A brief history of our understanding of mental health
Case study by Eoin Dunleavy
The mind has been the subject of extensive research for millennia, resulting in the emergence of various theories to explain mental health issues and practices to manage them. Eoin Dunleavy provides a whistle-stop tour of some of the key milestones in the journey to our modern-day understanding of mental health.
We have tried to understand and treat mental ill health for thousands of years. It is interesting to ponder whether early man suffered the mental blights that we do, with reportedly 970 million people suffering worldwide from some kind of mental disorder in 2019. One can imagine a caveman lying across a large rock whilst his bearded peer councils him. The cave man says: “It all started with my father”.
Mental illness and the supernatural
Throughout history, 3 general theories have been used to explain the causes of mental illness: the supernatural, somatogenic, and psychogenic. Examination of prehistoric skulls and cave art from as early as 6500BC has identified the surgical drilling of holes in skulls (known as trepanation) to treat head injuries and epilepsy. It is thought this was performed in order to release evil spirits – something that, along with displeasure of gods, eclipses, planetary gravitation, curses, and sin, many cultures historically believed were linked to mental illness.
Trepanned skulls, thought to be from the Bronze Age (3300–1200BC), on display at the Archeology Museum of Saint-Raphaël in Provence-Alpes-Côte d'Azur, France. All of the people that went through the process survived, as evidenced by the growth of bone at the edges of the holes.
Research suggests that the past perceived association of the supernatural with mental illness feeds into the stigma that mental ill-health sufferers face today. One study states that during the Middle Ages, mental illness was regarded as a punishment from God: sufferers were thought to be possessed by the devil and were burned at the stake, or thrown in penitentiaries and madhouses where they were chained to the walls or their beds.
Early Greek physicians are reported to have rejected supernatural theories of mental illness. Hippocrates (460–370 BC) is credited with establishing and promoting the somatogenic theory of mental illness referred to as Humor theory. Somatogenic refers to where the mental illness originates from and means that it is thought to originate from a fault in the body.
Humor theory believed that mental illness was caused by a deficiency or excess in one of the four essential bodily fluids – AKA ‘humors’ – that were thought to make up the body: blood, yellow bile, black bile and phlegm.
It is common to see the unification of the Humor theory with Empedocles' (a Greek philosopher) four elements model which pairs each humor with different age groups and personality traits.
Hippocrates classified mental illness into one of four categories: epilepsy, mania, melancholia, and brain fever. Interestingly, like other prominent physicians and philosophers of his time, Hippocrates did not believe that mental illness was shameful or that mentally ill individuals should be held accountable for their behaviour. This may be due to what Hippocrates viewed the cause of mental illness to be – a somatogenic one which the individual had no responsibility for having.
Humor theory began to fall out of favour in the 1850s with the advent of Germ Theory.
Modern treatments of mental illness are most associated with the establishment of hospitals and asylums beginning in the 16th century. Most inmates were institutionalised against their will, lived in filth, and chained to walls, and were commonly exhibited to the public for a fee.
Mental illness was nonetheless viewed somatogenically, so treatments were similar to those for physical illnesses: purges, bleedings, and emetics.
The 18th century saw the development of a more humane treatment of people with mental illness. Protest arose over the conditions in which the mentally ill lived, and in England, humanitarian reforms arose from religious concerns. In 1785, Italian physician Vincenzo Chiarughi removed the chains of patients at his St. Boniface hospital in Florence, Italy, and encouraged good hygiene and recreational and occupational training for people suffering from mental illness.
The emergence of psychogenic theory
In the 18th and 19th century, what we in the West recognise now as psychotherapy was beginning to develop. During this time period, people who were treating mental illness struggled between a somatogenic and a psychogenic explanation of mental ill health, the latter of which was growing in popularity thanks to the work of Sigmund Freud.
Sigmund Freud's iceberg theory of the human psyche revolutionised medical practices and understanding of human psychology of the time.
Psychoanalysis became the dominant psychogenic treatment for mental illness during the first half of the 20th century, providing the launching pad for the more than 400 different schools of psychotherapy found today. Somatogenic treatments for mental ill health were being developed also during this period, such as lobotomies, electric convulsive therapy, and psychotropic medication, all of which were in use by the mid-20th century.
Currently, the main means of treatment for mental illness are the use of psychotropic medication and talking therapies, with surgical intervention being all but obsolete.
An age of enlightenment(?)
We know that the ideas of the time shape the lens through which mental ill health is viewed and therefore how it is treated. What is considered mentally ill and what is considered mentally well can change depending on the cultural norms of the day.
Presently, we seem to have come a long way in our understanding of mental illness. However, it is important to not fall into the trap of thinking that the present moment is an age of enlightenment. No doubt the people of the future will look back in aghast at some of the methods used for treating mental illness currently.
Looking to the future, there are already debates taking place that questions some of the practices of the medical model of mental illness, for example the efficacy of anti-depressant medication has been called into question.
Let’s just hope the days of trepanation are firmly in the past.
Farreras, IG. History of mental illness. Available at: https://nobaproject.com/modules/history-of-mental-illness. Accessed 28 September 2022.
Magnavita, JJ. In search of the unifying principles of psychotherapy: Conceptual, empirical, and clinical convergence. American Psychologist. 2006;61(8): 882.
Rössler, W. The stigma of mental disorders: A millennia-long history of social exclusion and prejudices. EMBO reports. 2016;17(9):1250–1253.