History

Historically, persons with mental disorders have been beaten, driven from their homes, subjected to inhumane treatments, and put to death. Early views of mental disorders were founded on a mixture of demonology and theories of organic causality. Demonology is founded on the idea that evil spirits or an angry god can dwell within or directly influence a person. Organic theories attribute the development of mental disorders to physical causes—injuries, imbalances in body fluids, or abnormal body structures.

Skulls dating back as far as 500,000 years show evidence of trephining, a technique using stone instruments to scrape away portions of skulls. It is assumed that these operations were performed to allow evil spirits to escape from the bodies of the people whose skulls were found. A modified form of trephining was revived in Europe in the Middle Ages. As late as the sixteenth century, some patients were subjected to surgical procedures in which a physician would bore holes in a patient’s skull and an attending priest would remove stones that were assumed to be a cause of insanity.

An Egyptian papyrus of 3000 bce describes recommended treatments for war wounds and shows that the Egyptians recognized the relationship between organic injury and subsequent mental dysfunction. Another papyrus, of the sixteenth century bce, shows that in regard to diseases not caused by obvious physical injuries, the Egyptians were likely to rely on magic for their explanations and incantations for their cures. Still, superstition was tempered with humane care—dream interpretation, quiet walks, and barge rides down the Nile.

The Hebrews viewed insanity as resulting from God’s wrath or the withdrawal of his protection. Without God’s protection, a person was subject to invasion by evil spirits, which could cause madness. For the Hebrews, mental disease was a consequence of not living according to God’s word.

Prior to the fifth century bce Greek beliefs concerning mental illness were founded on a mixture of religion and superstition. While the most typical responses to persons with mental abnormalities were banishment and stoning, some individuals received humane and supportive care. As did the Egyptians, the Greeks built temples devoted to healing and medicine. Baths, changes in diet, moderate exercise, and dream interpretation were aspects of the early Greek treatment regimen.

Subsequent to the fifth century bce, Greek thought concerning diseases came under the influence of the physician Hippocrates. Hippocrates rejected the prevailing belief that attributed disease to possession. The writings of Hippocrates, nearly all of which were authored by his followers, are very clear in attributing diseases to natural processes. While many healthful remedies followed the Hippocratic idea that mental disorders could be traced to imbalances in body fluids, this same theory also led to many improper and inhumane interventions, such as bloodletting and the forced consumption of foul potions.

In addition to the deductions of Greek physicians, Greek philosophers also speculated concerning mental disturbances. The Greek philosopher Plato addressed the need to treat persons afflicted with mental disorders with compassion and argued that persons who commit a crime as a result of madness or disease should pay a fine but otherwise should be exempt from punishment.

The early Romans expanded upon and refined Greek ideas in regard to mental diseases. After the death in c. 199 ce of the Greek physician Galen, who practiced in Rome for most his lifetime, Roman medicine stagnated. While Europeans abandoned scientific explanations for mental disorders, Islamic countries continued the inquiries initiated by the Greeks. In 792, the first hospital devoted exclusively to the care of mentally ill persons was opened in Baghdad. Humane treatment and a concern for the dignity of disturbed persons were key aspects of treatments recommended by Islamic physicians.

European Traditions

In contrast to the Islamic tradition, Europeans routinely expelled, tortured, abused, and murdered the mentally disturbed. With the rise of Christianity, insanity was variously ascribed to demonic possession, hormonal imbalances, and folk superstitions. While some monasteries offered healing rituals based on incantations and prayer, it was far more common to view the mentally disturbed as abandoned by God or in league with Satan and in need of redemption rather than assistance.

During the mid-thirteenth century, the Church focused on the need to search out and identify witches and warlocks. Mentally ill persons were perfect targets for the papal inquisitors, although it is believed that many more sane than insane persons died as a result of the Inquisition. Commonly, the accused were tortured until they confessed, after which they were burned to death.

The fifteenth century also saw a major movement that was directed toward the confinement of the mentally ill. The institutions for the mentally disturbed were administered by physicians, and as a result, doctors assumed primacy in the care of the mentally disturbed. While the care of persons with mental disorders was transferred from the clergy to physicians, the quality of the patients’ lives showed little improvement. Bloodletting, emetic potions, straitjackets, chains, dunking chairs, spinning devices, and terror were the most frequently prescribed treatments.

It was not until the late eighteenth century that positive changes occurred in regard to the treatment of the mentally ill. In 1793 a French physician, Philippe Pinel, was put in charge of a Paris asylum. Dismayed by the treatment that was provided the inmates, Pinel initiated a series of reforms that became the foundation for what was later called the Moral Treatment Revolution. The Moral Treatment Revolution was founded on the principles that mental patients should be treated with compassion, provided with supportive counseling, housed in comfortable surroundings, and given purposeful work. While a number of existent asylums adopted the Moral Treatment approach and new hospitals were dedicated to its principles, it did not take long for economics and neglect to make a mockery of the stated principles. Over time, mental hospitals became little more than warehouses where the mentally ill were admitted, diagnosed, and forgotten.

The Modern Era

While the late nineteenth century saw the development of new theories and techniques for the treatment of mental disorders that were based on free association and catharsis, only a few affluent persons with mental disorders received these treatments. Still, by the early twentieth century, bloodletting, purging, terror, and treatments designed to cause disorientation were being abandoned. These treatments were replaced by somatic therapies and pharmacological interventions. Major problems existed, however, in that the somatic therapies caused brain damage, and the drugs that were available prior to the 1950s were sedatives that caused extreme lethargy and sometimes death.

By the early 1930s, psychiatrists began experimenting with various types of somatic therapy. Insulin coma therapy involved administrations of toxic doses of insulin to nondiabetic patients. Electroconvulsive therapy (ECT) involved passing an electric current through a patient’s brain, causing a seizure. Between the late 1930s and the 1960s, several hundred thousand mental patients were involuntarily treated with ECT.

During the mid-1930s, the Portuguese physician António Egas Moniz introduced a surgical procedure that evolved into the prefrontal lobotomy. Between 1935 and 1955, more than fifty thousand mental patients were subjected to lobotomies, in which healthy brain tissue was destroyed in a misdirected effort to treat mental illness.

By the mid-1950s, new pharmacological agents became available. The first of the drugs to be used was reserpine. Although the effects of reserpine on the behavior of psychotic patients were profound, the drug had dangerous side effects. Reserpine was soon replaced by the drug Thorazine. Over the next several years, hundreds of thousands of patients, some voluntarily and many involuntarily, were given Thorazine and other major tranquilizers. One side effect of Thorazine and other drugs of its class is tardive dyskinesia, a disfiguring disturbance that manifests as facial grimacing, palsy, and a staggering gait. For most patients, the tardive dyskinesia disappears when the drug is discontinued, but for some the symptoms are irreversible.

Partially as a result of the availability of psychotropic medications and as a result of changes in social policy, the 1960s saw the beginnings of the community mental health movement. The community mental health movement promoted the concepts of deinstitutionalization, treatment in the least restrictive environment, and treatment as close to the person’s home community as possible. Deinstitutionalization involved discharging as many patients as possible from state hospitals and discouraging new admissions. As a result of deinstitutionalization, state hospital populations went from a peak of more than 500,000 during the mid-1950s to fewer than 130,000 during the late 1980s.

Clarification of Terms

Throughout the preceding narrative the terms “mental illness,” “mental disease,” “insanity,” “madness,” “mental abnormality,” “mental disturbance,” “mental dysfunction,” and “mental disorder” have been used interchangeably. While this is a common practice, it can lead to misunderstandings. While medical practitioners, legal documents, and the general public frequently refer to aberrant behavior and mental disorders as mental illness, this is a misuse of the term “illness.” Illness implies that some underlying disease process exists. The American psychiatrist Thomas Szasz has argued that the complaints that are called symptoms of mental illness are simply communications concerning beliefs, discomfort, or desires that an individual experiences in regard to self or others. Labeling such communications as symptoms of mental illness is a sociopolitical process that vests authority in physicians to control and abuse persons whose communications make others uncomfortable or who are presumed to be dangerous.

While “insanity” is used interchangeably with “mental illness,” it would be best if the term “insanity” were reserved to describe a mental state pertinent to legal proceedings. Most countries mitigate punishment if it is determined that a person was insane at the time of committing an illegal act. In fact, most states in the United States allow a finding of not guilty by reason of insanity. This means that a person who commits an illegal act while insane should be found not guilty of any criminal offense.

The terms “madness,” “mental abnormality,” “mental disturbance,” and “mental dysfunction” are simply descriptive in nature. They have no particular standing in regard to the legal system or the medical establishment.

The term “mental disorder” is the official term adopted by the American Psychiatric Association and the American Psychological Association to describe abnormal behavioral or psychological states that cause personal distress, impaired functioning, or conflict with society. The Diagnostic and Statistical Manual of Mental Disorders catalogs the symptoms and behaviors of the various types of mental disorders. Only a minority of the several hundred disorders listed fit the criteria for identification as diseases. That is, it is not possible to identify infectious processes, biochemical imbalances, organ malfunctions, or physical trauma as causes of most disorders. Therefore, it is questionable to refer to them as illnesses.

Ethical Issues

The treatment of persons with mental disorders brings into consideration a number of ethical issues. Among the ethical issues that are of importance in regard to the treatment of persons identified as mentally ill are the following: paternalism, confidentiality, right to privacy, autonomy, informed consent, right to treatment, right to refuse treatment, and criminal responsibility.

In the United States, persons may be involuntarily confined in mental hospitals if they are “mentally ill” and a danger to self or others. Additionally, many states allow the commitment of “mentally ill” persons who are likely to deteriorate mentally or physically if they do not receive care. While at one time simply having a mental disorder could serve as grounds for loss of freedom, states nowrequire an additional finding of dangerousness or probability of deterioration. The right of the state to confine selected citizens involuntarily is based on the concepts of paternalism and police power. Paternalism, or parens patriae, allows the state to protect citizens from themselves.

Confidentiality

Confidentiality is central to the practice of psychotherapy. Professional codes and legal procedures require that certain communications be held in confidence. Still, all states provide exceptions to confidentiality, which include the following: when criminal charges have been filed, in child custody cases, when a criminal offense is planned, when the client is a danger to self or others, and when the client has been informed that certain communications are not privileged. While the right to privacy is a fundamental right that most citizens enjoy, it is frequently denied persons who have been diagnosed as mentally ill. If the mentally ill person does not cooperate with treatment, divulge personal secrets, and participate in routine hospital activities, he or she will be identified as an uncooperative patient and will find it very difficult to obtain his or her freedom.

Autonomy is the right to act in a manner that is consistent with one’s personally held beliefs and to make decisions that affect one’s fate and destiny. This is a right that is refused many mentally ill persons. Through involuntary commitment and forced treatment, persons deemed to be suffering from mental diseases are denied the right to make key decisions that affect their quality of life and their personal survival. Concerning personal survival, only two states have laws making suicide illegal. Furthermore, all states allow a competent adult to make decisions regarding the continuation of life-support devices. Most states either allow or are mute on the right of a competent person to terminate his or her life. Still, all states allow the forced incarceration of a mentally ill person who attempts suicide.

Patient Rights

Informed consent requires that persons understand the nature of the procedures they are to experience, that their participation be voluntary, and that possible consequences be explained. Involuntary commitment, forced treatment, and failure to discuss side effects of psychotropic medications are examples of violations of informed consent in regard to mentally ill persons.

Right to treatment refers to the concept that persons involuntarily confined in mental institutions have a right to humane care and therapeutic treatment. During the 1971 Alabama case Wyatt v. Stickney, Judge Frank Johnson stated, “to deprive any citizen of his or her liberty upon an altruistic theory that the confinement is for humane and therapeutic reasons and then fail to provide adequate treatment violates the very fundamentals of due process.”

During the 1975 case O’Connor v. Donaldson, the Supreme Court ruled that Donald Donaldson, who had been confined to a mental hospital in Florida for fourteen years, deserved a periodic review of his mental status and could not be indefinitely confined if he was capable of caring for himself and was not a danger to himself or others. While not directly ruling on the issue of right to treatment, the court let stand an earlier decision that if Donaldson was not provided treatment, he should have been discharged from the hospital.

The right to refuse treatment is an issue that causes a great deal of controversy. Prior to the 1960s, it was common practice to force patients to undergo dangerous and disabling treatments. Involuntary sterilizations, electroconvulsive therapy, and psychosurgery were frequently prescribed for recalcitrant or difficult patients. While patients now have specific rights in regard to certain invasive treatments, their right to refuse unwanted medications was undefined as late as the early 1990s. During the 1979 case Rogers v. Okin, a patient who had been committed to the Boston State Hospital complained that he should not be required to take psychotropic medications against his will. While the initial court finding was that Rogers should have had a right to refuse medication, the case was appealed, and no clear precedent emerged from the case.

The issue of criminal responsibility is bound up with the concept of insanity. If a person, because of mental defect or state of mind, is unable to distinguish right from wrong, then most states would find the person exempt from criminal punishment. Beginning in 1975, however, Michigan adopted an alternate verdict of “guilty but mentally ill.” As of 2000, twenty states had followed the Michigan example. The option of finding a person guilty but mentally ill increases the probability that incarceration will follow a crime committed by a person who previously would have been declared insane. Additionally, it allows for mitigation of the length of sentencing and provides for specialized treatment in a prison hospital.

Further Reading

See also: Child psychology; Confidentiality; Electroshock therapy; Hippocrates; Institutionalization of patients; Lobotomy; Psychology; Psychopharmacology; Soviet psychiatry; Suicide.