Archive for July, 2011

What Did American Psychologists Get Wrong in the Wake of 9/11?

The New York Times this past week featured an interesting piece, previewing an upcoming special issue of the journal American Psychologist.  The issue will feature analysis and assessments from psychologists of the shortcomings of psychology and psychotherapy revealed over the past ten years since the terrorist attacks of 11 September 2001.  Among other things, notes Times reporter Benedict Carey, studies show that mental health interventions were not terribly well coordinated in the aftermath of the attacks.

Chaos reigned in the New York area after the twin towers fell, both on the streets and in the minds of many mental health professionals who felt compelled to help but were unsure how. Therapists by the dozens volunteered their services, eager to relieve the suffering of anyone who looked stricken. Freudian analysts installed themselves at fire stations, unbidden and unpaid, to help devastated firefighters. Employee assistance programs offered free therapy, warning of the consequences of letting people grieve on their own.

Some given treatment undoubtedly benefited, researchers say, but others became annoyed or more upset. At least one commentator referred to therapists’ response as ‘trauma tourism.’

‘We did a case study in New York and couldn’t really tell if people had been helped by the providers — but the providers felt great about it,’ said Patricia Watson, a co-author of one of the articles and associate director of the terrorism and disaster programs at the National Center for Child Traumatic Stress. ‘It makes sense; we know that altruism makes people feel better.’


							

In Session: Psychotherapists Undergoing Psychotherapy

The latest issue of the Journal of Clinical Psychology features a special issue on psychotherapists discussing their own experiences undergoing psychotherapy.  As editor Jesse D. Geller explains, the issue

… provides 6 psychologists’ narrative accounts of their own personal therapies and a practice-friendly research review on the characteristics of therapist-patients and their own treatment experiences. In response to a standard set of questions, highly experienced psychotherapists hailing from diverse theoretical commitments wrote the accounts. Their accounts illuminate subtle nuances of the therapeutic relationship and treatment outcome, perhaps more fully than other sources of data. Much of value can be learned from these essays and the research findings about the linkages between receiving and conducting psychotherapy and about the technical and emotional challenges that arise when treating a patient who shares the same profession.

New Issue – Berichte zur Wissenschaftsgeschichte

A new issue of the periodical Berichte zur Wissenschaftsgeschichte is now out and it includes one article dealing with the history of psychiatry.

“Documenting and Describing. The Epistemic Function of Psychiatric Records, their Archiving and Reinterpretation into Case Histories” by Sophie Ledebur

The paper attempts to reconstruct the writing of published case histories. Due to the establishment of a scientific classification system in psychiatry there were at the Charité several changes from the late 1870s onwards: (1) Not only was the documentation in the clinical records altered significantly, but also (2) the archive was reorganized into a double filing system and (3) the casuistic made a development from describing seldom or sensational cases into a mode which aimed to unfold psychiatric theory through ‘typical cases’. Original medical records, the internal documentation of psychiatric observation, will be compared to their published version. Both, the narrative of a case study and the documentation in the clinical records reveal performative processes of observation and documentation.

CfP: Edited Volume on the History of Psychiatry in Communist Europe

We invite proposals for chapters to appear in an edited volume on the
history of psychiatry in Communist Europe.  Proposals on any topic of
psychiatric history during the Communist era are welcomed and should
initially take the form of a short 500 word abstract.

The history of psychiatry is one of the most dynamic and well-researched
fields within the broader history of medicine.  Despite the abundance of
work done in this regard, scholarly investigations of the psychiatric
developments within Eastern Europe and the former USSR remain relatively
rare.   The work that has been done, meanwhile, overwhelmingly
concentrates on the political misuse of psychiatry within Russia.

This volume seeks to contribute to the wider fields of medical history and
the history of Communism more generally.  It is interested in compiling
research on psychiatry outside of the abuse paradigm but also welcomes
contributions that approach the question of political misuse from novel
angles.  “Psychiatry” in this usage can be loosely defined and could
include topics related to abnormal or clinical psychology, psychiatric
nursing, neurology, or any other aspect of mental illness.  Interested
contributors are requested to send a 500 word abstract to the editors
outlining the key aspects of their proposed chapter.

The deadline for proposals is October 1, 2011.

Please contact:

Mat Savelli

(mathew.savelli@sant.ox.ac.uk)

Sarah Marks

(sarah.marks@ucl.ac.uk)

Peter Kramer Responds to Recent Criticisms of Antidepressants

As the previous post and a post from a few weeks ago highlight, criticism of the widespread use of antidepressants and other psychopharmaceuticals – especially in the United States – has appeared to grow in strength recently.  For this Sunday’s New York Times, Peter D. Kramer, the author of the influential book Listening to Prozac (1993), has written an opinion piece making the case for the efficacy of antidepressants.  “In Defense of Antidepressants” argues that critics, such as Marcia Angell, overstate their cases:

In the end, the much heralded overview analyses look to be editorials with numbers attached. The intent, presumably to right the balance between psychotherapy and medication in the treatment of mild depression, may be admirable, but the data bearing on the question is messy.

As for the news media’s uncritical embrace of debunking studies, my guess, based on regular contact with reporters, is that a number of forces are at work. Misdeeds — from hiding study results to paying off doctors — have made Big Pharma an inviting and, frankly, an appropriate target. (It’s a favorite of Dr. Angell’s.) Antidepressants have something like celebrity status; exposing them makes headlines.

Book Review – Robert Whitaker, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Crown 2010)

By Michael Oldani

By an odd coincidence I was able recently to watch the end of One Flew Over the Cuckoo’s Nest on television, while I was reading the end of the script for Next to Normal – the winner of the 2010 Pulitzer Prize for drama.  This proved to be an interesting and disturbing juxtaposition that allowed me to ruminate on the state of modern psychiatry and mental health treatment.  In Cuckoo’s Nest we have a fictional representation of the ‘beginning of the end’: the end of the mental health institution as we knew it (coming out of its 1950s high/low points), and the beginning of the deinstitutionalization movement in the United States.  The lasting final image embodies this moment, that of “Chief” breaking out of the institution and wandering back into the unknown, on his own, and reclaiming his life outside the institution.

Next to Normal, which I recommend reading (or seeing), captures the current moment forty years after Cuckoo’s Nest was published.  The musical centers on Diana, a bi-polar mother, who struggles with medication, family relationships, and the meaning of her life. If Diana had been cast in Cuckoo’s Nest she easily would have been a permanent resident in the women’s ward of that institution, perhaps even suffering the lobotomized fate of Randle McMurphy (Jack Nicholas’s character in the movie).  Instead, Diana lives with her family on and off medication for over a decade, trapped between pharmaceutical cocktails, eager-to-prescribe psychiatrists, and unspeakable grief (the loss of an infant child).  So much for psychiatric progress.

Similar to Chief at the end of Next to Normal, Diana breaks free and goes off on her own, walking away from her family (at least for the time being).  For me interesting parallels emerged between Chief and Diana and the representation of mental health (care) in America.  In particular, neither individual perceives their “self” as mentally ill.  Chief is a victim of institutional racism and clearly is sane.  For Diana the question is less clear-cut, her symptoms and moods allow for functional and less functional days.  Nonetheless, these characters and the fictional worlds they inhabit direct our attention towards pathologies that have changed little over the last forty years.  They point us away from the inner pathology of the mentally ill person and towards outer pathologies; the sickness of society, institutions, experts, caregivers, and even psychotropic medication itself – the pharmakon of efficacy/toxicity.

What has happened to psychiatry over the last forty years? Why have deinstitutionalization, the DSM-revolution, the modern pharmacopoeia of psychiatric medication, and the emergence of bio-psychiatry as the dominant form of expertise not converged to significantly improve the lives of the mentally ill, or reduce “psychiatric disease” – as mental illness is increasingly referred to by bio-psychiatrists and neurologists?  Here is where I think Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America becomes a very useful explanatory text.  Whitaker uses his considerable skill as an investigative journalist (e.g., in-depth interviews; archival work; media/press analysis; and exegesis of the psychiatric literature) to help tell an important story about psychiatry, roughly covering the last sixty years.

One thing to keep in mind is that most mainstream psychiatrists would find this book too radical. They might lump it together with Thomas Szasz and Scientology, thus dismissing this critique as conspiratorial or as operating on the fringe. Whitaker astutely anticipates these types of dismissals of his research by showing how most critics of psychiatry in the 1960s and 1970s were indeed marginalized as part of Szasz’s anti-psychiatry movement and/or “the cult” of scientology – many clinician’s careers were irrevocably altered.

So what is so radical about Whittaker’s claim? His work is part of a growing body of literature that questions the pharmaceutical-first model of psychiatric disease management (see Marcia Angell for a two-part published review of these newer works, including Whitaker’s http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/).  Whitaker’s real success is to show readers how a psychiatric narrative of care has been constructed over time.  There are powerful stories being told about mental illness or psychiatric disease that have deep political and ideological roots. To put it another way, psychiatric science remains important if it fits with the dominant psychiatric story of our times.  And this powerful narrative is quite simple: psychiatric disease is caused by neuro-chemical imbalances in the brain with biological/genetic roots, which can be treated by psychiatric medication. He astutely shows through case studies how, for example, depression became a “chronic disease” (chapter 8), bipolar (II) became an “epidemic” (chapter 9 and 10), and in particular how children have become the new markets for psychiatric medication (chapter 11).

In my opinion Part Four of this text, “Explication of a Delusion,” is the most powerful and most damning.  Here Whitaker provides us with a cultural history of psychiatry’s conversion to the biological model (at any cost – including marginalizing the careers of psychiatrists that encouraged social psychiatry models or non-drug-first models).  Of particular interest to readers may be the role granting agencies, such as the NIMH, played in funding biologically/pharmaceutically oriented studies.

Whitaker does for mental healthcare history what Greene (2007) accomplished for the diabetes-lipid-hypertension triad in Prescribing by Numbers. We cannot just blame Big Pharma’s marketing machine. Instead, it takes real detailed historical investigations to unearth how public (mental) health research dovetailed with ideological transformations within psychiatry to provide fertile ground for a sea change in how we view and treat the mentally ill individual.

Yes, researchers in the early half of the 20th century “discovered” drugs that altered “mental states” in all kinds of patients.  These became psychiatry’s “magic bullets” (see Part Two: The Science of Psychiatric Drugs). However, after reading Whitaker, it becomes clear that the real magic happened afterwards when psychiatry, and a range of institutions, staked everything on the pharmaceutical model.

The challenge after reading Whitaker’s important contribution will be how to use it to make real changes in psychiatric care.  A recent exchange between Thomas Szasz and Edward Shorter in the journal “The Psychiatrist” exemplifies the ongoing divide and the challenges ahead. Both, in my opinion, have made important contributions to the history and critique of psychiatry.  Yet, Szasz remains too radical for Shorter, who dismisses most of Szasz’s essay.  In fact, Shorter, whose Before Prozac is a recent contribution to psychiatric critique, advocates for using the term “psychiatric disease” to stress biological causation of mental distress.  Szasz, like Whitaker, continues to push us to see the ideological, the political, and the cultural components to the current psychiatric narrative. And this narrative has real human effects – Whitaker takes pains in his opening chapter to point out the consequences of 1,100 people a day (a quarter of them children) being diagnosed as mentally disabled in the United States.  How can this be described as psychiatric progress?

Michael J. Oldani, Phd, MS is Associate Professor of Medical Anthropology at the University of Wisconsin-Whitewater. He also holds an adjunct faculty appointment in the Medical Humanities and Bioethics Program at Northwestern University School of Medicine.  He previously worked in the pharmaceutical industry during the 1990s.  His work focuses on the intersection of pharmaceuticals sales and marketing, medical care, and culture.  He is currently working on an ethnographic manuscript (Duke Press) entitled Tales from the Script: An Ethnography of Pharmaceutical Prescribing – 1989 to 2010.

 

Book Review – Monika Ankele, Alltag und Aneignung in Psychiatrien um 1900. Selbstzeugnisse von Frauen aus der Sammlung Prinzhorn (Vienna 2009)

By Sabine Wieber

Shortly after his arrival in 1919 at the Psychiatrische Klinik der Universität Heidelberg, the German art historian and psychiatrist Hans Prinzhorn (1866-1933) petitioned colleagues across Germany, Austria and Switzerland to send him artefacts for the institution’s growing collection of patient art. The response was very positive and Prinzhorn acquired thousands of artworks that formed the foundation for his influential study Bildnerei der Geisteskranken: Ein Beitrag zur Psychologie und Psychopathologie der Gestaltung (1922) and that today comprises the Prinzhorn Collection [1]. In the book under review here, Monika Ankele draws on Heidelberg’s diverse collection to analyze and trace how female patients at three specific psychiatric institutions (Grossherzogliche Badische Universitäts-Irrenklinik Heidelberg, Grossherzogliche Badische Heil- und Pflegeanstalt Emmendingen, and Kuranstalt ‘Bellevue’ in Kreuzlingen/Bodensee) engaged with their highly regulated environments over a period of 20 years (1900-1920).

Ankele’s approach to this material emerges out of a recent shift in cultural history that replaces a more traditional (art historical) focus on object analysis with one that takes into account the practices and processes involved in its production [2]. Although Ankele draws on a long tradition of gender history concerned with the reconstruction of the ‘forgotten’ daily lives of historical women, she is much more interested in the ways in which female patients in the aforementioned institutions used seemingly insignificant and ephemeral acts of everyday practices such as eating, dressing, furbishing their spaces and working to appropriate the structures, spaces and materials of their institutional confinements (25). Taking her cue from Michel de Certeau’s key text The Practice of Everyday Life (trans. 1984), Ankele rehabilitates her female patients as active historical agents who, while confined within the spatial and institutional parameters of the psychiatric institution, left definite material traces of self-empowering acts (de Certeau would call these tactics) in the realms of “Selbstgestaltung” (self-formation) and “Raumaneignung” (spatial appropriation) (24). Ankele thus views the Prinzhorn Collection’s objects as creative, material traces of concrete behaviors by female patients at the heart of her study.

Ankele uses 33 patient records and 88 diverse self-testimonies such as letters, texts, drawings, embroideries, textiles, collages and ‘multi-media‘ scultpures composed of any material available to these women (including blood and excrement) to launch her investigation. The patient files are important historical documents because they not only give insight into the institutional histories and disease patterns of individual patients (mostly diagnosed with dementia praecox) but they also reveal a rich archive of additional self-testimonies such as confiscated letters, photographs, correspondances between physicians and relatives etc. In Chapter 2, Ankele employs these files to flesh out her subjects‘ institutional and medical identities, while unveiling some of the discursive regimes of early twentieth-century asylum-psychiatry which was largely grounded in medical observation and classification. Here, Ankele resists a more conventional interpretation of these patient files and proposes a reading against the grain because she believes that “this method of reading does not negate the determinative effects of ‚powerful’ structures, but proceeds from the assumption that – in the Foucaldian sense – power does not merely govern, but is also productive” (62).

Ankele locates this Foucauldian encounter with institutional power generating patient power within the concrete parameters of the three different psychiatric institutions. Chapter 3 therefore examines Bellevue (private), Heidelberg (university) and Emmendingen (state) as three distinct physical places regulated by normative structures, regulations and functions within which patients conducted their daily lives. If Chapter 3 provided a bird’s eye view into psychiatric institutions, then Chapter 4 offers a worm’s eye into the female patients‘ daily practices and the ways in which they constituted their personal and institutional spaces through a series of interactions and relations. Not surprisingly, this final chapter is less interested in the intentions of Ankele‘s historical actors and focuses instead on the effects of their actions: “effects that resulted in practices as well as effects that either made these practices possible, limited [them] or engendered [them] in specific ways“ (109). At this point, Ankele begins to connect with the material self-testimonies from the Prinzhorn Collection and leads the reader through a series of fascinating and nicely illustrated “everyday practices and forms of appropriation” (the title of Chapter 4). These are grouped in four highly effective categories: “Working – Keeping Oneself Occupied (Arbeiten-Sich Beschäftigen); Living-To Ensconce Oneself (Wohnen-Sich Einrichten); Hair-Dressing Oneself (Haar Tragen-Sich Kleiden); Eating-Nourishing Oneself (Essen-Sich Ernähren).”

Ankele makes a tremendous contribution to the scholarship on patient art (here understood in the broadest sense) by bringing her skills as an art historian and a gender historian to the history of psychiatry. She approaches the Prinzhorn Collection’s material from a highly sophisticated theoretical vantage point that takes into account the number of different historiographic ‘turns‘ (cultural, spatial, material, practical) to ultimately propose a cultural-historical re-assessment of female psychiatric patients as “agents on and in the world” (Caminero-Santanglo qtd. 181). These agents used material culture as a means of “creative appropriation of existing conditions” (23) – circumstances that represented a radical break from ‘ordinary‘ daily lives before their institutionalisation. Ankele’s analysis is sophisticated and elegant in that she not merely maps a theoretical framework onto archival material, but uses her carefully chosen self-testimonies and patient files as material points of access into otherwise ephemeral practices. Ankele categorizes her approach as a “practice-theoretical history of psychiatry (praxistheoretische Psychiatriegeschichte)” which aims to shift attention away from notions of intention and into the realm of practices and their material effects [3].  In this way, Ankele moves beyond Roy Porter’s call for a history of psychiatry from below (“The Patient’s View”, 1985) and problematizes the ways in which their subjectivities were constituted in the first place.

Ankele‘s focus on self-testimonies exclusively by women represents both a strength and a weakness of her book. It is a strength in that it allows the author to draw on a series of well-grounded methodologies from gender studies to develop her analytical framework for the Prinzhorn material. But it also limits the scope of her book because it obviously excludes the everday practices and appropriations of institutional space by male patients. This is not so much a criticism of Ankele’s carefully selected and clearly justified range of materials and methodologies, as it is a bemoaning of a missed opportunity. A recent exhibition at the Wellcome Collection attempted to problematize the potentially differing institutional experiences and responses of female and male patients, but the format of an international loan exhibition proved too limiting to fully explore this complex topic [4]. Viewed from this perspective, Ankele’s book raises the problematic question about the difference between a dissertation and a monograph. This work originated as a dissertation at the University of Vienna (2008) under the same title and of virtually equal length. Including at least a problematization of male “Alltag und Aneignung” in relation to the central topic of female self-testimonies might therefore have imbued the book with an even stronger disciplinary authority and intellectual identity. And yet, this is a beautifully written and convincingly argued piece of work that has been awarded several prizes by the Austrian government, and it should maybe be left to the reader to judge for herself [5].

Sabine Wieber is Lecturer in Art History at University of Glasgow. Previously, she worked as a post-doctoral research associate on the project ‘Madness and Modernity: Architecture, Art and Mental Illness in Vienna and the Habsburg Empire, 1890-1914.” She is currently working on a book project investigating central European salon culture between 1850 and 1918.

Notes

[1]. For a history of the Prinzhorn Collection see www.prinzhorn.uni-hd.de.

[2]. For example, Bettina Brandt-Claussen and Vila Michely. Irre ist Weiblich: Künstlerische Interventionen von Frauen in der Psychiatrie um 1900. Heidelberg:  Wunderhorn, 2004.

[3]. For a fascinating interview with Ankele on this topic consult

http://stimmen.univie.ac.at/2010/10/ankele_psychiatriegeschichte/

[4]. Gemma Blackshaw and Leslie Topp. Madness and Modernity: Mental Illness and the Visual Arts in Vienna 1900. Farnham: Lund Humphries, 2009.

[5]. Käthe Leichter-Preis für Frauen- und Geschlechterforschung (2009); Doc.Award der Stadt Wien (2009); Michael Mitterauer-Preis für Gesellschafts-, Kultur- und Wirtschaftsgeschichte (2010).

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