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The Mentally Ill The Mentally Ill in America: A Quest for the Perfect Treatment Liz Spaulding Choate Rosemary Hall 1 The Mentally Ill 2 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 The Mentally Ill 3 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, The Mentally Ill 4 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 The Mentally Ill 5 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 The Mentally Ill 6 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 The Mentally Ill 7 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 The Mentally Ill 8 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, The Mentally Ill 9 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 The Mentally Ill 10 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 The Mentally Ill 11 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 The Mentally Ill 12 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. The Mentally Ill 13 BIBLIOGRAPHY Anderson, E (1984). A family impact analysis: The deinstitutionalization of the mentally ill. Family Relations. 33, 41-46. Associated Press. (1955). More or less shock?. The Science News-Letter. 67, 325. 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 Press. 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 Institute of Criminal Law and Criminology. 7, 205-218 Morrissey, J. P., & Goldman, H. H. (1986). Care and treatment of the mentally ill in the United States: Historical developments and reforms. Annals of the American Academy of Political and Social Science. 484, 12-27. Myers, D. G. (2007). Psychology. New York: Worth Publishers. Whitaker, Robert (2002). Mad in America: Bad science, bad medicine and the enduring mistreatment of the mentally ill. Cambridge, MA: Perseus Publishing.