The Alan Gregg Lecture 1964: SOME ILLNESSES OF MENTAL HEALTH ROBERT S. MORISON, M.D.* Everybody who is asked to give the Alan Gregg Lecture must feel honored and touched. Almost everybody must experience more than a twinge of humility and many moments of self-doubt. I must feel more honored and more humbled than my predecessors since Alan set so many of the standards of behavior for what he liked to characterize as philanthropoids. And, for better or for worse, a philanthropoid is what I have spent twenty years of my life trying to be. When my colleague Warren Weaver gave this lecture, he remarked with be- coming, but’ quite unnecessary, modesty that as a layman he felt unable to comment upon Alan Gregg’s impact on medicine. This task he left to some future lecturer. I do not propose to take on the whole job, but I do think this is an appropriate time to say something about his relationship to that part of medicine known as psychiatry. Beginning in 1931 and for approximately the next two decades, Alan Gregg was responsible for the Rockefeller Foundation program in psychiatry which absorbed approximately two-thirds of the Founda- tion’s expenditures in the medical sciences. For several years thereafter until fis death in 1957, he mamtained close contact with many of the leaders of the field and continued to influence its development by serving on the Council of the National Institute of Mental Health and other advisory bodies. During all those years and in the seven subsequent ones, psychiatry has changed in several unexpected ways. Most unexpected of all perhaps for those who lived through the stringent thirties, psychiatry and its allied disciplines recently have fallen heir to large sums of money. Finally, to make the task of stock-taking easier, there has recently come to hand the detailed report of the Joint Commission on Mental Illness and Health (1) and in July of this year the collection of highly personal and impressionistic essays published by the Atlantic Monthly in a Special Supplement on Mental Iliness. Toward the end of this talk, we might use Alan Gregg’s career as a text to develop some views of how change takes place—how much can it be consciously * Director, Division of Basic Biology, Cornell University, Ithaca, New York. ¥3 7 rs tet on Sep. AG Payoliiat 985 986 Journal of Medical Education VoL. 39, NOVEMBER, 1964 influenced from outside; how much are events determined by some inner dynamic of their own; and how much do they come about by pure chance. Incidentally, I am sure that in one of his whimsical after-dinner moments when Alan was indulging his interest in le mot juste, he must have asked himself or his companions why we so often refer to chance as “pure.” Alan Gregg’s influence on psychiatry was exerted in numerous ways, but it is convenient to consider two broad categories—his work as an officer of The ckefeller Foundation and his influence as an individual an being. The secon eet been far the more important. ois at er vulgar matter of money out of the way. Among other things, it may give us some clue as to what manner of man Alan Gregg was and from where he felt that progress in psychiatry might most likely spring. The first thing that strikes the observer in 1964 is how small the amount of money really was——a little over $16 million in twenty years for psychiatry and kt mn related disciplines. As a matter of fact the related disciplines—neurology, ‘ neurophysiology, neuroanatomy, neurochemistry, and psychology—absorbed 4s rdakegnearly two-thirds of the funds. As might be imagined by anyone who remembers how long it took American psychiatry to develop-any competence in research, virtually all the research supported during this period was in the related dis- ciplines and not in psychiatry per se. The grants were few in number and not very large in size by today’s standards, but they almost all went to men of the very first rank: Cannon, Penfield, Yerkes, Richter, Gantt, Bremer, Granit, Pen- Col it rose, Eysenck, Adrian, Gray Walter, Lennox, and Gibbs. Any study section today would vote any projects of these men a priority in the very top percentile. Help to psychiatry itself went largely for the development of full-time teach- ing departments in medical schools, with smaller portions to training fellow- ships and some experiments in the application of psychiatry, as in mental health and child guidance clinics. Emphasis in the teaching departments was on bringing the specialty more fully into the mainstream of medicine. Often the emphasis was on psychiatry as seen in a general hospital. The hope here was twofold. On the one hand, it seemed that psychiatry was bound to profit by breaking out of its far from splendid isolation in the state asylum and coming to learn some of the new techniques which had proven so effective in medicine as a whole. Conversely, it was felt that psychiatry had much to do in humanizing the increasingly impersonal scientific practice of medicine which, excellent though it had become at prolonging life, still seemed to lack interest and skill in making life more tolerable for many who sought its help. Finally, the policy of generous support for the development of teaching rested on the thesis that the obviously backward state of psychiatry was directly traceable to its failure to attract and train adequate numbers of capable young people. The departments which received the most substantial help during the first half of this period were those at Yale, Chicago, Washington University in St. Louis, McGill, and the University of Pennsylvania. Only bwo. grants were made to a psychoanalytic institute as such—one of $100,000 and co , The Alan Gregg Lecture/Morison 987 the other of $120,000, the first in 19385 and the second in 1938, both to the institute in Chicago. ee _— What can one reasonably say about the result of the grants made by The Rockefeller Foundation almost wholly on Alan Gregg’s recommendation during this twenty-year period? So many other things were going on at the same time that it is very hard to single out the specific results of specific causes. But we can be fairly sure about some matters. For example, the Montreal Neurological Institute presumably would not have existed in anything like its present form had it not been for the help it received from the Foundation. Even more certain is the influence of this Ingtitute in consolidating and extending the North American tradition of the 4eholarly neurosurgeon pioneered by Harvey Cushing. Some of the work in Montreal and even more, perhaps, the devotion of Bill Lennox and his colleagues in Boston turned epilepsy from an almost unmen- tionable horror into an understandable and largely controllable inconvenience. li Much of the other research was of a basic nature which laid the groundwork for the recent great expansion in neurophysiology and neuropharmacology and the even more recent and even more promising synthesis of these two subjects with physiological psychology. Certainly the work of such pioneer human geneticists as Penrose, Tage Kemp, and Kallmann has compelled attention to the important hereditary element in certain incapacitating types of mental disorder. Similarly, Jordi Folch-Pi and Heinrich Waelsch in this country and Derek Richter in England must receive a significant share of the credit for the recent upsurge of interest in the biochemical background of higher nervous function. The original memorandum prepared by a subcommittee of the Trustees which led the Foundation to psychiatry as a field of concentration had stressed the importance of a biological approach, and the program of research grants as actually developed reflects this emphasis very strongly. A clear majority of the grants went to laboratories of genetics, physiology, and biochemistry. Toward the end of the period, an increasing number involved departments of psychology, but here again a high proportion supported work firmly based on the experi- mental method—the studies of Yerkes and Lashley at Orange Park, of Hebb at McGill, or the classical observations on the behavior of small groups by Elton Mayo at Harvard. That part of the program directed at the development of psychiatry as an academic discipline succeeded in.an almost spectacular way. Indeed, there are those who may feel that the plan to orient teaching more closely around the emotional problems seen in a general hospital succeeded perhaps almost too completely. Virtually all American medical schools have now made a large place in the curriculum for the department of psychiatry, and psychiatrists are commonly seen either on the genera] wards or in units closely associated with the general hospital. But what are we to say about the results of this successful effort to put psychiatry back into the mainstream of medicine? Has psychiatry really learned how to do productive research from its colleagues in a 988 Journal of Medical Education VoL. 39, NOVEMBER, 1964 the basic sciences and in the other clinical disciplines? Have internists, sur- geons, and gynecologists learned how to recognize and to deal with the psycho- logical aspects of ordinary illness? The answers are not written clearly enough to be read at a distance, and I can only leave them to you who are nearer to the situation than I am. Particularly difficult to trace is the effect of a series of grants to the National Committee on Mental Hygiene and the National Mental Health Foundation, the forerunners of the present National Association for Mental Health. Alan Gregg was enough of an American to recognize the importance of voluntary association for improving the public welfare, In spite of many discouragements he continued to foster the efforts of the at times pitifully small group of indi- viduals dedicated to enlarging public awareness and arousing public participa- tion in the mental health movement. How much of the recent improvement in psychiatric care in some of our more progressive states and the increasingly favorable attitude of Congress can be traced to such efforts is hard to say, but one suspects that their influence has been considerable. One thing does seem pretty clear and perhaps rather painful. Academic psychiatry has found it too easy to become preoccupied with the psychological problems of reasonably normal people and to leave the hard-core problem of major mental illness to others. Generally speaking, the big. advances in caring for the really seriously ill have not come from American medical school de- partments of psychiatry. Many of them have in fact come from the old-fashioned nerve clinics of Europe. Some of the more recent and very promising drug therapies and even some aspects of so-called milieu therapy have been developed in those despised state hospitals in the United States. Actually, Alan Gregg was aware of these facts, and shortly before his death, I can remember him some- what ruefully reflecting that it was not too comforting to recognize that most, yin not all, the apparently effective therapies had originated in places remote wes from active Foundation interest. But Alan was far too sophisticated a person to be either surprised or unduly upset to find that things had not turned out exactly as planned. Indeed, he was fond of quoting a former colleague (my informed guess is that it was Beardsley Ruml) who said as he looked back on his career that the only times he had failed completely were when he had an idea and had gone about hunting for some individual who would accept a grant to carry it out. Alan knew better than most men how useless it is to try to force events into some preconceived mold. Fated as he was to spend most of his productive years in close association with a field which is so complicated that it drives many men to oversimplified solutions, he never became doctrinaire; he never even pretended to see where the solution was likely to be found. If he favored one path over another, it was only because he felt that majority opinion might be unduly neglecting an obvious possibility. At a time, for example, when it was almost un-American to admit the possibility of hereditary differences, he could be found champion- ing the importance of human genetics. Incidentally, he publicly deplored the The Alan Gregg Lecture/Morison 989 rather curious fact that at one time the American Journal of Heredity had fewer physicians than lawyers on its subscription lists. Many of his addresses contain explicit recommendations to pay more attention to this field and the only time I personally remember his deliberately offering financial support to someone to work on an idea « of his own, the project was one in the field of genetics and behavioral differéfices. But on occasion he could be an equally strong champion of psychoanalysis or of the Kinsey studies. In all such instances his motivation was the same, an anxiety to make sure that a new approach to an obviously important problem not be held up by irrelevant prejudice. It is here, I think, that the really good foundation officer differs most markedly from the really good research worker. The good research man must believe that the solution he is working on is obviously better than all the other solutions so far proposed. The foundation officer must keep his mind constantly open to many different possibilities at once. He must be able to recognize a high quality of operation more or less regardless of the particular content. Alan was very nearly superb at this. He gave his support to many different kinds of research, but the particular projects, whether in genetics, neurophysiology, neurosurgery, clinical , psychology, or, yes, even psychoanalysis were tops in their class. He could well leave it to another generation of judges to pick the “best of show.” Actually, he was an outspoken member of that school of thought that holds that in psychiatry there is little utility in the “best of show” concept. Always he could be found emphasizing the view that human behavior is the result of a complex interaction of an almost infinite number of variables. One must be prepared to look at them all and use every stratagem in the hope of under- standing the whole. Indeed, it seemed to many of us that he was happiest when thinking in terms of medicine as a whole rather than of the specialty of psychiatry to which he was bound by what the jargon of his trade refers to as “program limitations.” Actually, only a small proportion of the papers or addresses in his bibliography deal with strictly psychiatric subjects, and he looked to psychiatry perhaps pri- marily as a means for improving the practice of medicine in general. One of his finest addresses (2) deals with the experiences shared by each of us on the way to becoming a doctor, whether in “Buenos Aires or Bangkok, Kyoto or Karachi, Utah or Uppsala.” Widely read and equally widely traveled, he was more ready than most Americans of his generation to admit that life is after all a difficult and troubled business. He knew also that in the 20th century, more and more people are bringing their troubles and difficulties to doctors. Much of his energy went into seeing to it that the doctors would be better prepared for this kind of responsibility. He even went so far as to ask the American Psy- chiatric Association at its centenary meeting, “Is it met a proper concern n of psy- offer the greatest opportunities for beauty and balance in the life of the spirit?” 990 Journal of Medical Education VoL. 39, NOVEMBER, 1964 As final evidence of his devotion to the broadest possible approach to the doctor's job, we may cite the fact that the only paper I have been able to find which mixes a measurable amount of acid with its irony is called “Narrative for a, Specialist.” It deals with Preserved Jones who in his fifth decade arrived “at the undisputed status of an experienced specialist, overloaded with work, too busy to be lonely, and too tired to be able to reflect without falling asleep.” Finally in his sixties, “From his deliberate ignorance he cannot impart wisdom or, from his embitterment, serenity.” For some minutes past we have been talking about both my first and my second categories together, Alan Gregg’s impact on psychiatry first as a founda- tion officer and second as an individual. We must now turn a little more exclu- sively to the second. In preparation for this talk, I wrote to a dozen or so prominent psychiatrists for their appraisal of Alan Gregg’s impact on their field. Most of them responded generously in apparent eagerness to let as many people as possible know how they felt. I am tremendously grateful for their help and especially for their perspective since, for the most part, I was too close to Alan Gregg to see the kind of figure he cut on a wider horizon. When I received the first of these letters, I couldn’t help noticing how intensely personal it was in tone. It seemed that the writer had interpreted my question about Alan’s impact on psychiatry as actually about Alan’s impact on him. Reaching into my bag of technical terms, I found myself asking whether my old friend had fallen prey to some newfangled mid-life sort of narcissism in which he mistook the image of his field for himself. But then the other replies began to arrive and I found that all my correspondents had interpreted the question in the same way. Obviously, Alan Gregg’s impact on the field was mediated through his extraordinary impact on individuals. He was the phy- sician’s physician, the psychiatrist’s psychiatrist, the administrator’s adminis- trator. It séemed that all of my correspondents had beef in trouble at one time or another, had had a difficult decision to make, or a tricky personnel problem to solve. Without telling them what to do, Alan had shown them what ought to be done, or better still had put the problem in such perspective that the solution stood out almost automatically in bold relief. . Many of you will remember how often he quoted Robert Walpole’s formula of “good sense, good manners, good humor, and good faith.” This typically 18th century emphasis on form and decorum strikes with particular force in a 20th century America which prides itself on having reduced etiquette and social con- vention to a minimum. Doubtless this neglect of the older amenities has enabled us to concentrate more fully on content and substance in a way which has greatly advanced the physical conditions of living. But when Alan Gregg first came into contact with psychiatry (and some of us may feel that it is still true today), the field had relatively little in the way of agreed upon content and substance. This lack of agreed upon substance often led in turn to feelings of inadequacy, guilt, frustration, and anxiety. The resulting emotional charge in the psychiatric atmosphere made it difficult to establish sound working relation- The Alan Gregg Lecture/Morison 991 ships with the rest of medicine and even within the field itself. Into this rather confused set of vortices walked Alan Gregg, if not exactly the glass of fashion and the mold of form, at least a physician with a very unusual sense of style $e and_ cosmopolitan urbanity which transcended the ordinary limitations oF Tae ales or space; and he said in effect, “Look here gentlemen, if you are really not very 95 sure of what you are trying to do, at least you can do it with ‘good sense, good g manners, good humor, and good faith.’ The effect on individuals was very great, and one may guess that a good deal of the acceptance gained for psy- Sg chiatry from other branches of academic medicine came from Alan Gregg’s afro success in making psychiatry look like a reasonable bet. , As I think back on this aspect of his personality, 1 find myself wondering if it ¥ may not have a wider meaning for us today. If we are frank with ourselves, I ~/ think most Americans of my generation would have to admit that they were brought up to be just a little suspicious of good manners and even to think of good sense as being a little bit stuffy. In the development of a new continent there were occasions in which good manners seemed awkwardly out of place and when good sense might hold a man back from taking the risk which would lead to fame and fortune. Even in Europe there was so much that was wrong with the old society of good manners that it finally broke down in a series of unmannerly wars and revolutions. Those of us who were especially interested in science or the creative arts were not particularly struck by the importance of good manners or even of good humor. It would have seemed incongruous to have approached a Pasteur engaged in one of his vigorous scientific controversies with the admonition that “manners maketh man.” Those who actually did attack the first great impressionist painting, “Le Déjeuner sur )’Herbe,” on the ground that it was bad manners look pretty ridiculous now. But maybe we have begun to push our luck too far. It may well be that a continent which will soon be bounded by 1,000-mile-long cities on both its eastern and western coasts will find increasing need for good manners and good humor. The doctrine of unconditional surrender which we proudly flaunted in the faces of our enemies for almost exactly a century was never very good manners nor good sense. Today it well may be suicide. Now let us return for a closer look at where psychiatry stands today, how it got that way, and what we may hope and try for in the future. The two rather different documents mentioned earlier, Action for Mental Health, the report of the Joint Commission on Mental Illness and Health, and the Atlantic Monthly symposium, both agree that we are not doing nearly as much as we might for sufferers from major mental illness. Worse than this, we in the United States are probably not doing as well as several European countries have already been doing for several years. Even the fragmentary reports we have from the Soviet Union suggest very strongly that at least a considerable number of the mental hospitals there are more fully staffed and present a pleasanter, more friendly atmosphere than one finds in comparable institutions in this country. fee, i 992 Journal of Medical Education VoL. 39, NOVEMBER, 1964 On the other hand, visitors from abroad are struck by the amount of time and effort spent on psychiatry in our medical schools and they marvel even more at the amount of psychiatric consultation made available in our schools and colleges. It is interesting to observe that the number of psychiatrists em- ployed in mental hospitals has increased only rather slowly between 1930 and 1960, while the number at Harvard College has grown from something less than one to seven, counting only those on the full-time staff. And the Harvard phenomenon is merely an index of the extent to which upper-class America has come to rely on the psychiatrist to help it bear the stresses and strains of what used to be thought of as normal life. To put the matter in its harshest terms, American academic psychiatry seems very largely to have ignored the already existing demand for its services and instead has devoted most of its energies to creating (or at least bringing to light) a demand which was scarcely felt before 1930. Note that I am not saying that interest in major mental illness and