“The Revolving Door”: From the Asylum to the Community and Back – Community Psychiatry, Part I

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SECOND THOUGHTS

A Walk on the Grounds of an Asylum with a Marxist Psychiatrist

Summer 1974. Hamilton Psychiatric Hospital (HPH). During the summer break of my studies in psychology at McGill University in Montreal, I was conducting a survey to catalogue the health and social services in my hometown of Hamilton, Ontario. We were looking at the annual report of the HPH and the numbers did not seem to make sense. My supervisor called it “the revolving door”—patients in, patients out, with no drop in numbers over time. What were the benefits? What were the costs?

I met Marcel Lemieux, MD, the Medical Director of HPH¹ who started going over the statistics with me, then stopped abruptly to announce, “I cannot answer your questions sitting in this chair, representing the hospital and the university. Let’s go for a walk.” Dr Lemieux invited me to a walk on the extensive grounds of the hospital that included an arboretum with a gazebo surrounded by well-tended vegetable gardens and flowerbeds. HPH was a classic “funny farm,” located as was the custom at the edge of the city. After a walk around the gardens, we sat in the gazebo and had a conversation that opened doors and puzzled me ever since.

Dr Lemieux told me that he had spearheaded the deinstitutionalization movement in Quebec where I was training in psychology and that he held a Marxist critique of psychiatry but could not express it as medical director of HPH. I asked what it meant to be a Marxist and to be critical of psychiatry. First, he talked about the history of psychiatry and recommended that I read Madness and Civilization by Michel Foucault, whom he had met in Montreal in 1973, just as I started my studies at McGill.² He talked about unusual people as exceptional people.

Coming from an immigrant working class family, I asked—and still wonder—if the world was only for exceptional people. His reply was unforgettable, “The world is for people who strive to be exceptional.” How does that relate to psychiatry? I wondered. Psychiatric patients, he explained, are people who are exceptional in their own way. And Marxism? Marxism makes space for such people. Here? I asked. Here for now, in the community eventually, he elaborated.

And yet, looking back after 50 years, he kept his position in the asylum. Many patients were moved out of HPH and the treatment was taken up by the network of psychiatric services in Hamilton’s general hospitals with the establishment of the academic department of psychiatry at McMaster University founded by Nathan Epstein, MD, a Canadian psychiatrist-family therapist who had trained with Nathan Ackerman, MD, in New York, a pioneer in family therapy. Family therapy flourished and fewer patients were hospitalized; community services also grew but as part of a hierarchical pyramid of services, always with recourse to hospital emergency departments and inpatient beds in general hospitals. And the revolving door, if anything, was busier than ever.

I spent that summer immersed in Michel Foucault’s revolutionary and now-classic text, Madness and Civilization,² the first of his works to be available in English. Fifty years later, I have worked through many rereadings and reevaluations of Foucault’s work, including my doctoral dissertation after taking the Foucault seminar with his last research assistant at Berkeley, American artist-philosopher Thomas Zummer. More on that in a later column on Foucault’s legacy for psychiatry.

Community Psychiatry

This was my introduction to the promise of community psychiatry. It had roots in many places, from my native Italy, where psychiatrist Franco Basaglia, MD, joined the Radical Party to close Italy’s asylums³ to the antipsychiatry and deinstitutionalization movements which followed, especially in Britain, Canada, and the US. In other words, first psychiatry had to be disqualified (via antipsychiatry) before its methods could be criticized and refuted (via deinstitutionalization). These included biological treatments (first ECT, then psychopharmacology) and long-term hospitalization. This has now morphed into a third critique: decolonization, based on Martinican psychiatrist Frantz Fanon, MD’s radical critique of psychiatry (via diversity, equity, and inclusion).⁴

Community psychiatry was a 2-stroke engine. One stroke was down—closing psychiatric hospitals down, pushing patients out. This was called deinstitutionalization. The other stroke was up—up and away, into the community, creating space for patients there, as Dr Lemieux envisaged it. This was called community psychiatry and mental health.⁵ Closing long-term hospital beds was difficult but easier to achieve in time than creating new services in the community which was supported by the hopeful ideology of social psychiatry and welcomed by governments across the political spectrum with a “feel-good” message as a cover for significant cost savings. With some exceptions, the communities themselves reacted to group homes for deinstitutionalized psychiatric patients with the cynical NIMBY (“not in my back yard”) resistance.

Metaphorically, we can say that this engine ran out of gas. Government funding for community and social programs dried up, everywhere, in favor of privately-funded health and social care services. At the same time, the internal combustion engine itself is being replaced by electric vehicles. We are now in both realms, in an era of the hybrid—running on gasoline and on electricity. We still have combustion engines and we still have psychiatric hospitals. Community psychiatry stalled and the sale of electric vehicles is also stalling.

Back to the Asylum

Previously, I referred to the popular conception in my youth of psychiatric hospitals as “funny farms.” This has a long and respectable history—going back to the notion of “moral treatment” in Britain and the “calming of nerves” in bucolic settings.⁶ Yet, I find this figure of speech about nervousness, which exists in all European languages, mildly annoying and smacks of the worst aspects of 19th century thinking in neurology and psychiatry about degeneration, which had both genetic and neurological aspects. American psychologist William James, MD, criticized it for expressing a reductive “medical materialism.”

With his lengthy volume Entartung (1892, “degeneration” in German), Max Nordau was the most widely read popular science writer in the late 19th and early 20th centuries, influenced by Cesare Lombroso’s criminal anthropology (“atavism” and “the born criminal”) and eugenics in the Anglo-American world. Suffice it to say that Entartung was an attack on Entartate Kunst (“degenerate art”), taken up with alacrity by the Nazis. Ironically, Nordau who was an agnostic Hungarian Jew and cofounder of Zionism, found his ideas pointedly used against “non-German” influences including his fellow Jews.

Back to the “funny farm.” Two kinds of hospitals had this philosophy. First, tuberculosis (TB) hospitals, like the Chedoke “Sanatorium” in Hamilton, a former TB hospital, and indeed the name of the bus route I used to take to go to medical school from our house on “The Mountain” near the Sanatorium or Chedoke Hospital. Second, psychiatric hospitals, asylums in the 19th century, built on large plots of land where buildings were well spaced-out, with gardens and literally acres of farmland for a kind of bucolic occupational therapy. That is where the name funny farm comes from.

As it happens, I trained and worked in psychology and psychiatry at some of the world’s most famous psychiatric institutions that started as asylums—from the Bethlem Royal Hospital, the world’s oldest asylum (founded in 1247) in London, UK, and Harvard’s McLean Hospital (founded in 1811) in Belmont, MA, to the Asile Saint-Jean-de-Dieu (founded in 1873), the oldest asylum in Quebec, celebrating our 150th anniversary with a new name, the Montreal University Institute of Mental Health.

Ironically, I became a community child psychiatrist just as that movement had passed its apogee. The places where I trained straddled that paradox and my career was framed by it. I call it the logic of the institution. Eminent Canadian sociologist Erving Goffman documented its meaning and impact in his incisive study, Asylums, which he characterized as “total institutions.”⁷ Austrian novelist Thomas Bernhard rendered it mordantly in his fictional autobiography, Wittgenstein’s Nephew.⁸ Bernhard uses his critique of the psychiatric hospital as a mirror of the vanity and emptiness of Viennese society. Neither psychiatry nor mental health more generally can escape that logic.

Taking Stock of the Community in Social Psychiatry

Of the 3 branches of social psychiatry (see “Social Psychiatry Comes of Age”), epidemiology and populational studies are solid and compelling as our basic science (see “The Social Determinants of Health—Social Psychiatry’s Basic Science”), and relational therapies (couple, family, and community therapies; see column “‘The Web of Meaning’: Family Therapy is Social Psychiatry’s Therapeutic Branch”) are the most significant, well-established and thriving of social psychiatry’s interventions. Accordingly, I see relational therapy as interventional social psychiatry (analogous to interventional anesthesia or radiology).

There is a historic connection between community psychiatry and family therapy as the first and most successful of the relational therapies and those of us who are family therapists and social psychiatrists are still committed to the community. Yet the movement as such has faltered.⁹

In Lemieux’s account, written just a few years after our meeting, he wrote that community psychiatry had created hopes of eliminating the asylum and the potential for prevention, tempered by failure¹⁰:

But the 1970's brought disillusionment. The rate of psychotic disorder remains unchanged, the cost-benefit of the program is less than had been anticipated and, in addition, the community approach has transplanted the asylum to the city thus creating a new immigrant—the psychotic individual.

I identified decreased public funding as a major cause for this but there may be a deeper and unresolved—perhaps unresolvable—issue. That is this: in spite of the “therapy wars” of the 1980s and 1990s where family therapy was jockeying for position and influence among individual and group therapies, all therapies have their followers in one form or another in the psy disciplines. But the psy disciplines, including social psychiatry, have much greater resistance to a nonclinical vision of psychiatry.

Criticize the medical model? Check! Criticize biological treatments? Check! Or criticize the dominance of psychodynamic psychotherapy and psychiatry? That was the animus behind DSM-III. Integrate the social determinants of health (SDH),¹¹ along with the powerful data of the adverse childhood experiences (ACE)¹² studies into social psychiatry? Absolutely! But abandon the clinical model altogether for community action? Very doubtful! While nonmedical clinicians may criticize the “medical model” as limited or reductionistic, only the social sciences and the humanities would argue to leave the clinical encounter altogether.

Two Kinds of Communities: The Clinical and the Cultural

Psychiatrists meet colleagues of both types. At meetings of mainstream professional groups, from family therapy to psychoanalysis and in psychology, psychiatry, or social work associations, we have productive exchanges with colleagues committed to practice, research, and teach clinical work. At other meetings, organized around cultural, political, or social aspects of our work, we listen to anthropologists, sociologists, and other social scientists, along with historians, philosophers, theologians, and other humanists. I go to many meetings of both types and have published with scholars in all these domains.

And yet, it is surprising, even shocking to my clinical colleagues to realize that social scientists and humanists read the same literature we do but use it to mount very different arguments. These are not only critical of psychiatry, but question the very basis for and the validity of clinical interventions. This is crucial. After training in the Harvard Program in Refugee Trauma, I decided to investigate the historical and philosophical foundations of trauma in my doctoral research and concluded that there are 2 trauma communities with radically different agendas: the clinical and the cultural trauma communities.¹³ Clinicians are only minimally aware of this chasm because we do not read the cultural community closely. Cultural scholars, on the other hand, are very aware of this chasm since they promote it by discounting the clinical manifestations of mental, relational, and social suffering. As a critical psychiatrist,¹⁴ I find the cultural community of humanist and social scientific accounts very appealing until I put them to the test in my clinical work. Invoking Freud’s model of repression, we may call this “the return of the repressed.”

So we are at a crossroads and perhaps an impasse. Across all the psy disciplines, there is a commitment to making a clinical difference with patients, clients, stakeholders, families, communities, and social groups. This may not always be shared by social scientists and humanists who privilege such poignant and powerful empathic strategies as witnessing, documenting, acknowledging, honoring, recognizing, and validating complex human predicaments like trauma as intrinsic values without recourse to clinical interventions.

I have experienced this chasm as a social psychiatrist. Among the members of my informal network of leaders in social psychiatry, there is some tension between researchers and clinicians (the usual suspects) but a much more intense one between social psychiatrists who are committed to clinical interventions including relational therapies and those who promote community approaches, which privilege public mental health and epidemiology, including the robust findings of the SDH and ACE studies, aimed at primary prevention.

Demonstrating the effectiveness of primary prevention through a community health approach is complex and costly as it requires resource-intensive long-term commitments which are not amenable to the 4-year cycle of democratic elections. As a result, as things stand, 2 of the 3 branches of social psychiatry are alive and well and increasingly integrated. The appeal of community-based social psychiatry persists but the challenge of who will conduct what kinds of practices in the community with which social and funding support is a serious challenge.

As my columns in this series hope to show, I am a community-based child and family psychiatrist with a social philosophy. The task I have set for myself as President of the World Association of Social Psychiatry (WASP) is to redefine the “terms of the social” and translate the powerful data and insights of the SDH down to the ground level in both clinical and community work.

Resources

• Smith M. The First Resort: The History of Social Psychiatry in the United States. Columbia University Press; 2023.
• Deinstitutionalization. Wikipedia. Accessed July 21, 2024. https://en.wikipedia.org/w/index.php?title=Deinstitutionalisation&oldid=1232286946

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addiction medicine at the University of Montreal and President of the World Association of Social Psychiatry (WASP). He has been recognized with numerous national and international awards, honorary professorships, and fellowships, and was recently elected a Fellow of the Canadian Academy of Health Sciences and given the Distinguished Service Award of the American Psychiatric Association. Dr Di Nicola’s work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s writing includes: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011, winner of a prize from the Quebec Psychiatric Association), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021); and, in the arts, his “Slow Thought Manifesto” (Aeon Magazine, 2018) and Two Kinds of People: Poems from Mile End (Delere Press, 2023, nominated for The Pushcart Prize).

Acknowledgements

I wish to thank Gary Chaimowitz, MD, Head of the Division of Forensic Psychiatry at McMaster University, for discussions about his senior colleague Marcel Lemieux, MD and the evolution of psychiatric services at my medical alma mater in Hamilton, ON. Dedicated to Dr. Marcel Lemieux (1930-2020) who introduced me to the work of Michel Foucault and the paradoxes of antipsychiatry and deinstitutionalization.

References

1. Lemieux M. Chapter 7. Reflections – Dr. Marcel Lemieux. In: Deadman J, ed. Moving Out of the Shadows: A History of Forensic Psychiatry in Hamilton. St. Joseph’s Healthcare; 2016:63-68.
2. Foucault M. Madness and Civilization: A History of Insanity in the Age of Reason. Vintage; 1973.
3. Basaglia F. Psychiatry Inside Out: Selected Writings of Franco Basaglia. Scheper-Hughes N, Lovell AM, eds. Columbia University Press; 1987.
4. Fanon F. The Wretched of the Earth. Farrington C, trans. Grove Press; 1963.
5. Smith M. The First Resort: The History of Social Psychiatry in the United States. Columbia University Press; 2023.
6. Stone MH. Healing the Mind: A History of Psychiatry from Antiquity to the Present. W.W. Norton & Co; 1997.
7. Goffman E. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Anchor Books; 1961.
8. Bernhard T. Wittgenstein’s Nephew. McLintock D, trans. Alfred A. Knopf; 1989.
9. Di Nicola V. Luminaries in Social Psychiatry—A Relational Dialogue with Maurizio Andolfi: Master Family Therapist and Social Psychiatrist. Special Issue on “Families, Family Interventions and Social Psychiatry.” World Social Psychiatry. 2024, 6(1):6-13.
10. Lemieux M. Prévention et chronicité en psychiatrie communautaire [Prevention and chronicity in community psychiatry]. Santé Mentale au Québec, 1977;2(2):67-74.
11. CSDH. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health Final Report of the Commission on Social Determinants of Health. World Health Organization; 2008.
12. Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: implications for health care. In: Lanius RA, Vermette E, Pain C, eds. The Impact of Early Trauma on Health and Disease: The Hidden Epidemic. Cambridge University Press; 2010:77-87.
13. Di Nicola V. Two trauma communities: A philosophical archaeology of cultural and clinical trauma theories. In: Capretto PT, Boynton E, eds. Trauma and Transcendence: Limits in Theory and Prospects in Thinking. Fordham University Press; 2018:17-52.
14. Di Nicola V, Stoyanov DS. Psychiatry in Crisis: At the Crossroads of Social Science, the Humanities, and Neuroscience. Springer Nature; 2021.