New Worlds: Treating Mental Afflictions

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.