes not yet in bloom. Involuntarily my hand moved to stop hers as she snapped off the crown of a bush, a long stalk heavy with tight buds. This she added stiffly to the salvia; then another and another awkward, frustrated stem. And satisfied, she walked quietly away.

I looked at my companion. On his face I read nothing beyond a kind of vicarious satisfaction in that free expression and fulfillment of a desire.

‘That’s what they’re for,’ he repeated.

I realized then, and increasingly during the day, that this friend of mine, in whom years of overstrain had shaken the mysteriously delicate nerve balance, disturbed that mechanism ‘fussily adjusted to environment like an electroscope’ — that he had found relief here. After long suffering in an effort to regain adjustment, he was resting on something represented by the gathering of the bouquet — on something not directly evaluated, but which, after months of the beneficent influence of the new system for treating nervous and mental illness, had been so certainly sensed that it had established an attitude which flowered in a feeling of bien-être.

We walked across the lawn toward the freshly painted, peaked cottage where he lived. Near it was a croquet ground.

‘ I ’m playing croquet — it was my own idea,’ he added with emphasis. ‘ It came to me one day when Morton and I were watching a game. There’s Morton now ’ — an aide had appeared on the cottage porch.

‘Would this be a good time for a match?’ I asked.

‘Yes, but a short one — there’s the luncheon food car.’ An enclosed truck was beginning the midday distribution of food containers from the kitchen in the central building to the kitchenettes of the cottages. While Morton went to get mallets and balls our eyes followed the course of the highly polished truck, and my friend commented on the success of the household administration of which it formed a part. ‘Take my tray. How, even with firstgrade dietitians in the kitchen, can food for so many be so good? Always surprises — I look forward to each meal hour. You’ll see the girls preparing things in our kitchenette. It’s neat, attractive — the china, too.’ It was clear that my friend felt not only interest but personal pride in the direction of this establishment which included himself. (I am, I may insert, not recording breaks in the conversation’s thread of continuity, but linking point with point.)

I went to the cottage porch, with its bright-covered couch, smoking stand, reading table, and settled in a comfortable chair from which to watch the croquet game. Morton seemed not to be directing it; yet I saw that he was. Later, I found one explanation of what seemed an ideal relationship between aide and patient. I learned that the initial concrete illustration of the desired relationship between those who are ill and those who care for them is a blotting out of the word ‘patient.’ There might have been endless abstract discussion of such relationship which would have gotten nowhere; but the simple act of barring one word and substituting for it the word ‘guest’ immediately registered something in the minds of the personnel. The obligation was placed upon them and the proper start made.

Along paths, across lawns, there was a continuous passing of alert young men and women. ‘You will find that staff on tiptoe,’ a physician had told me. Some of these aides were on their way to a nurses’ hall; some hurried to classes. Others, on duty, accompanied a guest to a treatment room, or shop; to a lecture, a group tea, the library, or perhaps merely on a walk, or to tennis courts or golf course. At times psychiatric aide and guest stopped for a chat with a physician on his rounds. My eye, substituting professor for physician, saw a campus picture repeated. I had the impression that within the park’s security moved something young and forward-looking. Life was fluid; not static, hopeless. How immeasurably removed, this atmosphere, from that one of finality which darkens the typical institution that cares for mental illness! Here not even the park is shut in. The open lawns sweep down to a low green picket fence. And along one street there is not so much as the garden fence. Guests driving in and out (frequent automobile excursions are included in the régime), going to the country or to a football game or the theatre, have no impression, on returning, of entering a separated place. So strongly did the scene recall the campus that I was interested, later on, to hear the physician-in-chief call the park by precisely that name, and to learn that his purpose is to convert an ‘institution’ into an institute of living, which combines hospital and school — a place for education and reëducation under psychiatric guidance based on sound medical practice.

II

When barely eighteen, I was given charge of a school often called ‘the asylum school,’ because, with few exceptions, the sixty-odd pupils were children of attendants in the sinister buildings, shut in by high brick walls, known as the ‘State Insane Asylum.’ The school trustees were attendants. Each month I had to go for my pay check to an office in one of these buildings. This took me along a corridor from whose barred windows I looked down on two blank-walled enclosures where the ‘dangerous’ were taken for exercise and air. The guards in those sealed yards were well armed.

One day, as I was about to pass through a door that divided a corridor into two lengths, a woman darted from somewhere up close behind me, clapped the hooded part of a sunbonnet over my face, and, as she deftly tied the strings at the back of my neck, cried, ‘The gate of hell — give up all hope, you who enter!’

After forty years, I can still feel those bonnet strings being tied at the back of my neck, and hear that Dantesque utterance. For it was not the mere crying out of the unbalanced brain that made me shudder then; it was the fact that my own impressions going and coming along those halls of doom gave the utterance a terrible verity. That is why it still rings across my brain.

This early experience was one of the reasons for my interest in the unique, humane work that has been carried on for centuries now in Belgium’s northern village, Gheel. There the normal family includes with its own members one or two, or perhaps more, ‘innocents,’ suffering from various degrees of nervous instability. The townspeople coöperate with directing physicians in the attempt to give these guests as natural an environment as possible—to the end that the condition of nervous unbalance shall be cured, or at least be so greatly alleviated that the person can be reinstated in society. And to aid in that reinstatement voluntary committees of citizens (the first was formed in Antwerp) offer in their turn to coöperate with Gheel to ensure a successful restoration, it being of course understood that Gheel accepts only those patients whose condition promises a possibility of such improvement that the reëntry into society may be successfully accomplished. It is more than eight years since I wrote a brief account of Gheel for the Atlantic, yet again this past year I had requests for further information. These letters so movingly reveal the search for what I felt I had discovered now, in our own country, that I determined to find out all that I could about the institute of living.

This game of croquet, for instance, pursued with a measure of success and unquestionably with pleasure — what had awakened the energy, the desire it represented? During a half-dozen hapless years my friend had been so bereft of both that he had attempted no game of any kind. I found the beginning of the answer in the belief on which the system rests — that is, that we can make no fundamental progress in our care of mental illness until we separate the care of pre-psychotic, acute, recoverable groups from the care of chronic and purely custodial cases.

For not only must the effect of the chronic type of illness on the acute type be considered, but the fact that facilities required for the two groups differ, and that the personnel with the emotional and mental make-up suited to intensive work with recoverable cases is not best suited to the care of chronic cases. Without in any way elevating the service of one of these personnel groups above the other, the staff of this institute recognizes that they are as incompatible as are the groups they care for, and doubts if both can attain their highest development in the same institution. It has chosen to do most of its work in the field of preventive psychiatry, and with recoverable or partially recoverable cases.

We have heard a great deal about the serious overcrowding of state hospitals, about the necessity of changing the asylums to hospitals. But we have not heard enough about separating the asylum type of case from the hospital type, so that institutions bearing the name of hospital may be that in fact as well as in name. Here already, because of the extent and the quality of physical medicine practised, the standard has been brought up to that of the better general hospitals.

For each guest the clinical laboratory conducts an exhaustive physical assay. For each, experts (some forty universities are represented on the professional staff) make initial and subsequent diagnoses. By installing a night shift in the medical record room, it has been made possible to coördinate within twelve hours all known medical facts regarding an individual case and to place this information promptly at the disposal of those in a position to use it. Thus the medical record is a tool in the daily management of the case. I had the impression of maximum mobility in medical practice.

In the physiotherapy rooms are bewildering activities of rays and waters, muscle training, and corrective exercises. The rooms themselves are so brightly attractive, the attitude of assistants is so keyed to that background, that the mere visit to a therapy hall is helpful.

I saw clearly proved the beneficial effect on my friend of an interesting, varied physical programme, intimately adjusted to his changing need — a programme which was never allowed to become stale, which, as his tray did, included surprises, and which had led him, by steps that made him feel that he himself had elected it, to the croquet game.

III

When I again visited my friend’s cottage, I found him on the porch with Morton, the aide. We pushed open the French doors and entered the living room, to which comfortable furniture, books and papers, a writing desk and radio, gave a homelike attractiveness. Someone was playing a piano.

‘That’s upstairs. There are two elderly ladies upstairs, one of them a musician. She plays or practises every day. We are really four in this cottage — there’s this bedroom off the living room [he showed it] besides my own on the first floor, but for the moment it is n’t occupied. So we’re three.’

A short corridor led to his own room, bright with chintz and fresh fruits and flowers. From this hall opened, too, the white kitchenette, where two girls in fresh caps and aprons were busy between the electric stove and the cupboard.

‘This I know you ’ll like to see. There are the containers; there, the trays — everything shining. A lot goes on here, and they don’t stop at trouble. They ’re glad to have you stay for lunch. That’s more than it seems, because it has to be arranged with the central kitchen. I’d think it difficult, but they don’t!’ He smiled. ‘ Only we should n’t be late. They have lessons afterward.’

I laughed.

‘Oh, yes, Morton keeps a check on them all, don’t you, Morton?’ he laughed in return. ‘Everything going all right to-day?’

Morton nodded ‘yes’ from the corridor end where he had gone to get a couple of tables.

Inside the bright bedroom I asked, ‘ Do you enjoy eating as well as looking at these fruits? Does Morton peel them for you?‘ (My friend has a difficult hand.) And quickly I realized that I had made a mistake. The eyes flashed. ‘Oh, you don’t understand. Peel them? He dices them to just the convenient size. It’s more than peeling!’ I had failed to appreciate that ‘more’ which made him contented in, and proud of, his home.

He took something from a dresser drawer. I noticed its neat arrangement, as I had before observed his own meticulous appearance.

I sat down by a reading table on which were several books. They looked new. ‘You may not have seen some of these,’ he said. ‘Our library has an arrangement with publishers by which we have books before they’re reviewed in the newspapers. You’ll find the last list in this,’ he handed me a little mimeographed magazine that looked like a college daily. ‘We publish it here — the cover design and the illustrations are competitive. This is, you see, a kind of college,’he added, as I ran through the pages with their reports of classes, exhibitions, plays, music, excursions, games, tea parties — a multifarious activity. ‘Over half the personnel have had some college training and everybody’s studying. I go to the library daily, to look over or to choose books. It’s convenient, too, because it’s near the barber shop! You know we have a street of shops.’

I did know; for en route to the cottage from the charming hall which houses the chiefs of staff I had come along a replica in miniature of an oldworld street, with barber shops for men, modiste and beauty shops for women, and a fascinating Dickensian library. The tuckshop, afternoon tea and smoking room, was lower down the lawn slope, more easily accessible to the golf course.

I turned to the little magazine’s book section, thinking as I did so of those nondescript novels of forgotten vintage that form the usual stock of institution shelves. I read: —

On our desk is a selected pile of books, widely varying in type, which are to appear in the shops next week. Of first interest is The Story of My Life, by Marie, Queen of Rumania. [There followed a brief review.] All who enjoy reading of Imperial Europe will revel in The Story of My Life.

Warwick Deeping has written a historical novel—The Man on the White Horse [review]. Deeping is taking a turn for the better.

The third volume of Jules Romains’s great novel, Men of Good Will, has just arrived — it’s title is The Proud and the Meek.

Other new arrivals at Ye Royale Booke:

New Frontiers — Henry Wallace

Best Plays, 1033-34 — Burns Mantle

The Tale of a Shipwreck — James Norman Hall

The Heroic Years — Fletcher Pratt

Reaction and Revolution — Frederick Artz

Brinkley Manor — P. G. Wodehouse

The White Reef— Martha Ostenso

Ye Royale Booke is offering individual programmes for guided reading. If you have an intellectual curiosity about history, Greek mythology, social theory, art, philosophy, and wish to pursue a concentrated study, the librarian will outline a programme of constructive reading for you. The books will be from our own library supplemented by books from the city library.

After lunch, in the office of the directing psychiatrist, I commented on the unusual activities of the library. ‘It’s only that we’ve made it a living, functioning thing,’ he said. Then he asked, ‘What happens when a patient returns home after months, perhaps years, of ill health spent in the typical institution? He finds family and friends talking about books he has n’t even heard of. He starts his new life feeling behind the times — with a feeling that is at once a handicap to his reinstatement. What, on the contrary, do our guests find on returning? That they are not only abreast of the family, but perhaps ahead. You would be astonished to know the total use of this library. It has surprised even me. The range of its use would give you some suggestion of the range of illness we try to relieve.’

‘To what degree of mental illness do you limit your acceptances?’ I asked.

‘The limit is set only by our belief that we cannot help the person who wishes to come here. We have people who, like your friend, are little more than nervously fatigued, and others who are just as ill as they are in any institution; only we don’t act strangely about it — it’s nothing to get excited about. One ill person is not different from another except as we make or keep him so. A typhoid patient is often delirious — do we set him apart as “different” because of that?’

IV

As we talked, I realized that I was in the presence of a pioneer, dedicated to that group among us about whom our past psychology has been cruelly, seemingly hopelessly, wrong; who was, with a consuming zeal, leading them out of that past darkness across a frontier into a new country. He sees no fundamental progress possible in the care of mental illness until we regard public and private institutions as essentially places for the education and reëducation of each individual patient, and of the personnel; until we regard service in the public and private mental and nervous hospital as a profession equal to, or in advance of, service in any other branch of the educational world; until the psychiatric staff has become a faculty, assiduously at work on a basic curriculum, modified to meet each patient’s need, a faculty which furnishes a progressive study course to accompany the physical-therapy programme.

‘You are right,’ this director said, ‘ in noting the seemingly trivial details which have interested you. Our objective rests upon just those little things. They make the pattern.’ And again he passionately assailed the old psychology that marked as ‘ different ’ the person mentally ill.

‘Take these things you’ve observed in your friend’s cottage — the women guests upstairs, the mixed men and women aides — those girls in the kitchenette that he pointed to with pride — all that touches a fundamental. What has been customary past procedure? If a person became mentally ill, the initial step was to destroy that normal human environment in which the sexes mingle. Men and women were set unnaturally apart. Our first step here is to ensure that normal environment in which men and women live and work together. Your friend may not appraise the cause, but that is a major reason for his contentment.

‘In recent years we have thought we had made a big advance when we emphasized the need of kindliness in our relationships with the mentally ill. But how can kindliness suffice? We have to add to it a new attitude of mind, a new type of thinking, a different psychology. In the past, psychiatric hospitals have been poorer in psychology than any others. Kindness does n’t get us far if practised within a false environment. You can see what this involves. It is not enough that chiefs of staff find a new mental axis — the whole personnel must; the community must.

‘There must be created a normal environment for the aide as well as for the patient. It was the former atmosphere, spreading from a wrong psychology, that made the type of person we need to help us here seek work elsewhere. During our first six months it was difficult to get assistants. Then the “attendant” type began to leave, and the type we wanted, to apply. The higher the standard, the easier it is to get help. We are not asking for attendants for the insane (the terms “sane” and “insane” we relegate to the legal world); we are asking for psychiatric aides, for teachers in a school of living. Here not only the ill but they themselves will be taught, will learn something about society and intellectual processes. We try to teach a nurse, for instance, to be a coördinator of the forty-odd therapeutic activities in progress here continuously; a coördinator, not a mere companion who watches and protects — not, God forbid, the traditional turnkey! Our psychiatric aide must be a reasonable judge of his patient’s mental reactions, play an active and constructive part in his therapeutic programme. He must be an assistant in psychotherapy, which, broadly conceived, is essentially personal guidance. We try to help him to get his own thinking straight, to find a philosophy of life — then all the other things fall into place and become usable. We are trying to develop not only an institute where the art as well as the science of medicine will be practised and taught, but also a home where the new profession of psychiatric nursing can be developed.

‘The result, even now, is that over half of our present aides have had some type of college or university training, and our nurses, in addition to being registered, are graduates of the better high schools or colleges. Educational standards for our personnel have advanced to the point where we are truly an institute. And we have made our beginning in postgraduate work for medical men in the field of psychiatry. In the old days, the burden was placed on the patient; we place it on the nurse and aide, on ourselves; that means constant study, constant advance. It means the substitution, for the terrible old symbols of separateness and hopelessness, of an alert sensitive response to need — an infinitely diversified response. The average age of our personnel is just under thirty years, which safeguards the enthusiasm and vigor of the institution. We have a staff on tiptoe in the battle to maintain for the mentally ill and for themselves an environment as nearly natural as possible. We never depart from the normal except when compelled to, and then for a minimum length of time. It is this opportunity for progress, this challenge to merit, that attracts the assistance we need.’

V

Because of its educational objective, pursued through intimate personal supervision and relationship, the institute and hospital has at any given time no more than two hundred ill persons in residence — for that many the directing physician knows the names, can carry in his mind the daily status. Could resources permit more acceptances, the total number of patients would then be broken up into units, each to include not more than two hundred. For such a number, too, the director can, as he does here, with another doctor personally make the group assignments.

I found fourteen groups, the composition of each determined by the individual need and by the reaction of one within that group upon the other. They shift as experience directs. If in Group I, for instance, tastes prove not congenial, if the graph is moving down instead of up, there is a regrouping. The reaction, too, of each patient to the persons in charge of each of his classes is considered of fundamental importance. Conditions, it is admitted, cannot be perfect, but always they must be moving toward the normal.

No doctor has a vested right in a particular guest; he remains in charge only so long as he is improving the condition of the guest. If he is not succeeding in doing that, another physician is assigned.

I was impressed with the number of visits by staff physicians to my friend’s cottage, and discovered one reason why they had so much time to give. They do not spend hours writing out the old type of report. Each morning they meet with the physician-in-chief to review their cases. The time saved from report writing is spent with patients.

Then I discovered a fact of revealing significance. There is here no receiving cottage, no receiving machinery. For a receiving cottage, no matter how kindly, is a tremendous mental insult to a person who already has more problems of adjustment than he can stand up under. When the staff began their work, others warned them that it would not be safe to assign guests directly to their attractive rooms — someone, for instance, might fling a lamp across such a room. ‘A lamp smashed — $1.80 lost!’ the director replied. ‘Often I’ve known it would do me a lot of good to smash a lamp. Instead, possessing a car and the liberty to run it, I’ve rushed out and stepped on the gas — and returned relieved! ’ So guests continue to be taken directly, as if they were arriving at a country club or hotel, to their rooms. Not to that typical old room with its wire screens, screw bed, untearable sheets — and suicide written all over its walls. No, not to that!

Conditions are made as safe as possible by a system of discipline — which begins with the aide; the more the responsibility rests upon him, the less burdensome it is to the patient. Incidentally, the illuminating result has been that in this institute and hospital the relative loss for damage is less than in any similar institutions of which I have knowledge.

Then, once a guest has entered in a direct, natural manner, the institute attempts to maintain for him normal surroundings, which calls for the highest degree of sensitive response to individual mental reactions. For, while the impression of naturalness must not be sacrificed, it is at the same time essential to create for the ill person an initial completely protective environment, which, as a progressive set of readjustments is established, must be as progressively, as delicately, withdrawn. In the past, what we have done to a person mentally ill was equivalent to asking a man with a broken arm to hold it out straight, or upright, until it was healed. We have given him something harder to do than we have asked of any other ill person. Here, today, he too is provided with the beneficent bandage.

VI

By this time I found myself back in the area of luminous perspectives, of greenhouses and experimental gardens, where I had started; and considering the subject of occupational therapy, to which they are linked; but, with the eyes of the faculty staff, viewing it from a new angle.

‘ I had an awful job getting the calico cats out of this place,’ the director had confided on the first day of my visit. ‘And to outlaw that raffia lamp that nobody on earth wants. If you get anybody into a frame of mind where he is willing to spend his day on those unpurposeful performances, there isn’t much hope for him.’

I saw all manner of things being taught. The institute connects, moreover, with extension courses of certain universities. But instead of condemning a woman, say, to making raffia baskets which have no connection with her past, nor will have with her future activity, the attempt is made to awaken her interest in courses of study which offer, to her, a channel for genuine selfexpression. Often the approach is by way of a hobby, by way of the question, ’Have you a hobby?’ or, ‘If you have n’t a hobby, can’t you find one?’ — which has led some women to the greenhouses, to the making of experimental gardens, to the study of horticulture; which has led others to the study of home economics, of social correspondence, of caterers’ service; to various classes in the arts and crafts; to dozens of other tonic, usable pursuits.

I thought illuminating the case of a certain banker, who arrived in a state of nervous instability. He had been encouraged to discover a hobby, and, after several visits to the greenhouses, had found it there. He was engaged in designing and carrying forward a garden. Had he, on his arrival, been arbitrarily assigned to gardening, as part of an occupationaltherapy programme, his reaction, in his overwrought condition, might easily have been, ‘Gardening? To be a gardener, then, is all that’s left for me — I ’ll cut my throat first!’

While he was looking for, considering, his hobby, the doctor was uncovering the fact that his illness was largely the outgrowth of a feeling of insecurity that had pursued him from the very beginning of a banking career embarked upon without an adequate knowledge of the fundamental system of accounting. Before long this banker was following a university extension course in precisely that troublesome subject of accounting; so that when he returns to his work he will be relieved of the former strain. It is from such an angle that the institute enters the field of occupational therapy.

It permits, moreover, no outside exhibitions and sales of articles made by its guests; nor will it allow them until the community, in its relationships with persons nervously ill, shall have discarded the old false psychology and learned the new — until it will no longer view such an exhibition with a breath-caught ‘Is n’t it remarkable? Think, made by the insane! ’ There are, on the other hand, all sorts of stimulating expositions and competitions on the campus itself. We have destroyed the false psychology of our former attitude toward tuberculosis; we can destroy that of our attitude toward mental illness.

When, stiffening my courage with the Jeffers lines, I first went to visit my friend, I little hoped for what I found. Now I go to the institute counting on the solacing effect of the picture of him, following, as he may, the restorative activities with which he feels himself so intimately identified; happy, whether he reads much or little, to have his books about him; pleased to hear the two elderly ladies at their playing overhead; interested to watch from the porch the gardeners preparing other flower borders for their satisfying ends.

And I have come to look on the little apartment I have occupied in the nurses’ hall as a place where my own mind has found healing.

Had I wished to trace the grim history of our failure to work out a humane treatment for the vast tragic company of those who, by the fateful gene or by other disastrous forces, have been thrust into the maelstrom of nervous illness, — had I tried to follow that path across long darkness into this light,— certainly I should have wanted not to minimize the importance of each least past effort by persons within and without institutions to break down the old walls. But, despite their isolated victories, there is still, in this country, a lack of any feeling of confidence that an adequate attack upon the problem of mental and nervous diseases as a whole has been made or will be made through our present type of institutional thinking.

There never has been excuse for our tolerance of unscientific, unsocial practice in the treatment of mental illness. Indeed, our past indifference conspicuously justifies the pessimism of those who see the spectacular advances of science as impotent to affect the intellectual fabric of our civilization; who see, as President Angell does, prejudice, custom, emotion, and instincts of immediate self-interest still largely controlling human conduct, and realize that only by long, slow process of education will the infiltration of scientific thought and method reach the deeper layers of personality.

To-day, in the field of mental illness, there is offered for our education so striking a demonstration of the ameliorating effects of a new psychology that now less than ever is there excuse for our tolerance of malign methods. It is for the public to demand that the principles embodied in such a private undertaking as this which I have attempted briefly to report shall be adopted by state and other institutions across our country. Whatever the new social order toward which we are moving may bring, who doubts that one of its first aims must be to widen the effort to help men to adjust themselves to life, to their fellow men?

It is for the public so to support each endeavor to effect an enlightened, humane technique for the treatment of nervous unbalance that the field of preventive psychiatry will be swiftly widened; that in the care of recoverable cases the new psychology will operate in its atmosphere of hope; and that even at the end of the forest, where the monarch mind is completely exiled, will be felt its mitigating influence.