2 historical and contemporary views of abnormal behavior
learning objectives 2
· 2.1 How has abnormal behavior been viewed throughout history?
· 2.2 What effect did the emergence of humanism have on abnormal psychology?
· 2.3 What developments led to the contemporary view of abnormal psychology?
An Artist in Bedlam The most famous patient committed to the historic Bethlem Hospital in England (better known as Bedlam) during its long existence was a well-known and talented young artist, Richard Dadd (1817–1886). Dadd was born in Chatham, England, in 1817. His father was a successful chemist. Dadd attended the Kings School in Rochester and also studied art at the Royal Academy School in London. He showed a strong aptitude for drawing and painting and was admitted to the prestigious Royal Academy of Arts at the early age of 20. When he was 25, he was invited to accompany Sir Thomas Phillips, the former mayor of Newport, on a grand tour through Europe, Greece, Turkey, Syria, and Egypt to serve as the draftsman and painter for the expedition. During the trip, Dadd produced a number of exceptional paintings of people and places he encountered on the journey, many of which are in museums today. The journey was reportedly difficult and stressful, and at one point, during a trip up the Nile River, Dadd underwent a remarkable personality change, becoming delusional and increasingly aggressive and violent toward people he met. He was reported to have expressed an urge to kill the Pope. He experienced delusional beliefs—for example, that he had come under the influence of the Egyptian god Osiris.
When he returned from the trip in 1843, he was diagnosed as being mentally unsound because of his hallucinations and his strange, delusional beliefs. In an effort to restore him to health, his family took him to recuperate in a countryside village in Kent, England. The records indicate that one day he came to the conclusion that his father was the Devil in disguise, and on a walk in the countryside Dadd killed his father with a knife. He attempted to escape by fleeing to France; however, his aggressive behavior continued, and he attempted to kill another tourist with a razor. He was arrested by the police and was eventually returned to England. He was committed to Bethlem Royal Hospital, where he was held in the criminal ward for dangerous inmates. He remained in Bethlem Hospital for almost 20 years but was transferred to Broadmoor Hospital, where he died in 1886. During his stay in both the Bethlem and Broadmoor hospitals he was allowed and encouraged to paint by the staff as part of his treatment. During this time he produced a number of paintings, many of which can be seen today in art museums.
Although he appears to have experienced symptoms of a mood disorder including acute mania (see Chapter 7 ) it is likely that Dadd suffered from paranoid schizophrenia (see Chapter 14 for further discussion). Interestingly, two of his siblings appeared to suffer from the same symptom pattern; thus he may have been genetically predisposed to this condition (see Greysmith, 1979 ; MacGregor, 1989 for a discussion of his life and art work).
Historical Views of Abnormal Behavior
Our historical efforts to understand abnormal psychology include both humor and tragedy. In this chapter, we will highlight some views of psychopathology, and some of the treatments administered, from ancient times to the twenty-first century. In a broad sense, we will see a progression of beliefs from what we now consider superstition to those based on scientific awareness—from a focus on supernatural explanations to knowledge of natural causes. The course of this evolution has at times been marked by periods of advancement or unique, individual contributions, followed by long years of inactivity or unproductive, backward steps.
Although human life appeared on earth some 3 million or more years ago, written records extend back only a few thousand years. Thus our knowledge of our early ancestors is limited. Two Egyptian papyri dating from the sixteenth century B.C. provide some clues to the earliest treatments of diseases and behavior disorders (Okasha & Okasha, 2000 ). The Edwin Smith papyrus (named after its nineteenth-century discoverer) contains detailed descriptions of the treatment of wounds and other surgical operations. In it, the brain is described—possibly for the first time in history—and the writing clearly shows that the brain was recognized as the site of mental functions. The Ebers papyrus offers another perspective on treatment. It covers internal medicine and the circulatory system but relies more on incantations and magic for explaining and curing diseases that had unknown causes. Although surgical techniques may have been used, they were probably coupled with prayers and the like, which reflected the prevailing view of the origin of mental illness.
Demonology, Gods, and Magic
References to abnormal behavior in early writings show that the Chinese, Egyptians, Hebrews, and Greeks often attributed such behavior to a demon or god who had taken possession of a person. Whether the “possession” was assumed to involve good spirits or evil spirits usually depended on the affected individual’s symptoms. If a person’s speech or behavior appeared to have a religious or mystical significance, it was usually thought that he or she was possessed by a good spirit or god. Such people were often treated with considerable awe and respect, for people believed they had supernatural powers.
Most possessions, however, were considered to be the work of an angry god or an evil spirit, particularly when a person became excited or overactive and engaged in behavior contrary to religious teachings. Among the ancient Hebrews, for example, such possessions were thought to represent the wrath and punishment of God. Moses is quoted in the Bible as saying, “The Lord shall smite thee with madness.” Apparently this punishment was thought to involve the withdrawal of God’s protection and the abandonment of the person to the forces of evil. In such cases, every effort was made to rid the person of the evil spirit.
The primary type of treatment for demonic possession was exorcism, which included various techniques for casting an evil spirit out of an afflicted person. These techniques varied but typically included magic, prayer, incantation, noisemaking, and the use of horrible-tasting concoctions made from sheep’s dung and wine.
Hippocrates’ Early Medical Concepts
The Greek temples of healing ushered in the Golden Age of Greece under the Athenian leader Pericles (461–429 B.C.). This period saw considerable progress in the understanding and treatment of mental disorders, in spite of the fact that Greeks of the time considered the human body sacred so little could be learned of human anatomy or physiology. During this period the Greek physician Hippocrates (460–377 B.C.), often referred to as the father of modern medicine, received his training and made substantial contributions to the field.
Hippocrates denied that deities and demons intervened in the development of illnesses and instead insisted that mental disorders, like other diseases, had natural causes and appropriate treatments. He believed that the brain was the central organ of intellectual activity and that mental disorders were due to brain pathology. He also emphasized the importance of heredity and predisposition and pointed out that injuries to the head could cause sensory and motor disorders.
Hippocrates classified all mental disorders into three general categories—mania, melancholia, and phrenitis (brain fever)—and gave detailed clinical descriptions of the specific disorders included in each category. He relied heavily on clinical observation, and his descriptions, which were based on daily clinical records of his patients, were surprisingly thorough.
Maher and Maher ( 1994 ) pointed out that the best known of the earlier paradigms for explaining personality or temperament is the doctrine of the four humors, associated with the name of Hippocrates and later with the Roman physician Galen. The four elements of the material world were thought to be earth, air, fire, and water, which had attributes of heat, cold, moistness, and dryness. These elements combined to form the four essential fluids of the body—blood (sanguis), phlegm, bile (choler), and black bile (melancholer). The fluids combined in different proportions within different individuals, and a person’s temperament was determined by which of the humors was dominant. From this view came one of the earliest and longest-lasting typologies of human behavior: the sanguine, the phlegmatic, the choleric, and the melancholic. Each of these “types” brought with it a set of personality attributes. For example, the person of sanguine temperament was optimistic, cheerful, and unafraid.
Hippocrates’ (460–377 B.C.) belief that mental disease was the result of natural causes and brain pathology was revolutionary for its time.
Hippocrates considered dreams to be important in understanding a patient’s personality. On this point, he was a harbinger of a basic concept of modern psychodynamic psychotherapy. The treatments advocated by Hippocrates were far in advance of the exorcistic practices then prevalent. For the treatment of melancholia (see Developments in Thinking on p. 31), for example, he prescribed a regular and tranquil life, sobriety and abstinence from all excesses, a vegetable diet, celibacy, exercise short of fatigue, and bleeding if indicated. He also recognized the importance of the environment and often removed his patients from their families.
Hippocrates’ emphasis on the natural causes of diseases, on clinical observation, and on brain pathology as the root of mental disorders was truly revolutionary. Like his contemporaries, however, Hippocrates had little knowledge of physiology. He believed that hysteria (the appearance of physical illness in the absence of organic pathology) was restricted to women and was caused by the uterus wandering to various parts of the body, pining for children. For this “disease,” Hippocrates recommended marriage as the best remedy.
developments in THINKING: Melancholia Through the Ages
Although the modern mental health sciences have made great strides in defining, describing, classifying, determining the causes of, and treating psychological disorders, we should not ignore or minimize the contributions to understanding these conditions that were made by many individuals in antiquity. Actually, some mental health problems that are receiving a great deal of research and clinical attention today have been recognized and well described for millennia. One recent study of surviving letters from patients who were hospitalized in Edinborough Asylum between 1873 and 1906 concluded that mental health problems in the nineteenth century were very similar to those in our day (Beveridge, 1997 ). One such disorder is depression.
Perhaps no other mental disorder received so much attention from earlier scholars as depression, or (as it has been referred to in the past) melancholia. Efforts to understand melancholia have been undertaken by physicians, philosophers, writers, painters, and religious leaders in Western civilization for over 2,000 years. Moreover, conditions similar to depression are described in surviving writings from ancient Egypt (Okasha & Okasha, 2000 ). These disorders might have been viewed variously as medical conditions or religious states or human frailties; however, the symptom structure and behavior described were unmistakable.
Radden ( 2000 ) published an interesting compendium of important writings on melancholia that span 24 centuries, some highlights of which are provided here.
· • Investigations into the nature of depression, beginning with Aristotle and Galen during the Greek and Roman eras, provide lucid descriptions of the disorder melancholia.
· • Even in the Middle Ages, when scholarship and inquiry were hindered by religious persecution that included the Spanish Inquisition, there were scholars interested in mental states such as melancholia. Hildegard (1098–1179), a nun known as the “first published woman physician,” carried the Greek views of melancholia further by noting, among other things, that melancholia took different forms in men and women. Johann Weyer (1515–1588) provided astute descriptions of melancholia and examined characteristics of persons who might be so affected, even though these observations were often couched in terms of demonic possession—perhaps as a concession to leaders of the Inquisition in order to avoid persecution.
· • The premodern view of melancholia as a disorder (without the taint of demonic possession or ancient Greek humors) was introduced by Philippe Pinel (1745–1826). A French physician widely recognized for his contributions to the humane treatment of people with mental disorders, Pinel also advanced our scholarly understanding of mental disorders such as melancholia by improving a classification schema and examining the causes of the disorder.
· • Two early modern contributors to our understanding of depression were Wilhelm Griesinger (1817–1868) and Emil Kraepelin (1856–1926). Griesinger’s views on the underlying biological basis for disorders such as melancholia focused the field of psychiatry on the need to seek biological determinants for disorders. Kraepelin is credited with preparing the way for the modern view of psychiatry. His classification schema is still cited today in contemporary writings as seminal in the evolution of diagnostic classification systems. He also identified manic depression as a major category of depression.
Even though much of our understanding of depression and our development of effective treatment methods has emerged over the past three decades, our debt to the ancients who struggled with describing and understanding this disorder needs to be recognized.
The earliest use of the concept “delirium” to describe symptoms of mental disorders that result from fever or physical injury or brain trauma occurred in the first century A.D. by Celsus (Adamis et al., 2007 ).
Early Philosophical Conceptions of Consciousness
The Greek philosopher Plato (429–347 B.C.) studied mentally disturbed individuals who had committed criminal acts and how to deal with them. He wrote that such persons were, in some “obvious” sense, not responsible for their acts and should not receive punishment in the same way as normal persons. He also made provision for mental cases to be cared for in the community (Plato, n.d.).
Plato viewed psychological phenomena as responses of the whole organism, reflecting its internal state and natural appetites. In The Republic, Plato emphasized the importance of individual differences in intellectual and other abilities and took into account sociocultural influences in shaping thinking and behavior. His ideas regarding treatment included a provision for “hospital” care for individuals who developed beliefs that ran counter to those of the broader social order. There they would be engaged periodically in conversations comparable to psychotherapy to promote the health of their souls (Milns, 1986 ). Despite these modern ideas, however, Plato shared the belief that mental disorders were in part divinely caused.
The celebrated Greek philosopher Aristotle (384–322 B.C.), who was a pupil of Plato, wrote extensively on mental disorders. Among his most lasting contributions to psychology are his descriptions of consciousness. He held the view that “thinking” as directed would eliminate pain and help to attain pleasure. On the question of whether mental disorders could be caused by psychological factors such as frustration and conflict, Aristotle discussed the possibility and rejected it; his lead on this issue was widely followed. Aristotle generally subscribed to the Hippocratic theory of disturbances in the bile. For example, he thought that very hot bile generated amorous desires, verbal fluency, and suicidal impulses.
Later Greek and Roman Thought
Hippocrates’ work was continued by some of the later Greek and Roman physicians. Particularly in Alexandria, Egypt (which became a center of Greek culture after its founding in 332 B.C. by Alexander the Great), medical practices developed to a higher level, and the temples dedicated to Saturn were first-rate sanatoria. Pleasant surroundings were considered of great therapeutic value for mental patients, who were provided with constant activities including parties, dances, walks in the temple gardens, rowing along the Nile, and musical concerts. Physicians of this time also used a wide range of therapeutic measures including dieting, massage, hydrotherapy, gymnastics, and education, as well as some less desirable practices such as bleeding, purging, and mechanical restraints.
Asclepiades (c. 124–40 B.C.) was a Greek physician born at Prusa in Bithynia in Asia Minor and practiced medicine in Rome toward the end of the second century B.C. He developed a theory of disease that was based on the flow of atoms through the pores in the body and developed treatments, such as massage, special diets, bathing, exercise, listening to music, and rest and quiet, to restore to the body (Stone, 1937 ).
One of the most influential Greek physicians was Galen (A.D. 130–200), who practiced in Rome. Although he elaborated on the Hippocratic tradition, he did not contribute much that was new to the treatment or clinical descriptions of mental disorders. Rather, he made a number of original contributions concerning the anatomy of the nervous system. (These findings were based on dissections of animals; human autopsies were still not allowed.) Galen also took a scientific approach to the field, dividing the causes of psychological disorders into physical and mental categories. Among the causes he named were injuries to the head, excessive use of alcohol, shock, fear, adolescence, menstrual changes, economic reversals, and disappointment in love.
Roman medicine reflected the characteristic pragmatism of the Roman people. Roman physicians wanted to make their patients comfortable and thus used pleasant physical therapies such as warm baths and massage. They also followed the principle of contrariis contrarius (“opposite by opposite”)—for example, having their patients drink chilled wine while they were in a warm tub.
Galen (A.D. 130–200) believed that psychological disorders could have either physical causes, such as injuries to the head, or mental causes, such as disappointment in love.
Early Views of Mental Disorders in China
China was one of the earliest developed civilizations in which medicine and attention to mental disorders were introduced (Soong, 2006 ). The following passage is taken from an ancient Chinese medical text supposedly written by Huang Ti (c. 2674 B.C.), the third legendary emperor.
· The person suffering from excited insanity initially feels sad, eating and sleeping less; he then becomes grandiose, feeling that he is very smart and noble, talking and scolding day and night, singing, behaving strangely, seeing strange things, hearing strange voices, believing that he can see the devil or gods. (Tseng, 1973 , p. 570)
Even at this early date, Chinese medicine was based on a belief in natural rather than supernatural causes for illnesses. For example, in the concept of yin and yang, the human body, like the cosmos, is divided into positive and negative forces that both complement and contradict each other. If the two forces are balanced, the result is physical and mental health; if they are not, illness results. Thus treatments focused on restoring balance (Tseng, 1973 , p. 570).
Ancient Persian physician Avicenna (c. 980–1037) approached the treatment of mental disorders with humane practices unknown to Western medical practitioners of the time.
Chinese medicine reached a relatively sophisticated level during the second century, and Chung Ching, who has been called the Hippocrates of China, wrote two well-known medical works around A.D. 200. Like Hippocrates, he based his views of physical and mental disorders on clinical observations, and he implicated organ pathologies as primary causes. However, he also believed that stressful psychological conditions could cause organ pathologies, and his treatments, like those of Hippocrates, utilized both drugs and the regaining of emotional balance through appropriate activities.
As in the West, Chinese views of mental disorders regressed to a belief in supernatural forces as causal agents. From the later part of the second century through the early part of the ninth century, ghosts and devils were implicated in “ghost-evil” insanity, which presumably resulted from possession by evil spirits. The “Dark Ages” in China, however, were neither so severe (in terms of the treatment of mental patients) nor as long-lasting as in the West. A return to biological, somatic (bodily) views and an emphasis on psychosocial factors occurred in the centuries that followed. Over the past 50 years, China has been experiencing a broadening of ideas in mental health services and has been incorporating many ideas from Western psychiatry (Zhang & Lu, 2006 ).
Views of Abnormality During the Middle Ages
During the Middle Ages (about a.d. 500 to a.d. 1500), the more scientific aspects of Greek medicine survived in the Islamic countries of the Middle East. The first mental hospital was established in Baghdad in a.d. 792; it was soon followed by others in Damascus and Aleppo (Polvan, 1969 ). In these hospitals, mentally disturbed individuals received humane treatment. One outstanding figure in ancient medicine was Avicenna from Persia (c. 980–1037), called the “prince of physicians” (Campbell, 1926 ), and the author of The Canon of Medicine, perhaps the most widely studied medical work ever written. In his writings, Avicenna frequently referred to hysteria, epilepsy, manic reactions, and melancholia. The following case study illustrates Avicenna’s unique approach to the treatment of a young prince suffering from mental disorder.
An Early Treatment Case A certain prince was afflicted with melancholia and suffered from the delusion that he was a cow…. He would low like a cow, causing annoyance to everyone, … crying, “Kill me so that a good stew may be made of my flesh.” Finally … he would eat nothing…. Avicenna was persuaded to take the case…. First of all he sent a message to the patient bidding him be of good cheer because the butcher was coming to slaughter him, whereat … the sick man rejoiced. Some time afterward Avicenna, holding a knife in his hand, entered the sickroom saying, “Where is this cow that I may kill it?” The patient lowed like a cow to indicate where he was. By Avicenna’s orders he was laid on the ground bound hand and foot. Avicenna then felt him all over and said, “He is too lean, and not ready to be killed; he must be fattened.” Then they offered him suitable food of which he now partook eagerly, and gradually he gained strength, got rid of his delusion, and was completely cured. (Browne, 1921 , pp. 88–89)
During the Middle Ages in Europe, scientific inquiry into abnormal behavior was limited, and the treatment of psychologically disturbed individuals was characterized more often by ritual or superstition than by attempts to understand an individual’s condition. In contrast to Avicenna’s era in the Islamic countries of the Middle East or to the period of enlightenment during the seventeenth and eighteenth centuries, the Middle Ages in Europe were largely devoid of scientific thinking and humane treatment for the mentally disturbed.
Mental disorders were quite prevalent throughout the Middle Ages in Europe, especially toward the end of the period, when medieval institutions, social structures, and beliefs began to change drastically. During this time, supernatural explanations of the causes of mental illness grew in popularity. Within this environment, it obviously was difficult to make great strides in the understanding and treatment of abnormal behavior. Although the influence of theology was growing rapidly, “sin” was not always cited as a causal factor in mental illness. For example, Kroll and Bachrach ( 1984 ) examined 57 episodes of mental illness ranging from madness and possession to alcohol abuse and epilepsy. They found sin implicated in only nine cases (16%). To understand better this elusive period of history, let us look at two events of the times—mass madness and exorcism—to see how they are related to views of abnormal behavior.
During the last half of the Middle Ages in Europe, a peculiar trend emerged in efforts to understand abnormal behavior. It involved mass madness —the widespread occurrence of group behavior disorders that were apparently cases of hysteria. Whole groups of people were affected simultaneously. Dancing manias (epidemics of raving, jumping, dancing, and convulsions) were reported as early as the tenth century. One such episode that occurred in Italy early in the thirteenth century was known as tarantism —a disorder that included an uncontrollable impulse to dance that was often attributed to the bite of the southern European tarantula or wolf spider. This dancing mania later spread to Germany and the rest of Europe, where it was known as Saint Vitus’s dance .
Isolated rural areas were also afflicted with outbreaks of lycanthropy —a condition in which people believed themselves to be possessed by wolves and imitated their behavior. In 1541 a case was reported in which a person suffering from lycanthropy told his captors, in confidence, that he was really a wolf but that his skin was smooth on the surface because all the hairs were on the inside (Stone, 1937 ). To cure him of his delusions, his extremities were amputated, following which he died, still uncured.
Mass madness occurred periodically all the way into the seventeenth century but had reached its peak during the fourteenth and fifteenth centuries—a period noted for social oppression, famine, and epidemic diseases. During this time, Europe was ravaged by a plague known as the Black Death, which killed millions (according to some estimates, 50% of the population of Europe died) and severely disrupted social organization. Undoubtedly, many of the peculiar cases of mass madness were related to the depression, fear, and wild mysticism engendered by the terrible events of this period. People simply could not believe that frightening catastrophes such as the Black Death could have natural causes and thus could be within their power to control, prevent, or even create.
Today, so-called mass hysteria occurs occasionally; the affliction usually mimics some type of physical disorder such as fainting spells or convulsive movements. A case of apparent mass hysteria occurred among hundreds of West Bank Palestinian girls in April 1983. This episode threatened to have serious political repercussions because some Arab leaders initially thought that the girls had been poisoned by Israelis. Health officials later concluded that psychological factors had played a key role in most of the cases (Hefez, 1985 ).
Ilechukwu ( 1992 ) describes an epidemic of mass hysteria that occurred in Nigeria in 1990 in which many men feared that their genitals had simply vanished. This fear of genital retraction accompanied by a fear of death is referred to as koro and has been widely documented in Southeast Asia. The afflicted persons believe this genital disappearance was caused by a supernatural occurrence in which they were robbed of their genitalia in order to benefit other people magically. Ilechukwu attributes some of this panic to male resentment of women’s success during a period of social strain and the symbolic equation between masculine sexuality and economic, social, and creative prowess.
EXORCISM AND WITCHCRAFT
In the Middle Ages in Europe, management of the mentally disturbed was left largely to the clergy. Monasteries served as refuges and places of confinement. During the early part of the medieval period, the mentally disturbed were, for the most part, treated with considerable kindness. “Treatment” consisted of prayer, holy water, sanctified ointments, the breath or spittle of the priests, the touching of relics, visits to holy places, and mild forms of exorcism. In some monasteries and shrines, exorcisms were performed by the gentle “laying on of hands.” Such methods were often joined with vaguely understood medical treatments derived mainly from Galen, which gave rise to prescriptions such as the following: “For a fiend-sick man: When a devil possesses a man, or controls him from within with disease, a spewdrink of lupin, bishopswort, henbane, garlic. Pound these together, add ale and holy water” (Cockayne, 1864–1866 ).
Interestingly, there has been a recent resurgence of superstition. For example, one can find those who believe that supernatural forces cause psychological problems and that “cures” should involve exorcism to rid people of unwanted characteristics or “spells.” Fries ( 2001 ) reported on a woman tragically drowning her 4-year-old daughter in an exorcism ritual attempting to rid her of demons that the mother believed possessed her daughter. In a more recent example, CBS News reported an incident in which an autistic boy was killed in an exorcism at a church in Milwaukee (CBS News, 2003 ).
It had long been thought that during the Middle Ages many mentally disturbed people were accused of being witches and thus were punished and often killed (e.g., Zilboorg & Henry, 1941 ). But several more recent interpretations have questioned the extent to which this was so (Maher & Maher, 1985 ; Phillips, 2002 ; Schoeneman, 1984 ). For example, in a review of the literature, Schoeneman ( 1984 ) notes that “the typical accused witch was not a mentally ill person but an impoverished woman with a sharp tongue and a bad temper” (p. 301). He goes on to say that “witchcraft was, in fact, never considered a variety of possession either by witch hunters, the general populace, or modern historians” (p. 306). To say “never” may be overstating the case; clearly, some mentally ill people were punished as witches. Otherwise, as we will see in the next section, why did some physicians and thinkers go to great lengths to expose the fallacies of the connection? In the case of witchcraft and mental illness, the confusion may be due, in part, to confusion about demonic possession. Even Robert Burton (1576–1640), an enlightened scholar, in his classic work The Anatomy of Melancholia ( 1621 ), considered demonic possession a potential cause of mental disorder. There were two types of demonically possessed people: Those physically possessed were considered mad, whereas those spiritually possessed were likely to be considered witches. Over time, the distinctions between these two categories may have blurred in the eyes of historians, resulting in the perception that witchcraft and mental illness were connected more frequently in the medieval mind than was the case.
The changing view of the relationship between witchcraft and mental illness points to an even broader issue—the difficulties of interpreting historical events accurately. We will discuss this concept in more depth in the Unresolved Issues section at the end of this chapter.
· • What aspects of Hippocrates’ alternative approach to mental disorders were truly revolutionary?
· • What were the historical views of the disorder of melancholia (known as depression today)?
· • What was the role of supernatural beliefs in efforts to understand mental disorders during the Middle Ages?
· • What is mass madness? Give some examples of this phenomenon.
Toward Humanitarian Approaches
During the latter part of the Middle Ages and the early Renaissance, scientific questioning reemerged and a movement emphasizing the importance of specifically human interests and concerns began—a movement (still with us today) that can be loosely referred to as humanism. Consequently, the superstitious beliefs that had hindered the understanding and therapeutic treatment of mental disorders began to be challenged.
The Resurgence of Scientific Questioning in Europe
Paracelsus (1490–1541), a Swiss physician, was an early critic of superstitious beliefs about possession. He insisted that the dancing mania was not a possession but a form of disease, and that it should be treated as such. He also postulated a conflict between the instinctual and spiritual natures of human beings, formulated the idea of psychic causes for mental illness, and advocated treatment by “bodily magnetism,” later called hypnosis (Mora, 1967 ). Although Paracelsus rejected demonology, his view of abnormal behavior was colored by his belief in astral influences (lunatic is derived from the Latin word luna, or “moon”). He was convinced that the moon exerted a supernatural influence over the brain—an idea, incidentally, that persists among some people today.
Johann Weyer (1515–1588), a German physician and writer who wrote under the Latin name of Joannus Wierus, was so deeply disturbed by the imprisonment, torture, and burning of people accused of witchcraft that he made a careful study of the entire problem. About 1583 he published a book, On the Deceits of the Demons, that contains a step-by-step rebuttal of the Malleus Maleficarum, a witch-hunting handbook published in 1486 for use in recognizing and dealing with those suspected of being witches. In his book, Weyer argued that a considerable number, if not all, of those imprisoned, tortured, and burned for witchcraft were really sick in mind or body and that, consequently, great wrongs were being committed against innocent people. Weyer’s work enjoyed the approval of a few outstanding physicians and theologians of his time. Mostly, however, it met with vehement protest and condemnation.
Johann Weyer, a sixteenth-century German physician, became so concerned over the torture and imprisonment of people accused of being witches that he wrote a book rebutting the church’s witch- hunting handbook, the Malleus Maleficarum.
Weyer was one of the first physicians to specialize in mental disorders, and his wide experience and progressive views justify his reputation as the founder of modern psychopathology. Unfortunately, however, he was too far ahead of his time. He was scorned by his peers, many of whom called him “Weirus Hereticus” and “Weirus Insanus.” His works were banned by the Church and remained so until the twentieth century.
The clergy, however, were beginning to question the practices of the time. For example, St. Vincent de Paul (1576–1660), at the risk of his life, declared, “Mental disease is no different than bodily disease and Christianity demands of the humane and powerful to protect, and the skillful to relieve the one as well as the other” (Castiglioni, 1924 ).
In the face of such persistent advocates of science, who continued their testimonies throughout the next two centuries, demonology and superstition gave ground. These advocates gradually paved the way for the return of observation and reason, which culminated in the development of modern experimental and clinical approaches.
The Establishment of Early Asylums
From the sixteenth century on, special institutions called asylums —sanctuaries or places of refuge meant solely for the care of the mentally ill—grew in number. The early asylums were begun as a way of removing from society troublesome individuals who could not care for themselves. Although scientific inquiry into abnormal behavior was on the increase, most early asylums, often referred to as “madhouses,” were not pleasant places or “hospitals” but primarily residences or storage places for the insane. The unfortunate residents lived and died amid conditions of incredible filth and cruelty.
The first asylum established in Europe was probably in Spain in 1409 (Villasante, 2003 ), although this point has been the subject of considerable discussion (Polo, 1997 ; Trope, 1997 ). Little is known about the treatment of patients in this asylum. In 1547 the monastery of St. Mary of Bethlem in London (initially founded as a monastery in 1247; see O’Donoghue, 1914 ) was officially made into an asylum by Henry VIII. Its name soon was contracted to “Bedlam,” and it became widely known for its deplorable conditions and practices. The more violent patients were exhibited to the public for one penny a look, and the more harmless inmates were forced to seek charity on the streets of London. Tuke ( 1882 ) describes Ned Ward’s account, in History of the Insane in the British Isles, of a visit to Bedlam:
· Accordingly we were admitted in thro’ an iron gate, within which sat a brawny Cerberus, of an Idico-colour, leaning upon a money-box; we turned in through another Iron-Barricado, where we heard such a rattling of chains, drumming of doors, ranting, hollowing, singing, and running, that I could think of nothing but Don Quevedo’s Vision where the lost souls broke loose and put Hell in an uproar. The first whimsey-headed wretch of this lunatic family that we observed, was a merry fellow in a straw cap, who was talking to himself, “that he had an army of Eagles at his command,” then clapping his hand upon his head, swore by his crown of moonshine, he would battle all the Stars in the Skies, but he would have some claret…. We then moved on till we found another remarkable figure worth our observing, who was peeping through his wicket, eating of bread and cheese, talking all the while like a carrier at his supper, chewing his words with his victuals, all that he spoke being in praise of bread and cheese: “bread was good with cheese, and cheese was good with bread, and bread and cheese was good together”; and abundance of such stuff; to which my friend and I, with others stood listening; at last he counterfeits a sneeze, and shot such a mouthful of bread and cheese amongst us, that every spectator had some share of his kindness, which made us retreat. (pp. 76–77)
Such asylums for the mentally ill were gradually established in other countries, including Mexico (1566) and France (1641). An asylum was established in Moscow in 1764, and the notorious Lunatics’ Tower in Vienna was constructed in 1784. This structure was a showplace in Old Vienna, an ornately decorated round tower within which were square rooms. The doctors and “keepers” lived in the square rooms, while the patients were confined in the spaces between the walls of the rooms and the outside of the tower, where they were put on exhibit to the public for a small fee. These early asylums were primarily modifications of penal institutions, and the inmates were treated more like beasts than like human beings.
In the United States, the Pennsylvania Hospital in Philadelphia, completed under the guidance of Benjamin Franklin in 1756, provided some cells or wards for mental patients. The Public Hospital in Williamsburg, Virginia, constructed in 1773, was the first hospital in the United States devoted exclusively to mental patients. The treatment of mental patients in the United States was no better than that offered by European institutions, however. Zwelling’s 1985 review of the Public Hospital’s treatment methods shows that, initially, the philosophy of treatment involved the belief that the patients needed to choose rationality over insanity . Thus the treatment techniques were aggressive, aimed at restoring a “physical balance in the body and brain.” These techniques, though based on the scientific views of the day, were designed to intimidate patients. They included powerful drugs, water treatments, bleeding and blistering, electric shocks, and physical restraints. For example, a violent patient might be plunged into ice water or a listless patient into hot water; frenzied patients might be administered drugs to exhaust them; or patients might be bled in order to drain their system of “harmful” fluids.
Clearly, by the late eighteenth century, most mental hospitals in Europe and America were in great need of reform. The humanitarian treatment of patients received great impetus from the work of Philippe Pinel (1745–1826) in France.
In 1792, shortly after the first phase of the French Revolution, Pinel was placed in charge of La Bicêtre, a hospital in Paris. In this capacity, he received the grudging permission of the Revolutionary Commune to remove the chains from some of the inmates as an experiment to test his views that mental patients should be treated with kindness and consider-ation—as sick people, not as vicious beasts or criminals. Had his experiment proved a failure, Pinel might have lost his head, but fortunately it was a great success. Chains were removed; sunny rooms were provided; patients were permitted to exercise on the hospital grounds; and kindness was extended to these poor beings, some of whom had been chained in dungeons for 30 or more years. The effect was almost miraculous. The previous noise, filth, and abuse were replaced by order and peace. Interestingly, a historical document, subsequently found in the French Archives, raises some question about the date at which humanitarian reforms were begun in France. The document, provided by Jean-Baptiste Pussin (Pinel’s predecessor at La Bicêtre), indicated that he had been the head of the hospital beginning in 1784 and had removed some of the chains from patients and employed slightly more humane straitjackets instead. He also pointed out in the document that he had issued orders forbidding the staff from beating patients (Weiner, 1979 ).
This painting depicts Philippe Pinel supervising the unchaining of inmates at La Bicêtre hospital. Pinel’s experiment represented both a great reform and a major step in devising humanitarian methods of treating mental disorders.
TUKE’S WORK IN ENGLAND
At about the same time that Pinel was reforming La Bicêtre, an English Quaker named William Tuke (1732–1822) established the York Retreat, a pleasant country house where mental patients lived, worked, and rested in a kindly, religious atmosphere (Narby, 1982 ). This retreat represented the culmination of a noble battle against the brutality, ignorance, and indifference of Tuke’s time.
The Quakers believed in treating all people, even the insane, with kindness and acceptance. Their view that kind acceptance would help mentally ill people recover sparked the growth of more humane psychiatric treatment during a period when mental patients were ignored and mistreated (Glover, 1984 ).
The Quaker retreat at York has continued to provide humane mental health treatment for over 200 years (Borthwick et al., 2001 ), even though the mental hospital movement spawned by its example evolved into large mental hospitals that became crowded and often offered less-than-humane treatment in the late nineteenth and early twentieth centuries. (See the picture of the York Retreat today below.)
As word of Pinel’s amazing results spread to England, Tuke’s small force of Quakers gradually gained the support of English medical practitioners such as Thomas Wakley and Samuel Hitch. In 1841 Hitch introduced trained nurses into the wards at the Gloucester Asylum and put trained supervisors at the head of the nursing staffs. These innovations, quite revolutionary at the time, not only improved the care of mental patients but also changed public attitudes toward the mentally disturbed. In 1842, following Wakley’s lobbying for change, the Lunacy Inquiry Act was passed, which included the requirement of effective inspection of asylums and houses every four months (Roberts, 1981 ) to ensure proper diet and the elimination of the use of restraints.
This picture shows a male ward of Bethlem hospital under the new, more humane treatment approach. Walford ( 1878 ) pointed out that by 1815, there was no more “show for a penny” at Bethlem Hospital, and patients were afforded more humane living facilities and activities.
The historic mental health facility, the York Retreat, continues to provide services in York, England, over 200 years since it was founded by William Tuke in 1796. This mental health facility is sponsored by the Quakers and provides a broad range of services in both inpatient and outpatient care.
In 1845, the Country Asylums Act was passed in England, which required every county to provide asylum to “paupers and lunatics” (Scull, 1996 ). Britain’s policy of providing more humane treatment of the mentally ill was substantially expanded to the colonies (Australia, Canada, India, West Indies, South Africa, etc.) after a widely publicized incident of maltreatment of patients that occurred in Kingston, Jamaica prompted an audit of colonial facilities and practices. In Kingston, an article written by a former patient disclosed that the staff used “tanking” to control and punish mental patients. During tanking, “lunatics” were routinely held under water in a bathing tank by nurses and sometimes other patients until they were near death (Swartz, 2010 ).
RUSH AND MORAL MANAGEMENT IN AMERICA
The success of Pinel’s and Tuke’s humanitarian experiments revolutionized the treatment of mental patients throughout the Western world. In the United States, this revolution was reflected in the work of Benjamin Rush (1745–1813), the founder of American psychiatry and also one of the signers of the Declaration of Independence. While he was associated with the Pennsylvania Hospital in 1783, Rush encouraged more humane treatment of the mentally ill; wrote the first systematic treatise on psychiatry in America, Medical Inquiries and Observations upon Diseases of the Mind (1812); and was the first American to organize a course in psychiatry (see Gentile & Miller, 2009). But even he did not escape entirely from the established beliefs of his time. His medical theory was tainted with astrology, and his principal remedies were bloodletting and purgatives. In addition, he invented and used a device called “the tranquilizing chair,” which was probably more torturous than tranquil for patients. The chair was thought to lessen the force of the blood on the head while the muscles were relaxed. Despite these limitations, we can consider Rush an important transitional figure between the old era and the new.
During the early part of this period of humanitarian reform, the use of moral management —a wide-ranging method of treatment that focused on a patient’s social, individual, and occupational needs—became relatively widespread. This approach, which stemmed largely from the work of Pinel and Tuke, began in Europe during the late eighteenth century and in America during the early nineteenth century.
Moral management in asylums emphasized the patients’ moral and spiritual development and the rehabilitation of their “character” rather than their physical or mental disorders, in part because very little effective treatment was available for these conditions at the time. The treatment or rehabilitation of the physical or mental disorders was usually through manual labor and spiritual discussion, along with humane treatment.
Moral management achieved a high degree of effectiveness—which is all the more amazing because it was done without the benefit of the antipsychotic drugs used today and because many of the patients were probably suffering from syphilis, a then-incurable disease of the central nervous system. In the 20-year period between 1833 and 1853, Worcester State Hospital’s discharge rate for patients who had been ill less than a year before admission was 71 percent. Even for patients with a longer preadmission disorder, the discharge rate was 59 percent (Bockhoven, 1972 ). In London, Walford ( 1878 ) reported that during a 100-year period ending in 1876, the “cure” rate was 45.7 percent for the famed Bedlam Hospital.
Despite its reported effectiveness in many cases, moral management was nearly abandoned by the latter part of the nineteenth century. The reasons were many and varied. Among the more obvious ones were ethnic prejudice against the rising immigrant population in hospitals, leading to tension between staff and patients; the failure of the movement’s leaders to train their own replacements; and the overextension of hospital facilities, which reflected the misguided belief that bigger hospitals would differ from smaller ones only in size.
Two other reasons for the demise of moral management are, in retrospect, truly ironic. One was the rise of the mental hygiene movement , which advocated a method of treatment that focused almost exclusively on the physical well-being of hospitalized mental patients. Although the patients’ comfort levels improved under the mental hygienists, the patients received no help for their mental problems and thus were subtly condemned to helplessness and dependency.
Advances in biomedical science also contributed to the demise of moral management and the rise of the mental hygiene movement. These advances fostered the notion that all mental disorders would eventually yield to biological explanations and biologically based treatments (Luchins, 1989 ). Thus the psychological and social environment of a patient was considered largely irrelevant; the best one could do was keep the patient comfortable until a biological cure was discovered. Needless to say, the anticipated biological cure-all did not arrive, and by the late 1940s and early 1950s, discharge rates were down to about 30 percent. Its negative effects on the use of moral management notwithstanding, the mental hygiene movement has accounted for many humanitarian accomplishments.
BENJAMIN FRANKLIN’S EARLY DISCOVERY OF THE POTENTIAL CURATIVE EFFECTS OF ELECTRIC SHOCK
In school, most people learn about Benjamin Franklin’s early experimentation with electricity in the early eighteenth century. His kite-flying during electric storms and its influence on the physical sciences is common knowledge. However, most people (even mental health professionals) are not aware that his work with electricity was among the earliest efforts to explore electric shock to treat mental illness, an insight he gained accidentally. His proposals for using electricity to treat melancholia (depression) grew out of his observations that a severe shock he had experienced altered his memories (see the informative discussion by Finger & Zaromb, 2006 ). Franklin published articles describing his experience and suggested that physicians further study this method for treating melancholia. Shortly afterward, one of his friends, a physician named Ingenhousz, reported a similar incident in which he observed alterations in his thinking following a shock he had received. He too called for clinical trials to study this phenomenon as a possible treatment for psychiatric patients.
Although these early efforts pointed attention to a potentially valuable treatment approach, medical research on the procedure was slow to develop. Finger and Zaromb ( 2006 ) point out that it was not until the middle of the eighteenth century that electric shock was associated with amnesia. Moreover, it was not until the twentieth century that Cerletti and Bini ( 1938 ), at the University of Rome, initiated electric shock as a treatment for depression.
DIX AND THE MENTAL HYGIENE MOVEMENT
Dorothea Dix (1802–1887) was an energetic New Englander who became a champion of poor and “forgotten” people in prisons and mental institutions for decades during the nineteenth century. Dix, herself a child of very difficult and impoverished circumstances (Viney, 1996 ), later became an important driving force in humane treatment for psychiatric patients. She worked as a schoolteacher as a young adult but was later forced into early retirement because of recurring attacks of tuberculosis. In 1841, she began to teach in a women’s prison. Through this contact she became acquainted with the deplorable conditions in jails, almshouses, and asylums. In a “Memorial” submitted to the U.S. Congress in 1848, she stated that she had seen
· more than 9000 idiots, epileptics and insane in the United States, destitute of appropriate care and protection … bound with galling chains, bowed beneath fetters and heavy iron bails attached to drag-chains, lacerated with ropes, scourged with rods and terrified beneath storms of execration and cruel blows; now subject to jibes and scorn and torturing tricks; now abandoned to the most outrageous violations. (Zilboorg & Henry, 1941 , pp. 583–584)
As a result of what she had seen, Dix carried on a zealous campaign between 1841 and 1881 that aroused people and legislatures to do something about the inhuman treatment accorded the mentally ill. Through her efforts, the mental hygiene movement grew in America: Millions of dollars were raised to build suitable hospitals, and 20 states responded directly to her appeals. Not only was she instrumental in improving conditions in American hospitals but she also directed the opening of two large institutions in Canada and completely reformed the asylum system in Scotland and several other countries. She is credited with establishing 32 mental hospitals, an astonishing record given the ignorance and superstition that still prevailed in the field of mental health. Dix rounded out her career by organizing the nursing forces of the Northern armies during the Civil War. A resolution presented by the U.S. Congress in 1901 characterized her as “among the noblest examples of humanity in all history” (Karnesh, with Zucker, 1945 , p. 18).
Dorothea Dix (1802–1887) was a tireless reformer who made great strides in changing public attitudes toward the mentally ill.
Later critics have claimed that establishing hospitals for the mentally ill and increasing the number of people in them spawned overcrowded facilities and custodial care (Bockhoven, 1972 ; Dain, 1964 ). These critics have further claimed that housing patients in institutions away from society interfered with the treatment of the day (moral therapy) and deferred the search for more appropriate and effective treatments for mental disorders (Bockhoven, 1972 ). These criticisms, however, do not consider the context in which Dix’s contributions were made (see the Unresolved Issues at the end of this chapter). Her advocacy of the humane treatment of the mentally ill stood in stark contrast to the cruel treatment common at the time (Viney & Bartsch, 1984 ).
THE MILITARY AND THE MENTALLY ILL
Mental health treatment was also advanced by military medicine. The first mental health facility for treating mentally disordered war casualties was opened by the Confederate Army in the American Civil War (Deutsch, 1944 ; Gabriel, 1987 ). An even more extensive and influential program of military psychiatry evolved in Germany during the late 1800s. Lengweiler ( 2003 ) reviews the evolution of military psychiatry in Germany between the Franco-Prussian War in 1870 and World War I in 1914. During this period, psychiatrists, a number of whom made great contributions to the field of abnormal psychology (e.g., Emil Kraepelin and Richard von Krafft-Ebbing), worked with the military administration, conducting research and training doctors to detect mental health problems that could interfere with performance of duty. One early research program illustrates the interplay between medicine and military administration. Kraepelin, who viewed alcohol as a key cause of psychological problems among soldiers, conducted a research project evaluating the extent to which alcohol consumption adversely affected the soldiers’ ability to fire their rifles effectively.
Nineteenth-Century Views of the Causes and Treatment of Mental Disorders
In the early part of the nineteenth century, mental hospitals were controlled essentially by laypersons because of the prominence of moral management in the treatment of “lunatics.” Medical professionals—or “alienists,” as psychiatrists were called at this time in reference to their treating the “alienated,” or insane—had a relatively inconsequential role in the care of the insane and the management of the asylums of the day. Moreover, effective treatments for mental disorders were unavailable, the only measures being such procedures as drugging, bleeding, and purging, which produced few objective results. However, during the latter part of the century, alienists gained control of the insane asylums and incorporated the traditional moral management therapy into their other rudimentary physical medical procedures.
Over time, the alienists acquired more status and influence in society and became influential as purveyors of morality, touting the benefits of Victorian morality as important to good mental health. Mental disorders were only vaguely understood, and conditions such as melancholia (depression) were considered to be the result of nervous exhaustion. That is, psychiatrists of the time thought that emotional problems were caused by the expenditure of energy or by the depletion of bodily energies as a result of excesses in living. The mental deterioration or “shattered nerves” that supposedly resulted from a person’s using up precious nerve force came to be referred to as “neurasthenia,” a condition that involved pervasive feelings of low mood, lack of energy, and physical symptoms that were thought to be related to “lifestyle” problems brought on by the demands of civilization. These vague symptoms, viewed by the alienists/psychiatrists as a definable medical condition, were then considered treatable by medical men of the times.
Changing Attitudes Toward Mental Health in the Early Twentieth Century
It is difficult to partition modern views of abnormal behavior into discrete, uniform attitudes or to trace their historical precedents without appearing arbitrary and overly simplistic. However, a brief, selective overview here will bring us into the contemporary era and set the scene for our discussion of the major viewpoints and causal considerations discussed in Chapter 3 . By the end of the nineteenth century, the mental hospital or asylum—“the big house on the hill”—with its fortress-like appearance, had become a familiar landmark in America (see Payne & Sacks, 2009 ). In it, mental patients lived under relatively harsh conditions despite the inroads made by moral management. To the general public, however, the asylum was an eerie place and its occupants a strange and frightening lot. Little was done by the resident psychiatrists to educate the public or reduce the general fear and horror of insanity. A principal reason for this silence, of course, was that early psychiatrists had little actual information to impart and in some cases employed procedures that were damaging to patients.
In the first half of the twentieth century, hospital care for the mentally ill afforded very little in the way of effective treatment. In many cases, the care was considered to be harsh, punitive, and inhumane.
Gradually, however, important strides were made toward changing the general public’s attitude toward mental patients. In America, the pioneering work of Dix was followed by that of Clifford Beers (1876–1943), whose book A Mind That Found Itself was first published in 1908. Beers, a Yale graduate, described his own mental collapse and told of the bad treatment he received in three typical institutions of the day. Although chains and other torture devices had long since been given up, the straitjacket was still widely used as a means of “quieting” excited patients. Beers experienced this treatment and supplied a vivid description of what such painful immobilization of the arms means to an overwrought mental patient in a widely read description of his experiences.
After Beers recovered in the home of a kind attendant, he launched a campaign to make people realize that such treatment was no way to handle the sick. He soon won the interest and support of many public-spirited individuals, including the eminent psychologist William James and the “dean of American psychiatry,” Adolf Meyer.
the WORLD around us: Chaining Mental Health Patients
Because of limited mental health treatment resources in some countries, it is not uncommon for mentally ill people to be chained. Westermeyer and Kroll ( 1978 ) conducted an epidemiologic study on the use of restraints for mentally ill people in 27 villages in Laos. They reported that mentally ill people who were aggressive toward others or who were considered to be a danger to themselves were sometimes restrained by being chained to posts. The woman from Laos in the photograph shown here suffered from a psychotic disorder and reportedly felt compelled to sweep her platform for 6 or 7 hours a day. She was restrained at a Buddhist temple in order to keep her from wandering into the jungle (Westermeyer, 2001 ).
Chained patient from Laos
Treatment of patients at the Mohammad Ali Shah Shrine in eastern Afghanistan involves being fed only a small piece of bread, a raw chili, and water each day for 21 days. Their family is charged 20 pounds a month. Many patients are chained as a means of controlling their behavior.
Many temples in some countries provide homes for psychologically disturbed individuals, although the care is typically inadequate. For example, Erwady, India, near Madras, has 15 privately run homes, many of which are without electricity, tap water, toilet facilities, and beds. In 2000, six people died from waterborne disease at one of the Erwady asylums, prompting the government to direct an inquiry into the conditions of the mental health asylums. Later, fire swept through a palm-thatched shed that housed mentally ill people at one Erwady asylum, killing 25 patients and injuring 5 others, many of whom were chained to heavy stones or pillars (Associated Press, 2001 ). At the time of the fire, the asylum housed 46 residents; only 16 of the patients escaped uninjured.
Mental Hospital Care in the Twentieth Century
The twentieth century began with a continued period of growth in asylums for the mentally ill; however, the fate of mental patients during that century was neither uniform nor entirely positive (see The World Around Us box). At the beginning of the twentieth century, with the influence of enlightened people such as Clifford Beers, mental hospitals grew substantially in number—predominantly to house persons with severe mental disorders such as schizophrenia, depression, organic mental disorders, tertiary syphilis and paresis (syphilis of the brain), and severe alcoholism. By 1940 the public mental hospitals housed over 400,000 patients, roughly 90 percent of whom resided in large state-funded hospitals; the remainder resided in private hospitals (Grob, 1994 ). During this period, hospital stays were typically quite lengthy, and many mentally ill individuals were destined to be hospitalized for many years. For the first half of the twentieth century, hospital care was accompanied by little in the way of effective treatment, and the care was often harsh, punitive, and inhumane. The year 1946, however, marked the beginning of an important period of change. In that year, Mary Jane Ward published a very influential book, The Snake Pit, which was popularized in a movie of the same name. This work called attention to the plight of mental patients and helped to create concern over the need to provide more humane mental health care in the community in place of the overcrowded mental hospitals. Also in 1946, the National Institutes of Mental Health was organized and provided active support for research and training through psychiatric residencies and (later) clinical psychology training programs. Moreover, the Hill-Burton Act, a program that funded community mental health hospitals, was passed during this period. This legislation, along with the Community Health Services Act of 1963, helped to create a far-reaching set of programs to develop outpatient psychiatric clinics, inpatient facilities in general hospitals, and community consultation and rehabilitation programs.
The need for reform in psychiatric hospitals was a prominent concern of many professionals and laypersons alike during the 1950s and 1960s. A great deal of professional attention was given to the need to improve conditions in mental hospitals following the publication of another influential book, Asylums, by the sociologist Erving Goffman ( 1961 ). This book further exposed the inhumane treatment of mental patients and provided a detailed account of neglect and maltreatment in mental hospitals. The movement to change the mental hospital environment was also enhanced significantly by scientific advances in the last half of the twentieth century, particularly the development of effective medications for many disorders—for example, the use of lithium in the treatment of manic depressive disorders (Cade, 1949 ) and the introduction of phenothiazines for the treatment of schizophrenia. (See Developments in Research on p. 45 and Chapter 17 for further discussion.)
During the latter decades of the twentieth century, our society had seemingly reversed its position with respect to the means of providing humane care for the mentally ill in the hospital environment. Vigorous efforts were made to close down mental hospitals and return psychiatrically disturbed people to the community, ostensibly as a means of providing more integrated and humane treatment than was available in the “isolated” environment of the psychiatric hospital and because of the success of medications (chlorpromazines) that emerged in the 1950s to alleviate psychotic symptoms (Alanen et al., 2009 ). Large numbers of psychiatric hospitals were closed, and there was a significant reduction in state and county mental hospital populations, from over half a million in 1950 (Lerman, 1981 ) to about 100,000 by the early 1990s (Narrow et al., 1993 ). These reductions are all the more impressive given that the U.S. population increased substantially over those years. This movement, referred to as deinstitutionalization , although motivated by benevolent goals, has also created great difficulties for many psychologically disturbed persons and for many communities as well.
As a phenomenon, deinstitutionalization is an international movement. For example, there has been a shift in the locus of care of patients with chronic psychiatric illnesses from psychiatric hospitals to community-based residential services in Hong Kong (Chan, 2001 ), in the Netherlands (Pijl et al., 2001 ), and in Finland (Korkeila et al., 1998 ). Some countries have experienced extensive deinstitutionalization over the past 20 years. For example, in England and Wales during the last decades of the twentieth century, only 14 of 130 psychiatric institutions remained open; and Australia showed a 90 percent reduction in hospital beds over the same period (Goldney, 2003 ). In a follow-up study of patients from 22 hospitals in Italy, D’Avanzo and colleagues ( 2003 ) report that all were closed and 39 percent of the patients in these hospitals had been discharged to nursing homes, 29 percent to residential facilities, and 29 percent to other psychiatric hospitals; only 2 percent were returned to their families.
The original impetus behind the deinstitutionalization policy was that it was considered more humane (and cost effective) to treat disturbed people outside of large mental hospitals because doing so would prevent people from acquiring negative adaptations to hospital confinement. Many professionals were concerned that the mental hospitals were becoming permanent refuges for disturbed people who were “escaping” from the demands of everyday living and were settling into a chronic sick role with a permanent excuse for letting other people take care of them. There was great hope that new medications would promote a healthy readjustment and enable former patients to live more productive lives outside the hospital. Many former patients have not fared well in community living, however, and authorities now frequently speak of the “abandonment” of chronic patients to a cruel and harsh existence. Evidence of this failure to treat psychiatric patients successfully in the community can be readily seen in our cities: Many of the people living on the streets in large cities today are homeless and mentally ill. The problems caused by deinstitutionalization appear to be due, in no small part, to the failure of society to develop ways to fill the gaps in mental health services in the community (Grob, 1994 ).
Freed from the confines of institutionalized care, or abandoned by society? Many homeless people suffer from one or more mental disorders. Deinstitutionalization, though motivated by benevolent goals, has created great difficulties for many psychologically disturbed individuals who have been released to a cruel and harsh existence.
The mental institution, once thought to be the most humane way to manage the problems of the severely mentally ill, came to be seen as obsolete or as an evil alternative, more of a problem than a solution to mental health problems. By the end of the twentieth century, inpatient mental hospitals had been substantially replaced by community-based care, day treatment hospitals, and outreach.
The twentieth century closed on a note of uncertainty with respect to the best ways to manage the needs of severely disturbed psychiatric patients. It is clear that closing mental hospitals and providing treatment for severely disturbed people in the community has not proved to be the panacea it was touted to be only a few years ago (Whitaker, 2009 ). As we will discuss further in Chapter 17 , deinstitutionalization has created problems for both patients and society as a whole. The role of the psychiatric hospital in helping those with severe psychiatric problems is likely to undergo further evolution as society again finds itself unable to deal effectively with the problems that severe mental illness can create if ignored or left unattended (see Grob, 1994 ).
· • Describe the changing views toward mental illness that evolved as scientific thinking came to have greater influence in Europe in the sixteenth and seventeenth centuries.
· • Discuss the development of the psychiatric hospital.
· • Describe the historical development of humanitarian reform, and give some of the reasons why it occurred.
· • Describe the changes in social attitudes that brought about major changes in the way persons with mental disorders have been treated.
The Emergence of Contemporary Views of Abnormal Behavior
While the mental hygiene movement was gaining ground in the United States during the latter years of the nineteenth century, great technological discoveries occurred both at home and abroad. These advances helped usher in what we know today as the scientific, or experimentally oriented, view of abnormal behavior and the application of scientific knowledge to the treatment of disturbed individuals. We will describe four major themes in abnormal psychology that spanned the nineteenth and twentieth centuries and generated powerful influences on our contemporary perspectives in abnormal behavior: (1) biological discoveries, (2) the development of a classification system for mental disorders, (3) the emergence of psychological causation views, and (4) experimental psychological research developments.
Biological Discoveries: Establishing the Link Between the Brain and Mental Disorder
Advances in the study of biological and anatomical factors as underlying both physical and mental disorders developed in this period. A major biomedical breakthrough, for example, came with the discovery of the organic factors underlying general paresis—syphilis of the brain. One of the most serious mental illnesses of the day, general paresis produced paralysis and insanity and typically caused death within 2 to 5 years as a result of brain deterioration. This scientific discovery, however, did not occur overnight; it required the combined efforts of many scientists and researchers for nearly a century.
GENERAL PARESIS AND SYPHILIS
The discovery of a cure for general paresis began in 1825, when the French physician A. L. J. Bayle differentiated general paresis as a specific type of mental disorder. Bayle gave a complete and accurate description of the symptom pattern of paresis and convincingly presented his reasons for believing paresis to be a distinct disorder. Many years later, in 1897, the Viennese psychiatrist Richard von Krafft-Ebbing conducted experiments involving the inoculation of paretic patients with matter from syphilitic sores. None of the patients developed secondary symptoms of syphilis, which led to the conclusion that they must previously have been infected. This crucial experiment established the relationship between general paresis and syphilis. It was almost a decade later, in 1906, when August von Wassermann devised a blood test for syphilis. This development made it possible to check for the presence of the deadly bacteria in the bloodstream of an individual before the more serious consequences of infection appeared.
Finally, in 1917, Julius von Wagner-Jauregg, chief of the psychiatric clinic of the University of Vienna, introduced the malarial fever treatment of syphilis and paresis because he knew that the high fever associated with malaria killed off the bacteria. He infected nine paretic patients with the blood of a malaria-infected soldier and found marked improvement in paretic symptoms in three patients and apparent recovery in three others. By 1925 several hospitals in the United States were incorporating the new malarial treatment for paresis into their hospital treatments. One of the earliest controlled studies of malarial treatment for paresis was conducted by Bahr and Brutsch in Indiana in 1928. They found that out of the 100 patients studied, 37 percent of paresis patients showed significant recovery, 25 percent had been discharged, and 21 percent of those had returned to their previous or similar occupations. Today, of course, we have penicillin as an effective, simpler treatment of syphilis, but the early malarial treatment represented the first clear-cut conquest of a mental disorder by medical science. The field of abnormal psychology had come a long way—from superstitious beliefs to scientific proof of how brain pathology can cause a specific disorder. This breakthrough raised great hopes in the medical community that organic bases would be found for many other mental disorders—perhaps for all of them.
BRAIN PATHOLOGY AS A CAUSAL FACTOR
With the emergence of modern experimental science in the early part of the eighteenth century, knowledge of anatomy, physiology, neurology, chemistry, and general medicine increased rapidly. Scientists began to focus on diseased body organs as the cause of physical ailments. It was the next logical step for these researchers to assume that mental disorder was an illness based on the pathology of an organ—in this case, the brain. In 1757 Albrecht von Haller (1708–1777), in his Elementa physiologae corporis humani, emphasized the importance of the brain in psychic functions and advocated postmortem dissection to study the brains of the insane. The first systematic presentation of this viewpoint, however, was made by the German psychiatrist Wilhelm Griesinger (1817–1868). In his textbook The Pathology and Therapy of Psychic Disorders, published in 1845, Griesinger insisted that all mental disorders could be explained in terms of brain pathology. Following the discovery that brain deterioration resulted in general paresis, other successes followed. Alois Alzheimer and other investigators established the brain pathology in cerebral arteriosclerosis and in the senile mental disorders. Eventually, in the twentieth century, the organic pathologies underlying the toxic mental disorders (disorders caused by toxic substances such as lead), certain types of mental retardation, and other mental illnesses were discovered.
Along with the advancements in mental health treatment in the twentieth century came some unfortunate missteps. During the early years of the twentieth century, Henry Cotton, a psychiatrist at a New Jersey hospital, developed a theory that mental health problems such as schizophrenia could be cured by removing the infections that he believed caused the condition. He used surgical procedures to remove all of a person’s teeth or body parts such as tonsils, parts of the colon, testicles, or ovaries in order to reduce the infection (Scull, 2005 ). In the 1920s through the 1940s, an American psychiatrist, Walter Freeman, followed the strategies developed by Italian psychiatrist Egas Moniz to treat severe mental disorders using surgical procedures called lobotomies. Freeman modified the surgery used by Moniz, using an ice pick to sever the neural connections in the brain after entering through the patient’s eye sockets (see discussion on lobotomy by El-Hai, 2005 ). These surgical efforts to treat mental disorder were considered to be ineffective and inappropriate by many in the profession at the time and were eventually discredited, although lobotomy is still used in some rare cases.
It is important to note here that although the discovery of the organic bases of mental disorders addressed the “how” behind causation, it did not, in most cases, address the “why.” This is sometimes true even today. For example, although we know what causes certain “presenile” mental disorders—brain pathology—we do not yet know why some individuals are afflicted and others are not. Nonetheless, we can predict quite accurately the courses of these disorders. This ability is due not only to a greater understanding of the organic factors involved but also, in large part, to the work of a follower of Griesinger, Emil Kraepelin.
The Development of a Classification System
Emil Kraepelin (1856–1926), another German psychiatrist, played a dominant role in the early development of the biological viewpoint. His textbook Compendium der Psychiatrie, published in 1883, not only emphasized the importance of brain pathology in mental disorders but also made several related contributions that helped establish this viewpoint. The most important of these contributions was his system of classification of mental disorders, which became the forerunner of today’s DSM classification (see Chapter 1 ). Kraepelin noted that certain symptom patterns occurred together regularly enough to be regarded as specific types of mental disease. He then proceeded to describe and clarify these types of mental disorders, working out a scheme of classification that is the basis of our present system. Integrating all of the clinical material underlying this classification was a Herculean task and represented a major contribution to the field of psychopathology.
Emil Kraepelin (1856–1926) was a German psychiatrist who developed an early synthesis and classification system of the hundreds of mental disorders by grouping diseases together based on common patterns of symptoms. Kraepelin also demonstrated that mental disorders showed specific patterns in the genetics, course, and outcome of disorders.
Kraepelin saw each type of mental disorder as distinct from the others and thought that the course of each was as predetermined and predictable as the course of measles. Thus the outcome of a given type of disorder could presumably be predicted even if it could not yet be controlled. Such claims led to widespread interest in the accurate description and classification of mental disorders.
Development of the Psychological Basis of Mental Disorder
Despite the emphasis on biological research, understanding of the psychological factors in mental disorders was progressing as well. The first major steps were taken by Sigmund Freud (1856–1939), the most frequently cited psychological theorist of the twentieth century (Street, 1994 ). During five decades of observation, treatment, and writing, Freud developed a comprehensive theory of psychopathology that emphasized the inner dynamics of unconscious motives (often referred to as psycho-dynamics) that are at the heart of the psychoanalytic perspective . The methods he used to study and treat patients came to be called psychoanalysis . We can trace the ancestral roots of psychoanalysis to a somewhat unexpected place—the study of hypnosis, especially in its relation to hysteria (for a contemporary discussion of hysteria see Brown, 2006 ). Hypnosis, an induced state of relaxation in which a person is highly open to suggestion, first came into widespread use in late-eighteenth- and early-nineteenth-century France.
developments in RESEARCH: The Search for Medications to Cure Mental Disorders
For centuries physicians have sought a medicinal cure for mental disorder. One of the earliest known treatises on the use of drugs to treat mental disorders is the work of the Roman physician Galen (A.D. 130–200). His writing details both the concoction of various medications and the clinical use of drug therapy with patients experiencing mental disorders. Most of his medications were laxatives and emetics (purgatives) that were used to cleanse the body of nonhuman materials believed to be causing the person’s ills. During the Middle Ages, another notable but highly controversial physician-chemist named Paracelsus (1490–1541) experimented with various chemicals as medications to treat human disorders. He even used a substance referred to as “mummy powder” (ground up particles of mummies) and various other, seemingly more potent substances such as mercury.
A more recent phase in the development of psychotropic medicine began in the 1950s. The root Rauwolfia serpentina had been used for centuries as an herbal folk medicine in India, where it had been prescribed for a wide array of afflictions, including insanity. In the early 1950s the active ingredient in Rauwolfia, reserpine, was isolated by a Swiss drug company, and in 1953 psychiatrist R. A. Hakim wrote a prize-winning paper on using Rauwolfia to treat psychosis (as cited in Gupta et al., 1943 ). Today reserpine has been surpassed as a treatment for psychoses because of the development of other drugs and because of its side effects, and it is mostly used in the treatment of hypertension.
The second psychoactive drug to emerge in the 1950s as a treatment for severe mental disorder was chlorpromazine. A German chemist named Bernthesen, searching for compounds that would operate as dyes, first developed the drug in the latter part of the nineteenth century. He synthesized a compound that is referred to as phenothiazine. Paul Erlich, a medical researcher and father of the field of chemotherapy, thought that this compound might be effective in treating human diseases by killing nonhuman cells while preserving human tissue. The drug was first tried as a means of treating malaria, and by the 1930s it was being employed as an anesthetic. In 1951, the French surgeon Henri Labroit employed the drug as an “artificial hibernator” to prevent shock among surgical patients. It was not until 1952 that two French psychiatrists, Jean Delay and Pierre Deniker, finding that the drug reduced psychotic symptoms, began to use chlorpromazine to treat psychiatric patients.
The almost magical impact of antipsychotic medication was immediately felt in the psychiatric community in the United States. By 1956, the first year of widespread use of reserpine and chlorpromazine, the impact on psychiatric hospitalization had begun to show a remarkable effect. The previously increasing admission rate to psychiatric hospitals leveled off at 560,000 psychiatric inpatients in the United States. This number dropped to 490,000 by 1964 and to 300,000 by 1971. Currier ( 2000 ) reported that the number of inpatient psychiatric beds decreased sharply over the past generation, both in absolute numbers and as a percentage of total hospital beds in seven countries including the United States. The drop in available hospital beds between and 1960 and 1994 was from 4 per thousand to less than 1.3 per thousand of the population. In the United States, the available bed reductions were fostered by the movement for deinstitutionalization and the development of managed care. In Europe and other regions, the number of beds decreased largely as a result of intense government pressure to curtail health care budgets. Interestingly, the need for psychiatric inpatient care has remained despite the closing of public mental health hospitals. Hutchins and colleagues ( 2011 ) point out that the number of private mental hospitals doubled between 1976 and 1992 and that two-thirds of all psychiatric hospitals and half of all inpatient beds were in private facilities.
The effectiveness of drugs in reducing psychotic symptoms has also led researchers to develop more specific causal hypotheses for mental disorders such as schizophrenia. Researchers have noted that antipsychotic drugs such as the phenothiazines modify the levels of dopamine, a neurotransmitter associated with schizophrenia. These observations have led theoreticians to the “dopamine hypothesis”—that the metabolism of dopamine is associated with the cause of schizophrenia.
Our efforts to understand psychological causation of mental disorder start with Franz Anton Mesmer (1734–1815), an Austrian physician who further developed the ideas of Paracelsus (the influential sixteenth-century physician and scholar; see Developments in Research above) about the influence of the planets on the human body. Mesmer believed that the planets affected a universal magnetic fluid in the body, the distribution of which determined health or disease. In attempting to find cures for mental disorders, Mesmer concluded that all people possessed magnetic forces that could be used to influence the distribution of the magnetic fluid in other people, thus effecting cures.
Mesmer attempted to put his views into practice in Vienna and various other cities, but it was in Paris in 1778 that he gained a broad following. There, he opened a clinic in which he treated all kinds of diseases by using “animal magnetism.” In a dark room, patients were seated around a tub containing various chemicals, and iron rods protruding from the tub were applied to the affected areas of the patients’ bodies. Accompanied by music, Mesmer appeared in a lilac robe, passing from one patient to another and touching each one with his hands or his wand. By this means, Mesmer was reportedly able to remove hysterical anesthesias and paralyses. He also demonstrated most of the phenomena later connected with the use of hypnosis.
Mesmer believed that the distribution of magnetic fluid in the body was responsible for determining health or disease. He further thought that all people possessed magnetic forces that could be used to influence the distribution of fluid in others, thus effecting cures. In this painting of his therapy, Mesmer stands on the far right, holding a wand. He was eventually branded a fraud by his colleagues. His theories did, however, demonstrate most of the phenomena later connected with the use of hypnosis.
Mesmer was eventually branded a charlatan by his medical colleagues and an appointed body of noted scholars that included the American scientist Benjamin Franklin (Van Doren, 1938 ). The committee conducted what have been referred to as the first psychological experiments (Dingfelder, 2010 ), or tests such as tricking a woman into believing that she had been influenced by magnetism. The committee concluded that the real source of Mesmer’s power was in the patients and not in “magnetism.” Mesmer was forced to leave Paris and quickly faded into obscurity. His methods and results, however, were at the center of scientific controversy for many years—in fact, mesmerism , as his technique came to be known, was as much a source of heated discussion in the early nineteenth century as psychoanalysis became in the early twentieth century. This discussion led to renewed interest in hypnosis itself as an explanation of the “cures” that took place.
Even after mesmerism was discredited in France, this method of inducing trance and its perceived potential for treating illness had a long life in the United States. The magical powers of mesmerism were introduced in 1836 and intrigued a number of Americans, ranging from the poet Emerson to the physician Benjamin Rush, with speculations about its higher mental powers and its potential application as an anesthetic for surgical procedures (Schmit, 2005 ). A number of lecturers traveled the United States illustrating its medical use and giving demonstrations, including to the U.S. Congress. The early mesmerists, though considered to be “quacks” by many physicians, had an influence on medical practice until the introduction of ether as a surgical anesthetic (Schmit, 2005 ). In spite of its limitations, mesmerism clearly had an influence on psychology and hypnosis for many years and came to be influential in spiritual movements such as Christian Science in the nineteenth century.
THE NANCY SCHOOL
Ambrose August Liébeault (1823–1904), a French physician who practiced in the town of Nancy, used hypnosis successfully in his practice. Also in Nancy at the time was a professor of medicine, Hippolyte Bernheim (1840–1919), who became interested in the relationship between hysteria and hypnosis. His interest was piqued by Liébeault’s success in using hypnosis to cure a patient whom Bernheim had been treating unsuccessfully by more conventional methods for 4 years (Selling, 1943 ). Bernheim and Liébeault worked together to develop the hypothesis that hypnotism and hysteria were related and that both were due to suggestion (Brown & Menninger, 1940 ). Their hypothesis was based on two lines of evidence: (1) The phenomena observed in hysteria—such as paralysis of an arm, inability to hear, and anesthetic areas in which an individual could be stuck with a pin without feeling pain (all of which occurred when there was apparently nothing organically wrong)—could be produced in normal subjects by means of hypnosis. (2) The same symptoms also could be removed by means of hypnosis. Thus it seemed likely that hysteria was a sort of self-hypnosis. The physicians who accepted this view ultimately came to be known as the Nancy School .
Meanwhile, Jean Charcot (1825–1893), who was head of the Salpêtrière Hospital in Paris and the leading neurologist of his time, had been experimenting with some of the phenomena described by the mesmerists. As a result of his research, Charcot disagreed with the findings of the Nancy School and insisted that degenerative brain changes led to hysteria. In this, Charcot was eventually proved