Goal and Means

(thesis, in Dutch, includes English summary)
M.A.J. Romme, MD PhD

Reviewed by Mira de Vries

After reading Sandra Escher’s thesis, which is based on her work with Marius Romme, I became curious about Romme’s own thesis, (self?-)published in 1967. The unimaginative title does injustice to the content, a thorough and scholarly study of the selection of patients for psychiatric hospitalization in Amsterdam. The study looks at:
  • Clinical factors such as the diagnosis, the type of doctor doing the admitting (psychiatrist, nerve doctor, family physician, trainee, etc.), and the patient’s previous history of hospitalizations;
  • Relational factors such as the referring party, the place of examination, and the attitude of the environment towards whatever is wrong with the patient;
  • Social factors, such as sex, age, marital status, type of housing, employment, income, education, hobbies, and religion.
A factor not looked at is whether the hospitalization is voluntary or compulsory. In a footnote, he mentions leaving it out because, according to him, this distinction is a consequence of the decision to hospitalize the patient rather than a reason for it. However, I suspect that this information was simply not available to him, notwithstanding the Dutch propensity for keeping meticulous records of just about everything. Gemma Blok reports in her thesis not finding this information in the files she investigated, and Jean Campbell confirms that such figures are not accessible in the US either. Perhaps coercion is too much of an embarrassment to psychiatry to be noted in the files? A simple Google search will readily turn up, for instance, the prison population of the US, but after many hours of searching, I never found how many people in the US are involuntarily committed, nor in any other country.

Even with this important factor missing, it would be interesting to see Romme’s work repeated in the present day, and the findings compared to Romme’s of nearly forty years ago.

Most fascinating for me is the first chapter. In it Romme provides a glimpse of the history of psychiatry in Amsterdam. The first mention of a madhouse was in 1549, predating the “Golden Age” of vast prosperity that international trade was to bring to Amsterdam in late medieval times. Thirteen years later an apparently wealthy citizen donated money for the building of a madhouse, in gratitude for his wife’s safely giving birth. She had been “attacked and assaulted by a madwoman during her pregnancy.” At the address Romme names for this madhouse, there is today a fish market. One thing will have changed, though it's hard to say for better or worse: the smell.

The same time period marks the introduction of that insufferable scourge of the Dutch health system: the waiting list. For lack of capacity in the madhouse, its target population spilled over into poorhouses and plague hostels. Yet, Romme speculates, quoting the work of his thesis advisor, probably most mad people remained free and neglected. It was in 1841, smack in the middle of the Netherlands’ liberal era when state power was viewed with suspicion, that a complex “Mad Law” was legislated. Among other things, it bestowed medical status on the existing madhouses.

Other bureaucratic aspects seem to be rooted deeply in our history as well. City subsidies, top jobs created to provide employment for favored fellows, and investigative committees, all flourished already in the nineteenth century. And then, like now, in spite of all the investigations, money, doctors, and intrusion into the lives of mad people, nobody ever recovered. The mad population (Romme uses the wonderfully descriptive term: social unsuitables) increased many times more rapidly than the general population.

Bureaucracy continued to snowball as liberal ideals were lost and the Dutch state invaded the private domains of its citizens more and more. Now – meaning when Romme wrote this nearly four decades ago, though it is more true today than ever – one of psychiatry’s major functions is to facilitate access to income and housing. Throughout four and a half centuries, psychiatric institutions have mainly been poorhouses in disguise.

Romme wrote his thesis during a period when little was yet known about what went on in neighboring Germany during WWII, and even less was said about it. Before the war (as well as after when Romme was writing) there were no secular madhouses in Amsterdam, only Protestant and Jewish ones, according to his thesis. Although Romme does not mention it, the nazis wiped out the people in the Jewish institutions along with the rest of the country’s Jewish population. However, they seem to have left the non-Jewish institutions in the Netherlands unmolested, contrary to what they did in Germany, Austria, France, and Poland. Why this is so I do not know. It would be an interesting subject for someone to research.

Romme never mentions the whole sordid holocaust, in spite of the fact that his thesis advisor was Dr. A. Querido, who, judging by his name, was born into the community of Jews who sought haven in Holland after eviction from Spain during the inquisition. Querido was one of the 10% of Amsterdam’s Jews who survived the holocaust. With formidable understatement, Romme but says in a footnote, “The period in which Dr. A. Querido directed the department of Mental and Nervous Diseases was interrupted by the war years, during which he was replaced by” so-and-so.

By the way, in 1956, Querido was a founding member of the Society for Social Medicine.

Is there any clue in Romme’s thesis that he was to become a hero of our movement by rejecting psychiatric labeling of voice-hearers and pioneering real solutions to their problems? Not that I could find, except for two of the conclusions listed not in the book itself but on the insert, for the benefit of the graduation ceremony:
  • An admission to a psychiatric hospital is not so much the result of a clinical thought process, but more the consequence of a relational pattern between the patient, his environment, and the physician; and
  • The danger is not unthinkable that in the organization of medical services, answers are sought to questions posed by the organizations themselves rather than answers to questions posed by those seeking help.
Romme's thesis, though of fine quality, is mainly of value locally. His later work with voice hearers, however, deserves a much larger audience, and voice hearers around the world deserve access to his ideas.

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