Psychiatry’s New Patient. Cultural Perspectives on Psychiatry and Patienthood 1960-2000
When the large mental hospitals shut down, the psychiatric view of the patients changed. The older institutions had described the patients from a starting point based on conditions of organised space and time. The scheduled everyday life and the hospital's permanent access to the inmates were fundamental to this perspective. Parallel to deinstitutionalization, there followed new expectations and a new view of the patient. He or she lived amidst society, met the rest of us, lived on his or her own, and had only now and then immediate contact with psychiatric care. But how and where did the new, open psychiatry acquire knowledge about its patients? In what way was the picture of the patient affected by the fact that he or she lived outside the institutions, as part of society?
The aim of this study is to investigate the cultural brickworks fundamental to the view of psychiatry on the "the patient", beyond the large psychiatric hospitals. A starting point is that psychiatry is not to be seen as isolated from society. Its therapies, treatments, and care are not only medical, but founded in cultural perspectives on what is considered to be normal and desirable human behaviour. One important source of the study is case records. They will be used as points of departure for narratives on individual's destinies as patients. The study is also based on sources such as reports, investigations, and textbooks for personnel.
Lars-Eric Jönsson, Dept. of Arts and Cultural Sciences, Lund University
Psychiatry's New Patient. Cultural Perspectives on Psychiatry and Patienthood 1960-2000
2008-2012
The project's aim was stated in the application to: 1) examine the cultural related performances that formed the basis of the open psychiatry's perspective on the "new patient", beyond the large mental institutions, and 2) examine the practices and locations of the open psychiatry's meeting with their patients.
The original aim included the delineation 1960-2000. It soon proved to be too narrowly set. At the design stage, I thought that 1960 would give me the margin to make adequate comparisons between the old institutionalized and the new, open psychiatry. This assessment was based on the opinion that the new psychiatry would represent a greater change than my investigation would later show. The traditions of psychiatry practices turned out to be more long lived than I thought. The traditions were to a lesser extent tied to institutions than to psychiatry\\\\\\\'s approach independent of these institutions. The traditions were created at the clinic, but could be removed from this and basically operate outside it. This discovery resulted in a decision to work with more liberal temporal boundaries. Although the focus of course is the initial period 1960-2000, I worked backwards in the history of psychiatry as it demanded attention.
One track that was unplanned and outside the original aim is about the use of history as found in the healthcare policy investigations conducted by state and county municipal heads before and during the transition of the Swedish psychiatric care from the institutional system to outpatient care in the 1970s and 1980s. This use of history is characterized by a antagonism to the past, not least to let contemporary changes appear in a clearer and better light. This way of working with the past as a kind of reference has hardly been given the scientific attention it deserves. In fact, the past appears as the most effective "diving board" into the future.
An extension of the aim was also to apply literary and autobiographical stories of contacts with psychiatric services. This extension of the project was related to an investigation that goes down in the late 19th century, an investigation that I already had some materials for. Within Psychiatry's new patient I enlarged the period that extends up to our own time, and conducted the survey in full and published it under the title "Stories from the inside. An essay on personal experiences in the history of psychiatry".
The project's three main results
With regard to the sources covered by the project revolves one of its most important results about change and continuity. As mentioned above, traditions were created at the clinic, but could be removed from this and basically operate outside it. In most surveys, and other sorts of texts and statements on the open psychiatry, as it came to be established in Sweden in the 1970s and 1980s, the objectives that the new psychiatry wanted to achieve is strongly emphasized. These objectives were formulated largely in contrast to the traditional, institutionalized psychiatric care.
However, by taking advantage of new sources, above all medical records, I have been able to show how the new psychiatry on some but not all aspects worked within well maintained tracks. A related result concerns the experiences of mental health over time. In "Stories from the inside", I describe how affected individuals distance themselves and define themselves in contrast to their fellow patients. I also show how patients perceive psychiatry as a blunt instrument in the treatment and understanding of the individual's problems. Both of these phenomena - attitude to fellow patients respectively. psychiatry practice - appears to be remarkably sticky over time, whether we put the spotlight on the 1900 or 2000.
A second result concerns the above detailed historical perspectives of health policy studies and programs. The result can be briefly described as perspectives on the past is reflected in two contrasting stories. One story dissociates from the past, the dark and unscientific. The second story sees the present as the crown of a long process of a good and productive development.
A third result is how well intertwined the open and closed psychiatric appears in the material. Even in the institution-bound era the cooperation between psychiatry and the inmates context outside the institutions was well developed. In the "new" psychiatry this relationship was developed further. Knowledge of and construction of the patienthood was increasingly based on laymen's reports, information from social services and general medical advice of for example nurses.
New research questions generated by the project
The past as resource points to the use of history, a research field that does not lack studies. My examples from psychiatry, however, points to a category of history producers who have hardly been investigated. I refer mainly to politicians and public authorities of various kinds. The past as resource points to issues of how these and other related actors are using and producing history and how this output is connected to contemporary depictions and political visions of the future.
In the book "Institution" and the article "At Home on the street" issues on how modern psychiatry works in urban landscapes are treated. Many people living with psychiatric diagnosis also suffer from homelessness. How do psychiatry meet and treat these people? How does psychiatry work in urban spaces and landscapes?
The project's two main publications
"Stories from the inside" was not part of the project when starting, but became a part of it. As mentioned above, this is a study of individual experiences of psychiatry from the late 19th century until today. For the project\\\\\\\'s original purpose, it is mainly the more recent stories that have direct and obvious relevance. I highlight and analyze debates about psychiatry as they are expressed in the literature, as well as the dual attitude to the new psychiatry which comprises both a demand for it, a willingness to take part of it, and a critique of its square, blunt way of working with those seeking help.
The project's second, most important publication is a collection of essays that obviously fit directly into the project's original aim. This collection is not yet published, but in essential parts, written. The collection will be offered to publishers for assessment and publication. The index will provisionally be: 1. Introduction, 2. The past as a resource, (attached) 3. The Door, 4. At Home, 5. Conclusions, 6. Sources, literature. Section 2 is mentioned above. Sections 3 and 4 contain descriptions and analysis of the knowledge construction of the patient, how knowledge is produced and in what arenas psychiatry operates. The third chapter - The door - covers how psychiatry has worked with access to the patient, within or outside the institutions and how the door has emerged as a problem but also an opportunity considered an architectural elements. Focus on psychiatry's approach to the door leads towards spatial practices both within and outside the clinic. It leads in particular to patients' homes (Section 4), which both appear to be a problem - they are not always available for psychiatric care - and an opportunity - they are the ideal place for treatment and rehabilitation.