A Psychiatrist's Choice
If you were beginning your career again, what branch of science or area of research would you choose? This question was put to one of England’s distinguished psychiatrists, the author of standard works in his field and a man who has won recognition as a teacher. His reply took the form of an article which has already been printed in England. A second paper by the same author, “Psychiatry and Spiritual Healing,”will be published in the August Atlantic, and we ask those who wish to reply to hold their fire until they have read both.
IF I were starling again, I should try to re-enter my main field of work: namely, investigation of all the varied physical methods of treatment of the brain and their selective uses in varying types of patient. And I should first of all, before entering psychiatry, try to learn more basic biochemistry, neurophysiology, and electronics instead of concentrating on psychology or philosophy. Or I might seriously consider becoming a neurosurgeon with a specialized psychiatric training. Either way, one’s future would then be more certain as far as finding out how to help the greatest number of nervously ill patients was concerned. Skilled treatment of the mentally ill must still remain the overwhelming priority and concern of psychiatry today. For, first of all, we must demonstrate our abilities to cure our patients before even thinking of daring to advise the world and his wife on their numerous everyday problems.
This may sound a strange viewpoint to the general public, who have now come to believe in large numbers that a practicing psychiatrist is mostly preoccupied with specialized psychotherapeutic techniques and beliefs, often derived from Freud’s work, which have been indoctrinated into him by several years spent on an analytic couch, before being permitted to practice what often amounts to an esoteric mystery with a dominant sexual theme. Psychoanalysis is now no longer always the pursuit of a science, but is tending to include an acceptance of almost rigidly held beliefs concerning a metaphysical psyche, and the mind of the psychoanalyst generally becomes blinkered in the process to advances arising in the various fields of general medicine and surgery and suddenly becoming applicable to the treatment of the mentally ill.
To show the reason for my present attitude of mind, it Is only necessary to look back to the time twenty years ago when I first entered psychiatry from general medicine. The dogmas and techniques of Freud, Adler, and Jung were in existence then and very little different from those of today. They had been practiced in England for some years previously, but had made no appreciable dent in the number of the nervously ill. It is sometimes forgotten how old Freudian practice really is. After the First World War, medical students at one of the London teaching hospitals wore being told by one of the founders of the English school of psychoanalysis that some people were possibly afraid of Zeppelins because they were phallic symbols. No increasing numbers of patients, however, are provenly leaving mental hospitals because of an increasing use of psychoanalytic methods in the last thirty years, and by now it is becoming extremely doubtful that they ever will.
Where, therefore, can one look for hope of more rapid practical progress? Only one mental disease was really being cured in 1934, and that was early syphilis of the brain. This discovery had at last been made when it was shown that the giving of a series of malarial rigors could kill effectively the spirochetes of syphilis in the human brain. Now injections of penicillin can be equally effective. The illness had at one time been called the “moral neurosis.” Little was then known as to its real cause except the patient’s past life, environment, and experiences; and the grandiose and wish-fulfilling nature of many of the symptoms seemed self-evident. Large churches in the hospital grounds are testimony to the only real therapy provided for such patients at that time, who might form up to a third of all those in some mental hospitals. Today, since injections of penicillin given in a general hospital may be all that is needed, psychiatrists may see as few as one of these patients in a year.
I was also taught as a student that the flushings of women at the change of life could result from a subconscious protest at the impending change in their sexual status, and even saw patients being psychoanalyzed for this complaint. Since the discovery of cheaply produced female sex hormones, however, the symptoms can now be cured with the greatest ease and simplicity despite all the postulated efforts of the subconscious mind. Likewise, in the southern states of the U.S.A. a group of persons became neurotic or mad in the spring of each year. They could only be encouraged psychologically to bear the apparently obvious precipitating burdens of poverty, poor food, and dismal homes. The discovery of vitamin B2 now allows a simple drug to be given them which cures their mental symptoms despite their poverty and environmental stresses, until more vitamins become available to them in the growing crops.
It is certain that many other major types of mental disorder will eventually be found to have a physical basis. Schizophrenia or “split mind” also used to be explained to me as being due to a subconsciously motivated withdrawal from reality, and states of depression are still taught by some as being the late results of breast frustration in infancy. But up to 70 per cent of patients treated in the first three months of an attack of schizophrenia can now have their symptoms relieved by a series of insulin comas, and a few electrically induced epileptic fits can quickly remedy a severe state of mental depression. Psychological dogma and psychiatric treatment have, in fact, started to become wildly at loggerheads, and only the Freudian faithful in psychiatry can still apparently ignore such discrepancies between their beliefs and presentday advances in physical treatments of the brain.
An excellent example of this discrepancy is seen in the problem of chronic pathological anxiety. Again the subconscious mind had to be called in as usual to explain this phenomenon. Convulsion therapy, too, while relieving depressions can make such anxiety states worse. But now it is being shown that the cutting of one special tract in the frontal lobes of the brain can reduce crippling chronic anxiety without any impairment of the patients intelligence, and the theoretical subconscious can be forgotten. Such operations arc therefore being used even in the chronic neuroses; and in severer cases of mental illness nearly 10,000 frontal lobe operations have already been performed in England, resulting in about a third of those hitherto considered incurably insane being able to leave their hospitals.
Epilepsy, also previously treated by attempted exorcism of the Devil, is now being controlled by ever more efficient chemical anticonvulsant drugs, and sometimes by operations on the brain to cut out small damaged areas where abnormal electrical discharges are occurring, which may fire off a major fit. Operations may soon be expected to reduce or abolish imaginary voices or hallucinations that play such a part in creating madness because of their understandable reality to the patient experiencing them.
THESE are some of the actual types of practical treatment measures being worked on in psychiatry today by many who are far too busy to beat the propaganda drums, discuss sex symbolism in Bloomsbury, or claim in theory to be able to prevent future wars by better child guidance clinics.
All this practical progress, of course, brings no satisfaction at all to philosophers in our midst — rather the reverse. They demand theories and explanations of how such physical treatments work before accepting them, and wish to continue increasingly fruitless arguments on the body-mind relationship. But it took many hundreds of years to find out why an environmentally determined disease like malaria could be cured by Jesuits’ bark (quinine), or scurvy by lemons. This was because microscopes were not available during all this time to see the parasites in the blood stream, and vitamins had not even been thought of. As scientists, we must be prepared to wait perhaps another hundred years or more before even starting to learn how the human brain really works. I would not change my present line of work because we are only at the very beginning of its possibilities rather than near the end of an already overcxplored and dogma-ridden field.
There is also the very urgent problem to be worked out of trying to achieve some sort of practical synthesis between already provenly valuable methods of psychological and spiritual healing and the newer physical ones. For all methods of treatment must be used, and combined if necessary, which are shown to help any patient in a practical manner. Patients must certainly never be deprived of any treatment because of as yet unproven dogma, theory, or belief as to the causation of the various types of mental disorders.
The psychiatric treatment problem at home is a desperately urgent one. Half the total hospital beds in England are still filled with psychiatric patients. The suffering involved is unimaginable to those not themselves mentally ill. It has been predicted that 70,000 persons now living in Greater London alone are, for instance, fated to kill themselves, mainly because of mental illness and sometimes solely to avoid having to go into a mental hospital. Even hopeless cancer patients rarely suffer to the point of setting out to destroy themselves deliberately as do the mentally ill even in the earlier stages of their illness.
Research has also hardly begun in prisons, where few specialized physical treatments of the brain are as yet used. Psychotherapy and religion are provided ; but current psychotherapeutic methods can never even dent the criminal treatment problem, just as they have failed in the psychiatric field, if only because of the large numbers involved, while religion has lost its sense of certainty, which was its most valuable treatment weapon.
The criminal field is now lying open to major advances and new lines of research once present policy is broadened. What is needed is to provide better research and treatment facilities in the now admittedly hopeless impasse that has been created by too much concentration on sometimes wrong objectives. As only one example of future possibilities, it is now known that crimes of impulsive violence are not only committed mostly by young persons, but by those whose electrical brain waves show a defect in normal brain maturation for their particular age. The broken and violent childhood home from which they so often come may not be the cause but often only evidence that this particular brain defect is an inherited abnormality from one or both parents. The abnormality generally rights itself by the age of forty, and impulsive violence then dies down for no other apparent reason. Simple drugs will almost certainly be found to correct this inherited form of delayed maturation process in the brain of such people, who may be of normal intelligence but have all the impulsive and selfish emotional responses seen normally in very much younger children.
The legal mind is inclined to laugh at psychiatry. But if facts are of importance before passing judgment, it might first wonder why the ordinary mental hospitals today contain many more violently antisocial people than the prisons, many more potential murderers and disturbers of the peace, who are handled with half the fuss and bother, and allowed in or out of hospital according to their prevailing state of mind and behavior. Furthermore, they get skilled treatment rather than punishment for their abnormal behavior, in addition to essential short or very long periods of compulsory detention.
No PERSON with any sort of skill in medical research can help making some sort of contribution to this whole new field in his lifetime, judging by the happenings of the past twenty years. But so deep is the present cleavage between concepts of mind and body that even among doctors themselves too few have the sense to see it. Also, psychiatry has had its status altered in recent years by the increasing number of more talkative, philosophic doctors flooding into it as a refuge from the concrete scientific approach now demanded by general medicine and surgery. These do too much of the talking at present and too little of the actual treatment of the mentally ill. They could have remained very happily in the general medicine of old, since most diseases could then be so easily and so convincingly explained to the patient by an interaction of metaphysical forces akin to the modern superego, ego, and id, though at that time they were thought of in terms of “humors,” “vapors,” or “innate heats.” Patients did not recover with the treatments based on such philosophical theories, but it still took centuries to get rid of them because they were so attractive to those who still demand or must give a plausible explanation for any sort of observable phenomenon.
It is a pity that medical philosophers have had to seek an asylum in psychiatry in more senses than one, for psychiatry’s main proven hope of practical progress is to return to a general medical outlook instead of seeking to create an ever-widening gulf between medicine and itself. It is too often forgotten that medicine has been able to make its spectacular advances in the last hundred years only by deliberately giving up all-embracing metaphysical theories, seeking for empirical physical remedies, and then perhaps only many years later finding out how and why they work. Even now we do not know how penicillin or insulin really acts, though the lives of tens of thousands have already been saved by them.
Another reason why I would not change my present and admittedly “limited” research viewpoint is due to a present paradox in medical research. Everybody realizes the importance of taking into account the “whole” man and his environment. Yet far greater practical progress has actually been achieved by deliberately neglecting this obvious truth and first studying perhaps the blood, liver, heart, brain, or chemical changes occurring in the body regardless of thousands of happenings that may all be influencing these in theory. When we have learned how to make the unstable brain and nervous system more capable of withstanding environmental stresses, better able to think and learn from experience, or be indoctrinated successfully if needed, I personally would then be prepared to hand it over to the philosophers, priests, and politicians, and let them carry on in their own fields what is essentially their proper work. Today too many psychiatrists are neglecting the brain itself and trying to interfere in functions outside the proper province of medicine; while men of God, philosophers, and politicians are working on the theory that better religion, better houses, or larger prisons can remedy the badly functioning brain.