Monthly Archives: January 2015

One Step Forward, Two Steps Back – Mental Illness Treatment Over the Past 150+ Years – Part III of IV

David Laing DawsonBy Dr David Laing Dawson

Part II ended with the phrase: “gradually reduce reliance on mental hospitals.” “Gradually” is the operant word here, even though, as I recall, during the kinds of planning workshops, conferences, meetings we had in those days, at least during the “visioning” part of the exercise – the “vision thing” as George H. W. Bush once called it – some of us imagined a day when mental hospitals would no longer be necessary.

From 1971 until 1995 I worked in a variety of settings, sometimes as a participant, sometimes as a leader, developing comprehensive outpatient programs for serious mental illness – programs for schizophrenia, supported housing, programs for mood disorders, programs for early detection and comprehensive treatment, programs for brain injury, for crisis intervention, programs for isolated regions, programs for consultation to medical wards and family doctors. We revamped the mental hospital, transferring more and more funding to outpatient services, redefining “chronic ward” to rehabilitation program, reducing the use of restraints. We worked at connecting with school and social services, housing and job training.

Still, for some people, the mental hospital remained an asylum, the one place in the world where they were safe, could eat meals and sleep in a bed, could receive medical and nursing and dental care, could sit in the sun on a bench, have a shower, cadge money from the medical director for a coffee, and wander about in eccentric fashion making outrageous observations.

And someone mentally ill in the jail on minor charges might be transferred to the hospital without a great deal of fuss. Some fuss, but not a great deal. Police would apprehend someone creating a disturbance, observed to be mentally unbalanced in some way, and bring that person to the emergency department, to the emergency psychiatric team rather than the jail. They would have to sit around for a bit to await outcome, but they could usually count on the hospital keeping that person and they could get back on patrol.

Government policy shifted focus and money from the worried well to those suffering from severe and persistent mental illness.

Better treatments were being developed, more money spent on research; our country was not at war, the economy was growing, more people were being educated, the digital age arrived, information became readily available. This era of progress could only continue, one would think.

Of course the new drugs proved only marginally better than the original mood stabilizer, the original anti-depressant, and the original anti-psychotic. Talk therapies were being refined, codified, made more practical, but they too did not add much more than having an empathic, nonjudgmental, reasonably wise counselor in your corner. Yet the world was becoming a better place for the mentally ill and their families, at least my part of the world, and much of Europe, and parts of the United States. Surely this progress would continue and Dorothea Dix, Drs. Pinel, Kraeplin, Tuke, and Rush would be pleased.

During the latter part of those years, I attended a psychiatric conference in San Francisco. I was probably there to talk about comprehensive treatment for schizophrenia. But what I remember most clearly is the number of homeless and psychotic people living on the streets near the hotel and convention headquarters. An ironic tableau: a thousand psychiatrists within, a hundred mentally ill living on the streets outside, and a few people picketing with anti-psychiatry placards. Another psychiatrist from another state (I think it was Georgia) came to give a talk in Ontario during that period. He came with a warning. Do not let happen in Canada what was happening in his country. His hospital, the mental hospital in which he had worked, in which he had pursued all the same goals mentioned in that second paragraph of mine – it had been closed and transformed into a medium secure prison facility for the mentally ill and criminally insane.

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One Step Forward, Two Steps Back – Mental Illness Treatment Over the Past 150+ Years – Part II

David Laing DawsonBy Dr David Laing Dawson

In the spring of 1969 a new psychiatric facility was opened on the campus of the University of British Columbia, the first component of a full service teaching hospital. This clearly heralded the future of psychiatry and the treatment of the mentally ill, or so I thought: a large outpatient department, space for a day hospital, and small wards for inpatients, wards for only 20 patients each, wide corridors, accessible nursing station, private rooms for some, no more than two to a bedroom and bathroom, earth-coloured patterned carpeting, earth-toned walls, residential style beds, comfortable furniture, warm lighting, pleasant dining room, a sitting area with lounge chairs and fireplace, meeting rooms, no locks on the doors. Even sliding doors to small balconies for many rooms occupying the ground and second floor.

Perhaps there was not quite enough security to manage the most disturbed, potentially violent patients, but it is really a small percentage of the mentally ill who do not respond well to treatment offered in a non-threatening compassionate fashion within a very comfortable environment. The impulse to flee is actually reduced when the door is open. The impulse to say NO is reduced when the treatment is offered gently and patiently. The impulse to rant and break things is reduced when the lighting is soft, the chairs comfortable, the colours soothing, the sounds not echoing off concrete walls. The impulse to hit someone is greatly reduced when that someone is not threatening you.

We were experimenting with forms of something we then called “The Therapeutic Community”, which really meant open meetings of staff and patients sitting in a big circle each morning, discussing everything from housekeeping issues to medications to ward rules and protocols, to the question of whether or not one patient should go off his medications or take more, and if another is ready for a weekend pass. It wasn’t thought of as “the treatment” but rather as a humane and democratic context for treatment, and an environment that would bring out the best in people.

It is true we were reading Thomas Szasz, R. D. Laing, Jay Haley, Erving Goffman, Michel Foucault, Gregory Bateson and all the others postulating that the roots of madness could be found in distorted parenting or unbridled capitalism or imposed social conformity, but you really don’t have to spend much time with someone in a manic state, a stuporous depression or an active schizophrenic psychosis before you know, as a colleague once succinctly put it, “It’s a brain thing.”

My next stop was England, to see first hand a large mental hospital that had eliminated locked doors altogether. Serving Cambridge and the surrounding shire it sat brooding on the fens just as you and Thomas Hardy would imagine, a large winged Victorian mansion with a few marginally more contemporary buildings around it. It was, by North American standards, poorly resourced, under-heated, and I was quickly appointed physician to six wards of forty patients each. But the doors were all unlocked; each ward had its daily community meeting, its occupational therapy programs, good nursing and medical care, grounds to walk on, work to do, social and entertainment programs. It was an asylum, a humane asylum, and proof of a sort that decent psychiatric care did not require modern buildings with state of the art security.

Still, it can be assumed, (and my personal survey supports this) that everybody, every patient, would prefer to live and be cared for in his own home rather than in any kind of institution.

It was 1971. We now had effective treatment for most psychiatric illnesses (not all but most). It was time to build an array of outpatient, community, and home treatment services that might gradually reduce reliance on mental hospitals.

One Step Forward, Two Steps Back – Mental Illness Treatment Over the Past 150+ Years – Part I of IV

David Laing DawsonBy Dr David Laing Dawson

In 1843 Dorothea Dix wrote: “I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience.”

And so began the development of asylums for the mentally ill in North America, and the Moral Treatment era. Dorothea had learned from the Quakers in England, and some reforms taking place on the continent, and had brought those experiences and her prodigious outrage back to North America. We were ready for these ideas, as they arrived amidst a developing belief, a new conviction that the “state” should bear some responsibility for the care of those among us who cannot care for themselves.

This was truly a new idea, and one that was transforming the Hotel Dieu in France into the General Hospital, transferring responsibility for the indigent and insane from religious orders to the state.

We were also beginning to notice that not all the indigent, the incapable, the socially dependent among us were the same. Perhaps some were simply lazy, a few others without morals and scruples, but many were insane, others mentally handicapped, and some were incurable inebriates. The latter three categories did not deserve the neglect, the punishment, the harsh treatment that befell them when lumped with the former two categories.

(The first building on the grounds of what was to become, eventually, Hamilton Psychiatric Hospital, was an institution designated for incurable inebriates, a branch of the Toronto Asylum for the Insane).

For the most part, with a few setbacks here and there, the next 150 years after Dorothea’s proclamation heralded incremental progress in the enlightened treatment of mental illness, mental handicap, and addictions. Science brought us more understanding of each form of mental illness and mental handicap, and, eventually, some medical treatments that are actually effective. In poor economic times and times of war (1914 – 1918, 1929 – 1939, 1939 – 1945) we neglected our growing, burgeoning institutions for the mentally ill and the mentally handicapped. Conditions deteriorated in each of these eras, and I’m sure some abuses occurred. The discharge rate was understandably very low during the 1930’s. But for all their failings, these now enormous asylums, with their own kitchens, farms, food production and laundries, set in the rural surround of our cities in North America, at the end of train lines in England, and on the banks of rivers in Australia, provided three meals a day, a chapel to pray in, grounds to walk on, and a bed to sleep in. But during peaceful and better economic times we paid attention. Conditions were improved in the 1920’s, reforms instituted within the knowledge and philosophies of the times: airing courts, more freedom, activities, visitation, better food, entertainment. And after the Second World War a new era began, one of hope, stability, idealism, and new convictions about rights and freedoms.

The first medications that actually helped depression, that controlled mania, were introduced in the 1950’s; the first medications that actually worked with psychosis, with schizophrenia, were introduced in the 1960’s. Rehabilitation, work programs, activities, music, exercise, social programs. Our academic institutions, medical schools, psychiatry departments, began to pay attention to these large asylums and their populations of seriously mentally ill, oddly neglected by academia the previous 50 years, save for field trips to demonstrate catatonia, mania, hebephrenia, and dozens of rare but severely disabling and disfiguring forms of congenital abnormality.

I stepped into one of these institutions in 1968 as a first year resident, along with three other young doctors and two associate professors of psychiatry. It was one of the acute admission wards serving Greater Vancouver, men and women, dormitory sleeping quarters, a brightly-lit day room, spacious grounds, forty patients, but just one component of a large mental hospital comprised of several enormous buildings, some from the Victorian era, this one built in 1931, originally for WWI veterans, all perched on a hillside overlooking Coquitlam and the county of Essondale. We unlocked the door; we instituted “community meetings” every morning, a quasi-democratic reform and a chance to air grievances. We prescribed the new drugs for mania, schizophrenia, and depression. But when someone was well enough to be discharged we had no community treatment programs and support programs to refer them to.

Clearly this was the next thing that needed to be developed.

Je Suis Charlie

cartoonBy Marvin Ross and Dr David Laing Dawson

As a journalist, on more than one occasion, I’ve been threatened with legal action for what I’ve written. And that is fair game for my often controversial articles. I once even had someone write a letter of complaint and cancel her subscription to a magazine because she objected to an article I did on hemorrhoids – yes piles because my lede said “ever since man began walking upright….”  I hurt her religions sensibilities and I have hurt the sensibilities of those who do not like psychiatric medications and some of them have called me some pretty nasty stuff. But the complaints against my writing have never gone farther than that.

And in our blog post on homegrown terror, Dr Dawson said “But at a certain low and troubled time in his life, how is a young man to know that this charismatic ordained bearded father with an ancient text under his arm, promising brotherhood, glory, certainty — is really a murderous psychopath?”

And, as Dawson’s blog on Sony and North Korea said:

“Of all the freedoms we have in our western democracies, the one we should prize the most is our freedom to poke fun at, to satirize, to lampoon, (and to seriously criticize) our leaders and our deities. It is by this freedom that all the others are protected. And so it is this freedom that deserves the most vociferous protection, the most careful vigilance, the strongest defense. It is this freedom that every would-be dictator first erodes (e.g. Russia, Turkey), and it is this freedom that allows us to become more than vassals, serfs, slaves, and supplicants.”

We must continue to tell the truth as we see it and to satirize for not to means that we have given in to terror and abandoned our freedoms.

RIP all the victims of terror everywhere.

What is Wrong with Luka Magnotta? Reflections on Forensic Psychiatry

David Laing DawsonBy Dr David Laing Dawson

Does he have schizophrenia or not? And if he does suffer from schizophrenia, is it the cause of his terrible behaviour? (murder, cutting up his victim and mailing the body parts to various people)

Actually, I’m not going to try to answer that question. Our courts decided he was responsible for his actions, whether or not he suffered from a mental illness.

But this case highlights an absurd inequity in our system. Mental hospitals have been closed, psychiatric beds reduced, psychiatric services limited, but for the past 20 years Forensic Psychiatry has been a growth industry. In some instances our old, a little run down, but functional and humane mental hospitals have been simply converted into maximum secure jails for mentally ill offenders. If Dorothea Dix were alive today she would be writing outraged petitions to our legislators.

We have made it harder for the average family with a mentally ill member to access psychiatric service by excluding the family (privacy laws), by reducing the number of psychiatric beds and staff, and by making it far more difficult to get that family member to the hospital and have the hospital keep him long enough to assess, treat, and stabilize. (Mental health laws and modern hospital management practices).

If that average family with a mentally ill member does get to see me on referral from a family doctor, I will spend about one hour figuring things out, “making a diagnosis”, about one half hour explaining, discussing and instituting treatment, about fifteen minutes documenting all this, another ten minutes trying to get a social worker involved, and then have them come back for “follow up” in two weeks. If I think the ill person needs to be in hospital I will spend half a day, on and off, while they wait, trying to find a bed and negotiate an admission. If my first impressions prove correct, and the treatment starts to help, we will have a series of half hour appointments perhaps every second week to once per month over the next couple of years to get treatment and rehabilitation and recovery on solid ground.

That’s it. We do have other mental health services in many of our communities that are better resourced, but for the most part they specialize with strict criteria and long waiting lists.

Now Luke Magnotta. The only real decision being made so expensively was whether he would be spending the rest of his life in a Prison or a Maximum Security Forensic Psychiatric Hospital. He would probably be safer in the Forensic Hospital, require isolation within the Prison, and perhaps be allowed escorted leaves from the Forensic Hospital a decade from now. In either facility he would receive psychiatric medication, perhaps with a little more care and expertise in the secure Forensic Hospital.

And to make this decision we spent a small fortune. I don’t have a figure but I can guess. Courts and lawyers and psychiatrists. Hours and hours of time spent by more than one psychiatrist examining, writing, reporting and testifying. Twenty-five thousand, a hundred thousand dollars of psychiatric time? A million dollars to house, feed, monitor and treat Mr. Magnotta over the next twenty years?

Now I don’t know if Mr. Magnotta has a treatable psychiatric illness, and if consistent treatment over the past five years would have prevented this tragedy. But it would have been a hell of a lot cheaper.