Popular Science Monthly/Volume 82/February 1913/The Advancement of Psychological Medicine

by Frederic Lyman Wells

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THE ADVANCEMENT OF PSYCHOLOGICAL MEDICINE

By FREDERIC LYMAN WELLS, Ph.D.

MCLEAN HOSPITAL, WAVERLEY, MASS.

TEACHING and research are the coordinate ways upon which any body of knowledge advances. Though we are apt to think first of the former, the latter is indeed the more basic, since before we can talk of teaching we must acquire something to teach; as, to a large extent, it is still the task of psychological medicine to do. It is neither a difficult nor an especially effective matter to urge in generalities the desirability of medical training in psychology in the hundred trite phrases that are current to every one; the abstractly favorable judgment is now of little meaning except as the basis of constructive ideas. We can best decide the place of psychology in medical education in examining what is the best that psychology has to give it. This question could indeed be dealt with more simply if there were greater unanimity of opinion as to what this best may be; for, as the recent addresses at Washington plainly showed, divergent opinions still reflect the different angles from which the subject is approached. The discourse of the medical man is one of problems, of the psychologist, one of methods; which under present conditions could scarcely be otherwise. The difficulty is that the methods of normal psychology and the problems of pathological psychology do not fit. One could well read this in and between the lines of Franz's remarks,^[1] deprecating certain inadequacies in the methods of pathological psychology, as well as the aloofness from practical issues on the psychological side. The doubtful attitude of the psychiatrist towards the psychological Problemstellung is of long standing. "They ask for a psychology. . . . applied toward a solution of their own problems, one which is aimed at practical ends. It has been assumed that psychology as it is being taught and investigated deals with matters of no concern, or of too abstract a nature for practise"; which assumption indeed has some measure of truth.^[2] Psychologists may not be scientifically at fault for this failure of application, but the medical justice of demanding it can scarcely be gainsaid, and such expressions are fair warning that in our natural wish to extend the scope and influence of psychological science, we do not lose sight of the fact that if psychology is to be successfully taught to medical students, it must afford them something they can use. The test of concrete experience is one that psychology has never been seriously called upon to face, in the sense that other natural sciences have been. I am fully mindful of Professor Titchener's^[3] cogent apologia for the failure of the contemporary psychology to "hold its men," who tended either to leave it for more frankly speculative departments of thought, or sought the concreter fields of education, or physiology and therapeutics. But the fact seems to be that psychology has not been over-forward in seeking the test of concrete experience.

A somewhat definite program for the medical course in psychology has been discussed by Watson.^[4] It seems, not unnaturally, determined more by the place of the methods in experimental psychology than by direct consideration of their applications to the study of psychopathological conditions. From this standpoint, one might in minor detail suggest some modification of Professor Watson's plan; thus in any work on sight, campimetry should probably occupy an equal place with color vision. The skin and kinesthetic sensations have a psychopathological importance quite equal to that of hearing. Watson's plan is for a systematic experimental course; I must confess that what seem the most fitting topics do not coordinate themselves so readily in my mind, and my own tendency would be to make such a course less one in experimental psychology than in psychological experiments. The content of the laboratory course may indeed change with the progress of the science, in accordance with the principle that properly governs it; but as we are not trying to make psychologists, but medical men, we must subordinate the desideratum of the academic system to a series of those experiments and methods most likely to be made use of in actual medical practise. It is evident that in the determination of the proper subject matter of such a course, there enters not only the available stock-in-trade, so to speak, of experimental psychology, but also the consideration of those particular clinical exigencies in which they are likely to be of service. Only such experiments and methods should form a part of such a course for which definite value in special situations can be indicated; and the understanding of the application is on a level of importance equal with that of the experiment itself. The application of experimental methods will, of course, be practically confined to the study of individual cases, and the procedure which should be followed in the laboratory is thus an intensive study of each experimental method with individual subjects; group experimentation or methods which involve it are out of place in such a course.^[5] In an enumeration of the experimental methods which would seem, from the writer's particular experience, to best deserve place, would be included the study of the free association experiment, the technique of the "psychogalvanic" reflex, or some allied method, the properties of the work-curve and a few of the less equivocal methods for determining it, and the better developed forms of memory experimentation. Nor should I question the inclusion of the Binet-Simon tests, though without personal experience with them. It would lead too far afield to explain just why these particular experimental methods have been spoken of and not others, but suffice it to express every assurance that they are among the methods most helpful to the better understanding of those cases with which psychiatric clinics are replete. It is true that such division would form practically separate units in the course, and they could be taken up in any desirable order, save that, e. g., certain phases of the association experiment and the "psychogalvanic" reflex are best considered together. Whether the content of a laboratory course were as above or something totally different, it must be governed essentially by its medical usefulness, and those features included which best justify themselves in this light. How much time can be given, and when, depends of course on administrative factors; all the time that Watson suggests could be profitably used, and it should be so ordered as to be convenient for those who take up the special work given in mental diseases.

Such, in principle, is the writer's conception of a laboratory course likely to be of most value to students of medicine, nor would it be claimed that its subject matter could be effectively dealt with under other than laboratory conditions. There yet remains that considerable body of psychological problems whose concern with medicine is not less immediate than those above, but whose relation to experimental, or indeed in any way objective, methods, is at present very indefinite. They are essentially problems of psychogenesis—the development of the various mental reactions and tendencies of which individual character and temperament are built up. It is readily discernible that a growing emphasis is laid in psychopathology upon the determining if not conditioning rôle of psychogenic factors in a variety of conditions, ranging from hysteria to the manic-depressive group; though the scientific development of methods, or their application to the study of normal mental reaction types, has been largely conspicuous in absence.

It is this phase of the situation that looms largest in Meyer's vision,^[6] with especial regard to its problems. The point of view goes back to some basal concepts of "mental reaction"^[7] and the remarks represented a none the less forceful, if indirect, criticism of the conventional Fragestellung in its relation to the problems on the pathological side. While at various times psychological writers have deprecated the tendencies inherent, from a scientific standpoint, in many doctrines associated with the name of psychoanalysis, it would be difficult to deny that the responsibility for psychoanalysis rests to some extent with the psychologists ourselves. The neurologist found himself confronted with certain problems psychological in their nature, with which the academic psychology had largely thought best not to concern itself. It is true that we have an "individual" psychology; one of the differences in simple reaction time, in color vision, or in memory for nonsense syllables, various elementary traits among which it has been difficult to establish relationships or other than superficial interpretation. From a medical standpoint it is better to give up this Problemstellung of individual differences in functions, for one, so to speak, of individual differences in individuals. The medical requirement is rather for a psychology that shall seek the correlation of objective methods for studying the personality with the mental reactions of that personality in the greater laboratory of mundane experience. The key-word to what medical psychology should be, and what academic psychology has not been, is, in fact, "personality." To our conventional chapter-headings of imagination, will, habit, experience and the like, let us mentally add the words as they affect the personality, if we wish to reach the standpoint of the greatest help in the medical relation. We shall study the mental evolution of the individual, rather than the genetic psychology of different mental faculties. Our psychology will be one of conduct, reactions, adjustments. As such we shall pay greater heed to feeling as a disturber of these adjustments. We shall start from the standpoint of the "mind as an adaptive mechanism";^[8] the personality as a sum of various tendencies in mental adaption or reaction-type. We shall study the various mental means through which different personalities react upon, or adjust themselves to, the vital situations they meet. We shall learn how some personalities react in ways that involve mental good, others in ways that involve mental harm, and we shall inquire into the modifiability of these reaction types, with the view to their possible amelioration.

Though having a somewhat different outlook upon the matter, and expressing it in different terms, it appears that the things which Prince^[9] finds to criticize in the pathological relations of the academic psychology are essentially the same.

The problems with which normal psychology has chosen to deal are exceedingly interesting from the point of view of the higher culture, but they scarcely touch the vital questions which the disturbed, distressed human organism presents to the physician. . . .If normal psychology is to become an applied science and in particular to become of help to medicine, . . . it must occupy itself more than it has done with problems of dynamics, of mechanism, of function.

He goes further, however, in formulating a definite scheme of instruction. This is governed in certain details by its author's special psychology; some rearrangement of headings, if not also some alterations of terminology, might well prove desirable. Yet it is quite evident that in a number of the titles we have at least an enumeration, in greater detail, of the phases which a course along the lines above indicated would take up.

When Dr. Prince was reading this summary in Washington, I turned to some one sitting next to me and rather lightly remarked that this was all very well, but Prince was the only man who could give such a course, my neighbor promptly assuring me that I was altogether mistaken, that he knew many persons who could give such a course. It was not meant, of course, that there was no one who could talk about these subjects for the number of hours the course would specify. But we can not consistently reproach psychology for our lack of knowledge in these matters, and at the same time propose their immediate fitness as a teaching subject. As a matter of fact we have very little systematic information about the majority of the topics presented in Prince's summary. It is most likely to increase if the student be brought to observe and study in his cases in these terms, but this side of the course could to-day no more than reflect the subjective reactions of certain original and more or less critical intellects upon the most adequate clinical experience.

The interest and import of these questions most thoughtful persons will admit, though any psychological critic would probably be quick to ask how such matters are to be in any part submitted to objective, not to say experimental, inquiry. Not with the color-wheel probably, or through the tonvariator, or the sound-hammer. Could the question now be satisfactorily answered, the proper psychology for medical schools would not be long under discussion. We are not in a position to say, however, that no progress towards a solution is possible. Our experimental inquiries have not been directed along lines that would develop such methods. We must also know with greater exactitude the questions our experimental methods are to be put to answer, and shall need to experiment with our experiments a good deal. There is to-day only one experimental method whose direct value in the dynamic psychology seems comparatively assured; this is the ordinary "free" association experiment, especially evaluated.^[10] There are also some possible adaptations of the method of "measurement by relative position "^[11] as well as other quite specialized tests, that hold out promises of value in these directions.

It will be appreciated that a dynamic psychology has no exclusive relation to the pathological, but rather seeks the recasting of psychological problems into a form more applicable to the uses not only of pathological psychology, but of normal psychology and society in general. It is in no way specificially referred to pathological material. Because psychiatry has to deal, on the mental side, with personality, it desires a psychology of personality. The study of normal personality, as such, has its obvious and necessary relation to the pathological. The university is in quite as favorable position to make essential contribution to a psychology of personality as is the hospital or clinic. Research in this direction encounters certain difficulties that are avoided in the customary lines of psychological investigation, but this is so by very virtue of its having personal applicability, its bearing upon more intimate and vital issues.

To adequately cover the teaching field of psychological medicine one should therefore, on the one hand, be conversant with and able to judge of the methods of experimental psychology in reference to their application to the analysis and interpretation of symptoms; and, on the other hand, able to recognize and elucidate the more general questions now stated dynamically. First-hand acquaintance with psychiatric conditions and problems is everywhere implicit, which involves the close and continual association with clinical material that is also necessary for research. Here then the problem of research merges with the problem of teaching, and we shall consider some phases of the subject also from this standpoint. It is proposed to discuss in this connection not the further special topics of investigation,^[12] but the practical conditions under which such research takes place, and the most effective means of furthering it.

The essential clinical material of psychopathology is derived from various sources, approachable from different angles. According to social stratum, the neuroses and various border-line and neurological conditions are most seen either in the private practise of the specialist, or in the appropriate departments of the general hospitals; the psychoses, as the term is generally understood, in the state or private hospitals devoted to their care and treatment. Special institutions, as a rule, care for the graver congenitally defective (feeble-minded) while in some instances it has been found advisable to provide special institutions for the management of such conditions as epilepsy and alcoholism. Much the greatest amount of material, and in its most accessible form, exists therefore in the institutions; though it does not so greatly surpass in psychological interest the smaller group of neurotic conditions that do not regularly come under institutional care.

It is not now easy to say how this latter group of cases will to any extent be brought under the observation of the psychologist. Except in isolated instances, the material of private practise may be systematically observed only by the physician who treats it. For our psychological understanding of these cases, we shall presumably remain dependent upon such studies as the specially interested physician is able to make in the course of his practise. These researches should improve in number, if not also in quality, as medical students acquire more knowledge of psychopathological problems, and of the means by which to approach them. The case is more favorable with that part of this material than is seen in general hospitals, or in small private institutions, but the obvious economic difficulty of providing for the systematic psychological study of this material is one which it has not yet been attempted to meet. If these conditions are thus less accessible as a group, it is partly compensated for by their greater accessibility as individuals, owing to the generally better preservation of the intellect and cooperative faculties, so far as these enter. In the comparative study of the neuroses and psychoses, these factors to some extent balance each other.

The most practical means to further the accessibility of psychopathological material for psychological research, has been through the establishment of research positions in the institutions whose facilities are adequate to them. The past decade has witnessed the inception of a considerable amount of this work, under various state and private auspices. The conspicuous success of Franz at Washington and of Goddard at Vineland may be mentioned. These positions have been regularly filled by persons of the university training in psychology, who are expected to devote their time to original investigation. Whatever the special character of the material investigated, the main responsibility for psychopathological investigation will rest—and perhaps it may be added that it ought to rest—with the men in these positions, relieved of the perpetual penalty of therapeutic promise. As the success of these positions depends upon the men whom they will draw, and this in turn upon the opportunities they offer, it may be well to briefly analyze from both standpoints the external conditions under which this work is done.

Institutions that make scientific appointments are presumably ready to devote themselves in some measure to work of a purely research character, the immediate practical realization of whose benefits is likely to be a matter of more than ordinary good fortune. The creation of such positions therefore implies in the administration a fair degree of sympathy with scientific motives. Institutions inadequate to this demand are scarcely suited for such positions, nor are good men for the work likely to be drawn to them. The salaries vary somewhat from place to place, and according as the incumbent lives within the institution or out of it; but a fair average compensation for work of this nature has been $1,200 a year plus maintenance. The teaching positions which psychologists ordinarily enter do not, of course, provide training of any particular technical value for these research activities; in some cases they might even lessen fitness for research. As Wallin^[13] put it, the only adequate training in this respect is an apprenticeship with one of the experts in the field, which is very rare at present. On the other hand, much might be said for the value of direct experience in allied fields, and their additional contacts with the broader problems of social psychology. In Titchener's ever-apt phraseology "the best work will always be done by the best men," who, with a mature outlook upon the psychological situation and its problems, enter the pathological field because of exceptional interest, or are selected at the outset of their careers through evidence of fitness and promise in these special questions of research. With the above reservation, the candidate is the fitter for the position the less the time since his Ph.D., and the positions should be made attractive to those at the outset of the psychological career.

If qualified men are to be drawn to these positions, they must be given a standing in keeping with the class of work expected of them. It should be commensurate with that accorded to the pathologist, who forms an integral part of the institution staff. Discrimination will simply exclude the more competent men. It is doubtful if the scale of salaries needs to be altered greatly. The additional cost of carrying on such work would include not less than $150 for annual library expenses, the remainder being dependent on the sort of work done, and the special equipment it requires. Many fruitful lines of inquiry require but little apparatus beyond stationery; some important problems, e. g., those concerned with the expressive movements, require elaborate and somewhat costly installations. Administrative direction of the precise subjects of research is not usually advisable, however, since it can seldom be guided by an adequate knowledge of the limitations of methods. In no case should the attempt be made to equip a general laboratory, but only to provide such equipment as is necessary for the investigations in hand. At some time in most investigations a certain amount of clerical assistance is an all but absolute requirement, and no holder of such a position should be expected to do his work properly without it. The greatest possible latitude should exist in regard to questions of printing; if an investigator is not to be trusted to publish when, where and what he thinks best, something is wrong with him or his position. As the worker in an institution laboratory does not have the same opportunity to place his work before Fachgenossen as is the case with his university colleagues, the institution may well accord some facility in the distribution of offprints.

From the standpoint of the young Ph.D., these research positions are economically quite superior to anything to be expected of the earlier years of a teaching career. As maintenance is provided, a very large part of the salary can, if desired, be saved; the conditions of living vary with the character of the institution, but may bring the actual value of a $1,200 position well towards $2,000. Vacations are short, compared with academic ones, but this may be quite compensated for by the absence of routine obligations and various other agreeable features of institution surroundings. The tremendous advantage, to him who is able to use it, lies in the freedom for original research; the possible disadvantages are the lack of library facilities, and the intellectual danger of isolation from colleagues. Absolved from routine activity, deprived of the immediate competitive and critical presence of others in the same field of work, the lack of energy and devotion means mental dry rot. However, being not only free, but expected to devote one's entire time to original research, one can obviously be more productive than his equally capable fellow-worker whose time is swamped by the routine activities of teaching; and, so far as personal advancement is based on the character of work done, the advantage seems to lie distinctly with the research position as against the teaching one. Still neither standing nor salary in these positions equals the professorial grade in the important universities, which is, practically speaking, the material end to which those following the career of psychologist now look forward; and once having abandoned the teaching side of the profession one is not likely to reenter it at a higher level, save upon evidence of altogether distinguished merit, probably more than would be necessary should the candidate follow the routine of academic promotion. For the greatest abilities these positions should then offer the greatest rewards; to mediocrity they spell destruction.

The cause of research in psychological medicine will prosper the better, the longer its special class of investigators can be held to their work. At present, the best men may not remain in it permanently, but be taken away at a time when their growing experience makes them increasingly valuable in it. It can not, of course, be questioned that this same experience, with the facilities of the position, places one in a peculiarly advantageous situation as regards teaching the subject, which it might be advisable also to do, in so far as it were possible without hampering research. University association with clinical research further offsets the possible difficulties of inadequate libraries and isolation from colleagues. An additional advantage of university association is that advanced students, academic or medical, may be brought into direct contact with research problems in psychopathology and means thus provided for the carrying on of much additional investigation. Under the present circumstances the clinical psychologist might often occupy his time very effectively with the combination of research and the training of others in its methods and problems; while from a practical standpoint it also tends to retain him longer in the work to do so.

The optimum of teaching in medical psychology involves, therefore, a unification of instruction and research. It deals, on the one hand, with the clinically useful procedures of experiment; on the other, with the broader problems of personality and psychogenesis. Its contemporary sources are, on the one hand, the university laboratory, on the other, hospital clinic, and it is best served by the experience of both. Throughout, it has been apparent that the subject matter of psychological medicine is one of particular appeal to students specializing in mental diseases, and should for the present be elective. It would be rather unwise to now seek the required study of psychology in medical schools, as psychology is not yet in a position to make sufficiently definite contributions of general value. Only through the encouragement of research, and its direction through proper teaching, are its great and obvious deficiencies to be supplied, and the endeavor has been to indicate how psychology and medicine can best meet upon grounds of mutual helpfulness towards this end.

1. Journ. Am. Med. Assoc, March 30, 1912, 909-911.
2. Cf. Hollingworth, Psych. Bull, May 15, 1912, 204-206.
3. Am. J. Psych., XXI., 1910, 406-407.
4. Journ. Am. Med. Assoc., March 30, 1912, 916-918.
5. Cf. Kraepelin, "Ueber Ermüdungsmessungen," Arch. f. d. Ges. Psychol., I., 1903, 28.
6. Journ. Am. Med. Assoc., March 30, 1912, 911-914.
7. Most simply outlined in the Psychological Clinic, June, 1908, 89-101.
8. Cf. a lucid but uneven article by White, "The Theory of the 'Complex,'" Interstate Med. Journ., XVI., 1909, No. 14. Also in "Mental Mechanisms," Ch. 4, pp. 48-70.
9. Journ. Am. Med. Assoc., March 30, 1912, 918-921.
10. Cf. the "Diagnostische Assoziations studien" of Jung; Kent and Rosanoff, "A Study of Association in Insanity," Am. Jr. Ins., LXVII., 1910, 37-96, 317-390.
11. Cf. the early work of Sumner and the more recent studies of Hollingworth and of Strong; also, in pathological reference, G. G. Fernald, Am. Jr. Ins., LXVIII., 1912, 545-547.
12. Some of which the writer has dealt with elsewhere; cf. "The Experimental Method in Psychopathology," N. Y. State Hospitals Bulletin, December, 1910.
13. Journ. Educ. Psychol., April, 1911, 208.