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Psychiatric Cultures Compared's
editors note that the history of psychiatry is usually written by psychiatrists
and principally focuses on institutions. Indeed, the first psychiatric history
placed in my hands as a junior resident was written by an emeritus professor of
psychiatry and was about the university department which he had helped found. The
flip-side of the coin is the Scientology-style antipsychiatric rant. Neither
boosterism nor bashing are particularly helpful, and Frank Huisman, one of the
volume's authors, notes that, "To put it in an exaggerated way: the
historian does not want to celebrate (like psychiatrists) or to criticize (like
social scientists); he wants to analyse" (p. 418).
In this case, the result of
historical analysis is an edited collection of 18 essays, the outgrowth of a
2003 conference at the Royal Netherlands Academy of Arts and Sciences, "Cultures
of Psychiatry and Mental Health Care in the Twentieth Century: Comparisons and
Approaches." The editors pursue two aims: first, an examination of Dutch
psychiatry in comparison with other selected nations to discover similarities,
differences, and unique features; second, to present new approaches and topics
in psychiatric historical scholarship. Thus, there are numerous stand-alone
essays on various aspects of psychiatry in France, Germany, Italy, Japan, Sweden, the UK, and the USA, grouped as "Overviews Psychiatry and Mental Health
Care." The special topics are, "Psychiatric Patients," "Psychiatric
Nursing," "Psychotropic Drugs," and the concluding "Reflections."
In grossly broad outline, the
twentieth century saw deinstitutionalization, the rise of community-based care,
the rise and fall of psychoanalysis, the rise of biological psychiatry, and the
integration of psychiatry into the mainstream of medicine. It is fascinating
to see how the particulars played out in the nations studied. For instance,
while the USA and Italy rushed headlong into deinstitutionalization in the
mid-fifties, Germany and the Netherlands actually reached their peak
psychiatric inpatient numbers around 1980. Fascinatingly (and ironically), the
latter nations had far better developed outpatient mental health services than
the former at the time of their respective asylum depopulations.
The historians uncover numerous
other similarities and contrasts, and they find much received wisdom simply
unsupported. It is common psychiatric lore that chlorpromazine, introduced in
1954, was responsible for the emptying of the asylums in North America. Gerald
Grob's essay on US psychiatry actually uncovers numerous forces pushing toward
deinstitutionalization, almost all of which pre-date modern pharmacology.
These include the development of social psychiatry, power struggles between
state bureaucrats who controlled asylums and federal bureaucrats who funded
outpatient care, and the mere relocation of significant numbers from asylums to
nursing homes, where care was cheaper, the phenomenon of "trans-institutionalization."
Even more telling, data between 1940 and 1950 reveal declining lengths of stay
in various diagnostic categories, including schizophrenia, a trend at least
fifteen years old before the first milligram of chlorpromazine was ever
swallowed by a psychiatric patient in America.
Antipsychiatry appears to have been
a universal phenomenon throughout European and American psychiatry, peaking in
intensity by about 1968, accompanied by significant changes in law and public
awareness. A key idea of antipsychiatry is the notion that mental illness is a
social label applied to suppress non-conforming behaviour. Psychiatric
patients do not have diseases and do not need treatment. They have problems in
living, problems often resulting from being on the bottom of socially accepted
hierarchies, of which psychiatry is among the most power-imbalanced and
coercive. The solution advocated was usually less psychiatry, especially
medications--frequently viewed as chemical strait-jackets--and a more general leveling
of society to do away with oppressive hierarchies.
Responses to antipsychiatric
criticism varied widely at a policy level. Gemma Blok uncovers that the Dutch
response was paradoxically a demand for increased psychiatric services and the
widespread use of therapeutic communities and group psychotherapy to treat
psychosis. This "social model" of treatment held the individual
fully responsible for both symptoms and recovery, fully in line with an agenda
of liberation and de-stigmatization. Some patients who came through these
experiences, however, look back on the time as one of "severe personal
neglect" or even as "a re-education camp" (p. 107).
The volume also includes
considerable discussion of whether there has been progress in psychiatry.
Again, answers are surprising. It turns out it is quite difficult to decide
what actually counts as progress, and it very much depends on the prevailing
values of the day. To the nineteenth century, the appearance of safe
facilities where the mad could seek asylum was very much the mark of a
progressive and humane society. Judged quantitatively, and thus ostensibly reducing
the impact of prevailing social values, the number of mental health patients
expanded dramatically throughout the twentieth century, no etiologies were
uncovered, and no cures were discovered, with the sole exception of penicillin
for tertiary syphilis. It is even argued by the editors and some authors that
the prevalence of psychiatric disorder and the appearance of demand for
psychiatric services is driven by the available supply of those services.
Economically this may make sense, but epidemiologically, it is a puzzle. The
prevalence of serious fractures in any given city does not increase when a new
orthopedic surgeon sets up shop.
The book does not just deal with
the puzzles of history, though. It introduces the historiographic concept of
the Seige cycle (p. 387). Max Seige was a German psychiatrist who noted in
1912 that reports on new psychiatric drugs in journals appear to go through
three phases: therapeutic optimism and ever expanding indications; criticism and
reports of side-effects; and finally pessimism and a reduction of usage. Several
authors note that the Seige cycle can be generalized beyond drugs to the broad
movements within psychiatry. Asylums were, in their day, hailed as the best
approach to cure mental disorders. Eventually, asylums came under sharp
criticism and ultimately significant curtailment of use. The same cycle can be
discovered in coma therapy, eugenics, insulin shocks, pharmacology, and
deinstitutionalization itself. Even antipsychiatry appears to be well modeled
by a Seige cycle. The suggestion is that with the birth of each new paradigm,
hope is invested in the next silver bullet, and uncertainty is relieved. It
remains to be seen whether Seige cycles apply to genetics and neuroscience.
Furthermore, Seige cycles seem to be unique to psychiatry. Newtonian physics,
for instance, did not go through any such cycle once relativity came along. It
simply came to be viewed as an excellent approximation with demonstrable
reliability—good enough to get men on the moon.
Although interesting and new ground
is broken, such as the examination of psychiatric nurses' and patients'
histories, the book notably lacks a history of psychiatric ideas, even though
this would surely go some distance to clarifying the rise of social psychiatry,
the subsequent rise of antipsychiatry, and the current hegemony of
biopsychiatry. The authors note the expansion of psychiatric treatment from
more severe psychiatric disorders into realms such as addiction, delinquency,
sexual difficulty, nervous disorders, and hysterical symptoms. There is little
comment, though, on the various shifts in the definition of mental disorder
through the twentieth century which allowed this expansion. How is it that
mental illness came to include problems which were once considered little more
than the vicissitudes of life or else spiritual and moral failings? Only in
the introduction do the authors mention the hypothesis that society is
progressively less willing to tolerate suffering and therefore open to the
medicalization of suffering with the consequent hope of medical remedy. The
treatment of this notion is unfortunately far too superficial to allow critical
engagement by the reader. The authors also seem to uncritically accept as
given a notion of mental illness which encompasses the most severe and
persistent psychiatric disorders while critically noting the ever expanding
size and scope of the DSM. The distinction, while perhaps defensible, is left
undefended and therefore seems arbitrary.
However, I don't want to fault this
book for what it lacks at the expense of distracting from what it does
contain. It sets out to compare psychiatric cultures, not to be a history of
ideas. Intellectual histories which are dispassionate will surely follow
along. For now, the editors and authors offer an excellent start to the story
of twentieth century psychiatry. They introduce the compelling historiographic
concept of the Seige cycle. They overturn received myths of recent psychiatric
history. They posit the surprising notion that we may actually be quite far
from being able to say what psychiatric progress even means, let alone whether
it has occurred. They introduce the histories of outpatient care, nurses, and
patients, moving the focus to ground besides psychiatrists and inpatient units.
Above all, by being at a distance from psychiatry, they approach the topic with
enough clarity that a very complex history is permitted to emerge, one which
assiduously avoids facile idealization or devaluation. To anyone with an
interest in psychiatric history, Psychiatric Cultures Compared will
amply reward your attention.
© 2006 Robert Tarzwell
Robert Tarzwell is a psychiatrist
at St. Paul's Hospital in Vancouver. His clinical work includes concurrent
disorders (patients with severe mental disorders and substance dependency) and
chronic pain. His intellectual interests include the psychiatric humanities,
in particular the philosophy of psychiatry, the history of psychiatry, and
psychiatry in literature.