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Harry Oosterhuis and Marijke Gijswijt-Hofstras.
Verward van geest en ander ongerief: psychiatrie en geestelijke gezondheidszorg in Nederland (1870–2005), 3 vols, Houten, Bohn Stafleu van Loghum, Nederlands Tijdschrift voor Geneeskunde, 2008, pp. xxvi, 1522, 135.00 (hardback 978-90-313-5238-8).
This study is the result of a collaborative research project funded by the Dutch Council for Scientific Research (NWO), which started in 1999. As well as this mammoth-size study, the research group published a series of comparative volumes and separate studies on more specific issues, which have brought the historiography of Dutch psychiatry to a level that is unsurpassed by that of other nations. The crowning glory of this work is this general overview of psychiatry in the Netherlands since 1870 by the project leaders, Harry Oosterhuis of the University of Maastricht, and Marijke Gijswijt-Hofstra, professor emeritus of the University of Amsterdam. Considering the strong international focus of the project, it is to be deplored that this final study is written in Dutch, also because an English or American university press might have been able to persuade the authors to write more concisely and more explicitly about the specifics of Dutch psychiatry in comparison with that of other western countries.
The history of Dutch psychiatry Oosterhuis and Gijswijt-Hofstra depict, seems to conform to the general pattern in western countries of a steady growth of patients, psychiatrists and institutions for mental health care. The strongest increase was between 1884 and 1914, when intramural care tripled from 5,000 to 14,000 intramural patients, and from 1.1 to 2.3 per thousand of the general population. The high point was reached in 1939, when 2.9 per thousand of the Dutch population was institutionalized; this number of around 30,000 patients started to decline after the 1960s, until it reached the current level of some 20,000 intramural patients, or 1.3 per thousand. Yet the de-institutionalization was not accompanied by a strong anti-psychiatric wave, since the number of professionals occupied with the mental health of Netherlanders continued to increase, from some 1,350 professionals around 1,900 to the current 30,000 professionals. They are involved in the treatment of hundreds of thousands of people outside hospitals and asylums, the majority of whom suffer from minor psychic discomfort—and in many cases not even that, but are tested by forensic psychiatrists in the army, human resources departments, social security offices, or insurance companies.
The strong development of extramural care appears to be specific for the Netherlands. Even though this pattern is also present in other countries, it started in the Netherlands as early as the 1920s, as psychiatrists became involved in bureaus for family and marriage counselling, alcohol abuse treatment, and extramural psychotherapy. The reasons for this shift were partly financial—to reduce the burden on asylums of increasing numbers of patients—but also inspired by the psycho-hygienist movement, which aimed to broaden the impact of psychiatric interventions. An important impetus was also the Laws on Psychopaths of 1925, which gave psychiatrists an important role in the criminal justice system, among other things by introducing forced treatment as an alternative to imprisonment.
Unlike France and the UK, but more like Belgium and Germany, this whole mental health care complex was rather fragmented, due to the specifically Dutch phenomenon of denominational compartmentalization of social life (“pillarization”). Most asylums and bureaus for extramural care were administered by private parties within civil society, even though they generally received their funds from the state. The system became more centralized after the introduction of a system for public finance for special medical needs (AWBZ 1968) and the integration of a whole range of mental health care services in regional institutions for ambulant mental health care (Riagg’s, 1982).
The authors suggest that Dutch pillarization also is an explanation for the early public acceptance of psychological categories to approach moral and social problems. Non-biological, phenomenological and psychoanalytic theories were especially welcomed by denominational psychiatrists, who used them to develop a more liberal approach to morally contested behaviour. Psychiatry became a vehicle for self-development, as a result of which Dutch psychiatry made less use of forced or invasive forms of treatment, yet ironically much more use of separation as a final resort.
These and many other interesting observations are the result of the authors’ empirical and descriptive approach to the topic. They explicitly distance themselves from the critical histories of psychiatry inspired by Foucault, which, according to them, never took root in the Netherlands. Instead, they take their theoretical inspiration from the work of Norbert Elias and the Dutch sociologist Abram de Swaan, according to whom psychiatry is a culturally specific response to real inconveniences (ongerief), which are then translated into psychic problems.
In order to explain this translation, the authors introduce the rather unfortunate metaphor of a market for psychiatry, in which demand stimulates supply, but more importantly, supply creates demand. Since it is hard to identify a need or demand for psychiatry, the authors focus mainly on the supply side of psychiatry as a set of institutions and as a profession, which generate concepts and discourse to handle moral and social problems. This only shifts the problem: what counts as psychiatry or mental health care is almost as difficult to identify as psychic need or demand. Although the self-definition of psychiatrists and their professional organizations are some indication of what the practices of psychiatry entail, it is clear that over the years, the psychiatric profession has had a hard time warding off competition from other specialists, including neurobiologists and all kinds of alternative mental health care professionals. Moreover, growing supply as an explanation for the growth of psychiatric definitions of social problems seems to beg the question, why there was a growth of the profession in the first place, and why so many people with “inconveniences” welcomed their expertise.
This leads us back to the demand side. The authors explicitly argue that it is hard to measure demand, which they seem to restrict to the expression of psychic needs by potential patients. Yet pressure to create a supply of psychiatric professionals also seems to come from political, financial or bureaucratic expediency (as is the case in the expansion of extramural care), or from the competition between different groups of specialists for professional recognition. However, the authors in the end explain an increased need for psychiatric care by pointing to cultural developments, such as increased individualism, but also to the specifically Dutch appetite for post-materialist values and a “feminine” orientation towards mutuality and care, which require a “fine-tuned management of emotions” (pp. 1263–5). Maybe it is this phenomenologically inspired, mildly anti-modernist position that is most characteristic of Dutch psychiatry, as well as of some of its historiography.