Tag Archives: Dorothea Dix

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

David Laing DawsonBy Dr David Laing Dawson

It is difficult, if not impossible, to fully understand the forces altering, changing, insidiously impacting our attitudes, laws, institutions, and behaviour in our own time. It takes distance and serious historians to dissect these things, and even then we are probably viewing them from a clouded contemporary prism. But something happened between 1990 and 2015 I would not have expected in 1970. Many of our mentally ill fellow citizens today are worse off than they would have been had they been born 50 years earlier. There are parts of the United States where one could make the case that they are worse off than they would have been had they been born in 1850. How could this have happened during a period of increasing knowledge, advanced medical tools, relative peace and prosperity?

This is one part of the puzzle:

The mental health laws were tightened, restricted during those years (1970 to 1990), and safeguards put in place, all toward the righteous goal of preventing anyone, ever, from being unnecessarily stripped of freedom and independence without “due process”. On paper it looks fine. Now one could not be held for a psychiatric assessment unless he or she was judged to present an imminent threat of harm to self or others. Within 72 hours if a psychiatrist came to the same conclusion about imminent threat to self or others, that person could be kept for another two weeks. Further safeguards were put in place – appeal processes, Review Board Hearings, lawyers made available, patient advocates. The wording, the processes are all a little different in each North American jurisdiction, but with similar intent and outcome.

And then the act of treating was separated from the act of detaining. A second process is required for involuntary treatment: a determination of not being competent to consent to treatment, and then the treatment authority would be conferred on a nearest relative, or, failing that, a public official. And this determination could also be appealed, taken to a Review Board, and ultimately to court.

This distinction between the right to detain and the right to treat has led to some paradoxical situations in which everybody loses. A person can be deemed too imminently dangerous to self or others to set free, to be allowed to leave, yet competent to refuse treatment. The patient suffers physically, mentally, left in a state of psychosis for a long period of time; families watch this suffering; unhappy doctors and nurses watch someone deteriorate to a state of chronic psychosis, to a state of true madness and unpredictability not seen in our mental hospitals since the introduction of effective medication.

Apart from this paradox all the new rules sounded commendable, and guaranteed to reduce or eliminate type I errors. Type I errors being the unnecessary detention of someone eccentric, a nuisance, but not dangerous, and the forced treatment of someone who should (within our current view of individual rights) be allowed to decide for himself. They prevent the abuse of a Nurse Rached, or a Dr. Donald Cameron. And these new rules were informed, to some extent I am sure, by our increasing awareness of the use of Psychiatry in the Soviet Union to deal with people deemed to be enemies of the state.

We need strong safe guards in all our systems and institutions, for humans in positions of power are always capable of abusing or misusing that power, of convincing themselves on some philosophical basis or other, that they are doing the right thing.

But when we completely eradicate the possibility of type I errors we open the door for type II errors. In this case not detaining someone who, in hindsight, should have been detained, not protecting and treating people who need treatment and protection. The most dramatic form of Type II error brings about the headline that we have read with horror and disbelief about twice per year the past twenty years. A patient is released from hospital, gets on a Greyhound bus, and decapitates a fellow passenger. A young man stops taking his pills and butchers his mother;  another shoots a journalist with a crossbow; yet another shoots an Arizona politician in the head.

But a less dramatic and more insidious type II error has been the increasing numbers of mentally ill (not deemed imminently dangerous to self or others) left to fend for themselves on the street, in shelters, and in jails and prisons. For a significant number of mentally ill people (and their families) we have, over the past 30 years, reversed the reforms provoked by Dorothea Dix in 1843.

 

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

David Laing DawsonBy Dr David Laing Dawson

In 1843 Dorothea Dix wrote: “I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience.”

And so began the development of asylums for the mentally ill in North America, and the Moral Treatment era. Dorothea had learned from the Quakers in England, and some reforms taking place on the continent, and had brought those experiences and her prodigious outrage back to North America. We were ready for these ideas, as they arrived amidst a developing belief, a new conviction that the “state” should bear some responsibility for the care of those among us who cannot care for themselves.

This was truly a new idea, and one that was transforming the Hotel Dieu in France into the General Hospital, transferring responsibility for the indigent and insane from religious orders to the state.

We were also beginning to notice that not all the indigent, the incapable, the socially dependent among us were the same. Perhaps some were simply lazy, a few others without morals and scruples, but many were insane, others mentally handicapped, and some were incurable inebriates. The latter three categories did not deserve the neglect, the punishment, the harsh treatment that befell them when lumped with the former two categories.

(The first building on the grounds of what was to become, eventually, Hamilton Psychiatric Hospital, was an institution designated for incurable inebriates, a branch of the Toronto Asylum for the Insane).

For the most part, with a few setbacks here and there, the next 150 years after Dorothea’s proclamation heralded incremental progress in the enlightened treatment of mental illness, mental handicap, and addictions. Science brought us more understanding of each form of mental illness and mental handicap, and, eventually, some medical treatments that are actually effective. In poor economic times and times of war (1914 – 1918, 1929 – 1939, 1939 – 1945) we neglected our growing, burgeoning institutions for the mentally ill and the mentally handicapped. Conditions deteriorated in each of these eras, and I’m sure some abuses occurred. The discharge rate was understandably very low during the 1930’s. But for all their failings, these now enormous asylums, with their own kitchens, farms, food production and laundries, set in the rural surround of our cities in North America, at the end of train lines in England, and on the banks of rivers in Australia, provided three meals a day, a chapel to pray in, grounds to walk on, and a bed to sleep in. But during peaceful and better economic times we paid attention. Conditions were improved in the 1920’s, reforms instituted within the knowledge and philosophies of the times: airing courts, more freedom, activities, visitation, better food, entertainment. And after the Second World War a new era began, one of hope, stability, idealism, and new convictions about rights and freedoms.

The first medications that actually helped depression, that controlled mania, were introduced in the 1950’s; the first medications that actually worked with psychosis, with schizophrenia, were introduced in the 1960’s. Rehabilitation, work programs, activities, music, exercise, social programs. Our academic institutions, medical schools, psychiatry departments, began to pay attention to these large asylums and their populations of seriously mentally ill, oddly neglected by academia the previous 50 years, save for field trips to demonstrate catatonia, mania, hebephrenia, and dozens of rare but severely disabling and disfiguring forms of congenital abnormality.

I stepped into one of these institutions in 1968 as a first year resident, along with three other young doctors and two associate professors of psychiatry. It was one of the acute admission wards serving Greater Vancouver, men and women, dormitory sleeping quarters, a brightly-lit day room, spacious grounds, forty patients, but just one component of a large mental hospital comprised of several enormous buildings, some from the Victorian era, this one built in 1931, originally for WWI veterans, all perched on a hillside overlooking Coquitlam and the county of Essondale. We unlocked the door; we instituted “community meetings” every morning, a quasi-democratic reform and a chance to air grievances. We prescribed the new drugs for mania, schizophrenia, and depression. But when someone was well enough to be discharged we had no community treatment programs and support programs to refer them to.

Clearly this was the next thing that needed to be developed.