Psychiatry Today

by WILLIAM C. MENNINGER

PSYCHIATRY is in a state of flux. It is becoming involved in many aspects of life that were considered foreign to it even a few years ago, and public resistance has changed to public demand for more and more psychiatric help. It is commonplace now for intelligent people to consult a psychiatrist about family or personal problems, long before they reach a stage of acute mental distress. The public responds immediately to each new radio program about psychiatry and to every item in the barrage of articles (some fine, some very poor) which appear in the daily press and the popular magazines. One passing reference in a syndicated article resulted in more than a thousand letters to the agency it mentioned, begging for answers to personal problems.

Mental illness was explained as witchcraft for so long that patients and their relatives are still subject to a deep-seated fear and horror of mental illness and to shame at its discovery. In common parlance the mind and the body are discussed as if they were two distinct and unrelated entities. The practice of psychiatry is still handicapped by the tendency to misjudge and misinterpret unusual human behavior instead of appreciating that that behavior may be evidence of maladjustment. This applies equally to criticizing the soldier who breaks down in combat, the clerk who comes late to work, the boss who is hyper-irritable, or the youngster who steals. Until education has succeeded in overcoming emotional prejudice the practice of psychiatry will continue to face these handicaps to its most effective utilization.

Psychiatry as a body of knowledge has grown tremendously. The theories and findings in psychoanalytic psychiatry have contributed a dynamic concept of the personality structure and physiology. The concept of the unconscious as a major portion of every personality, from which the powerful primitive energy drives spring, has become a fundamental consideration in understanding and interpreting all types of behavior. The automatic mental machinery, called defense mechanisms, which permits us to express the primitive energy drives, sometimes in healthy ways, sometimes as symptoms, gives an understandable basis for human behavior. It has presented conclusive evidence of the varied effects of certain kinds of training and experience in infancy and childhood. On the basis of such knowledge, psychiatrists can now postulate the preventive efficacy of some few principles that underlie human relationships. All these and many other new and helpful findings have increased our understanding of personality.

From concern with the individual as a biological unit psychiatry has progressed to a consideration of him as a social unit. More than any other branch of medicine, psychiatry has to be interested in the environment in which a person functions, as well as in the person himself. It has to accept as basic the fact that the emotional difficulties of any one person always involve other people. Consequently, it is not merely a matter of studying the blood or the X-ray or the physical pathology of the person. It involves investigation into the environment in which he lives, his family, his friends, his job. Psychiatry has become a social science as well as a medical science.

There are many specific areas in which psychiatry as a science has made conspicuous progress in addition to its understanding of the anatomy and physiology of the personality. It is gradually but definitely improving and clarifying its concepts of specific mental illnesses and its terminology for use in diagnosis.

New methods of treatment

In regard to treatment methods, psychiatry has made enormous gains. The trend has been toward intensification and consequent shortening of treatment, and toward discovery of new methods.

The method known as “psychotherapy” is the process of giving psychological understanding to the patient through his discussion of his problems with a physician who then interprets their meaning and suggests or supports the patient’s solution of them. This technique has received special study and improvement. There likewise have been improvements in physical treatment measures and in neurosurgery as applied to psychiatric patients. There is a keener recognition by both laymen and psychiatrists that early treatment can be much more effective than that which is delayed until the illness has become acute.

One of the most valuable gains in the treatment of hospitalized patients has been the wider use of ancillary treatment methods that are classified as occupation, education, and recreation. There has been considerable progress in making the prescription of all these different therapies specific for each individual patient. Major developments have been made in group therapy — treating several patients at one time. Where this is done chiefly through the medium of group discussion, it is known as group psychotherapy. Special values are being found in music, art, and drama as adjunctive treatment. No longer is psychiatric treatment merely a matter of custody, of keeping the patient busy or of giving him superficial encouragement through platitudes.

Another pertinent fact is the shift in type of work. In 1920, 76 per cent of the psychiatrists were devoting their full efforts to the care of patients in state and Federal institutions. In 1946, this number had fallen to 62 per cent, reflecting the fact that nearly 40 per cent are now in private practice or working in areas other than strictly mental institutions. Psychiatry has moved out of the massive mental institutions where only those individuals with the more severe types of mental illness are cared for. It has moved into many general hospitals, outpatient clinics, private office consultations and practice. One can speculate upon the possible far-reaching significance of this shift: namely, the eventual maintenance at an even level of the total number of persons who must reside in our mental hospitals at any one time. Theoretically, it could even decrease that number.

At least this was the experience in the Army. At the beginning of the war, psychiatrists were placed only in hospitals. Since anyone unable to go on duty was sent to the hospital, patients were admitted who in civilian life would not have gone to a hospital and perhaps not even consulted a physician. Once admitted to an Army hospital, too many psychiatric patients were entirely unable to return to active duty. By the end of the second year of the war we had psychiatrists in the field, in mental hygiene clinics where, for every patient whom they had to refer to the hospital, they saw nine men who remained on duty.

The psychiatric team

The “ team concept ” in the practice of psychiatry has been developed extensively within the last five years. For the most satisfactory outpatient psychiatric practice, a team is required consisting of psychiatrist, clinical psychologist, and psychiatric social worker. If the patient is hospitalized, the team is enlarged to include the psychiatric nurse and the psychiatric therapist who carries on occupational, recreational, and educational activities. This system permits a more comprehensive treatment program than that in which treatment is limited to interviews with the patient.

This concept of relationships in the practice of psychiatry is not new. Psychiatric social workers have assisted psychiatrists for thirty years. Clinical psychologists have made contributions in psychological testing techniques for even a longer period. But until recently the staff’s of only a very few psychiatric institutions, either hospital or clinic, have functioned on the team basis.

Like many other developments, the military experience gave this arrangement a major boost through making it, not without difficulty, “standard operating procedure” in every military hospital and clinic. The majority of our psychiatrists who had never worked with social workers or clinical psychologists learned how to make the most of their services. Most of our clinical psychologists who had never worked in a hospital or directly on a psychiatric team learned to work in that relationship. The net result has been a definite improvement in the practice of psychiatry, civilian as well as military.

Psychiatrists in the field

From their comparative isolation, psychiatrists have emerged from their hospitals and their offices to serve the community in various ways. They have ventured into the field of criminology and penology. At least ten of our adult criminal courts now have either a fullor part-time psychiatrist to aid the judge in his decisions about criminals. The great majority of our more progressive juvenile courts have enlisted the fullor part-time aid of the psychiatrist and clinical psychologist and social worker. All our Federal penal institutions have psychiatrists in so far as such professional personnel can be obtained. Even a few of our state penal institutions avail themselves of psychiatric advice and counsel.

Psychiatry has made some beginning steps into the area of public health. For many years there has been a mental hygiene division in the United States Public Health Service. Through its initiative and under its leadership, Congress passed the National Mental Health Act last year. It undoubtedly will be a major impetus to the improvement of national mental health through the provision of funds for state and community psychiatric projects — outpatient clinics and improvements in our state hospital practice. Under this act, grants have already been made for psychiatric research and for the improvement of the educational program in medical schools and other psychiatric training centers. The act needs to be extended to provide funds for physical facilities for treatment and research and training, currently one of the chief bottlenecks in the progress of psychiatry.

A psychiatrist is a member of the Department of Health in five of our states. Seven other states have a mental hygiene program under some special unit or division of their government. In an additional five, a psychiatrist functions under the Department of Public Welfare. In most of these state public health programs for psychiatry, a chief responsibility has been the state hospital system. In some, outpatient clinics have been created. In a few, some effort has been made in the development of statewide programs of mental hygiene.

Psychiatry has made some excursions, uncertain and totally inadequate, into other everyday problems to which potentially it can contribute. Specifically, several industries have taken on full-time psychiatrists to help with their personnel problems. At least thirty of our universities or colleges have a psychiatrist who acts as a mental hygiene counselor. An increasing number of universities and colleges are providing courses in mental hygiene for their students.

Psychiatry has made a small contribution to the field of academic education. In this instance, much of the progress has been made because informed educators have sought the help of psychiatric knowledge as it relates to teaching procedures. Many teacher training colleges now offer courses in child development, emotional as well as physical.

Coöperating with the medical man

The status of psychiatry in its relation to medicine is one of a much closer coöperation than even ten years ago. Although psychiatry was born in, and for years remained confined to, the isolated asylums and state hospitals, it now has become a functioning unit in many of our general medical and surgical hospitals. Often psychiatric patients are given beds on general medical services; in many hospitals there is at least one special psychiatric ward, and there is usually a section in the outpatient clinic which is devoted to the treatment of psychiatric patients. Psychiatrists are increasingly included in group-practice clinics.

In the Army and Navy during the war, doctors of all specialties found themselves working together closely; psychiatric consultations were used extensively on medical and surgical wards. The association of these physicians was healthy and beneficial not only to psychiatry but to the other branches of medicine.

This association in military experience has carried over in some degree into civilian life. Through the vision and determination of Dr. Paul Hawley, director of the medical services for the Veterans Administration, and Dr. Daniel Blain, the inclusion of psychiatry in the general hospitals has been adopted as the standard organization for all the Veterans Administration hospitals. In several university hospitals psychiatry is practiced and taught not in a psychiatric pavilion but on a general medical ward. At the last annual meeting of the American College of Physicians, the leading group of internists in this country, a half-day discussion was devoted to emotional factors in illness. That same organization is now sponsoring short post-graduate courses in psychiatry and psychosomatic medicine for any of its members who wish to attend.

Psychiatrists, perhaps more than anyone else, believe that a great percentage of the emotional problems seen in medical and surgical cases should be treated by the physician in charge of the case regardless of his major specialty. Unfortunately, too few physicians without psychiatric training have an adequate understanding of the emotional factors in illness. Nonetheless, the trend towards considering physical symptoms as evidence of problems that are disturbing an individual and contributing to his illness, instead of merely as evidence of disease, is encouraging to psychiatrists as well as to many other physicians.

Problems in psychiatry

In spite of distinct and important changes during the last twenty-five years in the status of psychiatry, every alert psychiatrist is aware of many vital needs which require survey, intensive study, and early action. It is essential that the public, so eager to take advantage of the benefits of psychiatry, should know of the deterrents to greater and faster progress.

By all odds, the present greatest need is for trained personnel. This applies particularly to psychiatrists but also to clinical psychologists, psychiatric social workers, psychiatric nurses, and therapists in the areas of occupation, recreation, and education who know how to apply these treatments to psychiatric patients. Of the approximately 4300 members of the American Psychiatric Association, a considerable number are older men who for many years have been concerned chiefly with administrative work. Many others are “associate” members — persons who have had a year of experience or training in psychiatry and can supply good references. This has seemed a wise practice in order to encourage young physicians to affiliate. But many of these men cannot be rated as seasoned, experienced psychiatrists.

In contrast to this comparatively small number of psychiatrists with varying degrees of experience and time for clinical practice, it is conservatively estimated that the country needs between ten and fifteen thousand well-trained psychiatrists at the present time.

Dr. Hawley recently indicated that he could use all the first-class psychiatrists now available in the United States to meet current demands within the Veterans Administration alone. Several of our states have no psychiatrists within their borders except those in the state hospital. It is equally serious that we have, roughly speaking, only about one tenth of our current personnel needs in clinical psychology and psychiatric social work, and less than this in psychiatric nursing. If such personnel were available in sufficient numbers, they could extend the services of psychiatrists considerably.

A natural question follows: Why is there such a shortage of psychiatrists? This isn’t an easy question to answer. One reason for the serious lag between need and availability is that adequate training in psychiatry requires a minimum of from five to seven years following medical school graduation. First, the graduate must serve one to two years of general medical internship in a hospital, like all doctors. This is followed by three years’ residency in psychiatry. Two additional years of practice are then required before a doctor is even eligible to take the examination for certification in this specialty. If he wishes to take psychoanalytic training — and a great majority of the younger men are seeking this — he must add two to three more years to his medical education. With the long training period following medical school, psychiatrists in numbers to meet the need cannot be supplied for some time.

The problem is complicated further because of the relatively few educational institutions where an adequate training is provided. There are approximately 1200 openings for residency training in psychiatry, but the training given in many of these is woefully inadequate, despite their presumably approved status.

Undoubtedly the most important stimulus to the training of psychiatrists has been received through the superb leadership in the Veterans Administration. Not only did Dr. Hawley and his associates tie the backward Veterans Hospitals to medical schools to ensure better treatment of all veteran patients: in many branches of medicine, resident training opportunities were established. Through this plan, the Veterans Administration established nearly five times as many residencies in psychiatry in its hospitals as had existed previously in all university medical school hospitals combined. Currently between four and five hundred psychiatric residencies are provided by the Veterans Administration.

Only recently have the majority of the alert leaders in medicine accepted the fact that there is an emotional component in every illness. Many of them now believe that in probably 50 per cent of all cases, emotional factors are the major cause of the illness. Because of the widespread lack of appreciation of its value, the teaching of psychiatry has comprised on the average only 3 to 4 per cent of the total number of hours in the four years of the medical course. There are still a number of medical schools which do not even have a department of psychiatry. Such material as is covered in this subject is presented by part-time teachers attached to the department of medicine. Probably less than half of our medical schools have a full-time psychiatrist on the faculty. In contrast, many have from two or three to as many as ten full-time teachers in their departments of medicine and surgery. The result is that many of the students graduating from our seventy-odd medical schools this year will not have a sound orientation in the field of psychiatry.

Along with a discussion of these darker aspects of the teaching of psychiatry in medical schools, it is worth while to point out a few of the bright spots. Within the current year at least five more medical schools will organize and develop a department of psychiatry with a full-time psychiatrist in charge. Many other departments will be strengthened. This progress was made possible through Federal grants from the United States Public Health Service. At the moment there is only one medical school which has an organized training course in psychoanalysis, although an increasing number have included analytically trained psychiatrists on their teaching staffs who offer lecture courses dealing with this subject. With the exception of the threeyear course given at the College of Physicians and Surgeons, Columbia University, psychiatrists must still go elsewhere than to medical schools for psychoanalytic training.

The need for research

The second major area in psychiatry that needs attention, and needs it badly, is that of tested knowledge. This means research. We need research into many aspects of human behavior. We need to know more about the normal individual; the causes of his misfunction; the chemical, the physical, the psychological nature of many of the mental afflictions from which he suffers. Above all, we need extensive research in the area of treatment. A pressing problem is how treatment can be given more intensively in order to enable more people to benefit from limited numbers of psychiatrists and their co-workers, thus also reducing the cost to the patient. At present most psychiatrists are functioning as clinicians — that is, they spend their time examining and treating patients. If they carry on research it has to be on their “own time” whenever they can steal it from an otherwise overburdened workday.

Another way of representing the inadequacy of research in psychiatry is to point out that for every case of poliomyelitis, approximately a hundred dollars is invested in research in that disease. For every case of mental illness, twenty-five cents is invested in research.

Psychiatric research, like most medical research, has been carried on through grants for specific projects. These grants, from foundations, are to be used within a specified length of time. The research worker naturally wonders whether he can secure a renewal of his grant to complete his work, or whether he will be able to obtain another grant for some new project. He lives from grant to grant.

One cannot separate the lack of funds from the lack of personnel, for if funds sufficient to ensure tenure were available, many more young men might be attracted to the field of psychiatric research. Psychiatrists have not played upon the public sympathy, nor have they had the wide support of Christmas seals or the March of Dimes. The prevention of suicide and neurotic ineffectiveness has not fired public interest to the point of supporting research along those lines. Nor has the tax dollar even begun to meet the mental health needs.

Wanted: good mental hospitals

A direct consequence is the serious state of affairs in our mental hospitals. The failure to care for and properly treat mental patients is a very black blot on the escutcheon of our social order. This is not the fault of psychiatry. It has resulted from the public refusal to be concerned with the patients in these institutions or to bother with checking on the adequacy of their care and treatment. To a considerable degree society has ostracized these institutions, their patients, and very frequently their physicians. Such a situation left the physician as the sole champion of his forgotten charges. He was hard pressed even to find the time to do his job; certainly he had — and still has — no time for public education or legislative lobbying.

Our state hospitals are badly overcrowded and they are critically understaffed. The staff in many of them have had little or no training, for the salary level in many states is not attractive to well-qualified men and women. This applies not only to the physicians but to the entire personnel who work with the patients. Most institutions housing mental patients are hospitals in name only. The few excellent state hospitals can be counted on the fingers of the two hands.

To some degree, the inadequacy of most state hospitals is a matter of simple mathematics. In round figures, about 2700 physicians care for 625,000 patients — which means an average of one doctor for every 233 patients in mental hospitals across the United States. In some instances, the ratio is one physician to 1000 patients! It is obvious that one doctor cannot provide treatment, make diagnostic studies, see relatives, write up his case histories and examinations, and carry on his administrative work and the many other minor duties involved in the care of 233 patients. He can hardly be expected even to know them. He has time to deal only with emergencies.

In many fields of medicine and surgery, the diagnosis is often immediately apparent and the treatment instructions or procedures are easily and quickly carried out. This is rarely the case in psychiatry. The most experienced psychiatrists do well if they gain sufficient understanding of a personality problem in two hours to recommend treatment with conviction and assurance.

In only an infinitesimally small percentage of our state hospitals have the personnel who care directly for the patients received adequate training. In most of them the attendants do not receive enough pay to attract even high school graduates. The direct result of no training and the low grade of aids or attendants is not merely poor care but the frank abuse of patients. Many of our state hospitals have no graduate nurses. Few of them have a psychiatric social worker for even as many as a thousand or two thousand patients. Only the occasional state hospital has a trained clinical psychologist.

The average cost per patient in a general hospital is about $9.00 a day. In the state mental hospitals across the country it averages $1.05 per patient per day. The food cost in a general hospital runs from 75 cents to $1.50 a day. In the state mental hospitals it averages 22 cents a day. It is also news to most people that even though a fourth of the total budget of most states is spent for the care of mental patients, this is on an average only a fourth or even a fifth as much as should be spent.

Current state hospital budgets are not sufficient to provide the patients in most such institutions with proper physical care, to say nothing of treatment. In far too many instances they are actually receiving mistreatment. The commitment laws in many of our states are antique. In one state they are medieval in requiring the patient to go to jail until committed by the court to a mental hospital. Most of the laws treat commitment as if it were entirely a legal rather than fundamentally a medical procedure. A major percentage of the population of many of our state hospitals are senile patients who should be given custodial care apart from younger persons. Part of an active treatment program should be an environment of hope and optimism. All our state institutions are housing many patients who could be cared for on an outpatient basis if clinical facilities were available. Such facilities would save staff, manpower, expense of custody, and lives of patients.

The enforcement of hospital standards is the responsibility of the public and must become its concern. The experts are willing and are ready to investigate specific institutions and make recommendations as to what can be done in order to provide good treatment. Then it is up to the citizens whether state authorities accept the recommendations or some political group blocks action. In the last analysis the full responsibility for the situation in most of our state hospitals lies with the people. If the public wants state hospitals which provide proper care and treatment for its ill citizens, it can have them.

Credit belongs to psychiatrists for establishing hospital standards. These standards set forth everything from the floor space per patient to the facilities needed, from the ratio of patients to various types of personnel, to the daily costs. Consultation and advice are available to any state on request to the United States Public Health Service or the hospital committee of the American Psychiatric Association or to the hospital committee of the Group for the Advancement of Psychiatry.

Maintaining mental health

One of the roles of psychiatry that must be greatly expanded is in the held of prevention of mental ill health. Army experience demonstrated that draft selection, diagnosis, and disposition of neuropsychiatric casualties were not the only duties of psychiatrists. We learned that a greater contribution could be made by preventing some of the casualties.

Lessons from the Army experience emphasized three major factors in maintaining mental health. The first, and the most important, was that the quality of leadership contributed to or prevented mental ill health. The second lesson was that the development of positive rational attitudes towards the job to be done — that is, conscious motivation — could be a great aid in the doing of that job. Unquestionably, good motivation was an important factor in maintaining mental health, for poor motivation was followed by an increase in the number of psychiatric casualties. Third, identification with his unit, which permitted a sense of pride, and provided comparative security, satisfaction, and unity of purpose, was extremely important to the mental health of the individual. These elementary factors in the maintenance of the soldier’s mental health apply also to individuals in a family, business, community, and nation.

One of the chief aims of preventive psychiatry should be the continued attempt to educate parents and all other leaders to the importance of developing mature persons. The “average” adult, even the “average” child, early learns sufficient information about his physical health to be reasonably informed as to how he should take care of it. He knows some elementary principles about diet, sleep and fresh air, and cleanliness. The chances are that ninetynine men and women out of one hundred know that they have a heart, and something about it. On the other hand, it is an unusual individual who knows even the simplest principles for keeping in good mental health. Most of that hundred do not know that the unconscious is the most powerful part of the personality; nor do they know its role in the struggle to attain maturity. It seems reasonable to assume that an elementary knowledge of the structure and development of the personality would be helpful to the average person.

In psychiatry, the primary aim of public education should be to provide the “average” man with a better knowledge of the steps to psychological maturity, and of how to fortify and improve his mental health. In participating in such education, psychiatrists have no intention of making amateur psychiatrists out of laymen any more than does popular education about anatomy make one into a surgeon. They cite facts and figures not as alarmists or sensationalists but as evidence of a need.

The American Psychiatric Association

What are psychiatrists doing about all these areas in which progress is so obviously needed? As an organized group, they are beginning to give more consideration to these problems. Their national organization of psychiatrists is the American Psychiatric Association. For 103 years its annual meetings have given them an opportunity to come together and exchange scientific ideas, a chance to learn from each other. It has a large number of standing committees which interest themselves in various subjects within the field of psychiatry. A few of these have done superb jobs in providing leadership and programs of action. Two other important organizations of psychiatric workers — the American Psychoanalytic Association and the American Orthopsychiatric Association — are also giving leadership in their specific areas of interest.

Another extremely important effort has been the creation of non-profit foundations to promote mental health. For over thirty-five years the National Committee for Mental Hygiene has carried on almost alone a crusade for a better understanding of mental health. It has a long list of achievements to its credit. The National Mental Health Foundation has recently been organized and is already making conspicuous strides in mental health education, particularly as it relates to the problems of the state hospital.

A newer organization is the Psychiatric Foundation, sponsored by the American Psychiatric Association for the purpose of raising funds to finance the program of that organization as well as other worthy psychiatric endeavors. These and other foundations form channels through which money can be directed towards vital accomplishments.

Help for a sick nation

The major task of most psychiatrists is the study and treatment of the individual sick person. Relief of acute distress is their special responsibility. Furthermore, clinical work with individual patients has been and always will be the source of knowledge for the extension of psychiatric efforts into the realm of prevention. The rules for mental hygiene, preventive psychiatry, emerge from observations and study of the sick personality.

Even now there is a sizable body of general principles about mental health which could be applied more widely if it could be interpreted for and distributed to the public. This would require an increasing number of psychiatrists who would take their places in our public health programs to initiate and carry on preventive measures just as that program now institutes measures to protect our physical health.

We know that psychiatric illness is the result of the conflict between the personality and its environment. If the personality is, by inheritance or training, defective or weak, either temporarily or permanently, it can be overwhelmed by the demands of the environment. Or if the environment creates severe stress for a long enough period, the integration of even a strong and healthy personality may be broken down. Of one fact we are certain: the world is full of varied stresses, many of which show no sign of diminishing, and others are increasing.

The war cost America 157 million dollars a day for over five years. The effect of war-created strain on human beings is beyond calculation. The pathological outpouring of the aggression and destructiveness of war can well be regarded as a psychosis. The overt outlet of mass emotion in killing which the shooting war provided is over, in at least part of the world. But our present status is definitely not one of convalescence and recovery. Locally, nationally, and internationally, our relationships are marked with tension, mistrust, suspicion, and selfishness. Suffering, physical and emotional, still afflicts a majority of the people in the world. Our advances in physical science as represented by the atomic bomb and television have progressed so much farther than our advances in the social sciences that our very existence is dangerously threatened. We have learned how to eliminate space and annihilate people, but we still lag far behind in learning how to get along with each other even in uncomplicated situations.

During the war the psychiatrist found his job in combat at odds with his civilian experience. Whereas in civilian life he attempted to understand and correct the abnormal reactions of persons to normal situations, in military life he had to understand and modify men’s normal reactions to an abnormal situation. One might seriously ask if the condition of the world does not now place many of us in a continuously abnormal situation to which we are reacting normally, even though such behavior by all previous standards appears pathological. In such a turbulent world, one wonders just what a normal reaction is. Can psychiatry contribute any suggestions toward individual and collective ability to stay mentally well under current conditions?

Disintegration of the family

Let us start with the family. It is apparent that major changes have been taking place in the organization and structure of the family. Various statistics can be marshaled as evidence of this. Divorces have increased from approximately 250,000 in 1937 to over 600,000 in 1946. Before the war, approximately 11 million women worked outside of the home; 2.5 million more wanted or needed work. In March, 1944, at the war peak, there were over 16 million women at work away from home, 7 million of whom were married. At present 44 per cent of our families have no children and an additional 22 per cent have only one child.

In considering these facts, the psychiatrist does not sit in moral judgment on the many individuals concerned. Taking into consideration changes in our method of living, changing mores, economic pressures, educational factors, the psychiatrist regards the statistical facts as symptoms of psychological stress.

Psychiatrists are in agreement that healthy development to emotional adulthood depends very largely upon a childhood home situation which provides affection, good example, and security. Today a great many American families are unable to satisfy these basic needs of their children.

The current status of the family undoubtedly has something to do with the changing relationships between men and women as a result of woman’s “emancipation” during the last thirty years. Her greatly increased opportunity for self-expression has also created an increasing number of potential conflicts for her. Magazines have been publishing protests, explanations, apologias, and demands of some women who feel that in spite of the changes in their status they do not derive sufficient satisfaction from their role in society. While the mature personality, man or woman, will find satisfaction in what has to be done and, if necessary, supplement that with selfchosen activity, the unfortunate fact is that many individuals are not emotionally mature. The tragedy is that the frustrated wife and mother will leave her mark on husband and children. The problem is not solely up to the woman to solve. It is a joint responsibility of man and wife.

Promiscuity

Immaturity, either male or female or both, is probably also a major factor in our high divorce rates and what appears to be increasing instability in marriage. It also expresses itself symptomatically in several other major problems: for instance, the marked increase in non-marital sexual relations.

This social sore point, too, is fraught with many influencing factors that are represented in our changing mores and moral standards. It may be related to the increase in emphasis on individualism and decrease in power of group disapproval. There can be no vital statistics on the extent of non-marital sexual relations. We do know that the reports of venereal disease in the continental United States indicated that the number of new cases of gonorrhea (no second exposures reported) practically doubled between 1941 and 1946, from 191,000 to 367,000.

Another one of our serious social problems related to immaturity is alcoholism. It is estimated that this evidence of maladjustment costs America nearly 800 million dollars a year and concerns 2.4 million persons, 85 per cent of whom are men.

Crime

Closely related to the family, which contributes so much to the cause or prevention of mental ill health, is America’s problem of crime and delinquency. It is variously estimated that this social ill costs the country between 8 and 10 billion dollars a year. This is more than six times as much as we spend for public education. Our overflowing penitentiaries, reformatories, and jails cost us over 100 million dollars a year to operate.

The Federal Bureau of Investigation reported that the 1.6 million crimes committed in 1946 broke all records for the past decade. This figure shows an increase of 120,000 over the previous year. Approximately 120,000 juveniles passed through the courts in 1945. That the behavior represented in crime and delinquency is evidence of maladjustment is another point on which there would be nearly 100 per cent agreement among psychiatrists. For some years they have maintained that all offenders against society should have the benefit of a psychiatric and a physical examination. Those who are salvable should be treated and socially rehabilitated. Those individuals with permanently distorted personalities should be committed to permanent detention without regard to the nature of their offense.

To these and other problems that are producing great stress and unhappiness for millions of Americans, psychiatry cannot find all the answers. To the solution of many it cannot even make any major contribution. They should be the object of intensive study by coördinated groups of social scientists, educators, religious leaders, statesmen, and many others. It seems reasonable to presume, however, that psychiatrists, those experts who spend their lives attempting to understand why people behave as they do, should be able to offer a major contribution to such study.

Social neuroses

Many of us in this field believe that the so-called social neuroses, which are such real stresses to our patients and our families, and are threats to our nation and world peace, must be carefully and immediately investigated for diagnosis which should lead to intensive treatment.

Number one among all of the social neuroses in America today is the widespread prejudice and discrimination against persons because of race, color, or religion. Bigoted intolerance, the thesis of “white supremacy,” anti-Semitic prejudice, discriminatory practices, hostile attitudes towards Catholicism and Protestantism, are all present in varying degrees in every section of the country. Psychiatrists are familiar with these as symptoms in their patients. Therefore, they have an opportunity to learn much about the psychological dynamics and, consequently, the significance of such prejudices for the individual. Surely, if they would crystallize their thinking on the subject, they could make constructive suggestions towards the solution of this problem.

Forced unemployment is another major mental health hazard. It is variously estimated that 60 to 80 per cent of unemployed persons manifest definite signs of mental ill health. In a majority of instances, the father appears to be a failure in the eyes of his wife, his children, his friends in the community, often even to himself. Most tragic is the effect on the children. Unemployment becomes a mental health problem which always affects two generations.

Serious too are the unhappiness and distress caused by the housing shortage, which makes it impossible for so many of our veterans and former warworkers to have homes or to find suitable accommodations in which to live. In 1946, we built approximately 500,000 homes but we needed 3,200,000. The resulting dislocation, crowding, and family friction compound an enormous emotional cost which will be paid for by those whose personalities cannot withstand the excessive stress.

One might continue this list almost indefinitely. The concomitant economic loss from strikes is not to be compared with the emotional cost to the workers, their families, and communities. The 350,000 persons who are permanently disabled each year as the result of accidents add to the amount of stress which must be borne by themselves and society. Systems of political graft leave their mark on weak or immature personalities.

As psychiatrists we meet the effects of these social ills in our daily work. As I have said, some of them are expressions of immaturity and the symptoms of maladjustment. Some of them are the cause of the stress which provokes the patient’s complaints.

Psychiatry must occupy itself chiefly with trying to treat some of the psychological wounds and wrecks that civilization produces in human beings. Relief of their suffering commands the highest priority. But while doing so, psychiatrists become more and more aware of the increased need for supports against the stresses of the environment. The family, the community, the nation, can alter their organization and methods so as to promote richer, more satisfying, and therefore more mentally healthy life. The question then is — how to do so?

To the answering of this question the experts in many fields of human endeavor must direct their attention. Psychiatrists, along with psychologists and sociologists, are scientists concerned with understanding the why and how of man’s feeling and thinking and acting. Psychiatrists as individuals and in groups have reached a new high in their interest in and study of social problems. They should be able to make a significant contribution to any panel of experts who would consider any or all of these social problems.