Why Care for the Mentally Ill is a Mess and What Needs to be Done.

By Dr. David Laing Dawson

We have made two big mistakes in the care of the mentally ill over the past 50 years. The first was transferring care from the Provincial Psychiatric Hospitals to the General Hospitals. The second was combining funding, organization, and institutions dedicated to the care of the mentally ill, with that of funding, organizations, and institutions for addictions and addiction treatment.

The first of these mistakes appeared, at first, to be a progressive move. After all, transferring care of the mentally ill to the general hospitals would level the playing field. Now the mentally ill would receive the same kind of funding, the same quality of facilities and staffing as the physically ill. And they could receive their care in the communities in which they lived. And the closing of “mental hospitals, lunatic asylums” would help with stigma.

We forgot our history, and we forgot the forces that brought about Asylums and Psychiatric Hospitals in the first place. The history varies a little in Europe, Great Britain, the USA, and Canada. But the vectors were similar. The severely mentally ill, and the people who were designated as “mentally defective”, needed care, were seen to need care. We had reached a point of social evolution where we considered that perhaps it is our collective responsibility to care for our most needy, most disabled citizens.

Local communities did not have the resources to offer this care, nor did they have the will. But the state did have the resources, and our social contract, our civilization, had evolved to the point (through the 17 and 18 hundreds) that our ancestors decided that the state should assume responsibility for those of our citizens most in need. We should no longer leave their care to charities, religious orders, Gods, charlatans, and chance. In Britain the state was embodied in the monarchy, so the mentally ill became the responsibility of the Queen or King. In Canada this meant transfer of money from Federal coffers to Provincial coffers and the development of Provincially operated services, including Provincial Mental Hospitals. In the United States, care fell to the development of State run asylums.

A hundred+ years later, the well-intentioned move from Provincial and State Mental Hospitals looking after the mentally ill, to local resources and General Hospitals, and, in the U.S. to Federal Mental Health Programs, allowed the Provincial and State governments to offload responsibility and cost. With State and Provincial run programs there was no buffer between a scandal or tragedy and the legislature. Politically, passing services off to local and Federal resources provided that buffer.

But the general hospitals are not asylums. They are not prepared, nor structured to care for the severely and persistently mentally ill. Alternative programs, charities, religious groups, and associations have developed, but they become driven by ideologies and finances. Ironically many (a great many) severely mentally ill in 2024 can now be found back in provincial, state, and federal prisons.

Clearly our civilization has not progressed to the point that local, General Hospital, community, charity, and religious groups can take over care of the seriously and persistently mentally ill. State and Provincial Governments must resume responsibility, with Federal help.

The second mistake, aligning care for the mentally ill with that for addiction, was just stupid. And probably came about for all the wrong political and economic reasons. It has helped neither those suffering from illness nor those with addictions. (note: accidental overdose deaths in B. C. reached an all time high in 2023).

And this merger has come about during a time in our social evolution when we have become very confused about such issues as personal responsibility, illness, agency, freedom, the role of government, of police, the bounds of the normal and permissible, culpability, onus, and personal choice.

We are no longer sure what we as a people, an organized community, should try to control: – gun ownership, car licensing, vaccinations, childhood gender choice, using addictive substances in public spaces, having and/or selling these substances…..

It is difficult to understand the zeitgeist of the time one is living within. But certainly we are not using our knowledge of illness, our knowledge of addiction, and our knowledge of human behaviour to our advantage.

In Canada, Provincial Governments must reaffirm their direct responsibility for the care and treatment of the severely and persistently mentally ill.

And when it comes to addictions, using our studied knowledge of human behaviour, we need to acknowledge two things: The first is that once addicted, humans behave in dishonest, predatory fashion. They lie, steal, and risk the health and welfare of themselves and others. The second is that addicts do not, from insight, awareness, humanity, spirituality, or a sudden burst of empathy, arrive at a decision to put themselves through the pain of withdrawal and the struggle of abstention; they come to this point when they have to.