10 JANUARY 1964, Page 24

Psychiatry in Fact and Fancy

BY WILLIAM SARGANT !THERE is no speciality in medicine at the present 1 time about which there is so much public mis- understanding as psychiatry. Psychiatric consul- tants may soon outnumber consultants in general medicine in the National Health Service, because they are having to look after nearly half the total patients occupying hospital beds in this country, as well as trying to cope with very large numbers of out-patients. This is because a third or more of all patients attending general practitioners are found, sooner or later, to be suffering from psychiatric illnesses. Yet the general public, and even some doctors, still seem to think of members of this overworked, and now almost over- whelmed, speciality as spending their days mostly talking seX to their patients lying on couches.

These three recently published books* will not help to get the subject in very much better perspective. While there are now around 2,500 medically qualified doctors practising psychiatry in Great Britain, only about 200 of them, and some additional lay analysts, adhere exclusively to the beliefs, sexual or otherwise, of Freud and confine themselves to using his treatment methods. And there are very few pure Adlerians indeed left at the present time. One of the reasons for this is that the average British psychiatrist has become very wary in recent years of using any particular theory on which to base all his treatment methods. Because he is so hard pressed, and mental illness may involve such terrible suffering for the patients concerned, he is more than prepared to use any method that provenly helps patients to get better, even if, like so many other medical treatments today, their exact mode of action is not yet clear, simply because we still know so very little about how the complicated brain, with 4s millions of nerve cells, really works. The book on Alfred Adler is a third revised edition of one published in 1939 by a woman admirer and co-worker, who apparently has no medical qualifications or degrees in psychology. It contains dogmatic and often untenable asser- tions and many laudatory reminiscences. When one reads as early as page thirteen that, 'if a man came to Adler and complained about sleepless- ness . . . he explored the man's whole person- ality in order to find the relationship between his insomnia and his personality, [and] after Adler had succeeded in explaining this relationship to the patient, the trouble disappeared,' then one knows just what the book is going to be like, and it is! Any experienced psychiatrist knows that the treatment of the insomnias is not as easy as all that. And no mention is made in this book of all the different sorts of psychiatric illness that exist and the need for their selective treatment by Adlerian methods. A variety of illnesses are lumped together for cure by, the use of Adler's philosophic principles. Even painful periods are reported as being relieved when women realise that they are quite equal in value to men.

The two books on Freud are a fascinating contrast. Psycho-Analysis and Faith reports a long series of letters from Freud to a Swiss pastor who tried to combine the lay practice of psycho- analysis with a firm belief in God, and some of

* ALFRED ADLER : THE MAN AND HIS WORK. By Hertha Orgler. (Sidgwick and Jackson, 30s.) PSYCHO-ANALYSIS AND FAITH: THE LETTERS OF SIGMUND FREUD AND OSKAR PFISTER. Edited by H. Meng and E. L. Freud. Translated by Eric Mos- bacher. (Hogarth Press, 21s.) FREUD: A CRITICAL RE-EVALUATION ION OF HIS. THEORIES. By Reuben Fine. (Allen and Unwin, 35s.)

the pastor's replies are also printed. Freud takes the part of the inquiring scientist, prepared to change his views when the facts warrant it, but treating very tolerantly those more fixed views of the pastor based on his religious faith. Little did Freud realise that his own views, so soon after his death, would form the basis of a series of almost religious faiths, much more intolerant than the Swiss pastor's, though he did actually write very unkindly at times about his two ex- apostles, Adler and Jung, during his lifetime.

Reuben Fine, a piychologist and lay psycho- analyst, writes the second book on Freud. On meeting a prominent clergyman and saying what his work was, he comments that the very first question the clergyman asked of him was, What denomination? And Reuben Fine's book suffers from all the defects of the lay psychoanalyst with no proper medical training in the treatment of mentally ill patients, who has been virtually brainwashed by his own years on the Freudian psychoanalytic training couch. For instance, he considers psychoanalysis appropriate for use in many types of mental illness, and that there is no need at all for this treatment to be given by a doctor. Every other available treatment is virtually ignored because of his ignorance of their use and value. And he holds these views despite the fact that he quotes Freud as repeatedly insisting that his methods were only useful in hysterias and obsessional neuroses. Now even most psychoanalysts have found out how wrong Freud was about the good results obtain- able in severe obsessional neuroses and chronic hysterias; while more recent hysterias are found to respond to a whole variety of modern treat- ment methods. Fine also insists on making his claims for Freudian methods despite pointing out the strange fact that Freud himself only actually reported on the detailed treatment of five patients during the whole of his lifetime of writing, and few of these seems to have got very much better under treatment.

The general public has every right to be suspicious of claims made in books of this type. What are the real treatment facts at the present time? When Freud was working and writing from 1900 to 1930, there were really no other effective treatments of mental illness, and he had this specialised treatment field largely to himself, with Adler and Jung bringing up the rear. Now, how- ever, 80 per cent of recent cases of schizophrenia, for instance, can be treated, greatly helped, and kept out of hospitals for long periods of time by the us:. of recently discovered drugs, sometimes with the addition of electric shock treatment. In the old days, when only psychotherapy was available as treatment, only a third of such patients ever recovered or greatly improved, and the rest became chronic cases in or out of hospitals.

Practically all depressive illnesses in patients of good previous personality also now respond to the new anti-depressant drugs and electric shock treatment combined, sometimes in less than a month, instead of being ill often for years, as so often happened in the old days with psycho- therapy alone. Anxiety states and anxiety hysterias in people of good previous personality, too, can now be greatly helped by newly discovered drug treatments. Only severe obses- sional compulsive neuroses generally still resist all the newer drug treatments, ECT and psycho- therapy combined, and some may therefore need one of the modified leucotomy operations to help them. Unfortunately, we still have few new successful treatments for the young aggressive psychopath and for patients with long-standing sexual deviations. Some of these may still be helped by psychoanalysis,. but many are not. Soon, however, better, swifter and more efficient methods of treatment are bound to be developed for these difficult patients as Well. Aversion therapy is already holding out some promise for sexual deviates.

In most ordinary British psychiatric treatment circles the facts given here are now largely accepted. In the US, where alone Reuben Fine's book could have been written, they definitely are not. Most ambitious American psychiatrists have to get themselves psychoanalysed so as to be in the swim and be able to treat mostly 'normal' people on couches, and preferably patients who are still working and can more easily afford to pay the very large fees involved in what may be several years' treatment. The bulk of the really mentally ill patients, in the absence of a National Health Service, are forced to go into mostly locked State mental hospitals, with up to 10,000 patients in each of them, and are given very little selective treatment indeed.

British psychiatry has now become the envy of the world, simply because the proper skilled treatment of patients in mental hospitals and in out-patient clinics in general hospitals is still our first and main interest; the doors of our mental hospitals are now mostly unlocked, and treatment is generally given there on a voluntary basis. All methods, both physical and psychotherapeutic, are used to attain this happy state of affairs. With so much work to do, and our doctors being paid adequate salaries under the NHS, most normal people are still encouraged by psychiatrists to leave their minds alone.

It is unfortunate that as yet English psychiatry is not without honour except in its own country. For instance, British psychiatrists are now being invited to lecture abroad possibly more than any other group of British physicians, because of the spreading fame of the all-round and humane British treatment approach. Because of the results being achieved by the wide variety of modern treatments now available and fully used, the Ministry of Health is also determined, some- times against the wishes of our general physicians, to put 100 psychiatric treatment beds into every new general hospital built in the future. This means that the days of most of the .old lunatic asylum buildings are now numbered, especially for all the early recoverable psychiatric patients who can be so easily and so speedily treated in general hospitals wherever beds are made avail- able for them. But rarely by the lengthy and now often out-dated methods extolled by Reuben Fine or Hertha Orgler.

Freud always remained a neurologist at heart. He was fully aware that eventually physical treatments would replace his psychotherapeutic methods. He said this repeatedly in his writings, and he welcomed the prospect; in fact, he is said to have kept up another long .correspondence with Fleiss in the hope that this German scientist would eventually be able to co-operate with him in the development of simple biological treat- ments to help his patients. He was doomed to disappointment, but such treatments have in fact been discovered or fully developed since his death, and it looks as if this more medical approach to treatment is still only in its infancy with tremendous promise for the future. Present- day psychiatrists have also to be good general physicians as well.