Introduction
People are social creatures who learn how to behave appropriately in families and in communities. What is considered appropriate, however, depends on a host of factors, including historical period, culture, geography, and religion. Thus, what is valued and respected changes over time, as do sociocultural perceptions of aberrant or deviant behavior. How deviancy is treated depends a great deal on the extent of the deviancy—is the person dangerous, a threat to self or to the community, in flagrant opposition to community norms, or is the person just a little odd? How the community responds also depends on its beliefs as to what causes aberrant behavior. Supernatural beliefs in demons, spirits, and magic were common in preliterate societies; in the medieval Western world, Christians believed that the devil was in possession of deranged souls. Hence, the mad were subjected to cruel treatments justified by the idea of routing out demons or the devil. For centuries, the prevailing explanation for madness was demonic possession.
Prior to the nineteenth century, families and communities cared for the mad. If they were unmanageable or violent, the mad were incarcerated in houses of correction or dungeons, where they were manacled or put into straitjackets. If a physician ever attended someone who was deemed mad by the community, it was to purge or bleed the patient to redress a supposed humoral imbalance. Most medical explanations before the advent of scientific medicine were expressed in terms of the four humors: black and yellow bile, blood, and phlegm. Imbalances usually were treated with laxatives, purgatives, astringents, emetics, and bleeding. In the late eighteenth century, however, understanding moved from the holistic and humoral to the anatomical, chemical, and physiological. Views of humans and their rights also changed enormously around this time as a consequence of the American and French Revolutions.
During the nineteenth and twentieth centuries, madhouses were first replaced by more progressive lunatic asylums and then by mental hospitals and community mental health centers. In parallel fashion, custodians and superintendents of madhouses became mad-doctors or alienists in the nineteenth century and psychiatrists, psychologists, and counselors of various kinds in the twentieth century. Similarly, the language changed: Madness was variously called lunacy, insanity, derangement, or alienation. The contemporary term is mental disorder. These changes reflect the rejection of supernatural and humoral explanations of madness in favor of a disease model with varying emphases on organic or psychic causes.
Early Views of Madness
One of the terrible consequences of the belief in supernatural possession by demons was the inhumane treatment in which it often resulted. An example is found in the book of Leviticus in the Bible, which many scholars believe is a compilation of laws that had been handed down orally in the Jewish community for as long as a thousand years until they were written down, perhaps about 700 b.c.e. Leviticus 20:27, in the King James version, reads, “A man or a woman that hath a familiar spirit . . . shall surely be put to death: they shall stone him with stones.” The term “familiar spirit” suggests demonic possession, and death was the response for dealing with demons in their midst.
There were exceptions to the possession theory and the inhumane treatment to which it often led. Hippocrates, who lived around 300 b.c.e. in Greece and who is regarded as the father of medicine, believed that mental illness had biological causes and could be explained by human reason through empirical study. Although Hippocrates found no cure, he did recommend that the mentally ill be treated humanely, as other ill people would be treated.
The period of Western history that is sometimes known as the Dark Ages was particularly dark for the mad. Folk belief, theology, and occult beliefs and practices of all kinds often led to terrible treatment. Although some educated and thoughtful people, even in that period, held humane views, they were in the minority regarding madness.
Eighteenth and Nineteenth Century Views
It was not until what could be considered the modern historical period, the end of the eighteenth century, that major changes took place in the treatment of the insane. Additionally, there was a change in attitudes toward the insane, in approaches to their treatment, and in beliefs regarding the causes of their strange behaviors. One of the pioneers of this new attitude was the French physician Philippe Pinel
. Pinel was appointed physician-in-chief of the Bicêtre Hospital in Paris in 1792. The Bicêtre was one of a number of “asylums” that had developed in Europe and in Latin America over several hundred years to house the insane. Often started with the best of intentions, most of the asylums became hellish places of incarceration.
In the Bicêtre, patients were often chained to the walls of their cells and lacked even the most elementary amenities. Under Pinel’s guidance, the patients were freed from their confinement—popular myth has Pinel removing the patients’ shackles personally, risking death if he should prove to be wrong about the necessity for confinement, but in fact it was Pinel’s assistant Jean Baptiste Pussin who performed the act. Pinel also discarded the former treatment plan of bleeding, purging, and blistering in favor of a new model that emphasized talking to patients and addressing underlying personal and societal causes for their problems, using medical treatments such as opiates only as a last resort. Talking to his patients about their symptoms and keeping careful notes of what they said allowed Pinel to make advances in the classification of mental illnesses as well.
This change was occurring in other places at about the same time. After the death of a Quaker in Britain’s York Asylum, the local Quaker community founded the York Retreat, where neither chains nor corporal punishment were allowed. In America, Benjamin Rush, a founder of the American Psychiatric Association, applied his version of moral treatment, which was not entirely humane as it involved physical restraints and fear as therapeutic agents. Toward the middle of the nineteenth century, American crusader Dorothea Dix
fought for the establishment of state mental hospitals for the insane. Under the influence of Dix, thirty-two states established at least one mental hospital. Dix had been influenced by the moral model, as well as by the medical sciences, which were rapidly developing in the nineteenth century. Unfortunately, the state mental hospital often lost its character as a “retreat” for the insane.
The nineteenth century was the first time in Western history that a large number of scientists turned their attention to abnormal behavior. For example, the German psychiatrist Emil Kraepelin spent much of his life trying to develop a scientific classification system for psychopathology. Sigmund Freud attempted to develop a science of mental illness. Although many of Freud’s ideas have not withstood empirical investigation, perhaps his greatest contribution was his insistence that scientific principles apply to mental illness. He believed that abnormal behavior is not caused by supernatural forces and does not arise in a chaotic, random way, but that it can be understood as serving some psychological purpose.
Modern Medicines
Many of the medical and biological treatments for mental illness in the first half of the twentieth century were frantic attempts to deal with very serious problems—attempts made by clinicians who had few effective therapies to use. The attempt to produce convulsions (which often did seem to make people “better,” at least temporarily) was popular for a decade or two. One example was insulin shock therapy, in which convulsions were induced in mentally ill people by insulin injection. Electroshock therapy was also used. Originally it was primarily used with patients who had schizophrenia, a severe form of psychosis. Although it was not very effective with schizophrenia, it was found to be useful with patients who had depressive psychosis. Now known as electroconvulsive therapy, it continues to be used in cases of major depression or bipolar disorder which are resistant to all other treatments. Another treatment sometimes used, beginning in the 1930’s, was prefrontal lobotomy. Many professionals today would point out that the use of lobotomy indicates the almost desperate search for an effective treatment for the most aggressive or the most difficult psychotic patients. As originally used, lobotomy was an imprecise slashing of the frontal lobe of the brain.
The real medical breakthrough in the treatment of psychotic patients was associated with the use of certain drugs from a chemical family known as phenothiazines. Originally used in France as a tranquilizer for surgery patients, their potent calming effect attracted the interest of psychiatrists and other mental health workers. One drug of this group, chlorpromazine, was found to reduce or eliminate psychotic symptoms in many patients. This and similar medications came to be referred to as antipsychotic drugs. Although their mechanism of action is still not completely understood, there is no doubt that they worked wonders for many severely ill patients while causing severe side effects for others. The drugs allowed patients to function outside the hospital and often to lead normal lives. They enabled many patients to benefit from psychotherapy. The approval of the use of chlorpromazine as an antipsychotic drug in the United States in 1955 revolutionized the treatment of many mental patients. Individuals who, prior to 1955, might have spent much of their lives in a hospital could now control their illness effectively enough to live in the community, work at a job, attend school, and be a functioning member of a family.
In 1955, the United States had approximately 559,000 patients in state mental hospitals; seventeen years later, in 1972, the population of the state mental hospitals had decreased almost by half, to approximately 276,000. Although all of this cannot be attributed to the advent of the psychoactive drugs, they undoubtedly played a major role. The phenothiazines had finally given medicine a real tool in the battle with psychosis. One might believe that the antipsychotic drugs, combined with a contemporary version of the moral treatment, would enable society to eliminate mental illness as a major human problem. Unfortunately, good intentions go awry. The “major tranquilizers” can easily become chemical straitjackets; those who prescribe the drugs are sometimes minimally involved with future treatment. In the late 1970s, the makers of social policy saw what appeared to be the economic benefits of reducing the role of the mental hospital, by discharging patients and closing some mental hospitals. However, they did not foresee that large numbers of homeless psychotics would live in the streets as a consequence of deinstitutionalization. The plight of the homeless during the early part of the twenty-first century continues to be a serious, national problem in the United States.
Disorder and Dysfunction
The twentieth century saw the exploration of many avenues in the treatment of mental disorders. Treatments ranging from classical psychoanalysis to cognitive and humanistic therapies to the use of therapeutic drugs were applied. Psychologists examined the effects of mental disorders on many aspects of life, including cognition and personality. These disorders affect the most essential of human functions, including cognition, which has to do with the way in which the mind thinks and makes decisions. Cognition does not work in “ordinary” ways in the person with a serious mental illness, making his or her behavior very difficult for family, friends, and others to understand. Another aspect of cognition is perception. Perception has to do with the way that the mind, or brain, interprets and understands the information that comes to a person through the senses. There is a general consensus among most human beings about what they see and hear, and perhaps to a lesser extent about what they touch, taste, and smell. The victim of mental illness, however, often perceives the world in a much different way. This person may see objects or events that no one else sees, phenomena called hallucinations. The hallucinations may be visual—for example, the person may see a frightening wild animal that no one else sees—or the person may hear a voice accusing him or her of terrible crimes or behaviors that no one else hears.
A different kind of cognitive disorder is delusions. Delusions are untrue and often strange ideas, usually growing out of psychological needs or problems of a person who may have only tenuous contact with reality. A woman, for example, may believe that other employees are plotting to harm her in some way when, in fact, they are merely telling innocuous stories around the water cooler. Sometimes people with mental illness will be disoriented, which means that they do not know where they are in time (what year, what season, or what time of day) or in space (where they live, where they are at the present moment, or where they are going).
In addition to experiencing cognitive dysfunction that creates havoc, mentally ill persons may have emotional problems that go beyond the ordinary. For example, they may live on such an emotional “high” for weeks or months at a time that their behavior is exhausting both to themselves and to those around them. They may exhibit bizarre behavior; for example, they may talk about giving away vast amounts of money (which they do not have), or they may go without sleep for days until they drop from exhaustion. This emotional “excitement” seems to dominate their lives and is called mania. The word “maniac” comes from this terrible emotional extreme.
At the other end of the emotional spectrum is clinical depression. This does not refer to the ordinary “blues” of daily life, with all its ups and downs, but to an emotional emptiness in which the individual seems to have lost all emotional energy. The individual often seems completely apathetic. The person may feel life is not life worth living and may have anhedonia, which refers to an inability to experience pleasure of almost any kind.
Treatment Approaches
Anyone interacting with a person suffering from severe mental disorders comes to think of him or her as being different from normal human beings. The behavior of those with mental illness is regarded, with some justification, as bizarre and unpredictable. They are often labeled with a term that sets them apart, such as “crazy” or “mad.” There are many words in the English language that have been, or are, used to describe these persons—many of them quite cruel and derogatory. Since the nineteenth century, professionals have used the term “psychotic” to denote severe mental illness or disorder. Interestingly, one translation of psychotic is “of a sickness of the soul” and reflects the earlier belief regarding the etiology, or cause, of mental illness. This belief is still held by some therapists and pastoral counselors in the twenty-first century. Until the end of the twentieth century, the term “neurosis” connoted more moderate dysfunction than the term “psychosis.” However, whether neurosis is always less disabling or disturbing than psychosis has been an open question. An attempt was made to deal with this dilemma in 1980, when the DSM-III officially dropped the term “neurosis” from the diagnostic terms.
The contemporary approach to mental disorder, at its best, offers hope and healing to patients and their families. However, much about the etiology of mental disorder remains unknown to social scientists and physicians.
In 1963, President John F. Kennedy signed the Community Mental Health Act. Its goal was to set up centers throughout the United States offering services to mentally and emotionally disturbed citizens and their families, incorporating the best that had been learned and that would be learned from science and from medicine. Outpatient services in the community, emergency services, “partial” hospitalizations (adult day care), consultation, education, and research were among the programs supported by the act. Although imperfect, it nevertheless demonstrated how far science had come from the days when witches were burned at the stake and the possessed were stoned to death.
When one deals with mental disorder, one is dealing with human behavior—both the behavior of the individual identified as having the problem and the behavior of the community.
The response of the community is critical for the successful treatment of disorder. For example, David L. Rosenhan, in a well-known 1973 study titled “On Being Sane in Insane Places,” showed how easy it is to be labeled “crazy” and how difficult it is to get rid of the label. He demonstrated how one’s behavior is interpreted and understood on the basis of the labels that have been applied. (The “pseudopatients” in the study had been admitted to a mental hospital and given a diagnosis—a label—of schizophrenia. Consequently, even their writing of notes in a notebook was regarded as evidence of their illness.) To understand mental disorder is not merely to understand personal dysfunction or distress, but also to understand social and cultural biases of the community, from the family to the federal government. The prognosis for eventual mental and emotional health depends not only on appropriate therapy but also on the reasonable and humane response of the relevant communities.
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