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The Mentally Ill
The Mentally Ill in America:
A Quest for the Perfect Treatment
Liz Spaulding
Choate Rosemary Hall
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The Mentally Ill
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The Mentally Ill in America:
A Quest for the Perfect Treatment
With any illness, the perceived cause determines the method of treatment. From a
historical viewpoint, mental illness is no different. At times neglectful, often well-intended, and
usually detrimental, the array of treatments offered for mental illness throughout the past three
centuries reflects the changing view of the scientific and social community on their mentally ill.
According to writer Gerald Grob (1984), a professor at Rutgers University, throughout the history
of America, there has clearly been a cyclical pattern that has alternated back and forth between
“enthusiastic optimism and fatalistic pessimism” in America’s attitudes towards the treatment of
the mentally ill. (Grob, 1984, p. 3) The various reform periods that have taken place in the past
three centuries—for example, Benjamin Rush’s scientific reform of treatment for the mentally
diseased, Dorothea Lynde Dix’s “moral” reform in the mid 1800s, and the mental hygiene
movement at the outset of the 20th century— are similar in that they were launched with little
appreciation of practical limits. When the general public eventually realized that the hopeful
expectations of American society had failed to be brought to fruition (not surprising when
considering the public’s ceaseless reluctance to allocate funds) there has always followed a period
of pessimism, retrenchment and neglect. Treatment for the mentally ill has come a long way in
the United States since the birth of the nation, a pathway that has been sadly marred by false
prejudices, constant neglect, and often brutal treatments.
Organized treatment of the mentally ill dates all the way back to Ancient Greece, whose
society believed mental illness was caused either by divine or demoniacal possession. In fact, a
popular Greek saying was “whom the gods would destroy, they first make mad,” exemplifying
how many Grecians believed, as well as Europeans, Romans, and future colonial Americans, that
mental illness was a punishment for ones’ sins. (Deutsch, 1967, p. 5) In Ancient times, the poor
mentally ill were often put to death, while treatment for the affluent mentally ill ranged from
herbs and ointments to incantations delivered by a priest; conveniently, the patients who did not
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respond successfully to priestly invocations were simply deemed “unworthy” of cure, and
consequently unceremoniously cast out of the temple. However, Hippocrates in the 4th century
B.C. laid a new basis for rational and scientific treatment of diseases, explaining mental illness
according to humoral pathology. Hippocrates’ pathology, along with his novel treatments such as
purging and blood-letting, would experience immense popularity centuries later as the American
nation came into existence. It is important to note that the strange and seemingly cruel nature of
many treatments administered in the U.S. over the past three centuries is not solely an American
phenomenon; violent beatings, starvation, and diets consisting solely of the “liver of a vulture or
the gall still warm from a dog” (concocted by Peter of Spain, a prominent physician in the 13th
century) were popular treatments for the mentally ill throughout medieval Europe. (Deutsch,
1967, p. 13) Even in the late 18th century, the inmates of Paris’ most famous asylum, the Bicetre,
were repeatedly whipped, utterly neglected, and had the “appearance of wild animals—beards
and hair matted with straw and infested with lice; tattered cloths, nails grown long like claws,
bodies encrusted with dirt and filth” (Deutsch, 1967, p. 90).
However, colonial America witnessed an even harsher and more ignorant attitude
towards the mentally ill than the centuries that preceded it. Handicapped by isolation and a lack
of knowledge, Americans in the 18th century had virtually no opportunity to study medicine. In
fact, treatment for the sick was often administered by the community’s clergymen, barbers, or
plantation owners. Even the treatment administered by physicians was questionable; the common
cure for epilepsy prescribed by virtually any colonial physician were pulverized human hearts and
human blood. (Deutsch, 1967, p. 27) Demoniacal possession still remained the most widespread
explanation for mental disease. And since many forms of mental illness came hand in hand with
hallucinations, many colonial Americans then perceived the patient to be inflicted by witchcraft
or Satan. This “supernatural” frenzy came to its apogee in the famous Salem witchcraft mania of
1692. Whatever the exact cause, mainstream society in colonial America believed the sufferings
of the handicapped were due to the fact that they were wicked and innately inferior; therefore,
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treatment in any form was rare, seen as something the mentally ill simply did not deserve. In fact,
the mentally ill were usually treated as if they were homeless peasants, until of course their
condition became a social danger or public nuisance. Their fate from them on was virtually
always a city jail or the gallows. Other times, the insane were driven out of their community by a
group of townspeople in the middle of the night, to diminish any chance that that person would
become a public charge in the future. Another popular method of caring for the dependent insane
was granting an individual lump sum for assuming permanent responsibility for a particular
person afflicted by mental illness. This method of disposal mirrored the selling of slaves off the
chattel block; only now, the person up for sale would be sold not to the highest but the lowest
bidder. In a time when public treatment was virtually non-existent, well-to-do families often took
advantage of private home care. However, such care did not always mean better treatment; in
many cases, the mentally ill were placed in kennel-like cages behind the family’s house. Though
colonial America was inarguably a very dark time in the treatment of the mentally ill, things
began to look up when the nation’s first mental asylum was established in 1773.
At the turn of the nineteenth century, political and social revolutions in American and
France acted as liberating agents for the reform movement of treating the mentally ill. This
reform came at a convenient time, for huge population growth in the United States meant care on
a case-by-case basis was no longer possible. Much of the reform was led by Quakers, who
believed in the “natural rights” of man, as well as evangelical Protestants who preached that
humans could be perfected by manipulating their social and physical environments. However,
though this period in America did encompass the creation of the first public institutions looking
to treat the mentally ill rather than lock them up, the majority of the mentally ill were placed in
almshouses and workhouses. Even those “lucky” enough to be placed in a hospital devoted solely
to caring for the mentally ill often received appalling treatment. The first institution where cure
was the main objective (revealing a shift from “asylum” to “hospital”) was the Pennsylvania
hospital, founded by Benjamin Franklin and Thomas Bond in 1773. Though treatments
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administered in this hospital were indeed intended to help, they also were often misguided,
proving that a new and improved outlook on treatment didn’t necessarily mean better results.
Patients were often bled to the point of syncope, purged until they vomited mucus, and chained
by waste or ankle to a cell wall and forced to wear “Madd-shirts”, or straitcoats. Such treatment
strangely harkened back to the same treatment mentally ill had received in prisons the century
before. In fact, many 19th century hospitals actually put the mentally ill up for exhibition to the
general public for an admission fee, a practice that was continued all the way up to 1822. Though
this was actually an attempt to decrease the amount of people who came to the first floor
windows of patients to “tease the crazy people” into a raving fury, (Deutsch, 1967, p. 64) the
practice of charging admission fees was clearly inhumane.
Several people during this time period had a profound impact on improving the treatment
of the mentally ill. Two influential English physicians, Philippe Pinel and William Tuke, shifted
the focus of treatment away from the ignorant attitudes of the past by approaching mental illness
from a medical-psychological rather than a theological standpoint. In 1815, Thomas Eddy, a
Quaker merchant who desired to build a new building in New York for the insane, was the first to
call attention to the necessity for keeping case histories (up to that point, many institutions had no
records of patients who had stayed there, or even died there). Benjamin Rush was another
important leader of this scientific reform, for he was the first American physician to attempt an
original systemization of the treatment of the mentally ill. Rush also emphasized the importance
of treatment patients with both kindness and honesty, and spurred the movement within the
scientific community to now explain “madness” as an arterial disease, most notably involving the
blood vessels located in the brain. Two of his inventions gained immense popularity with his
contemporaries; the first was the “tranquilizer”, a chair to which the patient was strapped by the
head and foot to reduce muscular action and thereby the pulse, while the second was the
“gyrator,” a rotating board to which patients were strapped so that blood would rush to the head.
(Whitaker, 2002, p. 15) It is important to remember that while these remedies may seem not both
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cruel and ridiculous to us now, they were administered with an unwavering belief that they were
both effective and humane. Another popular contraption for treating the mentally ill during the
time was a coffin-like box pierced with holes, in which the patient was placed. The box was then
lowered into the water, removed only when air bubbles ceased to rise, at which point the patient
was taken out, rubbed, and (hopefully) revived. Clearly, the reality of the matter was often dark,
but it cannot be argued that America in the beginning of the 19th century began to propel itself
towards attempting to provide sufficient care for the mentally ill.
However, while men such as Pinel, Tuke and Rush did supply a theoretical and practical
groundwork for reform, their small-scale experiments actually remained isolated among a wider
sphere of stagnancy and even retrogression. By 1825, eight different states had separate asylums
for the mentally ill, but such buildings still could only hold a small fraction of the total population
of the mentally ill. Poorhouses continued to draw from all dependent classes (a huge percentage
of which were the mentally ill) like magnets, and the incurable were often excluded from the
benefits of hospital treatment. Though Rush had made an attempt at classification of the various
types of mental illness, they were still mainly divided into two categories; the “dangerous and
violent” (often treated no differently than criminals) and the “harmless and mild” (who often were
treated simply as paupers). The practice of selling the mentally ill on the auction block had not
disappeared, and prospects for progression looked doubtful.
But in 1841, a woman named Dorothea Dix brought a ray of hope back into the reform
sphere. If Benjamin Rush was the “scientific” reformer of the 1700s, Dix could be labeled the
“moral reformer” of the 1800s. Acting as a spokesperson and lobbyist for construction and
expansion of public asylums, she helped reveal the horrendous conditions of mental hospitals to
the American public. Upon her first visit to a mental hospital in 1841, Dix found innocent patients
locked up in cells in the dead of winter, “huddled in their unheated cells, the cold piercing them
like knives.” (Deutsch, 1967, p. 159) In fact, a common belief of the time period was that the
mentally ill were insensible to extreme cold and heat. Due to reformers like Dix, the reform of the
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treatment for the mentally ill gained the title “Cult of Curability,” referring to the optimistic view
of 1940’s society that 90% of insanity was curable, overriding the previous belief that treatment
was a futile route to take. Mental asylums began to see a decrease in both chemical restraint as
well as the use of opium and other narcotics to pacify the disturbed. The nation also experienced a
shift from large asylums and hospitals towards the “cottage system,” referring to the grouping of
small buildings around a central administrative building. This set-up not only allowed for the
classification and separation of the different forms of mental illness, but provided more privacy
and less monotony. For the first time in American history, many hospitals enforced the
repudiation of all threats of physical violence (handcuffs, straitjackets, leg locks, etc.) replacing
such restraint with more humane treatments like occupational therapy, religious exercises, and
simple kindness. However, though this notion fueled a new generation of humanitarian zeal,
progressive ideals once again were simply not implemented successfully; merely labeling a
building a “Curative Hospital for the Insane” does not mean that patients will suddenly and
miraculously heal. And due to social trends of the time such as industrialization, urbanization,
and the huge influx of impoverished immigrants in the mid-century, public mental hospitals
morphed from small, therapeutic asylums to large, custodial institutions. Taxpayers did not want
to pay the extra money for the cottage system set-up, and severe overcrowding left medical
superintendents with duties far overreaching their capabilities. Overworked and exhausted, actual
curative treatment was the last thing on their minds. The overcrowding subsequently caused cure
rates to drop precipitously, and optimism regarding the possibility of cure once again began to
wane.
The arrival of the 20th century did nothing to lessen this pessimistic attitude. Though
there were some memorable exposes revealing asylum conditions in the early 1900s (most
notably Beers’ novel “A Mind that Found Itself”, describing how during his stay in a mental
asylum he was beaten mercilessly, choked, spat on, and forced to wear a straitjacket for 21
consecutive nights) the general public still believed that mental illness was less a disease than it
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was a family disgrace or punishment for sin. However, the mental hygiene movement that began
in the 1920s made great strides in science, consequently having a positive impact on methods of
treatment. The general community was finally focusing on the fact that insanity was a brain
disease, using improved microscopes to map out the brain and locate its motor areas. And the
classification of mental diseases was finally being determined not by their symptoms but their
causes; therefore, a disease that had alternating symptoms of melancholia and mania (such as
schizophrenia) was now labeled as one disease, not two. In 1928, the American Foundation for
Mental Hygiene was formed, and in 1930 the first International Congress on Mental Hygiene was
founded by Charles Beers. The dream of a world-wide movement on behalf on the mentally ill
had finally come true. Freud also had an impact on the movement, with his system of
psychoanalysis and replacement of hypnosis with “free association” influencing both the study
and treatment of mental disorders. “Fever therapy” also came into widespread practice, referring
to the injection of bacteria such as malaria to cure paralysis. Just like in the past, this mental
hygiene movement was short-lived, and another period of pessimism set into the American
public.
The first half of the 20th century is often referred to as the Dark Ages in the state care of
the mentally ill. Though turn-of-the-century reformers like Adolph Meyer and William James did
make great contributions to treatment, they were unable to cure chronic mental illness, causing
the general public to once again fall into pessimism (Morrissey, 1986, p. 18) As state asylums
continued to fill with lower class patients, well-to-do families began to seek private treatment,
causing a two-class system to emerge. The notion of “once insane, always insane” once more cast
a shadow upon the hope for improved treatment, and the mentally ill again became seen as
parasites on the social environment that needed to be either destroyed or isolated to protect
mainstream society. One contributing factor included the invention of the intelligence test in 1905
by Alfred Binet. (Myers, 2007, p. 443) By 1910 the mentally defective had a clear definition:
“idiots” had a mental age up to two years, “imbeciles” had a mental age of three to seven years,
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and “morons” had a mental age of eight to twelve years. (Kuhlmann, 1916, p. 211) Also, the
eugenics movement acted as a further detriment to improving care for the mentally ill. The belief
that fired this movement was that mental illness was 90% attributable to heredity, convincing
people that a cure was impossible and that the mentally diseased should simply be removed from
society. Discrimination became so fervent that sterilization laws came into effect, lasting well
into the fifties; by 1955, eugenic sterilization still existed in twenty eight states. (Deutsch, 1967,
p. 271)
The Great Depression acted as a further detriment to the mental healthcare movement as
standards for mental hospitals dropped enormously. By the 1930s, a fourth of state hospitals had
closed, while virtually all those that remained were severely overcrowded. As it became harder
for attendants to control an immense amount of patients, ways of beating patients without leaving
visible bruising began to surface. Methods included “wet toweling,” or the choking of the patient
to unconsciousness by tightening a wet towel around his neck, and “soaping a man down,” the
name given to the practice of beating a patient with a bar of soap placed in the toe of a sock.
(Whitaker, 2002, p. 69) The most popular treatment of the time period included insulin coma,
electroshock, and trepanning (the drilling of holes in the scalp), whose brutality harkened back to
the dark Colonial era. Ovariectomies were even performed as a method the “heal” insane females.
Hydrotherapy was also mainstreamed into care for the mentally ill, referring to the strapping of a
patient into a hammock suspended over a bathtub and covered by a canvas sheet with a hole for
the head. The patient was at times kept in this “prolonged bath” for days on end, often submersed
in freezing cold water (according to author Robert Whitaker, physicians believed the water bath
caused “physiological fatigue without the sacrifice of mental capacity”). (Whitaker, 2002, p. 76)
Many of the horrible treatments described here were simply methods to weaken and quiet the
patients, a reaction that somehow deemed the treatment successful. And of course, rarely did any
physician conclude that his own novel therapy, no matter how inhumane or ineffective, provided
no beneficial treatment, resulting in a few years of widespread enthusiasm for his creation, no
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matter how atrocious it was. After the case of Phineas Gage made headline news (Gage was a
patient whose traumatic brain injury negatively affected his emotional and personal traits),
prefrontal lobotomy gained huge popularity. It was only until years later that clinical reports
finally revealed that the procedure actually caused many intellectual and emotional deficits (not
surprising, since this was the effect that meddling with the frontal lobe had on Gage). Though one
bright spot during the Great Depression was Roosevelt’s Public Works Administration, a federal
organization that allocated funds for state hospital projects, it had little impact on the whole of
society. Institutions were further depleted of professional personnel during the second World
War. However, the war did spark new interest in mental illness as scientists searched for new
methods (most notably psychotropic medications) to treat “war neurosis” in young American
soldiers. However, regardless of a few small gains, the mid-20th century was an overall dark time
for the mentally ills’ treatment.
The final American movement in the treatment of the mentally ill can arguably be labeled
a period of “deinstitutionalization”. As a result of the overcrowding during the first half of the
20th century, the family care system emerged, advocating that in a home environment the
mentally ill would have more personalized care and more freedom, while the patients remaining
in hospitals would receive more effective treatment. Mental hospitals throughout the 1960s
continued to lower admissions rate and emphasize shorter and shorter lengths of stay. The fiscal
crises of the 1970s put further pressure on the federal government to continue the phase-down of
state institutions. While it is true that between 1955 and 1980, the population of state mental
hospitals was reduced by more than 75%, (Morrissey, 1986, p. 21) this cannot be seen as a
triumph in the eyes of deinstitutionalization advocates. Local communities were simply
unprepared for the influx of thousands of former patients, resulting in feelings of hostility and
rejection. Tens of thousands ended up in rooming houses, foster homes, nursing homes, and on
the streets, supporting the notion that what was labeled deinstitutionalization was merely a Bandaid for the real trans-institutionalization that was occurring. The explosive growth of urban
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homelessness since the 1970s seems to be greatly attributable to the deinstitutionalization
movement of the late 20th century.
The 1970s were a time of drug experimentation, a movement whose effects resounded on
the care of the mentally ill. Thorazine was the first “antipsychotic” medication released on the
U.S. market, and medicinal treatment for mental illness skyrocketed. Since many patients refused
to take the drugs, they were often tricked into consuming a liquid, odorless form unknowingly
mixed into their food or being held down and injected with the drug. Fortunately, the LSD and
mescaline injections that acted as popular treatment methods in the sixties finally lost their allure
as scientists finally realized the visual hallucinations they provoked did not mirror a model
psychosis seen in mentally ill patients. However, many patients began to be injected with
dopamine, since it was believed psychosis was caused by an overactive dopamine system.
Scientists theorized and wanted to test their premise that injected dopamine would make the
already severely mentally ill subsequently worse, an example of how the mentally ill have often
(and quite regrettably) been used as guinea pigs in research experiments over the course of
American history.
As we move into today’s times, we can by no means say the care for the mentally ill has
finally been perfected, but strides forward have been made. The knowledge regarding how to
effectively treat and care for the mentally ill has increased immensely, and researchers in the
1990s finally revealed to the public that neuroleptics, the medicine being fed to the mentally ill
for the past four decades, didn’t actually control delusions and hallucinations as well as doctors
had believed. (Whitaker, 2002, p. 256) Though modern American culture has finally begun to
view the improvement of the treatment of mental disease as an important social objective, there is
a downside to this hype. The scientific world is now developing drugs said to cure those at risk
for illnesses like schizophrenia, while others serve to cure emotional and behavioral disorders
feared to turn into full-blown mental disorders—often, in children as young as two years old.
(Whitaker, 2002, p. 286) Though America has unquestionably made immense strides towards the
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acceptance of their society’s mentally ill, only when we have successfully cleared the remaining
stigmas can we finally accomplish our quest for the perfect treatment.
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BIBLIOGRAPHY
Anderson, E (1984). A family impact analysis: The deinstitutionalization of the mentally ill.
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Deutsch, A (1967). The mentally ill in America: A history of their care and treatment from
Colonial times. New York, NY: Columbia University Press.
Grob, G (1984). The mad among us: A history of the care of america's mentally ill. NY: The Free
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Grumet, B (1985). The changing role of the federal and state courts in safeguarding the rights of
the mentally disabled. Publius, 15, 67-80.
Kuhlmann, F (1916) Distribution of the Feeble-Minded in Society. Journal of the American
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Political and Social Science. 484, 12-27.
Myers, D. G. (2007). Psychology. New York: Worth Publishers.
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mistreatment of the mentally ill. Cambridge, MA: Perseus Publishing.