The Transformation of the Psyche in British Primary Care 1880-1970

The human, the person as a category, may become a historical subject. To take this step, however, is to begin to destabilise the basic terms with which to think about experience and agency. Hence the need for recourse to a portmanteau term, which does not have to be and perhaps could not be clearly defined, like ‘the psyche’. There has to be a sign under which historically to explore self, subjectivity and even the very notion of there being a ‘psychological’ identity. A historian of the modern person must be able, at one and the same time, to speak and to hold in question the terms of everyday discourse, and all the practices that go with it, about people, like ‘character’, ‘intelligence’, ‘ethnicity’, ‘emotion’ and ‘human nature’. Historical work, for sure, makes much of the discipline of the archive, and there is an obvious difficulty when it comes to locating the ‘archive’ of ‘the psyche’. Sensitivity to what this may involve has, perhaps, been more characteristic of the work of literary scholars, or it has been the project of intellectuals more interested in theorizing the difficulty than writing history. Hence the value of a book like the present one. It locates a material site, with material records, in which to follow in considerable empirical detail the creation and/or reproduction of the categories of psychic life destabilized by the investigation. General questions become historically precise. How have people come to talk in the way they do about themselves and others? How is identity constituted in language? How does this structure the healing relationship? Very broadly speaking, the book is a history of doctors, primarily general practitioners, and their patients, as the relations between them have come to be understood and acted on in psychological terms. To be evidence based (to use the medical term), it relates to one society, Britain, though, as it ranges over a century of change, this is demanding enough. Rhodri Hayward, a Senior Lecturer in History (and a Wellcome Award Lecturer in History of Medicine) at Queen Mary, University of London, successfully marries the theoretically reflexive practices of science studies and cultural studies with the empirical precision historians necessarily demand. He may thus stimulate different kinds of interest; and his strength is to provoke these interests to confront each other.

The study depends on and draws in a number of areas of scholarship. First, the wealth of work on 20th-century British medicine and social policy, much of which feeds into a wider debate about the relations between advances in scientific medicine and the actual delivery of health care. Second, the studies, which the sociologist Nikolas Rose and the historian Mathew Thomson have (in quite different ways) done much to shape, on the historical creation of knowledge of the person understood as a psychological subject and, in turn, on the individual disciplines, institutional structures and social policies which deploy psychological practices. For some authors, this is the history of the creation of psychological society. Third, there is the large literature, covering the Victorian and Edwardian period in Britain, which has looked, especially through studies of mesmerism and spiritualism, into the unconscious. Long ago, this work began to de-mythologize Freud and understand the reasons for the impact he had in terms of pre-existing psychological formulations. Lastly, it’s necessary to mention the wealth of well-funded current activity in medical humanities. This heading covers a multitude of old and some new efforts to put sensitivity to the individual person into the delivery of scientific medicine, for example, by recognising the importance of narrative to identity. Hayward’s book should be an essential resource here, showing how the terms with which discussion in the medical humanities operates themselves have a history.

There are five chapters, preceded by a preface which is not so much a preface as the introduction. The leading theme is the modern way of life which takes for granted connections between physical health and psychological well-being: ‘The body is widely seen as [a] kind of witness or index of our personal travails’ (p. x). At first glance, such belief appears ancient, if not near universal – a belief that only a mechanistic post-17th-century natural science culture could have questioned. But the statement is about psychological well-being, that is, well-being represented in specifically psychological rather than religious, moral, ecological, political or other terms. Hayward’s position is self-consciously constructivist: the categories and practices of modern psychic life are historically contingent and traceable, as this book argues, to specific social changes. This is admirable: ‘constructivism’ is put to work and legitimated in written history rather than flung around as a term in factious dispute. The implications are substantial, however. Buried in a note (note 12, p. 135) is a large ontological claim (made in a defence of the use of qualitative sources like literature and film as historical evidence): ‘Psychological knowledge, unlike chemical or physical knowledge, lacks any fixed point of reference in the world. It is … purely “performative”, and our descriptions and redescriptions of psychological concepts, such as “instinct” or “character”, change their very nature’.  This would appear to radically divide the psychological (and social) sciences from the natural sciences, and to divide psychic healing from bodily healing – precisely the dualism which the substance of the book shows to be constantly, if in different ways, undermined.

The century or so which the book covers saw the embedding of the assumption that bodily well-being is the outcome of a person’s history, a history that has written the troubles of the psyche into the flesh. The connections of past and present appear natural, and this appearance of naturalness owes much to belief in unconscious forces (‘a kind of third party that could manipulate the body to advance the patient’s agenda’, p. 37). The reference is not by any means just to the Freudian unconscious but, as the book details, to the longer history of the recognition of hidden psychic forces, not to mention the ‘myriad ways of narrating the unconscious’ (p. 30), which are rightly given much emphasis. For the decades after 1970, when the book nominally ends, though the everyday use of such narratives in discussion of health persists, there appears to be a shift. Investment and research in the psycho-pharmaceutical technologies of the brain fosters a new vision of the psyche: the elements of the psyche can be designed, manufactured, marketed and bought, and the story of the psyche is one of self-governance and consumption. Self-shaping through biographical narrative and self-shaping through drugs or electronically operated prostheses exist side by side. This brings to a head the open-ended question of what, in what sense, was new, and now old, in the practices the book describes. The conscientious historian, like this author, is bound to be vexed by the ambivalence of continuity and discontinuity, though it certainly is this author’s preference, and I think it a strength, to find novelty and hence describe and account for change. This is accomplished at the micro-level, in terms of what actually goes on in the GP’s practice, and in terms of the social habits and policies in which the practice participates. It would need another, more knowledgeable reviewer to examine the accuracy of all this, but the informative richness of the book is not in question. In part, this richness comes with a wise choice not to seek one continuous story unfolding over time but to have each chapter take a different theme with its own time scale. Stylistically, this makes it possible to do justice to the many threads of the history.

The first chapter begins with the historical evidence that ‘the idea of the unconscious as an inner agent that somehow knits together the present and the past is a comparatively recent innovation’ (p. xii). The language of unconscious events was ubiquitous in the 19th century, but Hayward’s persuasive argument is that, then, the unconscious that knit events in mind and body was a form of anticipation or expectancy, unconscious desire for, or influence from outside to impose, one action rather than another, not unconscious memory of the past. The model case was the mesmerized subject: suggestion caused anticipation of what was not the case but what was to become the case. In the 20th century this changed: patients, or clients, re-imagined healing on the basis of narrative about the past – of experience forming personality, of suffering and trauma, of habit and, we might add, in the most recent incarnation of this way of thought, of the genes, that is, of an evolutionary past. The next chapter accordingly describes the uptake of new psycho-dynamic concepts in general practice, along with the inter-war turn to psychosomatic medicine and an eclectic commitment to link mind and body in presenting and responding to illness. As a historian, looking for the objective record of subjectivity, Hayward discusses general practice, and the recording systems of that practice, as the site of new forms of selfhood. In a revealing aside, which reminds us the site is about power as well as knowledge, Hayward notes that many GPs didn’t provide a chair for their patients.

The third chapter then sets general practice within the context of social policy. With the advent of railway accidents, there was debate about the financial and medical consequences of neurosis and malingering. This was a large issue in the inter-war years, when the proponents of psycho-somatic medicine, and in England James Halliday especially, developed epidemiological evidence to draw neurosis fully under the scope of social policy. There was a push towards preventative psychiatry. As Hayward shows, GPs played a large part in ‘the production of this epidemiological data and the implementation of new programmes of preventative psychiatry which ministered to the psychological health of the population’ (p. xiii). There was an enlarged interest in ‘environmental illness’, in part interestingly associated with the huge contemporary expansion of suburban housing. There was widespread psychiatric recognition of the continuity of psychic health and ill-health. ‘Once a psychological mechanism was assumed, the inefficient operation of just about any biological function could be taken as a sign of wider environmental failings and just about any aspect of the environment could be read back onto the symptom or sign’ (p. 77). After the war, however, there was increased interest in psychosomatic symptoms as a function of the approach of the GP – it became clear, for example, that reported rates of psychological illness varied widely. Hayward therefore discusses, in chapter four, the shift of the focus of attention from patient to physician: ‘the source of psychoneurosis began to shift from the “anxiety prone patient” to the “psychotherapeutically inclined physician” (p. 89). Then, following the rethinking of general practice which the introduction of the National Health Service precipitated, in the 1950s Michael Balint, working from the Tavistock, instituted psychological studies of general practice and training seminars which became a model for psychological self-examination and improvement in a number of professions. This chapter on the medical understanding of ‘the anxiety of influence’ (as the chapter is headed) is particularly rich.

The concluding chapter then draws towards the present, finding in the 1960s the beginnings of enhanced criticism of narratives of the unconscious. (Criticism, of course, had always been present.) Once historically constructed, the psychological language for assessing and practising well-being acquired a life of its own, a life not necessarily dependent on narratives about the unconscious. If the earlier narratives had sought in biography the means to use reason to take control over the self, or even uncover the nature of the true self, new psychological practices turned to the self, to identity, as something that could be fashioned – and bought. Thus the medical encounter became a process in which doctor and patient worked together on what the patient wanted. It became the material site for new forms of selfhood. But, as Hayward points out, what people wanted was not clear: ‘the incidence of medically unexplained syndromes has vastly increased and such syndromes now occupy around a third of the general practitioners caseload’ (p. xiv). The modern psyche, we may think, is still busy writing its own history.

Hayward maintains a concise, highly informed and consistently perceptive and interesting narrative across this range of material. The book provides more links between different areas of study than is usual, and it does justice to the depth of past work rather than opting for eye-catching but uninformed claims. It is often well written and readable. And it is largely free of the jargon and language hermetically sealed in to a narrow reference group that mars so much cultural studies. I would think all students of 20th-century British medicine will want to read and argue with it. And as Hayward would doubtless be the first to say, it calls out for comparison with developments elsewhere. If the book is written for historians, I imagine a considerable number of general practitioners, if they could find the time, would find it of great interest – it might provide insight into the psychological roles into which they are so often cast or into which they cast themselves (and quite which is the case is the sort of thing the book talks about). The book is massively referenced, and it would be interesting to know the author’s purpose here. I suppose views will differ about the appropriateness of half the text being devoted to notes and bibliography. This happens if an academic seriously tries to reference what has been published; yet, even the largest list will not, in fact, be comprehensive – and selection always rules.

Given the book’s articulacy and incisiveness, it is all the more regrettable that it should have been so misprinted. Proof-reading appears not to have taken place (though this has the benefit that the reader encounters a ‘sting quartet’). ‘Ancient regime’ is pathetic. The book cover gives different dates to the title page. In several places the text duplicates itself. It is as if the publishers want to advertise that they couldn’t care less.

A lot of readers will care, because they will turn to a book which merges the interests of a historian with the interests of self-identification and well-being in modern times. I think there will be much argument about what has and has not changed. The search for biographical narrative and the desire to self-fashion seem, for example, now to run side by side. The humoral medicine that lasted so many centuries, and continued to find echoes in the 20th century, for example, in characterology, and has persisted in many kinds of popular medical self-understanding around the world, surely continues to inform doctor-patient relations. That doctors ‘influence’ patients was always at the centre of medicine – for what else did clients pay? Perhaps one might even suggest that ‘influence’ (the slippery notion to which Hayward gives quite some attention at the beginning of chapter four) is a more inclusive category than ‘care’ or ‘healing’? There is more to be said on the placebo effect, with its long history in general practice, building on the discussion in chapter five (as well as the discussion of ‘influence’ earlier). Balint, Hayward reports, remarkably believed it impossible in psychotherapy for there to be a placebo effect. Not least, this would seem to run up against Hayward’s own constructivist aphorism: ‘The mere fact of belief is transformative’ (p. 131). There is no discussion of women GPs, or, taking a wider view, the flow of women into clinical psychology, which took off as a speciality after 1945. What kind of evidence would make it possible to ask whether gender, in doctors or patients, made a difference? There is also more to be said about how ‘the psychological’ comes to be so central a part, perhaps a defining part, of what it is so easy to call but so difficult to explicate as modernity. But such reflections just show how this book, with its fine interweaving of empirical knowledge and analytic commentary, will stimulate conversations. These are attractive conversations, both academic and everyday, both historical and medical, and relevant both to individuals and to policy.