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(p. 255) A Tendency in Therapeutics 

(p. 255) A Tendency in Therapeutics
Chapter:
(p. 255) A Tendency in Therapeutics
Author(s):

Donald W. Winnicott

DOI:
10.1093/med:psych/9780190271343.003.0040
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Subscriber: null; date: 12 December 2018

Originally published in the St Bartholomew’s Hospital Journal, February 1944, 7–9.

Sir Henry Dale in his recent Frederick Price Lecture, ‘A Prospect in Therapeutics’, contrasted the present day interest in treatment with the lack of such interest in the days when he was a student. ‘I think, indeed, that the period which I thus recall probably represented about the low-water mark of interest and confidence in remedial value of drugs’. ‘It was disappointing to discover … that treatment would so often be prescribed with no better hope than to make the patient easier by alleviation of his symptoms, leaving Nature to deal, if possible, with the cause of the trouble’. A brilliant description of the new remedies followed.

The enormous recent extension of our power to treat is indeed impressive. However, I hope we need not be dazzled and blinded by it, nor forget the value of the natural tendency towards health and the cure of disease, both physical and mental, which still forms the basis of therapeutics, and whose understanding gives the only good foundation for medical practice. Sir Henry would no doubt welcome the idea that if the instruction of medical students in active therapy should grow at the expense of instruction in what can be done by ‘leaving Nature to deal with the cause of the trouble’, medical practice must degenerate.

To make my point clear I will take two examples of modern therapy and draw attention to the danger of each. First I will mention the treatment of pneumonia by sulphanilamide.

My feelings on this subject, already fairly well formed, were sharpened recently when I found in the ward of a children’s hospital that none of the doctors or nurses had ever seen an untreated pneumonia, so that when a pneumonia patient who had had no drugs had a crisis on the fourth day there was general alarm. The belief was that the crisis in pneumonia could only be the miraculous effect of chemotherapy!

(p. 256) Now it horrifies me to think that doctors and nurses do not know that children with pneumonia recover. I cannot see how chemotherapy can be properly applied unless the natural tendency to cure is recognised and fully used. My hope is that at Bart’s the natural phenomena are properly respected, and that this fear of mine, based on contact with medical students from other hospitals, is unfounded in respect of the hospital that I still love.

Twenty-five years ago Drysdale’s aloof attitude towards therapy did seem rather extreme,i but one cannot help seeing that it is much more healthy for students to become familiar with the natural defences than with the drug miracles, which of course they will be glad to be able to use in their practices.

In saying these things I may be criticised by some who will imagine that because I value the natural bodily defences I am underrating the value of the new drugs and serums. I am sure this is not so.

But it may be legitimately asked: what actual harm is there in over-estimation of the value of drug therapy? My answer is that for every physically ill person who goes to see a doctor for whom therapy by the new drugs and serums can be scientifically justified, there are hundreds for whom this cannot be said to be true. Yet doctors are afraid to let symptoms go untreated, and they tend more and more to make a diagnosis through watching the effect of treatment rather than as a basis for treatment.

My contention is that it is bad for people never to be allowed to get well by natural recovery. People should go to the doctor to get the responsibility for their illnesses shared, but it is a poor look-out if they never do this without being magic’d, so that recovery, if it comes, cannot be felt by the patient to be natural and a sign that he has it in him to live and keep well.

It seems to be bad for patients, therefore, as well as bad for the education of doctors and nurses, that certain actual infections can now be treated almost mechanically, by little more than the administration of the appropriate drug.

The second way in which I illustrate my point of view, although the subject is vast and cannot be properly dealt with in a few words, is in the matter of the treatment of mentally ill people by induction of fits. Various different methods have been invented for the production of fits and these need not concern us here at the moment. The fact is that a very large number of people are being treated by being given fits. This is a matter which the medical profession should look into immediately. In my mind there is an urgency about this tendency in psychiatry, and I think that the medical profession as a whole should take part in the investigation. Perhaps the psychiatrists will take a long time collecting their 100 cases here and their 100 cases there, and sifting the results, whereas the general medical public could give an opinion right away.

(p. 257) To simplify my argument I must assume that no harm is done to the brain by such treatment, although this would be difficult to prove, and also that this form of therapy does sometimes ‘cure’ mental disorder, although this again is not beyond doubt.

The main point is that this form of therapy is having a very bad effect on the medical profession. The principle that mental illness is a disorder of emotional development has recently been established by the front line research workers, and the public as well as the medical profession have seemed to be on the point of accepting this fact, which is comparable to the acceptance of physiology as the basis of physical medicine. But now therapy by induction of fits appears on the horizon, with its promise of a short cut to mental health. This is retrogressive.

The theory that mental illnesses are disorders of emotional development entails certain painful ideas, including this, that there is no sharp line between mental health and mental illness, and that but few can claim either complete emotional development or perfect mental health. It is no wonder, then, that short cuts to the understanding of human nature are tried out with a good deal of hope before they are found to be disappointing. In this matter of mental health it is rather like it was in the field of morals when it was said: let him who is guiltless cast the first stone.

It is easily understandable that many psychiatrists like the idea, though it is a false one, that mentally ill people are as different from normal people as physically ill patients are different from the doctors and nurses who care for them. If the brain tissue can be incriminated all the better. But it is the truth that we seek, and this theory of mental disease is now thought by many to be discredited.

The important thing is that medical students should be informed correctly as to the relation of mental illness, both neurosis and psychosis, to normal emotional development. Let them not be lured aside by those sirens G.P.I.,ii post-encephalitis, primary mental defect and the senile dementias, physical brain conditions that naturally produce mental symptoms. The true compass in psychiatry is the study of that infinitely complex thing, human nature and its development in the normal individual, starting at least at birth. This subject is worthy of the best brains, and is the sister science of physiology, and is at least as complex. Its study requires years of training, and the application of its theories requires in the practitioner the very highest qualities of personality, even more than does ordinary general medical practice. Personal freedom combined with personal discipline is needed in maximum degree. The work is noble and is concerned with a noble thing, human nature. As compared with this the ‘cure’ of a few individuals by giving them fits is like the pithing of frogs to a physiologist.

(p. 258) I know that this is a strong view to take, but it is my sincere opinion.

Incidentally I have never heard of a doctor who prescribes courses of fits having a course of fits himself. This is incomprehensible to me. Would Pasteur or Ehrlich have developed therapeutic practices which they would not have been willing to undergo themselves? I suppose the explanation is that the psychiatrists say they would undergo a course of fits if they were mentally ill, but they do not believe themselves in fact to be ill. They see mental disease as a disease of the brain from which they are free. But for me and those who, like me, believe that the trouble in mental illness is a disturbance of emotional development, and that no one can claim to be entirely healthy in mind or absolutely fully developed emotionally, unwillingness on the part of the psychiatrists who prescribe fits to take fits themselves seems to indicate that they are not sure that this form of treatment is harmless. Conversely, any psychiatrist who is willing to take a course of fits himself now and again seems to me to have qualified for research in the subject.

A further disadvantage of the introduction of this form of therapy is the effect on the public of the knowledge that if they allow themselves to break down and need a period in a mental hospital they may have to be treated in this way, or (what is just as bad to a mentally ill person) may have to decide whether to allow or to refuse this therapy. It is to be hoped that the view will not be expressed that the public will be frightened off mental illness by the new fear which is being generated of mental hospitals. The best trend in modern psychiatry has been that towards inviting mentally ill people to ask for mental hospital treatment early in their illness. At present it is difficult to know where to send an early case as a voluntary boarder, because for the time being there is practically no institution where a mental patient is allowed to find his own power to recover, so great a hold has the new therapy taken on psychiatry.

Naturally, big claims appear for the efficacy of this new treatment, and the profession is only too familiar with the enthusiasm which brings with it its own successes, whatever the nature of the new therapeutic weapon. But it is sad to hear that depression is being ‘cured’ by fits, with no word to remind one that patients who are depressed tend to recover spontaneously if their case is properly managed. It used to be one of the useful things taught by the psychiatrists that depression phases tend to pass. The trouble with depression is in the degree of the persecutory element in any one case. If it is really intended to treat this persecutory element by dramatisation of the persecution by the giving of fits, then this should be done openly and consciously, and great care should be taken to avoid giving fits in cases in which delusions of persecution are relatively unimportant.

As a matter of fact, mild depression phases are extremely common, they occur in the best of us; and they merge into mourning, which is not only a healthy phenomenon but is actually a touchstone of mental health. Not (p. 259) to be able to mourn is a mental disease. Depression, if an illness, is a noble illness. Robert Burton thought its study worthy of long labour, as his text-book proves. Moreover it is true on the whole to say that people emerge from depression phases richer than they were before, knowing from experience that they have weathered the worst storm to which human nature can be subjected.

The tendency now is to deprive depressed people of the opportunity to gain what there is to be gained from natural recovery from depression, and to ‘cure’ them, that is to say, to drive them to pretend that what matters so much does not really matter. As one ‘fits’ patient said: ‘I feel happy since I had the fit, but what is the use of that to me? I know that I am not justified in feeling happy, and that the feeling is false’.

It should perhaps be pointed out that depression is not a rare illness, like pneumonia. It is in fact very much more common than any physical disease. It can be said that we all have to come to terms with depression, either by learning to tolerate frank Monday morning moods, or by developing hypochondriacal interests in physical organs or functions, or by extending the holiday feeling beyond the period of legitimate holidays, pretending that nothing really matters. There is no physical disease that is comparable. Depression can more easily be compared with hunger, which we tend to cope with by eating, and by organising the supply of food. We cope with depression by working, and by choosing the type of work that we do, and by generally organising what we do with our energy.

Yet depression is one of the diseases now to be treated by fits!

Cannot the profession help the psychiatrists to see human nature in the broad, and so preserve a sense of proportion in the treatment of human beings who in their journeyings only too often need a harbour? Must the very harbours be studded with mines? (p. 260)

Notes:

Editorial Note i Charles Robert Drysdale was a doctor, public health campaigner and president of the Malthusian League.

Editorial Note ii General paresis of the insane.