A Young Psychiatrist Looks at His Profession

BY ROBERT COLES, M.D.

RECENTLY, in the emergency ward of the Children’s Hospital in Boston, an eight-year-old girl walked in and asked to talk to a psychiatrist about her “worries.” I was called to the ward, and when we ended our conversation I was awake with sorrow and hope for this young girl, but also astonished at her coming. As a child psychiatrist, I was certainly accustomed to the troubled mother who brings her child to a hospital for any one of a wide variety of emotional problems. It was the child’s initiative in coming which surprised me. I recalled a story my wife had told me. She was teaching a ninth-grade English class, and they were starting to read the Sophoclean tragedy of Oedipus. A worldly thirteen-year-old asked the first question: “What is an Oedipus complex?” Somehow, in our time, psychiatrists have become the heirs of those who hear the worried and see the curious. I wondered, then, what other children in other times did with their troubles and how they talked of the Greeks. I wondered, too, about my own profession, its position and its problems, and about the answers we might have for ourselves as psychiatrists.

We appear in cartoons, on television serials, and in the movies. We are “applied” by Madison Avenue, and we “influence” writers. Acting techniques, even schools of painting are supposed to be derived from our insights, and Freud has become what Auden calls “a whole climate of opinion.” Since children respond so fully to what is most at hand in the adult world, there should have been no reason for my surprise in that emergency ward. But this quick acceptance of us by children and adults alike is ironic, tells us something about this world, and is dangerous.

The irony is that we no longer resemble the small band of outcasts upon whom epithets were hurled for years. One forgets today just how rebellious Freud and his contemporaries were. They studied archaeology and mythology, were versed in the ancient languages, wrote well, and were a bit fiery, a bit eccentric, a bit troublesome, even for one another. Opinionated, determined, oblivious of easy welcome, they were fighters for their beliefs, and their ideas fought much of what the world then thought.

This is a different world. People today are frightened by the memory of concentration camps, by the possibility of atomic war, by the breakdown of old empires and old ways of living and believing. Each person shares the hopes and terrors peculiar to this age, not an age of reason or of enlightenment, but an age of fear and trembling. Every year brings problems undreamed of only a decade ago in New York or Vienna. Cultures change radically, values are different, even diseases change. For instance, cases of hysteria, so beautifully described by Freud, are rarely found today. A kind of innocence is lost; people now are less suggestible, less naïve, more devious. They look for help from many sources, and chief among them, psychiatrists. Erich Fromm, in honor of Paul Tillich’s seventy-fifth birthday, remarked: “Modern man is lonely, frightened, and hardly capable of love. He wants to be close to his neighbor, and yet he is too unrelated and distant to be able to be close. . . . In search for closeness he craves knowledge; and in search for knowledge he finds psychology. Psychology becomes a substitute for love, for intimacy. . .”

Now Freud and his knights are dead. Their long fight has won acclaim and increasing protection from a once reluctant society, and perhaps we should expect this ebb tide. Our very acclaim makes us more rigid and querulous. We are rent by rivalries, and early angers or stubborn idiosyncrasies have hardened into a variety of schools with conflicting ideas. We use proper names of early psychiatrists—Jung, Rank, Horney — to describe the slightest differences of emphasis or theory. The public is interested, but understandably confused. If it is any comfort to the public, so are psychiatrists, at times. Most of us can recall our moments of arrogance, only thinly disguised by words which daily become more like shibboleths, sound hollow, and are almost cant.

Ideas need the backing of institutions and firm social approval if they are to result in practical application. Yet I see pharisaic temples being built everywhere in psychiatry; pick up our journals and you will see meetings listed almost every week of the year and pages filled with the abstracts of papers presented at them. These demand precious time in attendance and reading, and such time is squandered all too readily these days. Who of us, even scanting sleep, can keep up with this monthly tidal wave of minute or repetitive studies? And who among us doesn’t smile or shrug, as he skims the pages, and suddenly leap with hunger at the lonely monograph that really says something? As psychiatrists we need to be in touch not only with our patients but with the entire range of human activity. We need time to see a play or read a poem, yet daily we sit tied to our chairs, listening and talking for hours on end. While this is surely a problem for all professions, it is particularly deadening for one which deals so intimately with people and which requires that its members themselves be alive and alert.

It seems to me that psychiatric institutions and societies too soon become bureaucracies, emphasizing form, detail, and compliance. They also breed the idea that legislation or grants of money for expansion of laboratories and buildings will provide answers where true knowledge is lacking. Whereas we desperately need more money for facilities and training for treatment programs, there can be a vicious circle of more dollars for more specialized projects producing more articles about less and less, and it may be that some projects are contrived to attract money and expand institutions rather than to form any spontaneous intellectual drive. We argue longer and harder about incidentals, such as whether our patients should sit up or lie down; whether we should accept or reject their gifts or answer their letters; how our offices should be decorated; or how we should talk to patients when they arrive or leave. We debate for hours about the difference between psychoanalysis and psychotherapy; about the advantages of seeing a person twice a week or three times a week; about whether we should give medications to people, and if so, in what way. For the plain fact is that, as we draw near the bureaucratic and the institutionalized, we draw near quibbling. Maybe it is too late, and much of this cannot be stopped. But it may be pleasantly nostalgic, if not instructive, to recall Darwin sailing on the Beagle, or Freud writing spirited letters of discovery to a close friend, or Sir Alexander Fleming stumbling upon a mold of penicillin in his laboratory — all in so simple and creative a fashion, and all with so little red tape and money.

IF SOME of psychiatry’s problems come from its position in the kind of society we have, other troubles are rooted in the very nature of our job. We labor with people who have troubled thoughts and feelings, who go awry in bed or in the office or with friends. Though we talk a great deal about our scientific interests, man’s thoughts and feelings cannot be as easily understood or manipulated as atoms. The brain is where we think and receive impressions of the world, and it is in some ultimate sense an aggregate of atoms and molecules. In time we will know more about how to control and transform all cellular life, and at some point the cells of the brain will be known in all their intricate functions. What we now call “ego" or “unconscious” will be understood in terms of cellular action or biochemical and biophysical activity. The logic of the nature of all matter predicts that someday we will be able to arrange and rearrange ideas and feelings. Among the greatest mysteries before us are the unmarked pathways running from the peripheral nervous system to the thinking areas in the brain. The future is even now heralded by machines which think and by drugs which stimulate emotional states or affect specific moods, like depressions. Until these roads are thoroughly surveyed and the brain is completely understood, psychiatry will be as pragmatic or empirical as medicine.

Social scientists have taught us a great deal about how men think and how they get along with one another and develop from infancy to full age. We have learned ways of reaching people with certain problems and can offer much help to some of them. Often we can understand illnesses that we cannot so readily treat. With medicines, we can soften the lacerations of nervousness and fear, producing no solutions, but affording some peace and allowing the mind to seek further aid. Some hospitals now offer carefully planned communities where new friendships can arise, refuges where the unhappy receive individual medical and psychiatric attention. Clinics, though harried by small staffs and increasing requests, offer daily help for a variety ol mental illnesses. Children come to centers devoted to the study and treatment of early emotional difficulties. If the etiologies are still elusive, the results of treatment are often considerable. Failures are glaring, but the thousands of desperate people who are helped are sometimes overlooked because of their very recovery. Indeed, it is possible that our present problems may give way to worse ones as we get to know more. The enormous difficulties of finding out about the neurophysiology of emotional life may ultimately yield to the Orwellian dilemma of a society in which physicists of the mind can change thoughts and control feelings at their will.

HOWEVER, right now I think our most pressing concern is less the matter of our work than the manner of ourselves. For the individual psychiatrist, the institutional rigidities affect his thoughts and attitudes, taint his words and feelings, and thereby his ability to treat patients. We become victims of what we most dread; our sensibilities die, and we no longer care or notice. We dread death of the heart — any heart under any moon. Yet I see Organization Men in psychiatry, with all the problems of deathlike conformity. Independent thinking by the adventurous has declined; psychiatric training has become more formal, more preoccupied with certificates and diplomas, more hierarchical. Some of the finest people in early dynamic psychiatry were artists, like Erik Erikson, schoolteachers, like August Aichhorn, or those, like Anna Freud, who had no formal training or occupation but motivations as personal as those of a brilliant and loyal daughter. Today we are obsessed with accreditation, recognition, levels of training, with status as scientists. These are the preoccupations of young psychiatrists. There are more lectures, more supervision, more examinations for specialty status, and thus the profession soon attracts people who take to these practices. Once there were the curious and bold; now there are the carefully well-adjusted and certified.

When the heart dies, we slip into wordy and doctrinaire caricatures of life. Our journals, our habits of talk become cluttered with jargon or the trivial. There are negative cathects, libido quanta, “pre-symbiotic, normal-autistic phases of motherinfant unity,” and “a hierarchically stratified, firmly cathected organization of self-representations.” Such dross is excused as a short cut to understanding a complicated message by those versed in the trade; its practitioners call on the authority of symbolic communication in the sciences. But the real test is whether we best understand by this strange proliferation of language the worries, fears, or loves in individual people. As the words grow longer and the concepts more intricate and tedious, human sorrows and temptations disappear, loves move away, envies and jealousies, revenge and terror dissolve. Gone are strong, sensible words with good meaning and the flavor of the real. Freud called Dostoevsky the greatest psychologist of all time, and long ago Euripedes described in Medea the hurt of the mentally ill. Perhaps we cannot expect to describe our patients with the touching accuracy and poetry used for Lady Macbeth or Hamlet or King Lear, but surely there are sparks to be kindled, cries to be heard, from people who are individuals.

If we become cold, and our language frosty, then our estrangement is complete. Living in an unreliable world, often lonely, and for this reason, attracted to psychiatry as a job with human contacts, we embrace icy reasoning and abstractions, a desperate shadow of the real friendships which we once desired. Estrangement may, indeed, thread through the entire fabric of our professional lives in America. Cartoons show us pre-empted by the wealthy. A recent study from Yale by Doctor Redlich shows how few people are reached by psychiatrists, how much a part of the class and caste system in America we are. Separated from us are all the troubled people in villages and farms from Winesburg to Yoknapatawpha. Away from us are the wretched drunks and the youthful gangs in the wilderness of our cities. Removed from us are most of the poor, the criminal, the drug addicts. Though there are some low-cost clinics, their waiting lists are long, and we are all too easily and too often available to the select few of certain streets and certain neighborhoods.

Whereas in Europe the theologian or artist shares intimately with psychiatrists, we stand apart from them, afraid to recognize our common heritage. European psychiatry mingles with philosophers; produces Karl Jaspers, a psychiatrist who is a theologian, or Sartre, a novelist and philosopher who writes freely and profoundly about psychiatry. After four years of psychiatric training in a not uncultured city, I begin to wonder whether young psychiatrists in America are becoming isolated by an arbitrary definition of what is, in fact, our work. Our work is the human condition, and we might do well to talk with Reinhold Niebuhr about the “nature and destiny of man,” or with J. D. Salinger about our Holden Caulfields. Perhaps we are too frightened and too insecure to recognize our very brothers. This is a symptom of the estranged.

In some way our hearts must live. If we truly live, we will talk clearly and avoid the solitary trek. In some way we must manage to blend poetic insight with a craft and unite intimately the rational and the intuitive, the aloof stance of the scholar with the passion and affection of the friend who cares and is moved. It seems to me that this is the oldest summons in the history of Western civilization. We can answer this request only with some capacity for risk, dare, and whim. Thwarting us at every turn of life is the ageless fear of uncertainty; it is hard to risk the unknown. If we see a patient who puzzles us, we can avoid the mystery and challenge of the unique through readily available diagnostic categories. There is no end to classifications and terminologies, but the real end for us may be the soul of man, lost in these words: “Name it and it’s so, or call it and it’s real.” This is the language of children faced with a confusion of the real and unreal, and it is ironic, if human, to see so much of this same habit still among psychiatrists.

Perhaps, if we dared to be free, more would be revealed than we care to admit. I sometimes wonder why we do not have a journal in our profession which publishes anonymous contributions. We might then hear and feel more of the real give-and-take in all those closed offices, get a fuller flavor of the encounter between the two people, patient and psychiatrist, who are in and of themselves what we call psychotherapy. The answer to the skeptic who questions the worth of psychotherapy is neither the withdrawn posture of the adherent of a closed system who dismisses all inquiry as suspect nor an eruption of pseudoscientific verbal pyrotechnics. Problems will not be solved by professional arrogance or more guilds and rituals. For it is more by being than by doing that the meaningful and deeply felt communion between us and our patients will emerge. This demands as much honesty and freedom from us as it does from our patients, and as much trust on our part as we would someday hope to receive from them.

If the patient brings problems that may be understood as similar to those in many others, that may be conceptualized and abstracted, he is still in the midst of a life which is in some ways different from all others. We bring only ourselves; and so each meeting in our long working day is different, and our methods of treatment will differ in many subtle ways from those of all of our colleagues. When so much of the world faces the anthill of totalitarian living, it is important for us to affirm proudly the preciously individual in each human being and in ourselves as doctors. When we see patients, the knowledge and wisdom of many intellectual ancestors are in our brains, and hopefully, some life and affection in our hearts. The heart must carry the reasoning across those inches or feet of office room. The psychiatrist, too, has his life and loves, his sorrows and angers. We know that we receive from our patients much of the irrational, misplaced, distorted thoughts and feelings once directed at parents, teachers, brothers, and sisters. We also know that our patients attempt to elicit from us many of the attitudes and responses of these earlier figures. But we must strive for some neutrality, particularly in the beginning of treatment, so that our patients may be offered, through us and their already charged feelings toward us, some idea of past passions presently lived. Yet, so often this neutrality becomes our signal for complete anonymity. We try to hide behind our couches, hide ourselves from our patients. In so doing we prolong the very isolation often responsible for our patients’ troubles, and if we persist, they will derive from the experience many interpretations, but little warmth and trust.

I think that our own lives and problems are part of the therapeutic process. Our feelings, our own disorders and early sorrows are for us in some fashion what the surgeon’s skilled hands are for his work. His hands are the trained instruments of knowledge, lectures, traditions. Yet they are, even in surgery, responsive to the artistry, the creative and sensitive intuition of the surgeon as a man. The psychiatrist’s hands are himself, his life. We are educated and prepared, able to see and interpret. But we see, talk, and listen through our minds, our memories, our persons. It is through our emotions that the hands of our healing flex and function, reach out, and finally touch.

We cannot solve many problems, and there are the world and the stars to dwarf us and give us some humor about ourselves. But we can hope that, with some of the feeling of what Martin Buber calls “I-Thou” quietly and lovingly nurtured in some of our patients, there may be more friendliness about us. This would be no small happening, and it is for this that we must work. Alert against dryness and the stale, smiling with others and occasionally at ourselves, we can read and study; but maybe wince, shout, cry, and love, too. Really, there is much less to say than to affirm by living. I would hope that we would dare to accept ourselves fully and offer ourselves freely to a quizzical and apprehensive time and to uneasy and restless people.