Dan G. Routledge , 9 Jun - halaman. Depression has become the most frequently diagnosed chronic mental illness, and is a disability encountered almost daily by mental health professionals of all trades. Why, this book asks, has the incidence of depression been on such an increase in the last 50 years, if our basic biology hasn't changed as rapidly? To find answers, Dr. Blazer looks at the social forces, cultural and environmental upheavals, and other external, group factors that have undergone significant change. Entire textbooks have been devoted to cultural psychiatry in recent years.
In one chapter, Becker and Kleinman challenged usual current practices. In particular, Becker and Kleinman noted that psychiatric disorders always unfold in a particular social and cultural context. Finally, he reviewed in some detail the community responses to the mentally ill. Social origins and therefore social causation, which is key to sociology have virtually disappeared from this textbook. They have disappeared as an interest of psychiatrists. Cultural psychiatry, in contrast, continues to speak with a distinct though peripheral voice. Why Did Social Psychiatry Retreat?
The blossoming of social psychiatry during the s was in large part predicated on the ability of psychiatry to change society.
The potential of social psychiatry to actually transform society, however, was questioned from within even before the activism of the s emerged. H Warren Dunham, coinvestigator in the landmark Chicago study,32 as I describe in chapter 3, did not believe social psychiatrists had unique skills in the techniques of social action p.
In fact, he believed that social psychiatry was in its infancy. Psychiatrists had not adequately delineated social causes of psychiatric disorders. But has the abandonment of social psychiatry actually strengthened the field in the long run? Urban living has been associated with increased risk of psychiatric disorder,40, 41 yet other studies do not show such a relationship. Regardless of the intuitive appeal of social causation, the evidence accumulated to date has been modest.
The assertiveness community training program for such patients and their families is an exception.
Although the empirical evidence that such a program can be effective was emerging, governments slashed funds for community mental health centers the logical site to provide such care. Some have questioned if the investigation of the social origins of depression and other psychiatric conditions is discouraged at the federal level. Finally, the gravitation of the media to the latest scientific breakthroughs ensures that biological rather than social issues will receive attention. Poverty just does not sell. Others had broadened that definition to include the study of the variations and vicissitudes of human behavior, with optimal personal and social functioning as the goal.
The specialty had become a heterogeneous collection of sciences and practices without a unified goal. Psychiatry appeared to range from basic biology to philosophy.
Social psychiatry was never best served by a subgroup of social activists championing social theories that had not received adequate empirical study. It therefore never gained a firm foundation as a subspecialty within psychiatry.
Some people find postmodernism infuriating; some find it puzzling; others yawn. But love it or loathe it, the postmodern critique of psychiatry is here to stay. Dan G. Blazer, M.D., Ph.D., is J.P. Gibbons Professor of Psychiatry and Behavioral Sciences and Professor of Community and Family Medicine, Duke University.
According to Ransom Arthur, It is probable that the Zeitgeist of the last decade [the s], which emphasized awareness of social phenomena, disillusionment with human institutions, and political activism, has enormously enhanced the expansion of social psychiatric thinking. At best, social psychiatry should have been and should be a recognition of and reflection on the origins, perturbations, and treatment of emotional suffering by all mental health professionals from a societal perspective.
We should adopt and adapt current social theories, as I describe in chapter 9, for the social sciences have progressed in many notable areas. But instead, the excesses of social psychiatry opened the door for the neurosciences to crowd it out altogether. The public placed more confidence in the market.
Still, a far more pervasive public influence hastened the retreat of social psychiatry: the attraction of the public to the medical more specifically the genetic model of illness in general. Nevertheless, genes have become the blueprint for the body as a machine DNA builds the building, it does not just set the scaffolding. Attractions of genetic explanations include the allure of specificity and the ease of communicating specific causes.
The responsibility for illness shifts to individuals specifically to their biological makeup and away from environments and social structures. Scientists must continue to publish new biomedical discoveries, whether those discoveries will be refuted 6 months later or not. On the other hand, reports that major depression is more prevalent in urban than in rural areas are at best old news and at worst irrelevant news.
In , an advisory panel recommended that the NIMH increase its extramural research commitment to neuroscience and related brain and behavior research. In addition, clinical treatment studies as opposed to community intervention became its central focus. A new epidemiology see chapter 6 was to emerge.
Service should focus on the severely mentally ill. Direct federal support for the community mental health centers ceased during the s. The research budget of the NIMH therefore shifted dramatically to basic biological research and doubled during the s. The shift to biomedical research did not entirely stifle public advocacy. Advocacy, however, took a different face. The authors of this plan should not be criticized for omitting the social sciences. They reflected current mental health research agendas. These explorations, however, are to concentrate on biological issues.
For example, the focus on race, ethnicity, and culture is to ensure a racially and ethnically diverse scientific workforce and to include full racial and ethnic diversity within studies. Prevention is to be focused on persons who already experience an illness; that is, secondary early intervention and tertiary avoiding chronicity prevention. If race because it is associated with other psychosocial risk factors such as poverty is associated with an increased risk for depression, study of this increased risk does not fall within the plan. Yet caution was noted from the outset. We have been through these phases many times before [could the current era be similar?
The mental health centers were not prepared to treat the most severely mentally ill patients, and the patients gravitated to the streets. One of the prime causes of homelessness today is the persistent trend to deinstitutionalize patients who had lived many years in institutions, with little in the way of services in the community to assist them. What happened, however, was that social psychiatry failed and the hegemony of psychopharmacology and diagnostic psychiatry emerged.
The social psychiatry movement spectacularly failed to treat the severely mentally ill, as I describe in chapter 4. Therefore the social activism of psychiatry was actually social control. In The Myth of Mental Illness, Thomas Szasz, an especially strident critic, proposed that mental illness was in fact a myth that described people who actually experienced problems of living.
The argument is most relevant to social psychiatry, for as psychiatry became more active as an advocate for the mentally ill, psychiatrists also became advocates for labeling persons as mentally ill. Yet the movement certainly contributed to the decline of psychoanalysis and social psychiatry and to the emergence of a more scientific and medicalized psychiatry.
In , Torrey published The Death of Psychiatry. The others had brain disease and ought to be given back to the neurologists. In addition, the medical model is a kind of contract between patient and society—one of the clauses says that the patient is not responsible for getting the disease p.
The evidence of caring but not curing is no better seen than in a pivotal legal case during the late s. The Osheroff case in might have sealed the fate of psychoanalysis as a powerful force in psychiatry and social psychiatry at the same time. During inpatient and outpatient care, he received only psychotherapy. Imipramine had been introduced as an effective treatment 20 years previously. Empirical studies became the foundation of psychiatric therapies following Osheroff. Social psychiatric therapies could provide no empirical base.
Wells, A. Stewart, and R. Hays, Journal of the American Medical Association p. The message from the authors of this study is clear: Major depression is a critical public health problem and people are not being treated nearly as often as they should. Let us take a closer look at the studies that support such startling headlines.
The first wave was fielded during the s, and the results were published predominantly during the early s. These studies fueled and defined the social psychiatry movement of the s. Psychiatrists trained in psychoanalysis and the social psychiatry of Adolf Meyer primarily directed these studies. The second wave of studies emerged during the s and s.
The findings reinforced the new psychiatric nomenclature.