Schizophrenics Can Recover
Assistant Director of the Children’s Hospital Medical Center in Boston, GREER WILLIAMS served for fire years as Director of Informal am of Ihe .Joint Commission on Mental Illness and Health. A professional writer and medical public relations consultant, Mr. Williams was the editor of ATION FOR MENTAL HEALTH,the commission’s report to Congress, which was published in book form by Basic Books last spring, He is the author of VIRUS HUNTERS and the article “ The Dejection of Ihe Insane,” which appeared in the ATLANTIC Supplement on Psychiatry last July.
FEW of us are immune to the urge to reveal a feeling of the truth within us and thereupon blow a small blast on the trumpet. The impulse came to Alfred H. Stanton, now one of Harvard Medical School’s professors of psychiatry and chief of Boston’s so-called “country club of mental hospitals,” when he was still in his thirties.
The scene was Chestnut Lodge Sanitarium, a private mental hospital near Washington, D.C., the stamping ground of the late Dr. Harry Stack Sullivan, Stanton’s teacher and a believer in the idea that schizophrenics can be helped to recover by friendly manipulation of their relationships with other persons. Stanton had been observing his first successes with such patients and was elated. “Damn it, Harry,” he said to Dr. Sullivan. “Schizophrenia is not all that tough. It should be easy to cure. We have been missing the point.”
Sullivan was attentive. “What makes you say that?”
Stanton suddenly felt helpless. He could not remember the point.
The master was impatient. “Go on,” he said, “don’t stop. You were getting ready to say something.”
Dr. Stanton, now forty-nine years old, big, boyish, arch in manner and tentative in his opinions, still cannot specify the point, precisely. He has treated scores of schizophrenics, and as psychiatrist in chief of McLean Hospital, a division of world-famous Massachusetts General Hospital, has taken administrative responsibility for hundreds of others. He can lecture for hours at an abstract level on what is known of schizophrenia and its treatment. Yet he leaves it wholly clear that the cause and cure are still research problems of the first magnitude.
Nevertheless, great progress has been made in the treatment of this strange mental disorder. Dr. Stanton, as a leader in the field of social psychiatry, is an excellent example of the small but increasingly honored group of psychiatrists who have chosen to slight the world of neurotics anxiously clamoring for attention in order to treat the thorniest type of insanity, schizophrenia.
This disorder, according to some rough estimates, affects perhaps one million Americans, about 300,000 of whom are in mental hospitals at any given moment. A functional disorder, called that because no structural defect has been discovered, schizophrenia tends to make those whom it strikes resist rather than seek help. It occupies a position among disturbances of the mind similar to that which cancer occupies among diseases of the flesh, except that uncured schizophrenics live on in state institutions, like unreasonable skeletons in the human closet.
The doctors of schizophrenia have certain significant characteristics. They appear stupendously egotistic, unafraid of madness, cool in a battle of wits, impervious to insult, and they maintain a cheerful imperturbability reminiscent of a glacier in a bright spring sun. “You have to be kind of crazy yourself to treat schizophrenia,” remarked one of them. “It does make a freak of you.” Their patients comprise some of the coldest, oddest, most trying and unpleasant people on earth. What usually brings the schizophrenic to a hospital is the fact that he becomes impossible to live with. He is equally difficult to treat.
Doctors like Stanton treat their patients in group medical settings hospitals, clinics, day hospitals, or mental health centers — rather than in private offices. They are, for the most part, trained or interested in Freudian psychoanalysis, but do not believe, as do most psychoanalysts, that schizophrenics are beyond their reach. Nor do they believe, as do many psychiatrists, that the best way to bring the patient back to health is to submit him to a series of electric shocks. They do not go overboard on the use ol tranquilizing drugs, though they sometimes employ them.
They hold, instead, that many acute and some chronic schizophrenics can be helped to recover through a long series of individual talks combined with a temporary stay in a controlled environment, plus proper aftercare or rehabilitation. The psychiatrists of schizophrenia ordinarily sit face to face with the patient. In this position, it often becomes a question of who has greater endurance, the doctor or the patient.
Of the nation’s 12,000 psychiatrists, perhaps 4000 are up-to-date doctors of schizophrenia. Here we come to the essential dilemma of psychiatry: patients with major mental illness march on the intensive treatment centers in battalion numbers. There is an overpowering need to heal them on a mass basis, in the absence of sufficient technology to do so with the professional staff at hand. The therapist must have answers at the time when the scientist is only prepared to laise questions.
Most doctors, including the majority of psychiatrists, regard schizophrenic patients as unpleasant to be around and a waste of valuable time. Most believe the disease to be an organic one (perhaps connected with genes or acids or enzymes or fats or hormones), of origin as yet undetermined. Psychoanalysts and psychologists favor purely psychological explanations. Some experts judge schizophrenia to be a combination of family tendencies, undesirable habits of behavior, and social stresses. Some sociologists and psychologists, newcomers to the medical team, believe it to be not a disease but an educational problem, the product of some subtle miscarriage of learning resulting in deviant behavior. The psychiatrists of schizophrenia themselves do not agree on whether it constitutes a group ol diseases or merely symptoms ol some underlying disease. The one thing that they do agree on now, after a century of pessimism, is that schizophi enia can be successiully treated in many instances.
THERE is no lack ol descriptive (act about schizophrenic behavior. The “split mind characteristic of schizophrenia resembles the indecision we see in our associates in everyday life, except that in the patient it is carried to some crippling extreme.
Most of us know the funnier and also more terrifying aspects of schizophrenia, the business ol talking and listening to someone who isn’t there, the silly gesturing and posturing, the bizarre acts or social responses that are wholly out of place. The stereotyped “raving maniac” occasionally makes the headlines because he commits homicide.
We are likewise aware of the paranoid schizophrenic and his delusions of persecution (“ The Commies are after me”) and of grandeur (“I am the Virgin Mary”). We know many people who behave as if the world is conspiring against them, but few go to the same lengths as the paranoid who keeps a secret diary with a duplicate copy in a locked box and gets off a fifteen-page letter now and then to J. Edgar Hoover. This kind of insane person just will not take the chance of trusting anybody.
At least half of the schizophrenics have some spectacular hypersensitivity, a delusion or hallucination, but the simplest and most prevalent characteristic might strike the average person as just laziness or stupidity. There is an increasing self-centered ness and withdrawal from social contact. Another and equally fundamental characteristic is loss of sell-identity and self-esteem, a trend paradoxically opposed to the effort to find satisfaction entirely within oncself. this process of gradual self-extinction manifests itself in suicidal impulses and sometimes in delusions of disembodiment (“I have no stomach.” or “I have lost my body”). In sum, schizophrenia may be perceived as one kind of attempt to handle the human fear of being unloved.
The disorder always involves some loss of sellcontrol — loss of toilet training in extreme cases but it seldom, if ever, involves the total mind. Healthy areas remain, and in treatment offer a road back. Often the educated, intelligent schizophrenic retains an exquisitely tragic insight. One scholarly McLean patient trying to describe his feelings of emptiness murmured Latin. ”Cogito, ergo sum. Aon cogito” (“I think, therefore I am. I do not think”). The inference was plain: “I am nothing.”
The schizophrenic is also skilled at reading another person’s feelings, particularly the meaner ones. Dr. Stanton tells, for example, of a young psychiatrist who inwardly felt like kicking out an uncooperative woman patient after she refused, hour after hour in psychotherapy, to answer his questions. Suddenly one day she asked, “Why do you wish to kick me out?” He protested, but she merely stared fixedly at his foot, which was bobbing up and down in a kicking motion. It was enough to drive the young man deeper into his own training psychoanalysis.
Until the rise of psychoanalysis, the thoughts and acts of a crazy person were considered to be meaningless. But Sigmund Freud insisted that the schizophrenic’s symptoms had special meanings for him. Out of subsequent studies emerged the theory that, just as the milder neuroses were indications of emotional immaturity or childish feelings, so schizophrenia constituted a regression to infantile levels of development. A baby behaves as if the world revolves around him, as in fact his world does, normally. He feels simultaneously small and helpless, and strong-voiced and omnipotent. The schizophrenic behaves the same way.
The neurotic, and also the normal person, to some extent, is skilled at putting unpleasant or disturbing impulses or anxieties completely out of his conscious mind, through the psychological mechanism of repression. But the schizophrenic, and perhaps the normal person of schizoid personality, may at times be conscious of his unconscious and thus destined to proceed in full view of his shockingly primitive fantasies of love and hate; often they burst into his mind in obscene or perverted ways, though he rarely carries them over into action. More likely, they will frighten him into retreat from other people. It is little wonder that this mysterious malady produces such a gloomy, misanthropic aspect.
Unfortunately, there is no exact knowledge of the mechanism that causes regression. Lack of mother love and insufficient self-expression of anger in childhood have been indicted, but not all unmothered or rigidly disciplined children become psychotic in later life. Nor do particular social or psychological stresses explain much, for most of us undergo similar stresses without breaking down. What we see, vaguely, is that the person who lacks a proper balance of self-love and of brotherly love borrows trouble. Most of us somehow learn that the roads to social success and to good mental health are paved with the same brick — with wanting to do what we have to do. For some reason, the schizophrenic balks at doing what society expects of him.
Progress in solving this essentially social illness through psychotherapy appeared blocked insofar as psychiatrists held the original psychoanalytic position that it is impossible for the doctor to form a working relationship with an irrational, resistive psychotic. Here and there over the years, an isolated psychiatrist exploded this notion; for example, the late Dr. Frieda Fromm-Reichmann established a new beachhead at Chestnut Lodge by demonstrating that it was possible to achieve rapport with a schizophrenic and treat him in a modified psychoanalysis. To win the patient’s confidence, it was necessary for the doctor to forget his own dignity and authority and weather various rebuffs and much abuse. It was also necessary for him to learn intuitively to think as the patient did, in order to understand and change him.
Dr. John Whitehorn of Johns Hopkins Medical School in Baltimore, who got his early experience at McLean, was among the first to suggest tailoring the doctor to the patient, He observed that some psychiatrists get much better results with schizophrenics than do others. The more successful, he speculated, had a lawyerlike attitude, a tolerant expectation that people will misbehave, a readiness to debate right and wrong, and a kind of matter-of-fact, no-nonsense approach to life.
Meanwhile, it became evident - - and was a source of some alarm to traditional physicians that not only some clinical psychologists but others not medically or psychologically trained were having similar successes in leading hospitalized schizophrenics back to reality, often alter years on back wards. There were occasional reports of a physical or occupational therapist, a nurse, a social worker, an attendant, or even a volunteer worker with this mysterious X factor, a healing touch for the insane.
IT WAS in the midst of this quiet ferment, occurring largely in the post-war decade and involving only a few institutions, that Dr. Stanton made an original contribution at Chestnut Lodge. It was inspired by the then emerging interest in group therapy.
Do patients living on the same mental-hospital ward sometimes get better at the same time? Nurses whom he asked said yes. But, he recalls, there was a slightly embarrassing corollary: “They also get worse at the same time.”
Stanton asked that he be reassigned as administrative head of a single ward. The research program of the National Institute of Mental Health was just beginning in 1949. He applied for and obtained a grant to make a study, and found a kindred spirit, Dr. Morris S. Schwartz, now professor of sociology at Brandeis University, to collaborate with him. The two, who became known to patients as “‘Mutt and Jeff,” because of their contrasting heights, went on to produce a study culminating in 1954 in the publication of a 500-page book, The Menial Hospital. This work started a whole new era of psychiatric soulsearching in America. Indeed, the broad philosophy of Action for Mental Health, the 1961 recommendations for a national program, emanating from the Joint Commission on Mental Illness and Health, may be traced to it.
Stanton and Schwartz turned a critical eye on how doctors and nurses affected patients and documented the possibility that, at best, even a well-staffed mental hospital operates only as a part-time healing institution; the rest of the time the hospital does things that make patients worse rather than better and thus defeats the purpose of individual psychotherapy.
It was well known that staffs of mental hospitals were habitually impatient with patients, treating them as something less than human beings and thereby reinforcing instead of reversing the schizophrenic process of ego destruction. The humanitarian idea of turning the mental hospital into a therapeutic community already had taken hold in Great Britain, but the American social psychiatric team were not aware of it at the time. They were the first to do an intensive scientific study of the institutional impact on mental illness.
Stanton noticed that one patient was apt to form a center of attention in the ward, creating a disturbance by screaming, kicking, biting, or threatening suicide, or displaying excessive sexual excitement and active delusions. He elected to look not at the center of the conflict but at the staff and the other patients. What he saw was a covert disagreement among staff members on how tire particular patient should be handled. When the disagreement was resolved, the patient’s condition improved as if by magic, often within a few hours.
One case, showing how subtle the conflict may be, was that of a twenty-three-year-old woman who had been in the hospital for twenty-two months. She either stayed by herself or babbled to others incessantly, in a pressure of speech known in psychiatric slang as a “word salad.” Efforts to discover what, if anything, she was driving at failed until, one day, Stanton was struck by her repetition of the word “clothing.” Was she mixed up about her clothing? She nodded hastily but became incoherent again.
In a painstaking investigation of what it was about her clothing that bothered her, Stanton had the superintendent of nurses show the patient where her clothes were kept, in a locker, and said, “Tell her all about them.” Later he asked the nurse if she had done so. She said that she had.
A temporary improvement was noticed in the patient, but she relapsed. Half in jest, the doctor told the superintendent of nurses that it must be that she had not straightened out the patient on the matter. She bridled and said that she had told the patient everything — except, of course, about the things the patient had torn up when she first came to the hospital. These had been discarded. Why hadn’t she told the patient about these, too? Because, she replied, he had ordered her not to. As she said this, she suddenly realized that it was not the ward administrator but the patient’s psychotherapist who had given this order.
Stanton then overruled the therapist and asked the nurse to tell the patient the full story. As a result, the patient’s disturbed state rapidly vanished, and she now was able to carry on a conversation. She had forgotten about the dresstearing incident, which had occurred at a time when she was acutely excited, but was bothered about the loss because her family had to watch every penny, and her hospitalization already was costing more than they could afford, she said. This woman soon recovered and left the hospital, not to return.
It is important to the patient’s chances of recovery that everybody in a mental hospital, from the medical superintendent down to the lowliest attendant, work together.
FOR nearly a hundred and fifty years, the wealthy of Boston have gone to McLean Hospital to have their mental breakdowns. Before Stanton’s coming in 1955, McLean was very much the old-line strait-laced mental institution, as Boston banker Ralph Lowell, a leading M.G.H.—McLean trustee, is the first to acknowledge. The success of electricand insulin-shock therapy, which restored complete lucidity in schizophrenics who had been hopelessly demented for years, had brought a wave of optimism, but there were repeated relapses despite repeated treatments. So McLean had continued to put patients away for safekeeping as comfortably as possible until they died. When Stanton’s predecessor retired, the trustees came to the conclusion that the primary function of the mental hospital was to experiment with new methods. Dr. Erich Lindemann, the new M.G.H. chief of psychiatry, recommended Stanton to the Harvard Medical faculty, and he was summoned.
The modern McLean embodies the best that psychiatry can offer for those who can afford it; these, Stanton emphasizes, include not only the wealthy but upper-middle-class families. In 1960, with an average daily patient census of 210, McLean had twenty patients going to college while living in the hospital; one man got his law degree. An additional sixty-three patients spent their days at the hospital and their nights at home. About 120 inpatients were receiving individual psychotherapy three or more times a week, and about 100 had ground privileges.
Stanton does not believe in the present mentalhospital vogue of a completely open door, begun in Great Britain. Some patients want and need locked-ward protection from their own inability to control themselves, but the privilege of passing through the locked door is freely granted as the patient wishes it and his condition permits. Thus, some can sign out, as one did recently: “Destination: Beantown, U.S.A.” This might well have been, technically, a “chronic schizophrenic female” planning a little shopping in Filene’s Basement.
Scenery is not as important as the group therapeutic process, but in this respect, McLean has a head start in making the business of getting well as attractive as possible. For the last sixty-six years (the original Asylum, Massachusetts’ first hospital, admitted its first patient in 1817), McLean has occupied 380 acres of the choicest real estate in suburban Belmont. Its patients live in groups of from thirteen to twenty-three, in sixteen old Georgian mansions, each under the administration of a psychiatrist and each providing a dining room and living room as well as a private room for each patient. These halls, plus a much newer biochemistry laboratory and a score of other buildings, are pleasantly placed at the summit of rolling, wooded hills and meadows overlooking the Charles River.
McLean patients pay $38 a day for hospitalization and psychiatric treatment; this amounts to $266 a week, or $3458 for the average threemonth stay (the average in all American mental hospitals is about eight years). Dr. Stanton points out that $3458, a middle-range price for a new automobile, is not beyond the reach of a typical iamily with a salaried income, provided it is a one-time expense. The patient’s family is expected to pay, but if this becomes impossible, the policy is to keep the patient as long as there is a reasonable hope for successful treatment. The hospital in 1960 gave $358,000 in free care, equal to about twelve per cent of the total patient income of $3 million. The net operating deficit was $144,000.
Commonly, the patient is hospitalized for whatever time is necessary and then carried as an outpatient for continued psychotherapy, at $5 to $35 per treatment hour. It is easy to see where the high cost of treatment lies; it is in McLean’s ratio of three employees to one patient, as compared with one employee to three patients in the average state hospital. McLean has fifty staff psychiatrists (plus twenty-odd in training), more psychiatrists than can be found in any one of a score of states. As a matter of fact, the good therapeutic example set by McLean and other leading intensive treatment centers merely compounds the mental-health manpower problem; McLean has demonstrated that the ideal way to treat a patient is not with one psychiatrist but two (ward administrator and psychotherapist), plus a specialist in internal medicine, psychologists, nurses, social workers, and others.
Female patients outnumber male ones at McLean two to one. Obviously, a breadwinning husband is able to afford private care for a psychotic wife more readily than the reverse, unless they are independently wealthy. While McLean’s patients under twenty years old increased from sixteen to thirty-four last year, a third or more of its patients are older women who have been in the hospital five years or more, at $13,870 a year.
While the cost of topnotch psychiatric care is not out of fine with general hospital care for physical illnesses, extended treatment for psychosis is financially impossible for most people. McLean offers no solution for the mass-production problems of state hospitals, handling 80 per cent of all mental patients at an average cost of but $5 per patient a day. Its main value in the care of patients is, as its trustees concluded, as a research and teaching center.
A question still remains as to what kind of results a combination of psychotherapy and good social treatment can produce. If one takes any kind of capacity to five in the community as good and hospitalization as bad, then there is every indication that the results of modern psychiatric treatment are at least as good as those in any other major degenerative disease, and indeed, better than those in some. In 1960, McLean admitted 326 patients and discharged 346. Of the latter, 71 per cent were judged improved or recovered and returned to the community, 7 per cent died (at an average age of eighty-four), and 22 per cent were unimproved and sent to another hospital.
More than 40 per cent of the McLean patients have schizophrenia. The hospital’s general experience is that 85 per cent with this disorder respond to treatment well enough to return to the community within one year of first admission. Although the doctors of schizophrenia tout no panacea for this strange illness, the experience at McLean and some other intensive psychiatric treatment centers explodes the myth that schizophrenia is a hopeless, incurable disease requiring the victim to be removed from human society for the rest of his life.