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“HENRI COANDA” “GENERAL M.R. STEFANIK” INTERNATIONAL CONFERENCE of SCIENTIFIC PAPER A GLOBAL UNDERSTANDING OF MENTAL HEALTH
Barry L. JACKSON, Ph.D
Professor and Director Emeritus Drug, Alcohol and Wellness Network (DAWN) Bloomsburg University of Pennsylvania, Bloomsburg, Pennsylvania 17815 United States of America
Abstract: The modern day concept of mental health in Western European culture has deep historical
roots which continue to shape their understanding of mental health and mental disease. This article
reviews the history of concepts of mental illness and the progression of ideas and historical events which
have influenced modern mental health intervention. It examines the forces which lead to the three
competing views of mental health: biological/physical; psychological; and societal. Recently the field of
Global Mental Health has emerged. This movement places priority on improvement of the mental health
and general level of functioning for all people with respect to cultural differences. Caution must be taken
not to impose Western European values as counseling spreads globally.
An Historical Background to Understanding The first theory that emerged was supernatural in origin. A psychotic individual was seen as The concept of Mental Health dates to at least having visions from the gods or perhaps the the 5th century BCE.1 The Greeks first gods were speaking through them. Mental described mental illness and by the 4th century illness could be seen as either a blessing or BCE had developed a manual cataloging condemnation by a god. mental disorders.2 Three major illnesses were The gods could act for the benefit of mankind identified: madness (psychotic behavior), or do unspeakable harms. Religious leaders melancholy (depression) and epilepsy. The sometimes felt it necessary to rid the body of first major schools of philosophy were the the god’s possession through religious rites. Stoics, the Skeptics and Epicureans, later Many cultures around the world have had came the Socratics and the Aristotelian similar beliefs. Some faiths even today schools of thought. These philosophies conduct exorcisms in order to rid a person of expressed some of the earliest ideas about demons and evil spirits. mental illness and how to treat it. Even today A second view was that mental disorders were these philosophies have an influence on the way we conceptualize mental illness. For abnormality. Hippocrates, the founder of the example: the founders of cognitive therapy Hippocratic Oath, which is still taken by and rational-emotive therapy explicitly cited physicians in Western medicine today, wrote Stoic philosophy as the principal precursor of seeing his colleague Democritus dissecting and inspiration to their approach.3 animals in an effort to locate the organs involved in mental illness.4 Blood-letting, hot theories about the origin of mental illnesses. baths, purgatives, smelling incense and other physical interventions were used to relieve the than in previous centuries in Europe. The mentally ill, the physically deformed, and The competition between the spiritual and criminals were frequently locked up together. physical views of mental illness for They were tied or chained to beds, locked in dominance persisted through the height of the small cages without blankets or even clothes. Roman Empire’s reign. By the end of the 4th century A.D. mental illness had become nearly beginning of a new view of mental illness, one synonymous with sin. The search for physical in which physical and social causes were roots of mental illness was forgotten by sought as the origin of mental illness. In 1621, Europe for more than a millennium. The Roman Catholic clergy felt mental illness was God’s visitation of punishment for sin. published an English language book, The This belief lead to a fear of the mentally ill as Anatomy of Melancholy… 6 He made a essentially evil beings intent on doing harm to scholarly case for the need to study the human others. It was thought that the mentally ill mind. His call for the study of the human must be separated from the population, not so much for the good of the mentally ill as for the physician William Battie wrote his Treatise on protection of the society. The conditions Madness in 1758. He advocated humane which we might label schizophrenia, mania, or treatment of the mentally ill and the search for obsessive compulsive disorder were thought to the causes and cures for such conditions. be the result of demonic possession. In the When the English King George III recovered name of God exorcisms were brutally from his mental disorder a new era dawned.7 conducted as treatment to save the soul, if not Mental illness was then seen as an illness which could be cured or at the very least Sufferers of melancholia (depression) were controlled. By the 1790’s Philippe Pinel,8 M. treated with colonics and herbal teas and D., of France and William Tuke, an English medicines. Other unfortunate individuals Quaker and tea merchant, independently were locked away in dungeons or tortured in advocated for the removal of chains from the an effort to drive out the “evil” spirits. Many mentally ill.9,10 The York Retreat (Tuke’s were simply killed to “protect the facility) in England became a model for the community.” Those in the dungeons received Americas and Europe for the treatment of the no medical care, little in the way of food and mentally ill. A focus on moral development, were left in rotting rags and their own soil. healthy living and humane conditions was Many children born with some physical viewed essential for the patient’s recovery to deformity were also deemed mentally ill and mental health. Despite these emerging views were locked away with criminals and those the conditions and treatments offered to the mentally ill showed no improvement outside The first known specialist “hospitals” for of a few enlightened institutions. madness developed in what is modern day In 1808 Johann Christian Reil took the Greek Iraq. In 705 A.D. a hospital was built in words psyche “soul” or “breath” and iatros or Baghdad, another soon followed in Fes and a “healer” and combined them to create third in Cairo in 800 A.D. Several Medieval Islamic physicians wrote treatises on the medicine.11,12 During the next hundred years diagnosis and treatment of mental illness.5 the understanding of mental disorders and Little of the literature of those scholars their categorization grew dramatically, as did survives today. The first European hospitals the housing of those who were ill. Much of for the mentally ill appeared in the 13th this change must be attributed to the rise of the century and then these did not attempt a cure. scientific method which began its ascendency Their purpose was to incarcerate, to protect the general public from the lunatics. dominate religious fervor. This shift in Treatment in these hospitals was no different thinking allowed for the re-emergence of the “HENRI COANDA” “GENERAL M.R. STEFANIK” INTERNATIONAL CONFERENCE of SCIENTIFIC PAPER  search for physiological basis for mental the modern concept of social work. This illness. social welfare movement was gaining strength During the latter part of the 1800’s mood in the United Kingdom and the United States. disorders, levels of depression, monomania Dorothea Dix was a prominent American (obsessive-compulsive behaviors) and neurosis were identified and treatments were sought. Mesmer began mesmerism in the Massachusetts”13,14 described the conditions in 1850’s (hypnosis therapy), Freud followed which the mentally ill were kept and their with his version of psychotherapy and the brutal and inhumane treatment. She lobbied Vienna School. He believed that the brain for the humane treatment of the mentally ill function was somehow altered by childhood for many years. By the 1860’s the New York experiences and that by discovering those State Legislature established separate asylums experiences which have been subjugated to the for the mentally ill.15 Despite these new subconscious or unconscious mind one could facilities and improved living arrangements effect a cure within the individual. He also treatment was minimal and often still brutal. said that his technique would become obsolete Ice cold water submersions, the use of strait someday because medicine would be able to jackets and the experimentation with drugs explain the physiological malfunctions which were used without the modern constraints of caused various forms of mental disorders. patient’s rights or the ethical standards of While Freud and his Vienna Circle colleagues were exploring the art of psychoanalysis and By the early 1900’s the United States of creating an understanding of human behavior that included the ego, alter ego, unconscious mental ill and physically deformed people. and subconscious mind another movement German speaking countries had more than 400 was also developing independently of public and private mental facilities and medicine and psychiatry. psychiatry was a recognized medical specialty. Due to industrialization across Europe, Treatments included psychoanalysis and the England and the United States, living traditional treatments of ice cold baths, conditions deteriorated for the masses of electric shock, experimental drugs, colonics, people who migrated to the industrial centers for work or to escape the European armed Clifford Beers described what it was like to be conflicts and famine. These are the conditions a patient in an American asylum in 1908 in his which the famous author Charles Dickens book A Mind That Found Itself.16 This marked portrayed in his novels. A social conscience the beginning of the “mental hygiene” movement emerged in which poverty, living conditions, and the social class system were prevention. It also signaled a rejection of the challenged. The social conscience movement medical model of the common treatments of postulated that many of the mental health the time and a refocusing on mental health, issues of the day were the result of poverty and the lack of education and opportunity. social environment and its impact on This new movement was a social justice or maladaptive behavior. Now there were clearly social welfare model which eventually created three competing views regarding the original and thus the treatment of mental illness: is of course Client-Centered Counseling biological/physiological; psychological; and (Rogerian), Somatic Psychology, Expressive sociological. Therapy including art and play therapies and By this period the academic discipline of EMDR. There is career counseling, couples psychology was well established in many counseling, divorce counseling, addictions universities. There were studies of how the counseling and a host of other variations. And mind, as opposed to the physical brain, then there are specialties in the medical field worked. The American philosopher James of psychiatry. and others began to postulate theories of Notably Carl Rodgers began the “counseling learning and memory. Others examined group movement.” He was a trained psychoanalyst or mass psychology and what we would term who felt the patient–doctor relationship was an propaganda for the manipulation of the incorrect model for treatment of most mental masses. Intelligence testing for educational conditions. He preferred the legal model of purposes advanced. Employment and career client and counselor in which the client counseling emerged. determined the direction of therapy and what The temperance movement convinced issues were to be discussed. He stressed the Americans that alcohol and alcoholism were relationship between the therapist and client as “social diseases” which prohibition could the key to assisting the client in attaining a cure. Alcohol and drug addictions were healthier way to function in life. His goal in labeled as morale weakness from which the therapy was to help clients become “fully government needed to protect the greater functioning individuals” within the social society. Physicians saw addictions as a context in which they found themselves. This psychologically based disease with model shifted the control of treatment from physiological aspects. The social welfare the doctor to the patient. Behaviour movement viewed excessive drinking as a modification, first seen in the 1920’s, became symptom the decay of the social environment popular in the 1960’s and 1970’s. It and endemic poverty. Alcoholics emphasized the biological concept of stimulus Anonymous was founded by a physician on and response and learning theory. Notable tenets of religious faith, social fairness, and Africa, Shipiro and Eysenck in the United Throughout the first half of the century the Kingdom, and J.B. Watson and B.F. Skinner debate regarding mental health raged between in the United States.17 Another significant the medical, biological proponents, the therapeutic approach grew out of the Second psychological/psychiatry approach and the World War. Existential Psychology social work belief that mental illness was at concerned itself with the individual’s ability to least in part a response to the inequities of create and preserve meaning and purpose in After World War II a host of new approaches circumstances.18 This approach placed its to mental health emerged. In the last half emphasis on the social circumstances in which century there has been an astonishing growth the individual was situated and how that in mental health services available in the individual responded. Vocational Counseling, United States, Canada, and the United begun in the early 1900’s, never had much Kingdom. With this growth came the support or recognition as a profession. introduction of new therapy models and Following World War II and the Korean theories. Today the variety of psychotherapies Conflict the United States government funded is staggering. There are Albert Ellis’ Rational vocational education and built upon John Emotive Behavior Therapy (REBT), Aaron Holland’s theories. The government had two Beck’s cognitive therapy (CBT), Human basic objectives. One was to employ as many Social Functioning, Gestalt, Positive of the veterans as possible, and the second was psychotherapy, Narrative Therapy, Coherence Therapy, Feminist and Brief Therapies. There “HENRI COANDA” “GENERAL M.R. STEFANIK” INTERNATIONAL CONFERENCE of SCIENTIFIC PAPER  approach was different in structure and part of the century, also became common. theoretical foundation each originated from Career counseling services were established in social needs and was not based on medical every US secondary school, university and college. Although initially the funding was By 1950 the psychological model was also re- federally based, most institutions found it emerging with its own new approach to advantageous to continue services even after mental health. In that year the Diagnostic and Statistical Manual (DSM) was first published. schools these counselors helped “track” This was an attempt to label disorders for students into vocational education or research purposes and to collect data using a preparation for entrance into colleges and code system which categorized mental universities. In colleges and universities disorders. It was not dissimilar in conception counselors focused on placement in jobs post- to Karl Ludwig Kahlbaum’s disease graduation. classification19 on which Emil Kraepelin built Biological Psychiatry and Neuropsychology early in the last century.20 These ideas grew quickly in reputation and the number of culminated in medicine’s development of the providers after Otto Loewi’s discovery of International Classification of Diseases acetylcholine’s neuromodulating properties.24 (ICD).21 This was the first of many neurotransmitters to There were many opponents to the original be identified. Neuroimaging was developed DSM as it seemed to some to adopt a medical and utilized in the 1980’s. These discoveries model: perhaps most notable was William have further advanced the pharmacological Glasser, M.D., who still remains an opponent of the system and its subsequent editions. One dominates psychiatric interventions in mental repeated complaint is the DSM model portrays social adjustment and many normal Perhaps the most frequently employed model behaviours as mental disorders. In May of of initial data collection regarding a client’s 2013 the 5th Edition of the DSM was released care is based on the “bio-psycho-social” with nearly 1000 pages with several new model which recognizes the interaction of the diagnoses. The discoveries that lithium carbonate heredity. Although there are differences in the stabilized manic-depression (now known as emphasis placed on the three basic bi-polar disorder) in 1948 and chlorpromazine components of the model by different theories was effective in treating schizophrenia in 1952 and practitioners, the model recognizes the helped in the establishment of Biological intersection and interaction of the three Psychiatry.22,23 By the end of the decade the components. In medicine greater emphasis is psychoanalytic school of thought had been placed on the biological component. In marginalized. Psychology and counseling psychology the emphasis is on the techniques had become dominant in dealing psychological development of the individual, with the “simpler” forms of mental illness whilst counselors, social workers, marriage (neuroses). counselors, career counselors and addiction Social Workers, the natural outgrowth of the specialists stress the social and family aspects social welfare models of service of the first Even within these three approaches there is 2. the type of treatment was not a factor, psychotherapies that employ a medical 3. neither the theoretical bases of the orientation and those that employ an techniques used nor the strict adherence humanistic one. The medical orientation to the techniques were not factors. considers the patient as unwell and in need of 4. the therapist’s belief in the efficacy of the “curing” or at least controlling the progression of the disease. The DSM and ICD are the 5. the personality of the therapist is a factor, guide books for this orientation and have and become the Global standards. The humanistic 6. the alliance (rapport, trust, collaboration in view stands in stark contrast to the medical orientation. It seeks to depathologize the the therapist is a key factor in effecting a human condition and to understand emotional turmoil in the context of the environmental stressors faced by the client. Reactions to The conclusion drawn by Wampold was these stressors are seen as normal responses to therapy can effect an improvement in the difficult situations. Some responses are client due more to personality, client-unsuccessful or less successful than others in counselor relationship, and a belief in the coping with life circumstances. These effectiveness of the therapy than on the type of counseling approaches strive to assist the therapy or the counselor’s skill in utilizing the client in developing more successful coping strategies which will be available to the client The Global Mental Health Movement
The World Health Organization, seeking to Therapeutic Efficacy
find a definition which serves common ground The proliferation of therapies has resulted in across cultures, defines mental health as “a competing claims regarding the greater state of well-being in which the individual efficacy. Controversy surrounds which form realizes his or her own abilities, can cope with of psychotherapy is most effective and which interventions are optimal for certain productively and fruitfully, and is able to diagnoses. “Furthermore, it is controversial whether the form of therapy or the presence of community.”29 The agreement that mental factors common to many psychotherapies best health must be understood from a cultural separates effective therapy from ineffective perspective with the goal of improving one’s therapy.”25 It has been argued that the quality ability to succeed within one’s own culture of the relationship is of greater importance has gained wide acceptance. Recently a than the therapeutic theory. This position global mental health field has emerged and would be supported by Client-Centered has placed a “priority on improving mental therapists. health and achieving equity in mental health Psychotherapy outcomes research as early as for all people worldwide.”30 This movement 1952 found that two thirds of patients recognizes the biomedical aspects of mental improved significantly or recovered fully illness whilst endeavoring to hold the within two years with or without treatment.26 humanistic aspects of counseling as foremost The Helsinki Psychotherapy Study which is examining long-term effects of therapy will Psychiatry and psychology have agreed upon continue until 2014. The three and five year some definitions of mental disorders that follow-up reviews revealed that brief therapies bring more immediate results, but long-term schizophrenia, addictions and mania are some In 2001, Bruce Wampold published The Great Psychotherapy Debate28 which reported; 1. consensus. The ICD and the DSM are global “HENRI COANDA” “GENERAL M.R. STEFANIK” INTERNATIONAL CONFERENCE of SCIENTIFIC PAPER  attempts at gaining universal acceptance of more than a very general definition of mental definitions of specific disorders by listing a health will serve all peoples in various nations series of behaviours and thoughts which a and subcultures.33 Cultural differences make a patient/client reports or that are directly globally acceptable definition impossible at observed by the therapist which serve as a this time. basis for diagnosis. Both the DSM and the A notable criticism of therapy suggests that to ICD have tried to objectify diagnoses by some degree it is idealized as only a helping stating specific behavioural criteria on which relationship. But because of the cultural to base a diagnosis. One need not demonstrate context and its dominant value system therapy all of the listed criteria but a specified number must be met to receive a proper diagnosis. In supporting societal norms and practices while both of these diagnostic systems the presence of illness is determined on a polar basis: which deviate from the acceptable variation either one has the disorder or one does not. If from the norm. While this may be unintended, one meets enough of the criteria then the the counselor-client relationship always individual is ill. In parts of Canada a system participates in the society’s understanding of with a Likert type scale in which the degree of relationship power and political dynamics.34 functioning is estimated is being used. The higher the number on the scale the greater the presents a danger. The theories and systems particular behaviors or thoughts and feelings are present. This recognizes that mentally from Western European culture with its long healthy people may not always function well history and evolution. If care is not taken the and it allows for a fluid diagnosis as underlying European values may be imposed conditions change. It incorporates mental in a new colonialization of less developed health into the mental illness model on a nations. continuum from healthy to unhealthy. The The understanding of cultural importance Chinese have developed their own system for cannot be overstated. Even in countries which diagnosis of mental disorders based on their share a common language and heritage there cultural differences exist and words do not Although there is some agreement on what always have the same meaning. Different constitutes mental illness, there is wide experiences and cultural histories, which are at divergence in what is considered mental times subtle and often unrecognized, influence health. Health is not simply the absence of how people think about and react to the same illness and there is no one universally agreed stimuli. When two cultures do not share a upon definition of mental health. Mental common language the difference in health has been described as the capacity to enjoy life in the absence of a mental How one organizes thoughts is both culturally disorder.31,32 It may also be defined as the and linguistically determined and then in turn ability to cope appropriately and effectively how one thinks aids in the social construction with life’s stressors within one’s cultural of culture. This interaction is dynamic and environment. The idea that coping behaviors continuous causing an evolution of the cultural are culturally contextual means that nothing experience. The culture in which one grew to adulthood is not the same culture in which World Health Organization has proposed a one’s children and grandchildren will mature. broad statement of healthy behavior which can Language is symbolic shorthand for objects, focus efforts on improving the quality of thoughts, ideas, and concepts of human emotional well-being. There is a global experience. Some languages are more abstract than others thus permitting greater focused on just such a goal. Caution must be opportunities for misunderstandings. Anyone taken not to impose values which are deeply who speaks multiple languages recognizes that imbedded within the theories and techniques some words and phrases have no identical originating in the Western European cultures meaning in another language, thus requiring and the dualistic understanding of human Despite these considerations and difficulties Within the two positions of biological/medical there is merit in attempts to create an model and the humanistic model of mental international agreement in general terms as to what constitutes good mental health and how evolved. Wampold’s and others research have it can be achieved. There is room for both a biological, medical understanding of the brain regardless of type but associated with the physiology and chemistry which underlies counselor-client relationship. Therapy works some mental illness, and there must also be an acceptance of the social and environmental circumstances into which humans are born. It References
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