The Retreat from a Psychiatry of People

Since before the turn of the century the fields of psychiatry and psychoanalysis have engaged the intellectual, humane, and socially progressive forces of American practitioners and the public. World War II and the subsequent affluence, as well as the forward looking social programs of the Kennedy and Johnson administrations, stimulated rapid growth in the mental health field in terms of expansion of research and services, innovation in theory and practice, and, perhaps unfortunately, rising expectations regarding the ability of psychiatry and psychoanalysis to ameliorate both mental illness and social distress. The main thrust during these years was to deepen understanding not only of the suffering individual, but of societal groups. There was a parallel thrust in broadening the treatment base by the advent of effective drug therapies.

The Nixon and Ford administrations diminished the wherewithal for mental health activities. The current recession further eroded general support. Increasingly, third parties, as payors, have come into the physician-patient picture, with the requirement that treatment be rationalized. With the question, “How can medical treatment be rationalized,” a new dimension has entered the field. That which had been taken for granted, i.e., the need for treatment, now has to be defined and measured. Physicians have traditionally used such concepts as diagnosis, etiology, susceptibility, severity, degree of disability, duration, and prognosis in defining illness. As a result, it is not too difficult to define pneumonia; it is not so easy, however, in many psychiatric conditions. Since 1968 American psychiatrists have been using the “Diagnostic and Statistical Manual of Mental Disorders, 2nd ed.” (DSM-II) in reporting illness. A third edition is in preparation by the American Psychiatric Association Task Force on Nomenclature and Statistics under the chairmanship of Robert L. Spitzer, M.D., of the New York State Psychiatric Institute.

DSM-II was a t