During the first half of the twentieth century psychiatry developed in many directions. Kraepelin's monumental synthesis established around 1900 a nosological system which, in its broad outlines, has remained valid until today. Without being radically altered it was completed, to mention only a few contributions, in 1911 by Bleuler's description of schizophrenia and in 1913 by Jaspers' psychopathological perspective, developed by the Heidelberg school and Kurt Schneider, and by other psychiatrists working in academic institutions. However, the old conflict between the 'mentalists' and the 'somatists' reappeared in a modified form. The mainstream of psychiatry had abandoned the extreme positions of the 'brain pathologists' of the Meynert-Wernicke type but, while recognizing a limited influence of psychological factors, admitted in a general way the biological origin of the more severe mental disorders—the psychoses. The empirical discoveries of biological treatments—of general paralysis by malaria therapy (Wagner von Jauregg in 1917), of schizophrenia by insulin coma (Sakel in 1933) or by chemically induced seizures (von Meduna in 1935), and of depression by electroconvulsive therapy (Cerletti in 1938)—not only helped to dispel the prevailing therapeutic pessimism, but provided supporting arguments. However, an opposing ideological current represented by psychoanalysis had arisen from the study of the neuroses. Its attention was concentrated on the study of complex psychopathological mechanisms postulated to be at the origin of the neurotic, and later also of the psychotic, symptoms, favoured psychogenetic aetiological theories, and advocated psychotherapy as the fundamental form of treatment. Psychoanalysis expanded steadily during this period and gained enthusiastic adherents in many countries. However, partly because of the suspicion and even hostility of many members of the psychiatric establishment, they remained isolated in close-knit groups with their own teaching system independent of the official medical curriculum, and the use of their therapeutic technique was restricted to a small number of mostly neurotic patients seen in outpatient clinics or, more often, in private practice.
The great majority of patients suffering from mental disorders were still confined in asylums, and the enormous increase in their number, mainly related to the social changes accompanying industrialization and urbanization although other factors have been invoked, was striking. In Great Britain it grew from 16000 in 1860 to 98000 in 1910, three times more rapidly than the population. A similar phenomenon was observed in all countries and persisted until the end of the 1940s despite the introduction of the first biological therapies. In the United States they were already 188000 patients in mental hospitals in 1910, and by the end of the Second World War 850000 were lodged in huge institutions which were overpopulated, understaffed, and could only provide custodial care. This obvious degeneracy of the asylum system, contrasting with the progresses in the scientific field, stimulated efforts to improve the practice of psychiatry and its institutional framework. Most of these improvements took place after 1920 and, although their results remained relatively limited, they were the forerunners of later more drastic changes.
The education of psychiatric specialists, which had varied widely from country to country, was improved and systematized. A convergence of evolution is apparent during this period which can be said, to some extent, to have seen the formal administrative recognition of psychiatry as a medical specialty. Educational programmes and controls of the level of competence were introduced which extended beyond psychiatrists in academic positions. A limited teaching of psychiatry became compulsory even in the general medical curriculum. In France, psychiatrists for public asylums and, in some cases, residents in psychiatry were selected by a competitive examination system. In England, the Board of Control recommended in 1918 that a leading position in a psychiatric institution could only be occupied by a physician who had obtained a Diploma in Psychological Medicine awarded by the Royal College of Physicians and by five universities. In the United States the moving force behind the reforms was Adolf Meyer, the Director of the Henry Phipps Clinic at Johns Hopkins University from 1913 to 1939, who organized a systematic residency system and promoted the creation of the Board of Neurology and Psychiatry. This Board was established in 1936 and awarded a diploma which it became necessary to hold to be recognized as a specialist.
The changes were reflected in the vocabulary. The term psychiatry, originating in the German-speaking countries and mostly used there, was adopted everywhere at the beginning of the century. In France, the health authorities officially substituted ' hôpital psychiatrique' for 'asile d'aliénés' and 'psychiatre' for 'aliéniste' in the 1930s. In England, a Royal Commission used the words 'hospital', 'nurse', and 'patient' instead of 'asylum', 'attendant', and 'lunatic' for the first time between 1924 and 1926. However, efforts were also made to dissociate, when possible, the social protection function of the institutions from their medical role by allowing them to admit patients under the same conditions as the general hospitals. In 1923 a special section was created in the Paris Sainte-Anne asylum which provided treatment to voluntary patients and had both hospital beds and a large outpatient department. In England the Mental Health Act 1930 made voluntary admissions to psychiatric hospitals possible; by 1938 they already constituted 35 per cent of all admissions.
Social considerations had always been evident in psychiatry, but their traditional expressions had mainly been of a negative nature, i.e. the confinement of patients in asylums. The new possibility of free admissions reflected an increase in tolerance towards the disturbing character of mental illness. At the same time a differently oriented and broader social perspective appeared. The concept of mental hygiene originated in the United States with the creation in 1919 by a former patient, Clifford Beers, of an organization whose internationally growing influence was manifested by well-attended congresses held in Washington in 1930 and in Paris in 1937. From its beginnings the movement was not purely medical and was influenced by various humanitarian philosophical trends. It emphasized the role of social factors, such as living conditions or educational practices, in the origin of mental disturbances and promoted their prevention and treatment by the close co-operation of psychiatrists and nurses with non-medical groups in the community. One of the institutional consequences of these ideas was the creation of the profession of social worker. They began their activity in Adolf Meyer's clinic (Adolf Meyer had been an early supporter of the mental hygiene movement whose principles converged with his own ideas), at the Sainte-Anne Hospital in Paris, in England where the London School of Economics opened a special training course in 1929, and elsewhere.
Contemporary with the emergence of psychiatric social work was the expansion of clinical psychology. The Binet-Simon scale for the measurement of intelligence, developed in 1905, was the first application to psychiatry of the new discipline of experimental psychology which had originated at the end of the previous century. This initial contribution led to the creation of a professional class of clinical psychologists who were initially concerned with the development and use of psychological assessment instruments and with theoretical research in a few psychiatric centres. Their number initially remained low; in 1945 the United States, where they were most numerous, had about 4000 psychiatrists but only 200 clinical psychologists.
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