[In Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness, Andrew] Scull stresses the degree to which external pressures have shaped psychiatry. “Community psychiatry” supplanted “institutional psychiatry” in part because of professional insecurity. Psychiatrists needed a new model for dealing with mental diseases to keep pace with the advances that mainstream health care was making with other diseases. Fiscal conservatives viewed the practice of confining hundreds of thousands of Americans to long-term commitment as overly expensive, and civil libertarians viewed it as unjust.
Deinstitutionalization began slowly at first, in the 1950s, but the pace accelerated around 1970, despite signs that all was not going according to plan. On the ground, psychiatrists noticed earlier than anyone else that the most obvious question — where are these people going to go when they leave the mental institutions? — had no clear answers. Whatever misgivings psychiatrists voiced over the system’s abandonment of the mentally ill to streets, slums, and jails was too little and too late.
That modern psychiatry is mostly practiced outside of mental institutions is not its only difference from premodern psychiatry. Scull devotes extensive coverage to two equally decisive developments: the rise and fall of Freudianism, and psychopharmacology.
The Freudians normalized therapy in America and provided crucial intellectual support for the idea that mental health care is for everyone, not just the deranged. Around the same time as deinstitutionalization, Freud’s reputation, especially in elite circles, was on a level with Newton and Copernicus. Since then, Freudianism has mostly gone the way of phlogiston and leeches. That happened not just because people decided the psychoanalysts’ approach to therapy didn’t work but also because insurance wouldn’t pay for it. Insurance would, however, pay for modes of therapy that were less open-ended than the “reconstruction of personality that psychoanalysis proclaimed as its mission”, more targeted to a specific psychological symptom, and, most crucially of all, performed by non-M.D.s. Therapy was on the rise, but psychiatrists found themselves doing less and less of it.
As psychiatry cast aside Freudian concepts such as the “refrigerator mother”, which rooted mental illness in psychodynamic tensions, it increasingly trained its focus on biology. Drugs contributed to, and gained a boost from, this reorientation. Scull loathes the drug industry and only grudgingly allows that it has made improvements in the lives of mentally ill Americans. He divides up the vast American drug-taking public into three groups: those for whom they work, those for whom they don’t work, and those for whom they may work, but not enough to counter the unpleasant side effects. He argues that the last two groups are insupportably large.
Stephen Eide, “Soul Doctors”, City Journal, 2022-05-18.
September 11, 2022
QotD: De-institutionalization
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