Inside the Fortress

A Home for the Heart

by Bruno Bettelheim
Knopf, 461 pp., $12.50

In private mental hospitals in Japan—so Bruno Bettelheim tells us—each patient is provided with a special female attendant, called a tsukisoi, who remains with the patient at all times, caring for his needs by day and sleeping beside him at night. The idea is arresting in its simplicity; it plunges us at once into the imaginative effort required to think about the question of how sane people can go about restoring mad people to their common humanity.

Finding the point of common humanity between the sane and the mad, Bettelheim’s new book conveys, must be the tacit basis for any such treatment. For the young, usually “untrained,” college-age or graduate-student counselors who worked at Bettelheim’s famous residential treatment center for the most severely disturbed (psychotic and autistic) children and adolescents, that effort was a daily, intense, and unglamorous struggle. “A staff member must understand,” Bettelheim writes,

how terrorized a patient would have to be to hold onto his stools for weeks on end. He must realize how this would force him to think continuously about avoiding defecation, a preoccupation which would consume all of his time. Then when he holds the patient’s hand for hours while he is sitting on the toilet, empathy with the patient’s anxiety about letting go, or dirtying himself, becomes the staff member’s dominant emotion. There is no place left for disgust. [Page 313]

Bettelheim took over as director of the University of Chicago’s Sonia Shankman Orthogenic School in 1944, unlocking the doors and abolishing staff hierarchy in one cunning stroke by changing whatever locks remained so they opened by a single pass key. With his usual trenchant practicality he had noticed that each staff member’s status was indicated by the number of keys he or she ostentatiously carried. (When the window bars were also removed, a group of boys launched a second-story window “escape.” They were deflected by the spectacle of Bettelheim and staff rushing out to the street carrying mattresses to cushion their fall.)

A refugee Viennese psychoanalyst (of the same generation as Erik Erikson), Bettelheim was driven, as he has told us, by his experience of a year in Dachau and Buchenwald (1938-1939)—which he described in The Informed Heart—to create a therapeutic environment which in each detail of everyday life would create an existence that he envisioned as the exact opposite of the dehumanization so systematically engineered by the camps. When Bettelheim retired last year at seventy, he was respected internationally for his exceptionally high rate of success in treating the most “unreachable” types of cases, although the psychiatric profession has largely turned away from his controversial, and, some would say, cruel, insistence that a child’s perception that his mother wants to do away with him is at the root of childhood psychosis and autism.

A Home for the Heart is three books in one. It is a history of the Orthogenic School, a handbook on how to set up a …

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