WHAT REALLY IS MENTAL ILLNESS

The mental processes here described are complex and difficult to untangle in individ­ual cases, but they are not mystic and com­pletely unfathomable. Mental illness does not strike without warning. It is the cul­mination of unsuccessful reactions to life problems and long-time failure to adjust to real-life situations.

A precipitating factor in the illness can usually be identified. Often it is the depriva­tion of a source of emotional support a be­loved spouse, parent, or child. Psychiatrists also identify an "old-sergeant syndrome." This apparently tough-minded army person­ality breaks down emotionally when all the individuals upon whom he has previously depended are one by one removed by com­bat or transfer. The ability to rise above grief  and   snap   back   from   deprivation   is one of the hallmarks of the truly mature person. Over prolonged grief at the loss of a loved one unfortunately (and needlessly) embitters many lives.

As against the precipitating factors in mental illness, there are a host of predispos­ing factors. The most important of these can be summed up as current physical condition and all previous emotional experiences, espe­cially the emotional conditioning in infancy and childhood.

CAUSES OF MENTAL ILLNESS

Mental illness, thus conceived, is a reaction to external and internal stress. In much the same way fever is a reaction to the presence of infecting microorganisms in the body. The stress goes beyond the breaking point of the individual's particular personality structure. Even the most stable personalities have a breaking point—as World War II experiences often revealed.

When we seek the causes of mental disease, therefore, we must look first to the underly­ing personality structure of the individual in whom the disease appears. Of course, the search does not stop here. Whatever else may be said about the causes of mental illness, this much is clear: multiple factors are in­volved. It is misleading to attribute them to a single cause or to one traumatic event of childhood.

It is sometimes easier to put a finger on the immediate, precipitating causes of mental breakdowns, but even here great caution in the interpretation is necessary. Situational stresses or external events may precipitate the difficulty as in a sailor, shipwrecked in icy waters and picked up nearly dead from exposure, or in a young woman jilted by an intended husband. In some instances constant exposure to a "psychogenic," "emotionally contagious" individual, like a tyrant boss or parent constantly getting on other people's nerves, may either precipitate or predispose to mental illness.

In tracing the causation of mental illness, physical factors, reflecting the intimate rela­tionships of mind and body, must always be considered. In a certain percentage of the cases actual damage to or destruction of nerve cells in the brain can be located. But in a far larger percentage, and to some extent in all cases, purely psychological mechanisms and stresses are at work.

A distinction can be made between "or­ganic" and "functional" mental illnesses. In the "organic" class some definite and presum­ably primary damage to the nerve tissue of the brain can be demonstrated. In the "func­tional" cases, no such injury can be found.

Among the causes of direct damage to the brain can be listed infections, meningitis, syphilis, head injuries (trauma), drugs in­cluding alcohol used to excess, poisons, tu­mors, and hardening of the arteries in the brain (causing "little strokes," which are part of the aging process). Late syphilitic infection is responsible for general paresis. Alcoholic psychoses, which include delirium tremens, are typical of brain damage and malfunction induced by drugs or poisons.

WHAT REALLY IS MENTAL ILLNESS

Mental illness can be described as the exag­geration of personal feelings and consequent behavior to the point where it strikes other people as queer, odd, abnormal, annoying, or dangerous. The distinction between mental health and mental illness is, as we have al­ready noted, a very practical one: a person is mentally ill to the extent that he cannot love or work. Obviously, then, there are all degrees of mental illness, ranging from the very mild to the exceptionally severe.

Two other practical criteria (but not very accurate ones) for evaluating the severity of mental illness can also be set down: (1) Does the victim feel bad enough to seek profession­al or outside help for his distress? (2) Does the physician, usually a psychiatrist, who diag­noses his condition believe that he will benefit by hospital treatment or require hospitalization because he is a risk to himself or a danger to other people?

We have, then, three general classes of mentally ill people. The first, and by far the largest, comprises the millions of odd. emotionally disturbed, continually unhappy peo­ple who stumble through miserable lives without getting or accepting real help for their illness. Many of them are actually sicker than those who see physicians or go to the hospital.

The second class of mentally ill are those who have at least identified their need, often desperate, for help and have sought it. Most neurotics fall in this category.

The third, and smallest, class or group of mentally ill includes those who require or will benefit by hospitalization. A very high proportion of this group are definitely, if tem­porarily, psychotic. This is the class of pa­tients who are generally thought of and shunned as "the mentally ill," but they make up only a small fraction of the total.

The mentally ill are not so evidently differ­ent from mentally healthy, or "normal," peo­ple. Indeed, they are often the same people at different times. When a person finds he can­not eat, sleep, concentrate, or get along with other people for days on end, he is on the road to or in the throes of mental illness and needs help. Mental illness is emotional rather than mental (or intellectual) in origin and content.

It is possible, therefore, to regard mental illness as an extreme protective device adopted by the ego to shield itself from deeper hurts by unconscious conflicts and bludgeoning. To be sure, the cloak of illness is a very poor form of social adaptation and no shield at all against societal disapproval. But for the individual caught in the trap of his own in­ternal emotional strife, mental illness seems for a time at least the best way out of his un­consciously engendered difficulties.

We say "for a time" because the unconscious threats and situational stresses to which mental illness is the response may in time subside, with a disappearance of the symptoms of illness, or the patient may be gradually educated to a better solution than illness to his deep-seated fears. But when he dons the cloak of illness, the patient is saving himself from the inner threat of unthinkable annihilation or deprivation. The illness is an escape. Still when the mind shuts the door on reality, to be governed by inner voices, it is sometimes shut forever.

Types And Classifications Of Mental Illness

Manic-depressive psychoses involve extreme swings in mood, far beyond the essentially normal feelings of elation or depression. (Ev­eryone has some mood swings.) The hyper-manic may talk incessantly, pursue a flight of ideas, and sometimes require restraint for his protection. In acute depression the patient may feel so guilty, project so much anger upon himself, that he does not want to con­tinue living. He may absolutely refuse to eat and may plan or attempt suicide. The manic stage can be likened to reactions beyond those more commonly observed as extroversion. Manic-depressive reactions often, but not necessarily, move in a cycle. For weeks, months or years the person is depressed; then, for no apparent reason he feels unduly elated — and vice versa. The intellectual and emotional faculties are not impaired.

Related to the depressive phase of the cycle is the condition known as involutional melancholia, which usually occurs in women at the menopause.

Senile dementia describes the childishness of old age, the deterioration of mental and emotional facilities that sometimes accompa­nies the aging process. Often, however, there is some actual damage to the blood-vessels of the brain. This condition rarely occurs be­fore 60.

Hysteria describes the neurotic reaction characterized by lack of control over acts and emotions and by conversion of inner anxiety into physical symptoms (e.g. hysterical pa­ralysis

"Shell shock" was a term used in World War I. as was the term "combat fatigue" in World War II, to describe an essentially hys­terical psychosomatic reaction to military situations involving danger. The soldier's ego seeks to be removed from and escape the zone of danger without disgrace. "If you're sick, you can't fight," runs the winning argument in the unconscious mind.

"Nervous breakdown'' is a popular phrase used to describe almost any kind of mental illness, mild or severe, which incapacitates an individual and compels him to retire from his regular work or haunts. In a more professional vocabulary the milder breakdowns are often described as neurasthenia, psychasthenia, anx­iety state, or mild hysteria

Psychopathic personality is a vague term used to denote individuals who have no par­ticular mental disease but who cannot adjust themselves morally, socially, or legally to their environment. A high proportion of crim­inals vagrants, and delinquents fall into this category.

Particularly to be deplored is the label "psy­cho" on any individual who has ever suffered a mental illness. Careful study of the inti­mate lives of great and famous people reveals that many of them at one time or another suffered from some form of mental illness. Abraham Lincoln, for example, was subject to deep fits of depression.

More than half of all hospital patients are in mental hospitals, and more than half of these are suffering from schizophrenia. Most of these patients (90%) are in state hospitals, of which there are about 600 in the United States. Most of these are large hospitals, with 2000 to 12,000 beds, and most are badly overcrowded and woefully understaffed.

The cost of caring for these patients is high. Approximately 25% of the income of some states must be appropriated for the care of the mentally ill (and the feeble-minded). It costs United States taxpayers over $1 billion a year —or about $3 million a day —to care for mentally ill patients. In strange contrast, rel­atively few millions yearly are spent on research in mental illness.

Types And Classifications Of Mental Illness

Basically mental illness is classified by the severity of its symptoms, by the degree to which they incapacitate the patient for nor­mal living. Broadly and popularly, then, we speak of two major categories of mental illness: psychoses, which are the severe types of mental illness that often require a period of hospitalization; and neuroses, the less ex­treme forms of personality derangement. The difference between psychoses and neuroses is one of degree. The words "psychoneurosis" and   "neurosis"   are   used   interchangeably.

The   psychiatrist, of course,  makes more extensive and exact diagnoses and uses more elaborate descriptions of mental illness. The American Psychiatric Association has a classification of about 60 categories of mental illness, but there is a strong trend toward avoiding categorical diagnosis of mental ill­ness. As Karl Menninger has pointed out, patients recover from their mental illnesses but not from their diagnoses. It is preferable, therefore, to speak of "schizophrenic reac­tions" rather than schizophrenia. Since the diagnosis of mental illness is a job for the psychiatrist, not the college student, we shall limit the further description of mental ill­nesses to the few broadest types.

Schizophrenia, sometimes called dementia praecox, is the most common of the serious mental illnesses and the one for which hospi­talization is most often required. Literally the term means "split personality." Emotional disorganization is the hallmark of this condi­tion. The victims may be unaccountably sad or happy; they do not respond appropriately to real-life situations; they are withdrawn and usually apathetic; they are ready to day­dream their lives away; they often suffer from fantastic delusions and hallucinations. Delu­sions are false-fixed ideas; hallucinations are imaginary voices or visions.

Some schizophrenics act and talk silly and childishly, without orientation to time and place; others fall into a stupor or a state of muscular rigidity; still others go into a frenzy of excitement or overactivity. But mostly they withdraw draw from reality, and attempt to live in little worlds of their own.

Generally speaking, schizophrenics do not lose their mental capacities, as measured by I.Q. tests, but their intelligence is divorced from other phases of their personality. Schizo­phrenia usually develops gradually and is gen­erally apparent before the age of 40. The outlook for schizophrenic patients has im­proved in recent years.

Important recent research in the cause and treatment   of   schizophrenia   offers   greater promi.se than ever before of a "break-through" in the management of this tragic and crip­pling illness. For example, an unusual serum factor has been found in the blood of many schizophrenics. This suggests the possibility of an antiserum or other drug to combat the illness. Progress is also being made in ac­quiring basic information about childhood schizophrenia and ways of treating it  partially through family interviewing and counseling. When the disease appears in young children (under six), it is important to distinguish between childhood schizophrenia and mental retardation The schizophrenia may be curable.

Paranoia describes a state of mental illness characterized by persistent delusions of gran­deur or persecution. It is related to schizophre­nia but far less common. Many paranoiacs are "rational" on all subjects except one or two on which they have some irrational fixed idea. There are many paranoid personalities among people who are not hospitalized for mental illness. Adolf Hitler, for example, was one of the world's most dangerous paranoiacs.

Types And Classifications Of Mental Illness

With the introduction of new drugs and treatments, the outlook for patients in mental hospitals is steadily improving. In the best mental hospitals the improvement and recov­ery rate runs as high as 85'/i More and more patients can now be successfully treated on an out-patient basis in mental hospitals, in psychiatric wards or departments of general hospitals, in mental hygiene clinics, and in physicians' offices.

The present situation with mental hospitals is that the number of admissions, first and repeated, is continuing to rise. Rising also, however, are the number of discharges. The average length of stay and the total popula­tion of the hospitals are therefore both de­clining. As we empty mental hospital beds of young psychotics. however, these beds are immediately filled up by the aged. The geriat­ric problem is the big one. (Geriatrics means care of the aged.)

Who Treats Mental Illness?

Who treats mental illness? There is such a shortage of adequately trained physicians and psychiatrists and such a host of troubled peo­ple in the world that the treatment of mental illness has perforce fallen into many hands, some well qualified, many not. Lee R. Steiner, who has studied for many years the question of where people take their troubles, points out that they take them not only to psychiatrists and physicians but also to clinical psychologists, psychoanalysts, social workers, ministers, rabbis, priests, marriage counselors, vocational counselors, guidance counselors, bartenders, beauticians, fortune tellers, astrologers, and a miscellaneous as­sortment of self-appointed experts and char­latans. Steiner's most trenchant observation is that the outcome of treatment appears to depend more on the rapport, or personal rela­tionship, established between the patient and his "healer" (therapist) than on any other factor.

The psychiatrist, of course, is the best-qualified person to treat the whole range of mental illness and certainly the psychoses. All psychiatrists are doctors of medicine (M.D.'s) who have taken postgraduate train­ing in their specialty. Most are certified as medical specialists by the American Board of Psychiatry and Neurology. There are, how­ever, less than 20.000 psychiatrists in the whole United States. Not all psychoanalysts are M.D.'s.

TREATMENT OE MENTAL ILLNESS

The modern psychiatrist has many strings to his bow for treating both mild and severe mental illness. The oldest is hydrotherapy (water treatment, of which bathing in warm springs and the "ducking stool" are ancient examples) The latest are the new drugs, the ataraxics. introduced in the 1950's. The most disputed is psychoanalysis, which took root in the 1900's.

The type of treatment selected, or attempted, depends on specific diagnosis, length and severity of the illness, and the personality structure of the particular patient

Central to all types of treatment is psycho therapy, which essentially means purposeful conversation between the patient and his therapist. This includes directive and non-directive counseling, reassurance, group ther­apy, hypnosis, confession, orthodox Freudian psychoanalysis, and theoretical or practical ("short-cut") modifications of it.

Most of the short-range methods of psycho­therapy are called suppressive; they attempt to drive conflicts so deep into the unconscious mind that they are no longer troublesome. Many so-called "miracles" and faith cures are suppressive psychotherapy. They are usually most effective in caset of conversion hysteria. For example, in hysterical paralysis, a lame patient may visit a famous shrine or get a great shock, throw away his crutches, and walk again.

The power of suggestion can also be a pow­erful force in legitimate mental healing. (It is often employed by quacks too.) Suggestion is sometimes so effectively used in treatment (e.g. of hysterical paralyses) that the results seem "miraculous."

Expressive psychotherapy is something else again. Here the patient is encouraged to talk about himself, his problems, his thoughts, feelings, dreams, and inner conflicts to the extent that he is or becomes aware of them. The goal here is re-education of the patient, particularly to help him find a changed per­spective  toward  himself and  other  people.

Psychoanalysis

Psychoanalysis is the prototype of all forms of expressive psychotherapy, but it is only one of many kinds of psychotherapy. Pioneered in theory and practice by Freud, it established the vital importance of the unconscious mind and its anxious conflicts. It remains the basis of all psychodynamic psychology despite modifications by Adler, Jung, Rank, Horney, Sullivan, and many others.

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In directive counseling, which attacks pri­marily the patient's conscious worries about his immediate real-life situations, the coun­selor does most of the talking. He often tells the patient directly what he thinks the pa­tient ought to do. In non-directive counseling, at the same conscious level, the patient is left much more to his own devices to determine what steps he must take to shed his apparent difficulties.

In group therapy, under a skilled discussion leader, patients are encouraged to talk about themselves and share experiences in such a way that they get better insight into their problems and recognize, at the very least, that they are not alone in facing and striving to meet particular human troubles.

Hypnosis has some limited uses in treating neuroses but only in the hands of a well-qualified practitioner. Hypnotism can be dan­gerous when practiced by parlor amateurs or unscrupulous quacks. Approximately three out of four people can be hypnotized to some extent, but only one in five deeply. Women succumb to it more readily than men.

Suicide

Suicide, however, can be prevented. If you are genuinely and persistently troubled by suicidal thoughts, be quick to seek help from psychiatric sources. If a friend discusses such thoughts with you, be sympathetic and toler­ant of his problems —and guide him firmly to a psychiatrist, physician or other responsible source of help. The potential suicide should not be left alone, even for a minute.

The magnitude of the suicide problem in the United States is not generally appreciated. Suicide is three times as common as murder.

Deaths from Psychogenic Causes

It may come as a surprise that three out of the five principal causes of death in the col­lege age bracket are essentially psychogenic in origin, namely, accidents, suicide, and homicide. The unconscious trap which ac­counts for suicide itself is also responsible for "purposive accidents," which often end fatally

Accidents don't just happen; they are caused; and the cause of a high proportion of these ''accidentally on purpose" events is to be found in the unconscious mind. The at < ident prone individual unconsciously wants to hurt or kill himself. Failing, or even par­tially succeeding, he feels inwardly impelled to try again.

Automobile accidents frequently occur un­der circumstances that give rise to the suspi­cion that the accident was an attempted, or successful, suicide. One can only guess at the actual numbers, but the high toll of motor-vehicle accidents and fatalities in the late teens and twenties suggests that it is not in­considerable. Maladjusted young men now make up a larger share than ever before of the accident-prone group. They often use cars as misdirected instruments of power.

We must therefore list unconsciously moti­vated "purposive accidents" along with psy­choses, neuroses, alcohol and drug addiction, gambling, promiscuity, self-mutilation, delin­quent and antisocial behavior, suicide itself, and other forms of "partial suicide" as exhibi­tions of mental illness.