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The Transformation of the Psyche in
British Primary Care, 1880–1970

Rhodri Hayward

LON DON • N E W DE L H I • N E W YOR K • SY DN EY

 Bloomsbury Academic
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First published 2014

© Rhodri Hayward, 2014

Rhodri Hayward has asserted his right under the Copyright, Designs and
Patents Act, 1988, to be identified as Author of this work.

All rights reserved. No part of this publication may be reproduced or transmitted

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ISBN: HB: 978-1-7809-3726-7

ePDF: 978-1-7809-3719-9
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 For Griffith and Llewelyn
the sworn enemies of promise
vi
 Contents

Acknowledgements viii
Preface x

1 The Emergence of the Unconscious 1

2 The Healing Power of History 31
3 The Social Consciousness 61
4 The Anxiety of Influence 91
5 Placebo and the Problem of Truth 117

Notes 133
Bibliography 213
Index 259
 Acknowledgements

This book was written with the generous support, and sometimes active
encouragement, of the Wellcome Trust. The greater part of the research was funded
by a Fellowship (Grant no., 068387) to work at the Wellcome Trust Centre for the
History of Medicine although I also gained much from a research associateship
held at the Centre for Medical History at the University of Exeter. This book, as
many will recognize, shows just how how much I have learnt from colleagues
at those institutions: particularly Roger Cooter, Mark Jackson, Christopher
Lawrence, Joseph Melling, Sonu Shamdasani and Michael Neve. Its overall
conception however would not have been possible without the work of Mathew
Thomson, Roger Smith, Graham Richards and Thomas Dixon. Mathew has
perhaps done more than anybody to sketch out the shape of popular psychology
in modern Britain and to demonstrate its implication in the broader social
and cultural history of the state. I have learnt a tremendous amount from him.
Roger, Graham and Thomas have each shaped my understanding of psychology
demonstrating how it cannot be abstracted from language and history.
I owe the insights in this work to the quiet brilliance of librarians and
archivists at the Wellcome Library, Royal College of General Practitioners, the
Bethlem Archive, the Rockefeller Foundation Archive at Tarrytown, the British
Psychoanlytical Society Archive, the National Archives at Kew and the National
Library of Wales. Likewise my understanding of this subject has been shaped by
conversations with friends and colleagues. I am grateful that I had the chance to
present material at the Psy Studies Seminar at the University of Cambridge; the
Centre for Medical History, University of Exeter; the London School of Tropical
Hygiene and Medicine History Seminar; the Centre for the History of Science,
Technology and Medicine at the University of Manchester, the Department for
Social Studies of Medicine at McGill University; the Society of Apothercaries;
the Centre for Medical History, University of Warwick; and York University,
Toronto. And I am glad to have received the advice of Fay Bound Alberti, Peter
Barham, Tim Boon, Cornelus Borck, Ian Burney, Teri Chettiar, Sarah Crook,
Ali Haggett, Sarah Hayes, Andrew Hull, Rob Kirk, Kenton Kroker, Alex McKay,
Ben Mayhew, Chris Millard, Michael Neve, Ed Ramsden, Ben Shephard, Claudia
Stein and John Toms.
 Acknowledgements ix

Queen Mary has provided a supportive and deeply collegial environment

in which to complete this work. I am very grateful to my colleagues, Thomas
Dixon, Colin Jones and Barbara Taylor who read drafts of this work and to
Miri Rubin, James Ellison, Virginia Davis and Julian Jackson for their constant
encouragement. Roger Smith and Mathew Thomson provided valuable and
generous comments on the manuscript and Leonie Gombrich made a brilliant
and assured edit of the final draft.
A small amount of material in this work has previously appeared in different
form: ‘From Clever Hans to Michael Balint: Emotion, Influence and the
Unconscious in British Medical Practice’ in Fay Bound-Alberti (ed.), Medicine,
Emotion and Disease, 1700–1950 (Basingstoke: Palgrave, 2006): 144–68;
‘Desperate Housewives and Model Amoebae: the invention of suburban neurosis
in inter-war Britain’ in M. Jackson (ed.), Health and the Modern Home (London:
Routledge, 2007): 42–62; ‘Enduring Emotions: James Halliday and the Invention
of the Psychosocial’, Isis: A Journal of the History of Science 100 [Special Issue
on Emotional Economies of Science] (2009): 827–38.
 Preface

The idea of an implicit connection between our psychological well-being and our
physical health has become commonplace in contemporary culture. Newspaper
columnists and ‘lifestyle gurus’ encourage us to look for the seeds of our bodily
ills in episodes of personal unhappiness. We all have little hesitation in attributing
outbreaks of eczema or influenza to experiences of stress at work or episodes
of diarrhoea or migraine to the emotional turmoil of our domestic lives. The
body is widely seen as kind of witness or index of our personal travails. The
materials of modern medicine allow us to treat our ailments as sources of moral
guidance: they have become a kind of touchstone in which the sins or troubles
of the past are made apparent in the flesh.1 This idea of our history somehow
poisoning our relationships with our bodies has become a central dogma of new
age and modern therapeutic writings.2 As best-selling authors such as M. Scott
Peck, Harriet Braiker and Louise Hay argue, the relief of physical suffering can
only be achieved through an honest confrontation with the darkest aspects of
pathological past.3
The arguments promoted in these popular therapies seem to be borne out
by strong epidemiological evidence. From the 1950s, investigations began
to demonstrate an apparent correlation between emotional trials such as
bereavement and separation and the onset of illness. The incidence of physical
diseases, including cervical cancer, leukaemia and coronary heart disease, was
shown in these studies to be much higher in individuals who were widowed
or divorced.4 Although the experimental design of many such early studies has
been severely criticized, the apprehension that episodes of loss, stress or guilt
will result in subsequent physical suffering or even death remains with us to this
day.5
Moral narratives that draw together life stories and physical conditions are
not merely the didactic fables of lifestyle journalists or new age therapists. They
have become central to academic work across the arts and the social sciences.
Students in the medical humanities are taught that the achievement of coherence
in our life narratives or the ways that we represent our personal past are crucial
to the recovery of health and wholeness.6 Similarly, the political analyses
 Preface xi

that permeate the social history of medicine rest upon the idea that personal
experience of injustice or misfortune shapes later episodes of illness. In bravura
acts of narrative craftsmanship, authors such as Elaine Showalter, Karl Figlio
and Carol Smith Rosenberg have shown how the episodes of hysterical distress
manifested by Victorian housewives or World War I servicemen can be seen
as forms of somaticized social protest against a set of intolerable conditions.7
These arguments, in turn, draw upon older studies in medical anthropology,
such as those of Ioan Lewis, which linked illness and hysterical behaviour to the
experience of social or political deprivation.8
The assumed naturalness of the connection between health, illness and
personal history is underlined by the moral imperative implicit in the
psychological or psychosomatic model. The threat of punitive physical illness
hangs over those who fail to recognize or engage with aspects of their past. As the
American psychotherapy group Hopeallianz announces on its website: ‘When
you swallow your feelings, your body begins to digest itself. Ulcers, heart disease,
cancer – all have been shown to have a relationship with stress. While stress may
or may not create bacteria and cause renegade genes to mutate, it undeniably
creates an environment that is welcoming and supportive of physiological
processes that can – that will – ultimately kill you … when strong, sharp feelings
are hidden deep inside like shameful secrets. The feelings tear at your organs
and block the path that your blood wants to travel as it gives you life.’9 Although
the metaphors used to sustain this position are unusually gruesome, the basic
assumptions are rehearsed across the media and society. Facing the past has
become central to the present-day management of health.10
Despite the apparent naturalness and ubiquity of the belief that history is the
key to health, the premise itself rests on a number of technical and theoretical
innovations. The easy elision in modern thought between the realms of the
physical and the biographical has been made possible by the language of the
unconscious: in our everyday speech and therapeutic practice, we imagine some
sort of inner agent which records our experience and organizes its embodiment.
The unconscious seems to be engaged in a constant commentary on our affairs.
The smallest lapse of mind or slip of tongue indicates its persistent presence.
As Freud noted when reviewing the early successes of psychoanalysis: ‘When I
set myself the task of bringing to light what human beings keep hidden within
them, not by the compelling power of hypnosis, but by observing what they say
and what they show, I thought the task was a harder one than it really is. He that
has eyes to see and ears to hear may convince himself that no mortal can keep a
xii Preface

secret. If his lips are silent, he chatters with his fingertips: betrayal oozes out of
him at every pore.’11
The idea of the unconscious as an inner agent that somehow knits together
the present and the past is a comparatively recent innovation: an innovation
which rests upon a mixture of theoretical assumptions, practical achievements
and ideological exclusions. The effectiveness of this combination and its
centrality in modern thinking has obscured the contingency of our current ideas
of the unconscious. Nineteenth-century authors did not believe that the actions
of the unconscious were dictated by historical events. Instead, they insisted
that psychosomatic effects were generated through the individual’s sense of
anticipation. The mechanism that governed the course of healing and illness was
not the repressed sexual history imagined by the psychoanalytic pioneers but a
form of ‘expectant attention’ described and modelled in physiological research.
The first chapter of this book looks at these changing ideas of the unconscious
in the prehistory of primary-care psychiatry. Drawing on a mixture of medical
and literary sources, it shows how new ways of narrating illness and selfhood
generated new demands in the medical marketplace, leading to the development
of general practitioner psychotherapy.12
By the mid-twentieth century, the future-centred model of health and illness
had largely been abandoned. The proponents of the new dynamic psychologies
claimed that neurotic symptoms (both physical and mental) were caused by
unresolved conflicts or traumas buried deep in the patient’s forgotten past.
Doctors were encouraged to develop the interpretative skills of detectives,
or historians, in an attempt to root out the pathogenic secret in the patient’s
biography. At the same time, the novel conceptual framework and vocabulary
developed in these psychological approaches created new ideas and objects for
the practitioner to negotiate in his relationship with the patient. Phenomena such
as ‘repression’, ‘lifestyle’, ‘suggestion’, ‘frustration’, ‘transference’ and ‘catharsis’
now entered medical analyses, providing new materials through which both
patients and physicians could re-imagine the basis of their relationship and the
nature of the healing process.
My second chapter explores how these new psychodynamic concepts were
deployed in general practice and served to shape both the professional and the
personal identity of the primary-care physician. To a certain extent, the projects
of general practice and the new psychology shared a mutually reinforcing
agenda. The psychological emphasis on the medical significance of the patient’s
personality and biography opened an area of expertise that was beyond the
reach of the specialist and the hospital consultant. From the perspective of the
 Preface xiii

new holistic therapies, even the smallest episodes in the patient’s biography,
such as workplace squabbles or domestic upsets, could engender far-reaching
pathological consequences.
The new forms of analysis that the psychotherapeutic approach made possible
did not simply change the work of primary care but also transformed the political
significance of the discipline. In the 1930s, James Halliday, a practitioner working
for the Scottish Department of Health, began to make estimates of the incidence
of psychoneuroses among national insurance claimants.13 His aim was to establish
the necessity of a psychosomatic approach by demonstrating the prevalence of
mental distress and anxiety among patients presenting for rheumatic disease.14
Yet the significance of his epidemiological research was far broader for, as he
argued, the distribution of psychological illness could be seen as a reflection
of wider changes in the social conditions of the population. The establishment
of this putative link between mental suffering and social organization turned
the incidence of the psychosomatic disorder into an index of the effectiveness
of government policy initiatives. In the third chapter of this book, I explore
the role of general practitioners in the production of this epidemiological data
and the implementation of new programmes of preventative psychiatry which
ministered to the psychological health of the population.
Community epidemiology and preventative psychiatry placed the family
physician at the forefront of post-war planning and state formation, yet the
statistical data produced as part of these new projects was to carry a profounder
and more personal implication. By the early 1960s, the wide variations in the
reported rates of psychological illness recorded by general practitioners were
no longer understood as simple indices of local conditions such as poverty or
insecurity. Instead, they were treated as artefacts that revealed the different
diagnostic styles of individual physicians. A technique that had been developed
to reveal the mental health of the wider population was transformed into an
instrument that could reveal the doctor’s personal failings. This raised questions
about the individual approaches of each general practitioner, with the result
that the rhetoric of the new psychology was used to interrogate the personality
of the family physician. This rising interest in psychological introspection and
self-examination in general practice, which found its clearest expression in the
work of Michael Balint, is explored in the fourth chapter.
The magic of the psychological approach was that it made possible a whole
series of new relationships between doctor, patient and illness as new pathological
mechanisms were imagined and maps of influence charted out. Yet the creative
potential of this emerging rhetoric was perhaps to prove its undoing. Throughout
xiv Preface

its existence, the idea of a psychological unconscious that determines our health
has always been contested, and today we may be witnessing the concept’s
final demise.15 Contemporary writers suggest that we are entering an age of
‘cosmetic psychiatry’: an age in which psychological health does not depend
on the recovery of the self that has been lost, but is instead achieved through
the creation of the identity that we want.16 The equation of healing with the
recovery of our authentic identity has been abandoned. In cosmetic psychiatry,
an eclectic package of pharmaceutical and therapeutic treatments are deployed
to create a more effective or desirable self. This volume thus concludes with an
examination of the rise of this instrumental approach to self-identity. Against
accounts which argue that this sceptical perspective arose out of conflict with
the Freudian or dynamic psychiatries, my final chapter demonstrates how, by
so greatly extending the possibilities of influence, the new therapies eventually
undermined the concept of an essential identity. From World War II onwards,
there was a sense that almost every aspect of the medical encounter (from the
presentation of illness through to the experience of cure) could be affected by
the doctor’s mood, attitude or manner.
Although we live in an age in which we seem to be turning to physicians
and general practitioners with ever increasing frequency and in ever increasing
numbers, the medical nature of our demands is far from clear.17 As recent
surveys of primary care have revealed, the incidence of medically unexplained
syndromes has vastly increased and such syndromes now occupy around a third
of the general practitioner’s caseload.18 The physician’s role has moved beyond
providing medical solutions to dealing with social and psychological problems,
and the family doctor is held up as a kind of secular priest who makes possible
new kinds of identity.19 The belief that personal history might provide some
guide to our emotions has been replaced with the idea that the right emotions
might lead us to discover new forms of personal history. The patient’s encounter
with medicine – indeed, all our encounters – is now seen as a small act of theatre
in which new roles are fashioned and new forms of character embraced.20 This
shift away from psychological essentialism towards an instrumental conception
of identity can be attributed to many causes. Scholars have identified a wide
range of contributory factors, from economic globalization and social disruption
to the emergence of new forms of media.21 Yet the role of medicine cannot be
underestimated. As this book demonstrates, the language and techniques of
modern medicine have become fundamental resources on which we draw in
fashioning our own concepts of who we are.
 1

The Emergence of the Unconscious

1 Myths of origins

In December 1910, David Eder, a Zionist socialist general practitioner from

Golders Green, found himself engaged with a case of rheumatoid neck pain.1
His patient was a member of London’s burgeoning class of white-collar workers,
a callow young book keeper complaining of physical debility and muscular
strain.2 The usual treatment for cases of rheumatoid pain was the application
of hot compresses and bed rest but Eder pursued a very different approach.3
He attempted to recover an origin for the physical pain in the unconscious
memories of the patient. In twice weekly meetings over the course of 3 months,
the unhappy clerk was subjected to a series of verbal examinations that drew
upon the new continental techniques of free association and dream analysis:
methods of psychodynamic investigation that had been developed by Sigmund
Freud in Vienna and Carl Gustav Jung in Zurich.4
Eder recited stimulus words such as ‘tea’, ‘drop’, ‘rub’ and ‘cow’ to his patient
and recorded the clerk’s responses and reaction times. The pattern of these
reactions apparently revealed an ornate network of psychological fantasy that lay
beneath this mundane presentation of physical pain. The patient, Eder believed,
was involved in an unconscious protest against the monotony of clerkship, a
protest that was further complicated by the presence of a number of incestuous
and homosexual fantasies. The patient confessed that he had long harboured a
strong sexual desire for his sister; a desire that Eder, following Freud’s example,
interpreted as a cover for a deeper, unacknowledged, ‘mother complex’. The
inner life that Eder happened upon in his investigations became the key to the
patient’s recovery. As each aspect of his repressed story was reconstructed from
the evidence of the association tests, the rheumatoid inflammation subsided. In
the final session, Eder hypnotized his patient and informed the entranced clerk
that he was cured.5 The pain disappeared; the illness had been removed.