Reading about … the history of psychiatry

In recent decades ideological battles have raged over how the history of psychiatry should be interpreted. Should the emergence of psychiatry in the late 18th century be seen as the triumph of the Enlightenment, ushering in a rational approach to mental illness and overturning the primitive and often barbaric ideas of previous eras? Or should the rise of psychiatry be seen in a more sinister light? Does it represent the extension of the state into the lives of its citizens, controlling and policing the disaffected and discontented? Are psychiatrists benign humanitarians or agents of oppression? Should the historical narrative be one of progress, as psychiatry steadily extends its knowledge of mental illness and develops more and more effective therapy? Or is the reverse true: has the advent of psychiatry been a calamity for the mad?

A multitude of different disciplines: psychiatrists, psychologists, philosophers, sociologists, historians and cultural commentators, have sought to answer these questions, and, not surprisingly, have provided different answers depending on their perspectives. For the novice, this can be bewildering as so many contradictory voices fight to be heard. This, however, is one of the appeals of the subject. The reader has to determine for themselves what they consider to be the most convincing account of the history of psychiatry. This dilemma mirrors the situation in contemporary psychiatry. Although some would like to maintain that there is only one authoritative explanation of mental illness, the biomedical one, there are, in fact, many different and competing approaches, and the individual clinician has to decide which is the most appropriate for any given situation.

The history of psychiatry used to be written, in the main, by clinicians and, not unexpectedly, the tale they told was one of benign progress. These histories came to be viewed by those outside the discipline as self-congratulatory and serving to legitimise psychiatry's role in the present. This rather cosy state of affairs was unsettled by histories of the subject written by those outwith the psychiatric profession. The French philosopher, Michel Foucault's Madness and Civilisation ¹ appeared in English in 1965, and the Edinburgh-born American sociologist, Andrew Scull published Museums of Madness ² in 1979. These key works challenged conventional accounts, stirring debate and inspiring original historical research to test whether these authors’ broad generalisations were confirmed by an examination of primary sources.

The 1980s and 1990s witnessed a great deal of activity in the field of the history of psychiatry. It attracted psychiatrists who studied the case notes of Victorian asylums to discover who was admitted and the nature of their problems. ^3–6 Historians were attracted by the new readings of psychiatry's past, and a lively, if at times acrimonious, debate took place at conferences and in learned journals. Some degree of rapprochement between the opposing sides was eventually reached, as demonstrated by the appearance in 1991 of the journal History of Psychiatry, which was originally edited by a psychiatrist, German Berrios, and an historian, Roy Porter.

General histories of psychiatry

A good place to start reading about the history of psychiatry is with general overviews of the subject, though it is as well to be aware that these inevitably reflect the particular outlook of the authors. One of the earliest books on the subject was Chapters in the History of the Insane in the British Isles ⁷ by Daniel Hack Tuke, a former editor of the Journal of Mental Science (as the British Journal of Psychiatry was known in the 19th century). This book, which was published in 1882, told a story of the steady advancement of psychiatry from its origins at Bethlem, through the founding of the York Retreat, to the championing of the non-restraint policy at Lincoln and Hanwell asylums. Tuke concluded: ‘The old system, in short, believed in harshness and darkness; the creed of the new is, “I believe in sweetness and light’” (p. 495).

The mid-20th century saw the publication of Gregory Zilboorg's A History of Medical Psychology, ⁸ which also recounted a narrative of progress. However, in this book, it was the advent of psychoanalysis that was portrayed as the triumphant finale to the story. Episodes from the past were examined and judged by the extent to which they anticipated Freudian principles. Somatic approaches were generally decried as leading to a dead end, whereas psychological approaches were treated positively. Several decades later, Edward Shorter told a similar tale of the progress of psychiatry in A History of Psychiatry: From the Era of the Asylum to the Age of Prozac, ⁹ but this time it was biological approaches that were being celebrated and Freudian ideas that were derided as a fruitless detour from the path of the natural sciences. Fulford & Thornton offered an alternative reading to these linear accounts in their Oxford Textbook of Philosophy and Psychiatry. ¹⁰ Here, psychiatry is seen as alternating between psychological and physical approaches to mental illness. The authors suggest that exclusively focusing on only one is misguided and they see the task of present-day psychiatry as attempting to reconcile the two.

In the mid-20th century, the mother-and-son team of Ida Macalpine and Richard Hunter, both psychiatrists, produced many important works on the history of psychiatry. They edited the impressive and weighty Three Hundred Years of Psychiatry 1535–1860, ¹¹ in which they collected the key psychiatric texts of the period and provided a succinct summary of the authors and the significance of their work. They also wrote about the madness of George III, ¹² claiming that he suffered from porphyria, though this has recently been challenged by a re-examination of the clinical notes and contemporary letters, which suggest that he actually had a manic–depressive illness. ¹³

A Century of Psychiatry, ¹⁴ which appeared at the millennium, was edited by another former editor of the British Journal of Psychiatry, Hugh Freeman, who wrote extensively on the history of psychiatry and did much to encourage research. This multi-authored volume provides a very accessible introduction to a hundred years of psychiatry. Developments in psychiatry are placed in the context of world events, and there are plentiful illustrations and lists of suggested reading. Unsurprisingly, given that the authors are mainly psychiatrists, it presents a fairly positive, and at times uncritical, account of the development of the discipline. Freeman also co-edited with German Berrios two valuable volumes on the history of British psychiatry, 150 Years of British Psychiatry, 1851–1991 ¹⁵ and 150 Years of British Psychiatry: The Aftermath. ¹⁶ These are, again, multi-authored books which cover a wide range of subjects. There are biographies of individual psychiatrists, considerations of various institutions and essays on psychotherapy, psychosurgery and the anti-psychiatry movement.

The late Michael Shepherd, former editor of Psychological Medicine, was another psychiatrist who did much to promote historical research. Along with the historians William Bynum and Roy Porter, he edited the three-volume series entitled The Anatomy of Madness. ¹⁷ This contained essays which looked at individual patients, institutions and psychiatric theory. Stand-out chapters include Roy Porter on the melancholy of Samuel Johnson, Trevor Turner on the ‘gloomy genius’ of Henry Maudsley, and Anthony Clare on Freud's case histories.

Histories of madness and treatment

Two of the leading historians in the field have written short histories of madness: Roy Porter (Madness: A Brief History) ¹⁸ and Andrew Scull (Madness: A Very Short Introduction). ¹⁹ Significantly, they chose to write about the history of madness, rather than psychiatry, arguing that this allowed them to consider how the wider culture has conceived of mental disturbance over the centuries. Porter typically drew on his extensive reading in the humanities and his interest in individual patients to provide a highly readable account. He devoted a lot of attention to Freud to whom he was generally sympathetic. Scull is much more critical of Freud and, indeed, of psychiatry generally, but nevertheless, provides another very readable history of the subject. Written nearly a decade after Porter's book, Scull brings the story up to the present day and draws on the work of David Healy to express alarm at the influence of the pharmaceutical industry on the practice of psychiatry. Healy himself has been a major commentator on the development of drugs in psychiatry, notably in The Anti-Depressant Era ²⁰ and The Creation of Psychopharmacology, ²¹ the latter examining the discovery of antipsychotic medication. Healy's pioneering research on the often unhealthy relationship between the psychiatric profession and the drug companies has shed light on an area that vested interests wished to keep hidden. Healy has also co-written, with Edward Shorter, Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness, ²² while Elliot Valenstein has provided a history of physical treatments in the first half of the 20th century in Great and Desperate Cures: The Rise of and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. ²³

Various

There is a vast literature on Freud, much of it critical. A good introduction is Henri Ellenberger's classic The Discovery of the Unconscious, ²⁴ which, as well as examining the work of the Viennese analyst, looks at the origins of psychodynamic ideas in the context of European culture and considers such figures as Mesmer, Nietzsche, Janet and Jung. Scull and colleagues ²⁵ have looked at the lives of 19th-century British alienists, like W. A. F. Browne, John Conolly and Alexander Morison. Their tone is sceptical and they are critical of the ‘Great Man’ theory of history, which sees events being shaped by heroic individuals rather than by wider social forces. Talking about Psychiatry ²⁶ gathered together interviews with many of the leading British psychiatrists of the 20th century and provides a valuable oral historical record of the psychiatric profession. The early career of R. D. Laing is examined in Portrait of the Psychiatrist as a Young Man, ²⁷ a book which attempts to place the radical Scottish psychiatrist in his cultural and clinical context.

The most authoritative book on symptomatology is German Berrios's The History of Mental Symptoms, ²⁸ which draws on the author's extensive research and his command of foreign languages to trace the origins and changing concepts of psychopathology. Berrios has also co-edited with Roy Porter the useful A History of Clinical Psychiatry, ²⁹ which considers clinical syndromes from the psychiatric and historic point of view, and mania ³⁰ and hysteria ³¹ have each been the subject of recent books.

The patient perspective has been considered in A Mad People's History of Madness ³² by Dale Peterson and A Social History of Madness: Stories of the Insane ³³ by Roy Porter. Porter's The Faber Book of Madness ³⁴ also contains extracts from writings of the mentally afflicted, as well as contributions by psychiatrists, novelists and philosophers. Elaine Showalter wrote an early feminist critique of psychiatry in The Female Malady: Women, Madness and English Culture, 1830–1980, ³⁵ but a more balanced account is Lisa Appignansesi's Mad, Bad and Sad: A History of Women and the Mind Doctors from 1800 to the Present. ³⁶

The reader of books on the history of psychiatry will encounter many of the ethical and clinical issues which confront us today. They will see how our predecessors grappled with these problems and discover that many of the ideas which we regard as new were being discussed many years ago.