Medicine: Hospital on the River

Where Manhattan’s 68th Street deadends at the East River stands a striking group of stone and brick buildings known admiringly in the medical profession as “the great white palace”—officially, the New York Hospital-Cornell Medical Center. At one side, overlooking both the river’s traffic and the swirling autos of the Franklin D. Roosevelt Drive, rises the nine-story building of the Payne Whitney Psychiatric Clinic.

There are no outward signs that Payne Whitney is a hospital for the emotionally ill, for there are no fences, no guards, no barred windows. Yet this 108-bed hospital ranks with the nation’s best and most progressive in applying the newest of medical disciplines—and one of the most complex —to the healing of ailing humanity. Equally important, it carries on psychiatric research and a comprehensive teaching program. Interestingly enough, the clinic perpetuates an old tradition, for New York Hospital, the city’s first, pioneered 150 years ago in replacing Bedlam’s chains and floggings with kindly “moral management” of the mentally ill.

Lost Proportions. The Payne Whitney Clinic* does not ordinarily accept patients who appear incurable (and whose care most often must devolve upon state hospitals), though a few may be admitted for study or special treatment. It is devoted in the main to intensive, hopeful treatment of the curable, as “curable” can be defined at this stage of psychiatric progress. Payne Whitney’s achievement scores, like its methods of treatment, are typical of the institutions in its class: each year, with an average of 225 admissions, it discharges about 150 patients as recovered or substantially improved. But to the psychiatrists, the score (which could be boosted by accepting less difficult cases) is not so important as the bigger fact: each of the 150 represents a sick and troubled individual who had reached or passed the breaking point and has now been restored to his family, usually in as good mental health as before he fell ill, often better.

Here come both the young and the old (from eleven to 90), men & women (but largely because women are more often financially supported by others, they outnumber men in the hospital), rich and poor (but only about 45% can afford to pay the full costs of their care, and all the fees collected from patients add up to no more than half the hospital’s budget), bankers, businessmen, doctors, writers, artists, secretaries, housewives and students (there is a high proportion of patients in intellectual or creative pursuits).

With few exceptions, Payne Whitney’s patients are depressed, anxious and tense. Many have complaints such as peptic ulcers, migraine, asthma, colitis, or skin disorders of psychosomatic origin. Some are alcoholics, a few are narcotic addicts, many have precipitated their admission to the hospital by attempting or threatening suicide. Broadly, such cases are classed as neuroses and personality disorders; some are psychoses. However, less importance is attached to the label than to individualized treatment for the illness.

One thing is true of nearly all: they have lost the ability to deal with reality.

Though most of them face serious life problems arising from bereavement, failure at work or school, or difficulties with kin or colleagues, the problems are magnified in their minds. Sometimes it is an unreasonable fear that drives them to distraction; sometimes an unjustified feeling of guilt or inadequacy.

Often the patient is not consciously aware of the cause of his illness, and usually its roots are buried deep in the past. Whatever the cause, the effect is to make the patient feel that he cannot go on, and often those around him feel that they cannot go on with him. Something must be done—something short of commitment to a state hospital, and yet something more than periodically seeing a psychiatrist in an office.

Case of the Businessman. Such was the case of John X. Outwardly, he seemed to have nothing to worry about. At 46, he was one of the top executives of a key railroad; he had job security and a salary of better than $20,000 a year, a loyal and capable wife, a son who had just quit college to serve in Korea, two younger daughters, and a comfortable home on Long Island. John X was so well regarded by his neighbors that he was often called on to give his time and talents to community causes.

Inwardly, John X was not feeling so well. He said he was slipping—not doing as much work as he used to, and not doing it so well. He fretted about finances. He got so “nervous” that he could not stand the coltish antics of his younger children. Every trip on the rachitic Long Island Rail Road, every decision in the office or at home tied him up in knots.

But it did not occur to John X that he was emotionally ill. It was his stomach, he said. A battery of doctors found nothing wrong there. Then John X “knew” the worst: he was going to die soon, probably from one of those hard-to-detect cancers of the stomach. Forced to give up some meetings, he spent the evenings at home talking to his wife about his life insurance. He slept poorly and lost weight. He gave up hope. Late one night the tension in his mind became so great that John X threatened to end his life, but his wife talked him out of it. A doctor persuaded him that he must go voluntarily into the Payne Whitney Clinic or face commitment elsewhere because of his suicidal tendencies.

John X’s Treatment. John X was shown to a room very much like one in a small residential hotel. There was no lock on his door, though John X noted with annoyance that the nurse had used a key to open the door from the elevator bank to his landing: he was on one of the hospital’s most closely supervised floors. Next, like all new patients at Payne Whitney, John got a thorough physical checkup. Meanwhile, the outline of John’s case had been discussed at a staff meeting.

At these meetings, Psychiatrist in Chief Oskar Diethelm is joined by two other senior psychiatrists, Drs. Thomas A. C.J Rennie and Richard N. Kohl, who are at the clinic full time and share the supervision of all patients. Also present are the resident psychiatrist, with more than three years’ experience and training at the clinic; 13 assistant psychiatrists at various stages of three-to five-year courses as residents. Here an assistant psychiatrist is assigned to be the patient’s personal physician during his stay, and the patient’s daily routine is prescribed. He can be certain of excellent care, night & day. There are 74 graduate nurses, 20 student nurses and 25 psychiatric aides. Each psychiatrist treats a maximum of ten patients —in contrast to many state hospitals, where a single physician may be responsible for 400 or more patients.

On his first visit, the psychiatrist assigned to John X found his patient sputtering about being on a locked floor. “I’ve too much pride to be in a place like this,” John said. “My wife has given you a false picture of my condition.” Unaided, the doctor would have had a tough time with the determined executive, but twice each week his supervising senior psychiatrist joined them, reinforcing the younger man’s efforts.

By far the greatest part of the treatment lies in the psychiatrist’s efforts to help the patient to understand the origins of his problems. This means going back to how he developed as a person from earliest childhood—how his personality developed. It involves helping him to see that his poor ways of handling situations are complicating his problems. It does no good simply to tell him that; he must be helped to see for himself. It is no use exhorting him to use will power; he must be guided through the mazes of his mind and memory until he recognizes independently that he has resources to finish the journey alone. The psychiatrist shares the most intimate aspects of the patient’s life, thus affording both the relief of catharsis and the support of an understanding relationship. Painful memories lose their sting. The patient’s confidence is gradually restored through his faith in the doctor.

First to go was John X’s feeling 3 wounded pride. Then, though he still fretted about the office and his stomach pains, at least he fretted less. After about five weeks, he began to feel grateful for the overall physical and psychological care he was getting, and to welcome his doctor’s visits, even though some of the interviews were unpleasant. Thus he began to reveal more and more about the rockbound New England upbringing which had made him so rigidly “moral” that he was hardly human. He began to see that while he admired his wife’s easygoing personality, he also envied it and at times actually hated it. It took a bit longer for him to resolve these conflicting feelings within himself.

Then there were the strict sex taboos of John X’s childhood. He had married because, in good part, he thought it unhealthy not to. And though he prided himself on a successful marriage, it became clear that he regarded sex as a shameful rite to be conducted only furtively and in total darkness. Even before all this underbrush had been cleared, John X began to feel better. He got a kick out of woodworking and photography. He enjoyed his social activities with the other patients—badminton, card playing and musical evenings—all on unlocked floors. This gave him a feeling of responsibility, and confidence that his doctors no longer rated him a suicidal risk. Soon he was allowed to goout for an afternoon or an evening with his wife, to go shopping, to dinner and the theater. Concurrently, the detailed processes of psychotherapy went on—unraveling more of John X’s life story, his hurts, his rejections, dreams, all to help him recognize and manage his emotions better.

By easy stages, John X returned to his normal pattern of life. He went out alone, and home for weekends. Then he went back to the office two days a week. He found that he could do his work as well as any of his colleagues. Also, he could talk freely to them about his illness. His sense of shame left him when he realized how many others had had personal experience with similar illnesses. After nine months, satisfied that he did not have cancer, and realizing that he had been a victim of his own stubborn, driving perfectionism, John X went back to working five days a week and living at home. Today he is happier, more relaxed and more efficient than before his illness.

Case of the Housewife. Like many modem psychiatrists, Payne Whitney doctors pride themselves on being eclectics who take what they believe is the best from Freud and Pavlov, Bleuler and Meyer, Horney and Sullivan. Their treatment is analytic, but it does not extend to the orthodox form of analysis in which the patient may spend 200 or more hours in treatment.

The patient is studied intensively in many other ways. His behavior is continuously observed and recorded by check marks on his chart three times a day. Nurses and doctors note how he gets along with other patients. They record his weight and appetite, the swing of his moods, what incidents upset him, and how he handles his emotions.

The psychiatrist often gets productive information in answer to the simple greeting question, “How do you feel today?” The patient may refuse to answer if he is fearful, resentful or depressed. In such cases, it takes additional time for the psychiatrist to break through the barriers and win the patient’s confidence. But many patients are so full of their troubles that they pour them out at once. Their ideas of what ails them may be superficial, and may conceal deeply buried anxieties and guilt feelings. Nonetheless, they give the psychiatrist clues that he needs for ‘his understanding of the illness.

Edna Y, a 29-year-old housewife, had plenty of troubles to pour out. She had what many psychiatrists call the “suburban syndrome.” Edna had been the spoiled baby in a hard-pressed Midwestern family. Unable to afford college, she worked in a department store, and there met a young man who was going into dress manufacturing. Soon after they were married, he was transferred to New York City. Living in a fashionable New Jersey suburb, surrounded by Vassar and Bryn Mawr graduates, Edna felt that she could not keep up in dress, club memberships, home furnishings or Mayflower ancestors.

In this setting, she began to suffer severe migraine headaches. These made her withdraw more and more from her usual activities. Medication gave her temporary relief at best. Edna began to neglect her house and her only child. After a few months of worsening headaches and deepening depression, a doctor advised her to try psychiatric treatment.

Edna Y’s Treatment. John X had paid the full cost of his private room and care, $210 a week. For Edna Y, this was out of the question, and the rate for her was set at $42. Her care was identical with John X’s, but she shared a three-bed room. Her doctors believed it was a good thing for Edna to face, inside the hospital as she must face outside, the simple reality that some people have more money than others.

Edna Y was anxious to please. She got along famously with her psychiatrist, but her early progress was slow. Uncovering layer after layer of memory, she learned gradually to understand that one root of her trouble went back to childhood feelings of insecurity and a sense of inadequacy as compared with her sisters. Like John X, Edna learned that it was natural for her to have occasional feelings of hostility and resentment even toward those she loved. It took time for Edna to come to believe in her own abilities and good qualities. Then she discovered an unsuspected talent for painting and enrolled in an art school. With her new-found assets, she became confident of her ability to hold her own with other young matrons and her husband’s friends.

Edna went home after 4½ months. No psychiatrist would have pronounced her completely “cured,” but she had fewer and less severe headaches and faced her responsibilities capably. In her weekly, then monthly, visits as an outpatient, Edna’s psychiatrist helped her to anchor her ‘recovery more securely.

Case of the Frightened Boy. Sometimes a patient is so disturbed that the doctors cannot, at first, get through to him. In such cases, they may use sodium amytal, the so-called “truth drug,” to help the patient to communicate. Or, after the symptoms are fully understood, they may give electric shock, or “electroconvulsive therapy,” as they prefer to call it, always under the most rigorous safeguards.* They use insulin treatment in a similar way.

Bill Z was a case who needed insulin. Bill, 18, was found cowering and sobbing in a New York City cemetery. “I. am being followed because I have knowledge which might destroy the world,” he told the patrolman who found him.

“Who’s following you?” asked the cop.

“Three hundred Communists,” the boy replied. “And that’s not all—airplanes with radar are tracking me.”

“What’s your name?”

“I am Christ.”

In three weeks at a city hospital, Bill Z received five electroconvulsive treatments. These subdued his more extreme symptoms. Psychiatrists agreed that he might respond to intensive psychotherapy, and his parents arranged his transfer to the Payne Whitney Clinic.

Bill Z’s Treatment. Each morning for 60 days, before breakfast, Bill was given an injection of insulin, which cuts down the blood sugar. Bill sweated profusely and became increasingly drowsy. The doctors gradually increased the insulin dosage, but were careful to stop short of the point where Bill would have lapsed into coma. At one point, Bill had a stormy outburst, then quieted down and showed his first grudging signs of cooperating with his psychiatrist.

Before Bill Z lost control and ran out to the cemetery, he had spent hours locked in his room, studying religion, sex and science, and writing long discourses on philosophical problems. He was no easy patient to handle. He kept threatening to assault his psychiatrist. Mixed up about sex, he accused other patients of homosexual tendencies toward him (a reflection of his self-doubt) and made erotic advances to the nurses.

Only after insulin treatments did young

Bill begin to give up his delusions. But even after he admitted that his fellow patients might not all be Communist spies, he still insisted that the world outside was full of them, all threatening him personally. This delayed his visiting out. The psychiatrist also had to work with Bill’s assertive mother and wishy-washy father to show them how the boy’s troubles had arisen and how, by revamping their own feelings and attitudes toward him, they could give more of the support and love that he needed.

It took almost a year and a half (a long stay, by Payne Whitney standards) for Bill’s anxiety to subside enough for him to leave the hospital and take up his college studies again. The psychiatrists know that Bill will need further treatment, perhaps for a long time, before his recovery is really secure.

The Hopeful Art. For patients who are not ill enough to be admitted to the hospital, and for some who should be admitted but feel they cannot be spared from home, the clinic has an outpatient department headed by a full-time senior psychiatrist and staffed by 55 experienced psychiatrists who give two half days a week from their private practices. Fees range from nothing, for the penniless, to $2.50 a visit.

The Payne Whitney Clinic (and others like it) can hardly make a dent in the ranks of the 350,000 U.S. citizens who are admitted each year to psychiatric hospitals. Yet the psychiatrists who staff such institutions are confident that in their progressive, imaginative approach to the treatment of patients they have part of the answer.

The rest of the answer, they believe, lies in preventive work with children and schools, with, parent groups and teachers, with ministers and employers. It lies, too, in the training of more psychiatrists, clinical psychologists, nurses and social workers, who make up the team in modern psychiatric hospitals.

Payne Whitney psychiatrists divide their time almost equally among treatment, teaching and research. They study both the disordered workings of the sick mind itself and the relationships between emotions and physical illnesses, and between emotions and the chemicals in the blood, as well as neurological disorders and such special problems as alcoholism. The staff takes an active part in the treatment of patients throughout the general hospital. All the resident physicians are learning by experience what they need to know to become teachers and investigators as well as practicing psychiatrists. Staff members are on the faculty of Cornell University Medical College and give psychiatric courses to the practitioners of tomorrow, thus giving them insight into the emotional aspects of their patients’ illnesses.

These efforts combined, the Payne Whitney doctors believe, will carry forward the process which has already raised psychiatry from the management of hopeless Bedlams to the practice of one of the hopeful arts of healing.

* Payne Whitney (1876-1927), who inherited a fortune from street railways and tobacco and made millions, became a governor of the Society of the New York Hospital in 1912 and soon took a special interest in its division for mental patients. When plans were being drawn for the Medical Center in the 19203, Whitney resolved to finance the building and endowment of its psychiatric clinic. Even with the income from his generous $8,000,000 endowment, it still needs donations to meet annual deficits

* Only in unyielding cases do Payne Whitney psychiatrists resort to the drastic operation of lobotomy (TIME, June 22), in which nerve connections in the forebrain are cut.