Matthew Smith, The First Resort: The History of Social Psychiatry in the United States (New York: Columbia University Press, 2023)

Michael N. Healey, Johns Hopkins University

For many decades, the history of U.S. psychiatry was likened to a pendulum, one which repeatedly swung between a biological framework and a psychodynamic one. As Jonathan Sadowsky has argued, however, grand narratives such as these obscure more nuanced aspects of the discipline’s past (Sadowsky, 2006). There were many continuities between psychoanalysis and psychopharmacology, for example, as Jonathan Metzl demonstrates in his analysis of medical journals, popular magazines, and related sources (Metzl, 2003). Similarly, some Freudians were surprisingly receptive to somatic methods, as Sadowsky’s own research on electroconvulsive therapy has shown (Sadowsky, 2017). Works like these have broadened the historiography of psychiatry in generative ways, providing us with a richer understanding of this specialty’s development.

In his latest book, The First Resort, Matthew Smith makes a similar intervention. He does so, however, not by examining another convergence of biological and psychodynamic approaches, but by contrasting them to another paradigm entirely: social psychiatry. While the term itself has existed for well over a century, and has been used in a variety of contexts, The First Resort largely focuses on a cohort of U.S. psychiatrists that practiced after World War II, and the diverse group of allied professionals with which they collaborated. Indeed, to Smith (and many of his actors), it was this interdisciplinarity – in mental healthcare, yes, but primarily in research – that characterized social psychiatry during these “magic years” (as the title of an unpublished manuscript by APA president Daniel Blain cited by Smith characterized the era). Accordingly, the book revolves around his analysis of four classic studies: Robert Faris and H. Warren Dunham’s research on schizophrenia in Chicago, Illinois; August Hollingshead and Frederick Redlich’s research on class and mental health in New Haven, Connecticut; and the Midtown Manhattan and Stirling County projects, both conducted under the auspices of Cornell University. These case studies are bookended by an overview of the field’s social and intellectual origins – and the political trends that led to its decline. By chronicling the rise and fall of social psychiatry, Smith reminds us that this pivotal period in the mid-twentieth century was not merely the heyday of Freudianism. It was also the zenith of a more environmentalist perspective, one which shaped the contours of U.S. psychiatry for decades to come.

In a more granular sense, however, Smith has also deepened our understanding of several historical figures, in ways that open numerous avenues for further research. Take, for example, the Cornell psychoanalyst Thomas Rennie, who Gerald Grob once portrayed as just one of biological psychiatry’s many detractors (Grob, 1991). In Smith’s account, he is cast instead as a leading social psychiatrist, whose research in Midtown demonstrated how both somatic and sociocultural factors contributed to mental illness. By focusing less on the internecine disputes between these ideologies, and more on the projects that united them, historians of psychiatry might discover similar instances of exchange, and find that individual practitioners were less partisan than Grob’s narrative suggests. Historians of the human sciences, too, will benefit from Smith’s analysis. His chapter on Stirling County, in particular, highlights the early careers of Dorothea and Alexander Leighton, two physician-ethnographers that have previously appeared in histories of anthropology. By examining these and other connections between psychiatry and the social sciences, Smith provides a model for other scholars that seek to merge – or perhaps transcend – the historical literature on both.

In contrast, Smith is less interested in promoting further epidemiological research. Throughout the book, in fact, he criticizes psychiatrists and social scientists – both then and since – for quibbling over the minutia of their methods and results, instead of using them to inform policy. Their inaction has been especially harmful, he argues, when it comes to matters of income inequality. While discussing the findings of each study, Smith repeatedly emphasizes those on economic disparities (though related factors, like social disintegration, are also considered). These data, according to him, are enough to establish poverty as a determinant of mental health – and justify programs aimed at its alleviation. Smith concludes, then, by advocating for universal basic income (or UBI), a policy that was proposed by some social psychiatrists, but has become far more popular during the COVID-19 pandemic. Indeed, while it makes several important scholarly contributions, The First Resort is also an applied history, one which offers much to contemporary policy-makers and activists.

That said, it would be a mistake to dismiss Smith’s book as an exercise in presentism. On the contrary, he should be commended for his measured scrutiny, of both the studies themselves and the individuals that conducted them. Smith is particularly attentive to the prejudices of these researchers, for example, and repeatedly demonstrates how classism and ethnic discrimination shaped the collection and communication of data. Such biases, he suggests, help to explain social psychiatry’s political inertness, as its practitioners (by and large) were unwilling to advocate for welfare programs that would address the various inequities they had uncovered. Their elitism undermined clinical services too, as Smith explains in brief sections on community mental health centres. The First Resort, then, is not an unapologetic endorsement of social psychiatry, or an attempt to inspire its renaissance. Both here and elsewhere, in fact, Smith insists that patients are best served by a combination of biological, psychodynamic, and environmentalist approaches. His argument, rather, serves as a warning to the growing number of like-minded clinicians and scientists, who might otherwise replicate the shortcomings of their predecessors.

Indeed, if I have one criticism of Smith’s book, it is that crucial episodes of this cautionary tale are overshadowed by his own emphasis on research. Consider, for instance, his discussion of the community mental health movement, which I alluded to above. Smith’s account of the conflicts that arose between social psychiatrists, their staffs, and the populations they served should be required reading for anybody pursuing a career in public mental health. Similarly, his overview of the sociopolitical factors that undermined these preventative programs is invaluable to those advocating for similar interventions today. And yet, those skimming The First Resort, or reviewing its table of contents, might miss them entirely, as they are spread across chapters devoted to landmark projects in psychiatric epidemiology. This is not to say that these sections are out of place; on the contrary, they do much to demonstrate the broader relevance of this niche field. But the basic structure of The First Resort – four case studies of social psychiatric research that build toward an argument for UBI – does distract from these other moments and messages. Perhaps it is unfair to expect an author to accomplish more than they set out to. It is odd, though, that Smith (much like the researchers he criticizes) devotes most of his attention to the academic side of community mental health, instead of its many clinical and political manifestations.

These, of course, may be explored in subsequent histories. In any case, however, The First Resort will continue to resonate with both academic historians and mental health professionals – even if its policy prescriptions become dated. The evolution of psychiatric theory and practice may not be as pendulous as previously thought. As Smith reminds us, however, the profession will always be situated within a broader political context, one which is constantly oscillating between the left and the right. Just as social psychiatry’s larger ambitions were quelled by the neoliberal turn, UBI and related policies may soon encounter increased resistance, as rising inflation leads to yet another era of austerity. If and when they do, Smith’s book will be there to remind us of those fleeting moments, both in the mid-twentieth century and more recently, when the radical seemed reasonable. Because it was – and still is.