Mental Disease and the Urban Hospital

John H. Knowles, M.D.

NEITHER the mentally ill nor those who have struggled to care for them have ever had an easy time of it. At various times in history, those afflicted with mental disease have been deified, tortured, jailed, killed, chained, ridiculed, and, in the last hundred and fifty years, housed humanely in private upland sanatoriums or in less than ideal conditions in public institutions. They have been a source of tragedy, bewilderment, horror, and even amusement. They have been accused of possession by demons and evil spirits, having a “method in madness" to suit their own ends, and playing the most successful game they can with the social problems they encounter. Depending on whom you talk to in the medical profession, you will hear that the cause is organic and due to humoral toxins, or brain damage, or a failure of biophysical processes; or you will hear that the cause is not organic and is due to tricks of the unconscious, tempered and molded by unpleasant childhood experiences and family relationships now repressed and appearing as deviant behavior.

In its attempt to treat such behavior, society at large has rejected, punished, and committed those so afflicted (for care, or convenience, or self-protection), and families have disintegrated under the burden of justified or unjustified feelings of guilt. Treatment has progressed from ritualistic dances and orgies to drive out the evil spirits, to craniotomy to free the noxious vapors, to the externalization of anxieties by religious dogma and symbolism, to the moral treatment of Pinel emphasizing humane treatment and freedom from restraint, to the psychoanalysis of Freud, to the use of insulin and electric shock, to the use of the mental hospital as a studied therapeutic environment, and, finally, to the present use of tranquilizers and positive attempts to reintegrate mental patients back into the community. Superficial psychotherapy uses talk, environmental manipulation, programming of the patient’s life, as well as drugs and shock therapy. Some success has been claimed for all these methods, but none has a clear-cut superiority by scientific study thus far.

The psychiatrists have had an equally difficult time, burdened as they are with the onerous task of making rational what remains a largely irrational and illogical process, although Freud emphasized and established, at least partially, the rationale of irrationality. The organicists, some of whom are psychiatrists, point out that the discovery of the thyroid hormone, the infectious agent of syphilis, and the vitamin niacin removed from the lists of the insane asylum those afflicted not with mental disease but with myxedema, syphilis, and pellegra masquerading as mental disease; ergo, in time all mental disease will be found to have a metabolic, chemical, or structural basis.

Some doctors distrust the psychiatrists and question their motives. They point out that the upper social classes and the well-to-do receive long-term psychoanalytic care while the lower classes receive short-term drug and shock therapy, noting that one patient in psychoanalysis for one year is worth $5000 and eight such patients, for one hour a day, five days a week, are worth $40,000 to the analyst. Some are annoyed that the psychiatrist is virtually the only medical specialist who will not give professional courtesy to fellow doctors, with the explanation that the transfer of money is an integral part of the successful therapeutic relationship and he would otherwise be swamped with free psychiatric care for his colleagues and their wives and children. The public and some of the medical profession still view the psychiatrist as someone “a little queer himself,” entering psychiatry in order to gain dominance over people “the easy way” and to solve his own problems.

As the social scientist views the broad sweep of history and man’s attempt to control his destiny and to gain identity, he is particularly interested in the loss of an effective mechanism for handling personal guilt, The success of the Freudian revolution is partly explained by its assumption of psychological determinism and the power of the subconscious, which essentially freed man of responsibility for his acts and, furthermore, allowed him to hold others, such as members of his family, responsible for his predicament.

Critics have said that the adoption of the Freudian ethic has resulted in the subversion of the Protestant ethic of hard work and responsibility and that we in the United States, in particular, are breeding a nation of irresponsible and dependent sheep. What we all need, they say, is a good kick in the seat of the pants and a return to the days of self-reliance instead of sanctioning delinquency and other forms of deviant social behavior as sickness.

Many of these views reflect general ignorance and prejudice concerning Freud, whose aim was to help an individual to become more self-conscious and to gain self-understanding through the insights of psychoanalysis so that he could assume more responsibility for his activities, and therefore gain more self-reliance.

The social scientist wonders if the psychiatrists have been too passive in their acceptance of the social disease of man as mental illness. Physicians, too, wish there were clearer limits to what is at present a virtually open-ended concept. Where does legal responsibility for criminal acts end and sickness begin? Which comes first, mental illness or loss of job — or failure in school — or divorce? Where does the responsibility of psychiatry begin and of the community end in these matters? What part do poverty, our educational system, our recreational facilities and our current uses of leisure, the structure of the family, the religious profession, the legal profession, and the mass media play in mental disease, its cause, its prevention, and its cure? Why have psychiatrists not paid more heed to the social and behavioral sciences, instead of endlessly listening and talking to the individual patient, in order to alter the alienating and disruptive social processes at the root of mental illness?

THE PRESSURES ON THE GENERAL HOSPITAL

In the midst of this intellectual muddle, the urban teaching hospital has heard the rumble of a steadily expanding army of emotionally exhausted people — the anxious, the depressed, the alcoholic, the suicidal, the homosexual, the unemployed, the beatnik, and the patient with chronic illness looking for help and hope. They are all suffering from a loss of nerve and “the other type of heart failure.” The figures are staggering: half of all the hospital beds in the United States occupied by the mentally ill —600,000 on any one day; and an estimated 17 million people suffering from some form of psychological disturbance or mental illness. In the last half century, the population of the United States has doubled while the public mental hospital population has quadrupled, a trend which has only recently been checked. The overall prevalence of psychiatric illness in a community may be as high as 8.5 individuals per thousand, with much increased rates for the elderly (30 per thousand) and the urban dweller (twice the exurban rate). It has been estimated that one person in twelve will be hospitalized at some time during his life for mental illness.

Equally staggering is the fact that there are only 16,000 psychiatrists in the United States, of whom roughly 12,000 are qualified as members of the American Psychiatric Association to treat these millions and fewer than 1000 are qualified psychoanalysts. There is only one psychiatrist for every 15,000 people, contrasted with roughly 20 physicians and surgeons, 8 dentists, 20 priests, rabbis, and ministers, 7 social workers, and 215 federal employees per 15,000 people. Furthermore, the distribution of psychiatrists heavily favors the cities, particularly those with prominent, large medical schools and teaching hospitals. In smaller communities, the neurologist or neurosurgeon doubles as psychiatric specialist, while the general practitioner humors the neurotic and institutionalizes the psychotic patient. In 1959 there were 1.4 psychiatrists per 100,000 population in Alabama, contrasted with 15.6 in New York state.

It is apparent that the need, as currently defined by psychiatry, has far exceeded resources, not only as regards psychiatrists, but the equally important psychologists, psychiatric nurses, and psychiatric social workers. The urban hospital sits in the midst of the heaviest concentration of mental disease and social unrest. What is its role?

Today, the psychiatric service of the urban hospital is confined to the short-term, in-hospital or ambulatory clinic care of psychoneurotic patients. Traditionally, those afflicted with a psychosis or more long-term, debilitating psychoneurosis have been sequestered by their immediate removal to state institutions or to the urban hospital’s private psychiatric division in the country. The current principles of psychiatric care have been developed in these separate country asylums, evolving from a purely custodial function to the present use of intensive psychotherapy in an institutional social system geared to creating a positive, therapeutic environment, and the judicious use of electric shock and the tranquilizing drugs.

These advances, coupled with the trend toward community reintegration of the mental patient instead of mental hospital segregation and toward the increasing use of short-term hospitalization in general hospitals, have resulted in a steadily decreasing period of hospitalization and a much higher discharge rate, from 35 percent admitted in 1920 to 85 percent in 1953. The trend toward increasing numbers of hospitalized mental patients in proportion to the population has been reversed in the past eight years, a most important change which has occurred despite the accelerating expansion of population. Meanwhile, doors have been opened to the community with the development of day and night care, halfway houses, and active rehabilitation programs using music, art, crafts, and recreation. Schools have been developed on the grounds for disturbed children and adolescents so that they may continue their education.

At the urban hospital, the successful invasion of medical and surgical wards by psychiatrists with much knowledge to impart as regards the psychological significance of somatic (pertaining to the flesh, or organic) illness and surgical procedures, and the uncovering of serious psychological abnormalities in somatically ill patients, alone or as part of a psychosomatic illness, has earned the psychiatrist an important place on the medical team. In addition, he has conducted ambulatory clinics for psychoneurotic patients and for those with special problems such as alcoholism.

Recently the psychiatrist has turned increasing attention to the psychological growth and maturation of children, with the hope that better understanding of those processes will lead to the prevention of mental illness in later life. The learning process starts at birth and is determined biologically, by genic inheritance, and by numerous external factors and influences. What are some of the factors which may lead to mental disease?

Numerous studies have demonstrated the harmful psychic effects of maternal and paternal deprivation on both developing infants and children. Boys between the ages of five and eight are probably most susceptible to paternal deprivation. Delinquency and neurosis may result. Homosexuality may develop where there has been a strong attachment to a domineering mother combined with paternal deprivation. Maternal deprivation is more important in its consequence for children, particularly female children, before the age of five and leads significantly to adult neuroses and psychoses. Children deprived of their mothers may in later years show immaturity, psychopathic behavior, and retardation of growth, speech, and intellect. Juvenile delinquency and prostitution may develop. (It is extremely important for the lay reader to understand that these psychopathologic states do not develop inevitably and that there are many instances where deprived children have matured normally.)

There are also varying degrees of emotional and physical deprivation which may occur even though both parents are present in the house. It is this observation, coupled with other detailed studies showing the importance of the assumption of the appropriate role of mother or father by the parents, the proper identification of their parents’ roles by the children, and the critical nature of family interaction with the proper balancing of love, support, and approbation on the one hand with punishment, direction, and disapproval on the other, that has made the psychiatrist and his psychological theories of prime importance in the area of pediatrics.

The findings listed suggest that there may be a very important role in the prevention of mental disease, to say nothing of its detection in its incipieney, when the manifestations may very subtly suggest only a reading or a language problem or even mental retardation. Coincidentally, psychiatrists have decried the separation of mother and child when the child is hospitalized and have urged that the mother be present, if possible — a desirable practice which in most hospitals has been a long time coming.

SOCIAL AND PREVENTIVE PSYCHIATRY

The newly developing field of social and preventive psychiatry is effectively extending the interests of psychiatry and the urban hospital into the community. The psychiatrist interested in prevention attempts to intervene at strategic points in the social system of the community, so as to prevent mental disease which results from a disruption or inadequacy of the social system. His interest starts with the family unit and extends to the educational and the religious systems, the local public health unit, the political structure, and so on. His points of intervention and interest are applied both to the social environment and to points of potential crisis in the individual’s life, such as entrance to school, marriage, pregnancy and childbirth, menopause, retirement, and disease or death of a loved one. His intervention may promote the social well-being of the community by altering inadequate social systems; he may support the work of the religious profession and other caring groups, or lecture to groups of individuals on mental health, or help to provide the needed facilities and methods for coping with acute mental disease.

This kind of psychiatrist is interested in the improvement of the educational system, the elimination of poverty, the evolution of the legal system as it relates to deviant and delinquent behavior, the adequacy of recreational facilities, the upheaval of communities and their relocation as a result of urban renewal, and the proper use of the mass media to enlighten, uplift, and inform rather than stultily, confuse, and upset. He functions as an expert in social psychiatry and should work closely with and understand intimately the political and other power structures of the community in order to obtain action. His activities are concerned with the caring agencies — the clergy, the public health unit, the hospital and chronic care system, the law courts, and voluntary health agencies, such as the United Community Services. It is desirable for him to have training in the social and behavioral sciences in addition to traditional psychiatric training.

The plan may sound grandiose. It is. It may also imply that improvement of social conditions will decrease mental disease. This is true under some conditions, such as slums and poverty, and untried in other areas, such as the use of the mass media. It may also imply that the psychiatrist should run the entire community. He should not, but he should function as consultant.

The Wellesley Human Relations Center, under the direction of Erich Lindemann, chief of psychiatry at the Massachusetts General Hospital and a professor of psychiatry at the Harvard Medical School, is an example of a community health program. A team of social scientists and psychiatrists established a mental health program in Wellesley, Massachusetts, in order to study the effects of coordinated activity with the other agencies interested in health, welfare, and education. The first problem was to motivate people to use the service — a recurring problem in public health activities, and a particularly difficult one for mental health, for obvious reasons. The study concerned itself with intervention in situational crises, such as severe bereavement or the return of a mental hospital patient to the family. The successful coping with such crises was studied intensively with the ultimate aim of finding out what kind of intervention by community health organizations would be most beneficial to the individual, his family, and the community. In addition, the crises of transition were studied, such as entrance into kindergarten, marriage, and so on, as well as the general behavior of middle-class families as related to the growth of their children, their mental health, and their ability to adapt to crisis.

The importance of this pioneering effort is attested to by its continuing fruitful production of valuable information and its successful intervention in health-promoting activities in Wellesley. As Dr. Lindemann said recently:

Tracing and understanding the needs of the community, we have been helpful in creating a mental health agency which fitted well with the expectations and concerns of the citizens of this suburban middleclass community. These were the advancement and success of their children, the control of deviance and failure, and the early discovery of possible impairment of health. They were able to plan cooperatively and to develop their own program using us as resource persons.

PSYCHIATRIST VERSUS PHYSICIAN

The reader at this point may ask, justifiably, “How can psychiatrists do all this when there is such a shortage of them?” and “Why is the psychiatrist so well qualified for this position?”

In answer to the first question, there is indeed a serious shortage of psychiatrists and other psychiatric personnel, as we have pointed out, but the function of the preventive psychiatrist is to influence communities and their social systems to improve themselves, utilizing the existing facilities or providing new facilities and services where necessary, He works with groups rather than individuals to strengthen the social system.

The second question is usually asked by other members of the medical profession who look upon studies in the social and behavioral sciences as nonscientific, the worst adjective that can be applied to anything in the present era. But the psychiatrist as social scientist is the only one in the field of medicine trying to study and improve the situation; the rest of the medical profession has let these responsibilities go by default.

With expanding psychological theories, the increasing social ills of mankind, and the recent successes of psychiatry with drugs and therapeutic rather than custodial care, the psychiatrist has been taking a long look at his colleagues, particularly the specialist in internal medicine, and has been wondering seriously whether he should assume the center stage as the urban G.P. Why should he not see all patients first and last, calling in the specialist for specific purposes — for example, the treatment of heart failure or pneumonia, or the setting of a fracture, or the transplantation of a kidney? After all, isn’t he, the psychiatrist, the only one who really understands the psyche and the dilemma of modern man, and who is, therefore, in the best position to treat the whole patient? Now that he has utilized the social and behavioral sciences, a natural extension of his individualized care of the mentally ill, isn’t he really in the best position to provide continuity of care and to understand all aspects of the patient’s problem? Whether the patient has somatic or mental disease, the psychiatrist believes he needs psychological as well as somatic care; therefore, why shouldn’t he become the general practitioner of the urban hospital and the medical school, displacing the department of medicine from its traditional occupancy of this position?

This is a very healthy jurisdictional battle between two strong unions of the medical profession; and the psychiatrists, although they are gaining ground, are still on the weak side. First, the cults and camps of psychiatrists and their practices have seriously divided their team. Their very division has rendered their arguments less effective and has added evidence to bolster the charges that they arc unscientific and that their various theories as to the nature of mental disease are unproven.

Second, the cure rate of the mentally ill, although it is improving, does not emphatically point to any single mode of therapy as superior, and chronicity continues to characterize two thirds of all mental illness. (The psychiatrist argues that the internist does not cure many people either, and he is right.)

Third, many psychiatrists have chosen not to fight with the rest of medicine and have instead stayed in their own club and removed themselves from the battlefield of care, the urban hospital, to the country mental hospital. Tired of coping with what some of them call the stupidity of the organized hostility of physicians and surgeons, one told me he felt better working with his colleagues (provided, of course, they were of the same school) and getting on with his work in a less hostile environment.

PSYCHIATRIC CARE IN URBAN HOSPITALS

The urban general hospital must be able to offer all forms of psychiatric care and facilities to the urban dwellers. This is not to say that long-term and chronic care, as well as other special situations, will not continue to benefit from the freedom and pastoral tranquility of the country asylum. It does mean, however, that many patients will be able to obtain excellent care and aftercare in the general hospital that they now can obtain only through their segregation and institutionalization. The therapeutic environment can be obtained in the general hospital, and this, coupled with the atmosphere of the urban hospital, generally should facilitate more rapid reintegration of the patient into his community and his family without the added negative values and beliefs of our culture, These attitudes, if anything, help to maintain mental disease because of the stigma attached to hospitalization in a psychiatric institution (guilt by association). The urban hospital should provide facilities for acute and short-term care of all forms of mental illness, and its staff should be a little slower to commit such patients to state or private psychiatric institutions.

The possibilities of day and night care, halfway houses, and active rehabilitation programs should also be considered. In Massachusetts, a state program of mental-health-center construction has been instituted which will accomplish these things. The most important decisions were that the centers will be located in the environment of the patient population and will be as closely integrated as possible with the life of the urban general hospital. Federal support for this type of program is provided through the Hill-Harris bill (Community Mental Health Centers Construction Act of 1963).

In summary, the role of psychiatry in the urban setting should be expanded in four directions, preferably all based in the environment of the urban hospital:

1. The continued and increasing participation of psychiatrists in the care of medical and surgical patients, and the steady effort to bring their ideas concerning the psychology of illness and the crises surrounding it to the attention of internist and surgeon;

2. The increasing use of psychology and psychiatry in the care and study of children, their growth and development, with proper emphasis on the family as the focal point of mental health and normal psychological maturation;

3. The development of preventive and social psychiatry, which will extend the hospital’s interest to the community, where active intervention may prevent illness or provide patients with care and rehabilitation;

4. The integration of some of the practices and interests of the segregated specialty psychiatric institution, particularly the concept of the therapeutic environment, so that more of the community’s mentally ill can be cared for in their own locales and be returned more quickly and easily to job and home from the urban general hospital.