Re-Institutionalization: Forced Treatment and System Failures

So we’re back here again.

Modern western society sees activity or behaviour that makes it angry or uncomfortable and we leap to using “force” to solve that social dissonance.  “Lock them up” becomes the rallying cry of the unimaginative, the impatient or the simply intolerant.  The voice of those in the middle of society that are doing just fine resent their relative serenity being darkened by the “non-compliant” who are not living their lives exactly as the middle thinks they should.

The targets change but none are more maligned or easily ganged up on than the severely and chronically mentally ill.  Calls to relegate those that are unwell and living in the streets to locked wards against their will with treatment thrust upon them fall squarely into that poorly considered intellectual domain.

Back in the 1970s (and previously), Psychiatric hospitals were meant to be the compassionate place where people who were mentally unwell were sent to be “made better.”  More often than not, hospitals simply became warehouses to hide away those who made us uncomfortable.  Those people had no power, no voice and were often so medicated with powerful psychotropic drugs (usually to keep them stoned into compliance) that even if they were to miraculously improve, we would never know.  In the worst cases, they were experimented upon (e.g., the Quebec LSD trials), subjected to the latest in untested medical treatments (e.g., broadly applied electroconvulsive therapy) or brutalized (e.g., British Columbia and Alberta’s forced sterilization of the “mentally defective”).

That is the context leading to the deinstitutionalization efforts of the 1980s, efforts that led to Psychiatric hospitals freeing patients … to the streets.  The promise of the jurisdictions that shut down those institutions was that the resources that kept the hospitals open would be shifted to the community, supporting former patients to create meaningful lives.  There would be adequate clinical support, housing, social support and opportunity.

It never happened.  Sure, we released people, but those supports were, at best, sparsely distributed.  Instead, we relied on the social welfare and correctional systems to “manage” the mentally ill who quickly became homeless.  Police and correctional budgets swelled to gargantuan levels.  Those systems were provided additional human resources to apply the few and inappropriate tools that they had to meet loud social calls for a return to the appearance of social order.  And given the systemic racism embedded in those systems, swept up disproportionately were Black, Indigenous and People of Colour.

And the warehousing began again.  This time it wasn’t hospitals, it was (and is) prisons.  People locked away so the general public doesn’t have to see their pain, their misery, their awkward and sometimes self-destructive struggles to end their agony or deal with their trauma.

“But there are still severely ill people on the street that aren’t getting the support that they need.”  So true.  So, the solution is to go BACK to the same system, the Psychiatric facilities, that were so inhumane and damaging before? “Oh, but we’ve improved! We would never mistreat the disenfranchised and powerless for our own convenience and efficiency!”

Really.  Tell that to the elderly living in long term care (LTC) homes whose care was so wholly inadequate throughout the pandemic.  Tell that to the thousands of LTC residents who have been prescribed punishing drugs like Seroquel, not because they were psychotic (which is what Seroquel is prescribed for) but because it sedates them, allowing more people to be inadequately cared for by fewer LTC professionals. Tell that to the prisoners in our jails prescribed the same drug for the same reason.  Tell that to the thousands of Canadians sleeping each night in shelters rather than being given beds and homes and care.  We tut and shake our heads but ultimately, we go back to our lives and allow systems to keep misery from our rose-coloured view.  

And believe me, it’s not like using among the most expensive of institutions (i.e., hospitals and jails) is going to save us money.  

It’s not that the professionals in our systems are bad. Most are kind, well-meaning people that would like the best for the people they serve.  LTC workers don’t want the people in their charge neglected.  Psychiatric hospital staff didn’t want their patients abused.

Our systems are guided by values that undermine the care that is supposed to flow out of them.  Most egregiously, “efficiency” beats up on people.  Here’s what re-institutionalization would likely look like.

At first, there would be a small handful of truly ill people that would be scooped up.  They would have lots of resources in hospital; they would be cared for. And public attention would shift.  Slowly, more and more community systems would see the Psychiatric hospital as a “compassionate” response. “We can be GOOD people and send this clearly hurting person to hospital.” And hospital numbers would begin to swell.  Police would start to see the hospitals as a faster path to clearing their paperwork and shift more of the people with whom they interact to the hospital system.  Soon there would be more patients than the hospital staff can reasonably manage.  We would hire less qualified people for less money.  But public attention has shifted. “Budgets are tight; we have other priorities,” say the law makers.  “We already solved that problem.  Do more with less.”

And so it goes.  Why on earth would we advocate for a return to a previously failed model?  We haven’t solved schizophrenia; shall we return to the barbarism of trephining? Shall we use bloodletting to address chronic epilepsy?

Here’s a thought.  Why don’t we do what we actually said we were going to do back in the 80s.  Why don’t we give people the clinical, social and housing support that they need in their communities? For goodness sakes, why don’t we ASK people struggling with mental health concerns what would work for them? Why don’t we create systems from which people want to benefit rather than run?  Why don’t we make mental illness and its symptoms as deserving of compassion as cancer and its symptoms?

Why don’t we send using “force” to deal with social issues to the dustbin of history where it belongs and redouble our efforts at prevention, care and support.  Those that rely on force to enact their vision of the ideal society need to be ignored.

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