Notes on the history of mental health care

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Foreword

What is striking in looking at the history of mental health care is that at periods through the centuries, indeed through the millennia, there has been an accepted way of dealing with people with mental health problems, conventional for the time, that, however well-intentioned, has more often than not been inhumane, punitive, and largely unsuccessful, while alongside the orthodox practitioners there have been others with more enlightened approaches, attempting to do things differently. If there seems to be at least as much of the latter as the former in this factsheet, that is because it seems to be so little known: most histories concentrate on the gruesome, featuring medieval witchhunts (with the idea that they no longer happen), and the overcrowded back wards of Victorian asylums. Getting more humane treatments acknowledged continues to be one of the problems of psychiatry even at the end of the second millennium AD, however enlightened we wish to think we are. These historical notes show that there is not much that is new in present-day enlightened approaches - it has all been said before; but the problem of their acceptance as mainstream treatment retains its hold. 

Books on the history of mental health care frequently record 'the first' instance of something; this means in reality 'the first documented' instance, or even 'the first instance that my limited library search has revealed'. I have tried to avoid this phrase, feeling that most types of human thought and behaviour have probably happened before, unless very closely linked to some technological innovation.

10,000 BC In prehistoric times there was, as far as historians can tell, no division between medicine, magic and religion. In the Stone Age there is evidence of trepanning the skull, and also that parts of the cut skull were used as amulets.  Study of cave drawings indicates that mesolithic people utilised a magical law relating to all human activities of the time, by which they made sense of the world. A cave painting in Ariege, France, shows a strange being with human feet and hands and antlers who has been identified as a 'psychiatrist (witch doctor)', but it is not clear how this identification has been made.

In about 2,850 BC at Memphis, the temple of Imhotep, a great Egyptian healer who was deified, became a medical school where patients received sleep therapy, occupational therapy, excursions on the Nile, concerts, dances and painting. There were carefully worded malpractice laws and detailed clinical treatises; however psychiatric theory was largely magical, and successful treatments were attributed to amulets worn or to the patron god. 

In Mesopotamia in 2,000 BC, according to the code of Hammurabi preserved in Cuneiform clay tablets, priest-physicians dealt especially with mental disturbance which was attributed to demonic possession, whilst 'lay' physicians dealt solely with physical injury. This was the first known division between mental and physical symptoms. These priest-physicians, the Asu, used psychotherapy, and studied dreams which were regarded as showing the will of the gods. Every physician had his own god and every disease its own demon. Diseases and drugs were codified, and the doctor was responsible for his patient, whose life story was studied in a holistic approach.

The Talmud is full of psychological commentary.  Rabbi Hunah stated that good men have bad dreams, implying that dreams are a safety valve for wishes repressed by moral principles. Judaism also suggested that sickness and madness were punishments for sins. In the Old Testament, Saul suffered from suicidal depression, Nebuchadnezzar had a psychotic fear of being a wolf, and Ezekial was coprophagic, while David feigned madness to escape from the King of Gath. One effect of Hebrew psychiatry was that the religion of one God caused a lot of magical ideas to be discarded. However, despite the caring of the Hebrews, and the building of a special hospital for mentally ill people, statements like, 'a wizard shall surely be put to death; they shall stone them with stones' were to be used in an inhumane way for centuries. Deuteronomy names insanity as one of the many curses that God will inflict on those who do not obey Him: 'the Lord shall smite thee with madness, and blindness, and astonishment of heart'. Saul's psychotic episodes were attributed to an evil spirit sent by the Lord, and treated with music therapy: 'And it came to pass, when the evil spirit was upon Saul, that David took an harp, and played with his hand: so Saul was refreshed, and was well, and the evil spirit departed from him.' Rabbi Asi in ancient Judea recommended that disturbed patients should talk freely about their worries. 

In about the 6th century BC, in India, Buddha attributed human thoughts to our sensations and perceptions, which, he said, gradually and automatically combine into ideas.  In China, Confucius said, 'A man can command his principles; principles do not master the man', and 'learning undigested by thought is labour lost; thought unassisted by learning is perilous'. In Greece, either Solon or Thales (sources differ) gave the famous advice, 'Know thyself'.

Witch doctors in Africa could only qualify for their profession by first having undergone convulsions and sickness themselves and a thorough exposure of their dreams.

According to Homer (c800BC), an eminent specialist, Melampus, pioneered the use of white hellebore for treating delusions, and Greek comedies frequently satirised the taking of the drug, which was considered a panacea. An eminent physician, Aesculapius, developed a form of sleep-therapy in luxurious surroundings, taking great care with patients' diet and exercise.  Aesculapian temples, named after him, were built in places of particular beauty or near springs with medicinal waters, and there patients with psychological problems could be cared for and encouraged to sleep, with the suggestion that Aeculapius would appear in their dreams to cure them.

Hippocrates who was born in 460BC at Kos wrote 76 treatises which are still considered to be the foundations of modern medicine and psychiatry.  He described melancholia, postpartum psychosis, mania, phobias and paranoia, and was called as a psychiatric witness in trials. Hippocrates also believed that thoughts and feelings occur in the brain, rather than the heart as was often thought, and classified personality in terms of the four humours.  

Plato (c400BC) proposed a view of the soul (psyche) as a charioteer driving two horses, one noble, the other driven by base desires.  The charioteer struggles to balance their conflicting impulses.  This is similar to Freud's theory of the superego, ego and id. Plato also discussed the origin of dreams, as well as the nature of sexual sublimation. 

Aristotle (b.384BC) showed an awareness of the importance of genetic inheritance, and saw mental growth as a sequence of cause and effect: aspirations influence behaviour and thus become causes. Aristotle saw actions, feelings and thoughts as a single unit. His awareness of the potential for change and his image of a self-actualised person accords with Erich Fromm's description. Aristotle, like Meyer, also believed in the concept of total reactions, rather than separating man's faculties. Arateus antedated modern concepts of mental disease as extensions of normal personality traits. The concept of personal will and ego and of emotional and rational behaviour was defined by Pythagorus. Aristophanes' plays include classic Freudian free-association sessions, beginning 'come onto the couch'. 

Asclepiades was a Greek doctor who practised in Rome, using a form of physiotherapy designed to move the oppositely charged 'atoms' of which the human body was formed. He invented a swinging bed which had a relaxing effect on emotionally disturbed patients, found music helpful, and spoke out strongly against incarceration of mentally ill people. He disliked the term 'insanity', referring to 'passions of sensations', and differentiated between hallucinations and delusions. Asclepiades waged a strong campaign against bleeding, which in fact went on for another 1500 years.

In the 2nd century AD his follower, Soranus of Ephesus, said that patients should be kept in light, airy conditions, should not be beaten, kept in the dark or given poppy to make them drowsy, and he stressed the importance of convalescence and aftercare. He also took social background and culture into account and insisted on the importance of the doctor-patient relationship. Although he described mental distress in terms of an organic disturbance he treated it by psychological methods, minimising the use of drugs and other physical treatments. But he also suggested that mania should be treated with the alkaline waters of the town. These waters contained high levels of lithium salts. Lithium treatment was rediscovered for manic depression by John Cade, an Australian psychiatrist, in the 1940s.

The Romans tended to concentrate on pleasant physical therapies: warm baths, massage, diet, well-lighted and pleasant rooms, and music. They also used shocks by electric eels.

To elicit the state of mind of the mentally disturbed person, Cicero (c110BC) designed an interview format which contained the following items:

This assessment tool was used throughout the Roman Empire, was still used by the Celtic monasteries in the following centuries and continued in use until the Dissolution of the Monasteries in the 16th century (i.e for about 1600 years).

Cicero rejected the concept of the four humours, saying that melancholia was caused, not by black bile, as Hippocrates had suggested, but by violent rage, fear and grief.

Another Roman, Aretaeus (50-130AD), an eclectic medical philosopher, established the fact that manic and depressive states occur in the same individual and that lucid intervals exist between manic and depressive episodes. He also understood that not everyone with mental illness is destined to suffer intellectual deterioration, a fact not adequately emphasised until the twentieth century, if then, and he was very concerned about the welfare of his patients, understanding the undesirability of treatments that patients find unacceptable. He abandoned terms relating to the four humours and gave clear descriptions of emotional states.

In the last years before Christ the influence of enlightened views of the Roman doctors began to decline, and Cornelius Celsus (25BC-50AD) recommended starvation, fetters and flogging and anything 'which thoroughly agitates the spirit'.  He reinstated the idea that some illnesses were caused by the anger of the gods, and his words were used in the Middle Ages to justify the burning of witches. 

Galen (131-200) was an anatomist rather than a physician, and borrowed ideas from many sources. He dedicated many of his writings to a Creator, a fact which led to his having a far greater influence over the Christian world in later centuries than his work perhaps merited, and helped to retard the development of medicine. 

Rhazes (865-925), called 'the Persian Galen' (but 700 years later), was chief physician at Baghdad hospital where there was a psychiatric ward, and, because the Arabs had no fear of demons, patients were kindly treated. They used the writings of Galen and Aristotle to guide them, and appear to have made use of forms of behaviour therapy. 

In Salerno university, Constantinus Africanus (1020-1087) a Jew who became a Christian, translated Hippocrates from Arabic into Latin. Once again the nervous system was examined and the brain seen as the seat of mental illness. Hydrotherapy was used. 

Pietro Albano (1250-1316) was burned to death by the Inquisition for minimising spiritual principles in his attempt to unite Aristotle's thinking with the medical facts.

Medieval laymen had more enlightened attitudes toward mental health problems than did professionals, for poetry and other literature present very realistic views of the subject. The poems Amadas (late 12th century), and also Tristan both indicate an understanding of the idea that emotional crises may result in severe emotional disorders and that they may be corrected by a realistic psychological approach.

It was not until the 14th century that people with mental health problems were considered witches and again became victims of persecution. The physical care of the insane was better in the early middle ages than it was during the 17th and 18th centuries. In the early days of the Bethlehem hospital (Bedlam), which began to care for people with mental health problems in the 12th century, patients were treated with concern, and were issued with arm badges to wear so that they could be returned to hospital if their symptoms should recur. Apparently vagrants sometimes counterfeited the badges so that they could be taken for former patients of Bethlem.

Ironically, witchhunts began at the dawn of the Renaissance, provoked at least in part by anxiety about the sexual activities of some monks and nuns. The Church needed to take action against this and the blame fell upon women who stirred men's passions and were therefore seen as agents of the devil. At the same time severe plague killed 50 per cent of the population in Europe, leading to a conviction among some groups that it was sent as punishment for sin. These groups therefore practised self-flagellation and humiliation to relieve their guilt. In the 15th century the ideology of the mass movement of witch hunting was codified by two Dominican German monks, Johann Sprenger and Heinrich Kraemer, who wrote Malleus Maleficorum (The Witches' Hammer), a gruesome and pornographic book which became the witch-hunter's bible, with the backing of a Papal Bull in 1484. It consisted of three main parts, the first a collection of arguments in support of the existence of witches and witchcraft, concluding that to doubt their existence was to be a heretic; the second describing witches and how they may be identified; the third concerned with their treatment. A lot of the information was about deviant behaviour, much of it overtly sexual. This was at least partly due to the belief that insanity was caused by possession by the devil, and a devil possessed a witch by copulating with her. As the ultimate salvation of the immortal soul was more important than the comforts of the possessed body, physical punishments such as drowning and burning were used to make the body an intolerable refuge for the devil. The wide dissemination of this book was greatly facilitated by the development of printing, and it ran into 10 editions. Another obvious and kinder treatment for the supposed possession was exorcism which often succeeded.   

Some enlightened care was offered in monasteries. The Sisters of the Society of Hospitalers created hospitals offering good food, rest and calm, and a Franciscan monk, Bartholemew Anglicus in his book De Proprietatibis Rerum, prescribed music and occupation for depressed patients and sleep and gentle binding for frenzied patients. There was no hint of demonology.

In the 16th century, while demonology and witch-hunts continued, there were again those who put forward more enlightened beliefs. Juan Luis Vives, born in Valencia in 1492, died in Bruges at the age of 48, respected by Erasmus, Henry VIII and St Thomas More. He put forward a concept of treatment for mental distress which we might do well to bear in mind today:

Since there is nothing in the world more excellent than man, nor in man than his mind, particular attention should be given to the welfare of the mind; and it should be considered a highest service if we either restore the minds of others to sanity or keep them sane and rational ... One ought to feel great compassion for so great a disaster to the health of the human mind, and it is of utmost importance that the treatment be such that insanity be not nourished and increased, as may result from  mocking, exciting or irritating madmen ...

Since he was also deeply committed to education for women, presumably he included everyone in this view.

Similarly, Vives' contemporary, Paracelsus totally rejected demonology in dealing with mental distress. He saw it is a natural disease, writing,

We must not forget to explain the origin of the diseases which deprive man of his reason, as we know from experience that they develop out of man's disposition. The present-day clergy of Europe attribute such diseases to ghostly beings and threefold spirits: we are not inclined to believe them. 

Paracelsus (1493-1541) and another contemporary, Agrippa (1486-1535), disliked dangerous dispensing methods and complained of physicians recommended for their esoteric religions, splendid clothes and amulets. 'Simple and native medicines are quite neglected. Costly foreign remedies are preferred which latter are mixed in such enormous numbers that the action of one is counteracted by that of another'. But such ideas were treated with great suspicion by the religious community. Paracelsus claimed he learned all he knew from wise women - women skilled in the use of herbal remedies who acted as community midwives and laid out the dead.

Agrippa's pupil Weyer (b.1515) managed to bring a profound influence on the treatment of mental distress. Weyer emphasised that illnesses attributed to witches came from natural causes, and made the revolutionary demand that witches should themselves be sent to physicians for treatment. Weyer also considered the effects of drug-induced hallucinations, and provided clinical descriptions of auditory hallucinations and persecution mania. However his book, De Praestigiis Daemonum was proscribed by the Catholic church, and he himself was accused of being a sorcerer.

In the 17th century there was a belief that if mad people behaved like animals, they should be treated like animals. For example, Thomas Willis, a neuroanatomist and doctor, speaking of treatment of the mentally ill said,

The primary object is naturally curative discipline, threats, fetters and blows are needed as much as medical treatment...Truly nothing is more necessary and more effective for the recovery of these people than forcing them to respect and fear intimidation. By this method, the mind, held back by restraint, is induced to give up its arrogance and wild ideas and it soon becomes meek and orderly. This is why maniacs often recover much sooner if they are treated with torture and torments in a hovel instead of with medicaments.

In contrast to this Robert Burton's Anatomy of Melancholy (1621) written from his own experience, noted the aggression that lies behind depression, and proposed a therapeutic programme of exercise, music, drugs and diet, with a stress on the importance of discussing problems with a close friend, or, if one is not available, with a doctor.

In the 17th century people with mental health problems were often cared for privately. In 1661 the Rev John Ashbourne was stabbed by a patient who had been cared for in his house. Ashbourne was renowned in Suffolk as a 'clerical mad-doctor', and after his death Ashbourne's wife and son, who unlike Ashbourne had received the Cambridge licence to practise medicine from Trinity College, continued to run the 'mad-business' until at least 1686. This system of private treatment began with Helkiah Crooke, physician to James I and Bethlem Hospital who took patients into his own home for treatment. From boarding a single lunatic it was a short step to providing accommodation for numbers of patients, and thus setting up a private madhouse. 

Two doctors set up madhouses in London in the 1670s. John Archer, one of Charles II's 'Physitians in Ordinary', and Thomas Allen, a physician at Bethlem Hospital who also ran a private asylum. Allen seems to have been a humanitarian scientist who prevented his colleagues from transfusing sheep's blood into a man, and also ordered the first postmortem recorded at the Bethlem Hospital. One of his patients was James Carkesse, a clerk in Samuel Pepys's office at the Admiralty. Treatment varied according to ability to pay. Elsewhere in the country a Mistress Miller  'mad for two years' was treated by diet, glysters (large syringes used for purging), leeches, fresh cyder drinks, warm herb baths, and applying animal organs such as 'warm lungs of lambs' to her shaven head. 

The 18th century saw the development of new asylums built to house people with mental health problems separately from houses of correction and poor houses. One of these was the New Bethlem, seen to be so magnificent it was thought  'everyone might become half mad in order to lodge there'. (Palatial as it looked, it was built on a land-fill site and deteriorated rapidly.)  Whilst mental hospitals that followed New Bethlem were reasonably managed in London, the provincial institutions were often very poor. At Newcastle there were 'chains, iron bars, dungeon-like cells, many close, cold, dark holes, less comfortable than cow houses. There was no separation of the sexes, no classification, and for medical treatment the old exploded system of restraint and coercion.'  In 1773 a Bill passed the Commons on The Regulation of Private Madhouses, but it was thrown out by the Lords. In 1774 it became essential to produce a medical certificate confirming insanity before non-pauper lunatics could be confined, but the rights of paupers were totally disregarded. For the wealthy there was still the far more human alternative of being the individual private patient of a doctor or clergyman.

William Battie (1703-1776) was a pioneer in the care of mental patients (from whose name the term 'batty' is derived), who helped raise the 'mad business' to a respectable medical speciality. He wrote Treatise on Madness in 1758, and was founding medical officer of St Luke's Hospital in London. He was part of a new school of thought, that institutionalising patients in asylums was in itself therapeutic: their purpose in confining individuals was not just to protect them and society, but was in itself curative. He recognised that mental nurses needed special training, and wrote that madness is 'as manageable as many other distempers' and that its victims 'ought by no means to be abandoned, much less shut up in loathsome prisons as criminals or nuisances to the society'. 

New therapies at this time included water immersion:

the greatest remedy is to throw the patient unwarily into the sea, and to keep him under water as long as he can possibly bear without being stifled.

Another method was a special spinning stool which spun the patient round until he was dizzy. The spinning was supposed to rearrange the brain contents into the right positions.

Another specialist created a novel form of drama therapy involving lion's dens and executions which was part of a concept of 'non-injurious torture'. Benjamin Franklin in 1757 introduced a form of ECT, for which the rich were expected to make a donation of sixpence, but the poor 'to be electrified gratis'.

Other doctors believed in horse-riding, and George Cheyne, who saw melancholia as a particularly English condition, advocated a milk, seed and vegetable diet. Even King George III was subjected to hot irons, enemas and emetics and was chained to his bed in a straitjacket.

Pinel (1745-1826) is credited with revolutionising the Hospitals in France but in fact the humanitarian reforms were begun by Jean-Baptiste Pussin and his wife. Pussin had himself been a patient at the Bicetre, and it became the policy there to choose staff from among recovered or convalescing patients. Pinel described these people as best placed to understand the needs of the inmates as a result of what they themselves had experienced. Pinel went on to Salpetriere where he carried out similar reforms, establishing a regime of study and medical care to replace the bloodletting, purging and ducking that had previously been used. Chiarugi in Italy as well as Tuke in England independently arrived at the same conclusions at the same time or earlier.

In 1792 William Tuke (1732-1822), a Quaker tea merchant, founded the York Retreat. Tuke admired Pinel greatly and followed his ideas, providing an atmosphere of benevolence, comfort and sympathy for his patients. William Tuke's son Henry (1755-1814) and grandson Samuel (1784-1857) continued at York in the same humanitarian spirit.

At the beginning of the nineteenth century a public outcry about conditions in asylums led to the setting up of a select committee 'to consider of provision being made for the better regulation of madhouses in England'. The report describes appalling conditions of inadequate clothing, cramped and crowded accommodation filthy with excrement on straw, with patients chained to the walls, and in one case, a surgeon who was known to be drunk and insane. As David Stafford-Clark wrote in Psychiatry Today,

It may seem beyond belief that physicians could contemplate other human beings naked, cold, crusted with their own excrement, chained and starving in the dark on stone floors, without pity and without remorse.  But they could, and they did, and it is only by the exertions and the example of exceptional men that our own standards have been raised above this appalling state.

Asylum staff spent much of their working life locked away with their patients.

Husband and wife teams were a feature of asylum organisation in the early 19th century, many sharing their home life with their patients. In Britain, one such couple were George and Catherine Jepson at the Retreat in York, and Dr and Mrs Ellis at the Hanwell Asylum. Patients who came under these humanitarian regimes were lucky; many more were kept in conditions where fear and cruelty prevailed.

In the mid-nineteenth century Dorothea Lynde Dix was influential in changing conditions in institutions in New England, and in 1881 at 40 th anniversary of the Medico-Psychological Association at University College, Daniel Tuke, the president, paid respect to her 'who has a claim to the gratitude of mankind for having consecrated the best years of her life to the fearless advocacy of the cause of the insane'. The Association of Medical Superintendents of American Institutions for the Insane included among its tenets:

• Insanity is a disease to which everyone is liable.
• Properly and promptly treated, it is about as curable as most other serious diseases.
• In the majority of cases it is better and more successfully treated in well-organised institutions than at home.
• Overcrowding is an evil of serious magnitude.
• The insane should never be kept in penal institutions.

In the first part of the 19th century, a lot of doctors, such as Conolly, Kirkbride, Bucknill, and Hack Tuke were proud to work in the new asylums. There was also a new endeavour to study insanity. Esquirol in France followed the lead given by Pinel in attempting a classification of mental disorder. A line of successors in France and later in Germany culminated in Emil Kraepelin (1855-1927), a student of Wundt's, who produced a systematic classification of mental disease which forms the basis of modern systems. This is an attempt at grouping by causes as well as by symptoms, and in Kraepelin's work can be seen the merging of two psychological traditions: the experimental and the medical. At the same time growth in populations of asylums mirrored growth in unemployment and poverty following social upheaval caused by industrial revolution.

Alfred Meyer (1866-1950) believed in living medicine, seeing the patient in his own world. His wife became what was later called a social worker, visiting Meyer's patients to learn more about their home backgrounds. Rather than seeing disturbance as a result of brain pathology he saw it as a reaction or maladjustment involving the total person. He helped to change the hospital's approach from custody to active therapy, and stressed the importance of unhurried conversations with patients.

In the second half of the 19th century, Darwin's Origin of Species (1859) led to a pessimistic feeling that insanity, instead of being concerned with the will and moral management was a hereditary incapacity, leading to reduced concern for the unfortunate, and a feeling that the mad ought to be locked up.

The 1890 Lunacy Act was very different from the 1845 Lunacy Act, which was about running good hospitals; the 1890 Act was about locking people up. At the same time advances in general medical knowledge from strict attention to pathology and bacteriology led to a search for organic causes of mental distress, and the doctors in the asylums, instead of going out and playing cricket with patients, began to spend their time on research instead in the hope of finding the causes of the conditions they were treating, by for example dissecting the brains of deceased patients.

Development of Psychology

The 18th century saw the beginning of modern psychology as a separate discipline. The word psychology was used in the first half of the century to mean the secular philosophical analysis and interpretation of mental phenomena. In the latter half of the 19th century its reference shifted from a predominantly philosophic to a predominantly scientific study of mental phenomena. Wilhelm Wundt (1832-1920) is commonly regarded as the founder of scientific psychology. Although other people began experimental psychology earlier, Wundt had the first laboratory for teaching and research in the subject. Alexander Bain (1818-1903) was not an experimenter but wrote two very influential books, The Senses and the Intellect (1855) and The Emotions and the Will (1859). At the same time there were considerable influences from the growing understanding of the physiology of the nervous system. 

One development of the late 18th century which had a significant influence on the development of psychological practice was Mesmerism. Mesmer began by using magnets in the belief that they exercised some influence on the human body. He later abandoned this notion, but induced a number of phenomena which are now recognised as suggestion and hypnosis. Others in the 19th century took up mesmerism as an aid to medicine, and it was James Braid who attributed the phenomena to processes within the person, expectations arising from suggestion coupled with a narrowing of attention. An active school of hypnosis developed in Paris under the leadership of Charcot who established a notable neurological clinic at La Salpetriere. His work influenced Ribot who established a psychological laboratory under Beaunis and Binet. 

Emergence of Dynamic Depth Psychology

In the closing years of the 19th century several medical psychologists were developing psychogenic theories of the neuroses. Outstanding among them were Pierre Janet (1859-1949) and Sigmund Freud (1856-1939), a pupil and protégé of Charcot. Janet's view was that the neurotic lacked sufficient mental energy to hold his psyche together in a state of integration; as a result parts of it functioned in disassociation from the rest. Freud's view by contrast was that there were diverse mental energies in conflict with one another. Early in the development of his theory he spoke of the sex instincts versus the moral instincts; later of libido versus ego, and finally of eros (life instincts) versus thanatos (death instincts). Freud also proposed three major components to the psyche (strangely translated from German into Latin rather than English by his translators): das Es (the It, or Id) symbolising instinct or unconscious desire, das Ich (the I, or Ego) and das UberIch (the Upper-I, conscience or Superego). Freud's ideas are the basis for psychoanalytic theory. Although this began as a contribution to psychopathology, it quickly expanded into a more general theory. The interpretation of dreams, the explanation of slips of the tongue and of the pen, and an account of the psychic origins of art, religion and society began with Freud and have become part of everyday currency. Literature and literary criticism, art, morality and  religion have all felt this influence.

In the 20th century, there have been two major developments in psychology: Gestalt theory or a holistic approach, and behaviourism or stimulus-response theory. These two approaches begin to merge in the techniques of cognitive behavioural therapy which is increasingly practised at the present time.

In the 20th century the search for organic causes and treatments for mental health problems, continued, spurred on by the successful identification and treatment of conditions such as phenylketonuria and thyroid conditions. The observation of changes in emotional state in people treated for other conditions - for example the anti-depressant effect of iproniazid for tuberculosis - began the continuing search for biochemical treatments for every kind of mental state.

The end of the 19^th century and beginning of the twentieth, patients suffering from neurosyphilis were found to improve after infections, supposedly because the heat of the fever killed the infective agent which caused syphilis. So fever treatment was given, using first tuberculin injections and, later, infected blood from malaria patients. The malaria was treated with quinine. Later on, syphilis was treated with arsenic compounds, and then, from the 1940s, with penicillin, before this stage was reached, and neurosyphilis was no longer seen.

Other psychotic illnesses were, and of course still are, less easy to treat because their cause is not known. Sedatives, in the form of alkaloids such as morphine (an opium derivative), hyoscyamus (derived from the plant henbane, and from which hyoscine was derived), and chloral hydrate, which is still available as a sleeping drug today. Intravenous and intramuscular injections of morphine began in the mid-nineteenth century. Some cases of mania were treated with apomorphine mixed with hyoscine to make them vomit, which wore them out and hence had a calming effect. For a while bromide was fashionable, and this led to the development of deep sleep treatment. This involved inducing prolonged sleep, for days at a time, disturbing the patient every few hours just enough to give them some nourishment and toilet them. After the long period of sleep, patients would apparently wake with their psychotic symptoms resolved. Later it was also used for mood disorders, and people were thought to wake up in a state more amenable to psychotherapy. When bromide was deemed too toxic, it was replaced with barbiturates, the most popular of which was Veronal . Deep sleep treatment continued to be used until the 1960s by which time it was discredited, although it has been suggested more recently as a way of getting heroin addicts through cold turkey.

Other physical treatments used in the 20th century include insulin coma therapy in which patients were given insulin to induce a coma and convulsions, and then brought round with glucose injections. Camphor injections were also used to induce fits in the 1930s, and had been used to treat psychosis during the eighteenth century. Fits were also induced with drugs including metrazol.

Psychosurgery was used in the mid-20th century with an enthusiasm verging on abandon, and an appalling level of technical crudeness. A refined version is still practised on a small number of patients.

In the 1st World War the treatment of shell shock with talking therapies by psychiatrists such as William Rivers led eventually to treatment for what is now called post traumatic stress disorder, with debriefing for victims of traumatic incidents such as hostages, and eventually to the regular provision of counselling for survivors of traumatic incidents. But some soldiers were treated by people such as Lewis Yealland at the National Hospital for Nervous Diseases, who used electric shock treatment - techniques that were nothing short of torture, but as effective in achieving their immediate goal as torture often is.

The approach to traumatic stress in the 2nd World War was a spur to the evolution of group therapy by people such as Wilfred Bion and Foulkes.

The Mental Treatment Act 1930 introduced the category of voluntary patients and the notion of rehabilitation.

During the 1950s the tradition of caring for mentally ill people within large institutions came under intense criticism from both inside and outside the system. There was a growing realisation that the structure and organisation of mental hospitals was essentially pathogenic; innovators in care demonstrated that new therapeutic ideas could be introduced into the system with beneficial effects. Thomas Main at the Cassel Hospital, David Martin at Claybury and David Clark at Fulbourn were among the first to demonstrate that changing the organisation of mental hospitals and adopting open-door policies could result in significant improvement in even the most institutionalised patients. David Clark in five years 'turned Fulbourn from a closed hospital to a completely open-door hospital. We got workshops going, halfway houses, we had Open Days, brought the public in, took patients out. We changed the place completely. & Much of what we did was a return to the principles of sound asylum management, known for a century.... Fulbourn was much better in 1865 than in 1910.'   However these moves only allowed people out into the grounds; doctors still believed that their duty was to keep their patients in custody.

In 1961 Enoch Powell made his 'water tower' speech at a meeting of the National Association for Mental Health (not yet called Mind), announcing the proposed closure of the large psychiatric institutions with the development of care in the community. Edith Morgan (then a member of the Association's staff) commented,  'We all sat up, looked at each other and wondered what had happened. Because we'd been struggling for years to get the idea of community care and the eventual closure of mental hospitals on the map and here it was offered to us on a plate'.

The second half of the 20th century has seen the development of 'anti-psychiatry', whose main proponents were Ronald Laing and Thomas Szasz.  Laing's professional aim had been to 'complain against the denigration of experience and the dehumanisation of the patient, but in doing so I wanted to bring them back into the ordinary human fold'. Laing believed that psychiatric medication could be helpful, and was among those practitioners who used LSD themselves in experiments to explore their own psyches, and also gave it to their patients with the aim of facilitating the psychotherapeutic process. Laing and his followers set up the Philadelphia Association, and also Kingsley Hall, an experimental therapeutic community whose most famous patient was Mary Barnes who was encouraged to regress into babyhood as a means of achieving her recovery from psychosis.

Szasz has described mental illness as a metaphorical illness because 'the mind (whatever that is) is not an organ or part of the body.  Hence it cannot be diseased in the same sense as the body can'. He takes the view that any psychiatric diagnosis is a licence for coercion and the exercise of psychiatric power. 'If mental illness is not a disease why then treatment or indeed admission?' He also accepts that the corollary of this is that if patients have rights, they also have responsibilities, and should, for example accept responsibility for all their actions whatever their state of mind when they committed them. He has concluded that the only help that can be given to patients is through psychotherapy.

Psychotherapeutic treatment has declined in the latter part of this century, partly because of a case brought in 1979 against a private psychiatric clinic in the US by a physician with a psychotic depression. The patient sued successfully on the grounds that he should have been treated with proven effective medication rather than spending seven months undergoing in-depth psychoanalysis, and the case left a strong impression that treating psychiatric illness with psychoanalysis constituted malpractice.

New perceptions of mental illness are beginning to develop, informed partly by people like Szasz and Laing, and partly by the growing perception of a need for sensitivity in dealing with people from other cultures whose mental distress may be expressed as a spiritual crisis in a way that has become almost unknown in Western culture.

At the end of the 20th century, rather than adopting either 'the medical model' or 'the social model' of mental illness, people working in the field of mental ill health are beginning to recognise that mental distress has many different causes, and many different disciplines and approaches have a part to play in treatment. Distress may be explained in terms of responses to circumstances, of brain chemistry, of genetics, and all are increasingly seen not to be mutually exclusive but to interact and play a part in mental health: life events almost certainly change brain chemistry for good as well as for ill, and many different treatments may be successful in different circumstances. But treatments that are experienced by the patient as torturous or punitive, however well-intentioned, are unlikely to be so successful in the long-term as those which are experienced as therapeutic. Current practitioners would do well to bear in mind the precepts of such people as Imhotep, Vives, Pussin, and Laing, alongside the latest neuropharmacological theories.

Katherine Darton
February 1999
New material added March 2004

Sources and further reading

CE Goshen, Documentary History of Psychiatry: a Source Book on Historical Principles, Vision Press, 1967.

JR Whitwell, Historical Notes on Psychiatry (Early times - end of 16th century), HK Lewis and Co, 1936.

David Stafford-Clark, Psychiatry Today, Penguin, 1963.

Franz G Alexander and Sheldon T Selesnick, The History of Psychiatry: an evaluation of psychiatric thought and practice from prehistoric times to the present, Harper and Row, 1966.

WM O'Neil, The Beginnings of Modern Psychology, Penguin Science of Behaviour, 1968.

FG Alexander and ST Selesnick, The History of Psychiatry: an evaluation of psychiatric thought and practice from prehistoric times to the present, Harper and Row, NY, 1966.

The Faber Book of Madness, edited by Roy Porter, Faber and Faber, 1991.

Peter Nolan, A History of Mental Health Nursing, Chapman and Hall, 1993.

Morton Hunt, The Story of Psychology, Doubleday, 1993.

Talking about Psychiatry, edited by Greg Wilkinson Royal College of Psychiatrists, Gaskell, 1993.  A collection of interviews with eminent psychiatrists, first published in the Psychiatric Bulletin.

Edward Shorter, A History of Psychiatry from the Era of the Asylum to the Age of Prozac, Wiley, 1997.

Pat Barker, Regeneration, a novel based on fact, about Siegfried Sassoon, Wilfred Owen, William Rivers et al., Viking,1991.