Modified: 2020-10-05
In the early Middle Ages, treatment of the abnormal was largely left to the clergy. Again, this was a variant of milieu therapy, in that monasteries and abbeys tended to be self-sufficient and in out-of-the-way places. Treatment was fairly humane by modern standards. However, as the Middle Ages wore on, a new form of demonic possession theory, now in a Christian guise, took hold. Casting out demons via exorcisms became "therapy."
As the middle ages drew to a close, reaction to demonic possession theory grew. Led by figures such as Paracelcus and St. Vincent de Paul, the Inquisition was withdrawn, and asylums began to be established.
The first asylum in North America predated the founding of the U. S. It was established in 1773 in Williamsburg, Virginia. Treatment was better than under the inquisition, but it still was not humane. Patients rarely left the asylum after being committed, and treatment consisted of such things as immersion in cold water, stomping on patients (by doctors), and restraints.
In fact, the word "Bedlam," meaning craziness or uncontrollable behavior, derives from the contraction of the words "Bethlehem Hospital," an asylum outside of London. In the 1700s, people would visit that asylum on Sundays as a treat.
In the late 1700s, in France, Pinel, who was in charge of an asylum, decided to make conditions better. He removed patients' chains, improved conditions, and he found that patients actually began to improve. The revolution ended his career, and as a member of the old regime he was condemned to the guillotine. As he approached the device to be executed, he was recognized by one of the executioners, a former patient who had been one who had benefitted from Pinel's new policies. He argued that Pinel should not be executed, and he was not.
In the USA, Dorethea Dix was a champion for the founding of asylums. She was so successful that by the end of the 19th century, few American towns did not have an asylum or sanitarium nearby.
The number of public hospital beds devoted to mental health peaked in the mid 1950s. That was the era of the large, inpatient, mental hospital. The feature movie, One Flew Over the Cuckoo's Nest, depicts such a hospital faithfully. Just as in the time of Pinel, most patients required full-time treatment, some improved and left, but most did not. In fact, patients became "institutionalized," meaning that they slowly grew used to the conditions imposed by the hospital. They, in effect, became unable to leave, even if they wanted to.
The advent of successful drugs led to a major change in treatment. Those drugs, and others, enabled therapists to control behaviors that they formerly had been unable to. For instance, schizophrenic "acting out" could be effectively controlled by thorazine, or the threat of suicide could be controlled by anti-depressants.
The drugs and political considerations led to an emptying out and closing of the large mental hospitals, and to an outpatient model. In that model, initial and acute treatment may still require hospitalization. But, using drugs, patients are made manageable, and discharged as soon as possible, thus preventing institutionalization. After discharge, patients visit their therapists on a regular basis. Their drug levels are carefully monitored, and reduced as necessary over the course of their treatment, if possible. In many cases, patients may remain on drugs for long or indefinite periods.
Some problems have surfaced because of the outpatient model. One is that a small population that requires hospitalization and intensive care remains, but there are not enough beds or hospitals left for them. Some have argued that the large numbers of homeless in the US are in part a result of the implementation of the outpatient model. Overdependence on drug treatment over other types of treatment is another problem, as is getting patients to comply with the requirements of their drug prescriptions.