Reflections on Treatment Options

History and Philosophy of Psychology, First Edition. Man Cheung Chung and Michael E. Hyland.
© 2012 Man Cheung Chung and Michael E. Hyland. Published 2012 by Blackwell Publishing Ltd.

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History of Clinical Psychology
and Philosophy of Mental Health

People who are mentally ill sometimes engage in deviant behaviour, that is,
behaviour that would be described in common terms as ‘odd.’ There are two ways
of interpreting that deviant behaviour. One way is to interpret it not as illness but
as a morally wrong set of behaviours. The person is ‘normal’ and the only problem
is that what they are doing is wrong. Such ‘wrong’ behaviour has to be controlled.
The other way of interpreting the deviant behaviour is as illness, and so the
emphasis is on treating the illness rather than controlling the behaviour. In essence,
these two interpretations differ over whether deviant behaviour is labelled as ‘bad’
or ‘mad’. These two interpretations have co-existed at the same time in history, at
least until about 200 years ago. If the person is ‘bad’ then they should live in the
community but suffer the consequences of their atypical behaviour – unless they
are dangerous in which case they need to be locked up. If the person is ‘mad’ then
they need to be treated by therapies.

The history of clinical psychology is so closely linked to psychiatry that the two
need to be considered at the same time (Porter, 1987, 1988, 1991). The difference
between psychology and psychiatry is one of training. Psychiatrists are trained in
medicine, so the psychiatric approach to mental illness follows the medical tradi-
tion, or at least, the medical tradition of the time. Medical treatment of mental
illness has a history of more than two thousand years. By contrast, psychologists
have a psychological training, and their approach to mental illness can also be con-
sidered as part of the psychological tradition of the time. Psychological treatment
of mental illness is comparatively recent. Neither the medical nor psychological
traditions have remained static, so the relationship between the two changes over
time. Over time there have been various ‘tensions’, sometimes between different
psychiatrists, sometimes between different psychologists and sometimes between
psychiatrists and psychologists. These tensions include:

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Chung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882.
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Clinical Psychology and Philosophy of Mental Health 271

a. a tension between religious and a natural science interpretation of mental
illness;

b. a tension between the Hippocratic system and the system of modern Western
medicine;

c. a tension between a biological versus a psychological interpretation;
d. a tension between psychoanalytic versus behaviourist interpretations.

Religion Versus Natural Science

The Greek physician Hippocrates (460–377 BC) was born of a family of priest-
physicians but rejected the current superstitious belief that illness, including
mental illness was the work of the gods, and could be cured by superstitious
charms and prayers. He suggested an empirical method in understanding illness,
but also believed in a spiritually restoring principle or essence that the physician
could use to effect a cure (Alexander & Selesnick, 1966; Bynum, Porter & Shepherd,
1985; Jackson, 1986; Maher & Maher, 1985a). He believed that the brain was the
source of epilepsy and dementia and provided a variety of cures, including bleed-
ing, but also a variety of lifestyle and dietary recommendations. The technique of
bleeding a patient was not invented by Hippocrates himself – it can be traced back
to ancient Egyptian medicine.

The assumption of Hippocratic medicine that disease was caused by an imbal-
ance of bodily humours was accepted in the west for the next two thousand years.
There are four bodily humours: black and yellow bile, phlegm and blood. Ayurvedic
(i.e. traditional Indian) and traditional Chinese medicine also adopted similar
assumptions that disease was caused by an imbalance – an imbalance of three
doshas in the case of Ayurvedic medicine and of the five elements in traditional
Chinese medicine (Deng, 1999). The consequence of these assumptions is that
mental illness is located firmly within a biological conceptualization of illness,
and that mental illness is not seen as separate from physical illness. For example,
Hippocrates believed that hysteria was a purely female complaint and caused by a
wandering uterus (the Greek word hysterion means uterus). Galen, who was a phy-
sician during the 1st century AD (he was born in Turkey but often described as a
Roman physician), transmitted and extended Hippocrates’ ideas throughout the
Roman Empire and believed that mental and physical disease were linked. For
instance, he believed that melancholia (depression) in women caused breast cancer.

It is a noticeable feature of all the main traditional medical systems (Hippocratic,
Ayurvedic and traditional Chinese) that lifestyle, diet and psychology are important
parts of treatment, as well as herbs and other treatments (e.g. acupuncture,
enemas, massage). In Ayurvedic medicine, for example, the most important
therapeutic technique is meditation, and there is a clear emphasis on the need to
treat the psychological state of a person in order to achieve physical cures. This
link between the mental and the physical extends to recommendations for diet –
a vegetarian diet is assumed to promote the ability to meditate. Not only are diets

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272 History and Philosophy of Psychology

recommended according to the type of person (note: not the type of disease) but
in the case of traditional Chinese medicine, dietary recommendations also depend
on the weather. For example, spicy food is supposed to be better when the weather
is wet and cold.

In sum, the traditional medical approach does not treat mental illness as separate
from physical illness. Traditional medical practitioners do not have specialisms
because they treat the whole person not the disease. Thus, in the traditional
medical system, there is no such person as a psychiatrist or clinical psychologist,
there is a simply a therapist working within that medical tradition. An important
feature of all these traditional medical systems is that they reject supernatural
explanations which have always occurred in parallel with them. They also assume
that mental illness has a biological basis which is caused by an imbalance in the
principles that are supposed to be in balance.

Where there are strong religious belief systems, then mental illness is assumed
to have a supernatural origin. This supernatural view occurs in various guises
throughout history, both in the West under the influence of the Catholic Church,
and all other countries. In Africa, for example, the superstitious beliefs have led to
the idea of voodoo. Underlying this view is the belief that illness (often mental and
physical) is caused by another person, often a witch, and often but not always as an
intention of that other person to cause harm. This view fuelled the persecution of
witches that occurred between 1450 and 1750, which was officially sanctioned by
the Catholic Church. Pope Innocent VIII authorized the persecution of witches in
1484 and the practice was guided by a book called Malleus Maleficarum (The Witches’
Hammer) written by two Dominican priests who acted as inquisitors in Germany.
Malleus Maleficarum was used extensively by judges throughout Europe as a guide
to detecting witches. Anyone who behaved oddly (i.e. the mentally ill) could be
accused of being a witch, and these unfortunate individuals were tortured if they
refused to confess to gruesome witches’ practices. Whether or not they confessed,
these people were then killed, by burning, hanging or beheading, and their
confessions fuelled further belief in the existence of witches (Trevor-Roper, 1967).

The idea that people who are mentally ill are possessed by the devil is consistent
with the ‘bad’ not ‘mad’ perspective, and leads to a variety of sometimes inhumane
treatments, as a way of making the devil leave the person’s body, typically involving
some kind of physical pain on the basis that devils don’t like pain. Not all such
treatments are inhumane. Some undeveloped tribes in Africa and South America use
ritualistic ‘theatre’ where a healer, often with the help of the whole tribe, tries to drive
out the devil by exhortation. However, in the West, the supernatural belief in the
cause of mental illness led to the mentally ill being confined in difficult circumstances.

In the 15th century, mentally ill people were sometimes confined to a ‘ship of
fools’ (Foucault, 1962, 1967). The first mental Asylum was founded in Valencia in
Spain in 1409 with the explicit purpose of locking up those who were unable to
live in society. In 1547 Henry VIII founded an asylum at the priory of St Mary of
Bethlehem in London. This ‘hospital’ or Bedlam as it came to be known housed
mentally ill people in sordid, degrading conditions (MacDonald, 1981; Scull, 1979;

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Clinical Psychology and Philosophy of Mental Health 273

Shorter, 1998). Londoners would come to view the madmen through the iron
gates for a Sunday excursion, and viewing of madmen for entertainment (tickets
were sold for a view) went on into the early 19th century. The exceptions to poor
treatment occurred where mild mental illness occurred amongst wealthy people
(e.g. nobles). In the middle ages, ‘odd’ people from the nobility were often sent to
live in monasteries – which provide a safe and generally caring environment.
Nevertheless, for the majority the only treatment was incarceration in Bedlam, or
some similar degrading institution.

Robert Burton’s (1577–1640/1836) Anatomy of Melancholy was first published in
1621 and then went through six ever expanding editions with a last edition in1651.
The book can be seen as part of the Renaissance – the belief in rationality rather
than divine authority of the church. Burton provides a very detailed account of
what various authorities had said about the cause of melancholy – what would be
now called depression – as well as the various cures. Burton’s writing spans the
wide range of religious and scientific treatments then available, and included
cynical and often witty comments about some of the interpretations and
treatments and causes. Burton believed that melancholy had a physical not a
supernatural cause. His book can be interpreted as rational man trying to find
a rational solution when none was readily available. The following quotes are
taken from the electronic version of the book at http://www.gutenberg.org/
ebooks/10800 (no page numbers are given) and which the interested student
might care to examine in more detail:

‘To give some satisfaction to melancholy men that are troubled with these
symptoms, a better means in my judgment cannot be taken, than to show them the
causes whence they proceed; not from devils as they suppose, or that they
are bewitched or forsaken of God, hear or see, &c. as many of them think, but from
natural and inward causes, that so knowing them, they may better avoid the effects,
or at least endure them with more patience.’

‘Tis a common practice of some men to go first to a witch, and then to a physician,
if one cannot the other shall,‘

‘We must use our prayer and physic both together: and so no doubt but our prayers
will be available, and our physic take effect.’

Stanley (2000) provides a useful review of Burton’s book, pointing out that not
only was prayer suggested as cure but also herbal remedies such as marigold, black
hellebore, and mugwort featured as possible remedies. Wine was a possible cure as
was blood letting, leeches (particularly if applied to haemorrhoids) as well as
boring holes in the head to let out the vapours.

Burton examined a whole variety of techniques for curing depression, some of
which he dismissed as fanciful, but many others he suggested might be effective,
and these effective therapies included remedies based on the Hippocratic tradition
such as blood letting (to reduce levels of blood) and purging (to reduce levels of
phlegm). Purging involved either getting the person to vomit or causing diarrhoea.

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274 History and Philosophy of Psychology

Burton’s book was popular because it fitted with the growing trend in society
for rational thought. Of course, neither marigolds, boring holes in the head nor
blood letting are effective treatments for mental illness, but at least there was an
attempt for rational rather than supernatural interpretation. Burton was writing at
a time when persecution of witches was at its height, and which continued for
some time afterwards. The last legal execution of a condemned witch occurred in
Switzerland in 1782. Modern psychiatry can therefore be seen as the consequence
of the success of a rational, scientific cause of mental illness in contrast to a
religious interpretation.

Hippocratic Versus Modern Medicine

The principles underlying Hippocratic medicine continued to be applied to mental
illness right up to the 19th century. William Battie1 published his Treatise on Madness
in 1758. Battie believed in consequential illness – that particular events and experi-
ences could cause illness, and he was not optimistic about treatments. Battie wrote:

‘Madness is frequently taken for one species of disorder, nevertheless, when
thoroughly examined, it discovers as much variety with respect to its causes and
circumstances as any distemper whatever: Madness, therefore, like most other
morbid cases, rejects all general methods, e.g. bleeding blisters, caustics, rough
cathartics, the gumms and faetid anti-hysterics, opium, mineral waters, cold bathing
and vomits.’ (cited in Morris, 2008)

Battie’s treatise was the subject of considerable debate. John Monro who was the
physician to the Bethlem hospital (Bedlam) believed that it was possible to cure
madness and was a strong believer in the ‘cure’ effected by causing the patient to vomit.

Monro (1758) disagreed with Battie’s treatise and published the reasons for his
disagreement in a book published two months later. He provided strong support
for the method of getting patients to vomit. The rationale for this treatment was
that madness was caused by an excess of phlegm, and phlegm could be reduced by
vomiting. Incidentally, an excess of phlegm did not cause only madness – it also
could lead to other diseases that affected breathing (nowadays called bronchitis
and asthma).

‘Notwithstanding we are told in this treatise, that madness rejects all general
methods, I will venture to say, that the most adequate and constant cure of it is by
evacuation; which can alone be determined by the constitution of the patient and
the judgment of the physician. The evacuation by vomiting is infinitely preferable to
any other, if repeated experience is to be depended on…’ (Munro, 1758, p. 50)

‘I never saw or heard of the bad effect of vomits, in my practice; nor can I suppose
any mischief to happen, but from their being injudiciously administered; or when
they are given too strong, or the person who orders them is too much afraid of the
lancet.’ (Munro, 1758, p. 50)

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Clinical Psychology and Philosophy of Mental Health 275

‘The prodigious quantity of phlegm, with which those abound who are troubled
with the complaint, is not to be got the better of but by repeated vomits; and we very
often find, that purges have not their right effect, or do not operate to so good
purpose, until the phlegm is broken and attenuated by frequent emeticks.’
(Munro, 1758, pp. 50–1)

If one considers that being made to vomit is an aversive experience, it would follow
that people would be less likely to exhibit ‘unusual’ behaviours if someone was to
treat them with the vomiting cure! During the 19th century, other aversive treat-
ments included cold water baths and showers based on the principle of shock,
swinging chairs that induced fear and disorientation of the disturbed senses. The
Benjamin Rush’s ‘Tranquilizer, consisted of a box placed over the patient’s head
and the patient being strapped into a chair. The ‘tranquilizer’ was designed to
inhibit sensation and therefore irritation but in fact it was an early form of sensory
deprivation. Inhibition could be achieved by the straitjacket (invented in 1790) –
which inhibited movement of the arms but allowed the patient to walk around.
Although these inhibitory techniques were introduced with the best intentions, the
idea of sensory deprivation as a punishment was in fact used in the Model Prison in
Tasmania in the 19th century, as it was recognized that isolation was, as a type of
psychological punishment, more effective than the physical punishment of beating.

While mental illness was being treated using techniques deriving from the
Hippocratic tradition, an alternative to Hippocratic medicine was being developed,
which was being applied to physical illness and so could potentially be applied to
mental illness (Maher & Maher, 1985b). Instead of seeing illness as being caused by
an imbalance in humours, the new approach believed that there was a specific and
local cause for all illnesses. This new belief was based on an analogy of the body as
a mechanical system – and reflected the earlier development of clockwork and
other mechanical devices. So, for example, heart disease was caused by pathology
of the heart, rather than by an excess of blood. According to this perspective,
disease is caused by something analogous to a broken cog. There is something that
is wrong in the body which if corrected will cure the disease. A number of
physicians were behind this new approach, but the best known is Rudolf Virchow
(1821–1902), a pathologist who is famous for his declaration that there was no such
thing as non-specific illness (the basis for Hippocratic medicine) only specific illness
(Rather, 1958).

This new type of medicine formed the basis of modern Western medicine, and
became increasingly successful during the 19th century for several reasons. First,
there was evidence from the examination of corpses that diseases did indeed
involve specific pathophysiologies. Second, different diseases were associated with
different types of tissue abnormality. Finally diseases were shown to have distinct
characteristics at a cellular level. Each disease was found to be associated with a
particular physiological abnormality. If physical illness could be shown to be
caused by physiological abnormalities, it became logical to look for the causes of
mental illness in terms of pathophysiology of the brain.

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276 History and Philosophy of Psychology

The idea of specific pathophysiology was applied to mental illness in the early
19th century, with several authors suggesting that some kind of pathology in the
brain was responsible. This view was supported particularly by Wilhelm Griesinger
who was a psychiatrist working in Berlin. His textbook, Pathology and Therapy of
Mental Illnesses for Doctors and Students was published in 1845. One reason for
supporting this new form of biological cause of illness was the discovery that
syphilis was caused by a microbe. Advanced syphilis leads to a form of dementia,
and so it is logical to conclude that this dementia is caused by the microbe.
Griesinger believed that other specific and local explanations would explain other
mental diseases.

Although there was little in the way of new therapies, there was now a belief
that each mental illness was due to a different physiological abnormality, and
therefore each mental illness would respond to a different type of treatment,
namely a treatment that corrected that physiological abnormality. Hippocratic
techniques such as blood letting and purging were used both for physical and men-
tal problems. The same treatment would be used irrespective of the disease. The
hope engendered by the new biological theory of mental disease was that in time
new treatments would be discovered that applied solely to mental illness.

The pioneers in the new way of thinking about mental illness also suggested an
alternative approach to treatment. When Philippe Pinel (1745–1826) was put in
charge of a mental asylum in Paris, he decided that inmates should no longer be
shackled (Pinel, 1801/1962). Vicenzio Ciarugi (1759–1826) in Italy and Benjamin
Rush (1745–1813) in America also encouraged humane treatment of mentally ill
people. All three believed that the cause of mental illness was a specific pathology
of the brain, not an imbalance of humours. Rush, in particular, was dismissive of
the techniques based on the older Hippocratic medicine suggesting that they did
no good at all (Rush, 1812).

Moral Treatment

During the 19th century, the view that mental illness was caused by a
pathophysiology was gaining momentum, bolstered in part by the success of this
particular approach in other areas of medicine. However, in parallel with this
scientific approach a rather different religious inspired view of mental illness was
developing. During the late 18th century, Christianity and Protestant Christianity
in particular had moved away from an emphasis on the supernatural and towards
a moral position on contemporary life. Christianity was a moral framework for
understanding the world, and this moral framework included the concept of
charity. These moral Christians were instrumental in setting up an alternative
psychological framework for understanding mental illness. The psychological
framework was one where mental illness was seen as a psychologically caused
illness, and one where unsatisfactory environmental factors could contribute to
disease. So, in the 19th century an alternative type of treatment was development,

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Clinical Psychology and Philosophy of Mental Health 277

called ‘moral treatment’. In England, William Tuke (1732–1822) established the
York Retreat as an asylum with calming and religious overtones – Tuke was a
Quaker and philanthropist (Tuke, 1813/1964).

In the United States Dorothea Lynde Dix (1802–1887) was a teacher who, on
realizing how terrible asylums were, campaigned for better and more humane
treatment of the mentally ill (Dix, 1971/1843–1852). Neither of these were
medically trained. Both they and others like them provided a means for
caring for the mentally sick, where the money was often raised by charitable
donations.

Moral treatment had several characteristics. One was the idea that a person,
such as a doctor, could impose moral authority on the ill patient and so change
the ‘vicious chain of ideas’ which the patient was prone to experience. The idea
of moral authority ties in well with the idea of Church authority. There should be
a person or institution in charge which imposes on the will of others. A second
feature of moral treatment was that the mentally ill should be restrained in cir-
cumstances of harmony and peace – so they should be placed in pleasant rather
than degrading circumstances. A third feature of the moral treatment was the
idea that the patient should be subjected to discipline so as to lead a regular and
orderly life.

Those approaching mental illness from the point of view of ‘moral treatment’
as well as those adopting the new biological framework both believed in the
humane treatment of the mentally ill. The old asylums for restraining the ill were
built in cities. The new institutions for the care of the mentally ill were built in the
country, and there was an attempt to make them attractive. The new institutions
were also shielded from the public so that the degrading spectacle of the mentally
ill being ‘exhibited’ would not occur – though this also shielded the public from the
uncomfortable truth that the mentally ill existed. Mental institutions were built
with a curved drive way so they were not visible from the road – which is the origin
of the expression ‘going round the bend’. Many institutions were built in the
19th century based on a mixture of moral treatment as well as the very limited
treatments offered by the biological perspectives. One of these latter treatments,
invented by Rush, was the tranquilizing chair. The patient was strapped into a
chair so as to prevent movement, and prevented from seeing or hearing anything,
for hours at a time. So although there was a belief in humanity in the 19th century
treatment, this humanity was tempered by a somewhat strict view about how to
achieve good behaviour.

The mental asylums of the 19th century were large institutions with
attractive grounds that were to a large extent self-sustaining. There would be
a farm, and a laundry, and when electric lighting was invented, many asylums
had their own electric generator. As far as possible all work on the asylum was
carried out by inmates. There is a curious parallel between the asylums of the
19th century and monasteries of the middle ages. Both were safe havens for
the mentally vulnerable. Both were self-contained societies that operated, to
some extent, independently of the world outside. Some, such as Tuke’s York

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