Fall Schedule Colloquium on the History of Psychiatry and Medicine (McLean Hospital)

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Department of Postgraduate and Continuing Education, McLean Hospital and

Center for the History of Medicine, Francis A. Countway Library of Medicine

present

COLLOQUIUM ON THE HISTORY OF

PSYCHIATRY AND MEDICINE

David G. Satin, M.D., DLFAPA Director

Open to students of history and those valuing a historical perspective on their professions.

———-Fall, 2014———-

September 18 (Ballard Room)

Colonial Governance and Medical Ethics in British India, 1870-1910

Kieran Fitzpatrick: D.Phil candidate at the Wellcome Unit for the History of Medicine, University of Oxford; Wellcome Trust Medical Humanities Studentship holder 2013-16

October 16 (Minot Room)

Jewish Medical Resistance in the Holocaust

Michael A. Grodin, M.D.: Professor of Psychiatry, Boston University School of Medicine; Professor of Health Law, Bioethics, and Human Rights, Boston University School of Public Health

November 20 (Ballard Room)

Making the Suicidal Object: Sympathy and Surveillance in the American Asylum

Kathleen Brian, M.A., Ph.D.: Visiting Assistant Professor of American Studies, George Washington University

December 18 (Ballard Room)

Boundary Disputes Between British Psychiatry and Neurology

Stephen T. Casper, PhD: Associate Professor, History of Science, Humanities, and Social Sciences, Clarkson University

4:00 P.M.—5:30 P.M.

see room scheduled, fifth floor, Countway Library of Medicine, Harvard Medical Area

For further information contact David G. Satin, M.D., Colloquium Director,

e-mail: david_satin@hms.harvard.edu, phone/fax 617-332-0032,

Is This the Worst Time Ever to Have a Severe Mental Illness?

Psychiatrist Allen Frances, Professor Emeritus at Duke University and Chair of the DSM-IV Task Force, has published a new article in The Huffington Post today centered on the history of psychiatry. The piece also features the work of University of Toronto historian of medicine Edward Shorter. It is entitled “Is This the Worst Time Ever to Have a Severe Mental Illness?”

Is This the Worst Time Ever to Have a Severe Mental Illness?

My personal response to this depressing question would have to be an ashamed ‘Yes’ for the United States; a relieved ‘No’ for most of the rest of the developed world.

Admittedly, though, I am not the best person to provide a long view answer. We will soon be turning to Professor Edward Shorter, an eminent historian of psychiatry, to compare our current mistreatment of the severely ill with the practices of past epochs.

But I can speak from painful experience about the slippery downward slope of the past 50 years. When I first began work as a medical student on a psychiatric ward, we were very very optimistic that three new advances would dramatically improve the lives of our patients: 1) the availability of effective medication; 2) the availability of powerful research tools; and 3) the hope that state hospitals would disappear as patients were deinstitutionalized into the community.

Forty years ago, my optimism collided with reality when I was given charge of a short term inpatient ward. The medicines sometimes did work wonders, but often brought only partial relief and caused unpleasant side effects. The research findings were fascinating, but didn’t have any impact on patient care. And worst of all, it was clear from the outset that deinstitutionalization was being carried out so badly it was bound to fail.

Patients were irresponsibly discharged at breakneck speed with little or no provision for their housing or treatment in the community. They were left to sink or swim on their own and not surprisingly many sank.

The dream of deinstitutionalization turned into nightmare because most state governments didn’t, as promised, use the money saved by closing beds to provide adequate community treatment and housing. Deinstitutionalization was great for the state budget, but often terrible for the patients.

Many wound up on our unit. I am still haunted by a man I had to cut down after he had hanged himself in our shower room — he couldn’t tolerate his fallen status from chief car washer in the state hospital to deinstitutionalized street person.

In Europe, deinstitutionalization was usually done much better — with a sense of social justice, adequate funding, decent housing, and greater family involvement. Originally, there were also some excellent programs in the United States, but most of these have been eroded with time under pressure from shrinking budgets and the cherry picking of easier patients that accompanied privatization.

The severely ill are now often jailed or homeless — worse off than they were when I started psychiatry. For more on this heartbreaking development, see this blog post and a dozen others I have written.

Now we’re going to shift gears from my personal experiences to Edward Shorter’s historical perspective. He is professor of the history of medicine and professor of psychiatry at the University of Toronto and has written widely on the past and current problems of psychiatry. Professor Shorter writes:

“What was it like being a psychiatric patient in the remote past? Before 1800, before Philippe Pinel, things were quite grim. People often believed that mental symptoms were caused by demonic possession and took the ill to priests for painful, sometimes fatal, exorcism. Psychiatric patients were sometimes, if female, regarded as witches and burned at the stake.

Physicians, while not believing in demons, thought the abdomen — especially the spleen and colon — was the site of mental illness and treated patients with laxatives. Bleeding and many other futile and dangerous treatments were also routine.

There were no dedicated mental hospitals. Patients who needed to be swept off big-city streets were thrown into ‘hospices,’ together with the criminal, the medically sick, the elderly, and the poor. In smaller communities, mentally affected relatives might simply be locked in the attic or chained in the barn.

A fantasy has arisen among the followers of Parisian philosophy professor Michel Foucault that traditional societies viewed the mentally ill benignly — permitting them to drink red wine on the village commons all afternoon as the neighbors looked on smilingly. In the Foucauldian version of history, the downward slide of the mentally ill begins with ‘capitalism’ and the modern state, as the former benignly neglected denizens of the village commons were now ‘confined’ in barrack-like asylums.

Nothing could be further from the truth. Around 1800, proper mental hospitals were founded. These were intended to be, and originally were, humane institutions-the well-ordered routines of a hospital would restore a sense of order and normalcy; its high walls would grant a sense of safety; and medical reassurance constituted an early form of psychotherapy.

The wheels started to come off the wagon when these praiseworthy intentions were overwhelmed by the sheer press of numbers. Yet a core reality remained: For many, the asylum was a place of safety.

Since deinstitutionalization and the death of the asylum, the care of very ill psychiatric patients has gotten much worse. Psychiatry’s dirty secret is that if you had a severe mental illness requiring hospital care in 1900, you’d be better looked after than you are today. Despite a flurry of media hand-waving about new technologies in psychiatry, the average hospital patient probably does less well now, despite the new drugs, than the average hospital patient a century ago.

How can this be? Above all, the old asylums were committed to keeping the patients safe. A major source of mortality (aside from tuberculosis) was suicide, and the best way to preserve patients from suicide is to hold onto them until they are better. As David Healy’s research group has determined, in one British mental hospital around 1900, the average stay was 302 days, versus 41 days in the same hospital today. Suicide rates within ten years of discharge are much higher now despite the availability of drugs. In 1900, among patients with schizophrenia, 4 had killed themselves within ten years of discharge; today in a roughly similar population, it was 29. Note that most psychiatric inpatient units in the US now have a length of stay that has been shortened to an incredible 7 days — far too short to stabilize patients and keep them safe.

I am not trashing today’s psychopharmaceutical palette. Many patients are clearly better off with drugs than without them. Yet the crucial factor here is length of stay: the stays then were long (sometimes far too long); the stays now are ultra-brief and patients are discharged well before they are able to cope — especially since so few services are available in the community and adequate housing is in such short supply.

The old institutions were not wonderful — they were overcrowded, noisy, and often had a distinctive odor. Patients were neglected and mistreated. Yet those problems have been replaced with a different set: patients today are far too often relegated to jails and prisons, where their vulnerability leads to frequent solitary confinement and physical and sexual abuse. Patients used to work at productive jobs within the institutions; no longer available now that we’ve abolished the shelter the hospitals provided.

When in the 1970s the hospital administrators and state legislators began the massive program of deinstitutionalization — returning the patients to the community — it was under the pretense that they were being discharged to ‘community care,’ to a network of halfway houses and day clinics where they would be looked after and kept safe.

Guess what? Never happened. The well-meant institutions of community care foundered and sank, sometimes because of lack of money, or an antipsychiatry inspired belief that there was no such thing as mental illness and that problems could be treated with kindness alone. I am not against kindness, but some patients are very ill and need genuine medical treatments. Many patients today, booted from the former security of the asylum, find themselves on the street with no care at all or in prison. This is a national scandal and the term “progress in psychiatry” turns out to be cruelly ironic.”

Thanks so much, Professor Shorter, for providing this brief but illuminating historical context. There are two contradictory views on the study of history: 1) If we don’t learn from history, we are doomed to repeat it, versus 2) The one thing we learn from history is that we don’t learn from history. I am inclined to believe the second, but am unwilling to give up on the possibilities suggested by the first.

To read the rest of this article, click here.

New Issue of International Journal of Epidemiology

suppl_1.coverThe latest issue of the International Journal of Epidemiology is dedicated to the history of psychiatric epidemilogy.

Anne M Lovell and Ezra Susser What might be a history of psychiatric epidemiology? Towards a social history and conceptual account

This supplement heralds the start of an interdisciplinary and international effort to trace the origins of psychiatric epidemiology. As a first step, these papers focus primarily on developments during the period 1945 to 1980, in the USA, UK and France, as well as internationally through the World Health Organization (WHO). A post-war modern epidemiology centred on risk factors emerged during this time.

Anne M. Lovell, The World Health Organization and the contested beginnings of psychiatric epidemiology as an international discipline: one rope, many strands

This paper focuses on the relatively late emergence of psychiatric epidemiology as an international discipline, through local-global exchanges during the first 15 years of the World Health Organization (WHO). Building an epidemiological canon within WHO’s Mental Health Programme faced numerous obstacles. First, an idealist notion of mental health inherent in WHO’s own definition of health contributed to tensions around the object of psychiatric epidemiology. Second, the transfer of methods from medical epidemiology to research on mental disorders required mobilizing conceptual justifications, including a ‘contagion argument’. Third, epidemiological research at WHO was stymied by other public health needs, resource scarcity and cultural barriers. This history partly recapitulates the development of psychiatric epidemiology in North America and Europe, but is also shaped by concerns in the developing world, translated through first-world ‘experts’. Resolving the tensions arising from these obstacles allowed WHO to establish its international schizophrenia research, which in turn provided proof of concept for psychiatric epidemiology in the place of scepticism within and without psychiatry.

Nancy D Campbell, The spirit of St Louis: the contributions of Lee N. Robins to North American psychiatric epidemiology

This article takes up the history of North American psychiatric epidemiology with reference to production of knowledge concerning sociopathic or antisocial personality disorder and drug dependence, abuse, and/or addiction. These overlapping arenas provide a microcosm within which to explore the larger shift of postwar psychiatric epidemiology from community studies based on psychological scales to studies based on specific diagnostic criteria. This paper places the figure of sociologist Lee Nelken Robins within the context of the Department of Psychiatry in the School of Medicine at Washington University in St Louis, Missouri. The St Louis research group—to which Robins was both marginal and central—developed the basis for specific diagnostic criteria and was joined by Robert Spitzer, Jean Endicott and other architects of DSM-III in reorienting American psychiatry towards medical, biological and epidemiological models. Robins was a key linchpin working at the nexus of the psychiatric epidemiological and sociological drug addiction research networks. This article situates her work within the broader set of societal and governmental transformations leading to the technologically sophisticated turn in American psychiatric epidemiology and research on the aetiology of drug abuse and mental health and illness.

Dana March and Gerald M Oppenheimer, Social disorder and diagnostic order: the US Mental Hygiene Movement, the Midtown Manhattan study and the development of psychiatric epidemiology in the 20th century

Recent scholarship regarding psychiatric epidemiology has focused on shifting notions of mental disorders. In psychiatric epidemiology in the last decades of the 20th century and the first decade of the 21st century, mental disorders have been perceived and treated largely as discrete categories denoting an individual’s mental functioning as either pathological or normal. In the USA, this grew partly out of evolving modern epidemiological work responding to the State’s commitment to measure the national social and economic burdens of psychiatric disorders and subsequently to determine the need for mental health services and to survey these needs over time. Notably absent in these decades have been environmentally oriented approaches to cultivating normal, healthy mental states, approaches initially present after World War II. We focus here on a set of community studies conducted in the 1950s, particularly the Midtown Manhattan study, which grew out of a holistic conception of mental health that depended on social context and had a strong historical affiliation with: the Mental Hygiene Movement and the philosophy of its founder, Adolf Meyer; the epidemiological formation of field studies and population surveys beginning early in the 20th century, often with a health policy agenda; the recognition of increasing chronic disease in the USA; and the radical change in orientation within psychiatry around World War II. We place the Midtown Manhattan study in historical context—a complex narrative of social institutions, professional formation and scientific norms in psychiatry and epidemiology, and social welfare theory that begins during the Progressive era (1890-1920) in the USA.

Nicolas Henckes, Mistrust of numbers: the difficult development of psychiatric epidemiology in France, 1940–80

This article uses archival as well as published materials to trace the development of psychiatric epidemiology in France from 1945 to 1980. Although a research programme in this field was launched in the early 1960s at the National Institute of Medical Research (INH, later renamed INSERM), psychiatric epidemiology remained an embryonic field in France during the next two decades. French researchers in this field were hampered by limited resources, but their work was primarily characterized by a deep engagement with the epistemological challenges of psychiatric epidemiology. The history of French psychiatric epidemiology in the 1960s and 1970s can be seen as an attempt to create a specifically French way of doing psychiatric epidemiology research. In the first part of this article, the author relates this unique history to internal professional dynamics during the development of psychiatric research and, more broadly, to the biomedical institutional context in which epidemiological work was being done. The next part of this article examines the conditions under which the INH research team framed epidemiological research in psychiatry in the 1960s. The last part focuses on INH’s flagship psychiatric epidemiology programme, developed in cooperation with pioneers of French community psychiatry in Paris’s 13th arrondissement in the 1960s.

Steeves Demazeux, Psychiatric epidemiology, or the story of a divided discipline

This article traces the historical decisions, concepts and key professional collaborations that laid the foundations for the formation of American psychiatric epidemiology during the 20th century, up to the discipline’s institutional consolidation, circa 1980, when the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was published. Thomas Kuhn’s ‘disciplinary matrix’ is mobilized as a framework that allows the institutional and intellectual construction of a discipline to be analysed as separate but intertwined components, without assuming that the two evolve in tandem. The identification of the strengths as well as the frailties and internal divisions of the discipline as it developed reveals a paradoxical situation: a time lag between psychiatric epidemiology’s institutionalization and public recognition, on the one hand; and the weak coherence of its intellectual components, on the other hand. We briefly trace the origins of split among the discipline’s aetiological models of mental disorders and suggest that the lack of coherence among them has prevented psychiatric epidemiology from achieving the status of a normal scientific discipline, in the Kuhnian sense. Without a more explicit attention to the intellectual rationale of the discipline, psychiatric epidemiology will continue to maintain a strong institutional dimension and weak intellectual matrix.

Art, Anatomy and the Body: Vesalius 500 (NYAM, October 2014)

NYAM's Center for History and Public Health

2nd Annual Festival of Medical History and the Arts

Art, Anatomy, and the Body:
VESALIUS 500

Saturday, October 1​8 • 11:00​ AM – 6:30​ PM

Register now to join us as we celebrate the 500th birthday of anatomist and humanist Andreas Vesalius with a day-long event on October 1​8 from 11​:00 AM to 6:30 PM. Few figures have had as much influence on the arts, learning, and medicine as Vesalius. His groundbreaking De humani corporis fabrica (The Fabric of the Human Body) of 1543 profoundly changed medical training, anatomical knowledge, and artistic representations of the body.

A vibrant roster of performers and presenters will explore the intersection of anatomy and the arts, including the following:

  • Daniel Garrison on translating Vesalius for modern audiences
  • Heidi Latsky’s GIMP Dance Project
  • The comics artists of Graphic Medicine
  • Sander Gilman on posture controlling the unruly body
  • Alice Dreger on inventing the medical photograph
  • Bill Hayes on researching hidden histories of medicine
  • Steven Assael on anatomy in contemporary art
  • Chase Joynt’s Resisterectomy, a meditation on surgery and gender
  • Brandy Schillace on ambivalent depictions of female anatomy in the 18th century
  • Ann Fox exploring extraordinary bodies in contemporary art
  • Lisa Rosner on famous body snatchers Burke and Hare
  • The art of anatomical atlases with Michael Sappol
  • Medical 3D printing demos by ProofX
  • Anatomical painting directly on skin with Kriota Willberg
  • And many more!

“Art, Anatomy, and the Body: Vesalius 500″ is guest curated by artist and anatomist Riva Lehrer.

For more information and guest posts from participants throughout the summer follow our blog Books, Health, and History and join the conversation at #NYAMHistFest.

Date

Saturday, October 1​8, 2014

Time

11:0​0 AM – 6:3​0 PM

Location

The New York Academy of Medicine
121​6 Fifth Avenue at 10​3rd Street, New York, NY 1002​9

Sponsored by

The Brandt Jackson Foundation and
Friends of the Rare Book Room

Cost

General Admission – $35
NYAM Fellows, Members, and Friends of the Rare Book Room – $20
Students and Hospital House Staff (ID required) – FREE
Wheelchair Seating and Companion Seat – $35

Registration

www.nyam.org/events

 

The New York Academy of Medicine • 1216 Fifth Avenue, NY 10029 • (212) 822-7200www.nyam.org

New issue – History of Psychiatry

The September 2014 issue of History of Psychiatry is now out, and includes the following articles:

Benjamin Lévy
Cheryl McGeachan
Chris Walker
Herman Westerink
Ellen Nakamura

Psychopathological fringes. Historical and social science perspectives on category work in psychiatry

color spectrumDate: 13./14.2.2015
Venue: Berlin, Institute for the History of Medicine, Dahlem
Organization: Nicolas Henckes, Volker Hess, Emmanuel Delille, Marie Reinholdt, Stefan Reinsch, Lara Rzesnitzek,
Contact: stefanie.voth@charite.de

Over the last few years, the revision process of both the DSM and the chapter V on mental disorders of the ICD has stimulated within psychiatry a series of attempts at challenging established diagnostic categories. These challenges reflect both dissatisfaction with categories as they are defined in existing diagnostic classifications, and a will to adjust them to the demands of clinical and research activities. They are expressed in ways that sometimes strongly resembles the discourse of critical social science. For instance, the conveners of the conference “Deconstructing psychosis” – organized by the American Psychiatric Association along with the WHO and the US National Institutes of Health in 2005 – developed a stringent critique of the proliferation of diagnostic categories in the field of psychosis: “Although these categories are meant to refer to broadly defined psychopathological syndromes rather than biologically defined diseases that exist in nature, inevitably they undergo a process of reification and come to be perceived by many as natural disease entities, the diagnosis of which has absolute meaning in terms of causes, treatment, and outcome as well as required sampling frame for scientific research.” (( van Os, J. and C. Tamminga (2007). “Deconstructing psychosis.” Schizophrenia Bulletin 33(4) p. 861. ))
Controversies over diagnostic categorization in fact have a long history in psychiatry. Rejection of diagnosis has long been prominent among certain segments of psychiatry, from Adolf Meyer’s synthesis in interwar US psychiatry through parts of phenomenological psychiatry in Germany to antipsychiatry and Lacanian psychoanalysis in 1970s France. However, the deconstruction of diagnosis has also been a core feature of what might be termed category work in psychiatry, at least since the fall of the unitary psychosis concept in the last quarter of the 19th century. By the notion of category work we understand the multifaceted practices developed by clinicians, epidemiologists, biologists, administrators and patients to negotiate and objectify the boundaries of diagnostic categories. While such practices have mostly been devoted to securing the internal coherence of major categories, the requirements of both research and clinical work have prompted the development of liminal categories meant to target conditions situated between illness and health, or between broader established diagnostic classes. Examples of such categories include prodromal schizophrenia, latent depression as well as “borderline” disorder and a range of personality disorders. Closely related to these constructs are notions of comorbidity and dimensional concepts of diagnostic spectra or continua. In many of these cases, the challenge for psychiatrists has been to devise entities that include in their very definition the possibility of their transitory status. These diagnostic constructs thus convey a paradox: while they question categorical thinking, they are usually framed within the language of categories.
The aim of this workshop is to offer a historical and social science perspective on the history and current status of category work at the fringes of psychopathology. Unlike constructionist perspectives on psychiatric diagnosis that have aimed to demonstrate the less than solid nature of core categories such as depression, schizophrenia and neurosis, we are interested in the already internally contested and marginal categories devised to target conditions situated at the borders of psychopathology. Thus, rather than elaborating on the longstanding debates between “lumpers” and “splitters”, we would like to examine the ways in which psychiatry has developed knowledge and practices to target these conditions.
This workshop has its origins in the German-French research program “Psychiatric Fringes. A historical and sociological investigation of early psychosis in post-war French and German societies” funded by the ANR and the DFG for the period 2012-2014, and it will be an opportunity to discuss results from this research project. We welcome papers on other aspects of the history, the sociology and the anthropology of psychiatry at the fringes of psychopathology that complement our research and might lead to a wider understanding of this work. Papers may explore for instance one or more of the following issues:

  •   The construction of knowledge at the fringes of psychopathology. What knowledge practices have been involved in the creation of categories targeting liminal conditions? What have been the respective roles of epidemiology, biological science, brain imaging, biometrics, and the clinic in the development and objectification of these categories? What have been the practical and ethical implications of such work?
  • Diagnostic practices. Liminal categories have been developed to address specific clinical uncertainties, but they also have raised new ones. What are these, and how are they practically managed by clinicians and patients? What are the specific diagnostic instruments developed by clinicians, and how are these used? What has been the role of psychopathological scales, psychological tests or biological treatments in diagnostic processes?
  • The specific role of patients´ experience in category work. To what extent have patients, as individuals or as organized groups, contributed to shaping categories at the borders of psychopathology?
  • The trajectories of categories. Like the psychiatrists quoted above, we might be tempted to think that categories always end up in some ways reified. Is this always the case? What has been the use of liminal categories in different historical and social contexts? What has been the influence of these contexts on the very definition of such categories?

Interested prospective participants should send a title and a 350-word paper description to Ms. Stefanie Voth: stefanie.voth@charite.de by September 15th. Travel expenses and accommodation in Berlin will be covered by the conference organizers.

New issue of “Journal of the History of Medicine and Allied Sciences”

3.coverA new issue of Journal of the History of Medicine and Allied Sciences is available online. The July issue 2014 contains the following article that may interest readers of h-madness.

Cadaver Brains and Excesses in Baccho and Venere: Dementia Paralytica in Dutch Psychiatry (1870–1920) by Jessica Slijkhuis and Harry Oosterhuis

This article explores the approach of dementia paralytica by psychiatrists in the Netherlands between 1870 and 1920 against the background of international developments. The psychiatric interpretation of this mental and neurological disorder varied depending on the institutional and social context in which it was examined, treated, and discussed by physicians. Psychiatric diagnoses and understandings of this disease had in part a social–cultural basis and can be best explained against the backdrop of the establishment of psychiatry as a medical specialty and the specific efforts of Dutch psychiatrists to expand their professional domain. After addressing dementia paralytica as a disease and why it drew so much attention in the late nineteenth and early twentieth century, this essay discusses how psychiatrists understood dementia paralytica in asylum practice in terms of diagnosis, care, and treatment. Next we consider their pathological–anatomical study of the physical causes of the disease and the public debate on its prevalence and causes.

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