Throughout the history of humanity around the world, many different approaches to the treatment of mental illness have been implemented, including psychological, spiritual, physical, or some combination of all three. The following paper that I wrote for graduate school attempts to point to some key ideas throughout history, from the Paleolithic Era through the Middle Ages, focusing from the 16th century forward on treatment of mental illness in the United States and its primary influences.
Shamanism is humanity's oldest spiritual practice and healing art, probably dating as far back as the Paleolithic Era (Kahn, 2008). Through altered states of consciousness, shamans mediate between humans and the spirit world. Shamanism also involves physical practices, such as herbal medicine, and psychological practices, using "suggestion, expectation, and rituals to evoke placebo effects" (Serlin, 1993). In many cultures, a psychotic episode or initiatory crisis serves to initiate a person into shamanism and teach them about the nature of life and the spirit world. The pain of the crisis may also serve to help shamans empathize with their clients, thus making shamanism a very early form of peer support.
One early sign of possible mental health treatment is the archeological discovery of skulls with carefully drilled holes in them, dating back to the Neolithic Era at least 7000 years ago (Clarkson, 1999). This practice, called skull trepanation, or trephining, was done with primitive tools, and we can tell that a surprisingly high number of people survived this procedure by the abundance of skulls that demonstrate healing of the bone around the hole. Scientists have many ideas about why this was done; one popular theory is that prehistoric surgeons created holes to allow demons believed to cause mental illness to exit. Over the millenia, trepanation has been performed in many parts of the world, and is still performed today in parts of Africa, South America, and Melanesia (Clarkson, 1999).
Ancient Mesopotamians recognized headache and head trauma as being related to the head, but mental symptoms such as “not in full possession of his faculties” and “he wanders about (in a confused fashion)” were attributed to the heart (Yuste & Garrido, 2010, p. 4). Belief in the power of demons to incur illness is evident in this passage from a Mesopotamian medical treatise, “If a man is quivering all the time when lying down, shouts like the shouting of a goat, roars, is apprehensive, shouts a lot all the time, (then it is) the hand of bennu, the demon (šēdu), deputy of Sîn” (qtd. in Yuste & Garrido, 2010, p. 4). Each disease was attributed to a particular spirit (Mohit, 2001). Sorcerer-diagnosticians known as ashipus determined the spirt cause and may have also provided psychotherapy, and ashus specialized in herbal medicine (Mohit, 2001). Messages from the gods were received through dream analysis as far back as 2200 BC (Coolidge, 2006).
Ancient Persians also believed that illness was caused by demons, but believed diseases could be prevented through proper hygiene and "purity of the mind and body achieved through good deeds and thoughts" (Foerschner, 2010). Different medical specialties existed; ravan-pezeshk were the equivalent of today’s licensed psychiatrist (Mohit, 2001). Although medicine was separate from priesthood, most who became doctors had a background in both (Mohit, 2007). Evil eye amulets thought to ward off evil spirits were popular, and to a lesser extent still are.
In ancient Israel, illness was seen as a punishment by God for sinning, sometimes sent in the form of demons (Foerschner, 2010). In Deuteronomy 6:5 it is written, "The Lord will smite thee with madness" (Porter, 2002, p. 10). When Nebuchadnezzar speaks pridefully of his wonderful palace, he hears God's voice say, "the Kingdom is departed from thee," and is driven mad (Porter, 2002, p. 11). Hebrew priest-physicians believed in God's healing power and appealed to him for cures. (Foerschner, 2010). Madness was distinct from folly; folly referred to behavioral conditions linked to poor judgment rather than punishment from God (Gerig, 2007).
Ancient Egyptians did not distinguish between physician, magician and priest (Okasha, 2005). Healers were taught medical ethics which advised them to have compassion for people with mental illness (Nasser, 1987). Egyptians believed diseases could be caused either by God and demons or by organic causes (Mohit, 2001). Like the Greeks and Romans, Egyptians believed that hysteria in women, now known as Conversion disorder, was caused by the uterus “wandering” throughout the body, and would fumigate the vagina in an effort to lure it back into place (Nasser, 1987). Ancient papyri described the brain's physical structure for the first time and acknowledged it as the seat of mental functions (Nasser, 1987). Some psychotherapeutic methods were used in ancient Egypt, particularly "temple sleep,” which was akin to hypnotherapy (Mohit, 2001; Nasser, 1987). Egyptians recognized various mental disorders (Okasha, 2005; Mohit, 2001) and recommended that those people with mental distress seek symptom relief and a sense of normalcy in music, dance and art (Foerschner, 2010).
Therapeutics and Surgical Practice by Charaka and Susrutha, an ancient Ayurvedic medicine textbook, "states clearly that only an expert in the field of mental health should treat people with this illness" (Thara, Padmavati & Srinivasan, 2004). Conditions similar to schizophrenia and bipolar disorder are vividly described (Thara, Padmavati & Srinivasan, 2004). Ayurveda, which has continued in India to the present day, sees ill health as resulting from an imbalance between three bodily forces or Doshas called Vata, Pitta, and Kapha. Variation in balance of the doshas lead people to have different personality types and to be prone to different types of mental and physical challenges. Treatment includes appropriate diet, bodily and spiritual activity, and herbs. Also in ancient India, Siddhartha Gautama Buddha was a spiritual teacher who lived in the 6th and 5th centuries BC, upon whose teachings Buddhism was founded. Buddha’s teachings continue to influence psychotherapy today, as evidenced by the recent development of mindfulness-based cognitive-behavioral therapy.
The first written works of Traditional Chinese Medicine appeared around 100 BC, and since then, China, Japan, Korea and Vietnam have all developed their own distinct branches of the original Chinese system (Yang, 2009). Chinese describe human health and healing in terms of a vital energy called qi, the Ayurvedic counterpart of which is prana. Qi must be balanced in terms of the opposing forces of yin and yang and five Chinese elements. Major depression can be seen as excessive yin combined with a yang deficiency; mania is the opposite (Yang, 2009). An ancient text called Huang di nei jing, or the Yellow Emperor's Inner Canon, "discusses spirit, mood, soul, idea, will, anxiety, worry, wisdom, morale and their relations with human life, physiology and body-mind health" (Yang, 2004). Acupuncture and herbs are key to Traditional Chinese Medicine. Today, ample scientific evidence supports the use of acupuncture to treat various mental disorders, including depression, anxiety, insomnia and addiction.
The Greek physician Hippocrates (460-377 BC) denounced ideas about spiritual origins of mental illness; instead declaring it to be the result of physiological processes, particularly brain pathology (Porter, 2002). Similar to the Ayurvedic doshas, or the Traditional Chinese five elements, Hippocrates came up with four bodily fluids or humors, which when imbalanced could lead to behavioral tendencies and mental illnesses. Melancholia, described by Hippocrates as “fright or despondency [that] lasts for a long time” was thought to be caused by an excess of black bile (400 BC/n.d., 6.23). Melancholia as described in Porter (2002) would today refer not only to various forms of depression and extended grief but also anxiety, mania and psychosis. Humoral balance was attempted by means of tranquility, sobriety, lots of vegetables, exercise, and blood-letting (Gerig, 2007).
The Roman Cornelius Celsus (25 BC-50 AD) called for a return to the idea that some illnesses were punishments from gods, and believed that people with mental illness needed to experience "anything that thoroughly agitates the spirit,” including beating and starvation (qtd. in Risser, 2012). Other Romans were more forward-thinking and compassionate. Epictetus (50-138 AD) rejected the idea that emotions were beyond our control, recognizing that a correction in thinking could lead to happier feelings (Gerig, 2007; Graver, 2009). Galen (130-200 AD) believed in a balance of the bodily humors as described by Hippocrates, and recommended massage and relaxing in a warm bath with a glass of chilled wine (Gerig, 2007).
The Middle Ages in Europe and the Middle East
The witch hunts of the Middle Ages may have been partially a persecution of people with mental illness based on the perception that mental illness is caused by sin or demonic possession. However, Kroll and Bachrach (1984) and Schoeneman (1977) concluded that the relationship between Medieval witch hunts and mental illness has been overinflated. Medieval physicians continued to rely on a belief in humoral imbalance like their Greek and Roman predecessors, and also recognized the effects of improper diet and alcohol intake, overwork, and grief (Kroll & Bachrach, 1984). To restore humoral imbalance, doctors used emetics, laxatives and blood-letting. Customized diets for “raving madmen” included “cooling and diluting” foods such as milk, barley water, and salad greens, but banned wine and red meat (Porter, 2002, p. 42). Particularly in Medieval Christian Europe, people with mental disorders were abused, neglected and restrained by their family members, who hid them in cellars, caged them in pigpens, assigned their servants to control them, or sent them away to live a life of vagrancy (Porter, 2002). Many were flogged as punishment for mentally ill behavior, in an effort to “teach” them to be well (Foerschner, 2010).
The first mental hospital was built in 792 AD in Baghdad and was followed shortly by hospitals in Aleppo and Damascus (Foerschner, 2010). This was several hundred years before such institutions were established in Europe. The world’s oldest university, Jondi Shapour University in Dezful, Iraq, taught medical students about psychiatric diseases and psychotherapy during the Sasanide Dynasty, 224-651 AD (Mohit, 2001). Historical evidence indicates that medieval Islamic doctors probably diagnosed and treated schizophrenia (Youssef, Youssef, & Dening, 1996). Treatment in the later Middle Ages in the Middle East consisted of psychotherapy, music therapy, pharmacotherapy, humoral balance, reassurance, and support (Mohit, 2001). Ar-razi (later known as Rhazes) (865-925), chief physician in an ancient Bagdhad hospital with a psychiatric ward, was known for treating patients compassionately (Risser, 2012).
In 1407, the first lunatic asylum in Europe was established in Valencia, Spain (PBS, n.d.). Early European asylums were dumping grounds for people abandoned by their ashamed families or sentenced by the law (Risser, 2012). They were also often lumped together with people with other disabilities, criminals, the homeless and the poor, serving more to protect society from them than to serve their residents. Other asylums opened one by one, the most well-known being London's St. Mary of Bethlehem, a monastery-turned-hospital that began accepting mental patients in 1403 and by 1547 became exclusively devoted to people with mental illness. This hospital was known derogatively and infamously as Bedlam; according to historian Roy Porter, "Bedlam became a byword for man's inhumanity to man, for callousness and cruelty" (qtd. in Forsyth-Moser, 2004). Patients lay on the cold ground in filthy straw, chained and pinned to the walls by their arms, legs, waists and necks. They were frequently taunted and abused. Of course this treatment only aggravated their illnesses, and they would thrash about violently and wail in agony. Up until 1770, the asylum charged the public to visit this spectacle as a freak show (Jackson, n.d.). Some sources say that gentler patients were sent out into the streets to beg (Risser, 2012); O'Donoghue (1915), former chaplain of Bethlehem Hospital, claims that the hospital had no association with beggars who only pretended to be patients.
The 17th through 19th Centuries in Western Society
By the late 1600s, madness was decreasingly attributed to demons or moral failure and increasingly to organic phenomena, or "animal passions." Unfortunately, this did not lead to better treatment of people with mental illness, as abuse was thought to tame the animal passions. Dr. Thomas Willis, also known as the founder of clinical neuroscience, exemplified the attitude of his time and place when he wrote in The Practice of Physik: Two Discourses Concerning the Soul of Brutes, “Furious Madmen are sooner, and more certainly cured by punishments and hard usage, in a strait room, than by Physick or Medicines” (qtd. in Scull, 1983, p. 238).
In Paris, at La Maison de Bicetre, was an environment reminiscent of Bedlam. That changed with the arrival of lay superintendent Jean Baptiste Pussin and wife Marguerite, and later, Dr. Phillipe Pinel, who had developed a passion for treatment of mental illness after a friend experienced a bout of mania (Cohen, 1932). Pinel rejected the belief that madness was incurable, and believed that therapy which paradoxically combined compassion with “a formidable show of terror” ought to be employed (Grob, 1994, p. 27). In spite of his belief in physician dominance, Pinel was opposed to chaining patients and other cruel practices. According to Cohen (1932), political suspicions related to the French Revolution extended to those housed in the asylums, so Pinel was risking his own life when he unchained the residents, beginning with a man whose legs collapsed from disuse after having been chained to the wall for forty years. A few patients were cured and all became more peaceful once given freedom to move. Although mistreatment persisted in other places, Pinel was proving that mental illness responds better to kindness than to cruelty. This was the beginning of moral treatment, first described in Pinel's 1806 book, A Treatise on Insanity. Credit also goes to William Tuke, a Quaker who independently opened a moral treatment facility in 1796, following the death of a fellow Quaker who was mistreated in an asylum. This moral treatment facility, called the York Retreat, was a quiet country community were patients could rest, read, write, dance, and engage in crafts. They also helped with chores and pursued spiritual healing through prayer while at the Retreat. The Quakers’ version of moral treatment, founded on love and empathy, even more dramatically contrasted with the abuse of the past.
Meanwhile, in what is now the United States, Native Americans were using shamanic healing in various forms. In the 1770s, Native Americans formed the earliest recorded mutual self-help groups for alcohol problems (Risser, 2012). As Colonial Americans arrived, they brought with them a conglomeration of ideas from the Europeans, including humoral balance, blood-letting, exorcism and even astrology (Grob, 1994). Population density was too low at first to necessitate asylums; instead mental illness was dealt with by the family and by the community, and sometimes by one of the few doctors available (Grob, 1994).
The first hospital in America was Pennsylvania Hospital, founded in 1751 by Benjamin Franklin and Dr. Thomas Bond, who were inspired to add a mental ward by the "perfectly cured” people at St. Mary of Bethlehem (Bedlam) (Whitaker, 2002, p. 4). The two endeavored to create a similar institution, which would contain the “[lunatics] going at large [who] are a Terror to their neighbors, who are daily apprehensive of the Violences they may commit" (qtd. in Whitaker, p. 4). Pennsylvania Hospital, which opened its doors in 1756, kept people with mental illness in the basement, which was comparable at first to the darkest periods of Bedlam and La Maison de Bicetre. The environment changed with the arrival of Dr. Benjamin Rush in 1783, known as the founder of American psychiatry. This was a mixed blessing. Dr. Rush, the son of Quaker parents, immediately ordered that the patients be unchained and preached kindness toward the patients. He was also enamored with European medicine, specifically his personal belief that madness was caused by "morbid and irregular" actions in the blood vessels in the brain, so he used purges and emetics and called for blood-letting up to "four-fifths of the blood in the body" (Whitaker, 2002, p. 14). Caustics induced blisters and open wounds which were kept intentionally open for months or years, and a gyrator was used to spin patients at high speeds; both techniques were intended to change the balance of blood in the brain (Whitaker, 2002). Rush was also proud of having invented the tranquilizer chair, which completely immobilized patients from several hours up to six months (Whitaker, 2002). In spite of his insistence toward compassionate treatment, Rush paradoxically called for intimidation tactics and even death threats in an effort to "cure" patients through terror (Whitaker, 2002). He was impressed with a Georgia doctor who claimed to have cured a patient by nearly drowning him in a well, so he built a tank for near-drowning; patients were placed in a dark coffin with holes and lowered into the tank where they remained until no more air bubbles came out, upon which they were revived (Whitaker, 2002). Starvation was another form of “medicine.”
Moral treatment and European medicine were a discordant combination, so when Rush died in 1813, mental health treatment was at a crossroads (Whitaker, 2002). That same year, William Tuke's grandson Samuel published Description of the Retreat. Although the intention of moral treatment was to do “little more than assist nature,” Tuke reported that 70% of York Retreat patients who had been ill less than twelve months never relapsed, and 25% of patients formerly viewed as incurable had completely recovered at the retreat (Whitaker, 2002). Other moral treatment asylums reported similar rates, and although some have questioned their accuracy, historians have concluded the reported rates were indeed accurate (Grob, 1994; Whitaker, 2002). Quaker-style asylums popped up around the country, run by lay superintendents or physicians who were opposed to European treatments, such as Dr. Rufus Wyman at McLean Hospital, who dismissed the medicine of the time as “usually injurious and frequently fatal” (qtd. in Whitaker, 2002, p. 28). Traditional physicians felt threatened and lobbied to be in charge; this led to the formation of the Association of Medical Superintendents of American Institutions of the Insane (AMSAII), which would become the American Psychiatric Association in 1921. Moral treatment was not to last much longer in any form, however, ironically due to the unintended results of one of its greatest advocates. Dorothea Dix, who’d recovered from a breakdown with the help of the Tuke family, tirelessly and brilliantly advocated for more moral treatment asylums. Sadly, when a tremendous number of huge asylums opened up in a short period of time, staff could not keep up with the requirements of moral treatment (one of which was a limit on the number of patients), and care for patients regressed (Whitaker, 2002).
The 20th and 21st Centuries in Western Society
At the beginning of the twentieth century, the briefly-generous attitude of moral treatment was replaced by the idea that people with mental illness were “social wastage” with “defective germ plasm” who were unequal to others (Whitaker, 2002, p. 41-42). This view, called eugenics, was originated by Charles Darwin’s cousin Sir Francis Galton. Although other disabled people as well as African-Americans, people in poverty, and criminals were also viewed as unfit, eugenics saw people with mental illness as the lowest of the low. Galton saw eugenics as a new religion, one in which followers would be kind enough to stop these “defective stock” from breeding: “What Nature does blindly, slowly and ruthlessly, man may do providently, quickly, and kindly” (qtd. in Whitaker, 2002, p. 44). As a result of the Eugenics movement in America, it became illegal for people with mental illness to marry, and thousands of people were sterilized under the guise of humanitarian therapy. Other countries followed suit. Madison Grant, a wealthy New York lawyer who founded the American Eugenics Society, went one step further by calling for complete “obliteration… of worthless types” in his book The Passing of the Great Race (qtd. in Whitaker, 2002, p. 65). Adolf Hitler wrote Grant a fan letter, telling him the book was his Bible (Whitaker, 2002). American Eugenicists continued to toy with the idea of mass murdering people with mental illness, but Hitler beat them to it, gassing more than 70,000 patients, and then proceeding to eliminate others considered devoid of value (Whitaker, 2002). When the horrors of the Holocaust were exposed, the general public was horrified, and Eugenics in America came to a screeching halt.
One prominent Eugenicist was German psychiatrist Emil Kraepelin (Engstrom, 2007). Kraepelin is famous for discovering a new way of classifying mental illness. Instead of looking primarily at major symptoms, as his predecessors had, Kraepelin grouped symptoms into patterns, or syndromes. He is credited with differentiating between manic depression (his definition now encompasses a range of mood disorders including bipolar disorder and major depression) and dementia praecox. In 1908, psychiatrist Eugen Bleuler replaced the term dementia praecox with the word schizophrenia. Because some of his patients improved rather than deteriorated, Bleuler recognized that the disease was not a dementia. Schizophrenia, which translates roughly to "splitting of the mind," refers to the separation of function between personality, thinking, memory and perception that Bleuler found to be characteristic of the disorder. Even more optimistic than Bleuler was his lesser-known son Manfred, also a psychiatrist. In a 1974 study, M. Bleuler found that many more people with schizophrenia recover or make significant improvement than his father suggested, even without medication. Manfred has suggested that his father was overly pessimisstic because he did not follow patients after they left the hospital.
While Kraepelin and the elder Bleuler were laying the foundation for our modern system of diagnosis, Sigmund Freud was developing the theory of psychoanalysis. Therapy had been practiced in various forms over the ages, but Freud is considered to be the father of modern psychology. Anna Freud, Alfred Adler, Carl Jung, Otto Rank, Erik Erikson and others built upon Freud's theories, establishing psychodynamic therapy. Behavior therapy developed in the 1920s, followed by existentialism and Carl Rogers' person-centered therapy. In the 1950s, Albert Ellis and Aaron T. Beck independently developed two very similar approached to cognitive therapy, which in the 1970s were lumped together with behavioral therapy under the heading Cognitive Behavioral Therapy. Today there are perhaps hundreds of approaches to talk therapy, including ecopsychology, somatic psychology, contemplative psychotherapy, postmodern approaches, feminist therapy, and liberation psychology.
As modern psychotherapy emerged, the field of psychiatry was changing as well. In the 1930s, four treatments were widely used: insulin coma therapy, metrazol convulsive therapy, electroshock and lobotomy. All of these therapies worked by damaging the brain, rendering the patient incapacitated and sometimes dead. The idea was not to alleviate the subjective pain that patients experienced, but to make patients easier to manage. Journalist Robert Whitaker (2002) points out that this same concern guided the invention of psychiatric medication, when Thorazine went from pesticide to tranquilizer or “chemical lobotomy” in the early 1950s and was later re-labeled, for marketing reasons, as “anti-schizophrenic.” Thorazine was followed by more anti-psychotics, including atypicals, as well as anti-depressants and mood stabilizers.
In 1948, Albert Deutsch published The Shame of the States, exposing conditions in the asylums. Thirteen years later, sociologist Erving Goffman published Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, which described how institutionalization socializes people into "good patients," a demoralizing process which encourages chronicity in mental illness. In part as a result of these books, advocacy organizations were fighting for reform and for less restrictive environments. Meanwhile, funding for asylums was decreasing, and psychiatric medications may have allowed more people to live in the community of their choice. These factors converged and led to the closing of many hospitals in the mid-1960s, a movement known as deinstitutionalization. Many people with mental illness were able to live in the community for the first time as a result, but many others became homeless or ended up in jail.
Also in the 1960s, the consumer/survivor/ex-patient (C/S/X) movement began to hit the ground running. People with mental illness have published their own accounts of illness and treatment throughout history; those in English extend back as far as 1436 (Hornstein, 2011). In America, early patient advocates included Dorothea Dix, Elizabeth Packard, and Clifford Beers. In the 1960s and early 70s, consumers and survivors began to organize, inspired by movements for Civil Rights, Women’s Rights, Gay Rights and Physical Disabilities Rights, and it was this inspiration that formed the foundation of the movement we have today (Zinman and Bluebird, 2011). C/S/X groups include MindFreedom, Intervoice, the National Mental Health Self-Help Clearinghouse and the National Empowerment Center. The C/S/X movement led to the development of the peer specialist profession and other patient-controlled alternatives to the mental health system. It has also inspired the recovery movement, a range of philosophies that share the idea that people with mental illness can move forward with their lives after a diagnosis of mental illness.
Concluding Thoughts: The World and the Future
This paper has not examined recent treatment of mental illness outside of America and its primary influences, but people continue to grapple with mental illness around the world. In 1969, the World Health Organization set out to examine just how far ahead of the rest of the world developed nations were. Instead they found out (in two separate long-term studies) that complete recovery from schizophrenia is approximately twice as common in developing countries as it is in developed countries, concluding that "being in a developed country was a strong predictor of not attaining a complete remission" (Jablensky, et al, 1992, p. 88). Such results prompt the question: what are we (developed countries) doing wrong? Whitaker (2002; 2010) says research shows that although psychiatric medication can help calm symptoms in the short term, it actually encourages chronicity of illness in the long term. Dan Fisher, director of The National Empowerment Center and a psychiatrist who has himself recovered completely from schizophrenia, believes that the answer lies partly in differing social responses: developing countries respond to mental illness by reconnecting with people and reintegrating them back into the community, while developed countries respond with "ceremonies of segregation and isolation, which is really what our hospitalization process is" (Medscape, 2005).
Though largely ignored by today’s mental health system, the WHO studies and others (including but not limited to M. Bleuler’s 1974 study) raise important questions about the efficacy of our modern treatment of mental illness. There is much to be learned from examining our past and finding what has worked and what hasn’t. Each person and illness is different, so we must consider psychological, spiritual and biological factors rather than assuming the answer lies in only one idea- or in only one civilization or time period. If we all work together, making a special effort to include the historically ignored voices of consumers and survivors, we can improve and refine methods of treating and coping with mental illness.
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