The Decline of Mental Illness Treatment from the 1980s On

By Dr David Laing Dawson

Through the 1970’s into the 1980’s I ran what we called Community Psychiatry Services. They were General Hospital based and consisted of teams of psychiatrists, nurses, social workers and psychologists. We used what we called an “Active Intake” process that ensured that the severely ill received appointments very quickly and the worried well were rerouted to other agencies. The “active” part of the intake process was a pre-appointment engagement of the patient, the family, the other caregivers. Doing this required that the clinic not become specialized, and that it did not have exclusionary criteria.

The second component necessary for this is a true team, with each member involved, the care plan decided by the team led by a psychiatrist, and that the nurses and social workers be willing to function as case managers. It also required that each member of the team be prepared to help with medication compliance and monitoring, medical care, budgeting, finding bus passes, talking to families, giving shopping lessons, helping with all activities of daily living and also counseling.

Doing this work requires a high tolerance for chaos, uncertainty, anxiety, and insanity.

What happened?

Several things I think, though it is difficult to see the forces of change while living within them.

1. The length of stay in hospitals for the mentally ill became shorter and shorter, driven at least in part by spurious management and budget ideals.

2. The mental hospitals continued to downsize, in some part as a naive ideal, but mostly as a means of shifting cost (and responsibility) from Province and State to Community and Federal Governments. (Note the stats of the Chicago area show an exact mirror image between the declining numbers in hospitals, and the inclining numbers in jails and prisons from 1970 to 2010)

3. The general Community Psychiatry Service is not a good academic career choice. Academics need to specialize for teaching and research opportunities. Hence the development of Anxiety Disorder and Bipolar Clinics. This doesn’t work for the severely mentally ill because to satisfy all the research and protocol needs the waiting list is long, the assessment phase onerous.

4. Again, based on naive idealism, many community services shifted location from the hospital to the community. But once a clinic is moved away from the hospital (geographically and managerially) several things happen:

a. They can no longer risk taking disorganized, chaotic and potentially dangerous patients and

b. Non-medical and non-psychiatric philosophies start to dominate, and the severely ill are excluded. And

c. (at least in my experience) away from the stable budget and managerial practices of a hospital, strange things happen, all the way from pop psychology to fraud.

5. I suppose it was inevitable that each discipline develop more of a sense of autonomy and independence. Social workers and other mental health professionals are no longer case managers working with psychiatrists. They are independent counselors. The development of simplistic models of counseling (CBT and DBT) which can be applied once per week for ten weeks helped this along. This has also contributed to something of an anti-pharmaceutical attitude. (By the way, there is no evidence that CBT is any more helpful than any other professional counseling relationship, but being a rigid simplistic set of responses it is easier to study)

6. I am also convinced that by putting addictions and mental health (illness) under the same umbrella, we diluted what sympathy and empathy the community was developing for the seriously mentally ill.

7. This was compounded by the so-called recovery model, which at its heart, really means (and this may be appropriate for addicts) that if you really try hard enough and think only good thoughts (CBT), and are sufficiently “supported”, you can get well and recover fully.

8. The corollary of this being that if a person with a psychotic illness is not recovering it just means he is not trying hard enough.

9. De-stigmatization. I just happened to watch “Big” the other night and noticed that the actor who played a walk through part, non speaking, looking homeless and mumbling to himself in downtown New York, was listed in the credits as playing “Schizo”. The real way to de-stigmatize any illness is not by feel good infomercials, but by providing adequate and successful treatment. Think Leprosy, AIDS, cancer.

10. Without a team to work with, to case manage, to field crisis calls, to make home visits, to check on progress more frequently, a lone psychiatrist will find it difficult to treat the severely ill.

11. The tightening of the mental health acts and processes in each state and province,  the protection of individual rights and the provision of due process (as defined by lawyers), again based on a sort of naive idealism, resulted in four unintended consequences: thousands of people suffering from untreated psychotic illnesses in the streets and shelters, a burgeoning population of mentally ill in the prisons, the dramatic growth of locked Forensic Psychiatry Units, and a sad return to locked doors for the rest of the hospital now dominated by the Forensic units.

Between 1900 and 1960 the severely mentally ill were mostly institutionalized, treated in mental hospitals for long lengths of stay, by doctors who were often imported and/or had limited licenses. Then as now, the Academic and North American trained psychiatrists worked in private offices treating a small number of patients over many years. These patients could be counted on to be articulate, educated, and at least middle class.

Between about 1960 and 1990, with new effective medications and the move to de-institutionalize, community clinics like the ones I worked in developed in many parts of North America; the General Hospitals developed psychiatric programs, and for at least two decades, perhaps three, we seemed to be moving in the right direction. In parts of Canada incentives were developed to keep psychiatrists working in hospitals with the severely ill or as they were called then, the seriously and persistently ill. And the University Departments of Psychiatry finally took an interest in the medical treatment of the severely mentally ill.

We were going in the right direction.

And now it seems we must re-invent the wheel.

For more information on schizophrenia, check out the documentary Schizophrenia in Focus

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5 thoughts on “The Decline of Mental Illness Treatment from the 1980s On

  1. Terrific observations and historical analysis of the deterioration of mental health care. I always enjoy Dr. Dawson’s blogs. However, in this blog, I believe one key element was omitted. What was the part Psychiatry played in this debacle? The writer lays all the blame on non-psychiatrist professions and budget reductions. Where were the psychiatrists? I got my PhD in clinical psychology in a medical school department of psychiatry, 1969-1974. In those days, psychiatrists were fighting amongst themselves about everything from which school OKC psychoanalysis to whether mental illness actually existed. Those who actually worked with serious mental illness only had a handful of medications to chose from and realistically knew how much they needed a team approach. As new generation medication emerged psychiatrists began to believe that they needed no other professional support. To meet the demand and make the most money, they began to develop an assembly line practice where they spent fifteen minutes per patient. Those few who couldn’t or wouldn’t adopt the new practice model were considered less capable and worked for government agencies. I can tell you wild stories about prison psychiatrists. I can also tell fewer stories about wonderful psychiatrists.
    Dr. Dawson’s comments about non-psychiatrists reveals one of the reasons psychiatrists played a major role in the demise of multidisciplinary mental health teams. Dr. Dawson’s comments reveal a condescending attitude reinforced by an ignorance of research. For example evidence based CBT treatment has clearly been shown effective with approximately targeted patient problems. Moreover, medication and CBT combined are more effective than either separately.
    Guild (tribal) mentality and competition must be replaced by respect for the strengths of each profession and collaboration forged for the united goal of treating serious mental illness.

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    1. From Dr David Dawson:

      I didn’t mean to exclude psychiatrists from blame in this sorry slide backwards, and I didn’t mean to denigrate other health care professionals unfairly. I am sure a couple of months of CBT is far more cost effective than a couple of years on an analyst’s couch.

      In the early team days, with free wheeling case discussions, one could usually count on the psychiatrist wondering if a change of medication might help, the nurse suggesting more support, TLC, and better sleep hygiene, the social worker suggesting some job training and better housing, and the psychologist reporting on her testing, and recommending more psychotherapy.

      A year later it might be the psychiatrist asking if we can get the patient into a social skills program, and the social worker suggesting an increase in anti-psychotic medication. And we all knew that each contribution was valuable and each increased the likelihood of the others working. An ongoing counselling relationship improved the likelihood of medication compliance and success reducing symptoms, as did social support and a meaningful activity.

      This happens if all the professions are working together. Once separate each is at risk of self-delusion.

      The economic forces driving the regression of American mental illness treatment are quite different than those in Canada, though we have a bad habit of following along. Fuller Torrey’s “American Psychosis” delineates how the Federally funded mental health centres allowed the States to shutter the mental hospitals and pass the burden to these federally funded centres, which were ill equipped to serve the truly mentally ill. And didn’t.

      In Canada the shift followed an ideal of mental health care belonging with other health care in the general hospitals (Starting with the paper “More for the Mind” in the early 1960’s). General Hospital Psychiatry programs developed, depending on transfer money from the Feds to the Provinces. Much of the care of acute mental illness shifted to General Hospitals, and while the Provinces had direct responsibility for the Mental Hospitals, each Provincial Government was now shielded from what happened at Community Hospitals by several layers of bureaucracy. And the General Hospital’s
      accepted mandate of acute care and shorter hospital stays (post natal and post surgery care dropped from a few weeks to a few days), meant there was no longer room or space or grounds to keep a psychotic person for three or four months. Which is about the length of time it usually takes for stabilization, including consistency of medication plus consistency of case management and counselling.

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  2. You did a great job of delineating some of the issues standing in the way of finding and getting treatment for mental illness. I am familiar with the systems since my mom had schizophrenia and was in and out of hospitals from 1970s through the 90’s. There were issues then, and insurance coverage was almost non-existent. Recently I had a disappointing encounter when seeking weekend help for a friend with new onset paranoia who was in crisis. I sure hope eventually society can find a way to provide people with the help they need for mental illness.

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  3. This is the best summary I have read of all that has gone wrong in treating our seriously ill patients. The comments are also enlightening and obviously come from real life experience. I would like this to be read and absorbed by every law maker in the country. We need to change the way we deal with serious mental illness. Patients and their families are enduring untold suffering. It needs to stop.

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