Mental health and illness
Brass observation hole from St. Audry's Hospital, 1851-1900
Three psychiatric tests
Mental health and illness have never been the exclusive domain of medicine. The very idea of ‘mental illness’ raises many broad questions. What behaviour is ‘normal’? What is being ‘rational’? Opinions have always differed about the best way to define and treat mental health.
Many people today, including expert patients, view mental health as a biomedical issue. They choose to consult medical experts such as psychiatrists. Others see mental health problems as personal or interpersonal matters that should be ‘talked through’ in regular psychotherapy sessions. This may take the form of psychoanalysis, cognitive-behavioural therapy, group therapy or other methods. Some seek explanations beyond medicine. These include spirit possession, sin, and social injustice such as the legacy of genocide, enslavement or oppression. As a result, people may seek help through prayer, confession, spiritual guidance, exorcism, political activism, social change and creative expression.
These approaches are not separate and opposed. Few people are purists when confronted with a mental health problem. We mix and match approaches to make sense of what has happened to ourselves or a loved one. History shows people have always done this.
The term ‘mental health’ was popularised in the early 1900s by physicians, social reformers and former asylum patients. They wanted to reduce the stigma surrounding mental illness, and said ‘illness’ reinforced prejudices against asylum patients because it implied segregation between the sick and the well. Focusing on health countered a persistent misconception that only some people are prone to psychiatric problems.
Fighting stigma has gained an unexpected ally in recent decades: ‘Big Pharma’. Critics say large multinational pharmaceutical firms profit from expansion of the market for psychiatric drugs. Therefore any reduction of stigma leads to new customers. In response, some expert patients and psychiatrists argue the term ‘mental health’ is biased toward biomedicine and drug treatment. They prefer ‘mental distress’ instead.
There are good reasons to avoid outdated and stigmatised words such as ‘madness’. However, avoiding such terms in a historical account ignores the ways language changes. Labels also shape the experience of illness. ‘Madness’, ‘lunacy’ and ‘insanity’ were accepted medical usage even into the early 1900s. They were gradually displaced by ‘mental illness’, a term which first appeared in the 1847 novel Wuthering Heights. Other diagnostic terms such as hysteria, nervous breakdown, schizophrenia and depression slipped back and forth between medical and popular use. This again expresses the lesson that mental health and illness are not just in medicine’s domain. To completely avoid stigmatising terms would obscure this important point.
Possession and exorcism
Religion and humoral medicine in the European Middle Ages provided two contrasting but complementary understandings of ‘madness’. Christians believed people were occasionally possessed by demonic forces, which needed to be ritually exorcised by priests. Some deeply embedded demons, often in elderly or eccentric women, could only be driven out by torture or death.
The medical perspective viewed some cases of possession as naturally caused. The writing of ancient Greek physicians such as Galen and Arabic physicians such as Ibn Sina influenced medieval physicians. They argued excess bodily fluids such as black bile or choler were revealed in symptoms of hysteria, melancholia or mania. Medicine could not do much - nature and God’s will had to take its course.
The rise and fall of moral treatment
Christianity’s influence on mental health care remained dominant for centuries. For example, clergyman Francis Willis famously treated King George III. The York Retreat, founded by Quakers in the 1790s, was the most influential asylum of its time. It was one of the first private asylums to shun physical restraint and coercion. Its new methods, grounded more in religion than medicine, were called ‘moral treatment’, in deliberate contrast to ‘medical treatment’.
Asylums multiplied throughout Europe and North America in the 1800s and psychiatry became a recognised medical speciality. Scientific understanding of what physicians still called ‘lunacy’ had increased little since the 1600s, but medical men used the asylum boom to gain practical experience with patients. They drew on the increasing prestige of science and established themselves as publicly recognised experts on mental illness and its treatment. Critics argued asylum cure rates were exaggerated.
Many asylums were crowded, hopeless places by the early 1900s, increasingly separated from the outside world. These isolated institutions became testing grounds for controversial and dangerous treatments such as electroconvulsive therapy (ECT) and lobotomy. Such treatments helped some patients, but they reinforced the idea that asylums were places no-one wanted to end up. Asylums did not survive criticism in the 1970s from ex-patients, feminists and the antipsychiatry movement. Psychiatry’s focus has since moved from asylums to pharmaceuticals.
Optimists in the 1980s and 1990s hailed new technologies. These included specially targeted drugs like SSRIs, brain scanning techniques such as magnetic resonance imaging (MRI) and more consistent disease definitions in the Diagnostic and Statistical Manual (DSM). They were evidence to some that psychiatry had finally become based in hard, objective science. Critics argued such developments reflected the growing power of American psychiatry and Big Pharma, not scientific progress. Today public debates continue about the over-prescription of antidepressants such as Prozac and drugs to treat ADHD.
For those seeking biomedical solutions to mental distress, public debates surrounding psychiatry reflect its modest progression since the days of black bile. Rather than fuel debates about ‘progress’, this site offers a different interpretation. The story of psychiatry sketched here is of repeated but never quite successful campaigns to treat patterns of thinking and behaviour as medical problems. These repeated attempts raise important questions whose answers change over time. Who decides what counts as ‘troubling’ thinking? Where is the line between ‘normal’ behaviour and illness? What is meant by ‘medical’?
Related Themes and Topics
R Porter, Madness: A Brief History (Oxford: OUP, 2002)
D Peterson (ed.), A Mad People’s History of Madness (Pittsburgh, PA: University of Pittsburgh Press, 1982)
The name given to the medical practice that is based on the sciences of the body, such as physiology (the functioning of the body).
A mental disorder that has symptoms of delusions, hallucinations and a loss of a sense of self and relationship to the external world that lasts over a long period of time (more than six months).
A mental state associated with acute sadness. Activity can be decreased, especially interaction with others, and sleep, appetite, and concentration can also be disturbed.
Another word for yellow bile, one of the four humours - the fluids of the body whose balance was believed to be essential to well-being.
A category of mental illness from the Middle Ages to the 1800s. Melancholia expressed itself as dejection, anguish, sensations of mistrust, anxiety and trepidation with some hallucinations.
A category of mental illness from the Middle Ages to the 1800s. Those with mania experienced uncontrollability, euphoric highs and bouts of excessive energy.
A controversial surgical treatment to severe the nerves to the frontal lobe of the brain (responsible for attention, short-term memory and activities requiring planning and organization). It was used to treat severe mental illnesses but is now no longer used.
A behavioural disorder which begins in childhood. Symptoms include short attention span and impulsive tendencies, commonly but not always combined with hyperactivity.