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.
Published by RBC Financial Group. All editions from the RBC
Letter collection are available on our web site at www.rbc.com/responsibility/letter.
Our e-mail address is: rbcletter@rbc.com.
Publié aussi en francais.
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