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Chapter: Psychiatric Mental Health Nursing : Foundations of Psychiatric Mental Health Nursing

Historical Perspectives of the Treatment of Mental Illness

People of ancient times believed that any sickness indicated displeasure of the gods and, in fact, was a punishment for sins and wrongdoing.


Ancient Times

People of ancient times believed that any sickness indicated displeasure of the gods and, in fact, was a pun-ishment for sins and wrongdoing. Those with mental disorders were viewed as being either divine or demonic, depending on their behavior. Individuals seen as divine were worshipped and adored; those seen as demonic were ostracized, punished, and sometimes burned at the stake. Later, Aristotle (382–322 BC) attempted to relate mental disorders to physical disorders and developed his theory that the amounts of blood, water, and yellow and black bile in the body controlled the emotions. These four sub-stances, or humors, corresponded with happiness, calm-ness, anger, and sadness. Imbalances of the four humors were believed to cause mental disorders, so treatment was aimed at restoring balance through bloodletting, starving, and purging. Such “treatments” persisted well into the 19th century (Baly, 1982).

In early Christian times (1–1000 AD), primitive beliefs and superstitions were strong. All diseases were again blamed on demons, and the mentally ill were viewed as possessed. Priests performed exorcisms to rid evil spirits. When that failed, they used more severe and brutal mea-sures, such as incarceration in dungeons, flogging, and starving.

In England during the Renaissance (1300–1600), people with mental illness were distinguished from criminals. Those considered harmless were allowed to wander the countryside or live in rural communities, but the more “dangerous lunatics” were thrown in prison, chained, and starved (Rosenblatt, 1984). In 1547, the Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane, the first of its kind. By 1775, visitors at the institution were charged a fee for the privilege of viewing and ridiculing the inmates, who were seen as animals, less than human (McMillan, 1997). During this same period in the colonies (later the United States), the mentally ill were considered evil or possessed and were punished. Witch hunts were conducted, and offenders were burned at the stake.

Period of Enlightenment and Creation of Mental Institutions

In the 1790s, a period of enlightenment concerning persons with mental illness began. Phillippe Pinel in France and William Tukes in England formulated the concept of asylum as a safe refuge or haven offering protection at institutions where people were whipped, beaten, and starved just because they were mentally ill (Gollaher, 1995). With this movement began the moral treatment of the mentally ill. In the United States, Dorothea Dix (1802–1887) began a cru-sade to reform the treatment of mental illness after a visit to Tukes’s institution in England. She was instrumental in opening 32 state hospitals that offered asylum to the suffer-ing. Dix believed that society was obligated to those who were mentally ill; she advocated adequate shelter, nutritious food, and warm clothing (Gollaher, 1995).

The period of enlightenment was short-lived. Within 100 years after establishment of the first asylum, state hos-pitals were in trouble. Attendants were accused of abusing the residents, the rural locations of hospitals were viewed as isolating patients from their families and homes, and the phrase insane asylum took on a negative connotation.

Sigmund Freud and Treatment of Mental Disorders

The period of scientific study and treatment of mental dis-orders began with Sigmund Freud (1856–1939) and others, such as Emil Kraepelin (1856–1926) and Eugene Bleuler (1857–1939). With these men, the study of psychiatry and the diagnosis and treatment of mental illness started in earnest. Freud challenged society to view human beings objectively. He studied the mind, its disorders, and their treatment as no one had done before. Many other theorists built on Freud’s pioneering work. Kraepelin began classifying mental disorders according to their symp-toms, and Bleuler coined the term schizophrenia.

Development of Psychopharmacology

A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic drugs, or drugs used to treat mental illness. Chlorpromazine (Thorazine), an antipsychotic drug, and lithium, an anti-manic agent, were the first drugs to be developed. Over the following 10 years, monoamine oxidase inhibitor antidepressants; haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety agents, called benzodiazepines, were introduced. For the first time, drugs actually reduced agitation, psychotic thinking, and depression. Hospital stays were shortened, and many peo-ple were well enough to go home. The level of noise, chaos, and violence greatly diminished in the hospital setting.

Move Toward Community Mental Health

The movement toward treating those with mental illness in less restrictive environments gained momentum in 1963 with the enactment of the Community Mental Health Cen-ters Construction Act. Deinstitutionalization, a deliberate shift from institutional care in state hospitals to community facilities, began. Community mental health centers served smaller geographic catchment, or service, areas that pro-vided less restrictive treatment located closer to individu-als’ homes, families, and friends. These centers provided emergency care, inpatient care, outpatient services, partial hospitalization, screening services, and education. Thus, deinstitutionalization accomplished the release of individuals from long-term stays in state institutions, the decrease in admissions to hospitals, and the development of community-based services as an alternative to hospital care.

In addition to deinstitutionalization, federal legislation was passed to provide an income for disabled persons: Supplemental Security Income (SSI) and Social Security Disability Income (SSDI). This allowed people with severe and persistent mental illness to be more independent financially and to not rely on family for money. States were able to spend less money on care of the mentally ill than they had spent when these individuals were in state hospi-tals because this program was federally funded. Also, com-mitment laws changed in the early 1970s, making it more difficult to commit people for mental health treatment against their will. This further decreased the state hospital populations and, consequently, the money that states spent on them.

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