Psychiatry in Medicine

PSYCHIATRY IN MEDICINE

A SYMPOSIUM HELD AT THE SCHOOL OF MEDICINE

UNIVERSITY OF CALIFORNIA, LOS ANGELES

MARCH 10-1 1, 1961 TO MARK THE OPENING OF THE NE U RO PS YCH I AT R IC INSTITUTE

PSYCHIATRY

IN

MEDICINE

EDITED BY NORMAN Q. BRILL, M. D.

UNIVERSITY OF CALIFORNIA PRESS

BERKELEY AND LOS ANGELES, 1962

University of California Press

Berkeley and Los Angeles, California

Cambridge University Press

London, England

(c) 1962 by The Regents of the University of California Library of Congress Catalog Card Number: 62-11489 Designed by Frank J. Lieberman

Printed in the United States of America

PREFACE

A SYMPOSIUM on Psychiatry in Medicine was held at the UCLA School of Medicine on March 10 and 11, 1961, to mark the opening of the Neuropsychiatrie Institute. A guiding principle in the planning of the institute was the importance of closely integrating its structure and operation with the rest of the Medical Center.

Although emotional problems are encountered in medical practice more often than any other type of disorder, this aspect of medical education has been relatively neglected. The average medical school graduate is quite capable of treating most organic diseases, but he is usually not adequately prepared to diagnose and to treat emotional and functional disorders, nor does he understand sufficiently the important role that emotion plays in many organic disorders.

In part, this failure has stemmed from the isolation of psychiatric treatment facilities from the rest of medical treatment facilities, and this has impaired the proper integrating of

V psychiatric teaching with the rest of medical training. When psychiatric facilities are set apart, even by a small distance, from those of other medical disciplines, there is danger that student and patient alike will look upon the treatment of emotional illness as something apart from medicine.

Psychiatric treatment has changed radically in the past fifteen years, with a shift away from commitment and custodial care in isolated hospitals toward early active treatment in the general hospital. There has been a significant increase in the understanding of the intimate relation between psyche and soma. It has become increasingly clear that the responsibility for dealing with the many manifestations of emotional problems belongs to all physicians and particularly to the general practitioner.

The Department of Psychiatry has for several years been cooperating with the Division of Continuing Education in Medicine of the UCLA Extension in the postgraduate training of general practitioners. Generous support from the U.S. Public Health Service, National Institute of Mental Health, has made this program possible. The symposium on Psychiatry in Medicine was part of this program. It was designed for physicians who wished to attain greater understanding of the emotional disorders encountered in practice and greater effectiveness in the treatment of such disorders.

The topics covered in the series of lectures presented at the symposium were selected to achieve (in part) this purpose. The intricacies of the dynamics of psychophysiological reactions are reviewed by Dr. Felix Deutsch. By examples drawn from experimental work with animals and human subjects, he describes the role of unconscious forces in the production of physical disorders. The roots of psychosomatic disorders are seen as originating early in life when psychobiological reaction patterns become established. These patterns are often unobserved and escape clinical detection. They are later found to be motivated by appropriate stimuli. A disturbing idea in being repressed may become attached to some part of the body and thereby affect its function. Using classical psychoanalytical formulations, Dr. Deutsch explains somatization as a transformation of libido by innate mechanisms which are designed to maintain psychic equilibrium. He raises the hope that further knowledge of the reticular activating system may provide the long-sought biological foundation for bridging the gap between mind and body.

In a presentation by Dr. Eric D. Wittkower, psychological problems of sick patients and of the doctors who treat them are outlined. Existing or approaching illness may manifest itself by withdrawal of interest from the environment. Using the defense mechanism of denial, a patient may attribute his malaise to trivial causes, and later develop exaggerated anxiety when this mechanism begins to fail as a result of the mounting stimuli from the progressing disease. The point is made that minor degrees of anxiety in response to a diagnosis may be desirable for the acceptance of the sick role. If infantile fantasies in the doctor have not been adequately curbed by reality testing, the doctor may be pompous and conceited, and blind to his own limitations, and he may thus be tempted to undertake professional tasks for which he is not qualified. There is always the danger that he may not recognize the regressive dependent motives behind his patients’ fantasies, and may use them to feed his own self-adulation.

Dr. George L. Engel advances the argument that what is humanistic in medicine has also a scientific basis. He maintains that, when the concept of disease is sufficiently broadened to permit consideration of all the determinants (physical, chemical, biological, genetic, morphologic, psychologic, interpersonal, and social), the therapeutic significance of the personal and social aspects of medical care becomes more understandable. He examines some of the early determinants in terms of object relationships and self-concepts, and considers the evidence in both humans and animals that disruption of the valued object relationships constitutes a psychological stress which, under certain conditions, may eventuate in disease. Conversely, dynamic processes operating in the framework of the doctor-patient relationship and medical care may have restitutive or therapeutic value.

Some ecological and spiritual factors that are involved in human adaption are explored by Dr. Stewart Wolf. He believes the very fact that the evolution of man’s behavior has outrun the evolution of his bodily form and functionings may be pertinent to maladaptations and to development of disease. He reminds us that there was a time when man’s conception of society was more primitive, when the appropriate way to deal with an opponent was to kill and eat him. At that time, perhaps, the linking of gastric hypersecretion of acid and pepsin with circumstances that aroused hostility and resentment may have been an appropriate adaptation gradually established over millions of years. During the past several thousand years, however, man’s conception of society has been changing from a primary emphasis on competition to a greater concern with interdependence and cooperative living. More recently we have been moving in the direction of considering that man should be his brother’s keeper. The altered behavior that results from such altered attitudes has left no enemy flesh in his [man’s] stomach and nothing for his digestive juices to work on but his civilized meals and his own tissues. He suggests that now the need is for man to modulate his emotional as well as his behavioral responses to people. Perhaps he needs to love his enemy and hate him not.

The need to respect the protective nature of mental illness is emphasized by Dr. Douglas D. Bond, who is concerned with the human approach to medicine and who establishes a valid foundation for the art of medicine through vignettes of his patients.

In reviewing the broad subject of children’s emotional problems, Dr. George E. Gardner recognizes that certain stresses and crises occur in the life of every child at various age levels, merely because he is a human being living among other human beings and in a society, both personal and material, which generates threats of danger. This is natural because of the inherent vulnerability of the child to the effects of his smallness and his weakness. The solution of problems at each stage of development in large part determines his success or failure in tasks inevitably presented to the child as he grows older. There is an optimal emotional climate that should surround the child if he is to learn to solve problems successfully—a climate in which love, attention, warmth, and acceptance are expressed and enjoyed by all the persons (and particularly by the mother) surrounding the child in babyhood and early life. This climate alone and the sense of security it generates within the child will enable him to withstand the frustrations, delays, and denials (to the continuation of the full and unmodified expression of his instinctual drives) which are not only inevitably the lot of the infant and the child but essential if the child is to develop.

In dealing with problems at the other end of life’s span —the emotional problems of aging—Dr. Maurice E. Linden cautions against the marked tendency to regard the problems of oldsters merely as the problems of youngsters grown old. This notion may be the basis of the mistaken belief that any therapist or practitioner who possesses skill in the management of the emotional problems of any other age group must, perforce, be competent to deal with older people. Effective treatment for an older person must be based on an understanding that he is a product of his culture, a member of a sociologie group. He is the culmination of a massive aggregate of intrapsychic phenomena, and hence an individual with specific neurotic needs which arose in childhood, were influenced by living, and were exaggerated by the stresses of aging.

The cultural rejection of the elderly person has created a special group of problems with their accompanying psycho- pathological reactions. Elderly people are not afforded status and privilege in our culture, which is primarily child-centered and youth-oriented. Instead of enjoying a feeling of dignity, they are made to feel superfluous. Social mobility, materialism, and overevaluation of sexuality and physical attractiveness leave the older person feeling rejected, or even excluded. His conservatism contributes to his feeling of (and, at times, actual) isolation from the rapidly changing culture. There is a tendency to react with depression, which is often disguised by other symptoms.

Dr. Karl Menninger describes the change that has taken place in the concept of diagnosis as the intellectual world has moved from static to dynamic ways of perceiving experience. With the advance of medical knowledge the whole ontologie notion of disease as the invasion of the body by a foreign body no longer correctly represents medical thinking. The recognition of disease as an aspect of human existence, a phase of altered conditions of functioning in the life history of an individual interacting with an environment, requires us to abandon old names and old diagnostic methods. Treatment is, after all, the basic medical function, and diagnosis must serve the needs and purposes of treatment. Hence it must supply an accurate analysis of the illness processes so as to guide the physician in rational efforts toward an effective intervention.

Mr. Albert Deutsch, who spent several years surveying current psychiatric research in America, speaks of its explosive expansion in recent years and of the improvement in its quality. He is impressed by the breadth, the intensity, and the variety of current research, and by the diversity of scientists engaged in it. In view of the great public interest in announcements of new treatments, he warns against overenthusiastic claims which lead to sensational stories of miracle cures, such as those that occurred with the introduction of tranquilizing drugs. Mr. Deutsch points out that such stories, although tending to enliven public interest and stimulate public support of psychiatric research, carry with them the danger inherent in repeated disillusionment—a resigned and cynical public apathy. It seems to him that there is too much talk of breakthroughs on the therapeutic front, even among psychiatrists. This exaggeration of research accomplishments gives the false impression that the big one-shot cure for mental disease is just around the comer. The public must be made more aware of the very great problems that await solution. It must be better informed of the years and years of painstaking basic research behind such spectacular developments as the atomic bomb, the Salk vaccine, and most new therapies that burst seemingly full-blown before the public eye.

As an introduction to the symposium, I attempted to reappraise the psychotherapeutic process.

The symposium was planned and conducted by Drs. Frank F. Tailman, Charles W. Tidd, Charles W. Wahl, Ivan N. Mensh, Edward J. Kollar, and Henry H. Work, all of the UCLA Department of Psychiatry. I am indebted to them for their generous help, and to my secretary, Mrs. Margaret Conover, for all her assistance in making arrangements and in typing manuscripts. To Miss Betty Minifie and her staff in the office of Continuing Education in Medicine of University Extension go our special thanks for their many efforts in making the symposium possible. We are particularly grateful to the UCLA Medical Center Auxiliary and to a pharmaceutical firm, which has contributed actively to the support of psychiatric education and research, for their generosity which enabled us to publish this volume.

NORMAN Q. BRILL, M.D.

CONTRIBUTORS

NORMAN Q. BRILL, M.D.

Professor of Psychiatry, University of California, Los Angeles

KARL MENNINGER, M.D., D.SC.

Director of Education and Dean of Menninger School of Psychiatry, Menninger Foundation; Chief of Staff, Menninger Clinic; Clinical Professor of Psychiatry, University of Kansas School of Medicine

GEORGE L. ENGEL, M.D.

Professor of Psychiatry and Associate Professor of Medicine, University of Rochester School of Medicine

DOUGLAS D. BOND, M.D.

Professor of Psychiatry and Dean, Western Reserve

Contributors

School of Medicine, University Hospitals, Cleveland, Ohio

STEWART G. WOLF, JR., M.D.

Professor and Chairman, Department of Medicine, Consultant Professor of Psychiatry and Neurology, University of Oklahoma Medical Center

FELIX DEUTSCH, M.D.

Honorary Professor of Psychiatry, Boston University;

Senior Training Analyst, Boston Psychoanalytic Institute

MAURICE E. LINDEN, M.D.

Director, Division of Mental Health, Department of Public Health, Philadelphia; Assistant Professor of Psychiatry, University of Pennsylvania School of Medicine

ALBERT DEUTSCH

Author and Lecturer

ERIC D. WITTKOWER, M.D.

Associate Professor of Psychiatry, McGill University and Allan Memorial Institute, Montreal

GEORGE E. GARDNER, PH.D., M.D.

Director, Judge Baker Guidance Center, Boston; Psychiatrist-in-Chief, Children’s Hospital Medical Center, Boston; Clinical Professor of Psychiatry, Harvard Medical School

CONTENTS

CONTENTS

1 THE PSYCHOTHERAPEUTIC PROCESS

2 THE EVOLUTION OF DIAGNOSIS1

3 HUMANISM AND SCIENCE IN MEDICINE

4 THE HUMAN APPROACH

5 ECOLOGY AND THE SPIRIT OF MAN

6 PSYCHODYNAMICS

7 THE EMOTIONAL PROBLEMS OF AGING

8 CURRENT TRENDS IN PSYCHIATRIC RESEARCH2

9 THE PSYCHIATRIC ROLE OF THE GENERAL PRACTITIONER

10 PERSONALITY DEVELOPMENT AND CHILDHOOD BEHAVIORAL DISABILITIES

1

THE PSYCHOTHERAPEUTIC PROCESS

BY NORMAN Q. BRILL, M.D.

I WOULD LIKE to explain why Psychiatry in Medicine was chosen as the theme for this symposium. It would be difficult to conceive of a symposium entitled Pediatrics in Medicine or Obstetrics in Medicine, but psychiatry as a specialty seems to occupy a somewhat different position from other specialties. It deals with disturbed people rather than with disturbed organs or organ systems. The practice of other specialties is based much more on the sciences of anatomy, pathology, physiology, pharmacology, and physiological chemistry than is the practice of psychiatry, which is based much more (but by no means exclusively) on the science of psychology and, increasingly, on sociology and cultural anthropology.

For many years psychiatry used institutions and sanitariums, while other specialties used hospitals. Psychiatry provided custody; hospitals provided treatment. Psychiatry’s concepts and language were different. Psychopathology was described as disturbances in thinking, feeling, and acting, and not in terms of the more familiar cellular infiltrations, vascular lesions, or degenerative changes.

Judging from a resolution passed by the American Psychiatric Association ninety years ago, even