Journal of Religion and Health, Vol. 13, No. 1, 1974
Psychiatry in the Year 2001 IRVING M. ROSEN There are ominous clouds in m y view of the future of psychiatry. Perhaps I can find some flickers of hope; at least there is the possibility that prophecy may help to stave off disaster. Study of the recent past of psychiatry reveals rather clearly that the line of progress in this field is not straight up; instead, we see, particularly with regard to the more visible hospital population, cyclic, up-and~lown trends. We do, presumably, make some progress, but the tendency to cycle seems stronger than the thrust upward. I recall m y surprise some years ago at learning that the first half of the nineteenth century, the period of "moral t h e r a p y , " was an era of enlightenment with results equal to our current best. The treatment was humanistic and optimistic, directed to the whole person with emphasis on individual regimens of work and recreation, religious and educational services, and care by a sympathetic superintendent and well-disciplined attendants. 1 The light went out sometime about 1860. Psychiatry slid into a prolonged era of dehumanized practice, warehousing patients in monstrous asylums from which few ever emerged. This nadir of psychiatry coincided with the development of the new medicine that was making notable advances in finding organic causes and cures for m a n y age-old plagues. Unfortunately, the bulk of the c o m m o n mental disorders did not yield to this advancing medical technology. Answers were n o t found, even after decades of careful classification and microscopic brain tissue examination, to the riddles of schizophrenia, manic-depressive psychosis, neurosis, and character disorder. In the late 1940's we saw a change. Enough people became interested in talking with patients again to spark the emergence of a new humanistic era. Most likely the psychoanalysts and their imitators should be given much of the credit for the breakthrough. Though Freud believed in an ultimate organic cause for psychiatric illness, he encouraged mental health workers to know their patients and help t h e m with psychological insights while waiting for answers to be discovered under the microscope. Interest in the psychology of the individual led to concern about life in the family, various Irving M. Rosen, M.D., Director o f Education at the Cleveland Psychiatric Institute and a member o f the Institutes of Religion and Health, has written many articles published in journals of psychiatry and pastoral care. This paper was adapted from a talk given at the School of Applied Social Sciences, Case Western Reserve University, Cleveland, as part of an institute on the future, January 28, 1972. 19
20
Journal of Religion and Health
other groups and institutions, and the community. We are still, in 1974, I believe, under the dominating influence of a humanistic and holistic philosophy. Hospitals are increasingly humane; patients do leave quickly; and results are comparable to those of the early 1800's. I am mindful that some of our recent success must be attributed to the use of powerful tranquillizing drugs introduced in the mid-1950's. These drugs are not however, "magic bullets" or curative agents, but adjuncts serving to quiet and make secure the milieu of the hospitals and to pave the way for expanded educational and other rehabilitative programs extending beyond the gates of the institution. The very marked decrease in the census of some hospitals in the past decade, after the drugs had had their major effect by 1960, appears to have been the result of creative management, intensified efforts to combat dehumanizing practices, and new programs to meet developmental needs of maturing persons. At present, the Freudian dominance, so apparent during the 1950's, is rapidly fading. Students of psychiatry and social work want, and indeed demand, more effective and fast-acting tools for treatment. Training programs are changing as new philosophies and techniques are introduced. In my view, we have now entered an eclectic phase characterized by a competition of several philosophies. Among them one can discern, in addition to the older Freudian and medical-organic schools, three burgeoning trends: the neo-Freudian ego psychology of Hartmann, Erikson, and Federn emphasizing coping and fulfillment of developmental needs and de-emphasizing conflict and analysis; the existential, "here and n o w , " schools emphasizing awareness and self-emergence (Perls, Schutz, Rogers) or responsibility and cognition (Glasser, Ellis, Berne, Frankl); and the behavior modification schools adapting conditioning theories from animals to man (Skinner, Wolpe, Stampfl). For the purpose of prophecy, I believe the significant battle lines will be drawn between those schools of t h o u g h t that tend toward atomization of man versus those that see man as a whole--a conflict ultimately between efficient technology and holistic humanism. The organicists continue to improve their ability to bring about rapid and visible behavior change through drugs and mechanical methods of affecting brain tissue, and the conditioning technicians also are becoming more sophisticated and effective in manipulating behavior. Although effective tools are certainly desirable, there is a strong and u n f o r t u n a t e t e n d e n c y fo~ people to settle for short-term relief coming from external sources in contrast to the long and vague processes involved in learning to deal with emotions and in learning to function in a relatively a u t o n o m o u s and mature manner. The mistake of considering an adjunct to be the cure has occurred widely with the new psychiatric drugs and with electric shock methods. I fear that when people settle for immediate relief provided by strong sources outside themselves they are weakened and made susceptible to depression and dependence on drugs and helping persons. Methods that are simple, easily taught, and that give quick and easily documented relief will strongly tend to become
Psychiatry in the Year 2001
21
dominant over holistic methods, which are difficult to validate and to teach and learn and which tend to diffuse slowly through our schools. There is one other serious problem with holistic methods that comes precisely from their difficulty of validation. Pioneering theories like Freud's tend to become rigid quickly and to interfere with efforts to improve on the work of the hallowed pioneer. Critics of the pioneer--men like Frankl and Perls and Glasser--who have valuable improvements to demonstrate are not allowed soon enough to add their insights to the dominant school and to be taught widely. Thus the whole humanistic enterprise fails to compete in effectiveness. I am fearful of the ultimate effect of the rapid inroads being made by the learning theorists into the field of treatment. Their theories are useful and cannot be neglected. But they do not see whole people, only abstracted behaviors. Since only behavior can be measured, t h e y have a rationale for avoiding what goes on inside the person. Skinner and the other learning theory pioneers have some valuable things to tell us, but t h e y could emerge soon as the d o m i n a n t philosophers for the next era. It should be obvious by now that I am led to believe that we can expect a swing of the pendulum back to an atomistic, dehumanized period fed by the hope, as in 1860, that more efficient cures are in the offing with the new technologies. I expect people to become more dependent, addiction-prone, and depressed even as they are given strong temporary relief. In fact, this depressing tendency has already begun. Perhaps our asylums will not soon grow again, but our c o m m u n i t y caretakers will be very busy and antidemocratic tendencies will grow as people look outside their own reliable selves for direction, relief, and order. There are, sad to relate, other forces in our culture that are leading to an emptying of the competent self. There is a continuing loss of meaningful work and erosion of such stable h u m a n units as the family and church. There is what Silber, the new president of Boston University, calls the "pollution of t i m e " as meaning is drained from important landmarks of time, including rites of passage, annual religious holidays, and the unfolding of life slowly through childhood, adulthood, and old age. 2 All this loss of personal significance and stability could lead to more fundamentalism and authoritarianism and even to a flare up of extremism on the right or left. As I have intimated, c o m m u n i t y psychiatry as now constituted will not stem the antihumanistic trend. People need more than crisis t r e a t m e n t and the revolving door philosophy that has replaced institutionalization. Yes, they are living in the c o m m u n i t y , but t h e y are on periodic injections of a long-acting tranquillizer and are being seen by visiting nurses instead of hospital attendants. Their real developmental and social needs are n o t being met. The days of reckoning, of true problem-solving, of growing up, are being postponed. Until more attention is given to the concept of definitive treatment whether in a hospital, transitional facility, or c o m m u n i t y and until much more attention is paid to the scandal of our multiple relapsing clients, c o m m u n i t y psychiatry will n o t influence the insidious downswing of our cycle.
22
Journal of Religion and Health
It is clear t h a t I am pessimistic and do not believe that we can long delay Orwell's 1984, certainly not b e y o n d 2001. There is some hope, however, and we can at least go down fighting. Perhaps there is time to teach people how to relate and communicate, how to manage their emotions, how to create a stable family and rear children, and how to receive information, make decisions, and solve problems. In short, maybe our schools and churches will decide to teach the really important subjects of life. Perhaps our agencies, prisons, courts, police departments, churches, and schools, all of which have been subjects of recent books recounting their failures, will begin to fulfill their mandate and actually render useful service. This will happen when their workers and practitioners spend as much time learning about people as they do learning the bare tools of their trades. We may hope that our professional schools will begin to teach an up-to-date humanism based on all we know about personality and treatment and not just on the one obsolete theory to which the school may rigidly subscribe. While I believe there are enough effective theories and methods to revitalize the now retreating humanism, we must and can learn to validate this knowledge and to point out the long-range shortcomings of purely mechanistic and atomistic techniques. The latter should be kept strictly in their place as strategic adjuncts. After all, even powerful tools do n o t make good religious or political systems, and in psychiatry t h e y will not cure any of our current emotional plagues. One may hope that it will not take several generations to learn these lessons the hard way.
References 1. Caplan, R., Psychiatry and Community in Nineteenth Century America. New York, Basic Books, 1969. 2. Silber, J. R., "The Pollution of Time," Bostonia, Boston University Alumni Magazine, 1971, 45, 9-15.
Psychiatry in the Year 2001 IRVING M. ROSEN There are ominous clouds in m y view of the future of psychiatry. Perhaps I can find some flickers of hope; at least there is the possibility that prophecy may help to stave off disaster. Study of the recent past of psychiatry reveals rather clearly that the line of progress in this field is not straight up; instead, we see, particularly with regard to the more visible hospital population, cyclic, up-and~lown trends. We do, presumably, make some progress, but the tendency to cycle seems stronger than the thrust upward. I recall m y surprise some years ago at learning that the first half of the nineteenth century, the period of "moral t h e r a p y , " was an era of enlightenment with results equal to our current best. The treatment was humanistic and optimistic, directed to the whole person with emphasis on individual regimens of work and recreation, religious and educational services, and care by a sympathetic superintendent and well-disciplined attendants. 1 The light went out sometime about 1860. Psychiatry slid into a prolonged era of dehumanized practice, warehousing patients in monstrous asylums from which few ever emerged. This nadir of psychiatry coincided with the development of the new medicine that was making notable advances in finding organic causes and cures for m a n y age-old plagues. Unfortunately, the bulk of the c o m m o n mental disorders did not yield to this advancing medical technology. Answers were n o t found, even after decades of careful classification and microscopic brain tissue examination, to the riddles of schizophrenia, manic-depressive psychosis, neurosis, and character disorder. In the late 1940's we saw a change. Enough people became interested in talking with patients again to spark the emergence of a new humanistic era. Most likely the psychoanalysts and their imitators should be given much of the credit for the breakthrough. Though Freud believed in an ultimate organic cause for psychiatric illness, he encouraged mental health workers to know their patients and help t h e m with psychological insights while waiting for answers to be discovered under the microscope. Interest in the psychology of the individual led to concern about life in the family, various Irving M. Rosen, M.D., Director o f Education at the Cleveland Psychiatric Institute and a member o f the Institutes of Religion and Health, has written many articles published in journals of psychiatry and pastoral care. This paper was adapted from a talk given at the School of Applied Social Sciences, Case Western Reserve University, Cleveland, as part of an institute on the future, January 28, 1972. 19
20
Journal of Religion and Health
other groups and institutions, and the community. We are still, in 1974, I believe, under the dominating influence of a humanistic and holistic philosophy. Hospitals are increasingly humane; patients do leave quickly; and results are comparable to those of the early 1800's. I am mindful that some of our recent success must be attributed to the use of powerful tranquillizing drugs introduced in the mid-1950's. These drugs are not however, "magic bullets" or curative agents, but adjuncts serving to quiet and make secure the milieu of the hospitals and to pave the way for expanded educational and other rehabilitative programs extending beyond the gates of the institution. The very marked decrease in the census of some hospitals in the past decade, after the drugs had had their major effect by 1960, appears to have been the result of creative management, intensified efforts to combat dehumanizing practices, and new programs to meet developmental needs of maturing persons. At present, the Freudian dominance, so apparent during the 1950's, is rapidly fading. Students of psychiatry and social work want, and indeed demand, more effective and fast-acting tools for treatment. Training programs are changing as new philosophies and techniques are introduced. In my view, we have now entered an eclectic phase characterized by a competition of several philosophies. Among them one can discern, in addition to the older Freudian and medical-organic schools, three burgeoning trends: the neo-Freudian ego psychology of Hartmann, Erikson, and Federn emphasizing coping and fulfillment of developmental needs and de-emphasizing conflict and analysis; the existential, "here and n o w , " schools emphasizing awareness and self-emergence (Perls, Schutz, Rogers) or responsibility and cognition (Glasser, Ellis, Berne, Frankl); and the behavior modification schools adapting conditioning theories from animals to man (Skinner, Wolpe, Stampfl). For the purpose of prophecy, I believe the significant battle lines will be drawn between those schools of t h o u g h t that tend toward atomization of man versus those that see man as a whole--a conflict ultimately between efficient technology and holistic humanism. The organicists continue to improve their ability to bring about rapid and visible behavior change through drugs and mechanical methods of affecting brain tissue, and the conditioning technicians also are becoming more sophisticated and effective in manipulating behavior. Although effective tools are certainly desirable, there is a strong and u n f o r t u n a t e t e n d e n c y fo~ people to settle for short-term relief coming from external sources in contrast to the long and vague processes involved in learning to deal with emotions and in learning to function in a relatively a u t o n o m o u s and mature manner. The mistake of considering an adjunct to be the cure has occurred widely with the new psychiatric drugs and with electric shock methods. I fear that when people settle for immediate relief provided by strong sources outside themselves they are weakened and made susceptible to depression and dependence on drugs and helping persons. Methods that are simple, easily taught, and that give quick and easily documented relief will strongly tend to become
Psychiatry in the Year 2001
21
dominant over holistic methods, which are difficult to validate and to teach and learn and which tend to diffuse slowly through our schools. There is one other serious problem with holistic methods that comes precisely from their difficulty of validation. Pioneering theories like Freud's tend to become rigid quickly and to interfere with efforts to improve on the work of the hallowed pioneer. Critics of the pioneer--men like Frankl and Perls and Glasser--who have valuable improvements to demonstrate are not allowed soon enough to add their insights to the dominant school and to be taught widely. Thus the whole humanistic enterprise fails to compete in effectiveness. I am fearful of the ultimate effect of the rapid inroads being made by the learning theorists into the field of treatment. Their theories are useful and cannot be neglected. But they do not see whole people, only abstracted behaviors. Since only behavior can be measured, t h e y have a rationale for avoiding what goes on inside the person. Skinner and the other learning theory pioneers have some valuable things to tell us, but t h e y could emerge soon as the d o m i n a n t philosophers for the next era. It should be obvious by now that I am led to believe that we can expect a swing of the pendulum back to an atomistic, dehumanized period fed by the hope, as in 1860, that more efficient cures are in the offing with the new technologies. I expect people to become more dependent, addiction-prone, and depressed even as they are given strong temporary relief. In fact, this depressing tendency has already begun. Perhaps our asylums will not soon grow again, but our c o m m u n i t y caretakers will be very busy and antidemocratic tendencies will grow as people look outside their own reliable selves for direction, relief, and order. There are, sad to relate, other forces in our culture that are leading to an emptying of the competent self. There is a continuing loss of meaningful work and erosion of such stable h u m a n units as the family and church. There is what Silber, the new president of Boston University, calls the "pollution of t i m e " as meaning is drained from important landmarks of time, including rites of passage, annual religious holidays, and the unfolding of life slowly through childhood, adulthood, and old age. 2 All this loss of personal significance and stability could lead to more fundamentalism and authoritarianism and even to a flare up of extremism on the right or left. As I have intimated, c o m m u n i t y psychiatry as now constituted will not stem the antihumanistic trend. People need more than crisis t r e a t m e n t and the revolving door philosophy that has replaced institutionalization. Yes, they are living in the c o m m u n i t y , but t h e y are on periodic injections of a long-acting tranquillizer and are being seen by visiting nurses instead of hospital attendants. Their real developmental and social needs are n o t being met. The days of reckoning, of true problem-solving, of growing up, are being postponed. Until more attention is given to the concept of definitive treatment whether in a hospital, transitional facility, or c o m m u n i t y and until much more attention is paid to the scandal of our multiple relapsing clients, c o m m u n i t y psychiatry will n o t influence the insidious downswing of our cycle.
22
Journal of Religion and Health
It is clear t h a t I am pessimistic and do not believe that we can long delay Orwell's 1984, certainly not b e y o n d 2001. There is some hope, however, and we can at least go down fighting. Perhaps there is time to teach people how to relate and communicate, how to manage their emotions, how to create a stable family and rear children, and how to receive information, make decisions, and solve problems. In short, maybe our schools and churches will decide to teach the really important subjects of life. Perhaps our agencies, prisons, courts, police departments, churches, and schools, all of which have been subjects of recent books recounting their failures, will begin to fulfill their mandate and actually render useful service. This will happen when their workers and practitioners spend as much time learning about people as they do learning the bare tools of their trades. We may hope that our professional schools will begin to teach an up-to-date humanism based on all we know about personality and treatment and not just on the one obsolete theory to which the school may rigidly subscribe. While I believe there are enough effective theories and methods to revitalize the now retreating humanism, we must and can learn to validate this knowledge and to point out the long-range shortcomings of purely mechanistic and atomistic techniques. The latter should be kept strictly in their place as strategic adjuncts. After all, even powerful tools do n o t make good religious or political systems, and in psychiatry t h e y will not cure any of our current emotional plagues. One may hope that it will not take several generations to learn these lessons the hard way.
References 1. Caplan, R., Psychiatry and Community in Nineteenth Century America. New York, Basic Books, 1969. 2. Silber, J. R., "The Pollution of Time," Bostonia, Boston University Alumni Magazine, 1971, 45, 9-15.
