Abstract
This study explores the movement called social psychiatry in the USA, and how it went from being the driving force within mental health policy to being largely forgotten. First, the book presents the context of its emergence, then it focuses on four epidemiological surveys that became iconic within the movement, before concluding with its regression.
Social psychiatry endorsed the general assumption that it is easier to prevent mental disorders than to treat them, a mantra still favoured in today’s mental health practices. Influenced at the turn of the century by the works of Emile Durkheim and Georg Simmel, sociologists had started to explore the connections between socially problematic behaviours and socio-economic factors, soon followed by anthropological essays on the variations of disorders and treatment across cultures. After two decades, these works started attracting attention among psychiatrists, leading to the creation in 1927 of a joint committee by the American Psychiatric Association and the American Sociological Society. The growing interest for prevention was then fed by two movements: mental hygiene and child guidance. The first led to the creation of large medical surveys outside hospitals, focusing on social problems such as alcoholism, prostitution and juvenile delinquency. Until the 1940s, the mental hygiene movement developed connections with eugenicists, supporting policies of sterilisation in several states. Starting in the first decade of the century, the child guidance movement was strongly influenced by psychoanalysis. It too added a strong moral connotation to its exploration of the relations between child behaviour and family characteristics, with a limited ability to describe structural issues at stake (such as poverty, migration or housing). The goal of prevention led to the creation of new occupations: psychologists and psychiatric social workers. Mostly composed of women, these new professional groups contrasted, and were in tension, with psychiatrists, most of whom were men who focused on a classical therapeutic activity.
World War II seemed to be a turning point in the combining of these movements into social psychiatry, which soon became influential. During the war, psychiatric knowledge was called to the rescue in the management of large military populations. Psychiatrists then worked on tools for screening the unfit among draftees. They also implemented new therapeutic measures for trauma (shell shock) performed by first-line respondents who were neither doctors nor nurses. Then, while discovering the extent of Nazi horrors, public opinion as well as professionals became increasingly critical of eugenics, favouring a shift of focus onto the milieu rather than onto the individual. These elements offered psychiatrists the opportunity to extend their jurisdiction beyond the walls of the asylums, but also made them more reluctant to share it with non-psychiatrists.
In the following two decades, large epidemiological surveys exemplified the influence, if not hegemony, of social psychiatry. The creation of the National Institute of Mental Health (NIMH) in 1949 is emblematic of this trend. Matthew Smith offers here a detailed account of four of them: the survey on Chicago psychiatric hospital admissions by Robert E.L. Faris and H. Warren Dunham; the research on class and mental illness conducted in New Haven, Connecticut, by August B. Hollingshead and Frederick C. Redlich; the notorious Midtown Manhattan Study, initiated by Thomas A.C. Rennie; and the Stirling County Study by Dorothea and Alexander Leighton. This work gathered a vast body of evidence connecting mental disorders and socio-economic factors. It also contributed to new federal legislation such at the Community Mental Health Act of 1963, sustaining an optimistic view of so-called de-institutionalisation.
The last section of the book focuses on the disappearance of social psychiatry after the 1970s. While the actual war in Vietnam diverted resources, the metaphorical war on poverty, launched by President Johnson, had signalled a refocus on improving individuals rather than questioning social structures. Against this backdrop, the voice of social psychiatry became less and less audible. As Smith insightfully points out, it had also been muted by its inner contradictions. Social psychiatrists, who were ‘at the top of mental health care hierarchy and among the upper echelons of American society’ (p. 11 in e-book), had grown discomforted and became mostly quiet about the structural issues of social justice highlighted by their works, not to mention the effects of contemporary McCarthyism on this topic. In the 1980s and 1990s, the rise of psychopharmacology and its convergence with neoliberal health and social policies placed a nail in social psychiatry’s coffin, sweeping aside interest in the social determinants of mental health. As Smith puts it, the recurrence of a ‘rise-and-decline narrative’ in psychiatry points to the need for interdisciplinary and pluralistic research on mental disorders and their treatment.
The book concludes with a political lesson for the present. Rather than rediscovering the well-documented connections between mental health and social, cultural and economic adversity, Smith advocates for a universal basic income. Based on his history, he argues that such a social protection would represent a more complete articulation between the vast body of social psychiatric evidence and effective prevention policy. It would also neutralise the lasting effects of culturalist views on poverty with its insidious and pervasive moral judgement about administrating welfare.
This book is highly accessible for a lay reader, written in a lively style and sporadically illustrated by visual documents; well-balanced and very clear in its structure, the book is a solid addition to the history of contemporary psychiatry. Smith relies on existing research about the roots and aftermath of social psychiatry. He also gathered a corpus of published and unpublished writings, letters and interviews, and refers to the original, first-hand documents produced by the actors involved in the four epidemiological studies that he describes. The book contributes to a history of mental health practices and of psychiatric knowledge with a vantage point that does not primarily stand inside the asylum. It certainly calls for further historical and ethnographic research on the complex notion of de-institutionalisation.