From hospitals to encampments – the devolution of mental illness care in Canada

We have created the problem – or at least naive, idealistic do-gooders did.

It started in the 1960s when we had little causal understanding of severe mental illness like schizophrenia and other forms of psychosis. For the previous 100 years, those who suffered were housed in large institutions or mental hospitals while science tried to come up with causes and treatment. And there were many unscientific causes proposed, based in psychoanalytic theory, family idealization, superstition and a longing for a simpler pre-industrial era.

If you don’t know what causes something, you can’t fix it, but people tried – insulin shock, electric shock, psychosurgery, kindness. One unique attempt was to put together three people who all had delusions of being Christ together with each other. The theory was they would realize that not all of them could be Christ and give up their delusion. That did not work, and neither did most attempted cures, but at least the people had a clean place to live, proper food, companionship, activities and maybe more.

The main treatment was custodial care and routine, with patients often performing work in the institution. The Hamilton asylum for the insane in Hamilton had extensive grounds and inmates farmed much of it. The superintendent of the asylum lived on site with his family.

Then along came the 1950s and 1960s and the development of the first partially effective antipsychotic medication, chlorpromazine. Actually, new antipsychotic medications, developed through the 1960s and 70s, and new antidepressant medications were so effective that even some psychiatrists began to imagine a time when hospitals and asylums would no longer be needed. All required care and medical treatment could, in theory, be offered “in the community”.

Nobody chooses to be involuntarily hospitalized. The public image of these institutions was soured by depictions in film, television, books. They were mostly fiction, like One Flew Over the Cuckoo’s Nest, but some were accurate accounts of the underbelly of these large under-funded human institutions.

Politics played a role. In Canada, downsizing and closing the mental hospitals meant responsibility for the mentally ill population could be transferred from the province to the municipality. Along with promises, of course, to provide funds for the necessary community resources.

Institutions became evil by definition and clinicians oversimplified the efficacy of the new medicines. The medications quelled many of the overt and dramatic symptoms of the disease but did nothing for the other symptoms like cognitive decline, lack of motivation or flattened affect.

So, we began emptying the large institutions and then failed to provide community resources. The multi-facet deterioration of mental health services was outlined by David Laing Dawson, the psychiatrist-in-chief at the Hamilton Psychiatric Hospital, in his blog from 2017. He described how the care team had been led by a psychiatrist, and that the nurses and social workers functioned as case managers. It required that each member of the team be prepared to help with medication compliance and monitoring, medical care, budgeting, finding bus passes, talking to families, giving shopping lessons, helping with all activities of daily living as well as counselling.

Then a number of factors came into play that destroyed all that, including downsizing and closing hospitals. Dawson concluded: “I am also convinced that by putting addictions and mental health (illness) under the same umbrella, we diluted what sympathy and empathy the community was developing for the seriously mentally ill. This was compounded by the so-called recovery model, which at its heart, really means (and this may be appropriate for addicts) that if you really try hard enough and think only good thoughts, and are sufficiently ‘supported,’ you can get well and recover fully.”

Now, we face a situation in which we do not have enough psychiatrists. According to the Canadian Medical Association (CMA), in 2019, Canada had 13.1 shrinks/100,000 population, but distribution among the provinces was uneven. Compared to Europe, this is pathetic and on par with countries like Cyprus (12) and Malta (11). Switzerland has 52, the United Kingdom 18 and Norway 25. The CMA suggests that 15 per 100,000 would be an appropriate number.

Thanks to our emptying psychiatric hospitals without replacing them with community supports, beds have been drastically cut. Total hospital beds in Canada have been falling since the early 1990s. Between 1976 and 1990, there were about 690 beds per 100,000. By 2020, the number had dropped to 255 beds. Psychiatric beds decreased as part of that decline.

The Canadian Psychiatric Institute and the Treatment Advocacy Center in the U.S. suggest that an appropriate number of psychiatric beds be 50 per 100,000. In a comparison of 35 countries, Canada ranks 29th in beds, slightly ahead of New Zealand, the U.S., Chile and a few others.

In Ontario, mental illness counts for 10 per cent of the burden of diseases but only gets seven per cent of health-care dollars. The Centre for Addictions and Mental Health calculates that spending on mental illness is short about $1.5 billion. Organization for Economic Cooperation and Development countries spend between 10 to 11 per cent.

So, we have a lot of people with serious mental illness, many of whom are poorly or inadequately treated. Where do they live and what do they live on?

Most people with disabilities in Canada live in abject poverty on minuscule allowances from their provincial governments.

The number of jobs they can do with little or no required skill is rapidly dwindling. Some are lucky to have families that help them out, but where do the others live with the very little money the disability allowances all provinces pay. Add in the housing crunch and there is next to nowhere for them to go.

Given their dire circumstances, can anyone blame them for escaping their reality with drugs?

So now in some cases we have sick people with no or little medical treatment, little income, dependent on illicit drugs and nowhere to call home. They congregate in lanes, parks or wherever they can find a spot. The Homeless Hub at York University estimates that 30 to 40 per cent of the homeless have a mental illness. In one international study of wealthy countries that also included substance use disorders, that number jumped to 76 per cent.

What they really need is medical care for their psychiatric ailments, rehab to get them off drugs, a proper safe place to live with the supports they need and ongoing care. And a disability allowance that is livable. Most people with disabilities in Canada live in abject poverty on minuscule allowances from their provincial governments. Ottawa’s promise to help the disabled with more money is a farce, a proposed maximum of $2,400 a year.

The argument over safe drugs and clean needles – safe supply – ignores the underlying mental health problems. But let’s be sensible. Giving clean drugs to someone with schizophrenia and an addiction will not cure the underlying schizophrenia.

Effective strategies are based on solid theories and well-designed research that proves or disproves what is being considered. Personal emotions and beliefs should not factor into decisions.

What is often suggested for addiction (safe supply) is also touted for homelessness (a place to live). That is fine but with caveats. Someone recently said in a letter to the editor of my local paper that the solution to people living in parks is to put up buildings for them. Some agencies like the Christian charity, Indwell, that I’ve written a lot about, do just that and it mostly does not work.

You cannot take people from the streets, jails and hospitals and dump them into an apartment building. Among them are addicts, traffickers, violent offenders as well as the mentally ill. Those with mental illnesses need treatment that is appropriate to their condition while those with addictions need to be weaned off their drugs. And that is only the start.

The Homes First program in Finland and other Scandinavian countries gives people homes and services. For example: “Services have been crucial,” says Jan Vapaavuori, who was Finland’s housing minister when the original scheme was launched. “Many long-term homeless people have addictions, mental health issues, medical conditions that need ongoing care. The support has to be there.”

In one housing building, for example, the 21 residents are supported by seven staff. That’s a strategy that is not cheap, but it pays dividends in cost savings and in generating improvements in human dignity. Finland spent EUR 250 million to develop housing and hire 300 support staff but saved an annual EUR 15,000 per homeless person in emergency medical care, social services and the justice system.

Most people are not familiar with another aspect of residential care that some researchers refer to as invisible institutions. There are many privately owned small units throughout Ontario, often called group homes, that provide room and board to those with physical and intellectual disabilities as well as mental illnesses. The government directly pays the private operators a certain amount for the room, food and medication management. Rarely is there any programming. Institutionalized people pay for food and basic necessities of life – like toilet paper, bus passes and Wi-Fi. Instead of accessing social assistance programs like the Ontario Disability Support Program to cover these costs – which they might be eligible for if they lived in the community – institutionalized people instead receive personal “allowances.”

These monthly allowances pass through bureaucrats, social workers, business owners and personal support workers before a disabled person living in a group home, long-term care facility or some other variation of a residential treatment facility eventually receives them. They range from $91 in Prince Edward Island to $149 in Ontario and $380 in Manitoba.

Often referred to as comfort allowances, this money pays for public transportation, toiletries, menstrual products, cigarettes and entertainment. There is little comfort to be had in the comfort allowances.

Solutions are not easy. It took years to get into this mess and it will take years to improve it – but only if we go about doing it properly and systematically. If we want to call ourselves a civilized compassionate country, we have to do it.