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MUCH OF the literature of modern mental hygiene is reminiscent of a classic remark of Gerald Stanley Lee's. The true title of any book, he suggested, should be "How to Be More Like Me."
I know a psychiatrist who, with the best will in the world, tries to make his patients more like himself. When he gets mentally fagged, for example, he cultivates a hobby, an avocation; naturally enough he tells a patient who has been overworking that
he should cultivate a hobby. I know another who finds that biography is good relaxation for him; the patient is therefore told to read biography. These are more gross and obvious instances, from which many psychiatrists are of course completely free. In subtler ways, however, it is almost impossible to avoid the temptation to shape the patient into the mold of one's own best or most efficient self. This may go so far as attempting to give the patient the psychiatrist's own system of values; or as it is frankly stated by two well-known psychiatrists, to give the patient a philosophy of life. That the psychiatrist (or consulting psychologist or vocational guide) must do so in many cases is undeniable, and the parent is of course daily at work giving the child a philosophy of life, whether he wishes to or not. It is evident, however, that there is always pressure for conformity, often the picturing of a smooth easy-rolling conformist existence as the pinnacle and capstone of mental health. Even if we agree that all existence should be balanced and serene, we know altogether too little about the meaning of life to try to fit people to a given norm. A moment's reflection will convince the reader that thousands of different kinds of personalities making thousands of radically different kinds of life adjustments are
today enjoying life in a thousand different ways.
It is without dogmatism, therefore, that I venture to set down here a few tentative hints regarding individual and social mental health.
First we may consider the usefulness of four distinct methods of viewing mental abnormalities.
If you see a lame motor car, gasping along a rocky road, you may, according to your mood, make any one of four kinds of comments on it. "Why didn't Joe buy a
good car? That machine of his can't help going wrong." Or if you happen to know what particular symptom constitutes the car's present complaint, you may say: "Now if he'd only pay more attention to his spark plugs he'd have no more trouble." Or third, you may know that this immediate trouble is nothing but the end result of years of
bad treatment." Of course he has trouble; he never took care of the car; the trouble goes away back to the first day he drove it." If you are in a particularly generous mood towards Joe, you may
be content to remark that no car could navigate on a rock pile, and wonder why the county doesn't help the state to pay for decent roads.
If you make the first of these remarks you are taking the position of a large school of psychiatrists, for whom heredity is the chief explanation for bad navigation through
life. Once in existence, the machine never had a real chance. The second remark is that of the psychiatrist or psychologist who is interested in precipitating causes. The third is in general the viewpoint of most psychoanalysts and of a great many other psychiatrists and psychologists: adult maladjustments go back to whole life-histories of faulty adjustment. The fourth remark, though it does not really contradict any of the other three, reflects a viewpoint in which the important thing is to clear away the external obstacles that confront the machine as it is now.
The compiler of these selections on abnormal psychology finds himself quite unwilling to "defend" any of these views against the others; he sees no reason why society should be reluctant to do its utmost in the study and application of principles of all four types. For the practical worker, specialization based on the division of labor is necessary; for the student, the utilization of
every possible approach which may give insight into possible causes of mental disorder seems imperative. The most constructive kind of psychiatry, it seems to me, is reflected in these
remarkable words of Strecker and Ebaugh:
It is recommended that the student postpone final judgment in the general evaluation of the symptoms in the individual patient. What might be spoken of as a neurotic make-up - a neurasthenic, hysterical, or psychasthenic
trend - is not difficult to recognize and with it comes the temptation to generalize in the conception of the patient. Such generalization gives certain loose indications for treatment, but this kind of treatment is always slip-shod psychiatry, and not infrequently it is dangerous. There is a reason and a mechanism for every symptom and sign and the reason and mechanism is to be found in the patient and his history and not in any theory, however profound the theory may be. Just as any phenomenon of hysteria, or of anaesthesia, or of psychasthenia, such as a phobia of high places, or of neurasthenia, such as a selective fatigue, is not to be dismissed until it has been traced to its possible psychologic source, so also must it not be assumed that the only possible explanation is a psychological one. It is little short of criminal to assume because the patient has a neurotic attitude, that, necessarily, his body is sound. In the first place, there are numerous instances in which the somatic factor is strikingly important and even where it occupies a subsidiary position, it may still call for energetic treatment ... It is
not a question as to what degree these pathological conditions were instrumental in producing a neurosis or even whether they were influential at all. Such morbidity is to be found on careful examination, and,
therefore, careful examination becomes a matter, not of belief but of conscience and medical
ethics. Adherence to any particular doctrine does not remove the responsibility for determining the actual physical status of the patient. The only effective knowledge is the kind of knowledge that is derived from a thorough analysis of the patient, his symptoms, his history, and his setting in life - a psychologic analysis - a physical analysis, and an environmental analysis. There is no royal road nor are there any short cuts to a proper understanding of the
neuroses.
But the problem of preventing mental abnormality is a social problem, and the psychiatrist needs the support of an informed and vigorous public opinion. A clear case is the ordinary or simple type of mental deficiency, in which not only the defect in intelligence, but even the degree of the defect appears to be determined by the germ-cells of the parents. Notwithstanding the "optimistic" remark that we need some mental defectives in our social structure, the appalling social waste due to the difficulty of educating mental defectives and the sheer fact that most of them are both directly and indirectly a burden upon their families and a potential menace to their communities makes their possible positive value to society seem in proportion very small indeed. Discussion of this point quickly liberates a host of powerful emotions. Many who feel themselves to be humanitarians rise in their wrath proclaiming the "Right" of the feeble-minded to reproduce their kind. One of the first duties of the psychologist to the public is to encourage research upon the relation of mental defect to heredity and to make known the definite results already obtained. Public opinion will, of course, continue to resist, because the whole problem of sex and reproduction is regarded on the one hand as too sacred, on the other as too unclean, for discussion. Nothing but the appalling fact that undesirable stock is actually increasing at a menacing rate is likely to break down the barriers to open discussion.
The case is nearly as clear with regard to epilepsy, - I refer here to "essential epilepsy" appearing in the absence of demonstrable brain disease. An
absolute rule cannot be laid down with regard to the procreation of such individuals, because such an individual may occasionally be a person of such extraordinary intellectual or artistic powers that his children may actually be needed by society despite the taint. This is especially the case if he marries into a perfectly normal stock, - though even in this case the taint may appear after few or after many generations. These exceptional cases are, moreover, almost negligible in the total. The vast majority of epileptics continue their kind, generation after generation. Society pays the enormous social and moral cost and frowns upon discussion which might lead to intelligent grappling with the problem.
A number of mental disorders, including some of the most common, still baffle the student of the causes of maladjustment. Bad heredity is found with great frequency, and some authorities emphasize heredity throughout. Two difficulties, however, prevent any definite assignation of heredity as a cause. First, we lack what experimental scientists call a control group; we do not know how much bad heredity there would be in strictly comparable cases of normal individuals. Secondly, we still lack clear data as to the degree to which bad heredity, even when significant, may actually
force the individual into mental disease, and to what extent such heredity merely predisposes him to such a breakdown, by giving him a constitution which is unable to withstand such shocks as others might resist. The two large psychopathic groups designated dementia praecox and manic-depressive psychosis are naturally enough interpreted according to three distinct viewpoints. Some regard both as definitely hereditary; in contrast to this, others regard the shocks and vicissitudes of life, especially of childhood, as the chief causes; a third group strikes a compromise, believing that predisposing heredity plays a part, but that the actual onset of the disorder depends on environmental forces. The evidence for the importance of heredity in the manic-depressive group seems very strong, although occasional individuals possessing the worst imaginable manic-depressive heredity may perhaps
be able, through very careful avoiding of precipitating causes, to get through life without a smash. It must be remembered, however, that if heredity is really of prime importance, the mere fact that a given parent avoids the disorder will not guarantee that subsequent generations will do so. The
germ cells (carriers of heredity) go on perpetuating the psychopathic tendency. Fortunately, most individuals who come of manic-depressive stock can easily acquaint themselves with the family tree in relation to their problem, because the disorder is definite and can rarely be concealed. I feel sure that even rigorous anti-eugenists would, after acquainting themselves with the facts, agree that a person coming of definitely manic-depressive stock ought not to marry another also of clearly manic-depressive stock.
The problem of heredity in relation to dementia praecox is frightfully complicated. Some investigators regard the "shut-in" personality as the usual forerunner of dementia praecox. But whether the shut-in type of personality depends chiefly upon heredity or upon early environmental factors is hard to determine. It may be that some cases are constitutionally predisposed to such maladjustment, while others are the victims of twists received in early childhood. We can, however, draw two safe conclusions. First, there is no doubt whatever that shut-in personalities are in themselves less happy and less useful than more sociable ones, and that the tendency of children to remain without interest in playmates or activities outside of their own daydreams (especially if they are having sexual conflicts or worries) predisposes not only in some cases to dementia praecox, but to other unhappy and unsocial personalities. Secondly, remembering that the term dementia praecox is both vague and broad, we must keep our minds open to the possibility that various physical factors such as infected teeth or tonsils, glandular insufficiency or imbalance, etc., may in some cases lead to mental disorders coming under that general head. Even, in fact, if such physical causes are not known to be causing
any trouble, either physiological or mental, at present, they are likely to do so at any time, and the onset of such troubles is usually insidious.
A large number of abnormal personalities who are not definitely insane, but classified as "constitutional psychopaths" show life histories so full of maladjustment that it is quite impossible to say whether heredity or early childhood disturbances play the greater part. It is significant, however, that a large number of such cases, particularly those showing kleptomania, uncontrollable temper, sadistic tendencies, the impulse to wander, etc., have been found through recent careful studies to owe their condition to perfectly definite experience in childhood, particularly to faulty sexual education, lack of confidence between parent and child, feelings of inferiority, and other emotional conflicts.
The vast field of the psychoneuroses or functional nervous complaints, all the way from full-fledged cases of hysteria to the little obsessions and irrational worries which practically all of us have or have had, appear to be chiefly or perhaps entirely traceable to environmental sources. The causes of a large number of these have been traced in Dr. Van Teslaar's
Outline of Psychoanalysis and in the present volume, and need not be detailed anew.
It may not be true that every abnormality is but an exaggeration of what is found in the normal, but it is surely true of most of the common disorders. The recognition of the essential kinship which our own everyday life bears to that of the psychoneurotic and psychotic offers in fact the best augury for the protection of ourselves as individuals, and of society as a whole, from the encroachments of mental disease. For one thing, we shall in time give up the barbarous habit of treating sufferers from mental illness as beings inferior to ourselves. When the stigma attaching to abnormality has been removed, many will dare to seek relief from their inner queernesses who now dread the thought that another human being might know that "awful secret." In the second place the study of the overt forms of mental conflict and maladjustment helps greatly towards dispassionate recognition of one's own leanings, the analysis of one's own twists and foibles. When we can take these for what they are, patiently ferret out where they are leading us, and adjust ourselves to them, our security against mental disease is at its height. Not that we can, by any means, always do this alone. Mental conflicts and suppressions are often of such severity that we cannot ourselves discover their origin. We find ourselves irrationally bitter on some political or religious subject. It is well to spend some time quietly studying reasons we might have for such bitterness. Does our antipathy really arise simply from the conviction that another man's viewpoint is erroneous, or does it perhaps arise from a slight to ourselves? When we explain our conduct to ourselves in terms of a lofty devotion to duty, why do we experience a strange discomfiture upon recognizing that the absence of a tangible reward would leave us with no such inner-glow of satisfaction? Quiet self-analysis can do much.
If there is one clear principle of mental hygiene which stands out as a result of the psychiatry of the last forty years, it is the value of the Socratic maxim know thyself. For into thyself, gentle reader, the world has poured a frenzied multitude of influences, and from thyself come forth an equally complicated bundle of acts, almost all of which will be the happier the better they are understood. But almost equally clear is the principle that we can know ourselves well only through the indirect method of sharing ourselves, so to speak, with our friends or families. Introspective study of one's motives, for example, or even of one's prejudices, is often a rather unproductive process even when most conscientiously carried through. On the other hand, the process of taking off our daily masks and trusting our friends - or even our dogs - to show us hour by hour what we really are in terms of their reactions to us may accomplish very extraordinary results. Finding out what we really are is at least one important step towards finding out what we want to make of ourselves.
Now if in this process of self-study we become keenly conscious of worries, conflicts, lack of internal harmony, the chances are that the trouble lies in one fundamentally simple adaptive difficulty which occurs with almost deadening monotony in the life histories of all human beings. I should venture to say that abnormal psychology would lose most of its stock in trade if it had to give up this one commodity. I refer, of course, to lack of integration in the motives or impulses which control life. Personality seems to
the first naive glance to be a unity, the mystery of which is indeed so profound that it is easy to forget the possibilities which psychological analysis may offer. No personality is
really a unity. We are all at war with ourselves. The difference between the normal and the abnormal ordinarily lies, I believe, simply in the degree to which the unification or integration of our motives has been affected. Where there is abnormality, look for internal conflicts.
Again we are using "normal" in the sense of a "happily adjusted" life. The point is often made that certain abnormalities are the product of civilization. This is true in the sense that our wants become more complicated as our life becomes richer and more varied; and the more complicated the machinery the more room there is for conflicts. Insanity is rare in low-grade mental defectives. True mental derangement is almost never found in animals except when they are drugged, kept without sleep, or subjected to some terrific and prolonged strain. The appearance of abnormality may mean simply that the organism is one which is capable of many wants which have not learned to live together in the same body. This is one of many reasons for the insistence that he who suffers from an "abnormality" should feel no sense of intrinsic and inevitable inferiority to his fellows. We no longer believe that sickness is a proof of sin; but we are only gradually learning that abnormality of mind may be handled in an objective and matter-of-fact spirit, the fundamental humanity of each individual twist being much more obvious and important than the fact that the twist differs from other twists which for practical purposes we call normal.
But where and how do these conflicts between the fundamental motives or wants first arise? They are present at birth. The observer of any infant between birth and two or three years of age will constantly see such signs as these: A child has a habit of brandishing his thumb in the air whenever some one shakes his rattle; he also has the habit of sucking his thumb. One day in the midst of thumb-sucking the rattle is heard. Out comes the thumb immediately and is brandished aloft. But immediately weeping and wailing ensue, for somehow the thumb has been snatched away and it cannot be found. Brandishing and thumb-sucking are two fundamental satisfaction-getters, but the exercise of one undercuts the other. In time the conflict is adjusted by either of two fundamental mechanisms: unification of the two or elimination of one. Learning to brandish with the other thumb illustrates the first type; learning not to suck the thumb illustrates the second. Adult experience can do no more. But adult experience can handle the problem with much less pain than the child usually suffers in learning to handle his conflicts. The adult finds, ninety
percent of the time, that what has been a conflict and a source of misery can be resolved by patient study of the real mainsprings of the motive, what it is that is
really desired. To use a case of Holt's, the girl who has been taught that the theater is wicked is invited by some devoted friends to go to the theater with them. A conflict arises because two motives, filial affection and love of entertainment, appear to
be in conflict. If, however, the problem is really analyzed carefully, the basis for the parental opposition will be understood and the girl will find whether she really does or does not wish to classify all drama as bad. If analysis is carried one stage further and the real nature of filial affection is understood, it will even be possible to love the parents more deeply while looking upon life through one's own eyes rather than through theirs.
There remain, nevertheless, the ten-percent - or whatever you like - of instances in which motives are in arrant contradiction, and no more susceptible of unification than gluttony and starvation. Many of these direct conflicts are ordinarily handled by the method of evasion. The Freudian "suppression" is but one type of such evasion. Alternation between the conflicting motives is an equally common way of evading the solution of the problem; here appears, for example, the man who loses his temper every day, and tries to make up for it by giving the cat a double ration of milk in the evening. A large proportion, I believe, of what is called inconsistency in personality arises from conflicting impulses which have never been faced. When one has really decided what one most wishes in life-including, of course, what one wishes for those who are so close as to be "parts of ourselves" - there is no harm in the world in definitely weeding out and eliminating the unruly motive. There seems to be a general impression that such extermination of wishes is dangerous for mental health. On the contrary, such rational and deliberate solving of the conflict is in many
ways the best guarantee of mental health. It is only when we run away from the conflict or pretend not to see it that harm results; and harm comes not from the weeding out of the impulse, but from keeping it alive by feeding it daily with the energy of a baffled wish which we are unwilling to face clearly. Though the technique of mental hygiene be complicated, the basic principle is, I believe, very simple. Decide what you really want, and bend your energies toward it. What you really want is probably not much like the "ruby bush and diamond tree" which feature in your first day-dream after asking yourself the question.
You or some one of your friends may however find the storm of conflict blowing to a gale; any one of us may at any time confront a family tragedy or some harrowing situation which will cause at least a temporary mental upset. A few hints as to what to do in a case of mental disorder are therefore offered; and these remarks apply to anything from the recurrence of nightmares to the fear that one is going insane. First of all, unless you are certain that the trouble is purely of mental origin, get a thorough physical examination. I do not mean simply heart and lungs and blood count; I refer to a really careful study of your whole physical machinery. "Nervous breakdowns," worry, etc., are, for example, often the result of infected teeth; do not let the physician carry you around Robin Hood's barn in the search for "complexes" until you have first made sure (by X-rays, vitality tests, etc.) that you have no infected teeth or tonsils. Make sure also that you have no marked glandular imbalance (hyperthyroidism, etc.). Of course, even the most thorough physical examination may reveal nothing physically wrong; but get that assurance first. And if you find something physically wrong, do not assume that it is
necessarily the cause of the mental trouble. Get the teeth and so forth taken care of; but you may still want the mental factors carefully studied. In fifty or a hundred years psychiatry will probably be able to tell in nearly all cases from the nature of the disorder itself whether physical factors are contributing to it or whether it is purely psychogenic. Except in a small percentage of cases this cannot yet be done.
Now to get real help in straightening out such mental problems is not easy for most people. By all means, try to make contact with some physician who has specialized in mental disorders. To help you, he or she needs, of course, three cardinal qualities-intelligence, experience, sympathy. In the larger cities you have a choice among numerous psychiatrists. In a small city or in the country you will probably have to rely on. your general practitioner. A good general practitioner is, of course, much to be preferred to a cranky or dogmatic psychiatrist. By the way, it is really quite important to ask your psychiatrist early in the treatment regarding the fees; it is particularly unfortunate to have uncertainty and worry about money matters injected into the rather close personal relationships which must of course develop in any long and careful study of individual problems.
A final word about maintaining mental health and about making use of a psychiatrist's help. You may look at the job from the standpoint of patching up a source of annoyance or from the standpoint of creating something new, - namely, the happiest person you are capable of becoming.
Traditionally the task of the physician has been to heal, and it is only within the past generation that a serious social endeavor has been evident in the direction of preventive medicine. We find ourselves going beyond "public health work" to grapple seriously with the problems of exercise, diet, periodical examinations, and so on, which will make the physician and the dentist essentially guardians rather than repairmen. The same movement is very evident in the field of mental hygiene. We are at last grasping the elementary and obvious fact that mental health can in large measure be guaranteed by careful and intelligent shaping of the
child's personality so that he may be able to withstand life's tempests.
But just as a physical health program means not merely the avoidance of illness but the attainment of something positive, a robust and joyful physical existence, so the concept of mental health means not merely the avoidance of breakdowns, but the eager acceptance and utilization of every constructive element in the shaping of a vigorous and happy personality. It is here that the trifling and pica-yune admonitions of a "play safe" policy are apt, through their lack of vision, to miss magnificent opportunities. The child does indeed desperately need protection from warping influences, but he has just as urgent a need for freedom to develop, to be his most earnest and his happiest self, and to express without interference the interests and urges which mean most to him. Surely modern education has shown in a thousand ways that a child lives best and learns best when he is free from the cramping confinement of the adult's way of learning and acting. It is by no means an easy matter to combine such opportunity for freedom with the need for protection which we just noted above; and harder still to combine these two with the imperative need of saving the child from a reckless individualism in which his wishes will clash throughout his life with the wishes of similar individualists. In short, we are realizing that the jobs of the educator, of the mental hygienist, and of the parent are inextricably interwoven, and that every one of them is a job requiring all the brains and all the experience which can be brought to bear.
Note:
The
article above first appeared in "An Outline of Abnormal Psychology"
edited by Gardner Murphy (The Modern Library, 1929).
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