A Psychiatric Milestone by Various

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Through the disharmonies and inevitable disruption of a
self-disorganizing civilization, the Greek and Roman world was plunged
into the dark centuries during which the perils of the soul and the
sacrificial attainment of salvation by monastic life and crusades
threatened to overshadow all other concern. This had some inevitable
results: it favored all those views through which the soul became like a
special thing or substance, in contrast to and yet a counterpart of the
physical body. As long as there was no objective experimental science,
the culminating solution of life problems had to be intrusted to that
remarkable development of religious philosophy which arose from the
blending of Hebrew religion and tradition and the loftiest products of
the Greek mind, in the form which St. Paul and the early Church fathers
gave to the teachings of Christ. From being the form and activation, or
function, of the organism in life, the soul feature of man was given an
appearance in which it could neither be grasped nor understood, nor
shaped, nor guided by man when it got into trouble. From the Middle Ages
there arose an artificial soul and an artificial world of souls
presented as being in eternal conflict with the evil of the flesh--_and
thus the house of human nature was divided against itself_.

Science of the nineteenth century came nearer bringing mind and body
together again. The new astronomical conception of the world and the
growing objective experimental science gradually began to command
confidence, and from being a destroyer of excessively dogmatic notions,
science began to rise to its modern constructive and creative position.
But the problem of _mind_ remained on a wrong basis and still does so
even with most scientists. Too much had been claimed for the psyche, and
because of the singling out of a great world of spirit, the world of
fact had been compromised and left cold and dry and unattractive and
unpromising. No doubt it was necessary that the scientist should become
hardened and weaned from all misleading expectation, and shy of all the
spurious claims of sordid superstition and of childish fancy. He may
have been unduly radical in cutting out everything that in any way
recalled the misleading notions. In the end, we had to go through a
stage of psychology without a "soul," and lately even a psychology
without "consciousness," so that we might be safe from unscientific
pretensions. All the gyrations no doubt tended to retard the wholesome
practical attack upon the problems in the form in which we find them in
our common-sense life.

The first effort at a fresh start tried to explain everything rather
one-sidedly out of the meagre knowledge of the body. Spinoza had said in
his remarkable Ethics (III, Prop. II, Schol.): "Nobody has thus far
determined what the body can do, _i.e._, nobody has as yet shown by
experience and trial what the body can do by the laws of nature alone in
so far as nature is considered merely as corporeal and extended, and
what it cannot do save when determined by mind."

This challenge of Spinoza's had to be met. With some investigators this
seemed very literally all there was to be done about the study of
man--to show how far the body could explain the activity we call "the
mind." The unfortunate feature was that they thought they had to start
with a body not only with mind and soul left out but also with
practical disregard of the whole natural setting. They studied little
more than corpses and experimental animals, and many a critic wondered
how such a corpse or a frog could ever show any mind, normal or
abnormal. To get things balanced again, the vision of man had to expand
to take a sane and practical view of all of human life--not only of its
machinery.

The human organism can never exist without its setting in the world. All
we are and do is of the world and in the world. The great mistake of an
overambitious science has been the desire to study man altogether as a
mere sum of parts, if possible of atoms, or now of electrons, and as a
machine, detached, by itself, because at least some points in the
simpler sciences could be studied to the best advantage with this method
of the so-called elementalist. It was a long time before willingness to
see the large groups of facts, in their broad relations as well as in
their inner structure, finally gave us the concept and vision of
integration which now fits man as a live unit and transformer of energy
into the world of fact and makes him frankly a consciously integrated
psychobiological individual and member of a social group.

It is natural enough that man should want to travel on the road he knows
and likes best. The philosopher uses his logic and analysis and
synthesis. The introspectionist wants to get at the riddle of the
universe by crawling into the innermost depth of his own self-scrutiny,
even at the risk--to use a homely phrase--of drawing the hole in after
him and losing all connection with the objective world. The physicist
follows the reverse course. He gives us the appreciation of the
objective world around and in us. The chemist follows out the analytic
and synthetic possibilities of his atoms and elements, and the biologist
the growth and reproduction and multiplication of cells. Each sees an
open world of possibilities and is ready to follow as far as facts will
carry and as far as the imagination will soar. Each branch has created
its rules of the game culminating in the concept of objective science,
and the last set of facts to bring itself under the rules of objective
science, and to be accepted, has been man as a unit and personality.

The mind and soul of man have indeed had a hard time. To this day,
investigators have suffered under the dogma that mind must be treated as
purely subjective entity, something that can be studied only by
introspection, or at least only with ultra-accurate instruments--always
with the idea that common sense is all wrong in its psychology.
Undoubtedly it was, so long as it spoke of a mind and soul as if what
was called so had to be, even during life, mysterious and inaccessible,
something quite different from any other fact of natural-history study.

The great step was taken when all of life was seen again in its broad
relations, without any special theory but frankly as common sense finds
it, viz., as the activities and behavior of definite individuals--very
much as Aristotle had put it--"living organisms in their 'form' or
activity and behavior." Psychology had to wake up to studying other
minds as well as one's own. Common sense has always been willing to
study other persons besides our own selves, and that exactly as we study
single organs--viz., for what they are and do and for the conditions of
success and failure. Nor do we have to start necessarily from so-called
elements. Progress cannot be made merely out of details. It will not do
merely to pile up fragments and to expect the aggregates to form
themselves. It also takes a friend of facts with the capacity for
mustering and unifying them, as the general musters his army. Biology
had to have evolutionists and its Darwin to get on a broad basis to
start with, and human biology, the life of man, similarly had to be
conceived in a new spirit, with a clear recognition of the opportunities
for the study of detail about the brain and about the conditions for
its working and its proper support, but also with a clear vision of the
whole man and all that his happiness and efficiency depend upon.

All this evolution is strongly reflected in the actual work of
psychiatry and medicine. For a time, it looked to the physician as if
the physiology and pathology of the body had to make it their ambition
to make wholly unnecessary what traditional psychology had accumulated,
by turning it all into brain physiology. The "psychological" facts
involved were undoubtedly more difficult to control, so much so that one
tried to cut them out altogether. As if foreshadowing the later academic
"psychology without soul and consciousness," the venerable
Superintendent of Utica, Dr. Gray, was very proud when in 1870 he had
eliminated the "mental and moral causes" from his statistics of the
Utica State Hospital, hiding behind the dogma that "mind cannot become
diseased, but only the body." To-day "mental and moral causes" are
recognized again in truer form--no longer as mere ideas and
uninvestigated suppositions taken from uncritical histories, but as
concrete and critically studied life situations and life factors and
life problems. Our patients are not sick merely in an abstract mind, but
by actually living in ways which put their mind and the entire organism
and its activity in jeopardy, and we are now free to see how this
happens--since we study the biography and life history, the resources of
adaptation and of shaping the life to success or to failure.

The study of life problems always concerns itself with the interaction
of an individual organism with life situations. The first result of a
recognition of this fact was a more whole-hearted and practical concept
of personality.

In 1903 I put together for the first time my analysis of the neurotic
personality, which was soon followed by a series of studies on the
influences of the mental factors, and in 1908 a paper on "What Do
Histories of Cases of Insanity Teach Us Concerning Preventive Mental
Hygiene During the Years of School Life?" All this was using for
psychiatry the growing appreciation of a broad biological view-point in
its concrete application. It was a reaction against the peculiar fear of
studying the facts of life simply and directly as we find and experience
them--scoffed at because it looked as if one was not dealing with
dependable and effective data. Many of the factors mentioned as causes
do not have the claimed effects with sufficient regularity. It is quite
true that not everybody is liable to any serious upset by several of the
handicaps sometimes found to be disastrous during the years of
development; but we have learned to see more clearly why the one person
does and the other does not suffer. Evidently, not everybody who is
reserved and retiring need be in danger of mental disorder, yet there
are persons of just this type of make-up that are less able than others
to stand the strains of isolation, of inferiority feeling, of exalted
ambitions and one-sided longings, intolerable desires, etc. The same
individual difference of susceptibility holds even for alcohol. With
this recognition we came to lay stress again on the specific factors
which make for the deterioration of habits, for tantrums with
imaginations, and for drifting into abnormal behavior, and conditions
incompatible with health.

It was at this point that our great indebtedness to the Bloomingdale
Hospital began. Dr. August Hoch, then First Assistant of the
Bloomingdale Hospital, began to swing more and more toward the
psychobiological trend of views, and with his devoted and very able
friend Amsden he compiled that remarkable outline,[2] which was the
first attempt to reduce the new ideals of psychobiology to a practical
scheme of personality study--that clear and plain questionnaire going
directly at human traits and reactions such as we all know and can see
at work without any special theories or instruments.

After studying in each patient all the non-mental disorders such as
infections, intoxications, and the like, we can now also attack the
problems of life which can be understood only in terms of plain and
intelligible human relations and activities, and thus we have learned to
meet on concrete ground the real essence of mind and soul--the plain and
intelligible human activities and relations to self and others. There
are in the life records of our patients certain ever-returning
tendencies and situations which a psychiatry of exclusive brain
speculation, auto-intoxications, focal infections, and internal
secretions could never have discovered.

Much is gained by the frank recognition that man is fundamentally a
social being. There are reactions in us which only contacts and
relations with other human beings can bring out. We must study men as
mutual reagents in personal affections and aversions and their
conflicts; in the desires and satisfactions of the simpler appetites for
food and personal necessities; in the natural interplay of anticipation
and fulfilment of desires and their occasional frustration; in the
selection of companionship which works helpfully or otherwise--for the
moment or more lastingly throughout the many vicissitudes of life. All
through we find situations which create a more or less personal bias and
chances for success or failure, such as simpler types of existence do
not produce. They create new problems, and produce some individuals of
great sensitiveness and others with immunity--and in this great field
nothing will replace a simple study of the life factors and the social
and personal life problems and their working--the study of the real mind
and the real soul--_i.e._, human life itself. Looking back then this
practical turn has changed greatly the general view as to what should be
the chief concern of psychology. One only need take up a book on
psychology to see what a strong desire there always was to contrast a
pure psychology and an applied psychology, and to base a new science
directly on the new acquisitions of the primary sciences such as anatomy
and histology of the nervous system. There was a quest for the elements
of mind and their immediate correlation with the latest discoveries in
the structure of the brain. The centre theory and the cell and neurone
theory seemed obligatory starting-points. To-day we have become shy of
such postulates of one-sided not sufficiently functional materialism. We
now call for an interest in psychobiological facts in terms of critical
common sense and in their own right--largely a product of psychiatry.
There always is a place for elements, but there certainly is also a
place for the large momentous facts of human life just as we find and
live it.

Thus psychiatry has opened to us new conceptions and understandings of
the relation of child and mother, child and father, the child as a
reagent to the relations between mother and father, brothers and
sisters, companions and community--in the competitions of real concrete
life. It has furnished a concrete setting for the interplay of emotions
and their effects.

It has led us from a cold dogma of blind heredity and a wholesale
fatalistic asylum scheme, to an understanding of individual, familiar,
and social adjustments, and a grasp on the factors which we can consider
individually and socially modifiable. We have passed from giving mere
wholesale advice to a conscientious study of the problems of each unit,
and at the same time we have developed a new and sensible approach to
mental hygiene and prevention, as expressed in the comprehensive surveys
of State and community work and even more clearly in the development of
helps to individuals in finding themselves, and in the work in schools
to reach those who need a special adaptation of aims and means. To the
terrible emergency of the war it was possible to bring experienced men
and women as physicians and nurses, and how much was done, only those
can appreciate who have seen the liberality with which all the
hospitals, and Bloomingdale among the first, contributed more than their
quota of help, and all the assistance that could possibly be offered to
returning victims for their readjustment.

It is natural enough that psychiatry should have erred in some respects.
We had forced upon us the herding together of larger numbers of patients
than can possibly be handled by one human working unit or working group.
The consequence was that there arose a narrowing routine and wholesale
classifications and a loss of contact with the concrete needs of the
individual case; that very often progress had to come from one-sided
enthusiasts or even outsiders, who lost the sense of proportion and
magnified points of relative importance until they were supposed to
explain everything and to be cure-alls. We are all inclined to sacrifice
at the altar of excessive simplicity, especially when it suits us; we
become "single-taxers" and favor wholesale legislation and exclusive
State care when our sense for democratic methods has gone astray. Human
society has dealt with the great needs of psychiatry about as it has
dealt with the objects of charity, only in some ways more stingily, with
a shrewd system and unfortunately often with a certain dread of the
workers themselves and of their enthusiasm and demands. Law and
prejudice surrounded a great share of the work with notions of stigma
and hopelessness and weirdness--while to those who see the facts in
terms of life problems there can be but few more inspiring tasks than
watching the unfolding of the problematic personality, seeking and
finding its proper settings, and preventing the clashes and gropings in
maladjustments and flounderings of fancy and the faulty use and
nutrition of the brain and of the entire organism.

What a difference between the history of a patient reported and studied
and advised by the well-trained psychiatrist of to-day and the account
drawn up by the statistically minded researcher or the physician who
wants to see nothing but infections or chemistry and hypotheses of
internal secretion. What a different chance for the patient in his
treatment, in contrast to what the venerable Galt of Virginia reports as
the conception of treatment recommended by a great leader of a hundred
years ago: "Mania in the first stage, if caused by study, requires
separation from books. Low diet and a few gentle doses of purging
physic; if pulse tense, ten or twelve ounces of blood [not to be given
but to be taken!]. In the high grade, catch the patient's eye and look
him out of countenance. Be always dignified. Never laugh at or with
them. Be truthful. Meet them with respect. Act kindly toward them in
their presence. If these measures fail, coercion if necessary.
Tranquillizing chair. Strait waistcoat. Pour cold water down their
sleeves. The shower bath for fifteen or twenty minutes. Threaten them
with death. Chains seldom and the whip never required. Twenty to forty
ounces of blood, unless fainting occurs previously; ... etc."

To-day an understanding of the life history, of the patient's somatic
and functional assets and problems, likes and dislikes, the problem
presented by the family, etc.!

So much for the change within and for psychiatry. How about psychiatry's
contribution beyond its own narrower sphere? It has led us on in
philosophy, it has brought about changes in our attitude to ethics, to
social study, to religion, to law, and to life in general. Psychiatric
work has undoubtedly intensified the hunger for a more objective and yet
melioristic and really idealistic philosophical conception of reality,
such as has been formulated in the modern concept of integration.

Philosophical tradition, logic, and epistemology alike had all conspired
to make as great a puzzle as possible of the nature of mental life, of
life itself, and of all the fundamental principles, so much so that as
a result anything resembling or suggesting philosophy going beyond the
ordinary traditions has got into poor repute in our colleges and
universities and among those of practical intelligence. The consequence
is that the student and the physician are apt to be hopeless and
indifferent concerning any effort at orderly thinking on these
problems.[3]

Most of us grew up with the attitude of a fatalistic intellectual
hopelessness. How could we ever be clear on the relation of mind and
body? How could mind and soul ever arise out of matter? How can we
harmonize strict science with what we try to do in our treatment of
patients? How can we, with our mechanistic science, speak of effort, and
of will to do better? How can we meet the invectives against the facts
of matter on the part of the opposing idealistic philosophies and their
uncritical exploitations in "New Thought"--_i.e._, really the revival of
archaic thought? It is not merely medical usefulness that forced these
broad issues on many a thinking physician, but having to face the facts
all the time in dealing with a living human world. The psychopathologist
had to learn to do more than the so-called "elementalist" who always
goes back to the elements and smallest units and then is apt to shirk
the responsibility of making an attempt to solve the concrete problems
of greater complexity. The psychiatrist has to study individuals and
groups as wholes, as complex units, as the "you" or "he" or "she" or
"they" we have to work with. We recognize that throughout nature we have
to face the general principle of unit-formation, and the fact that the
new units need not be like a mere sum of the component parts but can be
an actually new entity not wholly predictable from the component parts
and known only through actual experience with the specific product.
Hydrogen and oxygen, it is true, can form simple mixtures, but when they
make an actual chemical integration we get a new specific type of
substance, water, behaving and dividing according to its own laws and
properties in a way not wholly predictable from just what we know of
hydrogen and oxygen as such. Analogy prompts us to see in plants and
animals products of physics and chemistry and organization, although the
peculiarity of the product makes us recognize certain specificities of
life not contained in the theory of mere physics and chemistry. All the
facts of experience prompt us to see in mentation a biological function,
and we are no longer surprised to find this product of integration so
different from the nature and functions of all the component parts. All
the apparent discontinuities in the intrinsic harmony of facts, on the
one hand, and the apparent impossibility of accounting for new features
and peculiarities of the new units, are shown to be a general feature of
nature and of facts: integration is not mere summation, but a creation
of ever-new types and units, with superficial discontinuities and with
their own new denominators of special peculiarities; hence there is no
reason to think of an insurmountable and unique feature in the origin of
life, nor even of mentally integrated life; no need of special mystical
sparks of life, of a mysterious spirit, etc.; but--and this is the
important point--also no need of denying the existence of all the
evidence there may be of facts which we imply when we use the deeply
felt concepts of mind and soul. In other words, we do not have to be
mind-shy nor body-shy any longer.

The inevitable problem of having to study other persons as well as
ourselves necessarily leads us on to efforts at solution of other
philosophical problems, the problem of integrating materialism and
idealism, mechanism and relative biological determinism and purpose,
etc. Man has to live with the laws of physics and chemistry unbroken and
in harmony with all that is implied in the laws of heredity and growth
and function of a biological organism. Yet what might look like a
limitation is really his strength and safe foundation and stability. On
this ground, man's biological make-up has a legitimate sphere of growth
and expansion shared by no other type of being. We pass into every new
moment of time with a preparedness shown in adaptive and constructive
activity as well as structure, most plastic and far-reaching in the
greatest feat of man, that of imagination. Imagination is not a mere
duplication of reality in consciousness and subjectivity; it is a
substitute in a way, but actually an amplification, and often a real
addition to what we might otherwise call the "crude world," integrated
in the real activities of life, a new creation, an ever-new growth, seen
in its most characteristic form in choice and in any new volition. Hence
the liberating light which integration and the concepts of growth and
time throw on the time-honored problem of absolute and relative
determinism and on the relation of an ultra-strict "science" with common
sense.

In logic, too, we are led to special assertions. We are forced to
formulate "open definitions," _i.e._, we have to insist on the open
formulation of tendencies rather than "closed definitions." We deal with
rich potentialities, never completely predictable.

This background and the demands of work in guiding ourselves and others
thus come to lead us also into practical ethics, with a new conception
of the relation of actual and experimental determinism and of what "free
will" we may want to speak of, with a new emphasis on the meaning of
choice, of effort, and of new creation out of new possibilities
presented by the ever-newly-created opportunities of ever-new time. We
get a right to the type of voluntaristic conception of man which most of
us live by--with a reasonable harmony between our science and our
pragmatic needs and critical common sense.

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