Is Treatment a Good Idea?

(1958)
‘Is treatment a good idea?’ When one poses such a question to an audience like this—an
audience dedicated to the mission of treating patients—he opens himself immediately to one of
three charges: Perhaps he has nothing more to offer than the traditional answer and everyone
hopes he will sit down as soon as he has said what he has to say. If not that, he must be a die-hard
hereditarian who doesn’t think crazy people can be helped and who is optimistic enough to think
that his pessimism will be listened to. Or, perhaps, he is merely employing a speech-maker’s
sensationalism in order to get folks to listen to what otherwise is going to be a very dull talk.
Now let me say at the outset that I do not want to be placed into any of these categories. What I
have posed is an honest question that I believe is worth examining carefully. Moreover, to show
my good faith and make it clear that I am not merely dangling a question in front of you in order
to make you keep your eyes open, let me say at the outset that my answer to this question is going
to be ‘No’.

‘No, treatment is not a good idea.’ Now, will you examine, along with me, the notion of
treatment itself—what it means—what it implies about the nature of man—and, in addition,
some of the serious mistakes the idea of treatment has led us to make. I am inviting you to do
this because I am convinced that a re-examination of the concept of treatment will have a salutary
effect on what we all do as professional people. First of all, I would like to say that, along with
most of you, I still think it is good for people who are sick to get well. In addition, I still think
there are things each of us can do to help them to get well. And I think some of those things are
already being done here and there—not as often as they should be, perhaps, and maybe only
in the out-of-the-way corners of hospitals and clinics, but still they are being done. Sometimes
they are done by professional or administrative intent, and sometimes, you all would agree, in
spite of it.

During the past century the notions of modern science have been extended to the realm of human
behaviour. One of those notions is that everything that happens can be explained in terms of what
preceded it. More particularly, this means that if we know everything that is going on today we
can put it together and tell exactly what will happen tomorrow. Of course, in the down-to-earth
practical sense, it is impossible to know absolutely everything that is going on today. Besides, as
some scientists have recently argued, even if today’s events are known, their consequences
can be predicted only probabilistically. But here I am not concerned with either of these two
interesting reservations on scientific reasoning. What I am concerned about is the effect such
reasoning has on the human enterprise, particularly when the human enterprise begins to involve
itself with the alteration of human behaviour.

Most psychologists, when they try to think scientifically about human behaviour, boil it down to
two notions—something that goes on independently of the person, usually outside his skin, and
something he does which is attributable to that outside event. The former the psychologist calls a
‘stimulus’ and the latter—once he had invoked the notion of ‘stimulus’—the psychologist has no
choice but to call a ‘response’.This little solipsistic invention of ‘stimulus and response’
underlies the major portion of psychology’s scientific efforts to figure out what people are up to.
While these efforts have by no means proved futile, the reasoning upon which they are
based forces a strong bias on what men try to do for each other. If a person’s behaviour
is faulty, change the stimulus—change the stimulus, for are not his responses attributable to
events which preceded them? Once we start to think this way the net result is inevitably to focus
our attention upon the treatment rather than upon the person who is in trouble, as if something
inherent in the treatment itself carries the seeds that will sprout into behaviour. Let us approach
treatment from another angle. Suppose, instead of abstracting the constructs of ‘stimulus’ and
‘response’, we talk about persons in ‘dynamic’ terms. In psychiatric circles this is supposed to be
good and if you are wise you will always be careful to use such language in the presence of
properly educated people, unless you happen to be one of those poor benighted creatures known
as a ‘state hospital’ psychiatrist. It has for some time been a matter of interest to me why it is that
people who can afford to pay private fees always have ‘dynamics’, while those who can’t have
‘diagnoses’. I have observed also that the more fees you can afford to pay the more dynamics you
are likely to have. But, then, this is not what I came here to talk about.

Dynamic interpretations explain human behaviour in terms of such notions as motives, needs,
and incentives, or, if you have invested in the Freudian lexicon, in terms of such artistic
inventions as oedipal strivings, hostility, libidinal cathexes, etc. While, as a model of human
thought, this is more primitive than the stimulus–response—in fact, if the truth is to be known,
even more primitive than Aristotelian thinking—it does provide certain advantages over its
competitors. For example, the dynamic model envisions the determinants of human behaviour as
residing within the person, a more helpful way of looking at the matter if you hope to see him
accomplish anything.

Treatment, under the aegis of dynamic thinking, becomes a matter of uncovering psychological
forces and mechanisms, of venting pent-up impulses, of supporting some self-critical evaluations
and undermining others, and various other interventions in the turmoil of the person’s psyche.
But still, even under this system of thought, the determinants of behaviour, while now residing
within the person, are abstracted from him as extra-personal entities and not altogether his own
doings.

Treatment continues to be undertaken as something imposed from without—something done to

juggle the patient’s dynamics. The person is still a ‘patient’ with all the inert passivity that that
unfortunate term has implied throughout its long history. May I approach my thesis from still
another angle. Mankind has a long history of intolerance and brutality. Over the centuries this
history has been unfolding itself alongside an equally impressive story of expanding
humanitarianism. For a long time it has been firmly believed that when a person went off his
rocker he should first be given loving admonishment, and if that did not work he should be
punished good. In the meantime, medical science had made great progress in treating illness.
Naturally enough it occurred to some physicians like Pinel that it might be better to treat certain
kinds of misbehaviour as if they were symptoms of illness rather than out-croppings of
devilment. This way of thinking has led to the employment of far more humane methods of
dealing with certain people. Incidentally, it has served to create an enormous paradox in our
system of social thought; some people get solicitous treatment for their misbehaviour while
others, judged to be ineligible, get punishment measured out to them. Thus we try to live under
two quite different and quite incompatible psychological systems for explaining human
behaviour and for deciding what we ought to do about misbehaviour.

Treatment, of course, seems to hold more promise than punishment. It seems more civilized to
say that a person is acted upon by forces over which he has no control and that therefore the
corrective measures must likewise be provided by an external agency. By this line of reasoning
any person who finds that he has done something he should not, is constrained to start looking
for someone who will treat him, and while he is waiting for the doctor to come he may apply a
little first aid, such as figuring out how it happened that his mother—the witch—made him into
the kind of a person he turned out to be. He won’t get far with this on his own, of course, because
it requires some pretty time-consuming rationalization, and some kind of treatment, at least in the
big cities nowadays, is not likely to be long in arriving.

Now what has all this to do with the topic of this symposium: ‘Therapeutic Roles in Patient
Treatment’? As you have probably already guessed, I am for assigning the most important role to
the patient himself—only, I would prefer not to call him a ‘patient’.This means developing a kind
of psychology that is not especially popular these days, a psychology that envisions human
behaviour as something initiated by the person who does the behaving. As I see it, such a
psychology would have to abandon such notions as ‘stimulus’ and ‘response’ as well as a lot of
psychodynamic constructs that imply that the determinants of human behaviour are independent
operants within the psyche. Personally, I would just plain throw them all out, but I would be
willing to settle for a compromise if psychodynamic concepts were used differently.

Something else follows from this line of thought. From our present vantage point in the course of
human thinking it now seems to be a historical misfortune that psychological problems were ever
placed in the medical context of illness. The twentieth-century institution which has emerged as
‘the hospital’ is so conceived, organized, and committed that it represents altogether too much
that is unwholesome for the troubled mind. The societal features which enlightened mankind
seeks to reform—a rigid class structure stratifying both for staff and patients, listlessness,
futility, anonymity, loss of family and community relationships, irrational authoritarianism,
regimentation, economic helplessness, endless waiting to ‘be treated’ for something to happen1
and passive conformity to ‘treatment programs’ what the straw boss says is ‘good for you’1 to
mention only a few.

Most of what I have said thus far will seem negative and destructive. If treatment is such an
inappropriate idea what then, one may well ask, are the roles that are to be played by those who
want to help? Certainly one thing becomes clear about such roles: they are to be played out as
person-in-relation-to-person roles rather than as specialist-in-relation-to-illness roles. The
primary question to answer about a staff member is: what do disturbed persons do with him? His
area and degree of competence, when the chips are down, are operationally defined not so much
by his education and list of former job incumbencies as by the practical uses to which he is
put by those who need his help.

Mankind’s approaches to its psychological problems are in for some drastic revision.
The notion of treatment, derived as it is from our fumbling efforts to apply notions of scientific
determinism to human troubles, misplaces the emphasis on the various external roles to be
played. But restoration of the wholesome life is something done by the person whose life it is.
His, then, is the principal role, and any system of psychological thought which envisions other
roles as more important than his will serve only to stagnate mankind’s efforts and turn out, for
somebody to take care of, a generation of helpless creatures who seek ‘treatment’ every time they
slip up, rather than doing something about it themselves.