Which psychoanalytic theorist's method was later renamed hypnosis?

2 historical and contemporary views of abnormal behavior

image1

learning objectives 2

· 2.1 How has abnormal behavior been viewed throughout history?

· 2.2 What effect did the emergence of humanism have on abnormal psychology?

· 2.3 What developments led to the contemporary view of abnormal psychology?

An Artist in Bedlam The most famous patient committed to the historic Bethlem Hospital in England (better known as Bedlam) during its long existence was a well-known and talented young artist, Richard Dadd (1817–1886). Dadd was born in Chatham, England, in 1817. His father was a successful chemist. Dadd attended the Kings School in Rochester and also studied art at the Royal Academy School in London. He showed a strong aptitude for drawing and painting and was admitted to the prestigious Royal Academy of Arts at the early age of 20. When he was 25, he was invited to accompany Sir Thomas Phillips, the former mayor of Newport, on a grand tour through Europe, Greece, Turkey, Syria, and Egypt to serve as the draftsman and painter for the expedition. During the trip, Dadd produced a number of exceptional paintings of people and places he encountered on the journey, many of which are in museums today. The journey was reportedly difficult and stressful, and at one point, during a trip up the Nile River, Dadd underwent a remarkable personality change, becoming delusional and increasingly aggressive and violent toward people he met. He was reported to have expressed an urge to kill the Pope. He experienced delusional beliefs—for example, that he had come under the influence of the Egyptian god Osiris.

When he returned from the trip in 1843, he was diagnosed as being mentally unsound because of his hallucinations and his strange, delusional beliefs. In an effort to restore him to health, his family took him to recuperate in a countryside village in Kent, England. The records indicate that one day he came to the conclusion that his father was the Devil in disguise, and on a walk in the countryside Dadd killed his father with a knife. He attempted to escape by fleeing to France; however, his aggressive behavior continued, and he attempted to kill another tourist with a razor. He was arrested by the police and was eventually returned to England. He was committed to Bethlem Royal Hospital, where he was held in the criminal ward for dangerous inmates. He remained in Bethlem Hospital for almost 20 years but was transferred to Broadmoor Hospital, where he died in 1886. During his stay in both the Bethlem and Broadmoor hospitals he was allowed and encouraged to paint by the staff as part of his treatment. During this time he produced a number of paintings, many of which can be seen today in art museums.

Although he appears to have experienced symptoms of a mood disorder including acute mania (see Chapter 7 ) it is likely that Dadd suffered from paranoid schizophrenia (see Chapter 14 for further discussion). Interestingly, two of his siblings appeared to suffer from the same symptom pattern; thus he may have been genetically predisposed to this condition (see Greysmith, 1979 ; MacGregor, 1989 for a discussion of his life and art work).

Historical Views of Abnormal Behavior

Our historical efforts to understand abnormal psychology include both humor and tragedy. In this chapter, we will highlight some views of psychopathology, and some of the treatments administered, from ancient times to the twenty-first century. In a broad sense, we will see a progression of beliefs from what we now consider superstition to those based on scientific awareness—from a focus on supernatural explanations to knowledge of natural causes. The course of this evolution has at times been marked by periods of advancement or unique, individual contributions, followed by long years of inactivity or unproductive, backward steps.

Although human life appeared on earth some 3 million or more years ago, written records extend back only a few thousand years. Thus our knowledge of our early ancestors is limited. Two Egyptian papyri dating from the sixteenth century B.C. provide some clues to the earliest treatments of diseases and behavior disorders (Okasha & Okasha, 2000 ). The Edwin Smith papyrus (named after its nineteenth-century discoverer) contains detailed descriptions of the treatment of wounds and other surgical operations. In it, the brain is described—possibly for the first time in history—and the writing clearly shows that the brain was recognized as the site of mental functions. The Ebers papyrus offers another perspective on treatment. It covers internal medicine and the circulatory system but relies more on incantations and magic for explaining and curing diseases that had unknown causes. Although surgical techniques may have been used, they were probably coupled with prayers and the like, which reflected the prevailing view of the origin of mental illness.

Demonology, Gods, and Magic

References to abnormal behavior in early writings show that the Chinese, Egyptians, Hebrews, and Greeks often attributed such behavior to a demon or god who had taken possession of a person. Whether the “possession” was assumed to involve good spirits or evil spirits usually depended on the affected individual’s symptoms. If a person’s speech or behavior appeared to have a religious or mystical significance, it was usually thought that he or she was possessed by a good spirit or god. Such people were often treated with considerable awe and respect, for people believed they had supernatural powers.

Most possessions, however, were considered to be the work of an angry god or an evil spirit, particularly when a person became excited or overactive and engaged in behavior contrary to religious teachings. Among the ancient Hebrews, for example, such possessions were thought to represent the wrath and punishment of God. Moses is quoted in the Bible as saying, “The Lord shall smite thee with madness.” Apparently this punishment was thought to involve the withdrawal of God’s protection and the abandonment of the person to the forces of evil. In such cases, every effort was made to rid the person of the evil spirit.

The primary type of treatment for demonic possession was exorcism, which included various techniques for casting an evil spirit out of an afflicted person. These techniques varied but typically included magic, prayer, incantation, noisemaking, and the use of horrible-tasting concoctions made from sheep’s dung and wine.

Hippocrates’ Early Medical Concepts

The Greek temples of healing ushered in the Golden Age of Greece under the Athenian leader Pericles (461–429 B.C.). This period saw considerable progress in the understanding and treatment of mental disorders, in spite of the fact that Greeks of the time considered the human body sacred so little could be learned of human anatomy or physiology. During this period the Greek physician Hippocrates (460–377 B.C.), often referred to as the father of modern medicine, received his training and made substantial contributions to the field.

Hippocrates denied that deities and demons intervened in the development of illnesses and instead insisted that mental disorders, like other diseases, had natural causes and appropriate treatments. He believed that the brain was the central organ of intellectual activity and that mental disorders were due to brain pathology. He also emphasized the importance of heredity and predisposition and pointed out that injuries to the head could cause sensory and motor disorders.

Hippocrates classified all mental disorders into three general categories—mania, melancholia, and phrenitis (brain fever)—and gave detailed clinical descriptions of the specific disorders included in each category. He relied heavily on clinical observation, and his descriptions, which were based on daily clinical records of his patients, were surprisingly thorough.

Maher and Maher ( 1994 ) pointed out that the best known of the earlier paradigms for explaining personality or temperament is the doctrine of the four humors, associated with the name of Hippocrates and later with the Roman physician Galen. The four elements of the material world were thought to be earth, air, fire, and water, which had attributes of heat, cold, moistness, and dryness. These elements combined to form the four essential fluids of the body—blood (sanguis), phlegm, bile (choler), and black bile (melancholer). The fluids combined in different proportions within different individuals, and a person’s temperament was determined by which of the humors was dominant. From this view came one of the earliest and longest-lasting typologies of human behavior: the sanguine, the phlegmatic, the choleric, and the melancholic. Each of these “types” brought with it a set of personality attributes. For example, the person of sanguine temperament was optimistic, cheerful, and unafraid.

image2

Hippocrates’ (460–377 B.C.) belief that mental disease was the result of natural causes and brain pathology was revolutionary for its time.

Hippocrates considered dreams to be important in understanding a patient’s personality. On this point, he was a harbinger of a basic concept of modern psychodynamic psychotherapy. The treatments advocated by Hippocrates were far in advance of the exorcistic practices then prevalent. For the treatment of melancholia (see Developments in Thinking on p. 31), for example, he prescribed a regular and tranquil life, sobriety and abstinence from all excesses, a vegetable diet, celibacy, exercise short of fatigue, and bleeding if indicated. He also recognized the importance of the environment and often removed his patients from their families.

Hippocrates’ emphasis on the natural causes of diseases, on clinical observation, and on brain pathology as the root of mental disorders was truly revolutionary. Like his contemporaries, however, Hippocrates had little knowledge of physiology. He believed that hysteria (the appearance of physical illness in the absence of organic pathology) was restricted to women and was caused by the uterus wandering to various parts of the body, pining for children. For this “disease,” Hippocrates recommended marriage as the best remedy.

developments in THINKING: Melancholia Through the Ages

Although the modern mental health sciences have made great strides in defining, describing, classifying, determining the causes of, and treating psychological disorders, we should not ignore or minimize the contributions to understanding these conditions that were made by many individuals in antiquity. Actually, some mental health problems that are receiving a great deal of research and clinical attention today have been recognized and well described for millennia. One recent study of surviving letters from patients who were hospitalized in Edinborough Asylum between 1873 and 1906 concluded that mental health problems in the nineteenth century were very similar to those in our day (Beveridge, 1997 ). One such disorder is depression.

Melancholia

Perhaps no other mental disorder received so much attention from earlier scholars as depression, or (as it has been referred to in the past) melancholia. Efforts to understand melancholia have been undertaken by physicians, philosophers, writers, painters, and religious leaders in Western civilization for over 2,000 years. Moreover, conditions similar to depression are described in surviving writings from ancient Egypt (Okasha & Okasha, 2000 ). These disorders might have been viewed variously as medical conditions or religious states or human frailties; however, the symptom structure and behavior described were unmistakable.

Radden ( 2000 ) published an interesting compendium of important writings on melancholia that span 24 centuries, some highlights of which are provided here.

· • Investigations into the nature of depression, beginning with Aristotle and Galen during the Greek and Roman eras, provide lucid descriptions of the disorder melancholia.

· • Even in the Middle Ages, when scholarship and inquiry were hindered by religious persecution that included the Spanish Inquisition, there were scholars interested in mental states such as melancholia. Hildegard (1098–1179), a nun known as the “first published woman physician,” carried the Greek views of melancholia further by noting, among other things, that melancholia took different forms in men and women. Johann Weyer (1515–1588) provided astute descriptions of melancholia and examined characteristics of persons who might be so affected, even though these observations were often couched in terms of demonic possession—perhaps as a concession to leaders of the Inquisition in order to avoid persecution.

· • The premodern view of melancholia as a disorder (without the taint of demonic possession or ancient Greek humors) was introduced by Philippe Pinel (1745–1826). A French physician widely recognized for his contributions to the humane treatment of people with mental disorders, Pinel also advanced our scholarly understanding of mental disorders such as melancholia by improving a classification schema and examining the causes of the disorder.

· • Two early modern contributors to our understanding of depression were Wilhelm Griesinger (1817–1868) and Emil Kraepelin (1856–1926). Griesinger’s views on the underlying biological basis for disorders such as melancholia focused the field of psychiatry on the need to seek biological determinants for disorders. Kraepelin is credited with preparing the way for the modern view of psychiatry. His classification schema is still cited today in contemporary writings as seminal in the evolution of diagnostic classification systems. He also identified manic depression as a major category of depression.

Even though much of our understanding of depression and our development of effective treatment methods has emerged over the past three decades, our debt to the ancients who struggled with describing and understanding this disorder needs to be recognized.

The earliest use of the concept “delirium” to describe symptoms of mental disorders that result from fever or physical injury or brain trauma occurred in the first century A.D. by Celsus (Adamis et al., 2007 ).

Early Philosophical Conceptions of Consciousness

The Greek philosopher Plato (429–347 B.C.) studied mentally disturbed individuals who had committed criminal acts and how to deal with them. He wrote that such persons were, in some “obvious” sense, not responsible for their acts and should not receive punishment in the same way as normal persons. He also made provision for mental cases to be cared for in the community (Plato, n.d.).

Plato viewed psychological phenomena as responses of the whole organism, reflecting its internal state and natural appetites. In The Republic, Plato emphasized the importance of individual differences in intellectual and other abilities and took into account sociocultural influences in shaping thinking and behavior. His ideas regarding treatment included a provision for “hospital” care for individuals who developed beliefs that ran counter to those of the broader social order. There they would be engaged periodically in conversations comparable to psychotherapy to promote the health of their souls (Milns, 1986 ). Despite these modern ideas, however, Plato shared the belief that mental disorders were in part divinely caused.

The celebrated Greek philosopher Aristotle (384–322 B.C.), who was a pupil of Plato, wrote extensively on mental disorders. Among his most lasting contributions to psychology are his descriptions of consciousness. He held the view that “thinking” as directed would eliminate pain and help to attain pleasure. On the question of whether mental disorders could be caused by psychological factors such as frustration and conflict, Aristotle discussed the possibility and rejected it; his lead on this issue was widely followed. Aristotle generally subscribed to the Hippocratic theory of disturbances in the bile. For example, he thought that very hot bile generated amorous desires, verbal fluency, and suicidal impulses.

Later Greek and Roman Thought

Hippocrates’ work was continued by some of the later Greek and Roman physicians. Particularly in Alexandria, Egypt (which became a center of Greek culture after its founding in 332 B.C. by Alexander the Great), medical practices developed to a higher level, and the temples dedicated to Saturn were first-rate sanatoria. Pleasant surroundings were considered of great therapeutic value for mental patients, who were provided with constant activities including parties, dances, walks in the temple gardens, rowing along the Nile, and musical concerts. Physicians of this time also used a wide range of therapeutic measures including dieting, massage, hydrotherapy, gymnastics, and education, as well as some less desirable practices such as bleeding, purging, and mechanical restraints.

Asclepiades (c. 124–40 B.C.) was a Greek physician born at Prusa in Bithynia in Asia Minor and practiced medicine in Rome toward the end of the second century B.C. He developed a theory of disease that was based on the flow of atoms through the pores in the body and developed treatments, such as massage, special diets, bathing, exercise, listening to music, and rest and quiet, to restore to the body (Stone, 1937 ).

One of the most influential Greek physicians was Galen (A.D. 130–200), who practiced in Rome. Although he elaborated on the Hippocratic tradition, he did not contribute much that was new to the treatment or clinical descriptions of mental disorders. Rather, he made a number of original contributions concerning the anatomy of the nervous system. (These findings were based on dissections of animals; human autopsies were still not allowed.) Galen also took a scientific approach to the field, dividing the causes of psychological disorders into physical and mental categories. Among the causes he named were injuries to the head, excessive use of alcohol, shock, fear, adolescence, menstrual changes, economic reversals, and disappointment in love.

Roman medicine reflected the characteristic pragmatism of the Roman people. Roman physicians wanted to make their patients comfortable and thus used pleasant physical therapies such as warm baths and massage. They also followed the principle of contrariis contrarius (“opposite by opposite”)—for example, having their patients drink chilled wine while they were in a warm tub.

image3

Galen (A.D. 130–200) believed that psychological disorders could have either physical causes, such as injuries to the head, or mental causes, such as disappointment in love.

Early Views of Mental Disorders in China

China was one of the earliest developed civilizations in which medicine and attention to mental disorders were introduced (Soong, 2006 ). The following passage is taken from an ancient Chinese medical text supposedly written by Huang Ti (c. 2674 B.C.), the third legendary emperor.

· The person suffering from excited insanity initially feels sad, eating and sleeping less; he then becomes grandiose, feeling that he is very smart and noble, talking and scolding day and night, singing, behaving strangely, seeing strange things, hearing strange voices, believing that he can see the devil or gods. (Tseng, 1973 , p. 570)

Even at this early date, Chinese medicine was based on a belief in natural rather than supernatural causes for illnesses. For example, in the concept of yin and yang, the human body, like the cosmos, is divided into positive and negative forces that both complement and contradict each other. If the two forces are balanced, the result is physical and mental health; if they are not, illness results. Thus treatments focused on restoring balance (Tseng, 1973 , p. 570).

image4

Ancient Persian physician Avicenna (c. 980–1037) approached the treatment of mental disorders with humane practices unknown to Western medical practitioners of the time.

Chinese medicine reached a relatively sophisticated level during the second century, and Chung Ching, who has been called the Hippocrates of China, wrote two well-known medical works around A.D. 200. Like Hippocrates, he based his views of physical and mental disorders on clinical observations, and he implicated organ pathologies as primary causes. However, he also believed that stressful psychological conditions could cause organ pathologies, and his treatments, like those of Hippocrates, utilized both drugs and the regaining of emotional balance through appropriate activities.

As in the West, Chinese views of mental disorders regressed to a belief in supernatural forces as causal agents. From the later part of the second century through the early part of the ninth century, ghosts and devils were implicated in “ghost-evil” insanity, which presumably resulted from possession by evil spirits. The “Dark Ages” in China, however, were neither so severe (in terms of the treatment of mental patients) nor as long-lasting as in the West. A return to biological, somatic (bodily) views and an emphasis on psychosocial factors occurred in the centuries that followed. Over the past 50 years, China has been experiencing a broadening of ideas in mental health services and has been incorporating many ideas from Western psychiatry (Zhang & Lu, 2006 ).

Views of Abnormality During the Middle Ages

During the Middle Ages (about a.d. 500 to a.d. 1500), the more scientific aspects of Greek medicine survived in the Islamic countries of the Middle East. The first mental hospital was established in Baghdad in a.d. 792; it was soon followed by others in Damascus and Aleppo (Polvan, 1969 ). In these hospitals, mentally disturbed individuals received humane treatment. One outstanding figure in ancient medicine was Avicenna from Persia (c. 980–1037), called the “prince of physicians” (Campbell, 1926 ), and the author of The Canon of Medicine, perhaps the most widely studied medical work ever written. In his writings, Avicenna frequently referred to hysteria, epilepsy, manic reactions, and melancholia. The following case study illustrates Avicenna’s unique approach to the treatment of a young prince suffering from mental disorder.

An Early Treatment Case A certain prince was afflicted with melancholia and suffered from the delusion that he was a cow…. He would low like a cow, causing annoyance to everyone, … crying, “Kill me so that a good stew may be made of my flesh.” Finally … he would eat nothing…. Avicenna was persuaded to take the case…. First of all he sent a message to the patient bidding him be of good cheer because the butcher was coming to slaughter him, whereat … the sick man rejoiced. Some time afterward Avicenna, holding a knife in his hand, entered the sickroom saying, “Where is this cow that I may kill it?” The patient lowed like a cow to indicate where he was. By Avicenna’s orders he was laid on the ground bound hand and foot. Avicenna then felt him all over and said, “He is too lean, and not ready to be killed; he must be fattened.” Then they offered him suitable food of which he now partook eagerly, and gradually he gained strength, got rid of his delusion, and was completely cured. (Browne, 1921 , pp. 88–89)

During the Middle Ages in Europe, scientific inquiry into abnormal behavior was limited, and the treatment of psychologically disturbed individuals was characterized more often by ritual or superstition than by attempts to understand an individual’s condition. In contrast to Avicenna’s era in the Islamic countries of the Middle East or to the period of enlightenment during the seventeenth and eighteenth centuries, the Middle Ages in Europe were largely devoid of scientific thinking and humane treatment for the mentally disturbed.

Mental disorders were quite prevalent throughout the Middle Ages in Europe, especially toward the end of the period, when medieval institutions, social structures, and beliefs began to change drastically. During this time, supernatural explanations of the causes of mental illness grew in popularity. Within this environment, it obviously was difficult to make great strides in the understanding and treatment of abnormal behavior. Although the influence of theology was growing rapidly, “sin” was not always cited as a causal factor in mental illness. For example, Kroll and Bachrach ( 1984 ) examined 57 episodes of mental illness ranging from madness and possession to alcohol abuse and epilepsy. They found sin implicated in only nine cases (16%). To understand better this elusive period of history, let us look at two events of the times—mass madness and exorcism—to see how they are related to views of abnormal behavior.

MASS MADNESS

During the last half of the Middle Ages in Europe, a peculiar trend emerged in efforts to understand abnormal behavior. It involved mass madness —the widespread occurrence of group behavior disorders that were apparently cases of hysteria. Whole groups of people were affected simultaneously. Dancing manias (epidemics of raving, jumping, dancing, and convulsions) were reported as early as the tenth century. One such episode that occurred in Italy early in the thirteenth century was known as tarantism —a disorder that included an uncontrollable impulse to dance that was often attributed to the bite of the southern European tarantula or wolf spider. This dancing mania later spread to Germany and the rest of Europe, where it was known as Saint Vitus’s dance .

Isolated rural areas were also afflicted with outbreaks of lycanthropy —a condition in which people believed themselves to be possessed by wolves and imitated their behavior. In 1541 a case was reported in which a person suffering from lycanthropy told his captors, in confidence, that he was really a wolf but that his skin was smooth on the surface because all the hairs were on the inside (Stone, 1937 ). To cure him of his delusions, his extremities were amputated, following which he died, still uncured.

Mass madness occurred periodically all the way into the seventeenth century but had reached its peak during the fourteenth and fifteenth centuries—a period noted for social oppression, famine, and epidemic diseases. During this time, Europe was ravaged by a plague known as the Black Death, which killed millions (according to some estimates, 50% of the population of Europe died) and severely disrupted social organization. Undoubtedly, many of the peculiar cases of mass madness were related to the depression, fear, and wild mysticism engendered by the terrible events of this period. People simply could not believe that frightening catastrophes such as the Black Death could have natural causes and thus could be within their power to control, prevent, or even create.

Today, so-called mass hysteria occurs occasionally; the affliction usually mimics some type of physical disorder such as fainting spells or convulsive movements. A case of apparent mass hysteria occurred among hundreds of West Bank Palestinian girls in April 1983. This episode threatened to have serious political repercussions because some Arab leaders initially thought that the girls had been poisoned by Israelis. Health officials later concluded that psychological factors had played a key role in most of the cases (Hefez, 1985 ).

Ilechukwu ( 1992 ) describes an epidemic of mass hysteria that occurred in Nigeria in 1990 in which many men feared that their genitals had simply vanished. This fear of genital retraction accompanied by a fear of death is referred to as koro and has been widely documented in Southeast Asia. The afflicted persons believe this genital disappearance was caused by a supernatural occurrence in which they were robbed of their genitalia in order to benefit other people magically. Ilechukwu attributes some of this panic to male resentment of women’s success during a period of social strain and the symbolic equation between masculine sexuality and economic, social, and creative prowess.