FIG1 Just out of internship in
1952, I spent three months at a large state hospital outside of Detroit. The
orderlies were upset that I drank out of the patients' water fountain. On each
of my three wards, both orderlies stayed locked in their station most of the
time. They viewed their charges as subhuman—such was the wethey
dichotomy they had developed to conceal from themselves the egregious neglect
and abuse imposed on those poor wretches, due overwhelmingly to underfunding
I was given a caseload of 300, all chronically ill men. When I made rounds
each morning, I was to examine the occasional physically ill patient. The
orderlies were perturbed, however, when I went around and spoke to other
patients. They lodged a complaint to the superintendent that I upset their
wards by doing examinations on all of the patients. There had been almost no
doctors' notes in my patients' charts for two-and-a-half years. Hard to
After conducting a quick physical, I would apply my then-meager diagnostic
skills to doing a mental status examination. Nearly half of my patients
carried a diagnosis of general paresis of the insane, due to tertiary
syphilis. I could not tell the difference between those patients and the ones
with schizophrenia. At that time, it didn't matter anyway—no treatments
were available for either condition.
Almost all of my patients were flagrantly delusional or actively
hallucinating. I remember one Ph.D. chemist who spent every hour vigorously
going through magazines, marking the many references that fed into his
delusional system. He liked me so long as I listened uncritically to his weird
explanations, but once when I challenged him, he screamed at me. After that he
would hiss at me every time he saw me, expressing his fury at me for
challenging his interpretations. This was a valuable lesson I never learned
well enough about the potential consequences of questioning the cherished
beliefs of others.
Most of the medical staff were residents. They spent their afternoons going
to Detroit for their five-hours-a-week personal psychoanalyses, a prerequisite
to becoming psychoanalysts themselves. My own work was usually finished by
noon or early afternoon, and I would often play golf with the"
pro" who managed the hospitals's golf course. I was not a
reformer, not a crusader—just getting by until I was inducted into the
In those days, Freudian psychoanalysis was de rigueur, both in psychiatry
and with the country's artistic elite. There were few respectable alternatives
for residency trainees in psychiatry. Electroshock therapy had been given to a
few depressed patients and even to schizophrenia patients. For outpatients,
however, psychoanalysis and "psychoanalytically oriented
psychotherapy" were the preferred treatments—cure-alls for every
patient, including many who were basically well but could afford those
enriching incursions into their "unconscious."
Free association, dream analysis, and analysis of the transference were the
three-pronged approach to understanding the unconscious mind. Resolution of
the Oedipus complex was the ultimate goal. The psychoanalytic literature was
replete with colorful psychodynamic explanations for all mental
illnesses—for the schizophrenias, manic-depressive illness, the neuroses
and character disorders, and a large array of supposed psychosomatic
disorders, such as diabetes.
The organization of staff and patients of most state hospitals was a strict
feudal system in those days, with the superintendent living in a large house
on the grounds, attended by patient-servants. Other permanent medical staff
also had houses and servants.
The patients were, of course, the lowest in the social hierarchy—the
peasants. In the 1950s state hospitals often had elegant arboretums on
grounds; many had large herds of livestock and acres of vegetable gardens and
orchards, cared for by patients doing "occupational therapy."
And as far as the public was concerned, in that psychiatric stone age,
merely 50 years ago, patients were "out of sight, out of mind."
Fewer than a third of patients ever left, except feet first. Newspapers didn't
assign investigative reporters to uncover the true state of patient care.
Pandering politicians perceived the public's apathy, or even antipathy, toward
the insane, and funding was cut to the barest minimum. Dr. Karl Menninger was
one of the few activist reformers of that era.
Around 1955, chlorpromazine became available for a limited number of
schizophrenia patients in state hospitals. Psychiatry then began to make
valuable use of a brilliant research tool, the double-blind study. Suddenly,
psychiatry could begin to put its treatments on a solid scientific footing,
and did so with considerable success. Psychiatry still has much yet to
achieve, but I hope that my younger colleagues will see what a long, long way
their profession has traveled in half a century.
But how will psychiatry look 50 years from now? How will we view the
multitudes of severely mentally ill people who are now homeless, granted the
freedom to self-destruct? the underfunding of psychiatric care for the
indigent? incarceration of mentally ill persons in jails and prisons? and
genetic determinants of mental illness? Will those situations seem as
appalling 50 years from now as conditions of the 1950s appear to us today?
What riddles will neuroimaging have answered by that time? I can only