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Bulletin of the History of Medicine 74.4 (2000) 794-802



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Therapeutics and the History of Psychiatry

Joel T. Braslow

Beyond the "Two Psychiatries": Jack Pressman's Last Resort and the History of Twentieth-Century American Psychiatry

Over the last couple of decades, historians of medicine and psychiatry increasingly have probed the messy and complicated world of clinical medicine. In so doing, they have asked fundamental questions regarding the nature of everyday medical practices. These questions have included, for example, why do physicians do what they do when treating and caring for their patients? How does a practitioner decide when to deploy a particular intervention and then judge whether or not it has worked? How do institutional, social, cultural, and scientific milieus shape these judgments? The recent publication of Jack Pressman's book, Last Resort: Psychosurgery and the Limits of Medicine, represents a further development of this historiographic trend and provides us with an opportunity to reflect on this growing body of scholarship within the historiography of psychiatry. 1 To this end, I will first outline the early phase of this shift that focused, for the most part, on nineteenth-century asylum practices. I then will turn to more recent work on the twentieth century, where specific therapeutic interventions have taken center stage. In particular, historians increasingly have been focusing on somatic or biological remedies, such as lobotomy, the shock therapies, and psychotropic drugs--an emphasis that reflects, in part, the current dominance of biological psychiatry. I will conclude with some thoughts about how this new historiographic trend, as exemplified by Last Resort, does more than simply [End Page 794] chart the course of psychiatric science and practice: it also makes significant insights into the nature of present-day clinical science and what it means to be a physician.

As has often been noted, historians are always writing within a contemporary cultural and scientific milieu, which shapes both the object of inquiry and what counts as important questions to examine. This, of course, is true for historians of psychiatry as well. 2 The dizzying speed with which psychiatric theory and practice have altered over the last fifty years has made for a particularly diverse historiography. Let me summarize these well-known vertiginous changes in psychiatric theory: in the 1930s and 1940s, psychiatrists held to an eclectic mix of biological and psychological theorizing; in the 1950s and early 1960s, psychoanalysts gained fleeting hegemonic influence over the profession; and by the late 1970s and early 1980s, biologically oriented psychiatrists largely dominated (as they continue to dominate) psychiatric theory. There have been equally dramatic changes in psychiatric practice and in who could be classified as a psychiatric patient. Most obvious among these changes has been the near extinction of the state hospital system and a massive expansion of who counts as a psychiatric patient, especially as an object of biological intervention. 3

Histories of psychiatry often have found themselves tightly linked to these gyrations in psychiatric theory and practice, yet many of these works tell us little about the nature of clinical care. Spanning the last fifty years of psychiatric historiography, Gregory Zilboorg's 1941 History of Medical Psychology and Edward Shorter's 1997 History of Psychiatry: From the Era of the Asylum to the Age of Prozac exemplify this particular genre, falling far short of illuminating the contemporaneous practices that have so strongly influenced them. 4 Writing on the eve of psychoanalytic hegemony, [End Page 795] Zilboorg chronicles a story that leads inexorably toward the triumph of psychoanalytic truth and largely ignores what he saw to be the blind alleys of biological psychiatry. Not surprisingly, given the revitalization of biological psychiatry, Shorter, more than fifty years later, has turned this history on its head: for him, psychoanalysis was an ill-begotten detour into pseudoscience, while contemporary biopsychiatry has been the inevitable outcome of psychiatric science and practice. Zilboorg's book was indebted to the growing influence of psychoanalysis, and Shorter's narrative was inextricably part of the biological psychiatry of the 1990s. Nonetheless, despite being enmeshed within whatever happens to be...

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