Beliefs that Create Madness

Beliefs about madness have evolved long before the emergence of science. From the ancient Egyptians, who believed that the heart controls the mind, to the Middle Ages, when it was thought that evil spirits took over the mind, these beliefs had consequences for how the patient was treated. There was no science in any of these treatments, just beliefs that we held about the behavior of others that did not fit with the norm. We always tried to understand it or explain it. What is important is that these beliefs are always tied to treatment. How we attribute a cause determines how we deal with it. If we believe that the reason why we are fat is because of our genes, then we have limited options. But if we attribute to cause to food intake, then our options become clearer.

The Egyptians practiced trepanation (drilling into the skull), but also relaxation, sleep, and other soothing therapies to relax the heart. In the Middle Ages, with their belief in evil spirits invading the body, the treatment was predetermined. You cannot reason with bad spirits; they only react to violence, and hence we get the draconian treatment of madness of the Middle Ages. Looking from the safety of our modern time, their treatment of chaining, beating, and restraining patients looks sadistic, but they had their reasons; they had their beliefs.

With the rise of science and the eminence of theory, a new set of beliefs was adopted. The Enlightenment in the middle of the 17^th century ushered in a new set of scientific theories, energized by the discovery of electricity in the body, and a new understanding of chemistry and biology. In the shadow of this newfound knowledge emerged new lay beliefs about madness. Madness was believed to be due to excess nervous energy, and since the business of pharmacology was still nascent and still morphing from apothecary, their option for lessening this excess energy was to provide a peaceful and nurturing environment that reduces stress and trauma. The way they believed that they could cure madness was by providing “moral” treatment (a mistranslation from the French meaning “psychological” care). Hospitals for the insane became the de jure cure for madness.

During the mid-to-late 19th century in the United States, the Kirkbride Buildings took hold of the imagination. They were magnificent buildings that were a testament to the glory of science over madness. Built to the specification of a physician and Quaker Thomas Story Kirkbride, each ward had expansive windows, wide corridors, fresh hot and cold water, gardens, and recreational outdoor areas. Kirkbrides were more retreats than hospitals. Instead of punishment to drive the evil spirits out, now there was psychotherapy to diffuse the trauma within the individual.

Dorothea Lynde Dix, a retired nurse, went around the country promoting these Kirkbrides as a panacea. An inspired fervent frenzy ensued, believing that civilized societies were bringing mental health science to the unfortunates. Cities clamored to build these symbols of scientific superiority over madness. At its apex, 78 Kirkbride Buildings crowned the landscape across the United States, mostly in the Northeast, half of which have been repurposed and still stand today.  They were described as the “cult of curability” as everyone believed that they worked. Designed to accommodate 200-250 patients, these buildings soon became seen as a panacea. As a result, they ended up becoming a warehouse for all sorts of unwanted. When they became too expensive, and the promise of cheaper, more effective drugs came on the market, they were abandoned. By the first half of the 20th century, Kirkbrides and the majority of insane hospitals devolved into dystopian tragedies. Increasingly, invasive treatments replaced “moral” care. Psychiatry, taken over by the much more powerful pharmaceutical industry, started to reel in random grasps for relevance.

The eventual failure of the 19th-century asylums led to the dead-end intervention of pharmacy (insulin coma therapy), biological (bloodletting, organ excising, and purging), chemical (toxification), skeletal (trephination), electrical (electroconvulsive therapy), physical manipulation (rotational therapy), neurological surgeries (lobotomies), and behavioral constraints (straightjackets)—all these therapies had dubious efficacy and definitive harm. All based on lay beliefs with a whiff of scientific method. All eventually shown to be sham, all.

In the 1900s, when psychiatry divorced from psychology and psychoanalysis, it became the turf keeper of biology and chemistry. With the eventual dominance of the pharmaceutical industry, psychiatry became subsumed as a pusher of drugs. With this new overlord came a change in attributions, a new paradigm, and a new meaning of mental illness emerged.

First came the anti-psychiatrists. The infamous Thomas Szasz and R.D. Laing, who became famous because they were not too radical and they were intellectual enough to make it through the filter of public decorum. Their criticisms were sanitized, discussing issues of ontology such as the meaning of madness, and they broadcast that they wanted to modify psychiatry to help change it to become more humane and more sensitive to the social context. In contrast to this pragmatic and acceptable (by the institution) approach, there are the less famous anti-psychiatrists, the radical Franco Basaglia and Frantz Fanon. These psychiatrists realized that you cannot modify psychiatry; you must revolutionize it, you have to abolish it. These factions helped to bring psychiatry into public focus.

But it was only when the patients themselves started to speak out that radical change became possible. With Mad Studies, which aims to reclaim humanity for patients, patients started to lobby for a new perspective to look at enhancing their well-being rather than pathologizing their behavior. Their criterion of outcome was different; they wanted to feel accepted, they wanted to feel better, and not necessarily to be cured, if that was even possible.

Fast forward to today. Now we have a new set of beliefs dictated by the industry, defining psychiatric disorders as a “broken brain”, a “chemical imbalance, ” or a “neurological mis-wire.” These are the beliefs underlying psychiatry’s “Bible,” the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is perhaps the most obvious approach for reliability in defining madness, at the expense of validity. It categorizes different aspects of madness by willfully discounting the main cause of all these variances—our context in a social environment.

Even if madness were somehow chemically or neurological determined, the behaviors are socially expressed and defined. Being aware of someone’s living conditions can help place the behavior in context. The social aspect of madness is crucial to understanding the behavior. How we see the cause of madness, our beliefs, dictate how we treat patients. Clinicians are less likely to see this social influence. There is an attribution bias with clinicians as they are biased to diagnose a patient‘s dysfunction as internal, stable, and uncontrollable. In reality, most dysfunctions are periodic and cyclical and therefore unstable, and through behavioral therapy, most are controllable.

Most madness is not the dramatic but the mundane. The emergence of ADHD among children and adults is but one instance where psychiatrists are pathologizing greater swaths of behavior, and even if these definitions are valid, then we have to ask how to make it less stressful and disturbing for those experiencing these conditions.

A new belief is emerging that accepts the role of sociology in creating and expressing dysfunction. Only by understanding how beliefs create madness can we predict the future of psychiatric treatment. By exposing the assumptions made about dysfunctional behaviors, treatment options can be better understood. Belief in the cause of a disorder determines what is done to alleviate it. With the social context gaining importance, social prescribing has become a more effective way of treating madness. Social prescribing is providing social services, housing, work, respite, drug treatment, physical therapy, all services that are usually in the realm of social work, psychology, or social services.

With Mad Studies promoting the perspective of the patients who use the mental health care system, the attribution of disease changes again, and a greater emphasis is placed on the external, unstable, and controllable aspects of madness. According to the theory of Power Threat Meaning Framework, ‘madness is a mental strategy that has become mismatched with its current context.’ The context determines the expression of dysfunction. While this approach argues that future treatment requires a population-based approach that offers social prescribing, short-term respite programs, and broad community-based cognitive-behavioral therapies, psychiatry remains stuck on “curing” the “diseases” with medication. A more pragmatic objective would be to focus on alleviating the anxiety and distress experienced by the individual and to aim for personal and functional recovery rather than to aim for a purely clinical recovery. A cure is possible if we redefine what a cure looks like.

With public awareness, the tide is changing, slowly but surely. The seeds are here already, as with the early inklings of Moral Treatment in the late 1700s; it takes time for them to grow. However, change is coming as our beliefs have already changed. Most of us have family members, friends, or personal experience with madness. We know that it is not simply a chemical imbalance or a broken brain. We know how the context plays a large role in how we behave. History has taught us that beliefs change first, and the rest follows. Perhaps the cult of curability, a derogatory slight for those who had the vision to believe in a cure, might materialize in this new ecological age.