Gerald N Grob
email: ggrob@rci.rutgers.edu

Who should write the history of psychiatry?

For nearly a half century the history of psychiatry has been a vibrant if contentious subject. Those who have ventured into this fi eld have come from a variety of disciplines, including medical and social history, medicine (especially psychiatry), and the social and behavioural sciences. The result has been twofold. First, there has been an outpouring of books and articles based on wide research in both printed and manuscript sources that has gone well beyond the traditional approach which made the history of psychiatry a history of enlightenment and progress. Secondly, approaches to the subject -to paraphrase Bernard Weisberger's description of the historiography of post-Civil War Reconstruction in the USA -have resulted in a 'dark and bloody' battlefi eld on which partisans on all sides rush to battle (and destroy) their protagonists [START_REF] Weisberger | Reconstruction: an American morality play[END_REF]. Those who have ventured into the subject have debated whether hospitals and psychiatrists were serving as repressive instruments of social control; whether the inability of institutions to live up to expectations was simply a perennial concomitant of the human experience or the consequences of malevolent intentions; and whether or not mental disorders were socially constructed or had an existence of their own. While many contributions have served to enrich our understanding of both individuals with severe mental disorders and psychiatrists, others have added little. Walter W. Winslow's The History of Psychiatry in New Mexico, 1889Mexico, -1989 is an example of the latter. A well-known psychiatrist who was associated for many years with the University of New Mexico's School of Medicine, Winslow decided to prepare a monograph that drew upon a very limited number of primary documents, oral interviews with many of the individuals who played a role in developing psychiatric services in the state, and his own experiences. That the history of psychiatry in New Mexico had potential is clear. It was a new state that lacked the traditions and institutions of older states like Massachusetts, New York and Pennsylvania, all of which played important roles in shaping mental health services in the USA.

Unfortunately, Winslow approached the subject without knowing anything about the historiography of psychiatry and its institutions or the perils of oral history. In offering such a judgement I am not arguing that only professionally trained historians are qualifi ed to write about this subject, nor am I unsympathetic towards involved laypersons. However, I do insist that those who write history have an unavoidable obligation to become familiar with a very large and rich historical literature as well as the techniques associated with oral history. There is not the slightest evidence that Winslow has read a single monograph or article dealing with the subject. Nor is there any indication that he understood the complexities involved in asking individuals to provide personal recollections. Properly done, oral history requires a great deal of research to ensure that appropriate questions be asked. There is, after all, a crucial distinction between history and memory. History is an attempt to understand the past by using source material in a critical manner. Memory, in contrast, includes the recollections of individuals, often fi ltered by the passage of decades. While the two may at times overlap, sharp differences often remain.

The result of Winslow's endeavours is to present a list of individuals and institutional changes that lack any interpretative or substantive foundation. It is an example of antiquarianism at its worst.

Alice Davis Wood's biography of Francis T. Stribling is another, albeit different, kind of amateur history. For many years she managed General Electric's technical publications department and offered writing courses for their engineers. After retiring she turned to history and biography. The subject of her study -Dr Francis T. Stribling -was superintendent of Virginia's Western State Hospital from 1836 to 1874, a period in which institutional care of persons with a severe mental disorder was becoming the norm. Stribling was also an active member of the American Association of Hospital Superintendents of the Insane (which in 1921 became the American Psychiatric Association).

Wood's work differs in fundamental respects from that of Winslow. Using annual reports, Stribling's correspondence in the archives of Western State Hospital and other primary sources, she has attempted to portray the life of a nineteenth-century asylum physician. Born in 1810, Stribling briefl y attended the newly-established medical school at the University of Virginia in Charlottesville. The school, however, lacked facilities for clinical instruction, and soon concluded an arrangement with the University of Pennsylvania by which Virginia graduates were accepted on an equal basis with other students. Stribling received his medical degree from Pennsylvania, and returned to his native Staunton to practise medicine.

Several years earlier Virginia had created its second mental hospital to serve the western part of the state, and the new facility opened in 1828. At that time a hospital superintendency was an attractive position. The medical profession was beset by rivalries and challenges, and its economic foundation was anything but secure. Indeed, for much of the nineteenth century the status of asylum physicians was much higher than that of their medical brethren. When the contract of Western State Hospital's superintendent expired in 1836, Stribling mounted a successful challenge and became superintendent, a position he held for nearly forty years. Wood provides a fairly detailed portrait of his long career.

To her credit, Wood has examined a large mass of valuable primary source material hitherto unused. Nevertheless, she missed a golden opportunity to use her sources in a sophisticated and informed manner. Her glowing and uncritical narrative tends to give Stribling a heroic character. More importantly, Wood is largely unaware of works by historians that have changed our understanding of nineteenth-century psychiatry. Nancy Tomes' superb biography of Thomas S. Kirkbride (1984), for example, illuminated in depth the career of one of the outstanding fi gures in nineteenth-century asylum psychiatry. Recent biographies of Dorothea L. Dix (who plays a prominent role in Wood's work) transformed our understanding of this important fi gure [START_REF] Brown | Dorothea Dix: New England Reformer[END_REF][START_REF] Gollaher | Voice for the Mad: The Life of Dorothea Dix[END_REF], and works by scholars such as Ellen [START_REF] Dwyer | Homes for the Mad: Life Inside Two Nineteenth-Century Asylums[END_REF]Peter McCandless (1996) have reshaped our understanding of institutions. Wood's failure to take into account the scholarship of the last four decades largely vitiates her work in primary sources. Moreover, she romanticizes Stribling's life and eschews analysis. Nor does she grasp the problems inherent in nineteenth-century psychiatric theory and therapeutics. The book, therefore, refl ects a tradition long-since rendered obsolete by recent scholarship.

In contrast, Lawrence B. Goodheart's Mad Yankees is the work of an academic historian who became interested in the Hartford Retreat for the Insane, one of America's oldest private institutions. Opened in 1824, the Retreat was designed to care for private patients, although it accepted a small number of charity cases. Because Connecticut, unlike other northeastern states, failed to create a public hospital, the Retreat accepted increasing numbers of individuals unable to pay the high charges associated with private care. The opening of a public hospital in 1868, however, gave John S. Butler, the Retreat's superintendent, an opportunity to transform his institution into an elite private hospital for affl uent individuals, a character that it retained for decades.

Aware of recent scholarship, Goodheart provides a complex history of the Retreat that places its origin and development within a broad context. Avoiding the simplistic accounts of the origin of institutions associated with such fi gures as Michel [START_REF] Foucault | Histoire de la folie à l'âge classique (Paris: Librairie Pion); the complete English translation appeared in 2006[END_REF]Foucault ( /2006) ) and David [START_REF] Rothman | The Discovery of the Asylum: Social Order and Disorder in the New Republic[END_REF], he emphasizes the complex forces that created the Retreat, including voluntarism, philanthropy and religion. Institutionalization of persons with severe mental disorders, as Goodheart observes, was not without irony. Those involved in its founding and early history believed that asylum care and treatment held out the promise of recovery. Yet the combined interaction of chronicity and custodial care, costs and class produced ironical outcomes that refl ected the profound differences between public and private medicine.

Goodheart's book is an example of institutional history done well. The book focuses largely on the crucial role of physicians and elites, although it does not neglect those social and economic factors that played such a signifi cant role in the evolution of the Retreat. It does not, however, examine the experiences of patients both prior to and including their committal. In this sense it is not on the cutting edge of recent scholarship, which utilizes such hitherto ignored sources as patient records. Institutional character, after all, resulted from the complex interplay of physicians, staff and patients; the latter were by no means inactive participants in shaping their destiny. This said, there is no doubt that Goodheart's monograph is a useful contribution to the history of American institutional psychiatry.

Precisely because of its controversial character, writing about the history of psychiatry is not an easy task. It cannot be written in a vacuum that ignores context and interrelationships. It also requires knowledge about past contributions and a willingness to explore both traditional and non-traditional sources. This is not to imply that the subject should be limited to academic historians. One has only to look at the contributions of such fi gures as Henry Sigerist, Erwin Ackerknecht, Owsei Temkin, Saul Jarcho and Lester King, trained in medicine but who helped to transform the writing of medical history. Their works have survived the test of time precisely because of their understanding of the complexities and ironies involved in the writing of history. One can only hope that others -regardless of their pedigree -follow their example.


Consultant Psychiatrist

Claire Hilton
email: claire.hilton@nhs.net

The provision of mental health services in England for people over 65 years of age, 1970-78

Keywords: closure of mental hospitals, community care, dementia, psychogeriatrics, Royal College of Psychiatrists

The twentieth century saw an increasing number of people living into old age, and consequently a higher prevalence of age-related chronic degenerative brain disorders. By 1971 the mental hospitals were almost half full with people over 65 years of age. Thus plans to close the mental hospitals meant that the development of community mental health services for older people was a necessity. Although there was a multi-disciplinary focus on the care of older people, the lead in service development was largely taken by psychiatrists, both individually and through the Group for the Psychiatry of Old Age at the Royal College of Psychiatrists.

Introduction

Major changes took place in the provision of mental health services in the 1970s. However, historians of psychiatry such as Andrew [START_REF] Scull | Decarceration: Community Treatment and the Deviant -A Radical View[END_REF] and Edward [START_REF] Shorter | A History of Psychiatry: From the Era of the Asylum to the Age of Prozac[END_REF] have largely ignored the impact of these changes on older people. This paper aims to fi ll this gap.

The study falls into four parts: psychiatrists and psychogeriatricians; new policies; multi-disciplinary working; and providing alternatives to the mental hospitals. Many of the sources referred to were in a bulging lever-arch fi le belonging to the secretary of the Group for the Psychiatry of Old Age . This file remained with his successor until 2004 when it came into my possession. Other primary sources include textbooks, journals, oral history interviews, and archives from the Bethlem Royal Hospital, King's Fund and Wellcome Library.

Background

Mental illnesses such as depression, schizophrenia and neuroses (functional disorders) affect older as much as younger adults. Dementia (organic degenerative brain disorders) and acute delirious states are more common in old age. These disorders can co-exist, and be further complicated by physical illness and frailty, plus psychological and social factors such as bereavement. Such complex clinical scenarios were clearly noted in the 1940s [START_REF] Lewis | Social causes for admission to a mental hospital for the aged[END_REF][START_REF] Post | Some problems arising from a study of mental patients over the age of 60 years[END_REF].

Mental health care for older people in England had been developing slowly in a piecemeal and sporadic fashion before 1970 (Hilton, 2005a(Hilton, , 2005b)). Felix Post, the fi rst old age psychiatrist at the Bethlem Royal Hospital, was appointed in 1947 and pioneered treatment of psychiatric disorders in older people [START_REF] Post | The Signifi cance of Affective Symptoms in Old Age[END_REF][START_REF] Post | Persistent Persecutory States of the Elderly[END_REF]. Martin Roth classifi ed the major psychiatric disorders in old age [START_REF] Roth | The natural history of mental disorders in old age[END_REF]. The fi rst international conference on the subject took place in London in 1965 (Anon., 1965). England was not alone in overlooking older people's mental welfare. In 1972 the World Health Organisation (WHO) noted this was an international phenomenon. In particular, 'Progress made towards implementation of the recommendations made in the [1959] report has been disappointing' (WHO, 1959(WHO, , 1972)).

In 1970 the memorandum Psycho-geriatric Assessment Units (DHSS) suggested a revival of Government interest in older people. A report in The Lancet of the older people's psychiatric unit at Goodmayes Hospital, Ilford [START_REF] Arie | The fi rst year of the Goodmayes psychiatric service for old people[END_REF], as well as considerable correspondence relating to psycho-geriatric assessment units suggested a medical interest [START_REF] Andrews | Psycho-geriatric assessment units[END_REF][START_REF] Burrowes | Psycho-geriatric assessment units[END_REF][START_REF] Exton-Smith | Psycho-geriatric assessment units[END_REF][START_REF] Exton-Smith | Psycho-geriatric assessment units[END_REF][START_REF] Hurst | Psycho-geriatric assessment unit[END_REF][START_REF] Wilson | Psycho-geriatric assessment unit[END_REF]). Whitehead's book In the Service of Old Age (1970) 'to inform public opinion of what can be done, and to stimulate self-scrutiny by authorities who should be doing more' was published by Penguin, suggesting a wider interest in the mental wellbeing of older people. Again pivoting around 1970, scientifi c papers from the 1969 symposium Recent Developments in Psychogeriatrics were published in 1971 (Kay and Walk). Also in 1970 the Hospital (later Health) Advisory Service (HAS) began to inspect long-stay hospitals [START_REF] Baker | The Hospital Advisory Service[END_REF], giving new insights into the care of elderly mentally infi rm (EMI) people.

While Ministry of Health and Department of Health and Social Security (DHSS) directives usually related to England and Wales, the Royal College of Psychiatrists, which had a major infl uence on service development, drew its membership from the entire British Isles and beyond. However, because of travelling distances, most of those attending the College Group for the Psychiatry of Old Age 1 in London were from England. 2 Thus this paper necessarily focuses on the provision of mental health services for older people in England only.

Psychogeriatrics: what is it? Rather like 'community care', the term 'psychogeriatrics' emerged without a clear defi nition or origin [START_REF] Isaacs | The development of psychiatric services for the elderly in Britain[END_REF]. Consequently it had different meanings to different people. When hyphenated as 'psycho-geriatric' in 1950 it implied geriatricians and psychiatrists working together to assess older people. 3 Hardly used for nearly two decades, it then became a bone of contention: 'part of the problem of the acquired respectability of the term is that people are beginning to believe that it really has a meaning' [START_REF] White | Psychogeriatrics -what next?[END_REF]. In 1971 the Society of Clinical Psychiatrists said psychogeriatrics included 'the whole range of psychiatric conditions in the aged' [START_REF] Enoch | The Organisation of Psychogeriatrics (Ipswich: Society of Clinical Psychiatrists[END_REF], while a group of geriatricians and psychiatrists concluded that since general psychiatrists should care for patients of all ages with functional disorders, there was no need for a separate specialty of psychogeriatrics [START_REF] Andrews | Planning of psychogeriatric care: a report of a joint working party of geriatric physicians and psychiatrists[END_REF]. It remained unclear whether geriatricians or psychiatrists should care for people with dementia. However, with the recognition that 'behavioural disturbance is the real "nitty gritty" of psychogeriatrics', 4 it was highly unlikely that division of labour by diagnosis rather than need was appropriate. Others considered that 'Psychogeriatrics … was largely a social problem'. 5 Whitehead (1976) commented: not only is psychogeriatrics an ugly word … but means different things to different people … Brice Pitt … defi nes it as 'that branch of psychiatry which is concerned with the whole range of psychological disorders developing in the senium'. Let us hope that this defi nition will become universally accepted.

Psychiatrists are medical doctors, in contrast to psychotherapists, psychoanalysts and psychologists who are usually not medically trained. Those working with older people in 1973 tended to identify themselves as general psychiatrists with a special interest in old age. The term 'psychogeriatrician', a psychiatrist working with older people, only gradually emerged. The early 1970s saw the embryonic development of psychogeriatrics within psychiatry. It remained somewhat nebulous in its identifi cation, with its roles open to negotiation.

Policy and organization

The Hospital Plan (Ministry of Health, 1962) proposed a comprehensive system of District General Hospitals (DGHs). Although both geriatrics and mental illness were included, there was no reference to the elderly mentally ill. Plans to close the mental hospitals predicted a reduction in mental hospital beds from 150,000 to 75,000 over 15 years, while integrating services for 'mental disease' into the community and DGH (Ministry of Health, 1962;[START_REF] Powell | Water Tower speech[END_REF].

Community care was an important concept traced back to a loosening of statutory restraints on care for the mentally ill, such as the Maudsley Hospital admitting voluntary patients in the 1920s, the Mental Treatment Act (1930) allowing psychiatric out-patient clinics, and some experimentation in community approaches before World War II [START_REF] Welshman | Rhetoric and reality: community care in England and Wales 1948-74[END_REF]. Further community development was promoted by the availability of new psycho-active medications in the early 1950s, the Mental Health Act (1959), an emphasis in the 1960s on personal autonomy and the emergence of the anti-psychiatry movement, although they showed little specifi c interest in older people [START_REF] Tantam | The anti-psychiatry movement[END_REF]. In 1963 the Ministry of Health urged local authorities to develop community care.

The 1974 reorganization of the National Health Service (NHS) theoretically supported these earlier objectives, aiming to provide locally organized health care tailored to population needs. In England, strategic Regional Health Authorities emerged with Area Health Authorities directing District Management Teams and Family Practitioner Committees, which organized care coterminous with local authorities (DHSS, 1972a). However, the medical profession appeared to view reorganization with some scepticism, for example, referring to the forthcoming 1 April changes: 'All Fools Day next year will see a tragi-comedy of epic proportions' [START_REF] Mckie | Those two reorganisations[END_REF], and will 'sacrifi ce both health workers and patients on the altar of "managerial effi ciency"' (Robson, Iliffe and Le Fanu, 1972). Psychiatrists in 1976 suggested 're-introduction of a body of educated people to whom one could turn at hospital level rather than the present situation of dealing with faceless voices'. 6 Other contemporaneous reports affected mental health services. For example, the 1966 Salmon report reorganizing senior nursing staff structure was criticised in that 'too many qualifi ed people have become desk bound'. 7 The Seebohm report (1968) organized social services into local area teams, making social workers more family orientated, but reducing the provision of specifi c mental health social workers.

The relative contributions of social ideology and economic forces are hard to ascertain. Secretary of State Barbara Castle wrote that psychiatric services would continue to be based in the mental hospitals for some years until the economic situation improved [START_REF] Dhss | Better Services for the Mentally Ill[END_REF]. Community care may have been proposed as a cheaper alternative to institutional care, due to concerns over ever-rising costs of healthcare within a capitalist welfare system [START_REF] Scull | Decarceration: Community Treatment and the Deviant -A Radical View[END_REF]. However, smaller units were pro rata more expensive to run [START_REF] Ross | Geriatric day hospitals: counting the cost compared with other methods of support[END_REF]Royal College of Psychiatrists, 1976). Despite optimistic policies, fi nancial constraints were a signifi cant limiting factor 8 (Anon., 1974a;[START_REF] Enoch | The Organisation of Psychogeriatrics (Ipswich: Society of Clinical Psychiatrists[END_REF].

The dilemma: would more old people fi ll the mental hospitals? In 1971, of 116,000 patients in mental hospitals 52,000 were over 65 years. Whereas numbers of long-stay patients were overall decreasing, the previous 15 years had seen an increase of 34% in those over 75 (National Association for Mental Health, 1972). The same year, in England and Wales, 13.3% [START_REF]Evidence of the Royal College of Psychiatrists to the Royal Commission on the National Health Service[END_REF]865,000) of the population were over 65 years and 4.7% (2,318,000) were over 75 compared with 4.7% and 1.4%, respectively, in 1901 [START_REF] Isaacs | The development of psychiatric services for the elderly in Britain[END_REF].

In part, this demographic change explains why Emil Kraepelin in his early twentieth-century classifications of mental illness hardly mentioned the degenerative brain diseases of old age. He did, however, refer to 'senile' and 'involutional' psychoses, but his patients 'of considerable age' were mostly aged under 60 [START_REF] Kraepelin | Lectures on Clinical Psychiatry[END_REF]. Even the original description of 'Alzheimer's disease' related to a 55-year-old woman [START_REF] Alzheimer | Ueber eine eigenartige Erkrankung der Hirnrinde[END_REF], thus setting up the inaccurate paradigm of 'senile dementia' being different from Alzheimer's in younger people. In 1946 Aubrey Lewis predicted that older people might eventually entirely fi ll the mental hospitals as age-related disorders became more commonplace. However, dementia was frequently missed in local statistical returns 9 and under-diagnosed in primary care [START_REF] Williamson | Old people at home: their unreported needs[END_REF] so data tended to underestimate prevalence and need, and hence resources. Although desegregation of the mentally ill was a moral issue for younger people, it was an essential medical one for older people with complex health needs. Despite this, older people were not prioritized.

Psychiatrists and psychogeriatricians: the Royal College of Psychiatrists and Group for the Psychiatry of Old Age

Many psychogeriatricians making the greatest impact like Tom Arie (Goodmayes 1969-77, then Nottingham), Anthony (Tony) Whitehead (Severalls, Colchester 1960s, then Brighton) and David Jolley (Manchester 1976) did this both through developing local clinical services and their involvement with the Royal College of Psychiatrists Group for the Psychiatry of Old Age (GPOA).

In 1971 a 'coffee house' group of psychiatrists working with older people was meeting to exchange views and consider ways of improving psychogeriatric services. 10 They included Tom Arie, Carrick McDonald (Warlingham Park, Surrey), Loic Hemsi and James Cockburn (Long Grove, Epsom), Brice Pitt (Claybury 1966-69, then Harlow, then the London Hospital 1971-84) 11 and Klaus Bergmann and Garry Blessed from Newcastle-upon-Tyne [START_REF] Arie | Martin Roth and the "psychogeriatricians[END_REF]. They realized that in order to make any impact, they would both have to increase their numbers and have to acquire a body through which they could fi nd a voice. Having written to some 50 members and fellows of the Royal College of Psychiatrists, they achieved a quorum of potential participants to form an offi cial College Group, inaugurated on 9 February 1973. 12 As a support and discussion group there were no terms of reference; these evolved later. 13 Felix Post was elected chairman, and Brice Pitt secretary. Martin Roth, president of the College, declined to participate despite his extensive research into older people's mental health. 14 The pioneering psychogeriatricians were noted for their enthusiasm [START_REF] Baker | Why psychogeriatrics?[END_REF], and [START_REF] Arie | Morale and the planning of psychogeriatric services[END_REF] wrote about psychogeriatrics: 'I have never before been in a professional setting where intellectual and emotional satisfaction go more closely hand in hand'. In 1975 the Group had about 100 members and enquired about becoming a more prestigious Section of the College. They were told that at least 500 members were required. 15 One advantage of Section status was representation on College Council, viewed as vital since 'The Group can not rely on the College putting matters concerning the psychiatry in old age before members'. 16 This, however, was temporarily resolved when Post was elected to Council (Anon., 1975). Despite inadequate membership for Section status, the College indicated that the Group was too big for their current structure and they should form an executive committee. The Group expressed some resentment at being told how to organize themselves. 17 However, one of the reasons given was that as a pressure group they were not making enough impact, since quarterly meetings were insuffi cient to prepare comments for submission to Council. An executive committee acting between meetings could do this. 18 If the College's perception was correct, it is regrettable that it took three years for this important point to be made since the Group was the only national organization solely dedicated to advocating for elderly mentally ill people.

Psychiatrists' attitudes to older people were ambivalent, with a degree of tension between the established College hierarchy and the new psychogeriatricians. [START_REF] Whitehead | Now tell us how to solve the psychogeriatric problem of the psychiatric hospitals[END_REF] commented that psychiatrists should stop 'pretending that the old were not their concern', and Pitt recollected:

General psychiatrists were dead keen to get us to take their old schizophrenics … it was quite absurd because there were a great many of them, so we said no, it has got to be mental illness which starts after the age of 65, which is arbitrary although makes a bit of sense … We were pretty paranoid about general psychiatrists … who were more likely to exploit than support us. 19 With this ambivalence, coupled with the DHSS's habit of planning for younger before older mentally ill people, psychogeriatrics risked being neglected. For example, the College and DHSS proposed increasing the number of consultants in general psychiatry without a proportional increase in psychogeriatricians, despite population trends. 20 Eventually this was amended. 21 The care of 'graduates', chronically ill patients admitted before modern treatment who had grown old in hospital, was also on the interface with general psychiatry. 22 Rehabilitation required overcoming numerous behavioural problems of institutionalization [START_REF] Goffman | Asylums[END_REF]. McDonald argued passionately for psychogeriatricians to be involved with rehabilitating older graduates, reporting in 1975 of his success, and: 'If we, the interested psychogeriatricians, turn our backs … they will be condemned to live out their lives in our mental hospitals for no better reason than that they have already spent many years incarcerated therein.' 23 Psychogeriatricians acknowledged an ethical obligation towards this work, but staffi ng levels were such that it would be 'impossibly burdensome'. 24 The College appeared to being doing little to improve awareness of trainee psychiatrists about older people. Psychotherapy, child and forensic psychiatry were on the syllabus while psychogeriatrics was noticeable by its absence (Royal College of Psychiatrists, 1973b). With respect to training psychogeriatricians, in 1973 consultant posts were being advertised, but there were inadequate numbers of senior registrars training. The Group therefore wrote to the DHSS to create six training posts. 25 This letter probably sparked an invitation for Group representatives to attend the College's manpower subcommittee which, although expressing 'some opposition' to psychogeriatrics, nevertheless supported the creation of these additional posts. 26 By 1975, however, there were still only three training posts, at Goodmayes, the Bethlem and Maudsley, and Tindal General, Aylesbury (Pitt, 1975). An unsupportive letter to the Group from Thomas Bewley (College sub-dean) emphasized that each individual would need to negotiate funding for training locally. 27 However, not to be thwarted, the Group established its own old age training sub-committee, and the British Post Graduate Medical Federation approved several 'advanced secondment' training units. 28 The benefi ts of this scheme were reported by [START_REF] Jolley | Psychiatrist into psychogeriatrician[END_REF].

Both training and appointing new consultant psychogeriatricians progressed inconsistently. When in 1977 it was reported that the Yorkshire Regional Manpower Committee had refused funding for consultant and senior registrar posts, it became apparent that neither psychiatrists nor geriatricians sat on that committee. The objectives of the posts were probably not understood, 29 emphasizing the need for those working with older people to be involved in medical management. The fact that the Group commented 'it is ill advised for a new consultant to be expected to manage with half an offi ce and a third share in an inferior typist' suggests that this sort of scenario actually occurred. 30 Arie's opinion (quoted in Anon., 1978) was that care for elderly mentally ill people was a 'political emergency', estimating that, based on existing recommendations, there were 200 psychogeriatric consultant vacancies, but still only six senior registrars training. Contrary to previous advice, in order to appoint a second consultant in some districts he even advocated appointments to relatively unresourced posts, as resources would not be allocated until someone was there to fi ght for them. Indeed, an important role for the psychogeriatrician was 'to organise services to meet the community's need … occasional militancy required to gain for the elderly a fair share of scant resources to put them to best use, to make do with too little while wheeling, dealing, and fi ghting for more.' 31 It was also considered that chronic dementia services were unlikely to attract enthusiastic applicants, and any post of less than 25 hours a week was probably unworkable, indicating that the health authority had little idea of the nature and extent of the work. 32 The Group's relationship with the College hierarchy was sometimes diffi cult, but Pitt (1974) argued that opponents to psychogeriatrics 'are in no stronger a position than Canute holding back the waves'. There were other hiccoughs, such as when the infl uential HAS suggested that only one consultant psychogeriatrician was required for a population of 700,000, leading to the director Dr Woodford-Williams being invited to explain such a 'wholly inadequate' proposal to the Group. 33 However, from the handful of psychiatrists with a special interest in older people in 1970, there were 120 psychogeriatricians by 1980, each dedicating on average 25 hours a week to older patients [START_REF] Post | Psychogeriatrics[END_REF]. That itself was a huge achievement.

A new policy: Services for Mental Illness Related to Old Age.

HM(72)71

Services for Mental Illness Related to Old Age (DHSS, 1972b) -originally Hospital Services for Mental Illness Related to old Age -followed Hospital Services for the Mentally Ill [START_REF] Dhss | Hospital Services for the Mentally Ill[END_REF], which hardly mentioned older people. Developed by the 'coffee house' group working closely with the DHSS, 34 'HM(72)71', as it became known, was the blueprint for developing psychogeriatric services. It identifi ed three groups of elderly patients: graduates who were to be rehabilitated and discharged if possible; those with functional illness who were to be treated along with younger patients in the DGH; and those with dementia who should be cared for either by psychiatrists or by geriatricians, depending on their physical health needs. While beds and 'places' were numerically specifi ed, staffi ng levels were not defi ned, and appointing a psychiatrist in each area with special responsibility for the aged was only tentatively proposed.

In response to HM(72)71, MIND, with Age Concern, surveyed psychogeriatric services. Problems identifi ed included a lack of assessment facilities, understaffed wards, staff discouraging visitors, and only 19% of psychiatric hospitals having a geriatrician or psychiatrist for older people. Concern remained that 'much more specifi c and realistic targets can and should be set' (National Association for Mental [START_REF] Ministry | Care of the aged suffering from mental infi rmity[END_REF]. [START_REF] Bergmann | Psychogeriatric services. News and Notes[END_REF] noted MIND's attack on DHSS policy, adding that clinicians 'may forget that their own attitudes may also have contributed to the present unsatisfactory situation'.

The merits or otherwise of the memorandum were immediately on the Group's agenda, a major question being 'Is the DHSS aware of, and prepared to condone the inadequacy of services?', and it requested an offi cial meeting with the DHSS. 35 Although an informal discussion took place, an offi cial conference was postponed until after Better Services for the Mentally Ill [START_REF] Dhss | Better Services for the Mentally Ill[END_REF] which also largely prioritized younger people. 36 Assessing the impact of policies and obtaining resources was in part difficult because of inadequate data. Lack of recognition of psychogeriatrics by the DHSS as a specialty until 1989 guaranteed a dearth of relevant data. Data about older people with mental illness were sometimes subsumed under the title 'For the elderly (including the elderly mentally infi rm)' (Ministry of Health, 1964). Statistics on day hospital usage did state numbers of people over 65, but were unreliable. In this instance, recording attendances on the last full working day of the year between Christmas and New Year risked showing an underutilization of available places (DHSS, 1973a). Both the lack of data and the diffi culties in interpreting it encouraged the Group to collect its own data.

In 1974 service-related research was undoubtedly led by Kay and Roth in Newcastle. However, the Group distributed a questionnaire to members about resources and working practices. 37 Importantly, this indicated that none of the areas surveyed had all the facilities deemed to constitute a comprehensive service by the DHSS, making it impossible to give meaningful statements on the adequacy of DHSS proposals. 38 Pitt's notes commented 'DHSS still dragging feet over specialty?', while Arie, in the presence of Dr Brothwood from the DHSS, suggested that lack of data on older people was hampering progress. 39 However, the DHSS appeared to listen to the Group, which was important for making progress. 40 The Group challenged itself to ascertain the real numbers of psychogeriatricians. The secretary wrote to 117 Area medical offi cers to fi nd out which psychiatrists had responsibility for psychogeriatrics. 41 Replies indicated that 61 Areas had psychiatrists with a special interest in older people, but '8 of these claims seem highly dubious'. 42 The secretary planned to write to those nominated who were not Group members 'asking if indeed they had an interest and would like to join'. 43 This scenario again emphasized the diffi culty in both obtaining and interpreting data for the specialty.

Other Group members, such as Langley working in conjunction with Exeter University's Institute of Biometry, shared their research on service development. 44 Promoting such research became an important objective of the Group, 45 probably contributing to England's lead in service development 'well ahead of the North American scene' [START_REF] Shulman | The future of geriatric psychiatry[END_REF].

Multi-disciplinary work

Collaboration and dissent: working with geriatricians

In the mid-1940s, Dr Marjory Warren reported on the successful rehabilitation of older physically ill people [START_REF] Warren | Care of chronic sick[END_REF][START_REF] Warren | Care of the chronic aged sick[END_REF]. She set the foundations of geriatric medicine which developed far more rapidly than psychogeriatrics. Collaboration between psychiatrists and geriatricians was crucial for providing care to older mentally ill people, although the physicians clearly placed the onus for service development on the psychiatrists. 46 Prior to 1970 there had been some successful joint ventures between psychiatrists and geriatricians, such as in Edinburgh [START_REF] Fish | A delirium unit in an acute geriatric hospital[END_REF], Nottingham [START_REF] Morton | The joint assessment and early treatment unit in geriatrics[END_REF]) and Cornwall [START_REF] Donovan | A fully integrated psychogeriatric service[END_REF], frequently infl uenced by the ideals of individual innovators [START_REF] Kerr | A "do-it-yourself" psychiatric-geriatric joint patient unit[END_REF]. Psycho-geriatric assessment units, initially proposed in 1950 47 had largely failed to become widespread. Nor did they fl ourish after their reiteration in 1970 (DHSS), a response to WHO's suggestions (1959) and an infl uential paper by [START_REF] Kay | Special problems of the aged and the organisation of hospital services[END_REF] and Kidd's study (1962) -later shown to be fl awed [START_REF] Copeland | Evaluation of a psychogeriatric service: distinction between psychiatric and geriatric patients[END_REF] -stressing poorer prognosis for older people placed in the wrong type of unit. Thus psycho-geriatric units aimed to ensure accurate assessment of elderly patients with complex problems, but were never of proven value (Pitt, 1974). The demise of the units may have been for several reasons, including the huge discrepancy in consultant numbers: 293 geriatricians in Great Britain and Northern Ireland [START_REF] Brocklehurst | King Edward's Hospital Fund)[END_REF]) but only a handful of psychogeriatricians. At times geriatricians regarded the joint units as an imposition, suspicious that the new psychiatric units proposed for the DGHs would never meet the needs of older people [START_REF] Andrews | Planning of psychogeriatric care: a report of a joint working party of geriatric physicians and psychiatrists[END_REF], while psychiatrists may have resented the directive that geriatricians should be in overall charge of the unit [START_REF] Dhss | National Health Service Psycho-geriatric Assessment Units[END_REF]. Geriatricians were appointed specifi cally to work in mental hospitals, but some preferred the lure of the new DGHs. 48 The HAS highlighted that disagreements not infrequently occurred over who should care for individual patients, 'Such lack of joint responsibility can only be deplored', and on these grounds they also advocated joint assessment units [START_REF] Nhs | Annual Report of the Hospital Advisory Service to the Secretary of State for Social Services and Secretary of State for Wales for the year 1974[END_REF]. Although there was some move to create entire integrated psychiatric-geriatric services such as the Department of Health Care of the Elderly in Nottingham with Tom Arie appointed professor in 1977, this model did not become widespread.

The Society of Clinical Psychiatrists organized a geriatric-psychiatric liaison committee aiming to promote widespread clinical services [START_REF] Enoch | The Organisation of Psychogeriatrics (Ipswich: Society of Clinical Psychiatrists[END_REF]. This pre-dated the BGS and Royal College of Psychiatrists discussions (1973). The latter led to agreements on managing patients with dementia based on their behaviour rather than diagnosis, on training and recruitment of nurses and doctors into psychogeriatrics, and on the need for specialist consultant psychogeriatricians in each area, with geriatricians on appointment committees for psychogeriatricians and vice versa. However, cooperation between geriatricians and psychiatrists on policy development fl uctuated. 49 In 1975, only after a joint BGS and DHSS report was written critical of the organization of psychogeriatrics, did they request consultation with psychiatrists. 50 This disconcerting report led to the reconvening of a liaison group. 51 Further collaborative guidelines in 1977 52 set out important principles: that services for the elderly should be a unity for consumers; that there should be reciprocal training schemes for psychiatry and geriatrics; that responsibility for treatment should be determined by needs not resources or 'quirks of referral'; and that no one should be labelled a psychiatric patient by virtue of some previous psychiatric episode [START_REF] Norman | Mental Illness in Old Age: Meeting the Challenge (London: Centre for Policy on Ageing)[END_REF]. Such important principles continued to infl uence practice at least into the 1980s.

The multi-disciplinary team: nursing, psychology and occupational therapy

Even in the 1970s, some nurses perceived older people stereotypically: 'Loss of weight is now more defi nite, and as the body dries up and the subcutaneous fat disappears, the skin becomes dry and wrinkled and the eyes sunken and lustreless … And ... their memory fails …' [START_REF] Roberts | A Handbook for Psychiatric Nurses[END_REF]. The body drying up refl ected the classical Greek medical theory of marasmus [START_REF] Theoharides | Galen on marasmus[END_REF]; implying that memory failure is inevitable was false. Perhaps the weight loss refl ected inadequate diet in long-stay hospitals. However, such attitudes of hopelessness in ageing may have had nihilistic effects on staff. Negative stereotypes of older people were not confi ned to nurses but also pervaded society at large, especially in the era of youth culture developing as the ideal. Simone de Beauvoir wrote Old Age in 1970 to challenge and explain such negative stereotypes, and the term 'ageism' was a new addition to the English language in 1969 (Oxford English Dictionary, 1980).

Unfortunately, in places with wards of over 70 beds it was 'virtually impossible to provide a satisfactory standard of nursing care' (Ministry of Health and CHSC, 1968). Nursing care became even more diffi cult when people with chronic functional illness were discharged and the wards fi lled with demented people requiring more intensive nursing. 53 Although special training was advocated for nursing elderly mentally ill people (Ministry of Health and CHSC, 1968), it was unclear if this meant a physical or a psychological approach.

In 1975 the Group expressed concerns over training nurses to care for the 'diffi cult dements' to be placed in the proposed community hospitals. 54 In 1976 there was unease about new DHSS proposals for residential homes, in that trends away from medical and nursing models might not meet the needs of more dependent residents. 55 The Group (GPOA, 1978) emphasized in a memorandum that standards in mental hospitals were unacceptably low, largely due to staff shortages, under-fi nancing and a 'serious lack of central guidance' on nursing requirements. Based on BGS recommendations for geriatric ward nursing and other reports, a ratio of 1 nurse to 1.2 patients was recommended for older peoples' assessment wards, considerably more than the 1 to 3 for younger people. It is unlikely that nurses were involved in developing this recommendation. However, shortly after the memorandum was published (GPOA, 1978), the nursing advisor to the DHSS was invited to discuss the subject with the Group. 56 Whether that was due to any disgruntlement from the nurses about doctors producing a memorandum about their work is unstated.

A BGS and Royal College of Nursing (1975) report on improving geriatric care stressed the importance of dignity, independence and mobility. However, mental health nursing appeared less progressive. Professor of Nursing Annie Altschul (Edinburgh) with Ruth Simpson (c.1977) wrote that the nurse can 'exploit the phase when the patient accepts dependence, use it to build up prestige and will be grateful for the patient's non-critical submission to treatment'. Such institutionalizing of nursing attitudes may have developed secondary to inadequate staffi ng, but was also likely to have contributed to a patient's sense of powerlessness and may have been related to the hospital scandals of the previous decade [START_REF] Robb | Sans Everything: A Case to Answer[END_REF]. Altschul and Simpson (c.1977) emphasized that in dementia 'Nursing care is concerned primarily with the preservation of physical health'. However, such advice was being questioned by other nurses such as Molly Clarke (Southampton) who commented that traditional acute nursing had little to offer the elderly and although sound principles for geriatric and psychogeriatric nursing were emerging they had not yet been incorporated into training [START_REF] Clarke | Organising nursing services[END_REF]. Nurses on long-stay wards still regarded themselves as working in a 'dumping ground' where 'failures' accumulated, while the very different goals of 'cure' and 'care and maximisation of function' still needed to be negotiated [START_REF] Isaacs | The development of psychiatric services for the elderly in Britain[END_REF]. However, things were changing. For example, [START_REF] Baker | Mental illness in the elderly[END_REF] were advocating active, non-custodial roles for nurses, a wider range of skills than traditionally acquired in training, and the importance of community psychogeriatric nurses for elderly confused people.

Psychology and occupational therapy

Although developing both before and during the 1970s, psychology was a slightly later addition to the old age team, with the establishment of the British Psychological Society Faculty for Old Age Psychology in 1980(British Psychological Society, 2007). Meanwhile, occupational therapy was well established but yet to take on its modern assessment and therapeutic role, concentrating instead on diversional tasks (Altschul and Simpson, c.1977) Closing the mental hospitals: the options Long term plans were to close the large mental hospitals, often far from where patients lived, and to consolidate local services. Calculation of bed numbers for community EMI services was based on a series of hospital censuses, with a fi nal recommendation of 2.5 per 1000 elderly people [START_REF] Eason | In-patient care of the mentally ill: a statistical study of future provision[END_REF], a fi gure incorporated into Services for Mental Illness Related to Old Age (DHSS, 1972b).

But all was not straightforward. Whitehead stated in 1972 that 'mental hospitals are becoming under-staffed, neglected dumps for the elderly', reiterating this in 1983. It is likely that recognition of the unsuitability of mental hospitals for older people with dementia was itself responsible for a fall in the number of admissions in the early 1970s [START_REF] Shulman | Fall in admission rate of old people to psychiatric units[END_REF]). Yet some people were as vehemently against hospital closure as others were for it. For example, [START_REF] Tucker | Number of mental health beds[END_REF] commented 'we must keep the socially disruptive mentally sick people in the mental hospitals where they belong'. Although less applicable to the elderly, they could undoubtedly be very disruptive. Among older people with identifi ed mental illnesses, behavioural diffi culties caused signifi cant distress in over half the families caring for them [START_REF] Bergmann | Management of the demented elderly patient in the community[END_REF].

Anxiety that hospitals would close without the provision of adequate suitable alternative accommodation (BGS and Royal College of Psychiatrists, 1973) was reiterated in 1977 in DHSS rhetoric: 'in some areas bed-closures programmes are out of phase with the development of alternatives'. Most long stay beds still remained in mental hospitals. 57 Although Powell's 'Water Tower speech' (1961) had specifi cally mentioned 'the old' requiring various levels of community care, the tendency to prioritize the young persisted. For example the Worcester Development Project feasibility study of community services failed to take into account older frail disorientated people when designing accommodation [START_REF] Rooney | Worcester Development Project Psychiatric Provision -Where do We Go from Here?[END_REF]. 58 Epidemiological studies and knowledge of disease processes were used to estimate need [START_REF] Kay | Mental illness and hospital usage in the elderly[END_REF], but little account was taken of other factors such as expectations of older people themselves [START_REF] White | Psychogeriatrics and community care[END_REF], working patterns of carers, or improved treatment. Innovative care schemes were not new, but nor were they widely practised [START_REF] De Largy | Six weeks in; 6 weeks out; a geriatric hospital scheme for rehabilitating the aged and relieving their relatives[END_REF][START_REF] Whitehead | the Service of Old Age[END_REF]. However, multi-agency cooperation and innovation was essential to develop services such as day hospitals, residential homes and community hospitals. A pragmatic summary in 1971 also suggested boarding-out services, day centres and clubs, sheltered workshops, meals-onwheels, home helps, 'sitters', laundry services, a 'good neighbour policy' and fi nancial support both for families caring for older people and for voluntary organizations as key to supporting mentally frail older people in the community [START_REF] Enoch | The Organisation of Psychogeriatrics (Ipswich: Society of Clinical Psychiatrists[END_REF].

The day hospital

For older people, the day hospital developed conceptually as an alternative to long-stay care. There was less focus on the possibility of psychiatric day assessment, such units existing in only a few places such as at Exminster in Devon [START_REF] Dhss | Hospital Services for the Mentally Ill[END_REF][START_REF] Kay | Special problems of the aged and the organisation of hospital services[END_REF][START_REF] Langley | The Exe Vale joint psycho-geriatric assessment unit (Hallett clinic)[END_REF]. Older people were unlikely to be admitted to general psychiatry day hospitals, and many geriatric day hospitals seemed also to exclude the demented. In only very few places was anything like the DHSS's recommended 2-3 places per 1000 population over 65 achieved [START_REF] Arie | Day care in geriatric psychiatry 1978[END_REF]. [START_REF] Whitehead | the Service of Old Age[END_REF] noted that: 'Some patients enjoy the ambulance journey more than the session in the day hospital'. In 1975, Arie humorously suggested 'Transport therapy', whereby the bus journey and activities on board were the focus of therapy. For many, the journey to the day hospital was the only glimpse of real life in an otherwise home-hospital bound world. However, not infrequently insuffi cient suitable transport effectively limited the availability of day places (Godber, quoted by Anon., 1978).

Residential homes

With the objectives of discharge from mental hospitals and preventing admission, residential placements were needed, and these were suggested in Services for Mental Illness Related to Old Age. Residential homes were to be provided at 'an overall ratio' of 25 places per 1000 elderly people, but numbers specifi cally for people with dementia remained unstated. Many elderly demented people needed residential homes not chronic psychiatric wards [START_REF] Arie | Morale and the planning of psychogeriatric services[END_REF], but there was doubt whether Local Authorities would fi nd the money for adequate quality and quantity of places within a reasonable time frame (Arie, 1973a).

In 1965 the Ministry of Health recognized that some people were so disturbed that they could not live amicably with mentally well residents. In the 1970s the moral debate on integration versus segregation questioned if older confused people should be cared for in homes giving various levels of care, or in specialist facilities. 59 The Group took up this issue following the imprisonment of the warden of a specialized EMI residential home, Orchard House in Oxford, with the Group expressing the feeling that 'there but for the grace of God' went many of the homes in their own areas. 60 Social workers preferred the integration model, but this did not necessarily work. It was reported that pressure to remove a confused resident from a home was more likely to come from residents than staff, 61 but staff also had preferences about the sort of residents with whom they wanted to work (GPOA, 1976). Specialized homes for behaviourally disturbed people could be designed to maximize independence and could develop supportive links with local psychogeriatric departments. But residential care home staff required training to care for confused people, in particular, as 'They do not know how to approach or handle them. Trial and error methods sometimes aggravate the condition', 62 and training required money.

Other issues were raised by the Group in order to ensure fl awless coordination of care. For example, if a person in a residential home required psychiatric admission, should it be to the hospital in the area from which the patient originated or the one close to the home? Emotive discussion on this led to farfrom-unanimous agreement. 63 Various colleagues had other, sometimes controversial, care schemes to propose, notably Langley, 64 with 'yet another knotty dissertation' 65 undoubtedly stimulating debate within the Group.

Community hospitals

Whereas EMI homes were for people with dementia and behavioural problems, long-term hospital care was for those 'requiring heavy nursing and "mindless" i.e. unable to appreciate their surroundings'. 66 With the closure of mental hospitals, this group and some 'diffi cult dements' 67 would be placed in the proposed community hospitals.

Community hospitals were alluded to in Services for Mental Illness Related to Old Age (DHSS, 1972b), and the Hospital Plan (Ministry of Health, 1962) vaguely referred to 'many small hospitals' in addition to DGHs. Cottage hospitals had existed for many years, and in some places there was public protest at threats to close them. Community hospitals probably in part emerged from such protests. New proposals were outlined in a memorandum (DHSS, c.1973b) obtained by the Group that was disconcertingly stamped 'For information only'. 68 Although some psychogeriatricians in rural locations welcomed community hospitals to help to provide local services [START_REF] Langley | Community hospitals[END_REF], others greeted them with consternation: 'the community hospital, whatever that may be. Is it perhaps the old workhouse? The half-empty tuberculosis hospital?' [START_REF] Bergmann | Psychogeriatric services. News and Notes[END_REF]; Arie (1973a) commented:

[M]any of us would have been happier if more consultation and public debate had taken place beforehand with an offi cial announcement afterwards, rather than the other way round, for if community hospitals become largely aggregations of patients who do not merit the services of the DGH we can expect to see in them something very similar to the institutions we have come to know so well.

This fear was also shared by geriatricians (BGS and Royal College of Psychiatrists, 1973).

Community hospitals were unlikely to meet pioneering architectural designs to promote independence and quality of life for confused people. 69 Concerns also related to an absence of defi ned staffi ng levels, plus the proposal of medical staffi ng largely by general practitioners in cooperation with consultants, a new relationship for hospital work which would require considerable negotiation 70 (DHSS, c.1973b) A statement that 'the use of existing buildings may enable some community hospitals to be established early' (DHSS, c.1973b) provoked the response that 'someone is trying to run this on the cheap'. 71 In addition, beds for younger patients would be in the more prestigious DGHs (DHSS, c.1973b), compounding fears that elderly people would be placed in the lower part of a two-tier hospital system. Even Dr Brothwood (DHSS) appeared uncertain of the benefi ts of community hospitals, stating that policy had outstripped experience. 72 The widespread implementation of new styles of service without adequate evaluation was apparently not uncommon [START_REF] Jolley | Organisation of psychogeriatric services[END_REF]. However, community hospitals never became as widespread as planned. In their absence, older people continued to accumulate in the mental hospitals (DHSS, 1980).

The interface with social services

The importance of social diffi culties leading to admission for older mentally ill people was well recognized, with implications that manipulating the social environment could be benefi cial [START_REF] Lewis | Social causes for admission to a mental hospital for the aged[END_REF]. A social worker was attached to Post's team from its inception 73 and Severalls Hospital also had specifi c social workers for older people from the 1960s [START_REF] Whitehead | the Service of Old Age[END_REF]. Health and Welfare (Ministry of Health, 1963) proposed developing social care but failed to be specifi c or to provide adequate costings and therefore a credible framework for progress. In addition, 'the Ministry did not seem willing to coerce those whose services were of poor standard' [START_REF] Welshman | Rhetoric and reality: community care in England and Wales 1948-74[END_REF]. Philosophy of social care, as with nursing and psychiatry, needed to undergo a major shift to improve mental health care for older people.

Both the roles of social workers and their management structure changed, moving from hospital to local authority employment at the same time as the 1974 NHS reorganization. 74 Although the DHSS had considered bringing together health and social services under a single administration, this had not happened (DHSS, 1972a). Such unifi cation would have had immense potential to benefi t older people. Woodford-Williams commented: 'The weakening of links with social services … is keenly felt by consultant geriatricians and psychiatrists, particularly in relation to community support where the shortage of psychiatric social workers is having repercussions on the "new" long-stay problem.' [START_REF] Nhs | Annual Report of the Hospital Advisory Service to the Secretary of State for Social Services and Secretary of State for Wales for the year 1974[END_REF]. These weakened links were accompanied by requests from the College for reintegration of mental health social workers into the health service (Royal [START_REF] College | Memorandum on the National Health Service Reorganisation[END_REF].

In 1977, however, there appeared to be increased interest towards older people by social work organizations such as the British Association of Social Workers (BASW). 75 Perhaps interest occurred later than in some other professions, which were already moving to ward specialization, because of the Seebohm genericization of social work. Social work speakers were invited to address the Group in 1977, 76 and they in turn requested more education on psychogeriatrics. 77 A multi-agency conference proposed in 1975 on psychogeriatric services also fi nally materialized in 1977. 78 Following Better Services for the Mentally Ill (DHSS, 1975) which briefl y mentioned older people and the treatability of some of their illnesses, Priorities for Health and Personal Social Services was published the next year (DHSS, 1976). However, with services for mental illness in one section and services for the elderly in another, older mentally ill people risked falling precariously between the two priority areas. Priorities for Health emphasized alternatives to hospital care, aiming to support elderly people in the community for as long as possible. Ideas were certainly constructive, but funding was not necessarily evident. Indeed, the section on personal care stated that expansion would not continue at 'anything like the recent rate' (DHSS, 1976). It appeared unlikely that measures would be adequate 79 [START_REF] Anon | Providing a district service for adult psychiatry, its special interests and related specialities -medical manpower priorities[END_REF]. Concern remained about diffi culties in coordinating care, insuffi cient mental health social workers, and that guidelines for developing community facilities for the mentally ill were not mandatory (Royal College of Psychiatrists, 1977). A Happier Old Age (1978), a DHSS discussion document, considered older people making choices about their own lives, while re-emphasizing the need for collaboration to make the best use of resources. Arie (1973b) commented that many doctors and social workers:

cannot formulate a 'psychogeriatric problem' in any other terms but as to the need to get it instantly off their hands … Few patients are so taxing to doctors as the confused and the demented. No other condition generates so much crisis, irritability, and interprofessional friction.

Although social workers and doctors did not always see eye to eye, directors of social services and doctors collaborated on strategic planning for community care (Anon., 1976), such meetings being indeed vital (GPOA, 1976). However, service provision was in part undermined by the removal of mental health social workers from the health service, and there appeared to be little, if any, extra resources to pay for community care which remained 'more apparent in rhetoric than reality' [START_REF] Welshman | Rhetoric and reality: community care in England and Wales 1948-74[END_REF].

Limitations and conclusions

The subject of this study began in 1970, the year Whitehead published In the Service of Old Age, and concluded in 1978 with the Group achieving the status of a Section of the Royal College of Psychiatrists. But were Whitehead's aims of informing public opinion of what can be done and stimulating self-scrutiny by the authorities achieved? There appeared to be little response from the public. It seems unlikely that self-scrutiny by the authorities would have been achieved without persistent and considerable pressure from the Group for the Psychiatry of Old Age. The 1970s saw developments in provision of community care for the elderly mentally ill, coordinated nationally rather than in the earlier piecemeal fashion. In part this was due to Services for Mental Illness Related to Old Age, despite the drawbacks that it was not obligatory and that it was often taken as gold standard, rather than being a bare minimum on which further improvements should be built.

The 1970s also saw the entrenchment of some unfortunate developments, in particular the prioritization of younger over older people. The demarcation of age 65 years as a cut-off for older people's care was probably necessary to establish distinct specialist services, but was not ideal in that chronological age has no precise relationship to physical health, care needs or social activity. In addition, the unenviable position of psychogeriatrics being neither psychiatry nor geriatrics but part of both placed it precariously between its two older and more powerful siblings.

This account has been very medically focussed, but since the subject is the management of illness, this is not unreasonable. Clearly various organizations were concerned such as MIND, the HAS and BGS. The Group frequently engaged with other specialties and agencies -from architects to geriatricians to social workers and policy makers (DHSS, 1980). Group members also generated ideas, supported peers, debated best practice and pursued implementation, all crucial to the development of the specialty. Yet their infl uence was moderated by resource issues, both fi nancial and manpower, throughout the 1970s. Resource allocation and ideology were not always reconcilable.

The year 1978 was by no means an end-point to developing services, and perhaps was only another beginning. Without doubt, the philosophy of care, active treatment in appropriate environments and respect for older people with mental illness clearly established by the Group was a vital cornerstone for further developments. It was not until 1989 that psychogeriatrics was recognized as a speciality by the DHSS, and having a consultant in each district with responsibility for older people's mental health services only materialized close to the millennium [START_REF] Post | Psychogeriatrics[END_REF]. When the mental hospitals fi nally closed in the mid-1990s, older people were often the last to leave. The developments after 1978 would be an area worthy of future historical investigation.

71. GPOA 30 Jan. 1975 notes. 72. GPOA 30 Jan. 1975 notes. 73. Felix Post andArthur Harris, letter to Bethlem andMaudsley Medical Committee, 5 May 1950, Bethlem Royal Hospital Archives. 74. DHSS, Social work support for the Health Service PPC13/74, circular letter, 5 Mar. 1974, GPOA archives. 75. GPOA 14 Apr. 1977 (25/77). 76. GPOA 23 June 1977 (51/77)

  including Dr Sinclair and Miss Neil, National Institute of Social Workers. 77. GPOA 23 June 1977 (40/77). 78. Colin Godber, 'Conference with DHSS on future psychogeriatric services: revised proposals', 27 Oct. 1975; Conference programme, 'Our elderly', July 1977, GPOA archives. 79. Pitt, 'Comments on Royal Commission' (see Note 53).

Acknowledgements

I am particularly grateful to Professor Tom Arie, Professor David Jolley and Dr Michel Neve for their comments and suggestions.


est destinée au dépôt

are ill-founded, they assert. The replacement of state with private for-profi t hospitals has been good, producing institutions that are more fl exible and more responsive to community and political pressures. Unfortunately, the authors support these controversial assertions with surprisingly little empirical data.

Overall, this book offers a fascinating, if at times unsettling, historical analysis of mental health policy, which relies heavily on aggregate statistical data. The arguments merit attention and additional testing. Frank and Glied falter primarily when dealing with those problems still unsolved: the continuing popular confl ation of mental illness with violence; the diffi culties of caring for medication-resistant, long-term mentally ill individuals; and the rise in their numbers in jails and prisons. While the authors acknowledge the importance of these problems, they devote little of the book to their analysis. Nonetheless, they present with commendable clarity and force the argument that, for many (if not all) of those with mental illnesses, public and private policies have improved health care since 1950. Spiritual physic, a branch of mental health care which fell under the remit of the clergy, is a topic that has received relatively little scholarly attention to date. Building on the work of MacDonald and Midelfort, Lederer aims to redress the balance, through a cultural study of this topic in the Duchy of Bavaria. Far from being merely a local study, the author offers a broad analysis which considers the impact of political, religious, social, material and cultural forces. Lederer emphasizes the dominant role of this branch of medicine in the early modern history of mental health (p. 6), arguing that it 'contributed to a psychological paradigm shift in the seventeenth century, permitting the emergence of bourgeois psychiatry in the eighteenth century while insuring a pastoral tradition that survives to the present' (p. 48).

ELLEN DWYER

The fi rst fi ve chapters, which focus on early modern spiritual physic, are the strongest. Lederer exploits a broad range of religious sources -e.g., miracles, confession, pilgrimage and exorcism. Case studies relating to pilgrimages to holy shrines such as Benediktbeuren highlight the importance of both studying notions of mental illness within their social and cultural context, and understanding the day-to-day experience of this affl iction. Clear connections are made between the rise of confessional tensions, social discipline and spiritual madness. Lederer reveals the ways in which the religious ordersin particular the Jesuits -used spiritual physic to maintain their position in both mental health care and court politics (p. 190). He devotes much space to demonic possessions and exoricsm, believing that their changing history highlights the 'links between mental health care, religion and contemporary politics ' (p. 196), which centres around the decline of supernatural explanations for mental illness and the rise of the insanity defence.

The fi nal two chapters look at suicide and the slow-paced development of institutional care for the mad -the Bavarian 'Great Confi nement' occurred, if at all, in the nineteenth century. Lederer largely follows the standard view of the decriminalization, secularization and medicalization of suicide. These chapters offer further illustration of the restraints of absolutism, as is exemplifi ed by civic and religious resistance to the burial of suicides. Such resistance is further evidenced in the problems faced by the state to fi nd a suitable location and funding for a public asylum. While retaining a religious view of madness, the populace were willing to accept a more secular view if it suited them; actively seeking the removal of the mentally ill who had become a burden to their community. This book will appeal both to early modern social and cultural historians and to those interested in tracing the religious roots of modern psychiatry. While the breadth and depth of the research has much to recommend it, readers unfamiliar with early modern history might initially be overwhelmed by the volume of explanations offered -the section on Freud, for instance, might have been better placed in a separate publication. Some historians might also question Lederer's emphasis upon traditional historical theories, such as 'popular' versus 'elite' and the pivotal role played by the 'general crisis' of the seventeenth century. Nevertheless, this is an important book, which makes a major contribution to the study of the history of psychology, religion, state formation, and popular infl uences upon medical practice.

LOUISE GRAY

The Wellcome Trust Centre for the History of Medicine, London

  Louise Gray. Book Review: David Lederer (2006) Madness, Religion and the State in Early Modern Europe. A Bavarian Beacon (Cambridge and New York: Cambridge University Press). Pp. 361, 19 plates. £50.00. ISBN 13 978-0-521-8537-7 (hbk). History of Psychiatry, 2008, 19 (1), pp.96-97. 10.1177/0957154X080190010504. hal-00570920


Andrew Scull (2006) The Insanity of Place/The Place of Insanity: Essays on the History of Psychiatry (London: Routledge). This is a book of chapters that will already be very familiar to those who have closely followed historiographical debates in the history of psychiatry over the past two decades. This is because, with the exception of the introductory chapter, all the chapters have been previously published (in their entirety or in part) in journals, reviews and edited volumes elsewhere. In Scull's own view, the purpose of such a collection is 'to contribute to some sort of sustained methodological, and historiographic [sic] refl ection upon major fi gures and developments in the fi eld; to address a number of continuing controversies that have roiled the discipline; and to suggest some important future directions for research' (p. 6). In the order in which they appear in this book, these chapters do constitute a kind of Anglo-American history of psychiatry from the eighteenth to the mid-twentieth century -one that showcases Scull's key arguments with his colleagues on subjects from the emergence of the asylum to the use of psychopharmaceuticals. As such, the collection is partly a reminder of the powerful infl uence that Scull has had (and continues to enjoy) in shaping those debates. At the same time, this collection highlights Scull's relative intellectual immunity to infl uence from the historiographical nuances and shifts that have recently marked this fi eld. By the end of the book, the reader is left with the rather disconcerting sense that all perceived historiographical foes have been fended off (in some cases demolished, in others merely dismissed), with only Scull left standing intellectually intact.

In the fi rst chapter following the introduction, 'The Insanity of Place', Scull reviews a 'little-known' paper published in 1969 by Irving Goffman with the same title. The focus of Goffman's article, and, presumably, of Scull's chapter, is the 'organisational havoc' that the mad create for their families and for the larger society. Scull notes that the 'almost unbearable disturbances in the texture of daily existence' created by mad behaviour has compelled us to react at all levels of social scale to maintain social order (pp. 14-15). After this start, the reader would not be surprised if Scull next took the opportunity to review the dozens of books and articles which have, for the last two decades, following Goffman's tentative lead, analysed in much greater detail the myriad challenges to the social order at the familial, community and institutional levels that these mental disruptions created in the nineteenth and twentieth centuries. I am thinking here of contributions by D. Wright, P. Bartlett, N. Tomes, C. Warsh, A. Cellard and M. Thifault, R. Fox, J. Moran, J. Hughes, T. Nootens, E. Dwyer, J. Reaume, A. Suzuki, W. Mitchinson and M. Jackson, among others. Instead, Scull largely side-steps this large and growing body of work, preferring to dismiss it later on in Chapter 9 for failing 'to acknowledge that there are gross imbalances of power and resources at work here for families, and even more clearly for patients …' (p. 111). Moreover, these researchers are collectively scolded for 'not accepting the obvious' fact that 'issues of power and control, broadly conceived, are indeed central' to the history of the response to madness (p. 111). In point of fact, many academics who have contributed to what Scull calls 'the new orthodoxy' do acknowledge and incorporate power differentials into their analyses, though not perhaps in ways that are satisfactory to Scull. Although acknowledging in Chapter 2 that there were literally thousands of mad people managed in 'a number of alternative mechanisms for coping with insanity' outside asylums (for example, on the geographical 'fringes' of Britain, and, I would argue, on the fringes and at the 'centre' of the USA), Scull insists that 'it was the brooding presence of the barracks-asylum which remained the lynch-pin of social policy toward mental illness till past the mid-twentieth century' (p. 24). Surely, it is more reasonable (and, we are discovering, more historically accurate) to consider some sort of integrated analysis (with due attention to geographic specifi city) of formal, institutional and less formal familial and community realities -an analysis that also acknowledges the complex relationship between non-asylum and asylum responses to madness.

Chapters 3 and 4 constitute highly critical engagements with two major players in the fi eld of madness studies: Michel Foucault and Roy Porter. There is a sameness to Scull's critical approach to the contributions of both of these authors. In the fi rst, although Scull claims that we 'owe multiple debts to the late Michel Foucault', these debts are, for Scull, more related to Foucault's ability to shake up earlier Whig interpretations of the fi eld, than to any real insights that Foucault actually provided on the subject. In part, this critique consists in Scull's conviction that a full translation of Foucault's seminal Histoire de la folie would not change the fact that it is hopelessly fl awed, both in its historical description and its central arguments. Scull issues a similar epithet to Porter: 'Roy Porter was a phenomenon … His loss is still felt keenly by his legions of admirers, nowhere more so than in the history of psychiatry, to which he made a whole series of important contributions … ' (p. 38). Yet, in Chapter 4 Scull proceeds largely to dismiss these contributions, reaffi rming his own 'great break' theory of asylum and moral therapeutic developments at the turn of the century against Porter's argument that moral therapy was alive and well in the long eighteenth-century era of the private madhouse. Later in the same chapter, although giving Porter some credit for his attempts in his later work to consider the experience of the psychiatric patient, Scull quickly minimizes the potential of this historiographical direction by pointing out that 'the dangers of romanticization is [sic] great' (p. 51).

Having dispatched with Foucault's eighteenth-century 'great confi nement' and Porter's 'long 18th century of moral therapy' (and, more curiously, the more enduring and valuable analytical insights that went with both), Scull turns his own attention to a short chapter on eighteenth-century madness by focusing on the life and times of John Monro. Largely drawn from Scull's and Jonathan Andrews' works, Undertaker of the Mind: John Monro and Mad-Doctoring in Eighteenth-Century England, and Customers and Patrons of the Mad Trade: The Management of Lunacy in Eighteenth-Century London, this chapter is a beautifully written account of the rich private practice of the dominant and domineering alienist of the eighteenth-century English mad trade. But how this chapter contributes to the historiographical debate about moral therapy and the long eighteenth century, the reader is left to surmise.

In what is, by this point of the book, a familiar pattern, Chapters 7 and 8 offer stinging critiques of Edward Shorter's biologically determined text, From the Asylum to Prozac, and the trilogy of Gerald Grob's works on the rise and development of the asylum and government mental health policy in the USA, respectively. In these chapters, Scull demolishes Shorter's central argument that the rise of biological psychiatry was a 'smashing success' in the treatment of mental illness. And, in a familiar reiteration of a decadeslong argument with Grob, Scull hammers away at the latter's conservative complexity thesis of the rise and demise of asylum psychiatry.

The last three chapters constitute Scull's own answer to the glaring analytical inadequacies that he sees in the work of historians like Shorter and Grob on twentieth-century psychiatry. These chapters focus on somatic therapies (from ECT, to the fever therapies, to gynaecological and other forms of surgery) and on psychopharmaceutical treatments. Here, Scull answers his rhetorically entitled critique of Grob's work, 'Nobody's fault?', by making it clear that a long line up of historical actors shared the blame for twentieth-century 'failures', most notably penny-pinching administrators of deinstitutionalization, and ambitiously blind and professionally arrogant psychiatric innovators. In each case Scull argues that these individuals are caught up in broader sociocultural movements, such as the neo-conservative economics of deinstitutionalization, the bacteriological paradigm and gendered models of the female body.

This volume would benefi t greatly from an effort to connect the chapters more coherently, and from a conclusion (or even a postscript) that tied together what Scull thought were the major themes and arguments he wished to make. It is tempting to surmise that this volume is the prelude to a more synthetic and systematic history of psychiatry from the eighteenth to the twenty-fi rst century. Given Scull's enormous infl uence and multiple contributions to the fi eld, this would be a welcome addition -but more especially so, if he was willing to consider seriously some of the important historiographical contributions since the 1980s that, in this volume, seem more threatening to him than they are engaging.

JAMES E. MORAN University of Prince Edward Island


established ideas about the power of free will and the importance of personal responsibility. Doctors were particularly sceptical, and increasingly concerned, about the intrusions of charismatic practitioners and the non-medical fringe. As Pick highlights, such attitudes were very reminiscent of earlier responses to mesmerism and hypnotism. However, he shows that among the non-medical intellectual elite some of the key psychoanalytic ideas became increasingly infl uential, and have to a large extent become incorporated into the cultural mainstream.

About a third of the essays in this volume deal directly with issues in the history of psychiatry. Within these contributions, there is much that is both informative and thought-provoking, as indeed there is in all the other very diverse essays. This is exactly what one would expect from disciples of Roy Porter, a man who would never allow himself to be tied down by historical, spatial, cultural or intellectual categories. This book is a polemic written with the intention of preventing future wars by demonstrating the enduring psychological scars caused to Vietnam veterans. Edited transcripts of interviews with the wives of servicemen who committed suicide after military service are interposed with historical passages on the psychiatric effects of battle. Driven in part by personal commitment (Penny Coleman's fi rst husband took his own life after service in Vietnam), this is a diffi cult book to review because little is left open for debate. The author has adopted an uncompromising stance, buttressed by traumatic cases. Nevertheless, there are numerous historical errors. For example, W. H. R. Rivers is described as being appointed director of Craiglockhart military hospital in 1915 (p. 33). In fact, he never became the hospital's director and had been deployed there in October 1916. More serious, however, is the contention that irritable heart, shell shock, battle fatigue and post-traumatic stress disorder (PTSD) are all the same disorder but with different labels (p. 19). Symptom-based research has shown that these are far from the same. Irritable heart was often a long-term disorder characterized by palpitations, shortness of breath, chest pain and inability to perform tasks. It bore no resemblance to current formulations of PTSD. Indeed, there are a number of unsubstantiated statements about this disorder: that it is caused by guilt (p. 75) or is particularly associated with killing in combat (p. 73). The source for the latter claim is a newspaper article. We know, in fact, that less than 20% of US servicemen sent to Vietnam experienced battle, the vast majority being in combat-support or base roles.

LEONARD SMITH

Throughout the book it is assumed that if a Vietnam veteran had committed suicide, then the war must have been the cause. Yet no information is given about the pre-confl ict life of such cases. Was the veteran subject to child abuse, or was there a family history of violence, mental illness or alcoholism? We know that individuals from abusive families with poor educational achievement are at greater risk of suffering from PTSD and that their recovery can be infl uenced by the environment to which they return. Also, it is far from true that everyone exposed to a life-threatening event then experiences PTSD; moreover, 60% of those who have the disorder recover -whether treated or not -within six months. These nuances are not considered by the author, who comes close to characterizing PTSD as an infectious disease spread by war. Like Jonathan Shay, who wrote the foreword, Coleman interprets PTSD as a universal stress reaction found at all times in all cultures. The alternative view, that it is a culturally-conditioned expression of distress, limited in the fi rst instance to English-speaking, Western societies, is not explored.

Everyone would have sympathy with Penny Coleman's concern for the psychological effects of war and the fact that these often have to be rediscovered, but slipshod and selective historical research has weakened her argument. A more subtle and carefully argued case would have served her ends more effectively.

EDGAR JONES

Institute of Psychiatry, London

Joseph Melling and Bill Forsythe (2006) The Politics of Madness: The State, Insanity, andSociety in England, 1845-1914 (London: Routledge). This book is the most comprehensive and large-scale study of psychiatric provision at a locale ever conducted. The authors' selected site is Devonshire, and they have investigated the nineteenth-and early-twentieth-century archives of asylums in this county in a most thorough, systematic and rigorous manner. Materials from the county asylum at Exminster form the core sources for this work. The asylum's 13,000 admissions were fed into databases; 4,000 patients were selected for intensive analysis of their social and personal background of their stay at the institution, using their certifi cates of insanity, magistates' orders, admissions registers and casebooks. Not content with this single institution, the authors have examined three other psychiatric institutions in the area: one private institution (Wonford House Asylum) and two borough asylums. The staggering amount of


historians, who generally work on rich but limited amounts of source material, will fi nd this work indispensable. For many years to come, this book will be read, examined and relied upon.

AKIHITO SUZUKI Keio University, Japan

Jesse F. Ballenger (2006) Self, Senility and Alzheimer's Disease in Modern America: A History (Baltimore: The Johns Hopkins University Press). Pp. 236. ISBN 0-8018-8276-1.

The astonishing development of older adult mental health services in the UK and USA over the last 30 years is a testament to signifi cant changes in the construction of old age, and senility in particular. The evolution of Alzheimer's disease from a rare condition of the middle-aged to a major preoccupation of government, medicine and the pharmaceutical industry is the core of Jesse Ballenger's fascinating book.

The central argument of the book is that changing stereotypes of ageing (particularly those of the successful white middle-class professional) have left sufferers from dementia increasingly pathologized. The growing rift between normal and pathological ageing creates anxiety that pharmaceutical companies and biological researchers are exploiting to the full. The fi nancial rewards involved in preventing the decline into dementia, and mending those who have succumbed, has led to greater investment in the development of biological models rather than care facilities. Ballenger explores the signifi cant position statements and political developments that cemented Alzheimer's disease at the heart of the ageing agenda in the USA.

The growing anxieties about ageing are traced, from the early nineteenth century, by looking at the way the meaning of senility has evolved. At the beginning of this period, the word merely meant 'being old' -Thomas Jefferson looked forward to his 'senile rest' -but by the end of the nineteenth century it had been transformed into a pejorative term with many of the associations that it has today. In 1905 William Osler gave his infamous assessment of ageing, which suggested that men over 40 were fairly useless and gave guarded support to euthanasia at the age of 60. Indeed, senility has become a word that can no longer be used; [START_REF] Gilleard | Cultures of Ageing: Self, Citizen and the Body[END_REF] argue from a UK perspective that Alzheimer's disease has become the new senility.

The greatest anxiety for the growing number of elderly people (the so-called 'apocalyptic epidemiology') seems to be the loss of 'self ' which accompanies the decline in cognitive abilities. Most of the professional literature is predicated on a version of the self that revolves around the coherence of memory, and the ability of the person to produce a coherent self-narrative [START_REF] Rose | The Making of Memory: From Molecules to Mind[END_REF]. The idea of coherent narrative defi ning a healthy self has its origins not only in the rationalist philosophers such as Locke and Hume but also in the darker labyrinths of psychoanalysis. This is also the view that appears to be most prevalent among the carers of dementia sufferers. The feeling that the person who inhabited a particular body has already died despite the continuation of the body is something commonly heard by professionals in the fi eld.

This idea is rejected in the preface to the book: Ballenger's personal experience of working with demented patients has led him to believe that the person with dementia remains a person even into the very end stages of the illness. The last part of the book explores these notions through the 'biographies' of those who suffer with dementia and struggle to present themselves as coherent selves in the face of increasing dependency. Their different techniques as analysed by Alzheimer's theorists suggest to Ballenger that there is cause for optimism, despite a discourse that has called into question 'their very moral status as persons ' (p. 187). 'Hearing the voice' of the person with dementia becomes the most important task of the carer. This re-civilizing process represents a signifi cant challenge to society, which Ballenger argues can sit in a creative tension with the exploration of the molecular biology of Alzheimer's disease.

At present, this issue is of great interest to professionals, but the lay public does not seem to have altered its stance towards the illness. In much the same way that Cartesian Dualism remains the paradigm of choice for the man in the street with unexplained medical symptoms, the coherent narrative of self remains the dominant explanatory model for the majority of carers and sufferers. Most carers do not seem ready for discussions of the post-modern self in a post-industrial society but mourn the loss of their loved one who has, to their eyes, disappeared. Ballenger's book helps us to understand the complex web of infl uences that have created Alzheimer's disease as it is experienced today, but also points to a more positive future. While many of us would not share this optimistic conclusion, this revealing and informative account is worth reading.

CHRIS BALL South London and Maudsley NHS Foundation Trust