REVIEW PAPER

The First Asylums in Canada: A Response to Neglectful Community Care and Current Trends

Sam Sussman, PhD¹

Objective: Humane treatment and care of mentally ill people can be viewed from a historical perspective. Intramural (the institution) and extramural (the community) initiatives are not mutually exclusive.

Method: The evolution of the psychiatric institution in Canada as the primary method of care is presented from an historical perspective. A province-by-province review of provisions for mentally ill people prior to asylum construction reveals that humanitarian motives and a growing sensitivity to social and medical problems gave rise to institutional psychiatry. The influence of Great Britain, France, and, to a lesser extent, the United States in the construction of asylums in Canada is highlighted. The contemporary redirection of the Canadian mental health system toward “dehospitalization” is discussed and delineated.

Results: Early promoters of asylums were genuinely concerned with alleviating human suffering, which led to the separation of mental health services from the community and from those proffered to the criminal and indigent populations. While the results of the past institutional era were mixed, it is hoped that the “care” cycle will not repeat itself in the form of undesireable community alternatives.

Conclusion: Severely psychiatrically disabled individuals can be cared for in the community if appropriate services exist.

(Can J Psychiatry 1998;43:260–264)

Key Words: asylum, dehospitalization, deinstitutionalization, community care, homelessness

The development of psychiatric provisions and services in what would become Canada in 1867 is the history of the institutionalization of mentally ill people. Perhaps surprising to some, the process of institutionalization and institutional change in the 19th and 20th centuries began with humane intentions as part of a progressive and reformist movement, which attempted to overcome neglect and suffering in the community, jails, poorhouses, and “hospitals.” Jones states that students of habitation during the asylum era indicated that “the masses were worse off than animals and that asylums provided better care than prisons or workhouses” (1, Table 1).

The development of mental illness services in Canada was largely ad hoc, and each province developed these services independently. There was some cross-fertilization of ideas between New Brunswick (NB), Nova Scotia (NS), and Prince Edward Island (PEI) with respect to asylum building in these provinces, but this phenomenon was short-lived, and institutional development in these provinces unfolded in an irregular manner. New Brunswick erected its first asylum in 1847, NS in 1857, and PEI in 1877. The development of institutional care was often influenced by the mother country, Great Britain, and, to a lesser extent, by the United States. Quebec’s institutional development, with its contracting-out system in which the King of France paid religious orders in New France to provide succour to military personnel who were mentally ill, was influenced by France’s unique colonial administrative practices. All the jurisdictions of British North America (BNA), however, shared 1 major attribute: they could all be characterized by the same general movement to provide separate and more adequate provisions for mentally ill people.  This segregated form of care, the psychiatric institution known as the asylum, was the very beginning of state provisions for mentally ill people in a vast and sparsely populated country.

The establishment of mental hospitals in Canada from the 1840s to the 1880s brought some relief to mentally ill people who had previously been placed in jails, almshouses, or who had been left to care for themselves. Throughout Canada’s early history, many mentally ill people were left to wander at will, provided that they neither endangered nor were perceived to endanger people or property. Others, who were viewed as disruptive or who elicited fear in the populace, were placed in almshouses, poorhouses, jails, and penitentiaries. This rise of institutional psychiatry in the form of asylums, while it did bring some relief to mentally ill people, also caused a considerable amount of misery for a portion of the asylum residents.

After the Treaty of Paris in 1763, the British were the unchallenged masters of what later became the Dominion of Canada. The reform movement that propagated the construction of separate institutions for mentally ill people was led by pioneering individuals who came from Great Britain (for example, the Tukes) and, to a lesser extent, from the United States (for example, Dorothea Dix). Reformists’ zeal was driven by the belief that the honour of their respective province was at stake if provisions for mentally ill people were any less than those of the mother country, Great Britain, evidenced, for example, in statements such as “a colony of England, so remarkable for its progress and intelligence as Canada . . . as existing . . . in the Montreal asylum (2), “asylum worthy of a British province” (3).

Prince Edward Island and Quebec present interesting case studies. No mental health care reformers have been identified historically with PEI. Great Britain’s poor communication with PEI and its inability to manage the affairs of that province could be viewed as a necessary condition for the “inertia” that surrounded the idea of building an appropriate asylum in that province (4). A suitable comparison, such as the construction of county asylums in Great Britain, was not recorded in PEI. Reformist zeal, which took the form of a social movement in the rest of BNA, and colonial funding were decidedly absent. Prince Edward Island did not provide institutional care until 1877, whereas NB and NS built asylums in 1847 and 1857 respectively.

Quebec, with its contracting-out system in which the state provided funding to religious orders and to physicians, in the case of proprietary hospitals, even after the British conquest of French Canada, was quite a deviation from established practice in the rest of BNA, the United States, and Great Britain. Notwithstanding this anomaly, in which the French Roman Catholic Church influenced the overall administration of psychiatric institutional life and structure, the British influence on care practices, daily asylum management, and funding moderated the differences between Quebec and the rest of Canada.

In most BNA asylums, the superintendents were British immigrants who had received their medical training in England or Scotland. Therefore, British thought and influence permeated the early beginnings of institutional care in Canada. This influence took the form of British modelling as regarded the administration, structure, and clinical treatment of mentally ill people. While there was an American influence, particularly in the Maritime provinces and especially in the person of Dorothea Dix, the British influence ran through the very fabric of early institutional care throughout BNA.

Two distinct characteristics can be extracted from the history of institutional development for mentally ill people in Canada. First, institutional provisions for mentally ill people were developed separately from services for the physically ill, indigent, and criminal populations. Second, this institutional process was wholly specialized and segregated from the community at large. The institution and the community were two separate and distinct solitudes.

The institution-building period in Canada was accomplished with little communication among the provinces. The 3 Maritime provinces originally worked together in an attempt to provide one shared institution, but this never came to fruition. The external impetus and influence regarding the nature and construction of asylums primarily took the form of provincial comparisons with Britain and the United States and with key individuals trained in or coming from these countries who were a major source of ideas and drive. One could even describe the evolution of institutions within a given province as being characterized by ad hoc processes because this institution-building period was often unplanned, and many of the provisions were improvised at the beginning (for example, converted jails and army barracks served as institutions in Ontario [ON] and Manitoba [MB]).

Despite the humane motives that drove much of the professional input for the institutionalization process, the results for the next century were very mixed. Eventually, institutionalization in Canada became a synonym for an inhumane response to mentally ill people, often because of a scarcity of resources.

The present situation contains its own contradictions, problems, and uncertainties about long-term benefits for mentally ill people. The post-World War II period in Canada and, indeed, in the western world has given rise to 2 interrelated “movements,” both of which can be seen as responses to the early period of institutionalization in which asylums very rapidly became overcrowded, custodial in nature, and countertherapeutic. The deinstitutionalization movement can be seen as a philosophical or “theoretical” reaction to the negative consequences of life in institutions. Dehospitalization was one of several policy approaches to deinstitutionalization. It can be viewed as being driven by a variety of factors, such as government parsimony and the problems of overcrowding in existing institutions. Deinstitutionalization and dehospitalization are far from synonymous, especially when dehospitalization is pursued within tight time or budgetary constraints.

In Canada, there is a redirection of the health system into community and general hospital-based alternatives. Table 2 outlines current rates of hospitalization in general hospitals and provincial psychiatric institutions.

Table 2.  The number of psychiatric beds in each Canadian province

NF = Newfoundland; PEI = Prince Edward Island; NS = Nova Scotia; NB = New Brunswick; QC = Quebec; ON = Ontario; MB = Manitoba;
SK = Saskatchewan; AB = Alberta; BC = British Columbia.
^aSource: 1994–1995 Preliminary Hospital Survey; ^bSource: 1993–1994
Annual Hospital Survey; cDerived from Annual Hospital Survey, Statistics Canada, 1996

Ontario’s goal is to have 30 beds per 100 000 people in the 21st century. The rest of Canada has also embraced the community care paradigm, with similar targets for the year 2000 and beyond. The current national average for Canada is 67.395 beds per 100 000 people (Table 3).

To date, only MB has met its community care objectives, treating many mentally ill people in residential care facilities. Some provincial regions, however, have fulfilled and even surpassed these goals. The central west region of ON, which is serviced by general hospital psychiatric beds and 1 provincial psychiatric hospital, the Hamilton Psychiatric Hospital, encompasses a catchment area population of 1.5 million and currently has 27 beds per 100 000 people.

It is hoped that sufficient community resources will qualitatively and quantitatively be developed. Before the rise of psychiatric institutions, mentally ill people in Canada only had unacceptable community alternatives in the form of the poorhouse, jail, and pauper-like institutions, such as the cholera hospital.  

In a position paper in 1981, the Canadian Psychiatric Association recommended that “a comprehensive network of services should be developed including provision for basic needs with a range of housing options”(5).  In this 16-year-old document, programming for discharged patients in the form of life-skills training, personal clinical support, and vocational assessment and training was also stressed.

In 1988 the federal government of Canada published a document titled Mental Health for Canadians: Striking a Balance. It states that in Canada, the closure of psychiatric institutions has not been offset by “strengthening community resources.” In a reference to what constitutes a comprehensive system, the document states that “deinstitutionalization has rarely been followed through in a consistent and logical way.” It states unequivocately that, because of the unequal distribution of resources exemplified by greater fiscal means allocated to institutionalized services, psychiatric patients “face a life of deprivation, danger and neglect. Some are homeless, or live in social isolation and squalor. Many are forced to rely on family caregivers who themselves have little or no access to respite or other kinds of support. Meanwhile, opportunities for promoting mental health and providing community mental health care are going largely unexploited” (6).

The inadequacy of housing provisions for discharged psychiatric patients has now entered the realm of history and is, unfortunately, still a modern-day truism. The evidence shows that deinstitutionalization is now the norm in both North America and Europe. Advances in medical and pharmacological care are making long-term hospitalization obsolete as a form of treatment. Other than in the most extreme cases, it appears that psychiatric care will be administered primarily on an outpatient basis. The increase in homelessness and an analysis of this population, however, indicates that a gap exists between deinstitutionalization, outpatient care, and community care. It must be stressed that the community is merely a background for further treatment and is not a treatment itself.

Psychiatrists today are emphasizing genetics, biochemical disorders, and complex physiological processes for the treatment of mental illness. To some health planners, mental illness is viewed as it was in the pre-1800s, primarily as a social rather than a medical problem. Emphasizing either the social or medical aspects of mental illness is bound to bring about only a partial solution to the misery inherent in mental illness. Partnership in service and provision is essential.

Community care should be about providing adequate treatment and not only about the closure of mental hospitals. This should not be a war between community care and institutional treatment. Treatment of a biopsychosocial nature is what matters, not whether the treatment is intramural or extramural. The careful selection of patients to be placed in community living and 24-hour availability of professional help are indispensable ingredients for successful programs (7).

Bureaucratic indifference to inadequate funding, legislative indifference to untreated psychotic behaviour, and the lack of compliance with treatment plans where violence is an issue, do much to reinforce hostility toward community care (8). Health planners cannot and must not be oblivious to society’s responsibility for the treatment of the vulnerable mentally ill population.

As we judge the period of institutional expansion, future generations will judge the era of community care, dehospitalization, and deinstitutionalization with reference to its outcomes and consequences, not to its good intentions.

Acknowledgements

The author thanks Professor Adrian Webb, Vice-Chancellor, University of Glamorgan, Pontypridd, Wales, United Kingdom, and Dr Cyril Nair, Chief of Health Statistics, Statistics Canada, Ottawa, Ontario, Canada.

References

1. Jones K. The culture of the mental hospital. In: 150 years of British history 1841–1991. London: Gaskell; 1991. p 17–28.

2. Tuke DH. The insane in the United States and Canada. London: Lewis HK; 1885. p 200.

3. Colonial Record Office. Correspondence from H Bell. Great Britain: April 15, 1847.

4. MacKinnon F. The government of Prince Edward Island. Toronto: University of Toronto Press; 1951.

5. Watt JA, el-Guebaly N. The chronic mental patient. Ottawa (ON): Canadian Psychiatric Association [CPA]; May 1981. Position Paper nr 1981–7. 8 p. Available from: CPA, 260–441 MacLaren Street, Ottawa, ON K2P 2H3.

6. Epp J, editor. Mental health for Canadians: striking a balance. Ottawa: Ministry of National Health and Welfare; 1988.

7. Stein L. Creating change: a case study. In: Dean C, Freeman H, editors. Community mental health care: international perspectives on making it happen. London: Gaskell; 1993. p 18–34.

8. Torrey F. Violent behaviour by individuals with serious mental illness. Hospital and Community Psychiatry 1994;45:653–62.

Résumé

Objectif : On peut aborder le traitement et les soins humains des personnes souffrant de troubles mentaux d’un point de vue historique. Les initiatives intramurales (l’établissement) et extramurales (la collectivité) ne s’excluent pas les unes les autres.

Méthode : L’évolution de l’établissement psychiatrique au Canada en tant que première méthode de soins est présentée dans une optique historique. Une étude par province de la prestation de soins à l’intention des personnes souffrant de troubles mentaux, avant la construction d’asiles, révèle que des motifs humanitaires ainsi que la sensibilisation grandissante aux problèmes d’ordre social et médical ont donné naissance à la psychiatrie institutionnelle. On souligne l’influence de la Grande-Bretagne, de la France et, dans une moindre mesure, des États-Unis en ce qui concerne la construction d’asiles au Canada. On aborde aussi la question de la réorientation des services de santé mentale au Canada vers la désinstitutionnalisation.

Résultats : Les premiers défenseurs des asiles désiraient véritablement soulager la souffrance humaine. C‘est ainsi que les services de santé mentale ont été isolés de la collectivité et des services prodigués aux populations criminelles ou indigentes. Si les résultats de l’époque de l’institutionnalisation sont partagés, on espère que le cycle de soins ne se répétera pas sous forme de solutions communautaires indésirables.

Conclusion : On peut traiter les personnes souffrant de troubles mentaux graves dans la collectivité, pourvu que celle-ci puisse offrir les services appropriés.

Manuscript received April 1997, revised and accepted August 1997.

¹Assistant Professor, Department of Psychiatry, University of Western Ontario, London, Ontario; Director of Archives, London Psychiatric Hospital, London, Ontario.

Address for correspondence: Dr S Sussman, London Psychiatric Hospital, 850 Highbury Avenue, PO Box 2532, London, ON N6A 4H1

Can J Psychiatry, Vol 43, April 1998