A New Classification And a Greater Hope

If anyone is in a position to assess the problems of U.S. psychiatry today, it is Kansas' Karl Augustus Menninger. He was a co-founder and has long been chief of staff of the Menninger Clinic, the world's most famed hospital for the mentally ill and its most fertile field for psychiatrists in training. He has interpreted psychiatry to the laity in such noted books as The Human Mind, Man Against Himself, and Love Against Hate. Now, in The Vital Balance (Viking; $10), Dr. Menninger not only spells out what he thinks is wrong with psychiatry; he also supplies some prescriptions for immediate relief. Much of the trouble, he says, is a hangover of hopelessness from the bad old days. Another, and even more important problem, says Dr. Menninger, is psychiatry's basic error of attaching too much importance to naming and labeling.

Radical Thoughts. Dr. Menninger came by both his iconoclasm and his optimism early in his career. As a student at Harvard Medical School he reproached his psychiatry professor: "What's the use? You give nearly every patient the same diagnosis, dementia praecox, and the treatment seems to be merely committing them to the nearest state hospital." That was in 1915, and only three years later, at Boston Psychopathic Hospital, the young Dr. Menninger found that "dementia praecox" had already gone out of fashion; the new label was "schizophrenia." But under any name the condition was still considered hopeless. Then, says Dr. Menninger, who had been moved by the inspired teachings of Ernest Southard, "we began to think in a heretical way . . . that perhaps schizophrenia was not so malignant as we thought but a process that might in some instances be reversible. These were radical thoughts in those days. Mental illness was not supposed to go that way."

Back in Topeka with his physician father, and soon joined in their clinic by Younger Brother William (TIME cover, Oct. 25, 1948), Karl Menninger began what has proved to be a fruitful lifetime of thinking radical thoughts and making sure that mental illness goes "that way." At 70, he remains an apostle of hope; he feels that all victims of mental illness are treatable and that most can make a good enough recovery to go back to their homes and jobs. If more psychiatrists and other physicians had a more hopeful attitude, they would give more effective help to more patients. After treatment, Dr. Menninger insists, many patients are better than ever before in their lives--"weller than well."

Troublesome Names. But mental illness still defies a simple, pat definition, which is one reason why its various forms have been given so many different labels. To Dr. Menninger, a psychoanalyst, the trouble is that even his fellow professionals seem to see magic in a name: "Giving a name to something implies acquaintanceship with it. . . a degree of mastery over it." In psychiatry, a collection of thousands of names has not come close to conferring mastery.

"We propose," he says, "that all the names so solemnly applied to various classical forms and stages of mental illness be discarded."

As a replacement, Dr. Menninger suggests something: skillful diagnosis. "But this means diagnosis in a new sense, not the mere application of a label. It is diagnosis in the sense of understanding just how the patient is ill and just how ill the patient is, how he became ill and how the illness serves him."

Obviously, even a Columbus of the mind needs some rough concept of latitude and longitude, so Dr. Menninger supplies a breakdown of degrees of mental illness by five levels, in ascending order of severity: sbNERVOUSNESS, "a slight but definite disturbance of organization, a slight but definite failure in coping." sbINCREASED DISORGANIZATION, marked by "painful symptoms," which "sometimes pain the environment almost as much as the patient." It calls for "expensive tension-reducing devices" on the part of the patient. The devices may range from crazy-clean tidiness to untidy drinking. Such illnesses have recently been called "neuroses" and "neurotic syndromes." sbREGRESSION, which is characterized by the escape of "dangerous, destructive impulses" leading to "outbursts, attacks, assaults and social offenses." sbDISRUPTION OF ORDERLY THOUGHT as well as of behavior. "These are . . . the 'lunacies' of our great-grandfathers, the 'insanities' of our grandfathers, the 'psychoses' of our fathers." sbABANDONMENT OF THE WILL TO LIVE, "an extremity beyond 'psychosis' in the obsolescent sense." A penultimate step to suicide.

From stage three on, almost all mental illness is likely to require some hospitalization. But Dr. Menninger refuses to dismiss any of the conditions, no matter how severe, as hopeless. Under his direction, Menninger Clinic psychiatrists use everything from a pat on the head to drugs, to talk-it-out therapy and all-out psychoanalysis. Only rarely now do they use insulin or electric shock.

Though he snorts at psychiatrists' traditional jargon, Dr. Menninger cannot refrain from performing some involved semantics of his own. He has coined the word "dysorganization" for the state of mental patients' minds, because the Greek prefix is milder than the Latin in "disorganization." And though he and his coauthors, Psychologists Martin Mayman and Paul Pruyser, do not go so far as some extremists who argue that all mental illness is a myth--a social disturbance and not a disease in the medical sense--Dr. Menninger concedes that it takes a lot of words to define what he really thinks it is. "In a sense," he says, "this entire book is an extended definition of the new view of mental illness"--a view that sees a wide spectrum of "dysorganization" from which everyone suffers at some time and in some degree, and from which nearly everyone can be helped to recover.

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