Psychiatry: Past, Present, and Prospect

433 Pages·2014·1.81 MB·English

by  Sidney Bloch, Stephen A. Green, Jeremy Holmes

Psychiatry:
Past, Present,
and Prospect
Edited by
Emeritus Professor Sidney Bloch
University of Melbourne, and
Honorary Consultant, St Vincent’s Hospital,
Melbourne, Australia
Professor Stephen A. Green
Clinical Professor of Psychiatry,
Georgetown University School of Medicine,
Washington DC, USA
Professor Jeremy Holmes
School of Psychology,
University of Exeter, UK
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1
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Preface
The provenance of this volume of essays is twofold. We editors, all at roughly the same
stage in our careers, were contemplating our impending retirement. We wondered
about writing a combined memoir that would address the highlights and frustra-
tions of the more than four decades of clinical practice, teaching, and research. The
prospect was exciting and intriguing, covering as it would scientific discoveries of all
kinds, biological and psychological, advances of treatment, conceptual breakthroughs,
and fiery intellectual debates on an inexhaustible range of topics. We also wanted to
face up to psychiatry’s negative side: perennial indecisiveness about the profession’s
boundaries—whether to promote an ambitious social vision or confine its activities
strictly to the medical clinic; the limitations of a narrow approach to human suffering,
dominated by arbitrary diagnosis; the retreat from the hope of a deinstitutionalized,
community-based psychiatry; the divide between biological treatments and psycho-
therapy; the technical and ethical complexities of psychiatric research; and the low
priority given to psychiatry, especially but far from exclusively in less developed coun-
tries. We would also have to deal with ethical challenges facing the profession, such as
maintaining the basic human rights of severely disturbed patients while at the same
time recognizing that many of them are unable to act independently without risk of
harming themselves or others.
A second rationale for producing such a memoir was a shared perception of deficien-
cies in training experienced by our junior colleagues. Increasingly, they lack a develop-
mental perspective for their patients and are taught to concentrate almost exclusively
on the present and the immediate future with an emphasis on the questionable proce-
dures of ‘risk assessment’. In addition, as they embark on their odyssey they have—in
our view—a relatively meagre knowledge of the contemporary history of psychiatry,
especially at the level of oral and personal experiences.
We then posed the question: would it not be to the advantage of trainees to hear
directly from the ‘elders’ of the profession—their observations, feelings, and fanta-
sies about psychiatry from graduation as psychiatrists through to retirement? They
could learn of our initial foray into the clinical setting, and the sense of excitement as
we began to get to know our patients—their tantalizing life stories and inner mental
lives—as well as our anxiety as to whether we were sufficiently equipped to help, let
alone cure them.
The 1960s saw the end of the 350-year era of the asylum. However enlightened an in-
novation in mental health care this was in its inception as the Enlightenment took over
from a religious context for conceptualizing mental illness, it had failed to rehabilitate
most of its occupants. This was due to a lack of core scientific knowledge, inadequacy
of rational treatments, and the degeneration of asylum conceived as caring and be-
nevolent, to one of custodial regimentation. The early 1960s offered reason for cautious
iv PREFACE
optimism, as stigma began to recede, more effective medicines were discovered, and
psychosocial concepts and therapies devised. A collective memoir, we surmised, had
the potential to provide a balanced picture of these changes, highlighting their benefits,
as well as unanticipated and unwelcomed consequences.
Appealing as the memoir idea seemed, were we adequately equipped to write an
authoritative and comprehensive narrative? Would our perspective on a half-century
of developments and limitations be broad enough? Though we disliked the increasing
fragmentation and subspecialization of medicine, from which psychiatry has not been
immune, we had to acknowledge that there were many subjects where each of us had
no direct experience or expertise. Then came the obvious solution: why not recruit
renowned and respected colleagues who, like ourselves, were nearing the end of their
active career? We would invite them to reflect on the area of psychiatry to which they
had devoted their energies, culminating in much-lauded contributions. Our new aim
was for a text comprising a set of perspectives written in essay form by an esteemed
group of colleagues. That is what we now offer.
Having arrived at this overall objective, we settled on the following goals:
1 To promote the curiosity of mental health professionals about key developments
in psychiatry over the past half-century and thus deepening their understanding
of the historical context within which they work;
2 Within Santayana’s rubric of ‘Those that do not learn from the past are destined to
repeat it’, to sensitize the next generation of mental health professionals to the role
they might play in advancing the state of knowledge about mental illness and its
treatment during the course of their careers;
3 To offer an unparalleled collection of the perspectives of internationally recog-
nized colleagues who have made notable contributions in specific domains;
4 To offer the interested laity an opportunity to gain a balanced account of psychia-
try’s evolution since the 1950s and its likely prospects in the 21st century; and,
finally,
5 To serve as a valuable archival resource for scholars.
In the light of these goals, we identified two principal groups of readers. First, psychi-
atrists and allied mental health professionals, such as psychologists, psychiatric social
workers, psychiatric nurses, and occupational therapists, both trained and in training.
Secondly, the lay public who are commonly puzzled about what contemporary psy-
chiatry has accomplished and what it may offer in the future. Many people harbour
a prejudice towards, and fear of, the profession, derived from its commonly distorted
portrayal in the media and possibly from personal experience of being a patient, or
knowing a relative or friend who has received psychiatric care.
Having determined our purpose and identified our principal readership, we encoun-
tered the tricky issue of what topics to cover; the possible range was overwhelming.
Readers will inevitably have misgivings about omissions but we feel confident they
will not find fault with what we have included. Suffice to say that we resisted targeting
individual diagnostic groupings—we believe that there are far too many of them and it
would serve little purpose covering the evolution of each.
PREFACE v
We are chary of drawing sweeping generalizations, programmes, or predictions from
our colleagues’ essays. They speak for themselves, and readers will draw what conclu-
sions they may. Nevertheless a number of themes, for good or ill, stand out that any
future mental health professional will want to take into account.
The first well-documented theme is the move in psychiatry since the mid-20th
century from a broadly psychosocial approach to a narrower neuroscience-oriented
perspective. The locus of interest and glamour has moved from societal ills and their
impact on mental health to unravelling the intricacies of brain functioning. This new
domain of neuroscience, vastly exciting as it is, risks focusing on the brain in isolation
from other salient fields in psychiatry. We believe, and our view is supported by several
of our contributors, that the opportunity now exists to see the brain-in-context, and
explore how its genetic, biochemical, and structural features cannot be separated from
lived experience, and the world of relating at the level both of the family and of the
overall social environment.
A second, related theme lies in the burgeoning science of neurogenetics. Molecular
biology was in its infancy when we started out, with genetics still confined within a
largely Mendelian paradigm. The new field of epigenetics means that the search for, say
‘the schizophrenia gene’, is seen as illusory, and promises to unravel how nature and
nurture are fascinatingly intertwined, aetiologically and clinically.
A third theme is the shifting power relations within psychiatry. Our generation was
the first for whom the provenance of mental illness was not presided over by Asylum
Superintendents, God-like figures (invariably men) who exercised near-feudal power
over the inmates and staff of the mental hospital. The ethos of the psychiatric world in
which we qualified was that of liberation from the atmosphere of institutional care that
was at the same time nurturing and stifling. Psychiatrists attempted to cling to their
hegemony, still claiming to be natural leaders of the mental health team, but that too
has become a nostalgic vestige. Patients are no longer subjugated souls, but ‘consumers’
with the rights that attend a business-like relationship with their ‘providers’. Psychia-
trists compete on a levelled professional playing field with a range of mental health pro-
fessionals and can no longer assume that they are primus inter pares; they must justify
their status and salaries on merit.
Another striking change has been in the arena of therapeutics. In our psychiatric
infancy treatments were broad-brush and non-specific: neuroleptics for psychosis;
antidepressants for mood disorders; psychoanalysis for neuroses; and abstinence for
addicts. Since then scientific advances and the influence of the multibillion-dollar
pharmaceutical industry have contributed to a proliferation of diagnoses and attempts
to find specific medications or psychotherapies to treat them. This trend leaves us won-
dering if something has been lost and in need of rediscovery. There is an urgent need
for a whole-person medicine that engages patients not in terms of quasi-mechanistic
dysfunction, but rather at the level of personal experiences, and agency.
With that cri-de-coeur we will desist. The future of our profession is uncertain. If
a comparable text were to be compiled in the middle of the 21st century how would
it look? Will psychiatry even exist as a medical speciality? Will it have merged with
neurology? Will it confine itself to the minutiae of brain function leaving the world of
emotions and relationships to psychology, nursing and social work? Or will psychiatry,
vi PREFACE
we hopefully, but perhaps vainly suggest, finally have taken its place as the queen of the
medical specialities, uniquely able to integrate the biological, psychological, social, and
cultural, and to connect with the lived existence and meanings of its patients?
Only time will tell how the story of psychiatry will unfold. In the meanwhile, we hope
that the perspectives provided by our contributors to this volume will assist younger
colleagues in fulfilling their professional role as effectively as possible, and to keep in
mind the essential lessons, both positive and negative, to be learned from the past.
We leave the last word, so apposite to our current purpose, to Thomas Hardy from his
poem, ‘An Ancient to Ancients’:
Much is there waits you we have missed;
Much lore we leave you worth knowing,
Much, much has lain outside our ken:
Nay, rush not: time serves: we are going …
Sidney Bloch
Stephen A. Green
Jeremy Holmes
Acknowledgements
Psychiatry: Past, Present and Prospect has self-evidently been a collaborative effort. By
all accounts, our esteemed colleagues did not find the task entirely straightforward.
What we did not want was a standard review of the scientific literature. Instead, what we
hoped for, and believe has been achieved, was a confluence of personal and professional
pathways, giving a unique perspective of the evolution of psychiatry in their area of ex-
pertise since the 1950s. The complexity and novelty of this writing assignment reflects
in part the unprecedented nature of the volume and the objectives we set and which we
have described in the preface. We are immensely grateful to our contributors for their
deft efforts in helping to accomplish those goals.
We are also indebted to our colleagues at Oxford University Press: Martin Baum,
Charlotte Green, Kathleen Lyle, Eloise Moir-Ford, Abigail Stanley, and Peter Steven-
son. Not only was their enthusiasm for the project palpable from the outset, but they
also carried out their editorial tasks effectively and efficiently. OUP’s decision to seek
the judgements of no less than five reviewers about our proposal provoked a degree of
anxiety in us but turned out to be a bonus in that we benefited substantially from their
suggestions. We thank them for their encouragement and diligence.

Contents
Contributors xi
1 Psychiatry and neuroscience 1
Steven E. Hyman
2 The past, present, and future of psychiatric genetics 22
Peter McGuffin
3 Fifty years of applied clinical research: schizophrenia
as an example 45
Vishal Bhavsar and Robin M. Murray
4 Social science and psychiatry, and the causes of mental disorders 64
Dana March and Ezra Susser
5 The history of cultural psychiatry in the last half-century 74
Anne E. Becker and Arthur Kleinman
6 History and development of social psychiatry 96
Julian Leff
7 Psychiatry in developed and developing countries 117
Norman Sartorius
8 Fifty years of mental health legislation: paternalism, bound
and unbound 133
George Szmukler
9 The ethical dimension in psychiatry 154
Stephen A. Green and Sidney Bloch
10 Defining and classifying mental illness 180
German E. Berrios
11 From alienist to collaborator: the twisting road to consultation–liaison
psychiatry 196
Don R. Lipsitt
12 Child and adolescent psychopathology: past scientific achievements
and future challenges 219
Michael Rutter
13 Psychiatry of old age 239
Catherine Oppenheimer
14 The forensic psychiatric specialty: from the birth to the subliming 263
Paul E. Mullen and Danny H. Sullivan