Karl Menninger was a title maven. When I served as editor of the Bulletin of the Menninger Clinic, I routinely went to his office with a list of ponderous titles of manuscripts we had accepted for publication. He went through them one by one, tightening them up and putting them into plain English. His book titles were simple and masterful: The Crime of Punishment. Man Against Himself. The Vital Balance. The Human Mind. His most provocative: Whatever Became of Sin?
What was a late twentieth-century psychiatrist doing, writing about sin? Rubbing salt in the wounds? We are continually fighting stigma, its lens rendering mental illness a disgrace—literally, withholding grace. Karl Menninger was a consummate humanitarian whose life work included a relentless public education campaign against stigma. He’d be the last to abet disgrace. And he was a keen proponent of a scientific approach to mental illness, which moves us toward objectivity and away from moralizing condemnation.
Putting sin behind us
Whatever became of sin? Thankfully, we think, we’ve put sin behind us. It’s been centuries since witches were burned at the stake, believed to be possessed by demons—evil incarnate. It’s been decades since alcoholics were condemned for moral failure; now we recognize alcoholism as a disease, with alcohol dependence now an official psychiatric disorder. With psychology and psychiatry in the forefront, the mental health profession has generated a century of science that has reshaped our attitudes toward mental illness. With the recent burgeoning of neuroscience, we are now elucidating the role of compromised brain functioning in psychiatric disorders. Concomitantly, psychiatry has seen the proliferation of increasingly effective psychiatric medications.
We psychologists have been equally prolific, developing myriad evidence-based therapies for a range of psychiatric disorders. Thus our science has its technology: treatment manuals that guide interventions. And we should not overlook Freud’s monumental contribution to the psychotherapist’s objectivity: Consistent with his quest to develop a science of the mind, he inaugurated therapeutic neutrality as the basis for psychoanalysis.
Accordingly, since Freud, psychotherapists have aspired to refrain from imposing their moral values on their patients. This value-neutral stance is essential to providing psychotherapy patients with a safe haven: They can express themselves freely with confidence that they will be heard, understood and accepted—not judged and condemned, further stigmatized and disgraced.
We might see enduring stigma as a reflection of our failure to induce the public to embrace fully our our profession’s scientific attitude toward mental illness. We might reassure ourselves and proceed undaunted, assuming we are on the right course and, if we are successful in the end, that science will triumph over stigma. This solution is too neat. My mentor at Menninger, psychologist Paul Pruyser, was fond of characterizing the human condition—and our scholarly efforts to fathom it—as inherently messy. We cannot escape tangles, ambiguities, paradoxes, dilemmas and contradictions.
Treating people vs. disorders
Accordingly, an articulate vocal band of protestors, Karl Menninger among them, have challenged the scientific ethos as being too restricted. In our healing endeavors, we do not (or should not) treat disorders; we treat persons. Like it or not, prepared or not, we have embroiled ourselves in the human condition, which includes not just mental illnesses (codified psychiatric disorders) but also ethical and moral considerations—how best to live and how best to treat each other. Notably, psychotherapy research suggests that we are having more success with ameliorating psychiatric disorders than with improving quality of life. Should we be content in hewing to science and psychotherapeutic technology, leaving the improvement of quality of life entirely up to the patient whom we have relieved of psychiatric disorder? I think not, but psychotherapy is a messy business, and there is no scientific manual for improving a life.
From the eighteenth-century Enlightenment onward, we have weighty authority on the side of science. Here I quote illustrative snippets of my favorite authorities on the side of protesting scientism in psychotherapy. In his penetrating critique of our current psychotherapeutic culture, The Triumph of the Therapeutic, sociologist Philip Rieff observed that “Freud sought to give men that power of insight which would increase their power to choose; but, he had no intention of telling them what they ought to choose.” Accordingly, in The Sovereignty of Good, novelist and philosopher Iris Murdoch criticized Freud for promoting “a scientific therapy which aims not at making people good but at making them workable.” Judging it by its cover, for decades I felt disdain for psychiatrist Thomas Szasz’s book, The Myth of Mental Illness—until I read it. Mental illness is no myth, but I agree with Szasz’s contention that “Psychologists and psychiatrists deal with moral problems which, I believe, they cannot solve by medical methods…. In actual practice they deal with personal, social, and ethical problems in living.” Szasz was half wrong and half right: We must deal with both psychiatric illnesses and problems in living.
Plainly, problems in living cannot be reduced to psychiatric disorders; each contributes to the other. Karl Menninger proposed that mental health “includes all the healths: physical, social, cultural, and moral (spiritual).” His book was addressed to the clergy as they, too, have a prominent role in mental health, broadly conceived. Menninger chronicled the disappearance of sin: troubled behavior morphed from sin into crime and then from sin into symptoms. We can stop using the word, but the phenomenon remains: By sin, Menninger had in mind “behavior that violates the moral code or the individual conscience or both; behavior which pains or harms or destroys my neighbor—or me, myself.”
“If a better word than sin is available, use it.” Karl Menninger, MD
Armed with ever increasing science and technology, mental health professionals cannot extricate themselves from the messiness of life in which illness and problems of living are entangled, bound up with the unavoidable ethical-moral dimension of human relationships—including patient-therapist relationships. We face a dilemma: Focusing exclusively on illness, we free the patient of responsibility, blame and stigma. Yet, this tack potentially does more harm than good. In his latest magisterial book, A Secular Age, moral philosopher Charles Taylor echoed Karl Menninger: “What was formerly sin is often now seen as sickness. This is the ‘triumph of the therapeutic,’ which has paradoxical results. It seems to involve an enhancement of human dignity, but can actually end up abasing it.” In short, the patient thus freed of responsibility is thereby robbed of human dignity.
Enhancing human dignity
Human dignity entails freedom and responsibility; illness constrains—but should not be seen to eliminate—freedom and responsibility. Our aim, in ameliorating illness and promoting multiple healths, is to enhance human dignity. Our challenge is to accept the fact that we work in the ethical-moral arena of freedom and responsibility where we must exercise our individual critical judgment about how best to live as we treat ill persons with due respect for their autonomy. We must continually strive to do this messy work of understanding and evaluating without condemning and blaming, thereby adding to the shame and stigma that Karl Menninger so eloquently opposed.