Mental illness, madness, insanity, lunacy, distraction—these terms have all been used to describe health conditions that negatively affect a person's thinking, feeling, or mood. Definitions of these disorders have changed dramatically over time and place and are often intertwined with larger community, economic, and even political surroundings. Historians have examined these maladies through legal, medical, and social lenses in an attempt to understand whether mental illness is associated with somatic or psychological causes. Heather Vacek, an associate professor of church history at the Pittsburgh Theological Seminary, expands this historical analysis of what she calls “madness” by examining it through the variable of religion. By doing this, she has expanded our understanding of both insanity and the American past by foregrounding the religious beliefs of five practitioners (four well-known, one much less so) in the mental health field and explaining the close and rather unexplored relationship between faith and practice.

Vacek starts an examination of madness in colonial America by focusing on the theological interpretations of famed seventeenth- and eighteenth-century Puritan clergyman Cotton Mather. To Mather, in line with Puritan theological doctrine, all human illness, including mental ones, resulted from either “the lasting effects of original sin . . . [or from] individual transgressions” (18). He also ascribed the origin of mental disorders to the supernatural realm and the struggle with Satan “partly because biological explanations remained unknown” (19). Cure was possible through prayer, counsel, or the traditional remedies of ingested herbs, topical strategies such as bleeding and the application of leeches, and behavioral therapies such as horseback riding. Caught on the cusp of modernity, Mather saw no clear delineation between science and religion. According to Vacek, “though certain of God's providence, his [Mather's] confidence in science as a gift of God molded his theological diagnosis” (15).

Benjamin Rush and Dorothea Dix provide the centerpieces of Vacek's analysis of madness in revolutionary and antebellum America. Rush was both a practicing physician and an important political figure. A signer of the Declaration of Independence, Rush was a true child of the Enlightenment, but also a devout Christian. His “views of madness challenged human sinfulness as the sole source of disease” (40). He published Medical Inquiries and Observations upon the Diseases of the Mind, America's first true text on mental illness, in 1812, just a year before he died. His Christian beliefs in the importance of charity and care made him a leader in the revolutionary era antislavery movement and tied in directly to the motivations of Dorothea Dix in her efforts to improve care for the mentally ill. Dix was infused with the benevolent evangelicalism of the Second Great Awakening and used her Christian beliefs in her lifelong mission to have asylums live up to the true meaning of that word. She did this by “claiming authority from her identity as a Christian . . . a new sort of authority, a moral authority rooted in her Christian faith” (56). Vacek focuses not only on Dix's nationwide (and even international) crusade to improve the plight of the mentally ill by providing better care through better institutions, but also on her Christian faith, aligning herself “fully with the optimism and hopefulness of the Unitarian movement” (65). Her fervent belief in the efficacy of the institutional model, one she viewed as based on the benevolence of Christianity, shaped the treatment of people with mental illness for decades to come.

Things changed dramatically in the years following the Civil War. Dix's institutional solution remained, but the optimism and Christian charity associated with her vision went away. Concerns about social dislocation and immigration combined with new ideas about the intersection of science, insanity, and crime, turned institutions from asylums of hope to warehouses of despair. Vacek uses the life and work of Protestant clergyman, and hospitalized mental patient, Anton Boisen to analyze these changes. Less well-known than Mather, Rush, or Dix, Boisen aimed to reconfigure the terrain of mental illness and reclaim for religion some of the ground lost to science and medicine. For him, “recovery—for himself and others—depended on a new understanding of the relationship between mental illness and religious experience (90). Boisen put this plan into action as he took a post as chaplain of Illinois's Elgin State School in the 1930s and 1940s. His mission was to provide pastoral care to patients, but also to train young pastors in a “holistic medical and religious approach to asylum care” (117). Vacek concludes, however, that Boisen's approach proved unsuccessful, as religion continued to cede ground to science and medicine.

Vacek's discussion of twentieth-century policy moves out of the institution and into the community through an examination of the work of renowned Kansas psychiatrist Karl Menninger. With a life that spanned much of the twentieth century, Menninger became the voice for “shaping both public and professional views of mental illness” (141). Menninger's vision of care for those suffering from mental disorders centered on a “belief that God called Christians to offer help” (156). Vacek ends her discussion of Menninger's influence by concluding that even with his tremendous influence, “twentieth-century believers turned first to medical professionals” (157).

The focus on biography to illuminate the relationship between Protestant religion and mental illness works quite well, although a more nuanced examination of the social milieu in which her subjects operated would have added much to her study. What makes this book most important, however, is Vacek's short last chapter, entitled “Suffering, Stigma, and Hospitality.” Moving past historical analysis, she lays out a call to “enable Christian action in the face of mental illness that has been disabled by social stigma and the abdication of care to scientific medicine” (161). She invokes the Christian ideas of hospitality, welcome, compassion, patience, and especially incorporation as important components of a new ethic “that counter[s] the forces of stigma and enfold[s] those who suffer into the life of the community and into the life of God in Christ” (179). In these difficult times, these words provide a guide for countering the forces of division and rancor that seem to have taken over American public life.