History of Psychiatry: Its Relevance in Training and Beyond

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Formal instruction on the history of psychiatry is currently a mandatory component of psychiatric residency training in the United States. The Accreditation Council for Graduate Medical Education (ACGME) requires psychiatry residents achieve competence in their knowledge of the “history of psychiatry and its relationship to the evolution of medicine.” The importance of this area of study has been recognized since at least the 1960s. A 1967 survey found that 44 teaching centers in the US and 2 in Canada were offering instruction on historical psychiatry, twice as many as in 1961.¹ Since then, there has been increasing recognition of the importance of history for the development of the future psychiatrist.

Here, we seek to highlight the relevance of the history of psychiatry not only in the training of residents but also in the day-to-day clinical work of the psychiatrist. One of us (QM) is a current psychiatry resident at Tufts Medical Center with interest in the history and philosophy of psychiatry, and the other (MR) is a psychodynamic psychotherapist who teaches history of psychiatry to residents at Tufts and the University of Central Florida. We have identified at least 5 reasons to study the history of the field.

1. The history of psychiatry exposes us to various modes of thinking about mental illness.

Speaking from the perspective of the path to an MD role in psychiatry (QM), something that has been notable in my medical education is the absence of historical context. Often said to be like drinking from a fire hose, medical school is a deluge of facts and models. A consequence of focusing on distillation and digestibility, however, can be a neglect of nuance and uncertainty. This is not a criticism of medical education. Its aim is breadth and passing knowledge (along with sorting); depth and specialization are expected to come with residency and fellowship selection.

Psychiatry is laid into the curriculum as just another science, for it has long jockeyed to be a member of the medical field, and perhaps practically it must be testable via multiple choice questions. Much of medicine suffers quite little from an ahistorical approach. It does not really matter who came up with the idea of flow rates or inotropes to manage heart failure, it just matters that it measurably works. Psychiatry, on the other hand, lacks these reliable models. Its foundations are much shakier and more splintered.

This became apparent to one of us (QM) quite abruptly when starting residency in psychiatry, having switched to the field after a year in a categorical internal medicine program. In medicine, it is often said that your treatment is only as good as your diagnosis. Looking to the DSM for orientation, however, can be jarring to this notion. Landing a diagnosis of adjustment disorder does very little for understanding; the patients are heterogeneous, the seeming armchair conjecture with no confirmatory testing provides no reassurance, and the sterile, impersonal terms typically do more to shroud rather than illuminate the real problems of the individual.

More seasoned practitioners are likely quick to recognize this experience as the naivete of reifying diagnosis and searching for cause and explanation in the DSM—which lays claim to neither.² But this “atheoretical” posture speaks to the problem of a lack of an authoritative framework. In looking for explanation, instead, one is quickly greeted by a cacophony of perspectives from different books, colleagues, and supervisors. Each view has persuasive lines of reasoning, but they do not necessarily seek to cohere together. The challenge then becomes reconciliation and integration. But how to do this with dialectal behavior therapy and Anna Freud’s ego defenses, or with object relations theory and the predictive processing model in cognitive neuroscience?

Thomas Kuhn might have suggested that this is a problem of incommensurability—that these are different languages that cannot fully communicate with one another.³ But clinicians and patients cannot wait around for a paradigm change; we must use the imperfect tools at hand. To understand and be useful then requires fluency in the multiple languages of psychiatry. For successful deployment, one must learn not just the ideas themselves but their context. Why should I use these ideas here becomes, in part, how did they evolve, and what facts and follies did they flow from?

In exhuming these questions more fully, a famous critic of psychiatry articulates an important concept to keep in mind. In his analysis of science in The Order of Things, Michel Foucault discusses the more broadly applied concept of an episteme. An episteme represents the state of knowledge at a given time, which constrains and directs the ideas by which individuals can construct thought.⁴ It parallels Kuhn’s idea of paradigms but emphasizes historicity and the way it limits the possible.

We are always in an episteme. In psychiatry especially, we must be aware of this, and reject the naïve realism that we see things as they are, and that in turn we do not engage in the same types of associative and metaphorical constructions that those in the past have made. Freud drew upon thermodynamics and engines for his modeling of the mind as repressed, full of unconscious pressures and drives.⁵ In the age of data, computers, and AI, it is tempting to see the brain through algorithmic or computational lenses, but will this also not constrain our thinking in some ways too?

We can pair acknowledgement of this with the further recognition that our organ of interest has immense complexity, and what this means for causality and levels of explanation. We are the sum total of nature and nurture, extending in time and space. Understanding attunement and development as causal to a current state is not exclusive to understanding hormone or neurotransmitter effects. It is like how in analyzing one billiard ball colliding and moving another, we can learn something about physics, and also need to learn about the intentions of the person who shot the cue stick. Moving through perspectives gleaned from a history of psychiatry can be like changing these different frames, which collectively contribute to understanding.

Our current lack of solidity in psychiatry is a call to be familiar with the corpus of knowledge, and to be able to move fluidly within it. In so doing, we can expand our concepts and become more flexible to our patients. It also forces a reflection of our own blinders and limitations in how we are thinking.

2. The history of psychiatry demonstrates the power and seductiveness of totalizing narratives.

Narrative creation is not something that is a unique capacity of psychiatry; it is an intrinsic part of human psychology. This ability allows us to navigate our environment, understand cause and effect, and bring order to our chaotic world. It underlies the fundamental human capacities for religion, superstition, and ideology. Mental health providers are acutely aware of the impact narratives have in our patients particularly as it relates to the sense of self, and part of where we can be most helpful is in reframing those that are pernicious and disempowering.

What bears more conscious reflection for providers is that we are naturally prone to the same sort biases and shortcomings from narrative creation in how we view our patients. Alas, it is always easier to see the subjectivity in others. As health care providers there are added pressures of being continually confronted by the complexity of humankind and asked to make sense of it. The phenomena are there, but then come our interpretations. Over time confirmation bias guides this, and impacts what we turn our attention to.⁶

While there are several paths to valid knowledge, medicine and science rest on a pillar of falsifiability. This was Karl Popper’s answer to the pitfalls of narrative creation (more formally, the problem of induction): we cannot come to valid knowledge simply confirming our suspicions, but by the ability to be proven wrong.⁷

It is here that psychiatry faces a considerable disadvantage compared to other fields: we navigate incredible complexity, spanning the biological, developmental, psychological, and social domains. We move into the realm of subjective experience, something that is, in many ways, intrinsically beyond verifiability. We lack biomarkers, such as pathology, lab tests, or imaging, to confirm whether we are wrong or even if our diagnoses are valid.⁸ Additionally, our treatment responses can be slow and variable.

In this open space unconstrained by clear refutation, narratives flower. Further, in a field of competing hypotheses vying for attention, the ones that promise the most are also the most attractive. Internal motivators alone can drive hypotheses to expand, but external incentives such as funding, publication pressure, and competition with others further propel the supposed explanatory depth and breadth of ideas.^9,10

In learning about psychiatry’s history, one sees many outdated and discredited theories that had strong seductive pull. The “schizophrenogenic mother,” for instance, is a rather natural conclusion from psychoanalytic theory. If all illness exists on the spectrum of neurotic to psychotic, and pathology reflects early developmental conflicts, then schizophrenia must have maternal origins.¹¹ A few more stark failures—each associated with its own theoretical underpinnings—include lobotomies, the repressed memory movement, Oedipus complex, and refrigerator mothers.

It might be easy to scoff at these ideas, for we have come a long way in the field of genetics and biology, and in many ways these specific failures have been empirically refuted. But this likely pales in comparison to how far we still must go in understanding, and how much remains empirically unsubstantiated. Further, moving into these harder scientific aspects does not provide reliable refuge.

The excitement of biological psychiatry in the 1980s and 90s, with its emphasis on manipulable neurotransmitters as a source and remedy for psychiatric disorders, has been tempered by moderate effect sizes, medication adverse effects, and one of our latest inventions, “treatment resistance.” The age of genetics has experienced similar crestfallen aspirations.¹² To reflect on our broader thesis about the utility of learning the past, this does not mean there are not truths to be gleaned. Antidepressants are helpful, and working knowledge of neurotransmitters can guide treatment. But in learning about how these previous movements in psychiatry tended to expand and over-promise, we start to take a healthier perspective on alluring current and future trends.

Another way to frame this is that psychiatry is faddish. Knowing this well encourages a provisional stance to diagnoses, treatments, and understanding, which helps foster humility and strike an appropriate balance of skepticism and openness to new information.

3. The history of psychiatry helps us contextualize changes in diagnosis and treatment over time.

The history of psychiatry is marked by major paradigmatic shifts in conceptualization, diagnosis, and treatment. Changes in the way we see and work with patients is the rule, not the exception. For instance, patients now considered to have borderline personality disorder were once considered to have a form of schizophrenic illness described as “pseudoneurotic schizophrenia.”¹³ A study in the early 1970s found that American psychiatrists diagnosed schizophrenia about twice as frequently as their British counterparts.¹⁴ The American concept of schizophrenia was much broader than that in the UK. The field is in a perpetual state of change and evolution in the way we see the problem of mental illness.

This is true also for psychiatric treatments. Lithium was discovered to be effective in the treatment of bipolar mood disorders in 1948, yet it was not approved by the US Food and Drug Administration until 1970. Ronald Fieve, MD, established the first lithium clinic in North America at Columbia University in 1966. The clinic closed in 1995, after nearly 30 years, as valproate and the new antipsychotics came on the scene. Yet lithium remains the single most effective agent in the treatment of bipolar disease. Because it could never be patented, it has been underutilized in favor of more profitable agents. Lithium’s rate of prescription in the US is much lower than in Europe, Asia, Australia, and New Zealand.¹⁵

Similarly, the enduring value of psychoanalytic and psychodynamic treatments was underappreciated in the 1990s and 2000s, when short-term, manualized therapies garnered all of the research funding—and media attention. Now, interest in these dynamic approaches is resurgent, and good efficacy studies are proving their utility in disorders across the diagnostic spectrum. Freud may have been dead in psychiatry, but it was not for long.

Clinicians knowledgeable about the history of psychiatry are able to evaluate these and other changes through a contextually-informed lens. Such knowledge also allows clinicians to recognize modern fads in diagnosis and treatment—and the social, political, scientific, and economic forces which drive them.

4. Some classic psychiatric concepts remain important in modern clinical practice.

In reading the history of psychiatry, one cannot help but notice that many classic descriptions of psychiatric illness are as apt today as they were in the past. The doctors and patients themselves may have changed, but the illnesses and their psychopathological mechanisms remain largely the same. Thus, one finds in the historical literature striking similarities to modern thought. Not all is new under the sun. In fact, many seemingly novel theories of psychopathology trace their origins back 30, 50, or 100 years. Without a knowledge of history, all of this is lost, as is the opportunity to critically appraise these new ideas based on a knowledge of the past. For instance, any discussion of traumatogenic theories of mental illness would be woefully incomplete without consideration of Fromm-Reichmann’s “schizophrenogenic mothering”¹¹ or Bateson’s “double bind” hypothesis.¹⁶

Indeed, some of the most pressing questions facing the field today implicate historical theories, concepts, and debates. Should antidepressants be used in the treatment of bipolar illness? Are personality disorders categorically pathological or do they exist on a continuum with normal personality traits? Is the unitary concept of depression a valid diagnostic construct? Should we clump or split psychopathological processes? How many psychiatric disorders are there anyway? All of these questions—and many more—invoke historical concepts and discussions; to try to answer them without knowledge of history strikes us as a rather hopeless endeavor.

5. The history of psychiatry helps us realize the significant advances that have been made.

Despite psychiatry’s failings, it undoubtedly true that the psychiatry of today offers better treatments and greater hope than at any time in the past. Without question, today is the best time in the history of the world to be suffering from a major mental illness. A little more than a half century ago, there existed not a single effective medication for any of psychiatry’s major disorders—not a single antidepressant, mood stabilizer, or neuroleptic drug. Those with chronic mental illness filled the back wards of the old state hospitals, where they were sent as young individuals and many went to die. Simple confinement to a state hospital was virtually the only thing to be done.

Psychotherapy, too, has witnessed significant advances, as specific psychotherapies have been developed for treating particular conditions. Psychoanalysis has broadened beyond its Freudian roots to include such varied theories as object relations, psychoanalytic self psychology, interpersonal psychotherapy, and relational analysis. Shorter-term directive approaches such as cognitive behavioral and dialectical behavioral therapy have revolutionized the treatment of certain conditions. A growing body of research is accumulating around transference-focused psychotherapy, an effective treatment for borderline and narcissistic pathologies.¹⁷

These enhancements in individual care are also complemented by the progressive destigmatization of mental illness that psychiatry has fostered. While the nature of illness and the second-order effects of our current frameworks remain hotly debated topics, and it is clear that there are significant often-overlooked negative effects,^18,19 it would be quite a leap to suggest things are worse overall, especially over decades. Our wider array of treatment options offers more hope for individuals. Knowledge of biological mechanisms, such as the overwhelming genetic profile of schizophrenia, can assuage guilt, shame, and misplaced responsibility. Socially, struggles are less likely to be seen as character flaws, and seeking help has become more acceptable. Legally, this progress includes patient autonomy, the right to treatment, humane standards, and increased protection from criminal responsibility. These accomplishments are not solely due to psychiatry, nor have they resulted from a unified advocacy. However, when comparing the current landscape with the past, it is evident that this field has not been entirely mired in a morass.

This, of course, is not to say that the psychiatry of today is without its problems. Many such problems exist, but without an appreciation for history, these major advances can get lost in the noise of the modern debate.

Concluding Thoughts

We have argued that learning a history of psychiatry has practical importance for the current provider, both in training and as lifelong learners. The applicable lessons include learning new perspectives for our complex and unsettled subject matter, contextualizing unfolding changes in the present and future, balancing open-mindedness with critical appraisal, and, amidst the sea of cynicism, reminding us of the positive arc of our field. This is not a comprehensive list of the fruit that studying our collective past can bear. Moreover, engaging in any sort of extra study is difficult to do if it is done just for the purposes of self-development. Our final appeal is that a history of psychiatry is a profoundly compelling and very human story of trying to understand health, sickness, and what we can do to help.

Dr MacDougald is a PGY-3 psychiatry resident at Tufts University School of Medicine in Boston, Massachusetts. Dr Ruffalo is an assistant professor of psychiatry at the University of Central Florida College of Medicine in Orlando and adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts.

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