‘I’m a psychogeriatrician’

In today's guest post, Claire Hilton argues that historical evidence about psychogeriatrics is crucial to understand the political, medical, social and professional factors which have shaped the specialty, drawing on her 2016 Medical History article ‘Psychogeriatrics in England: Its Route to Recognition by the Government as a Distinct Medical Specialty, c.1970–89’ (Medical History, 2016, 60, 2, 206-228) https://doi.org/10.1017/mdh.2016.4

‘I’m a psychogeriatrician’ uttered at a social event, almost always stops conversation. This was common during the formative years of the specialty of psychogeriatrics (or old age psychiatry) and remains common today. The questioner almost always implies: why would anyone want to work specifically with older people who are mentally unwell?

Psychogeriatricians in the 1970s and 1980s advocated for their patients. They fought to achieve government recognition for their specialty. Recognition enabled dedicated funding and training, and expansion of the specialty nationally and internationally. This helped to ensure that older people received evidence-based treatment for their mental illnesses. Treatment methods, at that time well established for younger people, were used infrequently for older people suffering the same illnesses. Treatment required some modification to take into account challenges associated with ageing, like frailty, risk of falls and co-existing physical illnesses. Importantly, the psychogeriatricians’ medico-psycho-social model of treatment could ameliorate problematic symptoms and behaviours, support carers, and enable older people to live in their own homes for longer, thus reducing bed use in institutions. Psychogeriatricians struggled against stereotypes of the ‘slippery slope’ of old age health expectations, lack of public and political interest in older people’s mental health, and therapeutic nihilism about treatment.

The psychogeriatricians used religious language to describe their work, such as ‘pilgrim’ and ‘crusade’. Those who discovered the rewarding nature of the work described themselves as ‘converts’. Their successors still do.

In 2015, leading psychogeriatrician Dr James Warner wrote about the ‘erosion of old age services’ (James Warner, ‘Old age psychiatry in the modern age’ British Journal of Psychiatry (2015) 207, 375–376). Erosion can be attributed to various factors, including austerity and financial constraints, ongoing under-valuing of older people, and misled political correctness about the anti-discrimination agenda. Anti-discrimination has led to the re-emergence of ‘ageless services’ in many parts of the UK, but this model of one-size-fits-all too frequently marginalises the specific needs of older people, and removes the enthusiastic staff who feel inspired to spend their careers working with them. We once again see older frail people being treated on the same ward as younger physically fit disturbed patients, and the occurrence of fractured bones when frail patients fall if accidentally pushed, an avoidable risk which the early psychogeriatricians aimed to eliminate.

Historical evidence about psychogeriatrics is crucial to understand the political, medical, social and professional factors which have shaped the specialty. This knowledge should help to avoid re-introducing risky treatment and care practices which undermine wellbeing and lead to unnecessary suffering and financial expense.

Claire Hilton

Dynamic Case Notes and Clinical Encounters

In our guest post today, Hazel Morrison provides reflections on her article, ‘Constructing Patient Stories: ‘Dynamic Case Notes and Clinical Encounters at Glasgow’s Gartnavel Mental hospital, 1921-32’ which featured in Medical History 60:1 (2016), 67-86.

My dear Dr. Henderson
              Above everything else congratulations on the second edition of your book! … What psychiatry needs is the courage of the case material and the problems shown therein, and less preoccupation with the traditional and formal principles.

Case notes and case histories, argued the doyenne of North American psychiatry – Dr Adolf Meyer - have the power to alter the course of the psychiatric profession. Meyer’s 1929 correspondence to his former student and colleague, Dr David Henderson, pre-empted the paradigmatic shift that would occur in British psychiatry between the two World Wars; as Henderson, at the height of his eminent career, steered patient case taking practices away from former emphases on description of symptoms, classification and brain pathology, and towards the study of individual personality, set within, and reacting to, his or her environment.

My article begins with Henderson’s articulation of his ‘dynamic’, otherwise known as psychobiological, approach to mental health care during the 1920s. The rest of the paper is an examination of the patient case note records produced during his physician superintendence of Glasgow’s Royal Asylum, Gartnavel, 1921-1932. Examination of the staff meeting record lies at the heart of this investigation. Instigated in Britain by Henderson at Gartnavel in 1921, this clinical practice spanned case presentation, patient examination and discussion of plans for treatment. Bringing together a multidisciplinary team of medical practitioners, the aim of the staff meeting was to study the whole person (body and mind) of a patient, reacting and adapting to the experimental stage of the clinical environment, while the patient’s own language and own understanding of illness formed the basis for therapeutic intervention. Recorded verbatim by clinical stenographers, transcripts allow this paper to ‘sit in’ on such meetings. The near uniqueness of these sources enables a new, rarely accessible kind of history to emerge; a history inclusive of patient-psychiatrist dialogues spoken within, and as an essential part of, the clinical encounter:

                   Dr. Henderson. You have spoken about your spine shifting. Do you believe that your                           spine is –

                   Patient. (breaking in) Yes I do. When the change comes on it about knocked me off my                       mind altogether. I think it was me getting the wind up - it made my nerves worse.”

Rarely can histories look beneath published records to access the clinical conversations, disputes and the situated possibilities for understanding and intervening in patient cases, but here such conversations are laid bare almost verbatim (in ‘real time’). Once the patient was escorted out of the meeting room, debate and discussion of the case continued between Henderson’s staff. Both senior and junior medical staff collaborated within a shared space wherein diverse psychiatric theories – from the most organic to the most psychoanalytic – are brought into dialogue with other branches of medicine, such as presented by staff working in the pathological laboratory or occupation department. Such dialogues almost never make their way into published, official records, as they lay bare the false starts, bold statements and interchanges that speak at cross purposes, before such exchanges were preened and presented at conferences, in papers and medical texts.

Drawing parallels with medical humanities scholarship, my paper endeavours to access a historical space in which methods and concepts, drawn from the humanities and biomedical sciences, mesh and are transformed into new medical knowledges. Situated within spaces, such as those of the staff conference, this project questions the extent to which Henderson’s initiation of multi-disciplinary working practices, which intersect with, and underscore the agency of the individual patient, were productive of case materials that transformed medical teaching and clinical practice in Britain.”

Hazel Morrison

To access Hazel’s article and find out more, please do visit Medical History’s website at https://doi.org/10.1017/mdh.2015.69

Focus on CGHH Research - China in the Worldwide Eradication of Smallpox, 1949-1980

In October 2017 Lu Chen joined CGHH as the recipient of a Wellcome Trust Medical Humanities PhD studentship. Lu is researching smallpox eradication in post-war China, focusing on how was smallpox eradication conceived, planned and delivered in China, and what international, regional, national and local political negotiations made success possible.

Lu writes: "In the US-and Western Europe-centric historiographical context on international and global health, China gets only short treatment. Different to many of its neighbouring countries where smallpox was still epidemic in 1950s, the Chinese smallpox eradication work did not rely on US assistance, had nominal links with WHO structures and budgets, and was, instead, built mainly upon a raft of bilateral aid agreements with the Soviet Union, the USSR’s Eastern European allies and, latterly, politically neutral Western European countries like Sweden. These international links provided vaccine, vaccinating kits and the transfer of vaccine production technologies. China’s government worked to its own timetables, independently gauging the value of international political alliances, and agreed to aid flows and involvement of overseas workers through very specific terms. In all this, Chinese representatives engaged the UN, the WHO, and the US and Western European aid agencies in distinctive ways, and only as and when they regarded it useful to do so (and, when internal politics allowed it). My research will investigate all these programmatic complexities independently and critically."

We look forward to hearing how the project progresses and would like to take this opportunity to welcome Lu to CGHH!

Smashed by the National Health

In our guest post today. Philip Conford gives us some insights into the reasons behind the Pioneer Health Centre, Peckham's demise. You can read his article “‘Smashed by the National Health’? A Closer Look at the Demise of the Pioneer Health Centre”, which appeared in Medical History 20:2 (2016), at https://doi.org/10.1017/mdh.2016.6

Philip writes: "In 2014, the medical journalist Ben Goldacre published a book called I Think You’ll Find It’s a Bit More Complicated Than That. This title struck me as an appropriate response to some comments made by former members of South London’s Pioneer Health Centre (PHC), about the reasons for the Centre’s closure in 1950. “The National Health smashed it,” said one of them, bitterly. But was the explanation for the Centre’s demise really that straightforward?

Material at the Wellcome Trust, the National Archives and the London Metropolitan Archives suggested not. For a start, the PHC had always struggled financially. A decade before the NHS was established, it was having to be bailed out by loans and donations because it was attracting insufficient numbers – payment of a subscription was necessary – to make it viable.

The reasons for this reluctance to be involved lay in the minds of all those families who chose not to belong to the Centre, and have therefore never been open to analysis, though Paul Rotha’s documentary film The Centre (1947) provides at least some idea of why people might have resisted what the PHC was offering.

Unable to raise sufficient money through membership, the PHC sought help from the government and the Medical Research Council (MRC). But the tone of George Scott Williamson, one of the Centre’s founders, in his correspondence with officialdom, and the fact that he was deeply antagonistic to the proposed National Health Service, would not have helped his cause.

Whereas the MRC had been sympathetic before the war, it was markedly less so after it. Techniques of medical statistics were rapidly advancing, and the PHC’s standards of record-keeping evidently did not meet the standards that the leading figures in this new field (for example Austin Bradford Hill) required. Again, Scott Williamson did not help his cause by emphasising that the PHC’s work was not an exercise in orthodox science. Harold Himsworth of the MRC was distinctly cool towards the Centre, which he seemed to regard as an irritant.

Nor was the cultural climate favourable to the PHC’s approach. A mood of what I have termed “chemical triumphalism” was abroad: the invention of sulphonamide drugs encouraged an aggressive faith in the power of industrial chemistry to defeat sickness and disease. The unorthodox and exploratory approach of the PHC would have seemed very uncertain in comparison with the dramatic, specific, results achieved by the pharmaceutical industry’s “silver bullets”.

The NHS was not directly responsible for the Pioneer Health Centre’s demise, although its medical approach to curing sickness rather than promoting health took health policy (or sickness policy, as its critics maintained) in a different direction from that explored at the Centre. Blaming the NHS fits in well with the current ideology of the “small state”, and one of my aims in writing this article was to suggest that the truth about the Pioneer Health Centre’s closure was indeed “a bit more complicated than that”."

Mental Health: Pasts, Current Trends and Futures

This is a guest post from Dr Philip Kerrigan, co-editor of Mental Health: Pasts, Current Trends and Futures

The Centre for Global Health Histories has co-produced a new book with the University of York’s Centre for Chronic Diseases and Disorders (now the Centre for Future Health) entitled Mental Health: Pasts, Current Trends and Futures (published by Orient BlackSwan). The book is available free to download from the University of York’s Digital Library [https://dlib.york.ac.uk/yodl/app/home/detail?id=york%3a932416&ref=browse].

Securing better mental health for everyone around the world is one of the greatest current challenges in global public health. Historically and to this day mental disability and illness has been closely linked to social and political stigmatisation, which has led this specialism to remain under-provisioned and under-represented in health structures.

Advancing the mental health of the world’s population is hence a challenge that requires multi-faceted solutions, cooperation between many stakeholders, and a fulsome understanding of the political, social, economic and cultural determinants of health. Mental illness is also in many cases not a condition existing on its own but rather one which connects to a wider range of afflictions (for example, post-epidemic disease community support, as has been seen in relation to Ebola in western Africa).

This new work offers a number of carefully researched but accessible case studies from different areas of the world and across periods in time which shed light on some of the many motivations and innovations in the field of mental health, and analyse the range of barriers and opportunities that continue to impact on this complex area of work. Each one is complemented by specially chosen photographs, prints and other visual records, drawn from a variety of libraries and repositories, including Wellcome Images and the WHO Picture Library, and which help to enrich and expand the arguments and themes presented in the text.

As well as highlighting historical failures and enduring problems, the chapters give hopeful evidence of successful initiatives that could be adopted and built on across the globe and of a burgeoning commitment by individuals and national and international organisations to bring forward changes for the better.

The book is trilingual with English, Portuguese and Hindi translations side by side so as to reach the widest possible audience within international agencies, national and local governments, and civil society groupings.

The origins of the work, which is the latest volume in a series examining a range of issues in global public health and health policy, lie in the University of York's commitment to health equity and promotion internationally, which it seeks to advance through independent and evidence-based research. The opportunities to prepare this book in close partnership with colleagues at the World Health Organization were made available through the Centre for Global Health Histories’ designation as the WHO Collaborating Centre for Global Health Histories through which it works closely with UN agencies and national governments on policy advocacy and public engagement. The editors have worked closely also with the Brazilian Federal Government (via Fiocruz, Rio de Janeiro), and the World Bank. The research and editing work was funded by the Wellcome Trust, a global charitable foundation based in the UK, via Centre for Chronic Diseases and Disorders, and the Centre for Global Health Histories at the University of York, UK.

A poster exhibition has been created from twenty of the most striking images from the book.  The exhibition will go on display in the University of York’s Ron Cooke Hub as part of a day of events to mark World Mental Health Day on 10 October 2017. The book will also be officially launched at a public lecture in the evening and free copies will be available to the public to take away.

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The book was co-edited by Philip Kerrigan, Sanjoy Bhattacharya, Samantha Peel, Magali Romero Sa, Raghav Kishore and Alex Wade.

Contents

Introduction

1) Andrew Scull – Asylums and care in the community: The dilemmas of mental health policy

2) Samantha Peel – A short visual history of the use of electricity in mental health

3) Jerome Wright – Building capacity and increasing access to community mental health care

4) Carlos Estellita-Lins – Mental health, indigenous suicide and shaminism in Brazil

5) Stephanie Charles & Poppy Nash – The role of schools in promoting the mental wellbeing of young people in the UK

6) Soumitra Pathare, Jasmine Kalha, Titus Joseph, Michelle Funk, Natalie Drew-Bold and Akwatu Khenti – QualityRights Gujarat

7) Patricio V. Marquez and Timothy G. Evans – Global burden of mental disorders: Is there a way forward?

8) Shekhar Saxena, Global mental health and the World Health Organization