It may be fairly asked if we need another history of psychiatry. After all, apart from the seminal text of Alexander and Selesnick, and more recently Edward Shorter, not to mention the forthcoming six volume set by German Berrios (who incidentally has a chapter here), there are many and numerous takes on the many aspects of psychiatry -- local (Surfacing Up: Psychiatry and Social Order in Colonial Zimbabwe, 1908-1968 by Lynette A. Jackson), social (Shorter again), socio-political (Colonial Madness: Psychiatry in French North Africa by Richard C. Keller), institutional, (Psychiatry for the Rich: A History of Ticehurst Private Asylum 1792-1917 by Charles MacKenzie), critical (Coercion as Cure: A Critical History of Psychiatry by Thomas Szasz), and brief (A Brief History of Psychiatry by John Maltby) to name just a few. However, there has not really one that takes as its touchstone the philosophical underpinnings and precepts that guide and shape the expression of psychiatric practice, by individuals, services and systems. This is the gap that Wallace and Gach admirably fill.
The tone of the book is careful and scholarly. The language is academic, precise albeit at times a little ornate and heavy, almost Victorian, but in the main this merely serves to ensure that the reader digests the complexity of the concepts slowly and methodically. The editors and authors certainly do not want to be misunderstood.
The editors themselves deserve special mention. First it should be noted that they contribute to the individual chapters far more than might normally be expected. Wallace has five chapters to his name and Gach, two. This is indicative of the very personal stamp that they place upon the book. It really feels like a book they wanted to publish and not a commission. There is a sense of intensity and purpose that wants to convey just how important and significant and fascinating this subject is.
Edwin Wallace is unfortunately no longer with us, and this is a particular loss. He was well known as a psychiatrist with a long-standing interest in philosophical concerns and a strong research record. He was a major figure and profoundly instrumental in making the philosophy of psychiatry a major issue for clinicians and researchers alike. His contributions in founding the Association for the Advancement of Philosophy and Psychiatry, and its journal (and of course its website offshoot) have already cemented his reputation and legacy -- this book confirms it.
John Gach, by contrast, is an antiquarian bookseller and writer and brings his enormous knowledge and keen intelligence to the contextual aspects of the philosophical developments. He is also the editor of Foundations of Psychiatry and Neuroscience. He brings a different perspective, but one that is broad and informed, inclusive and generous, and most helpful in charting the history and culture of the psychiatric imagination.
The text is distinctive in tone and initially laid out in an unusual way. It devotes a substantial amount of space to a prolegomenon; an introductory chapter to the historical and methodological concerns, and adds an extremely useful and comprehensive annotated bibliography. It covers major works from and which deal with antiquity, the medieval period, the Renaissance, a century by century listing from the seventeenth to the twentieth, a section devoted to non-Western historiography, a further one concerned with "encyclopaedic references, dictionaries and methodological manuals" and a fascinating rattle bag of gems that they call "Additional Speculative, or Philosophical, History" (as if they just couldn't bear to leave them out).The depth of the referencing and the scope of the scholarship are quite outstanding. This is almost a stand alone piece and would be worthy of publication in its own right, and its value is all the greater for the way in way in which it contextualizes the rest of the book.
In the following section the chapters work within a frame that begins with antiquity and moves through the Renaissance to the Enlightenment and so forth, up to and including the pharmacological revolution of the last few decades. There are further chapters that deal with changing notions of schizophrenia and depression, but the variety of perspectives brought by authors from outside the normal scope of medical psychiatry, such as Sander Gilman (known for his work in medical and psychiatric iconography), Dora Weiner (an expert on Pinel and his influence), Hannah Decker (whose area of interest is German cultural history), German Berrios (the Peruvian born epistemologist from Cambridge) and the recently deceased dean of American psychiatric history from Yale, George Mora, is perhaps more interesting and it makes for an exceptional cast.
The traditional structure of historical texts varies a little with two sections called Concepts and Topics. Both seem to some degree catch-all terms that try to deal with debates that don't quite fit neatly into the other sections of the book. There is a substantial critique of what is called biological psychiatry, essentially arguing that it is antiphenomenologic. However, this may be a bias that is not fully explored or examined, and may be one area in which opinions diverge. It may be arguable that the meshing of the physiological aspects of neurological functioning and the subjective experience of mental disorder is exactly where the cutting edge of psychiatry and its philosophical underpinnings are to be found. This is the debate.
On reflection it may seem that the text is quite American-centric, perhaps overly so. The editors, however, claim that this is not as much as it might appear. They point out that many of the authors were educated outside of America, and some still work in Europe, but it is not a particularly convincing defense. The tone and central concerns are American. The emphasis given to psychoanalysis seems to echo American rather than other psychiatric cultures. This is not to underestimate the significance of the psychoanalytic movement for it is has had a profound influence on common understandings of psychiatry and mental processes. Rather it is to balance it with the consensus within current practice which perhaps recognizes it as a seductive illustrative model, and seeks to understand its appeal, but does not see it so much as a scientifically verifiable theory.
Similarly there is little by way of cultural psychiatry except where it applies to immigrant or minority groups in America. It would have been interesting to explore the cross-cultural dimensions of psychiatry in a little more depth. The perspective of hospital psychiatry also seems under-represented both in the history, the development and the concerns. There is no mention, for example, of the notion of hospitals as therapeutic communities; the role of nurses, who are the mainstay of hospitals, is under-developed; the changing focus of long-term care towards a recovery model, community care and mental health literacy could also be explored more fully. The descriptions of therapeutic interventions, orientations and expertise of a range of disciplines may in this way reflect the American experience and system more than they are globally representative.
But these comments do not unduly detract from the worth and value of a very significant achievement. It is gratifying and welcome to see a major work attempting to understand and unravel the fundamentals around which psychiatry is built. The editors and authors see a certain beauty in the complexity of philosophical influences and legacies. They celebrate this and do not attempt facile or monological explanations. But they still seek precision in their meaning, and substance in their arguments. This book is sure to become a standard text in the field for many years to come. It will inform students and entertain the dippers in its readership.
In conclusion it may be said that if this text is Edwin Wallace's last contribution to the literature it is both worthy and fitting. It places the philosophy of psychiatry centrally in both the practice and academic worlds and it is unlikely that anyone but Wallace and the unique contribution of Gach could have done so in the same way. It is a very fine book.
© 2009 Mark Welch
Mark Welch, Ph.D., BC, Canada