The Walking Wounded and the Worried Well

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

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While the population of the mentally ill has grown dramatically since Freud's time (by definition, if by no other means), the percentage of that population who seek and receive treatment is still small. And a bizarre situation has evolved. The sickest, the traditional mentally ill, are receiving less attention than the less sick. Psychotherapy in particular has been occupied with treating the least disadvantaged. A number of events have conspired to create this anomaly.

A person's decision to go for psychiatric treatment is not determined by his psychological or emotional condition alone. Some of the most profoundly disturbed will never receive help, while others will devote years to treatment for the alleviation of what may be perceived by friends or acquaintances as a relatively minor dysfunction. An individual will seek psychotherapy not only because his mental health requires it, but also because certain social conditions are conducive to his going to a therapist.

A number of factors influence a person's decision to seek treatment: the extent to which a particular emotional illness burdens him socially or financially; the value he places on the function impaired by such illness; the readiness to define his pain (headaches) or disability (the inability to hold down a job) as a psychological problem; the degree of his understanding that emotional illnesses are treatable; the availability of psychotherapy; the availability of money for psychotherapy; the stigma he and his community attach to psychotherapy.

Let me offer some examples. If a sophisticated, urban, young, male advertising executive was suddenly to find himself incapable of maintaining an erection, he would be likely to end up in a psychotherapist's office, even fifty years ago. If a comparable woman was completely frigid, she would, until very recently, be unlikely to seek treatment.

This difference has been dictated by several facts. First, the biological peculiarity of the male genitalia is such that a man has to be aroused to perform. No interest means no action; the pleasure and procreative aspects of sex are linked. In a woman, however, sexual arousal and fecundity are biologically separated. A woman can, despite the total crippling of her sexual pleasure, support intercourse and be capable of procreating.

In addition, a man's impotence is publicly announced to his mate. A woman can dissemble. But more important, her rights to sexual pleasure had not been fully established until very recently. Many women simply did not know what they were missing, and when they did they did not feel the right to claim their pleasurable due. Orgasm was not fully established even in a woman's own mind, let alone in societal judgment, as her right and her norm. Whereas the absence of potency threatened the very identity of a man, the presence of female sexual passion was often viewed as somewhat inelegant and unladylike. Male and female sexual impotence are both crippling, yet one was much more likely to drive the individual to seek help than the other.

Even now, when the attitudes that contributed to such divergent behavior are changing, it remains true that an educated and sophisticated New York professional woman will be more likely to seek psychotherapy than a small-town or rural housewife. The sophisticated urban woman assumes that lack of orgasm is a medical problem; that it is treatable by psychotherapy; that there are therapists in the community who earn their living treating such conditions. Many unsophisticated women still view sex as a masculine pleasure and a feminine duty.

With neuroses in general, peer attitudes influence people's perspectives and determine their readiness to seek treatment. During the fifties, in certain professions such as acting, psychoanalysis was not only acceptable but de rigueur.

As previously suggested, geography can also be a factor. A white, upper-middle-class New Yorker is more likely to be analyzed than her Laramie or Biloxi counterpart. One reason is that there are more therapists in New York than elsewhere. Their mere availability permits people who are enduring certain problems to think in terms of therapeutic solutions.

The fact is that those who seek psychotherapy these days are not necessarily sicker than those who do not. They are often simply more ambitious, unwilling to settle for less than what they perceive as the fullest and richest life. Similarly, lack of education, social class, and religious bias all cause some people to go through life operating at less than their full potential rather than face what is seen as the indignity of seeking help.

That a person has undergone psychotherapy must not be perceived as an indication of emotional impairment. It may actually indicate reasonableness, courage, and emotional maturity. I have never found my patients to be a sicker population than my circle of friends.

Meanwhile, some perverse and paradoxical cultural effects are emerging in the attention we are paying to differing forms of mental illness. We have divided the population of the noninstitutionalized mentally ill into two divergent, and often politically antagonistic, camps, sometimes labeled the walking wounded and the worried well.

It early had become apparent to Freud and his immediate followers that psychoanalysis was ineffectual with the classically psychotic patients - those suffering from delusions, hallucinations, and major disruptions of lifestyle. Some psychotics were totally incapable of functioning on their own, but others - "compensated" psychotics - were still able to operate in the everyday world. Nonetheless, even this latter group, the so-called walking wounded, were screened out of the psychoanalyst's practice. This was not just because they were unresponsive to psychoanalytic methods, but also because psychoanalysis can be disastrous for them, precipitating acute psychotic breakdowns in schizophrenics who are tentatively holding on to their sense of reality.

Early treatment for severe psychoses consisted of rest, confinement, care, time, and nurture. In recent times we have seen the blessed emergence of psychotropic drugs. Antipsychotic drugs have revolutionized the treatment of the severely mentally ill. Many of these patients could still benefit from the support and counsel of a therapist, but, alas, they will often avoid therapy once their primary symptoms have been alleviated through drugs. In addition, such supportive treatment of psychotic patients is less dynamic, and therefore less exciting and challenging for most therapists. Chronic illness is "less fun" for physicians than acute illness. Curing is more exciting than caring. Both these factors - the patient's avoidance and the therapist's indifference - contribute to therapeutic neglect of this population.

The discrepancy in who gets psychotherapy has become illuminated in the battle of the bucks. In these days when budgets for health care are lean, with mental illness the particular stepchild, there is real danger that the sickest people, the traditional mentally ill - the walking wounded - are getting shortchanged.

Whether it is fair or not, those suffering from neuroses or simple maladjustments - the worried well - form the majority of patients in psychotherapy. The term does them an injustice. They are not well, and they are more than worried. They are suffering. These are, at any rate, the people who constitute the population that seeks ongoing psychotherapy (the "talking cures"), and these are the people that I will deal with in this book.

Copyright © 2000 by Willard Gaylin, M.D.

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.