Journal of Religion and Health, Vol. 14, No. 1, 1975
Psychoanalysis and the Community Mental I-l.ealthMovement LEO M. CROGHAN In 1964, the Mental Retardation Facilities and Community Mental Health Centers Construction Act became law. It marked the coming of age of the community mental health movement (CMHM), a movement that has been called this century's " t hi r d revolution" in the field of psychiatry. 1 The act made available federal monies for the construction of centers that would fulfill the following basic ideals long advocated by the supporters of CMHM: In a community setting, divorced from the idea of long-term hospitalization and isolation, all citizens with mental and emotional difficulties would be provided with inpatient services, outpatient services, partial hospitalization services (at least day care), emergency services 24 hours a day for at least one of the above-mentioned three, and consultation and educational services through community agencies and professional personnel. 2 Rubins found the other two "revolutions" occurring prior to 1964: The turn of the century brought psychoanalysis and its understanding of neurosis and personality dynamics; midcentury (c. 1952) saw the introduction of drugs and chemotherapy into hospital treatment and private care of the mentally disturbed. 3 The discovery of chemotherapy gave a great boost to the CMHM. It made possible the release of many hospitalized patients and made feasible the treatment of future patients in community settings. A new look was then taken at the over-all problem of mental disturbance. An optimistic report claimed that over one-half of psychiatric disorders in a community could be treated without hospitalization. 4 Th e two revolutions of CMHM and drug therapy have blended well. The same is not true of CMHM and psychoanalysis. The CMHM began with a blast at traditional psychoanalysis. The purpose of this paper is to examine the causes of the antagonism and to report on the current relations between these two revolutions.
Psychoanalysis The revolution of psychoanalysis, under the leadership of Sigmund Freud, focused its attention on the neurotic individual and contributed to personality Leo M. Croghan, Ph.D., a clinical psychologist with experience in individual therapy with emotionallydisturbed children and in familyand group therapy, is Directorof PsychologicalServices at Albemarle Mental Health Center, Elizabeth City, North Carolina. 28
Psychoanalysis and the Community Mental Health Movement
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theory its now well-known concepts of the unconscious, ego, id, superego, libido, drive, instincts, and defenses. H a nd in hand with these concepts came psychoanalysts, medically-trained men who applied psychoanalytic theory in one-to-one sessions with their patients. These sessions, as frequent as four or five a week and enduring over a span of years, were designed to effect a slow restructuring of the personality through the careful "working-through" of the patient's infancy-based difficulties. Within these sessions the analyst used the standard Freudian techniques of free association and dream analysis as well as the phenomena of exchanges between the analyst and the patient known as transference and countertransference. The techniques are designed to get at the underlying mental processes and to bring before the patient the content of his unconscious mind. It is important to remember that, while the practice of psychoanalysis was restricted to a small number of experts and concentrated on the nonpsychotic patient, the basic form of therapy for the mentally disturbed was built around the personal interview and formulated in such Freudian concepts as the unconscious and the determinance of the infancy period. The growth o[ C M H M
The revolution of CMHM cannot be attributed to one man. Its roots are more scattered. Authors differ in defining its source. Ewalt considers it a natural outgrowth of the multiplication of hospital programs, private clinics, mental health professionals, and government subsidies. ~ Rubins prefers to think of it as the result of convergence between the mental hygiene movement of Clifford Beers and Adolf Meyer and the present quest for social justice for the poor and minorities. Other important contributors to C M H M growth will appear in the next several paragraphs. Eighteen years prior to the 1964 act, President Truman signed the National Mental Health Act. It came at a time when the government was disturbed by mental health statistics associated with World War II. One out of eight applicants had been rejected for military service on the grounds of emotional instability. One-half of the admissions to military hospitals during the war were classified as psychiatric problems. Three hundred and eighty thousand men were discharged from the military with tisychiatric disabilities. 6 T he National Mental Health Act of 1948 reflected the government's concern. This law, among its provisions, offered grants to the states for setting up mental health programs outside of state hospitals. It also ordered an expansion of the Mental Hygiene Division of the Public Health Services. This expansion led, in 1949, to a reorganization of the Division into the National Institute of Mental Health. 7 The survey of the nation's mental health problems continued. In 1955, the Mental Health Study Act cited the results of that survey: e.g., 750,000 mentally ill and retarded patients were hospitalized on any given day and 47 percent of the hospital beds in the nation were occupied by mental patients. 8 The act ordered the formation of a Joint Commission on Mental Illness and Health. The commission, chosen by the National Institute of Mental Health, was instructed to "analyze and evaluate the needs and resources of the mentally ill in the United
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Journal of Religion and Health
States and make r e c o m m e n d a t i o n s for a national mental health program. ''9 Six years later, 1961, the commission finished its s t u d y and published it under the title, Action for Mental Health. This influential report furnished the foundation 9for President K e n n e d y ' s famous 1963 Message to Congress Relative to Mental Illness and Mental Retardation and resulted in the C o m m u n i t y Mental Health Construction Act cited at the beginning of this paper.
The criticism of psychoanalysis by the C M H M President K e n n e d y ' s message contained implicit criticism of psychoanalysis. He spoke of treating patients quickly; psychoanalysis is of long duration. He spoke of returning mental health care to the m a i n s t r e a m ; psychoanalysis is expensive and often restricted to the wealthy. His pertinent words are: I propose a national mental health program to assist in the inauguration of a wholly new emphasis and approach to care for the mentally ill. This approach relies primarily upon the new knowledge and new drugs acquired and developed in recent years which make it possible for most of the mentally ill to be successfully and quickly treated .... We need a new type of health facility, one which will return mental health care to the mainstream of American medicine9lo President K e n n e d y ' s words were u n d o u b t e d l y influenced by the 1961 commission's Action for Mental Health, which was far more direct in its charges against psychoanalysis. It criticized psychoanalysis for its t i m e - c o n s u m i n g methods, its neglect of the psychotic, its catering to the upper classes, the lack of proved results, and its pessimism toward the hospitalized mentally ill. It was this same commission t h a t r e c o m m e n d e d the building of c o m m u n i t y mental health centers, one for every 50,000 population, a r e c o m m e n d a t i o n t h a t took partial legislative form in the 1965 Construction Act. Therefore, it is not difficult to see how the new c o m m u n i t y mental health centers would be unenthusiastic about the psychoanalytic approach. Because of its importance in affirming and furthering the unfavorable attitude in the C M H M toward psychoanalysis, the actual words of the commission's report are given: Psychoanalytic treatment has many limitations. It is time-consuming, requiring a minimum of four treatment hours a week for a period of four or more years. It is necessarily expensive because of the amount of professional time required for each person. The practicing psychoanalyst can treat only a few patients on a closely ordered schedule of office visits, imposing an inflexibility that makes it difficult, if not impossible, for him to answer emergency calls as the conventional "good physician" feels himself obliged to do 9 Lastly, while any informed observer will recognize %he stimulation and fund of useful information psychoanalysis has contributed to our understanding of the human mind, its emotions, and its motivations, the results of psychoanalytic treatment, as of other forms of psychotherapy, are difficult to measure in any scientifically objective manner. In sum, then, psychoanalysis is adapted neither to the treatment of the psychoses nor to the mass application of any kind. It is principally effective for a limited number of
Psychoanalysis and the Community Mental Health Movement
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carefully selected patients who are not totally incapacitated by their illness and do not require hospitalization. It is the preferred treatment for adult neuroses and for some children with severe deviation in their personality development. The fact that psychoanalysts have influenced literature and education and have enjoyed considerable popularity among the intelligentsia plus the fact that they are not interested in and offer little help or hope for the psychotic quite possibly have had the side effect of enforcing the fatalistic attitude toward mental patients requiring hospitalization, thus seemingly deepening rather than lifting the heavy atmosphere of social rejection. 11 T h e criticism of the commission has been repeated often. T h e ideal of psychotherapy for individual patients has been called a fantasy because of the large numbers who need i m m e d i a t e help. ~2 Others have agreed that this impatience with one-to-one therapy has worked against psychoanalysis. 13 The horrors and catastrophes of world events cause another to wonder at analytic effectiveness or relevance: How could any behavioral scientist, faced with the horrible and shocking events of the Second World War, proceed calmly on his way concerned only about intrapsychic tbrces and interrelationships between the id, ego, and superego... For all the attempts to relate the outbursts of brutality and aggression to nationally shared patterns of psychosexual development, the evidence was at best unconvincing... Most behavioral scientists were compelled to come to grips with the social determinants of behavior and to begin to broaden their field of interpretation and inquiry concerning the causes of human behavior. 14 T h e t r u t h of the matter, recognized even by psychoanalysts themselves, was t h a t an unflattering stereotype had developed around the practice o f p s y c h o a n a l ysis: In a quiet office, the analyst, i m m u n e to the long lines of emotionally and mentally needy people in his own c o m m u n i t y , blissfully conducts pleasant one-to-one t h e r a p y sessions and concerns himself largely with the " i n t r a p s y c h i c minutiae of affluent neurotic women. ''15 At this point it is i m p o r t a n t to keep in mind the meaning of p s y c h o t h e r a p y in psychoanalysis and in the C M H M . In traditional Freudian dogma, psychotherapy is not psychoanalysis. Psycho.analysis is performed only by an analyst in long-term sessions with a patient and by making use of dream interpretations, free associations, and transference in order to render the unconscious conscious and thus relieve the patient of his difficulty. However, psychotherapy performed in the analytic tradition has modified certain Freudian techniques (e.g., length of stay in t r e a t m e n t , moderate use of dream material, etc.) and at times extended its theory to embrace other concepts (e.g., Sullivan's interpersonal emphasis). Nevertheless, all psychoanalytic p s y c h o t h e r a p y is joined together by an e m p h a sis on one-to-one treatment, on talk therapy as the basic m e d i u m of t r e a t m e n t , on a t t e m p t s to discover unconscious motivation, and on a belief in the determinism of infancy and childhood. T h e t h r u s t of the controversy between psychoanalysis and C M H M is directed at the over-all influence t h a t psychoanal-
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Journal of ~)eligion and Health (f
ysis has had on psychotherapy in orienting treatment to talk therapy in one-to-one sessions with emphasis on uncovering unconscious motivation. In contrast, the CMHM sees psychotherapy as only one of the many weapons in the treatment and prevention of mental and emotional problems. It is becoming increasingly clear that the CMHM considers psychotherapy to be one of the least efficient means and prefers to devote its energies to effeeting primary prevention of these social and cultural forces that promote mental illness. For CMHM, psychotherapy is at times a necessary but inefficient technique for meeting the crisis in mental health and, if it is to be used, it should limit its one-to-one sessions to a definite number of meetings in which the therapist and client would directly attack the client's problem without concern for unconscious motivation and various insight-oriented goals. These opposing views of the importance and technique of psychotherapy neatly reflect the argument between psychoanalysis and the CM'HM. The reaction of psychiatry to C M H M As a result of this hostile criticism, psychoanalysis, especially in the American Psychoanalytic Association, has remained aloof from the CMHM.16 However, it would be a mistake to equate psychoanalysis with the field of psychiatry. Even though psychoanalysis in the 1940s and 1950s claimed first place in the field of theory and ruled the professional world of psychiatry in terms of influence, 17 the Action for Mental Health report took pains to label psychoanalysis as a subspecialty of psychiatry and to point out that of the nation's 12,000 trained psychiatrists only 850 were qualified psychoanalysts. The fact that the commission felt called upon to make this point underlines the influence of psychoanalysis at that time. The commission's intention seemingly was to invite the nonpsychoanalytic world of psychiatry to more independent action. Many psychiatrists did respond to the CMHM and developed an attitude toward mental health problems that is now captured in the term "community psychiatry." A variety of practices and outlooks make up community psychiatry. In broad description, it stresses the external and social causes of mental disturbances; it advocates programs that are involved in community life; it has demoted to a secondary position the aims of reducing individual stress, of curing an individual's illness and restructuring his personality , and placed first the aims of establishing social competence among the poor and needy, of removing the symptoms of mental disturbance as quickly as possible, and of promoting mental health through preventive measures.~8 A concrete example of applied community psychiatry at work will give details to the broad description. Through the practice of community psychiatry, M. B. Ahmed, M.D., and his staffat Unit One of the State Hospital Complex in St. Louis, Missouri, have reduced the number of permanent patients from 500 in 1968 to about 100 in 1971. The Ahmed idea of community psychiatry includes the following applications: The patients are constantly reminded of their roles in the community outside the hospital; patients are told that they will be released as soon as possible and that their
Psychoanalysis and the Community Mental Health Movement
33
families are involved in planning for their release; many patients are allowed to stay at home and to travel to the hospital for day care; patients share with the staff in making decisions that affect them; a mental health clinic has been opened in north St. Louis County to bring psychiatric care to the people and to provide opportunity for preventive programs in the community setting. 19 The departures from standard psychoanalysis are obvious: short-term therapy, group participation and responsibility, an optimism even for psychotic problems, preventive work in the community, etc. The changing mood in C M H M and in community psychiatry The CMHM, encouraged and aided by community psychiatry, has itself developed, which must be kept in mind when one considers CMHM's present relation with psychoanalysis. Although its report of 1961 rejected psychoanalytic treatment, the commission continued to be interested mainly in the immediate, personal care of the emotionally and mentally disturbed. It warned against the concept of "primary prevention": t ha t is, activity directed against supposed causes of mental unbalance within a community and activity designed to promote healthy personalities, etc. The report called the idea of "pri m ary prevention" too vague and undefined. It could drain the energies of mental health centers away from the focal task of caring for those with explicit mental difficulties. 2~Indeed, in 1964 an investigation of 11 outstanding centers revealed that, in spite of the reaction against psychoanalysis, the emphasis of the centers remained on the individual and on individual treatment: "T here are indications that most of the centers considered individual psychotherapy as the t r e a t m e n t of choice. ''21 One director called it "the backbone of our therapeutic program." This attitude no longer has the field to itself. A similar study, six years later, also investigated 11 outstanding centers, including two represented in the 1964 study. A marked change was reported: Psychotherapy itself was challenged as an inadequate approach to people in lower-class situations; individual attention was being replaced by group activity; programs were increasingly being directed toward the political goal of increased power for the poor and other minorities; and the previous acknowledgments of the contributions of psychoanalytic theory (e.g., the unconscious, the influence of the past, the phenomenon of transference) were being withdrawn. The following paragraphs from the 1970 report are representative of the current opinions of 11 active and influential centers: Only communities with a large lower class population have social difficulties. Middle class members of a community attribute their psychopathology to their own internal psychological processes while lower class people frequently attribute their pathology to defects in society. Thus psychotherapy works for the middle class but not for the lower class. The concept of mental health is synonymous with the concept of power and therefore one of the primary tasks of the mental health movement is to increase the actual amount of power of those members of the community who have chronically been powerless.
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Journal of Religion and Health
Individual psychotherapy may not be the best form of treatment for many patients with emotional disorders even if it could be provided to all in need. The groups can influenee an individual much more than any single other individual can. It is useless to be concerned about the past. Therefore, many programs are totally ahistorical and adynamic. The unconscious is an unnecessary concept in treating patients. Many programs concentrate their efforts on operating on current overt behavior. Knowledge of personality dynamics is irrelevant in order to change behavior and, in fact, such knowledge might interfere with the ability to change behavior. Activities in the facilities visited have moved away from the study of individual conflict to the study of the social epidemiology of mental disorders. The facilities have placed greater emphasis on the development of' skills and the provision of clinical services. Diagnostic techniques for studying individuals are no longer as important as techniques for the diagnosis of groups, neighborhoods and communities at l a r g e . . . The focus in many of these programs is much more on preventive services than it is on therapeutic services. 22 It is obvious, therefore, t h a t m a n y of the C M H M centers h a v e m o v e d far beyond the 1961 Ac'tion report in their rejection of psychoanalysis a n d have t u r n e d their concentration, s t r i p p e d of any p s y c h o a n a l y t i c concepts, from the individual to the political a n d social ills of the c o m m u n i t y .
The rejection of the psychoanalytic stereotype T h e s t e r e o t y p e of the psychoanalyst, like m o s t stereotypes, fails to c a p t u r e the whole picture. P s y c h o a n a l y s t s recognize the facts of life: t h a t , while the n u m b e r of psychiatric a p p l i c a n t s h a v e increased, there has been a leveling off of p s y c h o a n a l y t i c students; ~3 t h a t the interests of m a n y young psychiatrists are moving toward c o m m u n i t y involvement; 24 and t h a t , unless psychoanalysis m o v e s in t h a t direction, it will lose influence over a very large p a r t of the m e n t a l health field. 25 T h e A m e r i c a n P s y c h o a n a l y t i c Association, cited above for its aloofness from the C M H M , within the last few years has established a C o m m i t t e e on Social P r o b l e m s a n d charged it with a s t u d y of preventive m e a s u r e s t h a t m i g h t be deployed in the c o m m u n i t y . M o r e destructive of the stereotype is the actual n u m b e r of psychoanalysts who are actively engaged in c o m m u n i t y m e n t a l health'. In 1966, the Los Angeles C o u n t y D e p a r t m e n t of M e n t a l H e a l t h h a d 71 psychoanalytically-oriented personnel associated with its programs. Sixty-five of t h e m , responding to a questionnaire, indicated t h a t their training h a d been quite helpful and in no way a hindrance. 26 W h a t is more suprising, the A m e r i c a n P s y c h o a n a l y t i c Association c o n d u c t e d its own survey a n d learned t h a t 78 percent of the respondents were involved in some form of c o m m u n i t y p s y c h i a t r y . 27 In St. Louis, Missouri, the P s y c h o a n a l y t i c F o u n d a t i o n has m a d e an effort to bring low-cost analysis to people in need. Fees are arranged according to one's ability to pay; t h e y m a y be as low as $1.00 per visit. Moreover, the foundation has m o v e d directly into c o m m u n i t y activities. It conducts a M a t e r n a l I n v o l v e m e n t Project to help answer the emotional needs of teen-age girls who are p r e g n a n t outside of m a r r i a g e a n d to suggest p r e v e n t i v e measures against the increase or
Psychoanalysis and the Community Mental Health Movement
35
recurrence of such pregnancies. It also holds a D a y Care M o t h e r s ' Consultation P r o g r a m and provides consultation services for clergymen a n d other professionals who serve in counseling roles. 2s T h e personnel of the C o m m u n i t y P s y c h i a t r y Division of St. L u k e ' s Hospital C e n t e r in New York are p s y c h o a n a l y t i c a l l y trained. T h e y h a v e entered into consultative roles with such c o m m u n i t y groups as policemen, guidance counselors, a n d school a d m i n i s t r a t o r s . It is interesting to see psychoanalysis fulfill one of the objectives of the 1965 Construction Act: i.e., the extension of service to the c o m m u n i t y via consultation with c o m m u n i t y agencies a n d professional personnel. T h e s e experiences have caused the St. Luke's group to be reassured a b o u t the need a n d contribution of p s y c h o a n a l y t i c influence: It has become patently clear to us that it is possible to be a consultant without losing anyone's capacity to be an analytic c l i n i c i a n . . . Community agents operate willy-nilly according to ideas about human motivation and behavior that may be inarticulate but still constitute a form of psychoanalytic theory and often are based on misunderstanding of psychoanalytic thinking or are directly contradictory to it. The psychoanalytic consultant has the capacity to contribute his understanding to community agents so that they may in turn have more positive effect on the mental health of their communities . . . . Our experience indicates that one can be a psychoanalyst and community consultant without conflict of roles. Psychodynamic consultation can be effectively applied to community consultation and can add a dimension that is often indispensable. 29 A n s w e r s to specific charges against psychoanalysis T h e foregoing p a r a g r a p h s greatly modify the s t e r e o t y p e of the aloof psychoanalyst. T h e literature contains the suggestion t h a t t h e c u r r e n t C M H M is in danger of diffusing its activities to such an extent t h a t m a n y centers m a y b e c o m e mere neighborhood centers. 3~ T h e active i n v o l v e m e n t of p s y c h o a n a l y s t s m a y prove to be a h e a l t h y c o u n t e r b a l a n c e a n d to r e m i n d the C M H M of its e m o t i o n a l a n d m e n t a l roots. Such a r e m i n d e r a p p e a r s implicit in the a b o v e s t a t e m e n t t h a t psychoanalysis can add " a dimension t h a t is often indispensable. ''31 Be t h a t as it m a y , specific charges have been leveled against the theory a n d p r a c t i c e of psychoanalysis. T h e y m u s t be answered directly. T h e o f t - r e p e a t e d charge t h a t psychoanalysis is of too long d u r a t i o n has found a receptive hearing a m o n g analysts. 32 T r a d i t i o n a l psychoanalysis has m a i n t a i n e d t h a t s h o r t - t e r m t h e r a p y is dangerous since it forces p r e m a t u r e interventions and i n t e r p r e t a t i o n s a n d does not p e r m i t the essential r e s t r u c t u r i n g of the personality. Moreover, it interprets early i m p r o v e m e n t s as a pseudo "flight into h e a l t h " r a t h e r t h a n a desired change. 33 Nevertheless, s o m e a n a l y s t s h a v e a c t u a l l y reduced the n u m b e r and length of t h e r a p y sessions w i t h o u t causing the feared dangers. ~4 Leopold Bellak and L e o n a r d S m a l l are two a n a l y s t s who have t a k e n the m a t t e r even further, T h e y endorse " b r i e f p s y c h o t h e r a p y , " a t r e a t m e n t covering a s p a n of one to six sessions a n d concentrating on s y m p t o m removal. Into this brief p s y c h o t h e r a p y they actively bring p s y c h o a n a l y t i c concepts a n d techniques. One
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Journal of Religion and Health
explicit example of this must suffice. Transference, "comprising all the nonrational sentiments of the patient toward the therapist," is deliberately used by the therapist to maintain himself as a "benign, interested, helpful figure. ''35 In other words, Bellak and Small hold that transference occurs inevitably even in brief encounters and that the therapist must enhance all signs of positive regard and avoid all tendencies toward negative transference because of the time factor and because of concentration on symptoms rather than on personality rebuilding. Thus, brief psychotherapy can be effective because of--not in spite of~psychoanalytic awareness. A more serious charge has been that psychoanalysis and even psychotherapy have no usefulness for the poor and the lower economic classes. At least one writer has challenged this, ~claiming that the lower classes can verbalize and introspect sufficiently to profit from analysis and individual therapy. 36 Indeed, Bellak and Small were mindful of the application of brief psychotherapy to lower-class people and inscribed the frontispiece of their work with this quotation from Sigmund Freud: "Some time or other, the conscience of the community will awaken; admonish it that the poor man has just as much right to help for his mind as he now has to the surgeon's means of saving life." Linn, aware that CMHM has moved beyond individual therapy, points to Freud's work, Group Psychology and Analysis of The Ego, in an effbrt to prove that Freud's concepts can be transformed fbr use in today's techniques of group dynamics. 37 Worthy as this effort may be, psychoanalysis does not have to await the transformation of earlier concepts in order to emphasize community involvement. Psychoanalysts have long dealt with social concerns: Alfred Adler's concern with the striving for power, Erich Fromm's persuasive presentation of man's loneliness and isolation in modern society, Harry Stack Sullivan's realization of the importance of interpersonal influence--these psychoanalytic works are immersed in the problems of community and society. Psychoanalytic theory has been able to produce concrete techniques and applications when it comes t o the treatment of the individual. It has been less successful in communitarian and societal areas. Bellak and Small and Linn point out that psychoanalysis, with its theory centered on the infant-mother relationship, has long dwelt on the effects of this bond on the infant. They argue that this rich psychoanalytic experience can now be turned toward the mother and the family, both to measure the effect of the infant on parent and to provide the parent and family with a set of expectations and guidelines. The St. Louis Psychoanalytic Foundation was cited earlier for trying to bring analytic insight to mothers. It is also to be hoped that analytic experience can transcend the therapy session to prove of value in less strict, less formal situations. In its role of consultation with policemen and other groups, St. Luke's Community Psychiatry Division of New York discovered the existence of hostility and dependence in the sessions with the consultees. It used this transference to demonstrate to the consultees the hostility and dependence operative in their daily work relations. The influence of the past is made visible in what is called the "anniversary psychosis," a break suffered by a large percentage
Psychoanalysis and the Community Mental Health Movement
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of w o m e n when their oldest child reaches an age at which the p a t i e n t s h a d lost their own mothers. 38 C o m m u n i t y p s y c h i a t r y could m a k e good use of this i n f o r m a t i o n to develop specific p r e v e n t i v e p r o g r a m s . T h e s e are a few r e c o m m e n dations for the application of psychoanalysis to the C M H M . By far the m o s t serious charge against psychoanalysis is the one m a d e in the 1970 report on the eleven centers (Bloom): i.e., t h a t the theory of psychoanalysis is irrelevant, t h a t the p a s t does not m a t t e r , a n d t h a t the unconscious is unnecessary. This strikes at the very h e a r t of psychoanalysis. All other charges can be answered by an a d a p t a t i o n of t e c h n i q u e (e.g., shorter sessions, group analysis) or by the extension of p s y c h o a n a l y t i c concepts into c o m m u n i t y activities. If psychoanalysis c a n n o t defend its f u n d a m e n t a l concepts, a d a p t a tions will m a t t e r little. One of its best defenders has been E r i k Erikson in his classic work, C h i l d h o o d a n d S o c i e t y . 39 Erikson has skillfully enlarged the vision of psychoanalysis, e x t e n d i n g it b e y o n d the early years to include each era of a m a n ' s life. He has s u m m e d up each stage in t e r m s of its basic work: trust, a u t o n o m y , initiative, industry, identity, i n t i m a c y , generativity, a n d integrity. B u t he has r e m a i n e d true to his psychoanalytic roots, a n d t h r o u g h o u t his work he keeps close to the indelible influence t h a t childhood and its culture h a v e on the m a t u r a t i o n of a h u m a n being and of a society. A few quotations from the close of his book illustrate how faithful he has been: Having learned in clinical work that the individual is apt to develop an amnesia concerning his most formative experiences in childhood, we are also forced to recognize a universal blind spot in the makers and interpreters of history: they ignore the fateful function of childhood in the fabric of society (p. 404). Every adult, whether he is a follower or a leader, a member of a mass or of an elite, was once a child. He was once small. A sense of smallness forms a substratum in his mind, ineradicably (p. 404). Thus the immature origin of his conscience endangers man's maturity and his works: infantile fear accompanies him through life. This we, the psychoanalysts, are attempting to correct in individual cases; this we try to explain and to conceptualize, because there is no universal cure--only, maybe, an alleviation by gradual insight--for the fact that each generation must develop out of its childhood and, overcoming its particular brand of childhood, must develop a new brand," potentially promising, potentially dangerous (p. 405). Erikson answers the charge of irrelevance b y describing vividly the e n d u r i n g influence of culture on childhood a n d of childhood on culture. H e r b e r t M a r c u s e , a psychoanalyst, answers in a s o m e w h a t different way. H e a d m i t s t h a t the F r e u d i a n p r e o c c u p a t i o n with the individual is being swallowed up b y the power of society. T h e role of the father figure in family d o m i n a n c e is over. T h e influences on the individual are multiple: family, c o m m u n i t y , the media. We are, he states, on the verge of a society w i t h o u t fathers. 4~ B u t M a r c u s e w a r n s of a n y d e v e l o p m e n t t h a t gets too far away from the individual, a warning t h a t p e r h a p s was behind the reluctance of the 1961 A c t i o n report to get involved with an
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Journal of Religion and Health
unanchored, free-floating preventive mental health program. Marcuse would h a v e us r e m a i n n e a r t h e i n d i v i d u a l , l i s t e n i n g to all t h e m o v e m e n t s w i t h i n t h e s i n g l e m a n , p r o b i n g t h e forces t h a t s t i r t h a t m a n to a c t i o n . P s y c h o a n a l y s i s does t h i s . M a r c u s e e n d s his r e m a r k s t h i s w a y : Thus psychoanalysis draws its strength from its obsolescence: from its insistence on individual needs and individual potentialities which have become outmoded in the social and political development. T h a t which is obsolescent is not, by this token, false. If the advancing industrial society and its politics have invalidated the Freudian model of the individual and his relation to society, if they have undermined the power of the ego to dissociate itself from the other, to become and remain a self, t h a t invokes the Freudian concept not only ~s a part left behind b u t also a future to be recaptured (pp. 60-61). Conclusion
P s y c h o a n a l y s i s a n d C M H M were o n c e e n e m i e s . P s y c h o a n a l y s i s h a s m a d e n o t e w o r t h y a d v a n c e s t o w a r d t h e C M H M i d e a b o t h in t e c h n i q u e c h a n g e s a n d in c o m m u n i t y i n v o l v e m e n t . I t is p o s s i b l e t h a t C M H M m a y f i n a l l y r e j e c t all p s y c h o a n a l y t i c c o n t r i b u t i o n a n d f a c e its f u t u r e w i t h o u t a t h e o r y . I f t h a t t a k e s place, t h e C M H M s o m e d a y in its f u t u r e m a y t u r n a c o r n e r a n d f i n d i t s e l f face to f a c e w i t h t h e lonely, i n d i v i d u a l m a n , c o n s c i o u s of his p a s t a n d f e a r f u l o f t h e u n e x p l a i n e d a n x i e t y w i t h i n h i m . I t is t h e n t h a t t h e C M H M will f i n d i t s e l f once a g a i n s t u d y i n g t h e w o r k s of H e r b e r t M a r c u s e , E r i k E r i k s o n , S i g m u n d F r e u d , a n d the psychoanalytic world. References
1. Rubins, J., The Changing Role of Psychoanalysis, Am. J. Psychoanal., 1967, 27, 147-162. 2. Glasscote, R., The Community Mental Health Center---An Analysis of Existing Models. Washington, D. C., Joint Information Service, 1964. 3. Rubins, op. cit. 4. Glasscote, op. cit. 5. Ewalt, J. and P., History of the Community Psychiatry Movement, Am. J. Psychiatry, 1969, 126, 43-52. 6. Glasscote, op. cit. 7. Szasz, T., The Manufacture of Madness. New York, Harper & Row, 1970. 8. Action for Mental Health. Final Report of the Joint Commission on Mental Illness and Health.
New York, Basic Books, 1961. 9. Ibid., p. vii.
10. Kennedy, J. F., Message to Congress Relative to Mental Illness and Mental Retardation, Am. J. Psychiatry, 1964, 120, 729-737. 11. Action for Mental Health, op. cit., pp. 79 80. 12. Glasscote, op. cit. 13. Aldrich, C. K., Brief Psychotherapy--A Reappraisal of Some Theoretical Assumptions, Am. J. Psychiatry, 1968, 125, 585-592. Wallerstein, R., The Challenge of the Community Mental Health Movement to Psychoanalysis, Am. J. Psychiatry, 1968, 124, 1049-1056. 14. Whittington, H. G., Psychiatry in the American Community. New York, Internat. Universities Press, 1966, p. 5. 15. Brichmer, H. R., Schwartz, D. A., and Doran, S. M., The Psychoanalyst as Community Psychiatrist, Am. J. Psychiatry, 1966, 122, 1081-1087. 16. Bindler, B., The American Psychoanalytic Association and Community Psychiatry, Am. J. Psychiatry, 1968, 124, 1037-1042.
Psychoanalysis and the Community Mental Health M o v e m e n t
39
17. Hersch, C., The Discontent Explosion in Mental Health, Am. Psychologist, 1968, 23, 497-507. 18. Rubin, B., Community Psychiatry, Arch. Gen. Psychiatry, 1969, 20, 497 507. Wallerstein, op. cit.; Hersch, op. cir. 19. Meyer, G., Shrinking One Mental Hospital, St. Louis Post-Dispatch, March 28, 1971. 20. Action for Mental Health, op. cit. 21. Glasscote, op. cit., p. 5. 22. Bloom, B., Training the Psychologist for a Role in Community Change. A Report of the First Institute on Innovations in Psychological Training. Unpublished paper, 1970, pp. 20-24. 23. Bindler, op. cit.; Rubins, o19 cit. 24. Aldrich, op. cit. 25. Dorn, R., The Role of the Psychoanalyst in Community Mental Health, Community Mental Health J., 1966, 2, 5-12. Wallerstein, o19. cit. 26. Brichmer, op. cit. 27. Brodsky, B., The Application of Psychoanalytic Method and Theory to Social Problems, J. Am. Psychoanalytic Association, 1967, 15, 686-694. 28. Psychoanalytic Foundation of St. Louis, 1970 Annual Report. Private brochure. 29. Papanek, G., Psychoanalysis and Community Psychiatry, Arch. Gen. Psychiatry, 1968, 19, 189-196. 30. Bloom, op. cit. 31. Papanek, op. cit. 32. Aldrich, op. cit. 33. Ibid. 34. Rubins, op. cit. 35. Bellak, L., and Small, L., Emergency Psychotherapy and Brief Psychotherapy. New York, Grune and Stratton, 1965, p. 40. 36. Rubins, op. cit. 37. Linn, L., Psychoanalysis and Community Psychiatry, J. Hillside Hospital, 1967, 16, 234-254. 38. Bellak and Small, op. cir. 39. Erikson, E. H., Childhood and Society. New York, W. W. Norton, 1963. 40. Marcuse, H., Five Lectures. Boston, Beacon Press, 1970.
Psychoanalysis and the Community Mental I-l.ealthMovement LEO M. CROGHAN In 1964, the Mental Retardation Facilities and Community Mental Health Centers Construction Act became law. It marked the coming of age of the community mental health movement (CMHM), a movement that has been called this century's " t hi r d revolution" in the field of psychiatry. 1 The act made available federal monies for the construction of centers that would fulfill the following basic ideals long advocated by the supporters of CMHM: In a community setting, divorced from the idea of long-term hospitalization and isolation, all citizens with mental and emotional difficulties would be provided with inpatient services, outpatient services, partial hospitalization services (at least day care), emergency services 24 hours a day for at least one of the above-mentioned three, and consultation and educational services through community agencies and professional personnel. 2 Rubins found the other two "revolutions" occurring prior to 1964: The turn of the century brought psychoanalysis and its understanding of neurosis and personality dynamics; midcentury (c. 1952) saw the introduction of drugs and chemotherapy into hospital treatment and private care of the mentally disturbed. 3 The discovery of chemotherapy gave a great boost to the CMHM. It made possible the release of many hospitalized patients and made feasible the treatment of future patients in community settings. A new look was then taken at the over-all problem of mental disturbance. An optimistic report claimed that over one-half of psychiatric disorders in a community could be treated without hospitalization. 4 Th e two revolutions of CMHM and drug therapy have blended well. The same is not true of CMHM and psychoanalysis. The CMHM began with a blast at traditional psychoanalysis. The purpose of this paper is to examine the causes of the antagonism and to report on the current relations between these two revolutions.
Psychoanalysis The revolution of psychoanalysis, under the leadership of Sigmund Freud, focused its attention on the neurotic individual and contributed to personality Leo M. Croghan, Ph.D., a clinical psychologist with experience in individual therapy with emotionallydisturbed children and in familyand group therapy, is Directorof PsychologicalServices at Albemarle Mental Health Center, Elizabeth City, North Carolina. 28
Psychoanalysis and the Community Mental Health Movement
29
theory its now well-known concepts of the unconscious, ego, id, superego, libido, drive, instincts, and defenses. H a nd in hand with these concepts came psychoanalysts, medically-trained men who applied psychoanalytic theory in one-to-one sessions with their patients. These sessions, as frequent as four or five a week and enduring over a span of years, were designed to effect a slow restructuring of the personality through the careful "working-through" of the patient's infancy-based difficulties. Within these sessions the analyst used the standard Freudian techniques of free association and dream analysis as well as the phenomena of exchanges between the analyst and the patient known as transference and countertransference. The techniques are designed to get at the underlying mental processes and to bring before the patient the content of his unconscious mind. It is important to remember that, while the practice of psychoanalysis was restricted to a small number of experts and concentrated on the nonpsychotic patient, the basic form of therapy for the mentally disturbed was built around the personal interview and formulated in such Freudian concepts as the unconscious and the determinance of the infancy period. The growth o[ C M H M
The revolution of CMHM cannot be attributed to one man. Its roots are more scattered. Authors differ in defining its source. Ewalt considers it a natural outgrowth of the multiplication of hospital programs, private clinics, mental health professionals, and government subsidies. ~ Rubins prefers to think of it as the result of convergence between the mental hygiene movement of Clifford Beers and Adolf Meyer and the present quest for social justice for the poor and minorities. Other important contributors to C M H M growth will appear in the next several paragraphs. Eighteen years prior to the 1964 act, President Truman signed the National Mental Health Act. It came at a time when the government was disturbed by mental health statistics associated with World War II. One out of eight applicants had been rejected for military service on the grounds of emotional instability. One-half of the admissions to military hospitals during the war were classified as psychiatric problems. Three hundred and eighty thousand men were discharged from the military with tisychiatric disabilities. 6 T he National Mental Health Act of 1948 reflected the government's concern. This law, among its provisions, offered grants to the states for setting up mental health programs outside of state hospitals. It also ordered an expansion of the Mental Hygiene Division of the Public Health Services. This expansion led, in 1949, to a reorganization of the Division into the National Institute of Mental Health. 7 The survey of the nation's mental health problems continued. In 1955, the Mental Health Study Act cited the results of that survey: e.g., 750,000 mentally ill and retarded patients were hospitalized on any given day and 47 percent of the hospital beds in the nation were occupied by mental patients. 8 The act ordered the formation of a Joint Commission on Mental Illness and Health. The commission, chosen by the National Institute of Mental Health, was instructed to "analyze and evaluate the needs and resources of the mentally ill in the United
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States and make r e c o m m e n d a t i o n s for a national mental health program. ''9 Six years later, 1961, the commission finished its s t u d y and published it under the title, Action for Mental Health. This influential report furnished the foundation 9for President K e n n e d y ' s famous 1963 Message to Congress Relative to Mental Illness and Mental Retardation and resulted in the C o m m u n i t y Mental Health Construction Act cited at the beginning of this paper.
The criticism of psychoanalysis by the C M H M President K e n n e d y ' s message contained implicit criticism of psychoanalysis. He spoke of treating patients quickly; psychoanalysis is of long duration. He spoke of returning mental health care to the m a i n s t r e a m ; psychoanalysis is expensive and often restricted to the wealthy. His pertinent words are: I propose a national mental health program to assist in the inauguration of a wholly new emphasis and approach to care for the mentally ill. This approach relies primarily upon the new knowledge and new drugs acquired and developed in recent years which make it possible for most of the mentally ill to be successfully and quickly treated .... We need a new type of health facility, one which will return mental health care to the mainstream of American medicine9lo President K e n n e d y ' s words were u n d o u b t e d l y influenced by the 1961 commission's Action for Mental Health, which was far more direct in its charges against psychoanalysis. It criticized psychoanalysis for its t i m e - c o n s u m i n g methods, its neglect of the psychotic, its catering to the upper classes, the lack of proved results, and its pessimism toward the hospitalized mentally ill. It was this same commission t h a t r e c o m m e n d e d the building of c o m m u n i t y mental health centers, one for every 50,000 population, a r e c o m m e n d a t i o n t h a t took partial legislative form in the 1965 Construction Act. Therefore, it is not difficult to see how the new c o m m u n i t y mental health centers would be unenthusiastic about the psychoanalytic approach. Because of its importance in affirming and furthering the unfavorable attitude in the C M H M toward psychoanalysis, the actual words of the commission's report are given: Psychoanalytic treatment has many limitations. It is time-consuming, requiring a minimum of four treatment hours a week for a period of four or more years. It is necessarily expensive because of the amount of professional time required for each person. The practicing psychoanalyst can treat only a few patients on a closely ordered schedule of office visits, imposing an inflexibility that makes it difficult, if not impossible, for him to answer emergency calls as the conventional "good physician" feels himself obliged to do 9 Lastly, while any informed observer will recognize %he stimulation and fund of useful information psychoanalysis has contributed to our understanding of the human mind, its emotions, and its motivations, the results of psychoanalytic treatment, as of other forms of psychotherapy, are difficult to measure in any scientifically objective manner. In sum, then, psychoanalysis is adapted neither to the treatment of the psychoses nor to the mass application of any kind. It is principally effective for a limited number of
Psychoanalysis and the Community Mental Health Movement
31
carefully selected patients who are not totally incapacitated by their illness and do not require hospitalization. It is the preferred treatment for adult neuroses and for some children with severe deviation in their personality development. The fact that psychoanalysts have influenced literature and education and have enjoyed considerable popularity among the intelligentsia plus the fact that they are not interested in and offer little help or hope for the psychotic quite possibly have had the side effect of enforcing the fatalistic attitude toward mental patients requiring hospitalization, thus seemingly deepening rather than lifting the heavy atmosphere of social rejection. 11 T h e criticism of the commission has been repeated often. T h e ideal of psychotherapy for individual patients has been called a fantasy because of the large numbers who need i m m e d i a t e help. ~2 Others have agreed that this impatience with one-to-one therapy has worked against psychoanalysis. 13 The horrors and catastrophes of world events cause another to wonder at analytic effectiveness or relevance: How could any behavioral scientist, faced with the horrible and shocking events of the Second World War, proceed calmly on his way concerned only about intrapsychic tbrces and interrelationships between the id, ego, and superego... For all the attempts to relate the outbursts of brutality and aggression to nationally shared patterns of psychosexual development, the evidence was at best unconvincing... Most behavioral scientists were compelled to come to grips with the social determinants of behavior and to begin to broaden their field of interpretation and inquiry concerning the causes of human behavior. 14 T h e t r u t h of the matter, recognized even by psychoanalysts themselves, was t h a t an unflattering stereotype had developed around the practice o f p s y c h o a n a l ysis: In a quiet office, the analyst, i m m u n e to the long lines of emotionally and mentally needy people in his own c o m m u n i t y , blissfully conducts pleasant one-to-one t h e r a p y sessions and concerns himself largely with the " i n t r a p s y c h i c minutiae of affluent neurotic women. ''15 At this point it is i m p o r t a n t to keep in mind the meaning of p s y c h o t h e r a p y in psychoanalysis and in the C M H M . In traditional Freudian dogma, psychotherapy is not psychoanalysis. Psycho.analysis is performed only by an analyst in long-term sessions with a patient and by making use of dream interpretations, free associations, and transference in order to render the unconscious conscious and thus relieve the patient of his difficulty. However, psychotherapy performed in the analytic tradition has modified certain Freudian techniques (e.g., length of stay in t r e a t m e n t , moderate use of dream material, etc.) and at times extended its theory to embrace other concepts (e.g., Sullivan's interpersonal emphasis). Nevertheless, all psychoanalytic p s y c h o t h e r a p y is joined together by an e m p h a sis on one-to-one treatment, on talk therapy as the basic m e d i u m of t r e a t m e n t , on a t t e m p t s to discover unconscious motivation, and on a belief in the determinism of infancy and childhood. T h e t h r u s t of the controversy between psychoanalysis and C M H M is directed at the over-all influence t h a t psychoanal-
32
Journal of ~)eligion and Health (f
ysis has had on psychotherapy in orienting treatment to talk therapy in one-to-one sessions with emphasis on uncovering unconscious motivation. In contrast, the CMHM sees psychotherapy as only one of the many weapons in the treatment and prevention of mental and emotional problems. It is becoming increasingly clear that the CMHM considers psychotherapy to be one of the least efficient means and prefers to devote its energies to effeeting primary prevention of these social and cultural forces that promote mental illness. For CMHM, psychotherapy is at times a necessary but inefficient technique for meeting the crisis in mental health and, if it is to be used, it should limit its one-to-one sessions to a definite number of meetings in which the therapist and client would directly attack the client's problem without concern for unconscious motivation and various insight-oriented goals. These opposing views of the importance and technique of psychotherapy neatly reflect the argument between psychoanalysis and the CM'HM. The reaction of psychiatry to C M H M As a result of this hostile criticism, psychoanalysis, especially in the American Psychoanalytic Association, has remained aloof from the CMHM.16 However, it would be a mistake to equate psychoanalysis with the field of psychiatry. Even though psychoanalysis in the 1940s and 1950s claimed first place in the field of theory and ruled the professional world of psychiatry in terms of influence, 17 the Action for Mental Health report took pains to label psychoanalysis as a subspecialty of psychiatry and to point out that of the nation's 12,000 trained psychiatrists only 850 were qualified psychoanalysts. The fact that the commission felt called upon to make this point underlines the influence of psychoanalysis at that time. The commission's intention seemingly was to invite the nonpsychoanalytic world of psychiatry to more independent action. Many psychiatrists did respond to the CMHM and developed an attitude toward mental health problems that is now captured in the term "community psychiatry." A variety of practices and outlooks make up community psychiatry. In broad description, it stresses the external and social causes of mental disturbances; it advocates programs that are involved in community life; it has demoted to a secondary position the aims of reducing individual stress, of curing an individual's illness and restructuring his personality , and placed first the aims of establishing social competence among the poor and needy, of removing the symptoms of mental disturbance as quickly as possible, and of promoting mental health through preventive measures.~8 A concrete example of applied community psychiatry at work will give details to the broad description. Through the practice of community psychiatry, M. B. Ahmed, M.D., and his staffat Unit One of the State Hospital Complex in St. Louis, Missouri, have reduced the number of permanent patients from 500 in 1968 to about 100 in 1971. The Ahmed idea of community psychiatry includes the following applications: The patients are constantly reminded of their roles in the community outside the hospital; patients are told that they will be released as soon as possible and that their
Psychoanalysis and the Community Mental Health Movement
33
families are involved in planning for their release; many patients are allowed to stay at home and to travel to the hospital for day care; patients share with the staff in making decisions that affect them; a mental health clinic has been opened in north St. Louis County to bring psychiatric care to the people and to provide opportunity for preventive programs in the community setting. 19 The departures from standard psychoanalysis are obvious: short-term therapy, group participation and responsibility, an optimism even for psychotic problems, preventive work in the community, etc. The changing mood in C M H M and in community psychiatry The CMHM, encouraged and aided by community psychiatry, has itself developed, which must be kept in mind when one considers CMHM's present relation with psychoanalysis. Although its report of 1961 rejected psychoanalytic treatment, the commission continued to be interested mainly in the immediate, personal care of the emotionally and mentally disturbed. It warned against the concept of "primary prevention": t ha t is, activity directed against supposed causes of mental unbalance within a community and activity designed to promote healthy personalities, etc. The report called the idea of "pri m ary prevention" too vague and undefined. It could drain the energies of mental health centers away from the focal task of caring for those with explicit mental difficulties. 2~Indeed, in 1964 an investigation of 11 outstanding centers revealed that, in spite of the reaction against psychoanalysis, the emphasis of the centers remained on the individual and on individual treatment: "T here are indications that most of the centers considered individual psychotherapy as the t r e a t m e n t of choice. ''21 One director called it "the backbone of our therapeutic program." This attitude no longer has the field to itself. A similar study, six years later, also investigated 11 outstanding centers, including two represented in the 1964 study. A marked change was reported: Psychotherapy itself was challenged as an inadequate approach to people in lower-class situations; individual attention was being replaced by group activity; programs were increasingly being directed toward the political goal of increased power for the poor and other minorities; and the previous acknowledgments of the contributions of psychoanalytic theory (e.g., the unconscious, the influence of the past, the phenomenon of transference) were being withdrawn. The following paragraphs from the 1970 report are representative of the current opinions of 11 active and influential centers: Only communities with a large lower class population have social difficulties. Middle class members of a community attribute their psychopathology to their own internal psychological processes while lower class people frequently attribute their pathology to defects in society. Thus psychotherapy works for the middle class but not for the lower class. The concept of mental health is synonymous with the concept of power and therefore one of the primary tasks of the mental health movement is to increase the actual amount of power of those members of the community who have chronically been powerless.
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Journal of Religion and Health
Individual psychotherapy may not be the best form of treatment for many patients with emotional disorders even if it could be provided to all in need. The groups can influenee an individual much more than any single other individual can. It is useless to be concerned about the past. Therefore, many programs are totally ahistorical and adynamic. The unconscious is an unnecessary concept in treating patients. Many programs concentrate their efforts on operating on current overt behavior. Knowledge of personality dynamics is irrelevant in order to change behavior and, in fact, such knowledge might interfere with the ability to change behavior. Activities in the facilities visited have moved away from the study of individual conflict to the study of the social epidemiology of mental disorders. The facilities have placed greater emphasis on the development of' skills and the provision of clinical services. Diagnostic techniques for studying individuals are no longer as important as techniques for the diagnosis of groups, neighborhoods and communities at l a r g e . . . The focus in many of these programs is much more on preventive services than it is on therapeutic services. 22 It is obvious, therefore, t h a t m a n y of the C M H M centers h a v e m o v e d far beyond the 1961 Ac'tion report in their rejection of psychoanalysis a n d have t u r n e d their concentration, s t r i p p e d of any p s y c h o a n a l y t i c concepts, from the individual to the political a n d social ills of the c o m m u n i t y .
The rejection of the psychoanalytic stereotype T h e s t e r e o t y p e of the psychoanalyst, like m o s t stereotypes, fails to c a p t u r e the whole picture. P s y c h o a n a l y s t s recognize the facts of life: t h a t , while the n u m b e r of psychiatric a p p l i c a n t s h a v e increased, there has been a leveling off of p s y c h o a n a l y t i c students; ~3 t h a t the interests of m a n y young psychiatrists are moving toward c o m m u n i t y involvement; 24 and t h a t , unless psychoanalysis m o v e s in t h a t direction, it will lose influence over a very large p a r t of the m e n t a l health field. 25 T h e A m e r i c a n P s y c h o a n a l y t i c Association, cited above for its aloofness from the C M H M , within the last few years has established a C o m m i t t e e on Social P r o b l e m s a n d charged it with a s t u d y of preventive m e a s u r e s t h a t m i g h t be deployed in the c o m m u n i t y . M o r e destructive of the stereotype is the actual n u m b e r of psychoanalysts who are actively engaged in c o m m u n i t y m e n t a l health'. In 1966, the Los Angeles C o u n t y D e p a r t m e n t of M e n t a l H e a l t h h a d 71 psychoanalytically-oriented personnel associated with its programs. Sixty-five of t h e m , responding to a questionnaire, indicated t h a t their training h a d been quite helpful and in no way a hindrance. 26 W h a t is more suprising, the A m e r i c a n P s y c h o a n a l y t i c Association c o n d u c t e d its own survey a n d learned t h a t 78 percent of the respondents were involved in some form of c o m m u n i t y p s y c h i a t r y . 27 In St. Louis, Missouri, the P s y c h o a n a l y t i c F o u n d a t i o n has m a d e an effort to bring low-cost analysis to people in need. Fees are arranged according to one's ability to pay; t h e y m a y be as low as $1.00 per visit. Moreover, the foundation has m o v e d directly into c o m m u n i t y activities. It conducts a M a t e r n a l I n v o l v e m e n t Project to help answer the emotional needs of teen-age girls who are p r e g n a n t outside of m a r r i a g e a n d to suggest p r e v e n t i v e measures against the increase or
Psychoanalysis and the Community Mental Health Movement
35
recurrence of such pregnancies. It also holds a D a y Care M o t h e r s ' Consultation P r o g r a m and provides consultation services for clergymen a n d other professionals who serve in counseling roles. 2s T h e personnel of the C o m m u n i t y P s y c h i a t r y Division of St. L u k e ' s Hospital C e n t e r in New York are p s y c h o a n a l y t i c a l l y trained. T h e y h a v e entered into consultative roles with such c o m m u n i t y groups as policemen, guidance counselors, a n d school a d m i n i s t r a t o r s . It is interesting to see psychoanalysis fulfill one of the objectives of the 1965 Construction Act: i.e., the extension of service to the c o m m u n i t y via consultation with c o m m u n i t y agencies a n d professional personnel. T h e s e experiences have caused the St. Luke's group to be reassured a b o u t the need a n d contribution of p s y c h o a n a l y t i c influence: It has become patently clear to us that it is possible to be a consultant without losing anyone's capacity to be an analytic c l i n i c i a n . . . Community agents operate willy-nilly according to ideas about human motivation and behavior that may be inarticulate but still constitute a form of psychoanalytic theory and often are based on misunderstanding of psychoanalytic thinking or are directly contradictory to it. The psychoanalytic consultant has the capacity to contribute his understanding to community agents so that they may in turn have more positive effect on the mental health of their communities . . . . Our experience indicates that one can be a psychoanalyst and community consultant without conflict of roles. Psychodynamic consultation can be effectively applied to community consultation and can add a dimension that is often indispensable. 29 A n s w e r s to specific charges against psychoanalysis T h e foregoing p a r a g r a p h s greatly modify the s t e r e o t y p e of the aloof psychoanalyst. T h e literature contains the suggestion t h a t t h e c u r r e n t C M H M is in danger of diffusing its activities to such an extent t h a t m a n y centers m a y b e c o m e mere neighborhood centers. 3~ T h e active i n v o l v e m e n t of p s y c h o a n a l y s t s m a y prove to be a h e a l t h y c o u n t e r b a l a n c e a n d to r e m i n d the C M H M of its e m o t i o n a l a n d m e n t a l roots. Such a r e m i n d e r a p p e a r s implicit in the a b o v e s t a t e m e n t t h a t psychoanalysis can add " a dimension t h a t is often indispensable. ''31 Be t h a t as it m a y , specific charges have been leveled against the theory a n d p r a c t i c e of psychoanalysis. T h e y m u s t be answered directly. T h e o f t - r e p e a t e d charge t h a t psychoanalysis is of too long d u r a t i o n has found a receptive hearing a m o n g analysts. 32 T r a d i t i o n a l psychoanalysis has m a i n t a i n e d t h a t s h o r t - t e r m t h e r a p y is dangerous since it forces p r e m a t u r e interventions and i n t e r p r e t a t i o n s a n d does not p e r m i t the essential r e s t r u c t u r i n g of the personality. Moreover, it interprets early i m p r o v e m e n t s as a pseudo "flight into h e a l t h " r a t h e r t h a n a desired change. 33 Nevertheless, s o m e a n a l y s t s h a v e a c t u a l l y reduced the n u m b e r and length of t h e r a p y sessions w i t h o u t causing the feared dangers. ~4 Leopold Bellak and L e o n a r d S m a l l are two a n a l y s t s who have t a k e n the m a t t e r even further, T h e y endorse " b r i e f p s y c h o t h e r a p y , " a t r e a t m e n t covering a s p a n of one to six sessions a n d concentrating on s y m p t o m removal. Into this brief p s y c h o t h e r a p y they actively bring p s y c h o a n a l y t i c concepts a n d techniques. One
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Journal of Religion and Health
explicit example of this must suffice. Transference, "comprising all the nonrational sentiments of the patient toward the therapist," is deliberately used by the therapist to maintain himself as a "benign, interested, helpful figure. ''35 In other words, Bellak and Small hold that transference occurs inevitably even in brief encounters and that the therapist must enhance all signs of positive regard and avoid all tendencies toward negative transference because of the time factor and because of concentration on symptoms rather than on personality rebuilding. Thus, brief psychotherapy can be effective because of--not in spite of~psychoanalytic awareness. A more serious charge has been that psychoanalysis and even psychotherapy have no usefulness for the poor and the lower economic classes. At least one writer has challenged this, ~claiming that the lower classes can verbalize and introspect sufficiently to profit from analysis and individual therapy. 36 Indeed, Bellak and Small were mindful of the application of brief psychotherapy to lower-class people and inscribed the frontispiece of their work with this quotation from Sigmund Freud: "Some time or other, the conscience of the community will awaken; admonish it that the poor man has just as much right to help for his mind as he now has to the surgeon's means of saving life." Linn, aware that CMHM has moved beyond individual therapy, points to Freud's work, Group Psychology and Analysis of The Ego, in an effbrt to prove that Freud's concepts can be transformed fbr use in today's techniques of group dynamics. 37 Worthy as this effort may be, psychoanalysis does not have to await the transformation of earlier concepts in order to emphasize community involvement. Psychoanalysts have long dealt with social concerns: Alfred Adler's concern with the striving for power, Erich Fromm's persuasive presentation of man's loneliness and isolation in modern society, Harry Stack Sullivan's realization of the importance of interpersonal influence--these psychoanalytic works are immersed in the problems of community and society. Psychoanalytic theory has been able to produce concrete techniques and applications when it comes t o the treatment of the individual. It has been less successful in communitarian and societal areas. Bellak and Small and Linn point out that psychoanalysis, with its theory centered on the infant-mother relationship, has long dwelt on the effects of this bond on the infant. They argue that this rich psychoanalytic experience can now be turned toward the mother and the family, both to measure the effect of the infant on parent and to provide the parent and family with a set of expectations and guidelines. The St. Louis Psychoanalytic Foundation was cited earlier for trying to bring analytic insight to mothers. It is also to be hoped that analytic experience can transcend the therapy session to prove of value in less strict, less formal situations. In its role of consultation with policemen and other groups, St. Luke's Community Psychiatry Division of New York discovered the existence of hostility and dependence in the sessions with the consultees. It used this transference to demonstrate to the consultees the hostility and dependence operative in their daily work relations. The influence of the past is made visible in what is called the "anniversary psychosis," a break suffered by a large percentage
Psychoanalysis and the Community Mental Health Movement
37
of w o m e n when their oldest child reaches an age at which the p a t i e n t s h a d lost their own mothers. 38 C o m m u n i t y p s y c h i a t r y could m a k e good use of this i n f o r m a t i o n to develop specific p r e v e n t i v e p r o g r a m s . T h e s e are a few r e c o m m e n dations for the application of psychoanalysis to the C M H M . By far the m o s t serious charge against psychoanalysis is the one m a d e in the 1970 report on the eleven centers (Bloom): i.e., t h a t the theory of psychoanalysis is irrelevant, t h a t the p a s t does not m a t t e r , a n d t h a t the unconscious is unnecessary. This strikes at the very h e a r t of psychoanalysis. All other charges can be answered by an a d a p t a t i o n of t e c h n i q u e (e.g., shorter sessions, group analysis) or by the extension of p s y c h o a n a l y t i c concepts into c o m m u n i t y activities. If psychoanalysis c a n n o t defend its f u n d a m e n t a l concepts, a d a p t a tions will m a t t e r little. One of its best defenders has been E r i k Erikson in his classic work, C h i l d h o o d a n d S o c i e t y . 39 Erikson has skillfully enlarged the vision of psychoanalysis, e x t e n d i n g it b e y o n d the early years to include each era of a m a n ' s life. He has s u m m e d up each stage in t e r m s of its basic work: trust, a u t o n o m y , initiative, industry, identity, i n t i m a c y , generativity, a n d integrity. B u t he has r e m a i n e d true to his psychoanalytic roots, a n d t h r o u g h o u t his work he keeps close to the indelible influence t h a t childhood and its culture h a v e on the m a t u r a t i o n of a h u m a n being and of a society. A few quotations from the close of his book illustrate how faithful he has been: Having learned in clinical work that the individual is apt to develop an amnesia concerning his most formative experiences in childhood, we are also forced to recognize a universal blind spot in the makers and interpreters of history: they ignore the fateful function of childhood in the fabric of society (p. 404). Every adult, whether he is a follower or a leader, a member of a mass or of an elite, was once a child. He was once small. A sense of smallness forms a substratum in his mind, ineradicably (p. 404). Thus the immature origin of his conscience endangers man's maturity and his works: infantile fear accompanies him through life. This we, the psychoanalysts, are attempting to correct in individual cases; this we try to explain and to conceptualize, because there is no universal cure--only, maybe, an alleviation by gradual insight--for the fact that each generation must develop out of its childhood and, overcoming its particular brand of childhood, must develop a new brand," potentially promising, potentially dangerous (p. 405). Erikson answers the charge of irrelevance b y describing vividly the e n d u r i n g influence of culture on childhood a n d of childhood on culture. H e r b e r t M a r c u s e , a psychoanalyst, answers in a s o m e w h a t different way. H e a d m i t s t h a t the F r e u d i a n p r e o c c u p a t i o n with the individual is being swallowed up b y the power of society. T h e role of the father figure in family d o m i n a n c e is over. T h e influences on the individual are multiple: family, c o m m u n i t y , the media. We are, he states, on the verge of a society w i t h o u t fathers. 4~ B u t M a r c u s e w a r n s of a n y d e v e l o p m e n t t h a t gets too far away from the individual, a warning t h a t p e r h a p s was behind the reluctance of the 1961 A c t i o n report to get involved with an
38
Journal of Religion and Health
unanchored, free-floating preventive mental health program. Marcuse would h a v e us r e m a i n n e a r t h e i n d i v i d u a l , l i s t e n i n g to all t h e m o v e m e n t s w i t h i n t h e s i n g l e m a n , p r o b i n g t h e forces t h a t s t i r t h a t m a n to a c t i o n . P s y c h o a n a l y s i s does t h i s . M a r c u s e e n d s his r e m a r k s t h i s w a y : Thus psychoanalysis draws its strength from its obsolescence: from its insistence on individual needs and individual potentialities which have become outmoded in the social and political development. T h a t which is obsolescent is not, by this token, false. If the advancing industrial society and its politics have invalidated the Freudian model of the individual and his relation to society, if they have undermined the power of the ego to dissociate itself from the other, to become and remain a self, t h a t invokes the Freudian concept not only ~s a part left behind b u t also a future to be recaptured (pp. 60-61). Conclusion
P s y c h o a n a l y s i s a n d C M H M were o n c e e n e m i e s . P s y c h o a n a l y s i s h a s m a d e n o t e w o r t h y a d v a n c e s t o w a r d t h e C M H M i d e a b o t h in t e c h n i q u e c h a n g e s a n d in c o m m u n i t y i n v o l v e m e n t . I t is p o s s i b l e t h a t C M H M m a y f i n a l l y r e j e c t all p s y c h o a n a l y t i c c o n t r i b u t i o n a n d f a c e its f u t u r e w i t h o u t a t h e o r y . I f t h a t t a k e s place, t h e C M H M s o m e d a y in its f u t u r e m a y t u r n a c o r n e r a n d f i n d i t s e l f face to f a c e w i t h t h e lonely, i n d i v i d u a l m a n , c o n s c i o u s of his p a s t a n d f e a r f u l o f t h e u n e x p l a i n e d a n x i e t y w i t h i n h i m . I t is t h e n t h a t t h e C M H M will f i n d i t s e l f once a g a i n s t u d y i n g t h e w o r k s of H e r b e r t M a r c u s e , E r i k E r i k s o n , S i g m u n d F r e u d , a n d the psychoanalytic world. References
1. Rubins, J., The Changing Role of Psychoanalysis, Am. J. Psychoanal., 1967, 27, 147-162. 2. Glasscote, R., The Community Mental Health Center---An Analysis of Existing Models. Washington, D. C., Joint Information Service, 1964. 3. Rubins, op. cit. 4. Glasscote, op. cit. 5. Ewalt, J. and P., History of the Community Psychiatry Movement, Am. J. Psychiatry, 1969, 126, 43-52. 6. Glasscote, op. cit. 7. Szasz, T., The Manufacture of Madness. New York, Harper & Row, 1970. 8. Action for Mental Health. Final Report of the Joint Commission on Mental Illness and Health.
New York, Basic Books, 1961. 9. Ibid., p. vii.
10. Kennedy, J. F., Message to Congress Relative to Mental Illness and Mental Retardation, Am. J. Psychiatry, 1964, 120, 729-737. 11. Action for Mental Health, op. cit., pp. 79 80. 12. Glasscote, op. cit. 13. Aldrich, C. K., Brief Psychotherapy--A Reappraisal of Some Theoretical Assumptions, Am. J. Psychiatry, 1968, 125, 585-592. Wallerstein, R., The Challenge of the Community Mental Health Movement to Psychoanalysis, Am. J. Psychiatry, 1968, 124, 1049-1056. 14. Whittington, H. G., Psychiatry in the American Community. New York, Internat. Universities Press, 1966, p. 5. 15. Brichmer, H. R., Schwartz, D. A., and Doran, S. M., The Psychoanalyst as Community Psychiatrist, Am. J. Psychiatry, 1966, 122, 1081-1087. 16. Bindler, B., The American Psychoanalytic Association and Community Psychiatry, Am. J. Psychiatry, 1968, 124, 1037-1042.
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17. Hersch, C., The Discontent Explosion in Mental Health, Am. Psychologist, 1968, 23, 497-507. 18. Rubin, B., Community Psychiatry, Arch. Gen. Psychiatry, 1969, 20, 497 507. Wallerstein, op. cit.; Hersch, op. cir. 19. Meyer, G., Shrinking One Mental Hospital, St. Louis Post-Dispatch, March 28, 1971. 20. Action for Mental Health, op. cit. 21. Glasscote, op. cit., p. 5. 22. Bloom, B., Training the Psychologist for a Role in Community Change. A Report of the First Institute on Innovations in Psychological Training. Unpublished paper, 1970, pp. 20-24. 23. Bindler, op. cit.; Rubins, o19 cit. 24. Aldrich, op. cit. 25. Dorn, R., The Role of the Psychoanalyst in Community Mental Health, Community Mental Health J., 1966, 2, 5-12. Wallerstein, o19. cit. 26. Brichmer, op. cit. 27. Brodsky, B., The Application of Psychoanalytic Method and Theory to Social Problems, J. Am. Psychoanalytic Association, 1967, 15, 686-694. 28. Psychoanalytic Foundation of St. Louis, 1970 Annual Report. Private brochure. 29. Papanek, G., Psychoanalysis and Community Psychiatry, Arch. Gen. Psychiatry, 1968, 19, 189-196. 30. Bloom, op. cit. 31. Papanek, op. cit. 32. Aldrich, op. cit. 33. Ibid. 34. Rubins, op. cit. 35. Bellak, L., and Small, L., Emergency Psychotherapy and Brief Psychotherapy. New York, Grune and Stratton, 1965, p. 40. 36. Rubins, op. cit. 37. Linn, L., Psychoanalysis and Community Psychiatry, J. Hillside Hospital, 1967, 16, 234-254. 38. Bellak and Small, op. cir. 39. Erikson, E. H., Childhood and Society. New York, W. W. Norton, 1963. 40. Marcuse, H., Five Lectures. Boston, Beacon Press, 1970.
