Introduction

This chapter examines mental disorders, the ways in which they have been regarded, and the ways in which they have been treated in past times. It traces the transition from individual family care to the emergence of organised care for the mentally ill. The consequent professionalisation of the people who treat and care for sufferers of mental disorders is described, and it will become clear that it is difficult to distinguish between the activity of nursing the physically ill and that of nursing the mentally ill when mental illness is often seen in physiological terms. We will establish what constituted a mental disorder in past times and societies, and how mental disorder was regarded, and consider how these perceptions about mental disorder differ from those of today.

Each generation and society blends new knowledge with the inherited scholarship of the past. Occasionally the progression falters, as it did during the Middle Ages when the vast scholarship of the Graeco-Roman period was for centuries barely kept alive by the diligence of monastic orders in the West, and by Eastern scholars. Fortunately, Graeco-Roman discoveries in science and medicine, literature and the arts were recovered during the Renaissance and thereafter.

The British statesman Winston Churchill believed that studying history gave the modern politician a practical advantage, saying: ‘The farther back you look, the farther forward you can see’ (Howells 1991, p 1). An opportunity to reflect upon the historical precedents for prevailing mental disorders, and the ways in which they have been diagnosed and treated in the past, can enhance the richness and depth of contemporary clinical practice.

Mental disorder cannot be discovered by archaeology, or by any other means than written sources, and sometimes the terminology cannot be translated exactly. It is inevitable that in the millennia covered briefly in this chapter, attitudes towards mental disorder and the mentally ill, and even mental disorders themselves, will have changed over time. Also, as with our own society and culture, attitudes towards mental disorder probably would have differed within any society or culture at a given time. Both ancient and modern ideas about mental disorder and ‘madness’ are contextual and shifting. Sometimes the ancient world seems remarkably familiar, but there are moments when we realise how different is the world we inhabit now. We can learn from both the differences and the similarities. The history of a discipline or profession provides a common ground from which to evaluate clinical experience. We can learn from the mistakes of the past but we can also take pride in our predecessors’ achievements.

The value of historical antecedents

There is an increasing tendency to discount the historical antecedents of mental disorders and their treatment as health and medical education abandons its emphasis on the teaching of Latin and Greek. Sigmund Freud and his colleagues received a sound classical education, which included the study of Latin and Greek, legend and mythology (Richards 1991). Just as the Greek language determined the nomenclature of most body parts and diseases, it also influenced the naming of early psychoanalytic phenomena such as mania and melancholia, neurosis and psychosis, the ego and the id and the Oedipal and Electra complexes.

Perhaps it is the need to believe that modern medical science holds the key to a better world that leads some writers to deride the achievements of the past, or to ignore them completely. However, in some cases medicine, culture and society have not improved dramatically. Sometimes the past can hold valuable lessons and precedents which have been lost and which, when rediscovered, can assist us to achieve the best possible outcome for ourselves as healthcare practitioners and for our clients. Suer (1995) says that modern French psychiatry is based on ancient medicine, and traces the survival in modern psychiatric care of ancient medical terminology, psychiatric terms (e.g. mania and melancholia), theories of aetiology (airs, climates and humours) and personality types.

Nursing is a genuinely ancient career with honourable credentials. Other professions use and even invent historical precedents to assist in the glorification of their own profession. For example, psychiatry as a profession has only slowly developed in the course of the past one hundred and fifty years since the American Psychiatric Association was commenced in 1844 with only thirteen members. Yet the influential medical historian and psychoanalyst Bennett Simon boasts that what makes the medical model ‘unique’ is the unbro ken line which joins ancient and modern practitioners (Simon 1978).

Alexander & Selesnick, in their classic and much-reprinted psychiatry text, maintain that psychiatrists and psychiatry are the culmination of an intellectual and professional evolution which began with witch doctors and philosophers, and claim that: ‘the precursor of the psychiatrist was any man who tended another in pain. The story of psychiatry thus begins with the story of the first professional healer’ (Alexander & Selesnick 1966, p 3). It is clear that the possession of a lengthy historical pedigree is considered an advantage for a profession. For example, occupational therapists also claim that their chosen work has ancient Graeco-Roman origins in the treatment of mental disorders (Busuttil 1992).

Some nurses have also wished to demonstrate that their profession has existed since ancient times. For example, Doona (1992) claims as ‘nurses’ three women from the ancient literature, Euryclea, Cilissa and Medea’s nurse, but none of these characters can be said to be ‘nurses’ as we understand the term today. All three characters are aged women who had in their youth ‘nursed’ or suckled children. They would not have cared for ill or wounded patients as would their modern ‘nursing’ counterparts.

In the present climate, which emphasises tertiary education, research and professionalisation in nursing, if nurses were to investigate and to own their own true history they could lay claim to a very distinguished lineage. Nurses do not need to invent or inflate the historical achievements of their ancient colleagues.

Burnard (2007) in a recent editorial laments the exclusive emphasis upon recent research in nursing education today and recommends that more historical research be performed by nursing scholars. Little is done at present, even by the authors of comprehensive mental health nursing texts such as Fontaine (2003), which entirely omits the originators of the Western medical knowledge base—the ancient Graeco-Roman medical writers—and commences its historical overview with Florence Nightingale’s The Art of Nursing. When this omission is compared with the conspicuous interest shown in treatment modalities such as Ayurvedic medicine, shamanic healing, naturopathy, animal-assisted therapy, aromatherapy and Reiki, the reader might consider the book’s focus to be excessively present centred.

Nursing scholarship in fact prides itself upon being present-centred in the belief that this is the same as being innovative and progressive. But Burnard (2007) claims that in the ‘clamour to cite only the latest papers … students are often citing older ideas without appreciating their genesis. Thus well known scholars’ work is often attributed, inaccurately, to more recent workers in the field’ (p 665). If we never use older works, how do we know if what we are reading is innovative or derived from some earlier, original thinker’s work?

Mental health nurses are not well served by existing mental health nursing texts if they seek to find out more about the history of mental healthcare or mental disorders. McAthie (1999) states that ‘Little is written about nursing in early historical accounts because the care of the sick was considered an ordinary event—it seems that it was not important enough to record’. This statement is debatable on many levels. It assumes that because no research is known to the author, none was undertaken; and it reveals a lack of awareness of the greatly enhanced ‘visibility’ of women in literature and society in recent years. The social context in which Western nursing takes place today has altered enormously. Today’s professional nursing, undertaken outside the home in institutions removed from the family, is an exception in the historical sense compared with the millennia during which nursing was undertaken by the family and their peripheral members, neighbours, slaves and servants, or later by religious orders.

The origins of medical care are addressed by McAthie (1999, p 4) in a brief and inaccurate statement using as the source a text written in 1938: ‘Religion and medicine were united very early, with medicine men, and later physicians, becoming priests’. This chapter will illustrate how an over-simplification of this kind can be misleading. Another standard mental health nursing text provides a similarly confused and barren coverage of the centuries preceding the eighteenth century. Boyd (2002) asserts that mental disorders in the first century AD were believed to be caused by sin or demonic possession and that ‘clergymen’ often treated patients by exorcism, which, if unsuccessful, led to the patients’ being excluded from the community or put to death. But as we will see, the Roman writer Celsus (25 BC – c. 79 AD) lived and wrote in the first century ad, and the enlightened and humane methods he advocated for the treatment of the mentally ill could as well be used to great effect today.

Brief, inaccurate and negative appraisals of the historical precedents for the treatment of mental illness are, sadly, all too common, as is the tendency to present the past in an inappropriately ethnocentric fashion. To Boyd, the History of Psychiatric Mental Health Nursing is relevant mainly in the context of the United States. A similarly narrow approach is taken by Frisch (2002) and by McAthie (1999), whose table of ‘Significant events in nursing in the twentieth century’ addresses only events that occurred in the United States. At least McAthie mentions the importance of the Nightingale model to the development of nursing programs in the United States, but Frisch’s sole mention of the ‘Nightingale model’ is provided with no explanation or context.

Neither does Frisch (2002) differentiate between ‘primitive cultures’ which confused medicine, magic and religion, and ‘early civilisations’ such as the Graeco-Roman, wherein the vast Hippocratic Corpus is reduced to a statement that Hippocrates attributed melancholy to an excess of black bile and believed that a cure could be effected by bloodletting. Frisch represents mental healthcare in the millennia preceding the eighteenth century as exclusively custodial and restricted to the confinement of lunatics who were thought to be evil, witches or heretics—a feared, criminal population.

The reverse was more often true. Having a mental disorder in past times was not necessarily an impediment to leading a productive and consequential life. Ancient societies did not acknowledge many of the manifold mental disorders which are assiduously identified and isolated today, and in some ways they were more compassionate and tolerant than many societies today. It seems that the aim of modern medical or psychiatric writers in propagating exaggeratedly negative notions about the past is to emphasise the belief that things have changed for the better, a belief which might be meaningful to the health profession, but does no justice to the past.

Past ideas about mental disorder

The terms ‘mad’ and ‘insane’ are not acceptable medical terms for mental illness today, but these general terms have in the past been used to describe a wide range of symptoms and behaviours. The Latin word insana means ‘not of right mind’ and the equivalent Greek term is mania. The term ‘mad’ is a middle-English, pre-twelfth century word which is still used today to describe a loss of reason and judgment. Metallic mercury poisoning in the felt-hat industry produced toxic effects which gave rise to the expression ‘mad as a hatter’.

The idea of ‘madness’ in the ancient world usually implied mania or psychotic illness. Medicine recognised and treated mainly those mental disorders which disrupted a person’s normal functioning in society, or which threatened the social order. Violence, agitation or excitement, being overtly out of touch with reality, experiencing hallucinations or delusions, melancholia causing inertia and inability to carry out one’s normal tasks, or epilepsy, usually succeeded in attracting medical attention. As is the case in our own society, sometimes a person was called ‘mad’ because their behaviour differed from the usual societal norms.

There are some issues which we can examine to help us in understanding the ways in which mental illness might have been constructed in the past. The theory of the humours was a systematic hypothesis that sought to explain why some people were susceptible to certain kinds of illness, including mental illness. The humoural theory (see below) was still being applied in the nineteenth century, and has been correctly described as the first diagnostic classification system (Mack et al 1994). Mental illness has in the past been seen by some as a punishment from the gods or God, and we will examine the role of the supernatural, and the perceived influence of God/gods upon the minds of humankind. The survival of some mental illness across different times and cultures will also be considered with the assistance of vignettes and case studies collected from primary source literature. Finally, the different meanings of ‘madness’ and the mental state which it implies will be assessed.

Mental disorders found in Graeco-Roman sources

What follows is the result of comprehensive research into mental disorders in the ancient Greek and Roman literature (Evans 2000).

The mood disorders or affective disorders (see Ch 16), consisting of mania and depression, alone or in combination, were found to exist in the ancient literature, although the term melancholia evolved in meaning over the centuries (Evans 2007). Melancholia by no means always meant the equivalent of ‘depression’, in the way it is constructed today. The most convincing and earliest conclusive instance of major depression was that suffered by the prominent Roman lawyer, statesman, philosopher and author, Marcus Tullius Cicero (106–43 BC).

At his most despondent, Cicero tended to withdraw from the Roman society in which he was celebrated, and retire to the country, as his surviving letters testify. Cicero wrote to his friend Atticus on most of the days they were separated, and his copious correspondence clearly documents three diagnosable episodes of major depression (Evans 2007). Cicero seems to have discovered for himself a self-help treatment method that really works and is recommended today to alleviate depression. Writing a daily journal that addresses

emotional issues over a period of months has been found by modern researchers to lighten depression, as has writing about bereavement following the death of a loved one (Range, Kovac & Marion 2000). Paradoxically, it is only narrative writing that helps to alleviate depression: writing poetry does not seem to help (Kaufman & Sexton 2006). Cicero experienced his last and most severe episode of depression after the death of his daughter Tullia. Latham & Prigerson (2004) find that bereavement complicated by depression frequently results in a very high risk of suicide. An excerpt of one of Cicero’s letters is shown on page 37.

The anxiety disorders (see Ch 18) as they were manifested in the ancient world have not previously been the subject of a great deal of critical attention in the modern secondary literature, but convincing examples of anxiety disorders are described in the classical texts. The case study from the Hippocratic Corpus (see below) describes two ancient examples of phobic avoidance, and that which follows from Plutarch describes an instance of post-traumatic stress disorder.

Both the anxiety disorders and the personality disorders (see Ch 17) were acknowledged by ancient cultures to be serious, chronic mental irregularities which could influence the sufferer’s life, but they were not considered to be illnesses which required treatment. A number of examples of personality disorders have been identified, but since the concept of a personality disorder is often culturally determined, particular care was taken to ensure that the subject of the case study was considered by their peers to have differed from societal norms (Evans 2000).

There was in the ancient literature evidence which affirmed that epilepsy was believed to be related to mental illness. Epilepsy can exhibit psychiatric sequelae, but whereas it was considered to be a mental disorder in the ancient world, it is not so regarded today. The substance-related disorders (see Ch 20) were, conversely, not in ancient times conceded to be mental disorders, although drunkenness might lead to socially unacceptable behaviour. Alcohol-related disorders proved to be a complex topic; examples of these disorders were located in ancient Greek and Roman literature. Indeed, although excessive alcohol consumption seems to have caused or complicated many medical conditions, ancient medical and societal opinion seemed to indicate that conditions such as alcohol abuse, dependence and withdrawal went largely unrecognised (Evans 2000).

Some psychotic disorders (see Ch 15) were documented and recognised as such in the ancient Graeco-Roman literature, but this author’s research indicates that the full gamut of criteria which would justify a modern diagnosis of schizophrenia (early onset, hallucinations, delusions and a degree of chronicity) was not apparent anywhere in the ancient Greek and Roman texts (Evans, McGrath & Milns 2003). The reportage of symptoms for all the major mental disorders in the ancient literature was often inadequate to satisfy modern diagnostic criteria with reference to the duration and range of symptoms.