2. are dangerous in which case they need to be locked up. If the
person is ‘mad’ then
they need to be treated by therapies.
The history of clinical psychology is so closely linked to
psychiatry that the two
need to be considered at the same time (Porter, 1987, 1988,
1991). The difference
between psychology and psychiatry is one of training.
Psychiatrists are trained in
medicine, so the psychiatric approach to mental illness follows
the medical tradi-
tion, or at least, the medical tradition of the time. Medical
treatment of mental
illness has a history of more than two thousand years. By
contrast, psychologists
have a psychological training, and their approach to mental
illness can also be con-
sidered as part of the psychological tradition of the time.
Psychological treatment
of mental illness is comparatively recent. Neither the medical
nor psychological
traditions have remained static, so the relationship between the
two changes over
time. Over time there have been various ‘tensions’, sometimes
between different
psychiatrists, sometimes between different psychologists and
sometimes between
psychiatrists and psychologists. These tensions include:
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5. c. a tension between a biological versus a psychological
interpretation;
d. a tension between psychoanalytic versus behaviourist
interpretations.
Religion Versus Natural Science
The Greek physician Hippocrates (460–377 BC) was born of a
family of priest-
physicians but rejected the current superstitious belief that
illness, including
mental illness was the work of the gods, and could be cured by
superstitious
charms and prayers. He suggested an empirical method in
understanding illness,
but also believed in a spiritually restoring principle or essence
that the physician
could use to effect a cure (Alexander & Selesnick, 1966;
Bynum, Porter & Shepherd,
1985; Jackson, 1986; Maher & Maher, 1985a). He believed that
the brain was the
source of epilepsy and dementia and provided a variety of
cures, including bleed-
ing, but also a variety of lifestyle and dietary
recommendations. The technique of
bleeding a patient was not invented by Hippocrates himself – it
can be traced back
to ancient Egyptian medicine.
The assumption of Hippocratic medicine that disease was
caused by an imbal-
ance of bodily humours was accepted in the west for the next
two thousand years.
There are four bodily humours: black and yellow bile, phlegm
and blood. Ayurvedic
(i.e. traditional Indian) and traditional Chinese medicine also
6. adopted similar
assumptions that disease was caused by an imbalance – an
imbalance of three
doshas in the case of Ayurvedic medicine and of the five
elements in traditional
Chinese medicine (Deng, 1999). The consequence of these
assumptions is that
mental illness is located firmly within a biological
conceptualization of illness,
and that mental illness is not seen as separate from physical
illness. For example,
Hippocrates believed that hysteria was a purely female
complaint and caused by a
wandering uterus (the Greek word hysterion means uterus).
Galen, who was a phy-
sician during the 1st century AD (he was born in Turkey but
often described as a
Roman physician), transmitted and extended Hippocrates’ ideas
throughout the
Roman Empire and believed that mental and physical disease
were linked. For
instance, he believed that melancholia (depression) in women
caused breast cancer.
It is a noticeable feature of all the main traditional medical
systems (Hippocratic,
Ayurvedic and traditional Chinese) that lifestyle, diet and
psychology are important
parts of treatment, as well as herbs and other treatments (e.g.
acupuncture,
enemas, massage). In Ayurvedic medicine, for example, the
most important
therapeutic technique is meditation, and there is a clear
emphasis on the need to
treat the psychological state of a person in order to achieve
physical cures. This
9. 272 History and Philosophy of Psychology
recommended according to the type of person (note: not the
type of disease) but
in the case of traditional Chinese medicine, dietary
recommendations also depend
on the weather. For example, spicy food is supposed to be better
when the weather
is wet and cold.
In sum, the traditional medical approach does not treat mental
illness as separate
from physical illness. Traditional medical practitioners do not
have specialisms
because they treat the whole person not the disease. Thus, in the
traditional
medical system, there is no such person as a psychiatrist or
clinical psychologist,
there is a simply a therapist working within that medical
tradition. An important
feature of all these traditional medical systems is that they
reject supernatural
explanations which have always occurred in parallel with them.
They also assume
that mental illness has a biological basis which is caused by an
imbalance in the
principles that are supposed to be in balance.
Where there are strong religious belief systems, then mental
illness is assumed
to have a supernatural origin. This supernatural view occurs in
various guises
throughout history, both in the West under the influence of the
Catholic Church,
and all other countries. In Africa, for example, the superstitious
10. beliefs have led to
the idea of voodoo. Underlying this view is the belief that
illness (often mental and
physical) is caused by another person, often a witch, and often
but not always as an
intention of that other person to cause harm. This view fuelled
the persecution of
witches that occurred between 1450 and 1750, which was
officially sanctioned by
the Catholic Church. Pope Innocent VIII authorized the
persecution of witches in
1484 and the practice was guided by a book called Malleus
Maleficarum (The Witches’
Hammer) written by two Dominican priests who acted as
inquisitors in Germany.
Malleus Maleficarum was used extensively by judges
throughout Europe as a guide
to detecting witches. Anyone who behaved oddly (i.e. the
mentally ill) could be
accused of being a witch, and these unfortunate individuals
were tortured if they
refused to confess to gruesome witches’ practices. Whether or
not they confessed,
these people were then killed, by burning, hanging or
beheading, and their
confessions fuelled further belief in the existence of witches
(Trevor-Roper, 1967).
The idea that people who are mentally ill are possessed by the
devil is consistent
with the ‘bad’ not ‘mad’ perspective, and leads to a variety of
sometimes inhumane
treatments, as a way of making the devil leave the person’s
body, typically involving
some kind of physical pain on the basis that devils don’t like
pain. Not all such
11. treatments are inhumane. Some undeveloped tribes in Africa
and South America use
ritualistic ‘theatre’ where a healer, often with the help of the
whole tribe, tries to drive
out the devil by exhortation. However, in the West, the
supernatural belief in the
cause of mental illness led to the mentally ill being confined in
difficult circumstances.
In the 15th century, mentally ill people were sometimes
confined to a ‘ship of
fools’ (Foucault, 1962, 1967). The first mental Asylum was
founded in Valencia in
Spain in 1409 with the explicit purpose of locking up those
who were unable to
live in society. In 1547 Henry VIII founded an asylum at the
priory of St Mary of
Bethlehem in London. This ‘hospital’ or Bedlam as it came to
be known housed
mentally ill people in sordid, degrading conditions (MacDonald,
1981; Scull, 1979;
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Shorter, 1998). Londoners would come to view the madmen
through the iron
gates for a Sunday excursion, and viewing of madmen for
entertainment (tickets
were sold for a view) went on into the early 19th century. The
exceptions to poor
treatment occurred where mild mental illness occurred amongst
wealthy people
(e.g. nobles). In the middle ages, ‘odd’ people from the nobility
were often sent to
live in monasteries – which provide a safe and generally caring
environment.
Nevertheless, for the majority the only treatment was
incarceration in Bedlam, or
some similar degrading institution.
14. Robert Burton’s (1577–1640/1836) Anatomy of Melancholy
was first published in
1621 and then went through six ever expanding editions with a
last edition in1651.
The book can be seen as part of the Renaissance – the belief in
rationality rather
than divine authority of the church. Burton provides a very
detailed account of
what various authorities had said about the cause of
melancholy – what would be
now called depression – as well as the various cures. Burton’s
writing spans the
wide range of religious and scientific treatments then available,
and included
cynical and often witty comments about some of the
interpretations and
treatments and causes. Burton believed that melancholy had a
physical not a
supernatural cause. His book can be interpreted as rational man
trying to find
a rational solution when none was readily available. The
following quotes are
taken from the electronic version of the book at
http://www.gutenberg.org/
ebooks/10800 (no page numbers are given) and which the
interested student
might care to examine in more detail:
‘To give some satisfaction to melancholy men that are troubled
with these
symptoms, a better means in my judgment cannot be taken, than
to show them the
causes whence they proceed; not from devils as they suppose, or
that they
are bewitched or forsaken of God, hear or see, &c. as many of
them think, but from
15. natural and inward causes, that so knowing them, they may
better avoid the effects,
or at least endure them with more patience.’
‘Tis a common practice of some men to go first to a witch, and
then to a physician,
if one cannot the other shall,‘
‘We must use our prayer and physic both together: and so no
doubt but our prayers
will be available, and our physic take effect.’
Stanley (2000) provides a useful review of Burton’s book,
pointing out that not
only was prayer suggested as cure but also herbal remedies such
as marigold, black
hellebore, and mugwort featured as possible remedies. Wine
was a possible cure as
was blood letting, leeches (particularly if applied to
haemorrhoids) as well as
boring holes in the head to let out the vapours.
Burton examined a whole variety of techniques for curing
depression, some of
which he dismissed as fanciful, but many others he suggested
might be effective,
and these effective therapies included remedies based on the
Hippocratic tradition
such as blood letting (to reduce levels of blood) and purging
(to reduce levels of
phlegm). Purging involved either getting the person to vomit or
causing diarrhoea.
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274 History and Philosophy of Psychology
Burton’s book was popular because it fitted with the growing
trend in society
for rational thought. Of course, neither marigolds, boring holes
in the head nor
blood letting are effective treatments for mental illness, but at
18. least there was an
attempt for rational rather than supernatural interpretation.
Burton was writing at
a time when persecution of witches was at its height, and which
continued for
some time afterwards. The last legal execution of a condemned
witch occurred in
Switzerland in 1782. Modern psychiatry can therefore be seen
as the consequence
of the success of a rational, scientific cause of mental illness
in contrast to a
religious interpretation.
Hippocratic Versus Modern Medicine
The principles underlying Hippocratic medicine continued to be
applied to mental
illness right up to the 19th century. William Battie1 published
his Treatise on Madness
in 1758. Battie believed in consequential illness – that
particular events and experi-
ences could cause illness, and he was not optimistic about
treatments. Battie wrote:
‘Madness is frequently taken for one species of disorder,
nevertheless, when
thoroughly examined, it discovers as much variety with respect
to its causes and
circumstances as any distemper whatever: Madness, therefore,
like most other
morbid cases, rejects all general methods, e.g. bleeding blisters,
caustics, rough
cathartics, the gumms and faetid anti-hysterics, opium, mineral
waters, cold bathing
and vomits.’ (cited in Morris, 2008)
19. Battie’s treatise was the subject of considerable debate. John
Monro who was the
physician to the Bethlem hospital (Bedlam) believed that it was
possible to cure
madness and was a strong believer in the ‘cure’ effected by
causing the patient to vomit.
Monro (1758) disagreed with Battie’s treatise and published the
reasons for his
disagreement in a book published two months later. He provided
strong support
for the method of getting patients to vomit. The rationale for
this treatment was
that madness was caused by an excess of phlegm, and phlegm
could be reduced by
vomiting. Incidentally, an excess of phlegm did not cause only
madness – it also
could lead to other diseases that affected breathing (nowadays
called bronchitis
and asthma).
‘Notwithstanding we are told in this treatise, that madness
rejects all general
methods, I will venture to say, that the most adequate and
constant cure of it is by
evacuation; which can alone be determined by the constitution
of the patient and
the judgment of the physician. The evacuation by vomiting is
infinitely preferable to
any other, if repeated experience is to be depended on…’
(Munro, 1758, p. 50)
‘I never saw or heard of the bad effect of vomits, in my
practice; nor can I suppose
any mischief to happen, but from their being injudiciously
administered; or when
22. Clinical Psychology and Philosophy of Mental Health 275
‘The prodigious quantity of phlegm, with which those abound
who are troubled
with the complaint, is not to be got the better of but by
repeated vomits; and we very
often find, that purges have not their right effect, or do not
operate to so good
purpose, until the phlegm is broken and attenuated by frequent
emeticks.’
(Munro, 1758, pp. 50–1)
If one considers that being made to vomit is an aversive
experience, it would follow
that people would be less likely to exhibit ‘unusual’ behaviours
if someone was to
treat them with the vomiting cure! During the 19th century,
other aversive treat-
ments included cold water baths and showers based on the
principle of shock,
swinging chairs that induced fear and disorientation of the
disturbed senses. The
Benjamin Rush’s ‘Tranquilizer, consisted of a box placed over
the patient’s head
and the patient being strapped into a chair. The ‘tranquilizer’
was designed to
inhibit sensation and therefore irritation but in fact it was an
early form of sensory
deprivation. Inhibition could be achieved by the straitjacket
(invented in 1790) –
which inhibited movement of the arms but allowed the patient
to walk around.
Although these inhibitory techniques were introduced with the
best intentions, the
idea of sensory deprivation as a punishment was in fact used in
the Model Prison in
23. Tasmania in the 19th century, as it was recognized that isolation
was, as a type of
psychological punishment, more effective than the physical
punishment of beating.
While mental illness was being treated using techniques
deriving from the
Hippocratic tradition, an alternative to Hippocratic medicine
was being developed,
which was being applied to physical illness and so could
potentially be applied to
mental illness (Maher & Maher, 1985b). Instead of seeing
illness as being caused by
an imbalance in humours, the new approach believed that there
was a specific and
local cause for all illnesses. This new belief was based on an
analogy of the body as
a mechanical system – and reflected the earlier development of
clockwork and
other mechanical devices. So, for example, heart disease was
caused by pathology
of the heart, rather than by an excess of blood. According to
this perspective,
disease is caused by something analogous to a broken cog.
There is something that
is wrong in the body which if corrected will cure the disease.
A number of
physicians were behind this new approach, but the best known
is Rudolf Virchow
(1821–1902), a pathologist who is famous for his declaration
that there was no such
thing as non-specific illness (the basis for Hippocratic
medicine) only specific illness
(Rather, 1958).
This new type of medicine formed the basis of modern
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276 History and Philosophy of Psychology
The idea of specific pathophysiology was applied to mental
illness in the early
19th century, with several authors suggesting that some kind of
pathology in the
brain was responsible. This view was supported particularly by
Wilhelm Griesinger
who was a psychiatrist working in Berlin. His textbook,
Pathology and Therapy of
Mental Illnesses for Doctors and Students was published in
1845. One reason for
supporting this new form of biological cause of illness was the
discovery that
syphilis was caused by a microbe. Advanced syphilis leads to a
form of dementia,
and so it is logical to conclude that this dementia is caused by
the microbe.
Griesinger believed that other specific and local explanations
would explain other
mental diseases.
Although there was little in the way of new therapies, there was
27. now a belief
that each mental illness was due to a different physiological
abnormality, and
therefore each mental illness would respond to a different type
of treatment,
namely a treatment that corrected that physiological
abnormality. Hippocratic
techniques such as blood letting and purging were used both for
physical and men-
tal problems. The same treatment would be used irrespective of
the disease. The
hope engendered by the new biological theory of mental
disease was that in time
new treatments would be discovered that applied solely to
mental illness.
The pioneers in the new way of thinking about mental illness
also suggested an
alternative approach to treatment. When Philippe Pinel (1745–
1826) was put in
charge of a mental asylum in Paris, he decided that inmates
should no longer be
shackled (Pinel, 1801/1962). Vicenzio Ciarugi (1759–1826) in
Italy and Benjamin
Rush (1745–1813) in America also encouraged humane
treatment of mentally ill
people. All three believed that the cause of mental illness was a
specific pathology
of the brain, not an imbalance of humours. Rush, in particular,
was dismissive of
the techniques based on the older Hippocratic medicine
suggesting that they did
no good at all (Rush, 1812).
Moral Treatment
28. During the 19th century, the view that mental illness was caused
by a
pathophysiology was gaining momentum, bolstered in part by
the success of this
particular approach in other areas of medicine. However, in
parallel with this
scientific approach a rather different religious inspired view of
mental illness was
developing. During the late 18th century, Christianity and
Protestant Christianity
in particular had moved away from an emphasis on the
supernatural and towards
a moral position on contemporary life. Christianity was a moral
framework for
understanding the world, and this moral framework included the
concept of
charity. These moral Christians were instrumental in setting up
an alternative
psychological framework for understanding mental illness. The
psychological
framework was one where mental illness was seen as a
psychologically caused
illness, and one where unsatisfactory environmental factors
could contribute to
disease. So, in the 19th century an alternative type of treatment
was development,
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called ‘moral treatment’. In England, William Tuke (1732–
1822) established the
York Retreat as an asylum with calming and religious overtones
– Tuke was a
Quaker and philanthropist (Tuke, 1813/1964).
In the United States Dorothea Lynde Dix (1802–1887) was a
teacher who, on
realizing how terrible asylums were, campaigned for better and
more humane
treatment of the mentally ill (Dix, 1971/1843–1852). Neither
31. of these were
medically trained. Both they and others like them provided a
means for
caring for the mentally sick, where the money was often raised
by charitable
donations.
Moral treatment had several characteristics. One was the idea
that a person,
such as a doctor, could impose moral authority on the ill patient
and so change
the ‘vicious chain of ideas’ which the patient was prone to
experience. The idea
of moral authority ties in well with the idea of Church
authority. There should be
a person or institution in charge which imposes on the will of
others. A second
feature of moral treatment was that the mentally ill should be
restrained in cir-
cumstances of harmony and peace – so they should be placed in
pleasant rather
than degrading circumstances. A third feature of the moral
treatment was the
idea that the patient should be subjected to discipline so as to
lead a regular and
orderly life.
Those approaching mental illness from the point of view of
‘moral treatment’
as well as those adopting the new biological framework both
believed in the
humane treatment of the mentally ill. The old asylums for
restraining the ill were
built in cities. The new institutions for the care of the mentally
ill were built in the
country, and there was an attempt to make them attractive. The
32. new institutions
were also shielded from the public so that the degrading
spectacle of the mentally
ill being ‘exhibited’ would not occur – though this also shielded
the public from the
uncomfortable truth that the mentally ill existed. Mental
institutions were built
with a curved drive way so they were not visible from the road
– which is the origin
of the expression ‘going round the bend’. Many institutions
were built in the
19th century based on a mixture of moral treatment as well as
the very limited
treatments offered by the biological perspectives. One of these
latter treatments,
invented by Rush, was the tranquilizing chair. The patient was
strapped into a
chair so as to prevent movement, and prevented from seeing or
hearing anything,
for hours at a time. So although there was a belief in humanity
in the 19th century
treatment, this humanity was tempered by a somewhat strict
view about how to
achieve good behaviour.
The mental asylums of the 19th century were large institutions
with
attractive grounds that were to a large extent self-sustaining.
There would be
a farm, and a laundry, and when electric lighting was invented,
many asylums
had their own electric generator. As far as possible all work on
the asylum was
carried out by inmates. There is a curious parallel between the
asylums of the
19th century and monasteries of the middle ages. Both were
35. 278 History and Philosophy of Psychology
Retreat (see above) which was founded by the Quakers (a
religious, protestant
group) in York, England opened in 1796, were founded on
genuine caring
principles in response to the harsh treatments at the latter part
of the 18th
century (Digby, 1985).
So far, our history of mental illness has focused on (a) the
Hippocratic idea of
imbalance, (b) the idea of specific pathophysiology which
forms the basis of
modern western medicine, and (c) the idea of moral treatment
which owes its
origins to religious beliefs. There is one other development
which needs to be
taken into account: the science of classification.
Classification of Mental Diseases
Science in the 19th century involved classification. Systems
were developed for
classifying plants, for classifying animals, and for classifying
the elements. It is not
surprising therefore, that classification of mental illness was
also part of Victorian
scientific thinking. An early classification of mental illness can
be found in a report
prepared in 1844 for the Metropolitan Commissioners in Lunacy
– a body of
people responsible for funding mental asylums in London. The
classification
36. consists of
I. Mania, which is thus divided:
1. Acute Mania, or Raving Madness.
2. Ordinary Mania, or Chronic Madness of a less acute form.
3. Periodical, or Remittent Mania, with comparatively lucid
intervals.
II. Dementia, or decay and obliteration of the intellectual
faculties
III. Melancholia
IV. Monomania
V. Moral Insanity
The three last mentioned forms are sometimes comprehended
under the term
Partial Insanity.
VI. Congenital Idiocy
VII. Congenital Imbecility
VIII. General Paralysis of the Insane
IX. Epilepsy
These classifications were influenced by Hippocratic medicine
but in reality were
a simply a brave attempt to make a classification system for
observed behaviour
of mentally ill patients. There was no attempt to link the
classification to any
underlying biological cause. Emil Kraepelin (1856–1926) had
studied with Wundt
and was impressed by Wundt’s attempt to classify the mind.
Kraepelin believed he
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39. illness had a
biological basis. As the director of an eighty-bed University
clinic at the University
of Tartu (now in Estonia), Kraepelin had plenty of opportunity
to observe and
classify mentally ill patients. Starting with the earlier
descriptions provided by
Hippocrates, Kraepelin developed a system of classification of
mental illness that
became highly influential, and which form the basis for modern
classification
systems of mental illness, such as the Diagnostic and Statistical
Manual of Mental
Disorders (DSM) published by the American Psychiatric
Association (1994). The
basis of Kraepelin’s system was to examine patterns of
symptoms, because no
one symptom of itself was able to classify a mental illness
(Berrios, 1996).
Kraepelin’s classification (Kraepelin, 1899/1990) was based on
an underlying
assumption that different mental diseases had different forms
of biological
pathology. Kraepelin used concepts such as mania and
melancholia which dated
back to Hippocrates, but also invented new classifications. One
of these, dementia
praecox, was defined as ‘sub-acute development of a peculiar
simple condition of
mental weakness occurring at a youthful age.’ Kraepelin
believed that dementia
praecox was an incurable degenerative disease. However, later,
Eugene Bleuler
(1847–1939) showed that the disease could sometimes be cured
and it was
renamed schizophrenia.
40. Although Kraepelin and Bleuler used different terms for what is
now known as
schizophrenia (Bleuler, 1911, 1924), there is one more
important difference
between them. Kraepelin based his classification on the
principle that there must
be a unique pathophysiology associated with each mental
illness, and so each
mental illness was distinct. Each mental illness fell into a
distinct category, just as
each physical illness fell into a distinct category. The idea that
mental illnesses are
distinct – i.e. they form types or categories – is the basis for the
modern clas-
sification of diseases. By contrast, Bleuler believed that people
varied
along dimensions of mental illness, leading to the idea that
there are not distinct
categories (i.e. you either have it or you do not) but rather
continua of mental
health problems. The idea of continua was used later by Hans
Eysenck and other
psychologists who favoured a psychological (i.e. variation along
continua) rather
than medical (i.e. variation between types) approach to mental
illness (see an
earlier chapter). Traditionally, psychiatrists have favoured types
whereas
psychologists have favoured traits, the former reflecting the
assumption of
specificity on which Kraepelin based his classification system.
The search for a biological basis for mental illness was a
common preoccu-
pation amongst psychiatrists at the end of the 19th century.
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280 History and Philosophy of Psychology
demonstrate abnormal brain tissue in people who died of the
disease, showing
that the cause of Alzheimer’s disease was specific, local and in
the brain (Goedert
& Ghetti, 2007). The discovery of Alzheimer’s disease was the
only case at the
time where mental illness could be positively identified with a
specific pathology.
Many historians of psychiatry believe that Kraepelin, not Freud
should be
considered the father of psychiatry. The reason is that
Kraepelin used a biological
model of mental illness that would, almost a century later, form
the basis for
modern psychiatric drugs.
The idea that there were different types of mental illness led to
the emergence
of a distinction which was important in the history of mental
illness. The distinction
was between madness and what were called ‘nervous disorders’.
Nervous disorders
were given a variety of names, including neurasthenia or
‘weakness of the nerves’.
Nervous disorders were treated with a variety of methods such
as hypnosis, but
44. included a variety of common-sense therapies such as rest, and
travel and good
quality food. The basic assumption of these therapies was that
nervous disorders
had a physical basis and required a cure which focused both on
the body and on the
mind. Sanatoria or spas were developed in Europe and had a
very different function
to either the older or newer asylums. For nervous diseases
patients were actively
treated rather than placed in a safe, moral environment until
they got better, and
they were treated by neurologists. One of the best known cures
was called the ‘rest
cure’ and it was developed by Silas Weir Mitchell (1894) in the
United States and
then widely used in Europe. The rest cure was used in particular
for women who
had hysterical nervous disorders. Florence Nightingale came
back from her
legendary work helping the wounded soldiers in the Crimean
War, and developed
neurasthenia – now known as Chronic Fatigue Syndrome. She
was prescribed the
rest cure and never rose from her bed again until the day she
died. The old cures
are not necessarily the best!
The Development of Psychoanalysis
The early days of psychoanalysis was described in Chapter 9.
As reviewed in that
chapter, Sigmund Freud was trained in physiology. He also
collaborated early in
his career with others who believed in a biological basis of
mental illness, such as
45. Charcot. Additionally, his ‘scientific project for psychology’
was based on the
assumption of a biological basis for mental illness. However,
Freud rejected this
biological interpretation in the development of psychoanalysis
(Ellenberger, 1970).
Some, such as Roith (2008), have suggested that this change
was in part motivated
by the current belief that mental illness had a hereditary basis
and that Jews had a
proneness to degeneration and hence mental illness, which
coupled with the
negative stereotypes towards mental illness at the time may
have fuelled Freud’s
acceptance of an alternative, non-biological, non-genetic,
interpretation. What is
clear, however, is that when Freud abandoned his ‘scientific
project for psychology’
he was adopting an approach to mental illness that was
inconsistent with the way
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Clinical Psychology and Philosophy of Mental Health 281
In the 19th century, having a mentally ill relative was
associated with social stigma.
People readily bought into the idea that madness ran in families
and so those with
mad relatives should be avoided as future spouses. However,
there is another very
obvious reason why the medical community turned its back on
the biological
interpretation of mental illness at the beginning of the 20th
century and embraced
psychoanalysis. The reason was that the therapy was at least
capable of doing some
good. Compare Freud’s talking therapy to the operations Fliess
was carrying out on
patients’ noses (see Chapter 9). Talking to patients can help,
even if it is for reasons
different from those believed by the therapists. Operating on
48. noses just does harm.
At the end of the 19th century and during the early 20th
century, the biological
model of mental illness was not confirmed by the data. Despite
careful examina-
tion of the brains of mentally ill patients, nothing wrong could
be found with
schizophrenics, depressives, or manic depressives. Not only had
the biological
model yielded little in the way of diagnosis, it yielded even
less when it came to
treatment. Medical treatment of mental illness followed a
psychoanalytic route
simply because it was more successful than anything else at the
time, and even
though its success was limited to nervous diseases. It is a
feature of the intractabil-
ity of mental illness that anything that works, however, little,
can be greeted as
a major breakthrough.
medicine was developing at that time. At the same time he
started a distinction
which was to persist – between mental and physical illness.
Box 13.1 Mental Versus Physical Versus Brain Illness
It is common to distinguish mental illness from physical illness.
Mental
illness includes depression and schizophrenia. Physical illness
includes heart
disease and cancer. However, this distinction is based on a
logically fallacy.
How can an illness be mental and not physical? Unless one
believes in
49. the medieval idea that mental illness was something visited by
Divine
intervention, all mental illnesses must be physical. There are no
minds
without bodies. Mental illness must involve some form of
physical represen-
tation. Of course, it would make sense to distinguish brain
illness from
illness in other parts of the body, but that is not what is done.
Brain illness
makes sense – Alzheimer’s disease is one of the few diseases
where a
pathophysiology of the brain is identified. Why do we use the
term mental
illness, then? The reason is that the term is applied because we
are unable to
find a physiological basis for the disease. But any rational
person will realize
that a physiological basis must exist – even if that
physiological basis is best
treated by psychological interventions.
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282 History and Philosophy of Psychology
During the first half of the 20th century psychiatry was based
almost entirely on
psychoanalysis. Freud and Jung were reviewed in detail in
Chapter 9, but it was
Freud’s rather than Jung’s theory which was dominant in the
medical community.
Jungian therapists did not require a medical degree whereas
Freudian ones did,
and this difference meant that Freud’s theory was more accepted
within the medi-
cal community.
The first clinical psychological clinic
The history above is one of psychiatry not psychology. The
only link we have made
52. with psychology as a discipline is that Kraepelin was an admirer
of Wundt. We
now turn developments that were taking place in psychology at
the end of the
19th century. We showed in previous chapters that there were
two major trends in
psychology: a European trend, started by Wundt, for examining
the structure of
the mind and where psychology is not considered an applied
science; and an
American trend, started by James, for examining the function of
the mind and
where psychology is considered to have applications, in
particular educational
applications.
Lightner Witmer (1867–1956) trained under Wundt in Leipzig
and on returning
to the USA in 1892 took up a position in the University of
Pennsylvania where he
taught psychology, the kind of psychology taught by Wundt.
Witmer also joined
the American Psychological Association (APA) as a charter
member when the APA
was formed in 1892. In 1894, his university put on courses for
school teachers and
Witmer became involved in teacher education. One teacher
described a boy who
had difficulty learning to spell – the boy would now be called
dyslexic – and Witmer
Box 13.2 An Excerpt From ‘Medicine’ in the Encylopaedia
Britannica, Published in 1926
In mental diseases little of first-rate importance has been done.
The chief
53. work has been the detection of chronic changes in the cortex of
the brain, by
staining and other histological methods, in degenerative
affections of this
organ…
An enormous accumulation of lunatics of all sorts and degrees
seems to
have paralysed public authorities, who, at vast expense in
buildings, mass
them more or less indiscriminately in barracks, and expect that
their sundry
and difficult disorders can be properly studied and treated by a
medical
superintendent charged with the whole domestic establishment
with a few
young assistants under him. The life of these insane patients is
as bright, and
the treatment as humane, as a barrack life can be; but of
science, whether in
pathology or medicine, there can be little.
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Clinical Psychology and Philosophy of Mental Health 283
saw the child to see if he could help. Soon after that, Witmer
offered a course on
how to work with students who were ‘mentally defective, blind,
or criminally
disturbed’, and formed the world’s first psychological clinic at
his university in
1896. Witmer coined the term clinical psychology to name this
new profession
which he set about ‘promoting, publishing an article entitled
‘Practical work in
psychology’ in the journal Pediatrics also in 1896 (Witmer,
1896). In 1908, Witmer
set up a residential school for the care and treatment of
children with intellectual
or behavioural problems (McReynolds, 1997).
56. Although the diversity of Witmer’s clinical cases increased,
there was always an
emphasis on educational aspects of clinical psychology
(Witmer, 1907). Witmer’s
approach was one which emphasized measurement, in particular
physical and
neurological traits, and has been criticized as being somewhat
limited, but this
criticism is not entirely justified. Witmer was interested in the
dynamic psychology
being developed in Europe by Freud, but was unconvinced. He
was also interested
in the work of Galton and others, and at first believed that
hereditary was important
for mental illness, but later came to the conclusion that the
environment was more
important. This shift in emphasis from hereditary to
environment had an immense
impact on the development of clinical psychology. If mental
illness is purely
genetic, then there is little that can be done about it, other than
lock up the poor
wretches out of harm’s way. However, if mental illness is
brought about by an
unsatisfactory environment, the implication is that improving
the environment of
patients will help them get better. Witmer promoted an approach
whereby the
mentally ill were helped to overcome the circumstances of their
lives, and instead
moved the mentally ill to better environments. This
environmental focus was
consistent with the emphasis on learning and education which
characterized early
psychology: mentally ill people had learned things incorrectly,
and this idea was to
57. resurface in the behaviourist approach to mental illness.
Witmer’s clinic was headed by a psychologist and was staffed
primarily by
psychologists and was a starting point for psychologists, rather
than medical
trained staff managing mental illness. Other and later clinics in
the USA also had a
focus on mentally ill people. William Krohn started a laboratory
for the study of
the insane in 1897 in Illinois, and in the early part of the 20th
century several
hospitals in the USA introduced the practice of a psychological
examination of
patients on admission. Psychologists worked alongside
psychiatrists in a way which
was later to be characteristic of clinical psychology in general,
however, these early
psychologists focused on measurement not on treatment
(Reisman, 1991).
Behaviourism
The history of behaviourism was covered in Chapter 7.
Behaviourism was the
dominant type of theory in psychology at the same time that
psychoanalysis was
the dominant type of theory in psychiatry. Behaviourism and
psychoanalysis were
therefore competitors in terms of therapy, but as Freudian
Psychoanalysts were
medically trained, they had the authority for treating patients.
One of the major
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60. (Eysenck, 1953, 1957). Eysenck provided evidence to support
the view that only
behavioural techniques worked, but, importantly for a medical
audience, he
suggested a physiological basis for individual differences, so
that his behavioural
theory was based on a biological understanding of psychology,
and the biological
orientation coincided with the discovery of psychoactive drugs.
According to behaviourist principles, mental illness is
understood in terms of
some form of conditioning. Watson and Raynor’s famous study
(Watson &
Raynor, 1920) with little Albert (see Chapter 7) provided a clear
rationale, at least
to behaviourists, about the cause of mental illness (see Chapter
7). The cure of
such illness had therefore to reside in conditioning. The cause
and the cure had the
same mechanisms.
In the 1950s, homosexuality was classified as an illness. Hence
a behavioural
technique for treating homosexuality was to give gay men
electric shocks while they
looked at naked pictures of men. Fortunately, such
interpretations and treatments
are a thing of the past. However, behaviourism has left one
particular type of
therapy that is in use today. Systematic desensitization was
developed by Joseph
Wolpe (1915–1997), a technique which gets its name from a
technique used in
immunotherapy (Wolpe, 1958). If a person is allergic to bee
stings, then immun-
61. otherapists use a technique called desensitization in which
minute quantities of bee
venom are injected under controlled conditions. Systematic
desensitization uses the
same principle, but for anxiety. In the case of systematic
desensitization, anxiety is
deconditioned, by exposing the person to the anxiety producing
object under
controlled conditions. So for example, if a person has an
irrational anxiety over dogs,
the dog will be presented at very large distance, and then
gradually brought closer
to the person. Systematic desensitization is in fact one of two
behavioural techniques
for curing anxiety. The other is flooding. If someone is
frightened of lifts, then using
the flooding technique, the person is locked in a lift. The result
is an intense fear, but
over time the fear subsides as the person becomes exhausted.
The important point to note about all behavioural techniques is
that they do not
involve talking – they are not talking therapies. Instead they are
behavioural the-
rapies in that behaviour is modified by introducing special
reinforcing conditions.
The techniques which have derived from behaviourism are all
techniques of
behaviour modification.
Humanistic/existential psychology
The development of humanistic/existential psychology was
reviewed in
Chapter 11. Humanistic/existential psychology grew out of a
rejection for both
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Clinical Psychology and Philosophy of Mental Health 285
talked. Hence, it is also a talking therapy. However, the
humanistic/existential
approach did not compete with psychoanalysis in the sense that
medical power
remained with the psychoanalytically trained medical doctors.
The humanistic/
existential therapy tended to be used as a way of achieving
personal growth rather
than as a therapy for mental illness.
One type of techniques developed by those who were part of
the ‘Third Force’
in psychology was called the encounter group. The encounter
groups were
popularized during the 1960s particularly under the Esalen
Institute in California,
an institute that characterized the counter-culture movement of
the 1960s. The
basic idea of the encounter groups (also called the t-group or
tension group) was
that people should be completely honest and open with each
other. This honesty
stands in opposition to what was perceived as the hypocrisy of
the previous
generation and, according to those promoting the idea, would
contribute to
growth. Two points should be made about the encounter group
movement. One
was that it was based on the idea that people who were not
65. trained could help
others. This idea that non-specialists could be therapeutic runs
counter to a medical
framework where training and accreditation is the basis for
practice. Hence, the
encounter group movement represented a type of therapy which
was unacceptable
to conventional medical opinion. The second point is that
because the group
members could quite legitimately say hurtful things in the
interests of honesty,
they had the potential to damage emotionally vulnerable people
(Fuller, 2008).
Critics of encounter groups therefore viewed them with
suspicion and considered
them a potentially dangerous form of therapy.
The strange case of nude psychotherapy
Nature provides an opportunity for people to gain meaning in
life. Several studies
show that an association with nature – for example looking at a
natural rather than
a built environment – leads to better health (Ulrich, 1984). One
of the most curious,
and largely forgotten, therapies associated with the humanistic
movement stems
from the idea that to become one with nature it was necessary to
be nude. Nude
psychotherapy was introduced by the psychotherapist, Paul
Bindrim in the 1960s
and stimulated both academic and popular interest (Bindrim,
1969; Nicholson,
2007). The idea of nude psychotherapy can be traced back to an
article which
appeared in a prestigious psychology journal in 1933, written by
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286 History and Philosophy of Psychology
public but also by academic psychologists. Nude psychotherapy
was supported by
Abraham Maslow, who had previously shown he was
sympathetic to nudism as
way of overcoming inhibitions and discovering the real person.
Bindrim
developed the use of nudism in ‘psychological marathons’
which were encounter
groups lasting 18–36 hours. Despite original support from
Maslow, Bindrim was
investigated by an ethics committee of the American
Psychological Association,
and although he was exonerated, support gradually waned for
what was perceived
as a wacky and morally questionable activity. Maslow’s report
waned on reading
negative reports from those taking part. Nude psychotherapy is
just one of several
69. types of therapy that derived from the belief that a particular
activity is therapeutic.
Other less contentious types of therapy include music therapy,
art therapy and
dance therapy.
The rise of drug therapy, physical treatments
and the antipsychiatry movement
The history of medicine is not one of gradual accumulation of
knowledge and
clinical skill. On the contrary, there is one period during the
last 100 years when
medicine has advanced far more rapidly than at other times, and
that is the period
around the Second World War and for the next two decades.
Developments as
diverse as the polio vaccine, antibiotics and steroids all dated
from this period.
Not only were there new drugs for otherwise incurable somatic
diseases, but
psychoactive drugs were developed. The first anti-psychotic
drugs and the first
anti-depressant drugs were both developed in the 1950s, with
the first clinical trial
of the anti-psychotic drug chlorpromazine being carried out in
1952 and its
widespread use by the late 1950s (Tuner, 2007). These drugs
had a revolutionary
effect, with the rapid reduction of the inpatient populations of
hospitals. Biological
psychiatry had at last arrived. The exact nature of mental
illness had not been
discovered – no-one had any idea about the biological basis of
schizophrenia – but
at last the disease was responding to the kind of treatments that
70. were familiar in
medicine.
Although drug therapy was the major break through for
biological treatments,
other treatments were also being developed. Electroconvulsive
therapy or ECT
as well as insulin shock therapy were pioneered during the late
1930s (Endler,
1988). Although these latter treatments are highly controversial
and now seldom
used, at the time they reflected a growing confidence in
biologically based
treatments.
The increased use of pharmacological medication preceded the
cultural
revolution of the 1960s. The 1960s was a time when freedom of
expression was
valued in contrast to the perceived control of earlier
generations. It is possible to
criticize all psychiatric treatments as being controlling – and
indeed that criticism
has been made very powerfully by Masson (1988). One of the
criticisms of anti-
psychotic drugs was that they acted like a chemical cosh. That
is, they did not cure
the patient; they just suppressed the patient’s symptoms but at
the same time
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suppressed any motivation that the patient may have had for
themselves.
Additionally, it was suggested that anti-psychotic drugs have
been used to control
behaviour, including the control of ‘naughty’ children, a use to
which these drugs
cannot ethically be put. The result of these criticisms was the
development of the
73. anti-psychiatry movement (of which Ronny Laing was one of
the most influential
figures (Laing, 1959, 1961, 1971). The anti-psychiatry
movement was part of the
1960s counter-culture which rejected the authority of current
psychiatric
treatments (Tantam, 1991). This rejection of the authoritarian
nature of medical
control was attached not only to drug therapy, but also to
behavioural therapies,
particularly those using electric shock as an aversive stimulus.
Anthony Burgess
wrote a novel in 1962, called A Clockwork Orange which was
later to be made into a
film. The essential idea of the film was that although socially
undesirable behaviour
was itself bad, it was equally bad to control such behaviour
through electric shock
therapy as such actions destroyed the individual who was being
treated.
It is important to stress how mental illness remains a problem
today even with
the rise of pharmacological treatments. Neither anti-
depressants nor anti-psychotic
drugs actually cure mental disease. All they do is control
symptoms. Indeed the
extent to which depression is actually controlled by drugs is
controversial. Meta-
analyses suggest that even the best anti-depressants today have
only a small
pharmacological effect – at least 80% of the improvement
observed in clinical
practice is due to placebo, namely the psychological effect of
taking a drug which
is believed to work in contrast to its biological effect (Kirsch,
74. 2009).
The rise of cognitive psychology, rational emotive
therapy and cognitive behavioural therapy
Cognitive psychology has several precursors in earlier ideas in
the history of
psychology. Hull (see Chapter 7) believed that it made sense to
analyse behaviour
using mechanical principles. Tolman (see Chapter 7) suggested
that rats could
form cognitive maps of their surroundings. Chomsky’s critique
of behaviourism
showed that behavioural principles could not explain higher
mental processes
(see Chapter 7). Kelly (see Chapter 11) suggested that people
understand the world
using a process of judgement which, to many, would be
considered cognitive.
Cognitive psychology does not start at any one point, but a
notable beginning was
Donald Broadbent’s (1958) book Perception and communication
which was published
in 1958. Ulrich Neisser coined the term cognitive psychology in
the book with that
term as its title in 1967.
The essential idea of cognitive psychology was that humans
were rational,
information processing machines, and could be understood as
that. The idea that
people are rational leads to the conclusion that mental illness
can be managed by
appealing to people’s rationality. Rational-emotive therapy was
published in a jour-
nal article by Albert Ellis in 1957 and later as a book in 1962.
77. 288 History and Philosophy of Psychology
their origins to behaviourism. Thus cognitive behaviour therapy
can be seen as
mixture of cognitive and behavioural techniques.
Conclusions and Some Remaining Issues
Nowadays there are two options to treating mental illness. One
is to use the
biological approach of drugs, with or without any other form of
physical treat-
ment (ECT therapy is seldom used). The other is to use talking
therapy – i.e. where
the patient or therapist or both talk. Talking therapy was
developed by a
psychiatrist, namely, Freud. Although psychodynamic therapies
are still used,
talking therapy nowadays is seldom used by psychiatrists.
Psychiatrists have
returned to their original medical roots: treating mental illness
with biological
therapies. Instead, talking therapies have become the province
of psychologists,
despite the fact that the earliest psychological therapy, that of
behaviour
modification, was not a talking therapy. Nowadays, most
psychologists either use
therapies which have arisen out of the cognitive revolution,
most frequently
cognitive behavioural therapy (CBT), or those which have
arisen out of the
humanistic/existential tradition, most commonly that labelled
counselling, or,
78. less commonly, some therapy that is based on a modern
interpretation of
psychoanalysis.
Whereas CBT therapy is a commonly accepted form of therapy
within state
and private health care systems, counselling has always a lower
status. Why is this?
Modern medicine is based on an assumption that each disease is
associated with a
particular physiological abnormality. This assumption is
sometimes called the
assumption of specificity. Each disease has a specific cause.
There are no non-spe-
cific diseases, and it was the rejection of non-specific diseases
that distinguishes
modern medicine from the earlier Hippocratic medicine. The
aim of modern
medicine is to (a) find out what is wrong by a process of
diagnosis and (b) correct
that which is wrong by an intervention of some kind. This idea
of correcting ‘that
which is wrong’ is not only a feature of biological
interpretations for mental illness
but also most psychological interpretations. In Freud’s theory
‘what is wrong’ is
the effect of repressed trauma. In the case of CBT theory
‘what is wrong’ is that
people have incorrect cognitions. In each case, whether drug or
psychological, the
therapist intervenes and corrects that which is wrong. Disease
can be treated
like a broken clock: the clockmaker repairs the bit which is
faulty and only that bit.
The assumption of specificity is central to medical theories,
and hence acceptance
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positive regard. Thus, Rogers’ theory and approach doesn’t fit
the medical model,
because it does not fit the medical assumption of specificity.
Who is right and who is wrong? Students should make up their
own minds, but
it is worth reflecting on the following. The heart pumps blood
round the body, and
so acts as a mechanical system. Other parts of the body fit the
mechanical analogy
very well– from the action of the muscles to the way nerves
provide a form of
communication. The idea of treating the body as a mechanical
system makes a lot
of sense. There is one little problem. Clocks, are like all
mechanical systems: they
go wrong and don’t repair themselves. Big jumbo jets do not
grow from little
jumbo jets. Living organisms have this strange property of
being able to self-heal.
And big people grow from little people – who we call children.
Mechanical systems
behave differently from living systems.
82. The reason why living systems differ from mechanical systems
has exercised
people for hundreds of years. For some, life is inanimate matter
plus some special
vital force. In the 19th century, the vital force was often
electricity – in Mary
Shelley’s Frankenstein dead bodies come to life with the action
of electricity
obtained from a thunderstorm. We now know that the vital force
argument is not
valid and the difference between living and non-living systems
is one of organiza-
tion. Living systems are parallel processing systems, in contrast
to the sequential
processing of familiar mechanical systems. The difference is
one of organization
of the bits which make up the system – not in some magical
force. The idea that
the body is both a parallel and sequential processing system
raises new ways of
thinking about people – who can sometimes self-heal but
sometimes cannot
(Hyland, 2011). It is possible that the reason that it has been so
difficult to find a
specific pathology of mental illness is because mental illnesses
have a different
underlying biology to that of other diseases, namely
dysregulation in parallel
processing system, rather than an error in a mechanical system
– but this is beyond
the scope of this book (see Hyland, 2011).
Box 13.3 Something To Think About
Here are some final thoughts to ponder. In his book The Great
83. Psychotherapy
Debate Bruce Wampold (2001) shows that (a) all
psychotherapies are
approximately equally effective (b) there are large differences
in therapist
effectiveness that cannot be explained in terms of type or
length of training
and (c) there is no evidence that the specific components of any
psychotherapy
is effective. The conclusion is that psychotherapy is a kind of
‘non-specific’
effect which is the result of therapeutic encounter.
Furthermore, Kirsch’s
analysis (2009) shows that at least 80% of anti-depressant
therapy is due to
the placebo. The research shows that therapy works, but in
many cases,
including complementary medicine, not for the reason most
therapists think
it is working (Hyland, 2005).
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290 History and Philosophy of Psychology
Philosophy of mental health
Peter believes that he is the President of the United States.
Sometimes, instead of
saying that he ‘is’ the President, he will say he ‘works’ for him.
So, everyday, he sits
in front of the television and follows the news about America.
He also sees
President Bush in the White House. He believes that Olivia
Newton-John (a well-
known singer) is his wife. In fact, he went to America to try to
‘make’ her his wife,
and was arrested outside her home.
Mark believes that he is the Virgin Mary. He dresses
accordingly, with a long
robe and a veil to cover his head. He puts on a female voice,
86. talks softly and often
talks about ‘baby Jesus’ and looks at the ground as he walks. He
has turned one of
the rooms in his flat into ‘a chapel’ where he worships and
prays to ‘Baby Jesus’. At
one time, he heard a voice telling him to cut off his penis
because, he said, it makes
him commit sin, in the form of sexual thoughts.
Paul believes that some people, probably the Americans and
Russians, are
plotting against him by implanting bugs in his ears. These bugs
control his
thoughts, broadcast his thoughts to other people, comment on
his behaviour, even
discussing it with each other, and make him aware of what
other people are doing.
Simon believes that an invisible Being is controlling his
thinking, behaviour and
indeed his life. He had never been an artist in his life until one
day when, according
to him, this invisible Being decided to guide his hand to paint.
That is, he is not the
one who is doing the painting. Consequently, he has produced
some massive paint-
ings with colourful and imaginative images. This invisible
Being also controlled his
driving one day. He drove a long way and said that he was
unable to stop because
this Being was leading him to a particular place. He finally
stopped in a shop where
he was offered a job as a shop assistant, but he turned it down.
Mary believes that she is being raped every day at home by
different men. She
87. can see her rapists around where she lives. Although she tries to
avoid them on the
street, she cannot avoid them at home. As soon as she arrives
home, they will
come up to her flat and rape her.
John believes that when the political parties sitting in the House
of Parliament
in London are having a debate, they are in fact talking about
him or about the
policies that he set for the politicians. He also believes that
certain gestures from
the Prime Minister are in fact giving special messages to him.
One time, he wrote
a very long letter to warn the Pope that someone was going to
assassinate him.
The letter explained detailed reasons as to why they wanted to
carry out the
assassination.
Subjective experience and meaning of schizophrenics
For many of us, psychiatric phenomena, exemplified by the
patients above (with
pseudonyms), are strange phenomena and difficult to
comprehend. While we can
understand them in terms of some biological or psychodynamic
explanations, in
recent years, some philosophers or philosophically informed
psychiatrists or
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Clinical Psychology and Philosophy of Mental Health 291
psychologists believe that philosophical explorations can also
help us understand
them (Bolton, 2001; Bolton & Hill, 1996; Fulford et al., 2003,
2006; Graham &
Stephens, 1994; Hundert, 1989; Parker et al., 1995; Radden,
1996, 2004). To dem-
onstrate this, in what follows, we wish to present a
90. philosophical understanding of
some psychiatric phenomena, particularly that manifested by
people who have
been diagnosed with schizophrenia (Chung et al., 2007).
For some philosophers or philosophically informed psychiatrists
or psycho-
logists, to try to understand these psychiatric phenomena is to,
first and foremost,
challenge the whole notion of schizophrenia. To say that people
suffer from
schizophrenia is to say that they have fulfilled some diagnostic
criteria and
have consequently been given a label of schizophrenia.
However, one could argue,
this does not tell us their subjective experience of being in this
so-called
schizophrenic world. The more clinicians use and develop
diagnostic classification
(i.e. the more they observe patients’ behaviour, affects, speech,
etc and fit them
into some diagnostic checklists), the further they get from
understanding patients’
subjective experiences and the more they undermine the
importance of such
experiences. In addition, some scholars argue that diagnostic
classifications
are intrinsically problematic in that they are full of
uncertainties, confusion,
conceptual difficulties, omissions and naïve philosophical
assumptions (Poland
et al., 1994; Sadler et al., 1994).
This is why some scholars argue that to understand psychiatric
phenomena,
diagnostic criteria and classification is not a good place to start.
91. In fact, this
diagnostic approach should be relinquished (Bentall, 1990,
2004; Boyle, 1990;
Wing, 1988). Instead, one should start from patients’ subjective
experience and
meaning. One should pay attention to their beliefs, values, the
deep significance of
their subjective experience and the way they organize and
express their mental
disorders. How can we understand schizophrenic patients’
subjective meanings
and experience (the first person data)? One approach which is
often thought to
be appropriate for examining subjective meanings and
experiences is that of
phenomenology (see Chapter 5) (De Koning & Jenner, 1982;
Mishara, 1997;
Schwartz et al., 1997).
The phenomenological movement in psychiatry was started by
Karl Jaspers
(1883–1969/1963, 1968) (Belzen, 1995). On the basis of
Husserl’s phenomenology
(see Chapter 12), he described his patients’ subjective
experiences or states of con-
sciousness (Walker, 1994a, 1994b, 1995; Wiggins & Schwartz,
1997). He pointed
out that there are two types of symptoms, namely, subjective
and objective symp-
toms. Patients’ subjective symptoms can only be understood by
empathy by which
he meant for clinicians to be able to transfer themselves into or
‘feel into’ patients’
psyche. Patients’ objective symptoms (e.g. patients’ movement,
speech, affects)
can only be understood on the basis of clinicians’ rational
94. d
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292 History and Philosophy of Psychology
The literature has drawn our attention to the works of four
phenomenological
psychiatrists, namely, Eugene Minkowski (1948, 1997, 2001),
Wolfgang Blankenburg
(1969, 1971, 1991, 2001), Kimura Bin (2001) and R.D. Laing
(1959, 1961, 1971).
Through a phenomenological approach, Minkowski showed us
how we can
enter into schizophrenic patients’ world and understand their
subjective
experiences and how their experiences determine their
behaviour. Through
phenomenology, we can explore the central factors which
constitute the essence
of a disorder (the trouble générateur). The latter refers to a
generative disorder
and the underlying core of patients’ manifest symptoms.
According to
Minkowski, the pheno menological nature of schizophrenia (the
trouble
générateur) is char acterized by an altered existential pattern, a
reduced sense of
basic, dynamic and vital connection with the world (the loss of
vital contact with
reality (VCR) (élan personnel)) with exaggerated intellectual
and static tendencies
(morbid rationalism, morbid geometrism), and by the
manifestation of itself in
an autistic form.
95. Two of the above characteristics, namely the loss of vital
contact with reality
(VCR) and autism are worth elaborating on. In terms of VCR,
Minkowski meant
that schizophrenic patients behave without a sense of natural,
contextual con-
straint or worldly demand. In other words, they have lost vital
contact with reality.
VCR originates from the ‘inner’ core of patients’ personality,
while patients simul-
taneously relate to the ‘outer’ fast-moving world. To
Minkowski, psychopathology
such as schizophrenia is characterized by the distorted
relationship between the
inner, the subjective, and the outer world.
With regard to the notion of autism, Minkowski distinguished
two types: ‘rich
autism’ (autisme riche) and ‘empty autism’ (autisme pauvre).
Rich autism (also called
plastic autism) is characterized by a degree of normal and vital
elements that
patients preserved in their personality. It is also characterized
by imaginary
attitudes and living in a dream or fantasy world. This world
consists of rigid,
stereotyped fantasy ideas which substitute reality and
determine patients’
behaviour. Patients also display sulking, irritability, extreme
egotism, obstinacy,
remorse and regret. On the other hand, empty autism (also
called aplastic autism)
is characterized by a more pure or primary autistic state, i.e. the
loss of vital
contact with reality (Urfer, 2001).
96. Turning briefly to Blankenburg, he also used Husserl’s
phenomenological
approach and the epoché to conceptualize schizophrenia. To
him, schizophrenic
patients suffer from a ‘basic change of existence’ in the
structure of their con-
sciousness. Consequently, they have lost their ‘common sense’
ability. That is,
while they may still retain their ability to use logic and to
discuss abstract con-
ceptual issues, they have lost their ability to see things in the
right light, make
interpretations and arrive at sound judgements, and carry out
daily practical activ-
ities and relate to others. Blankenburg, however, believed that
the loss of common
sense is not an exclusive phenomenon for those who suffer
from schizophrenia.
We are all vulnerable to it. However, those who are called
normal are those who
are able to resist the loss of common sense (Mishara, 2001).
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With regard to Bin, we should not conceive schizophrenia in
terms of patients’
inability to use intellect, logic, judgement or memory. Instead,
one should concep-
tualize schizophrenia in terms of the distortion of the ‘I’ or,
more precisely, in
terms of the profound uncertainty of the ‘I’ as personal subject
of experience and
action. As a result, patients are not able to experience
representations of things as
‘their’ representations or to see that certain things belong to
them. This distortion
of self hood also leads to a distorted relationship between
patients’ own subjectiv-
ity and the group subjectivity (the social or community group)
99. to which they
belong. Patients find themselves wanting to keep their
individual subjectivity from
being engulfed by the group subjectivity. Thus, for Bin,
schizophrenia is a disorder
of the self or self-experience. There are fundamental changes
in patients’ posses-
sion and control of their own thoughts, actions, sensations,
emotions, feelings and
the like. They feel uncertain about their self hood and often
struggle to restore or
maintain their self-identity by means of reflecting obsessively
upon themselves.
R.D. Laing’s phenomenological approach to schizophrenia has
been both influ-
ential and controversial in clinical psychology and psychiatry.
To him, schizo-
phrenic patients suffer from what he called ontological
insecurity. This insecurity
means that they have lost trust in their physical and concrete
existence in the
world. Patients have also lost trust in their dysfunctional
families who, they believe,
have not helped them to integrate with society in an acceptable
way. Instead,
patients feel suffocated or engulfed by their family because they
are not allowed to
develop their own independence and identity (Laing believed
that families, through
double-bind interactions [i.e. contradictory messages between
the family and the
schizophrenic], can make it impossible for the schizophrenic to
find their own
identity, to achieve independence and a sense of self and to
live accordingly).
100. Meanwhile, patients are desperately trying to find ways through
which they can be
real to themselves and others, trying to develop or preserve
their own identity and
resist the possibility of losing their own self. In other
words, schizophrenia results
from the dysfunctional interactions between the schizophrenics
and their families.
When patients are experiencing ontological insecurity, they also
experience a
strong sense of anxiety for different reasons. Firstly, they feel
anxious that they
might be engulfed, overwhelmed and indeed destroyed by
others. Secondly, they
feel anxious that they may develop a sense of complete
emptiness. Thirdly, they feel
anxious that they may be turned into an object or a thing. In
other words, their
own self and autonomy would disappear altogether. Instead,
they may develop a
false self which is being controlled, observed and manipulated
by others, and
which feels that it can only survive by conforming to the
expectations of the
outside world.
Schizophrenia and the self
One implicit message from the foregoing phenomenological
approach is the idea
that if we want to understand schizophrenia, we should start
from patients’
concept of self or, perhaps more precisely, distorted self.
Some scholars believe
103. core of schizophrenia. For example, recent research shows that
schizophrenia can
be conceptualized in terms of the doctrine of solipsism (Sass,
1994, 2001; Sass
et al., 2000). This doctrine says that the whole of reality, which
encompasses the
external world and other human beings, is only a representation
appearing to the
individual who holds the doctrine. In other words, solipsists are
those who would
say that only their feelings, emotions and perceptions are real.
Thus, solipsism
implies a mixture of increasing subjectivization of the world
and a specific type of
grandiosity.
In the light of this doctrine of solipsism, schizophrenia can be
seen as the
manifestation of a ‘pervasive sense of subjectivization’. This
means that the
schizophrenics are unable to regard others as subjects and
engage with them by
means of normal forms of communication, exchanging reason
and developing
interpersonal relationships. This is because to engage in such
communication
implies a relation of reciprocity or cooperation which the
solipsists (the
schizophrenics) are unable to do.
The literature shows another way of understanding
schizophrenia in the light
of the disorder of the self: schizophrenia is a self of ipseity-
disorder in which
patients have a strong sense that they are the centre of their
own experiences,
104. that their own self is separate from the objects that they are
perceiving and that
their representation of these objects is experienced as that
which is different
from the object itself. At the same time, they feel an acute self-
consciousness
and a heightened awareness of aspects of their own experience
(hyperreflexivity).
Patients with hyperreflexivity increasingly monitor or examine
their mental
lives or mental phenomena. In so doing, ideas or thoughts have
become objects
of focal awareness, i.e. they have been objectified as if they
existed in an external
or outer space. Consequently, patients may feel that certain
thoughts or ideas
can be felt in certain locations of their brains (Parnas & Sass,
2001; Sass &
Parnas, 2001).
Schizophrenia and agency
To look at schizophrenia from the notion of self, some
researchers have focused on
the self as an agent or the action of the self (agency). What
follows consists of
some examples of research looking at schizophrenic symptoms
in terms of the
notion of agency.
Some philosophers argue that the schizophrenic symptom of
thought-insertion
(e.g. patients often say ‘someone keeps putting thoughts into my
head’) should be
seen in terms of an error of agency. That is, certain thoughts
occur in the patients
107. e
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Clinical Psychology and Philosophy of Mental Health 295
Some philosophers argue that symptoms of illness can be
characterized in terms
of the feature of the things that patients do (i.e. hurting
themselves) and things
that are done to them (i.e. they are being hurt). Similarly, in the
case of thought-
insertion, while other people might conceptualize it in terms of
something wrong
with the patients, the patients themselves perceive it as
something which is done
to them (i.e. action failure of the self ) (Fulford, 1989, 1993,
1994a, 1994b).
The literature also suggests that schizophrenic symptoms can be
conceptualized
in terms of patients’ intention to act (Frith, 1987, 1992). There
is a type of intention
called willed intention. This refers to the fact that we may
intend to buy a German
dictionary because we want to pursue a goal of learning
German. There is an
internal cognitive monitor which monitors this intention and the
kind of actions
that we have actually chosen, as a result of the intention. This
monitor also
metarepresents an intention which would also bring that
intention into our
consciousness.
108. Schizophrenic symptoms, such as hallucinations and thought-
insertion, which
involve the loss of the sense of control or possession of
patients’ own thoughts or
movements, in fact result from the dysfunction of the monitor
to represent willed
intentions. For example, if we want to pursue our goal of
learning German, we
form the willed intention to buy a German dictionary. The
monitor in us metarep-
resents that willed intention and subsequently brings it into our
consciousness.
After having formed the intention to buy the dictionary, we then
carry out the
action in the form of buying the dictionary. Our internal
cognitive monitor
metarepresents both our intention and action and can confirm
that the action that
we have carried out has satisfied the relevant intention. For the
schizophrenic
patient, there is a dysfunction of the monitor. It fails to
represent the intention to
buy a dictionary and fails to bring it into their consciousness.
As a result, they
might buy a dictionary without being conscious of the fact that
they had formed
their intention to do so. That is, they have performed their
action, while they had
no consciousness or awareness of any intention to carry out
such action. To explain
this, thus, they might opt for the explanation that some external
forces have in fact
performed the action, hence, a delusion of control (alien
control) (Cahill & Frith,
1996; Cocoran et al., 1995; Mlakar et al., 1994).