Who Needs Help?

Talk is Not Enough: How Psychotherapy Really Works
by Willard Gaylin, M.D.

Until the end of the nineteenth century, few people with emotional disorders went for "help," i.e., professional treatment. They were taken, or more accurately dumped, someplace, that place usually being the insane asylum. These people were not defined as "mentally ill"; something was wrong with their brains or their nerves. The concept of mental illness - diseases of the mind as distinguished from the brain - had yet to evolve.

All illnesses, mental or otherwise, were perceived as dysfunctions whose causes were unknown but variously ascribed to humors, chills, trauma, spontaneous generation, or deterioration of organs from genetic or unknown causes. In other words, some physical disturbance of the anatomy (which by then was well understood) or the functions (which were only beginning to be understood) of the body parts.

The physician looked for a deterioration of structure comparable to what might be observed in any physical entity - a church spire, a bridge, a roof - due to aging or physical trauma. The prototype was heart disease. The heart is an extraordinary pump, with four valves and made of muscle fibers unlike any others in the body. Unlike all other muscle, it never fatigues or cramps from overuse. Thirty-eight million times a year it pumps! When it fails, one can safely assume some physical damage to the pump or its valves has occurred.

Consistent with this model, the insane were expected to have some damage to the brain. But this presented a problem. Abnormalities of the brain were difficult to identify, although the phrenologists tried. We did not (and still don't) understand even the basic anatomy of the brain and its interconnected parts, let alone the modes of operation of such higher activities as memory, cognition, and emotion.

In addition the insane were for years assumed to be different; not really sick but "possessed" by evil spirits - dybbuks, devils, or demons. The metaphoric term "bats in the belfry" had an almost literal meaning. Since the leading cause of psychosis in those days was advanced syphilis, the brain was indeed occupied by little "demons," in this case the spirochete Treponema pallidum. But there would be no awareness of this until the birth of modern medicine and the discovery of the germ theory. We had little understanding, for that matter, of the true cause of any disease, mental or physical.

In the latter half of the nineteenth century, all this would change. With a stunning burst of research in the laboratories of France and Germany, the discoveries of such great medical pioneers as Louis Pasteur, Robert Koch, Paul Ehrlich, Ignaz Semmelweis, Wilhelm Wundt, Hermann Helmholtz, and Rudolf Virchow initiated the age of modern medicine. The actual causes of common illnesses could now be scientifically demonstrated in the most rigorous manner, pointing the way to specific, cause-related treatments (although, tragically, seventy-five years would pass between Pasteur's proof of the germ theory in 1862 and the emergence of an effective treatment for bacterial infections with the discovery of the sulfonamides and penicillins). This was not to be the case with mental illness, a concept yet to be discovered.

Modern psychiatry actually emerged from the field of neurology, the study of the structure, function, and abnormalities of the nervous system. The leading center for neurological studies was in Paris, where the brilliant neurologist Jean-Martin Charcot (1825-1893) headed his famous clinic. This pioneer of modern neurology was particularly interested in the study of hysteria. As a disease hysteria does not in any way correlate to such lay usage as overreaction, hyperemotionalism, or a tendency to make scenes in public places. In actuality, the grand hysteria of the nineteenth century was characterized by something quite the opposite, a symptom called la belle indifference - the patients displayed profound physical symptoms to which they seemed quite indifferent.

What, then, was hysteria? Hysteria was a physical symptom that did not seem to have traditional physical causes - blindness, deafness, numbness of the hand or foot, and occasionally seizures. Charcot suggested that these were due to some nervous disorder, meaning literally an inflammation of nerves that affected the end organs - the eyes or the ears or the limbs. His theory was still firmly rooted in a physical model.

Sigmund Freud, the founder of psychoanalysis, may rightly be seen as the father of the concept of mental illness, and mental health. He was born in 1856 and received a medical degree from the University of Vienna in 1881. Freud was interested in research medicine, particularly in the field of neurology. He studied with Charcot and took Charcot's theory one giant step further. Freud decided that these nervous disorders - neuroses - were actually caused by psychic distress.

Freud's leap proved monumental. It abandoned the model common to all diseases - physical damage - and further put forward the incredible notion that feelings and ideas could produce illness as readily as toxins and bacteria. Freud postulated a new category of disease. These were clearly defined as mental disorders, impairments of function due to psychological processes, not inflammations of organs or neurological decays. Freud created the concept of mental illness as distinguished from brain damage. It was inevitable that we would now look at behavior in a new light and begin to redefine the mentally ill.

About the Author

Willard Gaylin, M.D., is the author of fifteen books, including Feelings, The Killing of Bonnie Garland, and The Rage Within. He is Clinical Professor of Psychiatry at Columbia College of Physicians and Surgeons and cofounder of the Hastings Center, the preeminent institute for the study of ethical issues in the life sciences. For more than thirty years he has been a leading theoretician, educator, and practitioner in the field of psychotherapy and psychoanalysis.