History of Madness and Mental Illness: A Short History of Care and Treatment in Canada
James E. Moran
Department of History
University of Prince Edward Island
Introduction
We have been concerned about our mental health for centuries in Canada. In a way, it is comforting to know that we have been identifying, enduring and responding to mental health concerns for generations. We can learn greatly from a close study of how various groups at different points in time have understood and responded to those they thought were mentally unwell. A study of the past helps us appreciate that the way we view mental health and ill-health is closely connected to the ways that we have organized ourselves socially and economically. Thinking historically also helps us to assess more constructively how we wish to approach this important aspect of health now and in the future.
Before thinking about stages in the history of mental health and madness, it is worth considering that in all periods, people who we have thought to be mad and mentally unwell have been people who we think fall outside of the norms of acceptable behavior in a given place and time. This greatly helps to explain why certain forms of behavior, such as expressions of religious fervor, depression, or wandering, have been considered quite normal in some historical and geographical contexts, while they have been considered to be forms of mental illness in others. This is not to say that all mental illness is “socially constructed”, but rather that our understandings and responses to mental health are, and always have been, shaped by the social, economic and cultural values of the society in which we live.
Mental health and illness are also very much bound up by culture. For example, forms of behavior that were quite understandable and acceptable in First Nations North American cultures have not been well understood and considered forms of madness to European American cultures. In all historical periods, the language of “madness” has been used to define, in everyday life, what falls within, and what lies beyond the norm. Thus, in our present era, we might say that someone was driving like a “lunatic”, was crying “hysterically”, was driving us “nuts”, or needs to “take a pill”. We use words for madness to remind each other what normal is.
Finally, the periods of madness and mental health history that we are about to explore overlapped considerably. For example, first Nation’s people still employ healing methods that have existed in similar form for centuries. Asylum care did not disappear quickly or completely as a result of the revolutionary era of psychopharmacology. Psychology and psychiatry have existed together as competing systems of treatment for a very long time. It is only recently that they were seen (by some) as complimentary.
First Nations
From what we can glean from oral histories, and the written records of Europeans during the early contact period, Native North Americans understood mental trouble as an indication of an individual who had lost his/her equilibrium with the cosmos in general, and with the rest of the group in particular. In Native healing beliefs, health and mental health were inseparable, so similar combinations of natural and spiritual remedies were often employed to try to relieve both mental and physical illness. Ill health was considered to be a community problem, not just an individual problem, and so the response frequently involved the participation of many in the group in the form of healing ceremonies.
We can see this outlook on madness at work in the ways that Iroquois and Huron First Nations understood and interpreted dreams. For these groups, dreams were unfulfilled desires and wishes of the soul that had to be fulfilled in some way, or else the dream could weigh heavily upon an individual, causing mental and physical suffering, and negatively affecting the whole community. This suffering could be relieved by reenacting the dreams in ceremonial form (either literally or symbolically) with the help of others in the community. Special healers (sometimes referred to as shamans), were often asked for help with interpreting dreams and with suggestions about how they might be reenacted to satisfy the dreamer.
For example, dreams about sexual desire, ceremonial sacrifice, and physical activities such as hunting or harvesting, were reenacted by the native group in order to satisfy and heal the frustrated desires of the dreamer. There was also the feast of Ononharoia, or “feast of fools” during which “men and women ran madly from cabin to cabin, acting out their dreams in charades and demanding the dream be guessed and satisfied.”[1]
Across Canada, First Nations linked the personal physical and mental health of individuals with the mental and physical wellbeing of the group. They understood mental health to be connected to the balance of powers in the spirit world and to the balance of forces in their everyday lives. That is why healing ceremonies were organized to address physical and mental concerns. In many parts of Canada, versions of these healing ceremonies have persisted through the centuries up to the present day.
Early European Settlers
It is ironic that early Europeans in Canada also thought that mental troubles were intimately connected to spiritual and physical well being. Both groups shared these broad outlooks on mental health. But, it seems that most European visitors and settlers who wrote about First Nations were highly critical of native approaches to mental health. This is partly because they rejected almost all other aspects of First Nations society, including their spiritual beliefs, their social practices, and their means of subsistence.
Early European settlers to Canada, in the 17th and 18th centuries closely linked mental troubles to demonic possession, God’s will, and to humeral imbalances. Bizarre behavior among early settlers was often attributed to a person’s body having been plagued by demons or by the devil. Exorcism was occasionally performed to remove the presence of the devil or demons. People also prayed to God to end the demonic presence in the sufferer. A famous chapel at Sainte-Anne-de-Beaupré (near Quebec city), built in 1658, became the site of a regular pilgrimage of people who thought that through worshiping St. Anne, their physical and mental ills could be miraculously cured.
Physicians and other healers in the early European settler period also made connections between mental health problems and an imbalance in the four humors that were thought to make up the human body: blood, phlegm, black bile and yellow bile. An imbalance of these vital bodily fluids could lead to a wide range of mental and physical disorders. In order to restore balance, early Canadian healers recommended a range of treatments including bloodletting, purges, emetics, and diets to deplete or restore one or more of the humors.
Home Care
It is becoming clear to historians that home care of those considered mentally ill was a very important and persistent aspect of mental health history. From the early settler period, through the asylum and desintitutionalization periods, and into the period of major drug therapies, and psychotherapies, a wide range of home care practices have been established by families. In the 17th and 18th centuries, some combination of prayers, and home remedies was often tried. Households that could afford it also often hired nursing care to help manage with the mentally unwell. Neighbors also helped to share the burden of mental illness by taking in a mentally disturbed relative or friend into their households until his/her condition improved. This practice led to some households gaining a reputation for their willingness to take in mentally distraught neighbours for a weekly or monthly fee. Women took on the lion’s share of home care in all of its forms. The work involved was often considered to be an extension of their maternal roles as mothers and wives. In some homes, separate accommodation was sometimes built outside of the home when the mentally troubled became difficult to manage or violent. Like many other forms of care, home care has been around for centuries. In later periods it was usually the first line of care before outside intervention from professional health providers was sought. It is also where many mentally troubled individuals ended up after more formal treatment strategies had run their course.
Asylum Treatment
Perhaps the best known and most controversial form of mental health treatment in Canadian history is Asylum care. By the mid 19th century, the first permanent “lunatic asylums” were established in the four eastern BNA colonies (New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland) and in Ontario and Quebec. By the turn of the 20th century, western Canada had also erected asylums. These institutions reflected a revolutionary form of health care for those considered “insane”. Run by asylum doctors and attendants (later psychiatric nurses), asylums were part of the same reform movement that led to more permanent schooling for children, reorganized prisons for criminals, and reformatories for wayward youth.
Reformers and psychiatrists believed that carefully constructed and run lunatic asylums could dramatically increase the cure rates for many forms of madness. This form of treatment was referred to as moral therapy. Different types of mental illness were more carefully classified, a strict daily routine of work, leisure activities and religious observation was established, medication was routinely prescribed, and patients’ progress was carefully recorded. Experts hoped that in removing patients from their home environments were the mental trouble usually began, they would quickly be cured in this carefully controlled asylum environment. Patients, it was hoped, would be cured by slowly reforming their behavior in conformity with the rational principles of asylum care. In some provinces, private asylums were also established to cater to wealthier families.
If measured by the number of asylum patients, these institutions were very successful. In most regions of Canada overcrowding became an immediate problem, due to the large numbers of people being committed. Families, it seemed, made good use of the asylum, though not always in ways that asylum doctors liked. Statistically, it is clear from a number of studies that a large percentage of patients had short stays of three months or less at the asylum, while others remained for years, and still others stayed for life. The initial optimism about cure rates did not materialize. Part of the problem was the overcrowded environment that made effective treatment (according to the terms of the day) next to impossible.
It is, in retrospect, also unclear how effective treatment of the mentally unwell could possibly be in an asylum environment where the daily care was provided by largely untrained attendants who were very poorly paid. Instances of wrongful confinement, institutional violence towards patients, and surgical experimentation did nothing to help the reputation of the 19th century asylum. Gradually, these institutions gained a reputation for being places of last resort for the incurable insane. Although considered “scientific” at the time of their creation, by the end of the 1800s asylums were considered by many to be backward institutions no longer at the cutting edge of mental health care. And yet, they persisted with record numbers of patients until the mid 20th century. By 1950, the asylum (or psychiatric hospital) population in Canada had grown to an estimated 66,000 patients.[2]
Psychology: Individualized Treatment
The asylum’s reputation was further challenged by an equally revolutionary form of treatment of the mentally troubled – psychological treatment. This concept of care stemmed in large measure from the pioneering work of Sigmund Freud and a subsequent generation of research and therapy of by many of his best students. In rigorous and sometimes lengthy patient/psychologist therapy sessions, psychologists carefully examined their patients’ unconscious desires, repressed urges, and their relationships with family and friends, to find explanations for their mental breakdowns and personality disorders. The best form of treatment, they argued, was individual or small group therapy, in which patients would slowly come to terms with their psychological malaise. From this perspective, treating patients in large asylums in overcrowded conditions through moral therapy made little sense. Since the mid 20th century there has been a proliferation of types of psychological treatment as the list of mental disorders has continued to grow and the profession has become increasingly specialized.
Radical Therapies
In an effort to revitalize asylum care into a more meaningful form of treatment, more radical therapies were introduced into the asylum setting in the early 20th century. These included electroconvulsive therapy, malarial therapy, insulin therapy, the use of the drug Metrazol to induce convulsions, and the surgical procedure of lobotomy. These were all more radical interventions into the bodies and brains of patients. Growing controversy over the use of these therapies led to the popularization of protest in blockbuster movies like “One Flew Over the Cuckoo’s Nest. Most fell into disuse by the 1980s. However, like many of the forms of care that we have reviewed in this short history, it is interesting to note that a modified form of electroconvulsive therapy is still widely used in Canada to treat some forms of depression.
Psychopharmacology
By far the greatest revolution in therapy in the 20th century was the development of psychopharmacology. Starting with chlorpromazine in the 1950s, a host of new drugs were created to treat patients diagnosed with psychosis and severe mood disorder. There was a wide range of negative side effects that went with most of these new psychopharmaceuticals. However, many of these drugs enabled patients to rely less on permanent care at a psychiatric hospital, a change that would accelerate the movement to deinstitutionalization (see below). In the 1970s and 80s, following research into the relationship between neurotransmitters in the brain and mental illness, a new generation of psychopharmaceuticals was introduced (the so-called “mood-drugs”) to further regulate emotional disorders. One needs only to consider the widespread use of antidepressants in Canada to understand the scope and acceptance of these developments in neuroscience and in drug therapy. In 1981, 3.2 million prescriptions of antidepressants were given to Canadians, at a cost of 31.4 million dollars. By 2000, these numbers had increased to 14.5 million prescriptions costing 543.4 million dollars. [3] This enormous consumption of psychopharmaceuticals has drawn critical attention from such scholars as David Healey and Janet Currie, who consider the medical and social consequences of this revolution in thought and therapy.[4]
Deinstitutionalisation
Access to sophisticated therapeutic drugs for a vast array of mental health problems contributed to another important development in Canada in the second half of the 20th century: deinstitutionalization. This wordy term was coined to explain the rapid exodus of patients out of psychiatric hospitals and into the community starting in the 1960s. The new drugs, it was hoped, would help patients to live more independently in the general community. Moreover, governments no longer wanted to bear the burden of hospital costs in the old psychiatric institutions (sometimes the same buildings formerly called asylums). The reputation of these institutions also continued to decline in the eyes of the public. These developments led to a major push to replace psychiatric hospital care with care in general hospital psychiatric units, and with psychiatric services in the community. As Donald Wasylenki notes, the change was astonishingly fast. “Between 1960 and 1975, the number of beds in provincial psychiatric hospitals had dropped from 50,000 to 15,000.”[5] Unfortunately, the rate of deinstitutionalization was much faster than the organization of community services. This has led to enormous difficulties in providing adequate care at the community services level for those who need and want it.
[1] Anthony F. C. Wallace, “Dreams and the Wishes of the Soul: A Type of Psychoanalytic Theory among the Seventeenth Century Iroquois”, American Anthropologist, New Series, Vol. 60, No. 2 (Apr., 1958), pp. 234-248 ). 240.
[2] Cyril Greenland, Jack Griffin and Brian Hoffman, “Psychiatry in Canada from 1951-2001, in Quentin Dae-Grant (Ed.), Psychiatry in Canada: 50 Years, 1951-2000 (Ottawa: Canadian Psychiatric Association, 2001), p. 2.
[3] See, M.E. Hemels, G. Koren, and T.R. Einarson, “Increased use of antidepressants in Canada: 1981-2000”, The Annals of Pharmacotherapy: Vol. 36, No. 9, pp. 1375-1379.
[4] David Healey, Let them Eat Prozac: The Unhealthy Relationship between the Pharmaceutical Industry and Depression (New York: New York University Press, 2004); Janet Curry, “The Marketization of Depression: The Prescribing of SSRI Antidepressants to Women” (Women and Health Protection, 2005), pp. 1-27.
[5] Donald Wasylenki, “The Paradigm Shift from Institution to Community”, in Quentin Dae-Grant (Ed.), Psychiatry in Canada: 50 Years, 1951-2000 (Ottawa: Canadian Psychiatric Association, 2001), 96.