Tag Archives: Moral Treatment

A Psychiatrist Critiques Open Dialogue

By Dr David Laing Dawson

We humans are a strange and contradictory species. While most of us are willing to take any number of potions and pills to limit the effect of the common cold, to boost our energy levels, to ward off aging, sore joints, and failing libidos, and a great many of us are willing to consume dangerous liquids, pills, and injectables to ameliorate the anxiety of knowing we are vulnerable, mortal and inconsequential life forms, and some of us decide to undergo toxic chemotherapy for a ten percent better chance of survival, there are others of us (perhaps not different people) who would deny (proven effective) antipsychotic drugs to someone suffering the devastating and dangerous symptoms of psychosis, of schizophrenia.

Even if some form of two year intensive counseling/therapy/group therapy worked as well as four weeks of Olanzapine, what on earth would be the justification for withholding the Olanzapine?

To be fair we have been here before. We have all, including psychiatrists, wanted to see, to understand, mental illness, both in mild form and severe form, as adaptations and temporary aberrations of the workings of the mind. And, by extension, amenable to persuasion, love, kindness, respect, and a healthy life style. In the Moral Treatment era of the mid to late 1800’s that healthy life style was based in Christian principals of routine, work, duty, etiquette, and prayer in a pastoral setting. For someone with a psychotic illness this undoubtedly would be preferable to the imprisonment that came before, to the massive overcrowded mental hospitals that grew and grew after the industrial revolution, and even, for many, preferable to the mental health systems of 2015. But it did not treat or cure psychosis.

Through the 40’s, 50’s and 60’s many notable psychoanalysts tried treating schizophrenia with their own particular form of “open dialogue”. I read many of their books and case histories. And while they are fascinating explorations of the human condition and equally interesting attempts to find meaning within madness, it did not work, at least not as a treatment to alleviate suffering and disability.

And then in the sixties and early seventies we experimented with therapeutic communities. When I listen to the staff of Open Dialogue in Finland talking about their program I can imagine my colleagues and I saying the same things about our experience in Therapeutic Communities of the 1960’s. It was humbling, as close to a level playing field as possible, a marvelous learning experience for staff, a laboratory of interpersonal and group dynamics, an open, respectful environment for patients, but it was not an effective treatment for psychotic illness, at least not without the addition of anti psychotic medication.

Harry Stack Sullivan, a psychiatrist working before the introduction of chlorpromazine wrote that “schizophrenics are not schizophrenic with me.” And what he meant, I think, was that, with a little skill, plus respect, patience, a non-judgmental attitude, knowing when to talk and when to listen, knowing what to avoid and what to ignore, one can have an enlightening and pleasant conversation (dialogue) with someone suffering from Schizophrenia. But that conversation is not a lasting treatment or cure.

It is also notable, I think, that the psychiatrist and director of Open Dialogue in Finland, in interview, acknowledged that she prescribes neuroleptic medication for “about 30 percent” of their patients. Now, from what I know of human nature and our tendency to round our figures up or down depending on the social moment, maybe that is 35 to 40%. And given the way they work as a 24 hour on call mobile immediate response team, with no filters for severity or urgency, even if only 30% receive neuroleptic medication, it sounds about right. In truth then, Open Dialogue in Finland is NOT not using neuroleptic medication to treat people with severe psychotic illness.

I have no doubt that they have created relationships and a social environment for their patients in which less medication is necessary to help them survive and function. I think it is the same thing our ancestors did in the moral treatment era, and again, what we did in some therapeutic communities of the 1960’s.

Open Dialogue also reminded me of some other experiments with around-the-clock, immediate response teams preventing hospitalization and achieving better results than hospitalization. When I explored some of these in the 1970’s and 1980’s wondering if they could be reproduced outside of their funded clinical trials I found young idealistic doctors and nurses quite willing at that time in their lives to be on call 24/7 without extra pay, with limited personal life during the course of the experiment. We could approximate these programs in real life but we could not replicate them.

We have ample reason to not trust big pharma and their incessant push to expand their customer base, but let us also be aware of both history, and the realities that surround us, of the many people with psychotic illness now back on the streets, in the hostels and jails, of the need for better mental health care systems, and the need for better cost effective treatment, and of the many people for whom our current medications have been both sanity and life-saving.

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.