Psychiatric Treatment: Here and in England

WILLIAM SARGANT, M.B.

MOST psychiatrists visiting the United States from abroad are bewildered at the way the direction and control of American psychiatry have been taken over since World War II by psychoanalysts, who are ideological followers of Freud and now sometimes call themselves “dynamically orientated” psychiatrists.

Roles between our two countries have been dramatically reversed since the war. In the pre-war years American psychiatry led the world, and the top positions in British psychiatry were most easily obtained by those who had specially gone to the United States to work and study, generally sitting at the feet of the great Adolf Meyer at the Phipps Clinic in Baltimore. Now British psychiatrists come mostly to wonder at the psychiatric scene, and not so often to learn.

The psychoanalytic dominance in the United States is a state of affairs which prevails in no other country in the world at the present time, except perhaps in Israel, where American psychiatric influences have been increasingly felt in recent years. In most other countries, a much more middle-ofthe-road psychiatric viewpoint prevails, and this in turn, of course, greatly influences the treatment approaches to the mentally and neurotically ill. For instance, there is a general realization in England of our almost total ignorance of the basic underlying causes of practically all forms of functional mental and nervous diseases. Because of our ignorance of causation, the British tend to welcome all types of empirical treatments, just as they do in general medicine, where, too, there is still much admitted ignorance of causation. We insist only that the empirical treatments in psychiatry used in England shall be demonstrably helpful in at least a small group of carefully selected patients.

It is not unprecedented in general medicine to have to wait many years to find out how new empirical treatments really do work, such as quinine in malaria or insulin in diabetes, penicillin in infectious diseases or liver extract in pernicious anemia. And it may well take much longer with diseases of the human brain, which is such a very complicated biochemical and electrical machine with several millions of nerve cells performing their independent and joint electrical and biochemical functions. In the present state of our psychiatric ignorance in England, many varying psychiatric viewpoints are, in fact, deliberately encouraged, and none is ever allowed to dominate the others too much, because it is generally realized that nobody yet knows where the effective and practical advances in the psychiatry of the future are going to come from. New treatments offering real hope are still sorely needed, especially, one would think, in the United States, judging by the thousands upon thousands of the insane locked away there in gigantic mental institutions which in some cases harbor as many as twelve thousand patients.

In recent years advances have already come from an enormous variety of approaches. Who, for instance, would ever have predicted fifty years ago the use of such contrasting treatments as psychoanalysis, with all its sexual preoccupations; group psychotherapy of alcoholism, done in a predominantly religious setting; and the very simple use of a drug like penicillin for cases of general paralysis of the insane (syphilis of the brain)? These last patients used to fill large numbers of hospital beds, but have now almost disappeared because of this effective and simple new treatment in psychiatry. Also, who would have imagined that such a simple method as the use of vitamin B2 (nicotinic acid) would be found to relieve so effectively the old mass epidemics of pellagrous madness and all the pellagrous neuroses that used to be so common in the Southern part of the United States; or that simple thyroid extract would so quickly relieve the neurosis and madness associated with myxedema? The madness and the behavior abnormalities associated with epilepsy are now responding to simple drug medication and to neurosurgical techniques in a way undreamed of years ago, when epilepsy was so often thought of as an illness of the psyche, and thousands of patients had to be committed to mental hospitals.

We have witnessed the discovery and effect of electroshock in severe and intractable melancholia, from which many patients in mental hospitals, up to a few years ago, used to die in agitated exhaustion. The new, much modified forms of lcucotomy (lobotomy) have shown in many countries, and especially in Great Britain, where these techniques have been widely used, that many of the chronically neurotic and insane can be helped to regain peace of mind; and sometimes, after years and years of terrible suffering in mental hospitals, patients are at last able to return to their homes and to active and efficient work again. More recently a large range of new tranquilizing drugs have been tested and have proved to be of great value in the treatment of acute and chronic schizophrenia; these, too, have altered the whole outlook for many patients with this terrible illness, especially when the drugs are combined with electroshock or insulin.

The antidepressant drugs which are now available have brought help to thousands upon thousands of less psychiatrical ly ill patients, such as those in acute anxiety states who previously had good personalities. Even some of those with longstanding and atypical depressive states now have hope of quick and practical relief of their often intolerable symptoms. These drug treatments are bound to be improved upon and to become more and more effective in the years ahead as research on them continues. In fact, apart from senility, mental defect, adolescent psychopathy, and sexual deviations, few mild or serious mental illnesses are now without some means of help by increasingly simple biological and chemical treatments. The soul of man is becoming as easily treatable as the body in many instances, and by simpler and more effective measures than the long years of psychotherapy which we once had to use because there were no other treatments then available to us.

FAITH IN PSYCHOANALYSIS

Despite the proved value of these varied types of new treatment in psychiatry, it has now, paradoxically, become increasingly difficult in only one country in the world, the United States, to obtain any high academic or university teaching post in general psychiatry, especially in a general medical school, unless one has first agreed to subject oneself to, or has already experienced, several years of personal Freudian “training” psychoanalysis on the couch. In the process, one must become fully converted to the extremely circumscribed and purely philosophical tenets of the Freudian faith, now well over fifty years old. For instance, one may still be expected to believe, if psychoanalyzed, that depression is caused by breast frustration in infancy, despite the demonstrated fact that it can often be cured by a drug or a few electroshock treatments. And in a Freudian training analysis, one must also come to accept, by a process akin to religious conversion, the premise that the Freudian dogma and its philosophical derivatives are still basic to the whole future development of psychiatry and that these methods should supplant in time — and, whenever possible, now — all the other more recent effective empirical methods of treatment. In fact, Freudian converts seem to become increasingly afraid of allowing any other methods of psychiatric treatment to gain any real recognition and acceptance in medical schools and university teaching centers.

Unless complete acceptance of the psychoanalytic faith comes about on the couch fairly quickly, the expensive training analysis goes on indefinitely, in an effort to dissolve what is called the trainee’s “negative transference” to Freudian interpretations and theories. The trainee may see the cost of his training mounting higher and higher while he gets no nearer his goal of becoming an analyst and earning a good living in private office practice. This anxiety situation certainly helps some to speed up their “conversion.” If the doctor on the couch happens to prove too resistant to indoctrination and continues to question the basic tenets of the faith desired of him, he may finally be pronounced unsuitable for acceptance as a trained analyst, and his money has virtually been wasted.

The American National Institute of Mental Health, for instance, the main government agency dispensing many millions of dollars every year to promote research, teaching, and the training of psychiatrists, recently had as its director someone who had been psychoanalyzed; the deputy director had been psychoanalyzed as well; and even the research director had been put on the couch. In the current climate of American psychiatry, it would otherwise have been virtually impossible for them to have obtained and held these influential and important posts. Most of the wealthier foundations, such as the Rockefeller and the Ford foundations, have also been advised, in recent years, to give by far the greater part of their very large grants to psychoanalytically orientated departments of psychiatry. And several of the most influential psychiatric journals in America are now being edited and directed by psychoanalysts. Yet we must ask ourselves just what has been the fruit of all this enormous expenditure of money when we look at American mental hospitals and compare the treatment of the less mentally ill in the United States today with that available in poorer industrial countries such as England.

There are, of course, other sorts of psychiatrists practicing in the United States. But only a very few of them have important and influential top professorial posts at universities and medical schools. New high professorial appointments are rarely given to the younger group of psychiatrists unless they have undergone analysis. Especially is this the case in those posts requiring the teaching of medical students. Some Southern universities and a few in the Middle West have not yet toed the line, and they find research grants much more difficult to obtain.

It is sickening to see the deliberate way all the physical and biochemical treatments, so generally useful and acceptable in all other countries as now basic to the proper treatment of the mentally ill, are dismissed by leading Freudian academic and medical teachers as merely “symptomatic” and “second-rate.” The patients being treated by such methods are often told by Freudian psychoanalysts and “dynamically orientated” psychotherapists that such speedy and effective treatments as they are having are simply not getting down to any basic understanding of the causes of their particular illness. This can be done, the Freudians claim, only by spending long hours on the analytic couch at an enormous cost in money to the patient concerned. They conveniently turn a blind eye to the fact that biological treatments in all other countries of the world are getting large numbers of patients better and out of the hospital again, and often in a very short time indeed, and that they work well even when the giving of only a minimal amount of additional psychotherapy is possible because of the tremendous number of patients.

One of the greatest tragedies and strengths of a Freudian analysis seems to be that it can completely brainwash even the most intelligent doctors, as well as many of their patients, into believing that Freudian dogma holds the only key to the real understanding of mental illness. In England, for instance, we have had a very active Freudian school for more than forty years, but there are only about 250 Freudian analysts who practice this method alone, compared with 2500 other psychiatrists who are fully prepared to use and combine all methods likely to help any individual patient. It has generally been found over the years that psychoanalysis is a poor weapon to treat most forms of mental and even neurotic illness.

Freud found this in World War I, and it became more and more obvious in World War II, when it was necessary to get a soldier well and back to duty or discharge him as one of psychiatry’s treatment failures. Psychoanalysis and methods deriving from it have, in fact, proved able to help only a very small proportion indeed of the thousands and thousands of mentally ill patients in Britain and elsewhere. And one has only to go today into the mental hospitals of the United States to see the total failure of Freudian methods.

Freud himself, when he came to England in his eighties, was still vainly insisting to his followers — some of whom had gone mad, he thought — that his methods were useful only in a limited number of cases of hysteria and obsessive neurosis. He was still insisting also that psychoanalysis was in the main a research tool, and of very limited value in treating many illnesses. In all of his extensive writings, for instance, he reported the detailed treatment of merely five patients, and even some of these highly selected few, he said, had not responded to his methods. Freud’s work may in fact prove to be one of the great hoaxes of the century if it turns out that all the data obtained on the couch have been unwittingly fed into the patient by the therapist and then, unknowingly, given back to him by the patient. For instance, Freud made no fewer than twelve consecutive women believe and confess to sexual interference by their fathers! This must have been brainwashing, as it occurred in 100 percent of the patients, and Freud himself finally realized that most of the confessions he had elicited were false.

HOW IT ALL HAPPENED IN AMERICA

In 1938, I first came to work for a year in the United States on a Rockefeller Fellowship at Harvard and the Massachusetts General Hospital, at a clinic where psychoanalysis and its derivatives were really all that was being done in the way of treatment. I then had to return to England at the outbreak of World War II.

Wealthy foundations, such as the Rockefeller Foundation, at that time were becoming increasingly interested in psychiatry and started to pour millions of dollars into the creation of better psychiatric teaching and research facilities. They were also looking for a method of breaking through some of the inertia regarding treatment which was then descending on the Meyerian school of psychiatry in the United States, with Adolf Meyer’s increasing age and rigidity and his preoccupation with the classifying and naming of mental illnesses. The Rockefeller Foundation decided to finance new psychiatric departments in general teaching hospitals and at university medical schools, rather than put more money into the older and more specialized psychiatric hospitals where, up to that time, most of the research and psychiatric teaching had been centered.

New professorial posts and psychiatric departments were therefore being created with Rockefeller money within university general medical centers, such as at the Massachusetts General Hospital in Boston, at the George Washington Medical School in St. Louis, at Duke University Hospital in Durham, North Carolina, and the like. Into most of these newly created academic and professorial teaching posts were placed, on the recommendation of the Rockefeller Foundation, neurologists, physicians, and even pure physiologists who might have shown high qualifications and academic abilities in other branches of medicine, but who had also been psychoanalyzed, generally for some quite personal reason or another. It was hoped that by doing this a new and much more productive brand of psychiatrist would be created in a brave new psychiatric world.

By a strange aberration at the time, the Rockefeller Foundation did not consider it at all necessary for persons appointed as professors of psychiatry to have had any sort of general psychiatric training or experience at all. Sometimes a personal psychoanalysis was all that was required to turn an ordinary physician, pure physiologist, biochemist, or neurologist into a top professor of psychiatry at a general university medical teaching school. And to a great extent this has set the fashion in American psychiatry even today, where we continue to see physicians, biochemists, and other research workers, with so little other general psychiatric training or experience, still being appointed to the highest professorial psychiatric positions, but only if they have been or are being personally analyzed. Such a state of affairs is inconceivable in any other progressive country.

Just before World War II, Nazi-dominated Europe was expelling many of its doctors, some of whom had played a prominent part in the development of psychoanalysis between the two world wars, especially in Vienna. Most refugee psychoanalysts came first to England. We fortunately intercepted some of the best of them to work with us, but most of them went on to America, and some found posts available in the new psychiatric departments in general teaching hospitals, under professors who themselves had had very little experience with psychiatric treatment except for their own personal psychoanalysis. In these new general hospital centers, psychoanalysts unfortunately concentrated initially on the research and treatment of only the very mildest forms of mental illness and on the milder neuroses. The more severe cases were sent to mental hospitals or just sent home. Most of the new clinics failed to grapple with the real problem of psychiatry — namely, learning more about how to treat the enormous numbers of the severely ill segregated in mental hospitals.

Then came World War II, and these refugee doctors were forbidden to enter the armed forces, and most of the university professors of psychiatry were not allowed to join the service either. After the war, the younger generation of American psychiatrists, who had volunteered or been drafted for the duration and who had developed a broad view of treatment in the army, found on their return that with the retirement of Adolf Meyer, the psychoanalysts had taken over control of many of the teaching and training centers in America, and the much more broadly based Meyerian discipline was on the way out. And ever since the war, the psychoanalysts have continued to consolidate their grip on the teaching and training of American medical students and psychiatrists.

During the war, I was part of a group that made what I considered a reasonably useful contribution to psychiatric treatment. With some of the Maudsley Hospital doctors at Belmont Hospital, Surrey, we had initiated the drug abreactive treatment of battle neuroses (which the Americans later renamed “narcoanalysis”). It employed immediate, frontline sedation of battle casualties, intensive use of continuous narcosis, a new technique of modified insulin treatment later used in over 20,000 American service patients during the war, and a subsequent group rehabilitation program. These first-aid treatments for those breaking down under bombing and in combat are now admitted to have saved the United States and Great Britain many millions of dollars in pensions, there being so few chronic war neuroses, especially in England, compared with the enormous numbers seen after World War I, when only psychotherapy and psychoanalysis were available as special treatments.

On returning to the United States and talking to one of my former psychoanalytic friends and colleagues at the Massachusetts General Hospital, I found him still teaching exactly the same theories and treatments, quite uninfluenced by the exciting developments of the six intervening years and all we had learned about treatment. He said to me, “It’s nice to see you again, Willie. We hear your group did supposedly great things in the war, but they really don’t amount to anything, since you cannot explain how your treatments worked”! The relief of a tremendous amount of suffering and the saving of many people from long psychiatric invalidism in fact meant nothing to him, because we had contributed nothing to psychoanalytic theory.

Freud found in World War I that his method of treatment was of very little use, and he had tried to alter his theories and introduce the concept of a death instinct in addition to early sex traumas, since the best of sexually adjusted people, with no obviously hidden sexual trauma, had become chronically and severely neurotic under persistent war stresses. But at the general teaching hospital where I now work in London, the Freudian psychiatrist who was in charge in 1917 had tried to explain to students, because of current Freudian theory at that time, that they were afraid of Zeppelins and bombs simply because these were subconscious phallic symbols acting on their repressed homosexuality! When he retired he was naturally replaced by a more broadly orientated psychiatrist, my immediate predecessor at this hospital.

In retrospect, it is a tragic fact that treatment findings which during the war showed the immense advantages of a biological, as opposed to a psychoanalytic, approach were later forgotten or ignored. A world psychiatric meeting, which made us a general laughingstock in London, was organized to prevent future wars by better child guidance and was supported by grants from wealthy American foundations such as the Macy Foundation. In those early post-war days, big money was bound to influence the decisions as to who should be appointed to important university teaching posts, especially since government agencies had not yet become so generous in their grants to psychiatry as they are now. Since the war, literally millions of dollars have continued to pour into research and teaching projects of a predominantly Freudian or “psychodynamic” nature. And for what? we should ask again and again, when we see the truly abhorrent state of most American mental hospitals today.

The same amount of money, or even a tenth of it, spent on the much more practical medical and biochemical approaches to the treatment of the mentally ill would have produced a revolution in conditions in American mental hospitals similar to that which occurred in British mental hospitals. In the United States, such a view has for the most part been criticized as showing a lack of proper psychiatric understanding and an anti-Freudian bias. Nevertheless, the physical and physiological approaches have actually brought about tremendous advances in the practical treatment of both the neuroses and psychoses in other parts of the world.

PRIVATE PRACTICE VERSUS HOSPITAL WORK

This predominance of psychoanalysis in the United States, and the faith it seems to have created in the minds of ordinary Americans regarding its power to heal the mentally and neurotically ill, has had unfortunate repercussions. Psychoanalysts teaching psychiatry to medical students have been able to convince many future doctors that only psychoanalysis holds out any real hope in treatment. There are few general physicians in the rest of the world who still believe this. And, whereas in Europe the leading professors of psychiatry and the best-qualified clinical psychiatrists are working in mental hospitals, where the greatest challenge to our treatment skills really lies, in America there is a totally different situation. Practically all of America’s best clinical psychiatrists and professors of psychiatry are now working outside mental hospitals and are usually attached to general hospitals. In private practice they treat a necessarily limited number of the well-to-do, who can afford the expense of prolonged psychoanalysis; and one has to be fairly normal and able to stay at work so as to meet the sometimes very large costs of this treatment that may last for years. Some of the very wealthy patients with schizophrenia and severe depression in the United States are also being treated by psychoanalysis, with results that cannot even approach those being obtained by biological methods.

Meanwhile, the masses of the severely mentally ill are segregated and locked away in large American state mental hospitals. Tranquilizers are now being used in them too often simply to damp down the cries for help which come from the chronic wards, rather than being combined with other modern methods of treatment, both physical and psychological, that are used successfully in other countries. In fact, if one travels around the United States, one learns that it is difficult to find any moderately competent and properly trained senior psychiatrists still working in its mental hospitals, except perhaps in the much better paid administrative posts. In some mental hospitals, medically unqualified psychologists are allowed to take over the routine treatment of patients, apart from their urgent physical illnesses, since it is said there is really no need to be a qualified doctor simply to give psychoanalytically orientated psychotherapy. This is inconceivable in Europe.

PROGRESS IN ENGLAND

When I entered psychiatry from general medicine over a quarter of a century ago, in 1934, apart from the malarial fever treatment of general paralysis of the insane there were no special treatments of the mentally ill at all, except the present Freudian psychotherapeutic ones, with the other special psychotherapies of Adler and Jung less used. With only these limited Freudian methods available in those days to help our patients, English mental hospitals presented the same terrible conditions as are seen today in American state hospitals. We worked hard at psychiatric hospitals like the Maudsley to help very ill patients by the psychotherapeutic techniques available at the time. But often we failed, and in the end we just had to lock up our failures in mental hospitals.

Freudian methods have really changed very little since then. In the last twenty-five years, however, we have seen the emergence, especially in Europe, of the new physical and physiological approaches to the treatment of the mentally ill. One of the most exciting results has been that a Minister of Health in Great Britain has recently been able to predict that no less than half of our state mental hospital beds may well be emptied in the next ten years. Most of the acute cases of recent mental illness, however severe, are in future to be treated by these new methods, combined with the older methods when helpful, in open psychiatric units attached to general hospitals. One hundred psychiatric beds are to be attached to every new general hospital being built in England and Wales. This arrangement will eliminate the chronic asylum care of most acute mentally ill patients, which becomes unnecessary if proper treatment is used early enough in their illness. Already several of these units have had good results with 95 percent of acutely ill mental patients and have had to send less than 5 percent on to the state mental hospitals.

In England and Wales, for instance, about 20,000 severely and chronically mentally ill patients have been lobotomized. The new modified brain operations relieve anxiety, agitation, and tortured self-concern, but cause practically no observable undesirable change in the general personality of correctly chosen patients. And certainly no change, except for the better, is seen in the patient’s intelligence. A Ministry of Health inquiry has recently shown that as a result of lobotomy operations done between 1942 and 1954, 45 percent of more than 10,000 chronically mentally ill were able to leave mental hospitals, many after six years or more of illness; and many of them have been able to resume work again and become self-supporting members of the community. Relapse rates have been far lower than was expected. Combined with the new antidepressant and tranquilizing drugs, the modified brain operations can be used with even greater beneficial effects than were possible when the old severe operations had to be used alone. If relapses do occur, they also can be much more quickly treated.

After the war, British mental hospitals used deep insulin-coma treatment in early and recoverable cases of schizophrenia instead of giving repeated and long courses of electroshock, so common in the United States. Insulin-coma treatment is now being given up, however, because of the advent of such drugs as chlorpromazine, which, when combined with electroshock and modified insulin techniques, give excellent results. Electroshock is still generally recognized and used all over England as the most effective treatment of severe depressions; it gets the patients well again in a matter of weeks, whereas the old psychoanalytic methods would often take months or years and still prove ineffective.

The recent discovery, originally by American workers, of a whole new range of antidepressant drugs is helping another large group of patients with milder depressions and anxiety states but basically good personalities to get well very quickly. Such patients, amenable for the first time to specific drug therapy, do not now so often need the addition of electroshock. These new biochemical treatments are also enabling some patients who formerly needed long courses of specialized psychotherapy to be treated speedily and effectively even by general practitioners, who are in many instances capable of giving them the additional necessary psychotherapeutic advice to consolidate the rapid improvement that occurs in less than a month with the new drugs.

THE FREUDIAN BIAS

By employing these rapid physical and biological methods of treatment, combined with psychotherapy, when needed, and special rehabilitation techniques, Britain has now been able to unlock the doors of the vast majority of the wards of its large mental hospitals. Most mental and severely neurotic patients now enter a hospital much more readily for treatment, knowing that they will generally be out again in a matter of weeks. The quick retreatment of the relapsing patient is one of the most satisfying aspects of current psychiatric treatment in England and makes for a very quick bed turnover.

Physical methods are also being used in America, but there is still a tendency for them not to be fully implemented, owing to the constant claims of Freudian psychiatrists that they are only superficial and symptomatic and that they do not get at the underlying basic causes of mental illness. Dr. Manfred Sakel, who developed insulin-coma treatment, died in New York a disappointed man because his treatment was being so little used in the United States compared with other countries. Dr. Ladislas Meduna, an internationally famous and revered figure, who discovered convulsive therapy in Budapest, now lives without very much honor among his psychoanalytic colleagues in Chicago. Dr. Walter Freeman, also internationally famous, who did so much to develop lobotomy from 1936 on, had to face almost unremitting persecution in Washington by some of his fellow psychiatrists until he retired to California. And one can safely predict that the American psychiatrist Dr. Nathan Kline, one of the discoverers of a group of antidepressant drugs which have turned out to be especially useful to patients of good personality previously suffering from anxiety and phobic states, will find his path becoming more difficult for him in established psychiatric circles, though his fame now rings round the rest of the world.

The claim of psychoanalysis to be able to get at the cause and treatment of mental illness is based on blind Freudian faith engendered on the couch rather than by any proven scientific fact. In more than fifty years’ experience with psychotinalysis in Europe and in the United States, there has never yet been any really satisfactory evidence published to show the special types of patients who can be helped, let alone cured, by Freudian methods of treatment. Freud himself believed that only hysterical patients and obsessional illnesses could be helped by psychoanalysis. In Europe it is now being questioned whether Freud did not in fact overstate his case. For we know that Freudian methods often fail completely in severe obsessional neuroses and in chronic hysterias. In England the use of Freudian methods is recommended only for the more specialized cases, and of course by psychiatrists who have undergone psychoanalysis themselves and use no other methods.

I do not believe that the almost religious faith constituting the present Freudian discipline can ever be destroyed in the United States by such criticism as has been made here. Any attack on rational grounds can only hope to get ordinary people to think afresh, and some general doctors also. But it will certainly be ridiculed or ignored by Americans in psychiatric authority at present. In fact, the couch technique is still continuing to recruit most of the new generation of psychiatrists, who would face real financial difficulties if their long, expensive training ever became discredited among the group of patients who are able to pay for their treatment.

But many general physicians, general practitioners, and neurologists in the United States are looking at the current results of psychiatric treatment more critically than are some of the psychiatrists themselves. They are demanding simpler, more effective biological treatments for their patients. This may help to cause a breakthrough, and the practical treatment of the mentally ill will be taken over to a greater extent by neurologists, physicians, and those psychiatrists who believe that the restoring of proper brain function by chemical as well as psychological means is still vitally important in helping patients to get well.

Sooner or later, it will be absolutely essential to appoint as heads of departments of psychiatry in American medical schools and in general teaching hospitals, and to influential positions in psychiatric research, those who have never been subjected to personal psychoanalysis, whatever their present approach to treatment. For personal analysis is almost bound to limit psychiatric perspective. In addition, research grants must be made more freely available to all progressive departments of psychiatry, whether or not their staff has been subjected to the discipline of the couch.

The trouble today is that psychoanalysts, attempting to stem the rising tide of criticism of their present predominance, are ostensibly supporting the appointment of professors of psychiatry who arc mainly interested in such things as physiological brain research. But what is generally overlooked is the fact that these professors would not have been appointed unless they had undergone or were in analysis.

A little while ago, one of America’s most famous teachers of psychoanalytic psychiatry came to England and addressed a large meeting of British psychiatrists. He told us that skilled psychiatric diagnosis, unlike medical diagnosis, has now become quite unnecessary for treatment purposes. The best treatment for any patient suffering from mental illness was to make him feel loved in his hostile world. His listeners asked him what happened when the patient’s friends and fellow workers refused to cooperate after he had left his mental hospital! Nobody in his senses can really believe that mental illnesses as different as schizophrenia, endogenous and reactive depressions, and simple chronic hysteria all respond to an exactly similar loving-treatment method. It would be the same as saying that one antibiotic cured all types of virus and bacterial infections in general medicine, with rheumatism and housemaid’s knee thrown in as well.

To continue to make progress, Britain has always had to adopt empirical approaches to the treatment of its medical and social problems. Its main criterion has had to be what works and what does not work in actual practice, and one learns not to pay too much attention to any particular theory as such.

English psychiatry is far from perfect, as its many grim old asylum buildings and shortage of staff testify. These old hospitals have somehow had to be adapted as well as possible to modern methods of treatment and rehabilitation to serve until more units in general hospitals are available. Socialized medicine may not be a necessity, or even desirable, for the United States at the present time. But a much more troubled social conscience is a necessity. Americans should be asking why it is that England has achieved so much in its mental hospitals, and America so little, despite the fact that England can spend very little each year on treatment research and on the special training of psychiatrists compared with America.

Research psychiatrists should be given every opportunity to develop all types of new effective and practical treatment approaches; and less money should be wasted on immediate and often fruitless attempts to find out how any new empirical and successful psychiatric treatment actually works. This may take fifty to a hundred years or more, just as all the theories as to why malaria was so easily cured by quinine were bound to be futile for over two hundred years, until the microscope was finally invented and the pathologist was able to detect the invading organism in the bloodstream.

The important point is whether a new treatment does really work or not, and what group of psychiatric illnesses it will help. Millions of dollars spent on psychiatric theories and research are bound to be wasted as long as researchers overlook the fact that the brain is the organ of thought and overstress the part played by environment and upbringing as the causes of illness, rather than recognizing that constitutional or acquired defects in brain function often make simple environmental stress damaging to the nervous system of man.

Government agencies must start to give grants primarily to train psychiatrists for work in mental hospitals and general hospital psychiatric units, as in Britain today; and less government money should be spent in training psychiatrists for private practice. As in England, high salaries should be paid to attract clinical psychiatrists to work in mental hospitals. Merit awards, even if secret, could be given to doctors who distinguish themselves in their clinical work in mental hospitals, as in Great Britain, so as to make sure that the most brilliant doctors can earn nearly as much in hospital psychiatric work as they can in private practice.

If possible, approximately two out of every three top professorial appointments in general teaching hospitals should be given to nonanalyzed psychiatric professors representing all types of thought, in order to ensure a fair and equal distribution of teaching and research into differing approaches in psychiatric treatment so that no particular school of thought could dominate the others. Let us hope, as with so many other British social improvements, America will sooner or later follow our present lead in psychiatric treatment, which has produced such happy results. However, for a time at least, the more “normal” persons in the American population would then have to be encouraged to “leave their minds alone.” This would enable the best psychiatric brains to work where they are most needed. And it might not prove too disastrous to those having to stand on their own feet in consequence, or having to get simpler forms of psychiatric help from general physicians, who ought to be better trained in psychiatry.

Freud died in England at the beginning of World War II, after confiding to a doctor friend of mine that he “did not mean it all to happen.”He was referring to the numbers of his followers in Harley Street (the Mecca of medical practice in London) who, he knew, were even then treating all sorts of patients who could not be helped by his methods, which were totally unsuitable for them. He stressed that his treatments had mostly been carried out not primarily for cure but for research purposes. Until late in life he remained very much a neurologist, ever hopeful, as his writings repeatedly show, that simple physical methods could be found to replace the more complicated psychotherapeutic ones that he was then using. He is known to have kept up a correspondence with the German scientist Fleiss for years in the hope that they could eventually cooperate in developing more simple physical methods for his patients.

It is a tragic paradox that his American followers, because of the present prestige of the analyst’s couch and the brainwashing processes implicit in psychoanalytic training, are generally the most insistent in stopping Americans from fully implementing all the biological treatment approaches that Freud knew were bound to come.

Can anything be done about it in the immediate future? The answer is a tragic no. But something must start to be planned for the years ahead, if change is ever to come about in the United States. This scientifically and medically progressive country must not remain almost completely isolated ideologically from all the rest of the psychiatric world.