Mental Health in CJ
DOI: 10.4324/9780367466763-6
Introduction
Never Give up on people with Mental Illness When “I” is Replaced by “We.”, Illness becomes Wellness.
- Shannon L. Alder
A New Vision
It is only fitting that Volume I ends with a chapter on the history of mental illness because his- tory has entrusted psychology with the responsibility of creating a better world from both its academic and clinical understandings. This is particularly true for one of the most misunder- stood populations in the world, individuals with mental illness. Although late to its focus on serious mental illness, psychology, with all the other mental health professions because of the current crisis in mental health care, shares a common responsibility to create a new vision for individuals with mental illness.
First, it is important to understand and learn from history to avoid repeating the injustices perpetrated on individuals with mental illness. But it is also important to avoid the belief that modern psychiatry and psychology have nothing to learn from the past because it is the past that might provide important lessons for the future (Penney & Stastry, 2008).
The goal of this chapter is to not only to focus on a history of mistreatment but also on the visionaries that transformed mental health care. During a crisis in the United States in which the mental health system is underfunded and neglected at the federal and state levels, it is important to have hope and act from the learnings of history.
Definition of Mental Illness
The definition has evolved throughout history. Currently, it is defined by the American Psychi- atric Association (2013) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a disturbance of cognition, emotion, or behavior that causes distress or disability in social, occupational, and other activities. It was only in recent history that a qualified mental health pro- fessional could diagnosis mental illness. Previously, it was a variety of unqualified people, rang- ing from priests to politicians, who believed mental illness was a demonic or political problem. In this chapter, it is the historic understanding of those who experienced serious mental illness in history that would include the DSM-5 diagnoses of schizophrenic spectrum and psychotic disorders, bipolar disorders, major depressive disorders, trauma and stressor-related disorders, and dissociative disorders.
6 The Symbols of the History of Mental Illness Past, Present, and a New Vision for the Future
206 The Symbols of the History of Mental Illness
A Community Mental Health Vision
In 1869, Vincent Van Gogh, a Dutch Impressionist, painted Starry Night, a scene just before sunrise about an imaginary village, from the Saint-Paul-de-Mausole asylum window in the Saint-Remy-de-Provence in France. The imaginary village provides a symbol of a community where individuals with mental illness could someday be valued. Although Van Gogh viewed the painting as a total failure, he did write to his brother, Theo, that the sun inspired a new day as it rose in all its glory (Naifeh & Smith, 2012).
Housed in a former monastery, the asylum catered to the wealthy and its sparse census pro- vided a safe place for Van Gogh to paint from various locations throughout the asylum. In the aftermath of a mental health crisis resulting from self-mutilation of his left ear, Van Gogh produced many of his greatest paintings. Symbolizing the potential of transforming the creative energies from mental disturbance into great art, the year Van Gogh stayed in the asylum was one of his most prolific, creating hundreds of paintings (Naifeh & Smith, 2012).
Figure 6.1
Personal Reflections
This chapter will include personal reflections from my 50 years of experience in the com- munity mental health system as a student, intern, staff psychologist, training director, program chief, and mental health director and in academia as chair of the Doctoral Clinical Psychology Program in Depth Psychology at Pacifica Graduate Institute in Santa Barbara, California.
The Symbols of the History of Mental Illness 207
Mental Illness
Historical Analysis of Mental Illness
Political Systems
Throughout history and until the present time, individuals with serious mental illness have had little political power to determine their future. It is important to understand that, as a vulnerable population, they have been dependent on others for political power, to protect their human rights and support their empowerment.
Although often talented and brilliant, with an understanding of life unavailable to most peo- ple, few have openly attained political power. In 1972, when it was discovered that Senator Thomas Eagleton of Missouri had been treated with electroconvulsive therapy (ECT) for de- pression, presidential candidate George McGovern, after supporting Eagleton “1000 percent” and consulting with psychiatrists who expressed concern that if he became president his depres- sion could return, asked Eagleton to withdraw. A Time magazine poll found that 77 percent of the American people said that the medical issues of Eagleton would not affect their vote (Ma- rano, 2003). The perceived lack of conviction was disastrous for the McGovern campaign as he went on to lose the election to Richard Nixon in a landslide.
The most inhumane treatment approaches in history often occurred because individuals with mental illness had no political power or personal rights to give consent to the treatments im- posed upon them. Political systems empowered doctors to make treatment decisions on their behalf, often leading to horrific impacts, even death. Another example of the need to always make shadow conscious with the understanding that the road to hell is often paved with good intentions.
Personal Reflections
This chapter is personal. For nearly 30 years, I dedicated my life in service to individuals with mental illness in the community mental health system. Every day, on the wall in my office, Starry Night inspired my vision to change the world for individuals with mental illness. As a mental health director in rural Shasta County in Northern California and in suburban Santa Barbara County in south-central California, I learned the history of mental illness not taught in my graduate education. As a treating clinical psychologist, I learned of the resiliency and courage it takes to live with mental illness. As an administrator, I hired individuals with mental illness and learned the importance of their engagement in program development and setting policy, since in the final analysis, the system exists in service to their needs. Most importantly I learned that individuals with mental illness want what everyone wants, love, friendship, a good job, and a quality life.
I also learned that many individuals with mental illness have incredible artistic abili- ties, producing some of the most powerful art that still grace my office walls. As a mental health director, in Starry Night, I saw the sky as symbolizing the incredible potential of individuals with mental illness; the tree stump, how mental illness can strike and wound; but the community below welcomes and provides the supports necessary for individuals with mental illness to feel valued as equal citizens, appreciated for their unique talents, and contributors toward building a stronger and more compassionate community.
208 The Symbols of the History of Mental Illness Benjamin Rush and Heroic Medicine
Benjamin Rush (1745–1813) is a perfect example of good people causing harm when individu- als with mental illness have no power to give consent for treatment (Fennel, 1996). In 1965, the American Psychiatric Association recognized Rush as the father of American psychiatry. How- ever, he was a proponent of the widely discredited heroic medicine that physically and emotion- ally endangered the lives of thousands of individuals with mental illness. Rush was a leading figure of the American Enlightenment and a revolutionary leader who signed the Declaration of Independence. He was a reformer who opposed slavery, advocated for public education, and supported women’s rights (Fried, 2018).
Rush (1812) published the first American psychiatric text, Medical Inquiries and Ob- servations, Upon the Diseases of the Mind. He was the first American psychiatrist to study mental disorders in a systematic and theoretical manner. His approach was rooted in academic medicine and provided a theoretical, not empirical, approach to psychiatric diagnosis. His theoretical orientation led Rush to become a leading proponent in Ameri- can medicine of the medical theory of heroic medicine, or heroic depletion theory. It was called heroic because the treatments were outside the norm of typical medical practice. The Age of Heroic Medicine lasted from 1780–1850 and focused on medical treatments that included rigorous bloodletting, purging, and sweating to shock the body back to equi- librium (Stavrakis, 1997). Rush was called the American Hippocrates, after he practiced heroic medicine on patients and even himself during the Philadelphia Yellow Fever out- break in 1793.
Humoral therapy dates to the Greeks and Hippocrates, who practiced some form of heroic medicine in their attempt to balance the homeostasis of the four humors: black bile, yellow bile, phlegm, and the blood. However, heroic medicine went far beyond those efforts by routinely draining 80 percent of the blood volume of a patient, often jeopardizing their life. In 1799, George Washington died after excessive bloodletting and administration of the substance can- tharidin to induce rigorous sweating (Stavrakis, 1997).
Although he led a successful campaign in 1792 for the Pennsylvania State Hospital to build a separate, more humane psychiatric ward, Rush believed that individuals with mental illness should be treated with heroic medicine, along with coercion, restraint, and physical punishment. He believed that mental disturbance was caused by poor blood circulation and by an overheated brain (Fried, 2018). This is symbolized by his advocacy for some of the most brutal treatments of mental illness in history; most specifically spinning therapy and the infamous tranquilizer chair.
Rush gained international acknowledgment when physicians began to use his tranquilizing treatment techniques. In spinning therapy, a patient was strapped horizontally to a gyrator board that would mechanically spin at great speeds until the patient was so dizzy and weak that any psychotic thoughts would be temporarily driven from the brain. If that did not work, there was always the infamous tranquilizer chair that he boasted could “cure madness” (Fried, 2018). Once strapped into the tranquilizer chair, the patient could not move, as the patient’s arms were bound, their wrists immobilized, their feet clamped together, and their sight blocked by a wooden box that did not allow for any movement. This was eagerly embraced by asylum doc- tors throughout the world. Rush claimed that it could make the most disturbed patient gentle and submissive. Some physicians reported keeping a patient in the tranquilizer chair for months (Whitaker, 2019).
The Symbols of the History of Mental Illness 209
Dorothea Dix and Political Advocacy
Dorothea Dix (1802–1887) became a role model for political advocacy. Dix had her own serious health issues. In 1836 she traveled to England to recover her health and met members of what was then called the lunacy reform movement. Upon her return to the United States, she began a two-year fact-finding review of asylums for poor individuals with mental illness in towns and cities throughout Massachusetts.
In her 1843 emotional and fiery presentation, Memorial to the Legislature of Massachusetts (Dix, 1843), she spoke about the lack of government support for individuals with mental illness, especially for the poor, known as looney paupers. Until Dix, asylums were privately funded and too dependent on the wealth of family members. Dix called attention to the fact that poor mentally ill people lived in cages, stalls, and even pig-like pens. She witnessed abuse that she felt was a scar on humanity itself as she saw individuals with mental illness naked, chained, and beaten into obedience. In the Quaker tradition, she made the issue a moral one and called upon the sacred duty of government to finally take responsibility for the treatment of mental illness. Her lobbying was effective. The legislature immediately expanded services at the Worcester Mental Hospital. In the next few years, her investigative style led to political reforms in asylums from New Hampshire to Louisiana. Her commitment for public tax dollars to support mental hospitals finally came to fruition in 1853 with the founding of the first publicly funded American mental hospital in Pennsylvania, the Harrisburg State Hospital.
Figure 6.2
210 The Symbols of the History of Mental Illness With all the state legislative success Dix took her “moral cause” on behalf of individuals with
mental illness to Washington, DC. The Bill for the Benefit of the Indigent Insane, which would have sold 12 million acres of federal land to build and maintain asylums throughout the United States, passed overwhelmingly in both houses. But in 1854, President Franklin Pierce vetoed it because he believed social welfare was the responsibility of the states. This began the legacy of neglect of mental health services by the federal government. Stung by the lack of American con- cern for the mentally ill, Dix returned to Europe, where she believed there was more openness to reform. Scotland and Nova Scotia passed her recommended legislative reforms. Significantly, after 13 years of advocacy an asylum was built in the Channel Islands. Extending her influence throughout Europe, upon her arrival in Rome, she met with Pope Pius IX and convinced him to visit an asylum. Afterward, the pope acknowledged that it took a Protestant from across the sea to call his attention to a sinful cruelty of mankind.
Dorothea Dix became the modern Greek goddess Themis, who symbolized justice as a divine law that transcended human law. In Greek, Themis, tithemi, means “to put into place divine law.” Her gift from the Greek gods was to provide social order and justice to humanity. Dix spoke to a moral justice and a moral responsibility calling upon political leaders to treat individuals with mental illness with not only respect but with justice, acknowledging their political rights to be treated as valued human beings. Themis became Lady Justice, named after the Roman goddess Justitia, the modern symbol of a blindfold because Lady Justice is objective, impartial,
Figure 6.3
The Symbols of the History of Mental Illness 211 and blind to gender, race, ethnicity, social status, class, religious affiliation, and disability. The scales of justice balance truth with fairness because true facts have no middle ground. The sword symbolized, like the life of Dorothea Dix, separating fact from fiction regarding mental illness, fighting for justice and humane places for healing mental illness.
The interest in mental illness for Dorothea Dix began with her experiences with the justice system. Her concern for reform started after teaching classes to women in an East Cambridge prison. There she saw mentally ill people in cells located in the prison basement where it was dark, dirty, and had foul air. There has been the suggestion that individuals with mental illness need a twenty-first-century Dorothea Dix because the American jails and prisons have become the new asylums. The Los Angeles County jail, Chicago’s Cook County jail, and New York Riker’s Island Jail Complex hold more individuals with mental illness than all the remaining psychiatric hospitals in the United States combined (Treatment Advocacy Center, 2016).
Twenty percent of inmates in jails and 15 percent of inmates in prisons have seriously men- tally illness, which makes approximately 400,000 individuals with mental illness incarcerated as criminals in jails and prisons across America (Roth, 2018, Treatment Advocacy Center, 2016). This is 10 times the number of patients in the remaining state mental hospitals. Because indi- viduals with mental illness are often “refusers” that mistrust the system and refuse to cooperate with researchers, jail and prison statistics are most likely understated.
Incarceration has replaced treatment for many individuals with mental illness as mental ill- ness became criminalized in the late twentieth century with vulnerable individuals often abused in jails and prisons by guards and other inmates. (Chaimowitz, 2012, Lamb, Weinberger & Gross, 2004, Roth, 2018). Despair and hopelessness are so commonplace that most of the sui- cides in jails and prisons are completed by individuals with mental illness (Roth, 2018). The sad economic reality is that although mental health treatment is less expensive than incarceration, and most county sheriffs and prison superintendents complain about housing individuals with mental illness, few are willing to divert any of their funding toward the mental health system.
Thomas Szasz – The Myth of Mental Illness
Thomas Szasz (1920–2012), in The Myth of Mental Illness (Szasz, 1961), argued that “mental illness” as a concept cannot exist because illness implies a physical disease that is based on bio- logical or chemical tests to prove a diagnosis. No such tests exist in psychiatry; therefore, it is better to view mental illness as a metaphor for dealing with problems of living. Szasz, a libertar- ian, viewed modern scientism as the new religion. Psychiatrists were the new priests, deciding what was normal and what was abnormal behavior.
As religious priests persecuted witches, Jews, gypsies, and homosexuals, psychiatrists and other mental health professionals were the new political persecutors who demanded that their patients convert to the new secular medical religion (Szasz, 1961). Szasz warned against the de- velopment of a therapeutic state, which was the political collaboration between psychiatry and government. In this unholy alliance, psychiatry became an important arm of state political control that protected state interests by diagnosing and treating disapproved behaviors, thoughts, and emo- tions. He argued that the therapeutic state swallowed up everything under the rational control of medicine and health as the church swallowed up everything under the guise of God and religion.
The state then has been empowered to persecute and punish. What Szasz viewed as real “madness” was the Enlightenment viewpoint that discovery of rational universal truths would lead to an expansion of human rights. The opposite had occurred because the rights of the “mad” modern individual were no different than a “mad” person living during medieval times. It is the political secularization of religion, and the medicalization of good behavior made modern
212 The Symbols of the History of Mental Illness Western civilization ill-prepared to deal with difference or “madness.” Once the power structure defines with psychiatry the current universal truths, there must be an all-out political effort to guard against unreason and “madness.”
Socioeconomic Systems
In the classic Social Class and Mental Illness, August Hollingshead and Fredrick Redlich (1958) examined the interrelationship between social class and mental illness. The 10-year study found that social class and mental illness can be symbolized by the Titanic ramming an iceberg in 1912. Ninety percent of the iceberg was below the surface, which symbolized the American denial of the existence of social classes. In the Titanic crisis, like today, class status played a role in in the determination of whether one survived or drowned. Only four people in first class of 143 died, while third-class passengers were ordered to stay below the deck, some at gun point.
Hollingshead and Redlich (1958) argued there was a distinct relationship between social class and mental illness; the higher classes were treated in private institutions with analytic psychotherapy while the lower classes were treated in public institutions with more directive and organic therapies, at the time, shock treatments, lobotomies, and high dosages of psychiatric medication. They concluded the lower the class, the more brutal the treatments.
In 1963, President Kennedy signed the Community Mental Health Act of 1963 which initi- ated the deinstitutionalization of state mental hospitals and the Community Mental Health movement throughout the United States. The goal was to create a high quality Community Mental Health service delivery system (Krieg, 2003, Sharfstein 2000). States did not reinvest the millions of dollars in savings from the closure of state mental hospitals into community care.
Most individuals with serious mental illness live in severe poverty, dependent on bureaucracies that have expressed little interest in their socioeconomic well-being. (Cunningham, McKenzie & Taylor, 2006) Although not hopeful, Dean (2017) argues that psychiatry should recognize the impact of socioeconomic inequality and its effect on mental disorders. His view is that a new model of mental health care is needed because, under the medical model, billions of dollars have been allocated toward brain, genetic, and psychotropic research, with little attention to social
Personal Reflections
I have mixed feelings about using the term mental illness to define people. Like Thomas Szasz, there are those who do not believe mental illness exists and others that have at- tempted to provide more positive descriptors. Being involved in mental health for over 50 years, I have found there is no consensus among individuals who struggle with mental health challenges on how they want to be identified whether it be mentally ill, consumer, patient, client survivor, or member, as long it is done with respect. I use the term mental illness in this chapter reluctantly, understanding that it may further the very stereotype that I hope I am attempting to change. On the other hand, I do not think “sugarcoating” history is helpful and that by understanding history, future generations will know what has and has not worked, particularly some of the most inhuman practices that should never occur in a humane society. By using “individual” or “people” throughout the chapter before mental illness will be a constant reminder, a written symbol, that individuals who struggle with mental health issues are not their diagnosis. That each person is a unique, valuable human being that has special gifts to offer the world.
The Symbols of the History of Mental Illness 213 and economic inequality. Perese (2007) recommends that stigma, poverty, and victimization be included in every patient assessment and treatment plan.
Poverty causes psychological distress; it undermines self-esteem and self-worth. It increases depression, anxiety, and suicidality (Manseau, 2014). Socioeconomic distress is associated with the development of mental disorders in children, adolescents, and adults; the lower the socio- economic status the higher the risk for mental illness (Hudson, 2005, Johnson, Cohen, Dohren- wend et al, 1999, Liem & Liem, 1978). Poverty decreases the ability to attend to basic needs and increases the risk for victimization.
After decades of advances in psychotropic medication and the era of mental illness as a “brain disease,” the mentally ill continue to die and commit suicide at significantly higher rates than the general population (Siris, 2001). Although there is little doubt that genetic and imag- ing studies have added to the understanding of brain structure, the delineation of brain circuits, and the biology of psychotropic drugs, the evidence remains limited that brain research has led to accurate psychiatric diagnoses, effective treatment plans for serious mental illness, or use- ful clinical biomarkers (Dean, 2017, Kapur, Phillips & Insel, 2012). Although medication is an important component of treatment, the medical model has led to neglect of other important treatment issues, particularly socioeconomic inequality.
The dramatic changes in the socioeconomic structure in American society have impacted not only the middle class, but the most vulnerable and disabled in society. Between 1973 and 1993, there has been a massive redistribution of wealth in the United States as $255 billion shifted from the middle class to the top 1 percent (Dean, 2017). Since 2008, the ranks of the middle class have fallen by 20 percent, with few, if any, real wage increases since the 1970s, leaving almost 50 million people in poverty in the United States.
Figure 6.4
214 The Symbols of the History of Mental Illness The economic effect is even more dire for individuals with mental illness because of their
lower-class status and their dependency on a dysfunctional and underfunded mental health sys- tem (Foster, 2021). In line with the research of Hollingshead and Redlich, the limited resources intended to support individuals with mental illness have often been spent on the most brutal treatments or no treatments at all by government bureaucracies, prisons, and to no treatment, relegated to survive on the unsafe streets in American communities.
During the 1980s, the Social Security Administration removed addiction as a disability and made it more difficult for individuals with mental illness to receive disability benefits. The Social Security Income (SSI) system is brutally dysfunctional, focused on denial of benefits, a complex bureaucratic system that can take years and often necessitates legal advocacy for the procurement of minimal financial benefits that still results in a life in poverty. The SSI system reinforces governmental dependency because there are few incentives to seek employment and become economically self-sufficient.
Since the 1970s, the prison population in the United States rose by 400 percent, with esti- mates that the rate of mental illness in prisons increased from 5 percent in 1970 to 40 percent by the 1990s, making the prison system the largest mental health institution in the United States. Vulnerable, stigmatized, and untreated individuals with mental illness are often victimized and resort to suicide to escape the brutal prison environment.
Although only 6 percent of the population, 25 percent or more of the homeless population in America is mentally ill. Few of the homeless mentally ill receive any public benefits and, like prisons and homeless shelters, unqualified to treat mental illness, often provide the only avail- able housing option (Bassuk, Rubin & Lauriat, 1984). Being homeless and mentally ill leads to catastrophic health crises requiring medical and psychological interventions (National Coalition for the Homeless, 2009). Unlike the medical system, there is no national mandate or standard for emergency mental health services, which leaves individuals with mental illness prone to homelessness, involuntary care, and incarceration.
Amid the economic struggles of the middle class and disinterest by the wealthy and political leaders, individuals with mental illness have been left in poverty with no societal or profes- sional advocacy yet seen on the horizon.
Cultural Systems
The reality in American culture is that one in four families will experience the challenge of mental illness. Cultural misunderstandings about mental illness are deeply rooted in history, starting with the Greek belief that Olympian Gods controlled human behavior, that mental disturbances came from external forces. This misconception continued during the Christian period, when it was believed that the mentally ill were possessed by evil forces, the devil. Historic misconceptions were created to understand mental illness like the concept of lunatic, “ship of fools,” and the art of A Rake Progress. In modern times, the cultural phenomenon of the movies One Flew over the Cuckoo’s Nest and Beautiful Mind shed light on the culture of mental illness.
There is limited research on mental illness as a culture, the unique qualities of that culture, the individual experiences of that culture, or the impact of that culture it interfaces with the dominant culture. Standpoint theory has been a popular method of feminist researchers. Sandra Harding (1991) coined the term, for people “not seen,” the oppressed in our culture. Harding believes the disenfranchised are constantly neglected by social scientists and this results in most research being in service to the current power structure and to the status quo. This negates the
The Symbols of the History of Mental Illness 215 possibility for both the scientist and the socially disenfranchised to change their cultural stand- point. In terms of mental illness, it is important to understand that dependency on the groups that individuals with mental illness need have often been part of the problem, which can make it difficult to risk alienating the people upon which dependence is essential for their survival.
Oppression is defined as the malicious and unjust exercise of power, often perpetrated by governmental, religious, political, or cultural authorities. It can be done consciously or uncon- sciously. Discrimination is oppression, targeting a special group of people, an example being individuals with mental illness (Szmukler, 2004).
Mental illness is the number one factor in episodes of police violence. A report by Doris Fuller, Richard Lamb, Michael Biasatti, et al (2015) from the Office of Research and Public Affairs, indicates that people with mental illness are 16 times more likely to be killed when ap- proached or stopped by police than other civilians; at least one of four fatal police encounters ends the life of an individual with mental illness.
These incidents often occur during an assessment by police for involuntary care when in- dividuals with mental illness in crisis feel ambivalent, even hostile, about being hospitalized against their will (M.J. Cherry, 2010, Hoyer, 2008). One can imagine the feeling of losing the freedom to make important, often life-threatening, decisions. From a client standpoint, invol- untary care often provides more trauma than treatment (Delgat, 2015, Large, Nielsen, Ryan, et al, 2008, Dennis & Monahan, 1997). Whether it is from disrespectful staff, treatment by police, or overuse of medication, involuntary care increases the mistrust of the mental health system (Hughes, Hayward & Finlay, 2009). That lack of trust leads to resistance to voluntary outpatient treatment because clients believe the system does not value their input and feedback, or are uninterested in their assessment, standpoint, of their treatment needs (Kirk, 2017, Swartz, Swanson & Hannon, 2003, New York Civil Liberties Union, 1971).
Figure 6.5
216 The Symbols of the History of Mental Illness For many centuries, until the eighteenth and nineteenth centuries, the term lunatic was asso-
ciated culturally with mental illness. “Lunatic” is derived from the Latin lunaticus, meaning “of the moon” or “moonstruck.” Historically, this word applied to epilepsy and “madness” because both appeared to be about losing control. In epilepsy, one loses physical control and “shakes” uncontrollably. In “madness,” a person loses control of their mind and “shakes” uncontrollably. Aristotle, Roman philosopher Pliny the Elder, and other philosophers in history believed that the brain was the moistest organ of the body and was most susceptible to the influences of the moon. They reasoned that when the full moon triggered high tides, the brain, like the earth, became susceptible to an intense emotional reaction. When that occurred, the full moon caused wild, bizarre, violent, out of control, and deranged behavior. For the Western world, the full moon symbolized “lunacy.”
“Lunatic”
It is the very moon She comes more near the earth Then she was wont And makes men mad. - William Shakespeare, Othello
Figure 6.6
The Symbols of the History of Mental Illness 217 “Lunatic” also comes from Luna, the divine Roman goddess of the moon. She is one of the
Roman gods that can be seen, distinguished from the unseen gods Neptune and Hercules. She brings light from the darkness. Luna is often viewed as driving a chariot called a biga, a two- horse chariot, with one white and brown horse, toward the sun god, Sol. As Luna traveled on her chariot from night to daytime toward the sun god, Sol, the brown horse keeps her seen and present in the moon throughout the day.
Since Luna is seen in Roman mythology and Mithraic iconography as a divine figure, it is a reminder that the negative modern cultural stigma of mental illness was viewed differently in some ancient cultures because of the belief that hearing voices or seeing things not there was not considered lunacy but as important messages from the divine, the gods (Ellenberger, 1970). The symbol of Luna speaks to a different experience of lunacy because out of the darkness of “lunacy” she brings light and reminds us that the moon symbolically fades every day from night into daytime, from darkness to light, from illness to health.
Figure 6.7
218 The Symbols of the History of Mental Illness “Ship of Fools”
The famous “Ship of Fools” symbolizes the belief that individuals with mental illness needed to be isolated from society because they were perceived as violent, deranged, and dangerous. These cultural efforts toward segregation and isolation are not unfamiliar to modern cultures.
The Renaissance meant rebirth for many, but not always for individuals with mental illness. In the early days of the Renaissance, inspired by the painting of Jeronimo de Bosh, El Bosco, of the same title, Sebastian Brandt (1494/1962) wrote a mythic poem called the “Ship of Fools.” The poem captured the pilgrimage of 111 “madmen” who were “not in their right minds.” They were sailing nowhere, which symbolized the historic plight of people with mental illness left by society to meander endlessly at sea with no real home, no place in European culture.
Michael Foucault (1926–1984), a twentieth-century French philosopher and strong advocate for mental health reforms, believed that “Ship of Fools” was not a myth, because in the Middle Ages, the cargo in some ships contained “fools,” another name at that time for “lunatics” (Fou- cault, 1987). These ships were not allowed to dock in any port, but the ship would get close so people on the shore could enjoy a sideshow of a ship full of “lunatics.” For Foucault, the symbol of the “Ship of Fools” symbolized the very essence of how modern society views mental illness. Unlike the empathy given to people with serious medical illnesses, there is little compassion afforded individuals with mental illness. Instead, their isolation, “meandering at sea,” gives
Figure 6.8
The Symbols of the History of Mental Illness 219 society an unenlightened sense of relief. Compassion is replaced by fear, which unleashes intol- erance, unspeakable cruelty, and a belief that permeates the lives of people with mental illness that they have no value to society.
A Rakes’ Progress – Bedlam Hospital
A Rakes’ Progress (1732–1734) is a series of eight engravings that became paintings by the eighteenth-century artist William Hogarth. It is the life story of Tom Rakewell, the rich son of a wealthy merchant, who, upon arrival in London, lived a life of debauchery. The paintings became famous in America in the 1930s by Walt Disney Productions for the graphic process known as a storyboard: the sequential illustration of images that are a previsualization of a mo- tion picture, animation, or active media sequencing.
In London Rakewell squandered all his money on prostitution, orgies and gambling which led to mental deterioration. He first was held at the Fleet Prison in London, then later at Bedlam Hospital, the infamous mental asylum in London (Einberg, 2016). Initially, A Rakes’ Progress went public, and many found the final painting disturbing. This painting depicted a well-dressed young woman, Sarah Young, who was trying to rescue him, and who was surrounded by “luna- tics.” It was not unusual during this period in history that people dressed up for a social outing
Figure 6.9
220 The Symbols of the History of Mental Illness and often paid money to visit asylums to be entertained by the bizarre behavior of the patients. This final painting came to symbolize an example of how a culture can sink into degradation, exploitation, and lack of human decency toward the vulnerable, especially individuals with mental illness.
One Flew Over the Cuckoo’s Nest
Cultural awareness of the dire situation in state mental hospitals, where shock treatment and lobotomies were being accepted as positive psychiatric treatment, was dramatically symbolized by Ken Kesey (1963) in his novel, One Flew Over the Cuckoo’s Nest.
Since the Middle Ages, the cuckoo nest was often a symbol for mental illness. In the modern One Flew Over the Cuckoo’s Nest, psychiatric rebel Randall Patrick McMurphy threatened the psychiatric institutional cuckoo nest of Nurse Mildred Ratched. This was a play on words be- cause of Kesey’s disdain for psychiatry and the emerging rat and behavioral psychology. Threat- ened by the rebellion, Nurse Ratched ordered a lobotomy, which left McMurphy like many lobotomy patients, psychologically castrated, mute, child-like, and without an adult personality.
Cuckoos have been a powerful symbol throughout history, mentioned by Aristotle and a favorite bird of the Greek goddess Hera. Cuckoos are a brood parasite bird that rely on others to raise their young. They carefully place their eggs in other host nests, which give the cuckoos time to produce other eggs to survive. Once their egg is hatched, the host bird and the parasite cuckoo become locked in an evolutionary battle for dominance.
In One Flew Over the Cuckoo’s Nest, there was a fight for dominance between McMurphy and Nurse Ratched for control of the patients who existed in the safe nest of a mental institution after being left by their parents, waiting to be reborn with the arrival of a host bird. McMurphy, the heroic figure, was the host bird inspiring the patients to fly to freedom from the parasitic and oppressive psychiatric nest of the institution.
The 1976 movie One Flew Over the Cuckoo’s Nest, starring Jack Nicholson as McMurphy and Louise Fletcher as Nurse Ratched, became a cultural phenomenon winning all five major Academy Awards. The American Film Institute rated it as one of the greatest films of all time. In 1993, the Library of Congress selected Cuckoo’s Nest for preservation in the National Film Registry because of its cultural and historical significance.
A Beautiful Mind
In 2001, the movie A Beautiful Mind was released to critical acclaim, reminding American culture that individuals with mental illness can achieve greatness, that schizophrenia can be successfully treated. The biographical drama was based on the life of American mathemati- cian and Nobel Laureate in Economics, John Nash. The film addressed the development of paranoid schizophrenia of Nash and how he endured delusional episodes. It showed in vivid detail the reality of mental illness and the lived experience of hallucinations and psychosis.
A Beautiful Mind demonstrated the importance of family, social, and cultural support, es- pecially from his wife, Alicia Nash. She continued to love and care for him through his most challenging psychotic episodes. The movie provided insight into how stigma led to social and cultural isolation from his fellow academic colleagues who struggled to understand and support him throughout his illness.
By its very title, A Beautiful Mind, the movie provided a powerful symbol for individuals with mental illness, challenging the current belief of a permanent disabling brain disease and the historic overemphasis on the “overheated and damaged brain.” The Nash story indicated that
The Symbols of the History of Mental Illness 221
a serious mental illness does not preclude great achievement, even a Nobel Prize. The movie showed how Nash became a unique and successful person beyond his diagnosis of schizophre- nia. Critics noted that the movie was not a totally accurate description of his life and that it was “too Hollywood” because most individuals with mental illness do not receive the needed psy- chiatric, familial, social, and cultural supports needed to overcome mental illness.
The movie was a cultural phenomenon, seen as inspirational and a close resemblance of how mental illness is experienced, that psychosis is real. In 2002, A Beautiful Mind was nominated for eight Academy Awards and won Best Picture of the Year as well as Best Director, Best Adapted Screenplay, and Best Supporting Actress. The American Film Institute (AFI, 2012) rated A Beautiful Mind one of the top 100 most inspiring American movies.
Historically Based Best Practices
Evidence-Based Practices (EBPs)
Evidence-based practices (EPBs) began in medicine in 1992, based on the work of epidemiolo- gist Archie Cochrane, who in 1972 argued that clinical decisions should be based on the best available research, professional expertise, and consideration of patient characteristics, culture, and preferences (Maynard & Chaimers, 1997). Clinical practices are now often categorized on a continuum of emerging, promising, leading, or best. The American Psychological Association (APA) adopted a policy statement on evidence-based best practices in psychology at their Au- gust 2005 APA Council of Representative meeting (APA, 2021).
Figure 6.10
222 The Symbols of the History of Mental Illness Because of the limited success in treating mental illness in modern times, it is important to ac-
knowledge historically based best practices (HBBPs). Family care in Geel, Belgium, and the Quaker moral treatment approaches showed positive outcomes that would be the envy of the modern mental health system. Geel providing community historically based best practices for over the 600 years. In recognition of the superiority of the Geel model for community mental health care, in 2002, the World Health Organization (WHO) designated family care as an “evidence-based best practice.”
Family Care – Adoption and a Community Approach
Six hundred years ago through the intercession and inspiration of St. Dymphna, a little commu- nity in Geel, Belgium, created a new vision that valued inclusion of individuals with mental ill- ness in community life. Once a spiritual inspiration for the cure of mental illness, St. Dymphna now inspires Geel and the world through myth.
Note: First read the myth, engage the symbol, reflect on their non-literal underlying meaning, and then read the narrative, understanding the myth can have many meanings.
Figure 6.11
Myth of St. Dymphna
There was a royal family that lived in harmony and peace in Northern Ireland until the wife of the Irish king became extremely ill. The wife had converted to Catholicism and raised her daughter as a Christian. After the wife died, the king was so inconsolable that his courtiers advised him to
The Symbols of the History of Mental Illness 223
Figure 6.12
find a new wife. He agreed, but only under the condition that the new wife bear total resemblance to his deceased wife. This became an impossible task and when the king became frustrated, one of his demonic advisors recommended that he marry his daughter, Dymphna.
The king said, “Why not?” When he approached his daughter, she was shocked and refused. He went into a psychotic rage with desire for his daughter. To escape the fury of her psychotic father, she decided to flee with her confessor priest, Gerebernus. They crossed the sea to Antwerp, Belgium, and traveled to a little town named Geel, discover- ing a humble dwelling close to a chapel.
Her father and his militia were able to follow her because, along the way, Dymphna and the priest dropped Irish coins. The coins led the king to a restaurant inn, and when the soldiers paid their bill, the landlady noted that they were paying with the same money as the recent guests, Dymphna and the priest. She pointed the Irish soldiers in the direc- tion of Dymphna’s hut and from that date forward, the landlady could not use her arm.
When the king found Dymphna, he again implored her to marry him and again she firmly declined. In a psychotic rage, he ordered his soldiers to kill the priest and, with his own hands, beheaded his daughter Dymphna on May 30, 600.
The remains of Dymphna and Gerebernus were interred in coffins of white stone. The type of stone was completely unknown in Geel, so the people believed that the martyrs were buried by Angels.
After the death of Dymphna and the priest, Geel became a sacred place, where people believed that through the intersession of these martyrs, through ritual, spiritual practices, and prayer, they could be cured of their mental illness.
224 The Symbols of the History of Mental Illness For over 600 years, the people of Geel have provided a loving community to individuals
with mental illness (Byrne, 1869). For hundreds of years, individuals with mental illness have journeyed to Geel to be cured. Initially, it was a religious pilgrimage, where the healing oc- curred through spiritual intervention. Frank Fahey (2002) distinguishes a tourist from a pilgrim. A pilgrim always has “faith expectancy,” meaning a search for psychological wholeness; the feeling of being part of a faithful community; the silence to create internal sacred space; ritual to externalize the change, votive offerings to leave something behind; a celebration of “victory over self”; perseverance; and a commitment that the pilgrimage is never over.
It is not only Christians that pilgrimage to sacred places. Buddhists pilgrimage to Mahabodhi Temple in India, where Buddha attained enlightenment. Kumbh Mela is one of the largest gath- erings in the world for Hindu pilgrims to bathe in the holy and sacred rivers. For Muslims, the Hajj pilgrimage to Mecca is a one of the five pillars of Islam, a pilgrimage required for every healthy Muslim during their lifetime. For Jews, the pilgrimage to the Temple of Solomon ended after its destruction by the Romans in in 70 CE. The Western Wall is now the most sacred and visited pilgrimage site for Jews. The Western Wall is the only remaining part of the Second Jewish Temple in the Old City of Jerusalem, which was off-limits to Jews from 1948–1967, when East Jerusalem was under Jordanian control.
The seashell symbolizes the key element of any pilgrimage: a natural bowl holding water and food needed throughout a pilgrimage, without which one could not survive. In the Birth of Venus, the Renaissance painter Sando Botticelli (1445–1510) painted Venus, the Greek goddess of love and of rebirth. She arises from a large scallop seashell and symbolizes how natural beauty can open the mind to experience spiritual beauty; the beauty that exists deep within every human soul.
St. Dymphna became the Venus of Geel, providing the inspiration for the rebirth of those strug- gling with mental illness. From all over Europe, thousands of pilgrims descended on the small town of Geel, Belgium. Because St. Dymphna had overcome evil, the devil, the psychosis of her father, thousands believed that through her intercession they too could overcome their own mental illness. So many came that the church fathers had to build special rooms to house the pilgrims next to the cathedral, built in her honor, a church still of worship in modern times They also built a hospital close by the church because in the fifteenth century it was believed that mental and physical illnesses had a spiritual component. Throughout the world, St. Dymphna became a symbol of the hope of recovery, even a cure for mental illness, as the patron saint of the mentally ill. St. Dymphna became the inspira- tion for family care, a system to treat mental illness through adoption and community empowerment.
The spiritual interventions proved so successful that the priests became overwhelmed by all the pilgrims and asked the Geel farmers for help (Liegoeis, 1991). On the farms, individuals with mental illness became valued and needed workers to the amazement of the farmers, who found them to be more reliable than many of the so-called normal workers. For the farmers, the “miracles” had both spiritual and human implications. The farmers began to reject the ste- reotype that this population was “useless to society” or even demonic. The result was that indi- viduals with mental illness became an essential Geel workforce, and farmers started “to adopt” them, making them important members of their families. They also became valued members of Geel society, involved in all aspects of Geel daily life, which included the social discourse that occurs in cafes and pubs where they began to be accepted as equals and hard-working citizens.
Between 1900 and 1973, thousands of individuals with mental illness journeyed to Geel for healing (Goldstein & Godemont, 2003). The peak came in 1937, when over 3,800 individuals journeyed to Geel, which at that time, had a population of only 15,000. The change in approach necessitated a change in what to call these new citizens. Initially, they were called boarders, then patients, and now clients and family members. Family members were initially called board givers, and now foster mothers, fathers, or parents. From the beginning the success of family care has been more dependent on the family and less, although important, on professionals.
The Symbols of the History of Mental Illness 225 In 1970, out of concern that family care might end, anthropologist Leo Srole, of Columbia Uni-
versity, completed an eight-year National Institute of Mental Health (NIMH) research grant whose purpose was to rescue family care from extinction and to document the history of the legend- ary program. The Geel Research Project (Srole, 1975) studied the behaviors of individuals with mental illness outside the family in the wider community, in the streets, churches, cafes, cinemas, stores, and other public places. Srole found that most individuals with mental illness had become respected, even treasured, members of their foster family; that the medical model was not essential for their healing; and that the family, not professionals, served as the essential caretaker, teacher, and role model. Most importantly, and to the amazement of many mental health professionals around the world, the mentally ill were active and valued members in all aspects of Geel daily life.
Although struggling through many challenges, family care remains alive and well in Geel, Belgium (Srole, 1977). The family care program had to adjust to the reality that Geel is no longer an agricultural community (Roosens & Van de Walle, 2007). Adoptions by the modern two-parent family have created new challenges, since a small family does not often have the human and financial resources of a farm. Belgium health authorities realized that the program needed to be modernized and, in 1991, family care and the regional psychiatric care were inte- grated into State Hospital Geel.
In 2006, the name was changed to State Psychiatric Care Center, OPZ, removing the name hospital to reflect the move from a medical to a community treatment model. To reflect the ongoing commitment to preserve family care, in 2006, a new, modern OPZ building and campus were inaugurated. The impressive grounds provide a rich number of mental health programs, including a new 135-bed psychiatric hospital. Besides family care, there are mental health programs for adults, youths, geriatrics, medical inpatients; long-term residential care; day treatment; job training; somatic medicine; clubhouse; and places for leisure and sport activities.
Family care adoption is not a legal process. Individuals with mental illness stay connected to their natural families. However, some families are better suited to handle mental illness than others. Great care is given by the OPZ staff when deciding on a family placement. Since family matches are based on behavioral, not medical, or psychiatric criteria, families are not given a psychiatric diagnosis. Families must have a stable income, no criminal record, and be com- mitted to work closely with the OPZ staff, but most importantly to commit to making a person with mental illness an active and valued member of their family. This means involvement in all aspects of family daily life, including taking vacations together.
In the 1970s, families rebelled against clergy and professionals because they believed they were not being fully appreciated. They also opposed the church and mental health system aban- donment of the legacy and importance of St. Dymphna. In response, family advisory committees were formed to empower families, since it was acknowledged that families continued to be the backbone of this legendary program. Families have no formal training but are provided 24-hour support by a lead nurse case manager and a multidisciplinary team that serves 24–30 clients. This team consists of social workers, physicians, psychiatrists, occupational therapists, and, when needed, psychologists. The entire town is considered a “hospital” for financial reimburse- ment and treatment purposes.
OPZ receives state funds for administration, professional staff, and care for the facilities and provides families with an adoption payment. In 2013, families received a daily stipend of around $22–$32, which is negotiable depending on the needs of the client. When a family mem- ber needs a psychiatric hospitalization, “no questions are asked” since a bed in a Geel family home is technically considered a hospital bed. The nurse case manager is called and coordinates the admission to the hospital. The client receives, unlike in most psychiatric hospitals through- out the world, their own private bed.
226 The Symbols of the History of Mental Illness This innovative approach to hospitalization cannot be overstated. In the United States, hos-
pitalization for mental illness is often mired in bureaucracy, red tape, and the involvement of untrained law enforcement personnel. Because of the lack of adequate crisis and emergency resources, individuals with mental illness are often forced into treatment against their will. In the United States, police officers are usually the first responders to a mental health crisis, which includes an assessment for an involuntary hospitalization (Dean, Steadman, Borum, et al, 1999). Involuntary care occurs when there is a determination that an individual is a danger to self or others, is or gravely disabled because of a mental disorder. The fact that in Geel a hospitaliza- tion is seamless and done in the most humane manner again speaks to the inadequacy of the crisis and emergency services for mental illness in the United States. It also speaks to the lack of funding for community mental health services since research indicates that quality community mental health services decrease the need for hospitalizations.
The pilgrimages are over. St. Dymphna has been symbolically secularized to the name of a Geel Shopping Mall, a high school, or a city street. She is also absent from the new modern OPZ treatment buildings, her statue left as a relic at the entrance in Geel of the old, empty central hospital admission building. However, her statue is seen in family homes, families saving her legacy by demanding a parade every five years to honor her on her feast day. A parade of the re- mains of St. Dymphna and priest Gerebernus are carried through the streets before their return to the church named in her honor. After the parade, the mayor honors those families that continue to adopt and support this legendry program, which continues to inspire the millions around the world who envision more effective community approaches to the treatment of mental illness.
Personal Reflections
When I visited Geel, Belgium, in 2013, I was amazed at the perception that individuals with mental illness were perceived so positively and with such deep respect. One memory was a waitress in a café speaking proudly of the long history in Geel of adopting individu- als with mental illness and how her family and neighbors had continued that proud history of family care. I wondered if this could ever happen in my country that a local waitress would so proudly represent their local community mental health system.
The spirit of St. Dymphna dominated the town, the cathedral, the high school, street signs, and even retail stores. Although the current leaders of family care show little inter- est in her myth and church leaders have abandoned the belief that her intercession could help cure mental illness, the family members we met often had her statue in their home. Families, unlike many of the professionals we met, understood that in stripping the spirit of St. Dymphna something important was being lost, although they fought for her ac- knowledgment every five years on her feast day. It is another reminder that myths and symbols are needed to touch people beyond ordinary understanding.
I began to realize that I was on my own pilgrimage to Geel. After being a community mental health director for over 20 years in two California counties (Shasta and Santa Barbara), the myth of St. Dymphna had inspired my pilgrimage to Geel. I wanted to see for myself what it would be like for a community to value and integrate individuals with mental illness into civic life. As I was leaving Geel, I knew that I could never leave, that the spirit of the 600-year-old program would forever touch my soul. When I lit the votive candle in the church of St. Dymphna, I felt I was leaving a little of myself behind, that my many years of public service were not in vain.
The Symbols of the History of Mental Illness 227 The Geel Question
Although there were some worldwide efforts to model the Geel approach, it has often been argued that the Geel model was implausible for the rest of the world. This argument began with Philippe Pinel (1745–1826), a French physician, who was the liberator of the mentally ill. He is often pictured symbolically removing the “chains” of individuals with mental illness while in a crowded dungeon. The removal of the chains would forever symbolize legitimizing mental illness as a medical problem and replacing the terms “mad” and “possession of the devil” with “patient” (Pinel, 1806/1988).
Pinel, influenced by the Enlightenment, believed in a more humane approach to mental ill- ness and established the asylum system that would become the worldwide institutional model for treating mental illness, He created the Hospice de la Salpetriere, a 600-bed asylum for indi- viduals with mental illness. This began a medical model approach to mental illness that included early attempts at psychiatric diagnosis and the creation of medical records to document medical progress. Salpetriere would later become the historic home to Charcot and Freud, and other early pioneers in psychoanalysis.
Pinel was influenced by the renowned French Enlightenment philosophy of Etienne Bonnot de Condillac (1714–1780), an empirical psychologist who utilized the symbol of a statue to explain empiricism. Condillac imagined a statue organized inwardly like a person and animated by a soul that had never received an idea nor a sensation. In his theory, the mind is formed as the statue symbolically unlocks each sensation, starting with smell and then each of the senses. Disagreeing with Locke and other philosophers of his time, Condillac believed consciousness results from the psychological transformation of physical sensations and their associations, not from abstract intuitive rational analysis (Hine, 1979).
Pinel approached mental illness from an empirical, Condillacian, physician-oriented phi- losophy (Pinel, 1806/1988). This laid the foundation for the subsequent medical model that
Figure 6.13
228 The Symbols of the History of Mental Illness throughout history became the dominant model for treating mental illness. The Pinel approach places the doctor, the knowledgeable empirical scientist, at the center of treatment; “the doctor knows best.” The physician as the key determinant in healing mental illness came into direct conflict with the Geel model, which argued that it is the family and the community, and not the physician, that is the key factor in healing mental illness.
Jean-Etienne Esquirol (1772–1840), a student and fervent follower and chosen successor of Pinel, recognized as the earliest proponent of the complete medicalization of mental illness, insisted that a new asylum be under total physician direction. In 1821, he visited Geel and was amazed how “lunatics” were roaming the streets unsupervised. Although an advocate for a hu- mane approach, he criticized the Geel model as lacking physician control and quality medical treatments. Another reason for Esquirol’s disdain for the Geel model was his belief that Geel physicians had betrayed the medical model by allowing the myth of a Catholic saint, St. Dym- phna, to interfere in the practice of modern scientific medicine (Roosens & de Walle, 2007). When the French conquered Belgium during the French Revolution, in their anti-religious furor they made every attempt to end family care and suppress any mention of St. Dymphna.
As Pinel and his followers developed asylums in the nineteenth century, doctors from all over the world traveled to Geel “to see the miracle.” This resulted in psychiatrists considering the question that continues to be asked worldwide regarding the best ways to treat mental illness. The famous Geel Question: Is the Geel model based on sound practices that could be exported to the rest of the world and is it superior to the new developing asylums? In other words, should mentally ill people be treated safely in institutions, or should they be integrated into the daily life of the community? In 1902, the International Congress of Psychiatry met in Antwerp, Bel- gium, to address the Geel Question. The answer was a resounding endorsement of the Geel model (Jay, 2015). The final recommendation was, wherever possible, the community model should be exported. After the Congress, the Geel community model spread quickly and, within a few years, 32 new programs started in Germany alone. It is estimated that there are now over 200 Geel-oriented programs throughout the world.
In America, there would be a different response. John Parigot (1865), the first colony medical director, visited Geel in 1865 and was impressed with the community model and argued that it was more humane and cost effective. Upon his return from Europe, his endorsement was totally rejected. The development of moral treatment and an emerging eugenics movement would take America on a different path toward institutional, not community, care.
Quaker Moral Treatment
Oppression…makes a wiseman mad…is it supposed that…insults…injuries…make a wiseman wise…why is furious mania almost a stranger at the Retreat…why all patients wear clothes, and are generally induced to cooperate to adopt orderly habits?
- William Tuke (Whitaker, p. 23)
In eighteenth-century England, another spiritual, historically based best practice would emerge from the Quakers. The trigger was the death of a Quaker, Hannah Mills, after her admission to the York Asylum. Before her death, she was not allowed any visitation from her family or friends, which led William Tuke (1827–1895) to investigate the asylum and find horrific medical practices (Whitaker, 2019). Tuke discovered that under the direction of physicians and asylum medicine, mentally ill people were being treated like wild animals and subjected to the most horrific torture. Doctors explained that the only way to control “these wild animals” was heroic
The Symbols of the History of Mental Illness 229 medicine, which had a tranquilizing effect, causing extreme physical weakness and submission. This occurred by the regular use of purges, emetics, and other nausea-inducing agents. Addi- tionally, this included a draconian approach and dangerous practice of bleeding the blood of the mentally ill by life-threatening cuts into the jugular vein.
The doctors in England found that hydrotherapy was another effective way to tranquilize pa- tients. Hydrotherapy mummified the patient in a wet cloth or by continually spraying the client with water and without warning dropping the agitated patient into an ice-cold bath. The patient, often screaming for mercy, was strapped into the tub with a canvas sheet covering the tub with just the head of the patient poking out. The bath could last for several hours or even several days until the patient denied their psychosis, depression, or suicidal thoughts. This practice continued well into the twentieth century and provides another symbol of the dark shadow of asylum medicine.
In response, Tuke embraced moral treatment, which combined Enlightenment philosophy with Quaker theology (Glover & Glover, 1984).The appeal for moral treatment was the Enlight- enment philosophy of social justice, human rights, and the power of reason. To many thinkers of the day, the Age of Reason did not apply to individuals with mental illness, as they were perceived as incapable of reason, and to be more like animals than humans.
Jean-Baptiste Pussin (1746–1811), an Enlightenment thinker, became the hospital super- intendent after Pinel of the renown LaBicere asylum in Paris. His approach, unlike Pinel, was primarily psychological because he believed having intimate, rational conversations with in- dividuals with mental illness led to significant healing (Weiner, 1979). By living daily among the mentally ill in the asylum, Pussin learned to appreciate their worth as unique, rational, and worthwhile human beings. His approach so impressed Pinel that he embraced moral treatment.
Tuke embraced moral treatment from primarily his Quaker faith and from his outrage and total rejection of asylums. Inspired by his faith, he approached mental illness differently (Glover & Glover, 1984). He was not impressed with physician-controlled asylums and believed it was not a medical asylum or hospital that was needed. Mentally ill people needed a place to retreat from the world that was based on Quaker principles. After two years of studying “madness” and the treatments of the day, in 1796, Tuke opened The Retreat. Also known as the York Retreat, it was founded on the core Quaker belief that “each soul is guided by an inner light.” This was a truly revolutionary approach in history when most often individuals with mental illness were as- sociated with acting like animals and being possessed by the devil. The Retreat is a symbol that continues to inspire reform throughout the psychiatric world, especially the current strength- based, rehabilitative approach to mental illness in community mental health (Bockoven, 1972).
The Quakers, known as the Religious Society of Friends, were founded by George Fox in 1650. They were known for their peaceful and progressive principles. Their doctrine of the “inner light” led to a rejection of a formal ministry and ritualistic forms of worship (Martin, 2016). There was no need for a “middleman” or a structured institution because the “inner light” came from a direct relationship with Jesus. The name “Quaker” originated from the idea that one would feel a spiritual “quake” when they heard the word of God. Besides their humane treatment of individuals with mental illness, the Quakers were part of early movements to end slavery and promote equal rights for women. They paid dearly for their beliefs, especially when they immigrated to a Puritan America, where they suffered discrimination and violence and were often beaten, murdered, and ostracized. In the mid-1650s, Massachusetts outlawed and fined anyone associated with the Quakers. During this time, if a Quaker was found in the Mas- sachusetts colony, Puritans were permitted by law to cut off their ears (Brayshaw, 1911).
As in Geel, the York Retreat model first and foremost treated the mentally ill as valued mem- bers of the Quaker family. As with any family, the expression of kindness, love, attentiveness, and respectful discipline brought order that was missing in asylum medicine.
230 The Symbols of the History of Mental Illness They adopted an approach that dated back to the Greeks and Aeschylus, the father of Greek
tragedy. In the play The Oresteia, Aeschylus (1975) dramatized the development of an internal psychology not directed by the gods from above but from a force from within, an inner light. Aeschylus used the power of symbol to dramatize his new psychology and showed how Zeus and Apollo symbolized the old gods who controlled the outer world while Athena symbolized the new order, the inner light. Through his play, Aeschylus reveled how the gods of Olympus could be experienced psychologically inside each person.
Aeschylus, like Pussin, explained that the best way to deal with internal psychological dis- turbance was through “soft speech.” “Soft speech,” discovered 2,000 years earlier, became a foundational principle of moral treatment (Barrientos, 2002). Gone from The Retreat was the verbal abuse and punitive environment of the asylums (Whitaker, 2019). The Quakers discov- ered that verbal or physical punishment only made mental illness worse; listening and engaging in the “soft speech” of Aeschylus was the key to healing.
Some confuse The Retreat with asylums. Although both had an institutional approach, they were significantly different in attitude and leadership. The main asylums were managed by phy- sicians who practiced the medical model. The Retreat opposed the medical model and operated under Enlightenment and Quaker philosophies. Many asylums under physician control adopted moral treatment, but the physical environment of The Retreat provided a dramatic contrast be- tween the two approaches.
The physical layout of The Retreat expressed a home, not a hospital (C. Cherry, 1989). The setting consisted of small, cottage-like homes that emphasized the importance of family and not doctors. Limited to around 250 patients, the environment was attractive with lush gardens and beautiful flowers. The superintendent had to be a compassionate leader, not necessarily a physi- cian, and operate from the Quaker principle that the light of God exists in everyone. The need for restraints and barbaric interventions decreased because positive behaviors were rewarded.
Figure 6.14
The Symbols of the History of Mental Illness 231 Negative behaviors were minimized by distraction to more productive activities. George Jepson, the first superintendent of the York Retreat, had no formal medical training. However, his authori- tative, yet compassionate approach proved much more effective than the authoritarian physician approach of asylum medicine. After his marriage to Retreat nurse, Katherine Allen, the Quaker value of equality between the sexes resulted in both Jepson and Allen managing the Retreat to- gether, as co-leaders. During this time in history, this was an unusual acknowledgment for women.
At The Retreat, occupational therapy was utilized for the first time in an institutional setting (Tuke & Bucknill, 1827). Geel had already proven that individuals with illness could be productive mem- bers of the community. In The Retreat setting, occupational therapy provided hope that by learning an occupation and real-world vocational skills, a productive life could await outside the institution. Throughout history, it was often the case that when an individual with mental illness was admitted to an asylum or mental hospital it was for life (Penney & Stastry, 2008). In fact, upon admission, they would often be measured for their burial gown and, after their death, be buried in unmarked grave sites on asylum or mental hospital grounds. To prevent this fate, occupational therapy was essential.
Astonishingly, during the first 15 years the Retreat existed, 70 percent of the patients who had been ill for less than 12 months fully recovered, defined by Tuke as never having a relapse. Of those that had a history of mental illness, viewed as incurable, 25 percent fully recovered (Whitaker, 2019). Outcomes that would be the envy of modern approaches to mental illness.
The contrast between The Retreat and modern psychiatric inpatient settings could not be more dramatic. For a medical and psychiatric system preoccupied with evidence-based best practices, clearly the Retreat experience indicates that the creation of a homelike environment could reduce the violence and the need for restraints and seclusion rooms that often plague our modern psychiatric hospitals.
The symbol speaks to the historic failure to develop crisis services that are conducive to healing mental illness. When in psychological distress, being in an environment not de- signed with mental illness in mind, sets the stage for the type of care from which the Quakers rebelled.
Figure 6.15
232 The Symbols of the History of Mental Illness Moral Treatment in the United States
Although moral treatment was slow to gain traction in America, it was Thomas Kirkbride (1809–1883), a Quaker, who, in 1840 became superintendent of the Pennsylvania Hospital for the Insane, would have the biggest impact on early American asylum treatment. As an envi- ronmental determinist, he created a therapeutic, not medical, oriented environment; Kirkbride designed the “archetypal” design for moral treatment.
Kirkbride (1854) developed the vision for the emerging asylums in the United States (Yanni, 2007). The Kirkbride Plan would become the model for the construction of asylums into the twentieth century. Kirkbride believed that the environment, especially exposure to light and air circulation, was crucial to any building that housed the mentally ill. The Pennsylvania Hospital was an opulent place. There was a large, lovely dining room for social activities and even for for- mal dinners in which the patients often dressed in suits and ties. The Pennsylvania Hospital had a museum for education and amusement. The grounds were meticulous, with lush gardens and flow- erbeds, which not only made the environment more therapeutic, but showed how nature mirrored the healing process. Teachers were hired to provide education, especially in reading and sewing. In the evening, entertainment was of such quality that it made the locals envious. The key was the limitation of 250 patients so that everyone received special individual care. This limitation allowed the Pennsylvania Hospital to provide each person a semiprivate room that resembled a pleasant hotel room. Each room was furnished with the best quality furniture and was adorned with beauti- ful wall hangings. Like The Retreat in York, England, the Kirkbride Plan became a symbol of a home-like and healing environment, creating the feeling of being part of a loving family.
Personal Reflections
In the late 1980s, Shasta County followed most California counties and closed its county hospital. The impact on medical care, especially for the poor, was immediate and nega- tive, since the remaining two private hospitals in Redding, California, made it clear they had no intention of filling the medical gap by serving the poor. The inpatient psychiatric unit remained in the closed hospital, which provided an opportunity to relocate outpatient services from downtown Redding to a remodeled hospital that would integrate inpatient and outpatient mental health services.
With significant county support, the old hospital was transformed into a therapeutic en- vironment. Clients entered the building through a grassy knoll and fountain and the facil- ity was filled with beautiful paintings and modern up-to-date offices. One client remarked, “What did we do to deserve this?” Although during my administration, the inpatient unit was remodeled twice, I came to understand the limitations of serving individuals with mental illness in crisis within a former acute medical unit. In Santa Barbara, there was a similar problem of providing inpatient services in an old county hospital.
In response, an outpatient crisis service was provided in a homelike environment in downtown Santa Barbara. The incidents of violence and need for involuntary admissions decreased, which, in the spirit of Kirkbride and moral treatment, indicated that the mental health crisis system is not only dysfunctional but inhumane, because it does not provide the environment necessary for healing and recovery, which leads to an overdependency on medication and use of seclusion and restraint to respond to out-of-control behaviors. I came to understand that a totally different mental health crisis system is needed including a different environment, a non-medical, setting to adequately serve individuals with mental illness in crisis, setting the stage for a more positive experience of the mental health system.
The Symbols of the History of Mental Illness 233 A Half Century of Darkness: 1900–1950
The End of Moral Treatment
Medical Takeover of State Mental Hospitals
The unintended consequences of Dix’s reforms led to the proliferation of state mental health hospitals throughout the United States. These were not the asylums in the Tuke, Kirkbride, and Quaker tradition. State mental hospitals became “dumping grounds” for other illnesses considered problematic for society. Individuals with mental illness now shared their hospitals with alcoholics, syphilitics, and the senile elderly. In 1840, there were only 2,500 individuals with mental illness in eighteen state mental hospitals or asylums in the United States. By the end of the nineteenth century, there would be over 74,000 individuals in 139 state hospitals and asylums (Whitaker, 2019). Gone from the growing number of state mental hospitals were the 250-bed limitations and the focus on creating a homelike environment. As physicians took over the Quaker facilities, the emphasis shifted to a medical model, uninterested in such unscientific Quaker beliefs such as the “light of God exists in everyone.”
After the Civil War, a whole new medical profession needed patients. During the war, neu- rology expanded to treat gunshot victims and after the war, neurologists felt a new level of im- portance. They believed they were best situated to treat the “brain disease” of individuals with mental illness and went on a direct assault on the asylum superintendents, whom they perceived as unqualified to treat mental illness. Many southern psychiatrists had a difficult time adjusting to the post–Civil War world. Samuel A Cartwright (1851) created a new medical diagnosis, dra- petomania, from the Greek root, meaning “crazy runaway slave.” Drapetomania was a mental illness that caused enslaved people to run away from their slave holders. The root of the mental problem was that those enslaved were “getting too familiar” with their owners, which gave those enslaved the feeling of equality. Not to be satisfied with a new racist mental illness, he added dysesthesias aethiopica, a mental illness that caused slaves to be lazy (Cartwright, 1851). One symptom was insensitivity of the skin, and the cure was to stimulate the skin by whippings, which caused massive lesions on the backs of the enslaved.
Meanwhile Quaker visionaries began to fade from the scene. Tuke died in 1822 of a paralytic attack, still living in his York Retreat. Kirkbride died in 1883 of pneumonia at his home at the Pennsylvania Hospital for the Insane. Dix died in 1887 at the asylum built from her political advocacy, Trenton State Hospital. They died as they had lived: living close and providing love to those they believed society had a moral obligation to uplift and value as individuals.
Kirkbride had founded the Association for of Medical Superintendents of American Institu- tions for the Insane (AMSAII). The AMSAII became the first specialized professional organi- zation in America and laid the foundation for the future American Psychiatric Association. The Civil War neurologists mocked the AMSAII for not having any mention of “science” in its preamble and documents. This began an onslaught that would in large part remove from psy- chiatric history a fair analysis of the successful moral treatment approach. Some of the results were phenomenal by current standards. Not only did individuals with mental illness leave the asylums, but many never returned. Most asylums that practiced moral treatment reported that over 50 percent successfully recovered (Whitaker, 2019). Over 80 percent recovered if the ill- ness was treated within a year of its emergence, indicating the importance of early intervention, crisis services, and public education.
The attacks on moral treatment were relentless, with doctors claiming that asylum doctors were old-fashioned charlatans who knew nothing about psychopathology, diagnosis, and treat- ment of insanity. They ridiculed the asylums as “deadly for the insane” and advocated for the
234 The Symbols of the History of Mental Illness new day when science, not “spiritual quacks,” would cure insanity. Since insanity was now a brain disease, it was only medically trained physicians, who were deemed competent to treat mental illness.
Scourge of Eugenics
Why do we preserve these useless and harmful beings? The abnormal prevent the development of the normal. This fact must be squarely faced. Why should society not dispose of the criminal and the insane in a more economical manner.
- Dr. Alexis Carrel (1938), Nobel Prize Winner, Rockefeller University
Eugen Bleuler (1857–1939), a eugenicist and advocate of sterilization, coined the term schizo- phrenia during a lecture in Berlin in April 1908. The word schizophrenia originates from the Greek root of schizo, meaning “broken,” and phrenos, for “mind.” Bleuler continued the earlier work of Emil Kraepelin (1856–1926), who used the term dementia praecox to describe schizo- phrenic symptoms. Both believed schizophrenia was the result of a deteriorating brain. How- ever, Bleuler thought that the central characteristic of schizophrenia was a dissociative split in the personality between the affective and intellectual, the rational and irrational (Berrios, 2011). This led to the cultural misunderstanding that schizophrenia is two separate personalities.
Doctors quickly changed the name of the ASMSAII to the American Medico-Psychological Association and vowed to replace the fraudulent treatments of the Quakers with science and medicine. The reforms that were initiated a century before against the horrific science and dan- gerous heroic medicine practiced by doctors came to an abrupt ending. The Quakers, a group of pacifists, provided no resistance, which ushered in one of the darkest periods for the mentally ill in American history.
Acknowledging failure has never been easy for physicians, However, most objective observ- ers would acknowledge that the twentieth century was not a great century for the treatment of mental illness (Beam, 2001). But it is the first half of the century that was especially dark and brutal. As the new century began, so did some of the most gruesome approaches to mental illness in history. Between the cold brutal forces of the medical model and the rise of eugen- ics, individuals with mental illness were powerless, with no civil rights or legal protections. They became a great scapegoat for the powerful to advance their scientific theories and medical practices.
As immigrants arrived from abroad, concern arose in the White Anglo-Saxon Protestant (WASP) class that their dominance in American culture was slipping away. Eugenics was ap- pealing because it reinforced the belief that people from abroad carried “bad plasma” and were lowering the quality of the American genetic pool. This belief was reinforced by the growing number of slums and people living in poverty. Social Darwinism was also appealing because of its belief that it was natural for the strong to survive. Social programs only delayed the in- evitable demise of the weak. In the meantime, the best way to eliminate the weak was through programs that isolated or prohibited the weak from procreation. Mental hospitals were no longer places for treatment but essential institutions for isolating individuals with mental illness from society, and society from their “bad plasma.” Under the guise of empirical science, psychia- try embraced the medical model and psychologists embraced eugenics. Left without any true organized professional advocacy, individuals with mental illness became easy pawns for the emerging psychiatric and psychological associations. Psychiatrists could now prove they were real doctors and psychologists could prove they were real scientists.
The Symbols of the History of Mental Illness 235 Thomas Galton, an Englishman, coined the term eugenics, from the Greek word for “well
bred.” He divided race into two classes: the eugenic well born and the cacogenic poor born classes. Individuals with mental illness were the poor born and Galton supported American ef- forts to sterilize and isolate them from society. After traveling to England and meeting Galton, Charles Davenport became a leading American convert to eugenics. Galton supported Dav- enport’s effort to fund the Eugenics Record Office. This would become an important force in “weeding out” the defectives in society. The Eugenics Record Office would become the national leader in translating empirical research findings throughout the country into societal laws, espe- cially compulsory sterilization.
In Heredity in Relation to Eugenics, Davenport (1911) described in glowing terms his own immigrant family history dating back a couple of hundred years. He described his “own white people” as people who loved liberty and who became social leaders and brilliant scholars. He believed the new immigrants were much different and inferior to earlier immigrants. To prove his point, Davenport used racist stereotypes that would become familiar themes within the eugenics movement. The arriving “hordes of Jews” were inferior to the British and Scan- dinavian people; the Irish were prone to alcoholism; the Italians were lazy and susceptible to criminal behavior; and the newly arrived black Portuguese agricultural workers lacked intelligence.
The state mental hospitals became a key part of the eugenic plan to isolate “mental defec- tives” from society. By the 1940s, of the over 500,000 people who were in state mental hospi- tals, only half were mentally ill (Whitaker, 2019). As the eugenicists achieved one major goal of isolating “mental defectives,” they turned their efforts to state legislatures and the Supreme Court to legalize compulsory sterilization. In 1907, Indiana became the first state to pass com- pulsory sterilization. Scientists provided so-called empirical evidence that heredity played a ma- jor role in the transmission of crime, alcoholism, “mental retardation,” and mental illness. Over the next 20 years, 30 states would pass compulsory sterilization legislation based on scientific testimony that defectives bred defectives.
As bad science became bad law, in 1927, the infamous Supreme Court Case, Buck v. Bell, in an 8–1 ruling, would come to symbolize the unholy alliance and shadow of science, medicine, and the judiciary (Cohen, 2016). These fields worked together to impose compulsory steriliza- tion of individuals legally and medically with mental illness. The eugenic movement made Carrie Buck a human symbol for their sterilization campaign, by calling her feebleminded and an imbecile. History has shown that professional people in the name of the eugenics movement fabricated medical, scientific, and legal information (Cohen, 2016). As it turned out, Carrie Buck was not “feebleminded” or an “imbecile.” But, by the time history cleared her name, the damage was done and compulsory sterilizations of the mentally ill became law.
The Supreme Court found that there was scientific evidence that hereditary played an impor- tant role in creating social problems and mental illness. Justice Wendell Holmes, often acknowl- edged as one of the greatest Supreme Court justices, argued that instead of waiting to execute criminals or letting individuals with mental illness starve to death, the more humane solution was for society to sterilize them (Cohen, 2016). Rarely is this case mentioned as an important civil rights case in legal lawbooks or important civil rights case in judicial literature or educa- tion. In a 1,778-page American Constitutional Law text, there is barely one sentence and one footnote regarding the Buck v. Bell case (Cohen, 2016). It was only in 1981 that Oregon ordered its last forced sterilization and between 2006 and 2010, 150 women were sterilized, often with- out their consent, in California prisons.
After the 1927 Supreme Court decision, compulsory sterilization increased expeditiously across the nation. Support came from many surprising quarters, including the national media.
236 The Symbols of the History of Mental Illness Editorials in the prestigious New York Times and the New England Journal of Medicine over- whelmingly endorsed compulsory sterilization. Public opinion polls showed that most of the American public supported forced sterilization of “mental defectives.” By the 1940s, over 45,000 Americans had been sterilized, with half performed in state mental hospitals. California performed the most sterilizations of any state (Whitaker, 2019).
Doctors rationalized that compulsory sterilization was therapeutic, since the male testicles of individuals with mental illness were larger than the normal male population. Cutting the vas deferens was proving to be a new effective treatment for mental illness. Sterilization was not popular in Europe except in Nazi Germany, where eugenics was implemented on a grand level and practiced the effectiveness of their new gas chambers. Seventy thousand individuals with mental illness were murdered before this practice was expanded to the Jews and other popula- tions. During the Nuremberg Trials of 1947, Nazis, who performed 375,000 forced eugenic sterilizations, cited Buck v. Bell as a defense.
Although the eugenics movement was eventually discredited by the 1950s, psychiatrists and psychologists who supported eugenic policies for many years never advocated for the Supreme Court to overturn Buck v. Bell, which still allows individuals with mental illness to be legally sterilized against their will. By the 1950s, a dark pessimism began to occur in the state mental hospitals, because, in contrast to Quaker-run asylums, only 15 percent of individuals were being discharged back to the community.
The Shock Therapy Generation in Psychiatry
As general medicine made progress in the treatment of cholera, diphtheria, typhoid, tu- berculous, and other serious medical illnesses, psychiatry showed little progress in the treatment of mental illness. In the medical world, psychiatrists began to be perceived as the weakest and most incompetent of physicians. To improve their status, psychiatrists turned to some of the most controversial, critics said draconian, approaches to mental illness in the hope to increase their status as competent physicians. Called “therapies,” psychiatrists ex- perimented in state mental hospitals, where most individuals with mental illness were now safely locked away from society. These therapies would come to symbolize the ultimate demise of state mental hospitals throughout the United States. Since mental illness was now perceived only as a brain disease with psychology and sociology minimized, psychia- try turned to “shocking” the brain by a variety of methods under the guise that these new and innovative treatments could possibly cure mental illness. The idea that mental illness was caused by an “overheated” brain had returned, and psychiatry now had the full force of modern chemicals, drugs, and technology at their disposal to prove their value to the medical community.
Insulin Coma Shock Therapy
Insulin, a hormone developed in the early 1920s, draws sugar from the blood into the muscles. A Viennese psychiatrist, Manfred Sakel (1900–1957) had found that small doses of insulin had helped morphine addicts cope with their withdrawal symptoms. He thought the insulin coma shock therapy approach might help patients with schizophrenia. In insulin coma shock therapy, the brain was deprived of essential brain sugar, so brain cells “starved” of sugar would shut down. This action would shock the higher intellectual brain functions with the hope of decreas- ing psychosis.
Deprived of insulin, the patient would go into a coma, often near death, for up to two hours. Twenty to 60 treatments could occur over a brief period as patients regressed to a childlike
The Symbols of the History of Mental Illness 237 state, which many doctors saw as the opportunity for “rebirth.” As more research occurred, it became clear that depriving the brain of insulin could result in neurological shrinkage, hem- orrhaging of the brain, destruction of nerve tissue in the central cortex, and cause permanent damage to the central nervous system. Although insulin coma shock therapy was an abysmal failure, psychiatrists continued the practice until the 1950s, even as they observed that most discharged patients who had received this therapy quickly returned to the hospital (Palmer, 1950). By conservative estimates, at least 5 percent of state mental hospital patients were dy- ing from this treatment.
Insulin shock therapy became a fascination of the public. It was positively represented in the 1940 film Kildare’s Strange Case, in which Dr. Kildare was cured of schizophrenia. Insulin shock therapy was also shown in a sinister light in the 1946 film, Shock, in which Vincent Price plots to murder a patient using an overdose of insulin to cover up his own murder.
Figure 6.16
238 The Symbols of the History of Mental Illness Metrazol Convulsion Shock Therapy
Since insulin shock coma therapy was costly because it took a significant amount of profes- sional and staff time, state mental hospitals looked for cheaper methods. Metrazol convulsion shock therapy required the injection of Metrazol, a powerful central nervous system (CNS) stimulant. When injected intravenously, it induced violent convulsions, which led to the patient having violent seizures. During the procedure, as Metrazol produced the convulsions, a patient’s bones would often begin to break, teeth would crack, and muscles tear.
Although little qualitative research is available as to how individuals with mental illness re- sponded to these new and shock therapy techniques, there is evidence that individuals with mental illness had a tremendous fear of Metrazol convulsion shock therapy. After a Metrazol injection, a patient would often scream, “in the name of humanity please stop these injections I don’t want to die” (Whitaker, 2019, p. 94). Many patients related to the experience as being roasted in a white- hot furnace. Some psychiatrists rationalized that the procedure was strangely liberating because it had a sadistic punishing attack; it helped the patient overcome their unconscious sense of guilt.
Shock therapies were often rationalized from the standpoint that psychological punishment was necessary to alleviate bad psychotic voices and thoughts. Through shock therapy, those voices and thoughts would be replaced by a healthier conscience and stronger ego. Metrazol convulsion shock therapy replaced insulin shock coma therapy in the mid-1930s as the dominate shock therapy in most state mental hospitals. Nearly 37,000 patients received the treatment by the early 1940s (Whitaker, 2019). Because of increasing death rates and the lack of clinical ef- ficacy of insulin and Metrazol therapies, psychiatry temporarily turned away from chemicals. Electricity was now seen as an even a better way to shock patients “back to reality.”
Electroconvulsive Shock Therapy
In Rome, an Italian psychiatrist, Ugo Gerletti (1877–1963), a major supporter of the new shock therapies, had been using electricity to study epilepsy. He found that electric shock to dogs in- duced convulsions like insulin and Metrazol. The question was how to make it safe for humans. He found his answer in a local slaughterhouse, where he observed that after pigs were anesthe- tized by shocks of electricity directly to their head, they became more compliant for slaughter. Gerletti, considered the father of electroconvulsive therapy (ECT), believed he had found the secret cure for mental illness by observing the slaughter of pigs. The key was to induce convul- sions by replacing chemical interventions with electricity. Even before ECT became a human therapy, he found during his experimentation that half of the animals died from the procedure. His first subject was a homeless man that he simply took off a Roman street. Although no one would ever discover his real identity, the homeless person, “S.E,” would become famous as the first person to receive what Gerletti would later claim as the first successful ECT treatment.
When ECT became widely used in American state mental institutions in the 1940s, there was concern that the damage to the brain was of greater magnitude than insulin and Metrazol therapies. Psychiatry, somewhat ambivalent about those concerns, began to endorse the medical concept of “decortication.” Psychiatrists reasoned that the positive impact of causing disorien- tation, amnesia, and trauma to the brain to calm the patient outweighed the negative impact of damage to the cerebral cortex. The “decortication” theory proved to be very wrong (Whitaker, 2019). The “decortication” process “dulled” the intellectual aspect of psychosis causing severe damage to the cerebral cortex, responsible for the higher intellectual functions of the central nervous system. This stripped the patient of the needed intellectual abilities to deal with the anxieties, delusions, fantasies, and paranoia often associated with psychosis.
The Symbols of the History of Mental Illness 239 Gerletti was concerned about the symbolism of using electricity on mentally ill people. He
noted that in America, criminals were often electrocuted in an electric chair. He lamented that his discovery could be viewed as barbaric and dangerous. ECT shock treatment would forever be linked to the electrocution of criminals in the electric chair.
Max Fink, in his book Electroshock Therapy: A Guide for Professionals and Their Patients (2009), advocated for the continued use of ECT, especially when all the other therapies, psycho- tropic medication, and psychotherapy did not work. He believed that tremendous improvements had been made in ECT treatment and found that ECT relieved feelings of depression, suicidal thoughts, and some forms of acute psychosis. Most importantly, unlike during the shock therapy generation in psychiatry, Fink noted that one of the most important modern improvements had been that by law a patient had to provide informed consent for ECT. This meant that the psy- chiatrist was required to educate the patient, especially about the possible side effects, and the patient must sign a consent form before ECT occurs. However, major societal concern remains for potential abuse and some states require that other doctors review and approve the necessity for ECT before the procedure occurs.
Figure 6.17
240 The Symbols of the History of Mental Illness Until the civil rights movement in the 1960s, individuals with mental illness had no legal
right to refuse psychiatric treatments. Although occasionally asked for their permission, there were no legal requirements that individuals with mental illness give written consent, be edu- cated about the psychiatric interventions, especially the possible side effects.
Lobotomies
Although the Greeks viewed the frontal lobes of the brain as the location of the higher forms of human intelligence, modern science believed it had discovered the distinguishing charac- teristic between a human and the ape brain was the frontal lobes because, in 1861, the French neurologist Pierre Paul Broca (1824–1880) proved that it was indeed the frontal lobes that gave humanity its most important intellectual powers. As the brain became the key for psychiatry, the only key, to the cure of mental illness, another even more dramatic way to damage the brain was instituted in mental hospitals throughout the United States.
The importance of the frontal lobes was also discovered in the American Crowbar Case of Phineas Cage. A young Vermont railroad worker, who, in 1848 while preparing a hole for blast- ing powder for an explosion, drove a 3.5-foot iron rod into his left check and into his frontal lobes. He survived and lived for another 12 years. However, he was supposedly never the same. His personality changed significantly. Prior to the accident, he was admired as a very competent, shrewd, and ambitious young man. After the blast, he became disagreeable, stubborn, and rude. The Cage case remains a fixture in neurology, psychology, and neuroscience curriculum, par- ticularly regarding the role of the brain in personality and social development. Often missing in the curriculum are reports that because of social supports, Cage appears to have fully recovered in Chile as a stagecoach driver (Macmillan, 2008).
The overemphasis on brain functioning in the treatment of mental illness continued even as shock treatments were being acknowledged as damaging the brain and causing intellectual and emotional problems. This acknowledgment was appealing to Portuguese neurologist Egas Moniz (1874–1955), who would become the father of the prefrontal lobotomy. Lobotomies became so popular in medicine and even in society at large that in 1949 Moniz received a Nobel Prize for discovering the therapeutic value of leucotomy, known today as lobotomy, for the treatment of psychosis. Moniz started as a political reformer, supporting the end of the Portuguese monarchy and advocating for democratic reforms in Portugal. His views led to jail time and eventual election to the Portuguese Parliament. Holding on to his dreams of having a significant impact on the world, after a military coup in 1926, he became disenchanted with politics and turned his sites to medicine and neurology.
Surgery to the brain was not new. In the twelfth century, the practice of trepanning was developed to cut holes in the brain to allow the demons to escape. In the late 1800s, Gottlieb Burckhardt, a Swiss asylum director, removed a part of a patient’s cerebral cortex to control hal- lucinations. In the early twentieth century, Ludwig Puusepp, a Russian surgeon, treated depres- sion by cutting into the frontal lobes of his patients. After attending professional conferences and reviewing research, Moniz was encouraged that there was sufficient evidence to start brain surgery to cure mental illness. His lobotomy procedure consisted of opening access to the brain by drilling holes into the skull. Before completion, a syringe was used to add alcohol to kill the white fiber tissue. His first patient was an unidentified 60-year-old woman who previously was a prostitute and suffered from psychosis, paranoia, and anxiety. After the operation, Moniz claimed she was cured when she returned to the asylum calm, cognitively stronger, and in con- trol of her emotions.
The Symbols of the History of Mental Illness 241
Another unidentified person was first treated by Moniz with a lobotomy, another important example of the mistreatment of individuals with mental illness and their historic lack of legal rights to give informed consent for treatment.
Moniz believed that thoughts, ideas, and feelings were stored in groups of connected cells in the brain. Mental illness was a result of a dysfunctional cellular connective system, especially in the frontal lobes. For Moniz and those that followed, lobotomies were the only effective way to destroy fixed cellular connections (Freeman & Watts, 1942). Never mind that these intrusions into the brain left irreparable damage. In the final analysis, lobotomies served institutional, not individual treatment goals, because the patients became more docile, less psychotic, and more manageable. Moniz described lobotomies as “surgery of the soul.” Critics say it was really the soul of psychiatry, not the patient, that was trying to be saved. If they could speak, patients would say lobotomies were not surgeries of the soul but surgeries that removed their soul (Whitaker, 2019).
Walter Freeman and James Watts (1942) became American converts to the practice of lobotomies. By the mid-1930s Freeman was acknowledged as the national leader in America for lobotomies placed on the front page of the New York Times in 1937, that his “surgery of the soul” lobotomies was creating miracles in psychiatry (Valenstein, 1984). Ironically, during this time, empirical re- search, supposedly the most scientific, continued to report the positive outcomes of lobotomies.
Figure 6.18
242 The Symbols of the History of Mental Illness The reality was that after lobotomy, patients were typically incontinent and lay in their beds
like dead “wax dummies.” Nurses had to spend an inordinate amount of time trying to wake them up by tickling, pounding their chests, and grabbing them by the neck to “playfully throttle them.” Patient behaviors often became bizarre, with a loss of the sense of shame, as they often walked around the hospital naked. The “good news” was that patients who were previously disruptive, violent, or aggressive now caused fewer problems. Freeman and Watts (1942) described the lo- botomy process as “surgically induced childhood.” Patients regressed to childhood. Adult interests were replaced by coloring books, dolls, and teddy bears. If by chance any previous negative be- haviors immediately resurfaced, ECT would follow, even close to a recently completed lobotomy.
After a lobotomy, over 25 percent of the patients never left the hospital (Whitaker, 2019). Outside the hospital, families were encouraged to treat their family member like a child. This meant teaching the patient manners and making them understand that no amount of “tears, pleading or reasoning” would have much of an impact. In fact, punishment was preferable over love and affection. Since individuals with mental illness were typically seen to have lost the sense of conscience and shame, therefore physical abuse was not only viable but recommended for controlling bad behavior. A few discharged patients progressed beyond a “household pet” to become employed or have a normal life. But Freeman and Watts (1942) cautioned families not to expect too much or cause too much stress. Their employment should be based on simple tasks, punctuality, and adaptability. This diminishment was viewed as necessary and a success- ful outcome for their survival in a complex world.
To please their financial donors, Walter Freeman and James Watt developed a transorbital lobotomy, which was cheaper and quicker to administer because it could be done without trained medical personnel. The transorbital lobotomy became known as the “ice pick lobotomy” be- cause the medical instrument used looked like an ice pick. No drilling of holes in the skull was necessary. A tool called an orbitoclast went straight through the eye socket of a patient. After the orbitoclast entered the eye, the doctor or staff attendant would tap lightly with a hammer to continue entry into the brain. This hammering broke through a thin layer of bone and into brain fibers that were then cut by the twisting of the orbitoclast.
It is estimated that around 50,000 lobotomies, 60 percent on women, were performed in the United States (Whitaker, 2019). Three thousand to 5,000 were done during the Freeman and Watts period alone. Since most were performed in state mental hospitals, the fact was that after a lobotomy individuals with mental illness became docile, lost their personality, and could no longer take care of themselves was often seen as a positive outcome, symbolized dramatically in One Flew Over the Cuckoo’s Nest.
Rosemary Kennedy, sister of President John F. Kennedy underwent a lobotomy in 1941 that left her incapacitated and institutionalized for the rest of her life. That experience inspired Presi- dent Kennedy to pass the Community Mental Health Act of 1963, which began the community mental health movement throughout the United States.
In recent years, there have been calls demanding that the Nobel Prize Moniz received be withdrawn because of all the human suffering he created. His so-called achievement did tre- mendous harm and caused unthinkable suffering to individuals with mental illness and their families. In 1939, Moniz was shot several times by a mentally ill patient and was confined to a wheelchair for the remaining 16 years of his life.
Shame of the States
By the mid-twentieth century, individuals with mental illness were dying at five times the rate of the general population (Whitaker, 2019). The situation was dire. As is often the case in history,
The Symbols of the History of Mental Illness 243 an important critique about psychiatric care in state mental hospitals came from outside the field. In 1948, Albert Deutsch (1948), a journalist and social activist, wrote Shame of the States, which exposed the horrific situation in American state mental hospitals. Besides interviews with hospital staff, much of the inspiration for the book originated from the experiences of conscien- tious objectors (COs) of World War II, who had been assigned to state mental hospitals in lieu of military service. Upon exposure to the state mental hospitals, COs reported being traumatized because they could not believe that a civilized society could tolerate such inhumanity.
The book could have been called the Shame of American Society or the Shame of American Professional Organizations because Deutsch made a scathing rebuke of societal and profes- sional attitudes about mental illness. He compared the medical, societal, and euthanistic at- titudes to Dr. Karl Brandt, Hitler’s physician, to the shameful American treatment practices but unlike the Nazis, there was no official state policy to kill the “insane.” Rather, the American system does it passively through neglect.
Deutsch saw himself as a modern Dorothea Dix and advocated for national leadership to end the shame. He believed the system was underfunded and understaffed, and that custodial care had replaced real treatment. Although the book received critical acclaim by the mental health community as well as journalists and advocates, few reforms occurred. Deutsch died in 1961, frustrated by the ongoing neglect of individuals with mental illness.
The 1968 Proclamation of Teheran
After World War II and the fall of Nazism, every nation had to reflect on its own eugenic and sterilization policies. Although modern science has produced new conditions for a neo-eugenic movement, the original eugenic science that the “weak breed the weak” became discredited. The 1968 Proclamation of Teheran (United Nations, 1968) became one moment in history when the world said “enough” to eugenics. The 1968 Proclamation of Teheran was read at the First Conference on Human Rights led by the United Nations. In the proclamation there was direct acknowledgment that all people had the basic right to determine freely and responsibly the number of children they would bear. There were to be no exceptions. One hundred and twenty nations, including the United States, signed the declaration.
The Psychiatric Pharmaceutical Revolution
First Generation Antipsychotics
In May 1954, with the advent of psychotropic medication, the world of psychiatry and the life of individuals with mental illness would dramatically change forever. Smith, Kline, and French introduced chlorpromazine, which would become known as Thorazine. The term neuroleptic, from the Greek, meaning, “take hold of nerve seizures,” described the goal of antipsychotic medication, which was to cause chemical restraint and to tranquilize the overheated brain. Kurt Schneider (1887–1967) was a German psychiatrist, who after the fall of the Third Reich, re- jected Nazi eugenics and became a leading phenomenological psychiatrist to rebuild German psychiatry. His phenomenology included the assessment of positive and negative symptoms of schizophrenia (Schneider, 1959). Positive symptoms of schizophrenia were hallucinations, delusions, and excited motor behavior; negative symptoms were emotional and social problems that included impoverished thought and speech, blunted affect, and social withdrawal.
The early anti-psychotics, Thorazine and Haldol, improved the positive symptoms of schizophrenia but had no impact on the negative symptoms. The release of dopamine into the
244 The Symbols of the History of Mental Illness mesolimbic pathway had been linked to psychosis. The antipsychotic drugs, especially Thora- zine, blocked the dopaminergic pathways in the brain and decreased psychosis. Since dopamine makes humans feel alive, dopamine inhibition reduced positive psychotic symptoms, often at the expense of basic human feeling. Some of the worst side effects left clients feeling like “zom- bies”: wax-like and without spirit. With the advent of neuroleptics, many patients could now leave state institutions and live in the community, although many described the neuroleptics as being “chemical lobotomies.”
In 1938, the Federal Food Drug and Cosmetic Act was passed by Congress, creating the Food and Drug Administration (FDA). Its mission was to protect and promote public health in most areas of health, including psychiatric medications. Until 1951 and the Durham-Humphrey Amendment to this bill, pharmaceutical companies sold medications directly to consumers through pharmacists. After this amendment passed, only physicians were authorized to pre- scribe habit-forming or potentially dangerous medications. Although the intent was meant to protect the public and have physicians who were trained in medicine to control the safe distri- bution of drugs, after this legislation the role of the American Medical Association and Ameri- can Psychiatric Association changed dramatically. Understanding that physicians were the only professional group that could prescribe medication, to gain their favor, the pharmaceutical in- dustry poured millions and millions of dollars into medical organizations. It is estimated that 30 percent of the budget of the American Psychiatric Association comes from drug advertise- ments in their academic journals. With the development of psychotropics and total medical control of prescription medication, psychiatry, strongly criticized for the failure of state mental hospital psychiatry, had another opportunity to prove its worth.
The pharmaceutical industry investment in psychiatry proved fruitful. By 1970, the Smith, Kline, and French initial investment of $350,000 in Thorazine had skyrocketed to $116 million (Whitaker, 2019). Psychiatric medication became one of the most profitable drugs for the pharmaceutical in- dustry. It was in the interest of psychiatry and the pharmaceutical industry to view mental illness as a “brain disease,” a disease primarily in need of medication. Thorazine quickly gave way to other neuroleptics. Haldol and Prolixin could also be injected to decrease psychosis quickly. There was hope in the mental health community that the new drugs would prove revolutionary.
However, the initial results were mixed. The marriage of psychiatry to the pharmaceutical in- dustry caused concern about an overemphasis on medication to the neglect of other treatment approaches (Jacobs, 1995). The “typical” psychotropics of Thorazine, Haldol, and Prolixin con- tinued to have mixed results because of serious side effects. One of the worst was Tardive Dyski- nesia, involuntary repetitive movements, which caused irreversible injury to the body. Akathisia, the constant desire to move, caused constant pacing, shaking of the legs, and rocking on the feet. Acute Dystonia caused involuntary contractions of the eye, twisting head, protruding tongue, and extension of the neck. Parkinsonism caused rigid muscles, increased salivation, slow movements, and changes in the posture of gait. The worst was Neuroleptic Malignant Syndrome (NMS), which caused life-threatening seizures, coma, renal failure, and many deaths. Robert Whitaker (2019) estimated that between 1960 and 1980, 100,000 Americans died from NMS, noting it could have been reduced to 20,000 deaths if psychiatrists had taken feedback from clients more seriously.
In human history, the pill has become a symbol of health. Pills preserve health and life; pills have a certain power and captivate in mysterious ways. How could something so small be so life sustaining? Over 4,000 years ago, Egyptians did recipes with medicinal substances to create pills. The Greeks called pills katapotia, meaning “something to be swallowed.” The Roman phi- losopher Pliny, around 55 CE, was the first to use the word pilule, “pill.” Although a pill is one of the oldest symbols of healing, pills in modern life have often replaced human agency, the im- portance of an individual to develop the skills to act in the face of discomfort and life challenges.
The Symbols of the History of Mental Illness 245
Second-Generation Antipsychotics
As the neuroleptics celebrated their fortieth anniversary in the late 1980s, the research of the effectiveness of the “pharmaceutical revolution” was at best mixed, and at worst, a failure. For many individuals with mental illness, anything that would allow them to escape state mental hospital psychiatrists was a positive. On the other hand, by the late 1980s 80 percent of in- dividuals with serious mental illness were unemployed, with most living in extreme poverty (Cunningham, McKenzie, & Taylor 2006). It was disconcerting that researchers found that the neuroleptic goal of controlling the positive symptoms of schizophrenia, the hallucinations, and delusions, were often a complete failure (Whitaker, 2004, 2010).
By the late twentieth century, most of the mental health community had fully embraced the “brain disease” approach to mental illness. It was now accepted as “normal” that the “old” typical antipsychotic drugs would consistently result in extrapyramidal symptoms (EPS) like Parkinsonian symptoms and encephalitis lethargica, damage to the dopaminergic systems. The pharmaceutical industry, understanding this reality, came to the rescue with new “atypical” an- tipsychotic medications. The hope was to impact the negative symptoms because the positive symptoms had most often paralyzed individuals with mental illness from social engagement and a quality life.
Figure 6.19
246 The Symbols of the History of Mental Illness Not to be ignored, was the enormous financial profit that would result if the new “atypi-
cal” antipsychotics proved successful. There was such excitement about the release of the new “atypical” medications that in 1994 Diana Ross played Pauline Cooper in Out of Darkness. This was a Hallmark Hall of Fame TV production about a 40-year-old medical student who had lost 20 years of her life to paranoid schizophrenia. Because of the drug Clozaril, the new “atypical,” she was now on the road to recovery.
Individuals with mental illness had another “brain disease” problem. Not only did their medi- cation need to continue to block dopamine, but now the serotonin receptors in the brain. This discovery led to a major competition within the pharmaceutical industry to replace the widely discredited old neuroleptics with a whole new generation of antipsychotics. These were in- tended to have a greater impact on the “overheated brain” and the negative symptoms of mental illness. Research on Clozaril, the granddaddy of the new antipsychotics, was tested in Europe by Sandoz Pharmaceuticals in the 1970s. It was found to reduce extrapyramidal symptoms (EPS). However, it also had serious neurotoxic effects that caused seizures, severe sedation, urinary incontinence, respiratory arrest, and heart attacks. Although that might have been enough to stop most medication trials, Sandoz only withdrew their support of Clozaril after discovering it caused agranulocytosis, the fatal depletion of white blood cells.
With neuroleptics denigrated and the pharmaceutical industry profits decreasing, Sandoz moved ahead in the 1980s and received approval from the FDA to use Clozaril only when the old neuroleptics did not show efficacy. That was easy to prove since the old neuroleptics were often discredited and there was a growing cynicism among mental health clients that all that seemed to matter to their parents and the mental health community was taking their medication, a biological determinism that reduced their lives to physiology and medical diagnosis.
After Sandoz and Clozaril, Janssen came next with Risperidone, then Eli Lilly with Zyprexa, and AstraZeneca with Seroquel. The cost of these drugs became astronomical. Initially, Sandoz provided a $9,000 a month package for Clozaril that included weekly blood tests for agranu- locytosis. Janssen charged $250 a month for Risperidone, 30 times the cost of Thorazine. Eli Lily topped them all for Zyprexa with annual sales in the late 1990s of over $1 million. By the end of the twentieth century, U.S. sales for the new atypical antipsychotic medication topped $2 billion (Whitaker, 2004). By changing how clinical trials occurred, the pharmaceutical indus- try had another strategy to profit from the psychiatric industry.
Before the atypical medications, most of the clinical trials occurred in academic settings by thought leaders, academicians whose concern was protecting patients and who often viewed the pharmaceutical industry with disdain. In return, the pharmaceutical industry viewed the academic process as too slow and tedious. By the 1980s, the pharmaceutical industry was fed up with academia and built a for-profit clinical trial process that would better serve their interests. It first started by paying community physicians who felt squeezed by the new managed care cost containment requirements to complete clinical trials in their private offices. With success from community physicians, the pharmaceutical industry supported the development of private affiliated research centers that could provide faster and larger patient pools for clinical trials. That being successful, venture capitalists built nationwide chains of private for-profit research centers. By the end of the twentieth century, the pharmaceutical industry had invested billions of dollars to support the for-profit system of clinical trials that was now under their total control.
Even though there were some skeptics about the rush to the atypical antipsychotics, there was little opposition since the pharmaceutical industry controlled the researchers and the results of their clinical trials. With little objective research and with significant money to be made by psychiatrists and the pharmaceutical industry, the old neuroleptics were quickly replaced by the atypical medication. In fact, there were national advertising campaigns led by the American
The Symbols of the History of Mental Illness 247 Psychiatric Association and the pharmaceutical industry celebrating the arrival of the second generation of antipsychotic medication.
Although atypical antipsychotics showed some improvements with positive symptoms, the hope for dramatic improvements in the negative symptoms did not occur. The atypical antip- sychotics continued to have many of the same serious side effects of the neuroleptics: tardive dyskinesia, neuroleptic malignant syndrome, stroke, sudden cardiac death, blood clots, and dia- betes. Most disturbing, after all the pharmaceutical industry bravado about the supposed success of psychiatric medication, individuals with mental illness continued to have higher incidents of health problems, commit suicide at twice the national average, live in extreme poverty, were often homeless, and suffered a stigma unlike any other health population (Murray and Lopez, 1996).
After experiencing such financial success with the new antipsychotics, the pharmaceutical industry turned more aggressively toward other mental health problems, particularly depres- sion, bipolar, and anxiety difficulties. By 2007, Americans spent over $2.5 billion annually on antipsychotics and antidepressants (Whitaker, 2010). In this “medication for every problem” generation, many hailed the twentieth as the “century of the brain.” Critics argued it was better called the “century of the pharmaceutical industry.”
The Psychological Revolution in the Treatment of Mental Illness
Resistance in America to eugenics and state hospital psychiatry came from all Four Forces in Psychology: behaviorism, psychodynamic, humanistic-existential, and transpersonal psychology.
Behaviorism
For behaviorists, learning replaced instinct and environmental conditioning was far more im- portant than hereditary. Behaviorists believed that people learn abnormal behavior the same way they learn normal behavior. When the environment changes, the person changes, not the other way around. Behaviorists also opposed punishment because not only was it ineffective, but punishment also reinforced bad behavior.
State mental hospitals began to develop behavior modification programs that provided posi- tive reinforcement. The token economy approach replaced coercion and punishment with pa- tients earning tangible goods for positive behaviors. With their tokens, a patient could “buy” goods in the state hospital store or earn a pass to eat at a local restaurant. Impressed with how some institutions were being transformed, in 1972, B. F. Skinner, the father of neo-behaviorism, was awarded the Humanist of the Year by the American Humanist Association.
Psychoanalysis
Initially, the classical Freudians adopted his view that individuals diagnosed with schizophrenia could not be psychoanalyzed because they could not form a transference which is the essential element to psychoanalytic treatment. This was rejected by neo-Freudians, especially by a lead- ing psychiatrist during this period, Henry Stack Sullivan, who said that individuals with schizo- phrenia could form a transference and recover from mental illness. He criticized psychiatry as appalling and inhumane for the belief that it was better to be psychologically docile without a personality than to have schizophrenia.
248 The Symbols of the History of Mental Illness Jungian Analysis
One of the most creative psychodynamic approaches came from Jungian psychiatrist John Weir Perry (1914–1998). In The Far Side of Madness (Perry, 2005), explained that schizophrenia was a self-healing process. During the healing process, the unconscious overwhelmed the ego, which resulted in a dreamlike state. A psychiatrist should not fight, or medicate this state away, but embrace the state like a dream. In dream analysis, the therapist attends to symbolic and mythological material, which helps the patient find meaning in their journey to create a new world view. Perry believed that the psychotic and visionary religious experience brain states were similar. Like a visionary religious experience, an acute psychotic episode typically lasts six weeks. Or, Perry noted, in Christian mythology, lasts for 40 days and 40 nights. As with Jesus, the psychotic episode starts with isolation and then a feeling of death. And as the ego dies, there is a feeling of being connected to what Jung described as the Self, the unconscious organizing principle of the psyche.
Perry believed psychosis connects the individual to the collective unconscious, which re- sulted in the recapitulation of human history. During the psychotic process, one experiences internally through symbols and myths the evolution of history. In this way, individuals with mental illness are the modern visionaries that carry the new history, the “messiahs” trying to communicate a new vision, a new mythology, for humanity.
Perry agreed with the Quakers and others, that medical hospitals were one of the worst places on earth to treat mental health problems, especially psychosis and schizophrenia. To create the safe, compassionate, and homelike environment, and a totally different attitude about mental illness, during the 1970s Perry founded Diabasis in Berkeley, California. The facility was de- signed for young adults who were experiencing early stages of schizophrenia. He claimed that individuals emerged from the “far side of madness” to a level of human understanding that transcended most so-called healthy people.
The approach of Perry was so successful that his Jungian approach was adopted by San Francisco General Hospital. Not attending to his own shadow, Perry began to violate patient boundary issues and surrendered his medical license in 1980. However, his Jungian approach to the visionary experience of mental illness awaits a new generation of revolutionary pioneers. Perry was able to achieve incredible results without the use of medication, shock treatments, re- straints, or inpatient locked facilities. Along with other leading psychiatrists in America, he be- gan a rebellion against state mental hospital psychiatry and formed an anti-psychiatry movement (Boyers & Orrill, 1971). The anti-psychiatry movement of the 1960s rejected shock treatment and involuntary forced treatment. The movement included some of the leading psychiatrists who rebelled against traditional psychiatry and advocated for treatment consent laws, racial and social justice, less dependence on medication, ending stigma, and the freedom to be different. Psychiatrists Thomas Szasz and R. D. Laing took different approaches, but both rejected tradi- tional and state mental hospital psychiatry.
Existential and Transpersonal Psychology
R. D. Laing (1927–1989), a Scottish psychiatrist, was influenced by existential philosophy and opposed shock treatments and the overemphasis on medication in psychiatry. Inspired by phenomenological psychology of anthropologist George Bateson and existentialist Jean-Paul Sartre, and by his extensive experimentation with mind-altering drugs, especially lysergic acid diethylamide (LSD), Laing argued it was hard to be sane in an insane world. In a play on words, he noted the insane are really the one’s in sanity.
The Symbols of the History of Mental Illness 249 Laing rejected the diathesis-stress model of psychiatry that sought to explain the origin of
mental illness. The word diathesis comes from the Greek and means predisposition or vulner- ability. Diathesis theory was developed by psychologist Paul Meehl to explain schizophrenia in the 1960s. The diathesis-stress model of psychopathology theorizes that mental illness results when genetic susceptibility combines with environmental stressors. Laing rejected this theory because of its overemphasis on biology and lack of focus on the impact of society and the fam- ily (Laing, 1967).
For Laing, it was culture and community, not biology, that ultimately socialized the person. Like Szasz, he believed that mental illness needed to be approached from the standpoint of the therapist learning a different and symbolic language. He implored psychiatry to remember that the Greeks saw the heart, not the brain, as the center of human understanding. Laing argued that there would a totally different approach to mental illness if modern psychiatry viewed schizo- phrenia as a “broken heart” rather than a “broken mind.”
As the psychoanalysts, Jungians, and behaviorists began to apply their theories to mental illness, Laing (1960) conceptualized mental illness through an existential perspective. Laing explained mental illness by utilizing the existential concept of ontological security, which is feeling secure about identity and being a real and autonomous person (Laing, 1960). Ontologi- cal insecurity is an overwhelming fear of losing self. This results in a defensive reaction that splits the mind from the body into separate components and generates psychotic symptoms to survive an imagined external threat of annihilation.
In 1965, Laing and a group of colleagues developed the Philadelphia Association, a United Kingdom charity concerned with understanding and treating psychological suffering in new and revolutionary ways. The Philadelphia Association also started Kingsley Hall in the 1960s, where Laing and other psychotherapists lived together with the residents. Like John Weir Perry, but from an existential perspective, Laing offered that psychosis was like a waking dream to be embraced. It was not to be treated through a Western psychiatric perspective of shock treat- ment and medication, but to learn from the ancient and Eastern cultures who were more com- fortable with a transpersonal psychology. Before Western approaches to medicine, psychosis had a different place in human history. It was often viewed as valuable spiritual, mystical, and shamanistic experiences, not only for the person, but also for their culture (Ellenberger, 1970). In the tradition of successful treatment approaches for mental illness, Laing believed the key to healing any mental health problem, especially psychosis, was kindness, respect, and empathy.
After reading The Divided Self (Laing, 1960) and being diagnosed with schizophrenia, Mary Barnes became the first and most famous patient of Kingsley Hall. She went on to describe her- self as an “ambassador for Laing” and Barnes (1978) wrote Two Accounts of a Journey Through Madness. This book explained how psychosis helped her discover her interest in painting and creative expression. David Edgar, one of the most prolific British playwrights of the post-1960s generation, made Mary Barnes famous with his 1979 play, Mary Barnes (Edgar, 1979).
The East London community became hostile to Laing and his approach to mental illness, which resulted in constant harassment. By the 1970s the program ended. The building returned to its famous roots in the 1980s by becoming a community center for social justice groups and the Gandhi Foundation. In the 1930s, Gandhi spent 12 weeks at Kingsley Hall discussing the future of India with many of the most influential political leaders of the day. He loved East London and the Hall, and, upon leaving, noted that the people of Kingsley Hall surrounded him with love throughout his stay. The Philadelphia Association has survived and continues to teach psychotherapeutic skills and provides affordable therapy and community housing for individu- als with mental illness seeking retreat.
250 The Symbols of the History of Mental Illness
Rollo May, the renowned American existentialist, considered Laing’s book, The Politics of Experience: The Bird of Paradise (Laing, 1967), as one of the most unsettling and thought- provoking books ever written about mental illness. For Laing, the Bird of Paradise symbolized the need for psychotherapists to embrace their own “madness.” The embrace was essential for the liberation of the patient. The bird of paradise looks like a bird ready for the flight of freedom, joy, and triumph. It is likely that Laing would encourage a bird of paradise flower be in the office of every psychologist as a symbol of their own “exotic” nature. A shared joy with a client of the feeling that both had triumphed over a mad and destructive world.
The Community Mental Health Revolution
Deinstitutionalization and the Birth of Community Mental Health
With the development of antipsychotic medication and a national interest in reforming the men- tal health system, new hope arose for community treatment. In 1963, President John F. Ken- nedy, as part of his New Frontier initiative, heralded the beginning of the community mental health movement. The Community Mental Health Act of 1963 provided funding for hundreds of community mental health and research centers throughout the United States.
Figure 6.20
The Symbols of the History of Mental Illness 251
Kennedy urged mental health professionals to leave their large institutions, universities, and state hospitals, and develop community treatment that provided individuals with mental illness a quality life in their home communities; to finally unlock the chains of mental illness by the experience of a loving, supportive community.
The ambitious goal was to build mental health centers in every population center of 30,000 people. With this type of support, individuals with mental illness could work, love, and feel at home in their local communities. Since the federal government was providing financial re- sources for the new community mental health movement, states began a massive deinstitu- tionalization of state mental hospitals throughout the United States. Between 1950 and 1990, states closed most of their state mental institutions, discharging nearly 500,000 individuals with mental illness back to their local communities.
After the Kennedy/Johnson administration, the federal government began to withdraw its support for the new community mental health centers. Only half of the federal commu- nity mental health centers were ever built, and none currently receive any federal funding from the Community Mental Health Act of 1963. Since most states did not reinvest the significant budget savings from closing their expensive state mental institutions into com- munity treatment, the community mental health vision of President Kennedy remains an unfilled dream.
Figure 6.21
252 The Symbols of the History of Mental Illness An inspiration for deinstitutionalization during this period was a book by sociologist Erv-
ing Goffman (1961): Asylums: Essays on the Conditions of the Social Situation of Mental Patients and Other Inmates. In his book, Goffman described his participant observation field research at a mental institution in Washington, DC. From his experience, Goffman developed the theory of total institution, which is when a guard and captor class structure forms within an institution. In this structure, everyone understands and plays their social role, which leads to an institutional psychology. Treatment becomes secondary in an institutional psychology because it is essential that the patient first play their social role as subservient to the role of the doctor. Goffman compared the medicalization of mental illness and various psychiatric treat- ment approaches to the role of workers during the nineteenth-century Industrial Revolution. Like a patient in a state mental hospital, the activities and routines relate more to the needs of the boss and the doctor, rather than to the needs of the worker and the patient (Krieg, 2003, Mansell & Ericsson, 1996).
Personal Reflection
In 1970, I was a student in Western Interstate Commission on Higher Education (WICHE), a program developed to encourage students to consider mental health as a career option by placing undergraduate students in various mental health programs throughout California. I was placed in Mendocino State Hospital in Ukiah, California.
It was a very progressive and experimental hospital with innovative programs for ado- lescents, addiction, and community reintegration. I lived and worked on the state hospital grounds. In fact, my housing was close by the unit I was assigned. Besides learning so much about mental illness, I learned to view individuals with mental illness with great admiration. Working on the community integration unit, I experienced firsthand com- munity discrimination as individuals with mental illness sought jobs in the community or registered to vote.
Since the hospital was set for closure, I saw the first examples of an unplanned deinsti- tutionalization that set individuals with mental illness up for failure. As deinstitutionaliza- tion progressed, many individuals with mental illness wanted to return to the safety and treatment of the state hospital because of their discharge to inept, local, six-bed residential facilities that were providing only custodial care, often only for money.
State officials used the closures to save millions of state general fund dollars with no commitment of state savings to fund a new community mental health system throughout California. In terms of the work of Goffman here was no real preparation for individuals with mental illness or their families on the psychological meaning of deinstitutionaliza- tion or how to leave the state hospital and build a non-institutional life in the community.
There was also an absence of planning at the community level, leaving many com- munities unprepared, even hostile to their new mental health responsibilities. Profession- als were also unprepared and untrained, building a community system often based on a private practice model of weekly psychotherapy, not on a rehabilitation; recovery and community support models developed many years later. The result was the first genera- tion of homeless mentally ill because of poor planning, scarce local financial resources, inadequate housing facilities, and the unavailability of community-based mental health services.
The Symbols of the History of Mental Illness 253 Gregory Baum (1979), a renowned Catholic theologian, provided social justice docu-
ments to the Vatican Ecumenical Council in the 1960s. He embraced teachings of the Frank- furt School of Social Research which resulted in his support of Liberation Theology. This theology emphasized social concern for the poor and the political liberation of oppressed peoples throughout the world. He viewed the lack of acknowledgment of the poor and the unseen as a “social sin,” being a collective blindness that resides within a community of people who oppresses human beings, violates human dignity, stifles freedom, and imposes great inequality. Hands over the eyes provides a stark symbol of the “social sin” of the failed deinstitutionalization and the continued neglect by society for the care of individuals with mental illness.
Community Psychology
Adjustment to community mental health did not come easy for traditionally trained mental health professionals, especially clinical psychologists. In 1965, psychologists gathered in Swampscott, Massachusetts, to assess the new role of psychologists in community mental health. From the Swampscott Conference emerged a new branch of psychology: community psychology. Com- munity psychology, separate from clinical psychology, was to focus on public policy and system change rather than individual change (Gibbs, Lachenmeyer & Sigal, 1980). The initial idea was that community psychologists would be a separate department within a community mental health center.
Community psychologists would not be burdened with direct services but available to be- come active in local community issues, especially focused on policy boards that had a direct im- pact on the lives of mental health clients. These boards included the local Board of Supervisors/ Commissioners, Housing Authority, Planning Commission, and many other areas where policy decisions could be made to improve the mental health of the community.
Figure 6.22
254 The Symbols of the History of Mental Illness Community psychologists would provide programs to reduce stigma and educate the com-
munity about the value of mental health services (Yanos, Rosenfield & Horowitz, 2001). For the community to “own” their local community mental health center, there would be ongoing pro- gram evaluation of community services. This would include supplying clinicians with treatment outcome reports to improve their clinical work. The result of this process would be community re- search, research that spoke to the needs of the community rather than to the needs of the research- ers. The sad reality is that after the Community Mental Health Act of 1963 there was no federal or state funding available, required, or prioritized for a separate community psychology division within the community mental health system. Observing no future in that system, community psy- chologists sought positions elsewhere and in 1965 created the 27th division in the APA now called the Society of Community Research and Action: Division of Community Psychology, which pub- lishes the American Journal of Community Psychology and The Community Psychologist.
In 2016, celebrating the fiftieth anniversary of the Swampscott Conference, the Ameri- can Journal of Community Psychology published a special issue on the future of community psychology. In Reflections on the Future of Community Psychology from the Generations; A Commentary and Introduction to the Special Issue, Jacob Tebes (2016) summarized how the basic principles of community psychology had survived and, although small, 10 doctoral pro- grams in community psychology still thrived. Of the 15 commentaries that followed about the future of community psychology, none focused on the role of community psychology in com- munity mental health centers or efforts to improve the lives of individuals with mental illness.
Clinical Psychology and the Realigned Community Mental Health System
By the 1980s the spirit of a broad-based community mental health system envisioned by the Community Mental Act of 1963 had died. Underfunded and understaffed and because of the tremendous need and neglect of the seriously mentally ill, with limited financial resources, community mental health centers prioritized serious mental illness as its top priority. The days were gone when community mental health centers provided a broad spectrum of mental health services. With homelessness and family and consumer advocacy increasing, the community mental health system would undergo a significant change in priorities that would continue to define the community mental health system into the twenty-first century.
In the late twentieth century, the community mental health centers became the specialists of treating the most seriously ill, the “heart surgeons” of mental health care. The “worried well” were now the responsibility of primary care doctors, private therapists, and insurance companies. By the 1980s it was clear community mental health needed a different type of staff; many tradition- ally trained professionals, especially traditional psychotherapists, felt marginalized and alienated and fled the system because of the medication and case management focus. Traditional profes- sionals did not feel trained or were often uninterested in community models, such as clinical case management, a model in which clinicians provided both psychotherapeutic and case management interventions to individuals with mental illness, most often outside the clinic in the community.
In response, a Doctor of Mental Health Degree (DMH) emerged in California in the 1980s, which was a degree that met the manpower need of the newly realigned community mental health system. This was a professional who could prescribe medication and provide psycho- therapy and social work support. Threatened, the psychiatric, psychological, and social work associations quickly criticized the degree as being unrealistic and claimed that one professional could not attain skills in medicine, psychology, and social work. After only a few years of the degree program and with only a few graduates, the professional associations, acting in a rare show of political unity, quickly killed the DMH degree.
The Symbols of the History of Mental Illness 255
Innovation and Best Practices in Community Mental Health
Program for Assertive Community Treatment (PACT)
The importance of a team approach, professionals and paraprofessionals working in close col- laboration emerged in the 1970s as crucial to the treatment of mental illness during deinsti- tutionalization (Allness & Knoedler, 2003). The “Madison Model” emerged as a successful model to patients leaving the Wisconsin state mental hospitals and by the 1980s it evolved into the Program for Assertive Community Treatment (PACT) that provided mentally ill clients a personalized, small, multi-disciplinary team available 24 hours a day, 7 days a week (Phillips, Burns, Edgar, et al, 2001).
PACT became an evidence-based treatment (EBT) because its team was mobile and com- posed of a nurse, psychiatrist, mental health professional, and case manager. Other specialists, especially psychologists, drug and alcohol and vocational counselors, were available as needed. A key to its success was a small client caseload, typically 25 clients and its “one-stop” wrap- around service-delivery system available around-the-clock. Some patient rights advocates have criticized the coercive methods of the PACT model.
Personal Reflections
If the Swampscott Conference clarified the role for the emerging community psycholo- gist, it did not address the future role of clinical psychology in the evolving community mental health system. Entering the community mental health system in Shasta County, California, in the late 1970s, I witnessed the resistance of mental health professionals, particularly clinical psychologists, to community approaches because the realigned sys- tem focused primarily on individuals with serious mental illness.
Many psychologists left public service to work in private organizations or to develop a private practice. The absence of strong psychological leadership in the realigned system left a permanent void filled by the other mental health professions. It also left individuals with mental illness with no strong professional counterbalance to the overemphasis on medication and case management. Without a stronger psychological perspective, clients were often seen as cases to be managed, not individuals to be psychologically understood. Psychotherapy, a place where individuals with mental illness could explore their lives, was often unavailable, cut statewide from budgets for more psychiatrists and case manag- ers, or not valued as a necessary part of a quality treatment plan.
Viewing the reality that graduate schools were not educating professionals in the new community treatment models, I successfully advocated for a pre-doctoral training pro- gram in clinical psychology, which eventually received accreditation from the American Psychological Association. As a director, I also added a post-residency program in clini- cal psychology and a training program for clinical social workers. As other counties were cutting psychological services, Shasta County was balancing the biopsychosocial needs of individuals with mental illness, with psychotherapy, and community-based services provided often against protests from psychiatrists and the medical community. Former and retired employees continued to meet for monthly lunches long after I left for Santa Barbara County, describing the period, with all its problems, as a “Renaissance” and one of the most satisfying times in their careers.
256 The Symbols of the History of Mental Illness Stuart Kirk (2017) argues that successful outcomes regarding PACT and other community
treatments are based on distortions of empirical research. The book claims that coercion in psychiatric treatment, the adoption of an unscientific diagnostic system into controlling access to community treatment and the failure of drug treatments, did not improve the lives of indi- viduals with mental illness. Proponents argue that the quality of staff, the fidelity to the original community-oriented model, and adequate funding of PACT and other similar community pro- grams decrease coercion and the overdependence on psychiatric medication (Phillips, Burns, Edgar, et al, 2001).
Recovery – Wellness Recovery Action Plan (WRAP)
Although a recovery model is a recent development, the concept dates as far back as to 1840 when John Perceval, son of a British prime minister, wrote of successful recovery after a psy- chotic episode, despite the treatment by heroic medicine and “lunatic doctors” (Bateson, 1962). Perceval was also a founder of the nineteenth-century Alleged Lunatics Friend Society, a pre- cursor to the psychiatric survivor movement. The society advocated against wrongful confine- ment, cruel treatment, and physicians establishing themselves as arbiters of sanity who relied on subjective diagnoses.
The concept of psychological recovery emerged as another important model after the failure of deinstitutionalization and from the advocacy of the psychiatric survivor and an- tipsychiatry movements. The recovery model is a rejection of the medical and psychologi- cal models that view mental illness as a chronic disability with the best outcomes being only symptom-reduction and relapse prevention. In line with the Alcoholics Anonymous 12-step model, mental health recovery, like substance dependence, is a personal journey that re- quires hope, purpose and meaning, supportive relationships, empowerment, social justice, and new coping skills. Most importantly, recovery requires social inclusion, the feeling of belonging and being valued by the community (Davidson, Rowe, Tondora O’Connell & Lawless, 2009).
One of the most successful consumer-oriented and evidence-based treatment (EBT) ap- proaches is the Wellness Recovery Action Plan (WRAP), developed in 1997 by Mary Ellen Copeland (2011). Both she and her mother had been diagnosed with manic depression. Her mother was treated in a state mental hospital for eight years. From her family and personal experience, Copeland believed that active involvement by mental health clients in treat- ment planning was essential for a successful recovery. Clients utilize the WRAP program to enhance the quality of their lives by developing an individual daily plan to improve self- help skills; monitor and understand emotions; list daily recovery activities; track triggering events; prepare healthy responses to challenging daily stressors; plan social activities; create a daily diet, exercise, relaxation, and sleep schedule; and develop creative skills, especially journaling, music, art, and reading. In other words, do what all healthy human beings do on a routine basis.
Psychiatric and Psychosocial Rehabilitation
In the spirit of moral treatment and Geel, psychiatric and psychosocial rehabilitation is the restoration of community functioning. The key role of the community mental health rehabil- itation professional is to effect environmental change. Rehabilitation requires the activation of all community support systems and includes a “network of community service provid- ers” outside the traditional mental health system. In the spirit of recovery, rehabilitation
The Symbols of the History of Mental Illness 257 practitioners focus on the clients experiencing themselves beyond a diagnostic label and rediscovering their value to community life. This entails a major focus on vocational train- ing and education because of the historic neglect of the importance of employment and education in mental health treatment. Attacking stigma in very concrete terms by provid- ing on-the-job support at the workplace shows how individuals with mental illness can be productive employees.
Often, psychologists find psychosocial rehabilitation under the auspices of other professions. Abraham Rudrick and David Roe (2018) provide a Rogerian, person-centered psychological approach to serious mental illness. They address the rehabilitation process from a psychologi- cal perspective that includes acknowledgment of the ongoing value of moral treatment. Often neglected in the traditional clinical world, Rudrick and Roe (2018) provide a guide on how to integrate person-centered and community rehabilitation approaches in assessment, treatment, self-help activities, community policymaking and research.
It took the American Psychological Association over a century from its inception to pub- licly endorse a rehabilitation approach to mental illness. In 2009, the APA Council of Rep- resentatives passed a resolution entitled Endorsement of the Concept of Recovery for People with Serious Mental Illness (APA, 2009). The resolution indicated that individuals with men- tal illness can live quality lives when there is community integration, supportive interpersonal relationships, vocational training, and educational opportunities. It endorsed a psychological model over the failed medical model and a psychologically oriented recovery-based treat- ment rather than a medical “medication-first” approach to mental illness. The APA resolution had no specific recommendations that required recovery and community-based education and training for accreditation of its doctoral-level graduate programs in clinical psychology. This left new and developing psychologists unaware of recent evidence-based best practices in serious mental illness, missing the opportunity for a community-based psychological renais- sance by learning the competencies needed for a satisfying career in the community mental health system.
Early Intervention – Dialogical Healing – Open Dialogue
Love is the life force, the soul, the idea. There is no dialogical relation without love, just as there is no love in isolation. Love is dialogic.
- David Patterson, Literature and Spirit
Open dialogue was developed in the 1980s in Lapland, Finland, by Jaakko Seikkula and Tom Erik Arnkill (2006). In Dialogical Meetings in Social Networks, they explain their innovative approach to mental illness (Seikkula & Arnkill, 2006). The treatment approach was rooted in the philosophy of language of Russian philosopher Mikhail Bakhtin (1895–1975). In Dialogic Imagination, Bakhtin (1981) described his philosophy in three major ways: dialogism, dialogue essential to effective communication; heteroglossia, various unique ways people speak; and chronotope, the time and place where communication occurs.
In open dialogue, the therapists suspend the language of their social world and enter into dia- logue with the language and meanings of the world of a psychotic or severely disturbed client. Bakhtinian philosophy rejects typical monolinguistic communication, the belief that the lan- guage of an individual is the most important element in communication. Rather, in dialogism, there is recognition that language shapes social reality, which can only be understood through a dialogical relationship that creates a shared language of understanding. This means that our
258 The Symbols of the History of Mental Illness language, our thoughts, and our behaviors are constructed through interpersonal relationships rather than on predetermined objective scientific truths.
Because of the chronicity that can occur with mental illness, early intervention is essential to the open dialogue approach. During the first hospitalization, staff includes daily dialogic meetings not only with the disturbed client, but with all essential staff, family members, friends, and essential community members. These are truly open dialogue meetings because there is no specific agenda or treatment plan for the therapy sessions. Although family therapy and person- centered techniques, especially unconditional positive regard, are utilized, the goal is egalitarian communication. It is not unusual for staff to disagree with each other, or for family members, the client, or community members to have the best therapeutic insights. All decisions about the client are made during the open dialogue sessions.
Seikkula and Arnkil (2006) report impressive community outcomes for the treatment of acute psychosis. After five years (1992–1997) of open dialogue treatment, 81 clients had no remain- ing psychotic symptoms and returned to full employment. After hospitalization, only 35 percent continue the use of antipsychotic medication. The open dialogue approach has inspired similar programs throughout the world, most notably in the United States, the Parachute Project in New York City. The Parachute Project provides a “soft landing” for entry into the mental health system by providing mobile crisis teams, crisis respite centers for short stays to prevent the need for hospitalization, and a peer support telephone line operated by mental health consumers to handle crises from a client perspective.
Public Policy – The President’s New Freedom Commission on Mental Health
After President Kennedy, there were other presidential federal efforts to improve mental health services. In 1977, President Jimmy Carter’s Commission on Mental Health made 117 recom- mendations to improve the community mental system and he signed the Mental Health Systems Act in 1980. This dedicated $800 million in federal grants over four years. The problem with grants was that poorer states and localities could not compete. These states were reluctant to apply because after the grant ends, the state is left to continue the programs without federal revenue.
In 1999, President Bill Clinton was first to ever host a White House Conference on Mental Health with the goal of reducing stigma. Tipper Gore, wife of Vice President Al Gore, emerged and remains a leading national advocate for improving mental health services.
George W. Bush signed Senators Paul Wellstone and Pete Domenici’s Mental Health Parity and Addictions Equity Act of 2008, which requires, by federal law, equity in insurance coverage of mental health and medical care, although there is no evidence that insurance companies are being held accountable.
In 2002, President George W. Bush appointed the New Freedom Commission on Mental Health: Transforming Mental Health Care in America (2003). This commission brought to- gether leading experts in all fields of mental health and included consumers, family members, providers, and advocates. Unlike many past commissions, there was also a focus on the mental health needs of children. The New Freedom Commission found that the mental health system was fragmented and in desperate need of a new vision. It sought to transform the system after assessing 50 years of the community mental health movement and the failures of deinstitution- alization. By listing six major goals for a reformed system, this document is a blueprint for the future development of the mental health system.
Although a good blueprint for a possible transformation, the report did not lead to any sig- nificant funding. The report, although visionary, continued the long history of federal neglect
The Symbols of the History of Mental Illness 259
of the mental health system. Another criticism was that the report was service-centered, not community-centered, as there was little mention of the role of communities in the transformation of the mental health system.
National Health Care – Patient Protection and the Affordable Care Act of 2010 (Obamacare)
Most industrial nations have a national insurance plan that covers all of its citizens. In America, insurance is primarily connected to employment, which has made medical coverage difficult for individuals with mental illness due to the many challenges they face when seeking employment. Feeding the stigma and bias that individuals with mental illness cannot work, mental health professionals and the community mental health system have too often not provided the needed supports for vocational success.
The President’s New Freedom Commission provided a blueprint for many of the mental health reforms in Obamacare. Obamacare provided America its first national insurance sys- tem and made dramatic changes in medical and mental health coverage. It allowed individuals through exchange pools to select their insurance from a new, open, competitive marketplace. To be in the exchange pools, insurance companies were required to offer 10 essential health benefits (EHBs). These benefits included mental health and substance abuse treatment.
In Obamacare, individuals with preexisting mental illness must be covered by insurance com- panies in the same manner as for cancer and diabetic patients. Insurance plans must offer parity in their mental and physical health coverage. Obamacare requires insurance companies to cover psy- chiatric medications as they would medical medications. However, Obamacare is vague on dis- tinguishing between how the requirement applied to “preferred” drugs, generics, and “specialty” drugs. Often, drugs for mental illness are considered “specialty” drugs, which are more expensive. This means physicians must often change psychiatric drugs for financial, not clinical, reasons.
Since private insurance does not meet the medical needs of many Americans, Medicaid insurance fills much of the gap. One in five Americans receives Medicaid benefits. Prior to Obamacare, in many states mentally ill adults had to be designated as disabled and receive Sup- plemental Security Income (SSI) to receive Medicaid services. Medicaid expansion ended that requirement and enabled adults with mental illness to receive services not covered by private insurance companies. Under Medicaid, expansion states could now bill Medicaid for case man- agement and other rehabilitative services.
Obamacare attempted to hold insurance companies accountable for parity between mental and medical health care. However, the disparities remain enormous since little of the nearly $3 trillion spent on medical health care in America goes for mental health care, even though research has indicated that quality mental health care reduces the cost of medical care. Critics argue there are no federal or state agencies holding insurance companies accountable for parity.
Six Goals of the President’s New Freedom Commission
Goal l: Americans understand that Mental Health is essential to overall health. Goal 2: Mental Health is Consumer and Family driven. Goal 3: Disparities in Mental Health are eliminated. Goal 4: Early Mental Health screening, assessment, and referral are common practice. Goal 5: Excellent Mental health Care is delivered, and research is accelerated. Goal 6: Technology is used to access Mental Health care and information.
260 The Symbols of the History of Mental Illness In fact, many insurance companies pay poorly or limit the number of professionals on their panels, making private insurance access to mental health care difficult.
The Consumer and Family Member Revolution
The Psychiatric Survivors Antipsychiatry Movement
Throughout history, individuals with mental illness have advocated for treatment and public poli- cies that would best meet their needs. In the modern era, it was Clifford Beers (1876–1943), a former patient of state mental institutions and viewed as the father of the psychiatric survivor movement. His book, A Mind That Found Itself (Beers, 1981), received critical acclaim because it was an early book written from the viewpoint of someone who had survived state mental hospitals.
Beers became a role model for individuals with mental illness because he was able to gain support from fellow survivors as well as the medical profession. His advocacy led to significant and long-lasting reforms. He founded the nation-wide Mental Health Association, which has, for over 100 years, continued to provide advocacy for mental health clients. He also founded the Clifford Beers Clinic in New Haven, the first outpatient mental health clinic in the United States. Although Beers provided inspiration to clients who advocated for reform, it was not until the civil rights movement of the 1960s that individuals with mental illness began to attain true civil rights. One of the most important rights was consent for treatment: the legal requirement that individuals with mental illness give their written permission after professionals have explained the benefits and risks of their treatment. For the first time in history, mental health clients could finally say “no” to psychiatrists and other mental health professionals.
The psychiatric survivor movement does not have a unified organization that speaks as one voice (Nelson, Ochocka, Rich & Trainer, 2006). It remains a diverse group of associations. However, it is unified in “talking back to the power of psychiatry” and creating organizations that advocate for self-determination and consumer empowerment. The key text, the “bible,” of the psychiatric sur- vivor movement was On Our Own: Patient-Controlled Alternatives to the Mental Health System written by Judi Chamberlin (1979). As a former patient, and as founder of the Mental Health Lib- eration Front, Chamberlin criticized psychiatry as creating passive patients, rather than discriminat- ing consumers who decide what services best meet their need. She was also concerned that the new community mental health centers were becoming bureaucratic “mini state hospitals.”
Chamberlin coined the term mentalism, which has remained an important concept in the evolving survivor movement. Mentalism is a form of discrimination like sexism and racism that results in many forms of oppression, social inequalities, and imbalances in power. It is how soci- ety, especially mental health professionals, stereotype individuals regarding their mental disor- der, cognitive impairments, or behavioral challenges. Most importantly, like sexism and racism, the negative attitudes become internalized in a mentally ill person, impacting self-esteem and value as human beings to society. Although not universally accepted, by the late 1980s, the term consumer replaced patient for many individuals with mental illness. Now also known as the consumer movement, most clients turned their focus to reform the current community mental health system, oppose forced treatment, fight stigma, and develop their own supportive services.
Throughout the United States, mental health mutual support groups (MSGs), self-help organ- izations (SHOs), and consumer-operated services (COSs) have continued to flourish, funded by grants as well as state agencies and local community mental health centers. Research completed by Geoffrey Nelson and associates (2006) described in A Longitudinal Study of Mental Health Consumer/Survivor Initiatives, indicated that consumer initiatives of social support, empower- ment, mental well-being, and self-management had transformed the lives of many individuals with mental illness. Consumer-run services had reduced hospitalizations, forced treatment, and
The Symbols of the History of Mental Illness 261 overuse of mental health services. The major obstacles for consumer-run services were fund- ing and the ongoing discrimination by some psychiatrists, family members, and mental health professionals against client empowerment.
There has been historic tension between the consumer and family advocacy groups, especially in relation to voluntary and involuntary treatment. During the civil rights movement, most states instituted more restrictive commitment laws that protected individuals with mental illness against centuries of abuse and against forced treatment without any legal basis. In response to the abusive history, most involuntary treatment laws require that a threat to self, others, or grave disability be- cause of a mental disorder had to be present under current, not previous, historical circumstances.
Controversy between Clients and Their Families – Involuntary Care
For many family members, protection of rights is extremely frustrating when seeking involun- tary care for their family member. Beyond involuntary inpatient hospitalizations, tragic events in New York and California led to legislation that allowed for involuntary outpatient treatment. In New York in 1999, a man diagnosed with schizophrenia pushed Kendra Webdale into the path of a subway train, which resulted in her death. In 2001, in California, Laura Wilcox was shot to death with other employees while working as a receptionist at the Nevada County Mental Health Clinic by a paranoid and delusional man refusing to be hospitalized.
The National Alliance on Mental Health (NAMI) and organized psychiatry pushed for invol- untary outpatient treatment in New York and California. In California, implementation was at the discretion of the local county Board of Supervisors. Less than half of the 58 California counties have implemented Laura’s Law because many view involuntary outpatient treatment as an excuse for the underfunding of the community mental health system. Many consumers fear that invol- untary outpatient treatment will begin the erosion of the rights they have fought so hard to attain.
Beyond involuntary treatment, psychiatrist E. Fuller Torrey, a family leader in the National Alli- ance on Mental Illness, has led efforts against funding of consumer groups and services, especially when antipsychiatry views are promoted. The opposition of some NAMI members to the con- sumer movement exacerbates tensions between the consumer and family advocacy movements.
MindFreedom International, founded in 1990, is rooted in the antipsychiatry survivor move- ment. It is an international coalition of over 100 grassroots consumer organizations in 14 coun- tries fighting against involuntary treatment, forced medication, and abusive medical procedures. Membership is opened to not only consumers, but mental health professionals, advocates, and family members. In 2003, the executive director of MindFreedom, David Oaks, went on a hun- ger strike until the American Psychiatric Association, NAMI, and the U.S. Surgeon General proved that mental illness was a “brain disorder.” He received no response.
National Alliance on Mental Health
Often discouraged by the state of the mental health system and the lack of perceived under- standing of the needs of families of the mentally ill, in the late 1970s, family members began to advocate for their adult mentally ill children. Until this time, parents, especially mothers, were often blamed for mental illness. A whole generation of psychologists and mental health profes- sionals were trained to believe that mental illness, especially schizophrenia, was the result of bad parenting. The family, especially the schizophrenogenic mother, symbolized the bad parent- ing in the family as the cause of mental illness. The theory held that schizophrenia was a result of the creation of inescapable double binds, which had no emotionally satisfying response. Be- sides double bind communications, the schizophrenogenic mother was perceived as a very cold, rejecting, emotionally unavailable, and disturbed perfectionist lacking in empathy.
262 The Symbols of the History of Mental Illness The term schizophrenogenic mother was first coined in 1948 by German psychiatrist Frieda
Fromm-Reichmann (1948), a protégé of Freud, in a paper Notes on the Development of Treatment of Schizophrenics by Psychoanalytic Psychotherapy. Unlike many American psychoanalysts who were abandoning the hope that psychotherapy could heal serious mental illness, Fromm- Reichman (1948) rejected the overemphasis in psychiatry on “brain disease” and treated people with schizophrenia with psychotherapy without medication. Her most famous patient was Han- nah Green (1964) who wrote a fictionalized autobiography, I Never Promised You a Rose Gar- den of her treatment by Reichman at the time of her hospitalization in a state mental institution. She described the key to her treatment was what psychoanalysts called a positive transference, a deeply trusting relationship with a gifted and empathetic psychotherapist. The movie version was nominated for Best Adapted Screenplay Academy Award in 1977 and Lynn Anderson made a song version a number one country music hit in 1971.
As many mental health professionals continued to view mental illness through a schizophre- nogenic mother lens, it was easy to understand the suffering of family members and the reason that a “brain disease” approach became very appealing. Frustrated with the view that bad parent- ing led to mental illness, in 1979, two mothers of mentally ill sons, Harriet Shetier and Beverly Yung, founded the National Alliance on Mental Illness (NAMI) because they were tired of being blamed for their sons’ mental illness.
NAMI endorsed a medical model approach to mental illness and have led various campaigns to educate the public that mental illness is a “serious brain disorder.” NAMI also endorsed the theory of anosognosia, which is the belief that many individuals are not able to accept or perceive that they have mental illness. This has led to legislative advocacy for more forced and involuntary treatment, even involuntary outpatient treatment.
NAMI became a powerful force after the 1980s in the mental health system as medication became a primary mode of treatment for serious mental illness. Since mothers had no control of the brain of their child, the schizophrenogeic mother theory became discredited and replaced by a diseased brain. Since there were limited resources in the evolving community mental health
Figure 6.23
The Symbols of the History of Mental Illness 263 centers, NAMI advocated for more psychiatrists to provide the medication and for case manag- ers to ensure individuals with mental illness took their medication. Budgets for psychotherapy, and other non-medical model approaches were reduced since NAMI believed those approaches had proven ineffective in the treatment of serious mental illness.
NAMI remains an important support for family members and has developed affiliates in all 50 states with over 1,000 chapters in many local communities. They provide a host of educa- tional and peer support programs to family members. The popular Family-to-Family Program was developed by clinical psychologist Joyce Burland. This program provides a 12-week course led by NAMI family members that teaches about the medical model, diagnosis, medication, and “biologically based” treatment approaches.
As NAMI became the most important advocacy group for family members throughout the Unites States, in 1999, an article in Mother Jones exposed a shadow of the unholy alliance between the pharmaceutical industry, psychiatry, and NAMI. After the article, a Senate inquiry found that the majority of NAMI funding came from the pharmaceutical companies, which continue to invest millions of dollars to assure that the “brain disease” approach remains strong within psychiatry and family advocacy.
The priestess of Apollo, Cassandra symbolizes those certain truths exist about individuals with mental illness that have often been ignored. For instance, that individuals with mental illness want love, productive work, and feel valued like everyone else in the world. Many times in history there has been a belief that they were not capable or even deserving of attaining normal human needs. According to Aeschylus in his play Agamemnon, Cassandra promised Apollo favors and then he gave her the divine power to see the future. When she went back on her word, he did not go back
Figure 6.24
264 The Symbols of the History of Mental Illness centers, NAMI advocated for more psychiatrists to provide the medication and for case manag- ers to ensure individuals with mental illness took their medication. Budgets for psychotherapy,
Personal Reflections
As we have seen in this chapter, many in history envisioned a new world for individuals with mental illness. But like Cassandra, although history has shown what can work, no one has really listened. Even though there have been improvements, most agree the men- tal health system is in dire need of reform.
The title of the President’s Commission, New Freedom, could have been called Eman- cipatory Opportunities. It was an opportunity to totally transform the mental health sys- tem, but again the federal government failed to fund the goals of another important report. History has shown the current approach of small changes around the edges is not work- ing. From my experience, there needs to be a bold massive injection, a modern Kennedy- like investment of billions of dollars, to build a quality mental health system.
An extensive discussion of each opportunity is not under the purview of this text. However, considering the history described in this chapter, there are indications of what works and what does not work. It is long overdue to finally build a system in communi- ties throughout the United States that work for individuals with mental illness. A strong community mental health system would psychologically uplift all of society and improve community life for every citizen.
Hopefully, one day soon, history will produce a President Kennedy, a William Tuke, a Dorothea Dix, a Clifford Beers, or a congressperson or senator who will not only envision, but provide funding for a new freedom, an emancipation, of the lives of individuals with seri- ous mental illness and all people who struggle with mental health and substance abuse issues.
In my final Personal Reflections, I want to end this Chapter and Volume I with a poem, I hope the poem touches, with the symbols, something deeper beyond the words in this Chapter. In the context of the subtitle of the book, From Reflective Study to Active Engagement, and after reviewing the history of mental illness, the hope is that you will be inspired to develop your own ideas and advocacy for a New Vision to Transform the Mental health System. The Emancipatory Opportunities to Transform the Mental Health System below are public policy recommendations for action from my experience which can assist in framing a discussion. The vision is that the reforms that occur in the future will truly transform, not only the mental health system, but our attitudes about individuals with mental illness.
The Mountain Top
I’ve been to the Mountain Top Saw a world where people with mental illness Were honored and loved as neighbors, friends, co-workers, colleagues and lovers. Valued as essential to all aspects of community life. Excelled in the world like their historic role models: President like Abraham Lincoln. Great military leaders like Napoleon Bonaparte and William Sherman. Great international leaders like Winston Churchill.
The Symbols of the History of Mental Illness 265
Emancipatory Opportunities to Transform the Mental Health System
Community Mental Health Act of the Twenty-First Century
An act of Congress to fund a complete overhaul of the community mental health system through- out the United States.
U.S. Department of Community Mental Health (CMH)
A cabinet position beyond the U.S. Department of Health and Human Services that tends to have a medical, not mental, health focus. It could be a federal agency implementing a bold com- munity vision and assuring parity between mental and physical health. The department would include an integrated mental health and substance abuse delivery system and involvement of consumers and family members.in all levels of policy development and service delivery.
National Campaign to Honor Individuals with Serious Mental Illness
Led by consumers to end stigma and national spokespersons to speak through various media outlets to the courage and achievements of individuals with mental illness. The department would fund consumer-led services in every CMH catchment area.
Community-Based Services per 50,000 Population
In the spirit of the Kennedy vision, assure there are CMH services available in population cent- ers of 50,000 or more with special consideration to the needs of rural areas.
24/7 Community Mental Health Crisis Services
Learning from moral treatment, the Kirkbride Plan, open dialogue, Geel et al., end inpatient ser- vices in medically modeled units, require every CMH to have a 24/7 psychologically oriented crisis wellness center in a beautiful, homelike environment (Callaway, 2007). Assure every CMH has 24/7 Mobile Crisis and Suicide Prevention Services.
Great scientists like Sir Isaac Newton, Charles Darwin and John Nash Great psychologists like William James Great authors like Charles Dickens, Leo Tolstoy, Edgar Allen Poe, Ernest Hemingway, Virginia Woolf and Sylvia Plath Great artists like Michelangelo, Merisi da Caravaggio, and Vincent Van Gogh and Edward Munch Great musicians like Ludwig van Beethoven. Great free thinkers like Jack Kerouac Mentally ill finally acknowledged for their incredible historic contributions. No longer scapegoats for societal problems, exploitive politicians, and bad science. Emancipated Gratitude filled my heart for those who struggled, against great odds, to make this happen. Inspired, I realize my soul never leaves that Mountain Top.
266 The Symbols of the History of Mental Illness Public Safety
Require that every police department implement Crisis Intervention Teams (CIT), or related programs to deal with mental health problems. Assure that every police officer is certified and qualified to deal with individuals with serious mental illness.
Outpatient Treatment Services – Believe in Psychotherapy Again
Assure adequate funding for children, adolescents, adults, and older adults the treatment services in each CMH catchment area. Require that services are linked into needed community supports. Offer psychotherapy to individuals with serious mental illness. Offer psychotherapeutic treatment to the dually diagnosed, clients who have both a mental health and substance abuse diagnosis.
School Services
Require every school district to have a continuum of mental health and substance abuse coun- seling services ranging from school and drug and alcohol counselors to licensed mental health clinicians.
Support Services
End the cycle of poverty. Require every CMH to have a Housing, Employment, and Education Department that is linked to local housing authorities, educational institutions, and the business community. Develop housing programs to assure that individuals with mental illness have qual- ity housing. Create financial and support incentives with local businesses to hire individuals with mental illness by assigning, when needed, employment counselors at the workplace. Pro- vide grants and scholarships for educational opportunities. Consider developing an “adoption” or “foster care” system like Family Care in Geel, Belgium (Arnold, 2015).
Reform the Medicaid System
Change the medical necessity requirement for Medicaid reimbursement to recovery necessity. Emphasize a strength-based, not a medical-based approach to mental illness (Rapp & Goscha, 2012). Change the archaic paperwork requirements that necessitate the mental staff treating the chart rather than the clients.
Focus on Socioeconomic Inequality
Lift individuals with mental illness out of poverty by developing systems that provide adequate disability income while at the same time provide incentives for employment. Make the dysfunc- tional Social Security Income (SSI) program, by reform or relocation, more accountable to the community mental health system. Assure that every treatment plan includes a socioeconomic evaluation. Provide consumer resources, i.e. stipends, to select services.
Require Primary Care and CMH Integration
Although the priority of CCMH should remain individuals with serious mental illness, a com- munity-based system should also include integration with other essential community mental health and substance abuse services. Since primary care doctors provide most of the psychiat- ric medication and many mental health problems are handled by primary care physicians, the
The Symbols of the History of Mental Illness 267 availability of mental health professionals on primary care sites would enhance medical care and avoid the need for higher level and costly health services.
Psychological Renaissance in CMH
Require community psychologists in each CMH for research, program assessment, consumer/family outreach, public policy development, and prevention. For APA accreditation, require community mental health coursework in doctoral-level programs in clinical and counseling psychology.
Expand Manpower
Invest in manpower expansion in psychiatry, clinical psychology, clinical social work, drug and alcohol counseling, and other related mental health professions, especially in regards to cultural diversity. Require curriculum to include community mental health, addiction, biopsychosocial treatment, psychiatric rehabilitation, recovery, and community support principles (Davidson, Rowe, Tondora O’Connell & Lawless, 2009). Consider reestablishment of the Doctor of Mental Health (DMH) degree.
Require Cultural Competency
Because of the disparity in cultural access, assure that all CMH centers have cultural compe- tency plans to serve the cultural diversity of their community.
Use Technology
Utilize technology to end stigma, improve mental health access, explain service delivery system, respond to community needs and crises, provide telehealth, and receive community feedback.
QUESTIONS 6 6.1 Explain how the political, socioeconomic, and cultural systems impacted individu-
als with mental illness.
6.2 Describe the relationship between historically based and evidence-based best practices.
6.3 Explain why St. Dymphna became the Patron Saint of individuals with mental illness.
6.4 Describe the importance of the Geel Question.
6.5 Explain the relevance of moral treatment to the current mental health system.
6.6 Describe why the period between 1900 and 1950 is described as a Half Century of Darkness.
6.7 Explain how the four forces of psychology contributed to mental health reform.
6.8 Describe the pros and cons of the psychiatric pharmaceutical revolution.
6.9 Explain the goals of the community mental health movement.
6.10 Describe the importance of consumer and family advocacy.
6.11 Envision a reformed mental health system.
268 The Symbols of the History of Mental Illness Universal Meanings of the Chapter Symbols
Figure 6.0: Photo source Albert Deutsch. (2022, January 8). In Wikipedia. https://en.wikipedia.org/wiki/
Albert_Deutsch-Fairuse Photo source Judi Chamberlin. http://archive.boston.com/bostonglobe/obituaries/articles/
2010/01/20/judi_chamberlin_writings_took_on_mental_health_care/ Photo source RD Laing. https://www.perlego.com/book/1562463/the-legacy-of-r-d-laing-an-
appraisal-of-his-contemporaryrelevance-pdf Photo source Michel Foucault. https://whoseknowledge.org/wp-content/uploads/2018/03/
Creating-drawings-.pdf Photo source Dorothea Dix. Courtesy of Saint Elizabeth’s Hospital, Washington, D.C. https://
www.britannica.com/biography/Dorothea-Dix Photo source William Tuke (2022, February 10). In Wikipedia. https://id.wikipedia.org/wiki/
William_Tuke Figure 6.1. A symbol of community mental health. Figure 6.2. A symbol of the failure of heroic medicine. Figure 6.3. A symbol that divine law transcends human law. Figure 6.4. A symbol that class determines the quality of mental health treatment. Figure 6.5. Symbolic of the lack of police training which leads to violence, brutality, and the
death of many individuals with mental illness. Figure 6.6. Belief the moon controls the mind and causes lunacy. Figure 6.7. The historic reality that “hearing voices” was once viewed as messages from the divine. Figure 6.8. A symbol for the isolation of individuals with mental illness. Figure 6.9. A symbol of oppressive and dehumanizing state mental hospitals Figure 6.10. Symbolic of the reality that individuals with mental illness can achieve greatness. Figure 6.11. Symbolic of the needed spiritual support to meet the challenges of mental illness. Figure 6.12. The need for family and community support for recovering from mental illness. Figure 6.13. A successful community life entails more than the historic removal of the chains. Figure 6.14. The reality that a therapeutic environment is crucial for healing mental illness. Figure 6.15. Symbol of the limitations of a traditional medical setting for mental health recovery. Figure 6.16. The shadow of asylum medicine, the “decortication:” of the brain. Figure 6.17. A psychological electric chair symbolizes the shock therapy generation in psychiatry. Figure 6.18. A symbol of the degradation of individuals with mental illness. Figure 6.19. A symbol of the overdependence on medication in modern life. Figure 6.20. A symbol to embrace “madness” and like a bird fly to freedom, joy, and triumph. Figure 6.21. Mental illness as a “broken heart” not a broken mind. Figure 6.22. The sin of “collective blindness.” Figure 6.23. Schizophrenogenic mother. Figure 6.24. Symbolic of Ignoring the truth.
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