Earliest Views of Abnormal Behavior
A Student’s Strange Experience During her third year of college, Jennifer began to have strange experiences. Ever since high school, she had struggled with feelings of extreme sadness that came and went over months at a time, as well as intense anxiety attacks that seemed to randomly appear. But now things were different. Jennifer’s sadness and anxiety began to intensify and were joined by other more bizarre experiences. She started to lose her motivation to carry out her normal daily activities, like going to class, hanging out with friends, and even showering and bathing. Even more concerning, she became extremely paranoid of others. It seemed like her professors and friends were all working together to try to harm her in some way, but she wasn’t yet quite sure how or why. She also began to see people out of the corner of her eye in strange places like her bedroom and bathroom, but they disappeared whenever she turned to focus on them. About one month after these strange experiences, Jennifer started hearing voices telling her that her friends and teachers were indeed trying to harm her. Jennifer was very frightened by all of this, but she believed that she couldn’t tell anyone about what was happening out of fear that the person she told might be in on the plot to harm her. Over the course of her junior year, all of these experiences grew more frequent and more intense, culminating in Jennifer never leaving her room and speaking incoherently about the plot to harm her. Her roommates ultimately called the police for help, and they took her against her will to the local hospital for an evaluation.
By the end of this course, you will have a very clear under-standing of the mental disorders that Jennifer was likely suffering from, along with what we currently know about their causes and most effective treatments. People have had experiences like Jennifer’s since the beginning of recorded history, but views about the causes and best treatments of them have changed dramatically over the years.
The First Views of Mental Disorders
2.1 Explain the first views of mental disorders.
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 descrip-tions 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 with unknown causes. But how has abnormal behavior been understood or explained throughout history?
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 typically 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 individuals 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.” This punishment was considered to be 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 techniques for casting an evil spirit out. These techniques varied but typically included magic, prayer, incantation, noisemaking, and trepanation, which involved carving or boring holes in the person’s head in order to let out the evil spirits inside.
Hippocrates’ Early Medical Concepts
Around 400 B.C.E. the ancient Greeks shifted the under-standing of mental disorders from the work of supernatural forces to problems in the human body (a view still held today). The Greek physician Hippocrates (460–377 b.c.), often referred to as the father of modern medicine, is widely considered to be largely responsible for this shift. 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 bestknown of the earlier paradigms for explaining personality or temperament is the doctrine of the four humors, associated with 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 (melancholic). 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 views of personality “types”: the sanguine (active, optimistic), the phlegmatic (calm, relaxed), the choleric (agitated, irritable), and the melancholic (pensive, thoughtful).
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 the Developments in Thinking box), 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 dis-eases, 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, which led to some total misses. For instance, 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 wander-ing to various parts of the body, pining for children. For this “disease,” Hippocrates recommended marriage as the best remedy.
Early Philosophical Conceptualizations of Abnormal Behavior
The Greek philosopher Plato (429–347 b.c.) studied individuals with mental disturbances 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 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 a person’s mental health (Still & Dryden, 2003). Despite these modern ideas, however, Plato shared the belief that mental disorders were in part divinely caused.
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. 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 sui-cidal impulses.
One of the most influential Greek physicians was Galen (a.d. 130–200), who practiced in Rome. He made a number of original contributions concerning the anatomy of the nervous system based on dissections of animals (human autopsies were not yet allowed at that time). 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.
Early Chinese Conceptualizations of Abnormal Behavior
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 ill-nesses. 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). 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 patients with mental illness) 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. During 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, individuals with mental disturbances received humane treatment. One outstanding figure in ancient medicine was Avicenna from Persia (c. 980–1037). Referred to as the “prince of physicians” (Campbell, 1926), he was 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 moo 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. Sometime afterward Avicenna, holding a knife in his hand, entered the sickroom saying, ,“Where is this cow that I may kill it?” The patient mooed 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)
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 those with mental illness. Management of people who were mentally disturbed was left largely to the clergy. Monasteries served as refuges and places of confinement. During the early medieval period, “treatment” for people with mental disturbances 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 “lay-ing 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 spew-drink of lupin, bishopswort, henbane, garlic. Pound these together, add ale and holy water” (Cockayne, 1864–1866). It had long been thought that during the Middle Ages many people with mental disturbances 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). For example, in a review of the literature, Schoeneman (1984) notes that “the typical accused witch was not a mentally ill per-son but an impoverished woman with a sharp tongue and a bad temper” (p. 301). He concluded 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 people with mental illness 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 misunderstandings 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 witch-craft and mental illness points to an even broader issue—the difficulties of interpreting historical events accurately.
Views of Abnormal Behavior in the 1500s and 1600s
2.2 Describe the effect that scientific thinking had on views of abnormal psychology and the rise of early asylums.
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 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. 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.
Johann Weyer (1515–1588), a German physician and writer who wrote under the Latin name of Johannes Wierus, was deeply disturbed by the imprisonment, torture, and burning of people whose strange behavior led them to be accused of witchcraft. In 1583 he published a book, On the Deceits of the Demons, which contained a step-by-step rebuttal of the Malleus Maleficarum, a witch-hunt-ing handbook published in 1486. Weyer argued that those accused of witchcraft were really mentally ill and not deserving of persecution. Weyer was one of the first physicians to specialize in the study and attempted treatment of 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 also beginning to question the practices of the time. For example, St. Vincent de Paul (1576–1660), at the risk of his life, declared, “Mental dis-ease 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 through-out 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
Beginning in the sixteenth century, societies began to put people determined to be suffering from mental illness into asylums—places of refuge meant solely for the care of people with mental illness. Asylums were initially created to remove from the community 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 people considered to be “insane.” Unfortunately, residents of these early asylums lived and died amid conditions of incredible filth and cruelty. In 1547 the monastery of St. Mary of Bethlem in Lon-don (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 Lon-don. Other asylums 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 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 patients with mental illness. The Public Hospital in Williamsburg, Virginia, constructed in 1768, was the first hospital in the United States devoted exclusively to patients with mental illness. The treatment of patients with mental illness 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 mental illness. Thus, the treatment techniques were aggressive, aimed at restoring a “physical balance in the body and brain.” These techniques, based on the scientific views of the day, were designed to intimidate patients. They included 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; or patients might be bled in order to drain their system of “harmful” fluids.
Humanitarian Reform
2.3 Describe the historical development of humanitarian reform.
After approximately 200 years of inhumane treatment in asylums, several leading physicians in Europe began to make major reforms that proposed a much more humanitarian treatment of patients.
Pinel’s Experiment and Tuke’s Work in England
In 1784, shortly after the first phase of the French Revolution, the French physician Philippe Pinel (1745–1826) was placed in charge of La Bicêtre, a hospital in Paris. He instituted the removal of chains from some of the patients as an experiment to test his views that people with mental illness should be treated with kindness and consideration—as sick people, not as criminals or dangerous animals. Had his experiment proved a failure, Pinel might have lost his head (they did that kind of thing back then), but fortunately for him (and his head) it was a great success. Chains were removed; sunny rooms were provided; patients were permitted to exercise on the hospital grounds; and kind-ness was extended to these patients, some of whom had been chained in literal dungeons for 30 or more years. The effect was almost miraculous. The previous noise, filth, and abuse were replaced by order and peace. 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 patients with mental illness lived, worked, and rested in a kindly, religious atmosphere. 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 with kindness and acceptance. Their view that kindness and acceptance would help people with mental illness recover sparked the growth of more humane psychiatric treatment during a period when such patients were ignored and mistreated. As word of Pinel’s amazing results spread to England, Tuke’s small force of Quakers gradually gained the sup-port of English medical practitioners such as Thomas Wak-ley 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, which were revolutionary at the time, not only improved the care of patients but also changed public attitudes toward people with mental disturbances. In 1842, following Wakley’s lobbying for change, the Lunacy Inquiry Act was passed, which included a requirement that asylums and houses be effectively inspected every 4 months to ensure proper diet and the elimination of the use of restraints. 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 to people with mental illness 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. An article written by a former patient from Kingston disclosed that the staff used “tanking” to control and to punish patients with mental illness. 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 patients with mental illness 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 patients with mental illness; 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 (Gentile & Miller, 2009). But even he did not escape entirely from the established beliefs of his time. His medical theory included components from astrology and some of his favorite treatments were bloodletting and using a device he invented called the “tranquilizing chair,” which was used to temporarily restrain and treat violent patients by strapping down their limbs and restricting the movement of their head. 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 attempted through manual labor and spiritual discussion. Moral management achieved a surprisingly high degree of effectiveness. For instance, 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.
Dix and the Mental Hygiene Movement Dorothea Dix (1802–1887) was an energetic New Englander who became a champion of poor and “forgotten” people who had been consigned to prisons and mental institutions for decades during the nineteenth century. Dix, herself a child of very difficult and impoverished circumstances, later became an important driving force in humane treatment for psychiatric patients. She worked as a school-teacher 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.
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 to people with mental illness. Through her efforts, the mental hygiene movement, which advocated a method of treatment that focused almost exclusively on the physical well-being of hospitalized patients, grew in America: Millions of dollars were raised to build suitable hospitals, and 20 states responded directly to her appeals. 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 at that time. Dix rounded out her career by organizing the nursing forces of the Union Army during the Civil War.
Views of the Causes and Treatment of Mental Disorders in the 1800s and 1900s
2.4 Describe the changes in social attitudes that led to changes in how we think about and treat mental disorders.
As described earlier, the humanitarian reform created a major shift in how physicians treated those exhibiting abnormal behavior. The nineteenth and twentieth centuries brought even more changes. Some of these changes were instituted by the physicians running the hospitals, whereas others were created by the patients themselves.
Nineteenth Century Views of Mental Disorders and the Increasing Role of Psychiatrists
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 (people began to realize that approaches like bloodletting and tranquilizing chairs didn’t produce favorable results). How-ever, 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 feel-ings 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 treat-able by medical men (yes, they were all men) of the times.
Mental Hospital Care in the Twentieth Century
The twentieth century began with a continued period of growth in asylums for people with mental illness, although the fate of patients with mental illness during that time was neither uniform nor entirely positive (see The World Around Us box). However, public perceptions of mental health began to change in the early twentieth century. 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 struggle with mental illness and the mistreatment he received in three different institutions. 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, in a widely read description of his experiences, supplied a vivid portrayal of what such painful immobilization of the arms means to an overwrought mental patient. 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 influential people, including the eminent psychologist William James and the “dean of American psychiatry,” Adolf Meyer.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 struggle with mental illness and the mistreatment he received in three different institutions. 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, in a widely read description of his experiences, supplied a vivid portrayal of what such painful immobilization of the arms means to an overwrought mental patient. 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 influential people, including the eminent psychologist William James and the “dean of American psychiatry,” Adolf Meyer.
As noted, during the first half of the twentieth century 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 men-tal hospitals housed over 400,000 patients, roughly 90 per-cent of whom resided in large state-funded hospitals; the remainder resided in private hospitals. During this period, hospital stays were typically quite long, for some patients totaling many years at a time. The year 1946, however, marked the beginning of an important period of change. Mary Jane Ward published an influential book, The Snake Pit, which was popularized in a movie of the same name. This work called attention to the plight of patients with mental illness 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. More-over, the Hill-Burton Act, a program that funded community mental health hospitals, was passed during this period. This legislation, along with the Community Mental Health 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 patients with mental illness 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—such as the use of antipsychotics and mood stabilizers for those with psychosis and bipolar dis-order, respectively.
During the latter decades of the twentieth century vigorous efforts were made to shut down mental hospitals and return psychiatric patients to the community in order to pro-vide more integrated and humane treatment. 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 to about 100,000 by the late 1980s. This movement, referred to as deinstitutionalization, although motivated by benevolent goals, has also created great difficulties for many people with psycho-logical challenges and for many communities as well. The original impetus behind the deinstitutionalization policy was that it was considered more humane (and cost effective) to treat those with severe mental illness in their own community. Many professionals were concerned that the mental hospitals were becoming permanent refuges for mentally ill 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. In a recent review on the influence of deinstitutionalization on discharged patients, Kunitoh (2013) found that, although many symptoms and social behavioral problems remained unchanged, both living skills and quality of life were improved after discharge. However, many former patients have not fared well in community living 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 com-munity can be readily seen in our cities: Many of the people living on the streets in large cities today are homeless and have mental illnesses. Moreover, just as rates of hospitalization decreased, rates of incarceration increased (Harcourt, 2011), leading many to suggest that as a society we were changing the way we treat those with severe mental illness—and focusing on imprisonment rather than treatment. 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 (see the Unresolved Issues box at the end of this chapter).
The Emergence of Modern Views of Abnormal Behavior
2.5 Identify developments that led to the contemporary view of abnormal psychology.
While the mental hygiene movement was gaining ground in the United States during the latter part of the nineteenth century, several significant discoveries led to the development of the current scientific, or experimentally oriented, view of abnormal behavior and its treatment. In this section we describe four major advances in the nineteenth and twentieth centuries that changed the way that abnormal behavior was viewed and treated: (1) biological discoveries, (2) the development of an agreed-upon classification system for mental disorders, (3) the emergence of scientifically informed views about the causes of abnormal behavior, and (4) the emergence of experimental psychology.
Biological Discoveries: Establishing the Link Between the Brain and Mental Disorders
Advances in the study of biological factors as underlying both physical and mental disorders developed during this period. A major biomedical breakthrough came with the discovery of the organic factors underlying general pare-sis—syphilis of the brain. One of the most serious mental illnesses of the day, general paresis produced symptoms including paralysis, mood changes, and seizures 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 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 (1799–1858) suggested that the collection of symptoms seen in those with general paresis are one 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. Years later, in 1897, the Viennese psy-chiatrist Richard von Krafft-Ebing conducted experiments showing that exposing patients with paresis to matter from syphilitic sores did not lead to the development of syphilis, which suggested they must already have been infected. This established the relationship between syphilis (a biological condition) and general paresis (a mental disorder). In 1906, August von Wassermann devised a blood test for syphilis, which 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. In 1917, Julius von Wagner-Jauregg introduced the malarial fever treatment of syphilis and paresis after realizing that the high fever associated with malaria seemed to kill off the syphilis bacteria. To test whether this association was causal, he infected nine patients with paresis with the blood of a malaria-infected soldier, held his breath, and found marked improvement in paretic symptoms in three patients and apparent recovery in three others (the other three did not improve). By 1925 several hospitals in the United States were incorporating the new malarial treatment for paresis into their hospital treatments. Today, 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. (See the Developments in Research box.)
BRAIN PATHOLOGY AS A CAUSAL FACTOR With the emergence of experimental science in the early 1700s, 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 physiologiae 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 view-point, 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. 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 (dis-orders caused by toxic substances such as lead), certain types of mental retardation, and other mental illnesses were discovered. Although the period from 1700 to 2000 brought amazing advances in our understanding of mental ill-ness, there were unfortunately some serious missteps along the way. For instance, in the early 1900s, 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 Portuguese psychiatrist Egas Moniz to treat severe men-tal disorders using surgical procedures called lobotomies. This crude procedure consisted of inserting an ice pick into the patient’s eye socket and using it to sever segments of brain tissue. These surgical efforts to treat men-tal disorder were considered to be ineffective and inappropriate by many in the profession at the time and were eventually discredited.
The Development of a Classification System for Mental Disorders
Emil Kraepelin (1856–1926), a German psychiatrist, played an enormous role in the development of methods for classifying different types of abnormal behavior. Kraepelin noted that certain symptoms 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 the system that we still use today. Integrating all of the clinical material underlying this classification was an enormous task and represented a major contribution to the field of psychopathology. 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. 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 psychodynamics) 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. 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-nine-teenth-century France.
MESMERISM 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 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, like a stage magician, appeared in a lilac robe, passing from one patient to another and touching each one with his hands or his wand (yes, wand). By doing so, Mesmer was purportedly able to remove hysterical anesthesias and paralyses. The scientific community impaneled a commission to investigate this treatment, which many thought to be suspect. The committee, which included the American scientist Benjamin Franklin, conducted a series of clever controlled experiments (believed to be the first psycho-logical experiments ever performed; Dingfelder, 2010) that involved exposing some of a group of afflicted people to objects that they believed to have been magnetized (only half of which actually were) and others to objects that they believed to not have been magnetized (but half the time were). It turns out that those who believed that they were exposed to magnetized objects improved, regardless of whether the objects actually were magnetized or not. This suggested that the effects were due to the power of suggestion (hypnosis) rather than to animal 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.
THE BEGINNINGS OF PSYCHOANALYSIS Although mesmerism was debunked, this approach did show that psychological factors (such as expectations) could influence and “cure” abnormal behavior. Thus, toward the end of the nineteenth century, it became clear that mental dis-orders could have psychological bases, biological bases, or both. But a major question remained to be answered: How do the psychologically based mental disorders actually develop? The first systematic attempt to answer this question was made by Sigmund Freud, a brilliant, young Viennese neurologist who received an appointment as lecturer on nervous diseases at the University of Vienna. In 1885 he went to study under physicians who had used hypnosis in their work (following the work of Mesmer). Freud was impressed by their use of hypnosis with patients experiencing hysteria and came away convinced that powerful mental processes could remain hidden from consciousness. On his return to Vienna, Freud worked in collaboration with another Viennese physician, Josef Breuer (1842–1925), who had incorporated an interesting innovation into the use of hypnosis with his patients. Unlike hypnotists before them, Freud and Breuer directed patients to talk freely about their problems while under hypnosis. The patients usually displayed considerable emotion and, on awakening from their hypnotic states, felt a significant emotional release, which they called a catharsis. This simple innovation in the use of hypnosis proved to be of great importance: It not only helped patients discharge their emotional tensions by discussing their problems but also revealed to the therapist the nature of the difficulties that had brought about certain symptoms. The patients, on awakening, saw no relationship between their problems and their hysterical symptoms. It was this approach that led to the discovery of the unconscious—the portion of the mind that contains experiences of which a person is unaware—and with it the belief that processes outside a person’s awareness can play an important role in determining behavior. In 1893, Freud and Breuer published a joint paper titled On the Psychical Mechanisms of Hysterical Phenomena, which was one of the great milestones in the study of the dynamics of the conscious and unconscious mind. Freud soon dis-covered, moreover, that he could dispense with hypnosis entirely. By encouraging patients to say whatever came into their minds without regard to logic or propriety, Freud found that patients would eventually overcome inner obstacles to remembering and would discuss their problems freely. Two related methods enabled him to understand patients’ conscious and unconscious thought processes. One method, free association, involved having patients talk freely about themselves, thereby providing information about their feelings and motives. A second method, dream analysis, involved having patients record and describe their dreams. These techniques helped analysts and patients gain insights and achieve a better understanding of the patients’ emotional problems. Freud devoted the rest of his long and energetic life to the development and elaboration of psychoanalytic principles. His views were formally introduced to American scientists in 1909, when he was invited to deliver a series of lectures at Clark University by the eminent psychologist G. Stanley Hall (1844–1924), who was then president of the university. These lectures created a great deal of controversy and helped popularize psychoanalytic concepts with scientists as well as with the general public.
The Evolution of the Psychological Research Tradition: Experimental Psychology
Psychoanalysis was introduced to North America at a famous meeting at Clark University in Worcester, Massachusetts, in 1909. Among those present were (back row) A. A. Brill, Ernest Jones, and Sandor Ferenczi; (front row) Sigmund Freud, G. Stanley Hall, and Carl Jung.
The origins of much of the scientific thinking in contemporary psychology lie in early rigorous efforts to study psychological processes objectively, as demonstrated by Wilhelm Wundt (1832–1920) and William James (1842–1910). Although the early work of these experimental psychologists did not bear directly on clinical practice or on our understanding of abnormal behavior, this tradition was clearly influential a few decades later in molding the thinking of the psychologists who brought these rigorous attitudes into the clinic. In 1879 Wilhelm Wundt established the first experimental psychology laboratory at the University of Leipzig. While studying the psychological factors involved in memory and sensation, Wundt and his colleagues devised many basic experimental methods and strategies. Wundt directly influenced early contributors to the empirical study of abnormal behavior such as William James, G. Stanley Hall, and a student of Wundt’s, J. McKeen Cattell (1860–1944) (Benjamin, 2014); they followed his experimental methodology and also applied some of his research strategies to study clinical problems. For example, Cattell brought Wundt’s experimental methods to the United States and used them to assess individual differences in mental processing. He and other students of Wundt’s work established research laboratories throughout the United States. It was not until 1896, however, that another of Wundt’s students, Lightner Witmer (1867–1956), combined research with application and established the first American psycho-logical clinic at the University of Pennsylvania. At Witmer’s clinic both research and therapy were conducted, with a focus on the problems of children with mental deficiencies. Witmer, considered to be the founder of clinical psychology (McReynolds, 1996, 1997), was influential in encouraging others to become involved in this new profession. Other clinics were soon established. One clinic of great importance was the Chicago Juvenile Psychopathic Institute (later called the Institute of Juvenile Research), established in 1909 by William Healy (1869–1963). Healy was the first to view juvenile delinquency as a symptom of urbanization, not as a result of inner psychological problems. In so doing, he was among the first to recognize a new area of causation—environmental, or sociocultural, factors. By the first decade of the twentieth century, psycho-logical laboratories and clinics were burgeoning, and a great deal of research was being generated (Goodwin, 2011). The rapid and objective communication of scientific findings was perhaps as important in the development of modern psychology as the collection and interpretation of research findings. This period saw the origin of many scientific journals for the propagation of research and theoretical discoveries, and as the years have passed, the number of journals has grown. The American Psychological Association publishes numerous scientific journals, many of which focus on research into abnormal behavior and personality functioning. This experimental psychology approach has continued to this day. Of course, as the methods available to scientists and clinicians have evolved over the past century (e.g., the development of methods for genetic testing, brain imaging, brain stimulation), our understanding of abnormal behaviors has advanced. In the next chapter we delve much more deeply into contemporary views about the causes of abnormal behavior. In this chapter we have touched on several important trends in the evolution of the field of abnormal psychology and have recounted the contributions of numerous individuals from history who have shaped our current views. For a recap of some of the key contributors to the field of abnormal psychology, see Table 2.1 . The vast amount of information available can cause confusion and controversy when efforts are made to obtain an integrated view of behavior and causation. We may have left supernatural beliefs behind, but we have moved into something far more complex in try-ing to determine the role of natural factors—be they biological, psychological, or sociocultural—in abnormal behavior.