Essay review of Cultures of Psychiatry and Mental Health Care in Postwar Britain and the Netherlands (eds) Gijswijt-Hofstra M & Porter R. Amsterdam: Wellcome Institute 1998
Sufficient time has elapsed to reflect on the history of "anti-psychiatry". One prevailing version of that history is that it was a passing phase (Tantam 1991). Another view places anti-psychiatry in its broader cultural context and sees it in terms of its continuities. The book Cultures of Psychiatry takes the latter refreshing approach. It is one of a productive series in the History of Medicine from the Wellcome Institute (series editors WF Bynum and Roy Porter). The contents emerged from a workshop held in June 1997 in Amsterdam organised by the Wellcome Institute for the History of Medicine (London) and the Dutch Huizinga Institute for Cultural History. Cross-national comparisons are made between post-war Britain and the Netherlands, exploring how these similar but contrasting national cultures have had an impact on the presence of critical psychiatry. Fourteen papers are presented, matched in Anglo-Dutch pairs, with two concluding commentatory chapters.
The quality of contributions naturally varies. Some chapters fail to provide a novel perspective, whereas others are an inspiring stimulus for further research. In all, the book deserves to be better known. This essay review concentrates on those aspects of the book which illuminate the nature of anti-psychiatry.
The first chapter by Joan Busfield sets an overview of twentieth century developments in mental health services in Britain. It includes the recent influence of the Thatcherite ideological bias for competition and private provision rather than public sector expenditure. In the matching chapter, Paul Schnabel focuses on Dutch psychiatry after the second world war. There may be something to learn for the current reform of the Mental Health Act in England and Wales from the fact that the present Dutch 'lunacy act' followed a parliamentary debate that took more than 20 years.
Mathew Thomson recognises the roots of anti-psychiatry in the social psychiatry of the Second World War and postwar reconstruction. As he notes, there was no earlier British equivalent of the lay critique of psychiatry by Clifford Beers, leader of the American mental hygiene movement. The links between mental hygiene and the promotion of peace are apparent in a letter drafted by the Netherlands Medical Association in 1935 and signed by 339 leading psychiatrists around the world. The psychological ideas related to mental hygiene came together in the formation of the World Federation of Mental Health in 1948 at an International Congress in London, of which J R Rees, who had been Consulting Psychiatrist to the British Army, was President. The pursuit of the positive concept of mental health by this movement laid itself open to the charge that it idealised dominant western values. The war had revealed the dangers of unbridled human drives, leading to an acceptance of the need for "social control", although not totalitarianism. Anti-psychiatry, in contrast, promoted personal self-discovery as a form of mental well-being without social control.
Leonie de Goei similarly notes the strengthening of the Dutch Mental Hygiene Movement by the experience of the Second World War. H C Rümke was elected Chairman of the Executive Board of the World Federation of Mental Health. Although he was an adherent of the medical model, his disciple C J B J Trimbos proclaimed a non-medical branch of psychiatry and recognised the socioplastic nature of mental disorder in his 1959 thesis entitled Mental Health Science and Mental Health Care. The revolutionary step of anti-psychiatry was the conviction that society and the family themselves are directly pathogenic, not just factors which alter the presentation of mental illness.
E M Tansey examines the origins of modern psychopharmacology, concentrating on British contributions. Developments were driven by the pharmaceutical companies and in the early years, much less than in current practice, there was controversy about whether psychoactive drugs were an advance in treatment. In the corresponding Dutch chapter on the influence of psychopharmacology, Stephen Snelders investigates the role of LSD in the elaboration of both biomedical and social concepts of mental illness. As LSD has effects on the brain, the resemblance of the hallucinogenic effect of LSD to psychotic phenomena gave support to biological models of mental illness. In contrast, the use of LSD in the counterculture of the 1960s promoted a comparison of transcendental and psychotic experience, particularly by R D Laing.
Jonathan Andrews concentrates on R D Laing's involvement as a psychiatric trainee in the 'Rumpus Room' experiment at Gartnavel hospital in the early 1950s. The emphasis on the importance of the hospital environment paralleled the therapeutic community approach of Maxwell Jones. The interpersonal psychiatry of J L Cameron, one of the co-authors of the Lancet article on the 'Rumpus Room', had more of an influence on Laing than is generally acknowledged, although Laing did make a distinctive contribution to part of the overall project. Laing was probably the most significant British "anti-psychiatrist"; his counterpart in Holland was Jan Foudraine, author of Not made of wood, as it was entitled in english translation, originally published in Holland in 1971. Gemma Blok describes Foudraine's disappointment as an assistant-psychiatrist with the lack of 'human dignity' in traditional psychiatric practice. He was also frustrated with the psychoanalytic approach of Chestnut Lodge in America, where he worked for a few years, transforming his ward there into a 'school for life'. He himself admitted he was confused by the reaction to his best-selling book and he became the 'personal ambassador' in Holland of Baghwan Shree Rajneesh.
The experiment from 1969 in Holland at the Dennendal Clinic for the learning disabled is set in context by Ido Weijers. The attempt to end the use of the medical model in the clinic is seen as driven by the prevailing "personalist" culture, stressing the dignity of the person, manifest for example in the School of Utrecht. The institution examined in the comparative British chapter is the Maudsley hospital, which occupies a special position in British psychiatry. Keir Waddington notes the lack of attention to anti-psychiatry at a formal level at the Maudsley hospital, and describes the impact of the ensuing conflict resulting from the Maudsley's merger with the Bethlem hospital in 1948.
In contrast to Britain, one professional organisation, the Dutch Association for Psychiatry and Neurology, represented both neurologists and psychiatrists in the Netherlands until 1974. Separate sections for neurology and psychiatry were only created from 1962. Harry Oosterhuis and Saskia Wolters describe the impact on the professional identity of psychiatry in the Netherlands of the increasing separation of psychiatry and neurology, which encouraged a multicausal, bio-psycho-social approach to psychiatry as opposed to the one-sided somatic emphasis of neurology. They see the professional dilemma of psychiatrists in the conflict between their separate status as scientific medical specialists and the need to be more than medical specialists if they are to influence other professionals. Peter Barham describes how the dehumanising potential of the asylum, with its aim of containing madness, has failed to be replaced by a commitment to a socially inclusive mental health policy in the community.
Hans Binnevald describes the development over the last decade of the Dutch psychological assistance service for UN peace-keeping operations. Holland is the only NATO country where such a system exists just for peace-keeping operations, and reflects the lack of any real Dutch military psychiatry previously. Roy Porter sees anti-psychiatry's emphasis on the pathogenic nature of the family as having its origins in the legacy of Freud, which he contrasts with the pre-Freudian worldview where the family was paramount and psychiatry dealt with mad relatives on its behalf.
In the first of the concluding chapters, Colin Jones examines what he calls "the act of negation and inversion at the heart of the [anti-psychiatry] movement ", or, in other words, "the 'anti' element in anti-psychiatry". Objectification of the mentally ill makes psychiatry part of the problem rather than the solution of mental illness. The attack on the biomedical model of mental illness and the centrality of the asylum encourages an anti-authoritarian stance. However, the language of opposition obscures how much the ideas which amounted to anti-psychiatry predated its emergence. Furthermore, Laing and Foudraine at times tried to maintain their links with the psychiatric profession and sought its endorsement. Their ideas were populist and associated with the counter-culture of the 1960s. Yet their quest for personal authenticity meant they were unable to carry through their ideas politically. Nonetheless, despite their personal fates, as Jones says, it is misleading "to reduce anti-psychiatry to a set of largely depassé ideas and concepts" and "the force and freshness of the 'anti-psychiatry movement' in western culture" should not be underestimated.
In the final chapter, David Ingleby also sees Laing as being more interested in the larger goal of changing the world than changing psychiatry. He suggests anti-psychiatry had a more sympathetic reception in Holland because by the seventies Holland had become a byword for liberalism and progressive social policies. For example, Kees Trimbos, one of the founders of Dutch social psychiatry, in his book Anti-psychiatrie warned against imagining that it was just a fad: "after all, anti-psychiatry is also psychiatry!". However, over recent years the pendulum has swung more towards medical rather than social models of mental illness. The definition of illness has broadened and demand for treatment overloads services. In academia, as Ingleby notes, "there has been a noticeable shift ... away from socially critical perspectives, which are increasingly regarded as an embarrassing hangover from the seventies". His sobering conclusion is that, in contrast to anti-psychiatry, the character of the mental health professions has become highly bureacratic and rationalised.
The chapters in the book concentrate on elucidating the origins of anti-psychiatry. There is less discussion of the reasons for its subsequent marginalisation and the cultural factors which were associated with this development. There may need to be more distance in time to be able to analyse this reaction historically.
Although the influence of American culture is acknowledged incidentally, the focus on Britain and the Netherlands in the book, despite simplifying the nature of anti-psychiatry and therefore leading to productive insights, avoids the complexities of a complete international understanding of its character. In particular, there is only one reference to Thomas Szasz, in Jones' concluding chapter, and this is not to discuss his theories, but merely to acknowledge his affinity with anti-psychiatry. If Laing and Foudraine are seen as the embodiments of anti-psychiatry in Britain and Holland respectively, their equivalent in the USA is Szasz. Associating Szasz with the former, however, does not do justice to their differences, which are substantial in many respects. Szasz remains vehemently hostile to Laing; in 1976, he scathingly entitled an article on Laing in The New Review 'Anti-psychiatry: The paradigm of a plundered mind'. A principle complaint was that Laing was inconsistent. Szasz's position is logically coherent in that the reality of mental illness is inevitably repudiated from the assumption that the term 'illness' implies physical pathology. Hence the title of Ssasz's (1972) original book The myth of mental illness, the theme of which and its implications, eg.the lack of justification for involuntary hospitalisation, have led to a plethora of books regurgitating Szasz's libertarian, free-market principles. Laing insisted he never rejected the existence of emotional turmoil, merely that it was more socially intellible than commonly assumed. It is clear from the transcript of recorded conversations that he made with Bob Mullan (1995) in the two years before he died that Laing was not concerned to work through his differences with Szasz. He was surprised that he was not more of an ally. For them to be seen as on the same side of the argument despite their substantial differences justifies Colin Jones' notion that the essence of anti-psychiatry derives from the sense in which psychiatry itself is regarded as part of the problem.
The case can evidently be made that Szasz's version of anti-psychiatry has links with the dominant capitalist culture of the USA. There are also clear connections between the reaction against anti-psychiatry and the evolution of the DSM-III, which ultimately had effects on ICD-10, through DSM-IIIR and DSM-IV. In particular, Robert Spitzer, who chaired the DSM-III Task Force, was concerned about the study by Rosenhan (1973). Accomplices of Rosenhan managed to gain admission to psychiatric hospital and acquire a diagnosis of schizophrenia merely by feigning a mundane, simple hallucination, indicating they were hearing a voice say "thud", "empty" or "hollow". Rosenhan concluded that professionals were unable to distinguish the sane from the insane, which raised the fear for Spitzer that unreliable diagnoses may invalidate the whole process of psychiatric practice (Spitzer & Fleiss 1974). Operationalisation of psychiatric criteria arose as a response in an attempt to create objectification in diagnosis. This movement in classification has been called neo-Kraepelinian (Klerman 1978) and essentially usurped Adolf Meyer's influence. Meyer devalued single-word diagnoses in favour of a full assessment of the patient as a person. His philosophy could be seen as providing roots for the British and Dutch versions of anti-psychiatry analysed in Cultures of Psychiatry. For example, the link with mental hygiene was examined by Mathew Thompson in his chapter in the book. Clifford Beers, who was the leader of the movement in the USA, was promoted by Adolf Meyer. More generally, Meyer's emphasis on understanding coincides with the "personalist" cultural influences described in the chapter by Ido Weijers. Meyer's ideas came to Britain via Aubrey Lewis and David Henderson. Of interest is how their transmutation led ultimately to anti-psychiatry's lack of influence.
What remains to be seen is whether cultural forces will lead to a resurrection of interest in anti-psychiatry. The Critical Psychiatry Network (http://www.criticalpsychiatry.co.uk) has recently been formed in Britain to develop a critique of the current psychiatric system. Other mental health professionals have challenged the biomedical dominance of psychiatry, but medical authority has been sustained by the avoidance of complexity and uncertainty. Current trends for the humanising of medicine in general may eventually produce change. The ideological implications of anti-psychiatry seem to have foundered for two main reasons: some of its main advocates were ultimately more interested in personal and spiritual growth; and its message became diluted and confused by combining conflictual viewpoints. The book Cultures of Psychiatry may help anti-psychiatry to clarify its origins and allow it to be reconstructed.
Klerman G L (1978) The evolution of a scientific nosology. In Schizophrenia: Science and Practice (Ed. J. C. Shershow). Cambridge, Mass: Harvard University Press
Mullan B (1995) Mad to be normal. Free Association Books: London
Spitzer, R.L. & Fleiss, J.L. (1974) A reanalysis of the reliability of psychiatric diagnosis. British Journal of Psychiatry, 125: 341-347
Szasz T S (1972) The myth of mental illness. Paladin: London
Tantum D (1991) The anti-psychiatry movement. In 150 Years of British Psychiatry, 1841-1991 (eds Berrios G E and Freeman H). Gaskell: London