Many people today, including expert patients, view mental health as a biomedical issue. They choose to consult medical experts such as psychiatrists. Others see mental health problems as personal or interpersonal matters that should be ‘talked through’ in regular psychotherapy sessions. This may take the form of psychoanalysis, cognitive-behavioural therapy, group therapy or other methods. Some seek explanations beyond medicine. These include spirit possession, sin, and social injustice such as the legacy of genocide, enslavement or oppression. As a result, people may seek help through prayer, confession, spiritual guidance, exorcism, political activism, social change and creative expression.
These approaches are not separate and opposed. Few people are purists when confronted with a mental health problem. We mix and match approaches to make sense of what has happened to ourselves or a loved one. History shows people have always done this.
The term ‘mental health’ was popularised in the early 1900s by physicians, social reformers and former asylum patients. They wanted to reduce the stigma surrounding mental illness, and said ‘illness’ reinforced prejudices against asylum patients because it implied segregation between the sick and the well. Focusing on health countered a persistent misconception that only some people are prone to psychiatric problems.
Fighting stigma has gained an unexpected ally in recent decades. Critics say large multinational pharmaceutical firms profit from expansion of the market for psychiatric drugs. Therefore any reduction of stigma leads to new customers. In response, some expert patients and psychiatrists argue the term ‘mental health’ is biased toward biomedicine and drug treatment. They prefer ‘mental distress’ instead.
There are good reasons to avoid outdated and stigmatised words such as ‘madness’. However, avoiding such terms in a historical account ignores the ways language changes. Labels also shape the experience of illness. ‘Madness’, ‘lunacy’ and ‘insanity’ were accepted medical usage even into the early 1900s. They were gradually displaced by ‘mental illness’, a term which first appeared in the 1847 novel Wuthering Heights. Other diagnostic terms such as hysteria, nervous breakdown, schizophrenia and depression slipped back and forth between medical and popular use. This again expresses the lesson that mental health and illness are not just in medicine’s domain. To completely avoid stigmatising terms would obscure this important point.
The rise and fall of moral treatment
Asylums multiplied throughout Europe and North America in the 1800s and psychiatry became a recognised medical speciality. Scientific understanding of what physicians still called ‘lunacy’ had increased little since the 1600s, but medical men used the asylum boom to gain practical experience with patients. They drew on the increasing prestige of science and established themselves as publicly recognised experts on mental illness and its treatment. Critics argued asylum cure rates were exaggerated.
Many asylums were crowded, hopeless places by the early 1900s, increasingly separated from the outside world. These isolated institutions became testing grounds for controversial and dangerous treatments such as electroconvulsive therapy (ECT) and lobotomy. Such treatments helped some patients, but they reinforced the idea that asylums were places no-one wanted to end up. Asylums did not survive criticism in the 1970s from ex-patients, feminists and the antipsychiatry movement. Psychiatry’s focus has since moved from asylums to pharmaceuticals.
Optimists in the 1980s and 1990s hailed new technologies. These included specially targeted drugs like SSRIs, brain scanning techniques such as magnetic resonance imaging (MRI) and more consistent disease definitions in the Diagnostic and Statistical Manual (DSM). They were evidence to some that psychiatry had finally become based in hard, objective science. Critics argued such developments reflected the growing power of American psychiatry and Big Pharma, not scientific progress. Today public debates continue about the over-prescription of antidepressants such as Prozac and drugs to treat ADHD.