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OF mental health care and mentally ill

A brief social history of psychiatric treatment

Sedgwick notes that two broad responses to emotional problems can be traced to antiquity. On the one hand, attempts have been made to tamper with the bodies of people with emotional afflictions, for example douching them in water or drilling holes in their skulls to allow evil spirits to escape. On the other hand, in ancient times good counsel was also purported to be of help. Thus, there are certain stable transhistorical themes, one somatic (today’s biological psychiatry) and the other conversational (today’s psychological therapies or talking treatments).

In the twentieth century, Western psychiatry developed an eclectic mixture of these interventions. Those entering the role of psychiatric patient will be prescribed physical interventions (drugs or ECT) or some version of psychological treatment, or a combination of the two, with the former typically predominating. In the late nineteenth century this was not the case. Psychiatrists at that time had a narrow interest in lunatics in their asylums. These were assumed to have disordered brains and were therefore treated accordingly.

Physical treatments were very limited and crude. By the 1930s, psychotic inpatients were being treated only with paraldehyde, chloral hydrate, laxatives and cold baths (Bean 1980). There was little or no interest in psychological treatments or in nonpsychotic disorders until the First World War created a crisis of legitimacy for the dominant bio-determinist model of psychiatry. This was built on the assumption that lunacy, alongside other forms of deviance like criminality and idiocy, was a result of a ‘tainted’ gene pool. This hereditarian emphasis was formalized with the emergence of the pseudo-scientific discipline of eugenics. Eugenicists were convinced that racial improvement necessitated the resistance to external contamination by an alien racial stock and to the internal contamination by the tainted genes of the lower classes. The latter threat was amplified by their purported greater fertility. With the First World War, ‘England’s finest blood’ began to break down with ‘shellshock’. Later this psychological disability was called ‘battle neurosis’ and then ‘post-traumatic stress disorder’. The officers and gentlemen and their lower-class volunteer subordinates could not be construed as being genetically inferior. Consequently, the tainted gene model of psychiatry virtually constituted a form of treason. To add to the problem for the hereditarian position, officers were breaking down at a higher rate than lower ranks. This crisis of legitimacy for the hereditarian model created a space for other approaches to mental disorder, especially psychoanalysis and its derivatives. Versions of psychotherapy were the stock-in-trade of the ‘shellshock doctors’ of the time and in the treatment centres like the Tavistock Clinic, set up after the war, to treat compensation cases of the new disorder. A fuller version of this shift from biological to psychological approaches in treatment can be found in Stone (1985).

Thus, by the end of the war, psychiatry began to become more eclectic, although a pattern was already discernible of neurosis being treated psychologically and madness being treated with physical means. The latter began to predominate again in the inter-war years, boosted in confidence by the appearance of insulin coma therapy in 1934, prefrontal leucotomy in 1935, and ECT in 1938.

Mainstream psychiatry after the Second World War marginalized the aetiological role of psychological factors and talking treatments. The main textbooks of that period, which were to dominate post-war psychiatric training, reasserted the Victorian bio-determinism of the profession’s founders (MayerGross, Slater and Roth 1954). Once major tranquillizers were introduced in the mid-1950s, psychiatrists could begin to make the claim, which is often repeated today, that these drugs opened the doors of the hospitals and paved the way for community care. This claim, though common, is unfounded. In-patient numbers were already dropping before the introduction of major tranquillizers and the reasons for deinstitutionalization are multiple.

While it is generally conceded by most commentators on twentieth century psychiatry that it developed eclecticism, the bias towards physical treatments remained strong. Despite the incorporation of social and psychological aetiological factors into modern psychiatry, it has tended to reject the centrality of their relevance compared with purported biological causes  Alternatively, they have been given equal consideration but they still legitimize the disease model and the authoritative power of medicine in the diagnosis and treatment of people with personal and social problems.

By the 1970s, this revision of the medical model by Clare (1976) was described as a ‘portmanteau model’ by Baruch and Treacher (1978) to indicate that the disease formulation now takes more on board without being undermined.

However, by the 1990s after a declarations of the ‘decade of the brain’ such a portmanteau or ‘biopsychosocial model’ was on the retreat from biological psychiatry within the profession as a whole .

The limited eclecticism of psychiatry is illuminated by trends in the content of mainstream psychiatric journals during the twentieth century. While there was a broadening in the scope of psychiatric interest to include mental disorders, such as neurosis and substance misuse and personality disorder, there was an enduring interest in biological treatments of mental illness with relatively little coverage of the alternatives, such as psychoanalysis or social psychiatry. Thus there seems to be a lack of evidence to support the notions that explanatory paradigms used by psychiatry changed much over the course of a century.

As well as psychiatry now offering a mixed therapeutic approach, biased towards drugs and ECT, other mental health professionals vary in the types of treatment they offer. Psychiatric nurses might provide client-centred counselling following the humanistic psychologist Carl Rogers or psychoanalytically oriented ‘psychodynamic’ psychotherapy, either individually or in groups. Some nurses are trained as specialists in cognitive-behavioural therapy. A similar eclectic mix can be found in the approach of clinical psychologists to treatment.

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