by Jerome D. Frank, Ph.D, M.D.
[February 1995; Vol. 22 No. 1]
At the request of MPS I am jotting down some personal impressions of the course of psychiatry at Hopkins over the past fifty - odd years during which I was on the full time staff.
I came as a junior assistant resident in 1940, the last year of the legendary Adolf Meyer, founder of the Department of Psychiatry and the Henry Phipps Psychiatric Clinic. When Hopkins recruited him in 1909 he was world-renowned as a psychiatric clinician and administrator as well as a distinguished neuroanatomist and neuropathologist. This background was reflected in his comprehensive view of humans as psychobiological and social organisms whose defining feature was the power to symbolize.
During his tenure he made Phipps a mecca for psychiatrists from all over the world and recruited colleagues who made outstanding contributions over many subsequent decades. These included Leo Kanner in child psychiatry, Horsley Gantt, who introduced Pavlov and conditioned reflexes to America, and Kurt Richter whose original psychobiological researches enriched many fields.
When I joined the House Staff, Meyer at 74 still had enough energy to wear us all out. In the work place he held us to the highest standards and was a strict disciplinarian. His formal lectures in psychobiology and clinical psychiatry, (except for those on organic brain disease, which were crystal clear) were often so convoluted as to be virtually unintelligible. At the same time he was lucidity itself in clinical rounds, when interviewing patients, or writing for the public. His students and colleagues speculated endlessly but inconclusively on the reasons for this discrepancy. In informal settings, such as the Sunday open house he and his vivacious wife held for members of his staff, medical students, and visitors, he was an informal host who entertained us with amusing reminiscences, often slightly wicked, of the luminaries around the world he had known.
His successor as Chairman from 1941-60, John C. Whitehorn, was a respected biochemist at McLean Hospital who was appointed to Hopkins in the hope that this background would motivate him to link psychiatry to the basic sciences. In actual fact, he devoted his clinical, teaching and research efforts almost exclusively to psychotherapy, at the time the major activity of psychiatrists. He soon closed down the clinical laboratory at Phipps and turned the space over to a program in group and individual psychotherapy headed by me. His Guide to Interviewing and Personality Study was a nationwide bible for psychiatric residents for decades.
His major research projects, conducted with a junior colleague, Barbara Betz, were based on detailed and-in the days before computers-infinitely laborious analyses of psychiatric residents’ clinical records. The major finding-that success of therapy with schizophrenics was related to the therapist’s “active personal participation” - has been widely confirmed and elaborated by others under the rubric of the therapeutic alliance. These projects still serve as models of clinical research in this difficult field.
Whitehorn’s personality bore traces of his childhood as the youngest child of an impoverished Nebraska farmer. (He once wryly observed that his birth was the worst calamity experienced by his family except the drought). He was taciturn and retiring and often seemed depressed. He was decisive but made decisions only after careful thought. As a result, in the words of one of his residents: “He took only tiny steps forward; he never took a step backward.” He made few innovations, nor did he actively advance members of the Department and some of them moved on to more rewarding environments. At the same time he secured the strong loyalty of those who remained, attested by the fact that his retirement dinner was attended by all one of his present and former chief residents who were able to come.
Impressed by his keen intelligence, excellent judgment and total integrity, his medical colleagues at Hopkins chose him to head the Medical School curriculum committee. Nationally, his psychiatric colleagues repeatedly chose him to chair major policy-making and funding committees. In these roles he exerted a powerful and continuing but unpublicized influence on the shape of American Psychiatry. If I devote so much space to his contributions, it is because I believe these to have been insufficiently recognized.
Whitehorn’s successor, Seymour Kety, a distinguished research neurophysiologist, like Whitehorn was appointed in the hope that he would move the Department more in the direction of basic science. He accepted the appointment with misgivings since he was not a clinician, and resigned after a few months when his misgivings were confirmed. It is a tribute to him that his resignation in no way diminished the respect in which he was held.
Still pursuing its search for a basic scientist, after an interregnum Hopkins appointed Joel Elkes (1965 -73), whose major research area was psychopharmacology. He was one of the early investigators of chlorpromazine. He is a widely learned man with numerous scientific and aesthetic interests (among them, oil painting) and is an eloquent and inspiring teacher. He added “Behavioral Sciences” to the Department’s name and confirmed this addition by bringing in innovators in many fields. These included Richard A. Chase whose own diverse interests ranged from design of educational toys to disorders of motility; and John Money, a pre-eminent sex psychologist. He recruited Joseph V. Brady, a biological psychologist, whose monumental contributions include a Biological Psychology Research Center, a research unit for studying small groups in confined spaces like submarines and space capsules, and a mobile research and treatment service for drug addicts on the streets. Finally, Elkes brought in Solomon Snyder as a psychiatric resident and actively advanced his subsequent meteoric career.
A creative innovator, Elkes paid insufficient attention to the financing and direction of projects after they were launched. It is ironic that Dr. Whitehorn, if anything over-cautious, was in charge during a period of abundant resources for teaching and research in mental health. In contrast, the Department was led by Dr. Elkes, an expansionist, in a period of shrinking resources. If only their periods of tenure had been interchanged!
After another brief interregnum Hopkins appointed Paul McHugh (1975- ) well trained in both clinical psychiatry and research, and, like his enthusiastic, dedicated teacher. During almost two decades he has presided over proliferation of new departments, divisions, programs and projects in the administrative, biological, genetic, psychological and social facets of our field to a degree that defies summarization.
In 1982, the Department under McHugh’s direction, moved to greatly expanded quarters in the new Adolf Meyer building, along with the Departments of Neurological Diseases and Neurosurgery. This reflected a nationwide evolutionary process, in which psychiatry began as a subdepartment under neurology, then successfully fought to be independent, a victory signalized by the creation of the Phipps Clinic, and finally rejoined neurology as an equal partner.
Concomitantly the Department of Psychiatry has undergone an upgrading and expansion of preclinical and clinical activities related to psychiatry. In 1940 the social work department consisted of two ladies, one a socialite who luckily was extremely competent; the other a lady who we strongly suspected was a former patient. A single psychologist performed intelligence and Rorschach tests, when they were not performed by members of the house staff or particularly interested senior psychiatrists. Both fields have long since become professionalized. Psychologists now staff a Division of Medical Psychology and perform many functions initially conducted by psychiatrists.
Dr. Meyer’s keen interest in the social aspects of Psychiatry, shown by his sponsorship of the Mental Hygiene Movement and his surveys of mental illness in the Eastern Health District, foreshadowed many service and research programs conducted today by members of the Department of Psychiatry in conjunction with the Hopkins School of Public Health and Government agencies.
The half-century under review has witnessed enormous changes in psychiatry itself and its relations with the larger society. As to the former, for approximately the first half of the period psychoanalysis and its congeners strongly dominated the field. A virtual qualification for chairmanship of most departments was being a psychoanalyst. Today this is, at best, regarded as irrelevant if not negative. The decline of so called dynamic psychotherapy was accompanied by the efflorescence of cognitive and behavioral psychotherapies, mostly dominated by psychologists.
Above all, new techniques such as neuro-imaging are revolutionizing the psychopharmacology and genetics of the brain with unforeseeable consequences for psychiatry.
While keeping in step with these developments, psychiatry recently has had to contend with sweeping changes in the conditions of practice created by the mushroom growth of third party payers and managed care. These present major challenges, both through intrusion of nonmedical bureaucrats into medical decisions concerning duration and type of treatment, and changes in the sources of psychiatrists’ livelihood, as summarized in Rita Novey’s article in the September 1994 issue of The Maryland Psychiatrist. To cope with these developments, Dr. William Breakey has graduated from his prize- winning program in Community Psychiatry to be named Deputy Director of the Department.
Looking back, I am struck by the extent to which Adolf Meyer’s concepts and policies have continued to guide and steady the Department during the vicissitudes of the last half century. It has continued to be receptive to and willing to learn from developments, while eschewing the fads that periodically sweep over the field. Thus, we allowed neurosurgeons to perform circumscribed, carefully studied, psychosurgical incisions, but abjured the ice pick. We administer electric shock treatments, but have never countenanced “deprogramming” shocks. In the strictly psychotherapeutic realm, while studying and conducting many forms of group therapy, we have stopped short at nude marathons. We have studied post-traumatic stress disorders and multiple personality disorders, but do not hold childhood sexual abuse to be the cause of most psychiatric suffering and have conducted and reported studies of the power of suggestion in eliciting false memories.
In short, the guiding philosophy of the Department since its foundation has been to develop a broad understanding of the bodily, mental and societal aspects of mental disorders, to stress empirical knowledge when available, using theoretical speculation only to bridge the gaps, and to avoid being diverted by new theories and methods, however spectacular, that lack a sound empirical base. With this basic philosophy and backed by extensive clinical and experimental experience, the Department is well positioned to take advantage of whatever challenges the future may hold.