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.

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

  1. Very, very interesting.
    Somehow the awareness that ‘it’s a brain thing’ has not made it into the consciousness of many who are influencing mental illness policies. And Szasz, Laing, etc are still on the reading lists of many courses and their books are selling well on Amazon.
    I really appreciate you sharing your well-informed perspectives.

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  2. Thanks for your usual research into things you write about, Marvin. But I don’t share your enthusiasm for home care. Most families are not equipped or capable of turning their homes into psych wards without even a nursing station to assist in crises.

    Parents naturally grow old and less capable. Apartments are small and crowded. Families have no recourse but to call the police in any crisis. This means a lasting police record for the patient. He/she now won’t find a job–volunteering or otherwise. Many families haven’t known this barrier to employment. When they find out, they curse a system that gives them no choice but to call police in these not-unusual crises.

    We know that families can lose their apartments if their loved ones bring shouting or other noisy events to their environments. I met one woman who had to move from her condo because she and her family were so shunned ,”despised” blamed until she moved away to avoid this. I wondered where she found a place on this earth where her family situation would be accepted.

    There are many other difficulties as well, younger children in the home are afraid of their changed sibling. It is a Sophie’s Choice for families. What a cruel choice to face.

    Families are reluctant to admit they can’t handle this responsibility because they know unknowing, insensitive professionals will say that they “caused the illness, now they should take care of the problem they created.” (I have heard this too often as (now retired) former Executive Director of a Family Organization

    This burden must not be forced on families who can’t manage it for good reasons. We deserve reasonable help for that which fate has handed us. And so do our loved ones .

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    1. Your comments are always welcome June and you now realize that this was written by Dr Dawson and not me. However, he is not advocating for anything in this series but rather talking about where we started with Dorothea Dix and where we are today. There are still two parts to come as this is about what he experienced in the late 60’s and early 70’s.

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      1. Mea culpa, Marvin. I would like to respond to the blog I mistook for yours.

        Why introduce the second to last paragraph in the piece that claims all mentally ill patients would prefer to be cared for in their own homes. It looks like a guilt trip on families, who dearly love, but find it impossible to care for their ill relatives in their homes.

        I am sure if you asked Alzheimer’s patients this question, many might say the same thing about preferring to be cared for in their homes.

        Their mental illnesses could prevent them from appreciating the difficulty. Even the ‘Waltons’ might not be able to manage this, presumably for a lifetime.

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    2. It would not be so much of a burden, if our work was acknowledged and supported by the medical/health care profession. If Recommendation 31 of the Mental Health Commission’s 2013 Family Guidelines were to be implemented that allowed families to say where the gaps in services were from their unique perspective, that would be a start. There is much research to say that family involvement can lead to better client outcomes. Families give people a sense of identity, a family history so that people know their roots, an opportunity for social connection, and caring extended family members. People with serious mental illness should not be forced to live with their families because there is no alternative housing. Neither should families be forced to house their ill relatives especially when the parents are aging. There is a desperate need for adequate supportive housing. But I know families who would prefer that their ill relative stay with them. Either way, supports and acknowledgement of the family contribution are desperately needed.

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  3. David, I wish to thank you for this series. I have over several decades seen the “change” in mental health hospitals and services. The open door issue is particualrly poignant because in Queensland, Australia all open MHU wards bacame locked wards in late 2013. Your observations mirror my concerns about this practise. I would be very interested in any data you mind have come across that illustrates this dynamic.

    Rick Thomson

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  4. A LONG STORY. I was a staff nurse at the Cambridge hospital a few years prior to your time Dr. Dawson. Yes the wards were open and the therapeutic community was more or less operating, They followed the Maxwell Jones model. In some ways it was a step forward, but there were mistakes and a fair bit of naivete was evident even at the time.

    One lady transported by ambulance from the general hospital immediately after birth was given her new born baby to hold, because a staff nurse insisted that mothers and babies should be together in the same room ! Fortunately another nurse caught the baby! I mention this because the woman had had a serious psychotic episode after her first child. In other words caution should have been the thing. Patients occasionally (on certificates) ran away… one on my old bicycle ! At least two people with brain tumours during my time were missed because they were not checked thoroughly. One languished there for several weeks because the psychiatric team thought that the very nice young woman mother of two was hysterical. In fact her family had a history of the particular type of neurological growths and she had had previously had a tumour removed from elsewhere. Social workers were sent to her home to inspect for abuse! Her non- malignant tumour was growing in an awkward place… caused her to vomit and eventually stop breathing . There was a state of the art neuro-unit up the road. She got there the evening before she died. The tumour was in fact one that could easily have been removed but it was too late. I tell these tales to say that psychiatry was not really all that professional.

    However on the whole I would agree that some of the novel ideas were beneficial. But personally I was beginning to grasp that we were dealing with serious brain diseases. In my training days elsewhere I had been somewhat seduced by Freud and the like, though I drew the line at Szasz and Laing.

    There were pernicious attitudes towards families. There was family blaming sometimes quite overt. But, I would say that patients were accessing appropriate medical treatment much more easily then than now.

    Perhaps the new step forward will come when some of the anti-psychiatry folks loosen their hold on the current mess of a system and the serious mental illness gets state of the art care.

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