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New Worlds: Treating Mental Afflictions

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When it comes to looking at the treatment of mental illness and disability throughout history, all too often, the simple answer is “there was none.”

Which in some cases may have been preferable to the alternative. For people whose disabilities and mental afflictions were relatively minor, they were likely chalked up as “a bit odd” and that was that. Their oddities probably led to a certain amount of interpersonal strife, but when society wasn’t as regimented and organized as it tends to be in the modern industrialized world, the norm from which they deviated may have been less rigidly defined. And when most people received very little formal education, conditions that interfered with the ability to acquire and retain such information would have been less of a problem.

But for those who went beyond “a bit odd” — those who were genuinely disabled by their conditions, impaired in their ability to function in daily life — things could get very bad, very fast.

In many cases there was no organized treatment available whatsoever. The person in question was either taken care of at home, or just . . . not taken care of at all. Home life might very well be abusive, given the prevalence of interpersonal violence in general; this could be intentional, on the the belief that stern handling would cure the character flaws or drive out the supernatural forces causing the affliction, or just the result of a frustrated relative losing their temper. Those thrown out of their homes often wound up as beggars, dependent on the charity of people who could range anywhere from compassionate to hostile. I can’t imagine the average life expectancy for someone in that situation was very good, even by the less-than-great standards of pre-modern life expectancy.

The lucky ones might be taken under the wing of a religious institution. Many of those at least provided sustenance and maybe a night’s shelter to beggars; others housed them more permanently, seeing caring for the afflicted as a sacred duty. But that care might still just amount to the basic necessities of life, maybe a bath now and again, with the person in question otherwise left to roam the premises unattended. In bad cases, the abuse I mentioned above was still a very real possibility.

Not all religious answers to mental illness are necessarily bad, though. It’s something of an open question, how much a ritual can affect an internal problem: on the one hand, our medicalized model would seem to suggest that it can’t fix a problem of brain chemistry, but on the other hand, anti-depressant pills apparently work better if their coating is a cheerful yellow than if it’s blue. Mind over matter is a real force, even if it can’t cure everything and we don’t quite understand how it works in the first place. If your whole community comes together for a cleansing ceremony, could that help treat your depression? Unclear — but at least it’s better than trying to beat the sadness out of you.

Even once we started taking a more organized approach to mental illness, beatings unfortunately did not leave the picture. Anybody who’s taken a cursory glance at the history of mental health probably knows the term “bedlam” comes from what is now called Bethlem Royal Hospital, a.k.a. St. Mary Bethlehem, a famous English institution for the insane. While today it’s a respected psychiatric hospital, its past is kind of a horrorshow: its main purpose was to sequester the mentally ill away from the general public, with little budget or concern for their humane treatment. The less violent ones were allowed to wander the halls; the troublemakers were chained up. And during the same centuries where the English thought a public execution was great entertainment, they could pay a fee to visit the madhouse, where the keepers might actively try to provoke outbursts from the inmates, for the amusement of the visitors.

The question of restraint has long been a vexed one. Not all people with mental illness require it — though the percentage is probably higher when the overall environment is brutal and dehumanizing — but some do. Straitjackets, bed restraints, and rooms with padded walls are some of the stereotypical markers of insanity because they’re relatively humane ways of preventing patients from harming themselves or those around them, compared to the earlier alternatives.

But it’s all too easy for the goal to morph from “prevent harm” to “make that person stop causing trouble.” As psychopharmacology has developed, we’ve found ways to drug patients into passivity, sometimes more for the convenience of their caretakers than for their own benefit. Troubling as that is, it still puts us a step ahead of the heydey of lobotomies, when surgeons would destroy brain tissue to “cure” their patients’ problems, generally at the cost of the subject’s personality and intellect (and with horrific side effects like seizures). More than half of lobotomy victims were women; of the remainder, many were gay men.

Lobotomies have almost completely gone away except in extremely limited circumstances, but medication — properly deployed — is a mainstay of treatment in the modern West. And yet, it’s also probably still in its infancy: there is so much we don’t understand why certain chemicals work for certain conditions, or why they work for some people and not others, or why they work for a while and then stop. Writers of science fiction can easily extrapolate from current research to a future where more tailored treatments are available, rather than our current blunt-force approach. And of course there’s a wide range of other therapies for various ailments, based on working with trained professionals to unearth causes, identify patterns of behavior, and build new habits of response. Though some of which have their own dangers: while hypnosis seems to be effective in treating anxiety, it’s also been used to help subjects “recover memories” of traumatic incidents that in truth never happened.

There’s a caveat here, especially when it comes to that idea of futuristic treatments precision-designed to be more successful than what we have now. In any discussion of disability — mental or physical — advocates caution against “cure narratives,” where the arc of the story ends with the person being wondrously relieved of their condition. There are a number of reasons to be wary of such narratives: they often divert attention away from measures that could be taken to improve people’s lives right now and toward imaginary fixes that may never exist; they send a message that disabled people cannot be accepted and loved for who they are, but must be changed; they deeply offend those who do not see themselves as needing a cure, but simply as different in ways society can and should learn to accommodate.

So for us writers of speculative fiction, it’s not that we can’t imagine better alternatives than the past or the present. It’s that we should be careful what we imagine, and what message it sends.

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7 thoughts on “New Worlds: Treating Mental Afflictions”

  1. Part of me wants to say that neurodivergent behavior is more prevalent now than before because we are more aware of it.

    Part of me also wants to say that our chemical and preservative laden diets and lack of exercise and fresh air are to blame.

    But illnesses and disorders have always been there. The more functional people self medicate with alcohol and drugs. No wonder the holiday season–mid-October to New Years–are approached with dread. We are expected to bring together the entire family and enjoy being insulted by Aunt Ethel, have a keeper on Uncle Malachi to keep him from wandering off, break up fist fights because cousin Johnny can’t understand why HIS team lost the football game. Suicidal niece Bonnie can be sent to hospital, but the rest must be endured.

    I would love to funnel more tax money into better understanding and treatment of mental illnesses. And anti-depressants that don’t rob us of creativity.

    1. We genuinely don’t know how much [fill in the blank] was a thing in the past! “Are we just noticing it more” vs. “has something changed that causes us to change” is a question we can’t really answer, short of inventing time machines and sending armies of psychologists into the past to assess people. And there were almost certainly disorders of the past that didn’t just have a different name from what we use today; they were disorders we don’t have, because our cultural framework and the environment we live in are both so different.

      I meant to note — and will add in for revised version of this in the annual collection — that people winding up on the streets is a problem today as well as in the past. Our shift in mental health spending left a lot of people without anywhere to go.

    2. There’s a meme going around discussing autism in pre-modern eras. Severe cases would have been diagnosed as changelings. Milder cases — well, in a world with much less in the way of stimulus (no neon lights, no sirens, etc.) and a lot of repetitive work that needed to be done, they would have fit in much more easily.

  2. Among the Greeks, the appropriate reaction was “offer sacrifice to the appropriate god.” It was a little tricky determining which one, they tended to be the ones that caused insanity, and if the sacrifice didn’t work, you had to determine whether it wasn’t enough or it was that a different god was offended.

  3. 1. The increased prevalence of neurodivergence and mental distress that is NOT treated as either demonic possession or some form of cowardice has a third aspect: That these “disorders” are not as frequently fatal prior to reproduction. Which both increases their general incidence in the general population… and allows any genetic components to be passed on.

    One example of the latter is the now-known-to-have-a-strong-genetic-component forms of schizophrenia. In “the old days,” upperclass dynasties would allow carriers and even symptomatic folk to reproduce to maintain the bloodline, and the wealth factors would give them a slightly better chance of reaching that age anyway. I’m not going to mention any well-known royal families in Europe, but…

    2. Something else to keep in mind is that both diagnosis and treatment of mental conditions are extremely culture-specific… and that a sufficient cultural distance may prevent diagnosis or successful treatment. Consider the true-dark-ages monk who has taken a vow of silence and becomes extremely distressed at missing any prayer time… and transport him to Rio during Carnivale, then see if he’s treated as “disordered!” This sort of problem is perhaps even worse when none of those doing the diagnosis and engaging in treatment — especially Freudian/Jungian-influenced talk therapies — have any personal exposure to the decision processes of the patients. This is one reason that cops have so much poorer a prognosis with PTSD than do firemen: They share traumatic origins, resulting in real distress, but for cops much of that origin is based on intentional decisionmaking (“Do I fire at that shadowy figure in the alley? I’ve got 0.8 seconds to decide…”).

    3. Let’s just not get into dealing with operant conditioning as a source of mental distress. Raymond, perhaps it’s time for a nice game of solitaire is the easy and obvious instance.

  4. I can see why you’d be chary of touching it, but is there any merit to the idea that some societies provided slots for some mentally different people? “Schizophrenia to shamans” is one idea I think I’ve seen. And per Jaws’ post, one could imagine that Christian monasteries with silence and rigid structure might appeal to certain people.

    (Of course not everyone who might benefit could get in, and many who did get in were happy to bend or break the rules as much as possible…)

    1. You describe a schizophrenic to people who live in a society with shamans, and all of them, including the shamans, will say he’s crazy.

      On the other hand, the Mennonites describe depression as “wrestling with an angel” and regard it as a particular mark of divine favor, so they provide emotional support, resulting in a culture with a higher rate of depression than the rest of society having a very low suicide rate.

      They also had a much lower rate of psychosis. Strong social structures increase depression but decrease psychosis. This, for instance, results in higher rates of psychosis among immigrants.

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