Mental Illness and Psychiatry Retrospect and Prospect

From our historical survey, several themes emerge concerning the linked development of psychiatry and conceptions of mental illness. Psychiatry as a learned discipline contains no one school of thought that is sufficiently dominant to control the medical meaning of insanity. Given the administrative realities within which mental health professionals currently labor, the move to a standardized diagnostic system may nonetheless win out. It is important for the various factions to share a common language, but this is not the same as reaching a consensus on why someone is disturbed and what should be done about it-two components of illness as a cultural reality.

This difficulty reflects in part psychiatry's unique evolution as a medical specialty. Common sociological wisdom holds that the livelihood of a scientific specialty depends on its capacity to defend the perimeter of its knowledge base. This task has always been problematic for psychiatrists, for the borders between lay and learned conceptions of madness remain indistinct, a situation that also pertains to the relations between psychiatry and other disciplines, medical as well as nonmedical. To begin with, mental disorders are not restricted to the controlled environs of the analyst's couch or laboratory bench, but are manifested in the home, school, or office, as disruption in love, work, or play. When the very stuff of madness is reduced to its basic elements, we find nothing more than a tangled heap of curious speech acts and defiant gestures, odd mannerisms and perplexing countenances - surely nothing as removed from everyday experience as is the retrovirus, the quark, or the black hole. Available for all to see and interpret, psychiatric phenomena thus form an epis-temological terrain that is not easily defended by a band of professionals who look to stake claims on the basis of privileged, expert knowledge.

Psychiatry's turf is also vulnerable at its flank, from adventurers in other learned disciplines who find that their own research endeavors, logically extended, encompass some aspect of mental illness. Thus, as a performance of the body, insanity has routinely been investigated by all the tools available to biomedical scientists and clinicians. Commentators have often noted that, as soon as a valid biological model is found to exist for a specific mental disorder (as in the case of syphilis and general paresis), that condition is moved out of the purview of psychiatry and is claimed by some other field - perhaps neurology or endocrinology. Over time, the condition even ceases to be considered psychiatric. And now that madness is known to have a cultural reality as well as a biological one, psychopathology has become a proper focus of most social sciences as well.

Unable to police its own borders, it is no wonder that psychiatry remains a confusing, polyglot world, one that reflects the input of myriad disciplines and sources. The surfeit of conceptual approaches to the problem of mental illness has often been cited as evidence that psychiatrists are a singularly contentious or poor-thinking lot. A popular professional response has been to invoke a "biopsychosocial" model of disease (expressed, e.g., by the multiaxial system of DSM-III), one that is interdisciplinary and multidimensional. The root of the problem is deeper, however. As mental disorders reflect the entirety of a person, so the study of insanity comes to reflect the present contradictions inherent in our universe of scholarly disciplines. Our various knowledge systems are unified more in rhetoric than in reality. The status of psychiatry and of the concept of mental illness suffers for making this situation visible.

Our historical survey provides us with another approach to the problem of mental illness, one that focuses not so much on the intellectual boundaries of knowledge as on the professional and social function of psychiatry. First, we have seen how modern psychiatry emerged not in isolation, but in relation to other areas of medicine: Psychiatry's peculiar domain is precisely those problems that baffle regular medicine. (The rise of the "nervous" disorders provides an excellent example of this phenomenon.) In the late nineteenth century, as medicine gained status as a scientific discipline, this role attained a special significance. Before, when virtually all of medicine was based on uncertain knowledge, there was no clinical problem that could be said to lie outside the physician's grasp. But as the physiological and bacteriological terrain came into sharper focus, so too did those areas in which medicine was admittedly ignorant. Paradoxically, as our scientific knowledge becomes increasingly sure, leading to ever higher expectations, those problems that cannot be solved develop an increased capacity to threaten our faith in science. "Functional" or "nonorganic" disorders, whose explanation as well as cure remain outside the boundaries of regular medicine, thus become disturbances not only within an individual but within the system of medicine as well. It is psychiatry's intraprofessional obligation to deal with these problems, shoring up the faith that, although no precise medical answers yet exist, they are still medical problems - and not yet the business of the astrologer or faith healer. Ironically, psychiatry is despised by the rest of medicine for this lowly, but vital role.

A more fundamental service role has been that of responding to personal crisis. As a specific construct, the term schizophrenia may one day find its way into the dustbin that holds neurasthenia, chlorosis, and other long-abandoned medical concepts. But the suffering and torment felt by persons so afflicted are not as easily dismissed, nor is the distress of their families. Patients and their families look to the psychiatrist to intervene in a situation where there is often little hope, to "do everything possible" to make the person whole again.

Put simply, psychiatry is the management of despair. This is the heart of the psychiatrist's social function, to care for those whose problems have no certain cure or satisfactory explanation, problems that often place a serious burden on society. To a large extent, this function stems from psychiatry's historical ties to the asylum, an institution into which poured a new class of social dependents. But psychiatry is more than custodial care that can be supervised by hospital administrators. Apparently, we find a measure of emotional security in entrusting these special woes to a group of trained professionals who have dealt with similar matters, believing that practical wisdom comes with experience; to those who can link our seemingly unique problems with past cases and thus somehow lessen the alienation and shame. The additional value of a medical degree is the promise that with it comes a trained intellect, a calm authority in response to crisis, and access to all available medical tools that might yield even a remote possibility of benefit, even if they are not yet understood.

In sum, psychiatry is a field defined not by reference to a specific part of the human body, like podiatry, or a specific class of people, like gerontology, or even a specific disease process, like oncology. Rather, it is a field demarcated by our collective helplessness in the face of human problems that by all appearances should be solvable and understandable through medical science, but as yet are not. Hence, what comprises mental illness is fundamentally a moving target, a hazy area that is redrawn by every generation and local culture as new problems and dilemmas arise. Specific categories of mental disorder are formed at the interface of social concern and professional interests, much in the way that the pressures of tectonic plates produce new features of the physical landscape. Thus, shifts in either cultural anxieties or professional priorities can shape the clinical geography. We have also seen that this border is a dynamic one, as professionals both respond to and in turn shape these areas of concern. That a given disease, once understood, is no longer considered psychiatric is thus not so much a loss for psychiatry as it is an indication of what has been psychiatry's true function. Once a disorder is well understood, psychiatry's proper business with it has in fact come to an end.

Now we have a perspective from which to view, in retrospect and prospect, the peculiar geography of mental illness. Looking backward at the history of the conditions associated with mental illness, at such things as hypochondriasis and monomania, we see an archaeological record not to be dismissed as mere professional folly, but a record of life's tragedies, large and small. No matter how successful science will be in the future in providing additional tools to alter the mind or brain, some of us nevertheless will be overwhelmed by life's new challenges, finding our own internal resources insufficient. For some, whether because of faults of biology, environment, or will, the collapse will be complete. That is the reality of mental disorders, which is surely not soon to disappear.

What the future holds for the organization of psychiatry as a medical specialty is not easily predicted. The special task of psychiatrists, in managing the unmanageable, is increasingly difficult to perform as it becomes harder to maintain the dual role of counselor and medical scientist. As medicine in general relies on ever stricter laboratory standards of what is real or valid, the definition of what constitutes a good doctor becomes that much narrower. The decline of the status of psychoanalysis, for example, may reflect the shrinkage that already has oc curred. In the past, part of a physician's medical authority stemmed from the assumption that he or she was learned in the ways of people and society, a knowledge that was seen as legitimating his or her right to intervene in intimate human affairs. Psychoanalysts, among the most scholarly of physicians, were thus looked upon as effective doctors. Now, however, such broad cultural learning is no longer considered an appropriate route to a career that demands the absorption and analysis of a tremendous volume of scientific facts. Whether psychiatry will dissolve into two separate professions, one of lay counseling and the other of purely biological treatment, remains to be seen. Yet there is also a possibility that general medicine will reintegrate the special function of the healing relationship into its list of medical priorities. Perhaps in this psychiatry might lead the way.

Jack D. Pressman

Healing Inside Out and Outside In

Healing Inside Out and Outside In

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