The History of Psychiatry: Some Personal Observations
In this short paper I would like to offer my observations of the last thirty years in the field of the history of psychiatry. I speak both from the perspective of a psychiatrist and as someone who has written on the subject.
From the 1970s onwards, interest in the history of psychiatry grew rapidly. Michel Foucault’s ground-breaking Madness and Civilisation, which had already been translated into English in 1965, challenged the notion of the history of psychiatry as a tale of benign progress, while Andrew Scull’s Museums of Madness, published in 1979, offered an essentially Marxist account of the rise of the asylum in Victorian Britain. Such work inspired a great deal of new research from historians and also psychiatrists.
The relation between historians and clinicians in these early days proved rather tense. Clinicians felt that their profession was being maligned and that historians were making ill-informed pronouncements about the nature of mental illness, a subject about which they usually had no direct experience. Historians felt that psychiatrists had a naïve and unsophisticated grasp of history and one that was self-serving and self-congratulatory. In time, as a result of dialogue, and, in some cases joint research, these opinions became less polarised and both sides learnt from each other.
I have been involved in three main strands of historical research. Firstly, I have analysed 19th century asylum case notes. This has demonstrated to me the essential similarity in the presentation of mental disorder over historical periods, albeit coloured by the particular culture of the time. Secondly, I have examined the patient’s perspective, mainly in the form of letters written by asylum inmates about their experiences. This has been a very illuminating exercise for a clinician and has hopefully led to a greater sensitivity about the dynamics of the doctor-patient interaction. Lastly I have undertaken biographical studies, the most extensive being that of RD Laing. Studying Laing’s clinical interviews and writing has stimulated reflection on my own practice.
John S Callender
University Of Aberdeen
Psychopathic Personality: Analysis of the Concept
It has been suggested that neuroscientific research into offending behaviour has a greater potential to change public policy than any other area of science. Much of this research has been focussed on ‘psychopathic’ offenders. One paper has described psychopathy as ‘one of the most important concepts to ever emerge in forensic psychology and law…’ (Nicholls & Petrila (2005, 729).
Scientific research rests on adequate conceptualisation of the subject of the research. If concepts are confused, research outcomes will be open to misinterpretation and this will lead in turn to mistakes being made in how we deal with offenders.
I argue that psychopathy is a dimensional concept with no non-arbitrary distinction from normality; that it is of dubious validity; that it may not be a unitary entity; that it is has no predictive value; that reliability of the diagnosis is inadequate; that it harmful to those so labelled and that it is essentially a social and moral value-judgment.
The concept of psychopathy formed an important basis of an initiative aimed at those deemed to have Dangerous Severe Personality Disorder. This was launched in England and Wales in 1999, and four sites were established. This project has failed in its main aims and is being wound down after running up costs estimated at £250 million. I conclude that failure of this project can be attributed in large part to weaknesses in its conceptual foundations.
Callender, J.S. (2010). Free Will and Responsibility. A Guide for Practitioners. Oxford: Oxford University Press.
University of Strathclyde
Centre for the Social History of Health and Healthcare
Mixing with Medics: Interacting with Mental Health Professionals on their Turf
Historians are increasingly required to produce research that makes an impact. This is particularly the case for medical historians, partly because of our funders’ expectations, but also because there is a sense that medical history can inform today’s thorny debates about health. Such ideas fuelled the foundation of prominent history of medicine associations, including the Society for the Social History of Medicine, and many prominent history of medicine centres. Unfortunately, many historians are at a loss as to how to make an impact. Health professionals are often suspicious of our expertise and motives, and the media is often not interested unless we are providing a polemic of some sort. So, how best can we interact with and inform those best placed to put our research into action?
In this paper, I suggest that participating in medical conferences (broadly defined), not only provides opportunities to make an impact on the medical community, but also offers chances to observe and participate in medical history as it happens. I describe my own experiences at a mental health conference addressing the ‘Social Determinants of Mental Health, presenting research on the history of social psychiatry which threatened to throw a wet blanket on the proceedings. While the experience threw up a number of challenges, it has also led to some opportunities which might not only allow me to have ‘impact’, but also improve the quality of the research I do.
University of Edinburgh
Faculty of Veterinary Medicine
All Sources Great and Small: approaching the history of animal medicine
Veterinary history has been neglected within academic history of medicine, yet writing it presents interesting challenges: the very wide reach of veterinary medicine; the different kinds of patient-doctor relationships found there; the connections between human and veterinary medicine in terms of ‘one health’ and ‘one medicine’; and associations with related cross-disciplinary fields such as bioethics and animal studies. This paper will explore the current state of veterinary history and present some approaches which attempt to foreground the animal in the historiography. To what extent have animals shaped the medicine they receive, as historical agents? Is it possible to write a veterinary history ‘from below’? What perspectives can the history of veterinary medicine shed on that of human medicine, where animals are ever present but historically silent? What might the scope of a ‘veterinary medical humanities’ be? I will explore some of these areas using examples from my own practice and research as a veterinary surgeon and historian of science, technology and medicine.
Gartnavel Royal Hospital
Why Historicise?-Lessons from the study of addictive substances in the modern era
The historical perspective on addictive substances in the modern era is capable of challenging polarized views on drug and alcohol policy. It is often the case today that journalistic and political accounts in this area lack a sense of this longer history with ‘drug scares’ being accompanied by amnesia for the past. It is a hopeful sign that historians have established research networks in this field and have made inputs into health and social policy. Within the British context, the work of historians such as Virginia Berridge has been influential in addressing this interface between our historical understanding of addictive substances and the formulation of a response to the current alcohol and drug “epidemics”. The role of the medical profession in the history of mind-altering and addictive drugs is of particular note. Doctors often discover and advocate the use of substances prior to a period of reversal where the medical profession seeks to restrict the use of the same drug. One author, Mike Jay, describes this as a Frankenstein narrative. Also arguably our current formulation of addiction as a medical concern is open to future challenge. The conflict between the temperance movement and the disease theory of inebriety in the late nineteenth and early twentieth century is a lesson in how medical specialization fails or becomes unnecessary in the face of major sociopolitical change. It will be argued that current medical specialism in this area, at least in the UK, has learned from this history in its move away from a disease-centred model of addiction to a more eclectic model that allows for the obvious cultural and economic influences on drug and alcohol misuse and dependence.
School of Health in Social Science
University of Edinburgh
From the 'therapy of the word' to 'concordance': is the freedom of the patient the basis of the humanity of the doctor?
The path-breaking work of Pedro Laín Entralgo showed how 'dialogic' and 'person-centred' medicine in the classical world could be. Of particular relevance to today is his description of the art of medicine as a branch of rhetoric, wherein the effectiveness of the physician's technical skill is seen as inseparable from his power to convince the patient of the indispensability of his own contribution to his own care/cure. Laín Entralgo is clear that this relationship was only to be found when a physician was treating a free patient – the care received by slaves was comparable to that received by animals – purely technical, in which they were not expected to play any determining part. In this paper I shall argue that a similar tension has surfaced in today's healthcare between, on the one side, the apostles of 'concordance' as the only approach to secure convinced collaboration by the patient with the recommended therapy, and the apostles of 'hard' Evidence-based Medicine, who argue that the decision as to therapy for any recognised diagnosis is pre-decided by the scientific record of properly conducted trials, and that permitting any other therapy is bad science and a waste of money. I shall offer for discussion the question as to where these different conceptions of medical practice leave the medical practitioner, the patient, and the relationship between them.
Centre for Medical Humanities
‘Risking Enchantment’: how are we to view the smoking person?
The idea of the smoking person portrayed in public health has been criticised as being based on too narrow a view of human nature. This paper outlines that view: that of a person with a stable core and epiphenomenal ‘behaviours’ that can be removed by rational persuasion or Pavlovian manipulation, and examines social scientific critiques of it. The social sciences explore the meanings smoking has for individuals and portray human identity as malleable, the result of ongoing interactions with human and non-human others. These portrayals hint at but do not necessarily explore the existential. Aspects of smokers’ experience revealed in qualitative research - descriptions of cigarettes as ‘companions’ or ‘friends’, deep reliance, sensual pleasure - are sometimes difficult to articulate but can be given full voice in the context of the literary arts. I explore some examples of these sources and argue that a complete picture of smoking meanings is impossible without reference to them. I take a pragmatic approach, following the philosopher William James, who argued that emotional and spiritual experiences contribute to the truth of human existence as much as material explanations, to suggest that this understanding should be part of a critical but supportive engagement with public health research in order to develop more nuanced approaches to smoking cessation.
Professor of Philosophy and Mental Health School of Health
University of Central Lancashire
Clinical judgment and the medical humanities
The medical humanities have grown in popularity at the same time that Evidence Based Medicine has established itself as the dominant ideology in medicine but also autonomy has become the key medical ethical value and person centred care (and ‘personalisation’) has become an important focus of policy. It is thus plausible to see the medical humanities as a complement to EBM, helping to balance the latter’s focus on the general with a focus on the particular or individual. Setting the medical humanities against the standard of EBM threatens, however, to undermine their epistemic status. In this presentation I will argue that this worry is best addressed head on through a philosophical examination of the nature and status of clinical judgement.