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In the early 20th century psychiatry was, in the words of Adolf Meyer, “largely an institutional and legal task.” The best institutions provided a clean and calm place where patients struggling with agitation or paranoia or self-destructive urges could live safe from society (and vice versa). Whatever treatment was offered quelled psychological distress generically using methods that might strike a 21stcentury citizen as primitive or brutal or at least dangerous; these included restraint, cold baths, sensory deprivation, or induced coma.
It was in this context that William Osler, in his farewell speech to the Johns Hopkins Hospital—then as now renowned for its rigorous, scientific approach to medical illness--called for a psychiatric clinic. Adolf Meyer became its first director.
Meyer had high hopes that scientific investigation would eventually reveal the biological underpinnings of mental illness, but he was also well aware that general medicine’s “hard and fast diagnostic, prognostic, etiological and descriptive and explanatory ‘pathological’ terms…may not be...applicable in our own field.” He called for psychiatrists to focus on the objective facts of a patient’s life, for “in contrast to the practice of past ages, we do not start from mythological and philosophical absolutes, but single out concrete data of experience in whatever complexity we may find them…(salient to) personality, character, experiences and tendencies, the intellectual and active and affective and thought processes and assets…life-attitudes…(and) behavior.” (all quotes from Meyer’s presidential address to the APA, 1928)
From its earliest days, the Phipps Clinic aimed primarily to study patients as individuals. The Phipps psychiatrist aimed to develop a multi-layered psychobiological formulation based on a patient’s biography; in contrast, psychiatry elsewhere had swung between rendering simple diagnoses based on symptoms and spinning elaborate narratives rooted in the interpretation of ambiguous signals from a patient’s unconscious mind.
Starting around the time Meyer retired, new developments in biological treatment of severe mental illness began to emerge. Some of these—electroconvulsive therapy and medications targeted to certain brain systems (those dependent on dopamine, serotonin, and norepinephrine as neurotransmitters)—have persevered to the present day, while others—insulin shock and frontal lobotomy to name a few—have justifiably died out. During those middle years of the 20th century, the Phipps faculty continued to apply a behavioral approach to comprehend the causes of mental disorder, a pragmatic focus to the use of psychotherapy, and an exploratory focus on the emerging psychopharmacologic revolution.
By the time Paul McHugh became chairman of the Phipps Clinic in the latter part of the 20th century, the modern biological approach had fully emerged and was expanding rapidly into the theoretical vacuum left behind by a retreating psychoanalytic paradigm. McHugh’s idea, as expressed with Philip Slavney in The Perspectives of Psychiatry, built on Meyer’s idea that mental disorder arises from a combination of biological insult, dimensional attributes, maladaptive behaviors, and the patient’s own life story. McHugh and Slavney added to Meyer’s focus on the content of the patient’s biography the phenomenological approach of Karl Jaspers, which called for a heightened sensitivity to form; that is, not simply what the patient has to say about his or her experiences, but how the patient says it, or conveys it through behavior.
The story of American psychiatry over the past century is a pendulum-like swing from the extremes of depth psychology—the idea that the key to mental illness hides in the dark caves of the unconscious—to the overreliance on superficial signs and symptoms to reduce an individual’s mental suffering to a numeric diagnostic code. From the time of Meyer, who stressed the objective details of a person’s life, to McHugh, who transformed the psychobiological model into a set of tools a psychiatrist can apply to help resolve the complex problems of any patient, Hopkins has stood steadfastly, proudly, and above all, pragmatically apart from fads, movements, and dogma.