we can fore, This is the touchstone. This is the key to all the therapeutic program of the modern psychiatric hospital; it dominates the behavior of its staff from director down to gardener. Karl Menninger, M. D. Preface This pamphlet, which is an extended study of treatment of the mentally ill at the Win- ter Veterans Administration hospital and of the Menninger Foundation, the largest psychiatric training organization in the country, is being released for nation-wide distribution because the sponsors feel it is the best documentation yet of the workings of a dynamically oriented psychiatry. The Winter mental hospital has been set up as the country’s model veterans’ institu- tion. Its generous financing and emphasis upon early, intensive treatment is proof positive that the American people will pay for a public psychiatry which is oriented to possible cure, rather than costly custody, of the mentally ill of the country. Many states are in the early stages of crusading movements to reform conditions in mental hospitals. Their major difficulty centers around the task of giving the ordi- nary Jaymen (and his representative, the legislator) a convincing picture of how addi- tional appropriations for mental hospitals can save the state many lives and untold amounts of money. “If We Can Love” fills this gap. First of all, it deals with a public mental institu- tion supported by the tax-payer’s money, so it supplies a legitimate basis for comparison with state institutions. Secondly, it shows, in carefully documented detail, just how greatly augmented staffs and intensive ther- apy programs pay off in the recovery of patients. Thirdly, it provides a detailed study and justification of advanced programs such as psycho-drama and art therapy, re- garded now as needless frills by too many people. The text has been heartily endorsed by top figures in American psychiatry. Dr. Daniel Blain, chief of the V. A. neuropsy- chiatric division, writes: ‘““Mike Gorman has done an excellent job with regard to the Topeka hospital, and has presented the material in an authoritative, strong and logical fashion.”” Drs. Karl and Will Men- ninger have both expressed their enthusiasm for the articles. From the important lay point of view, A. V. Lundgren, Winter hospital public re- lations officer, who has had as much experi- ence as anyone in the country marshalling public opinion behind a dynamic psychiatry, writes: “A superb job. Its the best approach on stirring up the problem that I have seen anywhere.” Mike Gorman, author of the articles, needs no introduction to anyone active in the mental hygiene field. A crusading reporter for The Daily Okla- homan, his two pre- vious pamphlets — “Misery Rules in State Shadowland” and “Let There Be Light” — have received the highest praise from the National Commit- tee for Mental Hygiene and have been dis- tributed nationally by a host of organizations. Mike Gorman Of his work, Dr. Karl Menninger wrote recently: “I think the historians of Okla- homa will one day have to record the fact that it was one Mike Gorman who began leavening the lump—his zeal and courage may have done for Oklahoma what in most states still remains to be done.” Joseph K. Peaslee, Executive Secretary, Oklahoma Committee for Mental Hygiene The sponsors wish to thank Mr. E. K, Gaylord, editor and publisher of The Daily Oklahoman, for permission to reprint these articles which originally appeared in that paper during December, 1947. For additional copies of this pamphlet, write to: The Oklahoma Committee for Mental Hygiene, 620 N. W. 21, Oklahoma City, Oklahoma, Topeka Has Model VA Mental Hospital By MIKE GORMAN A S recently as 1945, the Veterans’ administration’s handling of thous- ands of mentally ill veterans was re- garded as a national scandal. In testimony that year before a congressional investigating committee, leading psychiatrists and writers pre- sented documentary proof of gross mistreatment and shocking neglect in V.A. mental hospitals. Innumerable cases of physical brutality formed the paralleled in every way the recent exposes of conditions in our state mental hospitals. Albert Deutsch, author of “The Men- tally Il! in America,” wrote the follow- ing after a lengthy personal survey of conditions in every V.A. hospital handl- ing mental patients: “The most distressing part, in terms of the patient’s chances of recovery, was the evidence of widespread med- ical neglect—of ‘ersatz’ psychiatrists placed in charge of mental patients without any special training or experi- ence; of hopeful cases reduced to hope- less chronics through sheer mishandl- ing; of medical mediocrity at the top; of good doctors crushed under the weight of bureaucracy; of patients entombed in palatial institutions des- titute of modern medical science.” Bradley Tackies Problem JN August, 1945, Gen. Omar Bradley became Administrator of Veterans’ Affairs. Realizing that nearly 500,000 men had been discharged from the armed forces during World War II for neuropsychiatric reasons, with psychi- atric cases constituting more than half of all patients in veterans’ hospitals, Bradley tackled the “impossible” task of lifting V. A. mental hospitals from a level a notch below state mental hos- pitals to institutions giving the best care and treatment available in the country to mentally sick veterans. After a preliminary survey, it looked like Bradley was licked. There was an appalling shortage of personnel avail- able to staff the modern psychiatric hospitals he visioned. Then, one day, someone mentioned the Menningers of Topeka. The Menninger clinic had been started in 1923 by Dr. Charles F. Men- ninger, a Kansas country doctor. Feel- ing that group medicine was the solu- tion to many of America’s medical problems, Dr. C. F., with his sons, Drs. Karl and Will, gradually developed the Menninger clinic into a top-ranking psychiatric center wherein experts from all over the country worked as a psychiatric team. In time, it became to American psychiatry what the Mayo clinic is to American surgery. Army Experience Cited D® Will Menninger’s experience as chief of the Army Medical Corps’ psychiatric division during World War II heightened the interest of the Men- (chronic cases),” Dr. Will wrote. “It was true that a psychiatrist was in- cluded in the personnel of hospitals, ningers in the problem of the mentally ill veteran. When Dr. Will took over the Army’s psychiatric services, they too were on a level with those now in effect in state mental hospitals. “It is interesting to note that, in 1941, the Army thought of psychiatry largely in terms of the disposal of psychotics Dr. Kari Menninger but the only preparation made for the care of psychiatric patients was an excess number of locked wards in these hospitals.” Yet, in four years, Dr. Will trans- formed U. S. Army psychiatric ser- vices into the finest in the world. At its peak, there were 2400 medical offi cers assigned to psychiatric services, plus 400 clinical psychologists and more than 600 psychiatric social workers. Millions Are Admitted BETWEEN 1941 and 1946, there were over one million admissions to the Army’s neuropsychiatric services. By extensive use of out-patient clinics and mental hygiene consultation services, only one out of every four soldiers suf- fering mental disorder had to be hos- pitalized. Competent observers have attested to the remarkable recovery rate achieved by the Army, particularly in the psychotic or chronic cases. By 1945, seven out of ten psychotic pa- tients were sufficiently recovered to return to their homes rather than to a veterans’ hospital. “The net result and lesson from this experience was that intensive, effective treatment could be and was instituted for a large number of psychiatric pa- tients,” Br. Will wrote. “It would seem that Army psychiatry proved without a doubt that even with limited personnel, the treatment job could be done, if the attitude prevailed that this was the chief aim. It served to prove the theory that psychiatric pa- tients, if treated early, have an infin- itely better chance to recover.” Gen. Bradley and Dr. Daniel Blain, chief of the V.A.’s neuropsychiatric division, approached the Menningers with a proposition. The V.A. wanted to take over Winter Army hospital, just outside of Topeka, and convert it into a mental hospital for veterans. Would the Menningers also convert it into a training center for V. A. psy- chiatrists, nurses, psychologists, psy- chiatric social workers, and other needed personnel? Dr. Karl Takes Over THE Menninger brothers went into a huddle. It was agreed Dr. Karl, elder of the two, would take over Winter hospital, while Dr. Will would go back to running the expanded Menninger Foundation. But Karl, out-spoken and fearlessly honest, laid down a series of conditions the V.A. must meet before he would take over Winter. “First of all, I told them I wanted to run a hospital, not a custodial insti- tution wherein patients were regarded as belonging in the category of zoo- logical garden specimens,” Dr. Karl told this reporter. “Every patient at Winter would receive intensive treat- ment—he would not be labeled ‘chronic’ or ‘psychotic’ and relegated to a vegetative existence. “Secondly, I said I would not be connected with anything shoddy or second-rate. Whatever the cost, Win- ter woud have not only enough phychi- atrists, but enough psychologists, so- cial workers, therapists, teachers, nurses, and attendants to give every patient continuous individual atten- tion and treatment.” Dr. Karl also insisted that the hos- pital receive not only mentally ill pa- tients, but also those requiring general medical and surgical treatment. Like most advanced leaders in modern med- icine, the Menningers believe the trend must be toward breaking down the artificial distinction between men- tal, emotional, and so-called physical diseases. They point out that 70 per- cent of all “physical ailments” involve emotional factors and can’t be cured by drugs and surgery alone. _Gen. Bradley accepted the condi- tions and, in January, 1946, Dr. Karl took over as manager of the Winter V.A. hospital. Page 4 Psychiatric Training Programs at Winter WHat does Winter V.A. hospital look like today? Why is it pro- claimed the finest mental hospital in the country? Physically, Winter isn’t half as im- pressive as many state mental hos- pitals. It’s 176 one-story barracks-like buildings are scattered over 150 acres of Kansas flatland. Although the grounds are attractively landscaped, the over-all impression is one of monot- onous conformity to what passed in the Army for architectural style. However, once inside the gates, you step into a friendly whirl of psychi- atric activity which has no parallel anywhere in the country. There are 1632 full-time employees at Winter, with an additional 300 on a part-time basis. Since 900 of the 1200 patients at Winter are neuro- psychiatric cases, this allows a ratio of 2 employees for every mental patient. There are 14 full-time psychiatrists on the staff, but this tells only part of the story. The School of Psychiatry at Winter has 125 resident doctors in training and all of them, particularly second and third year men, spend a majority of their time in patient care. School of Psychiatry T HE School of Psychiatry is the key to Winter hospital. Here, at the largest teaching institution of its kind in the world, the V.A. is training one-half the doctors now enrolled in its nation- wide psychiatric .program, and one- third the doctors being trained in psy- chiatry in all the country’s institu- tions. It’s a tough school to get into. Dr. Karl Menninger has rejected three doctors for every one he has accepted. Every applicant is subjected to an awesome battery of diagnostic tests and personality interviews. The three-year course is the stiffest in the land. Residents soon learn they’re not going to be taught just to label patients and make out reports. More than 40 faculty members, in- cluding national leaders in psychiatry and renowned experts from many for- eign lands, teach residents a dynamic psychiatry oriented toward early, in- tensive treatment of mentally ill pa- tients. As an example of the breadth of the curriculum, the following excerpt from the training prospectus as out- lined by the Menningers is typical: “It might be too broad a statement to say that no doctor can become a good psychiatrist if he has not listened, at fairly frequent intervals, to some of the world’s best music. But it cer- tainly could be claimed that the lack of a general acquaintance with the best formalized expressions of human emo- tions will prevent a doctor from ever being a really good psychiatrist. It has been our experience that many residents, in the early days of their training, need to be directed first to a better acquaintance with such sour- ces as the Bible, Aesop’s’ Fables, Grimm’s Fairy Tales, and Dostoevski’s le Music is one of the most important therapies at Winter. A number of patients are given music iessons IF WE CAN LOVE novels rather than to technical treat- ises on Gestalt psychology and psycho- analysis.” TJ HERE are six full-time clinical psy- chologists on the staff, in addition to a large group of resident psycholo- gists receiving training at the Men- ninger School of Clinical Psychology. The nursing staff is one of the largest in the country, with close to 150 full- time nurses. They have all received advanced training in psychiatric nurs- ing, many of them at the Menninger Foundation. They work a 44-hour week (they are paid for four hours overtime) and receive from $220 to $280 a month. The ratio of one nurse to every six patients is one of the highest in the country. There are 21 full-time social workers, many of them graduates of the Men- ninger School of Psychiatric Social Work. Trained in the very latest methods practiced in social psychiatry, they work tirelessly to aid the patient in a readjustment to his social en- vironment. In addition, there are 17 full-time occupational and recreational thera- pists. 32 staff members of the Special Services division, 60 full-time em- ployees of the vital medical rehabili- tation section, and a_ host of other employees in various classifications. Attendants Important HOWEVER, the most important staff members at Winter hospital are the attendants. They are called “hospital aides” at Winter, in keeping with Dr. Karl’s insistence that they aren’t mere custodians or watchers. There are 600 hospital aides at Win- ter. They work a 44-hour week (they also receive four hours overtime pay) and they start at $170 a month. Through various in-grade pay raises, they may work up to $200 a month. Because of the good pay and _ short hours, the hospital has been able to attract top personnel—most of them are veterans in their early 30’s. The ratio of one aide on each shift to every five patients is the highest in the country. Before they start on the wards at Winter, the aides are given an 88-hour orientation course. In addition to ex- tensive class work in the nature and treatment of mental disorders, they are given special lectures in social ser- vice work, medical rehabilitation, phy- sical medicine, and a host of other subjcts. When they go on the wards, their training really begins. They are con- tinually called into conferences with the doctors, nurses, and social workers. Every treatment the patient receives is carefully explained to them, and they are frequently called into con- sultation to give their ideas on activity therapy. I thought this somewhat in- credible until I listened in at a typi- cal case conference in which the aide, a handsome air corps veteran in his mid-thirties, debated with the psychi- atrist on a new type of activity ther- apy being prescribed for one of his patients. Program Praised ALBERT Deutsch, the country’s out- standing lay authority on mental hospitals, has this to say of the at- tendants at Winter: iF WE CAN LOVE r Page 5 “The Menninger system is reflected in the attitudes and actions of the attendants on Winter wards. Tradi- tionally, these key workers have been regarded as cheap, unskilled labor. They used to be recruited mainly from local prisons and poorhouses. Good attendants are often ground down by unbroken monotony, a defeatist at- titude toward the curability of their charges, lack of appreciation, low pay, bad working conditions, and frequently, new attendants are thrown on the wards without any preliminary train- ing or orientation Ignorance of ‘in- sanity’ breeds fear. Fear, in turn, breeds brutality. “The new deal for psychiatric at- tendants, or hospital aides, is already paying heavy dividends at Winter. Patients on the psychiatric wards are handled not only with kindness but with intelligence. The hospital aides take an eager personal interest in helping their patients toward recovery, knowing that their efforts are appre- ciated. A classic example of the fruits of this new philosophy for attendants is cited by staff doctors. A combat dis- chargee hospitalized at Winter hadn’t uttered a word for eight months and frequently. had to be force-fed. In most state mental hospitals, he would have been labelled “chronic” and rele- gated to one of the back wards. Not at Winter. The mute patient’s ward attendant greeted him cheerily each day; for months he persevered in efforts to coax the man into con- versation. Then, one day, a routine question suddenly broke down the wall of silence. The floodgates of speech opened at last, and the man finally submitted to intensive treatment. He wis recently discharged from the hos- pital. New Hospital Idea: Patient Always Right At Winter hospital, the Veterans’ ad- _ministration’s model mental insti- tution, it is the patient who is always right. Dr. Karl Menninger constantly drums into his staff one important idea —that they are well and the patients are sick. Here’s how he put it in a recent article: “Tf we can love: This is the touch- stone. This is the key to the entire therapeutic program of the modern psychiatric hospital. It dominates the behavior of its staff from director to gardener. To our patient who cannot love, we must say by our actions that we do love him. We say to him: “*You can be angry if you must; we know you have had cause. We know you are afraid of your anger, your own self-punishment—afraid, too, that your anger will arouse our anger and that you will be wronged again and disappointed again and rejected again and driven mad once more. But we are not angry—-and you won't be, either, after a while. We are your friends; those about you all are your friends. You can relax your defenses and your tensions. As you—and we— come to understand your life better, the warmth of love will begin to re- place your present anguish, and you will find yourself getting well.’” The Teamwork Concept UPPLEMENTING this philosophic approach is a profound team con- cept in which every technician is given an equal part in an all-out attack on the baffling problems of mental illness. In four years of Army experience, Dr. Will Menninger proved to the “brass” that a team basically composed of a psychiatrist, clinical psychologist, and psychiatric social worker could do three and four times the work of one hard-pressed psychiatrist. The work of the clinical psychologist in diag- nostic testing and interpretation drew this comment from Dr. Will: “We gained tremendously from the help of the clinical psychologist, de- spite the fears and petty jealousies of him that existed in some places. There were a few instances in which the psychologist was more capable than the psychiatrist.” Dr. Menninger also had high praise for the psychiatric social workers who took intensive social case histories and counseled soldiers with the aim of aiding them to make a more effec- tive adjustment to their environment. Summing up the Army’s experience with the neuropsychiatric team, Dr. Will writes: NONE of them separately is ade- quately trained to undertake all of the functions required in the treat- ment process. . . . The work of the psychiatrist is founded on_ extensive medical and psychiatric training; that of the clinical psychologist is based on extensive training in academic, sys- tematic, experimental, and _ clinical training; and that of the psychiatric social worker is rooted in understand- ing of the case-work process as a method of helping people with their social-emotional difficulties. . “The use of auxiliary personnel must be greatly augmented. Faced with the shortage of psychiatrists for years to come, this is imperative. Not only do clinical psychologists and psychia- tric social workers have much to offer in the diagnosis and treatment of mental illness, but we could profit greatly from an increase in psychia- tric nurses and recreational, occupa- tional, and educational therapists.” At Winter, the Army team _ idea has reached full fruition. Psychiatrists, nurses, social workers, psychologists, therapists, aides and even the guards at the gates are co-equals in the job of understanding and treating the patients. No Caste System M* philosophy about running a hos- pital is that every employee is a member of the team,” says Dr. Karl. “Every member must have a clear idea of the purposes and objectives of the team and also of its tactics and methods.” There is no caste system or hierarchy at Winter. Doctors don’t look down at nurses. Nurses don’t snub attend- ants. Attendants don’t take it out on patients. The ideal of group practice is fully realized—the pooling of skills, knowledge and techniques toward a common goal: optimum improvement 7 the patient in the shortest possible ime. The results of this team cooperation are manifested in a hundred different highlights which distinguish this su- perb mental hospital. Take the question of restraint. Dur- ing the four days which this reporter spent studying conditions at Winter, he saw only one patient in any form of restraint. He was a highly dis- turbed patient who wore a pair of wristlet cuffs only when going from one ward to another. “At Winter even the most ‘violent’ wards, tenanted by homicidal and sui- cidal patients, are remarkably free of tension,” writes Albert Deutsch, author of “The Mentally Il] in Amer- ica.” “I didn’t see a single patient encased in a strait-jacket, camisole, muff or other form of mechanical re- straint so frequently encountered in other mental hospitals.” DE. Karl has a simple explanation for this lack of restraint. “If you give a patient a full outlet for his repressed impulses, there’s no need of bottling him up in mechanical restraint. If a patient becomes vio- lently disturbed, we have hydrotherapy tubs and packs to reduce the tension. But most of our patients are too busy taking part in therapeutic activities to develop severe tensions.” One of the staff doctors tells the story of a therapist who put maga- zines and books in the disturbed wards. At first, several of the patients pounced upon the reading material and tore it up. The therapist persist- ently and unobtrusively kept replac- ing the torn material. After a few weeks of alternate ripping and re- placing, the magazines and books were accepted and read in the disturbed wards. Take the question of food. The job of the seven full-time dieticians at Winter is to please the patients, not serve whatever is convenient for the hospital. There are four large dining halls where the patients are served in cafe- teria style. The food is not shoved in front of them-—they select whatever they. want. If they want seconds of any- thing, including dessert, they just march up to the counter and get it. I ate a typical Tuesday dinner with the patients. It consisted of breaded veal cutlet, tomato sauce, parsley po- tatoes, buttered lima beans, cole slaw with a delicious sour cream sauce, bread, butter, strawberry short-cake, and milk. I went up for seconds on the strawberry short-cake, and so did the. majority of the patients. Dr. Karl On Spot THE dieticians are instructed to quiz the patients on the quality of the food, and they get some mighty frank answers. Each ward has a patients’ committee, and one of their major jobs is to check on food. One of these committees, a few months back, decided a cook was put- ting too much salt in the food. The committee made several complaints to the kitchen staff of their cafeteria, but to no apparent avail. So one day, a group of patients marched in to see the boss himself. Dr. Karl listened, a twinkle in his eye, to the complaint. From then on in, things were any- thing but salty in that cafeteria. Page 6 Vast Medical Rehabilitation Program HE outstanding highlight at Topeka’s Winter hospital, the Veterans’ ad- ministration’s model mental institu- tion, is its medical rehabilitation pro- gram, without a doubt the most ad- vanced of its kind in the country. The entire medical rehabilitation rogram is built around the thesis of Br. Karl Menninger, famed director of Winter, that every hour of a patient’s day should be carefully prescribed by a psychiatrist. Every form of modern psychiatric treatment—electro and insulin shock, hypnosis, educational retraining, me- chano, actino, and high frequency ther- apy, psychotherapy through music, drama, and painting, etc—is devised and used for each patient's individual psychiatric needs. “The doctor should know whether the patient in his charge needs vo- cational counselling, athletic exercise, digitalis, a herniotomy or psychother- apy,” Dr. Karl writes. “The fact that the patient fancies it is one fact that the doctor will bear in mind, but the prescription of treatment is not based on fancy. Planned Treatment E consider it not to be our func- tion to amuse patients. It is our function to get them well and unless an amusement (or recreation, or a medi- cation, or anything else around this place) contributes to the recovery of a patient, it is a waste of time, energy, and money to continue it.” Each patient is admitted to a recre- ational or occupational activity only upon receipt of a prescription slip by the trained therapist in charge. Each prescription slip is obsolete after six weeks—the patient’s progress is then reviewed and new activities prescribed. A suggested guide for therapists in handling patients, prepared by Dr. Ed- ward D. Greenwood, chief of the medi- cal rehabilitation division, illustrates the amazing care devoted to prescrib- ing for each type of mental illness. For example, patients who have a narcissistic, self-centered interest in their own personalities to the exclus- ion of interest in the outside world are encouraged to express their nar- cissism in an acceptable manner. This may be done in creation of an utilitar- ian product, in painting or music or, additionally, in taking responsibility for a program or a party. Attendants and therapists are in- structed in attitudes to be displayed toward this type of patient. “Show active friendliness toward this type of patient,” the guide reads. “Take the initiative in making friend- ly gestures by showing special inter- est and thoughtfulness toward the pa- tient. Additional attitudes: Praise for acceptable behavior; encouragement; planning, stencilling, block printing, pattern weaving, jewelry, flower minimize unacceptable and_ protect against unfavorable social situations. “Make a special effort to comply in answering requests of the patient. This may be a way of rewarding the patient for some special effort on his part.” Suggested assignments for the self- centered type of patient include paint- ing, Grawing, pottery, music, party A veteran at Winter hospital works in the radio repair shop arrangements, leathercraft, keeping score in games, umpiring games, teach- ing others, etc. The Agressive Patient PATIENTS who have aggressive, com- bative personalities expressed in surly, stubbo.n, destructive behavior are at the other end of the prescrip- tion list. They need an opportunity to sublimate this hostile activity in more acceptable forms. At Winter, this substitution is expressed through hard work, particularly if it has a destructive element, such as cutting tearing, pounding, jabbing, demolish- ing or smearing. Suggested assignments for the ag- gressive type of patient include metal work, woodwork, tearing rags for rugs, spading, hoeing, woodcarving, bowling, drums, “beating out the pase punching bag, finger painting, etc. It would take several pages to list the multitudinous activities used to treat and rehabilitate patients at win- ter. For instance, in the department of physical therapy where mental or physical disease is treated by physi- cal agents, there are eight major di- visions which use every conceivable agent such as light, heat, water, elec- tricity, mechanical devices, and reme- d\al and re-education exercises in their program. There is one huge ward building for hydrotherapy and pack treatments, and an adjoining building with hundreds of gadgets such as whirlpool baths, needle showers, gal- vanic currents, bicycles, and the like. The physical therapy department alone averages 3,000 individual treat- ments a month! HE educational retraining depart- _ment is devoted to fitting the patient for his return to the outside world. It is probably the most com- plete and remarkable division of its kind in any mental hospital in the country. It is recognized as an accredited high school by the Kansas State de- partment of instruction. In addition to teaching academic subjects, courses in special fields are given so that IF WE CAN LOVE patients may go into specific occupa- tions when they are discharged. Typ- ing, shorthand, book-keeping, music theory and practice, show-card letter- ing, and home economics are a few of the subjects taught. Special activities sponsored by the educational retraining department in- clude a weekly patient newspaper, Winter Round-Up, published by a staff of 20 patients; weekly classes for the showing of educational films: a weekly discussion club in which pa- tients hold all the offices and lead the forum discussions; educational tours in Topeka and neighboring territory; and a daily 15 minute radio program over the hospital’s own radio station, WVAH. The largest department in the medi- eal rehabilitation is manual arts therapy. Elaborate shops in radio and electricity, woodworking, automotive mechanics, leathercraft, and ceramics highlight this division. Large printing, book-binding and photographic shops are constantly crowded with patient apprentices who put out the weekly paper and do the major part of the hospital’s printing. The creative arts division gives patients art instruction in 19 different media. Psycho-Drama, Group Therapy Aid Patients |N addition to individual activity ther- apy, patients are drawn into mutu- al aid activities through the medium of group therapy, which came into its own through its extensive use in the Army during World War II. Group therapy is most important in getting patients to “come out of” themselves and readjust to their fel- low patients and their environment. Under the careful prescription system in effect. at Winter, selected patients are brought together in groups to discuss, in amazingly frank fashion, their fears, inhibitions, and frustra- tions. Mutual confidences relax ten- sion and draw the patients out of unhealthy self-absorption as they gath- er emotional support from one another. In addition to bull sessions and dis- cussion groups, every effort is, de- veloped to promote teamwork = and “resocializing” among the _ patients. Ward teams are encouraged to form basketball, softball, volley-ball and swimming teams. They compete with one another in carefully scheduled games. Uneven contests are avoided to prevent undue loss of self esteem by the losing teams and the ward group it represents. Self government is stim- ulated by having the patients elect ward committees to promote orderly behavior and transmit ward gripes to the authorities. Summing up the results of the ac- tivity program, Albert Deutsch, author of “The Mentally Hl In America’, writes: “Winter has an all-out recovery pro- gram. Nobody there subscribes to the erroneous slogan, ‘once insane, always insane,’ openly or secretly. Every pa- tient is given a break in the push to- ward recovery. Menninger and his as- sociates have charted a 13-hour daily program of activity for cach patient, fitted to his individual needs and ca- IF WE CAN LOVE Page 7 pacities. Great stress is placed on men- tal rehabilitation, wherein patients are given meaningful work to help them back to normal ways of life. No Work Slaves ATIENTS aren't turned into work slaves under the pretense of getting ‘occupational therapy,’ as hap- pens in many mental hospitals, where they are used as substitutes for paid help with an eye to institutional econ- omy rather than to the patient’s wel- are. “Large numbers of patients, else- where, are consigned to deteriorating idleness on the wards, allowed to re- treat farther from reality into the private worlds of fantasy. At Winter you are spared the heart-breaking sight, too often witnessed in other in- stitutions, of long rows of mental pa- tients staring fixedly at blank walls or contemplating their navels, de- generating physically and mentally.” In one special field of rehabilita- tion, the bringing out of a patient’s repressions and inner conflicts through various art media, Winter is way out in the forefront, foreshadowing the fruit- ful psychiatry of the future. Dr. Victor Bikales and Dr. John Adams, both third year fellows in the School of Psychiatry, are doing amazing work in phychodrama, which is the use of dramatic therapy to bring out a patient’s psychological pattern. In most of their stagings, the pa- tients are given specific roles to play, but are instructed to improvise the dialogue and the reactions. Usually a critical situation is outlined, and the patient in the play then requested to act out a solution. For example, a group of patients are told they are adrift in a life-boat. They then act out what they would do ‘in this situ- ation. Effective Psychodrama N these make-believe roles, many patients no longer feel repressed. A young patient would never tell the psychiatrist of his fear of and domi- nation by women, but under the stress of acting out the part of a veteran returning to his wife and mother, he will blurt out all his pent-up bitter- ness. In psychodrama, he unconsciously objectifies his conflicts—all the arti- ficial barriers and facades are torn down because he feels he is merely playing a part. The case of Harry X is most reveal- ing. Harry was a catatonic schizoid, he had not only withdrawn from re- ality into a dream world of his own, but he had slumped into a stuporous state wherein he refused to talk to anyone. His case record showed a long his- tory of severe parental domination. As a result, he was completely lacking in aggression—his greatest worry was his fear of offending anyone. Under the stress of military combat, he cracked up completely. The task was the building up of his latent aggressive impulses, but how? He refused to talk to his psychiatrist. He shook his head negatively when any recreational or occupational ac- tivity was suggested. One day, Harry wandered into the playhouse. He watched the patients putting on one of their little playlets. He came back several times more, gazing intently at the actors but never saying a word. After watching him a number of times, Dr. Bikales came over and asked him if he’d like to play a part. Harry shook his head. However, after a series of dafly urgings, he agreed to try. The problem for Dr. Bickales was to create a situation wherein Harry could display aggression without identifying himself in any way with the dramatic situation. He hit upon the idea of hav- ing Harry play the part of a painter who was submitting his greatest work to a gallery director for exhibition. To create conflict, the gallery director was portrayed as a “stuffy” character who would brush Harry off. Harry Plays a Part THEY ran through the scene. Harry presented his painting to the di- rector. The director flew into a vio- lent denunciation of the painting. Harry became nervous, then tearful, finally rushed off the stage in a panic. When Harry had calmed down, Dr. Bikales came over and talked to him. He asked him why he had given in to the director. Wasn’t the painting the finest thing he had ever done? Harry said it was. Then what right had a stuffy, ignorant director to talk to Harry like that? Harry slowly be- came indignant. Dr. Bikales asked him to play the scene over. This time, when the director start- ed to give 'darry the brush-off, he was almost knocked off his feet by the resultant blast. Harry called him every name in the book. The director consented to hang the painting. Harry is now well on the road to recovery. But the most interesting phase of this case is its amazing, seem- ingly artless, use of group therapy to bring about his metamorphosis. During his withdrawn state, his fellow patients paid little attention to Harry. But as he started to come out of his stupor, they began to take approving notice of him. When he ripped into the director in the play they stood up and cheered him. Dr. Bikales talked to Harry about this. He pointed out that aggressive action, if justified, resulted in appro- val rather than disapproval. ‘Harry now understood, for the first time that his fear of decisive action was wrong. If he wanted the respect of his fellow men, he would have to stand up for his rights. The case of Harry has a somewhat amusing climax. On Tuesday morning, during the week I was there, several patients came rushing into Dr. Bikales’ office. They reported gleefully that Harry was giving one of his attend- ants a terrific verbal lacing. Dr. Bi- kales, hiding a smile, had to go out into the ward and persuade Harry to lay off the badgered attendant. As remarkable as the psychodrama program at Winter is, it is over-shad- owed by the revolutionary work be- ing done with patients in the allied fields of painting and sculpture. Art Useful In Treatment Of Mentally Sick § UPERVISING the program is Miss Mary Huntoon, a brilliant § art teacher who conveys, with mission- ary zeal, her conviction that her pro- gram is sounding new depths in bring- ing to the surface the subconscious of mentally ill people. Scores of patients at Winter, who have adamantly refused to discuss their psychological symptoms, have come into the art studios and painted out, unconsciously, complete histories of their mental illnesses. Take the case of Jack, an air force bombardier who cracked up after being shot down in the ETO. With- drawn tightly within himself, he re- fused to talk of his army experiences. Then one day he wandered into the studio. After a few days of piddl- ing around, he sat down and paint- ed a body in the snow. Near the body was the form of a Red Cross work- er, her hands out-stretched. Overhead was a flaming plane. When he had finished the painting, he broke into hysterical sobbing. A few days later, when he had recovered sufficiently, he talked freely to his psychiatrist for the first time, He told him he hadn’t known what he was painting at first—there seemed to be a force pushing his hand. Then he realized he had portrayed a frightful experience in which his buddy had been shot down. Release Through Painting THE important thing about this re- lease of subconscious experiences through painting is that many of them are forgotten, or traumatic. They are buried deep in the subconscious. In some cases, through the use of nar- cosynthesis (drugs) they are brought to the surface. Miss Huntoon calls the same thing in painting “art synthesis” —the striving to unite the unconscious and the conscious. Equally as important, the patient can objectify his work the same way he does in psychodrama. Where he could not talk of some horrible per- sonal experience or feeling, he can stand off and calmly discuss the way he has painted it. Thus a paranoid with severe persecution delusions will paint a picture of his father with an extra pair of eyes in his forehead. When asked to explain it, he will point out that is how his father seems to him. Many patients do remarkable jobs of painting themselves out of their mental illnesses. Take the case of Mary, a catotonic who had refused to get out of bed for eight months. 'Her case history revealed severe domination both by her father, a rabid religious evangelist, and by an_ over-bearing mother. The first painting Mary did had her mother, her head almost life-size, dom- Inating the scene. In the lower right- hand corner was a little girl in pig- tails sucking her thumb. This was obviously Mary. Mary Paints Her Problem THE emotional strain of painting the first picture was too much for her. Next, she painted a little girl in bed and called the picture “The Return.” She said it was a prophetic painting of herself. The next day, Mary be- came very depressed and returned to bed for two months, bearing out the propheey of the picture. Page & When she returned to the studio, she began for the first time to paint parts of the objective world outside her family. Her third picture showed her looking out of the window at_ the stars. in the fourth, she was walking along the countryside toward a pool. In her last picture, painted while this reporter was at Winter, she painted other people than those of her imme- diate family for the first time. Mary was on the road to recovery. In many cases like Mary’s, patients finally struggle out.from the prison of the subconscious through the magic of art. They make the transition from a subjective, narcissistic world to an outer reality, and this is the first step on the way back to mental health. Many patients also portray complete dream sequences in a series of paint- ings, giving the psychiatrist an un- paralleled insight into their subcon- scious wishes and fancies. Space does not permit mention of the many other media Miss Huntoon uses to achieve art synthesis. In sculp- ture alone, many of the faces and fig- ures chiselled out tell a whole story of a patient’s subconscious life. Miss Huntoon tells several stories of pa- tients who sculpted images of a hated or domineering relative, then smashed the images in a raging fury. This is both good therapy and good catharsis. Dr. Karl Menninger is deeply in- terested in the revolutionary expe- riments of Miss Huntoon. The paintings of her patient-students are hung in every building on the grounds. From time to time art exhibitions are held, with patients getting an inestimable lift upon seeing their work displayed in a formal exhibition. Recently, two former patients had professional ex- hibitions in Kansas City, a remarkable tribute to the genius of Miss Huntoon. It Costs Too Much! |X looking at Winter’s medical. reha- bilitation program in its entirety, you ‘have an immediate wish-fancy that it be transferred to every state mental hospital in the country. But your so- called realist immediately chants: “How fantastic! It costs too much money.” Dr. Karl has a ready answer. “It’s not so much a question of money as of attitude,” says Dr. Karl. “If the state hospital superintendents were oriented to a dynamic psychiatry em- phasizing intensive treatment rather than prison-like custody, they could convince the people and the legisla- tures of the crying necessity for ade- quate appropriations” Dr. Karl is not just mouthing words. Last spring, when budget cutting in congress threatened his entire program at Winter, he wrote a hot letter to Gen. Omar Bradley. “I came into this program because I saw the possibility of developing a @reat thing for the veterans and the nation,” Dr. Karl wrote. “But I, and many others like me, will drop it like a hot-cake if penny wise and pound foolish policies are forced upon it. I am not willing to be connected with something shoddy or_ second-rate, or something for which I must apologize _ Gen. Bradley, instead of reprimand- ing the writer or burying the letter, hailed it and released it for nation- wide distribution. Is it any wonder then, that in two years the Veterans Administration’s care of the mentally ill has developed from a scandal into the major miracle of modern psychia- try? How does the V.A. view Winter hospital today? “We're putting our chips on Winter and the Menningers,” Dr. Paul 'Hawley, V. A. chief of medicine, wrote recently. “We want Winter to be a model for all our veterans hospitals, demonstrat- ing that the best medical care costs least in the end. Topeka is a proving ground.” The Menninger Foundation: Its Training Schools WAY out on the flat plains of Kansas, just a few miles beyond Topeka, stands the Menninger Foundation, the largest psychiatric teaching and re- search organization in the world. To its staff havé come psychiatrists, clinical psychologists, research scien- tists and social workers from all 48 states and 17 foreign countries. Grad- IF WE CAN LOVE uate students from almost as many places are studying there to enter the psychiatric professions. Day in and day out, more than 300 staff members of the Foundation de- vote themselves to the most challeng- ing problem facing mankind—an un- derstanding of the human mind and its motivations. In 1941, the Menninger Foundation was established after years of pioneer- ing work by Dr. Charles F. Menninger and his two sons, Dr. Karl and Dr. Will. In 1946, the Menningers and a few of their close colleagues relin- quished private ownership of the en- tire establishment, its clinic, its hos- pital, its research center, its 35 acres and buildings. Today it is a non-profit organization, dedicated entirely to a public service attack upon the baff- ling problem of mental illness. The Hope of Psychiatry jus enormously expanded teaching program is, in reality, the hope of both American and world psychia- try. Every hospital, clinic, or service organization caring for the mentally ill is severely handicapped by the dire shortage of personnel in the psychia- Patients at Winter enjoying the outdoor poo! on the hospital i ‘ grounds. Aggressive patients who need an outlet for their bottled-up personalities benefit greatly from an hour a day of threshing about in the pool 'F WE CAN LOVE Page 9 tric professions. Leaders in psychiatry, must took to Topeka for the eventual solution of many of their personnel problems. To coordinate the various schools at the Foundation, the Menningers in 1946 organized the Institute for Psy- chological Medicine as the over-all body to give direction to the manifold teaching projects. Under its spreading wing come the Menninger Foundation School of Psy- chiatry, the Schools of Clinical Psy- chology and Psychiatric Nursing set up by the Foundation in collaboration w th the University of Kansas and the Veterans’ administration, the Division for Medical and Surgical Residency Training, and the Field Training Cen- ter for Psychiatric Social Workers set up in collaboration with the V. A. and the universities of Pittsburgh, Kansas, and Southern California. “The most important usefulness of such an institute is its revision of present inadequate concepts,” Dr. Will Menninger writes. “The expanding horizons of psychiatry make the iso- lated and independent teaching pro- grams of psychiatrists, psychologists, nurses, social workers, and therapists obsolete. The modern concept of a clinical team needs implementation in the teaching set-up by integration of all parts.” 1,393 Given Psychiatric Training DURING the past year, the institute gave varying degrees of psychiatric education to 1,393 persons, assuredly a major percentage of those receiving psychiatric education in all the coun- try’s institutions. Because there are only 4,000 psy- chiatrists in the country today, as against an estimated need of at least 20,000, the Menninger School of Psy- chiatry looms as most important in the program. Enrollment in the School of Psychi- atry today stands at 125 residents, one- third of the number being trained in the entire country. The curriculum, worked out in cooperation with the V. A., provides a back-breaking three year course. The students, who come from 28 states, receive the most ad- vanced psychiatric training from a faculty of 30 psvchologists and neurol- ogists, 20 associate members, and a slew of clinical psychologists, social workers, internists, etc. Two Oklahomans—Dr. G.H. Guthrey, Cardin, a second year fellow, and Dr. Frank Adelman, Haskell, a first year fellow—are enrolled in the school. To this reporter’s knowledge, they are the only Oklahomans receiving train- ing as psychiatrists anywhere in the country. When it is realized Oklahoma needs at least 20 more psychiatrists for its mental hospitals, and at least another 20 for clinical and preventive work, the importance of the Founda- tion is quickly realized. Most other states have a similar problem. Both Oklahomans, though they put in gruelling 16-hour days, are enthu- siastic about the school. Learning Dynamic Psychiatry "| BELIEVE we are receiving the finest psychiatric training avail- able anywhere today,” said Dr. Guthrey. “We are not taught descriptive psy- chiatry — merely labelling a patient and then giving him custody. We learn a dynamic psychiatry in which all of us here — attendants, nurses, psy- chologists, and social workers — are equals in a united team giving inten- sive treatment and therapy to every patient.” “T intend to return to Oklahoma to practice psychiatry. I would like to teach at the Medical school — to transmit to medical students what I have learned here. When I went to medical school, what little psychiatric training we received was so superfi- cial it prejudiced most of us against it.” Dr. Adelman concurred with Dr. Guthrey in his desire to return to Oklahoma. : “I’m just a first year man, so I don’t have any definite plans yet,” said Adelman. “I think Id like to work in a V. A. mental hospital. Since the V. A. has uniform standards for its mental hospitals, I know I'd have the same superb facilities we have at Winter hospital here.” School of Clinical Psychology SECOND in importance to the Schoo! ~ of Psychiatry is the School of Clin- ical Psychology, which has an enroll- ment of 20 at present. Both Drs. Karl and Will are continually harping on the importance of the clinical psychol- ogist, pointing out his vital role in diagnostic testing and interpretation, For this reason they have mapped out, in cooperation with the University of Kansas, a_ stiff four-year course leading to a FH.D. in clinical psychol- ogy. The most advanced course of study ever outlined in this field. it includes courses in the psychological aspects of imaginative literature. the psychological implications of cultural anthropology, and so on. Though Oklahoma like most other states, needs at least 20 clinical psy- chologists for hospital and clinical work, not a single state student is en- rolled at Topeka. Eight Research Projects In Mental Illness Underway THE Division of Psychiatric Social " Work has really started to roll dur- ing the bast year. Formed in coopera- tion with the social service division of the V. A., it now trains students from the University of Pittsburgh, Smith College, and Washington uni- versity. Since it is primarily a graduate field training center, it uses Winter V. A. hospital for its field placement and the total resources of the Institute of Psychological Medicine for the train- ing and teaching of social work stu- dents. No Oklahomans are in training there at present, although the state is, like most others, short at least 25 trained social workers. Formal opening of the School of Pychiatric Nursing took place Feb- ruary 1, 1948. It is operated in co- operation with the V. A. and the University of Pittsburgh. However, an elaborate in-service training program for nurses in psychiatry is now con- ducted at Winter hospital. Space permits only the briefest men- tion of the other schools in the Insti- tute of Psychological Medicine. The important division of medical and surgical residency had ten internes this year, but is expanding rapidly to include psychiatric training for residents of the University of Kansas’ medical school. School for Attendants AN experimental 12-week training program for psychiatric aides (atten- dants) was conducted this year. It was run by the psychiatric staff of Winter hospital and fifty fellows from the School of Psychiatry. It was regarded as a highly successful supplement to the 88-hour orientation course now given by the V. A. Expansion plans for the coming year call for a School of Clinical Pastoral Training, two field training courses in occupational therapy, a program of research and training in music therapy, two courses in corrective physical rehabilitation, and a course in physical therapy. Equally as important as the training program of the Menninger Foundation is the pioneering work being done in research to unlock the vast mysteries of mental illness. Research in Mental Iliness With just a pitifully small amount of research being done in the field of ‘mental illness — we spend 25 cents a year per patient for research in men- tal illness as compared, for example, to $100 a year per patient for cancer research — the Menninger Foundation is again a beacon light in the sur- rounding gloom. The Menningers are acutely con- scious of the desperate need for a speeding up and expansion of the research processes. “The real trouble is that psychia- trists and their associates do not know all of the answers,” writes Dr. Will. “Vast sums of money and thousands of hours of the efforts of many different people lie between us and the eagerly sought information. Research must be given every possible support.” Dr. David Rapaport, brilliant head of the research department, is deeply perturbed because teaching and clini- cal services command 90 per cent of the time of psychologists and psychia- trists, leaving little or no time for pure research. “The fact is that well-tested knowl- edge on mental illness is not extant and psychologists and_ psychiatrists are ~~ to use Raymond B. Fosdick’s words — guessing their way along,” Dr. Rapaport wrote recently. “Psychiatry and clinical psychology are in the stage in which there is a great discrepancy between the meagre- ness of teachable tested knowledge on the one hand and the richness of our experience and versatility in the clinical art on the other.” At the Foundation, research work may be divided into four areas. In these four areas, eight large-scale research projects are being carried on. 8 Research Projects | the field of the genesis of mental iliness, the major project is an elab- orate study of infant behavior. The study is attempting to determine which things babies do are normal in the process of growing up and which com- binations forecast pathological devel- opment. The significance of answers to this question in terms of preventive work is self-evident.