An Ounce of Prevention: A History of Social Psychiatry, 1939-Present

2010年，我参加了一个在芝加哥举行的题为“心理健康的社会决定因素”的国际会议。其重点是解决从贫困到暴力等被认为会导致精神疾病的社会经济因素。包括美国前卫生局局长David Satcher在内的与会者不仅主张采取一种更加社会知情的方法来理解精神卫生，而且还希望发起一场政治运动，将预防置于精神卫生政策和临床实践的核心。这种心理健康方法并不新鲜，但它的历史并没有被记录下来，因此大多数与会者都不知道。以20世纪初的精神卫生和儿童指导运动为基础，并在20世纪50年代和60年代达到顶峰，被称为社会精神病学的精神病学和政治运动同样主张对精神疾病采取预防性方法，强调减轻社会剥夺和不平等。但是，尽管社会精神病学将成为美国精神病学和政治的主要力量，影响美国精神病学协会的两位主席以及肯尼迪总统和约翰逊总统的立法，但在随后的几十年里，随着精神疾病的生物学方法成为美国精神病学的主导力量，它逐渐消失了。鉴于世界卫生组织最近警告说，精神疾病将在20年内成为世界上最常见的疾病（《精神卫生地图集》，2011年）——更不用说这种疾病的社会和经济成本不断上升——预防精神疾病的方法再次引起人们的注意也就不足为奇了。本项目不仅试图分析精神病学史学中被忽视的一章，而且还通过研究社会精神病学的成功和失败，为当前解决精神健康的社会决定因素的尝试提供信息。该项目分为三个部分。第一部分考察了社会精神病学的知识起源，包括它在二十世纪早期的心理卫生和儿童指导运动中的根源。人们对社会精神病学的广泛兴趣不断升级，不仅因为它解决了人们对精神疾病发病率上升的担忧，还因为它代表了精神科医生和社会科学家之间的跨学科合作，在学术和公共政策圈激发了广泛的受众。该项目将探讨这种合作所涉及的历史因素，并评估这种跨学科精神保健方法的利弊。该项目的第二部分考察了社会精神病学的顶峰，因为它在20世纪60年代威胁到精神分析和生物精神病学（强调精神疾病的神经解释和药物治疗）。然而，不幸的是，对于社会精神病学家来说，在20世纪70年代和80年代，随着心理药理学在精神病学家和他们的病人中越来越流行，经济和政治压力削弱了美国政治家和心理健康专家对社会进步的热情，人们对预防方法的兴趣减弱了。该项目的第三部分不仅将研究社会精神病学的衰落，还将探讨为什么预防精神疾病的方法在美国和其他地方再次受到青睐。

In 2010 I attended an international conference, entitled 'The Social Determinants of Mental Health' and held in Chicago. Its focus was to address the socioeconomic factors, ranging from poverty to violence, believed to cause mental illness. The participants, including David Satcher, the former US Surgeon General, not only advocated a more socially-informed approach to understanding mental health, but also wanted to launch a political movement that would place prevention at the heart of mental health policy and clinical practice.Such an approach to mental health was not new, but its history has not been written and so was unknown to most of the conference participants. Building on the mental hygiene and child guidance movements of the early twentieth century, and reaching its peak during the 1950s and 1960s, the psychiatric and political movement known as social psychiatry similarly advocated a preventive approach to mental illness, which stressed alleviating social deprivation and inequality. But, although social psychiatry would become a major force within American psychiatry and politics, influencing both presidents of the American Psychiatric Association and the legislation of Presidents Kennedy and Johnson, it faded away in the subsequent decades, as biological approaches to mental illness became the dominant force in American psychiatry.Given the World Health Organisation's recent warnings that mental illness will become the world's most common malady within twenty years (Mental Health Atlas, 2011) - not to mention the escalating social and economic cost of such conditions - it is not surprising that preventive approaches to mental illness are again attracting attention. This project seeks not only to analyse a neglected chapter in the historiography of psychiatry, but also to inform current attempts to address the social determinants of mental health by examining the successes and failures of social psychiatry. The project is divided into three sections. The first examines the intellectual origins of social psychiatry, including its roots in the mental hygiene and child guidance movements of the early twentieth century. Widespread interest in social psychiatry escalated not only because it addressed concerns about the rising rates of mental illness, but also because it represented an interdisciplinary collaboration between psychiatrists and social scientists that inspired a wide audience in academic and public policy circles. The project will address the historical factors involved in this cooperation, and assess both the benefits and disadvantages of such an interdisciplinary approach to mental health. The second section of the project examines the zenith of social psychiatry, as it threatened to eclipse psychoanalysis and biological psychiatry (which stressed neurological explanations of and pharmaceutical treatments for mental illness) during the 1960s. Unfortunately for social psychiatrists, however, the interest in preventive approaches waned during the 1970s and 1980s, as psycho-pharmacology became more popular amongst both psychiatrists and their patients, and economic and political pressures deflated the socially progressive zeal of American politicians and mental health professionals. The third section of the project will examine not only the decline of social psychiatry, but also explore why preventive approaches to mental illness have once again found favour in both the US and elsewhere.