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American Psychiatry: An Ambivalent Specialty

Published online by Cambridge University Press:  30 July 2009

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American psychiatry, perhaps more so than other medical specialties, has had a troubled and ambivalent past. For much of its history its members were employed in public mental hospitals and thus lacked the autonomy and independence of their colleagues in private practice. More significantly, psychiatry was indissolubly linked with the fate of public institutions, whose image and reputation often left much to be desired.

The ambivalent character of psychiatry has given rise to two distinct and polar interpretations of its past. On the one side is a Whiggish scholarship that indentifies the evolution of psychiatry with scientific progress. The barriers to the creation of a psychiatric utopia result from the actions of malevolent or narrow-minded individuals and groups unwilling to provide appropriate resources. Furthermore, there is a presumption that psychiatric scientific and objective knowledge provided the basis for policies capable of resolving many of the troublesome problems associated with mental illness. On the other side are those who maintain that psychiatrists were involved with the social control of deviant and troublesome individuals. Mental hospitals, therefore, were simply institutions that confined and brutalized individuals whose only crime was their inability to conform to traditional behavioral norms. Embedded in this approach is the assumption that mental disease is a social rather than a medical category.

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Research Article
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Copyright © Cambridge University Press 1987

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References

NOTES

Author's note: The research for this paper has been supported by a grant from the National Institute for Mental Health (MH 39030), Public Health Service, U. S. Department of Health and Human Services. Slightly different versions were delivered at the Davis Center Seminar at Princeton University in November 1985 and as the Benjamin Rush Lecture at the convention of the American Psychiatric Association in May 1986.

Part of the material in this essay is drawn from my previous books, Mental Institutions in America: Social Policy to 1875 (New York: Free Press, 1973), Mental Illness and American Society, 1875–1940 (Princeton: Princeton University Press, 1983), and The Inner World of American Psychiatry, 1890–1940: Selected Correspondence (New Brunswick: Rutgers University Press, 1985). For further documentation and greater detail, the reader can consult the text and footnotes in these volumes

1. For an expanded treatment of this theme, see Grob, , “Rediscovering Asylums: The Unhistorical History of the Mental Hospital,” in Vogel, Morris J. and Rosenberg, Charles E., eds., The Therapeutic Revolution: Essays in the Social History of American Medicine (Philadelphia: University of Pennsylvania Press, 1979), pp. 135–57.Google Scholar

2. The concept of “impure science” has been used by Silverstein, Arthur in Pure Politics and Impure Science: The Swine Flu Affair (Baltimore: John Hopkins Press, 1981).Google Scholar

3. Grob, , Mental Institutions in America, ch. 1.Google Scholar

4. Ibid., chs. 2–3.

5. Ibid., ch. 4. For stylistic purposes I have referred to psychiatry and psychiatrists throughout this essay, even though neither term came into common usage until relatively late in the century. In the early part of the nineteenth century a psychiatrist was simply a superintendent of a mental hospital, or an alientist. I have also used the term insanity, which was a medical rather than a legal term in its orignial meaning.

6. Utica State Lunatic Asylum, Annual Report 1 (1843): 36Google Scholar; Worcester State Lunatic Hospital, Annual Report 7 (1839): 72.Google Scholar See also Ibid., 9 (1841): 40–41; 10 (1841): 39; 13 (1845): 50–51; and Woodward, Samuel B., “Observations on the Medical Treatment of Insanity,” American Journal of Insanity 7 (07 1850): 134.Google Scholar

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8. Grob, , Mental Institutions in America, pp. 155–65.Google Scholar

9. Worcester State Lunatic Hospital, Annual Report 9 (1841): 88Google Scholar; Woodward, Samuel B. to Sedgwick, Charles, 01 16, 1844Google Scholar, in Woodward, , “Collected Writings,” vol. 1Google Scholar (typescript), Library of Worcester State Hospital, Worcester, Mass. For descriptions of medical and moral treatment in mid-nineteenth-century America, see Grob, , Mental Institutions in America, pp. 165–71Google Scholar; Grob, , The State and the Mentally Ill: A History of Worcester State Hospital in Massachusetts 1830–1920 (Chapel Hill: University of North Carolina Press, 1966), pp. 4379Google Scholar; Dain, Norman, Concepts of Insanity in the United States 1789–1865 (New Brunswick: Rutgers University Press, 1964)Google Scholar; and Tomes, Nancy, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum-Keeping, 1840–1883 (New York: Cambridge University Press, 1983).Google Scholar

10. Worcester State Lunatic Hospital, Annual Report 61 (1893): 70.Google Scholar See also Dain, Norman, Disordered Minds: The First Century of the Eastern State Hospital in Williamsburg, Virginia 1776–1866 (Williamsburg: Colonial Williamsburg Foundation, 1971), pp. 4546Google Scholar, and Bockoven, J. Sanbourne, “Moral Treatment in American Psychiatry,” Journal of Nervous and Mental Disease 124 (0809 1956): 167–94, 292321.CrossRefGoogle ScholarPubMed

11. Kirkbride, Thomas S., On the Construction, Organization, and General Arrangements of Hospitals for the Insane (Philadelphia: Lindsey and Blakiston, 1854), p. 59 and 2nd ed. (Philadelphia: J. B. Lippincott, 1880), p. 248.Google Scholar

12. American Journal of Insanity 8 (07 1851): 7981Google Scholar; 10 (July 1853): 67–69. See also Dewey, Richard S., “Present and Prospective Management of the Insane,” Journal of Nervous and Mental Disease 5 (01 1878): 62, 92.CrossRefGoogle Scholar

13. Grob, , Mental Institutions in America, chs. 5–6.Google Scholar

14. See Rosenberg, Charles E., “Inward Vision and Outward Glance: The Shaping of the American Hospital, 1880–1914,” Bulletin of the History of Medicine 53 (Fall 1979): 346–91Google Scholar; Vogel, Morris J., The Invention of the Modern Hospital: Boston, 1870–1930 (Chicago: University of Chicago Press, 1980)Google Scholar: and Ludmerer, Kenneth M., Learning to Heal: The Development of American Medical Education (New York: Basic Books, 1985).Google Scholar

15. American Journal of Insanity 10 (07 1853): 85Google Scholar; 28 (October 1871): 205–8, 212; American Medical Association, Transactions 17 (1866): 121ff.Google Scholar; 18 (1867): 399ff; 19 (1868): 161ff.; 22 (1871): 101–9.

16. Worcester State Lunatic Hospital, Annual Report 10 (1842): 1727Google Scholar; 38 (1870): 38–60; Virginia Western Lunatic Asylum, Annual Report 23 (1850): 1423Google Scholar; California Insane Asylum, Annual Report 8 (1860): 1632.Google Scholar

17. U. S. Bureau of the Census, Insane and Feeble-Minded in Hospitals and Institutions 1904 (Washington, D. C: Government Printing Office, 1906), p. 37Google Scholar; idem, Insane and Feeble-Minded in Institutions 1910 (Washington, D. C: Government Printing Office, 1914), p. 59Google Scholar; idem, Patients in Hospitals for Mental Disease 1923 (Washington, D. C: Government Printing Office, 1926), p. 36Google Scholar; and Dayton, Neil A., New Facts on Mental Disorders: Study of 89, 190 Cases (Springfield, Ill., Charles C. Thomas, 1940), pp. 414–29.Google Scholar

18. U. S. Bureau of the Census, Paupers in Almshouses 1904 (Washington, D. C: Government Printing Office, 1906), pp. 182, 184Google Scholar; idem, Paupers in Almshouses 1910 (Washington, D. C: Government Printing Office, 1915), pp. 4243Google Scholar; idem, Paupers in Almshouses 1923 (Washington, D. C: Government Printing Office, 1925), pp. 5, 8, 33Google Scholar; idem, Insane and Feeble-Minded in Hospitals and Institutions 1904, p. 29Google Scholar; idem, Patients in Hospitals for Mental Disease 1923, p. 27.Google Scholar

19. For a discussion of this theme, see Grob, , Mental Illness and American Society, pp. 9192, 180–81.Google Scholar

20. Malzberg, Benjamin, “A Statistical Analysis of the Ages of First Admissions to Hospitals for Mental Disease in New York State,” Psychiatric Quarterly 23 (1949): 344–66CrossRefGoogle ScholarPubMed; idem, “A Comparison of First Admissions to the New York Civil State Hospitals During 1919–1921 and 1949–1951,” Psychiatric Quarterly 28 (1954): 312–19Google Scholar; New York State Department of Mental Hygiene, Annual Report 52 (19391940): 174–75Google Scholar; U. S. Bureau of the Census, Census of Population: 1950Google Scholar, vol. 2, Characteristics of the Population, Part 32 (Washington, D. C: Government Printing Office, 1952), p. 58Google Scholar; Kramer, Morton et al. , A Historical Study of the Disposition of First Admissions to a State Mental Hospital: Experiences of the Warren State Hospital During the Period 1916–50Google Scholar (U. S. Public Health Service Publication No. 445: Washington D. C: Government Printing Office, 1955), p. 10Google Scholar, Landis, Carney and Farwell, Jane E., “A Trend Analysis of Age at First-Admission, Age at Death, and Years of Residence for State Mental Hospitals: 1913–1941,” Journal of Abnormal and Social Psychology 39 (01 1944): 323.CrossRefGoogle Scholar

21. Goldhamer, Herbert and Marshall, Andrew W., Psychosis and Civilization: Two Studies in the Frequency of Mental Disease (Glencoe, Ill.: Free Press, 1953), pp. 54, 91.Google Scholar

22. The statistics in this and the previous paragraph have been compiled from U. S. Bureau of the Census, Patients in Hospitals for Mental Disease 1923, Mental Patients in State Hospitals 1926 and 1927 (Washington, D. C: Government Printing Office, 1930)Google Scholar, and Patients in Mental Hospitals 1940 (Washington, D. C: Government Printing Office, 1943).Google Scholar See also Pollock, Horatio M., Mental Disease and Social Welfare (Utica, N. Y.: State Hospitals Press, 1941), pp. 93109Google Scholar; New York State Department of Mental Hygiene, Annual Report 52 (19391940): 176.Google Scholar

23. Wagner, Charles G., “Recent Trends in Psychiatry,” American Journal of Insanity 74 (07 1917): 14.Google Scholar

24. Flexner's observations were mentioned in Southard, E. E. to Salmon, Thomas W., 07 24, 1919Google Scholar, Salmon Boxes in American Foundation for Mental Hygiene Papers, Archives of Psychiatry, New York Hospital-Cornell Medical Center, New York, N. Y. See also Salmon to Southard, July 21, 1919, in the same source.

25. Grob, , Mental Illness and American Society, pp. 126–43.Google Scholar

26. Salmon, Thomas W., “Some New Fields in Neurology and Psychiatry,” Journal of Nervous and Mental Disease 46 (08 1917): 9099.CrossRefGoogle Scholar

27. The history of the National Committee for Mental Hygiene can be followed in Grob, , Mental Illness and American Society, pp. 147–66Google Scholar, and Dain, Norman, Clifford W. Beers: Advocate for the Insane (Pittsburgh: University of Pittsburgh Press, 1980).CrossRefGoogle Scholar

28. See the remarks of Southard, E. E. in Briggs, L. Vernon, History of the Psychopathic Hospital Boston, Massachusetts (Boston: Wright and Potter, 1922), p. 173Google Scholar, and also Southard, E. E. and Jarrett, Mary C., The Kingdom of Evils: Psychiatric Social Work Presented in One Hundred Case Histories Together with a Classification of Social Divisions of Evil (New York: Macmillan, 1922).Google Scholar

29. May, James V., “The Establishment of Psychiatric Standards by the Association,” American Journal of Psychiatry 90 (07 1933): 68.CrossRefGoogle Scholar For the background and events leading to the establishment of the American Board of Psychiatry and Neurology see Grob, , Mental Illness and American Society, pp. 271–83.Google Scholar

30. Appel, John W., “Incidence of Neuropsychiatric Disorders in the United States Army in World War II,” American Journal of Psychiatry 102 (11 1945): 433–36.CrossRefGoogle Scholar

31. Grinker, Roy R. and Spiegel, John P., Men Under Stress (Philadelphia: Blakiston, 1945), pp. 427–60.CrossRefGoogle Scholar

32. Felix, Robert H. and Bowers, R. V., “Mental Hygiene and Socio-Environmental Factors,” Milbank Memorial Fund Quarterly 26 (04 1948): 125–47CrossRefGoogle ScholarPubMed; Felix, , “Mental Public Health: A Blueprint,”Google Scholar presentation at St. Elizabeths Hospital, Washington, D. C., April 21, 1945, Felix Papers, National Library of Medicine, Bethesda, Md. See also Lemkau, Paul V., “The Future Organization of Psychiatric Care,” Psychiatric Quarterly 25 (04 1951): 201–12.CrossRefGoogle ScholarPubMed

33. Data on membership compiled from the following: American Medico-Psychological Association, Proceedings 2 (1895)Google Scholar; List of Fellows and Members of the American Psychiatric Association 1940/1941 (n.p.: n.p., ca. 1941)Google Scholar; Biographical Directory of Fellows & Members of the American Psychiatric Association as of October 1, 1957 (New York: R. R. Bowker, 1958).Google Scholar I have sampled 10 percent (n = 943) of the total membership of the APA for 1957.

34. For an extended discussion of these points see Grob, Gerald N., “The Origins of American Psychiatric Epidemiology,” American Journal of Public Health 75 (03 1985): 229–36.CrossRefGoogle ScholarPubMed

35. American Journal of Psychiatry 101 (09 1944): 248–49Google Scholar; 102 (July 1945): 117, 119; (March 1946): 694–700.

36. GAP, Minutes of the First Informal Gathering, 05 26, 1946Google Scholar, GAP Papers, Archives of Psychiatry, New York Hospital-Cornell Medical Center, New York, N. Y.

37. Menninger, William C. to Rickles, N. K., 11 22, 1948Google Scholar; Menninger, to Raeder, Oscar J., 03 31, 1947Google Scholar, William C. Menninger Papers, Menninger Foundation Archives, Topeka, Kansas.

38. GAP Circular Letter No. 154 (09 16, 1949)Google Scholar, GAP Papers, and “The Social Responsibility of Psychiatry, A Statement of Orientation,” GAP Report No. 13 (07 1950): 5.Google Scholar

39. Deutsch, Albert, “Split Ranks in Psychiatry,” New York Daily Compass, 05 24, 1949.Google Scholar

40. For an extended analysis of the internecine warfare in the APA see Grob, , “Psychiatry and Social Activism: The Politics of a Specialty in Postwar America,” Bulletin of the History of Medicine 60 (Winter 1986): 477501.Google ScholarPubMed

41. The generalizations in this paragraph rest on an analysis of the records of the APA and more than a dozen manuscript collections at the APA Archives, Washington, D. C, the Menninger Foundation Archives, and the GAP papers, as well as all of the printed literature.

42. The Mary E. Switzer Papers (Schlesinger Library, Radcliffe College, Harvard University, Cambridge, Mass.) and the Lawrence Kolb Papers (National Library of Medicine, Bethesda, Md.) have relevant material on the background and passage of the legislation. The hearings can be followed in 79th Congress, 1st session, National Neuropsychiatric Institute Act. Hearing Before a Subcommittee on Interstate and Foreign Commerce House of Representatives … on H. R. 2550 … 1945 (Washington, D. C: Government Printing Office, 1945)Google Scholar, and 79th Congress, 2d session, National Neuropsychiatric Institute Act. Hearings Before a Subcommittee of the Committee on Education and Labor United States Senate … on S. J. Res. 46 … 1955 (Washington, D. C: Government Printing Office, 1946).Google Scholar See also Kolb, Lawrence C., “Research and its Support Under the National Mental Health Act,” American Journal of Psychiatry 106 (12 1949): 407–12CrossRefGoogle ScholarPubMed, and Brand, Jeanne L., “The National Mental Health Act; A Retrospect,” Bulletin of the History of Medicine 39 (0506 1965): 231–45.Google ScholarPubMed

43. See Clausen, John A., “Social Science Research in the National Mental Health Program,” American Sociological Review 15 (06 1950): 402–9.CrossRefGoogle Scholar

44. APA, The Homeless Mentally III: A Task Force Report (Washington D.C: APA. 1984).Google Scholar See especially the comments of several important psychiatrists about the consequences of their activities in the 1950s and 1960s, in the New York Times, 10 30, 1984 (Section C).Google Scholar

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