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

David Laing DawsonBy Dr David Laing Dawson

Since writing Part IV, I’ve read E. Fuller Torrey’s American Psychosis. So there is my historian tracing the manner in which the personal struggles of politicians, the belief systems of leading professionals of the time, egos, idealism, personal tragedies, and, of course, power, politics, and money brought about the disastrous transformation and destruction of the mental illness treatment system from 1963 to present time in the US.

Canada is always a slightly more cautious, reticent, little brother too often lead astray by his risk taking, grandiose big brother. We are not as enamoured with the profit motive; we have evolved a somewhat different social contract; our minimum wages and safety nets are better; our Federal Government dare not (thanks in large part to Quebec) tamper with social and health programs long the responsibility of our provinces (or initiate something unilaterally that would undermine or destroy Provincial Programs). So we still have most of our mental hospitals, and they are mostly linked and associated with our community programs. Our psychiatric leaders and teachers remained a little more grounded in the observations of Dr. Kraeplin than the fanciful extrapolations of Drs. Freud and Laing. We realize, I hope, that privatizing our garbage collection (providing we retain sensible unions) might be both fiscally and socially responsible, but privatizing the care of the mentally ill is not.

Yet in our own slow and cautious way we are following the same path as the US. Completely discredited ideas about the causes, treatments, and “prevention” of serious mental illness, once promoted by the Psychoanalysists who designed the American Community Mental Health Programs of 1960 and 1970 are finding their way into our commissions and planning groups. Our linguistic avoidance of ‘illness’ in favour of ‘issues’ and ‘health’ is just another form of denial of the knowledge that, unfortunately, God help us, no matter how well we conduct our lives, we (and our children) can still be stricken with serious diseases of the body and brain. And, our cherished belief in inclusiveness, our understandable distrust of authority, even of scientific authority, and our wishful thinking and politeness, often allow equal voice to the speakers of nonsense on our commissions and task forces.

Much of the care of the seriously mentally ill has shifted to psychiatry programs and inpatient units of our General Hospitals. These are not for-profit institutions, but neither are they asylums; short stays are the goal; turn-over is rapid, and the doors we unlocked in the 1970’s are once again locked. (Security becomes paramount when the unit is situated on the fifth floor of a General Hospital next to the surgical suite and the Pediatric ward.) Overwrought privacy laws allow health personnel to avoid the onerous task of talking with families and other caregivers. Time consuming and difficult appeal processes facilitate psychiatrists prematurely discharging very ill people who are not, strictly speaking, imminently dangerous to self or others.

We too now have mentally ill homeless, and jails and prisons with burgeoning populations suffering from mental illness.

(I remember being mildly astonished, in perhaps 1990, to find that an Ontario Ministry of Health task force, seeking to determine the optimal number of psychiatric inpatient beds per 100,000 population, was using the State of Georgia as a benchmark. Not The Netherlands, Finland, Sweden, Denmark, but Georgia. It is sometimes difficult to resist American enthusiasm.)

We have had the opportunity of adopting some of the good and effective programs pioneered in the U.S. (the ACT programs) and avoiding some of their bad ideas; we are developing a number of programs to help the police (now often front-line mental health workers by default) in many jurisdictions; we have some means of mandating forced community treatment for those who remain at risk (though it is underutilized).

Still, our development of community programs to service the seriously mentally ill has definitely not kept up with de-institutionalization. We seem to be, once again, inexorably following the misguided steps of our big brother to the south.

But, we have not destroyed our mental illness treatment system, merely hobbled it. So, in theory at least, as a country with a smaller population than California, we should be able to fix it.

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

  1. It is good to get this perspective on the history of how people with serious psychiatric disorders have been treated through the decades. I have enjoyed each of the five parts. Recently, I did a little research on de-institutionalization or of “the Great Emptying” as families are calling it. I found myself deep in the lower floors of the Gerstein Library at U of T searching for the few articles available on this event that for many families has great significance. It was a surprise to see how little is available on what,I believe, is a major social event. Most of the articles were from the States.
    The best source was a slim volume written in 1984 by someone from the social work department at U of T. It also had an amazing bibliography. But my sense was that it had not been electronically copied. So a huge chunk of history could be destroyed if it were to get lost. One of the major drivers of De-institutionalization was to save costs. The money saved on emptying the institutions was to be spent on community services which were to be designed to replace the family not support the family, just as the asylums had been built to replace the family. Families were often considered “outsiders” by asylum staff, just as they are considered today. The reality was that many returned to their families who were not supported by the system to care for their relatives. Lack of support to families is still happening today where 50 to 90 percent of mentally ill people live with their families. When
    there is a crises, the relative is taken to the local hospital, sometimes by the police. After a brief hospitalization, he has a chance of being prematurely discharged and may de compensate and if lucky is re admitted. Given this reality, programs need to be in place to support families through education and financial compensation. Supporting the family as it tries to cope is one way to prevent homelessness. Many families would prefer that there was adequate supportive housing in place. But until that time, there needs to be a focus on supporting families with this task.

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    1. I agree with your points, but we Canadians did not just drift into de-institutionalization and scrapping the hospitals. Much of it was driven by a certain type of consumer survivors who were basically political activists , some were full blown anarchist, some totally against the idea that major mental illness was based in any way whatsoever in biology that had failed a person.

      Sad to say many of these people are not good for those who need medical help and honest advocates. Some have had and continue to have major political influence on policy makers. Some still have the high ground thirty years later and influence policy makers to the detriment of those who need serious prompt medical help. There are numerous examples of their activities and how they have skewered decent care. There are many people with serious mental illness( after they have been stabilized) who could be helpful to planners, but unfortunately it is nearly always those who downplay even deny the nature of serious mental illness who call the political shots. Look no further than Toronto to see what is happening.

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