Psychiatry in the 1990's
Dr. Motti Mark
Director, Mental Health Services, Ministry of Health
Psychiatry in the 1990's
Dichotomy vs. the Holistic Approach in Psychiatry
If I were to summarize the essence of psychiatry, my point of departure would be neither the illness nor the medical position but rather a wider perspective: that of health.
In May 1977, the World Health Organization declared (resolution no. 30.43) as follows: "Health is every person's fundamental right, and it is essential for the provision of his basic needs and for his quality of life." Following this theoretical declaration, the Organization approached health ministries throughout the world, requesting that they implement programs that would bring about the fulfillment of this fundamental right and direct resources towards this aim. During the 1990's, the W.H.O. referred in its "Health Trend 2000" to a resolution that with the approach of the year 2000 we should aspire to a reorganization and integration of mental health in order to represent the widest possible view of the combination of physical and mental health.
The questions which are asked with regard to aims and methodology within the various branches of medicine are relatively standard and clear. The same cannot be said for the area of psychiatry and mental health in which the questions are still unclear and only partially formulated.
David Kahn deals with this problem in a volume of the Psychiatric Clinic of North America which appeared in June 1990 and was devoted entirely to integrated psychiatric treatment, i.e. psychotherapy together with medicinal treatment (in other words, a combination of the physical and the mental). He points out that medical treatments can be divided into three categories:
1) Surgical: A macrocosmic change in the anatomy of a limb/organ by means of technical, structural intervention.
2) Pharmacological: A microcosmic change in the functioning of the cell by means of medicines.
3) Behavioral or Psychotherapeutic: Here the patient is required to perform certain motoric or mental tasks which are aimed at bringing about a change in certain body systems or in the general state of health, or a motoric change or autonomous changes or changes in development, where the principal ingredient or catalyst for change is a behavioral action.
In psychiatry or mental health, the brain is the central biological organ which these treatments involve, especially in the first category (surgical) and even more so in the second (pharmaceutical). The mind, on the other hand, is the observable psychological creation or result of these actions. When we turn our attention to the mind and try to understand what exactly it is that we refer to by that term, we are faced with ambiguous and vague definitions.
Today we make use of integrated treatments. The question of lobotomies (a neurological operation during which fibers of one lobe of the brain are severed) has returned to psychiatry despite the fact that the subject was taboo for many years. Electric-shock therapy is widely accepted, and today we have a clearer understanding of it on the physiological level. Psychotherapeutic procedures combined with medication facilitate treatment of mental patients suffering from schizophrenia and depression. The integrated approach is effective – and even preferable – for disturbances including anxiety, panic, compulsive disturbances, personality disorders, eating disorders, etc.
At the same time, the development of psychiatry is accompanied by a philosophical debate surrounding the dualistic view, i.e. the co-existence of body and mind as two separate entities. I am almost certain that no modern psychiatrist would declare this to be his view, but a great many of us are still influenced by it.
The debate surrounding this view is critical and influential. It is important to emphasize that today, certainly in the Western world, the integrated approach – which supports integration and a holistic perception of the human being as one entirety comprised of systems that are mutually integrated – is far more wide-spread. This view facilitates a more harmonious integration of the efforts of representatives of different branches of mental health. Today we already speak of the location and treatment of depression on the primary medical level and the integration of mental health in all branches of medicine.
Simultaneously, however, the actual fieldwork being done reflects a situation of dichotomy, as though the one area had nothing to do with the other. The move from this philosophy to the integrative approach is a difficult one. I personally doubt our ability to assist the wide scope of patients unless we find a way of inculcating and clarifying the integrative approach and bringing it to bear on every aspect of medical activity and on the health system in general.
The population with whom we deal is a varied one, starting with mild disturbances – concerning which we have little to say in the area of biology – and ending with severe organic problems. Within this continuum of patients there are some who function well, while others can really be classified as suffering from severe illnesses – the category known as the insane. Forced treatment of psychotic patients is a problematic area, while various and even contradictory approaches exist.
At the same time it is important to understand that when we speak of someone who is "insane," we refer to a type of illness which affects the person's basic tools – thought and motivation. This illness involves expressions of a problematic attitude towards family and close social figures. Within the religious community there can also be a problematic attitude towards the Torah authority – the Rabbi. Hence the situation of a patient within a religious community is even more severe. Sometimes the start of the illness is perceived only as insulting and rebellious behavior, but on occasion the opposite is true, and it is specifically the ultra-orthodox community which pinpoints the illness early on and provides shelter and support.
The Holistic Approach – A Jewish Approach?
I believe that the holistic approach does have some points of contact with Jewish religion. Judaism perceives man in his entirety, including illness and insanity. I want to differentiate here between the point of view of the halacha and the point of view held by religious people. Sometimes it is necessary to bring the perception of religious people with regard to mental illness into line with the view of the halacha, and certainly there is a need to introduce professionals in the field of psychiatry to halachic knowledge and a familiarity with the character of the religious community. These groups must be bridged and the patient and his family must be reached in the best possible manner.
In order to demonstrate to what extent Judaism and psychiatry stand on common ground, I quote the Sages:
"'He made everything beautiful in its time' – Everything that God made in the world is beautiful. David said to God, 'Master of the Universe, everything that You made in the world – and wisdom most of all – is beautiful, except for insanity. Of what benefit is a madman, someone who wanders around the marketplace tearing his clothes, with the children making fun of him and running after him, and everyone scorning him? Is this pleasant before You?' God answered him, 'David, are you complaining about insanity? By your life – you will need it and you will be sorry, and will pray for it until I grant you some of it.'" The Midrash goes on to explain how David came to Lachish, king of Gath, and became aware that his life was in danger. He prayed and said, "Master of the Universe, answer me at this time!" God replied, "David, what is it that you request?" He said, "Give me a portion of madness." He pretended to be a madman, scribbling on doors. Lachish king of Gath, observing his strange behavior, said, "Do I lack madmen?" – and released David.
This excerpt allows for two views of insanity. The first is that aspect which was perceived by David – the old man acting like a small child, with the children laughing at him and running after him, the insanity that David acted out. Madness is some type of balance between outer and inner reality. The old man who tore his clothes with all the children laughing at him was, in actuality, a grown adult, but his insanity made him like one of the children. This inability to separate and compartmentalize the two realities – the inner and the outer – may reach the point of the subject wishing for death, and sometimes the solution to this inability is insanity, representing a balance between these two worlds which we, observing from the outside, fail to understand.
The second type of insanity is one brought on at will. If a madman is someone who acts like a madman, and David is assumed to be a madman, then sometimes there is wisdom and thought behind the madness, and it can be a very sophisticated defense system. If this is so then there can indeed be "method in the madness" – we need only recognize the rationale. Does this view have any legal ramifications (e.g. with regard to power of attorney), or any influence on the halachic view of insanity? I shall not deal with these questions, but I would like to make the point that a person who appears insane is not always truly so.
R. Yisrael Salanter and the Definition of the Subconscious
With regard to those inner desires or forces that lie behind insanity, R. Yisrael Salanter emphasized that a person cannot reach completion without "aligning" his subconscious forces, which he calls the "dark forces.” His classic example is that of a man who has a son whom he hates, whom he has erased from his life, and a beloved student, a great scholar. These two live in the same room. A fire breaks out, and instinctively the man saves his hated son first. R. Yisrael Salanter explains that the love here was suppressed, perhaps even sub-conscious, but in the confusion and danger his intellectual considerations fall away together with the hate, and the unknown forces find expression. He emphasizes that these forces are not influenced by rational persuasion but rather by a situation of danger, as above, or by a state of great excitement.
Some sixty years later, Freud described the subconscious and the methods of making contact with it. Although R. Yisrael Salanter had preceded him, the subconscious described by Jewish sages is not the same as that of Freud, although they would seem to originate from the same source. The former is not created through deliberate suppression of inclinations or of unpleasant experiences. The Vilna Ga'on once said, "All of man's actions follow his prime will, and whatever his prime will desires seems positive to him." In other words, the will, or initiative – that action which is followed by behavior – has its source in something primary and basic of which we are unaware, and over which our consciousness has no control.
Social Tools
From intra-psychic structures rooted in Judaism and well understood by Judaism, let us turn to the societal apparatus – the social network support system. Every traditional Jewish community has institutions for assistance, and there is a feeling of mutual responsibility among community members: a world of contact and friendship, a world that is supportive – even without a National Health Law. "All of Israel are responsible for one another" – even without any Knesset legislation, and so it has been always.
The apparatus which we use to deal with existential anxiety consists of these support systems. The Sages’ profound insights provide the religious person with tools with which to deal with mental anguish. Here lies the answer to the anxiety which occupies psychiatry, psychology and the behavioral sciences to such a great extent. Heidegger concluded long ago that fear is the basic human emotion, and all that a person does in the world is in fact an attempt to overcome this fear.
The Tolerant Approach of Halacha and the Mental Health Law
From here let us proceed to the second part – that of halacha. Halacha is extremely tolerant in its attitude towards psychopathology. Its perception is in fact very modern in its treatment of psychiatry, psychology and the holistic mental health sciences. However, we must differentiate between the purely halachic approach and the practical attitude of the religious community towards psychiatric treatment. Here, it is vital that there be some contact between Torah authorities and religious educators on one hand and doctors and other mental health professionals on the other. The Torah's attitude towards medicine is very positive, and a doctor is permitted – obligated – to engage in healing. The patient, too, is obligated by the commandment of "You shall guard your souls carefully.” Does this obligation apply to the above-mentioned madman? Do we force treatment on him or not? This is not the place for a halachic response to these questions, but the response of Israeli psychiatry, which is very advanced in this regard, is highly complex and fascinating.
The new law of 1991 concerning treatment of mental patients allows the regional psychiatrist – take note: “allows,” not “obligates” – in the event of an accumulation of circumstances (e.g. a psychotic patient in a state which presents a danger to himself or to his surroundings), to prescribe – not forced hospital admission, as was the case previously, but rather – an examination. Only in accordance with the results of this forced examination may admission be prescribed. Take note: What is forced is not treatment, but rather an examination. And only at the second stage, only when it has been decided that both conditions exist – illness, in the sense of “insanity,” as well as tangible danger (as opposed to some abstract danger) – can hospital admission be forced.
The previous law, which was canceled in 1991, spoke of "maintenance" for mental patients. According to the old perception, society had to protect itself from the insane and to protect the insane person from himself. In other words, he was forcibly placed in a psychiatric hospital for the purposes of safety. However, the law failed to mention his right to treatment, his right to health. Today, in light of the declaration by the W.H.O. that health is a person's right, and in light of the new mental health law, the moment a regional psychiatrist forces hospital admission on a patient – via the two steps discussed above – the patient is entitled to receive treatment. There is no hospital admission without implicit expression of the patient's right to health. This principle obligates those of us who provide treatment to apply ourselves to the hospitalized patient with the goal of advancing his health.
In addition to the obligation of professionals to study and familiarize ourselves with the society around us, there is a similar obligation that applies to the public. I would imagine that among the audience here there are secular psychiatrists who are far removed from religion and from a religious life-style; nevertheless they are practicing in Israel. If these psychiatrists are serving a Jewish population, it can't be right for them to regard it as vitally important that they study and familiarize themselves with Indian culture in order to treat the post – traumatic syndrome displayed by a soldier of Indian origin from Vietnam, without at the same time realizing the necessity – and, in my opinion, the privilege – of studying his own ethnic sources. Not just out of curiosity and a search for knowledge, but certainly as a resource for treatment as well.
The religious community, too, sometimes has a problem in the form of its ambivalent attitude towards the mental patient. During the early stages of mental illness, the religious community is very supportive of the patient. But the moment that the patient is admitted to a psychiatric hospital, the moment that his contact with reality is broken, the moment that labels are attached to him, the feeling is that the patient is insane for life. Here it is important to broaden the conception and to draw appropriate halachic conclusions as well.
I am certain that halacha also differentiates between someone permanently insane and someone who is temporarily or momentarily suffering from mental illness. And just as Israeli law stipulates that power of attorney for someone insane applies only at certain times and is removed at those times when there is no need for it, so I am certain that similar sources exist in halacha as well.
