The Rejection of the Insane

THE way society handles its psychotics, by putting them away in human dumps, has been the subject of repeated public scandal. Surely the American press, whatever its failures, has lived up to its responsibility in this instance. It has published millions of words about inhuman care of the mentally sick since Nellie Bly wrote “Ten Days in a Madhouse” for the New York World in 1888. Most of this writing has been predicated on the assumption that if the plight — the shameful, subhuman condition — of the chronically sick of mind who populate the back wards of state hospitals were well exposed, the public would rise up in moral indignation and bring about reform. But the public remains unmoved, or, when it does move, does not move far enough. The thing that appears to be missing is public and professional action commensurate with the size of the mental illness problem.

One of the most revealing disclosures in Action for Mental Health, the final report of the Joint Commission on Mental Illness and Health, published last March by Basic Books, is that comparatively few of 277 state hospitals — probably no more than 20 per cent — have actively participated in the modern therapeutic trend toward humane, healing hospitals and clinics of easy access and easy exit, instead of locked, barred, prisonlike depositories of alienated and rejected human beings.

It is true, of course, that these institutions never have been quite the end of the road that has become fixed in the public’s mind. Actually, the number of patients now discharged annually from mental hospitals exceeds the annual number of first admissions. Including in the total figure the accumulated load of old patients who remain stubbornly psychotic, the average state hospital discharges 30 per cent of its patients each year.

The worst mental hospitals return to the community 40 to 50 per cent of the patients they treat for schizophrenia, the most serious of major mental illnesses; the best hospitals discharge 75 to 85 per cent.

But the typical state hospital, through the accumulation of its chronically ill patients and its tendency to make many patients worse instead of better, remains substantially what it was a hundred years ago, an asylum for the “incurably insane.” As such, it is characterized by rigidly authoritarian control, solemn vigilance, and covert despair. It does a good job of keeping patients physically alive and mentally sick. If a patient will not eat, he may be force-fed; if he will not talk

— well, he is less trouble that way. And as for the tranquilizing drugs, they make agitated patients friendlier and more cooperative, and therefore make the lives of attendants and nurses more tolerable. Thus, the drugs have introduced enthusiasm where there was none.

There has been some increase in hospital staffs. The average hospital has one employee (including psychiatrists) for every three patients; this compares with two or more employees per patient (not counting attending physicians) in the average community general hospital. But, with the exceptions indicated, the state hospital system of caring for the mentally ill — nearly a million patients every year — has shown an amazing resistance to change for the better.

WHAT is wrong here? Why, in the care of the mentally ill, do we lag, in the achievement of both our humanitarian and scientific goals, behind the public demand for mental health services — especially in clinics, where the waiting lists run on for months, and even years — and behind other major public health programs?

The reason of longest standing, perhaps, is that people do not recognize the insane, or psychotic, simply as sick human beings in need of help. Instead, people see the psychotic’s behavior, the symptoms of illness, as immoral or illegal, and therefore deserving of punishment rather than pity. We frequently go to great lengths to explain our friend’s clearly irrational and uncontrolled behavior simply as “the way he is”; that is, we put up with him until he does something that brings him a mental patient or psycho label. After that, we do not quite trust him, whatever he does.

Publicly recorded insanity, like convicted crime, tends to produce a stigma that cuts the bonds of human fellowship. Many other dread diseases — tuberculosis, syphilis, cancer — have in their time and their way branded their victims as unfit for human society. In modern times, however, the horror and shame of diseases recognized to be physically caused and highly lethal have tended to disappear — or, at any rate, to be offset — as they came under public scrutiny and attack. The person who goes to the hospital with cancer or heart disease and recovers is accepted back into the community in a way that the mental patient almost never is.

The stigma question leads us to the feeling of helplessness and hopelessness that the insane produce in us. If we only knew what to do with a mentally ill person, how to manage him, where to take him, how to get him well again, we would not feel so confused. Even the family doctor, let alone the psychiatrist, is hard to reach these days. At best, the mentally ill are a great nuisance; at worst, we are scared to death of them. In either case, they embarrass us.

In a broad sense, what we are saying is that if we only had more scientific knowledge of diagnosis and treatment or preventive techniques at our disposal, then we could conquer mental illness, including our feelings about it. There is a mixture of truth and fallacy here. In the first place, the mentally ill on the whole are not as dangerous as most people believe. Those disposed to physical violence are the exception rather than the rule, although, as with airliners, we read more about the few crashes than all the safe landings. When attacked by a person bent on destruction, one must defend himself or flee. But often psychotics are enraged by an impetuous or treacherous use of force against them that would equally anger a normal person.

Second, mental illness is not categorically a oneway street. Nobody is totally insane, any more than he is totally infected with a germ or totally cancerous. Some get well without treatment; others improve greatly if treated well; some recover and have later relapses; a few never recover.

It only misleads, therefore, to say that lack of an adequate technology, or a good scientific tool kit, is the main reason why the public fails to attack mental illness with vigor proportionate to the size of the problem.

Medical science is still searching for the cause and cure of cancer and of the major forms of heart disease, but the lack of better methods of treatment or prevention has not resulted in inhuman, substandard care for patients. In reality, the schizophrenic has a far better chance for recovery and a useful life than the victim of any of several major physical illnesses. There is an important economic difference, of course: in lung cancer or coronary thrombosis, death removes treatment failures from the scene, whereas chronic schizophrenics do not get well and do not die; they accumulate in public institutions.

Some would say that this is the big obstacle — so many patients with major mental illness live on and become indigent. Long hospitalization and psychiatric treatment impose costs the average family cannot afford. Thus, the burden of mental patient care, a good four fifths of it, falls on the state. State hospitals spend from two to six dollars per patient per day, compared with upward of thirty dollars a day in community general hospitals and leading private mental hospitals.

It is customary, at least among Republicans, automatically to regard state medicine as bad medicine, because it imposes a tax burden and involves politics. These make for a poor quality of medical care, it is argued. The generalization is a weak one, however. County tuberculosis hospitals have done a generally creditable job of long-term care for tuberculous patients at taxpayers’ expense, at an average of thirteen dollars per patient per day. Many did so even before modern advances in surgical and drug treatment. Of course, the patient load has been smaller for tuberculosis than for mental illness.

The Veterans’ Administration psychiatric hospitals, themselves well within the snake-pit range of description until after the war, now provide an acceptable quality of tax-paid mental patient care at an average cost per patient of twelve dollars per day. It is easy to document this observation. The hospitals’ national standard-setting agency, the Joint Commission on Accreditation of Hospitals, has approved only 30 per cent of state hospitals, contrasted with 100 per cent of V.A. psychiatric hospitals. Why can’t state hospitals do as well? One answer seems to be that the federal government has far greater financial resources than the states have, and, above all, veterans have influence through a well-organized pressure group.

WE NOW approach the nub of the matter. The insane sick are friendless, unless their families have money or a mental health worker unexpectedly befriends them. It is a truism in voluntary health organizations that people are prone to work for a cause which they can identify with personally. But an organization which seeds itself with workers who have been mentally ill accepts a considerable handicap. And how many others are prepared to identify themselves with insanity in the family? One psychiatrist, Dr. J. Sanbourne Bockoven of Framingham, Massachusetts, pinpoints these issues: “The very essence of mental illness is an incapacity to get along with other people, hence organization behind a leader is impossible.

The friends or relatives of the mentally ill are equally immobilized through fear of stigmatizing themselves.”

Quite a number of groups of former mental patients have come into being and then languished; none has flourished as, for example. Alcoholics Anonymous has. The difference seems to be that alcoholics, basically neurotic, are usually successful persons while sober. In any event, their “cure,” refusing a drink, is only slightly stigmatizing.

A psychosis is essentially a social disorder, or, as defined by the late Dr. Harry Stack Sullivan, founder of the Washington School of Psychiatry, one involving interpersonal relationships. The normal person will do whatever he has to do to get along in his group; the psychotic will not. He suffers from a sort of mental arthritis that turns individualism into a disease.

The person with an acute psychosis sooner or later disturbs or offends other people and is likely to be treated as a disturber and offender. He does not fit our conception of a sick person in need of help; often he does not recognize himself as sick. It has been observed countless times that the sight or even the thought of a person “out of his mind” stimulates fear in us; fear of what the irrational person might do, fear of what we ourselves might do in response to this threat, fear arising from the power of suggestion that “I, too, will go crazy.” For many of us, self-control is a lifelong problem.

The insane person has somehow lost control. We feel sorry for him, but not nearly as sorry as relieved to have him out of the way. We have some of the same feelings about a physically sick person, too, but he gives us little reason to lose faith in him. We can see that he is sick. If conscious, he knows he is sick. He behaves predictably.

If we spent our lives among psychotics rather then encountering them rarely, we would realize that a calm alertness is desirable, but fearfulness and distrust are not necessary. You hear of patients killing themselves, but did you ever hear of a patient killing his psychiatrist or nurse? It is extremely rare. It was known more than 150 years ago, by the French physician Philippe Pinel and the Quaker layman William Tuke, that figuratively turning the other cheek is not only a humane but a healing approach to the insane if pursued with friendly firmness and the sane recognition that the first problem is breaking the vicious circle of provocation and retaliation. Of course, it takes a good deal more brotherly love and physical courage than many of us have to find this out.

The mental hygiene, or mental health, movement was born out of the need to relieve medical and social guilt over the unloving and often brutally punishing way mental hospital workers used to treat the uncooperative insane. Not a physician but a young layman, a manic-depressive college graduate named Clifford Beers, while still in strait jackets and padded cells, swore he would get out and crusade against the evils he saw in mental institutions. Beers succeeded, writing A Mind That Found Itself, published in 1908.

Perhaps Beers in 1961 would receive a place on the future-appointments book of a good psychiatrist, work out his hostility and aggressions on the couch, and pay the fee out of his Book-of-theMonth Club and Hollywood royalties. Happily, he won the support of three great doctors who gave him a hearing rather than a diagnosis: William James, the psychologist; Adolf Meyer, the psychiatrist, and William H. Welch, the pathologist. They, with others, founded the National Committee for Mental Hygiene and made Beers its executive secretary.

Almost from the outset the movement was enthralled with the vision of doing away with mental illness entirely. One of the original circle, probably Meyer, told Beers that his own illness could have been prevented. Was not that the better approach? It turned out to be wishful thinking, but the mental hygienists had their heads turned by the microbe hunters, who were having impressive successes in disease prevention through sanitation and immunization. Eugenics and progressive education were also in the air. The larger goal became “building healthy minds in healthy bodies.”but instead of a simple remedy such as chlorine in drinking water or a vaccine to be scratched into the arm, there were complicated concepts of mental health education and child guidance. Yet, raising a child for a mentally healthy maturity is still a matter of theory, not scientific predictability, a hall century later, even when we add the interpretations and zeal of psychoanalysis. There is little scientific evidence today that mental hygiene education does in fact prevent mental illness, although we certainly believe it promotes human understanding and reduces stress. Furthermore, as our knowledge of genetic chemistry and the mathematical certainty of accidents of chromosome linkage has advanced, there is little cause for optimism about the production of healthy minds to order.

There are many persons in the mental health field, including some staff members of the National Institute of Mental Health, who still pursue the will-o’-the-wisp of positive mental health in preference to trying to love the mentally ill. Ironically. Beers himself provided some substance for their attitudes. His crusade did not come off well, in either its original or acquired objectives. As is characteristic of one with his disorder, he had his ups and downs, eventually dying in a mental hospital in 1943.

THE medical profession is as remiss as the public itself in grappling with the mental illness problem. It is common knowledge, confirmed by surveys, that the average physician, as well as the average layman, has unfavorable, sometimes openly antagonistic attitudes toward persons with psychological disturbances and toward psychiatrists themselves. The ordinary doctor’s training and experience is not slanted toward an appreciation of emotions and their implications, and many doctors have only one approach to mental illness: they try to get the patients out of their offices as quickly as possible.

Surprisingly enough, when we narrow the circle of rejection to the private practice of psychiatry, we find somewhat the same situation as far as psychotics are concerned. I have heard psychiatrists say they were interested in neurotics but wanted no part of psychotics. Their logic was indisputable: they could help the former but not the latter, they said; besides, their only possible basis for successful psychotherapy is that the patient wants help and will pay for it. Psychiatrists who work in mental hospitals or clinics with psychotics do not share these opinions; they frankly concede the limitations of psychiatric knowledge, but know and can see that persons with major mental illness can be helped, whether they pay or not. These psychiatrists are vastly in the minority.

Not long ago a young psychiatrist clarified for me the pivotal difficulty in the care of psychotics. I have the general impression that he had witnessed major mental illness in his own family, and therefore had the strongest of motives for wanting to help its victims — a personal one.

“Even before I went to medical school,” he told me, “I wanted to go into psychiatry and I wanted to treat psychotics. This was the real challenge. So I came to Boston to train in a hospital under three men who had the same objective. When I finished, I received a teaching and research appointment in this hospital, but the salary was low and I had the privilege of doing part-time private practice if I wished.

“So I started seeing patients privately, and again decided to concentrate on psychotics. I reached a point where f was treating six, in intensive psychotherapy, and felt that I was rebuilding their characters. There is a great satisfaction in it, but I found that I simply could not take them — not continuously. These are the most trying, tiring people on earth. So I cut down to three psychotics and filled in the open time with neurotics and mild character disorders.”

I felt a little sad, but also vastly relieved. Psychiatrists and their public relations spokesmen long have remonstrated with the public for turning its back on the mentally ill. “Mental illness is no different from any other illness. The mentally ill should be treated the same way as any other sick people.” These are expressions of good intentions. The public gives them some lip service, and a few sensitive and compassionate persons succeed in living by these principles, but out actions show that most of us really don’t agree with them, and for good reason. Psychotics are hard to take. Even the most conscientious of psychiatrists may find them so.

A recent study made at Washington University, Saint Louis, of criminal psychopaths confirms the pervasiveness of this rejection mechanism. Among social scientists studying the antisocial character of these persons, there was reported to be an active but not readily admitted effort to escape working with them. Likewise, a recent study of chronic schizophrenic patients under experimental treatment with a certain hormone at McLean Hospital in Boston bears out our thesis. A scientific analysis indicated that the treated patients were having more normal social relationships with other patients than those receiving a placebo. Further analysis showed that the treated group was not initiating these friendly approaches, but that the other patients were approaching them. It is of interest that the apparent effect of the drug was to make its users somewhat more receptive.

The psychotic’s lack of appeal strikes me as a satisfactory explanation of why, in the last analysis, the fight against mental illness never seems to get anywhere at the level of social action. It is safe to say that in our culture nobody gets anywhere without a positive appeal of some kind. However, upon further reflection, I would agree that the explanation is not a satisfactory one at the intellectual level. Why do we have so much difficulty in understanding psychological problems and solving them in the first place?

The great difficulty is that many people have trouble in recognizing psychological sickness as sickness, or in seeing sickness as having psychological forms. Unless the mind is educated to think in psychological as well as physical terms from a fairly early age, it may experience great difficulty in later life in thinking about itself and about other minds in relation to itself. The difficulty can be overcome, but against some odds, for the mind seems to resist the process, as if in the varied universe of knowing it were the one constant — fixed, dependable, sane. Most of us, in sum, are psychologically handicapped persons, mentally blind to our physical bias.

The mental health movement is engaged in an uphill pull against intellectual resistance to psychological insight. The nature of the psychotic’s trouble impels him to reject social order, and, heeding the ancient law of retaliation, we repay him in kind.

There is some evidence that the process has begun to reverse itself among younger, better educated people, since we have had a two-generation exposure to psychological and psychoanalytic information. Therapeutic techniques have evolved that break the circle of rejection and defeat it. Evaluations of the psychosocial approaches, proving old truths scientifically, show that some psychiatrists get amazingly good results from psychotherapy with schizophrenics. They also show that other persons, working individually or in groups in hospitals and clinics — social workers, psychologists, nurses, occupational therapists, attendants, enlightened volunteers—can do as much for the psychotic in their way as the psychiatrist can in his (it may be in the same way). In all cases, some kind of as yet ill-defined personal relationship develops between the therapist and patient. In most cases, the secret of reducing the fears, frustrations, and fatigues that beset those who try to work with psychotics is close moral support, given regularly or as needed by the therapist’s superiors or peers.

We know that insanity presents quite a different problem from a broken leg or gall-bladder attack. We also know that the line between abnormal and normal behavior is so blurred that anyone may step across it at one time or another. The psychotic, like the normal person, has good days as well as bad. The difference between mental illness and mental health is not as zero to a hundred, but, to press a fictitious measurement, it may perhaps be as little as forty-nine to fifty-one.

Consequently, with a fuller awareness of what people understand and believe, the mental health educators are going to have to revise their mental hygiene copybooks. Mental health is different from other health problems. Because it is different, we have to solve it differently. This new approach remains to be tested and proved, of course. Nevertheless, the older one has left so much to be desired, as studies of public attitudes have abundantly shown, that we have nothing to lose through a sharper public focus on our resistance to thinking about mental illness and on our rejection of its victims. We can hardly hope to hit a target unless we can locate it and aim at it.

READINGS IN PSYCHIATRY

A Selection for the Layman

For ATLANTIC readers interested in further pursuing topics discussed in this supplement and in learning more about psychiatry, Charles J. Rolo has prepared a selected, annotated list of books. Send your request for a free copy to Mr. Rolo at THE ATLANTIC MONTHLY, 8 Arlington Street, Boston 16, Massachusetts.