Psychology and Psychiatry in the 20th and 21st Century
In How Mental Illness was Treated Prior to the 20th Century, we looked at how mental disorders were perceived and treated in ancient civilizations. Throughout history there have been three approaches to mental illness: supernatural, psychogenic (psychological) and somatogenic (physical or cellular). All major civilizations have viewed those with troubled minds through the lens of these perspectives. Consequently, the treatment of mental illness ranged from exorcisms bloodletting, trepanation, to incarceration.
Fortunately, the treatments available today for those who suffer from mental illness have greatly advanced and are numerous. Psychotherapists and psychiatrist are able to effectively treat patients with "talk therapy" or with medication. Institutions for the mentally ill no longer employ the archaic custodial techniques of the past. Biopsychology, a relatively new field in the research and treatment of mental illness is persistently advancing.
This article will attempt to offer the reader a brief view of mental illness as well as treatments in the 20th and 21st century.
Mental Illness: 20th and 21st Century
Treatments for mental illness have come a long way in the last two hundred years. It wasn’t long ago in European and American history that people with psychiatric conditions were placed in institutions not much different from jails. Most internments into these asylums were one way trips. Once patient were admitted into institutions such as the Bethlem Royal Hospital in London or the Trans Allegheny Lunatic Asylum in Weston, West Virginia they simply were not given the opportunity to leave. Additionally, asylums of the time notoriously treated their residents with unspeakable cruelty.
The treatment of women during the Victorian era in Britain and the corresponding time in the United States allowed for abuses by a manifestly patriarchal mental health establishment. This was a time when women could be considered unbalanced and labeled as hysterical for such common occurrences as menstrual-related anger, pregnancy and post-partum depression, chronic fatigue, anxiety or even disobedience; any of which could land a woman in a mental facility.
Today, while some of these conditions are still considered mental health issues, they are easily treated through counselling and medication. In the mid to late eighteenth century, however, a largely male dominated mental health industry, with few scientific research tools available and archaic views on viable treatments for mental health patients, treated women markedly different from men.
Much of this has changed today. Treatments available for men and women are fundamentally similar. Practitioners are required to respect the rights of patients at all times. When the need arises for patients to be placed in a modern facility, they often have the opportunity to weigh in on available therapies. They are even allowed to leave the facility once they feel recovered.
20th Century – The Birth of Modern Psychotherapy
As experts began to try to decipher people’s thoughts, mental faculties, cognitive functions, erratic conduct and social behavior, the move away from a strictly somatic approach for treating mental disorders was begun. Prior to this time the idea that mental illness resulted from physical impairment or nervous disorders was rarely disputed. In an attempt to find evidence that pointed to mental deficiencies the scientific community of the 19th century conducted autopsies of mental patients as well as other experiments.
Although it was proven that some brain tumors and the final stages of syphilis were responsible for some mental abnormalities these efforts were fruitless. While in the early part of the 1900s asylums offered somatic treatments consistent of the times, including hydrotherapy, electrical stimulation and rest, the etiology of mental illness began an irreversible change.
Talking Cure – Consciousness - Subconscious
Around the end of the 19th century in Vienna, Sigmund Freud was developing his methods of psychoanalysis or “talking cure.” These were a set of theories and therapeutic techniques related to the study of the ‘unconscious mind.’ Freud used these as a form of treatment for mental disorders.
Around the same time in the United States a psychogenic approach to treating mental disorders started with a small group of physicians. Notable among them was Dr. Boris Sidis (1867–1923) who argued consciousness rather than the nervous system was the “data” of psychology. Sidis became the founder of the New York State Psychopathic Institute and the Journal of Abnormal Psychology. He was also a proponent of the importance of the subconscious and of hypnosis in order to gain access to memories buried deep in the patients' mind. His technique was to inform his patients of their memories after arising from hypnotic trance. He claimed their knowledge of their hidden memories would eliminate their symptoms.
Professor of Psychology at the University of Scranton John C. Norcross defines psychotherapy in 2012 as…“the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable"
Major Theories in Psychotherapy of the 20th Century
Following Boris Sidis’ work, different theories in psychology emerged that directly impacted the techniques in psychotherapy. These theories provided a model for understanding human thoughts, emotions, and behaviors, consequently greatly enhancing the treatments available to patients.
A systematic approach in the understanding of human and animal behavior known as ‘behaviorism’ became the dominant model between the 1920s and 1950s. It used techniques based on theories such as ‘operant conditioning’ ( a behavior is modified through reward or reinforcement); ‘classical conditioning’ (the association of certain stimuli with certain behaviors, i.e. dogs salivate when a bell they associate with meat is rung.); ‘social learning theory’ (new behaviors can be acquired by observing others.)
Major contributors to behaviorism were South African psychiatrist Joseph Wolpe, Hans Jürgen Eysenck a German-born British psychologist, B. F. Skinner, an American psychologist and Ivan Pavlov a Russian physiologist known for the development of classical conditioning.
As an answer to behaviorism two theories and therapies were independently developed in the 1950s – cognitivism and existential-humanistic therapy.
Cognitivists felt behaviorism neglected to explain cognition or how the mind processes information. They contended that while behaviorists acknowledged the existence of thinking, they merely identified it as behavior. In contrast, cognitivists argued that people’s thoughts and thinking processes impact their behavior.
They viewed the human mind as an information processing system, similar to what is known as computationalism or computational theory of mind (CTM). Therefore, while behaviorist use feedback as a way to change behavior, cognitivists use it as a way of guiding and supporting accurate mental connections and processes.
Today, Cognitive Behavioral Therapy (CBT) can be effective in the treatment of anger management, panic attacks, depression, drug or alcohol problems, habits, mood swings, excessive compulsive disorder, post-traumatic stress disorder, sleep problems, sexual or relational problems and many other mental health problems.
It is a psychological approach which gained prominence in answer to Sigmund Freud’s psychoanalytic theory and B.F. Skinner’s behaviorism. It focuses on people’s inherent drive to actualization or the process of realizing and expressing their full potential. It is based on the idea that all people are inherently good.
It adopts a holistic approach to human existence and focuses on creativity, free will, and positive human potential. It encourages self-exploration, development of the ‘whole person’ and acknowledges spiritual aspiration as an integral part of the psyche.
It primarily encourages self-awareness and mindfulness allowing the patient to change their state of mind and behavior from reactionary to productive and thoughtful actions. It embraces concepts such as depth therapy, holistic health, encounter groups, sensitivity training, marital therapies, body work and existential psychotherapy.
Existential therapy is well suited for dealing with anxieties, existence, taking personal responsibility, facing terminal illness, for those contemplating suicide or those going through transitions in life.
1970s to Present
In the 1970s other major sub-fields or schools of psychology were developed as methods of psychotherapy. These are:
- Family systems therapy - works with families and couples in nurturing change and development.
- Transpersonal psychology – focuses on the spiritual facet of human experience.
- Feminist therapy – focuses on societal, cultural and political causes and solutions aimed at the challenges and stressors women face. It addresses issues of bias, stereotyping, oppression, discrimination and other mental health issues.
- Somatic psychology – a form of psychotherapy focusing on the somatic (relating to the body) experience which includes therapeutic and holistic approaches to body. It incorporates into it therapy yoga, dance, Pilates and qigong.
- Expressive therapy – it uses various forms of creative expression such as music, art and dance in order to help people explore and transform difficult emotional and medical conditions. It is often used in combination with more traditional psychotherapy.
- Positive psychology – it is a scientific study of the assets and strengths that allow individuals and communities to thrive. Called the study of the “good life” it attempts to cultivate meaningful and fulfilling lives through enhanced experiences of love, work and play.
The word psychiatry originates from the Medieval Latin “psychiatria” and the 1800s French word “psychiatre” meaning “a healing of the soul.” Both of which come from the Latinized form of the Greek “psykhē” or mind plus iatreia meaning “healing” or “care.”
As a practice, psychiatry can be traced to the ayurvedic text Charaka Samhita of ancient India, where some of the first hospitals for the mentally ill were established during the 3rd century BCE. However, as an established medical specialty psychiatry dates back to the middle of the nineteenth century.
The Age of Enlightenment (also known as the Age of Reason or simply Enlightenment) a philosophical movement that emerged out of Europe from the 17th to 19th century created changes in the attitude toward the mentally ill. They began to be viewed as people with a disorder requiring compassionate treatment as a way to assist, support and rehabilitate them.
As society began to turn away from the barbaric custodial treatments used by asylums, a modern era of providing care for the mentally ill emerged in the early 19th century. In Britain as well as in the United States large state-led efforts to create public mental asylums led to their eventual transformation and replacement by the modern psychiatric hospital. This in turn gave rise to organized institutional psychiatry which allowed psychiatric hospitals to specialize in the treatment of serious mental disorders, such as schizophrenia, bipolar disorder and major depression.
Modern Electroconvulsive Therapy (ECT)
The Difference Between Psychiatry and Psychology
While the terms “psychologist” and “psychiatrist” are sometimes used interchangeably to describe someone who provides therapy to sufferers of mental illness, both professions and the work they do differ markedly. Psychiatrists are medical doctors able to perform psychotherapy in conjunction to prescribe medication, perform physical exams and order diagnostic tests.
On the other hand, while many psychologists hold doctorate degrees, they are not medical doctors. Subsequently, most, with the exception of those in Louisiana and Mexico, cannot prescribe medications. Rather, they are limited to providing psychotherapy, which may involve any of the sub-fields of psychology described above.
Psychiatrists typically treat people with complex conditions, such as: severe depression, schizophrenia, suicidal thoughts and bipolar disorder. Conversely, psychologists treat people with conditions that can be effectively treated with psychotherapy alone, such as behavioral problems, learning difficulties, depression and anxiety.
Both professions often work together in order to coordinate and provide the best available therapy to patients.
Psychiatric Treatments – Past and Present
Early 20th Century
Psychiatric treatments have been undergoing a constant stream of change and improvement since ancient times. As medical sciences have advanced, new treatments have replaced old less effective approaches to treating the mentally ill. However, in the early part of the 20th century, many of the treatments used by psychiatric hospitals and practitioners were based on faulty research and assumptions of the nature of illnesses and of the human mind. The following are some of the treatments rarely used or no longer in use today.
A set of techniques used in psychiatry to treat depression and schizophrenia as well as other illnesses. This was done by inducing seizures or other extreme brain states. These therapies included:
- Electroconvulsive therapy (formerly known as electroshock therapy): Seizures are electrically induced in patients to provide relief from mental disorders. It is still in use today. ECTs have been proven to be safe and effective treatments for the intervention of major depressive disorder, catatonia, bipolar disorder and mania.
- Insulin shock therapy: Introduced in 1927 by Austrian-American psychiatrist Manfred Sakel for the treatment of schizophrenia, insulin coma therapy was extensively used in the 1940s and 1950s. Treatments discontinued due to extreme obesity caused to patients as well as risk of death and brain damage.
- Convulsive therapy: Using pentylenetetrazol or other chemicals to induce seizures. Originally, it was believed there was a connection between schizophrenia and epilepsy. No longer in use due to uncontrolled seizures.
- Deep sleep therapy: also called prolonged sleep treatment or continuous narcosis, a treatment in which drugs are used to keep patients unconscious for days or weeks. Treatments were discontinued after the death of twenty-six patients at Chelmsford Private Hospital in Australia.
Treatments for the Mentally Ill in the 20th Century
A form of psychosurgery in which most of the connections in the prefrontal cortex of the brain are severed. It was used in some Western countries for more than two decades, despite the knowledge of serious side effects. Although some patients accrued some symptomatic improvements with this form of neurosurgery, other serious impairments were created. A benefit and risk analysis of this procedure made it controversial from the very outset of its origin. Prisoners were lobotomized against their will, in an attempt to "cure" them of their desire to commit crimes. In other cases, some battle-fatigued World War II veterans were given the procedure in order to free up space in hospitals. Today, lobotomies are considered crude, even barbaric and an obvious disregard of patients’ rights.
While the idea of intentionally injecting someone with malaria parasites as a way to cure a secondary disease seem total lunacy, this became a common treatment in 1921 for a psychosis known as “general paresis of the insane”, or GPI, a symptom of advanced syphilis. Known as pyrotherapy, due to the high fever brought on by malaria, the treatment hoped to kill the syphilis bacteria by high body temperature.
The treatment creator, Julius Wagner-Jauregg (1857-1940) was awarded the Nobel Prize for Medicine (the first ever in the field of psychiatry) in 1927 after showing overwhelming success. Unfortunately, despite the reported beneficial effect of the malaria fever treatment, mortality rates averaged 15%.
Psychiatric mediations affect the chemical makeup of the brain and nervous system and therefore treat mental illness. They are mostly made of synthetic chemical compounds and are typically prescribed by psychiatrists. Since the mid-20th century, they have become the leading treatments for a broad range of mental disorders. They have been responsible for decreasing the need for long-term hospitalization as well as the reduction in other psychiatric treatments such as electroconvulsive therapy or the usage of straitjackets for physical restraints. Their introduction has brought profound changes to the treatment of mental illness as more patients are able to be treated at home. Subsequently, many mental institutions have been closed on a global scale.
The two most important breakthroughs in medications for various types of mental illnesses came in the mid-1900s; Lithium and Chlorpromazide.
Lithium was first used as a psychiatric medicine in 1948. It is primarily used to treat bipolar disorder and major depressive disorder that does not respond well to antidepressants. In both disorders, it minimizes the risk of suicide. It is considered to be the most and perhaps the only effective mood stabilizer in use today.
Chlorpromazide, an antipsychotic medication used for schizophrenia, first introduced in 1952. It can also be used for bipolar disorder, severe behavioral problems in children, attention deficit hyperactive disorder (ADHD), nausea, vomiting, anxiety before surgery and hiccups that do not improve.
The following are the six main groups of psychiatric medications in use today:
- Antidepressants: Treat different types of disorders such as clinical depression, dysthymia, anxiety disorders, eating disorders and borderline personality disorder.
- Antipsychotics: Treat psychotic disorders such as schizophrenia and psychotic symptoms due to other mental illnesses such as mood disorders.
- Anxiolytics: Treat anxiety disorders.
- Depressants: Used as hypnotics, sedatives, and anesthetics.
- Mood stabilizers: Treat bipolar disorder and schizoaffective disorder.
- Stimulants: Treat disorders such as attention deficit hyperactivity disorder and narcolepsy.
The Biological Approach - Going Back to Hippocrates
Hippocrates, the Greek physician who lived around 400 BCE and considered one of the most outstanding figures in the history of medicine, was an early proponent that psychological disorders were caused by biological factors. Hence, rejecting the idea that insanity was caused by supernatural forces.
He suggested that humors or vital bodily fluids (blood, yellow bile, phlegm and black bile) were responsible for most physical ailments including mental illness. He theorized that the imbalance of these bodily fluids would need to be brought back to normal before a patient could return to health.
Sometime in the 19th century, mental illness practitioners began to move away from a somatogenic theory of mental illness in favor of a psychogenic approach. This eventually led to the “talking cure” proposed by Sigmund Freud and what we know today as psychotherapy.
However, in 1971 a new interdisciplinary concentration known as biopsychology was introduced, which in a way goes back to the somotogenic approach of the past. Today, biopsychologists look at how the nervous system, hormones, neurotransmitters and genetic makeup of humans affect behavior. It also looks at the connection between them and how that affects behavior, thoughts and feelings.
This biological approach attempts to not only understand the healthy human brain but also how illnesses like schizophrenia, depression and bipolar disorder develop from genetic roots. It also looks at how biological processes interact with cognition, emotions and other mental functions.
Biopsychology is often referred to by various different names such as physiological psychology, behavioral neuroscience, and psychobiology.
Research in this field continues to make important discoveries about the brain and the physical roots of behavior. Questions like: Can knowledge acquired during a lifetime be passed on to future descendants? How brain networks come ‘online’ during adolescence in order to allow teenagers to develop more adult-like social skills? And how can the brain’s immune system be harnessed to improve memory? Are being researched today.
Resources and Further Reading
- History of Mental Health Treatments
- History of Mental Illness
- Mental Disorders
- Mental Health Treatments - Past and Present
- History of Mental Disorders
- Misunderstanding Mental Health in the Early 20th Century
- The Diagnostic Concept of Schizophrenia: Its History, Evolution and Future Prospect
- A Burning Question: Can Pyrotherapy Treat Psychosis
- Treatment of Mental Disorders
- Studying the Brain and Behavior in Biopsychology
- Bipolar Disorders