I. The FieldRoy R. Grinher, Sr.
II. Child PsychiatryDavid M. Levy
III. Social PsychiatryAlexander H. Leighton
IV. Forensic PsychiatryWinfred Overholser
V. The Religio-Psychiatric MovementSamuel Z. Klausner
The major fields of psychiatry are discussed under this heading. Related material may be found under Analytical psychology; Clinical psychology; Individual psychology; Mental disorders; Mental disorders, treatment of; Mental health; Psychoanalysis; Psychology, article on Existential psychology; Psychosomatic illness. A guide to articles on specific syndromes is provided under Mental disorders. Also relevant are Magic; Medical care; Medical personnel. Major contributions to psychiatry are described in the biographies of Freud; Kraepelin; Meyer. Also of relevance are the biographies of Abraham; Adler; Alexander; Bleuler; Char-Cot; Ferenczi; Horney; Jones; Jung; Klein; Pinel; Rank; Rapaport; Reich; RÓheim; Rorschach; Rush; Sullivan.
For the last hundred years psychiatry has been considered a specialty of medicine usually defined as the medical practice or applied science of treating and preventing mental diseases, or disorders of the mind. Today, however, Masserman’s definition (1946) is more appropriate; it considers psychiatry broadly as a science that deals with the varieties of human behavior, their determinants, methods of analyzing them, and the techniques for coordinating behavior with optimal personal and social goals. The disparity between these two definitions indicates that profound changes have taken place in psychiatry. It is presently a peculiar admixture of biology, psychology, and sociology.
In the late eighteenth century psychiatric patients were released from chains and removed from dungeons, where they had been treated like animals and had died prematurely. Not until about 1820 (Kraepelin 1917), however, were some patients considered curable by medical means and no longer considered to be animals with innate weakness and baseness, or voluntary pursuers of evil whose insanity was contagious to their keepers. About the same time, psychiatric textbooks appeared and medical students were given instruction in a wide variety of physical therapies. The subject of psychiatry became less a concern of philosophers and more a medical discipline (Schneck 1960).
Although the strictly biological and medical approaches were pursued early, it was late in the nineteenth century before hypnosis, introspection, psychotherapy, and psychoanalysis placed the emphasis on deeper levels of mentation rather than on behavior, and the focus centered on the psychology of the individual. It is worthy of comment that the psychologies and sociologies that took significant hold in psychiatry were those developed by psychiatrists themselves. Academic psychological and social sciences had little influence on the field and, in fact, were more stimulated by, and receptive to, psychiatric thinking than they were contributory.
These sciences were also still in the early stages of development and concentrated on matters of little concern to the psychiatrists. Psychology was in the almost exclusive phase of “brass-instrument” studies of the mechanisms of behavior and animal experimentation. Anthropologists were describing customs of primitive populations, and cultural personality conjunctions were still vague. Neither psychology nor sociology could assist in the study of the mentally healthy or ill. Medical tradition, however, directed psychiatrists to reason from the abnormal to the normal. Psychopathology furnished insight into psychodynamics and into healthy structure and function.
In the last several decades the direction of influence has shifted, at least enough to indicate that the commerce between psychiatry and the social sciences traverses in two directions. As dynamic psychiatry has moved from concentration on unconscious instinctual representations, drives, and id forces to concern with stress responses, coping devices and defenses, signal anxiety, and reality testing of modern ego psychology, it has attempted to incorporate the vast amount of information acquired by psychologists about ego functions. As psychiatrists have learned that the functions and structures of the individual in the process of development are derived from experiences with people, that the major stresses of life arise from disturbed or broken relations with people, and that therapeutic processes occur best in a social setting, social sciences have become important for the understanding of man and his problems. Therefore, these fields have recently fused in some areas into new hybrids, social psychology and social psychiatry (Rennie & Woodward 1948). In fact, the definition of psychology emanating from Harvard University (1947) differs little from the ideal definition of psychiatry—a biopsychosocial discipline (Murphy 1947; Cameron 1963).
What is currently included within the field of psychiatry actually ranges from biodynamics to existentialism. In fact, psychiatry seems to involve a study of all human behavior and is as broad as life and its social and cultural derivatives. Behavior as the central focus of psychiatric research is not elucidated by a fractionation of man as a totality isolated from his environment of things, people, and symbols (Goldstein 1934). Furthermore, it does not ignore the nervous, circulatory, and endocrine systems, the visceral and somatic organs, and their constituent cells and fluids. Unfortunately there is no unified theory, so that controversy still exists between “reductionists,” who hope to explain man’s behavior exclusively on a physicochemical or cellular basis, and “extensionists” or “humanists,” who focus entirely on society and culture. These are polarities leading to futile arguments. The biological or the social sciences alone cannot explain behavior, but psychiatry cannot progress without them (Grinker 1964).
A point of view
We should approach living human beings as if they existed in a total field of multiple transactions, thereby avoiding the dichotomies of nature-nurture, organic–functional, lower–higher, or reduction—extension (Dewey & Bentley 1949). Furthermore, in dealing with multivariable problems, we can operationally behave as if we really believed in multicausality of both healthy and disordered function, within a total field whose constituents range from physicochemical to symbolic foci. We are then able to study each focus or system (for example, nervous, endocrine, cognitive, behavioral, and emotional) in terms of structure, function, integrative capacity, and transactions with one or more other systems. The specific or exclusive importance of one view or system of empirical events becomes minimized when we recognize that change in one system affects all others. However, one view or one technique has only limited usefulness, for although each system has considerable commonality in essence with all others, each also has its specific regulatory devices approachable only by special techniques (Grinker 1961). Multidisciplinary teams are essential for multisystems investigation at the present level of sophistication with respect to the large number of variables involved in human research (New York Academy of Medicine . . . 1957).
If psychiatry is a part of human behavioral sciences, it is differentiated operationally by its focus on the individual in relation to some other person or persons, things or situations, even though we know he can be isolated only temporarily for investigation from other foci in his life, just as the physiologist isolates a single organ or organic system for investigation.
In this temporary isolation the individual may be studied through the methods of observation, description, experimentation, and quantification in transaction with another focus by observers using the necessary techniques from a suitable frame of reference. Thus some parts—for example, endocrine processes, autonomic neurological activity, and muscle tension—may be studied at the same time as observable or reported behavior. In another example the behavior of the individual may be viewed in relation to the behavior of others. One focus or another may be utilized in the transactional analysis, and step by step the functional parts of man can be studied in relation to various behaviors until eventually the entire field may be covered. When physiology is considered in relation to emotion, the social group is absent; when the individual is viewed in his group, his component parts fade. On the other hand, the social scientist loses sight of the individual. To envisage the entire field requires a rapid shift of accommodation in mental imagery, in which it is necessary (but is rarely done) to state explicitly what is of concern.
Theory in psychiatry
Although it is well known that theory and investigatory methods interact by continuous feedback processes, in the field of psychiatry theoretical abstractions and hypotheses are rarely explicit but usually must be extracted from the operational procedures in use. Furthermore, because of the large number of foci or facets in the total field to which various disciplines hold proprietary rights, theory is not unified but is partial or fragmented. Psychoanalytic theory, because of its enormous influence on modern psychiatry and its vast scope, has been given high priority.
Psychoanalysis and its derivations
Horace Kallen (1934), in the Encyclopaedia of the Social Sciences, stated that psychoanalysis had no quantities, meaning systems of measurement, and could never be a science. He stated that inferences were employed as agents in their own verification. Psychoanalysis was considered a faith and a dogma; psychoanalysts were judges of their own truth and of the criteria establishing its validity.
Although Freud’s psychoanalytic science and metapsychology were speculative and the methods of psychoanalysis may be unreliable, Freud established the principle that psychological processes should be studied by psychological methods. Even though the data may be difficult to verify, and historical anecdotes may lead to invalid inferences, Freud did develop a new paradigm suitable to man as an animal capable of symbolic transformation, which in essence was a scientific revolution and a generative idea. Unfortunately, Freud was incapable of systematic presentation, and psychoanalytic theory and its modifications are criss-crossed by shifts to the new and reaffirmations of the old, written in poetic style interspersed with metaphors and confused by circular reasoning.
There is no use in attempting to formulate the totality of psychoanalytic theory. It is even difficult to extract precise declarative sentences suitable for the development of testable hypotheses, although the attempt has recently been made by Rapaport (1959). In general, it can be stated that psychoanalysis is not a philosophy and is not yet a science.
Despite justifiable criticism, psychoanalysis has had a profound effect on all of the psychological and social sciences (Hendrick 1934). It avoids reductionism, yet it is based on a theory of instincts (life and death), is motivational, and focuses on the present personality structure in the light of the individual’s past (structural). Psychoanalysis has a system of allocated mental functions: id, ego, and superego (topological). It deals with forces and conflicts (dynamic). Finally, it views the resultant personality structure in adaptational terms (economic).
The several early deviants from Freud’s classical psychoanalytic theories (Alfred Adler, Carl Gustav Jung, and Otto Rank) have had varying effects on psychiatry, psychology, and the social sciences (Munroe 1955). Adler’s concept of “individual psychology” formed the basis for a special therapeutic approach, which has been so diluted that it is now hardly recognizable as a separate school. Nevertheless, the concept of the “will to power” was the precursor of Freud’s later theory of the death instincts and their mastery through outwardly expressed aggression. Jung’s notion of the “collective unconscious” became more of a mystique and less of a theoretical or operational approach in psychiatry. It has become aligned with existential psychiatry. Rank’s concept of “birth trauma” led to a short-lived therapeutic procedure of establishing a patient-therapist relationship and setting a termination date well in advance, so that impending separation from the therapist might enable the patient to work through a new “birth trauma” under better conditions. [SeePsychology, article onexistential psychology; and the biographies ofAdler; Jung; Rank.]
The so-called Neo-Freudians (Harry Stack Sullivan, Frieda Fromm-Reichmann, Erich Fromm, Karen Horney, etc.) form a heterogeneous group with many divergencies from classical psychoanalysis. The interpersonal or interactional theory of Sullivan gave a great impetus, including the establishment of a “school,” to the treatment of schizophrenic psychoses. The Neo-Freudians attend more to the difficulties of present interpersonal processes (social) than to lengthy reconstructions of the past. [See the biographies ofHorney; Sullivan.]
Ascendancy of psychoanalysis—a critique
It is unfortunate that contemporary psychiatry has almost completely adopted the psychoanalytic or psychodynamic model. Psychodynamics is purported to be the basic science of psychiatry. It is frequently stated that the core process in psychiatry is a dyadic “depth” relationship in which diagnosis, prognosis, therapy, and research are processed, a technique that utilizes a participant–observer of uncertain reliability.
This “dynamic” approach within a dyad has superseded and even resulted in a depreciation of the basic psychiatric techniques through which so much progress was made in the nineteenth century. These are the methods of careful and controlled observations over time and accurate descriptions of behavior, including verbalizations but not limited to them.
According to these basic techniques, observation of behavior rather than inferences about feelings is the keystone of psychiatric research. Behavior, in actuality, represents functions allocated to a hypothetical ego that filters perceptions on the one hand and actions on the other, expresses reportable motivations, affects, defenses, and compromises, employs symptoms and sublimations, and demonstrates integrative capacities and disintegrative trends. About any of these effects there need be few inferences or interpretations. As observational material, they can be coded and rated, repeated and replicated, and tracked through time. These basic living data can then be interpreted according to fruitful theory and placed in juxtaposition to any hypothesis. Information gained from “depth” interviews may, in addition, account more adequately for deviances and interindividual variability. The behaviors of the participant-observer and of the subject whose “internal behaviors” are being observed, as in psychoanalytic sessions, require better systems of recording and more adequate subsequent analysis. The acquisition and validation of behavioral data are the core operations of psychiatry as a science, but this does not deny the existence of inner variables expressed by verbal behavior.
Animal study and quantification
As scientists, psychiatrists are interested mainly in the developmental, adaptive, and maladaptive processes that human beings experience, no matter how “pure” or “basic” their image of science may be. But the large number of variables and parameters involved in natural existence has inordinately complicated human research in increasing degrees as sophistication about the timing of responses and feedback processes among variables has developed. As a result, we are often compelled to approach human problems indirectly through animal experimentation.
Mathematical and statistical overemphasis has thereby become a danger modern psychiatry should avoid (Langer 1942). It did, however, succumb to a greater danger when the majority of psychiatrists became entrapped in the fascination of inferences elicited from dyadic observer-participant studies and became involved in psychodynamic stereotypes. There is still an area of scientific behaviorism that is properly the focus of psychiatry, requiring observations or “witness” and subsequent quantitative analysis. Advancement of psychological and psychiatric knowledge requires a combination of observation, description, depth interviews, and experimentation. There is no need for antagonism between the proponents of these complementary methods or between behaviorists, psychoanalysts, and phenomenologists (Wann 1964).
One of the first great advances in the field of psychiatry, as in all sciences, was the classification of a chaotic descriptive group into nosological entities. These carried with them the implication of specific causes, a course, and final result of so-called diseases of the mind. Necessary though this classification was at the beginning of modern psychiatry, it has created many difficulties. Although the etiological factors in most of the classified entities are far from known, classifications led to stereotypes, especially in terms of malignancy and susceptibility to therapy.
Gradually over the years, psychiatrists tried to make a classification that was less rigid and medically oriented and, instead, more dynamic and concerned with processes. The current official classification is much better than the previously fashionable ones but still represents disorders of mental functioning in terms of disease stereotypes. The neophyte in the field considers each entity as a disease and develops a mental image of its course and prognosis that is far from valid.
The most ambitious attempt to alter this classification has been made by Karl Menninger (Menninger et al. 1963), who has discussed mental disturbances in terms of coping with stress. Coping devices are sometimes successful but at other times are ineffective. One can conceive of the results as a series of dysfunctions in increasing order of disturbance. It is such a “process” type of classification that enables the psychologist and social scientist to make some kind of reasonable correlations with related variables within their fields. It is also this kind of “process” classification that enables us to speak of types of psychological treatment, no matter from which school they may stem, in terms of phases of dyscontrol and attempts at reinstitution of coping devices. For some time psychiatrists have been less interested in diagnostic labels and more concerned with the dynamic processes involving the individual which lead to his failure in adaptation; they have focused on the coping devices and the reasons for their lack of success, and in therapy they have sought to enable the individual to regain a more comfortable equilibrium.
Dynamic approaches to the etiology of many degenerate diseases not caused by trauma or bacterial invasion deal with the unconscious conflicts that are not expressed directly through the somatic nervous system but that result in physiological disturbances in organs innervated by the autonomic nervous system. Among these are hypertension, peptic ulcer, rheumatoid arthritis, migraine, and colitis. A promising breakthrough occurred in the 1920s and 1930s, when a specific repressed emotional constellation was postulated for each of the so-called psychosomatic diseases: peptic ulcer was associated with passive dependency, hypertension with chronic repressed rage, etc. However, this practical application broke down because emotional specificity could not be confirmed. Actually, specificity is a complex and holistic problem because of a large number of variables, including genie, early experiential, social, and other factors. In fact, the mind-body problem is theoretically at the same stage of nonresolution as it was two thousand years ago. It may be that a revolutionary concept is required regarding processes that link or identify the mental with the physical. For lack of better concepts, we are thrown back to operational research, in which more knowledge regarding psychophysiological processes can be acquired. The result may not be an elucidation of disease processes but a better understanding of the kinds of information communicated between the mental and physical process; a higher level of abstraction may be necessary before these basic systems of communication can be understood.
Fields of psychiatry
While psychoanalytic psychiatry, which focuses on internal dynamics, has attempted to reconstruct the libidinal experiences and the vicissitudes of the instincts in reconstructions of childhood experiences, Piaget (1937) has attempted to observe, describe, and classify actual childhood behavior in the process of development. Psychoanalysis has not developed a learning theory (Rapaport 1959) and, therefore, leans heavily on vaguely expressed concepts of conditioning (Pavlov 1873–1935). Piaget has stimulated research on child development to the point that it is becoming an independent discipline. Its application to psychiatry is still nebulous. There have been studies of transactions between mothers and infants in natural homes, and adult–child transactions in foundling homes and hospitals have been studied. Engel and Reichsman (1956) have been able to observe in a child with a gastrostomy changes in behavior and gastric acidity on the approach and departure of friendly or strange adults. The field of child development will become basic to our understanding of normal and pathological personality development. [SeeDevelopmental psychology; Personality, article onpersonality development.]
Concepts of normality. In the area of development, the absence of a substantive concept for definitions of normality presents considerable difficulty. The various concepts utilized in sociology, psychology, and psychiatry to define normality have been classified into four groups: normality as an average, normality as an ideal, normality as health, and normality as a process through stages of a lifetime.
The field of biological psychiatry has recently been revived many years after it was buried by the failure of neuropathology to link psychiatric syndromes with structural changes in the nerve cells of the brain. Constitutional differences have always been given lip service—for example, neurotic constitution, neurasthenia, Freud’s varying strength of the instincts, body types, and body inferiority. But these were static concepts lacking explanatory vitality and evidences of correlations. More recently, correlations between increased gastric secretion of pepsinogen and later development of peptic ulcer opened up a vast area of functional rather than structural constitutional differences.
Genetics. The development of scientific genetics with the breakthrough in the understanding of the genic codes transmitted by RNA revealed a wide range of genic differences. The suspicion has increased that schizophrenia is basically a genic enzymatic disorder, secondarily producing characteristic mental symptoms. The mental symptoms secondary to phenylketonuria have become the prototype of a constitutional psychiatry, just as syphilis of the brain was a prototype of a neuropathological psychiatry. [See Mental disorders, articles ongenetic aspectsandbiological aspects.]
Neural mechanisms. Discovery of a reticular activating system and the connections of the limbic or visceral brain focused interest on the higher levels of emotional control previously considered to reside in the hypothalamus. A succession of investigations revealed the role of the constituent parts of the visceral brain in emotional control and release. The new neuroanatomy and neurophysiology changed our concepts of brain function, extending them even to discoveries of sleep mechanisms and the functions of dreams. At the same time, advances in steroid chemistry have enabled us to observe the relations between brain physiology and the endocrine systems that respond to or are antecedent to anxiety, panic, anger, depression, and emotional confusion. [SeeNervous system; see also Interdisciplinary Research . . . 1962.]
The field of psychopharmacology constitutes a bridge between the biological and psychological approaches to healthy and disturbed behavior. Since the discovery of the tranquilizing and later the energizing drugs utilizable for the treatment of psychoses, the custodial state hospitals have been revitalized and chronic “untreatable” patients have been given appropriate attention, resulting in an increased rate of discharge and prolonged maintenance in the community of previously institutionalized psychotics (Uhr & Miller 1960).
The primary gain, however, has been an added stimulus to the study of brain chemistry and endocrinological and metabolic factors involved in behavior of individuals in group living. The bridging function of psychopharmacology is in the process of intensive investigation. [SeeDrugs, article onPsychopharmacology. ]
Model psychoses. Attempts have been made to utilize the effects of psychedelic drugs, such as LSD-25, as model psychoses. Similarly, the behavioral changes temporarily achieved by isolation and sensory deprivation resemble natural appearing disturbances. By far the most informative models appear in animal research dealing with prevention or early interruption of the symbiotic relationship of infant and mother. Prevention induces behavior similar to human schizophrenic “symbiotic” psychoses; interruption induces behavior resembling that of “borderline” patients, who, although not psychotic, have extremely attenuated affective relationships with human objects (Harlow & Zimmermann 1959).
The Pavlovian theory of conditioned reflexes and their influence on behavior, emotions, and thinking has extended beyond the Soviet Union and provides another such model (Pavlov 1873–1935). Facilitation, extinction, reinforcement and conflict are terms that can be translated into the language of psychoanalysis. More recently, psychiatrists have been utilizing reinforcement techniques in an attempt to help human patients overcome their inhibitions and anxieties (Gantt 1958).
Social psychiatry has recently blossomed into prominence through the interest of sociologists (Parsons & Bales 1955) and anthropologists in health and mental illness. Since psychiatry, in general, is concerned with persons and their interactions and considers that a person is the resultant of physiological, psychological, and situational factors, social psychiatry is derived from fractionating the total field.
Social psychiatry includes studies of the family, group, community, society, and culture. In general the field attempts to explore social systems and their effects on psychiatric processes—how the social matrix contributes to the cause, course, and results of mental illness. It is also the study of the effects of mental illness on social systems of various sizes.
Impressive diagnostic and therapeutic research on the family is being conducted. Emphasis is shifting from intrapsychic processes to a group-oriented approach. Both normal and disturbed families are being studied in the interpersonal rather than personal context, and families are being studied as systems rather than as conglomerations of individuals. Such research, however, is still utilizing a patchwork of systems theory, cybernetics, and information theory.
Group studies have been conducted in therapeutic settings, but group therapy is a vague and poorly defined ubiquitous term applied to any process observable in groups. Only lately have the principles of small-group dynamics been applied.
Community psychiatry is a relatively new venture that crystallized rather suddenly with both the increased cooperation between hospitals, clinics, and halfway houses and the merging of community aspects of prevention and rehabilitation (Bellak 1964). Communities are poorly defined as “clusters of people having a common destiny.” Community psychiatry deals with a wide variety of relationships among community social agencies, resources, clinics, and hospitals, and studies a wide variety of administrative, therapeutic, and research personnel. However, it lacks both theory and operational methods. There is no specific discipline and certainly no community psychiatrist knowledgeable enough to encompass the whole sector, including a broad network of agencies. At present, community psychiatry is an organizational concept.
Since psychiatric phenomena are social in that they arise from a social matrix, are precipitated, and flourish or decline under various social conditions (that is, have an epidemiology), and since therapy depends on social and cultural factors, interest in contributions to etiology from the social sciences, although late and naive, is now flourishing. If we ever have anything to contribute to prevention, it will be through widespread social education at all levels. If therapeutic efforts are not to be limited to a few, there will have to be an increased interest in methods of understanding and eventually in treatment of family, group, and societies, based on our understanding of the individual but not a direct extension of it. For these reasons, the education of psychiatrists will require extensive broadening, if not to widen the extent of their functions, at least to facilitate the cooperation of psychiatry with psychology, sociology, and anthropology.
Roy R. Grinker, Sr.
Alexander, Franz G.; and Selesnick, Sheldon T. 1966 The History of Psychiatry. New York: Harper.
Bellak, Leopold (editor) 1964 Handbook of Community Psychiatry and Community Mental Health. New York: Grune.
Cameron, Norman A. 1963 Personality Development and Psychopathology: A Dynamic Approach. Boston: Houghton Mifflin.
Dewey, John; and Bentley, Arthur F. 1949 Knowing and the Known. Boston: Beacon.
Engel, George; and Reichsman, Franz 1956 Spontaneous and Experimentally Induced Depressions in an Infant With Gastric Fistula: A Contribution to the Problem of Depression. Journal of the American Psychoanalytic Association 4:428–452.
Gantt, William H. 1958 Physiological Bases of Psychiatry. Springfield, Ill.: Thomas.
Goldstein, Kurt (1934) 1939 The Organism: A Holistic Approach to Biology Derived From Pathological Data in Man. New York: American Book. → First published as Der Aufbau des Organismus.
Grinker, Roy R. Sr. 1961 The Physiology of Emotions. Pages 3–25 in Symposium of the Kaiser Foundation Hospitals in Northern California, Third, San Francisco, 1959, The Physiology of Emotions. Edited by Alexander Simon, Charles C. Herbert, and Ruth Straus. Springfield, Ill.: Thomas.
Grinker, Roy R. Sr. 1964 Psychiatry Rides Madly in All Directions. Archives of General Psychiatry 10:228–237.
Harlow, Harry F.; and Zimmermann, Robert R. 1959 Affectional Responses in the Infant Monkey. Science 130:421–432.
Harvard University, Commission to Advise on the Future of Psychology at Harvard 1947 The Place of Psychology in an Ideal University. Cambridge, Mass.: Harvard Univ. Press.
Hendrick, Ives (1934) 1958 Facts and Theories of Psychoanalysis. 3d ed. New York: Knopf.
Interdisciplinary Research Conference, University of Wisconsin, 1961 1962 Physiological Correlates of Psychological Disorder. Edited by Robert Roessler and Norman S. Greenfield. Madison: Univ. of Wisconsin Press.
Kallen, Horace M. 1934 Psychoanalysis. Volume 12, pages 580–588 in Encyclopaedia of the Social Sciences. New York: Macmillan.
Kraepelin, Emil (1917) 1962 One Hundred Years of Psychiatry. New York: Citadel Press. → First published in German.
Langer, Susanne K. (1942) 1961 Philosophy in a New Key: A Study in the Symbolism of Reason, Rite, and Art. New York: New American Library.
Masserman, Jules H. (1946) 1961 Principles of Dynamic Psychiatry. 2d ed. Philadelphia: Saunders.
Menninger, Karl; Mayman, Martin; and Pruyser, Paul 1963 The Vital Balance: The Life Processes in Mental Health and Illness. New York: Viking.
Munroe, Ruth L. 1955 Schools of Psychoanalytic Thought. New York: Dryden.
Murphy, Gardner 1947 Personality: A Biosocial Approach to Origins and Structure. New York: Harper.
New York Academy of Medicine, Committee on Public Health 1957 Integrating the Approaches to Mental Disease. Edited by Harry D. Kruse. New York: Harper.
Parsons, Talcott; and Bales, Robert F. 1955 Family, Socialization and Interaction Process. Glencoe, III.: Free Press.
Pavlov, I. P. (1873–1935) 1957 Experimental Psychology and Other Essays. New York: Philosophical Library. → First published in Russian.
Piaget, Jean (1937) 1954 The Construction of Reality in the Child. New York: Basic Books. → First published in French. Also published by Routledge in 1955 as The Child’s Construction of Reality.
Rapaport, David 1959 The Structure of Psychoanalytic Theory: A Systematizing Attempt. Pages 55–183 in S. Koch (editor), Psychology: A Study of a Science. Volume 3: Formulations of the Person and the Social Context. New York: McGraw-Hill.
Rennie, Thomas A. C ; and Woodward, Luther E. 1948 Mental Health in Modern Society. New York: Commonwealth Fund.
Schneck, Jerome M. 1960 A History of Psychiatry. Springfield, Ill.: Thomas.
Uhr, Leonard; and Miller, James G. (editors) 1960 Drugs and Behavior. New York: Wiley. → A general reference book.
Wann, T. W. (editor) 1964 Behavior and Phenomenology: Contrasting Bases for Modern Psychology. Univ. of Chicago Press.
Child psychiatry is a subspecialty of medicine, and, as in other subspecialties of medicine, its practitioners are trained in the “parent” specialty to which it belongs. To be officially certified in child psychiatry (in accordance with the policy of the American Medical Association, the American Psychiatric Association, and the American Academy of Child Psychiatry), the candidate, after receiving his M.D. and completing his general hospital internship, must have two years of training in adult psychiatry—all preliminary to training in child psychiatry. Furthermore, the teaching staff of the institution at which the candidate is trained in child psychiatry must include psychologists and psychiatric social workers who work in collaboration with the child psychiatrists on the staff. Special qualifying examinations—a recent requirement— are held yearly by the American Board of Psychiatry and Neurology; the first examinations were given in 1959.
The history of this combined staff of psychiatrists, psychologists, and social workers, a distinctly American contribution to the field of child psychiatry, will form the major portion of this discussion. Its development in the United States is intimately related to the mental-hygiene and the child guidance movements, both American innovations, and to the juvenile court. Although child psychiatry was bound to develop into a special field of its own, both in the United States and abroad, it would probably have done so at a much slower pace without the impetus of events in the United States, beginning in 1909 with the study and treatment of delinquents in Chicago by William Healy and with the emergence of the mental-hygiene movement.
Until the nineteenth century the presence of children, however few, in mental hospitals seemed to excite little interest on the part of physicians, to judge by the small number of articles on this subject. Benjamin Rush—probably the first American psychiatrist and certainly the first one to write a standard reference book on the subject, Medical Inquiries and Observations Upon the Diseases of the Mind (1812)—made no mention of children (see also Whitehorn 1944). Rush’s work was based largely on observations made over the years on psychotic patients who were confined to a separate section (opened in 1752) in the Pennsylvania Hospital. He described a few cases of psychoses in children that he attributed to disease of the brain.
Hospitalization of the insane was started in the United States in 1751, and that is regarded as the beginning of psychiatry as a medical specialty in the United States. This was three to four decades before Rush or Philippe Pinel (of France) or Peter Frank (of Germany) lectured or wrote on “diseases of the mind.” It is surprising that so many years were to elapse before child psychiatry evolved.
In the first 45 years of publication of the American Journal of Insanity, 1844–1889, not one article that appeared had any reference to children. A review in 1883 of all the previous literature on mental illness in children contained 55 references (see Kanner 1961).
The paucity of studies by psychiatrists of mental aberrations in children, a lack which lasted for so long a time, requires some explanation. Although lectures on mental disorders were first given to medical students in this country in 1791 by Rush at the University of Pennsylvania, a regular course of study in psychiatry as part of the medical curriculum was not given in the United States until 1863, when one was offered by the Harvard Medical School.
In general, mental hospitals were very large, and, according to Adolf Meyer, the psychiatrist’s job “was then as it still is in many places an institutional and legal task” (1928). There was little opportunity for intensive studies. Children were not accepted in mental hospitals unless they were diagnosed as psychotic. There were few such cases in mental hospitals then, and there are still but few today. According to Malzberg (1959), in 1950 first admissions of children under 15 years of age to all mental hospitals in the United States accounted for only about one per cent of all such admissions. (Most of the children in special wards today are not psychotic.) Gillespie (1939) also found that out of 21,000 first admissions to a number of mental hospitals in different parts of the world, about one per cent were children diagnosed as psychotic. Nevertheless, the finding of such cases (largely schizophrenic and manic-depressive) led to a growing interest in the psychopathology of childhood, and although this interest was strongly influenced by an organic bias, at that time so firmly held by hospital psychiatrists, it advanced neurological research in child psychiatry in a valuable way.
As Gillespie noted, the incidence of childhood psychoses is very likely larger than statistics show, since many possibly psychotic alterations of mood and behavior in children are regarded as normal by their parents. Besides, a child is less likely to cause as much trouble through psychotic behavior as an adult is, and hence the child is less likely to be referred to a hospital. He is also more likely, in the case of a dementia, to be regarded as retarded rather than psychotic. It should be added that the dominance of a purely organic, largely a neurological, point of view was aided by the severity of the pathology seen, whether in mental deficiency or in psychosis. [SeeMental disorders, article onepidemiology.]
In the literature of medicine before the nineteenth century there are a number of case records and essays that present several ideas thought to be of much more recent origin. No doubt historical research will discover many more. A number of these are discussed by Alexander Walk (1964), among them a study of fear in dreams, a study of sleep disturbances (one by C. Rollins in the fifteenth century, the other by Thomas Phaer in the sixteenth century), a study of the psychotherapy of stuttering by “driving out” the emotion of fear (written by Hieronymus Mercurialis in the sixteenth century), an essay on “the medical education of children” in which the problem of the jealousy of infants is discussed (written by Brouzet in 1754), and a day-to-day account of a childhood psychosis and an etiological classification of mental aberrations that includes, besides organic causes, psychological ones like “reproof in school” and any incident causing loss of temper (written by William Perfect in 1803).
Starting in the mid-nineteenth century there was a spurt in publication (see Kanner 1948). Books were written on the psychiatry of childhood, and in the latter half of the nineteenth century numerous studies were published about child neurology, mental deficiency, child development, mental measurement, and education—all subjects relevant to child psychiatry.
Édouard Seguin, a French psychiatrist dealing primarily with problems of mental deficiency and education, had a significant influence upon child psychiatry. He studied with J. M. G. Itard, who originated the method of “sensory training” still utilized in the Montessori schools. Itard is best known for his book Wild Boy of Aveyron (1801), in which his method of “sensory training” was described fully in the discussion of his attempt to educate a boy, mute and apparently “wild,” who was captured in the woods by a party of hunters. After escaping from a home, the young savage was placed in a hospital and in 1800 was transferred for scientific study to Itard, then a physician at the institution for deaf mutes in Paris. Seguin further developed the method of sensory training.
Seguin also studied under the psychiatrist Felix Voisin at the Bicetre in Paris. Voisin was far advanced for his day. He worked out a method of “medical education” that he called orthophrenic treatment, which was to be adapted to four categories of children: feebleminded children, children with difficulties attributable to faulty education, children with character difficulties since early childhood, and children born of insane parents and hence considered to be predisposed to nervous maladies. He founded a private institution that closed after a decade, and he later become physician to the annex of the Bicetre in Paris dealing with feebleminded children. Seguin was on his staff there. Through the influence of Voisin and Seguin, doctors and teachers worked together in institutions for the feebleminded.
In Austria, J. D. Georgen, physician and teacher, applied Voisin’s method, under the name Heilpädagogik (see Walk 1964), to psychotic children and to a large variety of disturbed children, besides defectives. The development of “remedial training” remains the contribution of the field of education to child psychiatry in Austria and Germany.
Through the invitation of Samuel G. Howe, who founded in Massachusetts the first experimental school for the feebleminded in the United States, Seguin came to America in 1848. There he introduced the method derived from Itard and Voisin (see Lowrey 1944). By 1880 there were 15 such institutions in the United States. Howe was also familiar with the methods used by the Swiss physician Jean-Louis Guggenbiihl in the training of cretin idiots.
In 1867 Henry Maudsley published The Physiology and Pathology of the Mind. In a later edition he was the first, according to Alexander Walk, to include in a book on mental disease a chapter on the insanity that may occur in early life. In this chapter he noted the importance of the instincts and of childhood aggression and sexuality.
Emminghaus’ Die psychischen Storungen des Kindesalters (1887; “Psychic Disturbances of Childhood”) includes psychological causes besides the usual pathological ones. It includes also methods of psychotherapy. Emminghaus urged a collaboration of psychiatry and pediatrics.
The development of outpatient clinics was an important factor in the early development of child psychiatry (and also of neurology and general psychiatry). It meant expanding psychiatric service and including cases that were not extreme. The first outpatient clinic was established at the Philadelphia Hospital for Orthopedics in 1867 and included defective children among its patients. The first outpatient clinic at a mental hospital was opened in 1891, under the direction of Howe. The patients were mostly children. Howe’s successor was Walter Fernald, a leader in the study of mental retardation. Fern aid’s outpatient clinic accepted many children whose problems were not limited to mental retardation; indeed, many whose problems are typical of referrals to child guidance clinics today (Fernald 1920; Stevenson 1944; Abbot 1920).
G. Stanley Hall
G. Stanley Hall, an American psychologist, started the first journal of child psychology in 1891 (Pedagogical Seminary) and also the first society of child study, in 1894. Some studies made at this time, especially those of European origin (for example, those by Sully of England and Perez of France), including some biographical accounts of infants, remain of value today [see the biography ofHall; see also Hall 1907; Gesell 1930].
Thus, it is clear that child psychiatry began to develop long before child guidance came into being in the United States or elsewhere. However, the child guidance movement gave a great impetus to the development of child psychiatry, especially in the United States (Glueck 1930; Crutcher 1943; Healy 1915; Bunker 1944; Levy 1947; Lewis 1959; Stevenson & Smith 1934; Lowrey 1944; Kanner 1948).
Healy and the child guidance movement
The child guidance movement began with William Healy’s Juvenile Psychopathic Institute (Healy & Dummer 1909; Healy & Bronner 1948). In his account of the early years of the movement, Healy states:
. . . there was one central and often disastrous weakness in the proceedings [of the juvenile and municipal courts]: The individual before the court, given at most only a physical examination, was not in the least known with regard to his essential nature. Nor was anything known as to why he was a delinquent. Nevertheless, judgment was passed and the type of penalty or supposed treatment that a court can order was prescribed. How, these observers argued, can a judge or anyone else, laboring under such a handicap, possibly prescribe wisely for the individual who, if placed on probation, needs some special form of treatment or incentive to help him mend his ways; or should have some particular type of institutional training or segregation?
In a neurological clinic I had long been finding that the symptoms of numerous young patients as given by relatives included complaints of conduct difficulties. Many of these—head injury cases, choreics, epileptics, or hysteria—were reported over-restless, aggressive disturbers of the peace at home or at school, truants, runaways, or involved in stealing or sexual misbehavior. Some were already on probation from the juvenile court and others were soon taken there charged with delinquencies that led them to be sent to the Parental School or to what was . . . [euphemistically] termed a training school. To me in that clinic it seemed that the handling of these young people largely by punitive measures, whether in the home, school, or court, was so far removed from common sense application of scientific knowledge to the treatment of human beings that it savored of the dark ages of man’s dealing with his fellowmen. And on occasion I publicly said as much.
. . . relatives would come to the detention home and from interviews with them we could ascertain many things that we needed to know—heredity, developmental histories, personality peculiarities, family interrelationships, and much else. Then, besides the possibilities of studying the youngsters themselves during their period of detention, we could obtain facts from the school about their progress and conduct in that setting.… If resources for treatment were available, with better knowledge of them something better might be done to check delinquent behavior tendencies which, as everyone already knew, all too frequently led to criminal careers. . . .
No such clinic existed. The only places I found where even psychological testing was added to a physical examination were Witmer’s clinic for retarded children at the University of Pennsylvania, and Goddard’s laboratory for mental measurement of the feebleminded at Vineland. Interestingly enough, the various theories offered in possible explanation of delinquency and crime were none of them based on actual study of cases. Some original methodological suggestions for us were made, particularly by Thorndike. As for any scientific studies of the bases of children’s behavior tendencies, it was said that we in Chicago would have to blaze a new trail. . . .
The first psychologist with me was Dr. Grace M. Fernald. We two and our secretary comprised the paid staff. At that time and until years later the psychiatric social worker did not exist, but in all fairness it must be stated that some of the social workers who helped us to study cases and even do some treatment with the families had developed appreciation of psychiatric implications. . . . Our social work, whatever it amounted to, was done then by certain workers from other agencies and by well-trained probation officers. Relatives came with surprising willingness for interviews with me; indeed some of the earliest requests for our services came from parents with a child in court, and even lawyers asked the judge to continue a case in order that the new clinic might find out what was the matter with their client’s child that he should be behaving in a delinquent fashion.
It was our early decision to confine our research to delinquents who had committed offenses repeatedly. Rightly or wrongly these seemed to offer the greatest challenge for treatment by the court or in any other way. First offenders might have committed casual offenses that had little relationship to their nature or needs, and little significance for their future conduct. We took such cases as we could within our working limits, cases referred by the judge or probation officers, by families, and occasionally a policeman would bring a boy to us. (Healy & Bronner 1948, pp. 4–6)
In the rest of his account Healy showed how he disproved the theories of Lombroso and others that ascribed delinquency and crime to heredity (based on anatomical “stigmata of degeneracy”) and to causes such as enlarged tonsils and adenoids; focal infections; uncorrected refractive errors; peripheral irritations—for example, tight foreskin, impacted teeth. Healy began to look down on all theories of organic “causes” of delinquencies (1915). In time he admitted overlooking some cases in which organic factors were paramount, as in epidemic encephalitis, in conditions causing partial asphyxiation, and (in one case) the pathological effects on the personality of severe burns in early childhood. [See the biography ofLombroso.]
Healy had been well trained in neurology; he was an associate professor of nervous and mental diseases at the Chicago Polyclinic for 13 years. The physical examination was a routine procedure in his work with children. As time went on he paid less attention to neurological studies, being more absorbed with the social environment, the patient’s “own story,” psychological testing—to which he made important contributions (especially Healy’s Picture Completion ii)—and psychoanalysis. In time he recognized anew the importance of the neurological examination as neurology and neurophysiology became more and more relevant to child psychiatry.
In Healy’s early years, the important names in psychiatry were Adolf Meyer, Alfred Binet, and Sigmund Freud (Levy 1947; Whitehorn 1957; Kanner 1961). That is the order, I think, of their impact chronologically in the field later to be known as “child guidance.” Through Meyer, psychiatry had become liberated from the purely symptomatic approach to the study of man. The patient was no longer a collection of symptoms. Meyer presented to psychiatry a conception of man as an integrated, purposeful human being of whom the psychiatrist had previously lost sight. Healy benefited from Meyer’s restoration of man’s place in psychiatry. [See the biography ofMeyer.]
When Healy started his work in Chicago, Alfred Binet had already opened up the new field of mental measurement through his studies of school children in the city of Paris (Pressey & Pressey 1922; Terman 1919). Methods of quantitatively estimating intellectual capacities were to develop into a new science. Of importance in relation to Meyer’s concept was a further accentuation of the patient as the primary point of orientation. The determination of a child’s intelligence, which came to mean his capacity for schooling, was based on the actual study of the child himself by means of a standardized procedure, rather than on pronouncements by authorities derived from clinical impressions. Healy started at a period when testing devices, to which he contributed greatly, were already appropriate tools of psychiatric study. The enormous influence of the tests of Binet and Simon and also Seguin’s pedagogical ideas are clearly delineated in Benjamin Baker’s bulletin “History of the Care of the Feeble-minded.” [SeeIntelligence and intelligence Testing; and the biography ofBinet.]
Freud’s contribution was the energizing force in psychiatry. It marked the beginning of significant motivational studies. In Healy’s early work their impact was revealed in his book Mental Conflicts and Misconduct (1917). In The Individual Delinquent (1915), the classic book in the field, Healy wrote that he found the following psychoanalytic tenets of value: (1) that conduct is unconsciously motivated; (2) that “much that is formative of character does not appear above the surface”; (3) that “experiences which come to the individual with a great deal of emotional context are likely to cause the greatest amount of reaction”; (4) that “experiences . . . related to sex life [caused the] ‘strongest and subtlest reactions’”; and (5) that psychic traumata experienced most frequently in young children may be unknown to the parents (pp. 119–120).
The particular traits of Healy’s personality that gave shape to the new field were his receptivity and democratic nature (Levy 1947). He was receptive to knowledge from any source. He was free from the typical prejudices (so common in the psychiatrists of those days) against psychological tests and against anything that could be labeled Freudian. He was free also of the authoritarian attitude of the doctor that makes teamwork with co-workers in allied fields impossible. Actually, out of his alliance with the clinical psychologists and the social workers, a new group emerged. For the first time the psychiatrist, the psychologist, and the social worker worked together as an authentic unit, and problems of personal prestige were forgotten.
Starting with Healy, psychiatrists who worked in the field of delinquency and crime became increasingly aware that they were in a new field, one in which social problems and social agencies were of primary concern. The Institute for Juvenile Research in Chicago, the heir of Healy’s Juvenile Psychopathic Institute, became part of a large state organization involving penal, correctional, and other institutions, all under Herman Adler, the state criminologist (Adler 1926). Karl Menninger was the first to interest Herman Adler and Franwood Williams, then director of the National Committee for Mental Hygiene, in forming an association of the representatives of the neuropsychiatric or medical view of crime that would include the neuropsychiatrists primarily interested in what might be called medical criminology or disciplinary psychiatry or orthopsychics.
In January 1924 a committee of psychiatrists that was to become the American Orthopsychiatric Association was formed at the Institute for Juvenile Research in Chicago (Lowrey 1948). Of the names suggested for this committee “Social Psychiatry” was favored and then dropped. This was due to the belief that sociologists and social workers would regard such a field as belonging to them. The word “orthopsychiatry” was also chosen in preference to “social psychiatry” since the latter term, it was thought, stresses the idea of disease which was regarded as incidental to the general problem.
The other fields to which orthopsychiatry was closely related—clinical psychology, sociology, and social work—were thought of as sources of assistance. However, there were many clinics in which psychiatrists, social workers, and psychologists were then operating as equals. Furthermore, the original stress on delinquency and criminology gave way over a period of time to an increased emphasis upon the relationship between abnormal behavior and broader patterns of social behavior. The first annual convention of the American Orthopsychiatric Association was held at the Institute for Juvenile Research on June 10, 1924. William Healy was elected president. It is interesting that of the nine papers presented at that meeting only two dealt specifically with crime and delinquency.
The problem of the status of nonmedical people was an early issue. Those who held out for control by psychiatrists finally gave way. Amendments to the constitution of the society made provisions for other classes of members with voting privileges.
The fifth annual meeting of the association was held in New York City. There were 540 members registered. They represented 112 organizations from outside the city. There were registrants from 20 states and 5 foreign countries. The journal of the society was first issued in 1930 under the editorship of Lawson G. Lowrey. The 1965 meeting had eight thousand registrants. Of these, twelve hundred were members.
The mental-hygiene movement
In 1909, the year in which Healy began his work in Chicago, the mental-hygiene movement began (Deutsch 1937; 1944). It followed the publication (1908) of Clifford Beers’s book A Mind That Found Itself, an exposè of the brutal experiences suffered by the author when he was a patient in three different mental hospitals. Beers was an unusual combination of writer, organizer, and crusader. Through his initiative, the National Committee for Mental Hygiene came into being. Its goal, improving the care of the insane, soon expanded into the general field of preventive psychiatry. Later, through the aid of the Commonwealth Fund, it furthered the development of child guidance clinics. These were modeled after Healy’s Chicago Juvenile Psychopathic Institute and the Institute for Juvenile Research. A five-year demonstration of child guidance clinics started in 1922 in St. Louis. After each year’s demonstration it was hoped that the community would take over. In this sense no demonstration was ever more successful. By 1934 hundreds of child guidance clinics were established in the United States.
After the first five years of the demonstration clinics it had become all too clear that a special national teaching institute was necessary to train personnel—psychiatrists, psychologists, and psychiatric social workers—whose services could not be supplied in sufficient numbers by the clinics previously established. The Institute for Child Guidance was established in New York City in 1927 for the purpose of training and research (Lowrey & Smith 1933). In its six years of existence 50 psychiatrists and 289 psychiatric social workers went through a program of training there. The psychiatric social work students came chiefly from the Smith College School for Psychiatric Social Workers, started in 1918 as the first school of its kind, and the New York (now the Columbia) School of Social Work. Training of social workers in psychiatry began as an innovation of Adolf Meyer’s, at the turn of the century. It was brought into prominence by Elmer Southard of the Boston Psychopathic Hospital (see Southard & Jarrett 1922). The initial idea for such a school came from Southard, who at first was concerned to find social workers to serve as aides to psychiatrists in war service. The aides were able to schedule appointments and take histories. They could visit homes and prepare reports on the families of patients and, in general, about the child’s environment. While the psychiatrist worked directly with the patient—that is, the child—the social worker dealt with the mother and with other members of the child’s family. In this role he acted presumably under supervision of the psychiatrists. He gave counsel, information, and insight. When such methods were ineffective, he utilized various forms of psychotherapy. The role of social worker as therapist, especially as therapist in private practice, remains today a controversial issue (Lowrey & Smith 1933; Levy 1937; Witmer 1946; Group for the Advancement of Psychiatry 1948).
Child guidance and child psychiatry
The differentiation of child guidance and child psychiatry was easily made at first by the fact that a guidance staff always included a psychiatrist, a psychologist, and a social worker. Furthermore, child guidance clinics received their patients from juvenile courts and were never connected with hospitals. In contrast, child psychiatry was easily demarcated as a medical specialty, in the same manner as adult psychiatry. Healy’s work began as a search for psychopathology. Many of his case studies, however, were not in that field; they were examples not of psychosis or neurosis but of “maladjustment” as a result of the influence of the social environment, especially the child’s family and his companions. This environment produced certain antisocial attitudes. As Kanner has rightly emphasized, the special American contribution to child psychiatry is the recognition and study of attitudes (Kanner 1932; Glueck 1930; MacCalman 1939). This was probably facilitated by the fact that patients who showed evidence of mental deficiency or any form of severe psychopathology were not accepted in many child guidance clinics. Even when the field expanded beyond delinquency to all forms of “behavior problems” it was thought wise to limit patients to the milder cases.
The role of social agencies
Child guidance clinics like Healy’s Juvenile Psychopathic Institute had close relations with social agencies. According to Stevenson and Smith (1934), who were both closely involved with the development of the clinics, their functions were threefold: (1) to study and treat patients; (2) to stimulate the interest of other community agencies in prevention and treatment of behavior and personality disorders in children; and (3) to bring to the attention of the community the unmet needs of children.
Put in this way, the psychiatrist who, according to the original plan, was always the director of the clinic was not only a practitioner but was also cast in the role of community planner and leader. Stevenson and Smith stated also that the clinics should attempt child guidance only at those points where other agencies were unable to meet the child’s emotional needs. Presumably this involved a close relationship with other agencies and, as it turned out, the agency’s being able to select for guidance those children regarded as beyond its competence. This at least sharpened the problem for the agency in regard to selection of cases most suitable for the kind of service appropriate to its special skills. There was always some kind of adaptation to local problems, to differences in the personnel of social agencies, to their standards, and to their willingness to utilize and cooperate with the available child guidance clinics; there was also a testing period in which the usefulness of the new relationship was tried out.
Meanwhile, for various reasons, including economic ones, a number of social agencies took on the function of a psychiatric clinic without having a single psychiatrist as a permanent member of the staff. They utilized psychiatrists as lecturers or consultants who were useful in fulfilling their roles especially when a medical diagnosis was legally necessary for the admission of a child to a mental hospital. In some agencies the rule that the psychiatric social worker always be supervised in her case work by a psychiatrist was either withdrawn or complied with at the discretion of the worker. At times, psychiatrists also violated their function by making diagnoses without examining or even seeing the child, relying entirely on the psychiatric social worker’s case record.
Evaluation of child guidance clinics
Hardcastle, a British psychiatrist who studied the child guidance clinics in the United States from 1930 to 1933 and had been a student at the Institute for Child Guidance, found the widest variations in the original model and in methods of therapy (Hardcastle 1933). Besides visiting a number of clinics he received replies to a questionnaire from 12 clinic directors. He found that the “offspring” of psychiatry had taken many new directions and that “each year psychologists and other non-medical workers are gradually wresting it from the field of psychiatry.” The therapy was of all sorts, at one extreme psychoanalytic treatment of the child and each parent, at the other, purely didactic instruction.
Of the criticisms of child guidance clinics the most frequent are (1) its growing distance from the hospital and medical clinic, and (2) its rigidity (Bowman 1944; Levy 1952; Markey 1963; Murphy 1941).
As child guidance expanded it drew farther away from the hospital and into closer collaboration with many social agencies. Case referrals, as traced by Hardcastle for a representative clinic, were largely from the courts before 1920 (538 out of its first 600 cases); several years later the majority were from 31 other agencies (308 of its third list of 600 cases).
Child psychiatry as developed in hospitals started, according to Karl M. Bowman, for many years director of psychiatry at Bellevue Hospital in New York City, with the “dictum that a child is not to appear before a conference.” Bowman, after describing both the advantages of hospital settings for training in child psychiatry (1944), particularly at Bellevue Hospital, and the bed wards available for children and adolescents, was especially critical of the “stereotyped” requirements of child guidance clinics. Psychiatrists at Bellevue, however competent in child psychiatry, were not permitted to serve in child guidance clinics because a fully trained psychiatric social worker was not a member of the Bellevue teaching staff.
A number of referrals by psychiatrists in child guidance clinics had been made to psychiatrists in Bellevue in order to obtain a diagnosis. This is simply an illustration of the fact that the child guidance clinic dealt with a different variety of cases than those found in hospital wards. In the past, training for child guidance took place within the child guidance clinics. The more specifically psychiatric difficulties, for example, childhood schizophrenia, autism, dementia, severe emotional difficulties, severe retardation, anorexia nervosa, convulsive states, tics, and phobias, are relatively less commonly seen in a child guidance clinic. In the latter the more frequently seen cases are delinquency and other varieties of “behavior problems,” family relationship problems (for example, maternal overprotection, maternal rejection, sibling rivalry), so-called rearing problems, including “the everyday problems of the everyday child,” a special concern of Douglas Thorn’s Habit Clinic (Thom 1927).
Leo Kanner, the first person to develop a fulltime psychiatric service in a department of pediatrics (at Johns Hopkins Hospital in 1930), regarded “the cultivated estrangement from medicine” on the part of child guidance clinics and their “self-imposed limitation” in the selection of cases with favor because of “the great benefit derived from making certain types of children’s behavior problems a matter of community concern” (Kanner 1932). He regarded as the contribution of child guidance to psychiatry the broadening of the range of inquiry to include, in addition to the study of the home and the school, all influences outside the child, including the significant people in his environment—generally “interpersonal relationships.”
A second basic contribution is “multidisciplinary” collaboration. This influence was strongly felt by Kanner in his own clinic, in which, however, the selection of cases was not restricted to any particular type of difficulty.
Research in American child psychiatry may be traced in articles in the American Journal of Orthopsychiatry, which began in 1930. The contributors are mainly psychiatrists, psychologists, and psychiatric social workers, and the contributions have become more allied to psychiatry than to child guidance and tend to resemble such European journals as the French Revue de neuropsychiatrie infantile; the Swiss Zeitschrift für Kinderpsychiatrie (founded by M. Tramer in 1934 and now called Acta paedopsychiatrica); and the American Journal of Child Psychiatry, which was founded in 1962.
The trend of research is seen generally in a refinement and extension of the earlier studies on the influence of infantile experience on later growth, and in the study of every possible influence on the patient of all his human contacts, in single and composite form, as in family and cultural constellations. Clinical studies of syndromes and disease entities still continue in the historical tradition of medicine, from severe pathology to the mild “everyday problem.” In recent years there has been special interest in the biochemistry of behavior, brain physiology, neurology, drug therapy, family and group therapy, developmental psychology, projective tests, and the field of communication. There has also been an increase in the study of mental deficiency, childhood schizophrenia, residential treatment, and education therapy. [SeeDrugs, article onpsychopharmacology; Mental Disorders, article onbiological aspects; Mental disorders, treatment of, article onsomatic treatment; Mental retardation; Nervous system; Schizophrenia.]
Since about 1950 there has been an increasing number of child psychiatry clinics in hospitals and medical schools and an increasing collaboration with pediatrics and neurology. Child guidance clinics are becoming better grounded in psychiatry and psychodynamics. They remain, in keeping with their history and tradition, community-oriented, maintaining a special interest in problems of delinquency and school retardation, and, in general, in the psychiatric, psychological, and social aspects of community problems. The distribution of therapeutic functions among the members of the team remains a problem.
David M. Levy
[Directly related are the entriesClinical psychology; Mental disorders, article onchildhood mental disorders; Mental disorders, treatment of; Mental retardation; Social work. Other relevant material may be found inDelinquency, article onpsychological aspects; Developmental psychology; Infancy; Intellectual development; Intelligence and intelligence testing; Language, article onspeech pathology; Personality, article onpersonality development; Phobias; Reading disabilities; and in the biographies ofBinet; Meyer; Pinel; Rush.]
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Although the phrase “social psychiatry” is recent, the topic is not. Man has suspected for a long time that he could derange himself by his style of living and that the emotions engendered by interpersonal relations could lead to illness, including organic illness. The expressions “You will drive yourself crazy” and “You make me sick” were probably first uttered in all earnestness and without hyperbole in some now extinct cave-man tongue.
As a label, “social psychiatry” has not yet had sufficient clarity conferred upon it to permit exact definition. It is, however, becoming more and more commonly employed in referring to one, several, or all of a number of heterogeneous activities and orientations that have in common a focus on the interplay between social and cultural processes, on the one hand, and psychiatric disorders and mental health on the other. In this article I shall sketch first the total area of reference and then consider the main subareas to which some workers limit the label. These differences in usage reflect differences of trend, theory, action, and disciplinary view.
A general definition
Social psychiatry can be said to embody four major aspects: concern with people in numbers, concern with sociocultural systems, adaptation of social science knowledge, and transmission of psychiatric knowledge to the social sciences (A. H. Leigh ton 1960).
Concern with people in numbers
Social psychiatry focuses on problems of psychiatric disorder in populations. Questions are asked about frequency and distribution of people with disorders, about the causes of variation in these distributions, and about methods of control.
This perspective contrasts somewhat with that of clinical psychiatry, which places much greater emphasis on the individual patient and the problems of his particular diagnosis and treatment. But like clinical psychiatry, and like the physiological and chemical approaches to psychiatric disorder, there is in social psychiatry an ultimate concern for understanding the cause and prevention of disorder in persons. The individual is the basic unit, and social psychiatry as a field does not imply values that underestimate the importance of the individual. Rather, the importance of the individual is magnified by the number who exist in a state of mental and emotional difficulty.
By and large, those working in social psychiatry conceive of their primary responsibility as somewhat different from that of a practicing psychiatrist. There is less emphasis on a contractual type of understanding with particular individuals and more emphasis on an obligation to serve the welfare of a population or a subgroup within a population, such as a local community, an industry, a military unit, a school, or a family. The focus, however, remains on real people in real situations and not on an abstract entity such as the state.
The importance attached to people in numbers does not mean individual psychotherapy is played down, but it adds a corollary set of considerations: the possibility and desirability of altering those circumstances which can be shown to be a recurrent source of psychological disturbance.
Concern with sociocultural systems
Social psychiatry gives attention to understanding the patterns of values and sentiments, symbols of communication, interaction, work division, and social control through which human groups function. Just as the biological approach to disorder in human behavior leads to involvement with such matters as the functioning of the central nervous system and the structure of molecules, so here there is engagement with the functioning of various types of social systems. A social psychiatrist, for example, may find it important to know whether one culture as compared to another has a differential effect on the origin, precipitation, continuation, or relief of psychiatric disorders. He is thus led into questions of how culture is acquired and how its molding, directing, containing, and changing influences operate. Equally pertinent are various situations of stress, such as those occurring regularly and continuously in the lower socioeconomic levels of a society or those occurring more briefly but with greater intensity in disasters.
Adaptation of social science knowledge
As a consequence of its concern with sociocultural systems social psychiatry has an interest in the relevant discoveries and theories of the social or behavioral sciences for the purpose of applying them to the understanding and treatment of psychiatric disorders, to their prevention, and to the improvement of mental health generally. Finding himself confronted with social phenomena regardless of whether his approach is primarily action or primarily research, the social psychiatrist needs the facts and theories of anthropology, sociology, social psychology, ethology, political science, and economics.
The range of relevant fact, theory, and technique in these disciplines is, of course, very wide. It stretches from survey studies that attempt to grasp relationships in natural ongoing situations by means of statistical correlations to small-group investigations conducted on an experimental basis. A considerable amount of sifting and interpretation is therefore necessary.
At this point the reader may be inclined to ask who the people are who are engaged in social psychiatry. Are they the usual clinical team of psychiatrist, psychologist, and social worker with added training in the social sciences? Or are they social scientists working in the field of mental health? The answer is, of course, that they are both types. There are some interesting trends in the interrelationships of the disciplines, which will be discussed later.
The link between social psychiatry and the social sciences is more complex than a simple matter of the former drawing on the latter for what it needs. Social psychiatry has a role to play in the interpretations of social science findings for other branches of psychiatry, particularly the clinical, so that this knowledge can become part of teaching and, where appropriate, practice. In this there is continuity with the broader problem of the relationship of social science to the whole field of medicine.
Transmission of psychiatric knowledge
Conversely, social psychiatry is concerned with presenting the relevant discoveries and orientations of psychiatry to the social sciences so as to make contributions to theory and to improve understanding and actions directed toward human welfare. Psychiatry is able to make contributions to knowledge that go beyond the limits implied by its focus on individual health. Although this point of view has at times had wide acceptance, strong doubts about it have also been expressed. It seems worthwhile, therefore, to attempt to clarify the matter by stating a few core points.
The first point is that by definition the psychiatrist is an authority on psychiatric disorders and through experience and training has concepts and techniques for distinguishing such disorders from generally disagreeable behaviors and feelings. Consequently, he should have something to offer wherever psychiatric phenomena are relevant to theory building and research in the social sciences.
The second core point is that the psychiatrist has by virtue of his contact with patients a particular kind of access to the understanding of human motivation, both conscious and unconscious. While the claim can be overemphasized, and while there are certainly dangers in going too far with “psychiatrizing” normal behavior, it is also important not to minimize this potential. Major contributions to behavioral theory and to the framing of experimental tests have emerged from this source in the past and can be expected to continue in the future.
Third, the psychiatrist is oriented toward and experienced in dealing with human beings as whole entities. The demands of his work put before him both the opportunity and the obligation to see the individual as an ongoing integration of organic, psychological, and sociocultural processes.
The possibility of expanding the application of psychiatry’s insights has been for many people one of the attractions of social psychiatry. Rennie (1955) says that the field is concerned not only with the mentally ill but also with the problem of adjustment of all persons in society and with the factors that tend to damage or enhance their adaptive capacities. It assumes, he says, that most persons possess potentialities that have never been realized because of personal, emotional, or social interferences. Thus, social psychiatry attacks the whole social framework of contemporary living: it seeks to understand the dynamics of individuals seen in their total setting.
Some restricted definitions
Having presented, however sketchily, the largest area covered by “social psychiatry,” we may consider next some of the more limited ways in which the label is employed. One of the earliest uses referred to psychiatric social work. Although this use is no longer current it was doubtless a part of what Southard had in mind when he spoke of “social psychiatry” in the second decade of the present century (Southard 1919). It seems likely that he was the first to use the words in English, and one must add that some of his remarks make it clear that he was implying sociology as well as social work.
Most psychiatrists are apt to assume that social psychiatry is, despite its breadth and depth in subject matter, nothing other than a branch of psychiatry. It is often considered to be parallel to clinical psychiatry and what may be called “physiological psychiatry”—that is, the study of the organic processes underlying psychiatric disorders.
As might be expected, this view is not shared by many social scientists. They prefer to regard the field as a branch of a discipline, such as sociology, that is concerned with deviance and the effects of deviance on social process. In this orientation, social psychiatry is seen as a component in or a parallel to studies of delinquency, the use of narcotics, prostitution, suicide, and so on. In anthropology it may be looked upon as a way of studying cultural influences with particular reference to the interplay of personality and culture and to crosscultural comparisons on certain topics of interest, such as curing roles and rituals or cultural integration.
According to these views, then, “social psychiatry” is a name for a field that has autonomous status among the social sciences. Psychiatry is visualized as contributing some but by no means all of what is needed in terms of theory, method, and criteria for the study of the phenomena in question. In both research and action programs, the place of the psychiatrist is, in this framework, that of a specialist, one among several with technical skills to contribute.
This brings us plainly to issues of interdisciplinary rivalry as well as to matters of concept, theory, and method. Since such questions as “Who is entitled to head programs?” and “Should there be chairs of social psychiatry outside medical schools?” are apt to be of real concern, it is likely that divergent orientations of this kind will be with us for some time.
It has been advocated that “social psychiatry” be limited to describe research endeavors and that “community psychiatry” be used for enterprises concerned with action and the training of professionals for action (Bellak 1964; Goldston 1965). This division has been advocated in the hope of resolving some conflicts by using persons with clinical training to head mental health services and other activities aimed at prevention, while—depending on the nature of the problem, the institutional setting, and the particulars of individual training and ability—social scientists, psychiatrists, or clinical psychologists are used to direct research.
The usage outlined above has been vigorously attacked for drawing a line between action and research that is stultifying and unworkable. It is said that “community psychiatry” is merely a name for one of many areas of interest for the social psychiatrist. As such, however, the area embraces not only action and service but also teaching and research, in the manner customary for any subdivision of disciplinary subject matter. It is further pointed out that no reason exists for emphasizing the clinician as the director in community psychiatry action programs; on the contrary, social work, political science, or public administration may offer far better preparation and training for imaginative and effective development of the field.
Whether it lasts or not, the use of “community psychiatry” for action programs and “social psychiatry” for epidemiology, cultural comparisons, and other types of basic research has at present some currency. [SeeMental health.]
British and French definitions
In Great Britain there is also a lack of uniformity regarding the meaning of “social psychiatry,” but generally the term refers to social amelioration in the same sense as “social medicine” and is thus part of a broad philosophy regarding public responsibility for the handling of welfare problems. The emphasis is pragmatic, and action arises mainly from within the discipline of psychiatry. Research is, of course, performed, and social scientists have been drawn in, but the orientation is dominantly one of providing information that will help guide those programs concerned with such matters as rehabilitation, the employment of schizophrenics, and the analysis of “therapeutic communities.” It may be concluded, therefore, that what is called “social psychiatry” in Britain has more in common with what is called “community psychiatry” in the United States than it has with the definitions of social psychiatry discussed above (Jones 1952; Rapoport et al. 1961).
In France the term “socio-psychiatrie” appears to be used in a manner that approximates the more restricted definition of social psychiatry. The center of interest is research into the possibility that social factors play a major etiological role in the appearance of psychiatric disorder. Most of the French researchers are psychiatrists, but a great deal of work is nonetheless being conducted by social scientists in closely related areas (Bastide 1965; Encyclopédic Médico–Chirurgicale 1955).
An intervention framework
What has been said thus far is an attempt to summarize the present state of a complex emerging field, which has many crosscurrents and countercurrents. It depicts how things are rather than how a logical mind might arrange them. In the course of discussing these matters, R. N. Rapoport, an anthropologist with long experience in social psychiatry, has suggested (in an unpublished personal communication) the following:
The most fruitful way to look at social psychiatry is as an intervention framework. The “iatry” suggests intervention, and social psychiatry is the professional practitioners’ field that aims its intervention efforts at the level of social structure. Like individual clinical psychiatry and organic psychiatry, its aim is to heal ill individuals, to prevent others from becoming ill, and to assist all toward the realization of positive mental health. Clinical psychiatry seeks to do this [in] the direct one-to-one relationship [by] persuasion, transference interpretations, [and] interpersonal influence in the two-person situation. Organic psychiatry seeks to do this by altering biochemical substructures, etc.
Social psychiatry is supported by the basic sciences of the social science spectrum (sociology, anthropology, social psychology, economics, history, political science). Clinical psychiatry is supported by the psychological sciences (the various approaches to psychology, from behaviorism through symbolic interactionism). Organic psychiatry is underpinned by the basic sciences of biology and the physical sciences directly geared to biology.
When individual psychiatrists, of whatever persuasion, do research, they are participating in the basic science field that underpins their intervention specialty. One would call such individuals research social psychiatrists, or research clinical psychiatrists, or research organic psychiatrists to distinguish them from their colleagues who are mainly concerned with intervention as a focal professional activity. To the extent that the individual does not interest himself in interventions aimed at treating individuals, either as a professional practitioner or in terms of the goals in view for his research,… I would not think of him as a psychiatrist at all, but as a person who had psychiatric training but who was . . . something else—a biochemist, a sociologist, or a psychologist. The problem of commitment to a type of goal is crucial in denning a person’s professional identity.
As in medical research, the central targets in social psychiatry are treatment, prevention, and the discovery of causes. The topics are placed in that order because, contrary to what is sometimes supposed, successful methods for treatment and prevention have frequently been known long before the relevant causes were discovered—vaccination for smallpox being a notable example. In fact, much research is not strictly causal in its orientation but rather is concerned with probing the efficacy of steps intended as corrective.
Nevertheless, cause remains a central, although difficult, focus. This difficulty is manifest in the frequency with which research questions are posed that have answers already determined through built-in assumptions. It would seem that in psychodynamic issues, one man’s theory is another man’s fact. At the present stage of knowledge, therefore, much research effort must still be directed toward the primary task of observing, studying, and sorting phenomena in order to produce questions that can be answered with demonstrable public evidence and replicable procedures. As part of this process it is important for research workers to visualize the causes of psychiatric disorder not only in terms of multiple origins that range from the psychological to the organic but also in terms of factors that precipitate overt impairment and favor its perpetuation. From some points of view the critical question may be less “What are the psychodynamic roots of a neurosis?” and more “What are the factors which evoke certain patterns of feeling and behavior to such an extent that these are seriously disturbing to the person, to others, or to both?”
Thinking along this line has led in recent years to the formulation of such concepts as the “social breakdown syndrome” (Gruenberg 1966), the “culture of poverty” (Lewis 1961), and “sentiment patterns characteristic of sociocultural disintegration” (Hughes et al. 1960; D. Leighton et al. 1963). The social breakdown syndrome, in which withdrawal and hostility in patients are prominent features, is considered the result of social processes in large hospitals for chronic patients and to be superimposed on the schizophrenic, depressed, or senile condition or whatever it is that has led to hospitalization. The syndrome is regarded as serious because it is believed to compound disorder, prevent recovery, and cause severe deterioration. The culture of poverty and sentiments characteristic of sociocultural disintegration refer to very similar states of feeling and behavior in nonpatients living in deprived social systems of natural communities rather than in the back wards of hospitals.
The congruence of these independently developed concepts is very striking, and it raises a number of important questions. For example, to what extent is the epidemiological finding of high prevalence of psychiatric disorder in low socioeconomic groups a manifestation of the social breakdown syndrome? And further, since large chronic mental hospitals draw disproportionately from low socioeconomic groups, to what extent is the presence of the social breakdown syndrome in these institutions due to many patients already having the syndrome at the time they enter?
Looking at the matter from a different point of view, it may be asked whether one can transfer to communities what is learned experimentally in hospitals about the kinds of social processes that produce and prevent the social breakdown syndrome. This concern obviously marks a confluence point of the processes at work in both individual and societal functions.
Confluence points of this kind are characteristic of research in social psychiatry. The range of the whole field has already been outlined, but it may be further illustrated by listing more specific topics, such as epidemiology; transcultural and crosscultural psychiatry; culture and personality; social processes in psychiatric hospitals and other related therapeutic institutions; mental health and morale in the armed services, industry, and other nontherapeutic organizations; small-group studies, particularly those concerned with group psychotherapy; the relationships of various social roles to mental health; family patterning and therapy of families as groups; experimental studies of mothers and young among animals and of animal populations considered as social systems. It is of course not possible to deal with all of these in the space of this article, but four may be selected as examples for discussion: epidemiology, transcultural and crosscultural psychiatry, social process in hospitals, and small-group studies.
Epidemiology is one of the main avenues by which social psychiatry has sought clarification of its questions (Lin & Standley 1962; Hoch & Zubin 1953; Hollingshead & Redlich 1958; Hughes et al. 1960; Jaco 1960; The Midtown Manhattan Study 1962–1963; D. Leighton et al. 1963; Rennie 1955). Mapping the distribution, frequency, and types of disorders is basic to the understanding of environmental influences. It is of interest, therefore, to find that virtually all studies show marked variation in disorder prevalence in relation to demographic and social characteristics such as age, sex, marital status, socioeconomic level, and degree of sociocultural disintegration. In other words, numbers of relationships have emerged that suggest targets for more crucial investigation aimed at distinguishing antecedents from consequents.
To do this one must define and measure variation in the sociocultural systems in which these clusterings of psychiatric disorder occur. While some workers have been concerned with socioeconomic class and others with states of “integration” or the functional cohesiveness of social systems, such efforts are just a beginning. What must come now is more emphasis on the adaptation and development of theories from social psychology, sociology, and anthropology bearing on small-group and large-group processes as these are relevant to mental health research in general and psychiatric epidemiology in particular. The necessity for method development, is of course, concomitant.
By such steps it should be possible to narrow a gap that still exists in psychiatric epidemiology, despite much interdisciplinary cooperation, between those who think in terms of individuals and statistics about individuals and those who think in terms of social structure and function. I believe that without this linking emphasis, psychiatric epidemiology will bypass major opportunities for the advance of etiological understanding.
The case-counting aspect of psychiatric epidemiology has a number of desiderata for development that may be summarized as: a more precise and standardized linking of terms with phenomena (Glueck et al. 1964; Hoch & Zubin 1953; D. Leighton et al. 1963; Ward et al. 1962); the establishment of comparable methods of keeping hospital and other relevant cumulative records; the expansion of case registries (Bahn 1962; 1965); the achievement of greater reliability and validity in the survey methods of making estimates of prevalence and incidence; and the speeding up of the steps involved in ratings and statistical analyses through the use of computers. [SeeMental disorders, article onepidemiology; see also Dale 1964; Overall et al. 1964; Pearson et al. 1964; Swenson et al. 1965; Smith 1967.]
Surveys. Because the survey technique is relatively new and has promise of being one of the major advances in the field, it deserves an additional word of comment. The method essentially consists of drawing a representative sample from a general population and conducting a systematic interview with each individual in the sample by means of a prepared schedule of questions. The results of the interviews are evaluated, usually by psychiatrists, and a score is assigned to every respondent. The aim is to estimate the true prevalence of psychiatric disorder in a chosen population independently of the amount of treatment provided and accepted.
The survey procedure suffers at present from being both overvalued and undervalued. On the one hand, results are naively accepted without adequate understanding of the way in which they were obtained. On the other, they are naively rejected as unpsychiatric, if not unscientific, and it is sometimes asserted that they have no known relationship to what a clinician means when he makes a diagnosis.
In point of fact, considerable work has been done on reliability (in the sense of agreement between psychiatrists who conduct their ratings independently) and on validity (in the sense of agreement between survey and independent clinical judgment based on direct examination of individuals). While serving to highlight certain weaknesses and to point up priorities for advancement, such investigations support, on the whole, both the survey as an approach and most of the main findings obtained so far. [SeeInterviewing; Psychometrics; Survey analysis.]
Transcultural and crosscultural psychiatry
An overlap of transcultural and crosscultural psychiatry with epidemiology exists but each subsumes independent spheres as well (Murphy & Leigh ton 1965). Examples of such overlap are the comparative analysis of the incidence of a clinical entity (e.g., schizophrenia) in two or more cultures and the attempt to probe deeply into cultural variation in underlying psychological processes through dream analysis, projective tests, and the productions of psychiatrically disordered persons. In the past there has been concern with culturally determined basic personality and the effect this might have on the generation of disorder (see, e.g., Holmberg 1950).
There is a fairly large literature on syndromes such as piblokto, latah, koro, and susto, which have been thought to be peculiar to one or another cultural group. In most instances these disorders appear to be local variations of conditions such as hysteria or anxiety rather than fundamentally new types of illness that are otherwise unknown.
An important area that is progressively receiving more and more attention is the comparative examination and analysis of treatment methods in various cultures. There are apparently no cultures that fail to recognize psychiatric disorders and none that do not provide some sort of treatment. [SeeCulture and personality.]
Social process in hospitals
A third example of a research area views the psychiatric hospital as a societal system and is concerned with the relations between the way the system functions and the consequences for the patients’ mental health (Caudill 1958; Stanton & Schwartz 1954; Levinson & Gallagher 1964). The behavioral science techniques utilized include ethnographic description, participant observation, the recording of interactions, systematic interviews, sociometric mappings, and psychological tests. Although some of the most important investigations have been observational and comparative, experimentation has also been done through such methods as introducing an innovation in one part of a hospital while using other parts as controls. There have also been what might be called “trial studies” in which a new way of structuring an entire hospital is put into effect and the results studied by independent observers. Maxwell Jones’s “therapeutic community” (1952) and Rapoport’s analysis of it is a notable example [Rapoport et al. 1961; see alsoMental disorders, treatment of, article onthe therapeutic community].
The most difficult technical problem in much of this research is that of measuring change in the dependent variable, namely the patient’s mental health. Although the task of the hospital is the improvement of the patients’ health, and practical decisions have to be made every day as to whether improvement has or has not occurred in specific patients, objective standards remain elusive and a handicap to rigorous hypothesis testing. This is of course a difficulty common to studies of all types of psychiatric therapy, including the evaluation of drug effects.
Small-group studies constitute our final research illustration. As the term is commonly employed, “small group” refers to a recurrent gathering of individuals who are collectively trying to accomplish something. The number involved is generally between 5 and 15, such as might assemble around a table. Characteristically, the group has a longer life than the presence of any of its individual members. Groups of this kind are a world-wide phenomenon and of major importance in societal processes.
The observational and theoretical reasons for maintaining that the small group can have an influence on psychiatric patients are numerous and complex, but a few may be selected for illustration. One is the fact that strong emotions are apt to be engendered among the members, emotions having to do with acceptance and admiration or rejection and scorn. It is much more difficult to be an isolated, indifferent, or preoccupied bystander in a small group than in a large one. Fear, anger, anxiety, depression, and euphoria commonly succeed each other during the meetings at various levels of intensity and are transacted through a variety of interpersonal dramas. There is thus potential for arousing strong motivation of some kind in the individual members.
Another characteristic of small groups is that each is made up of a number of roles which provide opportunities and enjoin limitations and which are taught to every new member. When the new member is a patient and the group has objectives relevant to therapy, this process can possibly reduce the patient’s symptoms and increase his social capacities. The small group has therefore molding as well as motivating potential.
Numbers of industrial and other studies have shown that the morale and productive ability of small groups is increased when the group as a whole has a measure of self-determination. Each member then has an opportunity of exerting some influence and experiencing a sense of worth and belonging—of being somebody who matters. The greater the cohesiveness of the group, the greater this effect is apt to be. When these forces are acting on a patient in a group of his peers, the effect can be one of mitigating depressive and inferiority feelings or of shearing away the idiosyncratic and asocial aspects of schizophrenic behavior.
Other therapeutic properties of the small group include opportunity for catharsis, self-expression through dramatization, and the relinquishing of old defense patterns and the trying out of new ways of dealing with one’s self and others in a relatively safe context. The sense of safety is perhaps more a feature of therapeutic groups than of other kinds because it is deliberately fostered, but it is also part of the sense of belonging and so is a component in the emotional climate of any cohesive group. [SeeCohesion, social; Groups; Mental disorders, treatment of, article ongroup psychotherapy.]
The critical question about all these various possibilities is, do they work? Can group forces be harnessed in the service of treatment? The answers to these questions have not yet been found, but one can safely predict that when they are they will not be in any simple form. It is probable that some kinds of group processes will be helpful with some kinds of disorders, while other combinations will turn out to make no difference or will be actively harmful. In the meantime we can say that there is an enormous amount of evidence pointing to the effectiveness of group processes and that the outlook is promising; however, no studies known to this author are as yet definitive.
One study of exceptional interest has addressed itself to the possibility of forming autonomous problem-solving groups among hospital patients in order to see whether such groups have any positive effect on the patient’s mental health (Fairweather 1964). The design for the experiment was a twoby-four analysis of variance, factorial type, with two treatment and four diagnostic categories. The two treatment groups were made up of two wards of male patients matched to an extraordinary degree; their treatments differed only in that one ran according to traditional lines while the other had in addition the requirement that every patient join for two hours a day, five days a week, in a taskoriented, decision-making small group. The experiment, involving a total of 195 patients, lasted 27 weeks with a six-month follow-up and included an unusually large number and variety of observations designed to detect and measure results. Among the findings were the following: the patients who spent some of their time in small groups showed in their general behavior more physical activity than did those who experienced only the traditional ward program. More important, they showed greater social participation, more affability, and more eagerness to communicate with their peers in complex social relationships. As a whole, the ward containing the small groups displayed greater feeling of unity and social attraction among its members. Although the patients found the small-group ward taxing and many wished they were on a different one, many of them felt to a greater extent than did patients on the other ward that their treatment program had helped them. On the average, the small-group patients had 40 fewer days of hospitalization. In contrast to this, the sixmonth follow-up showed no statistically significant difference between the two wards in the percentage of patients returning again to the hospital. This suggests that while 40 fewer days of hospitalization is a gain in that it is not neutralized by early return, the problems of posthospital adjustment are not helped by the small-group treatment in its present form. This indicates the need for experimentation regarding the possibility of continuing this kind of small-group participation among patients after they leave the hospital.
Alexander H. Leighton
[Directly related are the entriesMental disorders; Mental disorders, treatment of. Other relevant material may be found inClinical psychology; Schizophrenia; Social work; and in the biography ofSullivan.]
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In Western civilization there has long been an interest in the mental state of persons coming before the courts. It is to this branch of psychiatry that we apply the adjective “forensic.” The criteria for establishing mental states vary, depending on whether the immediate concern be testamentary capacity, compulsory hospitalization (commitment), the appointment of guardians, the validity of deeds or contracts, the relation of emotional states to various symptoms (tort law), annulment or divorce, credibility of witnesses, fitness for trial, or criminal responsibility. Furthermore, the criteria vary from jurisdiction to jurisdiction; in France, for instance, an act is simply considered not to be a crime where there is a condition of mental disorder (demence), whereas the Anglo-Saxon courts have presumed to set up definitions, of greater or lesser clarity, of the symptoms and types of mental disorder which will entitle the accused to a verdict of “not guilty by reason of insanity.”
It may be assumed that these “tests,” set up at varying times, are far from being in line with modern psychiatric standards. After all, the law cannot be expected to lead; it must, rather, follow accepted standards. The chief difficulty is that the law changes in a very leisurely fashion. Both law and psychiatry are concerned with human behavior, but the viewpoints are in some respects far apart. To the psychiatrist, the patient is an individual, with problems largely of emotional origin, whereas the law deals with him as a willful offender against a code of generalized rules which apply to the average man. That is, the law assumes that the person possesses free will, whereas psychiatry recognizes the potency of the unconscious in the motivation of the individual. At the same time, the law does recognize some mitigating or nullifying factors, such as “heat of blood.”
The usual layman’s concept of forensic psychiatry is that it deals with criminal cases—the defense of insanity, mental fitness for trial, and so forth. As a matter of fact, however, criminal actions occupy but a small proportion of the forensic psychiatrist’s attention. For general purposes, we will be concerned primarily with civil rather than criminal law.
One type of civil action has to do with what one person has inflicted on another, either by negligence or by intent. For example, suits based on injury attributed to automobile accidents come in this category.
Emotional shock is often alleged as the cause of various symptoms, and sometimes unduly generous verdicts are allowed by the courts, apparently on the erroneous theory that traumatic neurosis is incurable. There are many types of action that fall under this heading, such as malpractice suits against physicians, but many of these have not yet attracted much psychiatric interest.
This is an area in which the law has been somewhat laggard in the extent to which it is guided by psychiatric concepts. It must be added, however, that many law schools are providing instruction in psychiatric concepts. The American Bar Association has worked in conjunction with the American Psychiatric Association; the American Law Institute gave much attention to this area in the recent formulation of its Model Penal Code (U.S. v. Currens, 290 F. 2nd 751, 1961). The American Bar Foundation has not only published a compendium of the laws relating to mental disorder and the law (American Bar Foundation 1961), but also is making extensive field studies of the actual operation of those laws. Further still, the law, by statute and decision, has materially extended the scope of the definition of mental disorder to include not only “insanity” in its old sense but psychoneurosis, sexual deviation, drug addiction, alcoholism, and (on occasion) juvenile delinquency, psychopathic or sociopathic personality, mental defect, and mental disorder of degree, to different extents in the various jurisdictions.
In most cases, the person who is the subject of litigation in the matter of a will is not available for examination. In the event that the validity of a will is disputed on psychiatric grounds, if the psychiatrist has known the testator and is not inhibited by a statute of privilege, he may testify on the basis of his own knowledge. Otherwise, he must answer a “hypothetical question” about the testator’s mental state, on the assumption that some (or all) of the facts pertaining to the mental state of the testator testified to are true.
A will may be disallowed if the testator is found generally incompetent mentally or the victim of “undue influence.” If a delusion had an obvious influence on a provision of the will, it may be disallowed on that ground. The legal definition of a delusion contains elements, however, with which the psychiatrist can hardly agree; briefly, if any factual basis existed, then there is considered to be no delusion. Even the most florid delusion may have a kernel of factual basis.
Contracts and deeds
The validity of a contract or deed may occasionally be questioned on the grounds that the contractor was mentally incompetent. In general, it may be said that the law requires somewhat more mental acuity for a valid contract or deed than is required in the making of a will (Overholser 1959). Very few cases of this sort arise.
Annulment and divorce
There has long been provision for a judicial finding that a marriage is invalid if there existed in one of the partners an extreme mental disorder or defect, or a state of drunkenness, at the time the ceremony was performed. A number of states have provided for divorce on the ground of “incurable insanity” where one of the partners has spent a certain number of years of continuous confinement in a mental hospital.
There are various reasons why a person is unable to act in his own behalf. In such a case the court may appoint a guardian or committee to act for him. This process has no necessary connection with compulsory institutionalization, although in some jurisdictions the two proceedings are as one, that is, the order of commitment is an automatic adjudication of incompetency.
Until very recently, nearly all admissions to psychiatric hospitals resulted from court order, after a finding (usually) that the patient is, by reason of mental disorder, “dangerous to himself or others.” The order authorized his detention until, in the opinion of the staff, he could safely be released (subject, of course, to court order). In general, release was a medical matter. More recently, with the advent of a therapeutic, rather than custodial, atmosphere, voluntary admissions are encouraged, and efforts are being made to make the process of admission as informal as it is in general hospitals. In fact, most general hospitals now provide psychiatric facilities. The advantages of this procedure are obvious as steps in removing the stigma of mental disorder which still prevails, although to a diminishing extent. The educational campaigns carried out by the National Association for Mental Health and by local mental health associations are bearing fruit. Much more might be said on the subject of mental hospitals, such as their use as receptacles for the so-called sexual psychopath or those offenders acquitted by reason of insanity, but space does not permit.
Criminal law and procedure
So far we have considered actions between persons. In criminal actions, law deals with actions against society. The accused is prosecuted in the name of the state or county or country, as the case may be. Let us reiterate that although criminal cases for various reasons attract wide attention, they are far fewer in number than other types of legal action. The accused, too, is presumed to be innocent until proved guilty and has certain rights which the prosecution must respect.
One of the elements of most crimes is what is known as criminal intent, or mens rea. Until 1843 only the most “furiously mad” were thought to be sufficiently deranged to meet the test of lunacy, or whatever it might be termed then. In that year, in the case of Daniel M’Naghten (M’Naghten’s Case, 10 Cl. & Fin. 200, 1843), the judges of England attempted to lay down the criteria of insanity—basically the “right and wrong” test. The M’Naghten test is strictly a cognitive one, yet it is in force in most of the English and American courts today. It maintains that a person can be excused from liability in criminal proceedings only if he did not understand the nature of his act or that it was wrong. Shortly before (State v. Matthew Thompson, Wright’s Ohio Rep. 617, 1834), an American court had recognized the importance of emotional factors and had enunciated the so-called irresistible impulse test, now recognized in about twenty states. In 1871 the New Hampshire Supreme Court threw out all tests, holding that “insanity” is a fact to be determined by the jury (State v. Jones, 50 N.H. 369, 1871).
In 1954 (Durham v. United States, 214 F. 2nd 862, 1954) the District of Columbia followed suit in the famous Durham decision, the opinion stating that the question to be decided by the jury is whether the act is the product of mental disease or defect. Several variants have been proposed (McDonald v. United States, 284 F. 2nd 232, 1960; Lynch v. Overholser, 369 U.S. 705, 1962), but the Durham decision still remains a pioneer.
The evidence on mental status is given in an atmosphere where adversaries oppose each other—hardly a situation that appeals to a physician.
Among other functions of the psychiatric expert is the determination whether witnesses are fit to testify. Courts, however, do not avail themselves of this opportunity very often and depend, rather, on the judge’s psychiatric insight.
Remedies—attempted and possible
It should not be thought that psychiatrists and lawyers are content with the status quo of definitions and procedures. Various groups have been at work on the problems, including the American Law Institute, the American Bar Foundation, and the American Psychiatric Association. Space, unfortunately, does not permit a discussion of the problem. For the long pull, however, there is some reason, despite the well-known hesitancy of the law to change, to be guardedly optimistic.
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Religio–psychiatry is a twentieth-century movement whose participants are concerned with the relation between religious and scientific approaches to mental, emotional, or spiritual healing. The participants are, by and large, clergymen and psychiatrists who, disenchanted with their respective institutional traditions of healing, introduce a form of healing which combines religious and psychiatric means to relieve emotional suffering, and the clients who seek help from these innovators. Some traditionalists in the ministry and in psychiatry, who attack the innovators and engage them in ideological debate, enter the action as antagonists. The movement is manifest in a literature which debates and publicizes the ideology; in professional associations through which its protagonists share ideas; in clinics for mental, emotional, and spiritual healing; and in training facilities for recruiting and socializing new participants.
Since classical times, science and religion have become institutionally differentiated. Science has come increasingly to shoulder primary responsibility for investigating and explaining natural events. Religion has retained a responsibility for guiding human attitudes toward those events. Mental and emotional healing, once the concern of what may be termed, anachronistically, religio-science, continues to concern religious pastors as well as scientific psychiatrists.
Chemists, physicists, and biologists who specialized in applying the knowledge of their respective disciplines to the problem of healing prepared the ground for a medical specialty dealing with mental and emotional disorders. Psychiatric specialists appeared toward the close of the eighteenth century. Their scientifically influenced approach is characterized by differential diagnosis of the disease in terms of the malfunctioning of the organism, by the empirical discovery of propositions relating therapeutic techniques to those malfunctions, and by the application of the indicated techniques in an effort to restore normal functioning (Zilboorg 1941).
Pastoral responsibility for emotional healing has traditionally fallen to the same clergyman who has acted as priest, teacher, and prophet. Western religion has termed this the “cure of souls” because the emotional manifestations have been considered symptomatic of a fundamental derangement of life values and of a distortion in the relation between man and the transcendental. A few medieval and early modern Christian clergymen wrote penitentials as a way of enacting their roles as spiritual directors. A specialized ministry to those suffering mental and emotional distress awaited the twentieth century. Religious healing is concerned with rectifying the sufferer’s distorted relation to nature, man, the cosmos, or the “ground of meaning,” through the mediation of a personal relation with the pastor (McNeill 1951).
Thus, pastoral and psychiatric roles have emerged side by side in Western society. They represent the applied specialization within the religious and scientific institutions, respectively, to meet the human exigency manifested by emotional distress. The religio–psychiatric movement is the product of an attempt by some pastors and psychiatrists to integrate their means and their goals.
Emotional and spiritual problems
There is little agreement among participants about criteria for discriminating between emotional and spiritual problems and, consequently, about criteria for assigning a problem to a medical or a religious specialist. The same symptomatology supports either diagnosis. Some differentiate between illusory problems (a concern of psychiatry) and real problems (a concern of the ministry). The psychiatrist would thus be concerned with guilt feelings when there is no objective basis for the feeling, while real guilt—for example, following a transgression against a fellow man—would be a religious problem. Roman Catholic priests are cautioned to discriminate between “scrupulosity,” a compulsive neurosis leading to detailed confessions of partly imagined misdeeds, and the appropriate confession of sin, a religious concern (Corcoran 1957).
Despite the paucity of criteria for distinguishing emotional from spiritual problems, there is some anxiety among ministers that psychiatrists may reduce the religious concern of a patient to its psychological component and so render disservice to the patient and to the church. Conversely, psychiatrists, both in and out of the movement, fear that ministers may not recognize such phenomena as the hallucinatory elements in a religious experience.
Research evidence for the effectiveness of psychiatric treatment is far from conclusive (Berelson & Steiner 1964). Systematic empirical evidence for the effectiveness of religious healing or of religio–psychiatric healing is almost totally lacking. Protagonists of the movement cite medical studies such as those of healing at Lourdes (West 1957); anthropological reports of healing in primitive societies through the intervention of charismatic “leeches” or healers (Rivers 1924); the power of religio–hypnotic phenomena such as voodoo healing and death (Métraux 1958); and an oral and written tradition of testimonials.
Given both the difficulty in distinguishing emotional from spiritual problems and the limited evidence for the effectiveness of religio–psychiatric therapy, the growth and persistence of the religio–psychiatric movement must be understood in terms of other social, psychological, and cultural functions it may subserve.
Conditions promoting the movement
Protagonists of the movement argue that religio–psychiatry responds to a demand for pastoral services where psychiatric personnel and facilities are limited. The geographical location of the movement, however, shows a simple ecological correlation. Religio–psychiatry arises in precisely those environments having the most psychiatric facilities. The religio–psychiatric movement is found in the urban centers of Western countries. Over two-thirds of its publications are in English, and most of these are published in the United States. France and Germany are secondary publication centers. The movement is centered in industrialized and scientifically oriented milieus (Klausner 1964a).
Religio–psychiatry is the product of the same cultural conditions that produced the mental health movement. This wing of the mental health movement has, however, its own particular characteristics. It seems to draw ministers and psychiatrists who are serious about both their religious and scientific commitments and who feel that these institutions impose conflicting behavioral demands. Ministers with advanced secular education (77 per cent of the ministerial authors hold doctorates) who serve denominations of higher socioeconomic status tend to have a greater affinity for scientific culture, which values empirically assessable achievements. These ministers are also committed to religion’s stress upon purpose, meaning, and the attainment—through personal relationship—of nonempirical ends. They accept both of these cultural systems as relevant to the same social role, that of counselor to the emotionally distressed.
Certain psychiatrists are exposed to this dual cultural demand. Some have been personally religious since their youth; others have come to religion through wartime experiences; and others—because they are members of, and receive referrals from, hierarchically structured churches, such as the Roman Catholic and Episcopal—are responsive to a demand for a more religiously oriented therapy.
Growth of the movement
Klausner (1964a; 1964b) examined 1,853 books and articles published between the turn of the century and the end of 1962, in the field of religion and psychiatry. The publication rate may reflect developmental patterns of the religio–psychiatric movement. Growth, as measured by number of publications per year, was quite slow between the turn of the century and the beginning of World War Ii; the rate of growth thereafter, however, increased rapidly. During the 1950s, though each year witnessed a greater number of publications than the preceding one, the rate of increase began to decline. It is conceivable that the movement, as reflected in its literature, will attain its maximum size by the late 1960s or early 1970s. Thereafter, barring new factors and generalizing from the growth pattern of other social movements and assuming a correlation between literary and organizational aspects, religiopsychiatry may be expected to begin its decline.
Stages in the growth of the religio–psychiatric movement are reflected in shifting thematic emphases in its literature. Comparison of religious and scientific conceptions of man, writ large, was the overriding theme prior to World War i. This theme reflects an early interest in exploring the possibility of relating the two institutions. After the war, interest shifted to comparing conceptions of emotional and mental deviance. The issues, while still theoretical, were more narrowly defined. Practical questions of counseling the emotionally disturbed and questions arising around relations between ministers and psychiatrists drew relatively more interest by the time of World War ii. This may reflect the crystallization of ideology in organizational form in the establishment of clinics and training centers. Recently, the training of ministers for a psychological-counseling role has drawn relatively greater attention in the literature. Concern with training may reflect consolidation of a new religio–psychiatric role.
Characteristics of participants
What are the characteristics of the ministers and psychiatrists who constitute the movement? This question may be answered in part from information available about writers in the field.
Ministers and psychiatrists are not the sole contributors to the literature of the movement, as shown in Table 1, but they are the major contributors. Psychiatrists, however, have had more influence on the ideology, especially in the movement’s early stages. This may be because the movement occurs within scientifically oriented societies, because minister-participants actively seek scientific knowledge, and because the ministers in the movement have tended to be younger than the psychiatrists. Minister-authors have been, modally, in their thirties and forties at the time of writing, while the psychiatrists have been, modally, ten to twenty years older. The age factor and the scientific orientation of the societies in which the movement emerges conspire to place leadership in psychiatric hands.
When the numbers of ministers and psychiatrists in the movement are compared with their respective numbers in the society as a whole, it appears
|Table 1 –Characteristics of the authors and country of publication of books and articles in the field of religio–psychiatrya|
|a. Total number of publications = 1,853.|
|b. Since the table is based on a total of publications rather than a total of individuals, the percentages accompanying each characteristic refer to the proportion of items written by individuals with that characteristic rather than to the proportion of all the authors who possess that characteristic.|
|Source: Adapted from Klausner 1964a, p. 65.|
|Other denominations and denomination unknown||21|
|Country of publication:|
|United States and Canada||72|
|Germany (and German Switzerland)||11|
|England and other Commonwealth||7|
|France (and French Switzerland)||6|
|Southern Europe (Spain, Greece, Italy)||3|
that a higher proportion of all psychiatrists than of ministers enters this movement. The counseling role is, of course, central to the psychiatric profession, while the pastoral is but one role—and usually not the central role—of the ministry.
Table 1 also shows this to be predominantly a Protestant movement. Among Protestant members are found many Episcopalians, Presbyterians, Methodists, Congregationalists, and Baptists—but very few fundamentalists. Few ministers serving poorer parishes participate in the movement. Since the religio–psychiatric movement is centered in the United States, where Methodists and Baptists far outnumber the wealthier Episcopalians, Presbyterians, and Congregationalists, one may infer that ministers and psychiatrists belonging to these latter denominations are more likely to be drawn to the movement.
In the United States, the proportion of Roman Catholics in the movement has reflected roughly the proportion in the population. Catholic interest in the movement increased during the 1950s following the declaration of Pope Pius xii (1953) that the techniques, but not the philosophy, of psychoanalysis are acceptable to the church. In the 1960s the proportion of Catholic priests, but not of Catholic psychiatrists, participating in the movement began to decline.
Jewish clerical interest has been meager. Historically, the rabbinate has more often played an educational role than a pastoral one. Rabbis of Reformed Judaism, responsive to new role definitions among the Christian clergy, have accounted for most of the Jewish clerical interest. Jewish psychiatrists, particularly psychoanalysts, tend to be prominent contributors to general psychotherapeutic literature, and their writings are used in training clergy of all faiths.
Protestant and Roman Catholic concern tends, at times, to be with a search for a Christian psychotherapy as an alternative to that so strongly influenced by Jewish psychiatrists or by nonreligious psychoanalysis. Between the 1930s and 1950s the movement became popular in Germany, England, and the United States, successively. This popularity paralleled that of the psychoanalytic movement in each of these countries. Religio–psychiatry seems to have emerged, in part, to countervail psychoanalysis. Nevertheless, Freudian influence on religio–psychiatric writings has increased steadily. Prior to World War II, about onethird of all writings could be identified as primarily Freudian in orientation. By the 1960s about seven out of eight publications had a Freudian orientation (Klausner 1964a).
New counseling norms
Ministers and psychiatrists, by participating in the movement, attempt to resolve the conflicting demands which they feel religious and scientific culture makes upon them. Their conflicts are revealed through complaints they voice against their respective institutions. These ministers and psychiatrists are critical of colleagues who argue that religious and scientific values are inconsistent. Ministers in this movement complain that contemporary religion fails to realize its ideal. Psychiatrists complain that lack of value commitment constitutes a gap in psychiatric practice. Ministers observe that religion is ineffective in helping parishioners with their emotional problems. Psychiatrists observe that traditional therapy is insufficiently effective. Some ministers feel that their lack of psychological training hampers their effectiveness in helping parishioners. This self-doubt finds little parallel among the psychiatrists, who feel little need for additional schooling in religious concepts. Both the ministers and the psychiatrists assert that a combination of religious and psychiatric elements generates a superior, more effective psychotherapy.
These ministers introduce psychiatric methods into their pastorate, while these psychiatrists introduce religious orientations into their counseling. Ministers advocate greater emphasis on techniques of counseling, on improving the psychological functioning of the counselee, and on maintaining an objective, detached stance. Psychiatrists advocate greater emphasis on personal relationships, on helping the patient to evolve a meaningful attitude to life, and on permitting their feeling about the patient to impinge upon the therapeutic relationship. Some ministers and psychiatrists evolve a form of counseling which combines psychiatric techniques with goals conceived in religious value terms. At the extreme, some psychiatrists provide a religious type of counseling, and some ministers are hardly distinguishable from psychologists in either the means or goals of counseling.
Both ministerial and psychiatric protagonists suffer attacks for advocating change in the counseling norms institutionalized in their respective groups. Ministers are criticized for distorting religion by church leaders who assume the role of the movement’s antagonists. The principal accusations revolve about the introduction of what the traditionalists argue are hedonistic, deterministic, materialistic, and pansexualistic elements. Psychiatrists are criticized by members of the medical profession for consorting with lay therapists and, by a few colleagues, for failing to deal with religion as symptomatic of an obsessional neurosis.
Ministers and psychiatrists in the religio–psychiatric movement appeal to the institutions to which they belong and to their clients to accept and approve their new activity. They offer four principal types of rationales or bases of legitimation. These are consolidating rationales, which argue that religion and science are really identical, that apparent differences are merely linguistic—for instance, that “revelation” in religion is the same as “insight” in psychiatry or that the psychiatric notion of “emotional security” has the same referent as the religious notion of “faith”; complementing rationales, which argue that religion and science are separate but complementary—that, for instance, psychiatry deals with functioning and the stresses of life, while religion deals with purpose, and that a total therapy attends to both; harbinger rationales, which argue that the contributions of one profession may help toward the goals of the other—that, for instance, the solution of emotional problems prepares a person to accept religious doctrine; and social rationales, which point to leading members of the group who introduced similar new norms—for example, the contention that Jesus was a practicing psychologist.
New relations of ministers and psychiatrists to their institutions and to their counselees take concrete form in religio–psychiatric or pastoral counseling clinics. These clinics have been established mostly in the United States, but there are some in England, France, Germany, Switzerland, and Belgium. An early organizational attempt to coordinate ministerial and psychiatric work was that of the Emmanuel Church in Boston, in the first decade of the twentieth century. Those active around this clinic—especially Ellwood Worcester, a priest, and Isador Coriat, a psychiatrist—became known as members of the Emmanuel movement.
During World War I a significant number of clergymen and psychiatrists were brought together by the military. The American military chaplaincy introduced parish preachers and teachers to a situation built around the pastoral ministry. Following the war, hospitals provided another institutional setting for ministerial and psychiatric cooperation. Traditionally, parish ministers visited parishioners in hospitals. Returning military chaplains established a model for a specialized hospital chaplaincy, drawing upon a tradition developed in the religious orders and applying it in a medical context. The mental-hospital chaplaincy followed. Its early development in the United States is associated with the name of Anton Boisen, who interpreted his own psychotic episode as a religious struggle and committed himself to the service of the mentally ill (1936).
Probably most pastoral counseling takes place in the study of the parish clergyman, just as its counterpart, religiously oriented psychiatry, takes place in a private office. Where individual service gives way to a clinical staff, questions of sponsorship and allocation of tasks appear. Some pastoral clinics are sponsored by a church and have clerical staffs. These staffs consult with and refer to psychiatrists as the need arises. Others are sponsored by a denomination or group of denominations or by educational institutions. Religious institutions may sponsor traditional psychiatric clinics with no clergymen on the staff. Independent clinics may be established with clergymen, social workers, psychologists, and psychiatrists cooperating as part of the regular staff (McCann 1962).
In the past, most chaplains entered upon their duties with no specialized clinical training. Some of them also had limited confidence in the worth of traditional religious approaches to the cure of souls. Bexley Hall Episcopal Seminary was probably the first seminary to provide formal clinical pastoral education by founding, in 1923, the Cincinnati Summer School in Social Work for Theological Students and Junior Clergy. Other Protestant, Roman Catholic, and Jewish seminaries followed with programs which generally combined classroom instruction in clinical psychology with internships in hospitals or church-affiliated clinics.
Clinical training programs have involved psychiatrists in the training of ministers. These programs have not been limited solely to chaplaincy training: they have also prepared parish clergymen to recognize psychological disturbances and to make appropriate referrals. Counseling training has been provided in a few instances. The relationship of continuing advice and referral has done much to sustain contact between ministers and psychiatrists in local communities.
The religio–psychiatric movement has produced its own characteristic literature. It consists of books and articles published in specialized, as well as general, theological and scientific journals. Perhaps 2,500 such items by psychiatrists about the role of religion in psychotherapy and by ministers about the place of psychiatric and psychological concepts in pastoral work were published between the turn of the century and 1962 (Klausner 1964b).
During the first decade of the twentieth century, a journal entitled Psychotherapy provided a common platform for ministers and psychiatrists in the United States. This was followed by Religion und Seelenleiden in Germany and, later, by the Journal of Psychotherapy as a Religious Process and the Journal of Religion and Health in the United States. This last is the organ of the Academy of Religion and Mental Health, the principal professional organization of religiously oriented psychiatrists and psychiatrically oriented ministers. In the United States Pastoral Psychology and in Belgium Lumen vitae, which also publishes in the general area of the psychology of religion, are more specifically directed to clergymen.
Titles of a few of the movement’s more significant books may illustrate some types of concern. Among the protagonists’ texts is Carl Gustav Jung’s Modern Man in Search of a Soul (1922–1931), which deals with religious symbols in mental processes, in general, and in psychotherapy, in particular. Less widely known are the writings of Oskar Pfister, such as his Religionswissenschaft und Psychoanalyse (1927). Pfister, a Swiss Lutheran pastor, corresponded with Freud about psychoanalysis and Christianity. While psychoanalysis was under attack by some authorities of the Roman Catholic church, Roland Dalbiez in France wrote Psychoanalytical Method and the Doctrine of Freud (1936), discussing the possibility of a reconciliation with psychoanalysis and Freudian thought. This reconciliation was actively pursued by Agostino Gemelli in Italy and is reflected in his Psychoanalysis Today (1953). Religio–psychiatric conferences under the leadership of Wilhelm Bitter, which began in Germany during the 1920s, are reported in Psychotherapie und Seelsorge (1952). The Anglican prelate Leslie D. Weatherhead, in Psychology in Service of the Soul (1930), sees counseling contributing to a fuller religious life. Boisen’s The Exploration of the Inner World: A Study of Mental Disorder and Religious Experience (1936) provided an early impetus to the clinical pastoral movement in the United States. Religious existentialism has been a road into the movement for some psychiatrists. Viktor E. Frankl, in The Doctor and the Soul (1946), describes some limits to a psychotherapy which, in not aiming at a reconstruction of values, does not deal with a holistic conception of man.
Among the antagonists’ writings is Thomas H. Hughes’s “Freudianism and Religion” (1934), which describes Freudianism as a menace to Christianity. Rudolph Allers, an American Roman Catholic professor of philosophy, in The Successful Error (1940), examines psychoanalytic thought from a Thomistic point of view. Ernest Jones, the English psychoanalyst, in his Essays in Applied Psychoanalysis (1923), implicitly warns psychiatrists away from the religio–psychiatric movement by arguing that religion represents a crude solution of the Oedipus complex. David Forsyth, in his Psychology and Religion (1935), calls upon psychotherapists, among others, to cease dissipating their energies in imaginary pursuits and accept the discipline of science.
Religio–psychiatry has implications for counseling, in that it coordinates two counseling traditions. The movement also has implications beyond the counseling situation. It serves the religious and psychiatric institutions involved, as a way of controlling the extent of normative deviance on the part of their leaderships. Ministers and psychiatrists who might break more completely with their institutions may find a middle ground. While the movement is simultaneously a variant of both traditional religion and traditional psychiatry, it still remains within both institutions.
For the broader society, the movement serves as a bridge between religion and science. The counseling situation provides a meeting place, an institutional boundary, across which religious and scientific conceptions having wider ramifications may be exchanged. In the past, the movement has also served to integrate the religious groups of a pluralistic society. Protestants, Roman Catholics, and Jews have been able to meet and share thoughts and problems on grounds which are doctrinally relatively neutral.
Samuel Z. Klausner
[SeeCounseling psychology; Mental disorders, treatment of, especially the article onPsychological treatment; Psychology, article onExistential psychology; Religion, especially the article onPsychological study; and the biography ofJung.]
Allers, Rudolph 1940 The Successful Error. New York: Sheed & Ward.
Anderson, George Christian 1963 The Partnership of Theologians and Psychiatrists. The Third Mary Hamingway Rees Memorial Lecture. Journal of Religion and Health 3:56–69. → This lecture was originally presented during the Sixteenth Annual Meeting of the World Federation for Mental Health.
Berelson, Bernard; and Steiner, Gary A. 1964 Human Behavior: An Inventory of Scientific Findings. New York: Harcourt.
Boisen, Anton 1936 The Exploration of the Inner World: A Study of Mental Disorder and Religious Experience. Chicago: Clark.
Corcoran, Charles J. D. 1957 Thomistic Analysis and the Cure of Scrupulosity. American Ecclesiastical Review 137:313–329.
Dalbiez, Roland (1936) 1941 Psychoanalytical Method and the Doctrine of Freud. 2 vols. New York: Longmans. → First published in French.
Forsyth, David (1935) 1936 Psychology and Religion. 2d ed. London: Watts.
Frankl> Viktor E. (1946) 1965 The Doctor and the Soul 2d ed. New York: Knopf. → First published as Artzliche Seelsorge.
Gemelli, Agostino (1953) 1955 Psychoanalysis Today. New York: Kenedy. → First published in Italian.
Hughes, Thomas H. 1934 Freudianism and Religion. Philosopher 12, no. 2:63–72.
Jones, Ernest (1923) 1951 Essays in Applied Psychoanalysis. 2 vols. London: Hogarth.
Jung, Carl Gustav (1922–1931) 1959 Modern Man in Search of a Soul. London: Routledge. → First published as Seelenprobleme der Gegenwart.
Klausner, Samuel Z. 1964a The Mellowing of the Religio–Psychiatric Movement. Parts 1 and 2. Review of Religious Research 5:63–74; 6:7–22.
Klausner, Samuel Z. 1964b Psychiatry and Religion. New York: Free Press.
McCann, Richard C. 1962 The Churches and Mental Health. Joint Commission on Mental Illness and Health, Monograph Series, No. 8. New York: Basic Books.
McNeill, John T. 1951 A History of the Cure of Souls. New York: Harper.
MÉtraux, Alfred (1958) 1959 Voodoo in Haiti. New York: Oxford Univ. Press. → First published in French.
Pfister, Oskar 1927 Religionswissenschaft und Psychoanalyse. Giessen (Germany): Töpelmann.
Pius XII 1953 Ils, qui interfuerunt conventui internationali quinto de psychotherapia et psychologia, Romae habito. Acta apostolicae sedis 45:278–286.
Psychotherapie und Seelsorge: Eine Einführung in die Tiefenpsychologie. Edited by Wilhelm Bitter. 1952 Stuttgart (Germany): Gemeinschaft Arzt und Seelsorger.
Rivers, W. H. R. 1924 Medicine, Magic and Religion. London: Routledge; New York: Harcourt.
Weatherhead, Leslie D. 1930 Psychology in Service of the Soul. New York: Macmillan.
West, Donald J. 1957 Eleven Lourdes Miracles. London: Duckworth.
Zilboorg, Gregory 1941 A History of Medical Psychology. New York: Norton.
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PSYCHIATRY. Psychiatry, a branch of medicine, is a discipline that takes the full range of human behaviors, from severe mental illness to everyday worries and concerns, as its study. In the nineteenth century the discipline was largely concerned with the insane, with the mentally ill sequestered in large custodial asylums located largely in rural areas; as a result, psychiatrists were cut off from medicine's main currents. In the early twentieth century, under the leadership of such men as Adolf Meyer and E. E. Southard, psychiatry expanded to address both the pathological and the normal, with questions associated with schizophrenia at the one extreme and problems in living at the other. Psychiatrists aligned their specialty more closely with scientific medicine and argued for its relevance in solving a range of social problems, including poverty and industrial unrest, as well as mental illness. Psychiatry's expanded scope brought it greater social authority and prestige, while at the same time intermittently spawning popular denunciations of its "imperialist" ambitions. The discipline's standards were tightened, and, in 1921, its professional organization, formerly the American Medico-Psychological Association, was refounded as the American Psychiatric Association. In 1934, the American Board of Psychiatry and Neurology was established to provide certification for practitioners in both fields.
Over the course of the twentieth century, psychiatry was not only criticized from without but also split from within. Psychiatrists debated whether the origins of mental illness were to be found in the structure and chemistry of the brain or in the twists and turns of the mind. They divided themselves into competing, often warring, biological and psychodynamic camps. Psychodymanic psychiatry, an amalgam of Sigmund Freud's new science of psychoanalysis and homegrown American interest in a range of healing therapies, was largely dominant through the early 1950s. From the moment of its introduction following Freud's 1909 visit to Clark University, psychoanalysis enjoyed a warm reception in America. By 1920, scores of books and articles explaining its principles had appeared, and Freudian concepts such as the unconscious, repression, and displacement entered popular discourse. The dramatic growth of private-office based psychiatry in the 1930s and 1940s went hand in hand with psychoanalysis's growing importance; by the early 1950s, 40 percent of American psychiatrists practiced in private settings, and 25 percent of them practiced psychotherapy exclusively. The scope and authority of dynamic psychiatry were further expanded in World War II. Nearly two million American recruits were rejected from the services on neuropsychiatric grounds, and the experience of combat produced more than one million psychiatric casualties— young men suffering from combat neuroses. Only one hundred of the nations' three thousand psychiatrists were psychoanalysts, yet they were appointed to many of the top service posts. The prominent psychoanalyst William Menninger, for example, was made chief psychiatrist to the army in 1943, and he appointed four psychoanalysts to his staff. The immediate postwar period was psychodynamic psychiatry's heyday, with major departments of psychiatry headed by analysts and talk of the unconscious and repression the common coin of the educated middle class.
The cultural cachet of psychoanalysis notwithstanding, most psychiatric patients were institutional inmates, diagnosed as seriously disturbed psychotics. The numbers of persons admitted nationwide to state hospitals increased by 67 percent between 1922 and 1944, from fiftytwo thousand to seventy-nine thousand. Critics charged psychiatrists with incompetence, neglect, callousness, and abuse. Both desperation and therapeutic optimism led psychiatrists to experiment with biological therapies, among them electroconvulsive shock therapy (ECT) and lobotomy. ECT was introduced to enthusiastic acclaim by the Italian psychiatrists Ugo Cerletti and Lucio Bini in 1938. Within several years it was in use in 40 percent of American psychiatric hospitals. Prefrontal lobotomy, first performed by the Portuguese neurologist Egas Moniz in 1935, involved drilling holes in patients' heads and severing the connections between the prefrontal lobes and other parts of the brain. More than eighteen thousand patients were lobotomized in the United States between 1936 and 1957. Psychosurgery promised to bring psychiatrists status and respect, offering the hope of a cure to the five hundred thousand chronically ill patients housed in overcrowded, dilapidated institutions. Instead, it was instrumental in sparking, in the 1960s and 1970s, a popular antipsychiatry movement that criticized psychiatry as an insidious form of social control based on a pseudomedical model.
Biological psychiatry entered the modern era with the discovery of the first of the antipsychotic drugs, chlorpromazine, in 1952. For the first time, psychiatrists had a means to treat the debilitating symptoms of schizophrenia—hallucinations, delusions, and thought disorders. Pharmacological treatments for mania and depression soon followed, and psychiatrists heralded the dawn of a new "psychopharmacological era" that continues to this day. The introduction, in the 1990s, of Prozac ®, used to treat depression as well as personality disorders, brought renewed attention to biological psychiatry. The oncedominant psychodynamic model, based on the efficacy of talk, fell into disrepute, even though studies showed that the best outcomes were obtained through a combination of drug and talk therapies. The profession, divided for much of the century, united around the 1980 publication of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry's official manual of nomenclature that endorsed a descriptive, nondynamic orientation, thus signaling psychiatry's remedicalization.
Psychiatry has had to constantly establish its legitimacy within and beyond medicine. Despite enormous advances in the understanding and treatment of mental illness, in the mid-1990s psychiatry was one of the three lowest-paid medical specialties (along with primary care and pediatrics). Psychiatry's success has spurred increased demand for services. But with increasing pressure on healthcare costs, and with the widespread adoption of managed care, psychiatry—that part of it organized around talk—has seemed expendable, a form of self-indulgence for the worried well that society cannot afford. Insurers have cut coverage for mental health, and psychologists and social workers have argued that they can offer psychotherapy as ably as, and more cheaply than, psychiatrists, putting pressure on psychiatrists to argue for the legitimacy of their domination of the mental health provider hierarchy. In this, psychopharmacological treatments have been critical, for only psychiatrists, who are medical doctors, among the therapeutic specialties have the authority to prescribe drugs. Advances in the understanding of the severe psychoses that afflict the chronically mentally ill continue to unfold, fueling optimism about psychiatry's future and insuring its continuing relevance.
Grob, Gerald N. Mental Illness and American Society, 1875–1940.Princeton, N.J.: Princeton University Press, 1983.
Healy, David. The Antidepressant Era. Cambridge, Mass.: Harvard University Press, 1997.
Valenstein, Elliot S. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books, 1986.
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In the 1820s to 1840s, medical interest in lunacy and therapeutic optimism were both high. Practitioners were often eclectic, many supporting moral treatment, which emphasized the therapeutic value of an ordered environment in building up inmates' capacities for self-control and self-esteem. However, higher-status practitioners were soon deterred from asylum work by the residency requirements in larger institutions, which restricted the opportunities for private practice, and by the predominance of pauper patients. Moreover, as the asylums grew and were increasingly filled with inmates having chronic and intractable problems, the medical role became primarily custodial rather than therapeutic. Increasing medical emphasis on the natural sciences was largely reflected in routine autopsies in the effort to identify brain pathology.
Two major changes occurred in the first half of the twentieth century. First, psychiatric work outside the asylums expanded, much of it on a private basis for more affluent patients, many with problems that Sigmund Freud identified as psychoneurotic. His influence on office psychiatry was considerable, especially in the United States, where private practice flourished. Second, there were major efforts to transform asylums into proper hospitals, and in the 1930s physical treatments such as electro-convulsive therapy (ECT) and psychosurgery (to be followed in the 1950s by new drug therapies) were developed, encouraging a new therapeutic optimism.
Both developments underpinned the acceptance of a policy of community care in the 1950s, initially as a supplement to asylum care, then as an alternative—the one representing a diversification of the locus of care and an increased role for psychiatry across a wider spectrum of conditions, the other a break with old pro-institutional and custodial models of care, a change facilitated by the introduction of voluntary admission in Britain in 1930 and the resulting decline in compulsory detention.
The implications for psychiatry of the subsequent run-down of mental hospitals and the shift to work in the community cannot yet be fully assessed. The loss of the old empire of the mental hospital has undoubtedly reduced psychiatrists' power, as has (to some extent) the development of multi-disciplinary teams. The power of psychiatrists now resides largely in their rights over prescribing and their expertise in the natural sciences. However, developments in biological psychiatry and the neurosciences could cut back the domain of illnesses deemed mental, to the advantage of neurologists and at the expense of psychiatry.
© A Dictionary of Sociology 1998, originally published by Oxford University Press 1998.
Psychiatry is the branch of medicine concerned with the study, diagnosis, and treatment of mental illnesses. The word psychiatry comes from two Greek words that mean "mind healing." Those who practice psychiatry are called psychiatrists. In addition to graduating from medical school, these physicians have postgraduate education in the diagnosis and treatment of mental behaviors that are considered abnormal.
Psychiatrists tend to view mental disorders as diseases and can prescribe medicine to treat those disorders. Other medical treatments occasionally used by psychiatrists include surgery (although rarely) and electroshock therapy.
Many, but not all, psychiatrists use psychoanalysis, a system of talking therapy based on the theories of Austrian psychiatrist Sigmund Freud (1856–1939). Freud believed that mental illness occurs when unpleasant childhood experiences are repressed (blocked out) because they are so painful. Psychoanalysts seek to cure patients by having them recover these repressed thoughts by talking freely until themes or issues related to the troubling conflicts arise, which are then addressed. Psychoanalysis often involves frequent sessions lasting over many years. Many psychiatrists use a number of types of psychotherapy in addition to psychoanalysis and prescription medication to create a treatment plan that fits a patient's needs.
History of psychiatry
The ancient Greeks believed people who were mentally ill had an imbalance of the elements (water, earth, air, and fire) and the humors (the bodily fluids of blood, phlegm, black bile, and yellow bile). In Europe during the Middle Ages (400–1450), most people thought that mental illness was caused by demonic possession and could be cured by exorcism. In the 1700s, French physician Philippe Pinel (1745–1826) became the first to encourage humane treatment for the mentally ill.
By the late 1800s, physicians started to take a more scientific approach to the study and treatment of mental illness. German psychiatrist Emil Kraepelin (1856–1926) had begun to make detailed written observations of how his patients' mental disturbances had come into being as well as their family histories. Freud began developing his method of using the psychoanalytic techniques of free association and dream interpretation to trace his patients' behavior to repressed, or hidden, drives. Others worked to classify types of abnormal behavior so that physicians could accurately diagnose patients.
Present-day psychiatry has become more specialized. Psychiatrists often focus on treating specific groups of people, such as children and adolescents, criminals, women, and the elderly.
Scientific researchers in the twentieth century have confirmed that many mental disorders have a biological cause. Those disorders can be treated effectively with psychiatric drugs that fall into four categories: antipsychotics (tranquilizers used to fight psychoses, or mental disorders characterized by loss of contact with reality), antidepressants, mood stabilizers, and antianxiety medications.
[See also Depression; Multiple personality disorder; Phobias; Psychology; Psychosis; Schizophrenia ]
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psychiatry (səkī´ətrē, sī–), branch of medicine that concerns the diagnosis and treatment of mental, emotional, and behavioral disorders, including major depression, schizophrenia, and anxiety. Although the Greeks recognized the significance of emotions in mental disorders, medieval thought emphasized demonic influence. From the Middle Ages until the time of the French physician Philippe Pinel (1745–1826), who instituted humanitarian reforms in the care of the mentally ill, there was no organized attempt to study or treat mental abnormalities or to provide decent institutional conditions for the mentally ill. Such 19th-century reformers as Dorothea Dix fought for improved conditions in asylums. The early 20th cent. saw the organization of the mental hygiene movement, dedicated to the prevention of mental disease through guidance clinics and education. Scientists of the period sought underlying causes of mental and nervous disorders. The German psychiatrist Emil Kraepelin was the first to divide psychosis into the two general classifications of manic-depressive psychosis (see bipolar disorder) and schizophrenia. Gradually, some psychiatrists, led by Sigmund Freud, turned to the behavior and emotional history of the patient as clues to the nature of psychoneurosis and psychosis.
Today, a wide variety of treatment strategies are used in psychiatry, to combat many different psychological disorders. Psychiatry may involve physiological or psychological treatment, or a combination of the two. Physiological treatment generally involves the use of drugs influencing neurotransmitter functions in the brain, or electroconvulsive treatment (see electroconvulsive therapy). Psychiatrists are licensed physicians, specially trained to treat patients with mental disorders and to prescribe drugs. In recent years, psychological difficulties have lost much of the stigma they once had, and many people have sought psychiatric help who might have been reluctant to do so in the past.
See C. M. McGovern, Masters of Madness: Social Origins of the American Psychiatric Profession (1985); C. Thompson, ed., The Origins of Modern Psychiatry (1987); L. Robins and D. Regier, ed., Psychiatric Disorders in America (1991); R. Michaels, ed., Psychiatry (1992); H. Kaplan and B. Sadock, Comprehensive Textbook of Psychiatry (2 vol., rev. ed. 1993); T. M. Luhrmann, Of Two Minds: The Growing Disorder in American Psychiatry (2000).
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psy·chi·a·try / səˈkīətrē; sī-/ • n. the study and treatment of mental illness, emotional disturbance, and abnormal behavior.
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—psychiatric (sy-ki-at-rik) adj.
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