FRONTIERS BEYOND FREUD

...Not only is intensive psychotherapy usually too protracted and costly to be of any help to patients of low or moderate income, but the nature of psychiatric treatment, with its dependence on verbal communication as a means of ventilating and relieving anxiety, is such that the poorly-educated, with their inability to express themselves verbally in abstract or highly imaginative terms, have difficulty in establishing a profitable therapeutic relationship...

...While this exploitation sometimes goes under the heading of "occupational therapy," it actually serves to hinder the recovery of some patients and to increase their pathological dependence on the institution as their hospital stays stretch from weeks or months into years...

...While psychotherapy and its results are by their very nature subjective and intrinsically unmeasurable by strictly controlled experimental procedures, a number of comparative studies have failed to show any material difference in the ratio of improvement between patients who have undergone psychotherapy and those who did not get any treatment...

...The average state hospital has less than one employe for every two patients as against 2.5 employes per patient in general hospitals...

...The discovery of the thyroid hormone, of the infectious agent of syphilis, and of the vitamin niacin already have removed from the lists of the insane the victims of myxedema, syphilis, and pellagra...

...Countless others who need psychiatric help are not getting any treatment...

...The number of available psychiatrists&mdash...

...About 2.5 million other persons receive private psychiatric care or are under treatment in mental health clinics...

...Foreign-trained doctors, many of them with questionable qualifications, predominate—particularly in the Eastern states—on state hospital medical staffs which have increasingly become isolated—socially, medically, and linguistically...

...But serious obstacles are raised by the shortage of professional personnel and the requirement for massive expenditures by the states to match Federal grants...

...Although many psychiatrists continue to adhere to the Freudian doctrine of the preeminence of psychological factors in the causation and treatment of mental disturbance, this viewpoint has been increasingly challenged by those who strongly suspect that the...

...Rosenthal said, "an inherited factor needs to be present for schizophrenia to develop...

...David Rosenthal of the National Institute of Mental Health recently reported that on the basis of an intensive study of a group of schizophrenics he was convinced that schizo phrenia results from an interplay of hereditary and environmental factors...

...The findings of the New York study, which may or may not be typical of the rest of the nation, hit the front pages of the newspapers for one day and were promptly forgotten...

...But in any case, mental patients now occupy about 720,000 hospital beds in the United States, or more than the beds required for all other diseases put together...

...The dimensions of need in what is unquestionably our Number One health problem are truly staggering...

...Even when the poor manage to find free psychiatric clinics, they are frustrated by the long waiting lists and elaborate "intake" procedures, and are bewildered by doctors who expect the patients to do most of the talking...

...For in no area of medicine are the problems so formidable, the gap between need and available resources so great, and the general reluctance to face up to the grim realities so pronounced as they are in mental disease...

...These are only rough estimates made by specialists in the relatively new field of public mental health...

...At a time when the art of listening has been largely lost in today's assembly-line medical practice, and patients often search in vain for "tender loving care," the psychiatrist's basic function as a listener—to what is unspoken as well as to the spoken—clearly has a beneficial effect...

...While Dr...

...There are grave shortages not only of psychiatrists but of the whole range of professional and related professional specialties—psychologists, social workers, nurses, and physical, occupational, and recreational therapists...

...But overshadowing these practical considerations is a still more basic dilemma—the frequently limited effectiveness of current psychiatric procedures...

...They point out that since every activity of a living organism is associated with some sort of change in bodily structure or chemistry, it is ridiculous to divide a person's reactions into mental versus physical compartments and to draw a distinction between behavioral and biochemical events...

...The researchers found that because of the greater pressures of their deprived existence, the poor tend to have a higher incidence of psychoses, the most serious forms of mental disease, than do people in the upper economic levels, and the poor and the better-off receive radically different forms of care for their difficulties...

...The frequent result is that medical standards which would not be tolerated in the treatment of physical illness prevail in the care of the mentally ill...

...It acknowledges that emotional threats can be fully as harmful to the organism as microbial or viral invaders...

...Research into the biochemistry of the brain and the central nervous system has been greatly stepped up in recent years and is producing evidence that is, so far, only suggestive—but nevertheless highly significant—of a probable causal relationship between mental disease and organic abnormalities...

...Certain inherited deficiencies of the enzymes—the catalysts of chemical action in the body—are now known to produce some kinds of mental retardation, and with this knowledge the deficiencies can be controlled and the retardation avoided or minimized...

...There is impressive evidence of an hereditary disposition toward schizophrenia, the severe psychosis which accounts for about half of the hospitalized mental patients, and this in itself strongly suggests a physical disorder...

...But the admission rate has gone up sharply, particularly in the younger-age groups...

...In no branch of medicine is there such a clear class distinction in the incidence and pattern of mental and emotional illness and in the character of treatment available for it as there is in psychiatry...

...He is the author of the book, "The Troubled Calling: Crisis in the Medical Establishment...

...The Ffollingshead-Redlich study also examines the marked difference in the relationship of the average psychiatrist, as a middle-class citizen, to patients of his own class and to the poor...

...But mental disease often has a natural tendency to remit spontaneously with time...

...This broader concept is anchored in the essential unity of mind and body...

...Treatment of the mentally ill in the community, often on a part-time basis that allows them to live at home and frequently even to continue working, is obviously a step in the right direction...

...Much impetus to this approach has been lent by studies of the tranquilizing drugs and of such hallucinogenic substances as LSD and mescaline which by their mode of action indicate that even the slightest distortion of naturally-occurring materials in the body may produce mental disturbance...

...But this is hardly surprising in an area so complex, so new, and beset by so many variables...

...Americans, or someone in one of every three families, will need some kind of treatment for mental disturbance in the course of a lifetime...

...Dr...

...A considerable number of new psychiatric clinics have been established with Federal aid since the enactment of the Community Mental Health Centers Act in 1963, and plans are underway for the construction of many more such facilities during the next few years...

...Frontiers beyond Freud by SELIG GREENBERG IVTOT LONG AGO a careful research study ^ " of the mental health of the residents of a 200-block area in the Yorkville section of New York City came up with some startling findings...

...There is a basic difference in this respect between psychiatry and the rest of medicine...

...Gradually emerging from the multitude of research approaches in the psychiatric field is the balanced view that emotional and mental disturbance, like all disease, cannot be attributed to any single cause but is the end result of many interacting factors...

...It is therefore logical to assume, they contend, that mental derangement results from chemical changes which are often brought about by environmental pressures...

...The trouble is that the causes of serious mental illness are still unknown, and there is no rigorous scientific proof that the prevalent forms of psychotherapy produce any lasting improvement...

...Even in the overcrowded state institutions where most of the poor are dumped, middle-class patients usually receive more attention and care...

...It views mental disease as the outcome of interaction between the physical and emotional elements in the human organism...

...principal answer lies instead in abnormalities of body chemistry...

...Before it can hope to do so, it faces the gargantuan task of resolving the profound mystery of the interdependence of mind and matter, of trying to evolve a rational explanation of what is frequently an irrational process, and of sorting out and integrating the great diversity of genetic, organic, psychological, and environmental factors which come together in the fashioning of human personality and in its breakdown...

...Most psychiatrists, with their economic and cultural affinity for well-heeled patients, are concentrated in the more affluent neighborhoods while a disproportionately small percentage—and that accorded the least prestige—is concerned with the care of the bulk of the mentally ill in the state institutions...

...There appears to be little question that social and economic deprivations are associated with a significantly higher frequency of mental illness, which often goes unrecognized and untreated, and that such symptoms are commonly handed down by the poor as a grim legacy to their children, making it all the harder for the young to escape the bondage of the hopelessness of slum existence...

...It recognizes that there is a reciprocal relationship between psychological events and physiological functions and that the degree to which a person can resist the damaging emotional impact of environmental conflicts is considerably influenced by his biological vulnerability...

...Many of these unfortunate patients also are the victims of a system of institutional peonage in which they are used as unpaid laborers to do some of the work which should properly be done by paid employes...

...Their classification as "mental" patients is clearly designed to justify their forcible removal to places of custody and to diminish the pressure on society to provide suitable accommodations for them...

...Between one-fourth and one-third of the patients in the large state mental hospitals are over the age of sixty-five, and there is good reason to believe that many of them do not belong there at all...

...Patients treated by any of our current rituals may show temporary spurts of improvement but retain no discernible advantage after five years over those diagnostically matched but left untreated," Dr...

...There is little proof, however, that psychiatric treatment can produce any permanent improvement in the milder forms of emotional disturbance and virtually none at all that it can cure serious mental illness...

...some 18,000—is pitifully small to cope with the demand, while the cost of private psychiatric treatment, usually ranging from $20 to $50 an hour, is out of reach of most people...

...If the troubled individuals in these groups had been included, the statistics would undoubtedly have been even more depressing...

...Of the 175,000 persons studied, only 32,000, or about eighteen per cent, were without any symptoms of mental illness...

...However, without severe environmental stresses the illness may not appear in those who have predisposition to it...

...Many emotionally disturbed people undoubtedly benefit from psychotherapy, a process of supportive communication with a therapist designed to help the patient gain some insight into the roots of his conflicts and frustrations, to reduce his irrational fears and feelings of inner guilt, and to develop more realistic attitudes toward the demands of daily living...

...The social and cultural gulf between doctor and mental patient can be an insuperable obstacle to effective treatment...

...Francis J. Braceland, former superintendent of the Institute of Living, a well-known private psychiatric hospital in Hartford, Connecticut, has urged his fellow psychiatrists to take into account the interrelationships between emotions and organic functions...

...Already burdened by the costs of their mental hospitals, many of the states are not happy about committing themselves to a new area of expenditure, even though it would not only spare much human misery but is likely to prove in the long run considerably more economical than the alternative of lifelong custody for many of the mentally ill...

...Hopefully, the future will bring other biogenic discoveries to add new weapons for combating mental disease or retardation...

...Mental illness is not so easy to treat, and the psychiatrist cannot depend upon pills, vaccines, or intravenous solutions, all nicely free of biases of personality and prejudices of class...

...Most of them are suffering from various degrees of senility and are in need of reasonable medical and nursing care...

...Unless more of these young adults can be treated on an outpatient basis in general hospitals and community psychiatric clinics, they will inevitably contribute to the accumulation of long-term patients in the state institutions...

...Moreover, it is extremely difficult to distinguish between the effects genuinely created by psychiatric treatment and the placebo effect produced by the therapist's concern and the patient's faith in the treatment process...

...Under these circumstances, the best most patients in mental hospitals can expect is no more than custodial care...

...The proponents of the organic orientation argue that behind every distorted mental process there must inevitably lie some physical abnormality...

...Psychoanalysis, the most elaborate form of psychiatric treatment, is a long and inordinately-costly process lasting several years during which the patient is required to see the analyst anywhere from two to five times a week...

...Psychiatry's approach is still crudely palliative, it is splintered into a plethora of schools with often mutually exclusive theories and practices, and it has so far failed even to begin to grapple with the enormous problem of the severely mentally ill locked away in the big state mental hospitals...

...It is estimated that one of every ten SELIG GREENBERG is a prize-winning reporter on medical and related subjects for The Providence Journal and Evening Bulletin...

...The state mental hospitals are struggling with inadequate personnel, overcrowding, antiquated housing, and poorhouse financing...

...Even with the best of intentions on the part of the psychiatrist, the poor are often hard for him to understand and hence to be suitably treated...

...More than fifty-eight per cent gave evidence of mild to moderate mental disturbance, while more than twenty-three per cent were found to suffer from marked or severe mental disease...

...Masserman's candid acknowledgment of the lack of a firm scientific base for Freudian-oriented psychotherapy was unusual for an official psychiatric gathering, it came as no news to those familiar with the heterogeneous collection of techniques which go under the name of psychiatry and the absence of solid evidence that any of these procedures has any lasting effect...

...Jules Masserman, a prominent psychoanalyst and co-chairman of the department of psychiatry at Northwestern University Medical School, told the World Congress of Psychiatry several years ago...

...Excluded from the study, made by the social psychiatry unit of Cornell Medical School, were children, the aged, Negroes, and Puerto Ricans, groups which generally show a high incidence of emotional maladjustment...

...There is a growing conviction among many researchers that the purely psychological concept of mental illness is vague and sterile and that such disease is basically the result of some biochemical abnormality which may be triggered by tense home environment, poverty, rootlessness, and a variety of other stresses...

...The seeming discrepancies in these estimates and the more alarming figures of the Cornell study only highlight the current cloudy view of what constitutes mental illness and the degree of its severity...

...Recent breakthroughs in the field of genetics through deciphering of the genetic code and the identification of the molecular structure of the chromosomes governing our inherited characteristics have rapidly proved to have practical applications...

...In most cases," Dr...

...While the well-to-do are likely to be treated with individual psychotherapy, the severely-disturbed poor are usually sent to the state mental hospitals where they are liable to be relegated to the chronic back wards, to vegetate there for the rest of their lives if they fail to respond quickly to shock treatment or drugs...

...Despite many promising leads, the biology of mental illness is still murky...

...The direct relationship between social and economic status and psychiatric symptoms and care has been scrupulously documented in a classic study by Drs...

...J. Sanbourne Bockoven, another well-known psychiatric researcher, has emphasized that physiological and psychological changes are enmeshed in "a circular series of events" resulting in mental illness...

...Alienated to a large degree from the mainstream of medicine, psychiatry has yet to attain a solid professional definition and to become an exact scientific discipline...

...An infection is an infection," one commentator has observed, "and rich and poor respond to the same dosage of penicillin...

...Although there has been some improvement in recent years in the level of care provided in our state mental hospitals, most of these institutions are still underfinanced and understaffed and unable to give intensive therapy to any but the most promising patients...

...A. B. Hollingshead and Frederick C. Redlich of Yale University and in two other studies made by the social psychiatry unit of Cornell Medical School...

...Freud himself said that "all our provisional ideas on psychology will some day be based on an organic substructure...

...The steady rise in the mental hospital patient census has been stemmed in recent years by the stepped-up discharge rate made possible by the calming effects of the tranquilizing drugs...

...While daily costs in the average general hospital are now running close to $50 per patient, operating expenses in mental hospitals still are averaging about $7 a day...