Changing American Psychiatry: A Personal Perspective
When I first picked up Changing American Psychiatry by the American Psychiatric Association's (APA's) medical director for 23 years (1974–1997), Melvin Sabshin, I immediately thought that Steven Sharfstein, the APA's 132nd president, should review this book. Unfortunately, Sharfstein has a blurb on the dust jacket, which rendered him ineligible as a reviewer. Sharfstein's comment, however, is so accurate that I must include it here: "This is the remarkable history of the transition in psychiatry from ideology to science, written by someone who helped make this transition happen."
Changing American Psychiatry is written by an individual whom I always perceived as a gentleman and a scholar, and this book reflects those qualities. This book oozes sagacity page after page. It is an interesting montage of Sabshin's personal story, the story of the APA during his tenure as medical director, and the history of American psychiatry during the second half of the 20th century. Sabshin's message has a greater purpose than simply to recount where American psychiatry has been. In the introduction he informs the reader, "One of the main purposes of this book is to suggest how a scientific, psychosocial renaissance might be encouraged and why such a development is important for the field as a whole." Amidst a tsunami of psychopharmacologic resources, research, and treatment, this call for such a renaissance is both rare and refreshing.
Sabshin sought and became the medical director of the APA and had a mission. A politically astute individual, he did not expound at any length about his ideas when being considered by the search committee. Sabshin notes, "If I had attempted to persuade the Search Committee that recommended me for the Medical Directorship to the APA Board that I already possessed a comprehensive plan to change American psychiatry systematically, I believe that I would have been given a diagnosis rather than a job." Not only did Sabshin have an agenda for the APA, but he had an agenda for its interactions with psychiatrists worldwide. He notes, "An American psychiatry that is respected and admired across the world and that is able to perceive and absorb the creative new ideas will be more likely to achieve equity than will an organization that functions as a self-absorbed isolated trade union." Consequently, Sabshin took the APA from a fairly isolationist position to one with an increased interest by its members in international psychiatry. American psychiatrists are now significantly more active in psychiatry in Eastern and Western Europe, Japan, China, South Africa, and the former Soviet Union and in the World Psychiatric Association.
Sabshin explains many of the "movements" that pulsed through American psychiatry after World War II. He pays particular attention to psychoanalysis and to psychopharmacology. He criticizes the former for the absence of a long-term research agenda and the latter for shutting out research in most other psychiatric endeavors. He bemoans the fact that "psychiatrists might lose their skill in talking to patients." He cautions psychiatry about its perpetual vulnerability to "regressive legal, political, and social censure." Whenever the public becomes outraged by violent acts committed by a former psychiatric inpatient, he passionately says, "I still react with fear of progressive policies enacted in the heat of our horror."
Progressive development of the Diagnostic and Statistical Manual of Mental Disorders ( DSM ) is covered at great length. There is much to learn here about the evolution of American psychiatric nosology, both present and future, as Sabshin covers the development of DSM-V to date. He reminds us that many psychiatrists have forgotten or never knew the degree to which American psychiatry neglected diagnoses in the postwar years. He jabs Freud with the comment that normality in Freud's words—"the capacity to love and to work"—may be poetic but has limited epidemiologic utility. He describes how the DSM has been one of APA's most progressive endeavors as a force for change.
What Sabshin hoped to do, and what he has significantly accomplished, was to assist American psychiatry in taking major steps to "behave like a medical science." He criticizes historians of American psychiatry for their failure to understand this. He returns repeatedly to the notion that restoring a more balanced research portfolio should be one of APA's and American psychiatrists' goals, a position that many do not agree with. Sabshin favors "support for an evidence-based, psychosocial renaissance for the field coordinated with neuroscience and embedded in a new and more rational health system."
Sabshin was a sustaining force in American psychiatry during his tenure from 1974 to 1997, a time he worked with 23 presidents of the APA. From this perspective, he cajoles American psychiatrists to move from a longing for days gone by to a state of "ebullience, optimism, and pride."
There are two obvious audiences for this book. First, any historian interested in the history of American psychiatry since World War II should read this book as a primer. Second, every American psychiatrist should read this book. Some should read this book twice. This includes psychiatric residents and all early-career psychiatrists. Two-time readers should also include all American psychiatrists who are not APA members. After doing so, I believe that a substantial percentage of them would join the APA. Changing American Psychiatry explains what the APA is, how it operates, and what it has done for psychiatry in the United States and worldwide over the past four decades.
Pick up a copy of Changing American Psychiatry and read it. Then, at the next APA annual meeting, track down Mel Sabshin (he still attends every one) and shake his hand or pat him on the back and simply say thanks.
