The Method in the Madness
The Method m the Madness
A. G A E D E
In reflecting on the problem of mental illness I am moved to quote an incisive passage from Alfred North Whitehead: "Distrust the jaunty assurances with which every age prides itself that it at last has hit u p o n the ultimate concepts in which all that happens can be formulated. T h e aim of science is to seek the simplest explanations of complex facts. We are apt to fall into the error of thinking that the facts are simple because simplicity is the goal of our quest. T h e guiding motto in the life of every natural philosopher should be, 'Seek simplicity and distrust it.' "1 Whitehead's passage is appropriate because the words "mental illness" (illness of the mind) have come to connote a kind of "ultimate concept in which all that happens can be formulated." T h a t is to say, the term has become so inclusive of physiological, social, and psychological elements that it has become less and less descriptive of the p h e n o m e n o n we try to understand. I think the time has come to "distrust" the concept and take another look at the words, not only at what they have come to mean today, but also at their origin and development. In trespassing in THE REV. ERWIN A. GAEDE, PH.D., has been minister of the First Unitarian Church of Ann Arbor, Michigan, for the past twelve years. His long-standing interest in mental health problems has found expression in the work of Project Transition, Inc., originated by Dr. Gaede's church and now assisted by other churches in the community. It is a group of volunteers who help mentally ill people break away from the geographical and social isolation of the state hospital.
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that field, I a m aware that I, too, m u s t be cautious lest I be tempted to hit u p o n one of those " u l t i m a t e concepts" that neatly explain c o m p l e x a n d involved conditions. I propose, therefore, that 1) the term " m e n t a l illness" as currently used by l a y m e n a n d professionals has become a myth, and, as is the n a t u r e of myths, tends to obscure clear t h i n k i n g on the subject; 2) because it is an inadequate concept, it has served to retard a n d inhibit the d e v e l o p m e n t of treatment programs; a n d 3) the term s h o u l d be discarded a n d n e w words should be f o u n d to describe m o r e adequately w h a t it is that so m a n y people experience. T h e s e propositions m a y s o u n d radical, if n o t unreasonable, but they will seem less so once we e x a m i n e the concept of " m e n t a l illness," bearing in m i n d that we are n o t d e n y i n g that m a n y people find life threatening, agonizing, and futile. Let us e x a m i n e the term " m e n t a l illness" to see w h a t it m e a n s today a n d w h a t it s h o u l d not mean. At this point, ! m u s t a c k n o w l e d g e m y indebtedness, as will be suspected, to Dr. T h o m a s Szasz, w h o has e x a m i n e d the words and their m e a n i n g w i t h rigorous logic. 2 We have gotten into a bind by t h i n k i n g of " m e n t a l illness" as t h o u g h it were not essentially different from other forms of bodily illness, such as diseases of the skin or the liver, that manifest themselves by certain symptoms. Similarly, mental illness is manifested by certain symptoms, such as nervousness, unreasonable fear, or hallucinations. T h i s u n d e r s t a n d i n g of " m e n t a l illness" is, obviously, based on the medical model. T h i s k i n d of t h i n k i n g rests u p o n the failure to m a k e a f u n d a m e n t a l distinction between a defect or disease of the brain, w h i c h is neurological, and w h a t we m i g h t call a " p r o b l e m of the m i n d . " T h e r e are diseases of the brain, a n d for a treatment of t h e m the n e u r o l o g i s t or the brain surgeon should be consulted. T h e r e are psychiatrists, physicians, a n d scientists, of course, w h o believe that all disorders of t h i n k i n g a n d behavior can be traced to neurological defects or to certain p h y s i c o c h e m i c a l conditions, the cure for w h i c h will eventually be discovered by medical research. T h i s is a p o i n t of view to w h i c h scientists are entitled. I do n o t subscribe to it because to claim that w h a t is called schizophrenia, for ex-
The Method in the Madness
ample, is caused by particular physicochemical properties or deficiencies would render irrelevant such social factors as family relations, social class, race, or minority status. There is, I understand, no conclusive, or near-conclusive, evidence from the chemical laboratories that schizophrenia has a physiological or chemical base. There is much evidence, on the other hand, that the environment, consisting of family, social class, race, and other social factors, contributes to the development of schizophrenia as well as to all forms of what we call "mental illness." I do not believe that we are prepared to disregard the mass of sociological data that throws light on disordered thinking and behavior. Neurological defects do produce what may be regarded as disordered thinking and behavior, but it is obvious that the basis for them is neurological; the defect is in the brain and not in what is called the mind. For the sake of clarity, we guard the distinction between the two. For a scholarly survey of the semantics of "mental illness" the reader will find Dr. Theodore R. Sarbin's essay, "Theoretical Perspectives," very instructive. ~ Dr. Sarbin presents the thesis that metaphors become realities in the minds of people so that particular words that were only intended to be tools to discover reality have, through carelessness and awkwardness, come to be. taken as reality itself. Sarbin points out that "mental illness" was first used to describe behavioral disorders of persons whose symptoms made them appear "'as if sick," but that over a period the "as if" disappeared in usage and the metaphor became real. I want to give just one illustration from Sarbin's article to show what can happen to words and their meaning. During the Middle Ages and the Inquisition of the sixteenth century, hundreds and thousands of people, mostly women, perished in the frenzy over witches. T h e w o m e n were burned alive or killed and then their bodies were burned because it was believed that they had been possessed by a demon, and the only way to destroy a demon effectively was to burn it. During the Inquistion a number of nuns became victims because they exhibited a behavior that we would call mass hysteria, very likely brought on by the depressiveness of cloister life. U p o n one occasion a n u n by the name of Teresa of Avila
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figured out a way by which she could save her sisters from the Inquisition. She would ask the inquisitor if the observed behavior could be explained by natural causes, and then proceed to list a n u m b e r of natural causes. If the behavior could be explained by any of them, then certainly the women were not evil but rather "as if sick." By employing the metaphor "as if sick," she implied that the physician rather than the priest should be the judge. Teresa was very clever and her scheme worked, except that over a period of years the "as if" was dropped and the word "sick" was used. It was dropped because it became too awkward to refer to one person "as if sick" and the other as as "really" sick. T h u s the view that disordered behavior results from an illness--and is indeed an illness --became deeply embedded in language and thought and persists to this day. It should be understandable, then, why m a n y psychiatrists and psychologists believe that the term "mental illness" has outlived whatever usefulness it ever had and should now be abandoned. We should not, as Dr. Davidson remarks, stretch the m e a n i n g of a word by doing as H u m p ty Dumpty did when he said, "When I make a word do a lot of work, I always pay it extra. ''4 Words are important and indispensable tools, but they must be handled with care. I turn now to the second aspect of this problem: that the inadequate and misleading character of the term "mental illness" has served to inhibit and retard the development of effective treatment programs. An important report to read in this connection is Action yor Mental Health, the published report of the Joint Commission on Mental Illness and Health authorized by a resolution of the United States Congress in 1955. 5 The commission is a multidisciplinary, nonprofit organization representing 36 national agencies concerned with mental health and welfare. On page four of this three-hundred page report we find these questions raised: "Why have our efforts to provide effective treatment for the mentally ill lagged (1) behind our own professional objectives, (2) behind the public demand for mental health services, and (3) behind programs staged against other major health problems?" These are questions of a crucial, if not disturbing, nature. T h e commission has no answer to these questions except to find some
The Method in the Madness
c o m f o r t in the fact that m u c h m o r e m o n e y was spent on mental health p r o g r a m s in the 1950's than in previous decades. B u t the a u t h o r s of o n e section c o m e perilously close to at least one answer when, in a brief history of the e v o l u t i o n of the treatment of mental illness, they cite the success of P h i l i p p e Pinel, the French doctor, who, f o l l o w i n g the French Revolution, was placed in charge of two Paris insane asylums. T o the shock a n d dismay of his colleagues (and one m i g h t include the patients also), he w e n t t h r o u g h the a s y l u m s striking off the chains shackling his charges. Dr. Pinel came to the conclusion, contrary to prevalent belief, that insanity was curable. H e credited a lay s u p e r i n t e n d e n t w i t h teaching h i m this insight. Listen to these sentences as Pinel recalls his discovery: Forgetting the empty honours of my titular distinction as a physician, I viewed the scene that was opened to me with the eyes of common sense and unprejudiced observation. I saw a great number of maniacs assembled together, and submitted to a regular system of discipline. Their disorders presented an endless variety of character; but their discordant movements were regulated on the part of the governor flay superintendent] by the greatest possible skill, and even extravagance and disorders were marshalled into order and harmony. I then discovered that insanity was curable in many instances, by mildness of treatment and attention to the mind exclusively . . . . I saw with wonder, the resources of nature when left to herself, or skillfully assisted in her efforts. 6 Dr. Pinel in France a n d a p p r o x i m a t e l y a dozen doctors in this c o u n t r y developed the principles of moral treatment (social d e v e l o p m e n t a l approach). Moral treatment at that time c o r r e s p o n d e d fairly closely w i t h o u r m o d e r n p r o g r a m s of rehabilitation. A m o n g the doctors in this country w h o were c o m m i t t e d to the m o r a l treatment m e t h o d a n d w h o were very successful in their efforts at rehabilitation were Samuel W o o d w a r d , Eli T o d d , Isaac Ray, J o h n S. Butler, L u t h e r Bell, A m a r i a h Brigham, T h o m a s Kirkbride, a n d P l i n y Earle. T h e c o m m i s s i o n report does n o t spell o u t the reasons [or the demise of the m o r a l treatment a p p r o a c h , b u t it does m a k e the rather startling observation that: to Pinel's principles for the treatment of psychotics twentieth century psychiatry can add little, except to convert them into modern terminological dress, con-
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tribute more systematic thought on the significance of various symptoms, intensify the doctor-patient relationship through scientific knowledge of psychological mechanisms, treat the patient as a member of a social group which expects him to behave in accepted ways, and specify that moral treatment has been subject to an incredible amount of distortion and misinterpretation, depending on the personality, motivations, and vicissitudes of its administrators.7 As an illustration of the success of the moral treatment method, here are a few statistics a b o u t patients w h o h a d been admitted to the Worcester State H o s p i t a l in the p e r i o d 1833-1852 after h a v i n g been ill less than one year: " D u r i n g the entire 20 years there were 2,267 such admissions, of w h o m 1,618 were discharged as recovered or improved, or 71% . . . During this same period the total of all admissions (including those w h o s e illnesses h a d lasted longer than o n e year prior to admission) was 4,119, of w h o m 2,439 or 59% were discharged recovered or i m p r o v e d . . . . " " T h i s record," states the c o m m i s s i o n report, "taken at face value, is e q u a l to that of first-class mental hospitals of today."8 T h e reasons w h y the m o r a l treatment m e t h o d collapsed is told by Karl M e n n i n g e r in his book, The Vital Balance. 9 T h e story is a l m o s t incredible, b u t here it is. After 20 years of p h e n o m e n a l success, "catastrophe struck," as M e n n i n g e r writes. A n u m b e r of things w e n t wrong. First, the psychiatric leaders w h o h a d i n t r o d u c e d the ideas resigned, died, or entered other fields, and an era of p e s s i m i s m set in. Second, this was the period w h e n m a n y i m m i g r a n t s h a d come, a n d were c o m i n g , to this country, filling o u r hospitals a n d other charitable institutions. T h e n came the Civil W a r a n d all that it r e q u i r e d in the w a y of diverted efforts. But most i m p o r t a n t of all were the u n f o r t u n a t e events in the life of Dr. P l i n y Earle, w h o was led to make charges that he d i d n ' t really believe. H e had been a wise a n d intelligent man: he favored the small 200-bed hospital a n d was c o m p l e t e l y c o m m i t t e d to the m o r a l treatment approach. H e h a d been successful in c h a n g i n g the attitude of state administrators in his o w n s t a t e - - N e w York. Some of the statistics q u o t e d on the success of the m o r a l treatment m a y be o p e n to question, b u t Dr. Earle so vigorously criticized some fallacies in the statistics of Dr. W o o d w a r d , his colleague, that he convinced the medical profession that the p r o g n o s i s of
The Method in the Madness
mental illness was extremely poor, which struck a blow at moral treatment. Karl Menninger comments on that paradoxical and pathetic happening with these words: "Within a few years no superintendent had the courage to admit that they had cured more than 5% of their patients! T h e effect u p o n legislatures of this change in the attitude of psychiatrists can be imagined. In spite of Dorothea Dix, in spite of the protests of Isaac Ray and others, the belief in the curability of the mentally ill declined and moral treatment disappeared,"10 That, needless to say, was a most unfortunate development in the history of psychotherapy. T h e moral treatment approach, or more correctly the social developmental model, represented an important advance in theory; it has taken us a long time to catch u p to where we were a century ago. Finally, I want to say something about the implications to the individual of the concept of an "illness of the mind," or the medical model. One should reflect for a m o m e n t on what it must mean to a person who is told that he is "mentally ill." S o m e t h i n g - - h e is.not sure what it is--has made h i m behave in a crazy kind of way. Whatever it is, he is sure that he is not responsible for his illness; nor can he cure himself. T h a t is what everyone tells him: his parents, his spouse, his relatives, his neighbors. He ought to go to a psychiatrist to get help. Perhaps he should go to a hospital and stay there for some time. This person is in trouble, not only because he has acquired beliefs that do not conform with the prevailing beliefs of his society, but also, and ultimately, because he has acted out some of his beliefs. It is in our c o m m u n i c a t i o n w i t h others that the social test of sanity or insanity lies. If a person keeps his weird beliefs to himself and acts normally, that is, the way social conventions and values expect him to act, he will not get into trouble. Once a person has entered a mental institution, voluntarily or forcibly, how is he expected to behave? It does not take long for h i m to learn that if his "illness of the m i n d " is to be taken seriously, and if he wishes help, certain peculiarities of behavior may be expected of him. A patient may first resist hospitalization; then he may become accustomed and adjusted to it; and finally, he finds security in it and fears leaving. And how can 9
Journal of Religion and Health
he leave the hospital w h e n his behavior peculiarities clearly reveal that he is not prepared to leave? Is it n o t evident that the concept of "mental illness" as c o m m o n l y understood is most u n h e a l t h y and devastating to whatever sense of wholeness and purpose a person may h a p p e n to achieve? T h e question naturally arises: Why not a b a n d o n the idea of "mental illness" and search for a phrase that can more adequately describe w h a t it is that people experience when they despair, cry, fight, withdraw, or just w a n t to call it quits? Is not the phrase that Dr. Szasz suggests far more accurate descriptively, namely: "problems in living?" Is not this what people really experience? Or it m i g h t be suggested that people have problems in " c o p i n g with living." Perhaps the person will have to remove himself p e r m a n e n t l y from the e n v i r o n m e n t a n d take u p life in a new location. Perhaps he is h a v i n g problems in living because he needs to change his attitudes a n d behavior in order to be accepted a n d loved. T h e implications of this new definition, "problems in living," are vastly different from those of "mental illness." W h e n we say that a person is experiencing serious "problems in living," we open the door to every facet of life that affects him. We are obliged to look at his emotional, intellectual, and attitudinal complexion; we are also obliged to look at those people and c o m m u n i t y forces that affect him: social status, social change, economic pressures, race, and politics. In d o i n g so we open the door to the social worker w h o often knows of c o m m u n i t y resources and developments that are not k n o w n by the psychiatrist. It opens the door to the sociologist and the urban planner, the public school teacher and the college professor, the city bus driver a n d the policeman. All of us have problems in l i v i n g m i t is only a matter of the magnitude of the problem and the resources we have within us or can muster from the outside. T h o u g h burdened beyond hope, m a n still retains his self-awareness and, it seems safe to say, most of his rational faculties. Shakespeare saw this when he had H a m l e t pretending to be insane and P o l o n i u s observing, on the side, " T h o u g h this be madness, yet there is m e t h o d in't." A m o m e n t later Polonius noted: " H o w p r e g n a n t sometimes his replies are!
The Method in the Madness
a happiness that often madness hits on, which reason and sanity could not so prosperously be delivered of." This reminds me of the time when I took a m a n to a mental institution for consultation and medication. I had persuaded h i m to go with me because I knew that week by week he was finding it more difficult to carry on. He was reluctant to go with me because he feared he m i g h t be retained in the hospital once I got h i m in. I assured h i m he would be as free to leave as he was to enter, so we went. I waited about an hour. We had no more than left the hospital when a joyous kind of expression came over his face and, almost laughing, he said, quoting Sir Walter Scott: Oh what a tangled web we weave When first we practice to deceive! My friend's spontaneous outburst (and confession) left me speechless for the moment, and I never did discuss with h i m what the experience had really meant. Suffice it to say, irrational as a person may appear to be, he is usually more rational and wise than we give h i m credit for being. Psychotherapy is facing criticism today just as are all professions and institutions--and rightly so. New alternatives are needed, all the way from the privacy and affluence of the psychoanalyst's couch to the loss of privacy and poverty of our prison-like mental institutions. Before I suggest alternatives to the available range of practice and care, I should like to relate briefly a program that originated in the church of which I am minister and that soon attracted the interest and involvement of approximately twelve churches in the community. In March of 1968, a group of concerned people, professional and lay, met at the First Unitarian Church of Ann Arbor to discuss how the church and the c o m m u n i t y m i g h t devise a program that w o u l d bypass the traditional programs of hospital visitation and strike out in a new direction. After a series of meetings, we devised a program, modeled on the half-way house, whereby we would bring to our church approximately 12 patients once a week for a luncheon and program for a period of 10 weeks. T h e idea was to bring the patient out of the hospital into
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t h e ' c o m m u n i t y from w h i c h he h a d been ostracized with the hope that we could demonstrate to h i m that the communit): is hospitable. T h i s kind of p r o g r a m required the co-operation of social workers, hospital staff, and volunteers. We began with fear a n d trepidation, but after four or five weeks, we knew that we had f o u n d a secret to the re-motivation a n d resocialization of people w h o had been hospitalized from six weeks to 30 years. T h e p r o g r a m has been an admirable success largely because it has been operated by volunteers. There is a very real difference, and I am sure that perceptive professionals will acknowledge this difference. T h e statistics - - a n d they are available--clearly d o c u m e n t the fact that Project Transition has helped and hastened the release of hundreds of residents from the Ypsilanti State Hospital. 11 T h e p r o g r a m of Project Transition, Inc., is u n i q u e in Michigan and perhaps u n u s u a l nationally. T h e success of its novel experiment suggests the development of further alternatives, such as: 1) A complete re-examination of the historical reasons for the establishment of state mental hospitals on acreages far removed from cities and communities. 2) A concerted attempt to study the condition and prognosis of every resident in a state hospital toward a view of their release a n d relocation in a c o m m u n i t y as soon as possible. 3) C o m m u n i t y development of the m a x i m u m resources available so that hospital residents may return with self-confidence, adequate housing, and a social p r o g r a m that will prevent, as far as possible, their reinstitutionalization in the c o m m u n i t y . 4) A p r o g r a m of medical care carried o u t on a local or county level. 5) Allocation of a specified n u m b e r of beds for psychiatric patients in c o m m u n i t y or sectarian hospitals. 6) T h e establishment and adequate f u n d i n g of half-way houses to provide not only food and shelter, but a p r o g r a m that will assist in the cont i n u i n g personal and social growth of the individual. These proposals do not at all exhaust the potentialities for change in
T h e M e t h o d in the Madness
our m e n t a l h e a l t h institutions. W h a t I a m asking for is p s y c h o t h e r a p y in the broadest, freest, a n d most h u m a n i t a r i a n sense. T h e art a n d practice of p s y c h o t h e r a p y m u s t transcend the clinic, the couch, the hospital, a n d any one person. It m u s t follow us into our homes, schools, churches, shops, industries, a n d government. If this paper raises m o r e questions t h a n it answers it will have served a w o r t h - w h i l e purpose. T h e r e is no d o u b t that a new age is u p o n us for the rehabilitation of those w h o have problems in living. Religion a n d the churches need to recover the role they once played in the caring for souls because they have a needed f u n c t i o n to fulfill in o u r time.
R e f eTerlces 1. Whitehead, A. N., The Concept of Nature. New York, Macmillan, 1926. Quoted from Menninger, K., with Mayman, M., and Pruyser, P., The Vital Balance. New York, The Viking Press, 1963, p. 34. 2. Szasz, T.S., The Myth of Mental Illness. New York, Hoeber-Harper, 1961. See also his essay by the same title, American Psychologist, 1966, 15, 113-118. 3. Sarbin, T., "Theoretical Perspectives." In Plog, S., and Edgerton, W., eds., Changing Perspectives in Mental Illness. New York, Holt, Rinehart and Winston, 1969. 4. Davidson, H. A., "The Semantics of Psychotherapy." In Milton, O., ed., Behavior Disorders, Perspectives and Trends. New York and Philadelphia, 1965, p. 42. 5. Action for Mental Health. Final Report of the Joint Commission on Mental Illness and Health. New York, Basic Books, Inc., 1961. 6. Ibid., p. 29. 7. Ibid., pp. 29-30. 8. Ibid., p. 32. 9. Menninger, op. cit.; see especially Chapter IV, "The Evolution of Treatment." 10. Ibid., pp. 70-71. 11. For free literature on Project Transition, Inc., write to 1917 Washtenaw Avenue, Ann Arbor, Michigan, 48104.