In any given year, as many as 30 percent of the adults and 19 percent of the children and adolescents in the United States display serious psychological disturbances and are in need of clinical treatment (Merikangas et al., 2013; Kessler et al., 2012, 2009, 2007, 2005). The rates in other countries are similarly high. Furthermore, most people have difficulty coping at various times and go through periods of extreme tension, dejection, or other forms of psychological discomfort.

It is tempting to conclude that something about the modern world is responsible for these many emotional problems—perhaps rapid technological change, the growing threat of terrorism, or a decline in religious, family, or other support systems (Gelkopf et al., 2013; North, 2010) (see PsychWatch below). Although the pressures of modern life probably do contribute to psychological dysfunctioning, they are hardly its primary cause (Wang et al., 2010). Every society, past and present, has witnessed psychological abnormality. Perhaps, then, the proper place to begin our examination of abnormal behavior and treatment is in the past.

Historians who have examined the unearthed bones, artwork, and other remnants of ancient societies have concluded that these societies probably regarded abnormal behavior as the work of evil spirits. People in prehistoric societies apparently believed that all events around and within them resulted from the actions of magical, sometimes sinister, beings who controlled the world. In particular, they viewed the human body and mind as a battleground between external forces of good and evil. Abnormal behavior was typically interpreted as a victory by evil spirits, and the cure for such behavior was to force the demons from a victim’s body.

This supernatural view of abnormality may have begun as far back as the Stone Age, a half-million years ago. Some skulls from that period recovered in Europe and South America show evidence of an operation called trephination, in which a stone instrument, or trephine, was used to cut away a circular section of the skull (Heeramun-Aubeeluck & Lu, 2013). Some historians have concluded that this early operation was performed as a treatment for severe abnormal behavior—either hallucinations, in which people saw or heard things not actually present, or melancholia, characterized by extreme sadness and immobility. The purpose of opening the skull was to release the evil spirits that were supposedly causing the problem (Selling, 1940).

In recent decades, some historians have questioned whether Stone Age people actually believed that evil spirits caused abnormal behavior. Trephination may instead have been used to remove bone splinters or blood clots caused by stone weapons during tribal warfare (Maher & Maher, 2003, 1985). Either way, later societies clearly did attribute abnormal behavior to possession by demons. Egyptian, Chinese, and Hebrew writings all account for psychological deviance this way. The Bible, for example, describes how an evil spirit from the Lord affected King Saul and how David feigned madness to convince his enemies that he was visited by divine forces.

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The treatment for abnormality in these early societies was often exorcism. The idea was to coax the evil spirits to leave or to make the person’s body an uncomfortable place in which to live. A shaman, or priest, might recite prayers, plead with the evil spirits, insult the spirits, perform magic, make loud noises, or have the person drink bitter potions. If these techniques failed, the shaman performed a more extreme form of exorcism, such as whipping or starving the person.

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In the years from roughly 500 b.c. to 500 a.d., when the Greek and Roman civilizations thrived, philosophers and physicians often offered different explanations and treatments for abnormal behaviors. Hippocrates (460–377 b.c.), often called the father of modern medicine, taught that illnesses had natural causes. He saw abnormal behavior as a disease arising from internal physical problems. Specifically, he believed that some form of brain pathology was the culprit and that it resulted—like all other forms of disease, in his view—from an imbalance of four fluids, or humors, that flowed through the body: yellow bile, black bile, blood, and phlegm (Wolters, 2013; Zuckerman, 2011). An excess of yellow bile, for example, caused mania, a state of frenzied activity; an excess of black bile was the source of melancholia, a condition marked by unshakable sadness.

To treat psychological dysfunctioning, Hippocrates sought to correct the underlying physical pathology. He believed, for instance, that the excess of black bile underlying melancholia could be reduced by a quiet life; a diet of vegetables; temperance; exercise; celibacy; and even bleeding. Hippocrates’ focus on internal causes for abnormal behavior was shared by the great Greek philosophers Plato (427–347 b.c.) and Aristotle (384–322 b.c.) and by influential Greek and Roman physicians.

The enlightened views of Greek and Roman physicians and scholars were not enough to shake ordinary people’s belief in demons. And with the decline of Rome, demonological views and practices became popular once again. A growing distrust of science spread throughout Europe.

From 500 to 1350 a.d., the period known as the Middle Ages, the power of the clergy increased greatly throughout Europe. In those days the church rejected scientific forms of investigation, and it controlled all education. Religious beliefs, which were highly superstitious and demonological, came to dominate all aspects of life. Once again behavior was usually interpreted as a conflict between good and evil, God and the devil. Deviant behavior, particularly psychological dysfunctioning, was seen as evidence of Satan’s influence. Although some scientists and physicians still insisted on medical explanations and treatments, their views carried little weight in this atmosphere.

The Middle Ages were a time of great stress and anxiety—of war, urban uprisings, and plagues. People blamed the devil for these troubles and feared being possessed by him (Sluhovsky, 2011). Abnormal behavior apparently increased greatly during this period. In addition, there were outbreaks of mass madness, in which large numbers of people apparently shared delusions (absurd false beliefs) and hallucinations (imagined sights or sounds). In one such disorder, tarantism (also known as Saint Vitus’ dance), groups of people would suddenly start to jump, dance, and go into convulsions (Prochwicz & Sobczyk, 2011; Sigerist, 1943). Some dressed oddly; others tore off their clothing. All were convinced that they had been bitten and possessed by a wolf spider, now called a tarantula, and they sought to cure their disorder by performing a dance called a tarantella. In another form of mass madness, lycanthropy, people thought they were possessed by wolves or other animals. They acted wolflike and imagined that fur was growing all over their bodies.

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Not surprisingly, some of the earlier demonological treatments for psychological abnormality reemerged during the Middle Ages. Once again the key to the cure was to rid the person’s body of the devil that possessed it. Exorcisms were revived, and clergymen, who generally were in charge of treatment during this period, would plead, chant, or pray to the devil or evil spirit (Sluhovsky, 2011, 2007). If these techniques did not work, they had others to try, some amounting to torture.

It was not until the Middle Ages drew to a close that demonology and its methods began to lose favor. Towns throughout Europe grew into cities, and government officials gained more power and took over nonreligious activities. Among their other responsibilities, they began to run hospitals and direct the care of people suffering from mental disorders. Medical views of abnormality gained favor once again, and many people with psychological disturbances received treatment in medical hospitals, such as the Trinity Hospital in England (Allderidge, 1979).

During the early part of the Renaissance, a period of flourishing cultural and scientific activity from about 1400 to 1700, demonological views of abnormality continued to decline. German physician Johann Weyer (1515–1588), the first physician to specialize in mental illness, believed that the mind was as susceptible to sickness as the body was. He is now considered the founder of the modern study of psychopathology.

The care of people with mental disorders continued to improve in this atmosphere. In England, such individuals might be kept at home while their families were aided financially by the local parish. Across Europe, religious shrines were devoted to the humane and loving treatment of people with mental disorders. Perhaps the best known of these shrines was at Gheel in Belgium. Beginning in the fifteenth century, people came to Gheel from all over the world for psychic healing. Local residents welcomed these pilgrims into their homes, and many stayed on to form the world’s first “colony” of mental patients. Gheel was the forerunner of today’s community mental health programs, and it continues to demonstrate that people with psychological disorders can respond to loving care and respectful treatment (Guarnieri, 2009; Aring, 1975, 1974). Many patients still live in foster homes there, interacting with other residents, until they recover.

Unfortunately, these improvements in care began to fade by the midsixteenth century. Government officials discovered that private homes and community residences could house only a small percentage of those with severe mental disorders and that medical hospitals were too few and too small. More and more, they converted hospitals and monasteries into asylums, institutions whose primary purpose was to care for people with mental illness. These institutions were begun with the intention that they would provide good care (Kazano, 2012). Once the asylums started to overflow, however, they became virtual prisons where patients were held in filthy conditions and treated with unspeakable cruelty.

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In 1547, for example, Bethlehem Hospital was given to the city of London by Henry VIII for the sole purpose of confining the mentally ill. In this asylum, patients bound in chains cried out for all to hear. The hospital even became a popular tourist attraction; people were eager to pay to look at the howling and gibbering inmates. The hospital’s name, pronounced “Bedlam” by the local people, has come to mean a chaotic uproar (Selling, 1940). Such asylums remained a widely used form of “care” until the late 1700s.

As 1800 approached, the treatment of people with mental disorders began to improve once again (Schuster et al., 2011; Maher & Maher, 2003). Historians usually point to La Bicêtre, an asylum in Paris for male patients, as the first site of asylum reform. In 1793, during the French Revolution, Philippe Pinel (1745–1826) was named the chief physician there. He argued that the patients were sick people whose illnesses should be treated with sympathy and kindness rather than chains and beatings (Yakushev & Sidorov, 2013). He unchained the patients and allowed them to move freely about the hospital grounds; replaced the dark dungeons with sunny, well-ventilated rooms; and offered support and advice. Pinel’s approach proved remarkably successful. Many patients who had been shut away for decades improved greatly over a short period of time and were released. Pinel later brought similar reforms to a mental hospital in Paris for female patients, La Salpetrière.

Meanwhile, an English Quaker named William Tuke (1732–1819) was bringing similar reforms to northern England. In 1796 he founded the York Retreat, a rural estate where about 30 mental patients lived as guests in quiet country houses and were treated with a combination of rest, talk, prayer, and manual work (Raad & Makari, 2010).

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The Spread of Moral TreatmentThe methods of Pinel and Tuke, called moral treatment because they emphasized moral guidance and humane and respectful techniques, caught on throughout Europe and the United States. Patients with psychological problems were increasingly perceived as potentially productive human beings whose mental functioning had broken down under stress. They were considered deserving of individual care, including discussions of their problems, useful activities, work, companionship, and quiet.

The person most responsible for the early spread of moral treatment in the United States was Benjamin Rush (1745-1813), an eminent physician at Pennsylvania Hospital who is now considered the father of American psychiatry. Limiting his practice to mental illness, Rush developed humane approaches to treatment (Grossman, 2013; Rush, 2010). For example, he required that the hospital hire intelligent and sensitive attendants to work closely with patients, reading and talking to them and taking them on regular walks. He also suggested that it would be therapeutic for doctors to give small gifts to their patients now and then.

Rush’s work was influential, but it was a Boston schoolteacher named Dorothea Dix (1802–1887) who made humane care a public and political concern in the United States. From 1841 to 1881, Dix went from state legislature to state legislature and to Congress speaking of the horrors she had observed at asylums and calling for reform. Dix’s campaign led to new laws and greater government funding to improve the treatment of people with mental disorders (Davidson et al., 2010; Zilboorg & Henry, 1941). Each state was made responsible for developing effective public mental hospitals, or state hospitals, all of which were intended to offer moral treatment. Similar hospitals were established throughout Europe.

The Decline of Moral TreatmentBy the 1850s, a number of mental hospitals throughout Europe and America reported success using moral approaches. By the end of that century, however, several factors led to a reversal of the moral treatment movement (Kazano, 2012; Cautin, 2011; Bockoven, 1963). One factor was the speed with which the movement had spread. As mental hospitals multiplied, severe money and staffing shortages developed, recovery rates declined, and overcrowding in the hospitals became a major problem. Another factor was the assumption behind moral treatment that all patients could be cured if treated with humanity and dignity. For some, this was indeed sufficient. Others, however, needed more effective treatments than any that had yet been developed. An additional factor contributing to the decline of moral treatment was the emergence of a new wave of prejudice against people with mental disorders. As more and more patients disappeared into large, distant mental hospitals, the public came to view them as strange and dangerous. In turn, people were less open-handed when it came to making donations or allocating government funds. Moreover, many of the patients entering public mental hospitals in the United States in the late nineteenth century were poor foreign immigrants, whom the public had little interest in helping (see MediaSpeak below).

By the early years of the twentieth century, the moral treatment movement had ground to a halt in both the United States and Europe. Public mental hospitals were providing only custodial care and ineffective medical treatments and were becoming more overcrowded every year. Long-term hospitalization became the rule once again.

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As the moral movement was declining in the late 1800s, two opposing perspectives emerged and began to compete for the attention of clinicians: the somatogenic perspective, the view that abnormal psychological functioning has physical causes, and the psychogenic perspective, the view that the chief causes of abnormal functioning are psychological. These perspectives came into full bloom during the twentieth century.

The Somatogenic PerspectiveThe somatogenic perspective has at least a 2,400-year history—remember Hippocrates’ view that abnormal behavior resulted from brain disease and an imbalance of humors? Not until the late nineteenth century, however, did this perspective make a triumphant return and begin to gain wide acceptance.

Two factors were responsible for this rebirth. One was the work of a distinguished German researcher, Emil Kraepelin (1856-1926). In 1883, Kraepelin published an influential textbook arguing that physical factors, such as fatigue, are responsible for mental dysfunction. In addition, as you will see in Chapter 4, he developed the first modern system for classifying abnormal behavior. He identified various syndromes, or clusters of symptoms; listed their physical causes; and discussed their expected course (Jäger, Frasch, & Becher, 2013; Zivanovic & Nedic, 2012).

New biological discoveries also triggered the rise of the somatogenic perspective. One of the most important discoveries was that an organic disease, syphilis, led to general paresis, an irreversible disorder with both physical and mental symptoms, including paralysis and delusions of grandeur (Hogebrug et al., 2013; Kaplan, 2010). In 1897, the German neurologist Richard von Krafft-Ebing (1840–1902) injected matter from syphilis sores into patients suffering from general paresis and found that none of the patients developed symptoms of syphilis. Their immunity could have been caused only by an earlier case of syphilis. Since all of his patients with general paresis were now immune to syphilis, Krafft-Ebing theorized that syphilis had been the cause of their general paresis. Finally, in 1905, Fritz Schaudinn (1871–1906), a German zoologist, discovered that the microorganism Treponema pallida was responsible for syphilis, which in turn caused general paresis.

The work of Kraepelin and the new understanding of general paresis led many researchers and practitioners to suspect that physical factors were responsible for many mental disorders, perhaps all of them. These theories and the possibility of quick and effective medical solutions for mental disorders were especially welcomed by those who worked in mental hospitals, where patient populations were now growing at an alarming rate.

Despite the general optimism, biological approaches yielded mostly disappointing results throughout the first half of the twentieth century. Although many medical treatments were developed for patients in mental hospitals during that time, most of the techniques failed to work. Physicians tried tooth extraction, tonsillectomy, hydrotherapy (alternating hot and cold baths), and lobotomy, a surgical cutting of certain nerve fibers in the brain. Even worse, biological views and claims led, in some circles, to proposals for immoral solutions such as eugenic sterilization, the elimination (through medical or other means) of individuals’ ability to reproduce (see Table 1-1 below). Not until the 1950s, when a number of effective medications were finally discovered, did the somatogenic perspective truly begin to pay off for patients.

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The Psychogenic PerspectiveThe late nineteenth century also saw the emergence of the psychogenic perspective, the view that the chief causes of abnormal functioning are often psychological. This view, too, had a long history, but it did not gain much of a following until studies of hypnotism demonstrated its potential.

Hypnotism is a procedure in which a person is placed in a trancelike mental state during which he or she becomes extremely suggestible. It was used to help treat psychological disorders as far back as 1778, when an Austrian physician named Friedrich Anton Mesmer (1734–1815) established a clinic in Paris. His patients suffered from hysterical disorders, mysterious bodily ailments that had no apparent physical basis. Mesmer had his patients sit in a darkened room filled with music; then he appeared, dressed in a colorful costume, and touched the troubled area of each patient’s body with a special rod. A surprising number of patients seemed to be helped by this treatment, called mesmerism (Musikantow, 2011; Dingfelder, 2010). Their pain, numbness, or paralysis disappeared. Several scientists believed that Mesmer was inducing a trancelike state in his patients and that this state was causing their symptoms to disappear. The treatment was so controversial, however, that eventually Mesmer was banished from Paris.

It was not until years after Mesmer died that many researchers had the courage to investigate his procedure, later called hypnotism (from hypnos, the Greek word for “sleep”), and its effects on hysterical disorders. The experiments of two physicians practicing in the city of Nancy in France, Hippolyte-Marie Bernheim (1840–1919) and Ambroise-Auguste Liébault (1823–1904), showed that hysterical disorders could actually be induced in otherwise normal people while they were under the influence of hypnosis. That is, the physicians could make normal people experience deafness, paralysis, blindness, or numbness by means of hypnotic suggestion—and they could remove these artificial symptoms by the same means. Thus they established that a mental process—hypnotic suggestion—could both cause and cure even a physical dysfunction. Leading scientists concluded that hysterical disorders were largely psychological in origin, and the psychogenic perspective rose in popularity.

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Among those who studied the effects of hypnotism on hysterical disorders was Josef Breuer (1842–1925) of Vienna. Breuer, a physician, discovered that his patients sometimes awoke free of hysterical symptoms after speaking candidly under hypnosis about past upsetting events. During the 1890s, Breuer was joined in his work by another Viennese physician, Sigmund Freud (1856–1939). As you will see in Chapter 3, Freud’s work eventually led him to develop the theory of psychoanalysis, which holds that many forms of abnormal and normal psychological functioning are psychogenic. In particular, Freud believed that unconscious psychological processes are at the root of such functioning.

Freud also developed the technique of psychoanalysis, a form of discussion in which clinicians help troubled people gain insight into their unconscious psychological processes. He believed that such insight, even without hypnotic procedures, would help the patients overcome their psychological problems.

Freud and his followers offered psychoanalytic treatment primarily to patients suffering from anxiety or depression, problems that did not typically require hospitalization. These patients visited therapists in their offices for sessions of approximately an hour and then went about their daily activities—a format of treatment now known as outpatient therapy. By the early twentieth century, psychoanalytic theory and treatment were widely accepted throughout the Western world (Cautin, 2011).