IT is with great pleasure that I accede to the kind request of Dr. Frankwood Williams to say something about the possible relations between the mental-hygiene movement and the psychological and therapeutical method originated and developed by Freud and called psycho-analysis. For a long time I have been convinced that the importance of those relations has, generally speaking, been too little appreciated. The literature of psychoanalysis has been concerned chiefly with the investigation of neuroses, from which it obtained all its new knowledge. Although this knowledge has at times been applied to the psychoses also, the analysis of the psychoses has remained only applied psychoanalysis, as it were; it has not developed into an independent source of knowledge.
It may nevertheless be asserted that psychiatric science has profited much by the analytic point of view. Before Freud’s time psychiatry was not based on psychology. Attempts were made to ascribe the symptoms of mental disease to anatomical changes in the brain. But such attempts were only half successful, and then only in connexion with certain deficiencies in severe organic lesions of the brain (psychotic disturbances in cases of brain tumours, multiple sclerosis, after repeated paralytic strokes, after inflammation of the brain, and in cases of progressive paralysis and senile dementia). All the so-called functional psychoses—mania, melancholia, paranoia, dementia praecox, and hysterical psychosis—remained inexplicable from an anatomical point of view, however much one tried to prove that specific microscopical changes took place in those disorders. The expression ‘functional’ served merely to veil our ignorance. How could we be able to give the slightest explanation of the pathological change in the functioning of the psyche when we did not know anything about its normal functioning? Instead of remembering that fact, the authors of psychiatric manuals indulged in fancies about invisible cellular and even molecular changes, which were supposed to be at the bottom of the psychoses. Not one psychiatrist thought of looking for psychological explanations of the psychotic symptoms.
Holding those fixed views, they of course took very little interest in the psychic contents of the acts and expressions of insane persons. These appeared to them to be merely inessential phenomena, attendant on the supposed molecular or functional change in the organ, which, at most, they used as a means for diagnosing the case or giving it the proper label. The psychic performances of the diseased were marked as ‘confused’, ‘disconnected’, ‘mannered’, ‘stereotyped’, ‘fickle’, and even as ‘incoherent’ and as ‘verbal salads’, and were shown to students and visitors of insane asylums almost as if they were curiosities.
The influence of psycho-analysis has brought about fundamental changes in this field. Freud taught us that the ‘psychoses’ manifest themselves not simply as the consequences of a psychic ‘shock’ (which idea was still based, though not admittedly, on the analogy with physical trauma and concussion of the brain), but that their symptoms are the final result of an inner psychic struggle between opposing tendencies. That inner struggle, which in neurotic persons ends in ‘repressions’ and the formation of neurotic symptoms, is something that so-called normal individuals may also observe directly in themselves by pure introspection. The consequence was that in the first place the neurosis was made accessible to introspective investigation and to therapeutics, and secondly that the partition wall which had been thought of as dividing healthy from neurotic individuals disappeared. Further progress in the investigation showed that the wall separating neurosis and psychosis must also be torn down, and that even the most singular acts and mental processes of the insane are to be reduced to psychic conflicts, analogous to those which exist in ‘normal’ individuals also. The conduct, too, of insane persons ceased to be senseless and their expressions ceased to be ‘verbal salads’; the skilful interpretation of their contents created the possibility of relating even the most scurrilous and confused words of the insane to those frequently tragic conflicts which are understandable by all of us.
The mental activity whose psychic analysis completely removed the chasm between insanity and mental health—which had hitherto been thought unbridgeable—was the activity of the psyche in dreams. Even the most normal individual is in a sense psychotic during the night; he has hallucinations; his logical, ethical, and aesthetic personality is completely changed in most cases in the direction of greater primitiveness. Formerly science consistently explained the dream also as an insignificant phenomenon accompanying molecular or other changes of the brain during sleep. But when Freud interpreted the first dream—i.e. made it understandable in spite of its senseless make-up—the statement that the sane and the insane could not be compared had to be dropped. The fact that all of us recognized in ourselves the possibility of performing the psychic acts that we call insane was immensely important for the treatment of the unfortunate victims of insanity. The psychiatrists began to pay attention when the insane individual said or did something strange; they began to interpret his conduct and to search for comprehensible associations between the disconnected words of his flow of thoughts; they tried to recognize in the shapes of his visions, in the voices of his auditory hallucinations, the pathogenetically important persons of his life’s history. It was by this step that psychiatry freed the insane from their tragic isolation. If the humanitarian spirit of the nineteenth and twentieth centuries did in fact relieve the insane of their chains and drag them forth out of their cells, of what avail was it if they were to remain as before mentally isolated and misunderstood? It was only after their expressions, too, became recognizable as representations of general human tendencies—i.e. after we began to understand the language of the insane—that these latter really were accepted as members of human society.
As far as I am informed, one of the main objects of the mental-hygiene movement is to better the lot of the insane, to facilitate their return to ordinary society. The hope exists that psycho-analytical investigation, by penetrating still deeper into the mechanisms of these forms of disease, will in time produce results in the cure of psychoses similar to those which have been produced in our days in the treatment of the psychoneuroses (hysterias and compulsion neuroses). In any case psycho-analysis is at present the only practicable road to the understanding of ‘functional’ mental diseases, and that understanding could even to-day contribute much to the improvement of the condition of the insane. I therefore think I was right when I asserted at the beginning of this paper that there are bonds of relationship between the aims of psycho-analysis and those of ‘mental hygiene’. Ways and means should be found to promote those common aims by co-operative exertions, and that will also be the most dignified manner of celebrating the birthday of the scientist who made such progress possible.
Co-operation might take two forms: some of the most experienced analysts should be given an opportunity to devote themselves for a lengthy period to the study of psychoses in sanatoria, and scholarships should be founded for physicians attached to institutions, to enable them to make use of the facilities available for psycho-analytical training.
1 English original: Mental Hygiene (1926), 10, 673.