I joined the Menninger Clinic as a Resident in Psychiatry in July 1945, unaware of the tremendous changes in the offing for this highly regarded program. Although there was already a strongly developing Research Division, the end of 1945 marked the beginning of the great expansion of the institution, initially in the area of psychiatric education. A nonprofit foundation had been created, but the Clinic had not yet changed its organization or operations very significantly and was still a small, intense, exciting place. There was an aura of part pioneer outpost, part intellectual and clinical enclave. There were four of us in this new residency class and four senior residents, the residency having only recently been increased to three years. Our work was primarily as inpatient hospital milieu physicians (most of the patients had separate psychotherapists), but also as psychotherapists. The program was informal, mainly on a preceptorship basis. There was little in the way of courses or an organized teaching program, but there were morning report conferences, supervision of work with patients, an informal reading seminar, intermittent meetings with senior staff, and…
The Case Conference was a focal point in the educational and treatment program; psychiatrists, psychologists, social workers, nurses, activities therapists, all would attend. It was a stellar group that included Karl and William Menninger, Robert Knight, Merton Gill, Jan Frank, Margaret Brenman, George Klein, Lester Luborsky, Herbert Schlesinger, Philip Holzman, Rudolf Ekstein, and David Rapaport. Each resident's presentation was a detailed report following an outline based on Will's “Guide to the Order Sheet.” All participated in the discussion, and here Karl's brilliance in diagnostic acumen, Knight's in dynamic formulation, and everyone's talents were manifest. The discussions were stimulating and informative.
A unique aspect was that after most of the discussions, not before, and reflecting his genius and the respect in which he was held, Rapaport would present the Psychological Test findings and conclusions, which were taken to be as much the final word on diagnosis and dynamic formulation as material for further discussion. His report was treated rather like that of the pathologist at CPC: as revealing the “real pathology.” His skill in test interpretation was fabled, and he often did seem to have the deepest insights and clearest conception of the patient. Rapaport was a phenomenon. His prodigious knowledge and memory of the literature, his intellectual curiosity, and his brilliant grasp of theory were endlessly stimulating, if sometimes intimidating. His seminars on metapsychology were classics; just as he was leading you to a more profound understanding of theory, he would present a new nettle to grasp.
The Case Conference was oriented to the “Guide,” a comprehensive effort to systematize hospital treatment along psychoanalytic principles. Will had taken Simmel's hospital as a model on which he developed an ego-psychological, adaptational, sublimation-oriented structure. At the Conference a diagnostic and dynamic formulation was established, drive disturbances (love and hate) and consequent conflicts identified, and then specific attitudes to be maintained by all staff prescribed, along with medications, activities, and constraints.
Much of our education was gained informally through intimate contact with the senior staff, both on campus and off. Intimacy was fostered by the general atmosphere of “family,” which was central to the organization and ambiance at Menninger. There was a total immersion in education and work, a constant state of stimulation and a tendency to blur boundaries. That staff were often in psychoanalysis with other staff with whom they also worked increased this “familial” tension. Displacements and transferences were inevitably lived out with a sense of reality that imposed special demands.
The Topeka Institute of Psychoanalysis was small but active, and an integral part of the Clinic community, so that educational elements were closely mingled. The emigre training analysts of the Institute—Jokl, Frank, Gross, Kaiser—were active in psychotherapy training and supervision in the Clinic and later in the School as well. In certain respects, the TIP was the captive of the Clinic and the Menningers, for whom they worked, and thus Karl had much control of the Institute and its staff and analysands.
Will Menninger's superb organizational and administrative skills, developed at the Clinic and exercised so effectively in the Army, were later critical in keeping the Foundation a functioning (and funded) agency. He underpinned the organization; he was a cohesive, stabilizing force and a humane, benign, genial, yet strong figure behind the scenes.
Karl was the central commanding presence at the Clinic and was its inspirational source. He was often quixotic, but the power of his position, intellect, and innovative ideas sustained his political, ideological, and intellectual leadership.
Karl elaborated on Freud's drive theory—Eros and Thanatos—and saw human distress and psychic illness as the consequence of the failure to integrate these forces. He incorporated his family's religious tradition of salvation through service to man and was influenced by a middle-American optimism that love conquers all, destructive forces in particular. The conflicts and ambivalences he spoke and wrote about were evident in him: he was compassionate yet sometimes cruel; committed to growth and expansion, yet insufficiently aware of the possible destructiveness of bigness; inspired and committed to freedom, and yet at times unable to grant autonomy to others. He worked, wrote, and spoke in the service of reform—of mental hospitals, law, prisons, environment, child care, and treatment. He had catholic interests, decried narrow intellectualism, and created an atmosphere and organization in which thousands flourished. He contributed much to the well-being of our fellow man. His teaching ranged over the whole of human endeavor, whatever came to his attention and struck his fancy. Everything in nature and man fascinated him, but he had a particular interest in the destructive behavior of man—war, crime, hunting, genocide, despoilation—hating it and trying to understand it at once.
In October 1945, a momentous meeting occurred. Gen. Paul Hawley had been placed in charge of medicine in the Veterans Administration and undertook to establish quality hospitals in conjunction with medical institutions, to include residency and other training
programs. He brought along Lt. Col. Arthur Marshall, who had developed and organized forward hospital installations in the European theater, to select military hospitals to be brought into this program. Arthur was about to evaluate installations in Texas and Oklahoma and mentioned to Hawley that he would return by way of Topeka, where he planned to meet me, my wife, Peggy being a favorite cousin whom he had not seen since before our marriage soon after the war began. Karl had been pressing Hawley to take over Winter General Hospital and with him establish with him a psychiatric training center, but this idea was considered impractical because of the rambling, jerry-built, uneconomic hospital barracks. Hawley suggested that while in Topeka Arthur reassess Winter and persuade Karl to desist his opportuning.
At Arthur's request, I arranged a meeting with Karl, and after Arthur's discouraging inspection of Winter, I urged him still to talk with Karl before dismissing the project. Respecting Karl's vision and innovativeness, I wondered if some modest plan might be implemented. When I introduced these two dynamic men, they immediately struck sparks. When they broke 90 minutes later, it was clear that history was in the making. Karl's exciting grand vision and Arthur's courage, conceptual grasp, bureaucratic finesse, and pragmatic effectiveness immediately meshed to make the impossible dream materialize. Arthur's own enthusiasm and plan to start the school in January seemed manic to me, but in two and a half months the nearly deserted Winter Hospital was open and operating, two dozen of a Fellows' class of 100 were already in place, and the premier psychiatric training program and Veterans Administration treatment and research center was established. More than 700 applications had been processed.
Standing (I to r) Merton Gill, Anne Benjamin, Earl Saxe, Robert Worthington, Mary O'Neil Hawkins, Lewis L. Robbins, Elisabeth Geleerd, Carl Tillman, Sylvia Allen, and Edward Greenwood. Seated (I to r) Ernst Levy, Douglass Orr, Karl Menninger, C.F. Menninger, W.C. Menninger, Robert P. Knight, and Harlan Crank.
Those were exciting times. The Fellows, all of whom came from the Armed Forces, where most had served as psychiatrists after brief training, were unusually mature, intelligent, and highly motivated, impressed with dynamic psychiatry from their military experience and eager to expand their limited psychiatric training and get on with their interrupted lives and careers. Training programs in psychology, social work, psychiatric nursing, neurology, and internal medicine were subsequently undertaken as well. By 1947 the School was training one-third of the psychiatric residents in the United States. Despite the reservations of some at the Foundation who felt that the new School of Psychiatry was stretching their resources too thin and threatening programs such as research, all devoted themselves to the project. Karl, like Arthur, was indefatigable. He used four telephones, initiated innovative programs throughout the Hospital and School, conducted staff meetings with two dictating machines under his table inconstant, simultaneous use, and taught, particularly the Saturday morning colloquia. Arthur was at once resident, analysand, section chief, principal red-tape cutter, and Washington liaison.
Although there were no precedents for a training center such as this and thus no model teaching programs, especially for psychoanalytically oriented training, and there was practically no lead time to research and organize such a program, it just grew in place. Often the teachers were only days ahead of the students in devising programs, let alone preparing the materials. The curriculum was taught by Menninger staff, TIP analysts, and somewhat overwhelmed senior residents. Autodidactism and learning from teachers, peers, other staff, and patients were all the order of the day. From the first loosely organized large classroom lectures to later small seminars, steady progress led to one of the first full didactic three-year residency programs. The TIP took on special importance with the establishment of the School. Training analysts served as senior teachers in the School, but the TIP was also an important resource as an analytic center, for most of the Fellows wanted psychoanalytic training.
The hospital programs gradually took shape. Whatever the early deficiencies, they were more than made up for by enthusiasm, humane interest, curiosity, and devotion. It was a pattern that repeated itself later, when the Topeka State Hospital was reformed and brought into the School program, although by then there was a better organized, experienced staff to make the changes effective. The sense of vitality and engagement was at least as therapeutic for the patients as were the treatment measures, especially in those days before psychotropics. The early insufficiency of ward supervision from the limited number of experienced psychiatrists stimulated these mature residents to independence and self-sufficiency.
Within this setting there developed a strong sense of dedication, relatedness, and affection and an appreciation of how such an environment enabled one to learn and develop competence and autonomy. The high degree of gratitude and respect graduates of the program feel, despite the flaws experienced, is a tribute to the individuals there, their inspiration, and their commitment to a human psychiatric ideal.