American Psychiatry After World War II: 1944–1994

This modern history of American psychiatry is a marvelous work. Its editors, two of the most outstanding psychiatrists of the half-century at issue, have selected unquestioned leaders to present overviews of the last 50 years in their respective fields. They have carefully edited their chapter authors’ work, dividing them into six useful subsections.

The first section, The Experience and Lessons of War, has chapters by Franklin Jones (“Military Psychiatry Since World War II”) plus separate chapters by the Spiegels (father Herbert and son David): “War, Peace and Posttraumatic Stress Disorder” by the latter and “Silver Linings in the Clouds of War: A Five-Decade Retrospective” by the former. The second section, Postwar Growth of Clinical Psychiatry, opens with Nathan Hale’s “American Psychoanalysis Since World War II.” Hale, Professor of History Emeritus at the University of California, Riverside, and an interdisciplinary member of the San Francisco Psychoanalytic Institute, is less critical of some of the shortcomings of psychoanalysis than one might be (although other chapter authors fill this void adequately). Glen Gabbard writes on “The Evolving Role of the Psychiatrist From the Perspective of Psychotherapy,” in which he laments the de-emphasis of psychotherapy in residency training programs and the shortsightedness of managed care companies in their emphasis on pharmacotherapeutic interventions. The chapter by James Scully, Carolyn Robinowitz, and James Shore on “Psychiatric Education After World War II” traces three enormous training shifts: 1) locale (from state hospitals to analytic couches to mental health centers), 2) whom we treat, and 3) how we treat. In “Psyche and Soma: Struggles to Close the Gap,” Donald Lipsitt pulls no punches in a review of psychosomatic medicine and consultation-liaison psychiatry over the past 50 years. Jerome Frank contributes a chapter on “Postwar Psychiatry: Personal Observations,” which is just that—a wonderful reminiscence in which he reviews his experiences in 1940 at a state hospital, possibly in Maryland, with its deplorable conditions and the sinecure it provided its psychiatrists. I wondered if it were the same one where, 22 years later, I moonlighted on weekends while I was at the National Institute of Mental Health (NIMH) and discovered that this 3,000-bed hospital employed only three full-time psychiatrists: one for each of the three 1,000-bed units (male, female, and admissions) and where I learned that Goffman may not have been altogether incorrect about asylums. Frank also discusses the downsides as well as the gains brought about during psychiatry’s romance with psychoanalysis.

Section 3, Public Attitudes, Public Perceptions, and Public Policy, begins with a chapter by Lawrence Kolb, Shervert Frazier, and Paul Sirovatka on “NIMH: Its Influence on Psychiatry and the Nation’s Mental Health.” NIMH is undoubtedly one of psychiatry’s great successes of this half-century—both inside and outside its walls. Gerald Grob’s chapter, “Mental Heath Policy in Late Twentieth Century America,” offers a superbly insightful historical perspective of psychiatry’s last 50 years. Richard Lamb’s “Deinstitutionalization and Public Policy,” although recovering some of Grob’s areas, offers its own unique perspectives. Norman Dain, in “Antipsychiatry,” and Philip Beard, in “The Consumer Movement,” also overlap to some extent, whereas John Beahr, in “The Cultural Impact of Psychiatry: The Question of Regressive Events,” presents a rather controversial but very interesting point of view—i.e., psychiatry’s role in facilitating cultural regression (although I think he attributes more power to psychiatry than it actually has). Anne Stoline, Howard Goldman, and Steve Sharfstein address “Managed Care and Other Economic Constraints.” I am not quite as sanguine as they are regarding our “potential bright future” under managed care.

Section 4, The Rise of Scientific Empiricism, begins with an excellent overview of the successes and problems to date of “American Biological Psychiatry and Psychopharmacology, 1944–1994” by Ross Baldessarini. Robert Cancro follows with “Functional Psychoses and the Conceptualization of Mental Illness,” and Andrew Skodol concludes the section with “Diagnosis and Classification of Mental Disorders.”

Section 5, Differentiation and Specialization, covers well four of our major subspecialty areas: “Child and Adolescent Psychiatry” (John Schowalter), “Geriatric Psychiatry” (Gene Cohen), “Addiction Psychiatry” (Marc Galanter), and “Forensic Psychiatry” (Seymour Halleck).

The editors state that the final section, Principles and People, addresses “human issues within the profession itself.” In “Ethics,” by Jeremy Lazarus, “Women Psychiatrists,” by Martha Kilpatrick and Leah Dickstein, and “Minorities and Mental Health,” by Jeanne Spurlock, Rodrigo Munoz, and Francis Lu, all of the authors creditably cover their areas.

So that’s the topic content with a few notations. How, otherwise, to critique this compendium? Obviously, not every reader can be satisfied by even the most encyclopedic work—his favorite expert isn’t included, her special interest wasn’t covered, he has a particular axis to grind. Nonetheless, this is a remarkably fair, balanced, and comprehensive attempt to cover the field. Its shortcomings are the inevitable result of an edited volume: it leaves us with a mosaic of 25 chapters and two editors. There are multiple overviews, some broad and most narrow. The editors might have eliminated some redundancies, but this is a minor issue. The more significant choice they made was between deferring to individual experts in their own special areas versus presenting their own individual, idiosyncratic, and (presumably) less expert views. The former is clearly more even-handed, the latter might have been more fun (and, possibly, more realistic). When my secretary relayed me a message asking if I would review a book by Menninger and Nemiah on the history of American psychiatry over the past 50 years (without mentioning that it was edited), I was thrilled! Who could have the chutzpah to write a grand overview of the last 50 years and speculate on the next 50? Who indeed—if not Roy Menninger and John Nemiah? With whom would you rather sit some evening in front of a fire (even metaphorically), schmoozing about psychiatry and getting their perspective? Terrific, I naively thought. Roy Menninger, of the royal Menninger dynasty, and John Nemiah, editor of this Journal for 15 years, distinguished professor and teacher, urbane handwriter of letters. Who has a better perspective? (Read Nemiah’s brief epilogue to this work and you’ll get the idea.) As I was writing this review, the move of Menningers from Topeka to Texas was announced. Having had the personal dubious distinction of presiding over its Institute when Pennsylvania Hospital decided to sell it to a for-profit group, I can assure you Roy Menninger must have plenty to say. Who better than these two to dispense with separate chapter writers and write it themselves? All of us would benefit from a historical perspective from our Nemiahs and Menningers, those who have “been there” and can make sense out of this maze of bright hopes, broken promises, and contradictions that have befallen us and speculate on where we are headed. Experts are nice but a little gossip and personal intimacy wouldn’t hurt. That’s my only real regret.

I realize that a nonedited book would have left many complaining that the authors missed something. Since we can’t have it both ways, the editors should be complimented for their humility, breadth, and even-handedness. As an aside to residency training directors, I would note that since psychiatry is the only (or one of the only) residencies whose mandate includes that its history be taught to all residents, this book is an ideal vehicle for filling that void. Not just residents, however, will enjoy and learn from this work—all of us will. It is a work to be cherished.