assessment

2504743 - Macmillan US ©

Deviance Abnormal psychological functioning is deviant, but deviant from what? Amira’s and Alberto’s behaviors, thoughts, and emotions are different from those that are considered normal in our place and time. We do not expect people to cry themselves to sleep each night, hate the world, wish themselves dead, or obey voices that no one else hears.

Deviance and abnormality This woman, like others from the Padaung tribe in Myanmar (Burma), is

preoccupied with the length of her neck and wears heavy stacks of brass rings to try to extend it — seeking

to achieve what her culture teaches her is the perfect neck size. In Western society, the same behavior and

goals would break behavioral norms and might well be considered abnormal.

2504743 - Macmillan US ©

In short, abnormal behavior, thoughts, and emotions are those that differ markedly from a society’s ideas about proper functioning. Each society establishes norms — stated and unstated rules for proper conduct. Behavior that breaks legal norms is considered to be criminal. Behavior, thoughts, and

emotions that break norms of psychological functioning are called abnormal.

Judgments about what constitutes abnormality vary from society to society. A society’s norms grow from its particular culture — its history, values, institutions, habits, skills, technology, and arts. A society that values competition and assertiveness may accept aggressive behavior, whereas one that

emphasizes cooperation and gentleness may consider aggressive behavior unacceptable and even abnormal. A society’s values may also change over time, causing its views of what is psychologically abnormal to change as well. In Western society, for example, a woman seeking the power of running a major corporation or indeed of leading the country would have been considered inappropriate and even delusional a hundred years ago. Today the same behavior is valued.

Judgments of abnormality depend on specific circumstances as well as on cultural norms. What if, for example, we were to learn that Amira was a young African American woman living with her family of four in a cramped New York City apartment during the early months of the COVID-19 pandemic? Within a matter of days, Amira and her partner Jayden had been “furloughed” from their jobs,

their daughters’ school had been closed, and the state had ordered them all to stay at home indefinitely. After a few weeks, the full impact of the shutdown and social isolation began to wear her down. Their savings were gone; she hadn’t seen her mother, sisters, or friends in person for ages; and the stress between the children, Jayden, and her was mounting. All with no end in sight.

Then, a month later, the truly unthinkable happened. Jayden, always so strong and energetic, came down with COVID-19 — at first a harmless cough, then a rising temperature, and eventually trouble breathing. He landed in an overcrowded and understaffed hospital in critical condition, fighting the virus

2504743 - Macmillan US ©

without Amira and the daughters he adored. Amira was devastated. She felt overwhelmed and horribly alone — unable to make everything work. Increasingly, she wondered whether her family would survive this ordeal intact.

In this light, Amira’s emotions and thoughts do not seem as strange. One clearly abnormal thing here is her situation—a pandemic, social isolation, extended unemployment, and more. Many human experiences produce intense reactions — financial ruin, large-scale catastrophes and disasters, rape, child abuse, war, terminal illness, chronic pain (Compean & Hamner, 2019; Comer, Furr, & Gurwitch, 2018). Is there an “appropriate” way to react to such things? Should we

ever call reactions to such experiences abnormal?

Distress Even functioning that is considered unusual does not necessarily qualify as abnormal. According to many clinical theorists, behavior, ideas, or emotions usually have to cause distress before they can be labeled abnormal. Consider the Ice Breakers, a group of people in Michigan who go swimming in lakes throughout the state every weekend from November through February. The colder the weather, the better they like it. One man, a member of the group for 17 years, says he loves the challenge of human against nature. A 37-year-old

lawyer believes that the weekly shock is good for her health. “It cleanses me,” she says. “It perks me up and gives me strength.” Certainly these people are different from most of us, but is their behavior abnormal? Far from experiencing distress, they feel energized and challenged. Their positive feelings must cause us to hesitate before we decide that they are functioning abnormally.

Should we conclude, then, that feelings of distress must always be present before a person’s functioning can be considered abnormal? Not necessarily. Some people who function abnormally maintain a positive frame of mind. Consider once again Alberto, the young man who hears mysterious voices. What if he enjoyed listening to the voices, felt honored to be chosen, loved sending

2504743 - Macmillan US ©

out warnings on the Internet, and looked forward to saving the world? Shouldn’t we still regard his functioning as abnormal?

Dysfunction Abnormal behavior tends to be dysfunctional; that is, it interferes with daily functioning. It so upsets, distracts, or confuses people that they cannot care for themselves properly, participate in ordinary social interactions, or work

productively. Alberto, for example, has quit his job, left his family, and prepared to withdraw from the productive life he once led. Because our society holds that it is important to carry out daily activities in an effective manner, Alberto’s behavior is likely to be regarded as abnormal and undesirable. In contrast, the Ice Breakers, who continue to perform well in their jobs and enjoy fulfilling relationships, would probably be considered simply unusual.

Context is key A couple dressed as Supergirl and

Superman stop and point upward as they cross a street in New York City. Their appearance and behavior might

suggest psychological dysfunction were it not for the fact that they are attendees at a recent Comic-Con, one

of the many popular conventions held across the country to showcase comic books, graphic novels, and

the like.

2504743 - Macmillan US ©

Danger Perhaps the ultimate psychological dysfunction is behavior that becomes

dangerous to oneself or others. Individuals whose behavior is consistently careless, hostile, or confused may be placing themselves or those around them at risk. Alberto, for example, seems to be endangering both himself, with his diet, and others, with his buildup of arms and ammunition.

Although danger is often cited as a feature of abnormal psychological functioning, research suggests that it is actually the exception rather than the rule (Ghiasi & Singh, 2019). Most people struggling with anxiety, depression, and even bizarre thinking pose no immediate danger to themselves or to anyone else. Moreover, in the absence of distress and dysfunction, dangerous behaviors alone do not signify psychological abnormality. Individuals working in professions characterized by everyday risk for injury or even death, such as firefighters or other emergency responders, typically choose these professions

for altruistic reasons and out of a sense of duty. Although their particular call to service may place them in routine danger, they typically enjoy a sense of honor, positive mental well-being, and satisfying family lives.

The Elusive Nature of Abnormality Efforts to define psychological abnormality typically raise as many questions as they answer. Ultimately, a society selects general criteria for defining abnormality and then uses those criteria to judge particular cases. One clinical theorist, Thomas Szasz (1920–2012), placed such emphasis on society’s role that he found the whole concept of mental illness to be invalid, a myth of sorts (Szasz,

2011, 1963, 1960). According to Szasz, the deviations that society calls abnormal are simply “problems in living,” not signs of something wrong within the person. A number of today’s clinical theorists similarly de-emphasize the role of “illness” or “disorder” when defining psychological abnormality, and instead look at the circumstances and coping challenges that bring individuals to treatment (e.g., Hofmann & Hayes, 2019; Marsh & de los Reyes, 2018).

2504743 - Macmillan US ©

What behaviors fit the criteria of deviant, distressful, dysfunctional, or dangerous but would not be considered abnormal by most people?

Even if we assume that psychological abnormality is a valid concept and that it can indeed be defined, we may be unable to apply our definition consistently. If a behavior — excessive use of alcohol among college students, say — is familiar enough, the society may fail to recognize that it is deviant, distressful, dysfunctional, and dangerous. Thousands of college students throughout the

United States are so dependent on alcohol that it interferes with their personal and academic lives, causes them great discomfort, jeopardizes their health, and often endangers them and the people around them (NIAAA, 2019; Martin & Chaney, 2018). Yet their problem often goes unnoticed and undiagnosed. Alcohol is so much a part of the college subculture that it is easy to overlook drinking behavior that has become abnormal.

Conversely, a society may have trouble separating an abnormality that requires intervention from an eccentricity, an unusual pattern with which others have no right to interfere. From time to time we see or hear about people who behave in ways we consider strange, such as a man who lives alone with two dozen cats and rarely talks to other people. The behavior of such people is deviant, and it may well be distressful and dysfunctional, yet many professionals think of it as eccentric rather than abnormal (see PsychWatch).

PSYCHWATCH Marching to a Different Drummer: Eccentrics

Writer James Joyce always carried a tiny pair of ladies’ bloomers, which he waved in the air to show approval. Benjamin Franklin took “air baths” for his health, sitting naked in front of an open window. To save money, financier Hetty Green — arguably the richest woman in America during the Gilded Age — wore the same dress each day and never changed her underwear until they wore out.

2504743 - Macmillan US ©

Eccentric, but not abnormal Tran Van Hay holds his hair — more than 20 feet in length — around his body, as if it were a cobra. By the time of his death

in 2010, he had not had a haircut for 50 years. The married Vietnamese man otherwise lived and

worked as a highly respected and productive herbalist. He just liked his hair on the long side —

longer than any other person on Earth.

Alexander Graham Bell covered the windows of his house to keep out the rays of the full moon. He also tried to teach his dog how to talk. Wealthy heiress Sarah Lockwood Winchester spent much of her great fortune on decades of uninterrupted, around-the-clock reconstruction of her home. She believed continuous modifications, including several staircases to nowhere, were needed to ward off evil spirits. Writer D. H. Lawrence enjoyed removing his clothes and climbing mulberry trees.

These famous persons have been called

eccentrics. The dictionary defines an eccentric

as a person who deviates from common

behavior patterns or displays odd or

whimsical behavior. But how can we separate

a psychologically healthy person who has

unusual habits from a person whose oddness

is a symptom of psychopathology? Little

research has been done on eccentrics, but a

few studies offer some insights (Sinclair, 2017;

Newman, 2013; Weeks & James, 1995).

Researcher David Weeks (2015) studied 1,000

eccentrics and estimated that as many as 1 in

5,000 persons may be “classic, full-time

eccentrics.” Weeks pinpointed 15

characteristics common to the eccentrics in

his study: nonconformity, creativity, strong

curiosity, idealism, extreme interests and

hobbies, lifelong awareness of being different,

high intelligence, outspokenness,

noncompetitiveness, unusual eating and living

habits, disinterest in others’ opinions or

company, mischievous sense of humor,

nonmarriage, eldest or only child, and poor

spelling skills.

Weeks suggests that eccentrics do not

typically suffer from mental disorders.

Whereas the unusual behavior of persons with

mental disorders is thrust upon them and

usually causes them suffering, eccentricity is chosen freely and provides pleasure. In short,

“Eccentrics know they’re different and glory in it” (Weeks & James, 1995, p. 14). Similarly, the

2504743 - Macmillan US ©

thought processes of eccentrics are not severely disrupted and do not leave these persons

dysfunctional. In fact, Weeks found that eccentrics in his study actually had fewer emotional

problems than individuals in the general population. Perhaps being an “original” is good for mental

health.

Changing times Here a woman congratulates her best friend as she gets ready for her wedding. Just decades ago, the elaborate body art on her arms and neck would

have been considered outrageous and strange, perhaps even abnormal. Today, however, tattoos — even extensive ones — are relatively common. As many as 40 percent of adults in the United States have at least one tattoo; 25 percent have

multiple tattoos (Statista, 2020a).

In short, while we may agree to define psychological abnormalities as patterns of functioning that are deviant, distressful, dysfunctional, and sometimes dangerous, we should be clear that these criteria are often vague and subjective. In turn, few of the current categories of abnormality that you will see in this book are as clear-cut as they may seem, and most continue to be debated by

clinicians.

2504743 - Macmillan US ©

What Is Treatment?

ONCE CLINICIANS DECIDE that a person is indeed suffering from some form of psychological abnormality, they seek to treat it. Treatment, or therapy, is a procedure designed to change abnormal behavior into more normal behavior; it, too, requires careful definition. For clinical scientists, the problem is closely related to defining abnormality. Consider the case of Bill:

FEBRUARY: He cannot leave the house; Bill knows that for a fact. Home is the only place where he

feels safe — safe from humiliation, danger, even ruin. If he were to go to work, his coworkers would

somehow reveal their contempt for him. A pointed remark, a quizzical look — that’s all it would take for

him to get the message. If he were to go shopping at the store, before long everyone would be staring at

him. Surely others would see his dark mood and thoughts; he wouldn’t be able to hide them. He dare

not even go for a walk alone in the woods — his heart would probably start racing again, bringing him

to his knees and leaving him breathless, incoherent, and unable to get home. No, he’s much better off

staying in his room, trying to get through another evening of this curse called life. Thank goodness for

the Internet. Were it not for his reading of news sites and blog posts and online forums, he would, he

knows, be cut off from the world altogether.

JULY: Bill’s life revolves around his circle of friends: Bob and Jack, whom he knows from the office,

where he was recently promoted to director of customer relations, and Frank and Tim, his weekend

tennis partners. The gang meets for dinner every week at someone’s house, and they chat about life,

politics, and their jobs. Particularly special in Bill’s life is Janice. They go to movies, restaurants, and

shows together. She thinks Bill’s just terrific, and Bill finds himself beaming whenever she’s around. Bill

looks forward to work each day and to his one-on-one dealings with customers. He is taking part in

many activities and relationships and more fully enjoying life.

Bill’s thoughts, feelings, and behavior interfered with all aspects of his life in February. Yet most of his symptoms had disappeared by July. All sorts of factors

2504743 - Macmillan US ©

may have contributed to Bill’s improvement — advice from friends and family members, a new job or vacation, perhaps a big change in his diet or exercise regimen. Any or all of these things may have been useful to Bill, but they could not be considered treatment or therapy. Those terms are usually reserved for

special, systematic procedures for helping people overcome their psychological difficulties. According to pioneering clinical theorist Jerome Frank, all forms of therapy have three essential features:

1. A sufferer who seeks relief from the healer. 2. A trained, socially accepted healer, whose expertise is accepted by the

sufferer and the sufferer’s social group. 3. A series of contacts between the healer and the sufferer, through which the

healer … tries to produce certain changes in the sufferer’s emotional state, attitudes, and behavior.

(Frank, 1973, pp. 2–3)

An early start At age 11, Ciro Ortiz set up a “therapy”

office each week on a New York City subway platform. Calling himself the Emotional Advice Kid, he talked to people of all ages with various kinds of psychological

issues. Ciro’s advice may have been therapeutic for many persons, but it was not therapy. The discussions

2504743 - Macmillan US ©

lacked, for example, a “trained healer” and a series of systematic contacts between healer and sufferer.

Frank’s criteria are still embraced by most of today’s clinical theorists. Despite

his seemingly straightforward definition, clinical treatment is surrounded by conflict and, at times, confusion. Some clinicians view abnormality as an illness and so consider therapy a procedure that helps cure the illness. Others see abnormality as a problem in living and therapists as teachers or coaches of more functional behavior and thought. Clinicians even differ on what to call the person who receives therapy: those who see abnormality as an illness speak of the “patient,” while those who view it as a problem in living refer to the “client.” Because both terms are so common, this book will use them interchangeably.

Despite their differences, most clinicians do agree that large numbers of people need therapy of one kind or another. Later you will encounter evidence that therapy is indeed often helpful.

2504743 - Macmillan US ©

How Was Abnormality Viewed and Treated in the Past?

IN ANY GIVEN YEAR, as many as 30 percent of the adults and 17 percent of the children and adolescents in the United States display serious psychological disturbances and are in need of clinical treatment (NAMI, 2019a; SAMHSA, 2019a). The rates in many other countries are similarly high. It is tempting to

conclude that something about the modern world is responsible for these many emotional problems — perhaps rapid technological change; deep political divides; increasing threats of terrorism, mass shootings, and natural disasters; or a decline in religious, family, or other support systems. But, as we shall see in the following sections, every society, past and present, has witnessed psychological abnormality.

Ancient Views and Treatments Historians who have examined the unearthed bones, artwork, and other remnants of ancient societies have concluded that these societies probably

regarded abnormal behavior as the work of evil spirits. People in prehistoric societies apparently believed that all events around and within them resulted from the actions of magical, sometimes sinister, beings who controlled the world. In particular, they viewed the human body and mind as a battleground between external forces of good and evil. Abnormal behavior was typically interpreted as a victory by evil spirits, and the cure for such behavior was to force the demons from a victim’s body.

This supernatural view of abnormality may have begun as far back as the Stone Age, a half-million years ago. Some skulls from that period recovered in Europe

2504743 - Macmillan US ©

and South America show evidence of an operation called trephination, in which a stone instrument, or trephine, was used to cut away a circular section of the skull (Ellis, 2019). Some historians have concluded that this early operation was performed as a treatment for severe abnormal behavior — either hallucinations,

in which people saw or heard things not actually present, or melancholia, characterized by extreme sadness and immobility. The purpose of opening the skull was to release the evil spirits that were supposedly causing the problem (Selling, 1940).

Expelling evil spirits The two holes in this skull recovered from ancient times indicate that the person

underwent trephination, possibly for the purpose of releasing evil spirits and curing mental dysfunction.

Later societies also explained abnormal behavior by pointing to possession by demons. Egyptian, Chinese, and Hebrew writings all account for psychological

deviance this way, and the Bible describes how an evil spirit from the Lord affected King Saul and how David feigned madness to convince his enemies that he was visited by divine forces.

2504743 - Macmillan US ©

What demonological explanations or treatments, besides exorcism, are still around today, and why do they persist?

The treatment for abnormality in these early societies was often exorcism. The idea was to coax the evil spirits to leave or to make the person’s body an uncomfortable place in which to live. A shaman, or priest, might recite prayers, plead with the evil spirits, insult the spirits, perform magic, make loud noises, or have the person drink bitter potions (Singh, 2018). If these techniques failed, the

shaman performed a more extreme form of exorcism, such as whipping or starving the person.

of NOTE … Their Words

“I became insane, with long intervals of horrible sanity.”

Edgar Allen Poe

Greek and Roman Views and Treatments In the years from roughly 500 B.C.E. to 500 C.E., when the Greek and Roman civilizations thrived, philosophers and physicians often offered different explanations and treatments for abnormal behaviors. Hippocrates (460–377 B.C.E.), often called the father of modern medicine, taught that illnesses had natural causes. He saw abnormal behavior as a disease arising from internal physical problems. Specifically, he believed that some form of brain pathology was the culprit and that it resulted — like all other forms of disease, in his view — from an imbalance of four fluids, or humors, that flowed through the body:

yellow bile, black bile, blood, and phlegm (Saunders, 2019; Javier, 2014). An excess of yellow bile, for example, caused mania, a state of frenzied activity; an excess

2504743 - Macmillan US ©

of black bile was the source of melancholia, a condition marked by unshakable sadness.

To treat psychological dysfunction, Hippocrates sought to correct the underlying physical pathology. He believed, for instance, that the excess of black bile underlying melancholia could be reduced by a quiet life, a diet of vegetables, temperance, exercise, celibacy, and even bleeding. Hippocrates’ focus on internal causes for abnormal behavior was shared by the great Greek philosophers Plato (427–347 B.C.E.) and Aristotle (384–322 B.C.E.) and by influential Greek and Roman physicians.

Humors in action Hippocrates believed that imbalances of the four humors affected personality. In these depictions of two of the humors, yellow bile (le�) drives a

husband to beat his wife, and black bile (right) leaves a man melancholic and sends him to bed.

Europe in the Middle Ages: Demonology Returns The enlightened views of Greek and Roman physicians and scholars were not enough to shake ordinary people’s belief in demons. And with the decline of Rome, demonological views and practices became popular once again. A growing distrust of science spread throughout Europe.

2504743 - Macmillan US ©

From 500 to 1350 C.E., the period known as the Middle Ages, the power of the clergy increased greatly throughout Europe. In those days, the church rejected scientific forms of investigation, and it controlled all education. Religious beliefs, which were highly superstitious and demonological, came to dominate all

aspects of life. Deviant behavior, particularly psychological abnormality, was seen as evidence of Satan’s influence.

How might social media, such as Twitter, Instagram, and Facebook, facilitate current forms of mass madness?

The Middle Ages were a time of great stress and anxiety — of war, urban uprisings, and plagues. People blamed the devil for these troubles and feared being possessed by him (Trenery, 2019; Ruys, 2017). Abnormal behavior

apparently increased greatly during this period. In addition, there were outbreaks of mass madness, in which large numbers of people apparently shared delusions (absurd false beliefs) and hallucinations (imagined sights or sounds). In one such disorder, tarantism (also known as Saint Vitus’ dance), groups of people would suddenly start to jump, dance, and go into convulsions (Lanska, 2018). All were convinced that they had been bitten and possessed by a wolf spider, now called a tarantula, and they sought to cure their disorder by performing a dance called a tarantella. In another form of mass madness, lycanthropy, people

thought they were possessed by wolves or other animals. They acted wolflike and imagined that fur was growing all over their bodies.

2504743 - Macmillan US ©

Bewitched or bewildered? A great fear of witchcra� swept Europe beginning in the 1300s and extending through the “enlightened” Renaissance. Tens of thousands of

people, mostly women, were thought to have made a pact with the devil. Some appear to have had mental disorders, which caused them to act strangely. This

woman is being “dunked” repeatedly until she confesses to witchery.

Not surprisingly, some of the earlier demonological treatments for psychological abnormality reemerged during the Middle Ages. Once again the key to the cure was to rid the person’s body of the devil that possessed it. Exorcisms were revived, and clergymen, who generally were in charge of treatment during this period, would plead, chant, or pray to the devil or evil spirit (Kingsbury & Chesnut, 2019). If these techniques did not work, they had others to try, some amounting to torture.

It was not until the Middle Ages drew to a close that demonology and its methods began to lose favor. Towns throughout Europe grew into cities, and government officials gained more power and took over nonreligious activities. Among their other responsibilities, they began to run hospitals and direct the care of people suffering from mental disorders. Medical views of abnormality

gained favor once again, and many people with psychological disturbances

2504743 - Macmillan US ©

received treatment in medical hospitals, such as the Trinity Hospital in England (Allderidge, 1979).

The Renaissance and the Rise of Asylums During the early part of the Renaissance, a period of flourishing cultural and scientific activity from about 1400 to 1700, demonological views of abnormality continued to decline. German physician Johann Weyer (1515–1588), the first

physician to specialize in mental illness, believed that the mind was as susceptible to sickness as the body was. He is now considered the founder of the modern study of psychopathology.

The care of people with mental disorders continued to improve in this

atmosphere. In England, such individuals might be kept at home while their families were aided financially by the local parish. Across Europe, religious shrines were devoted to the humane and loving treatment of people with mental disorders. Perhaps the best known of these shrines was at Gheel in Belgium. Beginning in the fifteenth century, people came to Gheel from all over the world for psychic healing. Local residents welcomed these pilgrims into their homes, and many stayed on to form the world’s first “colony” of mental patients. Gheel was the forerunner of today’s community mental health programs, and it

continues to demonstrate that people with psychological disorders can respond to loving care and respectful treatment (Thériault, 2019; Aring, 1975, 1974). Many patients still live in foster homes there, interacting with other residents, until they recover.

Unfortunately, these improvements in care began to fade by the mid-sixteenth century. Government officials discovered that private homes and community residences could house only a small percentage of those with severe mental disorders and that medical hospitals were too few and too small. More and more, they converted hospitals and monasteries into asylums, institutions whose primary purpose was to care for people with mental illness. These institutions were begun with the intention that they would provide good care

2504743 - Macmillan US ©

(Scult, 2018; Philo & Andrews, 2016). Once the asylums started to overflow, however, they became virtual prisons where patients were held in filthy conditions and treated with unspeakable cruelty.

In 1547, for example, Bethlehem Hospital was given to the city of London by Henry VIII for the sole purpose of confining the mentally ill. In this asylum, patients bound in chains cried out for all to hear. The hospital even became a popular tourist attraction; people were eager to pay to look at the howling and gibbering inmates. The hospital’s name, pronounced “Bedlam” by the local people, has come to mean a chaotic uproar (Arie, 2016; Selling, 1940).

The Nineteenth Century: Reform and Moral Treatment As 1800 approached, the treatment of people with mental disorders began to improve once again. Historians usually point to La Bicêtre, an asylum in Paris for male patients, as the first site of asylum reform. In 1793, during the French Revolution, Philippe Pinel (1745–1826) was named the chief physician there. He

argued that the patients were sick people whose illnesses should be treated with sympathy and kindness rather than chains and beatings (Charland, 2018). He allowed them to move freely about the hospital grounds; replaced the dark dungeons with sunny, well-ventilated rooms; and offered support and advice. Pinel’s approach proved remarkably successful. Many patients who had been shut away for decades improved greatly over a short period of time and were released. Pinel later brought similar reforms to a mental hospital in Paris for female patients, La Salpetrière.

of NOTE … Odd Name

Doctors who treated people with mental disorders in the eighteenth century were called “mad- doctors.”

2504743 - Macmillan US ©

Meanwhile, an English Quaker named William Tuke (1732–1819) was bringing similar reforms to northern England. In 1796 he founded the York Retreat, a rural estate where about 30 mental patients lived as guests in quiet country houses and were treated with a combination of rest, talk, prayer, and manual

work (Rollin & Reynolds, 2018).

The Spread of Moral Treatment

The methods of Pinel and Tuke, called moral treatment because they emphasized moral guidance and humane and respectful techniques, caught on throughout Europe and the United States. Patients with psychological problems were increasingly perceived as potentially productive human beings who deserve individual care, including discussions of their problems, useful activities,

work, companionship, and quiet.

The person most responsible for the early spread of moral treatment in the United States was Benjamin Rush (1745–1813), an eminent physician at Pennsylvania Hospital who is now considered the father of American psychiatry. Limiting his practice to mental illness, Rush developed humane approaches to

treatment (Brown, 2018). For example, he required that the hospital hire intelligent and sensitive attendants to work closely with patients, reading and talking to them and taking them on regular walks. He also suggested that it would be therapeutic for doctors to give small gifts to their patients now and then.

2504743 - Macmillan US ©

Dance in a madhouse A popular feature of moral treatment was the “lunatic ball.” Hospital officials would bring patients together to dance and enjoy themselves. One

such ball is shown in this painting, Dance in a Madhouse, by George Bellows.

Rush’s work was influential, but it was a Boston schoolteacher named Dorothea Dix (1802–1887) who made humane care a public and political concern in the United States. From 1841 to 1881, Dix went from state legislature to state legislature and to Congress, speaking of the horrors she had observed at asylums and calling for reform. Dix’s campaign led to new laws and greater government funding to improve the treatment of people with mental disorders (Strickler & Farmer, 2019). Each state was made responsible for developing

effective public mental hospitals, or state hospitals, all of which were intended to offer moral treatment. Similar hospitals were established throughout Europe.

The Decline of Moral Treatment

By the 1850s, a number of mental hospitals throughout Europe and America reported success using moral approaches. By the end of that century, however, several factors led to a reversal of the moral treatment movement (Bloom, 2020; Bartlett, 2017). One factor was the speed with which the movement had spread.

2504743 - Macmillan US ©

As mental hospitals multiplied, severe money and staffing shortages developed, recovery rates declined, and overcrowding in the hospitals became a major problem. Another factor was the assumption behind moral treatment that all patients could be cured if treated with humanity and dignity. For some, this was

indeed sufficient. Others, however, needed more effective treatments than any