Psychiatric Services: A Part of Harvard

Nearly everybody at the University encounters difficulties in trying to acquire a liberal education, but some students find that elements in their personal lives make the learning process either secondary or unaccountably difficult. To help meet these vexing personal obstacles, the University maintains a variety of services. Among them is the Psychiatric Service of the Hygiene Department.

The fact that nearly 800 people consulted University psychiatrists last year, and that at least as many are expected to do so this year, gives the psychiatric service, only 20 years old, an important place in University life. And, since the material with which many psychiatric interviews are concerned comes from what Sigmund Freud has called the unconscious, the Service's growing importance is likely to be the subject of debate, and often of unfavorable comment from those who feel psychiatry has no place in education.

Recent Growth

The sharpest growth in the Service's history has taken place during the past two years, since Dana L. Farnsworth succeeded Arlie V. Bock as head of the University Health Services. During 1953-1954, Gaylord P. Coon, Chief of Psychiatry since 1946 and the only full-time psychiatrist, and other, part-time, psychiatrists saw a little over 500 patients, a decrease from the previous year. In 1954-55, Farnsworth's first year, Coon was still the only full-time man, and the Service saw nearly 600 people. Last year, the staff had been expanded to include four full-time psychiatrists, three part-time men, and a half-dozen trainees. Plans for six full-time psychiatrists went awry when one psychiatrist was drafted and another caught polio. This year's staff includes six full-time psychiatrists, two on part-time, and no trainees, although Farnsworth hopes for some later this year.

Great Demand

The increase in staff has brought no relief from the crowding of which Coon annually complained in his reports. Coon's 1955-56 report describes the problem this way:

"Although our psychiatric staff is somewhat larger than that of many comparable universities, the clinical demands which are made upon it grow ever more taxing. Almost always every available space in the psychiatrists' appointment books is filled for weeks in advance. In this already overburdened setting new patients keep streaming in, often with urgent problems requiring immediate attention. Appointment schedules must be repeatedly altered to meet the new demands and new patients in acute difficulty must be sandwiched into the already crammed daily program of work. Some of the students with less pressing trouble must have their appointments set aside to make room for the accumulating emergencies."

The crowding of the psychiatric facilities places a sharp limit on the intensity of therapy which University psychiatrists undertake. Coon's report said, "Students with deep-seated, persistent neuroses can expect to receive from us with our present facilities little more than a holding action, or, at best, to be tided over crises." He hastened to add, however, "Such chronically disabled students are encouraged to obtain treatment from private psychiatrists or other outside sources such as out-patient psychiatric clinics attached to certain hospitals in the Metropolitan area." Some of these clinics offer care for low fees or, in some cases, free. For those who cannot get help outside, the Service tries to see them as often as possible.

The limit upon the length of therapy is also a matter of policy. It is felt that "the college is not a Sanatorium" and that a college psychiatric program should emphasize the removal of blocks to learning. Also, Dr. Farnsworth and others feel that a college psychiatric service, if it is to serve the student properly in the future, must keep some time in reserve for research, for talks with members of the community interested in psychological and mental health problems, and the relation of psychiatric insights to education.

A paradox arises here, to which the Hygiene Department's 1953-54 annual report called attention: "Unfortunately those students who require lengthy treatment are the ones most apt to provide the psychiatrist with a more thorough understanding of the psychological difficulties which beset students' lives."

Major Illness

The kinds of difficulty which arise in University students' lives are indicated somewhat by the list of diagnoses published each year by the Hygiene Department in its report to the President of the University. During the past year, 13 students became ill with "major psychoses" such as schizophrenia and manic-depressive reactions, and were committed to mental hospitals. Three students, none of whom were under psychiatric care here, committed suicide. Anxiety neuroses occur the most frequently, and what are known as "affective disorders" next most frequently. Alcoholism involved five people, and drug addiction none. Interpersonal problems were frequent.

Both Coon and Farnsworth have written about the kinds of student problems they have encountered in their psychiatric work. Coon has noted that Freud felt the neuroses to be "serious, constitutionally determined affections, which are seldom restricted to a few out-bursts, but make themselves felt as a rule over long periods of life, or even throughout its entire extent."

"The emotional disturbances," Coon continues, "which we meet so frequently in college students appear 'prima facie' to have the same more or less serious, intractable character commonly ascribed to the classical neuroses, but I think there is evidence to indicate that they are in many instances really troubles of a less stubborn and persistent nature.

"It is my impression that they are disorders which are more situational than constitutional; more the result of stresses pertaining to the especial time of life and way of life of the college student than an expression of the prolonged operation of deeply ingrained psychopathology."

Rapid Improvement

Coon feels this explains why disorders which, if found in an older person might lead to ominous predictions, but among students yield rapidly to treatment. An American-Psychological Association pamphlet put it another way: the college psychiatrist "sees people who are of superior intelligence, who are 'fresh from their symptoms,' and who are for the most part eager to get on with their work as soon as possible."

One distinction about the college student, Coon feels, is in the different types of responsibility a young man who goes to college, and one who does not, must take.

"The high school graduate who at eighteen takes a job in the work-a-day world, and soon afterwards takes a wife, may settle down promptly to responsible family living. The course of his life may not be altogether unruffled but at least he is usually able to gain a certain self-esteem and sense of manly accomplishment as he comes to grips with the real business of life.

College Immaturity

"Young men, on the other hand, who enter the field of higher learning lead a somewhat anomalous existence. They achieve the physical stature of men but retain the status of schoolboys. The college student, although scarcely any longer all adolescent, is still engaged in the difficult, sometimes turbulent, passage from youth to maturity.

"But the passage is unusually prolonged by the very nature of college life, and such an over-extension of this transitional period only serves to compound and intensify the emotional problems and strains which are naturally associated with it."

Farnworth, in an essay for a college and school association, called "Success and Failure as Viewed by the College Psychiatrist" has characterized the college years as ones of tension between biological maturity and the normal impossibility of marriage, of possibly frantic efforts to belong to the new college society, and of uncertainty, as well as ferment, of ideas.

More particularly, Farnsworth noted five "monotonously familiar" aspects of the background of students who fail or do poorly in-college work. 1) Discord between parents, making it impossible for the dependent child to love one parent without getting in trouble with the other. 2) "Absence of warm feelings and sincere emotional reactions on the part of those with whom the growing person has contact."

3) Inconsistencies of discipline which indicates that discipline is just another word for the parents' convenience. 4) Relative lack of masculine attributes in the father or feminine attributes in the mother, making a student unsure of what he or she wants to be like. 5) "The presence of distorted or squeamish attitudes about body functions, especially those of sexual nature." 6) Living in a "poor neighborhood environment."

Difficult Situations

In a Lowell Institute Lecture delivered last Spring, Farnsworth described stress situations which he felt were common in college life. Among these he named were, choosing a college because parents wanted it rather than out of personal preference; having very famous or successful parents; coming to a college where the standards are much higher than those the student is used to; sudden confrontation with a profusion of courses, and being held back, although a bright student.

How do the students who have these emotional problems find their way to the Psychiatric Clinics? The Hygiene Department's annual reports over the past 20 years show several usual sources of new patients: Freshman physical examinations, University Medical clinics, Deans and other administrative agencies, friends, parents, and finally, students who come voluntarily. From the first Hygiene department report on patient-referrals to the present, the number coming from Deans and other administrative offices has increased, and the number coming from the medical clinics has decreased. The number coming voluntarily varied from 10 to 20 percent until last year when a third came of their own accord.

Coon and Farnsworth have no ready explanation for the sudden spurt in the number of voluntary appearances at the Clinic. The services it offers have been advertised for years. Farnsworth has noted little resistance among students when the idea they might benefit from a talk with a psychiatrist is suggested. Coon says that his experience in first meeting students is that they are not too uneasy.

"In my experience," Farnsworth says, "the present college generation has to a large extent either overcome, or else has not acquired the idea that seeing a psychiatrist is a disgrace, that it is an admission that one is crazy or a weakling, or that it it an unwanted luxury."

Speaking of resistance to psychotherapy, Coon said several years ago, "When it occurs most commonly, the student is suspicious of authority of all kinds, and thinks of a possible blot on his record. He does not know that whether internists or psychiatrists we regard most of the problems brought up as part of the process of maturation."

Nothing Divulged

One real source of resistance to the idea of seeing a psychiatrist connected with a University is a doubt about whether remarks made to the psychiatrist will remain confidential. The psychiatrist, especially if an administrative official has referred the student to him, seems like another college official to some students.

Farnsworth, in his Lowell lecture series, took pains to emphasize the general principle of medicine of which psychiatry is a branch, "Nothing that the patient divulges during the course of a medical interview may be used by the physician without the patient's permission, unless the welfare of others is directly at stake."

Is this an "out" for the psychiatrist to report rule-infractions to the Dean's office? Farnsworth says not, "unless the safety of some person was threatened." He adds that most psychiatrists would point out the dangers involved in the rule-infraction.

After referring a student to a psychiatrist, Farnsworth added, an administrative official usually wants some kind of information so that he can continue to be helpful in the case. Farnsworth feels that whatever difficulty this presents is solved by asking the student for permission to "report back to the faculty member who suggested he come, assuring him that private or intimate details of the conversation will not be mentioned." Few students refuse this request, Farnsworth says, but if they do, the refusal must be honored.

Despite the many possibilities for disagreement between the University's psychiatrists and the administrative officers, both groups refer with pleasure to their good relationship with the other.

Farnsworth's remarks above are examples of his attempt to avoid mutual irritations. He says that "there is no particular body of doctrine or special knowledge possessed by the psychiatrist that he wants to pass on to the administrator or educator."

"What he does contribute," Farnsworth adds, "is a point of view about human emotions, motivations, and behavior that has been somewhat insufficiently represented in the past."

Youth Staff

The members of the psychiatric service are, for the most part fairly young men, many of whom have worked in hospitals in the Boston area before coming here.

Coon is a graduate of the University of Chicago Medical School, and served as the chief medical officer of the Boston Psychopathic Hospital from 1937 to 1946, when he came here.

Samuel Bojar, who works full-time at the Medical School, worked in several New York Hospitals and Boston Psychopathic.

Henry H. Babcock, who handles the Business School, got his M.D. degree in 1939, and worked at Butler Hospital in Providence rising to Superintendant before coming to the University a year ago.

Graham B. Blaine '40, got his M.D. in 1943 and worked at Bellevue and Veterans Hospital in New York City. A general practitioner in Connecticut in 1947-50, he worked for the Riggs foundation before coming here.

Robert L. Nelson caught polio just after his appointment as a psychiatrist here and so was unable to work last year. He is back on a nearly full schedule this fall. He was a resident in a Westchester hospital before two year's service in the Army. He got his M.D. in Colorado.

Army Experience

Paul Walters obtained his M.D. degree at Duke in 1951, worked at an Army hospital and Boston Veterans Hospital before coming here last year to work part-time.

M. Robert Gardner, M.D. Columbia '48, worked at the New York Psychiatric Institute and at Boston Psychopathic hospital. He now works part-time.

Carl Binger Psychiatric consultant for Radcliffe also works one day a week at the Hygiene Building.

The duties of these men do not end with interviewing students: they visit Stillman infimary, they have to keep records, and they have to confer, apparently endlessly, about their case work. Coon says in an annual report with what one suspects to be controlled weariness, "It is estimated that the writer, for example, is occupied an hour or more each day just by telephone conferences in behalf of patients."

As indicated, the problems they have to deal with are as varied as the students are in number. They may have to consult with a senior tutor about whether to let a student take his meals outside the House or to let him live out. They may talk to a student who has taken a medical leave of absence in order to undertake intensive therapy. They may be trapped on the telephone, trying to talk to a reporter as well, leafing through their calendars trying to find a student whose appointment they can cancel so that they can make room for a more urgent case.

To add to the confusion, the role of a psychiatrist in a University is only partly defined. There must be room for subtleties, which some have pointed out is a Harvard administrative speciality.

One administrative official, contacted for comment on this feature and asked what he thought the place of psychiatry in the University was, said, "Well, I don't want to say, because I want to be able to look upon psychiatry skeptically one day and as a comfort the next."

Various Aids

One element of imprecision, and not necessarily an undesirable one, is that the psychiatric service is but one of several places of resort of for the student in search of counsel. The skeptics say that the existence of the Bureau of Study Counsel, The Office of Student Placement, the Board of Freshman advisers, plus assorted Deans, ministers, departmental tutors, and so forth provides the possibility (which has become a reality in a few instances) that a student may see them all.

Defenders of the ad hoc system point out that a student may not see his problem as one needing a psychiatrist's help in unravelling and may instead go to the Bureau of Study Counsel. The Bureau, they point out, has a consultant who can give moral support in any borderline cases. It is better, the defenders say, to let a student go on talking to a man he trusts than to lose him altogether.

Dividing Roles

This imprecision has been the cause of considerable debate among faculty members, especially those concerned with the different advising services. It has led W. G. Perry, head of the Bureau, to write an article for the New York Academy of Sciences trying to picture the distinctions between teacher, adviser, counselor, and psychiatrist, without creating rigid divisions which he apparently considers a distortion of the real situation, which includes inevitable overlap.

The Psychiatric service has been concerned with different problems, which also suggest research. Almost anyone could mention a psychological problem which demands further research. Such questions as "What is mental health?" are asked often. Some consideration has been given to problems of how to notice men who are likely to have trouble later in their college career, and how to act to help them meet this trouble before it becomes too acute.

One of the men who would be involved in any research undertaken is Charles C. McArthur, Psychologist for the Hygiene Department who saw 90 or so people in 1954-55, and 150