SUMMARY
This chapter is an overview of the history of social psychiatry across the world and is divided into developments in the field in 18th–19th century, genesis of the discipline in early 20,th century, developments following the Second World War, formal recognition of the discipline around mid-twentieth century, decline following developments in biological psychiatry, and then re-emergence of social psychiatry. Authors have attempted to cover the global trends, both in the high income as well as the low and middle-income countries. Recognition of mental and substance use disorders as a major contributor to the global burden of disease and failure of biological research to come out with any breakthroughs in treatment have led to a focus on social psychiatry, which was being ignored in recent past. Social psychiatry appears to have a bright future in contemporary psychiatry.
INTRODUCTION
Before going into the history of social psychiatry, it is important to discuss the scope of social psychiatry. In simple words, it could be conceptualized as the subspecialty of psychiatry which deals with the social aspects of the discipline, i.e., role of social factors in genesis, clinical presentation, and treatment of mental disorders (Chadda, 2014). The scope can be further expanded, ranging from the impact of social structures and experiences on onset, course, and outcome of mental disorders to development of appropriate social interventions and service delivery. Julian Leff (2010) describes social psychiatry as a discipline, concerned with the effects of the social environment on the mental health of the individual, and the effects of the mentally ill person on his/her social environment. Social psychiatry has close linkages with the community psychiatry and other social sciences like sociology, social psychology, and social anthropology.
The discipline of social psychiatry has gone through many ups and downs, since the time it was first recognized over 100 years ago, and its importance is being further reinvented from the beginning of the twenty-first century due to the inability of the biological psychiatry to come out with any substantial discoveries after the initial successes.
This chapter is an attempt to trace the history of social psychiatry from beginning to the current period. Authors do not claim to include every aspect of the history since social psychiatry is a vast area.4
GENESIS OF THE SPECIALTY
Genesis of social psychiatry can be informally traced back to the late 17th and early 18th century, the period of reforms in the mental asylums like unchaining of the mentally ill, initiated by Vincenzo Chiarugi in Italy, William Tuke in England and Phillippe Pinel in France (Coip, 2009). In the mid-eighteenth century, many developments in psychiatry in Europe and the US were social in nature, important examples being moral treatment and obligation of the state to care for people in need. York Retreat in the UK, established by William Tuke, was one of the most renowned moral treatment asylums in the world. If we talk of South Asia and other continents across the world, persons with mental illness were mostly cared by the families in the community, since formal treatment facilities for mental illness did not exist.
Importance of close linkages between social factors and mental health started getting recognized by the beginning of the twentieth century, following declining standards of care in the mental asylums with the asylums becoming custodial institutions rather than practicing the therapeutic idea of moral treatment. The book A Mind That Found Itself published by Clifford Beers in 1908 about the bad treatment he had received as a mental patient in three asylums, brought important developments in social psychiatry in early twentieth century. Beers founded the National Committee for Mental Hygiene, and thus began the mental hygiene movement, which aimed at controlling and preventing mental disorders. This could be termed as one of the initial formal development in social psychiatry (Leff, 2010). Some of the classic epidemiological studies conducted during mid-twentieth century like Midtown Manhattan study (Srole et al., 1962), Stirling County study (Leighton et al., 1963), and social class and mental illness (Hollingshead & Redlich, 1958), are classical examples of social influences on mental disorders, explaining the complexities of the relationship between social class and mental illness. The finding of high prevalence of schizophrenia as reported by Hollingshead and Redlich in the deprived areas of the city of Chicago has been replicated by a number of researchers in similar locations across the world. Social causation hypothesis, which is based on the role of social factors in the causation of schizophrenia, and social drift hypothesis explaining the effect of illness on the social mobility, are based on the above mentioned historical epidemiological works on social class and schizophrenia. It is now well established that social adversities are associated with higher risk to develop mental illnesses. Contribution of sociological factors in personality development was later well stated in the personality theories by Erik Erikson, Harry Stack Sullivan and Karen Horney, given around the mid-twentieth century (Chadda, 2014).
Consequences of the Second World War had a great impact on the mental health scenario in Europe and the US. It is important to mention here that the psychiatric textbooks before the Second World War did not make any mention of social factors in mental illness. The Royal Medico-Psychological Association (which was to later become the Royal College of Psychiatrists) of the UK started a section on psychotherapy and social psychiatry in 1946. In the earlier period, the section focused on the study of social organizations, a conceptual framework which had come from the experiences of military psychiatrists from the Second World War. Two of the proponents of this movement, Maxwell Jones and Tom Main, worked on group therapy, which later evolved into the concept of “therapeutic community” (Leff, 2010).5
The World Health Organization (WHO) in its definition of health, way back in 1948, included mental and social wellbeing as integral components of health along with the physical one. Later, George Engel (Engel, 1980) proposed the biopsychosocial model of disease, which emphasizes the contributions of biological, psychological and sociological factors in genesis and management of mental as well as medical illnesses. These developments were indicative of the recognition of the discipline of social psychiatry in the scientific mind in that period.
The initial historical phase of mental health reforms brought by a number of visionary psychiatrists in the mental hospitals before the psychopharmacology revolution, which led to a number of improvements in the condition of the hospitals as well as the inmates, are important examples of the role of social interventions in mental illness. Recognition of the deleterious effects of long-term institutionalization on the wellbeing of the inmates, the positive effects of therapeutic community, and the deinstitutionalization movement are examples of the continuing existence of social psychiatry in that period of time.
INITIAL PROGRESS IN SOCIAL PSYCHIATRY
Social psychiatry had humble beginnings and progress across the world. In the UK, Sir Aubrey Lewis was the first psychiatrist to start research in social psychiatry, also credited with the founding of the Institute of Psychiatry in London. Role of social characteristics of mental hospitals on course and symptomatology of schizophrenia was recognized by the pioneering work by Wing and Brown that under-stimulating conditions lead to more defect symptoms (negative symptoms) and over-stimulating conditions lead to more florid psychotic symptoms (Leff, 2010). The concept of stressful life events and their role in genesis and relapse of different mental disorders including schizophrenia and depression was also recognized around this period (Brown et al., 1987).
A parallel movement of reforms in the mental health was started by the creation of the National Institute of Mental Health (NIMH) in the US in 1948. The coming years saw deinstitutionalization movement, the discovery of chlorpromazine and other antipsychotics and growth of community psychiatry. During this period, there was a lot of focus on social psychiatry in the US. Over the period, the NIMH played a significant role in shifting the focus of care from mental hospitals to the community settings. This was further facilitated by a release of a grant of 2.9 billion dollars by President Kennedy from the federal budget and passing of the Community Mental Health Centre Act by the Senate in 1963. These developments facilitated the community mental health movement in the US and were founded on the principles of social psychiatry. However, with a very large number of patients especially those with chronic schizophrenia or psychosis being discharged from the mental hospitals, it was not possible to provide high-quality care in the community, since the facilities available were not commensurate with the need. A substantial proportion of these patients required long-term rehabilitation, but the community services were not prepared for it. There was also considerable opposition from the lay public which held stigmatizing attitude for the discharged patients. Financial support was not of the magnitude to provide support for all these requirements. This led to the problem of homelessness amongst many patients discharged from the mental hospitals, and some would get readmitted to the mental hospitals while many would end up in the prisons over petty crimes, the trans-institutionalization. A similar phenomenon was observed across different European countries (Coip, 2009; Leff, 2010; Haack & Kumbier, 2012).6
One important development occurred in psychiatry in India around this period, when Vidya Sagar started involving families in the care of persons with mental illness in tents outside the premises of the mental hospital at Amritsar. This was the time when families were considered rather toxic in the Western world and responsible for mental illnesses in their wards. Vidya Sagar set an example of family therapy to the Western world (Kapur, 2004; Chadda, 2012). The topic is discussed in more detail in the chapter on the history of social psychiatry in India. India and other countries in the non-Western world, fortunately, did not face the problem of deinstitutionalization, since there were never so many mental hospitals with patients incarcerated in them, and most patients were being looked after by the families and the community (Chadda, 2001).
In the UK, the Royal College of Psychiatrists set up Social and Community Psychiatry Group in 1973, just two years after its establishment, confirming the significance social psychiatry carried. The annual meeting of the College in 1973 included a session on “prospects of social and community psychiatry.” The Group took over a number of activities including the development of community psychiatry services, liaison with general practitioners and promoting educational and scientific interests in social psychiatry. The Group was given the status of Section by the College in 1981 (Leff, 2010).
WHO had also important contributions to make in the field of social psychiatry in this period, by its International Pilot Study of Schizophrenia (IPSS) and the study on Determinants of Outcome of Severe Mental Disorder (DOSMeD). IPSS reported wide differences in course and outcome of schizophrenia across different countries in the world, with the developing countries showing better outcome as compared to the developed countries. Role of expressed emotions in relapse in schizophrenia, and its varied distribution across different cultures, as found in the DOSMeD study, were major findings from research in the field of social psychiatry (Leff et al., 1987; Wig et al., 1987; Kulhara et al., 2015).
DECLINE IN INTEREST IN SOCIAL PSYCHIATRY SINCE 1980S
In the last quarter of the twentieth century, there has been a significant improvement in our understanding of the structure and functioning of brain with advances in structural and functional imaging. Our understanding of the etiogenesis of most of mental disorders has also become better. But the exact etiology of most mental disorders remains unknown, though it comes under the broad umbrella of biopsychosocial paradigm. This period was also associated with the introduction of a large number of new medications for mental disorders including a range of antidepressants, antipsychotics, and use of anticonvulsants as mood stabilizers, and a declining interest in psychological, psychoanalytic and social therapies amongst the psychiatrists.
Though a reappraisal of the developments in biological psychiatry in the last 3 decades though confirms considerable progress in fundamental research in genetics and neuroscience related to psychiatry, there have been no breakthrough discoveries in our understanding of the exact etiology or in therapeutics. There have not been any new antipsychotics, antidepressants or mood stabilizers that could be labeled as more effective than the earlier ones (Saraga & Stiefel, 2011). The extensive continued funding for the biological research and declaration of 1990-2000 as the Decade of Brain in the US has led to the improved understanding of7 human brain and genome, and of the etiogenesis of mental disorders, but no novel biological treatments for psychiatric disorders have come up.
There was a marked decline in funding social psychiatry research received from the 1980s onwards, and most funding went to the biological research in psychiatry. But despite the fund crunch, there have been studies during this period proving the effectiveness of psychosocial treatments for schizophrenia and depression. In fact, family intervention for schizophrenia, cognitive behavior therapy for schizophrenia, and similarly for depression and anxiety disorders stands at a strong ground in the contemporary psychiatry (Priebe et al., 2013).
RE-EMERGENCE OF SOCIAL PSYCHIATRY IN THE 21ST CENTURY
Mental disorders are known to have a neurobiological, psychological and social dimension. The biological research in the last few decades has been able to identify changes in brain functioning in most of the mental disorders, but biology alone can not explain the genesis and clinical presentation of mental disorders. It is generally conceptualized that neurobiological changes in the mental disorders are expressed in form of psychological symptoms, experienced in a social context. The neurobiological findings in an individual patient are considered as the explanation for the illness and symptomatology, which is often expressed in interpersonal context with sociocultural factors affecting the clinical presentation. Similarly, modifications in the neurobiological processes in response to various treatments also explain how and why interventions work. This is also true for psychological, behavioral and cognitive interventions (Priebe et al., 2013).
The Global Burden of Disease, 1990 (GBD 1990) study published in the early nineties was a historical development, which brought focus on mental disorders and the social psychiatry (Murray & Lopez, 1996). GBD 1990 showed that mental and neurological disorders accounted for 10.5% of the total disability-adjusted life years (DALYs). Historically, mental disorders were never considered a health priority across the world, especially when compared with communicable diseases and non-communicable diseases such as cancer or cardiovascular disease, because of focus of the health planning on mortality statistics. The World Development Report in 1993, brought by the World Bank, brought global attention towards the relative burden associated with disease morbidity, rather than mortality alone. Mental, neurological and substance use disorders were identified as major contributors to the global burden of disease. The disease burden was reassessed in 2000, and the estimates showed neuropsychiatric disorders (mental, neurological and substance use disorders) to be responsible for more than a quarter of all non-fatal burden, measured in years lived with disability (YLD). Depression was identified as the most disabling disorder worldwide measured in YLDs, and the fourth leading cause of overall burden measured in DALYs. Depression was associated with the largest amount of disability, accounting for almost 12% of the YLDs. There was an increase in the contribution of mental and neurological disorders to the global burden to 12.3% in 2000 (World Health Organization, 2001). The Global Burden of Diseases, Injuries and Risk Factors Study 2010 (GBD 2010) re-estimated the burden in 2010 (Murray et al., 2012). In the GBD 2010, mental and substance use disorders were separated from neurological disorders in burden assessment. The group accounted for 183·9 million DALYs (95% UI 153·5 million–216·7 million),8 or 7·4% (6·2–8·6) of total disease burden in 2010. Global burden caused by the mental and substance use disorders was estimated to be more than that caused by HIV/AIDS and tuberculosis, and diabetes, urogenital, blood, and endocrine diseases, as separate groups. This finding is of great significance.
Dealing with the burden and disability associated with mental disorders is a huge task, which needs changes in the mental health policies, strengthening manpower resources, and targeting barriers to mental health care. The task is especially difficult in the low resource countries. Psychiatric services are though relatively well developed in the Western world, the non-Western countries in Asia, Africa, and South America suffer a gross deficiency in the mental health resources (World Health Organization, 2014). Most of the low and middle-income countries (LAMIC) have a gross deficiency of mental health manpower. According to the Mental Health Atlas (2005), the total number of mental health care workers in 58 countries from the LAMIC group was 362,000, representing 22.3 workers per 100,000 in low income countries and 26.7 per 100,000 in the middle income countries, comprising 6% psychiatrists, 54% nurses and 41% psychosocial care providers, putting the shortage of mental health workers at 1.18 million in the 144 LAMIC countries (Kakuma et al., 2011). A number of alternatives have been suggested to tackle the problem of limited mental health resources especially in the LAMIC. Key Strategies for meeting the challenges could include transforming health systems and policy responses, building human resource capacity, improving treatment and expanding access to care, prevention and implementation of the early interventions, and identifying the root causes, risks, and protective factors (Collins et al., 2011).
It has often been observed that there is a long delay in seeking treatment for mental disorders with reasons often being psychosocial in nature. Duration of untreated psychosis has emerged as an important outcome variable affecting the outcome in psychosis, emphasizing the need for early detection and beginning of treatment (Penttilä et al., 2014). Factors leading to delay in seeking treatment include ignorance, myths, and misconceptions about mental disorders and social stigma, and hence need social interventions. Non-adherence to treatment and not seeking help for mental disorders are other important factors identified to be associated with disability and burden associated with mental disorders and needs active interventions at the hands of social psychiatrists. There has also been a trend towards increasing suicide rates across some countries, which needs to be studied by the social psychiatrists. All these issues necessitate the need for a social paradigm in psychiatry, with social interventions being an important alternative strategy in psychiatric practice. The social paradigm has often been neglected, though the social interventions could be of great help in reducing barriers to seeking treatment, improving adherence, facilitating community rehabilitation and reducing disease-related burden and disability (Chadda, 2016).
SOCIAL CLASS, INEQUALITIES, AND MENTAL HEALTH
It is well known that there is a close association between social class and mental illness. There is also some evidence that social inequalities are associated with an increase in mental morbidity. Unfortunately, there has been increasing social inequalities in the society as well as increasing economic inequality between resourceful and poor countries across the world (Murali & Oyebode, 2004). There has also been a rapid increase in the gap in per capita income9 between the industrialized and developing world. The developing countries, which comprise 80% of the world's population, contribute to only 21% of the global gross national product. The differences in economic and health status within countries have also been found to be as great as or even greater than those between the rich and poor countries (Pickett & Wilkinson, 2010). Poverty is associated with high levels of common mental health disorders such as anxiety and depression. Similarly, the underprivileged areas are associated with higher rates of hospital admissions, outpatient visits and suicide. Poor financial status has been identified as a predictor of depressive symptoms independent of socioeconomic status, ethnic group and marital status (Heneghan et al., 1998). The New Haven Study of the 1950s and its follow up was one of the earliest studies to report a direct relationship between poverty and high rates of emotional and mental problems. The study had also shown that the different social classes accessed different types of treatment facilities (Hollingshead & Redlich, 1958; Kim et al., 2017).
Unemployment, another social variable, has been reported to be associated with increased prevalence of a number of mental disorders including depression, anxiety, phobias, psychosis and alcohol and substance use disorders (Meltzer et al., 1995). Unemployment has been identified to be one of the strongest predictors of suicide, even after adjusting for other socioeconomic variables (Lewis & Sloggett, 1998). Population-based studies from Netherlands (Bijl et al., 1998) and Ethiopia (Kebede & Alem, 1999) have reported the association of mood disorders with a range of social factors like unemployment, education, and under-achievement. Differences in educational attainment have also been identified as important factors contributing to social inequalities in psychiatric disorder in the world (Patel & Kleinman, 2003). A study from Brazil has shown an independent association of poor educational attainment and low income with increased prevalence of common mental disorders (Ludermir & Lewis, 2001). Thus, a range of social factors like education, income and occupational status which contribute to the socioeconomic status and also social inequalities independently as well as together can act as risk factors for mental illness.
ROLE OF THE WORLD ASSOCIATION OF SOCIAL PSYCHIATRY
The World Association of Social Psychiatry (WASP) has made substantial contributions to the social psychiatry movement across the world over the last 50 years. Joshua Bierer had the unique contribution of initiating the social psychiatry movement starting from the 1950s, and brought together the interested persons to London in the first international congress of social psychiatry in 1964. The meeting was a precursor to the founding of the WASP. Bierer was one of the earliest advocates in the UK for the closure of the custodial mental hospitals and played a leading role in designing and running community-based psychiatric services and psychosocial day hospital programs. Bierer was also the founder editor of the International Journal of Social Psychiatry. Second international congress of social psychiatry was organized in 1969, and the International Association of Social Psychiatry was formally launched with Joshua Bierer as Founder President and Jules Masserman as President. The name of the association was changed to the World Association of Social Psychiatry (WASP) in the international congress at Opatija, Croatia (Leff, 2010; Craig, 2016).10
The WASP (earlier under the umbrella of International Association of Social Psychiatry) has the distinction of propagating the cause of social psychiatry across the world by holding regular world congresses every 3 years in different countries across the world. A distinction lies in having its congresses both in the developed as well as the underdeveloped world. India has the unique distinction of organizing the WASP congresses thrice in 1992, 2001 and 2016.
WASP has the objectives of studying the nature of man, the culture, prevention and treatment of man's vicissitudes and behavioral disorders, promoting national and international collaborations among professionals and societies in fields related to social psychiatry, making the knowledge and practice of social psychiatry available to other sciences and to the public, and advancing the physical, social and philosophic wellbeing of the mankind (Craig, 2016). WASP has a number of special sections and task forces, some of which focus on the promotion of personal recovery, family support, and intervention, fighting stigma and migration. Thus, the WASP has played an important role in propagating the cause of the social psychiatry.
INITIATIVES TO BE TAKEN BY SOCIAL PSYCHIATRY
Social psychiatry needs to take a number of initiatives in future in promoting mental health, spreading awareness in the community about the mental disorders, early access to treatment, acting at barriers to pathways to the mental health delivery systems, and identifying and acting at the risk factors for mental disorders. Early interventions need to include educating patients and families, as well as making the society at large aware of the harmful consequences of mental illness. An understanding of the role of social factors in precipitation and perpetuation of mental illnesses is essential in developing a plan for such initiatives. It may not be possible for psychiatrists to reduce social inequalities, but they need to be aware of various psychosocial factors affecting mental health and help-seeking and take initiatives at sensitizing policymakers and others who matter about these aspects (Bhugra & Till, 2013).
Unfortunately, the medical education and also the education in psychiatry has become more biologically focused than a few decades ago. The medical, as well as mental health professionals, often lose sight of the psychosocial factors while interacting with their patients. Role of psychological and social factors in causation, course, outcome, and treatment of various psychiatric disorders is often ignored. This is not a healthy trend, and if this continues, main contributions of psychiatrists will be diagnostic assessment and psychopharmacological treatment, leaving psychotherapy to psychologists and psychosocial care to social workers and care managers? Here, social psychiatry has a crucial role to play, and the social psychiatrists need to sensitize the profession about the need and relevance of social psychiatry as an integral part of the discipline. Same is true for other branches of medicine.
Patients with mental and emotional disorders constitute a substantial part of the clinical practice in primary health care settings. Thus, the primary care physicians also need to be sensitized to this fact and equipped with necessary skills to identify and manage the common psychiatric problems in their routine clinical practice. Future psychiatrists should also be prepared to provide this kind of education and support. The profession needs to be flexible and respond to the changing needs, and be ready to take responsibility towards the society. However, the social psychiatrists also need to be cautious and resist attempts of the society to delegate all responsibility to psychiatry, especially the issues involving cultural sensitivities and values.11
It is important to mention here that the role of social factors can't be ignored in mental health despite all the biological advances. Biology can never replace the social factors. Since the psychiatrist works in a social situation and communication is an important part of the psychiatric assessment and psychiatric illnesses mostly manifest in interpersonal situations, social psychiatry will always remain an integral part of psychiatry. The psychiatrist needs to be familiar with various psychosocial risk and protective factors so as to take appropriate steps at mental health promotion and prevention.
A number of recommendations of the World Health Report of 2001, which was devoted to mental health, include social approaches such as providing treatment of mental disorders in primary care, bringing the services at doorsteps, mental health education to the community, involving consumers, families and the community in mental health care, developing human resources, developing linkages with other sectors like education, labor, social welfare, and monitoring community mental health services (World Health Organization, 2001).
CONCLUSION
Social psychiatry is an integral part of psychiatry since mental disorders manifest in interpersonal and social context, and hence for understanding and managing mental disorders, it is not possible to ignore it. The discipline may not be as popular as biological psychiatry due to the glamour attached to the latter but has existed all the time. There have been ups and downs in the importance social psychiatry has received by the psychiatrist and other mental health professionals over the period. Mental health reforms in the mental hospitals are one of the earliest examples of social interventions. Deinstitutionalization, therapeutic community, the concept of day hospital, psychosocial rehabilitation and other psychosocial methods of interventions are some important examples of social psychiatry initiatives in the twentieth century. The relevance of social psychiatry re-emerged in the last 2 decades especially on recognition of mental disorders as a major contributor to the global burden of disease and disease-related disability and absence of any major successes in biological psychiatry after initial hopes.
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