From an “imbalance of the humors” requiring leeches to a “possession by the devil” requiring whipping or an exorcism onwards to dysfunction to be cured essentially via torture, society’s perspective of mental health and treatment has come a long way to get where it is now. What once was seen as an influence of the heavens or simply a lack of training has become the theory of “cognitive imbalance,” and the torture devices of the previous century have been retired and replaced by psychopharmaceuticals.
Let’s skip over ancient history and look at how our collective understanding of the human mind, including mental health and mental illness, have changed in the last 100 years. Afterward, I plan to discuss what I perceive as some of our modern techniques and perspectives that will likely look archaic within the next 75 years.
At around the same time Sigmund Freud was working with Karl Jung to develop their psychoanalytical model of the human psyche, people were being imprisoned and essentially tortured for everything ranging from nervousness to paranoia. As Aaron Jackson’s article on the subject makes abundantly clear: people seemed to think that you could cure mental illness through physical and mental anguish.
The late 20th century brought more humanitarian treatment methods like cognitive-behavioral therapy and patient-centered incongruence reduction oriented humanistic therapy pioneered by Carl Rogers. A move was made away from seeing the patient as a dysfunctional “object” that needed to be “filled with healing” into seeing the patient as a subject who was complicit and involved in their own recovery process.
This realization that thinking (cognitive) and habit-based (behavioral) learning could play a role in helping people achieve mental health led to therapies based more on communicating and working with the patient and less oriented towards driving their problems out of them like demons in need of an exorcism.
Sometime in the 1960s, there was a split in psychology where many institutions decided on a primary use of pharmacology to treat behavioral and perception based disorders. Attention to “person-centered” therapies, and even the classic behavior-cognitive therapy, was relegated to the outskirts of mainstream psychology and a distant patient-doctor relationship and a treatment regiment based principally on the question of dose became normal.
The Rosenhan-Experiment (from the early 1970s, published in 1973) is one of my favorite examples of how a dehumanized pharmacological approach to mental health can lead to grievous mistakes. Psychologist David Rosenhahn wanted to see how mental asylums dealt with benign psychological problems or oddities, and in the first part of the experiment Rosenhan and 7 colleagues (totalling 3 women and 5 men) went to psychiatric hospitals in 5 different states.
Rosenhan and his 7 compatriots feigned benign auditory hallucinations, claiming to have heard words like “thud” or “bop”, but were otherwise to display normal and well-adapted behavior. All of them, without exception, were admitted and diagnosed with various psychiatric disorders (primarily schizophrenia) based on this interview despite the fact that hearing “thud” or “bop” was not listed as a marker of any psychiatric disorder. Absolutely none of them was allowed to leave the hospitals without first taking medication, and none was taken seriously when they attempted to talk to the staff about the situation.
Their stays ranged from 7 to 52 days, and the average was 19 days. All were discharged with a diagnosis of schizophrenia “in remission”, which Rosenhan took as evidence that mental illness is perceived as an irreversible condition creating a lifelong stigma, rather than a curable illness or phase.They were each given an average period of 6.7 minutes per day to talk to a doctor: not enough to adequately communicate or exchange any real information.
Rosenhahn extended this experiment after he and his colleagues’ releases: he informed the psychiatric hospitals of what we had done and challenged them to find the correct “fake patients,” which he implied to be sending over the next few months. The psychiatric hospitals found dozens of “imposters,” only to be snidely informed by Rosenhahn that he had not sent any further “fakers” to the hospitals.
This was a shocking indictment of blanket psychotropic therapy: if doctors could not even agree on who was actually mentally ill, and had no idea what was causing the disorder, then why would 6.7 minutes of doctor contact along with psychoactive pharmaceuticals be an effective therapy?
Even to this day, psychiatric hospitals and much of clinical psychology ignore the fact that a person can have a psychotic episode or delusions at one point in their life and then never again. The idea that having such an episode once makes you a “schizophrenic” in need of medication for the rest of your life flies in the face of our current model of the human brain. A study of the lifetime prevalence of psychotic experiences in the general population found that at least 3% of the population experiences a psychotic episode at least once in their lives, but yet only 1 in 2000 people is diagnosed with schizophrenia. This means that the vast majority of those who have experienced some type of psychotic episode never end up with a sustained psychosis and do not end up needing life-long medication to avoid future episodes.
Although we have moved away from considering homosexuality as a mental illness since the 1970s, we are still dehumanizing patients and treating many people with problems as if they were simply a shell to be “fixed” with the “right” drug. Medication has improved, and we have moved from putting people into insulin shock towards treatment based on pharmacology and neural science. The problem with this is that a lot of the medication is not nearly as effective as presented due to publication bias and the complicit silence of the FDA.
In an optimized future, we would combine patient-centered therapy with personalized medicine. Many mental health issues are attributable to failings in community and family structure to compensate for or teach compensation strategies to those with psychological problems. There exist many circumstances in which genetic predisposition makes individuals more likely to have certain problems, but different predispositions can also lead to the same problem or “behavioral phenotype,” and treatment will approach them primarily on a personal level instead of a standardized model dependent on medication.
In my opinion, it would be smart to use of genetic resources to see how much and what parts of a problem stem primarily from genetic predisposition instead of behavioral or cognitive programming. This type of genetic profile would also allow doctors to know what types of therapy or medicine will be most helpful or even dangerous for that individual.
In the future, the pharmacokinetics and pharmacodynamics of drugs will be tested on highly advanced chips with human cells carrying different receptor and enzyme types representing different sectors of the human population. At every step in LADME (Liberation-Absorption-Distribution-Metabolism-Excretion) we could see how different medications, or even levels of gene expression, can effect what a drug will do. This would make animal testing obsolete and allow medication to be used strategically and without side-effects in instances where it is needed, and also allow an avoidance of medication in instances where drugs would not necessary help solve any problems.
Many psychological problems can be more sustainably and effectively solved without the use of medication, including depression. In cases where medication is helpful it can be a great thing, but a doctor cannot determine this simply by using a checklist and a patient’s subjective perspective. We all know how prone people are to believing themselves sick with everything from parasites to Ebola once they’ve read a list of symptoms, so why should we expect their perspective to become more valid when asked yes or no questions by a psychologist?
The future will likely hold a move away from standardized treatments for behavioral phenotypes and a move towards identifying the root of a problem and then applying specific treatments.