British Psychiatry at 150
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British Psychiatry at 150, J. Birley, Lancet, 1991 AD
"Though 'tis hopeless to reclaim them, scorpion rods perhaps may tame them" Jonathan Swift.
In 1841 British psychiatry became organised. The Association of Medical Officers of Asylums and Hospitals for the Insane was founded after the initiative of Dr Samuel Hitch, Resident Physician of Gloucester General Lunatic Asylum--an inspired moment that gave him a brief but significant place in psychiatric history. The Association did not persist with its mouthful of a title: in 1865 its name was changed to the Medico-Psychological Association, which achieved royal patronage in 1926 before undergoing its latest metamorphosis to the Royal College of Psychiatrists in 1971. The College has marked this first 150 years of British psychiatry with a celebratory volume.(n1)
The doctors who met to found the association in 1841 were not the most respected members of their profession. While asylums grew apace in the reign of Queen Victoria and were felt to represent an enlightened attitude towards the mentally ill, the asylum doctors who started them were regarded, at best, as a necessary evil. Formation of the Association did not change matters overnight. The experiences of those who were admitted to the asylums were seldom complimentary--"at last I have reached the lowest rung of the medical ladder indeed; for what the wine-trade is to the man who has failed generally, so I take it is the lunacy trade to the doctor who is no good for any other `specialty', and knows he is not."(n2) Many of the asylum doctors were no more than medically qualified gaolers [jailers], whose only attempts at "care" were the tactics of restraint and punishment so angrily summarised by Swift a century earlier.
From this baseline of aggressive neglect it was not going to be difficult to improve matters, and the next 100 years saw changes that Dr Hitch and his colleagues could not have thought possible. The original, and admirable, objects of the Association--"improvement in the management of asylums and the treatment of the insane, and the acquirement of a more extensive and more correct knowledge of insanity"--were amply fulfilled under the tutelage of far-seeing men such as Samuel Tuke, John Conolly, Samuel Gaskell, and Henry Maudsley. The care of the mentally ill improved dramatically, even though there were no major advances in treatment until the 20th century. These and other psychiatrists helped to make the profession of asylum doctor respectable, while the founding of the Association removed the doctors' professional isolation.
Over the past 50 years psychiatry has undergone countless changes. Growth of asylums has been checked and reversed, and therapies have been introduced that have allowed psychiatrists to break free from the introspective convolutions of psychoanalysis and the iatrogenic dangers of bromides and barbiturates. Psychiatrists are no longer running their services like generals with private armies; the disciplines of nursing, psychology, occupational therapy and social work all play independent and important parts in the care of the mentally ill. Nevertheless, British psychiatry is not happy with itself. Many of the changes have been too rapid and too often generated from without rather than from within the discipline. The profession no longer feels that it has control over its own destiny and it has undergone fission as a consequence. Some argue for the good old days of the asylums when doctors were in control whereas others recommend the abolition of all mental hospitals and the opening of a brave new world of psychiatric units entirely within the bounds of district general hospitals. Both the promotion and the relegation of drug treatments, psychotherapy, and other psychological treatments have been advocated. There are similar controversies about the level of integration between psychiatry and other mental health disciplines. Outsiders can be forgiven for regarding such disputes as battles for power rather than attempts to improve patient care.
What about psychiatric research? We seem to be no closer to finding the real, presumed biological, causes of the major psychiatric illnesses. Social psychiatry has made considerable strides, yet one of its main proponents lately noted "there has been no major advance in the theory and practice of psychosocial methods of treatment, enabling, care or support during the past 30 years."(n3) Increasingly, research funds, which are already meagre, are being channelled into genetics, pharmacology, and biochemistry rather than into psychiatry itself. This is not to decry the value of such research--if the causes of conditions such as Alzheimer's disease and schizophrenia are found it will be an advance of the same magnitude as the identification of the syphilis spirochaete in the brains of patients with general paralysis of the insane--but the clinical goals seem a long way off. Too much of the psychiatric research that is funded is seen as divorced from daily clinical practice with a preoccupation towards the minutiae of diagnosis and terminology. Research on treatment is dominated by innumerable trials of new drugs in an ostensibly saturated market, with each investigator straining to extract a tiny advantage of one compound over its competitors so that it can be seized upon by marketing managers for promotion. While variations in this small part of treatment outcome enjoy frenzied activity, the remainder, from counselling to alternative medicine, is left unexplored or inadequately studied.
Psychiatrists in the middle of this turbulence need to have some long-term aims and values if they are not to pass from one group to another by random brownian movement. The aims of the original association 150 years ago are still desirable. There remains much room for improvement in the management of institutions for the treatment of the mentally ill and the need for "more extensive and more correct knowledge" is unchanged. Lack of progress in the latter should not unduly hinder the former. Far too often we learn about treatment falling short of accepted practice, staff who are demoralised and lack direction, and psychiatrists who are better known for their absences than their leadership.
All is not gloomy. In the 150th anniversary issue of the British Journal of Psychiatry Birley(n4) reminds us of the proper concerns of psychiatrists and the reasons why our late Victorian forefathers were so effective--they were good communicators. Good psychiatry is a joint enterprise, not only between doctors, but also between other professionals and, increasingly, with people. Birley asks us "to raise the level of discourse to something more sophisticated than often passes at present" and to avoid the impression of occupying "either an omnipotent stance or an impotent one, with nothing much in between". Psychiatrists need to widen their horizons again and remind themselves that the likes of John Conolly and Samuel Tuke achieved so much through their generosity of spirit, humanity, and commitment. British psychiatry needs to work on both its internal and public relations if its first 150 years are not to become its best.
(n1.) Berrios GR, Freeman H, eds. 150 years of British psychiatry. London: Gaskell, 1991.
(n2.) A sane patient. My experiences in a lunatic asylum. London: Chatto and Windus, 1879.
(n3.) Wing JK. Vision and reality. In: Hall P, Brockington IF, eds. The closure of mental hospitals. London: Gaskell, 1991: 10 19.
(n4.) Birley JLT. psychiatrists and citizens. Br J Psychiatry 1991; 159: 1-7.
(British Psychiatry at 150, J. Birley, Lancet, 1991 AD)
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