My favourite subject at university by far was the history of minds and madness, so I thought I’d share my essay with you all. Enjoy!
The notion of madness has long been acknowledged, but advancements have altered the way the mentally ill person is conceived, and there remains significant diversity in the accounts of treatments throughout history. Science routinely attempts to legitimise itself by highlighting its roots, but recollection of the history of the psych sciences (i.e psychiatry and proto-psychiatry) is complicated by sporadic progress and diverse origins. Furthermore, competing biological, social and psychological schools have repeatedly rewritten the past as they have risen to the forefront. In this essay, I put forth that the Whiggish perspective of a linear progression is too simplistic, and reflection is required to frame the changing epistemology and content of the psych sciences into wider social and ideological contexts. While there has been significant advancement in effective treatments, I argue that psychiatry needs to be humble in acknowledging that these have originated from its past, and refrain from ‘recasting its heroes as villains’, as events have only come to be seen as abuses in hindsight. Furthermore, I aim to highlight the present decline in progress of conceptualising and understanding mental illness. In order to do this, I will expand on the themes of; humoralism, confinement and moral therapy, shock therapy, the emerging pharmaceutical industry, and the classification system of the third Diagnostic and Statistical Manual of Mental Disorders (DSM-III).
The emergence of humoralism caused a departure from the long held tradition of attributing madness to supernatural and divine causes. Hippocrates medicalised illness through his proposition that wellbeing was contingent on the balance of four humours (blood, phlegm, yellow bile, and black bile). It was believed that physical and mental health were equivalent, and therefore mental ailments could be treated through physical methods such as cupping, bloodletting and induced vomiting which would restore the humours to optimal balance. This notion of physical qualities provided a naturalistic conception of madness that remained popular for much of the 17th Century, and the concept of balance which recent disease specificity has lost. Robert Burton endorsed humouralism in his Anatomy of Melancholy, whose namesake references the theory of melancholia; significant sadness and anxiety thought to be caused by an excess of black bile. On the other hand, mania was described as the possession of ideas that differed from the truth. In 1886, Wundt regarded these as two different dimensions, and thus established an early dimensional model. The notion of physical origin later became associated with reason (or lack of) through Cartesian dualism, but this was challenged by Locke’s tabula rasa which was significant as it proposed methods of retraining the brain. Thus hile it was eventually invalidated, the long endurance of humoralism can be attributed to its relatively sophisticated structure in a time of few alternatives.
Following humoralism came the mad doctors and institutionalisation of the 17th-18th Centuries, and the subsequent moral therapy. The early beginnings of ‘the great confinement’, as Foucault refers to it, can be traced back to the foundation of the Hôpital-Général in Paris in 1656. For a long time, madness was seen as an individual issue but greater awareness, population growth and ideological changes saw it ‘transform[ed]… into a social problem’. These first hospitals were the attempt to deal with the impoverished, incompetent and society’s outcasts. These were not state-led as sometimes argued, and highlights that the conception of the psychiatric inpatient predated medical psychiatry. Mad-doctors like Monro continued to use humoralism inspired methods, and patients were often managed like animals. Foucault reasons that this went beyond physical restraint by removing the fascination and ‘voice’ of madness, thereby reducing it to an absence of humanity. Such was the case for James Norris, who was chained leash-like for 12 years at Monro’s Bethlehem Hospital. Yet, many argue that contrary to Foucault’s previously mentioned claim, there was nothing ‘great’ or large-scale about confinement in the 17th century, as many favoured private asylums, and outside France institutionalisation rates were low. Furthermore, despite the common interpretation that ‘the 18th century…was a disaster for the insane’, massive rehabilitation of institutions occurred through the Mad House Act (1828), and alongside the legends of Tuke and Pinel, through Battie and Conolly, and emerging moral therapy. Moral therapy was based on the premise that routine and compassion could treat madness which was an illness, and asylums were restructured and built to be places of ‘calmness… hope… [and] satisfaction…where humanity…shall reign supreme’ . Nevertheless, this movement failed due to their increasingly chronic and aging population, and an inability to maintain high physician-patient-ratios in public institutions. Asylums were not where psychiatry was practiced, but where it was developed to treat and manage patients, and the location where theories were put into practice. While to Foucault, asylums remained repressive; it was here, that humoralism was shown to be ineffective and psychosurgery to be rarely useful; it was here, that optimism and early intervention were born . Hence, though the asylums are considered inhumane, moral therapy conveyed a level of care not previously available.
Before moving on to the biological movement, it seems necessary to define psychiatry and recognise other schools of thought. The term psychiaterie, meaning soul and mind physician, was introduced as a medical discipline in 1808 by Johann Reil who advocated for humane treatment, de-stigmatisation and argued that, ‘we will never find pure mental, pure chemical or mechanical diseases’. This idea of interrelatedness contrasts with the pure biological view of psychiatry, and the psychoanalytic period that Shorter describes as a ‘blip’ in psychiatry’s history. Influenced by Charcot’s inability to find a biological cause for hysteria, Freud’s popular 20th century paradigm focused on talk therapy and argued that mental illness was caused by conflict and repression in the unconscious. To the psychiatrists who wanted to legitimise their field as evidence based, it was a disaster; but from those that viewed psychiatry as pseudo-medical, it was ‘the most sophisticated sector’; and from a psychological view, it was the foundation for psychotherapy. Psychoanalysis occurred parallel to significant medical discoveries.
The ‘second’ biological movement of the 19th Century, the first involving phrenology and lobotomy, believed madness was caused by a malfunction of the brain and treatments were designed to shock it into correcting itself. The medical term shock refers to states of hypotension and hypothermia, and attempts to produce this were done through deep sleep therapy, and insulin comas (1933), which were originally thought would induce seizures. This was founded on Meduna’s observations that epilepsy was uncommon in schizophrenics, and of contrasting changes in the brains of epileptics and schizophrenics, all which suggested that schizophrenia was an antagonist of epilepsy. Subsequently, drugs like Camphor became used to induce seizures, but while arguably effective at reducing psychosis they also caused residual seizures. These side effects motivated the development of the Bini-Cerletti ECT machine in 1938 and the method of using electricity to treat Schizophrenia. The original experiment suggested a decline in symptoms, but is criticised for being vague and likely doctored, especially as it is not popularly known that the first patient Enrico X later relapsed. New methods have highlighted that the prevalence of epilepsy in schizophrenia was actually higher (1.5%) than early studies had suggested (0.13%) and support for biological antagonism declined. A search for a new basis of ECT found that it was more useful for depression than schizophrenia (1940s). As is a common theme in psychiatry, ECT became a treatment for a disease that it was not intended for which questions the basis and legitimacy of the original experiment. However, it is now thought to be one of the most successful treatments for both severe mood disorders and psychosis and schizophrenia. Highlighting again, that much of the underlying mechanisms is unknown.
Additionally, the growth in biological psychiatry demanded the development of psychopharmacology. Shorter claims that psychiatrists have a tendency to abandon a treatment once there appears to be a better one, and ECT was for a time largely discarded in preference for medications. The beginnings of psychopharmacology were marked by the discovery of lithium (1940s), and Chlorpromazine (1951), the first antipsychotic. In a time where psychoanalysis’ influence was apparent, chlorpromazine was beneficial, as it appeared to cause sedation while allowing capacity for therapy. Psychopharmacology began by using drugs whose mechanisms were not understood, to treat illnesses that were not yet defined, however the results of those that worked allowed investigation into the mechanisms behind mental illness. Thus, chlorpromazine made it possible to explore a neural basis of Schizophrenia, and in 1963, was found to increase the metabolism of dopamine, which led to the dopamine hypothesis (1966), that Schizophrenics may have overactive dopamine pathways. Thus changing the understanding from electrical impulses to ‘chemically mediated’ signals and leading to the discovery of more neurotransmitters. This allowed breakthroughs into the mechanisms of other illnesses, other antipsychotics, and ultimately to antidepressants. However, it is argued that the search to discover treatments has changed to ‘medicalizing aspects of the human condition’ and therefore in trying to progress, psychiatry has distanced itself from essential social and cultural discoveries of the past. Furthermore, the knowledge about pathology has often been overplayed, i.e. the psychiatry’s miracle drug chlorpromazine has been labelled by antipsychiatry as a ‘chemical straitjacket’, and research by Kirsch questions the foundations of the neural theories whose results he attributed to the placebo effect. Though there is increasing evidence in favour of the benefits of medication. Regardless, psychiatry has been beneficial insofar as individuals have become to be seen as suffering from a disease ‘in the same sense that cancer or high blood pressure are diseases’, and thus it is a step towards de-stigmatising mental illness. In summary, to evaluate the utility of medication it remains necessary to understand the influences involved in its creation, and how perceptions have changed.
Moreover, the line between mental illness and normality has still not been clearly described. As put by the Journal of Mental Science, ‘our knowledge of the mental functions of the brain is still comparatively obscure’. Early attempts at taxonomy were made by Kraepelin who abandoned the psychoanalytic focus on aetiology, and the idea of a continuum between normality and madness, in favour of descriptive pathology and categorisation of distinct biological diseases. This was replicated in the creation of the DSM-III (APA, 1980), a manual commonly used to diagnose mental health disorders. The DSM, now up to it’s 5th edition, has undergone many revisions through its attempts to please the current popular movements. These definitions indirectly influence society’s notion of mental illness through the inclusion of symptoms that subsequently, if not already, become perceived as abnormal and hence, the DSM has arguably created many illnesses. Furthermore, despite intending to provide clear definitions to be used by trained professionals, it has regularly failed to do so and there is subjectivity within the medical field. It is possible that this has been caused by the extrapolation of the diagnosing role to professionals other than psychiatrists. Nevertheless, to classify a disorder necessitates that it be understood, but time again history has highlighted the lack of knowledge around aetiology and thus the categories are likely to be incongruent with the structure of mental illness. Furthermore, the DSM was highly influenced by prestige, race, politics, culture and gender prejudices, and what makes something a disorder should instead depend on science and the level of disability it has on an individual. There is some argument that the DSM has also been shaped by drug use; occasionally responses to a psychoactive drug have led to distinctions between disorders or perceived boundary change. Additionally, the purely descriptive approach has impaired the development of valid diagnostic categories due to the absence of a testable system. While it may have been progressive in it’s time, the DSM highlights the lack of scientific progress that has occurred since the conception of the DSM-III.
In conclusion, retracing the past may appear to contrast with the linear progression aligning with biological psychiatry, yet progression is not usually undeviating, and it is necessary to understand how psychiatric methods and ideas become recognised as acceptable despite their many risks. I argue that the use and abuse of psychiatry, from humoralism to the asylums and more recent times, was often the result of limited knowledge and thus in the future, modern methods may be criticised for being ‘blinded by biology’. Psychiatry has made considerable advancements in treatments for mental illness, but it is necessary to remain humble about the past and recognise that what is perceived as moral, varies depending on the context. Furthermore, I contend that psychiatry’s conception of mental illness has scarcely progressed at all and this remains a significant problem when treatments are based on classifications provided by the DSM. Future classifications should critique the early theories that led to the DSM, and attempt to provide a measure that aligns with the true nature of mental illness.
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