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Psychiatric Cultures ComparedReview - Psychiatric Cultures Compared
Psychiatry and Mental Health Care in the Twentieth Century
by Marijke Gijswijt-Hofstra, Harry Oosterhuis, Joost Vijselaar, and Hugh Freeman (Editors)
Amsterdam University Press, 2006
Review by Robert Tarzwell, MD
Sep 19th 2006 (Volume 10, Issue 38)

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.


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