Reform and humanity

Textbooks of psychiatry like to present the history of the discipline as a humane progression from superstition and error through to scientific enlightenment. The 18th and 19th centuries saw the care of the 'insane' transferred from the responsibility of local parishes and city authorities to physicians (later alienists and psychiatrists). This is generally accepted to have led to more humane treatment and enlightened care - with Philippe Pinel's work at the 'Pitie-Salpetriere Hospital' in Paris leading the way. Quite naturally, with the medical profession having responsibility for care, a medical ethos now prevailed. And, as Richard Bentall described in his book 'Madness Explained',1 leading psychiatrists of the 19th century quite understandably incorporated the latest medical science into their care. So psychiatric diagnosis took hold and biomedical explanations became popular, attempting to emulate the success of similar, hugely important, developments in physical medicine.

It is very tempting to see a causal link between the undoubted progress towards humanity and the medicalisation of our understanding of psychological distress. The two developments happened at the same time, but a more humane approach towards people in distress was not dependent on developments of scientific medicine. Over a couple of hundred years, we saw the care of the 'insane' become the responsibility of physicians, psychiatry incorporated into medicine and simultaneously, significant improvements in the living conditions of many of the previous inmates. However ... contrary to the implicit messages offered by many, I am not at all sure that the first development was the cause of the second. So, while Pinel revolutionised care at the Parisian Pitie- Salpetriere Hospital, in the UK we celebrate the humanity of William Tuke's 'York Retreat', which was conceived of as a social, rather than a medical, initiative (and derided by the establishment of the time). The 18th and 19th centuries saw immense, revolutionary change in a swathe of social systems. Leaving aside the political revolutions of various kinds, both violent and non-violent, that swept across Europe, the past 250 years have seen reform ushering in humane care in many areas. We made impressive strides towards abolishing slavery. In the legal system, we have seen repeal of unjust laws and the development of a range of protection for defendants as well as wholesale reform of jails and regimes of punishment. We have seen the democratic enfranchising of working men and finally women, whereas political participation used to be a privilege for aristocrats and landowners. We have seen the spread of social welfare and (although we're still waiting for the USA to catch up) the development of universal healthcare. Although each of these reforms depended on developments in our scientific and academic understanding of human nature, they did not require a 'medical model'. Change, humane change, is clearly possible without labelling the subject matter as an 'illness'. We can decide to give working men and women a vote without diagnosing the illness of 'disenfranchisement'. We can offer people a decent quality of life if unemployed or retired without diagnosing an illness of 'poverty syndrome'. And we can treat defendants in criminal proceedings with justice and humanity without necessarily invoking illness. Indeed, a churlish commentator may well point out that individual members of the medical profession have occasionally applied a medical approach to oppose rather than promote reform. In 1851, a Dr Samuel A. Cartwright proposed that the pseudo-diagnosis of 'drapetomania' could be used to label the supposed mental illness that caused black slaves to flee captivity. In 1946, the British Medical Association initially opposed the development of the National Health Service, primarily because it was feared it could affect their incomes as private medical practitioners.

This is significant. Enlightened, humane, progressive social services are possible without invoking a medical framework. This is not to deny or minimise the heroic work that pioneering doctors undertook in recent centuries to rescue people from horrendous 'care'. Radical progress was needed, and physicians often led the way. But we do need to question whether a biomedical perspective is now an appropriate way to understand mental health and well-being. And dubious appeals to history are not necessarily useful guides to addressing that issue.

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