Signs of Stress

The Social Problems of Psychiatric Illness

J. Wallace McCulloch, Malcolm McCulloch, Herschel A. Prins

• Publisher: Routledge
• Year: 2005
• Print ISBN: 9781138420885
• eBook ISBN: 9781135784157
• Topic: Education
• Subtopic: Education General

First Published in 1978. One of the questions constantly being asked of a psychiatrist is, 'Are mental illnesses on the increase?' A second is, 'Do you think the stress of modern living is responsible for the increase in mental illness?' This book, which is one of a series on psychiatric illness, takes a cool but compassionate look at the whole field of psychiatric disorder and, in the process, rips away some of the veils of obscurity surrounding it. The series is not primarily designed for medical men, rather, it is designed for the concerned layman—a very wide term. It has been authoritatively calculated that one person in ten in the United Kingdom will enter hospital at some time in life with a predominantly psychological problem, and one in four will consult a doctor at some stage with such a condition.

I
Possession—containment—tolerance?

ancient times

In this chapter some account will be given of the history of the treatment of the mentally ill and of public attitudes that have influenced such treatment. There are available references to the treatment of persons we would describe today as mentally ill and of the manifestations of mental illness from very early times. An ancient Egyptian papyrus (circa 1500 BC) describes senility in the following brief, but accurate terms: ‘The heart grows heavy and remembers not yesterday.’ In this description we have two of the components of senile illness, namely the wasting physical process of old age, and the psychological component of memory loss. The ‘shamans’ (priests-cum-magicians) of early cultures used a process known as trephining (making small holes in the skull) to let out the devil spirits of those thought to be possessed. It is interesting to compare this ancient practice with the modern surgical treatment of some forms of mental disorder, in which fine probes are inserted in the frontal part of the skull. There are many references to the use of drugs for the treatment of mental illness in ancient times, for example Hellebore, which had been found useful in curing certain diseases in goats. The family too, was reminded of its responsibilities. Thus in Plato's Republic, we find the following comments. ‘If anyone is insane, let him not be seen S.S. B openly in the city, but, let the relations of such a person watch over him in the best manner they know of, and if they are negligent, let them pay a fine.’

There are numerous references in the Bible to various aspects of behaviour associated with mental illness and to mental illness itself. For instance, there are six reported cases of actual or attempted suicide in the Old and New Testaments (three such examples being Saul, Ahitopel and Judas Iscariot).

Such behaviour was viewed with very mixed feelings. If indulged in on the battlefield to avoid capture, it was considered acceptable, but if indulged in for other reasons, the biblical commentators of the time seem to have been less generous. Thus, in the works of Josephus (first century AD) we find the statement—‘for those who have laid hands upon themselves, the darker regions of the netherworld receive their souls.’

The periodic illness of King Saul is often mentioned as being one of the first accounts we have of what would today be described as ‘a depressive illness.’ Thus, in the first book of Samuel, we find the statement—‘And when it came to pass, when the evil spirit from God was upon Saul, that David took his harp, and played with his hand; so Saul was refreshed and was well, and the evil spirit departed from him.’ Though this is usually taken as an indication of depressive illness (and incidentally evidence of the early use of music as a form of therapy—a subject to which we will return later in this chapter), reference to Saul's illness in a later chapter of the Book of Samuel makes one wonder if it had some of the qualities of over-suspiciousness akin to what is today described as paranoia ‘And it came to pass on the morrow, that the evil spirit from God came upon Saul… and David played with his hand as at other times, and there was a javelin in Saul's hand…and Saul cast the javelin; for he said, I will smite David even unto the wall with it…’

We read of King Nebuchadnezzer, wandering in his delirium, in which he believed himself to be changed into an animal—‘He did eat grass like an ox, and his body was wet with the dew of heaven, till his hairs grew like the feathers of eagles, and his nails like birds' claws.’

So much then for these brief biblical allusions. We must now turn to the contributions of some of the early men of medicine. Of these, Hippocrates (circa 460 BC) is important, in that he made a special contribution to the study of psychological disorders. There were three main aspects of his work in this field. First, he recognised the importance of the brain as an organ of mind. Secondly, he sought a more rational (that is, physiological) explanation of the various temperaments, moods and emotional disorders he encountered in his patients, and endeavoured to make connections between physiological and psychological relationships. Thirdly, he attacked vigorously the conception of divinely ordained, and therefore unalterable illness. A good example of this was epilepsy, which was known for long as the ‘sacred’ disease. ‘You will see,’ he said, ‘on examination of the brains of epileptic patients—that it is not God which injures the body but disease.’ Needless to say, his teachings which tried to rescue medicine from the arena of mysticism were not at all well received (D.Stafford Clark). A number of other early physicians also made important contributions to the study of mental illness. Aesclepiades was a very shrewd clinical observer, and was, for his time, humane. He recommended music as a form of sedation (see above also), warm baths, soft hammocks and light. ‘Patients should be kept in well-lighted places; darkness leads to terror, and terror increases the misery of madness.’

Celsus was what we would describe today as a medical journalist. It is of interest to note how many of these early workers in the field of mental disorder appear to have been ‘laymen’ and not strictly physicians as then known. Perhaps they were the precursors of modern developments in psychiatry, in which laymen (in the sense of not being medical personnel) have been increasingly involved. Celsus wrote of the manic patient: ‘When he has said or done anything wrong, he must be chastised by hunger, chains and fetters…it is also beneficial in this malady to make use of sudden fright, for a change may be effected by withdrawing the mind from the state in which it has been…’ The intention may appear laudable, but the methods used seem to have been barbaric. Some people consider certain of the modern forms of psychiatric treatment in much the same light, as for example, treatment by electro-convulsive therapy; but the comparison is not really tenable and is only made here to show some historical connections. Aretaeus of Cappadocia was probably the first physician to consider the idea of spontaneous remission of psychiatric illness, and Soranus, the Greco-Roman physician (2nd century A.D.), attacked the barbarity of contemporary forms of treatment, stressing, as had Aesclepiades much earlier, the need for therapy and an approach that discriminated according to individual need. Much of his work comes to us through his chronicler Caelius Aurelianus. However, Caelius could not share Soranus's toleration of what we would now call the sexual perversions. In his book entitled De Incubone, he gave his own authority to the existing view that a special kind of demon existed which could enter the souls of women (and men for that matter) and possess them for sexual purposes.

These attitudes reflected what was probably the beginning of the shadow of demonology—a shadow which was to hang over the treatment of the insane for the next sixteen hundred years. However, before considering this period in more detail, brief mention must be made of the work of the physician Galen of Pergamum (2nd century A.D.). Galen tried to encourage a return to the use of clinical observation as first advanced by Hippocrates. He stressed the dependence of the personality on physical health and advanced a rather ambitious connection between brain substance and mental performance. ‘The keenness of the mind depends upon the firmness of the brain substance. Slow thinking is due to heaviness…its firmness and stability produces the faculty of memory…’ In statements such as these we have glimmerings of the later science of neurology—a sister science of much importance to psychiatry. The ‘dark ages’ in psychiatry can be said to begin with the death of Galen.

demonology: The period of demonology dates from about AD 200 and existed until the latter part of the eighteenth century. During these long ages, theologians were able to use biblical allusions to the mentally afflicted, to search out and eliminate those who were different and were thought to be ‘possessed’—those of whom they were afraid. Thus, they could refer to exhortations such as in Exodus: ‘Thou shalt not suffer a witch to live,’ and in Leviticus: ‘A man, also a woman, that hath a familiar spirit or that is a wizard shall be put to death.’ (The theologians had obviously not chosen to remember that Christ had ‘cast out devils.’)

There then ensued various manoeuvres to exorcise consort with the ‘power of evil’, by charms and prayers. Such exorcisms were used in an attempt to cure all kinds of disturbances, such as that now described as hysteria, for example. This was a malady long believed to be due to the wandering of the womb about the body. When these attempts failed, other and more brutal methods were resorted to. The first ‘witch’ was formally executed in about AD 430. They were soon to be executed in their thousands. In Geneva, some five hundred were burned in three months in 1515. Before the Reformation, the principal authority for such ‘witch-hunting’ practices was a work written by two monks called Kramer and Sprenger and entitled the ‘Malleus Malificarum’ (or ‘Witches’ Hammer'). One part of this terrifying book deals with the recognition of phenomena we now consider to be associated with certain forms of psychiatric illness (for example, anaesthetic areas of the skin, which can be increased or decreased at the suggestion of the examiner. Today we would describe this as an hysterical manifestation.) The sections in the ‘Malleus’ on the examination of suspects, and the physical extraction of confessions, bear comparison with the methods used by the Gestapo in the Second World War, and with the more recent accounts of the methods employed towards political prisoners in some countries.

After the Reformation, things if anything became worse, because it is said the Protestants vied in zeal with the Catholics in destroying those ‘possessed of Devils.’ Even so distinguished a physician as Paré (the father of modern surgery) believed that the only proper treatment for a man claiming magical powers was execution. However, there were some people holding more moderate views at this time of persecution and oppression. Paracelsus considered that ‘mental diseases (had) nothing to do with evil spirits or devils…one should not study how to exorcise the devil, but rather how to cure the insane.’ His contemporary, Vives, published many works which contested the whole basis of the ‘Malleus Malificarum’ and Johann Weyer, another fearless denunciator of persecution, made a considerable contribution to the beginnings of an attempt to classify mental conditions. He was much in conflict with the Inquisition, of which he said: ‘It is highly unpleasant to see how people, in order to kill errors, are busy killing human beings.’ (It is sad to relate that some hundred years after his death, nineteen people were executed and one tortured to death, in the famous Salem witch hunt of 1691–2.)

summary of attitudes in the middle ages

It is important to remember that, from a caring point of view, the village was in fact the ‘total institution’ for most people and that (more importantly) the last word on any subject rested with the Church as arbiter. The provision of hospitals was the Church's duty; psychological disorders became part of demonology, therefore coming within the aegis of the Clergy. It has also been suggested that the Black Death left physically and emotionally exhausted nations, prone to outbursts of neurotic illness. These have been well described by writers of those times.

the seventeenth century

The seventeenth century was characterised by what we would today describe as a ‘knowledge explosion’ in many fields, particularly in areas that were relevant to medicine. Three examples may be given. Firstly, the discovery of the mechanics of the circulation of the blood. Secondly, the invention and development of the microscope. Thirdly, the development of Newtonian physics. It was, of course, also the age of philosophical discovery and controversy. Despite these developments, not much attention was directed specifically towards mental illness at this time, but Felix Plater was a notable exception; he added to previous work on classification.

Despite advances in science and philosophy, fairly primitive ideas remained, as can be seen in the following examples. Willis, a famous anatomist, suggested of mental treatment that ‘the primary object is naturally curative; discipline, threats and blows are needed as much as medical treatment…’ Blood-letting was also common at this time (frequently until death intervened). This was eventually supplanted by crude attempts at blood transfusion in which the blood of young, sane men was transfused into the blood of the aged insane. Not surprisingly, it was a complete failure. Some of the medicines prescribed at this time make for fascinating, if somewhat unpalatable, reading. Thus Sydenham—a very famous physician—prescribed for mania a concoction known as ‘Venice treacle’. This contained the flesh and blood of vipers and sixty-one other ingredients, including canary wine and honey.

the eighteenth century

In the eighteenth century, an important principle was gradually recognised, namely, that the forces of mind and body interacted (this principle had been suggested by Hippocrates many centuries earlier). The re-establishment of this principle owed much to the work of George Stahl, a German professor of medicine. Yet, tragically enough, alongside these newer ideas and their far-reaching implications, there existed attitudes that we find hard to comprehend today. Thus, even forward-looking workers like Brown in this country, Rush in America and Reil in Germany, could all recommend treatments that we would consider barbaric; Reil used ‘non-injurious torture’—flinging patients into water, firing cannons, and confronting them with visions of those risen from the dead. Those interested in art will recognise the graphic presentations of various forms of mental illness in the paintings of Hogarth, particularly the ‘Rake's Progress’.

Attention was focused increasingly on the problems of the mentally ill through the thirty year intermittent illness of George III (the diagnosis of which has always been in some doubt). Even as a royal patient, however, he received no special favours. One attendant boasted that he had knocked the King ‘as flat as a flounder.’

The treatment provided for the mentally ill in the eighteenth century can be summarised in the following fashion (and in so summarising them, we should note that they were treatment provisions still based largely on superstition, moral condemnation, ignorance and apathy). There were patients:

(1) Confined under the Poor Laws.

(2) Confined under the Criminal Law.

(3) Confined under the Vagrancy Laws.

(4) Confined in private madhouses.

(5) Confined as Bethlem (Bedlam) Patients.

(6) Confined as ‘single lunatics’ (that is, confined alone in various places, under the most appalling conditions) (Jones, 1972).

Public concern about these provisions grew stronger towards the end of the century. This concern resulted in various enquiries and subsequent legislation ‘for the better regulation of private madhouses’. An interesting feature of the late eighteenth century was the apparently high proportion of famous literary people said to suffer from some form of mental illness. (Examples are Cowper, Dr Johnson, Oliver Goldsmith, William Collins, Blake, and the sister of Charles Lamb.) Their plight may also have encouraged this developing public concern.

The history of the treatment of the insane from earliest times up to the end of the eighteenth century is mainly characterised by fear of those who were ‘possessed’. There were, however, occasional instances of humane treatment and attempts to understand symptoms. As the nineteenth century began, there developed a preoccupation with ‘containment’; the latter part of this chapter deals with this preoccupation and the movement towards a greater degree of toleration and understanding of the mentally ill.

In the nineteenth and twentieth centuries, according to Henderson and Gillespie, four main areas of development are to be discerned in the treatment of the mentally ill, though these overlap very considerably.

(1) The period of humane reform.

(2) The introduction of non-restraint.

(3) The hospital period.

(4) The social and community period.

These will now be discussed in turn.

(1)
the period of humane reform

The movement for humane reform occurred in this country and on the Continent of Europe. Two of its most prominent leaders were the Frenchmen, Pinel and Esquirol; they are usually regarded as the pioneers of ‘moral treatment’ of the insane—that is, the abolition of restraints and of the more violent forms of treatment. In this country, the foundation of the ‘Retreat’ at York by William Tuke and th...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• Dedication
• Contents
• Editor's Foreword
• Introduction
• 1 Possession—containment—tolerance?
• 2 Mental health and mental illness
• 3 The neuroses
• 4 The functional psychoses
• 5 Psychiatric conditions due to old age or organic disorders
• 6 Abnormalities of personality and psychosexual disorders
• 7 The problems of drugs and alcohol
• 8 Social aspects of suicidal behaviour
• 9 Mental subnormality (mental handicap)
• 10 The legal aspects of psychiatric disorders
• 11 General discussion and conclusions
• Index
• Subject Index