The 1960s in North American Psychiatry

Mary V. Seeman
Toronto, Ontario, Canada

 

Rhonda’s “Monks” 1963
Private collection of Mary V. Seeman

When I graduated from medical school in 1960, an unprecedented wave of optimism was sweeping the field of psychiatry. Effective antipsychotic medication, the offspring of chlorpromazine,1  was clearing out mental asylums.  New antidepressants, such as imipramine and its many progeny, had recently come on the market.2 Anxiolytics such as meprobamate promised to become the “soma”  of the Brave New World.3 Psychoanalysis was spawning new schools and attracting ever-widening circles of believers.4-6  Family interventions with roots in anthropological and linguistic theory held out the prospect of cure for the more serious diseases that psychoanalysis could not reach.7 Watsonian and Skinnerian conditioning had been translated into effective behavioral therapies.8,9 New understanding of neurochemistry promised ever more specific therapeutic agents.  Electron microscopy allowed visualization of neurons in minute detail.10 The civil libertarian movement was removing the stigma of mental illness, introducing new egalitarian approaches to the patient-therapist relationship.11-12

I began my psychiatric residency at Manhattan State Hospital on Ward’s Island on a research unit housing thirty women. All the women had been diagnosed with “schizophrenic reaction” (the Meyerian term) but we did not share this information with patients or families. Patients were told they had had “a nervous breakdown” and were receiving “treatment” – no one asked “what treatment?” though some asked “why did this happen?” The answer was always: “upbringing.” Parental behavior was the accepted cause of schizophrenic reactions.13-16

Our unit was initially located in New Branch III.  Elisabeth Kübler-Ross, of On Death and Dying fame,17 was the resident who immediately preceded me on this research unit. She has described the Manhattan State Hospital of that time as a “nightmare of bedlam.”18, p. 213

Our unit moved twice while I was there and eventually settled in the newly constructed Adolf Meyer Building. Adolf Meyer (1886-1950) had come to the US from Switzerland in 1892 and had shaped much of American psychiatry by bringing with him Kraepelin’s system of classification as well as the psychodynamic concepts of the Freudian school.

“…for a long time, I have not been as much interested in the question:
Is the patient one of dementia praecox or manic-depressive insanity?
as in the question: What combination of facts and factors
does the patient present? What are the reaction groups and the
factors at work? What are the facts I have to reckon and work
with? What are the assets?”20, p. 358

Meyer believed that schizophrenia was not a disease entity, but rather that inadequate coping behaviors and acute situational stressors could lead to schizophrenic reactions.

Shortly after I started my residency, a patient punched me in the nose. My chief at the time was very much taken with the Stanton -Schwartz phenomenon, the observation that agitation in patients paralleled disagreements between members of staff and that the agitation disappeared and patients improved when the staff disagreements were resolved.21 My chief believed that the patient had punched me because he and I disagreed on her treatment and that the patient was doing to me what I unconsciously wanted to do to him. Stanton (a psychoanalytically trained psychiatrist) and Schwartz (a sociologist) had written about this phenomenon in a book that detailed their five-year sociological study of disturbed women patients at Chestnut Lodge, a mental hospital for the psychoanalytic treatment of psychotic conditions.22

One of the patients on our ward died of an opisthotonic crisis. This was one of the side effects of too high a dose of antipsychotics, an extrapyramidal reaction that consisted of a person’s neck extending uncontrollably backward and choking the person to death.23 The death of this seventeen-year-old young woman was exceedingly traumatic to her family, to me, to the other residents, and to our nursing staff. Our chief met with her parents and offered his condolences on behalf of us all. Six weeks later, when the parents returned to the ward to collect their daughter’s belongings, they bumped into the chief again who absentmindedly asked, “And how is your daughter doing?” I learned a lot about human nature working on the research ward.

It was also here that I learned about antipsychotic drugs and their many side effects.24 When the newly available long-acting fluphenazine enanthate injection first came out, one of our patients developed unbearable akathisia that lasted for five weeks. She paced uncontrollably up and down the halls of the Adolf Meyer building, talking about wanting to die. She did eventually recover.

Though we operated as a democratic therapeutic community,25 staff had more say than patients and some patients had more power than others. There were two in particular, Milly and Theresa (not their real names), who were midway between staff and patients because they had been on the research ward so long. They were career patients. Milly was the gentle one; Theresa could be harsh. When patients misbehaved, Theresa was not above threatening them with restraints,  heavier sedation, or the cancellation of a weekend outing. Milly and Theresa were entrusted with many responsibilities, all of which they performed extraordinarily well. They sacrificed their own comforts in order to please the nursing staff and to be of service. In doing so, they often drew the ire of the other patients who saw them as “fifth columns”, not to be trusted. In the always-present battlefield between patients and staff, they straddled the line – a very difficult position.

It was also during my residency that I learned about recovery. Rhonda (a pseudonym) was about thirty when I first arrived. She had been in hospital since age eighteen.  For the first few years, she did not speak. By the time I met her in 1961, though still very reticent, she did speak and attended daily art therapy. Her head was usually down and, when walking, she clung to the safety of the walls. When I completed my residency four years later, Rhonda had been discharged from hospital into a full time office job. Some of her artwork is on display in a report we wrote on her progress.26 Rhonda spent thirteen years in a hospital and then, through strength of character, perseverance, intrinsic artistic talent, individual care and attention, and effective medications, had been able to “make it”. From Rhonda I learned that the outcome of serious mental illness is unpredictable.

We conducted many drug trials on our research ward. Our group has been credited with delaying the introduction of haloperidol into North America.

“Furthermore, haloperidol’s debut in North America was marked
by a clinically and structurally erroneous clinical trial. This study,
carried out by Herman C.B. Denber (Department of Psychiatry,
Manhattan State Hospital, New York), was implemented by under
qualified staff and consisted of a sample of 10 patients presenting
chronic hebephrenic schizophrenia, precisely the patient group
for whom the worst results had been obtained in Europe. These
patients were administered increasing doses of haloperidol (up
to 90 mg/day), and the findings, published in 1959 in the American
Journal of Psychiatry were utterly negative. The authors
reported a worsening of behavioural disorders, and even went so
far as to question whether the drug they had used was the same
one as that which had been tested in Europe. Their conclusion,
that the disparity in findings and the inefficacy of the drug was the
result of genetic differences between European and North American
schizophrenic patients, presented an enormous obstacle to the
introduction of haloperidol in the United States.”27, p.136

Our original haloperidol paper was published before I arrived, but I have since looked it up. In fact, there were thirty patients in the study, not ten, and the drug our group used came from Searle (so was quite possibly different from the drug by Janssen that was being used in Europe).

Many of our patients were treated not by drugs but with a combination of insulin coma and family therapy – using a technique of psychological regression and rebirth in which family members were invited to participate.28 It was a treatment of last resort on our ward. Almost all our patients received barbiturates for sleep and they also all took part in psychosocial therapies, psychodrama and gestalt groups, and were rewarded (and punished) through a token economy system.29 Enrollment in trials in those days was done without patient consent. The first article addressing patient consent for investigational drugs was only published in 1967.30

Anna-Marie (not her real name) was a patient who made many attempts on her own life. She was chronically suicidal. On August 5, 1962, our ward was shaken by the news that Marilyn Monroe had committed suicide. The chief was away for his summer holiday so, on our own, one of my fellow residents and I got a group of suicidal patients together (we called it the Marilyn Monroe group), to meet once a week and discuss the existential meaning of life and death. Our well-meant therapeutic intervention proved to be a disaster. After the first meeting, three group members including Anne-Marie tried to kill themselves. It was a form of contagion called the Werther effect, after Goethe’s novel The Sorrows of Young Werther.31 Fortunately none of the patients succeeded in their attempts. But the head nurse immediately took it upon herself to telephone the chief long distance; my fellow resident and I were called to task and the group was disbanded. The chief said, according to the Stanton-Schwartz phenomenon, the three patients who had attempted suicide were acting out our unconscious wishes to kill our chief.

This was psychiatry from my perspective in the early 1960s.

 

References

  1. Delay J, Deniker P, Harl JM. Utilisation en thérapeutique d’une phénothiazine d’action centrale selective (4560). [The therapeutic use of a phenothiazine with selective central activity (4560 RP).] Annales Médico- Psychologiques, 1952;110:112-117.
  2. Kuhn R. The treatment of depressive states with G 22355 (imipramine hydrochloride). American Journal of Psychiatry, 1958;115:459-464.
  3. Berger FM. The central depressant properties of o-toloxypropyl carbamates: Journal of Pharmacology and Experimental Therapeutics, 1952;104:468.
  4. Boulanger JB. Psychoanalysis. Canadian Medical Association Journal, 1956;5:512–517.
  5. Galdston I. Psychoanalysis, 1959. Bulletin of the New York Academy of Medicine, 1960;36:702–713.
  6. Scott WCM. Indications for and limitations of psycho-analytic treatment. British Medical Journal, 1951;2:597–600.
  7. Bateson G, Jackson DD, Haley J, Weakland J. Toward a theory of schizophrenia. Behavioral Science, 1956;1:251-264.
  8. Lindsley O, Skinner BF, Solomon HC. Studies in Behavior Therapy (Status Report I). Waltham, MA: Metropolitan State Hospital: 1953.
  9. Wolpe J. The systematic desensitization treatment of neuroses. Journal of Nervous and Mental Disease, 1961;132:189-203.
  10. Palay SL, Palade GE. The fine structure of neurons. Journal of Biophysics and Biochemical Cytology, 1955;1:69-88.
  11. Szasz T. Commitment of the mentally ill: “treatment” or social restraint? Journal of Nervous and Mental Disease, 1957;125:293-307.
  12. Szasz T. The myth of mental illness. American Psychologist, 1960;15:113-118.
  13. Alanen YO. The mothers of schizophrenic patients: a study of the personality and the mother-child relationship of 100 mothers and the significance of these factors in the pathogenesis of schizophrenia, in comparison with heredity. Acta Psychiatrica et Neurologica Scandinavica, 1958;124:S1-S361.
  14. Lidz RW, Lidz T. The family environment of schizophrenic patients. American Journal of Psychiatry, 1949;106:332-345.
  15. Lidz T, Cornelison AR, Fleck S, Terry D. The intrafamilial environment of the schizophrenic patient. I. The father. Psychiatry, 1957;20:329-342.
  16. Wynne LC, Ryckoff IM, Day J, Hirsch SI. Pseudo-mutuality in the family relations of schizophrenics. Psychiatry, 1958;21:205-220.
  17. Kübler-Ross E. On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and Their Own Families. Abingdon, U.K.: Taylor & Francis: 2009.
  18. Gill D. Quest, the Life of Elisabeth Kübler-Ross. New York City: Ballantine Books:1980.
  19. Meyer A. Constructive formulation of schizophrenia. American Journal of Psychiatry, 1922;78:355-364.
  20. Stanton AH, Schwartz MS. The management of a type of institutional participation in mental illness. Psychiatry, 1949;12:13-26.
  21. Stanton AH, Schwartz MS. The Mental Hospital. New York: Basic Books, Inc.: 1954.
  22. Lichtigfeld FJ. Opisthotonus in drug-induced dystonic syndrome. British Journal of Psychiatry, 1964;110:734-735.
  23. Seeman MV, Denber HCB, Goldner F. Paradoxical effects of phenothiazines. Psychiatric Quarterly, 1968;42:90-103.
  24. Denber HCB, Turns D, Seeman MV. The therapeutic community: Nine years after. Psychiatric Quarterly, 1968;42:531-537.
  25. Seeman MV, Turns D, Denber HCB. Approches thérapeutiques multiples et leur effet sur la chronicité: Rapport d’un cas. [Multiple therapeutic approaches and their effect on chronicity. A case report.] Annales Médico-Psychologiques, 1969;127:727-732.
  26. López-Muñoz F, Alamo C. The consolidation of neuroleptic therapy: Janssen, the discovery of haloperidol and its introduction into clinical practice. Brain Research Bulletin, 2009;79:130-141.
  27. Laquer HP, LaBurt HA. The therapeutic community on a modern insulin ward. Journal of Neuropsychiatry, 1961;3:139-149.
  28. Seeman MV. Personal accounts: an account of multiple psychiatric hospitalizations in the 1960s. Psychiatric Services, 2002;53:151-152.
  29. Goddard JL. Consent for use of investigational new drugs on humans. Journal of Clinical Pharmacology and the Journal of New Drugs, 1967;7:171-172.
  30. Phillips DP. The influence of suggestion on suicide: Substantive and theoretical implications of the Werther effect. American Sociological Review, 1974;39:340-354.

 


 

MARY V. SEEMAN, MD, is Professor Emerita, Department of Psychiatry, University of Toronto. Her lifelong interest has been in the effect of psychosis on women and the effect of gender on psychosis.

 

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