In 1983, Melvin Sabshin, the Director of the American Psychiatric Association, summarized the overlapping chronologies of the psychodynamic, biological, and social waves as follows:*6)
Psychoanalysis surged through the United States during the 1940s and the 1950. During the 1950s a new psychopharmacological approach emerged which had great impact on psychiatric practice generally ... The 1960s saw the dawning of a community psychiatric approach which attempted to accomplish a massive desinstitutionalization of patients from public psychiatric hospitals.
Although less radical and not strictly identical, the general picture was similar in other countries. The 1960s saw an often uneasy coexistence of three schools. 'During that decade', wrote Sabshin, 'American psychiatry enlarged its boundaries and its practices so broadly that many critics grew increasingly concerned with the "bottomless pit" of the field'. The extension of the practice of psychotherapy, frequently to cases with no clear pathological character, tended to blur the limits of the mental disease concept and to neglect the traditional diagnostic approach. Social work was also tempted to concern itself with problems with no obvious medical nature, such as those still described in 1978 in the United States by the President's Commission of Mental Health, which asserted that 'American mental health cannot be defined only in terms of disabling mental illness and identified mental disorders' and identified as a domain of concern for workers in the field 'unrelenting poverty and unemployment and the institutionalized discrimination that occurs on the basis of race, sex, class, age...'. In sharp contrast, the new biological psychiatry recognized only a strictly medical model, stressing the necessity of an accurate diagnosis for the prescription of the drugs and for the testing of their efficacy, and advocated restrictive limits in the definition of the mental diseases.
Around 1970 a profound change took place. Although the institutional modifications of the care system favoured by the generalization of drug therapy continued and expanded under its various forms everywhere, the influence of psychodynamism began to decline within the psychiatric profession. According to the Director of the National Institutes for Mental Health 'it was nearly impossible in 1945 for a non-psychoanalyst to become Chairman of a Department of Psychiatry (in the United States)' but by the mid-1970s the situation was reversed. The publication by the American Psychiatric Association of the Third Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) is often considered as the symbolic expression of the change. This took place in 1980, but its origins were more than a decade previously, and it was significantly presented by its apologists, such as Klerman, as 'a decisive turning point in the history of American psychiatry... an affirmation of its medical identity'. The new nosology, which was categorical in nature and introduced diagnostic criteria borrowed from experimental psychology in the delimitation of the categories, did not allow any reference to 'unproven' aetiological factors or pathogenic mechanisms, unless 'scientifically demonstrated'. It claimed to be purely descriptive and therefore acceptable as a means of communication by all psychiatrists, whatever their individual orientation. It was in fact perceived, not only in its country of origin, as a reaction against the extreme socio-psychological positions—the deletion of the term neurosis because of its usual association with the psychoanalytic theory of intra-psychic conflicts raised violent controversies—and, despite its proclaimed 'a-theorism', as favouring the biological medical model. Although initially exclusively devised for the use of the American psychiatrists, to the surprise of its authors it was rapidly accepted in all countries and the WHO adopted finally its principles in its own nosological system, the International Classification of Diseases. Originally the result of a brutal reversal of trends in the American psychiatry, it expressed a general change of direction in the psychiatric way of thinking towards the affirmation, against the forces believed to threaten it, of the medical character of psychiatry.
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