Freud once predicted that psychoanalysis would be used as a treatment method in psychiatric hospitals, especially for the “narcissistic neuroses.” He also said that psychoanalytic treatment in such cases would become useful only if new knowledge were gained in ego psychology. Both of his predictions were eventually fulfilled, to a large measure because of what has taken place at The Menninger Clinic in Topeka, Kansas during the last fifty years.
The idea of a psychoanalytic hospital was first conceived by Ernst Simmel at Tegel, Germany in the late 1920's. Shortly afterward, psychoanalytic theory became integral to psychiatric hospital care in Topeka.
Simmel's aim, as he himself recalled several years later in Topeka, was to remove patients from their noxious milieu and provide them with a “psychic diet”—psychological treatment that would deal actively with internal as well as external stimuli. Simmel's primary concern was to safeguard and strengthen the analytic situation with patients who were prone to act out, to somatize, or to turn their natural milieu into a battlefield that diluted the transference or made it altogether inoperable. Realizing that patients tend to re-create their pathological home environment within the hospital, he tried to regulate their behavior in the hospital “to restrict concentrically the field of transference” to the relation between the analysand and the analyst. He utilized occupational therapy and systematic setting of limits; both procedures were conceptualized in terms of psychoanalytic theory, ego psychology in particular.
After visiting Tegel, William Menninger, with his brother Karl and such associates as Robert Knight, Norman Reider and Milton Wexler, incorporated Simmel's ideas into a comprehensive psychoanalytic treatment regimen for regressed patients, adult and children. Such treatment was to replace custodial care, time-filling occupational and recreational activities, and the p.r.n. prescription of warm baths and cold-wet packs —the standard hospital milieu treatment of those days.
The psychoanalytic hospital as developed in Topeka called—and still does—for the following conditions: (1) a sufficient number of professional and paraprofessional personnel (psychiatrists, nursing staff and activities therapists, social workers, psychologists and neurologists) to plan and implement an individualized treatment program; (2) special training for anyone involved in clinical work with patients in the hospital to familiarize them with psychoanalytic concepts and principles of treatment; (3) diagnostic studies to pinpoint infantile conflicts and patterns of family interaction; (4) facilities for an individually tailored program of daily activities (“devices intended to correct disturbances in the aggressive [or erotic] drive”).
Special management devices were prescribed for each patient to “encourage sublimation … atonement for a conscious sense of guilt … socially acceptable narcissistic gratifications.” In addition, specific attitudes were prescribed: “active friendliness,” “kind firmness” (initially referred to as “severe kindness”), and even “love unsolicited.” All these treatment prescriptions were systematically described in the so-called “Guide to the Order Sheet.” Privileges, including the regulation of freedom of movement, were awarded or withheld for the purpose of improving reality testing and ego control, but also in order to frustrate infantile wishes and thereby force the patient to take them to his psychoanalyst or psychotherapist.
The severity of the prescribed environment, however, tended to re-enforce passivity and dependence. Even though some emphasis on learning of skills was implied in the management devices originally prescribed at the Menninger hospital, there was little effort to help the patient learn how to cope with difficult problems, to exercise his judgment or sense of responsibility in actual situations of conflict or challenge, in other words to use the milieu for ego-building purposes. Besides, the treatment philosophy embodied in the “Guide to the Order Sheet” did not take cognizance of problems related to organizational dynamics—an omission that was eventually to be recognized by sociologically minded students of mental hospitals, and analysts sensitive to systems and object relations theories. Routinely prescribed and rigidly enforced attitudes toward patients tended to create an authoritarian, paternalistic climate, breeding passivity or rebelliousness among patients and countertransference reactions among staff members. Patient-staff and intrastaff conflicts, checked rather than worked out by a hierarchical, individually determined administrative structure, were bound to have a detrimental effect on treatment.
As the importance of institutional pathology became recognized, compensatory measures were gradually introduced. In the model of the therapeutic community developed in post-World War II England, the prescription of attitudes was relaxed and decision-making became more of a democratic, transactional process. The development of psychotropic drugs made possible the involvement of a larger number of patients in decisions concerning their life in the hospital and their treatment as a whole. Group dynamics, based in psychoanalytic object relations theroy, and the flexible use of group methods helped to make the hospital environment into a more effective medium of socialization and personal growth.
The psychoanalytic hospital, as it has gradually developed in Topeka, has evolved into a group oriented, yet highly structured psychotherapeutic center. Patients are encouraged to exercise their sense of responsibility and develop their conflict-free egos while exploring and working through their intrapsychic conflicts in psychoanalysis or psychoanalytic psychotherapy. Whereas the original treatment philosophy of the hospital aimed at protecting the patient from the conflicts of the outside world while depriving him of infantile gratifications, the new model tries to combine crucial characteristics of the external world with special consideration for the patient's internal reality in a unique interplay of controlling
and permissive conditions that should create the need, without external pressure, to channel his intrapsychic conflicts into the one-to-one psychoanalytic relationship.
In this brief outline of a psychoanalytic hospital and its history over the last fifty years, it is fair to emphasize the importance of working hand in hand with a psychoanalytic institute. An integral, even though autonomous, part of the Menninger Foundation from its inception, the Topeka Institute for Psychoanalysis has provided not only the impetus and ideas, but the administrative, clinical, and consultant staff of the hospital as well, through faculty members and a steady flow of analytic candidates and graduates.