The Struggle for Identity: Issues and Debates in the Emerging Specialty of American Psychiatry from the Late 19th Century to Post-WWII

Rigid self-inspection is the surest method of keeping sound, whether in theology or in medicine, and it can but be to our advantage to overhaul ourselves now and then to find out what we really are, what our motives and our purposes are, and what we are doing to attain the things we stand for. --A "distinguished Southern surgeon" (1) Introduction When someone seeks help for a mental health problem today, the options are many. Psychiatrists, psychologists, social workers, mental health counselors, religious leaders--all may be consulted when a person is faced with a mental health crisis. But at the top of this professional heap, in the consciousness of most Americans, sits the psychiatrist. In fact, the U.S. Department of Labor's "Occupational Outlook Handbook" describes psychiatrists as "the primary caregivers in the area of mental health," an official endorsement of their status at the top of the mental health field. Unlike any other mental health profession, to become a psychiatrist one must first become a medical doctor, completing four years of medical school and a one-year internship before spending three years specializing in psychiatry. Today, psychiatry is recognized as a distinct medical specialty, and psychiatrists are seen as uniquely qualified to treat those suffering from mental disorders. Behind all of this lies an inherent and important assumption: mental disorders are organic, biological diseases that are best treated by medically trained professionals. But here is the paradox--the specific organic nature and causes of mental disorders have yet to be found. Even more confounding, non-medical, psychological treatments have been found to be as effective in treating mental disorders as biological interventions in many instances, and occasionally may be even more effective. So how did psychiatry become the medical specialty it now is, and where did our conception of mental disorders as biological diseases come from? The truth is, the exact nature and causes of mental disorders remain elusive, and although more and more correlations are being drawn between certain disorders and specific patterns of brain function and anatomy, we no more hold the key to mental disorders now than we did 100 years ago. Although the American Psychiatric Association (APA) claims boldly on its website that mental illnesses are "real illnesses--as real as heart disease and cancer," (2) the truth is we don't know this for a fact. Ironically, the APA itself recommends in its practice guidelines a combination of medication and psychotherapy as the best treatment protocol for such illnesses as major depression and bipolar disorder, (3) a recommendation that could be viewed as contradictory to a strict disease model of mental illness (in no other medical specialty is a non-organic treatment officially recommended for the direct treatment of a purely organic disease). But despite this, psychiatry officially puts forth the foot that mental disorders are organic brain disorders best treated medically. Perception is a powerful thing, and if psychiatry is believed to be at the forefront of the mental health professions, and psychiatry as a profession promotes itself to be a science rooted in biology and mental disorder to be a medical disease just like any other, this is the message the public picks up, and this begins to color how we as a society see mental disorders. And in an age where insurance companies are dictating what constitutes appropriate treatment, pushing medications and abandoning psychotherapy, what we as a society are willing to believe about mental disorders, and therefore willing to accept as appropriate treatment, becomes critical. The question is: how did we arrive at the point we are today, with a belief in a medical model of mental disorder and psychiatry as the profession most qualified to treat it? Did psychiatry's biological stance influence the way we as a society view mental disorder, or did society's faith in biology drive the profession of psychiatry to adapt its own views? …