Menninger. The Family and the Clinic

By Lawrence J. Friedman

(Alfred A. Knopf, Inc., New York)

472 pp. with index; $29.95

Just as the afflicted used to journey long distances for the healing waters at Lourdes, so do contemporary sick people travel to world-famous medical centers in the hope of achieving cures for their ailments. Names such as Johns Hopkins, Mayo and Sloan-Kettering long ago lost their significance as mere family surnames and instead represent the finest in the art and science of healing.

In the same fashion, the family name Menninger (pronounced with a hard "G") has come to signify innovation and success in the treatment of mental illness.

The Menninger Clinic for Neuropsychiatric Diseases was founded in Topeka, Kan., in late 1919 by patriarch Charles Menninger, a general practitioner. Hoping to establish a group medical practice along the lines of the Mayo Clinic in Rochester, Minn., and the Joslin Clinic for Diabetes Mellitus in Boston, Charles Menninger traveled to these clinics a number of times for study and observation.

He soon realized that the set-up employed at the Mayo Clinic, a strictly family-run operation consisting of a father and his two sons, was infinitely more stable and tightly controlled than the Joslin Clinic, where unrelated junior physicians frequently left after completing their training. A major feature of Charles's dream of group practice was to work side by side with his sons.

Convincing the Menninger offspring, sons Karl, Edwin and Will, to study medicine and then practice with their father required a great deal of manipulation, propagandizing and cajoling on the parts of Charles and matriarch Flo, a strong-willed "practical Christian" given to charity work and taking in boarders. The complex family dynamics of alliances and outright feuding is the major theme in this institutional biography.

Charles and Flo were successful in convincing their eldest son, the brilliant but often unpredictable Karl, to enter medical school. After a mediocre career as a student at Harvard and an internship in surgery at Kansas City General Hospital, Karl completed a residency in psychiatry at the Boston Psychopathic Hospital. The lure of Topeka was strong, and Charles was successful in convincing Karl, who died last month at age 96, to return to the Midwest.

One of the conditions under which he agreed to come home was the promise that the focus of their medical partnership would be the emerging field of psychiatry, rather than Charles's primary interest: general internal medicine. Charles was so eager to have Karl working with him that he gladly acquiesced, changing not only the orientation of the Menninger Clinic but also in establishing Karl as its de facto leader.

After a lengthy, and somewhat tendentious excursion in psychohistory, author Lawrence Friedman explains that the middle son Edwin was left out of the family vision of creating a psychiatric dynasty and subsequent hopes were placed on the shoulders of Will, the youngest son. Despite definite leanings toward a career in internal medicine, cultivated during his student days at Cornell Medical School, Will was convinced to join the clinic in 1925.

By the mid-1920s, the Menninger Clinic was on its never-ending path of expansion. Beginning with the opening of the Menninger Psychiatric Hospital, an inpatient sanitarium administered by Will, the clinic was infused with a sense of family spirit, and Karl emerged as the central patriarchal figure.

Ironically, by this time, the real patriarch of the family, Charles, had been relegated to a secondary role and semi-retirement. It was also during this period that Will developed "milieu therapy," a standard treatment program in psychiatric hospitals in which a miniature community inside the facility is created. This therapy supposedly facilitated a major re-education of the individual patient in a protected environment. So successful was milieu therapy that it became an essential feature of psychiatric hospitals and granted the Menningers the self-assurance to branch out into child psychiatry, psychoanalysis and development of the Menninger School of Psychiatry.

Perhaps the most interesting chapter in this history deals with Karl's importation of European emigres just prior to and after World War II. The majority of these psychiatrists trained under Sigmund Freud. Karl Menninger, already a well-published authority in American psychiatric circles and one of the country's leading proponents of Freudian thought, was snubbed by Freud when they met briefly in 1934. Nevertheless, Karl consistently expressed his devotion to Freudian ideas and methods: "I'll defend it {Freudian psychoanalysis} against assault for the rest of my life."

In fact, 15 Freudian disciples were imported to the Menninger Clinic during this period, ostensibly as clinicians but primarily as personal tutors of psychoanalysis for Karl. Friedman documents with great care the strong influence these psychoanalysts had on the Menningers and the problems that resulted from their presence, ranging from financial remuneration and the emigre's' assimilation in Topeka to the interpretation of Freud.

Friedman also notes that Karl's anti-Semitic leanings surfaced as a result of these confrontations, because most of the emigre's were Jewish. Karl, for example, repeatedly called psychoanalysis "Freud's Jewish science," and he even placed a quota on how many Jews the Menninger Clinic would employ in a given year.

Friedman provides the reader with a backstage glimpse of the Menninger Clinic, a place rife with subterfuge, insecurities and adultery -- both Karl and Will had mistresses -- combined with a leitmotif of brother fighting brother in a constant power struggle.

In a lengthy and detailed description of the clinic's conversion to a nonprofit foundation and its rise to prominence as one of the nation's premier psychiatric institutions, Friedman heaps facts about budgets, appointments, educational programs and expansion plans on the reader.

In counterpoint to this account are the fraternal and intensely political struggles between Karl and Will for control of the foundation and the ultimate "palace revolt" in 1965, when Karl was deposed as chief of staff and Will assumed control. Friedman also records the failings of the clinic with its emphasis on psychoanalysis and social psychiatric techniques, such as marriage counseling, to the exclusion of investigation into biopsychiatry and the emerging field of psychopharmacology, which have made substantial inroads in the treatment of mental illness.

With Will's death in 1966 and Karl's exile, Roy Menninger, Will's oldest son, was made president of the psychiatric empire. Friedman's description of Roy is that of an administrator more concerned with fund-raising and buildings than psychiatric research.

Such a leader substantiates Friedman's conclusion, "If charisma is considered from Max Weber's perspective -- the pervasive belief in the extraordinary power of leaders -- Roy's presidency marked the end of an era." Perhaps this can be said of all family-run businesses handed down from geniuses to less-gifted offspring, whether it is Ford Motor Company or the Menninger Clinic.

Howard Markel is a clinical fellow in adolescent medicine in the department of pediatrics at Johns Hopkins Hospital in Baltimore.