Christian Guide To Mental Illness Vol 2 eBook: Helping Christians Obtain Treatment for Mental Illness

By Stephen M Saunders

How many people suffer from mental illness?Did you know that one in five people, including Christians, will suffer from a mental illness in any given year? This shocking statistic means that many churches will have families who are affected by and struggling with mental illness.This second entry in a two-volume set about mental illness by Dr. Stephen Saunders will help you respond to these difficult circumstances and directing Christian brothers and sisters to the care and support they need, while also reminding them of their Savior' s love.A Christian Guide to Mental Illness, Volume 2 details how core ideas about mental illnesses and their treatments have changed over time. The book also offers guidance to pastors and church workers who wish to provide practical assistance to the people they serve.You will learn how to begin the vitally important conversation on mental illness, prepare for crisis management, recognize the need for professional treatment, assist loved ones, and share with everyone impacted by mental illness the spiritual comfort that only comes from God' s Word.As he did in Volume 1, Dr. Saunders demonstrates in this book a thorough understanding of essential Christian teachings. Both church leaders and church members will find assistance and encouragement in this book as they reach out to family and friends affected by mental illness.

• Language: English
• Publisher: Northwestern Publishing House
• Release date: Jul 1, 2019
• ISBN: 9780810029224

Book preview

ONE

A REVIEW OF THE HISTORICAL CONCEPTUALIZATIONS AND TREATMENTS OF MENTAL ILLNESSES

Preview of Part 1

Part 1 of this volume covers the history of the treatment of mental illness. It includes a historical perspective on the ways mental illness was treated before the development of the scientific method, as well as a review of the current state of scientific research into mental illness. It includes reviews of the history of psychiatry, psychology, and social work.

Chapter 1 covers ideas about and treatments for mental illness from antiquity through the advent of the scientific revolution.

Chapter 2 reviews the major issues related to present-day scientific inquiry that have developed since the Renaissance. The three objectives of science—description, uncovering association, and investigating whether associations are due to a causal relationship—are reviewed, as are the notions of objectivity and reliability.

Chapter 3 tells the story of psychiatry from the late 19th century to the present, showing how things changed dramatically with the idea that mental illness, like all other illnesses, must be a biological problem. Then they changed again to accommodate Freud’s ideas and then again to the modern, concentrated focus on biological causes.

Chapter 4 tells the history of psychology and social work. It shows that psychology was founded for the study of human behavior and only later applied to helping those with mental illness, whereas social work was founded to help those in need, eventually including persons with mental health issues.

Chapter 5 reviews the scientific methods—introduced in chapter 2—used to study the cause and treatment of mental illness, including examples of how science has led to the end of inappropriate and ineffective treatments.

Chapter 1

Historical Conceptualizations and Treatments of Mental Illness

David … was very much afraid of Achish king of Gath. So he pretended to be insane in their presence; and while he was in their hands he acted like a madman, making marks on the doors of the gate and letting saliva run down his beard. Achish said to his servants, Look at the man! He is insane! Why bring him to me? Am I so short of madmen that you have to bring this fellow here to carry on like this in front of me? Must this man come into my house?

(1 Samuel 21:12-15)

Explanations for the cause of mental illness have changed tremendously over the centuries, but the supposed cause of mental illness has always inexorably led to the attempted treatment. As a result, the treatment of mental illness over the course of history has ranged from the cruel and sometimes savage to the kind, humane, and occasionally effective.

This chapter briefly reviews mental illness and treatment for it throughout history. The important role of the church in promoting and providing a compassionate attitude towards persons with mental illness is discussed, as are the parallels between Europe and the United States with regard to attitudes and treatment. The chapter ends with the Enlightenment. The contribution of science to understanding the causes and proper treatment of mental illness is covered in chapters 2 and 5.

Mental Illness in Antiquity

Explanations of mental illness were not consistent across either time or place. In antiquity, at various times and in different places at the same time, the abnormal behavior of persons with mental illness was attributed to supernatural influences, to biological causes, or to a combination of the two. Only seldom was mental illness attributed to psychological or environmental causes.

Prehistoric Societies and Demonology

In many prehistoric societies, demonology predominated explanations of frightening events, such as droughts, floods, earthquakes, and famine. Medical and mental illnesses were often attributed to witchcraft, sorcery, demonic possession, or the vengeance of an offended deity or spirit. Persons displaying a persistent negative mood, strange thinking, or bizarre behavior may have been thought to be willingly collaborating with an evil spirit or unwillingly afflicted because they did something warranting punishment.

Trephination and exorcism were sometimes attempted to eliminate troublesome spirits. Trephination involved sawing a hole into the person’s skull to allow the trapped evil spirit to escape. Skulls with holes in them and tools for creating those holes have been found worldwide, including in Europe, New Zealand, and both North and South America. Some of these skulls had multiple holes, meaning some people endured the procedure more than once. Exorcism was practiced by the early Greeks, Chinese, Hebrews, and Egyptians. It usually included prayer, sprinkling with holy water, loud noises, starvation, beatings, and other efforts to make the body uninhabitable to the evil spirit.

Greece and Rome: Those whom the gods would destroy …

Greek and Roman myths show familiarity with mental illness. Hyginus (64 B.C.–A.D. 17) wrote that Odysseus, the legendary Greek hero, wanted to avoid the Trojan War, a war that would separate him from his wife and newborn son for a long time. When Palamedes reminded him of his oath to defend the marriage of Helen and Menelaus, Odysseus feigned madness by yoking both an ox and a horse to his plow. Palamedes knew enough to recognize malingering, however, and he put the infant son of Odysseus into the plow’s path. The warrior swerved the plow away from the infant, showing he was not actually mad.

Present-Day Exorcisms

In a 2003 document, Kevin Christopher of the Committee for the Scientific Investigation of Claims of the Paranormal reported that in August 2003, an 8-year-old boy with autism, Terrance Cottrell of Milwaukee, died by asphyxiation when members of his church attempted to exorcise the evil spirits they blamed for his mental illness.

The report documented four other deaths caused by exorcism prior to this incident. In California in both 1995 and 1996, adult women were beaten to death during attempts to drive out demons. In the state of New York in 1997, a five-year-old girl died after being forced to drink a homemade, lethal potion intended to poison the demon possessing her. Also in New York, in 1998, a 17-year-old girl was suffocated by her mother and her sister as they tried to kill the demon inside of her. Since the 2003 report, more recent deaths related to attempted exorcism, of both children and adults, have been documented in the United States, England, France, New Zealand, and other parts of the world.

In at least some instances, the Greeks and Romans considered mental illness to be caused by the influence of the gods. The expression Quem deus vult perdere, prius dementat translates to Those whom the gods would destroy, they first make mad and is usually attributed to Euripides (480–406 B.C.). Sophocles (497–406 B.C.) tells how Ajax became angry that Odysseus was given the armor of the dead Achilles and vowed to kill as many Greeks as he could. The goddess Athena made Ajax temporarily insane so that he killed a flock of sheep instead. (Convinced that the others were laughing at him, Ajax killed himself.) Attempts at cures corresponded to putative cause. Cures included prayers and incantations to appease the gods. Greek physicians might instruct the person to wander for a few days in the temple of Asclepius in the hopes that the god of healing, during one of his visits, would take pity and cure.

As Greek civilization flourished, scholars attempted to understand nature and its laws. While never entirely abandoning the influence of the gods, physicians gradually embraced naturalistic explanations of illness, including mental illness. Detailed next, Hippocrates proposed the idea, but Galen wrote the book. That book influenced the understanding and treatment of mental illness for the next 1,500 years.

Hysteria: Natural or Supernatural?

The illness hysteria is a good example of how the supposed cause and proposed cure were directly related. It is also an example of the way some ancient explanations did not distinguish supernatural and natural causes, since the influence of gods and demons were everyday, natural occurrences for ancient civilizations.

The Greek explanation of the female malady known as hysteria borrowed heavily from Egyptian physicians. Writings from Mesopotamia and Egypt dating back to 1900 B.C. describe females seemingly suffering from mental illness (severe anxiety) due to an unmoored and wandering uterus. Plato and others seemed to believe that the uterus was a distinct being inside women, such that it might wander and become attached to the liver or chest cavity, causing nonspecific pain and discomfort. The Greek word husterikos means of the womb. Both the Egyptians and Greeks would attempt to lure the uterus back to its proper place using strong-smelling agents.

Interestingly, while the term hysteria is no longer commonly used by them, it was regularly employed by most mental health professionals until fairly recently, largely because Freud used the term extensively. The term was almost always used in reference to female patients. Like the common parlance hysterical, the general meaning was someone who exhibited great distress immensely out of proportion to any apparent cause.

Hippocrates Humoral Theory

Greek society flourished because its scholars had a practical tendency. They recognized the advantages of basing knowledge on observations of the physical world. Physicians understood that mental activity was located in the brain after repeatedly observing that injuries to it could cause abnormal mental activity. But they lacked an explanation of mental illnesses that had no observable physical cause, including the hallucinations of schizophrenia, the mania of bipolar disorder, and most cases of anxiety and depression.

The Greek physician Hippocrates (460–370 B.C.) proposed an explanation to resolve this mystery. He asserted that all illnesses have a material cause, even if that cause is not easily observed. Based on extensive study of human anatomy, he suggested that the physical causes of mental illness are the various humors or fluids in the body. Hippocrates’ ideas dominated for hundreds of years. Medical practice to this day honors him as the founder of modern medicine by having medical school graduates recite some version of the Hippocratic oath. That said, Hippocrates was not nearly the most influential Greek physician.

Galen’s Humoral Practices

About 500 years after Hippocrates, Claudius Galenus (A.D. 131–200) started his career in Pergamon, which had a library second only to the library in Alexandria. As a surgeon to gladiators, he gained a lot of practical experience treating traumatic wounds. After transplanting to Rome, he gained renown for his rational and compassionate care, not to mention his public demonstrations of human anatomy. His patients included Roman emperors.

Galen formalized the humoral theory of Hippocrates. He concluded that an imbalance of bodily fluids caused fevers, the plague, and other maladies, including mental illness. Regarding the latter, Galen specified how the body’s four humors (blood, phlegm, yellow bile, and black bile) corresponded to personality types and emotional problems. Galen’s ideas were astonishingly influential (see box) for numerous reasons. He wrote voluminously and comprehensively, using 20 scribes to write down his every observation. Importantly, foreshadowing the scientific revolution, Galen offered proof that others could replicate. His description of the human body was highly detailed, which lent veracity and authority to his works. Finally, he was a monotheist who incorporated religious ideas into his writings. As a result, centuries later, his research gained the approval of the church.

For all of these reasons—including the fact that science was not yet mature—later physicians and scholars rarely challenged Galen’s ideas, instead usually starting their own investigations from the foundations of his work. Thus Galen dominated medical thinking and practices for the next 1,500 years. His ideas about the humoral causes of illness led to corresponding treatments, such as bloodletting to reduce the volume of blood or purgatives and emetics to rid the body of various fluids.

The Melancholic, Phlegmatic, Choleric, and Sanguine

In testament to his astonishingly enduring influence, the terms Galen devised to describe personality types are still used today.

The phlegmatic person is relatively unemotional.

The sanguine person (sanguineus is Latin for of blood) is cheerful and optimistic.

The irritable, choleric person has an excess of yellow bile (or kholera).

The melancholic person has too much black bile (or melankolia) and is pensive, gloomy, and sad.

What About Stress and the Environment?

Hippocrates, Galen, and most other physicians allowed that mental illness could be caused by stress or trauma. Hippocrates actually suggested that it may help some persons exhibiting mental illness to be separated from difficult family environments. But stress and environment as causal factors were not seen as particularly significant for the simple reason that they were not particularly salient to what most—like Achish—considered to be mental illness.

As reviewed in Volume 1, the most commonplace mental illnesses are the anxiety, depressive, and substance use disorders. Moreover, these disorders are often related to stress and trauma. However, they were not and are not what most people think of when they think of mental illness. To this day, people think about mental illness in its conspicuous and dramatic presentations, such as bizarre behavior, hallucinations, and violence toward others. These are manifestations of serious mental illness, such as schizophrenia and bipolar disorder, and these are almost always caused by neurochemical imbalances in the brain (although they are exacerbated by stress). In other words, there were no observable reasons, such as stress or trauma, for the most easily recognized mental illnesses.

It should also be appreciated that, until relatively recently, daily life was often stressful and traumatic for everyone, not just those exhibiting mental illness. Infection and disease were particularly lethal to the young and old, but no one was safe. Society was dominated by the powerful, not by the rule of law. Since most persons’ daily environments were frequently marked by fairly severe stress, any association between stress and mental illness would have been difficult to observe.

But the association between stress and mental illness was not unknown. Those with severe mental illness tended to cause chaos in their environments and were often forced to live away from their family or community, which had the effect of making life even more stressful. This led some, such as Plato (429–347 B.C.), to conclude that society had a responsibility to care for persons with mental illness. Serious efforts both to alleviate stress and, more important, to provide for the basic needs of persons with mental illness did not appear until the establishment of hospitals and asylums dedicated specifically to such persons. These were founded in large part because of the influence of the Catholic Church. Putting this into perspective requires a brief history of the end of the Roman Empire.

The Medieval Period and the Church

Sometimes called the Dark Ages, or the Middle Ages, there are three notable things about the Medieval Period: the loss of influence of Greek and Roman scholarship, the lack of a centralized government, and the ascendancy of the authority of the Catholic Church.

The Time Frame of the Medieval Period

Diocletian (A.D. 245–311) was the victor of The Crisis of the Third Century, which followed the assassination of the last emperor of the Severan dynasty (which itself emerged after a civil war). To provide stability and give himself time to conduct wars, Diocletian appointed a co-emperor who would be situated in Rome and would defer to Diocletian. This arrangement proved successful, so he did it again. In A.D. 293, Diocletian appointed two additional junior emperors. The Tetrarchy was intended to bring stability, but it did not. War arose in practically all corners of the empire, and the various emperors struggled to secure dominance over their corulers.

Since he had done extremely well as a military tribune under Diocletian, Constantine (A.D. 272–337) was appointed emperor of the western region. He emerged the victor of the war between the Tetrarchs, and he became sole ruler of a reunified empire in A.D. 324. Wanting to merge the west and east more firmly, Constantine built a second capital in Byzantium—the previous capital of the western district—which he renamed Constantinople.

The Roman Empire was once again whole, but not for long. Constantine’s sons divided the empire and ruled as co-emperors. Four decades later, Theodosius I (A.D. 347–395) reunified the empire, but one of his last acts was to split it again so that each of his sons could be an emperor.

Constantine the Great

Constantine is known as the first emperor to convert to Christianity, although that assertion has been challenged. In contrast, one can easily find arguments that Constantine claimed to be Christian only out of political expediency, that he never really became Christian but only came to see the Christians’ God as the strongest of the pantheon, or that he was not really Christian at all. In any event, it must be recognized that Constantine did a great deal to increase tolerance of Christianity. The Edict of Milan of A.D. 313 explicitly granted Christians the freedom to practice their religion without fear of persecution. (It actually granted such liberty to all persons of any religion, not just to Christians.) Constantine also called the First Council of Nicaea in A.D. 325, which resulted in, among other things, the Nicene Creed.

The final division of the Roman Empire was complete. The eastern, Hellenistic part, with its capital in Constantinople, continued to flourish. But by now, the western, Classical part had been greatly reduced in size and influence. With the empire occupying only Italy and parts of Greece, incursions by Germanic nations and the invasion of the Huns under Attila weakened it further. The end of the Western Roman Empire is usually dated A.D. 476, when its emperor abdicated to Odoacer (A.D. 433–493), the Germanic warlord. This is the date usually described as the start of the Medieval Period.

The Loss of Roman and Greek Influence and the Fracturing of Governance

At the beginning of the thousand-year Medieval Period, Europe experienced a precipitous economic and cultural decline. Historians tend to agree that the decline was related to the loss of the influence of the cultural, political, philosophical, and scientific works of Greek and Roman scholars and to the disintegration of a central power. Further evidence of this is that the Eastern Roman Empire, also known as the Byzantine Empire, continued to prosper, perhaps because its scholars preserved, translated, and studied Roman and Greek works. Using this foundational knowledge, Arabic science, medicine, and mathematics were the best in the world by the time of the 11th century.

All of this occurred during a time of inevitable civil decline that followed the disappearance of the dominant, unifying power of the Western Roman Empire. No single ruling entity or government was able to replace the control exerted by the former empire. For this and other reasons, the church became dominant.

The Emergence of the Church as a Dominant European Institution

The Roman emperors Constantine and Theodosius I greatly helped the Catholic Church emerge as a powerful institution of the Medieval Period. Emperor Constantine declared that Christians should not be persecuted, and Theodosius I declared Christianity the official religion of the empire. Eventually, religious ideas came to dominate life for both peasant and king. European monarchs and other state leaders emerged and survived because of the power granted by the alliance with Rome. Probably the penultimate example of the merging of political and religious power occurred in A.D. 800, when Pope Leo III crowned Charlemagne Emperor of the Romans, establishing what would become the Holy Roman Empire.

The Renaissance

Life for most persons in medieval Europe was ensconced in the feudal system. A king granted fiefs to noblemen and the occasional bishop, whereas serfs were given protection while working the land. In the 11th century, as farming became more efficient and productive, fewer serfs were needed to produce increasing amounts of food, and the population of cities grew rapidly. Coastal cities in particular thrived, and by 1300 there were perhaps 15 European cities with populations greater than 50,000 people. In these cities, the gradual advances in mathematics, architecture, art, science, and medicine made during the Medieval Period began to accelerate, ushering in the Renaissance.

The Resurgence of Demonology and Other Supernatural Explanations

Terrifying things continued to happen when the Medieval Period gave way to the Renaissance, including the 14th century bubonic plague, which lasted 7 years and killed between one-third to one-half of the population of Europe. Partly as a result of the decimation of the ruling classes, there was near-constant warfare, with one war lasting over 100 years. There were also recurrent peasant uprisings, which actually began during the Medieval Period, including the one that Luther condemned in his 1525 treatise entitled Against the Rioting Peasants. Given the emergence of the church as the dominant institution, there was a resurgence of demonology. A not-uncommon explanation of the many, seemingly worldwide problems was that God was punishing humanity by abandoning it to the depredations of the devil and his legions. For some, the ultimate justification for (or perhaps manifestation of) God’s wrath was the Papal Schism that lasted from 1378 to 1417, in which two different men simultaneously laid claim to the papacy.

Demonology reached its apex with the 1487 publication of Malleus Maleficarum (The Witches Hammer) by Kramer and Srenger, German Catholic clergymen. The book was published soon after a 1484 papal decree that clergy should strive to identify and exterminate witches. The recent invention of the printing press allowed it to be widely read over the next two centuries. The book described methods for identifying witches, such as finding areas of insensitivity on the body (e.g., moles) where the devil had entered the person. Some of the accused were tortured to extract confessions. Accusations were frequently leveled at women, especially unpleasant women without family.

Witchcraft and Mental Illness

Many students of psychology, including the author, were taught in psychology coursework and textbooks that witch hunts were primarily directed at persons with mental illness. This is based on the idea that the witches confessed to all sorts of impossible acts, including flying, consorting with demons, and causing droughts and plagues. Psychiatric historians reasoned that, since these confessions were clear examples of delusions, persons with severe mental illness were frequent targets of witch trials. Although it is standard and salacious fare in textbooks of psychology, the notion that the mentally ill were the primary targets of witch hunts is simply untrue.

First, confessions of witchcraft were obtained through torture and deceit. The witches did not really believe they could fly or control the weather (as may someone genuinely experiencing delusions), but rather they were coerced into saying so. In addition, not everyone believed the accusations against supposed witches. Historical analyses indicate that many were aware that the accusations were typically leveled for personal, political, and economic reasons. Finally, most explanations of mental illness were more reasoned than demonology and the supernatural, and this was especially true within the church, which contained many scholars. Most of these scholars pointed to the ideas of Galen and to factors such as diet, excess alcohol, grief, and overwork. While there was fairly universal acceptance that witches and demons existed, there were few issues for which the supernatural was the primary explanation. To the contrary, in large thanks to the church, the most common attitudes and behaviors toward those with mental illness were guided by compassion.

While it is likely that some of those unfortunate enough to be accused of witchcraft suffered from mental illness (which makes for a fascinating psychology lecture—see box), research suggests that this was not usually the case. With the church’s teachings about God’s universal love, persons with mental illness were usually viewed as unfortunate and were usually, although not always, treated with kindness.

A Humanitarian Attitude Bolstered by the Christian Church

For all of history, most families have tried to take care of persons with mental illness, although their capacity to do so varied. Ideally, the person with mental illness was kept on the homestead and looked after by relatives or by a hired caregiver. When safety or disorderly behavior was of concern, the person may have been kept in some type of confinement. In instances of extreme poverty or of unmanageable behavior, affected persons may have been forced out of the home and even the community. But in most instances, individuals were offered compassionate care, especially as Christian teachings took root.

The church preached charity toward the unfortunate, including those with mental illness. In Our Lord’s Sermon on the Mount, According to Matthew, St. Augustine wrote about the compassion of those who minister to insane persons, at whose hands they often endure many things; and if their welfare demand it, they even show themselves ready to endure more.

The church did not just preach charity. It marshaled its resources to provide what families and communities could not. During the Medieval Period, Catholic monasteries were established throughout Europe, and they became essential to the provision of shelter, food, and protection to the needy. Over time, the church also took on the responsibility of medical care to the sick, opening hospitals in association with monasteries.

The Creation of Asylums for the Mentally Ill

At first, in both Byzantium (where hospitals had existed since the third century) and Europe, persons with mental illness were cared for alongside medical patients in hospitals. But it soon became evident that places specifically for the care of persons with mental illness were needed (see box). Unlike the medically ill, those with mental illness were not typically bedridden, weak, and helpless. Also, whereas the medically ill would usually and rather quickly either recover or die, those with mental illness did neither. Instead, they needed to be looked after for a long period of time, perhaps the remainder of their lifetime.

Father Jofré and the Establishment of an Asylum

After coming across a crowd harassing a madman in his city of Valencia, Spain, Father Juan Galiberto Jofré (1350–1417) became incensed. The following Sunday, he gave this sermon:

In this city, there are many and very important pious and charitable initiatives. However, one very necessary one is lacking, that is, a hospital or house where the innocent and frenzied would be drawn together because many poor, innocent, and frenzied people wander through this city. They suffer great hardships of hunger and cold and harm, because due to their innocence and rage, they do not know how to earn their living nor ask for the maintenance they need for their living. Therefore, they sleep in the streets and die from hunger and cold and many evil persons, who do not have God in their conscience, hurt them. … Thus, it would be a very holy thing and work for Valencia to build a hostel or hospital where such insane or innocent persons could be housed so that they would not be wandering through the city and could not hurt nor be hurt.

Wealthy donors in the city responded to this chastisement by establishing the Hospital de Nuestra Doña Santa Maria de los Inocentes in 1409.

In fact, Spain is often credited with doing more for the care of persons with mental illness than any other European country. Early on, Spain had asylums in Saragossa, Seville, Toledo, and Granada. Moreover, the treatment of the patients at these asylums was so humane and careful that it inspired Pinel, the now famous French reformer of asylums (see below), to declare Spain the country in which lunatics were treated with the most wisdom.

Some have attributed Spain’s kind attitude and treatment to the influence of Islam. But this idea, and the more general idea that Islamic countries had singularly benevolent attitudes towards mental illness, has little empirical or historical foundation.

The notion of a special place of refuge (asylum) for these poor souls had already existed in parts of the world. Fourth-century Constantinople had a morotrophium for persons with mental illness among its dozens of charitable institutions, and there are records of asylums in fifth-century Jerusalem. But Europe had few formal asylums until the 17th and 18th centuries, when so many were created that historians nickname that period the era of asylums. In England alone during this period, the patient population of asylums increased tenfold.

The Era of Asylums (and Their Inevitable Failure)

Asylums for persons with mental illness were usually created with the best of intentions, but not always. Mad houses were lucrative enterprises. Those not run by the church were privately operated and competed with one another. In either case, they were doomed to fail their purpose. The prevalence and nature of serious mental illness guaranteed it.

Through the Renaissance and into the Enlightenment, the population of cities in Europe exploded and, inevitably, so did the number of persons with severe mental illness (which helps explain why so many asylums were built during the era of asylums). But no matter how many were built, asylums inevitably had more residents than could possibly be managed benevolently.

Asylums reflected the current knowledge about mental illness, and that knowledge was woefully inaccurate. Galen’s theory of humors was all that they had, and treatment followed accordingly. Purging through emetics and bloodletting were common treatments. Other treatments were based on the idea that excess movement contributed to the imbalance of humors, which justified restraining patients in chairs, beds, and boxes (see box on the persistence of cruel treatments).

Since there was little expectation that treatment would lead to improvement, merely keeping mentally ill persons safe was deemed a worthy and worthwhile service. In other words, asylums soon offered mere custody, not treatment. The asylum workers chained the most troublesome patients to beds, chairs, and walls, or locked them in cells. The invention of the straitjacket enabled the workers to assure themselves that the patient was at least able to walk about, even though the agony caused by the device would have been apparent. There was a self-serving notion that persons with mental illness did not experience pain, basic needs, or even shame, so they were allowed to live in deplorable conditions without adequate sanitation, food, or the basic dignity of real clothing. This unfortunate state was compounded by the fact that asylums tended to be staffed by untrained and unqualified people. Since cure was impossible, training and qualifications were unnecessary.

Visiting Bedlam of London

The Royal Hospital at Bethlem in London was originally established in 1247 as a place for a religious group called the Order of the Star of Bethlehem. It became a hospital in 1337 and began to admit mentally ill persons in 1357. In 1547, as part of his Dissolution (or Suppression) of the Monasteries, King Henry VIII gave the Royal Hospital to the city of London for the exclusive treatment of mentally ill persons, making it an asylum.

There were a great number of people who needed care for serious mental illness in London, and their need was intense. Soon, the hospital deteriorated due to overcrowding, inadequate staff, ineffective treatments, and insufficient public funding. To support itself, the hospital became a tourist attraction. Londoners and visitors to the city would pay to tour the asylum to see the poor creatures, inoffensive madmen, and even dangerous maniacs, most of them being chained and terrible to behold (letter from Saussure, 1725). The price of admission was one penny.

The local pronunciation of Bethlem was Bedlam, and we still use the word to indicate a scene of uproar and confusion.

The Age of the Enlightenment

The Enlightenment, or the Age of Reason, was characterized by dramatic changes in science, philosophy, and politics. The changes can be summarized as trust in the legitimacy of human reason. Thus Kant (1724–1804) defined enlightenment in his 1784 treatise as liberation from immaturity or the inability to use one’s own understanding without the guidance of another.

New Philosophies and Scientific Advancement

New ideas in philosophy took shape during the Renaissance and continued apace during the Enlightenment. Philosophy distinguished itself from theology behind the theories and principles of Voltaire, Hume, Kant, and others. Philosophical ideas began to influence politics and society. For example, John Locke (1632–1704) suggested that it was acceptable to replace a monarch who would not protect the rights of his citizens, and Jean-Jacques Rousseau (1712–1778) argued that government should rule according to the general will of the people. (These and other ideas greatly influenced the founding fathers of the United States.) In the same way that philosophy grew distinct from theology, science began to distinguish itself from philosophy. Understanding and treating persons with mental illness benefited from both science and philosophy, but, at least at first, much more from the latter. The new humanitarian philosophy inspired moral treatment, which transformed—for a while—the fate of persons consigned to asylums.

Moral Treatment

Philippe Pinel (1745–1826) moved to Paris in 1778 in hopes of establishing a medical practice, but the established physicians rejected his training as insufficient and he was forced to find work, temporarily, as a scientist and writer. He became interested in mental illness after the suicide of a close friend. In 1793, he was appointed director of Bicêtre Hospital, a locked facility that housed mostly convicted criminals but also numerous patients deemed incurable. This included several hundred male patients, the so-called maniacs of Bicêtre. As at other asylums, many of these patients were chained to walls or tied to their beds or chairs.

Pinel implemented the ideals of the Enlightenment at the hospital. He removed the shackles and ordered that patients be allowed, and even encouraged, to exercise outside. Patients were moved to clean, sunny rooms. To the amazement of his staff, Pinel visited patients in their rooms simply to talk. He repeatedly heard them relate how much they missed their families and their livelihoods. He later wrote of the moral qualities of maniacs, saying that he had never before met—except in romances novels—with fonder husbands, more affectionate parents. He saw that treating patients with respect and dignity did much to help them recover qualities of normalcy and decency.

Two years later, Pinel took over a larger hospital that housed both male and female patients. Pinel again found that the manner in which patients with mental illness were approached mattered a great deal. Taking a kind, humane, and respectful attitude toward them and encouraging activities such as reading, walking, gardening, or playing music were beneficial to all patients to some extent. The improvement was so great that some patients were able to return home, an outcome of asylum care that was virtually unprecedented.

William Tuke, the York Retreat, and Moral Therapy in England

William Tuke (1732–1822) was an English-born American businessman and Quaker. When a fellow Quaker (Friend) died six weeks after being confined to York Lunatic Asylum, Tuke and other Friends investigated and were horrified by the conditions there, which were the same conditions found in nearly all asylums. Tuke led the effort to develop a more humane alternative. He became the first director of the York Retreat, which opened in 1796 in the quiet countryside outside of York. The Retreat implemented what later became known as moral treatment, emphasizing self-control, reintroducing patients to normal socialization opportunities, providing good nutrition and opportunities for exercise, and encouraging useful occupations.

There is thereby an ongoing friendly debate regarding who first developed moral treatment—Pinel or Tuke. The Retreat is still open, and its website asserts that Tuke inspired Pinel. Information about Pinel, however, tends to not mention Tuke at all. Pinel began his work in 1793, whereas the Retreat opened in 1796. Pinel published his own ideas, whereas Tuke’s grandson, Samuel (1784–1857), wrote Description of the Retreat in 1813, in which he described the principles of the therapeutic environment there.

Evidence suggests that Pinel and Tuke developed their ideas independently. Pinel was inspired by the philosophers of Europe and came upon his principles over the course of his work. In contrast, Tuke sprang to action at the shock of his friend’s death, was inspired by the principles of his Quaker faith, and worked with other Quakers to develop the Retreat. Both can be admired and accredited with being extremely influential in the reform movement that temporarily improved asylum conditions. But their everlasting contribution was to establish a touchstone to which the custodial care of persons with mental illness can always be held, even though it has not always been met.

In 1801, Pinel wrote about his ideas and experiences, labeling the approach moral treatment. He and other advocates promoted it heavily, and it gained great renown and prestige. The approach was adopted at asylums around the world.

The Madness (and Treatment) of King George III

In October, 1760, at the age of 22, King George III ascended the throne of the United Kingdom. The young monarch seemed healthy and happy, despite the war over and ultimate loss of the American colonies. He sired 15 children, including Prince Edward, the father of Queen Victoria, the only regent to have a longer reign than his. His subjects genially referred to him as Farmer George due to his love of that particular avocation.

In 1788, his personal physician found him trying to plant a steak. He apparently though that he would harvest the meat that would grow on the tree. Other examples of his emerging madness abounded. He mistook a tree for the late Frederick the Great, bestowed lavish honors on servants, composed rambling letters to foreign courts, and, on one occasion, spoke continuously for 19 hours straight. He admitted to severe depression and anxiety attacks, and he exhibited hallucinations. He also suffered numerous somatic symptoms, such as gastric distress, muscle pain, insomnia, and seizures and fits.

King George was given the best treatments available. The theory of humors was still dominant, so he was given purgatives and emetics; he was blistered and bloodlet. But nothing worked. At the recommendation of a friend of Queen Charlotte, Dr. Francis Willis (1718–1807) was summoned.

An Oxford-trained clergyman and a Harvard-trained physician, Willis ran a small, private asylum, and he had a reputation for providing humane and effective care to persons with mental illness. He utilized the customary methods, such as bloodletting, but his fame was due to more unusual methods, which were inspired by Pinel. His asylum was in the quiet of the countryside, and it provided a structured environment where patients were encouraged to exercise, plant gardens, and attend chapel. Even more unusual was that the doctor talked to his patients logically and respectfully.

Whether or not the treatment had any effect, King George III seemingly recovered his sanity in 1789. Willis’ reputation was so enhanced that he found it necessary to open a second asylum. But the madness of King George III returned in 1795. The king continued to be treated by Willis, until the latter died in 1807, and then by the sons of Willis. In 1810, the illness intensified, the king was declared incurably insane, and his son took the throne. Deaf and blind, he began talking on January 20, 1820, and did not stop for over two days. Nine days later, King George III passed away.

Perhaps inspired by the contemporaneous work of Tuke (see box), asylums were established in the countryside, where things were slower, cleaner, and healthier, and where moral treatment (with its walks and gardening) could most easily be accomplished. Moral treatment predominated asylum care through the 19th century. While its influence would only last about one hundred years, its philosophical essence endures. To this day, mental health professionals strive to adopt an attitude of compassion, respect, and consideration when they offer treatment to persons with mental illness.

The History of the Treatment of Mental Illness in the United States

The history of the treatment of mental illness in the United States has both parallels and dissimilarities to Europe. In the United States, as elsewhere, there was a desperate need to help persons with severe mental illness, as well as a sense of hopelessness that anything useful could be done besides permanently locking them away. As they did across the ocean, with the best of intentions, many in the United States used brutal methods to treat persons with mental illness. As always and everywhere, the supposed cause of mental illness inevitably led to attempts at treatment.

Dr. Benjamin Rush, the Father of American Psychiatry

Benjamin Rush (1746–1813) earned a medical degree from the University of Edinburgh at age 20. He returned to the colonies to open a practice in Philadelphia just as resentment towards English rule was reaching its peak. Elected to represent Pennsylvania at the Continental Congress, Rush was one of the signers of the Declaration of Independence. He was appointed to the role of surgeon general to the Continental Army and saw service at several battles. His lifelong concern for those whose welfare relied on the more powerful was evident during his military service. For example, he publicly accused George Washington of incompetence, and he played a major role in the court martial of a superior for stealing wine and medicine intended for the troops. After being discharged from the military, Rush became a professor at the University of Pennsylvania, where he trained medical students.

Rush and the Enlightenment. Rush was a citizen of the Enlightenment. He wrote in opposition to slavery and in favor of free public schools, argued for the education of women, and pushed for the transformation of the Pennsylvania penal code to be more rehabilitative rather than merely punitive. His philosophical attitudes were reflected in his professional behavior. Rush never abandoned those consigned to his care, regardless of the seeming hopelessness of the situation and the possible danger to himself. For example, unlike other wealthy citizens and most physicians, during the 1793 yellow fever epidemic in Philadelphia, Rush never left the city (he did send his wife and children away). He remained to treat patients and to comfort the dying.

But Rush is best remembered for his compassionate attitude toward persons with mental illness. He was influenced not only by Enlightenment philosophers and the work of Pinel but also by his personal experience dealing with the mental illness of his oldest son, who died 30 years after entering a hospital for depression. Rush pressed for reform of the treatment of patients with mental illness both at his hospital and beyond. Borrowing from Pinel, he insisted they be treated with humanity and allowed, to the extent possible, to lead normal lives. He required that only intelligent, sensitive, and well-trained attendants care for patients with mental illness. He took upon himself the responsibility to educate medical students in this regard.

Rush educated thousands of students through his affiliation with the University of Pennsylvania and his extensive writings on medical school education. He encouraged scores of students and fellow practitioners to adopt a benevolent attitude toward those with mental illness and well deserves the moniker, the Father of American Psychiatry. Former students founded Rush Medical College in Chicago in his honor.

Rush and Galen. Unfortunately, Rush is also remembered for the barbarity of his treatments and for his refusal to acknowledge scientific advancements. Rush could never be turned from Galen’s notion that illnesses were caused by an imbalance of the humors. He bled maniacs until their pulses diminished virtually to the point of cessation. The physically incapacitated were often too weak and lethargic to protest, but some patients with mental illness would not sit still for bloodletting, so Rush invented the tranquilizing chair, where a patient was strapped firmly in place with his head confined in a padded box. Other attempts to correct humoral problems included forcing patients to stand for days on end, spinning them in a chair attached to the ceiling by a rope (another one of his inventions), laxatives, emetics, cold baths to induce shivering, and hot saunas to induce sweating.

It is now known, of course, that these techniques could not work and were, in fact, dangerous. Bloodletting, for example, led to the death of thousands of patients, probably including George Washington. It is likely that some patients died when Rush inflicted the treatment on them. As the evidence against them accumulated, most of his medical contemporaries abandoned bloodletting and other treatments, but Rush never did. Because of his outmoded methods, his practice suffered, and in 1799, he gratefully accepted appointment by his friend President John Adams to be US Treasurer.

The Persistence of Cruel Treatments

One may wonder how some of the odd, and even cruel, treatments of mental illness persisted, given that they had no relationship whatsoever to the causes of mental illness. Why would doctors, especially someone like Rush who so cared for the welfare of his patients, continue to do something that could have no effect? In fact, these treatments did have an effect. These methods persisted because they worked. Several documents from the asylum era indicate that, when all other treatments had failed, providing patients with these treatments or threatening them with more of the same would often lead to improvement. It seems that regardless of how far disconnected they were from reality, patients who were spun for days on end, who nearly died from bloodletting, or who were painfully confined to straightjackets changed their behavior (such as no longer talking to themselves) to avoid further treatment.

Dorothea Dix and the Establishment of State Asylums in the United States

Asylums had been established in Europe for several centuries by the time of Benjamin Rush, but relatively few existed in the United States. Most persons with mental illness were cared for by their families, but unmanageable cases would usually end up in almshouses, jails, or medical hospitals. A common notion in the United States was that mental illness was caused by moral failings, and punishing persons exhibiting deviant behavior was thereby considered appropriate. Whether in jails, hospitals, homes, sheds, or barns, persons with mental illness were caged or chained to iron rings affixed to walls. This is where Dorothea Dix found them.

Born in Maine, Dix (1802–1887) was the daughter of a Methodist preacher. Her home life was unhappy, and she ran away to live with her grandmother in Boston. After hearing William Channing preach, she joined the Unitarian Church. At the age of 14, she opened an afternoon school in an empty store. Twenty-five years later, Dix was asked by a young minister to find someone who could teach Sunday school to the female inmates at the local jail. Dix volunteered herself.

At the jail, Dix found women with alcohol use problems, severe cognitive impairment, and various other mental illnesses housed in cramped, unheated, unfurnished, foul-smelling quarters. Dix was appalled at the explanation that the insane do not feel heat or cold. She wondered whether this particular jail was an anomaly and over the next 18 months visited every jail in Massachusetts. She documented similar and worse treatment of insane persons who were chained, naked, beaten with rods, and lashed into obedience while confined in cages, closets, and cellars.

Dix was a friend of the governor, and in 1843, two years after she began her tour of the jails, she read a petition to the Legislature of Massachusetts. Those in attendance had to strain to hear her, but her words resonated with Christian compassion and indignation. She described what she saw and asked the legislature to pass laws and provide resources to enact change. She followed her petition with letters to newspapers throughout the state. The legislature balked at the cost, but Dix’s countless sad accounts of persons with mental illness aroused the public. The legislature finally passed laws prohibiting the housing of persons with mental illness in the same facilities as criminals. Soon after, it directed funds for the expansion of Worcester State Hospital.

Despite poor health, Dix took her message to every state east of the Mississippi. She individualized her appeal by visiting each state’s penitentiaries, county jails, and almshouses. After 13 years of tireless work, she went to Europe for a well-deserved rest. But Dix was not good at vacationing. She stayed for two years, visiting 13 countries to document the mistreatment of persons with mental illness and push for reform.

She returned to the United States in 1854 and used her prestige to coax the US Congress into allowing her to address them as well. She asked that 12 million acres be set aside for the housing and treatment of persons with mental illness, as well as those with problems with speech, hearing, and sight. Both houses of Congress approved her proposal in 1854, but Franklin Pierce vetoed it because of expense. So Dix continued her work in those states she had not yet visited. After the Civil War (during which she was superintendent of Union Army Nurses), she continued her advocacy. Due to her efforts, by 1890 every state had built at least one publicly supported mental hospital.

The Apogee of Asylum Treatment

Reflecting the fact that moral treatment within an asylum was the only treatment known to be in any way effective, the medical specialty dedicated to mental illness came to be called asylum medicine. Especially in the US, where they were being newly constructed, hospitals were built to fit the philosophy of moral treatment. Medical journals featured articles on architecture that debated the advantages of a long, single building (the Kirdbride Plan) compared to numerous smaller cottages (the Cottage Plan). Hospitals were located in the country, where fresh air and open grounds were abundant. They offered nutritious food and numerous activities, and they were staffed by well-trained caregivers.

In summary, in both Europe and the United States, the treatment for mental illness was as good as it could get for a while. But this could not last. The demands created by mental illness were and are inexorable. Simply put, moral treatment could never be either as effective or efficient as needed to keep up with the tremendous need.

The Deterioration of Asylum Care and the Downfall of Moral Treatment

By the end of the Enlightenment, asylums were abject failures in all ways. Begun with good intentions, they inevitably turned into warehouses for the least fortunate, most vulnerable members of society. At the same time, however, asylums enabled progress in our understanding and treatment of persons affected by mental illness.

Overcrowding in Underfunded Asylums

Moral treatment within a beautiful building on expansive, therapeutic grounds was expensive. Some private asylums were able to limit their population to the family members of the wealthy and offer moral treatment, but government-funded asylums could not do this. As before Pinel’s reforms, asylums in both Europe and the US were forced to accommodate more patients than originally intended, and they became desperately overcrowded and understaffed. For example, in 1827, asylums in Britain housed an average of 166 persons, whereas 100 years later—in the same asylums—the average was over 1,200. Fairly quickly, asylums deteriorated back to the conditions Pinel and Dix had so vigorously worked to reform. Well into the 20th century, patients were threatened, beaten, and locked inside cramped and filthy rooms. Some were simply chained to the wall, floor, or bed, and many patients suffered malnutrition. (Unfortunately, such deplorable conditions still characterize the treatment of persons with mental illness, intellectual disability, or other diseases in many poor and some not-so-poor countries.) In terrible irony, the inhumane conditions that came to prevail at so many asylums were allowed because they were usually in remote locations, which had been deemed necessary for the provision of moral treatment.

The Undoing of Moral Treatment

Moral treatment was the preferred treatment in asylums since its promotion by Pinel in the latter part of the 18th century. It was the only treatment that had any inkling of success. However, by the latter half of the 19th century, it was losing its appeal. The effectiveness of moral treatment had been greatly oversold, and families and state governments became disillusioned with its failed promises.

Ironically, advances in medicine also doomed moral treatment. The emerging biomedical model asserted that illness is caused by a biological process, and it was being shown time and again to be valid. Within a century, the focus on environmental factors in the development and treatment of mental illness was being undermined by autopsies showing brain lesions and other abnormalities in persons with mental illness. (Even during the era of moral treatment, the prevailing explanation was that unhealthy environments damaged the brain, which was then repaired by the healthy environment of moral treatment.) For several decades after these and other discoveries, the idea that environmental factors could cause mental illness was basically abandoned. It was not until Freud that the idea regained scientific respectability.

Also, unfortunately, widespread acceptance of the biomedical model led to widespread acceptance of the idea that mental illness was both inevitable and incurable. These ideas led to debates about the fate of persons with mental illness, including whether it was worth treating them at all and even advocacy for eugenics (see next chapter). Given the absence of effective treatments, consignment to an asylum once again became an acceptable fate.

Asylums Lead to the Psychiatric Profession

It is probably unsurprising that the dramatic changes in asylums that occurred over the centuries were accompanied by dramatic changes in their overseers. Initially, asylum superintendents tended to be well-educated, although they were not necessarily trained in medicine. They were sometimes called alienists in recognition of the distinctive quality of mental illness wherein the person seems to become alien to himself (in contrast to medical illnesses, wherein the person’s body is afflicted by an invasive malady). Superintendents opened and operated asylums at a good profit and with substantial social prestige. Both profit and prestige were enhanced with the establishment of beautiful, publicly funded hospitals in the countryside.

But alienists were asked to treat more patients than their asylums could handle, and the funds began to diminish. As their work became seemingly impossible, they faced a mixture of pity and scorn from their colleagues. The net result was that asylum work, especially the task of being superintendent, became much less appealing than it had been at one time. Over time, the field became the destination of some of the least qualified medical doctors. But there were many who reacted to the scorn of medical colleagues by becoming self-protective. While this sounds bad, it led to considerable good.

Superintendents did several things to promote the importance of their work and to protect their status. They created professional organizations, such as the Association of Medical Superintendents of American Institutions for the Insane (AMSAII). In 1844, the association began to publish the American Journal of Insanity. The AMSAII later became the American Psychiatric Association, and its journal became the still-published and highly influential American Journal of Psychiatry. Superintendents endorsed the biomedical model and were thereby able to limit their membership to medical doctors, which created the medical specialty of psychiatry.

The notion that mental illness resulted from biological problems created a flurry of activity. Autopsies were conducted on mental patients to search for lesions or other brain abnormalities. Advances in understanding were hampered by the lack of a consistent diagnostic system, since without agreement regarding what an illness entailed, there could hardly be agreement on the cause of it. The biomedical model justified the regular use of drugs, such as chloroform, bromides, and ether. The discoveries and misapplication of the relatively new science of heredity led to a fatalistic view of any chance for recovery. Influenced by Darwin’s ideas, some argued that mental illness could be eliminated through eugenics.

Given the implications of the biomedical model, psychiatrists insisted that custodial care was the best that could be accomplished. They also insisted that it was best to keep hospitals away from the public eye, especially after several magazine accounts of deplorable asylum conditions in the United States and Europe. Thus, up until the mid-20th century or so, a lifetime of asylum care was the fate for many persons with severe mental illness.

The Enduring Conundrum

As reviewed in following chapters, hospital-based care for persons with severe mental illness is drastically improved today. The moral treatment movement, with its emphasis on respect, empathy, and autonomy, continues to provide the foundation of psychiatric care. Moreover, the overall maturation during the 20th century of the scientific method and the maturation of the profession of psychiatry have enabled the development of a variety of effective treatments for mental illness. Today, mental health practitioners start with a moral treatment attitude of respect for the person and a desire to provide quality care, and they build from there using a combination of effective, evidence-based psychological and biological treatments, which are reviewed in later chapters.

On the other hand, three inexorable and powerful factors lead to an enduring conundrum with regard to severe mental illness in particular: overwhelming need, the intrinsic incapacity of persons with mental illness to advocate for themselves, and cost. As shown in the following chapters, these same factors that overwhelmed moral treatment continue to vex us today.

But by their very existence, psychiatric hospitals and asylums contributed to the development of the science of mental illness. Simply put, psychiatric hospitals and asylums allowed the observation and study of large numbers of persons with mental illness gathered into the same facility. They enabled the decades of research and effort needed to develop a diagnostic system and, subsequently, the medications and methods for the effective treatment of mental illness.

Chapter 2

The Development of Science as a Way of Knowing

[Jesus] replied, When evening comes, you say, ‘It will be fair weather, for the sky is red,’ and in the morning, ‘Today it will be stormy, for the sky is red and overcast.’ You know how to interpret the appearance of the sky, but you cannot interpret the signs of the times.

(Matthew 16:2,3)

The foundational components of science—observation and reason—have been around for a long time. When asked for a sign from heaven, Jesus retorted with the basic scientific principle that if you repeatedly observe one thing preceding another, then the two are associated. (Jesus then admonished his audience for ignoring the signs all around them.) But the development of the scientific method as a legitimate and powerful way to study phenomena and their causes only began in earnest about three centuries ago.

The present chapter begins with a brief review of the history of scientific thought before the scientific revolution. It reviews the development of the principles of scientific inquiry. The three objectives of science—description, uncovering association, and investigating whether associations are due to a causal relationship—are reviewed, as are the needs for objectivity and reliability. The chapter ends with a brief description of the process of publication in science. The current chapter thereby sets up chapter 5, which focuses on the scientific study of mental illness and its treatment.

Setting the Stage for the Scientific Revolution

This section reviews the interplay between rationalism and empiricism, as well as the important role that the church had in the establishment of universities and the promotion of science as a way of knowing.

The Foundations of Science: Rationalism and Empiricism

Scientists study description and cause. Descriptive questions in early science included what matter is (e.g., fire, earth, air, and water), and how to describe the movement of heavenly bodies. Modern descriptive questions related to these volumes include how many persons have mental illness, the difference between schizophrenia and bipolar disorder, and the effects of domestic violence.

Discovering causal relationships makes it possible to control things or at least to predict them. Scientists cannot control earthquakes, but they strive to understand the cause so that earthquakes can be predicted and the damage can be limited. Understanding that smoking causes cancer has led many persons to quit smoking, which has saved many lives. Mental health researchers are likewise interested in cause so that mental illness can be both prevented and treated more effectively.

Questions of description and cause are of primary interest to scientists. But a more fundamental question, underlying both description and cause, is how we know what we know.

Plato and Aristotle: Can a Person Trust His or Her Experiences?

Observation is a fundamental human behavior and is the most basic way of knowing something. Everyone observes every conscious moment of every day of their lives. But can a person trust what he observes? That is, can a person trust that what she perceives as reality is accurate?