RCPsych

Devolved psychiatries - Professor Rab Houston

In this podcast, Professor Houston talks about the psychological impact on those affected by the Aberfan disaster of 1966. The podcast expands on an interview Prof Houston gave to BBC Wales as part of a series of podcasts recently produced about the disaster. It is strongly advised that you listen to podcast 7 of the BBC series prior to listening to this podcast. https://www.bbc.co.uk/sounds/brand/p09z3n7y

Further reading:
https://www.nhs.uk/conditions/electroencephalogram/ 

Iain McLean and Martin Johnes, Aberfan: government and disasters (Cardiff: Welsh Academic Press, 2000), especially chapter 5.
Morgan, L., Scourfield, J., Williams, D., Jasper, A., & Lewis, G. (2003). The Aberfan disaster: 33-year follow-up of survivors. British Journal of Psychiatry, 182(6), 532-536. doi:10.1192/bjp.182.6.532

The 1966 Aberfan disaster

Today’s podcast outlines what makes psychiatry a distinctive medical discipline with a special image, primarily because it deals with something we cannot see - the mind. Its history too is distinctive and a combination of history and psychiatry allows us to delve deeply into all aspects of human life: mind and body, emotions and experiences, thoughts and moods, the self and others, lay and expert opinion, health and illness, science and society, normal and abnormal, liberty and compulsion. The podcast also offers some basic modern and historic definitions of mental disorders: conditions that for centuries were known generically as ‘madness’.

Image: Cover page of William Battie's Treatise on Madness. Courtesy of Wellcome Images. Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/

1.1 Psychiatry And Its Subject

This podcast is about what historians do and what they can bring to an understanding of mental medicine. I talk a little about myself, set out what you might expect from the series, and explain why I did these podcasts and for whom they are intended. The series is not just for historians or healthcare professionals, but for anyone interested in our minds, what can go wrong with them, and how we can help sufferers and those around them. Madness is fascinating because it takes us to the heart of being human and because it tells us much about both medicine and wider social attitudes.

1.2 An Historian’s Approach To Psychiatry The Aims Of The Series

In this block of podcasts I’m going to look again at the language used to describe mental problems, the ways lay and professional people identified them in the past, and the possible confusions that lie in wait for us in history, when both culture and the material world were very different from the present day. Nowadays we are faced with a sometimes bewildering array of mental conditions and syndromes. By contrast, medical classifications in the past were often remarkably basic. The spectrum of mental illness could be encompassed by just two words: mania and melancholy.

2.1 Melancholy And Mania The Main Classifications

One of the themes of these podcasts is that the boundaries between medicine and other disciplines in the past were much less clear cut than nowadays and the way knowledge was organised was also quite different. One of the most famous contributors is the seventeenth century French philosopher Renée Descartes and in today’s podcast I want to explain briefly his theory that the mind (what he called the ‘rational soul’) was distinct from the body.

2.2 Mind And Body

This week's podcast explores the ways in which mental illness has been identified and described.  The popular, vernacular, or 'street' vocabulary of mental dysfunction has always been remarkably rich, perhaps more so than the technical one prior to the twentieth century, including some words and phrases we may still recognize today.    

Image of the week: Two photographs of an idiot, St Bartholomew’s Hospital, c. 1895
Full Bibliographic Record: Wellcome Library Catalogue L0067002
Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/


2.3 Describing and identifying mental problems: lay and legal language

Early modern Europe saw an unprecedented craze for hunting, prosecuting, and executing witches, tens of thousands of whom were burned. It was widely believed witches could manipulate evil forces to do harm to people and property. Were the witches of the sixteenth and seventeenth century the mad people of the nineteenth and twentieth century? 

Image of the week: James VI, Daemonologie (1603 edition)
Full Bibliographic Record: Wellcome Library Catalogue L0078964
Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/


2.4 Madness, Witchcraft, And Religion

The theme for this section of podcasts is the shifting balance between organic or somatic causes and mental or psychological ones. As new discoveries were made, physicians, scientists, and others did not simply abandon existing theory, but looked for ways to reconcile innovations with what they already knew. Today’s podcast explores the processes behind a move away from a humoral balance theory of health towards nervous and neurological interpretations.

Image of the week: Mania: from Sir Charles Bell’s The anatomy and philosophy of expression as connected with the fine arts (1804)
Full Bibliographic Record: Wellcome Library Catalogue L0031760 
Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/


3.1 From Humours To Nerves

The nineteenth century in Britain belongs to materialist or somatogenic interpretations of the causes of mental problems, founded on scientific advances in physiology. Rather than mind and body, medical writers focused on the brain as the organ of the mind.  British specialists such as W. A. F. Browne, physician at Crichton Royal Institution, Dumfries, built on emerging pathological anatomy, to argue that mental problems were basically organic in origin. Some doctors claimed to be able to read skulls for tell-tale signs of the physical degeneration that accompanied behavioural abnormalities, and proposed that heredity, cerebral deformation, and bad upbringing created degenerates and defectives who were a menace to society.

Image of the week: Down syndrome child. Girl aged 3 months. 1898
Courtesy of Wellcome Images. Full Bibliographic Record: Wellcome Library Catalogue L0003077EB
Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/




3.2 Brain And Body

If the nineteenth century had been mostly about physiology and somatogenic interpretations of mental problems, the early twentieth century was the golden age of psychodynamic psychiatry.   Vienna-based physician Franz Anton Mesmer is usually credited with being the first to unlock the secrets of the psyche at the end of the eighteenth century.  Mesmer’s successors included Jean-Martin Charcot, who famously hypnotised hysterics at the Salpêtrière asylum in late nineteenth-century Paris, and early in his career Sigmund Freud worked with Charcot.  Freud’s influence has been enormous, though more in the German lands and the United States than elsewhere. Psychoanalysis was shunned in France and never widely accepted in Britain or Ireland, though Freud lived in London for a short time towards the end of his life.  He died in 1939 and his family home in Hampstead, north London is now a museum, complete with his famous consulting couch.

Image of the week: 
Freud’s consulting couch [copyright Freud Museum London] 



3.3 Freud And The Psyche

Physical treatments dominated sixteenth and seventeenth century mental healthcare. One important change was a greater role for psychological treatments or ‘moral therapy’ in the eighteenth-century. Moral therapy drew on the associational theory of the physician and philosopher John Locke, who argued that people were the product of their environment and upbringing. This profoundly optimistic approach to psychology meant that the mad, who had mis-associated ideas, could be brought back to sanity by a carefully constructed programme of re-education in an appropriate setting: what we now call psychotherapy.

Image of the week: William Hallaran’s spinning chair, 1810
Full Bibliographic Record: Wellcome Library Catalogue L0001487 
Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 creativecommons.org/licenses/by/4.0/

4.2 Moral Therapy And The Origins Of Psychological Treatment

Drugs are central to the ways modern clinicians handle mental disorders. But more or less consistently effective medicines for specific conditions are a very recent innovation. The new drugs of the 1950s and beyond promised to work on the underlying physical bases of specific disorders. The podcast looks at the emergence and use of anti-psychotic, anti-depressant, and mood-stabilising drugs. It ends by assessing the effectiveness of modern pharmacological treatments.

4.4 The Pharmacological Revolution

This is the first of two podcasts about the only public lunatic asylum in England for centuries: St Mary of Bethlehem Hospital in London, usually known as Bethlem. It symbolises the history of psychiatry. I want to look at the sort of image this institution had (and still has in the modern mind) and to assess if it is justified. I’ll explore what was special about Bethlem, whether it was typical of developing institutional provision, and what it really tells us about the way insanity was cared for in the past. This podcast asks: Was Bethlem a freak show? Was its administration chronically corrupt?

Image of the week: Cibber’s statues at Bethlem Hospital, 1680
Full Bibliographic Record: Wellcome Library Catalogue L0011832  
Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 creativecommons.org/licenses/by/4.0/

6.1 Bedlam Part 1 A Corrupt Freak Show

The last two podcasts have shown how mad people are different before the law. Psychiatry has certain legal privileges in how it handles patients. The implications of these two facts have stimulated debate for at least the last three centuries. I’d like to confront them this week and discuss the charge that psychiatry and the law conspire to oppress certain sections of the population. The podcast revisits some of the themes of anti-psychiatry and shows how they influence modern perceptions of the practice of mental medicine.

Image of the week: man in restraint chair, West Riding Lunatic Asylum, Wakefield, Yorkshire, c. 1869
Full Bibliographic Record: Wellcome Library Catalogue L0019069 
Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 creativecommons.org/licenses/by/4.0/

9.3 Doctor And Patient Anti - Psychiatry Revisited

This extract accompanies Podcast 10 A ‘silent madness’. Hugh Blair (1747)

IMAGE: James Robertson of Kincraigie; John Dhu (Dow, MacDonald); Jamie Duff by John Kay. Credit: National Portrait Gallery / Universal Images Group, Rights Managed / For Education Use Only

Voice credits: Matthew Lansdell (Intro: Oli Savage, Questions: Sebastian Bridges)

The Voice of the Madu

Extract 10.1 Hugh Blair

I have been asked by the Scotland Malawi Mental Health Project to prepare a short series of podcasts to act as a component of the training programme for psychiatrists at the College of Medicine in Malawi. Like much of the less developed world, Malawi has limited resources for specialist psychiatric care: the ratio of psychiatrists per head of population is less than 1% of that in Western Europe. The two series of podcasts already broadcast have been used to help train clinicians and nurses in Anglophone sub-Saharan Africa, including Malawi.
The practice of psychiatry in a colonial setting is surprisingly varied. Even within British colonies around the world, those who received psychiatric care, where they were treated, and to what ends was significantly different. Other European colonies were different again.
So colonial psychiatry, as practised between the 18th century and the 1940s, 1950s, and 1960s, is a rich and varied topic. I want to narrow it down. I’m going to stick to Anglophone southern and eastern Africa, between the 1880s and 1960s, because that covers the geographical and cultural area in which Malawi is located. Between 1891 and 1964, when it became independent, Malawi was the British Protectorate of Nyasaland.
Up to the middle of the nineteenth century the old world shared many of the characteristics we shall encounter in African colonies between the 1880s and 1960s. I’m going to set out 8 key similarities. I then explain what changed in Britain and Ireland over the last two centuries. Finally, I’ll summarise the distinctive experience of southern Africa under colonization, which I’ll explain in detail next time.

Image: Eket, Nigeria. Copyright Robin Hammond, Condemned, ( http://www.witnesschange.org )

Colonial psychiatry

Colonial Psychiatry 1 - What and where?: colonial psychiatry’s origins and characteristics

At the end of the last podcast I explained what was special about colonial psychiatry from the 1880s to the 1960s, compared with mental medicine in the United Kingdom. 
1)	Continuing medical pluralism
2)	Limited institutionalization of patients and professionalization of services
3)	Persistently low resources
4)	Attempts to introduce European-style practices of care
5)	Racism
Today I’m going to deal with the first three of these points.
An important theme in my podcasts on the history of psychiatry in the United Kingdom is the enduring importance of different ways of dealing with the mad, including religious healing and traditional talking therapies as well as formal or learned medicine. Medical pluralism meant that there was in effect a marketplace for therapies, chosen according to availability of practitioners, the cost of treatment, the nature of the condition, the person experiencing it, and the social context in which the illness had presented itself. Biomedicine gained dominance only in the nineteenth century. 
I then go on to explain how the care of insane people in institutions came very late to much of colonial Africa and psychiatry as a specialisation later still. Finally, I talk about the experience of white people who went mad, because it is an important counterpoint to race and racism, which will be the subject of next week’s third of the four podcasts in this mini-series.

Image: male patients, Zomba hospital courtyard, copyright Daniel Maissan, www.danielmaissan.nl

Colonial Psychiatry 2 - Colonial psychiatry over time and space

If you have listened to my series of podcasts on the history of psychiatry in Britain and Ireland you will know that psychiatric relationships are at least partly about power and about the assumptions medical practitioners made concerning those they treated. In the old world, class and sex were important differentiators. 
In a colonial setting there was an added dimension. Daniel H. Tuke, a British expert on insanity and visiting medical officer at England’s York Retreat, wrote in the Journal of Mental Science for 1857 that ‘the liability to mental disease is greater (other things being equal) in a civilized and thinking people, than in nomadic tribes’. So madness was the price Europeans paid for living in civilization, but transposed to a colonial setting it was the price Africans paid for encountering civilization.
Colonial psychiatrists worked to address fundamental issues of social anthropology: 
How did race affect mind and behaviour? 
Was it possible to change peoples and cultures? 
The answer was sadly predictable and the racist ideas I outline provided a rationale for maintaining colonial dependency because they seemed to prove that Africans were unsuited to governing themselves or interacting with the wider world. Their societies had both too many and too few restraints, making them inherently unstable.

Image: Juba Central Prison, Sudan, copyright PBS (Robin Hammond, Condemned)( www.witnesschange.org )

Colonial Psychiatry 3 - How and why?: Ethno-psychiatry and racism

In the first podcast of our new series, Professor Rab Houston is in conversation with Dr Miles Mack, Past chair of RCGP Scotland and a GP partner in Dingwall, Scotland. 

General Practice is the backbone of the British NHS and GPs provide a vital role in providing medical health care to patients registered to their practices. They provide continuity of care and a comprehensive approach, both in the first point of care and coordinating ongoing care for long term conditions. This podcast discusses their work in mental health, its relationship to physical well being and how they provide an interface with the hospital and specialist services in the wider health and care services.

Understanding Mental Health: conditions, caring, and contexts - Dr Miles Mack RCGP

Gerry Hastie trained between 1993-96, when nurse training programmes were changing from being delivered by the Local Health Authority to Higher Education. He has always been a mental health nurse and has worked in care home settings, long term in-patient care settings, acute admissions, addictions and the community.

In this podcast he illustrates his personal journey to doing what he does, and what it takes to be a mental health nurse, focusing on values and personal qualities; skills and different remits and the many roles taken on by nurses with patients, their families and colleagues. Nurses are simultaneously therapists, advocates, teachers and researchers who within their own training and skill set but whose work is essential with other professionals.  He offers a perspective on what makes nursing unique and how nurses complement the multi-disciplinary team.

Finally, Gerry tries to step outside and looks into his profession as an observer and use examples from clinical experience and popular culture to imagine what the public think mental health nurses do.

Understanding Mental Health: conditions, caring, and contexts - Mental Health Nursing, Gerry Hastie

In this podcast, Professor Rab Houston speaks to Alexander Baldacchino, Professor of Medicine, Psychiatry and Addictions, University of St Andrews and Clinical Lead and Consultant in Addiction Psychiatry with NHS Fife.  This podcast will hopefully provide the right incentive for listeners to understand better the finer details pertinent to the topic of substance misuse disorder and dependence. Listeners will be taken through some of the relevant historical, clinical, epidemiological, humanistic and other cross cutting themes to allow a more positive formulation of what the problems caused or as a consequences of substance misuse can be crystallised without stigmatising the individual or population involved. The interview explores understandings and misunderstandings of substance misuse, and the possibilities for helping misusers against a background of rapid changes in society, medical provision, and the proliferation of substances.

Understanding Mental Health: conditions, caring, and contexts - Prof. Alex Baldacchino

Symptoms of schizophrenia develop in more than 1:200 people, in all cultures, while 2- 4% of the population may experience major depression at some time in their life. Mild and moderate depression are, of course, much more common. Sometimes illnesses run in families and show higher concordance among identical compared to non-identical twins suggesting an important genetic contribution to risk. Molecular genetics now gives us the tools to analyse genetic risk using DNA samples donated by people with schizophrenia, bipolar disorder, depression, autism, attention deficit, obsessive-compulsive disorder, anxiety, anorexia, substance use and post-traumatic stress. These disorders are the focus of ongoing international collaborations performing genome -wide association studies. Results to date are remarkable. Genes have been found that contribute to these illnesses and it is hoped this new knowledge could lead to novel drug targets and new preventative interventions. The use of advanced techniques such as gene editing and improved possibilities for accurate prenatal testing are raising important ethical questions that require informed public discussion and debate.

Understanding Mental Health: conditions, caring, and contexts - Prof Douglas Blackwood

In the podcast I talk about my research on the biological basis of schizophrenia using brain imaging and my attempts to understand symptoms such as hallucinations in terms of brain based cognitive processes. I describe what schizophrenia is like from the point of view of clinicians and from the point of view of patients. I suggest that the experiences described by patients in history are very similar to those described today.  Finally, I discuss treatments. There has been much improvement since the discovery of drug treatments in the 1950s, but we still have not identified the causes of schizophrenia and, for the majority of patients, life remains very hard.

Chris Frith is Emeritus professor of Neuropsychology and the Wellcome Centre for Human Neuroimaging at UCL and Honorary Research Fellow at the Institute of Philosophy.

Understanding Mental Health: conditions, caring, and contexts - Prof. Chris Frith

Social workers and care in the community

Social workers have a crucial part to play in improving mental health services and mental health outcomes for citizens. They bring a distinctive social and rights-based perspective to their work. Their advanced relationship-based skills, and their focus on personalisation and recovery, can support people to make positive, self-directed change. Social workers are trained to work in partnership with people using services, their families and carers, to optimise involvement and collaborative solutions. Like community psychiatric nurses, social workers also manage some of the most challenging and complex risks for individuals and society, and take decisions with and on behalf of people within complicated legal frameworks, balancing and protecting the rights of different parties. This includes, but is not limited to, their vital role as the core of the Approved Mental Health Professional (AMHP) workforce. Social workers are central to the holistic, individualised treatment available to sufferers from mental disorders, which epitomises the goals of modern healthcare provision.
Dr Ruth Allen, Chief Executive, British Association of Social Workers

Understanding Mental Health: conditions, caring, and contexts - Dr Ruth Allen

People with learning disability were understood and treated very differently in the past from the present. While attempts were always made to help them, this was against a background of pessimism about their prospects. Much progress has been made in the past half century in positive attitudes towards this group, with closures of the large institutions in which they were often housed and better integration into the community. Nonetheless, challenges remain, including a significantly shorter life expectancy compared with the general population. Dr Fionnuala Williams clarifies misconceptions and enlightens listeners on the definition, causes, and treatments relevant to this diverse population group, where communication is key.

Understanding Mental Health: conditions, caring, and contexts - Dr Fionnuala Williams

Chief Inspector Michael Brown: ‘Police, policing, and mental health in the UK’.

Police services all over the world are essential as a de facto mental health service, especially around crisis care. All have struggled with untoward incidents involving the use of force, or deaths following police contact, which have framed – perhaps distorted - discussion. Reviews of these incidents have concluded that police officers are usually working in a context where the professional options available to them are not always adequate and that support after police decision-making is not always available. Reviews have also emphasized the need to improve police training and awareness of mental health, without necessarily specifying what that means and without taking account of contributory problems in healthcare provision by other agencies. Better police training and awareness of the mental health issues they face professionally is essential, but not sufficient. Many of the people the police encounter, where mental health is a factor in the incident, are known to have a history of mental health problems and have often been service users previously. The challenge is twofold – to reduce reliance upon the police service (and criminal justice system, including the prison service) to the extent we can; and to improve the quality of the police response where it is necessary for officers to become involved.

Understanding Mental Health: conditions, caring, and contexts - Michael Brown

In this podcast Professor Chris Williams, a researcher and teacher in the area of cognitive behavioural therapy (CBT) introduces CBT as a self-help form of therapy. It gives people the tools help themselves. Although correctly described as a form of psychotherapy, another way of conceptualising CBT is as a form of adult learning. That perspective can help make sense of recent advances in CBT where key CBT principles are communicated via CBT books, classes or websites. The key elements are a CBT structure that then builds on the therapeutic relationship and helps people both understand why they feel as they do, and also learn new skills to make changes. CBT provides a structure of how to make these changes in a planned and evidence-based way. However it also requires and effective and supportive therapeutic relationship to encourage people to keep on track as they plan changes in their lives. It is on this balance of structure and relationship that CBT aims to help achieve change.

Understanding Mental Health: conditions, caring, and contexts - Chris Williams

Professor Rory O’Connor, Suicidal Behaviour Research Laboratory, University of Glasgow

Suicide and self-harm are major public health concerns with complex aetiologies which encompass a multifaceted array of risk and protective factors.  There is growing recognition that we need to move beyond psychiatric categories to further our understanding of the pathways to both. As an individual makes a decision to take their own life, an appreciation of the psychology of the suicidal mind is central to suicide prevention.  Another key challenge is that our understanding of the factors that determine behavioural enaction (i.e., which individuals with suicidal thoughts will act on these thoughts) is limited.  Although a comprehensive understanding of these determinants of suicidality requires an appreciation of biological, psychological and social perspectives, the focus in this podcast is primarily on the psychosocial determinants of self-harm and suicide. To this end, The Integrated Motivational–Volitional (IMV) Model of Suicidal Behaviour (O’Connor & Kirtley, 2018; O’Connor, 2011) is discussed; it provides a framework in which to understand suicide and self-harm.  This tripartite model maps the relationship between background factors and trigger events, and the development of suicidal ideation/intent through to suicidal behaviour.  

In this podcast, we talk about a range of different topics including: 

•	The epidemiological context. Suicide rates.
•	The myths around suicide and self-harm
•	The determinants of suicide and self-harm
•	The IMV model of suicidal behaviour
•	The implications for the prevention of suicide 

References

O'Connor, R.C., Kirtley, O.J. (2018). The Integrated Motivational-Volitional Model of Suicidal Behaviour. Philosophical Transactions of the Royal Society B. 373: 20170268.

Steve Platt's work on inequalities and suicidal behaviour https://onlinelibrary.wiley.com/doi/abs/10.1002/9781118903223.ch15

www.suicideresearch.info

Understanding Mental Health: conditions, caring, and contexts - Professor Rory O'Connor

This is a 50 minute audio file of a talk I delivered at the National Records of Scotland on 7 August 2019, in connection with my hugely successful exhibition that they kindly hosted: ‘Prisoners or Patients? Criminal Insanity in Victorian Scotland’. It explains the records I used and the development of the criminal justice system’s attempts to deal with those who had committed serious offences, but were found to be insane and thus not responsible for their actions. The justice system faced the same problems as today and dealt with ‘prisoner-patients’ or ‘state lunatics’ (as they were known) in a remarkably humane fashion, given the constraints of limited resources, basic medicine, and different social attitudes 150 years ago. The talk explains in depth who the offenders were and what they had done, the processes for admission to, and release from the only such specialist facility in Scotland prior to the opening of The State Hospital at Carstairs in 1948, medical and scientific understandings of insanity, and the social context of Victorian Scotland.

Prisoners or Patients? Criminal Insanity in Victorian Scotland

Prof John Crichton - Consultant Forensic Psychiatrist and 
Chair of the Royal College of Psychiatrists in Scotland.

What is a forensic psychiatrist?  Far from the media stereotypes forensic psychiatrists are not so different to other doctors but working at the most extremes of human experience.  Any one of us may have a mental health problem.  Very rarely that problem may result in an inability to control ones actions and may lead to direful consequences.  Forensic psychiatry is all about helping people recover their lives after such life changing events and by placing the care and treatment of patient at the centre ensuring everyone’s safety.

Professor Rab Houston

Understanding Mental Health: conditions, caring, and contexts - Professor John Crichton

Rab Houston was born in Hamilton, Scotland, lived in India and Ghana and was educated at the Edinburgh Academy and St Andrews University before spending six years at Cambridge University as a research student (Peterhouse) and research fellow (Clare College). He has worked at the University of St Andrews since 1983 and is Professor of Modern History, specialising in British social history. He is a fellow of both the Royal Historical Society and the Royal Society of Edinburgh (Scotland’s national academy), and a member of the Academia Europaea. He is married to a senior university manager and lives in Edinburgh. In his spare time he likes any form of active meditation.
http://www.st-andrews.ac.uk/history/staff/rabhouston.html
https://arts.st-andrews.ac.uk/psychhist/

History of Psychiatry Podcast Series

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