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Books, Journals, New Media
December 20, 2000

Psychiatry History: American Psychiatry After World War II (1944 -1994)

Author Affiliations

Harriet S.MeyerMD, Contributing EditorDavid H.MorseMS, Journal Review EditorRobertHoganMD, adviser for new media


Not Available

JAMA. 2000;284(23):3059-3060. doi:10.1001/jama.284.23.3059

Psychiatrists who trained 20 years ago or more will find this book fascinating. The newer generation of psychiatrists, who missed the earlier emphasis on psychodynamics and were indoctrinated with the promise of biologic psychiatry, will also find the book illuminating. The multifarious, nationally renowned chapter authors delineate shifting psychiatric values that traverse from biologically rooted pre-World War II (WWII) custodial practices, to postwar psychodynamic perspectives, to the current neuropsychopharmacologic biological perspectives, but from different viewpoints.

The first section contains several chapters on the lessons of war, which underscore how psychiatrists could successfully use psychodynamic methods to treat American servicemen with neuroses created by environmental stress. An interesting finding is that, unlike all other wars, in the Vietnam War the wounded-in-action rate and neuropsychiatric casualty rate showed an inverse relationship. Herbert Spiegel, MD, provides an absorbing first hand account of maxims learned during WWII about the difference between disease and illness and between paradigm and nosology.

Section 2 begins by highlighting the tremendous impact of psychoanalytic theory and practice during the post-WWII growth of psychiatry. The 1946 formation of the Group for the Advancement of Psychiatry helped to establish the role of dynamic psychiatry and psychosocial influences on behavior, thus causing the field to move farther away from treating psychotic patients. The same year the American Psychoanalytic Association began its organizational efforts, and critical developments in ego psychology and self-psychology began to occur. Glenn Gabbard, MD, pursues psychiatry's interest in psychotherapy. During the 50-year period after WWII, emphasis on training residents in psychotherapy decreased. He attributes this decline (from 50% down to 2.5% of the time residents were trained in psychotherapy) to the advances in neuroscience and psychopharmacology and to a shift from a phenomenologically based to an empirically based diagnostic schema. Three outstanding scholars review the trends in psychiatric education after WWII in a well-organized chapter and follow the transition from the belief that psychoanalysis could even solve social problems to an emphasis on biological psychiatry. Another interesting chapter tackles the discipline of psychosomatic medicine, which the war brought into a sharper focus. In his observations of postwar developments, Jerome D. Frank, MD, PhD, points out the plethora of nonmedical psychotherapists and brief psychotherapies that significantly changed the mental health landscape.

Lawrence C. Kolb, MD, DSc, and Shervert H. Frazier, MD, who lived the experience, supply the development and influence of the National Institute of Mental Health (NIMH) on psychiatry and the nation's mental health. Their chapter clarifies the overwhelming influence NIMH had on critical research that facilitated the shift from phenomenological diagnoses to empirical categories. The noted psychiatric historian Gerald N. Grob, MD, focuses on the "panacea" of the community mental health movement as a way to address social problems, along with the efforts of various presidents and federal government policies over the last 50 years. H. Richard Lamb, MD, considers that over the past 50 years, state hospital bed occupancy went down from 339 to 40 per 100 000, and he highlights the difficulties in treating the generation that has grown up since deinstitutionalization. He provides excellent suggestions on how to make deinstitutionalization work. Another chapter unravels the various antipsychiatry forces and illustrates the complexity of this factor in psychiatry over the last half a century. An exemplary chapter on the ex-patient and family consumers' movements adds to the mix. A very provoking chapter on the cultural impact of psychiatry as a biomedical science, agent of social control, and facilitator of social change notes that, despite the larger society benefiting from the increasing efficacy of psychiatric interventions, there has not been corresponding improvement in the problems of child abuse, crime, and drug dependency.

Section 4 follows the ebbs and flows of psychiatric values by using tables and charts that highlight relevant biological psychiatric and psychopharmacologic discoveries, biological publications, and research funding in biological psychiatry. This section appropriately demonstrates discoveries in psychopharmacologic treatment that spurred proposals of biological pathophysiology of mental disorders involving neurotransmitters and gave added impetus to the study of psychopathology, nosology, and epidemiology. In a hard-hitting chapter, Robert Cancro, MD, points out the numerous post WWII diagnostic schemes and how the 1952 American Psychiatric Association publication Diagnostic and Statistical Manual: Mental Disorders (DSM) reduced confusion. He accentuates some tragic errors made during the early years, eg, patients in old state hospitals would have their teeth extracted to treat the infections hidden beneath their teeth felt to contribute to the etiology of schizophrenic illness. Andrew E. Skodol, MD, delves deeper into the diagnosis and classification of mental disorders by carefully outlining the developments that have improved the reliability and validity of psychiatric diagnoses since WWII and punctuates the scientific rigor that went into the development of DSM-IIIR and DSM-IV.

Section 5 discusses how psychiatry has differentiated into various subspecialties. Remarkably, while US psychia try is more than 150 years old, child and adolescent psychiatry has been around for only the last half century. A tidy chapter covers the critical advances in child psychiatry chronologically but somehow manages to overlook the issue of children's exposure to trauma, which surfaced in the 1990s. The well-arranged chapter on geriatric psychiatry touts as a major accomplishment the field's overcoming mischaracterizations of aging. Addiction psychiatry is shown to have undergone a "remarkable transformation," and a thorough exposition on forensic psychiatry covers its role in administration, criminology, and criminal and civic courts.

The last section notes how the Nazi atrocities during WWII led the American Medical Association and World Medical Association to adopt codes of ethics. The 1960s human rights struggles also greatly changed the ethical focus in medicine, and the women's movement began raising issues about psychiatric sexual misconduct. Martha Kirkpatrick, MD, and Leah J. Dickstein, MD, admirably narrate women psychiatrists' efforts, and they credit the establishment of the National Organization for Women as bringing rape out of the US closet. Finally, the last chapter, led by an outstanding leader in the field, the late Dr Jeanne Spurlock, catalogues the influence of African-American psychiatrists on the American Psychiatric Association, which led to several formal structures in the association.

A weakness of the text is that there is no common vista among the authors. However, this weakness is also a strength, as it allows many different, cogent, and fascinating perspectives on the waxing and waning of various psychiatric values.