Treatments for mental illness

Contents

The History of Inhumane Mental Health Treatments

Mental health treatment today is no walk in the park — from insurance companies denying coverage, to a lasting stigma, to the fact that the many of the most severely mentally ill among us to their own devices on the streets or relegated to prison. It’s an understatement to say that there is work left to be done. Yet, the inhumane history of mental health treatment reminds us how far we have already come.

Asylums

While terrifying mental health remedies can be traced back to prehistoric times, it’s the dawn of the asylum era in the mid-1700s that marks a period of some of the most inhumane mental health treatments. This is when asylums themselves became notorious warehouses for the mentally ill.

“The purpose of the earliest mental institutions was neither treatment nor cure, but rather the enforced segregation of inmates from society,” writes Jeffrey A. Lieberman in Shrinks: The Untold Story of Psychiatry. “The mentally ill were considered social deviants or moral misfits suffering divine punishment for some inexcusable transgression.”

Journalist Nellie Bly captured the asylum atmosphere firsthand when she went undercover at the Blackwell Island Insane Asylum in New York in 1887. Not only was Bly committed without much of an examination to determine her sanity, but the conditions were harsh, cruel, and inhumane.

“For crying the nurses beat me with a broom-handle and jumped on me,” described one patient to Bly. “Then they tied my hands and feet, and throwing a sheet over my head, twisted it tightly around my throat, so I could not scream, and thus put me in a bathtub filled with cold water. They held me under until I gave up every hope and became senseless.”

Hydrotherapy proved to be a popular technique. Warm, or more commonly, cold water, allegedly reduced agitation, particularly for those experiencing manic episodes. People were either submerged in a bath for hours at a time, mummified in a wrapped “pack,” or sprayed with a deluge of shockingly cold water in showers.

Asylums also relied heavily on mechanical restraints, using straight jackets, manacles, waistcoats, and leather wristlets, sometimes for hours or days at a time. Doctors claimed restraints kept patients safe, but as asylums filled up, the use of physical restraint was more a means of controlling overcrowded institutions.

At the same time asylums were on the rise, so too was psychiatry, a fledgling wing of the medical profession bent on proving their ability to treat as opposed to simply manage the ill. Asylums served as the perfect lab for psychiatric treatments.

Early Psychiatric Treatments

Though Benjamin Rush, considered the father of American psychiatry, was first to abandon the theory that demon possession caused insanity, this didn’t stop him from using old “humoral treatments” on asylum patients to cure their minds. Instead of letting out demons, as the treatment was originally intended, he thought the body’s fluids were out of balance. As such, “he purged, blistered, vomited, and bled his patients,” writes Mary de Young in Madness: An American History of Mental Illness and Its Treatment.

Similarly, Henry Cotton — superintendent at New Jersey’s Trenton State Hospital from 1907 to 1930 — thought infected parts of the body led to mental illness. He focused on pulling rotting teeth, which he thought caused madness-inducing infections. When that didn’t work, presumably because contaminated saliva still made its way into the body, Cotton began removing tonsils as well.

And then he took it a step further, removing parts of stomachs, small intestines, appendixes, gallbladders, thyroid glands, and particularly parts of the colon — any place where it was thought infection could linger. Unsurprisingly, this did not prove to be a reliable cure and it carried a high mortality rate.

Inspired by the discovery that high fevers helped stop the symptoms of advanced syphilis, Julius Wagner-Jauregg experimented with inducing fevers in people with schizophrenia by injecting them with malaria-infected blood. This popular method even earned Wagner-Jauregg the 1927 Nobel Prize in Physiology or Medicine, the first ever awarded for the field of psychiatry.

Like Cotton’s body-part-removal technique before it, malaria-induced fevers had a high mortality rate: “About 15 percent of patients treated with Wagner-Juaregg’s fever cure died from the procedure,” writes Lieberman.

Shock Therapies

By then, however, the professional community was ready to move on to the next fad — insulin shock therapy.

Brought to the United States by Manfred Sakel, a German neurologist, insulin shock therapy injected high levels of insulin into patients to cause convulsions and a coma. After several hours, the living dead would be revived from the coma, and thought cured of their madness.

This process would be repeated daily for months at a time, with doctors sometimes administering as many as 50 to 60 treatments per patient, according to Lieberman. However, the procedure was obviously risky and caused amnesia. Nevertheless, the treatment proved popular based on a questionable success rate.

“By 1941, according to a U.S. Public Health survey, 72 percent of the country’s 305 reporting public and private asylums were using insulin coma therapy, not only for schizophrenia, but also for other types of madness,” writes de Young.

Another shock therapy was yet to come. Metrazol shock therapy, like insulin, worked on the mistaken premise that epilepsy and schizophrenia couldn’t exist at the same time. The key? Seizures. Laszlo von Meduna, a Hungarian physician, discovered that the drug metrazol could produce seizure-like convulsions in patients, therefore shocking their brains out of mental illness. It proved to be a shock physically as well.

“Metrazol also provoked thrashing convulsions so violent they could become, quite literally, backbreaking,” writes Lieberman. “In 1939, an X-ray study at the New York State Psychiatric Institute found that 43 percent of patients who underwent metrazol convulsive therapy experienced fractures in their vertebrae.”

“You get blown up and you go unconscious, like something boils up,” described one patient of treatment. “I felt every time I took that as if I was going to die.”

Beyond its terrifying experience, metrazol shock therapy also produced retrograde amnesia. Luckily, the Federal Drug Administration revoked metrazol’s approval in 1982, and this method of treatment for schizophrenia and depression disappeared in the 1950s, thanks to electroconvulsive shock therapy.

Electroconvulsive Shock Therapy

Buzz box, shock factory, power cocktail, stun shop, the penicillin of psychiatry. One of the most infamous treatments for mental illness includes electroconvulsive shock therapy. Types of non-convulsive electric shock therapy can be traced back as early as the 1st century A.D., when, according to de Young, “the malaise and headaches of the Roman emperor Claudius were treated by the application of a torpedo fish — better known as an electric ray — on his forehead.” But their heydey in treating mental illness began in 1938.

ECT carried less risk of fracture than metrazol shock therapy, and with the use of anesthetics and muscle relaxers in later years, the fracture rate became negligible. It wasn’t without side effects, however, including amnesia as well as increased suicidal tendencies. Ernest Hemingway, for example, died by suicide shortly after an ECT treatment.

“ECT was a welcome replacement for metrazol therapy,” writes Lieberman. “Depressed patients in particular often showed dramatic improvements in mood after just a few sessions, and while there were still some side effects to ECT, they were nothing compared to the daunting risks of coma therapy, malaria therapy, or lobotomies. It was truly a miracle treatment.”

Lobotomies

Around the same time, doctors overseas performed the first lobotomies. The practice was brought to the United States thanks to Walter Freeman, who began experimenting with lobotomies in the mid-1940s, which required damaging neural connections in the prefrontal cortex area of the brain thought to cause mental illness.

“The behaviors were trying to fix, they thought, were set down in neurological connections,” Barron Lerner, a medical historian and professor at NYU Langone Medical Center in New York, told Live Science. “The idea was, if you could damage those connections, you could stop the bad behaviors.”

The problem was, lobotomies didn’t just stop bad behaviors. They damaged people’s memories and personalities, which even Freeman admitted: “Every patient probably loses something by this operation, some spontaneity, some sparkle, some flavor of the personality.”

According to de Young, despite the side effects, by the time Freeman died in 1972, approximately 50,000 lobotomies had been performed on U.S. patients, mostly in asylums. However, less than 350 lobotomies were performed per year in the 1970s. By then, medication dominated mental health treatment.

Psychiatric Medications

Drugs had been used in treating the mentally ill as far back as the mid-1800s. Their purpose then was to sedate patients to keep overcrowded asylums more manageable, a kind of chemical restraint to replace the physical restraints of earlier years.

Doctors administered drugs such as opium and morphine, both of which carried side effects and the risk of addiction. Toxic mercury was used to control mania. Barbiturates put patients into a deep sleep thought to improve their madness. Chloral hydrate came of use in the 1950s, but like the drugs before it, it had side effects, including psychotic episodes.

And then came Thorazine, the medical breakthrough psychiatrists had seemingly been searching for all these years. While it wasn’t perfect, it proved much safer and effective at treating severe mental illness. Its use, along with other drugs that quickly followed, such as Risperdal, Zyprexa, Abilify, and Seroquel, marked the beginning of a sea change for mental health patients.

In 1955, the year the first effective antipsychotic drug was introduced, there were more than 500,000 patients in asylums. By 1994, that number decreased to just over 70,000. Starting in the 1960s, institutions were gradually closed and the care of mental illness was transferred largely to independent community centers as treatments became both more sophisticated and humane.

While these changes and modern care come with their own challenges, the treatment of mental health has come a long way in 250 years. No longer do the mentally ill need to fear living in inhumane asylums for life, being subjected to experimental shock treatments or undergoing dangerous surgeries without consent. Mental health treatment may still come with a stigma, but there’s a lot of hope for the future.

Page 3. Mental hospitals, 1910s to 1930s

New Zealand psychiatry

Dr T. Gray, a young British-trained psychiatrist, described his first experience of New Zealand mental hospitals in the early 20th century: ‘The almost complete divorcement of psychiatry from general medicine created a profound impression upon me when I came to New Zealand . I was struck by the singularly isolated position which the mental hospitals occupied in the public life of the country … their existence was merely tolerated as a necessary evil and their drab and dreary structure and routine symbolised the hopelessly pessimistic attitude of the public towards the prognosis of those who had to be admitted.’1

The villa system

The villa system was a hospital design based on a group of small detached buildings rather than a single large and architecturally imposing structure. This design became government policy from 1903, making it much easier to classify patients by age, gender, behaviour, likelihood of recovery and, to some extent, social class. A typical self-contained 40–50-bed villa had several dormitories and single rooms, kitchen, dining room, lounge and offices. In 1969 a quarter of all mental patients were still housed in traditional asylum-era buildings. These 19th-century buildings were much harder to modernise.

The effect of shell shock

Public pressure for ‘halfway houses’ to treat nervous disorders helped take services out of mental hospitals, especially for war veterans. Queen Mary Hospital at Hanmer Springs opened in 1916 as the first ‘halfway house’ to treat nervous breakdown, shell shock and borderline mental conditions. The treatment and status of people suffering from mental illness improved after the First World War, when numbers of shell-shocked war veterans returned to New Zealand. Patriotism demanded that these men should not be treated like ordinary mental patients, who were then widely regarded as incurable.

War veterans were treated with dignity and compassion, and gently encouraged to talk about the circumstances causing their illness. Because of the rapid success of this early form of psychotherapy, it was later applied to some other groups of patients in mental hospitals.

In the same period, a few doctors in general hospitals grew more interested in psychiatry (the diagnosis and treatment of mental disorders). Some hospital boards began providing observation wards for mental patients at base general hospitals, to protect ‘those of unsound mind from the indignity, distress and humiliation of being treated as delinquents and criminals’.2 Psychiatrists in mental hospitals set up outpatient clinics to treat less serious patients without admitting them.

New treatments

From the late 1930s a number of new treatments for severe mental illness were introduced. It was hoped that these would transform the lives of people with chronic illness. These included injecting patients to induce insulin coma and prefrontal leucotomy (a form of surgery on the brain). Both produced serious side effects and were eventually discontinued. Convulsive therapy was initially introduced using a chemical to induce a seizure but electroconvulsive therapy (ECT) soon replaced it as more reliable and safer. While considered a beneficial treatment for some, it has become increasingly controversial. Over time ECT was modified for greater safety, and it is still occasionally used.

The History & Evolution of Mental Health & Treatment

Article Overview:

The question of how to address mental health issues has existed since antiquity; the answers have evolved across cultures and millennia, adapting as the understanding of the human condition has changed in the face of advances in science, chemistry, medicine, and psychology. The history and evolution of mental health and treatment is not always a flattering story, but it explains a great deal about how and why the landscape of mental health treatment is what it is today and where it could possibly go next.

Mental Health Treatment in Ancient Times

Ancient theories about mental illness were often the result of beliefs that supernatural causes, such as demonic possession, curses, sorcery, or a vengeful god, were behind the strange symptoms. Remedies, therefore, ran the gamut from the mystical to the brutal. Anthropological discoveries dating as far back as 5000 BCE showed evidence of trephining, which the Inquiries journal explains as the process of a hole (or a trephine, from the Greek word for boring) being bored into the skull, with the use of rudimentary stone instruments. The humans of the Neolithic era believed that opening up a hole in the skull would allow the evil spirit (or spirits) that inhabited the head of the mentally ill to be released, thereby curing them of their affliction.1

Remarkably, the process was not universally fatal. Since some trephined skulls showed signs of healing, researchers believe that those individuals survived the trephining process and might even have lived for years afterwards. This may have encouraged the practice, as did the incidental success of relieving brain swelling that can arise from infections or trauma to the head.2 As a result, trephining endured for centuries, used as a treatment for a number of different conditions: skull fractures, migraines, and mental illnesses, although the tools were gradually upgraded to skull saws and drills that were developed for the exclusive purpose of “treatment.”

The Oldest Medical Books in the World

When violence wasn’t used, priest-doctors (like those in ancient Mesopotamia) would use rituals based on religion and superstition since they believed that demonic possession was the reason behind mental disturbances. Such rituals would include prayer, atonement, exorcisms, incantations, and other forms of tribalistic expressions of spirituality. However, shamans would also resort to threats, bribery, and even punishment if the ritualistic methods proved unsuccessful in changing the behavior of a tribe member.

Two papyri, dated as far back as the 6th century BCE, have been called “the oldest medical books in the world.”

It was the ancient Egyptians who had the most progressive ideas (of the time) in how they treated the people among them who had mental health concerns. The medicine men of the Nile recommended that patients engage in recreational activities, such as music, dancing, or painting, to relieve their symptoms and work toward some semblance of normalcy, uncannily similar to some of the avenues of treatment offered in contemporary treatment facilities.3 The ancient Egyptian civilization was also notably advanced for its time in the fields of medicine, surgery, and knowledge of human anatomy (which came in handy for preserving their dead). Two papyri, dated as far back as the 6th century BCE, have been called “the oldest medical books in the world,” for being among the first such documents to have identified the brain as the source of mental functioning (as well as covering other topics like how to treat wounds and perform basic surgery).4

The Four Humors

A standard belief across many of those ancient cultures was that mental illness was seen as a supernatural in origin, usually the result of an angry god (or goddess). In an attempt to attribute this to an understandable cause, people of those civilizations believed that a victim or a group of people had somehow trespassed against their deity and were being punished as a result.

It took the influence of early European philosophers to nudge ideas of mental illness forward. Somewhere between the 5th and 3rd centuries BCE, the Greek physician Hippocrates rejected the idea that mental instability was the result of supernatural wrath, and wrote that imbalances in thinking and behavior were from “natural occurrences in the body,” in particular, the brain.5

Hippocrates and two other prominent Greek thinkers, Galen and Socrates, each developed the idea of there being four essential elements to the human body: blood, bile, black bile, and phlegm. The unique characteristics and personalities of human beings could be attributed to the idiosyncratic balances of these so-called “humors.” When the humors were out of balance, mental illness was the result.6

This belief persisted through the Middle Ages. Doctors of the time would give patients laxatives, emetics (substances that would induce vomiting), leeches, and cupping therapy to restore the body’s proportions of humors. Recipes consisting of aloes, black hellebore, and colocynth, for example, would cure a patient of depression. Tobacco imported from the Americas was used to make patients vomit out the excess humors. Other treatments saw doctors extracting blood from the forehead or tapping veins across the body to drain the guilty humors away from the brain.

Less invasive therapies included specialized diets, such as a regimen of salad greens, barley water, and milk for “raving madmen,” who were told to abstain from red wine and meat.

Caring for the Mentally Ill

Typically, the patient’s family was responsible for custody and care of the patient. Outside interventions and facilities for residential treatment were rare; it wasn’t until 792 CE in Baghdad that the first mental hospital was founded.7 In Europe, however, family having custody of mentally ill patients was for a long time seen as a source of shame and humiliation; many families resorted to hiding their loved ones in cellars, sometimes caging them, delegating them to servants’ care, or simply abandoning them, leaving their mentally unhealthy flesh and blood on the streets as beggars.
Regrettably, the social stigma attached to mental health problems is still prevalent in countries and cultures that place a strong emphasis on family honor, where marriages are less a union of love and more a tool for forging alliances and sending off daughters. Here, the burden of caring for a mentally ill family member can be seen as a blight on the family honor, and discarding such a person is considered preferable to inviting dishonor upon the household. Having a mentally ill person in the family suggests an inherited, disqualifying defect in the bloodline and casts doubt on the social standing and viability of the entire family.

For that reason, mentally unhealthy family members were (and still are) brutally and mercilessly ostracized. It was not unheard of for some families to turn their loved ones into the police, for fear that the mental health disorder could be considered dangerous or too difficult to manage at home. Life imprisonment was not out of the question. During the Middle Ages in Europe, mentally ill people were sometimes subject to physical punishment, usually beatings as a form of reprisal for their antisocial and undesired behavior, and sometimes in an attempt to literally beat the illness out of them.

From Workhouses to Asylums

However, there were some options for treatment beyond the limitations of family care (or custody). These including putting up the mentally unhealthy in workhouses, a public institution where the poorest people in a church parish were given basic room and board in return for work. Others were checked into general hospitals, but they were often abandoned and ignored.

Clergy in respective churches played a key role in the treatment mentally ill people received since some medical practice was considered a logical extrapolation of priests’ duty to do what they could to tend to the ailments of their people. If a family could afford the care, they could send their loved one to a private home, owned and operated by members of the clergy who would do what they could to offer some treatment and comfort. Countries with majority (or politically established) Catholic populations would often staff their mental health facilities with members of the clergy; Russia’s Orthodox monasteries housed most of the nation’s mentally ill until the rise of asylums.

Not entirely dissimilar to the methods advocated by shamans and witch doctors from millennia prior, European clergy had long recommended regular church attendance, as well as religious pilgrimages, as a cure for mental distress. Patients were encouraged to repent of their sins and throw themselves at God’s mercy, but such methods had little success. However, the treatment offered by facilities run by clergy and nuns was markedly more humane than the alternate methods of the time.

But workhouses and monasteries could not keep up with the full scope of the population that needed mental health treatment, which opened the door for asylums to take over. The Actas Españolas de Psiquiatría writes of how the first psychiatric hospital in the world was founded in Valencia, Spain, in 1406, but historians note that this is not remembered as a cause for celebration. Asylums like the one in Valencia offered no real treatment or comfort to the mentally ill, forcing patients to live in inhuman conditions and subjecting them to cruel abuse.8 Such facilities were, in effect, prisons in everything but name, and sometimes even worse than penal institutions. There was no concept of actively caring for mentally ill individuals, only sequestering them away from their families and societies at large, and minimizing the perceived harm they could do to their communities.

The first psychiatric hospital in the world was founded in Valencia, Spain, in 1406.

The Roots of Reform

While bloodletting and inducing vomiting were still the preferred form of treatment (when staff actually deigned to help their wards), additional forms of “therapy” included dousing the patients in extremely hot or cold water, the idea being that the shock would force their minds back into a healthy state. The belief that mental disturbance was still a choice prevailed, so staff used physical restraints, straitjackets, and even threats to further try to “cure” patients. Drugs were sometimes given to the more dangerous and difficult patients. A Dutch doctor even developed a “gyrating chair” that was supposed to literally shake up the body’s anatomy and blood to try and restore the balance of the humors, but only succeeded in rendering patients unconscious with no improvement in their condition.

As word spread of the subhuman environments within asylums, a call for reform arose in the latter part of the 19th century. An example of this took place at an asylum in Devon, England, which abandoned methods of treatment based on restraint.

Moral Treatment

But it was in Paris, in 1792, where one of the most important reforms in the treatment of mental health took place. Science Museum calls Pinel “the founder of moral treatment,” which it describes as “the cornerstone of mental health care in the 1800s.”9,10 Pinel developed a hypothesis that mentally unhealthy patients needed care and kindness in order for their conditions to improve; to that effect, he took ownership of the famous Hospice de Bicêtre, located in the southern suburbs of Paris. He ordered that the facility be cleaned, patients be unchained and put in rooms with sunlight, allowed to exercise freely within hospital grounds, and that their quality of care be improved.

The roots of moral treatment were founded across the English Channel by the director of the York Retreat asylum run by the Quaker society. Moral treatment eschewed the traditional medical treatments commonly found in asylums, such as bloodletting and physical restraints, and instead focused on making the asylums more like a “strict, well-run household.” Instead of being caged and hidden away in cellars, patients were expected to act civilized and polite, encouraged to consider the consequences of disruptive behavior and participate in the maintenance of the facility. They would be subject to rules and surveillance, and given simple rewards and punishments as appropriate.

As a result, the York Retreat came to resemble a pleasant country house, more so than the filthy prisons of asylums past. The focus was on creating a home-like environment that would be conducive for patients to live, work, and rest. The Quaker traditions of treating all people, even the mentally ill, with respect and kindness manifested in how staff handled patients: with equal doses of humility and humanity.

Moving away from Moral Treatment

The radical nature of moral treatment made waves on the other side of the Atlantic Ocean. When the moral method reached the shores of the United States, doctors understood it to be a comprehensive way of treating mentally ill people by working on their social, individual, and occupational needs. This was the first time that the idea of rehabilitating mentally ill people back to recovery, and eventual reintegration with their families and communities at large, was floated. Doctors would encourage their patients to participate in manual labor and intellectual conversation, effectively training them to be healthy and contributing members of society again.

Moral treatment was highly effective (especially compared to the systems it succeeded), but it died out in the waning years of the 19th century. Critics argued that the method did not really treat patients but made them dependent on their doctors and the asylum staff for comfort. In the 20th century, historians and contemporary doctors argued that the moral method simply substituted one form of control for another.

Sigmund Freud

Notwithstanding the end of the moral treatment movement, the conversation about mental health treatment was ready to take a big step forward. A major figure in that progression was Sigmund Freud. The famous Austrian neurologist and psychiatrist developed his theory of psychoanalysis, which gave rise to the practice of “talking cures” and free association, encouraging patients to talk about whatever came to mind. Freud’s theory was that the avenues of conversation would open a door to the patient’s unconscious mind, granting access to any kind of repressed thoughts and feelings that might have compelled the mental instability.

Psychoanalysis proved influential enough that around 25 percent of practicing therapists use methods developed by Sigmund Freud

Part of Freud’s approach involved dream analysis, which encouraged patients to keep a journal of what their unconscious mind was trying to tell them through their dreams. The psychiatrist would study the contents of the journal, discerning messages and patterns that would unlock the mental illness. Remnants of his methodology are found in how the cognitive behavioral therapists of today engage in “talk therapy” with their clients, encouraging them to keep journals of their thoughts and feelings, and then devising a treatment plan based on the subtext of what is written.

Freud’s psychoanalysis eventually went the way of the moral treatment method, being widely criticized and eventually discarded for lacking verifiability and falsifiability, but it proved a popular form of mental health treatment until the mid-1900s. Psychoanalysis proved influential enough that around 25 percent of practicing therapists use methods developed by Sigmund Freud, as recently as 2012, according to the results of a survey published in the journal of Psychotherapy.11

The Rise and Fall of Electroconvulsive Therapy

Mainstream psychology may not have thought much of psychoanalysis, but the attention Freud’s work received opened other doors of mental health treatment, such as psychosurgery, electroconvulsive therapy, and psychopharmacology. These treatments originated from the biological model of mental illness, which put forward that mental health problems were caused by biochemical imbalances in the body (an evolution of the “four humors” theory) and needed to be treated like physical diseases; hence, for example, psychosurgery (surgery on the brain) to treat the symptoms of a mental health imbalance.

But there was still a lot of work to do be done. Electroshock therapy proved promising at first – experiments in Italy were successful in curing a patient with schizophrenia – but was quickly abandoned because the convulsions it induced in patients were so severe that patients became too scared to willfully participate. Word spread of abuse and torture, with unscrupulous doctors and administrators threatening to use electroconvulsive therapy on uncooperative patients. Some patients even hurt themselves because of the effects of the therapy. However, like psychoanalysis, electroshock therapy still exists today, albeit as a last resort for mental illnesses that cannot be treated by standard methods, such as severe depression with symptoms of psychosis.12

Psychosurgery

One of the most infamous chapters in the history of mental health treatments was psychosurgery. First developed in the 1930s, a patient would be put into a coma, after which a doctor would hammer a medical instrument (similar to an icepick) through the top of both eye sockets. The process would cut the nerves that connected the frontal lobes (which regulate behavior and personality) to the centers of the inner brain that regulate emotion. The idea behind lobotomies was to induce calm in patients who were uncontrollably hysterical or emotional, especially in conditions like schizophrenia, manic depression, and bipolar disorder.13

Psychosurgery was highly controversial from the outset, and many doctors decried the sheer invasiveness and risk of physically tampering with patients’ brains in the hopes of affecting behavior changes. But lobotomies were relatively simple and quick to perform, and the practice took off around the world.

From Lobotomies to Psychopharmacology

However, the process rendered patients immature and lethargic, which may have seemed preferable to their previously uncontrollable behavior but was soon recognized as not being a “cure” in any sense of the idea. A 2011 article published in the Journal of Neurosurgery noted that patients also reported vomiting, loss of bladder and bowel control, problems with their vision, and unnatural states of apathy, lethargy, and hunger. As more and more evidence of the harmful effects of lobotomies started piling up, and other treatments became more popular, psychosurgery was relegated to horror movies and urban legends.14

In 1949 an Australian psychiatrist introduced the drug Lithium into the market

Substances like chloral hydrate, bromides, and barbiturates had been given to mentally ill patients as sedatives as far back as the late 1800s, but doctors were unsatisfied with the short-term treatment potential. But that changed in 1949 when an Australian psychiatrist introduced the drug Lithium into the market. The drug did not cure psychosis but proved better at controlling the symptoms than any other method that had been tried. It was the earliest sign of the rise of (modern) psychopharmacology and changed the landscape of mental health treatment.

Mental Health and Treatment in the 21st Century

As lithium became the standard for mental health treatment, other drugs like chlorpromazine (better known as Thorazine), Valium and Prozac became household names during the middle and latter decades of the 20th century, becoming some of the most prescribed drugs for depression across the world. There are now hundreds of psychoactive drugs in circulation, all targeting a variety of mental health disorders and allowing patients a degree of comfort and privacy with how their conditions are treated.

An unexpected side effect of this is that the need for dedicated facilities to house mentally ill persons declined; inpatient treatment centers usually see clients for a few months at a time, and outpatient centers operate on the basis of there being no overnight stays. As welcome as this was, it created the problem of people with severe mental health problems, but with no social or family networks to support their recovery (or who could not afford the fees or insurance plans for rehabilitation) being moved to jails and prisons.15

Similarly, the rise of prescription medication has also created a massive black market for illicit trading of expensive and hard-to-obtain pills as well as an epidemic for abuse, either by desperate patients with legitimate medical needs or people looking for a legal way to obtain a recreational high.

Both realities speak to the complexities of treating mental illnesses. Where incantations and brain surgery have fallen short, drug therapy and counseling have picked up the treatment baton for the 21st century, helping millions of people achieve health and recovery. However, this evolution has come at a price, with many thousands falling prey to addiction and falling through the cracks of the modern healthcare system. The challenges indicate that proper treatment for mental health will not be easy or straightforward, but the evolution and advancements suggest that the improvements of today are infinitely better than anything that has come before.

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Citations

  1. ” The History of Mental Illness: From Skull Drills to Happy Pills.” (2010). Inquiries. Accessed November 22, 2016.
  2. “Brain Swelling.” (n.d.) Web MD. Accessed November 22, 2016.
  3. “Art Therapy Institute Draws on Healing Power of Creating.” (November 2016). The News & Observer. Accessed November 23, 2016.
  4. “The Oldest Medical Books in the World.” (n.d.) World Research Foundation. Accessed November 23, 2016.
  5. “A Beautiful Mind: The History of the Treatment of Mental Illness.” (March 2015). History Cooperative. Accessed November 23, 2016.
  6. “Humors.” (n.d.) Science Museum. Accessed November 23, 2016.
  7. “Hospitals.” (December 2011). US National Library of Medicine. Accessed November 23, 2016.
  8. “The Founding of the First Psychiatric Hospital in the World in Valencia.” (January-February 2008). Actas Españolas de Psiquiatría. Accessed November 23, 2016.
  9. “Philippe Pinel (1745-1826).” (n.d.) Science Museum. Accessed November 23, 2016.
  10. “Moral Treatment.” (n.d.) Science Museum. Accessed November 23, 2016.
  11. “Psychologists Conducting Psychotherapy in 2012: Current Practices and Historical Trends Among Division 29 Members.” (December 2013). Psychotherapy (Chic.). Accessed November 24, 2016.
  12. “ECT, TMS and Other Brain Stimulation Therapies.” (n.d.) National Alliance on Mental Illness. Accessed November 24, 2016.
  13. “Lobotomy: Definition, Procedure & History.” (August 2014). LiveScience. Accessed November 25, 2016.
  14. “Egas Moniz (1874–1955) and the ‘Invention’ of Modern Psychosurgery: A Historical And Ethical Reanalysis Under Special Consideration of Portuguese Original Sources.” (February 2011). Journal of Neurosurgery. Accessed November 25, 2016.
  15. “TIMELINE: Deinstitutionalization And Its Consequences.” (April 2013). Mother Jones. Accessed November 25, 2016.

Haunting Photos Taken Inside Mental Asylums Of Decades Past

These harrowing photos look inside mental asylums of the 19th and 20th centuries and reveal just how disturbing their conditions once were.

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1 of 45 A patient sits inside Ohio’s Cleveland State Mental Hospital in 1946.Mary Delaney Cooke/Corbis via Getty Images 2 of 45 A patient sits in a restraint chair at the West Riding Lunatic Asylum in Wakefield, England in 1869.Wellcome Library, London 3 of 45 Child patients sit bound and tied to a radiator inside the psychiatric hospital at Deir el Qamar, Lebanon in 1982.José Nicolas/Corbis via Getty Images 4 of 45 A patient sleeps on a thin mattress on the floor of an otherwise bare room in Ohio’s Cleveland State Mental Hospital in 1946.Jerry Cooke/Pix Inc./The LIFE Images Collection/Getty Images 5 of 45 A patient sits alone in a dark room inside Ohio’s Cleveland State Mental Hospital on February 3, 1955. Jerry Cooke/The LIFE Picture Collection/Getty Images 6 of 45 A hungry boy stands alone and eats with his hands as other boys sit together under a blanket on a bed beside a small wood-burning stove at a hospital for mentally-handicapped children in Kavaja, Albania in March 1992.Peter Turnley/Corbis/VCG via Getty Images 7 of 45 A psychiatric patient poses for a photo at Paris’ Salpêtrière Hospital circa 1876-1877.Wellcome Library, London 8 of 45 A child patient sits inside Normansfield Hospital in Teddington, England on February 12, 1979.John Minihan/Evening Standard/Hulton Archive/Getty Images 9 of 45 A patient at a mental hospital undergoes electroshock treatment in 1956.Thurston Hopkins/Picture Post/Getty Images 10 of 45 Patients sit inside Ohio’s Cleveland State Mental Hospital in 1946.Mary Delaney Cooke/Corbis via Getty Images 11 of 45 Workers restrain a patient at a hospital in Moscow, Russia on February 19, 1992.Peter Turnley/Corbis/VCG via Getty Images 12 of 45 A patient suffering from “general paralysis” poses for a photo at the West Riding Lunatic Asylum in Wakefield, England circa 1869.Wellcome Library, London 13 of 45 On March 29, 1950, at Philadelphia’s Bella Vista Sanitorium, a fire killed nine patients, five of whom had been chained to concrete slabs like the one pictured.Bettmann/Contributor/Getty Images 14 of 45 A nurse tests out electronic equipment designed to monitor various patient data at a psychiatric hospital in Toronto on March 12, 1964.Mario Geo/Toronto Star via Getty Images 15 of 45 Pioneering and prolific lobotomist Dr. Walter Freeman performs a lobotomy with an instrument similar to an ice pick at Western State Hospital in Lakewood, Washington on July 11, 1949.Bettmann/Contributor/Getty Images 16 of 45 One of Walter Freeman’s lobotomy patients ten days after the procedure. 1942.Historical Medical Library of The College of Physicians of Philadelphia 17 of 45 A young patient’s rotted teeth, due to poor dentistry, are revealed at London’s Friern Hospital (previously known as the Colney Hatch Lunatic Asylum) circa 1890-1910.Wellcome Library, London 18 of 45 A patient lies on the floor of Ohio’s Cleveland State Mental Hospital in 1946.Mary Delaney Cooke/Corbis via Getty Images 19 of 45 Patients go about their day inside Ohio’s Cleveland State Mental Hospital in 1946.Mary Delaney Cooke/Corbis via Getty Images 20 of 45 A patient stands in a straightjacket inside Ohio’s Cleveland State Mental Hospital in 1946.Mary Delaney Cooke/Corbis via Getty Images 21 of 45 A psychiatric patient poses for a photo at Paris’ Salpêtrière Hospital circa 1876-1877.Wellcome Library, London 22 of 45 Nurses hold down a patient receiving electroshock treatment at a facility in England on November 23, 1946.Kurt Hutton/Picture Post/Getty Images 23 of 45 A surgeon uses a brace and bit to drill into a patient’s skull before performing a lobotomy at a mental hospital in England, November 1946.Kurt Hutton/Picture Post/Hulton Archive/Getty Images 24 of 45 Doctors test a new method of using radio waves to treat psychiatric patients at a hospital in Paris on May 13, 1938.Bettmann/Contributor/Getty Images 25 of 45 Two patients rest in the sleeping area of Ohio’s Cleveland State Mental Hospital in 1946.Mary Delaney Cooke/Corbis via Getty Images 26 of 45 Patients at the Riul Vadului Mental Asylum in Romania huddle together in an unheated room in the middle of winter. Date unspecified.ANDREW HOLBROOKE/Corbis via Getty Images 27 of 45 Dr. James G. Shanklin administers electric shock and anesthesia in preparation for Dr. Walter Freeman to demonstrate his new transorbital lobotomy procedure at Western State hospital in Lakewood, Washington on July 11, 1949.Bettmann/Contributor/Western State Hospital 28 of 45 A prisoner sits inside the West Riding Lunatic Asylum in Wakefield, England in 1869.Wellcome Library, London 29 of 45 Patients lie on a bed inside a psychiatric hospital in Bucharest, Romania. Date unspecified.Bernard Bisson/Sygma via Getty Images 30 of 45 A guard at Vacaville State Prison prepares a prisoner for a lobotomy in 1961. The warden of Vacaville at that time was Dr. William Keating, a psychiatrist who was convinced that “criminality” was lodged in certain areas of the brain, and so lobotomies at Vacaville became routine.© Ted Streshinsky/CORBIS/Corbis via Getty Images 31 of 45 Child patients sit in their room at a mental hospital in Ursberg, Germany circa 1934-1936.Wolfgang Weber/ullstein bild via Getty Images 32 of 45 A patient lies back in a Bergonic chair, an early electroshock treatment apparatus, circa World War I.Otis Historical Archives National Museum of Health and Medicine 33 of 45 Dr. James Watts (left) and Dr. Walter Freeman examine a patient after lobotomy. Date unspecified.George Washington University 34 of 45 A young patient’s rotted teeth, due to poor dentistry, are revealed at London’s Friern Hospital (previously known as the Colney Hatch Lunatic Asylum) circa 1890-1910.Wellcome Library, London 35 of 45 An amputee psychiatric patient of London’s Friern Hospital (previously known as the Colney Hatch Lunatic Asylum) poses for a photo circa 1890-1910.Wellcome Library, London 36 of 45 A British patient identified only as “Mary C” poses for a photo following her lobotomy. October 28, 1960.M. Winn/Daily Express/Getty Images 37 of 45 Ties bind a patient’s feet to a bed at a mental hospital in Bucharest, Romania. Date unspecified.Bernard Bisson/Sygma via Getty Images 38 of 45 Patients sit inside Ohio’s Cleveland State Mental Hospital in 1946.Mary Delaney Cooke/Corbis via Getty Images 39 of 45 Orderlies wash patients at the Long Grove Asylum in Epsom, England circa 1930.Wellcome Library, London 40 of 45 Orphans share a feces-stained crib at the Riul Vadului Mental Asylum in Romania. Date unspecified.ANDREW HOLBROOKE/Corbis via Getty Images 41 of 45 A patient diagnosed with “hysteria-induced narcolepsy” lies strapped down to a bed in Paris’ Salpêtrière Hospital in 1889.Wellcome Library, London 42 of 45 A policeman stands guard at the bars of the ward for psychiatric patients (possibly the “criminal insane,” per original annotation) at New York’s Bellevue Hospital circa 1885-1898.Wellcome Library, London 43 of 45 Debris litters the floor at Maryland’s Crownsville State Hospital psychiatric hospital (formerly Hospital for the Negro Insane of Maryland) during the aftermath of a riot in 1949.Afro American Newspapers/Gado/Getty Images 44 of 45 A patient lies in bed at Ohio’s Cleveland State Mental Hospital in 1946.Mary Delaney Cooke/Corbis via Getty Images 45 of 45

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Haunting Photos Taken Inside Mental Asylums Of Decades Past View Gallery

“The degree of civilization in a society,” goes Russian novelist Fyodor Dostoyevsky’s deathless phrase, “can be judged by entering its prisons.” But perhaps that phrase also applies to another class of institutions meant to house those deemed unfit for society: mental asylums.

And for centuries — right up until the present day, in some places — the quality of most mental asylums, at least those in the European tradition, revealed little degree of civilization at all.

It wasn’t until the very end of the 18th century that just a few doctors in France and England, including Philippe Pinel and William Tuke, first brought forth the then-revolutionary notion of doing away with chains and corporal punishment.

It wasn’t until England’s Lunacy Act of 1845 that a government first officially designated the mentally ill as actual patients in need of treatment.

And it wasn’t until the middle of the 19th century that France, England, and the United States first established public, state-run asylums with government oversight and committees in place to investigate abuses — the full extent of which will never be truly known.

Of course, abuse, neglect, and mistreatment inside mental asylums hardly ended in the middle of the 19th century — on the contrary. While facilities for the mentally ill had now become institutionalized, the late 19th and 20th centuries brought many new problems.

For one, the growth of psychiatry as a discipline meant more diagnoses and thus patients to fit into facilities that were growing ever more overcrowded. Likewise, the growth of psychiatry meant more doctors developing more procedures that seemed increasingly radical throughout the early and mid-20th century, which gave us electroshock therapy and the lobotomy, among others.

At the same time, the rise of fascism and totalitarianism in Europe gave rise to a wave of politically-motivated abuses in mental asylums, with powerful regimes including those in Nazi Germany, the Soviet Bloc, and apartheid-era South Africa summarily institutionalizing suspected enemies of the state and/or creating eugenics programs to weed out those who truly were mentally ill.

But even in cases not nearly so extreme, even in the garden-variety mental asylums (a term itself that has now fallen out of favor) of 20th century Europe and America, the institutional conditions were often startling by today’s standards: lobotomies performed with repurposed ice picks, patients chained to concrete slabs, children in straight jackets tied to radiators, and worse.

Let the harrowing photos above return you to a comparatively benighted era in psychiatric care — one that wasn’t actually all that long ago.

Next, see 37 haunting portraits of life inside Victorian mental asylums. Then, step inside one of the most infamous mental asylums of all time with this look at Bethlem Royal Hospital, more commonly known as “Bedlam.”

Inside the ‘world’s most dangerous’ hospital

A hospital in Guatemala has been described by campaigners as the world’s most abusive and dangerous mental health institution. Former patients say they were raped while sedated, and the director himself admits – while being filmed undercover by the BBC – that patients are still being sexually abused.

Wherever I look I see motionless bodies lying on the crumbling concrete floor of a barren courtyard in the burning sun. The patients appear to have been heavily sedated. Their heads have been shaved and most are dressed in rags with nothing on their feet.

Others are totally naked, exposing their dirty skin covered in their own faeces and urine. They look more like concentration camp prisoners than patients.

The Federico Mora Hospital is home to around 340 patients, including 50 violent and mentally-disturbed criminals. But according to the hospital’s director, Romeo Minera, only a minority have serious mental health problems – a staggering 74% have arrived in need of little more than attention and care and should have stayed in the community.

Minera believes we are charity workers, offering help to his failed institution. Journalists are not welcome here – our cover story was the only way to get access to a hospital that has been condemned by human rights groups.

Walking into one of the wards is like entering a hell on Earth. We find more patients in rags sitting on the floor and in plastic chairs, rocking themselves for comfort. There appears to be no form of stimulation in the dark, sparse ward.

Media playback is unsupported on your device Media captionChris Rogers reports whilst undercover at Federico Mora

The patients reach out to us, desperate for human contact. A man wraps his arms around my chest and begs me to take him away from the hospital.

A male nurse tells me that two or three nurses have to look after 60 to 70 patients, others explain the only way they can cope is by sedating them. As my translator distracts the director, I slip away to the sleeping quarters that line a long, dark corridor. Here I find more patients lying in broken, rusting metal beds.

The patients appear too sedated to take themselves to the toilet. There are puddles of urine on the mattresses, and the clothing on some of the patients is covered in their own faeces. The stench of human filth overwhelms me and I try desperately to stop myself from vomiting.

In response to our investigation, the Guatemalan government said that the hospital “uses the minimum dose of sedatives as recommended by the World Health Organization” and defended conditions in the hospital. “There are trained nurses to attend to the needs of patients including keeping them clean and dressed; and a maintenance team to keep the wards clean,” it stated.

But this is not the end of the horror that surrounds us. We are secretly filming the director as he makes an astonishing admission – the guards sexually abuse the patients. The hospital, he says, is a big place “where anything can happen”.

Image caption Hospital director Romeo Minera

Two former patients told me they were raped at the Federico Mora Hospital. And that the perpetrators included medical staff as well as guards.

One woman says she was sexually abused by a male nurse while sleeping. She was just 17 years old at the time, and a virgin.

“Since I was sedated I wasn’t aware of it – I didn’t realise until the next day that I had lost my innocence. I was bleeding down my legs, so I realised that what had happened that night is that a male nurse had come in and raped me,” she explains.

This was on her third day in the hospital. After two weeks her cries for help led her family to remove her. “You can never forget that experience,” she says, tearfully. “You store it in your mind. I still think of the patients in there.”

Ricardo, another former patient, says he was raped throughout the three years he spent at Federico Mora. He was only released after a legal battle, claiming he was wrongly diagnosed with schizophrenia.

“They took advantage of the female patients when they were sedated and not in their right mind,” Ricardo says. “The police officers, the patients and the male nurses – and some doctors too. They put the prettiest girls aside for themselves at night.”

The US campaign group Disability Rights International (DRI) spent three years collecting evidence on Federico Mora. In a report published in 2012, the group described the hospital as “the most dangerous facility our investigators have witnessed anywhere in the Americas”.

It said “any person with or without a disability detained in this hospital faces immediate risk to his or her life, health and personal integrity, as well as risk of inhuman and degrading treatment or torture”.

The report explained that patients were denied medical care, exposed to serious and contagious illnesses and infections and – compounded by the “widespread” sexual abuse – were at risk of contracting HIV.

On one visit DRI managed to film a female patient explaining she had been sexually abused on her first day in the hospital, while she was tied to a wall.

“The sexual abuse makes this place one layer more horrific than any place I’ve seen before,” says DRI’s founder, Eric Rosenthal.

“I also saw patients held in isolation. There was a man literally trying to climb out of an isolation cell. He was up on the wall desperately trying to get out. And people were locked in these cells for hours or days at a time.”

On my visit to the hospital, I also saw one of the isolation rooms used for patients who become too violent to handle. It’s a room of two square metres (22 sq ft) with a small window. A man was cowering in the corner, the floor covered in human waste.

The director told me these rooms were monitored, but admitted in the same breath that one patient had recently committed suicide by climbing up to the window and hanging himself.

The Guatemalan government defended its use of isolation, saying “patients are held in isolation for only two hours at a time” and constantly monitored. The government also claimed no-one was being held in isolation during our visit.

The use of isolation rooms formed part of the evidence DRI took to the Inter-American Commission on Human Rights (IACHR) in 2012, which issued an “emergency measure” – effectively ordering the government to address the issues raised by DRI in order to “save lives”.

The authorities agreed to act immediately and to launch an investigation into allegations of sexual abuse. But two years on, it appears they have done nothing. Now DRI is bringing a new legal case against the Guatemalan government in an attempt to have the hospital closed down.

The case will be heard in the autumn of 2015, and will see the Guatemalan government effectively placed on trial by the IACHR over the problems found at the hospital. It could face economic and trade sanctions from other Inter-American Commission members.

Hospital staff fear reprisals if they speak out, but six of them agree to talk to me on condition they are interviewed together, and not identified.

“We don’t have the medication we need to treat patients. It is dirty, there are rats and cockroaches,” admits one, her hands shaking with nerves.

“I think I speak for all when I say that the abuses committed in the hospital by guards are common knowledge,” another adds. By now all six of the care staff are in tears.

“It’s not just dangerous for the patients but for us too,” says a male care worker, holding the hands of his colleagues. “We have complained but no-one listens. Working at the hospital is terrifying.”

Back in the UK, I show some of the footage to a leading human rights lawyer, John Cooper QC. “There is a man lying in his bed with faeces around him. This is an individual at his most vulnerable, I’m just speechless to see that,” he says.

He adds it is probably the worst case of poor care and lack of humanity he has ever seen.

The Guatemalan government told the BBC that it has begun the process of improving mental healthcare across the country and is starting to build a wall to separate the prisoners from the rest of the patients. While it had not received any reports of sexual abuse or rape, it said, it has ordered another internal investigation.

DRI’s Eric Rosenthal says he has heard such promises before, in 2012, and believes only legal action can save the patients of Federico Mora.

“Being a developing country with a poor economy is not an excuse for torture, sexual abuse and no dignified care,” he says.

“It is total dehumanisation. These people are not treated as human beings. They have been written off. They are being locked up for the crime of having a disability.”

Our World: World’s Most Dangerous Hospital broadcasts on the BBC News Channel 04:30 and 14:30 GMT on Sunday 7 December – or catch up online.

You can also listen online to an extended version on BBC World Service’s Assignment.

Internationally, you can see the programme on BBC World News on Saturday 6 December at 05:30 and 11:30 GMT and Sunday 7 December at 17:30 and 22:30 GMT.

16 Terrifying Facts About Mental Asylums in the Early 20th Century

Few institutions in history evoke more horror than the turn of the 20th century “lunatic asylums.” Infamous for involuntary committals and barbaric treatments, which often looked more like torture than medical therapies, state-run asylums for the mentally ill were bastions of fear and distrust, even in their own era. The truly mentally sick often hid their symptoms to escape commitment, and abusive spouses and family would use commitment as a threat. Far from being a place of healing, mental hospitals of the early 20th centuries were places of significant harm.

A large mental asylum. Wikimedia.

16. Doctors Sent Patients to Asylums for Non-Mental Health Reasons

Today, the vast majority of patients in mental health institutions are there at their own request. Sadly, during the first half of the twentieth century, the opposite was true. The laws of the era allowed people to be involuntarily committed by their loved ones with little to no evidence of medical necessity required. Even worse, mental health issues weren’t actually necessary to seek an involuntary commitment. The history books are full of women who were committed to asylums for defying their husbands, practicing a different religion, and other marital issues.

Children were not spared from the horrors of involuntary commitment. Families were able to purchase “confinement” for children who were disabled or naturally unruly that prestigious families didn’t want to deal with raising. Children could also be committed because of issues like masturbation, which was documented with a New Orleans case in 1883. Given that only 27% of asylum patients at the turn of the 20th century were in the asylum for a year or less, many of these involuntarily committed patients were spending large portions of their lives in mental hospitals.

Concordia St. PaulBlog & News Updates

A History of Mental Illness Treatment: Obsolete Practices

Posted October 14, 2016 | By Tricia Hussung

Mental illness affects many individuals in the United States. According to the National Alliance on Mental Illness, approximately one in five American adults experience mental illness each year. That’s 43.8 million people, or more than 18 percent of the population. Children are affected as well, with about 13 percent of those ages 8 to 15 experiencing a severe mental disorder at some point during their lives.

With data like this, it’s no surprise that attitudes toward mental health have changed for the better in recent years. Though stigma still exists, CNN reports that 90 percent of Americans value mental and physical health equally, according to a 2015 survey by the American Foundation for Suicide Prevention (AFSP), the National Action Alliance for Suicide Prevention and the Anxiety and Depression Association of America. “People see connection between mental health and overall well-being, our ability to function at work and at home and how we view the world around us,” Dr. Christine Moutier of AFSP told CNN. This change comes as mental health approaches continue to focus on community-oriented, holistic care.

This hasn’t always been the case, however. Mental health treatment has undergone extensive change over the years, with some strategies being ineffective and even dangerous: “Many of the treatments enacted on mentally ill patients throughout history have been ‘pathological sciences’ or ‘sensational scientific discoveries that later turned out to be nothing more than wishful thinking or subjective effects’” rather than actually benefiting patients, History Cooperative says. The following are just some of history’s strangest obsolete mental illness treatments.

History of Mental Illness Treatment

Trephination

As one of the earliest forms of mental health treatment, trephination removed a small part of the skull using an auger, bore or saw. Dated from around 7,000 years ago, this practice was likely used to relieve headaches, mental illness or even the belief of demonic possession. Not much is known about the practice due to lack of evidence.

Bloodletting and Purging

Though this treatment gained prominence in the Western world beginning in the 1600s, it has its roots in ancient Greek medicine. Claudius Galen believed that disease and illness stemmed from imbalanced humors in the body. English physician Thomas Willis used Galen’s writings as a basis for this approach to treating mentally ill patients. He argued that “an internal biochemical relationship was behind mental disorders. Bleeding, purging, and even vomiting were thought to help correct those imbalances and help heal physical and mental illness,” according to Everyday Health. These tactics were used to treat more than mental illness, however: Countless diseases like diabetes, asthma, cancer, cholera, smallpox and stroke were likely to be treated with bloodletting using leeches or venesection during the same time period.

Isolation and Asylums

Isolation was the preferred treatment for mental illness beginning in medieval times, so it’s no surprise that insane asylums became widespread by the 17th century. These institutions were “places where people with mental disorders could be placed, allegedly for treatment, but also often to remove them from the view of their families and communities,” Everyday Health says. Overcrowding and poor sanitation were serious issues in asylums, which led to movements to improve care quality and awareness. At the time, the medical community often treated mental illness with physical methods. This is why brutal tactics like ice water baths and restraint were often used.

Insulin Coma Therapy

This treatment was introduced in 1927 and was used for several decades until the 1960s. In insulin coma therapy, physicians deliberately put the patient into a low blood sugar coma because they believed large fluctuations in insulin levels could alter the function of the brain. Insulin comas could last anywhere between one and four hours. Patients were given an insulin injection that caused their blood sugar to fall and the brain to lose consciousness. Risks included prolonged coma (in which the patient failed to respond to glucose), and the mortality rate varied between 1 and 10 percent. Electroconvulsive therapy was later introduced as a safer alternative to insulin coma therapy.

Metrazol Therapy

In metrazol therapy, physicians induced seizures using a stimulant medication. Seizures began roughly a minute after the patient received the injection and could result in fractured bones, torn muscles and other adverse effects. The therapy was usually administered several times a week. Metrazol was withdrawn from use by the FDA in 1982. While this treatment was dangerous and ineffective, seizure therapy was the precursor to electroconvulsive therapy (ECT), which is still used in some cases to treat severe depression, mania and catatonia.

Lobotomy

This now-obsolete treatment won the Nobel Prize in Physiology and Medicine in 1949. It was designed to disrupt the circuits of the brain but came with serious risks. Popular during the 1940s and 1950s, lobotomies were always controversial and prescribed in psychiatric cases deemed severe. It consisted of surgically cutting or removing the connections between the prefrontal cortex and frontal lobes of the brain. The procedure could be completed in five minutes. Some patients experienced improvement of symptoms; however, this was often at the cost of introducing other impairments. The procedure was largely discontinued after the mid-1950s with the introduction of the first psychiatric medications.

Mental Health Treatment Today

As we learn more about the causes and pathology of various mental disorders, the mental health community has developed effective, safe treatments in place of these dangerous, outdated practices. Today, those experiencing mental disorders can benefit from psychotherapy along with biomedical treatment and increased access to care. Treatments will continue to change along with scientific and research developments, and as mental health professionals gain more insight.

If you are interested in the treatment of mental disorders and relevant topics in psychology like those covered here, consider Concordia University, St. Paul’s online Bachelor of Arts in Psychology. This program equips students with the knowledge and tools necessary to excel in the field of psychology.

1950: The Beginning of a New Era in Mental Health

The post-World-War-II years were heady times in psychiatry. During the war, scores of nonpsychiatric physicians were pressed into service as psychiatrists and learned a combat psychiatry very different from the prevailing long-term psychoanalytic model found in civilian life.

Thousands of young men inducted into military service were found unfit for duty due to mental illnesses. The number was so great that during one period more men were reported to be discharged for mental health reasons than were inducted. The scandalous conditions in both the overcrowded, creaking state hospital system and underfunded Veterans Administration hospitals were featured in exposés in Albert Deutsch’s Shame of the States and in Life magazine. States, starting with California, began to move toward community care. And a number of “young Turks” who considered the American Psychiatric Association too stodgy to act quickly on important issues founded the Group for the Advancement of Psychiatry (GAP).

Thus in just a few critical years—1945 to 1950—the stage was set for powerful changes in the field, made possible by new federal and state mechanisms to fund and direct shifts in care, a willingness by society and psychiatry to move in new directions, and leadership equipped and ready to act. What was missing was a means of communication.

Daniel Blain, M.D., APA’s first medical director, responded to the need for better communication, as well as the broader impetus for change, by initiating the A.P.A. Mental Hospital Service Bulletin in January 1950. The Bulletin quickly evolved into a journal—now Psychiatric Services—whose purpose was, and is, to help mental health clinicians and administrators improve the care and treatment of persons with severe mental illness.

This year we celebrate the journal’s 50 years of service to the field by reliving some of the most exciting and disappointing events in the last half-century of psychiatry. We begin in this issue with an overview by Jeffrey L. Geller, M.D., M.P.H., of the entire 50 years. In the February through November issues we will concentrate on important developments occurring during five-year periods. From each period, we will reprint an article that reflects a key development, with a commentary on the subsequent impact of the development and a Taking Issue column that presents a different, “Yes, but…” perspective. Finally, in December, we’ll look at what’s in store in the new millennium.

We’ve had great fun planning this celebratory year’s volume; we hope you will enjoy reading it as much.—

Asylums to antidepressants: a short history of mental illness in the west

The English word ‘bedlam’ is derived from the nickname of London’s Bethlehem Royal Hospital, one of the world’s oldest insane asylums. Image:

William Hogarth

The English word ‘bedlam’ is derived from the nickname of London’s Bethlehem Royal Hospital, one of the world’s oldest insane asylums.

Image:

William Hogarth

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The fifth edition of the Diagnostic and Statistical Manual caused an outcry when it was published by the American Psychiatric Association last year. Some argued that the definitions in the new edition were so broad that 50 per cent of the population could now be diagnosed with a mental disorder. Yet, as Keri Phillips writes, a brief look at the history of mental illness shows that western ideas about its definition, symptoms, and treatment have always been debated.

The modern notion of mental disorders as diseases of the mind rather than something with a moral or religious dimension began to take shape during the 19th century. During the previous century, a handful of both private and public madhouses had confined lunatics in Britain, and elsewhere, in appalling conditions. In 1845, the Lunacy Act in Britain enshrined the rights of the mentally ill as patients who required treatment. Similar approaches in France, Germany and the United States encouraged the growth of public institutions to house the insane.

‘The asylum goes from some place where people are restrained, literally restrained with shackles, to places by the 1830s and 1840s where the asylum is seen as a big family,’ says Sander Gilman, professor of psychiatry at Emory University, Atlanta. ‘People in asylums now grow their own food and the head of the asylum is seen as almost the father of the asylum. That’s a big shift from the idea of un-treatability to the idea of treatability, from moral failing to behavioural change. Some of the therapies were social therapies, things like dances on the weekends. Some of therapies were shock therapies: water therapy for example, where people were wrapped in wet sheets and basically strapped into a chair.’

Nobody in the late ’40s or early ’50s would have believed that we ever could have treatments, medications for depression.

Gillman says that there were usually genuine reasons for confinement to institutions, although there were notorious cases like that of Elizabeth Packard, who was committed as insane because she would not agree with the religious beliefs of her husband.

‘Most of the time people were put into asylums because of actions against people’s own best interests,’ says Gillman. ‘People in the asylums for the most part were there because they were unable to work and love.’

‘Some of things that they were in for today we understand as neurological diseases. The most common disease in the 19th century asylum was called general paralysis of the insane, GPI. By 1904 when we had a test for syphilis, it turned out that most of the people with GPI had a neurological deficit, they had tertiary syphilis.’

During the late 19th century, the ideas of Sigmund Freud, an Austrian neurologist, became the catalyst for a revolution in western notions of mental illness. Freud was the founder of psychoanalysis, a set of psychological and therapeutic theories and associated techniques. Controversial at the time and criticised today as pseudoscience, Freud’s ideas continue to influence our understanding of mental illness.

‘Freud was one of the key people in pulling the domain of anxiety into the mental health field,’ explains David Healy, a professor of psychiatry at Bangor University. ‘Where before, all the way back for eons people had been scared, they had been fearful and maybe unduly fearful from time to time, Freud was the person who began to argue this isn’t just a normal response to being alive, it can be a disorder in its own right.’

‘One of the consequences is that it has led to an understanding that all mental problems are just an abnormal response to life’s stresses, and all the person needs to do is to just learn how to cope with life’s stresses, and if they do this they won’t need physical treatments. That’s an extreme point of view but it’s one that a lot of people have.’

Healy argues that Freud’s theories made it difficult to legitimise the idea that there are real mental illnesses that aren’t simply abnormal responses to handling stress.

‘It’s extraordinarily important to be able to distinguish a physical illness of that sort, of which there may not be very many, from the huge range of ways in which we handle stress, at times inappropriately and at times to psychotic proportions.’

In the middle of the 20th century a drug called chlorpromazine was developed, fuelling an extraordinary explosion of new drugs including antipsychotic and antidepressant drugs as well as tranquillisers and stimulants. In one way or another, almost all the drugs now in use stem from the 1950s. These discoveries led to great expectations that the drugs would be tools to learn how the mind and the brain worked.

They were so successful at treating mental illness that it looked like it might be possible to close all the mental hospitals. By the 1960s, large asylums were considered to be terrible places and ideas about mental illness and how to treat it were about to undergo another shift, influenced by the social movements of the time.

‘As part of that rethinking there were lots of new theories about what a mental illness really was, says Gillman. ‘Dr Thomas Szasz, a prominent critic of conventional psychiatry, said there is no such thing as mental illness, it’s simply people trying to get a free ride, they’re just acting.’

‘Some people looked at mental illness in families and decided that the one defined as mentally ill was the healthy person and the family was in point of fact crazy. Some people talked about mental illness as if mental illness was a kind of societal label for people who really should be tolerated because they were eccentrics.’

Read more: Dealing with anxiety disorders

Deinstitutionalisation became the catchcry and across the world there were campaigns to replace asylums with smaller day hospitals and halfway houses which would allow patients to work, live normal lives and be better integrated into society.

The difficulty was that it was easier to close the big asylums than it was to create large numbers of smaller institutions. What really happened between 1960 and 1980 was that the asylums dumped their inmates onto the streets of cities. Today in the United States, Canada, Australia, Britain many of the severely mentally ill end up in prison.

While the debate over the very existence of mental illness was going on, chlorpromazine and other new drug therapies were augmented by developments in neuroscience, the study of the nervous system.

‘Nobody in the late ’40s or early ’50s would have believed that we ever could have treatments, medications for depression,’ says Professor Philip Mitchell from the School of Psychiatry at the University of New South Wales.

‘What happened was that there was a molecule that was derived from chlorpromazine that a drug company in Europe was studying. They were used on some patients with schizophrenia in some private hospitals in Switzerland. One of the researchers decided to try it on his severely depressed patients, and much to his surprise it actually changed their behaviour. So for the first time we saw a medication actually changing depression and this was remarkable.’

It’s still not entirely clear how prescribed antidepressants work, however, and despite the optimism surrounding the early breakthroughs in understanding the brain, 40 or 50 years of research has not revealed essential differences in the brains of people with serious psychiatric disorders.

‘I think that optimism was too simplistic and I think, in retrospect, naive,’ Mitchell says. ‘We thought that complex disorders like severe depression, bipolar and schizophrenia could be ascribed to simple changes in single neurone transmitters or neurochemicals. The brain has been the most difficult organ of the body to study. It’s our most complex organ, and it’s clearly the least accessible.’

‘The pharmaceutical industry has essentially lost interest in psychiatric disorders over the last five years. Our understandings were so poor that they have retreated. It’s only in the last year or so that you can see interest re-emerging that there are potential targets for new drug developments.’

In recent decades, while research into brain imaging, genetics, and molecular and cellular biology has continued to explore the idea that mental disorders are related to disturbances in brain function, debate over whether we are catching too many of life’s normal experiences and behaviours in the mental illness net has continued.

‘There has been a shift in views over time, and it’s not necessarily clear that these shifts have always been based on progress in our understanding of the illnesses,’ says Healy. ‘They’ve often been based on the interests of the people who can earn a living out of treating the illness.’

‘For instance, the pharmaceutical companies recently have clearly stood to gain from persuading people that there is a lot of depression and more recently a lot of bipolar disorder around the place, and the doctors who prescribe these drugs also stand to gain from seeing things that way.’

  • Mental illness – a history

    Listen or download this program at Rear Vision.

It is obviously unrealistic to expect a consensus about what mental illness is and where the boundaries lie. Agreement is possible where specific causes can be identified, whether they are environmental like lead poisoning or neurological like Alzheimer’s. There will continue to be debate over people who may have spectrum disorders or a mild forms of depression which allow them to function.

‘We must not confuse those people with those with severe mental illnesses or severe developmental disabilities,’ cautions Sander Gillman. ‘We as a society have an obligation to provide succour, to provide asylum for people, and to provide the best possible treatment for them.’

‘Yes, there are going to be expanding categories. Autism has grown in the United States greatly, ADHD has grown greatly. As a historian of mental illness, I can see that we really do create bigger categories which then, over time, self-correct. We mustn’t say that mental illness doesn’t exist, nor that it’s simply normal behaviour not recognised or eccentric behaviour.’

‘Mental illness is illness, it’s pain, it creates in people an inability for them to love and work. In this world, loving and working, having relationships with human beings and having a productive way in the world are the things that define us.’

Mental As: show your support and donate to mental health research today.

Horrifying Psychiatric Treatments from the Age of Reason

The 17th century saw the Age of Reason and the Scientific Method developed in Europe, and along with it the rise of the asylum in the treatment of mental illness. Asylums were seen as a place to keep the mentally ill out of the way of the rest of society – unless that same society decided they wanted a laugh. At one point in Bethel Royal Hospital’s notorious history, the asylum was opened for public viewings, offering London’s citizens the opportunity to wander through areas of the asylum, unsupervised and with direct access to the patients, for two pennies each. In order to raise funds for the running of the hospital, “suitable” patients were displayed for the entertainment and mirth of whoever entered through the Penny Gates. As horrifying as this practice may seem to us today, when Bethlem closed its doors to the public in 1770, removing a certain level of public oversight of its treatment of its patients, the real horrors began.

Treatments such as lobotomy and electro-convulsive therapy are widely known, but there were many other “creative” methods the psychiatric practice used in treating mental illness, beginning in the 17th century up to the late 20th century. One treatment that became popular in the 1700s was the Swinging Chair, or rotational therapy. With this therapy, developed by Charles Darwin’s grandfather Erasmus, was based on his observations of children spinning themselves in order to induce vertigo, resulting in laughter. Darwin believed that this could work with an adult as well, and developed a “rotational chair,” where a person was placed in a chair, often with a box around that head or body to impede their sight, and then spun by hand until they experienced vertigo, sedation, nausea and vomiting or uncontrollable bowel movements. It was co-signed as a treatment by Dr. Benjamin Rush, the “Father of American Psychiatry,” and so rose to popularity in both the US and England. It was reportedly very effective – as a threat – in sedating unruly patients.

Another treatment that was widely used for the treatment of mental illness in the 17th and 18th centuries was the Bath of Surprise. In its original form, the Bath of Surprise was exactly like the Dunk Tank, except it was ice-cold water and an agitated mentally ill patient being dropped into it without warning. Again, an effective but deranged way of sedating patients. In fact, it was deemed so effective that it evolved into “hydrotherapy,” a practice of continuous baths, mummifying a patient in wet cloth or spraying the patient with water that continued late into the 20th century. With a continuous bath, the patient was basically strapped into a tub, with a canvas sheet covering the bath and just their head poking out. The bath could last for several hours to several days, ands most often used as a treatment for insomnia or depression and suicidal thoughts.

A hydrotherapy pack could be used with either cold or warm water, depending on the illness being treated. Cold water was considered effective in treating manic-depressive symptoms, or any agitated or excited behaviour in a patient. Patients were wrapped in sheets that were soaked in water and then wrapped around the patient mummy-style. The patient would lay wrapped in wet sheets for several hours.

The most brutal of the hydrotherapy treatments were the sprays. While they were compared to showers, they look more like a hosing down. The patient stood in a shower-like stall, sometimes strapped in for support, while an attendant used a hose or a spraying station to bombard the patient with either hot or cold water for several minutes at a time. While shorter than the other hydrotherapy methods, this one seems the most traumatizing and humiliating.

Over here in Canada, in 1895 the superintendent of the London Asylum in Ontario was a great advocate of gynaecological surgery as a method of treating female patients. He performed over 200 surgeries on women living at the London asylum, and claimed a high success rate in “curing” their mental illness. Things like removing and replacing their uterus in “proper alignment,” performing a hysterectomy, removing ovaries or removing lesions on the cervix or vaginal walls were done in order to improve the patients’ mental health, and although gynaecological surgery was practiced in some other asylums for the same reasons, the idea that a misaligned uterus was the cause of a woman’s mental illness never really caught on. But the idea that the body of a mentally ill person was fodder for experimentation just became more and more popular in psychiatric treatment.

Confinement has always been a popular way to deal with psychiatric patients who are experiencing a breakdown. Confines have ranged from chains to cages to straightjackets, but the most terrifying of all was the Utica Crib, popularized in the United States in 1846 through its use at the New York State Lunatic Asylum at Utica. It was similar to a crib but with way less space and a caged lid, and for adults. The patient would be laid in the narrow and cramped crib, and locked in it for hours in order to sedate them. Patients who were thrashing around in the crib would often come out very quiet and well-behaved, but it fell out of favour when the Sunday Herald published an interview with New York Dr. William Hammond, who was famous for his advocacy to remove restraints from psychiatric treatment. Dr. Hammond was quoted as describing the Utica crib as a “barbarous and unscientific instrument,” stating:

It is a bed like a child’s crib, with slatted sides, eighteen inches deep, six feet long and three feet wide. It has a slatted lid which shuts with a spring lock. A lunatic put in it can barely turn over. There is not as much space between the patient’s head and the lid as if he were in a coffin. He is kept in the crib at the will of an attendant, the key being in the possession of the latter and not of a physician. Patients have sometimes died in these cribs.

He suggested that a padded room would be a much more effective choice for confinement purposes. And we all know how well those have gone over in popular culture.

While it’s easy to look at the past of psychiatric treatments with horror and revulsion, today we’ve mostly replaced these treatments with pharmaceuticals that do the same things. Many of the prescribed drugs are addictive or harmful to the patient, and it’s very possible that in another couple of hundred years we’ll be looking back at today’s methods, judging them with the same harsh hindsight. maybe by then we’ll have returned to the methods used by ancient societies in Egypt or aboriginal practices, which involved acceptance into society, effectively using music, dance and art therapies millennia before western psychiatry ever tried them. Mental illness has always been a mystery to those who don’t suffer from it, but hopefully our future selves will have a better idea of how to handle it.

Sources:

Treatments in Mental Health: A Brief History

1880 The Utica Crib

History of Mental Health Treatment

Mental illness isn’t a uniquely modern phenomenon. The genetic influences that stand behind some types of mental illnesses, along with the physical and chemical assaults that can spark illnesses in some people, have always been part of human life. But the ways in which impacted people are treated by their peers, as well as the help ill people might get from their doctors, has undergone a significant amount of revision. In fact, the ways in which modern cultures both understand and deal with mental illnesses have undergone a radical transformation. However, much work remains to be done, if people who have mental health concerns are to reach their true potential.

A Feminine Example

Nowhere is the sea change the mental health field has undergone more evident than in treatments for women. Parsing this one example could make the reams of data in this article just a little easier to understand.

In Victorian times, a woman could be considered unbalanced due to a variety of causes, including:

  • Menstruation-related anger
  • Pregnancy-related sadness
  • Post-partum depression symptoms
  • Disobedience
  • Chronic fatigue syndrome
  • Anxiety

Some of these conditions are still considered mental health conditions. But some of these situations are simply part of living as a woman in the world, and they wouldn’t be treated at all by modern practitioners. However, Victorian woman could be placed in institutions due to these conditions, which doctors often labeled “hysteria,” and once there, these women were cared for by a doctor who typically ruled the facility in the same manner in which a Victorian father might rule a home. Women had few, or no, rights, and disobedience was often met with severe punishment.

By D.M. Bourneville and P. Régnard , via Wikimedia Commons

Much has changed since then. A modern woman with a true mental illness might get treatments that are somewhat tailored due to her gender, but the underlying fundamental theories of mental illness don’t shift from man to woman, and a practitioner is required to respect the rights of the patient at all times. A woman in a modern facility might also have the opportunity to weigh in on the therapies she does, or does not, accept, and she might be allowed to leave as soon as she feels at least somewhat recovered. It’s a huge shift, and it’s been made via a series of small, difficult-to-measure steps.

Illness in the 1840s

See page for author , via Wikimedia Commons

In the early part of America’s history, people who had mental illnesses were placed in institutions that were quite similar to jails. Once inside these facilities, people simply weren’t given the opportunity to leave, no matter how much they might want to do so. In addition, some of these facilities had terrible procedural rules that allowed people with illnesses to be treated in ways that were unspeakably cruel.

In the 1840s, a woman in Boston, Dorothea Dix, began to research conditions in traditional mental health institutions. It’s been suggested that Dix had a mental illness of her own, and she was more receptive to the plight of the ill as a result, but no matter the underlying motivation, Dix spent years conducting interviews with experts and patients, and her results were startling.

In a piece she wrote to the General Assembly of North Carolina, she outlines cases in which the mentally ill were chained to their beds, kept in filthy conditions and even abused. She begins her report with this series of sentences:

“I admit that public peace and security are seriously endangered by the non-restraint of the maniacal insane. I consider it in the highest degree improper that they should be allowed to range the towns and country without care or guidance; but this does not justify the public in any state or community, under any circumstances or conditions, in committing the insane to prisons…”

Rather than committing the mentally ill to prisons, Dix hoped to open a series of institutions devoted to mental health, and she hoped these facilities would provide work, recreation and understanding to the ill. It’s one of the first documents to outline compassionate care, although it wasn’t widely implemented due to the work that Dix did.

History Timeline

Ancient civilizations like the Romans and Egyptians considered mental health problems to be of a religious nature. Some thought a person with a mental disorder may be possessed by demons, thus prescribing exorcism as a form of treatment. During the 5th century BC, Greek physician Hippocrates, however, believed that mental illness was physiologically affiliated. As a result, his methods involved a change in environment, living conditions, or occupations.

1400 to Early 1900s+

  • 1407: The first facility specifically for mental health is established in Spain.
  • 1700s: Advocacy for mentally ill persons occurred in France. Phillipe Pinel, displeased with living conditions in hospitals for those with mental disorders, orders a change of environment. Patients are given outside time as well as more pleasant surroundings like sunny rooms. He forbids the use of shackles or chains as restraints.
  • 1840s: Dorothea Dix fights for better living conditions for the mentally ill. For over 30 years she lobbies for better care and finally gets the government to fund the building of 32 state psychiatric facilities.
  • 1883: German psychiatrist Emil Kraepelin studies mental illness and begins to draw distinctions between different disorders. His notes on the differences between manic-depressive disorder and schizophrenia are still used today.
  • Early 1900s: Using psychoanalytical theories, Sigmund Freud and Carl Jung treat their patients for mental illness. Many of the theories they employed are still discussed today and used as a basis for the study of psychology.

1930s to Today+

After the 1920s, the United States saw yet again another shift in society’s view on mental health. A Mind That Found Itself, a book by Clifford Beers, prompts discussion on how mentally ill people are treated in institutions. His ideas begin the roots of the National Mental Health Association. Countless other books like Ken Kesey’s One Flew Over the Cuckoo’s Nest in 1962 also offered an interesting perspective on how people are treated in psychiatric hospitals. This early period of the 20th century marked a big movement in advocacy and care standards for mental health care.
After the 1920s, the United States saw yet again another shift in society’s view on mental health. A Mind That Found Itself, a book by Clifford Beers, prompts discussion on how mentally ill people are treated in institutions. His ideas begin the roots of the National Mental Health Association. Countless other books like Ken Kesey’s One Flew Over the Cuckoo’s Nest in 1962 also offered an interesting perspective on how people are treated in psychiatric hospitals. This early period of the 20th century marked a big movement in advocacy and care standards for mental health care.

  • 1946: President Harry Truman signs a law that aims to reduce mental illness in the United States, the National Mental Health Act. This law paved the way for the foundation of the National Institute on Mental Health (NIMH) in 1949.
  • 1950s to 1960s: A wave of deinstitutionalization begins, moving patients from psychiatric hospitals to outpatient or less restrictive residential settings. Institutionalization was often thought of as the best method of treatment but overstaffing and poor living conditions prompted a push to outpatient care. This movement also sparks the development of antipsychotic drugs, so as to make a person’s life outside an institution more manageable. In fact, over a 30-year period the number of institutionalized patients dropped from 560,000 in the 1950s to 130,000 in 1980.
  • 1990s: A new generation of prescription antipsychotic drugs emerge, as well as new technology in the medical field.
  • 2008 to 2010: The Wellstone and Domenici Mental Health Parity and Addiction Equity Act passes into law. This made it so insurers who did provide mental health coverage could not put limitations on benefits that are not equal to limits on other medical care coverage.

Wider Outrage in the 1880s

Placing the mentally ill in facilities allowed members of the general public to ignore the problem. They didn’t see anyone who had a mental illness roaming the streets, and if they placed a person in an institution like this, they may not have come back to visit or shared stories of any visits they did make. The people just seemed to disappear.

Much of that changed in the late 1880s, due to the work of a writer named Nelly Bly. She agreed to pose as a mentally ill woman on an assignment for a local newspaper, and she documented everything that happened to her in a series of articles, which were later turned into a book. Bly was a wonderful writer, and her descriptions were hard to ignore.

By McD (Penn University library) , via Wikimedia Commons

By McD (Penn University library) , via Wikimedia Commons

By McD (Penn University library) , via Wikimedia Commons

“… I could not sleep, so I lay in bed picturing to myself the horrors in case a fire should break out in the asylum. Every door is locked separately and the windows are heavily barred, so that escape is impossible. In the one building alone there are, I think Dr. Ingram told me, some three hundred women. They are locked, one to ten in a room. It is impossible to get out unless these doors are unlocked.”

In addition to describing the physical building, Bly describes the harsh treatments she obtained, including solitary confinement, hair pulling and more. Bly’s book was a sensation, and according to news reports, the institution in which she lived was reformed as a result of her work. But she also managed to outline what living in a facility like this was actually like and how it didn’t seem to help anyone to get better, and that may have deepened the discussion people in this country had about mental illness, and it may have spurred experts to come up with radical treatments that could actually effectively treat mental illnesses. If housing them and isolating them didn’t work, they needed to find something else that would.

Innovative Therapies in the 1930s

In the early part of the 1900s, experts began to try to understand what might make a person behave in an erratic way, and what kinds of thoughts and opinions might be attached to what outsiders would deem “madness.” Sigmund Freud was a major influence here, obviously, as he developed a number of theories that attempted to explain unusual behavior, and he devised therapies that aimed to help people who might once have been placed in a prison with no help at all.

But work advocated by Freud could take months or even years to complete, and some people didn’t seem to get better when they were under the guidance of the so-called “talking cure.” As a result, practitioners began dabbling in radical cures in the 1930s, hoping to eliminate mental illnesses altogether with one big gesture.

By Photography Harris A Ewing (Saturday Evening Post, 24 May 1941, pages 18-19) , via Wikimedia Commons

Techniques that were used on the mentally ill included:

  • Insulin-induced comas
  • Lobotomies
  • Malarial infections
  • Electroshock therapy

This work continued in some institutions well into the 1940s and 1950s, and in some cases, it did help some people who had serious illnesses. But many of these techniques fell out of favor, and in the years to come, an entirely different method of treatment began to take prominence in people with mental illnesses.

Chemical Interventions

In the 1940s and 1950s, chemists began to experiment with different powders and pills that could calm imbalances inside the brain and deliver real relief to people who had mental illnesses. Rather than strapping people down to their beds, or asking people to simply talk about their problems, these chemists hoped to use a form of chemical restraint. People would feel better, and they might behave better, and no institutionalization would be needed at all.To a large extent, this was a successful project. Medications like lithium seemed capable of soothing people with very severe cases of bipolar disorder, while antipsychotic medications seemed capable of helping people with schizophrenia.

At the same time, the number of people hospitalized due to mental illness had reached staggering proportions.

It was a global problem, and experts began to wonder if they could take people out of the institutions and provide them with medications they could use at home.

Relevant Videos

Deinstitutionalization Movement

Beginning in the 1950s, experts began moving people out of institutions and into communities, and the number of people enrolled in formal institutions dropped dramatically in just a few short years.Unfortunately, communities were slow to adapt to this onslaught of people who needed very intense care.

Few were able to provide the support needed, such as:

  • Housing assistance
  • Job training
  • Psychiatric counseling
  • Life skills training
  • Social support

As a result, many people who moved out of terrible facilities moved into situations that were merely different, not noticeably better. For example, in a grueling piece from The New York Times, a story emerges of a number of very young men who were removed from state institutions and forced to work in a turkey-processing plant for years, for less than $100 per month. These men had no contact with their families, no opportunities to learn life skills and no way to get out.

“A lucky few returned South for a week’s vacation every year. Others tried to stay in touch with family by schoolhouse telephone, some of them calling disconnected numbers, over and over, year after year. Or they lingered at the post office, where there was rarely anything for them, other than the candy on the counter … But every once in a great while, a lucky man received a birthday card or Christmas letter, sent from another world.”

They were left there until 2009, when inspectors from the federal Department of Labor, as well as officials from nearby communities, reported conditions that they felt were abusive.

Those who weren’t shipped to programs like this sometimes slipped between the cracks altogether, and they made a life on the streets, sleeping in cardboard boxes, begging for food and railing at the sky when the days were bad. In one study of the issue, conducted in 1988, researchers found that 28 percent of the homeless people they studied had a diagnosable mental illness. That’s a remarkably high number.

In the 1990s, experts discovered that many people with mental illness entered the criminal justice system, due to a combination of drug use and mandatory sentencing rules. Administrators of these facilities scrambled to keep up with the demand for services from people who were profoundly ill and unable to get the help they needed on the outside.

Modern Therapies

Community agencies have worked for years to provide people with the help they need to manage their conditions without entering a facility for life. Social workers, mental health counselors and more have all been involved in this movement, and while it’s safe to say that some communities provide help that’s superior to the level of assistance seen in other communities, it’s clear that people have options for treatment today through community resources that just didn’t exist a decade or so ago.

Laws have also changed, and they now allow concerned family members and community members to place people with mental illnesses inside therapeutic facilities for a short period of time, until they gain control. Some state laws even force people with mental illnesses to take medications, even if they don’t wish to do so.

It’s easy to view these legislative changes as a method that can allow people in the community to live with people who have mental illnesses, without worrying about their health and harm. But people who have mental illnesses have rights, and some don’t wish to accept this kind of treatment. Some patients want to manage their own conditions, using online resources as well as their doctors, and they’d like to have much more autonomy.

It’s unclear what role this might play in the future. But it is clear that practitioners now respect people with mental illnesses to an unprecedented degree, compared with previous years. Rather than silencing them with restraints and drugs, experts now want to partner with patients and help them. This could bring about a form of mental health treatment everyone could support.

If you’d like to know more about how mental health issues are treated in Foundations Recovery Network facilities, we urge you to give us a call. Our admissions coordinators are here 24/7 to answer your questions.

Sources “Women and Psychiatry.” (n.d.). Science Museum. Accessed March 14, 2014.

Parry, M. (April 2006). “Dorothea Dix (1802-1887).” American Journal of Public Health. Accessed March 14, 2014.

“Dorothea Dix Pleads for a State Mental Hospital.” (n.d.). Dog Justice for Mentally Ill. Accessed March 14, 2014.

“Nellie’s Madhouse Memoir.” (n.d.). American Experience. Accessed March 14, 2014.

DeMain, B. “Ten Days in a Madhouse: The Woman Who Got Herself Committed.” (2011). Mental Floss. Accessed March 14, 2014.

“Sigmund Freud.” (n.d.). NNDB. Accessed March 14, 2014.

“Timeline: Treatments for Mental Illness.” (n.d.). American Experience. Accessed March 14, 2014.

Ibid.

Koyanagi, C. (August 2007). “Learning from History: Deinstitutionalization of People with Mental Illness as a Precursor to Long-Term Care Reform.” Kaiser Commission on Medicaid and the Uninsured. Accessed March 14, 2014.

MENTAL HEALTH TREATMENT TODAY

Today, there are community mental health centers across the nation. They are located in neighborhoods near the homes of clients, and they provide large numbers of people with mental health services of various kinds and for many kinds of problems. Unfortunately, part of what occurred with deinstitutionalization was that those released from institutions were supposed to go to newly created centers, but the system was not set up effectively. Centers were underfunded, staff was not trained to handle severe illnesses such as schizophrenia, there was high staff burnout, and no provision was made for the other services people needed, such as housing, food, and job training. Without these supports, those people released under deinstitutionalization often ended up homeless. Even today, a large portion of the homeless population is considered to be mentally ill (). Statistics show that 26% of homeless adults living in shelters experience mental illness (U.S. Department of Housing and Urban Development , 2011).

(a) Of the homeless individuals in U.S. shelters, about one-quarter have a severe mental illness (HUD, 2011). (b) Correctional institutions also report a high number of individuals living with mental illness. (credit a: modification of work by C.G.P. Grey; credit b: modification of work by Bart Everson)

Another group of the mentally ill population is involved in the corrections system. According to a 2006 special report by the Bureau of Justice Statistics (BJS), approximately 705,600 mentally ill adults were incarcerated in the state prison system, and another 78,800 were incarcerated in the federal prison system. A further 479,000 were in local jails. According to the study, “people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four times the general population” (Prins & Draper, 2009, p. 23). The Treatment Advocacy Center reported that the growing number of mentally ill inmates has placed a burden on the correctional system (Torrey et al., 2014).

Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals focused on short-term care. In all types of hospitals, the emphasis is on short-term stays, with the average length of stay being less than two weeks and often only several days. This is partly due to the very high cost of psychiatric hospitalization, which can be about $800 to $1000 per night (Stensland, Watson, & Grazier, 2012). Therefore, insurance coverage often limits the length of time a person can be hospitalized for treatment. Usually individuals are hospitalized only if they are an imminent threat to themselves or others.

Link to Learning

View this timeline showing the history of mental institutions in the United States.

Most people suffering from mental illnesses are not hospitalized. If someone is feeling very depressed, complains of hearing voices, or feels anxious all the time, he or she might seek psychological treatment. A friend, spouse, or parent might refer someone for treatment. The individual might go see his primary care physician first and then be referred to a mental health practitioner.

Some people seek treatment because they are involved with the state’s child protective services—that is, their children have been removed from their care due to abuse or neglect. The parents might be referred to psychiatric or substance abuse facilities and the children would likely receive treatment for trauma. If the parents are interested in and capable of becoming better parents, the goal of treatment might be family reunification. For other children whose parents are unable to change—for example, the parent or parents who are heavily addicted to drugs and refuse to enter treatment—the goal of therapy might be to help the children adjust to foster care and/or adoption ().

Therapy with children may involve play. (credit: “LizMarie_AK”/Flick4)

Some people seek therapy because the criminal justice system referred them or required them to go. For some individuals, for example, attending weekly counseling sessions might be a condition of parole. If an individual is mandated to attend therapy, she is seeking services involuntarily. Involuntary treatment refers to therapy that is not the individual’s choice. Other individuals might voluntarily seek treatment. Voluntary treatment means the person chooses to attend therapy to obtain relief from symptoms.

Psychological treatment can occur in a variety of places. An individual might go to a community mental health center or a practitioner in private or community practice. A child might see a school counselor, school psychologist, or school social worker. An incarcerated person might receive group therapy in prison. There are many different types of treatment providers, and licensing requirements vary from state to state. Besides psychologists and psychiatrists, there are clinical social workers, marriage and family therapists, and trained religious personnel who also perform counseling and therapy.

A range of funding sources pay for mental health treatment: health insurance, government, and private pay. In the past, even when people had health insurance, the coverage would not always pay for mental health services. This changed with the Mental Health Parity and Addiction Equity Act of 2008, which requires group health plans and insurers to make sure there is parity of mental health services (U.S. Department of Labor, n.d.). This means that co-pays, total number of visits, and deductibles for mental health and substance abuse treatment need to be equal to and cannot be more restrictive or harsher than those for physical illnesses and medical/surgical problems.

Finding treatment sources is also not always easy: there may be limited options, especially in rural areas and low-income urban areas; waiting lists; poor quality of care available for indigent patients; and financial obstacles such as co-pays, deductibles, and time off from work. Over 85% of the l,669 federally designated mental health professional shortage areas are rural; often primary care physicians and law enforcement are the first-line mental health providers (Ivey, Scheffler, & Zazzali, 1998), although they do not have the specialized training of a mental health professional, who often would be better equipped to provide care. Availability, accessibility, and acceptability (the stigma attached to mental illness) are all problems in rural areas. Approximately two-thirds of those with symptoms receive no care at all (U.S. Department of Health and Human Services, 2005; Wagenfeld, Murray, Mohatt, & DeBruiynb, 1994). At the end of 2013, the U.S. Department of Agriculture announced an investment of $50 million to help improve access and treatment for mental health problems as part of the Obama administration’s effort to strengthen rural communities.

Children and Mental Health

  • Family counseling. Including parents and other members of the family in treatment can help families understand how a child’s individual challenges may affect relationships with parents and siblings and vice versa.
  • Support for parents. Individual or group sessions that include training and the opportunity to talk with other parents can provide new strategies for supporting a child and managing difficult behavior in a positive way. The therapist can also coach parents on how to deal with schools.
  • To find information about treatment options for specific disorders, visit www.nimh.nih.gov/health/.
  • Choosing a Mental Health Professional

    It’s especially important to look for a child mental health professional who has training and experience treating the specific problems that your child is experiencing. Ask the following questions when meeting with prospective treatment providers:

    • Do you use treatment approaches that are supported by research?
    • Do you involve parents in the treatment? If so, how are parents involved?
    • Will there be homework between sessions?
    • How will progress from treatment be evaluated?
    • How soon can we expect to see progress?
    • How long should treatment last?

    Additional information related to identifying a qualified mental health professional and effective treatment options is available on the NIMH website at www.nimh.nih.gov/findhelp as well as through other organizations listed in the Resources section of this brochure.

    Working with the School

    If your child has behavioral or emotional challenges that interfere with his or her success in school, he or she may be able to benefit from plans or accommodations that are provided under laws originally enacted to prevent discrimination against children with disabilities. The health professionals who are caring for your child can help you communicate with the school. A first step may be to ask the school whether an individualized education program or a 504 plan is appropriate for your child. Accommodations might include simple measures such as providing a child with a tape recorder for taking notes, permitting flexibility with the amount of time allowed for tests, or adjusting seating in the classroom to reduce distraction. There are many sources of information on what schools can and, in some cases, must provide for children who would benefit from accommodations and how parents can request evaluation and services for their child:

    • There are Parent Training and Information Centers and Community Parent Resource Centers throughout the United States. The Center for Parent Information and Resources website lists centers in each state.
    • The U.S. Department of Education has detailed information on laws that establish mechanisms for providing children with accommodations tailored to their individual needs and aimed at helping them succeed in school. The ED also has a website on the Individuals with Disabilities Education Act, and the ED’s Office of Civil Rights has information on other federal laws that prohibit discrimination based on disability in public programs, such as schools.
    • Many of the organizations listed in this brochure as additional resources also offer information on working with schools as well as other more general information on disorders affecting children.

    Learn More

    Information on specific disorders is available on the NIMH website and in our publications and health information pages. The organizations below also have information on symptoms, treatments, and support for childhood mental disorders. Participating in voluntary groups can provide an avenue for connecting with other parents dealing with similar issues.

    Researchers continue to explore new means of treatment for childhood mental disorders; the “Join a Study” section below provides information on participating in clinical research.

    Resources

    Please Note: This resource list is provided for informational purposes only. It not comprehensive and does not constitute an endorsement by NIMH.

    The following organizations and agencies have information on mental health issues in children. Some offer guidance for working with schools and finding health professionals:

    • American Academy of Child and Adolescent Psychiatry. see Facts for Families on many topics
    • Association for Behavioral and Cognitive Therapies
    • Society for Clinical Child and Adolescent Psychology
    • EffectiveChildTherapy.org
    • Centers for Disease Control and Prevention. see the Children’s Mental Health page
    • Children and Adults with Attention Deficit/Hyperactivity Disorder
    • Depression and Bipolar Support Alliance
    • Interagency Autism Coordinating Committee. see these webpages on autism: Federal Agencies; Private and Non-Profit Organizations; and State Resources
    • International OCD Foundation
    • Mental Health America
    • National Alliance on Mental Illness
    • National Association of School Psychologists
    • National Federation of Families for Children’s Mental Health
    • Stopbullying.gov (https://www.stopbullying.gov/)
    • Substance Abuse and Mental Health Services Administration Behavioral Health Treatment Services Locator
    • Tourette Association of America

    Addressing Disorders Affecting Children

    The NIMH is conducting and supporting research that could help find new and improved ways to diagnose and treat mental disorders that occur in childhood. This research includes studies of risk factors, including those related to genetics and to experience and the environment, which may provide clues to how these disorders develop and how to identify them early. NIMH also supports efforts to develop and test new interventions, including behavioral, psychotherapeutic, and medication treatments. In addition to providing ways to diagnose and treat disorders in childhood, research can help determine whether beneficial effects of treatment in childhood continue into adolescence and adulthood.

    Participating in a Research Study for Children

    Children are not little adults, yet they are often given medicines and treatments that were only tested in adults. There is a lot of evidence that children’s developing brains and bodies can respond to medicines and treatments differently than how adults’ brains and bodies respond. The way to get the best treatments for children is through research designed specifically for them.

    NIMH supports a wide range of research, including clinical trials that look at new ways to prevent, detect, or treat diseases and conditions. During clinical trials on conditions affecting mental health, treatments being tested might be new behavioral treatments, new drugs or new combinations of drugs, or new approaches to enhance existing treatments. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individual participants may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

    Please Note: Decisions about whether to apply for a clinical trial and which ones are suited for your child are best made in collaboration with his or her licensed mental health professional. For more information on clinical research, visit NIH Clinical Research Trials and You: For Parents and Children.

    Finding a Clinical Study

    Researchers at the NIMH conduct research on numerous areas of study, including cognition, genetics, epidemiology, and psychiatry. These NIMH studies take place at the National Institutes of Health’s Clinical Center in Bethesda, Maryland, and require regular visits. To find studies for children and teens being conducted at NIMH, visit Join a Study: Children. You can find out whether a study would be appropriate for your child by talking with the contacts listed for each study.

    In addition to trials underway at NIMH, there are clinical trials testing mental health treatments that are being conducted across the United States and around the world. To find a clinical trial near you, you can visit ClinicalTrials.gov. This is a searchable registry and results database of federally and privately supported clinical trials. ClinicalTrials.gov gives you information about a trial’s purpose, who funds it, who may participate, locations, and phone numbers for more details. This information should be used in conjunction with advice from mental health professionals.

    Reprints

    This publication is in the public domain and may be reproduced or copied without permission from NIMH. Citation of NIMH as a source is appreciated. We encourage you to reproduce it and use it in your efforts to improve public health. However, using government materials inappropriately can raise legal or ethical concerns, so we ask you to use these guidelines:

    • NIMH does not endorse or recommend any commercial products, processes, or services, and our publications may not be used for advertising or endorsement purposes.
    • NIMH does not provide specific medical advice or treatment recommendations or referrals; our materials may not be used in a manner that has the appearance of providing such information.
    • NIMH requests that non-Federal organizations not alter our publications in ways that will jeopardize the integrity and “brand” when using the publication.
    • The addition of non-Federal Government logos and website links may not have the appearance of NIMH endorsement of any specific commercial products or services, or medical treatments or services.
    • Images used in publications are of models and are used for illustrative purposes only. Use of some images is restricted.

    If you have questions regarding these guidelines and use of NIMH publications, please contact the NIMH Information Resource Center at 1–866–615–6464 or e-mail [email protected]

    For More Information

    Mental Health Treatment Locator

    The Substance Abuse and Mental Health Services Administration (SAMHSA) provides this online resource for locating mental health treatment facilities and programs. The Mental Health Treatment Locator section of the Behavioral Health Treatment Services Locator lists facilities providing mental health services to persons with mental illness. Find a facility in your state at https://findtreatment.samhsa.gov/. For additional resources, visit https://www.nimh.nih.gov/findhelp.

    Questions to Ask Your Doctor

    Asking questions and providing information to your doctorealth care provider can improve your care. Talking with your doctor builds trust and leads to better results, quality, safety, and satisfaction. Visit the Agency for Healthcare Research and Quality website for tips at www.ahrq.gov/patients-consumers.

    National Institute of Mental Health
    Office of Science Policy, Planning, and Communications
    Science Writing, Press, and Dissemination Branch
    6001 Executive Boulevard
    Room 6200, MSC 9663
    Bethesda, MD 20892-9663
    Phone: 301–443–4513 or
    Toll-free: 1–866–615–NIMH (6464)
    TTY Toll-free: 1–866–415–8051
    Fax: 301–443–4279
    E-mail: [email protected]
    Website: www.nimh.nih.gov
    U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
    National Institutes of Health
    NIH Publication No. 18-4702
    Revised 2018

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