Biomedicine and Health: Psychology and Psychiatry
Biomedicine and Health: Psychology and Psychiatry
Modern psychology and psychiatry rests on a long history of observation, experimentation, and evaluation of human behavior. The struggle societies face in determining the difference between aberrant and acceptable behavior, and applying explanations and sanctions for aberrant behavior, has been documented and studied since ancient times.
Ancient societies including the Egyptians and Greeks identified external and internal forces that triggered or caused deviant behavior; at the same time, other seemingly supernatural experiences such as dreams and hallucinations became, in some settings, accepted and honored. The idea that physical sensations could be connected to mental events (and vice versa), that consciousness could be identified, explored and studied, and that an entire scientific discipline could be devoted to the study of the mind and emotions emerged in the late 1800s and early 1900s in both Europe and the United States.
Historical Background and Scientific Foundations
Ancient societies, including the Egyptians, Greeks, Romans, and early Judaic culture, documented views on aberrant behavior and the treatment of individuals exhibiting deviant traits. Egyptians often honored dreams and dream interpretations. Judaic scripture specifies the root causes of mental illness. Many Greeks and Romans thought that interference from the gods created mental illness, but the Greek physicians Hippocrates of Cos (460–375 BC) and Galen of Pergamum (AD 129–c.216) took a different approach, claiming that aberrant behavior was a result of humoral imbalance rather than supernatural interference or moral failure. The Greek philosopher Plato (428–348 BC) believed mental illness was caused by an imbalance between the psyche and the body; the resulting loss of reason led to the aberrant behavior.
In Andean cultures, trepanning—surgical removal of a small section of the skull—was intended to release demons or supernatural forces that were thought to cause deviant behaviors. In addition to skulls from South America, archaeologists have found evidence of trepanning in Europe, North Africa, and some Polynesian societies as well.
The supernatural or religious interpretation of mental illness and associated behaviors is a thread that runs through most societies worldwide, persisting to the present day. Whether in China, Baghdad, ancient Babylon, among the Nazca in South America, or in medieval Western Europe, the belief that spirits or demons possessed the soul and/or body of an afflicted person shaped the treatment of the mentally ill.
In Europe and the Middle East, this involved a wide range of approaches, from isolation, banishment, bloodletting, purging, and physical torture to the use of calming baths, aromatherapy, purification rituals, and sedation. Some European monasteries became mental illness treatment centers, while eighth- and ninth-century Damascus and Baghdad were known for their creation of calm environments to treat deviant behavior at institutions such as the Baghdad Hospital.
Italian theologian St. Thomas Aquinas's (1224–1274) concept of the separation of mind and soul and his assertion that the soul could not be sick altered church thinking on mental illness. If the soul could not be ill, Aquinas argued, then mental illness was a physical construct, a result of too little reason caused by too much passion.
Mental illness as a medical construct emerged in western civilization by the twelfth century in Europe, when centers for isolation and treatment of mental illness were established. The Bethlem (pronounced “Bedlam”) Royal Hospital was built in 1247 in London and accepted mentally ill patients by the fifteenth century. Multiple explanations for deviant behavior fed differing approaches; where church officials often saw demonic possession, peasants might see witchcraft and medical personnel might work to restore “humoral balance” in line with Hippocrates's and Galen's writings, an idea that persisted for nearly a millennium.
Religious explanations for deviant behavior dominated Western thought for centuries. While Aquinas struggled to reconcile mental illness within a religious framework, the average person viewed aberrant behavior as a choice, or even as a byproduct of supernatural possession. As towns grew and urbanization increased, church and municipal authorities began to create institutions to serve the mentally ill, the poor, and the sick. These early versions of hospitals and social service centers were concerned more with containment than treatment; many shackled or caged the inmates in an effort simply to separate them from society.
Renaissance and Enlightenment thinkers contributed to increasing secularization and a reliance on reason over faith; the view of mental illness as a push-pull between God's will and the devil's work or witchcraft was replaced with a more philosophical view of mental illness as an outgrowth of emotional conflict. This change in approach to the cause of deviant behavior did not change treatment approaches, but the broader view of the mind's processes in conjunction with external stimuli, personal consciousness, and faith slowly altered society's view of normal and abnormal psychology.
By the 1700s reform efforts in Europe and the United States produced a more medical approach to treating the mentally ill. The Pennsylvania Hospital in Philadelphia accepted patients with mental illness as early as 1752, and the first asylum for the mentally ill was built in 1773 in Virginia. In Vienna, the Narrenturm was built in 1784 to house the mentally ill exclusively. Reform movements sought to separate them from the poor and the sick.
The term “psychiatry” was first used in 1808 by German physician Johann Reil (1759–1813). “Psychology” was probably first coined by German theologian Philipp Melanchthon (1497–1560) in the mid-sixteenth century, from the Greek psychke, meaning “breath” or “spirit,” and logia, “study of”; its first modern usage, meaning “study of the mind” seems to have appeared in German philosopher and scientist Christian Wolff's Psychologia empirica (1732).
England's 1828 Madhouse Act allowed for the creation of mental asylums across the country, but many patients still lived in unsanitary conditions, were fed poor-quality food, and were restrained with chains and other devices; conditions in the United States were similar. Social concern over proper treatment and care of the mentally ill was not a priority until reform and education movements began in the 1840s. These had limited success, with reformers such as British physician Robert Gardiner Hill (1811–1878), American reformer Dorothea Dix (1802–1887) and mental patient Clifford Beers (1876–1943) pushing for humane treatment in asylums.
“Moral Treatment,” a regimen consisting of removal from family, calm surroundings, decreased exposure to stimuli, and a highly rigid schedule and structured life, formed in part as an outgrowth of new theories about the mind's processes and self-expression. The idea that patients could strengthen their internal control and thought processes thorough an emotionally and psychologically healthy environment drove this method; therapeutic asylums sought to provide serene environments to aid the mentally ill in self-control.
German psychologist Wilhelm Wundt (1832–1920) opened the first psychology laboratory in 1879 in Leipzig, Germany, while in 1890 William James (1842–1910), a professor of physiology at Harvard, published a two-volume work on the emerging field, Principles of Psychology. James, a professor of physiology, anatomy, philosophy, and psychology at various times during his career, posited the functional perspective: Consciousness serves a specific, organizing function to create order from the stream of thoughts, sensations, and ideas that fill the mind. The value of a specific experience or thought is related to its utility; the mind interprets based on its practicality or application in the person's life according to James' positivist approach. James believed that in addition to the conscious mind, which applied pragmatism, there was also a subconscious mind.
James's and Wundt's contemporary, Austrian neurologist Sigmund Freud (1856–1939), expanded the concept of the unconscious into a theory of the mind that viewed interpretation as a key to solving emotional conflict and mental illness. The unconscious mind, according to Freud, was at the heart of conflict that fostered aberrant behavior and insanity. This interpretation, called psychoanalysis, used talk therapy to help patients unearth repressive thoughts and understand destructive behaviors by unlocking the subconscious. Bringing unconscious thoughts into the conscious mind and discussing them with a trained therapist, Freud posited, would end the patient's internal conflict and resolve mental illness.
Freud's theory of the unconscious took positivism and pragmatism and argued that although patients could take personal experience and use it to exercise control over thoughts and emotions, the subconscious mind drove internal conflict, a view that James also espoused in his Principles of Psychology. Freud viewed dreams as the gateway to the unconscious mind, and dream interpretation became a cornerstone of his theory.
By the 1910s a competing theory, behaviorism, cast psychology as a hard science, one that studies behavior to understand the patient's condition, rather than interpreting unconscious conflict. American psychologists John Watson (1878–1958) and B.F. Skinner (1904–1990) were founders of this school of psychology. Psychiatrists used both behavioral therapy techniques and psychoanalysis to treat patients; as psychopharmacology and the use of drugs to alter psychological conditions gained acceptance in the 1950s, the use of drugs to control aberrant behavior became increasingly popular.
At this time lobotomies and electroconvulsive therapy were developed as treatments for mental illness, especially schizophrenia, mania, and severe depression. In the mid-1930s the lobotomy, or prefrontal leukotomy, was pioneered as a surgical remedy for the most seriously disturbed patients by Portuguese neurologist António Egas Moniz (1874–1955), who won a Nobel Prize in 1949 for its development. The procedure, which severs neural pathways and destroys tissue in the prefrontal cortex, was further refined by British psychiatrists, including Eric Cunningham Dax (1908–).
In the United States the lobotomy was popularized and simplified by the physician and self-styled neurologist and psychiatrist Walter Freeman (1895–1972). More than 40,000 were performed from the 1920s through the 1950s, many of them, critics charged, as a brutal form of control for minorities and unruly patients, not as a last resort for suffering patients. By the 1970s many countries banned the surgery, deeming it helpful only in extreme cases. The U.S. National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research came to the same conclusion in 1977. By the end of the decade the procedure had essentially been abandoned, although a few are still performed each year.
Electroconvulsive or electroshock therapy was first administered in Rome in 1938 by neurologist Ugo Cerletti (1877–1963) and psychiatrist Lucio Bini (1908–1964) as a treatment for severely depressed, schizophrenic, and disturbed patients. The procedure uses electrodes to pass alternating current through the brain, causing an immediate loss of consciousness and triggering a convulsive seizure. Repeated treatments seemed to relieve symptoms, although patients often experienced memory loss and some confusion.
Both electroconvulsive therapy and lobotomies declined with the advent of antipsychotic or neuroleptic drugs, which effectively calmed the severe agitation of schizophrenia. The first of these was chlorpromazine, trademarked as Thorazine; this drug tranquilized patients exhibiting violent behaviors and led to a reduction in the use of restraints in institutions. Following Thorazine's introduction in 1955, other antipsychotic and, later, antidepressant drugs developed and prescribed by psychiatrists and family physicians alike for patients exhibiting psychosis, depression, and anxiety.
Institutionalization rates declined dramatically from the mid-1950s in Europe and the United States; in the early 1960s new laws restricting involuntary committal also reduced patient numbers. Psychologists and psychiatrists shifted to community-based care and psychopharmacology to meet the new social standards in care for the mentally ill. In the 1980s a new form of antidepressant, the selective serotonin reuptake inhibitor (SSRI) gradually replaced long-term psychoanalysis; changes in advertising allowed pharmaceutical companies to advertise SSRIs directly to the public, driving demand.
Modern Cultural Connections
The idea of mental illness as a spiritual or religious manifestation has largely yielded to a medical model, in which aberrant behavior is explained by inherited conditions, external stimuli, or organic causes. In recent years, as the fields focus on pharmaceuticals, many psychiatrists have moved away from their roles in talk therapy and toward a drug-based approach to mental illness; licensed psychologists work in concert with psychiatrists when managing patients who require both approaches. Critics of the intense reliance on pharmaceuticals point to the lack of social support and cognitive approaches to treating mental illness.
Media depictions of mental illness in the mid-1950s included such movies as The Snake Pit and The Three Faces of Eve, showcasing women in chaotic, malevolent asylums or as psychotic victims of mental illness in need of extreme interventions. By the 1960s and 1970s movies and books such as One Flew Over the Cuckoo's Nest, I Never Promised You a Rose Garden, and David and Lisa explored the conflict between mental illness and society, questioning the definition of “deviant” or “abnormal” psychology.
Freudian terminology has become part of everyday speech; many of his constructs, such as the Oedipal complex or symbol interpretation, are a staple of literary studies and popular culture. While Freud's traditional psychoanalysis as a resolution for mental illness is practiced by only a small number of psychologists and psychiatrists, many elements of the process endure in modern practice.
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Melanie Barton Zoltán