History, policy and clinical psychiatric practice

Houston highlights the dangers of a limited understanding of the history of psychiatry.^{Reference Houston2} He identifies two aspects of what he labels as ‘pastism’. Positive pastism is that all was good, such as holistic ‘moral treatment’ in the early 18th century asylums. Negative pastism is ‘the notion that everything in the [psychiatric] past was “bad, weird, or confused”’, unscientific and lacking evidence, even when in keeping with the science of the times. Pastism-type generalisations do not do justice to the history of psychiatry.

The history of psychiatry is not an inevitable progression from bad to good. There were bad and even cruel practices, but others were exemplary. Modern problems in psychiatry are not solely a function of new difficulties, often being revisitations of old problems, for which studying their history can inform current debate, albeit without providing solutions. Scandals of abuse of vulnerable people recur, and good practices from the past have been lost, such as holistic mental health teams for older people. The recent opioid crisis has confirmed that epidemics of iatrogenic harm are neither restricted to history, nor limited to psychiatry. Through better understanding of our collective professional history, we may be able to develop our value systems, improve the services we provide and help safeguard against future harmful practice.

The College and external organisations, including the BBC and other national media, have sought advice from the History of Psychiatry Special Interest Group (HoPSIG) on historical aspects of psychiatry. Providing accurate information and insights into past practice can influence public perceptions of psychiatry today. The College has recently appointed a Historian in Residence, who takes a lead on these requests. A recent College request to HoPSIG concerned the eponymous use of the name of Hans Asperger.^{Reference Czech3} Asperger worked as a paediatrician in Vienna and published his research on autistic psychopathy during the Nazi era. Recent historical research has established that he directly referred children to his close colleagues in charge of the wards that functioned as part of the child euthanasia programme, in the enactment of the Nazi legal, medical and political ideology of ending ‘life unworthy of life’. Engagement with the historical background to the Asperger eponym, in the context of clinical teaching about intellectual disability, would provide opportunities to consider the meaning of being a dedicated doctor. How would we have responded in Asperger's situation, and how might we respond if faced by an ideologically powerful but abusive regime in the future? Discussion within the RCPsych about Asperger has pointed to the need for training in the ethics of psychiatric practice: historians can contribute to that process, alongside others.

Ideologies within mental health may be forces for better, for worse or both. They may arise from society and its politics, within medicine and mental health services, and from patient and carer networks. Psychiatrists need to understand the values expressed by ideologies to help them manage systems, engage patients and work collaboratively across disciplines, in addition to undertaking their direct clinical responsibilities.^{Reference Bouras and Ikkos4} Reflective discourse and debate on the histories of ideologically influenced deinstitutionalisation, normalisation, patient and carer advocacy, empowerment and the recovery model, would provide learning opportunities toward achieving these goals. Many perceptive primary sources could facilitate this, including some created by patients.

Reflective historical engagement could also help psychiatrists better address the ideas, concerns and expectations of individual patients and their families, many of whom have their own understanding of the history of psychiatry. A legacy remains today of unhelpful and detrimental treatments and discrimination, conceptualised and practiced by some leading psychiatrists in the past: for women, about hysteria arising from the womb; for older people, ideas of inevitable decline and untreatability; for minority groups, discrimination associated with ‘degeneration’ theories; for gay men, ‘treatment’ with aversion therapy. Other socioculturally embedded fears, ideas and stigma emerge in impactful films such as One Flew Over the Cuckoo's Nest. These still influence expectations of services (in this instance, especially electroconvulsive therapy and in-patient wards) even before patients encounter them. In addition, psychiatrists are frequently represented in a damaging light in fiction, film and popular culture. When combined with stigma around mental disorders, these stereotypes have an effect on recruitment into psychiatry and the profession's goal of ensuring best outcomes for patients. Historical understanding of how and why cultural negativity has been transmitted through the generations can help inform discussion about how to tackle ongoing or recurrent problems.

Current issues that challenge psychiatrists include social vicissitudes and service deficits such as bed shortages and restricted access to treatment. These are not new, but have historical foundations. Understanding their history can induce us to act at health service management, College (or other professional representative body) or government levels. These points apply beyond the Western world. Global efforts to provide treatment for people with mental disorders have frequently had historical links with European colonialism.^{Reference Oyebode5} Psychiatry in the UK has also been the recipient of international influences, notably in the late 19th and early 20th centuries from German-speaking schools of psychiatry and related disciplines – Emile Kraepelin, Alois Alzheimer, Eugen Bleuler and Sigmund Freud, to name but a few – some of whom have left us a mixed legacy.

History can inform us about past policy decision-making and implementation, which may have relevance to how we formulate future strategies. The ‘history and policy’ model is exemplified by the peer-reviewed journal of the same name. History and Policy has become the first port of call for many civil servants, wanting to understand the implications of history for social, economic and political issues today (http://www.csap.cam.ac.uk/organisations/history-policy/). A cycle of repeated executive failures and underfunding has undermined the goal of achieving parity of esteem for people with chronic severe mental disorders. In the past, many such patients were consigned to the wildernesses of underfunded long-stay wards, and more recently, to the social isolation of community care. Psychiatrists need to continue to advocate for parity for their patients. Historical analysis can provide evidence of causes, continuities and discontinuities in the history of our services, the knotty history of funding interwoven with stigma and ideological bias, and may help to challenge discriminatory funding.

Learning the history of psychiatry

The syllabus for the Membership of the College (MRCPsych) includes facts about historical roots of psychotherapeutic approaches, psychopharmacology and theories of human development. Facts provide a simplistic chronology of what happened when, rather than arguing the more important and contextualised questions of ‘how’ and ‘why’. Lectures given on MRCPsych courses rarely mention more than the chronologies, but a grasp of appropriate methodology alongside the facts is vital to critical analysis of historical evidence, just as it is for evaluating scientific data. University history of medicine and medical humanities departments already work with undergraduate medical schools. They offer rich learning opportunities about the broad history of psychiatry and its value to practice, often using creative writing and visual art activities based on historical documents and artefacts, to enhance empathy by better understanding patients’ cultural perspectives. Change Minds in Norwich (http://changeminds.org.uk/) and Whittingham Lives in Preston (http://whittinghamlives.org.uk/) have both utilised former mental hospital archives to engage local people with historically based creative activities. Similar models could provide ways forward for psychiatric education.

In our experience, trainee psychiatrists are more likely to engage positively with historical material and associated ethical or other issues when these are presented as part of an interdisciplinary approach to the medical humanities and integrated into learning about clinical disorders. We and our patients encounter historically determined and still widely prevalent societal attitudes and perils. Learning about history reflects and respects the diverse backgrounds of psychiatrists, their colleagues and patients, and is underpinned by GMC and College values. Our practices today will be judged in the history books of tomorrow.