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As the big psychiatric institutions closed in the 1960s and 1970s, many of the staff followed their former patients, finding work in community mental health programs. This move created a host of new challenges. Chris Dooley gathered extensive oral histories from front-line mental health workers in Saskatchewan and Manitoba. He presents them in this exhibit, alongside his responses as an historian of psychiatric nursing. Read what the practitioners have to say about their struggles to redefine themselves in a deinstitutionalized world.
Practitioner Voices on Deinstitutionalization
This exhibit presents the recollections of front-line mental health workers from Manitoba and Saskatchewan–primarily Registered Psychiatric Nurses–of their experiences working through this period of rapid mental health reform. These reflections are excerpted from interviews conducted in connection with a much larger oral history project on psychiatric nursing in Prairie Canada. Employing my training as a historian, I aim to give voice to practitioners who were themselves deinstitutionalized, whose careers began in the 1950s and 1960s at large in-patient facilities and who later worked in community roles. This is not a well-ordered set of memories, but rather a series of recollections and personal reflections, some of which challenge commonly-held professional stereotypes and assumptions about deinstitutionalization.
Deinstitutionalization had profound effects on the lives of front-line mental health workers. As the big institutions closed in the 1960s and 1970s, many followed their former patients into the community, working as community mental health nurses, with social services agencies, or on the acute-care psychiatric wards that opened in general hospitals. These were fraught times when mental health workers faced professional and economic dislocation and uncertainty. As jobs disappeared in the old “asylum towns” many were forced to uproot their families and move elsewhere. New contexts also offered new challenges, and workers were obliged to develop different skills and approaches, to re-invent themselves as mental health care providers, and to re-examine patient-practitioner relationships.
Taking account of these dislocations helps us to see practitioners not simply as instruments of a bureaucratized health and welfare system, but as individuals implicated in complex relationships with the people and systems they served. By paying attention to their own words, we can appreciate that many imagined themselves not simply as professional caregivers, but also as protectors, allies, advocates and friends to those for whom they cared.
"I don't believe in dumping."
Although deinstitutionalization presented personal and professional challenges, most of the practitioners I interviewed embraced the goals of care in the community. One woman summed it up in seven words: “It was necessary; it was their right.” None, however, expressed no reservations about the means by which this was achieved, and this same woman, after a long, emotional pause, followed with the qualification, “But sometimes we went too far, too fast.” Most often, these reservations came from the sense that deinstitutionalization was driven by political expediency, and they condemned what they saw to be the inhumane policies and approaches taken by governments concerned primarily with cost-savings.
Closing the mental hospitals was always my ultimate goal, but I thought that it was too soon.... I think we dumped, and I don't believe in dumping.
When the big hospital emptied, the patients were thrown out and there was no machinery in place. Nothing was done for them. [They] just threw them out on the street, filled them with tranquillizers. And that generation just died.
"What’s the count this morning?"
The sense that deinstitutionalization was undertaken with scant regard for patient welfare was particularly acute among those who had worked in Saskatchewan, which had in the mid-1960s been the site of some of Canada’s earliest and most radical experiments in depopulating mental hospitals. This was especially true for practitioners who had worked at the Saskatchewan Hospital, Weyburn, an institution which, in the 1950s, had been an international beacon of progressive psychiatry. In the five years between 1963 and 1968, that institution’s in-patient population (which had peaked at over 2,500 in 1946) was reduced by more than two thirds from over 1,200 to under 400. More than four decades later, some practitioners remained palpably angry at what they remembered as a program driven by bureaucratic imperatives, not human needs.
When the superintendent used to come ‘round in the morning, he wouldn’t even say good morning to the patients. He would go straight to the nurse and say, “what’s the count this morning?” What’s the count; the count was what mattered, not the patients!
So one day the social workers would pack them up with their little bag of worldly possessions – which was nothing – and drive them and put them in a home and introduce them to the landlady and just leave them there.... This was just cruel, really.
"The work was an insult to them."
Front-line workers feared that their former patients would fare poorly; they were not adequately prepared to blend into the wider community and the community was not adequately prepared to receive them. Often patients had been hospitalized for decades and quite simply had none of the tools required for living on the outside. Few had access to meaningful employment, and for those who found jobs, the work was often menial or infantilizing, and it was a poor substitute for the genuinely responsible positions that many had held in the institutions.
Many of them didn’t even know how to use a phone or cook an egg. How could they be expected to look after themselves?
We had some very bad foster homes where patients were locked out of the house first thing in the morning and they couldn’t go back until supper time. They had no choice but to wander around all day with nothing to do.... About twenty-five would show up every morning at the acute in-patient unit [at the general hospital]. They had nothing else to do, and they needed a place to socialize. So we just kept track of their names, and we put on coffee.
I remember this one fellow, they sent him to the sheltered workshop in North Battleford where he was set to making toys. Before that, he had practically run the hospital’s dairy operation…. I remember him saying to me, “I’m a farmer; I’m not Santa Claus.” The kind of work they were given after they got out was an insult to them.
"It was more of an asylum than the asylum!"
Practitioners worried about the discrimination, the economic exploitation by foster families, and the poor material circumstances that patients faced in the community. They were also concerned that clinical care in the community was inferior and tended to be more coercive. When former patients landed in the psychiatric wards of general hospitals, for example, they encountered a ward culture that was highly regimented and demanded strict compliance with rules of decorum. General hospital staff, mindful of the expectations of public visitors and other patients and unaccustomed to psychiatric cases, were prone to respond harshly to disruptive or non-conforming behaviors. Moreover, general hospital measures of success turned on producing the “good patient”: one who embraces the sick role and submits to treatment. By this standard, illness itself could be interpreted as non-compliance, with the consequence that patients were often subject to unwarranted seclusion and restraint simply because they were incapable of adapting to unforgiving hospital routines.
Going to work at the general hospital was like stepping back in time. It was more of an asylum that the asylum! It was very regimented... and residents who acted-out had a really tough time because the [nurses] couldn’t understand when it was the illness, not the person.
In psychiatric nursing, it's about being non-threatening and treating people as equals... But at [the general hospital] I got in trouble for that kind of thing. Nurses were supposed to lord over their patients and to make them behave in certain ways. And I was there to help people get better, not to teach them manners.
[General hospital wards] were like military academies. When you have difficult people, that’s what you do, you just lower the boom on them, make it regimental. People got punished for being themselves.
"The nursing homes were often the worst."
The former mental hospital workers I interviewed observed that few physicians had the time or experience to manage complicated mental health cases and that the fee-for-service model did not produce good patient care. And while community mental health teams that comprised nurses, social workers, and psychiatrists often worked well with families and family physicians, these teams were spread-thin, and their advice was not always welcomed. A common consequence was that a large number of patients cared for by general practitioners were badly over-medicated or placed on inappropriate drug regimens. The problem of over-medication was especially acute in nursing homes, where physicians acceded to the requests of staff who were ill-equipped to manage former mental hospital patients. Several former practitioners singled out nursing homes as sites of inadequate care, noting that former patients living in these facilities were far more likely to be subject to restraint - physical and chemical - and more apt to be over-medicated than they had been in their prior institutional settings.
When the MDs took over from the psychiatrists, a lot of them really blundered.... [They] had no idea what to do, so they just wrote prescriptions. Lots of guys were really over medicated, especially in the nursing homes. Sometimes we would get a doctor who would throw up his arms and say, “Here, you know what this guy needs. Do up a medication plan for me.” But most times they’d just blunder on.
The nursing homes were often the worst. They were full of what we used to call “hidden restraint.” When they didn’t know how to handle somebody, they just gave them a sedative and stuck them in an armchair or recliner so they couldn’t get up and wander around. Then these guys would get pneumonia, and it was the staff [that] as good as killed them.
“We were pretty institutionalized ourselves”
But few practitioners with whom I spoke were nostalgic about the institutions that they had left behind. For many, the chance to work away from the old mental hospitals afforded them the opportunity for the first time to look critically at how that system produced institutionalization and chronicity. Significantly, both of these conditions were attributed by a number of former institutional workers, not just to in-patients, but also to institutional staff, and even to themselves.
The clients, they had less problem with change; it was the older staff, myself included. I guess we were pretty institutionalized ourselves. I just couldn't understand some of that back then the way I do now.
Lots of the old guys had become chronic themselves; they couldn’t adapt; some couldn’t even understand that it might be OK for patients to pour their own coffee.
I had to be de-institutionalized myself. I was stale and in a rut, so I left and sold insurance for a few years. When I came back, it was to the Saskatoon Mental Health Clinic... I'm not sure I could have gone back to the mental hospital or I would have wound-up like the old guys there.
The staff in the big hospitals really became chronic themselves. A person really burned-out and lost perspective.
"You just had to step back."
Often, the practitioners’ stories about deinstitutionalization became a professional reflection on working between two mental health worlds. They described how they came to recognize the paternalism of the asylum system and their own role in it, but also their own misgivings about the process of deinstitutionalization. On reflection, many came to see that their own expectations of patient behaviour and potential were framed by practices that cultivated and rewarded chronicity and dependency.
A lot of the old supervisors were afraid of what was going to happen to [discharged patients].... You got a protective feeling, over protective, really. And you got scared that this or that was going to happen to these people. And it probably did, but you just had to step back.
It’s about producing expected behaviours; if you create expectations of success, people rise to them. We were way too overprotective at first, too afraid that people would fail.
The hardest transition for me was from nurturing and fixing to stepping back and letting you solve your own problems. We thought that we were helping [people] by not letting them make bad decisions; in the end, the bad decision was not letting go. Letting go is the hardest part; you’ve got to let people succeed or fail on their own terms.
"Maybe that’s progress in some way."
Working in the community also helped practitioners to rethink the meanings of success and failure. While some of my interviewees were harshly critical of the new hospital psychiatric wards, they acknowledged that in the old asylums, too, success was often measured by patient compliance with therapeutic regimens and the nurses’ ability to maintain order, cleanliness and discipline. Community care meant rethinking the concept of “achievement” in cases where a patient remained socially and economically marginal or failed to maintain sanctioned standards of hygiene or comportment.
Even the ones on the street, when you saw them [on the wards] they were so doped up there was no future for them. But now you see them, they’re walking the streets,... [but] they’re talking to people.... Maybe that’s progress in some way.
"The power relations were totally different."
Insight came most often to practitioners who began their careers working in the old-line custodial institutions and who later moved into community mental health positions or into non-nursing roles with community agencies. Some recalled that it was only once both they and their former patients were established in the community that they was able to discern the fictions that masked involuntary confinement or to re-vision former patients as people. Others commented that working in the community gave them the opportunity to re-evaluate their implication role in prior regimes of paternalism and authoritarian control.
While some clients fought to remain in the hospital and continued to regard it as a refuge, most everybody wanted to get out and stay out. We used to joke and brag that the bars were there to keep the discharged patients from climbing back in the windows, but even those who struggled and had tough times seldom wanted to come back. In the end I took this as a sign that whatever kind of community we provided, for most it was never really home to them. We were fooling ourselves, I guess, but you had to believe you were doing the right thing.
You’re quite blinded when you only work with in patients. You only see a patient. Only when I became a CPN [Community Psychiatric Nurse] did I see a person.
Out in the community, the power relations were totally different. OK, they weren’t really reversed, because you still had the power, but when you went to see them, it was like you were a guest in their home. And that made a big difference.
This exhibit is based on the following article:
Chris Dooley, “‘The older staff, myself included, we were pretty institutionalized ourselves’: Authority and insight in practitioner narratives of psychiatric deinstitutionalization in Prairie Canada,” Canadian Bulletin of Medical History 29:1 (Fall 2012), 101-124.