TRENDS IN THE HISTORY OF
A lecture given at the Senior
University Georgetown's Summer Program, June 12, 2014)
Adam Blatner, M.D.
Two years ago I gave
a summer talk about the history of
psychotherapy This will supplement that and also
address a lot of new material.
I'm planning on another lecture or two titled "We
Don't Do That Anymore--Parts 2, and maybe 3" talking about other
trends in medical practice and theory.
For now, let's note first that Psychiatry is a medical
field, ---iatros meaning physician in ancient Greek. -ology
refers to the study of. (In England and the UK, psychiatry is
called medical psychology---but that's not entirely accurate,
because as we'll note, a goodly number of conditions that affect
thinking and behavior are mainly biologically-based. But of
course, such conditions also require some talking with the
patient about the impact of their condition!
Today I'll be talking about some trends in psychiatry over the
last century and more in the last 50 years.
It's necessary to both feel good about the advances we've
made over a century ago or even within our lifetime, and at the
same time remember to be humble about the vast dimensions that
remain mysterious to us. We really don't know all that much
about the causes of various serious problems, nor do we know how
to cure them.
I have a number of sayings that sustain and remind me. One is a
translation from the first aphorism of the legendary so-called
"Father" of medicine, the ancient Greek, Hippocrates. He started
off by acknowledging that life is short, but the great art of
medicine is "long,"---i.e., goes on for millennia. How to find
out what is wrong, how to treat it, how to offer comfort? A
second line is from another famous physician, Sir William Osler,
who once defined the goals of medical practice as "to cure,
rarely; to ameliorate, occasionally; to comfort, always.
The third line is apocryphally part of a graduation speech given
at a college of medicine about a century or so ago: "Gentlemen,"
the speaker said---there were few women practitioners at the
time---"I have a confession to make. Half of what we have taught
you is wrong. Unfortunately, we don't know which half." the
point is that some stuff that we think is so is not, and vice
versa, and much of our knowledge changes. To be humbly aware of
that does not require that we throw up our hands helplessly. No
one to our knowledge knows more, though on this or that topic
some few claim to.
In the 18th through the mid-19th centuries, mental illness was
not treated well by others. It was an era of general cruelty in
the West, or at least non-compasson.
One of the topics I mentioned in the brochure is the use of
fever, induced by giving
patients malaria, to treat his talk will describe “dementia
paralytica.” also known as General Paresis of the Insane,
also known as tertiary syphilis of the brain. This condition
represented at least a fourth of patients hospitalized for
mental conditions, a higher percentage if one confines the
search to people with an onset of insanity between the ages
of 30 and 60. Indeed, if you hear in history of someone who
was okay until that age range and then became increasingly
unstable, consider this diagnosis. Often they'd die of some
other complication of late-stage syphilis---a great vessel
of the heart or abdomen rupturing being not uncommon in this
condition. But sometimes they'd become first a bit
manic-like, grandiose, irritable, and then demented.
It turns out that a bout of high fever kills off most or
rarely all of these germs and the patient, if not too far
gone, makes what in those days was a remarkable, near
miraculous recovery. The Austrian physician Julius Wagner
von Juaregg noticed this in the late 19th century and
researched it more in the early 20th at the University of
Vienna. He ended up getting one of the few Nobel Prizes in
psychiatry, as part of medicine, in 1929.
By that time, interestingly, other approaches to raising the
patient's temperature were tried, ones that might not be so
risky---it was called "pyro-therapy." It seemed to work in
many cases, but some folks were too far gone to benefit. It
was as one author called it, a great and desperate cure,
because nothing else would halt the degeneration of mind in
this disease. But with the advent of penicillin, we don’t do
Not a Shrink
Okay, that got your attention. The biggest change I want to
note is the emergence of psychoanalysis as a dominant trend in
psychoanalysis between 1920 to 1945, its continuous dominance
from the 1940s through the 1960s, and its gradual and rather
precipitous decline as a dominant trend in the mid-late 1970s
The cultural lag in this case is the tendency to think of all
psychiatrists as "shrinks." Cultural lag
is when the actualities of change have moved on but significant
islands or even the mainstream hasn't caught on. The sense of
shock experienced by many Americans at the snubs and arrogance
of people in other countries is based on a residual sense of
entitlement, a cultural lag, harkening back to the era when the
USA held a hegemony. "They should be grateful to all we've done
Another example of cultural lag is the way that so many
cartoonists use the "trope" or theme of the psychoanalyst and
the couch as a metaphor for people seeking counseling---and what
they're complaining about are often contemporary themes of
alienation. But in truth, as I said psychoanalysis has retreated
from it's position of dominance in the 1960s. (Indeed, perhaps
this trend has overshot the mark, but I'll comment on this
The point is that psychiatrists should not be called "shrinks"
because most don't engage in a "head-shrinking" process of
Freudian psychoanalysis. Indeed, I comment on this in another paper on this website.
Better we should be called expanders---at least that's how I
think of myself. I do think there was some validity to that
epithet 60 years ago because psychoanalysis dominated the field
and their various interpretations revolved around a number of
theoretical constructs that hardly did justice to the complexity
of the human mind, individually or collectively. They were in a
sense "shrinks," I'm sorry to say, but in another sense, even
that narrow view was nevertheless an expansion of what our
notion of what humans were about. Now it's even more expanded.
What I mean by exapanded is that human experience should include
much more of
talents or abilities
disabilities or weaknesses
(transpersonal and cultural)
Alas, though psychoanalysis introduces a
number of perspectives, some I agree with, some not, it tends to
ignore the aforementioned variables, and in that respect
psychoanalysts lacking that broader perspective tend to be
shrinks, not just ignoring all these variables, but
Marginalization is an important element in this
lecture. It's the act of blithely ignoring something that
shouldn't be ignored, acting as if it doesn't count because it
exists on the margins. For example, people of color were
marginalized in the movies and other mainstream cultural
vehicles in the 50s, less so in the 70s, and even less so since.
But then, African-Americans were either servants or picturesque
"others" (as in the Porgy & Bess musical opera).
Hegemony is another word to be learned. A field,
nation, world-view, has a hegemony when it has come to dominate
a field, its potential competitors being weak or less
articulate. In the 1960s the United States had a hegemony over
the "free world." From 1950 - 1960 psychoanalysis had a hegemony
in psychiatry. Adler's and Jung's schools were largely eclipsed.
Since those times, competition has risen in both those areas,
but hegemony continues in many people's minds as a function of
Of late I've been taken by the idea of all the changes in the
field that I've been associated with for 50 years, and want to
share some of these changes, trends, in part to inform and in
part to clear up a number of stereotypes.
I’m a psychiatrist—The Greek word-root iatros in
the word psychiatrist meaning physician—not a psychologist,
ology means study of
In fact, the field has been as varied as the history of
computers or medicine or other major developments. There have
been swings of what’s in fashion and what’s out. So here goes.
3. Other Dimensions of Psychiatry: Psychiatrists did before
managed care organize hospitals, clinics, how health delivery
services would be organized. They did the kinds of talk therapy
that is most of psychotherapy, but they also did a lot of
4 In the 19th century and early 20th century, not so much, but
in the mid 20th century, psychotherapy was a big part of
psychiatry. Organic psychological organic pendulum swing:
One of the changes that has happened in the realm of
psychotherapy is that most psychiatrists have retreated to being
more caught up with brain-neurology and with treating the brain
with various medicines. In a way that’s been good: Talk therapy
hasn’t been found to be particularly effective with the major
mental illnesses and continuing research on these conditions is
important. However, there are a fair number of the old-time
psychiatrists who went into this field because the mind itself
is so very fascinating.
5 But during much of the mid-20th century,
psychiatrists were involved in understanding the psychology—the
workings— of the mind and its relations to the social network,
since this was considered a major factor in mental
illness. So being a psycholoGIST is a type of discipline,
but we all do psychology in a sense whenever we wonder why
people behave as they do. During this mid-20th century talk
therapy was considered a major element in psychiatry.
6 .Types of Psychotherapists. I made this slide in the
early 1990s: Alas, many psychiatrists have retreated to
the arena of physical treatments, evaluations for and
adjustments of medications and other types of treatment. I have
a friend who’s exploring magnetism’s effect on depression. But
this is not psychotherapy. It’s therapy, pharmaco therapy, other
treatment, but psychotherapy is now for the most part being done
by non-psychologists, often by counselors whose training was as
counselors. We won’t go into the politics of all this except to
say that many of the pioneers in the first and middle part of
the century were psychiatrists, M.D’s, and increasingly advances
in the realm of psychotherapy are being made by more experienced
psychologists and other non-psychiatrists.
7. Psychotherapy iis helping people.. Talk
8. In a larger sense, it partakes of the art of bringing people
forth into their highest potential..
(Network of People-Helping)
Even though I’m retired from
clinical practice, the art of bringing people forth continues to
interest me. It applies in a larger sense to parenting,
teaching, leadership in general, coaching, skilled management,
and other roles. I think these have something to teach the field
of psychotherapy, and psychotherapists in turn have something to
teach the larger society.
So to repeat, many psychiatrists, although not
professionally accredited within the academic field of
psychology per se, still were dealing with psychology insofar as
they really explored how the mind works. Indeed, in England,
psychiatry is often called medical psychology.
9. I heard a colleag
10. The field has evolved a lot in the last century. The
mid-part was dominated by Freud, the post-Freudians,
psychoanalysis, the couch, weird theories of what the mind is
about, and so forth. And although that peculiar approach gained
dominance for a while in the field, it never actually involved
more than a minority of the profession. Maybe 20% max were
accredited as psychoanalysts around 1958, which was close to the
apex of this trend, and another 50% sympathetic, but not
formally trained, but lots has happened since, and now it’s less
than 5% accredited and most psychiatrists are hardly sympathetic
with Freud, although a few of his ideas have held up to further
research. We are largely consumed by irrationality, though not
in the ways he described. Back to that later.
I’ll be talking about psychoanalysis as a core from which others
diverged or contrasted themselves. I myself am part of a stream
that contrasts itself with the psychoanalytic technique but I
appreciate many of the elements of depth psychology. It’s
invigorating to be in the middle, but invigorating but also a
bit slippery and difficult—people keep wanting to classify you
in a way that’s are you with us or against us.
Okay, let’s carry on.
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