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| SPECIAL COMMUNICATION |
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| Year : 2023 | Volume
: 5
| Issue : 1 | Page : 21-28 |
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Attachment, Family, and Social Systems: London's “Cradle to Grave” Contributions as a Model for Social Psychiatry
Vincenzo Di Nicola
Department of Psychiatry, Institut Universitaire en Santé Mentale de Montréal; Department of Psychiatry and Addiction Medicine, Université de Montréal, Montreal, Canada; Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC, USA; Founder and President, Canadian Association of Social Psychiatry; President, World Association of Social Psychiatry
| Date of Submission | 21-Mar-2023 |
| Date of Acceptance | 22-Mar-2023 |
| Date of Web Publication | 26-Apr-2023 |
Correspondence Address:
Prof. Vincenzo Di Nicola
Department of Psychiatry, Institut Universitaire En Santé Mentale De Montréal, 7401, Rue Hochelaga, Montreal, Quebec, H1N 3M5, Canada
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_17_23
This article explores the parallels among postwar Britain's “cradle to grave” welfare state with its “social safety net,” especially the National Health Service, the consequent social realism and social upheaval in every sphere of the society, and the birth of the Social Psychiatry (SP) movement in London. From Bowlby's attachment theory, to the pivot from individual to relational therapies, and from research on the social origins of depression in women and Expressed Emotion in family relationships, to the hospice movement, London has uniquely served as a model for SP. There is an organic relationship among these social phenomena in a collectivist society that values “the commons” that created a social safety net, manifested by social realism in the arts reflecting a social upheaval that challenged tradition, notably the class structure of British society. The hallmark of SP is to discern governing patterns across social domains. Anthropologist Gregory Bateson sought “the pattern that connects” while sociologists and systems theorists found patterns in the structures, scripts, and systems of a society. What distinguishes SP is in perceiving these patterns, taking them seriously to re-vision how we think about determinants and influences of mental and social health, and to construct new approaches in psychiatry from research to pedagogy and clinical practice to policy-making.
Keywords: Attachment, families and family therapy, social psychiatry, social systems, world association of social psychiatry
How to cite this article:
Di Nicola V. Attachment, Family, and Social Systems: London's “Cradle to Grave” Contributions as a Model for Social Psychiatry. World Soc Psychiatry 2023;5:21-8 |
| The Birth of Social Psychiatry as a Movement | |  |
I have a duty to the past – Our shared past as social psychiatrists – And to my own past in London, both north and south of the River Thames. The International Association of Social Psychiatry was founded in London by Bierer,[1],[2] where the first International Congress of Social Psychiatry (SP) took place in 1964 and again in 1969 as well as the World Association of SP (WASP) Jubilee Congress celebrating WASP's 50th anniversary in 2014 organized by Royal College of Psychiatrists with WASP President Thomas Craig.[3],[4]
Between those events, I trained at the Institute of Psychiatry (IoP) south of the Thames in Camberwell, where I had the opportunity to study child psychology and psychiatry with Bill Yule and Sir Michael Rutter and SP with Julian Leff. I also went north to the Tavistock Institute, where I took a course on death and dying with Colin Murray Parkes, a pioneer of the hospice movement, and began my psychotherapy training. Four decades later, I am a child and adolescent psychiatrist, a relational psychotherapist, and a socio-cultural psychiatrist. And I would like to speak to the systems that connect these domains: Attachment, family, and social systems.
London: “The Pattern that Connects”
There is an organic relationship among these social phenomena, with a collectivist society that values the commons, which created a social safety net, manifested by social realism in the arts that both expressed and fostered a social upheaval challenging tradition, especially the class structure of British society. The hallmark of SP is to perceive governing patterns across social domains and to connect them to other levels of human functioning in the now-classic bio-psycho-social formulation.[5]
Anthropologist Bateson[6] sought the “pattern that connects” across diverse social phenomena, while sociologists and systems theorists see patterns in the structures, scripts and systems of a society. What distinguishes SP is attention to these patterns, taking them seriously to re-vision how we think about determinants and influences of mental and social health, and to construct new approaches in psychiatry from research to pedagogy to clinical practice. If the key words of psychoanalysis and psychodynamic psychiatry are introspection and insight; for family therapy they are process, structure and systems; and for child psychology and psychiatry they are attachment and development; then for SP they are: context, class and society.
| Social Context: “From the Cradle to the Grave” | | |
When Joshua Bierer created the SP movement in London in 1964, Britain had been living in its postwar modern welfare society with “cradle to grave” social security for a generation. Those services ranged from the National Health Service (NHS) and national insurance (child subsidies, sickness benefits, and unemployment insurance) to create a “social safety net” for all, including the homeless, the physically disabled, unmarried mothers, and supplementary benefits for the elderly, with provisions for suitable accommodations.[7] The roots of this cradle-to-grave social safety net were in the wartime Beveridge Report (1942).[8],[9],[10]
The Beveridge Report offered a “comprehensive policy of social progress” aimed at eliminating “five giant evils” on the road to reconstruction – Want, Disease, Ignorance, Squalor and Idleness.[8] The Times, Britain's newspaper of record called it, “a momentous document which should and must exercise a profound and immediate influence on the direction of social change in Britain.”[9] In 1943, Prime Minister Winston Churchill gave a radio broadcast announcing measures “After the War” for “national compulsory insurance for all classes for all purposes from the cradle to the grave” (emphasis added).[9],[10] Nonetheless, Churchill and the Conservative Party were against much of the Beveridge Report and voted against the founding of the NHS, leading to their postwar downfall. The 1945 UK general election brought in the Labour Party, which created the modern British welfare state with a series of Acts of Parliament based on the Beveridge Report. Historians trace Britain's welfare state directly back to this influential government document and perhaps as far back as the social reforms of Prime Minister David Lloyd George and his Liberal Party of 1911.[10]
The history of psychiatry and social services in London closely parallels the social background of Britain in every sphere, from the arts to politics, in creating concepts (such as attachment), practices (notably, the hospice movement), and research paradigms (psychiatric and social epidemiology, Expressed Emotion [EE]) “from the cradle to the grave,” covering the entire life span. We will look at Britain's postwar social background in detail, followed by a survey of its translation into psychology, psychiatry, and social services under three headings: I. Attachment: “A Secure Base,” II. “The Politics of the Family”: RD Laing and His Legacy, and III. The Social Origins of Mental and Relational Distress.
The Global Mental Health (GMH) movement,[11] the WHO Social Determinants of Health (SDH)[12] Study and the Adverse Childhood Experiences (ACE) Study[13] all point to an organic relationship between the social environment and health outcomes, insisting that there is no health without mental health[14] and that the gap between known mental health problems and services is itself a negative index of a population's health,[15] so we can construct a model of a healthy society as one that is attentive to all aspects of health and care across the lifespan, from cradle to grave. London, in its social, political, and psychiatric history, has created just such a model for a convivial community of the commons, even if it does not always live up to that ideal.
”Kitchen-Sink Realism” and “Angry Young Men”
Postwar Britain was turning against its colonial past as a global power and moving into a more realistic view of the world, from the independence movements of its colonies in Africa and Asia to the social realism of the arts in painting, theatre, and film. The galleries, stages, and screens of Britain were filled with “kitchen-sink realism” by a generation of “angry young men.” The titles tell the story – John Osborne's play Look Back in Anger (1956), John Braine's play Room at the Top (1957), and the film Bitter Harvest (1963) by Peter Graham Scott. Domestic life was portrayed as cramped and stifling, often showcasing people from the poorer Northern areas struggling to escape the confines of traditional social roles and a rigid socio-economic class structure.[16] Music saw Benjamin Britten's War Requiem (1962) with its anti-war themes of death, destruction, and trauma based on the poetry of Wilfrid Owen.[17] And drawing talent from outlying regions like Liverpool (The Beatles) and Newcastle-upon-Tyne (The Animals) to London (The Rolling Stones) to create a new sound, the “British invasion” was an amalgam of British skiffle and American rock'n'roll and rhythm and blues. The joyful exuberance of the early Beatles belied the social suffering expressed in the American blues expressed by groups like The Animals, whose titles express this best, “Don't Let Me Be Misunderstood” and “We Gotta Get out of this Place,” and The Rolling Stones' “(I Can't Get No) Satisfaction” and “Paint It Black.”
This postwar creative explosion saw the flourishing of the British Film Institute,[18] the establishment of the National Theatre (1963)[19] and a renewed British Library (1973). A jewel of this creative flourishing was Jacob Bronowski's The Ascent of Man (1973), a BBC documentary brilliantly straddling both arts and sciences, from Blake's metaphysical poetry to what Bronowski depicted as Heisenberg's “principle of tolerance” in physics.[20] What Bronowski says there could also stand for the SP movement.
Man is unique not because he does science, and he is unique not because he does art, but because science and art equally are expressions of his marvelous plasticity of mind.[21]
In the figurative arts, who could forget Francis Bacon or Lucian Freud who brought a savage sensibility to their psychological astuteness? In his sculptures, Henry Moore portrayed both solitude and relationships in ways we hadn't seen since Auguste Rodin. David Hockney's Polaroid collages deconstructed perspective in ways we hadn't witnessed since Picasso's Cubism. And Damien Hurst's account of Natural History opened a new dialogue between art and nature. Finally, perhaps the most famous artist to emerge from contemporary Britain, the anonymous “Banksy” illuminated the grim realities of daily life in ways that are both satirical and hopeful, shining a bright light on dark prejudices.[22]
In sociology, the pioneering study, Family and Kinship in East London (1957) by Young and Willmott, architects of Britain's postwar welfare state, documented the life of the urban working class.[23] The New Left was on the rise and competing visions of psychology, psychiatry, and social relations were being promoted. South of the Thames in Camberwell, the IoP had a SP group headed by Michael Sheppard and a behavioral psychology department led by Hans Eysenck. North of the Thames, the Tavistock Institute became the premiere place for psychoanalysis, with three major figures in child psychoanalysis cohabiting in the same space – Anna Freud, Melanie Klein, and Donald Winnicott. Where else but in London? And John Bowlby conducted a masterful synthesis of child psychology, psychiatry and psychoanalysis with his attachment theory.[24] His supervisee, Ronald David Laing, became a ground-breaking psychiatrist-psychoanalyst investigating “the divided self.”[25]
When I arrived in London in the mid-1970s, it was a grey place with the right-wing National Front jockeying for political relevance, football hooligans and skinheads roaming the streets in their Dr. Martens boots and braces, and the emergence of the anarchic Sex Pistols that I saw in an early performance. And later, The Clash baldly announced that “the ice age is coming” and “London is drowning” in their apocalyptic rant, “London Calling.” All this was before the “Big Bang” hit The City in 1986. Prime Minister Margaret Thatcher's financial deregulation of the London Stock Exchange transformed London into the world's major financial center. And yet, social inequalities have persisted even as the social safety net raised the overall socio-economic status of the population and this was manifested in health inequalities. The City rose to global financial prominence while another London, “the world city,” struggled to accommodate the world in its own backyard.[26]
| I. Attachment: “A secure base” | | |
John Bowlby (1907–1990) was a psychiatrist and psychoanalyst at the Tavistock Institute who studied children and maternal deprivation, synthesizing a wide swath of clinical observations and research findings into attachment theory outlined in his classic trilogy: Attachment (1969),[27] Separation (1973),[28] and Loss (1980),[29] whose message is encapsulated in the title of a later volume, A Secure Base: Parent-Child Attachment and Healthy Human Development (1988).[24]
Attachment theory became the dominant model for the study of early social development. The key features are that toddlers form emotional attachments to familiar caregivers, establishing a lifelong “secure base,” that forms the foundation of later behavior, emotions, and personality. Events that interrupt or interfere with attachment have negative consequences. Such events include the separation of a toddler from attachment figures and caregivers' lack of sensitivity, responsiveness, or consistency when interacting with toddlers.
Attachment is also reflected in the Life Stress Events Scale (43 stressful life events in the past year), which yields “Life Change Units.” Changes in individuals and their families are most stressful, followed by changes at work or school.[30] ACEs[31] are strongly associated with poorer health outcomes. ACEs include physical, emotional and sexual abuse, neglect, and household dysfunction. The robust results of the Ace Study reveal a linear gradient between the number of ACEs and worsening health outcomes.[13],[31]
Bowlby's work was taken up at the IoP in Camberwell by Michael Rutter. With his more empirical approach, Rutter studied maternal deprivation[32] and pioneered child psychiatric epidemiology with the Isle of Wight Study[33] as well as developmental psychopathology – The study of mental health problems (psychopathology) during children's growth and across the human life span (development).[34],[35]
Although attachment theory was not without its critics, notably Keller's cogently reasoned multicultural critique that questioned its cultural universality,[36] it formed the basis for much research, theorizing, and the construction of attachment-based therapies with couples and families.
Summary
Attachment theory spawned a veritable industry of research and applications in everything from infant bonding to understanding trauma and now attachment-based therapies.
| II. “The politics of the family”: RD Laing and his legacy | | |
Before family therapy become an institution, families had to be noticed by clinical psychiatry. Paradoxically, while maternal-child relationships were being studied by Bowlby, the principled study of families was lagging. The scene was set by politics with the social safety net for unwed mothers and poor families, by the arts with kitchen-sink dramas, by the sociologists who studied families in the East End of London, and by Bowlby and Rutter studying attachment, but the clinical family drama had no director until Scottish psychiatrist-psychoanalyst Ronald David Laing came along:
The first family to interest me was my own. I still know less about it than I know about many other families. This is typical. Children are the last to be told what “really” was going on before they came into the world…[37]
Laing made his name with his 1960 study of “the divided self”[25] – An “existential study” of schizophrenia, a condition later described by a British historian as the “sublime object of psychiatry.”[38] Like Murray Bowen in the USA, Laing talked to his patients about their family relationships rather than actually seeing families in therapy. Laing's observations about the social phenomenology of schizophrenia led to his own and many others' research on the families of psychiatric patients.
His reception in the psychiatric establishment was mixed – While his narratives were compelling, his methods deviated from both psychiatric and psychoanalytic traditions.[39] And yet, he was an original thinker who stimulated the rethinking of psychiatric theories and practices, especially with the most difficult-to-reach patients experiencing the alienating phenomena called psychoses.
Much of the work on couples and families was happening on the margins of mainstream psychiatry and psychology, eventually reaching for a new way to understand them with systems theory. This represented nothing less than a rethinking of human psychology and clinical psychiatry based on relationships and the therapies that follow from such a psychology. In the USA, Minuchin articulated a coherent model with a structural theory of family functioning, a theory of change, and techniques for therapy.[40] Nonetheless, it was the Milan Model of systemic family therapy that became the most theoretically original and innovative in practice.[41]
Once again, the IoP, with its more empirical approach, stepped up to the challenge with two research paradigms initiated by sociologist George Brown. One was the EE paradigm to study the family relations of chronic schizophrenic patients. Exposure by such patients to families with high EE (marked by critical comments and hostile interactions) led to higher recidivism rates than those who were discharged to community lodgings.[42] This research was advanced by Julian Leff and Christine Vaughan at the IoP and applied to many clinical conditions from anorexia nervosa to depression and exported as a model around the world, with attendant critiques from cultural psychiatry.[43]
The other research paradigm by Brown and Harris studied the social origins of depression in women.[44] This demonstrated that isolated women who had experienced early maternal loss, lacked a confiding partner to share the child-rearing tasks, with more than three young children at home, were much more vulnerable to depression.
The IoP developed the Maudsley Model of Family-Based Treatment was proven successful with eating disorders.[45] Other notable figures in family therapy in London included Robyn Skynner at the IoP, who wrote about families with comedian Skynner and Cleese[46] and Byng-Hall, who was a pioneer on family scripts and one of the founders of the Institute of Family Therapy.[47]
Summary
RD Laing's integration of social phenomenology with clinical psychiatry proved to be path-breaking and instigated new thinking, research paradigms, and clinical interventions to help patients and families in relational distress.
| III. The social origins of mental and relational distress | | |
The roots of thinking about the social in psychiatry in Britain go back at least to Aubrey Lewis[48],[49] at the IoP and his mentee Michael Shepherd who held the world's first Chair in Epidemiological Psychiatry. The psychiatric epidemiology that was pioneered by Rutter with children's mental health and Shepherd in the study of psychiatric illness in general practice,[50] finds its apotheosis in the authoritative WHO study of SDH conducted by Sir Michael Marmot, the world's leading social epidemiologist.[12],[15] SDHs are the most robust findings that we have not only in SP or general psychiatry but in medicine. SDHs, along with the cognate ACE studies, are the basic science of SP. Perhaps Marmot's greatest innovation is “Proportionate Universalism (PU)” (see below.)
The SDH data are methodologically robust such that SP does not need to look further for its basic science. SP may refine, update, and adapt these studies, but these findings will stand. What SP does need to do is to digest them – And do translational research to adapt them so that they don't “cruise at thirty-five thousand feet” like GMH, as its critics complain.
”Mind the Gap” – Social Gradients in Health
This line of research starts with the social origins of mental and relational distress to then identify health inequalities. This research has convincingly established the social gradients in health. The current mantra of the public discourse sees them as structural and systemic (”built into the cake”). The challenge then becomes how to reduce health inequalities or the “mental health gap” between the known burden of suffering in the population and access to effective and efficient care.[51]
Summary
The social origins of mental and relational distress begin with enlarging the frame of observation from the clinic to the community and are tested through populational studies. The psychiatric epidemiology pioneered in London by Rutter and Shepherd is complemented by Marmot's social epidemiology. If health inequalities are the problem, SDH studies revealing the social gradient of health are the methodology, and PU points to the solution (see below).
| Conclusion: From Society to the Individual | | |
My manifesto for 21st century SP outlined three branches of SP:[52]
- Psychiatric epidemiology – SDH
- Community psychiatry and mental health – Which includes social rehabilitation and recovery
- Relational approaches from family therapy to Moreno's psychodrama to Brazil's Integrative Community Therapy.
There is a theme that cuts across all our preoccupations and projects in SP that has been present in all the branches of our field from the outset. That theme is belonging and a sense of community – Called “the commons” in Britain and elsewhere. The commons may be defined as a “social practice” of governing a resource not by the state or the market but by a community of users that self-governs the resource through institutions that it creates (see Nobel Prize-winning economist Elinor Ostrom's work on governing the commons),[53],[54] The commons is related to progressive social movements in the creation of public spheres.[55] Ostrom was the first woman to win a Nobel Prize in Economics and opened a bridge between economics and political science. Her work should be studied by social psychiatrists, along with sociologists from Pareto[56] in Italy to Parsons and Putnam in the USA and, of course, Young and Willmott, in their classic study of family and kinship in East London.[23]
Belonging is to SP what attachment is to child psychiatry. Furthermore, belonging is the glue that holds the SDHs together and gives them meaning.
Expanding Our View of Health: “Fair Society, Healthy Lives”
If there is no health without mental health as the GMH movement declared[14] and was adopted as the slogan of the Royal College of Psychiatrists, then there can be no mental health without a healthy body in a healthy community, or as Marmot put it: “Fair society, healthy lives.”[57]
Now, that's a slogan for WASP and SP. SDHs need to be understood and translated into clinical and community applications, not just documented as adverse experiences.[58] For example, SDHs cannot be only about trauma as the ACE Study suggests since even complex and severe traumas are mitigated by family and social support, as the burgeoning literature on trauma-informed care has amply demonstrated.[59] Another example of a fair society is the compassionate care of Britain's hospice movement, pioneered by Colin Murray Parkes at St. Christopher's Hospice in Sydenham.[60]
Marmot's solution is in PU: A means of addressing the dichotomization between universalism (dealing with the whole population) and targeting (focusing on a particular segment) in the health field.”[57] This is a notion that evolved from the classical opposition of universalism to targeting in European socio-political history, to “targeting within universalism” or “progressive universalism” and, finally, to the PU approach which focuses on “upstream determinants” by advocating on social policies such as education or employment.[61]
And Now, to the Future…
SP should promote convergence, integration, and social solidarity as the guiding values of our field[58],[62] (See my Guest Editorial in this issue.).
While SP cannot account for or represent all the issues in psychiatry, SP cannot be dismissed or minimized. Sometimes, the social aspects of psychiatry are in the foreground, as with the ACEs and SDHs, and sometimes they are in the background, as in climate change and the coronavirus syndemic, depending on what we choose to study or address, but the social aspects of psychiatry are always in the frame.
Rather than debating what is primary or more important in psychiatry, let us simply put forward the notion that we must expand a narrow view of a narrowly constructed “medical model” to include the social surround and that the definition of health must necessarily include social context.[5],[63],[64]
As a social psychiatrist, I inverse the Western view that starts with the individual and moves out in expanding concentric circles to attachment, family, community, culture, and finally to society: I reason from society to the individual. SP is better served by Italian sociologist Pareto's seminal Mind and Society (1935)[56] than by the Romantic individualism of Swiss philosopher Jean-Jacques Rousseau in The Social Contract (1762). This was elaborated in a re-appraisal of Indian psychiatrist JS Neki's gurū-chelė relationship as a model for SP in which the individual is guided and nurtured through a trusting relationship, reflecting the social dynamics of Indian society.[65]
The Myth of the Atomistic Individual
Against the assertion of former British PM Margaret Thatcher that, “There is no such thing as society,” without society, there is no such thing as an individual. Children who are not raised in abiding attachments (cf. Bowlby, Rutter), who are not nurtured by family ties (cf. Byng-Hall, Laing, Leff, Skynner) and supported by social networks (cf. Brown and Harris, Shepherd, Young and Willmott) do not become optimally functional human beings who might share the happy ideal of autonomy and independence. Their exposure to ACEs undermines health across the lifespan with a linear gradient between the number of ACEs and long-term negative health impacts. The pioneering studies of Tirrell Harris and George Brown on the social origins of depression in women compellingly demonstrated that confiding partners and social relationships are critical in protecting women against depression.[44] It is now well established that we are richly socially interdependent and not only health but recovery and rehabilitation too depend on a shared sense of belonging and reciprocal social obligations. A more realistic and mature perspective recognizes the interdependence of all relationships in a convivial community.[66] As French Philosopher Jean-Luc Nancy (2000) puts it in his Being Singular Plural: there is no being without “being-with,” that “I” does not come before “we,” and that there is no existence without co-existence.[67] And a Zulu saying captures it relationally: “A person is a person through other persons.”[68]
I have been involved in attachment, family and social systems all of my careers since my training days at the IoP and the Tavistock Institute in London. My work is inspired by such congenial approaches as systems theory which situates human beings in relational contexts called systems and attachment theory, which situates human development in the context of parent – Child bonds and family-based caregiving. Together, attachment theory and systems theory highlight the crucial, life-defining importance of early childhood growth and lifelong family and social support. Projected onto the larger screen of SP, these theories become the critical issue of belonging. In a world of complex, competing, and often confusing identities, belonging reminds us that we are first social beings who need to relate to others through family, friendship, and communal relationships.[52]
The pattern that connects them all can be captured with these key words – Belonging, the commons, and relationships – And not only fine institutions but society itself is what makes SP possible, unavoidable, and necessary.
Acknowledgments
This paper is based on my Plenary Address as incoming President of the WASP at the WASP/Royal College of Psychiatrists Joint Congress of Social Psychiatry, London, England, January 16-18, 2023. I would like to express my gratitude to my teachers, mentors, fellow students and psychotherapist in London, notably psychologists Graham Powell, Bill Yule, Vicky Rippere, Derek Bolton, Joanna Collicutt, Stephen Frosh and Fraser Watts; psychiatrists Sir Michael Rutter, Felix Post, Anthony Clare, Julian Leff, Isaac Marks, Robin Skynner and Gerald Russell at the IoP; Colin Murray Parkes of the Tavistock Institute and St. Christopher's Hospice, Michael Simpson of the Royal Free Hospital and R.D. Laing of the Philadelphia Association. Finally, I wish to express my deep appreciation of my colleagues at CASP and WASP as well as the WASP Past Presidents I have known for their leadership and vision:
- Antonio Guilherme Ferreira (Portugal, 1988-1992)
- Jorge Alberto Costa e Silva (Brazil, 1992-1996)
- Eliot Sorel (USA, 1996-2001)
- Shridhar Sharma (India, 2001-2004)
- Tsutomu Sakuta (Japan, 2004-2007)
- Julio Arboleda-Flórez (Canada, 2007-2010)
- Driss Moussaoui (Morocco, 2010-2013)
- Thomas Jamieson-Craig (UK, 2013-2016)
- Roy Kallivayalil (India, 2016-2019)
- Rachid Bennegadi (France, 2019-2022).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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