The Revolution in Psychiatry
Preskorn, Sheldon H., National Forum
Psychiatry and the Public. For the general public, no other area of medicine is shrouded in more mystery than psychiatry. It is often viewed with an admixture of fascination and concern. This ambivalence is reflected in the public's contradictory beliefs that psychiatry is, on the one hand, therapeutically without substance and, on the other, virtually omnipotent and able to deal with such diverse subjects as the effects of poverty and holiday mood swings.
The profession itself has contributed to these misconceptions. In the 1950s and 1960s, leading psychiatrists suggested that adherence to psychoanalytically derived principles could virtually free human beings from their restrictions and allow them to realize their "full potential." Yet psychiatry did not fulfill its promise to cure serious mental illness by redefining the meaning of psychosis as simply "being sane in insane places." Nor was psychiatry able to ensure that the chronically mentally ill, released from state hospitals under the therapeutic optimism of the 1960s, would not suffer a much more dehumanizing and terrifying existence on the streets of large U.S. cities.
The Detour. What may be difficult for many Americans to understand is that American psychiatry took a significant detour from the rest of world psychiatry and is only now regaining its medical roots. Because of the right constellation of forces, American psychiatry became dominated by psychoanalysis for much of the first half of this century and still feels the effects today. The foothold of classic psychoanalysis and its derivatives extends into many parts of American life, including the arts (e.g., Freudian themes in books, plays, and movies), the popular press (e.g., "holiday blues," "stress-induced mental illness"), and even business with the popularity of motivational speakers and programs.
The factors that made the United States a good medium for the growth of the psychoanalytic movement were varied and included the movement's promise of being able to cure psychiatric illness through personal reflection, which resonated with the basic philosophies of the country, especially those formalized and popularized by Dewey and James at the end of the nineteenth century; the reliance of a young country on imported knowledge from Europe, perhaps particularly in medicine, following the Flexner report in the early twentieth century; and the fact that large numbers of psychoanalysts emigrated from central Europe to escape religious and cultural prejudice and eventually overt persecution under the Nazis. All of these forces promoted the growth of psychoanalysis in this country in the first half of the century to the virtual exclusion of a more medically oriented approach to psychiatry. Interestingly, the converse was true in much of the rest of the world, with the result that after World War II, American psychiatry had little similarity to its European progenitor.
The Quiet Revolution. Psychoanalysis and its derivatives are not without merit but have not proved to be effective as primary treatment for serious psychiatric illness (e.g., schizophrenia and manic-depressive illness). That fact, coupled with the discovery of medications that are effective in treatments of these disorders, led to a quiet revolution within American psychiatry and a return to its medical roots. That revolution has been and continues realigning American psychiatry with the rest of the world's psychiatry and with medicine in general. Without fanfare, psychiatry has changed so that today it bears little resemblance to the popular image of the field. The gap between that image (e.g., the couch and talking as the exclusive mode of treatment) and reality is growing. This paper will present a view of the current status of the field and the further changes that are expected with increased knowledge from basic and clinical neuroscience research concerning basic brain mechanisms relevant to psychiatric illness.
Psychiatry and the Medical Model. …