Ever since I've been involved in the problems of the chronically mentally ill, I've been intrigued by the number of psychoanalysts interested in this issue. When I first began work at the state hospital, which I was later to direct, I was pleased to find several distinguished members of the faculty of the analytic institute I was associated with, teaching and supervising residents. Later, I was impressed that five of the eight members of the American Psychiatric Association's Committee on the Chronic Mental Patient were or now are members of the American Psychoanalytic Association. All this, seemingly in the absence of any apparent focus on this population in the curricula of most institutes or scientific programs of psychoanalytic societies. Some wags I approached, seeking an explanation, suggested that it had to do with the fact that seriously mentally ill (psychotic) persons got better, or that analysts were compensating for spending so much time with so few patients, or that it allowed them to escape from intrapsychic conflict into the real world. But I think there are other, more serious motivations.
First, since the deinstitutionalization movement (which began in 1955) has virtually emptied state and county hospitals of their charges, they are strikingly visible in most urban populations. In addition, most psychiatrists are now aware that neither institutional nor community care has proved an outstanding success with this group. As a result, most of us agree that chronic mental patients, whether dehospitalized or never admitted, represent the single largest unsolved public health problem facing psychiatry today—at least numerically—with estimates of between one and seven million.
Second, since all research to date suggests that the population responds best to a combination of medication and psychotherapy, the chronic mentally ill comprise one population that is clearly “ours,” a claim which cannot be made equally by social workers, psychologists, nurses, or nonpsychiatric physicians.
Third, analysts are experienced in dealing with longterm treatment situations. They are not interested in a quick fix or superficial solutions and thus can understand the need for long term treatment and care.
Fourth, analysts, because of their training and experience, are best able to understand the dynamics underlying the patient's symptoms, and as opposed to others who may think that immediate articulation of these dynamics is always therapeutic, know when to utilize this information to assist the patient without utilizing direct interpretation.
Fifth, because the chronically mentally ill suffer from illnesses that have attendant disabilities, they have problems in adaptation and coping much the same as patients with physical disabilities. Therefore, not only does the schizophrenic have “neurotic” problems when not psychotic, he or she also has problems with everyday living, as do the “worried well.”
Sixth, treating the chronically ill allows the analyst to use both his or her knowledge of psychodynamics as well as to become involved in extra-analytic and extraoffice activities. Since current thinking holds that the chronically ill require a broad range of medical, psychiatric, social, rehabilitative, and human (e.g., housing, food) services woven into some sort of community support system; since families offer the best hope for providing some stabilizing structure, if worked with, and are no longer universally seen as noxious disease-producers; and since psychoanalysts continue to be held in high esteem and are vigorously sought after for advice and counsel by society—analysts are able to combine their interest in intrapsychic and extrapsychic issues by treating the chronically ill.
Finally, as Arthur Meyerson has pointed out, analysts are uniquely able to understand the countertransferential elements in therapeutic relationships and utilize this information to help alter public attitudes, change professional biases, and effect better patient care. Meyerson has stated that in psychiatry we have four situations affecting care: 1) Where our current system is not designed for the patient; 2) Where the system is appropriate to the patient's needs and the patient uses it; 3) Where the system is appropriate but the person chooses not to use it; and 4) Where the system is appropriate but it does not want the erstwhile patient. And it is with this last group that countertransference issues arise and the analyst's understanding can be critical.
Undoubtedly there are other reasons why analysts seem so interested in the chronically mentally ill—clearly their contributions to crisis theory and the practice of crisis intervention, short-term therapy, and community psychiatry bespeak an ongoing concern with utilization of psychoanalytic theory and technique beyond the couch—but this introduction will perhaps provide a framework for understanding this issue. Likewise, it bodes well for this most neglected population that some of psychiatry's most highly trained individuals are in the forefront of care for and concern about them.
John A. Talbott, M.D.
New York