Why People Go to Psychiatrists

Charles Kadushin, George C. Galster

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781351471572
• Topic: Medicina
• Subtopic: Psiquiatría y salud mental

This is the first examination in depth of the reasons and ways that people seek psychiatric help. Viewing contemporary metropolitan life from the standpoint of an experienced social analyst, Charles Kadushin deals with such issues as, why people believe they have emotional problems, what types of problems send them to psychiatrists, how, why, and by whom potential patients are told they are disturbed, why people choose psychiatry over other healing methods, and why many people do not receive treatment from the sources to which they apply.

The author develops a new theory of social circles, describing how people move in a network of friends and acquaintances with varying degrees of knowledge of and interest in psychiatry. This factor affects decisions to obtain professional help and also has bearing on the types of problems presented. The study encompasses a wide variety of persons in a complex community environment--New York City, the psychotherapy capital of the world. The basic data were obtained from 1,500 patients in ten psychiatric clinics in three major treatment areas medical, analytic, and religio-psychiatric.

The book provides new insights into the motivations of the patients as well as information about their social setting. It is an informative and engrossing work for students and scholars; for sociologists in the areas of medicine and mental health; for psychiatrists, clinical psychologists, and social workers actively engaged in treatment and casework; and for all professionals in the community health field.

THE STUDY AND
THE CAST OF
CHARACTERS
I

The Decision to Go to
a Psychiatrist

1

If this is not the age of anxiety it is certainly the age of the recognition and treatment of anxiety through psychiatry. Traditionally rejected by the public, forgotten by philanthropists, and belittled by medical practice, the mentally disturbed and those who treat them are now elevated into positions not only of respectability but even of honor and prominence. Ours is the first generation in which a President of the United States has delivered to Congress a message on mental illness.¹ In the ten-year period from 1950 to 1960, voluntary contributions to mental health campaigns have increased fivefold.² And federal contributions to this field have sharply and continually risen since World War II both in the field of research and now more recently in the provision of facilities and personnel for community mental health centers.³ The number of psychiatrists and neurologists has vastly increased, and the field itself has been gaining in medical prestige as more and more medical students have been given early training in modern psychiatry. The number of nonmedically trained professionals in the mental health field, including psychologists, social workers, and ministers, has also increased in the last twenty years. There is even evidence that the traditional reaction of the public to mental disorder—denial of its presence and rejection of those labeled ill—is undergoing considerable change.⁴

Although it is true that only 2 per cent of the adult American population will admit that they have ever consulted a psychiatrist or a psychologist for a personal problem,⁵ the importance of the people who have actually received office therapy transcends the sheer numbers involved. The opinion leaders of the nation’s culture—writers, artists, and people in the communications industry—together with those in the health professions, form at least one-third of those who have been in analytic office treatment. The college-educated are between six and twenty times as likely as others (depending on the particular locale) to go to psychiatrists. These educated persons have written, published, and read an enormous number of books and articles about psychotherapy and psychoanalysis. American fiction has been so affected by psychoanalytic material that one literary critic complained that the very style of the modern novel has been ruined by “our psychiatrically centered culture.”⁶

As a result, though there are more patients in mental hospitals than there are in office treatment, when people think of psychiatrists they think of the couch rather than the hospital. In terms of the distribution of psychiatrists, at any rate, this stereotype is true, for the majority of psychiatrists spend most of their time with office patients rather than with those who are hospitalized.* Outpatient psychotherapy⁷ is the most influential procedure in modern psychiatry and has contributed no less than have tranquilizers to a re-evaluation of our entire system of dealing with mental illness, crime, and other forms of social deviation.

Do People Go to Psychiatrists Because They Are “Sick”?

The success and importance of outpatient psychotherapy depend on the supply of patients. Had not the right kind of patient come to him, Freud could not have made his contributions to psychiatry. This book examines the very basis of the doctor-patient relationship which is often taken for granted—the willingness of the patient to come to the healer. Why should better educated people in the United States seek psychiatric help? Are they more neurotic than others? For that matter, why should anyone go? Though psychoanalysis was developed as a technique for aiding middle-class neurotics,⁸ contemporary community mental health centers offer some form of psychotherapy to all classes. For the psychotherapy movement aims not only to re-educate the intelligentsia but also to give insight to the masses. Re-education and insight available through psychotherapy require as a precondition that the potential patient, no matter what his background, recognize his need and be willing to endure an expenditure of time, money, and psychic pain. To the psychotherapist with his medical model firmly in mind, there seems to be only one logical reason for entering psychotherapy: people do so because they are “sick” and need treatment.

The distinguished psychoanalyst Lawrence S. Kubie is one of the few who has written on this topic.

The so-called “neurotic” among adults is merely one in whom there are … those crystallized neurotic states which we call the psychoneuroses. These are self-diagnosing. Their recognition requires no skill or subtlety. Indeed, such patients come to us without urging, telling us that they have fears, depressions, compulsions, obsessions, etc. With few exceptions they seek help on their own initiative for the relief of their painful symptoms. … The cultural tolerance for overt neurotic symptoms may vary widely in different settings, as will the cultural tolerance for those personality quirks which manifest in concealed ways the subtle influence of the neurotic process. Therefore, culture is one of the forces which determine if and when a patient will look upon himself as ill or at least as needing help and whether he will seek help. Ultimately, however, what determines a patient’s attitude toward his own neurotic process and neurotic symptoms is the amount of pain these cause him.⁹

This statement is ambiguous, however. Symptoms are viewed as automatically self-diagnosing and yet also dependent on “culture.” In the end, just how “sick” the patient feels determines whether or not he will seek help, so that the ultimate answer remains: people go to psychiatrists because they feel sick.

But the fact is that a great many people who feel sick do not seek treatment. About 5 per cent of a national sample of American adults said they worried all the time.¹⁰ This surely means that they feel “pain.” Yet of these, less than one-quarter said they had actually used some form of professional help—usually not a psychiatrist. Another eighth of those who were worried all the time admitted that they could have used professional help. The rest did not want help at all from any professional source. Almost one-fifth of the entire sample said they had feelings of an impending nervous breakdown. This too seems to be an experience of psychic pain. Yet, of these, less than one-third actually sought professional help. Only a small part of the iceberg shows.

Perhaps the judgment of psychiatrists themselves should be introduced as evidence that even “sick” people fail to seek the help they need. A sample of midtown Manhattan was interviewed with a wide battery of questions about personal problems and emotional well-being. These protocols were then independently evaluated by two psychiatrists. They estimated that about one-quarter of the population was psychiatrically impaired. But only a little over one-quarter of those judged impaired had ever been to a psychotherapist.¹¹ In comparison, fewer than one out of ten who were judged not impaired went to a psychiatrist or psychologist. Although being “sick” thus accounts for some of the difference between those who went to a therapist and those who did not, there is obviously much more to the story.

What, then, does explain the decision to seek psychiatric help? This is the basic problem with which we are here concerned. In the first place, there is not one decision to go to a psychiatrist, there are many. Though not all people decide these matters in exactly the same sequence, there are several stages in the process of going to a psychiatrist: realizing a problem, consulting with relatives and friends, deciding upon the type of healer (minister, palm reader, doctor, or psychiatrist or other psychotherapist), and finally choosing an individual practitioner. Different factors affect each stage. To be sure, the first requirement for admission to a psychiatrist is having a “problem” and thus almost everybody who goes to a psychiatrist must decide that he has something the psychiatrist can “fix.” In this sense, everybody who goes to a psychiatrist is “sick.” Though all professionals believe that the client has an incorrect formulation of his problem, the stand taken by psychotherapists deserves further examination. One of Karen Horney’s pupils reports Miss Horney’s views of the initial psychiatric interview:

The reasons the patient gives for coming to the initial interview may be quite different [from the deeper reasons]. His real reasons for coming may not always be clear to him, even after a year or two of analysis. Most patients come into analysis at a time of acute disturbance, although they may give a history of chronic suffering.¹²

In addition, “other patients may come for advice about others,” though this may be only the surface desire. And “patients come for advice about analysis in general when they actually want advice about themselves.” Finally, “even though there seems to be no real incentive, the patient is in the office for some reason. …”

There are several themes in this account. First, problems come in layers, ranging from the most immediate to the most basic and longstanding. Second, the patient is unlikely to present the “right” problem. Third, no matter what the patient says, he must have some problem, that is, he is likely to be “sick.” The import of these themes is that the patient’s formulation of his “ticket of admission” is to be ignored or at least does not present serious data for understanding the reasons why he came. Yet a patient does have to give some account of his presence in the office. At the very least, then, some people come to psychotherapists while others do not because some people can formulate a “problem” they feel appropriate to take to a psychotherapist and about which they can talk; others either cannot condense their experience into a “problem,” or do not feel free enough to talk about it, or cannot find a connection between their “problem” and a psychotherapist. For example, if I should feel a pain in my jaw, I might decide it was a toothache and go to a dentist. Others might not even notice such pain or, if they did, might be afraid to go to a dentist. In any case, upon my arrival at the dentist’s office he might tell me that what is really wrong is that my sinus is inflamed. I came to the dentist for the “wrong” reasons. Nonetheless, anyone who wanted to know why I had gone to the dentist had at least better find out that I thought I had a toothache, that I think toothaches are something dentists can “fix,” and that I knew how to find a dentist. At the level of “problems,” then, the issue for research is what kinds of people formulate what kinds of problems— for no problem, no psychotherapist! Presenting problems are now seen not as “rationalizations” or the “wrong” problem or not the “real” problem but as indicators reflecting the complex process of the decision to seek psychiatric care.

Social Forces and Presenting Problems

People do not go to psychiatrists because they are “really sick.” They go because they think they are sick, and even this does not fully explain their action. Holding in abeyance the other factors which explain going to a psychiatrist, the question now becomes why do some people feel that they have problems suitable for psychiatric help, for we can assume that everyone has the potential to feel emotional distress. In particular, what is the process through which these problems come to the attention of people who go to a psychiatrist? Why do different people present different problems? A study of the differences between applicants for therapy affords us some perspective on the social forces that produce the chainlike development of problems. First there is stress, then the reaction to stress, and then the conceptualization of the reaction. In addition, the problems of people who go to psychotherapists are affected by everything that happens to them during the referral process. This chain suggests that we refine the question of why different people eventually present different problems by breaking it down into five separate but related questions:

Do people present different problems because they are under different pressures?

Do people present different problems because they have different socially and culturally defined ways of reacting to pressure?

Do people present different problems because they have different ways of expressing their feelings and emotions which result from their reaction to pressure?

Do people present different problems because they are differently affected by the recruitment and referral processes that led to the psychotherapist’s office?

Do people present different problems because they have differing expectations of what therapists want to hear?

Beneath all these issues is the question of why some problems appear so devastating to some people that they must take them to a psychotherapist. In our culture there are basically two reactions people can have to a problem. In the first reaction—which for lack of a better name I shall call a Marxian reaction—one blames the situation or the environment: “The reason I cannot advance in my job is that the employer is prejudiced.” The second type of reaction is Freudian: “The reason I cannot advance in my job is that I am inadequate to the task.” One must see problems in some Freudian manner before they become fit material to take to a psychotherapist. Our contention is that social position has a good deal to do with the attitude of people to all these issues.¹³

This point will become clearer if we get down to some concrete cases. Here are two typical applicants for therapy, both of whom present some sort of physical symptom as a reason for seeking help, but who have strikingly different social positions.¹⁴

A 24-year-old single woman applied to a psychoanalytic clinic. She is now working as a social worker but will go back for her second year of social work school in the Fall. She comes from a lower-middle-class Jewish family, with whom she still lives in Brooklyn.

She is fairly well read in psychoanalytic theory. She had also received a fair amount of psychotherapy before applying, but she has not been in treatment for many years. She has discussed her problem with friends but was referred to this clinic by her social work supervisor during a discussion of her general problems. She is obviously quite sophisticated about therapy.

In answer to our questionnaire, she wrote as follows (our questions are italicized):

Please write a general description of your problem.

“Lack of confidence in myself. Free-floating anxiety. Psychosomatic symptoms.”

What seem to be the main things about your problem that are bothering you now? Please list them in order of their importance to you.

“1. Lack of confidence in myself. Feeling that I am a failure.

2. Being frightened all the time but not being able to put my finger on exactly what bothers me.

3. Stomach pains.”

How did you first notice the problem or become aware of it? What was it like then? When did it occur? Write a brief description,

“I first noticed this problem many years ago. I can’t really recall exactly when I first became aware of it. I do know that as a child I was terribly frightened and was afraid to leave my mother’s side. I used to be afraid of going to school and would vomit every morning before leaving the house.”

The following case is quite different, although the ma...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Acknowledgments
• PART I The Study and the Cast of Characters
• PART II The Realization of a Problem
• PART III Intermediate Steps in the Decision to Seek Therapy
• PART IV The Decision to Go to a Clinic
• PART V Toward Better Community Mental-Health Programs
• Appendix
• Bibliography
• Index