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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 therapeutic community—including such practical matters as how many square feet of living space is desirable for psychotic patients—and a plea addressed to the general reader that all mental hospitals should be therapeutic “milieus”—communities on the model of Bettelheim’s school.

Bettelheim’s argument for using the community approach with psychotic adults is made with some oversimplification (as he acknowledges) but irrefutable good sense. The paranoid schizophrenic, for example, experiences his life as controlled by forces which he is powerless to affect. If he is to learn that he has himself created these forces, the hospital must give him every opportunity to exercise autonomy, and to participate in decisions which affect his life. The psychotically depressed person, overwhelmed by “his feelings of utter worthlessness, must be exposed only to persons who deeply believe in his worthwhileness…what they say will not be trusted; the depressed patient will view statements that he is a good person as another demonstration that people simply don’t want to bother with him and his agonies…. What is needed is a positive acceptance of the great troubles he is creating” (page 49). We can note here Bettelheim’s two dominant themes: autonomy and self-respect.

Even the subtlest forms of coercion are to be avoided.

Any slight suggestion that our way of life is superior to his is but another arrogance on our part—another rejection of the patient, another demonstration that we do not understand him. His mode of life, whatever it is, is indeed superior to ours as far as the patient is concerned, because it offers him much needed protection, which he did not find in our world. [Page 7]

His way of life, for an autistic child like Joey the Mechanical Boy (whose story Bettelheim told at length in The Empty Fortress),* may mean living as a machine. Autistic children are those who seem incapable of relating to anything human in their environment, though they may be otherwise bizarrely astute. Responding in a human way seems to implicate them in anxiety so acute that Bettelheim compares it to what we would feel if we were facing imminent death. In The Empty Fortress, Bettelheim argued that the accounts we have of “feral” or “wild” children, such as Kasper Hauser, suggest they were in fact autistic.

Truffaut’s film about Itard’s relationship with the wild child of Aveyron can give a notion of the degree of patience needed to work with such children in the face of the setbacks that recur exactly when one has begun to feel encouraged. But Truffaut’s chaste romanticism doesn’t convey the disturbing grotesqueness of Joey, who couldn’t go from one room to another without desperately replugging in the motor he carried everywhere into some imaginary source of electrical power to keep himself alive. Periodically he’d scream, “Explosion!” and violently throw off (real) radio tubes which shattered around him. Joey’s gestures were so robot-like that “often it took a conscious act of will to make ourselves perceive him as a child” (The Empty Fortress, p. 235).

Such a child may need years to learn that he can and does have control over his own body and that the basic processes of eating and elimination can be pleasurable. It may take him much longer to form an attachment to a mothering person. Hence daily life is the therapy and the caretaking person is the therapist. The child will also later have individual psychotherapy sessions, but again the therapist will usually be the counselor to whom he is attached. Bettelheim never describes these sessions. He underplays the role of interpretation and shows us instead the child working out one anxiety after another in the benign daily life of the school. The treatment is thus presented as a spontaneous healing process—which may take six or more years. During this time the children may sometimes see their own parents but the staff in effect becomes their parents.

Half of Bettelheim’s staff lived in the school, their rooms accessible to the children, since “a ‘parent’ whom one must not disturb during his off-duty hours is a false pretence” (page 80). Each worker had primary and independent responsibility for a small number of children; his chief technique had to be personal involvement rather than “professional detachment.” Those who applied to work with Bettelheim were given a brief trial. As he tells us, the criterion for judging who would be successful soon became clear: the good applicants were exhausted after a few hours.

The degree of commitment required to train with Bettelheim was notorious: it was well known that for a few years you could not call your life your own. The cooperation Bettelheim enlisted extended to the janitors who had to be ready cheerfully to unstop a toilet many times a day if a child was working out some psychotically symbolic problem by stopping it up—and even to the local fire department who kept showing up equally cheerfully for false alarms because the doctor had convinced them they were thereby helping a girl’s recovery.

Bettelheim’s dedication was remarkable. What maintained the energies of the staff was the informal staff meeting after hours which functioned as a forum for mutual encouragement, consciousness-raising, and self-criticism. Bettelheim was usually present. What he doesn’t make explicit is that these meetings (at least during some periods of the school’s history) took place at one in the morning.

The liveliest section of the book gives taped recordings of the five-times-weekly “formal” staff meetings, which were also, in effect, the training. Instruction in psychiatric theory was frowned on: intellectualizing kept you at a distance from the patient and interfered with spontaneous empathy. Young workers were thrown in cold and learned by dealing with the concrete problems they faced. It’s exciting to follow Bettelheim’s strategy (which he uses also in his Dialogues with Mothers). He questions the worker until he gets him to discover a point of empathy with the seemingly incomprehensible panic or anger of a patient (e.g., what circumstance would make you act that way?)—and then gets the worker to use this insight to think out for himself what the helpful response would be. But there is an interesting unintentional subplot to these Socratic dialogues, for those who talk with Bettelheim are often gradually entrapped into voicing his own view. They tend to arrive at the discovery that the distressed patient was reacting to the worker’s own unconscious disapproval—thereby reaffirming Bettelheim’s larger theory of schizophrenia as a response to maternal rejection. This is Bettelheim’s central myth.

Enormous pride broods over A Home for the Heart. It is forgivable that Bettelheim dwells grandly on the symbolic “messages” of the school’s conventionally semi-abstract statuary and murals. And some of the laboriousness of Bettelheim’s account is explained by the fact that he is trying to describe the essence of a therapeutic community through useful real-life anecdotes. But the idea of a therapeutic community is no longer so new, radical, or embattled as Bettelheim’s pleading implies. It has been the leading trend in psychiatry for some time. The problem, rather, is that the idea is so fashionable that we now have the sad spectacle of hospitals all over the country setting up “therapeutic community” units (partly in response to federal guidelines for grants) which soon fail or become spurious because they are communities in name only, still subject to the hospital hierarchy and to professional chains of command.

One could put down this book believing that the Orthogenic School was the only example of a therapeutic community ever to exist. Bettelheim does allude to R. D. Laing, whose romanticizing of madness he predictably disapproves of. Still, he finds Laing’s “felicitous statement” that “psychotherapy must remain an obstinate attempt of two people to recover the wholeness of being human through the relationship between them” to be “also the essence of milieu therapy” (page 284). Of course Bettelheim acknowledges as his spiritual mentor the psychoanalyst August Aichhorn, whose home for delinquent boys in Vienna in the 1920s was Bettelheim’s inspiration. Bettelheim was a pioneer, and unique in that he dealt with children who were more difficult and disturbed than the adult patients in most such “communities.”

But if one compares his school with the other successful and pioneering therapeutic communities set up since the late 1930s, such as Maxwell Jones’s in England, or Harry Stack Sullivan’s, or Thomas Detre’s at Yale, one can draw a stronger lesson than Bettelheim does. The interesting question is what these successful therapeutic communities have in common. They share not so much ideology or temperament as certain structural features:

  1. All were small and completely autonomous units, worlds of their own, imbued with a certain righteous enthusiasm about their distinctiveness—“us against them.”

  2. All were nonhierarchical, with a maximum amount of autonomy for the staff and minimal differences among them in status or professional roles.

  3. All were staffed largely by young unmarried people in their twenties who signed on for two or three years of training and then usually left—a kind of rotating Peace Corps.

  4. The young staff saw the work they did with the patients as part of their own development. Therefore they were willing to make extraordinarily devoted and enthusiastic efforts, and to live in the community. The struggle to respond therapeutically in ordinary human situations with the mad was understood by the young staff as part of their own learning to become more integrated, or more directly related to others, or more empathic, or self-accepting, etc. Hence there is a sense of reciprocity—that patients and staff are helping each other. (I find it interesting that this ethos spontaneously recurs in such disparate places as Bettelheim’s school-for-autonomy, in Laing’s Kingsley Hall, and in so special a venture as Maitri, the experimental Buddhist therapeutic community recently set up by American students of the Tibetan spiritual teacher Trungpa Rinpoche.)

  5. Each staff member’s daily problems are resolved by the staff community in continuously on-going discussions and meetings—which are positively Maoist in their frequency! The theme recurs: When the staff begins functioning as a community among themselves they find that then—and only then—do they start helping the patients. (A study of the structure of the patients’ community life would be an interesting and perhaps a more complex story.)

  6. The founder and director is a charismatic figure. Whatever else this may mean, it seems to be a prerequisite in a practical sense, for only such people manage to get the resources necessary to set up a genuinely independent unit—and to attract their Peace Corps.

The anthropologist Jules Henry, the author of Pathways to Madness, did a study of Bettelheim’s school in 1957. The contrasts he points out between Bettelheim’s “milieu” and the conventional psychiatric hospital put Bettelheim’s case with dry eloquence. (Bettelheim fortunately includes his conclusions in A Home for the Heart.) But Henry described the school’s structure as “simple undifferentiated subordination”—and Bettelheim is miffed that the word “subordination” was even mentioned. Bettelheim is of course wonderfully oblivious to what a confident and autocratic old-school Austrian he is. To encourage his workers to be independent he tells them that the Austrian monarchy had a special medal, the Maria Theresa Ritter Orden, which was awarded exclusively to soldiers who had dared to disobey their superiors in time of war—if it turned out that the soldier had been right, and thereby saved the day! Then there’s the slightly odd advice Bettelheim gives to other administrators: “In fact, it is sometimes necessary to provoke disagreements with the worker when opportunities present themselves. Only through such disagreements will he come to feel sure of his autonomy” (page 248).

Bettelheim’s work and thought—and the paradox of his character as the authoritarian provoker of independence—fall into place, I think, around the theme of autonomy, and the need to defend it from threat. This lies behind his analogy between the victim of the concentration camps and the autistic child. Infants or children become autistic, he believes, because they are made to feel that their autonomous activity is helpless to affect the (hostile) world around them. The cure is not only to show them that the world doesn’t want their destruction, but to help them regain autonomy. And indeed a large number of Bettelheim’s patients are able to leave the school and deal with the world.

Bettelheim’s views of childhood schizophrenia, and even more so his account of autism, mold the complexities of mental illness into the bold and simple forms of myth. But he needed his myth of autism—which utterly minimizes the role that innate ego defects may have in autism—in order to believe that those most “inhuman” of children were redeemable. Others have succeeded with schizophrenic and with some autistic children by using different theories and approaches (e.g., Margaret Mahler’s approach, which uses the mother as cotherapist).

Probably most severely disturbed children do have innate defects which made it difficult for them to use their mothers as “a beacon of orientation,” to use Mahler’s phrase. Much research suggests that there is a complex relation between the child’s innate ability to organize his experience and the organizing effect of empathic, consistent mothering (or the disorganizing effect of indifference). Very early (or primary) autism is fascinating because it shows us a child trying to organize the world without depending on human relations at all. But why does a boy such as Joey, who advanced to the point where he could speak, sometimes retreat to the autistic state? The theories attempting to explain this are more various than Bettelheim conveys. Margaret Mahler, for example, sees such “secondary” autism as a further retreat from the psychotic child’s anxieties about “symbiotic” fusion of his identity with the mother. (In Joey’s defensive “de-animation” of the world, the mother may still be disguised as the source of power.)

Developing a sense of self goes hand in hand with developing a relationship to another—as Bettelheim would agree. A disturbed relationship yields a shaky sense of self, prone to the anxiety that closeness means loss of identity. Bettelheim construes such children’s destructive fantasies as a recapitulation of what they experienced from their mothers, but they need not be read that way. All we can say for certain is that where the child has had a problem in sorting out “self” from “other,” feelings of anger at his mother quickly imply that his world is being destroyed.

But Bettelheim’s myth of the embattled child served to inspire a powerful amount of goodness within the fortress of his school. His clinical intuitiveness and resourcefulness and the unfailing respect he showed his psychotic children were remarkable. In spite of his often pontificating tone, there are many useful lessons to be learned from Bettelheim’s retrospective look at his life’s work.

  1. *

    The Empty Fortress: Infantile Autism and the Birth of Self (The Free Press, 484 pp., $9.95; $3.95, paper).

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