December THE AMERICAN JOURNAL OF PSYCHIATRY 1959

THE ACADEMIC LECTURE HOPE

KARL MENNINGER, M.D.2

INTRODUCTORY REMARKS research or a discovery, and it is no dark President Gerty’s invitation to address hour, calling for exhortation or comfort. this assembly of the future leaders of I speak, rather, to the point of focussing our Association was one of the great attention upon a basic but elusive ingredi- pleasures and honors of my life. ent in our daily work-our teaching, our I can well remember my excitement healing, our diagnosing. I speak of hope. when, in company with my father and my Long before love became medically re- teacher Ernest Southard, I attended my spectable, long before Sigmund Freud first annual meeting-the 75th anniversary. demonstrated it to be a basic consideration This was 40 years ago, here in Philadel- in psychiatry, philosophers and poets and phia. I think I have missed only one meet- the common people of the world knew that ing since then. In those days we were a it was essential to our mental health. Per- small, intimate, informal group of a few haps the most beautiful essay ever written hundred; everyone knew everyone. The was about love and its manifestations in program was simple, the entertainment lav- personality. ish and the whole meeting a kind of family To that essay is appended a footnote reunion. Southard and father and many which is often quoted as if it were a others are gone now-but there are new summation. True, observed the writer, elements of a family affair for my brother there are other permanent goods in the Will and myself of which we are proud. world beside love: there is faith, and there In the years since then there has been is hope. But, he added, “the greatest of a vast development in the numbers and these is love.” With this concluding phrase complexity of our organization. I am glad most psychiatrists, I presume, would agree. to have had a part in the planning for its Most of us, I think, would also agree to re-structuring, even though the immediate include faith-the faith that sustains our impact of the suggestions made by the conviction that what we are doing is worth Committee on Reorganization was a shock doing, the faith that our existence has reaction. That 14 of our 18 recommenda- meaning and the faith that our concern for tions have been put into effect is gratify- one another reflects the concern of a ing. But I find the greatest satisfaction in Creator. the emphasis which the program commit- Our shelves hold many books now on tees and officers have placed on our contin- the place of faith in science and psychi- ued self-improvement, on psychiatric edu- atry, and on the vicissitudes of man’s ef- cation, on, for example, academic lectures! forts to love and to be loved. But when it it is from a background of teaching that comes to hope, our shelves are bare. The the topic which I propose to discuss journals are silent. The Encyclopaedia emerged. I would like to warn you not to Britannica devotes many columns to the expect a scientific analysis of it along topic of love, and many more to faith. But conventional lines. The subject does not hope, poor little hope! She is not even permit of that; we don’t yet know enough listed. about it, and it would be presumptuous to I confess I was astonished to discover make the attempt. I am not reporting a this. And yet, I realized that this avoidance of the theme reflected my own attitude. 1Read at the 115th annual meeting of The Time was when for this occasion I should American Psychiatric Association, Philadelphia, Pa., Apr. 27-May 1, 19)9. have chosen as my subject “Love” or 2 Menninger Foundation, Topeka, Kan. “Hate” or “Conflict” or “Instinct” or “Sub- This One 481 IHill11111111111UIliUiliilliliIUIU NX7R-Z43- RY6Q 482 THE ACADEMIC LECIVRE [December limation” or “Symptom Formation”-but far, they presume, they expect or promise never such a thing as “Hope.” It seems al- too much. More often frustration, sad ex- most to be a tabooed topic, a personal mat- perience, or self-depreciation erodes the ter, scarcely appropriate for public dis- confidence required for persistent effort, cussion. And yet-since when has psychiatry and the little candle of hope, which for eschewed examination of our innermost awhile burned so brightly, weakens, sput- thoughts and feelings? Should we not ad- ters and goes out. We see the beginning of here to our professional habit of self-ex- a repetition of scenes so common 25 years amination and contemplation? If we dare ago-hopeless physicians presiding, passive- to hope, should we not dare to look at ly, over hopeless patients. “Psychiatry,” we ourselves hoping? will hear, “has been oversold. The enthusi- This is not the way I began to think asm of inexperience only awaits the dis- about the topic. Nor did I come to it illusionment of time. It is enough if we fresh from struggles with Kierkegaardian bestow kindness and wait for the inevitable. logic, or from brooding over Greek pessi- Hope is for the hopeless, and for fools.” mism, or from apprehensiveness concerning We would like to think that the young the muddled management of unsettled men who pass through our training pro- world affairs. It was all in the day’s work, grams mostly emerge with certain limits so to speak, some preoccupations with the put upon their expectations and certain motivations of the young doctors I teach. guards upon their implied promises, but The miracle of growth has long intrigued with the flame of their hope unextinguished me: the growth of the child, the growth and unextinguishable. We like them to be- of plants, the growth of cultures and the lieve that there is no patient for whom growth of young psychiatrists. I have seen something helpful cannot be done. But we one after another young doctor step for- also like them to realize that the changes ward, fresh from his internship or from the patient desires in himself, or the physi- his military duty, to enter the mysteries of #{149}cian desires in his patient, may not be the psychiatric training. I have seen these ones which come about, may not even be, young men approach the abstruse and in the long run, the changes that it were puzzling material of our field of medicine best to have sought for. It is a responsibility with resolute courage-let us say, rather, of the teacher to the student, just as it is of with hope. the young doctor to his patient, to inspire But behind the fa#{231}adepresented by these the right amount of hope-some, but not acolytes there are often tumults of con- too much. Excess of hope is presumption flicting voices, fearful insecurity and bold and leads to disaster. Deficiency of hope is over-self-confidence. The dramatic picture despair and leads to decay. Our delicate of psychiatry fascinates them, the reputed and precious duty as teachers is to properly resistance to treatment challenges them, tend this flame. the multiplicity of method appalls them. I propose, therefore, that we examine this They are assigned to wards filled with essential constituent of both treatment and vacant or frantic faces, turned now upon teaching. How shall we think of it? Is it “the new doctor.” It is usually long after something which deserves our concern as their initiation into the uncanny world of scientists? Or only as philosophers and mental illness that they can distinguish poets? Is it only an epiphenomenon of life the moving process, or would have the and the healing art? Do we, perhaps, tacit- personal experience of interaction with a ly ascribe hope to temperament, a sort of recovering patient. fringe benefit deriving from certain fortui- Nevertheless, the novitiates assail their tous congenital arrangements of glands and tasks headlong, sometimes with a furor neurons? This is slight improvement upon therapeuticus. There is nothing mercenary the humoral theories of sanguinity and or aggressive about this. They are not melancholy treasured by our forebears. If working for money. They are struggling to we ascribe hope, as some psychoanalytic become effective in a new kind of relation- writers have done, to recollections of ma- ship with patients. Sometimes they go too ternal infallibility and recurrent oral grati- 1959 1 KARL MENNINGER 483 fications, what combination of these experi- indeed of St. Paul, writing to Greek friends, ences shall we regard as optimum? Others to declare that hope should stand along have seen in hope a prevailing note of fear, with love. In this Paul was loyal to his a counter-phobic denial of the horror and Hebrew heritage (Psalms 42, Isaiah 40) as despair born of self-destructive trends or of well as his Christian convictions. For while the immanence of existential doom. the Jews were, to be sure, people of faith, More congenial to my thinking is the they were also at all times a people of ascription of hope to the mysterious work- hope who, despite tribulation, clung to the ings of the repetition compulsion, the very expectation that the Messiah would come essence of which is a kind of relentless and and the world get better. Hence, with the indefatigable pursuit of resolution and spread of Christianity and the dispersion freedom. I would see in hope another as- of the Jews, hope had its missionaries, and pect of the life instinct, the creative drive Paul was one of them. which wars against dissolution and destruc- Martin Luther, like St. Paul, shook his tiveness. But some will say, with Freud, fist at Greek fatalism and declared: “Every- that this is only our speculative abstractions thing that is done in the world is done by to supply a model for practical thinking hope.” Samuel Johnson opined that “where and behavior. Our mythology, he called it. there is no hope there can be no endeavor,” Here we might pause a moment to con- and our own countryman, Emerson, took sider another mythology about hope. Pan- up the cudgels for hope: it is by his hope, dora, it will be recalled, was an agent he said, that we judge of a man’s wisdom. in the infliction of revenge of mankind by “You cannot put a great hope into a small an angry Zeus. Curiosity led to her opening soul,” said another (Jones) and Tennyson’s the box from which all the evils now in the words, “The mighty hopes that make us world emerged. Biting, stinging creatures men,” now echo in our ears. flew through the air and attacked mortals; But many poets have tended to accept but remaining behind was one good little (rather bitterly) the fatalistic if not cynical sprite, man’s consolation, Hope. But if view of the Greeks: Hope was a blessing, why did she remain Hope-fortune’s cheating lottery, where for one in the box? And if, on the other hand, she prize a hundred blanks there be. (Cowley, was an evil like the rest, perhaps even 1647) the worst evil of all, why did she not fly out with them and begin work? Worse than despair, worse than the bitterness The Greeks mostly did consider hope an of death, is hope. (Shelley: The Cenci, 1819) evil. The Greek philosophers and the later Hope is the worst of evils, for it prolongs the Greek literature tended more and more to torment of man. (Nietzsche: Human All-too- the view that since fate was unchangeable, Human, 1878) hope was an illusion, “the food of exiles” (Aeschylus) and, indeed, “man’s curse I have had some patients who agreed (Euripides). Quotations from Solon, Si- with these poets. Partly that is why they monides, Pindar, Thucydides and others were patients. But when I searched the say this in different ways. The Greek feeling literature for some kind words about hope, about hope is vividly expressed in Anouilh’s I experienced some uneasiness lest I find adaptation of Sophocles’ Antigone, where, that very little (that my colleagues would referring to herself, the heroine cries, “We accept) had ever been said for hope! And are of the tribe that asks questions, and we very little I found, indeed. But the cup- ask them to the bitter end-until no tiniest board proved not to be entirely bare. Par- chance of hope remains to be strangled by ticularly Dr. Thomas French, in his 5 vol- our hands. We are of the tribe that hates ume examination of the psychoanalytic your filthy hope, your docile, female hope; process, has dealt extensively with hope as hope, your whore. .. .“ the activating force of the ego’s integrative From this one can see that it was intrepid function.

Which Creon interrupts with “Shut up If you Anouilh, Jean: Antigone and Eurydice: Two Plays. could see how ugly you are, shrieking those words London: Methuen, 1951. 484 THE ACADEMIC LECTURE 1 December

Twenty years ago Mrs. Menninger and I When Doctors Bartemeier, Romano, Ku- submitted the thesis in Love Against Hate bie and Whitehorn and I went to the that hope was the dim awareness of un- European Theatre of World War II for my conscious wishes which, like dreams, tend brother Will and the surgeon-general, we to come true. We said, arrived at the Buchenwald prison camp a few days after it had been entered by our There is no such thing as “idle hope.” The armed forces. What I remember most vivid- thoughts and hopes and wishes that we en- ly of that terrible place was something we tertain are already correlated to the plan of didn’t actually see. But we heard it at first action which would bring these about, even hand. The night before we got there, our though the whole project is ultimately re- U. S. Army doctors had given what they nounced as too difficult or too dangerous. called a “smoker” for the physician pris- This essential identity of hoping, wishing, purposing, intending, attempting, and doing is oners they had discovered and released. a little difficult for the practical common-sense It was a kind of unearthly medical society man to grasp, because for him it makes a great meeting. Army rations were put out as difference whether a thing is executed or only refreshment, with some wine and tobac- planned or only hoped for. There is an external co, incredibly relished by the emaciated but difference, to be sure; and there is an internal overjoyed guests. Communication in words difference, too. But internally, (psychological- was imperfect because of language difficul- ly) from the standpoint of motive, there is no ties, but the spirit was unmistakable. The difference. There is a difference in the fate of members of a fraternity were reunited. the impulse, the degree with which it is cor- And in the spirit of the fraternity, experi- related with reality, inhibited by internal fears, ences were exchanged. supported by other motives, etc.-but the mo- These doctors, prisoners along with all tive force is the same. . . . The hopes we develop are therefore a measure of our ma- the others, had followed the same routines turity. of 4:00 a.m. rising, shivering roll calls, day- long drudgery on the Autobahn, shivering At that time it seemed to me that educa- roll calls again, and finally a cold bowl of tion best expressed the hope of the human thin soup. They were starved and beaten race. But today I think I see the expression and overworked like all the others, with no of hope in many clinical phenomena, as reason to expect any other fate than the well. miserable death and cremation which they Each of us here who has been in prac- observed about them daily. tice more than a decade has seen the “hope- But now comes the surprise. At night, less case” recover. And we have sometimes when the other prisoners were asleep, these seen, or so it seemed, that a mother’s or thin, hungry, weary doctors got up and father’s indomitable hope was a factor in huddled together in a group, and talked. this recovery. True, we have also seen hope They discussed cases. They organized a deferred making the heart sick. But hope medical society. They prepared and pre- must be distinguished from expectation. sented papers. They made plans for im- “We are saved by hope,” wrote St. Paul proving health conditions. Then they began to some Roman Christians, “but hope that to smuggle in materials to make various is seen is not hope: for what a man seeth, medical instruments. And finally they built, why doth he yet hope for?” of all things, an X-ray machine! The pieces Nor is hope identical with optimism; had to be found somewhere; they had to optimism always implies some distance be stolen, they had to be concealed in the from reality, as Marcel points out, so that prisoners’ clothes; they had to be carried obstacles appear attenuated. The optimist, back to the prison on the long, weary like the pessimist, emphasizes the impor- marches after work. The guards had to be tance of “I.” But hope is humble, it is bribed or otherwise thrown off the scent. modest, it is self-less. Unconcerned with But little by little, with the aid of some the ambiguity of past experience, hope engineers and electricians among the pris- implies process; it is an adventure, a oners, these doctors put together a work- going forward, a confident search. able X-ray machine and used it, secretly, 1959] KAL MENNINCER 485 at night, in their efforts to ameliorate the of hopelessness, all avenues of escape ap- lot of their fellow prisoners. This was what pearing to be closed.”4 dedication to medicine and humanity could This is not an isolated observation or do-kept alive by hope. hypothesis. For example, from a large But, someone who remembered may ask, amount of psychosomatic investigation En- bitterly-what of the thousands who died gel and his associates in Rochester, New miserably for all the hopes they nurtured? York, consider that what they describe as Even here I would not concede that hope “helplessness” and “hopelessness” reflect a had altogether failed. I would believe that necessary if not a sufficient condition for hope had sustained them in their martyr- the development of organic disease. dom, and that their hopefulness, however And then there is the Queequeg phenom- frail and tortured and ultimately defeated, ena of “Voodoo Death” in Moby Dick was communicated on down through prison which Walter Cannon and others have generations to those who were ultimately amply substantiated with authentic data freed and brought us the record of this from primitive societies. No doubt most of medical miracle. Who can read the elo- us can recall instances in which the loss quent last messages of the condemned as of hope seemed to accelerate the arrival collected by Cottwitzer, Kuhn and Schnei- of death for a patient. There are many such der and published as Dying We Live, and stories, unconfirmed of course but highly fail to catch a spark of hope from them? suggestive, in the daily press. Confirmation for the sustaining function All of these things seem to me to sup- of hope in life has recently come from a port the theoretical proposal that hope most unexpected quarter-the psychobio- reflects the working of the life instinct in logical laboratory. At the annual convention ‘ Richter, C. P.: Sudden Death Phenomenon in of the American Psychological Associa- Animals and Humans. Unpublished Manuscript. tion in September 1956, Curt Richter of Schrnale, A. H., Jr.: Relationship of Separation Johns Hopkins reported an astonishing and Depression to Disease (i) A Report on a phenomenon. It was simply this, that when Hospitalized Population. Psychosomatic Medicine: July.Aug. 1958. pp. 259.277. placed in certain situations which seemed 6 For example: “Blasts End Mother’s Will to to permit of no chance for escape, even Live,” Tucson, Arizona. vigorous animals gave up their efforts and Twelve days ago, Mrs. Helen E. Hopke lay in her bed fighting to stay alive to see her daughter’s rapidly succumbed to death. This was ob- wedding. served experimentally in both laboratory Incurably ill for the past five years, Mrs. Hopke rats and wild rats. “After elimination of the had been indirectly responsible for the meeting about hopelessness feature,” reported Ritcher, a year ago of her daughter, Rose Marie, 20, and the girl’s intended husband, Arthur Woodrow Hudson, “the rats do not die... (Indeed, the speed 26. of their recovery is remarkable). A rat Rose Marie had acted as nurse and housekeeper that would quite certainly have died in to her bedfast mother. While buying medicine she another minute or two, becomes normally met Hudson, a pharmacist in a local drug store. Friends said it was the girl’s first romance. active and aggressive,” swimming vigorous- They also said all that kept Mrs. Hopke alive in ly for 50 to 60 hours. Ritcher emphasized recent months was the thought of the impending that not the restraint alone, nor the immer- marriage. sion, nor the exposure, nor the trimming of The 56.year.old mother heard the couple enter the house laughing and talking about the April 4th whiskers will explain the phenomenon. It wedding. She heard them enter the next room. is, he insisted, the loss of hope. Their chatter ended in three blasts from a shotgun. Richter added some confirmatory data Police said Hopke, opposed to the marriage, wanted from other fields and suggested an extra- his daughter to continue to care for her mother. He became enraged at reading the wedding notice in polation from his laboratory observations to the paper, shot the couple then turned the gun on explain the occurrence of sudden death in himself. rabbits, chimpanzees, foxes, raccoons, some Rose Marie was taken to one hospital where she birds, musk oxen, otters, mink and even is recovering. Her mother was taken to another. Tuesday night, Mrs. Hopke died. human beings. “Some of these instances,” (Topeka Daily Capital, he said, “can best be described in terms Thursday, April 2, 1959) 486 THE ACADEMIC LECTURE [December its constant battle against the various receive only placebos sometimes show forces that add up to self-destruction. It much improvement. In one study that I would be too narrow to regard it as a form know about, testing an excellent drug, more of refined narcissism since, as Marcel points patients in the group which had only place- out, there is something essentially unnarcis- bos were able to be discharged from the sistic and beyond self in hope. One sees hospital than from the group of those who this in the hopefulness, not of the patient got the actual remedy (although a larger but of the physician. How much our pa- number of the latter showed marked im- tients do for us doctors! provement). We in Kansas have lived through the Another phenomenon that is perhaps re- experience of a state hospital revival. Al- lated to hope is the sudden improvement though we have built almost no new build- and even recovery of patients who have ings, and although our admissions have in- been for a long time fixed, as it were, at creased tenfold in 15 years, our once over- low levels of organization and regression. crowded patient population has steadily A new doctor arrives, or a new aide, and diminished until we now always have avail- the patient promptly and most unexpected- able empty beds. We have even closed ly begins to recover.7 some wards as unneeded. We are proud Whatever the explanation offered for of this, and proud that the voters and such phenomena, to invoke suggestion or officials of our state appreciate it, and con- coincidence (whatever they are) will not sider the cost per stay more significant than suffice. There is more to it. And yet we the commonly used cost per day. A dis- doctors are so schooled against permitting tinguished governor visited us for several ourselves to believe the intangible or im- days, determined, as he said, to “discover palpable or indefinite that we tend to dis- the secret.” “Our state has more men and count the element of hope, its reviving more money than Kansas,” he said. “Why effect as well as its survival function. Be- can’t we do these things?” cause of the vulnerability of every doctor He didn’t discover the secret partly to the temptation of playing God and because he didn’t believe what we told him. taking the credit for the workings of the Many of my colleagues in this audience vis medicatrix rsaturae, we are necessarily may not believe it now, either. But we extremely cautious in attributing change to consider the crucial element in the Kansas any particular thing and least of all to our state hospital program to have been the own wishful thinldng. inculcation of hope. Not in the patients There are many sufferers in the world, directly, but in the doctors and all those and there are many who seek to afford who help them, in the relatives of the pa- them relief. Among the latter there are tients, in the responsible officials, in the those who use intuition and magic, and whole community, and then in the patients. there are those who attempt to derive basic It was not just optimism ; it was not faith; principles checked by experiment and ob- it was not expectation. We had no reason servation, which we call the scientific meth- to expect what happened, and what still od. For the former group, healing is more happens, and our faith was only that which important than truth ; for the latter, truth all scientists share. But we did have hope. is more important than healing. Indeed, We had more than hope, you will say; the search for truth, the desire to heal, and we had had experiences which encouraged the earning of one’s living are three persist- hope. But these experiences were them- ently confficting forces in medical prac- selves based partly on hope, confirming tice. the assumption that hope fires hope. This is not a conscious process, or at least not TBut it is also true that just the opposite occurs: A patient on whom intensive efforts have been made entirely so. I have wondered if we might fails to respond and is given up in despair, dismissed perhaps understand the placebo effect in by her physician or removed to a custodial hospital. this way, a transmitted hope or reinocula- We have all frequently seen this result in a prompt improvement and even recovery. Perhaps we could tion, as it were ? In control research studies regard this as an awakening of dormant hope by a of the new drugs, for example, patients who desperate and unintentional shock.ty’pe method. 1959 1 KARL MENNINGER 487

In the daily performance of healing acts, were the physicians, with their plasters and the scales are weighted heavily against clysters. All were busy “treating.” scientific truth. Patients long to be de- Out of this confusion, under the leader- ceived. Driven by pain and desperate with ship of a gallery of immortais on pillars fear, they are ready to seize at “straws of erected here and there over a wide area, hope.” They prostrate themselves before there slowly arose the magnificent edifice the doctor; they queue up in weary, strag- of modern, scientific medicine. The elimi- gling lines awaiting the opportunity to nation of superstition and magic took a cen- submit themselves to humiliations and new tury, but the purge strengthened medical sufferings, or even to hear a few words of science mightily. Thousands of remedies reassurance. Beseiged by such multitudes of were tested, found wanting and discarded. petitioners, often with gifts in their hands, Many improvements in diagnostic tech- the doctor, knowing his limitations, must niques and instruments were introduced. try to be patient, kind and merciful-but Treatment, except for the most superficial simultaneously “objective” and honest. The palliation, was apt to be regarded with desire to bring comfort, the need to earn great suspicion, while the memory of re- one’s living, the suppressed longing for cent quackery, pretention and deceit was prestige and popularity, the honest con- fresh. viction of the efficacy of a pill or a program, In psychiatry, the efforts of our predeces- sympathy for the pleading sufferer-all of sors to bring order out of the apparent cha- these throw themselves upon the scales os of the phenomena of madness were re- in the moment of decision. Every physician flected in assiduous efforts to describe dis- in the world has heard the devil whis- ease entities, to name them, to identify pering, “Command that these stones become them, to graph them, and to seek for “etiol- bread . . . All these things I will give thee ogies.” This was the traditional concept if thou wilt fall down and. . .“ And some- of diagnosis and it offered little to justify times he falls down. He exploits the pa- hope. The broken or misshapen personal- tient’s hope. ities coming under medical observation Against such dangers there have been were described or christened with tens of for 25 centuries an oath of loyalty, a tradi- thousands of names and groupings, pains- tion of humility, and certain maxims of takingly put together by assiduous workers, practice. One of the latter is the putting only to be discarded by those of a later of diagnosis before treatment, empiricism generation. These old labels, like epitaphs before hope. Even in pre-scientific days it on tombstones, may be read with sober re- was indefensible for a doctor not to indi- flections that life is short and the art long, cate some comprehension of what one that our grasp of human phenomena is claiming to be a healer was dealing with. limited and narrow, and that our concepts For the patient, even a diagnosis offered are ever changing and unclear. some hope, since it showed that his condi- Once diagnosis in the sense of recog- tion was not unique. But for the doctor, nizing, naming, classifying and distinguish- who was better acquainted with tie impli- ing between different forms of behavior cations of a diagnosis for which he had no disorder seemed of fundamental impor- real treatment, the temptation was ever tance. The best psychiatrist in my early present to neglect diagnosis in the interests days was one who could most convincingly of hope, or at least in the interests of treat- distinguish between some of the many ment. varieties of “paranoia” or “dementia prae- It should be remembered that there were cox”8 or “psychopathic personality.” Some once many different kinds of competing of my colleagues “discovered” new varieties healers. There were the apothecaries who of these; I even thought that I did. in 1617 were granted a charter permitting Today it seems to me most important that them to sever their 200 year association we not do that. Our impressive labels only

with the grocers. There were the various 8 A term introduced 99 years ago by B. A. Morel trade guilds: the barber-surgeons, mid- in 1860 describing the mental condition of a boy of wives and bone setters; and then there 14 years. 488 THE ACADEMIC LECIVRE [December reify and freeze a phase of aprocess ; they giving them a name. That is not the basis misrepresent our modem concepts and they of our hope, and if it is the basis of Smith’s strike a blow at hope, and hence at treat- hope, it is one we should not exploit. ment. Words like non coinpos mentis or It is our responsibility as physicians to “responsible” and “irresponsible” really in- instigate some change in the relations of dicate only whether or not we think an Smith to his environment-directly if pos- accused person is able to appreciate being sible, indirectly and gradually most likely. executed. “Psychotic” and “neurotic” can- To do this we must attempt to understand not be competently defined, since what the man, how he has become what he is, they mean at any one moment depends up- what goes on inside of him, what goes on on who is using them to describe whom. around him and how these interact. By Many of us have urged their abolition, but observing the internal and external proc- they persist as weapons in scientific name- esses we can discover what in his world calling. Some colleagues incline to label is good for Smith and what is unbearable, “psychopathic personality” all patients who what damage he inflicts upon himself and admit having broken the law. And surely others, and what potentials within him re- it is more than a little disturbing to us all main underdeveloped. And here enters in to contemplate the results of the recent hope, for we acquire, thus, a rationale for researches by colleagues Hollingshead and therapeutic intervention. Redlich exposing the fact that what one This is what we now call diagnosis. It gets called by psychiatrists depends to a were better to call it diagnosing, to indicate degree upon what class of society one its transitive, continuing nature, its look comes from. -toward the future rather than toward some- But over and above the matter of social thing static or past. Diagnosing is the first and political and medical misuse of terms, step in a cooperative relation between these diagnostic designations belie the patient, physician and environment work- progress we have made in understanding ing toward the betterment of a situation, the nature of illness. A name is not a diag- especially as it affects our patient. This nosis. It does not determine treatment. Its is based upon hope, hope implicit in our original purpose, perhaps, was to distin- effort and hope nurtured in our patient. guish between wise and foolish expecta- The practice of medicine today is vastly tions, but its net effect has come to be that different from that of a hundred years ago of destroying hope. when Samuel Gross wrote (1861): Today there is a trend away from names, It requires no prophetic eye, no special fore- states and entities and toward dynamics, sight, to discover that we are on the very relativity and process. Just as the nature of verge of one of the most fearful and wide- matter has assumed a new aspect, so the spread revolutions in medicine that the world nature of disease has come to be under- has ever witnessed.9 stood differently. The only entities in dis- ease, said Allbutt long ago, are the indi- That revolution came about (Dr. Earl vidual patients, Smith and Jones, in certain Bond reviewed it this morning) but not so phases of their being. “Diseases are not soon as Gross expected. Yet it is hard to specifics such as cats and mushrooms; they believe today that there was ever a time are ‘abnormal’ behaviors of animals and when a doctor had to defend himself to plants.” Today we are following Allbutt. his colleagues if he claimed to have cured It is the privilege of some of us to be someone. In those days hope was faint and called doctors. And if the peculiar phases precious. Today it seems sometimes almost of existence which Jones and Smith are as if hope was considered unnecessary. experiencing lead them to approach us in The revolution that elevated our medical the belief that we can help them, they can profession from a discouraged, submerged then be called patients and their afflictions may be called disease. But we cannot dis- Gross, Samuel: Quoted by Leikind, Morris C.: The Evolution of Medical Research in the United charge our responsibility by “calling.” We States. In History of American Medicine. (ed. Felix may not exorcise Smith’s afflictions by Marti-Ibanez) N. Y.: MD Publications, 1958. p. 126. 1959 1 KARL MENNINGER 489 state to a progressive and confident one they said. Penicillin and the other miracle was partly the result of new discoveries, drugs are more definite and exciting than and partly from the recognition of psychol- the dreary wards of state hospitals, filled ogy as one of the basic medical sciences, with silent, staring faces. along with physics and chemistry. This We can see, now, that these students had came about from the experiences of World been shown the wrong side of psychiatry, War I, and from the discoveries of Sigmund its failures rather than its successes. But Freud. The latter were introduced into one thing struck me then which has re- American psychiatry about 1920, the way mained in my mind indelibly. I perceived prepared for them by J. J. Putnam, Ernest vividly how hopelessness breeds hopeless- Southard, Adolf Meyer, William A. White, ness, how the non-expectant, hope-lacking A. A. Brill and Smith Ely JellLffe. or “unimaginative” teacher can bequeath I cannot describe all of these old friends to his student a sense of impotence and here, but I must say a word about South- futility, utterly out of keeping with facts ard, because he was my teacher and be- known to both of them! Surely even cause above all men I have known, and these misled students knew that some psy- entirely out of keeping with the spirit of chiatric patients recover, even if they didn’t his day, he placed great hope in psychiatry. know that the vast majority does so. But He said here, long ago, in 1919, remember: like their teachers, they adopted some of the very symptoms of their patients: hope- May we not rejoice that we (psychiatrists) lessness and goal-lessness! Physicians in are to be equipped by training and experi- state hospitals at that time did not expect ence better, perhaps, than any other men to their patients to recover, and were a little see through the apparent terrors of anarch- surprised when recovery occurred. Some ism, of violence, of destructiveness, or paranoia superintendents quite unabashedly an- -whether these tendencies are showing in nounced (published) recovery rates of 5% capitalists or in labor leaders, in universities per year! or in tenements, in Congress or under deserted This experience only reinforced my con- culverts. . . . Psychiatrists must carry their analytic powers, their ingrained optimism and viction that hope, that neglected member their tried strength of purpose not merely into of the great triad, was an indispensable the narrow circle of frank disease, but, like factor in psychiatric treatment and psy- Seguin of old, into education; like William chiatric education. James, into the sphere of morals; like Isaac At the end of the war, veterans re- Ray, into jurisprudence; and above all, into quiring continued psychiatric treatment be- economics and industry. I salute the coming gan returning to this country in large num- years as high years for psychiatrists! bers, and at the same time the physicians who had seen these phenomena of stress These “high years” really began after and overstress develop and recede were Southard died. The public had been alerted demobilizing. Many of these doctors now by the literary dissemination of the discov- sought to learn more about this psychiatry eries of Freud and also by the growing which seemed so important in understand- “mental hygiene movement.” Most doc- ing these cases. During the first few months tors had had almost no psychiatry in their of its existence, the Menninger School of medical school training. Twenty-five years Psychiatry received over 600 applications. after Southard had spoken those prophetic Other training centers were similarly words-and died-we were in the midst of flooded. another World War. There was a shortage Some of them no doubt came into psy- of psychiatrists. To enlist interest and re- chiatry because of an awareness of their cruit doctors, I visited medical schools over own threatened disorganization and the the country and talked at length to stu- dim realization that this human-all-too- dents, deans and faculty members. I found human tendency was one against which that a common objection to entering psy- penicillin and heart surgery and all the chiatry was an impression that our patients discoveries of modem medicine offered no “never get well.” It is such a hopeless field, protection. By Freud discoveries of quite 490 THE ACADEMIC LECTURE 1 December another sort had been made and knowledge asked it every hour of the day, and about the of them had slowly become common prop- largest as well as the smallest, the most theoreti- erty. These discoveries promised no mira- cal as well as the most practical things. We cles, no instantaneous cures; they did not answer by consents or non-consents and not seem to justify hope. In fact, Freud was by words. What wonder that these dumb re- frequently accused of a devastating pes- sponses should seem our deepest organs of communication with the nature of things! simism. Surely hope has rarely entered What wonder if the effort demanded by them medical science through so narrow and tor- be the measure of our worth as men! tuous a crevice. But it did enter and its rays transformed the face of modem psy- “Ye shall know the truth and the truth chiatry in our lifetime. A whole new view- shall make you free,” said another wise point in medicine developed, one that gave One. For this emancipating truth Freud authority and technique to efforts at sys- searched not in physics or chemistry or tematic self-scrutiny, a kind of extended biology, but in the tabooed land of the emo- and continuous diagnostic case study. tions. From the Pandora chest of man’s In a way it seems curious that the psy- mind, full of harmful and unlovely things choanalytic process, which is so obviously to be released upon a protesting world, diagnostic, has generally come to be called there turned up-last of all-Hope. treatment. Diagnosis is the hopeful search Selfishness, vengefulness, hate, greed, for a way out; but the setting forth on the pettiness, bitterness, vindictiveness, ruth- way which one discovers and the unflinch- lessness, cruelty, destructiveness and even ing persistence in making the effort-that self-destructiveness-all these are in us. But is the treatment; that is the self-directed, not only those. Invisible at first, but slowly self-administered change. pervasive and neutralizing came love, and The psychoanalytic treatment method is then-perhaps because of it-came faith, a great discovery but this is not what and then hope. changed psychiatry. It was the new under- Love, faith, hope-in that order. The standing that psychoanalytic research gave Greeks were wrong. Of course hope is real, us concerning men’s motives and inner and of course it is not evil. It is the enemy resources, the intensity of partially buried of evil, and an ally of love, which is good- conflicts, the unknown and unplumbed ness. depths and heights of our nature, the for- Freud’s great courage led him to look midable power each of us holds to deter- honestly at the evil in man’s nature. But he mine whether he lives or dies. It was the persisted in his researches to the bottom of realization that we must encourage each the chest, and he discerned that potentially individual to see himself not as a mere love is stronger than hate, that for all its spectator of cosmic events but as a prime core of malignancy, the nature of men can mover; to regard himself not as a passive be transformed with the nurture and dis- incident in the infinite universe but as one persion of love. important unit possessing the power to in- This was the hope that Freud’s discov- fluence great decisions by making small eries gave us. This was the spirit of the new ones. psychiatry. It enabled us to replace thera- It was not the treatment technique of peutic nihilism with constructive effort, to psychoanalysis that changed psychiatry; replace unsound expectations-first with it was the new understanding of men’s hope, and then with sound expectations. motives and inner resources, of the inten- This is what it did for us, for psychia- sity of partially buried conflicts, the un- trists. And for our patients-miserable, ap- known and unplumbed depths and heights prehensive, discouraged and often des- of our nature, the formidable power each perate-what can we do better than that? of us holds to determine whether he lives What can we do better than to dispel their or dies. Wrote William James: false expectations-good and bad-and then light for them a candle of hope to show Will you or won’t you have it so? is the most them possibilities that may become sound probing question we are ever asked.” We are expectations? 1959 1 KARL MENNINCER 491

And we who are teachers-can we do counsel, to us whom they have so highly better by our eager, young seekers for the honored and so generously rewarded with keys to wisdom than to help them sharpen prerogatives and opportunities. They are the accuracy of their expectations without our friends, our brothers and sisters, our extinguishing the divine fire? neighbors, our cousins in foreign lands. But there are many people in the world For these people-for them and for our- who are neither our patients nor our stu- selves-are we not now duty bound to speak dents, and who are nonetheless filled with up as scientists, not about a new rocket or great apprehensiveness, partly from ignor- a new fuel or a new bomb or a new gas, ance and mistrust of one another. They are afflicted with great suffering which all our but about this ancient but rediscovered discoveries have not ameliorated, and awed truth, the validity of Hope in human devel- by vast discoveries which none of us fully opment,-Hope, alongside of its immortal comprehend. Some of them look to us for sisters, Faith and Love.