Reviewing Madness A History


Petteri Pietikainen’s 2015 Madness: A History intends to provide a general history of psychiatry, the author intending it the first general history since Shorter’s 1997 A History of Psychiatry (presumably Pietikainen started this book before Scull’s recent book came out). The scholarly quality appears to be first rate, a well researched analysis with lots of well thought out arguments. It also covered some ground which I’d not seen discussed elsewhere. On this basis the book is recommended. I do wonder if some of the material is too specific for a general history, such as the chapter on cold war psychiatry which included a section on various attempts at mind control, or the 1960s research into sensory deprivation. To my mind, these are not so crucial as an in depth discussion of the origin and evolution of the DSM, which is present just not as long as I’d like (though that is my specific interest so I might be biased). Basically, providing one reads the book without the assumption that the book will provide THE full history of psychiatry then it is recommended.

The part I found most interesting was Pietikainen’s remarks at the end of the book. He is broadly critical of two relatively recent trends. Firstly, modern focus upon what he calls the “worried well”, which are roughly people with relatively minor psychological issues. This he considers problematic because it can make people with relatively minor issues believe they have serious problems, “influence the person’s self-understanding and potentially cultivate a culture of vulnerability, no matter if it is done with a benevolent purpose”. Meanwhile, this distracts from helping people with more serious issues. Secondly, and relatedly, insufficient care for the more seriously mentally ill, especially after the 1980s “dismantle [of] the Keynesian welfare state”. Since then, “a solid infrastructure of mental health services is still missing in most if not all western countries. As a consequence of deinstitutionalization, homelessness skyrocketed, for example in the UK and the United States, and a growing number of mental patients ended up on the streets, in jails or in shelters for the homeless”. In contrast to some recent histories of psychiatry (especially recent histories of autism), this history suggests that in some important reguards things have actually got worse for the severely mentally ill. Recognising the good intentions behind community care, Pietkainen suggests this ultimately can result in simply not really doing anything to help the mentally ill. “If the mentally ill do not have a safe place to go and receive treatment – other than pills – then how does ‘community care’ differ from systematic negligence?… We have gone around full circle and are back in a world that has uncanny resemblances with the ‘pre-confinement’ era, with the exception of psychiatric pills, patient organizations and the individual ethos of self-management”.

Being a 1930s onward historian and primarily dealing with psychiatric classifications rather than psychiatric care, I’m not really in a position to judge the accuracy of these claims. I do, however, find them fascinating: the idea that without realising it through dressing up our modern situation up as community care and user led care we have returned to situation which most people would be deeply upset about if we realised it had happened. It makes one think about the power of concepts to shape perception, that by portraying (presumably in good faith) many modern innovations in a positive light modern psychiatry has only concealed how badly they are not working. Ultimately, I cannot judge if Pietkainen is exaggerating these claims, so I treat them with caution, but I cannot rule out the possibility they are partially or even wholly true. If so, his message is important and deserves a wider audience.

Robert Spitzer

Robert Spitzer (1932 to 2015) died last Friday (25th December).

Plausibly, Robert Spitzer could be described as the most influential figure in psychiatry of the last 50 years. He made contributions in many different areas. Most media reports focus significantly on his contribution in removing homosexuality as a diagnosis, something which certainly deserves praise. His biggest contribution, which I will discuss, is his influence on the DSM.

Robert Spitzer was the chairman of the task force for the DSM III and DSM III R. This process has been discussed by historians, some of whom go into specific details the about exact steps Spitzer took (Kirk and Kutchin’s The Selling of the DSM is a good overview). Rather than discuss that, I wish voice my thoughts about whether DSM III was a positive step or not (it is important to note that Spitzer was partially reacting to and redirecting existing desires for change, he was not fully responsible for all the changes).

DSM III (compared to earlier editions) brought much more standardisation to classification of mental illness. The diagnostic criteria in DSM III were much more detailed than those of earlier DSMs, the description of each mental illness being assigned many more pages. This was partly intended to improve reliability, to increase the degree psychiatrists agree about which mental illness the patient exhibits.

DSM III also went someway to reduce the impact of psychoanalytical approaches. DSM III intended to be a-theoretical (though it failed in this), but it certainly placed the emphasis on describing symptoms and how they cluster rather than basing classification on causes (be them psychoanalytical, cognitive psychological or biological). This was partly intended to then allow studies which might improve validity, finding the actual underlying causal basis (rather than speculative psychoanalytical causes).

These two DSM approaches, broadly present also in later editions, resulted in major problems. Firstly, it contributed to removing the subjectivity of the patient from psychiatry, standardised criteria not capturing the aspects of patient which were specific to himself or herself (including symptoms not mentioned by the diagnostic criteria). Secondly, by making the diagnostic criteria more specific, it then meant alternative formulations of psychiatric classifications, potentially superior ones, stopped being employed for diagnosis or for studies. Thirdly, very few DSM psychiatric diagnosis have had their causal basis established. Fourthly, it resulted in high levels of co-morbidity with associated difficulties of establishing which symptoms should be part of which diagnosis.

Despite these problems, I believe Spitzer’s influence was a step in the right direction, but his influence went too far. Standardisation is generally a good thing for creating scientific reliable generalisations, which can then be modeled to specific contexts in a more reliable way. So in this sense I think the DSM III had to happen. I think it went wrong by blocking out alternative psychiatric classifications. We need modify the psychiatric classifications we employ and try new approaches, modeling symptoms and how they cluster in many different ways. This would be ideally done using multiple classifications system at the same time, though each variation needs standardisation. So Spitizer’s contribution of standardisation was a positive one, but the psychiatric classifications should not have been set in stone. Instead, we needed to develop further sophistications in our approach to classification, rather than stopping with the important step of standardisation. If Spitzer had to happen then we now need to move beyond him, take his contribution and use it in new ways, further innovating how we approach classification.

Kanner vs Despert – Round 2

A new article by Dan Olmsted and Mark Blaxill has just been published which partly responds to my own article. They intend their article as an objection to my claims but I believe it broadly supports what I say.

I argued Leo Kanner conceptualised an initial idea of autism after reading Louise Despert’s 1938 article. Her article effectively is a bridge between 1930s notions of childhood schizophrenia and Kanner’s 1943 notion of autism. 1930s childhood schizophrenia made a set of claims, Despert’s 1938 paper partly modified them in ways which was quite close to Kanner’s 1943 autism and then Kanner made further modification to conceptualise his notion of autism. As I said in my article, Kanner built on Despert. Olmsted and Blaxill’s article has very helpfully found in the archives some letters written between Despert and Kanner. Written in 1943, just after Kanner’s publication on autism, Despert praises Kanner’s paper but objects to his claim to have discovered something new. She appears to think she has already described something like autism. Kanner, in a letter sent a few days later, praises Despert’s work but argues his own paper contains an important additional claim – the children showed the symptoms from birth, whereas Despert’s children only showed some symptoms from birth. As I wrote, Kanner’s “innovation was realising that actually no onset took place, all symptoms were presentfrom birth. Generally, it was believed all symptoms of all childhood schizophrenia occurred after a period of normality, but then Despert claimed some childhood schizophrenics had some symptoms present from birth, and finally Kanner claimed some childhood schizophrenics had all symptoms present from birth, renaming those childhood schizophrenics as autistic.” (2275-2276).

At this point we need ask, what does it mean to describe something first? Kanner’s autism has also undergone major modifications by later psychiatrists, so in a sense you could say that Lorna Wing really discovered autism, since her notion seems closest to our own (but then Wing’s notion has undergone minor modification). This is why I concluded by saying “Who wrote the original account of autism? This is not a helpful question. Kanner and other child psychiatrists worked within scientific communities, engaging in a mutual process of borrowing and expanding ideas” (2276). I think the archival material Olmsted and Blaxill have produced nicely show this borrowing and expanding process, a process that does not easily fit notions of “who first described something”.

Reviewing Kanner’s In Defense of Mothers

Kanner’s In Defense of Mothers arrived last week, having been ordered from America. It was published in 1941, two years before he developed his notion of autism. This books is very different in focus to most his writings, unusually being primarily about children who did not see psychiatrists.

The message is primarily ‘let children be children’, and to a lesser degree ‘let mothers be mothers’. He seemingly has a notion of natural mothering and believes this is distorted through bad advice given by various sources of supposed experts on mothering. He tells mothers not to insist on rigid diets, not to overburden the children with work, not to interfere dramatically in the child’s social life (i.e not decide who their friends can be), trying to counter various cultural sources who insist the mother must perfectly raise children lest the child ends up neurotic and delinquent. He thinks society should just let mothers be mothers, which would mean mothers would let children be children, a good route to healthy children in Kanner’s view.

There was very little about psychoanalysis in the book. The specific claim that poor mothering causes mental illness (such as childhood schizophrenia) was not really discussed (there were some ambiguous passages related to this but much more moderate than what came later). Whilst such claims really took off around 1950, it seems they were of little significance in the early 1940s.

The guiding principle throughout the book was ‘put the child in context’. If the child does something bizarre then there probably is good reason for this, talk to the child, try to understand what is happening with their life, but do not take this as a sign of some ominous symptom that must be immediately countered. This looks like Kanner taking a Meyerian approach, emphasising the individual as a whole who must be understood contextually, rather than more common approaches of just interpreting everything under one pet theory, something some child psychaitrists did and Kanner hated.

It was interesting to see Kanner would often describe the family in political terms, outlining a democracy as an ideal family where the child was an active member who was listened to. This contrasted with totalitarian families where the exact path the child must take was laid out in advance by the parents. Written in 1941, using such political terminology was understandable.

Overall, I’d put In Defense of Mothers as Kanner’s least valuable book to read, measured by all those published since he became a child psychiatrist. It does not particularly illuminate Kanner’s views, at least not more so than his 1935 text book, which goes into much more detail. It does give some nice social history though, giving a good feel for early 1940s American approaches to childhood.

The History of Secondary Histories of Autism

Over the next few months I’ll be reviewing some secondary history texts, so firstly I’ll outline a brief history of the secondary history. I’m only counting work written from 1980 onwards, since this is when the major steps towards our modern autism started (for earlier histories see some of Kanner’s and Eisenberg’s texts). All texts I refer to below are listed here:

The earliest histories were written by medical practitioners. Sanua (1983) has other agendas than strictly writing a history but he gives an excellent account of the relationship between autism and childhood schizophrenia. Lorna Wing (1997) describes the basics but focuses too much on Kanner and Asperger, though I think her understanding of Kanner is more nuanced that some historians claim. Wolff (2004) is brief and also focuses too heavily on Kanner and Asperger, though she does give a good account of her own work.

The watershed came with Nadesan (2005). This was the first book length history of autism, additionally, it was written by someone who was not a medical practitioner, by someone who is not an important historical figure, unlike Wing and Wolff. Nadesan discusses of concepts of child development prior to autism and discuss how concepts of autism change over time due to changing theories in psychology, also giving wider cultural context to why those theories in psychology changed. Whilst not perfect the book was a massive step forward.

Except for Grinker (2007) (who is worth reading but is not primarily intending to write history), there was a major gap of four years between Nadesan’s book until what I call the first golden age started. 2010 saw books by Feinstein (2010) and Eyal et al (2010). Feinstein interviewed many historical figures whilst Eyal et al described in great detail the wider socio-medical changes and how this impacted concepts and classifications. 2010 also saw Jacobsen’s (2010) article which compared Kanner with Bettelheim and relates their work to modern autism. The next major publication was Silverman’s (2012) book. I believe her book is the least ground breaking of the four history of autism books, covering less new material than the others, but I believe it the most well developed and factually accurate. 2013 saw ground breaking articles by Verheoff (2013) and Evans (2013), both describing how wider theoretical changes in psychiatry influenced the changes to the classification. 2014 saw Evans (2014) provide background to 1950s and 1960s British psychiatry whilst Hollin (2014) and Verhoeff (2014) are the first history papers to cover beyond the 1980s in detail. I’ve missed out Neumärker (2003), Silverman (2010), Blacher & Christensen (2011) and Raz (2014) because they are very specific in their focus, though they are all still worth reading.

So far, to my knowledge, at time of writing (July), there has only been one secondary history publication in 2015 (my own, Fellowes (2015)). Perhaps the first golden age has ended. Alternatively, perhaps the second half of 2015 will see many publications; another of my articles will be submitted soon and Bonnie Evans’ book is due out in 2015. The history of autism has come far, especially since 2010, and I personally can identify many areas not yet covered. From where I sit, a continued stream of publications seems more likely than the field dying at this point – existing texts have raised many questions and it will be historians who read those secondary histories published during this first golden age who will produce the next wave of research.

British Society History of Science Conference Swansea 2015

This time last week saw the end of the BSHS annual conference. My talk seemed to be received well.

I’d never been to a history conference before and found myself pleasantly surprised. Everyone was very friendly and there was very little confrontational arguments. Typical questions were along the lines of asking speakers to expand upon their argument, what else was going on during these particular events, what theories were dominate, how did this relate to what came before and afterwards, how did this relate to activity in a wider setting (other counties, other sciences). Questions allowed the speaker another opportunity to discuss their research. This felt quite different to philosophy conferences (which I am more used to) where quite a few questions, though by no means a majority, focus upon criticizing the speaker’s argument: what about this counter example, surely you are making this particular assumption, maybe you should consider whoever’s view points. The history approach certainly makes for a more relaxing conference but which one is best? Generally, the history questions gave opportunities to present more empirical evidence rather than specifically defend a particular argument. Philosophy is typically more about defending the argument. To varying degrees (and with many exceptions) both history and philosophy need an empirical basis and a strong argument. The historian seems to build up from lots of empirical evidence to an argument whereas philosophy focuses more on the argument but then often need make their argument compatible with empirical evidence, i.e. fit available evidence as so avoid counter arguments. Personally, I prefer philosophy when it starts with a lot of empirical evidence and tries to analyse that evidence, systematise it and see how it relates to wider bodies of knowledge. I do not know how far it could be taken but I think philosophy could benefit from some approaches adopted by historians.

The other difference is how specific many history papers were, totally unrelated to my field, whereas most philosophy of science is relevant to most other philosophy of science. With exceptions, I think a philosopher of physics could still benefit from seeing, say, a philosopher of biology speak. Both cases may use notions in similar or different ways, i.e. cause, explain, predict, inductive, law, model, etc. You can learn from both the similarities and the differences. The benefits of attending many presentations at history conferences are less obvious but still there. History of 1800s paleontology is no use to the history of autism but you see a historian try to create a historical narrative or create explanations from a particular type of evidence, often using very different type of evidence than I’m used to. For instance, that presentation on paleontology had to appeal to a very limited number of paintings to understand 1800s views of woolly mammoths whereas I primarily deal with journal articles. Someone else deals with diaries, another with hospital records, another with medical equipment. Observing how a historian employs a particular type of evidence, with associated limitations that evidence brings, makes one reflect upon how I go about using evidence, how reliable is it, how representative is it, what is it missing, etc. A useful experience, but, again, useful in a different way to the benefits of seeing philosophers of science dealing with other sciences speak.