H. J. Eysenck on
psychiatry without tears
This is a difficult book to review"' Its sub-title is "A new approach to the treatment of the mentally ill," and one might think that it would be easy to indicate just what the novelty consists in, and whether it works or not. Unfortunately, this is not so. Bettelheim is a very warm-hearted, kind, concerned psychiatrist; he has himself suffered much at the hands of the Nazis (he was inmate of a concentration camp); he is full of ideas which arouse his enthusiasm, which he manages to communicate to others. To judge the value of these ideas is not always easy, and to estimate the actual success of his work — that is almost totally impossible, due in no small measure to his failure to conform to even the most elementary demands of the scientific method. His heart takes over from his head (no wonder so many of his books have the noun "heart" in the title, for example The Informed Heart); this makes him a very attractive figure (I have never heard anyone say an unkind word about him—this is a rarity in psychoanalytic circles!), but not one to pin down easily to percentages and facts. So much the worse for percentages and facts, many people will say; still, when a new method of treatment is suggested, a method moreover which is extremely expensive and time-consuming, then one would like to have some down-to-earth evidence about its effectiveness.
Bettelheim starts out by stating some home truths:
There was never any proper reason or excuse for the dreadful places where mental patients are kept; nor for the neglect and outright mistreatment that camouflages itself as their therapy. Our mental institutions are shameful, festering sores of society which break shockingly into public awareness, only to be quickly forgotten before they seriously disturb our consciences. Not so long ago the image of the snake pit shook many into realising how inhumanly we treat the mentally ill. Yet the treatment of these wretched people is no better today, even though every year or two there is this great public outcry when the utter degradation of mental patients is discovered in some institution, as if such conditions were not typical of mental-hospitals all over the world.
So far, so good. Then comes Bettelheim's. explanation: "This can all be explained only as a basic ambivalence in our treatment of the' insane, which has its source in our own anxiety about insanity." Surely this is nonsense. The reasons are twofold: lack of money, and lack of knowledge. We have not the money to rebuild, staff, and keep up the many hospitals which would be needed to do a proper job, and we do not know just how to set about improving the treatment of the patients, ow-,
• ing to lack of research of a high quality in this area. Bettelheim does not try to prove his hypothesis; typically, for him to state It is to.
*A Home For The Heart Bruno Beitelheim (Thames and Hudson £4.50)
believe it. That there is no empirical support for it at all does not worry him in the least; he is not interested in such mundane requirements as proof.
What then does he himself suggest as an alternative? As founder and former director of the Orthogenic School at the University of Chicago, he has put up his alternative in brick and mortar: a therapeutic community, basically similar to Aichhorn's "total treatment" in Vienna and Redl's Pioneer House in Detroit. Concentrating on children (and later adolescents and young adults) suffering from schizophrenia and autism, he tried to give them what he regarded as the first requirement for cure: an environment of complete emotional security, personal attention and love. His method involves total cooperation between patients and staff. The psychiatrist is available to the patients day and night; he gives them (and the staff) a voice in decisions which affect their lives at the School. Down to the doorman, all have a say in such matters as which new staff members are appointed, and even which new patients are accepted. The book describes how this School works, in some considerable detail; as might be expected, there is much psychoanalytic verbiage to camouflage the actual facts, but most readers will.be able to get some idea of the intention behind the plan. . There are four parts to the book: a discussion of the physical setting; an account of "total residential therapy" as it evolved over some twenty seven years; a discussion of how the staff operates; and how its training is carried out.
Does the method work? Bettelheim makes great claims:
Better than 85 per cent of those with whom we worked have been restored to full participation in life. Most are doing well ... Among the more than two hundred former patients are pilots of commercial airlines, social workers, journalists, nurses and professors of nursing education; businessmen and bankers, but also some master barbers, construction foremen, and secretaries..
This sounds fine, and indeed it is a fine record; why then does one not join in the jubilation?
There are many reasons. Diagnosis is one of the many Achilles' heels of psychiatry; one would have to know much more than one is told of the actual symptoms of the patients in order to be able to form a proper opinion of the rate of cure. Schizophrenia is a term used with quite different connotations in the USA and in this country; the same patient is five times as likely to be diagnosed as schizophrenic over there as he is here. Thus presumably these patients were not schizophrenics in our sense, but suffered from other types of mental disorder, possibly with a much more favourable prognosis. Autism, too, is a work without too secure a diagnostic foundation; different authorities apply it to quite divergent types of disorder. As in all psychiatric disorders of a functional kind (although it is still doubtful if autism is in fact functional), there is a good deal of spontaneous remission, and much of the success in Bettelheim's School may simply be due to this factor. Any appreciation of the curative effects of a specified therapy in psychiatrY requres absolutely a control group not subjected to the regime to be evaluated; without that no proper claims can be made. This Is particularly necessary when the patients constitute a highly selected sample; they cannot be compared with a random group of schizophrenics in a State Hospital. AutistiC children tend to have very bright parents; this may be an important factor in their future job success, as they are likely to have inherited.a high IQ. There are hundreds of pitfalls in making any assessment of the success rate, and we are simply not told enough to even guess at what the success of Bettelheim's method might be — as compared, say, with a non-therapeutic home, equally well kept and looked after, and spending the same amount of money on food, heating, furniture, and so on as was the case in the Orthogenic School. It is in considering this sort of question that heart is not enough, and head must take over; from what is said we cannot say whether this "new" treatment of the mentally ill is in fact more successful than good, orthodox treatment, or not. From the point. of view of the National Health system, this is an important question. I have calculated that we could easily double the cost of the system if we tried to provide similar conditions to those described by Bettelheim for all our schizophrenic patients and autistic children; even to think of doing tills would surely require some more knowledge of just what were the important ingredients in the total design, and did the design as a whole M fact do better than other types of treatment? Is Bettelheim's method suitable to all psychotic patients, or how do we recognise those for whom it is indicated? It is. such mundane questions which make the book less enjoyable to the critical reader; how we would like to agree with Bettelheim that this is the answer to mental disease, and how sad that we cannot. Professionals will of course read it with the proverbial pinch of salt; the ordinal"' reader must be warned that we have had many messianic tablets from Mount Sinai, promising deliverance, but failing when put to the test. This may ust be another such.
H. J. Eysend is Professor of Psychiatry at the University of London.
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