HHH column: A problematic legacy by Joost Vijselaar
The HHH column is a monthly blog in which History, Health & Healing members share their thoughts: on research, current affairs, and anything to do with medical history. Each edition is written by another member – in due time, we hope to offer everybody a chance to publish a contribution here. This month, the floor is for Joost Vijselaar, professor by special appointment in the history of psychiatry at Utrecht University. On the occasion of his retirement, Joost makes a plea for a renewed historical consciousness in his field, in particular with regard to its material culture.
The 1970s and 80s witnessed a surge of historical interest in psychiatry and mental health care both internationally and in the Netherlands. This happened in the context of the critical evaluation of the scientific foundations and social role of psychiatry, as well as rapid changes in the field of mental health. At the same time, historians paid new attention to ‘oppressed groups’, like women, labourers, prisoners or, for that matter, psychiatric patients. Scientific interest in the ‘psychiatric past’ in the Netherlands went along with concern for the material heritage of psychiatry, resulting in the creation of historical collections of psychiatric institutions.
Ever since, The Netherlands – besides the UK – has become one of the countries whose psychiatric past has been studied and described most intensively and where major steps have been taken to preserve and use historical heritage. The establishment of a national museum for the history of psychiatry, the Dolhuys (now Museum van de Geest, Museum of the Mind) in Haarlem, crowned the museological efforts, while the historical research of recent decades culminated in the publication of the handbook Verward van geest en ander ongerief, Psychiatrie en geestelijke gezondheidszorg in Nederland (1870-2005) by Harry Oosterhuis and Marijke Gijswijt-Hofstra in 2008. All along, the historical initiatives had been supported by organizations within the field of mental health, like the National Institute for Mental Health (NcGv/Trimbos-institute), the national inspectorate and individual psychiatric institutions.
During the last twenty years, however, there seems to be a decline in historical awareness and interest in mental health care. This may perhaps be due to a saturation of interest owing to the large number of historical publications and the cyclical character of interest in historical themes in general. However, this decrease may also be attributable to a number of structural trends in mental health care. The mergers of mental healthcare institutions around 2000 into large, multifaceted organizations weakened the natural ties with the original, sometimes centuries-old institutions from which they emerged. At the same time the number of clinical beds decreased and buildings and sometimes entire institutional complexes were abandoned (and even demolished) as a result of the ongoing process of deinstitutionalization. This process distances psychiatric organizations both literally and figuratively from their (own) history and architectural heritage.
Furthermore, the process of deinstitutionalization and ambulantization of care, which started in the 1980s, constitutes a fundamental break with the previous phase of clinical, institutional psychiatry. As part of the underlying ideology of deinstitutionalization, this period is in hindsight almost invariably referred to as one of isolated, repressive institutions in which patients were locked up against their will and in which a punitive regime was maintained. The psychiatric hospital did not promote healing, but instead lead to hospitalization and reinforcement of the stigma and exclusion of the mental patient. The modern community mental healthcare system wants to avoid association with this historical heritage, which means that it is consciously emphasizing discontinuity with regard to the institutional period.
The need to combat stigma in the face of socialization and ambulantization means that aspects of psychiatric history that might confirm those prejudices – such as past forms of coercion and treatment (straightjackets, solitary confinement) – have gradually become a controversial, ‘uneasy’ legacy. Or, as it is plainly stated on a joint website of GGZ Eindhoven and the Van Abbemuseum: ‘… psychiatric illnesses are still stigmatized by society, not least because of the problematic history of psychiatric care.’
This is all the more so because psychiatry and mental healthcare of the past also have – according to current opinions – many other ‘obsolete’ characteristics, such as a philosophical view on psychiatry, the dominance of psychoanalysis, and harmful somatic cures such as insulin coma therapy and lobotomy. History thus seems unable to provide direct lessons for the present, apart from using the contrasts with the past to present actual psychiatry in a favorable, enlightened perspective, a strategy which seems to be a universal psychological mechanism.
As in medicine in general, there is something in psychiatry that could be called the ‘innovation imperative’: the continuous and legitimate pursuit of improving the quality of care and treatment. With the introduction of evidence based medicine, the neuroscientific turn in psychiatry and the process of deinstitutionalization, this driving force seems to have been strengthened. This reinforced orientation towards the future makes the past seem less relevant. At the 150th anniversary of the Dutch association of psychiatry last year, marginal attention was paid to history, whereas much of the program was dedicated to the future.
As a consequence of these developments, less attention is being paid to the conservation of archives (patient records among them), small museums of psychiatric institutions are being closed, while history has been reduced to a minor theme within the new permanent exhibition of the Museum van de Geest. The picture isn’t entirely bleak: for example, the chair for the history of psychiatry at Utrecht University will be continued, financed by mental health institutions, while three new biographies of major psychiatrists from the 20th century – Jan Foudraine, Jan Bastiaans and P.C. Kuiper – are being published. Yet the recent decrease of historical consciousness within the domain of mental health demonstrates that a persistent interest in the past of a specific field is not self-evident even within historiography. Historical awareness requires continuous upkeep.