Turning the pages, or why history is important to psychiatry

In all disciplines of medicine, it is an oft-repeated truism that both diagnosis and management are based on good histories. In fact, among the required tools that a good clinician has to possess, the ability to take a good history is perhaps the highest rated. This takes on another dimension in the practice of the discipline of psychiatry. What makes psychiatric presentations complex is, of course the disorder, be it an anxiety disorder or a severe mental illness, but also the personality characteristics of the individual experiencing the disorder. So, an easily anxious, nervous person will respond very differently to any illness, or even any significant life event, as opposed to a less anxious person. To add further spice to the mix, socioeconomic factors and the importance of money (or lack of it), gender, perceived identity, community, and a host of other factors would also clearly play a role. Therefore, a good psychiatric history tries to identify what the individual is experiencing, who he/she is, where he/she comes from, and the milieu that he/she is a part of, for adequate intervention to be planned. This requires that the clinician, while retaining his/her clinical “lens,” also use other tools to get a more nuanced sense of the individual requiring assessment and management. As any experienced doctor can tell us, this may, however, not necessarily be as daunting a task as it sounds, and developing a good empathetic listening ear may actually be what is required. This is what Dr. Jal Dhunjibhoy, a psychiatrist of a bygone era, said when he spoke of the need to “…stand alongside him in his difficulties…”[1]

In the same vein, when we shift the perspective somewhat, and talk of the history of the medical discipline of psychiatry, it becomes abundantly clear that for us to be able to get a sense of where we are as a specialty today, we should try to remember and understand where we were yesterday, and that in turn may help us to steer toward the many possible tomorrows. The practice and thinking in the clinic tends by its very nature to be ahistorical because of the many pressures on the here and now, and the imperatives to action. So, a doctor in a psychiatric emergency service will genuinely be more concerned with calming an acutely disturbed and agitated individual, rather than pondering on the larger meanings and consequences of societal or personal inequity. The difficulty, however, is when this “call to action” prevents us from stopping to think of what we need to do, apart from what seems to be the obvious. In that sense, our approaches and attitudes will be informed by what we know of what has gone before, and that is limited only by what our “listening ear” lets us hear, or what we train it to hear.

So, whether we try and understand our approach to the individual patient, or whether we think about the sort of services that we should have, the nature of institutions, large or small, voluntary or custodial, and how we feel about what has gone before is certainly something that will influence action. This is perhaps most important when we think in terms of what the engagement of a mental health service should be with community. How “medical” should it be, and how “embedded” in the community, whether cultural and social elements need to be part of the discourse, and whether concerns about livelihood, work, and living spaces need to be addressed are all perhaps questions that are as important now as they were then.

A classic case in point here is the history of the psychiatric institution. As the photographer and architect Christopher Payne in his spectacular photographic documentation of the now defunct mental hospitals of America says,

“We tend to think of mental hospitals as “snake pits”–places of nightmarish squalor and abuse–and this is how they have been portrayed in books and film. Few Americans, however, realize that these institutions were once monuments of civic pride, built with noble intentions by leading architects and physicians, who envisioned the asylums as places of refuge, therapy, and healing.”[2]

What has happened, however, is that the mental hospitals have got a bad press, and this has created a move to “de-institutionalization,” or a shutting down of the hospitals. This, in turn, has created a “new” trend of many people with severe mental illness either on the streets or in jails (a phenomenon described as “trans-institutionalization”). Even cursory readings of history will tell us that this is precisely the reason why the mental hospitals were conceived of in the first place. What has however been lost in this contemporary monochromatic version of the history of the hospitals is the fact that actually many more things happened in the hospitals, the stories of which also need to be told.

As Oliver Sacks in the foreword to Payne's book of pictures says,

“They evoke for me not only the tumultuous life of such places, but the protected and special atmosphere they offered when, as Anna Agnew noted in her diary, they were places where one could be both mad and safe, places where one's madness could be assured of finding, if not a cure, at least recognition and respect, and a vital sense of companionship and community.”[3]

In a sense, the discipline of psychiatry “has a long past but a short history.” In this special supplement of the Indian Journal of Psychiatry, we are focusing only on the short history of the past 200 years or so, when institution-based psychiatry, and psychiatry, as a formal, medical discipline, became a part of civic life in our country.

It must be remembered that till the time of the Independence of India, the history of Indian psychiatry is actually the history of the mental hospitals. Archival research on the history of the mental hospitals has looked at a number of sources of information. The first among these have been the annual reports of the mental hospitals that were submitted to the imperial government. Often detailed, many of these, apart from being records of admission, discharge, and expenditure, were often studded with details of musings on the nature of illness, prevalence rates, causality, and possible treatments, and offer us rich insights into the thoughts of the various medical superintendents. Also available are various other materials, scattered case notes, the writings of various psychiatrists, official records, and other historical writings. Thankfully, much of the material can be revisited, and a sense of continuity, and thus community, be imagined.

To provide a nuanced polychromatic picture of the history of a bygone era, the researcher needs to look at a diversity of primary sources to be able to fit the various pieces of the jigsaw together, and that is, of necessity a painstaking process. Over the last few years, the Indian Journal of Psychiatry has hosted a special section titled “From the Archives,” which has attempted to stimulate archival research in the history of Indian psychiatry.

In this special supplement, we are pleased to bring to you a collection of articles on the history of psychiatry. Many of these focus on various institutions and on institutional histories and understand how the institutions have changed over the years. A few have attempted to look at the growth and development of disciplines and aspects of the discipline such as psychopharmacology, child psychiatry, rehabilitation, and the development of the general hospital psychiatric unit as modes of the delivery of service, even in the recent past. From a different perspective, there is also an attempt to trace the history of some specific disorders while one essay interrogates the ethic of work in the mental hospitals.

The pieces reflect, as they should, the thoughts of the authors and have used different sources for research. Given the fact that many are invited pieces, the tone and tenor of the essays varies quite widely. The opinions and conclusions expressed are those of the authors, most of whom are psychiatrists. The texts suggest that most of the contributors are very passionate about the history of their services, the role these have played in providing care, and the transformations they have seen and experienced at first hand themselves.

As the editors, we provide brief commentaries on most of the pieces. It will become apparent to the reader that many of the articles in this collection use secondary sources as their source of information, relying on earlier published accounts of histories of psychiatry, and some are clearly opinion pieces. While this certainly has a space, it must be recognized that the actual historical research should certainly attempt to look at the primary archival sources to have true validity, and thus lend itself to many different viewpoints.

This collection is best seen as a beginning of conversations about the establishment of historical research in psychiatry as a discipline in its own right, and we would hope that these conversations continue.

We would like to thank the contributors and the reviewers for their patience, time, and effort, and we hope that the readers enjoy these offerings as much as the editors did.