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Ivory v. Red Brick. The gulf between the ivory-tower and red-brick schools of psychiatry over the new drugs has significance far beyond the profession. On its resolution depends the full and effective use of important new psychiatric tools. Essentially the trouble goes back to the Freudian revolt against the 19th century's physiological approach to mental illness. Freud admitted that the usefulness of his method was virtually limited to the neuroses and could not yet reach the psyhoses. Experience has shown that it takes countless hours of the most grueling work by a topnotch psychotherapist to bring a "deteriorated" schizophrenic back to something like normal. Even if all U.S. psychiatrists dropped everything else and no more new cases cropped up, most inmates would be dead before a doctor got around to them.
Some orthodox psychiatrists have performed thousands of lobotomies, in which a knife is slashed through the cortex, the most essentially human part of the brain. Some do not hesitate to give patients scores or even hundreds of electric or insulin-shock treatments, or to put them in an insulin coma. Alongside these procedures, the red-brick school points out, the use of chlorpromazine and reserpine is gentle. It can make the patient readily accessible if the overworked psychiatrist has a few minutes to practice psychotherapy on him. If psychotherapy can prove its worth even in psychoses, these drugs give it its chance.
The ivory-tower critics argue that the red-brick pragmatists are not getting to the patient's "underlying psychopathology" and so there can be no cure. These doctors want to know whether he withdrew from the world because of unconscious conflict over incestuous urges or stealing from his brother's piggy bank at the age of five. In the world of red bricks, this is like arguing about the number of angels on the point of a pin. Psychiatrists who have worked on the back wards readily admit that they can claim no technical cures—they will have to wait at least five years after a patient's discharge for that. What they do claim is an impressive number of "social recoveries": cases in which a patient for whom there had been little hope has been brought around to the point where he can go back to a normal life. They know that there will be many relapses, but they are confident that these also can be treated successfully.
Middle Ground of Hope. Eventually, says Montreal's Dr. Lehmann, the physiological and analytic schools will have to meet on common ground in the middle. His quietly persuasive argument: the analysts talk of ego defenses being torn down in a psychosis, and when this happens the already anxious patient is overwhelmed. Psychotherapy tries to restore the ego, but this is extremely difficult because the anxiety, now almost a physical entity, has unleashed a flood of physiological processes.
What do drugs like chlorpromazine do? Nobody knows precisely, but they seem to act on a primitive part of the midbrain or on the nerve pathways connecting this to the cortex. At any rate, this primitive part of the brain seems to be a center for mobilizing anxiety, even though the anxiety is experienced only in the cortex. This explains both the anxiety-relieving effect of the lobotomy and the different type of reaction to chlorpromazine.