Chapter 9 The Swinging Pendulum

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Chapter 9 The Swinging Pendulum

Psychiatry has had various reform periods during its history from the celebrated loosening of the chains of the inmates of the Bicêtre Asylum in Paris by Philippe Pinel, through to the policies of non-restraint in the mid-nineteenth century, and efforts at reform of the committal laws during the twentieth century. These reforms are often lumped together with the convulsion that struck psychiatry during the 1960s that has been termed “antipsychiatry,” and some have argued that psychiatry has always had its anti-psychiatrists.1

In fact antipsychiatry in the 1960s was a fundamentally different movement from anything that had gone before. Previous reforms focused on conditions within the asylum and did not threaten medical claims that the conditions being treated were mental illnesses; indeed reform essentially involved a medicalization of what previously had been seen as social problems. 1960s anti-psychiatry, however, hinged on the notion that mental illnesses did not exist or at least not in the form that psychiatrists claimed. The anti-psychiatrists argued that in fact society had gone mad and that those suffering from mental illness were only its most apparent victims.
This is an argument that anti-psychiatrists might seem to have lost, given the increasing numbers of people who are taking psychotropic medication of one sort or the other and the increasing numbers of illnesses that are listed in diagnostic manuals such as DSM-III, and IV, and the increasing amount of media coverage not to mention direct to consumer adverts for psychotropic medications, all of which assume some reality to mental illness. But arguably the claims of anti-psychiatry have been proven rather than disproven by these developments: While the headline claims of 1960s antipsychiatry focused on the frankly and clearly mentally ill who were committed to asylums, in fact the concern was with the rest of society who for the first time were exposed on a mass scale to the attentions and ministrations of psychiatry.

There was a deinstitutionalization that began in the 1950s with the development of chlorpromazine and the psychopharmacological revolution, but in fact there are no fewer patients in service beds now than there were fifty years ago. Before the Second World War, very few people were at any risk of being committed to an asylum or indeed of knowing anyone who was in treatment with a psychiatrist or other mental health professional for mental illness. Now all of us know many people on treatment with Prozac, Paxil and Zoloft, and children from the age of 2 to seniors of the age of 102 are likely to be on one or another of these medications. There has been a tripling of the rates of detention to psychiatric facilities and a 15-fold increase in the number of patients who are admitted to a mental health service bed even in remote parts of Britain which, compared with the United States, are light in service provision for mental illness.2 Arguably those who were really deinstitutionalized were psychiatrists and other mental health therapists rather than their patients.

It was a recognition of this extension of the psychiatric reach that motivated the anti-psychiatrists of the 1960s, although in focusing on ECT and the seriously mentally ill they missed their target, and became themselves instead an easy target. Alienists who had previously been confined to asylums were now likely to appear as psychiatrists running clinics in offices or other medical settings in the community. Access to the new treatments that had come on stream during the 50s was by prescription only; thus in order to get help people had to go through psychiatrists in a way that they had not had to do before. Huge areas of personal life were coming under the purview of psychiatrists. Who were they to make ethical judgments about aspects of an individual’s life? How can we know whether the views are correct that certain behaviors were manifestations of psychological disorder rather than of discomforts that stemmed from political concerns or difficulties?
All these issues came to a focus in the case of Randle McMurphy, the hero of One Flew Over the Cuckoo’s Nest, Ken Kesey’s 1962 book.3 This book, made into a film in 1975, is often cited as being one of the greatest disasters than befell ECT. (see chapter 7)

Kesey compares life on an asylum ward to the State in which we all live, an increasingly all controlling, Nanny State. The message is that you have to protest in order to survive, and that dynamic therapy was a means of ensuring conformity rather than a means to liberate the person from the shackles holding them. But the ultimate message was that if this can happen to someone like Randle McMurphy, it can happen to you, because as the book makes very clear from the start, McMurphy does not have mental illness in any traditional sense of this word. He is simply using a mental illness ticket to escape a jail rap. This anticipated a famous experiment undertaken by sociologist David Rosenhan in the late 1960s, which infiltrated volunteers posing as mentally ill patients into hospitals. It turned out to be frighteningly easy to fool medical staff and get detained in hospital and indeed in some cases it was difficult to get out of hospital afterwards.4 The message was that psychiatrists did not know what they were doing and there was little that could stop them doing it to almost anyone they chose.

But as is so often the case with visions like this that challenge a received world view, global concerns can often focus in on specific highly dramatic symbols and in the case of One Flew Over the Cuckoo’s Nest the specific focus for many, particularly after the release of the movie, was on the ECT/psychosurgery scenes. McMurphy at the first signs of serious trouble is punitively treated with unmodified ECT delivered in an almost barbarous setting. In the denouement, as a penalty for breaking the rules, he is reduced to vegetable status after another punitive intervention, which readers of the book know was psychosurgery but which those only watching the movie could easily interpret as a further course of ECT. Either way ECT is portrayed as one step toward total lobotomy.

The anti-psychiatry movement fed into many of the currents that made the 1960s and early 1970s a time of upheaval in Western societies. This was a time when for what ever reason the democratic process took hold in a deeper sense than before. Where democracy before had simply referred to the ability of people to vote, now women claimed that they needed to resist the colonization of their minds by men and began demanding an equal say in the more general processes of government, from representation in the ministry of churches through to equal opportunities at work and equal legal rights. It was a time when other ethnic groups challenged the hegemony of the white elites of Western countries and argued that the acceptance of established views risked an internalization of white imperialism. The processes of teenage rebellion came to be seen as resistance by the young to having their minds manipulated by their elders. Against the backdrop of World War II, the Cold War and later the Vietnam War, this resistance to the “wisdom” of a previous generation not only made sense but even felt that it might be necessary for survival.

The convulsions that resulted were often led by university students who, in Paris and Tokyo, marched on the universities and in particular on the departments of psychiatry. In Paris, the offices of Jean Delay, the discoverer of chlorpromazine, who also had worked prominently on the shock therapies in the early phase of his career, were ransacked and occupied for three months. More than anyone else, Delay was the symbol of the new physical therapies. He was forced into retirement. The department of psychiatry in Tokyo was occupied for 10 years and all research came to an end. Hiroshi Utena, the chair of the department, who was closely linked with research on the use of physical treatments, was also forced to retire.5
The notion of conflicts of interest was born in the ‘60s. But whereas conflict of interest refers today to a supposed corruption of research by private interests, in the 1960s and 70s the most obvious and threatening conflicts of interest were perceived to be the funding of research and education by the state.6 Eisenhower’s vision of a military industrial complex that threatens the liberty of all of us was the founding vision of concerns about conflicts of interest. And in the United States, as in One Flew Over the Cuckoo’s Nest, anti-psychiatry involved a much greater element of protest against the State than it did in Europe, and student protests in the US became linked to protests against the Vietnam War.

Psychiatrists and philosophers using psychiatry as a metaphor for the rest of society provided the public face of the 1960s upheavals. The figurehead names were Ronnie Laing and David Cooper in Britain, Thomas Szasz, Erving Goffman and Herbert Marcuse in the United States, along with Michel Foucault and Frantz Fanon in France. These in their different ways offered visions of the confinement of deviance within the mental health system, of the need for individuals to resist therapy in order to stay in tune with their true self, and of the revolutionary potential of the oppressed. The disturbances in Tokyo erupted after the visit of Szasz and Laing in 1968.

In 1969 Szasz co-founded the Citizens’ Commission for Human Rights along with the Church of Scientology. A key event in this founding centered on Viktor Gyory, a recent Hungarian immigrant detained at Haverford State Hospital in Philadelphia, where he was held in seclusion, forcibly medicated and then given ECT. Szasz interviewed the man in Hungarian and was prepared to testify that all that was wrong was his inability to communicate in English. Rather then face a challenge to the laws on detention in Pennsylvania, the hospital released Gyory. CCHR and the Church of Scientology have since consistently been the most sustained critics of psychiatry and especially of ECT, within the United States.
Szasz’s vision that mental illness did not exist, and in particular that people designated as mental patients needed to assert their basic rights as citizens, was a key driver in American but not European antipsychiatry.7 Taking inspiration from some of these themes, in 1970 The Insane Liberation Front was established in Portland, Oregon, and in 1971 a Mental Patients’ Liberation Front in Boston, and a Mental Patients’ Liberation Project in New York.

For a number of reasons, ECT became a key focus for all these groups. One reason was the simple salience of the treatment. Another was its symbolic value. A third reason was that some of the most coherent patients critical of psychiatry were individuals who had had ECT. But taking on ECT meant taking issue with a treatment that many thought clearly worked for severely ill patients, which was strategically a very different matter than taking on a treatment that did not work such as psychoanalysis in the 1960s, or the widespread and indiscriminate usage of SSRIs today. ECT however was more readily portrayed as a treatment that had been “survived” than psychoanalysis or Zoloft.

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