2010/07/02 by Leon Eisenberg, Laurence Guttmacher · 1 citation
Arts and Humanities · Psychology · Health Professions · #Mental Health and Psychiatry #Historical Psychiatry and Medical Practices #Healthcare cost, quality, practices #Reminiscence #Psychology #Psychiatry #Psychoanalysis #Psychotherapist #Cognitive psychology
paper · pdf · doi:10.1111/j.1600-0447.2010.01544.x
openalex publication_date 2010/07/02 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/29
While academic psychiatrists sought evidence in clinic and laboratory for health-related decisions, the ‘monetarization of medicine’ (1) overruled science and made large de facto decisions for the profession. There have been enormous changes in psychiatry during the nearly 70 years since I entered medical school in 1940: The modalities of treatment; The venues in which treatment is provided; The numbers and kinds of health personnel who provide care; The organization and financing of medical care; and in The theories and practices of psychiatri c diagnosis and treatment. Just how extraordinary those changes have been, was not fully apparent to me until I sat down to prepare this memoir. While we were occupied with debates about issues internal to our field, changes in organization and financing of care proved to be decisive in its evolution. In 1956 the United States had 550 000 mental hospital beds (2). The prediction was that the number of hospitalized mental patients would climb to 700 000 by the year 2000, yet the reverse occurred. By 1998 the supply of inpatient beds as measured by beds per capita was a quarter of that in 1956. The predominant venue of care shifted to the outpatient department, to chronic disease hospitals and nursing homes for geriatric patients, and to jails. When I entered the field, the university psychiatric departments in the leading medical schools were predominantly psychoanalytic in orientation, and most of the residents undertook a didactic psychoanalysis in the course of their training. By the 1960s, treatment had been medicalized. The first psychotropic drugs were discovered by serendipity and introduced into psychiatry. The symptom relief they brought was so startling and persuasive that there was a major shift from psychologic to pharmacological treatment. The financing of medical education during World War II was through the federal government. Male medical students (and 95% were male) were automatically drafted into the Armed Forces, provided with tuition, books, meals, dormitory facilities, and marched off to the cafeteria and classrooms! We had no financial indebtedness! With the end of the War, the doctor draft ended and tuition became a personal responsibility. By 2009, mean student indebtedness is 156 456! (3) As World War Two dawned, it became clear that the number of psychiatrists in the United States (about 2500 in 1940) was far short of the total needed and rapid, short training programs were introduced to gear up internists to function as neuropsychiatrists. Some of them found the field attractive enough to undertake formal psychiatric training after the War. The large number of returning veterans with psychiatric disorders spurred the veteran’s administration (VA) to finance expanded psychiatric residency training slots. The result was that the number of psychiatrists rose from 2500 in 1940 to about 6500 in 1960. Outpatient psychiatrists, often psychoanalytically oriented, tended to cluster in large cites with analytic institutes. In 1954, 20% of practicing psychiatrists in the US were located in Manhattan (4). As recently as 1977, 64% of psychiatric visits were exclusively for psychotherapy with no prescription provided; in 2002 this was true for <10% of visits to psychiatrists. A survey of office-based psychiatrists looking only at visits over half an hour found that only 19.1% of psychiatrists provided psychotherapy to all of their patients in 1997; this further declined to 10.8% by 2005. Inclusion only of outpatient visits more than 30 min undoubtedly inflated the prevalence of psychotherapy (5). Training in psychotherapy, once abundant, now is neglected. As the 19th century ended, psychiatric patients and the doctors who cared for them remained isolated in remote asylums, stigmatized by the fear and shame the patients (and their diseases) aroused. At their Annual Meeting in 1894, American asylum psychiatrists were castigated by S. Weir Mitchell, Professor of Neurology at the University of Pennsylvania, in these terms: Want of competent original work is to my mind the worst symptom of torpor the asylums now present…Where…are your careful scientific reports?…You live alone, uncriticized, unquestioned, out of the healthy conflicts and honest rivalries which keep us [neurologists] up to the mark of the fullest possible competence… (6) Whether or not Mitchell’s rebuke of American psychiatrists was warranted, his criticism of the field certainly was. Only at the turn of the 20th century were the foundations for a research enterprise in psychiatry established; but for a significant period they remained widely spaced oases in an academic desert. As late as 1958, most US medical schools had at best a part-time psychiatric faculty, constantly hectored as barely discriminable from its clientele and heavily dependent on private practice(7). Yet, by the end of the 20th century, every US medical school had an academic department of psychiatry. How did that come about? Whether or not psychoanalysis is a science and just how effective it is as a therapy, it has, nonetheless, had a powerful impact on our field. It provided plausible explanations for the bizarre symptoms patients exhibited. It taught trainees to listen to patients and to try to understand their distress, not simply to classify their diseases or sedate them or lock them away. It highlighted the importance of memory, its vulnerability to distortion, and its centrality to patients’ life narratives, the stories we tell ourselves and others. It made clear how those narratives can be self-defeating and defined the task of therapy as helping patients to reconstruct their autobiographies to permit growth. Psychoanalysis helped psychiatry preserve an abiding interest in the individuality of patients while other medical specialists were losing sight of the patient in their preoccupation with the biology of the disease. It connected the symptoms of mental illness to the psychopathology of everyday life. Psychiatrists learned to help patients by paying attention to their mental symptoms in an era when psychiatry had no procedures. Although Freud saw no role for psychoanalysis in the treatment of the psychoses, his method gave birth to outpatient psychiatric practice. Diagnosis and classification—the hallmarks of the medical approach—became increasingly irrelevant to clinical practice because analytically oriented psychotherapy dealt with individual and family dynamics, rather than with syndromes or diseases. The influence of psychoanalysis grew apace with the European intellectual migration after the Nazi putsch in Germany. When it was banned from the Congress of Psychology at Munich as ‘a Jewish science’ in October 1933, psychoanalysts in Berlin and Vienna began to migrate to the UK and the US. Jahoda has estimated that some 100–200 European analysts and some 30–50 analytically orientated psychologists emigrated to America in the 1930s (8). That number is small, but the membership of the American Psychoanalytic Association was only 135 in 1936 and almost doubled to 249 by 1944 (B. Canty, personal communication). The European influx was as significant intellectually as it was numerically; many of the refugees enriched post-Freudian psychoanalytic theory and became leaders in the movement. Psychoanalysis became the dominant trend in academic psychiatry in the US. By the early 1960s, although only 10% of American psychiatrists were analysts, more than half of the chairs of medical school departments held membership in psychoanalytic societies. America, became ‘the world center for psychoanalysis’ (8). In contrast, Professor Aubrey Lewis of the Maudsley noted that ‘none of the recognized teachers of psychiatry in the undergraduate medical schools of London is a member of the Psychoanalytical Society’ (9). How did psychoanalysis come to be so dominant? There was no other psychologic theory that provided what was purported to be so comprehensive an account of the origins of psychopathology. The brain sciences were largely irrelevant to clinical practice. At mid-century, descriptive psychiatrists were held in little esteem because diagnosis was unreliable and made little difference for treatment. The psychiatric pharmacopeia was limited to hypnotics and sedatives. Lack of empirical evidence was not unique to psychiatry. Treatments in all of medicine were based on the authority of clinical experience. New treatments were assessed by the results reported ‘by senior members of the medical profession, who had tried them out on a series of patients…and concluded that the outcome was better than that reported by others or by themselves in the past’ (10). The influence of the authority of one’s teachers, the experience of seeing patients improve during psychotherapy (most non-psychotic patients did), the logic and malleability of psychodynamic explanations and the readiness with which patients desperate for a way out of their dilemmas accepted those explanations combined to make believers of all but the most skeptical of trainees. Those who were non-believers were easily dismissed with ad hominem attacks on their unanalyzed resistance. By the 1950s’ and 1960s,’ a two-class system of psychiatric care had arisen in the US. Middle and upper class patients (those who could pay out of pocket and those with generous insurance coverage) sought psychoanalytically oriented out-patient psychotherapy with private practitioners. Rogow surveyed a sample of psychoanalysts about the patients they had in treatment (11). Not only were the patients middle or upper class, but not one was Hispanic and very few were black. The yearly cost of an analysis was more than 80% of the median income of an American worker. Psychiatric trainees vied for opportunities to treat young, articulate, and well-educated patients with anxiety disorders. Working class patients with psychoses were cared for in grossly under-resourced state or county mental hospitals. Although many dedicated psychiatrists worked in the public sector, all too many worked in the state hospitals because either they had no choice: they had yet to qualify for full licensure, or their psychiatric training was marginal, or they had limited command of English. The paradox that the most seriously ill patients often receive care from the least well-trained psychiatrists remains the case today. In 1962, I described my dismay that ‘in some centers…almost all the residents enter personal analysis…in my observation, it has been the bright and not the incompetent, the curious and not the unimaginative residents who have been attracted to psychoanalysis and thus lost to research, university teaching and public service’ (12). My dismay stemmed from (a) restrictions on the resident’s geographic mobility for the duration of a didactic analysis which might last for 5–7 years, (b) the press to earn supplementary income from after hours private practice to pay for the analysis, (c) the acquisition of a therapeutic technique altogether inappropriate to meet public need, and (d) lack of curiosity because they thought they possessed the exclusive road to salvation. Almost 50 years later, the pendulum has swung so far that some young psychiatrists seem to no longer listen to patients at all. Personal psychotherapy during residency training has become decidedly more unusual. Physician applicants to teaching institutes affiliated with the American Psychoanalytic Association numbered 265 in 1977; they fell to 109 in 1987 and to 88 in 1996 (Myrna Weiss and Joan Abramowitz, personal communication). The institutes do not suffer from a dearth of students; the number of non-physician applicants has risen steadily since the 1986 US Federal Court decision that non-physicians could not be excluded from analytic training programs because such exclusions would constitute restraint of trade. What explains the decline in medical candidates? In part, it stems from the greater allure of competing career lines in psychopharmacology and neuroscience; in part, the reason is economic: medical students graduate with far greater indebtedness than was the case a generation ago when many could afford to undertake a didactic analysis and they are far less likely to have insurance coverage that meaningfully supports psychoanalysis. According to American Association of Medical Colleges data, 81% of graduating US students have educational debts in excess of 100 000. Cost is now a deterrent in view of the debt to be repaid. It is a rare psychiatrist who opts for a research career in psychotherapy. Indeed, few opt for research careers at all, a serious threat to the future of psychiatry (13). The first double-blind randomized controlled trial (RCT) in medicine, the United Kingdom Medical Research Council (1949) trial of streptomycin for the treatment of tuberculosis, was not carried out until 1949. The RCT rapidly became the gold standard for research in psychopharmacology, but attitudes and beliefs relating to other treatments, notably psychotherapy, all too often were governed by the training physicians had received; research data and controlled clinical trials have developed far more slowly. Picture: Leon Eisenberg with Leo Kanner, MD in New York May 17, 1960 when Dr. Kanner became the recipient of the First Annual Award of the National Organization for Mentally Ill Children. Through the ‘1950s,’‘1960s’, and ‘1970s’ there was a large psychotherapy sector untroubled by the lack of evidence for effectiveness. Varying schools of thought, each with fierce adherents, battled for supremacy. One of the few serious students of psychotherapy, Jerome Frank, compared research in the field to: the nightmarish game of croquet in Alice and Wonderland in which the mallets were flamingos, the balls hedgehogs, and the wickets soldiers. Since the flamingo would not keep its head down, the hedgehogs kept unrolling themselves and the soldiers were always wandering to other parts of the field…it was a very difficult game indeed. (14) Frank recognized that psychotherapy outcomes were better than wait-list comparison groups but remarkably similar to one another despite differences in the theories and techniques to which therapists professed allegiance. He concluded that a number of non-specific psychologic processes were common to successful psychotherapy: an intense confiding relationship with a therapist; a set of explanations for the patient’s distress; suggested alternative ways of dealing with the identified problems; the arousal of hope; and the restoration of morale. His conclusion offended proponents of all the schools of psychotherapy. Two decades later, Smith, Glass, and Miller made a more successful foray when they reported the results of meta-analysis of extant studies of psychotherapy (15). Their book was widely hailed by practitioners as establishing the effectiveness of psychotherapy because most treatments had a significant effect size; however, once again, outcome differences between treatments or between novices and experts were hard to detect. Myrna Weissman’s paper on the ‘paradox of psychotherapy’ provides an elegant analysis of the development, and present status of Evidence-Based (psycho)Therapies (16). The matter will not be pursued further here except to note the irony that just as certain forms of psychotherapy have proved their worth, the economics of managed care have sharply restricted the ability of practitioners to provide psychotherapy! Until recently there was no formal requirement that psychiatric residents learn about, let alone acquire competence in, any non-psychodynamically oriented forms of psychotherapy. To the extent psychotherapy is taught at present (rather than being swamped by psychopharmacology), it remains mostly psychodynamic (that is, based on psychoanalytic principles) reflecting the training of the senior teachers in academic programs (17). The Accreditation Council for Graduate Medical Education 2007 program requirements for residency training in psychiatry include (IV.A.5.a.3.e): residents shall develop competencies in ‘applying supportive, psychodynamic, and cognitive-behavioral psychotherapies to both brief and long-term individual practice, as well as to assuring exposure to family, couples, group, and other individual evidence-based psychotherapies’ (18).To address the challenge of measuring competence, the American Association of Directors of Psychiatry Residency Training has established a task force (with assistance from experts in each modality of psychotherapy) to operationalize these competencies in order to assess residents’ performance and to plan for remediation if they fall short (Lisa Mellman, personal communication). The decision to evaluate education by measuring competencies rather than by number of seminars attended, number of patients seen and years of training is a major positive change. In the last half of the 19th Century, progress in pathology and bacteriology uncovered the pathogenesis of many diseases; yet there was disappointingly little progress about mental disorders. 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