The Twentieth Century 331United States psychoanalysis became a medical specialty and
also the predominant theoretical viewpoint of psychiatrists.
Theories generally do not so much decline because of their
inherent defects as because they have been replaced by better
alternatives. Psychoanalysis declined as an influence in psy-
chology for several reasons. One was the rise in psychophar-
macology, another was the spread of behaviorist techniques,
and a third was the increasingly evident defects of the theory
itself.
The Rise of Psychopharmacology
Public hospitals provided the most dramatic evidence for the
development of medications that could effectively alleviate
the symptoms of both the neuroses and the psychoses. Wortis
(1959) reported a survey of the world’s medical literature be-
tween 1930 and 1959. Before 1953, reports of pharmacolog-
ical treatments comprised less than 10% of published papers.
By 1959, they comprised more than 70%, and the number
was rising rapidly. The World Health Organization (1958) is-
sued a classification of psychopharmacological compounds
that covered seven categories, of which the most significant
category, the major tranquilizers chlorpromazine and reser-
pine, were effective with psychoses. Psychoanalysts com-
plained that medication merely removed the symptoms
without curing the patient. Because they believed that the
basic cause was psychological, they asserted that biological
treatments were therefore inherently limited to palliative
effects. As psychoanalysis itself was not achieving even pal-
liative effects with psychotic patients, the argument was
unimpressive. A more important problem with the early med-
ications was their frequent and unpleasant side effects. These
included dryness of mouth, involuntary motor movements of
the tongue and lips (tardive dyskinesia), occasional episodes
of dizziness, and such. When the psychotic symptoms sub-
sided, patients often discontinued taking the medication
because of the side effects, and relapsed into their previous
psychotic condition. Improved drugs and techniques of su-
pervised administration and/or injection of long-lasting
timed release compounds have been developed to eliminate
this cyclical effect.
The Rise of Behavior Modification
The first to report extension of behavioral methods to hospi-
talized psychosis patients were Allyon and Haughton (1962).
Their approach consisted primarily of controlled application
of rewards to patients when they behaved in an adaptive (i.e.,
“normal”) manner. The underlying concept was that tradi-
tional treatment gave attention and care when a patient’s
behavior was maladaptive but ignored the patient when be-
havior was adaptive (“normal”) thereby serving to reinforce
symptomatic behavior and to extinguish normal behavior.
Rewarding normal behavior would provide a more rational
approach to eliminating symptoms. Studies directed toward
eliminating eating problems, mutism, and other symptoms,
reported successes (e.g., Allyon, 1963, Allyon & Haughton,
1962) and led some public hospitals to develop large-scale
“token reinforcement” programs.
Behavioral methods of this kind ran into criticism. One
criticism was that they turned the professional ethical imper-
ative to provide care and attention to the sick on its head and
therefore compromised patients’ rights. Another was that pa-
tient improvements often were specific to the hospital setting
and failed to persist after the patient was discharged. But the
main factor in limiting the spread of this approach was the
success of the new medications.
Behavior therapy proved broadly successful in treating
nonpsychotic problems such as systematic desensitization of
phobias, eliminating fear of flying, smoking reduction, and
training mentally retarded patients and passed into the reper-
toire of psychiatric practice.The Rise of Anti-PsychiatryA point of view arose that opposed the medical definition
of psychopathological disorders. Known as “anti-psychiatry,”
it drew inspiration from several sources. One source was
Erving Goffman’s (1961)Asylums,which described the ef-
fects of hospital rules and disciplines on patient behavior,
finding their behavior similar to the inmates of other “total in-
stitutions” such as convents, the military, and prisons. Scheff
(1966) argued that the distinction between sane and insane is
not a scientific one, but essentially a matter of social judg-
ment and social labeling of the deviant.
Perhaps the single most influential book was The Myth of
Mental Illness(Szasz, 1961), in which Thomas Szasz as-
serted that the mental illnesses had no established biological
basis and that they were not really a proper subject for
medical diagnosis and treatment. Terms such as disease,
symptom, diagnosis, therapy, and the like were therefore
metaphorical when applied to psychopathology. In support of
his contention, he pointed out the failure to find a biological
basis for the various mental illnesses. Instead, he said, the
“patient” suffers from problems of living in a stressful world,
and his behavior may be best understood as a form of both
communication and coping. While much of the work was
centered on the problematic status of hysteria as a disease,
his criticisms were addressed to the medicalization of de-
viant behavior generally. He alleged that the diagnosis that