6 PANIC AND ANXIETY

RESEARCH PERSPECTIVES: PROFESSIONAL ISSUES

MELVIN SABSHIN

American Psychiatric Association, 1400 K Street NW, Washington, D.C. 20005, U.S.A.

Psychiatry has been undergoing massive changes during the last 20 years, and it is likely that the profession will continue this transformation through the first decade of the next century. In previous publications, the author has related these changes to the joint impact of research advances and economic pressures upon professional practice. In this paper, these developments will be reviewed historically. The author will then outline his predictions for the next phase of psychiatric professional development, which, he believes, will become evident by the second decade of the next century. While the author is most familiar with transformation of the psychiatric profession in the United States, he will utilize his experience as an officer of the World Psychiatric Association to indicate how the American developments are relevant and, in some cases, irrelevant to international psychiatry.

Since the second World War, psychiatry in the United States has experienced considerable upheaval. From the broadest perspective, the past 45 years can be divided into two phases: The first phase began after the war and continued for about 25 years. The second phase began in about 1970 and is still proceeding. Research perspectives have become increasingly significant in dominating the profession's clinical practice in the current phase, and there are strong indications that this trend will accelerate for the foreseeable future. The period from 1945 to 1970, however, was dominated by conflicting therapeutic ideologies which relied heavily upon theoretical constructs and charismatic leaders. The proliferation of ideologies developed, in part, because of the relatively weak status of psychiatric research. Psychotherapeutic, somatotherapeutic, and sociotherapeutic perspectives abounded, and groups of professionals clustered around persuasive leaders. Simultaneously, the boundaries of psychopathology broadened radically to include a wide variety of patients with problems not previously included in any diagnostic system. The period 1945 to 1970 also involved a structural demedicalization of psychiatry that deemphasized diagnosis, specific standards of treatment, prevention, and epidemiology. Psychiatry was regarded by many as a shortage specialty, and efforts were made to recruit as many people as possible into the field and into other related mental health professions. The growth was essentially unregulated, and there seemed to be no limit to the number of practitioners that could be absorbed.

By 1970, however, significant changes had become evident. The unregulated practice of psychiatry came to an end with increasing concem about the cost of psychiatric care becoming a major preoccupation of fiscal decision-makers. They also questioned the reliability of

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psychiatric diagnosis and the validity of divergent therapeutic approaches. Partially in response to these criticisms, but also stimulated by research advances, a period of clinical empiricism evolved, which ultimately superseded ideologies. Logical positivism became the dominant model, and scientific values began to replace the array of theoretic constructs that had not been tested by adequate scientific methodology. Objectification of psychiatry emerged, largely influenced by rapid advances in psychopharmacology, neuroscience, and nosology. The DSM-III became the symbol of psychiatry's change. It was propelled by scientific developments, but also by the need to demonstrate the increased reliability of psychiatric diagnoses and therapeutic techniques to relevant decision-makers and the public-at-large. Simultaneously, a structural remedicalization of psychiatry replaced the demedicalization; nosology, epidemiology, and rational guidelines for psychiatric treatment moved to the center of professional interest. Psychiatry was forced to give up its unregulated growth in numbers of professionals, and solo practitioners became an endangered species. The need to justify diagnosis and therapeutic procedures became stronger and is still accelerating.

Many of these developments occurred in countries other than the United States, although the intensity and extent of the changes has been most dramatic in the United States. The current period is, in part, an overcorrection for the post-war phase. The author predicts a new type of stabilization early in the next century and will conclude the paper by describing the potential contours of the new stabilization. Research values will still predominate, incorporating new technology and new theory with professional practice, dominated by the combined use of psychopharmacologic and psychotherapeutic techniques.