16.1 Mental Health Treatment: Past and Present

Treatment in the Past

For much of history, people with mental illness have been treated very poorly. It was believed that mental illness was caused by demonic possession, witchcraft, or an angry god (Szasz, 1960). For example, in medieval times, abnormal behaviors were viewed as a sign that a person was possessed by demons. If someone was considered to be possessed, there were several forms of treatment to release spirits from the individual. The most common treatment was exorcism, often conducted by priests or other religious figures: Incantations and prayers were said over the person’s body, and they may have been given some medicinal drinks. Another form of treatment for extreme cases of mental illness was trephining: A small hole was made in the afflicted individual’s skull to release spirits from the body. Most people treated in this manner died. In addition to exorcism and trephining, other practices involved execution or imprisonment of people with psychological disorders. Still others were left to be homeless beggars. Generally speaking, most people who exhibited strange behaviors were greatly misunderstood and treated cruelly. The prevailing theory of psychopathology in earlier history was the idea that mental illness was the result of demonic possession by either an evil spirit or an evil god because early beliefs incorrectly attributed all unexplainable phenomena to deities deemed either good or evil.

From the late 1400s to the late 1600s, a common belief perpetuated by some religious organizations was that some people made pacts with the devil and committed horrible acts, such as eating babies (Blumberg, 2007). These people were considered to be witches and were tried and condemned by courts—they were often burned at the stake. Worldwide, it is estimated that tens of thousands of mentally ill people were killed after being accused of being witches or under the influence of witchcraft (Hemphill, 1966)

By the 18th century, people who were considered odd and unusual were placed in asylums (Figure 16.4). Asylums were the first institutions created for the specific purpose of housing people with psychological disorders, but the focus was ostracizing them from society rather than treating their disorders. Often these people were kept in windowless dungeons, beaten, chained to their beds, and had little to no contact with caregivers.

Figure 16.4 This painting by Francisco Goya, called The Madhouse, depicts a mental asylum and its inhabitants in the early 1800s. It portrays those with psychological disorders as victims.

In the late 1700s, a French physician, Philippe Pinel, argued for more humane treatment of people with mental illness. He suggested that they be unchained and talked to, and that’s just what he did for patients at La Salpêtrière in Paris in 1795 (Figure 16.5). Patients benefited from this more humane treatment, and many were able to leave the hospital.

Figure 16.5 This painting by Tony Robert-Fleury depicts Dr. Philippe Pinel ordering the removal of chains from patients at the Salpêtrière asylum in Paris.

In the 19th century, Dorothea Dix led reform efforts for mental health care in the United States (Figure 16.6). She investigated how those who are mentally ill and poor were cared for, and she discovered an underfunded and unregulated system that perpetuated abuse of this population (Tiffany, 1891). Horrified by her findings, Dix began lobbying various state legislatures and the U.S. Congress for change (Tiffany, 1891). Her efforts led to the creation of the first mental asylums in the United States.

Figure 16.6 Dorothea Dix was a social reformer who became an advocate for the indigent insane and was instrumental in creating the first American mental asylum. She did this by relentlessly lobbying state legislatures and Congress to set up and fund such institutions.

Despite reformers’ efforts, however, a typical asylum was filthy, offered very little treatment, and often kept people for decades. At Willard Psychiatric Center in upstate New York, for example, one treatment was to submerge patients in cold baths for long periods of time. Electroshock treatment was also used, and the way the treatment was administered often broke patients’ backs; in 1943, doctors at Willard administered 1,443 shock treatments (Willard Psychiatric Center, 2009). (Electroshock is now called electroconvulsive treatment, and the therapy is still used, but with safeguards and under anesthesia. A brief application of electric stimulus is used to produce a generalized seizure. Controversy continues over its effectiveness versus the side effects.) Many of the wards and rooms were so cold that a glass of water would be frozen by morning (Willard Psychiatric Center, 2009). Willard’s doors were not closed until 1995. Conditions like these remained commonplace until well into the 20th century.

Starting in 1954 and gaining popularity in the 1960s, antipsychotic medications were introduced. These proved a tremendous help in controlling the symptoms of certain psychological disorders, such as psychosis. Psychosis was a common diagnosis of individuals in mental hospitals, and it was often evidenced by symptoms like hallucinations and delusions, indicating a loss of contact with reality. Then in 1963, Congress passed and John F. Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Act, which provided federal support and funding for community mental health centers (National Institutes of Health, 2013). This legislation changed how mental health services were delivered in the United States. It started the process of deinstitutionalization, the closing of large asylums, by providing for people to stay in their communities and be treated locally. In 1955, there were 558,239 severely mentally ill patients institutionalized at public hospitals (Torrey, 1997). By 1994, by percentage of the population, there were 92% fewer hospitalized individuals (Torrey, 1997).

Mental Health Treatment Today

Today, there are community mental health centers across the nation. They are located in neighborhoods near the homes of clients, and they provide large numbers of people with mental health services of various kinds and for many kinds of problems. Unfortunately, part of what occurred with deinstitutionalization was that those released from institutions were supposed to go to newly created centers, but the system was not set up effectively. Centers were underfunded, staff was not trained to handle severe illnesses such as schizophrenia, there was high staff burnout, and no provision was made for the other services people needed, such as housing, food, and job training. Without these supports, those people released under deinstitutionalization often ended up homeless. Even today, a large portion of the homeless population is considered to be mentally ill (Figure 16.7). Statistics show that 26% of homeless adults living in shelters experience mental illness (U.S. Department of Housing and Urban Development [HUD], 2011).

Figure 16.7 (a) Of the homeless individuals in U.S. shelters, about one-quarter have a severe mental illness (HUD, 2011). (b) Correctional institutions also report a high number of individuals living with mental illness. (credit a: modification of work by "Carl Campbell"/Flickr; credit b: modification of work by Bart Everson)

Mental health issues are also significant concerns regarding those involved in the corrections system. According to a 2006 special report by the Bureau of Justice Statistics (BJS), approximately 705,600 adults with mental health issues were incarcerated in the state prison system, and another 78,800 were incarcerated in the federal prison system. A further 479,000 were in local jails. According to the study, “people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four times the general population” (Prins & Draper, 2009, p. 23). The correctional system faces increasing burdens in managing and supporting people with mental health issues (Torrey et al., 2014). The incarceration experience itself exacerbates existing issues, triggers disturbances, or leads to long term effects such as PTSD, depression, or other disorders. While incarcerated, people are often subjected to or witness violence or sexual assault, face isolation from family, and endure other physical or emotional traumas (Edgemon & Clay-Warner, 2019).

Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals focused on short-term care. In all types of hospitals, the emphasis is on short-term stays, with the average length of stay being less than two weeks and often only several days. This is partly due to the very high cost of psychiatric hospitalization, which can be about $800 to $1000 per night (Stensland, Watson, & Grazier, 2012). Therefore, insurance coverage often limits the length of time a person can be hospitalized for treatment. Usually individuals are hospitalized only if they are an imminent threat to themselves or others.

Most people who have mental illnesses are not hospitalized. If someone is feeling very depressed, complains of hearing voices, or feels anxious all the time, they might seek psychological treatment. A friend, spouse, or parent might refer someone for treatment. The individual might go see their primary care physician first and then be referred to a mental health practitioner.

Some people seek treatment because they are involved with the state’s child protective services—that is, their children have been removed from their care due to abuse or neglect. The parents might be referred to psychiatric or substance abuse facilities and the children would likely receive treatment for trauma. If the parents are interested in and capable of becoming better parents, the goal of treatment might be family reunification. For other children whose parents are unable to change—for example, the parent or parents who are heavily addicted to drugs and refuse to enter treatment—the goal of therapy might be to help the children adjust to foster care and/or adoption (Figure 16.8).

Figure 16.8 Therapy with children may involve play. (credit: modification of work by UNHCR Ukraine/Flickr)

Some people seek therapy because the criminal justice system referred them or required them to go. For some individuals, for example, attending weekly counseling sessions might be a condition of parole. If an individual is mandated to attend therapy, they are seeking services involuntarily. Involuntary treatment refers to therapy that is not the individual’s choice. Other individuals might voluntarily seek treatment. Voluntary treatment means the person chooses to attend therapy to obtain relief from symptoms.

Psychological treatment can occur in a variety of places. An individual might go to a community mental health center or a practitioner in private or community practice. A child might see a school counselor, school psychologist, or school social worker. An incarcerated person might receive group therapy in prison. There are many different types of treatment providers, and licensing requirements vary from state to state. Besides psychologists and psychiatrists, there are clinical social workers, marriage and family therapists, and trained religious personnel who also perform counseling and therapy.

A range of funding sources pay for mental health treatment: health insurance, government, and private pay. In the past, even when people had health insurance, the coverage would not always pay for mental health services. This changed with the Mental Health Parity and Addiction Equity Act of 2008, which requires group health plans and insurers to make sure there is parity of mental health services (U.S. Department of Labor, n.d.). This means that co-pays, total number of visits, and deductibles for mental health and substance use treatment need to be equal to and cannot be more restrictive or harsher than those for physical illnesses and medical/surgical problems.

Finding treatment sources is also not always easy: there may be limited options, especially in rural areas and low-income urban areas; waiting lists; poor quality of care available for indigent patients; and financial obstacles such as co-pays, deductibles, and time off from work. Over 85% of the 1,669 federally designated mental health professional shortage areas are rural; often primary care physicians and law enforcement are the first-line mental health providers (Ivey, Scheffler, & Zazzali, 1998), although they do not have the specialized training of a mental health professional, who often would be better equipped to provide care. Availability, accessibility, and acceptability (the stigma attached to mental illness) are all problems in rural areas. Approximately two-thirds of those with symptoms receive no care at all (U.S. Department of Health and Human Services, 2005; Wagenfeld, Murray, Mohatt, & DeBruiynb, 1994). At the end of 2013, the U.S. Department of Agriculture announced an investment of $50 million to help improve access and treatment for mental health problems as part of the Obama administration’s effort to strengthen rural communities.