Psychotherapy for the Normal as a Postwar Growth Industry
The doubts that began to cramp clinicians' high spirits by the late 1960s were somewhat removed from the concerns of the general public. During the years after 1945, ordinary people sought therapeutic attention more insistently than ever before and for more reasons than ever before. While the direction of federal policy may have helped to push clinicians out of asylums, the explosion in public interest was at least as pivotal in pulling clinicians into the lives of ordinary citizens. Gushing demand for psychotherapy was much discussed by clinicians. Even dissenters like C. C. Burlingame, the director of the Hartford, Connecticut, Institute for Living and a staunch advocate of psychosurgery, who denounced the prevalent mood of therapeutic optimism as "psychiatric nonsense," admitted that "it has come to be quite the fashion to have a psychoneurosis!" Unlike Burlingame, most experts welcomed the surge in popular demand as evidence of a sort of public enlightenment "peculiar to the United States." They were quick to herald it as "one of the remarkable features of our culture," whether they understood it or not.
We have already seen that, in the wake of world war, new federal laws, bureaucracies, and funding embraced the changing emphasis from mental illness to health, spurred along by reenergized old and new professional pressure groups. By generating a new, publicly supported infrastructure for training, research, and service delivery in mental health fields, the federal government contributed to the migration of clinical experts out of isolated institutions devoted to insanity and into the heart of U.S. communities. A 1948 survey conducted by the American Psychiatric Association found that 35 percent of its members were already primarily engaged in private practice. The 1954 introduction of the first psychoactive drug, chlorpromazine (known by the trade name Thorazine), accelerated the trend, already under way, toward emptying traditional institutions. In 1956 the total number of patients residing in public mental hospitals declined for the first time since the nineteenth century, and the deinstitutionalization process picked up speed in the
mid-1960s. In 1957 only 17 percent of all American Psychiatric Association members were still charged with supervising custodial care to severely and chronically ill individuals in state or VA hospitals, the sort of institutions where virtually all psychiatrists had been located prior to 1940.
The new policy emphasis on deinstitutionalization was conveniently compatible with the case for normalization, delivery of preventive clinical services, and expansion of experts' authority and jurisdiction. Indeed, these factors were mutually reinforcing. The standard argument was that outmoded and ineffective institutional care would be replaced by more efficient and enlightened services delivered in a community setting. The community mental health movement, as it turned out, did not cause the numbers of institutionalized mental patients to drop. Rather, changes in federal programs during the 1960s—especially the creation of Medicare and Medicaid in the 1965 amendments to the Social Security Act—shifted elderly and chronic patients out of state hospitals and into nontraditional institutions as states quickly took advantage of new funding sources.
Advocates' rhetoric notwithstanding, the movement into the community neither replaced the old system of public mental institutions, nor adequately cared for severely and chronically mentally ill individuals, most of whom were simply moved from a publicly funded custodial setting to one in the private sector, typically a nursing home. In retrospect, it appears ironic that the expansion of the welfare state, with which liberal clinical reformers identified so strongly, undermined public commitments to the mentally sick and ushered in an era during which the logic of cost containment superseded the ethic of care. Ardent critics of the policy have consequently accused reformers of "ideological camouflage" and deinstitutionalization of "allowing economy to masquerade as benevolence and neglect as tolerance." Historians more sympathetic to policy reformers after World War II point to the fact of human fallibility, the impossibility of determining all consequences in advance, and the dangers of retrospective judgment and arrogance.
If it failed to achieve its stated goals, community mental health did succeed in providing new services—far more psychotherapeutic in emphasis—to a new clientele—far larger, better educated, and more middle-class. This accomplishment reflected a sharp reorientation of professional interests and a decided expansion in the market for therapeutic services among normal individuals. Increases in the sheer num-
bers of psychiatrists were startling in the postwar decades—professional association membership grew from 3,634 in 1945, at the end of World War II, to 18,407 in 1970—and the percentage of medical school graduates choosing to specialize in psychiatry ranged from a high of 7.1 percent right after the war to 6.4 percent at the end of the 1960s, numbers two to three times greater than the 1925-1940 period. Institutional care faded as the center of professional gravity it had once been. Psychiatric staff positions in public mental facilities were notoriously difficult to fill, with openings running around 25 percent nationally in the mid-1960s.
By the late 1950s and 1960s, most psychiatrists were either self-employed in private office practice or worked in educational institutions, government agencies, or the growing number of community clinics that catered to a "normally neurotic" clientele. In order to help veterans adjust to student life, the VA sponsored programs that expanded counseling on the university level and in 1958, the National Defense Education Act created sixty thousand jobs for an entirely new type of professional—the school guidance counselor—making individual testing and deliberate self-inspection an ever more routine feature of young students' lives. In outpatient clinics exclusively devoted to adult mental health, according to one 1955 estimate, at least 233,000 people annually were already receiving outpatient psychotherapy.
Clinical psychology underwent an especially rapid process of professionalization after World War II, spurred by the popularization of psychotherapy as well as by government generosity. In 1947 the American Psychological Association gave its institutional stamp of approval to the mushrooming practice of psychotherapy when it made clinical training a mandatory element of graduate education in psychology. The first effort to take stock of feverish postwar efforts to establish new training programs in clinical psychology came in August 1949 in Boulder, Colorado. Thanks to an NIMH grant, seventy-one psychologists from around the United States met to consider the future of clinical training on the graduate level. There was great excitement about future opportunities in the field, a feeling reflected in NIMH Director Robert Felix's opening comments. "The mental health program is going forward, and neither you nor I nor all of us can stop it now because the public is aware of the potentialities."
Problems were nevertheless immediately apparent. Although no one present at the conference seemed to know exactly what a clinical psychologist was or what a clinical psychologist did, they quickly agreed
that a doctoral degree was necessary to do it. The Ph.D. was necessary "to protect the public and to create some order out of the present confusion" because "in the public mind there is considerable confusion of the professionally trained clinical psychologist with the outright quack."
What to do about the practice of psychotherapy in particular was equally baffling but probably more pressing and definitely more controversial. Conference attendees were aware of the need to balance the huge market for this service against the many unresolved questions surrounding its practice and outcomes. "Social needs, demands for service, and our own desire to serve effectively have compelled us to engage in programs of action before their validity could be adequately demonstrated." Pressured to respond to public demand, they were still at a loss to describe psychotherapy or list its benefits with even minimal precision. The only definition of psychotherapy generating consensus was so general that it was of negligible use in planning training programs. According to the conference record, "psychotherapy is defined as a process involving interpersonal relationships between a therapist and one or more patients or clients by which the former employs psychological methods based on systematic knowledge of the personality in attempting to improve the mental health of the latter."
Because the practice of psychotherapy was evidently as vague as it was popular, little agreement existed about the type of educational preparation required to make a good therapist, but much agreement existed that more good therapists were needed. Should therapists-in-training be required to be in psychotherapy themselves? Did students aspiring to careers as therapists really need rigorous training in scientific research methods? No one was certain. One sarcastic, unidentified conference participant summarized the muddled thinking on this question. "Psychotherapy is an undefined technique applied to unspecified problems with unpredictable outcome. For this technique we recommend rigorous training."
The details governing psychotherapy and its practice remained contentious matters among the experts long after the Boulder conference. The first really damaging critique, in fact, came more than three years later from Hans Eysenck. Eysenck was a British psychologist with a reputation as a hard-nosed experimentalist whose career had taken a sharp turn toward clinical work during World War II; he eventually taught the first British course on clinical psychology. In 1952 Eysenck
suggested not only that no evidence of psychotherapy's tangible benefits existed but that there was "an inverse correlation between recovery and psychotherapy." Ironically, Eysenck's heresy provided psychotherapy's defenders with years' worth of work. Throughout the 1950s and 1960s, they assiduously devised ever more creative ways to define and measure psychotherapeutic outcomes and this new field of scientific research evolved into a small industry.
Then there was the very delicate question of how clinicians in psychology or other professions should negotiate with psychiatrists, who had always monopolized psychotherapy and uniformly opposed its practice by other professionals. The forces of organized medicine repeatedly asserted that "psychotherapy is a form of medical treatment and does not form the basis for a separate profession." According to many physicians, the psychologist should have been grateful to play a limited and subordinate role similar to that played by the nurse in general medicine, who, they pointed out with some annoyance, was far more likely to understand "her" place.
None of this did much to slow experts outside of psychiatry, who grew ever bolder in their claims to autonomous practice as the definition of psychotherapy stretched. To them, it was a service "sought by people who do not think of themselves as ill but who wish to avail themselves of something they believe to be good for them, and it is offered by people who consider not that they are treating disease but that they are aiding in the realization of certain ethical values." The struggle over whether psychotherapy treated the health of the body or the existential status of the soul and social welfare of humanity resulted in an ongoing professional "cold war."
Outside the professions, these turf battles hardly mattered. The popularization of psychotherapy proceeded rapidly during the postwar decades, becoming a staple in drama, films, and on television. Most of the cultural images were highly exaggerated. Psychological interpretation, as often as not, appeared to involve pat formulas, and portrayals of mental health professionals included malevolent abusers and incompetent fools alongside caring father figures and magical healers. Aware that their talents were being put to cultural tests at least as rigorous as the scientific proofs prized within the professions, organizations like the American Psychiatric Association actively lobbied in Hollywood and elsewhere to safeguard good public relations and avert unflattering stereotypes. Whatever damage the professionals feared to their collective reputation was clearly outdistanced by the almost insatiable public
demand for accessible, entertaining information about who mental health experts were and what they did.
Psychotherapy was also an experience in which more and more people participated directly (fig. 17). By 1970 approximately twenty thousand psychiatrists were ministering to one million people on a purely outpatient basis. Well over ten thousand psychologists were providing some type of counseling service, more than were involved in any other single area of work, and close to half of all doctoral degrees in psychology were being granted in clinical and counseling fields. This was truly an extraordinary feat considering that only a tiny handful of psychologists (less than three hundred APA members) had even called themselves "clinical" thirty years earlier.
In 1957, according to a major national study done for the JCMIH, ordinary people were relying more heavily than ever on clinical experts and formal help in order to deal with their routine personal problems: 14 percent of all those surveyed sought therapeutic assistance for a problem they defined in psychological terms. In 1976, when the study was repeated, the percentage had almost doubled, to 26 percent, and approximately 30 percent reported consulting therapists in crisis situations. More important, the highly conscious pursuit of personal and interpersonal meaning that the authors termed a "psychological revolution" had spread. Activated first among better-off and better-educated sectors of the population during the 1950s, the revolution radiated outward and downward to become "common coin" by the 1970s. Further, the reasons why people entered psychotherapy were changing. By the 1970s, "many people use a relationship with a professional as a way to explore and expand their personalities rather than as a way to undo painful or thoroughly negative feelings about themselves." Using psychotherapy to cope with a "normal" dose of emotional anguish was no longer considered a prelude to psychiatric hospitalization or even a mark of mental abnormality.
The surge in psychotherapy's popularity was much more than a fad, and its consequences were much more than merely professional. The availability of new, government-supported services and opportunities for professional education and research did not, in themselves, generate a mass market for psychotherapy, though they helped immeasurably to do so. Psychotherapy for the normal gained momentum not only because of the formal expansion of government services but because it meshed easily with cultural trends that made therapeutic help appear acceptable, even inviting, to ordinary people at midcentury: the contin-
ued thinning of community ties; a vehement emphasis on the patriarchal nuclear family that put that institution under great pressure to satisfy the emotional needs of children and adults after World War II and had gone so far to challenge women's conventional gender roles; a sense of depersonalization and loss of self in huge corporate workplaces and other mass institutions.
Clinicians, for their part, encouraged people to think of psychotherapy as a perfectly appropriate way to cope with the ups and downs of modern existence. Because the logic of psychological development guaranteed each and every individual the potential for neurosis, so-called normal individuals were just as deeply affected by mental symptoms and disturbances; they were simply better at hiding them. And they went further. Just as clinicians had trumpeted psychotherapy's potential to systematically aid in postwar social adjustment, so too did they (and their clients) proclaim in later years that the trend toward psychotherapy for the normal illustrated promising moves toward cultural change and development. Psychotherapy, according to one sym-
pathetic observer in the late 1960s, was a noble effort to map "the country of the soul [so that] the meaning of the long-sought civilization comes into sight and may be occupied." By the early 1970s, Lawrence Kubie, a psychiatrist who had opposed the involvement of nonphysicians in diagnosis and treatment prior to World War II, and who had been involved in touchy postwar discussions about clinical psychologists practicing psychotherapy independently, was offering glowing accolades to psychotherapy's popularization.
As we make therapy more widely available, an understanding in depth of the role of the neurotic process in human development will begin to permeate our culture. In fact, this is essential for the maturation of any society. . . . Insofar as the development of the new discipline [psychotherapy] will bring insight to more people than was previously possible and infuse the work of more and more of our institutions with self-knowledge in depth, we can look to this to increase each individual's freedom to change, and his freedom to use his potential skills creatively. Ultimately this state of affairs can bring the freedom to change to an entire culture.