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RBC Letter

Vol. 72 No. 4 — July/August 1991 —
Towards Better Mental Health

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The deinstitutionalization of the mentally ill has presented a challenge to all Canadians. If we are to improve our collective mental health, we must change our approach to mental illness on the way to a generally healthier society ...

Despite the progress made in the treatment of mental illness in recent years, some of our thinking about the subject is back in the dark ages. It was then that European bishops spread the doctrine that madness derived from sin. Other theologians claimed that mad people were possessed by demons, but nonetheless blamed the victims for having somehow invited the demons to possess them. In any case, the theory that insane people brought insanity on themselves gave others an excuse to despise them, a medieval attitude which persists to this very day.

In a society which is supposed to care for those who are suffering through no fault of their own, mentally ill people continue to be treated callously. Perhaps this is because so-called "normal" people find them threatening. The same good, kind citizens who would help a physically-injured person on crutches to cross the street will hurry across the street themselves to get away from a mentally-ill person who is raving. Though the great majority of mentally disturbed persons are harmless, all are automatically deemed to be dangerous, an impression strengthened by terror books and movies which glory in depicting obsessed kidnappers, "homicidal maniacs" and other criminal psychopaths.

When a society is prejudiced against a group whether consciously or not, it unfailingly makes its members into objects of ridicule. And now as ever, jokes about "crazy" people abound. The mentally ill are called facetious names like "nuts" and "loonies," the latter harking back to the fact that "lunacy" was once thought be caused by the phases of the moon, an idea which originated with the ancient Romans. The jokes and jibes reflect another prejudicial myth , which is that mental illness can be a painless and even a pleasant condition. People will refer to a mental institution as the "funny farm" or the "laughing academy," conjuring up a stereotypical picture of its inmates talking to themselves in blissful fantasies.

Typical of the notion that madness is not so bad after all are the words of the iconoclastic essayist Logan Pearsall Smith: "Are there not soporific dreams and sweet deleriums more soothing than reason ?" Well, no - in fact, those "sweet deleriums" are usually either the products of misinformed imaginations like Pearsall Smith's or the manic phase of manic depression, one of the grimmest of all mental afflictions. Ex-mental patients will testify that having no control over your mind is a very horrible condition indeed.

Perhaps we as a society like to pretend that the mentally ill are happy in their state to assuage our guilt over the way we have treated them. For many, many years in this ostensibly liberal country, "normal" people stayed as far away from their mentally-ill compatriots as they possibly could. This was accomplished by locking them up out of the sight of the public. In pre- Confederation Canada, people who had been incarcerated solely for being of unsound mind were put in prisons alongside criminals who treated them with great cruelty. So shocking was their condition that it led to campaigns for the protection of the insane. These succeeded in having mental "hospitals" established across the country during the latter part of the 19th century. But the hospitals eventually proved to be just as inhumane as the jails.

Teams of mental health workers sent out to inspect Canadian mental institutions from 1917 to 1919 encountered appalling squalor, neglect and brutality. In a Manitoba asylum which had one doctor for 700 patients, black eyes offered evidence of the strong-arm methods of the attendants; and "patients sat in complete idleness on long hard wooden benches, many of them in physical restraint, staring vacantly into space, dejected, waiting for death to give them release." In Saint John, N.B., patients were individually locked at night inside crude wooden coffin-like boxes. In Halifax, one team recorded, "We saw a scantily-clad man in a small unheated room who was kept there throughout the damp cold weather. When we remonstrated with the authorities, we were told that the insane man did not feel the cold."

These reports reflect two views of the mentally ill which linger on in our collective subconscious. The first is the medieval one that they are in some way culpable for their troublesome state, and so deserve to be treated roughly. The second is that they are not quite human anyway; they do not "feel the cold."

If they are not quite human, it follows that they do not quite qualify for the full range of human rights. For many years mentally- disturbed people were the victims of blatant, official, systemic discrimination in Canada. In some jurisdictions, for example, people could only be committed to institutional care by magistrates . Until the legal system got around to dealing with their cases, they languished in jails without having been charged, deprived of habeas corpus and subject to violent man-handling by guards and police.

It may be said in defence of Canadians and citizens of other liberal democracies that they were not generally aware that their mentally-ill compatriots were being so abused by the system. But if they were unaware of what was happening, they were largely unconcerned. There was a tacit social understanding that people who showed clear signs of mental disturbance were to be "put away" in custody. No very close attention was paid to what happened to them in the limbos into which they disappeared.

Ironically, putting the mentally ill effectively in quarantine has always hindered efforts to control the illness. As long as the most conspicuous of our mental health problems were hidden behind institutional walls, there was no compelling reason to tackle the more common problems around us.

Though the predecessor of the Canadian Mental Health Association was called the Canadian Committee for Mental Hygiene when it was founded in 1918, it concentrated in its early years more on the pathetic plight of institutional patients than on "hygiene" in the sense of preventive public health measures. At any rate, it is doubtful that many at the time seriously believed that you could establish conditions that would prevent mental illness the way inoculation could prevent smallpox. It was vaguely concluded that mental illness sprang from a kind of bad seed, a character flaw owing to one's heredity. With equal vagueness, it was popularly assumed that madness was pretty well incurable.

'Shell shock' showed that anyone at all can break down under stress

The driving force behind the mental health movement in North America was a living contradiction of this theory. Clifford W. Beers, author of A Mind That Found Itself , had recovered from a severe mental breakdown. Before his book was published in 1908, Beers had been in and out of sanitariums in the United States. Beers was active in establishing mental hygiene societies in the U.S ., and in 1917 collaborated with the future general director of the Canadian Mental Health Association, Dr. C. M. Hincks, in organizing a mental health movement in Canada. The interesting story of the movement is told in the history of the CMHA by a later general director, John D. Griffin, entitled In Search of Sanity , published in 1989 by Third Eye of London, Ont. We are indebted to Dr . Griffin and his work for many of the details herein.

The horrors of World War I confirmed that mental disorders could be caused by environmental stresses in otherwise well-adjusted individuals. In the early months of that conflict, it was widely believed that severe nervous breakdowns among front-line soldiers were the result of concussion from exploding shells - literally " shell shock." Identifying this as a psychological ailment brought several breakthroughs in the professional approach to mental hygiene .

Chief among these was that anyone - anyone at all - can break down when sufficiently exposed to intense strain and upheaval. If they remained long enough on active service, the bravest and most battle- hardened soldiers would inevitably suffer a mental collapse from fear and fatigue. This exploded the time-honoured fallacy that only people with inherent character weaknesses were vulnerable to mental illness. It meant that exterior conditions had a decisive effect on whether a person was mentally well or ill.

As thousands of psychiatric casualties streamed home from the war, mental health became a matter of widespread public concern for the first time in Canadian history. The practice of sending shell shock victims back to their home provinces for treatment drew attention to the unconscionable conditions in provincial institutions. The knowledge that strong men could be "wounded" psychologically as well as physically helped to make the fact of mental illness more acceptable and better recognized. Most importantly, the war and its aftermath proved that people with serious psychiatric conditions could recover and reintegrate themselves into community life.

Still, it took the popularization of the work of Freud and Jung to show that there could be such a thing as mental hygiene. They identified the existence of neurosis, a condition which merges normal and deranged behaviour and stops short of its sufferer losing touch with reality.

The fact that neurotic conditions could be brought under control by therapeutic techniques opened the conceptual door to preventive mental medicine. Out of the great psychiatrists' discoveries, later workers in the field would make a broad distinction between psychotic "mental disorders" such as schizophrenia, manic depression and dementia, and neurotic "mental health problems." The latter conditions essentially arise from disturbances in the individual's interaction with the environment. If the disturbances can be settled, the problem will go away.

Guided partly by the theories of Freud and Jung on the influence of childhood on the adult mentality, the forerunner of the Canadian Mental Health Association initiated mental hygiene programs among children in the early 1930s. Studies were undertaken in child development, and programs launched to educate parents and teachers in how to encourage healthy relationships and instil a balanced approach to the psychological demands of growing up.

As more research was done into what constitutes good mental health, it became clear that many of the most common psychological problems were problems of adaptation. Children have to adapt to adolescence, adolescents to adulthood, and adults to different conditions - being married, having children, holding and losing jobs, growing old , losing loved ones, and so forth. It was found that counselling and efforts to improve socialization in such situations helped to maintain sound mental health.

Immigrants in particular have to adapt to a new way of life which is always strange and sometimes frightening. The attitude towards this group in Canadian mental health circles offers a telling example of how much times have changed. One of the major preoccupations of the mental hygiene movement in its early years was screening immigrants for mental unsoundness with a view to denying them entry or deporting those already admitted. In a report in 1931, a respected psychologist wrote that "the immigrant with a lame or crippled mind is not a healthy immigrant, nor is he a whole man. Canada needs whole men."

Advances in science have meant that patients may now treat themselves

In later years the CMHA came around to an entirely different view of that figurative immigrant. It argued in briefs to the federal government that mentally ill persons should be permitted entry when their presence in Canada is of significant benefit to their families in this country, and that holding a deportation notice over a mentally-ill immigrant's head might well impede his recovery . The association found it necessary to remind the government of the falsity of the assumption that "once a person is judged mentally ill (or 'insane' in legal terminology) he will always be mentally ill." It stressed that immigrants - or anyone else - can be treated successfully and go on to lead full and useful lives.

One reason why successful treatment is more common now than formerly is that great advances have been made in psychiatric medicine. For a long time, the psychiatric field was largely overlooked in the allocation of public funds for staff, facilities, and research. It did not rank with physical medicine as a political priority. This was the case as recently as 1962, when the federal Royal Commission on Health Services presented a scathing critique of the discriminatory differences between mental and physical health care.

In the years since, there has been an impressive increase in the number of psychiatrists, clinical psychologists, specialized social workers and other mental health professionals practising in Canada. Methods of treatment have greatly improved, particularly in the use of medication. The fact that drugs are portable has meant that outpatients can partially administer their own treatment, using the facilities of a growing number of community mental health clinics when necessary.

The portability of treatment was one of the reasons for the historic exodus from mental hospitals throughout the 1970s and '80s . In the past 25 years, the number of beds in provincial institutions has declined by more than 75 per cent. However, there has not been a corresponding decline in the number of patients. Many are now treated in the psychiatric wards of general hospitals and chronic care centres instead of the old specialized "mental homes."

Deinstitutionalization and the integration of former mental patients into society is a great progressive step in the history of mental health care. As Health and Welfare Canada's 1988 discussion document Mental Health for Canadians: Striking a Balance pointed out, "It is quite possible for someone to have a mental disorder and still enjoy a considerable degree of mental health" - and the best place to accomplish this is outside of institutions.

But, the document goes on to say, deinstitutionalization has not been without its dark aspects: "The closing of hospital beds has rarely been offset by a corresponding strengthening of community resources.... Some psychiatric patients who have been diverted or discharged from inpatient care face a life of deprivation, danger and neglect. Some are homeless, or live in social isolation or squalor. Many are forced to rely on family caregivers who themselves have little or no access to respite or other kinds of support."

While improvements in treatment have increased the odds of recovery among the mentally ill, they have had no appreciable effect on the incidence of this type of illness. The estimated proportion of the Canadian population afflicted with serious mental disorders is about the same as ever; at least eight in every hundred Canadians suffer from depression badly enough to require treatment, and at least one in a hundred has schizophrenia.

The incidence of mental health problems, as opposed to disorders, is clearly many times higher. It is hard to tell exactly how common they are, basically because it is hard to distinguish a simple aberrant personality trait from a mental problem. Also, these problems often go untreated or are sublimated in other problems such as alcohol and drug abuse.

If statistics on suicides, family violence, child abuse, substance abuse and violent crime are any indication of a nation's mental health, it would appear that Canada's has been deteriorating lately . Since mental health problems are a reaction to the human environment, it is time for a hard critical look at the environmental circumstances in which they exist.

Clearly, the pace and pressures of modern life are not conducive to peace of mind, with people constantly being called upon to adapt mentally and emotionally to often-disagreeable social and economic changes. Most Canadians now live in urban settings, where they experience an incongruous mix of loneliness and crowding. Putting people in solitary confinement is, of course, an age-old way of driving them crazy; and experiments with rats have shown that they quickly become deranged when they were exposed to the equivalent of a rush-hour traffic jam.

In Striking A Balance , the health and welfare ministry called mental health "something experienced not only individually but collectively." Thus just as the proper public sanitation facilities have an effect on an individual's physical wellbeing, so the conduct of our society has an effect on an individual's mental and emotional wellbeing. The document cites poverty as a leading contributor to mental health problems. Accompanied as it usually is by unemployment, poverty breeds feelings of worthlessness, frustration, rage, and despair.

Other characteristics that detract from mental wellbeing include one's sex (women are much more likely to suffer from severe depression than men) age (youths and old people are especially vulnerable to emotional difficulties) and ethnic background (immigrants and natives are considered to be at higher risk than others). It is instructive that most of these groups are discriminated against.

Thus a key to better national mental health is greater justice and equality. If the correction of injustices begins at home, the obvious place to start in this context is to attack discrimination against the mentally ill in housing, employment, and legal status. What is needed is public education that seeks to eliminate the stigma attached to mental illness and stresses the right of its sufferers to be treated on a level with any other human beings.

This includes the right to make their own decisions and deal with their own problems through mutual aid groups. The acceptance of the mentally ill as full members of society calls for a change in approach to "self-determination rather than paternalism, autonomy and mutual support rather than passivity or dependence," as the discussion paper says.

It goes on to proclaim: "The protection and promotion of mental health should be a matter of compelling priority for every community in Canada." It certainly should be, because if our glaring shortcomings in this regard are not addressed with multidisciplinary action, they can only get worse.

It is not beyond Canada's medical ability to treat mental disorders satisfactorily and ameliorate mental health problems before they develop into more serious conditions. Indeed, it may not be beyond our ability to find outright cures. But in the long run, the problems of national mental health will respond to only one solution . And that is to build a healthier society.

 

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