New Approaches to Mental Illness

VTR: 6/23/1957
GUESTS: Dr. Nathan S. Kline, Dr. Wayne Umbreit, Dr. Viola W. Bernard

MR, HEFFNER: Before we begin today’s program I’d like to take this opportunity to thank the judges of the Robert E. Sherwood Awards, for The Open Mind during this past week received one of their special awards for programs devoted in part at least to the principles of freedom and justice. Hugh McPhillips, Marshall Stone, Barbara Davidson, Eleanor Riger, these are the people who have primarily worked with me on the show. From all of them and from me thanks to the Robert E. Sherwood judges. It has been a great honor.

Now today, getting to our subject, the question of the validity of the new approaches to mental illness, I think I ought to bring up the fact once again that during the past, I guess about six weeks, we have alternately done programs in cooperation with the Manhattan Society for Mental Health. These programs have drawn a great deal of response. Obviously a good many of us are interested in the problems concerning mental health.

The last program we did on the subject I had a psy¬choanalyst and a lay person — Mike Gorman — who has been very much involved in community relations in terms of mental health. Dr. Sandor Rado was the psychoanalyst, and these people were pitched, in a sense, against each other, on the question of the validity of psychoanalysis: Is psychoanalysis a blind alley? or maybe the most important avenue to mental health?

A number of viewers wrote in and said that in a sense they were pitched on different levels. One person was concerned with the usefulness, the community usefulness of a psychiatric technique; and the other person, the psychoanalyst, was concerned with the scientific validity of the technique, have a feeling that the two really cant be separated, that they have to be brought together, and today Z hope that we do do this in our discussion of the new means, the new tech¬niques of approaching mental health. Of course I’m referring parti¬cularly to the drug treatment and to the whole biochemical approach of our times. Reserpine, chlorpromazine, these drugs have been most important in the news these days. 1 have a folder full of clippings from recent newspapers indicating how often references to them have appeared.

In this month’s Harpers — just before we begin our discussion — in this new Harpers, introducing editorially an article on tranquilizers and the mind by Dr. Jon Stevenson, Harpers says during its first 21 months 10,789 people applied for free or low-cost psychoanalytic treatment at a private clinic which opened in New York in May 1955 — 10,789 people! Only five hundred of these applicants could be served in that period.

This has been offered as one of the reasons why we have to turn now in psychiatric treatment methods to drugs; and in examining their validity let us turn now to our three expert guests.

My first guest is a doctor, Dr. Nathan S. Kline, who has been very closely identified with the development of drug treat¬ment. He is the Director of Research at Rockland State Hospital in Orangeburg, New York.

My second guest is Dr. Viola W. Bernard, who is a practicing psychoanalyst, and an Associate Professor of Clinical Psychiatry at Columbia, where she teaches community psychiatry.

My third guest is Dr. Wayne W. Umbreit, who is Associate Director of the Merck Institute for Therapeutic Research. People there have been very much involved in the development of our new drugs.

Well, Dr. Bernard, and gentlemen, suppose I begin our discussion by referring back to the title question and asking you, Dr. Bernard, as a psychoanalyst, how valid you think the new approaches, particularly the drug and biochemical approach, how valid these are as approaches to mental illness. And suppose as a lay person by valid I mean useful in not only a technical but in a community sense.

DR. BERNARD: Well, it’s a huge question of course. MR. HEFFNER: I realize that.

DR. BERNARD: And I think all of us in psychiatry are aware of the tremendous scope of the problem and we are all receptive continually to any promising development, and I think we all recognize from the findings so far that there is much that is promising and encouraging in the use of these newer drugs. I think we have to break down the question and make certain distinctions. For one thing I hope that we can look at this not in terms of biochemical approaches instead of psycho¬logical approaches to mental illness, but treatment approaches that recognize that a sick human being or a well human being is a social beinfr„ a psychological being, and a biological being all at once; and I think the most promising developments of the biochemical approaches so far lie in ways in which they can be combined in treatment so that the very disturbed hospitalized patient may become more receptive to improving his adjustment through better use of psychological and social forces both within himself and those that can be made available to help him. I do think that we probably should distinguish too between the usefulness of these drugs for hospitalized patients and the conditions that require hospitalization, and those whose difficulties are such that they usually are treated in clinics or in office practice. By and large while the drugs seem to be help¬ful to some of the patients in office or clinic practice they are less efficacious I believe, according to most results, and in my experience, than for the very disturbed hospitalized patient. think our other members here could speak to that more informedly than

MR. HEFFNER: Dr. Kline?

DR. KLINE: I have no basic disagreement on this point. The drugs have been overrated in some places and condemned in other ways. We know that as far as the hospitals themselves go that a real revolution has occurred in two respects. One, that there are patients now whom we are able to discharge who three years ago would have been considered really hopeless cases; and within, the hospital itself the use of electric shock, insulin, and restraints, seclusions and older less refined methods of treatment have dropped off to a mere fraction.

I think one important point to make, since Dr. Bernard draws the distinction between hospitalized and non-hospitalized patients, is that in a paper which I gave with Dr. Brill a year or so ago we stressed the point that the drugs actually should be the first line of defense against mental disease or attack against it, and not something that came at the end of the line.

I think that there are applications of the pharma¬ceuticals so that many patients who are now in mental hospitals had they been adequately treated would not have had to be hospitalized, and this is to my mind one of the major applications which has not yet been fully taken advantage of.

MR. HEFFNER: Well before I turn to Dr. Umbreit and ask him his opinion of this I wonder if I could just pursue this question? When you talk about the discharge from hospitals — and I gather as you said before the program one very dramatic statistic comes in our expectation that there would be many thousands of new patients in mental hospitals over the past year; instead we had fewer patients in the hospitals.

DR. KLINE: That’s correct.

MR. HEFFNER: And you feel that this is at least in large part due to the use of drugs?

DR. KLINE: Well it appears to be one of the major factors. The expectation for last year for the country as a whole was the increase of somewhere between nine and twelve thousand patients in mental hospitals. That is admissions over discharges. Instead of which there was an actual decrease of some 7000 patients, which adds up to almost 20,000 patients.

MR. HEFFNER: This is a very dramatic statistic, but the question I really wanted to ask is what do you mean by dis¬charge? Are you satisfied that these people then are — well, I’ll use the word cured and I’m sure youtll say cure is a peculiar word, but are they cured or are they just able to function and are we just giving them something that will put them back in society and let us empty out the mental hospitals?

DR. KLINE: I sat through a conference not too long ago, a four-day one, on this question of cure or evaluation of improvement, and got so annoyed at some of the opinions that I went to the extent of writing an article on it, and my feeling is that at the present time there are only two criteria for improvement. One is, can the patient get along in the community productively, and is he a socially useful being? Secondly, is he not too un¬happy? no more unhappy than you or I or whoever is judging him as improved. And if these two criteria are met why I think at the present time you would have to say that the patient is improved.

MR. HEFFNER: OK, that’s fair enough. Dr. Umbreit, I wonder what your reaction is?

DR. UMBREIT: Well I should like to add one other point to all this, and that is I feel that we are just at the beginning of all this affair. I think there’s been a tremendous change in the past three or four years in that up until this point mental disease if treatable at all was treatable only in a long, slow, complicated fashion. Today I think the feeling is that a great deal more can be done, and I think this is a tremendous help in a field where for many years the situation was not very good to have just the spirit abroad that things can happen here. I think we are just on the threshold of finding out what are the causes of these diseases and what to do about them,
MR. HEFFNER: When you say a great deal more can be done do you mean that a great many more people can have some¬thing done to or with them or that a great deal more can be done for the individual patient?

DR. UMBREIT: I think both.

MR. HEFFNER: Dr. Bernard?

DR. BERNARD: I was struck by Dr. Umbreits mention¬ing that one of the beneficial effects was the spirit abroad, an improved spirit abroad which of course gets us back to the psycho¬logical sphere. It has seemed to me in this view of the matter as a combined one, an integrated one, that some of the benefit of the symptom relief of patients in a mental hospital, for example, has been through really the psychological and social implications of greater hopefulness and greater ability to improve the quality of human relations both between the patients, their families, and the staff, so that some of the attention that patients receive and some of the implied hope that goes with this creates a climate, an atmosphere which it may be unsteady — and the-re are some signs that this is so from studies we’ve already initiated — that some of the beneficial effect is due to the initiating of new psycholo¬gical processes. would like to add to some of the precautions that Dr. Kline mentioned in the use of this advance some of the draw¬backs. In the population at large there has been a tendency which think quite properly has been warned against in many media, against everyone seizing upon a quick method of relieving any tension or any anxiety. There are drawbacks to this and T don’t think we should overlook the promising therapeutic uses by overemphasizing the drawbacks but we need to handle the drawbacks and conserve the advantages.

One of the drawbacks is that we fail to recognize that anxiety and tension can be a healthy and essential self-protective mechanism; just as pain sometimes is a signal that some¬thing is amiss needing corrective action, so anxiety and tension is a normal signal that there are problems to be dealt with, and the lulling of this signal

MR. HEFFNER: Through drugs you mean?

DR. BERNARD: —through drugs, can reduce the-inidivid¬ual’s activity to really fix the problem instead of have a false security of feeling there isn’t any.

MR. HEFFNER: Well I find that very interesting that you should say that because I know that in things I’ve read written by Dr. Kline he has made this same point, and therefore I wonder if I could ask both of you whether you feel that — I think I’m setting up a question to come to you, sir — whether you feel that the drugs can in any way be a substitute for the deeper anxiety-removing rather than anxiety-alleviating process of analytic therapy?

DR. KLINE: That’s a loaded question,

MR. HEFFNER: I ask loaded questions and long ones.

DR. KLINE: You accept as one thing the fact that the psychoanalytic process is more capable of removing deep anxiety than our pharmaceutical means of treatment.

MR. HEFFNER: Do you reject that or accept that?

DR. KLINE: I don’t know. I mean I take refuge in my position as a researcher and say that this is something that would have to be investigated. But certainly patients with tremen¬dous anxieties where analytic procedures at times have failed, have been relieved of these symptoms by pharmaceutical means. Now whether deeper means that you have to go plumbing in the psyche or whether you can also plumb around in presumably the middle of the brain somewhere with some pharmaceutical means I think is a little aside from the actual point.

I don’t think that there is a basic conflict be¬tween the use of psychotherapeutic treatment in the very broad sense, that is including anything in the environment, not necess¬arily a psychoanalyst, but anything that helps an individual re¬establish himself, and the use of chemical means of treatment; so that in a sense I would agree I think in principle with Dr. Bernard that there’s no dichotomy.

I certainly would also agree that the drugs are used on a much more widespread basis and indiscriminately. I don’t think it’s difficult to draw a borderline between the two things. I think when anxiety, tension, discomfort, guilt, whatever you want to call it, reaches a point where the individual is disabled that this is the time that treatment is indicated, and as long as he is able to function I think that they’re a very healthy stimuli to action.

I think one of the things you referred to that I had written is the nice tranquil monkey that looks beautiful and is wonderful to handle in a laboratory but would last no longer than ten minutes in his jungle, so that the “jungle” in which we live requires a good deal of attentiveness, and a certain amount of dis¬comfort, if we are going to get things done.

MR. HEFFNER: Is it like the story of the actor who took the tranquilizer because he was about to perform and wanted to be at ease but was so much at ease that he gave a very very poor performance?

DR. UMBREIT: Isn’t Dr. Bernard talking about two things originally? One is as Dr. Kline says, the patient who’s in¬capacitated by his anxiety — and here I would agree that after all here is the place where such drugs have their greatest use; where a patient or a person is anxious or worried about something else, but.it is not enough to incapacitate him, then there are other means for doing this. Probably one should not apply drugs in these cases. That is, not everybody necessarily needs to be tranquil all the time.

But I should like to add another point about all of this and that is I would believe from what my experience shows -¬which is confined, admittedly, to experiments in behavior in ani¬male — that anxiety probably has a biochemical basis. There is a substance which is produced during anxiety and that such drugs counteract the effect of such substances, that one can impress upon animals behavior patterns by chemical means and by psychological means, and that presumably the psychological means is producing in the mind or somewhere in the body of the animal a substance which counteracts or is the cause of the anxiety.

MR. HEFFNER: Do you mean, is it the implication then that the human process is a biochemical process?

DR. UMBREIT: This would be my conclusion at the mo¬ment, except for this point, that we probably cannot honestly project animal experiments quite into the human situation with this degree of certainty in that the human situation is much more com¬plex.

We can however find in the body fluids of particularly schizophrenic individuals chemical substances which are markedly different than those found in normal persons, and the curious thing about this is that these substances will cause behavioral changes in animals.

MR. HEFFNER: Well Dr. Bernard has been champing at the bit.

DR. BERNARD: Yes, I’ve been hearing many thoughts here I would like to react to a bit. On the matter of the amount of anxiety, the quantity, as being the pivotal question of the use of drugs in relation to psychological means I think as well, and perhaps very importantly, there is a qualitative distinction to be made about tension and anxiety from the standpoint of mental ill¬ness, and that is a distincition which for oversimplification I would say call sick tension and healthy tension; and the reduction of the perhaps transient discomfort of healthy anxiety or tension think is to be avoided, and the therapies — be they analytic, bio¬chemical, sociological, psychosocial, et cetera — that we are working on on many fronts, are largely referrable to the, as say in an oversimplified way, the sick forms of tension; a distinc¬tion, for example, being between whether the fears are in a way the private ghosts that haunt an individual as against perhaps a response to a realistic obstacle which calls for mobilizing all his strengths. Another point Zr would like to speak to about this, what I felt was getting into an either/or, about psychoanalysis or—

MR. HEFFNER: That my fault because 1= posed the question that way.

DR. BERNARD: -is a plea that we do everything possible to have, as it were, a range of treatment efforts. We speak in medicine and in psychiatry about differential diagnosis. That means trying to figure out in great distinction the kind of in¬flames people suffer from, and what goes with that is having, if you
will, having differential treatments for the different illnesses as diagnosed, and different combinations of treatment. We need to be more and more precise about what the indications for any given treatment are; and also some of the treatments l think have suffered in their efficiency by being given in isolation as though they were competing with other treatments instead of in combination We need, for example, I think, to bolster whatever improvement the drugs can bring to hospitalized patients, and may hasten their discharge. We need to improve in the community those resources then that can further combine with this relief to strength¬en it and extend it such as rehabilitative services, community clinics, followup clinics, and in these efforts we need to combine recognition of helping families in their ability to understand and help with the illness of the sick member of the family through such means as social work, rehabilitation centers, et cetera.

MR. HEFFNER: What about this quotation from Harpers about the ten thousand people who come for help and five hundred can be served? Wouldn’t this indicate that the differential cal¬culus here is going to mean that those who can afford the very ex¬pensive treatment that is provided by private persons in the psycho¬analytic field will be on that field and won’t the rest of us have to look to the mass scale drug treatment?

DR. BERNARD: There’s no question that there is a tremendous sociological and economic problem about medical services in general and psychiatric services in particular which is compli¬cated by the painstaking and time-consuming and individualized methods in psychiatric treatment. I certainly don’t have a single answer to cope with this. S do feel, however, that it would be a misfortune if the drug approach were to set back the endeavors we are making on many fronts to make available appropriate methods of treatment to larger numbers of people regardless of economic cir¬cumstances by drugs becoming a therapy instead of what is indicated rather than using it when indicated.

Now in those efforts, while I have no answer, I do think more progress is being made than is apparent by your quota¬tion from the article.

MR. HEFFNER: That’s fair enough.

DR. BERNARD: Because I believe, for example, that psychoanalysis is not only to be assessed in terms of the numbers of patients treated by the full and complete formal psychoanalytic method but also by the contributions that psychoanalysis as a psycho¬logical set of concepts has made to psychiatry in general, and to many of the social sciences which are applying it as well as through education into many larger realms through preventive, curative, and rehabilitative programs.

MR. HEFFNER: Let me ask Dr. Kline’s reaction to this.

DR. KLINE: Violent.

MR. HEFFNER: Why? In the three minutes we have left. DR. KLINE: Three minutes? All right. The first point is that I think the cry of the analyst and also of the psy¬chiatrist has been that there are just too many patients, “we can’t handle as many patients as are overwhelming us,” and yet as soon as a method appears which may provide some relief there is appre¬hension raised. I’ve pointed out before that actually the patient heals himself to a large extent; the doctor creates the conditions under which healing can take place,

Now many psychiatric episodes are relatively short lived. If the pharmaceuticals will provide an adequate enough bridge to allow the individual to use his self-curative process that will eliminate a lot of need for psychiatric help, which may not be the happiest thing economically for the psychiatrist but certainly is to the benefit of the patient. Two or three months of pharmaceutical treatment is much less expensive and time-consuming than two or three years of deep analysis.
I think therefore that the general practitioner has a perfectly valid reason for using these pharmaceuticals. If there is not recovery within a reasonable time then the psychiatrist as the specialist should be called in.

The other thing is the assumption that the know¬ledge which seeps down from the well-trained psychoanalyst to the less well trained personnel who nibble at the fringes of psycho¬analysis is going to be properly applied. I’ve seen it brutally misapplied by people who pick out the parts of psychoanalytic theory which titillates them and which they enjoy and feel that they are therefore applying psychoanalytic principles when they’re not at all.

MR. HEFFNER: Dr. Umbreit, what would you say in the one minute remaining?

DR. UMBREIT: Well the arguments seem to me very much like saying we don’t want to use penicillin because we’ve been making such good progress with antipneumococcu.s serum. That is, here is a new type of treatment and while I’ll agree that in many situations one should use all possible treatment, still, why ignore this one? Here is one which I believe is just at the threshold of changing this whole mental disease picture.

MR. HEFFNER: And you would fit it into an entire biochemical approach?

DR. UMBREIT: Oh yes, but don’t ignore it at all, use it.

MR. HEFFNER: Uh huh. Use this new approach. Dr. Bernard?

DR. BERNARD: Well I had meant to convey I want to use it but use it with the other therapies and not throw overboard what we have learned in an understandable enthusiasm for a short cut.

MR. HEFFNER: Usually at the end of a program we come to some balance and agreement but l suspect that the dispute or the exchange of views between the biochemical approach and the drugs and the psychoanalytic approaches will continue for some time, but thanks very much for joining me today, Dr. Kline, Dr. Bernard, and Dr. Umbreit,

Next week The Open Mind will not been seen here in New York but up in Boston they will be showing a kinescope of a program we did some time ago on television censorship. Until two weeks from now here in New York then, until next week by kinescope in Boston,this has been The Open Mind. Thank you, and good-bye.