Leaping Back to the Psychiatry of 50 Years Ago

netrun78/AdobeStock

PSYCHIATRIC VIEWS ON THE DAILY NEWS

Today is the day added every 4 years, known as a Leap Year. Leaping generally means leaping ahead to something or the future, but as a colleague pointed out to me, the Leap Year is paradoxically “slowed down” by the extra day. Actually, as an elder, anything that seems to slow down time is welcomed!

Why February 29th, say, instead of December 32nd? That seems very complicated, but has important social and psychological meaning. In some way, it goes back to ancient cultures who thought that the world began in the spring and thereby March. That date, too, would keep the spring equinox and Easter celebrations on track.

Psychiatry has had a history to also leap back to look into the past, at least in terms of analyzing a patient’s history and possible genesis of current psychiatric disorders. In that spirit of leaping back into the past, 2024-2025 will be the 50th year anniversary of when I finished my psychiatric training at the University of Chicago. That brings back memories and here they are, without any attempt to verify them as I compare them to my current perception of psychiatry.

Pluralism

During my residency education, it was clear that psychiatry was expanding from its prior dominance of Freudian psychodynamic theories and psychotherapy. Psychopharmacology was assuming a stronger presence, even making its way into complementing psychodynamic psychotherapy. Behavioral approaches even had a small presence. Faculty engaged in relatively friendly debates on what they thought was best.

Psychotherapy

The preferred psychotherapy approach was clearly Freudian-based psychotherapy, and Freud himself was not yet being widely criticized. There was a little behavioral psychotherapy here and there. Cognitive behavioral therapy as a formal approach was unknown.

Psychopharmacology

There were no SSRIs. Medication for clinical depression was the tricyclic antidepressants. There were only first-generation antipsychotics, including the use of the first, thorazine (chlorpromazine). Lithium for what was called manic-depression was emerging. Though adverse effects were often very problematic, I am not sure that there was a dramatic difference in actual effectiveness compared to today.

Social

The appreciation of the social in the bio-psycho-social model of psychiatry was just emerging in the formation of the American Association for Social Psychiatry. As applied to service delivery, the heydays of community mental health to serve the poor were thriving. For the more well-to-do, self-pay and good insurance still allowed long hospitalizations of months and even years if seemingly indicated.

Research

Our chairman made his mark in biological psychiatry and consequent psychopharmacology. That reflected the field as it was changing. There was not yet much research into psychotherapeutic outcomes. Tools to investigate the brain were very limited. Mothers tended to be blamed for some conditions like schizophrenia and autism. With new legal prohibitions, the earlier studies on the therapeutic potential of psychedelics went to the wayside with widespread underground usage and “bad trips,” including patients I saw with unremitting psychosis after using LSD.

DSM

The DSM II of the time reflected the psychodynamic approach. Diagnosis was generally based on the concept of neuroses and unresolved conflicts.

Ethics

The Goldwater Rule to not give a public psychiatric opinion of a public figure came out in 1973, 9 years after the embarrassment caused by the comments of some psychiatrists when Barry Goldwater was running for president in 1964.

50 Years Later

By now, the pluralistic nature of psychiatry is taken for granted. However, psychiatry has come under much criticism from some quarters, including from what is called antipsychiatry, about an overreliance on medications and a lack of appreciation of their serious long-term adverse effects. The so-called Goldwater Rule has curbed the wild psychiatrist opinions that occurred when Barry Goldwater ran for President in 1964, but have seemingly gagged most any psychiatrist from usefully commenting on our current political nomination race.

On the other more positive hand, there are more medication options with less adverse effect problems, though new breakthroughs have seemed lacking. The second coming of psychedelics with controlled research and better guidelines does seem promising for a variety of disorders.

More mixed from my perspective is the DSM 5, which is more of a symptomatic cookbook approach of diagnosis, easier to use but arguably less sophisticated. Community mental health has become fragmented, hospitalizations are very short with the rise of business control by for-profit managed care, and manual approaches for psychotherapy are readily available. There is probably more undertreatment now rather than the excessive treatment in the past. We do better appreciate the role of religion and spirituality, as well as the importance of cultural humility, but arguments arise as to who is most appropriate to know and speak about what from the cultural standpoint. The internet provides ready information and has helped to destigmatize psychiatry somewhat, though some of the information is erroneous and even cultish. Telepsychiatry and Zoom provide new ways of clinically connecting, though without the actual live human presence.

While it seems from this personal and rather simplistic perspective that psychiatry has progressed favorably overall, there have not been great leaps in advances. Even how to define psychiatry is not easy. It is likely that many older psychiatrists can—and do—treat some patients more or less like we did 50 years ago. That can be interpreted positively or negatively. Perhaps artificial intelligence, which is proceeding so swiftly, can provide the great leap forward of psychiatry. Or does it and the rest of technology need to be slowed down some?

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.