Book Review

The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America

N Engl J Med 1994; 331:1662-1663December 15, 1994

Article

The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America
By Elizabeth Lunbeck. 431 pp. Princeton, N.J., Princeton University Press, 1994. $29.95. ISBN: 0-691-04804-5

Elizabeth Lunbeck has written an ambitious, detailed, and very interesting book about early 20th-century American psychiatry. Using the tools of a historian and the skills of a talented writer, she presents a history of the discipline in a period of essential transition. Whereas so many historical studies of psychiatry are written by members of the discipline, reflecting the development of a particular school of thought, Lunbeck has attempted to view this period of psychiatric history more broadly, using a social context to examine how psychiatrists viewed society and how society shaped the development of psychiatric thought.

We are accustomed to thinking about psychiatry and psychotherapy as concerned with our daily lives, with our happiness and unhappiness, with our fulfillment and disappointments, as well as with the psychopathology of major mental illness. But, of course, this involvement of psychiatry in the business of everyday normal life is relatively new, and it is this enormous change that Lunbeck chronicles. Calling on the writings of Michel Foucault and referring often to his ideas about the evolution of social and professional disciplines, she tells the story of the change in roles from asylum keepers to modern psychiatrists, from the “alienists” (those who studied the alienated mentally ill) to the judges of normality, the doctors of mental health.

The scope of the book is broad, but the main research tools are quite specific. Lunbeck uses extensive case histories and records from the Boston Psychopathic Hospital, an institution at the forefront of modern psychiatric practice, more like a hospital than an asylum, where the new discipline of social work was incorporated and where the focus was distinctly academic. Over the past 80 years, the Boston Psychopathic Hospital has evolved to become one of the most respected psychiatric teaching hospitals, enjoying a long association with Harvard Medical School and eventually becoming the Massachusetts Mental Health Center, a public hospital with a distinguished academic faculty. Simply as a study of such an institution over the course of this century, this book is fascinating and gives a much-needed historical perspective to current students of the mental health disciplines, who are caught today in another period of abrupt change.

In the first half of the book, Lunbeck uses case records of the Boston Psychopathic Hospital as a window into the workings of this model institution and into the professions of psychiatry, psychology, and social work. She explores the life and teachings of the psychiatrist E.E. Southard, who led the hospital and championed the leap of the psychiatric profession into a new position of cultural authority. She cites the discovery of a diagnostic test and treatment for neurosyphilis as an enormous shift for psychiatry -- not only into the realm of the more scientific medical mainstream, but also into the realms of private sexuality and public morality. She examines, too, the development of psychological assessment tools, based on the normative distribution, which once again brought diagnostic thinking into a new sphere, laying the groundwork for the modern study of personality and its overlap with the personality disorders. In describing the development of the new discipline of social work, she opens a discussion of sex as a defining (and limiting) aspect of the identities of both professions.

Sex and sexual politics of the early 20th century dominate the second half of the book. The author here uses her case material somewhat differently, as a window outward into society. Here, the book departs from its early aims. Though it continues to be highly readable, informative, and even picturesque in its evocations, through the case material, of everyday life in Boston at this time, the breadth of the book tends to diminish the wonderful acuity that characterizes the first half. There is certainly enough material here for two books -- one on the development of the psychiatric profession and one on the evolution of sex roles in mental health and mental illness in the early 20th century. These sections, addressing differences between the sexes in diagnosis, homosexuality, the sexual politics of marriage, notions of manhood, and alcoholism, are provocative and full of both information and speculation, but the thesis becomes confused. Is the author suggesting that psychiatrists helped to define the sex roles of society, or that they were reflecting the views of their society in their work? Although the author often acknowledges the complexity of this issue, she sometimes extrapolates from specific case material a view of psychiatrists in general that seems oversimplified and disparaging to the profession as a whole.

In The Psychiatric Persuasion, Lunbeck has achieved a great deal. She has written a careful history that is lively and enjoyable to read. She has defined her point of view and avoided the pitfalls of many “antipsychiatry” writers as well as the insularity of the histories of psychiatry by psychiatrists. Her book will be of interest to students and professionals in the field of mental health, as well as to historians, sociologists, and general readers interested in the early 20th century in America.

Ann R. Epstein, M.D.
Harvard Medical School, Boston, MA 02115

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