The Supplement on Disturbed Americans in your July issue struck me as an unusual public service. It is full of interest. One article, however, impressed me as outstanding in its force and originality: “Psychiatric Treatment: Here and in England,” by William Sargant. Dr. Sargant has written of some things that badly need to be known and discussed. It may cause heavy criticism from some sources, but I for one am grateful to you for publishing it. I have seen nothing quite like it in years of following developments in mental health.
Editor, The Courier-Journal
I have read with great interest your Supplement on Mental Illness and am immensely gratified that a journal of such stature as the Atlantic should give us this much attention at a time when we are striving to bring about fundamental changes in the national approach to mental illness. I can only congratulate you on a most stimulating series. It will, I hope, sharpen the interest of a broad spectrum of intellectual leaders in America in the nature of the problems we face.
You, however, would be the last, I am sure, to expect us to be uniformly pleased with the presentations, and I fear that some of them, if taken too seriously, can only enhance the doubts of the doubters that it is possible to put the care of the mentally ill on a truly civilized and scientific footing in our country.
It is unfortunate, for example, that you selected the British psychiatrist Dr. William Sargant to present the picture of psychiatric treatment in the United States today. His biases are well known on both sides of the Atlantic. It is simply not true, as he suggests, that one must be a psychoanalyst to hold high position in American psychiatry. To be sure, substantial numbers of American psychiatrists have undergone psychoanalytic training and utilize psychoanalytic knowledge and insights in their psychotherapeutic work, as do psychiatrists in most, if not all, countries. But only about 10 percent of American psychiatrists — about the same as in England — confine their practice exclusively to “classical” psychoanalysis. Moreover, leaders in American psychiatry, psychoanalytically trained or not, consider themselves physicians first, psychiatrists second, and subspecialists third (that is, psychoanalysts, biological psychiatrists, child psychiatrists, industrial psychiatrists, and so on).
It was distressing to me that Greer Williams, to whom psychiatry is in such great debt for his superb work with the Joint Commission on Mental Illness and Health, attempted to pinpoint responsibility for what was a collective failure to secure the staffing provision in what became Public Law 88-164. I happen to know, for example, that the National Association for Mental Health worked very hard to rally public support for the bill, and so did many leaders in the AMA, not to mention my own American Psychiatric Association. But if one is to rely on the same agencies for a successful future effort, it is well to credit them with honest and “almost successful performance” in the past.
Dr. Bartlett’s thesis about the benefits to be expected from paying mental-hospital patients for nontherapeutic labor has obvious merit. But it is not a new idea, or a panacea. Some mental hospitals, as a matter of fact, do conduct vocational rehabilitation programs in which patients receive some compensation. All of this is constructive. But how much more enticing is the image of a mental hospital as part of a continuum of services in a community wherein the treatment is so prompt, so intensive, and of such short duration that there will be precious little time for elaborate work-for-pay programs!
All in all, the Special Supplement fails to convey the exciting dynamics of the national mental health program, in which psychiatry and the other mental health disciplines are now so deeply involved. It is surprising, for example, that there is no article on the concept and meaning of the “community mental health center.” No one has captured the spirit behind our favorite slogan of the moment — “let’s bring the mentally ill back into the main stream of American medicine” (President Kennedy’s phrase). A number of leading child psychiatrists might have contributed a stimulating piece on the promise of that subspecialty for prevention of mental illness.
DANIEL BLAIN, M.D.President, American Psychiatric Association
Your issue on mental illness was great. The article by Wilder Penfield, even though I knew most of the facts he recites, was thrilling. Sargant’s assault on the psychoanalysts was needed, and convincing. He did not use the American word “racket,”but he certainly implied it. A good job all around!
But one thing was missing. The most important work by far, in the chemotherapeutic approach to problems of mental illness, is being carried on in the laboratories of the pharmaceutical industry. I know something about this, for when I retired from Washington, I went into the pill-making business, convinced that it was one of the most exciting and rewarding activities an old chap could engage in, and so it turned out. There have, for example, been two attacks on schizophrenia that looked very promising for a time, and faded out. There was an attack on alcoholism which promised much, and failed. The real advances, on tranquilizers and energizers, have come from this source. The methods used to explore are fascinating.
While I have been disappointed by recent lack of real progress, for I thought we were on the threshold of great things, I believe it is a pause only and that we will again see chemotherapeutic advance.
Your series of articles on mental illness in the July Atlantic is particularly appreciated by those physicians who have been promoting the transfer of psychiatry to a scientific medical framework as opposed to the predominantly speculative approach Which has usurped the field of psychiatry for so many years — to the great misfortune of many patients.
The more patients know what they should be protected from in medicine — and this particularly applies to psychiatry — the more patients are likely to obtain such protection from their own personal physicians. The public should be repeatedly told that some patients have their mental depression as a result of chronic exposures to small doses of toxic fumes, that “psychosomatic" symptoms causing patients to wander all over the nation from one psychiatrist to another have been dramatically cured when a diagnosis of kidney infection was made and adequately treated, and that an occasional psychotic hospitalized for years has been promptly returned to normal by the administration of thyroid hormone. The public should know that the same mental symptoms can be caused by a number of underlying diseases and, conversely, that diverse kinds of mental symptoms may be the result of different expressions of the same disease, varying from one patient to another. There is no excuse for not screening patients with mental symptoms just as a patient is screened for digestive or circulatory symptoms. When the public realizes the real score, they will insist that real and alleged mental patients be given a proper diagnostic workup by highly qualified physicians, and patients themselves will refuse both diagnostic and therapeutic management unless such a regimen is handled in the same systematic manner as is the rest of medical practice.
MARSEILLE SPETZ, M.D.Eastern representative
Mind: Psychiatry in General Practice
The articles on Disturbed Americans in your July issue are of particular interest to me, having experienced, at different times, both intensive psychoanalysis and shock therapy. I believe I am qualified to make the observation that Dr. Coles’s statement that electric shock therapy is less humane than individual psychotherapy is not just an exaggeration, it is entirely untrue. Quite the opposite is the case. There is no discomfort whatever in properly administered shock therapy, while unaided psychoanalysis involves prolonged suffering while the patient endures needlessly exaggerated anxiety as he gradually faces his inner conflicts, striving to find a way out that carries no assurance of success.
By this I do not mean to imply that shock therapy promises an easy way out. For the treatment of long-standing, incapacitating neurotic difficulties, my personal experience indicates that this is not so. To me, the ideal is a combination of therapies, for a mind freed of anxiety and compulsive behavior can be much more amenable to insight therapy. Psychoanalysts would surely enjoy a much higher rate of cure if they could be induced to overcome their prejudices and gain sufficient understanding of other therapies to be able to make proper use of them supportively. Clinical psychiatrists, on the other hand, cannot feel assured that they have achieved a permanent cure of a chronic disorder unless the patient has the insight into his illness that could be provided by properly administered psychotherapy, so that he can avoid behavior patterns that would encourage relapses or substitute symptoms.
The articles in your July issue confirm the unfortunate hostility between the psychoanalytically oriented and the clinical psychiatrists. Many unfortunate patients are being denied proper treatment so long as this emotional immaturity in the ranks of the doctors results in misconceptions, the hurling of timeworn clichés, and lack of proper understanding of one another’s techniques. For example, it is popular for many clinical men to misquote statements of Freud which they do not understand and which are made to sound absurd by being taken out of context, and to refer constantly to the errors made in the early days when his technique was new. Similarly, and more important, analytic men cry “brain damage” and “cure of symptoms only” as reasons for avoiding presentday shock therapy, of which they, in turn, do not have any understanding. I can testify that my own brain never functioned as well in my entire life as it does now. It is a sad commentary that only luck enabled me to have the advantages of both therapies.
A FORMER PATIENTWellesley, Massachusetts
The Special Supplement on Mental Illness reflects the high standards of public service which discriminating readers have come to expect from the Atlantic.
Without endorsing all of the conclusions enunciated by the authors of the various articles, I know that the total impact of the stimulating views expressed cannot but have a salutary effect in major areas of mental health concern and practice.
I was particularly interested in two points made by Dr. Bartlett in his article, “Institutional Peonage.” They are (1) the author’s criticism of the widespread practice of using unpaid patient labor as a cost-saving device, without adequate regard to the therapeutic needs of the patients involved, and (2) his implied view that the Federal Mental Health Act, in focusing exclusively on community psychiatry — excellent in itself—failed to meet the federal government’s responsibility to assist more directly in raising standards of care and treatment for the approximately half million patients in our state mental institutions.
The Supplement deserves widespread dissemination.
IRVING BLUMBERGLegislation Chairman
New York Slate Association for Mental Health, Inc.
I wish to let you know how refreshing and absolutely accurate I found William Sargant’s article in the July Atlantic; it should be reprinted in the Journal of the American Medical Association. Congratulations!
ROBERT FLEMING, M.D.
A loud hosanna for Disturbed Americans; a hearty and grateful amen for William Sargant’s illuminating and provocative words on psychiatric treatment. Our debt to Freud is great, but is it not time for us to see him in proper perspective, our guide and not our God?
This reader wishes that Donald Fleming (“The Meaning of Mental Illness”) had concentrated on historical objectivity; that he had not assumed a considerably less than scholarly stance in pontificating with the sweeping, unexamined, and undefended generality: “meaninglessness is another name for the inscrutable will of God.” He is guilty of a theologically “obscene perversion”!
THE REVEREND EARLE C. HOCHWALDMiddleton, Wisconsin
Having read most of Donald Fleming’s article, “The Meaning of Mental Illness” with interest and approval, I was disappointed to find him capable of such a crass oversimplification as “the confrontation between Jaspers and Freud is the great contemporary re-enactment of the old conflict between religion and science, for meaninglessness is another name for the inscrutable will of God.”
As a Roman Catholic, hence probably somewhat prejudiced, I would like to plead for the preservation of the distinction between the word “meaningless” and the word “inscrutable.” God’s will, not being bound by temporal considerations, is unknowable for precisely the same reason that the future is unknowable. But since the Catholic view of life is teleological, the will of God, far from being meaningless, promises an ultimately discoverable reason or end for even the most apparently unreasonable of events. As a corollary, Catholicism demands that each man seek to discover what God’s will is for him, which is another way of saying that it not only presumes life to be meaningful but demands that each individual find out, specifically, how it is meaningful for himself.
When the situation is considered in this way, the conflict between religion and science with which Mr. Fleming is concerned does not, essentially, exist; both religion and science have as their object the discovery of order in a world which is, at first glance, rather chaotic.
MARGARET WOODWashington, D.C.
It was a great public service to have published that Supplement on Mental Illness.
Dr. William Sargant’s critique of American psychiatry in the July Supplement aroused thoroughly mixed feelings in this psychiatrist, for like so many critics of the field, Dr. Sargant is devastatingly right but for deplorably wrong reasons.
He succeeds brilliantly in his sociological analysis of the American psychoanalytic scene and perceives correctly the grip of this institution on the mind and heart of the American psychiatric community. His mistake is his failure to distinguish the institution of psychoanalysis as a political entity from the discipline of psychoanalysis as a technique and theory, condemning the latter for its misuses by the former. One might as well blame Christianity for the Inquisition.
Furthermore, he fails to see the differences between analytic psychiatry as a method of investigation of human reality and meaning, and psychiatry as a technique for controlling human behavior, as with the use, or threat of use, of drugs, electroshock, psychosurgery, and incarceration. In this light, the recent achievements of biological psychiatry are open to the same criticism which Dr. Sargant levels at psychoanalytic “brainwashers.” The author is quick to see how tranquilizers are used in American hospitals “merely to mute the cries for help,” but he overlooks the fact that this practice need not be restricted within hospital walls. I am surprised that he does not mention the recent American mental health movement, with which I am sure he would be quite pleased.
Unfortunately, as long as Dr. Sargant persists in his search only for “causes” of mental illness, he will fail to discover and to understand the meaning of “sick” behavior; for behavior, like language, always has meaning, whereas it rarely has “cause.”
I reciprocate the doctor’s horror of the washed brain with my own horror for the leucotomized, shocked, and drugged one. Evidently, if one can convince the recipient of such treatment that it is for his own good, then one can convince oneself that one is rendering humanitarian service. One brain washes the other.
JOSEPH DUBEY, M.D.Syracuse, New York
Congratulations on your symposium Disturbed Americans. Special congratulations for Dr. William Sargant’s article, of which I would like to buy a score of reprints if they are available. As president of the Manfred Sakel Psychiatric Foundation. I waged a futile battle with the psychoanalysts who controlled the American Psychiatric Association, and finally resigned in disgust. Dr. Sakel, discoverer of insulin shock treatment, was a close friend. Through the late Governor Herbert Lehman I obtained for him a license to practice here after he fled from Berlin. Sakel and other eminent physicians declared that many patients were given psychoanalytic treatment when they were suffering from physical diseases which deranged their minds. Another who said the same was Dr. Samuel Seidlin, medical consultant of the Atomic Energy Commission. As pathologist of Johns Hopkins in his younger years, Seidlin performed autopsies on patients who died under psychoanalytic treatment, and he often found pathological conditions which accounted for mental disorder.
The Sakel Foundation attempted to persuade the APA to adopt a clause in its code of ethics that a thorough physical checkup must precede psychoanalytic treatment, but they got nowhere. As Sakel explained it, “When a patient walks into his office it is too much to expect the psychoanalyst to send twenty-five thousand dollars back to his general practitioner for a thorough physical.”
J. DAVID STERNNew York, New York
Dr. Sargant’s article provided most welcome reading, especially to a groping resident in the midst of his psychiatric training. Dr. Sargant’s plea for a more eclectic approach will be well received in many training centers today.
It is therefore regrettable to have to apply the same criticism to Dr. Sargant that he levels at American psychiatry. Dr. Sargant weakens many of his very cogent arguments by his unjustified antipsychoanalytic prejudice. Psychoanalytic theory has not prevented psychiatrists from employing physical and chemical methods of treatment where indicated. Even a cursory glance at admission and discharge statistics in any mental hospital since the advent of psychopharmacological agents proves the wide vase of these drugs. Nor should Dr. Sargant be allowed to go unchallenged when he depicts American psychiatry as being ruled by Freudian analysts. The roster of distinguished and respected leaders of American psychiatry ranges from sociologists to brain physiologists - both of the analyzed and the nonanalyzed variety.
The idea which I found most disturbing is the one in which Dr. Sargant implies that lying down on the couch leads to the loss of rational powers. He carries this thought to the point of suggesting that two of every three professorial appointments be given specifically to nonanalyzed psychiatrists. My own experience with people who have been analyzed has shown that those who were intellectually endowed prior to analysis did not become idiots, and the schnooks remained schnooks. Psychoanalysis seems, in many cases, to have helped people to act more effectively without having made them into mental cripples.
Many of us in training are openly puzzled. We are quite impatient with extremist viewpoints which claim to be on the side of God. I for one have not yet found God, and I suspect the same is true for many of my colleagues. I feel that progress in psychiatry depends on maintaining a flexible and open viewpoint firmly rooted in empiricism. I feel that Dr. Sargant started out in such a manner, but unfortunately, he allowed prejudice to creep in. SAMUEL G. KLAGSBRUN, M.D.
Resident in Psychiatry
Grace-New Haven Hospital
I must tell you my reaction to Dr. Sargant’s article on American psychiatry. I have known for years that psychoanalysts have no place in mental hospitals and that they never should treat psychotics. Never. I had to stand by, a helpless parent, and watch an analyst send my maniacally excited son back into unimaginable hell because she thought she could cure him by joining together his ego and his superego which had somehow been separated. She took his medicine away so she could doctor him more easily, and it was weeks before he could be made comfortable and manageable again.
The first time I saw an analyst at work was in 1955 when my son begged to be sent to a hospital. He could feel the excitement rising in his mind, and he knew where it could be handled best.
The misguided doctor brushed his request aside. “You just want the hospital as a refuge from life,” he said.
Six weeks later, another Freudian-oriented psychiatrist took away the medication which had quieted John’s wildness. He could not believe that a drug could stop hallucinations and the sound of voices.
I was indignant and very outspoken about that removal. It was shocking to find John racing wildly in a seclusion room when he had been so calm and sensible just three days before. So he was returned to the drug, and the same wonderful calm came back. He improved unbelievably, and in a few weeks he was able to leave the hospital for a period of twelve months. Skeptics could say “coincidental remission” until they were black in the face, but the improvement was too dramatically connected with Thorazine for me ever to believe them.
It was seven years later when the next analyst appeared. John’s own doctor went on a month’s vacation, and his place was taken by one of these misplaced experts. John has periods of complete rationality, and this doctor had observed him through one of these. She had never watched John in one of his periods of wildness, but the story was all in his records. She decided as soon as she was responsible for his treatment that she would remove him from all medication so that she could use her skilled therapy to better advantage. The result was dreadful.
When I went to visit John in the hospital, a wild creature was led out from his ward to start kneeling at my feet. Later that day I watched two attendants trying to hold him down in his chair so that a nurse could feed him. The day John’s own doctor returned he found my son tied in a chair which was tied to a post in the dayroom. John had to be restrained, and there were no seclusion rooms anymore for patients as wild as he. This manic excitement was an old story to me. It was common enough in the days before tranquilizers, but utterly wrong and unnecessary today.
Now John is comfortable, sensible, and easy to manage. I know the drugs have not cured his illness, but neither does insulin cure diabetes. And how my heart has been lifted up by Doctor Sargant’s article. Everything he writes is so sadly true.
This miserable, analytical nonsense has spread everywhere, but one place it should never be is in a locked ward. It may be that analysts can help the neurotic, but finding a confidant and pouring out the soul can do just as well in my opinion. A good marriage can also do as well as any analysis. Humans need other humans but not with a panoply of poppycock.
MARA E. MULLIGANSheepscott, Mnine