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A conversation with John Trainor, Jonathan Cohen, and Judith Klein
Moderator: Joanna Erdman
Recorded Nov. 12, 2018




You are listening to a recording of the Open Society Foundations, working to build vibrant and tolerant democracies worldwide. Visit us at OpenSocietyFoundations.org.



All right, so-- welcome, everyone. Thanks so much for joining us. We're-- here for Madness and Human Rights: Ideas About the Past and Future of Mental Health Treatment. My name is Joanna Erdman, and I'm the chair of the O.S.F. Public Health Program's advisory board-- and we are hosting the event tonight in honor of John Trainor-- and his many, many years of service-- on our board. So, I'll just quickly-- introduce-- fellow members who are up here at the table with me. Jonathan Cohen.



Good evening. I'm Jonathan Cohen. When I'm not on sabbatical, I direct the Public Health Program at the Open Society Foundations.



And Judy Klein.



Hi, I'm Judy Klein, and I am-- I've been at O.S.F. for over two decades-- leading the-- the work on mental health here. And-- I'm now a senior advisor to the Public Health Program.



Great. Thanks. So, I'll do a quick introduction of John and let him then take the floor. So, in 2013, John retired as the director of the Community Support and Research Unit at the Center for Addiction and Mental Health in Toronto, Canada. But through his retirement, we kept a very talented, and I would say wicked advisor. John's worked in mental health for over 40 years, including clinical work-- program planning and policy development.

He's currently the chair of Mental Health Research Canada, which promotes research funding and fellowships in the field. I'd say probably for me, it's his-- service as a policy advisor that's really proved a source of endless learning for us on-- the committee. And what I've learned most from John is the fact that there's something to be understood in everything. So-- I think I would say John says that there are always people behind any policy, and part of great advocacy is really asking not what people should do, but more asking why do they do what they do.

And so, to really engage in injustice in mental health policy not as something to be only condemned, but also to be something to be understood. So, this evening, John's going to help us explore and learn from society's past reactions to mental illness, how they can lead us-- to better treatment strategies for the future. So, John? (APPLAUSE)



Thank you. Thank you very much. And-- and I-- (CLEARS THROAT) want to thank-- the Open Society Foundations and the Public Health Program for the chance to-- to talk tonight- - and welcome everybody here. It's very nice to see you. I'm gonna make remarks and then I-- we're gonna have, I think, some responses and then time for questions and input from-- from all of you.

I do want to talk about madness and human rights. And I've always had-- a tendency to look at these things from a kind of historical perspective. If you look at the history of madness, and I-- I'm working kind of mostly in a kind of western tradition here, but if you look at the history of madness, what you do not see is an arc toward-- more humane and more enlightened treatment over the centuries. You see something that looks more like a rollercoaster.

You can find, for instance, quotes from ancient Greece-- 400 B.C. or 500 B.C., which say if somebody is showing what we would call the symptoms of mental illness, take them to a nice place, care of them, give them lots of light and air, and support them until they recover.

You can fast-forward from that, almost 2,000 years to Thomas Moore, at the time of Henry VIII-- who says people who show the signs of mental illness should be chained to a tree and the devil whipped out of them.

So, it's not-- a line of just progress and enlightenment. It's-- it's much more a mixed story than that. But I think looking at historical perspectives is-- is essential to understand-- where we are now in the treatment of people with mental illness, to use that kind of terminology, but we want to be careful about getting a little too over-confident, again, about our approaches. There was a very interesting series of studies done in the 1980s by the W.H.O. called the Pilot Studies in Schizophrenia.

And they looked at the five-year outcome for what we would call, in western society, schizophrenia. And what they found was that the best outcomes were not in our cities or where there's, you know, up-to-date treatment, hospitals, medications. The best five-year outcomes were in-- some traditional-- villages in the developing world, where they did not have the hospitals and the medications and the professionals.

What they did have tended to be a high level of social inclusion and a way of interpreting the phenomena of what-- that we call mental illness in a way that was much more positive and-- and much more respectful of people who were dealing with that. Now, here's a straightforward way of looking at the past as I'm gonna deal with it, 'cause I wanna look at two primar-- primary eras. One is the moral treatment era and the other is the era that I think we're still in, which is deinstitutionalization.

So, beginning slowly in the late 18th century, but gathering speed in the 19th, a movement called moral treatment developed. And it was really a very new way of looking at how to deal with the phenomena of mental illness in society. Earlier forms of treatment had focused on the body. And there were a variety of approaches-- which were often a bit disturbing to the modern ear. One example was the cupping and bleeding.

Cupping and bleeding was-- either drawing blood or cupping-- this is a cupping and bleeding kit you see. And it involved-- various kinds of blades and knives. And it involved cupping, where you heated the cup over a candle and then put it on the skin, with-- and sealed it on the skin. And as it cooled, it would suck the-- the skin into the cup. And it was quite painful, but it was meant to draw out humors. This is a somewhat older picture of someone in the bleeding.

And I-- if you notice the look on the patient's face, I'm thinking maybe this was a promotional (LAUGHTER) photo for-- for that particular bleeding clinic. But these-- these were all focused physically. And in that sense, how they saw mental illness is not that different from now. We have different types of theories, but we're very much focused-- some professionals anyway, on brain chemistry and other-- other-- physical features or physical factors.

Now, with moral treatment, you had a complete change because the focus became the mind or the person or the person's moral self. Complete and radical change from-- assaulting--the body. And one of the-- the famous cases that-- (CLEARS THROAT) that sort of illustrated the shift was the case of George III, king of England, known as Mad King George. He was the king of England during the American Revolution. And sometime after that, he went mad, to use the terms of the day.

And at first, they tried the old treatments. They-- they cupped him and they bled him. They almost killed him. They would rub caustic substances on his skin so it-- boils would arise, which were felt to be bringing out humors that were-- and-- and-- fluids that were detrimental to him. But then that didn't work. And it was a political crisis in England and they brought in a moral treatment-- one of the early moral treatment practitioners, named Dr. Willis, who had been a minister-- and decided-- had decided to switch to become a doctor.

And at that time, that-- what that didn't require was going to medical school. So, he-- he re-- recast himself as a doctor. And it was felt-- this actually turns out not to have been-- it's historical true, but it's not actually what-- what cured King George, and he was only cured for a certain period of time, but the moral treatment was seen to work and it therefore caught on.

Now, the moral treatment movement was really based on about four foundations. It had a new theory and a new technology. The theory was, again, you approach the mind and the moral self. The technology that was felt to express this was the asylum. So, it was an institutional expression of moral treatment, was the asylum. And remember, asylum then, and to some extent now, depending on how it's used, was a good word.

One of the earliest moral treatment-- asylums was York Retreat in England, opened in the late 18th century by William Tuke, who said he wanted it run like a well-run household, with patients living ordered lives in healthy surroundings. So, they felt they had a theory and a technology. The other driver-- another driver was the Victorian fear of mental illness. By the time you get into the Victorian period, from the 1830s on-- people are really afraid that mental illness is a-- is a growing phenomenon.

There was a lot of social change then. The Industrial Revolution was in its heyday, and there was a great deal of fear that-- that this problem had to be contained. It's-- it's-- there's some similarities to today. And it was felt we need a strategy and we have one. We have the technology and we have the asylum. There was-- a growing belief in humane care. Part of moral treatment was driven by enlightenment ideas about humane care.

But it also brought in a new kind of power. It wasn't just a story of humanitarian concern. There was a new kind of power. This is what's discussed by Michel Foucault-- years ago in his book, Madness and Civilization, and that is that, okay, we weren't going to control your body in the same way, but we are gonna use a disciplined approach and a disciplinary approach to dealing with your mind.

Now, the asylum idea was based on two things. One was their theory of what led to people being mentally ill. And what they felt at this time was that it had a lot to do with problems in the community. It's sort of the opposite of now, where we think people need to get out of institutions and into the community. They felt that the-- that-- that situations in the community created problems. And if you look at 19th century admission records to asylums, you get, and I'm quoting-- causes for admission such as loss at love-- living in squalid conditions, or political excitement.

You don't see that in Canada as much as here, but-- (LAUGHTER) there was some of it. So, it was felt that we want to bring people away from that, into a protected setting, and that's the asylum. But the asylum, itself, was also felt to be a machine for curing mental illness. And its curative potential was based on putting moral treatment principles into play.

Now, here's an example. That is an institution that was in Toronto. It opened in 1849. It's called the Lunatic Asylum of Upper Canada. I was actually in that building-- not when it opened, but-- later, when it-- when-- the year before it was torn down in the 19-- late 1970s. The moral-- treatment approach was reflected in a number of ways. The architecture had a lot of Greek features, which were felt to represent reason. It was built within sight and overlooking water, Lake Ontario, which was felt to be calming for people.

The first-- administrator of the hospital, and head of it, was Dr. Joseph Workman. He lived with his family in the center of the center block of the hospital. And it was felt that that created a moral example for the patients in the hospital and that influence would been seen directly. It was, in 1850, the largest and most expensive public building ever built in Canada. That's the degree of commitment to this kind of-- of asylum. And it was the first building actually in Toronto that had central heating and running water. So, it was considered a hightech operation and it was-- you-- you find this in other asylums, where there was not only the-- the physical plant, but there was also this spirit of it.

In Massachusetts, in an institution, they would bring patients in when it was opening, who had come from jails, where they had been essentially chained in cells, and the chains would be struck from them. At dinner, there was a great hall and the patients ate with the senior staff in the great hall every night. And they would take the patient in in his chains. They'd be struck off at the table and he would sit down and have dinner with the senior staff as a symbolic representation of his return to the human community.

So, you had some real spirit to this movement. And it's really hard to overstate how much it changed the approach. The scale at which it was bought into, I-- it was really-- to me, you can sum up with one fact, and that is in the 19th century, in Britain, they spent more money and put more resources into psychiatric hospitals than they did in the British Navy. And if you know your British (LAUGH) history, the navy there was pretty much number one. So, it was-- it was a very large commitment.

Now, when we look at moral treatment, what does it show us about rights and about what creates open society for people with mental illness? Obviously, from our perspective now, when you talk about mental institutions or mental asylums, people think of terrible conditions-- warehouses to exclude people, and that in fact is what happened to these places, but they didn't start out that way.

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