Voluntarism, Psychiatry and the Social Entrepreneur:

R D Laing and the Business of the Sixties

 

Ian Carthy, University of Glasgow

(8904191C@student.gla.ac.uk)

Supervisor: Dr Malcolm Nicolson

 

The counter-cultural movements that emerged over the course of the 1960's were a collective response to the practices of established economic, social and political institutions. Those individuals and groups who opposed the dominant culture were often assumed to have experienced a process of social marginalization, perhaps as the result of blocked ambition or through occupying an ambivalent position set apart from, yet part of, the wider society. Challenges to the dominant culture were typically expressed in diversity of lifestyles, beliefs and attitudes, with discernibly creative aspects. In an apparently separate field of enquiry, social marginality was also identified as a background factor in theories of entrepreneurial behaviour that were more generally concerned with cultural values related to risk-taking, independence and innovation. The present discussion of the Scottish psychiatrist R D Laing considers the relative importance of marginalization and entrepreneurial values to the understanding of his work. Laing continues to be closely associated with the 1960's counter-culture, and over the same period was involved in a range of entrepreneurial activities, from business planning and fund raising through to company formation. The nature of the enterprise and the interests at stake, however, were firmly rooted in clinical psychiatry and the controversy surrounding the dominant form of knowledge.

 

Laing played a leading role in the establishment and work of the Philadelphia Association, a voluntary organisation that provided treatment for people with psychiatric problems in a non-hospital residential setting.[1] While previous studies have examined the medical, social and political aspects of Laing's career in varying degree, the significance of the contemporary culture, particularly the economic context of Laing's practice, has been neglected in favour of biographical and theoretical exposition.[2] In contrast, the present discussion explores Laing's designs and intentions for the Philadelphia Association, first of all positioning them both in relation to the wider field of psychiatry, before assessing the extent to which his voluntarism was constrained by economic and related material processes. As a marker of entrepreneurial behaviour, the creative extension of his practice and interests invites the suggestion that Laing's cultural resources were drawn from dominant values in society as much as counter-culture opposition.

 

Voluntary organisations, as charities formally constituted under company law, are not immune to the economic pressures and organisational constraints that shape the interests and survival of other private sector ventures. Medical charities, in particular, are typically engaged across a range of activities, from the provision of support systems for patients to the advocacy and funding of new research. As a result of shifting priorities, often dictated by the physical reality of disease, new patterns of co-operation or conflict among members may form, and ultimately be constituted in the establishment of a new and separate organisation.[3] In the case of the Philadelphia Association, it will be seen that incorporation in 1965 was the result of a modelling process, the interaction between material constraints and Laing's intentions.[4] His initial plans and aims met resistance within the economic and social structures that framed his practice. New interests emerged and goals were revised as Laing attempted to accommodate the failure of his plans. Thus, the structure of the Philadelphia Association was neither determined in advance, nor the outcome of successive stages of development from initial idea to end product. The key to understanding its formation lies in the interplay of material processes, social marginality and entrepreneurial behaviour.

 

The Philadelphia Association advanced, and was shaped by, a particular set of economic, social and political interests. From 1965 until 1970 a former community centre in east London, Kingsley Hall, served as the principal location for the new organisation. During this period Laing and his colleagues at Kingsley Hall came to be identified with the 'anti-psychiatry' movement. Exponents of this critique were also to be found in America, France, Italy and Holland. Although anti-psychiatry lacked a coherent framework of theory and practice those associated with it were united in opposition to the prevalent physical methods of treating patients. Accordingly, these critics of the profession, among them psychiatrists as well as social scientists, viewed mental hospitals as socially and politically oppressive. For Laing in particular, disorders such as schizophrenia were intelligible in social and environmental terms, and as such called for the creation of new therapeutic communities that were fully independent of the mainstream hospital system.

 

As well as taking up a committed position on one side of a major controversy in psychiatric knowledge, Laing's criticism of existing institutions and power structures also shared some of the democratizing aims that characterized the New Left at the time.[5] However, the desire for de-institutionalization, and the significant reduction of the in-patient population this entailed, was not restricted to Laing and others in the anti-psychiatry movement. Following the introduction of new drug therapies in the 1950's and the policy framework of the 1959 Mental Health Act, government agencies and psychiatrists faced the challenge of developing community alternatives to institutionalized care. A shift away from the crowded and increasingly strained in-patient system of mental hospitals, and towards the treatment of patients in community settings, required nothing less than the reconfiguration of psychiatric provision under the National Health Service. Additional demands were inevitably placed on the financial, material and human resources allocated to mental health services. In the main, the ideal of community care in its early stage of development was limited to the extension of service provision through out-patient clinics and psychiatric units within the general hospital system.[6] Political enthusiasm for embarking on a major programme of change and de-institutionalization in the 1960's was not matched by financial commitment. The early impetus towards a comprehensive and integrated network of community psychiatric services hence slowed into a period of further policy research and planning.

 

The therapeutic community, in spite of its connotations, characterized the ethos of the proposed changes to the institutional structure of psychiatry rather than a radically new method and context of treatment. In practice, the therapeutic community was primarily a form of hospital psychiatry. Through the rehabilitation initiatives of the Second World War psychiatrists recognized the benefit to patients of using the social milieu of the hospital environment as a therapeutic tool in its own right. Patients were encouraged to organize and participate in a range of social, leisure, craft and industrial activities in addition to individual and group therapy with a psychiatrist. In the post-war period the main proponents of the therapeutic community, such as Maxwell Jones, gained an increasingly high profile.[7] At an early stage in his career Laing had conducted an experiment in socio-environmental therapy along similar lines within a National Health Service hospital.[8] As the1960's commenced, the significance of the social milieu for patients was a widely utilized element in psychiatric knowledge and clinical practice. Nonetheless, the majority of psychiatrists remained committed to explanations of mental disorder in terms of underlying biological causes and the related physical methods of treatment. In its direct opposition to the dominant form of knowledge, the emerging Philadelphia Association would borrow and exaggerate the established concepts and context of the therapeutic community, a characteristic strategy of marginalized interest groups.

 

Following his medical education and early psychiatric experience in Glasgow, Laing moved to London in 1956 to undertake further training as a psychoanalyst and a related post within a National Health Service clinic. By 1961 he had set up in private practice as a fully accredited psychoanalyst and had left the National Health Service. In addition, he held a fellowship from an American-based independent research trust, the Foundations Fund for Research in Psychiatry. The award was for a three-year study on schizophrenic patients and their families. Administration of the study in London rested with the sponsoring organisation, the Tavistock Institute of Human Relations. As an independent and self-financing operation, the Tavistock Institute sustained a range of research interests, from social psychiatry and applied psychology to management consultancy and organisational development. The position from which Laing later advanced his critique of psychiatry was thus a marginal one in relation to the mainstream of National Health Service provision.

 

As a research fellow working within the Tavistock Institute, Laing relied on his personal network of associates for practical assistance in the conduct and analysis of family interviews, the raw data of the study. Although Laing's network included colleagues who were members of the Tavistock Institute, his key associates constituted a small group of psychiatrists and social care workers with no official role or status within the Tavistock organisation, other than their active interest in Laing's research. Nevertheless, with the title of the Schizophrenia and Family Research Unit designated by Laing, the group acquired at least some form of collective identity. At a meeting held in the Tavistock Institute in late 1962, Laing reported that the main findings from the study added significant weight to a 'general environmental theory' of the disorder.[9] For the most part, however, the discussion was directed towards the status of the Research Unit, particularly its future development as a specialist clinical centre and the funding required for such a venture. With the research support from the Foundations Fund moving in to its third and final year, Laing's interests were evidently under threat, irrespective of his original sponsorship by the Tavistock Institute. His task of constructing a new form of psychiatric knowledge entailed transforming a fixed-term research project into a viable clinical centre. Clearly, support from the Tavistock Institute was not yet assured. In terms of social relations, Laing's research relied on a form of patronage that was disconnected from and independent of the state health system. There was, in effect, a need to attract other external agencies with related interests as partners in the venture, much in the same way as he had attracted the initial investment of the Foundations Fund for his earlier study.[10] Laing had attained a pivotal and potentially strong position through creatively combining the cultural resources available to him, and establishing the centre required the same entrepreneurial skills. At the same time, however, the position was a marginal one that had been determined by his career decisions. 

 

The centre that Laing envisaged was an experimental model unit for the specific purpose of investigating the schizophrenic patient's 'process of personal disintegration and reintegration'. In terms of material needs, the centre was to be a house, ideally in a rural environment, with sizeable grounds and around 12 rooms to accommodate the in-patient treatment of 'acutely disturbed' individuals. To this end, Laing and his team had entered into discussion with the Richmond Fellowship, a voluntary organisation that provided residential and social support to individuals in the community who were living with mental health problems. The role of the Richmond Fellowship was to serve as a 'half-way house' for those in-patients who were progressing and recovered sufficiently enough to move out of the model centre. From a different perspective, however, it can be seen that Laing's group had succeeded in the initial recruitment of an external agency that had a common interest in the creation of a new institution. The Richmond Fellowship had even gone as far as to approach a local authority and an independent trust to canvas support for the purchase of suitable premises and subsequent annual contributions for a proportion of salary and maintenance costs.

 

Laing and his associates produced a five-year spending plan that included the purchase of buildings and equipment, the salaries of three research psychiatrists and those of a research social worker and social therapist. On the income side no specific amounts were given, though the projected expenditure was to be offset against the equivalent earnings from the psychiatrists' private practices. Other income was to be generated from local authority grants, trusts' awards, residents' rent, and fees from family therapy and training seminars. The financial plans were included in a detailed letter that Laing sent to numerous trusts and funding bodies in a bid to canvas support for the experimental centre.[11] In summarizing the main findings from his study of schizophrenia and the family, Laing made the case for further investigation and the translation of the research into practical terms that would have direct implications, no less, for the planning of mental health services and the future of community care. He also described schizophrenia in terms of it being 'as great a scourge as cancer', stressing the high cost of medical services at £150 million per annum in Britain alone. The continuation of the current research in the form of a specialist centre would be in advance of any other psychiatric service, according to Laing, and was bound to attract visiting scientists from all countries.

In spite of contacting a significant number of health boards, local authorities and trusts, Laing and his associates received no positive response whatsoever in the form of financial support.

 

In linking his plans to the Tavistock Institute and the Richmond Fellowship, Laing had formed a potentially strong and strategic alliance, a community of interests, for the purposes of attracting funding support. Instead, Laing and his associates found themselves in a relatively weak and isolated position within the field of psychiatry. While the proposed specialist centre was an attempt to extend his interests, it can also be seen as a move to re-connect with the mainstream of mental health service provision that failed. Funding support from local authorities or health boards implied the contracting out of psychiatric services, a public-private partnership that can be described as a 'mixed economy' of care. Although financial constraints were no doubt a factor, the interplay of material, social and conceptual processes explains the dissolution of the community of interests surrounding the specialist centre. The Tavistock Institute was a research and development culture whose activities did not extend to the delivery of clinical services, especially on an in-patient basis. Likewise, the Richmond Fellowship operated as a residential, advocacy and support network, at the boundary where formalized clinical psychiatry and therapy began and ended. Close alignment with a specialist clinical centre was thus something of a risky strategy for the two partnership organisations, notwithstanding the lack of a proven track record from the perspective of the funding bodies. The experimental purposes of the centre could also be seen as a distortion of the therapeutic community ethos. In terms of knowledge, the environmental theory of schizophrenia was only one element in the range of explanations for the disorder. For the majority of psychiatrists, biological theories continued to dominate.

 

In spite of these setbacks, the Philadelphia Association was incorporated in April 1965, taking up a five-year lease at Kingsley Hall in London's East End at a nominal cost. Through their network of personal contacts Laing and his colleagues had approached and entered protracted negotiations with the Board of Trustees that managed Kingsley Hall. Private and contractual relations now framed Laing's practice. The 'Memorandum and Articles of Association' set out the aims of the seven subscribers to the Philadelphia Association, who included Laing and two psychiatrist colleagues.[12] The two main objects were 'to relieve mental illness of all descriptions and in particular schizophrenia' and 'to provide residential accommodation for persons suffering mental illness by way of treatment'. As a non-profit voluntary organisation with no hierarchy of members, the form and function of the new organisation was as a social enterprise in the field of clinical psychiatry.

 

The Philadelphia Association was Laing’s creative response to social marginality and the end product of his entrepreneurial behaviour. A new institutional form was required to demonstrate the specific practical value of the environmental theory of schizophrenia. The location and constitution of the new organisation, however, emerged as the outcome of the interaction between material constraints and human agency. Hence, the blocking of Laing's plans do not fully explain his counter-cultural opposition to the dominant forms of psychiatry. In seeking to establish a new specialist centre Laing was always in a marginal position relative to the main body of mental health service provision. When his attempts to attract funding support from National Health Service agencies failed, the centre was subsequently set up as a private and fully independent venture. As an autonomous institution, the Philadelphia Association was the ultimate expression of Laing's desire for independence, innovation and minimal state intervention in clinical psychiatry. In other words, Laing's practice asserted the dominant values of the capitalist culture.