Social Psychiatry

Social psychiatry is concerned with the relationships between mental disorder and sociocultural processes
Alexander Leighton, 1960 An Introduction to Social Psychiatry [1]

Although Freud was fully aware that the development of human personality must be seen in terms of the influence of the prevailing social standards and values to which the person is subjected [2], other psychiatric workers focused more on the interpersonal dimensions of human experience. William Alanson White, an influential early twentieth century psychiatrist observed, “Society, while it is composed of individuals, reflects its degree of development in each individual psyche, so that man and society occupy relations of mutual interdependence, each profoundly affecting the other.” [3].

The Sanctuary Model Trigant Burrow helped found the American Psychoanalytic Association in 1911 and became its president in 1926. His work has been largely ignored because he took a radical turn away from individual psychoanalysis and toward a study of the group. In his papers and books from 1914 on, he developed the idea that the neurotic elements that Freud had identified in individual patients were embodied in the entire society. He gathered around him a group of colleagues, family members, and patients and they formed the nucleus of a group of investigators that remained together in an experimental community for more than thirty years. In this group setting, called the Lifwynn Foundation as of 1927, they spent their time observing interrelational processes through their own interactions, using themselves as the laboratory agents. Burrow regarded conflict, alienation, crime and war as major public health problems that could be solved through science [4]. “Man is not an individual,” he said. “His mentation is not individualistic. He is part of a societal continuum that is the outgrowth of a primary or racial continuum” [5]. Later he warned “My researches clearly indicate to me ... that with the enhancement of individualism the balance in favor of group survival has been placed in serious jeopardy. Today the very existence of the species is threatened because the antagonisms characterizing man have been largely divorced from his biological needs and actualities” [6].

The Sanctuary Model Early in his career Alfred Adler worked with underprivileged laborers and was struck by the deplorable conditions under which they worked and how these conditions contributed to their physical and mental problems. At least in part as a result of these experiences he had a well-developed social consciousness. In his later writings, he stressed that mental health could be judged by the degree to which a person could direct himself to his work, love his fellow man, and fulfill his social and communal obligations. In his book Social Interest, he stated, “The growing irresistible evolutionary advance of social feeling warrants us in assuming that the existence of humanity is inseparably bound up with ‘goodness’” [2].

Adolph Meyer had a vital impact on American psychiatry. He was influenced early in his career by Clifford Beers , a reformer who had himself received horrendous treatment in mental hospitals and devoted his life to reforming them. He was also influenced by his wife, Mary Brooks Meyer. Around 1904, Mrs. Meyer began visiting the families of her husband’s patients to learn more about their background and in doing so she became the “first American social worker.” He said of these visits, “We thus obtained help in a broader social understanding of our problem and a reaching out to the sources of sickness, the family and the community.” Meyer believed that the individual must be understood as a complete whole, a unique entity, and could best be understood by searching for all forces that react upon him and that affect his interaction with the social milieu [2].

The Sanctuary Model Harry Stack Sullivan considered mental illness as related to disturbed relationships between people, seeing the basic conflict as located between the individual and his interpersonal environment. During the years between World War I and World War II, he played a key role in altering the traditional focus of psychiatry from the individual to the interpersonal. “Personality,” he wrote in 1938, “is made manifest in interpersonal situations, and not otherwise.“ His work paved the way for the socially oriented therapies that were to dominate post-war psychiatry [7]. Karen Horney ’s theories placed human development firmly in a cultural context, and she believed the neurotic person was one who had experienced injurious cultural influences in childhood [8].

Developing his ideas in the first half of this century, Moreno, the originator of psychodrama, said, “Mankind is a social and organic unity” . He termed his area of interest "sociatry" and saw its aim as the healing of normal society. “Sociatry treats the pathological syndromes of normal society, of interrelated individuals and of interrelated groups. It is based upon two hypotheses: 1) The whole of human society develops in accord with definite laws; 2) A truly therapeutic procedure cannot have less an objective than the whole of mankind.” [9].

As early as 1922, Dr. E. E. Southard of Harvard Medical School, taught his students about "Social psychiatry" which he termed “an art now in the course of development by which the psychiatrist deals with social problems” and as “that part of the knowledge of psychiatry which has a bearing upon social problems” [10]. As a result of the massive disruptions of World War II, American and British psychiatry took on a decidedly social and political complexion. Maxwell Jones referred to this as the "general tendency to change which was apparent in many spheres during war time" [11]. The first World War had shaken psychiatry and medicine as a whole, because of the considerable incidence of battle neurosis, or “shell shock. "Experience in that war led to the development of special hospitals and clinics for servicemen and then for civilians, at least in Great Britain [12]. But it was World War II that brought about major changes in the psychiatric system and ideology.

As a result of World War II military psychiatrists came to some important conclusions: that neuropsychiatric problems were more serious than had been previously recognized, that environmental stress was a major contributor to mental maladjustment, and that purposeful human interventions could alter psychological outcomes. Their experience with the number of men rejected from military duty because of mental health problems led them to conclude that mental illness was a more serious problem then had been recognized. Fourteen percent of men ages eighteen to thirty-five were disqualified from service because of neuropsychiatric disorders [13]. It also became vividly apparent that a continuum existed between mental health and mental illness that was related to the degree of stress a person was forced to endure. A year after the end of the war, J. W. Appel and G. W. Beebe concluded that combat exposure for 200 to 240 days would break anyone and that psychiatric casualties were as inevitable as gunshot and shrapnel wounds [14]. Early treatment in non-institutionalized settings appeared to confirm the need for a different way of viewing hospitalization [7].

These psychiatrists had seen that treating servicemen in the context of their social relationships was essential. With enough supportive forms of psychotherapy, combined with rest, sleep, and food, severely stressed combatants were able to rapidly return to the front. And it was not the specific treatments that mattered. “Successful treatment seemed to depend less upon specific procedures or specific drugs than upon general principles - promptness in providing rest and firm emotional support in a setting in which the bonds of comradeship with one’s outfit were not wholly disrupted and in which competent psychiatric reassurance was fortified, symbolically and physiologically, by hot food and clean clothes and by evidences of firm military support and command of the situation” [7]. They had also seen that the effects of overwhelming stress, were in fact, treatable. William C. Menninger believed that the war demonstrated the significance of group cohesion, leadership" , and motivation. He believed it was vital to determine the “more serious community-based sources of emotional stress” if effective strategies were to be developed to treat that stress [7].

When they left the service these psychiatrists applied the same notions to civilian care and began to emphasize treatment in a family and community setting, rather than within the state hospital systems exclusively. New epidemiological work focused on the general population rather than the institutionalized mentally ill. These studies supported the wartime experience that cultural factors that caused significant stress played a central role in mental health and mental illness. William Menninger said that every institution in American society had to to evaluate its program “in terms of the contribution to individual and group mental health” and that it was vital to determine “the more serious community-caused sources of emotional stress”. These observations led to a dramatic increase in social activism and an optimism that was typical of the times. Prominent psychiatric leaders called upon the mental health professions to deal with “ignorance, superstition, unhealthy cultural patterns, and the rigidities and anxieties of parents, as well as with social conditions which foster the development of neuroses and maladjustments” [7].

Social psychiatry developed out of the work of these and other pioneers. Rennie wrote “Social psychiatry is etiological in its aim, but its point of attack is the whole social framework of contemporary living." The goals of social psychiatry were broad: “To include all social, biological, educational, and philosophical considerations which may come to empower psychiatry in its striving towards a society which functions with greater equilibrium and with fewer psychological casualties” [15]. The horrific events of the first and second World Wars had convinced many people that the individual could not be treated as separate from the society and that the society contributed greatly to mental disorders.

The principles of social psychiatry were summarized in six postulates:

Human behavior can only be understood in the context of the total social and other energies (including living and inert physical matter) of this universe.

A person should always be a subject and never an object of an interpersonal transaction.

There is meaningful interrelationship, a relativity, between the behaviors of one individual and all social and mythological institutions and groups.

Social problems, including individual, institutional and group deviant behaviors, cannot be solved without collaboration between all the institutions and disciplines of human knowledge, influence, and action.

Values of compassion, caring, and consideration for all human beings are essential to the operations of social psychiatry.

Human behavior acquires purpose and meaning in reference to and by virtue of adherence to these postulates [16].

Adherents of social psychiatry tried to place the patient and his or her symptoms within a total sociopolitical context “The mentally ill person is seen as a member of an oppressed group, a group deprived of adequate social solutions to the problem of individual growth and development” [17]. Other clinicians and theorists began to view each patient’s symptoms as an adaptive response to dysfunctional systems, most importantly the patient’s family. In 1969, one of the original family therapists, Don Jackson, said, “The important point here is that the behavior which is usually seen as symptomatic in terms of the individual can be seen as adaptive, even appropriate, in terms of the vital system within which the individual operates.” [18]. Recognition grew that deviant behavior was not just irrational, insane, animalistic, and inexplicable, but could be understood in a relational context. “Deviant behavior can be seen as a form of communication, but to elicit and understand what lies behind such behavior is a difficult and painful process” [15].

Around the same time, increasing numbers of critiques were published about the overall health - or lack thereof - of the entire society as well as an attempted redefinition of the role of the therapist in dealing with this sick society. From 1914 on, Trigant Burrow was convinced that sometime in the course of social evolution our primary unity was inadvertently distorted, and that subsequently we substituted an arbitrary standard called "normality." He believed that this maladaptation had become so extensively systematized that a social neurosis exists throughout the species [4].

In 1936, Lawrence K. Frank wrote: “Today we have so many deviations and maladjustments that the term ‘normal’ has lost almost all significance. Indeed, we see efforts being made to erect many of the previously considered abnormalities into cultural patterns for general social adoption. . . The disintegration of our traditional cultures, with the decay of those ideas, conceptions, and beliefs upon which our social individual lives were organized, brings us face to face with the problem of treating society, since individual therapy or punishment no longer has any value beyond mere alleviation of our symptoms ” [19].

The tumultuous 1960s, provided an opportunity for the reevaluation of psychiatry’s traditional role. The fundamental health of society was questioned. Given two world wars, , slavery, genocide, racial discrimination, discrimination against and abuse of women, child abuse and gross economic inequality, could our society be construed as healthy in any way? If someone whom we designate as mentally ill actually sees the contradictions and hypocrisy more clearly than we, can that person be truly considered mentally ill or are our definitions distorted by our own misperceptions? Should we be helping them “adjust” to a sick society, or should we be doing something to make the society less sick?

The Sanctuary Model In 1963 Eric Fromm wrote a book titled “The Sane Society,” in which he echoed and extended the thinking of Durkheim and presented a cogent argument for the essential sickness of what we call normal society [20]. In Pathways to Madness, written in 1965, Jules Henry wrote: “Under the proposition that ‘he was doomed by his upbringing’ we acquit all the institutions in our culture except the family of complicity in the destruction of the individual” [21].

Strident criticisms began after the war and continued through the 1970s of what had become mainstream psychiatry, particularly in the profession’s apparent willingness to support the status quo, even to the detriment of patients. Thomas J. Scheff wrote in Labeling Madness, “What I am suggesting is that researchers in the field of mental illness. . .are helping to further confound the moral issues by giving laymen the impression, however subtly or unintentionally, that there is absolute scientific justification for the prevailing American world view. . . It is our responsibility as scholars and students of human behavior to make visible the hidden moral values in psychiatry and mental health, so that they can be made the subject of research and open public discussion” [22].

Dr. Eugene Brody, M.D., in a 1973 book titled The Lost Ones, described the results of a study looking at the relationship between social forces and mental illness in Rio de Janeiro. He concluded: “Psychiatric symptoms and attitudes cannot be understood without reference to the social context in which they occur. . . The major dilemma for mental health professionals lies in the fact that primary prevention of mental handicaps and the assurance of overall community health is total. It involves the whole social system and is thus beyond his power as well as his expertise . . . There is no reason to believe that most mental health professionals have the interests or capacities which would allow them to become expert or to develop the political power necessary for effective action regarding most of these issues.” [23].

Out of these critiques, and the growing social activism of the 1960s, some psychiatric workers began more seriously addressing the issue of prevention. “Preventative psychiatry ” as defined by Caplan was both theoretical and practical - a public health approach. The traditional focus of psychiatry is on treating illnesses that are already well-established, or in simpler terms, fixing someone who is already broken. Caplan and his colleagues became interested in discovering ways to prevent mental illness from occurring in the first place - primary prevention, and to reduce the spreading damage of mental illness once it had already started - secondary prevention. Tertiary prevention would reduce the amount of impairment that would result from already existing mental disorder [24]. This focus on prevention led inevitably toward a movement to correct the environment forces that were so obviously contributing to mental and social illness.

Jerome Frank wrote in 1976, “anyone who takes the goal of prevention seriously is bound to recognize that it involves social reform. We go on trying to fix up damaged adults in one-to-one relationships when a more proper professional function would be to spend a considerable portion of our energies trying to fix up a society in ways that will increase the strength and stability of the family, thereby affecting positively the mental health of generations to come. . . for prevention people like ourselves would be needed as teachers, researchers and especially, as radical social activists, proselytizing for changes in our society to make it more supportive, less dehumanized” [25].

Excerpt from Sandra L. Bloom (1997) Creating Sanctuary: Toward the Evolution of Sane Societies. New York: Routledge.

References

Leighton, A.H., An Introduction to Social Psychiatry. 1960, Springfield, IL: Charles C. Thomas.

Alexander, F.G. and S.T. Selesnick, The History of Psychiatry. 1966.

White, W.A., Thoughts of a Psychiatrist on the War and After. 1919, New York: Paul B. Hoeber.

Burrow, T., Toward Social Sanity and Human Survival. 1984, New York: Horizon Press.

Burrow, T., The Social Basis of Consciousness: A Study in Organic Psychology Based Upon a Synthetic and Societal Concept of the Neuroses. 1927, New York: Harcourt, Brace & Company.

Burrow, T., Science and Man's Behavior: The Contribution of Phylobiology. 1953, New York: Philosophical Library, Inc.

Grob, G.N., From Asylum to Community: Mental Health Policy in Modern America. 1991, Princeton, NJ: Princeton University Press.

Portnoy, I., The School of Karen Horney. , in American Handbook of Psychiatry, Second Edition, Volume One: The Foundations of Psychiatry, S. Arieti, Editor. 1974, Basic Books: New York.

Moreno, J.L., Who Shall Survive: Foundations of Sociometry, Group Psychotherapy, and Sociodrama. 1953, Beacon, NY: Beacon House Inc.

Southard, E.E. and M.C. Jarrett, The Kingdom of Evils. 1922, New York: Macmillan.

Jones, M., The Therapeutic Community: A New Treatment Method in Psychiatry. 1953, New York: Basic Books.

Rees, J.R., The Shaping of Psychiatry By War. 1945, New York: W. W. Norton.

Menninger, W.C., Psychiatry and the war. Atlantic Monthly, 1945. 176: p. 107-114.

Herman, J., Trauma and Recovery. 1992, New York: Basic Books.

Jones, M., Beyond the Therapeutic Community: Social Learning and Social Psychiatry. 1968, New Haven, CT: Yale University Press.

Carleton, J.L. and U.R. Mahlendorf, Dimensions of Social Psychiatry. NOTES AVAILABLE ed. 1979, Princeton, NJ: Science Press.

Ullman, M., A unifying concept linking therapeutic and communit process., in General Systems Theory and Psychiatry. Boston, Little, Brown and Company., W. Gray, R.J. Duhl, and N.D. Rizzo, Editors. 1969, Little, Brown and Company: Boston.

Jackson, D., The individual and the larger contexts., in General Systems Theory and Psychiatry, W. Gray, F.J. Duhl, and N.D. Rizzo, Editors. 1969, Little, Brown and Company: Boston.

Sanford, N., Self & Society: Social Change and Individual Development. 1966, New York: Atherton Press.

Fromm, E., The Sane Society. 1956, London: Routledge and Kegan Paul.

Henry, J., Pathways to Madness. 1965, New York: Random House.

Scheff, T., ed. Labeling Madness. 1975, Prentice-Hall, Inc.: Englewood Cliffs, NJ.

Brody, E., The Lost Ones: Social Forces and Mental Illness in Rio de Janeiro. 1973, New York: International Universities Press, Inc.

Caplan, G., Principles of Preventive Psychiatry. 1964, New York: Basic Books.

Frank, J., New Therapeutic Roles., in Further Explorations in Social Psychiatry, B.H. Kaplan, R.N. wilson, and A.H. Leighton, Editors. 1976, Basic Books: New York.