255
major academic centres a reappraisal of American psychiatry seemed opportune. the
Occasional
Survey
THE DECLINE OF PSYCHOANALYSIS
A REAPPRAISAL OF AMERICAN PSYCHIATRY
ROBIN M. MURRAY Institute of
Psychiatry, De Crespigny Park, London SE5 8AF
Remarkable changes have taken place in American psychiatry over the past twenty years. The era of psychoanalytical supremacy has passed, and realism is replacing the exaggerated claims which were made of psychiatry’s ability to produce personal, social, and even political change. The importance of phenomenology and accurate diagnosis is increasingly recognised, and American researchers have made many impressive contributions to psychiatric genetics and to psychopharmacology. Despite these advances, office practice generally continues to function on an outmoded model and psychiatric resources remain inequitably distributed.
Summary
The greatest difference, in the practice of psychiatry, between the U.S.A. and the remainder of the Englishspeaking world has been the influence of psychoanalysis. The leaders of American psychiatry in the post-war years were overwhelmingly analytically orientated, and the centennial year of Freud’s birth was celebrated in 1956 with such furious devotion as to confirm the dominant role which psychoanalysis had come to play.5 Analytically based psychiatry proved fortuitously compatible with the free-enterprise ethic. For example, in an article entitled Freud and Third Party Payment, Pulver6 argued that "Freud was fully aware of the potential dangers of extremely low fee or gratuitous analysis." In the post-war
period, academic departments too often incorporate biological, sociological, and behavioural knowledge into integrated and pluralistic training programmes’ and in consequence produced a generation of analytically biased psychiatrists89 exhibiting "ideological parochiafailed
to
lism".1O
.
However, the results of research into the effectiveness of
INTRODUCTION
AMERICAN psychiatry has a distinguished history of clinical care, scholarship, and research. Furthermore, psychiatry has been accepted to a greater degree by the medical profession and by the general public in the U.S.A. than in any other nation. There has been a rapid expansion since the 1940s; student time devoted to psychiatry and behavioural science in American medical schools increased fourfold between 1940 and 1966,1 and the absolute number of psychiatrists in the U.S.A. rose from 4700 in 1947 to 28 000 in 1976.2 The ratio of psychiatrists to population, at 12 .5per 100 000, compares well with that in the U.S.S.R. (55), West Germany (4-7), and England and Wales (3.7). Arthur3 has commented that after the Second World War American psychiatry entered a golden age in which it gained power, popularity, and respect. "Departments of psychiatry flourished in medical schools throughout the nation. State University schools that had formerly had one half-time psychiatrist on the faculty developed departments with as many as 100 members. Larger schools had departments that grew to correspondingly greater dimensions. Money flowed in, and all was sunny morning." But, in contrast to other medical specialties, post-war American psychiatry has not been regarded favourably from the other side of the Atlantic. In 1957, for instance, Shepherd4 said of American psychiatry "There is a distaste for the detailed knowledge dismissed as ’descriptive psychiatry’, an antagonism to many of the facts and concepts associated with the study of heredity; a neglect of much biological investigation; and as Kanner has so strikingly shown, in many centres a biased ignorance of the evolution and historical roots of modern psychiatry." Much subsequent comment has been in a similar vein. But, major changes have recently occurred in American psychiatry. When the author, like Shepherd twenty years earlier, had the opportunity to spend a year in the U.S.A. on a travelling fellowship, and to visit many of
twenty-year-long
psychoanalysis were not encouraging," 12 and Bergin and Strupp’3 reported widespread disillusion with every aspect of psychotherapy research. In 1975 West and Walsh’4 surveyed opinions on psychiatry among physicians at a mid-Western University, and found a very negative attitude towards analytical theories. The proportion of American psychiatrists who were practising analysts began to decline,15 and psychiatric training became more eclectic. In a review of a typical mentalhealth system Redlich and Kellert’6 noted that "In 1975 only 45% of psychiatric residents rated psychoanalysis as an important tool compared with almost universal acclaim in 1950." Subsequently, a nationwide survey revealed that residents valued experience in pharmacotherapy and in medical education much more highly than training in psychoanalysis. 17 The passing of the era of psychoanalytical supremacy has opened up exciting yet unpredictable prospects for psychotherapy. American psychiatrists have much greater expertise in psychotherapeutic relationships than their British counterparts, but are faced with the problem of how to deal with the large numbers of (relatively healthy) clients who were attracted by the possibility of personality reconstruction and enhancement held out by psychoanalysis. The American consumer market abhors a vacuum, and as the theoretical foundations of psychoanalysis were discredited so alternative therapies have flourished. Primal scream therapy, transactional analysis, biosynthesis, Gestalt, family, and network therapy compete with cults based on Eastern philosophies and a bewildering variety of encounter and sensitivity groups. At a more pedestrian level running has been rediscovered as a therapy, and how-to-do-it books for the home psychotherapist have proliferated. The remarkable growth of these alternative therapies attests to a great deal of personal distress. Clare18 discusses the possibility that this is related to the disintegration of "social bonds which bind us together. and support us in difficult periods in our lives", and points to the profoundly religious overtones of many of the newer therapies such as Erhard Seminar Training and psychodrama. Others take a less charitable view. Maher,’9 for instance, declares that there is so much money to be
256
they are "packed with kooks, cranks, cripples, non-producers, outright thieves, confimade in these vogues that
dence men". It is certainly tempting to dismiss the nonrational visceral therapies as merely evanescent fads. But to do so ignores the fact that they provide an escape from the highly systematised and constricting interactions which orthodox analysis can degenerate into, and many offer the hope that through their own efforts individuals can heal their own psychic wounds. Behavioural treatments too are slowly becoming more widely accepted, and research methodology is at last being brought to bear on the validity of analytical concepts. One outstanding example of the latter has been Vaillant’s demonstration2° that particular ego mechanisms said to reflect the maturity of subjects’ defences correlated with objective measures of their psychopathology and social adjustment over thirty years. When the dust settles and we are able to distinguish the significant from the trivial, then the break-up of psychoanalysis in the U.S.A. may be seen as a highly productive event in the
development of psychotherapy. DIAGNOSIS
cal psychiatry, so influential elsewhere, never took root in North America. Consequently, even in the most research-oriented centres, the attempt to diagnose according to strictly defined conventions founders at times on an inability to elicit mental phenomena accurately. Nevertheless, there has been an upsurge of interest in the phenomenological approach to psychopathology which augurs well for the future. BIOLOGICAL PSYCHIATRY
It is in biological psychiatry that American psychiatry has seen the most profound changes. The neglect of genetic and biological investigation noted by Shepherd in 19574 is no longer evident. Indeed, the opposite is true. In the intervening decades American researchers have made important contributions to psychiatric genetics. Fruitful collaborations with European workers have elucidated the role of heredity in schizophrenia34 35 and have suggested a genetic contribution to alcoholism.36 These workers and others such as Winokur, Heston, Reich, and Matthysse have rendered the U.S.A. the outstanding centre of psychiatric genetics.
origins of the increased emphasis on neuropsychopharmacology are to be found in the mid-1950s when the National Institute of Mental Health (N.I.M.H.) and the National Academy of Science sponsored a meeting to project future needs.5 The establishment of the Psychopharmacology Research The
No area of psychiatric practice has attracted more criticism from overseas than American diagnostic habits. Nosology has not traditionally been of great import in the United States, with priority usually being given to lengthy analytical formulations of each patient’s predicament. Indeed, some authorities advocated abolishing diagnosis completely.21 Partly in consequence of this cavalier attitude the American concept of schizophrenia broadened 22 to embrace much of what the rest of the world regarded as affective disorder,23 only to shrink again when lithium became available.24 2S Not surprisingly, European psychiatrists came to doubt the accuracy of what their American colleagues were saying about diagnosis. The claim by Rosenhan26 that psychiatrists were unable to differentiate between psychologists feigning abnormality and psychotic individuals, was interpreted as further evidence of abysmal American diagnostic practice. Clare,2’ for example, states that if Professor Rosenhan presented to a British mental hospital complaining only of a single auditory hallucination he "might well be advised to go home like a good man, get a decent night’s rest, and come back in the morning."
the spots on the American psychiatric leopard changing and we are seeing the effect of the fresh winds of change that have been blowing for some time from the Washington University School of Medicine in St. Louis. The value of the operational definitions of psychiatric disorder outlined by Feighner and his colleagues28 has been internationally recognised and the derivative Research Diagnostic Criteria 29 offer improved prospects of different investigators’ carrying out their research on replicable patient populations. The new awareness of the need for a reliable and valid nosology has been emphasised by the holding of three recent conferences in North America on diagnosis and classification.30-32 Furthermore, the incorporation of operational definitions into the DSM III diagnostic manua133 gives the U.S.A. an everyday classificatory system potentially superior to those in use elsewhere in the world. Sad to say, these criteria may not be employed to the fullest advantage because many American psychiatrists are not familiar with systematic examination and recording of the mental state. German phenomenologi-
However, are
now
Branch as an extramural arm of the N.I.M.H. provided further impetus3’ while, under far-sighted leadership, the N.I.M.H. intramural programme achieved a very distinguished record of clinical and laboratory research. Service in the intramural laboratories under scientists such as Axelrod and Kopin spawned a research elite who made notable discoveries concerning neurotransmitters and their regulating enzymes3$and began to develop credible animal models of psychiatric disorder.39 Neuropsychopharmacology has been largely an American creation, as evidenced by the impressive volume Psychopharmacology ; A Generation of Progress40 published by the American College of Neuropsychopharmacology to celebrate its fifteenth anniversary. So far, research has shown greater strength at the basic neurochemical level, conclusions being much more guarded at the clinical level. However, to use Kety’s41 analogy, although the jigsaw puzzle linking neuroregulating mechanisms to the organisation of complex behavioural states remains far from complete, some solid and substantial pieces have been carved, coloured, and interdigitated.
Animal data on the mode of action of pharmacological agents has led to increasingly elaborate theories concerning the role of monoamines in affective disorder and schizophrenia. Bunney,42 who has lately reviewed these productive hypotheses, expects further rapid advances from the new analytical tools such as mass spectrometry, radioimmunoassays, and radioenzymatic techniques. Promising areas of current investigation include the search for genetic markers, studies of postsynaptic receptors, and examination of the central effects of poly-
peptides. SOCIAL PSYCHIATRY
The practice of psychiatry reflects the ethos of the soin which it operates, and the social climate in the U.S.A. has not been conducive to the equitable distribution of psychiatric resources. Psychiatrists prefer to work in the private sector, which in 1971 accounted for 34% of inpatient days, 86% of outpatient visits, and 51%
ciety
257 of expenditure.43 In that year the average private mental hospital employed 502 full-time professional staff per 1000 inpatients, while the comparative figure for public mental hospitals was 106.44 But the use of private facilities is effectively denied to the poor and the Black. In a typical area Blacks constituted 15% of patients in the
hospital and 23% of those attending a community mental-health centre but only 3% of private hospital patients.16 Non-White and low-social-class patients were especially likely to be treated by a low-status mental health professional. Evidence has also been accumulating that there is a correlation between low income and increased psychiatric symptomatology,45 and that institutionalised Blacks are more likely to be in prison and less likely to be in psychiatric facilities than CauState
casians.46 No area illustrates the inequitable distribution of resources better than metropolitan Washington where, according to Torrey," there are 35 psychiatrists per 100 000 population"more than any place in the world". These psychiatrists huddle together in the affluent districts, profiting from the generous health-insurance benefits of federal employees,48 while the "public psychiatric services in the District of Columbia are probably the worst in the nation", and standards at the once renowned St. Elizabeth’s Hospital have deteriorated so badly that the Joint Commission on American hospitals has removed its accreditation.
As Arthur49 points out, there has been a feeling "often anti-intellectual in tone, that the process of enumeration, categorisation, and statistical analysis do violence to the complexity of human interactions between those who help and those who are being helped". This failure to appreciate the important research responsibilities of social psychiatry has meant that major changes in the provision of psychiatric services have been implemented without adequate thought to their testing. The effectiveness of strategies for the prevention of mental illness were never examined, and little attention was given to evaluating the programme of closing large mental hospitals, which has characteristically been more energetic and extreme in the U.S.A. than elsewhere; the consequences for the quality of life of former patients are well known. The community mental-health centres, too, were insufficiently monitored, deviated from their original purpose, and focused on treating the "healthy but unhappy" to such an extent that Zussman and Lamb50 have now called on them to give a higher priority to rehabilitating the seriously mentally ill. The above failures of epidemiology are all the more surprising as American epidemiologists have in the past made major contributions to psychiatry. Pioneering studies such as those of Farris and Dunham in the 1930s, Hollingshead and Redlich in the 1950s, and the Midtown Manhattan survey in the early 1960s all set new standards of scientific rigour. But progress in American psychiatric epidemiology seemed to come to a halt in the late 1960s. Weissman and Klerman5l attributed this to the drawbacks of the unitary concept of mental illness which until recently held sway among American epidemiologists, while Robins52 blamed deficiencies in Government support. Fortunately, there now seems to be a reawakening of interest in the potential of epidemi-
ology.,, 52 THE PSYCHIATRISATION OF LIFE AND ITS REVERSAL
The
by
an
ascendency of psychoanalysis was accompanied to enlarge the area of psychiatry’s com-
attempt
a tendency evident as early as 1944, when Gregg53 told the American Psychiatric Association "psychiatry will find great extensions of its content and obli-
petence,
There will be applications ... to the human relations of normal people-in politics, national and international, between races, between capital and labor, in government, in family life, in education, in every form of human relationship, whether between individuals or groups". By 1957 Kubie54 was declaiming that "all cultural influences and institutions must become infused with knowledge that can be gained only from the study of the lessons of illness", and a decade later Wedge 55 called for the training of psychiatrists as consultants in the sphere of international relations. Even the latest edition of that authoritative text, The Comprehensive Textbook of Psychiatry,56 contains chapters on the creative process, social violence, inter-racial relations, and the women’s movement. Presumably these marginal chapters are compulsory reading for the media psychiatrist who Miller57 accused of misusing his jargon "to confuse every topical issue in an incessant series of television interviews". There is in the U.S.A. an "insatiable demand for the opportunity to engage in self-examination",18 a demand which is fuelled by the apparently endless psychobabble which emanates from much of the media. But foreign critics of expansionist psychiatry45 have now been joined by those within North America who question whether the profession should continue to exploit this epidemic narcissism. Cerrolaza58 complained that psychiatrists were "treating human misery and misfortune at large, and more and more forms of deviant behaviour were being subsumed under the competence of psychiatry, the goals of which seem to expand without limit to encompass all human activities". Kety59 subsequently considered that psychiatry had branched out into areas it was not especially qualified to handle, and Arthur49 sadly concluded "while psychiatric assistance in the elimination of poverty, war, injustice and crime is a welcome prospect, the practical difficulties of implementation prove to be daunting". Heralded in the post-war period as the discipline that could provide the answers to broad social problems, psychiatry in the 1970s has at last realised that it is incapable of such social cures.
gations.
CONCLUSION
The new realism regarding the limits to psychiatric competence, the explosive growth of neurochemistry and psychopharmacology, and mounting doubts about the cost-effectiveness of psychoanalysis have all combined to shift the emphasis in academic departments towards biological psychiatry and behavioural psychotherapy. But office practice has largely continued to function on an insight-oriented model which eschews both drug and behavioural treatments. Gerald Klerman, the new director of the Alcohol, Drug and Mental Health Administration (A.D.M.H.A.) has listed the American hierarchy of therapies in descending order as (i) insight therapy, (ii) supportive therapy, and (iii) pharmacotherapy, and is quoted6O as stating that "the degree of involvement of the profession in these therapies is in inverse proportion to their effectiveness". The fact that Klerman is director of A.D.M.H.A. is
258
illustrative of
a new force likely to have a profound influence on psychiatry in the U.S.A. Not only has President Carter’s Commission on Mental Health61 highlighted many of the deficiencies in current practice and outlined amore scientific and socially responsible approach to psychiatry, but the administration has brought in a new breed of academic psychiatrists to high-level posts in the powerful federal agencies. It is to cooperation between such agencies and academic departments that American psychiatry must look for further research advances and for the integration of such advances into broad-based training programmes and eventually into everyday practice. Meanwhile, one can confidently state that the dark clouds which enveloped American psychiatry in the post-war period have now
largely dispersed. 1. Webster, T. G. in Working Papers of the Conference on Psychiatry and Medical Education. American Psychiatric Association, Washington, 1969. 2. Brown, B. Am. J. Psychiat. 1977, 134, March suppl. p. 1. 3. Arthur, R. J. ibid. July suppl. p. 2. 4. Shepherd, M. ibid. 1957, 114, 417. 5. Shepherd, M. Compreh. Psychiat. 1971, 12, 302. 6. Pulver, S. E. Am. J. Psychiat. 1974, 131, 1400. 7. Blackwell, B., Allen, A., Wales, E., Paper read at the Maurice Levine Society, Cincinnati, September, 1977. 8. Armor, D. J., Klerman, G. L. J. Hlth soc. Behav. 1968, 9, 243. 9. Stone, W., Stein, L. S., Green, B. Archs gen. Psychiat. 1971, 24, 468. 10. Casariego, J. I., Greden, J. F. Compreh. Psychiat. 1978, 19, 241. 11. Kernberg, O. F., Burstein, E. D., Coyne, L., Appelbaum, A., Horwitz, L.
Voth, H. Bull. Menninger Clin. 1972, 36, 1. R. B., Staples, F. R., Cristol, A. H., Yorkston, N. J., Whipple, K. Psychotherapy Versus Behavioural Therapy. Cambridge, Mass., 1975. 13. Bergin, A. E., Strupp, H. H. Changing Frontiers in the Science of Psychotherapy. Chicago, 1972. 14. West, N. D., Walsh, M. A. Am. J. Psychiat. 1975, 132, 1318. 15. Kline, W. Paper read at the Royal College of Psychiatrists, London, July, Sloane,
1975. 16. Redlich, F., Kellert, S. R. Am. J. Psychiat. 1978, 135, 22. 17. Coryell, W., Wetzel, R. D. ibid. p. 732. 18. Clare, A. W. Listener. Nov. 9, 1978, p. 608. 19. Maher, J. quoted by Clare.18 20. Vaillant, G. Archs gen. Psychiat. 1976, 33, 535. 21. Menninger, K. The Vital Balance: The Life Process in Mental Health and Illness. New York, 1963. 22. Kuriansky, J. B., Gurland, B. J., Spitzer, R. L., Endicott, J. Am. J. Psychiat.
1977, 134, 631. 23. World Health Organisation. International Pilot Study on Schizophrenia, vol. I. Geneva, 1973. 24. Baldessarini, R. J. Am. J. Psychiat. 1970, 127, 759. 25. Dunne, D. L., Fieve, R. R. in Psychiatric Diagnosis: Exploration of Biological Predictors (edited by H. S. Akiskal and W. L. Webb). New York, 1977. 26. Rosenhan, D. Science, 1973, 179, 250. 27. Clare, A. W. Psychiatry in Dissent. London, 1976. 28. Feighner, J. P., Robins, E., Guze, S. B., Woodruff, R. A., Winokur, G.,
Munoz, R. Archs gen. Psychiat. 1972, 26, 57. R. L., Endicott, J., Robins, E. Research Diagnostic Criteria. New York State Psychiatric Institute, Biometrics Research, New York, 1975. 30. Rakoff, V. M., Stancer, H., Kedward, H. B. Psychiatric Diagnosis. New York, 1977. 31. Akiskal, H. S., Webb, W. L. Psychiatric Diagnosis: Exploration of Biological Predictors. New York, 1977. 32. Spitzer, R. L., Klein, D. Critical Issues in Psychiatric Diagnosis. New York, 29.
CONGENITAL RUBELLA DEAFNESS: A PREVENTABLE DISEASE CATHERINE S. PECKHAM
Department of Medicine, Charing Cross Hospital Medical School, Fulham Palace Road, London W6 8RF
J.
A. M. MARTIN
Nuffield Hearing and Speech Centre, Royal National Throat, Nose and Ear Hospital, Gray’s Inn Road, London WC1 W. C. MARSHALL
REFERENCES
12.
Preventive Medicine
Department of
J. A. DUDGEON
Microbiology, Institute London WC1
of Child Health,
Over a 4-year period (1972-75) an unselected sample of 568 children aged under 4 years attending the Nuffield Hearing and Speech Centre were tested for rubella antibody. Sensorineural deafness was subsequently diagnosed in 349 of these children, and 83 (24%) of this group had rubella antibody. In contrast, only 19 (9%) of the remaining 219 children in whom sensorineural deafness was excluded had rubella antibody. The seropositive and seronegative children with sensorineural deafness showed striking differences in family history, history of maternal rubella, adverse perinatal events, and presence of other defects. Congenital rubella is an important cause of deafness, and the rubella vaccination programme must be pursued more vigorously if this serious defect is to be prevented in the future.
Summary
INTRODUCTION
SENSORINEURAL deafness is the
most common abnorassociated with mality congenital rubella, and it is the defect caused this fetal infection which occurs only by alone with any consistency. 1-4 It has been suggested that the number of children with hearing impairment due to intrauterine rubella has been seriously underestimated,5 probably because of the high incidence of subclinical
Spitzer,
1978.
33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. New York, 1977. 34. Mednick, S., Schulsinger, F., Higgins, J., Bell, B. (editors). Genetics, Environment and Psychopathology. Amsterdam, 1974. 35. Gottesman, I. I., Shields, J. Schizophrenia and Genetics. New York, 1972. 36. Goodwin, D. W., Schulsinger, F., Moller, N. Hermansen, L., Winokur, G., Guze, S. Archs gen. Psychiat. 1974, 31, 164. 37. Levine, J. in Psychopharmacology: A Generation of Progress (edited by M. A. Lipton, A. DiMascio, and K. F. Killam). New York, 1978. 38. Usdin, E., Hamburg, D. A., Barchas, T. Neuroregulators and Psychiatric Disorders. New York, 1977. 39. Hanin, I., Usdin, E. Animal Models in Psychiatry and Neurology. Oxford, 1977. 40. Lipton, M. A., DiMascio, A., Killam, K. F. (editors). Psychopharmacology: A Generation of Progress. New York, 1978. 41. Kety. S. ibid. 42. Bunney, W. E Am. J. Psychiat. 1978, 135, July suppl., p. 8.
43. Koran, L. M. ibid. 1976, 133, 1052. 44. National Institute of Mental Health. Staffing Patterns in Mental Health Facilities. N.I.M.H., Series B., Washington, 1972. 45. Ilfeld, F. W. Archs gen. Psychiat. 1978, 35, 716. 46. Kramer, M. Paper given at the Institute of Psychiatry, London, April, 1976. 47. Torrey, E. F. Washington Post, Sept. 4, 1977. 48. Hustead, E. C., Sharfstein, S. S. Am. J. Psychiat. 1978, 135, 315. 49. Arthur, R. J. ibid. 1973, 130, 841. 50. Zussman, J., Lamb, H. R. ibid. 1978, 134, 887. 51. Weissman, M. M., Klerman, G. L. Archs gen. Psychiat. 1978, 35, 705. 52. Robins, L. ibid. p. 697. 53. Gregg, A. Am. J. Psychiat. 1944, 101, 285. 54. Kubie, L. S. Archs Neurol. Psychiat. 1957, 78, 283. 55. Wedge, B. Science, 1967, 157, 281. 56. Freedman, A. M., Kaplan, H. I., Sadeck, B. J. Comprehensive Textbook of
Psychiatry. Baltimore, 1975. 57. Miller, H. G. World Med. 1969, 5, 44. 58. Cerrolaza, M. Compreh. Psychiat. 1973, 14, 299. 59. Kety, S. Am. J. Psychiat. 1974, 131, 957. 60. Klerman, G. L., quoted by Lebensohn, Z. M. Psychiat. Ann. 1975, 5, 376. 61. President’s Commission on Mental Health. Report for the President. Wash-
ington, 1978.
major academic centres a reappraisal of American psychiatry seemed opportune. the
Occasional
Survey
THE DECLINE OF PSYCHOANALYSIS
A REAPPRAISAL OF AMERICAN PSYCHIATRY
ROBIN M. MURRAY Institute of
Psychiatry, De Crespigny Park, London SE5 8AF
Remarkable changes have taken place in American psychiatry over the past twenty years. The era of psychoanalytical supremacy has passed, and realism is replacing the exaggerated claims which were made of psychiatry’s ability to produce personal, social, and even political change. The importance of phenomenology and accurate diagnosis is increasingly recognised, and American researchers have made many impressive contributions to psychiatric genetics and to psychopharmacology. Despite these advances, office practice generally continues to function on an outmoded model and psychiatric resources remain inequitably distributed.
Summary
The greatest difference, in the practice of psychiatry, between the U.S.A. and the remainder of the Englishspeaking world has been the influence of psychoanalysis. The leaders of American psychiatry in the post-war years were overwhelmingly analytically orientated, and the centennial year of Freud’s birth was celebrated in 1956 with such furious devotion as to confirm the dominant role which psychoanalysis had come to play.5 Analytically based psychiatry proved fortuitously compatible with the free-enterprise ethic. For example, in an article entitled Freud and Third Party Payment, Pulver6 argued that "Freud was fully aware of the potential dangers of extremely low fee or gratuitous analysis." In the post-war
period, academic departments too often incorporate biological, sociological, and behavioural knowledge into integrated and pluralistic training programmes’ and in consequence produced a generation of analytically biased psychiatrists89 exhibiting "ideological parochiafailed
to
lism".1O
.
However, the results of research into the effectiveness of
INTRODUCTION
AMERICAN psychiatry has a distinguished history of clinical care, scholarship, and research. Furthermore, psychiatry has been accepted to a greater degree by the medical profession and by the general public in the U.S.A. than in any other nation. There has been a rapid expansion since the 1940s; student time devoted to psychiatry and behavioural science in American medical schools increased fourfold between 1940 and 1966,1 and the absolute number of psychiatrists in the U.S.A. rose from 4700 in 1947 to 28 000 in 1976.2 The ratio of psychiatrists to population, at 12 .5per 100 000, compares well with that in the U.S.S.R. (55), West Germany (4-7), and England and Wales (3.7). Arthur3 has commented that after the Second World War American psychiatry entered a golden age in which it gained power, popularity, and respect. "Departments of psychiatry flourished in medical schools throughout the nation. State University schools that had formerly had one half-time psychiatrist on the faculty developed departments with as many as 100 members. Larger schools had departments that grew to correspondingly greater dimensions. Money flowed in, and all was sunny morning." But, in contrast to other medical specialties, post-war American psychiatry has not been regarded favourably from the other side of the Atlantic. In 1957, for instance, Shepherd4 said of American psychiatry "There is a distaste for the detailed knowledge dismissed as ’descriptive psychiatry’, an antagonism to many of the facts and concepts associated with the study of heredity; a neglect of much biological investigation; and as Kanner has so strikingly shown, in many centres a biased ignorance of the evolution and historical roots of modern psychiatry." Much subsequent comment has been in a similar vein. But, major changes have recently occurred in American psychiatry. When the author, like Shepherd twenty years earlier, had the opportunity to spend a year in the U.S.A. on a travelling fellowship, and to visit many of
twenty-year-long
psychoanalysis were not encouraging," 12 and Bergin and Strupp’3 reported widespread disillusion with every aspect of psychotherapy research. In 1975 West and Walsh’4 surveyed opinions on psychiatry among physicians at a mid-Western University, and found a very negative attitude towards analytical theories. The proportion of American psychiatrists who were practising analysts began to decline,15 and psychiatric training became more eclectic. In a review of a typical mentalhealth system Redlich and Kellert’6 noted that "In 1975 only 45% of psychiatric residents rated psychoanalysis as an important tool compared with almost universal acclaim in 1950." Subsequently, a nationwide survey revealed that residents valued experience in pharmacotherapy and in medical education much more highly than training in psychoanalysis. 17 The passing of the era of psychoanalytical supremacy has opened up exciting yet unpredictable prospects for psychotherapy. American psychiatrists have much greater expertise in psychotherapeutic relationships than their British counterparts, but are faced with the problem of how to deal with the large numbers of (relatively healthy) clients who were attracted by the possibility of personality reconstruction and enhancement held out by psychoanalysis. The American consumer market abhors a vacuum, and as the theoretical foundations of psychoanalysis were discredited so alternative therapies have flourished. Primal scream therapy, transactional analysis, biosynthesis, Gestalt, family, and network therapy compete with cults based on Eastern philosophies and a bewildering variety of encounter and sensitivity groups. At a more pedestrian level running has been rediscovered as a therapy, and how-to-do-it books for the home psychotherapist have proliferated. The remarkable growth of these alternative therapies attests to a great deal of personal distress. Clare18 discusses the possibility that this is related to the disintegration of "social bonds which bind us together. and support us in difficult periods in our lives", and points to the profoundly religious overtones of many of the newer therapies such as Erhard Seminar Training and psychodrama. Others take a less charitable view. Maher,’9 for instance, declares that there is so much money to be
256
they are "packed with kooks, cranks, cripples, non-producers, outright thieves, confimade in these vogues that
dence men". It is certainly tempting to dismiss the nonrational visceral therapies as merely evanescent fads. But to do so ignores the fact that they provide an escape from the highly systematised and constricting interactions which orthodox analysis can degenerate into, and many offer the hope that through their own efforts individuals can heal their own psychic wounds. Behavioural treatments too are slowly becoming more widely accepted, and research methodology is at last being brought to bear on the validity of analytical concepts. One outstanding example of the latter has been Vaillant’s demonstration2° that particular ego mechanisms said to reflect the maturity of subjects’ defences correlated with objective measures of their psychopathology and social adjustment over thirty years. When the dust settles and we are able to distinguish the significant from the trivial, then the break-up of psychoanalysis in the U.S.A. may be seen as a highly productive event in the
development of psychotherapy. DIAGNOSIS
cal psychiatry, so influential elsewhere, never took root in North America. Consequently, even in the most research-oriented centres, the attempt to diagnose according to strictly defined conventions founders at times on an inability to elicit mental phenomena accurately. Nevertheless, there has been an upsurge of interest in the phenomenological approach to psychopathology which augurs well for the future. BIOLOGICAL PSYCHIATRY
It is in biological psychiatry that American psychiatry has seen the most profound changes. The neglect of genetic and biological investigation noted by Shepherd in 19574 is no longer evident. Indeed, the opposite is true. In the intervening decades American researchers have made important contributions to psychiatric genetics. Fruitful collaborations with European workers have elucidated the role of heredity in schizophrenia34 35 and have suggested a genetic contribution to alcoholism.36 These workers and others such as Winokur, Heston, Reich, and Matthysse have rendered the U.S.A. the outstanding centre of psychiatric genetics.
origins of the increased emphasis on neuropsychopharmacology are to be found in the mid-1950s when the National Institute of Mental Health (N.I.M.H.) and the National Academy of Science sponsored a meeting to project future needs.5 The establishment of the Psychopharmacology Research The
No area of psychiatric practice has attracted more criticism from overseas than American diagnostic habits. Nosology has not traditionally been of great import in the United States, with priority usually being given to lengthy analytical formulations of each patient’s predicament. Indeed, some authorities advocated abolishing diagnosis completely.21 Partly in consequence of this cavalier attitude the American concept of schizophrenia broadened 22 to embrace much of what the rest of the world regarded as affective disorder,23 only to shrink again when lithium became available.24 2S Not surprisingly, European psychiatrists came to doubt the accuracy of what their American colleagues were saying about diagnosis. The claim by Rosenhan26 that psychiatrists were unable to differentiate between psychologists feigning abnormality and psychotic individuals, was interpreted as further evidence of abysmal American diagnostic practice. Clare,2’ for example, states that if Professor Rosenhan presented to a British mental hospital complaining only of a single auditory hallucination he "might well be advised to go home like a good man, get a decent night’s rest, and come back in the morning."
the spots on the American psychiatric leopard changing and we are seeing the effect of the fresh winds of change that have been blowing for some time from the Washington University School of Medicine in St. Louis. The value of the operational definitions of psychiatric disorder outlined by Feighner and his colleagues28 has been internationally recognised and the derivative Research Diagnostic Criteria 29 offer improved prospects of different investigators’ carrying out their research on replicable patient populations. The new awareness of the need for a reliable and valid nosology has been emphasised by the holding of three recent conferences in North America on diagnosis and classification.30-32 Furthermore, the incorporation of operational definitions into the DSM III diagnostic manua133 gives the U.S.A. an everyday classificatory system potentially superior to those in use elsewhere in the world. Sad to say, these criteria may not be employed to the fullest advantage because many American psychiatrists are not familiar with systematic examination and recording of the mental state. German phenomenologi-
However, are
now
Branch as an extramural arm of the N.I.M.H. provided further impetus3’ while, under far-sighted leadership, the N.I.M.H. intramural programme achieved a very distinguished record of clinical and laboratory research. Service in the intramural laboratories under scientists such as Axelrod and Kopin spawned a research elite who made notable discoveries concerning neurotransmitters and their regulating enzymes3$and began to develop credible animal models of psychiatric disorder.39 Neuropsychopharmacology has been largely an American creation, as evidenced by the impressive volume Psychopharmacology ; A Generation of Progress40 published by the American College of Neuropsychopharmacology to celebrate its fifteenth anniversary. So far, research has shown greater strength at the basic neurochemical level, conclusions being much more guarded at the clinical level. However, to use Kety’s41 analogy, although the jigsaw puzzle linking neuroregulating mechanisms to the organisation of complex behavioural states remains far from complete, some solid and substantial pieces have been carved, coloured, and interdigitated.
Animal data on the mode of action of pharmacological agents has led to increasingly elaborate theories concerning the role of monoamines in affective disorder and schizophrenia. Bunney,42 who has lately reviewed these productive hypotheses, expects further rapid advances from the new analytical tools such as mass spectrometry, radioimmunoassays, and radioenzymatic techniques. Promising areas of current investigation include the search for genetic markers, studies of postsynaptic receptors, and examination of the central effects of poly-
peptides. SOCIAL PSYCHIATRY
The practice of psychiatry reflects the ethos of the soin which it operates, and the social climate in the U.S.A. has not been conducive to the equitable distribution of psychiatric resources. Psychiatrists prefer to work in the private sector, which in 1971 accounted for 34% of inpatient days, 86% of outpatient visits, and 51%
ciety
257 of expenditure.43 In that year the average private mental hospital employed 502 full-time professional staff per 1000 inpatients, while the comparative figure for public mental hospitals was 106.44 But the use of private facilities is effectively denied to the poor and the Black. In a typical area Blacks constituted 15% of patients in the
hospital and 23% of those attending a community mental-health centre but only 3% of private hospital patients.16 Non-White and low-social-class patients were especially likely to be treated by a low-status mental health professional. Evidence has also been accumulating that there is a correlation between low income and increased psychiatric symptomatology,45 and that institutionalised Blacks are more likely to be in prison and less likely to be in psychiatric facilities than CauState
casians.46 No area illustrates the inequitable distribution of resources better than metropolitan Washington where, according to Torrey," there are 35 psychiatrists per 100 000 population"more than any place in the world". These psychiatrists huddle together in the affluent districts, profiting from the generous health-insurance benefits of federal employees,48 while the "public psychiatric services in the District of Columbia are probably the worst in the nation", and standards at the once renowned St. Elizabeth’s Hospital have deteriorated so badly that the Joint Commission on American hospitals has removed its accreditation.
As Arthur49 points out, there has been a feeling "often anti-intellectual in tone, that the process of enumeration, categorisation, and statistical analysis do violence to the complexity of human interactions between those who help and those who are being helped". This failure to appreciate the important research responsibilities of social psychiatry has meant that major changes in the provision of psychiatric services have been implemented without adequate thought to their testing. The effectiveness of strategies for the prevention of mental illness were never examined, and little attention was given to evaluating the programme of closing large mental hospitals, which has characteristically been more energetic and extreme in the U.S.A. than elsewhere; the consequences for the quality of life of former patients are well known. The community mental-health centres, too, were insufficiently monitored, deviated from their original purpose, and focused on treating the "healthy but unhappy" to such an extent that Zussman and Lamb50 have now called on them to give a higher priority to rehabilitating the seriously mentally ill. The above failures of epidemiology are all the more surprising as American epidemiologists have in the past made major contributions to psychiatry. Pioneering studies such as those of Farris and Dunham in the 1930s, Hollingshead and Redlich in the 1950s, and the Midtown Manhattan survey in the early 1960s all set new standards of scientific rigour. But progress in American psychiatric epidemiology seemed to come to a halt in the late 1960s. Weissman and Klerman5l attributed this to the drawbacks of the unitary concept of mental illness which until recently held sway among American epidemiologists, while Robins52 blamed deficiencies in Government support. Fortunately, there now seems to be a reawakening of interest in the potential of epidemi-
ology.,, 52 THE PSYCHIATRISATION OF LIFE AND ITS REVERSAL
The
by
an
ascendency of psychoanalysis was accompanied to enlarge the area of psychiatry’s com-
attempt
a tendency evident as early as 1944, when Gregg53 told the American Psychiatric Association "psychiatry will find great extensions of its content and obli-
petence,
There will be applications ... to the human relations of normal people-in politics, national and international, between races, between capital and labor, in government, in family life, in education, in every form of human relationship, whether between individuals or groups". By 1957 Kubie54 was declaiming that "all cultural influences and institutions must become infused with knowledge that can be gained only from the study of the lessons of illness", and a decade later Wedge 55 called for the training of psychiatrists as consultants in the sphere of international relations. Even the latest edition of that authoritative text, The Comprehensive Textbook of Psychiatry,56 contains chapters on the creative process, social violence, inter-racial relations, and the women’s movement. Presumably these marginal chapters are compulsory reading for the media psychiatrist who Miller57 accused of misusing his jargon "to confuse every topical issue in an incessant series of television interviews". There is in the U.S.A. an "insatiable demand for the opportunity to engage in self-examination",18 a demand which is fuelled by the apparently endless psychobabble which emanates from much of the media. But foreign critics of expansionist psychiatry45 have now been joined by those within North America who question whether the profession should continue to exploit this epidemic narcissism. Cerrolaza58 complained that psychiatrists were "treating human misery and misfortune at large, and more and more forms of deviant behaviour were being subsumed under the competence of psychiatry, the goals of which seem to expand without limit to encompass all human activities". Kety59 subsequently considered that psychiatry had branched out into areas it was not especially qualified to handle, and Arthur49 sadly concluded "while psychiatric assistance in the elimination of poverty, war, injustice and crime is a welcome prospect, the practical difficulties of implementation prove to be daunting". Heralded in the post-war period as the discipline that could provide the answers to broad social problems, psychiatry in the 1970s has at last realised that it is incapable of such social cures.
gations.
CONCLUSION
The new realism regarding the limits to psychiatric competence, the explosive growth of neurochemistry and psychopharmacology, and mounting doubts about the cost-effectiveness of psychoanalysis have all combined to shift the emphasis in academic departments towards biological psychiatry and behavioural psychotherapy. But office practice has largely continued to function on an insight-oriented model which eschews both drug and behavioural treatments. Gerald Klerman, the new director of the Alcohol, Drug and Mental Health Administration (A.D.M.H.A.) has listed the American hierarchy of therapies in descending order as (i) insight therapy, (ii) supportive therapy, and (iii) pharmacotherapy, and is quoted6O as stating that "the degree of involvement of the profession in these therapies is in inverse proportion to their effectiveness". The fact that Klerman is director of A.D.M.H.A. is
258
illustrative of
a new force likely to have a profound influence on psychiatry in the U.S.A. Not only has President Carter’s Commission on Mental Health61 highlighted many of the deficiencies in current practice and outlined amore scientific and socially responsible approach to psychiatry, but the administration has brought in a new breed of academic psychiatrists to high-level posts in the powerful federal agencies. It is to cooperation between such agencies and academic departments that American psychiatry must look for further research advances and for the integration of such advances into broad-based training programmes and eventually into everyday practice. Meanwhile, one can confidently state that the dark clouds which enveloped American psychiatry in the post-war period have now
largely dispersed. 1. Webster, T. G. in Working Papers of the Conference on Psychiatry and Medical Education. American Psychiatric Association, Washington, 1969. 2. Brown, B. Am. J. Psychiat. 1977, 134, March suppl. p. 1. 3. Arthur, R. J. ibid. July suppl. p. 2. 4. Shepherd, M. ibid. 1957, 114, 417. 5. Shepherd, M. Compreh. Psychiat. 1971, 12, 302. 6. Pulver, S. E. Am. J. Psychiat. 1974, 131, 1400. 7. Blackwell, B., Allen, A., Wales, E., Paper read at the Maurice Levine Society, Cincinnati, September, 1977. 8. Armor, D. J., Klerman, G. L. J. Hlth soc. Behav. 1968, 9, 243. 9. Stone, W., Stein, L. S., Green, B. Archs gen. Psychiat. 1971, 24, 468. 10. Casariego, J. I., Greden, J. F. Compreh. Psychiat. 1978, 19, 241. 11. Kernberg, O. F., Burstein, E. D., Coyne, L., Appelbaum, A., Horwitz, L.
Voth, H. Bull. Menninger Clin. 1972, 36, 1. R. B., Staples, F. R., Cristol, A. H., Yorkston, N. J., Whipple, K. Psychotherapy Versus Behavioural Therapy. Cambridge, Mass., 1975. 13. Bergin, A. E., Strupp, H. H. Changing Frontiers in the Science of Psychotherapy. Chicago, 1972. 14. West, N. D., Walsh, M. A. Am. J. Psychiat. 1975, 132, 1318. 15. Kline, W. Paper read at the Royal College of Psychiatrists, London, July, Sloane,
1975. 16. Redlich, F., Kellert, S. R. Am. J. Psychiat. 1978, 135, 22. 17. Coryell, W., Wetzel, R. D. ibid. p. 732. 18. Clare, A. W. Listener. Nov. 9, 1978, p. 608. 19. Maher, J. quoted by Clare.18 20. Vaillant, G. Archs gen. Psychiat. 1976, 33, 535. 21. Menninger, K. The Vital Balance: The Life Process in Mental Health and Illness. New York, 1963. 22. Kuriansky, J. B., Gurland, B. J., Spitzer, R. L., Endicott, J. Am. J. Psychiat.
1977, 134, 631. 23. World Health Organisation. International Pilot Study on Schizophrenia, vol. I. Geneva, 1973. 24. Baldessarini, R. J. Am. J. Psychiat. 1970, 127, 759. 25. Dunne, D. L., Fieve, R. R. in Psychiatric Diagnosis: Exploration of Biological Predictors (edited by H. S. Akiskal and W. L. Webb). New York, 1977. 26. Rosenhan, D. Science, 1973, 179, 250. 27. Clare, A. W. Psychiatry in Dissent. London, 1976. 28. Feighner, J. P., Robins, E., Guze, S. B., Woodruff, R. A., Winokur, G.,
Munoz, R. Archs gen. Psychiat. 1972, 26, 57. R. L., Endicott, J., Robins, E. Research Diagnostic Criteria. New York State Psychiatric Institute, Biometrics Research, New York, 1975. 30. Rakoff, V. M., Stancer, H., Kedward, H. B. Psychiatric Diagnosis. New York, 1977. 31. Akiskal, H. S., Webb, W. L. Psychiatric Diagnosis: Exploration of Biological Predictors. New York, 1977. 32. Spitzer, R. L., Klein, D. Critical Issues in Psychiatric Diagnosis. New York, 29.
CONGENITAL RUBELLA DEAFNESS: A PREVENTABLE DISEASE CATHERINE S. PECKHAM
Department of Medicine, Charing Cross Hospital Medical School, Fulham Palace Road, London W6 8RF
J.
A. M. MARTIN
Nuffield Hearing and Speech Centre, Royal National Throat, Nose and Ear Hospital, Gray’s Inn Road, London WC1 W. C. MARSHALL
REFERENCES
12.
Preventive Medicine
Department of
J. A. DUDGEON
Microbiology, Institute London WC1
of Child Health,
Over a 4-year period (1972-75) an unselected sample of 568 children aged under 4 years attending the Nuffield Hearing and Speech Centre were tested for rubella antibody. Sensorineural deafness was subsequently diagnosed in 349 of these children, and 83 (24%) of this group had rubella antibody. In contrast, only 19 (9%) of the remaining 219 children in whom sensorineural deafness was excluded had rubella antibody. The seropositive and seronegative children with sensorineural deafness showed striking differences in family history, history of maternal rubella, adverse perinatal events, and presence of other defects. Congenital rubella is an important cause of deafness, and the rubella vaccination programme must be pursued more vigorously if this serious defect is to be prevented in the future.
Summary
INTRODUCTION
SENSORINEURAL deafness is the
most common abnorassociated with mality congenital rubella, and it is the defect caused this fetal infection which occurs only by alone with any consistency. 1-4 It has been suggested that the number of children with hearing impairment due to intrauterine rubella has been seriously underestimated,5 probably because of the high incidence of subclinical
Spitzer,
1978.
33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. New York, 1977. 34. Mednick, S., Schulsinger, F., Higgins, J., Bell, B. (editors). Genetics, Environment and Psychopathology. Amsterdam, 1974. 35. Gottesman, I. I., Shields, J. Schizophrenia and Genetics. New York, 1972. 36. Goodwin, D. W., Schulsinger, F., Moller, N. Hermansen, L., Winokur, G., Guze, S. Archs gen. Psychiat. 1974, 31, 164. 37. Levine, J. in Psychopharmacology: A Generation of Progress (edited by M. A. Lipton, A. DiMascio, and K. F. Killam). New York, 1978. 38. Usdin, E., Hamburg, D. A., Barchas, T. Neuroregulators and Psychiatric Disorders. New York, 1977. 39. Hanin, I., Usdin, E. Animal Models in Psychiatry and Neurology. Oxford, 1977. 40. Lipton, M. A., DiMascio, A., Killam, K. F. (editors). Psychopharmacology: A Generation of Progress. New York, 1978. 41. Kety. S. ibid. 42. Bunney, W. E Am. J. Psychiat. 1978, 135, July suppl., p. 8.
43. Koran, L. M. ibid. 1976, 133, 1052. 44. National Institute of Mental Health. Staffing Patterns in Mental Health Facilities. N.I.M.H., Series B., Washington, 1972. 45. Ilfeld, F. W. Archs gen. Psychiat. 1978, 35, 716. 46. Kramer, M. Paper given at the Institute of Psychiatry, London, April, 1976. 47. Torrey, E. F. Washington Post, Sept. 4, 1977. 48. Hustead, E. C., Sharfstein, S. S. Am. J. Psychiat. 1978, 135, 315. 49. Arthur, R. J. ibid. 1973, 130, 841. 50. Zussman, J., Lamb, H. R. ibid. 1978, 134, 887. 51. Weissman, M. M., Klerman, G. L. Archs gen. Psychiat. 1978, 35, 705. 52. Robins, L. ibid. p. 697. 53. Gregg, A. Am. J. Psychiat. 1944, 101, 285. 54. Kubie, L. S. Archs Neurol. Psychiat. 1957, 78, 283. 55. Wedge, B. Science, 1967, 157, 281. 56. Freedman, A. M., Kaplan, H. I., Sadeck, B. J. Comprehensive Textbook of
Psychiatry. Baltimore, 1975. 57. Miller, H. G. World Med. 1969, 5, 44. 58. Cerrolaza, M. Compreh. Psychiat. 1973, 14, 299. 59. Kety, S. Am. J. Psychiat. 1974, 131, 957. 60. Klerman, G. L., quoted by Lebensohn, Z. M. Psychiat. Ann. 1975, 5, 376. 61. President’s Commission on Mental Health. Report for the President. Wash-
ington, 1978.
