Menninger: The Family and the Clinic.

Menninger: The Family and the Clinic. By Lawrence J. Friedman (New York: Alfred A. Knopf, Inc., 1990. xix plus 472 pp.).

In Menninger: The Family and the Clinic Lawrence Friedman takes on the formidable task of drawing together the extraordinary lives of members of the Menninger family and the development of the institution which they established. His central thesis is that the institution cannot be understood apart from the |family spirit' which pervaded its earliest years and persisted in its very structure. This |family spirit' included a drive toward innovation, a sense of Christian mission, a dedication to work, and a tradition of institution building, as well as sibling rivalry, a need to control and dominate, and psychological problems with independence and self-esteem. All members of the family possessed each of these characteristics to greater or lesser degrees, but the heart of the work centers around the conflict between Karl and Will Menninger. Friedman describes the brothers' consistently rocky relationship as arising from Karl's alliance with his mother, Flo, the domineering partner in the parents' marriage, and Will's alliance with Charles, the father, who was more cooperative and less aggressive. The persistence of this identification with competing family groups sometimes supported cooperation between family members, but more frequently required the development of institutional mechanisms to avoid direct confrontation. Friedman believes these mechanisms, and the infighting that they were designed to circumvent, often interfered with the mission of the institution to provide cutting edge, innovative psychiatric care.

Friedman's blending of collective biography and institutional history offers interesting and important insights into the nature of institution building in mid-twentieth century America. He provides a critical framework for understanding institutional development in medicine when he suggests that the Menninger Clinic was created by four separate but interrelated forces: the personalities of the founders, the ideals of science and progress that permeated medicine, professionalization efforts of competing groups, and the development of institutional community. In his effort to understand the relative impact of each of these forces Friedman reveals a wealth of previously unavailable detail about the inner workings of the Menninger Clinic and the inner lives of the individuals who established it. He concludes that there are three basic stages in the evolution of the clinic resulting from a shifting balance among the competing forces in his model: "A Family Spirit 1919-1945," "The Making of a National Institution 1941-1953," and "The Passing of the Founding Generation."

However, Friedman is not even-handed in his examination of the relative impact of these competing forces. Friedman repeatedly details the "Karl centered" nature of the family and the institution. His monograph, as the title indicates, echoes that pattern; it is Karl and, to a lesser extent, Will centered. This Menninger-centeredness produces a particular vision of the nature of the institution.

For example in citing Will's development of a power base through alliances with nurses and occupational and recreational therapists, Friedman claims that the younger Menninger saw nurses as more than the "handmaids of the doctor." This claim does not hold up to careful scrutiny. In the same chapter in which he proclaims Will's visionary approach, Friedman also notes that Will defined nurses as mothers not as professionals and "He added that the greatest evil in psychiatric nursing was for nurses to become enmeshed as a 'family of sisters.' |Sisterhood' constricted support for the physician."(1) Will Menninger can only be seen as visionary on nursing if you adopt the perspective of hospital administrators, which Friedman has done.

My research on the history of nursing at the Mayo foundation indicates that there is another history in institutions of this nature, a history of institutional sub-communities with which the administration has limited contact and of which it has limited understanding. Though Friedman includes the impact of the community in his model of institution building, the components of the institutional community in Topeka are defined almost exclusively in terms of their relationship to the guys at top.

Perhaps the most important indication of the Menniger-centeredness of the monograph is Friedman's adoption of the Freudian paradigm to explain familial relationships and their influences on institution building. For obvious reasons Karl, Will and much of the staff described themselves and the major events in their lives in Freudian terms. Since his subjects incorporated this paradigm into their understanding of and approach to the world, Friedman's rightly uses this outlook to comprehend why people at Menninger behaved as they did.

My central problem with the Freudian interpretation is that it focuses on Karl's sense that his mother's domineering personality was at the root of his psychological problems. This interpretation embraces the Victorian/Freudian assertion that submissiveness in women is normative. I would like to propose an alternative interpretation - that the real issue in Menninger's internal struggle over his feelings toward his mother is that he never challenges the societal standards on which the Freudian paradigm is based. If Karl had been able to accept that it is normative for some women to be strong, he would not have felt the need to break so dramatically - and for the institution so destructively - from his wife and mother. Similarly, while Friedman used the works of feminist historians on the cult of domesticity to interpret Flo and Charles Menninger's relationship, he does not embrace the central point of these works that both men and women were oppressed by the Victorian ideal. Perhaps he does not do this because this interpretation also directly challenges the Freudian paradigm.

Overall, this book is rich with fascinating tidbits of information about the Menningers and their clinic. Additionally, it offers compelling insights into the interaction between individuals and institutions. But in the end it leaves the reader with two impressions which I am certain Friedman did not intend to convey: that one should avoid psychoanalysis at all costs and that the Menninger brothers never really grew up.

(1.) At the same time that nursing leaders were trying to redefinite their work as instumental and professional, Will Menninger harkens back to the image of maternal instinct. The descriptions within the quotation come from an article by William Menniger on psychiatric nursing written in 1938 quoted page 76.