Critical psychiatry: The implications for community mental health practice
We may have moved on from the polarisation in the debate between those 'for' and 'against' community care. At least in the UK, with the development over recent years of crisis intervention and home treatment teams, assertive outreach teams and early intervention teams, we seem to hear less of an outright opposition to community care.
The origins of community care
In this context, it may be worth reminding ourselves of the motivation for community psychiatry. The mentally disordered have always received care outside the hospital, as there was a turnover of patients even in the traditional asylum and boarding-out of chronic cases and trial discharge took place. Nonetheless the numbers of people in psychiatric hospitals increased until a peak in the 1950s in the UK and USA and later in other countries. Community psychiatry is associated with the subsequent period of dehospitalisation. I prefer the term 'dehospitalisation' to 'deinstitutionalisation' because many people are still accommodated in at least semi-institutional settings, such as residential homes, smaller than the traditional asylums.
The motivation for dehospitalisation arose from attempts to make the traditional asylum more therapeutic. David Clark (2005) has called the starting point for community care the "dismay and disgust with the old asylum system". This led to pioneers opening the doors of the psychiatric hospital, such as T.P. Rees at Warlingham Park in 1948. Rees (1957) called for "a return to moral treatment" in his presidential address to the Royal Medico-Psychological Association in 1956. He was also a member of an expert committee on mental health of the World Health Organisation (1953) that produced its third report in 1953, in which the need to create a therapeutic milieu in hospital was recognised. Elements of this therapeutic atmosphere included encouraging patients' self-respect and sense of identity; and the general assumption that patients are trustworthy and retain capacity for a considerable degree of responsibility and initiative. Purposeful, planned activity was promoted in a patient's day.
Alongside these developments, the negative effects of the process of institutionalisation were acknowledged. Russell Barton (1976) saw this as a version of disease called 'institutional neurosis', characterised by symptoms such as apathy, lack of initiative, loss of interest and submissiveness. The cause of institutional neurosis was said to be factors such as loss of contact with the outside world, enforced idleness, brutality and bossiness of staff, loss of friends and personal possessions, poor ward atmosphere and loss of prospects outside the institution.
Similarly, Erving Goffman (1961) described the 'total institution' by which he meant "a place of residence and work where a large number of like-situated individuals, cut off from the wider society for an appreciable period of time, together lead an enclosed, formally administered round of life". Prisons would be a clear example. Breaking laws was not necessary to get into prison-like institutions, such as asylums, but the institutional effects were similar. This kind of thinking about institutionalisation encouraged the search for alternatives to hospital, including the development of community care.
With the opening up of the culture of mental health services, the traditional hospitals went into decline and alternative services were developed, including psychiatric units in general hospitals, residential homes and day centres. Many old long-stay patients grew old and died in hospital, and the number of new long-stay patients to replace them has been much less. Bed numbers have steadily continued to decrease although in fact the number of admissions, including recurrent admissions, has increased related to a significant reduction in the length of stay in hospital. Long admissions to hospital are, therefore, now unusual. They are no longer needed because of alternative provisions in the community.
The relationship between critical psychiatry and community care
What I want to look at in this presentation is some aspects of the philosophy underlying community care. In particular, I want to look at the role that anti-psychiatry and critical psychiatry played. "Anti-psychiatry" was a movement of the 1960s and 70s, associated with the names of people like RD Laing and Thomas Szasz, which had an anti-authoritarian, popular, even romantic, appeal as an attack on psychiatrists' use of psychiatric diagnosis, drug and ECT treatment and involuntary hospitalisation.
It is commonly said that anti-psychiatry at least partially contributed to the process of dehospitalisation. For example, Thomas Scheff's (1999) book Being mentally ill, which describes the labelling theory of mental illness, forms part of the identified corpus of anti-psychiatric writings. As Scheff himself notes in a later edition of the book, the first edition was regarded as the "Bible" by the group that wrote the bill that became the new mental health law for California, and later for the rest of the United States. The new law made it more difficult for people to be kept in hospital indefinitely, which in the long run could be said to have contributed to the subsequent closure of mental hospitals.
Perhaps even more obviously would be the case of Franco Basaglia, who is commonly seen as one of the core group of anti-psychiatrists. He was the principle architect of law 180 in Italy, which prevented new admissions to existing mental hospitals and decreed a shift of perspective from segregation and control in the asylum to treatment and rehabilitation in society. Also of interest is his initial motivation when he was asylum director, which was the effect of institutionalisation. He was initially interested in the therapeutic approach of Maxwell Jones (1952), although he later came to see such reformist measures as inadequate. This led to his anti-institutional struggle to abolish the asylum.
There has been a resistance to the rundown of the traditional asylums. By contrast, critical psychiatrists have tended to be at the forefront of community care developments. For example, Pat Bracken and Phil Thomas, who have developed the notion of post-psychiatry (Bracken & Thomas, 2005), perhaps the best articulated modern form of critical psychiatry, were known for their development of a home treatment service in Bradford, well before the NHS as a whole facilitated the development of such services. In fact the Bradford service was seen by the NHS as an example of good practice - a beacon service - for other services to follow.
The nature of critical psychiatry
Perhaps before I go further, I need to say a little more about the nature of critical psychiatry. It has become more explicit over recent years in its opposition to the reductionist tendency within psychiatry. By this I mean that psychiatry has become increasingly dominated by the claim that mental illness is caused by neurobiological abnormalities, such as chemical imbalances in the brain. This postulate has the tendency to reduce people to brains that need their physical abnormalities cured. Critical psychiatry does not believe that this is the whole story and proposes a more ethical foundation for practice. It concentrates on the person, both in assessment and treatment. It recognises the primacy of context for understanding personal action.
Critical psychiatry has its origins in anti-psychiatry but sees itself as an advance over the polarisation created by the divisions of anti-psychiatry. Critical psychiatry is clearly part of psychiatry, but challenges psychiatry to reflect about its practice. Anti-psychiatry may have tended to deny the reality of mental illness, but critical psychiatry is clear that the term 'mental illness' may have meaning as a psychosocial concept. Anti-psychiatry tended to object to psychiatry as an agent of social control, whereas critical psychiatry acknowledges the inevitable social dimension of psychiatric practice. In essence, critical psychiatry proposes that psychiatric practice does not need to be justified by postulating brain pathology as the cause of mental illness.
Anti-psychiatry and institutionalisation
One of the prime motivations for anti-psychiatry, as it was for community care, was the effects of institutionalisation in the traditional asylums. This led to a search for alternatives. I have already mentioned Thomas Scheff and Franco Basaglia in this respect. What I want to do now is look at the role that institutionalisation had for the development of the ideas of RD Laing and his associates. Laing is commonly seen as a core contributor to anti-psychiatry, although he himself always disowned the term. Despite this disavowal, if the term 'anti-psychiatry' has any meaning, the work of Laing is central to its understanding.
What Laing was looking for in his approach to psychiatry was:
a whole new approach … without those features of psychiatric practice that seemed to belong to the sphere of social power and structure rather than to medical therapeutics (Laing1985).
This therapeutic aim is also apparent in the work of David Cooper (1967), who was one anti-psychiatrist who was happy to accept the term of himself. His motivation was to create a community in which patients would have the chance to discover and explore authentic relatedness to others. To do this required positive non-action, "an effort to cease interference, to 'lay off' other people and give them and oneself a chance". Being allowed to 'go to pieces' was necessary before one could be helped to come together again. He set up Villa 21 in Shenley Hospital between January 1962 and April 1966. An experimental phase of staff withdrawal led to rubbish accumulating in the corridors and dining room tables being covered with the previous days' unwashed plates. Some staff controls were re-introduced with the threat of discharge if patients did not conform to the rules. These apparent limits to institutional change led to the conclusion that a successful unit could only be developed in the community rather than the hospital.
Cooper was involved with Laing and others in setting up the Philadelphia Association, which in 1965 established Kingsley Hall, a 'counterculture centre' in the East End of London. Kingsley Hall sought to allow psychotic people the space to explore their madness and internal chaos. It did not attempt to 'cure' but provided a place where "some may encounter selves long forgotten or distorted" (Schatzman, 1972). The local community was largely hostile to the project. Windows were regularly smashed, faeces pushed through the letter box and residents harassed at local shops. After five years, Kingsley Hall was largely trashed and uninhabitable. Even for Laing, Kingsley Hall was "not a roaring success" (Mullan, 1995).
Laing had previously been involved in an experimental therapeutic venture within the health service as a psychiatric trainee at Gartnavel hospital in Scotland (Andrews 1998). He started at Gartnavel as a registrar in 1953. In his autobiography he described the experience as impersonal and depersonalising (Laing 1985) - much the same conditions as I mentioned earlier that Clark saw as the origin for community care. The project he was involved in recognised the role that the hospital environment had in 'enforced inactivity' of patients. It encouraged patients and nurses to develop interpersonal relationships of a reasonably enduring nature. The nurses called the scheme the "Rumpus Room".
To reiterate the point I am making is that anti-psychiatry was intimately involved in the same concerns about institutional care in the asylum that promoted community care. As other examples, I would mention Joseph Berke and Leon Redler. Both these men came from the United States and worked with Maxwell Jones at Dingleton hospital before moving to Kingsley Hall. The therapeutic community approach of Maxwell Jones was extremely important in opening and changing the culture of psychiatric hospitals alongside the development of community care. Although many anti-psychiatrists thought they had moved on from what they saw as the reformist rather than sufficiently radical approach of Jones, they were initially interested in his ideas.
The relation of critical psychiatry with other psychosocial approaches
If anti-psychiatry was so intimately involved in the same factors as other developments in community psychiatry at the time, did it provide anything new? Anti-psychiatry tends to be seen as 'other', an aberrant phase which psychiatry went through, but I think it is important to recognise the continuities as well as the discontinuities with the rest of psychiatry. I want therefore to look a little at some of the antecedents of these ideas.
For example, Harry Stack Sullivan established a small ward for schizophrenic men that was staffed with hand-picked attendants, set apart from the rest of the Sheppard Pratt Hospital in the 1920s. He gave his staff autonomy to operate on their own with patients. He found that:
… intimacy between the patient and the employee blossomed unexpectedly, … that any signs of the alleged apathy of the schizophrenic faded, … and that the institutional recovery rate became high (Sullivan 1962).
Sullivan's experimental ward could be seen as a precursor of the therapeutic community movement and maybe not that much different in many respects from Laing's "Rumpus Room". It was achieved much earlier and was motivated by the interpersonal perspective of Sullivan. Laing spoke favourably of the influence of Sullivan on his own ideas.
Similarly, Adolf Meyer had a clear appreciation of the psychosocial aspects of psychiatry in his understanding of Psychobiology. His wife developed an interest in volunteer service, visiting patients' homes and speaking to their relatives - the first psychiatric social worker. Mrs Meyer then channelled her sympathetic intelligence into occupational therapy. She introduced work into the wards as a systematic activity and also organised recreation and encouraged patients in folk dancing as a form of group therapy. This sort of development was much earlier than the call of the World Health Organisation for the psychiatric hospital to become therapeutic.
Meyer's interest in the origins of mental disorder created a focus on mental health promotion, on which he built the notion of public hygiene and for which he coined the term 'mental hygiene'. The mental hygiene movement had its inception in the experiences of Clifford Beers (1908), who approached Meyer for support to improve conditions in the asylums, based on his own adverse experiences of his treatment for his manic-depressive illness. The US National Committee for Mental Hygiene was formed in 1909 and the first International Congress on Mental Hygiene was held in 1930. These psychosocial therapeutic developments coincide with the interests of critical psychiatry.
The implications for critical psychiatry
Elements of critical psychiatry are therefore identifiable before the origin of anti-psychiatry. They were also influential in psychiatry before post-modernism, which suggests that it may be a mistake to tie critical psychiatry to post-modernism in postpsychiatry. Essentially psychosocial perspectives have a long history in psychiatry. They were important in the development of community care. I would say these more general psychosocial influences were probably more important than anti-psychiatry in particular, which tended to encourage alternatives outside the psychiatric system rather than being committed to changing the system from within. Basaglia, however, would be one example that breaks this rule.
In fact, there may be a sense in which critical psychiatry could be said to be an advance over earlier psychosocial perspectives such as that of Adolf Meyer. Meyer's tendency to compromise may mean that he did not take as explicitly ethical a stance as does critical psychiatry. By way of conclusion, I want to look at the example of Clifford Beers in this respect.
In his book The mind that found itself, Beers (1908) described his manic-depressive illness and its treatment, which was often inhumane and cruel. He exposed the truth of what he witnessed in hospital in no less a way than modern psychiatric survivors. Critical psychiatry sees the challenge of the user movement as crucial to the development of an ethical community psychiatry. Although Adolf Meyer encouraged Beers, he did not propose the development of a user movement. Obviously this does not make sense in retrospect - it was before its time.
In a way and with hindsight, Meyer could be said to have diverted the full impact of Beers' critique into the mental hygiene movement. Critical psychiatry instead recognises the expertise of users of the service and works towards a combination of this expertise by experience and the expertise of the professions to create the highest quality mental health service.
In summary, although it may be misleading to see anti-psychiatry itself as a motivating factor in the origins of community care, its overlap with psychosocial perspectives in general were influential and anti-psychiatry had many of the same interests as other psychosocial perspectives, in particular in relation to institutionalisation in the asylum. Critical psychiatry has clear implications for community mental health practice in its more thoroughgoing ethical stance and explicit focus on the survivor perspective. These elements need to be reinforced so that the influence of critical psychiatry is accepted, rather than being marginalised as happened with anti-psychiatry.
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