Adam Blatner, M.D.

A lecture given at the Senior University Georgetown's Summer Program, June 12, 2014)

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.
Some Background
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 that anymore

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 and 1980s.

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 for them!"

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 later.)

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
   neuro-physiology             temperament            talents or abilities        disabilities or weaknesses        cultural world-view
   social embeddedness      status, rank              role repertoire              flexibility, playfulness                mythic systems (transpersonal and cultural)
  .... etc.
      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 marginalizing them.

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 "cultural lag."

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.

2. .

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 other treatments.

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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