Monday, March 30, 2020

Towards a history of anti-psychiatry

Tom Burns (who I have mentioned before eg. see previous post) has an essay in The Lancet Psychiatry about the history of anti-psychiatry. He focuses this on 4 revolutionary books all published in 1960/1. A complete history of anti-psychiatry probably still needs to be written, although one of my book chapters covered aspects of it. The term was probably first introduced by David Cooper in his books Psychiatry and anti-psychiatry (1967) and The dialectics of liberation (1968) (see eg. another of my book chapters). As Burns points out this was quite a bit later than 1960/1.

The four books discussed by Burns are:-
1. The divided self (1960) by R.D. Laing
The basic purpose of Laing's (1960) first book, The divided self, was to make madness, and the process of going mad, comprehensible. As I said in my last post, Laing (1964) said in New Society that he thought there was a revolution happening at that time that was changing the clinical point of view in psychiatry to one that is both existential and social. His second book was not Sanity, madness and the family (1964), as Burns says, but The self and others (1961). Nor was Sanity, madness and the family made into the film Family Life as such. This film was directed by Ken Loach from a screenplay by David Mercer. It was a remake of In Two Minds, an episode of the BBC's Wednesday Play series, written by Mercer and directed by Loach. Mercer drew on Sanity, madness and the family for the play, which caused a sensation (see eg. BFI Screenline article).

Sanity, madness and the family was the result of five years of study of the families of schizophrenics. The aim was to establish the social intelligibility of the events in the family that prompted the diagnosis of schizophrenia in one of its members. The book was co-authored by Laing and Aaron Esterson. Esterson is an underrated figure in the history of anti-psychiatry, a term that he thought devalued the work he was doing. The research he was involved with could be said to have succeeded in making the apparently absurd symptoms of schizophrenia intelligible. Esterson was the lead author of a study that showed that the results of family orientated therapy with people diagnosed as schizophrenic compared favourably with those reported for other methods of treatment (Esterson et al, 1965). Esterson (1976) made clear in a letter in The New Review about anti-psychiatry that, as far as he was concerned, Sanity, madness and the family was not an anti-psychiatric text. In fact, he saw anti-psychiatry, by which he meant the writings of Cooper and also of Laing, to the extent that he went along with Cooper, as a movement that had done enormous damage to the struggle against coercive, traditional psychiatry.

To be honest, I find it quite bizarre that Burns thinks that The Politics of Experience and The Bird of Paradise (1967) and Knots (1972) are inscrutable. The former was first published by Penguin books. Most of the contents had been published as articles or lectures during 1964/5. The divided self was republished by Penguin in 1965 under the Pelican imprint, and Laing's other books were also eventually republished by Penguin making him a bestseller and cult figure. True, Laing helped to articulate for the counter-culture the need for the free spirit of the age to escape from the nightmare of the world.

Burns was born in 1946 and, therefore, lived through the 1960s. Was he that out of touch? True, The politics of experience provides a stark, political perspective that was absent from Laing’s earlier work. Laing later suggested that The divided self did not originally focus enough on social context when attempting to describe individual existence. He eventually became explicit that civilisation represses transcendence and so-called 'normality' is too often an abdication of our true potentialities. But that's not a reason for dismissing everything Laing wrote after Sanity, madness and the family as "arcane speculation".

In 1965, Laing and colleagues founded the Philadelphia Association (PA) as a charity. Kingsley Hall was the first of several therapeutic community households that it established (see previous post). Kingsley Hall did not attempt to 'cure' but provided a place where "some may encounter selves long forgotten or distorted" (Schatzman in Boyers & Orrill (eds), 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). Nonetheless, the PA has continued until this day (see eg. my book review and book chapter extract).

In March 1971, Laing went to Ceylon, where he spent two months studying meditation in a Buddhist retreat. In India he spent three weeks studying under Gangroti Baba, a Hindu ascetic, who initiated him into the cult of the Hindu goddess Kali. He also spent time learning Sanskrit and visiting Govinda Lama, who had been a guru to Timothy Leary and Richard Alpert. For many commentators, this retreat symbolised a lack of commitment to the theory and therapy of mainstream psychiatry (Peter Sedgwick in Boyers & Orrill (eds), 1972).

Laing returned the following year and lectured to large audiences as well as engaging in private practice. Knots (Laing, 1970) was another bestseller. It described relational 'knots' or in Laing's words "tangles, fankles, impasses, disjunctions, whirligogs, binds". It was couched in playful, poetic language and was successfully performed on stage.
2. Madness and civilisation (1964) by Michel Foucault
Folie et déraison: Histoire de la folie à l'âge classique (1961) by Foucault was abridged by him in 1964 and translated into english as Madness and civilization in 1965. An English translation of the complete 1961 edition, entitled History of Madness, was published in 2006 (see previous post). Foucault is often included within anti-psychiatry, because he is seen as having regarded the Enlightenment as oppressive. However, he was not necessarily for or against the Enlightenment (see previous post). Foucault stressed he was ignorant of anti-psychiatry at the time of writing History of madness (see another previous post).

I'm very grateful to John Iliopoulos (2017) for any understanding I have of Foucault. History of madness is a philosophical and historical analysis of the origins of psychiatry. The Enlightenment is not so much about the principles of humanism, liberalism and positivism but the point when reason itself started to question the rational foundations of what is accepted as reason. It was this critical engagement of reason with itself which brought psychiatry as a discipline into existence, and it is the same conflict, the same battle which fuels current debates in psychiatry. In the late eighteenth century, alienism identified certain individuals who were agents of an experience whose content eludes understanding. Foucault's 'great confinement' needs to be clearly distinguished from the birth of the asylum a few decades later. The mad were extracted from the places of confinement and inserted into asylums specifically designed for their treatment.

I think Burns apparent bracketing of Franco Basaglia with Foucault may come from the book by Roth & Kroll (1976). This book divided anti-psychiatrists into those that said that mental illness does not exist (this includes Szasz - see below - and social labelling theorists, such as Thomas Scheff), and those that merely regarded the use of the term 'mental illness' as metaphorical, saying that mental diseases are not diseases in the medical sense but reactions to unbearable stresses in life (see eg. previous post). The latter group were divided into those that relate mental illness to interpersonal behaviour, perhaps particularly within the family, like Laing, and those that emphasise the broader societal factors rather than the family, like Basaglia and Foucault. I actually don't think Foucault was saying that mental illness is primarily of social origin. Rather he emphasised the origins of descriptive psychopathology in the Enlightenment.

Certainly Basaglia had come across History of madness (see previous post) amongst other critical texts, such as Goffman's Asylums (see next book considered by Burns). As far as Basaglia was concerned, the asylum did not so much contain madness, but rather poverty and misery. Hence his anti-institutional struggle to abolish the asylum. Basaglia was the principal architect of law 180, passed by the Italian parliament in May 1978. It 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. Basaglia was less concerned about whether mental illness had a biological basis, like Laing and Thomas Szasz (see final book considered by Burns below). Basaglia was probably also not so ideological in having less worry about the use of psychotropic medication.

Burns also mentions labelling theory. Scheff's (1966) book Being mentally ill is the best-known and most comprehensive application of labelling theory to mental illness (see my book review of third edition). Mental illness was not seen as a biopsychiatric problem, but instead said to be defined by the reaction of others by labelling the residually deviant person (after other forms of deviance, such as criminality, perversion, drunkenness and bad manners have been identified) as mentally ill. Mentally ill people conform to the idea of how they ought to behave and labelling is regarded as an important cause of ongoing residual deviance. Labelling theory is very much a sociological theory of mental illness.

With Basaglia as the obvious example in Italy, anti-psychiatry can be said to have contributed to the promotion of human rights in mental health legislation. For example, in an appendix to the third edition of his book, Scheff noted that the first edition of Being mentally ill was regarded as the "Bible" of the group that wrote a bill that became the new mental health law for California, and later for the rest of the United States.
3. Asylums (1961) by Erving Goffman.
Erving Goffman (1922-82) was professor of anthropology and sociology at the University of Pennsylvania, having previously been a faculty member in the sociology department at the University of California, Berkeley, when he wrote Asylums based on his field work at St Elizabeth's in Washington, DC in 1955-6. Asylums was his second book after The presentation of self in everyday life (1956). Goffman was one of the most influential American sociologists of the 20th century and Asylums is a classic book.

Although it is questioned whether he coined the term 'total institution', certainly he popularised it. The first essay in Asylums on the total institution did not just focus on asylums but referred also to all types of total institutions, for example, the military, convents, prisons, boarding schools, institutions for the mentally disabled, and recognised their commonality as well as differences. True, he did not have much respect for psychiatric practice and was critical of psychiatry like Laing and Szasz. Goffman was in tune with Laing because he found that patients were not as crazy as was commonly thought.

Total institutions strip individuals of their former identities and then re-socialise them. Mental hospitals force patients to acknowledge the control of the hospital and the error of their ways. Patients may try to beat the system to function effectively within it. I'm not sure what Burns means by all this being the result of "deliberate policy". Burns also mentions Russell Barton (1959) who called the effects of institutionalisation a disease, for which he coined the term ‘institutional neurosis’. This syndrome was characterised by symptoms such as apathy, lack of initiative, loss of interest and submissiveness. The cause 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.

Laing, Cooper and others experimented with institutional alternatives. For example, David Cooper set up Villa 21 in Shenley Hospital (see extract from my book chapter). Cooper's (1967) "experiment in antipsychiatry" failed to change the ward staff's role-bound behaviour. 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. The Philadelphia Association’s Kingsley Hall, as mentioned above, was outside the hospital system and was perhaps more like a commune. Criticism of its laissez-faire ethos should take account of Laing's own concession, that he had failed to find "a tactical, workable, pragmatic . . . . sort of thing that could work for other people" (Mullan, 1995). 

Before this, Laing had been involved in an experimental therapeutic venture within the health service as a psychiatric trainee at Gartnavel hospital in Scotland (Andrews in Gijswijt-Hofstra & Porter, 1998). The nurses called the project the ‘Rumpus room’. It recognised the role that the hospital environment had in ‘enforced inactivity’ of patients, and encouraged patients and nurses to develop personal relationships of a reasonably enduring nature. There is historical precedent. 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 (Barton Evans III, 1996). He gave his staff autonomy to operate on their own with patients. He found unexpected genuine relationships flourished between patients and staff leading to an improvement in institutional recovery (Sullivan, 1962). 

The idea of the mental hospital as a therapeutic institution was coined in 1945 by Tom Main in an experiment at Northfield military hospital to orientate the whole hospital to a healthy socialisation of neurotic casualties of the Second World War. At the Effort Syndrome Unit at Mill Hill from 1942, Maxwell Jones introduced large group lecture-discussions, sociodramatic performances and nurses as therapeutic aides to educate patients towards an acceptance of group responsibility. At the end of the war, he replicated this regime at an ex prisoner-of-war unit in Dartford. In 1946, he moved to Belmont for the treatment of psychopathic patients who had a poor employment record, developing a proper therapeutic community, which in 1959 became the Henderson hospital. Similarly, after the war, Tom Main became medical director at the therapeutic community at the Cassel hospital.

These therapeutic communities proper were relatively small compared to the size of mental hospitals. It was not until 1962 that Maxwell Jones became medical superintendent at Dingleton hospital in Scotland. Dingleton became well-known for its implementation of the therapeutic community approach across a whole large mental hospital. Both Joseph Berke and Leon Redler, labelled as anti-psychiatrists by Cooper (1968), came from the USA to work with Maxwell Jones at Dingleton hospital before moving to collaborate with Laing. The hospital had already been one of the first British mental hospitals to have a comprehensive open door policy under George MacDonald Bell. David Clark (1996), as another example, tells the story of how Fulbourn hospital opened its doors in The story of a mental hospital, developing its reputation for its therapeutic community approach, social therapy and rehabilitation. The dismay and disgust with the old asylum system and recognition of the negative effects of institutionalisation led to the development of alternative community services and the decline of the traditional mental hospital. Anti-psychiatry could be said to have contributed to and built on this trend in the development of the therapeutic community and community care.

As Burns notes, one of the features that encouraged the rundown of the psychiatric hospital was the recognition of the potential harm caused by psychiatric institutionalisation. There were a number of scandals that uncovered mistreatment of patients in hospital (Martin, 1984). The political response was to set up the Hospital Advisory Service, which, independent of the normal departmental machinery, provided visiting teams for inspecting hospitals. The other main consequence was the government’s renewal of its promotion of the policy of community care. The view was strengthened that society should not reject its mentally ill and handicapped people. No longer was it appropriate to consign these people to distant institutions where they lived their lives out of sight and mind of the rest of society, with the potential for them being abused. The trouble is that at times the systems in community care are still as bureaucratic as those in the traditional asylums (eg. see my unpublished article).
4. The myth of mental illness (1960) by Thomas Szasz.
As Burns indicates, The myth of mental illness was the first of a plethora of books that reiterated Thomas Szasz's treatise on psychiatry. Despite what Burns implies, there is a value in Szasz's position in the way that he regards the biological basis of mental illness as a myth (see eg. previous post). It is important to understand exactly what Szasz was saying, rather than dismiss his views as anti-psychiatry, a term which neither he nor Laing ever accepted of themselves (see eg. another previous post).
Comment
As Burns indicates, the anti-authoritarian, popular, even romantic attack on psychiatry was attractive and eminent psychiatrists, such as Robin Murray and Simon Wessely, have said that they came into psychiatry because of the controversy of anti-psychiatry and because of Laing in particular  (not sure about Tom Burns himself). I ended up having a different view about psychiatry than them (see eg. post on my personal blog). I'm not sure if psychiatry has ever really had good reason to feel pleased with itself (which is how Burns starts his essay) (see eg. previous post).

In The grammar of living, David Cooper (1974) made a further attempt to define anti-psychiatry. As I said in my book chapter:-
He [Cooper] saw it as reversing the rules of the psychiatric game of labelling and then systematically destroying people by making them obedient robots. The roles of patient and professional in a commune may be abolished through reversal. With the right people, who have themselves been through profound regression, attentive non-interference may open up experience rather than close it down. To go back and relive our lives is natural and necessary and the society that prevents it must be terminated. The subversive nature of anti-psychiatry includes radical sexual liberation. The anti-psychiatrist must give up financial and family security and be prepared to enter his/her own madness, perhaps even to the point of social invalidation. Cooper never hid his zealous fanaticism.

As I also point out in that chapter, Laing rightly found this embarrassing. If this is really what anti-psychiatry means, David Cooper may well have been out on his own. As I've kept saying throughout this blog (eg. see previous post), the definition of anti-psychiatry is more to do with mainstream psychiatry wanting to dismiss criticism of the biomedical model (which ranges from radical reductionism to eclecticism). Kees Trimbos (1975), one of the founders of Dutch social psychiatry, in his book Anti-psychiatrie warned against imagining that anti-psychiatry was just a fad: "after all, anti-psychiatry is also psychiatry!" (see my essay review). I’ve tried to give some indications in a recent editorial how mainstream psychiatry overlaps with so-called anti-psychiatry. Burns' essay is useful for highlighting the four revolutionary texts but the history of anti-psychiatry deserves to be put more thoroughly in context. 

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