Category Archives: hisotry of psychiatry

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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