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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.

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