In a Darkness
Recovered psychiatric patients don’t usually write about their experiences in and out of the hospital, but enough of them have done so to make a tradition of sorts. One thinks of A Mind That Found Itself, written by Clifford Beers in 1907; or Fight Against Fears, Lucy Freeman’s dramatic account of her troubles—a bestseller in the middle 1940s, when psychiatry was catching hold among the middle and upper American bourgeoisie; or more recently, Barbara Field Benziger’s The Prison of My Mind, from which the reader learns how the rich can be hoodwinked and devastated by the seamier side of medicine and its various specialties—all those “rest homes” and “sanitoria” with their pretty names, set up to fleece patrons, whom they insult and humiliate, then quickly discharge when cash runs out or suspicions (no doubt called “paranoia”) get dangerously active.
Then there are those who don’t recover. They start out with something that is called “anxiety” or a “phobia” by the family doctor. With his help they struggle against their symptoms for a time, only to feel worse and worse. If they are reasonably well-to-do and educated they are likely to take themselves to a private psychiatrist. If they have little money but are students or young professional men or women they may go to a clinic, where their youth and “promise” earn them favored status—“individual psychotherapy.” If they are poor or their parents are working people—mechanics, gas station attendants, waitresses, switchboard operators—the chances are that “medication” will be prescribed, infrequent and brief “follow-up” visits recommended, and maybe, under the best of circumstances, some “group therapy” made available.
In 1958, August Hollingshead and Frederick Redlich in their study Social Class and Mental Illness concluded that money commands attention from psychiatrists, among others; those who are relatively poor or uneducated (meaning millions and millions of ordinary working people, who can barely pay the baby doctor for the routine childhood illnesses that come up, let alone bills for psychotherapy) are commonly treated in ways that require much less of the doctor’s time. In the fourteen years since their book appeared, nothing has happened to change their description.
Yet here, as in so many other respects, psychiatry has to be distinguished from other branches of medicine. Nowhere in this country, or in any other country, do the rich and powerful fail to get better “care” than the poor. Hospitals vary, as does nursing care or the quality and quantity of medical attention, according to the patients’ pocketbooks or positions in society. (Since Hippocrates, the call for another, more equalitarian approach has been given unremitting lip service.) Yet whether a patient is rich or poor, penicillin is prescribed for bacterial pneumonia, surgery for an inflamed appendix; class barriers have nothing to do with the way children are protected from polio or tetanus—the same vaccine is used throughout the country.
In contrast, psychiatrists talk about various “modalities of treatment,” supposedly a rational response to separate “clinical entities,” whereas in fact different patients, possessed of the very same “difficulties” (or “illnesses” as they are mainly called, an arguable use of medical imagery), receive thoroughly different kinds of “therapy” (in psychiatry, where irony and mystery if not mystification abound, quotes around words are not a temptation, but a necessity). One patient with the diagnosis of a severe “phobic disorder” or, perhaps more ominous, “border-line schizophrenia,” is called “treatable,” seen two or three times a week with what some of Freud’s patients called “the talking cure.” Another patient, similarly diagnosed, is pronounced “a poor treatment case,” maybe especially “resistant” to intervention, or “unmotivated,” an “undesirable candidate for psychotherapy”—to draw upon a phrase that I used to hear over and over again when I was a resident and, damn fool that I was in those calm Eisenhower years, never once thought to question.
Psychiatric terms, apparently so clear-cut and emphatic, have extraordinarily versatile lives: they come and go, blend into one another, are used by one doctor, scorned by another. More dangerously, they can have subtle and not so subtle moral or pejorative implications. “Good” patients, liked by their doctors, are described one way, “bad” patients, whose mannerisms (maybe just plain manners) or “attitude” or deeds are found to be unattractive, are described differently.
The difference is one of tone, emphasis, and, always, choice of words, many of them as portentous as they are slippery. This youth is “obsessive,” but much of his behavior is “egosyntonic,” and his primary struggle is “oedipal,” even if his “defenses” are by no means adequate, and sometimes shaky indeed. Another youth is also “obsessive,” but underneath are serious “pre-oedipal” conflicts. Furthermore, his defenses are “primitive,” and he may well be a “border-line case.” With additional exploration we might even discover an “underlying psychotic process.”
Needless to say, the very same youth can be seen by one psychiatrist, then another, and on and on, with a similar divergence of opinion. X-rays do not affect the diagnosis. Blood tests cannot establish without doubt what has to be done. We are in a world of feeling, the doctor’s as much as the patient’s, so no amount of training or credentials or reputation can remove the hazards of such a world: inclinations of various kinds, outright biases, blind spots. I do not deny the enormous value that a personal psychoanalysis has for a future psychiatrist, or the effect years of supervision can also have. By the time most psychiatrists have finished their long apprenticeship they do indeed tend to know what kind of patient they work well with, what kind of patient they ought to avoid, and most important, what their vulnerabilities are.
Still, such awareness isn’t always translated into wise clinical decisions. Patients are accepted who ought to be referred. Patients are treated one way, when perhaps another tack might make things a lot easier for both them and their doctors. And even when in a particular case things do begin to work well, “life” is always to be reckoned with. Not everyone can keep at therapy or analysis for those months that have a way of becoming years. There is a job to hold, and it might require a move. There is the draft. There are unavoidable accidents or emergencies that come up from time to time.
From the other side, a similar range of disruptions may arise: the doctor decides to move, or is in training, and so leaves one clinic or hospital for another; he may decide to switch from “practice” to more teaching and research; he finds that his private patient no longer can afford his fees, hence is to be referred to a clinic. It is no doubt painful for many of us to think very long about that last “factor,” but it is not an uncommon one, and is yet another reminder about the nature of our society—psychiatrists make themselves available to those whose position in the world enables the purchase of the special kind of intimacy provided by the doctor-patient relationship.
Nor can the implications of such an arrangement be completely forgotten, by either the one who pays or the one who receives the money. Expectations and, later on, demands are backed up by expenditures, and payments establish for the man or woman who receives them their own mandate—while week after week two individuals are talking about the most extraordinarily personal matters and developing between themselves honest and, it is hoped, sustaining exchanges. As well as those “transferences” and “countertransferences” that measure our unfailing ability to find targets for our irrational strivings in those we meet and spend time with (and also, at one remove, in the books we read and the authors we occasionally lavish with praise or feel ourselves inexplicably turning against).
Obviously some of these issues are almost infinitely complicated; they have to do with how various human beings get on and, just as important, the subtleties of class and even caste (some would insist, thinking of patients in mental hospitals) as they affect the lives of both psychiatrists and patients. Once in a while, though, generalities and difficult arguments come into especially clear view for both psychiatrists and patients through the medium of a particular, concrete event.
James Wechsler’s In a Darkness provides such an occasion. The reader knows from the beginning that unlike Clifford Beers, Lucy Freeman, or Barbara Benziger, Michael Wechsler, son of James and Nancy Wechsler and brother of Sally Karpf, committed suicide at age twenty-six, after a long and stormy series of involvements with no fewer than eight therapists, whose offices are scattered over Boston and New York, which, incidentally, contain the heaviest concentration of psychiatrists in the world.
Mr. Wechsler is a well-known journalist; he is now editorial page editor of the New York Post. He has written his book with the help of his wife and daughter. They have wanted to look back and ask themselves questions which they know ought to be asked, not because they are laboring under “grief reaction” and need “catharsis,” but out of respect to their rights as intelligent and sensitive human beings who have gone through a saddening, at times harrowing, experience. They do not want to leave unexamined the many circumstances, moments of crisis, tragic as they turned out, which they and their son went through from the spring of 1960, when the boy, then in the Fieldston School at Riverdale, New York, first felt the need to see a psychiatrist, until the spring of 1969, when his parents found him in bed and without a pulse, and rushed him to a nearby hospital, where he was pronounced dead, a victim of an overdose of barbituates.
The book is short and unpretentious. Mr. Wechsler wastes no time in eulogies, nor has he any desire to use his considerable skill as a writer in order to achieve the kind of self-justification it would be only human for him to want. Rather his effort is to describe, from his and his family’s point of view, a certain progression in the short life of a bright, sensitive, gifted youth, whose parents’ emotional, social, economic, and political resources, however substantial, were in the end not enough to save his life—and when one says that, one must immediately make it clear that Mr. Wechsler has been moved to write this book and give it the title he has because he does not know to this day what would have been enough, what was needed to save his son’s life.
Still faced with “darkness,” the mystery and confusion that he as the father of a severely troubled psychiatric patient could never somehow escape from, Mr. Wechsler has written a book of great narrative power which will doubtless unnerve his readers (notably the educated lay public, but, I would hope, also the psychiatric profession itself).
Michael Wechsler was apparently a “normal” boy and youth until he was seventeen and a senior in high school. That is to say, he got along reasonably well with his family, was a first-rate student, had a number of good friends and a fairly active social life. He had presented no real problems to his parents as he grew up, and so they were taken aback when he asked them for the money to see a psychiatrist. Why? For what “problem”?