Churchill's Black Dog and Other Phenomena of the Human Mind

by Anthony Storr

  Psychiatrists, therefore, tended to be men of little professional distinction. There were honorable exceptions: men like Tuke and Connolly in England or Pinel in France, who were responsible for replacing brutality with enlightened regimes for lunatics; but psychiatrists in the nineteenth century were all too often indolent failures content to carry out a perfunctory “round” of their charges once a day and to spend the rest of their time playing cricket. The idea that such men had a special role to play in society other than that of seeing that their patients were safely confined and treated with reasonable humanity would not have occurred to anyone.

  The custodial role of the psychiatrist is still important. In England in 1978, the Department of Health and Social Security estimated that there were 79,165 patients resident in mental illness hospitals and units, representing a rate of 171 per 100,000 population; 26 percent of all hospital beds were occupied by patients with mental illness.2 In 1975, 193,000 people were inpatients in the state and county mental hospitals of the United States. Another 75,000 were patients in private and federal hospitals.3 These figures are not often appreciated by the general public. During the last twenty years, advances in the discovery of tranquilizing drugs and other physical methods of treatment have made it possible for a number of patients to live outside mental hospitals who would formerly have had to remain as inpatients. The news media have publicized this and given the public the false impression that the mental hospitals are rapidly emptying. The figures belie this hopeful supposition.

  Although there is certainly a more rapid turnover of patients than there was, many of those discharged are readmitted and there remains a chronic core of patients who are unable to take their place in the ordinary community. How far this chronicity is the consequence of living in a hospital is as yet undetermined. On both sides of the Atlantic a great deal still requires to be done to transform mental hospitals from places of confinement into truly therapeutic institutions; to integrate these hospitals into the community; and to prevent the deterioration which inevitably occurs in persons deprived of liberty who are confined for any long period in any institution.

  It is worth noting that, in England, four-fifths of those admitted to mental hospitals are “voluntary patients”; whereas, in America, four-fifths of admissions are involuntary. American psychiatrists working in public mental hospitals are, therefore, compelled to assume the distasteful role of jailers to an even greater extent than are their British counterparts.

  That there is bound to be some conflict between the roles of therapist and jailer is obvious. What is not so generally realized is that society’s greater appreciation of the possibilities of psychiatric treatment has resulted in an increased threat to personal liberty. We shall return to this topic at a later point.

  Around the beginning of this century, society’s attitude to psychiatrists began to change; very largely because of the rise of psychoanalysis. Psychiatrists started to emerge from their remote seclusion in mental hospitals to become, increasingly, the guides and mentors, not of the insane, but of those troubled people we call neurotic. The popular image of the psychiatrist changed from that of jailer to that of crank or eccentric; a label which has, with some justification, been attached to him ever since. However, as with other eccentrics in other societies, psychiatrists tended to become invested with special, almost magical powers, supposedly gained from dredging in psychic depths to which no ordinary person would care to descend. It was even assumed that their new knowledge of human nature could somehow come to embrace the whole range of human affairs and be used to transform society. Gradually these eccentrics began to be consulted by persons from the upper strata of society; partly because no one else could afford their fees, and partly because psychoanalysis and its offshoots had an intellectual appeal to which the less educated were unable to respond. This tendency was further underlined by the fact that the psychoses, to which psychoanalysis has but a limited application, occur more commonly in the underprivileged; while neurosis, though no respecter of class, is more often found among the sophisticated and complex. In Europe, and later in America, psychoanalysts began to be consulted by intellectuals; a social phenomenon to which, perhaps, too little attention has been paid. On the face of it, it is surprising that the highly educated and socially secure should have apparently demeaned themselves so far as to seek analytical help at a period when self-esteem, far more than today, depended upon position in society. It is, I think, no coincidence that this phenomenon should have been contemporaneous with the decline of belief in conventional Christianity and with the dissolution of a class structure based upon land and family in favor of a less secure hierarchy based more upon the acquisition of wealth. Nowadays, we take it for granted that psychoanalysts will be consulted by distinguished figures, from politicians to philosophers; but in the 1900s it must have seemed an odd thing to do to those who were brought up to think that they were the elite and that no one else was likely to know more than themselves about human nature and the conduct of human relationships and human affairs in general.

  Moreover, the idea of progress, of a general tendency towards the improvement of society and the world in general as a result of increasing civilization, so dear to the Victorians, was still operative. Disillusion with Western civilization had not yet overtaken its protagonists, nor had anthropology revealed that so-called “savages” might be better adapted to their environment than we to ours. Psychoanalysis, as it gradually gained recognition, was regarded as a scientific discovery on a par with the discovery of radium or the like; a way of ameliorating man’s lot by abolishing neurosis. Freud himself was no utopian. Indeed he became increasingly pessimistic about psychoanalysis as a therapeutic method, though remaining convinced of its scientific status. Many of his followers, however, both in the early days and even today, believed that psychoanalysis was far more than a therapy designed to relieve a few neurotic sufferers. Melanie Klein, for example, writes in one passage of her hope that child analysis will one day become universal.4 Admittedly, she refers to this hope as “utopian”; but even to imagine that “child-analysis will become as much a part of every person’s upbringing as school education is now” is an extraordinary flight of fancy.

  This tendency towards utopianism has persisted to some extent among psychoanalysts, although it is probably rather less than it was. It is reinforced by the fact that many analysts lead isolated, dedicated lives, seeing few people other than patients and colleagues, and playing less part than most other professional men in public affairs. It is easier to sustain the belief that one has the answer to the universe if one has no idea how the universe works. Psychoanalysis is primarily an interpretative discipline; a method of making sense out of the previously incomprehensible, and a way of helping individuals to understand themselves better. Although Freud did apply psychoanalytic interpretation to social phenomena to some extent and, for example, conducted correspondence on the subject of war, he was never unrealistic enough to suppose that a method of individual treatment of neurosis could readily be transferred to solve all the problems of society.

  That psychoanalysis has not proved to be a universal panacea, nor even the therapeutic success for which enthusiasts hoped, does not mean that psychiatrists and psychoanalysts have nothing to contribute to the study of society. It is a truism to say that society is composed of individuals and that political institutions are, or in an open society should be, designed to promote the well-being of society’s members. What constitutes individual well-being and what best contributes to this end are both arguable matters. Whether the health and happiness of individuals is best achieved by material prosperity, by sexual fulfillment, through faith or through agnosticism, by being reared in a kibbutz or in a small family, by being encouraged to be, or discouraged from being, competitive; all these and many similar topics are themes to which the psychiatrist may legitimately address himself and upon which he is entitled to something of a special hearing because of his intimate knowledge of the emotional
problems of individuals. It does not, however, follow that he should therefore be regarded as an expert upon education, the control of crime, the resolution of color prejudice or the abolition of war. To all these subjects, the psychiatrist has something to contribute, but it is a limited contribution, derived from his experience with comparatively few individuals.

  The analytical treatment of neurotics takes a very long time; which is one reason why psychoanalysis has so far been available, with very few exceptions, only to the privileged rich. This state of affairs is bound to create the hope, however utopian, that if only greater resources of time, money, and trained personnel were provided, many of the misfits in society could be better fitted to take their place in it. Moreover, this hope contains the unspoken assumption that psychoanalysis, or some such psychotherapeutic method, is likely to be as effective a treatment for social deviants as it is for neurotics; and that, if only all criminals, drug addicts, sexual perverts, and the like were treated as patients rather than offenders, their problems and the problems they create would be solved. Hence, there is a strong tendency to exaggerate what psychiatric treatment can accomplish and to suggest that more facilities for treatment exist than is in fact the case. Readers of Popper’s The Open Society will be familiar with his thesis that utopianism inevitably leads to tyranny. The present tendency in society to idealize the therapeutic approach to misfits is a good example. I do not mean to suggest that, were greater resources available, nothing further could be done for the mentally ill. There is an enormous amount which could and should be done but, as things are at present, the resources do not exist, and psychiatrists are being asked to undertake more than they can possibly accomplish and to direct their therapeutic efforts towards a clientele who are less likely to respond to their efforts than are neurotics who seek help voluntarily. This has led to a number of abuses, of which unnecessary deprivation of liberty is the most obvious. It has been demonstrated that, as one might expect, the majority of psychiatrists and psychoanalysts are mildly left-wing, liberal, and anti-authoritarian. It is perhaps paradoxical that the therapeutic approach to persons who would, in previous generations, have been considered wicked or feckless has resulted in a decline in liberty, but such is the case. In what follows I am heavily indebted to The Right to Be Different by Nicholas N. Kittrie.5 It is significant that a professor of criminal law should be moved to write such a powerful indictment of what he calls the “therapeutic state.”

  In his book, Professor Kittrie demonstrates, with a wealth of examples, that misplaced therapeutic enthusiasm has led to many persons being confined for indefinite periods with few of the safeguards against wrongful confinement which are available to criminals being effectively operative. Thus, thirty-three U.S. states have laws allowing the indefinite commitment of drug addicts to therapeutic institutions from which they can only be released if “cured.”6 Since, even after extensive exposure to the best treatment programs, only about 3 percent of addicts remain abstinent after release, it is obvious that many persons are being confined indefinitely upon false premises.

  It is surely the duty of the psychiatrist to society to point out that he has, as yet, no effective method of treating the personality disorder which, it is generally agreed, underlies the phenomenon of addiction to narcotics; and, while pursuing research which may lead to effective treatments, it is his duty to refuse to act as jailer for those he cannot as yet help. He might add that, in the recent exacerbation of anxiety about the taking of drugs, it is often forgotten that the legal control of narcotics is of very recent origin, as is the supposition that crime and addiction are necessarily linked. Before 1914, there were no laws in the United States regulating the traffic in narcotics, and there is little doubt that, in the U.S., the association of drug addiction with crime is the result of punitive legislation.

  In Great Britain, the poet Crabbe took opium for over forty years; yet it did not interfere with his literary output and he died at the age of seventy-eight. Wilkie Collins took increasing doses of laudanum (tincture of opium) from 1862 to his death at the age of sixty-five in 1889. His novels may have deteriorated but he did not cease production. Addiction to even heroin and morphine does not cause as much physical damage as does addiction to alcohol; and it is often preferable, as the law allows in Britain, for addicts to be allowed to obtain a regular dose of narcotic upon prescription than to try and fail to forcibly wean them from it.

  Similarly, in the mistaken belief that psychiatrists can cure large numbers of alcoholics of their addiction against their will, twenty-six U.S. states have laws which allow the commitment of alcoholics to institutions from which release is conditional upon cure.7 Since the treatment facilities available fall far short of what is required, the effect of this compulsion, intended as a liberal, therapeutic device, is simply to extend the period during which an alcoholic offender is confined, without in fact improving his condition. This is, of course, not to argue that no alcoholics can be cured. Some can and are helped by psychiatric treatment to achieve and sustain total abstinence; but, in my limited experience, this is entirely dependent upon the voluntary cooperation of the alcoholic.

  More dubious still are the laws determining the confinement of so-called “psychopaths”; a category of mental abnormality so hard to define that “a 1950 New Jersey report cited twenty-nine different definitions of the condition by twenty-nine medical authorities.” At least twenty states have made use of statutes relating to psychopaths, with the result that mental institutions are overloaded with people for whom they have no effective treatment. Kittrie gives examples of offenders guilty of only trivial offenses—for example, indecent exposure—who have been committed to institutions for indefinite periods. I will add one example from Great Britain. The Mental Health Act of 1959 unfortunately included provision for the forcible confinement of psychopaths. In the words of the act, psychopathic disorder is defined as “a persistent disorder or disability of mind (whether or not including subnormality of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient and requires or is susceptible to medical treatment.”

  In 1968, Eric Edward Wills, aged twenty-one, who had been charged with larceny and with obtaining money under false pretenses, was sent to a mental hospital for a report. He was there diagnosed as a psychopath. The medical report submitted to the magistrate revealed that he was a compulsive gambler and recommended that the operation of prefrontal lobotomy be performed upon him. The magistrate promptly ordered that this operation be carried out. Fortunately, the press heard of the case, realized the implications, and the decision was rescinded.

  Deprivation of liberty on the grounds of insanity, whether or not accompanied by the intention of enforced therapy, is also open to abuse. In the Soviet Union, confinement in a mental hospital may be instituted if the “patient” is regarded as being a “public danger.” More particularly, Soviet law allows for forcible commitment if an individual is said to suffer from a “hypochondriacal delusional condition, causing an irregular, aggressive attitude in the patient towards individuals, organizations or institutions.” Even more sinisterly, the law recognizes that “externally correct behavior and dissimulation” may mask what is supposed to be the individual’s true intention.

  It is well known and amply documented that mental hospitals are used in the Soviet Union to confine persons who are thought to be hostile to the regime; and that psychiatrists have cooperated in this misuse of their medical function. Perhaps some psychiatrists are such dedicated Communists that they do in fact believe that anyone who does not share their faith must be insane. Others may well be threatened with dismissal and loss of livelihood if they do not agree to treat as patients those whom the government wishes to remove from society. As readers of A Question of Madness by Zhores and Roy Medvedev will know, whatever the reasons may be, it is clearly not difficult for the Soviet government to find psychiatrists who will cooperate.8

  In the West, it is less likely
that individuals are wrongly committed to mental hospitals on purely political grounds, although the cases of Earl Long, the governor of Louisiana, and, more especially, of May Kimbrough Jones, both quoted by Kittrie, must give rise to doubt. But it is very easy indeed for individuals to be judged insane upon dubious criteria; to be committed indefinitely to mental institutions where they will receive no treatment; and to be deprived of liberty, perhaps for life, in spite of the fact that they may be causing no harm to themselves or to anyone else.

  In the United States, Thomas Szasz, a psychoanalyst, has propounded the thesis that the inmates of mental hospitals are the scapegoats of society, fulfilling the same function for society as did witches in the Middle Ages. He believes that any form of coercion applied to the so-called mentally ill is unjustifiable and that the psychiatrist’s function should be confined to elucidating the “problems in living” of those who voluntarily seek his help.9 This, to my mind, is oversimplifying the issue. There are a number of persons in any society who are, and should be, regarded as mentally ill and who may, unfortunately, require confinement against their will, at any rate temporarily. In his essay on liberty, John Stuart Mill wrote: “The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.”10 Although Mill admits of some modification of this principle in the case of juveniles, he does not really consider the case of the mentally ill, in spite of the fact that, in a footnote to a later passage of the essay, he has sharp observations to make about the inadequacy of the evidence as to insanity which is often accepted by jurors. According to Mill, it would obviously be right to certify and confine an individual who was suffering from paranoid schizophrenia and threatening to murder his imagined persecutors. (In this connection it is of interest to note that acute paranoid episodes, in which individuals go berserk and do in fact kill others, are among the few forms of mental illness common to all cultures and are universally recognized as calling for the forcible restraint of the sufferer.)