Unpromising configurations: Towards local historical geographies of psychiatry

ARTICLE IN PRESS Health & Place 15 (2009) 649–656

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Unpromising configurations: Towards local historical geographies of psychiatry Chris Philo a,, John Pickstone b a b

Department of Geographical and Earth Sciences, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK Centre for the History of Science, Technology and Medicine, University of Manchester, Oxford Road, Manchester M13 9PL, UK

a r t i c l e in fo

abstract

Article history: Received 30 January 2009 Accepted 3 February 2009

This paper introduces a theme section comprising of three other papers, written from cross-disciplinary perspectives, exploring what might be termed ‘local historical geographies of psychiatry’, and in particular demonstrating how pioneering innovations in the treatment of mental health problems sometimes emerge from the most ‘unpromising’ of spaces and places. The introductory paper contextualises the studies that follow, laying out claims regarding the need to take seriously the thoroughly situated character of the knowledge and practices that are taken to comprise the ‘stuff’ of science, technology and medicine, and more specifically drawing out what such claims mean for an emerging ‘spatial turn’ in historical research on psychiatry and other mental health subjects. We focus on innovations which emerged where least expected, in ‘backwaters’ or even ‘deprived’ locations and institutions, thereby qualifying more conventional accounts of change in the field that prioritise centres of learning as the key sites from which developments arise and diffuse. & 2009 Elsevier Ltd. All rights reserved.

Keywords: Historical geography of psychiatry Innovations in psychiatry Psychiatric history Sociology of Scientific Knowledge (SSK)

Introduction In 1988, at a conference held by the (UK) Society for the History of Medicine to mark the fortieth anniversary of the National Health Service (NHS), one of the authors of the present paper, John Pickstone, gave a paper entitled ‘Psychiatric units in District General Hospitals: the history and geography of a ‘silent’ innovation’ (Pickstone, 1988, 1992). He explained why asylums in early 20th-century Lancashire, a large county in northwest England, were seen as ‘laggard’ in terms of mental health policy, but argued that from circa 1950, after the introduction in 1948 of the NHS, these same geographical circumstances led the Manchester Regional Hospital Board (MRHB) to pioneer specialist psychiatric units set within the district general hospitals of its industrial towns. The success of this experiment was a significant factor in the national policy shift in the 1960s towards replacing asylums by ‘care in the community.’ From the late 19th century, the asylums of Lancashire had been run by a federal body, the ‘Lancashire Asylums Board’, which covered a massive population in a dense industrial region. Its asylums, mostly dating from the first half of the century, had become uncommonly large, each with about 3000 beds, even though many of the ‘mild cases’ were left in the workhouse hospitals run by local Poor Law authorities until 1930 and

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E-mail address: [email protected] (C. Philo). 1353-8292/$ - see front matter & 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2009.02.009

thereafter by the municipalities until 1948. In Lancashire, as elsewhere, the retention of mental cases in pauper workhouses, sometimes in sizeable ward blocks, was seen as regressive by ‘lunacy’ experts who assumed that standards of care and treatment would be deficient compared to the asylums (Philo, 2004, Ch. 5, esp. 229–262). Under the NHS, the county of Lancashire (together with Cheshire) was divided between two new Hospital Regions, based on Liverpool and Manchester, respectively. The mental patients in the former workhouses of industrial towns now came under the Hospital Management Committees which administered all of the hospitals in any given district, although each of the mammoth asylums was given its own Management Committee, thus prolonging the separation of mental and non-mental services that the NHS was supposed to diminish. The Manchester Region faced peculiarly acute problems in maintaining and staffing its huge asylums, and there was also pressure from town representatives to institute local care for their considerable numbers of local mental patients, rather than relying on visits by asylum-based psychiatrists. In the MRHB, policy for psychiatry was hence made by the medical elite around the teaching hospital, not by asylum doctors; they experimented by appointing a psychiatrist, Arthur Pool, to the ex-municipal hospitals in two neighbouring mill towns, Oldham and Rochdale, with a further attachment at the nearest asylum. In Oldham, although not in Rochdale, Pool succeeded in building a local service, closely linked with the municipal public health service. He brought substantial institutional experience but made little

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use of his new asylum attachment, preferring to keep his Oldham patients in the local hospital, which arguably became easier once new medications were introduced in the mid-1950s. The experiment was reckoned a success, and similar appointments were made in several other Lancashire towns, creating posts which proved more attractive to young psychiatrists than did appointments to a large asylum. The model was well-publicised, and certainly well-known in the national Ministry of Health by 1960 when ministers began to consider how mental care could be given in a new generation of district general hospitals. In summary, the MHRB encouraged the ‘hospitalisation’ of psychiatry, and was seen as a leader for this innovation: where the Manchester region had been ‘last,’ it came to be ‘first’ (Pickstone, 1988, 1992). Pickstone’s study clearly serves to introduce this theme section on what we term the ‘local historical geographies of psychiatry’, given that it was unusual in 1988 for a historian of medicine to be so explicit about the importance of geography. In analysing the local decisions circa 1950, he drew on what we might term ‘spatial histories’, emphasising the mill towns as products of heavy industrialisation, with large and relatively impoverished populations residing at some distance from the massive lunatic asylums but serviced by large proximate workhouses. He also explained how, once the MHRB was appointing (non-psychiatric) consultant surgeons and physicians to serve the district general hospitals (including most of the former workhouses), calls arose from some MRHB members ‘‘concerned to obtain specialist supervision for their local mental patients’’ (Pickstone, 1992, p.194). Pickstone’s stress on a seemingly ‘backward’ region innovating in medicalpsychiatric history is continued in Val Harrington’s paper below, which explores the later history of a ‘backwater’ within the city of Manchester. More broadly, his arguments prefigure a general theme of this collection: the importance of what we are calling ‘unpromising configurations’ in the history of psychiatric services. Historical geographies of science, technology and medicine Looking back on the MRHB paper, we can see how it combined a general interest in innovation with a geographically specific interest in medical services in and around Manchester. The research was prompted by a commission to write the history of the region’s hospitals, given to a History of Science and Technology Department (at UMIST1) with strong local interests (Pickstone, 1985). In the mid-1970s, when this work was begun, ‘localism’ was proving generally productive in the history of medicine and science, as more generally in the then resurgent disciplines of economic, social and urban history. This localism proved crucial to an emerging history of science, technology and medicine, as a more or less unified field, and also to developments in ‘science studies’ which have since been widely influential in many other areas of social and cultural studies, including human geography. It is worth briefly reviewing some of these key developments before turning to their implications for studying psychiatric history. In doing so we will also gently critique certain more recent ‘fashions’, both for neglecting this older localist tradition and for perhaps over-emphasising different kinds of spaces – as in types of sites, irrespective of their exact worldly location – at the expense of the specificities of places – as in named parts of the world where diverse phenomena co-mingle in distinct ways to lend an ultimately unique character to whatever instances of science, technology and medicine might arise there. Many 1 University of Manchester Institute of Technology, now merged with the University of Manchester.

complex philosophical and social-theoretical debates, old and new, bear upon this latter distinction between space(s) and place(s), of course, further complicating it with critical questions about what might be meant by constructs such as scale, context and network. Limitations of ‘space’ preclude a more extended treatment of such issues and the relevant literatures (e.g. Crang and Thrift, 2000; Hubbard et al., 2004; Massey, 2005), but the aim below is to substantiate something of our claims about spaces and places as a framing for our following remarks about psychiatric history and the challenge of geography.

Localist histories? The social history of science, as that historiography developed from the 1970s especially in the North of England and in Edinburgh and Glasgow, usually focused on local and regional studies, especially of the industrial revolution and the Scottish Enlightenment. At their best, these studies encompassed ‘ideas’ as well as local Societies and associations, colleges, ‘knowledge practices’ and technologies; and they linked closely with the regional studies then prominent in economic and social history (e.g. Musson and Robinson, 1969). The studies from Leeds and Manchester (Cardwell, 1971, 1989; Farrar, 1999) showed how local studies might illuminate major issues in global science history, such as how the concept of energy was developed. The work of Morrell (1972) on Scotland or Thackray (1974) on Manchester, and especially their joint study of centre–periphery relations in the early years of the British Association for the Advancement of Science (Morrell and Thackray, 1981), together with the American work of Kargon (1977), helped to convince historians of scientific ideas and practices that local studies were crucial. They showed how the intellectual configurations of Victorian Britain, including ‘our’ very notion of ‘science’, were shaped by a concrete geography of places. We may note here the personal geographies entangled in this historiographical reshaping. Thackray grew up in Manchester and worked on its scientific hero, John Dalton (Thackray, 1972); like Morrell, he was part of the seminal History of Science group established by Toulmin in Leeds. After a PhD in Cambridge, Thackray went to the United States and set up the exceedingly productive Department for History and Sociology of Science at the University of Pennsylvania, where social (and often local) history was the main approach to science, medicine and technology—the three taken together. Morrell spent time at ‘Penn’, and Shapin was a product of that department. After Shapin moved to Britain, he first worked on northern provincial topics as he collaborated with Barnes and Bloor (e.g. Barnes and Shapin, 1979) to develop the Edinburgh ‘Strong Programme in Sociology of Knowledge’ (Barnes, 1974; Barnes et al., 1996; Bloor, 1976), closely related to ‘Sociology of Scientific Knowledge’ (SSK) studies, which tended to focus on scientific controversies in well-defined geographical contexts. Something of that localism was still evident in his collaboration with Schaffer on Leviathan and the Air Pump (Shapin and Schaffer, 1985), although the main focus was now on the practicalities of establishing and replicating (esp. Collins, 1992) laboratory-based ‘experiments’ as the basis for belief in science, and the geography was mostly that of either small group ‘witnessing’ or the diffusion of wider persuasion by literary technologies. This explicitly sociological work, which also drew on Polanyi’s (1958) insights into the ‘tacit’ dimension in science, was hence largely about ‘sites’ and not about particular places and their contextual peculiarities. Thus the focus on laboratory procedures (also Latour and Woolgar, 1979) opened a certain kind of abstract geography of spaces, tackling the differences between types of sites – laboratories

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to be sure, but also field stations, museums and many other sites too – as well as the connections between such sites. Indeed, this approach has sometimes come to involve what might be deemed a ‘soft site-determinism’ where the nebulous entity ‘science’ is divided up primarily by the generic nature of the sites in question; and in his historical sociology of science, Golinski (1998) very usefully deploys such divisions as his prime organisational device. But for all the gains brought by this ‘spatialising’ of science in social-historical accounts, there has arguably been a concomitant retreat from addressing precisely where these sites get located in the world. As such, a general model of interactive sites enters into partial tension with the continuing tradition of specifically local science studies, as in accounts of early modern Florence (Biagioli, 1993) or Amsterdam (Cook, 2007), or of Victorian Manchester (Thackray, 1974; Kargon, 1978; Cardwell 1989; Pickstone, 1985, 2007b; Pickstone and Butler, 2005), Cambridge (Warwick, 2003; Weatherall, 2000) and Glasgow (Smith and Wise, 1989). The latter, more place-specific studies often include medicine and technology, and they see ‘science’ as a particular dimension of local social life. As a result, they commonly include biographies of groups; they operate with informal or implicit models of local or regional ‘societies’; and they tend to depict changing configurations of knowledge and practice, rather than illustrating general issues in the ‘history and philosophy of science’ (for more on this point, see Pickstone 2007a, esp. 496). For the sociologists who developed SSK after Edinburgh, however, the ‘social’ in ‘social construction’ tended to mean disciplinary communities, rather than the press of immediate geographical contexts. They were often anti-realists, who on methodological grounds also excluded ‘nature’. That this latter exclusion was needless is evinced by recent re-introductions of the constraints and affordances of the material world—via ‘material culture’ or the ‘mangle of practice’ (Pickering, 1995), or through treating inanimate objects and people together as coenrolled ‘actants’ (Latour, 1987a, b), so that non-humans become part of the ‘social’. This last move has proved especially popular because actants can interact, allowing the relations of the local and the general to be treated as the spreading of ‘actor-networks.’ If Latourian Actor-Network Theory (ANT) usefully stresses ‘recruitment’ across time and space, we would argue that its exponents have underplayed the historical-geographical configurations of (what in many cases have been the highly) localised social worlds of science—with curious academic effects. Such is the fondness for imported ‘theory’ that abstracted products of social history become ‘opportunities’ for local ‘applications’; which hardly does justice to their own historiographical development or indeed to that de-centering of ‘theory’ which was a major product arising from historical-sociological understandings of scientific knowledge.2 These same academic predilections also seem to require that protocols for researching such esoteric and mathematical scientific knowledge as had indeed once seemed asocial, and hence unplaced, now be presented as necessary for understanding practices whose sociality, materiality and emplacement have, ironically enough, never really been in doubt (Edgerton, 1993)—such as the history of technology or the history of medical practices and institutions, psychiatric history partially included.3

2 Our argument here is that to an extent the older localist histories of science laid the foundations for SSK – and, more indirectly, ANT – but that some of the richly place-sensitive (‘contextual’) qualities of this earlier work have been somewhat lost in more theoretically driven pronouncements about the importance of spaces (of sites, networks, connectivities, etc.). 3 Although, as we will shortly show, the precise extent of a place sensitivity in the latter has been distinctly uneven.

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Into academic geography Steven Shapin has provided reviews useful for geographers, showing how social-historical studies of science can take seriously questions of space and place (see in particular Orphir and Shapin, 1991; see commentary in Livingstone, 1995, pp. 15–16). He contributed a paper to a leading geographical journal entitled ‘Placing the view from nowhere’ (Shapin, 1998), insisting that, if truth – we might say Truth with a capital ‘T’ – is the ‘view from nowhere’, any hint that ‘‘knowledge is geographically located is widely taken as saying that the knowledge in question is not authentically true at all’’ (Shapin, 1998, p. 5). In contrast, for Shapin as a participant in the historiographical developments outlined above, any sustained attention to how science has actually been made and remade, circulated, contested, utilised, reworked in practice, and so on, immediately bumps up against the details of ‘‘locality and spatial situation’’ (Shapin, 1998, p. 6). No knowledge, however ‘scientific’ or prestigious, can ever truly come from nowhere; it cannot but originate somewhere, being thoroughly situated, in Donna Haraway’s (1991) valuable terminology; and it commonly bears marks of that originsituation wherever it might then travel. Thus inspired, a number of geographers over the last decade have been active in tracing the geography in histories of science and its offshoots, and an impressive body of work has been convened—which usefully extends the social-historical work of the 1970s. At best, the new work draws on various theoretical positions (for instance, Kuhnian, Foucauldian, SSK and ANT: Demeritt, 1996; Greenhough, 2009); it remains attentive to earlier social histories, and mobilises a variety of archival and oral history sources to explore a diversity of spaces and places, both little and large, wherein science – including academic or popular geography – has been pieced together (e.g., Driver, 2001; Heffernan, 2001; Jo¨ns, 2006; Lorimer, 2003; Lorimer and Spedding, 2005; Naylor, 2002, 2004; Withers, 2001, 2002, 2007). Prominent in this respect has been David Livingstone, who early set a compelling agenda for ‘a historical geography of science’ (Livingstone, 1995), and who has recently provided a multi-disciplinary synthesis of materials in his Putting Science in its Place (subtitled ‘Geographies of Scientific Knowledge: Livingstone, 2003). As he reflects on the writing of this book: The obvious thing to do was to take some very traditional geographical motifs – the sorts of things that conventionally geographers have been interested in – location, site, region, diffusion, circulation, and to ask the question, ‘do these matter in the practices of science?’ So I began to read in the historical and sociological literature on sites of scientific enquiry and to ask the question, ‘how does the site of enquiry influence the cognitive content of scientific enterprises?’ (Livingstone et al., 2002, p. 89). As ‘‘a massive exercise in social trust,’’ he continues, it turns out that ‘‘we are supposed to believe in science because its findings have been delivered by appropriate people in appropriate places’’ (Livingstone et al., 2002, p. 89). This conclusion leads beyond the specific brief of what we might investigate under the rubric of an historical geography of science, and has particular salience for a highly contestable ‘science’ like psychiatry, but for the moment we can stick with the substance of Livingstone’s 2003 book. In summary, tackling a cornucopia of examples, always drawing out interpretative and comparative threads, he scales up his investigations from the production of knowledge in the physical sites of, say, laboratories and museums to its reception within the layered cultural regions of, say, Europe, Britain and England. He also addresses the connective sinews allowing ideas and practices to

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travel, in effect to jump scales (from the micro and the macro) and thereby to diffuse unevenly and sometimes reversibly. Intriguingly, and as a bridge into the next section of this paper, Livingstone (2003, pp. 69–72) identifies the historical lunatic asylum as a ‘scientific space’ where ‘medical knowledge’ and ‘scientific-moral therapy’ were cultivated, more-or-less purposefully, and where the characteristics of the spaces involved – their neighbourhood, architecture and functioning as social milieux for admixtures of doctors, attendants and patients – were deeply and unavoidably implicated in the making of modern psychiatry.

The history of psychiatry and the geographical challenge A smallish but vibrant subfield, sometimes called psychiatric history, has emerged since 1960s. It includes histories of psychiatry as a medical specialism (so named from the 19th century), but also embraces work on previous centuries and on a wide range of mental health subjects such as folk aetiologies of mental ill-health, coping with ‘lunacy’ in the community, and artistic and literary portrayals of ‘madness’. A specialist journal History of Psychiatry has been published since March 1990, and a stream of monographs and edited collections can readily be identified (notably the three-volume series of essays edited by Bynum et al., 1985a, 1985b, 1988; see also Melling and Forsythe, 1999). The voices range from trained psychiatrists reflecting on the origins of their profession, through antiquarians tracing the stories of ‘the asylum next-door’, to social historians, sociologists and other social scientists reflecting on how mentally distressed populations have fared when confronted by the ideas, practices and institutions of past mental health care ‘systems’. Much of the relevant British literature since the 1970s has been produced by social historians of medicine; Roy Porter was exemplary, especially for his work on the literary cultures of madness, the recovery of patients’ histories and, more broadly, the embeddedness of past ‘madnesses’ within the entangled discourses and practices of medicine, philosophy, religion, politics, popular culture and everyday life in Britain (esp. Porter, 1987a, 1987b). Somewhat counterposed to Porter’s approach was the earlier and more critical approach associated with Michel Foucault, and more generally with ‘anti-psychiatry’, thereby positioning psychiatric medicine as an oppressive instrument for silencing ‘the mad’. Foucault’s major text Madness and Civilisation (Foucault, 1965) has been recently published in a revised and unabridged English edition entitled History of Madness (Foucault, 2006a); and it is now up for reassessment in the light of lectures from a recently published lecture course entitled Psychiatric Power (Foucault, 2006b). Spaces, places and geography in psychiatric history Much can be said about the status of space, place and geography within the overall corpus of psychiatric history. A sustained geographical critique of this corpus – treating of contributions major and minor, remembered and forgotten, most of them from practitioners of psychiatry – can be found in Philo (2004, Ch. 2). At the risk of over-simplifying, however, it can be claimed that, insofar as any broader awareness of geography intruded into writings before the 1960s, it did so in the sense of envisaging an overall surface of ‘modernisation’. Certain ideas and practices, envisaged as progressively improving, better approaching the truth of ‘madness’ as ‘mental illness’, were portrayed as arising in particular (often urban) centres of learning, themselves set within the more ‘civilised’ countries, and spreading to other places, whether the (rural) peripheries of the advanced nations or

the territories of so-called ‘uncivilised’ countries.4 A stark (if obscure) example of such a vision, lifted from Whitwell’s 1936 Historical Notes on Psychiatry, runs as follows: y it is only necessary to move through a few degrees of longitude or latitude in order to find some community small or large, at a different stage of evolution, which holds today the same views concerning mental disorder as those current in [Britain] only a few centuries ago. [T]here frequently appear, like coral reefs in the full tide of high civilization, little atolls of aberrant thought (Whitwell, 1936, pp. 1, 3). In effect, histories such as Whitwell’s prioritised time over space, often entailing a simple progressive teleology confronted by spatial pockets of ignorance, backwardness and cussedness. To be fair, a good few of the earlier works did contain elements of a geographical sensibility: some comparison of ‘national’ or ‘regional’ patterns5 within the development of psychiatry and mental health care facilities, for instance, or some commentary on aspects such as the sorts of environments (e.g. urban and rural, upland or valley-bottom) where particular institutions, notably 19th-century asylums in Britain and North America, were built. Such material is worth recovering, but it hardly amounts to a sustained engagement with White’s note, as long ago as 1937, about the story being unfolded here amounting to ‘‘the whole complex picture as it is distributed in time and space’’ (White, 1937, pp. viiviii [our emphasis]). It is telling that White immediately prefaced this remark by talking about ‘‘reforms in certain places having progressed further than in others’’ (White, 1937, p. vii), in effect collapsing space back on to time (i.e. by supposing that certain places are merely further down the developmental path than are others: for a comprehensive theoretical critique of such a negation of space by time, see Massey, 2005).6 In more recent versions of psychiatric history, the situation has changed, as we might see by returning to Porter and Foucault who, albeit in rather different ways, were alert to space and place. Porter was always cautious about glib generalisations, warning against histories that imply more coherence in ideas and practices than was ever the case. He once noted, with a message that we are sure should be exported to other times and settings, that: The 18th-century madhouse map reveals less a co-ordinated system than a highly uneven spattering of heterogeneous establishments – big and small, private enterprise and charity, subscription and proprietary. The term ‘system’ hints at a misleading uniformity. Diversity remained of the essence (Porter, 1987a, p. 156). He was insistent that we should recognise the specificity of the British, indeed English, history of mental institutions, and in part 4 Most recent historians, like most psychiatric and lay commentators, see some overall improvements in patient care since WWII, not least via pharmaceuticals; but most writers, in all these groups, also recognise that many key psychiatric problems are but transposed over time, and that most regimes and medicines remain deeply problematic. Indeed, in psychiatry, as in other ‘marginal’ medical fields such as public health, some of the best histories by practitioners are reflections on persistent problems. For psychiatry, however, almost uniquely, some practitioner history, and much of the history by social scientists and professional historians, has been based on explicit opposition to medical practices that remain dominant. The historiography of madness from the 1960s is inseparable from the ‘anti-psychiatry’ debates, and even now much history is frankly critical, if sometimes in new ways. An interesting example is Burnham’s (2006) historical critique of ‘deinstitutionalisation’ in America, including its legitimation by social sciences. 5 For those interested in the differences within and between national traditions in psychiatry, we can commend a recent edited volume with some serious attempts at comparative analysis (Gijswijt-Hofstra et al., 2005). 6 This line of argument, complete with numerous examples, is advanced in Philo (2004, esp. 21–33, and associated endnotes).

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(esp. Porter, 1992) he did so precisely to question the extent to which the assertions of Foucault could be generalised across the Channel from France (and more specifically from Paris). A group of radical French geographers once identified ‘‘a rigorous concern with periodisation that contrasts with the vagueness and relative indeterminacy of [Foucault’s] spatial demarcations’’ (in Gordon, 1980, p. 67), but at the same time they were excited by his emphasis on ‘spatial configurations’: ‘‘the closed space of the asylum’’, ‘‘a space of confinement’’ tied up with all knowledges and practices that imagine borders between ‘us’ and ‘them’, the ‘‘figure of the Panopticon’’, a model of power dependent upon ‘‘a dispersed network of apparatuses without a single organising system,’’ and so on (in Gordon, 1980: esp. 71, 72). The conclusion to draw is that Foucault did offer a profound ‘spatial history’ (Elden, 2001) of myriad historical phenomena, madness included, but that – excepting claims to be advanced about the greater sensitivity to particular ‘scenes’ of psychiatric encounter displayed in his Psychiatric Power lectures7 – his interest in space as the dimension of exclusion and power was often neglectful of place – in the sense of the specificities inhering in particular named locations (also Philo, 1992, 2004, pp. 34–50). While overcompressed, our suggestion here must be that Foucault risked a prioritising of spaces and sites over the particularities of place which is not entirely dissimilar to that which we identified above in SSK and ANT. For the historical geographer of psychiatry, the ideal might therefore be a combination of Foucault’s spatiality with Porter’s placedness. The present state of play in Britain might be discerned from a conference held at Oxford Brookes University in 2002, entitled ‘Space, psyche and psychiatry: mental health/illness and the construction and experience of space’, drawing together contributors and participants from across many disciplines and spheres of expertise, and leading to the edited volume Madness, Architecture and the Built Environment (Topp et al., 2007). The main title perhaps misrepresents the scope of this volume, implying a too rigidly architectural or at least bricks-and-mortar emphasis,8 and the subtitle, ‘Psychiatric spaces in historical context’, better captures the rich sense of interplays between all manner of spaces – configured as physical, social, technical and ideological – and the many ways in which psychiatry and mental health care have been shaped, reshaped, imposed, contested, represented and resented, discussed and performed, purposefully structured and humanly experienced at different times in different places. As the editors declare: By combining the more complicated picture emerging from new scholarship in this history of psychiatry [new criticaltheoretical positions; new methodologies; new substantive studies] with the perspective that the role of constructed space is not incidental, we aim to shed new light on a number of questions. yThese include: the role built space played in narratives of psychiatric progress; the spatial formations of non-institutional responses to madness; the intersection of the domestic and the institutional; the situating of psychiatric institutions and the way they related spatially to the world beyond their borders; the way spaces and architecture were 7 These lectures consider countless localised ‘scenes’, distributed across 19thcentury Europe: specific practices of power that cannot but have been enacted in every asylum – in every ward, dayroom and corridor – as physicians and nurses sought to supervise, calm and control the disorders of the patients embodied before them. The ‘spatial history’ offered here departs somewhat from, or is a serious gloss upon, that in Madness and Civilization (Philo, 2007b), 8 The editors underline that they wish the term ‘architecture’ ‘‘to indicate more than the buildings themselves – it encompasses, for example, unbuilt projects, competitions, manuals, professional rivalries, and images used for publicity’’ (Moran and Topp, 2007, p. 4).

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manipulated both to classify patients and to create visual impact; the complex intersection between space and surveillance; and visual and spatial features imported into psychiatric spaces from outside psychiatry (Moran and Topp, 2007, p. 4). Their volume ranges in scale from the most intimate (i.e. a patient finding a ‘small corner’ for herself: Davies, 2007) to the most systemic (i.e. managing a whole imperial asylum system across, say, British India: Ernst, 2007); and at the same time there is an impetus to integrate fresh perspectives on space, with Foucault cited as an ongoing influence, with the sensibilities of the historian alert to places, ‘‘to the comparison of aspects of madness history from different times and in different geographical locations’’ (Moran and Topp, 2007, p. 12).9

Psychiatry at the margins Of particular significance for this theme section, however, is that various contributors to this ‘spatial turn’ in psychiatric history have recognised the importance of what we earlier called ‘unpromising configurations’, appreciating that many relevant developments have originated in places ‘off the beaten track’. This is not to insist that key developments have only occurred in what may be construed as the more marginal spaces of past mental health care ‘systems’; it would be foolish to deny that many such developments have surfaced in ‘leading’ institutions or medical schools, and often in national capitals. Yet mental health has been geographically peculiar: first in that many asylums, even large and well-known ones, were operated in places remote from both teaching centres and urban centres; as such, they were spatially and intellectually marginal, for reasons that we will now discuss. And second, as we show here, because many innovations arose in places that were not even central to the mental health ‘system’, whether or not they were geographically remote. From at least the 18th century, and through the middle of the 20th century, the largest institutions housing mentally unwell patients – the lunatic asylums, renamed as mental or psychiatric hospitals – were usually found in the hinterlands of urban centres, or in more rural and remote locations.10 The wish to rid populous localities of difficult-to-manage social groupings meshed with seemingly sound medical and moral-therapeutic reasons; and a recurrent ‘medico-moral’ locational discourse directed asylums into the relative seclusion of agricultural districts, forested valleys or desolate moorlands (Philo, 2004, Chs. 6 and 7; also Moran and Topp, 2007, pp. 7–8). One upshot was the denigration of provincial ‘loonybins’ as unfulfilling backwaters to which a posting, even as a superintendent, could signal professional and social death (for both [male] physicians and their families). In practice, however, some superintendents and their staffs experimented in all kinds of ways with their (often sizeable) inmate populations. Experiments 9 Other straws in this wind can readily be identified, and a fuller review of recent literature would cover Scull’s (2004) address on ‘The insanity of place’, itself inspired by Goffman’s (1969) essay of the same title; Melling and Forsythe’s (2006: esp.Ch.5) openness to distance-decay patterns in the geography of asylum admissions; the constant interest in built, neighbourhood and social spaces of Georgian lunatic hospitals shown by Smith (2007); or other contributions briefly reviewed by Moran and Topp (2004: 3–4). A handful of academic geographers have also tried to inject a geographical sensibility into psychiatric historiography, as a 1997 theme issue of this journal attests (Park and Radford, 1997; see review there by Philo, 1997). One of the authors of this paper has contributed a substantial body of empirical research (Philo, 2004). 10 A remarkable survey of ‘city and country’ in German psychiatry from the 19th century up until the era of National Socialism, contrasting city-orientated ‘university psychiatry’ with its country-orientated ‘asylum psychiatry’ cousin, is found in Pru¨ll (1999). A more sustained historical geography of psychiatry not written by a professional geographer is hard to imagine.

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in the removals of perimeter walls, locked doors and barred windows emerged from unlikely spaces such as the Inverness District Lunatic Asylum, opened in 1864 on the outskirts of this remote Highland town (Philo, 2007a). Experiments with convalescent homes and other ways of creating ‘variety’ in the institutional experience emerged from similarly unlikely spaces such as the Devon County Pauper Asylum, opened in 1845 in Exminster, a village four miles outside of Exeter in one of the most westerly counties of Britain (Philo, 1987a; Melling and Forsythe, 2006: esp. 18–20). Revealingly, the most innovative superintendent at the Devon asylum, Dr John Charles Bucknill, used his editorship of the Asylum Journal of Mental Science as a vehicle for connecting the scattered proto-psychiatrists labouring in the provincial ‘bins’, notably through regular articles summarising accomplishments which might never have been published except in institutional annual reports with small circulations. Bucknill did much to establish a discipline of mental science,11 by corralling spatially diverse ideas and practices into something with the semblance of overall shape, logic and focus. It can therefore be asserted – echoing Foucault of Psychiatric Power (2006b)12 and the geographically sensitive historians referenced above – that the ‘science’ (the body of understanding and application which was eventually to be termed ‘psychiatry’) was created in large measure from countless shards of evidence about what the lonely asylum-based physicians (and their staffs) had been thinking-and-enacting in their relative isolation.13 This asylum-based geography of mental health ‘care’ has been gradually dismantled since the 1950s, creating a much more messy, uneven and unstable post-asylum geography (Wolch and Philo, 2000) characterised by more and more potential spaces of innovation. As is well known (e.g. Bean and Mounser, 1993; Dear and Wolch, 1987, esp. Ch. 3; Parr, 2008, Ch.1; Scull, 1997), various challenges to the older institutional paradigm began to arise after circa 1950: from psychiatrists convinced that drug treatments could obviate the need for segregation; from policy-makers hopeful that alternative systems could be created, perhaps centred on general hospitals; from fiscal conservatives looking to cut costs to the public purse; from libertarians critiquing the ‘police’ functions of asylums and beginning to see mental health sufferers as ‘consumers’ deserving greater choice (e.g. Szasz, 1961, 1970); and from radicals and social scientists (including psychiatric ‘survivors’) objecting to the alienating oppressions of the asylum (e.g. Goffman, 1961). The upshot has been more-or-less committed state programmes of asylum closure, and the associated laying out of a new deinstitutional landscape wherein people with mental health problems could be better serviced – so

11 Tellingly, the journal was initially just named the Asylum Journal (1853–1855), and was very much the ‘house journal’ of the Association of Medical Officers of Asylums and Hospitals for the Insane, itself founded in 1841. It soon became the Asylum Journal of Mental Science (1856–1858) and then the Journal of Mental Science in 1859, signalling a growing sense of a unified scientific basis to the activities of medical officers serving in these scattered asylums. The journal eventually became the British Journal of Psychiatry. See Philo (1987b, 1994). 12 Foucault repeatedly stresses that the 19th-century ‘science’ here (mental science as proto-psychiatry) was itself derivative from the grounded practices of situated asylum physicians, rather than being a coherent body of knowledge informing these practices. The science was a precarious edifice tottering on the back of these practices, justifying them ‘after the event’, far more so than occurred in mainstream medicine precisely because questions of power – of the physician’s mind over the patient’s mind-and-body – so permeated each and every local ‘scene’ of proto-psychiatric encounter. 13 Many more examples could be added, and here we quote from a referee’s mention of ‘‘some other historical examples of significant developments occurring in out-of-the-way places—e.g. the early-18th-century establishment of the Bethel Hospital in Norwich; the development of the York Retreat in the 1790s; the stateof-the-art private Brislington House in 1808; the first abolition of mechanical restraint, at Lincoln Asylum, in the late 1830s, etc.’’ (Anon., 2008). All of these institutions are mentioned at different points in Philo (2004).

the reasoning went – in their own communities (rather than consigned to distant mental hospitals). This new landscape has been pieced together at varying rates, with many differences of detail, across much of the Western world over the past halfcentury or so. In many cases the asylums have still not quite disappeared and remain as shrunken, overcrowded, in-patient facilities; but now joined (if briefly in some cases) by all manner of new spaces – psychiatric units in general hospitals, day care and treatment centres, drop-in clinics, half-way hostels and other supported accommodation, counselling services, therapeutic schemes, and many more – funded, run and managed by an amalgam of the state (national and local), the voluntary sector and private enterprises.14 It is true that in some eyes a clear hierarchy remains in terms of generating reliable psychiatric knowledge; the likes of university-based teaching hospitals and global pharmaceutical companies, together with the associated research laboratories, teams and trials, are the new centres of excellence for biomedicalpsychiatric innovation (Micale, 2000). But for many others involved in mental health policy, the ‘experiments’ with most potential to improve the conditions of life for sufferers, and more broadly to promote positive mental health in all of us, arise in all manner of spaces from the psychoanalyst’s couch through the arts-and-music therapy sessions of diverse small-scale mental health groups to the more politicised rights-based projects of mental health activists (Parr, 2008). Seen in this light, no single ‘centre’ holds sway, and, while this eventuality can itself be critiqued, there are now multiple creative centres and margins, and many points in-between. The geographies, including the recent historical geographies, of these spaces are so many and varied, and require such careful configurational unpicking, that many of our previous conceptual and methodological tools are simply not up to the job.

This theme section Depicting matters in this way starts to clarify what we mean by taking seriously local historical geographies of psychiatry, not (just) as exercises in loving local empiricism, but also as contributions towards rewriting the stories of psychiatry and other mental health subjects wherein ‘big themes’ still emerge in creative – if sometimes tense – relationship with local complexities. Ideally we would say far more to support this claim, to flesh out its many epistemological dimensions, and indeed to reflect upon certain ethical and political implications regarding what we might advocate for future – non-totalising, geographically sensitive and appropriately human-scaled – mental health policies (see Parr, 2008). Nonetheless, we hope that enough has been said to frame the three papers that follow in this theme section, each of which is a persuasive instance of local psychiatric historical geography in its own right. Specifically, we begin with Erika Dyck’s investigation, as a social and cultural historian, into how the Canadian prairie province of Saskatchewan played host in the 1950s to various controversial experiments in the use of psychedelic drugs, notably LSD. This ‘out-of-the-way’ region, often seen inhospitable and barely ‘on the electric’ was, for various conjunctural reasons, associated with a distinctive agricultural-socialist politics and with innovations in state medicine; thus it became a ‘magnet’ for a number of leading pioneers in psychiatric medicine who sought sustainable alternatives to the prevailing warehouse model of 14 In England, most of the ‘elderly (and severely) mentally ill’ are now in private ‘homes’, which cannot but recall the 18th and 19th-century ‘trade in lunacy’ (Parry-Jones, 1972).

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asylum ‘care’ (also Mills, 2007). The second paper is by Val Harrington, working as a social and oral historian, who carries forward some of the issues about hospitals and psychiatric services discussed in Pickstone’s 1988 presentation. She dissects a pioneering development of community services in the 1980s, which helped ‘resettle’ long-stay patients from local asylums. North Manchester was a district consistently under-resourced and not blessed with a teaching hospital, and its mental facility, Springfield Hospital, was uniquely depressing—neither a major asylum nor a general hospital psychiatry unit—and run in an awkward relation with a large general hospital, Crumpsall Hospital, on the same ex-workhouse site. Yet it was here, rather than in the more privileged districts of Manchester, that something unexpected and radical (in political and policy terms) surfaced. The final paper is by Helen Spandler, proceeding from a more explicitly anthropological-sociological background and mobilising concepts from the recent geographical literature, wherein she examines how, for a period from the late-1960s into the 1970s, the Paddington Day Hospital in North London became a radical experiment: as a ‘therapeutic community’ predicated on an open-door policy, self-consciously adopting and radicalising a specific form of (group) psychoanalysis, and suffused with a potent mix of psychoanalytic and politicised convictions. In all three papers, ‘unpromising configurations’, spaces and places produced important and influential innovations which would ‘not have been looked for there’. In all three cases, the sites were later returned towards the norms, but norms that they maybe helped to shift. Temporarily, at least, they had become distinctly hopeful local historical geographies of psychiatric, or even it might be said anti-psychiatric, innovation. They brilliantly illustrate the broader themes raised in this introductory paper, but they also matter in their own right as pointers to what could be different in the local worlds of people who have to cope with mental demons.

Acknowledgements Versions of the three main papers in this theme section were delivered at the Symposium on ‘Developments in mental health since 1945: international and local perspectives’ held in the Centre for the History of Science, Technology and Medicine, University of Manchester, on 23 February 2007. Thanks must be extended to Val Harrington for her work in organising this event, to the Wellcome Trust for funding it, and to all participants at the conference for their enthusiastic participation. Special thanks are also due to two referees who provided detailed responses to all contributions in the theme section, our own included, and particular thanks are extended by the two editors to the three contributors for their hard work, patience and flexibility in preparing and revising their papers. References Anon., 2008. Referee’s comments. Pers. comm. to the, editors. Bean, P., Mounser, P., 1993. Discharged from Mental Hospitals. Macmillan, Basingstoke, UK. Barnes, B., 1974. Scientific Knowledge and Sociological Theory. Routledge and Kegan Paul, London. Barnes, B., Bloor, D., Henry, J., 1996. Scientific Knowledge: A Sociological Analysis. Athlone, London. Barnes, B., Shapin, S. (Eds.), 1979. Natural Order: Historical Studies of Scientific Culture. Sage, London. Biagioli, M., 1993. Galileo, Courtier: The Practice of Science in the Culture of Absolutism. Chicago University Press, Chicago. Bloor, D., 1976. Knowledge and Social Imagery. Routledge, London. Burnham, J., 2006. A clinical alternative to the public mental health approach to mental illness: a forgotten social experiment. Perspectives in Biology and Medicine 49, 220–237.

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