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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.
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.”
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
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.
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.
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.
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.
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.
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.
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
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
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.
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.
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.