Abstract
Objective: The purpose of this article is to review the development of concepts about the contribution of nature and nurture to brain structure and mental function, and to derive the implications of these changing concepts for clinical practice. Method: The literature of the past five decades, as refracted by the author's personal experience in academic psychiatry during that interval, is reviewed. Results: Psychiatric theory has swung through mighty arcs in recent years but has begun to re-equilibrate. Fifty years ago, psychoanalysis dominated the academic scene; for the past two decades, reductionist biological determinism has held the fort. Neither position is tenable. To subscribe to either is possible only by ignoring conflicting evidence. Worse, it means short-changing patients, whose disorders do not come neatly packaged into örganic" and "functional" compartments. Development is neither predestined in the genome nor completely malleable to shaping by the environment. Children inherit, along with their parents' genes, their parents, their peers, and the communities they inhabit. Conclusions: Contemporary psychiatric research conclusively demonstrates that mind/brain responds to biological and social vectors and is jointly constructed by both. Major brain pathways are specified in the genome; detailed connections are fashioned by, and consequently reflect, socially mediated experience in the world. Just at the time when integration at the level of theory is coming into sight, comprehensive patient care is endangered by for-profit corporate managed care, which is transforming medical visits into commodities on a production line. Physicians and patients must join in a coalition to protect quality, ensure access, and build continuity into all of medical care.
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