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Social Psychiatry, Managed Care, and the New Millennium

Social Psychiatry, Managed Care, and the New Millennium

The advent of the new millennium has stimulated many discussions about what changes can-and should-occur in the world. For social psychiatry, there could not be a more fortuitous time to review and reaffirm our role in this country's health care.

Brief History of Social Psychiatry

Perhaps the first indication of the importance of social psychiatry came in the form of the "moral treatment" for hospitalized psychiatric patients in Europe at the turn of the 19th century. This movement provided evidence that a change in the inpatient environment and more humane social interactions produced an improvement in patients' functioning. The importance of social psychiatry became even more obvious in the United States at the beginning of the 20th century with the work of Adolf Meyer, M.D. He became well-known for emphasizing many important social factors, including studying the whole individual, constructing life charts of major events in a patient's life and integrating social work into psychiatric treatment settings (Brady, 1975).

Many American psychiatrists and other mental health professionals followed in Meyer's footsteps, writing major texts on various aspects of social psychiatry. Among them, Karen Horney, M.D., wrote about personality in terms of "toward," "against" and "away from" other people (1937); Erik Erikson discussed societal influences on life development (1950); Harry Stack Sullivan, M.D., reviewed interpersonal psychotherapy (1953); August Hollingshead, Ph.D., and Fredrick Redlich, M.D., revealed social class influences on the provision of psychiatric treatment (1958); and Alexander Leighton, M.D., explained the influence of social disintegration on the development of mental illness (1959).

World War II and the surprising number of psychiatric casualties from trauma made the influence of social stress more apparent. The success of crisis resolution on the war front and in other outpatient interventions, along with a moral concern over hospital warehousing, led to deinstitutionalization and a new social system of care in the guise of the community mental health care movement of the 1960s.

In general medicine, attention to social variables was admonished by Hippocrates, with his concern for the total human in his or her total environment. This perspective crystallized in 1977 in the work of George Engel, M.D., who wrote a classic article emphasizing a biopsychosocial paradigm instead of biomedical reductionism. Of all the medical specialties, psychiatry seemed to pay the most attention to this model.

In 1971, American psychiatrists who were giving special attention to the social part of the model started the American Association for Social Psychiatry (AASP). By the 1980s, social factors had a presence in our DSM-III in the Axis IV and V categories. American Psychiatric Association presidents (Fink, 1988; Hartmann, 1992) intermittently reminded us of the importance of the integrated biopsychosocial model.

Social Psychiatry in the 1990s

With the burgeoning recognition of the influence of social factors on the prevention, etiology, access, diagnosis, treatment and repercussions of mental disorders, social issues continued to receive attention in the 1990s. Many of these issues were discussed in a major international conference and in a reference book on social psychiatry (Sorel, 1993). Advances occurred in psychosocial rehabilitation techniques, addressing homelessness, reducing stigma, increasing clinical cultural competence, attention to trauma, services in jails and prisons and successful advocacy groups, among other things.

Add to these social psychiatric achievements the continued refinements of psychotherapies and the striking advances of biological psychiatry in the form of helpful new medications, and one would expect psychiatry to be in a golden age. But it is not. Why?

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