Thursday, 6 July 2017

History of psychiatry. History as psychiatry.

Somewhere between symptoms and intentional actions lie behaviors that are both deliberate and compulsive, owned and alien. Such behaviors are troubling, either to the people who so behave or (more commonly) to those around them. How do we make sense of actions which can't be fully explained even by their actors? Psychiatry has tended to ascribe meanings at the personal or sub-personal level. But such explanations break down when behaviours interact with broader social patterns, messily assimilating, communicating and discharging. Psychiatry needs a wider angle lens; psychiatry needs history.

This truth is brought into relief by Sarah Chaney's book Psyche on the Skin, a wonderful new history of self harm. That such an important and enjoyable read could have arisen from someone's PhD thesis seems almost a little unfair. 

Chaney's subject threatens to pull apart any coherent historical account. The history of self-harm strains in almost as many different directions as there are acts and actors. This is not a limitation of the project, it is part of its point. In its prehistory (Chaney demarcates as "prehistory" those forms of self-harm that preceded psychiatry and thus escaped its codification), self harm could signify religious piety, self-cure, or sexuality among other things. Individual motivations may have involved some all or none of these and to different degrees. At different times, a cultural framework made specific forms of self-harm intelligible. Religious flagellants acted under a description which accounted for their behaviour. When particular expressions of religious zeal came to be less widely shared, they looked more and more pathological. When medicine stopped endorsing so widely the practice of bleeding, the impulse to purge in this way looked less like a cure and more like an illness. Psychiatry's arrival signalling a shift to a new over-arching lens. Self harm became the sign of a simple psycho-biological "morbidity", an inwardly directed aggression, or an attention-seeking malingering, depending on which psychiatric epoch you lived through. 

The surprising fact at the heart of this book is the diversity of forms self-harm has taken, even in its recent history. The diversity of the associative networks it has occupied. Each era finds new ways to physically manifest misery. These have fluctuated through the ages. It is tempting to frame this in terms of a trend, but something else also played a role. Chaney presents evidence that the prominence of a phenomenon in the medical literature did not accurately represent its prevalence in reality. In the last two decades of the 19th Century, around 25% of publications on self mutilation focused on castration, but this was seen only around 2% of self-harm cases admitted to the Maudsley. For less headline grabbing phenomena (picking and "knocks") the statistics were approximately reversed. British alienists developed a penchant for the sensational, and this of course shaped their view of what they were studying. 

The running theme here is not the search for some over-arching cultural true meaning that can be bestowed on self harm. Rather it is psychiatry's engagement with the phenomenon that is under scrutiny. Each chapter unfolds like a historical case study, but the objects of the case study are the doctors who have tried to bring order. Self-harming persons are not absent by any means, but Chaney declines to speak on their behalf. Instead they appear in simply elaborated descriptions or images, silently looking out at us like Robert H, photographed in the Maudsley hospital at the end of the 19th Century. 

Chaney's treatment of these individuals reminds me of Ian Hacking's approach to fuguers in "Mad Travelers." She doesn't pretend she can account for the behaviour of someone who rubs at their head until their hair has worn away, or inserted needles into her skin, she simply presents facts. We are left with a respectful outline, of people doing perhaps what they had to, or felt they had to do under the circumstances. My reading of the book dovetailed with the broadcast of Hilary Mantels' Reith Lectures, which proved apt. Mantel reflects on the impossibility of a fully psychologically informed history. History for Mantel is
...the multiplication of the evidence of fallible and biased witnesses, combined with incomplete accounts of actions not fully understood by the people who performed them. It’s no more than the best we can do, and often it falls short of that. (page 4)
So in providing an honest history, Chaney offers a subtle contrast to the confident and totalizing narratives of many of her psychiatrist and psychologist subjects. She doesn't overdo it (her book is not a polemic), but the desperate need to explain and domesticate self-harm is a thread that binds a diversity of medical encounters across time. Confident pronouncements abound, particularly during the psychoanalytic heydey of the US in the 1950s. Psyche on the Skin expands the historical horizon, and in turn shrinks the parochial theoretical perspectives of its medical and custodial protagonists. There is a clear lesson here for modern practitioners; resist too strong an attachment to your theory of choice, otherwise anachronism awaits.

There is a personal note to this book too. Chaney has her own experiences of self harm. In her conclusion she says "The history of medicine has been a solution for me in the way medicine itself never was." There is a warning in there for those of us who would too readily organize our own lives around the particular brand of sense-making that is mental health care.

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