Is Everyone Mental?
I came into psychiatry at a time of near revolution.
Fueled by the rage for civil liberties across race and gender preference, mental patients came to attention as a vast oppressed minority unable to speak on their own behalf.
Erving Goffman’s monumental treatise,
Asylums
, was a revelatory touchstone. It delineated the multiple ways that institutionalization created the enclosed, wholly divided community of patients and hospital staff and, in prison, of convicts and guards.Mental patients learned to adapt to their role as passive and compliant. Worse, their potential for self-direction, initiative, and socialization was seen as markedly diminished by the demands of their role, their fear of the outside that they had lost touch with, and their untreated and untreatable symptoms.
The introduction of antipsychotic medication, which began in the mid-1950s, illuminated the path to freedom for many of these patients. By markedly reducing, even eliminating, the prominent symptoms of auditory hallucinations and paranoid delusions, mental patients could be released from hospitals and returned to live in the community. Although maintaining these patients in such open settings required major supportive programming, most state commissions overseeing psychiatric hospitals saw the program of
as a huge money-saving initiative. So hospitals with patient populations of, say, 6,000 were reduced almost overnight to 600. But money was not allotted to develop the supportive programs that would adequately maintain and mainstream the discharged patients.
Unfortunately, the key operative techniques, the psychotherapeutic base of psychoanalysis, has also been largely dismissed by academic psychiatry
.In the early 1970s, Schizophrenia, which affects almost one percent of the American population (i.e., 3.5 million) constituted the vast majority of those released patients. The deficit symptoms of schizophrenia (social ineptitude, mental blocking, low motivation, apathy, blunted affect) were not immediately recognized. These individuals could not readily integrate into mainstream society and were rendered homeless or confined to restrictive adult homes. Deinstitutionalization became a pejorative term but alternatives remained financially prohibitive. The voice for the nation’s mentally ill remains mostly silenced.The 1970s revolution in psychiatry virtually brought down the almost imperial role that psychoanalysis held from the post-war era. In America, psychoanalysis claimed to comprehend the cause and treatment of all mental illness, from schizophrenia to obsessive-compulsive, panic, and personality disorders, to neuroses. Antipsychotic medication proved that the psychoanalytic treatment of schizophrenia, already dubious, was ineffective. As medications came into use for Attention Deficit Hyperactivity Disorder, Obsessive-Compulsive Disorder, Depression, Panic Disorder, etc. the curative value of psychoanalysis became at most questionable, and at least costly and lengthy. The psychiatric dominion of psychoanalysis vanished.Unfortunately, the key operative techniques, the psychotherapeutic base of psychoanalysis, has also been largely dismissed by academic psychiatry. It is no surprise today that a patient will be astonished to learn that a psychiatrist would offer psychotherapy along with psychopharmacologic treatment.The spirit of that 1970s psychiatric revolution has thus been subverted and vitiated. That radical focus, even by extremists such as the unfortunate R.D. Lang, had been to restore the personhood, the functional humanity, of individuals floundering in life. Medications may greatly facilitate that process but the abiding damage to the self-induced by psychiatric disturbances will often require serious psychotherapy.
The category of personality disorders, often called disorders of the self, arose late in the evolution of psychoanalytically and has also been markedly diminished, almost nullified, in the American Psychiatric Association’s Diagnostic and Statistical Manual. Yet such terms as borderline, narcissistic and schizoid are still bandied about, more as character traits or mere slander.Personalities appear to be formed in the early stages of the evolution of our sense of self. For many the negotiation with parents for love, acceptance, and recognition seems to have been conditional. No one escapes childhood without some scrapes and bruises. But the stresses of maturation become intensified in our highly structured society with its open architecture and multiple, often egregious strictures. Negotiating a path through this life is hardly easy.Evolutionarily we are all equipped with the capacity to fear, to experience grief, to crave pleasure, to mate, to think, and to imagine and fantasize. Any of these capacities are subject to expansion and exaggeration. And then there is trauma.Not everyone suffers from mental disorders or psychiatric afflictions. But many people pass through life bruised and, often in small but significant ways, they suffer.
The techniques of psychotherapy when employed by skilled, empathically aware, ethically motivated therapists do provide pathways out of psychological suffering.Research on the functions of the brain and especially on the dysfunctions,great and small, that arise and dwell there are leading to a new understanding about the role of the brain in all our behavior.`That news presses on the role of experience, past and ongoing, in forming and maintaining our personality, our behavior, our thoughts, our lives. Psychotherapy can be a change-making experience. Try it.