Engravings from 1525 showing trephination. It was believed that drilling holes in the skull could cure mental disorders.
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Prehistoric and Ancient Beliefs
Prehistoric cultures often held a supernatural view of abnormal behavior and saw it as the work of evil spirits, demons, gods, or witches who took control of the person. This form of demonic possession often occurred when the person engaged in behavior contrary to the religious teachings of the time.Trephinationis an example of the earliest supernatural explanation for mental illness.Treatment by cave dwellers used a technique calledtrephination, in which a stone instrument known as atrephinewas used to remove part of the skull, creating an opening. Through it, the evil spirits could escape thereby ending the person’s mental affliction and returning them to normal behavior.Examination of prehistoric skulls and cave art from as early as 6500 BC has identified surgical drilling of holes in skulls to treat head injuries and epilepsy as well as to allow evil spirits trapped within the skull to be released (Restak, 2000).Abuse the body badly enough, and the spirit will want to leave it.
Early Greek, Hebrew, Egyptian, and Chinese cultures used a treatment method calledexorcismin which evil spirts were cast out through prayer, magic, flogging, starvation, having the person ingest horrible tasting drinks, or noise-making.
This is the Taijitu (太極圖), with black representing yin and white representing yang. It is a symbol that reflects the inescapably intertwined duality of all things in nature, a common theme in Taoism.
Around 2700 BC, Chinese medicine’s concept of complementary positive and negative bodily forces (“yin and yang”) attributed mental (and physical) illness to an imbalance between these forces. As such, a harmonious life that allowed for the proper balance of yin and yang and movement of vital air was essential (Tseng, 1973).
Mesopotamian and Egyptian papyri from 1900 BC describe women suffering from mental illness resulting from a wandering uterus (later namedhysteriaby the Greeks): The uterus could become dislodged and attached to parts of the body like the liver or chest cavity, preventing their proper functioning or producing varied and sometimes painful symptoms. As a result, the Egyptians, and later the Greeks, also employed a somatogenic treatment of strong smelling substances to guide the uterus back to its proper location (pleasant odors to lure and unpleasant ones to dispel).
Throughout classical antiquity we see a return to supernatural theories of demonic possession or godly displeasure to account for abnormal behavior that was beyond the person’s control. Temple attendance with religious healing ceremonies and incantations to the gods were employed to assist in the healing process. Hebrews saw madness as punishment from God, so treatment consisted of confessing sins and repenting. Physicians were also believed to be able to comfort and cure madness, however.
Greek physicians rejected supernatural explanations of mental disorders.Rejecting the idea of demonic possession, Greek physician, Hippocrates (460-377 B.C.), said that mental disorders were akin to physical disorders and had natural causes.
According to the theory of the four humors, the substances that make up the human body are: black bile, yellow bile, blood, and phlegm. Hippocrates linked each of these humors to an element in the universe and atmospheric conditions: Black bile: related to earth, with cold and dry properties.
He attempted to separate superstition and religion from medicine by systematizing the belief that a deficiency in or especially an excess of one of the four essential bodily fluids (i.e., humors)—bloodwhich arose in the heart,black bilearising in the spleen,yellow bileorcholerfrom the liver, andphlegmfrom the brain —was responsible for physical and mental illness. Mental disorders occurred when the humors were in a state of imbalance such as an excess of yellow bile causing frenzy and too much black bile causing melancholia or depression. Hippocrates believed mental illnesses could be treated as any other disorder and focused on the underlying pathology. For example, someone who was too temperamental suffered from too much blood and thus blood-letting would be the necessary treatment.
Hippocrates classified mental illness into one of four categories—epilepsy, mania, melancholia, and brain fever—and like other prominent physicians and philosophers of his time, he did not believe mental illness was shameful.Also important was Greek philosopher, Plato (429-347 B.C.), who said that the mentally ill were not responsible for their own actions and so should not be punished. It was the responsibility of the community and their families to care for them. Humorismremained a recurrent somatogenic theory up until the 19th century.
Many of Hippocrates’ medical theories are no longer practiced today. However, he pioneered medicine as an empirical practice and came up with the “Hippocratic oath,” which all doctors must swear to before joining the profession (i.e., the promise to never intentionally harm a patient).
While Greek physician Galen (AD 130–201) rejected the notion of a uterus having ananimistic soul, he agreed with the notion that an imbalance of the four bodily fluids could cause mental illness. Galen said mental disorders had either physical or mental causes and included fear, shock, alcoholism, head injuries, adolescence, and changes in menstruation.therefore, he opened the door for psychogenic explanations for mental illness by allowing for the experience of psychological stress as a potential cause of abnormality. Galen’s psychogenic theories were ignored for centuries, however, as physicians attributed mental illness to physical causes throughout most of the millennium.
The Middle Ages – 500 AD to 1500 AD
The progress made during the time of the Greeks and Romans was quickly reversed during the Middle Ages with the increase in power of the Church and the fall of the Roman Empire. Mental illness was yet again explained as possession by the Devil and methods such as exorcism, flogging, prayer, the touching of relics, chanting, visiting holy sites, and holy water were used to rid the person of his influence. In extreme cases, the afflicted were exposed to confinement, beatings, and even execution. Scientific and medical explanations, such as those proposed by Hippocrates, were discarded.
By the late Middle Ages, economic and political turmoil threatened the power of the Roman Catholic church. Between the 11th and 15th centuries, supernatural theories of mental disorders again dominated Europe, fueled by natural disasters like plagues and famines that lay people interpreted as brought about by the devil. Superstition, astrology, and alchemy took hold, and common treatments included prayer rites, relic touching, confessions, and atonement. Beginning in the 13th century the mentally ill, especially women, began to be persecuted as witches who were possessed. At the height of the witch hunts during the 15th through 17th centuries, with the Protestant Reformation having plunged Europe into religious strife, two Dominican monks wrote theMalleus Maleficarum(1486) as the ultimate manual to guide witch hunts. Johann Weyer(1515-1588), a German physician, and Reginald Scot tried to convince people in the mid- to late-16th century that accused witches were actually women with mental illnesses and that mental illness was not due to demonic possession but to faulty metabolism and disease, but the Church’s Inquisition banned both of their writings. Witch-hunting did not decline until the 17th and 18th centuries, after more than 100,000 presumed witches had been burned at the stake (Schoeneman, 1977;Zilboorg & Henry, 1941).
Near the end of the Middle Ages, mystical explanations for mental illness began to lose favor and government officials regained some of their lost power over nonreligious activities. Science and medicine were called upon to explain psychopathology.
The Renaissance – 14th to 16th centuries
The most noteworthy development in the realm of philosophy during the Renaissance was the rise ofhumanism, or the worldview that emphasizes human welfare and the uniqueness of the individual. This helped continue the decline of supernatural views of mental illness.
Modern treatments of mental illness are most associated with the establishment of hospitals andasylumsbeginning in the 16th century. Such institutions’ mission was to house and confine the mentally ill, the poor, the homeless, the unemployed, and the criminal. War and economic depression produced vast numbers of undesirables and these were separated from society and sent to these institutions. Two of the most well-known institutions, St. Mary of Bethlehem in London, known as Bedlam, a term that today means “a state of uproar and confusion”, and the Hôpital Général of Paris—which included La Salpêtrière, La Pitié, and La Bicêtre—began housing mentally ill patients in the mid-16th and 17th centuries. As confinement laws focused on protecting the publicfromthe mentally ill, governments became responsible for housing and feeding undesirables in exchange for their personal liberty. Hospitals and monasteries were converted into asylums. Though the intent was benign in the beginning, as they began to overflow patients came to be treated more like animals than people. Most inmates were institutionalized against their will, lived in filth and chained to walls, and were commonly exhibited to the public for a fee. Mental illness was nonetheless viewed somatogenically, so treatments were similar to those for physical illnesses: purges, bleedings, and emetics.
While inhumane by today’s standards, the view of insanity at the time likened the mentally ill to animals (i.e., animalism) who did not have the capacity to reason, could not control themselves, were capable of violence without provocation, did not have the same physical sensitivity to pain or temperature, and could live in miserable conditions without complaint. As such, instilling fear was believed to be the best way to restore a disordered mind to reason.
Reform Movement – 18th to 19th centuries
The rise of themoral treatment movementoccurred in Europe in the late 18th century and then in the United States in the early 19th century.By the 18th century, protests rose over the conditions under which the mentally ill lived, and the 18th and 19th centuries saw the growth of a more humanitarian view of mental illness. In 1785 Italian physician Vincenzo Chiarughi (1759–1820) removed the chains of patients at his St. Boniface hospital in Florence, Italy, and encouraged good hygiene and recreational and occupational training. More well known, French physician Philippe Pinel (1745–1826) and former patient Jean-Baptise Pussin created a “traitement moral”( Moral treatment)at La Bicêtre and the Salpêtrière in 1793 and 1795 that also included unshackling patients, moving them to well-aired, well-lit rooms, and encouraging purposeful activity and freedom to move about the grounds (Micale, 1985), stressing affording the mentally ill respect, moral guidance, and humane treatment, all while considering their individual, social, and occupational needs.
In England, humanitarian reforms rose from religious concerns. William Tuke (1732–1822) , a Quaker tea merchant, urged the Yorkshire Society of (Quaker) Friends to establish the York Retreat in 1796, where patients were guests, not prisoners, and where the standard of care depended on dignity and courtesy as well as the therapeutic and moral value of physical work (Bell, 1980).The Quakers believed that all people should be accepted for who they were and treated kindly. At the retreat, patients could work, rest, talk out their problems, and pray (Raad & Makari, 2010).
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While America had asylums for the mentally ill—such as the Pennsylvania Hospital in Philadelphia and the Williamsburg Hospital, established in 1756 and 1773—the somatogenic theory of mental illness of the time—promoted especially by the father of America psychiatry, Benjamin Rush (1745–1813)—had led to treatments such as blood-letting, gyrators, and tranquilizer chairs. When Tuke’s York Retreat became the model for half of the new private asylums established in the United States, however, psychogenic treatments such as compassionate care and physical labor became the hallmarks of the new American asylums, such as the Friends Asylum in Frankford, Pennsylvania, and the Bloomingdale Asylum in New York City, established in 1817 and 1821 (Grob, 1994).