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.

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

  1. As the mother of an adult with chronic and significant mental illness who also happens to live, literally, across the street from Dorothea Dix in Raleigh, NC, the irony of what has become of this woman’s hard work in my state does not escape me. Today, the city of Raleigh reached an agreement to turn the Dorothea Dix hospital into a destination park – they envision something like a Central Park on the 306 acres of this facility. Several months ago a man with mental illness, incarcerated in NC, died after being in solitary confinement and left to lie in his own feces and urine for 5 days without food and water. This sounds not much different than your opening recollection of the way things used to be and it stands as a continual reminder to myself and others who fight this battle that for all things may have changed – yet they remain the same. We are still in the dark ages.

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    1. I agree with you, though sometimes I think that things have gone from bad to worse. I have just reread American psychosis by E Fuller Torrey ( How the Federal government destroyed the mental health system ) Much of it began with the Kennedy’s who naively tried to launch a new Federal mental health system for the mentally retarded and the mentally ill under the direction of a Drs Felix, Yolles and Brown. Well intentioned maybe, but their beliefs were so over confident arrogant and ignorant about the true nature of serious mental illnesses. They along with the civil libertarians made the mess that would follow. Eventually the states took less and less responsibility regarding funding and we now have the utter mess of neglect and the sad criminalization of the seriously mentally ill. There are now so many ironies about the Dorothea Dix and her efforts. Torrey cites may of them . Tragic tragic ….. Patricia Forsdyke.

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  2. With respect, the sad disjointed history of mental illness need not include a history of
    psychiatric practices. At first we did not have the knowledge to understand so we did what all early humans did, and sometimes still do.

    We used our imaginations to explain these new diseases, relying on our primitive knowledge. We still do this. So we have uncritically added assumptions about mental illnesses from all sorts of people ,mostly the ideas of unscientific guru-like teachers (Freud, for example.) Though lots of other “professionals” have also used their own personal presumptions to explain the origins of mental illnesses. All this has firmly embedded these erroneous beliefs into public consciousness.

    I recall my surprise at the author’s advice at the end of my college text book entitled “Theories of Personality”. The author suggested, (with honesty that I admired at the time) that students ‘immerse themselves’ in one theory of personality and think of it as the best possible way to conceive of behavior. He added “only reserve in one small corner of your minds the reservation that the final crucible of any theory is the world of reality studied under ‘controlled conditions’. (If he had said ‘scientific research” it might have cleared the way ahead for scientific research to understand that microbial agents are now known to create these human brain diseases.)

    This dismissal of scientific research still lingers. Why, even the recent tax-heavy Mental Health Commission, Canada barred scientific research and scientists from participating in its discussions. This omission left this Commission to lean on the bent reeds of social studies to explain human disease and make untested recommendations to citizens.. .

    And this tight grip on old, untested ideas by governments has made it even more difficult for citizens to accept the medical reality of schizophrenia, depression and other neurological diseases.

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    1. It is probably a good thing for us learn about the past history in psychiatry and its relationship to mental disorders. The sad bit is that there is now a resurgence of RD Laing followers in U.K , I looked him up recently on the internet It would seem that mistakes are repeated time and time again.

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  3. I am going through the agonizing process currently with my son. He is currently sitting in jail pending a hearing and has been in jail for over a month. My son has a brain disorder and has been labelled schizophrenic paranoid disorganized type and has been struggling since 2012, with the illness progressively getting worse. I work full time with a BA in sociology/education and am a behavioral health professional for a non-profit mental health company as an ed tech in their high school. My son receives state insurance and I am very poor. With no insight into his illness treatment has been very difficult. He is 21 years old which further complicates treatment. His crime is directly related to his illness and I have been fighting the jail as my son is receiving no mental health treatment and his mental health is languishing. I am fearful for my families safety and my son’s mental health. I know he needs an extensive hospital stay to stabilize but struggle with the fact that the system has my son trapped as the jail can only transfer to the one state hospital Maine has and that is a 35 facility in Augusta called Riverview. If my son is released under my supervision, I could not enroll him at Riverview. On top of helping my son manage his illness since 2012, now I find the systems available to help are only seriously exasperating an already extremely stressful situation, as well as further damages my son’s health. I can not tell you how many times I have been given misleading information, no information or incorrect information, as well as oversights and mistakes. Is this how one of the richest countries wants to treat their people? With all the money in the world, is this the best we can do. My family is one of the hard working poor families of America, law abiding productive citizens. Before my son exhibited extreme symptoms, he was a college student and dedicated collegiate athlete. He was studying to be a health teacher and wanted to coach high school sports. He was popular, social and happy. My son currently is unable to function, socialize or have any quality life. His prognosis with meds is fair to good, without poor. We are seeing the poor. With proactive treatment deterioration would be prevented. Instead he suffers in a jail without any medical treatment or even a psychiatrist. Untreated and un-medicated.

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    1. I feel for you. It is outrageous and cruel that he is left to flounder . But press on if you can and try and advocate as much as possible. The system must be held to some account. It is a mess and some who should know better do nothing. As someone said “The freedom to be insane is a cruel hoax perpetuated on those that cannot think clearly by those who won’t think clearly” Families who love their ill relative are given little voice. This has to change.

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  4. Very good article. Mental Health Agencies should be ashamed of themselves, how when the mental institutions closed, threw patients into the communities and are not helping their lives. I have seen my peers struggle.

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