Jack Pressman and the Future of the History of Psychiatry

I would like to attempt to forecast the direction in which historians of psychiatry will be headed in the immediate future, focusing first on the circumstances and then on the narrative of the history of psychiatry. My take is similar to, and yet a little different from, that of Joel Braslow in this symposium.

Prediction

Reading the future is of course a difficult, if not an impossible, task. I am fond of quoting the wisdom, variously attributed, that predicting is very difficult, especially concerning the future. ¹ We are all forced, throughout our lives, for our own guidance, to project the past and present into the future, and on this occasion I particularly want to suggest how Jack Pressman's book affords a glance into what lies ahead for historians of psychiatry in the next few years.

In trying to read what is coming, I shall not go through all of the philosophical contingencies that Nicholas Rescher describes in his comprehensive new book on predicting the future. Both technical analysis and common sense, however, suggest that the best possible information on current trends, along with past experience, yields the best predictors. ²

A dozen years ago, Nancy Tomes reviewed the then-most-recent publications in the history of psychiatry. She found that already a "'post-Foucaultian' generation" had appeared, and that cutting-edge historians were no longer obsessed with "the 'march of progress' versus the 'great confinement,'" and the "treatment-incarceration dichotomy." ³ Indeed, she was writing an epitaph for the social control writers who conceived of the history of psychiatry as the history of psychiatrists' imposing their "power" on patients and society. ⁴

The Changing Presents of Presentism

Since Tomes wrote, it has become more obvious how the writing of the history of psychiatry has been further affected by forces in the contemporary world. Therefore, like so many others attempting to explain changes in historical writing, I wish to revert to the tired but valid cliché that all historians write to a variety of presents, even as the better ones try to avoid the worst consequences of Whig history. For it is not possible to discuss the historiography of psychiatry without mentioning the impact of recent forces upon the specialty itself.

The first force is the circumstance that, in the United States, the formerly large and flourishing specialty of psychiatry is being reshaped (if not substantially destroyed) by external socioeconomic conditions, acting chiefly through managed care. A second current force is the dominance within psychiatry of a biological and pharmacological approach to mental illnesses.

Not even the most antiquarian historian, it seems to me, can ignore the remarkable erosion of the economic base of the specialty of psychiatry. Do we have, in the history of medicine, any precedents for a specialty that was so damaged by outside economic forces? Some small fields dependent upon a particular instrument or technology might come to mind, such as the late-nineteenth-century practice of electrotherapeutics. But that development, one might argue, reflected changes in medical science, not an outside economic force. ⁵ We have many other examples of fields destroyed by new knowledge. At almost exactly the same time that electrotherapeutics was fading, for instance, the germ theory of disease destroyed the field of pharmacognosy. But the specialty of pharmacognosy had been limited largely to teachers of the subject in medical schools, and in other ways it does not offer an apt comparison to what is going on in psychiatry now. ⁶

Perhaps the closest parallel of which we might all think was midwifery. By the mid-twentieth century, specialist historians like Harold Speert had written midwives out of the history of obstetrics. ⁷ But in this case, still another external force, modern feminism, quite transparently brought midwives...