By Dr David Laing Dawson
There have been many reformers in the history of mental illness treatment: Phillipe Pinel cutting the chains of the insane locked in Bicetre in 1796. William Tuke, 1792, founding The Retreat, in York. Benjamin Rush and the Moral Treatment pioneers from the late 1700’s. Dorothea Dix actively promoting more treatment facilities through the same period. And long before that Ahmed ibn Sahl al-Balkhi (850-934) within the Islamic Faith.
More recently the publication (1963) of More for the Mind by the Tyhurst Committee of the Canadian Mental Health Association on psychiatric services in Canada: “Mental illness should be dealt with in precisely the same organizational, administrative and professional framework as physical illness”. Tyhurst is the same psychiatrist who contributed to the design of the Psychiatric wards of the new hospital on the UBC campus, opened in 1969.
But it also becomes clear, looking at the realities of institutional psychiatric treatment over the past 300 years, that how we view and treat people suffering from severe mental illness, and the design and function of our institutions, ultimately depend more on economics, politics, the preoccupations and social forces of the time, than on any single person’s ideas.
The reforms of Pinel and Rush coincide with the ideas fostered by the French and American Revolutions. As our cities grew in size, roughness and clamour, the Moral Treatment era sprung from a combination of new psychological thought, religion, and nostalgia for the rural life.
Unfortunately the industrial revolution sealed the fate of those Moral Treatment Institutions, which started as large Manor Houses, built in the countryside where the inmates and staff and the Superintendent ate together, prayed together, followed healthy routines of sleeping, working, prayer, rest, and eating.
With the industrial revolution immigrants arrived, cities grew, workhouses and poor houses proliferated, and the small buildings of the moral treatment era were expanded and expanded. With the same architectural inspiration as prisons, wings were added to left and right, and then from those corners to form a U shape and often then finished at the back to form a rectangle with a large courtyard in the middle. As these institutions grew conditions deteriorated and security became a prime motive. By the turn of the century (1900) the number of patients who were discharged from any American Asylum, dropped to a tiny percent. To be admitted to an asylum was often for life.
After the First World War public interest in the conditions inside our mental hospitals increased, at least in part because of the number of hospitalized veterans. In the mental hospital in Hamilton, Ontario, “airing courts” and vocational programs were added for the patients. These reforms and more humanitarian attitudes coincided with suffrage for women and child protection laws being enacted.
With the depression and the “dirty thirties” into the 40’s the mental hospitals are forgotten once again, and in many, conditions deteriorate. The only effective treatment available is the newly discovered ECT. It actually works for severe depression and psychosis but as with all medical discoveries it becomes overused. On the other hand, as a colleague once pointed out to me, these asylums with their own farms and kitchens were some of the few places in those years where one could be guaranteed a bed and three meals a day.
After the Second World War, again with many veterans being admitted to mental hospitals, public interest in the conditions in these hospitals increased. And finally, medications that actually work for psychosis, mania, and depression are introduced in the late 50’s. These are good economic times, and new attitudes evolve with a renewed interest in human rights and human dignity.
To be continued