Arts, Faculty of
Anthropology, Department of
DSpace
UBCV
Gordon, Robert Macaire
Doctor of Philosophy - PhD
University of British Columbia
A survey and analysis of Canadian statutes and cases affecting the management of the mentally disordered demonstrates that this area of law has experienced several periods of reform since 1900. In the early 1900's, legislation was characterized by 'limited legalism'. Governments subsequently eased, removed, and then re-imposed forms of judicial and quasi-judicial supervision over the activities of medical practitioners, and the periods of reform are referred to as 'medicalization', 'enhanced medicalization', and the 'new legalism'. The law reforms are associated with changes in state strategies for the management of the mentally disordered, and the relationship between these reforms and changes, the state, structural conditions (e.g., shifts in economic policy), and human agency (e.g., the work of reformers) is explored through an analysis of the emergence of 'enhanced medicalization' in the 1950's/60's, and the rise of the 'new legalism' in the 1970's/80's. This includes a detailed case study of shifts in strategy and the process of law reform in the province of British Columbia. This component of the research involved an analysis of documentary and archival materials, and the structuralist theoretical trajectory within the neo-Marxist sociology of state and law is utilized to explain the changes. Enhanced medicalization was an integral part of a strategy involving de-institutionalization, an abandonment of segregated confinement, and the use of community-based resources integrated with the health care component of a Keynesian, 'welfare state'. Institutions were seriously over-crowded, ineffective, expensive, and discredited, and the emergence of social assistance and other features of the welfare state enabled the development of alternatives. The conditions were favourable to the efforts of a group of reformers that was an auxiliary part of the state apparatus; namely, the Canadian Mental Health Association. The latter constructed a strategy and supporting legislation which advanced the interests of psychiatry and resolved the state's order maintenance and legitimation problems in a manner consistent with welfare state expansion. Economic difficulties and changes which began to emerge in the 1970's created new problems for the state, and cost-stabilization and restraint measures were imposed throughout the politically sensitive health care field. The strategy for the management of the mentally disordered consequently shifted to, in particular, accelerated de-institutionalization aimed at hospital closure. In order to facilitate and legitimate the shift, the state has adopted reforms proposed by the patients' rights movement and, despite the objections of organized psychiatry, introduced legislation which limits the use of hospitals and erodes medical domination (i.e., the new legalism). The contributions to the sociologies of social control, state and law are discussed and the convergence of these fields is identified. The implications for the neo-Marxist theoretical research programme are examined.
MENTAL DISORDER, LAW, AND STATE: SOCIOLOGICAL ANALYSIS OF THE PERIODS OF REFORM CANADIAN MENTAL HEALTH LAW By ROBERT MACAIRE GORDON B.A. (Hons.)/ La Trobe U n i v e r s i t y , 1979 M.A. (Crim.)/ Simon Fr a s e r U n i v e r s i t y , 1981 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n THE FACULTY OF GRADUATE STUDIES (Department of Anthropology and Sociology) We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA October 1988 © Robert Macaire Gordon, 1988 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of J^TftgMH'OfrV Sc> t (6 io y / The University of British Columbia Vancouver, Canada Date Ocroge£ l| DE-6 (2/88) ABSTRACT A s u r v e y and a n a l y s i s of C a n adian s t a t u t e s and c a s e s a f f e c t i n g the management of the mentally d i s o r d e r e d demonstrates that t h i s area of law has experienced s e v e r a l p e r i o d s of reform s i n c e 1900. In the e a r l y 1900's, l e g i s l a t i o n was c h a r a c t e r i z e d by ' l i m i t e d l e g a l i s m 1 . Governments subsequently eased, removed, and then r e - i m p o s e d forms of j u d i c i a l and q u a s i - j u d i c i a 1 s u p e r v i s i o n over the a c t i v i t i e s of medical p r a c t i t i o n e r s , and the p e r i o d s of r e f o r m a r e r e f e r r e d to as ' m e d i c a l i z a t i o n ' , 'enhanced m e d i c a l i z a t i o n 1 , and the 'new l e g a l i s m ' . The law r e f o r m s are a s s o c i a t e d w i t h changes i n s t a t e s t r a t e g i e s f o r the management of the mentally d i s o r d e r e d , and the r e l a t i o n s h i p between these reforms and changes, the s t a t e , s t r u c t u r a l c o n d i t i o n s (e.g., s h i f t s i n economic p o l i c y ) , and human agency (e.g., the work of reformers) i s e x p l o r e d through an a n a l y s i s of the emergence of 'enhanced m e d i c a l i z a t i o n ' i n the 1950's/60's, and t h e r i s e o f t h e 'new l e g a l i s m ' i n t h e 1970's/80's. T h i s i n c l u d e s a d e t a i l e d case study of s h i f t s i n s t r a t e g y and the p r o c e s s of law r e f o r m i n the p r o v i n c e of B r i t i s h Columbia. T h i s component of the r e s e a r c h i n v o l v e d an a n a l y s i s of documentary and a r c h i v a l m a t e r i a l s , and the s t r u c t u r a l i s t t h e o r e t i c a l t r a j e c t o r y w i t h i n the n e o - M a r x i s t s o c i o l o g y of s t a t e and law i s u t i l i z e d to e x p l a i n the changes. Enhanced m e d i c a l i z a t i o n was an i n t e g r a l part of a s t r a t e g y i n v o l v i n g d e - i n s t i t u t i o n a l i z a t i o n , an abandonment of segregated confinement, and the use of community-based resources i n t e g r a t e d i i w i t h the h e a l t h care component of a Keynesian, 'welfare state'. I n s t i t u t i o n s were s e r i o u s l y o v e r - c r o w d e d , i n e f f e c t i v e , e x p e n s i v e , and d i s c r e d i t e d , and the emergence of s o c i a l a s s i s t a n c e and other f e a t u r e s of the w e l f a r e s t a t e enabled the development of a l t e r n a t i v e s . The c o n d i t i o n s were favourable to the e f f o r t s of a group of reformers that was an a u x i l i a r y p a r t of the s t a t e a p p a r a t u s ; namely, the C a n adian M e n t a l H e a l t h A s s o c i a t i o n . The l a t t e r c o n s t r u c t e d a s t r a t e g y and supporting l e g i s l a t i o n which advanced the i n t e r e s t s of p s y c h i a t r y and r e s o l v e d the state's order maintenance and l e g i t i m a t i o n problems i n a manner c o n s i s t e n t with w e l f a r e s t a t e expansion. Economic d i f f i c u l t i e s and changes which began to emerge i n the 1970's c r e a t e d new p r o b l e m s f o r the s t a t e , and c o s t -s t a b i l i z a t i o n and r e s t r a i n t measures were imposed throughout the p o l i t i c a l l y s e n s i t i v e h e a l t h care f i e l d . The s t r a t e g y f o r the management of the mentally d i s o r d e r e d consequently s h i f t e d to, i n p a r t i c u l a r , a c c e l e r a t e d d e - i n s t i t u t i o n a l i z a t i o n aimed a t h o s p i t a l c l o s u r e . In o r d e r t o f a c i l i t a t e and l e g i t i m a t e the s h i f t , the s t a t e has adopted reforms proposed by the p a t i e n t s ' r i g h t s movement and, d e s p i t e the o b j e c t i o n s of o r g a n i z e d p s y c h i a t r y , i n t r o d u c e d l e g i s l a t i o n which l i m i t s the use of h o s p i t a l s and e r o d e s m e d i c a l d o m i n a t i o n ( i . e . , t h e new l e g a l i s m ) . The c o n t r i b u t i o n s to the s o c i o l o g i e s of s o c i a l c o n t r o l , s t a t e and law are d i s c u s s e d and the convergence of these f i e l d s i s i d e n t i f i e d . The i m p l i c a t i o n s f o r the neo-Marxist t h e o r e t i c a l r e s e a r c h programme are examined. i i i TABLE OF CONTENTS Ab s t r a c t i i L i s t of Tables i x L i s t of F i g u r e s x Acknowledgements x i Chapter 1. I n t r o d u c t i o n : Mental Health Law, and State S o c i a l C o n t r o l S t r a t e g i e s . 1 I: I n t r o d u c t i o n . 1 I I : Mental Health Law Reform: The Rise of the 'New Legalism'. 6 The 'New Legalism': A D e f i n i t i o n . 13 I n i t i a l E x p l a n a t i o n s f o r the Rise of the 'New Legalism'. 15 I I I : Mental D i s o r d e r , Law, and S t a t e : An I n t r o d u c t i o n to the T h e s i s . 24 Endnotes. 31 Chapter 2. From L i m i t e d Legalism to M e d i c a l i z a t i o n : Changes i n Strat e g y and Law - 1900 to 1939. 35 I: I n t r o d u c t i o n . 35 I I : The Law and the Management of Insane and L u n a t i c Persons i n the E a r l y 1900*s. 37 The Imperial Lunacy Act, 1890: The Epitome of 'Legalism'. 41 The Impact of Legalism i n Canada. 46 Summary. 58 I I I : The Dec l i n e of 'Limited Legalism' and the Rise of ' M e d i c a l i z a t i o n ' . 60 Changes i n St r a t e g y and L e g i s l a t i o n : 1919 -1939. 63 Summary. 71 i v Endnotes. 75 Chapter 3. The Enhancement of M e d i c a l i z a t i o n and The Rise of the New Legalism; Changes i n S t r a t e g y and Law - 1950's to 1980's. 87 I: I n t r o d u c t i o n . 87 I I : The Law and the Management of the M e n t a l l y D i s o r d e r e d i n the 1950's and 1960's: The Emergence of Enhanced M e d i c a l i z a t i o n . 90 The Saskatchewan Mental Health Act, 1961 and The Emergence of Enhanced M e d i c a l i z a t i o n . 93 Summary. 103 I I I : The Law and the Management of the M e n t a l l y Disordered i n the 1970's and 1980's: The Rise of the 'New Legalism'. 106 The Rise of the 'New Legalism' i n Canada: S t a t u t o r y Reforms. 107 The Rise of the New Legalism i n Canada: TheRole o f the Courts. 127 Summary. 131 Endnotes. 138 Chapter 4. T h e o r i e s of Legal Change and Mental Health Law Reform. 155 I: I n t r o d u c t i o n . 155 I I : E x p l a n a t i o n s Focussing Upon Developments Within Mental Health Systems. 163 I I I : E x p l a n a t i o n s Focussing Upon the Impact of I n d i v i d u a l Reformers and I n t e r e s t Groups. 173 IV: E x p l a n a t i o n s Focussing Upon S t r u c t u r a l Developments and the Role of the State i n a C a p i t a l i s t S o c i e t y . 196 V: P u b l i c Scandals and E x c e p t i o n a l Changes to the Legal Form: A d d i t i o n a l F a c t o r s A f f e c t i n g Mental Health Law Reform i n Canada. 226 VI: A Summary and Framework For a Comprehensive E x p l a n a t i o n of Mental Health Law Reform i n Canada. 231 Endnotes. 239 v Chapter 5. The Emergence of Enhanced M e d i c a l i z a t i o n . 2 40 I: I n t r o d u c t i o n . 240 I I : The Advent of the Canadian Welfare State and the Problems With the Management of the Mentally D i s o r d e r e d . 242 The C r i s i s i n the Management of the M e n t a l l y D i s o r d e r e d : The Case of B r i t i s h Columbia. 246 I I I : D e - I n s t i t u t i o n a l i z a t i o n and the S h i f t to Community Care and Treatment: The New S t r a t e g y f o r the Management of the Mentally D i s o r d e r e d . 265 The ' T o t a l Push' f o r D e - i n s t i t u t i o n a l i z a t i o n : The Development of the New Str a t e g y i n B r i t i s h Columbia. 267 The Impact of the New S t r a t e g y . 279 The Entrenchment of the Long-Term S t r a t e g y : The Ross Report on Mental Health S e r v i c e s i n B r i t i s h Columbia. 291 IV: The Role of the Canadian Mental Health A s s o c i a t i o n i n E n g i n e e r i n g Reforms. 297 The Tyhurst Committee Reports. 300 The O r i g i n s of the Ideas and the C o n d i t i o n s Favourable to Reform. 307 The Canadian Mental Health A s s o c i a t i o n and The S t a t e . 311 The Canadian Mental Health A s s o c i a t i o n and The Quest f o r I n t e g r a t i o n . 318 V: The C o n s t r u c t i o n of a New Legal Framework: The Emergence of 'Enhanced M e d i c a l i z a t i o n ' . 325 The Emergence of Enhanced M e d i c a l i z a t i o n i n B r i t i s h Columbia. 330 VI: The Emergence of 'Enhanced M e d i c a l i z a t i o n ' : An E x p l a n a t i o n . 348 Endnotes. 358 v i Chapter 6. The Rise of The 'New Legalism'. I: I n t r o d u c t i o n . I I : Economic Problems, The Attack on the Welfare S t a t e , and the Impact Upon the Strat e g y f o r the Management of the Mentally D i s o r d e r e d . Adjustments i n the Keynesian Economic S t r a t e g y and the Impact Upon the Welfare S t a t e . The Impact Upon the St r a t e g y f o r the Management of the Mentally D i s o r d e r e d i n Canada. I l l : The St r a t e g y f o r the Management of the Me n t a l l y Disordered, The Impact of Economic Changes, and the Rise of the New Legalism i n B r i t i s h Columbia. The Management of the Me n t a l l y D i s o r d e r e d During the 1960's and 1970's. The Impact of Economic Problems. C o s t - S t a b i l i z a t i o n , The Cumming Report on P r o v i n c i a l Mental Health Care, and the Rise of the New Legalism. IV: The Canadian P a t i e n t s ' Rights Movement and the Rise of the New Legalism. The Emergence of a P a t i e n t s ' Rights Movement i n B r i t i s h Columbia. The P a t i e n t s ' Rights Movement and the S t a t e . V: The C o n f l i c t With Organized P s y c h i a t r y . The State Response: Appeasement, L i m i t a t i o n and the New Legalism. VI: The Rise of the New Legalism: An E x p l a n a t i o n . Endnotes. Chapter 7. Mental D i s o r d e r , Law, and S t a t e : The General T h e o r e t i c a l I m p l i c a t i o n s . I: I n t r o d u c t i o n . I I : T h e o r e t i c a l I m p l i c a t i o n s For the S o c i o l o g y of S o c i a l C o n t r o l . v i i I l l : The C o n t r i b u t i o n to and I m p l i c a t i o n s f o r Neo-Marxist Theory i n the S o c i o l o g y of the State and Law. IV: F u r t h e r Research. V: The Law and the C o n t r o l of the Mentally D i s o r d e r e d Future D i r e c t i o n s . Endnotes. Appendix I : Methodology. B i b l i o g r a p h y . v i i i LIST OF TABLES Table 2.1: Procedures A f f e c t i n g Insane Persons i n Canada: 1900. 59 Table 2.2: Procedures A f f e c t i n g M e n t a l l y Diseased Persons i n Canada: 1939. 73 Table 3.1: Procedures A f f e c t i n g M e n t a l l y 111 Persons i n Canada: 1972. 104 Table 3.2: Procedures A f f e c t i n g M e n t a l l y 111 Persons i n Canada: 1987. 133 Table 4.1: Dominant Trends i n the S t r a t e g y and L e g i s l a t i o n A f f e c t i n g M e ntally D i s o r d e r e d Persons i n Canada: 1900 - 1987. 156 i-x LIST OF FIGURES Figure 5.1: The R e l a t i v e Autonomy o f , and Connections Between, The L e v e l s of the S t a t e , and Components of the Canadian Mental Health A s s o c i a t i o n . 356 Figure 6.1: The R e l a t i v e Autonomy o f , and Connections Between, The L e v e l s of the State and I n t e r e s t Groups. 499 x ACKNOWLEDGEMENTS The r e s e a r c h f o r and p r e p a r a t i o n of t h i s t h e s i s would not have been p o s s i b l e without the guidance, a s s i s t a n c e and support of many people. I am indebted to my s e n i o r s u p e r v i s o r - Dr. Bob Ratner - f o r h i s e x a c t i n g and trenchant c r i t i c i s m of my work at a l l stages. The f i r s t d r a f t of the t h e s i s was m o n o l i t h i c and Drs. Yunshik Chang and N e i l Guppy p r o v i d e d the g u i d a n c e necessary to produce a more co n c i s e and cogent f i n a l product. Dr. Simon Verdun-Jones was t i r e l e s s i n h i s s u p p o r t and I am g r a t e f u l f o r h i s constant and h e l p f u l c r i t i c i s m of the way i n which I r e a d , a n a l y s e d and p r e s e n t e d the law. Dr. Douglas Cousineau provided encouragement and t i m e l y a n a l y t i c a l i n s i g h t s . F i n a l l y , I w i s h t o thank my u n i v e r s i t y e x a m i n e r s (Drs. John Hogarth, Nancy Waxier-Morrison, and Robert Hare) and e x t e r n a l examiner (Dr. Andrew S c u l l ) f o r t h e i r c h a l l e n g i n g comments and suggestions f o r f u t u r e work. V a r i o u s f o r m s o f a s s i s t a n c e were p r o v i d e d by Dave M a c A l i s t e r , A l i s o n Hatch, Lynda F l e t c h e r , Raj S a n t i n i , P a t r i c i a R a t e l and Nola J o n e s . I thank them f o r t h e i r e f f o r t s . The r e s e a r c h would not have been p o s s i b l e w i t h o u t the i n v a l u a b l e g u i d a n c e and i n v o l v e m e n t of the f o l l o w i n g : the s t a f f o f the Woodward B i o - M e d i c a l and Law L i b r a r i e s a t the U n i v e r s i t y of B r i t i s h C o l u m b i a ; i n d i v i d u a l members o f , and o r g a n i z a t i o n s w i t h i n , the C a n adian p a t i e n t s ' r i g h t s movement; numerous p s y c h i a t r i s t s and s o c i a l workers; the p r o v i n c i a l p u b l i c t r u s t e e s and t h e i r s t a f f ; and, s e v e r a l s e n i o r p r o v i n c i a l government employees. The c o n t r i b u t i o n s were made o v e r the c o u r s e of s e v e r a l years and I am immensely g r a t e f u l f o r the time, energy and i n t e r e s t . F i n a l l y , I wish to thank the members of the Izaak Walton K i l l a m Memorial F e l l o w s h i p Committee f o r awarding a two year, P r e - D o c t o r a l F e l l o w s h i p . T h i s was a great honour and provided the f i n a n c i a l support necessary f o r the conduct of the research. x i CHAPTER 1 INTRODUCTION; MENTAL HEALTH LAW^ AND STATE SOCIAL CONTROL STRATEGIES l£_ INTRODUCTION In the p a s t decade, a new approach t o the H o b b e s i a n problem of s o c i a l o r d e r has been e v i d e n t i n two, g r a d u a l l y converging r e s e a r c h programmes. S e v e r a l s o c i o l o g i s t s and s o c i a l h i s t o r i a n s have s p e a r h e a d e d a s h i f t from a c o n c e r n w i t h questions of 'order' (the focus of s t r u c t u r a l - f u n c t i o n a l i s m ) to questions of 'control', and they have sought to e x p l i c a t e both the o r i g i n s and the c h a n g i n g n a t u r e of s t a t e s o c i a l c o n t r o l s ystems and s t r a t e g i e s . T h i s has c o i n c i d e d w i t h a s e p a r a t e i n q u i r y i n t o the nature and r o l e of both the s t a t e and s p e c i f i c a s p e c t s of the s t a t e ' s s o c i a l c o n t r o l a p p a r a t u s i n advanced c a p i t a l i s t s o c i e t i e s . A group of s o c i a l h i s t o r i a n s - the s o - c a l l e d ' r e v i s i o n i s t h i s t o r i a n s of s o c i a l c o n t r o l ' - has explored the emergence and impact of the n i n e t e e n t h century, t r i p a r t i t e system of s o c i a l c o n t r o l i n Europe and N o r t h A m e r i c a (see, e.g., S c u l l , 1979; Rothman, 1971, 1980; I g n a t i e f f , 1978). 1 The e n t e r p r i s e r e s t s upon a foundation provided by the l a t e M i c h e l Foucault (1965), and the a n a l y s t s have examined both the r i s e o f , and the connections between, the p e n i t e n t i a r y , asylum, and workhouse s y s t e m s . These networks of i n s t i t u t i o n s were i n t r o d u c e d t o s e g r e g a t e and r e g u l a t e t h r e e groups of ' s o c i a l d e v i a n t s ' ; namely, c r i m i n a l s , l u n a t i c s , and i n d i g e n t s . The t r i p a r t i t e 1 system was the b a s i s upon which the c o n t e m p o r a r y s y s t e m s of s o c i a l c o n t r o l are b u i l t and some s o c i o l o g i s t s have i n i t i a t e d a major e x p l o r a t i o n of both the nature and scope of these systems and the causes and f u t u r e d i r e c t i o n of changing s o c i a l c o n t r o l s t r a t e g i e s (see, e.g., S c u l l , 1984; Warren, 1981; Cohen, 1985). The p r o j e c t has i n v o l v e d a. r e v i s i o n of the c o n v e n t i o n a l image of s o c i a l c o n t r o l as an a c t i v i t y l y i n g s o l e l y w i t h i n the domain of c r i m i n a l j u s t i c e . A broader and more accurate v i s i o n has been d e v e l o p e d and t h i s encompasses a l l the f o r m a l and i n f o r m a l s y s t e m s and n e t w orks of c o n t r o l t h a t e x i s t i n a s o c i e t y , many of which can be subsumed under the heading of the ' w e l f a r e s t a t e ' . S o c i a l w e l f a r e , h e a l t h , and e d u c a t i o n s e r v i c e s a r e v i e w e d as c o n t r a d i c t o r y phenomena. On the one hand, these components of the welfare s t a t e ensure the e q u i t a b l e and humanitarian d i s t r i b u t i o n of b e n e f i t s and s e r v i c e s ; on the other hand, they serve to l e g i t i m i z e the s t a t e , f a c i l i t a t e the p r o c e s s of c a p i t a l a c c u m u l a t i o n , and c o n t r o l the p o p u l a t i o n (see, e.g., Gough, 1979). A s i m i l a r image has been developed i n the case of the i n f o r m a l s y s t e m s or networks of c o n t r o l ; notably, the f a m i l y (see, e.g., Donzelot, 1979; Cohen, 1985). The burgeoning i n t e r e s t i n t h i s t o p i c i s due, i n p a r t , to the p i o n e e r i n g e f f o r t s of two s o c i o l o g i s t s - Andrew S c u l l (1984) and P a u l Lerman (1982). These i n d i v i d u a l s have a n a l y s e d the emergence and impact of a major s h i f t i n contemporary s o c i a l c o n t r o l s t r a t e g y ; namely, the p r o c e s s of ' d e c a r c e r a t i o n 1 , or ' d e - m s t i t u t i o n a l i z a t i o n ' . The work has spawned a number of s t u d i e s f o c u s s e d upon the n a t u r e , causes and i m p act of o t h e r 2 c l o s e l y r e l a t e d s t r a t e g i e s ; notably, n o n - i n s t i t u t i o n a l i z a t i o n , t r a n s - i n s t i t u t i o n a l i z a t i o n , and p r i v a t i z a t i o n (see, e.g., Warren, 1981).^ State s t r a t e g i e s f o r the management of those whom S p i t z e r (1975) r e f e r s to as ' s o c i a l junk' (e.g., mentally d i s o r d e r e d p e o p l e ) and ' s o c i a l d y n a m i t e 1 (e.g., young a d u l t o f f e n d e r s ) are c h a n g i n g d r a m a t i c a l l y and t h i s p r o c e s s i s m a n i f e s t i n , f o r example, the c l o s u r e of v a r i o u s p u b l i c i n s t i t u t i o n s w h i c h f o r m e r l y h o u s e d ' s o c i a l j u n k ' . The i n s t i t u t i o n s i n c l u d e l a r g e mental h o s p i t a l s , homes f o r the i n f i r m e l d e r l y , and t r a i n i n g s c h o o l s f o r the d e v e l o p m e n t a l l y d i s a b l e d . The c l o s u r e of p u b l i c i n s t i t u t i o n s i s accompanied by the p i e c e m e a l development of a v a r i e t y of 'community-based' a l t e r n a t i v e s and, s i n c e these i n c l u d e s m a l l e r i n s t i t u t i o n s and f a c i l i t i e s owned and o p e r a t e d by p r i v a t e i n d i v i d u a l s and companies, the c h a n g i n g o w n e r s h i p of the s o c i a l c o n t r o l a p p a r a t u s ( i . e . , p r i v a t i z a t i o n ) has a l s o become a f o c u s of i n q u i r y (see, e.g., Warren, 1981). The e f f o r t s o f those i n v o l v e d i n the ' s o c i a l c o n t r o l ' r e s e a r c h programme have c o n v e r g e d w i t h a n o t h e r a r e a o f s o c i o l o g i c a l i n q u i r y ; namely, a n - a n a l y s i s of the nature and r o l e of the s t a t e i n advanced c a p i t a l i s t c o u n t r i e s . ^ This programme has encompassed not only a debunking and r e f o r m u l a t i o n of the p l u r a l i s t conception of the s t a t e but a l s o an e x p l o r a t i o n of the nature and r o l e of v a r i o u s f e a t u r e s of the s t a t e apparatus such as the ' w e l f a r e s t a t e ' , the c r i m i n a l j u s t i c e system, and the l e g a l s y s t e m ( s e e , e.g., R a t n e r & M c M u l l a n , 1987). The programme i s a t t r a c t i n g s o c i o l o g i s t s concerned with a range of 3 s u b s t a n t i v e i s s u e s and t h e s e i n c l u d e s o c i o l o g i s t s of law. Indeed, the development of a coherent s o c i o l o g y of the s t a t e has provided a f r e s h impetus f o r the s o c i o l o g y of law, an area which had e x p e r i e n c e d few, i f any, t h e o r e t i c a l advances s i n c e the c o n t r i b u t i o n s of Weber and Durkheim (Hunt, 1978) and that had, i n s t e a d , been l a r g e l y pre-occupied with the s o c i a l e n g i n e e r i n g o b j e c t i v e s of l i b e r a l r e f o r m e r s (see, e.g., B e i r n e & Quinney, 1982) . The g r a d u a l c o n v e r g e n c e of those i n t e r e s t e d i n s o c i a l c o n t r o l and those i n t e r e s t e d i n the s t a t e may be detected i n a number of a r e a s . In h i s c e l e b r a t e d s t u d y of d e c a r c e r a t i o n Andrew S c u l l (1984) a c c o u n t s f o r the s h i f t i n s o c i a l c o n t r o l s t r a t e g y by r e f e r e n c e t o a key c o n c e p t employed by some s o c i o l o g i s t s of the s t a t e ; namely, the ' f i s c a l c r i s i s of the state'. T h i s concept has been u t i l i z e d and r e f i n e d i n s t u d i e s of, f o r example, ' t r a n s c a r c e r a t i o n ' (see, e.g., Lowman, et a l , 1988). S i m i l a r l y , the concepts and concerns of those w i t h i n the ' s o c i a l c o n t r o l ' r e s e a r c h programme have sur f a c e d i n the work of s t a t e t h e o r i s t s (see, e.g, Fine, et a l . , 1979) and a p o t e n t i a l l y f r u i t f u l union i s developing. The convergence i s of s i g n i f i c a n c e f o r the s o c i o l o g y of law p a r t i c u l a r l y where a n a l y s t s focus upon the emergence and a p p l i c a t i o n of laws which have a d i r e c t bearing upon the formal systems of s o c i a l c o n t r o l . Systems such as c r i m i n a l j u s t i c e and m ental h e a l t h a r e e s t a b l i s h e d and r e g u l a t e d by law and, e x p l a n a t i o n s f o r the emergence and a p p l i c a t i o n of such laws at 4 any p a r t i c u l a r h i s t o r i c a l juncture may be found i n the f a c t o r s which a f f e c t the changing s t r a t e g i e s of c o n t r o l . A change i n , f o r example, mental h e a l t h l e g i s l a t i o n , may be e x p l a i n e d by r e f e r e n c e to both a c h a n g i n g s t r a t e g y f o r the management of ' s o c i a l junk' and the f a c t o r s which underpin a development of t h i s kind. T h i s t h e s i s b r i d g e s the two r e s e a r c h programmes and c o n t r i b u t e s to t h e i r convergence. The o b j e c t i v e i s to d e s c r i b e and e x p l a i n the changing nature of the laws governing the system f o r the management of m e n t a l l y d i s o r d e r e d p e r s o n s i n Canada. Consequently, while the t o p i c i s approached from the p e r s p e c t i v e of a s o c i o l o g y of law i n f o r m e d by s t a t e t h e o r y , the a n a l y s i s cannot be d i v o r c e d from the i s s u e of c h a n g i n g s o c i a l c o n t r o l s t r a t e g i e s . S i n c e the l a t e 1970's, the d e l i v e r y of mental h e a l t h s e r v i c e s i n advanced c a p i t a l i s t c o u n t r i e s such as Canada has been c h a r a c t e r i z e d by a p r o c e s s of r a p i d d e - i n s t i t u t i o n -a l i z a t i o n , n o n - i n s t i t u t i o n a l i z a t i o n , and p r i v a t i z a t i o n (see, e.g., M a r s h a l l , 1982; Lightman, 1986). Large mental h o s p i t a l s are being 'phased out' i n favour of 'community-based resources' and p a t i e n t s are b e i n g d i s c h a r g e d to t h e s e a l t e r n a t i v e s . A s t r a t e g y of n o n - i n s t i t u t i o n a l i z a t i o n i s i n p l a c e and the admission of p a t i e n t s to h o s p i t a l s i s becoming more d i f f i c u l t . At the same time, evidence of p r i v a t i z a t i o n can be found i n the growth of p r i v a t e s e c t o r r e s i d e n t i a l f a c i l i t i e s and resources f o r mental h e a l t h p a t i e n t s ( S o c i a l Planning C o u n c i l of Metro-p o l i t a n Toronto, 1984). The changes i n s t r a t e g y are accompanied by major reforms 5 to mental h e a l t h l e g i s l a t i o n r e f e r r e d to as the 'new l e g a l i s m ' and, as t h i s t h e s i s w i l l demonstrate, the two developments are i n t e r l o c k e d . New mental h e a l t h l a w s have been i n t r o d u c e d by p r o v i n c i a l governments i n o r d e r to f a c i l i t a t e and j u s t i f y a s h i f t i n s t r a t e g y and the state's adoption of t h i s t a c t i c w i l l be explored i n d e t a i l . At the outset, however, i t i s of value to u n d e r s t a n d the n a t u r e and scope of the 'new l e g a l i s m ' ; the t e n t a t i v e e x p l a n a t i o n s w h i c h have been o f f e r e d f o r i t s emergence; and, the a p p a r e n t l i n k s w i t h s t a t e s o c i a l c o n t r o l s t r a t e g i e s . l i t MENTAL HEALTH LAW REFORM; THE RISE OF THE 'NEW LEGALISM' A m a j o r r e c o n s t r u c t i o n o f C a n a d i a n m e n t a l h e a l t h l e g i s l a t i o n has been underway s i n c e the 1970's. S i g n i f i c a n t reforms have been made to the mental h e a l t h s t a t u t e s of A l b e r t a , Nova S c o t i a , O n t a r i o and New Bru n s w i c k and new s t a t u t e s have been e n a c t e d i n Saskatchewan and the Northwest T e r r i t o r i e s . 5 Some key changes have been made to the B r i t i s h Columbia Mental Health Act and the Mental Health Act Regulations, and f u r t h e r r e f o r m s are imminent.^ Reforms have been recommended f o r Newfoundland and the Yukon T e r r i t o r y ( M i n i s t r y of H e a l t h : Newfoundland, 1983; Verdun-Jones & Gordon, 1985). Within the l a s t few y e a r s , i t has been p r o p o s e d t h a t f u r t h e r e x t e n s i v e changes be made to the A l b e r t a , Mental Health Act ( M i n i s t r y of S o c i a l S e r v i c e s and Community Health: A l b e r t a , 1983) and a new Mental Health B i l l was presented to the L e g i s l a t i v e Assembly i n March 1987.^ A new Mental Health B i l l '.was a l s o i n t r o d u c e d to the M a n i t o b a l e g i s l a t u r e i n the S p r i n g of 1987 8 and, i n Nova 6 S c o t i a , mental h e a l t h l e g i s l a t i o n i s , once again, under review (Kaiser, 1986). F i n a l l y , the Uniform Law Conference of Canada has formed a 'Mental Health Law Project', charged with the task of d e v e l o p i n g a 'model' mental h e a l t h s t a t u t e t h a t can be a p p l i e d i n t e r - p r o v i n c i a l l y (Savage & McKague, 1987). As a r e s u l t of the e f f o r t s of mental h e a l t h law advocates, some Canadian co u r t s have been c o n t r i b u t i n g to reform. In some provinces, the p r o v i s i o n s of mental h e a l t h s t a t u t e s have been i n t e r p r e t e d i n a way t h a t s u p p o r t s a c e n t r a l theme of the l e g i s l a t i v e changes; namely, the establishment or expansion of p a t i e n t s ' r i g h t s . T h i s has been p a r t i c u l a r l y e v i d e n t i n B r i t i s h C o l u m b i a , O n t a r i o , M a n i t o b a , and P r i n c e Edward I s l a n d . ^ i n a d d i t i o n , j u r i s p r u d e n c e w hich has d e v e l o p e d i n the a r e a of a d m i n i s t r a t i v e law - notably, the d o c t r i n e of ' f a i r n e s s ' - has had a marked impact in the mental h e a l t h law f i e l d i n s o f a r as t h i s d o c t r i n e has e s t a b l i s h e d the 'rules of conduct' f o r mental h e a l t h r e v i e w boards (Jones & De V i l l a r s , 1985; R o b e r t s o n , 1987) . More r e c e n t l y , the i s s u e of g u a r d i a n s h i p f o r m e n t a l l y d i s a b l e d a d u l t s who are r e c e i v i n g c a r e and t r e a t m e n t i n community s e t t i n g s , has r e c e i v e d a t t e n t i o n . An i n n o v a t i v e s t a t u t e (The Dependent A d u l t s Act) and a s s o c i a t e d system of p u b l i c g u a r d i a n s h i p has been i n o p e r a t i o n i n A l b e r t a s i n c e December, 1978 (Robertson, 1987).^® A s i m i l a r s t a t u t e has been propo s e d f o r Saskatchewan and the Yukon T e r r i t o r y w h i l e , i n Manitoba, Newfoundland, O n t a r i o and Quebec, i n t e r - m i n i s t e r i a l 7 c o m m i t t e e s a r e c u r r e n t l y e x a m i n i n g t h e i s s u e o f a d u l t g u a r d i a n s h i p w i t h a view to i n t r o d u c i n g major changes (Law Reform Commission of Saskatchewan, 1981; Verdun-Jones & Gordon, 1985; Gordon, et a l , 1986; Robertson, 1987). It i s a n t i c i p a t e d that, w i t h i n the next f i v e years, each of these p r o v i n c e s and the Yukon T e r r i t o r y w i l l have enacted new l e g i s l a t i o n and that t h i s w i l l be i n f l u e n c e d by the model provided by A l b e r t a . In an a l l i e d d e v e l o p m e n t , s e v e r a l p r o v i n c e s ( i . e . , M a n i t o b a , Saskatchewan, and Nova Sc o t i a ) have r a t i o n a l i z e d t h e i r p u b l i c t r u s t systems by i n t r o d u c i n g the o f f i c e of the P u b l i c Trustee, an agency t h a t p l a y s a c e n t r a l r o l e i n a d u l t g u a r d i a n s h i p p r i m a r i l y by p r o t e c t i n g the a s s e t s of m e n t a l l y d i s a b l e d p e r s o n s . H In g e n e r a l , the p r o p o s e d and a c t u a l r e f o r m s s t r e s s the f o l l o w i n g changes: ( i ) The e s t a b l i s h m e n t of s t r i c t c r i t e r i a which must be met before a person can be i n v o l u n t a r i l y admitted to, and c o n f i n e d i n , a mental h e a l t h f a c i l i t y . ( i i ) A r e d u c t i o n i n the p e r i o d s o f time d u r i n g which an i n v o l u n t a r y p a t i e n t can be con f i n e d , without f u r t h e r examination and c e r t i f i c a t i o n , and the p l a c e m e n t of s t r i c t l i m i t s on the p r a c t i c e of a l t e r i n g the s t a t u s of a v o l u n t a r y p a t i e n t , whenever such an i n d i v i d u a l seeks to be discharged from a mental h e a l t h f a c i l i t y c o n t r a r y to the op i n i o n of a medical p r a c t i t i o n e r . ( i i i ) The ban n i n g or s t r i c t r e g u l a t i o n of c e r t a i n forms of treatment (notably, psychosurgery), where a person does not or cannot give consent to such treatment. ( i v ) A s p e c i f i c a t i o n of the c r i t e r i a which must be met when making d e c i s i o n s about a p a t i e n t ' s c a p a c i t y t o c o n s e n t t o treatment or h i s / h e r competency to manage an e s t a t e . (v) The s p e c i f i c a t i o n of the l e g a l , e q u a l i t y , and other r i g h t s of a l l persons admitted to mental h e a l t h f a c i l i t i e s . ( v i ) A change i n the membership, powers and d u t i e s of mental h e a l t h r e v i e w boards i n o r d e r t o ; (a) s t r e n g t h e n the 'due 8 p r o c e s s ' r i g h t s of mental h e a l t h p a t i e n t s who c h a l l e n g e the d e c i s i o n s of m e d i c a l p r a c t i t i o n e r s ; (b) e n s u r e t h a t the f u n d a m e n t a l p r i n c i p l e s of j u s t i c e s e t out i n the Canadian Charter of Rights and Freedoms are respected; and, (c) extend the mandates of boards i n t o areas of incompetency and treatment decision-making. ( v i i ) The p r o v i s i o n of a r i g h t to a p p e a l the d e c i s i o n s of mental h e a l t h review boards to the c o u r t s . ( v i i i ) The e s t a b l i s h m e n t of advocacy schemes f o r mental h e a l t h p a t i e n t s . (ix) The c o n s t r u c t i o n of s p e c i a l s t a t u t e s to provide f o r the guardianship of the persons and e s t a t e s of those deemed to be incapable of taking care of themselves and t h e i r a f f a i r s , and the i n t r o d u c t i o n of ' f u n c t i o n a l ' , r a t h e r than medical, t e s t s of competency. The reforms which have a f f e c t e d Canadian mental h e a l t h law have a l s o emerged i n many B r i t i s h Commonwealth and United States j u r i s d i c t i o n s , as w e l l as some European c o u n t r i e s ; notably, the Netherlands and I t a l y (Curran & Harding, 1978; Gordon & Verdun-/Jones, 1986; Beis, 1984; MIND, 1981; Bean, 1983; Sedgwick, 1982; B r a k e l , e t a l , 1985). In the B r i t i s h Commonwealth, new l e g i s l a t i o n has been introduced i n the A u s t r a l i a n s t a t e s of New South Wales, Western A u s t r a l i a , South A u s t r a l i a , V i c t o r i a , Q ueensland, and The N o r t h e r n T e r r i t o r y ( O ' S u l l i v a n , 1981; C a m p b e l l , 1 9 8 3 ) . 1 3 M e n t a l h e a l t h and a l l i e d l e g i s l a t i o n i s under review i n New Zealand. In each of these j u r i s d i c t i o n s , the new l e g i s l a t i o n r e f l e c t s the kinds of changes introduced i n Canada, a l t h o u g h t h i s i s most pronounced i n New South Wales (Verdun-Jones, 1985). In a c l o s e l y connected development, the s t a t e s of New South Wales, South A u s t r a l i a , Q u e e nsland and V i c t o r i a have a l s o introduced new procedures f o r arranging and managing the guardianship of d i s a b l e d a d u l t s and t h e i r e s t a t e s (op c i t ) . 1 4 9 Major reforms have been in t r o d u c e d i n B r i t a i n where the kinds of changes which have appeared i n Canada were int r o d u c e d w i t h the proclamation of the England and Wales Mental Health (Amendment) A c t , 19 82 (now c o n s o l i d a t e d i n the M e n t a l H e a l t h Act, 1983) (Carson, 1983; Whitehead, 1982; Hoggett, 1984; Gost i n , 1983a). The s t a t u t e marked the c u l m i n a t i o n of a decade of v i g o r o u s debate l e d by the N a t i o n a l A s s o c i a t i o n f o r M e n t a l Health (MIND), and the o r g a n i z a t i o n i s now t u r n i n g i t s a t t e n t i o n to the i s s u e s of pers o n a l g u a r d i a n s h i p and e s t a t e p r o t e c t i o n f o r mentally or developmentally d i s a b l e d a d u l t s ; p a r t i c u l a r l y , those who are r e c e i v i n g care and treatment i n the community (Gostin, 1977; 1979; 1983a; 1983b). In the United States, mental h e a l t h law reform began to progress s t e a d i l y during the 1970's in response to the e f f o r t s of c i v i l r i g h t s , p u b l i c i n t e r e s t , and l e g a l a i d lawyers. T h e i r a c t i v i t i e s were focussed p r i m a r i l y upon l i m i t i n g the powers of mental h e a l t h p r o f e s s i o n a l s , r e s t r i c t i n g the use of i n v o l u n t a r y commitment, improving c o n d i t i o n s i n mental h e a l t h f a c i l i t i e s , p u r s u i n g n o n - i n s t i t u t i o n a 1 t r e a t m e n t a l t e r n a t i v e s , and e s t a b l i s h i n g and p r o t e c t i n g the fundamental r i g h t s and l i b e r t i e s of mental h e a l t h p a t i e n t s (Warren, 1982; B e i s , 1984; Wexler, 1981; B r a k e l , et a l , 1985). In many c a s e s , a d v o c a t e s i n v o k e d the U n i t e d S t a t e s C o n s t i t u t i o n as the b a s i s f o r change, and many f e d e r a l c o u r t s have f a v o u r e d t h e e s t a b l i s h m e n t o f p a t i e n t s ' r i g h t s on c o n s t i t u t i o n a l grounds (Friedman, 1979; Beis, 1984; Bra k e l , et 10 a l , 1985). These have i n c l u d e d : the r i g h t to r e c e i v e treatment i n the l e a s t r e s t r i c t i v e s e t t i n g ; the r i g h t to r e c e i v e treatment i f i n v o l u n t a r i l y committed, or to be r e l e a s e d i n the absence of t r e a t m e n t ; the r i g h t t o due p r o c e s s p r i o r t o i n v o l u n t a r y commitment; and, the r i g h t to r e f u s e c e r t a i n forms of treatment, p a r t i c u l a r l y where such treatment could be regarded as u n u s u a l l y i n t r u s i v e or hazardous (Parry, 1984; B e i s , 1984). 1 5 The United S t a t e s Supreme C o u r t has y e t t o e n d o r s e t h e s e r i g h t s u n e q u i v o c a l l y ( P a r r y , 1984), a l t h o u g h most s t a t e s have n e v e r t h e l e s s r e v i s e d t h e i r mental h e a l t h s t a t u t e s i n order to b r i n g them i n l i n e w i t h the d e c i s i o n s of the lower c o u r t s and the l e g i s l a t i v e examples s e t by c e r t a i n j u r i s d i c t i o n s . For example, C a l i f o r n i a ' s Lanterman-Petris-Short A c t , 1 6 considered by many to be a model s t a t u t e and a 'Magna Carta' f o r p a t i e n t s ' r i g h t s , has been p a r t l y a d o pted i n a number of o t h e r s t a t e s (Morris, 1978; Beis, 1984). W h i l e r e f o r m i s s t i l l o c c u r r i n g i n the U n i t e d S t a t e s , p a r t i c u l a r l y i n r e l a t i o n to the r i g h t to refuse treatments such as e l e c t r o c o n v u l s i v e therapy (Parry, 1984), there are s i g n s that the p r o c e s s may be s l o w i n g down. Indeed, some a n a l y s t s are suggesting that a more 'conservative' posture i s emerging and that t h i s i n v o l v e s a s i g n i f i c a n t capping, i f not a r e v e r s a l , of some of the gains of p a t i e n t s ' r i g h t s advocates ( E l p e r s , 1987; Durham & La Fond, 1987). The scope of, and r e a s o n s f o r , t h i s development have yet to be c l e a r l y d e l i n e a t e d but i t i s apparent that the process of reform reached something of a peak in the e a r l y 1980's when the United S t a t e s Congress passed the Mental 11 H e a l t h Systems A c t . 1 1 T h i s s t a t u t e i n c l u d e d a recommended ' P a t i e n t s ' B i l l of R i g h t s ' which r e f l e c t e d the r e s u l t s of a decade of mental h e a l t h law reform i n the United S t a t e s (Beis, 1984). I t i s of v a l u e , t h e r e f o r e , t o l i s t t h e s e r i g h t s i n summary form. B r i e f l y , the recommended r i g h t s are as f o l l o w s : The r i g h t t o r e c e i v e t r e a t m e n t i n a s e t t i n g t h a t s u p p o r t s pe r s o n a l l i b e r t y and i s the l e a s t r e s t r i c t i v e of l i b e r t y . The r i g h t to an i n d i v i d u a l i z e d treatment plan and the p e r i o d i c review of the plan. The r i g h t to p a r t i c i p a t e i n treatment d e c i s i o n s . The r i g h t not to r e c e i v e treatment i n the absence of consent, except i n an emergency or where d i r e c t e d by a court. The r i g h t not to be subjected to experimental treatment, without consen t . The r i g h t to freedom from r e s t r a i n t or s e c l u s i o n , other than i n an emergency. The r i g h t to a humane treatment environment. The r i g h t to c o n f i d e n t i a l i t y i n r e l a t i o n to medical records. The r i g h t to o b t a i n a c c e s s to p e r s o n a l r e c o r d s , e x c e p t under s p e c i f i e d circumstances. The r i g h t , i f a d m i t t e d t o an i n s t i t u t i o n , t o p r i v a t e c o m m u n i c a t i o n w i t h o t h e r s by m a i l , t e l e p h o n e or v i s i t a t i o n , except under s p e c i f i e d circumstances. The r i g h t to be informed promptly of one's r i g h t s . The r i g h t to a s s e r t grievances and to have these heard. The r i g h t to e x e r c i s e r i g h t s without r e p r i s a l . The r i g h t to r e f e r r a l t o mental h e a l t h p r o f e s s i o n a l s , on discharge from a f a c i l i t y . These r i g h t s complement those a l r e a d y e s t a b l i s h e d and a f f e c t i n g the procedures i n v o l v e d i n a d m i t t i n g a person to an 12 i n s t i t u t i o n as an i n v o l u n t a r y p a t i e n t ; that i s , the r i g h t to due process before l i b e r t y i s removed or withheld. They are a l s o supported by the development of s p e c i a l advocacy s e r v i c e s f o r those detained i n i n s t i t u t i o n s (Friedman, 1979; Beis, 1984). In the United S t a t e s , a t t e n t i o n i s now being focussed upon other mental h e a l t h i s s u e s such as competency, guardianship of the person, and c o n s e r v a t o r s h i p of the e s t a t e . T h i s s h i f t i n emphasis i s connected to growing concerns about the impact of the p o p u l a t i o n aging process and the need to undertake the r a p i d development of new systems and procedures to meet the needs of the i n c r e a s i n g numbers of d i s a b l e d e l d e r l y persons (Schmidt, et a l , 1981; La France, 1982). It i s a l s o connected to the need to f i n d a l t e r n a t i v e ways of managing those who are m e n t a l l y or d e v e l o p m e n t a l l y d i s a b l e d and who have been d i s c h a r g e d from i n s t i t u t i o n s f o l l o w i n g the a d o p t i o n of a s t r a t e g y of de-i n s t i t u t i o n a l i z a t i o n ( M o r r i s , 1980; Warren, 1981; A p o l l o n i & Cooke, 1984; S c u l l , 1981; Mahar, 1980; Massad & Sales, 1981). The 'New Legalism': A D e f i n i t i o n The c u r r e n t p e r i o d of mental h e a l t h law reform i s r e f e r r e d to as the 'new l e g a l i s m ' , a term coined by Gostin (1983c; 1983d) i n o r d e r to both d e s c r i b e the c o n t e n t of new l e g i s l a t i o n and u n d e r s c o r e the s i m i l a r i t i e s between the p r e s e n t wave of law reform and a p e r i o d of lunacy law reform that occurred i n 19th century England. The l a t t e r culminated i n the passage of the I m p e r i a l , Lunacy A c t , 1 8 9 0 1 8 and t h i s s t a t u t e had a p r o f o u n d impact upon the procedures and systems f o r d e a l i n g with mentally d i s o r d e r e d p e r s o n s i n many B r i t i s h c o l o n i e s and Dominions, 13 , i n c l u d i n g Canada ( S t r o n g , 1983; K i r b y , 1981). There a r e , however, some s i g n i f i c a n t d i f f e r e n c e s between the o l d I m p e r i a l s t a t u t e and the new l e g a l i s m . The 'new l e g a l i s m ' may be viewed as embodying a mode of l e g a l r e g u l a t i o n that i s q u i t e d i s t i n c t i v e i n nature from the t r a d i t i o n a l l e g a l formalism underpinning the lunacy laws of the l a t e 19th century, although i t bears some s i m i l a r i t i e s to those e a r l i e r laws. The l a t t e r encompassed a set of p r i n c i p l e s which l i m i t e d the use of c o m p u l s o r y powers i n the management of l u n a t i c s and insane persons by imposing s t r i c t l e g a l c o n t r o l s on the process of commitment and the management of those c o n f i n e d i n i n s t i t u t i o n s . However, i t was, i n e s s e n c e , both ' n e g a t i v e ' and ' r e a c t i v e ' , b e i n g more c o n c e r n e d w i t h r e g u l a t i o n than p o s i t i v e 'activism' i n the i n t e r e s t s of the r e s i d e n t s of p u b l i c and p r i v a t e asylums (Gostin, 1983c; 1983d). W h i l e the 'new l e g a l i s m ' i n v o l v e s the r e s t o r a t i o n of c o n t r o l s on the a c t i v i t i e s of mental h e a l t h p r o f e s s i o n a l s , i t does not d i c t a t e the c o n s t r u c t i o n of a cumbersome l e g a l framework or the use of t e c h n i c a l , l e g a l procedures. Instead, i t r e f l e c t s an approach that embodies a c e n t r a l r o l e f o r law and l e g a l a c t i v i s m i n p r o v i d i n g , e f f e c t i v e h e a l t h s e r v i c e s f o r p a t i e n t s (e.g., by a r t i c u l a t i n g a ' r i g h t to t r e a t m e n t ' ) ; e f f e c t i v e f a c i l i t i e s and r e s o u r c e s f o r m e n t a l h e a l t h p r o f e s s i o n a l s ; and, p r o t e c t i o n s a g a i n s t u n j u s t i f i e d d e p r i v a t i o n s of l i b e r t y through the i m p o s i t i o n of l i m i t s on the p r a c t i c e s of mental h e a l t h p r o f e s s i o n a l s (e.g., i n the areas of compulsory 14 admission and treatment). In a d d i t i o n , both the r e s t o r a t i o n of the c i v i l s t a t u s of p a t i e n t s (e.g., through enfranchisement) and the p r e v e n t i o n of d i s c r i m i n a t i o n are important o b j e c t i v e s (op c i t ) . G o s tin contends, that . . . i t i s i m p o r t a n t to r e m a i n v i g i l a n t to any a t t e m p t by t h e l e g a l p r o f e s s i o n t o e r e c t a s u p e r s t r u c t u r e o f t e c h n i c a l p r o c e d u r e s o r cumbersome l e g a l r e g u l a t i o n s ; nor s h o u l d the d i s c r e t i o n of lawyers and c o u r t s be s u b s t i t u t e d f o r that of mental h e a l t h p r o f e s s i o n a l s on matters of t r e a t m e n t . The modern f u n c t i o n of law...does not u surp the f u n c t i o n of c a r i n g p r o f e s s i o n a l s . I t seeks to a l t e r s o c i a l p e r c e p t i o n s of the mental h e a l t h s e r v i c e s , which should place an emphasis on the p e r s o n d i s t r e s s e d and not on the c o n c e r n s of s o c i e t y or the p r o f e s s i o n (1983c: 66 - 67). Where the use of the p o l i t i c a l p r o c e s s f a i l s t o r e s u l t i n e f f e c t i v e s e r v i c e s , l e g a l a c t i v i s m (e.g., the p u r s u i t of a r i g h t to treatment) becomes a v i a b l e a l t e r n a t i v e and, f o r G o s t i n , t h i s i s a c e n t r a l p r i n c i p l e of the 'new l e g a l i s m 1 embodied i n the England and Wales, Mental Health Act, 1983. I n i t i a l E x p l a n a t i o n s For The Rise of the 1 New Legalism' A debate focussed upon both the impact and the causes of the 'new l e g a l i s m ' i s g r a d u a l l y emerging. However, the impact of t h i s t r e n d i s u n c l e a r (e.g., the e x t e n t to which i t has produced more e f f e c t i v e s e r v i c e s ) and the e x p l a n a t i o n s of i t t e n d to be s u p e r f i c i a l ; f o r example, no a t t e m p t has y e t been made to f o r g e a l i n k between the c u r r e n t e r a of r e f o r m and c h a n g i n g s t a t e s t r a t e g i e s f o r the management of m e n t a l l y d i s o r d e r e d persons. The d e v e l o p m e n t s i n B r i t a i n have been a s s e s s e d by some w r i t e r s . S h apland & W i l l i a m s (1983) have argued t h a t the 15 reforms may not r e f l e c t the major s w i t c h i n emphasis suggested by G o s t i n . Indeed, they contend t h a t the new l e g i s l a t i o n i s m e r e l y an e x e r c i s e i n ' t i n k e r i n g 1 and t h a t the p s y c h i a t r i c p e r s p e c t i v e continues to dominate the procedures r e l a t e d to the d e l i v e r y of mental h e a l t h s e r v i c e s . T h i s view i s s h a r e d by Carson (1983), who argues t h a t the new s t a t u t e i s m e r e l y ' s y m b o l i c ' and i s u n l i k e l y to have any r e a l e f f e c t on the management of m e n t a l l y d i s o r d e r e d p e o p l e . Jones (1980) has argued that i n c r e a s e d l e g a l involvement i n mental h e a l t h systems i s c o u n t e r - p r o d u c t i v e , t h a t m e n t a l h e a l t h s e r v i c e s need more resources (rather than more law), and that the c u r r e n t e f f o r t s of the modern ' D i c e y i s t s ' of the p a t i e n t s ' r i g h t s movement are merely reproducing l e g a l f o r m a l i s m . H o w e v e r , s i n c e the impact of the s t a t u t e has yet to be thoroughly assessed, the extent to which i t a f f e c t s both p a t i e n t s and p r o f e s s i o n a l s l i e s i n the realm of s p e c u l a t i o n . Gordon & Verdun-Jones (1986) have s u g g e s t e d t h a t the reforms which have occurred i n Canada, A u s t r a l i a , and B r i t a i n are concerned l e s s w i t h l i m i t i n g p r o f e s s i o n a l d i s c r e t i o n and more with r e s t r i c t i n g both the extent to which p a t i e n t s can gain access to p u b l i c mental h e a l t h s e r v i c e s and the l e n g t h of time a p a t i e n t can spend as a r e s i d e n t i n a mental h e a l t h f a c i l i t y . They have argued, f o r example, t h a t the ' r i g h t to r e c e i v e treatment' has not r e c e i v e d l e g i s l a t i v e endorsement whereas the 'right to r e f u s e treatment', and other r i g h t s which l i m i t r a t h e r than expand the p r o v i s i o n of p u b l i c mental h e a l t h s e r v i c e s , are being embraced e n t h u s i a s t i c a l l y by governments. In t h e i r view, 16 the reforms are connected c l o s e l y with the economics of mental h e a l t h s e r v i c e s but t h i s c l a i m i s not explored f u r t h e r . F o r G o s t i n (1983c, 1983d), the 'new l e g a l i s m ' i s a m a n i f e s t a t i o n of the ' i d e o l o g y of e n t i t l e m e n t ' ; t h a t i s , the idea that, . . . s e r v i c e s s h o u l d be p r o v i d e d , as a r i g h t , a ccording to the needs of the person and not at the d i s c r e t i o n of the p r o f e s s i o n a l ; a person's consent should be the o p e r a t i v e f a c t o r and not what others f e e l would be i n the i n d i v i d u a l ' s b e s t i n t e r e s t ; and the r e c e i p t of s e r v i c e s s h o u l d be f o r the b e n e f i t o f t h e p e r s o n and n o t t o p r o v i d e an a u t o m a t i c r a t i o n a l e f o r s o c i e t y to d i m i n i s h the c i v i l and s o c i a l s t a t u s of the i n d i v i d u a l (Gostin, 1983c: 50). The o r i g i n s and i m p l i c a t i o n s of t h i s ideology are not e x p l a i n e d ; however, i n a recent c r i t i c i s m of the fundamental p r i n c i p l e s and a s s u m p t i o n s which u n d e r p i n G o s t i n ' s p o s i t i o n , one a n a l y s t -N i k o l a s Rose - has i d e n t i f i e d a s i g n i f i c a n t r o o t . Rose (1985) argues that the 'ideology of e n t i t l e m e n t ' i s d e r i v e d from the p e r s p e c t i v e s and arguments of those who, i n the 1960's and 1970's, were i n v o l v e d i n l e g a l a c t i v i s m aimed at s o c i a l welfare reform; an e n t e r p r i s e i n s p i r e d by Charles Reich's concept of 'new property' (Reich, 1964). The 'patients' r i g h t s movement 1 and a t t e n d a n t i d e o l o g y i s thus an e x t e n s i o n of the complex 'poverty law' and l e g a l a i d movements which have developed throughout North America and the B r i t i s h Commonwealth o v e r the p a s t twenty y e a r s . A l t h o u g h i t i s c l a i m e d t h a t the c o n c e p t of ' e n t i t l e m e n t ' s u p p o r t s an e f f e c t i v e s t r a t e g y ( i t transforms ' p r i v i l e g e s ' i n t o ' r i g h t s ' and hence strengthens the p o s s i b i l i t y of o b t a i n i n g e f f e c t i v e s e r v i c e s by l e g a l means), 17 t h i s has not proved to be the case. For Rose, t h i s i s because, i n the mental h e a l t h context, the ideology i s based upon a set of f a l s e premises. P a r t i c u l a r p r o b l e m s l i e w i t h t h e c o n t e n t i o n t h a t p s y c h i a t r y i s a n o n - s c i e n t i f i c branch of medicine which has been r e c r u i t e d u n w i t t i n g l y as an instrument of s o c i a l c o n t r o l . In Rose's view, t h i s i s not the c ase; p s y c h i a t r y i s no l e s s ' s c i e n t i f i c ' than any other branch of medicine and i t s c o n t r o l f u n c t i o n i s i l l u s o r y . In a d d i t i o n , other b a s i c assumptions of t h o s e a d v o c a t i n g ' p a t i e n t s ' r i g h t s ' are a l l e g e d to be e q u a l l y f a l s e ; namely, the s a n c t i t y of i n d i v i d u a l r i g h t s and l i b e r t i e s , and the b e l i e f t h a t m e n t a l h e a l t h r e v i e w t r i b u n a l s are an e f f e c t i v e way of p r o t e c t i n g the i n d i v i d u a l . The c o n c e p t of ' r i g h t s and l i b e r t i e s ' i s b u i l t upon a m y t h i c a l ' i n d i v i d u a l ' "invented by Western s o c i a l and p o l i t i c a l d i s c o u r s e " (op c i t : 203) and l i b e r t a r i a n s have n e g l e c t e d t o r e c o g n i z e t h e fundamental need to "weigh up the choice between a sho r t p e r i o d of ' c o e r c i o n ' l e a d i n g to a l o n g p e r i o d of 'autonomy', and r a d i c a l n o n - i n t e r v e n t i o n l e a d i n g to a l i f e permanently at the mercy of the f a t e s " (op c i t : 204). M e n t a l h e a l t h r e v i e w t r i b u n a l s do n o t r e g u l a t e p r o f e s s i o n a l d e c i s i o n - m a k i n g e f f e c t i v e l y , and the i n t r o d u c t i o n of more ' l e g a l i s m ' i n the t r i b u n a l context w i l l not change t h i s s i t u a t i o n . Rose a r g u e s t h a t the advancement of the ' i d e o l o g y of e n t i t l e m e n t ' has not c o n t r i b u t e d to the development of improved mental h e a l t h s e r v i c e s . Indeed, he suggests that the e n t e r p r i s e " i s i m p o t e n t when i t comes to d e b a t i n g or s e c u r i n g p o s i t i v e 18 p o l i c y a l t e r n a t i v e s " (op c i t : 210). Instead, i t has c o n t r i b u t e d to the ' m o d e r n i z a t i o n of p s y c h i a t r y ' . I t has f a c i l i t a t e d , the a b s o r p t i o n and a c c e p t a n c e of p s y c h i a t r y w i t h i n the s p h e r e of general medicine; a r e d u c t i o n i n the use of i n s t i t u t i o n s ; and, the advancement of community treatment a l t e r n a t i v e s , however i n a d e q u a t e these may be. In t h i s r e g a r d , i t i s e s s e n t i a l to r e c o g n i z e t h e p o l i t i c a l b e n e f i t s w h i c h a r i s e f r o m t h i s d e velopment. In s h o r t , i t i s n e c e s s a r y to c o n s i d e r the ' p o l i t i c s of r i g h t s ' ; t h at i s , the p o l i t i c a l gains which can be made by u t i l i z i n g ' r i g h t s ' as the j u s t i f i c a t i o n f o r a s h i f t i n p o l i c y . As he argues, The language of r i g h t s d i s g u i s e s a s o c i a l judgment and a p o l i t i c a l s t r a t e g y - to curb the p r o f e s s i o n a l powers of p s y c h i a t r y and hence reduce the r o l e of the i n s t i t u t i o n s c o n t r o l l e d by the p s y c h i a t r i c p r o f e s s i o n . To f o r w a r d s u c h a s t r a t e g y by a p p e a l i n g t o a r i g h t , a p p e a r s t o remove t h e n e c e s s i t y f o r the b a s i s and i m p l i c a t i o n s of t h i s judgment to be argued out (op c i t : 212). Rose does not set out the reasons why the need f o r such a ' p o l i t i c a l s t r a t e g y ' has a r i s e n ; he does not, f o r example, forge a l i n k between the state's endorsement of r i g h t s , changes i n the s t r a t e g i e s f o r managing m e n t a l l y d i s o r d e r e d p e r s o n s , and the f a c t o r s which u n d e r p i n these changes. In f o c u s s i n g upon the ' p o l i t i c s of r i g h t s ' he has n e g l e c t e d to c o n s i d e r , f o r example, the 'economics of r i g h t s ' . However, he does h i n t a t b o t h the s i g n i f i c a n c e of the economic f a c t o r s s u g g e s t e d by Gordon & V e rdun-Jones (1986) and the i s s u e of c h a n g i n g s o c i a l c o n t r o l s t r a t e g i e s : The a p p e a l t o r i g h t s t h u s s u b s t i t u t e s l e g a l r h e t o r i c f o r p o l i t i c a l argument, and grounds an 19 a t t e m p t t o s h i f t p o w e r s f r o m th e p o l i t i c a l apparatus to the l e g a l apparatus; p a r a d o x i c a l l y , i t d e - p o l i t i c i s e s the d e b a t e o v e r p r i o r i t i e s in the a l_l_o£a_t i_o n o f £ £ £ ° u r ere s_ a_n d o v e r d^£f_e_r e_n_t mechanisms of s o c i a l r e g u l a t i o n (op c i t : 213) (emphasis added). Thus, f o r some a n a l y s t s , the 'new l e g a l i s m ' i s seen as an outgrowth of the c i v i l l i b e r t a r i a n and l e g a l a i d movements of the 1960's. Indeed, i t i s a measure of the s u c c e s s of the members of one i n t e r e s t group; namely, the l a w y e r s and o t h e r a d v o c a t e s who form the ' p a t i e n t s ' r i g h t s movement'. T h i s i n t e r e s t group fought s u c c e s s f u l l y to have i t s p e r c e p t i o n s of a p a t i e n t ' s 'best i n t e r e s t s ' accepted by s t a t e policy-makers and l e g i s l a t o r s , even though the m a t e r i a l consequences may not have been those which were o r i g i n a l l y sought. A c l a s h of p e r c e p t i o n s r e g a r d i n g what i s r e a l l y i n a p a t i e n t ' s 'best i n t e r e s t s ' can be t r a c e d to the emergence of the 'new l e g a l i s m ' i n the e a r l y 1970's. Those a d v o c a t i n g the i m p o s i t i o n of s t r i c t e r c o n t r o l s on the work of m e n t a l h e a l t h p r o f e s s i o n a l s do so i n the f i r m b e l i e f t h a t an i n d i v i d u a l ' s r i g h t to l i b e r t y i s of paramount importance. I t i s contended t h a t the p r a c t i c e of p s y c h i a t r y i s i m p r e c i s e and t h a t mental h e a l t h p r o f e s s i o n a l s should not be given the power to deprive mentally d i s o r d e r e d persons of t h e i r l i b e r t y on the s o l e b a s i s that they can be t r e a t e d . The blanket i m p o s i t i o n of treatment has dominated the d e l i v e r y of mental h e a l t h s e r v i c e s f o r many decades and has not r e s u l t e d i n the s u c c e s s f u l t r e a t m e n t of p a t i e n t s . Indeed, i t has r e s u l t e d i n many abuses; such as, the ' w a r e h o u s i n g ' o f i n d i g e n t and ' i n c u r a b l e ' p e r s o n s , th e 20 w i d e s p r e a d use of h a r m f u l t r e a t m e n t s , and i n a p p r o p r i a t e c o n f i n e m e n t . In the view of many c i v i l l i b e r t a r i a n s , i t has been necessary, t h e r e f o r e , to l i m i t the 'therapeutic orgy' which has a r i s e n as a consequence of the removal of l e g a l c o n t r o l s on the work of mental h e a l t h p r o f e s s i o n a l s (Weisstub, 1980; Toews, et a l , 1980; Warren, 1982; Anand, 1979; Stone, 1976; 1979; Bradley & C l a r k e , 1976; Kopolow & Bloom, 1977; Roth, 1980; Wald & Friedman, 1978; Ingleby, 1981; Wexler, 1981). On the other hand, those opposing the i m p o s i t i o n of l e g a l c o n t r o l s (e.g., p s y c h i a t r i s t s ) c o n t e n d t h a t , w i t h o u t good h e a l t h , l i b e r t y cannot be e n j o y e d . I t i s argued t h a t m e n t a l d i s o r d e r s can o f t e n be t r e a t e d e f f e c t i v e l y and, even where t h i s i s not p o s s i b l e , the more f l o r i d symptoms of a person's c o n d i t i o n can be a m e l i o r a t e d . Indeed, i t has been the v e r y success of modern treatments which has l e d to the demands f o r more r i g h t s and l i b e r t i e s and more c o n t r o l s on the work of mental h e a l t h p r o f e s s i o n a l s . In l i g h t of t h i s , the process of r e s t r i c t i n g the freedom of m e n t a l h e a l t h p r o f e s s i o n a l s i s tantamount to denying a person the r i g h t to-enjoy the ' l i b e r t y t o be a t l i b e r t y ' . In some i n s t a n c e s , m e n t a l l y d i s o r d e r e d persons are being l e f t to 'rot w i t h t h e i r r i g h t s on' as a d i r e c t consequence of the i m p o s i t i o n of l e g a l c o n t r o l s . Where the goal of p a t i e n t s ' a d v o c a t e s has been to r e l e a s e p e r s o n s from i n s t i t u t i o n s , t h e i r work has not r e s u l t e d i n b e t t e r treatment and care; d e t e n t i o n i n the 'back-wards' has merely been r e p l a c e d with e i t h e r a l e s s s h e l t e r e d e x i s t e n c e on the 'back-streets' or i n d u c t i o n i n t o t h e c r i m i n a l j u s t i c e s y s t e m . In t h i s 21 p e r s p e c t i v e , mental h e a l t h s e r v i c e s need more r e s o u r c e s , not more law, and those g i v i n g p r i o r i t y to h e a l t h needs favour the p r e s e r v a t i o n of maximum l e v e l s of ' p r o f e s s i o n a l d i s c r e t i o n ' , supported by i n c r e a s e d resources f o r the treatment of persons a f f l i c t e d w i t h mental d i s o r d e r s ( B r a d l e y & C l a r k e , 1976; Weisstub, 1980; Jones, 1980; Toews, et a l , 1980; Warren, 1982; Stone, 1976; 1979; Roth, 1980; Wald & Friedman, 1978; C l a r k e , 1976; Wing, 1978; Wexler, 1981). T h i s can be seen as a c l a s h between two i n t e r e s t groups composed of two powerful groups of p r o f e s s i o n a l s , and which embodies a c o n f l i c t between the p e r c e i v e d ' l e g a l needs' of p a t i e n t s (notably, t h e i r c i v i l r i g h t s needs), and the p e r c e i v e d 'health care needs' of p a t i e n t s . In attempting to balance these competing p e r c e p t i o n s , s t a t e policy-makers and l e g i s l a t o r s have a l s o been r e q u i r e d to take account of a l a r g e r paradox, embedded i n the ideology and l e g a l s t r u c t u r e of l i b e r a l democracies; that i s , t h e p r o b l e m o f r e s o l v i n g t h e c o n f l i c t b e t w e e n an i n d i v i d u a l ' s r i g h t t o s e l f - d e t e r m i n a t i o n , and the need to deprive an i n d i v i d u a l of t h i s r i g h t where i t i s i n h i s or her 'best i n t e r e s t s ' and/or where i t i s necessary to do so f o r the p r o t e c t i o n of s o c i e t y . T h i s may be summarized as a c l a s h between the r i g h t s of the i n d i v i d u a l , the state's parens p a t r i a e power and duty, and the state's p o l i c e power and duty (Weisstub, 1980). I t can be contended that the 'new l e g a l i s m ' r e f l e c t s the r e l a t i v e dominance of t h ose e m p h a s i z i n g ' l e g a l needs' and t h e r e f o r e i n d i v i d u a l r i g h t s and freedoms ( p a r t i c u l a r l y , the r i g h t to s e l f - d e t e r m i n a t i o n ) , o v e r those h o l d i n g c o n t r a r y 22 p o s i t i o n s . However, t h i s o b s e r v a t i o n does not e x p l a i n why s t a t e p o l i c y - m a k e r s and l e g i s l a t o r s have chosen to embrace t h i s p a r t i c u l a r p e r s p e c t i v e . I t i s c l e a r that the 'new l e g a l i s m ' i s now assuming a l i f e of i t s own i n s o f a r as i t i s seen as the cause of reforms which r e f l e c t the growth of ' l e g a l i s m ' (see, e.g., Toews, e t a l , 1980). The t a u t o l o g o u s n a t u r e of t h i s mode of e x p l a n a t i o n i s o v e r l o o k e d but i t s p r o p o n e n t s can be f o r g i v e n the e r r o r p r i m a r i l y because the 'causes' of the 'new l e g a l i s m ' have yet to be d e l i n e a t e d . Indeed, a key q u e s t i o n s t i l l remains unanswered: that i s , why i s i t that a movement to reform mental h e a l t h law has d e v e l o p e d s i m u l t a n e o u s l y i n s e v e r a l c o u n t r i e s , i n c l u d i n g Canada, at t h i s p a r t i c u l a r h i s t o r i c a l juncture? The f o r e g o i n g has p r o v i d e d a g l i m p s e of some p o s s i b l e e x p l a n a t i o n s . On the one hand, the c u r r e n t era of reform may be a product of the emergence of an 'ideology of e n t i t l e m e n t ' ; on the o t h e r , i t may be c o n n e c t e d to the 'economics' of m e n t a l h e a l t h s e r v i c e d e l i v e r y . P a t i e n t s ' r i g h t s may be used as a p o l i t i c a l p l o y i n o r d e r to d i s g u i s e and f a c i l i t a t e a l a r g e r s t a t e s t r a t e g y that i n v o l v e s a 'modernization of p s y c h i a t r y ' but which i s l i n k e d to b o t h economic c o n s i d e r a t i o n s and c h a n g i n g s o c i a l c o n t r o l s t r a t e g i e s . The endorsement of p a t i e n t s ' r i g h t s may simply be the outcome of a c o n f l i c t between two p r o f e s s i o n a l i n t e r e s t groups i n which one group ( l a w y e r s ) has s e c u r e d a v i c t o r y . In each case, the e x p l a n a t i o n s are t e n t a t i v e ; however, they do c o n t a i n some c l u e s which p o i n t to both the importance of a t r a n s f o r m a t i o n i n s t a t e s t r a t e g i e s f o r the management of 23 m e n t a l l y d i s o r d e r e d persons and the r o l e of law i n f a c i l i t a t i n g and j u s t i f y i n g a new s t r a t e g y . The e x p l a n a t i o n s a l s o underscore the importance of human agency i n the reform process. At l e a s t two p r o f e s s i o n a l i n t e r e s t groups have been at work - lawyers and mental h e a l t h p r o f e s s i o n a l s - and the r o l e and impact of these groups cannot be overlooked. I l l : MENTAL DISORDER, L A A N D STATE: AN INTRODUCTION TO THE THESIS Th i s t h e s i s seeks to accomplish three g o a l s : ( i ) To d e s c r i b e not o n l y the 'new l e g a l i s m ' but a l s o o t h e r p e r i o d s of reform which have a f f e c t e d the l e g i s l a t i o n governing the management of mentally d i s o r d e r e d persons i n the p r o v i n c e s and t e r r i t o r i e s of Canada, s i n c e 1900. 2^ ( i i ) To explore and e s t a b l i s h the reasons f o r these p e r i o d s of reform. ( i i i ) To a r t i c u l a t e the i m p l i c a t i o n s of the d e s c r i p t i o n and a n a l y s i s of the reforms f o r the general body of theory i n the s o c i o l o g y of law, w i t h a p p r o p r i a t e r e f e r e n c e to b o t h the s o c i o l o g y of the s t a t e and the s o c i o l o g y of s o c i a l c o n t r o l . I t i s a p p a r e n t t h a t the c u r r e n t p e r i o d of r e f o r m ( i . e . , the new l e g a l i s m ) i s but the l a t e s t i n a s e r i e s of s t a t u t o r y changes which have o c c u r r e d s i m u l t a n e o u s l y i n many B r i t i s h Commonwealth c o u n t r i e s s i n c e the end of the 19th century. A major p e r i o d of reform began i n B r i t a i n i n the l a t e 1800's and s p r e a d to the r e s t of the (then) B r i t i s h Empire (Jones, 1955; 1960; 1972; B u t l e r , 1985; Armour, 1981; K i r b y , 1981). T h i s a f f e c t e d the p r o c e d u r e s f o r b o t h h a n d l i n g i n s a n e p e r s o n s and 24 l u n a t i c s and s e c u r i n g guardianship of the person and e s t a t e . A s m a l l e r , but n e v e r t h e l e s s s i g n i f i c a n t wave of reform a f f e c t i n g o n l y the p r o v i s i o n of 'mental h y g i e n e ' s e r v i c e s , o c c u r r e d i n B r i t a i n during the 1920's and culminated i n the passage of the Mental Treatment Act, 1930 (Bean, 1980; Armour, 1981; B u t l e r , 1985). Another major and widespread p e r i o d of change occurred, throughout the B r i t i s h Commonwealth, during the 1960's (Gostin, 1979; Jones, 1972; K i r b y , 1981; S t r o n g , 1983; B u t l e r , 1985). Although the primary focus was upon the procedures a f f e c t i n g the p r o v i s i o n of mental h e a l t h s e r v i c e s , the processes a s s o c i a t e d w i t h a d u l t guardianship were a l s o s u b j e c t e d to some r e v i s i o n . In each i n s t a n c e , a major r e c o n s t r u c t i o n of l e g i s l a t i o n o c c u r r e d w hich both r e f l e c t e d and imposed a new a p p r o a c h to the management of mentally d i s o r d e r e d persons. Although the p e r i o d s of reform which occ u r r e d i n B r i t a i n up u n t i l the 1960's have been e x p l o r e d , the e v e n t s i n Canada have not been analysed. C e r t a i n l y , some w r i t e r s have examined the s t a t e of C a n a d i a n m ental h e a l t h l e g i s l a t i o n a t v a r i o u s t i m e s , a t the n a t i o n a l and p r o v i n c i a l l e v e l s , as w e l l as p a r t i c u l a r a s p e c t s of t h i s a r e a of law (see, e.g., Swadron, 1964; Swadron & S u l l i v a n , 1972; 1973; Draper, 1976; 1976a; Draper & W i l l i a m s o n , 1976; W e l l s c h , 1983; W e i s s t u b , 1980; M a r s h a l l & Hughes, 1974; Mazer, 1978; Savage & McKague, 1987; R o b e r t s o n , 1987). T h i s work i s u s e f u l ; however, i t has i n v o l v e d , almost e x c l u s i v e l y , e i t h e r pure d e s c r i p t i o n or l i m i t e d l e g a l a n a l y s i s , and the c o n t r i b u t o r s have been p r e d o m i n a t e l y lawyers or l e g a l s c h o l a r s concerned p r i m a r i l y w i t h p r e s e n t i n g 25 arguments i n f a v o u r of r e f o r m . H i s t o r i c a l or s o c i o l o g i c a l a n a l y s e s , designed to e x p l a i n the p e r i o d s of reform, whether by r e f e r e n c e to c h a n g i n g s t a t e s o c i a l c o n t r o l s t r a t e g i e s , or otherwise, have not yet been attempted. There are some i n d i c a t i o n s t h a t , i n Canada, the emergence of the 'new l e g a l i s m ' , i s c l o s e l y connected to changing s t a t e s t r a t e g i e s f o r the management of mentally d i s o r d e r e d persons. In Ontario, f o r example, the 'new l e g a l i s m ' f i r s t appeared i n the l a t e 1970's and i t has evolved w i t h an emphasis p r i m a r i l y upon l i m i t i n g the use of i n v o l u n t a r y c i v i l commitment. The c r i t e r i a which must be met before commitment can occur have been t i g h t e n e d . In a d d i t i o n , s t r i c t l i m i t a t i o n s have been p l a c e d upon b o t h the use o f c e r t a i n forms of t r e a t m e n t ( n o t a b l y , p s y c h o s u r g e r y ) and the t r e a t m e n t of p a t i e n t s w i t h o u t t h e i r consent. More r e c e n t l y , changes have been int r o d u c e d to expand the r i g h t s of p a t i e n t s i n the context of mental h e a l t h review board hearings and to provide a comprehensive advocacy s e r v i c e ( R o b e r t s o n , 1 9 8 7 ) . 2 1 T h i s a c t i v i t y has c o i n c i d e d w i t h the adoption of a s t r a t e g y of d e - i n s t i t u t i o n a l i z a t i o n , n o n - i n s t i t u t -i o n a l i z a t i o n , and p r i v a t i z a t i o n i n the province ( M a r s h a l l , 1982; S o c i a l Planning C o u n c i l of M e t r o p o l i t a n Toronto, 1984). The 'new l e g a l i s m 1 a l s o emerged i n B r i t i s h Columbia i n the l a t e 1970's and reforms have been g r a d u a l l y introduced over a p e r i o d of s e v e r a l y e a r s . A major r e c o n s t r u c t i o n of m e n t a l h e a l t h l e g i s l a t i o n i s imminent, and t h i s a c t i v i t y i s o c c u r r i n g i n c o n j u n c t i o n w i t h the p r o v i n c i a l government's s t r a t e g y of 26 d e c a r c e r a t i o n and p r i v a t i z a t i o n i n the mental h e a l t h context. ^ In a d d i t i o n , the c o u r t s i n B r i t i s h Columbia have become an arena of reform due to the e f f o r t s of an ag g r e s s i v e , p a r t i s a n advocacy s e r v i c e (The Mental P a t i e n t s ' Advocate P r o j e c t ) . T h i s agency has had some success i n e s t a b l i s h i n g some p a t i e n t s ' r i g h t s and has been a c t i v e i n r e p r e s e n t i n g persons seeking discharge from m e n t al h e a l t h f a c i l i t i e s ( H i m m e l f a r b & L a z a r , 1981). I t has secured the r e l e a s e of many p a t i e n t s , and the reforms which have been made to p r o v i n c i a l mental h e a l t h l e g i s l a t i o n have supported the work of the agency. As the examples of events i n these two p r o v i n c e s suggest, the emergence of the new l e g a l i s m may be c o n n e c t e d t o .the development and implementation of a new s t a t e s t r a t e g y f o r the management of mentally d i s o r d e r e d persons. However, the nature of the r e l a t i o n s h i p i s u n c l e a r , as i s the l i n k between the f a c t o r s underpinning the s h i f t i n s t r a t e g y , the t h r u s t of the s t r a t e g y , and the new l e g i s l a t i o n . Is the a s s o c i a t i o n between a new s t r a t e g y and new l e g i s l a t i o n merely c o i n c i d e n t a l , or i s the law being used by the s t a t e i n order to f a c i l i t a t e and j u s t i f y the changes? The new l e g a l i s m has emerged most c l e a r l y i n pr o v i n c e s that were governed by c o n s e r v a t i v e p o l i t i c a l p a r t i e s ; that i s , Nova S c o t i a , Ontario, A l b e r t a , B r i t i s h Columbia, and (more r e c e n t l y ) Saskatchewan. Conservative governments are not norma l l y a s s o c i a t e d with the a c t i v e advancement of the r i g h t s of the disadvantaged, yet t h i s appears to have been the case with the r i g h t s of mental h e a l t h p a t i e n t s . This suggests that the endorsement of l e g a l and o t h e r ' r i g h t s ' may, as Rose (1985) 27 argues, have played an important r o l e i n the implementation of a new s t a t e s t r a t e g y which i n v o l v e d a s h i f t i n ' r e s o u r c e s ' r e q u i r i n g p o l i t i c a l j u s t i f i c a t i o n . Has t h i s been the case and, i f so, what are the i m p l i c a t i o n s f o r an u n d e r s t a n d i n g of the l a w - s t a t e r e l a t i o n ? Is t h i s the f i r s t time t h a t the s t a t e has used law i n t h i s way or i s t h i s a c o n s i s t e n t f e a t u r e of previous s h i f t s i n s o c i a l c o n t r o l s t r a t e g y ? What does t h i s say about the r o l e and impact of i n t e r e s t groups (e.g., medical p r a c t i t i o n e r s and c i v i l l i b e r t a r i a n lawyers) i n the process of reform? Securing answers to these questions, through an a n a l y s i s of the p e r i o d s of reform a f f e c t i n g Canadian mental h e a l t h law, would c o n s t i t u t e a c o n t r i b u t i o n to a s o c i o l o g y of law informed by s t a t e theory. The area i n v o l v e s an examination of a key i s s u e f o r s t a t e - l a w t h e o r i s t s ; namely, how, why, and under what c o n d i t i o n s do laws emerge and change, and what i s the nature of the r e l a t i o n s h i p between law, s t a t e , s t r u c t u r a l c o n d i t i o n s , and human agency? In the case of mental h e a l t h law r e f o r m , the q u e s t i o n may be r e - e x p r e s s e d i n the f o l l o w i n g way: to what e x t e n t and under what c o n d i t i o n s i s law r e f o r m m e r e l y a by-p r o d u c t of a s t a t e s t r a t e g y f o r the management of m e n t a l l y d i s o r d e r e d persons, and to what extent and under what c o n d i t i o n s i s i t an a c t i v e and c r u c i a l mechanism employed by the s t a t e i n order to both implement and j u s t i f y a new s t r a t e g y ? A study of mental h e a l t h law a l s o has a b e a r i n g upon s e v e r a l a l l i e d i s s u e s ; namely, the r o l e of reformism, l e g a l r i g h t s , and l e g a l s e r v i c e s i n an advanced c a p i t a l i s t s o c i e t y . In short, an a n a l y s i s of the p e r i o d s of r e f o r m a f f e c t i n g Canadian m ental h e a l t h law 28 presents an o p p o r t u n i t y to forge a l i n k between i s s u e s of s o c i a l c o n t r o l , law and s t a t e and thereby c o n t r i b u t e to both the 'state theory' and the ' s o c i a l c o n t r o l ' r e s e a r c h programmes. In k e e p i n g w i t h the t h r e e g o a l s of the t h e s i s , the s t a r t i n g p o i n t i s a d e s c r i p t i o n and a n a l y s i s of the l e g i s l a t i v e and j u r i s p r u d e n t i a l h i s t o r y of mental h e a l t h law i n Canada. One o b j e c t i v e i s to demonstrate how the era of new l e g a l i s m i s but the l a t e s t i n a s e r i e s of reforms which have occurred s i n c e the beginning of t h i s century. T h i s kind of a n a l y s i s has not been attempted before and Chapters 2 and 3 c o n t a i n a d e s c r i p t i o n of the p e r i o d s of reform, as w e l l as an o u t l i n e of the a s s o c i a t e d changes i n s t a t e s t r a t e g i e s f o r the management of m e n t a l l y d i s o r d e r e d persons. Chapter 4 c o n t a i n s a comprehensive review of the d i f f e r e n t e x p l a n a t i o n s which may account f o r the p e r i o d s of reform. These are drawn from the e x i s t i n g l i t e r a t u r e on mental h e a l t h p o l i c y and law r e f o r m i n c o u n t r i e s o t h e r than Canada, and they f a l l i n t o three d i s t i n c t groups; namely, e x p l a n a t i o n s f o c u s s i n g upon developments w i t h i n mental h e a l t h systems; those concerned w i t h the a c t i v i t i e s of r e f o r m e r s and i n t e r e s t groups; and, those concerned with both the impact of s t r u c t u r a l developments and the n a t u r e and r o l e of the c a p i t a l i s t s t a t e . O t h e r p o s s i b l e e x p l a n a t i o n s are assessed and the s t r e n g t h s and weaknesses of a l l t h e a c c o u n t s a r e e v a l u a t e d . The f r a m e w o r k o f a comprehensive e v a l u a t i o n that combines s t r u c t u r a l c o n s i d e r a t i o n s and i s s u e s of human agency w i t h i n one t h e o r e t i c a l t r a j e c t o r y (i.e., s t r u c t u r a l Marxism) i s d i s c u s s e d and t h i s i s used as the 29 b a s i s f o r a d e t a i l e d a n a l y s i s of the pe r i o d s of reform i n Canada which have occurred s i n c e the 1950's, with a p a r t i c u l a r emphasis upon the s i t u a t i o n i n the pro v i n c e of B r i t i s h Columbia. This a n a l y s i s i s presented i n Chapters 5 and 6. Chapter 5 co n t a i n s an e x p l o r a t i o n of the events l e a d i n g up to the passage of new mental h e a l t h l e g i s l a t i o n i n B r i t i s h Columbia during the 1960's, while Chapter 6 c o n s i s t s of an a n a l y s i s of the e v o l u t i o n of the 'new l e g a l i s m ' i n the province. Both chapters encompass an examination of the r o l e of human a c t o r s i n e n g i n e e r i n g change (i.e., the work of i n t e r e s t groups both w i t h i n and out s i d e s t a t e m e n t a l h e a l t h s e r v i c e b u r e a u c r a c i e s ) and an a n a l y s i s of the imp a c t of the s t r u c t u r a l c o n d i t i o n s under which t h i s human a c t i o n has occurred. In Chapter 7, the general t h e o r e t i c a l i m p l i c a t i o n s of the a n a l y s i s are examined w i t h a p a r t i c u l a r emphasis upon the c o n t r i b u t i o n t o a Ca n a d i a n s o c i o l o g y of s o c i a l c o n t r o l and a Canadian s o c i o l o g y of law i n f o r m e d by s t a t e t h e o r y . In a d d i t i o n , the need f o r f u r t h e r r e s e a r c h i n v a r i o u s a r e a s i s d i s c u s s e d . M e t h o d o l o g i c a l i s s u e s are examined s e p a r a t e l y i n Appendix I. 30 ENDNOTES: CHAPTER 1. 1: This work i s reviewed i n gr e a t e r d e t a i l i n Chapter 4. 2: The term ' d e - i n s t i t u t i o n a l i z a t i o n ' r e f e r s to the process of r e l e a s i n g persons c o n f i n e d i n v a r i o u s i n s t i t u t i o n s . 3: The term ' n o n - i n s t i t u t i o n a l i z a t i o n ' r e f e r s to the process of r e t a i n i n g i n the community those persons who might otherwise be deemed s u i t a b l e f o r c o n f i n e m e n t . The t e r m ' t r a n s -i n s t i t u t i o n a l i z a t i o n ' r e f e r s to the p r o c e s s of t r a n s f e r r i n g c o n f i n e d persons from the i n s t i t u t i o n s found w i t h i n one system of s o c i a l c o n t r o l (e.g., s o c i a l w e l f a r e ) to those o p e r a t i n g under the au s p i c e s of another system (e.g., c r i m i n a l j u s t i c e ) . The term ' p r i v a t i z a t i o n ' r e f e r s to the process of t r a n s f e r r i n g the ownership of s o c i a l c o n t r o l r esources and f a c i l i t i e s from the p u b l i c to the p r i v a t e s e c t o r . 4: T h i s work i s reviewed i n g r e a t e r d e t a i l i n Chapter 4. 5: M e n t a l H e a l t h A c t , S.O., 1978, c. 50. (now, R.S.O., 1980, c.262). H o s p i t a l s A c t , S.N.S., 1977, c. 45 (now, C.S.N.S., 1979, c. H - 19). M e n t a l H e a l t h A c t , S.A., 1972, c. 118 (now, R.S.A., 1980, c . M - 13). M e n t a l H e a l t h A c t , S.M., 1980, c. 62. Mental Health Amendment Act, S.N.B., 1985, c. 59. Mental Health S e r v i c e s A c t S.S., 1984 - 85, c. M-13.1. M e n t a l H e a l t h A c t , S.N.W.T., 1985 (2nd) c. 6. 6: M e n t a l H e a l t h (Amendment) A c t , S.B.C., 1973, c. 127; M i s c e l l a n e o u s S t a t u t e s Amendment A c t , S.B.C., 1980, c. 31; M e n t a l H e a l t h A c t R e g u l a t i o n s : B.C. Reg. 118/80, D i v i s i o n 8; Mental Health Amendment Act, S.B.C. 1985, c. 12; Health S t a t u t e s Amendment A c t , S.B.C. 198 6, c. 6; M i s c e l l a n e o u s S t a t u t e s Amendment Act (No. 1), S.B.C. 1987, c. 42. 7: Mental Health B i l l , No. 3/87: March 11th 1987. 8: Mental Health B i l l , No. 59/87: June 5th 1987. 9: See, e.g., Re Robinson and H i s l o p , (1980), 114 D.L.R. (3d) 620 (B.C.S.C.); H o s k i n s v. H i s l o p , (1981), 26 B.C.L.R. 165 (B.C.S.C.); H i l t o n v. D u f f y , (Unreported) A802065, Sept. 18, 1980 (B.C.S.C.); 1980, B.C.D.Crim. Conv. 575201; Rosandik v_;_ M a n n i n g , (1978) 5 B.C.L.R. 347 (B.C.S.C.); E g g l e s t o n e and Mousseau and the Advisory Review Board, (1983), 42 O.R. (2d) 268 (Ont. H.C.J.) ; T h e r e s a L u s s a v. H e a l t h S c i e n c e C e n t r e and D i r e c t o r o f P s y c h i a t r i c S e r v i c e s , (1983), 5 C.H.R.R. D/2203 (Man. Q.B.); C l a r k v. C l a r k , (1982), 40 O.R. (2d) 383 (Ont. Co. Ct.); Reference Re Procedures and the Mental Health Act, (1984), 5 D.L.R. (4th) 577 (P.E.I.S.C.); Re T and the Board of Review fo r the Western Region, et a l . , (1983), 3 D.L.R. (4th) 442 (Ont. H.C.J.); D i r e c t o r of Riverview H o s p i t a l v. Andrzejewski, (1983), 150 D.L.R. (3d) 535 (B.C. Co. C t . ) ; Ketchum v. H i s l o p (1984) 54 31 B.C.L.R. 327 (B.C.S.C.); S c h e r b a v. H i s l o p , ( U n r e p o r t e d ) B.C. Di v . C i v . 2668 - 02, June 22, 1981 (B.C.S.C.); Re A b e l , e t a l , and A d v i s o r y R e v i e w B o a r d , ( 19 8 1), 56 C.C.C. (2d) 153 (Ont.C.A.); Re E g g l e s t o n and Mousseau and the Adv i s o r y Review Board, (1983), 42 O.R. (2d) 268 (Ont. H.C.J.); Re McCann and The Queen, (1982), 67 C.C.C. (2d) 180 (B.C.C.A.). 10: The Dependent A d u l t s A c t , R.S.A., 1980, c. D - 32; as amended by R.S.A., 1980, c. 6 (Supp.) and, S.A., 1985, c. 21. 11: The P u b l i c T r u s t e e A c t , S.S. 1983, c. P-43.1; The P u b l i c Trustee Act, S.M. 1971, c. P-275 (proclaimed i n f o r c e , Feb. 1, 1973); P u b l i c Trustee Act, S.N.S., 1973, c. 12. 12: A d e t a i l e d d i s c u s s i o n of these changes, and the v a r i o u s s t a t u t o r y c i t a t i o n s , are provided i n Chapter 3. 13: See, e.g., M e n t a l H e a l t h A c t , 1983 (New South Wales); Mental Health Act, 1979 (Northern T e r r i t o r y ) ; Mental Health Act, 1976 - 1977 (South A u s t r a l i a ) ; Mental Health Act, 1981 (Western A u s t r a l i a ) . 14: S ee, e.g., M e n t a l H e a l t h A c t , 1976 - 1.9.22 ( S o u t h A u s t r a l i a ) : Part IV; P r o t e c t e d E s t a t e s Act, 1983 and Community Welfare Act, 1982: Part XI (New South Wales). 15: See, i n p a r t i c u l a r , Dixon v. Weinberger, 405 F. Supp. 974 (D.D.C. 1975); Lake v^ Cameron, 264 F. 2d. 657 (D.D.C. 1966); Rouse v. Cameron, 387 F. 2d. 241 (D.C. C i r . 1967); Wyatt v. S t i c k n e y , 325 F. Supp. 781 (M.D. A l a . 1971) (subsq. h i s t o r y omitted); O'Connor v. Donaldson, 422 U.S. 563 (1975); Lessard v. Schmidt, 349 F. Supp. 1078 (F.D. Wise. 1972) (subsq. h i s t o r y o m i t t e d ) ; Rogers v. Okin, 478 F. Supp. 1342 (D. Mass. 1979); Rennie v^ K l e i n , 462 F. Supp. 1131 (D.N.J. 1978). 16: C a l i f o r n i a Welfare <& I n s t i t u t i o n s Code; D i v i s i o n 5. Added by the Mental Health Act, 1967, C a l . Stat s , ch. 1667. 17: M e n t a l H e a l t h Systems A c t , P.L. 96 - 398, 94 S t a t . 1564 (1980): S. 9501 ( B i l l of R i g h t s ) . 18: Lunacy Act, 1890, 53 V i c t . c. 5 (Imp.). 19: The term ' D i c e y i s t s ' was c o i n e d by Jones (1980) t o d e s c r i b e a d v o c a t e s who are o b s e s s e d w i t h the r u l e of law and r e f e r s to a n i n e t e e n t h c e n t u r y E n g l i s h j u r i s t who was so obsessed. 20: The f o c u s w i l l be upon the l e g i s l a t i o n a f f e c t i n g the process of c i v i l commitment and confinement and the management of mentally d i s o r d e r e d persons who have not f a l l e n w i t h i n the p u r v i e w of the c r i m i n a l j u s t i c e system ( i . e . , the m e n t a l l y d i s o r d e r e d o f f e n d e r ) . S i n c e t h i s t h e s i s i s c o n c e r n e d w i t h the l a w s and 32 s t r a t e g i e s a f f e c t i n g the management of those deemed to be 'mentally disordered', i t i n t e r s e c t s with the debate over the e x i s t e n c e and n a t u r e of 'mental i l l n e s s 1 and the v a l i d i t y of terms such as 'mental d i s o r d e r ' . A b r i e f , c l a r i f y i n g comment on t h i s issue i s , t h e r e f o r e , warranted. As Warren (1982) p o i n t s out, t h e r e are two, major and competing p e r s p e c t i v e s r e g a r d i n g the e x i s t e n c e of 'mental i l l n e s s ' ; one s o c i o l o g i c a l , the o t h e r m e d i c a l . L a b e l l i n g t h e o r i s t s p o i n t t o the c u l t u r a l l y d e t e r m i n e d and s o c i a l l y c o n s t r u c t e d nature of a l l deviance l a b e l s , i n c l u d i n g those used to c a t e g o r i z e i n d i v i d u a l s who behave i n a s o c i a l l y unacceptable or u n u s u a l manner but who are not c l a s s i f i a b l e i n o t h e r ways (e.g., as ' c r i m i n a l s ' ) . In t h i s view, terms such as 'lunacy', 'madness', 'mental i l l n e s s ' , or 'mental d i s o r d e r ' are l a b e l s w h ich i d e n t i f y p a r t i c u l a r forms of d e v i a n t b e h a v i o u r and f a c i l i t a t e the management of s o c i a l l y m a r g i n a l i n d i v i d u a l s , r a t h e r than d e s c r i p t i o n s of s p e c i f i c and c o n c r e t e c o n d i t i o n s which c o n s t i t u t e forms of i l l n e s s or s i c k n e s s . The l a b e l s are a p p l i e d i n order to c a t e g o r i z e deviant behaviour and d e v i a n t s , w i t h a view t o c o n t r o l l i n g , r a t h e r than t r e a t i n g , t h e s e i n d i v i d u a l s through the 'mental health* component of the s o c i a l c o n t r o l s y s t e m . The m e d i c a l p e r s p e c t i v e , on the o t h e r hand, views mental i l l n e s s or mental d i s o r d e r as a p h y s i c a l i l l n e s s or p s y c h o l o g i c a l d i s o r d e r amenable to treatment or other forms of m e d i c a l i n t e r v e n t i o n (e.g., p s y c h o a n a l y s i s ) . In t h i s view, m e d i c a l i n t e r v e n t i o n t h r o u g h the p r o v i s i o n of mental h e a l t h s e r v i c e s i s an humanitarian response to s u f f e r i n g , r a t h e r than an e x e r c i s e i n s o c i a l c o n t r o l , and mental i l l n e s s i s t o be vie w e d and responded to i n the same manner as o t h e r f o rms of i l l n e s s or s i c k n e s s . The g o a l of t h i s t h e s i s i s not to e n t e r or r e s o l v e t h i s s p e c i f i c debate but to focus upon the concrete way i n which the s t a t e r e g u l a t e s and manages the group of ' s o c i a l d e v i a n t s ' who, a t v a r i o u s t i m e s , have been i d e n t i f i e d and l a b e l l e d a s ' l u n a t i c s ' , 'insane', ' m e n t a l l y d i s e a s e d ' , ' m e n t a l l y i l l ' , ' m e n t a l l y d i s o r d e r e d ' , and 'mental h e a l t h p a t i e n t s ' . The purpose i s to a n a l y s e the s t a t e ' s r e s p o n s e t o the ' m e n t a l l y d i s o r d e r e d ' , r a t h e r than 'mental d i s o r d e r ' , p e r se, and terms such as 'mental d i s o r d e r ' , ' m e n t a l l y d i s o r d e r e d ' and 'mental h e a l t h p a t i e n t ' , are employed i n t h i s t h e s i s as a way of i d e n t i f y i n g the group i n ques t i o n , r a t h e r than acknowledging the v a l i d i t y of, f o r example, the medical p e r s p e c t i v e . Despite the d i f f e r e n t o n t o l o g i c a l assumptions about the nature of mental d i s o r d e r , p e o p l e have been and are l a b e l l e d and managed, and mental h e a l t h p a t i e n t s are a concrete and i d e n t i f i a b l e s o c i a l group who u t i l i z e (or are f o r c e d to u t i l i z e ) , c o n c r e t e and i d e n t i f i a b l e i n s t i t u t i o n s , r e s o u r c e s and o t h e r f a c i l i t i e s e s t a b l i s h e d by the s t a t e . The s t a t e has e n d o r s e d the use of c a t e g o r i z i n g l a b e l s (e.g., mental i l l n e s s , mental d i s o r d e r , and mental h e a l t h p a t i e n t ) , c r e a t e d i n s t i t u t i o n s and r e s o u r c e s , devised management s t r a t e g i e s , and c o n s t r u c t e d a p p r o p r i a t e laws, and t h i s has oc c u r r e d d e s p i t e the debate between the proponents of the c o m p e t i n g p e r c e p t i o n s of the e x i s t e n t i a l r e a l i t y of 33 mental d i s o r d e r . In s h o r t , the o b j e c t of t h i s a n a l y s i s i s the r e a l , c o n c r e t e and i d e n t i f i a b l e , s t a t e r e s p o n s e t o t h e management of a group of s o c i a l d e v i a n t s c a t e g o r i z e d as "mentally disordered', r a t h e r than the v a l i d i t y of c l a s s i f y i n g t h e i r behaviour as a form of medical 'disorder' or i l l n e s s . Nevertheless, the c o n c e p t u a l i z a t i o n of the response to the mentally d i s o r d e r e d as a process of s o c i a l c o n t r o l does i n v o l v e an a d o p t i o n o f t h e s o c i o l o g i c a l , r a t h e r t h a n m e d i c a l , p e r s p e c t i v e on mental i l l n e s s . T h i s does not e n t a i l or imply any n e c e s s a r y r e j e c t i o n of the m e d i c a l p e r s p e c t i v e , m e r e l y r e c o g n i t i o n that the management of those designated as 'mentally d i s o r d e r e d ' i n v o l v e s a v a r i e t y of mental h e a l t h 'care and treatment' methods, the s u i t a b i l i t y and a p p l i c a t i o n of which i s d e t e r m i n e d and e x e c u t e d by m e n t a l h e a l t h s y s t e m p e r s o n n e l , a c c o r d i n g to p r e v a i l i n g s t a n d a r d s , b e l i e f s , and 'knowledge'. General management s t r a t e g i e s and a s s o c i a t e d bodies of r u l e s and r e g u l a t i o n s ( i . e . , m e n t a l h e a l t h laws) are c o n s t r u c t e d by the s t a t e and t h i s t h e s i s focusses upon these s t r a t e g i e s and laws. 21: The v a r i o u s p r o v i s i o n s of the new l e g i s l a t i o n a r e d e s c r i b e d and c i t e d i n Chapter 3. 22: The p r o v i s i o n s o f t h e a m e n d i n g s t a t u t e s and new Regulations are d e s c r i b e d and c i t e d i n Chapter 3. Chapters 5 and 6 c o n t a i n a d i s c u s s i o n of the s h i f t s i n s t r a t e g y and the work and impact of the Mental P a t i e n t s Advocate P r o j e c t . 34 CHAPTER 2 FROM LIMITED LEGALISM TO MEDICALIZATION: CHANGES IN STRATEGY AND LAW - 1900 TO 1939 I: INTRODUCTION In the e a r l y 1900's, the s t a t e s t r a t e g y f o r the management of insane and l u n a t i c persons i n Canada emphasized the use of asylums. 1 Insane i n d i v i d u a l s were segregated from other ' s o c i a l d e v i a n t s ' and c o n f i n e d i n both p u b l i c and p r i v a t e i n s t i t u t i o n s f o r the purposes of medical and moral treatment. The p r o v i n c i a l and t e r r i t o r i a l laws a s s o c i a t e d with t h i s s t r a t e g y resembled l e g i s l a t i o n w hich had emerged i n B r i t a i n d u r i n g the 19th c e n t u r y . The I m p e r i a l , Lunacy A c t , 1890 2 - a p r o d u c t of 50 years of reform e f f o r t - had had an impact across the country and v a r i o u s forms of j u d i c i a l and q u a s i - j u d i c i a l s u p e r v i s i o n of the asylum system were i n pla c e . In the t e r r i t o r i e s and some pro v i n c e s , the j u d i c i a r y s u p e r v i s e d the commitment of insane p e r s o n s t o a s y l u m s , but the t r e a t m e n t and r e l e a s e of those c o n f i n e d i n such p l a c e s was l e f t to the d i s c r e t i o n of medical s u p e r i n t e n d e n t s . In o t h e r p r o v i n c e s , the commitment of dangerous persons was s u p e r v i s e d by the j u d i c i a r y but both the commitment of non-dangerous persons and the treatment of the i n s a n e were l e f t to the d i s c r e t i o n of m e d i c a l p r a c t i t i o n e r s . However, i n these p r o v i n c e s q u a s i - j u d i c i a l bodies monitored the c o n d i t i o n s under which persons were c o n f i n e d , p a r t i c u l a r l y i n p r i v a t e a s y l u m s . In a l l the t e r r i t o r i e s and p r o v i n c e s , the j u d i c i a r y c o n t r o l l e d the a p p o i n t m e n t o f 'committees', or guardians, who were to manage the f i n a n c i a l and p e r s o n a l a f f a i r s 35 of l u n a t i c s . By 1915, s i g n s o f a s h i f t i n t h e s t r a t e g y f o r t h e management of i n s a n e p e r s o n s had emerged and t h i s g r a d u a l l y a f f e c t e d a l l the p r o v i n c e s . A new, m e d i c a l i z e d l e x i c o n appeared, and steps were taken to both d i s t i n g u i s h between and d e v i s e t a c t i c s f o r the management of d i f f e r e n t t y p e s of 'patients*. In p a r t i c u l a r , e f f o r t s were made to f a c i l i t a t e the e a r l y a d m i s s i o n o f ' m e n t a l l y d i s e a s e d ' p e r s o n s t o new ' p s y c h o p a t h i c ' h o s p i t a l s and wards. These f a c i l i t i e s were designed to provide short-term admission f o r o b s e r v a t i o n and m e d i c a l t r e a t m e n t , r a t h e r than l o n g - t e r m c o n f i n e m e n t . The a s y l u m s were r e f e r r e d t o a s ' h o s p i t a l s ' and s e r v e d a s d e p o s i t o r i e s f o r p a t i e n t s r e f e r r e d from the new t r e a t m e n t f a c i l i t i e s . New l e g i s l a t i o n was in t r o d u c e d and t h i s r e f l e c t e d a r e d u c t i o n i n the s u p e r v i s o r y r o l e of the j u d i c i a r y . While the j u d i c i a r y c o n t i n u e d t o b o t h c o n t r o l the a p p o i n t m e n t o f committees and s u p e r v i s e the apprehension and i n i t i a l commitment of dangerous m e n t a l l y d i s e a s e d p e r s o n s , the power to admit people to the new treatment f a c i l i t i e s was passed to medical p r a c t i t i o n e r s . V o l u n t a r y a d m i s s i o n t o p u b l i c i n s t i t u t i o n s became p e r m i s s i b l e and o t h e r s t e p s were t a k e n which r e d u c e d j u d i c i a l and q u a s i - j u d i c i a l involvement i n the management of mentally d i s e a s e d persons. In t h i s c h a p t e r , a d e s c r i p t i o n of bo t h the s h i f t i n s t r a t e g y and the corresponding changes i n l e g i s l a t i o n w i l l be p r o v i d e d . The d i s c u s s i o n b e g i n s w i t h an e x a m i n a t i o n of the s i t u a t i o n a t the t u r n of the c e n t u r y when a form of ' l i m i t e d 36 l e g a l i s m ' c o u l d be found i n the p r o v i n c i a l and t e r r i t o r i a l l e g i s l a t i o n a f f e c t i n g the management of i n s a n e p e r s o n s . The emergence of a 'medicalized' approach i s then t r a c e d through a review of the changes i n s t r a t e g y and l e g i s l a t i o n which appeared i n a l l the p r o v i n c e s between 1919 and 1939. I I ; THE LAW AND THE MANAGEMENT OF INSANE AND LUNATIC PERSONS IN THE EARLY 1900's In the f i r s t decade of t h i s c e n t u r y , the s t r a t e g y f o r managing insane persons i n Canada r e s t e d f i r m l y upon the use of p l a c e s of segregated, t h e r a p e u t i c confinement. The process of developing p u b l i c i n s t i t u t i o n s began as e a r l y as 1848 when the f i r s t p r o v i n c i a l insane asylum was b u i l t i n New Brunswick and, by 1900, a l l the p r o v i n c e s had f o l l o w e d s u i t ( B u r g e s s , 1898; Hurd, 1917; Smandych & Verdun-Jones, 1986). However, i n the newly e s t a b l i s h e d Yukon T e r r i t o r y 3 and i n the v a s t a r e a then known as the Northwest T e r r i t o r i e s , there were no i n s t i t u t i o n s f o r the insane. This s i t u a t i o n was to p r e v a i l i n both A l b e r t a and Saskatchewan f o r s e v e r a l years a f t e r these p r o v i n c e s were carved from the Northwest T e r r i t o r i e s . 4 Those who needed to be c o n f i n e d were to be e i t h e r 'deported' to t h e i r home pr o v i n c e s , or t r a n s f e r r e d to the nearest p r o v i n c i a l asylum, and the l a t t e r o p t i o n u s u a l l y i n v o l v e d a p e r i o d of b r i e f confinement i n a l o c a l gaol, f o l l o w e d by a lengthy and uncomfortable journey to one of the p r o v i n c i a l insane asylums i n Manitoba (Hurd, 1917; Appleton, 1967) . 5 Every e f f o r t had been made to segregate the insane from other i n c a r c e r a t e d ' s o c i a l deviants', such as vagrants and those 37 c o n v i c t e d of crimes (Verdun-Jones & Smandych, 1982). In two provinces, however, the asylums served as f a c i l i t i e s i n which people other than the insane could be detained. In Nova S c o t i a , a number o f l o c a l , o r c o u n t y , l u n a t i c a s y l u m s had been e s t a b l i s h e d to b u t t r e s s the work of the p r o v i n c i a l h o s p i t a l f o r the i n s a n e ( B u r g e s s , 1898; A p p l e t o n , 1967; F r a n c i s , 1977; L e i g h t o n , 1982). These a s y l u m s were e r e c t e d and funded by m u n i c i p a l i t i e s or towns and while they were designed p r i m a r i l y to house the 'harmless insane' (e.g., those who were d e s t i t u t e and i n f i r m because of age), they c o u l d be used as 'poors' houses'.** In P r i n c e Edward Island, a multi-purpose asylum had been b u i l t at Charlottetown to house the poor, the i n f i r m and the insane (Burgess, 1898; Appleton, 1967). The f a c i l i t y served i n t h i s c a p a c i t y u n t i l a new almshouse and i n f i r m a r y was b u i l t i n 1908. Both the poor and the i n f i r m were then t r a n s f e r r e d , l e a v i n g the asylum f r e e to d e a l with those who were insane and amenable to treatment.^ In O n tario, a dual system of asylums s p e c i f i c a l l y f o r the insane had developed and a network of p u b l i c asylums c o - e x i s t e d w i t h a s y l u m s owned and o p e r a t e d by p r i v a t e o r g a n i z a t i o n s (Burgess, 1898; McNeel & L e w i s , 1960). As Smandych (1982) notes, the p r o v i n c e was q u i t e proud of i t s p u b l i c asylums and, i n the l a t e 19th century, "...advocates f o r s o c i a l reform i n the p r o v i n c e c l a i m e d to have a system of mental i n s t i t u t i o n s of equal or b e t t e r q u a l i t y than those i n e i t h e r the United S t a t e s or E ngland" (op c i t : 144). In Quebec, t h e r e were no p u b l i c asylums and a l l the i n s t i t u t i o n s f o r the confinement of insane 38 persons were owned and operated by the C a t h o l i c and P r o t e s t a n t churches. T h i s s i t u a t i o n had e x i s t e d f o r more than a century and t h e p r i v a t e a s y l u m s c o n t r a c t e d w i t h t h e p r o v i n c i a l government to r e c e i v e and care f o r insane persons who could not a f f o r d p r i v a t e c a r e and t r e a t m e n t ( B u r g e s s , 1898; A p p l e t o n , 1967; Smandych & Verdun-Jones, 1982). The p r o v i n c i a l government had s t e a d f a s t l y r e f u s e d to c o n s t r u c t and operate p u b l i c asylums d e s p i t e the f i n d i n g s of a Royal Commission which had exposed the abundant inadequacies of the p r i v a t e asylum system (Appleton, 1967; Verdun-Jones & Smandych, 1982). A c r o s s Canada, both the use of the p u b l i c and p r i v a t e p l a c e s of confinement, and the general management of insane and l u n a t i c persons, was governed by p r o v i n c i a l i n s a n i t y and lunacy s t a t u t e s . The body of law had been i n f l u e n c e d by developments i n E n g l i s h lunacy law which had occurred d u r i n g the 19th century and t h i s r e f l e c t e d the s t a t u s of Canada as a Dominion w i t h i n the B r i t i s h E mpire and the consequent impact of b o t h the E n g l i s h common law and the s t a t u t e s passed by the I m p e r i a l Parliament, such as the Lunacy Act, 1890. 8 By 1900, E n g l i s h lunacy law, which had been i n a c h a o t i c s t a t e throughout the 19th century, had been i n p a r t c o n s o l i d a t e d and i n p a r t r e f o r m e d by the Lunacy A c t . The Act was an extensive, omnibus s t a t u t e that d e a l t s i m u l t a n e o u s l y with a l l m a t t e r s and p r o c e d u r e s a f f e c t i n g the s o c i a l , economic and m e d i c a l management of l u n a t i c s ( i . e . , i d i o t s and p e r s o n s of unsound mind). I t was a s t a t u t e that r e f l e c t e d the 'triumph of 39 l e g a l i s m ' i n s o f a r as i t c o n t a i n e d e v e r y c o n c e i v a b l e l e g a l s a f e g u a r d a g a i n s t the i m p r o p e r d e t e n t i o n and t r e a t m e n t of l u n a t i c s (Jones, 1960). As Bean (1980) n o t e s , i t embodied a d i s p l a y of l e g a l power which r e f l e c t e d the 19th century ideas of l i b e r t y and the s a n c t i t y of the i n d i v i d u a l , both elements being e m b e l l i s h e d by the extreme pessimism that e x i s t e d r e g a r d i n g the e f f i c a c y of medical treatment f o r the insane. In t h i s regard, most a n a l y s t s of Commonwealth mental h e a l t h law view the Act as a watershed i n lunacy law reform (Gordon & Verdun-Jones, 1986; Bean, 1980; Jones, 1960). Widespread p u b l i c concern f o r the improper treatment of insane persons i n i n s t i t u t i o n s i n B r i t a i n began to emerge i n the l a t e 18th century and t h i s r e s u l t e d i n the formation of s e v e r a l , P a r l i a m e n t a r y S e l e c t Committees of Enquiry (Jones, 1955; 1960; Bean, 1980; B u t l e r , 1985). Throughout the 19th century, these Committees made numerous recommendations f o r reform which were expressed promptly i n new l e g i s l a t i o n . D espite these reforms, f u r t h e r S e l e c t Committees were formed, p r i n c i p a l l y to f i n d ways of b a l a n c i n g the need f o r safeguards a g a i n s t improper d e t e n t i o n with the need f o r the e a r l y treatment of i n s a n i t y . Regardless o f t h e p r o t e s t a t i o n s and c o u n t e r - c l a i m s o f t h e m e d i c a l p r o f e s s i o n , by the l a t e 19th c e n t u r y f e a r s s u r r o u n d i n g the i m p r o p e r management o f t h e i n s a n e a p p e a r t o have b e e n s u f f i c i e n t l y powerful to o v e r r i d e the o b j e c t i o n s of p h y s i c i a n s and r e s u l t i n the s u c c e s s f u l passage of the Lunacy Act (Jones, 1960; B u t l e r , 1985). P a r a l l e l developments were o c c u r r i n g i n the United S t a t e s and, because of the widespread disenchantment 40 with the asylum system, many Stat e s adopted l e g i s l a t i o n which a l s o sought to r e s t r a i n the a c t i v i t i e s of asylum operators and medical p r a c t i t i o n e r s (Rothman, 1980; Grob, 1973; 1983; B r a k e l , et a l , 1985). The I m p e r i a l Lunacy Act, 1890; The Epitome of 'Legalism' The s i g n i f i c a n c e of the Lunacy Act as a 'watershed' i n lunacy law reform, and the extent to which i t embodied a method of r e g u l a t i n g the s y s t e m f o r the management of i n s a n e and l u n a t i c persons known as 'legalism', can be gleaned from a b r i e f sketch of i t s main p r o v i s i o n s . The I m p e r i a l s t a t u t e made p r o v i s i o n f o r the j u d i c i a r y to appoint 'committees' (i.e., guardians) who could take charge of both the person and e s t a t e s (i.e., property and other assets) of l u n a t i c s . The r e l e v a n t p r o v i s i o n s of the Act c o n s t i t u t e d a c o n s o l i d a t i o n , r a t h e r than a p r o f o u n d r e c o n s t r u c t i o n , of the law; however, t h i s i s not to devalue t h e i r importance s i n c e a r a t i o n a l i z a t i o n of the procedures f o r a p p o i n t i n g committees was long overdue (Jones, 1955; 1960). B r i e f l y , any person could apply to a 'Judge i n Lunacy 1 f o r an i n q u i r y i n t o an i n d i v i d u a l ' s 'soundness of mind' and a b i l i t y to manage h i s or her e s t a t e or person.^ The i n d i v i d u a l d i d not have to be detained as a l u n a t i c i n an asylum and a Judge c o u l d e i t h e r order a t r i a l or, i f there was no doubt that the person was a l u n a t i c , r e f e r the matter to a 'Master i n Lunacy'. These j u d i c i a l o f f i c i a l s were empowered to appoint a 'committee' f o r the l u n a t i c and t h i s i n d i v i d u a l would then take charge of the 41 l u n a t i c ' s e s t a t e and person. The committee was to a d m i n i s t e r a l u n a t i c ' s p r o p e r t y and business, pay any debts, and meet any c o n t i n u i n g f i n a n c i a l o b l i g a t i o n s (e.g., support any dependants and pay the c o s t of c o n f i n e m e n t ) . However, a committee was subject to the d i r e c t i o n s and s u p e r v i s i o n of the c o u r t and t h i s e n s u r e d t h a t the i n d i v i d u a l e x e r c i s e d h i s or her powers and a u t h o r i t y i n the best i n t e r e s t s of the l u n a t i c . An i n d i v i d u a l under committeeship could recover c o n t r o l over h i s or her l i f e by a p p l y i n g t o a J u d g e i n L u n a c y and t h e l a t t e r c o u l d 'supersede' the o r i g i n a l order i f t h i s was deemed a p p r o p r i a t e . The p r o c e d u r e was aimed p r i m a r i l y at the management of l u n a t i c s who were b o t h under the c a r e and c o n t r o l of p r i v a t e i n d i v i d u a l s (e.g., a f a m i l y member) and endowed w i t h property (Jones, 1955). However, the management of the a f f a i r s of persons c o n f i n e d i n asylums, those w i t h s m a l l e s t a t e s , and those who were c l a s s i f i e d as 'mentally i n f i r m ' r a t h e r than l u n a t i c , a l s o f e l l w i t h i n the domain of the j u d i c i a r y . A person's e s t a t e c o u l d be placed i n the hands of a committee at the time he or she was being committed to an asylum by a judge and, i f an e s t a t e was v a l u e d at l e s s than 2,000 Pounds, the judge c o u l d pass c o n t r o l to l o c a l government o f f i c i a l s . 1 ^ Since confinement i n an i n s t i t u t i o n c o n s t i t u t e d a grave d e p r i v a t i o n of l i b e r t y , new c o n t r o l s and p r o c e d u r e s were introduced to govern the admission and r e l e a s e of l u n a t i c s . In a d d i t i o n , the s t a t u t e p r e s c r i b e d new r e g u l a t i o n s and procedures a f f e c t i n g a l l aspects of the d e t e n t i o n , treatment and i n s p e c t i o n of c o n f i n e d p e r s o n s , i n c l u d i n g l u n a t i c s who were c o n f i n e d i n 42 p r i v a t e homes (i.e., ' s i n g l e patients') (Jones, 1960). To these ends, a comprehensive system f o r the r e g u l a t i o n , l i c e n s i n g and i n s p e c t i o n of county asylums, p r i v a t e a s y l u m s , and ' l i c e n s e d houses', was e s t a b l i s h e d . The management of l u n a t i c s was to be ' p o l i c e d 1 by a s i n g l e , n a t i o n a l , and i n d e p e n d e n t i n s p e c t o r a t e known as 'The C o m m i s s i o n e r s i n Lunacy' (op c i t ) . T h i s body, which was comprised of p h y s i c i a n s and b a r r i s t e r s , was granted sweeping powers to v i s i t and i n s p e c t a l l p l a c e s of confinement and the C o m m i s s i o n e r s c o u l d p r o s e c u t e any p e r s o n who b r e a c h e d the p r o v i s i o n s of the s t a t u t e . In a d d i t i o n , l o c a l i n s p e c t o r a t e s , c o n s i s t i n g of three j u s t i c e s and a p h y s i c i a n , were c r e a t e d to s u p e r v i s e c o u n t y a s y l u m s , w h i l e a l o n g - s t a n d i n g system of i n s p e c t i o n by l e g a l and m e d i c a l ' O f f i c i a l V i s i t o r s ' was expanded. The l a t t e r were g r a n t e d a d d i t i o n a l powers to su p e r v i s e the treatment of lunatics.-'-* The s t a t u t e i n t r o d u c e d s t r i c t j u d i c i a l c o n t r o l s over the commitment of persons to i n s t i t u t i o n s . While, i n emergencies, a p e r s o n c o u l d be a d m i t t e d and d e t a i n e d f o r seven days on the b a s i s of one medical c e r t i f i c a t e , long-term commitment r e q u i r e d a ' r e c e p t i o n o r d e r ' i s s u e d by a J u s t i c e , M a g i s t r a t e or County Court Judge. An a p p l i c a t i o n f o r an order had to be supported by two medical c e r t i f i c a t e s and the j u d i c i a l o f f i c i a l was charged with the task of ensuring that a commitment was j u s t i f i e d . The p o l i c e were g r a n t e d the power to bo t h apprehend l u n a t i c s who were ' w a n d e r i n g a t l a r g e ' and seek a w a r r a n t f o r the 43 a p p r e h e n s i o n of a l u n a t i c whom they b e l i e v e d was not under proper care or c o n t r o l . However, f o l l o w i n g apprehension, the l u n a t i c had to be taken before a J u s t i c e and t h i s o f f i c i a l could e i t h e r r e l e a s e the person or i s s u e a 'summary r e c e p t i o n order' committing the person to an i n s t i t u t i o n . 1 2 I t was not p o s s i b l e f o r a person to be l e g a l l y c o n f i n e d i n an i n s t i t u t i o n u nless these procedures had been f o l l o w e d and the s t a t u t e p r e s c r i b e d s t i f f p e n a l t i e s f o r any person who ignored i t s p r o v i s i o n s . 1 3 There were, however, two ways i n which the commitment process could be circumvented. As Bean (1980) p o i n t s out, persons could admit themselves as 'voluntary boarders' to a l i c e n s e d house or r e g i s t e r e d h o s p i t a l . A l t e r n a t i v e l y , a person d e c l a r e d to be a l u n a t i c f o l l o w i n g an i n q u i s i t i o n b efore a Judge i n Lunacy could be admitted to an asylum on an order signed by h i s or her committee. 1 4 However, these 'streamlined' procedures were only a c c e s s i b l e to those who could pay f o r t h e i r own care and treatment; that i s , those c l a s s i f i e d as ' p r i v a t e p a t i e n t s ' . Those without s u f f i c i e n t funds were t r e a t e d as 'pauper p a t i e n t s ' and were u s u a l l y committed to asylums by means of a 'summary r e c e p t i o n o r d e r ' s e c u r e d by e i t h e r the p o l i c e or a Poor Law r e c e i v i n g o f f i c e r (Bean, 1980). While the commitment process was c l o s e l y r e g u l a t e d by the j u d i c i a r y , the l a t t e r ceased to e x e r c i s e c o n t r o l once an insane p e r s o n had e n t e r e d an a s y l u m . However, t h e p r o c e s s o f determining the need f o r continued d e t e n t i o n , the treatment of l u n a t i c s , and the discharge of c o n f i n e d persons was monitored c l o s e l y by a q u a s i - j u d i c i a l body; namely, the Commissioners i n 44 Lunacy. W i t h i n one month of a l u n a t i c ' s a d m i s s i o n t o an i n s t i t u t i o n , the m e d i c a l o f f i c e r i n charge was to submit a r e p o r t to the Commissioners. R e p r e s e n t a t i v e s of the i n s p e c t o r a t e were then t o v i s i t the p e r s o n , r e v i e w the need f o r d e t e n t i o n and, i f n e c e s s a r y , o r d e r h i s or her r e l e a s e . In a d d i t i o n , a l u n a t i c c o u l d o n l y be d e t a i n e d f o r s e t p e r i o d s o f t i m e ( i n i t i a l l y , 12 months) without being re-examined and c e r t i f i e d by t h e m e d i c a l o f f i c e r . Whenever t h i s o c c u r r e d , t h e C o m m i s s i o n e r s had to be n o t i f i e d and they were empowered to review the case and discharge the person as they thought f i t . ^ Those c o n f i n e d i n i n s t i t u t i o n s were a f f o r d e d s e v e r a l p r o t e c t i o n s and g r a n t e d some r i g h t s . M e c h a n i c a l r e s t r a i n t s c ould not be used without medical c e r t i f i c a t i o n s p e c i f y i n g the need f o r such 'treatment' and without t h e i r use being recorded. There could be no i n t e r f e r e n c e w i t h a person's m a i l where he or she was c o m m u n i c a t i n g w i t h , f o r example, the C o m m i s s i o n e r s . L u n a t i c s had a r i g h t to see v i s i t i n g Commissioners and a n o t i c e of t h i s r i g h t had to be p o s t e d i n a c o n s p i c u o u s p o s i t i o n . L u n a t i c s had a r i g h t to r e c e i v e v i s i t o r s i f t h i s was approved by the C o m m i s s i o n e r s and p r i v a t e p a t i e n t s had a r i g h t t o be examined by an independent j u d i c i a l o f f i c i a l i f they had been admitted by a committee, without f i r s t being seen by a member of the j u d i c i a r y . ^ Asylum i n m a t e s were to be d i s c h a r g e d once they had recovered t h e i r 'reason' and the Commissioners were charged w i t h the task of ensuring that t h i s occurred. For example, i f i n 45 the c o u r s e of a v i s i t to an i n s t i t u t i o n , two C o m m i s s i o n e r s formed the o p i n i o n that a person should be r e l e a s e d , they c o u l d order the i n d i v i d u a l ' s immediate di s c h a r g e , r e g a r d l e s s of the 1 7 views of the medical o f f i c e r i n charge. As the f o r e g o i n g sketch i n d i c a t e s , the Lunacy Act imposed s t r i c t c o n t r o l s on the commitment of l u n a t i c s to p l a c e s of confinement i n B r i t a i n . While the admission process r e q u i r e d medical c e r t i f i c a t i o n , the j u d i c i a r y were r e s p o n s i b l e f o r making the f i n a l d e c i s i o n a f t e r a thorough review of the grounds f o r confinement. A measure of post-commitment s u p e r v i s i o n was a l s o p r ovided by the Commissioners i n Lunacy who were to ' p o l i c e ' the d e t e n t i o n , t r e a t m e n t and r e l e a s e of l u n a t i c s . Very l i t t l e u n m o n i t o r e d power and a u t h o r i t y was g r a n t e d t o m e d i c a l p r a c t i t i o n e r s i n r e g a r d to most a s p e c t s of the management of l u n a t i c s and i t i s , t h e r e f o r e , p o s s i b l e to see how and why the I m p e r i a l s t a t u t e i s viewed' as the epitome of 'legalism'. The Impact of Legalism i n Canada Although the I m p e r i a l s t a t u t e had an impact i n Canada, i t s e f f e c t was not i n s t a n t a n e o u s , u n i v e r s a l , or e v e n l y d i s t r i b -u t e d . 1 8 At the b e g i n n i n g of the c e n t u r y the p r o c e d u r e s f o r a p p o i n t i n g c o m m i t t e e s v a r i e d , a l t h o u g h t h i s a s p e c t of the management o f l u n a t i c s was f i r m l y i n t h e hands o f t h e j u d i c i a r y . 1 ^ S i m i l a r l y , the apprehension and i n i t i a l commitment of dangerous insane persons was a matter f o r the j u d i c i a r y . By c o n t r a s t , the laws a f f e c t i n g b o t h the e s t a b l i s h m e n t and r e g u l a t i o n of asylums, the commitment of non-dangerous persons, and the p r o c e s s of t r e a t i n g and r e l e a s i n g asylum i n m a t e s 46 r e f l e c t e d two d i f f e r e n t a s p e c t s of the l e g a l model which had been embraced i n B r i t a i n . In some p r o v i n c e s , a d m i s s i o n to p l a c e s of segregated, t h e r a p e u t i c confinement was s u p e r v i s e d s t r i c t l y by the j u d i c i a r y . In other p r o v i n c e s , commitment was l e f t i n the hands of the medical p r o f e s s i o n but the continued confinement and treatment of some c a t e g o r i e s of insane persons was s u p e r v i s e d by q u a s i - j u d i c i a l bodies which were s i m i l a r to the Commissioners i n Lunacy. P r o v i n c i a l laws recognized, and e s t a b l i s h e d procedures f o r d e a l i n g with, two c a t e g o r i e s of insane person; namely, those who were dangerous and wandering a t l a r g e , and t h o s e who d i d not meet t h e s e c r i t e r i a . In t h e T e r r i t o r i e s , h o w e v e r , no d i s t i n c t i o n was made. An insane person was to be apprehended, brought before a J u s t i c e , t e m p o r a r i l y detained i n a gaol, and t h e n removed s w i f t l y from the r e g i o n . 2 0 E l s e w h e r e , the d i s t i n c t i o n between dangerousness and non-dangerousness was of importance. The p r o c e d u r e s f o r the management of dangerous i n s a n e p e r s o n s wer^e c o n s i s t e n t a c r o s s the c o u n t r y and had been i n e x i s t e n c e f o r d e c a d e s . A d a n g e r o u s p e r s o n was t o be apprehended and brought before a J u s t i c e who was then r e q u i r e d to decide whether or not the person was insane and i n need of c o n f i n e m e n t . I f t h i s was the case, the p e r s o n was to be t e m p o r a r i l y c o m m i t t e d to an i n s t i t u t i o n f o r e x a m i n a t i o n by medical p r a c t i t i o n e r s . The l a t t e r would then decide whether or not to admit the i n d i v i d u a l on a long-term basis. 2-'-47 In Manitoba, f o r example, the Insane Asylums A c t ^ set out the procedures to be f o l l o w e d before a person c o u l d be committed to a p r o v i n c i a l i n s a n e asylum. Any p e r s o n c o u l d l a y an i n f o r m a t i o n before a J u s t i c e of the Peace i f i t was f e l t t h a t an i n d i v i d u a l was " i n s a n e and dangerous to be a t l a r g e " , and e x h i b i t i n g e i t h e r "a purpose of committing some crime which, i f committed, such person would be l i a b l e to be i n d i c t e d " , or "a purpose of doing some grievous b o d i l y harm to h i m s e l f " . 2 3 The J u s t i c e c ould then i s s u e a warrant f o r the apprehension of the p e r s o n and commit the i n d i v i d u a l to e i t h e r a g a o l or to the custody of some other i n d i v i d u a l , pending both the completion of i n q u i r i e s i n t o the s o c i a l and economic standing of the person and a t r i a l of h i s or her s a n i t y . 2 4 ( I f , f o l l o w i n g a t r i a l , the J u s t i c e was s a t i s f i e d t h a t the i n d i v i d u a l was i n s a n e and dangerous, the commitment p r o c e s s c o u l d begin. The person could be returned to h i s or her home province or t r a n s f e r r e d to the p r o v i n c i a l asylums at S e l k i r k or Brandon. However, the l a t t e r c o u r s e of a c t i o n was dependent upon both the a v a i l a b i l i t y of space i n an i n s t i t u t i o n and the outcome of an e x a m i n a t i o n by two m e d i c a l p r a c t i t i o n e r s . The l a t t e r had t o c e r t i f y t h a t the p e r s o n was i n s a n e b e f o r e admission could o c c u r . 2 5 As the example provided by Manitoba i n d i c a t e s , w h ile the process of i n i t i a l apprehension and temporary d e t e n t i o n was a m a t t e r f o r the j u d i c i a r y , d e c i s i o n s r e g a r d i n g l o n g - t e r m commitment were l e f t to medical p r a c t i t i o n e r s . S i m i l a r l y , once an insane and dangerous person had been c o n f i n e d i n an asylum, 48 h i s or her f a t e was l e f t to the d i s c r e t i o n of the m e d i c a l superintendent. 2** This r e f l e c t e d the s i t u a t i o n a f f e c t i n g those who were insane but not deemed to be dangerous. While the p r o v i n c i a l laws were c o n s i s t e n t i n regard to those deemed to be dangerous, the procedures f o r managing insane but non-dangerous p e r s o n s d i f f e r e d . In some p r o v i n c e s , the commitment of t h i s category of person was s u p e r v i s e d c l o s e l y by the j u d i c i a r y ; however, once a d m i t t e d to an asylum the w e l l -being of the insane person ceased to be of i n t e r e s t . In other p r o v i n c e s , commitment was l e f t to the d i s c r e t i o n of m e d i c a l p r a c t i t i o n e r s but a measure of post-commitment s u p e r v i s i o n by q u a s i - j u d i c i a l bodies was provided f o r those who were paying f o r t h e i r own confinement i n p r i v a t e asylums. In Nova S c o t i a , P r i n c e Edward Island, Manitoba and B r i t i s h C o l u m b i a , the j u d i c i a r y p l a y e d a key r o l e i n the commitment p r o c e s s , 2 ^ and B r i t i s h Columbia was the f i r s t p r ovince to adopt both the ' l e g a l model' and the a l l i e d procedures set out i n the I m p e r i a l Lunacy_ A c t . T h e r e i s l i t t l e d o u b t t h a t t h i s development was s t i m u l a t e d by the f i n d i n g s of a Royal Commission which, i n 1894, i n v e s t i g a t e d the g r o s s m a l t r e a t m e n t of the i n s a n e at the p r o v i n c i a l a s y l u m i n New W e s t m i n s t e r ( F o u l k e s , 1961; 1974). The Commission made sweeping recommendations f o r reform, many of which appeared subsequently i n the H o s p i t a l s f o r Insane A c t . 2 8 T h i s s t a t u t e , which was e n a c t e d i n 1897, was c o n c e r n e d p r i m a r i l y w i t h the r e g u l a t i o n of the p r o v i n c i a l asylum, but p r o v i s i o n was a l s o made f o r the l i c e n s i n g and 49 i n s p e c t i o n of ' p r i v a t e houses' i n which l u n a t i c s were r e c e i v i n g care or treatment. 2^ These e s t a b l i s h m e n t s were to be under the c o n t r o l of a s p e c i a l Inspector but the process of commitment was to be governed by the general p r o v i s i o n s of the s t a t u t e . No person c o u l d be admitted to an i n s t i t u t i o n without a commitment order signed by a j u d i c i a l o f f i c i a l who had examined the i n d i v i d u a l i n question. The order had to be accompanied by the c e r t i f i c a t e s of two medical p r a c t i t i o n e r s i n d i c a t i n g that the p e r s o n was i n s a n e and "a p r o p e r p e r s o n f o r c a r e and t r e a t m e n t " i n an i n s t i t u t i o n . In emergency s i t u a t i o n s , one c e r t i f i c a t e would s u f f i c e and an i n d i v i d u a l c ould be t e m p o r a r i l y c o n f i n e d on the b a s i s of an 'urgency o r d e r ' i s s u e d by a •3(1 J u s t i c e . J U The p r o c e d u r e found i n B r i t i s h C o l u m b i a was g e n e r a l l y f o l l o w e d i n the other p r o v i n c e s . In Nova S c o t i a , f o r example, admission to the Nova S c o t i a H o s p i t a l r e q u i r e d a warrant i s s u e d by e i t h e r a M a g i s t r a t e or two J u s t i c e s who had reviewed the case of an insane person to ensure that commitment was n e c e s s a r y . 3 1 The warrant had to be accompanied by two medical c e r t i f i c a t e s i n d i c a t i n g t h a t the i n d i v i d u a l was i n s a n e , and the m e d i c a l s u p e r i n t e n d e n t of the h o s p i t a l had to approve the a d m i s s i o n . Those who were ' i d i o t s ' , e p i l e p t i c s , dangerous to themselves or o t h e r s , or u n l i k e l y to b e n e f i t from t r e a t m e n t would not be a d m i t t e d . These p e r s o n s , a l o n g w i t h the i n c u r a b l e 'harmless i n s a n e ' , were t o be c o n f i n e d i n t h e c o u n t y a s y l u m s and commitment to these p l a c e s had to be approved by two J u s t i c e s . 3 2 50 W h i l e , i n t h e s e p r o v i n c e s , the j u d i c i a r y , p l a y e d a key s u p e r v i s o r y r o l e i n r e l a t i o n to the i n i t i a l commitment process, t h e i r i n t e r e s t waned once an insane person had been confined. The continued d e t e n t i o n , treatment and r e l e a s e of a person was l e f t t o t h e d i s c r e t i o n o f an i n s t i t u t i o n ' s m e d i c a l s u p e r i n t e n d e n t . In B r i t i s h C o l u m b i a , f o r example, i n s a n e p e r s o n s were p l a c e d under the s u p e r v i s i o n of the as y l u m s u p e r i n t e n d e n t who was c h a r g e d w i t h the duty to " d i r e c t and c o n t r o l the m e d i c a l and moral t r e a t m e n t " of i n m a t e s . He was empowered to d i s c h a r g e those under h i s ch a r g e , a b s o l u t e l y or c o n d i t i o n a l l y , and c o u l d , f o r example, r e l e a s e a p e r s o n 'on p r o b a t i o n ' . 3 3 S i m i l a r d i s c r e t i o n a r y powers were granted to the medical superintendent of the Nova S c o t i a H o s p i t a l where inmates were to be c o n f i n e d and t r e a t e d u n t i l e i t h e r c u r e d or deemed s u i t a b l e f o r t r a n s f e r to a county asylum. 3^ As t h e f o r e g o i n g i n d i c a t e s , i n some p r o v i n c e s the government had chosen to p l a c e the commitment process i n the hands of j u d i c i a l o f f i c i a l s and the procedures were s i m i l a r to those which e x i s t e d i n B r i t a i n . However, no Commissioners i n Lunacy had been appointed to 'police ' the subsequent treatment of c o n f i n e d persons. C e r t a i n l y , i n Manitoba and Nova S c o t i a the g e n e r a l c o n d i t i o n s i n a s y l u m s were m o n i t o r e d by government i n s p e c t o r s and, i n the case of county asylums i n Nova S c o t i a , l o c a l b o a r d s of v i s i t o r s . 3 ^ T h e i r mandate d i d not, however, ext e n d t o the d i r e c t s u p e r v i s i o n of the conduct of m e d i c a l s u p e r i n t e n d e n t s and a s y l u m s t a f f . The p r i m a r y t a s k o f i n s p e c t o r s was to ensure that s t a t i s t i c s and general standards 51 were maintained. They d i d not have the power to i n t e r f e r e w i t h the d e c i s i o n s of medical superintendents i n regard to i n d i v i d u a l inmates (Strong, 1930). The commitment, treatment and continued confinement of non-dangerous insane persons were handled d i f f e r e n t l y i n New Brunswick, Ontario, and Quebec. In these p r o v i n c e s , the power to admit insane persons was granted to medical p r a c t i t i o n e r s but the p r o c e s s of t r e a t m e n t and c o n t i n u e d c o n f i n e m e n t c o u l d be s u p e r v i s e d by q u a s i - j u d i c i a l bodies s i m i l a r to the Commissioners i n Lunacy i n B r i t a i n . However, i n O n t a r i o and Quebec, t h i s depended upon where the insane person was c o n f i n e d and who was paying f o r the i n d i v i d u a l ' s care and treatment. Those who were paying f o r t h e i r own confinement i n a p r i v a t e asylum were b e t t e r p r o t e c t e d than those c o n f i n e d i n the p u b l i c asylums of O n t a r i o or housed at p u b l i c expense in the p r i v a t e asylums of Quebec. The commitment of non-dangerous insane persons to both the p u b l i c asylum i n New B r u n s w i c k and the p u b l i c and p r i v a t e a s y l u m s i n O n t a r i o , m e r e l y r e q u i r e d the c e r t i f i c a t e s of two medical p r a c t i t i o n e r s accompanied by s u p p o r t i n g documentation. ° In a d d i t i o n , i n Ontario, a person could be admitted to a p r i v a t e asylum on a 'voluntary* b a s i s p r o v i d i n g one medical p r a c t i t i o n e r c e r t i f i e d t h a t the i n d i v i d u a l needed ' e a r l y t r e a t m e n t ' to prevent the development of 'mental derangement'. 3^ In Quebec, a p e r s o n who c o u l d not pay f o r c a r e and t r e a t m e n t c o u l d be c o m m i t t e d to a p r i v a t e asylum t h a t c o n t r a c t e d w i t h the p r o v i n c i a l government f o r the r e c e p t i o n and confinement of such cases. This course of a c t i o n r e q u i r e d one medical c e r t i f i c a t e 52 sworn before a J u s t i c e , supported by c e r t i f i c a t e s i s s u e d by a member of the c l e r g y and the mayor of the person's m u n i c i p a l i t y , c o n f i r m i n g both the need f o r c o n f i n e m e n t and the person's i n a b i l i t y to pay ( L a n g l o i s , 1976). Those who were able to pay c o u l d e i t h e r admit t h e m s e l v e s , or be a d m i t t e d by a p e r s o n r e s p o n s i b l e f o r t h e i r c a r e (e.g., a c u r a t o r or g u a r d i a n ) ; however, any a p p l i c a t i o n f o r admission had to be supported by the c e r t i f i c a t e s of medical p r a c t i t i o n e r s . 3 8 G e n e r a l l y , medical c e r t i f i c a t e s were s u f f i c i e n t a u t h o r i t y f o r an insane person to be conveyed to and c o n f i n e d w i t h i n an asylum where the i n d i v i d u a l was sub j e c t to the c o n t r o l of the medical superintendent. The l a t t e r was r e q u i r e d to d i r e c t and c o n t r o l the medical and moral treatment of those i n h i s charge and insane persons were to remain i n confinement u n t i l such time as the s u p e r i n t e n d e n t f e l t t h a t they were e i t h e r 'cured' o r ready to be r e l e a s e d to the custody of f r i e n d s or r e l a t i v e s . 3 ^ Persons who were paying f o r t h e i r own confinement i n p r i v a t e asylums could be r e l e a s e d on the order of the i n d i v i d u a l who had admitted them but a medical superintendent could o b j e c t to the r e l e a s e of an inmate whom he f e l t was dangerous. 4^ Consequently, the governments of these p r o v i n c e s had seen f i t to p l a c e the management of non-dangerous insane persons i n the hands of the m e d i c a l p r o f e s s i o n . There was no j u d i c i a l s c r u t i n y of the commitment p r o c e s s a l t h o u g h , i n Quebec, p r o v i s i o n was made f o r a form of post-commitment j u d i c i a l review fo r those paying f o r t h e i r own confinement. A person who f e l t 53 that he or she had been w r o n g f u l l y committed to an asylum c o u l d apply to a d i s t r i c t court judge f o r r e l e a s e . 4 1 Elsewhere, and n o t w i t h s t a n d i n g the p o s s i b i l i t y of a p p l y i n g to a c o u r t f o r a w r i t of habeas corpus, the r e l e a s e of a person was l e f t to the d i s c r e t i o n of an asylum s u p e r i n t e n d e n t . 4 2 T h i s i s not to s u g g e s t t h a t b o t h the c o n d i t i o n s o f confinement and the treatment of a l l insane persons were not s c r u t i n i z e d . In O n t a r i o and Quebec, asylum c o n d i t i o n s were monitored by government i n s p e c t o r s who were r e s p o n s i b l e f o r both the e s t a b l i s h m e n t and enforcement of general standards and the p e r i o d i c i n s p e c t i o n of many types of f a c i l i t i e s (Strong, 1930). In O n t a r i o , two p e r s o n s a c t e d as i n s p e c t o r s of the p u b l i c a s y l u m s , h o s p i t a l s , common g a o l s and r e f o r m a t o r i e s i n the p r o v i n c e and one of th e s e i n s p e c t o r s was r e s p o n s i b l e f o r v i s i t i n g and examining the f i v e p u b l i c asylums at l e a s t three times per y e a r . 4 3 However, and l i k e the government i n s p e c t o r s i n p r o v i n c e s such as Nova S c o t i a and M a n i t o b a , he was not in v o l v e d i n the d i r e c t s u p e r v i s i o n of c o n f i n e d persons (op c i t ) . In a d d i t i o n , the w e l l - b e i n g of insane persons c o n f i n e d i n the p u b l i c asylum i n New Brunswick, and those c o n f i n e d on a p r i v a t e b a s i s i n On t a r i o and Quebec, was su p e r v i s e d by q u a s i - j u d i c i a l bodies s i m i l a r to the Commissioners i n Lunacy found i n B r i t a i n . In New Brunswick, the w e l l - b e i n g of those i n the p u b l i c i asylum was m o n i t o r e d by both a p a n e l of C o m m i s s i o n e r s and a group of independent, ' o f f i c i a l v i s i t o r s ' . 4 4 The former had to ins p e c t the asylum once a month and the v i s i t o r s were empowered to undertake an i n s p e c t i o n at any time. The v i s i t o r s i n c l u d e d 54 j u d i c i a l o f f i c i a l s such as the C h i e f J u s t i c e and the A t t o r n e y -General, as w e l l as other i n d i v i d u a l s , such as the P r o v i n c i a l S e c r e t a r y and r e p r e s e n t a t i v e s of the d i f f e r e n t C h r i s t i a n denominations. Both t h e i r p r e c i s e r o l e and the scope of t h e i r powers i s u n c l e a r but the goal appeared to be the e s t a b l i s h m e n t of a body of r e s p o n s i b l e i n d i v i d u a l s who could e i t h e r respond to complaints or undertake independent i n s p e c t i o n s whenever t h i s was deemed necessary. The ' o f f i c i a l v i s i t o r ' scheme a l s o e x i s t e d i n O n t a r i o and Quebec where the mandate of v i s i t o r s was more c l e a r l y s p e l l e d out; however, the v i s i t o r s were concerned only w i t h the conduct of p r i v a t e a sylums and the w e l l - b e i n g of those c o n f i n e d on a p r i v a t e b a s i s . In b o t h p r o v i n c e s , the p r i v a t e a s y l u m s were r e g u l a t e d by s t a t u t e s which set out s t r i n g e n t c o n d i t i o n s f o r the e s t a b l i s h m e n t and conduct of such i n s t i t u t i o n s and t h i s was p a r t i c u l a r l y e v i d e n t i n Q u e b e c . 4 5 As a r e s u l t of a s t e a d y barrage of c r i t i c i s m , the p r o v i n c i a l government had taken steps to improve c o n d i t i o n s w i t h i n the p r i v a t e i n s t i t u t i o n s (Appleton, 1967; Smandych & Verdun-Jones, 1982). Where asylums were under c o n t r a c t with the government, the province appointed and p a i d the s a l a r i e s of, the medical superintendents and s e n i o r medical s t a f f . These personnel had complete c o n t r o l over both the care and treatment of inmates and the s t a f f who were employed by the asylum p r o p r i e t o r (i.e., 'keepers' and 'matrons'). 4*' In b o t h O n t a r i o and Quebec, a p r i v a t e a s y l u m c o u l d not o p e r a t e w i t h o u t a g o v e r n m e n t l i c e n c e and a t h o r o u g h 55 i n v e s t i g a t i o n of the proposed asylum had to be conducted before a l i c e n c e could be i s s u e d . A p r o p r i e t o r had to pay a bond, with e q u i v a l e n t s u r e t i e s , " f o r the good b e h a v i o u r of such p e r s o n during the time f o r which the l i c e n c e continues i n f o r c e . " 4 ^ E v e r y p r i v a t e asylum had to have a b o a r d or group of • v i s i t o r s ' who were to oversee the conduct of the i n s t i t u t i o n . In Ontario, the board of v i s i t o r s f o r an asylum was to c o n s i s t of a Judge of the County C o u r t , the warden of the county, the c l e r k of the peace f o r the county, and a l o c a l p h y s i c i a n . 4 8 In Quebec, the v i s i t o r s were to be a group c o n s i s t i n g of three or more J u s t i c e s and one or more p h y s i c i a n s . 4 ^ G r e a t c a r e was taken to ensure t h a t the v i s i t o r s were independent; indeed, they were d i s q u a l i f i e d from membership i f they held any pecuniary or p r o f e s s i o n a l i n t e r e s t i n an asylum. 5^ 1 A l t h o u g h a v i s i t c o u l d o c c u r at any t i m e , members of a group or board of v i s i t o r s were to v i s i t the asylum or asylums i n t h e i r area at l e a s t four times each year. They were r e q u i r e d to examine the e n t i r e b u i l d i n g and i t s grounds, and v i s i t every inmate, t a k i n g p a r t i c u l a r note of the extent to which persons were being kept under r e s t r a i n t . The reasons f o r t h i s mode of 'treatment' were to be e x p l o r e d . The v i s i t o r s were a l s o r e q u i r e d to determine whether there had been any i r r e g u l a r i t i e s i n the commitment procedures and to e s t a b l i s h whether d i v i n e s e r v i c e was b e i n g p e r f o r m e d , "...to what numbers...and the e f f e c t thereof". The nature and impact of any "occupations or amusements" was a l s o to be a s s e s s e d . 5 1 56 In b o t h p r o v i n c e s , asylum p r o p r i e t o r s were r e q u i r e d to keep d e t a i l e d records of the admission, c o n d i t i o n , treatment, d i s c h a r g e and d e a t h s of i n m a t e s and the v i s i t o r s c o u l d , on r e q u e s t , a r r a n g e f o r a s e a r c h of asylum r e c o r d s to d e t e r m i n e whether or not a person was under confinement. They were to be n o t i f i e d of any ' v o l u n t a r y ' a d m i s s i o n and duty bound t o immediately v i s i t the person i n order to v e r i f y t h a t he or she had been admitted v o l u n t a r i l y . An i n d i v i d u a l who had admitted an insane person c o u l d order that person's discharge; however, i f the a t t e n d i n g p h y s i c i a n f e l t that the person was dangerous, he c o u l d a t t e m p t to o b s t r u c t r e l e a s e . I f t h i s o c c u r r e d , two v i s i t o r s (one b e i n g a p h y s i c i a n ) c o u l d v i s i t the inmate and a u t h o r i z e d i s c h a r g e , r e g a r d l e s s of the a t t e n d i n g p h y s i c i a n ' s v i e w s , i f they b e l i e v e d t h a t the p e r s o n was b e i n g d e t a i n e d without s u f f i c i e n t cause. Although the medical superintendent of an asylum was a l l o w e d to a u t h o r i z e ' t r i a l l e a v e ' , the v i s i t o r s e x e r c i s e d c o n t r o l over a number of other matters such as the admission of r e l a t i v e s and f r i e n d s who wished to v i s i t an i n d i v i d u a l . They c o u l d a l s o a u t h o r i z e 'excursions' f o r inmates i f i t was b e l i e v e d that t h i s might b e n e f i t t h e i r h e a l t h . ^ The v i s i t o r s were a l s o empowered to hold an i n q u i r y i n t o any m a t t e r of i n t e r e s t t o them and they c o u l d i n i t i a t e a p r o s e c u t i o n f o r any breach of the p r o v i s i o n s of the r e g u l a t i n g s t a t u t e s . This was not an e x c l u s i v e power; however, before any person could launch a p r o s e c u t i o n or commence l i t i g a t i o n , the matter had to be r e f e r r e d to the v i s i t o r s f o r i n v e s t i g a t i o n and a p p r o v a l . 5 3 57 The v i s i t o r s were to play a r o l e i n the ' p o l i c i n g ' of the p r i v a t e asylums and the scheme was s i m i l a r to the Commissioners i n Lunacy found i n B r i t a i n a t the t i m e . I n s o f a r as the membership of a b o a r d or group of v i s i t o r s was d o m i n a t e d by j u d i c i a l o f f i c i a l s , c o n t r o l s of a ' l e g a l ' n a t u r e were p l a c e d upon t h e a c t i v i t i e s o f a s y l u m p r o p r i e t o r s and m e d i c a l p r a c t i t i o n e r s . However, these bodies were concerned only w i t h the w e l l - b e i n g of those c o n f i n e d on a p r i v a t e b a s i s . Those housed i n the p u b l i c a s y l u m s i n O n t a r i o , and t h o s e who were c o n f i n e d i n p r i v a t e asylums at p u b l i c expense i n Quebec, were not a f f o r d e d the same p r o t e c t i o n s . O n l y New B r u n s w i c k had e x t e n d e d t h i s mode o f q u a s i - j u d i c i a 1, p o s t - c o m m i t m e n t s u p e r v i s i o n to insane persons c o n f i n e d i n i t s p u b l i c asylum. Summary While the emergence of ' l e g a l i s m ' i n B r i t a i n had an impact on the l e g i s l a t i o n a f f e c t i n g the s t r a t e g y f o r the management of insane and l u n a t i c persons i n Canada, the r e c e p t i o n was mixed. Although some aspects of the I m p e r i a l , Lunacy Act, 1890 were to be found i n the r e l e v a n t s t a t u t e s of a l l the p r o v i n c e s at the turn of the century, nowhere was the ' l e g a l i s t i c ' scheme adopted i n i t s e n t i r e t y . Indeed, t h i s p e r i o d may be d e s c r i b e d as one of ' l i m i t e d l e g a l i s m ' and the b a s i c f e a t u r e s of the l e g i s l a t i o n i n e x i s t e n c e across Canada at the time are set out i n Table 2.1. A l l t h e p r o v i n c e s and t e r r i t o r i e s had p l a c e d t h e a p p o i n t m e n t of c o m m i t t e e s and g u a r d i a n s i n the hands of the j u d i c i a r y . The i n i t i a l commitment of dangerous insane persons to p l a c e s of s e g r e g a t e d , t h e r a p e u t i c c o n f i n e m e n t was a l s o a 58 matter f o r the j u d i c i a r y but the i s s u e of long term confinement was l e f t to the d i s c r e t i o n of medical p r a c t i t i o n e r s . In some pro v i n c e s , the commitment of non-dangerous insane persons was TABLE 2.1: PROCEDURES AFFECTING IN CANADA: 1900 INSANE PERSONS Medical S u p e r v i s i o n J u d i c i a l / Q u a s i -J u d i c i a l S u p e r v i s i o n I n i t i a l Commitment of Dangerous Persons - A l l p r o v i n c e s and t e r r i t o r i e s . I n i t i a l Commitment of Non-dangerous Persons Ont., Que., N.B. N.S., B.C., Man., P.E.I., T e r r i t o r i e s Long-Term Commitment of any Person A l l p r o v i n c e s . -Post-Commi tment Confinement of P u b l i c P a t i e n t s N.S, B.C., Man., P.E.I., Ont., Que. N.B., (Que)* Post-Commitment Confinement of P r i v a t e P a t i e n t s - Ont., Que. Committeeship/ Guardianship. - A l l p r o v i n c e s and t e r r i t o r i e s . * = S p e c i f i c r i g h t to seek j u d i c i a l review i f d e s i r e d . A review would not occur a u t o m a t i c a l l y . s u p e r v i s e d by the j u d i c i a r y , but m e d i c a l c e r t i f i c a t i o n was, ne v e r t h e l e s s , r e q u i r e d before a person c o u l d be admitted to an asylum. Once an i n s a n e p e r s o n had been committed, c o n t i n u e d confinement was su p e r v i s e d by medical superintendents. In other p r o v i n c e s , non-dangerous insane persons could be committed by 59 medical p r a c t i t i o n e r s , and c o n f i n e d by medical s u p e r i n t e n d e n t s , without j u d i c i a l s u p e r v i s i o n . However, q u a s i - j u d i c i a l bodies s i m i l a r to the B r i t i s h Commissioners i n Lunacy, s u p e r v i s e d the c o n f i n e m e n t of those who were p a y i n g f o r t h e i r own c a r e and treatment i n the p r i v a t e asylums i n Quebec and Ont a r i o , as w e l l as those committed to the p u b l i c asylum i n New Brunswick. I l l : THE DECL J.NE OF 'LIMITED ^GALI_SMJ_ AND THE RISE OF 'MEDICALIZATION' By 1915, s i g n s of a s h i f t i n the s t r a t e g y a f f e c t i n g the management of insane persons had appeared i n s e v e r a l p r o v i n c e s and changes had been made to s t a t u t e s . P u b l i c asylums were r e -named ' h o s p i t a l s f o r the insane' or 'mental h o s p i t a l s ' 5 4 and, i n O n t a r i o , the p r i v a t e a s y l u m s became ' s a n i t a r i a ' . 5 5 P e r s o n s c o n f i n e d i n i n s t i t u t i o n s were r e f e r r e d to as 'patients', r a t h e r t h a n ' l u n a t i c s ' o r ' i n m a t e s ' , and the c o n c e p t o f ' m o r a l t r e a t m e n t ' was removed from the l i s t of d u t i e s imposed upon medical s u p e r i n t e n d e n t s . 5 6 In a d d i t i o n , the c o n d i t i o n known as ' i n s a n i t y ' or 'lunacy' was r e f e r r e d to as a 'mental d i s e a s e ' . The idea of v o l u n t a r y admission to p u b l i c h o s p i t a l s had emerged and Nova S c o t i a was the f i r s t p rovince to take t h i s i n n o v a t i v e s t e p . In 1912, the Nova S c o t i a Hospi t a l A c t was amended to allow f o r the admission and treatment of 'voluntary p a t i e n t s ' , as w e l l as those who were committed i n v o l u n t a r i l y . Any persons who wis h e d to su b m i t t h e m s e l v e s to t r e a t m e n t and who were considered competent to make such a request, could be admitted to the Nova S c o t i a H o s p i t a l a t the d i s c r e t i o n of the m e d i c a l superintendent and without j u d i c i a l involvement. 5^ By 1913, the 60 idea of 'voluntary' admission to p u b l i c asylums had spread to O n t a r i o and t h e P u b H c L u n a t i _ c As_y^jjm£ A£_t was amended a c c o r d i n g l y . 5 8 A new type of f a c i l i t y f o r the 'active' medical treatment of p e r s o n s s u f f e r i n g from m e n t a l d i s e a s e s had a l s o been introduced i n Ontario. In 1914, a p u b l i c 'reception h o s p i t a l ' was added to the province's p u b l i c and p r i v a t e asylum system and t h i s f a c i l i t y was e s t a b l i s h e d i n a p a r t of the o l d T o r o n t o G e n e r a l H o s p i t a l (McNeel & L e w i s , 1960). I t was i n t e n d e d to d e a l w i t h p e r s o n s "whose c o n d i t i o n r e n d e r s i t d e s i r a b l e t h a t they s h o u l d be p l a c e d under o b s e r v a t i o n and t r e a t m e n t f o r nervous and mental di s e a s e s " , and admission was to be by medical c e r t i f i c a t i o n . 5 ^ These events r e f l e c t e d a general s h i f t i n the management of insane persons which occurred s i m u l t a n e o u s l y i n both B r i t a i n (Jones, 1960; Bean, 1980; B u t l e r , 1985) and the U n i t e d S t a t e s (Rothman, 1980; Grob, 1983). The developments were i n f l u e n c e d by the work of an i n t e r n a t i o n a l , 'mental hygiene 1 movement which had e s t a b l i s h e d ' n a t i o n a l c o m m i t t e e s ' i n B r i t a i n , the U n i t e d S t a t e s , and Canada (Armour, 1981; Rothman, 1980; Grob, 1983; G r i f f i n , 1967) and, between 1919 and 1939, a l l the Canadian p r o v i n c e s adopted the new s t r a t e g y . An e f f o r t was made to d i s t i n g u i s h between, segregate, and devise d i f f e r e n t t a c t i c s f o r the management of, d i f f e r e n t kinds of p a t i e n t s . In p a r t i c u l a r , a d i s t i n c t i o n was made between those who were m e n t a l l y d i s e a s e d and amenable to imme d i a t e , 61 i n t e n s i v e , medical treatment; those who were me n t a l l y d i s e a s e d but l e s s e a s i l y and q u i c k l y t r e a t e d ; and, t h o s e who were mentally d e f e c t i v e or mentally d i s o r d e r e d as a consequence of, f o r example, e p i l e p s y or a d d i c t i o n t o a l c o h o l . W h i l e the e x i s t i n g p l a c e s of segregated confinement were r e t a i n e d , new f a c i l i t i e s - ' p s y c h o p a t h i c ' h o s p i t a l s and w a r d s - were e s t a b l i s h e d to deal w i t h both new p a t i e n t s and those deemed to be immediately t r e a t a b l e . These p l a c e s were f o r the o b s e r v a t i o n and i n t e n s i v e treatment (rather than long-term confinement) of p a t i e n t s , and the idea was drawn from the United States where s i m i l a r f a c i l i t i e s had been e s t a b l i s h e d (Rothman, 1980; Grob, 1983). The o l d i n s t i t u t i o n s were to c o n t i n u e to c o n f i n e p a t i e n t s but an i n d i v i d u a l would be committed only a f t e r being o b s e r v e d and a s s e s s e d i n one of the new f a c i l i t i e s . In a d d i t i o n , s t e p s were taken to s e g r e g a t e ' m e n t a l l y d e f e c t i v e ' persons and, i n many pr o v i n c e s , s p e c i a l i n s t i t u t i o n s were b u i l t to e n s u r e t h a t t h e s e i n d i v i d u a l s were housed s e p a r a t e l y from those deemed to be mentally d i s e a s e d . 6 ^ The s t r a t e g y i n v o l v e d another suggestion o f f e r e d by the Canadian N a t i o n a l Committee f o r M e n t a l Hygiene; namely, an at t e m p t t o improve the 'mental h y g i e n e ' of the p o p u l a t i o n t h r o u g h p u b l i c e d u c a t i o n , p r e v e n t i o n and e a r l y d e t e c t i o n measures ( G r i f f i n , 1967). T h i s a s p e c t was l e s s c l e a r l y developed although, by the mid 1930's, the province of O n t a r i o had introduced s p e c i a l , 'mental h e a l t h c l i n i c s ' w i t h a mandate to enhance the mental hygiene of the community. The s h i f t i n s t r a t e g y was r e f l e c t e d i n new l e g i s l a t i o n 62 which both e n a b l e d the e s t a b l i s h m e n t of new f a c i l i t i e s and i n t r o d u c e d new 'medicalized' procedures f o r the management of m e n t a l l y d i s e a s e d p e r s o n s . W h i l e the j u d i c i a r y c o n t i n u e d to both c o n t r o l the appointment of committees and s u p e r v i s e the i n i t i a l commitment of those deemed to be dangerous, t h e i r i n v o l v e m e n t i n o t h e r m a t t e r s d i m i n i s h e d . In p a r t i c u l a r , the j u d i c i a r y p l a y e d no p a r t i n the commitment of non-dangerous mentally diseased persons to the new treatment f a c i l i t i e s and the power to admit p a t i e n t s was handed to medical p r a c t i t i o n e r s . In a d d i t i o n , v o l u n t a r y a d m i s s i o n to any type of i n s t i t u t i o n became p e r m i s s i b l e , p r o v i d i n g an a p p l i c a t i o n was supported by a medical p r a c t i t i o n e r . In s h o r t , the medical p r o f e s s i o n , which had played an important but s u b s i d i a r y r o l e i n the admission process i n many pr o v i n c e s at the turn of the century, began to dominate the o v e r a l l management of mentally d i s e a s e d persons i n a l l p r o v i n c e s . Changes i n S t r a t e g y and L e g i s l a t i o n : 1919 - 1939 W h i l e the changes which had a p p e a r e d by 1915 were of importance, a c l e a r s h i f t i n the management of mentally d i s e a s e d persons was marked by developments i n Manitoba i n 1919. Indeed, the passage of the Mental Diseases A c t ^ and the e s t a b l i s h m e n t of a ' p s y c h o p a t h i c ward' i n the Winnipeg G e n e r a l H o s p i t a l , s i g n a l l e d the beginning of a p e r i o d of change which had a f f e c t e d a l l the p r o v i n c e s by 1939. The psychopathic ward was to be the i n i t i a l c l e a r i n g - h o u s e f o r the p r o v i n c i a l 'mental h y g i e n e ' system ( S t r o n g , 1930; 63 P i n c o c k , 1970) and was f o r t h e " r e c e p t i o n , d e t e n t i o n , examination and treatment of persons who are or are b e l i e v e d to be feeble-minded or of unsound mind, or insane, or s u b j e c t to or a f f l i c t e d w i t h m e n t al d i s e a s e . . . " 6 2 The ward was to be under the c o n t r o l of a s u p e r i n t e n d e n t who was i n v e s t e d w i t h b r o a d d i s c r e t i o n a r y powers to a d m i t , t r e a t , r e l e a s e and t r a n s f e r p a t i e n t s t h r o u g h o u t the mental h y g i e n e system. A l t h o u g h the j u d i c i a r y c o n t i n u e d to s u p e r v i s e the i n i t i a l commitment of dangerous persons, admission to both the ward and the p r o v i n c i a l H o s p i t a l s f o r the Insane was to be by o t h e r means; namely, v o l u n t a r i l y , at the request of f r i e n d s or r e l a t i v e s , or on the b a s i s of two medical c e r t i f i c a t e s . 6 3 Once a d m i t t e d t o e i t h e r the p s y c h o p a t h i c ward or a H o s p i t a l a p a t i e n t could be c o n f i n e d , t r e a t e d , t r a n s f e r r e d to d i f f e r e n t f a c i l i t i e s or r e l e a s e d , at the d i s c r e t i o n of medical superintendents. The j u d i c i a r y d i d not s u p e r v i s e the commitment and c o n f i n e m e n t of p a t i e n t s , and l o n g - t e r m c o n f i n e m e n t i n a H o s p i t a l merely r e q u i r e d the approval of the superintendent of the p s y c h o p a t h i c ward. T h i s i n d i v i d u a l had the power to co n f i n e p a t i e n t s i n any p r o v i n c i a l i n s t i t u t i o n and could d e t a i n a p a t i e n t " f o r such lengths of time...and f o r such examination, treatment or courses of treatment as he may deem necessary or a d v i s a b l e . " 6 4 He c o u l d d e c i d e whether or not to d i s c h a r g e a p a t i e n t as 'cured', or uncured but h a r m l e s s and u n t r e a t a b l e ; p l a c e a p a t i e n t i n the care of r e l a t i v e s ; d e t a i n the p a t i e n t i n the ward; or, commit the p a t i e n t to a H o s p i t a l . The di s c h a r g e or c o n d i t i o n a l r e l e a s e of a p a t i e n t from a H o s p i t a l could only 64 occur with h i s approval.*' 5 By the e a r l y 1920's, the s t r a t e g y had a f f e c t e d o t h e r p r o v i n c e s and complementary changes were made to l e g i s l a t i o n . The B r i t i s h Columbia, Mental H o s p i t a l s Act had been amended to permit v o l u n t a r y admission to the p r o v i n c i a l h o s p i t a l s a t New W e s t m i n s t e r and E s son da 1 e 6 6 w h i l e , i n Nova S c o t i a , t h e l e g i s l a t u r e had passed the I n s t i t u t i o n s f o r the Insane Act. The l a t t e r a l lowed the province to take over the o p e r a t i o n and f u n d i n g of the county asylums and to ' c o n v e r t ' them i n t o " h o s p i t a l c e n t r e s , p s y c h o p a t h i c h o s p i t a l s , and c o n v a l e s c e n t homes" f o r the " s c i e n t i f i c c a r e and t r e a t m e n t and c u s t o d y of insane persons."*' 8 In New Brunswick, j u d i c i a l s u p e r v i s i o n of the i n i t i a l commitment of dangerous persons was e l i m i n a t e d i n f a v o u r of m e d i c a l c e r t i f i c a t i o n , and those who c o u l d pay f o r t h e i r own care and treatment were able to admit themselves to the p r o v i n c i a l h o s p i t a l , on a v o l u n t a r y b a s i s . ^ New s t a t u t e s a f f e c t i n g the management of mentally d i s e a s e d persons were a l s o i n t r o d u c e d i n both Saskatchewan and A l b e r t a . ^ 0 While the i n i t i a l commitment of dangerous persons remained under the s u p e r v i s i o n of the j u d i c i a r y , non-dangerous i n d i v i d u a l s c o u l d be admitted to the new p r o v i n c i a l h o s p i t a l s on e i t h e r a v o l u n t a r y o r i n v o l u n t a r y b a s i s . The l a t t e r r e q u i r e d the c e r t i f i c a t e s of two medical p r a c t i t i o n e r s although, i n A l b e r t a , any long-term admission had to be f i r s t approved by a j u s t i c e . ^ By 1925, A l b e r t a had i n t r o d u c e d a p r o c e d u r e w h e r e b y an i n d i v i d u a l c ould be admitted to and c o n f i n e d i n a H o s p i t a l f o r 30 days, f o r "observation and i n q u i r y " , on the b a s i s of medical 65 c e r t i f i c a t e s a l o n e ; however, c o n f i n e m e n t f o r a l o n g e r p e r i o d s t i l l r e q u i r e d the approval of a j u s t i c e . Once c o n f i n e d i n a h o s p i t a l i n e i t h e r Saskatchewan or A l b e r t a , a p a t i e n t was under the c o n t r o l of the i n s t i t u t i o n ' s medical superintendent who had the power to d e t a i n , t r e a t , and discharge p a t i e n t s as he thought f i t . 7 3 However, both p r o v i n c e s i n t r o d u c e d a form of post-commitment j u d i c i a l r e v i e w . A v o l u n t a r y p a t i e n t who sought discharge could be r e - d e f i n e d and d e t a i n e d as an i n v o l u n t a r y p a t i e n t , p r o v i d i n g t h i s c o u r s e of a c t i o n had been approved by a j u s t i c e . More i m p o r t a n t l y , i f any p a t i e n t f e l t that h i s or her commitment and confinement was not j u s t i f i e d , an a p p l i c a t i o n f o r discharge c o u l d be made to a judge of the p r o v i n c i a l Supreme C o u r t . 7 4 The judge could order the person's r e l e a s e and, while the e f f e c t i v e n e s s of t h i s o ption was blunted by the l o g i s t i c s of launching an appeal, the procedure provided an avenue of r e d r e s s f o r those who wished to c h a l l e n g e the d e c i s i o n s of medical p r a c t i t i o n e r s . 7 5 By the e a r l y 1930's, both the reform of 'mental hygiene' l e g i s l a t i o n and the e s t a b l i s h m e n t of new treatment f a c i l i t i e s , was c o n t i n u i n g unabated. In O n t a r i o , the l e g i s l a t u r e had p a s s e d the P s y c h i a t r i c H o s p i t a l s A c t 7 6 and t h i s event was heralded as a " d i s t i n c t step forward i n the treatment of mental d i s e a s e s " ( S t r o n g , 1930:184). The s t a t u t e e n a b l e d t h e c o r p o r a t i o n s of l a r g e c i t i e s to e s t a b l i s h h o s p i t a l s " f o r the o b s e r v a t i o n and t e m p o r a r y t r e a t m e n t of p e r s o n s who might be b e n e f i t t e d t h e r e b y " (op c i t ) . A d m i s s i o n t o a p s y c h i a t r i c 66 h o s p i t a l was to be by m e d i c a l c e r t i f i c a t i o n but the t y p e s of p a t i e n t s who could be admitted was narrowed to exclude those who were, f o r example, i n s a n e , a d d i c t e d to drugs or a l c o h o l , m e n t a l l y i n f i r m due to age or i n c u r a b l e d i s e a s e , m e n t a l l y d e f e c t i v e , and e p i l e p t i c . 7 7 The new f a c i l i t i e s were to a c t as s m a l l c l e a r i n g - h o u s e s f o r the p r o v i n c i a l mental hygiene system and t h e y were a b l e t o p r o v i d e o u t - p a t i e n t , a s w e l l as r e s i d e n t i a l , treatment s e r v i c e s (op c i t ) . In 1931, the A l b e r t a government f o l l o w e d the example set by M a n i t o b a by e s t a b l i s h i n g a p s y c h o p a t h i c w a r d a t t h e U n i v e r s i t y of A l b e r t a H o s p i t a l , Edmonton. The Mental Diseases Act was amended to a l l o w f o r the v o l u n t a r y and i n v o l u n t a r y admission of p a t i e n t s who were deemed to be " f i t s u b j e c t s f o r t r e a t m e n t " . 7 8 Involuntary p a t i e n t s could be committed f o l l o w i n g a j u s t i c e ' s hearing or on the b a s i s of medical c e r t i f i c a t e s . A p a t i e n t c o u l d be detained, t r e a t e d f o r up to three months, and d i s c h a r g e d a t the d i s c r e t i o n of the p r o v i n c i a l D i r e c t o r of Mental Health. I f confinement f o r a longer p e r i o d was deemed n e c e s s a r y , t h i s r e q u i r e d the a p p r o v a l of a j u s t i c e and the p a t i e n t was to be t r a n s f e r r e d to the p r o v i n c i a l h o s p i t a l s a t e i t h e r Ponoka or O l i v e r . 7 ^ In Quebec, the passage of the P r i v a t e H o s p i t a l s A c t 8 0 i n 1935 r e s u l t e d i n an abandonment of q u a s i - j u d i c i a l s u p e r v i s i o n of p r i v a t e asylum p a t i e n t s . Instead, the l i c e n s i n g and i n s p e c t i o n of a l l p r i v a t e h o s p i t a l s ( i n c l u d i n g those f o r m e r l y known as p r i v a t e l u n a t i c asylums) was to be c a r r i e d out by the p r o v i n c i a l M i n i s t r y of Health. Although the system of p r i v a t e , c o n t r a c t i n g 67 'asylums' was r e t a i n e d , along with the procedures f o r a d m i t t i n g p u b l i c and p r i v a t e p a t i e n t s which e x i s t e d at the t u r n of the c e n t u r y , a l l r e f e r e n c e s to p r i v a t e asylum l i c e n s i n g and r e g u l a t i o n were e v e n t u a l l y removed from the L u n a t i c Asylums A c t . 8 1 In the same year, a new Mental H o s p i t a l s A c t 8 2 was passed in O ntario. While the s t a t u t e d i d not introduce s p e c i f i c , new powers f o r medical p r a c t i t i o n e r s i t d i d c o n s o l i d a t e , c l a r i f y and expand t h e i r involvement i n the management of m e n t a l l y d i s e a s e d persons. A new mental hygiene l e x i c o n was i n t r o d u c e d and new mental hygiene r e s o u r c e s and s e r v i c e s were e s t a b l i s h e d . The s t a t u t e s e t o u t a c o m p r e h e n s i v e scheme f o r t h e m e d i c a l management of a l l c a t e g o r i e s of persons l i k e l y to be using the p r o v i n c i a l mental hygiene system and r a t i o n a l i z e d the procedure to be f o l l o w e d whenever a person being admitted to the system was deemed to be incapable of managing h i s or her property. The new Act was an omnibus s t a t u t e which, i n the view of i t s a r c h i t e c t ( t h e l a w y e r and p s y c h i a t r i s t , Dr. K.C. G r a y ) , ' l i b e r a l i z e d 1 the p r o v i s i o n of medical care and treatment (Gray, 1960). The p r o v i n c i a l h o s p i t a l s f o r the i n s a n e were r e t i t l e d 'Mental H o s p i t a l s ' and mental d i s e a s e s were to be r e f e r r e d to as 'mental i l l n e s s e s ' . A new, l e g a l d e f i n i t i o n of mental i l l n e s s was introduced and a mentally i l l person was d e f i n e d as someone, other than a mental d e f e c t i v e , who was "...suffering from such a d i s o r d e r of mind that such person r e q u i r e ( d ) care, s u p e r v i s i o n 68 and c o n t r o l f o r h i s own p r o t e c t i o n or w e l f a r e , or f o r the p r o t e c t i o n of o t h e r s . " 8 4 Since the d e f i n i t i o n e s t a b l i s h e d the parameters of i n t e r v e n t i o n , i t e f f e c t i v e l y expanded the reach of medical p r a c t i t i o n e r s by employing a measure of i m p r e c i s i o n . For example, the use of the term 'disorder of mind', r a t h e r than 'disorder of the brain', p e r m i t t e d the e x e r c i s e of c o n s i d e r a b l e p r o f e s s i o n a l d i s c r e t i o n i n d e c i d i n g w hich c o n d i t i o n s c o u l d c o n s t i t u t e a d i s o r d e r . S i m i l a r l y , the c o n d i t i o n a l c l a u s e s ( i . e . , the ' w e l f a r e ' t e s t ) encompassed e v e r y c o n c e i v a b l e circumstance that might have been presented by a mentally i l l person. The s t a t u t e r e - a f f i r m e d m e d i c a l d o m i n a t i o n o v e r the p r o c e s s e s of a d m i s s i o n and c o n f i n e m e n t by a l l o w i n g b o t h v o l u n t a r y and i n v o l u n t a r y a d m i s s i o n on the b a s i s of m e d i c a l c e r t i f i c a t e s . However, the j u d i c i a r y were to continue to play a r o l e i n the apprehension and i n i t i a l commitment of mentally i l l p e r s o n s who were dangerous and wandering at l a r g e . 8 4 Those admitted or committed to h o s p i t a l s continued to be p l a c e d under the c o n t r o l and custody of h o s p i t a l superintendents who c o u l d maintain, care f o r , t r e a t , and r e l e a s e t h e i r p a t i e n t s at t h e i r d i s c r e t i o n . Even v o l u n t a r y p a t i e n t s , who sought d i s c h a r g e c o n t r a r y to the o p i n i o n of a superintendent, could be d e t a i n e d pending an examination and r e - d e f i n i t i o n as a ' c e r t i f i e d ' (i.e., i n v o l u n t a r y ) p a t i e n t . 8 5 New m e n t a l h y g i e n e f a c i l i t i e s and r e s o u r c e s were i n t r o d u c e d and t h e s e complemented the e x i s t i n g network o f P s y c h i a t r i c and Mental H o s p i t a l s . In a p a r t i a l adoption of the 69 i d e a of p s y c h o p a t h i c wards, the O n t a r i o l e g i s l a t o r s made p r o v i s i o n f o r the es t a b l i s h m e n t of h o s p i t a l 'examination u n i t s ' to which any person i n need of o b s e r v a t i o n , care and treatment could be admitted and detai n e d f o r one month, on the c e r t i f i c a t e o f one m e d i c a l p r a c t i t i o n e r . 8 * * P r o v i s i o n was a l s o made f o r p r o v i n c i a l , 'Mental H e a l t h C l i n i c s ' w h ich were i n t e n d e d t o provide both o u t - p a t i e n t treatment and p u b l i c , mental hygiene education s e r v i c e s . The c l i n i c s were to be s t a f f e d by medical p r a c t i t i o n e r s , p s y c h o l o g i s t s , and at l e a s t one person " t r a i n e d i n s o c i a l s e r v i c e " , who were a u t h o r i z e d to examine the p h y s i c a l and mental c o n d i t i o n of any person who sought or was r e f e r r e d f o r a s s i s t a n c e . In a d d i t i o n , c l i n i c s t a f f c ould v i s i t s chools and examine the p u p i l s , as w e l l as p r o v i d e a d v i c e on mental h e a l t h m a t t e r s whenever t h i s was sought by an i n d i v i d u a l or o r g a n i z a t i o n . 8 ^ The new O n t a r i o l e g i s l a t i o n p r o v e d a t t r a c t i v e to the governments of other p r o v i n c e s and, by the end of 1936, s i m i l a r s t a t u t e s had been i n t r o d u c e d i n S a s k a t c h e w a n and New Brunswick. 0 0 The procedures f o r a d m i t t i n g , d e t a i n i n g , t r e a t i n g and d i s c h a r g i n g p a t i e n t s were v i r t u a l c o p i e s of the O n t a r i o l e g i s l a t i o n a l t h o u g h , i n Saskatchewan, a r i g h t t o seek p o s t -commitment j u d i c i a l review was r e t a i n e d . 8 ^ The Saskatchewan government chose to embrace the i d e a of ' p s y c h o p a t h i c wards* and, i n keeping w i t h the s i t u a t i o n i n other p r o v i n c e s , p l a c e d the a d m i s s i o n , t r e a t m e n t and d i s c h a r g e of p s y c h o p a t h i c ward p a t i e n t s e n t i r e l y i n the hands of medical p r a c t i t i o n e r s . ^ 0 The New Brunswick government d i d not introduce psychopathic wards or 70 examination u n i t s although an e f f o r t was made to f a c i l i t a t e the admission of p a t i e n t s f o r o b s e r v a t i o n and short-term, i n t e n s i v e treatment. The new l e g i s l a t i o n made p r o v i s i o n f o r mentally i l l persons to be admitted to the p r o v i n c i a l h o s p i t a l on the b a s i s of one medical c e r t i f i c a t e , f o r a p e r i o d of 60 days. A p a t i e n t c o u l d be p l a c e d under 'observation' and then e i t h e r d i s c h a r g e d or admitted f o r long-term t r e a t m e n t . ^ By the end of the 1930's, the change i n both s t r a t e g y and l e g i s l a t i o n had a f f e c t e d a l l the p r o v i n c e s , ^ 2 P r i n c e Edward I s l a n d b e i n g the l a s t to i n t r o d u c e r e f o r m s . In 1939, the l e g i s l a t u r e passed the Falconwood H o s p i t a l and I n f i r m a r y Ac_t^3 w h i c h changed the p r o c e d u r e s f o r h a n d l i n g m e n t a l l y d i s e a s e d persons i n the province. The Falconwood H o s p i t a l was to provide the "most humane and e n l i g h t e n e d c u r a t i v e treatment of mental d i s e a s e s i n (the) Province" and both v o l u n t a r y and i n v o l u n t a r y a d m i s s i o n was p e r m i t t e d . ^ 4 I n v o l u n t a r y a d m i s s i o n m e r e l y r e q u i r e d one medical c e r t i f i c a t e and the medical superintendent was i n v e s t e d w i t h the power to admit, c o n f i n e , t r e a t , and d i s c h a r g e p a t i e n t s . The s u p e r i n t e n d e n t c o u l d , f o r example, r e f u s e to admit t h o s e who were u n l i k e l y to b e n e f i t from treatment, e p i l e p t i c s , and i d i o t s , and these i n d i v i d u a l s were to be c o n f i n e d i n the p r o v i n c i a l i n f i r m a r y r a t h e r than the h o s p i t a l . 3 3 Summary By 1939, both the s t r a t e g y and the l e g i s l a t i o n a f f e c t i n g the management of m e n t a l l y d i s o r d e r e d p e r s o n s i n Canada had 71 changed c o n s i d e r a b l y when compared w i t h the s i t u a t i o n at the turn of the century. New, medical terms had been in t r o d u c e d to d e s c r i b e b o t h m e n t al d i s o r d e r s and t h o s e a f f l i c t e d w i t h d i s o r d e r s , and an e f f o r t had been made to d e f i n e and segregate d i f f e r e n t kinds of p a t i e n t s . I n s t i t u t i o n s f o r segregated, l o n g -term c o n f i n e m e n t c o n t i n u e d to e x i s t but these had been r e -d e f i n e d as 'hospitals'. New f a c i l i t i e s and res o u r c e s had been introduced and these took the form of psychopathic h o s p i t a l s or wards and, i n Ontario, examination u n i t s , p s y c h i a t r i c h o s p i t a l s , and mental h e a l t h c l i n i c s . The s h i f t i n s t r a t e g y was accompanied by new s t a t u t e s w h ich b o t h e s t a b l i s h e d the new f a c i l i t i e s and s e t out new p r o c e d u r e s f o r the management of m e n t a l l y d i s e a s e d p e r s o n s . T h i s p e r i o d o f l a w r e f o r m may be d e s c r i b e d as one o f ' m e d i c a l i z a t i o n * and the b a s i c f e a t u r e s of the new l e g i s l a t i o n are set out i n Table 2.2. Those s u f f e r i n g from mental d i s e a s e s c o u l d be a d m i t t e d to the new f a c i l i t i e s f o r s h o r t p e r i o d s of t i m e , on a v o l u n t a r y or i n v o l u n t a r y b a s i s , p r o v i d i n g m e d i c a l p r a c t i t i o n e r s i s s u e d c e r t i f i c a t e s i n d i c a t i n g the need f o r a d m i s s i o n and t r e a t m e n t . Once a d m i t t e d , a p a t i e n t c o u l d be observed and t r e a t e d and then e i t h e r d i s charged or admitted to an i n s t i t u t i o n . Long-term admission to a h o s p i t a l c ould occur on a v o l u n t a r y or i n v o l u n t a r y b a s i s , p r o v i d i n g a m e d i c a l p r a c t i t i o n e r c e r t i f i e d that t h i s course of a c t i o n was necessary. Once c o n f i n e d i n a f a c i l i t y or h o s p i t a l , a p a t i e n t was s u b j e c t to the c o n t r o l of the medical superintendent who could d e t a i n , t r e a t and discharge the i n d i v i d u a l at h i s or her d i s c r e t i o n . 72 TABLE 2.2: PROCEDURES AFFECTING MENTALLY DISEASED PERSONS IN CANADA: 1939 Medical S u p e r v i s i o n J u d i c i a l / Q u a s i -J u d i c i a l S u p e r v i s i o n I n i t i a l Commitment of Dangerous Persons N.B. Ont., Que., B.C., N.S., Man., A l t a . , Sask., P.E.I., T e r r . I n i t i a l Commitment of Non-Dangerous Involuntary P a t i e n t s N.B., Ont., Que., P.E.I., Man.,Sask., A l t a . B.C., N.S., T e r r . V o l u n t a r y / S h o r t -Term Admission. A l l p r o v i n c e s . -Long-Term Admission of any P a t i e n t . N.B., Ont., Que., P.E.I., B.C., N.S., Man., Sask. A l t a . Post-Admission Confinement i n P u b l i c F a c i l i t i e s . A l l p r o v i n c e s . (Que, Sask. & A l t a . ) Post-Admission Confinement i n P r i v a t e F a c i l i t i e s . Que. Ont. Committeeship/ Guardianship. A l l p r o v i n c e s and t e r r i t o r i e s . * = S p e c i f i c r i g h t to seek j u d i c i a l review i f d e s i r e d . A review would not occur a u t o m a t i c a l l y . While medical p r a c t i t i o n e r s dominated the s u p e r v i s i o n of m e n t a l l y d i s e a s e d p e r s o n s , the r o l e of the j u d i c i a r y was not e l i m i n a t e d e n t i r e l y . The l a t t e r c o n t i n u e d t o c o n t r o l the appointment of c o m m i t t e e s ^ and, i n the m a j o r i t y of p r o v i n c e s , they s u p e r v i s e d the a p p r e h e n s i o n and i n i t i a l commitment of dangerous persons. Fu r t h e r , i n A l b e r t a , B r i t i s h Columbia, Nova S c o t i a and the T e r r i t o r i e s , an element of l e g a l i s m was r e t a i n e d 73 s i n c e the j u d i c i a r y continued to s u p e r v i s e the commitment of non-dangerous persons. However, new l e g i s l a t i o n i n these (as i n o t h e r ) p r o v i n c e s p e r m i t t e d e i t h e r v o l u n t a r y a d m i s s i o n or i n v o l u n t a r y admission f o r short-term treatment on the b a s i s of medical c e r t i f i c a t e s (or both), and a s i g n i f i c a n t concession had t h e r e f o r e been made t o t h e m e d i c a l p r o f e s s i o n . As a consequence, the s u p e r v i s o r y r o l e of the j u d i c i a r y was reduced and, i n k e e p i n g w i t h the s i t u a t i o n e l s e w h e r e i n the c o u n t r y , they p l a y e d a s u b s i d i a r y , r a t h e r than dominant, r o l e i n the management of mentally d i s e a s e d persons.^ 7 C e r t a i n l y , i n t h r e e p r o v i n c e s , p a t i e n t s c o u l d seek j u d i c i a l review of commitment d e c i s i o n s i f they so wished, but an a p p e a l had to be l a u n c h e d by e i t h e r a p a t i e n t or someone a c t i n g on h i s or her b e h a l f . I f t h i s d i d not o c c u r , the j u d i c i a r y would not become i n v o l v e d . The idea of q u a s i - j u d i c i a l s u p e r v i s i o n of the confinement of p a t i e n t s had been abandoned, other than i n O n t a r i o where ' v i s i t o r s ' continued to r e g u l a t e the confinement of p a t i e n t s i n p r i v a t e s a n i t a r i a . While some p r o v i n c i a l mental hygiene s t a t u t e s were amended i during the 1940's and 1950's, these changes r e i n f o r c e d , r a t h e r than weakened, the process of ' m e d i c a l i z a t i o n ' . The j u d i c i a r y c o n t i n u e d to p l a y a s u b s i d i a r y r o l e i n the management of m e n t a l l y d i s o r d e r e d p e r s o n s and t h e i r i n v o l v e m e n t was to be r e d u c e d f u r t h e r w i t h the emergence of a new s t r a t e g y and new l e g i s l a t i o n during the 1960's. 74 ENDNOTES: CHAPTER 2 1: While the term 'insane' was used to d e s c r i b e those who are now r e f e r r e d to as ' m e n t a l l y i l l ' , the term ' l u n a t i c ' has no contemporary e q u i v a l e n t . The l a t t e r was a g e n e r i c term i n the f i e l d of lunacy law (i.e., the common and s t a t u t e law governing the appointment of committees to manage the a f f a i r s of l u n a t i c s ) and encompassed ' i d i o t s ' , 'imbeciles' and those who were insane, i n f i r m or of 'unsound mind'. In order to preserve the f l a v o u r of the l e g i s l a t i o n during t h i s and subsequent epochs, the terms used at the time w i l l be employed throughout t h i s chapter. 2: 53 V i c t . , c. 5 (Imp.). 3: The Yukon T e r r i t o r y had been c o n s t i t u t e d and d e c l a r e d to be a separate t e r r i t o r y i n 1898. 4: Saskatchewan was c o n s t i t u t e d and d e c l a r e d to be a p r o v i n c e i n 1906. A l b e r t a was c o n s t i t u t e d and d e c l a r e d i n 1907. 5: The province had two asylums; one at S e l k i r k ( e s t a b l i s h e d i n 1886), and the o t h e r a t Brandon ( e s t a b l i s h e d i n 1891) (Burgess, 1898; Hurd, 1917; Pincock, 1970). 6: L o c a l L u n a t i c Asylums Act R.S.N.S. 1900, c. 46: s. 5. 7: An Act to E s t a b l i s h an Almshouse and I n f i r m a r y f o r P r i n c e Edward I s l a n d S.P.E.I. 1908, 8 Edw. VII, c. 10: s. 9. 8: 53 V i c t . , c. 5 (Imp.). A l t h o u g h the i n f l u e n c e of B r i t i s h law g r a d u a l l y dwindled, the formal connection to the s t a t u t e s of the B r i t i s h P a r l i a m e n t c e a s e d o n l y w i t h the passage of The Statute of Westminster, i n 1931. 9: 53 V i c t . , c. 5 (Imp.): P a r t s I I I & IV, passim. 10: I b i d , ss. 116 & 132. 11: I b i d , P a r t s V, VI & VII. 12: I b i d , ss 4 - 6 (Reception Orders); 11 (Urgency Orders); & 13 - 15 (Summary R e c e p t i o n O r d e r s and p o l i c e powers). The s t a t u t e a l s o imposed s t r i c t r u l e s regarding the completion of medical c e r t i f i c a t e s . In p a r t i c u l a r , every c e r t i f i c a t e had to s t a t e the f a c t s upon which the medical p r a c t i t i o n e r had based h i s o p i n i o n , d i s t i n g u i s h i n g the f a c t s observed by him from those communicated by others. A l u n a t i c could not be committed s o l e l y on the b a s i s of f a c t s communicated^ by others. The c e r t i f i c a t e was o n l y v a l i d f o r one week and, where the o p i n i o n s of two p h y s i c i a n s were r e q u i r e d , the examinations had to be conducted s e p a r a t e l y . R e l a t i v e s of a l u n a t i c could not s i g n a c e r t i f i c a t e , nor c o u l d any person who might have a s p e c i a l i n t e r e s t i n the l u n a t i c ' s commitment to an asylum or p r i v a t e house ( s s . 28 -32). These s t r i c t r u l e s were adopted i n a l l the p r o v i n c e s of 75 Canada. 13: I b i d , ss. 315 - 322. 14: I b i d ; Part VIII & s. 12. 15: I b i d , ss. 38 & 39. 16: I b i d , s s . 8 & 40 - 52. The C o m m i s s i o n e r s were under a duty to v i s i t and i n s p e c t asylums at l e a s t once a year. They were r e q u i r e d to take p a r t i c u l a r note of the standards of care and treatment and the a c t i v i t i e s and c o n d i t i o n of the inmates. They were to determine, f o r example, whether d i v i n e s e r v i c e was being h e l d (and i t s e f f e c t upon the inmates), whether inmates were b e i n g s u b j e c t e d to c o e r c i o n and r e s t r a i n t , and whether inmates were provided with occupations and amusements. Many of these d u t i e s were imposed upon the o f f i c i a l v i s i t o r s to p r i v a t e asylums i n Canada. 17: I b i d , ss. 49 - 51 & 72 - 83. 18: The a n a l y s i s i s concerned only with the s i t u a t i o n i n the p r o v i n c e s and t e r r i t o r i e s of Canada. The colony of Newfoundland was not p a r t of the Confederation and i s t h e r e f o r e excluded from the d i s c u s s i o n . I t should be noted, however, that many of the p r o v i s i o n s of the I m p e r i a l , Lunacy Act were adopted by the c o l o n i a l House of Assembly and e n a c t e d i n the Lunacy Act S.N. 1907, c. 13. In a d d i t i o n , the p r i m a r y f o c u s i n t h i s c h a p t e r , and chapter 3, i s upon the form and content of the law, r a t h e r than the way i n which the law was a p p l i e d i n p r a c t i c e . The i n t e n t i s to d e s c r i b e and analyse the laws c o n s t r u c t e d by the s t a t e , and the a s s o c i a t e d s t r a t e g i e s f o r the management of the m e n t a l l y d i s o r d e r e d , a t a 'macro* r a t h e r than 'micro' l e v e l . The p o s s i b i l i t y of a gap between 'law on the books' and 'law i n a c t i o n ' i s acknowledged but, s i n c e there are no s t u d i e s of the r o u t i n e , e v e r y d a y p r a c t i c e s of m e d i c a l p r a c t i t i o n e r s and the j u d i c i a r y i n Canada, p a r t i c u l a r l y d u r i n g the e r a of ' l i m i t e d l e g a l i s m ' and ' m e d i c a l i z a t i o n 1 , the e x i s t e n c e and s i z e of any gap r e m a i n s unknown. I t seems u n l i k e l y , however, t h a t a gap would have e x i s t e d d u r i n g the e r a s of ' m e d i c a l i z a t i o n ' and 'enhanced m e d i c a l i z a t i o n ' . As we s h a l l see, the l e g i s l a t i o n i n c r e a s e d medical domination over the management of the m e n t a l l y d i s o r d e r e d and m e d i c a l p r a c t i t i o n e r s (the i n d i v i d u a l s most l i k e l y to be circumventing the p r e s c r i b e d r u l e s and procedures) had no reason to d e v i a t e . S i m i l a r l y , during the era of ' l i m i t e d l e g a l i s m ' , any d e v i a t i o n would have e x i s t e d o n l y i n t h o s e provin c e s where the j u d i c i a r y dominated the i n i t i a l commitment p r o c e s s and m e d i c a l p r a c t i t i o n e r s were w i l l i n g to r i s k the i m p o s i t i o n of p e n a l t i e s f o r f a i l i n g to abide by the l e g i s l a t i o n . On balance, i n d i v i d u a l a c t s of d e v i a t i o n probably occ u r r e d but i t seems u n l i k e l y that a major gap e x i s t e d between the law on the books and the law i n a c t i o n . 76 19: Each p r o v i n c e and t e r r i t o r y made p r o v i s i o n f o r the appointment of a committee or guardian of the person and e s t a t e of a l u n a t i c and the procedure was set out i n s t a t u t e s separate from those a f f e c t i n g the r e g u l a t i o n of asylums. J u r i s d i c t i o n o v e r l u n a c y m a t t e r s was g r a n t e d to the s u p e r i o r c o u r t of a province or t e r r i t o r y and, w i t h one exception, the procedures r e f l e c t e d those p r e s c r i b e d i n e i t h e r the I m p e r i a l Lunacy Act or B r i t i s h lunacy laws which e x i s t e d p r i o r to the passage of the l a t t e r s t a t u t e . In Quebec, the p r o c e d u r e f o r the ' j u d i c i a l i n t e r d i c t i o n ' of t hose i n a s t a t e of i m b e c i l i t y , i n s a n i t y or madness was f i r s t s e t out i n the C i v i l Code of 1866 and the o r i g i n s of the procedure l a y with the French Code Napoleon. The j u d i c i a r y c o n t r o l l e d the process of d e c l a r i n g a person t o be a l u n a t i c , a p p o i n t i n g a c o m m i t t e e o r g u a r d i a n (a 'curator', i n Quebec), and 'superseding' d e c l a r a t i o n s of lunacy (i.e., d e c l a r i n g a person to be no longer a l u n a t i c ) . While the o p i n i o n s of medical p r a c t i t i o n e r s were sought i n such matters, a d e c l a r a t i o n of l u n a c y would be made o n l y a f t e r a j u d i c i a l h e a r i n g . A c ommittee was g r a n t e d e x t e n s i v e powers to manage the l u n a t i c and h i s or her a f f a i r s , and could commit the person to an asylum i f necessary. However, i n e s t a t e matters, a committee was s u b j e c t a l w a y s to the d i r e c t i o n and s u p e r v i s i o n of the co u r t . See, Lunacy Act R.S.B.C. 1897, c. 126; Lunacy Act R.S.O., 1909, c. 37; Lunacy Act R.S.M. 1902, c. 103; Chancery A c t , S.P.E.I. 1910, c. 8; T r u s t e e Act R.S.N.B. 1903, c. 162; Supreme C o u r t i n E q u i t y A c t , C.S.N.B. 1877, c. 49; Lunacy Act R.S.N.S. 1900, c. 125; and, C i v i l Code S.Q. T i t l e X: A r t s . 325 - 350. I t s h o u l d be n o t e d t h a t , i n s e v e r a l p r o v i n c e s , a government o f f i c i a l c o uld be a u t o m a t i c a l l y appointed to take charge of an i n s a n e and c o n f i n e d person's e s t a t e , i f no o t h e r person had been or could be appointed. A p r o v i n c i a l ' o f f i c i a l committee' c o u l d be appointed at the time of committal and, i n Ontario, t h i s task was undertaken by the Inspector of P r i s o n s and P u b l i c C h a r i t i e s . In New B r u n s w i c k , the c h a i r m a n of the a sylum C o m m i s s i o n e r s was to be 'committee' w h i l e , i n B r i t i s h Columbia, (and, l a t e r , i n A l b e r t a and Saskatchewan) t h i s burden was p l a c e d on the shoulders of the p r o v i n c i a l Attorney-General. In Manitoba, the ' o f f i c i a l a d m i n i s t r a t o r ' was to be committee of a l l persons i n asylums who d i d not have committees appointed by a c o u r t . See, P u b l i c L u n a t i c Asylums Act R.S.O. 189 7, c. 317: ss. 4 7 - 6 5; An Act Respecting the P r o v i n c i a l L u n a t i c Asylum and i t s Management R.S.N.B. 1903, c. 100: s. 42; H o s p i t a l f o r the Insane Act S.B.C. 1897, c. 17: s s . 45 - 50; I n s a n i t y Act S.A. 1907, c. 7: s. 16; I n s a n i t y Act S.S. 1906, c. 22: s. 16; and, Lunacy Act R.S.M. 1902, c. 103. 20: Ordinance Respecting Insane Persons C.O.Y.T. 1902, c. 77; Ordinance Respecting Insane Persons C.O.N.W.T. 1898, c. 90. The f i r s t s t a t u t e s a f f e c t i n g the management of insane and l u n a t i c persons i n the new p r o v i n c e s of A l b e r t a and Saskatchewan 77 c o n t a i n e d a r e s t a t e m e n t of the p r o v i s i o n s of the t e r r i t o r i a l ordinances. Insane persons were to be committed by j u s t i c e s and t r a n s f e r r e d to one of the p u b l i c asylums i n Manitoba u n t i l new p r o v i n c i a l i n s t i t u t i o n s c o u l d be b u i l t . In A l b e r t a , the f i r s t h o s p i t a l f o r the insane was opened at Ponoka i n 1911 w h i l e , i n Saskatchewan, the f i r s t h o s p i t a l opened i n 1914 a t N o r t h B a t t l e f o r d (Hurd, 1917; Demay, 1973; A p p l e t o n , 1967). The process of commitment to these i n s t i t u t i o n s was su p e r v i s e d by the j u d i c i a r y . See, I n s a n i ty A c t S.S. 1906, c. 22; and, I n s a n i t y Act S.A. 1907, c. 7; passim. 21: See, e.g., H o s p i t a l s f o r the Insane A c t S.B.C. 1897, c. 17: ss. 13 - 25; Nova S c o t i a H o s p i t a l Act R.S.N.S. 1900, c. 44, ss. 15 - 17; P u b l i c L u n a t i c Asylums Act R.S.O. 1897, c. 317: ss. 12 - 35; L u n a t i c Asylums A c t R.S.Q. 1909, T i t l e V I I I , c. 4: Ar t s . 4131 - 4135; An Act Respecting Dangerous L u n a t i c s R.S.N.B. 1903, c. 101: passim. 22: R.S.M. 1902, c. 80. 23: I b i d , s. 4. 24: I b i d , ss. 6 - 8 & 17. 25: I b i d , ss. 9 - 19, 22 & 23. A dis c h a r g e could be ordered by a judge of the C o u r t of King's Bench or a county c o u r t i f , during the course of commitment and f o l l o w i n g an examination of the 'prisoner', i t was found that he or she was not insane and dangerous. 26: See, e.g., I b i d , ss. 50 - 56. 27: See, Nova S c o t i a H o s p i t a l Act R.S.N.S. 1900, c. 44; L o c a l L u n a t i c Asylums A c t R.S.N.S. 1900, c. 46; An A c t R e l a t i n g to Lun a t i c s and the Custody of L u n a t i c s S.P.E.I. 1875, 38 V i c t . c. 4; Lunacy Act R.S.M. 1902, c. 80; and, H o s p i t a l s f o r the Insane Act S.B.C. 1897, c. 17. 28: S.B.C. 189 7, c. 17. 29: I b i d , s. 6. The f i r s t p r i v a t e e s t a b l i s h m e n t d i d not appear u n t i l the opening of the H o l l y w o o d S a n i t a r i u m i n New Westminster i n 1919 (Foulkes, 1961). 30: S.B.C. 1897, c. 17: s s . 5, 7 & 10 - 12. 31: Nova S c o t i a H o s p i t a l Act R.S.N.S. 1900, c. 44: ss. 7 - 12. An 'extreme urgency' p r o v i s i o n was added t o s. 8 i n 1905, p e r S.N.S. 1905, c. 8. 32: L o c a l L u n a t i c Asylums A c t R.S.N.S. 1900, c. 46: s s . 12 -20. 33: H o s p i t a l s f o r the Insane A c t S.B.C. 1897, c. 17: s s . 7 & 32 - 36. 78 34: Nova S c o t i a H o s p i t a l A c t R.S.N.S. 1900, c. 44: s. 13; and, L o c a l L u n a t i c Asylums A c t R.S.N.S. 1900, c. 46: s. 15. See, a l s o , Lunacy A c t R.S.M. 1902, c. 80; and, An Act R e l a t i n g to L u n a t i c s and the Custody of L u n a t i c s S.P.E.I. 1875, 38 V i c t , c. 4. 35: In Nova S c o t i a , t h i s was the Inspector of Humane and Penal I n s t i t u t i o n s ; a p o s i t i o n e s t a b l i s h e d pursuant to the Inspector of Humane and P e n a l I n s t i t u t i o n s A c t R.S.N.S. 1900, c. 49. Boards of v i s i t o r s were e s t a b l i s h e d by the Lo c a l L u n a t i c Asylums Act R.S.N.S. 1900, c. 46. 36: P u b l i c L u n a t i c Asylums A c t R.S.O. 1897, c. 317: s s . 7 -11; L u n a t i c Asylums A c t R.S.Q. 1909, T i t l e V I I I , c. 4: A r t s . 4131 - 4135; An Act Respecting the P r o v i n c i a l L u n a t i c Asylum and i t s Management R.S.N.B. 1903, c. 100 (as amended by S.N.B. 1904, 4 Edw. V I I , c. 21): s s . 15 - 17 & 28 - 30. The l a t t e r was amended f u r t h e r by S.N.B. 1906, 6 Edw. V I I , c. 24, to a l l o w emergency commitment on the b a s i s of one medical c e r t i f i c a t e . 37: P u b l i c L u n a t i c Asylums Act R.S.O. 1897, c. 318. 38: L u n a t i c Asylums A c t R.S.Q. 1909, T i t l e V I I I , c. 4: A r t s . 4088 - 4118 & 4188 - 4191. 39: P u b l i c L u n a t i c Asylums Act R.S.O. 1897, c. 317: ss. 4, 7 -11 & 39 - 41; An Act Respecting the P r o v i n c i a l L u n a t i c Asylum and i t s Management R.S.N.B. 1903, c. 100: ss. 15 - 17 & 28 - 30; Lun a t i c Asylums Act R.S.Q. 1909, T i t l e V I I I , c. 4: Ar t s . 4088 -4093. 40: P r i v a t e L u n a t i c Asylums Act R.S.O. 1897, c. 318: ss. 59 & 60; L u n a t i c Asylums A c t R.S.Q. 1909, T i t l e V I I I , c. 4: A r t s . 4100 - 4101. 41: L u n a t i c Asylums A c t R.S.Q. 1900, T i t l e V I I I , c. 4: A r t s . 4188 - 4191. 42: An a p p l i c a t i o n f o r a w r i t of habeas c o r p u s was the p r i n c i p a l remedy f o r those who f e l t t h a t they were u n l a w f u l l y or i n c o r r e c t l y c o n f i n e d . However, t h i s avenue of r e d r e s s was a v a i l a b l e o n l y to th o s e who c o u l d a f f o r d the s e r v i c e s of a lawyer and the extent to which i t was used i s unknown. The few r e p o r t e d c a s e s i n the f i r s t q u a r t e r of t h i s c e n t u r y i n d i c a t e that the co u r t s would not grant l i b e r t y to both those who had been committed i n an i r r e g u l a r f a s h i o n but who were insane and dangerous (Re King [1917], 1 W.W.R. 132 (Man. S. C ) , and those who were c l e a r l y insane (Re Pack (1914) 5 O.W.N. 774; Re Donnell (1915) 7 O.W.N. 605). I f an a p p l i c a n t was c l e a r l y sane then the c o u r t s would o r d e r h i s or her immediate r e l e a s e (Re_ D a v i d s o n (1915) 8 O.W.N. 481). By 1925, the co u r t s i n Ont a r i o had r u l e d t h a t , s i n c e t h e l i b e r t y o f t h e s u b j e c t was a t s t a k e , a p p l i c a t i o n s f o r habeas should be thoroughly i n v e s t i g a t e d (Re Minehan (1925) 28 O.W.N. 263). 79 43: I n s p e c t i o n of Asylums, H o s p i t a l s , P r i s o n s and Court Houses Act R.S.O. 1897, c. 321: s s . 16 - 18. 44: An Act Respecting the P r o v i n c i a l L u n a t i c Asylum and i t s Management R.S.N.B. 1903, c. 100: ss. 7 - 10. 45: P r i v a t e L u n a t i c Asylums Act R.S.O. 1897, c. 318; L u n a t i c Asylums Act R.S.Q. 1909, T i t l e V I I I , c. 4. 46: L u n a t i c Asylums A c t R.S.Q. 1909, T i t l e V I I I , c. 4: A r t s . 4088 - 4093. 47: P r i v a t e L u n a t i c Asylums A c t R.S.O. 1897, c. 318: s s . 2 -7, 17 - 19 & 24 - 28. L u n a t i c Asylums A c t R.S.Q. 1909, T i t l e VIII, c. 4: A r t s . 4164 - 4187. 48: P r i v a t e L u n a t i c Asylums A c t R.S.O. 189 7, c. 318: s s . 8 -15. 49: L u n a t i c Asylums A c t R.S.Q'. 1909, T i t l e V I I I , c. 4: A r t s . 4227 - 4331. 50: I b i d , notes 48 & 49. In b o t h p r o v i n c e s , the r e g u l a t i o n s w hich a p p l i e d t o l i c e n s e d , p r i v a t e asylums were extended to cover the a c t i v i t i e s of i n d i v i d u a l s who had custody of, or who were p r o v i d i n g board and l o d g i n g f o r , insane persons i n u n l i c e n s e d premises. Before ta k i n g charge of a person, the a p p r o p r i a t e medical c e r t i f i c a t e s had t o be o b t a i n e d , and the p r o p r i e t o r of an u n l i c e n s e d e s t a b l i s h m e n t had to r e p o r t a l l a d m i s s i o n s to the o f f i c i a l v i s i t o r s f o r the county or d i s t r i c t . The p r o p r i e t o r was a l s o o b l i g e d t o s u b m i t r e g u l a r r e p o r t s on the c o n d i t i o n of each i n s a n e p e r s o n i n h i s or her c h a r g e , to the o f f i c i a l v i s i t o r s . P r i v a t e L u n a t i c Asylums A c t R.S.O. 1897, c. 318: s s . 32 - 34; L u n a t i c Asylums A c t R.S.Q. 1909, T i t l e V I I I , c. 4: A r t s . 4192, 4193 & 4198 - 4200. 51: P r i v a t e L u n a t i c Asylums Act R.S.O. 1897, c. 318: ss. 50 -58; L u n a t i c Asylums A c t R.S.Q. 1909, T i t l e V I I I , c. 4: A r t s . 4243 - 4245. These p r o v i s i o n s appear to have been c o p i e d d i r e c t l y f r o m t h e l i s t o f d u t i e s p r e s c r i b e d f o r t h e Commissioners i n Lunacy i n B r i t a i n , per the Lunacy Act, 1890. 52: P r i v a t e L u n a t i c Asylums Act R.S.O. 1897, c. 318: ss. 37 -49 & 61 - 74; L u n a t i c Asylums A c t R.S.Q. 1909, T i t l e V I I I , c. 4: A r t s . 4150 - 4155, 4210 - 4222 & 4246 - 4251. 53: P r i v a t e L u n a t i c Asylums Act R.S.O. 1897, c. 318: ss. 77 -96; L u n a t i c Asylums A c t R.S.Q. 1909, T i t l e V I I I , c. 4: A r t s . 4259 - 4266. 54: The H o s p i t a l s f o r the Insane Act S.O. 1913, c. 83; Mental H o s p i t a l s Act, S.B.C, 1912, c. 13; Insane H o s p i t a l s Act, S.M., 80 1910, c. 30; P r o v i n c i a l H o s p i t a l Act, S.N.B., 1904, c. 21. 55: The P r i v a t e S a n i t a r i u m Act, S.O., 1913, c. 85. The s t a t u t e a l s o expanded the membership of the boards of o f f i c i a l v i s i t o r s by adding one medical p r a c t i t i o n e r , and e s t a b l i s h e d new d u t i e s f o r the boards. A f t e r 1913, they were r e q u i r e d to assess the standards of care and treatment being a d m i n i s t e r e d to p a t i e n t s and take p a r t i c u l a r note of the q u a l i t y and standard of t r a i n i n g of the n u r s i n g s t a f f (ss. 9 & 44). 56: See, e.g., The Hospi t a l s F or the Insane A c t , S.O., 1913, c. 8 3; s. 5. 57: R.S.N.S., 1900, c. 44, as amended by S.N.S., 1912, c. 31. 58: The Hospi t a l s For the Insane A c t , S.O., 1913, c. 83; s. 12. 59: The Reception H o s p i t a l s For the Insane Act, S.O., 1914, c. 54; s. 2 & passim. 60: T h e s e were i n t r o d u c e d i n A l b e r t a i n 1919 ( M e n t a l D e f e c t i v e s A c t , S.A. 1919, c. 21); Nova S c o t i a i n 1921 ( I n s t i t u t i o n s f o r M e n t a l l y D e f e c t i v e Persons Act, S.N.S., 1921, c. 8, l a t e r changed t o the T r a i n i n g " S c h o o l s A c t , S.N.S., 1927, c. 5); Saskatchewan i n 1930 (Mental D e f e c t i v e s Act. S.S., 1930, c. 71; l a t e r i n c o r p o r a t e d i n t o the M e n t a l Hygiene A c t , S.S. 1936, c. 91); and, M a n i t o b a i n 1933 ( M e n t a l D e f i c i e n c y A c t , S.M., 1933, c. 24). In O n t a r i o , a f o r m a l s e g r e g a t i o n o c c u r r e d w i t h the passage of the Mental H o s p i t a l s Act i n 1935 (S.O. 1935, c. 39) although, as Wolfensberger (1974) p o i n t s out, the process of s e g r e g a t i o n a c t u a l l y began much e a r l i e r . In B r i t i s h Columbia, the 1925 Royal Commission i n t o mental hygiene s e r v i c e s d e a l t w i t h the i s s u e of mental d e f i c i e n c y i n g r e a t d e t a i l . While an attempt was made to segregate those who were d e f e c t i v e from those who were diseased, w i t h i n the e x i s t i n g i n s t i t u t i o n s , no new f a c i l i t i e s were c o n s t r u c t e d . In a d d i t i o n , no s p e c i a l l e g i s l a t i o n was e n a c t e d i n the p r o v i n c e o t h e r than t h a t p e r m i t t i n g the i n v o l u n t a r y s t e r i l i z a t i o n of d e f e c t i v e s (Clark, 1947; Foulkes, 1961). 61: S.M. 1919, c. 53. 62: I b i d , s. 4. 63: I b i d , ss. 6 - 9 & 16 - 18. 64: I b i d , s. 16. 65: I b i d , ss. 43 - 49. 66: S.B.C, 1920, c. 56, p a s s i m. The 1925 Royal Commission i n t o p r o v i n c i a l m e n t a l h y g i e n e s e r v i c e s recommended the c o n s t r u c t i o n and o p e r a t i o n of a psychopathic h o s p i t a l ; however, t h i s d i d not appear u n t i l the l a t e 1940's. A C h i l d Guidance 81 C l i n i c and a S o c i a l S e r v i c e Department were e s t a b l i s h e d w i t h i n the mental hygiene system during the 1930's but these i n n o v a t i v e steps d i d d i d not r e q u i r e new l e g i s l a t i o n (Clark, 1947; Foulkes, 1961). 67: S.N.S. 1921, c. 7. In a d d i t i o n , j u d i c i a l s u p e r v i s i o n of the commitment of persons to the l o c a l asylums was g r a d u a l l y r e d u c e d from 1915 onwards. By 1918, i n v o l u n t a r y commitment merely r e q u i r e d two medical c e r t i f i c a t e s . See, L o c a l L u n a t i c Asylums (Amendment) Act, S.N.S., 1915, c. 18; L o c a l Asylums f o r the H a r m l e s s Insane A c t , S.N.S., 1917, c. 20; S t a t u t e Law Amendment Act, S.N.S., 1918, c. 3. 68: S.N.S. 1921, c. 7: s. 3. The a d m i s s i o n and d i s c h a r g e p r o c e d u r e s were t o be the same as those a f f e c t i n g the Nova S c o t i a H o s p i t a l . Once opened, the new f a c i l i t i e s were t o r e c e i v e and t r e a t insane persons who r e s i d e d i n the reg i o n s of the provi n c e , and p a t i e n t s i n the Nova S c o t i a H o s p i t a l were to be g r a d u a l l y t r a n s f e r r e d i n t o the f a c i l i t i e s ( I b i d : ss. 4 - 10). One goal was to empty the H o s p i t a l and s e l l the prop e r t y ( I b i d : ss. 9 & 12) ; however, t h i s e a r l y attempt at d e - c e n t r a l i z a t i o n and p a r t i a l d e - i n s t i t u t i o n a l i z a t i o n foundered and the province continued to r e l y upon both the H o s p i t a l and the l o c a l asylums u n t i l the 1960's (Leighton, 1982). 69: S.N.B., 1923, c. 3: s s . 6, 12 - 16 & 18. 70: M e n t a l D i s e a s e s A c t S.S. 1921-22, c. 75, r e p e a l i n g b o t h the I n s a n i t y A c t S.S. 1906, c. 22, and the Dangerous L u n a t i c s Act S.S. 1918-19, c. 57. Mental Diseases Act S.A. 1924, c. 25, r e p e a l i n g the I n s a n i t y Act S.A. 1907, c. 7. The f i r s t s t a t u t e s a f f e c t i n g the management of insane and l u n a t i c persons i n the new pr o v i n c e s of A l b e r t a and Saskatchewan contained a restatement of the j u d i c i a l commitment procedures set out i n t e r r i t o r i a l ordinances; see, I b i d , note 20. O n l y m i n o r amendments were made t o t h e r e l e v a n t t e r r i t o r i a l o r d i n a n c e s d u r i n g the 1920's and 1930's and, i n these p a r t s of Canada, the j u d i c i a r y continued to supe r v i s e the p r o c e s s of a p p r e h e n d i n g and c o m m i t t i n g m e n t a l l y d i s e a s e d persons. 71: M e n t a l D i s e a s e s A c t S.S. 1921-22, c. 75: s s . 7, 15 & 36. Mental Diseases Act S.A. 1924. c. 25: ss. 4 & 6. 72: S.A. 1925, c. 46. 73: M e n t a l D i s e a s e s A c t S.S. 1921-22, c. 75: p a s s i m ; M e n t a l Diseases Act S.A. 1924, c. 25 (as amended): passim. 74: M e n t a l D i s e a s e s A c t S.S. 1921-22, c. 75: s. 16. M e n t a l Diseases Act S.A. 1924, c. 25 (as amended): s. 15. 75: Those seeking a j u d i c i a l review would have to a c q u i r e the 82 s e r v i c e s of a lawyer. More i m p o r t a n t l y , an a p p l i c a t i o n c o u l d proceed only i f the M i n i s t e r of Health or the Attorney-General f i r s t gave t h e i r approval. See, I b i d . 76: S.O., 1926, c. 71. Repealing the Reception H o s p i t a l s f o r the Insane Act. 77: I b i d , s. 13. 78: S.A. 1931, c. 62. 79: I b i d , ss. 3 & 4. 80: S.Q./ 1935, c. 66. 81: See, R.S.Q., 1941, c. 188. 82: S.O., 1935 c. 39. 83: I b i d ; s. 2. A 'mentally d e f e c t i v e ' person was d e f i n e d i n the same s e c t i o n as, "a person i n whom there i s a c o n d i t i o n of a r r e s t e d or incomplete development of mind, whether a r i s i n g from i n h e r e n t c a u s e s or i n d u c e d by d i s e a s e or i n j u r y , and who r e q u i r e s care, s u p e r v i s i o n and c o n t r o l f o r h i s own p r o t e c t i o n or welfare or f o r the p r o t e c t i o n of others." 84: I b i d , P a r t s I I I & IV. S t e p s were taken to d i s t i n g u i s h between, and s e g r e g a t e , d i f f e r e n t k i n d s o f p a t i e n t s . In a d d i t i o n to the d i s t i n c t i o n between men t a l l y i l l and mentally d e f e c t i v e p e r s o n s , the s t a t u t e r e c o g n i z e d ' h a b i t u e s ' (those a d d i c t e d to drugs or a l c o h o l ) and e p i l e p t i c s ( I b i d , P a r t s V & VI ) . W h i l e the a d m i s s i o n p r o c e d u r e s were s i m i l a r f o r a l l c a t e g o r i e s of p a t i e n t (habitues could be committed by a judge f o r up to one year), i n s t i t u t i o n a l s e g regation occurred. For example, those s u f f e r i n g from e p i l e p s y were to be co n f i n e d i n the s p e c i a l p r o v i n c i a l h o s p i t a l at Woodstock. These p r o v i s i o n s were a c o n t i n u a t i o n of e x i s t i n g procedures a l b e i t drawn together i n a s i n g l e , omnibus s t a t u t e . 85: I b i d , P a r t s I I I & IV. 86: I b i d ; Part VII. 87: I b i d ; Part IX. 88: Mental Hygiene Act S.S. 1936, c. 91; P r o v i n c i a l H o s p i t a l Act S.N.B. 1936, c. 34. 89: Mental Hygiene Act S.S. 1936, c. 91: s. 22. 90: I b i d ; ss. 41 - 43. 91: P r o v i n c i a l H o s p i t a l Act S.N.B. 1936, c. 34: ss. 20 & 21. 92: For the r e a s o n s s e t out i n note 18 i b i d , the c o l o n y of 83 Newfoundland has been excluded from t h i s a n a l y s i s . However, i t may be noted that the Newfoundland Lunacy Act was repealed i n 1931 by the H e a l t h and P u b l i c W e l f a r e Act (S.N., 1931, c. 12). Regardless, no change occurred i n the procedures a f f e c t i n g the management of mentally d i s e a s e d persons s i n c e the o l d Lunacy Act p r o v i s i o n s were s i m p l y t r a n s f e r r e d to P a r t XXI of the new s t a t u t e . 93: S.P.E.I. 1939, c. 16. 94: I b i d , s. 10. 95: I b i d , ss. 3 - 9, 12 - 14, 22 - 24, & Part I I I . 96: W h i l e p r o v i n c i a l s t a t u t e s a f f e c t i n g the a p p o i n t m e n t of committees and guardians were amended between the e a r l y 1900's and 1939, the j u d i c i a r y r e t a i n e d c o n t r o l . In the m a r i t i m e p r o v i n c e s and Quebec, the p r o c e d u r e s r e m a i n e d unchanged although, by 1943, New Brunswick had adopted the committeeship p r o v i s i o n s of the I m p e r i a l , Lunacy Act. (Mental Incompetency Act S.N.B. 1943, c. 41). The p r o v i n c e s of Saskatchewan, A l b e r t a , and M a n i t o b a a l s o i n t r o d u c e d new s t a t u t e s which bore the h a l l m a r k of the I m p e r i a l s t a t u t e (Lunacy Act S.S. 1918-19, c. 58; E s t a t e s of the M e n t a l l y Incompetent Act S.A. 19 37, c. 22; Lunacy Act S.M. 1934, c. 25). The l e g i s l a t i o n s e r v e d to s t r e n g t h e n , r a t h e r than weaken, j u d i c i a l i n v o l v e m e n t i n t h i s area. The p r o c e d u r e f o r p l a c i n g c o n t r o l of an i n d i v i d u a l ' s e s t a t e i n the hands of an ' o f f i c i a l committee' at the t i me of commitment to a h o s p i t a l , was r e t a i n e d i n some p r o v i n c e s and i n t r o d u c e d i n o t h e r s . F o r e x a m p l e , i n Quebec, th e A c t Respecting C u r a t o r s h i p of N o n - I n t e r d i c t e d Insane Persons (S.Q., 1937, c. 80) was i n t r o d u c e d to s t r e n g t h e n a p r o c e d u r e , f i r s t i n t r o d u c e d i n 1919 (S.Q., 1919, c. 53), whereby the p r o p e r t y of i n s a n e p e r s o n s d e t a i n e d i n i n s t i t u t i o n s c o u l d be c o n t r o l l e d s w i f t l y . I f such a p e r s o n d i d not have a c u r a t o r a p p o i n t e d pursuant to the C i v i l Code, the medical superintendent of the i n s t i t u t i o n was to be the e_x o f f i c i o c u r a t o r of the p r o p e r t y u n t i l such time as another person was appointed. In some pr o v i n c e s , government management of e s t a t e s was r a t i o n a l i z e d . In Manitoba, Saskatchewan and A l b e r t a the o f f i c e of the 'Administrator of L u n a t i c s ' E s t a t e s ' was c r e a t e d w h i l e , i n O n t a r i o , e s t a t e a d m i n i s t r a t i o n was p a s s e d to the newly c r e a t e d o f f i c e o f t h e P u b l i c T r u s t e e . See, L u n a c y A c t (Amendment) A c t S.M. 1913, c. 29; A d m i n i s t r a t o r of L u n a t i c s ' E s t a t e s A c t , S.S., 1914, c. 10; Admlni s t r a t o r of L u n a t i c s ' E s t a t e s Act, S.A., 1916, c. 11; and, O n t a r i o P u b l i c Trustee Act, S.O., 1919, c. 32. 97: A l a c k of j u d i c i a l i n v o l v e m e n t i n the management o f mentally d i s e a s e d persons was a l s o evident i n a d i f f e r e n t , but r e l a t e d , s p h e r e of j u d i c i a l a c t i v i t y ; namely, c i v i l c a s e s brought a g a i n s t those r e s p o n s i b l e f o r improper confinement. 84 A review and a n a l y s i s of r e p o r t e d cases between the e a r l y 1900's and 1939 i n d i c a t e s l i t t l e i n t e r e s t i n , f o r example, the r i g h t s and l i b e r t i e s of i n d i v i d u a l s . C e r t a i n l y , t h e r e were cases where the j u d i c i a r y spoke out r e g a r d i n g the p r o t e c t i o n of the r i g h t s of the i n d i v i d u a l at the time of commitment. In Re G i b s o n (1907), 15 O.L.R. 245 (O.C.A.), f o r example, M e r e d i t h J.A. emphasized that s i n c e the " e f f e c t of the i n c a r c e r a t i o n of a p e r s o n i n a p u b l i c l u n a t i c asylum...is of so f a r r e a c h i n g a c h a r a c t e r , as to b o t h p e r s o n and p r o p e r t y " , then e v e r y c a r e s h o u l d be t a k e n " t h a t a l l t h e r e q u i r e m e n t s o f the l a w a u t h o r i z i n g i t are duly observed by everyone b r i n g i n g i t about or concerned i n i t " (@ 246). S i m i l a r l y , i n two l a t e r cases - Re Bowyer (1930), 66 O.L.R. 378 (O.C.A.) and Re Watts [1933], 2 D.L.R. 800 (N.B.C.A.) - the c o u r t s e x h i b i t e d a c o n c e r n f o r c o n t r o l l i n g the w r o n g f u l commitment of those who were not c l e a r l y insane, p a r t i c u l a r l y where the commitment d e c i s i o n was based on the presence of an 'immoral' s t a t e of mind (unless the p e r s o n was a danger to h i m / h e r s e l f ) , or the p r e s e n c e of some p e c u l i a r i t y of mind or e c c e n t r i c i t y of conduct. It i s unclear whether the r e l a t i v e absence of cases was due to the l o g i s t i c s of launching an a c t i o n , the r e l u c t a n c e of the c o u r t s t o i n t e r f e r e w i t h t h e a c t i v i t i e s o f m e d i c a l p r a c t i t i o n e r s , or the impediments c r e a t e d by v a r i o u s s t a t u t o r y p r o v i s i o n s which p r o t e c t e d asylum and h o s p i t a l personnel and others who were e x e r c i s i n g t h e i r a u t h o r i t y under the s t a t u t e s . Among o t h e r m a t t e r s , t h e s e p r o v i s i o n s i m p o s e d s p e c i a l l i m i t a t i o n s on the commencement of any form of l i t i g a t i o n . Most s t a t u t e s contained a p r o t e c t i v e and l i m i t i n g p r o v i s i o n , which was e x e m p l i f i e d by s. 11 of the Ontario, Mental H o s p i t a l s Act S.O., 1935, c. 39. No a c t i o n , p r o s e c u t i o n or other proceedings s h a l l be b r o u g h t or be i n s t i t u t e d a g a i n s t any...person f o r an act done i n pursuance or execution or intended execution of any duty o r a u t h o r i t y u n d e r t h i s A c t o r t h e r e g u l a t i o n s , or i n r e s p e c t of any a l l e g e d n e g l e c t or d e f a u l t i n the e x e c u t i o n of any such duty or a u t h o r i t y , without the consent of the Attorney-General. As a consequence, the Attorney-General c o u l d screen a l l cases and d e a l w i t h m a t t e r s as he thought f i t . In a d d i t i o n , a l l a c t i o n s had to be launched w i t h i n s i x months of the o r i g i n a t i n g i n c i d e n t . T h i s would have r a i s e d , and i n f a c t d i d r a i s e , s i g n i f i c a n t problems f o r a person wishing to take l e g a l a c t i o n a g a i n s t , f o r example, a medical superintendent or a m a g i s t r a t e (see, e.g. Green v. L i v e r m o r e ; Green v. B r i c k e n d e n [1940] O.R. 381) . Some p r o v i n c e s went f u r t h e r and enacted t i g h t p r o t e c t i v e p r o v i s i o n s . In M a n i t o b a , f o r e x a m p l e , p e r s o n s s i g n i n g c e r t i f i c a t e s , w a r r a n t s , and o r d e r s p u r s u a n t to the M e n t a l 85 D i s e a s e s A c t S.M., 1919, c. 53, were p r o t e c t e d from c i v i l p r o c e e d i n g s i f they " a c t e d i n good f a i t h and w i t h r e a s o n a b l e care" (s. 50). Even i f proceedings were launched, they c o u l d be stayed by a judge of the p r o v i n c i a l , Court of Queen's Bench i f he f e l t that there were "no reasonable grounds f o r a l l e g i n g want of good f a i t h or of r e a s o n a b l e c a r e " (s. 51). Under the s e c i r c u m s t a n c e s , i t i s easy to see why t h e r e were s i g n i f i c a n t impediments to pursuing c i v i l l i t i g a t i o n . In some i n s t a n c e s , persons were able to launch proceedings i n an a t t e m p t to r e c o v e r damages f o r n e g l i g e n c e , m a l i c i o u s p r o s e c u t i o n and wrongful commitment, and i t was i n such cases t h a t the e x i s t e n c e of 'good f a i t h and reasonable care' became a c e n t r a l i s s u e . As such, they demonstrate the way i n which, even i f a p a t i e n t was able to launch l i t i g a t i o n , the j u d i c i a r y were r e l u c t a n t to award damages i n favour of a person who s u f f e r e d a wrong, unless the wrong was extreme and unquestionable. The p r i n c i p l e of good f a i t h and reasonable care a c t u a l l y o r i g i n a t e d i n the E n g l i s h common law (see, e.g., H a l l v. Semple (1862), 176 E.R. 151 (Q.B.)). It was subsequently enacted i n the I m p e r i a l , Lunacy Act and c l a r i f i e d i n s e v e r a l post-1890 E n g l i s h cases (see, e.g., W i l l i a m s v. Beaumont and Duke (1894) 10 T.L.R. 543 (C.A.) and E v e r e t t v^ G r i f f i t h s [ 1920], 3 K.B. 163). I t was adopted by Canadian l e g i s l a t o r s and f o l l o w e d i n the judgments of s e v e r a l c o u r t s . For example, i n B a s i l v. S p r a t t (1918) 44 O.L.R. 155 (C.A.), i t was held that where the persons r e s p o n s i b l e f o r a f a l s e a r r e s t and d e t e n t i o n d i d not act i n good f a i t h or under a b e l i e f t h a t they were d o i n g what they had a r i g h t t o do, p u n i t i v e damages may be awarded. However, the case had to be one t h a t was b u i l t on extreme c i r c u m s t a n c e s . In t h i s r e g a r d , i n Lumsden v. G l i d d e n (1920), 18 O.W.N. 354, (O.H.C.) - an a c t i o n f o r c o n s p i r a c y , wrongful c e r t i f i c a t i o n and wrongful d e t e n t i o n -the matter was d i s m i s s e d with c o s t s because the p l a i n t i f f was unable to show that the c e r t i f y i n g medical p r a c t i t i o n e r s had not acted i n good f a i t h and w i t h reasonable care. S i g n i f i c a n t l y , the c o u r t was c o n c e r n e d not t o i m p a i r the " e f f i c i e n c y of the (Ho s p i t a l s f o r the Insane) Act" by hol d i n g medical p r a c t i t i o n e r s l i a b l e f o r the consequences of the i s s u e of c e r t i f i c a t e s . C e r t i f y i n g p h y s i c i a n s r e c e i v e d a s i m i l a r measure of p r o t e c t i o n from Owens v. Dobson ( 1934 ), 49 B.C.R. 283 (B.C.S.C.) where an ac t i o n was stayed because a p h y s i c i a n had acted to the best of h i s a b i l i t y and w i t h o u t any u l t e r i o r m o t i v e . However, i n the rare cases where there was c l e a r and abundant evidence that a p h y s i c i a n , or any o t h e r p e r s o n , had been e i t h e r n e g l i g e n t or v i n d i c t i v e the c o u r t s were prepared to support the cause of a p l a i n t i f f ( H i b b e r d v. J a m i e s o n [1927], 3 W.W.R. 543 ( A l t a . S.C.); Durand v. P r e j e t [ 1932 ], 2 W.W.R. 545 (Man. C.A.). 86 CHAPTER 3 THE ENHANCEMENT OF MEDICALIZATION AND THE RISE OF THE NEW LEGALISM: CHANGES IN STRATEGY AND LAW - 1950's TO 1980's I: INTRODUCTION During the l a t e 1950's and the 1960's, the s t a t e s t r a t e g y f o r the management of mentally d i s o r d e r e d persons s h i f t e d away from the use of p l a c e s of segregated confinement. A process of d e - i n s t i t u t i o n a l i z a t i o n began and those c o n f i n e d i n i n s t i t u t i o n s were g r a d u a l l y r e l e a s e d to community-based care and treatment a l t e r n a t i v e s . S i m i l a r l y , new p a t i e n t s were to be t r e a t e d i n the community f o r as l o n g as p o s s i b l e , a d m i t t e d f o r s h o r t - t e r m i n t e n s i v e t r e a t m e n t o n l y i f a b s o l u t e l y n e c e s s a r y , and then r e t u r n e d to the community wit h a minimum of delay. Community mental h e a l t h c e n t r e s , p s y c h i a t r i c u n i t s i n general h o s p i t a l s , and other community-based reso u r c e s began to p r o l i f e r a t e and, while the o l d i n s t i t u t i o n s remained, t h e i r p o p u l a t i o n s began to d e c l i n e . T h e s e d e v e l o p m e n t s were a c c o m p a n i e d by c h a n g e s i n p r o v i n c i a l mental h e a l t h l e g i s l a t i o n . Mental h e a l t h laws were standardized, the l a s t v e s t i g e s of j u d i c i a l s u p e r v i s i o n were removed, and the ' m e d i c a l i z a t i o n ' which c h a r a c t e r i z e d l e g i s l -a t i o n i n the 1920's and 1930's was enhanced. The j u d i c i a r y continued to c o n t r o l the appointment of committees but a new p r o c e d u r e was i n t r o d u c e d which i n c r e a s e d the i n v o l v e m e n t of medical p r a c t i t i o n e r s i n the process of e s t a t e management. The j u d i c i a r y c e a s e d t o p l a y a r o l e i n the s u p e r v i s i o n of the 87 commitment and confinement of p a t i e n t s , other than to provide an avenue of appeal f o r those d i s s a t i s f i e d w i t h the d e c i s i o n s of m ental h e a l t h r e v i e w b o a r d s . These m u l t i - d i s c i p l i n a r y , a d m i n i s t r a t i v e t r i b u n a l s were e s t a b l i s h e d to provide f o r the review of medical d e c i s i o n s whenever a p a t i e n t f e l t t h a t he or she was b e i n g i n a p p r o p r i a t e l y d e t a i n e d or t r e a t e d , and they c o n s e q u e n t l y s e r v e d to r e a c t i v e l y ' p o l i c e ' the management of p a t i e n t s . . W hile the new s t a t u t e s s p e c i f i e d t h a t c o n f i n e d p a t i e n t s had to be re-examined and r e - c e r t i f i e d at set p e r i o d s by medical p r a c t i t i o n e r s , the decision-making process was l e f t e n t i r e l y i n the hands of the l a t t e r . In a d d i t i o n , m e d i c a l p r a c t i t i o n e r s had the power to a d mit, t r e a t , d e t a i n and d i s c h a r g e p a t i e n t s w i t h o u t j u d i c i a l o r q u a s i - j u d i c i a 1 i n t e r f e r e n c e . In short, the medical p r o f e s s i o n dominated the management of mentally i l l persons and the j u d i c i a r y played a s u b s i d i a r y , and almost n e g l i g i b l e ' , r o l e i n the process. By the l a t e 1970's, however, new l e g i s l a t i o n had emerged i n s e v e r a l p r o v i n c e s and, s i n c e the mid-1980's, a major r e -c o n s t r u c t i o n of mental h e a l t h l e g i s l a t i o n has been o c c u r r i n g a c r o s s the c o u n t r y . S t r i c t c r i t e r i a f o r the i n v o l u n t a r y a d m i s s i o n of p a t i e n t s have been i n t r o d u c e d and r e s t r i c t i o n s have been p l a c e d upon bo t h the t r e a t m e n t of p a t i e n t s w i t h o u t t h e i r consent and the use of c e r t a i n forms of treatment. The r i g h t s of m e n t a l h e a l t h p a t i e n t s have been e n s h r i n e d i n s t a t u t e s , mental h e a l t h review boards have become q u a s i - j u d i c i a l i n nature, and the j u d i c i a r y i s p l a y i n g a more a c t i v e r o l e i n r e g u l a t i n g the management of p a t i e n t s by e s t a b l i s h i n g and 88 p r o t e c t i n g p a t i e n t s ' r i g h t s . P r o v i s i o n has been made f o r s p e c i a l advocacy s e r v i c e s f o r p a t i e n t s and these are to play a p a r t i n the p r o t e c t i o n and enhancement of p a t i e n t s ' r i g h t s . While medical p r a c t i t i o n e r s continue to play a key r o l e i n the management of p a t i e n t s , t h e i r d i s c r e t i o n a r y powers have been c u r t a i l e d and e f f o r t s have been made to ensure that they comply w i t h the p r o v i s i o n s of the new l e g i s l a t i o n . The s t a t u t o r y reforms have heralded the emergence of the 'new l e g a l i s m ' and they are c o i n c i d i n g w i t h the adoption of a new s t r a t e g y f o r the management of mentally d i s o r d e r e d persons. The process of d e - i n s t i t u t i o n a l i z a t i o n has a c c e l e r a t e d and t h i s t a c t i c h a s b e e n c o m p l e m e n t e d by p o l i c i e s o f n o n -i n s t i t u t i o n a l i z a t i o n and p r i v a t i z a t i o n . Mental h e a l t h p a t i e n t s are to be d i s c h a r g e d from p l a c e s of c o n f i n e m e n t at a f a s t e r r a t e , p a t i e n t s are to be admitted only as a l a s t r e s o r t , and the goal appears to be the c l o s u r e of l a r g e , p u b l i c i n s t i t u t i o n s . While community-based care and treatment a l t e r n a t i v e s have been d e v e l o p e d , many of t h e s e o p t i o n s are o p e r a t e d by p r i v a t e , p r o p r i e t a r y and n o n - p r o f i t o r g a n i z a t i o n s , and the ownership of sm a l l p l a c e s of confinement and treatment i s s h i f t i n g from the p u b l i c to the p r i v a t e realms. In t h i s c h a p t e r , a d e s c r i p t i o n of both the s h i f t s i n s t r a t e g y and the c o r r e s p o n d i n g changes i n m e n t a l h e a l t h l e g i s l a t i o n w i l l be p r o v i d e d . The d i s c u s s i o n b e g i n s w i t h an e x a m i n a t i o n of the emergence and n a t i o n - w i d e a d o p t i o n of 'enhanced m e d i c a l i z a t i o n ' d u r i n g the 1960's. A t t e n t i o n i s then f o c u s s e d upon the r i s e of the 'new l e g a l i s m ' and t h i s i s 89 f o l l o w e d by an examination of the extent to which t h i s wave of mental h e a l t h law r e f o r m has a f f e c t e d the p r o v i n c e s and t e r r i t o r i e s of Canada s i n c e the 1970's. I I : THE LAW AND THE MANAGEMENT OF THE MENTALLY DISORDERED IN THE 1950's AND 1960's: THE EMERGENCE OF ENHANCED MEDICALIZATION By the l a t e 1950's, Canada was p o i s e d on the verge of major s h i f t i n the s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d . The network of mental h e a l t h i n s t i t u t i o n s and resources was e x t e n s i v e and i n c l u d e d , p u b l i c mental h o s p i t a l s , community p s y c h i a t r i c h o s p i t a l s , p s y c h i a t r i c u n i t s i n general h o s p i t a l s , f o r e n s i c p s y c h i a t r i c s e r v i c e s and i n s t i t u t i o n s , i n s t i t u t i o n s f o r s p e c i a l c a t e g o r i e s of p a t i e n t s (i.e., mental d e f e c t i v e s , e p i l e p t i c s , a l c o h o l i c s , and t h o se s u f f e r i n g from d i s e a s e s of aging), l o c a l h o s p i t a l and mental h e a l t h c l i n i c s , a handful of p r i v a t e mental h o s p i t a l s , and s e r v i c e s f o c u s s i n g upon the mental h e a l t h of c h i l d r e n ( N a t i o n a l H e a l t h and W e l f a r e , 1954). D u r i n g t h e c o u r s e o f t h e n e x t f i f t e e n y e a r s , a p a r t i c u l a r emphasis was to be placed upon a r e d u c t i o n i n the use of p l a c e s of c o n f i n e m e n t and the c o n c o m i t a n t d e v e l o p m e n t of community-based c a r e and t r e a t m e n t r e s o u r c e s f o r b o t h new p a t i e n t s and those being r e l e a s e d from i n s t i t u t i o n s . S i m i l a r d e v e l o p m e n t s o c c u r r e d i n b o t h B r i t a i n (Jones, 1972; Armour, 1981; S c u l l , 1984) and the United S t a t e s (Lerman, 1982; Grob, 1983; Armour, 1981; S c u l l , 1984; Bloom, 1984) but one Canadian pr o v i n c e appears to have been i n the vanguard of c h a n g e . The s h i f t i n s t r a t e g y was e x e m p l i f i e d by t h e development and implementation of the s o - c a l l e d 'Saskatchewan 90 Plan', and t h i s "was to e a r n the p r o v i n c e an i n t e r n a t i o n a l r e p u t a t i o n as a pioneer i n improving mental h e a l t h care" (Task Force Committee, 1983: 19). In 1944, a new, C.C.F. government came to power i n the province and, i n 1947, the Premier - Tommy Douglas - announced plans to develop a new mental hygiene programme. T h i s was to be an i n t e g r a l p a r t of a new, general h e a l t h care s t r a t e g y f o r the p r o v i n c e (Guest, 1985) and was b u i l t around the use of mental hygiene c l i n i c s , r a t h e r than l a r g e i n s t i t u t i o n s . An impetus was subsequently provided by the development of v o l u n t e e r and p u b l i c education programmes sponsored by the Canadian Mental Health A s s o c i a t i o n and, i n the mid-1950's, the a v a i l a b i l i t y of a n t i -p s y c h o t i c drugs (Task Force Committee, 1983). In a d d i t i o n , the use of l a r g e i n s t i t u t i o n s was the s u b j e c t of a growing body of c r i t i c i s m , and key p o l i c y - m a k e r s i n S a s k a t c h e w a n were c o n t r i b u t i n g to an i n t e r n a t i o n a l debate. For example, i n 1958, the D i r e c t o r of P s y c h i a t r i c S e r v i c e s i n the p r o v i n c e - Dr. F.S. Lawson - was w r i t i n g of ' p s y c h i a t r o g e n i c i l l n e s s 1 ( c h r o n i c mental d i s o r d e r s c r e a t e d by h o s p i t a l i z a t i o n ) ; the i m p o s s i b i l i t y of p r o v i d i n g e f f e c t i v e treatment i n over-crowded i n s t i t u t i o n s ; and, the woeful c o n d i t i o n s which e x i s t e d i n such p l a c e s (Lawson, 1958) . The Saskatchewan Plan r e s t e d upon two general p r i n c i p l e s ; namely, the need to provide s e r v i c e s i n the 'community' c l o s e to where people l i v e d and worked i n order to f a c i l i t a t e the e a r l y t r e a t m e n t of d i s o r d e r s ; and, the need to p r o v i d e adequate 91 r e h a b i l i t a t i o n f o r p a t i e n t s being d i s c h a r g e d from i n s t i t u t i o n s i n t o the community. I t was b e l i e v e d that the l a t t e r would a i d r e c o v e r y and r e d u c e the l i k e l i h o o d of r e - a d m i s s i o n , and new community-based resources were developed. While the e x i s t i n g i n s t i t u t i o n s f o r mentally i l l and mentally r e t a r d e d persons were to be t e m p o r a r i l y r e t a i n e d , e x i s t i n g p a t i e n t s were to be discharged. S i m i l a r l y , new p a t i e n t s were to be t r e a t e d i n the community wherever p o s s i b l e . An e f f o r t was made to develop a network of g e n e r a l h o s p i t a l p s y c h i a t r i c wards, p s y c h i a t r i c c e n t r e s , mental h e a l t h c l i n i c s f o r o u t - p a t i e n t s , and 'approved homes', and some of these resources could be p r i v a t e l y owned and operated (Smith, 1970, 1971, 1979? Task Force Committee, 1983). The s t r a t e g y a l s o r e f l e c t e d a change i n a t t i t u d e x towards mental h e a l t h p a t i e n t s s i n c e they were to be viewed and t r e a t e d i n the same manner as other p a t i e n t s using the p r o v i n c i a l h e a l t h care system (Canada's Mental Health, 1961). The s t r a t e g y was implemented i n the e a r l y 1960's and the impact was keenly f e l t at one i n s t i t u t i o n ; namely, the mental h o s p i t a l at Weyburn. Between January 1963 and June 1966, the p o p u l a t i o n dropped from 1,519 to 421; the sharpest d e c l i n e in a h o s p i t a l p o p u l a t i o n i n B r i t a i n or North America, at that time (Task F o r c e C o m m i t t e e , 1983). However, i m p l e m e n t a t i o n encountered some problems p a r t i c u l a r l y i n r e l a t i o n to the impact of r a p i d d e - i n s t i t u t i o n a l i z a t i o n on the communities which hosted c o n c e n t r a t i o n s of newly d i s c h a r g e d p a t i e n t s . Adequate, community-based treatment a l t e r n a t i v e s had not been developed and p a t i e n t s were f a i l i n g to adhere to p r e s c r i b e d r e g i m e s of 92 chemo-therapy. The s t r a t e g y was s t r o n g l y c r i t i c i z e d and a c r i s i s was p r e c i p i t a t e d i n the summer of 1967 when a newly d i s c h a r g e d p a t i e n t c o m m i t t e d a mass murder. The P l a n was evaluated and found to be sound but under-funded and p a r t i c u l a r c r i t i c i s m was l e v e l l e d at the government f o r i t s f a i l u r e to e s t a b l i s h and finance 'home placement' and other community care programmes. The p r o v i n c i a l government subsequently r e c t i f i e d the s i t u a t i o n (Task Force Committee, 1983). The s t r a t e g y adopted i n Saskatchewan was implemented i n o t h e r p r o v i n c e s ; f o r example, i n Nova S c o t i a , a new 'mental h e a l t h p l a n ' was i n t r o d u c e d i n t h e e a r l y 1960's. T h i s emphasized the use of community-based care and treatment; the d e - c e n t r a l i z a t i o n of s e r v i c e s ; and, the i n t e g r a t i o n of mental h e a l t h s e r v i c e s w i t h i n the r e s t of the p r o v i n c i a l h e a l t h care system ( M a r s h a l l , 1962; Townsend, 1972). A network of new, community mental h e a l t h c e n t r e s was to form the c e n t r e p i e c e of the m e n t a l h e a l t h system ( L e i g h t o n , 1982). S i m i l a r changes emerged i n p r o v i n c e s such as B r i t i s h C o l u m b i a and O n t a r i o ( F o u l k e s , 1961, 1974; T y h u r s t , e t a l , 1963; M a c K e r r a c h e r , 1964). 1 The Saskatchewan Mental Health Act, 1961 and the Emergence of Enhanced M e d i c a l i z a t i o n The s h i f t i n s t r a t e g y was accompanied by sweeping changes to p r o v i n c i a l mental h e a l t h l e g i s l a t i o n which served to enhance the reforms introduced d u r i n g the era of ' m e d i c a l i z a t i o n ' . The l a t t e r had continued, on a piecemeal b a s i s , d u r i n g the 1940's and 1950's and s e v e r a l p r o v i n c e s i n t r o d u c e d amendments to 93 s t a t u t e s which both eroded the s u p e r v i s o r y r o l e of the j u d i c i a r y (where t h i s aspect of l e g a l i s m s t i l l e x i s t e d ) and enabled the e s t a b l i s h m e n t of new, i n t e n s i v e treatment and community care f a c i l i t i e s . In B r i t i s h Columbia, f o r example, the Mental H o s p i t a l s Act was amended i n 1940 and a new, 'mental hygiene* l e x i c o n was adopted. 2 In a d d i t i o n , a 'patients' review panel', composed of two medical p r a c t i t i o n e r s , was introduced and granted a mandate to r e v i e w the c a s e s of those c o n f i n e d i n i n s t i t u t i o n s . 3 The p r o v i n c e a l s o i n t r o d u c e d s e g r e g a t e d f a c i l i t i e s f o r m e ntal d e f e c t i v e s , mental h e a l t h c entres, and a 'psychopathic' c l i n i c to w h ich p a t i e n t s c o u l d be a d m i t t e d on the b a s i s of m e d i c a l c e r t i f i c a t e s . 4 New l e g i s l a t i o n i n Quebec served to r a t i o n a l i z e and 'medicalize' the management of mentally i l l p a t i e n t s 5 while, i n O n t a r i o , new f a c i l i t i e s were i n t r o d u c e d i n the form of ' o b s e r v a t i o n u n i t s ' , s p e c i a l h o s p i t a l s f o r c h i l d r e n , and 'community p s y c h i a t r i c hospitals'.** In Nova S c o t i a , p r o v i s i o n was made f o r the i n v o l u n t a r y commitment of p a t i e n t s on the b a s i s of m e d i c a l c e r t i f i c a t e s and the r o l e of the j u d i c i a r y was reduced to the p r o v i s i o n of post-commitment review f o r those who f e l t that t h e i r commitment and confinement was unnecessary.' W h i l e t h e s e changes were of i m p o r t a n c e , they m e r e l y foreshadowed a major, nation-wide r e c o n s t r u c t i o n and standard-i z a t i o n of m e ntal h e a l t h s t a t u t e s w hich o c c u r r e d d u r i n g the 1960's. The new l e g i s l a t i o n was e p i t o m i z e d by the Saskatchewan, Mental Health A c t , 8 and the passage of t h i s s t a t u t e i n 1961 was an i n t e g r a l p a r t o f the new p r o v i n c i a l s t r a t e g y f o r the 94 management of mentally d i s o r d e r e d persons. The Act proved to be a b l u e p r i n t f o r other p r o v i n c e s and a b r i e f review of i t s main p r o v i s i o n s i s consequently warranted. A new d e f i n i t i o n o f ' m e n t a l d i s o r d e r ' e s t a b l i s h e d d i f f e r e n t c a t e g o r i e s of p a t i e n t s and a p a r t i c u l a r d i s t i n c t i o n was drawn between those s u f f e r i n g from 'mental i l l n e s s * , those who were ' m e n t a l l y r e t a r d e d ' , and t h o s e a f f l i c t e d w i t h ' p s y c h o p a t h i c d i s o r d e r s ' . The l e g a l d e f i n i t i o n of mental i l l n e s s r e f e r r e d t o ' d i s o r d e r s of the mind' which r e q u i r e d e i t h e r medical treatment or the placement of an i n d i v i d u a l under c a r e , s u p e r v i s i o n and c o n t r o l f o r h i s or her p r o t e c t i o n or welfare, or f o r the p r o t e c t i o n of others.^ The province thus int r o d u c e d a broad and mixed 'test' which had to be s a t i s i f i e d b e f o r e a d m i s s i o n c o u l d o c c u r , and t h i s encompassed s e v e r a l c r i t e r i a ; namely, ' t r e a t a b i l i t y ' , w e l f a r e needs, or the l i k e l i h o o d of harm. An i n d i v i d u a l could seek treatment on a v o l u n t a r y b a s i s or be admitted i n v o l u n t a r i l y f o l l o w i n g c e r t i f i c a t i o n by two medical p r a c t i t i o n e r s . However, a p a t i e n t could only be c o n f i n e d f o r s h o r t p e r i o d s o f t i m e , w i t h o u t r e - e x a m i n a t i o n and r e -c e r t i f i c a t i o n . 1 ^ I n v o l u n t a r y p a t i e n t s could be t r e a t e d without t h e i r consent and, p r o v i d i n g p e r i o d i c examinations occurred, a p a t i e n t c o u l d be c o n f i n e d and t r e a t e d u n t i l such time as the 'attending p h y s i c i a n ' f e l t that temporary or permanent discharge was a p p r o p r i a t e . 1 1 The d e c i s i o n was l e f t i n the hands of medical p r a c t i t i o n e r s although p a t i e n t s were not to be detained 95 i n f a c i l i t i e s i f they were not dangerous and i f r e l a t i v e s guaranteed the p r o v i s i o n of care and s u p e r v i s i o n . * An a d m i n i s t r a t i v e t r i b u n a l composed of a p h y s i c i a n , a lawyer, and one 'other' person was e s t a b l i s h e d f o r each f a c i l i t y and g r a n t e d the mandate to r e v i e w the c a s e s of p a t i e n t s who d i s p u t e d the need f o r c o n f i n e m e n t . A 'review p a n e l ' c o u l d discharge a p a t i e n t but, i f i t d e c l i n e d to do so, a p a t i e n t had the r i g h t to a p p e a l the d e c i s i o n to the C o u r t of Queen's Bench.-'-3 A judge c o u l d then r e v i e w the case and o r d e r the person's r e l e a s e . Consequently, a modicum of post-commitment a d m i n i s t r a t i v e and j u d i c i a l review was a v a i l a b l e , p r o v i d i n g a p a t i e n t (or a f r i e n d or r e l a t i v e ) made a p p l i c a t i o n . T h i s was t h e o n l y a r e a where t h e j u d i c i a r y p l a y e d a r o l e i n t h e s u p e r v i s i o n of the commitment and confinement of p a t i e n t s . The A c t a l s o e s t a b l i s h e d a new p r o c e d u r e f o r t h e management of the e s t a t e s of d i s o r d e r e d p e r s o n s . W h i l e the j u d i c i a r y r e t a i n e d c o n t r o l o v e r the p r o c e s s of a p p o i n t i n g permanent c o m m i t t e e s , those b e i n g a d m i t t e d to m e n t a l h e a l t h f a c i l i t i e s c o u l d be examined and c e r t i f i e d as incompetent, by m e d i c a l p r a c t i t i o n e r s . I f t h i s o c c u r r e d , the p r o v i n c i a l ' A d m i n i s t r a t o r of E s t a t e s ' c o u l d assume management of the p a t i e n t ' s p r o p e r t y and f i n a n c i a l a f f a i r s . 1 4 W h i l e t h i s procedure dispensed w i t h the assumption that those admitted to i n s t i t u t i o n s were a u t o m a t i c a l l y incompetent, i t a l s o ensured t h a t the d e c i s i o n - m a k i n g p r o c e s s r e m a i n e d i n the hands of medical p r a c t i t i o n e r s . The j u d i c i a r y became i n v o l v e d only i f a f r i e n d or r e l a t i v e a p p l i e d f o r c o m m i t t e e s h i p or i f a p a t i e n t 96 chose to appeal a c e r t i f i c a t e of incompetency to a review panel, l o s t the appeal, and then sought the a s s i s t a n c e of the Court of Queen's Bench. The new l e g i s l a t i o n p r ovided the l e g a l framework necessary f o r the i m p l e m e n t a t i o n of the Saskatchewan P l a n . The A c t enabled the e s t a b l i s h m e n t of new f a c i l i t i e s and resources-*- 5 and, more i m p o r t a n t l y , introduced new procedures f o r the management of mentally d i s o r d e r e d persons which were c o n s i s t e n t w i t h the main t h r u s t of the s t r a t e g y (i.e., d e - i n s t i t u t i o n a l i z a t i o n to community c a r e and t r e a t m e n t ) . In p a r t i c u l a r , b o t h the requirement that p a t i e n t s be p e r i o d i c a l l y re-examined to ensure t h a t they s t i l l needed t r e a t m e n t i n an i n s t i t u t i o n and the i n t r o d u c t i o n of review panels, can be seen as an expression of a d e s i r e to ensure that p a t i e n t s were not c o n f i n e d u n n e c e s s a r i l y . At the same time, the s u p e r v i s i o n of p a t i e n t s was l e f t almost e n t i r e l y i n the hands of medical p r a c t i t i o n e r s and, while t h e i r a c t i o n s might be subjected to the s c r u t i n y of an a d m i n i s t r a t i v e t r i b u n a l , t h i s was u n d e r t a k e n on a r e a c t i v e , r a t h e r than p r o a c t i v e , b a s i s . The j u d i c i a r y played a s u b s i d i a r y , and almost n e g l i g i b l e , r o l e i n the management of p a t i e n t s . Within three years of the passage of the new Saskatchewan l e g i s l a t i o n other p r o v i n c e s began to introduce s i m i l a r s t a t u t e s . B r i t i s h Columbia was the f i r s t to enact a new Mental Health Act and, s e v e r a l weeks l a t e r , A l b e r t a f o l l o w e d suit.-'-*' Both provinces abandoned the l a s t v e s t i g e s of j u d i c i a l involvement i n the commitment p r o c e s s and embraced enhanced, m e d i c a l i z e d 97 procedures; n o t a b l y , v o l u n t a r y and i n v o l u n t a r y admission on the b a s i s of m e d i c a l c e r t i f i c a t e s , the p e r i o d i c r e - e x a m i n a t i o n requirement f o r i n v o l u n t a r y p a t i e n t s , treatment without consent, r e v i e w p a n e l s , and, i n the case of B r i t i s h C o l u m b i a , the new p r o c e d u r e f o r d e t e r m i n i n g the competency of p a t i e n t s . Both p r o v i n c e s a l s o made p r o v i s i o n f o r p a t i e n t s t o seek p o s t -commitment j u d i c i a l r e v i e w . 1 7 By the end of 1965, Manitoba had passed a Mental Health A c t 1 8 which c o n t a i n e d some a s p e c t s of the new l e g i s l a t i o n . P r o v i s i o n was made f o r the e s t a b l i s h m e n t of mental h e a l t h c l i n i c s and s p e c i a l community-based f a c i l i t i e s f o r 'retardes'. A broad d e f i n i t i o n of 'mental d i s o r d e r ' d i s t i n g u i s h e d between d i f f e r e n t c a t e g o r i e s of p a t i e n t s , and b o t h v o l u n t a r y and i n v o l u n t a r y admission on the b a s i s of one medical c e r t i f i c a t e was p e r m i s s i b l e . 1 9 Medical p r a c t i t i o n e r s were granted the power to d e t a i n , examine and t r e a t any category of p a t i e n t and, while an i n v o l u n t a r y p a t i e n t could only be held without re-examination f o r 21 days, t h i s p e r i o d c o u l d be extend e d i n d e f i n i t e l y w i t h q u a s i - j u d i c i a l a pproval. Long-term confinement r e q u i r e d an order from a ma g i s t r a t e or j u s t i c e who had r e v i e w e d the case and was s a t i s f i e d t h a t treatment was nece s s a r y . 2 ^ The medical p r a c t i t i o n e r s i n charge of mental h e a l t h f a c i l i t i e s were appointed as M a g i s t r a t e s w i t h the a u t h o r i t y to d e a l w i t h a p p l i c a t i o n s f o r o r d e r s and, as a consequence, independent j u d i c i a l involvement was n e g l i g i b l e (Katz & Larsen, 1975). No p r o v i s i o n was made f o r the e s t a b l i s h -ment of r e v i e w p a n e l s , a l t h o u g h p a t i e n t s c o u l d a p p e a l t h e i r 98 commitment and confinement to a judge of a county c o u r t . 2 * M e d i c a l p r a c t i t i o n e r s c o u l d , a t t h e i r d i s c r e t i o n , d i s c h a r g e o r r e l e a s e a p a t i e n t u n d e r v a r i o u s t e r m s and c o n d i t i o n s ; f o r example, on 'probation' or under the s u p e r v i s i o n of an approved agency or i n d i v i d u a l . Those who were unnecess-a r i l y c o n f i n e d c o u l d be r e l e a s e d and then cared f o r and t r e a t e d , under s u p e r v i s i o n , i n the c o m m u n i t y . 2 2 W h i l e the j u d i c i a r y continued to c o n t r o l the appointment of committees, those who were i n v o l u n t a r i l y admitted or c o n d i t i o n a l l y r e l e a s e d (e.g., under s u p e r v i s i o n ) l o s t c o n t r o l of t h e i r p r o p e r t y and f i n a n c i a l a f f a i r s . Management was p a s s e d i n t o the hands of a p u b l i c a d m i n i s t r a t o r who was g r a n t e d sweeping powers to c o n t r o l a p a t i e n t ' s e s t a t e . 2 3 By the mid-1960's, the p r o c e s s of r e f o r m which had a f f e c t e d a l l the western p r o v i n c e s began to have an impact i n c e n t r a l and maritime Canada. In Nova S c o t i a , the l o c a l l u n a t i c asylums became 'municipal mental h o s p i t a l s ' to which p a t i e n t s c o u l d be a d m i t t e d on the b a s i s of m e d i c a l c e r t i f i c a t e s . 2 4 Medical p r a c t i t i o n e r s a d m i t t i n g i n v o l u n t a r y p a t i e n t s to the Nova S c o t i a H o s p i t a l had to c e r t i f y that the i n d i v i d u a l c o u l d not be t r e a t e d a d e q u a t e l y i n the community, and a p e r i o d i c r e -e x a m i n a t i o n r e q u i r e m e n t was i n t r o d u c e d . 2 5 S i m i l a r l y , i n Newfoundland, i n v o l u n t a r i l y c o n f i n e d p a t i e n t s were to be r e -examined every s i x months.2** In Ontario, a new Mental Health A c t 2 ' was passed i n the S p r i n g of 1967 and t h i s bore the d i s t i n c t h a l l m a r k of the 99 Saskatchewan l e g i s l a t i o n . A new and s i m p l e d e f i n i t i o n of ' m e n t a l d i s o r d e r ' was i n t r o d u c e d ( i . e . , "any d i s e a s e o r d i s a b i l i t y of mind"), and i t s i m p r e c i s e n a t u r e enhanced the d i s c r e t i o n a r y powers of medical p r a c t i t i o n e r s . The p r a c t i c e of p e r m i t t i n g both v o l u n t a r y and i n v o l u n t a r y admission on the b a s i s of medical c e r t i f i c a t e s was continued; however, i n v o l u n t a r y admission had to be e i t h e r urgent or necessary i n the i n t e r e s t s of the pa t i e n t ' s s a f e t y (or that of o t h e r s ) . Once admitted, an i n v o l u n t a r y p a t i e n t had t o be p e r i o d i c a l l y r e - e x a m i n e d and c o n f i n e m e n t c o u l d c o n t i n u e o n l y i f the c r i t e r i a were s t i l l a p p l i c a b l e . 2 8 Medical p r a c t i t i o n e r s continued to c o n t r o l the c o n f i n e -ment, r e - e x a m i n a t i o n , t r e a t m e n t and d i s c h a r g e of p a t i e n t s , a l t h o u g h m u l t i - d i s c i p l i n a r y r e v i e w boards were i n t r o d u c e d . However, no p r o v i s i o n was made f o r p a t i e n t s t o a p p e a l the d e c i s i o n s of boards to a court. The new procedure f o r the man-agement of p a t i e n t s ' e s t a t e s was introduced and the p r o v i n c i a l P u b l i c Trustee c o u l d assume c o n t r o l i f medical p r a c t i t i o n e r s c e r t i f i e d that a p a t i e n t was incompetent. 2 9 W i t h i n a year, a v i r t u a l copy of the new On t a r i o s t a t u t e had been adopted i n P r i n c e Edward I s l a n d . 3 0 Twelve months l a t e r , New Brunswick f o l l o w e d s u i t (Sykes, 1 9 7 0 ) 3 1 and, by the end of 1971, Newfoundland had pa s s e d i t s own v e r s i o n of the Ontari o l e g i s l a t i o n . * In the same year, the l e g i s l a t u r e i n the Northwest T e r r i t o r i e s a l s o passed a new Mental Health Ordinance that m i r r o r e d the developments which had been o c c u r r i n g i n the 100 p r o v i n c e s . J Only Quebec r e m a i n e d u n a f f e c t e d by the wave of reform, although t h i s s i t u a t i o n had been r e s o l v e d by the end of 1972. The passage of the Mental P a t i e n t s P r o t e c t i o n A c t 3 4 marked the end of any major j u d i c i a l involvement i n the s u p e r v i s i o n of mental h e a l t h p a t i e n t s i n Quebec. P r o v i s i o n was made f o r the e x a m i n a t i o n of m e n t a l l y d i s o r d e r e d p e r s o n s and f o r t h e i r admission to 'close treatment* (cure fermee) p r i m a r i l y on the b a s i s of the opini o n s of two p s y c h i a t r i s t s . 3 5 Any examination was to in c l u d e an assessment of the p a t i e n t ' s c a p a c i t y to manage an e s t a t e and the P u b l i c C u r a t o r c o u l d assume c o n t r o l of a person's a f f a i r s i f n e c e s s a r y . 3 6 P s y c h i a t r i s t s were granted the power to c o n f i n e and t r e a t a p a t i e n t f o r up to 21 days, f o l l o w i n g which p e r i o d i c re-examinations were to o c c u r . 3 ' A m u l t i - d i s c i p l i n a r y Board of Review was e s t a b l i s h e d to hear a p p e a l s f r o m t h o s e d i s s a t i s f i e d w i t h t h e d e c i s i o n s o f p s y c h i a t r i s t s 0 0 and the s t a t u t e g e n e r a l l y f o l l o w e d the model provided by the other p r o v i n c e s (Gagne, 1973; L a n g l o i s , 1976). At the same time, however, c e r t a i n p r o v i s i o n s foreshadowed the next wave of r e f o r m t h a t was to a f f e c t C a n a d i a n m ental h e a l t h law; namely, the 'new l e g a l i s m ' . In p a r t i c u l a r , the Quebec l e g i s l a t i o n i n t r o d u c e d the concept of 'dangerousness' as the p r i n c i p a l c r i t e r i o n which had to be met before i n v o l u n t a r y admission could occur. No person was to be admitted to 'close t r e a t m e n t ' u n l e s s the i n d i v i d u a l ' s m e n t a l c o n d i t i o n was such that i t might endanger h i s or her own h e a l t h or s e c u r i t y or the he a l t h or s e c u r i t y of o t h e r s . 3 ^ Although, 'dangerousness* was 101 not d e f i n e d , thereby l e a v i n g i n t e r p r e t a t i o n of the term i n the hands of medical p r a c t i t i o n e r s ( H i l l , 1977), i t s use r e f l e c t e d a d e s i r e to impose r e s t r a i n t s upon those seeking to admit persons i n v o l u n t a r i l y . The government c o m m i s s i o n of i n q u i r y w h i c h recommended the i n t r o d u c t i o n of the new s t a t u t e e x p r e s s l y sought to reduce the chances of u n j u s t i f i e d admission and to f a c i l i t a t e e a s i e r d i s c h a r g e from an i n s t i t u t i o n (Commission D'Enquete, 1970). The r e s u l t was the i n t r o d u c t i o n of a c r i t e r i o n that was s t r i c t e r than that which e x i s t e d elsewhere i n Canada and t h i s helped reduce both the numbers of i n v o l u n t a r y admissions and the l e n g t h of time which p a t i e n t s spent i n f a c i l i t i e s ( H i l l , 1977). In a d d i t i o n , the s t a t u t e c o n t a i n e d a s p e c i f i c d i v i s i o n s e t t i n g out the r i g h t s of those under 'close t r e a t m e n t ' . 4 0 On a d m i s s i o n , p a t i e n t s were to be i n f o r m e d of t h e i r r i g h t s (and avenues of r e c o u r s e ) as s e t out i n the Act (e.g., the r i g h t to apply to the Board of Review) and every a t t e n d i n g p h y s i c i a n was r e q u i r e d to advise both the p a t i e n t and h i s or her r e l a t i v e s of the p r o p o s e d programme of c a r e and t r e a t m e n t as w e l l as "the measures l i k e l y to h a s t e n . . . r e c o v e r y " . 4 1 P a t i e n t s were a l s o granted the r i g h t to uncensored correspondence w i t h s p e c i f i e d government o f f i c i a l s , departments, and p r o f e s s i o n a l s . With the e x c e p t i o n of the r e q u i r e m e n t t h a t p h y s i c i a n s provide i n f o r m a t i o n r e g a r d i n g treatment, the v a r i o u s ' r i g h t s ' were not new. Other p r o v i n c e s had introduced s i m i l a r p r o v i s i o n s and the l i m i t e d r i g h t to send and r e c e i v e m a i l had been a l o n g -standing f e a t u r e of l e g i s l a t i o n . However, the idea of a c t u a l l y 102 s e t t i n g t h e s e out i n a s p e c i f i c and s e p a r a t e s t a t e m e n t was a s i g n i f i c a n t development. I t represented an acceptance of the view t h a t , d e s p i t e t h e i r demise, mental h e a l t h p a t i e n t s were j u r i d i c a l i n d i v i d u a l s who were i n v e s t e d with r i g h t s and e n t i t l e d to c e r t a i n p r o t e c t i o n s . T h i s a p p r o a c h would s u b s e q u e n t l y dominate Canadian mental h e a l t h l e g i s l a t i o n d u r i n g the era of the 'new l e g a l i s m ' . Summary By 1972, both the s t r a t e g y and the l e g i s l a t i o n a f f e c t i n g the management of mentally i l l persons i n Canada had undergone a t r a n s f o r m a t i o n . W h i l e some changes had been made d u r i n g the 1950's, the a d o p t i o n and i m p l e m e n t a t i o n of the 'Saskatchewan P l a n ' i n the e a r l y 1960's s i g n a l l e d the b e g i n n i n g of a major s h i f t . The s t r a t e g y i n v o l v e d a r e d u c t i o n i n the use of p l a c e s of segregated confinement and a p r e f e r e n c e f o r the p r o v i s i o n of care and treatment i n community-based f a c i l i t i e s and resources. P a t i e n t s were to be discharged from h o s p i t a l s and new p a t i e n t s were to be admitted only i f the community-based options were un a b l e to p r o v i d e t r e a t m e n t . Community r e s o u r c e s were to be e s t a b l i s h e d and mental h e a l t h p a t i e n t s were to be viewed i n the same manner as other persons using h e a l t h care resources. The new, s t a n d a r d i z e d m e n t a l h e a l t h l e g i s l a t i o n was c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' and e x e m p l i f i e d by the Saskatchewan, Mental Health Act of 1961. Over the course of ten years, a l l the p r o v i n c e s and t e r r i t o r i e s i n t r o d u c e d s i m i l a r reforms and the b a s i c f e a t u r e s are set out i n Table 3.1. The new s t a t u t e s f a c i l i t a t e d the d e velopment of community-based 103 treatment a l t e r n a t i v e s and in t r o d u c e d new procedures f o r the management of mentally i l l persons which s i m u l t a n e o u s l y enhanced the s u p e r v i s o r y r o l e of medical p r a c t i t i o n e r s and supported the main t h r u s t of the s t r a t e g y . TABLE 3.1 PROCEDURES AFFECTING MENTALLY ILL PERSONS IN CANADA: 1972 Med i c a l S u p e r v i s i o n A d m i n i s t r a t i v e Supervi s i o n J u d i c i a l S u p e r v i s i o n I n i t i a l Admission of a l l P a t i e n t s Long-Term Admission of a l l P a t i e n t s A l l p r o v i n c e s A l l p r o v i n c e s except Man. T e r r i t o r i e s , T e r r i t o r i e s & Man. Post-Admission Treatment Post-Admission Confinement A l l provinces, N.S. & Man. A l l p r o v i n c e s except N.S. & Man. ( A l l p r o v i n c e s except Ont) Committee-ship/Guard-i a n s h i p E s t a t e Management by P u b l i c T r u s t e e / A d m i n i s t r a t o r A l l p r o v i n c e s and t e r r i t o r i e s . B.C., Ont., Sask., Que., P.E.I., N.B. (Sask. , Ont.,, P.E.I., N.B.) * = P a t i e n t s granted a" r i g h t to seek review by a d m i n i s t r a t i v e t r i b u n a l s and/or c o u r t s , and to a p p e a l the d e c i s i o n s o f t r i b u n a l s to the j u d i c i a r y . No automatic review to occur. V o l u n t a r y and i n v o l u n t a r y a d m i s s i o n c o u l d o c c u r on the 104 b a s i s of medical c e r t i f i c a t e s and the l a s t v e s t i g e s of j u d i c i a l s u p e r v i s i o n were removed i n the p r o v i n c e s which had r e t a i n e d t h i s element of ' l e g a l i s m 1 . While the p e r i o d i c re-examination of c o n f i n e d p a t i e n t s became mandatory, decision-making was l e f t i n the hands of medical p r a c t i t i o n e r s and the l a t t e r were able to t r e a t and discharge p a t i e n t s at t h e i r d i s c r e t i o n . However, m u l t i - d i s c i p l i n a r y a d m i n i s t r a t i v e t r i b u n a l s ( i . e . , r e v i e w boards) were e s t a b l i s h e d to hear a p p e a l s from p a t i e n t s who d i s p u t e d the need f o r c o n f i n e m e n t . In most p r o v i n c e s , the j u d i c i a r y could review e i t h e r the need f o r continued confinement and/or the d e c i s i o n s of a board, p r o v i d i n g a p a t i e n t made a p p l i c a t i o n , and t h i s was the only area where they played a part i n the s u p e r v i s i o n of c o n f i n e d p a t i e n t s . While the j u d i c i a r y r e t a i n e d c o n t r o l of the appointment of committees, a new procedure f o r the management of e s t a t e s was i n t r o d u c e d i n many p r o v i n c e s . On a d m i s s i o n t o a f a c i l i t y , p a t i e n t s could be examined by medical p r a c t i t i o n e r s to determine whether t h e y were competent to a d m i n i s t e r t h e i r e s t a t e s . I f in c o m p e t e n c y was e s t a b l i s h e d , a p a t i e n t ' s e s t a t e c o u l d be managed by a P u b l i c T r u s t e e or A d m i n i s t r a t o r of E s t a t e s . In some p r o v i n c e s , p a t i e n t s were granted the r i g h t to appeal the issuance of a c e r t i f i c a t e of incompetency to a review board. In s h o r t , w hile the a c t i v i t i e s of medical p r a c t i t i o n e r s c o u l d be reviewed by a d m i n i s t r a t i v e t r i b u n a l s , they dominated the management of mentally i l l persons and the j u d i c i a r y played a s u b s i d i a r y and almost n e g l i g i b l e r o l e . However, some of the p r o v i s i o n s of the mental h e a l t h l e g i s l a t i o n which appeared i n 105 Quebec i n 1972 s i g n a l l e d the emergence of a new p e r i o d of mental h e a l t h law reform - the 'new l e g a l i s m ' - which i s c h a r a c t e r i z e d by the e r o s i o n of medical domination. I l l ; THE LAW AND THE MANAGEMENT OF THE MENTALLY DISORDERED IN THE 19 70's AND 1980's: THE R_ISE OF THE _"_NEW LEGALISM ' By the l a t e 1970's, an adjustment i n the s t r a t e g y f o r the management of the mentally d i s o r d e r e d had emerged which i s now a f f e c t i n g a l l the p r o v i n c e s of Canada. The s h i f t away from the use of i n s t i t u t i o n s has c o n t i n u e d , but the p r o c e s s of 'de-i n s t i t u t i o n a l i z a t i o n ' has a c c e l e r a t e d and a p r e f erence f o r 'non-i n s t i t u t i o n a l i z a t i o n ' has become more evident. M e n t a l l y i l l persons who have been (and those who are being) di s c h a r g e d from mental h o s p i t a l s are to be s u p e r v i s e d and t r e a t e d by community mental h e a l t h c e n t r e s and teams of mental h e a l t h p r o f e s s i o n a l s . New p a t i e n t s are a l s o to be t r e a t e d i n the community and general h o s p i t a l p s y c h i a t r i c u n i t s ( r a t h e r than the o l d p l a c e s of confinement) are to p rovide short-term r e s i d e n t i a l treatment where necessary. The management of developmentally d i s a b l e d p e r s o n s ( f o r m e r l y , t h o se deemed to be m e n t a l l y d e f e c t i v e and mentally retarded) has ceased to be the r e s p o n s i b i l i t y of mental h e a l t h s e r v i c e s and t h e s e p e r s o n s are a l s o b e i n g t r a n s f e r r e d from i n s t i t u t i o n s to community-based a l t e r n a t i v e s at a r a p i d r a t e (Toews & Barnes, 1982, 1986; R i l e y & Richman, 1983; Health & Welfare: Canada, 1982; M a r s h a l l , 1982). One of the g o a l s of d e - i n s t i t u t i o n a l i z a t i o n and non-i n s t i t u t i o n a l i z a t i o n appears to be the c l o s u r e of both the o l d p l a c e s of s e g r e g a t e d c o n f i n e m e n t and the s p e c i a l , i n t e n s i v e 106 t r e a t m e n t f a c i l i t i e s which were b u i l t d u r i n g the 1920's and 1930's ( i . e . , the ' p s y c h o p a t h i c ' and ' p s y c h i a t r i c ' h o s p i t a l s ) (see, e.g., M i n i s t r y of Health, 1987). Instead, p a t i e n t s are to be e i t h e r maintained i n t h e i r own homes or housed i n p r i v a t e , p r o p r i e t a r y and n o n - p r o f i t f a c i l i t i e s . P r i v a t e s e c t o r involvement in the p r o v i s i o n of care i s growing r a p i d l y and the emergence of a p r i v a t e n u r s i n g home i n d u s t r y i s seen as an i n d i c a t i o n of a s h i f t i n the ownership of p l a c e s of confinement from the p u b l i c to the p r i v a t e realms (Lightman, 1986; Canadian M e d i c a l A s s o c i a t i o n , 1984; S o c i a l P l a n n i n g C o u n c i l o f M e t r o p o l i t a n Toronto, 1984). The t a c t i c s of a c c e l e r a t e d d e - i n s t i t u t i o n a l i z a t i o n , non-i n s t i t u t i o n a l i z a t i o n and p r i v a t i z a t i o n have been adopted i n both B r i t a i n and the U n i t e d S t a t e s (Sedgwick, 1982; S c u l l , 1981, 1981a, 1984; Lerman, 1982; Warren, 1981; Emerson, 1981) and, i n Canada, t h e i r emergence has been accompanied by changes i n mental h e a l t h l e g i s l a t i o n . The Rise of the 'New Legalism' i n Canada; S t a t u t o r y Reforms While the p r e l i m i n a r y s i g n s of the 'new l e g a l i s m ' appeared i n Quebec i n 1972, the passage of a new mental h e a l t h s t a t u t e i n A l b e r t a i n the F a l l of that year marked the beginning of a phase of reform which i s s t i l l a f f e c t i n g many p r o v i n c e s . 4 2 P r o v i n c i a l and t e r r i t o r i a l governments have adopted and a d a p t e d key p r o v i s i o n s of both the A l b e r t a l e g i s l a t i o n and amendments to the O n t a r i o , M e n t a l H e a l t h A c t , which were p a s s e d i n 1 9 78. 4 3 A 'Uniform M e n t a l H e a l t h A c t 1 i s b e i n g c o n s t r u c t e d and i t i s 107 a n t i c i p a t e d that the m a j o r i t y of p r o v i n c e s and t e r r i t o r i e s w i l l enact the p r o v i s i o n s of t h i s model s t a t u t e i n the near f u t u r e . The reforms are not c h a r a c t e r i z e d by a r e t u r n to d i r e c t j u d i c i a l s u p e r v i s i o n of the management of p a t i e n t s . While the j u d i c i a r y c o n t i n u e to r e t a i n c o n t r o l o v e r the a p p o i n t m e n t of permanent committees and g u a r d i a n s 4 4 they are not to be i n v o l v e d i n i n i t i a l admission or continued confinement d e c i s i o n s , on a r o u t i n e b a s i s . Instead, the changes i n v o l v e the i m p o s i t i o n of s t a t u t o r y r e s t r a i n t s on t h e p r a c t i c e s o f m e n t a l h e a l t h p r o f e s s i o n a l s , and q u a s i - j u d i c i a l and i n d i r e c t j u d i c i a l s u p e r v i s i o n of admission and treatment. T h i s i s accomplished by i n t r o d u c i n g s t r i c t c r i t e r i a f o r i n v o l u n t a r y a d m i s s i o n , c o n t r o l l i n g the treatments given to p a t i e n t s , and e s t a b l i s h i n g p a t i e n t s ' r i g h t s . These i n c l u d e the r i g h t to appeal to mental h e a l t h review boards and c o u r t s , and the t r i b u n a l s have become q u a s i - j u d i c i a l i n n a t u r e as a consequence of changes i n b o t h s t a t u t e s and case law. In a d d i t i o n , p r o v i s i o n has been made f o r p a t i e n t s ' a dvocacy s e r v i c e s d e s i g n e d to b o t h m o n i t o r the p r a c t i c e s of p h y s i c i a n s and ensure that c o n f i n e d persons have access to the l e g a l s e r v i c e s necessary f o r q u a s i - j u d i c i a l and j u d i c i a l bodies to p r o t e c t and enforce t h e i r r i g h t s . The A l b e r t a , Mental Health A c t 4 5 of 1972 was to provide the l e g a l framework necessary f o r a major r e - o r g a n i z a t i o n of the p r o v i n c e ' s m e n t a l h e a l t h s e r v i c e s and i t s o r i g i n s l a y i n a comprehensive e v a l u a t i o n of the system c a r r i e d out i n 1968 under the d i r e c t i o n of Dr. W.R.N. B l a i r ( B l a i r , 1969). The a n a l y s i s produced recommendations which were u n e q u i v o c a l l y i n favour of a 108 massive s h i f t away from the use of the over-crowded and under-s t a f f e d p r o v i n c i a l m e n t a l h o s p i t a l s and towards the use of community-based care and treatment s e r v i c e s . An emphasis was to be p l a c e d upon the use of l o c a l , general h o s p i t a l s r a t h e r than l a r g e and g e o g r a p h i c a l l y i s o l a t e d mental h o s p i t a l s . The l o c a l h o s p i t a l s were to be a base f o r the p r o v i s i o n of m u l t i -d i s c i p l i n a r y s e r v i c e s and programmes of a n o n - r e s i d e n t i a l nature and i t was hoped that t h i s would reduce the burden being p l a c e d upon the shoulders of the mental h o s p i t a l s . These i n s t i t u t i o n s were not to be c l o s e d immediately; however, the i n t e n t was to reduce t h e i r s i z e , improve t h e i r s e r v i c e s , and g r a d u a l l y s h i f t t h e i r r esources i n t o the d e l i v e r y of community-based s e r v i c e s (Hellon, 1973; M a r s h a l l , 1973). The new l e g i s l a t i o n i n troduced a new c r i t e r i o n that had to be met b e f o r e b o t h i n v o l u n t a r y a d m i s s i o n and c o n t i n u e d c o n f i n e m e n t c o u l d o c c u r ; namely, 'dangerousness' to s e l f o r o t h e r s . The i n i t i a l p e r i o d s of c o n f i n e m e n t w i t h o u t r e -e x a m i n a t i o n were r e d u c e d and, i f a p a t i e n t c e a s e d to be a danger, he or she had to be d i s c h a r g e d . 4 6 H o s p i t a l s were placed under a c o n d i t i o n a l duty to both provide treatment and p r o t e c t a p a t i e n t from harm. 4' The c o m p o s i t i o n of the m e n t a l h e a l t h review panel was changed i n a way that eroded the dominance of p s y c h i a t r i s t s , and the r i g h t s of t hose s e e k i n g r e v i e w were incre a s e d . P a t i e n t s were granted the r i g h t to apply f o r review whenever c e r t i f i c a t e s of admission or renewal were i s s u e d and an a p p l i c a t i o n had to be i n v e s t i g a t e d w i t h i n 28 days. I f the panel conducted a hearing, a p a t i e n t had the r i g h t to be present w i t h 109 a r e p r e s e n t a t i v e whenever evidence was given by another party. I f the p a t i e n t c o u l d n o t be p r e s e n t and d i d n o t have a r e p r e s e n t a t i v e , the panel was o b l i g e d to appoint counsel. Since other p r o c e d u r a l r i g h t s were assured (e.g., the r i g h t s to c r o s s -examine witnesses and appeal any d e c i s i o n to the Supreme Court), the p r o v i s i o n s c r e a t e d a more f o r m a l and l e g a l i s t i c type of r e v i e w . 4 8 A s p e c i a l p o r t i o n of the Act was d e d i c a t e d e n t i r e l y to a statement of the r i g h t s of p a t i e n t s . 4 9 In a d d i t i o n to s e t t i n g out t h e i r r i g h t s i n r e l a t i o n to review procedures, the s t a t u t e endorsed the f o l l o w i n g : (i) The r i g h t to be informed, i n simple language, of the reasons f o r i n v o l u n t a r y a d m i s s i o n . I f n e c e s s a r y , a p a t i e n t was to r e c e i v e the a s s i s t a n c e of an i n t e r p r e t e r . ( i i ) The r i g h t to be p r o v i d e d with a w r i t t e n statement of the a u t h o r i t y f o r and p e r i o d of d e t e n t i o n i n the f a c i l i t y ; the f u n c t i o n of and i n f o r m a t i o n p e r t a i n i n g to review panels; and, the r i g h t to apply f o r review. T h i s i n f o r m a t i o n was a l s o to be g i v e n to a p a t i e n t ' s n e a r e s t r e l a t i v e and the h o s p i t a l was o b l i g e d to do a l l t h a t was n e c e s s a r y to f a c i l i t a t e the s u b m i s s i o n of an a p p l i c a t i o n f o r review i f the p a t i e n t (or h i s or her r e l a t i v e s ) decided to take t h i s course of a c t i o n . ( i i i ) The r i g h t to send and r e c e i v e m a i l without c e n s o r s h i p or other i n t e r f e r e n c e . (iv) The l i m i t e d r i g h t to v i s i t a t i o n by f r i e n d s and r e l a t i v e s but the u n l i m i t e d r i g h t to r e c e i v e v i s i t s from a lawyer at any time. W i t h i n a y e a r , p r o p o s a l s f o r s i m i l a r changes began to appear i n o t h e r p r o v i n c e s . In M a n i t o b a , a r e p o r t on the p r o v i n c e ' s m e n t a l h e a l t h s e r v i c e s was p r e s e n t e d by Dr. J.C. 110 Clarkson and t h i s i n c l u d e d a recommendation that the e x i s t i n g m e n t a l h e a l t h s t a t u t e be r e p e a l e d and r e p l a c e d by new l e g i s l a t i o n c o n t a i n i n g p r o v i s i o n s that improved the r i g h t s of p a t i e n t s ( C l a r k s o n , 1973). S p e c i f i c a l l y , C l a r k s o n f e l t t h a t while the p r o v i s i o n of emergency treatment and a s s i s t a n c e should be f a c i l i t a t e d , a new s t a t u t e should make i t more d i f f i c u l t to d e t a i n a p a t i e n t on an i n v o l u n t a r y b a s i s . To t h i s end, he favoured the adoption of 'dangerousness' as the c r i t e r i o n that had to be met before commitment and confinement c o u l d occur. The i s s u e was passed to the Manitoba Law Reform Commission ( M a n i t o b a Law Reform Commission, 1979) but i t would be seven y e a r s b e f o r e new l e g i s l a t i o n a ppeared. The o n l y i n t e r i m d e v e l o p m e n t came i n 1974 when, as a m a t t e r o f p o l i c y , p s y c h i a t r i s t s were p r o h i b i t e d from a c t i n g as M a g i s t r a t e s f o r the purposes of r e v i e w i n g the need f o r the long-term confinement of an i n v o l u n t a r y p a t i e n t . T h i s t a s k was handed to P r o v i n c i a l C o u r t j u d g e s and, w h i l e the change was seen as i n a d e q u a t e by those who sought more r i g h t s f o r p a t i e n t s , i t represented one step towards the r e t u r n of 'legalism' (Katz & Larsen, 1975). In the Spring of 1977 elements of the new l e g a l i s m made an appearance i n Nova S c o t i a . New procedures a f f e c t i n g i n v o l u n t a r y admission, treatment, and post-admission review were in t r o d u c e d through a new, omnibus, H o s p i t a l s A c t , 5 0 and the l e g i s l a t i o n r e f l e c t e d many of the p r o v i s i o n s of the A l b e r t a s t a t u t e . One goal was to safeguard the r i g h t s and l i b e r t i e s of Nova S c o t i a n s and i t was f e l t t h a t t h i s could be achieved by t r e a t i n g mental 111 h e a l t h p a t i e n t s as i f they were c o n v e n t i o n a l h e a l t h c a r e p a t i e n t s (Rozovsky, 1979). Involuntary i n t e r v e n t i o n was not to occur unless a person was dangerous to h i m / h e r s e l f or o t h e r s , or where an emergency e x i s t e d , and the e x i s t i n g , broad c r i t e r i a f o r i n v o l u n t a r y admission were changed. The new procedures were a l s o i n t r o d u c e d to c o n t r o l the use of i n v o l u n t a r y admission and, as Kaiser (1986) r e p o r t s , t h i s goal was achieved. The numbers of i n v o l u n t a r y admissions have f a l l e n c o n s i d e r a b l y s i n c e 1979. The c r i t e r i a f o r i n v o l u n t a r y commitment were narrowed. Two medical p r a c t i t i o n e r s had to have 'reasonable and probable grounds' to b e l i e v e t h a t a d i s o r d e r e d p e r s o n ( i . e . , someone s u f f e r i n g from any disease or d i s a b i l i t y of mind) r e q u i r e d the s e r v i c e s a v a i l a b l e i n a f a c i l i t y and needed care because he or she was a danger to h i s or her own s a f e t y or to the s a f e t y of others. By s p e c i f y i n g that there be 'reasonable and probable grounds' f o r b e l i e v i n g t h a t a p e r s o n was a danger, the l e g i s l a t u r e imposed an o b j e c t i v e r a t h e r than s u b j e c t i v e t e s t of dangerousness, and t h i s l i m i t e d the extent to which p h y s i c i a n s could e x e r c i s e t h e i r d i s c r e t i o n during the admission p r o c e s s . 5 1 The p e r i o d s d u r i n g w h i c h a p a t i e n t c o u l d be c o n f i n e d without mandatory re-examination were reduced and a p a t i e n t was to be r e l e a s e d once he or she c e a s e d to be a d a n g e r . 5 2 A p a t i e n t was not to be t r e a t e d without h i s or her consent and, on admission, the person was to be examined) by a p s y c h i a t r i s t who was to determine whether or not the p a t i e n t had the c a p a c i t y to g i v e or w i t h h o l d c o n s e n t . The p s y c h i a t r i s t was to c o n s i d e r s p e c i f i c q u e s t i o n s (e.g., whether or not the person understood 112 the nature and purpose of the treatment and the r i s k s i n v o l v e d i n w i t h h o l d i n g consent) and could then make a d e c l a r a t i o n to the e f f e c t t h a t the p a t i e n t was i n c a p a b l e . I f t h i s o c c u r r e d , t r e a t m e n t c o u l d be g i v e n but o n l y w i t h the c o n s e n t o f a guardian, spouse, next of k i n , or the P u b l i c Trustee. P e r i o d i c r e - e x a m i n a t i o n s had to o c c u r and the p a t i e n t was g r a n t e d the r i g h t to appeal the issuance of a d e c l a r a t i o n to e i t h e r a county court judge or to the newly formed review b o a r d . 5 3 S t r i c t c o n t r o l s were a l s o p l a c e d on t h e use o f p s y c h o s u r g e r y . T h i s mode of t r e a t m e n t was not to be used u n l e s s : a p a t i e n t consented (or s u b s t i t u t e consent was secured); a f u l l a s s e s s m e n t had been c a r r i e d out; recommendations had been r e c e i v e d from b o t h the a t t e n d i n g p s y c h i a t r i s t and two, ind e p e n d e n t p s y c h i a t r i s t s ; the s u r g e r y was p e r f o r m e d a t an approved h o s p i t a l ; and, the review board had reviewed the case and d e t e r m i n e d t h a t the r e q u i r e m e n t s of the s t a t u t e had been c a r r i e d o u t . 5 4 Although the s t a t u t e continued to make p r o v i s i o n f o r p o s t -admission review by a county court judge, the primary mechanism was to be the review board. In t h i s regard, Nova S c o t i a adopted the system t h a t had been i n op e r a t i o n i n the other p r o v i n c e s f o r s e v e r a l years although w i t h m o d i f i c a t i o n s which r e f l e c t e d an emergent concern with safeguarding the r i g h t s of p a t i e n t s . A m u l t i - d i s c i p l i n a r y board was c r e a t e d and granted a mandate to review the admission, treatment and continued confinement of p a t i e n t s . I t was to a u t o m a t i c a l l y r e v i e w the c a s e s of e v e r y 113 formal p a t i e n t at l e a s t once every s i x months durin g the f i r s t two y e a r s of d e t e n t i o n and a n n u a l r e v i e w s were to o c c u r t h e r e a f t e r . P a t i e n t s were g r a n t e d the r i g h t to a p p l y f o r a h e a r i n g , a t t e n d , be he a r d , and to be r e p r e s e n t e d by c o u n s e l . Indeed, the board was empowered to appoint a lawyer to act on behalf of a p a t i e n t i f i t f e l t t h i s was n e c e s s a r y . 5 5 O t h e r p a t i e n t s ' r i g h t s were s e t out i n the s t a t u t e a l t h o u g h the l e g i s l a t o r s d i d not adopt the a p p r o a c h t a k e n i n A l b e r t a ; t h a t i s , the i n c l u s i o n of a s p e c i f i c p a r t d e d i c a t e d s o l e l y to a statement of r i g h t s . Nevertheless, p a t i e n t s were granted a l i m i t e d r i g h t to send and r e c e i v e m a i l and telephone c a l l s , and the r i g h t to r e c e i v e v i s i t s . The f a c i l i t y was pl a c e d under a duty to post n o t i c e s of r i g h t s and a l s o to provide each p a t i e n t w i t h a w r i t t e n s t a t e m e n t s e t t i n g t h e s e out. I f n e c e s s a r y , the r i g h t s were to be e x p l a i n e d to a p a t i e n t (an i n t e r p r e t e r was to be used where a p p r o p r i a t e ) , and f a c i l i t y s t a f f were to a s s i s t the p e r s o n i n c o n t a c t i n g a l a w y e r and making an a p p l i c a t i o n to the review b o a r d . 5 6 By the end of 1978, s t a t u t o r y r e f o r m s of an e q u a l l y s u b s t a n t i a l nature had made an appearance i n Onta r i o and these accompanied a s h i f t i n the s t r a t e g y a f f e c t i n g the management of mentally d i s o r d e r e d persons (Martin, 1985; M a r s h a l l , 1982). The passage of the Mental Health Amendment A c t 5 ' was i n f l u e n c e d by the p r o v i n c i a l government's urgent d e s i r e to " l i m i t the use of i n v o l u n t a r y c o m m i t m e n t i n f a v o u r o f i n c r e a s e d d e -i n s t i t u t i o n a l i z a t i o n and community based h e a l t h s e r v i c e s " (Manitoba Law Reform Commission, 1979: 42) and one goal of the 114 l e g i s l a t i o n was to ensure that community and f a m i l y resources were used ( M a r t i n , 1985). I t was c o n t e n d e d t h a t s t a t u t o r y r e f o r m was n e c e s s a r y i n the l i g h t of d e v e l o p m e n t s i n chemo-therapy, the emergent 'philosophy 1 of treatment i n the community ( w i t h h o s p i t a l i z a t i o n as a l a s t r e s o r t ) , the d e velopment of community h o s p i t a l and o u t - p a t i e n t s e r v i c e s , and the growth of new treatment and support s e r v i c e s i n the community ( M i n i s t r y of Health: O n t a r i o , 1979). 5 8 The p r o v i n c i a l M i n i s t e r of H e a l t h had c r e a t e d s e v e r a l 'Task Forces' to examine mental h e a l t h s e r v i c e s and one of these was to a s s e s s the need f o r l e g i s l a t i v e change (Committee on Mental Health S e r v i c e s i n O n t a r i o , 1979). However, the M i n i s t e r d i d not w a i t f o r the f i n a l r e p o r t and, w h i l e some p u b l i c c o n s u l t a t i o n occurred (Standing Committee, 1978), he chose to introduce a set of s t a t u t o r y amendments which had been d r a f t e d by h i s l e g a l counsel - G i l b e r t Sharpe. The l a t t e r had reviewed the t r e n d s i n m e n t a l h e a l t h law r e f o r m i n the U n i t e d S t a t e s , B r i t a i n , and Canada, and f a v o u r e d the d e v e l o p m e n t s which had o c c u r r e d i n b o t h A l b e r t a and the U n i t e d S t a t e s ; t h a t i s , an expansion of p a t i e n t s ' r i g h t s and the concomitant i n t r o d u c t i o n of s a f e g u a r d s t h a t would p r e v e n t u n w a r r a n t e d a d m i s s i o n , confinement and treatment. The e x i s t i n g p r o v i n c i a l l e g i s l a t i o n was too vague and there was evidence that medical p r a c t i t i o n e r s were a d m i t t i n g p a t i e n t s improperly and u n n e c e s s a r i l y (Sharpe, 1978, 1979). The p r o c e d u r e s f o r i n v o l u n t a r y a d m i s s i o n and c o n f i n e m e n t had been c r i t i c i z e d by the 1968, McRuer R o y a l Commission on C i v i l R i g h t s 5 9 and r e f o r m was l o n g overdue 115 (Sharpe, 1978). The passage of the new l e g i s l a t i o n s i g n a l l e d the a r r i v a l of the 'new l e g a l i s m * i n On t a r i o . New c r i t e r i a f o r i n v o l u n t a r y admission and continued confinement were introduced, and these amounted to a d e t a i l e d and 'objective' t e s t of dangerousness. 6 0 C o n f i n e d p a t i e n t s had to be p e r i o d i c a l l y r e - e x a m i n e d and the tim e between e x a m i n a t i o n s was s h o r t e n e d . 6 1 P s y c h i a t r i c t r e a t m e n t was not t o be g i v e n w i t h o u t a p a t i e n t ' s c o n s e n t a l t h o u g h , i f t h e p e r s o n was deemed n o t t o be ' m e n t a l l y competent', s u b s t i t u t e consent could be obtained from e i t h e r a r e l a t i v e or the mental h e a l t h r e v i e w b o a r d . The use of 'ps y c h o s u r g e r y ' was p r o h i b i t e d i n the case of i n v o l u n t a r y p a t i e n t s and co n s e n t c o u l d not be g i v e n by p a t i e n t s , t h e i r r e l a t i v e s , or the review b o a r d . 6 2 Consequently, l i m i t a t i o n s were p l a c e d upon the amount and type of p s y c h i a t r i c treatment t h a t c o u l d be g i v e n t o i n v o l u n t a r y p a t i e n t s , w i t h o u t t h e i r c o n s e n t , and an o u t r i g h t ban was p l a c e d on the use of one, c o n t r o v e r s i a l mode of treatment; namely, psychosurgery. A l t h o u g h the mandate of r e v i e w boards was ex t e n d e d to en c o m p a s s i s s u e s o f c o m p u l s o r y t r e a t m e n t , t h e i r m u l t i -d i s c i p l i n a r y composition d i d not change. However, i n re a c h i n g d e c i s i o n s r e g a r d i n g the need f o r confinement they were r e q u i r e d to assess whether or not the s t r i c t e r c r i t e r i a f o r i n v o l u n t a r y admission were s a t i s f i e d . In a d d i t i o n , automatic reviews were to occur and e f f o r t s were made to improve the r i g h t s of p a t i e n t s who were s e e k i n g r e v i e w . 6 3 A p h y s i c i a n who a d m i t t e d o r 116 a u t h o r i z e d the continued confinement of a p a t i e n t was to provide w r i t t e n n o t i c e of the r i g h t to review to both the p a t i e n t and the d i r e c t o r of l e g a l a i d f o r the area i n which the f a c i l i t y was l o c a t e d . Requests f o r a hearing before a review board could be l o d g e d w i t h the o f f i c e r i n charge of the f a c i l i t y who was o b l i g e d to forward these to the chairman of the board. These p r o c e d u r e s f a c i l i t a t e d b o t h the p r o c e s s of r e v i e w and the p r o v i s i o n of l e g a l advice and r e p r e s e n t a t i o n f o r p a t i e n t s . 6 4 P a t i e n t s (and t h e i r r e p r e s e n t a t i v e s ) were e n t i t l e d to examine t h e i r c l i n i c a l records p r i o r to a hearing and members of a review board were not p e r m i t t e d to d i s c u s s or i n v e s t i g a t e a case p r i o r to a h e a r i n g . In a d d i t i o n , a member of a b o a r d could not p a r t i c i p a t e i n a d e c i s i o n r e s p e c t i n g a p a t i e n t ' s case unless he or she had been present during the person's hearing. A f u r t h e r safeguard was provided i n s o f a r as p a t i e n t s were to be granted the r i g h t to appeal the d e c i s i o n of a board to a county or d i s t r i c t c o u r t , and a judge was p e r m i t t e d to both conduct a f u l l hearing i n t o the matter and over t u r n the d e c i s i o n of the b o a r d . 6 5 By the end of 1979, proposals f o r reforms c o n s i s t e n t with the new l e g a l i s m had been presented i n both Manitoba and B r i t i s h C o l u m b i a . The M a n i t o b a Law Reform Commission p u b l i s h e d the r e s u l t s of i t s s t u d y of m e n t a l h e a l t h l e g i s l a t i o n i n the province (Manitoba Law Reform Commission, 1979) and recommended the adoption of p r o v i s i o n s comparable to those found i n Ontario. One year l a t e r , an amending s t a t u t e i n t r o d u c e d some ch a n g e s , 6 6 and a new Mental Health B i l l r e f l e c t i n g a f i r m endorsement of 117 the O n t a r i o s t a t u t e was introduced i n the L e g i s l a t i v e Assembly i n June 1987. 6 7 In B r i t i s h Columbia, the 'Cumming Report 1 on p r o v i n c i a l m ental h e a l t h s e r v i c e s recommended t h a t the m e n t a l h e a l t h s t a t u t e be " e n t i r e l y r e w r i t t e n , modernized and expanded to cover those areas now d e a l t w i t h inadequately" ( M i n i s t r y of Health: B r i t i s h Columbia, 1979: 112). The c r i t e r i a f o r commitment were seen as too b r o a d and the a d m i s s i o n p r o c e d u r e i n need of c l a r i f i c a t i o n . The r i g h t s of p a t i e n t s were to be s e t out c l e a r l y and i n c l u d e the r i g h t to reasonable communication, the r i g h t to p r i v a c y , and the r i g h t to i n f o r m a t i o n about treatment. In a d d i t i o n , p a t i e n t s were to be accorded the r i g h t to r e c e i v e t r e a t m e n t , the r i g h t to r e f u s e t r e a t m e n t , and the r i g h t to t r e a t m e n t i n the " l e a s t r e s t r i c t i v e ' s e t t i n g . C r i t i c i s m was a l s o l e v e l e d a t the p r o c e d u r e s a f f e c t i n g the r e v i e w p a n e l . Cumming f e l t that they l a c k e d "any of the safeguards of a f a i r h e a r i n g " and, i n h i s view, the r e v i e w p r o c e s s was " p a t e n t l y open, i f not to abuse, at l e a s t to n e g l e c t of the l e g i t i m a t e r i g h t s of the p a t i e n t " (op c i t ) . W i t h i n a matter of months the p r o v i n c i a l government had responded by amending the M e n t a l H e a l t h A c t R e g u l a t i o n s , and the r i g h t s of p a t i e n t s s e e k i n g review were improved. 6 8 While the Mental Health Act was not amended a t the t i m e , the l e g i s l a t i o n i s now under r e v i e w and there are i n d i c a t i o n s that a r e c o n s t r u c t i o n i s imminent. 6 9 By the e a r l y 1980's, the process of reform had spread to other p r o v i n c e s and the T e r r i t o r i e s . - In June 1980, an i n t e r -118 m i n i s t e r i a l c o mmittee was e s t a b l i s h e d i n Newfoundland and c h a r g e d w i t h the t a s k of r e v i e w i n g p r o v i n c i a l m e n t a l h e a l t h l e g i s l a t i o n . A f i n a l r e p o r t had been p r e p a r e d by the end of 1983 and a number of changes have been recommended; n o t a b l y , that p a t i e n t s should not be t r e a t e d without t h e i r consent (or s u b s t i t u t e consent) and t h a t they should be granted the r i g h t to appeal treatment d e c i s i o n s to a review board. The Committee has proposed that the composition of the board be changed to ensure p r o f e s s i o n a l balance and that the p r o c e d u r a l r i g h t s of p a t i e n t s be expanded. In p a r t i c u l a r , the Committee recommended t h a t p a t i e n t s be granted a r i g h t to l e g a l counsel, and t h a t access to l e g a l a i d s e r v i c e s be i m p r o v e d ( M i n i s t r y o f H e a l t h : Newfoundland, 1983). 7 0 By 1983, a Task F o r c e had been e s t a b l i s h e d to examine mental h e a l t h l e g i s l a t i o n i n A l b e r t a and the r e v i e w was conducted i n c o n j u n c t i o n w i t h two major s t u d i e s of the d e l i v e r y of p r o v i n c i a l m e n t a l h e a l t h s e r v i c e s ( M i n i s t r y of S o c i a l S e r v i c e s and Community Health, 1983). Both s t u d i e s emphasized the need f o r r e s t r i c t i o n s on the use of mental h o s p i t a l s and the enhancement of community care and treatment resources. The f i n a l r e p o r t of the Task F o r c e c o n t a i n e d numerous r e c o m m e n d a t i o n s c o n s i s t e n t w i t h t h e new l e g a l i s m . The d a n g e r o u s n e s s c r i t e r i o n f o r i n v o l u n t a r y a d m i s s i o n was to be r e t a i n e d and the p e r i o d s of confinement without re-examination were to be shortened. L i m i t s were to be placed upon the type and amount of treatment that could be given to non-consenting p a t i e n t s and r e v i e w b o a r d s were to be empowered to r e v i e w 119 t r e a t m e n t d e c i s i o n s ( e s p e c i a l l y i n r e g a r d to p s y c h o s u r g e r y ) . P a t i e n t s were to be g r a n t e d a r i g h t to r e c e i v e t r e a t m e n t , a r i g h t to an independent medical o p i n i o n , a r i g h t to be f r e e from abuse, a r i g h t to send and r e c e i v e telephone c a l l s , and a r i g h t to be n o t i f i e d of t h e i r r i g h t s . The review process was to be improved by the i n t r o d u c t i o n of automatic reviews, the r i g h t to a speedy review, the r i g h t to attend hearings, the r i g h t to an i n t e r p r e t e r , and the r i g h t to seek j u d i c i a l review. The Task Force a l s o recommended the i n t r o d u c t i o n of a p a t i e n t advocacy scheme that would provide f r e e l e g a l s e r v i c e s f o r i n v o l u n t a r y p a t i e n t s (op c i t ) . Some of t h e s e recommendations ( n o t a b l y , those p e r t a i n i n g to the treatment of p a t i e n t s without consent) have been adopted by the p r o v i n c i a l government and a new Mental Health B i l l was i n t r o d u c e d i n March 1987. 7 1 P r o v i n c i a l m e n t a l h e a l t h l e g i s l a t i o n has a l s o been r e c o n s t r u c t e d i n Saskatchewan. In the F a l l of 1985, and f o l l o w i n g government sponsored s t u d i e s by the Saskatchewan Law Reform Commission and the M e n t a l H e a l t h A s s o c i a t i o n i n Saskatchewan (Law Reform Commission of Saskatchewan, 1981, 1981a; Task Force Committee, 1983; Committee of Enquiry, 1984), the p r o v i n c i a l l e g i s l a t u r e passed the new Mental Health S e r v i c e s A c t . The s t a t u t e p r o v i d e s the l e g a l framework f o r the development of new, community-based, r a t h e r than i n s t i t u t i o n a l , m ental h e a l t h s e r v i c e s and these may be p r o v i d e d by p r i v a t e 7 3 s e c t o r agencies and o r g a n i z a t i o n s , on a c o n t r a c t b a s i s . The Act imposes l i m i t s upon the a c t i o n s of mental h e a l t h 120 p r o f e s s i o n a l s w hich a r e c o n s i s t e n t w i t h the government's p r e f e r e n c e f o r community-based s e r v i c e s . A more p r e c i s e d e f i n i t i o n of mental d i s o r d e r and a new s e t of c r i t e r i a f o r i n v o l u n t a r y admission have been introduced and the l a t t e r are b u i l t around a s s e s s m e n t s of the need f o r t r e a t m e n t i n a f a c i l i t y , a p a t i e n t ' s a b i l i t y to make i n f o r m e d d e c i s i o n s regarding treatment, and the p r o b a b i l i t y that the person w i l l cause harm. The pe r i o d s of time during which p a t i e n t s can be c o n f i n e d w i t h o u t r e - e x a m i n a t i o n have been s h o r t e n e d and new l i m i t s have been p l a c e d upon t h e i r t r e a t m e n t . V o l u n t a r y p a t i e n t s are not to be t r e a t e d without t h e i r consent (except i n e m e r g e n c i e s ) and i n v o l u n t a r y p a t i e n t s can o n l y be t r e a t e d without consent i f the treatment i s c o n s i s t e n t w i t h good medical p r a c t i c e and not o t h e r w i s e p r o h i b i t e d by the A c t . In t h i s r e g a r d , the s t a t u t e imposes an o u t r i g h t ban on the use of p s y c h o s u r g e r y and e x p e r i m e n t a l t r e a t m e n t w i t h i n v o l u n t a r y 74 p a t i e n t s . P r o v i s i o n i s made f o r o t h e r p a t i e n t s ' r i g h t s . An a t t e n d i n g p h y s i c i a n i s r e q u i r e d to c o n s u l t w i t h h i s or her p a t i e n t whenever p o s s i b l e and take due n o t i c e of the pa t i e n t ' s v i e w s r e g a r d i n g the c h o i c e of t h e r a p i s t s and t r e a t m e n t . A l i m i t e d r i g h t to r e c e i v e treatment i s a l s o set out i n s o f a r as a p h y s i c i a n i s pl a c e d under a duty to endeavour to provide care and treatment as a r e s u l t of which the p a t i e n t w i l l no longer need to be c o n f i n e d i n a f a c i l i t y . The s t a t u t e c o n t a i n s a general statement guaranteeing the e q u a l i t y r i g h t s of former and cu r r e n t p a t i e n t s and such persons are not to be deprived of any 121 r i g h t or p r i v i l e g e enjoyed by others simply because they have been or are, mental h e a l t h p a t i e n t s . On a d m i s s i o n , p a t i e n t s are to be i n f o r m e d of b o t h the r e a s o n s f o r t h e i r d e t e n t i o n and t h e i r r i g h t to a p p e a l to the review panel. The p a t i e n t ' s a t t e n d i n g p h y s i c i a n i s o b l i g e d to n o t i f y the ' O f f i c i a l Representative' of every admission and t h i s i n d i v i d u a l i s r e q u i r e d t o a c t as an a d v i s o r and a d v o c a t e f o r p a t i e n t s . The R e p r e s e n t a t i v e i s to v i s i t and a d v i s e e v e r y i n v o l u n t a r y p a t i e n t , and a s s i s t p a t i e n t s w i t h a p p l i c a t i o n s f o r r e v i e w . The r i g h t s of t hose who seek a r e v i e w have been strengthened. An a p p l i c a t i o n f o r review may be made every s i x weeks and an a u t o m a t i c r e v i e w i s to o c c u r e v e r y s i x months. P a t i e n t s are granted f u l l r i g h t s to r e c e i v e a hearing, to appear i n p e r s o n , to g i v e e v i d e n c e , c r o s s - e x a m i n e w i t n e s s e s , and be represented by c o u n s e l . 7 6 S t a t u t o r y reforms c o n s i s t e n t w i t h the new l e g a l i s m were a l s o passed i n New Brunswick i n 1985. 7 7 A mentally d i s o r d e r e d person may be i n v o l u n t a r i l y admitted and c o n f i n e d f o r 72 hours f o r e x a m i n a t i o n and o b s e r v a t i o n , on the b a s i s of m e d i c a l c e r t i f i c a t e s ; however, f u r t h e r i n v o l u n t a r y confinement can only be a u t h o r i z e d by a ' t r i b u n a l ' . An a t t e n d i n g p s y c h i a t r i s t may r e f e r a case to a t r i b u n a l o n l y i f a p a t i e n t i s m e n t a l l y d i s o r d e r e d , u n s u i t a b l e f o r admission as a v o l u n t a r y p a t i e n t , and 'dangerous'; that i s , the person's r e c e n t behaviour must present a s u b s t a n t i a l r i s k of imminent p h y s i c a l or p s y c h o l o g i c a l harm. 7 8 The composition of the t r i b u n a l has yet to be determined ( i t may be e i t h e r a c o u r t or an a d m i n i s t r a t i v e body) but the new 122 p r o v i s i o n s s p e c i f y that long-term confinement s h a l l only occur i f a d d i t i o n a l c r i t e r i a a re s a t i s f i e d . The t r i b u n a l must be s a t i s f i e d t h a t l e s s r e s t r i c t i v e a l t e r n a t i v e s w o u l d be i n a p p r o p r i a t e and that the p a t i e n t needs to be c o n f i n e d i n the i n t e r e s t s of h i s or her own s a f e t y or the s a f e t y of o t h e r s . On admission, p a t i e n t s (and t h e i r nearest r e l a t i v e ) are to be a d v i s e d of both the r e a s o n s f o r t h e i r d e t e n t i o n and t h e i r r i g h t t o r e t a i n and i n s t r u c t c o u n s e l . The p e r i o d s o f confinement without re-examination have been shortened and r e -examinations are to be conducted by two p s y c h i a t r i s t s . I f the c r i t e r i a f o r i n v o l u n t a r y confinement cannot be s a t i s f i e d , the p a t i e n t must be d i s c h a r g e d . 8 0 While an i n v o l u n t a r i l y c o n f i n e d p a t i e n t may be g i v e n " r o u t i n e c l i n i c a l m e d i c a l t r e a t m e n t " without consent, the person may o b j e c t and apply to the mental h e a l t h review board f o r an order to stop the t r e a t m e n t . 8 1 The new l e g a l i s m has a l s o been embraced by the governments of the T e r r i t o r i e s . In 1985, a new M e n t a l H e a l t h A c t 8 2 was passed i n the Northwest T e r r i t o r i e s and the contents m i r r o r the reforms which have occ u r r e d i n both Ontario and Saskatchewan. 8 3 M e n t a l h e a l t h l e g i s l a t i o n - i n the Yukon T e r r i t o r y has been s u b j e c t e d to a d e t a i l e d a n a l y s i s and an i n t e r - m i n i s t e r i a l c ommittee has d r a f t e d new l e g i s l a t i o n w h ich r e f l e c t s the l e g i s l a t i o n i n O n t a r i o , S a s k a t c h e w a n and t h e N o r t h w e s t 84 T e r r i t o r i e s . As the f o r e g o i n g i n d i c a t e s , the new l e g a l i s m has emerged i n many pr o v i n c e s and t e r r i t o r i e s . Major reforms have been, or 123 are about to .be, i n t r o d u c e d and one f u r t h e r development serves to s u p p o r t the c o n t e n t i o n t h a t the changes w i l l a f f e c t e v e r y p r o v i n c e and t e r r i t o r y w i t h i n the next few y e a r s . In the s p r i n g of 1985, and at the request of p r o v i n c i a l mental h e a l t h d i r e c t o r s , the Uniform Law Conference of Canada formed a 'Mental H e a l t h Law P r o j e c t ' c h a r g e d w i t h the t a s k of d e v e l o p i n g s t a n d a r d i z e d , n a t i o n a l , m e n t a l h e a l t h l e g i s l a t i o n . S i x p r o v i n c e s , and the Northwest T e r r i t o r i e s , are p a r t i c i p a t i n g i n the p r o j e c t and the p r i m a r y g o a l i s to c o n s t r u c t a 'model' s t a t u t e - a U n i f o r m M e n t a l H e a l t h Act - t h a t c o u l d form the b a s i s f o r m e n t a l h e a l t h l e g i s l a t i o n i n any p r o v i n c e o r t e r r i t o r y . I t i s a n t i c i p a t e d that the p a r t i c i p a t i n g p r o v i n c e s w i l l make any necessary amendments to e x i s t i n g s t a t u t e s once the model i s f i n a l l y developed, and that the impact w i l l be g r e a t e s t i n those p r o v i n c e s which have yet to adopt a f u l l measure of the new l e g a l i s m (e.g., B r i t i s h Columbia). The M e n t a l H e a l t h Law P r o j e c t has c o m p i l e d a s e r i e s of d r a f t s t a t u t e s , the most recent c i r c u l a t e d i n February 1987. A b r i e f e x a m i n a t i o n of the c o n t e n t s of t h i s document w i l l demonstrate the extent to which the Uniform Mental Health Act e p i t o m i z e s the new l e g a l i s m . One o b j e c t i v e i s to ensure that mental h e a l t h l e g i s l a t i o n complies with the p r o v i s i o n s of the Canadian Charter of Rights and Freedoms; n o t a b l y , those which p e r t a i n to the s a f e g u a r d s a g a i n s t a r b i t r a r y d e t e n t i o n ; the r i g h t to r e t a i n and i n s t r u c t c o u n s e l ; the r i g h t not to be d e p r i v e d of l i b e r t y w i t h o u t due 124 process; the r i g h t not to be subjected to unreasonable search or s e i z u r e ; and, the safeguards a g a i n s t c r u e l and unusual treatment or punishment ( M i l l i k e n , 1987). To t h i s end, the Act c o n t a i n s s e v e r a l p r o v i s i o n s t h a t draw upon the O n t a r i o mental h e a l t h l e g i s l a t i o n . In p a r t i c u l a r , the f o l l o w i n g have been adopted: the c r i t e r i a which must be met before i n v o l u n t a r y admission can occur; the p e r i o d i c re-examination requirements f o r c o n f i n e d p a t i e n t s ; the r i g h t to appeal to a review board; the requirement that boards review cases a u t o m a t i c a l l y ; the use of review boards as a mechanism f o r the p r o v i s i o n of s u b s t i t u t e c o n s e n t to treatment; the r i g h t s of p a t i e n t s during review board hearings; and, the r i g h t to appeal d e c i s i o n s to a c o u r t . S e v e r a l new r i g h t s have a l s o been proposed, p a r t i c u l a r l y f o r i n v o l u n t a r y p a t i e n t s . I f a p e r s o n i s 'apprehended' and t a k e n to a h o s p i t a l , he or she i s t o be i n f o r m e d of the d e s t i n a t i o n , the reasons f o r the 'apprehension', and the r i g h t to counsel. I f the person i s not admitted he or she has a r i g h t to be r e t u r n e d to the place of apprehension. A p a t i e n t may only be detained f o r examination and assessment f o r 48 hours and the p e r s o n must then be e i t h e r r e l e a s e d or a d m i t t e d . I f the admission i s to be on an i n v o l u n t a r y b a s i s , the p a t i e n t i s to be a d v i s e d of the r i g h t to both c o u n s e l and a r e v i e w b o a r d hearing, and t h i s i s to be repeated whenever a c o n f i n e d p a t i e n t i s re-examined and detained. I t i s proposed that, on admission, a p h y s i c i a n be r e q u i r e d t o a s s e s s t h e e x t e n t t o w h i c h a p a t i e n t has t h e m e n t a l competence to make d e c i s i o n s (e.g., to consent to treatment) and 125 a p a t i e n t i s to be g r a n t e d the r i g h t to a p p e a l a f i n d i n g of i ncompetence to a r e v i e w b o a r d . S u b s t i t u t e d e c i s i o n s may be made by the nearest r e l a t i v e of an incompetent p a t i e n t but t h i s i n d i v i d u a l i s t o a c t i n the b e s t i n t e r e s t s of the p a t i e n t . Review bo a r d s may g i v e s u b s t i t u t e c o n s e n t under c e r t a i n c o n d i t i o n s . Competent p a t i e n t s are to be granted a s p e c i f i c r i g h t not to be given any form of treatment without consent, and i n c o m p e t e n t p a t i e n t s who o b j e c t to t h e i r t r e a t m e n t are to be e n t i t l e d to a second medical o p i n i o n . P a t i e n t s are to be g r a n t e d a r i g h t of a c c e s s to t h e i r c l i n i c a l r e c o r d s , a l t h o u g h a r e v i e w b o a r d may a l l o w some i n f o r m a t i o n to be w i t h h e l d i f i t i s l i k e l y to r e s u l t i n harm to a p a t i e n t or o t h e r p e r s o n . P a t i e n t s a r e to be g r a n t e d the ' r i g h t of c o r r e c t i o n 1 ; that i s , they may request that any e r r o r s or omissions be c o r r e c t e d and that a statement of disagreement be lodged. A l l the r i g h t s of p a t i e n t s are to be p r o t e c t e d and enforced by a 'patient a d v i s o r s e r v i c e ' and i t i s proposed that a d v i s o r s be granted the r i g h t to meet and c o n f e r with p a t i e n t s at any reasonable time. The A c t a l s o c o n t a i n s a 'statement of purpose' ( i . e . , a c l a u s e t h a t i s to be used as a g u i d e to the i n t e r p r e t a t i o n o f i t s p r o v i s i o n s ) and t h i s r e f l e c t s a d e s i r e to p l a c e l i m i t a t i o n s upon the i n v o l u n t a r y admission and treatment of p a t i e n t s . The 'dangerousness' c r i t e r i o n f o r admission and confinement i s to be f o l l o w e d s t r i c t l y , and the l e a s t r e s t r i c t i v e and i n t r u s i v e form of care and treatment i s to be used whenever p o s s i b l e . To t h i s 126 end, p r o v i s i o n i s made f o r the r e l e a s e of i n v o l u n t a r y p a t i e n t s to a l e s s r e s t r i c t i v e , community-based, treatment a l t e r n a t i v e . P h y s i c i a n s are to be a l l o w e d to r e l e a s e p a t i e n t s 'on leave' but s u b j e c t to r e - c a l l at any t i me and t h i s w i l l p e r m i t the r e -a d m i s s i o n of a d e t e r i o r a t i n g p a t i e n t (e.g., a p e r s o n who i s f a i l i n g to f o l l o w a course of treatment i n the community) wi t h a minimum of delay and p r o c e d u r a l impediment. At the same time, a p a t i e n t who i s r e - c a l l e d i s to be granted the r i g h t to appeal t h i s a c t i o n to a review board. I t i s u n c l e a r whether the l a t e s t v e r s i o n of the model s t a t u t e i s to be the f i n a l product and i t i s i m p o s s i b l e to t e l l whether the A c t w i l l be embraced i n i t s e n t i r e t y by the p a r t i c i p a t i n g p r o v i n c e s and t e r r i t o r y . However, s i n c e the p r o j e c t was i n i t i a t e d a t the r e q u e s t of the d i r e c t o r s of p r o v i n c i a l mental h e a l t h s e r v i c e s , i t may be s a f e l y assumed t h a t some or a l l of the p r o v i s i o n s w i l l form the b a s i s of mental h e a l t h l e g i s l a t i o n i n a m a j o r i t y of p r o v i n c e s i n the near f u t u r e . The Rise of the New Legalism i n Canada: The Role of the Courts The process of s t a t u t o r y reform has been accompanied by an i n c r e a s e d j u d i c i a l i n t e r e s t i n p r o t e c t i n g the r i g h t s of mental h e a l t h p a t i e n t s . Although the c o u r t s have continued to e x h i b i t a r e l u c t a n c e to p u n i s h m e d i c a l p r a c t i t i o n e r s who exceed the bounds p r e s c r i b e d by l e g i s l a t i o n , 8 6 they have taken other steps to r e g u l a t e the management of p a t i e n t s . T h i s i s not to say that Canadian co u r t s have engaged in the same degree of a c t i v i s m as t h e i r c o u n t e r p a r t s i n the United S t a t e s (Beis, 1984; B r a k e l , et 127 a l , 1985). There have been no s u c c e s s f u l c o n s t i t u t i o n a l c h a l l e n g e s to mental h e a l t h l e g i s l a t i o n and no landmark cases e s t a b l i s h i n g l e g a l d o c t r i n e and a f f e c t i n g the l e g i s l a t i v e process. Nevertheless, the emergence of the new l e g a l i s m has been e n c o u r a g e d by c o u r t s which, o f t e n as a consequence of e f f e c t i v e advocacy, have e s t a b l i s h e d p r o c e d u r a l r u l e s f o r mental h e a l t h review boards and, w i t h i n c e r t a i n l i m i t s , i n t e r p r e t e d the p r o v i s i o n s of s t a t u t e s i n a manner g e n e r a l l y to the b e n e f i t of p a t i e n t s . 8 7 Developments i n the f i e l d of a d m i n i s t r a t i v e law during the 1970's and 1980's have a f f e c t e d the conduct of r e v i e w b o a r d s and, as a consequence, hearings have become q u a s i - j u d i c i a l i n nature. A l l a d m i n i s t r a t i v e t r i b u n a l s ( i n c l u d i n g , mental h e a l t h r e v i e w boards) have been p l a c e d under a 'duty to a c t f a i r l y ' when handling appeals, and the c o u r t s have s y s t e m a t i c a l l y set out the minimal p r o c e d u r a l requirements necessary to s a t i s f y t h i s duty. G e n e r a l l y , these have i n v o l v e d the adoption of l e g a l r i g h t s which match those made a v a i l a b l e to i n d i v i d u a l s i n v o l v e d i n c o n v e n t i o n a l l e g a l p r o c e e d i n g s (e.g., the r i g h t t o be n o t i f i e d of a hearing, the r i g h t to appear and give evidence, and the r i g h t to counsel). However, i n s e t t i n g out the elements of t h i s duty the c o u r t s have stopped s h o r t of the p o i n t at which the o b j e c t i v e s of an a d m i n i s t r a t i v e t r i b u n a l (i.e., d e c i s i o n -making by s p e c i a l i s t s i n an i n f o r m a l , n o n - a d v e r s a r i a l s e t t i n g ) could be l o s t (Jones & De V i l l a r s , 1985; Robertson, 1987). In the mental h e a l t h context, the duty to act f a i r l y has been most f i r m l y e n d o r s e d i n the case of r e v i e w t r i b u n a l s 128 handling the appeals of persons committed and d e t a i n e d through the c r i m i n a l j u s t i c e system (Robertson, 1987). However, with the advent of the Canadian Charter of Rights and Freedoms and the requirement that no person be deprived of l i b e r t y except i n accordance w i t h the p r i n c i p l e s of fundamental j u s t i c e , review boards handling c i v i l commitment cases are being r e q u i r e d to observe the canons of f a i r n e s s (op c i t ) . T h i s i s r e f l e c t e d i n r e f o r m s to mental h e a l t h s t a t u t e s which e s t a b l i s h new l e g a l r i g h t s f o r p a t i e n t s seeking review and there i s some i n d i c a t i o n t h a t the c o u r t s are p r e p a r e d to c l a r i f y t h e s e r i g h t s where l e g i s l a t i o n has not yet been changed. 8 8 In a d d i t i o n , j u d i c i a l a t t e n t i o n has been f o c u s s e d upon a c l a r i f i c a t i o n of the procedure where p a t i e n t s e i t h e r seek j u d i c i a l review of the need f o r c o n f i n e m e n t or a p p e a l the d e c i s i o n s of r e v i e w b o a r d s to c o u r t s . The burden of p r o v i n g t h a t c o n t i n u e d c o n f i n e m e n t i s necessary has been p l a c e d upon the shoulders of mental h e a l t h p r o f e s s i o n a l s and w h i l e the c o u r t s have r e j e c t e d the i m p o s i t i o n of a s t r i c t standard of proof (i.e., beyond a reasonable doubt) they have r u l e d that the c i v i l standard s h a l l be used; namely, on the 'balance of p r o b a b i l i t e s ' or on a 'preponderance of the P. Q evidence' . 0 : 7 While the Charter has had an impact i n the area of review board hearings, there i s no i n d i c a t i o n that i t w i l l be used to any g r e a t e x t e n t (or w i t h any degree of s u c c e s s ) by those a d v o c a t i n g o t h e r p r o t e c t i o n s f o r mental h e a l t h p a t i e n t s . S e v e r a l Charter cases have been presented to the c o u r t s i n the past few years but the j u d i c i a r y seem r e l u c t a n t to endorse the 129 arguments of a d v o c a t e s u n l e s s the case i n v o l v e s a marked i n j u s t i c e (Robertson, 1987). 9 0 Nevertheless, some cou r t s have demonstrated a concern f o r safeguarding the l i b e r t y of the i n d i v i d u a l a g a i n s t the a c t i o n s of medical p r a c t i t i o n e r s and r e g a r d l e s s of Charter i s s u e s . For example, i n a recent A l b e r t a case where the meaning of the term ' d a n g e r o u s ' was c o n s i d e r e d , t h e C o u r t o f Queen's Bench e f f e c t i v e l y narrowed the c r i t e r i a f o r i n v o l u n t a r y commitment by s e t t i n g out the c o n d i t i o n s t h a t are deemed to c o n s t i t u t e a danger. In M v^ A l b e r t a 9 * the court expressed d i s s a t i s f a c t i o n w i t h both the s u b j e c t i v e nature of assessments of dangerousness and the extent to which the term was i n t e r p r e t e d d i f f e r e n t l y by p s y c h i a t r i s t s . I t was held that the l i k e l i h o o d of danger must be c u r r e n t (i.e., not be based on behaviour that might occur i n the d i s t a n t future) and that while evidence of a dangerous act was not necessary, there must be a s e r i o u s r i s k of p h y s i c a l harm to the i n d i v i d u a l or to o t h e r s . O t h e r forms of harm (e.g., p s y c h o l o g i c a l harm) were to be excluded. I t would be i n c o r r e c t to assume, however, that there are no l i m i t s on the e x t e n t to w hich the c o u r t s are p r e p a r e d to p r o t e c t the l i b e r t y of the i n d i v i d u a l . T h i s was most ev i d e n t i n Re Hoskins and H i s l o p , 9 2 a case before the B r i t i s h Columbia Supreme C o u r t i n v o l v i n g a j u d i c i a l r e v i e w of the need f o r c o n t i n u e d d e t e n t i o n . The c o u r t p o i n t e d out t h a t s i n c e the consequences of confinement were great (an i n d i v i d u a l not only l o s t h i s or her l i b e r t y but c o u l d a l s o be s u b j e c t e d to any form 130 of t r e a t m e n t ) i t would p e r m i t c o n t i n u e d d e t e n t i o n o n l y i f i t heard c l e a r and unequivocal evidence of both the presence of a mental d i s o r d e r and the need f o r treatment. However, the court r u l e d that i f a p a t i e n t seeking r e l e a s e i n d i c a t e d that he or she would r e f u s e to comply with a p r e s c r i b e d course of treatment, t h i s was a s u f f i c i e n t g r o u n d f o r t h e d i s m i s s a l o f an a p p l i c a t i o n . Other c o u r t s have tempered t h e i r concern f o r the r i g h t s and l i b e r t i e s of p a t i e n t s where t h e r e i s a s u g g e s t i o n t h a t a r u l i n g might r e s u l t i n the r e l e a s e of e i t h e r a d a n g e r o u s l y d i s o r d e r e d person or an i n d i v i d u a l who w i l l l i k e l y d e t e r i o r a t e w i t h o u t t r e a t m e n t i n a f a c i l i t y (see, e.g., R o b e r t s o n , 1987). While medical p r a c t i t i o n e r s are cautioned and advised to take g r e a t e r care when committing and d e t a i n i n g t h e i r p a t i e n t s , the c o u r t s have allowed d e f e c t s i n the commitment procedure to be remedied so that confinement can c o n t i n u e . 9 3 I t i s apparent, t h e r e f o r e , that the j u d i c i a r y w i l l not allow the r i g h t s of the i n d i v i d u a l to o v e r r i d e the need to ensure that the 'community 1 i s p r o t e c t e d from those who are d i s o r d e r e d , dangerous, and d e c l i n i n g to adhere to a treatment regime that c o n t r o l s t h e i r behaviour. Summary Both the s t r a t e g y and the l e g i s l a t i o n a f f e c t i n g the management of m e n t a l l y i l l p e r s o n s i n Canada have undergone changes s i n c e 1972. W h i l e a s h i f t away from the use of i n s t i t u t i o n s f o r segregated confinement began i n the 1950's, the d e - i n s t i t u t i o n a l i z a t i o n p r o c e s s has a c c e l e r a t e d and one g o a l 131 appears to be the c l o s u r e of mental h o s p i t a l s . P a t i e n t s are to be t r e a t e d i n community-based a l t e r n a t i v e s (e.g., mental h e a l t h c e n t r e s and p s y c h i a t r i c u n i t s i n g e n e r a l h o s p i t a l s ) and h o s p i t a l s are to be used o n l y as a l a s t and t e mporary r e s o r t . N o n - i n s t i t u t i o n a l i z a t i o n has been accompanied by a measure of p r i v a t i z a t i o n ; that i s , the p r o v i s i o n of r e s i d e n t i a l care f o r those r e c e i v i n g treatment i n the community i s passing from the p u b l i c to the p r i v a t e s e c t o r . The a d j u s t m e n t i n s t r a t e g y has been accompanied (or -is about to be accompanied) by reforms to mental h e a l t h s t a t u t e s and the b a s i c f e a t u r e s of the new l e g i s l a t i o n are s e t out i n T a b l e 3.2. The changes i n v o l v e the i m p o s i t i o n of numerous s t a t u t o r y r e s t r a i n t s on most of the p r a c t i c e s of m e d i c a l p r a c t i t i o n e r s . W h i l e the l a t t e r are r e s p o n s i b l e f o r making d e c i s i o n s about the v o l u n t a r y and i n v o l u n t a r y a d m i s s i o n of p a t i e n t s (and t h e i r subsequent confinement and treatment), t h e i r c a p a c i t y to e x e r c i s e p r o f e s s i o n a l d i s c r e t i o n has been s e v e r e l y c u r t a i l e d . C u r t a i l m e n t s i n c l u d e , s t r i c t i n v o l u n t a r y admission c r i t e r i a , shortened p e r i o d s between mandatory re-examinations, l i m i t a t i o n s on the treatment of p a t i e n t s without consent, and the b a n n i n g of c e r t a i n forms of t r e a t m e n t . In a d d i t i o n , the a c t i v i t i e s of p r a c t i t i o n e r s are to be c l o s e l y m o n i t o r e d and s u p e r v i s e d by advocacy s e r v i c e s , q u a s i - j u d i c i a l a d m i n i s t r a t i v e t r i b u n a l s and, to a l e s s e r d egree, the j u d i c i a r y . Indeed, mental h e a l t h law i s now c h a r a c t e r i z e d by a d i f f e r e n t and new mode of l e g a l i s m t h a t i s more r e s t r i c t i v e than the l i m i t e d l e g a l i s m which e x i s t e d at the t u r n of the century. 132 TABLE 3-2: PROCEDURES AFFECTING MENTALLY ILL PERSONS IN CANADA - 1987 S t a t u t o r y C o n t r o l of Medical D e c i s i o n s Monitoring By Q u a s i - J u d i c i a l Review Monitoring By J u d i c i a l L i b e r a l S t r i c t Boards Advocacy Services S u p e r v i s i o n I n i t i a l Admission P.E.I., B.C., A l t a . , Que., Ont., A l t a . , B.C., Ont., B.C., Ont., B.C.* of P a t i e n t s N f l d . N.S., Sask., (Man.), (N.B.), (N.W.T.), (U.M.H.A.) N.S., P.E.I., Que., Sask., (Man.), ( N f l d . ) , (U.M.H.A.) Sask., ( A l t a . , ) , (U.M.H.A.) T e r r i t o r i e s Long-Term P.E.I., N f l d . A l t a . , Que., Ont., A l t a . , B.C., Ont., B.C., Ont., B.C.* Admission of B.C., N.S., Sask., N.S., P.E.I., Que., Sask., T e r r i t o r i e s P a t i e n t s (Man.), (N.B.), (N.W.T.), (U.M.H.A.) Sask., (Man.), ( N f l d . ) , (N.B.), (U.M.H.A.) ( A l t a . ) , (U.M.H.A.) Post Admission Ont., N.S., Sask., Ont., Sask., N.S., B.C., Ont., — Treatment Que. ( A l t a . ) , (Man.), ( N f l d . ) , (N.B.), (N.W.T.), (U.M.H.A.) (Man.), ( N f l d . ) , (N.B.), (U.M.H.A.) Sask., ( A l t a . ) , (U.M.H.A.) Post Admission P.E.I. A l t a . , B.C., Ont., A l t a . , B.C., Ont., B.C., Ont., B.C., N.S.* Confinement N.S., Que., Sask., (Man.), (N.B.), (N.W.T.), (U.M.H.A.) N.S., P.E.I., Que., Sask., (Man.), ( N f l d . ) , (N.B.), (U.M.H.A.) Sask., ( A l t a . ) , (U.M.H.A.) T e r r i t o r i e s Commiteeship/ Guardianship A l l p rovinces and T e r r i t o r i e s E s t a t e Management by P u b l i c A l l provinces and Ont., N.S., Sask., A l t a . , P.E.I., B.C., Ont., Sask., ( A l t a . ) , Trustee T e r r i t o r i e s N.B., Que. (U.M.H.A.) Notes: * = J u d i c i a l review may occur on request. An automatic review does not occur. U.M.H.A. = Uniform Mental Health Act. The use of brackets denotes an impending reform. P a t i e n t s have been granted numerous r i g h t s (some of which are c o n n e c t e d to the c u r t a i l m e n t s a f f e c t i n g m e d i c a l p r a c t -i t i o n e r s ) and p r o v i s i o n has been made f o r e i t h e r improved access to l e g a l a i d s e r v i c e s or s p e c i a l advocacy s e r v i c e s designed to ensure t h a t b o t h p a t i e n t s ' r i g h t s and the new, r e s t r i c t i v e procedures are respected. Consequently, p a t i e n t advocates and lawyers play a r o l e i n the monitoring of medical p r a c t i t i o n e r s . They may a s s i s t p a t i e n t s i n e x e r c i s i n g t h e i r r i g h t s to b o t h appeal the d e c i s i o n s of medical p r a c t i t i o n e r s to q u a s i - j u d i c i a l a d m i n i s t r a t i v e t r i b u n a l s , and seek j u d i c i a l review of t r i b u n a l d e c i s i o n s . In a d d i t i o n , some review boards have been granted a mandate to m o n i t o r the p r a c t i c e s of p r a c t i t i o n e r s w i t h o u t a s p e c i f i c request from a p a t i e n t (i.e., automatic reviews of the need f o r i n i t i a l and continued confinement are to oc c u r ) . While the j u d i c i a r y s t i l l p l a y a s u b s i d i a r y r o l e i n the r o u t i n e management of p a t i e n t s they have been i n v o l v e d i n the p r o t e c t i o n of p a t i e n t s ' r i g h t s where cases are brought to them by p a t i e n t s ' a d v o c a t e s . T h i s i s of i m p o r t a n c e s i n c e , w i t h o u t j u d i c i a l s u p p o r t , the e f f o r t s of a d v o c a t e s c o u l d be seen as i r r e l e v a n t , i l l u s o r y , or f u t i l e by medical p r a c t i t i o n e r s . The j u d i c i a r y c o n t i n u e to dominate the a p p o i n t m e n t of permanent committees and guardians, and l i t t l e change has o c c u r r e d i n t h i s a r e a . W h i l e the p r o v i n c e , of A l b e r t a has i n t r o d u c e d a new s t a t u t e a f f e c t i n g the g u a r d i a n s h i p of a d u l t s w hich may be adopted by other p r o v i n c e s i n the near f u t u r e , t h i s s t a t u t e has a f f i r m e d j u d i c i a l dominance over t h i s aspect of the management of p a t i e n t s . In a d d i t i o n , medical domination of the process of \ 134 e s t a t e management by P u b l i c T r u s t e e s has been p a r t l y e r o d e d . W h i l e m e d i c a l p r a c t i t i o n e r s c o n t i n u e to be i n v o l v e d i n the e v a l u a t i o n of p a t i e n t s to determine t h e i r c a p a c i t i e s to manage t h e i r e s t a t e s , i n some pro v i n c e s p a t i e n t s have been granted a r i g h t to appeal the d e c i s i o n s of p r a c t i t i o n e r s to mental h e a l t h review boards. These have become q u a s i - j u d i c i a l i n nature as a r e s u l t of both case law and s t a t u t o r y change. As the f o r e g o i n g a n a l y s i s has demonstrated, the c u r r e n t p e r i o d of reform a f f e c t i n g mental h e a l t h l e g i s l a t i o n i n Canada i s the most recent i n a s e r i e s of reforms which have occu r r e d s i n c e the t u r n of the c e n t u r y . The ' l i m i t e d l e g a l i s m ' of the e a r l y 1900's was g r a d u a l l y a b a n d o n e d i n f a v o u r o f ' m e d i c a l i z a t i o n ' and, d u r i n g the 1960's, a p e r i o d of 'enhanced m e d i c a l i z a t i o n ' o c c u r r e d ; t h i s i s now b e i n g r e p l a c e d as the p r o v i n c e s and t e r r i t o r i e s g r a d u a l l y adopt the 'new l e g a l i s m ' . T h r o u g h o u t t h e s e p h a s e s o f r e f o r m , t h e p r o c e s s o f a p p o i n t i n g permanent c o m m i t t e e s and g u a r d i a n s f o r m e n t a l l y d i s o r d e r e d p e r s o n s has r e m a i n e d f i r m l y i n the hands of the Q A j u d i c i a r y . ^ However, o t h e r a s p e c t s of the management of p a t i e n t s have not, and a key f e a t u r e of the reforms has been the tendency f o r governments to a l t e r n a t e l y impose, ease, and then re-impose forms of j u d i c i a l and q u a s i - j u d i c i a l s u p e r v i s i o n on the p r a c t i c e s of medical p r a c t i t i o n e r s . The forms of j u d i c i a l and q u a s i - j u d i c i a l s u p e r v i s i o n which e x i s t e d at the t u r n of the century were removed i n favour of a l l o w i n g medical p r a c t i t i o n e r s to e x e r c i s e t h e i r d i s c r e t i o n i n the admission, treatment, and c o n f i n e m e n t of p a t i e n t s . The j u d i c i a r y were c o n s e q u e n t l y 135 r e l e g a t e d to a s u b s i d i a r y r o l e i n the process and, as a r e s u l t o f t h e r e f o r m s o f t h e 1960's, t h e i r i n v o l v e m e n t i n t h e management of p a t i e n t s was e r o d e d to such a degree t h a t i t became almost n e g l i g i b l e . Only a l i m i t e d form of p o s t-admission s u p e r v i s i o n was to be p r o v i d e d by a d m i n i s t r a t i v e t r i b u n a l s . S i n c e the e a r l y 1970's, however, a new form of l e g a l i s m has e m e r g e d i n w h i c h b o t h a d v o c a t e s and q u a s i - j u d i c i a 1 a d m i n i s t r a t i v e t r i b u n a l s are p l a y i n g a dominant r o l e i n the management of p a t i e n t s . Advocates and t r i b u n a l s are m o nitoring and s u p e r v i s i n g medical p r a c t i t i o n e r s to ensure that they both r e s p e c t the r i g h t s of p a t i e n t s and o b s e r v e the new s t a t u t o r y c u r t a i l m e n t s which have been placed upon t h e i r a c t i v i t i e s , and t h e j u d i c i a r y have been i n v o l v e d i n t h e p r o t e c t i o n and enhancement of p a t i e n t s ' r i g h t s . The q u e s t i o n now to be addressed i s , "why?" Why have the p e r i o d s of reform occ u r r e d and why have there been s h i f t s from one f o r m o f r e g u l a t i o n (e.g., e n h a n c e d m e d i c a l i z a t i o n c h a r a c t e r i z e d by medical domination) to another (e.g., the new l e g a l i s m c h a r a c t e r i z e d by q u a s i - j u d i c i a l and o t h e r forms of l e g a l d o m i n a t i o n ) ? F u r t h e r , what are the l i n k s between the s t a t u t o r y r e f o r m s , the c h a n g i n g s t a t e s t r a t e g i e s f o r the management of m e n t a l l y d i s o r d e r e d p e r s o n s , and the f a c t o r s underpinning these s h i f t s i n s t r a t e g y ? In the next c h a p t e r , the d i s c u s s i o n f o c u s s e s upon an e x p l o r a t i o n of the f a c t o r s which may account f o r the p e r i o d s of s t a t u t o r y change, the p a r t i c u l a r form which the l e g i s l a t i o n has 136 t a k e n , and t h e l i n k s t o s h i f t s i n s t a t e s o c i a l c o n t r o l s t r a t e g i e s . This w i l l i n v o l v e a review of the work of a n a l y s t s who have f o c u s s e d t h e i r a t t e n t i o n upon the phases of mental he a l t h law reform which have emerged i n other c o u n t r i e s , as w e l l as the key t h e o r e t i c a l t r a j e c t o r i e s w i t h i n the s o c i o l o g y of law, the s o c i o l o g y of the s t a t e , and the s o c i o l o g y of s o c i a l c o n t r o l . The goal i s to provide a framework f o r a d e t a i l e d a n a l y s i s and ex p l a n a t i o n of two p e r i o d s of reform i n Canadian mental h e a l t h law; namely, the emergence of enhanced m e d i c a l i z a t i o n , i t s subsequent demise, and the r i s e of the new l e g a l i s m . 137 ENDNOTES: CHAPTER 3. 1: The emergence and nature of these changes, p a r t i c u l a r l y i n B r i t i s h Columbia, w i l l be examined i n g r e a t e r d e t a i l i n Chapter 5. 2: S.B.C, 1940, c. 27. 3: I b i d , s. 20. P r o v i s i o n was made f o r a panel of independent m e d i c a l p r a c t i t i o n e r s and f o r the monthly s e l e c t i o n of two members who were to review the cases of those making appeals. Any p a t i e n t who had been i n a h o s p i t a l f o r three months, or an a u t h o r i z e d r e p r e s e n t a t i v e , could apply f o r review and the panel could order the person's d i s c h a r g e . The superintendent of the h o s p i t a l i n which the p a t i e n t was c o n f i n e d c o u l d a c t as the pa t i e n t ' s r e p r e s e n t a t i v e and an a p p l i c a t i o n could be made every 12 months. 4: S c h o o l s f o r M e n t a l D e f e c t i v e s A c t S.B.C, 1953, c. 26; e s t a b l i s h i n g a s p e c i a l f a c i l i t y f o r mentally r e t a r d e d people at Woodlands School i n New Westminster. C l i n i c s of P s y c h o l o g i c a l M e d i c i n e Ac t S.B.C, 1948, c. 6; e s t a b l i s h i n g the 'Crease C l i n i c ' ; a ' p s y c h o p a t h i c ' f a c i l i t y l o c a t e d i n the m e n t a l h o s p i t a l complex a t E s s o n d a l e . P a t i e n t s c o u l d be a d m i t t e d e i t h e r v o l u n t a r i l y or on an i n v o l u n t a r y b a s i s (two m e d i c a l c e r t i f i c a t e s were required) and c o n f i n e d f o r i n t e n s i v e treatment f o r up to four months. P r o v i n c i a l C h i l d Guidance C l i n i c s Act S.B.C, 1955, c. 8, and P r o v i n c i a l M e n t a l H e a l t h C e n t r e s Act S.B.C, 1955, c. 48. These s t a t u t e s made p r o v i s i o n f o r the es t a b l i s h m e n t and o p e r a t i o n of 'community-based' mental h e a l t h s e r v i c e s . Both made p r o v i s i o n f o r the d i r e c t o r of a c l i n i c or centre to be appointed as a j u s t i c e of the peace and t h i s meant t h a t even though he or she was a m e d i c a l p r a c t i t i o n e r , the d i r e c t o r c o u l d approve the i n v o l u n t a r y admission of a c l i n i c or c e n t r e p a t i e n t t o a p r o v i n c i a l m e n t a l h e a l t h f a c i l i t y . Consequently, bona f i d e j u d i c i a l s u p e r v i s i o n of the commitment p r o c e s s was e r o d e d c o n s i d e r a b l y . The emergence of t h e s e s t a t u t e s w i l l be examined i n d e t a i l i n Chapter 5. 5: Mental P a t i e n t s I n s t i t u t i o n s Act S.Q., 1950, c. 31, and Detained Persons P s y c h i a t r i c I n s t i t u t i o n s Act S.Q., 1950, c. 72. The changes i n v o l v e d the d i v i s i on of the f o r m e r , omnibus, l u n a t i c asylums s t a t u t e i n t o two s e p a r a t e A c t s . The D e t a i n e d Persons P s y c h i a t r i c I n s t i t u t i o n s Act was concerned only w i t h the continued o p e r a t i o n of the p r o v i n c i a l i n s t i t u t i o n f o r mentally d i s o r d e r e d o f f e n d e r s . No changes were made to the system of p r i v a t e h o s p i t a l s which continued to provide care and treatment under c o n t r a c t w i t h the government. However, the a r c h a i c t e r m i n o l o g y of the o l d L u n a t i c Asylums A c t was abandoned ( p a t i e n t s were no longer to r e c e i v e 'moral treatment'), along w i t h the d i s t i n c t i o n between p r i v a t e and p u b l i c p a t i e n t s . The new l e g i s l a t i o n a l s o c o n t a i n e d p r o v i s i o n s w hich r e f l e c t e d the es t a b l i s h m e n t of the o f f i c e of the P u b l i c Curator; 138 a p r o v i n c i a l a g e n c y c r e a t e d i n t h e mid-1940's (£ubli_c C u r a t o r s h i p Act., S.Q., 1945, c. 62). P r o v i s i o n was made f o r a p r o c e d u r e whereby, on a d m i s s i o n o r c o n f i n e m e n t f o r ' c l o s e t r e a t m e n t ' ( i . e . , i n v o l u n t a r y c a r e and t r e a t m e n t ) , the P u b l i c Curator would a u t o m a t i c a l l y assume management of a pa t i e n t ' s property (s. 21). 6: M e n t a l H e a l t h A c t S.O., 1954, c. 50. T h i s s t a t u t e r e -o r g a n i z e d the p u b l i c , m e n t a l h e a l t h s y s t e m . The p r i v a t e s a n i t a r i a system was d e c l i n i n g i n importance but continued to o p e r a t e under the p r o v i s i o n s of the P r i v a t e S a n i t a r i a A c t , R.S.O., 1950, c. 290. T h i s s t a t u t e had r e m a i n e d v i r t u a l l y unchanged s i n c e the f i r s t decade of the c e n t u r y . M e n t a l H o s p i t a l s A c t s S.O., 1952, c. 56, S.O., 1954, c. 51, and S.O. 1960, c. 67. These s t a t u t e s e s t a b l i s h e d o b s e r v a t i o n u n i t s i n p u b l i c h o s p i t a l s and made p r o v i s i o n f o r one p h y s i c i a n to admit a p a t i e n t f o r 30 days. E x i s t i n g mental h e a l t h c l i n i c s were given the t i t l e 'mental h e a l t h c e n t r e s ' and s p e c i a l h o s p i t a l s were intr o d u c e d f o r c h i l d r e n s u f f e r i n g from "emotional or p s y c h i a t r i c d i s o r d e r s (S.O., 1961 - 62, c. 79; The C h i l d r e n s M e n t a l H o s p i t a l s A c t , S.O., 1960, c. 9.) Community p s y c h i a t r i c h o s p i t a l s were e s t a b l i s h e d per the The Community P s y c h i a t r i c H o s p i t a l s Act, S.O., 1960 - 61, c. 9. 7: Nova S c o t i a H o s_p ^ t ^ a 1_£ A£t_ S.N.S. 1960, c. 8. The Superintendent r e t a i n e d the power to refuse admission to c e r t a i n c l a s s e s of p a t i e n t s ; notably, mental d e f e c t i v e s , those who were i l l but not dangerous, and those u n l i k e l y to b e n e f i t from t r e a t m e n t ( s s . 14 - 16). A modicum of i n i t i a l j u d i c i a l involvement was r e t a i n e d i n s o f a r as a Ma g i s t r a t e could order the examination of a mentally i l l person and could i s s u e a warrant f o r the person's apprehension. He or she could a l s o commit a person to h o s p i t a l or order that the i n d i v i d u a l be t e m p o r a r i l y d e t a i n e d f o r o b s e r v a t i o n and treatment f o r a p e r i o d of up to 30 days (s. 19). A county c o u r t judge c o u l d , on a p p l i c a t i o n , order the dis c h a r g e of a p a t i e n t i f continued confinement was deemed i n a p p r o p r i a t e (s. 25). In g e n e r a l , the new s t a t u t e r e f l e c t e d the p r o v i s i o n s of the mental hygiene l e g i s l a t i o n which had been i n t r o d u c e d i n other p r o v i n c e s i n the 1930's. The Act a l s o made p r o v i s i o n f o r the speedy appointment of a guardian of the person and e s t a t e of a p a t i e n t . The M i n i s t e r of H e a l t h was g r a n t e d the power to a p p o i n t (and revoke the appointment of) a guardian f o r a co n f i n e d p a t i e n t i f he or she di d not have a guardian (s. 29). I t should a l s o be noted that i n 1960 the f o r m e r Lunacy A c t was renamed The Incompetent P e r s o n s Act (S.N.S., 1960, c. 39). However, the p r o c e d u r e s f i r s t set out at the end of the 19th century remained i n e f f e c t . Some changes a l s o o c c u r r e d i n P r i n c e Edward I s l a n d . In 1957, the Falconwood H o s p i t a l and I n f i r m a r y Act (S.P.E.I., 1939, c. 16) was repealed and r e p l a c e d by The R i v e r s i d e H o s p i t a l Act (S.P.E.I., 1957, c. 32). This development r e f l e c t e d , i n p a r t , a r e - o r g a n i z a t i o n of i n s t i t u t i o n s i n the prov i n c e and the s t a t u t e was accompanied by The P r o v i n c i a l I n f i r m a r y Act (S.P.E.I., 1957, 139 c. 30) which made separate p r o v i s i o n f o r the a d m i n i s t r a t i o n and o p e r a t i o n of the p r o v i n c i a l f a c i l i t y h o u s i n g the 'poor and i n f i r m ' . The medical d i s c r e t i o n model e s t a b l i s h e d i n 1939 was r e t a i n e d i n The R i v e r s i d e H o s p i t a l Act. Indeed, i t was p a r t l y s t r e n g h t e n e d i n s o f a r as the Board of T r u s t e e s (re-named the Board of Governors) ceased to p l a y a part i n the i n s p e c t i o n of premises and p a t i e n t s . In a d d i t i o n , the medical superintendent was granted f u r t h e r powers i n c l u d i n g the power to r e q u i r e t h a t i n m a t e s of the h o s p i t a l engage i n work " i n and about the h o s p i t a l " or i t s grounds. This a c t i v i t y was to be r e f e r r e d to as ' i n d u s t r i a l therapy' (s. 16). 8: S.S., 1961, c. 68. 9: I b i d , s. 2 ( t ) . 10: I b i d , ss. 10, 11, 15 & 38. Voluntary p a t i e n t s had a r i g h t to be r e l e a s e d w i t h i n 24 hours of a r e q u e s t . I n v o l u n t a r y p a t i e n t s could be c o n f i n e d i n i t i a l l y f o r 14 days, at which p o i n t a re-examination had to occur. Subsequent re-examinations were r e q u i r e d every three months, every s i x months and then annually. At each e x a m i n a t i o n , the p h y s i c i a n had to a s s e s s whether the c r i t e r i a f o r i n v o l u n t a r y admission were s t i l l s a t i s f i e d . Emergency admission f o r 72 hours was p e r m i s s i b l e on the b a s i s of one c e r t i f i c a t e . However, the i n d i v i d u a l had to be r e l e a s e d or re-examined during t h i s time (s. 12). In a d d i t i o n , the A c t r e t a i n e d an e x i s t i n g commitment o p t i o n i n s o f a r as p r o v i s i o n was made f o r a M a g i s t r a t e to is s u e a warrant f o r the a p p r e h e n s i o n and e x a m i n a t i o n of a p e r s o n wandering a t l a r g e . The p o l i c e power to both apprehend a mentally d i s o r d e r e d person wandering i n a p u b l i c place and convey the person to a h o s p i t a l f o r e x a m i n a t i o n , was r e t a i n e d ( s s . 18 & 20). However, t h e s e o p t i o n s were used i n f r e q u e n t l y (Task Force Committee, 1983). 11: I b i d , s s . 19 & 26 - 28. 12: I b i d , s s . 26 - 28. 13: I b i d , ss . 21 - 23 & 25. 14: I b i d , s s . 20 & 23. 15: I b i d , ss . 4 & 34 - 36. A l t h o u g h t h e M e n t a l H e a_JL t_h A cjt r e m a i n e d l a r g e l y u n d i s t u r b e d u n t i l the mid-1980's, some amendments were made which strengthened the powers of p h y s i c i a n s to admit m e n t a l l y d i s o r d e r e d persons i n emergency s i t u a t i o n s . In a d d i t i o n , a new p r o c e d u r e was i n t r o d u c e d t h a t would a l l o w p s y c h i a t r i s t s t o enforce treatment regimes while p a t i e n t s were r e s i d i n g i n the community. In the event that a p a t i e n t f a i l e d to, f o r example, take p r e s c r i b e d medication and consequently r e l a p s e d , he or she c o u l d be apprehended and r e t u r n e d to an i n s t i t u t i o n w i t h a minimum of f o r m a l i t y . See, S.S., 1967, c. 60; S.S., 1968, c. 140 50; & S.S., 1970, c. 43. 16: M e n t a l H e a l t h A c t S.B.C, 1964, c. 29; M e n t a l H e a l t h A c t S.A. 1964, c. 54. 17: S.B.C, 1964, c. 29: s s . 2, 11, 21 - 24, 29, & 31 - 36. S.A., 1964, c. 54: s s . 5 - 7 , 12 - 24 & 32. In many r e s p e c t s , the B r i t i s h Columbia l e g i s l a t i o n r e f l e c t e d a f i r m e r endorsement of enhanced m e d i c a l i z a t i o n than was the case i n Saskatchewan. The treatment of any category of p a t i e n t c o u l d occur without the person's consent and superintendents were granted the power to d e a l w i t h c o n f i n e d p a t i e n t s at t h e i r d i s c r e t i o n . P a t i e n t s could be t r a n s f e r r e d to other f a c i l i t i e s and c o n f i n e d and t r e a t e d f o r up t o 12 months w i t h o u t r e - e x a m i n a t i o n . The r e v i e w p a n e l c o n t i n u e d to c o n s i s t of two m e d i c a l p r a c t i t i o n e r s and the pr o v i n c e d i d not adopt the m u l t i - d i s c i p l i n a r y model pr o v i d e d by Saskatchewan. Those who were m e n t a l l y r e t a r d e d c o u l d be admitted to a 'school' f o r 30 days on the b a s i s of one medical c e r t i f i c a t e . While the s t a t u t e dispensed w i t h j u d i c i a l involvement i n the i n i t i a l commitment process, p r o v i s i o n was made f o r a p a t i e n t to apply to a judge f o r a review of the need f o r commitment or continued confinement. A p p l i c a t i o n had to be made at the time, or w i t h i n three months, of admission and a judge could i s s u e an o r d e r p r o h i b i t i n g a d m i s s i o n , r e l e a s i n g t h e p a t i e n t , o r c o n f i r m i n g the need f o r c o n f i n e m e n t (s. 30). There i s some evidence that, i n p r a c t i c e , j u d i c i a l involvement i n the i n i t i a l commitment p r o c e s s had a l r e a d y d e c l i n e d t o a p o i n t where i t me r e l y i n v o l v e d a r u b b e r - s t a m p i n g of m e d i c a l d e c i s i o n s . For example, the c u r s o r y n a t u r e of the ' p e r s o n a l e x a m i n a t i o n s ' c o n d u c t e d by j u s t i c e s of the peace was i l l u s t r a t e d i n a ca s e before the p r o v i n c i a l Court of Appeal i n 1964. In W i l l i a m s v. B a l l a m (1964) 48 W.W.R. (N.S.) 182, the c o u r t h e a r d how a committing j u s t i c e spoke b r i e f l y to a men t a l l y d i s o r d e r e d person i n an ambulance p r i o r to her conveyance to a mental h o s p i t a l . A l t h o u g h i t was argued t h a t t h i s was an i m p r o p e r commitment 'hearing' the court r u l e d that the confinement was proper s i n c e , d e s p i t e the b r e v i t y of the encounter, the j u s t i c e had examined the person and formed the o p i n i o n that she was mentally i l l . Separate p r o v i s i o n was made f o r medical p r a c t i t i o n e r s to examine p a t i e n t s and c e r t i f y t h a t they were i n c a p a b l e o f managing t h e i r a f f a i r s ( P a t i e n t s E s t a t e s A c t S.B.C. 1962, c. 44), and t h i s c o i n c i d e d with the e s t a b l i s h m e n t of the o f f i c e of P u b l i c T r u s t e e ( P u b l i c T r u s t e e A c t S.B.C. 1963, c. 38). The procedure had been introduced e a r l i e r , f o r those being admitted to the 'Crease C l i n i c ' ; the province's 'psychopathic' h o s p i t a l (Lunacy A c t S.B.C. 1951, c. 51). In A l b e r t a , however, no p r o v i s i o n was made f o r p h y s i c i a n s to examine p a t i e n t s r e g a r d i n g t h e i r c a p a b i l i t i e s . The province continued to use the e x i s t i n g procedure whereby, on admission to a h o s p i t a l , a person who d i d not have a committee would have h i s or her e s t a t e p l a c e d under the c o n t r o l of a p u b l i c o f f i c i a l . In 141 1949, the province i n t r o d u c e d the O f f i c e of the P u b l i c Trustee ( P u b l i c T r u s t e e A c t , S.A., 1949, c. 85) and t h i s o f f i c i a l assumed r e s p o n s i b i l i t y f o r the management of the e s t a t e s of those who were s u f f e r i n g from a mental d i s e a s e , a mental d e f e c t , or an a d d i c t i o n , and who were de t a i n e d i n h o s p i t a l , on p r o b a t i o n from h o s p i t a l , or under the s u p e r v i s i o n of the P r o v i n c i a l P s y c h i a t r i s t or the M i n i s t e r of Health (ss. 2 (e) & 12). 18: S.M., 1965, c. 48. 19: I b i d , ss. 2, 3, 5, 7, 9 & 27. S p e c i a l p r o v i s i o n was made f o r the admission of those c a t e g o r i z e d as mentally r e t a r d e d and such persons could be pl a c e d under the charge of a 'custodian 1 i n l i e u of commitment (ss. 30 to 35). 20: I b i d , s s . 4, 10 & 11. 21: I b i d , s. 26. A 'Minister's Board', c o n s i s t i n g of lawyers and p h y s i c i a n s , was c r e a t e d to r e v i e w c a s e s i n v o l v i n g the mentally r e t a r d e d ( s s . 28, 29 & 40). 22: I b i d , s s . 2, 16 & 17. Those who were not r e s i d i n g i n i n s t i t u t i o n s c o u l d be p l a c e d u n d e r s u p e r v i s i o n on t h e recommendation of one medical p r a c t i t i o n e r . 23: I b i d , P a r t I I I , p a s s i m . The a d m i n i s t r a t o r would assume management only i f the p a t i e n t d i d not have a committee. . The p r o v i s i o n s d i d not a p p l y t o v o l u n t a r y p a t i e n t s and an e s t a t e would not be managed u n t i l a f t e r the f i r s t 21 days of d e t e n t i o n . In cases of urgency, the superintendent of an i n s t i t u t i o n could request immediate i n t e r v e n t i o n (s. 79). 24: M u n i c i p a l Mental H o s p i t a l s Act S.N.S., 1965, c. 12. The s t a t u t e r e f l e c t e d a p r o c e s s of s t a n d a r d i z a t i o n and i n c r e a s e d p r o v i n c i a l s u p e r v i s i o n of mu n i c i p a l h o s p i t a l s . These were to continue to work i n c o n j u n c t i o n w i t h the c e n t r a l , Nova S c o t i a H o s p i t a l . V o l u n t a r y admissions were p e r m i t t e d and i n v o l u n t a r y a d m i s s i o n s c o u l d o c c u r but o n l y w i t h the c o n s e n t of the p r o v i n c i a l a d m i n i s t r a t o r of mental h e a l t h s e r v i c e s ( s s . 8 to 15) . 25: Nova S c o t i a H o s p i t a l Act was amended and c o n s o l i d a t e d per S.N.S., 1967, c. 15. A p a t i e n t c o u l d o n l y be c o n f i n e d f o r a p e r i o d of 12 months without re-examination and t h i s l i m i t a t i o n was int r o d u c e d i n 1966 (S.N.S., 1966, c. 73). The s t a t u t e a l s o s p e c i f i e d t h a t no person was to be i n v o l u n t a r i l y committed i f he or she had the mental a b i l i t y t o u n d e r s t a n d the need f o r admission (ss. 14, 16 & 24). 26: H e a l t h and P u b l i c W e l f a r e A c t S.N., 1966, c. 78. Newfoundland entered the Confederation i n the l a t e 1940's and i s t h e r e f o r e i n c l u d e d i n the a n a l y s i s of changes to Canadian mental h e a l t h law. The amending s t a t u t e r e t a i n e d the e x i s t i n g p r o c e d u r e whereby M a g i s t r a t e s s u p e r v i s e d the i n v o l u n t a r y admission of p a t i e n t s . However, before a commitment order could 142 be issued , the proposed p a t i e n t had to be behaving i n a manner that was dangerous and a M a g i s t r a t e had to o b t a i n the op i n i o n s of two m e d i c a l p r a c t i t i o n e r s . In a d d i t i o n , a new, m u l t i -c a t e g o r y d e f i n i t i o n of mental d i s o r d e r was i n t r o d u c e d . T h i s e m p h a s i z e d the l i k e l i h o o d of harm to s e l f or o t h e r s but the c a t e g o r i e s were broadly d e f i n e d and a l l o w e d f o r the e x e r c i s e of c o n s i d e r a b l e m e d i c a l d i s c r e t i o n . A p a t i e n t who d i s p u t e d the need f o r continued confinement c o u l d apply f o r a M a g i s t r a t e to review h i s or her case. 27: M e n t a l H e a l t h A c t S.O. 1967, c. 51. Reforms i n c l u d e d a r e - o r g a n i z a t i o n of the m e n t a l h e a l t h s t a t u t e s . The e x i s t i n g M e n t a l H e a l t h A c t was re-named the M e n t a l Hospi t a l s A c t and became an e n a b l i n g s t a t u t e only. The e x i s t i n g Mental H o s p i t a l s Act was r e p e a l e d and r e p l a c e d by the new M e n t a l H e a l t h A c t . Other en a b l i n g s t a t u t e s (i.e., the C h i l d r e n s ' Mental H o s p i t a l s Act and the Community P s y c h i a t r i c Hospi t a l s A c t ) r e m a i n e d i n f o r c e , as d i d the P r i v a t e S a n i t a r i a Act. 28: S.O. 1967, c. 51: s s . 1, 6 to 8, & 13. A 'mental d i s o r d e r ' was d e f i n e d as "any di s e a s e or d i s a b i l i t y of the mind". No secondary d e f i n i t i o n s (e.g., of 'mental i l l n e s s ' ) were provided. Involuntary admission c o u l d occur on the b a s i s of one m e d i c a l c e r t i f i c a t e and the s t a t u t e c o n t i n u e d the p r a c t i c e s of a l l o w i n g a M a g i s t r a t e to i s s u e an o r d e r f o r the apprehension and examin-ation of a men t a l l y d i s o r d e r e d person and a l l o w i n g the p o l i c e to apprehend a d i s o r d e r e d person (ss. 9 & 10). W i t h i n 30 days of commitment, a p a t i e n t had to be r e -examined and he or she could be r e - c e r t i f i e d and detained f o r two months. Fu r t h e r examinations were to occur at i n t e r v a l s of three, s i x , and then twelve months (s. 13). 29: I b i d , ss. 20, 27 to 30, & 32. See, a l s o , Part I I I , passim. 30: Mental Health Act S.P.E.I. 1968, c. 37. Minor d i f f e r e n c e s e x i s t e d . The b r o a d d e f i n i t i o n of mental d i s o r d e r i n c l u d e d a s p e c i f i c r e f e r e n c e to d i s o r d e r s caused by the use of a l c o h o l or d r u g s ( s . 2). A s i n g l e , t h r e e member r e v i e w b o a r d was e s t a b l i s h e d and t h i s was to be composed of one county c o u r t judge, one p h y s i c i a n , and one o t h e r p e r s o n (s. 25). The opi n i o n s of two p h y s i c i a n s were r e q u i r e d before a p a t i e n t c o u l d be c e r t i f i e d as incompetent to manage h i s or her e s t a t e (s. 30). In the same year, the province e s t a b l i s h e d a p r o v i n c i a l p u b l i c t r u s t e e s e r v i c e i n the form of the o f f i c e of the O f f i c i a l Trustee ( O f f i c i a l Trustee Act S.P.E.I. 1968, c. 38). 31: M e n t a l H e a l t h A c t S.N.B. 1969, c. 13. The s t a t u t e d i f f e r e d from the model p r o v i d e d by O n t a r i o i n the f o l l o w i n g ways. A s p e c i f i c ( r a t h e r than i m p l i c i t ) power to a s s e s s and t r e a t a p a t i e n t was granted to medical p r a c t i t i o n e r s (s. 8) and, as was the case i n P r i n c e Edward Is l a n d , the review board was to c o n s i s t of t h r e e members o n l y (s. 30). The s t a t u t e a l s o made p r o v i s i o n f o r the l i c e n s i n g and use of 'approved homes'. Medi c a l p r a c t i t i o n e r s were granted the a u t h o r i t y to t r a n s f e r 143 p a t i e n t s to these homes, or to other mental h e a l t h f a c i l i t i e s , at t h e i r d i s c r e t i o n ( s s . 20 to 26). The Act a l s o e s t a b l i s h e d the o f f i c e of the A d m i n i s t r a t o r of E s t a t e s . The A d m i n i s t r a t o r was c h a r g e d w i t h the tas k o f managing the a f f a i r s of p a t i e n t s who d i d not have committees (see, Part I I I , passim). 32: Mental Health Act S.N. 1971, No. 80. The s t a t u t e d i f f e r e d from the model pr o v i d e d by the other maritime p r o v i n c e s i n the f o l l o w i n g ways. The c e r t i f i c a t e s of two p h y s i c i a n s were r e q u i r e d before a person could be committed i n v o l u n t a r i l y and the c r i t e r i a f o r commitment i n c l u d e d the need to ensure s a f e t y to p r o p e r t y (s. 6). S p e c i f i c p r o v i s i o n was made f o r the treatment of i n v o l u n t a r y p a t i e n t s without t h e i r consent (ss. 7 & 20). An a p p l i c a t i o n to the mental h e a l t h review board could be made but only once every s i x months. In a d d i t i o n , the board was empowered t o d i s m i s s an a p p l i c a t i o n w i t h o u t an i n q u i r y and hearing, i f they f e l t that the appeal was not j u s t i f i e d (ss. 16 to 18). However, a p a t i e n t was g r a n t e d the r i g h t to a p p e a l a d e c i s i o n of the board to the p r o v i n c i a l Supreme Court, but only on a question of law (s. 19). No p r o v i s i o n was made f o r the management of the e s t a t e s of p a t i e n t s . However, reforms to mental h e a l t h l e g i s l a t i o n were preceded by the passage of a new Me n t a l l y Incompetent Persons' E s t a t e s A c t (S.N. 1968, c. 3). A l t h o u g h t h i s was p r i m a r i l y a restatement of the o l d lunacy laws governing the appointment of a guardian f o l l o w i n g a j u d i c i a l hearing, p r o v i s i o n was made f o r the R e g i s t r a r of the p r o v i n c i a l Supreme Court to assume the r o l e of e s t a t e guardian f o r any person admitted to a mental h e a l t h f a c i l i t y (s. 20). The province had cons i d e r e d the e s t a b l i s h m e n t of the o f f i c e of the P u b l i c Trustee and a P u b l i c Trustee Act had been p a s s e d i n 1962 (S.N. 1962, c. 27). However, the s t a t u t e was not proclaim e d i n f o r c e . 33: O.N.W.T. 1971, c. 13. The Ordinance r e f l e c t e d the i n f l u e n c e of b o t h the O n t a r i o and Ma n i t o b a l e g i s l a t i o n . V o l u n t a r y and i n v o l u n t a r y admissions were p e r m i t t e d on the recommendation of one p h y s i c i a n . However, i n v o l u n t a r y commitment c o u l d occur only i f h o s p i t a l i z a t i o n was necessary to prevent harm. Detention was pe r m i t t e d f o r one month f o l l o w i n g which j u d i c i a l a u t h o r i t y was re q u i r e d . A p a t i e n t could apply to a cou r t f o r review of the need f o r continued d e t e n t i o n at any time a f t e r commitment. In 1969, the T e r r i t o r i e s e s t a b l i s h e d the o f f i c e of the P u b l i c T r u s t e e ( P u b l i c T r u s t e e O r d i n a n c e O.N.W.T. 1969, c. 27) and p r o v i s i o n was made f o r the Trustee to take charge of a person's e s t a t e on admission to a mental h e a l t h f a c i l i t y . In the Yukon T e r r i t o r y , some changes were made i n the e a r l y 1970's. Cosmetic changes r e f l e c t i n g the new mental h e a l t h l e x i c o n appeared i n 1971 (Mental Health Ordinance O.Y.T. 1971, c. 11) and, i n 1973, p r o v i s i o n was made f o r d i s o r d e r e d persons to o b t a i n mental h e a l t h s e r v i c e s on a v o l u n t a r y b a s i s (O.Y.T. 1973, c. 14). O t h e r w i s e the p r o c e d u r e s f i r s t s e t out a t the 144 turn of the century remained i n p l a c e . 34: S.Q. 1972, c. 44. 35: An e l e m e n t of j u d i c i a l i n v o l v e m e n t i n the a d m i s s i o n p r o c e s s was r e t a i n e d . I f a p e r s o n r e f u s e d to undergo an e x a m i n a t i o n or c l o s e t r e a t m e n t , an o r d e r was to be o b t a i n e d from, i n t e r a l i a , a judge of the P r o v i n c i a l Court. The process i n v o l v e d the s u b m i s s i o n of an a p p l i c a t i o n w i t h s u p p o r t i n g d o c u m e n t a t i o n i n t h e f o r m o f c e r t i f i c a t e s f r o m two p s y c h i a t r i s t s . I f s a t i s f i e d t h a t the requirements of the Act had been met, the judge could then make an order f o r examination of treatment (ss. 13 to 20). 36: S.Q. 1972, c. 44: s s . 2, 3, 8, 10 & 12. In 1971, the P u b l i c C u r a t o r s h i p Act was amended (S.Q. 1971, c. 81) i n a way t h a t f o r e s h a d o w e d t h e new m e n t a l h e a l t h l e g i s l a t i o n . P r o v i s i o n was made f o r the Curator to assume the a d m i n i s t r a t i o n of the property of any p a t i e n t i n h o s p i t a l i f a p s y c h i a t r i s t c e r t i f i e d t h a t he or she was incapable (s. 6). The p r o c e d u r e f o r s e c u r i n g ' j u d i c i a l i n t e r d i c t i o n ' , and f o r the appointment of a c u r a t o r by a c o u r t , remained the same as that s e t out i n the C i v i l Code i n the mid 19th c e n t u r y . However, some p r o c e d u r a l m a t t e r s had been t r a n s f e r r e d t o the Code of C i v i l Procedure i n 1965 (S.Q. 1965, c. 80). 3 7 : I b i d , s s . 22 & 23. A f t e r t h e i n i t i a l 21 d a y s of c o n f i n e m e n t , a p a t i e n t had to be r e - e x a m i n e d and c o u l d be c o n f i n e d f o r a f u r t h e r three months. Subsequent re-examinations were to occur every s i x months. 38: I b i d , s s . 30 to 56. Any d e c i s i o n of a Board c o u l d be appealed to the Court of Appeal but on a q u e s t i o n of law only. The p r o v i s i o n s a f f e c t i n g the Board were s t r u c k out on the passage of the S o c i a l A f f a i r s Commission Act (S.Q. 1974, c. 43). I n t e r a l i a , t h i s s t a t u t e e s t a b l i s h e d a s p e c i a l 'mental p a t i e n t s ' p r o t e c t i o n d i v i s i o n ' of the Commission which took o v e r the d u t i e s and f u n c t i o n s of the Board. The Commission was a l s o a u t h o r i z e d to review the issuance of c e r t i f i c a t e s of i n c a p a c i t y r e s p e c t i n g p a t i e n t s admitted to c l o s e treatment. 39: I b i d , s. 11. A l t h o u g h the s t a t u t e d i d not d e f i n e the meaning of the term 'dangerous', some guidance was obtained from an e a r l i e r r u l i n g of the Quebec Court of Appeal. In Dame L. v. LaRue [1959] B.R. 549, the c o u r t h e l d that a p a t i e n t was to be d e t a i n e d o n l y i f t h i s was n e c e s s a r y f o r h i s o r h e r own p r o t e c t i o n or f o r the p r o t e c t i o n of others. Consequently, there had to be some r i s k of harm. 40: I b i d , D i v i s i o n I I I : R i g h t s of Person's Under C l o s e Treatment. 41: I b i d , s. 28. 42: M e n t a l H e a l t h A c t S.A. 1972, c. 118; as amended by S.A. 145 1973, c. 76. 43: Mental Health (Amendment) Act S.O. 1978, c. 50. 44: Only cosmetic changes have been made to the p r o v i n c i a l and t e r r i t o r i a l l e g i s l a t i o n a f f e c t i n g the appointment of committees and g u a r d i a n s (e.g., terms have been 'modernized') and the j u d i c i a r y have r e t a i n e d c o n t r o l o v e r t h i s a r e a of p a t i e n t management. See, e.g., Mental Incompetency Act R.S.O. 1980, c. 264; M e n t a l l y Incompetent Persons E s t a t e s Act R.S.N. 1970, c. 234; P a t i e n t s Property Act R.S.B.C. 1979, c. 313; I n f i r m Persons Act S.N.B. 1973, c. 1-8; Chancery J u r i s d i c t i o n T r a n s f e r Act S.P.E.I. 1974, c. 65; M e n t a l l y P i s o r d e r e d P e r s o n s Act R.S.S. 1978, c. M-14; and, Incompetent Persons Act C.S.N.S. 1979, c. I-3. A new and i n n o v a t i v e s t a t u t e was passed i n A l b e r t a i n 1976 (The Dependen t A d u l t s Ac t S.A. 1976, c. 63) and t h i s made p r o v i s i o n f o r the p e r s o n a l g u a r d i a n s h i p of p h y s i c a l l y and m e n t a l l y d i s a b l e d a d u l t s . The a p p o i n t m e n t of a p u b l i c or p r i v a t e g u a r d i a n / t r u s t e e i s a m a t t e r f o r the j u d i c i a r y and a s s e s s m e n t s of the need f o r a g u a r d i a n / t r u s t e e are t o be c o m p r e h e n s i v e and m u l t i - d i s c i p i i n a r y i n n a t u r e ; t h a t i s , the j u d i c i a r y r e q u i r e more t h a n t h e o p i n i o n s o f m e d i c a l p r a c t i t i o n e r s before a p p o i n t i n g a g u a r d i a n / t r u s t e e . The s t a t u t e (now, R.S.A. 1980, c. D-32 (as amended)) endorses the p r i n c i p l e of l i m i t e d , t a i l o r - m a d e g u a r d i a n s h i p and c o n t a i n s numerous s a f e g u a r d s f o r 'dependent' a d u l t s (see, e.g., C h r i s t i e , 1984). The s t a t u t e has been viewed f a v o u r a b l y by those a d v o c a t i n g reforms to mental incompetency l e g i s l a t i o n i n the p r o v i n c e s and t e r r i t o r i e s (see, e.g., McLaughlin, 1979; Law Reform Commission of S a s k a t c h e w a n , 1981a) and c h a n g e s a r e i m m i n e n t i n Saskatchewan, Manitoba, Ontario, Newfoundland, and the Yukon T e r r i t o r y (Gordon, et a l , 1986). 45: I b i d , note 42. 46: I b i d , ss. 1, 25 to 28, 30, 31 & 47. Involuntary p a t i e n t s were to be r e f e r r e d t o as ' f o r m a l p a t i e n t s ' and c o u l d be i n i t i a l l y c o n f i n e d f o r 24 hours f o r the purposes of examination and c e r t i f i c a t i o n . A p a t i e n t could be c o n f i n e d f o r a f u r t h e r month and then e i t h e r r e l e a s e d or r e - c e r t i f i e d . Subsequent r e -e x a m i n a t i o n s had to o c c u r a f t e r two months and then a t s i x -monthly i n t e r v a l s . A p a t i e n t was to be discharged i f he or she ceased to present a danger. The s t a t u t e a l s o made p r o v i s i o n f o r a p r o v i n c i a l judge to i s s u e a w a r r a n t f o r the conveyance and e x a m i n a t i o n of a m e n t a l l y d i s o r d e r e d and dangerous p e r s o n . S i m i l a r l y , the p o l i c e were g r a n t e d the power t o apprehend d i s o r d e r e d and dangerous persons who were wandering at l a r g e (ss. 33 & 34). An a t t e n d i n g p s y c h i a t r i s t was empowered to grant leaves of absence and to t r a n s f e r p a t i e n t s to other resources with a minimum of f o r m a l i t y (ss. 51 & 52). No p r o v i s i o n was made f o r v o l u n t a r y admissions. I t was f e l t that the term 'voluntary p a t i e n t ' was s t i g m a t i z i n g and that 146 t h e r e was no need t o r e t a i n t h i s c a t e g o r y of p a t i e n t w i t h i n mental h e a l t h l e g i s l a t i o n . Persons who wished to secure mental h e a l t h s e r v i c e s on a v o l u n t a r y b a s i s could be d e a l t w i t h i n the same way as those s e e k i n g g e n e r a l h e a l t h s e r v i c e s ( H e l l o n , 1973). 47: ik.i.d, s « 2 4 - The d u t y t o p r o v i d e t r e a t m e n t was c o n d i t i o n a l s i n c e a h o s p i t a l was only r e q u i r e d to provide the d i a g n o s t i c and treatment s e r v i c e s needed by a p a t i e n t and that the s t a f f were capable and able to pro v i d e . A s i m i l a r duty to provide treatment f i r s t appeared i n the B r i t i s h Columbia mental h e a l t h s t a t u t e i n 1964. 48: I b i d , s s . 19 to 22, 38 to 43, & 46. 49: I b i d , P a r t 3; e s p e c i a l l y , s s . 36, 37, 44 & 45. The s t a t u t e a l s o introduced the procedure found i n other p r o v i n c e s whereby a p a t i e n t ' s e s t a t e could be placed i n the hands of the p r o v i n c i a l p u b l i c t r u s t e e s e r v i c e . I f two me n t a l h e a l t h p r o f e s s i o n a l s examined a p a t i e n t and were of the o p i n i o n that he or she was incapable of managing an e s t a t e , they could complete c e r t i f i c a t e s t o t h a t e f f e c t . Once t h e s e c e r t i f i c a t e s were r e c e i v e d by the P u b l i c T r u s t e e , the o f f i c e would assume management of the patie n t ' s e s t a t e (ss. 35 to 37.1). A p a t i e n t had the r i g h t to a p p e a l the i s s u a n c e of a c e r t i f i c a t e of i n c a p a c i t y to the review panel (ss. 19 to 22 & Part 3). These p r o v i s i o n s were t r a n s f e r r e d to The Dependent Adults Act i n 1976 (see, i b i d , note 44). 50: S.N.S. 1977, c. 45. The s t a t u t e r e p e a l e d the M u n i c i p a l Mental H o s p i t a l s Act R.S.N.S. 1967, c. 202, and key s e c t i o n s of the Nova S c o t i a H o s p i t a l Act R.S.N.S. 1967, c. 210. The l a t t e r became an e n a b l i n g s t a t u t e . 51: I b i d , s s . 1 & 28. 52: I b i d , s s . 26 & 34 to 36. A p a t i e n t c o u l d be i n i t i a l l y admitted and c o n f i n e d f o r seven days during which s/he was to be assessed w i t h a view to developing a long-term treatment plan. The p e r s o n c o u l d then be c o n f i n e d f o r one month as a ' f o r m a l patient'. A re-examination had to occur a f t e r three months and then at six-monthly i n t e r v a l s . 5 3 : I b i d , s s . 43 to 50. The power of the P u b l i c T r u s t e e to g i v e s u b s t i t u t e c o n s e n t t o t r e a t m e n t was c l a r i f i e d i n Re Boudreau ( 1980) 43 N.S.R. (2d) 212 (N.S.S.C.). In t h i s c a s e , i t was held that the Trustee's consent could be used even where a spouse or r e l a t i v e d e c l i n e d to give consent. The Act a l s o made p r o v i s i o n f o r the de t e r m i n a t i o n of the e x t e n t to which a p a t i e n t was competent to manage h i s or her es t a t e . As i n the case of c a p a c i t y to consent to treatment, a p s y c h i a t r i s t was to examine a p a t i e n t according to p r e s c r i b e d c r i t e r i a d e s i g n e d t o o b j e c t i f y competency a s s e s s m e n t s . I f deemed to be i n c o m p e t e n t , the P u b l i c T r u s t e e was to assume 147 management of the e s t a t e on a temporary b a s i s and pending e i t h e r an a p p l i c a t i o n f o r the appointment of a guardian by a court, or the f o r m u l a t i o n of an a l t e r n a t i v e arrangement (s. 51). 54: I b i d , s. 52. The term 'psychosurgery 1 was not d e f i n e d i n the s t a t u t e . 55: I b i d , s s . 39 & 53 to 61. 56: I b i d , s. 62. P r o v i s i o n was a l s o made to p r o t e c t the c o n f i d e n t i a l i t y of p a t i e n t s ' medical records (s. 63). In t h i s way, a p a t i e n t was granted a ' r i g h t ' to p r i v a c y . 57: S.O. 1978, c. 50. I t s h o u l d be n o t e d t h a t i n 1974 the O n t a r i o l e g i s l a t u r e passed the Developmental S e r v i c e s Act S.O. 1974, c. 2. This s t a t u t e made s p e c i a l p r o v i s i o n f o r the care of d evelopmentally d i s a b l e d persons (i.e., the mentally retarded) and t h i s group ceased to f a l l w i t h i n the purview of the mental h e a l t h s t a t u t e . 58: In keeping with the p o l i c i e s of d e - i n s t i t u t i o n a l i z a t i o n and n o n - i n s t i t u t i o n a l i z a t i o n , the p r o c e d u r e s a f f e c t i n g the i m p o s i t i o n of c o n t r o l o v e r a p a t i e n t ' s e s t a t e were changed. P r o v i s i o n was made f o r p s y c h i a t r i s t s to examine and c e r t i f y out- pa t i en t s as i n c o m p e t e n t to manage t h e i r a f f a i r s and f o r the P u b l i c Trustee to assume the management of t h e i r e s t a t e s ( I b i d , s. 13). 59: The McRuer Royal Commission on C i v i l Rights r e s u l t e d i n the passage of The C i v i l Rights Statute Law Amendment Act S.O. 1971, c. 50. The primary o b j e c t i v e of t h i s v ast s t a t u t e was to p r o v i d e new s a f e g u a r d s by r e q u i r i n g t h a t a l l a d m i n i s t r a t i v e a c t i o n s be s u b j e c t to review. I t a f f e c t e d s t a t u t e s as d i v e r s e as The W i l d R i c e H a r v e s t i n g Act (R.S.O. 1960, c. 431), The L i g h t n i n g Rods Act (R.S.O. 1960, c. 213), and The Pregnant Mare U r i n e Farms Act (S.O. 1968-69, c. 97). However, i t had no Tmmediate, d i r e c t impact upon mental h e a l t h l e g i s l a t i o n . 60: S.O. 1978, c. 50: s s . 3 to 6. A p h y s i c i a n had to have reasonable cause to b e l i e v e that a proposed p a t i e n t had behaved or was behaving i n a dangerous manner. In p a r t i c u l a r , he or she had to be sure that the person, (a) has threatened or attempted or i s t h r e a t e n i n g or attempting to cause b o d i l y harm to another; (b) has behaved or i s behaving v i o l e n t l y towards another person or has caused or i s causing another person to f e a r b o d i l y harm from him; or, (c) has shown or i s showing a lack of competence to care f o r h i m s e l f . If any of these 'objective' c o n d i t i o n s e x i s t e d , a p h y s i c i a n then had to be of the o p i n i o n that the person was s u f f e r i n g from a mental d i s o r d e r (i.e., any disease or d i s a b i l i t y of the mind) of a nature or q u a l i t y that l i k e l y would r e s u l t i n , 148 (d) s e r i o u s b o d i l y harm to the person; (e) s e r i o u s b o d i l y harm to another person; or (f) imminent and s e r i o u s p h y s i c a l impairment of the person. These s t r i c t c r i t e r i a had to be met at a l l stages i n the i n i t i a l admission process and the l i k e l i h o o d of s e r i o u s b o d i l y harm or p h y s i c a l impairment had to be taken i n t o c o n s i d e r a t i o n whenever subsequent re-examinations o c c u r r e d . 61: I b i d , s s . 1, 3 & 6. A p e r s o n c o u l d o n l y be c o n f i n e d and r e s t r a i n e d f o r an i n i t i a l p e r i o d of 120 hours during which time an a s s e s s m e n t was to take p l a c e . A p a t i e n t , c o u l d t h e n be admitted i n v o l u n t a r i l y f o r two weeks. A re-examination was to o c c u r and the p a t i e n t c o u l d be c o n f i n e d f o r a f u r t h e r month. Subsequent re-examinations were to occur a f t e r two months, and then every three months. 62: I b i d , s. 12. The term 'mentally competent' was deemed to mean "having the a b i l i t y to u n d e r s t a n d the s u b j e c t m a t t e r i n r e s p e c t of which consent i s requested and able to a p p r e c i a t e the consequences of g i v i n g or w i t h h o l d i n g consent" (s. 1). The term ' p s y c h o s u r g e r y ' was deemed t o mean "any p r o c e d u r e t h a t , by d i r e c t or i n d i r e c t a c c e s s to the b r a i n , removes, d e s t r o y s or i n t e r r u p t s the c o n t i n u i t y of h i s t o l o g i c a l l y normal b r a i n t i s s u e , or which i n s e r t s i n d w e l l i n g e l e c t r o d e s f o r p u l s e d e l e c t r i c a l s t i m u l a t i o n f o r the purpose of a l t e r i n g behaviour or t r e a t i n g p s y c h i a t r i c i l l n e s s , b u t d o e s n o t i n c l u d e n e u r o l o g i c a l procedures used to diagnose or t r e a t o r g a n i c b r a i n c o n d i t i o n s or to diagnose or t r e a t i n t r a c t a b l e p h y s i c a l pain or e p i l e p s y where these c o n d i t i o n s are c l e a r l y demonstrable" (s. 12). In Re T and The Board of Review f o r the Western Region, et a l (1983) 23 A.C.W.S. (2d) 50 (Ont.H.C.J.) i t was held that e l e c t r o c o n v u l s i v e therapy was not psychosurgery. 63: I b i d , s. 11. P r o v i s i o n was a l s o made to p r o t e c t the c o n f i d e n t i a l i t y of p a t i e n t s ' medical records (s. 10). 64: The requirement that a l e g a l a i d s e r v i c e be n o t i f i e d was not p r o c l a i m e d i n f o r c e u n t i l March 1984. Delay was due to a c o n c e r n t h a t t h i s m e a s u r e w o u l d r e s u l t i n a b r e a c h o f p h y s i c i a n / p a t i e n t c o n f i d e n t i a l i t y . 65: I b i d , s. 4. The r i g h t to seek j u d i c i a l r e v i e w was not proclaimed i n f o r c e u n t i l March 1984. 66: Mental Health Amendment Act S.M. 1980, c. 62. The amendments i n c l u d e d the a d o p t i o n of the d a n g e r o u s n e s s c r i t e r i a used i n O n t a r i o but o n l y i n the case of emergency a p p r e h e n s i o n s by the p o l i c e . V a r i o u s s e m a n t i c changes a l s o occurred which r e f l e c t e d , i n p a r t i c u l a r , the e s t a b l i s h m e n t of a p r o v i n c i a l p u b l i c t r u s t e e s e r v i c e . P r o v i s i o n was made f o r a m u l t i - d i s c i p l i n a r y mental h e a l t h review board and f o r improved p a t i e n t s ' r i g h t s , i n c l u d i n g the ' r i g h t ' to a u t o m a t i c r e v i e w . However, t h i s s e c t i o n of the Act was not proclaimed. 149 67: B i l l 59/87, June 5th 1987. 68: B r i t i s h Columbia Regulations 118/80, D i v i s i o n 8. Approved and ordered per Order i n C o u n c i l 780, A p r i l 2nd, 1980. The new r e g u l a t i o n s served to b u t t r e s s the work of the Mental P a t i e n t s ' A d vocate P r o j e c t ; a s p e c i a l l e g a l s e r v i c e w hich had been e s t a b l i s h e d i n the mid 1970's to a s s i s t and p r o t e c t p a t i e n t s . The emergence and impact of t h i s l e g a l s e r v i c e w i l l be examined i n d e t a i l i n Chapter 6. 69: See, M e n t a l H e a l t h Amendment Act S.B.C. 1985, c. 12. Inter a l i a , t h i s s t a t u t e c l a r i f i e d a p a t i e n t ' s r i g h t to apply f o r r e v i e w a f t e r the f i r s t 30 days of c o n f i n e m e n t , and then every 90 days unless the chairman of the review panel was of the op i n i o n that a review should occur at an e a r l i e r time. Fur t h e r amendments have been i n t r o d u c e d per the H e a l t h S t a t u t e s Amendment Act, S.B.C. 1986, c. 6, and the M i s c e l l a n e o u s S t a t u t e s Amendment Act (No. 1) S.B.C. 1987, c. 42. These s t a t u t e s s h o r t e n the p e r i o d s of time d u r i n g which a p a t i e n t may be c o n f i n e d w i t h o u t r e - e x a m i n a t i o n . Both the c i r c u m s t a n c e s surrounding the 'Cumming Report' and the imminent r e c o n s t r u c t i o n of p r o v i n c i a l mental h e a l t h l e g i s l a t i o n , are examined i n d e t a i l i n Chapter 6. 70: The review of l e g i s l a t i o n was s t i m u l a t e d by the f i n d i n g s of the 'Langdon Report', the product of a j u d i c i a l i n q u i r y i n t o the murder of one Thomas Hagan by a d i s c h a r g e d m e n t a l h e a l t h p a t i e n t who was n e g l e c t i n g t o f o l l o w a p r e s c r i b e d t r e a t m e n t programme (Langdon, 1980). The r e p o r t c r i t i c i z e d both e x i s t i n g p r a c t i c e s and the mental h e a l t h l e g i s l a t i o n , and the Committee was c h a r g e d w i t h t h e t a s k o f d e v e l o p i n g more e f f e c t i v e mechanisms f o r the s u p e r v i s i o n of p a t i e n t s r e l e a s e d 'on leave' from m e n t a l h e a l t h f a c i l i t i e s . In the l i g h t of the Langdon R e p o r t , the Committee chose t o r e t a i n the e x i s t i n g ' w e l f a r e ' t e s t f o r i n v o l u n t a r y admission, r a t h e r than the more r e s t r i c t i v e 'dangerousness' t e s t adopted i n , f o r example, Ontari o . Reforms w i l l be int r o d u c e d once the Committee has concluded i t s r e p o r t on a d u l t guardianship l e g i s l a t i o n . 71: B i l l 3/87, March 11th 1987. 72: M e n t a l H e a l t h S e r v i c e s A c t S.S. 1984-85, c. M-13.1. Proclaimed i n f o r c e , March 1986. 73: I b i d , s. 3. The p r o v i s i o n of adequate r e s o u r c e s i s not mandatory. The s t a t u t e m e r e l y l e a v e s the m a t t e r t o the d i s c r e t i o n of the D i r e c t o r of the P s y c h i a t r i c S e r v i c e s Branch. 74: I b i d , s s . 1, 24 & 25. B e f o r e a d m i t t i n g a p a t i e n t on an i n v o l u n t a r y b a s i s , two m e d i c a l p r a c t i t i o n e r s (one b e i n g a p s y c h i a t r i s t ) have to have p r o b a b l e cause to b e l i e v e t h a t a person i s s u f f e r i n g from a mental d i s o r d e r and needs treatment or c a r e and s u p e r v i s i o n w hich can o n l y be p r o v i d e d i n a f a c i l i t y . In a d d i t i o n , they must be of the o p i n i o n t h a t the proposed p a t i e n t cannot understand and make an informed d e c i s i o n 150 r e g a r d i n g the need f o r treatment and that he or she i s l i k e l y to cause harm to h i m / h e r s e l f or o t h e r s , or s u f f e r s u b s t a n t i a l mental or p h y s i c a l d e t e r i o r a t i o n (s. 24). A p a t i e n t may only be co n f i n e d without re-examination f o r p e r i o d s of 21 days. R e s i d e n t s of the p r o v i n c e a r e g r a n t e d the r i g h t to seek mental h e a l t h s e r v i c e s on a v o l u n t a r y b a s i s . Such p a t i e n t s can secure discharge at any time and they cannot be r e - c e r t i f i e d as i n v o l u n t a r y p a t i e n t s i f they e x p r e s s the w i s h t o l e a v e a f a c i l i t y ( s . 17). The s t a t u t e makes p r o v i s i o n f o r t h e L i e u t e n a n t Governor i n C o u n c i l t o make r e g u l a t i o n s p l a c i n g r e s t r i c t i o n s upon the use of any treatment, as the need a r i s e s . 75: I b i d , s s . 14, 16, 25, 27 & 33. 76: I b i d . Improvements i n p a t i e n t s ' r i g h t s have been spurred by the p r o c l a m a t i o n of the Ca n a d i a n C h a r t e r of R i g h t s and Freedoms and the r e s u l t s of a p r o v i n c i a l government study of the impact of the C h a r t e r on a l l p r o v i n c i a l l e g i s l a t i o n (Lane, 1984). The impact of the Charter on mental h e a l t h l e g i s l a t i o n w i l l be d i s c u s s e d f u r t h e r i n the next chapter. 77: M e n t a l H e a l t h Amendment A c t S.N.B. 1985, c. 59 (not proclaimed i n f o r c e at the time of w r i t i n g ) . 78: I b i d , s s . 1 & 6 to 8. 79: I b i d , s. 8. The t r i b u n a l i s to be the only body that can au t h o r i z e the i n v o l u n t a r y admission of a v o l u n t a r y p a t i e n t who seeks d i s c h a r g e w i t h o u t the a p p r o v a l of h i s or her a t t e n d i n g p s y c h i a t r i s t (s. 13). 80: I b i d , ss. 14 & 29. The per i o d s of d e t e n t i o n without r e -c e r t i f i c a t i o n have been shortened to one month, three months, and then every s i x months. 81: I b i d , ss. 1, 15 & 30. The composition and procedures of the review board have remained l a r g e l y unchanged. The county c o u r t judge has been r e p l a c e d by a l a w y e r , and the board i s r e q u i r e d to respond q u i c k l y to an a p p l i c a t i o n . A p a t i e n t has a r i g h t to be present with h i s or counsel ( s . 31). 82: M e n t a l H e a l t h A c t S.N.W.T. 1985 ( 2 n d ) , c. 6 ( n o t proclaimed i n f o r c e at the time of w r i t i n g ) . 8 3 : I ' s s • 8 t o 1 2 ' 2 1 t o 2 3 ' & 3 6 t o 4 1 • W h i l e experimental treatment i s p r o h i b i t e d , psychosurgery may be given i f a p a t i e n t i s mentally competent and gives h i s or her consent. The Act i n c l u d e s the d e f i n i t i o n of mental competency found i n the O n t a r i o s t a t u t e . At a minimum, the s u b s t i t u t e consent of a spouse or r e l a t i v e i s r e q u i r e d before e l e c t r o c o n v u l s i v e therapy may be given to a p a t i e n t . P r o v i s i o n i s made f o r other p a t i e n t s ' r i g h t s ; notably, the r i g h t to be informed of the reasons f o r admission, the r i g h t to 151 an independent medical o p i n i o n , the r i g h t to be f r e e from abuse, and the r i g h t not to be subjected to d i s c r i m i n a t i o n i n regard to such matters as employment, s e r v i c e s and accommodation. The st a t u t e c o n t a i n s a preamble that s t r e s s e s both the use of the l e a s t r e s t r i c t i v e treatment option and the need to acknowledge t h a t the p r o c e s s of d e f i n i n g m e n t a l i l l n e s s i s a f f e c t e d by c u l t u r a l d i f f e r e n c e s . P r o v i s i o n i s made f o r m e d i c a l p r a c t -t i o n e r s to c o n s u l t w i t h community e l d e r s p r i o r t o making d e c i s i o n s r e g a r d i n g the a d m i s s i o n of p e r s o n s of a b o r i g i n a l descent. The s t a t u t e c o n t a i n s other p r o v i s i o n s which meet the p e c u l i a r needs of the T e r r i t o r i e s ; f o r example, s p e c i a l procedures f o r t r a n s f e r r i n g p a t i e n t s to treatment f a c i l i t i e s i n the pr o v i n c e s , and the use of the T e r r i t o r i a l Supreme Court as the post-admission review body. 84: See, Verdun-Jones & Gordon (1985). The c o n t e n t s of the new mental h e a l t h s t a t u t e and a companion, a d u l t guardianship s t a t u t e w i l l n ot be made p u b l i c u n t i l an i n t e r - m i n i s t e r i a l committee has concluded i t s d e l i b e r a t i o n s . 85: The p r o v i n c e s of B r i t i s h C o l u m b i a , A l b e r t a , O n t a r i o , Quebec, New Br u n s w i c k , and Newfoundland, and the Northwest T e r r i t o r i e s , are p a r t i c i p a t i n g i n the Conference. 86: The ca u t i o u s approach to awarding damages a g a i n s t e r r a n t medical p r a c t i t i o n e r s , which was adopted by the co u r t s i n the p e r i o d p r i o r to 1939 (see, Chapter 2), has continued. A c t i o n s f o r f a l s e imprisonment, a s s a u l t , b a t t e r y , c o n s p i r a c y , and n e g l -i g e n c e have been l a u n c h e d by these have e i t h e r f o u n d e r e d or r e s u l t e d i n the award of m i n i m a l damages. F o r example, i n Schmidt v. Katz and Shnider (1954) 13 W.W.R. 654 (Sask.S.C), a case where a p e r s o n had been apprehended and d e t a i n e d even though no medical examination had taken place, the court awarded damages of $500. A l t h o u g h the p h y s i c i a n s were found to have been ' c a r e l e s s 1 , the court d i d not f e e l t h a t s e r i o u s damage had r e s u l t e d . In Burke v^ E f s t a t h i a n o s , et a l (1961) 34 W.W.R. 337 (Man.C.A.), the court found that p h y s i c i a n s were not j u s t i f i e d i n committing a p a t i e n t . I t was s t r e s s e d that the powers given to p h y s i c i a n s should be e x e r c i s e d reasonably and that i n t h i s case they had been r e s p o n s i b l e f o r the f a l s e imprisonment of an i n d i v i d u a l . D e s p i t e a condemnation of the b e h a v i o u r of the m e d i c a l p r a c t i t i o n e r s the c o u r t awarded damages of $25. Likewise, i n X Y [1969] Q.C.A. 795, the court awarded a mere $1,500 damages to a pe r s o n who had been i m p r o p e r l y d e t a i n e d . This award was l a t e r overturned by the Supreme Court of Canada (Coulombe v. W a t i e r [1973] S.C.R. 673). In a more r e c e n t A l b e r t a c a s e , t h e c o u r t f o u n d t h a t a p s y c h i a t r i s t had p e r s i s t e n t l y t r i e d t o commit an i n d i v i d u a l m a l i c i o u s l y . S u b s t a n t i a l damages ($28,500) were awarded f o r the f a l s e a r r e s t and i m p r i s o n m e n t ( T a n n e r v ^ Nory_s [ 1 9 7 9 ] 5 W.W.R. 724 ( A l t a . S . C ) . On a p p e a l , however, the d e c i s i o n and award were o v e r t u r n e d (Tanner v. Norys (1980) 21 A.R. 372 (Alta.C.A.). In C o c h l i n v^ The Queen (1983) 4 D.L.R. (4th) 763 (Alta.Q.B.), a case where t h e r e had been i r r e g u l a r i t i e s i n the commitment p r o c e s s , the c o u r t s a l s o d e c l i n e d to award damages f o r f a l s e 152 a r r e s t and i m p r i s o n m e n t . The a c t i o n was d i s m i s s e d s i n c e the de f e c t s i n the commitment documents had been remedied and the cour t e x h i b i t e d a concern that a p a t i e n t who was d i s o r d e r e d and dangerous not be r e l e a s e d . I t i s c l e a r t h a t t h i s f a c t o r i n f l u e n c e d the judgment. A recent example of t h i s c h a r i t a b l e a t t i t u d e towards m e d i c a l p r a c t i t i o n e r s comes from B r i t i s h C o l u m b i a . In Ketchum Hi^s l o p (1984 ) 54 B.C.L.R. 327 (B.C.S.C.), a p l a i n t i f f who had been i m p r o p e r l y c o m m i t t e d , i n v o l u n t a r i l y confined, and f o r c i b l y t r e a t e d was awarded a mere $500 damages (see, a l s o , Green v. Livermore, et a l [1940] O.R. 381 (Ont.H.C.J.); T y n d a l l v^ Walker, e t a l [1942 ] O.W.N. 91 (Ont.H.C.J.); Moase v. Pr i n c e County H o s p i t a l , et a l (1979) N.& P.E.I.R. 369 (P.E.I.S.C.) ; and, Cascone v. Rodney, e t a l (1981) 131 D.L.R. (3d) 593 (Ont.H.C.J.). Where improper commitment has r e s u l t e d from the a c t i o n s of i n d i v i d u a l s who are not mental h e a l t h p r o f e s s i o n a l s , the c o u r t s have adopted a s t r o n g e r p o s i t i o n . An award of s u b s t a n t i a l damages was u p h e l d i n B e a t t y and Mackie v. Kozak (1958) 13 D.L.R. (2d) 1 (S.C.C.), a case where the p o l i c e apprehended a per s o n who had been m e n t a l l y i l l and d i s o r d e r l y s e v e r a l days before apprehension, but who was not behaving i n that manner at the time of a r r e s t . S i m i l a r l y , i n G i f f o r d v. Kelson [1943] 2 W.W.R. 76 (Man.K.B.) damages were awarded a g a i n s t an i n d i v i d u a l who had a l l e g e d m a l i c i o u s l y t h a t a r e l a t i v e was a dangerous l u n a t i c . 87: Cases s u p p o r t i v e of the r i g h t s of p a t i e n t s i n c l u d e , Rosandik v. Manning ( 1978) 5 B.C.L.R. 347 (B.C.S.C.) ( u p h o l d i n g the r i g h t of an i n v o l u n t a r y p a t i e n t to seek j u d i c i a l review i n hi s / h e r own r i g h t and d e s p i t e the o b j e c t i o n s of a committee); D i r e c t o r of Riverview v. Andrzejewski (1983) 150 D.L.R. (3d) 535 (B.C.Cty.Ct.) ( i n v o l u n t a r y p a t i e n t s do not have t o pay d a i l y charges f o r care and treatment); and, P.M. v. Lindsay (1981) 26 A.R. 159 (Alta.C.A.) ( s u p p o r t i n g a p a t i e n t ' s r i g h t to examine h i s / h e r medical r e c o r d s ) . 88: Re Azhar v^ Anderson (1985) 33 A.C.W.S. (2d) 521 (Ont. Pis t . C t . ) . In t h i s case, the court r u l e d that i n review board hearings the burden of proof l a y wit h those seeking to d e t a i n a person. The standard of proof should be on 'the preponderance of the e v i d e n c e 1 . 89: See, Re Robinson and H i s l o p (1980) 114 P.L.R. (3d) 620 (B. C.S.C.); Scherba v. H i s l o p [1981] B.C.P.Civ. 2668-02 (B.C.S.C); and, M. v. A l b e r t a (1985) 63 A.R. 14 (Alta.Q.B.). 90: See, Lussa v. The Health Sciences Centre and P i r e c t o r of P s y c h i a t r i c S e r v i c e s (1984) 5 C.H.R.R. D/2203 (Man.Q.B.); Refer- ence Re P r o c e d u r e s and the M e n t a l H e a l t h Act (1984) 5 D.L.R. (4th) 577 (P.E.I.S.C); Kohn v^ Globerman [1986] 4 W.W.R. 1 (Man.C.A.); Thwai t e s v. H e a l t h S c i e n c e s C e n t r e P s y c h i a t r i c F a c i l i t y [1987] 1 W.W.R. 468 (Man.Q.B.); Re Jenkins (1986) 59 N. & P.E.I.R. 62 (P.E.I.S.C); and, Re Swain ( 1986) 13 O.A.C. 161 (C.A.). 153 91: (1985) 63 A.R. 14 (Alta.Q.B.). 92: (1981) 121 D.L.R. (3d) 337 (B.C.S.C.). 93: See, e.g., Re Dearing [1976] W.W.D. 21 (B.C.S.C.); Scherba v. H i s l o p [1981] B.CD.Civ. 2 668-02 (B.C.S.C.); Re G.G. and Swamy_ ( 1986) 36 A.C.W.S. (2d) 247 (On t.D.i s t . C t . ) ; Re Azhar and Anderson (1985) 33 A.C.W.S. (2d) 521 (Ont.Di s t . C t . ) ; Re K o s i n k a and C l a r k e I n s t i t u t e of P s y c h i a t r y (1980) 4 L.Med.Q. 153 (Ont. S.C.); L.B. v^ O'Doherty ( 1986) 38 A.C.W.S. (2d) 152 ( O n t . D i s t . Ct. ) . 94: The maintenance of j u d i c i a l c o n t r o l over committeeship can be tra c e d to the B r i t i s h North America Act. This c o n s t i t u t i o n a l i n s t r u m e n t g r a n t e d j u r i s d i c t i o n o v e r l u n a c y m a t t e r s to the su p e r i o r c o u r t s of the provinces and t e r r i t o r i e s and i t i s not p o s s i b l e f o r t h i s r e s p o n s i b i l i t y to be e n t i r e l y r e l i n q u i s h e d or d e l e g a t e d . The o r i g i n s of t h i s p r o v i s i o n l i e w i t h E n g l i s h lunacy law which e s t a b l i s h e d and maintained j u d i c i a l c o n t r o l i n order to p r o t e c t the i n t e r e s t s of ' l u n a t i c s ' who were members of t h e s o c i a l c l a s s e s w h i c h p o s s e s s e d p r o p e r t y ( s e e , e.g., McLaughlin, 1979; Jones, 1955). 154 CHAPTER 4^ THEORIES OF LEGAL CHANGE AND MENTAL HEALTH LAW REFORM I; INTRODUCTION As the a n a l y s i s i n the preceding chapters has i n d i c a t e d , there have been changes i n both the s t r a t e g y and the l e g i s l a t i o n a f f e c t i n g the management of m e n t a l l y d i s o r d e r e d p e r s o n s i n Canada, s i n c e 1900. At the t u r n of the c e n t u r y , a mode of s t a t u t o r y r e g u l a t i o n r e f e r r e d t o as ' l i m i t e d l e g a l i s m ' was u t i l i z e d i n c o n j u n c t i o n w i t h a s t r a t e g y o f s e g r e g a t e d confinement i n p u b l i c and p r i v a t e asylums. By the 1930's, most p r o v i n c e s had i n t r o d u c e d new l e g i s l a t i o n and t h i s was a c c o m p a n i e d by a d i f f e r e n t a p p r o a c h t o t r e a t m e n t and confinement. The era of ' m e d i c a l i z a t i o n ' had emerged and, while the o l d i n s t i t u t i o n s were r e t a i n e d , new f a c i l i t i e s and reso u r c e s were i n t r o d u c e d f o r the i n t e n s i v e , medical treatment of those deemed to be ' m e n t a l l y d i s e a s e d ' . D u r i n g the 1960's, mental h e a l t h laws were subjected to sweeping reforms c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' and t h i s occurred i n c o n j u n c t i o n w i t h a new s t r a t e g y ; namely, d e - i n s t i t u t i o n a l i z a t i o n and the u t i l i z a t i o n of 'community-based' care and treatment resources. Since the e a r l y 1970's, the 'new l e g a l i s m ' has been embraced by most provin c e s and t e r r i t o r i e s and the c u r r e n t era of reform i s o c c u r r i n g i n a s s o c i a t i o n w i t h a c c e l e r a t e d d e - i n s t i t u t i o n -a l i z a t i o n , n o n - i n s t i t u t i o n a l i z a t i o n , p r i v a t i z a t i o n , and the c l o s u r e of i n s t i t u t i o n s (see, Table 4.1). 155 TABLE 4.1 DOMINANT TRENDS IN THE STRATEGY AND LEGISLATION AFFECTING MENTALLY DISORDERED PERSONS IN CANADA: 1900 - 1987 State Strategy C h a r a c t e r i s t i c s of L e g i s l a t i o n 1900 I n s t i t u t i o n a l i z a t i o n : segregated confinement of insane persons i n public and private asylums. Limited Legalism: Various forms of j u d i c i a l and q u a s i - j u d i c i a l supervision of commitment and confinement but decisions subject to medical opinion 0 1920's/30's Short and long-term i n s t i t u t i o n a l i z a t i o n for care and medical treatment„ Short-term admission f o r intensive medical treatment of mental diseases, i n psychopathic h o s p i t a l s 0 Long-term confinement i n public and private h o s p i t a l s . Medicalization: Medical p r a c t i t i o n e r s granted power to admit/treat/discharge voluntary and involuntary patients, e s p e c i a l l y to psycho-pathic facilities„ Some j u d i c i a l and quasi-j u d i c i a l supervision of long-term confinement. 1960's D e - i n s t i t u t i o n a l i z a t i o n : mentally i l l persons to be discharged/admitted to p u b l i c , community-based care and treatment resources. Enhanced Medicalization: medical p r a c t i t i o n e r s granted power to admit/treat/discharge a l l categories of patient. Decisions subject to review by administrative t r i b u n a l s . No routine j u d i c i a l supervisions 1970's/80's Accelerated d e - i n s t i t u t i o n a l i z a t i o n , non-i n s t i t u t i o n a l i z a t i o n , and p r i v a t i z a t i o n . Mentally i l l persons to be treated i n pub l i c , community-based resources and housed by the private sector. Old i n s t i t u t i o n s for segreg% ated confinement and intensive treatments to be closed,, New Legalism: S t r i c t statutory controls on admission/treatment/confinement of pat i e n t s , and establishment of patients' r i g h t s . Advocacy services and proactive, quasi-j u d i c i a l administrative tribunals to protect patients' rights and supervise/monitor mental health professionals, backed by the j u d i c i a r y . I t i s now n e c e s s a r y to c o n s i d e r the r e a s o n s f o r the t r a n s f o r m a t i o n s , with a p a r t i c u l a r emphasis upon the changes which have occu r r e d s i n c e the 1950's. Why i s i t that p r o v i n c i a l governments chose to adopt 'enhanced m e d i c a l i z a t i o n ' o n l y to then abandon t h i s mode of r e g u l a t i o n i n f a v o u r of i m p o s i n g s t r i c t r e s t r a i n t s on the a c t i o n s of those charged with the tasks of c o n f i n i n g , c a r i n g f o r and t r e a t i n g p e r s o n s c a t e g o r i z e d as mentally d i s o r d e r e d ? Have there been s i g n i f i c a n t problems i n the d e l i v e r y of mental h e a l t h s e r v i c e s which r e q u i r e d remedial a c t i o n on the p a r t of the s t a t e ? Has t h e r e been a p r o f o u n d s w i t c h i n the ideology a f f e c t i n g treatment and confinement which has n e c e s s i t a t e d a r e c o n s t r u c t i o n of the s t a t u t e s g o v e r n i n g mental h e a l t h systems? Is the seedbed of reform to be found i n c h a n g i n g economic c o n d i t i o n s a f f e c t i n g the d e l i v e r y of a l l p u b l i c h e a l t h and s o c i a l w e l f a r e s e r v i c e s ( i . e . , the ' w e l f a r e s t a t e ' ) ? Are the p e r i o d s of r e f o r m a p r o d u c t of the work of i n f l u e n t i a l i n d i v i d u a l s and groups? To what extent have each of these (and other) f a c t o r s combined to produce mental h e a l t h law reform? An e x a m i n a t i o n of t h e s e q u e s t i o n s w i l l b e g i n w i t h an e x p l o r a t i o n of the work of a n a l y s t s of m e n t a l h e a l t h law and p o l i c y reform i n B r i t a i n and the United States. T h i s w i l l both generate some e x p l a n a t i o n s which may account f o r the p e r i o d s of change i n Canada and ensure that the a n a l y s i s i s anchored f i r m l y i n the e x i s t i n g bodies of knowledge i n the s o c i o l o g y of law and other r e l e v a n t areas of s o c i o l o g i c a l i n q u i r y . Each p e r i o d of mental h e a l t h law reform i n Canada can be 157 e x p l a i n e d as a response to changing s t a t e s t r a t e g i e s a f f e c t i n g the management of those who, at d i f f e r e n t t i m e s , have been r e f e r r e d to as 'insane 1, 'mentally diseased', or 'mentally i l l ' . As the a n a l y s i s has shown, changes i n the a r c h i p e l a g o of i n s t i t u t i o n s and resources e s t a b l i s h e d f o r the containment, care and t r e a t m e n t of t h i s group c o i n c i d e d w i t h changes i n m e n t al h e a l t h law. For example, the i n t r o d u c t i o n of the 'psychopathic' h o s p i t a l i n the 1920's, and the 'community-based' c a r e and treatment resource i n the 1960's, were r e f l e c t e d i n the mental h e a l t h l e g i s l a t i o n which was c o n s t r u c t e d a t those t i m e s . Consequently, an e x p l a n a t i o n f o r law reform may be seen to l i e with the a c t i v i t i e s of mental hygiene and mental h e a l t h p o l i c y -makers who responded to developments i n the f i e l d of p s y c h i a t r y . As these occurred, so a new l e g a l framework f o r the p r o v i s i o n of s e r v i c e s became n e c e s s a r y and was e v e n t u a l l y p r o v i d e d . Therefore, an e x p l a n a t i o n f o r reforms to mental h e a l t h law c o u l d perhaps be sought s o l e l y i n the spheres of mental h e a l t h p o l i c y -making and medicine, r e g a r d l e s s of any other c o n s i d e r a t i o n . T h i s a c c o u n t of l e g a l change i s a t t r a c t i v e f o r i t s s i m p l i c i t y . Law i s seen as a mere a d m i n i s t r a t i v e v e h i c l e that i s employed by benevolent governments as a means f o r conveying new p o l i c i e s and s t r a t e g i e s w hich have been d e v i s e d , i n c o n j u n c t i o n w i t h the m e d i c a l p r o f e s s i o n , i n an atmosphere of consensus. The s t a t e i s seen as a benign and humanitarian e n t i t y which a c t s as a n e u t r a l dispenser of common b e n e f i t s and t h a t , i n the mental h e a l t h context, i s motivated s o l e l y by a concern f o r the w e l f a r e of those a f f l i c t e d w i t h 'mental i l l n e s s e s ' . 158 Where en l i g h t e n e d and p r o g r e s s i v e developments i n mental h e a l t h c a r e emerge, the s t a t e responds by r e f o r m i n g p o l i c i e s and l e g i s l a t i o n s i n c e i t i s c l e a r that change w i l l be to the d i r e c t advantage of both those d i s p e n s i n g and those r e c e i v i n g , care and treatment (Ralph, 1983). I t i s c l e a r , however, t h a t t h i s a c c o u n t of p o l i c y and l e g i s l a t i v e r e f o r m i s i n c o r r e c t . As Jones (1955, 1960, 1972), Bean (1980), Unsworth (1979), and B u t l e r (1985) have shown, i n B r i t a i n the t r a n s f o r m a t i o n s a f f e c t i n g mental h e a l t h law over the c o u r s e of n e a r l y 150 y e a r s have o c c u r r e d i n an atmosphere of c o n s i d e r a b l e c o n f l i c t . W h ile t h e r e may have been co n s e n s u s amongst i n t e r e s t groups r e p r e s e n t i n g the medical p r o f e s s i o n , t h e i r p e r s p e c t i v e has been a t t a c k e d by groups r e p r e s e n t i n g m e n t a l h e a l t h p a t i e n t s , s p e a r h e a d e d by l a w y e r s and o t h e r advocates concerned with the p r o t e c t i o n of fundamental r i g h t s and l i b e r t i e s . In a d d i t i o n , other p r o f e s s i o n a l groups - notably, s o c i a l workers - have opposed the views of medical p r a c t i t i o n e r s i n an e f f o r t to secure involvement i n the care and treatment of consumers (Jones, 1972; Unsworth, 1979). The c u r r e n t era of the 'new l e g a l i s m ' has been c h a r a c t e r i z e d , i n both Canada and other c o u n t r i e s , by intense c o n f l i c t between competing p r o f e s s i o n a l and other i n t e r e s t groups. In p a r t i c u l a r , c i v i l l i b e r t a r i a n l a w y e r s and p a t i e n t s ' a s s o c i a t i o n s have c l a s h e d w i t h m e n t a l h e a l t h p r o f e s s i o n a l s (see, e.g., Savage & McKague, 1987). A new group of t r e a t e r s - c l i n i c a l p s y c h o l o g i s t s - has emerged and staked a c l a i m i n the mental h e a l t h f i e l d and i t i s c l e a r that i n c r e a s e d involvement by t h i s p r o f e s s i o n a l group i s not e n t i r e l y 159 welcomed by p s y c h i a t r i s t s (see, e.g., C a t t e l l , 1983; Sedgwick, 1982). There i s , t h e r e f o r e , abundant evidence of c o n f l i c t not o n l y between the m e d i c a l p r o f e s s i o n and c i v i l l i b e r t a r i a n lawyers but a l s o w i t h i n the complex of p r o f e s s i o n s which have been and are i n v o l v e d i n the d e l i v e r y of mental h e a l t h s e r v i c e s . S i m i l a r l y , i t i s a p p a r e n t t h a t s t a t e p o l i c y - m a k e r s and l e g i s l a t o r s have not been p a s s i v e a c t o r s i n the p r o c e s s of reform. There i s c o n s i d e r a b l e evidence that p o l i c y and l e g a l r e f o r m s i n i t i a t e d by the government i n B r i t a i n a t d i f f e r e n t times occurred i n advance of concomitant developments in the f i e l d of p s y c h i a t r y and that the l e g i s l a t i v e changes c o n t r i b u t e d s i g n i f i c a n t l y to the development of new p r a c t i c e s and resources i n the mental h e a l t h context ( S c u l l , 1984; Bean, 1980; Unsworth, 1979; B u t l e r , 1985). The law was, t h e r e f o r e , used as a v e h i c l e f o r i n t r o d u c i n g changes decided upon by the s t a t e i n response to e i t h e r broader i d e o l o g i c a l or m a t e r i a l c o n d i t i o n s , r a t h e r than a m i r r o r of changes which had a l r e a d y occurred as a consequence of advances i n the c a r e and t r e a t m e n t of t h o se deemed t o be mentally d i s o r d e r e d . In t h i s regard, i t i s worth noting t h a t , i n Canada, the essence of the s o - c a l l e d 'Saskatchewan Plan' - an i n n o v a t i v e s t r a t e g y f o r the c a r e and t r e a t m e n t of 'mental diseased' persons - was f i r s t announced i n 1947 and some time before the t e c h n o l o g i e s and resources of mental h e a l t h s e r v i c e s were c o m p a t i b l e w i t h the g o a l s of the scheme ( i . e . , 'de-i n s t i t u t i o n a l i z a t i o n ' ). T h i s i s not to say t h a t d e v e l o p m e n t s i n the c a r e and 160 t r e a t m e n t of p a t i e n t s , as s t i m u l a t e d by b o t h t e c h n o l o g i c a l ' d i s c o v e r i e s ' and new, widely supported s t r a t e g i e s d e v i s e d and implemented by mental h e a l t h p r o f e s s i o n a l s , have had no impact on the law reform process. In p a r t i c u l a r , the a v a i l a b i l i t y of new drugs f o r the r e l i e f of symptoms provided support f o r the popular s t r a t e g y of community care and treatment which emerged i n the 1950's and 1960's and that was subsequently r e f l e c t e d i n reforms to mental h e a l t h law. However, the s t r a t e g y could not have been imp l e m e n t e d w i t h o u t complementary changes i n the network of resources which surrounded mental h e a l t h s e r v i c e s and that came with the c o n s t r u c t i o n of the 'welfare state'. The f o r e g o i n g p r o v i d e s a glimpse of a complex i n t e r a c t i o n between a v a r i e t y of f a c t o r s which converged at p a r t i c u l a r times to produce the major periods of reform to mental h e a l t h laws. A r g u a b l y , the r e f o r m s a r o s e from more than a c o n s e n s u s among those p r o v i d i n g care and treatment and r e f l e c t e d the outcomes of c o n f l i c t s between human a c t o r s (and groups of a c t o r s ) , which were i n f l u e n c e d by d e v e l o p m e n t s i n the t e c h n o l o g i e s and i d e o l o g i e s a f f e c t i n g t r e a t m e n t and c o n f i n e m e n t , and t h a t o c c u r r e d w i t h i n a s p e c i f i c and broader p o l i t i c a l , i d e o l o g i c a l and economic context. The l a t t e r d i c t a t e d the extent to which the s t a t e (as the primary policy-making and l e g i s l a t i v e body) produced the new r u l e s f o r the management of the m e n t a l l y d i s o r d e r e d . I t a l s o s u g g e s t s two uses of law by the s t a t e which, at a general t h e o r e t i c a l l e v e l , has been recognised by s o c i o l o g i s t s of law as a c l a s s i c dualism of c e n t r a l importance to an u n d e r s t a n d i n g of the n a t u r e of law (see, e.g., Schur, 161 1968; Sugarman, 1981). W h i l e new s t a t u t e s may r e f l e c t new p o l i c i e s and s t r a t e g i e s d e v i s e d as a consequence of a w i d e l y supported quest f o r change, they may a l s o c o n s t i t u t e an attempt by the s t a t e i t s e l f to impose changes i n l i n e with i m p e r a t i v e s a r i s i n g from the broader s t r u c t u r a l context, and r e g a r d l e s s of any s p e c i f i c request f o r reform a r t i c u l a t e d by i n d i v i d u a l s or groups s i t u a t e d o u t s i d e the s t a t e apparatus. This complex f o r m u l a t i o n can be b e t t e r e x p l i c a t e d through a more d e t a i l e d r e v i e w of the work of those who have both analysed the t r a n s f o r m a t i o n s i n mental h e a l t h law i n c o u n t r i e s other than Canada and developed e x p l a n a t i o n s which purport to account f o r the d i f f e r e n t p e r i o d s of change. In so doing, and where s p e c i f i c c o n n e c t i o n s are made to the main body of knowledge i n the s o c i o l o g y of law, the b r o a d e r t h e o r e t i c a l t r a j e c t o r i e s which underpin t h e i r work w i l l be both set out and c r i t i c i s e d . This process w i l l generate t e n t a t i v e e x p l a n a t i o n s which could account f o r the t r a n s f o r m a t i o n s which have occurred i n Canada. G e n e r a l l y , e x i s t i n g e x p l a n a t i o n s f a l l i n t o t h r e e main groups. The f i r s t to be addressed i s comprised of those that f o c u s upon the impact of d e v e l o p m e n t s w i t h i n m e n t a l h e a l t h systems which, i t i s contended, subsequently l e d to changes i n mental h e a l t h law. In t h i s f o r m u l a t i o n , l e g a l change i s seen as a r e f l e x of pre-determined p o l i c i e s and s t r a t e g i e s , while the law i s m e r e l y a mechanism which p r o v i d e s both the r e s o u r c e s (e.g., budgetary a l l o c a t i o n s ) and the framework of r u l e s w i t h i n which the p o l i c i e s and s t r a t e g i e s are be be implemented. The 162 second category c o n s i s t s of those that focus upon the work of i n d i v i d u a l s o c i a l r e f o r m e r s and i n t e r e s t groups. Changes i n p o l i c y and l e g i s l a t i o n are seen as a product of the e f f o r t s of reformers, and analyses c o n s i s t of a c a r e f u l e x p l i c a t i o n of both t h e i r i d e o l o g i c a l commitments and the c o n f l i c t s between the r e f o r m e r s and i n t e r e s t g r o u p s r e p r e s e n t i n g t h e m e d i c a l es t a b l i s h m e n t . The t h i r d category i s comprised of e x p l a n a t i o n s p r o v i d e d by a n a l y s t s who c o n c e n t r a t e on t h e i m p a c t o f developments i n the s o c i a l and economic s t r u c t u r e s w i t h i n which the p r o c e s s of r e f o r m i s embedded. T h i s has i n v o l v e d an examination of the r o l e of the s t a t e i n the c a p i t a l i s t economic and s o c i a l o r d e r . Two a d d i t i o n a l e x p l a n a t i o n s , which f a l l o u t s i d e the f o r e g o i n g c a t e g o r i e s ( i . e . , the im p a c t of p u b l i c scandals and the impact of changes to the l e g a l form) w i l l a l s o be d i s c u s s e d . I I : EXPLANATIONS FOCUSSING UPON DEVELOPMENTS WITHIN MENTAL HEALTH SYSTEMS F o r some a n a l y s t s of mental h e a l t h law, the s o u r c e of change i s to be found with reformers w i t h i n the s t a t e apparatus (Armour, 1981). I t i s contended t h a t i n d i v i d u a l s or groups w i t h i n e i t h e r a mental h e a l t h bureaucracy or a l e g i s l a t u r e (or both) c o n s c i o u s l y s u p p o r t and a c t i v e l y promote new i d e a s r e g a r d i n g the t r e a t m e n t and c a r e of the m e n t a l l y d i s o r d e r e d . I n s o f a r as these p a r t i e s hold i n f l u e n t i a l p o s i t i o n s w i t h i n the s t a t e a p p a r a t u s , they are a b l e to a r t i c u l a t e t h e i r c o n c e r n s e f f e c t i v e l y and t h e r e b y persuade o t h e r p o l i c y - m a k e r s and l e g i s l a t o r s t o a l t e r p o l i c i e s and p r a c t i c e s , and b r i n g 163 l e g i s l a t i o n i n l i n e w i t h these reforms. Since these i n d i v i d u a l s and groups are p a r t i c u l a r l y w e l l - p l a c e d , they are a b l e to achieve t h e i r goals. Armour (1981) argues that, i n the United S t a t e s , reformers of t h i s kind were p a r t i c u l a r l y i n f l u e n t i a l i n the development of Community Mental Health Centres i n the 1960's (see, a l s o , Foley, 1975) and that they were motivated by an humanitarian commitment to the ' m o d e r n i z a t i o n ' of mental h e a l t h c a r e . The i d e a s r e g a r d i n g new and b e t t e r forms of c a r e and t r e a t m e n t were b r o u g h t t o t h e a t t e n t i o n o f t h e f e d e r a l g o v e r n m e n t by i n f l u e n t i a l i n d i v i d u a l s such as medical p r a c t i t i o n e r s working w i t h i n the upper echelons of the nation's mental h e a l t h system and members of a key, government-sponsored agency - the N a t i o n a l I n s t i t u t e of Mental Health. T h i s r e s u l t e d i n the i n t r o d u c t i o n of new p o l i c i e s , new, s u p p o r t i v e l e g i s l a t i o n , and new care and treatment p r a c t i c e s (Bloom, 1984). In t h i s view, those seeking reform are p a r t of the s t a t e a p p a r a t u s and, w h i l e they may be s u p p o r t e d by i n d i v i d u a l s or i n t e r e s t groups l o c a t e d i n both the mental h e a l t h system and the community, they are i d e n t i f i e d as the p r i m a r y a r c h i t e c t s of change. They are seen as a c t i n g i n an autonomous f a s h i o n guided s o l e l y by a c o m b i n a t i o n o f h u m a n i t a r i a n c o n c e r n and a p r o f e s s i o n a l commitment to the employment of the most e f f e c t i v e and e n l i g h t e n e d care and treatment techniques. Consequently, the focus i s e n t i r e l y upon the impact of these i n d i v i d u a l s and groups r a t h e r than both the work of reformers outside the s t a t e apparatus and the economic and p o l i t i c a l c o n d i t i o n s under which 164 the reform a c t i v i t y occurs. T h i s has p r o v e d to be a p o p u l a r e x p l a n a t i o n f o r mental h e a l t h p o l i c y r e f o r m and hence changes to mental h e a l t h law (B u t l e r , 1985). In the Canadian context, f o r example, Foulkes (1961) and Gee (1953) have provided accounts of the h i s t o r y of the m e n tal h e a l t h s e r v i c e i n B r i t i s h C o l u mbia i n which the p e r i o d s of p o l i c y and l e g i s l a t i v e r e f o r m are t r e a t e d as the outcomes of changes i n t r e a t m e n t s t r a t e g i e s i n t r o d u c e d by s p e c i f i c p h y s i c i a n s or a d m i n i s t r a t o r s who acted i n an ap p a r e n t l y autonomous manner. The a n a l y s i s p rovided by Foulkes (1961) i s p a r t i c u l a r l y i l l u s t r a t i v e of the tendency to n e g l e c t both the impact of i n t e r e s t groups o u t s i d e the s t a t e apparatus, and the i n f l u e n c e of s t r u c t u r a l c o n d i t i o n s . In Foulkes' view, changes i n both p r o v i n c i a l m e n t a l h e a l t h c a r e s t r a t e g i e s and mental h e a l t h law were due p r i m a r i l y to the e f f o r t s of a succession of m e d i c a l p r a c t i t i o n e r s who were p l a c e d i n c h a r g e o f t h e p r o v i n c i a l mental h e a l t h s e r v i c e , and who advocated p a r t i c u l a r t r e a t m e n t s t r a t e g i e s . The h i s t o r y of mental h e a l t h c a r e i s d i v i d e d i n t o a set of 'periods', each c h a r a c t e r i z e d by the new s t r a t e g y and i t s p r o m o t o r / s ; f o r example, the e r a of 'Moral Treatment' which emerged i n the f i r s t two decades of the century was f a c i l i t a t e d p r i m a r i l y by the work of Dr. C.E. Doherty, the Superintendent of the P r o v i n c i a l H o s p i t a l s f o r the Insane at New W e s t m i n s t e r and E s s o n d a l e , and Dr. Henry Esson Young, the P r o v i n c i a l S e c r e t a r y . Foulkes argues that the death of Doherty i n 1920 marked the end of an era of optimism and the dawn of the e r a of ' C u s t o d i a l Care'. T h i s was to p r e v a i l , p r i m a r i l y under 165 the d i r e c t i o n of Dr. A.L. C r e a s e , u n t i l 1950 when, on the r e t i r e m e n t of C r e a s e , a ' r e n a i s s a n c e ' o c c u r r e d w i t h the a scendancy of Dr. A.M. Gee as D i r e c t o r of M e n t a l H e a l t h S e r v i c e s . This was marked by, among other events, the emergence of community care and treatment a l t e r n a t i v e s . Foulkes does r e f e r , i n passing, to l a r g e r economic events (e.g., the depression of the 1930's); p r o f e s s i o n a l developments o c c u r r i n g o u t s i d e the p r o v i n c e (e.g., the emergence of the c o n c e p t of the p s y c h o p a t h i c h o s p i t a l ) ; and, the impact of commissions of i n q u i r y which occurred from time to time w i t h i n the p r o v i n c e . However, the p r i m a r y s o u r c e and a r c h i t e c t s of change are i d e n t i f i e d as the i n f l u e n t i a l i n d i v i d u a l s w i t h i n the s t a t e a p p a r a t u s who s t r o v e to i n t r o d u c e what they f e l t were e n l i g h t e n e d p o l i c i e s and p r a c t i c e s . Indeed, reforms occurred as a consequence of the comings and goings of s e n i o r p h y s i c i a n s and b u r e a u c r a t s . C e r t a i n l y , he makes i t c l e a r t h a t t h e s e i n d i v i d u a l s were i n many ways c o n s t r a i n e d by the m a t e r i a l r e s o u r c e s made a v a i l a b l e to them and, i n t h i s s e n s e , the a n a l y s i s p r o v i d e s a g l i m p s e of the p r o b l e m s f a c e d by the reformers. However, these are t r e a t e d as a n c i l l i a r y matters and the image i s one of d e d i c a t e d , s t a t e f u n c t i o n a r i e s s t r i v i n g ( u s u a l l y s u c c e s s f u l l y ) to improve the p r o v i s i o n of c a r e and treatment f o r the m e n t a l l y d i s o r d e r e d . While the e x p l a n a t i o n has many weaknesses, i t cannot be discounted e n t i r e l y . C l e a r l y , i n d i v i d u a l s h o l d i n g key p o s i t i o n s w i t h i n the s t a t e a p p a r a t u s have had an i m p a c t on b o t h l e g i s l a t i v e and p o l i c y r e f o r m . However, i t i s e q u a l l y e v i d e n t that other f a c t o r s were at work. 166 I t i s w i t h i n t h i s general t r a j e c t o r y that some a n a l y s t s have adopted a p e r s p e c t i v e embodying some elements of c o n f l i c t . I t i s argued t h a t r e f o r m s to mental h e a l t h p o l i c y o c c u r as a c o n s e q u e n c e o f l o b b y i n g w i t h i n a m e n t a l h e a l t h s y s t e m . P a r t i c u l a r g roups of p s y c h i a t r i s t s and o t h e r m e n t a l h e a l t h p r o f e s s i o n a l s who a r e c o m m i t t e d t o t h e i n t r o d u c t i o n o f p r o g r e s s i v e and e n l i g h t e n e d care and treatment s t r a t e g i e s b r i n g pressure to bear on policy-makers and l e g i s l a t o r s i n an e f f o r t to expand and improve p s y c h i a t r i c s e r v i c e s . I n s o f a r as they are s u c c e s s f u l i n c o n v i n c i n g r e l e v a n t p a r t i e s w i t h i n the s t a t e that they can cure 'mental i l l n e s s ' they overcome the o p p o s i t i o n of other mental h e a l t h p r o f e s s i o n a l s who then come to see the new s t r a t e g y as l e g i t i m a t e . T h i s t r a n s f e r of a l l e g i a n c e o c c u r s p r i m a r i l y because p r o f e s s i o n a l s r e c o g n i z e t h a t the s h i f t i n p o l i c y w i l l be accompanied by a s h i f t i n f i n a n c i a l r e s o u r c e s f o r the implementation of the new s t r a t e g y (Ralph, 1983). A n o t h e r e x p l a n a t i o n f o r r e f o r m p o i n t s to the im p a c t of both new t h e r a p e u t i c s t r a t e g i e s and t e c h n o l o g i c a l ' d i s c o v e r i e s ' i n the t r e a t m e n t of mental d i s o r d e r s . Indeed, one of the s t r o n g e s t a r g u m e n t s o f f e r e d a s an e x p l a n a t i o n f o r t h e i n t e r n a t i o n a l r e f o r m s a f f e c t i n g m e n t a l h e a l t h c a r e and ( i n d i r e c t l y ) mental h e a l t h law, s i n c e the 1950's, i s advanced by t h o s e who p o i n t t o d e v e l o p m e n t s i n b o t h t r e a t m e n t p h i l o s o p h i e s and p s y c h o - p h a r m a c o l o g y . I t i s argued t h a t the emergence of the philosophy of the 'therapeutic community' - the no t i o n that a constant and p o s i t i v e i n t e r a c t i o n between mental h e a l t h p r o f e s s i o n a l s and p a t i e n t s w o u l d i n c r e a s e t h e 167 e f f e c t i v e n e s s o f p s y c h o l o g i c a l t r e a t m e n t - p r o v i d e d a s i g n i f i c a n t impetus f o r the development of community care and treatment (Bloom, 1984). T h i s c o i n c i d e d w i t h new d i s c o v e r i e s i n psycho-pharmacology that c r e a t e d an environment i n which new t r e a t m e n t s t r a t e g i e s and new mental h e a l t h p o l i c i e s and programmes could be implemented (Mechanic, 1969; Swazey, 1974; Bloom, 1984). The a v a i l a b i l i t y of new drugs c a p a b l e of r e l i e v i n g the symptoms of mental d i s o r d e r r e s u l t e d i n e i t h e r the development of new, or the awakening of dormant, ideas r e g a r d i n g care and treatment p r a c t i c e s , which were held by i n d i v i d u a l s i n the upper e c h e l o n s of mental h e a l t h s e r v i c e b u r e a u c r a c i e s . These people then designed and implemented care and treatment s t r a t e g i e s which r e p r e s e n t e d the b e s t p o s s i b l e method of t r e a t i n g and c a r i n g f o r those c a t e g o r i z e d as ' m e n t a l l y i l l ' . Reforms to mental h e a l t h law occurred as an i n e v i t a b l e outcome of these developments s i n c e the new s t r a t e g y r e q u i r e d a new set of r u l e s f o r the a d m i n i s t r a t i o n and r e g u l a t i o n of the mental h e a l t h system. In t h i s view, s t a t e policy-makers and l e g i s l a t o r s are seen as benign and r e s p o n s i b l e i n d i v i d u a l s responding to the advice of key p r o f e s s i o n a l s who were both i n v o l v e d i n the d e l i v e r y of mental h e a l t h s e r v i c e s and f a m i l i a r with the improved treatment techniques which had developed as a consequence of advances i n m e d i c i n e . T h i s i s a c o m p e l l i n g argument and the s u c c e s s f u l 'treatment' of d i s o r d e r s has been seen as a f a c t o r i n f l u e n c i n g change at other times. For example, Foulkes (1961) notes t h a t , during the f i r s t two decades of the century, s y p h i l i s was the 168 cause of 12% of admissions to the H o s p i t a l s f o r the Insane i n B r i t i s h Columbia. The s u c c e s s f u l treatment of venereal disease i n s ubsequent y e a r s had an impact on the numbers of p e r s o n s b e i n g a d m i t t e d w i t h mental d i s o r d e r s c a used by t h i s o r g a n i c c o n d i t i o n . - S i n c e t h e s e p a t i e n t s c o n s t i t u t e d a s i g n i f i c a n t p r o p o r t i o n of h o s p i t a l inmates, the appearance of a 'cure' had an impact on g e n e r a l c a r e and t r e a t m e n t s t r a t e g i e s . Sedgwick (1982) has set out the way i n which the treatment of venereal d i s e a s e had a s i m i l a r impact i n B r i t a i n . However, as Bean (1980), S c u l l (1984), Sedgwick (1982), Armour (1981), and Ralph (1983) p o i n t out, the s i g n i f i c a n c e of the t e c h n o l o g i c a l ' r e v o l u t i o n ' i n p s y c h i a t r y b r o u g h t about by the d i s c o v e r y of ps y c h o a c t i v e drugs i s probably over-emphasized. There can be no doubt that i t a f f e c t e d mental h e a l t h care s t r a t e g i e s i n s o f a r as i t b u t t r e s s e d the development of community care and treatment programmes. However, s i n c e t h i s s t r a t e g y had been developed and w i d e l y e n d o r s e d b e f o r e the i n t r o d u c t i o n of new d r u g s , the e x p l a n a t i o n f o r change must l i e elsewhere. As Armour (1981) p o i n t s out, a n o t h e r i m p o r t a n t a c c o u n t focuses upon the impact of changes i n the o r g a n i z a t i o n of h e a l t h care s e r v i c e s . I t i s contended t h a t , where these s e r v i c e s are r e - o r g a n i z e d and expanded, they w i l l n e c e s s a r i l y shape the c o n s t r u c t i o n and implementation of reform p r o p o s a l s by c r e a t i n g both b a r r i e r s to and o p p o r t u n i t i e s f o r , change (Krause, 1977; A l f o r d , 1975). Bloom (1984) a r g u e s t h a t the development of Community Mental Health Centres i n the United S t a t e s was due, i n p a r t , t o an a d m i n i s t r a t i v e r e - o r g a n i z a t i o n of l a r g e , s t a t e 169 mental h o s p i t a l s : a s t r a t e g y v a r i o u s l y known as 'geographical d e c e n t r a l i z a t i o n ' and ' r e g i o n a l i z a t i o n ' . The goal was to a l l o w s t a t e h o s p i t a l p a t i e n t s to r e c e i v e c a r e and t r e a t m e n t i n h o s p i t a l wards c l o s e to t h e i r p l a c e s of r e s i d e n c e , and the s t r a t e g y i n v o l v e d an a t t e m p t to f o r g e s t r o n g e r l i n k s between h o s p i t a l and community which had not e x i s t e d where p a t i e n t s were h o u s e d i n i n s t i t u t i o n s w h i c h were f u n c t i o n a l l y and g e o g r a p h i c a l l y i s o l a t e d . A c c o r d i n g to Bloom (1984), t h i s p r o c e s s of r e - o r g a n i z a t i o n had the u n e x p e c t e d consequence of c r e a t i n g an e n v i r o n m e n t c o n d u c i v e to the d e velopment of community-based mental h e a l t h resources. However, the extent to which t h e s e r e s o u r c e s were used by d e - i n s t i t u t i o n a l i z e d and c h r o n i c p a t i e n t s has been d i s p u t e d ( S c u l l , 1984). In s o f a r as t h i s l i n e of e x p l a n a t i o n addresses the impact of changes i n the s t r u c t u r e s which a f f e c t reformers w i t h i n the s t a t e apparatus, i t p r o v i d e s a more comprehensive understanding of the c i r c u m s t a n c e s s u r r o u n d i n g the p e r i o d s of change. However, the focus i s upon the inner dynamics of o r g a n i z a t i o n s ( i . e . , h e a l t h and m e n t a l h e a l t h b u r e a u c r a c i e s ) and a n a l y s t s u s u a l l y f a i l to p l a c e these occurrences i n t h e i r broader context (Armour, 1981). While the post-1945 p e r i o d s of mental h e a l t h p o l i c y and l e g i s l a t i v e reform have r e f l e c t e d the r e - o r g a n i z a t i o n of h e a l t h care s e r v i c e s brought about by the development of a new system of p u b l i c s o c i a l w e l f a r e (i.e., the modern, 'welfare s t a t e * ) , the impact of both the emergence and (more r e c e n t l y ) the r e - c o n s t r u c t i o n of t h i s system are u s u a l l y not emphasized. Indeed, a n a l y s t s tend to p a i n t a p i c t u r e i n which s t a t e mental 170 h e a l t h p olicy-making appears as an autonomous a c t i v i t y that can be e x p l a i n e d by recourse to the general t e n e t s of ' o r g a n i z a t i o n s theory'. F o r example, W i l e n s k y (1975) has argued t h a t major p o l i c y (and t h e r e f o r e l e g i s l a t i v e ) reforms, such as the p o s t -1945 d e v e l o p m e n t s i n m e n t al h e a l t h c a r e , are the p r o d u c t s of i n c r e m e n t a l g r o w t h b a s e d upon i n i t i a l , l i m i t e d p o l i c y a c h i e v e m e n t s . Where p o l i c y - m a k e r s ' f e e l good' about t h e i r s t r a t e g y , i t w i l l be perpetuated. One a d d i t i o n a l e x p l a n a t i o n , which i s c o n n e c t e d to the i s s u e of o r g a n i z a t i o n a l d e v e l o p m e n t s , has been o f f e r e d . As Armour (1981) notes, some a n a l y s t s of reforms i n the post-1945 p e r i o d have p o i n t e d to the i m p o r t a n c e of World War II (and modern warfare g e n e r a l l y ) as a f a c t o r t h a t r e v i v e d and continues to s t i m u l a t e an i n t e r e s t i n community c a r e a l t e r n a t i v e s to h o s p i t a l i z a t i o n (see, e.g., A b e l - S m i t h , 1964; B u t l e r , 1985). Warfare i n c r e a s e s the numbers of i n d i v i d u a l s r e q u i r i n g mental h e a l t h s e r v i c e s (i.e., p s y c h o l o g i c a l c a s u a l t i e s ) which p l a c e s extreme p r e s s u r e on l i m i t e d h e a l t h c a r e r e s o u r c e s . T h i s , i n turn, c r e a t e s an environment where a l t e r n a t i v e s are f e v e r i s h l y explored and new s t r a t e g i e s developed. In a d d i t i o n , as a r e s u l t of the mass m e d i c a l e x a m i n a t i o n s of p r o s p e c t i v e m i l i t a r y p e r s o n n e l f o r the two g l o b a l c o n f l i c t s of t h i s c e n t u r y , the extent to which mental i l l - h e a l t h e x i s t e d i n the community at those t i m e s was r e a l i z e d and g e n e r a t e d a demand f o r b e t t e r h e a l t h c a r e r e s o u r c e s f o c u s s e d upon 'mental hygiene'. I t i s contended that these twin pressures c o n t r i b u t e d s i g n i f i c a n t l y to the o r g a n i z a t i o n a l changes, and hence l e g i s l a t i v e reforms, which 171 o c c u r r e d i n the wake of both World Wars. However, w r i t e r s have recognized that, while warfare may have s t i m u l a t e d changes, i t was not s o l e l y r e s p o n s i b l e f o r mental h e a l t h reforms. Instead, i t generated changes i n the p r o v i s i o n of g e n e r a l , p u b l i c s o c i a l w e l f a r e s e r v i c e s and t h i s p r o v i d e d a framework w i t h i n which changes a f f e c t i n g the p r o v i s i o n of mental h e a l t h c a r e and treatment, c o u l d occur (see, e.g., B u t l e r , 1985). These v a r y i n g e x p l a n a t i o n s may each c o n t a i n some v a l u a b l e elements and a u s e f u l p i c t u r e can be developed where an e f f o r t i s made to examine and a n a l y s e the i n t e r a c t i o n s between, f o r example, the e f f o r t s of p s y c h i a t r i s t s , o r g a n i z a t i o n a l changes, and t r a n s f o r m a t i o n s i n treatment techniques. In the Canadian c o n t e x t , f o r example, C r i c h t o n (1975) has p r o v i d e d a u s e f u l r e v i e w of d e v e l o p m e n t s i n m e n t a l h e a l t h s e r v i c e s and law between 1955 and 1975. Changes have occurred as a r e s u l t of the i n i t i a t i v e s of p s y c h i a t r i s t s , d e v e l o p m e n t s i n the f u n d i n g of mental h e a l t h s e r v i c e s , and the work of p r o f e s s i o n a l i n t e r e s t groups w i t h i n mental h e a l t h systems. Even more pe r s u a s i v e i s an a n a l y s i s by W i l l i a m s and L u t e r b a c k (1976). In t h e i r view, p s y c h i a t r i s t s dominated policy-making u n t i l the 1960's at which p o i n t a combination of f a c t o r s became the d r i v i n g f o r c e ; namely, c h a n g i n g h e a l t h needs; p u b l i c demands; the p e r s p e c t i v e s of v a r i o u s p r o f e s s i o n a l groups w i t h i n mental h e a l t h s e r v i c e s ; and, the need to keep h e a l t h care c o s t s w i t h i n acceptable l i m i t s . Regardless, as the f o r e g o i n g i n d i c a t e s , numerous problems can be found with the work of those who attempt to account f o r 172 mental h e a l t h p o l i c y and l e g i s l a t i v e r e f o r m by f o c u s s i n g p r i m a r i l y upon the impact of developments w i t h i n mental h e a l t h systems. These e x p l a n a t i o n s do not account adequately f o r the simultaneous emergence of mental h e a l t h p o l i c y and l e g i s l a t i v e reform i n s e v e r a l c o u n t r i e s (Ralph, 1983). There i s a f a i l u r e to explore the nature and impact of i n t e r e s t s which have a stake i n the r e f o r m s but which l i e on the p e r i p h e r y of mental h e a l t h s y stems (e.g., the p h a r m a c e u t i c a l companies) ( R a l p h , 1983; Sedgwick, 1982). I n s o f a r as the f o c u s i s upon the p o l i t i c a l machinations of p s y c h i a t r i c i n t e r e s t groups and t h e i r l e a d e r s , a mental h e a l t h system i s t r e a t e d as an autonomous e n t i t y which i s a f f e c t e d only by developments w i t h i n t h i s p a r t i c u l a r branch of m e d i c i n e . I t i s seen as b e i n g i n s u l a t e d from b o t h the w i d e r s t r u c t u r a l f a c t o r s a f f e c t i n g s t a t e p o l i c y - m a k i n g and the a c t i v i t i e s of i n d i v i d u a l s and i n t e r e s t groups o p e r a t i n g o u t s i d e the s t a t e apparatus. The l a s t f a c t o r i s the concern of those who c o n s t i t u t e the second major category of a n a l y s t s of mental h e a l t h law reform. I l l ; EXPLANATIONS FOCUSSING UPON THE IMPACT OF INDIVIDUAL REFORMERS AND INTEREST GROUPS S e v e r a l w r i t e r s have argued t h a t the p e r i o d s of change a f f e c t i n g mental h e a l t h p o l i c y and law i n B r i t a i n and the United S t a t e s have a r i s e n as a consequence of the a c t i v i t i e s of h u m a n i t a r i a n r e f o r m e r s (see, Armour, 1981). I t i s co n t e n d e d t h a t t h e s e i n d i v i d u a l s and groups s u c c e s s f u l l y c h a l l e n g e d e x i s t i n g and entrenched i n t e r e s t s and brought pressure to bear on governments which responded by c o n s t r u c t i n g and a p p l y i n g new l e g i s l a t i o n to e i t h e r complement or c r e a t e new p o l i c i e s and 173 p r a c t i c e s i n the m e n t a l h e a l t h c o n t e x t . In the main, t h e s e a n a l y s t s have f o l l o w e d a s p e c i f i c t h e o r e t i c a l t r a j e c t o r y w i t h i n the s o c i o l o g y of law - ' i n t e r e s t group theory' ( a l s o known as ' p r e s s u r e group' or ' p l u r a l i s t c o n f l i c t ' t h e o r y ) - and f o c u s t h e i r a t t e n t i o n upon the human agency embodied i n the law reform process. As Armour (1981) p o i n t s out, t h e r e i s c o n s i d e r a b l e evidence that d e d i c a t e d s o c i a l r eformers - at f i r s t i n d i v i d u a l s and l a t e r i n t e r e s t groups - were i n s t r u m e n t a l i n e n g i n e e r i n g the changes which have a f f e c t e d mental h e a l t h p o l i c y and law over the p a s t 150 y e a r s . These r e f o r m e r s , who were o s t e n s i b l y s i t u a t e d outside the s t a t e apparatus, recognized the p l i g h t of the m e n t a l l y d i s o r d e r e d and demanded the i n t r o d u c t i o n of humane c a r e and t r e a t m e n t p r a c t i c e s . D u r i n g the 19th c e n t u r y , r e f o r m e r s who were a p p a l l e d by the c o n d i t i o n s i n p r i v a t e and p u b l i c asylums sought to separate ' l u n a t i c s ' and ' i d i o t s ' from those who were p h y s i c a l l y i l l , c o n v i c t s or unemployed. Since, i n t h e i r view, l u n a c y was amenable to a p a r t i c u l a r form o f treatment (i.e., moral treatment) no e f f o r t was to be spared i n ensuring that t h i s technique was introduced (Grob, 1973? 1983? Armour, 1981? Rothman, 1971). I n d i v i d u a l reformers sought to convince p o l i t i c a l e l i t e s of the need to adopt new modes of care f o r the mentally d i s o r d e r e d and the p e r i o d between the l a t e 18th and the l a t e 19th c e n t u r i e s has been r e f e r r e d to as the era of the 'charismatic reformer' - the Tukes i n B r i t a i n , Packard, Rush and Dix i n the U n i t e d S t a t e s , and P i n e l i n France (Armour, 1981). 174 The s i t u a t i o n i n B r i t a i n d u r i n g t h i s p e r i o d has been analysed e x t e n s i v e l y by Jones (1955, 1960). She has d e s c r i b e d the i n f l u e n c e w i e l d e d by the Tukes and P i n e l , as w e l l as the impact of the w r i t i n g s of V i c t o r i a n n o v e l i s t s such as Dickens and Bronte. More i m p o r t a n t l y , she has set out the work of the numerous P a r l i a m e n t a r y S e l e c t Committees which d e l i b e r a t e d on the lunacy question throughout the 19th century, and i d e n t i f i e d the key a d v o c a t e s f o r r e f o r m who were i n v o l v e d i n t h e s e Committees. In her view, t h e s e i n d i v i d u a l s , who were o f t e n placed s t r a t e g i c a l l y on the p e r i p h e r y of (or w i t h i n ) the s t a t e a p p a r a t u s , were ( i n p a r t ) r e s p o n s i b l e f o r the l o n g c h a i n of reforms which culminated i n the Lunacy Act, 1890. For example, she p o i n t s to the e a r l y achievements of one Robert Gordon, the Dorset M a g i s t r a t e and Member of Parliament who i n t r o d u c e d asylum i n s p e c t i o n s y s t e m s . She a l s o examines the work of o t h e r champions of lunacy reform, such as the e v a n g e l i s t , Ashley, E a r l of Shaftesbury, who wanted change but who were opposed to the i n t r o d u c t i o n of s t r i c t l e g a l c o n t r o l s over the commitment and treatment of l u n a t i c s . Jones has a l s o i d e n t i f i e d and d e s c r i b e d both the p u b l i c and the i n d i v i d u a l concerns which were paramount i n shaping new l e g i s l a t i o n (e.g., the f e a r of u n j u s t i f i e d confinement and the prospect of being subjected to b r u t a l treatment), as w e l l as the c o n f l i c t s w h i c h o c c u r r e d between those d e d i c a t e d to the p r o t e c t i o n of the l i b e r t y of the i n d i v i d u a l , and the m e d i c a l p r o f e s s i o n . Indeed, i n her view, the Lunacy A c t , 189 0 - the e pitome of ' l e g a l i s m ' - was the p r o d u c t of a l o n g and 175 c o n s i s t e n t campaign on the p a r t of one powerful pressure group, c o m p r i s e d of the l e g a l p r o f e s s i o n and the j u d i c i a r y , w h ich s u c c e s s f u l l y overwhelmed a weaker pressure group; namely, the nascent p s y c h i a t r i c e s t a b l i s h m e n t (Jones, 1960; 1972). In t h i s regard, a t t e n t i o n has a l s o been focussed on the impact of the work of s p e c i f i c groups a s s o c i a t e d with the r e f o r m e r s ; notably, the A l l e g e d L u n a t i c s ' F r i e n d S o c i e t y (Jones, 1960), the Mental A f t e r - C a r e A s s o c i a t i o n ( A r m o u r , 1981), and t h e C h a r i t y O r g a n i z a t i o n S o c i e t y ( B u t l e r , 1985). I t has been c o n t e n d e d t h a t the e a r l y 20th c e n t u r y was marked by the d e c l i n e of the i n d i v i d u a l r e f o r m e r and the e m e r g e n c e o f t h e o r g a n i z e d r e f o r m g r o u p , a l b e i t u n d e r c h a r i s m a t i c l e a d e r s h i p (Armour, 1981). In the United S t a t e s , f o r example, the foremost champion of reform i n the e a r l y 1900's was the N a t i o n a l Committee f o r M e n t a l Hygiene; a l a y and p r o f e s s i o n a l o r g a n i z a t i o n founded i n 1909, by (among o t h e r s ) C l i f f o r d Beers. T h i s o r g a n i z a t i o n c o n s i s t e d of an amalgamation of reform groups and was e n e r g e t i c i n i t s attempts to engineer the i n t r o d u c t i o n of both new care and treatment res o u r c e s and s t r a t e g i e s (e.g., treatment i n psychopathic h o s p i t a l s and out-p a t i e n t c l i n i c s ) and l e g i s l a t i o n which eased j u d i c i a l c o n t r o l over the management of the 'mentally diseased' (Armour, 1981; Rothman, 1980; Grob, 1983). In B r i t a i n , the N a t i o n a l C o u n c i l f o r M e n t a l Hygiene, which was m o d e l l e d on the A m e r i c a n Committee, was e s t a b l i s h e d i n 1919 and was i n s t r u m e n t a l i n the reforms to the lunacy laws which f o l l o w e d the d e l i b e r a t i o n s of the M a c M i l l a n Commission i n the 1920's ( i . e . , the M e n t a l 176 T r e a t m e n t A c t , 1930) (Armour, 1981; Bean, 1980; B u t l e r , 1985; Jones, 1960). I t i s argued t h a t the emergence of t h e s e o r g a n i z a t i o n s s t a b i l i z e d the reform process which, by the e a r l y 1930's, had undergone a f u r t h e r t r a n s f o r m a t i o n . The emergence of h e a l t h and welfare s e r v i c e s organized by the s t a t e provided an environment i n which governments assumed a g r e a t e r r e s p o n s i b i l i t y f o r e n g i n e e r i n g r e f o r m (Armour, 1981). T h i s i s not to s u g g e s t , however, that s t a b i l i z a t i o n and government involvement r e s u l t e d i n a r e d u c t i o n i n the c o n f l i c t s between those advocating change and those seeking to preserve the s t a t u s quo. As Rothman (1980) has shown, i n the U n i t e d S t a t e s , groups of p h i l a n t h r o p i c r e f o r m e r s such as the N a t i o n a l Committee f o r M e n t a l Hygiene faced entrenched i n t e r e s t s i n the shape of those who managed and s t a f f e d i n s t i t u t i o n s . These i n d i v i d u a l s wished to p r o t e c t t h e i r b a i l i w i c k s from the ' p r o g r e s s i v e s ' who p r e f e r r e d i n d i v i d u a l casework, the use of o u t - p a t i e n t f a c i l i t i e s , and the development o f a f t e r - c a r e s e r v i c e s , t o c u s t o d i a l c a r e . The s t a t e governments of the day were faced w i t h a c o n f l i c t between men and women of 'conscience' and the p r a c t i c a l demands m i r r o r e d i n the v i e w s of t h o s e who were a d m i n i s t e r i n g the system of i n s t i t u t i o n s (i.e., convenience). The compromise that r e s u l t e d i n v o l v e d t h e p r e s e r v a t i o n o f l a r g e m e n t a l h o s p i t a l s as d e p o s i t o r i e s f o r the c h r o n i c a l l y insane and these d e t e r i o r a t e d to such an extent that new pressures f o r reform emerged. In t h i s regard, Armour (1981) has t r a c e d the way i n which, 177, i n the U n i t e d S t a t e s , the c r e a t i o n and d e velopment of a f e d e r a l o r g a n i z a t i o n during the 1940's and 1950's - the N a t i o n a l I n s t i t u t e of M e n t a l H e a l t h - r e s u l t e d i n the c o n s t r u c t i o n of new, mental h e a l t h p o l i c i e s . A strong reform movement emerged w i t h i n t h i s w e l l - p l a c e d agency which became the seedbed f o r , i n p a r t i c u l a r , the community mental h e a l t h c e n t r e s movement of the 1950's and 1960's. In B r i t a i n , the c e n t r a l i z a t i o n of s e r v i c e s and the emergence of the N a t i o n a l Health S e r v i c e which accompanied the c r e a t i o n of the 'welfare s t a t e ' i n the 1940's, had an impact on the process of reform. I t i s contended that organized reform movements, both w i t h i n and o u t s i d e Parliament, sought to change mental h e a l t h l e g i s l a t i o n and consequently brought pressure to bear on the government. This r e s u l t e d i n the e s t a b l i s h m e n t of a Royal Commission, under the chairmanship of Lord Eustace Percy, which d e l i b e r a t e d on the q u e s t i o n of reform from 1954 to 1957. S i g n i f i c a n t l y , membership of t h i s body i n c l u d e d r e p r e s e n t a t i v e s from o r g a n i z e d i n t e r e s t groups as w e l l as i n d i v i d u a l s who a d v o c a t e d p o l i c y and l e g i s l a t i v e r e f o r m . L o r d P e r c y was i n favour of reform and h i s Commission i n c l u d e d Dr. T.P. Rees (an i n n o v a t i v e p s y c h i a t r i s t who advocated the use of 'open wards'), Bessy Braddock (a s o c i a l i s t Member of P a r l i a m e n t and champion of the urban p o o r ) , and Lady A d r i a n ( r e p r e s e n t i n g the N a t i o n a l A s s o c i a t i o n f o r M e n t a l H e a l t h a n d o t h e r v o l u n t a r y o r g a n i z a t i o n s ) . Thus, while the Commission i n v i t e d and r e c e i v e d s u b m i s s i o n s from a wide range of i n t e r e s t e d p a r t i e s and o r g a n i z a t i o n s , key r e f o r m e r s were i n v o l v e d d i r e c t l y i n the 178 d e v e l o p m e n t of the recommendations f o r change. These were s u b s e q u e n t l y a c c e p t e d ( v i r t u a l l y w i t h o u t a l t e r a t i o n ) by the c o n s e r v a t i v e government of the day, and appeared i n the England and Wales, Mental Health Act, 1959 (Jones, 1972; B u t l e r , 1985; Bean, 1980; Armour, 1981). 1 I t i s c l e a r , t h e r e f o r e , that while a n a l y s t s who adopt t h i s a p p r o a c h r e c o g n i z e the s i g n i f i c a n c e of b r o a d e r s o c i a l and p o l i t i c a l d e v e l o p m e n t s , t h e p r i m a r y f o c u s i s upon t h e i n d i v i d u a l s and groups who a r e i n v o l v e d i n the p r o c e s s o f reform. The work of Jones (1955, 1960, 1972) tends to e x e m p l i f y t h i s t h e o r e t i c a l p e r s p e c t i v e and she has been c r i t i c i z e d f o r her f a i l u r e to e x p l o r e the s t r u c t u r a l c o n d i t i o n s ( i d e o l o g i c a l , economic and p o l i t i c a l ) under which the reform process occurs (Bean, 1980; B u t l e r , 1985; Unsworth, 1979). However, t h i s a p p r o a c h has r e s u l t e d i n the development of a c o m p r e h e n s i v e image of the c o n f l i c t s which have surrounded the v a r i o u s p e r i o d s of reform, thereby e n r i c h i n g both a general understanding of the ways i n which laws emerge and change, and an a p p r e c i a t i o n of the f o r c e s a f f e c t i n g the s p e c i f i c f i e l d of mental h e a l t h law. In p a r t i c u l a r , i t focusses a t t e n t i o n upon the i d e o l o g i c a l dimension of the r e f o r m s which have o c c u r r e d a t p a r t i c u l a r t i m e s , e s p e c i a l l y where a broader a n a l y s i s i s attempted. For example, i n h i s e x p l o r a t i o n of the process of reform i n B r i t a i n during the 19th and e a r l y 20th century, B u t l e r (1985) has s u c c e s s f u l l y t r a c e d the a f f i l i a t i o n s between l u n a c y law r e f o r m e r s and p h i l a n t h r o p i c and e v a n g e l i c a l movements. T h i s i s not to say t h a t t h o se i n t e r e s t e d i n r e f o r m 179 movements al w a y s n e g l e c t to a d d r e s s s t r u c t u r a l q u e s t i o n s . Armour (1981), f o r example, t r i e s to p r o v i d e an image of the l a r g e r s o c i a l and economic f o r c e s a f f e c t i n g the c y c l e s of reform and he r a i s e s some p e r t i n e n t questions about the r e l a t i o n s h i p between o r g a n i z e d r e f o r m movements and the s t a t e . T h i s i s p a r t i c u l a r l y t r u e of h i s l i m i t e d t r e a t m e n t of the p r o c e s s of mental h e a l t h reform d u r i n g what he r e f e r s to as the c u r r e n t era of 'scarce resources'. I n s o f a r as he a n a l y s e s the t r a n s f o r m a t i o n s which have a f f e c t e d a key, B r i t i s h i n t e r e s t group s i n c e 1970 - the N a t i o n a l A s s o c i a t i o n f o r M e n t a l H e a l t h (MIND) - he t o u c h e s on a s i g n i f i c a n t i s s u e . Since i t s i n c e p t i o n (as the N a t i o n a l S o c i e t y f o r Lunacy Reform), t h i s o s t e n s i b l y independent o r g a n i z a t i o n has had strong t i e s to the s t a t e ; i t s sponsors and l e a d e r s have been (and continue to be) i n d i v i d u a l s drawn from both the p r o f e s s i o n s and the upper e c h e l o n s of B r i t i s h s o c i e t y . Yet, i n the mid-1970's, the agency became a r e l a t i v e l y r a d i c a l o r g a n i z a t i o n which was at the f o r e f r o n t of the movement to r e f o r m m e n t al h e a l t h l e g i s l a t i o n . Indeed, the o r g a n i z a t i o n i s seen as the p r i n c i p a l a r c h i t e c t of the Mental Health Act, 1983; a s t a t u t e t h a t e p i t o m i z e s the 'new l e g a l i s m ' (Jones, 1980; Shapland & W i l l i a m s , 1983; Carson, 1983; G o s t i n , 1983c, 1983d; Gunn, 1983). T h i s r a i s e s some i m p o r t a n t q u e s t i o n s about the r e l a t i o n s h i p between a government f a c i n g not only a f i s c a l c r i s i s , but a l s o a c r i s i s of o r d e r (see, e.g., Gough, 1979), and a r e f o r m group pre-occupied with e n g i n e e r i n g change in an expensive system that i s concerned w i t h the management of those deemed to be i n need 180 of c o n t r o l through treatment and confinement. S i n c e the r i s e o f the 'new l e g a l i s m ' i n B r i t a i n s t i l l awaits a comprehensive a n a l y s i s , t h i s i s s u e (indeed, the e n t i r e q u e s t i o n of the r o l e of r e f o r m groups d u r i n g t h i s p e r i o d ) remains unexplored. However, some u s e f u l i n s i g h t s are provided by Sedgwick (T982). While, i n h i s view, a concern f o r abuses w i t h i n the B r i t i s h mental h e a l t h system can be t r a c e d back to the complaints of the N a t i o n a l C o u n c i l f o r C i v i l L i b e r t i e s i n 1951, t h e c i v i l l i b e r t a r i a n p e r s p e c t i v e d i d n o t become i n f l u e n t i a l u n t i l the 1970's. In 1971, MIND began to launch a campaign f o r both improved mental h e a l t h c a r e and improved r i g h t s f o r mental h e a l t h p a t i e n t s . S i g n i f i c a n t l y , t h i s s t r a t e g y r e c e i v e d s t r o n g s u p p o r t from the p s y c h i a t r i s t s and o t h e r p r o f e s s i o n a l s a s s o c i a t e d w i t h MIND, and i t was o r g a n i z e d by David Ennals; an i n d i v i d u a l who became M i n i s t e r of Health i n the Labour government of 1974-79. In the mid-1970's, MIND appointed two key i n d i v i d u a l s to take charge of the campaign; namely, the c i v i l l i b e r t a r i a n , Tony Smythe, and an American lawyer, L a r r y G o s t i n . From t h i s p o i n t onwards, the o r g a n i z a t i o n became p r o g r e s s i v e l y more v o c a l and i n f l u e n t i a l as i t l o b b i e d f o r l e g i s l a t i v e reform that would improve the fundamental human and c i v i l r i g h t s of mental h e a l t h p a t i e n t s (see, e.g., G o s t i n , 1977). In Sedgwick's (1982) view there are strong l i n k s between the e v o l u t i o n of the work of MIND and the state's development of an a c c e l e r a t e d s t r a t e g y of d e c a r c e r a t i o n i n response to growing economic d i f f i c u l t i e s . 181 W r i t e r s have y e t to i d e n t i f y a l l the p r i n c i p a l s o c i a l r eformers who were i n v o l v e d i n the periods of mental h e a l t h law reform i n Canada; however, there i s l i t t l e doubt t h a t , d u r i n g the 19th c e n t u r y , such i n d i v i d u a l s and groups e x i s t e d (see, e.g., Smandych, 1982). As Leighton (1982) has demonstrated, the American r e f o r m e r , D o r o t h e a Dix, had a p r o f o u n d impact upon l e g i s l a t i v e r e f o r m i n t h e e a s t e r n p r o v i n c e s o f C a n a d a ; p a r t i c u l a r l y , Nova S c o t i a . Guest (1985) has shown that reform movements spearheaded by r e l i g i o u s and other i n t e r e s t groups emerged in the l a t e 19th century to t a c k l e a v a r i e t y of problems a r i s i n g from r a p i d u r b a n i z a t i o n and i n d u s t r i a l i z a t i o n . While these reformers had only a l i m i t e d impact upon the development of ' p u b l i c ' h e a l t h and w e l f a r e s e r v i c e s i n the e a r l y p a r t of t h i s century, the e f f e c t s of World War I and the f i n d i n g s of the R o y a l Commission on I n d u s t r i a l R e l a t i o n s i n 1919, p r o v i d e d a more f a v o u r a b l e c l i m a t e . 'Mental h y g i e n e ' became one of the concerns of reformers and a mental hygiene movement emerged i n Canada. Two p r o g r e s s i v e medical p r a c t i t i o n e r s who worked w i t h i n the p u b l i c m e n t a l h o s p i t a l system i n O n t a r i o - Dr. C l a r e n c e Hincks and Dr. C.K. Clarke - j o i n e d f o r c e s w i t h a s o c i a l worker ( M a r j o r i e Keyes) to form the Canadian N a t i o n a l Committee f o r Mental Hygiene. The o r g a n i z a t i o n was founded i n A p r i l , 1918 and was m o d e l l e d upon i t s American c o u n t e r - p a r t ; i n d e e d , C l i f f o r d B e e r s h e l p e d H i n c k s and C l a r k e t o o r g a n i z e the Committee. T h e i r p r o p o sals f o r reform encompassed a range of mental hygiene i s s u e s ; i n c l u d i n g , adequate care of p s y c h i a t r i c 182 c a s u a l t i e s from the c o n f l i c t i n Europe; medical examinations of i m m i g r a n t s ; c a r e f o r the 'feeble-minded'; and, adequate f a c i l i t i e s f o r the e a r l y d e t e c t i o n , d i a g n o s i s and i n t e n s i v e treatment of mental d i s e a s e s (e.g., 'psychopathic h o s p i t a l s ' and o u t - p a t i e n t c l i n i c s ) ( G r i f f i n , 1967; C h a l k e , 1962; H i n c k s , 1962). The Committee was extremely a c t i v e d u r i n g the 1920's and 1930's, and Hincks and Keyes undertook 'mental hygiene' surveys at the i n v i t a t i o n of p r o v i n c i a l governments. In most c a s e s , t h e i r work r e s u l t e d i n e i t h e r f u l l s c a l e Commissions of Enquiry o r an immediate a d o p t i o n of t h e i r recommendations ( G r i f f i n , 1967). While the N a t i o n a l Committee suspended f u l l o p e r a t i o n s d u r i n g the 1940's, i t re-emerged i n the 1950's as the Canadian Mental Health A s s o c i a t i o n ; an i n t e r e s t group that continued to engineer reform and which c o n t r i b u t e d to the mental h e a l t h law reforms i n the 1960's (Chalke, et a l , 1964). Ralph (1983) has i d e n t i f i e d Dr. F.S. Lawson as a foremost pioneer of community p s y c h i a t r y i n Canada in the 1950's. Lawson was a member of the C a n a d i a n M e n t a l H e a l t h A s s o c i a t i o n and became d i r e c t o r of p s y c h i a t r i c s e r v i c e s i n Saskatchewan at the t i m e of the 'Saskatchewan Plan'. S i m i l a r l y , i t i s evident that the reforms c u r r e n t l y a f f e c t i n g Canadian mental h e a l t h law (i.e., the new l e g a l i s m ) have been e n g i n e e r e d by s p e c i f i c g r o u p s and i n d i v i d u a l s w i t h i n the l o o s e l y bonded conglomerate of i n t e r e s t g roups known as the 'mental p a t i e n t s ' r i g h t s movement' (see, e.g., Savage & McKague, 1987). I t i s c l e a r , t h e r e f o r e , t h a t any a t t e m p t to e x p l a i n the 183 p e r i o d s of mental h e a l t h law reform i n Canada must take account of the impact, and explore the motives of, s p e c i f i c i n d i v i d u a l s and groups t h a t have been a c t i v e o u t s i d e the f o r m a l s t a t e a p p a r a t u s ( i . e . , o u t s i d e p r o v i n c i a l m e n t a l h e a l t h s e r v i c e b u r e a u c r a c i e s ) . At the same time, i t i s necessary to analyse the c o n n e c t i o n s between r e f o r m e r s and the s t a t e and, as a c o r o l l a r y , both changes i n the o r g a n i z a t i o n of reform (i.e., the s h i f t from i n d i v i d u a l s to the c r e a t i o n of what Handler (1978) r e f e r s to as 'reform b l o c s ' ) and the e x t e n t t o which those s e e k i n g change have t a k e n p a r t i n r e f o r m s o r g a n i z e d by the s t a t e . In re c e n t years, f o r example, i n d i v i d u a l s r e p r e s e n t i n g key i n t e r e s t groups have been members of p r o v i n c i a l government committees e s t a b l i s h e d to examine the is s u e of amending mental h e a l t h l e g i s l a t i o n and they have, t h e r e f o r e , been i n v o l v e d d i r e c t l y i n a process i n i t i a t e d by the s t a t e (see, e.g., S o c i a l S e r v i c e s and Community H e a l t h : A l b e r t a , 1983; Task F o r c e Committee, 1983). I t i s a l s o n e c e s s a r y t o e x a m i n e t h e i d e o l o g i c a l underpinnings of reform groups s i n c e t h i s w i l l both e s t a b l i s h t h e i r m o t i v e s and i l l u s t r a t e the s o u r c e s of t h e i r i d e a s . Canadian r e f o r m e r s have not been o p e r a t i n g i n an i d e o l o g i c a l vacuum; f o r example, the changes which occurred d u r i n g and s i n c e the 1960's have c o i n c i d e d with both major s t a t u t o r y reforms i n B r i t a i n and s i g n i f i c a n t l e g i s l a t i v e and j u r i s p r u d e n t i a l a c t i v i t y i n the U n i t e d S t a t e s . In a d d i t i o n , the 'new l e g a l i s m * has emerged i n the wake of a s e r i e s of s i g n i f i c a n t c r i t i q u e s of p s y c h i a t r y , mental h e a l t h s y s t e m s , and the v e r y c o n c e p t of 184 'mental i l l n e s s * . I t i s e v i d e n t t h a t these d e v e l o p m e n t s have provided a j u r i s p r u d e n t i a l and i d e o l o g i c a l f o o t i n g f o r Canadian reformers. The p e r i o d of reform which occurred i n the 1960's f o l l o w e d the passage of the England and Wales, Mental Health Act, 1959. Since Canadian mental h e a l t h l e g i s l a t i o n bore the hallmarks of t h i s s t a t u t e i t can be concluded that those seeking reform i n the p r o v i n c e s were i n f l u e n c e d by both the B r i t i s h l e g i s l a t i o n and the recommendations of the Percy Commission upon which the s t a t u t e was based. One of the major i n t e r e s t groups at work i n Canada at that time was the Canadian Mental Health A s s o c i a t i o n and the p e r s p e c t i v e and recommendations of the A s s o c i a t i o n r e f l e c t e d the r e f o r m s which had been i n t r o d u c e d i n B r i t a i n (Chalke, e t a l , 1964). S i m i l a r l y , the c u r r e n t p e r i o d of r e f o r m - the 'new l e g a l i s m ' - r e f l e c t s developments i n the United S t a t e s . Indeed, i n s o f a r as the l e x i c o n of American mental h e a l t h law has been predominant i n both proposals f o r reform (see, e.g. Manitoba Law Reform Commission, 1979; M i n i s t r y of Health: B r i t i s h Columbia, 1979) and the outcomes of the reform process (i.e., new mental h e a l t h l e g i s l a t i o n ) i t i s a p p a r e n t t h a t e v e n t s i n the U n i t e d S t a t e s have been i n f l u e n t i a l . Terms such as 'the l e a s t r e s t r i c t i v e a l t e r n a t i v e ' , 'the r i g h t to r e c e i v e treatment', and 'the r i g h t to r e f u s e t r e a t m e n t 1 have t h e i r r o o t s i n A m e r i c a n l e g a l d o c t r i n e but have been p r o m i n e n t i n the d i s c o u r s e of Canadian reformers. 185 I t i s a l s o apparent that, l i k e t h e i r c o u n t e r p a r t s i n other c o u n t r i e s , C a n adian r e f o r m e r s have been i n f l u e n c e d by the s u s t a i n e d c r i t i q u e of p s y c h i a t r y o r i g i n a t i n g from n o v e l i s t s , s o c i a l s c i e n t i s t s , and the s o - c a l l e d ' a n t i - p s y c h i a t r i s t s ' (see, e.g., R o b i t s c h e r , 1978). Indeed, t h i s c r i t i q u e i s a s p e c i f i c f e a t u r e of the d i s c o u r s e of r e f o r m a s s o c i a t e d w i t h the 'new l e g a l i s m 1 (see, e.g., M a r s h a l l & Hughes, 1974; Mazer, 1978; M a n i t o b a Law Reform Commission, 1979; Anand, 1979) and i t s s i g n i f i c a n c e should not be overlooked. Since i t s b i r t h i n the e a r l y w r i t i n g s of Szasz (1961) and Goffman (1961), the c r i t i q u e has f o l l o w e d two d i s t i n c t i v e t r a j e c t o r i e s ; namely, a s p e c i f i c f o c u s upon the r i s e of the ' t h e r a p e u t i c s t a t e ' , and a g e n e r a l q u e s t i o n i n g of both the e f f i c a c y of p s y c h i a t r i c medicine and the r o l e of mental h e a l t h systems i n the management of 'deviance' ( R o b i t s c h e r , 1978). I n s o f a r as the l a t t e r has i n v o l v e d an a l l e g a t i o n that the p r a c t i c e of p s y c h i a t r y c o n s t i t u t e s a process of s o c i a l c o n t r o l r a t h e r than the treatment and cure of i l l n e s s , t h i s t r a j e c t o r y has c o n t r i b u t e d to the work of c r i t i c s of the ' t h e r a p e u t i c s t a t e 1 . As R o b i t s c h e r (1978) and Noble (1981) have p o i n t e d out, a s i g n i f i c a n t f e a t u r e of the c u r r e n t era of i n t e r n a t i o n a l mental h e a l t h law r e f o r m i s t h a t i t has been p r o p e l l e d by t h e a r t i c u l a t i o n of r e a l and p e r c e i v e d problems with p s y c h i a t r y and mental h e a l t h systems. I r o n i c a l l y , these c r i t i c i s m s are s i m i l a r to those which accompanied the 19th century reforms to E n g l i s h lunacy law (Noble, 1981). At that time, c r i t i c s were (amongst o t h e r t h i n g s ) s k e p t i c a l a b o u t th e c a p a c i t y o f m e d i c a l 186 p r a c t i t i o n e r s to diagnose and t r e a t 'lunacy 1 and i t was b e l i e v e d that u n j u s t i f i a b l e confinement under b a r b a r i c c o n d i t i o n s was o c c u r r i n g . T h i s posed a s e r i o u s t h r e a t to fundamental r i g h t s and l i b e r t i e s and, i n the l i g h t of s e v e r a l concrete and w e l l -p u b l i c i z e d examples of improper a c t i o n s , i t became c l e a r t h a t the s i t u a t i o n r e q u i r e d r e s o l u t i o n . In many r e s p e c t s , the p e r s p e c t i v e s of those who have championed the 'new l e g a l i s m ' have t h e i r i d e o l o g i c a l r o o t s i n a s i m i l a r set of concerns. These c o n c e r n s were e x p r e s s e d i n the w r i t i n g s of those who, d u r i n g the 1960's, r e c o g n i z e d a g r o w i n g tendency f o r governments to endorse a ' m e d i c a l i z a t i o n of deviance'; that i s , to d e f i n e a wide range of non-conformist conduct as 'sickness' r a t h e r than 'badness', and to encourage the use of m e d i c a l or q u a s i - m e d i c a l s o l u t i o n s to problems of s o c i a l c o n t r o l ( I l l i c h , 1975; Conrad & S c h n e i d e r , 1980; M i l e s , 1981; H o r o w i t z , 1982). I t was f e l t t h a t t h i s s i g n a l l e d the emergence of a s e r i o u s t h r e a t to f u n d a m e n t a l r i g h t s and l i b e r t i e s ; namely, the 'therapeutic s t a t e ' (Szasz, 1963; 1978). S i g n i f i c a n t l y , e a r l y c r i t i c s of t h i s development reco g n i z e d that weapons from the l e g a l a r s e n a l c o u l d be employed to s t o p the growth of an O r w e l l i a n nightmare (Szasz, 1963). Nowhere i s t h i s more c l e a r l y e x p r e s s e d than i n the work of N i c h o l a s K i t t r i e (1971), an American lawyer who was a strong advocate f o r the ' r i g h t to be d i f f e r e n t ' . A s i g n i f i c a n t movement d e v e l o p e d i n the U n i t e d S t a t e s that was spearheaded by c i v i l l i b e r t a r i a n o r g a n i z a t i o n s and lawyers, such as Bruce Ennis (1972), who drew upon the work of l i b e r a l s o c i a l s c i e n t i s t s and ' a n t i - p s y c h i a t r i s t s ' . 187 Reformers armed themselves w i t h concrete s o l u t i o n s to what they thought was a s i g n i f i c a n t a t t a c k on human p h y s i c a l and mental i n t e g r i t y and, t h e r e f o r e , the v e r y f o u n d a t i o n s of l i b e r a l , democratic s o c i e t i e s (Sedgwick, 1982). One of these s o l u t i o n s -l i t i g a t i o n - became the p r i m a r y s t r a t e g y of the ' p a t i e n t s * r i g h t s movement' and i t i s contended that t h i s had a s i g n i f i c a n t impact on the development of new, r e s t r i c t i v e r u l e s governing the treatment and confinement. Indeed, f o r some, the movement has been r e s p o n s i b l e f o r the 'death' of the mental h o s p i t a l , p a r t i c u l a r l y i n the United S t a t e s (see, e.g., Talb o t , 1978). W h i l e the second d i s t i n c t i v e t r a j e c t o r y was c o n c e r n e d p r i m a r i l y with the e f f i c a c y of p s y c h i a t r i c medicine and systems of mental h e a l t h care, i t has provided support f o r the c r i t i c s of the t h e r a p e u t i c s t a t e and, t h e r e f o r e , the movement to reform mental h e a l t h laws. The c h a l l e n g e s to both the d e f i n i t i o n of ' m e n t a l i l l n e s s ' and t h e a s s u m p t i o n s and p r a c t i c e s o f c o n v e n t i o n a l p s y c h i a t r y mounted by the s o - c a l l e d ' a n t i -p s y c h i a t r i s t s ' - Szasz (1961, 1970, 1970a, 1974, 1975, 1976, 1977, 1977a, 1978), L a i n g (1961, 1967), L a i n g and E s t e r s o n (1970 ), and C o o p e r ( 1 9 ^ 7 , 1971) - and t h e c r i t i q u e o f i n s t i t u t i o n s s p e a r h e a d e d by Goffman (1961), d e v e l o p e d i n t o a l a r g e r t h e o r e t i c a l and e m p i r i c a l a s s a u l t upon mental h e a l t h systems (Ingleby, 1981; M i l e s , 1981; Sedgwick, 1982). While the r e s e a r c h f i n d i n g s and arguments of ' l a b e l l i n g t h e o r i s t s ' such as S c h e f f (1966) and Rosenhan (1973, 1975), s y m b o l i c i n t e r -a c t i o n i s t s ( S p i t z e r & D e n z i n , 1968), and e t h n o m e t h o d o l o g i s t s such as C o u l t e r (1973, 1979) and P f o h l (1978) may have had a 188 l i m i t e d impact (see, e.g., S c u l l , 1984), t h e r e can be l i t t l e doubt that, r e g a r d l e s s of t h e i r c r i t i c s (see, e.g. Gove, 1975; Wing, 1978), they helped to c a s t a shadow over the v a l i d i t y and r e l i a b i l i t y of the process of diagnosing s c h i z o p h r e n i a , as w e l l as other p s y c h i a t r i c p r a c t i c e s and assumptions. As M i l e s (1981) n o t e s , the doubts r a i s e d about the l e g i t i m a c y of p s y c h i a t r y and p s y c h i a t r i c p r a c t i c e s l e d some s o c i a l s c i e n t i s t s to the c o n c l u s i o n that both the p r o f e s s i o n and i t s a l l i e d system of i n s t i t u t i o n s and resources were l i t t l e more than a v e i l e d and under-rated mechanism of s o c i a l c o n t r o l (see, e.g., S c h e f f , 1966, 1975; C o u l t e r , 1979). I t i s i n t h i s sense t h a t the work of s o c i a l s c i e n t i s t s i n t e r l o c k e d w i t h and b u t t r e s s e d those who were examining the 'therapeutic s t a t e ' and who were i n v o l v e d d i r e c t l y i n the p a t i e n t s ' r i g h t s movement. I t i s noteworthy that t h i s p a r t i c u l a r c l a i m was a l s o a r t i c u l a t e d by the E n g l i s h ' a n t i - p s y c h i a t r i s t s * (notably, Cooper (1967, 1971)) who sought to i n s t i t u t e r e f o r m s of t h e i r own t h r o u g h the development of a l t e r n a t i v e environments i n which those l a b e l l e d ' s c h i z o p h r e n i c ' c o u l d f i n d s h e l t e r and s y m p a t h e t i c ' h e a l i n g ' (e.g., Laing's ' K i n g s l e y H a l l ' e x p e r i m e n t ) . Thomas Szasz has a l s o sought ways of i n f l u e n c i n g p o l i c y and l e g i s l a t i v e reforms w h i c h a r e c o n s i s t e n t w i t h h i s r i g h t - w i n g ' l i b e r t a r i a n ' p e r s p e c t i v e (Sedgwick, 1982). He was one of the founders of the ' C i t i z e n s ' Commission on Human R i g h t s ' ; an i n t e r n a t i o n a l and extremely e n e r g e t i c group o p e r a t i n g under the a u s p i c e s of the Church of S c i e n t o l o g y and which i s d e d i c a t e d to the exposure of p s y c h i a t r i c involvement i n the process of 'mind c o n t r o l ' . 2 189 Inasmuch as the c r i t i q u e of p s y c h i a t r y and mental h e a l t h s y s tems had a d i r e c t and i n d i r e c t impact on the f o r m a t i o n , d i s c o u r s e s and a c t i v i t i e s of reform groups, i t i s apparent t h a t i t was (and i s ) v i e w e d s e r i o u s l y by the m e d i c a l p r o f e s s i o n . T h i s i s i l l u s t r a t e d by t h e c o n s e q u e n t p r o c e s s o f s e l f -e x a m i n a t i o n on the p a r t of p s y c h i a t r y . An e x t e n s i v e body of l i t e r a t u r e has emerged i n which the fundamental assumptions of the p r o f e s s i o n are examined c r i t i c a l l y and a d e b a t e has d e v e l o p e d amongst p s y c h i a t r i s t s (see, e.g., Wing, 1975, 1978; C l a r e , 1976; Ingleby, 1981; Robitscher, 1978; Weisstub, 1980). T h i s has been b u t t r e s s e d by e x p e r i m e n t a l and o t h e r e m p i r i c a l r e s e a r c h c o n d u c t e d by s o c i a l and b e h a v i o u r a l s c i e n t i s t s and medical p r a c t i t i o n e r s , some of which was conducted under the auspices of the American P s y c h i a t r i c A s s o c i a t i o n . In 1973, and i n response to a growing disenchantment w i t h i n the p r o f e s s i o n as w e l l as e x t e r n a l c r i t i c i s m , t h i s i n f l u e n t i a l body e s t a b l i s h e d a Task Force to develop a new and more v a l i d and r e l i a b l e scheme f o r c l a s s i f y i n g mental d i s o r d e r s . The r e s e a r c h demonstrated t h a t t h e r e were i n d e e d p r o b l e m s not o n l y i n the d i a g n o s t i c context but a l s o i n r e l a t i o n to the treatment of d i s o r d e r s (see, e.g., C o l e s , 1982). In r e s p o n s e to the f i n d i n g s of t h i s , l a r g e l y 'in-house' r e s e a r c h , the A s s o c i a t i o n p r o d u c e d an e n t i r e l y r e c o n s t r u c t e d nosology - the D i a g n o s t i c and S t a t i s t i c s Manual, E d i t i o n I I I - that purports to provide a more v a l i d and r e l i a b l e instrument and set of procedures f o r the d i a g n o s i s of mental d i s o r d e r s (Coles, 1982). The e x p l a n a t i o n s f o r reforms to mental h e a l t h p o l i c y and 190 law w h i c h a r e o f f e r e d by t h o s e f o l l o w i n g t h i s g e n e r a l t h e o r e t i c a l t r a j e c t o r y ( i . e . , ' i n t e r e s t g r o u p 1 , ' p r e s s u r e group 1, or ' p l u r a l i s t c o n f l i c t ' theory) are q u i t e c o m p e l l i n g and s e e m i n g l y a p p l i c a b l e to an e x p l a n a t i o n of mental h e a l t h law reform i n Canada. However, there are s i g n i f i c a n t problems w i t h t h i s approach, some of which have been i d e n t i f i e d and b r i e f l y d i s c u s s e d i n the forego i n g a n a l y s i s . One key problem l i e s w i t h the l e v e l of a n a l y s i s . The e x p l a n a t i o n s a r e e s s e n t i a l l y i n c o m p l e t e s i n c e t h e r e i s a s i n g u l a r f o c u s upon human agency, r a t h e r than the complex i n t e r a c t i o n between the a c t i v i t i e s of r e f o r m e r s (and t h e i r opponents), the s t a t e , and the broader economic, i d e o l o g i c a l and p o l i t i c a l f a c t o r s which a f f e c t the s t a t e ' s c a p a c i t y and w i l l i n g n e s s to endorse (or r e j e c t ) the new p o l i c i e s and l e g i s l a t i o n p r o p o s e d by r e f o r m e r s . Thus, t h e o r i s t s f a i l to e s t a b l i s h the reasons why a government w i l l accept and respond to the v i e w s of r e f o r m e r s , and t h e r e f o r e f a v o u r one i n t e r e s t group over another, at a p a r t i c u l a r time ( S c u l l , 1984). In the mental h e a l t h law context, the f a c t that there was, at one time, w i d e s p r e a d s u p p o r t f o r ' m e d i c a l i z a t i o n ' o r 'enhanced m e d i c a l i z a t i o n ' but, a t other times, a quest f o r j u d i c i a l and q u a s i - j u d i c i a l r e g u l a t i o n , i s e x p l a i n e d as an outcome of the r e l a t i v e e f f e c t i v e n e s s of one i n t e r e s t group i n d e f e a t i n g a competitor (see, e.g., Jones, 1960, 1972). A l t e r n a t i v e l y , i t i s seen as an a r t i f a c t of p o l i t i c a l e x p e d i e n c y o r p o l i t i c a l p r e f e r e nce (Handler, 1978). These may be r e l e v a n t f a c t o r s but they cannot alone provide a complete e x p l a n a t i o n f o r the state's 191 e n t h u s i a s m f o r l i m i t i n g the powers and a u t h o r i t y of m e d i c a l p r a c t i t i o n e r s at one time, but not at another. An e x p l a n a t i o n that focuses e x c l u s i v e l y on the c o n f l i c t s between i n t e r e s t groups i s a l s o unable to a c c o u n t f o r the s i t u a t i o n where law reform i s i n i t i a t e d by the s t a t e . T h i s i s an i s s u e of paramount i m p o r t a n c e i n the m e n t a l h e a l t h law c o n t e x t s i n c e , a t v a r i o u s t i m e s , governments have c l e a r l y adopted the s t r a t e g y of f i r s t announcing an i n t e n t i o n to amend p o l i c i e s and s t a t u t e s and t h e n i n v i t i n g v a r i o u s c o m p e t i n g i n t e r e s t groups to t ake p a r t i n the r e f o r m p r o c e s s . In some i n s t a n c e s they may have gone much f u r t h e r . F o r example, Unsworth (1979) has argued that the s t a t e has a c t u a l l y helped s p e c i f i c , but d i s o r g a n i z e d , i n t e r e s t groups where t h e i r p r o p o s a l s f o r reform have been c o n s i s t e n t with the state's p r e -determined s t r a t e g y . Where the s t a t e takes the i n i t i a t i v e i n these ways, i n t e r e s t group t h e o r i s t s are unable to e x p l a i n why a government s t a r t s the r e f o r m p r o c e s s i n the f i r s t p l a c e . C e r t a i n l y , i n some cases w r i t e r s have considered the impact of changes i n the s t r u c t u r e of the o r g a n i z a t i o n s w i t h i n the s t a t e i a p p a r a t u s . As we have seen, at l e a s t one a n a l y s t of m e n t a l h e a l t h law - Kathleen Jones (1960, 1972) - has woven t h i s f a c t o r i n t o the f a b r i c of her e x p l a n a t i o n . However, she n e g l e c t e d to explore the r e l a t i o n s h i p between o r g a n i z a t i o n a l changes i n the p r o v i s i o n o f s t a t e h e a l t h c a r e s e r v i c e s and t h e l a r g e r s t r u c t u r a l c o n d i t i o n s a f f e c t i n g s t a t e decision-making. Those who f o l l o w t h i s t h e o r e t i c a l t r a j e c t o r y are a l s o unable to account completely f o r the simultaneous emergence of 192 mental h e a l t h p o l i c y and law reforms i n d i f f e r e n t c o u n t r i e s (Ralph, 1983). C e r t a i n l y , i n t e r n a t i o n a l reform groups have been o p e r a t i n g a t c e r t a i n t i m e s . F o r example, the f o r m a t i o n of Na t i o n a l Committees on Mental Hygiene i n d i f f e r e n t c o u n t r i e s d u r i n g the , f i r s t two decades of the c e n t u r y s u g g e s t s t h a t a strong, i n t e g r a t e d , and i n t e r n a t i o n a l o r g a n i z a t i o n e x i s t e d f o r the e x p r e s s purpose of r e f o r m i n g mental h e a l t h p o l i c i e s and l e g i s l a t i o n . L i k e w i s e , i t i s apparent that the emergence of the 'new l e g a l i s m ' has been accompanied by a c e r t a i n l e v e l of i n t e r n a t i o n a l d i a l o g u e between reformers. However, while t h i s c o u l d be a r e l e v a n t f a c t o r , i t cannot a l o n e a c c o u n t f o r the w i l l i n g n e s s of governments i n d i f f e r e n t c o u n t r i e s to adopt the proposals f o r change. The r e f o r m s which o c c u r r e d i n Canada d u r i n g the 1960's f o l l o w e d i n the wake of new l e g i s l a t i o n i n B r i t a i n and c o i n c i d e d w i t h a l m o s t i d e n t i c a l r e f o r m s i n A u s t r a l i a ( K i r b y , 1981; O ' S u l l i v a n , 1981). C o n s e q u e n t l y , o v e r a p e r i o d of ten y e a r s , s e v e n t e e n s e p a r a t e and g e o g r a p h i c a l l y d i s t a n t , l e g i s l a t i v e bodies chose to do much the same t h i n g . S i m i l a r l y , the c u r r e n t era of the 'new l e g a l i s m ' i s u n f o l d i n g s i m u l t a n e o u s l y i n Canada, B r i t a i n , and A u s t r a l i a , and i n tandem wit h a l l i e d developments i n the United S t a t e s (Gordon & Verdun-Jones, 1986). Short of assuming that some magical and as yet undiscovered process of l e g i s l a t i v e osmosis i s o c c u r r i n g , the e x p l a n a t i o n must l i e w i t h a set of f a c t o r s that are common to these governments. As we s h a l l see, t h i s i s s u e i s addressed i n p a r t by those who focus upon the s t r u c t u r a l c o n d i t i o n s a f f e c t i n g reform and the nature 193 and r o l e of the modern, c a p i t a l i s t s t a t e . In t h i s r e g a r d , the i n t e r e s t group p e r s p e c t i v e can be a t t a c k e d f o r the a s s u m p t i o n s which are made about the s t a t e , s o c i e t y , and the p o l i t i c a l process. In g e n e r a l , a n a l y s t s have i m p l i c i t l y or e x p l i c i t l y accepted the p l u r a l i s t account of the s t a t e ; that i s , the p e r s p e c t i v e propounded during the 1950's and 1960's by A merican p o l i t i c a l s c i e n t i s t s such as Dahl and L i p s e t . In t h i s view, a l i b e r a l d e m o c r a t i c government ( i . e . , s t a t e ) i s seen as a benign, n e u t r a l and d i s i n t e r e s t e d r e f e r e e t h a t l i s t e n s t o and f i n d s an a c c e p t a b l e compromise between c o n f l i c t i n g groups which w i l l be both e f f e c t i v e and i n the best i n t e r e s t s of a n a t i o n at l a r g e (Stevenson, 1983). I t i s assumed that s o c i e t y c o n s i s t s of a p l u r a l i t y of f r e e and equal i n t e r e s t groups who compete f o r both the power necessary to implement t h e i r views and the resources which the s t a t e can provide but which i t has no i n t e r e s t i n a l l o c a t i n g to any p a r t i c u l a r c l a s s , f a c t i o n or b l o c . Since law i s both an instrument of power and one of t h e s e s t a t e c o n t r o l l e d r e s o u r c e s , governments w i l l be l o b b i e d (and counter-lobbied) by those who wish to e f f e c t reform (or oppose r e f o r m ) e i t h e r i n tandem w i t h a new and p r e f e r r e d s t r a t e g y (e.g., a new m e n t a l h e a l t h c a r e p l a n ) , or s i m p l y because a problem i s recognized and seen as r e s o l v a b l e by the c r e a t i o n or amendment of l e g i s l a t i o n (e.g., to b a n i s h a p a r t i c u l a r form of behavior, or to provide safeguards a g a i n s t a s s a u l t s on fundamental r i g h t s and l i b e r t i e s ) . As we s h a l l see i n the next s e c t i o n , t h i s view of the 194 s t a t e has been c r i t i c i z e d ; e s p e c i a l l y , by neo-Marxist t h e o r i s t s . However, the p e r s p e c t i v e has u n d e r p i n n e d the work of many s o c i o l o g i s t s of law (e.g., A u s t i n Turk) and d e v i a n c e (e.g., the ' s o c i e t a l r e a c t i o n ' t h e o r i s t s ) , as w e l l as o t h e r a n a l y s t s who have focussed upon l e g i s l a t i v e reform i n f i e l d s other than mental h e a l t h law. In p a r t i c u l a r , i t was popular amongst those who, d u r i n g the 1950's and 1960's, took a s p e c i a l i n t e r e s t i n a n a l y s i n g the emergence of c r i m i n a l laws; f o r example, Jerome H a l l (the law of t h e f t ) , J o s e p h G u s f i e l d ( p r o h i b i t i o n ) , and Howard Becker ( m a r i j u a n a laws) ( B e i r n e & Quinney, 1982; Chambliss & Seidman, 1982). W i t h i n t h i s s c h o o l of th o u g h t , e x p l a n a t i o n s f o r the emergence and reform of laws i n v o l v e d the c o n s t r u c t i o n and use of c o n c e p t s such as 'moral p a n i c s ' , 'moral c r u s a d e s ' and the 'moral entrepreneur'; a theme a l s o found i n the work of a n a l y s t s who have focussed upon the r i s e and d e c l i n e of other law reform movements a f f e c t i n g , f o r example, consumer p r o t e c t i o n , s o c i a l w e l f a r e , and c i v i l r i g h t s (see, e.g., Handler, 1978). Indeed, at one t i m e , i n t e r e s t group t h e o r y e n j o y e d a d i s t i n c t i v e and i n f l u e n t i a l p o s i t i o n w i t h i n the s o c i o l o g y of law (Grace & W i l k i n s o n , 1978; C a m p b e l l & W i l e s , 1979). I t i s n o t e w o r t h y , however, t h a t t h i s t r a j e c t o r y r e a c h e d i t s z e n i t h d u r i n g the e a r l y 1970's and has g r a d u a l l y d e c l i n e d with the emergence of a coherent a l t e r n a t i v e ; namely, the neo-Marxist analyses of law and the l a w - s t a t e r e l a t i o n s h i p . Indeed, there has been a s h i f t of a l l e g i a n c e on the p a r t of some f o r m e r i n t e r e s t group t h e o r i s t s who have now recognized the many shortcomings of t h e i r 195 o r i g i n a l p e r s p e c t i v e (see, e.g., Chambliss & Seidman, 1982 (cf 1971); P i a t t , 1977 (cf 1969)). IV: EXPLANATIONS FOCUSSING UPON STRUCTURAL DEVELOPMENTS AND THE ROLE OF THE STATE IN A CAPITALIST SOCIETY In the c o u r s e of h i s c o m p r e h e n s i v e a n a l y s i s of m e ntal h e a l t h law reform i n B r i t a i n , Bean (1980) argues that i n t e r e s t group t h e o r i e s which purport to account f o r l e g i s l a t i v e reform n e c e s s a r i l y take the study of the s o c i o l o g y of law i n t o a c u l -d e - s a c . In h i s v i e w , w h i l e t h e r e can be no d o u b t t h a t i n d i v i d u a l s and groups have an impact on l e g a l change, i t i s always necessary to determine the ' s t r u c t u r a l c o n d i t i o n s ' under which such laws are introduced. Thi s i s p a r t i c u l a r l y true of the s i t u a t i o n where governments i n i t i a t e change i n advance of comparable developments i n p s y c h i a t r y . In h i s view, two of the major p e r i o d s of reform i n B r i t a i n i n the 20th c e n t u r y have o c c u r r e d as a consequence of s t a t e a c t i o n s . Both the M e n t a l T r e a t m e n t A c t , 1930 and the M e n t a l He_a_l t_h A£t__j_ JL9.5J3 a r o s e as a c o n s e q u e n c e o f g o v e r n m e n t commissions of i n q u i r y which were a f f e c t e d by l a r g e r s t r u c t u r a l changes. The Percy Commission (1954 - 1957) i s a case i n p o i n t . T h i s i n q u i r y o c c u r r e d a t a time when massive changes were a f f e c t i n g the s o c i a l and economic s t r u c t u r e s of B r i t a i n . The adoption of Keynesian economic p o l i c i e s and the implementation of the B e v e r i d g e p l a n f o r p o s t - w a r s o c i a l r e c o n s t r u c t i o n r e s u l t e d i n the development of the B r i t i s h w e l f a r e s t a t e and, i n Bean's view, t h i s was accompanied by a s h i f t i n the dominant id e o l o g y , from c l a s s i c l i b e r a l i s m to 'welfarism'. 196 These e v e n t s a f f e c t e d m e n t a l h e a l t h law r e f o r m i n two ways. The emergence of the welfare s t a t e meant that personnel ( i . e . , p s y c h i a t r i s t s and s o c i a l w o r kers) who c o u l d s t a f f new i n s t i t u t i o n s and other resources became a v a i l a b l e . It a l s o made p o s s i b l e , the r e d e f i n i t i o n of v u l n e r a b l e groups (e.g., l u n a t i c s c o u l d be d e f i n e d as 'mentally i l l ' ) ; the advancement of powers f o r h e a l t h and w e l f a r e p r o f e s s i o n a l s ; and, an approximation of s t a t e and s o c i e t y through the development of semi-autonomous p r o f e s s i o n a l bodies which could both apply and a d j u s t p o l i c i e s and suggest a p p r o p r i a t e changes where necessary. These f a c t o r s c r e a t e d the m a t e r i a l c o n d i t i o n s necessary f o r the development of a new type of law - 'therapeutic law' - which was a l s o a f f e c t e d by t h e e m e r g e n c e o f t h e new, o v e r a r c h i n g i d e o l o g y o f 'welfarism'. Thus, two s t r u c t u r a l d e v e l o p m e n t s - one m a t e r i a l ( i . e . , the w e l f a r e s t a t e ) , the other i d e o l o g i c a l - combined to c r e a t e an environment that was conducive to a p a r t i c u l a r form of mental h e a l t h law r e f o r m . For Bean (1980), t h i s took the form of 'therapeutic law", a phenomenon that embodied an endorsement of the d o c t r i n e o f p a r e n s £ a t r i^a e; t h e a d v a n c e m e n t o f a d m i n i s t r a t i v e (rather than j u d i c i a l or p a r l i a m e n t a r y ) d e c i s i o n -making powers; an a c c e p t a n c e of the need f o r the e x e r c i s e of p r o f e s s i o n a l ( e s p e c i a l l y , medical) d i s c r e t i o n ; and, a s h i f t from f o r m a l i s t i c law to purposive or p o l i c y - o r i e n t e d law (i.e., the use of law as a mechanism f o r i m p l e m e n t i n g , and as a m i r r o r r e f l e c t i n g , a p a r t i c u l a r p o l i c y ) . In Bean's view, the England and Wales Mental Health Act, 1959 was the epitome of t h i s new 197 form of law and i t s emergence and content can be e x p l a i n e d as an outcome of the m a t e r i a l and i d e o l o g i c a l c o n d i t i o n s surrounding the Percy Commission. Another key a n a l y s t of mental h e a l t h law reform i n England - Unsworth ( 1979) - has a l s o a t t a c k e d the i n t e r e s t group t h e o r i s t s ; p a r t i c u l a r l y , K a t h l e e n Jones. In h i s view, her a c c o u n t of the r e f o r m s as an outcome of c o n f l i c t s between co m p e t i n g p r o f e s s i o n a l p r e s s u r e groups i s f l a w e d , s i n c e i t i n c o r r e c t l y assumes the e x i s t e n c e of both consensus w i t h i n these groups and a c o n s i s t e n c y i n t h e i r p e r s p e c t i v e s over time. In f a c t , U n s w o r t h a r g u e s , t h e r e were c o n f l i c t s w i t h i n t h e p r o f e s s i o n s over the need f o r and d i r e c t i o n of reform, as w e l l as a m a r k e d s h i f t i n p e r s p e c t i v e a t d i f f e r e n t t i m e s . Furthermore, i t was the s t a t e , and not the i n t e r e s t groups which took the i n i t i a t i v e i n e n g i n e e r i n g r e f o r m . I t a c t i v e l y o rganised and promoted those i n t e r e s t s which were c o n s i s t e n t w i t h a p r e d e t e r m i n e d s t r a t e g y and on two o c c a s i o n s (1930 and 1959) i n t r o d u c e d p o l i c i e s and l e g i s l a t i o n which were i n advance of developments i n the resources and t e c h n o l o g i e s of treatment and confinement. F o r Unsworth (1979), the r e a s o n s f o r r e f o r m are to be found i n the broader s o c i a l and p o l i t i c a l context and, l i k e Bean (1980), he c o n s i d e r s the impact of t r a n s f o r m a t i o n s i n the dominant i d e o l o g y . However, i n s o f a r as he a t t e m p t s to l i n k i d e o l o g i c a l change, s o c i a l u n r e s t and t h r e a t s to o r d e r , the w e l f a r e s t a t e , and mental h e a l t h law r e f o r m , h i s a n a l y s i s i s more complex. In h i s view, there i s a l i n k between i d e o l o g i c a l 198 t r a n s f o r m a t i o n s and t h r e a t s to s o c i a l o r d e r . The c l a s s i c l i b e r a l i s m of the 19th c e n t u r y gave way, i n the e a r l y 20th century, to an 'ideology of n a t i o n a l e f f i c i e n c y ' which endorsed s t a t e i n t e r v e n t i o n i n the h e a l t h and w e l f a r e of the n a t i o n . T h i s , he argues, arose as a consequence of growing s o c i a l unrest and i t i s s i g n i f i c a n t that the development cut across p o l i t i c a l boundaries. Consequently, the p o s s i b l e source of a c o l l a p s e i n s o c i a l c o n t r o l - the nascent s o c i a l i s t p a r t i e s and f a c t i o n s -were e n j o i n e d i n a g e n e r a l , and s t a t e i n i t i a t e d , movement to produce a ' b e t t e r ' s o c i a l o r d e r which u l t i m a t e l y l e d to the emergence of a new and more r e f i n e d ideology - 'welfarism" - and the c r e a t i o n of the welfar e s t a t e . The concern f o r mental h e a l t h (or 'mental hygiene') was an i n t e g r a l p a r t of the push f o r ' n a t i o n a l e f f i c i e n c y ' and, i n Unsworth's v i e w , t h i s e x p l a i n s the B r i t i s h government's e x t r a o r d i n a r y f a i t h i n both the p s y c h i a t r i c e n t e r p r i s e and the c a p a b i l i t i e s of s o c i a l w o r k e r s , d u r i n g the 1920's. I t was a f a i t h o u t o f p r o p o r t i o n w i t h t h e a b i l i t i e s o f t h e s e p r o f e s s i o n a l s . N evertheless, t h i s confidence was r e s p o n s i b l e f o r the l e g i s l a t i v e changes which both promoted mental h e a l t h care and reduced the numerous b a r r i e r s that guarded access to h o s p i t a l s (i.e., j u d i c i a l c o n t r o l over commitment). F o r U n s w o r t h , t h e e m e r g e n c e of new m e n t a l h e a l t h l e g i s l a t i o n i n 1959 can be seen as a l o g i c a l development from the e v e n t s of the l a t e 1920's, as w e l l as an a r t i f a c t of the broader i d e o l o g i c a l and m a t e r i a l changes which accompanied the 199 w e l f a r e s t a t e . S i g n i f i c a n t l y , t h i s new l e g i s l a t i o n - w h i c h promoted the s t r a t e g y of community c a r e and t r e a t m e n t - was p r o c l a i m e d as a ' l i b e r a l ' measure. However, i t e n d o r s e d the medical, r a t h e r than the c i v i l l i b e r t a r i a n , view of ' l i b e r t y ' ; t h a t i s , the idea that h e a l t h needs were to dominate over c i v i l r i g h t s i s s u e s s i n c e true l i b e r t y c o u l d not be enjoyed without hea l t h . T h i s was the u l t i m a t e e x p r e s s i o n of both the ideology of w e l f a r i s m and the p o l i c y of s t a t e i n t e r v e n t i o n w h ich, Unsworth a r g u e s , was c o n n e c t e d to a s u b t l e s o c i a l c o n t r o l s t r a t e g y o r i g i n a t i n g with the reform of the 1920's. This r e s t e d upon the promotion of a c c e s s i b i l i t y to the r e s o u r c e s necessary f o r p e o p l e to v o l u n t a r i l y r e c o g n i z e t h a t they were a f f l i c t e d w i t h mental ' i l l - h e a l t h ' and to v o l u n t a r i l y seek a 'cure'. In t h i s way, one mechanism of s o c i a l c o n t r o l - c o n f i n e m e n t f o r treatment - c o u l d be employed i n the name of ' l i b e r a l i s m ' and without g r a n t i n g c o e r c i v e powers to mental h e a l t h p r o f e s s i o n a l s . A f o c u s upon bo t h emergent and c h a n g i n g i d e o l o g i c a l c o n d i t i o n s and the s o c i a l c o n t r o l s t r a t e g i e s of the s t a t e has been the c o n c e r n of a n o t h e r s i g n i f i c a n t group of a n a l y s t s ; namely, the s o - c a l l e d ' r e v i s i o n i s t ' h i s t o r i a n s of s t a t e s o c i a l c o n t r o l s t r a t e g i e s d u r i n g the 19th c e n t u r y (Cohen & S c u l l , 1983). I n s o f a r as t h i s work i s both t a n g e n t i a l l y connected to the i s s u e of mental h e a l t h law reform i n the 20th century and the source of an i n t e r e s t i n the impact of changing c o n d i t i o n s i n the sphere of economics, a b r i e f d i s c u s s i o n i s warranted. The work of these h i s t o r i a n s was s t i m u l a t e d by Foucault's c e l e b r a t e d s t u d y of the h i s t o r y of madness, and the s o c i a l 200 r e s p o n s e to madness, i n Europe d u r i n g the ' c l a s s i c a l age' (Foucault, 1965). Among other matters, Foucault examined the r i s e of i n s t i t u t i o n s as a means f o r both m a i n t a i n i n g order and b u i l d i n g a d i s c i p l i n e d and p r o d u c t i v e p o o l of l a b o u r . I t i s t h i s a s p e c t of h i s work which g e n e r a t e d the o u t p u t from the s o c i a l c o n t r o l h i s t o r i a n s - S c u l l (1979), Rothman (1971), and I g n a t i e f f (1978) - who p r o c e e d e d to d e s c r i b e , a n a l y s e , and e x p l a i n the development and e v o l u t i o n of a t r i p a r t i t e system of s o c i a l c o n t r o l i n B r i t a i n and the U n i t e d S t a t e s d u r i n g the n i n e t e e n t h century. For Rothman (1971), t h i s t r i p a r t i t e system - a network of p e n i t e n t i a r i e s , asylums, and almshouses and workhouses - emerged i n the U n i t e d S t a t e s d u r i n g the J a c k s o n i a n p e r i o d . At t h i s time, a need arose to s t a b i l i z e and c r e a t e cohesion w i t h i n the new r e p u b l i c and, i n c o n j u n c t i o n w i t h a broadly expressed d e s i r e to c o r r e c t the i m p e r f e c t i o n s of the o l d s o c i e t y , an i d e o l o g i c a l c l i m a t e c o n d u c i v e to r e f o r m m a t e r i a l i z e d . There were, he argues, an abundance of reformers who promised success i n the cure of ' s o c i a l i l l s ' and, i n the context of the management of the insane, t h e i r ideas l e d to the development of the asylum. T h e s e i n s t i t u t i o n s , w h i c h were t o e x e m p l i f y t h e p r o p e r p r i n c i p l e s of o r g a n i z a t i o n , were f o r those s u f f e r i n g from a c o n d i t i o n - i n s a n i t y - t h a t r e f l e c t e d a s e r i o u s f l a w i n s o c i e t y . These p e o p l e were the v i c t i m s of f a u l t y s o c i a l o r g a n i z a t i o n ; anathema to the a s p i r i n g new r e p u b l i c . While they were not to be blamed f o r t h e i r a f f l i c t i o n s , i t was necessary t h a t the i n s a n e be c u r e d and, to t h i s end, they were to be 201 housed i n i s o l a t e d , 'Utopian' c o m m u n i t i e s where they c o u l d b e n e f i t from r e g u l a t i o n and m o r a l t r e a t m e n t i n a p a s t o r a l s e t t i n g . T r a g i c a l l y , by the middle of the n i n e t e e n t h century these asylums had d e t e r i o r a t e d i n t o over-crowded, c u s t o d i a l and d i s c i p l i n a r y warehouses which were used f o r the c o n t r o l of a range of s o c i a l 'undesirables.' The p o s s i b i l i t y that the e s t a b l i s h m e n t of asylums can be e x p l a i n e d as a product of broader i d e o l o g i c a l t r a n s f o r m a t i o n s r e c e i v e s some support from Skultans (1979). In her study of the management of madness i n England, she argues that the r i s e of asylums was i n t i m a t e l y connected to the i d e a s of order and r e g u l a r i t y which r e f l e c t e d a b r o a d e r s o c i a l c o n c e r n w i t h the d e v e l o p m e n t of a new s o c i e t y from the chaos of f e u d a l i s m . However, as was the case i n the United States, the asylum system c o l l a p s e d i n t o a network of d e p o s i t o r i e s f o r the r e s t r a i n t of s o c i e t y ' s ' r e f u s e ' . The emphasis upon i d e o l o g i c a l t r a n s f o r m a t i o n s i s not to the l i k i n g of other s o c i a l c o n t r o l h i s t o r i a n s ; e s p e c i a l l y Andrew S c u l l (1979). He views the r i s e of the asylum i n England i n a very d i f f e r e n t l i g h t i n s o f a r as he t i e s t h i s development to the growth of a c a p i t a l i s t s o c i a l o r d e r . The r i s i n g , i n d u s t r i a l b o u r g e o i s i e p r e s s e d f o r a new system of s o c i a l c o n t r o l t h a t would encourage p r o d u c t i v i t y and provide a r e l i a b l e supply of l a b o u r f o r c a p i t a l i s t e n t e r p r i s e s . As p l a c e s of s e g r e g a t i v e c o n t r o l , i n s t i t u t i o n s s o r t e d the a b l e - b o d i e d from the non-ablebodied so that the former could be d i s p a t c h e d to workhouses 202 where they c o u l d b o t h l e a r n the v i r t u e s of hardwork and d i s c i p l i n e and be t r a i n e d f o r the labour p o o l . Those who were u n a b l e to conform ( n o t a b l y , the i n s a n e ) were to be s e p a r a t e d from the r e s t so that they d i d not i n t e r f e r e with the process of t r a i n i n g w i t h i n both the formal i n s t i t u t i o n a l complex and the i n f o r m a l i n s t i t u t i o n s which e x i s t e d i n s o c i e t y ; n o t a b l y , the f a m i l y . In S c u l l ' s view, t h i s l a r g e r , s o c i a l c o n t r o l s t r a t e g y and i t s d i r e c t connections with developments i n the c a p i t a l i s t economy, accounts f o r the s p e c t a c u l a r r i s e of both the asylum and the p s y c h i a t r i c p r o f e s s i o n . The l a t t e r was promoted by the r u l i n g c l a s s i n an e f f o r t to give s c i e n t i f i c l e g i t i m a c y to the new p r o c e s s o f d e f i n i n g and m a n a g i n g t h e ' r e f u s e ' o f a c a p i t a l i s t s o c i e t y . T h i s p r o m o t i o n o c c u r r e d even though the knowledge and t e c h n o l o g i e s of the p r o f e s s i o n were some d i s t a n c e from a p o i n t where i t c o u l d even b e g i n to t r e a t and c u r e •3 i n s a n i t y . S c u l l ' s i n t e r e s t i n the r e l a t i o n s h i p between developments i n the economic sphere and changing s t r a t e g i e s of s o c i a l c o n t r o l i s c o n t i n u e d i n h i s i m p o r t a n t s t u d y o f t h e more r e c e n t phenomenon of 'decarceration' ( S c u l l , 1984). This trend, which has a f f e c t e d two of the descendants of the n i n e t e e n t h century, t r i p a r t i t e , s ystem of s o c i a l c o n t r o l ( i . e . , m e n t a l h e a l t h and c r i m i n a l j u s t i c e ) , has a d i r e c t b e a r i n g on the mental h e a l t h law reforms which have occurred s i n c e 1945. In S c u l l ' s view, the s h i f t from the use of i n s t i t u t i o n s to care and treatment i n the 'community', which began to emerge i n b o t h B r i t a i n and the U n i t e d S t a t e s d u r i n g the 1950's and 1960's, was a r e s p o n s e to 203 the c h a n g i n g e x i g e n c i e s of d o m e s t i c p a c i f i c a t i o n and c o n t r o l under welf a r e c a p i t a l i s m . With the coming of the w e l f a r e s t a t e , s e g r e g a t i v e modes of s o c i a l c o n t r o l became c o s t l y and d i f f i c u l t to j u s t i f y ( e s p e c i a l l y i n r e l a t i o n to the m e n t a l l y i l l ) and l i b e r a l reformers began to press f o r change. The a v a i l a b i l i t y of an organized, s o c i a l welfare system provided an o p p o r t u n i t y f o r the r e s o l u t i o n of t h e s e mounting p r o b l e m s and p r e s s u r e s . The i n m a t e s of i n s t i t u t i o n s c o u l d be s a f e l y r e l e a s e d to o r g a n i z e d , c a r e and t r e a t m e n t a l t e r n a t i v e s i n the community which would be b o t h e q u a l l y e f f e c t i v e i n c o n t r o l l i n g the m e n t a l l y i l l and cheaper to o p e r a t e . Governments would a l s o avoid the need to expend c a p i t a l funds on much needed h o s p i t a l r e s t o r a t i o n and r e b u i l d i n g p r o j e c t s . However, S c u l l argues, while t h i s s o c i a l c o n t r o l s t r a t e g y was being implemented, governments began to encounter a growing ' f i s c a l c r i s i s ' . The c o s t s of running the s o c i a l w e l f a r e i n f r a -s t r u c t u r e began to o u t s t r i p revenues as new w e l f a r e reforms and s e r v i c e s were i n t r o d u c e d i n r e s p o n s e to p o p u l a r demand. Governments, p a r t i c u l a r l y i n the U n i t e d S t a t e s , then f a c e d a s i g n i f i c a n t c o n t r a d i c t i o n t h a t was r e s o l v e d by a s t r a t e g y o f a c c e l e r a t i n g the d e c a r c e r a t i o n process but without p r o v i d i n g the funding necessary f o r the development of e f f e c t i v e community-based a l t e r n a t i v e s . The f o r m e r i n m a t e s of i n s t i t u t i o n s were dumped i n t o the community where they g r a v i t a t e d towards, and c r e a t e d 'ghettos' w i t h i n , the i n n e r urban areas of l a r g e c i t i e s . Consequently, a p r i v a t e welfare i n d u s t r y developed in order to meet the demand f o r s u p e r v i s e d accommodation, and a new breed of 204 entrepreneur emerged to e x t r a c t a p r o f i t from the ' s o c i a l junk' which was f o r m e r l y c o n t a i n e d w i t h i n the w a l l s of s t a t e h o s p i t a l s . The p r o c e s s of d e c a r c e r a t i o n was s u p p o r t e d by both humanitarian l i b e r a l reformers and c o n s e r v a t i v e p o l i t i c i a n s who were faced w i t h the p r e s s i n g problem of the ' f i s c a l c r i s i s ' . In S c u l l ' s view, t h i s u n l i k e l y a l l i a n c e of i n t e r e s t s a c t u a l l y c o n s t i t u t e d a c o - o p t a t i o n of r e f o r m e r s by the s t a t e . In p r a c t i c e , d e c a r c e r a t i o n " d i s p l a y e d remarkably l i t t l e resemblance to l i b e r a l r h e t o r i c " which was used as " i d e o l o g i c a l camouflage, a l l o w i n g economy to masquerade as benevolence and n e g l e c t as t o l e r a n c e " ( S c u l l , 1984: 152). The h i g h l y v i s i b l e , 'sewers of human misery' and the a p p a l l i n g c o n d i t i o n s which e x i s t e d behind the w a l l s of p r i v a t e n u r s i n g and b o a r d i n g homes c o u l d be e x p l a i n e d i n the language of l i b e r a l reform and c i v i l r i g h t s , r a t h e r than as a product of an e c o n o m i c a l l y determined s o c i a l c o n t r o l s t r a t e g y . S c u l l ' s t h e s i s , which was o r i g i n a l l y p u b l i s h e d i n 1977, has spawned a burgeoning number of s t u d i e s of the d e c a r c e r a t i o n p r o c e s s i n B r i t a i n and N o r t h A m e r i c a . He has c o n t i n u e d to a n a l y s e the f i e l d b o t h w i t h a view to a n s w e r i n g h i s c r i t i c s (see, S c u l l , 1984; Cohen & S c u l l , 1983) and i n an e f f o r t to map, among o t h e r t h i n g s , the new and b u r g e o n i n g 'trade i n l u n a c y ' ( S c u l l , 1981, 1981a). While h i s a n a l y s i s of d e c a r c e r a t i o n i n the c r i m i n a l j u s t i c e context has been shown to be p r o b l e m a t i c (Matthews, 1979; Chan & E r i c s o n , 1981), a f a c t that he r e a d i l y acknowledges ( S c u l l , 1984), h i s account of developments in the 205 mental h e a l t h context has been widely supported. One s t u d y of the d e c a r c e r a t i o n p r o c e s s i n B r i t a i n has s u p p o r t e d S c u l l ' s c o n t e n t i o n t h a t l i b e r a l , m e n t a l h e a l t h r e f o r m e r s have been c o - o p t e d by the s t a t e . P e t e r Sedgwick (1982) has argued that a d e c a r c e r a t i o n s t r a t e g y was adopted long b e f o r e l i b e r a l r e f o r m e r s began to p l a c e p r e s s u r e on the government and t h a t both d e - i n s t i t u t i o n a l i z a t i o n and the d i s m a n t l i n g of the mental h o s p i t a l have been p r o p e l l e d by r i g h t -wing l i b e r t a r i a n r h e t o r i c . Indeed, an e x a m i n a t i o n of the p o l i t i c s of mental h e a l t h care (rather than j u s t a focus upon problems of resource a l l o c a t i o n ) demonstrate the extent to which d e c a r c e r a t i o n i s 'markedly i d e o l o g i c a l ' . The l i b e r t a r i a n r h e t o r i c i s nothing more than a smokescreen masking the b i t t e r consequences of a new form of s o c i a l oppression; consequences s u c h as t h e d e p l e t i o n o f s e r v i c e s , t h e a c c u m u l a t i o n o f d i s c h a r g e d p a t i e n t s i n p r i s o n s and l o d g i n g houses, the s c a r c i t y of community care and treatment resources, and the dumping of p a t i e n t s i n t o the hands of h e l p l e s s f a m i l i e s . T h i s occurred i n the s e l f - i n t e r e s t of a powerful m i n o r i t y who, responding to the economic d i f f i c u l t i e s c o n f r o n t i n g the s t a t e , co-opted the work and ideology of l i b e r a l reformers without extending t h e i r ideas f o r the development of a l t e r n a t i v e s that would provide e f f e c t i v e care and treatment f o r the mentally i l l (Sedgwick, 1982). O t h e r w r i t e r s have f o c u s s e d upon the ways i n w h i c h g r o w i n g economic p r e s s u r e s have a f f e c t e d the p r o v i s i o n of h e a l t h , s o c i a l w e l f a r e , and y o u t h j u s t i c e s e r v i c e s . I t i s 206 g e n e r a l l y argued t h a t , s i n c e the l a t e 1970's, a complex set of developments have occurred i n B r i t a i n and North America which r e f l e c t a s i g n i f i c a n t r e - a l i g n m e n t i n s t a t e s o c i a l c o n t r o l s t r a t e g i e s ; namely, a c c e l e r a t e d d e - i n s t i t u t i o n a l i z a t i o n ; non-i n s t i t u t i o n a l i z a t i o n ; t r a n s - i n s t i t u t i o n a l i z a t i o n ; and, p r i v a t -i z a t i o n (Lerman, 1982; Warren, 1981, 1982; Cohen, 1985; S o c i a l P l a n n i n g C o u n c i l of M e t r o p o l i t a n T o r o n t o , 1984; E s t e s & Harrington, 1981; Dunlop, 1979; E s t r o f f , 1981; F e l t o n & Shinn, 1981; T a y l o r , 1983; Emerson, 1981; Rose, 1979; G i l b e r t , 1983; Lightman, 1986; Toews & Barnes, 1986). Some a n a l y s t s have s t u d i e d the impact of t h i s process on s o c i a l c o n t r o l p r a c t i c e s and have examined the c l a i m t h a t d e c a r c e r a t i o n r e s u l t s i n an i n c r e a s e d use of the c r i m i n a l j u s t i c e s ystem as a mechanism f o r c o n t r o l l i n g the f o r m e r r e s i d e n t s of i n s t i t u t i o n s . As Roesch & G o l d i n g (1985) have r e c e n t l y noted, in the United S t a t e s , the emergence of s t r i n g e n t laws governing c i v i l commitment, as w e l l as the p o l i c y of de-i n s t i t u t i o n a l i z a t i o n , appear to have r e s u l t e d i n a s i t u a t i o n where men t a l l y d i s o r d e r e d persons ( e s p e c i a l l y those l i v i n g i n e x - p a t i e n t ' g h e t t o s ' ) a r e b e i n g p r o c e s s e d by, b u t n o t n e c e s s a r i l y detained w i t h i n , the c r i m i n a l j u s t i c e system. The p o l i c e , i n p a r t i c u l a r , are faced with the task of managing both f o r m e r and p o t e n t i a l h o s p i t a l p a t i e n t s by t h e use o f d i s c r e t i o n a r y d i v e r s i o n and short-term lodgments i n j a i l s . In t h i s r e g a r d , a t l e a s t one commentator has argued t h a t N o r t h A m e r i c a i s w i t n e s s i n g the emergence of a ' f u n c t i o n a l i n t e r -r e l a t i o n s h i p ' between the w e l f a r e , mental h e a l t h and c r i m i n a l 207 j u s t i c e systems (Stone, 1976). I t i s e v i d e n t , t h e r e f o r e , t h a t t h e s t r a t e g y o f d e c a r c e r a t i o n has been implemented by governments i n B r i t a i n and North America, and that some of the l e s s d e s i r a b l e consequences are now e m e r g i n g . I t i s e q u a l l y c l e a r t h a t t h e r e i s a l i n k between t h i s s t r a t e g y and mental h e a l t h law reform although the p r e c i s e connection remains l a r g e l y unexplored. Sedgwick (1982) has b r i e f l y mapped the way i n which the process of d e c a r c e r a t i o n i n B r i t a i n has been a s s i s t e d by the main p r e s s u r e group i n p s y c h i a t r i c p o l i t i c s : the N a t i o n a l A s s o c i a t i o n f o r Mental Health (MIND). This o r g a n i z a t i o n became extremely e n e r g e t i c during the e a r l y 1970's and began to f o l l o w the c i v i l l i b e r t a r i a n t r a i l which had been blazed by American mental h e a l t h law advocates. The work of MIND reached a climax w i t h the p r o c l a m a t i o n of the new, Mental Health Act, 1983; the epitome of the new l e g a l i s m . S c u l l (1984) r e f e r s b r i e f l y to b o t h the impact of new, r e s t r i c t i v e commitment laws and the e f f e c t of p a t i e n t s ' r i g h t s l i t i g a t i o n i n the United S t a t e s which threatened to i n c r e a s e the c o s t s of o p e r a t i n g s t a t e mental h o s p i t a l s . In a s i m i l a r v e i n , Rubin (1978) has set out the economic consequences of the work of mental h e a l t h law advocates. In h i s view, the e s t a b l i s h m e n t of r i g h t s such as, 'the r i g h t to r e c e i v e treatment i f detained', the ' r i g h t to treatment i n the l e a s t r e s t r i c t i v e environment', and the ' r i g h t to c o m p e n s a t i o n 1 f o r work u n d e r t a k e n w h i l e r e s i d e n t i n a s t a t e h o s p i t a l have had s i g n i f i c a n t f i s c a l i m p l i c a t i o n s f o r s t a t e governments (see, a l s o , Wald & Freidman, 1978; Lerman, 1982). Where cou r t s have ordered changes such as 208 improvements i n the q u a l i t y of care and treatment i n h o s p i t a l s and the banishment of p a t i e n t l a b o u r , t h i s has t h r e a t e n e d t o in c r e a s e c o s t s . One o p t i o n has been to c l o s e h o s p i t a l s ; that i s , adopt a p o l i c y of d e - i n s t i t u t i o n a l i z a t i o n . S i m i l a r l y , the es t a b l i s h m e n t of a r i g h t to the l e a s t r e s t r i c t i v e a l t e r n a t i v e has p r o v i d e d the j u s t i f i c a t i o n s n e c e s s a r y to l e g i t i m a t e the c l o s u r e of h o s p i t a l s but, at the same t i m e , n e c e s s i t a t e d the t r a n s f e r of u n s p e c i f i e d (and t h e r e f o r e r e d u c i b l e ) funds to the community care f i e l d . As Lerman (1982) has shown, i n one p l a c e ( C a l i f o r n i a ) t h i s provided the government with an o p p o r t u n i t y to s l a s h the mental h e a l t h c a r e budget. I t i s n o t e w o r t h y t h a t t h e s e ' r i g h t s ' have appeared i n the s t a t u t e s and d i s c o u r s e s a s s o c i a t e d w i t h the new l e g a l i s m i n c o u n t r i e s such as Canada. While the adoption of the d e c a r c e r a t i o n s t r a t e g y has been w e l l mapped, c o n s i d e r a b l e u n c e r t a i n t y s t i l l s u r r o u n d s the q u e s t i o n 'why'? A t t e m p t s have been made t o e x p l a i n d e c a r c e r a t i o n and the r i s e of community p s y c h i a t r y i n , f o r example, Canada. R a l p h (1983) argues t h a t t h i s d evelopment r e f l e c t e d a long-term s t r a t e g y f o r both the r e g u l a t i o n of the l a b o u r f o r c e and the management of the l a b o u r market; a view that i n t e r s e c t s w i t h the work of those concerned w i t h a c r i t i c a l examination of the e n t i r e Canadian 'welfare s t a t e ' (see, e.g., Moscovitch & Drover, 1981). Regardless, c r i t i c s of S c u l l o b j e c t not only to h i s 'economic determinism' but, more p a r t i c u l a r l y , to h i s f a i l u r e to s e t out the c h a n g i n g economic c o n d i t i o n s w i t h i n c a p i t a l i s m which r e s u l t e d i n the ' f i s c a l c r i s i s ' (see, Matthews, 1979). His ' h i s t o r i c a l l y informed, m a c r o - s o c i o l o g i c a l 209 a n a l y s i s ' , w h i l e v a l i d and w e l l - i n t e n d e d , t h e r e f o r e f a l l s s h o r t of i t s g o a l . In t h i s regard, an a n a l y s i s of the changing nature of both mental h e a l t h s t r a t e g i e s and mental h e a l t h law i n t e r s e c t s with the burgeoning body of l i t e r a t u r e which addresses the o r i g i n s , development, and r o l e of the modern w e l f a r e s t a t e (e.g., F l o r a & H e i d e n h e i m e r , 1981; M o s c o v i t c h & D r o v e r , 1981; Guest, 1980; i Gough, 1979). Likew i s e , the work which examines the emergence of the r e a l and p e r c e i v e d , i d e o l o g i c a l and economic c r i s e s t h a t have confronted the w e l f a r e s t a t e s i n c e the mid-1970's, i s of d i r e c t r e l e v a n c e (e.g., T a y l o r - G o o b y , 1985; Gough, 1979; T h e r b o r n & Roebroek, 1986; O r g a n i z a t i o n f o r Economic Co-o p e r a t i o n and Development, 1981; Piven & Cloward, 1982; Stoesz, 1981; M i s h r a , 1984). S i n c e t h i s i s s u e w i l l be a d d r e s s e d i n l a t e r c h a p t e r s the p r e s e n t e x c u r s i o n i n t o t h i s f i e l d w i l l be c u r s o r y . S u f f i c e i t to note t h a t , s i n c e the p r o v i s i o n of care and treatment f o r mental d i s o r d e r s f e l l w i t h i n the ambit of a p u b l i c s o c i a l w e l f a r e system (i.e., a 'welfare state') i n most w e s t e r n c o u n t r i e s d u r i n g the l a t e 1940's and e a r l y 1950's, mental h e a l t h care s t r a t e g i e s (e.g., d e - i n s t i t u t i o n a l i z a t i o n ) are o b v i o u s l y connected to broader developments a f f e c t i n g the w e l f a r e s t a t e . I t f o l l o w s , t h e r e f o r e , that any a n a l y s i s of the s t r u c t u r a l c o n d i t i o n s surrounding mental h e a l t h s t r a t e g y and law reform must take account of the changing f o r t u n e s of the w e l f a r e s t a t e . M e n t a l h e a l t h law i s , i n a b r o a d s e n s e , ' w e l f a r e s t a t e law', 210 s i n c e i t r e g u l a t e s one sphere of a c t i v i t y w i t h i n t h i s aspect of the s t a t e a p p a r a t u s . C o n s e q u e n t l y , i t might be e x p e c t e d t o r e f l e c t changes a f f e c t i n g p u b l i c s o c i a l w e l f a r e systems, which have t h e i r r o o t s i n the l a r g e r i d e o l o g i c a l and economic s t r u c t u r e s of s o c i e t y . The w e l f a r e s t a t e f l o u r i s h e d d u r i n g t h e h e y d a y o f Keynesian economic theory; the foundation of the s t r a t e g y f o r s o c i a l r e c o n s t r u c t i o n and economic growth adopted by western n a t i o n s i n the 1940's. It i s contended that Keynesian p o l i c i e s encountered major d i f f i c u l t i e s d uring the e a r l y 1970's w i t h the emergence of a s e r i e s of problems which manifested themselves a s , f i r s t i n f l a t i o n , t h e n s t a g f l a t i o n and, f i n a l l y , an e n g i n e e r e d r e c e s s i o n w h i c h d e v e l o p e d i n t o an e c o n o m i c depression. Some c o n s e r v a t i v e western governments switched to a new economic p o l i c y based upon the p r i n c i p l e s of monetarism and s u p p l y - s i d e e c o n o m i c s ( t h e s o - c a l l e d T h a t c h e r n o m i c and Reaganomic s t r a t e g i e s ) and the new s t r a t e g y i n v o l v e d b o t h an adjustment i n major Keynesian p r i n c i p l e s (notably, a r e d u c t i o n i n d i r e c t government i n v o l v e m e n t i n the management of the economy), and a d e c r e a s e i n (or at l e a s t a s l o w i n g of) p u b l i c s e c t o r e x p e n d i t u r e s (Crane, 1981; T a r s h i s , 1985; Lightman, 1986). The l a t t e r was, i n any c a s e , n e c e s s a r y to s a t i s f y i n t e r n a t i o n a l debt o b l i g a t i o n s ( T a r s h i s , 1985). I t i s w i t h i n t h i s broader economic context that the phenomenon a l l u d e d to by S c u l l as the ' f i s c a l c r i s i s ' of the s t a t e (O'Connor, 1973), and otherwise r e f e r r e d to as the 'budget d e f i c i t 1 , and the 'problem with the p u b l i c s e c t o r borrowing requirement' (Taylor, 1983), 211 has emerged. The s h i f t i n economic s t r a t e g y has been accompanied by a s i g n i f i c a n t i d e o l o g i c a l t r a n s f o r m a t i o n . The dominant ideology of ' w e l f a r i s m ' has g i v e n way to a ' n e o - c o n s e r v a t i v e ' i d e o l o g y t h a t r e - a f f i r m s the v i r t u e s of (among o t h e r t h i n g s ) rugged i n d i v i d u a l i s m , p a t r i o t i s m and n a t i o n a l i s m . I t a l s o condemns o r g a n i z e d t r a d e u n i o n s f o r t h e i r r o l e i n c r e a t i n g economic i n s t a b i l i t y and c h a s t i z e s the s o c i a l l y and e c o n o m i c a l l y disadvantaged f o r t h e i r f a i l u r e to succeed (Taylor-Gooby, 1985; S t o e s z , 1981; M i s h r a , 1984). T h i s i d e o l o g y - g e n e r i c a l l y r e f e r r e d to as the 'New R i g h t ' - a p p e a r s to be an e s s e n t i a l i n g r e d i e n t i n the 'plan to adopt the new economic s t r a t e g y s i n c e the l a t t e r n e c e s s a r i l y i n v o l v e s a d e c i m a t i o n of some s o c i a l w e l f a r e s e r v i c e s f o r the d i s a d v a n t a g e d (Drover, 1983). In a t t a c k i n g the w e l f a r e s t a t e - a d evelopment t h a t has most r e c e n t l y reached the hallowed ground of h e a l t h care (Weller & Manga, 1983; Gray, 1983) - a government i s r e q u i r e d to m o b i l i z e a l e g i t i m a t i n g i d e o l o g y l e s t i t s a c t i o n s draw the i r e of the e l e c t o r a t e . I t i s contended t h a t the i d e o l o g y o f 'neo-conservatism' has been u s e f u l l y employed to t h i s end (see, e.g., Stoesz, 1981; Mishra, 1984). The f o r e g o i n g p r o v i d e s a b r i e f overview of the' kinds of ' s t r u c t u r a l c o n d i t i o n s ' under which the post-1945 p e r i o d s of mental h e a l t h law reform have occurred. In g e n e r a l , r e v i s i o n i s t a n a l y s t s hold a r a d i c a l l y d i f f e r e n t view of the s t a t e than that which underpins the work of the ' i n t e r e s t group' t h e o r i s t s . The s t a t e i s seen as the agency which s t i m u l a t e s mental h e a l t h 212 p o l i c y and law reform, and changes occur as a consequence of (or as a p a r t o f ) a l a r g e r s t r a t e g y ; f o r example, a new p l a n f o r c o n t r o l l i n g ' s o c i a l junk'. The l a r g e r s t r a t e g y i s , i n t u r n , a f f e c t e d by b r o a d e r economic and i d e o l o g i c a l d e v e l o p m e n t s . T h i s i s a f a r c r y from the p l u r a l i s t model of the l i b e r a l democratic government s i n c e the r e v i s i o n i s t p e r s p e c t i v e views the s t a t e as an i n t e g r a l p a r t , r a t h e r than a n e u t r a l f e a t u r e , of the c a p i t a l i s t economic and s o c i a l order. I t s a c t i v i t i e s are molded by i m p e r a t i v e s which a r i s e from the needs of c a p i t a l i s m ; namely, l e g i t i m a t i o n of b o t h the s t a t e and the c a p i t a l i s t s y s t e m , a c o n t i n u a t i o n o f t h e c o n d i t i o n s n e c e s s a r y f o r a c c u m u l a t i o n (O'Connor, 1973), and the maintenance of s o c i a l order through c o e r c i o n (Panitch, 1979). A r e n e w e d d e b a t e o v e r t h e n a t u r e and r o l e o f t h e \ c a p i t a l i s t s t a t e has a b s o r b e d many s o c i o l o g i s t s s i n c e the c e l e b r a t e d exchange between Ralph M i l i b a n d and Nicos Poulantzas i n the e a r l y 1970's (see, e.g., M i l i b a n d , 1983; J e s s o p , 1982). This f i e l d of i n q u i r y , which i s neo-Marxist i n c h a r a c t e r , has p a s s e d t h r o u g h a s e r i e s of phases from which f o u r , c o r e p e r s p e c t i v e s have e m e r g e d ; n a m e l y , i n s t r u m e n t a 1 i s m , s t r u c t u r a l i s m , neo-Gramscian analyses, and the ' c a p i t a l l o g i c ' or s t a t e d e r i v a t i o n ( s t a a t s a b l e i t u n g ) approaches. Surrounding t h e s e are o t h e r t r a j e c t o r i e s such as those of the 'stamocap', H e g e l i a n / M a r x i s t , and ' p o l i t i c a l c l a s s s t r u g g l e ' t h e o r i s t s ( J e s s o p , 1982). The f o u r c o r e p e r s p e c t i v e s may be b r i e f l y summarised as f o l l o w s : I n s t r u m e n t a l i s t s argue that the s t a t e and s t a t e apparatuses are 213 the t o o l s of a c l a s s of c a p i t a l i s t s who h o l d an unequal amount of power and wealth. Representatives of t h i s c l a s s occupy key p o s i t i o n s w i t h i n the s t a t e which i s made to work at the behest of the e l i t e (see, e.g., M i l i b a n d , 1969). S t r u c t u r a l i s t s argue t h a t w h i l e the n a t u r e of the s t a t e i s determined by the c l a s s s t r u c t u r e of c a p i t a l i s t s o c i e t y , i t i s an agency w o r k i n g on b e h a l f of c a p i t a l i s m as a whole, r a t h e r than a p a r t i c u l a r group of c a p i t a l i s t s . I t i s o b l i g e d to p e r f o r m c e r t a i n f u n c t i o n s f o r c a p i t a l i s m (e.g., o r d e r maintenance and l e g i t i m a t i o n ) and, to t h i s end, i t has a degree of ' r e l a t i v e autonomy'. I t s a c t i v i t i e s are determined by deep s t r u c t u r a l r e l a t i o n s and an o b j e c t i v e (rather than a s u b j e c t i v e , or personal) r e l a t i o n e x i s t s between the s t a t e and the dominant c l a s s (see, e.g., Poulantzas, 1973). Neo-Gramscian t h e o r i s t s argue that the s t a t e i s a c l a s s f o r c e w i t h a v i t a l r o l e i n : the o r g a n i z a t i o n of c l a s s d o m i n a t i o n ; s e c u r i n g the long-term i n t e r e s t s and cohesion of the c a p i t a l i s t c l a s s ; and, f a c i l i t a t i n g concessions to the subordinate c l a s s e s . Most i m p o r t a n t l y , the s t a t e must secure the a c t i v e consent of the g overned ( i . e . , produce and r e p r o d u c e the hegemony of the d o minant c l a s s ) . The s t a t e i s an i n t e g r a t e d form composed of ' p o l i t i c a l s o c i e t y ' (government and i t s a p p a r a t u s ) and ' c i v i l s o c i e t y ' , the l a t t e r being the seat of popular consensus where s o c i a l r e l a t i o n s and i n s t i t u t i o n s s e r v e to s u s t a i n (but a l s o challenge) hegemony (Jessop, 1982). C a p i t a l l o g i c t h e o r i s t s argue that the form and f u n c t i o n s of the c a p i t a l i s t s t a t e can be s y s t e m a t i c a l l y d e r i v e d from a b s t r a c t p r i n c i p l e s of p o l i t i c a l economy. Since the s t a t e i s an i n t e g r a l p a r t of the p r o c e s s of c a p i t a l a c c u m u l a t i o n i t r e f l e c t s and r e p r o d u c e s b o t h t h e b a s i c 'laws' ( o r l o g i c ) and t h e c o n t r a d i c t i o n s of c a p i t a l i s m . At the same time, i t i s necessary to e x p l o r e the s o c i a l r e l a t i o n s of c a p i t a l and the l i m i t s p l a c e d on the a c t i o n s of both the s t a t e and c a p i t a l which a r i s e from c l a s s s t r u g g l e s (see, e.g., H o l l o w a y & P i c c i o t t o , 1978; Esping-Andersen, et a l , 1976). While European t h e o r e t i c a l f o r m u l a t i o n s tend to dominate t h i s 'new' s o c i o l o g y of the s t a t e , North American c o n t r i b u t i o n s h a v e e m e r g e d . As S t e v e n s o n ( 1 9 8 3 ) p o i n t s o u t , t h e ' i n s t r u m e n t a l i s t ' p e r s p e c t i v e was r e f l e c t e d i n the work o f Domhoff (1967), w h i l e the ' s t r u c t u r a l i s t 1 p o s i t i o n i s to be found i n O'Connor's c l a s s i c a n a l y s i s of both the 'functions' and the ' f i s c a l c r i s i s ' of the s t a t e (O'Connor, 1973). Both c o r e p e r s p e c t i v e s have had a s i g n i f i c a n t impact on the development of 214 analyses of the Canadian s t a t e ; a task that has been embraced by s o c i o l o g i s t s (see, e.g., P a n i t c h , 1979; Stevenson, 1983; Ratner & McMullan, 1987; Olsen, 1980), a n a l y s t s of the s o c i a l w e l f a r e system ( F i n d l a y , 1978; Moscovitch & Drover, 1981), and the 'new' p o l i t i c a l e c o n o m i s t s (see, e.g., Clement, 1975, 1977; N i o s i , 1981; Glenday, e t a l , 1978; Marchak, 1981; Deaton, 1973). G e n e r a l l y , these Canadian c o n t r i b u t o r s have yet to reach f i r m c o n c l u s i o n s about the n a t u r e and r o l e of the s t a t e . W h i l e c l e a r , i n t e r - s u b j e c t i v e r e l a t i o n s h i p s e x i s t between the s t a t e and c a p i t a l i s t f a c t i o n s , the c onsequences are u n c e r t a i n . Indeed, the n a t u r e and r o l e of the s t a t e a p p e a r s to d i f f e r a ccording to the h i s t o r i c a l juncture under examination, the type of s t a t e ( i . e . , p r o v i n c i a l or f e d e r a l ) , the r e g i o n , and the nature of the concrete s i t u a t i o n or problem confronted by the s t a t e ( M c M u l l a n & R a t n e r , 1983; R a t n e r & M c M u l l a n , 1987; Stevenson, 1983). Since law i s an i n t e g r a l p a r t of the apparatus of a s t a t e , some s t a t e t h e o r i s t s have addressed the s i g n i f i c a n c e of law and the l e g a l form, as w e l l as the q u e s t i o n of law reform as a mode of p r a x i s ( J e s s o p , 1980). In the i n s t r u m e n t a l i s t view, a l l p u b l i c law i s a weapon of c o e r c i o n wielded by the r u l i n g c l a s s , while p r i v a t e law i s a mechanism f o r r e g u l a t i n g o r g a n i z a t i o n s and r e l a t i o n s h i p s f o r the same economic i n t e r e s t s . J u r i d i c a l i d e o l o g y p l a y s a s i g n i f i c a n t r o l e i n the m y s t i f i c a t i o n and l e g i t i m a t i o n of power r e l a t i o n s , the law, l e g a l i n s t i t u t i o n s , and economic r e l a t i o n s , a l l i n the i n t e r e s t s of c a p i t a l i s t p roduction. The process of law reform i s n e c e s s a r i l y s u b j e c t to 215 t h e s e p r e v a i l i n g c o n d i t i o n s and i t i s f u t i l e to suppose t h a t a n y t h i n g but m i n i m a l r e f o r m s can be a c h i e v e d w i t h i n the c a p i t a l i s t s o c i a l and economic order (Hunt, 1980; Jessop, 1980; Bankowski & Mungham, 1976, 1980; C h a m b l i s s & Seidman, 1982; Beirne & Quinney, 1982). For s t r u c t u r a l i s t s , the law ( l i k e o t h e r a s p e c t s of the s t a t e apparatus), i s a ' r e l a t i v e l y autonomous' system. I t has three primary f u n c t i o n s . I t r e g u l a t e s , o r g a n i z e s and s a n c t i o n s a c t i v i t y i n the economic sphere thereby ensuring both cohesion and the c o n d i t i o n s n e c e s s a r y f o r c a p i t a l a c c u m u l a t i o n . I t ensures s o c i a l cohesion through i t s i d e o l o g i c a l f u n c t i o n (i.e., i t p l a y s a v i t a l r o l e i n the maintenance of hegemony). F i n a l l y , the law o r g a n i z e s and r e g u l a t e s a c t i v i t i e s both w i t h i n the s t a t e apparatus (i.e., the r a t i o n a l - l e g a l a d m i n i s t r a t i o n of a s o c i e t y and an economy by a bureaucracy), and i n the s o c i e t y at l a r g e . In the l a t t e r c o n t e x t , i t e n s u r e s c o h e s i o n by c o n t r o l l i n g p o l i t i c a l c l a s s s t r u g g l e s . Where c o n f l i c t emerges, the law o r g a n i z e s the s t r u c t u r e of a 'compromise' which i s always imposed on the dominated, even though t h i s may mean l i m i t i n g the power of the dominant c l a s s . The l a t t e r i s necessary to defuse the d o m i n a t e d , i n the i n t e r e s t s of c a p i t a l i s m as a whole (Jessop, 1980). Since the law i s ' r e l a t i v e l y autonomous', and s i n c e i t i s a f f e c t e d by the p o t e n t i a l l y c o n t r a d i c t o r y i m p e r a t i v e s of both the s t a t e (e.g., m a i n t a i n i n g order and l e g i t i m a c y ) and i t s own c h a r a c t e r i s t i c s (e.g., formalism and b u r e a u c r a t i c i n t e r e s t s ) the 216 use of law by the s t a t e i s l i m i t e d (Balbus, 1977). Indeed, one aspect of the l e g a l form which was c r e a t e d , and i s maintained, by the s t a t e - the n o t i o n of the r u l e of law - can be used a g a i n s t the s t a t e p r o v i d i n g i t i s a p p l i e d competently. However, while the r e l a t i v e autonomy of law means that e f f e c t i v e reform i s p o s s i b l e , reformers always stand i n danger of being co-opted by the s t a t e ( J e s s o p , 1980; F i n e , e t a l , 1979; C h a m b l i s s & Seidman, 1982; Beirne & Quinney, 1982; Sumner, 1981). Neo-Gramscian t h e o r i s t s focus upon the ways i n which law becomes r e i f i e d and then turned i n t o a f o r c e that dominates i t s human c r e a t o r s . In t h i s regard, the primary concern i s w i t h the r o l e of r e i f i e d law i n the m a n u f a c t u r e and maintenance of hegemony. T h i s p e r s p e c t i v e i s not i n c o m p a t i b l e w i t h the focus upon the i d e o l o g i c a l f u n c t i o n s of law found amongst t h e o r i s t s from the other core p e r s p e c t i v e s (Albrow, 1981), and i t has been used e f f e c t i v e l y to e x p l i c a t e the state's m o b i l i z a t i o n of law as a key t o o l i n a s t r a t e g y f o r meeting a c r i s i s of hegemony ( H a l l , e t a l , 1978; J e s s o p , 1980). E f f e c t i v e law r e f o r m i s both p o s s i b l e and d e s i r a b l e , p r o v i d i n g i t i s undertaken by the ' o r g a n i c ( i . e . , 'working c l a s s ' ) i n t e l l e c t u a l s ' who e x i s t i n ' c i v i l s o c i e t y ' . In Gramsci's view, the l a t t e r i s the l o c u s of counter-hegemony where i d e o l o g i c a l s t r u g g l e s can produce s o c i a l change t o the b e n e f i t of s u b o r d i n a t e d c l a s s e s , and o r g a n i c i n t e l l e c t u a l s are key a c t o r s who can begin the s t r u g g l e through a r e - c o n s t r u c t i o n of wo r k i n g - c l a s s consciousness (Jessop, 1982; Sumner, 1979). Since the ' c a p i t a l l o g i c ' t h e o r i s t s attempt to d e r i v e the 217 form and f u n c t i o n of the s t a t e from the c a p i t a l i s t mode and r e l a t i o n s of pr o d u c t i o n , the l e g a l form (and the f u n c t i o n s of law) a r e t o be u n d e r s t o o d a s an a r t i f a c t o f t h e s e same phenomena. Consequently, t h e o r i s t s t r y to e x p l a i n law, l e g a l i t y and the l e g a l o r d e r (e.g., the n o t i o n of the r u l e of law) as a r e f l e c t i o n of the mode and r e l a t i o n s of p r o d u c t i o n w i t h i n which both the s t a t e and i t s l e g a l system are embedded (Jessop, 1980). While the focus i s p r i m a r i l y upon the c a p i t a l i s t form of law, t h i s i s not an e x c l u s i v e concern s i n c e t h e o r i s t s are i n t e r e s t e d i n the l e g a l t r a n s f o r m a t i o n s which may occur where c a p i t a l i s m i s r e p l a c e d by a s o c i a l i s t economic system ( i . e . , the s h i f t to •popular j u s t i c e ' ) (De Sousa S a n t o s , 1980). In t h i s r e g a r d , c o n s i d e r a b l e i n t e r e s t has been shown i n the works of a (now departed) S o v i e t j u r i s t who i s seen as the fountainhead of the c a p i t a l l o g i c approach to law; namely, Evgeny Pashukanis (Beirne & S h a r l e t t , 1980). In h i s view, the form and f u n c t i o n of law (e.g., i t s concern w i t h market r e l a t i o n s and the f e t i s h of the j u r i d i c a l i n d i v i d u a l ) was a r e f l e c t i o n of the needs of both the p r e v a i l i n g , b o u r g e o i s form of commodity-exchange and the a s s o c i a t e d r e l a t i o n s between s u b j e c t s . T h e o r i s t s are u n c l e a r on the quest i o n of the p r a x i s of law r e f o r m . I t i s n o t e w o r t h y t h a t t h e p r i n c i p a l p i o n e e r ( P a s h u k a n i s ) was d i s s a t i s f i e d w i t h a t t e m p t s to r e p l a c e the b o u r g e o i s l e g a l form i n S t a l i n i s t R u s s i a , b e f o r e a co m p l e t e t r a n s f o r m a t i o n t o s o c i a l i s m had been a c c o m p l i s h e d . The consequent demise of both the i n d i v i d u a l and h i s work suggests that those who oppose reforms d e s i r e d by the s t a t e are u n l i k e l y 218 to succeed. Conversely, those who seek reform, at a time when the s t a t e does not, are e q u a l l y u n l i k e l y to achieve t h e i r g o a l s . However, t h i s example of r e p r e s s i o n by an 'exceptional s t a t e ' does not s e r v e to d i s c o u n t the p o s s i b i l i t y of e f f e c t i v e law reform i n other s i t u a t i o n s . Nevertheless, i t may be presumed t h a t s i n c e t h e l e g a l f o r m i s s e e n as b e i n g t i e d t o t h e p r e v a i l i n g mode and r e l a t i o n s of p r o d u c t i o n , reform i s p o s s i b l e only to the extent that i t i s compatible with economic changes. I t s h o u l d be no t e d t h a t , as thes e a n a l y s e s of the law-s t a t e r e l a t i o n have emerged, a c o n s i d e r a b l e amount of c r o s s -f e r t i l i z a t i o n has o c c u r r e d . A degree of c o n v e r g e n c e i s p a r t i c u l a r l y n o t i c e a b l e among the s t r u c t u r a l i s t and c a p i t a l -l o g i c t h e o r i s t s (De Sousa Santos, 1980; Balbus, 1977a), as w e l l as those i n t e r e s t e d i n the i d e o l o g i c a l form of law (Albrow, 1981). T h i s f i e l d of i n q u i r y has a l s o i n t e r s e c t e d w i t h , and in d e e d c o n s t i t u t e s a d i s t i n c t i v e f e a t u r e o f , a f r e s h and b u r g e o n i n g t r a j e c t o r y w i t h i n the s o c i o l o g y of law. As many w r i t e r s have noted (e.g., Hunt, 1981, 1981a; Fryer, et a l , 1981; C h a m b l i s s & Seidman, 1982; B e i r n e & Quinney, 1982), the s o c i o l o g y of law i s e x p e r i e n c i n g a p e r i o d of r a p i d , t h e o r e t i c a l and methodological t r a n s f o r m a t i o n . The emergence of a coherent and s y s t e m a t i c neo-Marxist c o n t r i b u t i o n to an understanding and e x p l a n a t i o n o f law and t h e l e g a l f o r m has been l a r g e l y r e s p o n s i b l e f o r t h i s d evelopment. In the c o n t e x t of t h e o r y , f o u r main themes a r e e v i d e n t : a f o c u s upon the i d e o l o g i c a l 219 dimension of law (Sumner, 1979; H i r s t , 1979; Edelman, 1979); a f o c u s upon l e g a l i t y and the form of law ( B e i r n e & S h a r l e t t , 1980); a f o c u s upon the i n t e r - s u b j e c t i v e , p h e n o m e n o l o g i c a l dimensions of law and the r e l a t i o n s h i p s between l e g a l a c t o r s (Fraser, 1978; Gabel, 1977; Trubek, 1977); and, as we have seen, a focus upon the l a w - s t a t e r e l a t i o n s h i p (Jessop, 1980). These themes are heralded as c o n s t r u c t i v e avenues along which to break away from the c o n s t r a i n t s of the 'coercion-consent 1 dichotomy and the ' s o c i a l engineering' approach of s o c i o - l e g a l s t u d i e s , as w e l l as p r o v i d i n g an e f f e c t i v e c r i t i q u e o f l i b e r a l i s m , f o rmalism, and the r e s i d u e of R e a l i s t j u r i s p r u d e n c e w i t h i n the s o c i o l o g y of law (Fryer, et a l , 1981). At a methodological l e v e l , the neo-Marxist c o n t r i b u t i o n has encouraged such developments as a u s e f u l r e f o r m u l a t i o n of r e s e a r c h addressing the gap between *law-on-the-books' and 'law-i n - a c t i o n ' by l i n k i n g t h i s important approach with a meaningful t h e o r e t i c a l framework (Gregory, 1979). I t has a l s o i n s p i r e d a r a d i c a l r e - e x a m i n a t i o n of l e g a l h i s t o r y , i n the form o f 'emergence s t u d i e s ' (Sugarman, 1981), l e a d i n g to the development of a d i s t i n c t i v e s o c i o - h i s t o r i c a l method and, i n some cases, a c o n c o m i t a n t f o c u s upon h i s t o r i c a l m a t e r i a l i s m (see, e.g., Sumner, 1979). As Fryer, et a l (1981) p o i n t out, t h i s emerging h i s t o r i c a l method i s e p i t o m i z e d by the c o n t r i b u t i o n s of Thompson (1977) and Hay, et a l (1975). The growth of t h i s general t h e o r e t i c a l and methodological t r a j e c t o r y can be s y n t h e s i z e d around three main g o a l s : (i) the d e v e l o p m e n t o f t h e o r y i n an a r e a o f s o c i o l o g y t h a t has 220 e x p e r i e n c e d few, i f any, t h e o r e t i c a l advances s i n c e the c o n t r i b u t i o n s of Durkheim and Weber; ( i i ) the d e velopment of t h e o r e t i c a l l y informed e m p i r i c a l i n v e s t i g a t i o n s ; and, ( i i i ) the r e - d i r e c t i o n of a t t e n t i o n away from the c r i m i n a l s p h e r e and t owards b o t h c i v i l law and the q u e s t i o n of the form of law ( F r y e r , e t a l , 1981). S i g n i f i c a n t l y , the l a s t g o a l i s a l s o s ought by t h o se w o r k i n g o u t s i d e the n e o - M a r x i s t t r a j e c t o r y . F e e l e y (1976), f o r example, has argued t h a t the narrow but dominant concern of s o c i o l o g i s t s of law w i t h the f o r m a t i o n and a p p l i c a t i o n of c r i m i n a l laws has both c o n s t r a i n e d developments and l e d to a n e g l e c t of the numerous and s u b t l e methods of s o c i a l c o n t r o l embodied i n v a r i o u s types of ' f a c i l i t a t i v e ' law; notably, the law of t o r t s and t a x a t i o n law. S p e c i f i c c o n t r i b u t i o n s a p p l y i n g n e o - M a r x i s t themes to p a r t i c u l a r forms of law have been emerging r a p i d l y . While an i n t e r e s t i n c r i m i n a l law i s s t i l l e v i d e n t (see, e.g. S p i c e r , 1981), o t h e r a r e a s are r e c e i v i n g a t t e n t i o n . These i n c l u d e , redundancy payments l e g i s l a t i o n (Fryer, 1981); the f o r m a l i z a t i o n of c o n t r a c t law ( C o t t e r r e l l , 1981); c h i l d - c a r e l e g i s l a t i o n ( B o l g e r , e t a l , 1981); t r a d e p r a c t i c e s l e g i s l a t i o n (Heydon, 1980); l a n d l o r d and tenant law ( P a r t i n g t o n , 1980; Beirne, 1977); company law (Hadden, 1975); r a c e r e l a t i o n s and sex d i s c r i m i n a t i o n law (Rendel, 1976, G r e g o r y , 1979); l a b o u r r e l a t i o n s law ( K l a r e , 1982); e n v i r o n m e n t a l law (Gunningham, 1974), and the law r e l a t i n g to i n d u s t r i a l h e a l t h and s a f e t y ( C h a m b l i s s & Seidman, 1982). In each c a s e , the c o n t r i b u t o r s c o n n e c t t h e i r e m p i r i c a l s t u d i e s to one (or more) of the 221 p r i n c i p a l , neo-Marxist themes. I t i s e v i d e n t , t h e r e f o r e , t h a t a s i g n i f i c a n t body of t h e o r e t i c a l and e m p i r i c a l i n v e s t i g a t i o n has developed w i t h i n the n e o - M a r x i s t t r a j e c t o r y ; however, t h i s work has not esc a p e d c r i t i c i s m . While the r e a c t i o n s of some c r i t i c s have been shown to be s e r i o u s l y i n e r r o r ( B e i r n e , 1979), some v a l i d p r o b l e m s have been exposed. I t has been argued that the approach leads to s t r u c t u r a l ( e s p e c i a l l y economic) determinism and t h e r e f o r e de-values human agency. The s t a t e i s seen as a m o n o l i t h i c and mani p u l a t i v e (and manipulated) e n t i t y i n v e s t e d w i t h p r o p h e t i c powers, and t h i s i s simply not the case; f o r example, t h e o r i s t s n e g l e c t to deal w i t h the impact of b u r e a u c r a t i c s t r u c t u r e s and systems (which embody human act i o n ) on law c r e a t i o n and l e g a l i n t e r p r e t a t i o n . There i s a tendency f o r a n a l y s t s to concentrate upon those a r e a s of n o n - c r i m i n a l law which d i s p l a y a c l e a r r e l a t i o n s h i p between the s t a t e , c a p i t a l i s m , and law, t h e r e b y maximising the chances that the data w i l l f i t the theory (i.e., the quest i s f o r v e r i f i c a t i o n , not f a l s i f i c a t i o n ) ( S t e i n , 1980; Jacobs, 1980). W h i l e the employment of the c o n c e p t of the ' r e l a t i v e l y autonomous' s t a t e has erased the crude i n s t r u m e n t a l i s m evident i n e a r l y s t u d i e s , t h i s has r e s u l t e d i n the dev e l o p m e n t of a M a r x i s t brand of f u n c t i o n a l i s m t h a t i s as t a u t o l o g o u s as the P a r s o n i a n e n t e r p r i s e which M a r x i s t t h e o r i s t s so v i g o r o u s l y r e j e c t (Jacobs, 1980). In a d d i t i o n , the tendency to s e l e c t , f o r example, laws r e l a t e d to the management of c l e a r - c u t economic 222 r e l a t i o n s r e s u l t s i n a n e g l e c t of those areas of law which are not o b v i o u s l y r e p r e s s i v e or r e g u l a t o r y . Indeed, i n any one year, a l e g i s l a t u r e passes numerous and v a r i o u s types of laws. Some may be ' r e p r e s s i v e ' i n n a t u r e and some may be c o n c e r n e d w i t h f a c i l i t a t i n g and r e g u l a t i n g economic r e l a t i o n s . However, many a r e m o re b r o a d l y r e g u l a t o r y , some a r e p u r e l y a d m i n i s t r a t i v e , and others a c t u a l l y c o n s t r a i n the power of the s t a t e or o t h e r w i s e advance the i n t e r e s t s of the ' r e p r e s s e d ' . F u r t h e r , they may be aimed a t s p e c i f i c groups or s p e c i f i c r e l a t i o n s h i p s r a t h e r than a t a whole s o c i e t y . N e o - M a r x i s t s o c i o l o g i s t s of law have to a d d r e s s t h e s e i s s u e s i f t h e i r t h e o r e t i c a l c l a i m s are to be s u s t a i n e d ; p a r t i c u l a r l y , i f they wish to c o n s t r u c t a general theory of law ( S t e i n , 1980). The f o r e g o i n g d i s c u s s i o n of the work of those i n t e r e s t e d i n an examination of the broader s t r u c t u r a l f a c t o r s a f f e c t i n g b o t h the s p e c i f i c f i e l d of m e n t a l h e a l t h law and the more g e n e r a l i s s u e of the l a w - s t a t e r e l a t i o n s h i p , p r o v i d e s an i m p o r t a n t c o n t r i b u t i o n to an u n d e r s t a n d i n g of the f a c t o r s a f f e c t i n g reform at p a r t i c u l a r times. However, these analyses have f o c u s s e d upon the s i t u a t i o n i n B r i t a i n and the U n i t e d S t a t e s and i t i s consequently necessary to q u e s t i o n the extent to which they might account f o r mental h e a l t h law reforms i n the Canadian context. Since no attempt has yet been made to analyse the p e r i o d s of reform a f f e c t i n g Canadian mental h e a l t h law, the u t i l i t y of the e x p l a n a t i o n s provided by B r i t i s h w r i t e r s such as Bean (1980) and Unsworth (1979) remains uncle a r . C e r t a i n l y , there have been 223 t r a n s f o r m a t i o n s i n the dominant, Canadian ideology. According to Marchak (1981), the nation's h i s t o r y i s c h a r a c t e r i z e d b r o a d l y by a s h i f t from conservatism to l i b e r a l i s m , and then to a f u s i o n of l i b e r a l i s m and s o c i a l i s m . T h i s i s now g i v i n g way to a r e v i t a l i z e d form of c o n s e r v a t i s m - ' c o r p o r a t i s m ' or 'neo-c o n s e r v a t i s m ' (Marchak, 1981; R e s n i c k , 1984). However, the e x t e n t to w h i c h th e s e changes have i n f l u e n c e d mental h e a l t h p o l i c i e s and l e g i s l a t i o n i s unknown. S i m i l a r l y , Canada has e x p e r i e n c e d p e r i o d s where a c r i s i s of o r d e r has emerged, r e q u i r i n g the m o b i l i z a t i o n of both r e p r e s s i v e and i d e o l o g i c a l mechanisms (see, e.g., P a n i t c h , 1979). A g a i n , however, the impact on the f i e l d of mental h e a l t h i s unknown. S o c i a l c o n t r o l s t r a t e g i e s have changed and can be l i n k e d to broader economic developments (see, e.g., T a y l o r , 1983; Chan & E r i c s o n , 1981) but the s i g n i f i c a n c e of these developments f o r mental h e a l t h p o l i c y and law i s u n c e r t a i n . Canada developed a 'welfare s t a t e ' d u r i n g the l a t e 1940's and e a r l y 1950's and i t i s c l e a r t h a t , i n r e c e n t years, t h i s has come under attack through a r e d u c t i o n and r e -a l l o c a t i o n of p u b l i c s e c t o r expenditures (Guest, 1980; T a y l o r , 1983; Drover, 1983). The s i g n i f i c a n c e of these developments f o r the changing nature of mental h e a l t h law i s u n c l e a r although, s i n c e the l a t t e r r e g u l a t e s one p a r t of the w e l f a r e s t a t e a p p a r a t u s , a c o n n e c t i o n must e x i s t . In s h o r t , t h e r e i s e v i d e n c e t h a t some s t r u c t u r a l f a c t o r s are of r e l e v a n c e to an u n d e r s t a n d i n g of mental h e a l t h law r e f o r m i n Canada but the connections have yet to be e x p l i c a t e d . L i k e w i s e , the e x p l a n a t o r y u t i l i t y of the work of those 224 concerned w i t h the l a w - s t a t e r e l a t i o n s h i p i s u n c e r t a i n . While some i n d i c a t i o n of an i n t e r e s t i n the n e o - M a r x i s t t r a j e c t o r y -began to appear i n the l a t e 1970's (see, e.g., Reasons & R i c h , 1978; Greenaway & B r i c k e y , 1978; McDonald, 1976), t h e s e c o n t r i b u t i o n s were entangled i n the 'coercion-consent* t h i c k e t and no s i g n i f i c a n t l i n k a g e s were made with the emergent t h e o r i e s of the s t a t e . Indeed, t h e r e a p p e a r e d t o be c o n s i d e r a b l e c o n f u s i o n i n s o f a r as elements of the new t h e o r i e s of the s t a t e became c o n f u s e d w i t h a c i v i l l i b e r t a r i a n c o n c e r n f o r the widening net of s o c i a l c o n t r o l . In the context of mental h e a l t h law, f o r example, two c o n t r i b u t i o n s i n the Greenaway & Br i c k e y c o l l e c t i o n - Maddison (1978) and Mazer (1978) - r e f l e c t e d the f e a r t h a t Canada was e v o l v i n g i n t o a ' t h e r a p e u t i c s t a t e ' . P s y c h i a t r i s t s were seen as p l a y i n g a key r o l e as agents of 'soft s o c i a l c o n t r o l ' who both imposed 'moral hegemony' and maintained the l e g i t i m a c y of the s t a t e (Maddison, 1978). The b r o a d e r , t h e o r e t i c a l s i g n i f i c a n c e of t h i s r e v e l a t i o n was not explored. While Canadian s o c i o l o g i s t s of law were i n i t i a l l y slow to c o n t r i b u t e to the neo-Marxist t r a j e c t o r y , a body of re s e a r c h i s now emerging and a p a r t i c u l a r emphasis has been p l a c e d upon v a r i o u s a s p e c t s of the c r i m i n a l law and the s t a t e c r i m i n a l j u s t i c e a p p a r a t u s (see, e.g., West, 1984; M c M u l l a n & Ratner, 1983; Snider & West, 1980; Fleming, 1985; Boyd, 1986; Ratner & McMullan, 1987). In a d d i t i o n , a c o n t r i b u t i o n has been made by 'new' p o l i t i c a l economists who have d e a l t i n d i r e c t l y with the la w - s t a t e r e l a t i o n s h i p as a consequence of t h e i r focus upon the state's management of economic r e l a t i o n s . A n a l y s t s i n t h i s area 225 have p r o v i d e d e x c e l l e n t i n s i g h t s i n t o t h e e m e r g e n c e o f l e g i s l a t i o n at p a r t i c u l a r h i s t o r i c a l junctures and d e a l i n g w i t h such m a t t e r s as p a t e n t s , the r e g u l a t i o n of m o n o p o l i e s ( i . e . , a n t i - c o m b i n e s l a w s ) , and unemployment i n s u r a n c e (see, e.g., N a y l o r , 1975; Cuneo, 1979; 1980). T h e s e s t u d i e s have demonstrated not only how the law can be used as an instrument o f c a p i t a l i s t c l a s s i n t e r e s t s , b u t a l s o t h e r e l a t i v e l y a u t o n o m o u s n a t u r e o f t h e s t a t e and l a w u n d e r c e r t a i n c o n d i t i o n s . I r o n i c a l l y , l i b e r a l p o l i t i c a l economists have a l s o helped to e x p l i c a t e the nature of the s t a t e and the l a w - s t a t e r e l a t i o n . In p a r t i c u l a r , t h r o u g h t h e i r a n a l y s i s of the r e g u l a t i o n of the o i l and gas i n d u s t r y i n A l b e r t a , Richards and P r a t t (1979) have exposed the r e l a t i v e l y autonomous nature of one p r o v i n c i a l s t a t e , and i t s use of law as a mechanism f o r c o n t r o l l i n g one group of c a p i t a l i s t s i n the i n t e r e s t s of c a p i t a l i s m as a whole. These i n s i g h t s are i n v a l u a b l e s i n c e they inform the more a b s t r a c t d i s c u s s i o n s of the l a w - s t a t e r e l a t i o n i n Canada. B e f o r e moving t o a g e n e r a l summary of the v a r i o u s e x p l a n a t i o n s f o r mental h e a l t h law reform, i t i s necessary to b r i e f l y c o n s i d e r two f u r t h e r f a c t o r s which may a c c o u n t f o r change. Vj_ PUBLIC SCANDALS AND EXCEPTIONAL CHANGES TO THE LEGAL FORM: ADDITIONAL FACTORS AFFECTING MENTAL HEALTH LAW REFORM IN CANADA In h i s a n a l y s i s of the p e r i o d s of mental h e a l t h law reform i n B r i t a i n , B u t l e r (1985) makes a case f o r an examination of the p o l i t i c a l dimension of law-making. In h i s view, t h i s aspect has 226 been n e g l e c t e d by a n a l y s t s , who have c o n s e q u e n t l y f a i l e d t o r e c o g n i z e the p o l i t i c a l i m p a ct of b o t h w i d e l y p u b l i c i z e d s c a n d a l s i n v o l v i n g the p r a c t i c e s of p h y s i c i a n s and h o s p i t a l s t a f f , and i n d i v i d u a l c a s e s of i n j u s t i c e or b r u t a l i t y w h i c h reach the c o u r t s . He argues t h a t , from the middle of the 19th c e n t u r y onwards, the p e r i o d s of r e f o r m have been p r e c e d e d by i n c i d e n t s of t h i s type and t h a t t h e s e c o n t r i b u t e d to the w i l l i n g n e s s of governments to e i t h e r i n i t i a t e change or l i s t e n c a r e f u l l y and s y m p a t h e t i c a l l y to the concerns of reformers. The M a c M i l l a n Royal Commission i n q u i r y i n the 1920's arose i n an atmosphere of c o n c e r n c r e a t e d by the p u b l i c a t i o n of s e n s a t i o n a l accounts of the b r u t a l i t i e s and i n j u s t i c e s of asylum l i f e , as w e l l as examples of i l l e g a l d e t e n t i o n ( B u t l e r , 1985; Bean, 1980). These were e p i t o m i z e d by the e f f o r t s of an asylum p h y s i c i a n - Dr. Montague Lomax - and one p a r t i c u l a r court case i n v o l v i n g a Kent f a r m e r ; W i l l i a m H a r n e t t . Lomax p u b l i s h e d a d e v a s t a t i n g c r i t i c i s m of asylum p r a c t i c e s , w h i l e Harnett was awarded damages of 25,000 Pounds f o r h i s wrongful d e t e n t i o n and f a l s e imprisonment i n a p r i v a t e asylum. Although the Court of Appeal subsequently reversed the judgment of the lower c o u r t , 4 t h i s d i d n o t h i n g to q u i e t g r o w i n g p u b l i c and P a r l i a m e n t a r y c o n c e r n , which u l t i m a t e l y l e d to the a p p o i n t m e n t of the M a c M i l l a n Commission ( B u t l e r , 1985). In B u t l e r ' s view, a s i m i l a r s i t u a t i o n arose 30 years l a t e r . The Percy Commission i n q u i r y i n the 1950's was preceded by p u b l i c o u t c r y over, and P a r l i a m e n t a r y d i s c u s s i o n s o f , a p a r t i c u l a r case of i n j u s t i c e i n v o l v i n g the i m p r o p e r d e t e n t i o n of a 14 y e a r o l d g i r l i n a 227 C mental h o s p i t a l (the s o - c a l l e d , 'Shropshire g i r l ' case). I t i s argued that t h i s matter provided a s i g n i f i c a n t impetus f o r the c r e a t i o n of a Royal Commission i n t o mental h e a l t h i s s u e s . There i s some e v i d e n c e t h a t s i m i l a r e v e n t s have b o t h t r i g g e r e d the for m a t i o n of committees of i n q u i r y and r e s u l t e d i n reforms to mental h e a l t h law i n Canada. For example, i n the l a t e 19th century the a p p a l l i n g c o n d i t i o n s and b r u t a l p r a c t i c e s i n the New Westminster Asylum i n B r i t i s h Columbia were the sub j e c t o f an i n q u i r y by a R o y a l C o m m i s s i o n ( F o u l k e s , 1961). L e g i s l a t i v e r e f o r m s f o l l o w e d q u i c k l y i n the wake of t h i s d i s c l o s u r e . In the mid-1960's, the murder of n i n e p e o p l e a t S h e l l Lake, Saskatchewan, by a discharged mental h e a l t h p a t i e n t , r e s u l t e d i n a review of, and changes to, mental h e a l t h s e r v i c e s and l e g i s l a t i o n (Task F o r c e Committee, 1983). In the l a t e 1960's, the c o n d i t i o n s i n the H a l i f a x County H o s p i t a l i n Nova S c o t i a were the subject of a Royal Commission i n q u i r y (MacKeen, 1970) and may have s t i m u l a t e d p o l i c y and l e g i s l a t i v e r e f o r m . More r e c e n t l y , the murder of Thomas Hagan of Kingman's Cove, Newfoundland, by a di s c h a r g e d mental h e a l t h p a t i e n t , r e s u l t e d i n both a j u d i c i a l i n q u i r y (Langdon, 1980) and a major review of the p r o v i n c e ' s m e n t a l h e a l t h l e g i s l a t i o n . C o n s e q u e n t l y , the p u b l i c d i s c l o s u r e of s c a n d a l o u s p r a c t i c e s and o t h e r e v e n t s cannot be overlooked when attempting to account f o r changes i n mental h e a l t h law. I t can be argued t h a t , whenever unexpected events p r e c i p i t a t e a c r i s i s of l e g i t i m a c y f o r the state's system of mental h e a l t h care and treatment, then reform of some ki n d may f o l l o w . 228 F i n a l l y , i t i s n e c e s s a r y t o c o n s i d e r the impact of e x c e p t i o n a l changes a f f e c t i n g the l e g a l form w i t h i n which a p a r t i c u l a r set of mental h e a l t h laws are s i t u a t e d . T h i s i s of p a r t i c u l a r relevance to an understanding of the emergence of the 'new l e g a l i s m ' i n Canada s i n c e the advent of the Canadian C h a r t e r o f R i g h t s and Freedoms. 5 I t might w e l l be contended that the p r o c l a m a t i o n of t h i s s i n g l e , C o n s t i t u t i o n a l instrument i s r e s p o n s i b l e f o r the sweeping changes which are a f f e c t i n g p r o v i n c i a l mental h e a l t h s t a t u t e s . In the l i g h t of the Charter p r o t e c t i o n s a g a i n s t a t t a c k s upon f u n d a m e n t a l r i g h t s and freedoms, many p r o v i n c e s have set about examining t h e i r e n t i r e body of s t a t u t e law to e n s u r e c o m p l i a n c e . M e n t a l h e a l t h s t a t u t e s p r e s c r i b e powers and procedures which a f f e c t both the l i b e r t y of the person and the e q u a l i t y r i g h t s of i n d i v i d u a l s . C o n s e q u e n t l y , r e v i e w s have i n c l u d e d an e x a m i n a t i o n of t h e s e s t a t u t e s and many of the cu r r e n t reforms can be l i n k e d to the r e s u l t s of t h i s work. 6 However, w h i l e the Charter may have provided a s i g n i f i c a n t impetus, i t i s c e r t a i n l y not r e s p o n s i b l e f o r the 'new l e g a l i s m ' . The c u r r e n t era of reform f i r s t emerged i n A l b e r t a i n 1972; ten y e a r s b e f o r e the p r o c l a m a t i o n of the C h a r t e r . As the decade passed, other p r o v i n c e s e i t h e r i n t r o d u c e d or began to co n s i d e r reforms which r e f l e c t e d the 'new l e g a l i s m ' and these were not i n s p i r e d by the prospect of s i g n i f i c a n t C o n s t i t u t i o n a l changes. Indeed, s i n c e the advent of the C h a r t e r t h e s e p r o v i n c e s a r e , once a g a i n , r e v i e w i n g s t a t u t e s w i t h a v i e w t o e n s u r i n g 7 compliance. 229 In a d d i t i o n , the Charter c o n t a i n s two c l a u s e s p e r m i t t i n g a p r o v i n c i a l l e g i s l a t u r e to e i t h e r pass or r e t a i n s t a t u t e s which c o n t a i n p r o v i s i o n s t h a t might be i n c o n t r a v e n t i o n . S e c t i o n 1 s p e c i f i e s that the guaranteed r i g h t s and freedoms may be s u b j e c t to such r e a s o n a b l e l i m i t s p r e s c r i b e d by law t h a t can be demonstrably j u s t i f i e d i n a f r e e and democratic s o c i e t y . More i m p o r t a n t l y , i n circumstances where the necessary j u s t i f i c a t i o n cannot be found, S e c t i o n 33 p r o v i d e s t h a t a l e g i s l a t u r e may s t i l l p a s s or r e t a i n l e g i s l a t i o n which a d v e r s e l y a f f e c t s f u n d a m e n t a l freedoms, l e g a l r i g h t s , and e q u a l i t y r i g h t s . An ' o v e r - r i d e 1 clause may be i n s e r t e d i n any p r o v i n c i a l l e g i s l a t i o n and, p r o v i d i n g the clause i s re-enacted every f i v e years, t h i s i s s u f f i c i e n t t o p r e v e n t the mounting of a c h a l l e n g e on C o n s t i t u t i o n a l grounds. The P r o v i n c e of Quebec has a l r e a d y enacted such a clause to prevent C o n s t i t u t i o n a l c h a l l e n g e s to i t s p r o c e d u r e s a f f e c t i n g the c o m p u l s o r y management of the property and persons of mental h e a l t h p a t i e n t s . 8 In short, a province i s not f o r c e d to amend l e g i s l a t i o n i n keeping with the Charter. Where reforms to mental h e a l t h law have occu r r e d s i n c e the advent of t h i s C o n s t i t u t i o n a l instrument, these have been ' v o l u n t a r i l y ' introduced. The impact of the Charter i s , t h e r e f o r e , only one f a c t o r to be considered i n any attempt to account f o r the c u r r e n t era of mental h e a l t h law reform. I t cannot be viewed as a cause of the r i s e of the 'new l e g a l i s m ' i n Canada a l t h o u g h i t has p r o v i d e d a s i g n i f i c a n t i m petus. Reforms c o n s i s t e n t w i t h the 'new l e g a l i s m ' have emerged in other c o u n t r i e s and i t i s c l e a r l y 230 necessary to look elsewhere f o r the f o r c e s which have generated t h i s t r a n s f o r m a t i o n i n the r u l e s and r e g u l a t i o n s a f f e c t i n g the management of the ment a l l y d i s o r d e r e d . VI; A SUMMARY AND FRAMEWORK FOR A COMPREHENSIVE EXPLANATION OF MENTAL HEALTH LAW REFORM IN CANADA T h i s c h a p t e r has p r o v i d e d a co m p r e h e n s i v e o v e r v i e w and general e v a l u a t i o n of the ex p l a n a t i o n s f o r the s h i f t s i n mental h e a l t h s t r a t e g y and l e g i s l a t i o n , which have been o f f e r e d by B r i t i s h and American a n a l y s t s . In gene r a l , the changes are seen as a r i s i n g from e i t h e r , t e c h n o l o g i c a l , o r g a n i z a t i o n a l or other developments w i t h i n mental h e a l t h systems; the a c t i v i t i e s of reformers both w i t h i n and ou t s i d e the s t a t e apparatus (i.e., a mental h e a l t h s e r v i c e b u r e a u c r a c y ) ; c h a n g i n g s t r u c t u r a l c o n d i t i o n s (i.e., i d e o l o g i c a l and economic s h i f t s ) ; or, v a r i o u s combinations of these f a c t o r s . The chapter has a l s o set out the essence of the t h e o r e t i c a l t r a j e c t o r i e s w i t h i n the s o c i o l o g y of law which are of relevance to the i n q u i r y at hand. I t i s a p p a r e n t t h a t two i n t e r l o c k i n g s p h e r e s of human a c t i v i t y have to be examined i n order to account f o r the p e r i o d s of mental h e a l t h law reform; namely, the work of i n t e r e s t groups w h i c h b o t h seek and o p p o s e r e f o r m ; and, the e f f o r t s o f i n d i v i d u a l s and groups w i t h i n the s t a t e apparatus. The l i n k s between these spheres must be explored i n order to determine the extent to which those working w i t h i n the s t a t e apparatus have been i n f l u e n c e d by v a r i o u s i n t e r e s t groups, and the ways i n which the v i e w s of both the l a t t e r and mental h e a l t h s e r v i c e bureaucrats have shaped s t r a t e g i e s and l e g i s l a t i o n . At the same 231 time, i t i s necessary to explore the s t r u c t u r a l context w i t h i n which the human a c t i v i t y i s embedded; t h a t i s , to a s s e s s the impact of developments such as s h i f t s i n economic s t r a t e g y , and the emergence of the ' w e l f a r e s t a t e ' . I t i s a p p a r e n t t h a t these d e v e l o p m e n t s have both e n a b l e d and c o n s t r a i n e d the a c t i v i t i e s of reformers and i n f l u e n c e d the s t a t e ' s w i l l i n g n e s s to adopt p r o p o s a l s f o r change. In s h o r t , w h i l e s e p a r a t e analyses of i n t e r e s t group a c t i v i t y , or the work of those w i t h i n the s t a t e a p p a r a t u s , or s t r u c t u r a l d e v e l o p m e n t s , c o u l d each y i e l d v a l u a b l e i n s i g h t s , an adequate e x p l a n a t i o n can o n l y be developed through an examination of the events w i t h i n , and the i n t e r a c t i o n between, a l l three areas. Nevertheless, some p r i o r i t i z a t i o n i s warranted and, on the b a s i s of the e x p l a n a t i o n s p r o v i d e d by B r i t i s h and A m e r i c a n w r i t e r s , i t would seem t h a t s t r u c t u r a l d e v e l o p m e n t s are of paramount importance. For example, the post-1945 s h i f t i n the dominant, c a p i t a l i s t economic s t r a t e g y (i.e., the adoption of K e y n e s i a n p o l i c i e s ) u n d e r p i n n e d the emergence of the w e l f a r e s t a t e . The l a t t e r p r o d u c e d the p e r s o n n e l and r e s o u r c e s n e c e s s a r y f o r d e - i n s t i t u t i o n a l i z a t i o n to o c c u r and t h i s , i n turn, r e s u l t e d i n the c o n s t r u c t i o n of a new, complementary l e g a l framework; that i s , the mental h e a l t h law reforms r e f e r r e d to as 'enhanced m e d i c a l i z a t i o n ' . The c o n t e n t of b o t h the s t a t e s t r a t e g y f o r the management of mentally d i s o r d e r e d persons and the accompanying l e g i s l a t i o n may, t h e r e f o r e , be seen as a product of a major economic and s o c i a l development r a t h e r than a d i r e c t outcome of the work of reformers. C e r t a i n l y , the l a t t e r 232 cannot be ignored; however, the a c t i v i t i e s of reformers w i t h i n and o u t s i d e the s t a t e apparatus can only be understood i n the l i g h t of broader s t r u c t u r a l developments. In o r d e r to make sense of both t h e s e e v e n t s and the c u r r e n t s h i f t i n s t r a t e g y and l e g i s l a t i o n , i t i s necessary to s e l e c t one of the competing t h e o r e t i c a l t r a j e c t o r i e s w i t h i n the s o c i o l o g y of law; that i s , to choose the body of theory which, at the outset, seems best able to e x p l a i n the changes i n mental h e a l t h l e g i s l a t i o n . While i t i s safe to r e j e c t the 'consensus' view of law c r e a t i o n and law r e f o r m , i t would be unwise to di s c o u n t the other t r a j e c t o r i e s without f u r t h e r i n v e s t i g a t i o n . Indeed i t i s apparent t h a t , w h ile two main avenues e x i s t (i.e., i n t e r e s t group theory and neo-Marxist theory), both need to be c o n s i d e r e d i f t h e g o a l i s t o e s t a b l i s h a c o m p r e h e n s i v e e x p l a n a t i o n of mental h e a l t h law reforms. I n t e r e s t group t h e o r y f o c u s e s a t t e n t i o n upon i s s u e s of human agency and the p o l i t i c s of law r e f o r m but n e g l e c t s to a s s e s s t h e i m p a c t o f b r o a d e c o n o m i c and i d e o l o g i c a l developments. Conversely, neo-Marxist theory focuses a t t e n t i o n upon s t r u c t u r a l f a c t o r s and t h e n a t u r e and r o l e o f t h e c a p i t a l i s t s t a t e but e i t h e r n e g l e c t s to address i s s u e s of human agency or devalues t h i s aspect of the reform process. While the domain assumptions of these two t h e o r e t i c a l t r a j e c t o r i e s seem inco m p a t i b l e , at a methodological l e v e l they are not n e c e s s a r i l y i n c o n f l i c t ; i n d e e d , they can be seen as complementary. The is s u e i s not "which e x p l a n a t i o n i s best, to the e x c l u s i o n of the other?" but, to what extent i s the human a c t i v i t y embodied i n 233 r e f o r m movements s u b j e c t to the e n a b l i n g or c o n s t r a i n i n g i n f l u e n c e s of s t r u c t u r a l f a c t o r s , and what does t h i s say about the r e l a t i o n s h i p between the emergence of laws, law r e f o r m , s t a t e s o c i a l c o n t r o l s t r a t e g i e s , and s o c i a l , e conomic and p o l i t i c a l c o n d i t i o n s ? By s y n t h e s i z i n g the two a p p r o a c h e s to -form a m e t h o d o l o g i c a l s t r a t e g y t h a t examines i s s u e s of b o t h agency and s t r u c t u r e , a comprehensive e x p l a n a t i o n of the p e r i o d s of reform can be developed.. A n e o - M a r x i s t t h e o r e t i c a l t r a j e c t o r y , enhanced by a thorough examination of the r o l e and impact of human agency, i s the p r e f e r r e d i n t e r p r e t i v e framework and, of the f o u r c o r e p e r s p e c t i v e s w i t h i n t h i s a r e a , the ' s t r u c t u r a l i s t 1 a p p r o a c h seems the most v a l i d . The review of the e x p l a n a t i o n s o f f e r e d by B r i t i s h and A m erican w r i t e r s s u g g e s t s t h a t , i n the f i e l d of mental h e a l t h law, the s t a t e i s a r e l a t i v e l y autonomous e n t i t y that a c t s i n the best i n t e r e s t s of c a p i t a l i s m as a whole, r a t h e r than s p e c i f i c c a p i t a l i s t f a c t i o n s . The r e l a t i o n s h i p between the s t a t e and economic i n t e r e s t s i s o b j e c t i v e and s t r u c t u r a l i n n a t u r e , and s t a t e p r a c t i c e s (e.g., t h e d e v e l o p m e n t of a p a r t i c u l a r s t r a t e g y and l e g i s l a t i o n f o r the management of the mentally disordered) are a f f e c t e d by i t s r o l e i n the r e s o l u t i o n of three, p o t e n t i a l l y c o n t r a d i c t o r y , i m p e r a t i v e s or ' c a r d i n a l f u n c t i o n s ' ; namely, o r d e r maintenance, l e g i t i m a t i o n , and the r e p r o d u c t i o n of the c o n d i t i o n s necessary f o r continued c a p i t a l accumulat i o n . In order to s a t i s f y these i m p e r a t i v e s , the s t a t e w i l l use 234 a l l the means at i t s d i s p o s a l , i n c l u d i n g both the law and the l e g a l a p p a r a t u s . The law i s a r e l a t i v e l y autonomous e n t i t y which organi z e s and r e g u l a t e s a c t i v i t i e s w i t h i n other components of the s t a t e apparatus (e.g., a mental h e a l t h system) and may, t h e r e f o r e , f a c i l i t a t e new s t r a t e g i e s and p o l i c i e s a f f e c t i n g , f o r example, the management of mentally d i s o r d e r e d persons. It may a l s o l e g i t i m i z e s t a t e p r a c t i c e s by r e f e r e n c e to i t s own 'autonomous' components (e.g., the r u l e of law and n o t i o n s o f fundamental human r i g h t s and l i b e r t i e s ) even though these may be s u b s i d i a r y c o n s i d e r a t i o n s i n , f o r example, the c o n s t r u c t i o n of a new s o c i a l c o n t r o l s t r a t e g y . The law a l s o c h a n n e l s and o r g a n i z e s c o n f l i c t s between competing i n t e r e s t groups and t h i s a f f o r d s the s t a t e an o p p o r t u n i t y to use o s t e n s i b l y i n d e p e n d e n t r e f o r m e r s i n the r e s o l u t i o n of i t s c o n t r a d i c t o r y i m p e r a t i v e s . The s t a t e may e n l i s t the a i d of i n t e r e s t groups that seek reforms c o n s i s t e n t w i t h i t s l a r g e r g o a l s . I t may co - o p t r e f o r m e r s i n o r d e r to c o n s t r u c t and l e g i t i m i z e a new s t r a t e g y and, i n the mental h e a l t h c o n t e x t , t h i s may a c c o u n t f o r the ch a n g i n g c o n t e n t of l e g i s l a t i o n ( i . e . , t h e a l t e r n a t i o n b e t w e e n j u d i c i a l and m e d i c a l i z e d modes of s u p e r v i s i o n ) a s s o c i a t e d w i t h the v a r i o u s p e r i o d s of reform. At the same t i m e , however, the law embodies i t s own c o n t r a d i c t i o n s (e.g., formalism and b u r e a u c r a t i c i n t e r e s t s ) and i t cannot be viewed as a mere instrument or t o o l of the s t a t e . W h ile i t s autonomy i s r e l a t i v e to the needs of the s t a t e , i t must m a i n t a i n an image of a b s o l u t e autonomy i n o r d e r to be 235 e f f e c t i v e . T h i s image must be supported by concrete p r a c t i c e s and these c o n s i d e r a t i o n s p o i n t to both the p o t e n t i a l l y unstable nature of law and i t s c a p a c i t y to f r u s t r a t e , r a t h e r than always support (e.g., f a c i l i t a t e and l e g i t i m i z e ) , s t a t e p r a c t i c e s . In short, law i s an i n v a l u a b l e component of the s t a t e apparatus but there are l i m i t s on the extent to which i t can be used to achieve s t a t e goals. In o r d e r to a c q u i r e an u n d e r s t a n d i n g of the f a c t o r s a f f e c t i n g r e f o r m , and t o d e t e r m i n e th e a d e q u a c y o f t h e s t r u c t u r a l i s t p o s i t i o n , i t i s necessary to c o n s i d e r more than one p e r i o d of reform. The nature of the r e l a t i o n s h i p between i n t e r e s t groups, a s t a t e m e n t a l h e a l t h b u r e a u c r a c y , and s t r u c t u r a l c o n d i t i o n s must be assessed at d i f f e r e n t h i s t o r i c a l j u n c t u r e s s i n c e t h i s w i l l provide a more thorough e x p l i c a t i o n of s t a t e p r a c t i c e s aimed at the r e s o l u t i o n of i t s c o n t r a d i c t o r y i m p e r a t i v e s . An examination of, f o r example, the emergence of 'enhanced m e d i c a l i z a t i o n ' c o u l d r e v e a l a s i t u a t i o n q u i t e d i f f e r e n t from t h a t a s s o c i a t e d w i t h the r i s e of the 'new l e g a l i s m 1 . Separate analyses could r e s u l t i n c o n f u s i o n , so an. examination that combines at l e a s t two p e r i o d s of reform seems warranted. An a n a l y s i s of t h i s type can provide a p i c t u r e of both the v a r i e t i e s of a c t i v i t y which surround the emergence of new l e g i s l a t i o n and new s t a t e s t r a t e g i e s , and the p r a c t i c e s of a c a p i t a l i s t s t a t e under d i f f e r e n t s t r u c t u r a l c o n d i t i o n s (e.g., the extent to which i t co-opts reformers and the form that t h i s c o - o p t a t i o n takes). At the same time, an h i s t o r i c a l a n a l y s i s of t h i s kind can a l s o expose c o n s i s t e n t p r a c t i c e s which are of 236 equal value- i n determining the nature of the l a w - s t a t e r e l a t i o n . The next two chapters c o n t a i n a comprehensive a n a l y s i s of the emergence of 'enhanced m e d i c a l i z a t i o n ' , i t s su b s e q u e n t demise, and the r i s e of the 'new l e g a l i s m ' , i n Canada, w i t h a p a r t i c u l a r emphasis upon one province; namely, B r i t i s h Columbia. The p r o v i n c e has e x p e r i e n c e d the s h i f t s i n s t r a t e g y and l e g i s l a t i o n found i n other p r o v i n c e s and i t was one of the f i r s t to adopt 'enhanced m e d i c a l i z a t i o n ' i n the e a r l y 1960's. T h i s e v e n t was a c c o m p a n i e d by t h e new s t r a t e g y o f d e -i n s t i t u t i o n a l i z a t i o n and community c a r e and t r e a t m e n t . In keeping with developments elsewhere i n Canada, B r i t i s h Columbia considered the adoption of the 'new l e g a l i s m ' i n the l a t e 1970's and made some c o r r e s p o n d i n g r e f o r m s . W h i l e a c o m p l e t e r e -c o n s t r u c t i o n of p r o v i n c i a l mental h e a l t h l e g i s l a t i o n has not yet occurred, there are c l e a r s i g n s that t h i s i s imminent. These reforms are t a k i n g place i n c o n j u n c t i o n w i t h a new s t r a t e g y f o r the management of m e n t a l l y d i s o r d e r e d p e o p l e t h a t i n v o l v e s a c c e l e r a t e d d e - i n s t i t u t i o n a l i z a t i o n , n o n - i n s t i t u t i o n a l i z a t i o n , p r i v a t i z a t i o n , and the c l o s u r e of the o l d p l a c e s of bot h segregated confinement and i n t e n s i v e medical treatment. The examination of each p e r i o d of reform w i l l focus upon, the two s p h e r e s of human a c t i v i t y , the r e l a t i o n s h i p s between them, the s t r u c t u r a l c o n d i t i o n s s u r r o u n d i n g the p e r i o d s of reform, the i m p l i c a t i o n s f o r the content of the laws which were (and are being) i n t r o d u c e d by the s t a t e , and, the way i n which the p r a c t i c e s of the s t a t e were (and are) a f f e c t e d by the need 237 to r e s o l v e p o t e n t i a l l y c o n t r a d i c t o r y i m p e r a t i v e s i n the i n t e r e s t s of c a p i t a l i s m as a whole. 238 ENDNOTES: CHAPTER 4 1: The Commission c o n s i s t e d of eleven people, i n c l u d i n g Lord Percy. These i n c l u d e d , a r e p r e s e n t a t i v e from the Health S e r v i c e Employees Union, a c o n s u l t i n g p s y c h i a t r i s t who was an expert on mental r e t a r d a t i o n , and a n e u r o l o g i s t (the a p p r o p r i a t e l y named, Dr. S i r W. R u s s e l l B r a i n ) . The l e g i s l a t i o n was d r a f t e d by the two l e g a l p r a c t i t i o n e r s on the Commission. 2: See, Freedom News J o u r n a l ( S p e c i a l E d i t i o n ) , June, 1986. 3: An i n t e r e s t i n the c o n n e c t i o n s between the needs of c a p i t a l i s m and s t a t e s o c i a l c o n t r o l s t r a t e g i e s i s a l s o r e f l e c t e d i n the work of I g n a t i e f f (1978). However, h i s focus i s e n t i r e l y upon the r i s e of the p e n i t e n t i a r y . 4: Harnett v. F i s h e r [1927] A.C. 573. See, a l s o , the e a r l i e r case of E v e r e t t v. G r i f f i t h s [1920] 3 K.B. 163, where the court e x h i b i t e d c o n s i d e r a b l e concern f o r the fundamental r i g h t s and l i b e r t i e s of those who were a l l e g e d to be s u f f e r i n g from lunacy. 5: E x c e p t i o n a l changes to the l e g a l form have a l s o occurred, to a l e s s e r extent, i n B r i t a i n . F o l l o w i n g i t s entry i n t o the European Economic Community, B r i t a i n r a t i f i e d the European C o n v e n t i o n of Human R i g h t s , t h e r e b y a d o p t i n g ( f o r the f i r s t time) a formal and w r i t t e n Human Rights Charter. Some of the a r t i c l e s of the Convention are q u i t e s i m i l a r to the clauses of the American B i l l of Rights and the Canadian Charter of Rights and Freedoms. These have been used by the N a t i o n a l A s s o c i a t i o n f o r M e n t a l H e a l t h i n t h e p u r s u i t o f l e g i s l a t i v e and a d m i n i s t r a t i v e reform, p r i m a r i l y i n cases i n v o l v i n g m entally d i s o r d e r e d o f f e n d e r s . However, there i s no suggestion that the r a t i f i c a t i o n of the C o n v e n t i o n r e s u l t e d i n new me n t a l h e a l t h l e g i s l a t i o n (Gostin, 1982). 6: These reviews, and the connections to the Charter, were examined i n Chapter 3. 7: I b i d . 8: See, P u b l i c C u r a t o r s h i p A c t R.S.Q. 1977, c. C-80 (as amended) . 239 CHAPTER 5 THE EMERGENCE OF ENHANCED MEDICALIZATION I; INTRODUCTION The p e r i o d of mental h e a l t h law reform c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' was preceded by a s h i f t i n the s t a t e s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d . During the l a t e 1940's and e a r l y 1950's problems emerged with the use of s e g r e g a t e d c o n f i n e m e n t and changes were i n t r o d u c e d . The emphasis s h i f t e d t o a ' d e - i n s t i t u t i o n a l i z a t i o n ' o f , i n p a r t -i c u l a r , l o n g - s t a y p a t i e n t s and the d e v e l o p m e n t of v a r i o u s community-based care and treatment a l t e r n a t i v e s i n t e g r a t e d with the general h e a l t h care component of the emerging w e l f a r e s t a t e . The new mental h e a l t h l e g i s l a t i o n which appeared across Canada during the 1960's p r o v i d e d the l e g a l framework necessary f o r the long-term implementation of the new s t r a t e g y and r e f l e c t e d the e f f o r t s of a key i n t e r e s t group that was c l o s e l y a s s o c i a t e d w i t h the s t a t e a p p a r a t u s ; namely, the C a n a d i a n M e n t a l H e a l t h A s s o c i a t i o n (C.M.H.A.). T h i s chapter begins w i t h a b r i e f d e s c r i p t i o n of the advent of the C a nadian w e l f a r e s t a t e i n the l a t e 1940's and the s u b s e quent exposure of the p r o b l e m s a f f e c t i n g the p r e v a i l i n g s t r a t e g y f o r the management of the mentally d i s o r d e r e d . Both the nature and i m p l i c a t i o n s of these problems, and the i n i t i a l r e s p o n s e on the p a r t of the s t a t e , are examined t h r o u g h a d e s c r i p t i o n of e v e n t s i n a p r o v i n c e where the s i t u a t i o n had assumed c r i s i s p r o p o r t i o n s ; namely, B r i t i s h Columbia. This i s 240 f o l l o w e d by an a n a l y s i s of the c o n s t r u c t i o n of the new s t r a t e g y of ' d e - i n s t i t u t i o n a l i z a t i o n ' and the use of community-based care and treatment a l t e r n a t i v e s i n t e g r a t e d w i t h the general h e a l t h care system. The c o n s t r u c t i o n and impact of the new s t r a t e g y i n B r i t i s h Columbia and the favourable nature of the c o n d i t i o n s c r e a t e d by the advent of the w e l f a r e s t a t e a re examined, and t h i s i s f o l l o w e d by an a n a l y s i s of the r i s e of the C.M.H.A. as the p r i n c i p a l a r c h i t e c t of mental h e a l t h r e f o r m i n Canada. The development, content, and impact of the A s s o c i a t i o n ' s p r o p o s a l s and the connections between these recommendations, the work of the C.M.H.A.'s predecessor (The Canadian N a t i o n a l Committee f o r Mental Hygiene), and i n t e r n a t i o n a l developments i n the mental h e a l t h f i e l d are e x p l o r e d . In a d d i t i o n , the n a t u r e of the r e l a t i o n s h i p between the A s s o c i a t i o n and the f e d e r a l and p r o v i n c i a l l e v e l s of the s t a t e i s examined. A t t e n t i o n i s then focussed upon the emergence of mental h e a l t h law reforms c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' , and the r e l a t i o n s h i p between the l e g i s l a t i o n and the new st r a t e g y . This i s accomplished, f i r s t l y , by an a n a l y s i s of the C.M.H.A.'s q u e s t f o r law r e f o r m and, s e c o n d l y , by a d e t a i l e d examination of the emergence of a new l e g a l framework f o r the management of the mentally d i s o r d e r e d i n B r i t i s h Columbia. The c h a p t e r c o n c l u d e s w i t h an e x p l a n a t i o n f o r t h i s p e r i o d of law reform. 241 I I : THE ADVENT OF THE CANADIAN WELFARE STATE AND THE PROBLEMS WITH THE MANAGEMENT OF THE MENTALLY DISORDERED The s h i f t i n s t r a t e g y f o r the management of m e n t a l l y d i s o r d e r e d p e r s o n s , and the emergence of new mental h e a l t h l e g i s l a t i o n c h a r a c t e r i z e d by "enhanced m e d i c a l i z a t i o n ' , occurred d u r i n g a p e r i o d when major changes a f f e c t e d the economic and s o c i a l s t r u c t u r e of Canada. In k e e p i n g w i t h d e v e l o p m e n t s i n o t h e r c a p i t a l i s t c o u n t r i e s ( n o t a b l y , B r i t a i n ) , the p e r i o d between 1945 and the l a t e 1960's was marked by the adoption and i m p l e m e n t a t i o n o f K e y n e s i a n e c o n o m i c p o l i c i e s and t h e concomitant emergence and gradual growth of a system of p u b l i c h e a l t h and welfar e s e r v i c e s ( i n c l u d i n g the p r o v i s i o n of d i r e c t -payment b e n e f i t s ) , a t both the f e d e r a l and p r o v i n c i a l l e v e l s ; namely, the 'welfare state'. Wolfe (1979, 1984) s u g g e s t s t h a t Canada was one of the f i r s t c a p i t a l i s t c o u n t r i e s to adopt Keynesian economic p o l i c i e s . These c o n s t i t u t e d the core of a major and i n t e r n a t i o n a l s h i f t i n the dominant economic s t r a t e g y that began i n the l a t e 1940's and the f i r s t s i g n s of t h i s new s t r a t e g y a p peared i n the f e d e r a l budgets i n the l a t e 1930*s. By the mid-1940's, a group of economists w i t h i n the f e d e r a l M i n i s t r y of Finance had pl a n t e d Keynesian ideas w i t h i n the minds of the policy-makers who were then d e v i s i n g plans f o r post-war economic management and s o c i a l r e c o n s t r u c t i o n that would assure the r e p r o d u c t i o n of c a p i t a l i s m . These i d e a s i n c l u d e d i n c r e a s e d s t a t e i n t e r v e n t i o n i n the management of the economy with the goal of s u s t a i n i n g both high l e v e l s of employment and sound economic growth i n the post-war p e r i o d . C o u n t e r - c y c l i c a l f i s c a l p o l i c i e s , which i n v o l v e d 242 i n c r e a s e d p u b l i c expenditure, were an i n t e g r a l f e a t u r e of t h i s a p p r o a c h and, by 1945, the f e d e r a l government had p u b l i c l y announced i t s " o f f i c i a l commitment" to Keynesian p r i n c i p l e s and the a d o p t i o n of a s t r a t e g y t h a t was to dominate the economic management of Canada f o r 30 years (op c i t ) . The development and i n t r o d u c t i o n of the ' w e l f a r e s t a t e ' was, i n par t , a concrete and l o g i c a l m a n i f e s t a t i o n of the new economic s t r a t e g y . It represented a compromise between labour, c a p i t a l and the s t a t e t h a t would s e r v e the i n t e r e s t s of a l l t h r e e groups. For l a b o u r , the w e l f a r e s t a t e would e n s u r e s e c u r i t y f o r and the e q u i t a b l e d i s t r i b u t i o n of b e n e f i t s to, the e n t i r e p o p u l a t i o n . At the same t i m e , i t would s e r v e the i n t e r e s t s of both c a p i t a l and the s t a t e by m a i n t a i n i n g order, a s s u r i n g l e g i t i m a t i o n , and reproducing the c o n d i t i o n s necessary f o r continued c a p i t a l accumulation (Gough, 1979; Moscovitch & A l b e r t , 1987). The plans f o r the development of v a r i o u s s o c i a l w e l f a r e measures had t h e i r r o o t s i n the f i n d i n g s of a s e r i e s o f Commissions and r e p o r t s that f i r s t began to emerge i n the wake of the economic depression of the 1930's. The proposed reforms were i n a r e a s such as s o c i a l s e c u r i t y , h e a l t h i n s u r a n c e , and ho u s i n g and, by the l a t e 1940's, the d e l i b e r a t i o n s had been c o m p l e t e d (Guest, 1985). A p l a n to i n t r o d u c e s o c i a l w e l f a r e reforms was announced by the f e d e r a l government i n the Throne Speech i n January 1944. As Wolfe p o i n t s out, (T)he primary o b j e c t of post-war domestic p o l i c y would be ' s o c i a l s e c u r i t y and human welfare'. The 243 government committed i t s e l f to aim f o r the e s t a b -lishment of a n a t i o n a l minimum of s o c i a l s e c u r i t y w i t h regard to such matters as employment, n u t r i -t i o n , housing, and p r o t e c t i o n from unemployment, the e f f e c t s of a c c i d e n t , i l l - h e a l t h , and o l d age. In sum, the speech was f a r - r a n g i n g and i n n o v a t i v e i n the degree of government involvement i t promised i n o r d e r to ease the t r a n s i t i o n from w a r t i m e to peace, to guarantee f u l l employment i n the post-war economy, and to p r o v i d e a n a t i o n a l minimum of s o c i a l s e c u r i t y f o r a l l Canadians (1984: 54). However, as Guest (1985) has shown, the g o a l s of the f e d e r a l government were not e a s i l y achieved. The 1945 Dominion-P r o v i n c i a l Conference on R e c o n s t r u c t i o n , which was intended to e s t a b l i s h the f o u n d a t i o n s of the w e l f a r e s t a t e , c o l l a p s e d i n d i s a g r e e m e n t and t h i s f o r e s t a l l e d any hope of i m m e d i a t e l y i n t r o d u c i n g sweeping reforms. 1 Instead, the f e d e r a l government began to introduce a number of l i m i t e d s o c i a l s e c u r i t y measures and the 1950's saw some i m p r o v e m e n t s i n t h e a r e a s o f unemployment insurance, v a r i o u s pensions f o r s p e c i a l v u l n e r a b l e groups (e.g., the b l i n d and the aged), a f a m i l y a l l o w a n c e scheme, and housing f o r low-income f a m i l i e s (op c i t ) . The c o l l a p s e of the D o m i n i o n - P r o v i n c i a l C o n f e r e n c e f r u s t r a t e d the i m p l e m e n t a t i o n of r e f o r m s to the h e a l t h c a r e s e c t o r ; n o t a b l y , the i n t r o d u c t i o n of a h e a l t h i n s u r a n c e programme (op c i t ) . However, by 1948, the f e d e r a l government had taken one step towards the e s t a b l i s h m e n t of a p u b l i c h e a l t h care system by i n i t i a t i n g the n a t i o n a l h e a l t h grants programme; a development that had p a r t i c u l a r r a m i f i c a t i o n s f o r the prev-a i l i n g s t r a t e g y f o r the management of the mentally d i s o r d e r e d . The f e d e r a l government's r e s p o n s i b i l i t y f o r the p r o v i s i o n 244 of d i r e c t mental h e a l t h s e r v i c e s was l i m i t e d to veterans, n a t i v e p e o p l e s , and those r e s i d i n g i n the T e r r i t o r i e s , and i t had n e i t h e r a mandate nor a duty to i n t e r f e r e w i t h the d e l i v e r y of m e n t a l h e a l t h s e r v i c e s i n t h e p r o v i n c e s . However, t h e implementation of the n a t i o n a l h e a l t h grants programme r e s u l t e d i n the d i s c o v e r y of problems with the management of the mentally d i s o r d e r e d which were a cause f o r c o n c e r n . Between 1950 and 1951, the f e d e r a l government funded p r o v i n c i a l h e a l t h surveys to a s s i s t i n making sound d e c i s i o n s about the d i s t r i b u t i o n of d i r e c t grants (Richman, 1964). While the goal was to assess a l l h e a l t h c a r e s e r v i c e s , e a c h p r o v i n c e made s p e c i f i c r ecommendations r e g a r d i n g the d e l i v e r y of m e n t a l h e a l t h s e r v i c e s . In general, the r e s u l t s of these surveys p o i n t e d to the need f o r u r g e n t improvement and e x p a n s i o n i n the m e n t a l h e a l t h f i e l d . Indeed, as Richman has noted, the s i t u a t i o n was deemed to be extremely s e r i o u s : These surveys confirmed...the d e p l o r a b l e s t a t e of m e ntal i l l n e s s i n Canada at t h a t t i m e . They po i n t e d out the great shortage of p s y c h i a t r i s t s and of personnel equipped with medical t r a i n i n g to meet t h i s p r o b l e m , the l a c k of p e r s o n n e l g e n e r a l l y , (and) the lack of i n s t i t u t i o n a l f a c i l i t i e s i n many pr o v i n c e s (1964: 6). By 1954, the Department of N a t i o n a l Health and Welfare had p r o d u c e d a summary of the f i n d i n g s of the s u r v e y s and a statement of the n a t i o n a l s i t u a t i o n . I t was recommended t h a t the f e d e r a l government i n i t i a t e changes i n a number of areas and t h e s e i n c l u d e d , e n h a n c i n g community mental h e a l t h s e r v i c e s , i n t e g r a t i n g p s y c h i a t r i c programmes wi t h other h e a l t h s e r v i c e s , and r e - a s s e s s i n g the t r a i n i n g of mental h e a l t h w o r k e r s . The 245 Department's r e p o r t a l s o expressed concern over the f a i l u r e to develop a s t a n d a r d i z e d plan f o r expansion i n mental h o s p i t a l s . While f e d e r a l funds had been pro v i d e d f o r c o n s t r u c t i o n aimed at reducing over-crowding i n h o s p i t a l s , new b u i l d i n g s had simply been g r a f t e d onto o l d s t r u c t u r e s (Department of H e a l t h & Welfare, 1954; Richman, 1964). The s t r a t e g y f o r the management of the mentally d i s o r d e r e d was i n need of urgent and s u b s t a n t i a l r e f o r m and i n a t l e a s t one p r o v i n c e - B r i t i s h C olumbia - the s i t u a t i o n had reached a c r i s i s p o i n t . The C r i s i s i n the Management of the M e n t a l l y D i s o r d e r e d : The Case of B r i t i s h Columbia In 1951, Dr. R a l p h Chambers, the C h i e f I n s p e c t o r of the C e n t r a l I n s p e c t i o n B u r e a u o f t h e A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n (A.P.A.) v i s i t e d B r i t i s h C o l u m b i a to a s s e s s the extent to which the mental h o s p i t a l s (and a l l i e d s e r v i c e s ) met the s t a n d a r d s f o r A.P.A. a c c r e d i t a t i o n . At t h i s t i m e , the mental h o s p i t a l s were e x p e r i e n c i n g many problems and these were exposed i n Chamber's r e p o r t . The h o s p i t a l s ( p a r t i c u l a r l y , the main mental h o s p i t a l at E s s o n d a l e ) were d e f i c i e n t i n a number of a r e a s i n c l u d i n g : a severe shortage of q u a l i f i e d personnel i n the p r o f e s s i o n a l and n o n - p r o f e s s i o n a l c a t e g o r i e s ; the absence of a s p e c i a l i n f e c t i o u s d i s e a s e s u n i t ( e s p e c i a l l y f o r t h o s e s u f f e r i n g f r o m t u b e r c u l o s i s ) ; o b s o l e t e and run-down b u i l d i n g s c o n t a i n i n g inadequate equipment and poor medical support s e r v i c e s (e.g., a p r o p e r l y equipped pharmacy); and, a lack of proper f a c i l i t i e s and general s e r v i c e s f o r p a t i e n t s . Indeed, p a t i e n t s were p o o r l y 246 c l o t h e d and housed, and denied adequate c h a p l a i n c y , s o c i a l work, d e n t a l and c o n v e n t i o n a l m e d i c a l s e r v i c e s . The t h e r a p i e s and treatments were deemed to be below standard; p a r t i c u l a r l y , the o c c u p a t i o n a l , r e c r e a t i o n a l , and p h y s i c a l t h e r a p i e s . P a t i e n t s of a l l ages and c a t e g o r i e s were herded together. A l l wards were locked and h o s p i t a l s t a f f used p h y s i c a l r e s t r a i n t s , ' s e c l u s i o n rooms', and 'sedation s u i t e s ' i n the c o n t r o l of p a t i e n t s . Although an 'active treatment' f a c i l i t y had been opened, t h i s was a r e c e n t d evelopment, and the h o s p i t a l s , which were p h y s i c a l l y and a d m i n i s t r a t i v e l y segregated from the community and the general h e a l t h care system, were s t i l l o r i e n t e d towards c u s t o d i a l care r a t h e r than treatment. Inasmuch as the h o s p i t a l s were segregated, so too were t h e i r personnel and p a t i e n t s . No r e s e a r c h was t a k i n g p l a c e and t h e r e was no p u b l i c v o l u n t e e r programme to bridge the gap between the i s o l a t e d h o s p i t a l and the r e s t of the community. With the exception of c h i l d guidance c l i n i c s , t h e r e were no community f a c i l i t i e s and s e r v i c e s f o r p r e v e n t i o n , p u b l i c e d u c a t i o n , c o n s u l t a t i o n and o u t - p a t i e n t treatment. Worst of a l l , the h o s p i t a l s ( p a r t i c u l a r l y Essondale) were s e v e r e l y o v e r - c r o w d e d . The p r o v i n c i a l s ystem f o r the management of the m e n t a l l y d i s o r d e r e d d i d not meet A.P.A. s t a n d a r d s and f u l l a c c r e d i t a t i o n was w i t h d r a w n by t h e o r g a n i z a t i o n (American P s y c h i a t r i c A s s o c i a t i o n , 1951; Ross, 1961) . 2 Dr. Chambers submitted a comprehensive r e p o r t immediately a f t e r h i s survey and i n s p e c t i o n , and the o f f i c i a l d e c i s i o n to award only ' p r o v i s i o n a l a c c r e d i t a t i o n ' was announced i n 1953. 3 247 At that time, the D i r e c t o r of mental h e a l t h s e r v i c e s - Dr. A.M. Gee - was p rovided with d e t a i l s of a l l the d e f i c i e n c i e s which had to be addressed f o r the s e r v i c e to meet A.P.A. standards; a goal that he was eager to achieve. As he wrote at the t i m e , 4 I t becomes encumbent upon us to meet the r e q u i r e -ments i n o r d e r t h a t we may r e c o v e r our f o r m e r ' f u l l y a c c r e d i t e d ' s t a t u s . A c h i e v i n g f u l l a c c r e d i t a t i o n was i m p o r t a n t , not because the A.P.A. exerted d i r e c t c o n t r o l over the o p e r a t i o n of the mental h e a l t h s e r v i c e (the p r o v i n c i a l government could have ignored the f i n d i n g s of t h i s p r o f e s s i o n a l body), but because of the p o s s i b l e p u b l i c and p r o f e s s i o n a l r e p e r c u s s i o n s . Indeed, the p r o v i n c i a l government f a c e d a p roblem of l e g i t i m a t i o n which had to be addressed. As Gee p o i n t e d out, f u l l a c c r e d i t a t i o n was d e s i r a b l e i f the mental h e a l t h system was to " r e t a i n the confidence of the community." 5 T h i s was the e r a i n which t h e r e was w i d e s p r e a d p u b l i c c o n c e r n , p a r t i c u l a r l y i n the U n i t e d S t a t e s , over the e x i s t e n c e of ' s n a k e - p i t ' m e n t a l h o s p i t a l s . With the a c t i v e (although sometimes covert) support and a s s i s t a n c e of h o s p i t a l a d m i n i s t r a t o r s and mental h e a l t h p r o f e s s i o n a l s , j o u r n a l i s t s and w r i t e r s ( n o t a b l y , A l b e r t Deutsch) had v i s i t e d s t a t e m e n t a l h o s p i t a l s and subsequently p u b l i s h e d accounts of the a p p a l l i n g c o n d i t i o n s w hich e x i s t e d i n t h e s e i n s t i t u t i o n s (see, e.g., D e u t s c h , 1948; 1949; Ward, 1946). I t was a r g u e d t h a t r e s p o n s i b i l i t y l a y w i t h s t a t e governments which r e f u s e d to provide adequate funding (Deutsch, 1948). Some Canadian mental h o s p i t a l s had been found to c o n t a i n s i m i l a r l y u n d e s i r a b l e 248 c o n d i t i o n s (MacKerracher, 1964) and, while B r i t i s h Columbia was s p a r e d d i r e c t c r i t i c i s m , t h e r e was c o n s i d e r a b l e "scope f o r improvement" (Mental Health Branch, 1970). In the l i g h t of t h i s w i d e s p r e a d atmosphere of c o n c e r n , where a p r o v i n c i a l m e n t a l h o s p i t a l had been i n s p e c t e d and approved by the A.P.A., t h i s would serve to assuage any p u b l i c concern that the p r o v i n c e was supporting a 'snake-pit'. O t h e r c o n s i d e r a t i o n s were of e q u a l i m p o r t a n c e . As Gee n o t e d , 6 F u l l a c c r e d i t a t i o n i s very e s s e n t i a l when i t comes to r e c r u i t i n g p r o f e s s i o n a l s t a f f at a l l l e v e l s and to enable us to p a r t i c i p a t e i n advanced e d u c a t i o n a l programmes. A p r o v i n c i a l mental h e a l t h s e r v i c e that was not a c c r e d i t e d would not be a t t r a c t i v e to p s y c h i a t r i s t s and other personnel and there was a s e v e r e s h o r t a g e of t h e s e p r o f e s s i o n a l s . Indeed, the s i t u a t i o n r e f l e c t e d a l l the q u a l i t i e s of a v i c i o u s c i r c l e . F u l l a c c r e d i t a t i o n was d e n i e d , i n p a r t , because of a s h o r t a g e of p e r s o n n e l but p e r s o n n e l c o u l d not be r e c r u i t e d because the s e r v i c e was not f u l l y a c c r e d i t e d . The A.P.A.'s exposure of the v a r i o u s d e f i c i e n c i e s cannot have been a s u p r i s e to the government. Senior, mental h o s p i t a l personnel had, f o r many years, been complaining to the M i n i s t e r r e s p o n s i b l e - the P r o v i n c i a l S e c r e t a r y - and many of the d e f i c i e n c i e s had been p o i n t e d o u t i n t h e r e p o r t o f t h e p r o v i n c i a l Health Survey Committee; a group that had reviewed the s t a t e of the mental h e a l t h s e r v i c e (and other components of the p r o v i n c i a l h e a l t h c a r e system) i n December, 1948. T h i s 249 Committee, which was appointed by the p r o v i n c i a l government to s a t i s f y the requirements of the n a t i o n a l h e a l t h grant programme, made i t s f i n d i n g s and recommendations p u b l i c before the A.P.A.'s d e c i s i o n was announced ( E l l i o t , 1952), and the mental h e a l t h s e r v i c e had a l r e a d y embarked upon a l i m i t e d programme of improvements. Consequently, there can be l i t t l e doubt that the P r o v i n c i a l S e c r e t a r y knew the mental h e a l t h system was e x p e r i e n c i n g d i f f i c u l t i e s . Of a l l the problems which e x i s t e d , one stood out from the o t h e r s ; namely, o v e r - c r o w d i n g . A f t e r r e c e i v i n g the A.P.A.'s d e c i s i o n not to award f u l l a c c r e d i t a t i o n , Gee wrote: 7 The most d i f f i c u l t o b s t a c l e which we have to over-come i n order to r e g a i n f u l l a c c r e d i t a t i o n i s the overcrowding which occurs i n a l l our p a t i e n t accom-m o d a t i o n s . B e f o r e t h i s o v e r c r o w d i n g can be overcome, i t w i l l be n e c e s s a r y f o r us to p r o c e e d wi t h d e f i n i t e p lans f o r a new mental h o s p i t a l at the e a r l i e s t o p p o r t u n i t y . The humanitarian and economic consequences were recognized and there was an urgent need to devise e f f e c t i v e s o l u t i o n s . Over-crowding i n the province's mental h e a l t h i n s t i t u t i o n s (and the humanitarian and economic consequences) was not a new problem. Constant r e f e r e n c e had been made to the i s s u e almost from the time when the f i r s t insane asylum was c o n s t r u c t e d i n New Westminster (Clark, 1947; Gee, 1953) and, i n the l a t e 1940's and e a r l y 1950's i t was a n a t i o n a l problem (MacKerracher, 1964). I t would be s h o c k i n g to hear a mental p a t i e n t of 1948 speak to us from that time...Community t r e a t -ment was mostly u n a v a i l a b l e . I t was the day of the 'snake p i t ' m e n t a l h o s p i t a l - b a r s , l o c k s , r e s t r a i n t s , 'herding' and a l l the r e s t . . . P a t i e n t s were a d m i t t e d by l e g a l p r o c e s s and r e t a i n e d i n locked wards. Because of u n d e r - s t a f f i n g and over-250 crowding, the emphasis was on custody r a t h e r than therapy (Richman, 1964: 34). Saskatchewan was s i n g l e d out as the p r o v i n c e where over-crowding was p a r t i c u l a r l y bad and the c o n d i t i o n s i n the mental h o s p i t a l at Weyburn were d e s c r i b e d as " i n d e f e n s i b l e " (MacKerracher, 1964: 102). The s i t u a t i o n i n B r i t i s h C olumbia a l s o a p peared to be p a r t i c u l a r l y c h r o n i c . S p e c i f i c r e f e r e n c e was made to the i s s u e i n the N a t i o n a l R e f e r e n c e Book on H e a l t h , W e l f a r e and Labour which was used at the D o m i n i o n - P r o v i n c i a l C o n f e r e n c e on Re-C o n s t r u c t i o n i n 1945. Here i t was noted t h a t , over a ten year p e r i o d , the p r o v i n c e had experienced the highest degree of over-c r o w d i n g i n the c o u n t r y . T h i s was due to an i n c r e a s e i n the numbers of p a t i e n t s (29.2%) i n e x c e s s of the n a t i o n a l a verage (22.6%) but no c o r r e s p o n d i n g e x p a n s i o n i n f a c i l i t i e s . I t was noted that, i n the mid-1940's, the province had 3,958 p a t i e n t s but only 2,458 beds ( D o m i n i o n - P r o v i n c i a l Conference, 1945). The problem was of great concern to the then D i r e c t o r of Mental Hygiene and P s y c h i a t r y - Dr. A.L. Crease - who had been i s s u i n g warnings about the s e r i o u s and dangerous over-crowding s i t u a t i o n s i n c e at l e a s t the mid-1930's. By the l a t e 1930's Crease was p r o t e s t i n g that there was a b s o l u t e l y no more space i n the h o s p i t a l and he admitted that the h o s p i t a l could do l i t t l e more than p r o v i d e a c u s t o d i a l s e t t i n g . E f f e c t i v e t r e a t m e n t c o u l d not be given and t h i s was having an adverse e f f e c t upon the d i s c h a r g e r a t e . By 1942 he was a d v i s i n g the P r o v i n c i a l ft S e c r e t a r y that the s i t u a t i o n was approaching a c r i s i s p o i n t : The space i n which to put more beds throughout the I n s t i t u t i o n i s scant, such as basements, a t t i c s and s e r v i c e rooms. There are o n l y some of the day 251 rooms l e f t and they are being used. In h i s view, t h e r e were o n l y t h r e e ways of a d d r e s s i n g the p r o b l e m : b u i l d more accommodation, remove p a t i e n t s to o t h e r accommodation, or i n c r e a s e d i s c h a r g e s . The l a t t e r , he f e l t , c o u ld be accomplished through the i n t r o d u c t i o n of a boarding-out programme and he a l s o mentioned the p o s s i b i l i t y of r e l i e v i n g the s i t u a t i o n by p l a c i n g "subnormal c a s e s . . . i n s m a l l c o l o n i e s on abandoned farms"; a prospect he d i d not r e l i s h . 9 T h i s problem was, t h e r e f o r e , endemic to the province and i t i s a p p a r e n t t h a t , d u r i n g the 1940's, C r e a s e had l i t t l e success i n a c h i e v i n g a r e s o l u t i o n . In March 1947, f o r example, he w r o t e , 1 0 i t would be w e l l a g a i n t o c o n s i d e r the e s t a b -lishment of a new i n s t i t u t i o n f o r mental i l l n e s s , now that Essondale has grown w e l l beyond the p o i n t f o r which i t was e r e c t e d . A year l a t e r he emphasized the problem a g a i n . H (T)he overcrowding has now reached the l e v e l of a hazard; one wonders where the wheel w i l l stop... Crease s t a t e d t h a t the s i t u a t i o n was e x a c e r b a t e d by b o t h the i n c r e a s i n g admission r a t e and the age of the e x i s t i n g b u i l d i n g s . The former problem was p a r t i c u l a r l y acute and B r i t i s h Columbia s t o o d out as the p r o v i n c e w i t h the h i g h e s t r a t e s of f i r s t admissions and re-admissions i n the country. In 1945, the f i r s t admission r a t e (per 100,000 population) stood at 93.0, compared with the n a t i o n a l average of 78.7, while the re-admission r a t e stood at 28.3 ( n a t i o n a l average, 23.1). By 1950, the province's f i r s t admission r a t e had climbed to 163.1 and was unprecedented i n Canada ( n a t i o n a l a v e r a g e , 87.0). The r e - a d m i s s i o n r a t e , 252 which had i n c r e a s e d to 67.0, was a l s o ahead of the o t h e r p r o v i n c e s ( n a t i o n a l average, 32.9). T h e age o f t h e e x i s t i n g i n s t i t u t i o n s was a l s o unquestionable and t h i s problem of 'obsolescence* was not unique to the province. Across Canada, the bulk of i n - p a t i e n t care was provided by l a r g e , i s o l a t e d mental h o s p i t a l s l o c a t e d i n r u r a l a r e a s and s e g r e g a t e d from the r e s t of the h e a l t h c a r e system (Richman, 1964). In many i n s t a n c e s , the o r i g i n a l h o s p i t a l b u i l d i n g was f i r s t b u i l t i n the n i n e t e e n t h c e n t u r y , w i t h f u r t h e r c o n s t r u c t i o n of a d d i t i o n a l wings or u n i t s through the years as the demand f o r accommodation inc r e a s e d (op c i t : 46). In the l a t e 1940's, B r i t i s h Columbia had an i s o l a t e d , o b s o l e t e i n s t i t u t i o n which was one of the l a r g e s t p r o v i n c i a l m e n t a l h o s p i t a l s i n Canada; namely, E s s o n d a l e H o s p i t a l (Gee, 1953). The f a c i l i t y had been b u i l t i n 1913 and i t was used to b o t h c o n f i n e the m e n t a l l y i l l and i n f i r m and p r o v i d e a ' c l e a r i n g -house' f o r the other f a c i l i t i e s ( E l l i o t , 1952). The province had two o t h e r i n s t i t u t i o n s : the h o s p i t a l a t New W e s t m i n s t e r (the o r i g i n a l i n s a n e asylum which had been r e n o v a t e d and housed 'subnormal' p a t i e n t s ) , and the h o s p i t a l a t S a a n i c h f o r the c r i m i n a l l y insane ( C o l q u i t z ) . These were q u i t e inadequate and Essondale H o s p i t a l was f i l l e d beyond c a p a c i t y as the numbers of p a t i e n t s (both i n r e s i d e n c e and treated) s t e a d i l y i n c r e a s e d . In f i s c a l 1945/46, an average of 3,164 p a t i e n t s were r e s i d i n g i n the f a c i l i t y and 3,964 r e c e i v e d treatment; by f i s c a l 1950/51, the numbers had r i s e n to 3,425 and 5,116 r e s p e c t i v e l y . 1 3 Dr. Crease d i d not, however, favour the b u i l d i n g of a new 253 mental h o s p i t a l ; f o r example, i n March 1948, he wrote, "there has been a world-wide tendency to r e j e c t the idea of expenditure toward mental h o s p i t a l s , " n o t i n g t h a t the a d v e r s e p u b l i c i t y g i v e n to mental h o s p i t a l s i n A m e r i c a , had s t i m u l a t e d t h i s o p p o s i t i o n to the b u i l d i n g of more i n s t i t u t i o n s . 1 4 Indeed, he had l o n g r e c o g n i z e d t h a t o u t - p a t i e n t t r e a t m e n t , p r e v e n t a t i v e care, and the r e h a b i l i t a t i o n of c h r o n i c cases were p r e f e r a b l e s t r a t e g i e s . These were not o n l y "more s a t i s f a c t o r y to the p a t i e n t s , r e l a t i v e s and employees", but a l s o , "a great deal more economical" s i n c e , when coupled with e a r l y , a c t i v e treatment of d i s o r d e r s , t h e y w o u l d p r e v e n t h o s p i t a l a d m i s s i o n s . ^ Humanitarian and economic c o n s i d e r a t i o n s were thus c a r e f u l l y blended. The r e f e r e n c e to the economic consequences of o v e r -crowding was not ignored and i t i s apparent that the p r o v i n c i a l government d i d not r e l i s h the prospect of s t a r t i n g a major, new c o n s t r u c t i o n plan. In 1950, f o r example, the Deputy P r o v i n c i a l S e c r e t a r y (R.A. Pennington) noted that mental i l l n e s s was, "the l a r g e s t s i n g l e cause of the h o s p i t a l i z a t i o n of our people" and welcomed the f a c t that a s t a r t was being made " i n the f i e l d s of r e s e a r c h , p r e v e n t i o n and e a r l y treatment/ r e h a b i l i t a t i o n . " He went on to emphasize t h a t , * 6 W i t h o u t d e v e l o p m e n t i n t h e s e f i e l d s , i t i s i n e v i t a b l e t h a t the f u t u r e must h o l d n e c e s s i t y (sic) f o r vast c a p i t a l c o n s t r u c t i o n (at l e a s t a 250 bed h o s p i t a l each year) and f o r the maintenance of p a t i e n t s i n h o s p i t a l i n ever i n c r e a s i n g degree. One year l a t e r , Pennington had adjusted h i s e s t i m a t e s upwards. 1 7 In h i s annual r e p o r t to the P r o v i n c i a l S e c r e t a r y , he wrote;-1-' 254 The need i n v a r i a b l y exceeds the budget...It i s i m p e r a t i v e t h a t the a c c e n t be more and more on pre v e n t i o n and e a r l y treatment of mental i l l n e s s . Without f a c i l i t i e s f o r these, a complete new 500 -1000 bed mental h o s p i t a l would be r e q u i r e d every year, and the d r a i n on the budgetary resources of the province would grow i n d e f i n i t e l y . The c o s t o f b u i l d i n g new f a c i l i t i e s was l i k e l y t o "be s u b s t a n t i a l . F i v e y e a r s e a r l i e r , f o r example, i t had been estimated that a h o s p i t a l f o r 1000 - 2000 p a t i e n t s would c o s t $2500 to $3500 per bed to b u i l d . Even the c o n s t r u c t i o n of a d d i t i o n s to e x i s t i n g i n s t i t u t i o n s was an expensive p r o p o s i t i o n s i n c e t h i s would e n t a i l e x p e n d i t u r e i n the range of $1500 to $2000 per bed ( D o m i n i o n - P r o v i n c i a l Conference, 1945). In a d d i t i o n , Pennington was w e l l aware of the c o n t i n u i n g c o s t s i n v o l v e d i n the o p e r a t i o n of i n s t i t u t i o n s . The t o t a l o p e r a t i n g c o s t s of the e x i s t i n g i n s t i t u t i o n s had r i s e n from $2.5 m i l l i o n i n f i s c a l 1945/46, to $6.2 m i l l i o n i n 1950/51, and the bulk of the money was consumed by Essondale H o s p i t a l where the c o s t s had r i s e n from $1.7 m i l l i o n to $3.4 m i l l i o n . 1 8 The inc r e a s e was due to, among other developments, the i n c r e a s e i n the numbers of p a t i e n t s , upward f l u c t u a t i o n s i n the p r i c e o f food and s u p p l i e s , and personnel expenditures. S t a f f s a l a r i e s consumed the l a r g e s t p r o p o r t i o n of the o p e r a t i n g c o s t s and these e x p e n d i t u r e s were s t e a d i l y c l i m b i n g as the c o n d i t i o n s and b e n e f i t s of employment were improved i n an e f f o r t to a t t r a c t q u a l i f i e d personnel (Gee, 1953; Richman, 1964). 1 9 Indeed, the o v e r a l l cost of the mental h e a l t h system was a c c o u n t i n g f o r a s i g n i f i c a n t p r o p o r t i o n of the p r o v i n c i a l 255 government's t o t a l e x p e n d i t u r e s on h e a l t h s e r v i c e s and t h i s r e f l e c t e d the s i t u a t i o n e l s e w h e r e i n the c o u n t r y . M e n t a l i l l n e s s .was seen as the nation's primary h e a l t h problem and the cost of main t a i n i n g p a t i e n t s i n i n s t i t u t i o n s was e s c a l a t i n g . In f i s c a l 1952/53 f o r example, the cost exceeded $60 m i l l i o n and e x p e n d i t u r e s had r i s e n more than 70% over a f i v e y e a r p e r i o d (Department of N a t i o n a l H e a l t h & W e l f a r e , 1954). W h i l e the in c r e a s e was due, i n p a r t , to a general r i s e i n p r i c e s , i t was a l s o a f u n c t i o n of i n c r e a s e d h o s p i t a l i z a t i o n and improvements i n treatment s e r v i c e s (op c i t ) . Since the bulk of the c o s t was met by the provin c e s (approximately 80%), the f i s c a l s t r a i n was both c o n s i d e r a b l e and growing, and, by 1953, the cost of c a r i n g f o r the m e n t a l l y i l l was seen as the " h e a v i e s t burden which the p r o v i n c i a l governments had to bear i n p r o v i d i n g h e a l t h s e r v i c e s " (op c i t : 171). The system of s e g r e g a t e d c o n f i n e m e n t was becoming expensive throughout Canada. B r i t i s h Columbia was no exception. In 1949, f o r example, the mental h e a l t h component absorbed 27% ($3.6 m i l l i o n ) of the t o t a l e x p e n d i t u r e ($13.3 m i l l i o n ) , the bulk of which ($10.4 m i l l i o n ) was p r o v i d e d by the p r o v i n c e ( E l l i o t , 1952). S i n c e t h i s was the year during which a new h o s p i t a l insurance scheme had been i n t r o d u c e d i n the p r o v i n c e ( t h e r e b y i n c r e a s i n g the c o s t s of o p e r a t i n g the c o n v e n t i o n a l , p u b l i c h o s p i t a l system) i t i s apparent that the p r o p o r t i o n of the expenditures absorbed by the mental h e a l t h s e r v i c e i n p r e v i o u s y e a r s had been l a r g e r . The advent of an h o s p i t a l i n s u r a n c e scheme a l s o r a i s e d the spe c t r e of f u r t h e r i n c r e a s e s i n the c o s t of o p e r a t i n g the mental 256 h e a l t h system (as w e l l as h e a l t h care i n general) i f there was to be any e x t e n s i o n of the scheme to the v a s t numbers of i n s t i t u t i o n a l i z e d mental h e a l t h p a t i e n t s . T h i s could c r e a t e a d i f f i c u l t f i s c a l s i t u a t i o n and the p r o v i n c i a l H e a l t h S u r v e y Committee extended a f i r m warning. The r i s i n g c o s t s of h e a l t h care i n the p r o v i n c e were due p r i m a r i l y to the i n t r o d u c t i o n of the h o s p i t a l i n s u r a n c e scheme and i t was n e c e s s a r y to move c a r e f u l l y i n regard to both the adoption of comprehensive h e a l t h c a r e i n s u r a n c e and any e x p a n s i o n of the h o s p i t a l i n s u r a n c e scheme (op c i t ) . T h i s p r o s p e c t a s i d e , i t i s e v i d e n t t h a t the e x i s t i n g s i t u a t i o n was s u f f i c i e n t l y worrisome. In 1951, Pennington noted t h a t , 2 0 n e a r l y one q u a r t e r of the province's e n t i r e c i v i l s e r v i c e was engaged i n c a r e and t r e a t m e n t of the ment a l l y i l l , and t hat the task was the e q u i v a l e n t o f , the 24 hour a d m i n i s t r a t i o n of a community l a r g e r than the c i t i e s of Nanaimo or Nelson. He r e p o r t e d t h a t the h i g h o p e r a t i n g c o s t was due to the f a c t t h a t h o s p i t a l s p r o v i d e d not o n l y the f u l l range of m e d i c a l , d e n t a l and s o c i a l s e r v i c e s a s s o c i a t e d with both p s y c h i a t r i c and con v e n t i o n a l treatment, but a l s o food, f u e l , s h e l t e r , c l o t h i n g , o c c u p a t i o n a l and r e c r e a t i o n a l t h e r a p y , r e h a b i l i t a t i o n , and s p i r i t u a l and f u n e r a l services. 2- 1-It was apparent that something had to be done about what P e n n i n g t o n then r e f e r r e d to as the " g r i e v o u s o v e r c r o w d i n g " , p a r t i c u l a r l y at Essondale. At the end of March 1951 there were 257 6,028 c i t i z e n s i n general h o s p i t a l s i n the pro v i n c e and 5,394 i n mental h o s p i t a l s , with a w a i t i n g l i s t of 200. * A year l a t e r , and as a r e s u l t of an in-house survey conducted at the request of the f e d e r a l government, i t was noted that the over-crowding had r e a c h e d a c r i s i s p o i n t t h r o u g h o u t the e n t i r e E s s o n d a l e complex. In the West Lawn B u i l d i n g , 1,018 beds had been set up even though the b u i l d i n g ' s bed c a p a c i t y had been f i x e d a t 778 beds (30.8% o v e r - c r o w d i n g ) . In the E a s t Lawn B u i l d i n g , 1,445 beds had been set up i n a space that should have contained only 921 beds (56.8% over-crowding). The s i t u a t i o n was p a r t i c u l a r l y bad i n the mens' s e c t i o n of the Centre Lawn B u i l d i n g where 260 beds occupied a space that should have held only 143 beds (81.8% over-crowding). The surveyors a l s o noted that the basements and a t t i c s i n a l l the b u i l d i n g s were h o u s i n g p a t i e n t s . J I t was a p p a r e n t , t h e r e f o r e , t h a t Crease's w a r n i n g of an impending c r i s i s , f i r s t a r t i c u l a t e d a decade e a r l i e r , had come t o f r u i t i o n . The p r o v i n c i a l government responded by i n t r o d u c i n g some short-term measures drawn from the recommendations of the 1925, p r o v i n c i a l Royal Commission on Mental Hygiene. The Commission had been formed i n the wake of a s u r v e y c o n d u c t e d by the Canadian N a t i o n a l Committee f o r Mental Hygiene i n 1919, and had i s s u e d a r e p o r t i n 1927 e n d o r s i n g the N a t i o n a l Committee's p r o p o s e d r e f o r m s : n o t a b l y , d i s p o s i n g of j u d i c i a l commitment hearings; improving s o c i a l s e r v i c e s to allow e a r l y d i s charge on 'probation'; i n t r o d u c i n g mental h e a l t h c l i n i c s to both s u p e r v i s e p a t i e n t s on p r o b a t i o n and prevent and detec t mental d i s e a s e s at 258 an e a r l y s t a g e ; p l a c i n g d i f f e r e n t c a t e g o r i e s of p a t i e n t s i n separate i n s t i t u t i o n s ; and, e s t a b l i s h i n g a psychopathic h o s p i t a l f o r the e a r l y and a c t i v e treatment of d i s o r d e r s (Clark, 1947). In s h o r t , the changes a s s o c i a t e d which the e r a of ' m e d i c a l -i z a t i o n ' during the 1920's and 1930's. Although the recommendations were aimed at r e s o l v i n g the l e v e l s of o v e r - c r o w d i n g which had been c r i t i c i z e d i n the N a t i o n a l Committee's 1919 s u r v e y , few had been i m p l e m e n t e d owing to the o n s e t of the economic d e p r e s s i o n i n the e a r l y 1930's ( C l a r k , 1 9 4 7 ) . 2 4 The f a i l u r e to i n t r o d u c e the changes had p r e c i p i t a t e d the c r i s i s which c o n f r o n t e d the p r o v i n c i a l government i n the e a r l y 1950's and the p r o p o s a l s of the o l d Commission were r e s u r r e c t e d i n an e f f o r t t o d e a l w i t h the s i t u a t i o n . The g o v e r n m e n t b u i l t a f o u r - s t o r e y , t h r e e w i n g ' p s y c h o p a t h i c h o s p i t a l ' - the Crease C l i n i c - and the f i r s t p a t i e n t s were admitted f o r e a r l y , a c t i v e treatment before the e n a b l i n g l e g i s l a t i o n (The C l i n i c s of P s y c h o l o g i c a l M e d i c i n e A c t 2 5 ) had been p r o c l a i m e d i n f o r c e (Gee, 1953). The C l i n i c was f o r m a l l y e s t a b l i s h e d i n January 1951 and the new s t a t u t e made p r o v i s i o n f o r v o l u n t a r y admission, i n v o l u n t a r y admission, and c o n f i n e m e n t f o r up to f o u r months, w i t h o u t the need f o r a j u d i c i a l hearing. The p r o v i n c i a l government was o p t i m i s t i c t h a t the C l i n i c would r e s o l v e the p roblem of o v e r - c r o w d i n g without b u i l d i n g one or more new, l a r g e mental h o s p i t a l s and, s h o r t l y a f t e r the opening of the C l i n i c , Pennington announced that he had "put on i c e plans f o r a second l a r g e mental h o s p i t a l 259 f o r long-term p s y c h o t i c p a t i e n t s - plans which had m a t e r i a l l y d e v e l o p e d . " 2 6 The P r o v i n c i a l S e c r e t a r y a l s o a p proved o t h e r t a c t i c s : notably, an expansion i n the accommodation f o r 'defective' and a g i n g p a t i e n t s . ' New and e x i s t i n g a g i n g p a t i e n t s ( i . e . , those who were being admitted f o r the f i r s t time and those who had grown o l d i n the i n s t i t u t i o n s ) were to be removed and c o n f i n e d a p a r t from o t h e r p a t i e n t s , and the p l a n i n v o l v e d a r a t h e r ingenious use of a v a i l a b l e f a c i l i t i e s . The government a c q u i r e d and r e n o v a t e d an o l d m i l i t a r y h o s p i t a l at Vernon (a c o l l e c t i o n of wooden barracks l a t e r known as D e l l v i e w H o s p i t a l ) and 200 aged p a t i e n t s were t r a n s f e r r e d from E s s o n d a l e . By 1951, the o l d m i l i t a r y h o s p i t a l i n Terrace had been a c q u i r e d f o r the express purpose of housing 300 aged p a t i e n t s and t h i s f a c i l i t y was l a t e r known as Skeenaview H o s p i t a l (Gee, 1953). Crease a l s o announced a plan to c o n s t r u c t a 'cheap b u i l d i n g ' i n the Essondale area f o r aging p a t i e n t s : "a permanent s t r u c t u r e , 9 P. l e s s adorned but p l e a s i n g i n appearance". ' M e n t a l l y d e f e c t i v e ' p a t i e n t s were to be removed from E s s o n d a l e and s t e p s were taken to e n s u r e t h a t t h e r e were no f u r t h e r admissions of ' d e f e c t i v e s ' to the f a c i l i t y . By 1951, the government had announced that a new 300 bed u n i t was to be opened at the h o s p i t a l i n New Westminster (re-named 'Woodlands School') which would permit the t r a n s f e r of p a t i e n t s from the mental h o s p i t a l . In a d d i t i o n , new admission procedures were to be i n t r o d u c e d w hich would c i r c u m v e n t the need f o r m e n t a l l y 260 d e f e c t i v e p a t i e n t s to be f i r s t admitted to Essondale, and these e v e n t u a l l y a p peared i n the S c h o o l s For M e n t a l l y D e f e c t i v e s A c t . 2 9 The p r o v i n c i a l government a l s o considered the i n t r o d u c t i o n of day h o s p i t a l s and o u t - p a t i e n t c l i n i c s , "where the expense of d o m i c i l i a r y care and personal s e r v i c e s w i l l be n e g l i g i b l e " and which would "obviate the need of long-term h o s p i t a l care i n many c a s e s " . 3 0 O u t - p a t i e n t s e r v i c e s f o r a d u l t s were to be modelled upon the e x i s t i n g ' C h i l d G u i d a n c e C l i n i c s ' (a s y s t e m o f permanent and t r a v e l l i n g c l i n i c s that f i r s t appeared i n 1932) and the recommendation that t h i s p a r t i c u l a r s t r a t e g y be adopted appeared i n the Health Survey Committee Report ( E l l i o t , 1952). Here i t was noted that the c h i l d guidance c l i n i c s provided the only complete o u t - p a t i e n t s e r v i c e . I t was suggested that t h i s s y stem be extended to i n c l u d e a d u l t s s i n c e t h i s would a l l o w e a r l i e r d i a g n o s i s and treatment and "thus d i m i n i s h the need f o r beds" (op c i t : 37). T h i s t a c t i c was c o n s i s t e n t w i t h the view l o n g h e l d by Crease who re-emphasized i t s value on the eve of h i s r e t i r e m e n t as D i r e c t o r i n 1950. In h i s o p i n i o n , the expensive, 'continued treatment' idea was on the d e c l i n e while the 'modern' p r i n c i p l e of ' i n t e n s i v e t r e a t m e n t ' was s p r e a d i n g r a p i d l y . The l a t t e r embodied the n o t i o n s of e a r l y d e t e c t i o n , r a p i d and a c t i v e t r e a t m e n t , and speedy d i s c h a r g e back to the community where f u r t h e r , 'out-patient' treatment should be provided. I n t e n s i v e treatment was not only l i k e l y to be more e f f e c t i v e but a l s o l e s s c o s t l y , p a r t i c u l a r l y i n the long-term. As Crease n o t e d , 3 1 261 In e v e r y way i t i s f e l t t h a t e v e n t u a l l y a c o n s i d e r a b l e saving of money w i l l be e f f e c t e d f o r , as the y e a r s go by, e x p e n d i t u r e f o r the c a r e and treatment of p a t i e n t s i n the h o s p i t a l i t s e l f w i l l be g r e a t l y lessened. The need f o r a new treatment s t r a t e g y was, i n p a r t , due to the f a i l u r e of e x i s t i n g treatments to reduce the p o p u l a t i o n of the mental h o s p i t a l s . While there was l i t t l e that could be done to ' t r e a t 1 m e n t a l l y d e f e c t i v e and a g i n g p a t i e n t s , i t was b e l i e v e d that a f r e s h approach to those s u f f e r i n g from mental i l l n e s s m i g h t have b e n e f i c i a l r e s u l t s . The ' c o n t i n u e d treatment' s t r a t e g y c r i t i c i z e d by Crease i n v o l v e d , p r i m a r i l y , c u s t o d i a l c a r e d u r i n g which at l e a s t one form of t r e a t m e n t -p s y c h o s u r g e r y - was u s e d t o m a i n t a i n o r d e r i n s i d e t h e i n s t i t u t i o n s . In the l a t e 1940's, the t r e a t m e n t methods at E s s o n d a l e i n c l u d e d the s o m a t o t h e r a p i e s ( i . e . , e l e c t r o t h e r a p y , i n s u l i n shock therapy, and psychosurgery), hydrotherapy (i.e., v a r i o u s kinds of baths), and some psychotherapy; however, the e f f o r t s were hampered by both s t a f f shortages and c h r o n i c over-crowding. I n s u l i n shock therapy had been introduced i n the l a t e 1930's and i t was hoped t h a t t h i s method would i n c r e a s e the numbers of dis c h a r g e s and a l l e v i a t e the problem of over-crowding (Clark, 1947). E l e c t r i c - s h o c k therapy had been introduced i n the e a r l y 1940's and t h i s was a l s o viewed as an inexpensive and e f f e c t i v e means to reduce the h o s p i t a l p o p u l a t i o n (op c i t ) . I t was seen as a "safe and r a p i d form of treatment", the use of which was j u s t i f i e d "by the high discharge r a t e of p a t i e n t s r e c e i v i n g t h i s 262 type of therapy". A more d r a s t i c form of treatment had been in t r o d u c e d f o r those who f a i l e d t o respond t o i n s u l i n and e l e c t r o - s h o c k therapy; namely, lobotomy. The f i r s t o p e r a t i o n s were c a r r i e d out on nine p a t i e n t s i n 1945/46 and the r e s u l t s were deemed to be 'encouraging' (Gee, 1953). By 1947, Essondale h o s p i t a l had e s t a b l i s h e d a committee c h a r g e d w i t h the t a s k of s e l e c t i n g s u i t a b l e p a t i e n t s f o r t h i s " c l a s s i c a l l y a c c e p t e d type of 3 3 operation"-'-' and, even where a lobotomy d i d not r e s u l t i n the d i s c h a r g e of a p a t i e n t , i t was n o t e d t h a t i t p r o d u c e d "more f a v o u r a b l e conduct on the w a r d s " . 3 4 Indeed, by 1949, t h i s s e c o n d a r y ' b e n e f i t * a p p e a r e d t o be the p r i m a r y r e a s o n f o r u n d e r t a k i n g the o p e r a t i o n . In t h a t y e a r , 24 l o b o t o m i e s were performed f o r the " r e l i e f of symptoms", while 27 were performed f o r "improved h o s p i t a l a d j u s t m e n t " ; t h a t i s , i m p r o v i n g the a b i l i t i e s of " d i s t u r b e d and troublesome" p a t i e n t s to "adjust to o r d i n a r y h o s p i t a l r o u t i n e s " . 3 5 The h o s p i t a l had l i t t l e e l s e to o f f e r i n the way of treatment. Apart from 'hydrotherapy' there was, f o r some of the men, ' i n d u s t r i a l therapy'; an a c t i v i t y t h a t i n v o l v e d h o s p i t a l m a i ntenance, work i n v a r i o u s h o s p i t a l s e r v i c e s , and the pro d u c t i o n of commodities both f o r s a l e and f o r use w i t h i n the i n s t i t u t i o n . Indeed, w h i l e a l i m i t e d form of ' r e c r e a t i o n therapy' was a v a i l a b l e , the focus of 'treatment' was upon "water and work". In s h o r t , i n the l a t e 1940's and e a r l y 1950's, Essondale was l i t t l e more than an over-crowded and expensive segregated c u s t o d i a l i n s t i t u t i o n where an i n c r e a s i n g number of 263 p a t i e n t s languished, at times i n p h y s i c a l r e s t r a i n t , ' s e c l u s i o n rooms' or ' s e d a t i o n s u i t e s ' , and a l w a y s under the t h r e a t of d r a s t i c , d i s c i p l i n a r y treatment i n the event of misconduct. The s t a t e was c o n f r o n t i n g a c r i s i s w ith i t s s t r a t e g y f o r the management of the mentally d i s o r d e r e d , and steps were taken to address the a s s o c i a t e d order maintenance and l e g i t i m a t i o n p r o b l e m s . In p a r t i c u l a r , s o m e t h i n g had to be done about the l a r g e and e s c a l a t i n g i n s t i t u t i o n a l i z e d p o p u l a t i o n , and the r e s u r r e c t i o n of the o l d R o y a l Commission's recommendations p r o v i d e d the p r o s p e c t of some r e l i e f . The use of the C r e a s e C l i n i c would allow f o r the e a r l y admission, i n t e n s i v e treatment, and r a p i d discharge of new p a t i e n t s and t h i s would both prevent a d m i s s i o n s to E s s o n d a l e and a s s i s t i n the r e d u c t i o n of the e x i s t i n g p o p u l a t i o n . O v e r - c r o w d i n g would be r e l i e v e d , the e s c a l a t i n g c o s t s of i n s t i t u t i o n a l confinement would slow, and the need to b u i l d e x p e n s i v e and d i s c r e d i t e d m e n t a l h o s p i t a l s would be circumvented. While the measures devised by s e n i o r personnel w i t h i n the s t a t e apparatus (i.e., the mental h e a l t h s e r v i c e bureaucracy), provided grounds f o r optimism i t was evident that a long-term plan was necessary. The p r o v i n c i a l government had to devise a new s t r a t e g y f o r the management of the mentally d i s o r d e r e d t h a t would be e f f e c t i v e i n c o n t r o l l i n g t h i s group, r e s o l v e the p r o b l e m of l e g i t i m a t i o n c r e a t e d by the A.P.A.'s r e p o r t ( i . e . , r e s t o r e f u l l a c c r e d i t a t i o n and, thereby, p u b l i c and p r o f e s s i o n a l c o n f i d e n c e ) , but not c o n f l i c t w i t h i t s t h i r d c a r d i n a l f u n c t i o n ; 264 namely, r e p r o d u c i n g the c o n d i t i o n s n e c e s s a r y f o r c o n t i n u e d c a p i t a l a c c u m u l a t i o n . The A.P.A.'s recommendations a p p e a r e d c a p a b l e of s a t i s f y i n g the s t a t e ' s o r d e r m a i n t e n a n c e and l e g i t i m a t i o n i m p e r a t i v e s and, to the extent that the proposed changes were c o n s i s t e n t w i t h the development of a ' w e l f a r e s t a t e ' b u i l t upon new K e y n e s i a n economic p o l i c i e s , the t h i r d i m p erative was a l s o f u l f i l l e d . Indeed, while implementation of the recommended changes r e q u i r e d a s o c i a l welfare system w i t h i n which n o n - i n s t i t u t i o n a l modes of management could be developed, t h i s c o u r s e of a c t i o n a l s o b u t t r e s s e d the s t a t e ' s g o a l of w e l f a r e s t a t e e x p a n s i o n . The s t a t e ' s t h r e e , p o t e n t i a l l y c o n t r a d i c t o r y c a r d i n a l f u n c t i o n s c o u l d be s y n c h r o n i z e d , and s e n i o r mental h e a l t h p e r s o n n e l c o n s e q u e n t l y c o n s t r u c t e d a s t r a t e g y based upon the A.P.A.'s recommendations. This i n v o l v e d a t r a n s f o r m a t i o n o f t h e e x i s t i n g s y s t e m o f s e g r e g a t e d confinement i n t o one c h a r a c t e r i z e d by community-based, medical and s o c i a l work management, i n t e g r a t e d w i t h i n the general h e a l t h care component of the emerging p r o v i n c i a l w e l f a r e s t a t e . I l l ; DE-INSTITUTIONALIZATION AND THE SHIFT TO COMMUNITY CARE AND TREATMENT: THE NEW STRATEGY FOR THE MANAGEMENT OF THE MENTALLY DISORDERED The o r d e r m a i n t e n a n c e and l e g i t i m a t i o n p r o b l e m s a s s o c i a t e d with the mental h e a l t h system i n B r i t i s h Columbia i n the l a t e 1940's and e a r l y 1950's were not p e c u l i a r to the pro v i n c e . The system of segregated confinement was e x p e r i e n c i n g d i f f i c u l t i e s i n o t h e r p a r t s of Canada and, d u r i n g the 1950's, e v e r y p r o v i n c e i n t r o d u c e d r e m e d i a l measures. In p a r t i c u l a r , s t e p s were ta k e n t o r e l i e v e the o v e r - c r o w d i n g i n mental 265 h o s p i t a l s (Richman, 1964). The bulk of those r e s i d i n g i n h o s p i t a l s were ' l o n g - s t a y ' p a t i e n t s ( i . e . , those who had been c o n f i n e d f o r more than two years) and a major e f f o r t was made to both h a l t the long-term confinement of new p a t i e n t s and engineer the d i s c h a r g e of e x i s t i n g p a t i e n t s to community-based a l t e r n -a t i v e s (op c i t ) . P r o v i n c i a l governments had to remedy the s i t u a t i o n without the guidance and d i r e c t a s s i s t a n c e of the f e d e r a l government. Although Ottawa provided c o n s t r u c t i o n and p r o f e s s i o n a l t r a i n i n g grants under the n a t i o n a l h e a l t h grants programme, i t d i d l i t t l e e l s e , d e s p i t e the recommendations of the Department of N a t i o n a l Health and Welfare (1954). H o s p i t a l c o n s t r u c t i o n grants f o r the development of f a c i l i t i e s that could c a r r y more p s y c h i a t r i c beds were d i s t r i b u t e d and over 20,500 new beds were c r e a t e d between 1948 and 1961; however, t h i s was not seen as an e f f e c t i v e way of r e l i e v i n g over-crowding (Richman, 1964). The f e d e r a l g o v e r n m e n t d i d n o t a d o p t t h e o t h e r recommendations of the Department of Health and Welfare and made no e f f o r t to improve the s i t u a t i o n o t h e r than to i n d i r e c t l y d i s c o u r a g e the use of mental h o s p i t a l s by e x c l u d i n g t h e s e i n s t i t u t i o n s from a new h o s p i t a l insurance scheme. In 1957, the f e d e r a l government introduced a system f o r s h a r i n g the co s t s of acute h o s p i t a l care and d i a g n o s t i c s e r v i c e s w i t h any province that had int r o d u c e d a u n i v e r s a l , h o s p i t a l insurance programme. T h i s measure was aimed a t i m p r o v i n g the g e n e r a l h e a l t h c a r e component of the welfar e s t a t e . Subsequently, a l l the p r o v i n c e s i n t r o d u c e d h o s p i t a l i n s u r a n c e , and s i g n e d c o s t - s h a r i n g 266 agreements, between 1958 and 1960. However, mental h o s p i t a l s and other ' c u s t o d i a l care f a c i l i t i e s ' (e.g., n u r s i n g homes and homes f o r the aged) were excluded from the agreements (Guest, 1985) . F e d e r a l government involvement i n the mental h e a l t h f i e l d was, t h e r e f o r e , c h a r a c t e r i z e d by i n a c t i o n and, i n the absence of a s s i s t a n c e and guidance from Ottawa, the p r o v i n c e s were l e f t to develop t h e i r own s t r a t e g i e s . The task f e l l upon the shoulders of s e n i o r p e r s o n n e l w i t h i n the s t a t e a p p a r a t u s ( i . e . , m e n t a l h e a l t h s e r v i c e bureaucracies) and, i n B r i t i s h Columbia, these personnel began to implement the recommendations of the A.P.A. The 'Total Push' f o r D e - I n s t i t u t i o n a l i z a t i o n : The Development of the New S t r a t e g y i n B r i t i s h Columbia In 1952, the f i r s t S o c i a l C r e d i t government was e l e c t e d to o f f i c e i n B r i t i s h Columbia and, by 1953, i t had expressed i t s commitment to improving the mental h e a l t h s e r v i c e . Indeed, the 1953 Throne Speech contained a s p e c i f i c r e f e r e n c e to the govern-ment's 'grave concern' f o r the i n c r e a s i n g number of c i t i z e n s who needed the help of mental h e a l t h s e r v i c e s , and i t s i n t e n t i o n to extend accommodation, treatment and p r e v e n t i v e f a c i l i t i e s . 3 6 T h i s announcement was f o l l o w e d , s e v e r a l months l a t e r , by a concrete e x p r e s s i o n of the government's i n t e r e s t ; namely, a tour of the E s s o n d a l e complex by the P r o v i n c i a l S e c r e t a r y , h i s deputy, and 13 Members of the L e g i s l a t i v e Assembly. 3 7 The v a r i o u s mental h e a l t h f a c i l i t i e s had been r e - o r g a n i z e d a d m i n i s t r a t i v e l y and the system became known as the p r o v i n c i a l 267 'Mental H e a l t h S e r v i c e ' . A new d i r e c t o r - Dr. A.M. Gee - was appointed and he s t a t e d that the f u t u r e p o l i c y of the s e r v i c e would be d i r e c t e d towards two aims; namely, i n c r e a s e d e a r l y , a c t i v e treatment (in the Crease C l i n i c ) to prevent p a t i e n t s from e n t e r i n g i n t o long-term treatment in the mental h o s p i t a l ; and, the a l l e v i a t i o n of the over-crowding which e x i s t e d i n the mental h o s p i t a l . Gee was f a c i n g a steady i n c r e a s e i n admissions which, i n h i s view, were due to a number of f a c t o r s ; n o t a b l y , an i n c r e a s e i n the p r o v i n c i a l p o p u l a t i o n ; an i n c r e a s e i n the numbers of e l d e r l y people i n the p o p u l a t i o n ; the p r o v i s i o n of b e t t e r f a c i l i t i e s f o r the care of aged, p s y c h o t i c p a t i e n t s (a f a c t o r which r e d u c e d the i n - h o s p i t a l d e a t h r a t e ) ; and, an improvement i n community a t t i t u d e s which r e s u l t e d i n an i n c r e a s e i n v o l u n t a r y admissions. ° Gee's s t r a t e g y f o r a c h i e v i n g h i s t w i n g o a l s was one of ' t o t a l push'; t h a t i s , the u t i l i z a t i o n of "every t h e r a p e u t i c modality a v a i l a b l e f o r the cure of the mentally a f f l i c t e d " (Gee, 1953: 21). Having seen the e s t a b l i s h m e n t of a f a c i l i t y f o r e a r l y , a c t i v e treatment (i.e., the Crease C l i n i c ) he turned h i s a t t e n t i o n to the ' d e - i n s t i t u t i o n a l i z a t i o n ' of l o n g - s t a y p a t i e n t s who were co n f i n e d i n Essondale H o s p i t a l . The s t r a t e g y i n v o l v e d s e v e r a l i n t e r l o c k i n g e l e m e n t s w h i c h were i n t r o d u c e d s y s t e m a t i c a l l y o v e r a t e n y e a r p e r i o d ; namely, the ' r e -a c t i v a t i o n ' of i n s t i t u t i o n a l i z e d p a t i e n t s ; the gradual b u i l d - u p of s o c i a l work s e r v i c e s and c o m m u n i t y r e s o u r c e s ; t h e i n t r o d u c t i o n of new treatment methods; and, the development of mental h e a l t h centres. 268 I m p l e m e n t a t i o n of the s t r a t e g y was made p o s s i b l e by favourable developments w i t h i n the p r o v i n c i a l s o c i a l w e l f a r e system, and i t a l s o b u t t r e s s e d the government's p o l i c y of w e l f a r e s t a t e expansion. P u b l i c s o c i a l w e l f a r e measures began to appear i n the p r o v i n c e d u r i n g the 1930's and a c h i e v e d a modest peak with the i n t r o d u c t i o n of comprehensive, p r o v i n c i a l s o c i a l a s s i s t a n c e l e g i s l a t i o n i n 1945 (Clague, e t a l , 1984). S o c i a l w e l f a r e became a p u b l i c , p r o v i n c i a l r e s p o n s i b i l i t y , r a t h e r than t h a t of the m u n i c i p a l i t i e s and c h a r i t i e s , and p r o v i s i o n was a l s o made f o r u n i v e r s a l , p r e v e n t i v e ' c o u n s e l l i n g s e r v i c e s ' d e s i g n e d to " p r e s e r v e and s t r e n g t h e n f a m i l y l i f e " , r e g a r d l e s s of the i s s u e of (or need for) f i n a n c i a l a i d (op c i t : 13). The p r a c t i c e of s o c i a l work consequently r e c e i v e d a f i r m endorsement and, w i t h i n a year, i t was f u r t h e r strengthened w i t h the c r e a t i o n of a Department of Health and Welfare and a ' S o c i a l Welfare Branch' that employed t r a i n e d s o c i a l workers (op c i t ) . A l i m i t e d h o s p i t a l insurance programme was introduced i n 1949 and, by the e a r l y 1950's, the foundations of the p r o v i n c i a l w e l f a r e s t a t e were i n p l a c e . The government then embarked upon a programme of gradual expansion, s t i m u l a t e d by f e d e r a l c o s t -sharing arrangements, and t h i s was accompanied by c o n s i d e r a b l e enthusiasm and optimism on the part of s o c i a l w e l f a r e planners and p r a c t i t i o n e r s . As Clague, et a l have noted, ( t ) h r o u g h o u t the 1950's a s t r o n g , c o n f i d e n t mood p r e v a i l e d among o f f i c i a l s w i t h i n B r i t i s h Columbia's s o c i a l w e l f a r e system. The a r c h i t e c t s of the new system possessed a sense of p r i d e and s a t i s f a c t i o n i n t h e i r a c c o m p l i s h m e n t s . The s t r u c t u r e was v i r t u a l l y complete; only a few more b u i l d i n g b l o c ks were needed (1984: 17). 269 U n i v e r s a l , comprehensive h e a l t h insurance was one of the missing b u i l d i n g b l o c k s but, s i n c e progress i n t h i s area was d i c t a t e d by Ottawa, the p r o v i n c e was u n a b l e to remedy the s i t u a t i o n . Nevertheless, by the end of the 1950's the p r o v i n c i a l government had demonstrated i t s commitment to w e l f a r e s t a t e expansion and the p r o v i s i o n of e f f e c t i v e , a l l i e d s e r v i c e s (op c i t ) . Two aspects of the p r o v i n c i a l w e l f a r e s t a t e had an impact upon the development of the new s t r a t e g y f o r the management of the mentally d i s o r d e r e d . F i r s t l y , the p r o f e s s i o n of s o c i a l work expanded and a new group of 'mental h e a l t h p r o f e s s i o n a l s ' -p s y c h i a t r i c s o c i a l workers - became a v a i l a b l e to take p a r t i n the management of p a t i e n t s . S o c i a l workers played 'a key r o l e i n s u p e r v i s i n g d i s c h a r g e d p a t i e n t s , l o c a t i n g v a r i o u s community r e s o u r c e s , and ' r e - a c t i v a t i n g ' p a t i e n t s i n p r e p a r a t i o n f o r d i s c h a r g e . S e c o n d l y , the a v a i l a b i l i t y of s o c i a l a s s i s t a n c e b e n e f i t s enabled both new and discharged p a t i e n t s - many of whom were u n a b l e to work - t o s u p p o r t t h e m s e l v e s w i t h i n the community. P a t i e n t s could r e c e i v e treatment i n , f o r example, mental h e a l t h c e n t r e s , while r e s i d i n g i n e i t h e r t h e i r own homes or p r i v a t e board and care f a c i l i t i e s . The process of ' r e - a c t i v a t i o n ' was a c r i t i c a l element i n Gee's s t r a t e g y and i n v o l v e d e f f o r t s t o s t i m u l a t e and t r a i n i n s t i t u t i o n a l i z e d , l o n g - s t a y p a t i e n t s ; t h a t i s , i n d i v i d u a l s s u f f e r i n g from what p s y c h i a t r i s t s came to r e c o g n i z e as an ' i n s t i t u t i o n a l n e u r o s i s * s y n d r o m e ( R i c h m a n , 1964). The c o n d i t i o n was c h a r a c t e r i z e d by apathy, a l a c k of i n i t i a t i v e , 270 l o s s of i n t e r e s t , submissiveness, an i n a b i l i t y to plan f o r the f u t u r e , and a l o s s of i n d i v i d u a l i t y . While these symptoms were o r i g i n a l l y thought to be m a n i f e s t a t i o n s of a p a t i e n t ' s i l l n e s s , p s y c h i a t r i s t s began to recognize that they were, i n s t e a d , the outcome of both prolonged confinement and the c o n d i t i o n s which e x i s t e d i n i n s t i t u t i o n s (op c i t ) . In s h o r t , the syndrome was caused by the segregated, c u s t o d i a l nature of p r e v a i l i n g methods f o r the 'treatment' of mental i l l n e s s . A p a t i e n t who had been admitted but not d i s c h a r g e d w i t h i n two years would l i k e l y become ' i n s t i t u t i o n a l i z e d ' and a p e r i o d of confinement should, t h e r e -f o r e , never exceed two years (op c i t ) . In support of ' r e - a c t i v a t i o n ' Essondale H o s p i t a l adopted an 'open-ward' p o l i c y (i.e., the gradual removal of the obvious s i g n s of a c u s t o d i a l s e t t i n g ) , the abandonment of v a r i o u s forms of p h y s i c a l r e s t r a i n t , and new treatment methods based on i n t e r -d i s c i p l i n a r y treatment teams. The teams were to focus upon the ' s o c i a l i z a t i o n ' of p a t i e n t s and an e f f o r t was to be made to both i d e n t i f y and 'treat' the ' s o c i a l ' causes of mental i l l n e s s ( i n the community at l a r g e ) and remove the ' s o c i a l ' b a r r i e r s to e f f e c t i v e treatment w i t h i n the h o s p i t a l . Treatment was to be aimed at improving "the p a t i e n t ' s a b i l i t y to l i v e w i t h h i m s e l f and o t h e r s " , and t h e r e was t o be a new e m p h a s i s upon ' r e l a t i o n s h i p t h e r a p y . ' 3 9 S t a f f at a l l l e v e l s were to come to ' u n d e r s t a n d ' and ' a c c e p t ' t h e p a t i e n t and t h e i r r o l e as c u s t o d i a n s was t o c h a n g e t o t h a t o f ' t h e r a p i s t s ' . The somatotherapies were to be r e t a i n e d but they would be used to h e l p p a t i e n t s work t o w a r d s t h e i r r e c o v e r y , g i v e up t h e 271 ' i s o l a t i o n ' of t h e i r i l l n e s s e s , and " p a r t i c i p a t e i n s o c i e t y once a g a i n " . 4 0 To t h i s end, the h o s p i t a l a b o l i s h e d p h y s i c a l r e s t r a i n t , reduced the use of s e c l u s i o n rooms, unlocked wards, intr o d u c e d 'group therapy' and 'therapeutic teams', encouraged v i s i t s by r e l a t i v e s and f r i e n d s , and e x t e n d e d 'grounds p r i v i l e g e s ' t o a l a r g e r number of p a t i e n t s . 'Walks' j o i n e d 'work' as a f e a t u r e i n the t h e r a p e u t i c armamentarium, and 'water' (i.e., hydrotherapy) f e l l from favour. The s u c c e s s of the r e - a c t i v a t i o n and r e h a b i l i t a t i o n programme r e s t e d h e a v i l y upon the a v a i l a b i l i t y of not o n l y s o c i a l a s s i s t a n c e b e n e f i t s f o r those discharged to the community but a l s o both p s y c h i a t r i c s o c i a l workers and community-based r e s i d e n t i a l and r e h a b i l i t a t i o n s e r v i c e s . A S o c i a l S e r v i c e Department was f i r s t e s t a b l i s h e d at Essondale i n 1930 (Clark, 1947) but i t was q u i t e s m a l l and r e m a i n e d t h a t way f o r two decades; f o r example, by 1947, only seven s o c i a l workers were employed i n the e n t i r e mental h e a l t h system. These personnel s t r u g g l e d with an i n c r e a s i n g c a s e l o a d (during the 1940's, s o c i a l workers were handling about 1,200 cases per year and, by 1952, t h i s had almost doubled) but an i n c r e a s e i n s t a f f began in 1953 as p r o p e r l y q u a l i f i e d personnel became a v a i l a b l e . 4 1 The s o c i a l worker complement g r a d u a l l y i n c r e a s e d and, by the end of the decade, 71 were employed by the mental h e a l t h s e r v i c e (MacKerracher, 1964). In a d d i t i o n , s o c i a l work s e r v i c e s were r e - o r g a n i z e d and p e r s o n n e l became i n v o l v e d i n t h e e v a l u a t i o n of p a t i e n t s and t h e i r f a m i l i e s on a d m i s s i o n , the p r o v i s i o n of casework s e r v i c e s to p a t i e n t s and t h e i r f a m i l i e s 272 d u r i n g confinement, the development of discharge plans, and the p r o v i s i o n of a f t e r - c a r e s o c i a l s e r v i c e s . * The l a s t of these tasks was c r u c i a l to the s t r a t e g y s i n c e s o c i a l workers were able to i n v e s t i g a t e and e s t a b l i s h community networks f o r d i s c h a r g e d p a t i e n t s . Once these had been developed, i t was hoped t h a t the h o s p i t a l would be able to r e l e a s e more, i f not a l l , of i t s l o n g -stay p a t i e n t s . 4 3 The p r o v i s i o n of r e s i d e n t i a l a l t e r n a t i v e s (i.e., ' f o s t e r homes' and 'boarding homes') was an i m p o r t a n t a s p e c t of the s t r a t e g y and e f f o r t s were made to d e v e l o p t h e s e r e s o u r c e s . W hile a l i m i t e d b o a r d i n g home programme had been s t a r t e d i n 1945, 4 4 Gee was r e s p o n s i b l e f o r an expansion of the scheme. In h i s view, the programme was e s s e n t i a l where the i n t e n t i o n was to r e l e a s e p a t i e n t s i n t o the community, but r a p i d implementation was i n i t i a l l y f r u s t r a t e d by the lack of s o c i a l w o r k e r s . 4 5 By March 1958, h o s p i t a l s o c i a l workers had explored v a r i o u s ways of enhancing a f t e r - c a r e s e r v i c e s f o r discharged p a t i e n t s who were without s u p p o r t i v e f a m i l i e s , and they had developed a plan which i n v o l v e d the use of p r i v a t e board and care homes. As the s o c i a l work s t a f f complement and s u p p o r t i v e r e s o u r c e s grew, so the prospect of implementing the programme became more f e a s i b l e and, by 1959, i t became p o s s i b l e to take the f i r s t t e n t a t i v e steps. Over 50 p a t i e n t s were di s c h a r g e d from Essondale and placed i n p r i v a t e ' c u s t o d i a l boarding homes'. 4 6 The homes were f o r p a t i e n t s "whose c o n d i t i o n s are not l i k e l y to improve but who can l i v e o u t s i d e the h o s p i t a l . . . a n d 273 thus r e l e a s e a bed f o r the c a r e of a p a t i e n t i n a c u t e need of t r e a t m e n t " . 4 " 7 I t was e x p e c t e d t h a t they would p r o v i d e a "protected g r o u p - l i v i n g s i t u a t i o n as an e x t e n s i o n of h o s p i t a l care;" that i s , "care and s u p e r v i s i o n f o r those p a t i e n t s whose primary need i s f o r d o m i c i l i a r y care of a more i n d i v i d u a l i z e d nature than can be provided on l a r g e mental h o s p i t a l wards." The p r i v a t e b o a r d i n g homes were e s t a b l i s h e d and funded by p r o v i n c i a l and m u n i c i p a l s o c i a l w e l f a r e departments but h o s p i t a l s o c i a l workers were r e s p o n s i b l e f o r the s e l e c t i o n of p a t i e n t s , the long-term s u p e r v i s i o n of r e s i d e n t s , and the monitoring of the homes. By March 1961, the programme was expanding and 180 l o n g -stay p a t i e n t s had been s u c c e s s f u l l y d i s c h a r g e d from Essondale to boarding-homes. T h i s had "worked to the p a t i e n t s ' advantage and f r e e d h o s p i t a l space r e q u i r e d f o r the more a c u t e l y i l l . " 4 9 The programme was deemed a s u c c e s s 5 0 and, by March 1962, a t o t a l of 317 p a t i e n t s had been discharged to homes. 5 1 H o s p i t a l s o c i a l w o r kers had commenced a new t r a i n i n g programme to p r e p a r e p a t i e n t s f o r boarding-home l i f e and plans had been developed f o r an e x t e n s i o n of the programme to r e s i d e n t s a t b o t h Woodlands School and the g e r i a t r i c h o s p i t a l at V a l l e y v i e w . A l t h o u g h d i s c h a r g e d p a t i e n t s were e l i g i b l e f o r s o c i a l a s s i s t a n c e , s u c c e s s f u l r e - a c t i v a t i o n was, i n p a r t , dependent upon the a v a i l a b i l i t y of employment i n the community. The mental h e a l t h s e r v i c e took steps to develop s p e c i a l community r e s o u r c e s t h a t would bo t h a s s i s t r e h a b i l i t a t i o n and p r o v i d e employment o p p o r t u n i t i e s , and t h i s provided an impetus f o r the 274 d e v e l o p m e n t of r e h a b i l i t a t i v e 'half-way' houses. A p r i v a t e , n o n - p r o f i t agency - the New V i s t a S o c i e t y - had opened a r e h a b i l i t a t i o n home f o r women i n 1943 and t h i s o p e r a t e d i n co n j u n c t i o n with the h o s p i t a l s o c i a l s e r v i c e department (Clark, 1947). The home was used e x t e n s i v e l y d u r i n g the e a r l y 1950's and e f f o r t s were made to e s t a b l i s h a s i m i l a r f a c i l i t y f o r men. Indeed, the h o s p i t a l r e h a b i l i t a t i o n s e r v i c e f e l t t h e r e was a d e s p a r a t e need f o r an 'in-town' c e n t r e t h a t would e n a b l e discharged male p a t i e n t s to maximize job o p p o r t u n i t i e s . 5 2 By J u l y 195 7, a r e h a b i l i t a t i o n c e n t r e f o r men - the 'Venture' half-way house - had been opened and, throughout the l a t e 1950's and e a r l y 1960's, both t h i s c e n t r e and the V i s t a home were i n h i g h demand. 5 3 The s o c i a l w o r k e r s at E s s o n d a l e d e v i s e d and implemented a new programme to b e t t e r p r e p a r e p a t i e n t s f o r discharge to both the ce n t r e s and boarding homes, and t h i s became known as the " a c t i v i t i e s of d a i l y l i v i n g " programme. The goal was to r e - t r a i n and re-educate p a t i e n t s i n the a r t of 'modern l i v i n g ' so they could a d j u s t more q u i c k l y and r e a d i l y t o l i f e o u t s i d e the h o s p i t a l , t h e r e b y r e d u c i n g the p r o b a b i l i t y of re-admission. To t h i s end, the s o c i a l workers were p r o v i d e d w i t h a house, i n s i d e the h o s p i t a l grounds, i n w h i c h p a t i e n t s c o u l d r e c e i v e ' i n t e n s i v e d o m e s t i c r e h a b i l i t a t i o n ' . P a t i e n t s were to r e s i d e i n the house, under minimum s u p e r v i s i o n , so they c o u l d e x p e r i e n c e 'independent l i v i n g ' , p r i o r to d i s c h a r g e . 5 4 While the ' t o t a l push' at E s s o n d a l e began b e f o r e the 275 i n t r o d u c t i o n of new, drug treatments, there i s l i t t l e doubt that the appearance of t h i s weapon i n the t h e r a p e u t i c a r s e n a l was of c o n s i d e r a b l e importance i n both reducing the c u s t o d i a l image of the h o s p i t a l and f a c i l i t a t i n g the d i s c h a r g e of p a t i e n t s . The new chemo-therapies f i r s t appeared i n 1955 when i t was noted t h a t shock t r e a t m e n t s were b e i n g r e i n f o r c e d by the new drugs chlorpromazine and r e s e r p i n e . Both modes of treatment a s s i s t e d , and were used i n c o n j u n c t i o n w i t h , p s y c h o t h e r a p y and ' s o c i a l t h e r a p y ' . 5 5 Within a year, the drugs were being used r o u t i n e l y at both the Crease C l i n i c and Essondale H o s p i t a l . I t was noted that t h i s development had r e s u l t e d i n the opening of more wards; the e x t e n s i o n of 'grounds p r i v i l e g e s ' to a g r e a t e r number of p a t i e n t s ; t h e i n t r o d u c t i o n o f 'group t h e r a p y ' ; and, t h e development of 'ward c o u n c i l s ' . 5 6 By 1957, the C l i n i c a l D i r e c t o r at Essondale was commenting favo u r a b l y on the growth of chemo-therapy. While the new drugs were not a cure, they d i d permit the f u r t h e r 'opening' of both the h o s p i t a l and the C r e a s e C l i n i c , and the development of a ' t h e r a p e u t i c community' w i t h i n t h e s e i n s t i t u t i o n s t h a t would encourage the "withdrawn to come c l o s e r to r e a l i t y " . 5 7 Within a y e a r , chemo-therapy was the dominant mode of t r e a t m e n t and, while e l e c t r o - s h o c k therapy remained, both other somatotherapies and psychosurgery were g r a d u a l l y phased o u t . 5 8 Indeed, by the l a t e 1950's the mental h e a l t h s e r v i c e had s w i t c h e d to a combination of chemo-therapy, e l e c t r o - s h o c k , psychotherapy, and ' s o c i a l therapy'. These treatments enabled the ' r e - a c t i v a t i o n ' and ' m o b i l i z a t i o n ' of an i n c r e a s i n g number of l o n g - s t a y 276 p a t i e n t s , and the new chemo-therapies al l o w e d the h o s p i t a l to unlock more wards, extend grounds p r i v i l e g e s to more p a t i e n t s , p e r m i t s h o r t p e r i o d s of "home l e a v e ' , and p l a c e a s t r o n g e r emphasis upon ' r e h a b i l i t a t i o n ' . 5 9 The new s t r a t e g y a l s o i n v o l v e d t h e d e v e l o p m e n t o f community mental h e a l t h c e n t r e s , and the f i r s t of these opened i n January 1957. Plans f o r the c o n s t r u c t i o n of a mental h e a l t h c e n t r e had been d r a f t e d by 1955, and a b u i l d i n g was e r e c t e d on a s i t e i n Burnaby t h a t was much c l o s e r to the main p o p u l a t i o n c e n t r e ( i . e . , Vancouver) than E s s o n d a l e . A p p r o p r i a t e l e g i s l -a t i o n - the P r o v i n c i a l Mental Health Centres Act - was passed by the L e g i s l a t u r e i n 1955 6 0 which allowed f o r the development of cent r e s , and p r e s c r i b e d the procedure f o r admission. P a t i e n t s had to be v o l u n t a r y and r e f e r r e d by a p h y s i c i a n . The g o a l was to open a f a c i l i t y t h a t would p r o v i d e an a c t i v e treatment programme f o r p a t i e n t s r e s i d i n g i n t h e i r own homes and e n a b l e the e a r l i e r d i s c h a r g e of r e - a c t i v a t e d and a c t i v e t r e a t m e n t p a t i e n t s from the E s s o n d a l e c o m p l e x . 6 1 The Centre was to provide treatment f o r a d u l t s i n the e a r l y stages of mental i l l n e s s (thereby p r e v e n t i n g admissions to the mental h o s p i t a l ) , as w e l l as a f t e r - c a r e s e r v i c e s f o r d i s c h a r g e d p a t i e n t s , w i t h o u t d i s r u p t i n g t h e i r work r o u t i n e s and f a m i l y l i f e . P a t i e n t s could attend e i t h e r the day h o s p i t a l or the out-p a t i e n t c l i n i c and the focus would be upon i n d i v i d u a l therapy designed f o r "people whose inner s e c u r i t y and t r o u b l e d s o c i a l a d a p t a t i o n i s at the core of t h e i r i l l n e s s whatever symptoms may be m a n i f e s t . " 6 2 To t h i s end, the C e n t r e o f f e r e d i n t e n s i v e , 277 ' m i l i e u therapy', psychotherapy, o c c u p a t i o n a l and r e c r e a t i o n a l therapy, the somatotherapies, and chemo-therapy. 6 3 In short, the Centre provided the treatments a v a i l a b l e i n the Essondale complex, but without the added burden of m a i n t a i n i n g p a t i e n t s . I t was a model of e c o n o m i c a l , i n t e r - d i s c i p l i n a r y co-o p e r a t i o n which, by 1959, was being p r a i s e d f o r i t s success i n d e f l e c t i n g b o t h a d m i s s i o n s and r e - a d m i s s i o n to E s s o n d a l e . T r e a t m e n t was b e i n g o f f e r e d by s m a l l teams c o n s i s t i n g of a p s y c h i a t r i s t , a s o c i a l worker, a p s y c h o l o g i s t , a nurse, and an o c c u p a t i o n a l t h e r a p i s t , and the teams were h e l p i n g p e o p l e to 'adapt' by f o c u s s i n g upon the s o c i a l aspects of a p a t i e n t ' s l i f e r a t h e r than simply the r e l i e f of symptoms. 6 4 E f f e c t i v e a f t e r -c a r e was b e i n g p r o v i d e d f o r d i s c h a r g e d p a t i e n t s and, i n an e x p e r i m e n t c o n d u c t e d i n 1960, the C e n t r e d e m o n s t r a t e d how i t c o u l d p r e v e n t t h e r e - a d m i s s i o n o f e v e n t h e m o s t i n s t i t u t i o n a l i z e d type of d i s c h a r g e d p a t i e n t . E i g h t y p a t i e n t s who had, c o l l e c t i v e l y , spent 251 years i n h o s p i t a l were r e l e a s e d to the C e n t r e and p e r s o n n e l s u p e r v i s e d the p a t i e n t s ' chemo-therapy. Of the experimental group, only 11 were re-admitted to the h o s p i t a l . 6 5 The s u c c e s s of the Burnaby M e n t a l H e a l t h C e n t r e had a s u b s t a n t i a l impact and, by 1962, plans had been d r a f t e d f o r two new c e n t r e s i n V i c t o r i a and Kelowna. Both c e n t r e s were i n o p e r a t i o n w i t h i n two y e a r s and 1964 a l s o saw m e n t al h e a l t h c e n t r e s open i n Nanaimo and T r a i l . In each case, the f a c i l i t i e s a d o p t ed the p r i n c i p l e s and f o l l o w e d the model p r o v i d e d by 278 Burnaby. The Impact of the New Strategy There i s l i t t l e doubt that the new s t r a t e g y was s u c c e s s f u l i n r e s o l v i n g the problems of order maintenance and l e g i t i m a t i o n a s s o c i a t e d w i t h the management of the mentally d i s o r d e r e d i n the e a r l y 1950's. At the same time, implementation of the s t r a t e g y b u t t r e s s e d , and was f a c i l i t a t e d by, the p r o v i n c i a l government's p o l i c y of w e l f a r e s t a t e expansion; a development p r o p e l l e d by f e d e r a l - p r o v i n c i a l c o s t - s h a r i n g agreements which s t i m u l a t e d the p r o v i s i o n of s o c i a l w e l f a r e s e r v i c e s and b e n e f i t s . The c r i s i s of over-crowding was eased by both the use of e a r l y , a c t i v e treatment and the d e - i n s t i t u t i o n a l i z a t i o n of r e -a c t i v a t e d , long-stay p a t i e n t s . By 1955, f o r example, Gee was c l a i m i n g that the a c t i v e treatment aspect of the ' t o t a l push' was working. In h i s view, the trend was f o r p a t i e n t s to enter mental h e a l t h f a c i l i t i e s f o r treatment on a short term b a s i s and e v e r y e f f o r t had been made to make a d m i s s i o n to h o s p i t a l as fi ft " b r i e f and t h e r a p e u t i c as p o s s i b l e . " 0 0 While there had been an i n c r e a s e i n the numbers b e i n g a d m i t t e d and t r e a t e d , t h i s was acceptable, p r o v i d i n g they were dis c h a r g e d q u i c k l y . Throughout the 1950's and e a r l y 1960's, the b u l k of the a c t i v e t r e a t m e n t was o c c u r r i n g i n the Crease C l i n i c which contained, on average and on any g i v e n day, about 230 p a t i e n t s . 6 7 N e a r l y 1,500 p a t i e n t s were t r e a t e d i n the C l i n i c each year (on average) and an i n c r e a s i n g p r o p o r t i o n of the p a t i e n t s were a d m i t t e d on a v o l u n t a r y b a s i s . In 1952/53, 37% of the a d m i s s i o n s were v o l u n t a r y and t h i s p r o p o r t i o n s t e a d i l y i n c r e a s e d to 74% by 279 1963/64. P a t i e n t s were t r e a t e d and d i s c h a r g e d as q u i c k l y as p o s s i b l e and w h i l e the maximum, p e r m i s s i b l e p e r i o d of confinement was four months, most p a t i e n t s only stayed f o r about two months. However, while the e f f e c t i v e , a c t i v e treatment of incoming p a t i e n t s was a s s i s t i n g w i t h the pr o b l e m of o v e r - c r o w d i n g i n E s s o n d a l e , i t was an e x p e n s i v e a c t i v i t y . S i n c e the Cre a s e C l i n i c had a s m a l l p a t i e n t / s t a f f r a t i o , the o p e r a t i n g c o s t s (per r e s i d e n t p a t i e n t , p e r diem) were h i g h e r than the E s s o n d a l e H o s p i t a l and r o s e s t e a d i l y from $9.95 i n 1951/52 to $17.87 i n 1963/64, as s t a f f s a l a r i e s i n c r e a s e d . 6 8 In f i s c a l 1951/52, the o p e r a t i n g c o s t s amounted to $684.7 thousand; t h e s e i n c r e a s e d and, by f i s c a l 1963/64, stood at $1.4 m i l l i o n . The high c o s t of op e r a t i n g the f a c i l i t y was noted from time to time during the 1950's and e a r l y 1960's and, w h i l e the burden was a p p a r e n t l y a c c e p t a b l e i n l i g h t of the C l i n i c ' s success, some questions of c o s t / e f f e c t i v e n e s s were r a i s e d . From the time i t opened, the C l i n i c was g e n e r a l l y f u l l , i n high demand, ap p a r e n t l y e f f e c t i v e , but r e l a t i v e l y c o s t l y . . I t was a l s o an i n s t i t u t i o n , and while i t was to be d i s t i n g u i s h e d from the main mental h o s p i t a l , i t was p a r t of the same complex. By the mid-1950's an a l t e r n a t i v e had been i n t r o d u c e d - the mental h e a l t h c e n t r e - which c o u l d be e q u a l l y e f f e c t i v e but l e s s expensive to operate. Since the ce n t r e s d i d not perform a c u s t o d i a l r o l e , few s t a f f were r e q u i r e d t o han d l e a l a r g e number of c a s e s . In f i s c a l 1959/60, f o r example, the Burnaby Centre had 40 s t a f f who 280 t r e a t e d 583 p a t i e n t s . By March 1965, the s t a f f complement had i n c r e a s e d to 113 and, i n the f i s c a l year, these personnel had t r e a t e d 1,335 p a t i e n t s . 6 9 T h i s had a b e a r i n g upon i t s c o s t e f f e c t i v e n e s s and the c a p a c i t y of the C e n t r e to manage l a r g e numbers of p a t i e n t s at minimal cost d i d not escape a t t e n t i o n . In f i s c a l 1959/60 the d a i l y per c a p i t a ( t r e a t e d ) c o s t a t the C e n t r e was $1.14 w h i l e , a t E s s o n d a l e , the c o s t was $3.74. By f i s c a l 1964/65, the d a i l y per c a p i t a cost at Essondale had r i s e n to $4.20, w h i l e the c o s t at the C e n t r e s t o o d a t $1.22 - the d a i l y per c a p i t a (treated) cost at Essondale H o s p i t a l i n f i s c a l 1945/46. 7 0 Despite the impressive comparative f i g u r e s , the opening of the C e n t r e d i d not n e c e s s a r i l y mean a m a s s i v e s a v i n g f o r the p u b l i c p u r s e as a whole. At the o u t s e t , the C e n t r e was e s t a b l i s h e d p r i m a r i l y f o r the t r e a t m e n t of those who d i d n o t have the means to o b t a i n p r i v a t e p s y c h i a t r i c treatment or who 7 1 d i d not have i n s u r a n c e t h a t c o v e r e d p s y c h i a t r i c i l l n e s s . Indeed, i t was assumed that some p a t i e n t s would be i n d i g e n t and r e c e i v e s o c i a l a s s i s t a n c e , p a r t i c u l a r l y those who had been dis c h a r g e d from Essondale. Consequently, i n a d d i t i o n to f e d e r a l w e l f a r e b e n e f i t s (e.g., d i s a b l e d p e r s o n s ' a l l o w a n c e s ) , the Department of S o c i a l Welfare would provide cash allowances to a p a t i e n t ( i n k e e p i n g w i t h the p r o v i n c i a l s o c i a l a s s i s t a n c e scheme), which would not have been p a i d to the i n d i v i d u a l had he or she been r e s i d i n g i n a m e n t a l h o s p i t a l . In I960, the p r o v i n c i a l a l l o w a n c e s ranged from $55 per month f o r a s i n g l e person to $194.50 per month f o r a f a m i l y of e i g h t . In a d d i t i o n , 281 i n d i g e n t p a t i e n t s were e n t i t l e d to v a r i o u s s e r v i c e s and goods 72 (e.g., drugs) f r e e of charge (Ross, 1961). While i t i s d i f f i c u l t to e s t a b l i s h the extent to which the Burnaby Centre generated savings f o r the p r o v i n c i a l government (or, a l t e r n a t i v e l y , r e s u l t e d i n higher l e v e l s of expenditure) i t can be contended that, without the f a c i l i t y , the cost of mental h e a l t h c a r e and t r e a t m e n t would have r i s e n a p p r e c i a b l y . Admissions and re-admissions to the Essondale complex would have probably i n c r e a s e d s i n c e p a t i e n t s would not have been d i v e r t e d at the 'community' level.. Fewer l o n g - s t a y p a t i e n t s would have been d i s c h a r g e d and the p r o b l e m of o v e r - c r o w d i n g may have remained, with the concomitant p o s s i b i l i t y that a new h o s p i t a l would have been n e c e s s a r y . C e r t a i n l y , the b u i l d i n g of the Centre i n v o l v e d c a p i t a l o u t l a y , but t h i s was l e s s than the cost of b u i l d i n g a new i n s t i t u t i o n . More i m p o r t a n t l y , i t was the type of f a c i l i t y that a t t r a c t e d f e d e r a l government c o n s t r u c t i o n and maintenance funds. In a d d i t i o n , both the mental h e a l t h s e r v i c e and the D e p a r t m e n t o f S o c i a l W e l f a r e may have f a c e d a d d i t i o n a l expenditures as a consequence of the admission to the Essondale complex of i n d i v i d u a l s who had not, to t h a t p o i n t , been r e c e i v i n g s o c i a l a s s i s t a n c e . The h o s p i t a l would be m a i n t a i n i n g p a t i e n t s who could otherwise have been s i m u l t a n e o u s l y r e c e i v i n g treatment and working to support themselves. Furthermore, where p e r s o n s b e i n g a d m i t t e d t o h o s p i t a l were a l s o f a m i l y 'breadwinners', t h e i r dependents may have been both e l i g i b l e f o r s o c i a l a s s i s t a n c e payments and i n need of the f a m i l y s u p p o r t 282 s e r v i c e s p rovided by p r o v i n c i a l s o c i a l workers. Arguably, both these 'hidden' savings, and the more obvious f i n a n c i a l b e n e f i t s , add w e i g h t to the c o n t e n t i o n t h a t the o p e n i n g and subsequent growth of the Centres was an act of f i s c a l r e s p o n s i b i l i t y on the p a r t of the p r o v i n c i a l government. As the ' t o t a l push' gathered momentum i t s e f f e c t i v e n e s s i n c o n t r o l l i n g the problem of over-crowding throughout the mental h e a l t h system became i n c r e a s i n g l y evident. The Deputy P r o v i n c i a l S e c r e t a r y was o p t i m i s t i c and, by 1955, he had n o t e d t h a t the a c c e l e r a t e d r e - a c t i v a t i o n and t r e a t m e n t programme aimed a t d i s c h a r g i n g those i n the l o n g - s t a y areas of Essondale h o s p i t a l , was working. Indeed, the p r o v i n c e had had the lowest i n c r e a s e i n i t s p a t i e n t p o p u l a t i o n i n ten y e a r s . 7 3 By A p r i l 1956, the average number of p a t i e n t s i n r e s i d e n c e i n a l l i n s t i t u t i o n s had peaked at 6,328 and, by 1962/63, t h i s had d e c l i n e d to 6,095 d e s p i t e an i n c r e a s e i n the p r o v i n c i a l p o p u l a t i o n . 7 4 Indeed, when the l a t t e r f a c t o r i s taken i n t o account, the impact of the s t r a t e g y i s even more apparent. In 1950, the p a t i e n t p o p u l a t i o n r a t e (per 100 thousand population) stood at 410.5 and was above the n a t i o n a l r a t e (392.4); indeed, i t was the t h i r d highest i n the country (behind Saskatchewan and Manitoba). By 1955, the p r o v i n c i a l r a t e had r i s e n to 481.3. T h i s was h i g h e r than the n a t i o n a l r a t e (406.4) and the p r o v i n c e was i n second p l a c e b e h i n d Saskatchewan (528.9). In k e e p i n g w i t h the s i t u a t i o n across the country, a d e c l i n e began the f o l l o w i n g year and, by 1960, i t had f a l l e n to 369.0 and was below the n a t i o n a l p a t i e n t 7 5 p o p u l a t i o n r a t e (372.0). 283 Since the primary t a r g e t of Gee's s t r a t e g y was the p a t i e n t p o p u l a t i o n i n Essondale H o s p i t a l , i t s impact at t h i s i n s t i t u t i o n was f a r more pronounced. The average number of p a t i e n t s i n r e s i d e n c e peaked a t 3,518 d u r i n g f i s c a l 1954/55 and f e l l s t e a d i l y t h e r e a f t e r ; indeed, by 1962/63 the number had f a l l e n to 2,719. 7 6 The process of d e - i n s t i t u t i o n a l i z a t i o n had an impact upon the o p e r a t i n g c o s t s of the h o s p i t a l . In f i s c a l 1954/55, the t o t a l cost amounted to $4.6 m i l l i o n and, while the co s t s of o p e r a t i o n rose t h e r e a f t e r , the i n c r e a s e s were not great; indeed, between 1954/55 and 1962/63 the a n n u a l i n c r e a s e i n o p e r a t i n g c o s t s averaged only $350,000 and they a c t u a l l y f e l l by $100,000 f o r f i s c a l 1957/58. 7 7 The d e c l i n e i n the r e s i d e n t p o p u l a t i o n r e f l e c t e d , i n p a r t i c u l a r , the s u c c e s s of the ' r e - a c t i v a t i o n ' a s p e c t of the s t r a t e g y i n r e - l o c a t i n g the long - s t a y r e s i d e n t s of the h o s p i t a l . Many p a t i e n t s were r e l e a s e d 'on p r o b a t i o n ' and t h i s t a c t i c became i n c r e a s i n g l y popular as mental h e a l t h c e n t r e s and other community resources became a v a i l a b l e . In f i s c a l 1951/52, 7.8% of d i s c h a r g e d p a t i e n t s were r e l e a s e d 'on p r o b a t i o n ' . By 1956/57, the p r o p o r t i o n had i n c r e a s e d to 17.3% and, by 1963/64, 20% of a l l s e p a r a t i o n s were p a t i e n t s 'on p r o b a t i o n ' . 7 8 N e v e r t h e l e s s , the s e r v i c e s of the h o s p i t a l r e m a i n e d i n high demand and, wh i l e the i n - r e s i d e n c e p a t i e n t p o p u l a t i o n f e l l , the numbers of p a t i e n t s being t r e a t e d g e n e r a l l y i n c r e a s e d . The trend was e r r a t i c but, between 1954/55 and 1963/64, the t o t a l number of p a t i e n t s b e i n g t r e a t e d r o s e from 4,620 to 5,308. 7 9 284 Indeed, while the s t r a t e g y was s u c c e s s f u l i n ' d e - i n s t i t u t i o n -a l i z i n g ' r e - a c t i v a t e d , l o n g - s t a y p a t i e n t s , i t d i d l i t t l e to slow the numbers of f i r s t admissions (i.e., new p a t i e n t s e n t e r i n g the h o s p i t a l f o r the f i r s t time) and, more i m p o r t a n t l y , r e -admissions. The numbers of f i r s t a d m i s s i o n s dropped from 976 i n 1952/53 to 597 i n 1954/55 but s t e a d i l y i n c r e a s e d t h e r e a f t e r and, by 1964, had r i s e n t o 970. The numbers of r e - a d m i s s i o n s c l i m b e d s t e a d i l y t h r o u g h o u t the 1950's and, by 1960, had exceeded the number of f i r s t admissions. In 1951/52 - a year i n which t h e r e were 880 f i r s t a d m i s s i o n s - the number of r e -a d m i s s i o n s s t o o d a t 337. In 1959/60, t h e r e were 736 f i r s t admissions and 795 re-admissions. This trend continued i n t o the 1960's and, i n 1963/64, 1,420 (55%) of the 2,568 admissions were r e - a d m i s s i o n s . 8 0 The numbers of s e p a r a t i o n s (i.e., p a t i e n t s who were b e i n g d i s c h a r g e d ) a l s o i n c r e a s e d s t e a d i l y and the numbers of s e p a r a t i o n s exceeded the t o t a l number of admissions; however, i t i s apparent that many p a t i e n t s who had been r e l e a s e d were f i n d i n g t h e i r way back to the h o s p i t a l . T h i s i s not to s u g g e s t t h a t Gee's s t r a t e g y c o n t a i n e d a major f l a w ; i n d e e d , when the p o p u l a t i o n i n c r e a s e , the a c t i v e treatment aspects of the s t r a t e g y , and the p r e v a i l i n g b e l i e f s r e g a r d i n g the use of mental h o s p i t a l s are taken i n t o account the i n c r e a s e i n a d m i s s i o n s and r e - a d m i s s i o n s was not a mark of f a i l u r e . I n c r e a s e s of t h i s n a t u r e were e x p e r i e n c e d a c r o s s Canada and, as the r a t e and numbers of d i s c h a r g e s rose, so too d i d the r a t e of f i r s t admissions and re-admissions. The trend 285 manifested i t s e l f most c l e a r l y i n B r i t i s h Columbia and, i n 1950, when the n a t i o n a l , f i r s t a d m i s s i o n r a t e (per 100 thousand p o p u l a t i o n ) s t o o d a t 87.0, the p r o v i n c e was e x p e r i e n c i n g an unprecedented r a t e of f i r s t admissions: 163.1. By 1955, when the n a t i o n a l r a t e had i n c r e a s e d to 139.0, the p r o v i n c i a l r a t e had reached a s t r o n o m i c a l l e v e l s (243.2). The p r o v i n c i a l r a t e began to f a l l t h e r e a f t e r ( r e l a t i v e to the country as a whole), and w h i l e i t was s t i l l above the n a t i o n a l r a t e i n 1960 (197.0 compared wi t h 151.0) there had been a decrease, r e l a t i v e to the p i i n c r e a s e i n the p r o v i n c i a l p o p u l a t i o n . A s i m i l a r trend a f f e c t e d the r a t e of re-admissions. In * 1950, when the n a t i o n a l re-admission r a t e stood at 32.9, B r i t i s h Columbia was ahead of the other p r o v i n c e s (67.0). By 1955, the n a t i o n a l r a t e had i n c r e a s e d to 66.7 and the province had a r e -a d m i s s i o n r a t e t h a t was n e a r l y t h r e e t i m e s as h i g h (185.3). However, by 1960 when the n a t i o n a l r a t e stood at 88.0, the r a t e i n B r i t i s h Columbia had dropped to 168.0. T h i s was s t i l l n e a r l y t w i c e the n a t i o n a l r a t e but, r e l a t i v e to the i n c r e a s e i n p o p u l a t i o n , showed some s i g n of improvement. 8 2 Throughout the 1950's, the h o s p i t a l d o o r s were 'swinging' v i g o r o u s l y a c r o s s Canada and t h i s was p a r t i c u l a r l y e v ident i n B r i t i s h Columbia. N e v e r t h e l e s s , by the end of the decade, the ' r e - c y c l i n g ' o f p a t i e n t s i n the pro v i n c e had slowed c o n s i d e r a b l y . The i n c r e a s e i n the numbers of f i r s t admissions and r e -a d m i s s i o n s i n the p r o v i n c e d i d not appear to be a cause f o r c o n c e r n p e r h a p s because, by the l a t e 1950's, the r a t e s of 286 admission were f a l l i n g . The r e s i d e n t p o p u l a t i o n of Essondale H o s p i t a l was s t e a d i l y d e c l i n i n g and t h i s meant that the problem of o v e r - c r o w d i n g , i n t h i s i n s t i t u t i o n , was b e i n g t a c k l e d e f f e c t i v e l y . Indeed, apart from an o c c a s i o n a l r e f e r e n c e to the need f o r more space f o r ' r e - a c t i v a t i o n ' programmes, complaints about over-crowding v i r t u a l l y disappeared. More i m p o r t a n t l y , the ' r e - c y c l i n g ' of p a t i e n t s was c o n s i s t e n t w i t h the p r e v a i l i n g b e l i e f s r e g a r d i n g the use of mental h o s p i t a l s . Those s u f f e r i n g from mental d i s o r d e r s were encouraged t o admit t h e m s e l v e s on a v o l u n t a r y b a s i s , r e c e i v e a c t i v e t r e a t m e n t f o r a s h o r t p e r i o d of t i m e , r e t u r n to the community, and then r e - a d m i t t h e m s e l v e s to the h o s p i t a l f o r f u r t h e r t r e a t m e n t as and when r e q u i r e d . By 1955, Gee was r e f e r r i n g to the importance of 'community-centred' p s y c h i a t r y , the need t o u n l o c k more wards and, i n t h i s way, remove the s t i g m a a s s o c i a t e d w i t h mental i l l n e s s . T h i s , he f e l t , would encourage those s u f f e r i n g from mental d i s o r d e r s t o p r e s e n t t h e m s e l v e s f o r t r e a t m e n t . The p r o p o r t i o n o f v o l u n t a r y p a t i e n t s had i n c r e a s e d d r a m a t i c a l l y (from 23% i n 1954/55, to 40% i n 1963/64), but a c o m p a r i s o n was made w i t h the s i t u a t i o n i n c o n v e n t i o n a l m e d i c i n e and the p r o c e s s became known as the 'swinging-door' approach. This represented an a p p r o p r i a t e use of m e ntal h e a l t h f a c i l i t i e s and r e f l e c t e d a l a u d a b l e , new approach to care and treatment (Ross, 1961). While re-admission was viewed as acceptable, i t could be prevented by the i n t r o d u c t i o n of improved community s e r v i c e s . By 1960, t h r e e groups of p a t i e n t s c o u l d be found i n the 287 Essondale complex: namely, the 'continuing treatment group' t h a t c o n s t i t u t e d the b u l k of the p a t i e n t s (60%) but which was d i m i n i s h i n g i n s i z e ; the 'acute i l l n e s s ' group that was t r e a t e d mainly at the Crease C l i n i c , recovered r a p i d l y , and stayed only f o r a s h o r t p e r i o d of time; and, the ' r e m i t t i n g g r o u p 1 . The l a s t of these c o n s i s t e d of p a t i e n t s who p e r i o d i c a l l y f a i l e d to f u n c t i o n i n the community and who r e q u i r e d a b r i e f p e r i o d of r e -a d m i s s i o n . While t h e i r r e t u r n was due, i n p a r t , t o p r o b l e m s a s s o c i a t e d w i t h m a i n t a i n i n g the chemo-therapy r e g i m e s of dis c h a r g e d p a t i e n t s (notably, the lack of s u p e r v i s i o n and the h i g h c o s t of drugs f o r those w i t h m a r g i n a l i n c o m e s ) , i t was s t r e s s e d that t h i s was not a s i g n that the s t r a t e g y had f a i l e d . Instead, i t was an i n d i c a t i o n t h at d i s c h a r g e d p a t i e n t s were able to f u n c t i o n some of the time, and t h i s p o i n t e d to the need to d e v e l o p both f u r t h e r s u p p o r t s e r v i c e s i n the community and b e t t e r p r e - r e l e a s e t r a i n i n g i n the f a c i l i t i e s . Adequate 'follow-up' would enhance the p r o b a b i l i t y of success as would the i n t r o d u c t i o n of b e t t e r 'group l i v i n g ' programmes i n the h o s p i t a l . The l a t t e r would enable p a t i e n t s to leave h o s p i t a l i n Q A a ' f u n c t i o n i n g ' c o n d i t i o n . ^ E x i s t i n g f a c i l i t i e s were renovated, cleaned and expanded d u r i n g the p e r i o d of the ' t o t a l push' (e.g., an i n f e c t i o u s d i s e a s e s wing was opened a t E s s o n d a l e f o r p a t i e n t s s u f f e r i n g from t u b e r c u l o s i s ) and some b u i l d i n g s were c l o s e d down (notably, i n the Colony Farm a r e a of E s s o n d a l e ) . In a d d i t i o n , by 1960, p a t i e n t s were b e i n g t r a n s f e r r e d from the i n s t i t u t i o n f o r the c r i m i n a l l y insane (i.e., C o l q u i t z ) to the Essondale complex wi t h 288 a view to c l o s i n g the former f a c i l i t y as q u i c k l y as p o s s i b l e . While the government had b u i l t a s m a l l h o s p i t a l f o r g e r i a t r i c p a t i e n t s (i.e., V a l l e y v i e w H o s p i t a l ) , and had taken over the o l d t u b e r c u l o s i s s a n i t a r i u m at T r a n q u i l l e with a view to housing s e v e r e l y m e n t a l l y r e t a r d e d p e o p l e ( t h e r e b y r e l i e v i n g the pressure being placed on Woodlands School) the success of the s t r a t e g y e f f e c t i v e l y r e s o l v e d the problem of whether or not to b u i l d another l a r g e and c o s t l y mental h o s p i t a l . The f a c i l i t y was not c o n s t r u c t e d and there i s l i t t l e doubt that t h i s was a p o p u l a r d e c i s i o n . In Gee's view, f o r example, l a r g e m e n t a l h o s p i t a l s were ' b a n k r u p t i n s t i t i t u t i o n s ' t h a t s h o u l d be abandoned. 8 5 I n s o f a r as the s u c c e s s f u l implementation of the s t r a t e g y d e a l t with the order maintenance problem which had confronted the s t a t e , i t a l s o r e s o l v e d the p r o b l e m of l e g i t i m a t i o n . By 1958, the changes which had o c c u r r e d t h r o u g h o u t the m e n t a l h e a l t h s e r v i c e were such t h a t i t s s e n i o r p e r s o n n e l fe>lt c o n f i d e n t e nough t o i n v i t e t h e A.P.A. t o r e t u r n f o r an i n s p e c t i o n . In the F a l l of that year, the government contacted the A.P.A., and Dr. Matthew Ross - the A s s o c i a t i o n ' s M e d i c a l D i r e c t o r - a r r i v e d i n the p r o v i n c e to begin an e v a l u a t i o n . The event was deemed to be s u f f i c i e n t l y i m p o r t a n t t o w a r r a n t a mention i n the 1959 Throne Speech where i t was s t a t e d t h a t the government had engaged the A.P.A. to conduct a "thorough survey of the mental h e a l t h needs and resources of the province", i n o r d e r t o "keep a b r e a s t o f t h e g r e a t a d v a n c e s i n m e n t a l h e a l t h . " 8 6 Both the outcome of the e a r l i e r v i s i t by the A.P.A. 289 and the c o n n e c t i o n between the work of Dr. Chambers and Dr. Ross, were not mentioned. An exhaustive survey and i n s p e c t i o n was underway by the Spring of 1960 and Ross' r e p o r t was submitted to both the A.P.A. and the p r o v i n c i a l government i n 1961. I t was f a v o u r a b l y r e c e i v e d by both p a r t i e s and, s i n c e the mental h e a l t h s e r v i c e g e n e r a l l y met w i t h A.P.A. s t a n d a r d s , f u l l a c c r e d i t a t i o n was r e s t o r e d . Indeed, s p e c i a l c e r t i f i c a t e s of approval were i s s u e d f o r Essondale, the Crease C l i n i c and the V a l l e y v i e w H o s p i t a l , and the m e n t a l h e a l t h c e n t r e s were s i n g l e d out f o r s p e c i a l p r a i s e . The o n l y p roblem l a y w i t h Woodlands S c h o o l ; t h i s f a c i l i t y s t i l l d i d not meet the r e q u i r e d standard and the A.P.A. only i s s u e d ' c o n d i t i o n a l approval' (Ross, 1961). A l t h o u g h Gee's s t r a t e g y had been s u c c e s s f u l , t h e p r o v i n c i a l government was not i n a p o s i t i o n where i t c o u l d a f f o r d t o r e l a x . The f i n d i n g s of the Ross R e p o r t were s u f f i c i e n t to ensure p u b l i c and p r o f e s s i o n a l confidence i n the p r o v i n c i a l mental h e a l t h s e r v i c e but both continued l e g i t i m a t i o n and the a v o i d a n c e of any r e t u r n to the c o n d i t i o n s which had c r e a t e d the order maintenance problem (notably, over-crowding) were dependent upon f u r t h e r improvements and the l o n g - t e r m adoption of the s t r a t e g y . These improvements i n c l u d e d a major r e c o n s t r u c t i o n of the l e g a l framework a f f e c t i n g the m e n t a l l y d i s o r d e r e d ; an i s s u e which, to that p o i n t , had not been given p r i o r i t y . 290 The Entrenchment of the Long-Term Str a t e g y : The Ross Report on Mental Health S e r v i c e s i n B r i t i s h Columbia The p r o v i n c i a l government was handed the Ross Report i n 1961 and the document was f a v o u r a b l y r e c e i v e d by b o t h the M i n i s t e r of Health S e r v i c e s and H o s p i t a l Insurance - E r i c M a r t i n p 7 - and s e n i o r mental h e a l t h s e r v i c e personnel. ' Indeed, i n the foreword to the r e p o r t , M a r t i n made the f o l l o w i n g comment: I would l i k e to commend Dr. Matthew Ross and h i s c o l l e a g u e s f o r the thorough and competent manner i n which they undertook t h i s survey. The Government f e e l s t h i s i s a good r e p o r t and w i l l s e r v e as an i n v a l u a b l e g u i d e to the f u t u r e d e v e l o p m e n t s of Mental Health S e r v i c e s i n B r i t i s h Columbia... We sought the recommendations of i n t e r n a t i o n a l l y a c c l a i m e d a u t h o r i t i e s to c o n f i r m t r e n d s a l r e a d y e s t a b l i s h e d and to guide programs being charted f o r the f uture... ( Ross , 1961: i ) . He s t a t e d t h a t the R e p o r t had i n f l u e n c e d the p r o v i n c i a l government by c o n f i r m i n g i t s d e c i s i o n to i n i t i a t e a number of changes i n c l u d i n g : the r e g i o n a 1 i z a t i o n of s e r v i c e s ; the c o n s t r u c t i o n of a s m a l l h o s p i t a l and mental h e a l t h c e n t r e i n V i c t o r i a ; and, the e x p a n s i o n of g e n e r a l h o s p i t a l p s y c h i a t r i c wards. M i n i s t e r i a l r e s p o n s i b i l i t y had a l r e a d y passed from the P r o v i n c i a l S e c r e t a r y to the M i n i s t e r of H e a l t h S e r v i c e s and H o s p i t a l I n s u r a n c e , and the D i r e c t o r of the M e n t a l H e a l t h S e r v i c e had a c q u i r e d the s t a t u s of a Deputy M i n i s t e r . These changes brought the mental h e a l t h s e r v i c e c l o s e r to the r e s t of the h e a l t h care f i e l d and provided the s e r v i c e with a means of o b t a i n i n g d i r e c t access to Cabinet (MacKerracher, 1964). The Report had a l s o i n f l u e n c e d the government's d e c i s i o n to c r e a t e a new l e g a l framework governing mental h e a l t h matters. The Report contained 50 major recommendations which, i f 291 implemented, would r e s u l t i n the c r e a t i o n of a " s a t i s f a c t o r y -mental h e a l t h programme i n B r i t i s h Columbia" (op c i t : 2). These were founded upon 'modern' a s s u m p t i o n s about the c a u s e s of m e n t a l i l l n e s s ( i . e . , an i n t e r a c t i o n between b i o l o g i c a l , p s y c h o l o g i c a l , and ' s o c i o l o g i c a l ' f a c t o r s ) and t h e most ap p r o p r i a t e methods of treatment. The l a t t e r were to be m u l t i -d i s c i p l i n a r y i n nature w i t h an important r o l e f o r s o c i a l workers as w e l l as a l l h e a l t h c a r e p r o f e s s i o n a l s . In a d d i t i o n , the r e p o r t s e t out f o u r major p r i n c i p l e s which c o n s t i t u t e d the fundamental b e l i e f s of Ross and h i s team of a d v i s o r s . In b r i e f , these p r i n c i p l e s were as f o l l o w s : that the long-range o b j e c t i v e should be to strengthen the mental h e a l t h of the community; that p r i v a t e o r g a n i z a t i o n s and i n d i v i d u a l s (as w e l l as government) were r e s p o n s i b l e f o r "combatting mental i l l n e s s and promoting mental health"; that advances i n p s y c h i a t r y made i t p o s s i b l e f o r people to r e c e i v e treatment other than i n mental h o s p i t a l s , and that t h i s "should be r e f l e c t e d by i n c l u d i n g the mental d i s o r d e r s i n h o s p i t a l and medical insurance c o n t r a c t s " ; and, f i n a l l y , t h a t an adequate m e n t a l h e a l t h programme needed w e l l - t r a i n e d p e r s o n n e l , r e s e a r c h programmes, and " m e d i c a l and s o c i a l programs" aimed at p r e v e n t i n g mental i l l n e s s (op c i t : 1). In a d d i t i o n , any s a t i s f a c t o r y programme had to c o n t a i n s i x b a s i c e l e m e n t s : an i n f o r m e d and ' a l e r t ' c i t i z e n r y ( i . e . , t a x p a y e r s ) who would s u p p o r t the f i n a n c i a l i n v e s t m e n t i n the programme; e f f i c i e n t a d m i n i s t r a t i v e o r g a n i z a t i o n ; i n t e r -d e p a r t m e n t a l c o - o p e r a t i o n (e.g., a M e n t a l H e a l t h C o u n c i l ) ; adequate f i n a n c i a l support p a r t i c u l a r l y i n the form of r e v i s e d 292 h o s p i t a l insurance plans; the support of communities, agencies and i n d i v i d u a l c i t i z e n s who would take some r e s p o n s i b i l i t y f o r t h e m e n t a l h e a l t h o f t h e i r c o m m u n i t i e s ; and, f i n a l l y , a p p r o p r i a t e l e g i s l a t i o n . In regard to the l a s t element, Ross s t r e s s e d that, s u i t a b l e l e g i s l a t i o n must be enacted to provide the framework upon which a P r o v i n c i a l , r e g i o n a l , and l o c a l m e n t a l h e a l t h program can be b u i l t . The l e g i s l a t i v e program should i n c l u d e p r o v i s i o n s f o r m o d e r n i z i n g laws c o n c e r n e d w i t h the a d m i s s i o n , d e t e n t i o n , and r e l e a s e of p a t i e n t s i n m e n t a l i n s t i t u t i o n s . Laws d e a l i n g w i t h the management of property of persons d e c l a r e d incompetent by reason of mental d i s o r d e r should a l s o be r e v i s e d (op c i t : 2). The recommendations of Dr. Ross and h i s team were b o t h s p e c i f i c and d e t a i l e d , and they r e f l e c t e d a goal of c o n t i n u i n g the t r a n s f o r m a t i o n of the mental h e a l t h s e r v i c e from a system of c a r e and t r e a t m e n t d o m i n a t e d by s e g r e g a t e d c o n f i n e m e n t i n c u s t o d i a l i n s t i t u t i o n s , t o one c h a r a c t e r i z e d by a combined medical and s o c i a l work management of p a t i e n t s through v a r i o u s community-based re s o u r c e s , i n t e g r a t e d with the g e n e r a l h e a l t h care system. To t h i s end, the Report proposed a r e d u c t i o n i n the use of c u s t o d i a l care and a s h i f t to the use of a r e g i o n a l network of s m a l l h o s p i t a l s and p s y c h i a t r i c u n i t s i n g e n e r a l h o s p i t a l s where p a t i e n t s could r e c e i v e e a r l y , a c t i v e treatment f o l l o w e d by r a p i d d i s c h a r g e - to community c a r e and t r e a t m e n t a l t e r n a t i v e s . The l a r g e i n s t i t u t i o n s were to be c l o s e d and E s s o n d a l e was to be c o n v e r t e d i n t o a s h o r t - s t a y , a c u t e c a r e f a c i l i t y to which p a t i e n t s c o u l d be r e f e r r e d from the s m a l l e r h o s p i t a l s and u n i t s . The approach r e q u i r e d an expansion i n the numbers of community f a c i l i t i e s and resources ( i n c l u d i n g those 293 provided or a s s i s t e d by v o l u n t e e r agencies) and, i n p a r t i c u l a r , an i n c r e a s e i n the numbers of mental h e a l t h c e n t r e s . S i n c e e f f e c t i v e community care and pr e v e n t i o n r e q u i r e d the s e r v i c e s of s o c i a l workers, t h i s component of the mental h e a l t h s e r v i c e was to be expanded. 8 8 No attempt was made to estimate the c o s t s i n v o l v e d i n the implementation of the recommendations but the i s s u e of h o s p i t a l insurance was addressed. Indeed, t h i s aspect of the process of f i n a n c i n g mental h e a l t h care a t t r a c t e d c o n s i d e r a b l e c r i t i c i s m . The legacy of the 19th century system of segregated confinement was seen as a f f e c t i n g a t t i t u d e s , p o l i c i e s and p r a c t i c e s i n the mental h e a l t h f i e l d throughout North America. Those r e c e i v i n g c a r e and t r e a t m e n t i n p u b l i c i n s t i t u t i o n s were assumed to be both i n d i g e n t and i n need of humane but c u s t o d i a l care, and t h i s was r e f l e c t e d i n the a t t i t u d e s surrounding the i s s u e of h o s p i t a l insurance. G e n e r a l l y , B r i t i s h Columbia was no exception but the province was poised at a p o i n t where i t could "design a modern s y s t e m o f f i n a n c i n g c a r e " t h a t w o u l d t a k e a c c o u n t o f contemporary p s y c h i a t r i c p r a c t i c e s and developments i n the f i e l d of c o n v e n t i o n a l h o s p i t a l insurance (op c i t : 147). For Ross and h i s team, the o l d a t t i t u d e s were r e s p o n s i b l e f o r the f a c t that p a t i e n t s were denied f e d e r a l (and t h e r e f o r e p r o v i n c i a l ) h o s p i t a l insurance coverage once they were placed i n a p u b l i c f a c i l i t y . The a t t i t u d e s were a l s o r e s p o n s i b l e f o r the i m p l i c i t treatment of p a t i e n t s as paupers i n need of c u s t o d i a l care r a t h e r than s i c k i n d i v i d u a l s i n need of medical treatment. 294 P a t i e n t s c o u l d n o t , f o r example, p u r c h a s e e x t r a h o s p i t a l s e r v i c e s . As a consequence, two p a r a l l e l s y s t e m s of m e n t a l h e a l t h care were developing: a 'private' system i n v o l v i n g care and t r e a t m e n t i n both p r i v a t e h o s p i t a l s (e.g., the H o l l y w o o d H o s p i t a l i n New Westminster) and p u b l i c , general h o s p i t a l s ; and, c u s t o d i a l c a r e i n p u b l i c i n s t i t u t i o n s which were vi e w e d as 'second-rate'. I t was argued that t h i s was a waste of resources and money which was not i n the best i n t e r e s t s of p a t i e n t s and t a x - p a y e r s . I t was a l s o i n e q u i t a b l e and a d v e r s e l y a f f e c t i n g b o t h t h e m o r a l e and t h e p e r f o r m a n c e o f m e n t a l h e a l t h p r o f e s s i o n a l s and other personnel (op c i t ) . The s o l u t i o n was s t r a i g h t f o r w a r d . The f i r s t 90 days of an a d m i s s i o n s h o u l d be f i n a n c e d by h o s p i t a l i n s u r a n c e and the f e d e r a l insurance scheme (which at that time excluded the mental h o s p i t a l s ) s h o u l d be e x t e n d e d to c o v e r t h i s p e r i o d . I t was a r g u e d t h a t t h i s w o u l d i n c r e a s e m e n t a l h e a l t h f u n d i n g , f a c i l i t a t e the r e c r u i t m e n t of more and b e t t e r personnel, improve the q u a l i t y of p s y c h i a t r i c care, encourage v o l u n t a r y admissions, support the 'swinging-door' approach, and i n c r e a s e the discharge r a t e . A r e d u c t i o n i n the s i z e of a s i g n i f i c a n t f i n a n c i a l m i l l s t o n e - the c h r o n i c p a t i e n t p o p u l a t i o n - would f o l l o w . In a d d i t i o n , the 'pauper' view of the mental h o s p i t a l p a t i e n t would vanish and s t a f f morale would improve (op c i t ) . The Ross R e p o r t t h u s s e r v e d n o t o n l y t o r e s t o r e l e g i t i m a t i o n but a l s o to s e t out some s p e c i f i c and g e n e r a l recommendations which amounted to a long-term s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d i n the p r o v i n c e . The 295 recommendations i n v o l v e d an entrenchment of most elements of the s t r a t e g y f i r s t i m p l e m e n t e d by Dr. Gee a decade e a r l i e r (a s t r a t e g y t h a t had r e s o l v e d the s t a t e ' s o r d e r m a i n t e n a n c e and l e g i t i m a t i o n problems) and confirmed the goal of i n t e g r a t i n g the mental h e a l t h s e r v i c e w i t h the general h e a l t h care component of the w e l f a r e s t a t e . In t h i s r e g a r d , the l o n g - t e r m s t r a t e g y b u t t r e s s e d the government's p o l i c y of w e l f a r e s t a t e expansion s i n c e i t e n v i s a g e d , i n p a r t i c u l a r , more s o c i a l w o r k e r s , more community-based and other a l t e r n a t i v e s to l a r g e i n s t i t u t i o n s , and the adoption of a h o s p i t a l insurance scheme which covered the treatment of mental d i s o r d e r s . While the e v a l u a t i o n had been conducted under the auspices of the A.P.A., i t i s evident that the recommendations had been c o n s t r u c t e d i n c o n j u n c t i o n w i t h the r e p r e s e n t a t i v e s of an i n t e r e s t group that had r i s e n to a p o s i t i o n of prominence i n the process of mental h e a l t h reform i n Canada; namely, the Canadian M e n t a l H e a l t h A s s o c i a t i o n (C.M.H.A.). When the Ross s u r v e y began i n 1958, the C.M.H.A. announced that i t would be p r o v i d i n g f u l l c o n s u l t a t i o n s e r v i c e s and such other a s s i s t a n c e as may be r e q u i r e d ( C a n a d i a n M e n t a l H e a l t h A s s o c i a t i o n , 1 958). 8 9 C o n s u l t a t i o n and a s s i s t a n c e were provided and two of the four ' o f f i c i a l r e p r e s e n t a t i v e s ' f o r the e v a l u a t i o n were members of the A s s o c i a t i o n (Drs. G r i f f i n and Jones). Another member of the Ross team was Dr. D.G. MacKerracher - the former chairman of the A s s o c i a t i o n ' s N a t i o n a l S c i e n t i f i c P l a n n i n g C o u n c i l - who, on t h i s o c c a s i o n , was r e p r e s e n t i n g the C a n a d i a n P s y c h i a t r i c A s s o c i a t i o n . 296 There i s l i t t l e doubt that these i n d i v i d u a l s helped shape the recommendations found i n the Ross Report. The C.M.H.A. was i n the p r o c e s s of c o n s t r u c t i n g i t s own recommendations f o r mental h e a l t h r e f o r m t h r o u g h o u t Canada and the Ross R e p o r t provided one medium through which the A s s o c i a t i o n was able to a r t i c u l a t e i t s p e r s p e c t i v e . Indeed, the r o l e of the A s s o c i a t i o n i n e n g i n e e r i n g changes i n B r i t i s h Columbia was a m i r r o r of the nationwide a c t i v i t i e s of t h i s i n t e r e s t group. IV; THE ROLE OF THE CANADIAN MENTAL HEALTH ASSOCIATION IN ENGINEERING REFORM A l t h o u g h the C.M.H.A. was c o n s t i t u t e d as a " n a t i o n a l c i t i z e n s ' o r g a n i z a t i o n " i n 1950, i t had fo r m e r l y e x i s t e d as the Canadian N a t i o n a l Committee f o r Mental Hygiene ( G r i f f i n , 1967). The l a t t e r was a h i g h l y r e s p e c t e d , i n d e p e n d e n t o r g a n i z a t i o n e s t a b l i s h e d by a group of p r o g r e s s i v e p s y c h i a t r i s t s i n 1918 and, from i t s i n c e p t i o n , i t had a t t r a c t e d the patronage, sponsorship and s u p p o r t o f many C a n a d i a n d i g n i t a r i e s , i n c l u d i n g the su c c e s s i v e Governors-General. I t became i n a c t i v e during World War II but was r e - e s t a b l i s h e d , as the C.M.H.A., at a time when the p r e v a i l i n g system f o r the management of the m e n t a l l y d i s o r d e r e d was e x p e r i e n c i n g problems. The N a t i o n a l Committee had a h i s t o r y of a s s i s t i n g the s t a t e i n the c o n s t r u c t i o n of s t r a t e g i e s f o r the management of the mentally d i s o r d e r e d . From 1919 onwards, the o r g a n i z a t i o n had p r o v i d e d c o n s u l t a t i o n , f r e q u e n t l y a t the r e q u e s t of governments. I t had undertaken surveys, s p e c i a l s t u d i e s , and researc h on an array of 'mental hygiene' i s s u e s , and f a c i l i t a t e d 297 the t r a i n i n g of personnel (Canadian Mental Health A s s o c i a t i o n , 1958). I t had a l s o played a prominent p a r t i n the development of reforms during the era of ' m e d i c a l i z a t i o n ' i n the 1920's and 1930's. The Committee had p r o v i d e d a v a l u a b l e s e r v i c e t h a t r e l i e v e d governments of the task of d e a l i n g w i t h mental hygiene i s s u e s , and the t r a d i t i o n was continued by the C.M.H.A. When f e d e r a l government e f f o r t s i n the mental h e a l t h f i e l d f a l t e r e d i n t h e m i d - 1 9 5 0 ' s , t h e A s s o c i a t i o n s e i z e d t h e i n i t i a t i v e and, by the l a t e 1950's, i t had become the p r i n c i p a l a r c h i t e c t of m e n t a l h e a l t h r e f o r m t h r o u g h o u t Canada. The o r g a n i z a t i o n ' s i d e a s had a m a j o r i m p a c t upon b o t h t h e development of a new s t r a t e g y f o r the management of the mentally d i s o r d e r e d and the c o n t e n t of the complementary l e g i s l a t i o n which emerged duri n g the era of 'enhanced m e d i c a l i z a t i o n ' i n the 1960*s. The A s s o c i a t i o n gathered and propogated ideas about the c a r e and t r e a t m e n t of the m e n t a l l y d i s o r d e r e d and a c t e d as a ' c l e a r i n g - h o u s e ' m o n i t o r i n g d e v e l o p m e n t s i n B r i t a i n and the United S t a t e s . I t a l s o r e s u r r e c t e d ideas that had been advanced by the N a t i o n a l Committee duri n g the era of ' m e d i c a l i z a t i o n ' . In the wake of the f e d e r a l government's f a i l u r e to respond to the recommendations of the 1954 r e p o r t of the Department of N a t i o n a l H e a l t h and W e l f a r e , the A s s o c i a t i o n ' s N a t i o n a l S c i e n t i f i c Planning C o u n c i l met under the chairmanship of Dr. D. G. MacKerracher. The C o u n c i l d i s c u s s e d both the nation's mental h e a l t h needs and the government's i n a c t i o n and, i n 1954, i t appointed a standing committee on mental h e a l t h s e r v i c e s . The 298 Committee, which was composed of s i x p s y c h i a t r i s t s , was c h a i r e d by Dr. J.S. Tyhurst, and t h i s group was charged w i t h the tasks of reviewing the n a t i o n a l s i t u a t i o n and developing standards and p r i n c i p l e s upon which an e v a l u a t i o n c o u l d be based (Richman, 1964 ). To t h i s end, i t c o n s u l t e d w i t h m e n t a l h e a l t h p r o f e s s i o n a l s and p o l i c y - m a k e r s a c r o s s the c o u n t r y (Canadian Mental Health A s s o c i a t i o n , 1961). As the a n a l y s i s of the s i t u a t i o n i n B r i t i s h Columbia has demonstrated, many problems had to be addressed: c h r o n i c over-crowding; a s e r i o u s shortage of personnel; and the absence of community care and treatment resources. In the Council's view, there appeared to be a consensus about what needed to be done, but chaos reigned. There was, f o r example, no apparent lack of funding but there was confusion about what to do w i t h the money. D i f f e r e n t i n t e r e s t e d p a r t i e s (e.g., the l e v e l s of government) appeared to be i n c o n f l i c t and there was no c l e a r programme or s e t of p r e m i s e s upon which to b u i l d e f f e c t i v e m e n t a l h e a l t h s e r v i c e s . N e g a t i v e p u b l i c a t t i t u d e s towards mental i l l n e s s , mental h o s p i t a l s , and those who r e c e i v e d and those who p r o v i d e d care and treatment, p r e v a i l e d . F i n a l l y , the d e l i v e r y of p u b l i c h e a l t h care s e r v i c e s was organized i n such a way t h a t the needs of the mental h e a l t h component were obscured. Instead, p r i o r i t y was g i v e n to o t h e r h e a l t h p r o b l e m s ; n o t a b l y , t u b e r c u l o s i s , p o l i o , and poor n u t r i t i o n (op c i t ) . By 1961, the year i n which the Ross Report was handed to the government i n B r i t i s h Columbia, the 'Tyhurst Committee' had p r o d u c e d s i x i n t e r i m r e p o r t s a d d r e s s i n g v a r i o u s a s p e c t s of 299 mental h e a l t h care and treatment i n Canada. These were intended to provide the b a s i s f o r d i s c u s s i o n and a m e l i o r a t i v e a c t i o n (op c i t ) and contained a statement of a l l that was sought by t h i s group of reformers. The Tyhurst Committee Reports In the Committee's view, i t was e s s e n t i a l that p s y c h i a t r y be i n t e g r a t e d with the r e s t of medicine. Mental h e a l t h p a t i e n t s s u f f e r e d from i l l n e s s e s , not maladies that r e q u i r e d segregated c o n f i n e m e n t . They were not ' c h r o n i c d e g e n e r a t e s ' who needed o n l y c u s t o d i a l c a r e or hard work on a farm and the growth of p s y c h i a t r i c wards i n general h o s p i t a l s was seen as a s i g n of the extent to which the d e s i r e d i n t e g r a t i o n was beginning to occur. I l l n e s s e s began i n the community and t h a t was where an i n d i v i d u a l should be t r e a t e d ; consequently, i t was necessary to develop community care and treatment resources. P a t i e n t s might need h o s p i t a l i z a t i o n d u r i n g the acute phase of t h e i r i l l n e s s e s but they were to be returned to the community once h o s p i t a l care was no longer necessary. I n - p a t i e n t s e r v i c e s were to be only one aspect of a treatment s t r a t e g y and many p a t i e n t s probably d i d not need to be h o s p i t a l i z e d (op c i t ) . The Committee f e l t that h o s p i t a l and community s e r v i c e s should be c l o s e l y bonded and t h a t , wherever p o s s i b l e , a p a t i e n t should r e c e i v e treatment from the same p h y s i c i a n or p s y c h i a t r i s t r e g a r d l e s s of l o c a t i o n . S i n c e m e n t a l h e a l t h p a t i e n t s o f t e n needed o t h e r h e a l t h c a r e s e r v i c e s , f a c i l i t i e s and r e s o u r c e s should be i n t e g r a t e d w i t h i n a province's general system of care. 300 A person who needed treatment should be able to r e c e i v e i t as e a r l y as p o s s i b l e , with as l i t t l e d i s l o c a t i o n as p o s s i b l e , and w i t h as much c o n t i n u i t y and ' s o c i a l r e s t o r a t i o n ' as p o s s i b l e . To t h i s end, mental h e a l t h s e r v i c e s should be d e c e n t r a l i z e d and d i s p e r s e d t h r o u g h o u t t h e c o m m u n i t y ( r a t h e r t h a n b e i n g concentrated i n l a r g e , i s o l a t e d , and segregated i n s t i t u t i o n s ) so that help could be obtained without the l o s s of a job, without l e a v i n g home, and without s e v e r i n g community and f a m i l y t i e s (op c i t ) . A number of i s s u e s and problems u n d e r l y i n g the d e l i v e r y of s e r v i c e s were i d e n t i f i e d and the Committee s t r e s s e d the need f o r an e a r l y r e s o l u t i o n . In the f i e l d of treatment, f o r example, the advances i n p s y c h i a t r y and t h e i r p o s i t i v e impact upon the r a t e of discharge were i d e n t i f i e d . At the same time, however, i n c r e a s e d d i s c h a r g e s were accompanied by a growing re- a d m i s s i o n r a t e . Although p s y c h i a t r y could not always provide a 'cure', i t c o u l d (and s h o u l d ) f i n d b e t t e r ways of m a i n t a i n i n g a p a t i e n t once he or she had been d i s c h a r g e d . Indeed, the - ' s o c i a l r e h a b i l i t a t i o n ' of p a t i e n t s should be a paramount concern and the Committee f e l t t h a t stronger l i n k s should be forged between h o s p i t a l t r e a t m e n t s (e.g., m i l i e u t h e r a p y ) and community treatments (op c i t ) . At the same t i m e , the Committee v i e w e d the i n c r e a s e i n a d m i s s i o n s and d i s c h a r g e s as a p o s i t i v e d e v elopment. Those s u f f e r i n g from d i s o r d e r s were p r e s e n t i n g t h e m s e l v e s f o r treatment at an e a r l i e r stage (a d e s i r a b l e s t a t e of a f f a i r s ) , and they were o b v i o u s l y r e c e i v i n g e f f e c t i v e t r e a t m e n t and 301 a s s i s t a n c e . In t h i s r e g a r d , the new ' t h e r a p e u t i c a g e n t s ' ( n o t a b l y , drugs) had had a s i g n i f i c a n t i m p a c t . Indeed, i f b e t t e r p r e v e n t i o n s t r a t e g i e s could be developed (e.g., mental hygiene programmes f o r schools, f a m i l i e s and the workplace) and more r e s e a r c h undertaken, the p r o b a b i l i t y that mental i l l n e s s could be combatted was high (op c i t ) . There i s l i t t l e doubt that the Committee was o p t i m i s t i c about the f u t u r e of mental h e a l t h care and treatment. I t was a l s o s e n s i t i v e to the f a c t that i t s proposals might be viewed as e x p e n s i v e and t h e r e f o r e u n t e n a b l e , p a r t i c u l a r l y s i n c e they i n c l u d e d the d e v e l o p m e n t of new community s e r v i c e s and r e s o u r c e s . The Committee was u n a b l e to e s t i m a t e the c o s t s i n v o l v e d and the c o s t - e f f e c t i v e n e s s of i t s plans. Instead, i t was argued t h a t , i f minimum standards were maintained, the c o s t of an unchanged system would e s c a l a t e . D i s c h a r g i n g e l d e r l y and c h r o n i c p a t i e n t s (who could only be given care) to the community would, i t was s u g g e s t e d , r e s u l t i n s a v i n g s . S i m i l a r l y , an emphasis upon e a r l y (and, t h e r e f o r e , t i m e l y ) t r e a t m e n t would r e s u l t i n reduced c o s t s (op c i t ) . The Committee a l s o addressed both the problems a f f e c t i n g the a d m i n i s t r a t i o n of mental h e a l t h s e r v i c e s and the i s s u e of law r e f o r m . S i n c e m e n t a l h e a l t h s e r v i c e s were p r o v i d e d by p r o v i n c i a l governments, and s i n c e budgets were an i m p o r t a n t d e t e r m i n a n t of i mproved s e r v i c e s , i t was s u g g e s t e d t h a t the d i r e c t o r of a p r o v i n c i a l mental h e a l t h s e r v i c e hold the s t a t u s of a Deputy M i n i s t e r w i t h i n a p r o v i n c e ' s M i n i s t r y of H e a l t h . 302 F u r t h e r , the Committee f e l t i t e s s e n t i a l t h a t the p r o v i n c e s r e v i e w mental h e a l t h l e g i s l a t i o n . New s t a t u t e s s h o u l d be developed that would f a c i l i t a t e and emphasize the use of a co-o r d i n a t e d and c o n t i n u o u s system of h o s p i t a l and community s e r v i c e s , i n t e g r a t e p s y c h i a t r i c t r e a t m e n t w i t h the r e s t of medicine, ensure that mental h e a l t h p a t i e n t s were viewed and a s s i s t e d i n the same manner as other p a t i e n t s , and, e s t a b l i s h r e g i o n a l mental h e a l t h s e r v i c e s c h a r a c t e r i z e d by a system of de-c e n t r a l i z e d decision-making (op c i t ) . The Committee's i n t e r i m r e p o r t s were d i s c u s s e d i n January 1962 at the 2nd Canadian I n s t i t u t e on Mental Health S e r v i c e s i n O t t a w a . The f o l l o w i n g y e a r , t h e C.M.H.A. p u b l i s h e d a comprehensive r e p o r t - 'More For The Mind' - and t h i s package of reforms (commonly r e f e r r e d to as the 'Tyhurst Report') amounted to a new s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d i n Canada. I t c o n t a i n e d a s y n t h e s i s of the i n t e r i m r e p o r t s t o g e t h e r w i t h b o t h a more c o h e r e n t s t a t e m e n t o f t h e A s s o c i a t i o n ' s views and a f o r c e f u l and unambigous ex p r e s s i o n of i t s p r i n c i p a l concern: Mental i l l n e s s should be d e a l t w i t h i n p r e c i s e l y the same o r g a n i z a t i o n a l , a d m i n i s t r a t i v e and p r o f -e s s i o n a l framework as p h y s i c a l i l l n e s s . . . T h i s b e l i e f ( i s ) the p i v o t a l p o i n t on w hich a l l arguments r e s t . The p a t i e n t s u f f e r i n g from mental i l l n e s s s h o u l d r e c e i v e the same e x c e l l e n c e of medical and a n c i l l a r y h e a l t h s e r v i c e s as q u i c k l y , e a s i l y and e f f i c i e n t l y as the p a t i e n t s u f f e r i n g from p h y s i c a l i l l n e s s (Tyhurst, et a l , 1963: 38). The Report r e s t a t e d and up-dated the A s s o c i a t i o n ' s views on both p o l i c y and l e g i s l a t i v e reform and the need to improve 303 the p u b l i c image of p a t i e n t s and p s y c h i a t r i s t s - a g o a l t h a t would be a c c o m p l i s h e d once the m e n t a l h e a l t h f i e l d became i n t e g r a t e d w i t h the r e s t of the h e a l t h care system. The need to abandon l a r g e , c u s t o d i a l m e n t a l . h o s p i t a l s was emphasized, as was t h e n eed f o r an a l t e r n a t i v e s y s t e m o f s m a l l , r e g i o n a l h o s p i t a l s , p s y c h i a t r i c u n i t s i n general h o s p i t a l s , and community care and treatment. The A s s o c i a t i o n was more f o r t h r i g h t i n i t s c l a i m s that implementation would r e s u l t i n long-term savings and i t was argued t h a t , i n some p r o v i n c e s , t h e r e might even be immediate savings. I t would not be necessary to c o n s t r u c t new f a c i l i t i e s to meet the demand f o r beds and, i n the case of O n t a r i o , i t was e s t i m a t e d t h a t the p r o v i n c e would save $120 m i l l i o n i n c o n s t r u c t i o n c o s t s s i n c e i t would not be necessary to provide an a d d i t i o n a l 12,000 beds (op c i t ) . In the s p h e r e of p u b l i c o p i n i o n , the T y h u r s t Committee f e l t t h a t t h e r e was s t i l l w i d e s p r e a d f e a r of the c u s t o d i a l 'snake-pit', negative views of p a t i e n t s , and the widespread use of euphemisms to deny the ' r e a l i t y ' of mental i l l n e s s . Shame and stigma were rampant, and p s y c h i a t r i s t s were viewed i n an un-favourable l i g h t . The medical p r o f e s s i o n demonstrated ignorance of the i l l n e s s and i t s i m p a c t , and t h e r e was w i d e s p r e a d s k e p t i c i s m about p s y c h i a t r y s i n c e i t appeared unable to f i n d the causes of, and t h e r e f o r e e f f e c t i v e l y t r e a t , mental i l l n e s s e s . While there were s i g n s of improvement i n these p u b l i c and p r o f -e s s i o n a l a t t i t u d e s , much needed to be done (op c i t ) . M e n t a l h e a l t h p r o f e s s i o n a l s ( p a r t i c u l a r l y , p s y c h i a t r i s t s ) were r e c e i v -i n g s h o r t s h r i f t from b o t h the p u b l i c and t h e i r p r o f e s s i o n a l 304 c o l l e a g u e s , and the A s s o c i a t i o n was c o n c e r n e d to a l t e r t h i s s t a t e of a f f a i r s . The C.M.H.A. was a l r e a d y t a k i n g s t e p s t o e n g i n e e r improvements and, as the case s t u d y o f B r i t i s h C o l u m b i a i n d i c a t e s , elements of i t s recommended s t r a t e g y had been e i t h e r i n t r o d u c e d i n or proposed f o r some pr o v i n c e s . In a d d i t i o n , the o r g a n i z a t i o n was a c t i v e l y i n v o l v e d i n the development of v a r i o u s 'volunteer programmes' that provided not only d i r e c t a s s i s t a n c e i n support of a s h i f t to community-based care and treatment but a l s o p u b l i c e d u c a t i o n d e s i g n e d t o improve the p r e v a i l i n g a t t i t u d e s towards mental h e a l t h i s s u e s (op c i t ) . During the 1950's, the o r g a n i z a t i o n e s t a b l i s h e d and operated 'White Cross C e n t r e s ' : community r e s o u r c e s , s t a f f e d by v o l u n t e e r s , t h a t provided p u b l i c education and s o c i a l r e h a b i l i t a t i o n , i n f o r m a t i o n and r e f e r r a l s e r v i c e s f o r d i s c h a r g e d p a t i e n t s (Rohn, 1961; Canadian Mental Health A s s o c i a t i o n , 1958). It a l s o e s t a b l i s h e d h o s p i t a l 'volunteer programmes' which helped to both bridge the gap between h o s p i t a l and community and f a c i l i t a t e the r e -a c t i v a t i o n and dis c h a r g e of long- s t a y p a t i e n t s ( P e r r e t z , 1960; Canadian Mental Health A s s o c i a t i o n , 1958). In B r i t i s h Columbia, f o r example, the p r o v i n c i a l d i v i s i o n of the C.M.H.A. e s t a b l i s h e d a v o l u n t e e r programme i n Essondale H o s p i t a l i n 1954. T h i s development was f u l l y supported by the mental h e a l t h s e r v i c e and the b e n e f i t s were deemed to be many. The programme would not only improve p u b l i c understanding of me n t a l i l l n e s s and the m e n t a l l y i l l , but a l s o p r o v i d e a 'new a s p e c t ' f o r t h e t r e a t m e n t programme. I t was f e l t t h a t 305 v o l u n t e e r s would a s s i s t the h o s p i t a l d i r e c t l y by b r i n g i n g " p e r s o n a l c o n t a c t and a s s i s t a n c e to the p a t i e n t s i n a c l o s e r r e l a t i o n s h i p than c o u l d be a c c o m p l i s h e d by s t a f f / p a t i e n t r e l a t i o n s h i p s . " 9 0 By 1956, the A s s o c i a t i o n had e s t a b l i s h e d an ' a p p a r e l shop' t h a t d i s p e n s e d f r e e , donated, used c l o t h i n g to p a t i e n t s , and the p r o v i n c i a l government had p r o v i d e d a 'small grant' to a s s i s t the o r g a n i z a t i o n ' s e f f o r t s . The programme was e x t r e m e l y u s e f u l and i t p r o v i d e d the h o s p i t a l w i t h an o p p o r t u n i t y to enhance i t s s t a f f complement. The mental h e a l t h s e r v i c e was s t r u g g l i n g to a c q u i r e , t r a i n and r e t a i n p e r s o n n e l and, by 1956, the s t a f f t u r n o v e r r a t e had reached an a l l time high of 30%. The D i r e c t o r of Mental Health S e r v i c e s admitted that the v o l u n t e e r s were h e l p i n g to ease t h i s acute personnel problem and, when the turnover r a t e rose to 35% the f o l l o w i n g y e a r , s p e c i a l l a u r e l s were handed to the 100 v o l u n t e e r w orkers i n the E s s o n d a l e c o m p l e x . 9 2 By 1960, the programme had grown and the 243 v o l u n t e e r s at Essondale were p l a y i n g a s i g n i f i c a n t " t h e r a p e u t i c r o l e " by both h e l p i n g to prepare p a t i e n t s f o r discharge and p r o v i d i n g a measure of p o s t -discharge f o l l o w - u p . 9 3 G e n e r a l l y , the workers were of immense value to both mental h e a l t h s e r v i c e personnel and the p r o v i n c i a l government. They h e l p e d t o implement the s t r a t e g y of de-i n s t i t u t i o n a l i z a t i o n and t h e i r appearance was c o n s i s t e n t w i t h the recommendations of the A.P.A.; moreover, t h e i r s e r v i c e s were provided f r e e of charge. I t i s evident, t h e r e f o r e , that the C.M.H.A. was doing more 306 than merely p r o v i d i n g the f e d e r a l and p r o v i n c i a l governments w i t h a new s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d . The A s s o c i a t i o n was o r g a n i z i n g and p r o v i d i n g c o n c r e t e forms of a s s i s t a n c e aimed a t f a c i l i t a t i n g the i n t r o d u c t i o n of the s t r a t e g y and these were of d i r e c t b e n e f i t to, i n p a r t i c u l a r , p r o v i n c i a l governments. The O r i g i n s of the Ideas and the C o n d i t i o n s Favourable to Reform Many of the ideas being advanced by the A s s o c i a t i o n were f a r from new and t h i s was acknowledged by the Tyhurst Committee (Tyhurst, et a l , 1963). An emphasis upon v o l u n t a r y treatment, easy a c c e s s to e a r l y , a c t i v e , m e d i c a l t r e a t m e n t , and the development of s m a l l , r e g i o n a l mental h o s p i t a l s , p s y c h i a t r i c u n i t s i n g e n e r a l h o s p i t a l s , and community t r e a t m e n t a l t e r -n a t i v e s , were each p a r t of the p r o p o s a l s f o r reform advanced by the Canadian N a t i o n a l Committee f o r Mental Hygiene during the 1920' and 1930's. Some changes had been i n t r o d u c e d i n some pro v i n c e s (e.g., v o l u n t a r y admission and the e s t a b l i s h m e n t of ' p s y c h o p a t h i c ' h o s p i t a l s and wards) but o t h e r i d e a s had remained dormant, such as the e s t a b l i s h m e n t of community care and treatment a l t e r n a t i v e s . Two developments - one domestic, the other i n t e r n a t i o n a l -c r e a t e d a s e t of c o n d i t i o n s t h a t were more f a v o u r a b l e to an i m p l e m e n t a t i o n of the o r i g i n a l o b j e c t i v e s of the N a t i o n a l Committee. The s y s t e m f o r the management of the m e n t a l l y d i s o r d e r e d was e x p e r i e n c i n g d i f f i c u l t i e s and p r o v i n c i a l governments were c o n f r o n t i n g order maintenance and l e g i t i m a t i o n problems which could not be ignored. The l a r g e i n s t i t u t i o n s f o r 307 s e g r e g a t e d c o n f i n e m e n t were o v e r - c r o w d e d , o b s o l e t e , and expensive to both operate and r e p l a c e . They were a l s o counter-p r o d u c t i v e to the goal of e f f e c t i v e treatment and the o b j e c t s of i n t e r n a t i o n a l c r i t i c i s m . Large mental h o s p i t a l s were simply no longer tenable; a l t e r n a t i v e s had to be found. The C.M.H.A. was able to propose ( r a t h e r , r e s u r r e c t ) a set of e f f e c t i v e a l t e r n a t i v e s ; notably, care and treatment through v a r i o u s 'community-based' f a c i l i t i e s and r e s o u r c e s . Implem-e n t a t i o n was, however, dependent upon the a v a i l a b i l i t y of a s o c i a l w e l f a r e network that could s u s t a i n and support m e n t a l l y d i s o r d e r e d p e r s o n s who were r e s i d i n g o u t s i d e the w a l l s of i n s t i t u t i o n s . The network d i d not e x i s t during the 1920's and 1930's but d i d emerge w i t h the advent of the s o c i a l w e l f a r e component of the Canadian w e l f a r e s t a t e . As the case study of d e v e l o p m e n t s i n B r i t i s h C o l u m b i a has d e m o n s t r a t e d , both the a v a i l a b i l i t y of s o c i a l a s s i s t a n c e and the growth i n the p r o f e s s i o n of s o c i a l work produced the necessary resources and p e r s o n n e l . In a d d i t i o n , the C.M.H.A.'s p r o p o s e d s t r a t e g y was c o n s i s t e n t w i t h (indeed, i t buttressed) the state's p o l i c y of w e l f a r e s t a t e expansion. I n t e r n a t i o n a l d e v e l o p m e n t s a l s o c r e a t e d f a v o u r a b l e c o n d i t i o n s . D u r i n g the 1950's, s t a t e - s p o n s o r e d C o m m i s s i o n s examined the i s s u e of mental h e a l t h reform i n both B r i t a i n and the U n i t e d S t a t e s , and the T y h u r s t Committee's p r o p o s a l s r e f l e c t e d the recommendations of these bodies. By 1957, the B r i t i s h , R o y a l Commission on M e n t a l I l l n e s s and M e n t a l 308 D e f i c i e n c y (the P e r c y R o y a l Commission) had p u b l i s h e d i t s f i n d i n g s and recommendations, and these were used by the Tyhurst Committee to b u t t r e s s i t s p r o p o s a l s . D i s o r d e r s of the mind were to be viewed i n the same manner as p h y s i c a l i l l n e s s e s , an emphasis was to be p l a c e d upon c a r e and t r e a t m e n t i n the community (rather than i n s t i t u t i o n s ) , and mental h e a l t h s e r v i c e s were to be an i n t e g r a l p a r t of the new, N a t i o n a l Health S e r v i c e (Armour, 1981). These changes were welcomed by B r i t i s h p s y c h i a t r i s t s who had a l r e a d y implemented new, complementary t r e a t m e n t s t r a t e g i e s ; n o t a b l y , 'open-wards', o u t - p a t i e n t c l i n i c s , and day h o s p i t a l s (MacKerracher, 1964). D e v e l o p m e n t s i n t h e U n i t e d S t a t e s were o f e q u a l importance. In 1955, and four months a f t e r the e s t a b l i s h m e n t of the Tyhurst Committee, the United S t a t e s Congress appointed the J o i n t Commission on Mental I l l n e s s and Health. T h i s Commission was c h a r g e d w i t h the t a s k of d e v e l o p i n g a n a t i o n a l , m e n t a l h e a l t h p o l i c y and i t was e s t a b l i s h e d i n response to a g i t a t i o n by both the A.P.A. and the N a t i o n a l A s s o c i a t i o n f o r Mental Health (the C.M.H.A.'s Ame r i c a n c o u n t e r p a r t ) . A c o m p r e h e n s i v e , s i x year study was undertaken c u l m i n a t i n g i n the p u b l i c a t i o n of the r e p o r t , ' A c t i o n F o r M e n t a l H e a l t h ' ( M a c K e r r a c h e r , 1964; Grob, 1983; Armour, 1981). 9 4 When the J o i n t Commission p r o d u c e d i t s r e p o r t i n 1961, there were many areas of agreement between i t s views and those of the A s s o c i a t i o n ( T y h u r s t , e t a l , 1963). The Commission p o i n t e d to the u r g e n t need f o r improvement i n m e n t a l h e a l t h s e r v i c e s and made numerous recommendations: no f u r t h e r mental 309 h o s p i t a l c o n s t r u c t i o n ; the c o n v e r s i o n of e x i s t i n g s t a t e h o s p i t a l s i n t o s m a l l , acute care f a c i l i t i e s ; the development of c o m m u n i t y m e n t a l h e a l t h c e n t r e s and day h o s p i t a l s ; t h e enhancement of p s y c h i a t r i c u n i t s i n g e n e r a l h o s p i t a l s ; the p r o v i s i o n of adequate a f t e r - c a r e r e s o u r c e s f o r d i s c h a r g e d p a t i e n t s ; an i n c r e a s e d use of s o c i a l workers and p s y c h o l o g i s t s ; more r e s e a r c h and b e t t e r t r a i n i n g f o r mental h e a l t h personnel; and, i m p r o v e d p u b l i c e d u c a t i o n on m e n t a l h e a l t h m a t t e r s (MacKerracher, 1964; Bloom, 1984). The J o i n t Commission's recommendations were seen as the answer to the problem of over-crowding i n s t a t e h o s p i t a l s and were w e l l r e c e i v e d by the Kennedy A d m i n i s t r a t i o n . By the F a l l of 1963, Congress had passed l e g i s l a t i o n which provided f e d e r a l funds f o r the c o n s t r u c t i o n of community mental h e a l t h c e n t r e s and these were to form the backbone of a new, n a t i o n a l , mental h e a l t h p o l i c y (Bloom 1984; Leighton, 1982; Armour, 1981). The p o l i c y r e f l e c t e d a p a r t i c u l a r set of b e l i e f s which were to be found among t h o s e s e e k i n g r e f o r m i n both B r i t a i n and Canada; namely, that mental h e a l t h and g e n e r a l h e a l t h s e r v i c e s should be i n t e g r a t e d and t h a t t h i s could best be accomplished at the l e v e l of 'community' (Bloom, 1984). The changes o c c u r r i n g i n other c o u n t r i e s served to both s t i m u l a t e the p r o c e s s of r e f o r m i n Canada and l e g i t i m i z e the proposals o f f e r e d by the C.M.H.A. In the absence of a f e d e r a l government i n i t i a t i v e , the A s s o c i a t i o n had assumed a prominent p o s i t i o n i n the reform process and was undertaking a task that 310 was s i m i l a r t o t h a t b e i n g p e r f o r m e d by the P e r c y R o y a l Commission i n B r i t a i n and the J o i n t Commission i n the United S t a t e s . The p r i m a r y d i f f e r e n c e l a y w i t h the f a c t t h a t , i n Canada, a n a t i o n a l i n q u i r y i n t o mental h e a l t h i s s u e s was being undertaken by an i n t e r e s t group. The Canadian Mental Health A s s o c i a t i o n and the State The T y h u r s t R e p o r t was seen as a b l u e p r i n t f o r the development of p s y c h i a t r i c s e r v i c e s i n Canada and the authors were o p t i m i s t i c that t h e i r proposals would be implemented. The N a t i o n a l Department of Health and Welfare openly embraced the f i n d i n g s and recommendations t h r o u g h i t s o f f i c i a l j o u r n a l -•Canada's M e n t a l H e a l t h ' - and i t was e v i d e n t t h a t t h e A s s o c i a t i o n ' s p r o p osals were viewed f a v o u r a b l y at the f e d e r a l l e v e l of the s t a t e . The impact was more obvious at the p r o v i n c i a l l e v e l and, p r i o r to the r e l e a s e of the <final r e p o r t , governments were r e s p o n d i n g to the i n t e r i m documents. In Saskatchewan, f o r example, a new mental h e a l t h s t r a t e g y (i.e., the 'Saskatchewan Plan*) was i n p l a c e by 1961 and T y h u r s t s t a t e d t h a t the A s s o c i a t i o n had p l a y e d a key r o l e i n i t s development and i m p l e m e n t a t i o n ( T y h u r s t , e t a l , 1963). The A s s o c i a t i o n ' s i n t e r i m r e p o r t s a l s o had an impact upon the development of a new m e n t a l h e a l t h p l a n f o r Nova S c o t i a (Canadian M e n t a l H e a l t h A s s o c i a t i o n , 1958; L e i g h t o n , 1982; M a r s h a l l , 1962), the c o n s t r u c t i o n of new s t r a t e g i e s i n Ontario and Quebec (Canadian M e n t a l H e a l t h A s s o c i a t i o n , 1958; T y h u r s t , e t a l , 1963; M a c K e r r a c h e r , 1964), and b o t h Gee's ' t o t a l push' s t r a t e g y and 311 the Ross e v a l u a t i o n of mental h e a l t h s e r v i c e s i n B r i t i s h Columbia. The A s s o c i a t i o n had played a major r o l e i n the Ross survey and the recommendations of the Report were c o n s i s t e n t with the views of the Tyhurst Committee. The C.M.H.A. was deeply immersed i n the process of reform i n t h e s e p r o v i n c e s , two of which - Saskatchewan and B r i t i s h C o l u m b i a - had been c o n f r o n t i n g o r d e r m a i n t e n a n c e and l e g i t i m a t i o n problems (e.g., the nation's worst h o s p i t a l over-c rowding) which r e q u i r e d an u r g e n t r e s o l u t i o n . There were strong l i n k s between s t a t e mental h e a l t h policy-makers and the A s s o c i a t i o n and, p r i o r to the r e l e a s e of the Tyhurst r e p o r t s , changes c o n s i s t e n t w i t h the l a t t e r had been i n t r o d u c e d . The p o s i t i v e impact of the r e f o r m s b u t t r e s s e d the A s s o c i a t i o n ' s n a t i o n a l r e c o m m e n d a t i o n s , and t h e S a s k a t c h e w a n P l a n i n p a r t i c u l a r was viewed as an exemplar f o r the r e s t of Canada to f o l l o w . In some p r o v i n c e s , t h e r e f o r e , the Tyhurst Report served to confirm the v a l i d i t y of a s t r a t e g y that was al r e a d y i n p l a c e , r a t h e r than t o o f f e r a new ap p r o a c h to the management of the mentally d i s o r d e r e d . In keeping with the precedent set by i t s predecessor (the N a t i o n a l Committee f o r M e n t a l Hygiene) the C.M.H.A. was p r o v i d i n g the s t a t e w i t h i n v a l u a b l e a s s i s t a n c e and t h i s was to the advantage of, i n p a r t i c u l a r , the f e d e r a l government. The l a t t e r was r e l i e v e d of the t a s k of u n d e r t a k i n g a p o t e n t i a l l y c o s t l y n a t i o n a l i n q u i r y that was necessary to b r i n g order to the chaos which c h a r a c t e r i z e d the mental h e a l t h f i e l d i n the mid-312 1950's, and i t c o u l d do so w i t h o u t r a i s i n g p r o b l e m s o f l e g i t i m a c y . The government could address any c r i t i c i s m of i t s f a i l u r e to d e a l w i t h m e n t al h e a l t h i s s u e s by p o i n t i n g to the p r e s e n c e of an i n q u i r y by a competent and k n o w l e d g e a b l e o r g a n i z a t i o n of e x p e r t s w e l l a c q u a i n t e d w i t h d o m e s t i c and i n t e r n a t i o n a l i s s u e s and developments. The A s s o c i a t i o n was a l e g i t i m a t e , r e s p e c t a b l e and s e e m i n g l y i n d e p e n d e n t body t h a t was w i l l i n g and a b l e t o undertake the work. I t was headed and steered by p r o g r e s s i v e (but not r a d i c a l ) reformers and the o r g a n i z a t i o n had a h i s t o r y of a s s i s t i n g ( r a t h e r than opposing) the s t a t e . The f e d e r a l government could, t h e r e f o r e , a f f o r d to allow the A s s o c i a t i o n to c o m p l e t e i t s i n q u i r y , p u b l i s h i t s f i n d i n g s , a nd make recommendations. At the same time, Ottawa was not o b l i g e d to endorse a l l the proposed changes and any recommendations which might have been i n c o n s i s t e n t with l a r g e r plans and s t r a t e g i e s ( n o t a b l y , the dev e l o p m e n t of a w e l f a r e s t a t e i n k e e p i n g w i t h Keynesian economic p o l i c i e s ) could have been e a s i l y r e j e c t e d as the u n r e a l i s t i c or unworkable v i e w s of a p a r t i c u l a r i n t e r e s t group. T h i s i s not to suggest, however, the presence of c o l l u s i o n between the f e d e r a l government and the C.M.H.A. The l a t t e r was s e p a r a t e from the s t a t e and t h i s a rrangement was m u t u a l l y b e n e f i c i a l . Ottawa a c q u i r e d the a s s i s t a n c e of a r e l i a b l e but independent o r g a n i z a t i o n , and the A s s o c i a t i o n was presented w i t h an o p p o r t u n i t y to r e s u r r e c t , c o n s t r u c t , a r t i c u l a t e and pursue i t s p r o p o s a l s f o r r e f o r m . The arrangement had a r i s e n as a 313 m a t t e r of mutual c o n v e n i e n c e and was a p r o d u c t of the low p r i o r i t y a c c o r d e d t o m e n t a l h e a l t h m a t t e r s by the f e d e r a l government. The d e l i v e r y of mental h e a l t h s e r v i c e s was a p r o v i n c i a l r e s p o n s i b i l i t y , and Ottawa had n e i t h e r a c l e a r mandate nor a duty to i n t e r f e r e . An h i a t u s had been created, the C.M.H.A. was not slow to s e i z e the op p o r t u n i t y , and i t was i n t h e i n t e r e s t o f t h e f e d e r a l g o v e r n m e n t t o a l l o w t h e A s s o c i a t i o n to act as a g r a t i s , autonomous, n a t i o n a l , c o n s u l t -a t i v e body. The r e l a t i o n s h i p between the A s s o c i a t i o n and the s t a t e at the p r o v i n c i a l l e v e l was, however, q u i t e d i f f e r e n t . The o r g a n i z a t i o n p r o f e s s e d to be an autonomous 'national c i t i z e n s ' o r g a n i z a t i o n ' and a " v o l u n t a r y s o c i e t y o f c i t i z e n s and s c i e n t i s t s " ( G r i f f i n , 1 9 6 7 ) , 9 5 but t h e r e were d i r e c t and person a l l i n k s between the A s s o c i a t i o n ' s d i r e c t o r s (and other p r i n c i p a l s ) and the s e n i o r personnel w i t h i n p r o v i n c i a l mental h e a l t h b u r e a u c r a c i e s who were r e s p o n s i b l e f o r the development of mental h e a l t h s t r a t e g i e s . Indeed, at the s e n i o r l e v e l , the A s s o c i a t i o n was v i r t u a l l y i n d i s t i n g u i s h a b l e from the s t a t e apparatus. The C.M.H.A. was a popular o r g a n i z a t i o n of some magnitude. The g e n e r a l membership was l a r g e and composed c h i e f l y of i n d i v i d u a l s who vol u n t e e r e d t h e i r time and energy i n order to p r o v i d e d i r e c t s e r v i c e s to p a t i e n t s . In 1958, f o r example, d i v i s i o n s and branches had been e s t a b l i s h e d i n most p r o v i n c e s and the o r g a n i z a t i o n had over 94,000 members, 6,300 of whom were 314 a c t i v e v o l u n t e e r s w o r k i n g i n 51 v o l u n t e e r programmes and 47 White Cross Centres across the country (Canadian Mental Health A s s o c i a t i o n , 1958). However, a t t h e s e n i o r l e v e l t h e A s s o c i a t i o n was dominated by p s y c h i a t r i s t s ( G r i f f i n , 1967). The C.M.H.A. had the support of the body which represented organized p s y c h i a t r y (i.e., the Canadian P s y c h i a t r i c A s s o c i a t i o n (CP.A.)) and the l a t t e r c o n s i s t e n t l y endorsed and supported the C.M.H.A. in i t s quest f o r reform ( E d i t o r i a l , 1958; 1960; 1961; B r i t i s h Columbia Medical A s s o c i a t i o n , 1964). In a d d i t i o n , there were d i r e c t l i n k s between the two o r g a n i z a t i o n s ; f o r example, two of the l e a d i n g f i g u r e s i n the C.M.H.A. - Drs. M a c K e r r a c h e r and Lawson - s e r v e d terms as P r e s i d e n t s of the CP.A. ( D i c k s o n , 1980). More i m p o r t a n t l y , t h e r e were p e r s o n a l t i e s between the p s y c h i a t r i s t s who dominated the A s s o c i a t i o n and s t a t e mental h e a l t h policy-makers; indeed, i n the three p r o v i n c e s which were in the vanguard of reform (i.e., B r i t i s h Columbia, Nova S c o t i a , and Saskatchewan) the C.M.H.A. and the s t a t e were i n s e p a r a b l e . In the e a r l y 1950's i n B r i t i s h C o l u m b i a , bo t h the f o r m e r d i r e c t o r of the me n t a l h e a l t h s e r v i c e (Dr. Crease) and the incumbent d i r e c t o r (Dr. Gee) were among the f i r s t d i r e c t o r s of the p r o v i n c i a l branch, and Gee viewed the C.M.H.A. as a "great a l l y . " The o r g a n i z a t i o n r e c e i v e d h i s "whole-hearted s u p p o r t " 9 6 and, by the l a t e 1950's, Gee was making d i r e c t r e f e r e n c e to the views of the A s s o c i a t i o n to j u s t i f y the i n t r o d u c t i o n of v a r i o u s elements of the ' t o t a l push' s t r a t e g y (notably, the enhancement of community care and treatment r e s o u r c e s ) . 9 7 Throughout the 315 1950's and 1960's, the d i r e c t o r a t e c o n s i s t e n t l y i n c l u d e d e i t h e r s e n i o r mental h e a l t h s e r v i c e p e r s o n n e l , or c l o s e l y a l l i e d i n d i v i d u a l s and t h e r e were " c l o s e l i n k s " between p h y s i c i a n s , p o l i c y - m a k e r s , and the A s s o c i a t i o n . 9 8 A l l d e p a r t m e n t s and d i v i s i o n s of the me n t a l h e a l t h s e r v i c e were p a r t i c i p a t i n g a c t i v e l y i n C.M.H.A. committee work and t h e r e was " c l o s e c o -ope r a t i o n " between the s e r v i c e and the o r g a n i z a t i o n . " The c o n n e c t i o n s which e x i s t e d i n B r i t i s h C o l u m b i a were a l s o found i n Nova S c o t i a . The i n d i v i d u a l r e s p o n s i b l e f o r the development of a new mental h e a l t h plan f o r the prov i n c e - Dr. Clyde M a r s h a l l - was a member of the C.M.H.A. and, i n March 1962 he j o i n e d a C.M.H.A. committee formed to develop p r o p o s a l s f o r l e g i s l a t i v e reform (Chalke, et a l , 1964). The Nova S c o t i a plan r e f l e c t e d the A s s o c i a t i o n ' s proposals f o r reform and M a r s h a l l s t a t e d that the o r g a n i z a t i o n had provided c o n s i d e r a b l e guidance ( M a r s h a l l , 1962). In Saskatchewan, the l i n k s between the A s s o c i a t i o n and the s t a t e were e v e n more a p p a r e n t . The a r c h i t e c t o f t h e 'Saskatchewan Plan' (and the new, complementary mental h e a l t h l e g i s l a t i o n ) was Dr. F.S. Lawson (Canada's Mental Health, 1970). Lawson was both the d i r e c t o r of the p r o v i n c e ' s p s y c h i a t r i c s e r v i c e s and a member of the Tyhurst Committee. The chairman of the A s s o c i a t i o n ' s N a t i o n a l S c i e n t i f i c Planning C o u n c i l (the body which c r e a t e d the Tyhurst Committee) was Dr. D.G. MacKerracher; Lawson's predecesssor. C l e a r l y , i n the case of Saskatchewan, those recommending changes t h r o u g h the C.M.H.A. and those c o n s t r u c t i n g new p r o v i n c i a l s t r a t e g i e s and l e g i s l a t i o n were the 316 same people. I t i s c l e a r , t h e r e f o r e , that while the C.M.H.A. prof e s s e d to be an autonomous o r g a n i z a t i o n i t was d i r e c t l y l i n k e d to the s t a t e apparatus at the p r o v i n c i a l l e v e l and provided a v a l u a b l e s e r v i c e at the f e d e r a l l e v e l . The r e l a t i o n s h i p w i t h the f e d e r a l government was c h a r a c t e r i z e d by a c l e a r s e p a r a t i o n , but t h i s was a m u t u a l l y b e n e f i c i a l a rrangement. At the p r o v i n c i a l l e v e l , however, the upper e c h e l o n s of the A s s o c i a t i o n and s t a t e personnel were i n s e p a r a b l e . Since those c o n s t r u c t i n g new mental h e a l t h p o l i c y f o r t h e s t a t e a nd t h o s e d e v e l o p i n g t h e Ass o c i a t i o n ' s p r o p o sals f o r reform were i n d i s t i n g u i s h a b l e , the o r g a n i z a t i o n was not e n t i r e l y autonomous. Indeed, i t may be seen as an a u x i l i a r y p a r t of the s t a t e apparatus which was used to generate a sound and l e g i t i m a t e long-term s t r a t e g y c o n s i s t e n t w i t h the p r e v a i l i n g p o l i c y of w e l f a r e s t a t e e x p a n s i o n . The C.M.H.A. r e s o l v e d t h e p r o b l e m s o f o r d e r m a i n t e n a n c e a nd l e g i t i m a t i o n c o n f r o n t i n g the s t a t e while s i m u l t a n e o u s l y ensuring t h a t the p r o b l e m s would not r e s u r f a c e . I t a l s o f o s t e r e d a v a r i e t y of vol u n t e e r s e r v i c e s and p u b l i c education programmes which were of d i r e c t b e n e f i t to p r o v i n c i a l governments. At the same time, the A s s o c i a t i o n may a l s o be viewed as an i n t e r e s t group t h a t had s u c c e s s f u l l y p e n e t r a t e d the s t a t e apparatus and which was consequently able to accomplish most of i t s goals. Both the order maintenance and l e g i t i m a t i o n problems c o n f r o n t i n g the s t a t e i n the mental h e a l t h area and the l a r g e r s t r u c t u r a l changes aimed a t e n s u r i n g a r e p r o d u c t i o n of the 317 c o n d i t i o n s n e c e s s a r y f o r c a p i t a l a c c u m u l a t i o n ( n o t a b l y , the emergence of a w e l f a r e s t a t e b u i l t upon K e y n e s i a n economic p o l i c i e s ) c r e a t e d a set of c o n d i t i o n s that were favourable to the A s s o c i a t i o n ' s quest f o r reform. I t was i n the i n t e r e s t s of the s t a t e to embrace the changes, many of which had r e m a i n e d dormant s i n c e the 1920's and 1930's, s i n c e they s u p p o r t e d the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . N e v e r t h e l e s s , the o r g a n i z a t i o n was more than a p a s s i v e 'instrument' of the s t a t e ; i t had i t s own o b j e c t i v e s and these were woven i n t o the f a b r i c of the new s t r a t e g y f o r the management o f t h e m e n t a l l y d i s o r d e r e d . I n s o f a r as t h e o b j e c t i v e s were not i n c o n s i s t e n t with those of, i n p a r t i c u l a r , p r o v i n c i a l governments, the o r g a n i z a t i o n was s u c c e s s f u l . Indeed, the A s s o c i a t i o n sought a r e s o l u t i o n of only one potent-i a l l y c o n t e n t i o u s i s s u e ; namely, the i n t r o d u c t i o n of h e a l t h i n s u r a n c e f o r mental h e a l t h p a t i e n t s . The l a t t e r became the focus of the A s s o c i a t i o n ' s reform e f f o r t s at the f e d e r a l l e v e l and the o r g a n i z a t i o n accomplished t h i s goal p r i m a r i l y because of the f e d e r a l government's d e c i s i o n to c o n s t r u c t a n a t i o n a l h e a l t h care p o l i c y as p a r t of a programme of w e l f a r e s t a t e expansion. The C a n a d i a n M e n t a l H e a l t h A s s o c i a t i o n And The Quest Fo r I n t e g r a t i o n The A s s o c i a t i o n ' s quest f o r reform was dominated by one primary o b j e c t i v e ; namely, to engineer a permanent s h i f t from a system of m e n t a l h e a l t h c a r e c h a r a c t e r i z e d by s e g r e g a t e d confinement and a d m i n i s t r a t i v e i s o l a t i o n , to one c h a r a c t e r i z e d 318 by v a r i o u s f o r m s of community-based c a r e and t r e a t m e n t i n t e g r a t e d w i t h the r e s t of the h e a l t h c a r e system. T h i s t r a n s f o r m a t i o n would s i m u l t a n e o u s l y b e n e f i t both mental h e a l t h p a t i e n t s and p s y c h i a t r i s t s . T here i s no q u e s t i o n t h a t t h a t C.M.H.A. was s t r i v i n g to create b e t t e r c o n d i t i o n s and more e f f e c t i v e and humanitarian modes of care and treatment which would be of d i r e c t b e n e f i t to e x i s t i n g and p r o s p e c t i v e m e n t a l h e a l t h p a t i e n t s . The A s s o c i a t i o n was o p t i m i s t i c t h a t m e n t a l i l l n e s s would be combatted p r o v i d i n g the resources were made a v a i l a b l e and the a d m i n i s t r a t i v e and l e g a l i m p e d i m e n t s w h i c h f r u s t r a t e d p s y c h i a t r i s t s were removed. M e d i c i n e had conqu e r e d t u b e r -c u l o s i s , p o l i o and other scourges, and i t was about to turn i t s a t t e n t i o n to the g r e a t e s t b l i g h t of a l l - mental i l l n e s s . New knowledge, new drugs, and new treatment methods were emerging which would provide p s y c h i a t r i s t s with the weapons necessary to engineer a mentally healthy s o c i e t y and no o b s t a c l e s should be p l a c e d i n t h e i r p a t h . The i n t e g r a t i o n of m e n t a l h e a l t h s e r v i c e s w i t h the g e n e r a l h e a l t h c a r e system would h e l p to achieve t h i s goal and r e l i e v e the s u f f e r i n g of those a f f l i c t e d w i t h mental d i s o r d e r s . At the same time, the A s s o c i a t i o n wanted to improve the s t a n d i n g of p s y c h i a t r y and p s y c h i a t r i s t s . As the G e n e r a l D i r e c t o r of the C.M.H.A. - Dr. J.D. G r i f f i n - noted i n the mid-1960's, Many ( p s y c h i a t r i s t s ) d e p l o r e d the s e p a r a t i o n between p s y c h i a t r y - a t l e a s t as p r a c t i s e d i n government m e n t a l h o s p i t a l s - and the r e s t of 319 m e d i c i n e . They d e s i r e d a p r o f e s s i o n a l n i c h e analagous to, or even i d e n t i c a l with, that of the p h y s i c i a n i n p r i v a t e p r a c t i c e ( G r i f f i n , 1967: 1252). P s y c h i a t r i s t s wanted to e s t a b l i s h a system of mental h e a l t h care t h a t was an i n t e g r a l p a r t of the g e n e r a l h e a l t h c a r e system. P u b l i c and p r o f e s s i o n a l images of p s y c h i a t r y were f a r from favourable and i n t e g r a t i o n would, i t was b e l i e v e d , a l t e r t h i s s i t u a t i o n . The i n t e r e s t s of other mental h e a l t h p r o f e s s i o n a l s were e i t h e r b y - p a s s e d or i n c o r p o r a t e d w i t h those of p s y c h i a t r i s t s and, w h i l e the f o r m e r were c o n s u l t e d and i n v i t e d t o s u b m i t working papers to the Tyhurst Committee, they were g e n e r a l l y e x c l u d e d from the p r o c e s s of c o n s t r u c t i n g the p r o p o s a l s f o r r e f o r m ( G r i f f i n , 1967). T h i s a t t r a c t e d the c r i t i c i s m o f , i n p a r t i c u l a r , s o c i a l workers and p s y c h o l o g i s t s and the Tyhurst Committee, somewhat a p o l o g e t i c a l l y , acknowledged t h a t t h e i r r e p o r t s ( p a r t i c u l a r l y , 'More For The Mind') r e p r e s e n t e d the o p i n i o n s of a group of p s y c h i a t r i s t s ( T y h u r s t , e t a l , 1963). The Committee o p e n l y a c c e p t e d t h a t the mental h e a l t h of a s o c i e t y was a ' t o t a l community concern', and t h a t a m u l t i -d i s c i p l i n a r y a p p r o a c h was e s s e n t i a l , b u t t h e v i e w s o f p s y c h i a t r i s t s dominated. The l a t t e r wanted mental i l l n e s s to be v i e w e d and t r e a t e d as a m e d i c a l p r o b l e m t h a t was to r e m a i n f i r m l y under t h e i r c o n t r o l and they were o p t i m i s t i c t h a t t h i s would be a c c o m p l i s h e d a l o n g w i t h an improvement i n t h e i r p r o f e s s i o n a l s t a n d i n g . A l t h o u g h o t h e r m e n t a l h e a l t h p r o f e s s i o n a l s were "unhappy and r e s t l e s s " with t h i s s i t u a t i o n , and while they c h a l l e n g e d "the u s e f u l n e s s of the medical model 320 i n many areas of mental and emotional d i s t r e s s and d i s a b i l i t y " , j t h e i r p r o t e s t a t i o n s were i n v a i n ( G r i f f i n , 1967: 1254). The A s s o c i a t i o n ' s o b j e c t i v e s a l s o e n c o m p a s s e d t h e i n t r o d u c t i o n of a h o s p i t a l or h e a l t h insurance plan that would c o v e r mental h e a l t h p a t i e n t s as w e l l as those s u f f e r i n g from p h y s i c a l i l l n e s s e s . The i s s u e was of c o n s i d e r a b l e importance s i n c e the goal of i n t e g r a t i o n w i t h the r e s t of h e a l t h care could not be accomplished so long as an i n c o n s i s t e n t system of funding mental h e a l t h care and treatment e x i s t e d . While other aspects of the C a n a d i a n w e l f a r e s t a t e were e v o l v i n g i n a manner c o n s i s t e n t w i t h the d e s i r e d r e f o r m s (e.g., the p r o v i s i o n of s o c i a l a s s i s t a n c e and s o c i a l workers b u t t r e s s e d community care and treatment), changes i n the system of h e a l t h insurance were l a g g i n g b e h i n d . The f e d e r a l government had e x c l u d e d m e n t al h o s p i t a l p a t i e n t s ' f r o m the system of b e n e f i t s granted to those i n g e n e r a l h o s p i t a l s and p r i v a t e s e c t o r h e a l t h insurance d i d not c o v e r m e n t al h e a l t h c a r e and t r e a t m e n t . I t was c l a i m e d t h a t t h i s type of c a r e was p r o v i d e d f r e e of charge i n p r o v i n c i a l i n s t i t u t i o n s and that i t would, i n any case, be too c o s t l y to implement (Tyhurst, et a l , 1963). For the T y h u r s t Committee, t h i s s i t u a t i o n e f f e c t i v e l y s e g r e g a t e d p a t i e n t s and, e q u a l l y i m p o r t a n t l y , d e n i g r a t e d p s y c h i a t r i s t s and other mental h e a l t h p r o f e s s i o n a l s (op c i t ) . No e f f o r t was t o be s p a r e d i n l o b b y i n g t h e f e d e r a l and p r o v i n c i a l governments to c o r r e c t the s i t u a t i o n and the A s s o c i a t i o n e n l i s t e d the a i d of p o l i t i c i a n s ; n o t a b l y , A l a n MacNaughton, a member of the f e d e r a l L i b e r a l o p p o s i t i o n . In 321 l a t e 1960, MacNaughton introduced a p r i v a t e r e s o l u t i o n i n the House of Commons, c a l l i n g upon the f e d e r a l government to conduct a n a t i o n a l s u r v e y aimed at e s t a b l i s h i n g both the e x t e n t and causes of mental i l l n e s s and the methods o f (and pr o b l e m s a s s o c i a t e d with) t r e a t i n g those s u f f e r i n g from t h i s c o n d i t i o n (Richman, 1964). The s o - c a l l e d 'MacNaughton R e s o l u t i o n ' was debated and adopted by the House i n December 1960 and, i n June 1961, the f e d e r a l government a p p o i n t e d a R o y a l Commission c h a i r e d by C h i e f J u s t i c e Emmett H a l l t o s t u d y the n a t i o n ' s system of h e a l t h care (op c i t ) . 1 0 0 The H a l l R o y a l C o m m i s s i o n has been d e s c r i b e d a s a 'landmark' i n the h i s t o r y o f Canada's s o c i a l s e c u r i t y s ystem (Guest, 1985). I t r e p r e s e n t e d a major b u i l d i n g b l o c k f o r the w e l f a r e s t a t e and i t i s e v i d e n t t h a t the Commission was not formed s o l e l y i n re s p o n s e to a g i t a t i o n by the C.M.H.A. The n a t i o n a l i n q u i r y was a product of a general programme of we l f a r e s t a t e e x p a n s i o n and the me n t a l h e a l t h a r e a b e n e f i t t e d as a consequence. Indeed, the e f f o r t s of the A s s o c i a t i o n were s u c c e s s f u l p r i m a r i l y because the f e d e r a l government had made a d e c i s i o n to address the e n t i r e h e a l t h care f i e l d . N e v e r t h e l e s s , f o r t he mental h e a l t h a r e a , the n a t i o n a l i n q u i r y c o n s t i t u t e d Canada's o f f i c i a l e q u i v a l e n t of both the Percy Royal Commission i n B r i t a i n and the United S t a t e s J o i n t Commission. The H a l l Royal Commission r e p o r t was r e l e a s e d i n 1964 and, among other matters, the Commissioners u n e q u i v o c a l l y endorsed the views of the C.M.H.A.; f o r example, recommendation 322 29 read as f o l l o w s : That henceforth a l l d i s c r i m i n a t i o n i n the d i s t i n c t -i o n between p h y s i c a l and m e n t a l i l l n e s s i n the o r g a n i z a t i o n and p r o v i s i o n of s e r v i c e s f o r t h e i r t r e a t m e n t , and the a t t i t u d e s upon which t h e s e d i s c r i m i n a t i o n s are based be disavowed f o r a l l time as unworthy and u n s c i e n t i f i c (Royal Commission, 1964: 31). The r e p o r t p o i n t e d to the n e g l e c t and i g n o r a n c e t h a t had a f f e c t e d the mental h e a l t h f i e l d i n the past and which had l e d to c a l l o u s n e s s and a " g h e t t o a t t i t u d e " . W hile changes were o c c u r r i n g , these were to be a c c e l e r a t e d s i n c e mental i l l n e s s was tremendously c o s t l y to both the economy and s o c i e t y . G e n e r a l l y , the Commission's recommendations f o r a f u t u r e , n a t i o n a l mental h e a l t h care s t r a t e g y might w e l l have been copied d i r e c t l y from the Tyhurst Report and t h i s was probably due to the f a c t t h at the c o n s u l t a n t s f o r the Commission i n c l u d e d some of the l e a d i n g f i g u r e s w i t h i n the C.M.H.A. ( n o t a b l y , Dr. D.G. MacKerracher). I t was suggested that the f e d e r a l government s h a r e i n the c o s t of i m p l e m e n t a t i o n and t h a t i t s h o u l d , f o r example, provide grants f o r the c o n s t r u c t i o n of s m a l l h o s p i t a l s (no more than 300 beds), o u t - p a t i e n t and day care programmes, and community-based r e h a b i l i t a t i o n programmes. Most import-a n t l y , i t recommended the removal of the l a s t b a r r i e r to f u l l i n t e g r a t i o n ; namely, the l i m i t a t i o n s on medical insurance which e x c l u d e d c o verage of those r e c e i v i n g c a r e and t r e a t m e n t i n mental h o s p i t a l s . The Commission recommended the i n t r o d u c t i o n of a comprehensive, u n i v e r s a l , 'medicare' scheme which was to be a d m i n i s t e r e d and f i n a n c e d by government. The programme was to be based on the p r i n c i p l e s of u n i v e r s a l i t y , comprehensiveness, 323 a c c e s s i b i l i t y , p o r t a b i l i t y , and p u b l i c a d m i n i s t r a t i o n , w i t h the f e d e r a l government c o n t r i b u t i n g to the c o s t s of the scheme (Guest, 1985). I t i s a p p a r e n t , t h e r e f o r e , t h a t w h i l e the C.M.H.A. was c l o s e l y c o n n e c t e d to and a s s i s t i n g the s t a t e , i t took f u l l a dvantage of the r e l a t i o n s h i p . The o r g a n i z a t i o n h e l p e d t he f e d e r a l and p r o v i n c i a l governments to deal with the problems of order maintenance and l e g i t i m a t i o n a f f e c t i n g the system f o r the management of the m e n t a l l y d i s o r d e r e d but a l s o s e i z e d the o p p o r t u n i t y to advance the i n t e r e s t s of both m e n tal h e a l t h p a t i e n t s and p s y c h i a t r i s t s . A system of mental h e a l t h care and t r e a t m e n t i n t e g r a t e d w i t h the r e s t of the h e a l t h c a r e system would, i t was b e l i e v e d , b e n e f i t both p a t i e n t s and those r e s p o n s i b l e f o r t h e i r treatment. The c r e a t i o n of such a system was the p r i m a r y o b j e c t i v e of the A s s o c i a t i o n and i t was c o n s i s t e n t with, and b u t t r e s s e d , the state's p o l i c y of welfar e s t a t e expansion. The C.M.H.A. was s u c c e s s f u l i n engi n e e r i n g reforms to the system f o r the management of the m e n t a l l y d i s o r d e r e d w hich s i m u l t a n e o u s l y b e n e f i t t e d t h e s t a t e ( e s p e c i a l l y a t t h e p r o v i n c i a l l e v e l ) , mental h e a l t h p a t i e n t s , and p s y c h i a t r i s t s . The o r g a n i z a t i o n ' s package of r e f o r m s i n c l u d e d changes to p r o v i n c i a l m e n t a l h e a l t h l e g i s l a t i o n , and i t was e q u a l l y s u c c e s s f u l i n e n g i n e e r i n g change i n t h i s p a r t i c u l a r a r e a . Indeed, law reform was e s s e n t i a l s i n c e t h i s would provide both a l e g a l framework f o r the i m p l e m e n t a t i o n of the p r o p o s e d , n a t i o n a l , m e n t a l h e a l t h s t r a t e g y and a means whereby the 324 A s s o c i a t i o n ' s goal of f u l l i n t e g r a t i o n could be accomplished. The C.M.H.A. sought the c o n s t r u c t i o n of a l e g a l framework c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' , and both the way i n which t h i s o c c u r r e d and the reasons why t h i s was necessary w i l l now be examined. V: THE CONSTRUCTION OF A NEW LEGAL FRAMEWORK; THE EMERGENCE OF 'ENHANCED MEDICALIZATION' The d evelopment of a new l o n g - t e r m s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d was accompanied by a r e c o g n i t i o n of the need f o r law reform. A new l e g a l framework was not c r u c i a l during the p e r i o d when v a r i o u s elements of the s t r a t e g y were b e i n g i n t r o d u c e d ( i . e . , d u r i n g the 1950's) but, once the s t r a t e g y became entrenched, i t was apparent that new, complementary l e g i s l a t i o n was necessary. The C.M.H.A. wanted c h a n g e s t o p r o v i n c i a l m e n t a l h e a l t h s t a t u t e s and t h e As s o c i a t i o n ' s p r o p osals f o r reform were f i r s t s p e l l e d out i n the T y h u r s t Committee's i n t e r i m r e p o r t s i n 1961. The p r o p o s a l s amounted to an abandonment of the l a s t v e s t i g e s of ' l i m i t e d l e g a l i s m ' and an 'enhancement' of the p r o c e s s o f ' m e d i c a l -i z a t i o n ' which had emerged i n the 1920's and 1930's. In the Committee's view, new l e g i s l a t i o n should remove the r e m a i n i n g l e g a l i m p ediments t o h o s p i t a l a d m i s s i o n ; n o t a b l y , j u d i c i a l s u p e r v i s i o n of the commitment p r o c e s s . M e d i c a l c r i t e r i a and m e d i c a l d i s c r e t i o n were to be employed i n the admission process, and a p a r a l l e l was drawn wi t h admissions to con v e n t i o n a l h o s p i t a l s . L e g i s l a t i o n was to be used to erase the d i s t i n c t i o n between the p a t i e n t who needed t r e a t m e n t f o r a 325 mental h e a l t h problem and the p a t i e n t who needed treatment f o r other i l l n e s s e s or i n j u r i e s , and every e f f o r t was to be made to a d m i t p a t i e n t s on a v o l u n t a r y ( i . e . , ' i n f o r m a l ' ) b a s i s . Admission was to be s u b j e c t to the d i s c r e t i o n of the d i r e c t o r of a f a c i l i t y s i n c e t h i s would enable the i n d i v i d u a l to c o n t r o l the q u a l i t y of c a r e and t h e r e b y p r e v e n t a r e t u r n to the days of s e r i o u s over-crowding and warehousing. G e n e r a l l y , the Committee wanted a system whereby p a t i e n t s would be be admitted on request w i t h one m e d i c a l recommendation. At the t i me of a d m i s s i o n , p a t i e n t s would be r e q u i r e d to s i g n a consent to treatment form t h a t would c o v e r a l l the t r e a t m e n t s which the p a t i e n t ' s a t t e n d i n g p h y s i c i a n might deem a p p r o p r i a t e . I f an i n f o r m a l p a t i e n t wished to be discharged t h i s should occur, r e g a r d l e s s of the o p i n i o n of h i s or her p h y s i c i a n . A l l of these measures were c o n s i s t e n t w i t h p r a c t i c e s i n general h o s p i t a l s (Canadian Mental Health A s s o c i a t i o n , 1961). Those who were 'not w i l l i n g ' but who needed c a r e and t r e a t m e n t , were to be a d m i t t e d (but not 'committed') and r e t a i n e d f o r two or t h r e e weeks on the b a s i s of two m e d i c a l c e r t i f i c a t e s ; a l t h o u g h , i n emergency s i t u a t i o n s , s h o r t - t e r m admission should be p o s s i b l e w i t h one c e r t i f i c a t e . The grounds f o r a d m i s s i o n were to be s i m p l e ; namely, t h a t the p e r s o n was s u f f e r i n g from a m e n t a l i l l n e s s and t h a t he or she r e q u i r e d o b s e r v a t i o n and treatment. The Committee was of the view that a p e r i o d of 14 days allowed s u f f i c i e n t time f o r a p s y c h i a t r i s t to d i a g n o s e a c o n d i t i o n and d e v e l o p a t r e a t m e n t p l a n , and t h a t p h y s i c i a n s be granted the power to, i n i t i a l l y , d e t a i n a p a t i e n t 326 d u r i n g t h i s p e r i o d . At the end of the peri o d , a p a t i e n t was to be re-examined and new c e r t i f i c a t e s completed, and l e g i s l a t i o n s h o u l d make p r o v i s i o n f o r subsequent r e - e x a m i n a t i o n s a t s e t per i o d s ; notably, two weeks, one month, f i v e months, s i x months, and then annually. In t h i s way, a p h y s i c i a n would be r e q u i r e d to conduct a p e r i o d i c i n - h o u s e r e v i e w of a p a t i e n t ' s case t o ensure that the i n d i v i d u a l s t i l l needed care and treatment i n h o s p i t a l (op c i t ) . The i s s u e of p a t i e n t s ' ' r i g h t s ' was a l s o addressed by the Committee. A necessary adjunct to the goal of i n t e g r a t i o n was a r e - d e f i n i t i o n of the mental h e a l t h p a t i e n t as an i n d i v i d u a l i n v e s t e d with 'rights'. Those seeking the s e r v i c e s of general h o s p i t a l s were not s t r i p p e d of t h e i r r i g h t s on admission, and the same p r i n c i p l e was to apply i n the case of those e n t e r i n g or using mental h e a l t h f a c i l i t i e s . Since the legacy of ' l i m i t e d l e g a l i s m ' s t i l l p r e v a i l e d i n many p r o v i n c e s and s i n c e t h i s i n v o l v e d both a set of assumptions and a commitment procedure that r e s u l t e d i n the l o s s of ' c i v i l r i g h t s ' , new l e g i s l a t i o n had to c o r r e c t the s i t u a t i o n . I t would have t o make a f i r m statement to the e f f e c t that mental h e a l t h p a t i e n t s were to be view e d and t r e a t e d i n the same manner as those u s i n g o t h e r components of the h e a l t h care system (op c i t ) . I t was s u g g e s t e d t h a t p a t i e n t s be g r a n t e d the r i g h t to a p p e a l to a d m i n i s t r a t i v e t r i b u n a l s and t h a t r e v i e w boards be e s t a b l i s h e d f o r each mental h e a l t h f a c i l i t y . W h i l e i t was u n l i k e l y t h a t m i s t a k e s would be made, the r i g h t t o seek independent review would provide safeguards a g a i n s t unnecessary 327 or unwarranted confinement and thereby both adequately p r o t e c t a person's r i g h t to l i b e r t y and ensure that treatment was provided i n the b e s t l o c a t i o n (e.g., the community r a t h e r than an i n s t i t u t i o n ) . In a s i m i l a r v e i n , where a p r o p o s e d t r e a t m e n t might be dangerous and there was doubt about the competency of a p a t i e n t to give informed consent, a d d i t i o n a l independent consent s h o u l d be s o u g h t . T h i s a p p l i e d t o r a r e l y u s e d s p e c i a l t r e a t m e n t s , such as lobotomy, which were a l r e a d y s u b j e c t to i n t e r n a l h o s p i t a l review. The proposal r e f l e c t e d the procedure i n g eneral h o s p i t a l s and the Committee were of the view that i t should be extended to the mental h e a l t h context (op c i t ) . The d i s c u s s i o n of p a t i e n t s ' r i g h t s touched upon the i s s u e of 'guardianship' (i.e., committeeship). The Committee s t r e s s e d t h a t the p r o v i s i o n of g u a r d i a n s h i p of both the p e r s o n and an i n d i v i d u a l ' s p roperty and a f f a i r s would become an i n c r e a s i n g l y important i s s u e f o r those p r o v i d i n g and those r e c e i v i n g care and treatment i n the community. However, i n the i n t e r i m , and i n the c o n t e x t of h o s p i t a l i z a t i o n , g u a r d i a n s h i p of the p e r s o n and g u a r d i a n s h i p of an e s t a t e should be t r e a t e d as separate i s s u e s w h ich were u n r e l a t e d to a p a t i e n t ' s s p e c i f i c s t a t u s i n a h o s p i t a l . In p a r t i c u l a r , i t s h o u l d not be assumed t h a t a p a t i e n t r e c e i v i n g t r e a t m e n t i n a f a c i l i t y was i n c a p a b l e of managing h i s or her a f f a i r s (op c i t ) . 1 0 1 G e n e r a l l y , the Committee was b u i l d i n g an argument i n f a v o u r of e s t a b l i s h i n g , t h r o u g h the medium of l e g i s l a t i o n , g eneral h o s p i t a l p r a c t i c e s and procedures i n the mental h e a l t h 328 context, and t h i s was c o n s i s t e n t w i t h the quest f o r i n t e g r a t i o n with the general h e a l t h care system. Some m o d i f i c a t i o n s had to be made t o d e a l w i t h t h e ' u n w i l l i n g 1 p a t i e n t b u t t h e s e n e v e r t h e l e s s i n v o l v e d a procedure dominated by medical d e c i s i o n -making r a t h e r than d i r e c t j u d i c i a l s u p e r v i s i o n . C e r t a i n l y , the p r a c t i c e s of p h y s i c i a n s would be sub j e c t to both in-house review and independent review by a board but the j u d i c i a r y were to play no part i n the management of p a t i e n t s . The f i n a l Tyhurst Report of 1963 r e - s t a t e d the Committee's v i e w s on law r e f o r m , a t t h e same t i m e n o t i n g t h a t new l e g i s l a t i o n i n both Saskatchewan and B r i t a i n p r o v i d e d sound examples of r e f o r m s t h a t s h o u l d be adopted by the p r o v i n c e s ( T y h u r s t , e t a l , 1963). A new M e n t a l H e a l t h A c t had been passed i n Saskatchewan i n 1961 and t h i s had provided the l e g a l framework necessary f o r the implementation of the 'Saskatchewan Pl a n ' . The Act had been m o d e l l e d a f t e r the new E n g l a n d and Wales M e n t a l H e a l t h A c t , 1959 ( M a c K e r r a c h e r , 1964) and the emergence of t h i s s t a t u t e served to b u t t r e s s the A s s o c i a t i o n ' s recommendations. The B r i t i s h l e g i s l a t i o n had been fashioned by the Percy Royal Commission which had recognized that e x i s t i n g l u n a c y l a w s were i n c o n s i s t e n t w i t h ( i n d e e d , f r u s t r a t i n g ) the i n t e g r a t i o n of mental h e a l t h s e r v i c e s w i t h i n the general h e a l t h care system. The new mental h e a l t h l e g i s l a t i o n was intended to provide f o r admission, treatment and discharge procedures that r e f l e c t e d p r a c t i c e s i n general h o s p i t a l s and i n c l u d e d p r o v i s i o n s that e s t a b l i s h e d , preserved and p r o t e c t e d the ' c i v i l r i g h t s ' of p a t i e n t s (Royal.Commission, 1957). 329 The C.M.H.A. h a d o r i g i n a l l y i n t e n d e d t o o f f e r c o m p r e h e n s i v e recommendations f o r law r e f o r m i n the T y h u r s t Report and, i n March 1962, a committee was formed to undertake t h i s task. The group began to examine the body of f e d e r a l and p r o v i n c i a l law p e r t a i n i n g to mental h e a l t h matters and q u i c k l y d i s c o v e r e d that i t had taken on an Herculean task. The p r o j e c t c o u l d not be c o m p l e t e d i n ti m e f o r the p u b l i c a t i o n of the T y h u r s t R e p o r t , and two volumes of the committee's r e p o r t , c o n t a i n i n g a f i r m e n d o r s e m e n t o f t h e new B r i t i s h and Saskatchewan l e g i s l a t i o n , were p u b l i s h e d a year l a t e r (Chalke, et a l , 1964). The A s s o c i a t i o n ' s p r o p o s a l s f o r the i n t r o d u c t i o n of 'enhanced m e d i c a l i z a t i o n ' , b u t t r e s s e d by developments i n both B r i t a i n and Saskatchewan, had an impact upon the c o n s t r u c t i o n of a new l e g a l framework i n the p r o v i n c e s . B r i t i s h Columbia was one of the f i r s t p r o v i n c e s to introduce reforms and the C.M.H.A. i n f l u e n c e d the process through the medium of the Ross Report. The Emergence of Enhanced M e d i c a l i z a t i o n i n B r i t i s h Columbia The i s s u e of law r e f o r m was a p r o m i n e n t f e a t u r e of the Ross Report of 1961. New mental h e a l t h l e g i s l a t i o n was seen as one of the b a s i c e l e m e n t s of any s a t i s f a c t o r y m e n t a l h e a l t h programme and was e s s e n t i a l f o r the i m p l e m e n t a t i o n of the recommended fut u r e s t r a t e g y f o r the management of the mentally d i s o r d e r e d . In the view o f Ross and h i s team of C.M.H.A. ad v i s o r s , new l e g i s l a t i o n should remove both the l e g a l b a r r i e r s to r a p i d , short-term treatment and the f o r m a l i t i e s that d e t e r r e d 330 the use of a l l mental h e a l t h r e s o u r c e s . I t s h o u l d encourage v o l u n t a r y admission f o r treatment and the 'swinging door' use of mental h e a l t h f a c i l i t i e s s i n c e t h i s would ensure that p a t i e n t s were not permanently c o n f i n e d i n c u s t o d i a l 'warehouses'. The e x i s t i n g l e g a l framework was "inadequate, a r c h a i c , u n n e c e s s a r i l y complicated, and sometimes degrading to the mentally i l l " , and had to be r e p l a c e d (Ross, 1961: 145). P r i o r to the r e l e a s e of the Ross R e p o r t , the p r o v i n c i a l government had tak e n some s t e p s to r e v i e w p r o v i n c i a l m e n t a l h e a l t h l e g i s l a t i o n . Indeed, w h i l e the Ross e v a l u a t i o n was t a k i n g p l a c e , the A t t o r n e y - G e n e r a l approved a s t u d y by the F a c u l t y of Law a t the U n i v e r s i t y of B r i t i s h C o l u m b i a . Ross r e f e r r e d to and c o n c u r r e d w i t h the f i n d i n g s of t h i s group of r e s e a r c h e r s and, s i n c e t h e i r r e p o r t was i n f l u e n t i a l i n the c o n s t r u c t i o n of new l e g i s l a t i o n , an examination of t h e i r work i s warranted. As Gee's s t r a t e g y began to gather momentum durin g the mid-1950's, the q u e s t i o n of s t a t u t o r y r e f o r m was r a i s e d . By the Spring of 1957, Gee was p o i n t i n g to the need to review a l l the p r o v i n c i a l mental h e a l t h l e g i s l a t i o n with a view to c o n v e r t i n g the "cumbersome s t a t u t e s " i n t o "more simple procedures". In h i s v i e w , 1 0 2 I t should be our general aim to produce laws which would p r o v i d e n e c e s s a r y t r e a t m e n t w i t h the same degree o f f a c i l i t y and l a c k o f r e s t r i c t i o n of_ l i b e r t y as i s a p p l i e d t o the t r e a t m e n t o f the p hy s__i c a l_l_y i l l . R e s t r i c t i o n and powers o f compulsTon should only be used i n those few cases where p r o t e c t i o n of the p a t i e n t or the publ ic i s of paramount i n t e r e s t (emphasis added). i 331 A year l a t e r , developments i n B r i t a i n which were c o n s i s t e n t w i t h Gee's v i e w , were n o t e d . The r e p o r t o f t h e P e r c y R o y a l Commission e n t e r e d the p u b l i c domain and i t was r e a d b o t h c l o s e l y and with approval, by Dr. Ian Kenning, the D i r e c t o r of T r e a t m e n t S e r v i c e s . He drew p a r t i c u l a r a t t e n t i o n to the emphasis upon the p r o v i s i o n of c a r e and t r e a t m e n t " w i t h o u t compulsion and without the automatic l o s s of c i v i l r i g h t s " . He 1 f)'3 went o n , i U J As we c o n t i n u e to i n t e g r a t e p a t i e n t s i n t o a more a c t i v e l i f e w i t h i n the H o s p i t a l , I b e l i e v e we should give thought to a p o s s i b l e f u t u r e amendment a l l o w i n g a d m i s s i o n t o t h e P r o v i n c i a l M e n t a l H o s p i t a l w i t h o u t a u t o m a t i c l o s s of c i v i l r i g h t s . Although t h i s would put an a d d i t i o n a l burden on our a d m i n i s t r a t i v e s t a f f , i t should be recognized that our p r i m a r y purpose i s to s e r v e the p a t i e n t s ' needs. The ' c i v i l r i g h t s ' under q u e s t i o n were those a f f e c t i n g the p a t i e n t s ' r i g h t s to c o n t r o l t h e i r property and a f f a i r s , and d i d not a f f e c t the power of p h y s i c i a n s to c o n t r o l the c a r e and treatment of p a t i e n t s i n an i n s t i t u t i o n . Some m e a s u r e s , a i m e d a t i m p r o v i n g t h e ' r i g h t s ' o f p a t i e n t s , had a l r e a d y been introduced and these were c o n s i s t e n t w i t h the p r o c e s s of 'opening-up' E s s o n d a l e H o s p i t a l . In June 1953, a p o l l i n g s t a t i o n was s e t up f o r the f i r s t t i m e at the Crease C l i n i c so that p a t i e n t s ( i n c l u d i n g v o l u n t a r y p a t i e n t s i n the main h o s p i t a l ) could " e x e r c i s e t h e i r v o t i n g p r i v i l e g e s " i n the p r o v i n c i a l e l e c t i o n . E i g h t y p a t i e n t s took advantage of the o p p o r t u n i t y . 1 0 4 By 1956, the h o s p i t a l had i n t r o d u c e d l o c k e d m a i l boxes i n the open wards so t h a t p a t i e n t s c o u l d s e a l and m a i l t h e i r own (uncensored) l e t t e r s whenever they wished, and 332 t h i s was extended to other wards w i t h i n a year. P a t i e n t s c o n f i n e d i n the Crease C l i n i c were a l r e a d y being a l l o w e d to r e t a i n t h e i r ' c i v i l r i g h t s ' upon a d m i s s i o n as a r e s u l t of amendments to the Lunacy Act which were introduced on the p r o c l a m a t i o n of the C l i n i c s of P s y c h o l o g i c a l Medicine Act i n 1 9 5 1 . 1 0 6 Although admission to a mental h o s p i t a l would r e s u l t i n the automatic l o s s of c o n t r o l over an e s t a t e , t h i s would only occur i n the case of those e n t e r i n g the C l i n i c , i f the C l i n i c a l D i r e c t o r examined a p a t i e n t and c e r t i f i e d t h a t he or she was incapable. I t was claimed that "very few" p a t i e n t s l o s t t h e i r 1 fl 7 c i v i l r i g h t s J - u / and, i n 1961, the C l i n i c i s s u e d s u p p o r t i n g s t a t i s t i c s . Of the 1,581 p a t i e n t s admitted to Crease i n f i s c a l 1960/61, 68% were deemed to be capable of e x e r c i s i n g t h e i r f u l l c i v i l r i g h t s d u r i n g the course of t h e i r t r e a t m e n t . 1 0 8 Despite these changes, the body of l e g i s l a t i o n which Gee f e l t was i n need of reform was indeed "cumbersome" and c o n s i s t e d of s i x p r i n c i p a l s t a t u t e s r e f l e c t i n g a mixture of both the era of ' l i m i t e d l e g a l i s m ' and the era of ' m e d i c a l i z a t i o n ' . Reforms were n e c e s s a r y and, i n the S p r i n g of 1959, a group of s e n i o r , U n i v e r s i t y of B r i t i s h Columbia law students under the d i r e c t i o n of P r o f e s s o r A.W.R. Ca r r o t h e r s conducted an exhaustive a n a l y s i s of a l l the p r o v i n c i a l s t a t u t e s and case law which r e l a t e d to the mentally d i s o r d e r e d . The study was undertaken at the suggestion of the M i n i s t r y of the A t t o r n e y - G e n e r a l and a c o m p r e h e n s i v e r e p o r t , t h a t i n c l u d e d d r a f t s of new l e g i s l a t i o n , had been prepared by e a r l y summer. 333 The r e s e a r c h e r s met w i t h the Deputy Attorney-General and canvassed the views of a number of key i n d i v i d u a l s and groups; i n c l u d i n g , the O f f i c i a l Committee, the D i r e c t o r of Mental Health S e r v i c e s , t h e p r o v i n c i a l s e c t i o n o f t h e C a n a d i a n Bar A s s o c i a t i o n , the Vancouver Bar A s s o c i a t i o n , and the C.M.H.A. They a l s o d i s c u s s e d v a r i o u s i s s u e s w i t h medical p r a c t i t i o n e r s and p r a c t i s i n g lawyers, and sought the counsel of Dr. K.C. Gray, of the Toronto P s y c h i a t r i c H o s p i t a l ; a lawyer and p s y c h i a t r i s t who was widely recognized as one of the i n d i v i d u a l s r e s p o n s i b l e f o r the development of the ' l i b e r a l ' mental h e a l t h l e g i s l a t i o n t h a t emerged i n O n t a r i o d u r i n g the e r a of ' m e d i c a l i z a t i o n ' ( M a c K e r r a c h e r , 1964). In a d d i t i o n , the r e s e a r c h e r s s t u d i e d both the Percy Commission Report and the then England and Wales Mental Health B i l l ( F a c u l t y of Law, 1959). As a r e s u l t of t h e i r e x tensive a n a l y s i s of the s i t u a t i o n both i n law and i n p r a c t i c e , the r e s e a r c h e r s concluded that the s i x p r i n c i p a l s t a t u t e s (as w e l l as the Supreme C o u r t , Lunacy R u l e s ) were i n u r g e n t need of r e v i s i o n and c o n s o l i d a t i o n p r e f e r a b l y w i t h i n a new omnibus mental h e a l t h s t a t u t e . E x i s t i n g d e f i n i t i o n s and terms s h o u l d be changed to r e f l e c t 'modern' p r i n c i p l e s i n m e ntal h e a l t h c a r e and t r e a t m e n t , and the r e s e a r c h e r s s u g g e s t e d the a d o p t i o n of the s e t of ' w e l f a r e ' o r i e n t e d d e f i n i t i o n s of 'mental defect', 'mental i l l n e s s ' , and 'mental d i s o r d e r ' recommended by the P e r c y R o y a l Commission. These e f f e c t i v e l y broadened the c r i t e r i a f o r a d m i s s i o n and p l a c e d wide d i s c r e t i o n a r y powers i n the hands of m e d i c a l p r a c t i t i o n e r s (op c i t ) . 334 A mental d i s o r d e r was to be viewed as a medical c o n d i t i o n amenable to treatment l i k e any other i l l n e s s and the procedure f o r admission to a mental h e a l t h f a c i l i t y should be the same as that p e r t a i n i n g to any other h o s p i t a l . While M a g i s t r a t e s were to be granted the power to i s s u e warrants f o r the apprehension of those who were dangerous and wandering at l a r g e , an emphasis was to be placed upon v o l u n t a r y and i n v o l u n t a r y admission on the b a s i s of medical c e r t i f i c a t e s . P a t i e n t s ( e s p e c i a l l y those who were voluntary) should be granted the r i g h t to be examined by a p h y s i c i a n of t h e i r choice but, otherwise, i s s u e s of treatment, t r a n s f e r and d i s c h a r g e ( i n c l u d i n g f o r m s o f ' t r i a l ' o r ' c o n v a l e s c e n t ' l e a v e ) were to be l e f t to the d i s c r e t i o n of medical p r a c t i t i o n e r s . In a d d i t i o n , new l e g i s l a t i o n should make p r o v i s i o n f o r short-term, i n v o l u n t a r y d e t e n t i o n on the b a s i s of medical c e r t i f i c a t e s to v a r i o u s community-based f a c i l i t i e s (op c i t ) . J u d i c i a l i n v o l v e m e n t i n t h e c o m m i t m e n t p r o c e s s ( p a r t i c u l a r l y , i n c a s e s of urgency) was seen as no l o n g e r workable, e s p e c i a l l y where a J u s t i c e of the Peace was in v o l v e d . The pre-commitment ' h e a r i n g s ' w hich took p l a c e were, i n most cases, q u i t e f a r c i c a l ; they were a mere f o r m a l i t y , M a g i s t r a t e s and J u s t i c e s o f t e n d i d not examine a p a t i e n t , and these j u d i c i a l o f f i c i a l s were not q u a l i f i e d to make judgments about another person's s t a t e of mental h e a l t h . Even more ques t i o n a b l e was the f a c t t h a t the e x i s t i n g l e g i s l a t i o n made p r o v i s i o n f o r h o s p i t a l superintendents to be ex o f f i c i o J u s t i c e s of the Peace f o r the cou n t y i n which t h e i r h o s p i t a l was l o c a t e d . T h i s meant t h a t 335 s u p e r i n t e n d e n t s c o u l d o r d e r a commitment even though the o r i g i n a l i n t e n t i o n was to have t h i s procedure c o n t r o l l e d by an independent, j u d i c i a l o f f i c i a l . Consequently, the procedure o f f e r e d few r e a l safeguards a g a i n s t improper confinement (op c i t ) . In a d d i t i o n , the process was viewed as s t i g m a t i z i n g s i n c e s i c k i n d i v i d u a l s were b e i n g s u b j e c t e d to ' j u d i c i a l h e a r i n g s ' designed to e s t a b l i s h whether or not they were ' g u i l t y ' of the 'crime' of mental i l l n e s s . At the same t i m e , the a d m i s s i o n procedure had to " s t r i k e a balance between the p r o t e c t i o n of the r i g h t s of the i n d i v i d u a l and the p r o t e c t i o n of s o c i e t y " (op c i t : 77). To t h i s end, a r o l e was to be r e t a i n e d f o r the j u d i c i a r y i n the form of a r i g h t to seek pre and post-admission review. Where a p a t i e n t was o b j e c t i n g to h o s p i t a l i z a t i o n , he or she s h o u l d be e n t i t l e d to have the i s s u e examined by a County or Supreme Court Judge. I t was f e l t t h a t t h i s would r e s u l t i n the e s t a b l i s h m e n t of p r o p e r s a f e g u a r d s (op c i t ) . The e x i s t i n g procedure f o r appeal to a medical panel was unique i n Canada but the r e s e a r c h e r s concluded that i t was of l i t t l e p r a c t i c a l use and s h o u l d be e i t h e r abandoned or r e c o n s t i t u t e d . The r e v i e w panel had been f i r s t e s t a b l i s h e d i n 1940 and while i t may have served a u s e f u l purpose at the time, the procedure was of l i t t l e u t i l i t y i n t h e l a t e 195 0's. In p r a c t i c e , t h e M e d i c a l Superintendent at Essondale was anxious to discharge p a t i e n t s as s o o n as p o s s i b l e and t h e p a n e l u s u a l l y a c c e p t e d h i s recommendations whenever an a p p e a l o c c u r r e d . Indeed, the r e s e a r c h e r s noted that the same group of p a t i e n t s appealed from 336 year to year. u y Nevertheless, i t was f e l t t h a t a r e c o n s t i t u t e d review panel (i.e., one composed of more than p h y s i c i a n s ) could be o f v a l u e . I n d e e d , a c o m b i n a t i o n o f j u d i c i a l and a d m i n i s t r a t i v e review would ensure p r o t e c t i o n f o r the i n d i v i d u a l i n "those few c a s e s where bad f a i t h or e r r o r a re p r e s e n t " , without i n t e r f e r i n g with the need to h o s p i t a l i z e those who were i l l (op c i t : 77). F i n a l l y , the r e s e a r c h e r s recommended r e f o r m of the l e g i s l a t i o n g o v e r n i n g the a p p o i n t m e n t of c o m m i t t e e s and the management of the pro p e r t y and a f f a i r s of mentally d i s o r d e r e d persons. The Lunacy Act was to be re p e a l e d and r e p l a c e d with a new s t a t u t e t h a t i n c o r p o r a t e d the Supreme Court Lunacy Rules, e s t a b l i s h e d b e t t e r procedures, and placed more c o n t r o l over the a c t i v i t i e s of committees. Since the Lunacy Act was a copy of the I m p e r i a l s t a t u t e of 1890, the F a c u l t y of Law group u t i l i z e d the P e r c y R o y a l Commission's c r i t i c i s m s of the s i t u a t i o n i n B r i t a i n . The r e s e a r c h e r s argued that while there was a need f o r j u d i c i a l c o n t r o l o v e r the a p p o i n t m e n t of c o m m i t t e e s , the e x i s t i n g method of ' i n q u i s i t i o n ' (which c o u l d i n v o l v e a t r i a l by jury) was t o t a l l y i n a p p r o p r i a t e . However, while i t might have been p r e f e r a b l e (on humanitarian grounds) not to use the c o u r t s at a l l , the consequences of committeeship were so severe that t h e p r o c e s s o f a p p o i n t m e n t had t o be s u p e r v i s e d by t h e j u d i c i a r y . T h i s was the only way to ensure "honesty and good f a i t h " and, i n p a r t i c u l a r , to safeguard a g a i n s t the p o s s i b i l i t y that d e c l a r a t i o n s of i n c a p a c i t y might be sought by unscrupulous p e o p l e or p e r s o n s a c t i n g i n good f a i t h but i n e r r o r (op c i t : 337 105-106). While the r e s e a r c h e r s thought that some e x i s t i n g p r a c t i c e s s h o u l d be r e t a i n e d (e.g., most of the Lunacy R u l e s , and the r e q u i r e m e n t t h a t an a p p l i c a t i o n f o r the a p p o i n t m e n t of a committee be accompanied by the a f f i d a v i t s of two m e d i c a l p r a c t i t i o n e r s ) , they a l s o recommended t h a t p r o v i s i o n be made f o r a l e s s arduous p r o c e d u r e . I f an a p p l i c a t i o n was made to the c o u r t and t h e r e was no r e a s o n a b l e doubt t h a t a p e r s o n was mentally incapable, the court should be empowered to appoint a committee of the p e r s o n , the person's a f f a i r s , or both. In cases of doubt, the court was to be empowered to order f u r t h e r e x a m i n a t i o n s and, i f d o u b t s t i l l e x i s t e d , t o o r d e r an examination of the i n d i v i d u a l by a panel of three p h y s i c i a n s . The l a t t e r would r e p l a c e the o l d 'jury' method and was seen as p r e f e r a b l e s i n c e mental incompetency was, p r i m a r i l y , a medical question. The proposed l e g i s l a t i o n a l s o contained appeal and r e s c i s s i o n p r o c e d u r e s which, i t was f e l t , would p r o v i d e a d d i t i o n a l s a f e g u a r d s a g a i n s t the w r o n g f u l or u n n e c e s s a r y d e p r i v a t i o n of a person's r i g h t to govern h i s or her a f f a i r s and p h y s i c a l person (op c i t ) . The F a c u l t y of Law r e p o r t was d e s c r i b e d i n glowing terms by Dr. Ross and h i s team. The p r o p o s a l s were s e e n as c o n s t i t u t i n g "a most advanced and e n l i g h t e n e d p l a n " (Ross, 1961: 142) and the recommendations a f f e c t i n g the h o s p i t a l i z a t i o n p r o c e s s were e n d o r s e d a l m o s t w i t h o u t c r i t i c i s m . 1 - 1 - 0 In Ross' view, 338 The p r o p o s e d r e v i s i o n s r e f l e c t the most modern a t t i t u d e s toward the treatment of the mentally i l l p e r s o n . A n t i q u a t e d t e r m i n o l o g y i s dropped and procedures are shortened, as much as p o s s i b l e , to p e r m i t the i n v o l u n t a r y h o s p i t a l i z a t i o n of the mentally i l l on a b a s i s comparable to that of any other s i c k i n d i v i d u a l who r e q u i r e s h o s p i t a l care (op c i t : 142). The l a s t p o i n t - the hallmark of the i n t e g r a t e d approach - was e m p h a s i z e d s t r o n g l y . For example, on the q u e s t i o n of the admission of p a t i e n t s to mental h e a l t h f a c i l i t i e s , Ross wrote: The more n e a r l y the a d m i s s i o n of a m e n t a l l y i l l person to a mental h o s p i t a l resembles the admission o f t h e p h y s i c a l l y i l l p a t i e n t t o a g e n e r a l h o s p i t a l , the b e t t e r i s the t h e r a p e u t i c atmosphere c r e a t e d and the l e s s i s the s o c i a l stigma attached to mental i l l n e s s (op c i t ) . Since the proposals endorsed v o l u n t a r y admission and i n v o l u n t a r y admission on the b a s i s of medical c e r t i f i c a t e s , they met w i t h a p p r o v a l . S i m i l a r l y , the removal of any j u d i c i a l involvement i n the admission process was supported. I n s o f a r as a r c h a i c t erminology was o f f e n s i v e and s t i g m a t i z i n g , so too was the requirement that a d m i s s i o n o c c u r o n l y a f t e r an h u m i l i a t i n g , j u d i c i a l h e a r i n g . However, i t was suggested t h a t p a t i e n t s who f e l t t h a t they were being " u n j u s t l y r e t a i n e d i n a h o s p i t a l " should be able to appeal to a c o u r t of law (op c i t ) . These f e a t u r e s of the d r a f t l e g i s l a t i o n were, t h e r e f o r e , endorsed. Ross and h i s team f e l t t h a t mental h e a l t h l e g i s l a t i o n should encourage e a r l y discharge to community a l t e r n a t i v e s (even though a p a t i e n t might not have recovered f u l l y ) and permit the r e l e a s e of p a t i e n t s on 'convalescent leave', subject to c e r t a i n l i m i t a t i o n s and ' r e - c a l l ' at the d i s c r e t i o n of h o s p i t a l s t a f f . 339 Wherever p o s s i b l e a p a t i e n t was to be discharged to h i s or her home community, and the proposed new l e g i s l a t i o n supported a l l these o b j e c t i v e s . The F a c u l t y of Law recommendations r e g a r d i n g the 'lunacy' l e g i s l a t i o n were a l s o e n d o r s e d , a l t h o u g h Ross and h i s team expressed r e s e r v a t i o n s about some aspects of t h e i r p r o p o s a l s . The Lunacy Act was d e s c r i b e d as " h o p e l e s s l y a r c h a i c " and i n need of complete reform. The procedure was seen as "complicated" and the terminology "degrading" (the term ' l u n a t i c ' was p a r t i c u l a r l y o f f e n s i v e ) (op c i t : 142). The proposed changes r e s o l v e d these p r o b l e m s , but Ross and h i s team were u n c e r t a i n about the p r o p r i e t y of r e p l a c i n g the o l d o p t i o n of ' t r i a l by jury' with a ' t r i a l ' by a panel of three p h y s i c i a n s . The suggestion was to be "considered most gravely" s i n c e the knowledge that, p r i o r to the l o s s of l e g a l r i g h t s , an i n d i v i d u a l could have the matter t r i e d "by a j u r y of h i s p e e r s " , " s u b s t a n t i a l l y c o n t r i b u t e s to the peace of mind and s e c u r i t y of the e n t i r e c i t i z e n r y " . Indeed, "must such general b e n e f i t be given up f o r the sake of expediency i n the i n d i v i d u a l case?" (op c i t : 143). Another i s s u e a t t r a c t e d c r i t i c i s m . Ross and h i s team were not s a t i s f i e d with the way i n which the F a c u l t y of Law group had r e t a i n e d the assumption that admission be a u t o m a t i c a l l y equated w i t h i n c o m p e t e n c y , and the v i e w s of the f o r m e r r e f l e c t e d the p e r s p e c t i v e of both the C.M.H.A. and the Percy Royal Commission. Commitment and incompetence procedures should be s e p a r a t e . L o s s of c i v i l r i g h t s i s u s u a l l y un-necessary, h u m i l i a t i n g , and a b a r r i e r to r e h a b i l -i t a t i o n . The s u p e r i n t e n d e n t s h o u l d , however, be 340 allowed to impose temporary l i m i t a t i o n s upon those r i g h t s u n t i l a d j u d i c a t i o n can take place (op c i t : 147) . In a d d i t i o n , they were not c o n t e n t w i t h the way i n which the group had d e a l t with a c l o s e l y a l l i e d i s s u e . For want of time and i n s p i r a t i o n , the i s s u e of ' p a r t i a l ' g u a r d i a n s h i p had been side - s t e p p e d and, while the group had acknowledged the value of a l l o w i n g p a t i e n t s to have p a r t i a l c o n t r o l over t h e i r a f f a i r s , i t was f e l t t h a t t h i s posed too many p r o b l e m s . 1 1 1 In the view of Ross and h i s team, i t was r e g r e t t a b l e t h a t the .issue had not been addressed f u l l y . They argued, Many p a t i e n t s i n m e n t a l i n s t i t u t i o n s a r e q u i t e capable of managing t h e i r own a f f a i r s or property, p a r t i c u l a r l y when such property i s l i m i t e d . Indeed, encouragement of the p a t i e n t to i n t e r e s t h i m s e l f i n the management of h i s own a f f a i r s may e x e r t a potent t h e r a p e u t i c e f f e c t and may m i t i g a t e a g a i n s t t h e d e v e l o p m e n t o f t h e h e l p l e s s , d e p e n d e n t a t t i t u d e s so o f t e n found among mental p a t i e n t s and which are so d e s t r u c t i v e to t h e i r r e h a b i l i t a t i o n (op c i t : 14 3). I t was recommended t h a t a f u r t h e r a t t e m p t be made to d r a f t l e g i s l a t i o n t h a t "could then be a p p l i e d with d i s c r e t i o n to the more favo u r a b l e cases" (op c i t ) . The p r o v i n c i a l government responded to both the F a c u l t y of Law r e p o r t and the Ross Report by i n t r o d u c i n g new l e g i s l a t i o n . The process began with the r e p e a l of the Lunacy Act and a new, P a t i e n t s E s t a t e s Act was passed and p r o c l a i m e d i n J u l y , 1962. 1 1 2 The A t t o r n e y - G e n e r a l chose to e n a c t a c o m b i n a t i o n of the recommendations of the F a c u l t y of /Law group ( i n c l u d i n g the o p t i o n of a ' t r i a l ' by t h r e e p h y s i c i a n s ) and Ross' p r o p o s a l s r e g a r d i n g the temporary suspension of c i v i l r i g h t s on admission to a f a c i l i t y . The procedure being used at the Crease C l i n i c 341 was extended to a l l p a t i e n t s and, i n k e e p i n g w i t h the new l e g i s l a t i o n i n B r i t a i n and Saskatchewan, persons being admitted to any mental h e a l t h f a c i l i t y were to be examined by m e d i c a l p r a c t i t i o n e r s to determine whether they were capable of managing t h e i r a f f a i r s . T h i s was to be the only way i n which p a t i e n t s could l o s e t h e i r ' c i v i l r i g h t s ' and there would no longer be an automatic assumption of incompetency on admission. The new l e g i s l a t i o n was favourably r e c e i v e d and, s h o r t l y a f t e r p r o c l a m a t i o n , the D i r e c t o r of M e n t a l H e a l t h S e r v i c e s o f f e r e d some p o s i t i v e comments. S i n c e a m e n t a l l y i l l p e r s o n could be admitted to h o s p i t a l without l o s i n g h i s or her ' c i v i l r i g h t s ' , t h i s was " c e r t a i n l y i n keeping with modern p s y c h i a t r i c t h i n k i n g and i s a d e f i n i t e s t e p f o r w a r d i n mental h e a l t h l e g i s l a t i o n . " ± ± J There were no complaints from mental h e a l t h p r o f e s s i o n a l s ; indeed no complaints from anyone. W i t h i n a y e a r , a n o t h e r c l o s e l y r e l a t e d s t a t u t e - the P u b l i c T r u s t e e Act - had been p a s s e d and p r o c l a i m e d . 1 1 4 The F a c u l t y of Law group had i n d i c a t e d that the work of the O f f i c i a l Committee - the government agency r e s p o n s i b l e f o r the management of the e s t a t e s of p a t i e n t s who d i d not have a p r i v a t e committee - might be a f f e c t e d by the i n c r e a s e i n the numbers of p a t i e n t s r e c e i v i n g care and treatment i n the community ( F a c u l t y of Law, 1959). The i m p o r t a n c e of the O f f i c i a l Committee's work was being r e c o g n i z e d by the mental h e a l t h s e r v i c e and i t was evident t h a t the most e f f e c t i v e way to a d m i n i s t e r the p r o p e r t y and a f f a i r s of an i n c r e a s i n g number of d i s c h a r g e d m e n t a l h e a l t h 342 p a t i e n t s was being c o n s i d e r e d . 1 1 - 3 E s t a t e management f o r those l i v i n g i n the community was p o t e n t i a l l y complex and there was a need f o r the c a r e f u l a d m i n i s t r a t i o n of, i n p a r t i c u l a r , the v a r i o u s f e d e r a l and p r o v i n c i a l b e n e f i t s , pensions, and a l l o w -ances, which were payable to m e n t a l l y i l l persons. In a d d i t i o n , i n the absence of s u p e r v i s i o n , those s u f f e r i n g from m e n t a l d i s o r d e r s who had p r o p e r t y or o t h e r a s s e t s might w e l l have squandered t h e i r money (or been p r e y e d upon), and i n d i g e n c e might w e l l have r e s u l t e d i n an a d d i t i o n a l burden f o r the s o c i a l a s s i s t a n c e system. The new P u b l i c T r u s t e e A c t c r e a t e d the O f f i c e of the P u b l i c Trustee and thereby r a t i o n a l i z e d the a d m i n i s t r a t i o n of the property and a f f a i r s of persons who were unable to do so on t h e i r own b e h a l f (Sheppard, 1966). The new agency assumed r e s p o n s i b i l i t y f o r the a f f a i r s of those who were not mentally d i s a b l e d (notably, i n f a n t s and the deceased), and took over the d u t i e s f o r m e r l y undertaken by the O f f i c i a l Committee; namely, the management of the a f f a i r s (and, o c c a s i o n a l l y , the p h y s i c a l person) of mentally d i s o r d e r e d persons. C a t e r i n g to the needs of t h i s group q u i c k l y proved to be a s u b s t a n t i a l task and, by 1966, the P u b l i c T r u s t e e was r e p o r t i n g t h a t h i s o f f i c e had experienced a high volume of work generated, p r i m a r i l y , by those who had been c e r t i f i e d as incapable of managing t h e i r a f f a i r s on a d m i s s i o n to h o s p i t a l s and o t h e r f a c i l i t i e s (op c i t ) . The agency had become p a r t of the p r o v i n c i a l w e l f a r e s t a t e apparatus and was p l a y i n g an important r o l e i n support of the new s t r a t e g y f o r the management of the mentally d i s o r d e r e d . 343 The p r o v i n c i a l government then turned i t s a t t e n t i o n to the t h i r d , and f i n a l , component i n the new l e g a l framework; namely, a new Mental Health Act. During 1963, the proposals f o r reform o f f e r e d by b o t h the F a c u l t y of Law group and the Ross Repor t were fashioned i n t o a f i n a l product under the s u p e r v i s i o n of the Deputy M i n i s t e r and D i r e c t o r of M e n t a l H e a l t h S e r v i c e s - Dr. A.E. Davidson (Mental Health Branch, 1970). By that time, the l e g i s l a t i v e d r a f t s m e n had the b e n e f i t of the new E n g l a n d and Wales, Mental Health Act, 1959, from which to e x t r a c t v a r i o u s f i n e , p r o c e d u r a l d e t a i l s (Taylor & Davidson, 1 9 6 4 ) . 1 1 6 In March 1964, the M i n i s t e r of H e a l t h S e r v i c e s and H o s p i t a l Insurance - the Honorable E.C.F. M a r t i n - introduced the new M e n t a l H e a l t h B i l l ( B i l l 64) to the L e g i s l a t i v e Assembly. While some aspects of the l e g i s l a t i o n were of concern to members of the N.D.P. O p p o s i t i o n ( p r i m a r i l y , the s e c t i o n s w h i c h d e t e r m i n e d e l i g i b i l i t y f o r and a c c e s s i b i l i t y t o , h o s p i t a l s ) , the B i l l was passed and r e c e i v e d Royal Assent w i t h i n a p e r i o d of two weeks. 1 1 7 The Mental Health Act was e v e n t u a l l y p r o c l a i m e d i n f o r c e one year l a t e r ; a delay that was necessary both to allow the c o m p i l a t i o n and approval of new Regulations and to p r o v i d e mental h e a l t h s e r v i c e p e r s o n n e l w i t h t i m e to p r e p a r e f o r the impact of the new l e g i s l a t i o n by making a d m i n i s t r a t i v e and other p r o c e d u r a l a d j u s t m e n t s . 1 1 8 For the Deputy M i n i s t e r and D i r e c t o r of the Mental Health S e r v i c e , the new s t a t u t e was designed to, b r i n g the t r e a t m e n t and c a r e of the m e n t a l l y i l l more i n l i n e w i t h the treatment of p h y s i c a l i l l n e s s 344 and to make such treatment more r e a d i l y a c c e s s i b l e to t h o s e r e q u i r i n g i t ( T a y l o r & D a v i d s o n , 1964: 19) . I t encompassed "the most r e c e n t advances i n p s y c h i a t r i c and m e n t a l h e a l t h c o n c e p t s " s i n c e the a d m i s s i o n p r o c e d u r e would emphasize m e d i c a l r e a s o n s f o r a d m i s s i o n . The m e n t a l h e a l t h s e r v i c e had been p r o v i d e d w i t h a l e g a l framework t h a t would enable personnel to embark upon a new era of mental h e a l t h care, f r e e of the ' c o n s t r a i n t s ' imposed by the r e s i d u e of the era of ' l i m i t e d l e g a l i s m ' . In a d d i t i o n , the s t a t u t e would b o t h "encourage the development of l o c a l l y o p e r a t e d m e n t a l h e a l t h s e r v i c e s " and "enable mental h e a l t h s o c i e t i e s to be formed, which may be a u t h o r i z e d to undertake to operate a mental h e a l t h s e r v i c e or p a r t of such s e r v i c e . " In Dr. Davidson's view, " t h i s w i l l allow the o p p o r t u n i t y of e s t a b l i s h i n g and developing new s e r v i c e s " . 1 1 9 By the end of the f i r s t year of implementation, Davidson's enthusiasm had not waned. The new s t a t u t e a llowed people to be " a d m i t t e d on the b a s i s of m e d i c a l need", a t the same time p r o t e c t i n g t h e i r c i v i l r i g h t s . Indeed, " i t i s g e n e r a l l y considered that the (Act) r e p r e s e n t s a s i g n i f i c a n t advance i n mental h e a l t h l e g i s l a t i o n . " 1 2 0 His sentiments were echoed by both Dr. B.F. Bryson - the S u p e r i n t e n d e n t of the P r o v i n c i a l Mental H o s p i t a l (re-named, Riverview) - and Ms. A.K. C a r r o l l , the D i r e c t o r of P s y c h i a t r i c S o c i a l Work. For Bryson, 1965 had been a " c h a l l e n g i n g , e x c i t i n g , and p r o d u c t i v e y e a r as new programmes and procedures became p o s s i b l e with the s t i m u l u s of t h e more l i b e r a l and p r o g r e s s i v e l e g i s l a t i o n " and t h e 345 implementation of the new s t a t u t e had "promoted much c l i n i c a l p r o g r e s s . " 1 2 1 For Ms. C a r r o l l , 1 2 2 the l e g i s l a t i o n was a welcome development that marked a much needed s h i f t i n emphasis, from the o l d system of treatment and care which was l e g a l i s t i c i n a p p r o a c h and d e s i g n e d f o r t h e p r o t e c t i o n of the i n d i v i d u a l and p r o p e r t y , to a system whose aim i s to p r o v i d e the s i c k p a t i e n t with a continuum of treatment and care. It i s evident, t h e r e f o r e , that new l e g i s l a t i o n c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' was welcomed by s e n i o r p e r s o n n e l w i t h i n the mental h e a l t h s e r v i c e . O t h e r groups e i t h e r d i d not o b j e c t t o , or g e n e r a l l y s u p p o r t e d , the new l e g i s l a t i o n . The c o n c e r n s of the N.D.P. Op p o s i t i o n were focussed upon the extent to which the s t a t u t e ensured access to e f f e c t i v e mental h e a l t h s e r v i c e s , r a t h e r than the adoption of 'enhanced m e d i c a l i z a t i o n ' . I n i t i a l d r a f t s of the l e g i s l a t i o n had been compiled by a group of lawyers (i.e., the F a c u l t y of Law r e s e a r c h e r s ) who e x h i b i t e d a c o n c e r n f o r p r o t e c t i n g c i v i l r i g h t s , and the new s t a t u t e was seen as p r o v i d i n g b e t t e r s a f e g u a r d s than the o l d l e g i s l a t i o n , even though the l a t t e r made p r o v i s i o n f o r the j u d i c i a r y to s u p e r v i s e the commitment p r o c e s s . Indeed, both the l a w y e r s and the m e n t a l h e a l t h p r o f e s s i o n a l s who were i n v o l v e d i n the c o n s t r u c t i o n of the new s t a t u t e were eager to engineer a s h i f t t o a new l e g a l framework c h a r a c t e r i z e d by 'enhanced m e d i c a l -i z a t i o n . ' The passage of the new, B r i t i s h Columbia Mental Health Act marked bo t h the end of a p e r i o d of l e g i s l a t i v e r e f o r m i n the p r o v i n c e and the advent of 'enhanced m e d i c a l i z a t i o n ' . The new 346 l e g a l framework, which encompassed a l l aspects of the management of the mentally d i s o r d e r e d , was introduced i n response to the recommendations of Dr. Ross and h i s team of C.M.H.A. a d v i s o r s , and the A s s o c i a t i o n ' s p e r s p e c t i v e was c l e a r l y i n f l u e n t i a l . The new l e g i s l a t i o n was an i n t e g r a l p a r t of a long-term s t r a t e g y f o r the management of the mentally d i s o r d e r e d that would ensure the e f f e c t i v e c o n t r o l of t h i s group, g u a r a n t e e the c o n t i n u e d l e g i t i m a t i o n of the mental h e a l t h system, and prevent a r e t u r n to the problems of order maintenance and l e g i t i m a t i o n which had confronted the s t a t e 15 years e a r l i e r . At the same time, the s t r a t e g y was c o n s i s t e n t w i t h , and b u t t r e s s e d , the p o l i c y of welfare s t a t e expansion which had been adopted by the f e d e r a l and p r o v i n c i a l l e v e l s of the s t a t e , i n keeping w i t h Keynesian economic p o l i c i e s aimed a t e n s u r i n g the r e p r o d u c t i o n of the c o n d i t i o n s necessary f o r continued c a p i t a l accumulation. The appearance of 'enhanced m e d i c a l i z a t i o n ' i n Sask-atchewan and B r i t i s h C o l u m b i a s i g n a l l e d the b e g i n n i n g of the wave of reform which subsequently spread to the r e s t of Canada. In 1964, the C.M.H.A. r e l e a s e d i t s co m p r e h e n s i v e r e p o r t s on mental h e a l t h l e g i s l a t i o n (Chalke, et a l , 1964) and these proved to be i n f l u e n t i a l . A lawyer who was a member of the committee which had compiled the documents - Barry Swadron - became an a c t i v e advocate of the A s s o c i a t i o n ' s p e r s p e c t i v e (Swadron, 1964; 1966) and was i n p a r t r e s p o n s i b l e f o r the p r e p a r a t i o n of new l e g i s l a t i o n which appeared i n Ontario i n 1967 (Canada's Mental H e a l t h , 1968). T h i s s t a t u t e was s u b s e q u e n t l y c o p i e d by the p r o v i n c e s which had not a l r e a d y embraced 'enhanced m e d i c a l -347 i z a t i o n 1 . The new l e g i s l a t i o n was supported by p h y s i c i a n s and p s y c h i a t r i s t s (op c i t ) and d e m o n s t r a t e d t h a t the C.M.H.A. had s u c c e s s f u l l y e n g i n e e r e d the c o n s t r u c t i o n of a new l e g a l framework f o r the e n t i r e country. F o r t i f i e d by i t s success, the A s s o c i a t i o n turned i t s a t t e n t i o n to both the s t a t e of the law a f f e c t i n g m entally d i s o r d e r e d o f f e n d e r s (Chalke, et a l , 1967) and the i s s u e of the general c i v i l l i b e r t i e s and c i v i c r i g h t s of p a t i e n t s (Swadron & S u l l i v a n , 1973), an e n t e r p r i s e t h a t was subsequently overwhelmed by the changes which came w i t h the r i s e of the 'new l e g a l i s m ' . VI: THE EMERGENCE OF 'ENHANCED MEDICALIZATION': AN EXPLANATION The p e r i o d of mental h e a l t h law reform c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n * was the outcome of the c o n s t r u c t i o n , implementation and entrenchment of a new s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d . In the l a t e 1940's and e a r l y 1950's, the t a c t i c of s e g r e g a t e d c o n f i n e m e n t i n l a r g e i n s t i t u t i o n s was encountering d i f f i c u l t i e s throughout Canada. In B r i t i s h Columbia, f o r example, the s t a t e faced problems of o r d e r m aintenance and l e g i t i m a t i o n i n the form of a h o s p i t a l o v e r - c r o w d i n g c r i s i s , i n c r e a s i n g c o s t s , the p r o s p e c t of e x p e n d i t u r e on new but d i s c r e d i t e d i n s t i t u t i o n s , and the withdrawal of A.P.A. a c c r e d i t a t i o n . Senior personnel w i t h i n the s t a t e a p p a r a t u s ( i . e . , p r o v i n c i a l mental h e a l t h s e r v i c e b u r e a u c r a c i e s ) began to i n t r o d u c e measures to d e a l w i t h the problems and these i n v o l v e d , a ' r e - a c t i v a t i o n ' and ' d e - i n s t i t -u t i o n a l i z a t i o n ' of l o n g - s t a y p a t i e n t s , and the development of v a r i o u s community-based care and treatment a l t e r n a t i v e s . 348 Although the d i f f i c u l t i e s a s s o c i a t e d w i t h the management of the m e n t a l l y d i s o r d e r e d were r e c o g n i z e d by the f e d e r a l government, i t had n e i t h e r a c l e a r mandate nor a s p e c i f i c duty to in t e r v e n e . The r e s p o n s i b i l i t y f o r r e s o l v i n g the problems of order maintenance and l e g i t i m a t i o n l a y with the p r o v i n c i a l l e v e l of the s t a t e , but i t s autonomy was s u b j e c t to the f e d e r a l government's p l a n s and s t r a t e g i e s f o r the r e p r o d u c t i o n of the c o n d i t i o n s necessary f o r • c o n t i n u e d c a p i t a l accumulation. The l a t t e r i n v o l v e d the adoption of Keynesian economic p o l i c i e s and, i n s o f a r as these i n c l u d e d the development of a 'welfare state', they s y n c h r o n i z e d w i t h the changes which were n e c e s s a r y to r e s o l v e the p r o b l e m s a t the" p r o v i n c i a l l e v e l . Indeed, the changes s i m u l t a n e o u s l y r e q u i r e d and b u t t r e s s e d the c o n s t r u c t i o n and expansion of, i n p a r t i c u l a r , the s o c i a l w e l f a r e component of the w e l f a r e s t a t e . In B r i t i s h C o l u m b i a , f o r example, the a v a i l a b i l i t y of s o c i a l a s s i s t a n c e b e n e f i t s p e r m i t t e d the maintenance of p a t i e n t s i n the community, w h i l e an i n c r e a s e d complement of s o c i a l workers played a c r u c i a l r o l e i n p r e p a r i n g l o n g - s t a y p a t i e n t s f o r d i s c h a r g e , d e v e l o p i n g a v a r i e t y of community-based s e r v i c e s and r e s o u r c e s (e.g., b o a r d and c a r e homes), and managing p a t i e n t s i n the community (e.g., through mental h e a l t h c e n t r e s ) . J While the f e d e r a l government was not o b l i g e d to i n t e r v e n e d i r e c t l y i n the management of the m e n t a l l y d i s o r d e r e d i n the p r o v i n c e s , i t c o u l d i n f l u e n c e p o l i c y changes through the medium of c o s t - s h a r i n g agreements. However, mental h e a l t h i s s u e s were i n i t i a l l y accorded a low p r i o r i t y by the f e d e r a l government and 349 t h i s f a c t o r , along with both the emergence of a s o c i a l w e l f a r e system and the pr o b l e m s c o n f r o n t i n g p r o v i n c i a l governments, cr e a t e d a set of c o n d i t i o n s that were favourable to the e f f o r t s of an o s t e n s i b l y autonomous i n t e r e s t group; namely, the C.M.H.A. Indeed, the o r g a n i z a t i o n became the p r i n c i p a l a r c h i t e c t of reform i n Canada. The A s s o c i a t i o n had p r e v i o u s l y e x i s t e d as the Canadian N a t i o n a l Committee f o r Mental Hygiene and the l a t t e r had a s s i s t e d the s t a t e i n the development of s t r a t e g i e s f o r the management of the m e n t a l l y d i s o r d e r e d d u r i n g the 1920's and 1930's. The arrangement continued and, i n the l a t e 1950's and e a r l y 1960's, the C.M.H.A. undertook a n a t i o n a l i n q u i r y i n t o mental h e a l t h i s s u e s . A comprehensive package of reforms was produced and many of the As s o c i a t i o n ' s p r o p o s a l s were drawn from ideas f i r s t a r t i c u l a t e d by the N a t i o n a l Committee. The ideas had remained dormant i n many pro v i n c e s but the c o n d i t i o n s which p r e v a i l e d i n the l a t e 1950's and e a r l y 1960's crea t e d a c l i m a t e i n which they became a c c e p t a b l e t o both the f e d e r a l and p r o v i n c i a l governments. The A s s o c i a t i o n ' s r e f o r m package c o m p r i s e d a l o n g - t e r m s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d and emphasized a s h i f t away from the use of segregated confinement in l a r g e i n s t i t u t i o n s i n favour of v a r i o u s forms of community-based care and treatment. The proposals were strengthened by the f i n d i n g s and recommendations of the Percy Royal Commission i n B r i t a i n and the J o i n t Commission on M e n t a l I l l n e s s i n the U n i t e d S t a t e s . In a d d i t i o n , e l e m e n t s of the s t r a t e g y were i n t r o d u c e d i n p r o v i n c e s where the s t a t e c o n f r o n t e d s e r i o u s 350 problems of order maintenance and l e g i t i m a t i o n i n the mental h e a l t h c o n t e x t ( n o t a b l y , Saskatchewan and B r i t i s h Columbia) p r i o r t o the c o m p i l a t i o n and r e l e a s e of the A s s o c i a t i o n ' s f i n d i n g s and recommendations. In these p r o v i n c e s , strong l i n k s had been f o r g e d between the C.M.H.A. and s t a t e m e n t a l h e a l t h policy-makers and, as the example of B r i t i s h Columbia i n d i c -a t e s , the t y p e s of changes sought by the A s s o c i a t i o n were demonstrably e f f e c t i v e i n r e s o l v i n g the order maintenance and l e g i t i m a t i o n problems. The experience i n these p r o v i n c e s served to strengthen the A s s o c i a t i o n ' s p r o p o s a l s . The C.M.H.A. was a r e l i a b l e and k n o w l e d g e a b l e group of p r o g r e s s i v e ( r a t h e r than r a d i c a l ) r e f o r m e r s who e n j o y e d the c o n f i d e n c e of the f e d e r a l government. The pro p o s e d r e f o r m s b u t t r e s s e d the p l a n s f o r w e l f a r e s t a t e e x p a n s i o n and the st r a t e g y was endorsed by the f e d e r a l Royal Commission on Health S e r v i c e s . The Commission undertook an i n q u i r y i n t o the e n t i r e h e a l t h c a r e a r e a and recommended bot h the a d o p t i o n of a u n i v e r s a l h e a l t h i n s u r a n c e scheme t h a t would i n c l u d e m e n t al h e a l t h p a t i e n t s and the p r o v i s i o n of f e d e r a l government funding to develop community-based a l t e r n a t i v e s to segregated c o n f i n e -ment. The r e l a t i o n s h i p between the A s s o c i a t i o n and the f e d e r a l government was c h a r a c t e r i z e d by a mutually convenient separ-a t i o n , r a t h e r than c o l l u s i o n . The C.M.H.A. demonstrated both a w i l l i n g n e s s and an a b i l i t y to r e s o l v e the problems a f f e c t i n g the mental h e a l t h area and i t was f r e e to independently r e s u r r e c t , c o n s t r u c t , a r t i c u l a t e and pursue i t s proposals f o r reform, many 351 of w hich had r e m a i n e d dormant f o r s e v e r a l decades. The o r g a n i z a t i o n acted as a g r a t i s , independent c o n s u l t a t i v e body and t h i s r e l i e v e d the f e d e r a l government o f the ta s k of u n d e r t a k i n g a c o s t l y n a t i o n a l i n q u i r y w i t h o u t a l s o f a c i n g a p o s s i b l e problem of l e g i t i m a t i o n a r i s i n g from i t s f a i l u r e to a s s i s t the provinc e s i n the mental h e a l t h area. At the same time, Ottawa was under no o b l i g a t i o n to adopt proposals which might c o n f l i c t w i t h i t s g e n e r a l s t r a t e g y of c o n s t r u c t i n g a we l f a r e s t a t e based upon Keynesian economic p o l i c i e s . At the p r o v i n c i a l l e v e l , however, the r e l a t i o n s h i p was d i f f e r e n t . The C.M.H.A. professed to be an autonomous i n t e r e s t group composed of ' c i t i z e n s and s c i e n t i s t s ' but i t was dominated by p s y c h i a t r i s t s and strong l i n k s e x i s t e d between the l a t t e r and the s e n i o r p e r s o n n e l w i t h i n the s t a t e a p p a r a t u s who were r e s p o n s i b l e f o r the c o n s t r u c t i o n of mental h e a l t h s t r a t e g i e s . Indeed, the A s s o c i a t i o n was an a u x i l i a r y part of the p r o v i n c i a l s t a t e a p p a r a t u s r a t h e r than an e n t i r e l y autonomous i n t e r e s t group. It was deeply immersed in the process of reform i n the pro v i n c e s and, as the example of B r i t i s h Columbia i n d i c a t e s , i t p r o v i d e d two main forms of a s s i s t a n c e . The o r g a n i z a t i o n f o s t e r e d a v a r i e t y of v o l u n t e e r programmes which h e l p e d to r e s o l v e the pro b l e m s a s s o c i a t e d w i t h the management of the mentally d i s o r d e r e d . In a d d i t i o n and through the medium of the Ross R e p o r t , the C.M.H.A. p r o v i d e d a l o n g - t e r m s t r a t e g y t h a t would a s s u r e the e f f e c t i v e and l e g i t i m a t e management of the m e n t a l l y d i s o r d e r e d i n a manner c o n s i s t e n t w i t h the s t a t e ' s p o l i c y of w e l f a r e s t a t e expansion. 352 The A s s o c i a t i o n was n o t , h o w e v e r , a mere p a s s i v e ' i n s t r u m e n t ' of the s t a t e . The o r g a n i z a t i o n had i t s own o b j e c t i v e s and took f u l l advantage of i t s c l o s e t i e s with the s t a t e to c r e a t e not o n l y b e t t e r c o n d i t i o n s f o r .mental h e a l t h p a t i e n t s but a l s o an improvement i n the p u b l i c and p r o f e s s i o n a l standing of p s y c h i a t r i s t s and p s y c h i a t r y . Both goals could be a c c o m p l i s h e d by i n t e g r a t i n g mental h e a l t h s e r v i c e s w i t h the general h e a l t h care component of the w e l f a r e s t a t e and, s i n c e t h i s was a f e a t u r e of the A s s o c i a t i o n ' s long-term s t r a t e g y f o r the r e s o l u t i o n of the p r o b l e m s c o n f r o n t i n g the s t a t e , the o r g a n i z a t i o n achieved i t s o b j e c t i v e s . I n s o f a r as the C.M.H.A. was s u c c e s s f u l i n c r e a t i n g and implementing a new s t r a t e g y f o r the management of the mentally d i s o r d e r e d , i t a l s o a c h i e v e d i t s g o a l s i n the a r e a of law reform. The c o n s t r u c t i o n of a new l e g a l framework governing the mental h e a l t h area was both an i n t e g r a l part of the proposed new s t r a t e g y and a c r u c i a l f e a t u r e of the A s s o c i a t i o n ' s quest f o r i n t e g r a t i o n . The o r g a n i z a t i o n sought an 'enhancement' of the process of ' m e d i c a l i z a t i o n ' which had emerged i n the 1920's and 1930's and, as the example of B r i t i s h Columbia demonstrates, i t exerted a strong i n f l u e n c e over the development of a new l e g a l framework i n the p r o v i n c e s . Indeed, the era of mental h e a l t h law r e f o r m s c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' was a d i r e c t outcome of the o r g a n i z a t i o n ' s e f f o r t s . The A s s o c i a t i o n sought to e s t a b l i s h , through the medium of l e g i s l a t i o n , c o n v e n t i o n a l h o s p i t a l p r a c t i c e s i n the m e n t a l 353 h e a l t h area. T h i s r e q u i r e d an abandonment of the l a s t v e s t i g e s of ' l i m i t e d l e g a l i s m ' ( n o t a b l y , j u d i c i a l s u p e r v i s i o n of the admission process); the adoption of f u l l y m e d i c a l i z e d admission, treatment and discharge procedures (subject to both 'in-house' and a d m i n i s t r a t i v e review); and, the d i s p o s a l of any d i s t i n c t i o n between mental h e a l t h p a t i e n t s and p e r s o n s u s i n g the g e n e r a l h e a l t h c a r e system. As was the case i n g e n e r a l h o s p i t a l s , p a t i e n t s were to be viewed as i n d i v i d u a l s with ' r i g h t s ' and the c o n c e p t s of ' l i b e r a l i s m ' and ' c i v i l r i g h t s ' were a f e a t u r e of the A s s o c i a t i o n ' s d i s c o u r s e . The ' r i g h t s ' i n q u e s t i o n were, however, those which p r i m a r i l y a f f e c t e d the power of p a t i e n t s to c o n t r o l t h e i r p r o p e r t y and a f f a i r s w h i l e they were r e c e i v i n g care and treatment. The ' r i g h t s ' d i d not i n t e r f e r e unduly with the e x e r c i s e of medical d i s c r e t i o n , and the support f o r t h e i r i n t r o d u c t i o n was c o n s i s t e n t with the quest f o r i n t e g r a t i o n and, hence, an improvement i n the standing of p s y c h i a t r y . In short, the emergence of the mental h e a l t h law reforms c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' was the outcome of the c o n s t r u c t i o n and adoption of a new s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d . This i n v o l v e d a s h i f t away from the use of s e g r e g a t e d c o n f i n e m e n t to a system c h a r a c t e r i z e d by m e d i c a l and s o c i a l work management t h r o u g h community-based a l t e r n a t i v e s , i n t e g r a t e d with the general h e a l t h care component of the w e l f a r e s t a t e . The s h i f t was necessary to r e s o l v e the o r d e r m aintenance and l e g i t i m a t i o n p r o b l e m s c o n f r o n t i n g the p r o v i n c i a l l e v e l of the s t a t e , but the new s t r a t e g y could not be implemented without a comprehensive s o c i a l 354 w e l f a r e system. In t h i s regard, the s t r a t e g y synchronized with (indeed, i t enhanced) the development of a wel f a r e s t a t e b u i l t upon the K e y n e s i a n economic p o l i c i e s a d o pted by the f e d e r a l l e v e l of the s t a t e , i n order to ensure the r e p r o d u c t i o n of the c o n d i t i o n s n e c e s s a r y f o r c a p i t a l a c c u m u l a t i o n . The new st r a t e g y was, t h e r e f o r e , compatible with a s y n c h r o n i z a t i o n of the c a r d i n a l f u n c t i o n s of the s t a t e at both the f e d e r a l and p r o v i n c i a l l e v e l s . The s t r a t e g y was co n s t r u c t e d and implemented by s e n i o r p e r s o n n e l w i t h i n the p r o v i n c i a l s t a t e a p p a r a t u s w o r k i n g i n tandem w i t h the C.M.H.A., an i n f l u e n t i a l n a t i o n a l o r g a n i z a t i o n t h a t was c l o s e l y a l i g n e d w i t h p r o f e s s i o n a l and s t a t e i n t e r e s t s . The f e d e r a l and p r o v i n c i a l l e v e l s of the s t a t e e n l i s t e d the a i d of a r e l i a b l e , l e g i t i m a t e and 'independent' o r g a n i z a t i o n i n the e x e r c i s e and s y n c h r o n i z a t i o n of t h e i r c a r d i n a l f u n c t i o n s (Figure 5.1 i l l u s t r a t e s the r e l a t i v e autonomy of (and connections between) the two l e v e l s of the s t a t e , and the n a t i o n a l and p r o v i n c i a l components of t h i s i n t e r e s t group). S i n c e the g o a l s of the A s s o c i a t i o n were c o n s i s t e n t w i t h the permanent r e s o l u t i o n of o r d e r m a i n t e n a n c e and l e g i t i m a t i o n p r o b l e m s , i n a manner c o n s i s t e n t w i t h b o t h p l a n s f o r an expansion of the we l f a r e s t a t e and i n t e r n a t i o n a l developments i n the mental h e a l t h area, the f e d e r a l and p r o v i n c i a l l e v e l s of the s t a t e endorsed the proposed changes and these were implemented by p r o v i n c i a l governments. There i s l i t t l e doubt that the mental h e a l t h law reforms of the 1960's c o n s t i t u t e d a moment of triumph f o r p s y c h i a t r y . The C.M.H.A. was dominated by p s y c h i a t r i s t s and i t s u c c e s s f u l l y 355 FIGURE 5.1: THE RELATIVE AUTONOMY OF, AND CONNECTIONS BETWEEN, THE LEVELS OF THE STATE AND COMPONENTS OF THE CANADIAN MENTAL HEALTH ASSOCIATION The spheres represent the relatively autonomous and interlocking federal and provincial levels of the state, and the connections with, the. components of the C.M.H.A. The national component exerted an influence a t the federal and, through i t s l o c a l branches, provincial levels of the state. (1) " Autonomy t o reproduce"" conditions necessary for" continued""capital acc-umulation (over-arching, national economic strategy). Some responsibility f o r addressing national health and welfare matters but no power/duty t o intervene i n the management of the mentally disordered i n the provinces. (2) Autonomy i n the management of the mentally disordered and t o resolve associated order maintenance and legitimation problems, but autonomy r e l -ative t o federal economic plans/strategies and associated cost-sharing agree-ments. (3) Ostensibly autonomous interest group dominated by psychiatrists and with links t o national and international professional organizations (notably, the C.P.A. and the A.P.A.). (4) Branch of the national interest group. Large volunteer body dominated by psychiatrists and interlocked, a t the senior l e v e l , with the provincial state apparatus. Autonomy relative to the national.component. 356 a d v a n c e d t h e i n t e r e s t s o f t h i s g r o u p o f p r o f e s s i o n a l s . Consequently, those r e s p o n s i b l e f o r the d i r e c t management of the m e n t a l l y d i s o r d e r e d d i d not o b j e c t . By the 1970's, however, bot h the f e d e r a l and the p r o v i n c i a l l e v e l s of the s t a t e were c o n f r o n t i n g new p r o b l e m s which a f f e c t e d the e x e r c i s e and s y n c h r o n i z a t i o n of t h e i r c a r d i n a l f u n c t i o n s , and these had an impact upon the s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d . At the same time, and as a r e s u l t of the e f f o r t s of the p a t i e n t s ' r i g h t s movement, the p r o p r i e t y of 'enhanced m e d i c a l i z a t i o n ' came under question. Indeed, as we s h a l l see i n the next c h a p t e r , the i s s u e of p a t i e n t s ' r i g h t s took on a d i f f e r e n t complexion as p r o v i n c i a l governments r e a l i z e d that the es t a b l i s h m e n t and p r o t e c t i o n of such r i g h t s would help achieve s t a t e o b j e c t i v e s , even though they might not be to the l i k i n g of p s y c h i a t r i s t s . 357 ENDNOTES: CHAPTER 5 KEY TO ABBREVIATIONS D.B.S.: D o m i n i o n B u r e a u o f S t a t i s t i c s . M e n t a l ii£fLii.jl S t a t i s t i c s , Annual R e p o r t . Ottawa: King's P r i n t e r / Q u e e n ' s Pr i n t e r . J.L.A.: J o u r n a l s of the L e g i s l a t i v e Assembly of the Province of B r i t i s h Columbia. V i c t o r i a : King's Printer/Queen's P r i n t e r . M.Hosp.A.R.: Department of the P r o v i n c i a l S e c r e t a r y . M e n t a l Hosp i t a l s, P r o v i n c e of_ B r i t i s h C o l u m b i a . Annual Re p o r t . V i c t o r i a : King's P r i n t e r . M.H.S.A.R.: Department of the P r o v i n c i a l S e c r e t a r y . M e n t a l Health S e r v i c e , Province of B r i t i s h Columbia. Annual Report. V i c t o r i a : King's Printer/Queen's P r i n t e r . M.H.S.B.A.R.: Department o f H e a l t h S e r v i c e s and H o s p i t a l Insurance. Mental Health S e r v i c e s Branch, Province of B r i t i s h Columbia. Annual Report. V i c t o r i a : Queen's P r i n t e r . 1: The meetings l a s t e d nine months and, ac c o r d i n g to Guest (1985), were c h a r a c t e r i z e d by c o n f l i c t over the gat h e r i n g of tax revenues and the d i s t r i b u t i o n of f e d e r a l grants. O n t a r i o and Quebec o b j e c t e d to the proposed f i s c a l arrangements and re f u s e d to s i g n an agreement w i t h the f e d e r a l government. In the absence of a consenus, the Conference c o l l a p s e d . 2: The s t a n d a r d s were b u i l t from a number of f u n d a m e n t a l p r i n c i p l e s . In b r i e f , t h e s e were as f o l l o w s : t h a t e v e r y h o s p i t a l s h o u l d p r o v i d e a c t i v e t r e a t m e n t and humane c a r e f o r p a t i e n t s and e d u c a t i o n and r e s e a r c h f o r i t s s t a f f . A mental h o s p i t a l s h o u l d be d i r e c t e d by an i n d e p e n d e n t p s y c h i a t r i s t . P h y s i c i a n s should c o n t r o l the p r o v i s i o n of treatment and there s h o u l d be enough p h y s i c i a n s to t r e a t e f f e c t i v e l y . A u x i l i a r y p r o f e s s i o n a l s e r v i c e s should be provided by t r a i n e d personnel. A m e n t a l h o s p i t a l s h o u l d c o n t a i n adequate f a c i l i t i e s and t e c h n i c a l s e r v i c e s . M e d i c a l r e c o r d s s h o u l d be a c c u r a t e and complete. B u i l d i n g s and equipment should be f r e e of hazards. New mental h o s p i t a l s s h o u l d be b u i l t c l o s e to p o p u l a t i o n centres. Every mental h o s p i t a l should be an i n t e g r a l part of the general system of h e a l t h care s e r v i c e s (American P s y c h i a t r i c A s s o c i a t i o n , 1951). On the b a s i s of these p r i n c i p l e s , the A.P.A. e s t a b l i s h e d s t a n d a r d s a f f e c t i n g the o r g a n i z a t i o n and o p e r a t i o n of p u b l i c mental h o s p i t a l s . The A s s o c i a t i o n ' s requirements covered a l l a s p e c t s o f h o s p i t a l o p e r a t i o n a n d i n c l u d e d ; p r o p e r p e r s o n n e l / p a t i e n t r a t i o s (e.g., one p h y s i c i a n f o r e v e r y 30 p a t i e n t s i n i n t e n s i v e treatment areas); the q u a l i f i c a t i o n s of 358 personnel; the use of v o l u n t e e r s ; and, the nature and q u a l i t y of the non-medical s e r v i c e s being provided (e.g., s o c i a l s e r v i c e s , c h a p l a i n c y , r e c r e a t i o n , and p s y c h o l o g i c a l s e r v i c e s ) (op c i t ) . 3: D i r e c t o r ' s Report, M.H.S.A.R., Repo r t , M.H.S.A.R., 1953/54: p. 23. 1950/51: p. 17. D i r e c t o r ' s 4: I b i d . 5: i d . 6: i d . 7: i d . 8: D i r e c t o r s Report, 9: I b i d . 10: D i r e c t o r s Report, 11: D i r e c t o r 's Report, 12: D.B.S., 1946 and 1946/47: P-P-15. 14. 951. The d i s c h a r g e r a t e s (per 100 p a t i e n t s i n residence) were a l s o higher. In 1945, the r a t e i n the p r o v i n c e s t o o d a t 18.2 ( n a t i o n a l a v e r a g e , 16.9) and, by 1950, t h i s had c l i m b e d t o 45.3 ( n a t i o n a l a v e r a g e , 20.2); a f i g u r e that was u n p a r a l l e l e d i n Canada. 13: M.Hosp.A.R. & M.H.S.A.R., 1945/46 - 1950/51. 14: D i r e c t o r ' s Report, M.Hosp.A.R., 1947/48: p. 10. 15: D i r e c t o r ' s R e p o r t , M.Hosp.A.R., 1945/46 D i r e c t o r ' s Report, M.Hosp.A.R., 1946/47: p. 10. 13. 16: R e p o r t o f Deputy P r o v i n c i a l S e c r e t a r y , 1949/50: p. 1. 17: R e p o r t of Deputy P r o v i n c i a l S e c r e t a r y , 1950/51: pp. 5 - 6 . 18: M.Hosp.A.R. & M.H.S.A.R., 1945/46 - 1950/51. are expressed i n cu r r e n t d o l l a r s . M.Hosp.A.R., M.H.S.A.R., The amounts 19: Reports of the Business Manager, M.Hosp.A.R., 1947/48 to 1949/50. In 1948, f o r example, the Business Manager noted that e x p e n d i t u r e s had r i s e n owing to both s a l a r y a d j u s t m e n t s and changes i n the hours of work. A l l personnel, with the exception of the female nu r s i n g s t a f f at Essondale, had been p l a c e d on an e i g h t hour day, 44 hour week, which n e c e s s i t a t e d a d d i t i o n a l o u t l a y i n s a l a r i e s . S i m i l a r l y , i n 1950, he r e p o r t e d t h a t i n c r e a s e s i n c o s t s had been, i n pa r t , due to the i n t r o d u c t i o n of cost of l i v i n g bonuses f o r s t a f f . 359 20: R e p o r t of the Deputy P r o v i n c i a l S e c r e t a r y , M.H.S.A.R., 1950/51: p. 5. 21: I b i d . The co s t s were high, i n p a r t , because the province was not ( r e l a t i v e to the r e s t of the country) s t i n g y with i t s mental h e a l t h care funds. In the l a t e 1940's and e a r l y 1950's, the per diem expenditure on a p a t i e n t i n B r i t i s h Columbia was higher than the n a t i o n a l average (Department of N a t i o n a l Health and Welfare, 1954). For example, i n 1945, when the n a t i o n a l per diem e x p e n d i t u r e s t o o d a t $1.08, the p r o v i n c e was expending $1.65. By 1950, these amounts had i n c r e a s e d to $2.23 and $3.19 r e s p e c t i v e l y . 22: i d 23: Quoted i n D i r e c t o r ' s Report, M.H.S.A.R., 1951/52: p. 24. 24: A psychopathic ward (Ward X) had been e s t a b l i s h e d i n the basement of the Vancouver General H o s p i t a l i n 1918. However, p a t i e n t s were m e r e l y r e s t r a i n e d and se n t i m m e d i a t e l y to E s s o n d a l e . D e s p i t e c o n s i d e r a b l e c r i t i c i s m , the f a c i l i t y r e m a i n e d i n use u n t i l 1945 when a s p e c i a l ward (Ward R) was opened. T h i s o p e r a t e d as a 'day h o s p i t a l ' and a l s o p r o v i d e d short-term care and e l e c t r o - s h o c k and i n s u l i n coma treatments. A s i m i l a r p s y c h i a t r i c ward was opened at the Royal J u b i l e e H o s p i t a l i n 1937, and an o b s e r v a t i o n ward was opened i n 1947 (Clark, 1947). 25: S.B.C, 1948, c. 6. 26: R e p o r t of the Deputy P r o v i n c i a l S e c r e t a r y , M.Hosp.A.R., 1950/51: p. 5. 27: I b i d . 28: D i r e c t o r ' s Report, M.Hosp.A.R., 1947/48: p. 14. 29: S.B.C, 1953, c. 26. In the main, the procedures were the same as those s e t out i n the e x i s t i n g M e n t a l H o s p i t a l s A c t S.B.C, 1940, c. 27, but p e r m i t t e d the i n v o l u n t a r y (and voluntary) admission of mental d e f e c t i v e s d i r e c t l y to Woodlands. 30: I b i d , note 26. 31: D i r e c t o r ' s Report, M.Hosp.A.R., 1949/50: p. 21. 32: D i r e c t o r ' s Report, M.H.S.A.R., 1952/53: pp. 20 - 21. 33: D i r e c t o r ' s Reports, M.Hosp.A.R., 1947/48 & 1948/49. 34: D i r e c t o r ' s Report, M.Hosp.A.R., 1947/48. 35: D i r e c t o r ' s R e p o r t , M.H.S.A.R., 1950/51. The use of lobotomies f o r the c o n t r o l of p a t i e n t s was noted and c r i t i c i z e d i n 1957 by the new C l i n i c a l D i r e c t o r , Dr. Ian Kenning. As he 360 commented at the time, . . . f o r t y e i g h t l o b o t o m i e s were done i n 1950, whereas i n 1956 only eleven were done. The l a t t e r f i g u r e probably r e p r e s e n t s the c o r r e c t number of t h o s e i n d i v i d u a l s who have c o n d i t i o n s w h i c h p a r t i c u l a r l y respond to t h i s o p e r a t i o n , whereas the 1950 f i g u r e r e p r e s e n t e d a more d e s p e r a t e s t a f f u s i n g r a d i c a l p r o c e d u r e s t o c o n t r o l c h r o n i c a l l y d i s t u r b e d people when there was l e s s i n the way of t r e a t m e n t r e s o u r c e s . L e t us not r e t u r n to t h a t former s t a t e (emphasis added). ( R e p o r t o f t h e C l i n i c a l D i r e c t o r o f T r e a t m e n t S e r v i c e s , M.H.S.A.R., 1956/57: p. 66.) 36: J.L.A., 1953: p. 3. Throne Speech, February 2nd 1953. 37: D i r e c t o r ' s Report, M.H.S.A.R., 1953/54. 38: D i r e c t o r ' s Report, M.H.S.A.R., 1950/51. 39: R e p o r t of the C l i n i c a l D i r e c t o r of T r e a t m e n t S e r v i c e s , M.H.S.A.R., 1952/53: p. 36. 40: I b i d . 41: M.Hosp.A.R. & M.H.S.A.R., 1945/46 - 1953/54. 42: Report of the P r o v i n c i a l S upervisor of P s y c h i a t r i c S o c i a l Work, M.H.S.B.A.R., 1959/60. 43: D i r e c t o r ' s Report, M.H.S.A.R., 1956/57. 44: D i r e c t o r ' s Report, M.Hosp.A.R., 1945/46. 45: D i r e c t o r ' s Report, M.H.S.A.R., 1954/55. 46: Report of the P r o v i n c i a l S u p e r v i s o r of P s y c h i a t r i c S o c i a l Work, M.H.S.B.A.R., 1959/60. 47: I b i d : p. 42. 48: Id. Report of the P r o v i n c i a l S u p e r v i s o r of P s y c h i a t r i c S o c i a l Work, M.H.S.B.A.R., 1960/61: p. 54. 49: Report of the P r o v i n c i a l S u p e r v i s o r of P s y c h i a t r i c S o c i a l Work, M.H.S.B.A.R., 1960/61: p. 49. 50: D i r e c t o r ' s Report, M.H.S.B.A.R., 1960/61: p. 10. 51: Report of the P r o v i n c i a l S u p e r v i s o r of P s y c h i a t r i c S o c i a l Work, M.H.S.B.A.R., 1961/62. 52: Report of the R e h a b i l i t a t i o n O f f i c e r , M.H.S.A.R., .1953/54: 361 p. 82. 53: D i r e c t o r ' s Report, M.H.S.B.A.R., 1961/62. 54: Report of the P r o v i n c i a l S u p e r v i s i o r of P s y c h i a t r i c S o c i a l Work, M.H.S.B.A.R., 1961/62. 55: R e p o r t of the C l i n i c a l D i r e c t o r of T r e a t m e n t S e r v i c e s , M.H.S.A.R., 1954/55. 56: R e p o r t of the C l i n i c a l D i r e c t o r of T r e a t m e n t S e r v i c e s , M.H.S.A.R., 1955/56. The c o u n c i l s gave p a t i e n t s an o p p o r t u n i t y to p a r t i c i p a t e i n the management of t h e i r environment and i t was f e l t that t h i s was an important t h e r a p e u t i c development. 57: R e p o r t of the C l i n i c a l D i r e c t o r of T r e a t m e n t S e r v i c e s , M.H.S.A.R., 1956/57 and 1957/58. 58: D i r e c t o r ' s R e p o r t , M.H.S.A.R., 1953/54: p. 4. Report of the C l i n i c a l D i r e c t o r o f T r e a t m e n t S e r v i c e s , M.H.S.A.R., 1957/58. 59: Reports of the C l i n i c a l D i r e c t o r of Treatment S e r v i c e s , M.H.S.A.R. & M.H.S.B.A.R., 1951/52 - 1959/60. 60: S.B.C., 1955, c. 48. 61: D i r e c t o r ' s Report, M.H.S.A.R., 1954/55. 62: R e p o r t of the C l i n i c a l D i r e c t o r of T r e a t m e n t S e r v i c e s , M.H.S.A.R., 1956/57: p. 231. 63: I b i d . 64: D i r e c t o r ' s Report, M.H.S.A.R., 1958/59. 65: R e p o r t of the D i r e c t o r of the M e n t a l H e a l t h C e n t r e : Burnaby, M.H.S.B.A.R., 1959/60. 66: R e p o r t of the C l i n i c a l D i r e c t o r of T r e a t m e n t S e r v i c e s , M.H.S.B.A.R, 1959/60: p. 75. 67: The f o l l o w i n g d a t a and i n f o r m a t i o n p e r t a i n i n g to the Cre a s e C l i n i c were g a r n e r e d from a r e v i e w of M.H.S.A.R. & M.H.S.B.A.R., 1950/51 to 1963/64. 68: I b i d . Amounts are expressed i n cu r r e n t d o l l a r s . 69: D i r e c t o r ' s Report, M.H.S.B.A.R., 1959/60 & 1964/65. 70: M.H.S.B.A.R., 1956/57 - 1964/65. Amounts are expressed i n cu r r e n t d o l l a r s . 362 71: R e p o r t of the D i r e c t o r of the M e n t a l H e a l t h C e n t r e : Burnaby, M.H.S.A.R., 1956/57. 72: These a d d i t i o n a l c o s t s would have to be known b e f o r e a f i r m c o n c l u s i o n c o u l d be drawn r e g a r d i n g the o v e r a l l c o s t -e f f e c t i v e n e s s of the Centre. U n f o r t u n a t e l y , no such data e x i s t . 73: Report of the Deputy P r o v i n c i a l S e c r e t a r y , M.H.S.A.R., 1954/55. 74: M.H.S.A.R. & M.H.S.B.A.R., 1951/52 - 1963/64. 75: D.B.S., 1950 to 1960. 76: M.H.S.A.R. & M.H.S.B.A.R., 1951/52 - 1963/64. 77: I b i d . Amounts are expressed i n cur r e n t d o l l a r s . 78: Data g a r n e r e d from M.H.S.A.R. & M.H.S.B. A.R. f 1951/52 -1963/64. 79: M.H.S.A.R. & M.H.S.B.A.R., 1951/52 - 1963/64. 80: . M.H.S.A.R. & M .H.S.B.A.R., 1949/50 - 1963/64. 81: D.B.S., 1950 to 1960. 82: I b i d . 83: D i r e c t o r ' s Report, M.H.S.A.R., 1954/55. 84: R e p o r t of the C l i n i c a l D i r e c t o r of T r e a t m e n t S e r v i c e s , M.H.S.B.A.R., 1959/60: p. 75. 85: D i r e c t o r ' s Report, M.H.S.A.R., 1957/58. 86: J.L.A., 1959: p. 7. Throne Speech, January 22nd, 1959. 87: The A.P.A. survey began i n November 1958 and ended i n June 1960. The surveyors were a s s i s t e d by four medical p r a c t i t i o n e r s who were appointed as ' o f f i c i a l r e p r e s e n t a t i v e s ' ; i n a d d i t i o n , the s e r v i c e s of one Canadian and 12 American c o n s u l t a n t s were used. The survey team a l s o v i s i t e d and ins p e c t e d a l l the mental h e a l t h f a c i l i t i e s and met with persons d i r e c t l y i n v o l v e d i n the d e l i v e r y of mental h e a l t h s e r v i c e s (Ross, 1961). C o n t r i b u t i o n s were r e c e i v e d from 70 d i f f e r e n t p r o v i n c i a l o r g a n i z a t i o n s , a g e n c i e s and government d e p a r t m e n t s which submitted e i t h e r b r i e f s or commentaries (op c i t ) . One of these submissions came from the B r i t i s h Columbia Medical A s s o c i a t i o n ' s 'Mental Health Committee'. This body had a l r e a d y s t u d i e d the •Tyhurst Report' - a document prepared by the C.M.H.A. - and i t had c o n s t r u c t e d a s u b m i s s i o n recommending t h a t the changes p r o p o s e d by t h e C.M.H.A. be e n d o r s e d . W i t h some m i n o r m o d i f i c a t i o n , they were to form the b a s i s of a new approach to 363 mental h e a l t h s e r v i c e s i n B r i t i s h Columbia. T h i s submission was to be p a s s e d to the p r o v i n c i a l government but i t was i n s t e a d handed to Dr. Ross ( B r i t i s h Columbia Medical A s s o c i a t i o n , 1959). 88: Ross 1 recommendations a l s o i n c l u d e d the abandonment of C o l q u i t z ; the development of e n l a r g e d f a c i l i t i e s f o r the m e n t a l l y r e t a r d e d a t T r a n q u i l l e ; and, the c o n s t r u c t i o n of a s p e c i a l f a c i l i t y f o r e m o t i o n a l l y d i s t u r b e d c h i l d r e n . These recommendations were e v e n t u a l l y c a r r i e d out. 89: See, I b i d , note 86. I t should be noted that the focus of the C.M.H.A. was p r i m a r i l y upon the needs of the mentally i l l . A n o t h e r i n t e r e s t group e x i s t e d f o r those c h i l d r e n who were deemed to be m e n t a l l y r e t a r d e d and who were r e s i d i n g i n p r o v i n c i a l ' t r a i n i n g s c h o o l s ' . The A s s o c i a t i o n f o r R e t a r d e d C h i l d r e n of B r i t i s h C olumbia (a n o n - p r o f i t s o c i e t y c o m p r i s e d p r i m a r i l y of the parents of a f f l i c t e d c h i l d r e n ) was f i r s t formed i n 1955. The A s s o c i a t i o n was a b r a n c h o f a n a t i o n a l o r g a n i z a t i o n (The N a t i o n a l A s s o c i a t i o n f o r Retarded C h i l d r e n ) and i t s i n i t i a l o b j e c t i v e was to e s t a b l i s h and operate p r i v a t e schools (funded by the p r o v i n c i a l Department of Education) i n order to both r e l i e v e the pressure on Woodlands School and to reduce the w a i t i n g l i s t f o r beds. By 1957, the A s s o c i a t i o n had expanded r a p i d l y , was r e c e i v i n g a government grant i n support of i t s a c t i v i t i e s , and was o p e r a t i n g p r i v a t e s c h o o l s f o r 300 c h i l d r e n , w i t h f i n a n c i a l s u p p o r t from the Department o f Education. Indeed, the government amended the P u b l i c Schools Act (S.B.C, 1956) i n o r d e r t o f a c i l i t a t e the A s s o c i a t i o n ' s work. By 1958, the ra n k s of the A s s o c i a t i o n had expanded c o n s i d e r a b l y and i t had e s t a b l i s h e d 32 sch o o l s which s e r v i c e d the needs of 348 c h i l d r e n . I t had a l s o persuaded the government to amend the Schools For Mental D e f e c t i v e s Act so that c h i l d r e n c o u l d be p e r i o d i c a l l y a d m i t t e d to Woodlands f o r 30 days of r e s p i t e care. The o b j e c t i v e was to allow 'care-givers' a b r i e f p e r i o d of r e s t from the s t r e s s of c a r i n g f o r a r e t a r d e d c h i l d . The l e g i s l a t i v e changes a l s o p e r m i t t e d the a d m i s s i o n of non-r e s i d e n t s to the day s c h o o l a t Woodlands. In g e n e r a l , the A s s o c i a t i o n was a s u c c e s s f u l i n t e r e s t group and when the Schools For Mental D e f e c t i v e s Act was repealed by the new Mental Health A c t , t h e l a t t e r l r T c l u d e d a r e - s t a t e m e n t o f t h e v a r i o u s amendments secured dur i n g the 1950's. 90: D i r e c t o r ' s Report, M.H.S.A.R., 1954/55. 91: D i r e c t o r ' s Report, M.H.S.A.R., 1955/56. 92: I b i d . D i r e c t o r ' s Report, M.H.S.A.R., 1956/57. 93: D i r e c t o r ' s Report, M.H.S.B.A.R., 1959/60. 94: The s e r v i c e s of o v e r 200 c o n s u l t a n t s were used and the f u l l r e p o r t , which ran to 11 volumes, consumed i n excess of $1 m i l l i o n . 364 95: Canadian Mental Health A s s o c i a t i o n (B.C. D i v i s i o n ) , Annual Report, 1953. 96: D i r e c t o r ' s Report, M.H.S.A.R., 1952/53: p. 31. 97: D i r e c t o r ' s Report, M.H.S.A.R., 1957/58. 98: D i r e c t o r ' s R e p o r t , M.H.S.A.R., 1955/56. The comments r e g a r d i n g the C.M.H.A. are based upon a r e v i e w of the a n n u a l r e p o r t s of the B.C. D i v i s i o n , 1953 - 1967. Other key d i r e c t o r s i n c l u d e d , Drs. McNair, Tyhurst, and Richman. At v a r i o u s times, the p o s i t i o n of 'Honorary P r e s i d e n t ' was held by the M i n i s t e r of Education, the P r o v i n c i a l Secretary, and the M i n i s t e r of Health S e r v i c e s and H o s p i t a l I n s u r a n c e . The c h i e f p a t r o n of the A s s o c i a t i o n has alw a y s been the L i e u t e n a n t - G o v e r n o r and i t s honorary o f f i c e r s have in c l u d e d , p r o v i n c i a l c a b i n e t m i n i s t e r s , m a g i s t r a t e s , and p r o f e s s o r s . 99: D i r e c t o r ' s Report, M.H.S.A.R., 1956/57. 100: The McNaughten r e s o l u t i o n was o r g i n a l l y compiled i n 1956, by Claude R i c h a r d s o n , M.P. However, R i c h a r d s o n s u b s e q u e n t l y l o s t h i s s e a t i n a g e n e r a l e l e c t i o n and McNaughten a g r e e d to c a r r y the C.M.H.A. banner on h i s behal f ( E d i t o r i a l , 1961). 101: The Committee a l s o e x p r e s s e d c o n c e r n r e g a r d i n g some p r a c t i c e s a f f e c t i n g h o s p i t a l i z e d p a t i e n t s and i t was suggested t h a t l e g i s l a t i o n be used to p l a c e s t r i c t l i m i t a t i o n s on, f o r example, the use of p a t i e n t s i n drug and d i e t e x p e r i m e n t s c o n d u c t e d by p h a r m a c e u t i c a l companies and p h y s i c i a n s . The Committee a l s o f e l t t h a t l e g i s l a t i o n should make p r o v i s i o n f o r the e s t a b l i s h m e n t of community mental h e a l t h c e n t r e s , day h o s p i t a l s , o u t - p a t i e n t c l i n i c s , and p s y c h i a t r i c u n i t s i n general h o s p i t a l s where ' u n w i l l i n g ' p a t i e n t s could be t r e a t e d . 102: D i r e c t o r ' s Report, M.H.S.A.R., 1956/57: p. 19. 103: R e p o r t of the C l i n i c a l D i r e c t o r of T r e a t m e n t S e r v i c e s , M.H.S.A.R., 1957/58: p. 59. 104: R e p o r t of the C l i n i c a l D i r e c t o r of T r e a t m e n t S e r v i c e s , M.H.S.A.R., 1953/54: p. 39. 105: Report of the Medical Superintendent: Essondale H o s p i t a l , M.H.S.A.R., 1956/57: p. 64. 106: Lunacy Act Amendment Act, S.B.C, 1951, c. 51. 107: Report of the Med i c a l Superintendent: Essondale H o s p i t a l , M.H.S.B.A.R., 1959/60: p. 51. 108: Report of the Medical Superintendent: Essondale H o s p i t a l , M.H.S.B.A.R., 1960/61. 365 109: The two person, medical review panel was e s t a b l i s h e d i n 1941, f o l l o w i n g the passage of the Mental H o s p i t a l s Act, S.B.C, 1940, c. 27. T h i s o c c u r r e d a t a t i m e when o v e r - c r o w d i n g was reaching a c r i s i s p o i n t and when complaints had been made that p a t i e n t s were being 'rai1-roaded' i n t o Essondale H o s p i t a l and d e t a i n e d u n n e c e s s a r i l y ( D i r e c t o r ' s R e p o r t , M.Hosp.A.R., 1940/41) . The c o n t e n t i o n t h a t the p a n e l had l i t t l e e f f e c t i s supported by the s t a t i s t i c s p e r t a i n i n g to the r a t e of discharge (per 100 p a t i e n t s 'on the books'). Between 1935 and 1939, the d i s c h a r g e r a t e r o s e from 11.7 to 16.5. I t f e l l , i n 1940, to 14.6 but rose the f o l l o w i n g year (the year i n which the review panel was introduced) to 15.9. By 1943, the discharge r a t e had r i s e n but only to the l e v e l s achieved i n 1939 (Source: D.B.S., 1957). The e s t a b l i s h m e n t of the p a n e l d i d n o t , t h e r e f o r e , r e s u l t i n a sudden r i s e i n the discharge r a t e . In a d d i t i o n , by the l a t e 1940's, few a p p e a l s were b e i n g made. In 1946, only 20 appeals were heard and, the f o l l o w i n g y e a r , the p a n e l r e v i e w e d o n l y 51 c a s e s . In 1948, 36 a p p e a l s and, i n 1952, o n l y 39 a p p e a l s were made. The p a t i e n t s who appealed were r a r e l y discharged. If they were discharged, they were r e l e a s e d 'on probation'. Although a p a t i e n t was e n t i t l e d to r e p r e s e n t a t i o n , t h i s r a r e l y occurred (J.L.A., 1947: February 17th. J.L.A., 1949: February 17th. J.L.A., 1953: February 9th). N e v e r t h e l e s s , an a p p e a l p a n e l was e s t a b l i s h e d f o r Woodlands School when, i n 1953, s p e c i a l l e g i s l a t i o n was passed g o v e r n i n g the o p e r a t i o n of the s c h o o l s f o r m e n t a l d e f e c t i v e s (Schools For Mental D e f e c t i v e s Act, S.B.C, 1953, c. 26: s. 18). 110: Despite t h e i r overwhelming endorsement of the work of the F a c u l t y of Law group, the Ross team d i d n o t i c e two omissions i n the d r a f t l e g i s l a t i o n a f f e c t i n g h o s p i t a l i z a t i o n . In Ross' view, p a t i e n t s s h o u l d be g r a n t e d the r i g h t to communicate w i t h r e s p o n s i b l e r e l a t i v e s , l e g a l c o u n s e l , the c o u r t s , and the d i r e c t o r of the mental h e a l t h s e r v i c e . In a d d i t i o n , p a t i e n t s should have "the r i g h t to humane care and treatment" and t h i s s h o u l d be g u a r a n t e e d r e g a r d l e s s of " r a c e , c r e e d or economic c o n d i t i o n " (Ross, 1961: 146). I l l : A l t h o u g h p a r t i a l g u a r d i a n s h i p might have a s s i s t e d treatment and p r o t e c t e d .patients' c i v i l r i g h t s , the r e s e a r c h e r s were unsure as to whether p a r t i a l c o n t r o l should be mandatory or p e r m i s s i v e . A mandatory requirement may have p l a c e d s t r e s s on a p a t i e n t ; p e r m i s s i v e c o n t r o l presupposed that i t was p o s s i b l e to d e t e r m i n e d e g r e e s of i n c a p a b i l i t y . At the t i m e , the l a t t e r seemed an i m p o s s i b l e task. In a d d i t i o n , p e r m i s s i v e c o n t r o l may have c r e a t e d c o n f u s i o n s i n c e no one would be sure who had power over a person's a f f a i r s , and when (Facu l t y of Law, 1959). 112: S.B.C, 1962, c. 44. The P a t i e n t s ' E s t a t e s B i l l ( B i l l 91) was introduced and passed, without debate, i n three weeks, i n March 1962 (J.L.A., 1962, March 2nd - March 29th). 366 113: D i r e c t o r ' s Report, M.H.S.B.A.R., 1962/63: p. 11. 114: S.B.C, 1963, c. 38. 115: R e p o r t of the P r o v i n c i a l S u p e r i n t e n d e n t of P s y c h i a t r i c S o c i a l Work, M.H.S.B.A.R., 1961/62. 116: The l e g i s l a t i v e d r a f t s m e n adopted the term ' i n f o r m a l a d m i s s i o n ' r a t h e r than ' v o l u n t a r y a d m i s s i o n ' and, i n k e e p i n g w i t h the Percy Royal Commission recommendations, i n t r o d u c e d the requirement that an i n f o r m a l p a t i e n t be r e l e a s e d w i t h i n 72 hours of h i s o r h e r r e q u e s t f o r d i s c h a r g e . In a d d i t i o n , t h e d e f i n i t i o n of mental i l l n e s s i n c l u d e d a r e f e r e n c e to the need f o r medical treatment; a p r o v i s o t h a t , i n the view of the Percy Commission, was n e c e s s a r y t o p r e v e n t the 'warehousing' of p a t i e n t s (Royal Commission, 1957). The d i s c r e t i o n a r y powers to r e t a i n an i n v o l u n t a r y p a t i e n t were a l s o modified, i n l i n e with the new B r i t i s h s t a t u t e , with the requirement that a p a t i e n t be re-examined (and the c e r t i f i c a t e of admission be renewed) on an annual b a s i s . The use of the England and Wales Mental Health Act, 1959 by p r o v i n c i a l d r a f t s m e n was not an i n d i c a t i o n of doubts r e g a r d i n g the C.M.H.A.'s p r o p o s a l s . The A s s o c i a t i o n o p e n l y endorsed the l e g i s l a t i o n and support was expressed i n a re p o r t compiled f o r the H a l l Royal Commission by Dr. D.G. MacKerracher. In h i s view ( e x p r e s s e d p r i o r to the r e f o r m s o f the e a r l y 1960's), the "laws g o v e r n i n g p s y c h i a t r i c c a r e i n B r i t i s h Columbia range from the obsolete to the modern" (MacKerracher, 1964: 138). The l e g i s l a t i o n helped to perpetuate "the image of the m e n t a l l y d i s o r d e r e d as b e i n g v i o l e n t p e o p l e who are "dangerous to be at l a r g e " and p e r m i t t e d the temporary d e t e n t i o n of m e n t a l l y i l l p e o p l e i n j a i l s . He argued f o r r e v i s i o n s i n l i n e w i t h the new B r i t i s h s t a t u t e . 117: J.L.A., March 4th 1964 to March 20th 1964. A debate arose at the second reading stage when the N.D.P. o p p o s i t i o n o b jected to ss. 7 and 21 of B i l l 64. These a f f e c t e d e l i g i b i l i t y f o r and a c c e s s i b i l i t y to, mental h e a l t h f a c i l i t i e s . The House d i v i d e d i n favour of the government. The B i l l was read a t h i r d time on March 19th and passed. I t r e c e i v e d Royal Assent the f o l l o w i n g day. The N.D.P. argued t h a t the p r o p o s e d A c t e n a b l e d the government t o a b r o g a t e i t s r e s p o n s i b l i t y to p r o v i d e m e n t a l h e a l t h s e r v i c e s and th a t i t might w e l l pass the r e s p o n s i b i l i t y to the m u n i c i p a l i t i e s . T h i s p o s s i b i l i t y was a l a r m i n g , i n p a r t i c u l a r , to the C i t y of Vancouver. The O p p o s i t i o n c l a i m e d that the s o - c a l l e d ' d e c e n t r a l i z a t i o n ' plan, and the p r o v i s i o n s which enabled the government to u t i l i z e the s e r v i c e s of p r i v a t e s o c i e t i e s , i n f a c t c o n s t i t u t e d an abandonment of mental h e a l t h s e r v i c e s . The B i l l made no p r o v i s i o n f o r the funding of t h i s new a p p r o a c h and t h i s was a s e r i o u s f l a w . S e c t i o n 21 of the pr o p o s e d A c t , which g r a n t e d the d i r e c t o r s of f a c i l i t i e s the d i s c r e t i o n to admit p a t i e n t s , could be used to deny access to 367 h o s p i t a l s , and t h e r e f o r e undermined the c i t i z e n ' s r i g h t to r e c e i v e treatment. The government assured the O p p o s i t i o n that s e r v i c e s would be funded, but t h a t i t was a w a i t i n g the r e s u l t s of the Royal Commission on H e a l t h S e r v i c e s . I t was a n t i c i p a t e d t h a t the n e c e s s a r y f i s c a l framework would appear t h r o u g h f e d e r a l -p r o v i n c i a l c o s t - s h a r i n g agreements, and t h i s e v e n t u a l l y came to f r u i t i o n . (See, Vancouver Sun, March 5th 1964 to March 19th 1964) . 118: The Mental Health Act S.B.C, 1964, c. 29 was proclaim e d i n f o r c e on A p r i l 1 s t , 1965. The Act r e p e a l e d a l l e x i s t i n g s t a t u t e s a f f e c t i n g mental h e a l t h matters; namely, the C l i n i c s of P s y c h o l o g i c a l M e d i c i n e A c t , the M e n t a l Hospi t a l s A c t , the P r o v i n c i a l C h i l d Guidance C l i n i c s A c t , the P r o v i n c i a l M e n t a l Health Centres Act, and the Schools f o r M e n t a l l y D e f e c t i v e s Act. The reasons f o r the delay i n pr o c l a m a t i o n were set out by the D i r e c t o r of the M e n t a l H e a l t h S e r v i c e s Branch - Dr. A.E. Dav i d s o n - i n h i s Annual R e p o r t f o r f i s c a l 1964/65. See, M.H.S.B.A.R., 1964/65. 119: M.H.S.B.A.R., 1963/64: p. 9. 120: M.H.S.B.A.R., 1965/66: p. G.10. 121: M.H.S.B.A.R., 1965/66: pp. G.54 & G.56. 122: M.H.S.B.A.R., 1964/65: p. 47. 123: The a v a i l a b i l i t y of drugs such as c h l o r p r o m a z i n e a l s o enabled the p r o v i s i o n of treatment other than i n i n s t i t u t i o n s , and t h i s f a c i l i t a t e d the use of community a l t e r n a t i v e s . 368 CHAPTER 6 THE RISE OF THE 'NEW LEGALISM' I; INTRODUCTION The p e r i o d of mental h e a l t h law reform c h a r a c t e r i z e d by the 'new l e g a l i s m ' has emerged i n c o n j u n c t i o n with a s h i f t i n t h e s t a t e s t r a t e g y f o r t h e management o f t h e m e n t a l l y d i s o r d e r e d . T h i s has been p r o p e l l e d by p r o b l e m s and changes which have a f f e c t e d one of the s t a t e ' s c a r d i n a l f u n c t i o n s ; namely, r e p r o d u c i n g the c o n d i t i o n s n e c e s s a r y f o r c o n t i n u e d c a p i t a l a c c u m u l a t i o n . I n c r e a s i n g e x p e n d i t u r e s on the h e a l t h care component of the w e l f a r e s t a t e became a cause f o r concern i n the l a t e 1960's and c o s t - s t a b i l i z a t i o n measures were introduced by the f e d e r a l government. By the mid-1970's and i n response to both domestic economic problems and i n t e r n a t i o n a l developments, Ottawa adopted a p o l i c y of monetary gradualism and c o n s e q u e n t l y began to a d j u s t the K e y n e s i a n economic p o l i c i e s upon which the w e l f a r e s t a t e had been b u i l t . These changes had an impact i n the p r o v i n c e s where corresponding h e a l t h care c o s t -s t a b i l i z a t i o n p o l i c i e s were introduced. The p o l i c i e s were s u f -f i c i e n t u n t i l the e a r l y 1980's when f u r t h e r r e s t r a i n t measures were introduced as a consequence of an economic r e c e s s i o n and the adoption of elements of a monetarist economic p o l i c y . A l t h o u g h e f f o r t s were made t o p r e s e r v e the system of h e a l t h care, the economic problems and changes had an impact, p a r t i c u l a r l y on the p r o v i s i o n of c a r e and t r e a t m e n t i n hosp-i t a l s . In an e f f o r t to, f i r s t l y , s t a b i l i z e and then r e s t r a i n expenditures, steps were taken to reduce the u t i l i z a t i o n of a l l 369 h o s p i t a l s . The mental h e a l t h area was a f f e c t e d and the process of d e - i n s t i t u t i o n a l i z a t i o n , which had been underway s i n c e the mid-1950's, a c c e l e r a t e d with a view to c l o s i n g mental h o s p i t a l s . In a d d i t i o n , a t a c t i c of ' n o n - i n s t i t u t i o n a l i z a t i o n ' was adopted and p r i v a t e s e c t o r involvement i n the p r o v i s i o n of a l t e r n a t i v e resources and f a c i l i t i e s (a t a c t i c i n i t i a t e d i n the 1960's) was enhanced. While the s h i f t i n s t r a t e g y has been r e q u i r e d i n order to complement f e d e r a l and p r o v i n c i a l measures aimed at reproducing the c o n d i t i o n s n e c e s s a r y f o r c a p i t a l a c c u m u l a t i o n , i t has r e q u i r e d c a r e f u l j u s t i f i c a t i o n . The h e a l t h care component of the w e l f a r e s t a t e ( i n c l u d i n g , the mental h e a l t h area) i s hallowed and p o l i t i c a l l y s e n s i t i v e ground and governments are aware of the l e g i t i m a t i o n p r o b l e m s which c o u l d a r i s e as a consequence of any i n t e r f e r e n c e . In o r d e r to r e s o l v e the competing imperatives, p r o v i n c i a l governments have introduced a new l e g a l framework ( i . e . , the new l e g a l i s m ) g o v e r n i n g the p r o v i s i o n o f m e n t a l h e a l t h s e r v i c e s t h a t i s i n h e r e n t l y j u s t i f i a b l e and which s i m u l t a n e o u s l y l e g i t i m a t e s and f a c i l i t a t e s the s h i f t i n s t r a t e g y . In t h i s regard, the s t a t e has embraced the reforms sought by an autonomous, d i s o r g a n i z e d , and l o o s e l y bonded i n t e r e s t group; namely, the p a t i e n t s ' r i g h t s movement. The c h a p t e r b e g i n s w i t h a d e s c r i p t i o n of the p r o b l e m s a s s o c i a t e d w i t h expenditures on the h e a l t h care component of the w e l f a r e s t a t e and the f e d e r a l government's response. This i s f o l l o w e d by an e x a m i n a t i o n of the a d j u s t m e n t i n K e y n e s i a n 370 economic p o l i c i e s , the i n t r o d u c t i o n of elements of a monetarist s t r a t e g y , and the impact upon the Canadian w e l f a r e s t a t e . The n a t i o n a l trends i n the p r o v i s i o n and funding of mental h e a l t h s e r v i c e s s i n c e the l a t e 1960's are then r e v i e w e d i n o r d e r to i l l u s t r a t e both the impact of the economic changes upon the state's s t r a t e g y f o r the management of the mentally d i s o r d e r e d and the problems which have emerged. The impact of the economic problems and changes, and the state's use of the law to l e g i t i m a t e and f a c i l i t a t e i t s mental he a l t h s t r a t e g y , are then assessed through a d e t a i l e d a n a l y s i s of developments i n one province; namely, B r i t i s h Columbia. T h i s i n v o l v e s an e x a m i n a t i o n of the s t e p s taken to implement the s t r a t e g y recommended by the Ross Repo r t i n the 1960's, the economic d i f f i c u l t i e s c onfronted by the s t a t e , the response to t h e s e p r o b l e m s and the impact of t h i s r e s p o n s e upon the p r o v i s i o n o f h e a l t h c a r e ( p a r t i c u l a r l y , m e n t a l h e a l t h s e r v i c e s ) , the i n i t i a l emergence of the new l e g a l i s m , and, f i n a l l y , the use of law reform as a mechanism f o r l e g i t i m a t i n g and f a c i l i t a t i n g s t a t e mental h e a l t h p o l i c i e s . A t t e n t i o n i s then f o c u s s e d upon the emergence of the p a t i e n t s ' r i g h t s movement (the p r i n c i p a l proponent of the new l e g a l i s m ) and an a n a l y s i s of the f o l l o w i n g : the c o m p o s i t i o n , i d e o l o g i c a l f o u n d a t i o n s , and o b j e c t i v e s of the movement; the i n i t i a l c o n f l i c t with organized p s y c h i a t r y and the compromise subsequently sought by the l a t t e r i n the face of s t a t e economic r e s t r a i n t p o l i c i e s ; the problems which have a r i s e n f o r the s t a t e ( n o t a b l y , a p p e a s i n g o r g a n i z e d p s y c h i a t r y i n o r d e r to a v o i d a 3 71 l e g i t i m a t i o n p r o b l e m and c u r b i n g the a c t i v i t i e s of p a t i e n t s ' r i g h t s advocates); and, f i n a l l y , the state's r e a c t i o n to these problems. T h i s i n c l u d e s a d e t a i l e d a n a l y s i s of the r i s e of the p a t i e n t s ' r i g h t s movement i n B r i t i s h C o l u m b i a , the s t a t e ' s response to i t s a c t i v i t i e s , and, the e s t a b l i s h m e n t of a form of new l e g a l i s m that complements a new p r o v i n c i a l s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d , w h i l e s i m u l t a n e o u s l y appeasing organized p s y c h i a t r y and c o n t r o l l i n g p a t i e n t s ' r i g h t s advocates. The chapter concludes w i t h an e x p l a n a t i o n f o r t h i s p e r i o d of law reform. I I ; ECONOMIC PROBLEMS, THE ATTACK ON THE WELFARE STATE, AND THE IMPACT UPON THE STRATEGY FOR THE MANAGEMENT OF THE MENTALLY DISORDERED The p e r i o d of mental h e a l t h law reform that began i n the 1970's (i.e., the era of the 'new legalism') c o i n c i d e d with two developments which a f f e c t e d the p r o v i n c i a l s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d . F i r s t l y , by the l a t e 1960's, the c o s t of the e n t i r e h e a l t h c a r e component of the w e l f a r e s t a t e became a cause f o r c o n c e r n and the f e d e r a l government i n i t i a t e d i n q u i r i e s aimed at i d e n t i f y i n g l e s s c o s t l y a l t e r n a t i v e s t o , i n p a r t i c u l a r , h o s p i t a l c a r e and t r e a t m e n t . Secondly, by the mid-1970's, d i f f i c u l t i e s began to emerge with the dominant Keynesian economic s t r a t e g y and adjustments were made by both the f e d e r a l and p r o v i n c i a l l e v e l s of the s t a t e i n order to assure the r e p r o d u c t i o n of the c o n d i t i o n s necessary f o r continued c a p i t a l accumulation. The l a t t e r had (and continues t o have) p a r t i c u l a r r a m i f i c a t i o n s f o r the e n t i r e Canadian w e l f a r e s t a t e . 372 The r e l e a s e of the f i n d i n g s and recommendations of the H a l l R o y a l Commission on h e a l t h c a r e i n 1964 was vie w e d as a moment of triumph f o r proponents of the Canadian welfa r e s t a t e (Guest, 1985). The Commission proposed the i n t r o d u c t i o n of a comprehensive, u n i v e r s a l , 'medicare' system a d m i n i s t e r e d and funded through f e d e r a l - p r o v i n c i a l c o s t - s h a r i n g agreements, and i t was estimated that Canada could w e l l a f f o r d such a system. The economic p r o j e c t i o n s prepared f o r the Commission i n d i c a t e d that, as a p r o p o r t i o n of gross n a t i o n a l expenditure, the scheme would only i n c r e a s e h e a l t h care c o s t s by approximately one h a l f of a p e r c e n t a g e p o i n t ( i . e . , f r o m 5.5% t o 6.1%) ( R o y a l Commission, 1964) and. that the expanding economy could e a s i l y a b s o r b the c o s t s . The scheme would not a f f e c t a d v e r s e l y the " r e q u i r e m e n t s of the Canadian p e o p l e f o r o t h e r goods and s e r v i c e s to b u i l d a s t r o n g e r economy and a c h i e v e a h i g h e r s t a n d a r d of l i v i n g " (op c i t : 85). Indeed, the growth of a stronger economy might w e l l be f a c i l i t a t e d s i n c e medicare would improve the h e a l t h of the n a t i o n . A u n i v e r s a l , comprehensive h e a l t h programme would cre a t e employment, generate a l a r g e and prod u c t i v e labour f o r c e , ensure the h e a l t h of f u t u r e generations of workers, ensure the p r o d u c t i v i t y of the f a m i l y (by c a r i n g f o r s i c k p e r s o n s ) , and p r e v e n t the l o s s of p r o d u c t i v i t y amongst workers due to s i c k leave (op c i t ) . The f e d e r a l L i b e r a l government embraced the Commission's recommendations and, i n 1966, Parliament passed the Medical Care Act. P r o v i s i o n was made f o r the f e d e r a l government to pay 50% of the c o s t s of medicare to each province and a l l the provinc e s 373 s u b s e q u e n t l y s i g n e d c o s t - s h a r i n g agreements (Guest, 1985). Medicare became an i n t e g r a l part of the Canadian w e l f a r e s t a t e but, by the end of the 1960's, the r i s i n g c o s t s of h e a l t h care had become a cause f o r c o n c e r n i n Ottawa. The economic p r o j e c t i o n s prepared f o r the H a l l Royal Commission had proved to be i n a c c u r a t e and, i n 1968, the f e d e r a l government e s t a b l i s h e d a f e d e r a l - p r o v i n c i a l Task F o r c e to r e v i e w the c o s t s of h e a l t h s e r v i c e s and make recommendations t h a t would c o n t a i n the i n c r e a s i n g expenditures. The Task Force examined the components of the h e a l t h care system and a f i n a l comprehensive r e p o r t was r e l e a s e d i n 1970. An economic a n a l y s i s i n d i c a t e d t h a t the p r o p o r t i o n of the n a t i o n ' s r e s o u r c e s a l l o c a t e d to h e a l t h s e r v i c e s was growi n g r a p i d l y and th a t the "remorseless e s c a l a t i o n of cost s " could not continue (Task Force Report, 1970: 7). Expenditures had r i s e n to 6.6% of the gross n a t i o n a l product, w i t h h o s p i t a l care cons-uming a l a r g e and growing p r o p o r t i o n of the t o t a l expenditure (55%), and they were i n c r e a s i n g almost 50% f a s t e r than the gross n a t i o n a l product.. The f e d e r a l government was bearing the brunt of the i n c r e a s e s and i t f a c e d t h r e e a l t e r n a t i v e s ; namely, to redu c e the s t a n d a r d s of h e a l t h c a r e , i n c r e a s e t a x e s and premiums, or r e s t r a i n the growth of c o s t i n c r e a s e s "through b e t t e r o p e r a t i o n of the h e a l t h s e r v i c e s t r u c t u r e " (op c i t : 1). The l a s t of these options was favoured and the Task Force made 384 recommendations designed to improve the c o s t - e f f e c t i v e n e s s of the e x i s t i n g system. 374 G e n e r a l l y , the i n v e s t i g a t o r s found that the h e a l t h care system c o u l d be r a t i o n a l i z e d and t h a t economies c o u l d be achieved without reducing the q u a l i t y of s e r v i c e ; f o r example, expensive acute treatment h o s p i t a l beds were being mis-used and the demand could be reduced by e s t a b l i s h i n g community h e a l t h c e n t r e s . In a d d i t i o n , the Task Force favoured the i n t r o d u c t i o n of p r e v e n t i v e and e d u c a t i o n a l measures that would slow down the u t i l i z a t i o n of h o s p i t a l s . In the mental h e a l t h context, i t was argued that c e n t r a l i z e d p s y c h i a t r i c f a c i l i t i e s were untenable and had to be 'dispersed' and that community-based options had to be developed to r e p l a c e i n - p a t i e n t beds. Indeed, i n view of the f a c t that more than o n e - t h i r d of the t o t a l p a t i e n t days of h o s p i t a l care are provided by mental h o s p i t a l s and p s y c h i a t r i c u n i t s i n g e n e r a l h o s p i t a l s , and s i n c e approximately 20 per cent of h o s p i t a l expenditures are i n t h i s area, there i s no question about the need f o r a more a c t i v e r o l e by the o f f i c i a l l o c a l h e a l t h agency i n the p r o v i s i o n of p r e v e n t i v e and community mental h e a l t h s e r v i c e s (op c i t : 374 - 375). Despite a shortage of mental h e a l t h p r o f e s s i o n a l s i t was thought t h a t e x i s t i n g p e r s o n n e l c o u l d be used more e f f e c t i v e l y , t h a t mental h e a l t h s e r v i c e s could develop more adequate community resources f o r the p r e v e n t i o n , e a r l y d i a g n o s i s and r e h a b i l i t a t i o n of the mentally i l l , and that community mental h e a l t h c l i n i c s could be e s t a b l i s h e d i n a l l p u b l i c h e a l t h c e n t r e s . These would be supported by acute, i n t e n s i v e p s y c h i a t r i c care beds i n gen-e r a l h o s p i t a l s , the e a r l y use of which would prevent c h r o n i c i t y . The Task F o r c e r e p o r t s p u r r e d the development of c o s t -containment measures aimed, i n p a r t i c u l a r , at the u t i l i z a t i o n of a l l h o s p i t a l s . Indeed, by 1973, the f e d e r a l Department of 3 75 Health and Welfare had commissioned and r e c e i v e d the s o - c a l l e d 'Hastings Report' on community h e a l t h c e n t r e s . The r e p o r t was seen as a "major m a n i f e s t a t i o n of the...high p i t c h of c o n c e r n about the c o s t s and the adequacy of h e a l t h and ' p e r s o n a l ' s e r v i c e s " (Freeman, 1973: 3) and the p r i n c i p a l author - Dr. John H a s t i n g s - was i n f a v o u r of e s t a b l i s h i n g community h e a l t h centres (Hastings, 1972). The cen t r e s would be m u l t i - s e r v i c e , i n t e r - d i s c i p l i n a r y , and semi-autonomous u n i t s p r o v i d i n g h e a l t h care f o r a l l types of p a t i e n t s , i n c l u d i n g those s u f f e r i n g from mental i l l n e s s . They would be the means whereby the p r e s s i n g problems c r e a t e d by the high c o s t s of h e a l t h care ( p a r t i c u l a r l y , a c u t e h o s p i t a l c a r e ) c o u l d be r e s o l v e d , a t the same t i m e i m p r o v i n g b o t h a c c e s s i b i l i t y t o , and the q u a l i t y o f , h e a l t h s e r v i c e s . 1 O t h e r measures were i n t r o d u c e d i n the wake of the Task F o r c e r e p o r t on h e a l t h c a r e c o s t s . By the mid-1970's, the f e d e r a l government had s t a r t e d to r e - n e g o t i a t e the f e d e r a l -p r o v i n c i a l c o s t - s h a r i n g agreements which were signed f o l l o w i n g the passage of the Med i c a l Care Act. T h i s was s t i m u l a t e d by the c o n t i n u i n g c o n c e r n s u r r o u n d i n g r i s i n g e x p e n d i t u r e s , and the f e d e r a l government was attempting to " r e s t r a i n s o c i a l spending g e n e r a l l y and the c o s t s of medicare i n p a r t i c u l a r " (Guest, 1985: 225). The government sought to abandon the e x i s t i n g 50/50 f u n d i n g arrangement and s h i f t to b l o c k g r a n t f u n d i n g , w i t h i n c r e a s e s pegged to the gross n a t i o n a l product, s i n c e t h i s would keep f e d e r a l funding l e v e l s w i t h i n manageable l i m i t s . Despite o b j e c t i o n s from the pro v i n c e s , by 1977, the new 376 funding arrangements had been introduced w i t h the passage of the F e d e r a l - P r o v i n c i a l F i s c a l A rrangements and E s t a b l i s h e d P r o g - rammes Finan c i n g Act. As Guest (1985) p o i n t s out, t h i s proved to be a t i m e l y move on the part of the f e d e r a l government f o r , by 1981, the n a t i o n a l economy had e n t e r e d a s t e e p r e c e s s i o n . S i n c e , by v i r t u e of the new agreement, f e d e r a l funds were s e n s i t i v e to f l u c t u a t i o n s i n the business c y c l e , f e d e r a l cont-r i b u t i o n s d e c l i n e d . The p r o v i n c e s responded by c l a i m i n g that Ottawa was reducing i t s commitment to medicare and the e a r l y 1980's was c h a r a c t e r i z e d by c o n f l i c t between the f e d e r a l and p r o v i n c i a l l e v e l s of the s t a t e (op c i t ) . The f e d e r a l response was to s t r i k e yet another commission of i n q u i r y c o n s i s t i n g of the doyen of C a n adian h e a l t h c a r e c o m m i s s i o n s , Mr. J u s t i c e Emmett H a l l . H a l l was asked to d e t e r m i n e the e x t e n t to which the o r i g i n a l p r i n c i p l e s of the m e d i c a r e system were b e i n g m a i n t a i n e d s i n c e t h e r e was a s u s p i c i o n that some p h y s i c i a n s were engaged i n the process of e x t r a - b i l l i n g . It was a l s o a l l e g e d that, in order to maintain funding l e v e l s , some pr o v i n c e s had introduced h o s p i t a l u s e r - f e e s and h e a l t h c a r e premiums (Guest, 1985). H a l l s u b s e q u e n t l y undertook a n a t i o n a l i n q u i r y and, i n J u l y 1980, he submitted h i s r e p o r t to the f e d e r a l L i b e r a l government. The i n q u i r y confirmed the e x i s t e n c e of both a nationwide demand f o r the p r e s e r v a t i o n of medicare and a widespread d e s i r e that v a r i o u s problems and i n e q u i t i e s be remedied ( H a l l , 1980). Consequently, H a l l produced a number of recommendations that, i n 377 h i s view, would preserve the f a b r i c of medicare; these i n c l u d e d , o u t l a w i n g e x t r a - b i l l i n g by p h y s i c i a n s and the a b o l i t i o n o f h o s p i t a l c h a r g e s and m e d i c a l c a r e premiums (op c i t ) . These recommendations were endorsed by the f e d e r a l government and, by 1984, a p p r o p r i a t e measures had been i n t r o d u c e d t h r o u g h the medium of the Canada Health Act (Guest, 1985). The p u r p o s e o f t h e s t a t u t e was t o " r e - a s s e r t t h e p r i n c i p l e s of medicare and set f o r t h the c o n d i t i o n s to be met by the p r o v i n c e s f o r f u l l payment of f e d e r a l money f o r h e a l t h care i n c l u d i n g the f i n a n c i a l p e n a l t i e s that would be i n c u r r e d i f the Ac t were c o n t r a v e n e d " (op c i t : 227-228). The Act r e - a s s e r t e d the o r i g i n a l p r i n c i p l e s of the m e d i c a r e scheme ( i . e . , p u b l i c a d m i n i s t r a t i o n , comprehensiveness, u n i v e r s a l i t y , p o r t a b i l i t y and a c c e s s i b i l i t y ) and a f f i r m e d the f e d e r a l government's "enabling and s t a n d a r d - s e t t i n g r o l e " (op c i t ) . As Guest p o i n t s out, the H a l l Report was submitted to a L i b e r a l government t h a t was f a c i n g c o n s i d e r a b l e economic d i f f i c u l t y and the Act was introduced " i n a time of s t r i n g e n t economic r e s t r a i n t " (op c i t : 229). I t p u b l i c l y r e - a f f i r m e d the f e d e r a l government's commitment to me d i c a r e (a scheme many people regard as a 'right') but c o n s t i t u t e d a " r e l a t i v e l y c o s t -f r e e piece of l e g i s l a t i o n from the f e d e r a l p o i n t of view" (op c i t ) . I n s t e a d , t h e f i n a n c i a l b u r d e n was p a s s e d t o t h e pro v i n c e s . Indeed, the Canada Health Act was introduced without f u l l p r o v i n c i a l a p p r o v a l and s e v e r a l p r o v i n c e s (e.g., B r i t i s h Columbia) i n i t i a l l y d e c l i n e d to abide by i t s p r o v i s i o n s (Gold, et a l , 1986). 2 378 The developments a f f e c t i n g the h e a l t h care component of the w e l f a r e s t a t e c o i n c i d e d with an adjustment i n the dominant economic s t r a t e g y and, f o r some a n a l y s t s , these two events are i n t e r - r e l a t e d (Gold, e t a l , 1986; Guest, 1985). The changes have had an impact upon the e n t i r e Canadian w e l f a r e s t a t e a l t h o u g h , i n the wake of the H a l l R e p o r t , the f e d e r a l and p r o v i n c i a l governments "have been a s t u t e i n r e a l i z i n g t h a t medicare has a strong p o l i t i c a l support from the p u b l i c " , and have taken care to demonstrate support f o r the scheme (Gold, et a l , 1986: 1118). Adjustments i n the Keynesian Econom i c S trategy and the Impact Upon the Welfare State D e s p i t e s e v e r a l s e t - b a c k s a r i s i n g from d o m e s t i c and i n t e r n a t i o n a l p o l i t i c a l and economic e v e n t s , a K e y n e s i a n economic s t r a t e g y was f i r m l y e s t a b l i s h e d i n Canada by the 1970's. The s t r a t e g y provided the economic i n f r a s t r u c t u r e upon which the Canadian w e l f a r e s t a t e was b u i l t (Wolfe, 1984), and K e y n e s i a n a s s u m p t i o n s and p r i n c i p l e s d o m i n a t e d the economic a n a l y s i s prepared f o r the H a l l Royal Commission i n the 1960's ( R o y a l C o m m i s s i o n , 1964). However, by 1975, and as a consequence of both i n t e r n a t i o n a l economic developments and the poor performance of the domestic economy ( T a r s h i s , 1984), the f e d e r a l government began to d i s p l a y a "growing s k e p t i c i s m about the e f f i c a c y of K e y n e s i a n p o l i c i e s " ( Wolfe, 1984: 70). The economy appeared to be d e t e r i o r a t i n g and t h i s was due to a combination of events; notably, an i n t e r n a t i o n a l commodities p r i c e boom which t r i g g e r e d a general, i n t e r n a t i o n a l r e c e s s i o n ; 379 i n c r e a s i n g u n i o n wage demands; a d e t e r i o r a t i n g b a l a n c e of i n t e r n a t i o n a l payments; and, the emergence of a r e c o r d balance of payments d e f i c i t of $4,757 b i l l i o n (op c i t ) . The f i r s t i n d i c a t i o n s of an a d j u s t m e n t of K e y n e s i a n p o l i c i e s came i n the f e d e r a l budgets of 1975 and 1976 (Crane, 1981; C a l v e r t , 1984; Wolfe, 1984). F i s c a l s t i m u l a t i o n designed to s u s t a i n l e v e l s of employment and income had i n t e n s i f i e d , r a t h e r than c o n t r o l l e d , the i n f l a t i o n a r y s p i r a l and the balance of payments s i t u a t i o n had worsened. Consequently, the f e d e r a l government switched to a l t e r n a t i v e s ; notably, the monetarist s t r a t e g y of c o n t r o l l i n g i n f l a t i o n by d e c r e a s i n g the r a t e of growth of the money s u p p l y (op c i t ) . I n f l a t i o n became the primary t a r g e t of s t a t e economic policy-makers and, by the F a l l of 1975, the government had introduced a s p e c i f i c a n t i - i n f l a t i o n programme. T h i s i n v o l v e d four, i n t e r l o c k i n g measures; namely, f i s c a l and monetary p o l i c i e s to reduce the r a t e of i n f l a t i o n ; government expenditure r e s t r a i n t aimed at k e e p i n g the r a t e of i n c r e a s e i n government s p e n d i n g t o l e s s than t h a t of ( g r o s s n a t i o n a l expenditure); s t r u c t u r a l p o l i c i e s to deal with the supply of energy, food, and housing; and, a p r i c e s and incomes p o l i c y that e s t a b l i s h e d g u i d e l i n e s f o r determining wage and p r i c e i n c r e a s e s (Wolfe, 1984: 72). The t a c t i c of r e s t r a i n i n g government expenditure was to apply to a l l l e v e l s of the s t a t e - f e d e r a l and p r o v i n c i a l - and t o t a l spending by a l l governments was to be pegged to trends i n the g r o s s n a t i o n a l p r o d u c t . In Wolfe's view, the s e d e v e l o p m e n t s s i g n a l l e d the demise of Keynesian p o l i c i e s and the adoption of a new s t r a t e g y of 'monetary gradualism' (op c i t ) . The a n t i - i n f l a t i o n programme achieved mixed r e s u l t s and 380 some a n a l y s t s have suggested that monetary gradualism may w e l l have i n c r e a s e d the s e v e r i t y of the r e c e s s i o n i n the e a r l y 19,80's (Wolfe, 1984; C a l v e r t , 1984). Nevertheless, i t i s apparent that elements of a monetarist economic p o l i c y have been and are being i n t r o d u c e d , t h a t the K e y n e s i a n s t r a t e g y has been a d j u s t e d a c c o r d i n g l y , and that t h i s process i s , i n part, due to a g l o b a l r e - s t r u c t u r i n g of the i n t e r n a t i o n a l c a p i t a l i s t economy (op c i t ) . M o n e t a r i s t p o l i c i e s , along with the c l o s e l y a l l i e d 'supply-side' s t r a t e g y , have been adopted by c o n s e r v a t i v e governments i n B r i t a i n and the United S t a t e s and, by v i r t u e of i t s involvement i n the i n t e r n a t i o n a l economic system, Canada's o p t i o n s are l i m i t e d (Crane, 1981; C a l v e r t , 1984). C e r t a i n l y , e f f o r t s have been made to s o f t e n the impact of monetarist p o l i c i e s i n Canada (Crane, 1981). For example, on resuming power i n 1980, the f e d e r a l L i b e r a l government sought to f a s h i o n a new economic s t r a t e g y t h a t i n c o r p o r a t e d monetary g r a d u a l i s m and K e y n e s i a n i n t e r v e n t i o n i s m i n the i n d u s t r i a l s e c t o r (e.g., the N a t i o n a l Energy Programme of 1980) (Wolfe, 1984). However, t h i s was thwarted by the i n t e r n a t i o n a l r e c e s s -ion of 1982 ( p a r t i c u l a r l y , the f a l l i n energy p r i c e s ) , and the f e d e r a l C o n s e r v a t i v e government i s both e r o d i n g the L i b e r a l compromise and d e m o n s t r a t i n g an i n t e r e s t i n and a g r a d u a l commitment to, key monetarist t a c t i c s ; notably, reducing p u b l i c s e c t o r expenditure, tax r e d u c t i o n s , and p r i v a t i z a t i o n ( C a l v e r t , 1984; Walker, 1988). A l t h o u g h they have no c o n t r o l o v e r the money s u p p l y , 381 elements of a monetarist s t r a t e g y have a l s o been adopted by ,the m a j o r i t y of p r o v i n c i a l governments ( C a l v e r t , 1984). B r i t i s h C o l u m b i a has p r o v e d to be an exemplar and, s i n c e the e a r l y 1980's, f e d e r a l economic p o l i c i e s have borne a " s t r i k i n g r e s e m b l a n c e to those of the B r i t i s h C olumbia S o c i a l C r e d i t government" ( A l l e n & R o s e n b l u t h , 1986: 142). Indeed, some a u t h o r s have s u g g e s t e d t h a t the p r o v i n c e has been a p r o v i n g -ground f o r a new economic s t r a t e g y ( C a l v e r t , 1984). F o l l o w i n g i t s r e - e l e c t i o n i n 1983, the p r o v i n c i a l S o c i a l C r e d i t government embarked upon a programme of 'economic renewal' designed to both r e s o l v e the deep and widening r e c e s s i o n and b r i n g the p r o v i n c i a l economy i n l i n e with the changes that had a f f e c t e d the s t r u c t u r e of the i n t e r n a t i o n a l economic system ( A l l e n & Rosenbluth, 1986). This programme i n v o l v e d the adoption of a number of monetarist p r i n c i p l e s . On the b a s i s of a b e l i e f i n the v i r t u e s of both 'minimal government' and the need to e r a s e the budget d e f i c i t , S o c i a l C r e d i t policy-makers sought to reduce government spending and l i m i t i n v o l v e m e n t i n the management of the economy. De-r e g u l a t i o n would remove government from the 'backs of business' and permit both the p r i n c i p l e s of f r e e e n t e r p r i s e and the f o r c e s of the f r e e market to engineer an economic recovery. However, these goals were not to a f f e c t the d i s t r i b u t i o n of government f i n a n c i a l a i d to the p r i v a t e s e c t o r or the development of mega-p r o j e c t s which would s t i m u l a t e economic growth and p r o v i d e employment. Indeed, money was d i v e r t e d i n t o these e n t e r p r i s e s (op c i t ) . 382 The money was to be g e n e r a t e d by r e d u c i n g government expenditures on the 'non-productive' p u b l i c s e c t o r . The l a t t e r was to be 'down-sized', and v a r i o u s s e r v i c e s and p ublicly-owned e n t e r p r i s e s were to be ' p r i v a t i z e d ' . Reducing the s i z e of the p u b l i c s e c t o r would a l s o r e s u l t i n a r e d u c t i o n i n the state's c a p a c i t y to r e g u l a t e v a r i o u s aspects of the economy. The labour market was s i n g l e d out f o r s p e c i a l a t t e n t i o n and, t h r o u g h a s e r i e s of i n t e r l o c k i n g measures, the p r o v i n c i a l government sought to both r e d u c e r e a l wages and weaken the power of the l a b o u r u n i o n s (op c i t ) . T h i s a c t i v i t y was b o o s t e d by i d e o -l o g i c a l preconceptions; namely, t h a t government a c t i v i t y i s w a s t e f u l , t h a t o n l y p r i v a t e e n t e r p r i s e -produces ' r e a l ' o u t p u t and employment, and t h a t r e g u l a t i o n of business i s both u n d e s i r a b l e and unworkable (op c i t : 150). These views underpin both the f e d e r a l government's adjustment i n economic s t r a t e g y and the monetarist p o l i c i e s which have emerged i n other c o u n t r i e s (op c i t ) . The g r a d u a l i n t r o d u c t i o n of m o n e t a r i s t p o l i c i e s and t a c t i c s has had an impact upon both the f e d e r a l and p r o v i n c i a l l e v e l s of the Canadian w e l f a r e s t a t e . As both T a r s h i s (1984) and C a l v e r t (1984) have pointed out, an attack has been mounted on the p u b l i c s e c t o r and, i n p a r t i c u l a r , the ' n o n - p r o d u c t i v e ' s o c i a l w e l f a r e component. It i s c l a i m e d that the n a t i o n can no l o n g e r a f f o r d to a l l o w the w e l f a r e s t a t e to grow s i n c e i t a b s o r b s too much of the n a t i o n ' s r e s o u r c e s and p l a c e s an excessive tax burden upon the p r o d u c t i v e p r i v a t e s e c t o r . These monies are b e t t e r l e f t i n the hands of the p r i v a t e s e c t o r where 383 they can be used t o s t i m u l a t e the economy ( C a l v e r t , 1984). Indeed, as Crane (1981) p o i n t s out, m o n e t a r i s t s are 'adamant foes' of the p u b l i c s e c t o r and the w e l f a r e s t a t e i n p a r t i c u l a r . For those who favour the s t r a t e g y , t r a n s f e r payments, r e g u l a t i o n s and other forms of government i n t e r v e n t i o n a l l impede the f r e e and e f f i c i e n t f u n c t i o n s of the market mechanism. Thus they would a b o l i s h many government r e g u l a t i o n s , r e d u c e the l e g a l p r o t e c t i o n a f f o r d e d u n i o n s , c u t back on the s o c i a l s e c u r i t y net, and reduce taxes (op c i t : 3). One i m p o r t a n t g o a l , a s s o c i a t e d w i t h the q u e s t f o r r e d u c e d t a x a t i o n , i s to f a c i l i t a t e both the "systematic d i s m a n t l i n g of the w e l f a r e s t a t e " and the a d o p t i o n of a new o r i e n t a t i o n i n which, i d e a l l y , the p r o v i s i o n of h e a l t h , education and s o c i a l w e l f a r e s e r v i c e s are c a r r i e d out by the p r i v a t e s e c t o r ( C a l v e r t , 1984: 71). For C a l v e r t (1984), t h i s goal appeared almost immediately a f t e r t h e f e d e r a l g o v e r n m e n t began t o e m b r a c e m o n e t a r y g r a d u a l i s m i n the mid-1970's. The measures adopted i n 1977, which a l t e r e d the f e d e r a l - p r o v i n c i a l c o s t - s h a r i n g agreement f o r h e a l t h and e d u c a t i o n a l programmes, appeared in the wake of the f e d e r a l government's a n t i - i n f l a t i o n programme and were a f u n c t i o n of the new s t r a t e g y . The process was designed to l i m i t the f e d e r a l government's f i n a n c i a l o b l i g a t i o n to, f o r example, the medicare system and t h i s c o n s t i t u t e d a "major step towards d i s m a n t l i n g the w e l f a r e s t a t e " (op c i t : 14). In C a l v e r t ' s view, r e g a r d l e s s of t h e i r p o l i t i c a l c o l o u r s , s u c c e s s i v e f e d e r a l governments have continued with the programme of c o s t - c u t t i n g i n the s o c i a l s e r v i c e s e c t o r i n keeping w i t h the need to provide 384 tax b e n e f i t s f o r the p r i v a t e s e c t o r and to thereby s t i m u l a t e the economy. The p r o c e s s has a f f e c t e d not o n l y f e d e r a l - p r o v i n c i a l agreements but a l s o the s o c i a l s e r v i c e programmes provided by the f e d e r a l government. As Guest (1985) p o i n t s out, s i n c e the l a t e 1970's, numerous s o c i a l w e l f a r e programmes have been e i t h e r reduced, f r o z e n , or a b o l i s h e d and these measures have a f f e c t e d e s t a b l i s h e d schemes of d i r e c t t r a n s f e r payments as w e l l as programmes such as O p p o r t u n i t i e s f o r Youth. By 1978, the f e d e r a l government had i n t r o d u c e d cuts to f a m i l y allowances, reduced tax exemptions f o r dependants, and had proposed reforms to the unemployment insurance system (e.g., a t i g h t e n i n g of the e l i g i b i l i t y c r i t e r i a and a withdrawal of b e n e f i t s f o r those who earned high incomes). By the e a r l y 1980's, the p r o c e s s of c u t t i n g back on the costs of s o c i a l w e l f a r e programmes had not abated and f e d e r a l government e f f o r t s i n the s o c i a l s e r v i c e area were dominated by a c o n c e r n to r e s t r a i n p u b l i c e x p e n d i t u r e (op c i t ) . W h i l e an e f f o r t was made to s u s t a i n s o c i a l programmes which might c o n t r i b u t e t o a r e v i v a l o f t h e economy, t h e g o v e r n m e n t demonstrated a p r e f e r e n c e f o r r a t i o n a l i z i n g - the e x i s t i n g system by r e v i e w i n g v a r i o u s programmes; notably, the income r e t i r e m e n t b e n e f i t s p o l i c y . T h i s approach continued a f t e r the Conservative government took o f f i c e i n 1984; i n d e e d , d e s p i t e e l e c t i o n promises to maintain the 'sacred t r u s t ' of u n i v e r s a l i t y , a more s u s t a i n e d a t t a c k was mounted. The government q u e s t i o n e d the wisdom of paying u n i v e r s a l b e n e f i t s such as f a m i l y allowances 385 and o l d age s e c u r i t y but withdrew from i t s p o s i t i o n i n the face of p u b l i c o p p o s i t i o n (op c i t ) . In s h o r t , l i k e i t s c o u n t e r p a r t i n both B r i t a i n and the United States, the Canadian welfa r e s t a t e has been subjected to a s y s t e m a t i c a t t a c k and t h i s i s l i n k e d to an a d j u s t m e n t i n Keynesian p o l i c i e s and the gradual adoption of some monetarist p r i n c i p l e s and t a c t i c s , i n keeping with a new and i n t e r n a t i o n a l economic s t r a t e g y . As M i s h r a (1984) has d e m o n s t r a t e d , i n B r i t a i n , the emergence of monetarism has r e s u l t e d i n a general p o l i c y of ' r o l l i n g - b a c k ' the s t a t e i n many areas. The ' p r i v a t -i z a t i o n ' of p u b l i c s e c t o r s e r v i c e s and p u b l i c e n t e r p r i s e s has accompanied c u t s i n the h e a l t h and w e l f a r e s e c t o r and the n a t i o n ' s w e l f a r e s t a t e has been 'under s i e g e ' s i n c e the mid-1970's (Le Grand & Robinson, 1984). S i m i l a r l y , i n the U n i t e d States, v a r i o u s aspects of the p u b l i c s o c i a l w e l f a r e s e c t o r have been e x p e r i e n c i n g r e s t r a i n t s i n c e the mid-1970's and, i n the context of d i r e c t t r a n s f e r payments, the Reagan A d m i n i s t r a t i o n has i n d i c a t e d a d e s i r e to s h i f t from a p o l i c y of u n i v e r s a l i t y to one of s e l e c t i v i t y (Mishra, 1984; G i l b e r t , 1983). Cuts i n the welfare s e c t o r have a l s o r e s u l t e d i n the p r i v a t i z a t i o n of d i r e c t s e r v i c e s and an i n c r e a s i n g use of v o l u n t e e r s to provide s e r v i c e s f o r those i n need ( G i l b e r t , 1983). These developments are m i r r o r e d i n Canada where, as Guest (1985) argues, the 'beleagured' w e l f a r e s t a t e i s e x h i b i t i n g a r e t u r n to a r e s i d u a l , r a t h e r than i n s t i t u t i o n a l , model of s o c i a l w e l f a r e ; t h a t i s , a s h i f t back to the p r i n c i p l e s of s e l f -386 r e l i a n c e or r e l i a n c e upon the f a m i l y , the p r i v a t e market, and, when a l l e l s e f a i l s , c h a r i t y . The process i s being a s s i s t e d by the r h e t o r i c of n e o - c o n s e r v a t i v e c r i t i c s who see the w e l f a r e s t a t e as an o b s t a c l e i m p e d i n g economic r e c o v e r y . I t i s c o n -tended that e x c e s s i v e government expenditure on s o c i a l s e r v i c e s has c r e a t e d l a r g e d e f i c i t s and the c r i t i c s argue f o r a r e d u c t i o n i n s o c i a l spending, the e l i m i n a t i o n of u n i v e r s a l programmes, and an end to the government monopoly on s o c i a l w e l f a r e s e r v i c e s . Indeed, i t i s argued that i t would be to the advantage of both consumers and taxpayers i f a l l s o c i a l s e r v i c e s were o f f e r e d to p r i v a t e entrepreneurs (Guest, 1985; Mishra, 1984). I t i s e v i d e n t , t h e r e f o r e , t h a t the w e l f a r e s t a t e i n w e s t e r n c a p i t a l i s t c o u n t r i e s i s under s i e g e and t h a t the p r o v i s i o n of h e a l t h care has been a f f e c t e d by t h i s process. The development i s l i n k e d to an i n t e r n a t i o n a l s h i f t i n the dominant economic s t r a t e g y ( i . e . , the f u l l o r , i n the case of Canada, p a r t i a l adoption of monetarism) and t h i s s t r u c t u r a l change has been deemed necessary i n order to ensure the r e p r o d u c t i o n of the c o n d i t i o n s necessary f o r continued c a p i t a l accumulation. A l l of t h i s has been accompanied by the l e g i t i m a t i n g d i s c o u r s e s of neo-c o n s e r v a t i v e s , and t h e i r p e r s p e c t i v e has g a i n e d a f o o t h o l d (Mishra, 1984). The Impact Upon the Strategy f o r the Management of the M e n t a l l y Disordered i n Canada Ins o f a r as mental h e a l t h s e r v i c e s became an i n t e g r a l p a r t of the h e a l t h care component of the w e l f a r e s t a t e i n the 1960's, the changes have which a f f e c t e d the l a t t e r have had an impact 387 upon p r o v i n c i a l s t a t e s t r a t e g i e s f o r the management of the mentally d i s o r d e r e d . The s t r a t e g y c o n s t r u c t e d by the C.M.H.A. i n the 1960's was adopted a c r o s s the c o u n t r y and the use of i n v o l u n t a r y s e g r e g a t e d c o n f i n e m e n t i n l a r g e i n s t i t u t i o n s d e c l i n e d i n f a v o u r of v o l u n t a r y c a r e and t r e a t m e n t i n e i t h e r community-based a l t e r n a t i v e s (e.g., mental h e a l t h centres) or the p s y c h i a t r i c u n i t s of g e n e r a l h o s p i t a l s (Toews & Barnes, 1982; R i l e y & Richman, 1983). The p r o c e s s of d e - i n s t i t -u t i o n a l i z a t i o n which began i n the mid-1950's has a c c e l e r a t e d w i t h a view to c l o s i n g l a r g e i n s t i t u t i o n s and p r o v i n c i a l governments have adopted two complementary t a c t i c s ; namely, ' n o n - i n s t i t u t i o n a l i z a t i o n ' (i.e., the avoidance of any form of h o s p i t a l i z a t i o n ) and ' p r i v a t i z a t i o n ' ( i . e . , e n h a n c i n g p r i v a t e s e c t o r involvement i n the mental h e a l t h care f i e l d ) . Many of t h e s e d e v e l o p m e n t s were i d e n t i f i e d i n a r e p o r t i s s u e d by the f e d e r a l Department of Health and Welfare i n the e a r l y 1980's ( H e a l t h & W e l f a r e : Canada, 1982). I t was n o ted that p s y c h i a t r i c u n i t s i n general h o s p i t a l s had been, and were, a c t i n g as a c t i v e treatment f a c i l i t i e s and t h a t the r o l e of l o n g -term, c u s t o d i a l care, p s y c h i a t r i c h o s p i t a l s was under review i n every province (op c i t ) . A s h i f t towards ' r e g i o n a l i z a t i o n ' had o c c u r r e d ( i . e . , d e - c e n t r a l i z a t i o n of the s e r v i c e s p r o v i d e d by l a r g e mental h o s p i t a l s ) and there had been a concomitant s w i t c h to the use of community mental h e a l t h s e r v i c e s . This was p a r t of a long-term, n a t i o n a l development t h a t had f i r s t emerged i n the e a r l y 1960's (Wattie, 1977) and the system of mental h e a l t h c e n t r e s i n B r i t i s h Columbia was used as an example of the trends 388 which were common to the n a t i o n as a whole (Health & Welfare: Canada, 1982). There was every i n d i c a t i o n t h a t a s h i f t to community care was a c o s t - e f f e c t i v e way of c a r i n g f o r and t r e a t i n g a c u t e l y i l l p a t i e n t s , and the trend had a c c e l e r a t e d . However, i t was noted that, i n the case of c h r o n i c p a t i e n t s , community care was only e f f e c t i v e i f adequate support s e r v i c e s were provided (op c i t ) . In t h i s r e g a r d , the e f f i c a c y of a t a c t i c a dopted i n B r i t i s h Columbia - p s y c h i a t r i c home care s e r v i c e s - had been g e n e r a l l y c o n f i r m e d . While i t was d i f f i c u l t to measure the p r e c i s e o v e r a l l c o s t s of o p e r a t i n g such a s e r v i c e , they were d e f i n i t e l y no h i g h e r , and p r o b a b l y l o w e r than, i n s t i t u t i o n a l c a r e . The s e r v i c e was c e r t a i n l y b e t t e r f o r , and more p o p u l a r among p a t i e n t s (op c i t ) and t h i s had been c o n f i r m e d by a number of e x p e r i m e n t s which d e m o n s t r a t e d t h a t home c a r e was a c o s t -e f f e c t i v e a l t e r n a t i v e . To the e x t e n t t h a t c o s t has been an important c o n s i d e r a t i o n i n the development of p r o v i n c i a l mental h e a l t h s t r a t e g i e s , the t a c t i c had been adopted i n a number of pro v i n c e s (Fenton, et a l , 1984). The s h i f t away from the use of i n s t i t u t i o n s was r e f l e c t e d i n the movement of the p a t i e n t p o p u l a t i o n . From the e a r l y 1960's onwards, the p o p u l a t i o n s of the n a t i o n ' s l a r g e mental h e a l t h f a c i l i t i e s had d e c l i n e d s t e a d i l y w i t h the w i d e s p r e a d a d o p t i o n of p o l i c i e s o f d e - i n s t i t u t i o n a l i z a t i o n and non-i n s t i t u t i o n a l i z a t i o n . The t a c t i c s were r e f l e c t e d i n bot h an i n c r e a s e i n d i s c h a r g e s and the d e c l i n i n g numbers of f i r s t admissions. While the numbers of re-admissions rose during the 389 l a t e 1960's and e a r l y 1970's, by the end of the decade the ' s w i n g i n g door' phenomenon ( r e - d e f i n e d , n e g a t i v e l y , as the 'revolving door' problem) appeared to be under c o n t r o l . Indeed, the number of re-admissions was f a l l i n g . S i m i l a r l y , the average number of p a t i e n t s i n i n s t i t u t i o n s across the country had f a l l e n s t e a d i l y from 70,539 i n 1965, to 16,238 i n 1980/81. De-i n s t i t u t i o n a l i z a t i o n had occurred, d e s p i t e an i n c r e a s e i n the n a t i o n ' s p o p u l a t i o n , and t h i s was r e f l e c t e d i n the d e c l i n i n g r a t e of r e s i d e n c e . In 1965 , the r a t e s t o o d a t 3.6 per 1000 p o p u l a t i o n but, by 1980/81, t h i s had f a l l e n to 0.7.3 D e s p i t e i t s e f f e c t i v e n e s s i n e m p t y i n g the p l a c e s of segregated confinement, the process of d e - i n s t i t u t i o n a l i z a t i o n c r e a t e d d i f f i c u l t i e s f o r p r o v i n c i a l governments. In O n t a r i o , f o r example, the emptying and c l o s i n g of i n s t i t u t i o n s p r i o r to the e s t a b l i s h m e n t of adequate community-based a l t e r n a t i v e s , l e d to b o t h the c r e a t i o n of 'urban g h e t t o s ' p o p u l a t e d by mental h e a l t h p a t i e n t s and a s t r i d e n t c r i t i q u e of the government's m e n t a l h e a l t h p o l i c y ( O n t a r i o A s s o c i a t i o n of S o c i a l Workers, 1979; M a r s h a l l , 1982). The problem e x i s t e d , and continues to e x i s t , i n o t h e r p r o v i n c e s where the a l l e g e d u n d e r - f u n d i n g of community a l t e r n a t i v e s c r e a t e s both h e a l t h system overload and the t r a n s f e r of the ' r e v o l v i n g door' phenomenon from m e n t a l h o s p i t a l s to the p s y c h i a t r i c u n i t s of general h o s p i t a l s (Toews & Barnes, 1982; 1986). D i f f i c u l t i e s have a l s o a r i s e n i n t h e c o n t e x t o f ' p r i v a t i z a t i o n ' . While i t was not addressed s p e c i f i c a l l y i n the 390 Department of Health and Welfare r e p o r t i n 1982, the process of m o b i l i z i n g n o n - p r o f i t s o c i e t i e s and p r o p r i e t a r y f a c i l i t y o p erators to provide a l t e r n a t e care and treatment resources has o c c u r r e d i n many p r o v i n c e s ( M a r s h a l l , 1982; Ligh t m a n , 1986; S o c i a l Planning C o u n c i l of Metro Toronto, 1984; Canadian Medical A s s o c i a t i o n , 1984). The 'commercialization' of human s e r v i c e s has been c o n s i s t e n t w i t h m o n e t a r i s t p o l i c i e s but i t has been accompanied by a l l e g a t i o n s of rampant p r o f i t e e r i n g , poor q u a l i t y s e r v i c e s , and abuse and n e g l e c t of p a t i e n t s (op c i t ) . The is s u e i s not new; f o r example, doubts about the e f f i c a c y of p r i v a t e f o s t e r and boarding homes began to emerge i n the e a r l y 1970's when c o n c e r n s were r a i s e d t h a t t h e s e f a c i l i t i e s were, i n p r a c t i c e , m e r e l y p r o p r i e t a r y 'back-wards' (Murphy, 1972). However, the l e v e l of c o n c e r n i n no way matched the c u r r e n t c r i t i c i s m of the process of 'caring f o r p r o f i t * . I t i s a p p a r e n t , t h e r e f o r e , t h a t w h i l e the e m e r g i n g s t r a t e g y f o r the management of the mentally d i s o r d e r e d has been necessary to complement s t a t e p o l i c i e s aimed at reproducing the c o n d i t i o n s necessary f o r c a p i t a l accumulation, problems have appeared, p a r t i c u l a r l y at the p r o v i n c i a l l e v e l . Mental hosp-i t a l s have been c l o s e d , but funds have not been t r a n s f e r r e d to community care a l t e r n a t i v e s ( M a r s h a l l , 1982). The process of r e s t r a i n i n g expenditure on mental h e a l t h s e r v i c e s i s interwoven w i t h a t t e m p t s t o s t a b i l i z e the g r o w i n g c o s t s of h e a l t h c a r e g e n e r a l l y , and the i n t e g r a t i o n of mental h e a l t h s e r v i c e s w i t h i n the general system of h e a l t h care has meant that the former has had to bear the r e s t r a i n t s experienced by the l a t t e r . 391 In t h i s r e g a r d , Toews (1980) has a r g u e d t h a t c o s t containment in the mental h e a l t h f i e l d began, across Canada, in the mid-1970's and, i n h i s view, a s i g n i f i c a n t f a c t o r was the change i n the f e d e r a l - p r o v i n c i a l c o s t - s h a r i n g agreement. Health care has been, and i s , expensive, and i t has consequently been the t a r g e t of c o s t - c o n s c i o u s governments. However, s i n c e any move towards l i m i t i n g or r e d u c i n g e x p e n d i t u r e s on h e a l t h i s l i k e l y to r e s u l t i n an adverse p u b l i c response (a view echoed by Evans (1986)), p r o v i n c i a l governments have adopted the s t r a t e g y of ' s t a b i l i z i n g 1 budgets, at the same time f a i l i n g to provide s u f f i c i e n t funds to keep pace w i t h i n f l a t i o n . W h i l e t h i s r e p r e s e n t s an e f f e c t i v e r e d u c t i o n i n funding, governments have r e f e r r e d to the p r o c e s s i n a p o s i t i v e manner; t h a t i s , as 'preserving the h e a l t h d o l l a r ' . In Toews' (op c i t ) view, t h i s " s u b t l e and w i d e l y p r a c t i s e d " d e c e p t i o n has been employed by many p r o v i n c i a l governments which have i n s t r u c t e d t h e i r mental h e a l t h s e r v i c e d i r e c t o r s to c o n t a i n c o s t s , balance budgets, and accept percentage i n c r e a s e s below the r a t e of i n f l a t i o n . T h i s view corresponds w i t h the o p i n i o n s of other a n a l y s t s of m e n t a l h e a l t h f u n d i n g t r e n d s (e.g., E l - G u e b a l y & P a p i n e a u , 1984) and the Canadian Medical A s s o c i a t i o n . In i t s recent task f o r c e r e p o r t on the a l l o c a t i o n of h e a l t h c a r e r e s o u r c e s (Canadian Medical A s s o c i a t i o n , 1984), the A s s o c i a t i o n expressed concern regarding the pressures c r e a t e d by the severe government r e s t r a i n t s a f f e c t i n g a l l h e a l t h s e r v i c e s . The h e a l t h c a r e system i s seen as " d a n g e r o u s l y u n d erfunded" and p r o v i n c i a l governments a c r o s s Canada have been a c t i v e l y r e d u c i n g the 392 numbers of h o s p i t a l beds i n an attempt to r e s t r a i n h e a l t h care budgets. A l t e r n a t i v e s , such as home-care and other community care resources, have not been adequately funded. Consequently, across the n a t i o n there are bed shortages, long w a i t i n g - l i s t s f o r e l e c t i v e surgery, and over-worked emergency u n i t s . In the face of r e s t r a i n t , h o s p i t a l s have had to introduce h i r i n g and s a l a r y f r e e z e s , and ward c l o s u r e s . Yet, data i s s u e d by the f e d e r a l Department of Health and W e l f a r e s u g g e s t t h a t h e a l t h c a r e e x p e n d i t u r e s have been m a i n t a i n e d at a r e a s o n a b l e l e v e l ( H e a l t h & W e l f a r e : Canada, 1983). For example, a g g r e g a t e h e a l t h e x p e n d i t u r e s ( c o n s t a n t d o l l a r s ) i n Canada rose from $165 per c a p i t a i n 1960, to $445 per c a p i t a i n 1982; a 169% i n c r e a s e . In c u r r e n t d o l l a r s , the n a t i o n a l h e a l t h b i l l rose f o u r t e e n - f o l d from $2,137 b i l l i o n i n 1960, to $30,088 b i l l i o n i n 1982. At the same t i m e , the p r o p o r t i o n of the gross n a t i o n a l product expended on h e a l t h a l s o i n c r e a s e d from 5.6% i n 1960, to 8.4% i n 1982. While, i n recent y e a r s , the i n c r e a s e i n the p r o p o r t i o n of the g r o s s n a t i o n a l product which has been expended i s a f u n c t i o n of the impact of the economic r e c e s s i o n (Evans, 1984), i t does s u g g e s t t h a t governments are attempting to preserve h e a l t h care expenditures and p r o t e c t the h e a l t h care component of the w e l f a r e s t a t e . In the s p e c i f i c c o n t e x t of m e n t al h e a l t h s e r v i c e s , the data suggest a s i m i l a r s i t u a t i o n . While the p r o p o r t i o n of the t o t a l n a t i o n a l h e a l t h expenditures absorbed by mental h o s p i t a l s f e l l from 6.5% i n 1970, to 1.9% i n 1980 ( H e a l t h & W e l f a r e : 393 Canada, 1983), c o n s t a n t d o l l a r e x p e n d i t u r e s on mental h e a l t h s e r v i c e s as a whole have i n c r e a s e d . Between 1960 and 1970, constant d o l l a r expenditures rose 18% and, i n the p e r i o d between 1971 and 1979, they i n c r e a s e d 75%. 4 These data suggest that the s t a t e has taken care to expend d o l l a r s on h e a l t h , w i t h i n c e r t a i n l i m i t s (no more than seven to e i g h t percent of the gross n a t i o n a l product)(Evans, 1984). They a l s o s u g g e s t t h a t the c o s t s of c a r e and t r e a t m e n t have been high, d e s p i t e the i n t r o d u c t i o n of s t a b i l i z a t i o n and r e s t r a i n t measures. Esti m a t e s of the i n c r e a s e s which might have o c c u r r e d i n the absence of such measures are not a v a i l a b l e but i t seems probable that i f a l t e r n a t i v e s to, i n p a r t i c u l a r , h o s p i t a l i z a t i o n had not been c r e a t e d and u t i l i z e d , the c o s t s of the h e a l t h care component of the w e l f a r e s t a t e would have been even higher. The s w i t c h from i n s t i t u t i o n a l to community-based care and treatment i n the m e n t a l h e a l t h c o n t e x t r e f l e c t e d a g e n e r a l and t i m e l y s h i f t away from the use of h o s p i t a l s and, i f such measures had not been introduced, the f e d e r a l and p r o v i n c i a l l e v e l s of the s t a t e might w e l l be f a c i n g a more severe problem i n regard to the funding of h e a l t h care. The p e r i o d of mental h e a l t h law reform c h a r a c t e r i z e d by the 'new l e g a l i s m ' has, t h e r e f o r e , emerged under a s e t of economic c o n d i t i o n s which have a f f e c t e d p r o v i n c i a l s t a t e s t r a t e g i e s f o r the management of the m e n t a l l y d i s o r d e r e d . A s p e c t s of the s t r a t e g y a d o pted i n the 1960's have e i t h e r a c c e l e r a t e d (notably, d e - i n s t i t u t i o n a l i z a t i o n ) or been enhanced (e.g., p r i v a t i z a t i o n ) , and a d d i t i o n a l t a c t i c s have emerged 394 (i.e., n o n - i n s t i t u t i o n a l i z a t i o n ) . However, some l e g i t i m a t i o n and order maintenance problems have a r i s e n as a consequence of both p r i v a t i z a t i o n and a f a i l u r e to provide adequate community a l t e r n a t i v e s to i n s t i t u t i o n s . In a d d i t i o n , s t a t e i n t e r f e r e n c e w i t h the f u n d i n g of the h e a l t h c a r e component of the w e l f a r e s t a t e r e q u i r e s c a r e f u l l e g i t i m a t i o n s i n c e h e a l t h s e r v i c e s are g e n e r a l l y viewed as a 'right*. In short, while the p r o v i n c i a l l e v e l of the s t a t e i s r e q u i r e d to reduce expenditures on h e a l t h care i n keeping w i t h new, f e d e r a l , economic p o l i c i e s designed to assure continued c a p i t a l accumulation, i t must a l s o ensure c o n t i n u e d l e g i t i m a t i o n , a t the same time e s t a b l i s h i n g an e f f e c t i v e system f o r the c o n t r o l of the mentally d i s o r d e r e d that i s c o n s i s t e n t w i t h other i m p e r a t i v e s . In order to accomplish, and ensure a s y n c h r o n i z a t i o n of, t h e s e p o t e n t i a l l y c o n t r a d i c t o r y o b j e c t i v e s , the s t a t e has employed the t a c t i c of law reform, and the emergence of the 'new l e g a l i s m ' r e f l e c t s the s t a t e ' s use of law to s i m u l t a n e o u s l y implement and l e g i t i m a t e i t s p o l i c i e s . The entrenchment of the s t r a t e g y c o n s t r u c t e d by the C.M.H.A. i n the 1960's, the impact of the economic problems and changes upon that s t r a t e g y , and the state's use of the law to r e s o l v e the attendant problems w i l l now be e x p l o r e d i n more d e t a i l through an a n a l y s i s of events i n the province of B r i t i s h Columbia. 395 I l l : THE STRATEGY FOR THE MANAGEMENT OF THE MENTALLY DISORDERED, THE IMPACT OF ECONOMIC CHANGES, AND THE RISE OF THE NEW LEGALISM IN BRITISH COLUMBIA The development of the s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d i n B r i t i s h Columbia from the mid-1960's t o t h e mid-1980's o c c u r r e d i n two p h a s e s . The recommendations of the Ross Report were implemented i n the mid-1960's and t h e s e c o n s t i t u t e d the b a s i s f o r a s t r a t e g y t h a t remained i n e f f e c t u n t i l the e a r l y 1980's. In 1979, the s t a t e of the p r o v i n c i a l mental h e a l t h s e r v i c e was examined and a number of improvements were recommended. The government respond-ed and, by the mid-1980's, a major review of the mental h e a l t h system had been i n i t i a t e d and a new 'mental h e a l t h p l a n ' c o n s t r u c t e d . The Management of the M e n t a l l y Disordered During the 1960's and 1970's. The passage of the l e g i s l a t i o n a f f e c t i n g the management of the mentally d i s o r d e r e d i n B r i t i s h Columbia in the e a r l y 1960's creat e d a l e g a l framework w i t h i n which the recommendations of the Ross R e p o r t c o u l d be implemented. In A p r i l 1967, the M i n i s t e r of Health S e r v i c e s and H o s p i t a l Insurance appointed a committee under the chairmanship of the Deputy M i n i s t e r f o r the Mental Health Branch to review the o r g a n i z a t i o n and f u t u r e r o l e of the Branch. The goal was to "meet the changing p a t t e r n s of c a r e f o r the m e n t a l l y i l l and r e t a r d e d " 5 and the committee began the p r o c e s s of i m p l e m e n t i n g the l o n g - t e r m s t r a t e g y p r e s c r i b e d by Dr. Ross and h i s team of C.M.H.A. a d v i s o r s . In k e e p i n g w i t h the Ross R e p o r t , an emphasis was to be 396 p l a c e d upon the development of community-based p s y c h i a t r i c programmes; f a c i l i t i e s and s e r v i c e s f o r the, mentally r e t a r d e d ; and, i n t e g r a t e d programmes f o r the aged me n t a l l y i l l . 6 Large c e n t r a l i z e d f a c i l i t i e s were t o be 'adapted' t o meet new programme needs, and the t r a i n i n g and r e c r u i t m e n t of s t a f f were t o i m p r o v e . T h e r e w o u l d be an i n c r e a s e d e m p h a s i s upon p r e v e n t i o n as w e l l as an improvement i n (and e v a l u a t i o n of) treatment methods and, i n a c o n f i r m a t i o n of the C.M.H.A.'s goal of i n t e g r a t i o n , i t was a n t i c i p a t e d t h at the " e x i s t i n g d i v i s i o n i n the care of p h y s i c a l and mental i l l n e s s w i l l g r a d u a l l y l e s s e n and l a r g e l y disappear". 7 The s t r a t e g y was to be implemented on a r e g i o n a l b a s i s and c o n s i s t e d of four main i n t e r l o c k i n g t a c t i c s : a m o b i l i z a t i o n of n o n - p r o f i t s o c i e t i e s and f o r - p r o f i t boarding home operators; an i n c r e a s e i n the numbers of mental h e a l t h c e n t r e s and the dev e l o p m e n t of a d d i t i o n a l community s e r v i c e s ; c o n t i n u e d de-i n s t i t u t i o n a l i z a t i o n ; and, an inc r e a s e i n the number of general h o s p i t a l p s y c h i a t r i c u n i t s . The m o b i l i z a t i o n of n o n - p r o f i t s o c i e t i e s and f o r - p r o f i t operators began almost immediately and was f a c i l i t a t e d by the p r o v i s i o n s of the new Mental Health Act which p e r m i t t e d the use o f , i n p a r t i c u l a r , n o n - p r o f i t s o c i e t i e s i n the d e l i v e r y of mental h e a l t h s e r v i c e s . S o c i e t i e s were to both operate s m a l l f a c i l i t i e s f o r m e n t a l l y r e t a r d e d and g e r i a t r i c p a t i e n t s and develop a v a r i e t y of community-based s e r v i c e s f o r the mentally i l l ; n o t a b l y , a c t i v i t y c e n t r e s and group l i v i n g homes. F o r -p r o f i t operators were to provide board and care homes f o r both 397 discharged and new mental h e a l t h p a t i e n t s . The f i r s t 'community' o p e r a t e d , n o n - p r o f i t f a c i l i t y -Bevan Lodge - opened i n December 1968 and was f o l l o w e d q u i c k l y by two others - the E r i c M a r t i n I n s t i t u t e and Glendale Lodge. 8 In each c a s e , the government b u i l t the f a c i l i t i e s but handed them over to n o n - p r o f i t s o c i e t i e s , and the Deputy M i n i s t e r saw t h e s e e v e n t s as m e r e l y t h e b e g i n n i n g o f a much l a r g e r e n t e r p r i s e . 9 I t i s hoped t h a t i n the near f u t u r e the d e v e l o p -ment of s o c i e t i e s w i l l permit programming at the l o c a l l e v e l w i t h the optimum degree of l o c a l p a r t -i c i p a t i o n and government support. Non-profit, s o c i e t i e s were to operate f a c i l i t i e s f o r the s t a t e , and the r o l e of the l a t t e r was to be reduced to the p r o v i s i o n of funds, c o n s u l t a t i o n , and o v e r a l l s u p e r v i s i o n . 1 0 By the mid-1970's, i t was apparent that the involvement of n o n - p r o f i t s o c i e t i e s i n the p r o v i s i o n of f a c i l i t i e s would be l i m i t e d to g e r i a t r i c p a t i e n t s and the mentally r e t a r d e d . The Skeenaview H o s p i t a l (a g e r i a t r i c f a c i l i t y ) had been handed over to the newly i n c o r p o r a t e d 'Skeenaview So c i e t y ' and, s i n c e the p r o j e c t had appeared to be s u c c e s s f u l , the Deputy M i n i s t e r of Health announced t h a t D e l l v i e w H o s p i t a l would be t r a n s f e r r e d to a s o c i e t y as soon as p o s s i b l e . 1 1 Bevan Lodge, Glendale Lodge, and other f a c i l i t i e s f o r the mentally r e t a r d e d were o p e r a t i n g e f f e c t i v e l y and n o n - p r o f i t s o c i e t i e s were a l s o p r o v i d i n g a range of a d d i t i o n a l community s e r v i c e s . A l l the programmes and resources f o r the mentally r e t a r d e d 398 were t r a n s f e r r e d to the Department of Human Resources i n 1975 (a development s t i m u l a t e d by bot h s i m i l a r t r a n s f e r s i n o t h e r provin c e s and the United Nations D e c l a r a t i o n on the Human Rights of the M e n t a l l y R e t a r d e d ) 1 2 and, at the time, s o c i e t i e s were i n v o l v e d i n the p r o v i s i o n of f o s t e r homes, group l i v i n g homes, short stay h o s t e l s , and cen t r e s which were aimed at t r a i n i n g the m e n t a l l y r e t a r d e d t o move to an 'independent l i v i n g ' s t a t u s . One n o n - p r o f i t s o c i e t y had introduced an experiment i n v o l v i n g the o p e r a t i o n of independent l i v i n g apartments and t h i s appeared to be a p r o m i s i n g o p t i o n . G e n e r a l l y , t h r o u g h o u t the 1970's, s o c i e t i e s were working i n 'close p a r t n e r s h i p ' w i t h the s t a t e to p r o v i d e a l t e r n a t i v e s t o i n s t i t u t i o n s ( i . e . , Woodlands and T r a n q u i l l e ) and, by the end of the decade, t h i s r e l a t i o n s h i p had 1 o become f i r m l y entrenched. By the end of the 1970's, n o n - p r o f i t s o c i e t i e s were p l a y i n g an a d d i t i o n a l r o l e i n the p r o v i s i o n of mental h e a l t h s e r v i c e s ; namely, the op e r a t i o n of i n t e r m e d i a t e care homes f o r g e r i a t r i c p a t i e n t s and the mentally i l l , as an extension of the boarding home programme. From i t s i n c e p t i o n , t h i s programme had been h e a v i l y dependent upon the s e r v i c e s of f o r - p r o f i t boarding home operat o r s and i t s t e a d i l y expanded throughout the 1960's and 1970's. At the end of 1968, over 600 p a t i e n t s were r e s i d i n g i n more than 100 homes and, of these, 394 had been discharged from R i v e r v i e w H o s p i t a l . The s e a r c h f o r more homes had commenced and the s o c i a l s e r v i c e c o n s u l t a n t was plann i n g and o r g a n i z i n g an expansion of the boarding home programme i n each of the e i g h t r e g i o n s . 1 4 By 1970, the numbers of p a t i e n t s i n 399 homes had i n c r e a s e d t o 789 and, by the end of 1979, 2,280 p a t i e n t s were r e c e i v i n g care i n more than 300 e s t a b l i s h m e n t s . The trend was due, p r i m a r i l y , to a s e r i e s of s t a t e i n i t i a t i v e s designed to s t i m u l a t e use of these community-based resources; a l t e r n a t i v e s which reduced the l e n g t h of stay of new admissions at Riverview H o s p i t a l , aided the r e - l o c a t i o n of the H o s p i t a l ' s r e m a i n i n g l o n g - s t a y p a t i e n t s , and s u p p o r t e d the work of the mental h e a l t h centres i n t r e a t i n g the mentally i l l i n t h e i r home communities. 1 6 The process of m o b i l i z i n g p r i v a t e n o n - p r o f i t o r g a n i z a t i o n s and f o r - p r o f i t operators was accompanied by a steady expansion i n the numbers of mental h e a l t h centres. Indeed, the c e n t r e s p l a y e d a major r o l e i n e s t a b l i s h i n g and s u p e r v i s i n g p r i v a t e s e c t o r f a c i l i t i e s and community s e r v i c e s . E q u a l l y i m p o r t a n t l y , the p r o l i f e r a t i o n of c e n t r e s supported both the t a c t i c of de-i n s t i t u t i o n a l i z a t i o n and another p o l i c y which began to emerge i n the 1970's; namely, n o n - i n s t i t u t i o n a l i z a t i o n . By 1968, t h e numbers o f m e n t a l h e a l t h c e n t r e s had i n c r e a s e d and, during the year, the ten centres had d e a l t w i t h o v e r 7,000 p a t i e n t s . I t was f e l t t h a t the c e n t r e s were e f f e c t i v e i n d i s c o u r a g i n g both admissions and re-admissions to Riverview and the network s t e a d i l y expanded. By 1979, there were 31 c e n t r e s and 10 s u b - o f f i c e s throughout the province and the numbers of p e r s o n s r e c e i v i n g c a r e and t r e a t m e n t had i n c r e a s e d a c c o r d i n g l y . In f i s c a l 1966/67, the caseload of the c e n t r e s t o t a l l e d 5,877 and, at year end, the c e n t r e s were handling 2,279 a c t i v e cases. By 1975, the annual caseload had 400 r i s e n to 20,725 and the centres were r e s p o n s i b l e f o r 64% of the c l i e n t s of the mental h e a l t h s e r v i c e . By the end of the decade, the c e n t r e s were managing over 21,000 c l i e n t s per year and, i n September 1980, had a t o t a l a c t i v e c a s e l o a d of 14,573. T h i s represented 74% of the province's mental h e a l t h p a t i e n t s and i t was apparent that the centres had become an important component i n the mental h e a l t h s y s t e m . 1 7 The c e n t r e s o f f e r e d v a r i o u s d i a g n o s t i c and t h e r a p e u t i c s e r v i c e s (notably, c o u n s e l l i n g , psychotherapy and medication); e s t a b l i s h e d , c o - o r d i n a t e d and s u p e r v i s e d p r i v a t e s e c t o r , community-based s e r v i c e s and f a c i l i t i e s (notably, the boarding home programme); and, a c t i v e l y encouraged the c r e a t i o n of s e l f -help groups and other community o r g a n i z a t i o n s . Personnel were a l s o i n v o l v e d i n p r e v e n t a t i v e , community mental h e a l t h education and e a r l y i n t e r v e n t i o n i n c h i l d management problems; a task that i n v o l v e d the p r o v i s i o n of c o n s u l t a t i o n and guidance to parents as w e l l as co- o p e r a t i o n with government and mu n i c i p a l agencies which had contact with c h i l d r e n . An a d d i t i o n a l r e s o u r c e a l s o emerged d u r i n g the 1970's; namely, the co - o r d i n a t e d , comprehensive, m u l t i - d i s c i p l i n a r y , community m e n t a l h e a l t h s e r v i c e . In 1973, the G r e a t e r Vancouver M e n t a l H e a l t h S e r v i c e (G.V.M.H.S.) began to o p e r a t e under the auspices of the M e t r o p o l i t a n Board of Health, w i t h the goal of supporting and a s s i s t i n g c h r o n i c a l l y d i s a b l e d mentally i l l people through community-care teams (Cumming, et a l , 1976). I t was to be a 'bed r e p l a c e m e n t p r o j e c t ' t h a t would h e l p 401 p a t i e n t s to " f u n c t i o n i n the community and avoid or minimize h o s p i t a l i z a t i o n " , and was v i e w e d as an " e f f e c t i v e and l e s s expensive a l t e r n a t i v e to the t r a d i t i o n a l h o s p i t a l a d m i s s i o n " . 1 9 By the end of 1975, the G.V.M.H.S. had become an important r e s o u r c e ( i t had, f o r example, assumed management of the Riverview H o s p i t a l o u t - p a t i e n t c l i n i c ) , the number of community-care teams had been increased, and the caseload had r i s e n . At the end of 1974, the S e r v i c e was handling -949 cases and, by the end of the f o l l o w i n g year, the caseload had r i s e n to 2,116. As the decade passed, g r e a t e r use was made of community-care teams i n both Vancouver and Burnaby and, by September 1980, they had a t o t a l a c t i v e c a s e l o a d of 3,011 p a t i e n t s . At t h a t t i m e , the mental h e a l t h c e n t r e s and the community-care teams combined, were r e s p o n s i b l e f o r managing 90% of the p r o v i n c e ' s m e n t a l h e a l t h p a t i e n t s . 2 0 The growth of community-based a l t e r n a t i v e s d u r i n g the 1960's and 1970's was accompanied by a steady d e c l i n e i n the use of mental h o s p i t a l s ; p a r t i c u l a r l y , Riverview H o s p i t a l . By the end of 1968, c e n t r a l i z e d i n - p a t i e n t s e r v i c e s were being viewed as ' a n a c h r o n i s t i c ' and the process of 'adapting' l a r g e , c e n t r a l -i z e d f a c i l i t i e s began to take shape. The i n s t i t u t i o n s were to operate only as an i n t e r i m measure, " u n t i l such time as needs can be more a p p r o p r i a t e l y p r o v i d e d f o r on a d e c e n t r a l i z e d , c o m m u n i t y - o r i e n t e d , and m e d i c a l l y i n t e g r a t e d b a s i s " . 2 1 Community resources were to be developed along with "maximum i n v o l v e m e n t of community p a r t i c i p a t i o n " and t h e s e were t o i n c l u d e day and n i g h t h o s p i t a l s , group l i v i n g homes, n u r s i n g 402 homes, f o s t e r homes, and o u t - p a t i e n t s e r v i c e s . ^ The d e v e l -opment of these s e r v i c e s would r e q u i r e some time and, s i n c e the h o s p i t a l s remained, every e f f o r t would be made to provide a high q u a l i t y s e r v i c e i n the i n s t i t u t i o n s . To t h i s end, whenever t h e r e was a s h o r t a g e of s t a f f , the number of a d m i t t i n g beds w.ould be t e m p o r a r i l y r e d u c e d ; t h a t i s , s t a n d a r d s would be maintained by r e s t r i c t i n g admissions to f a c i l i t i e s . 2 3 The p r o c e s s of d e - i n s t i t u t i o n a l i z a t i o n , w h ich began a t Riverview H o s p i t a l i n the 1950's, continued, and, between 1965 and 1980, there was a steady d e c l i n e i n the numbers of p a t i e n t s who were t r e a t e d a t , admitted to, r e l e a s e d from, and r e s i d i n g i n the f a c i l i t y . 2 4 In f i s c a l 1965/66, a t o t a l of 4,295 p a t i e n t s had been a d m i t t e d , 7,213 had been t r e a t e d , and 4,891 had been r e l e a s e d . At year end (i.e., A p r i l , 1966) 2,815 p a t i e n t s were i n r e s i d e n c e at the H o s p i t a l . By 1980, the numbers had been reduced d r a s t i c a l l y . A t o t a l of 1,314 p a t i e n t s were admitted between September 1979 and September 1980, and, duri n g the same p e r i o d , 2,412 were t r e a t e d . In September 1980 o n l y 1,113 p a t i e n t s were i n re s i d e n c e at the H o s p i t a l and 1,296 had been r e l e a s e d during the 1980 calendar year. By September 1981, the i n - r e s i d e n c e p a t i e n t p o p u l a t i o n had f a l l e n f u r t h e r to 1,097. 2 5 I t was evident that the t a c t i c of d e - i n s t i t u t i o n a l i z a t i o n and the e m e r g i n g p o l i c y of n o n - i n s t i t u t i o n a l i z a t i o n had been s u c c e s s f u l . The e x i s t i n g Riverview p o p u l a t i o n ( e s p e c i a l l y the l o n g - s t a y p a t i e n t s ) was b e i n g d i s c h a r g e d , the numbers of new admissions and re-admissions had been reduced, and t h i s had been accomplished by expanding the network of community a l t e r n a t i v e s 403 and by the p r a c t i c e of pegging the number of admissions to the personnel a v a i l a b l e i n the H o s p i t a l . D e - i n s t i t u t i o n a l i z a t i o n a l s o a f f e c t e d f a c i l i t i e s o t h e r than Riverview H o s p i t a l ; namely, the schools f o r the mentally r e t a r d e d and the g e r i a t r i c h o s p i t a l s . At the end of 1970, f a c i l i t i e s f o r the mentally r e t a r d e d held 1,837 r e s i d e n t s and the g e r i a t r i c h o s p i t a l s contained 1,170 p a t i e n t s ; by 1980, the numbers had f a l l e n t o 1,535 and 687 r e s p e c t i v e l y . 2 6 I n s t i t u t i o n s were being s t e a d i l y emptied and the t a c t i c had been s p u r r e d on by s e v e r a l s t u d i e s c o n d u c t e d by the M e n t a l H e a l t h Branch. In 1970, a s u r v e y of a l l i n - p a t i e n t f a c i l i t i e s was undertaken and i t was found that l e s s than 50% of the r e s i d e n t s needed c a r e i n a f a c i l i t y . Many p a t i e n t s ( p a r t i c u l a r l y at Riverview) could be discharged i f adequate resources were made , a v a i l a b l e i n the community and i t was r e p o r t e d t h a t the o n l y l o n g - s t a y p a t i e n t s remaining i n the H o s p i t a l were those with " g r e a t e r r e s i d u a l p s y c h i a t r i c d i s a b i l i t y " and those who were aged and i n f i r m . 2 7 The p a t i e n t p o p u l a t i o n survey was repeated i n 1972 and i t was c o n c l u d e d t h a t 46% of those r e s i d i n g i n f a c i l i t i e s r e q u i r e d only v a r y i n g degrees of pe r s o n a l care and a t t e n t i o n . 2 8 I t was c l e a r , t h e r e f o r e , t h a t the p o p u l a t i o n s of the v a r i o u s m e n t a l h e a l t h i n s t i t u t i o n s c o u l d be r e d u c e d f u r t h e r , p a r t i c u l a r l y i f more, a l t e r n a t i v e , community reso u r c e s could be developed. To t h i s end, the Mental Health Branch i n i t i a t e d an experiment i n Vancouver - the ' P s y c h i a t r i c Home Treatment Prog-404 ramme 1 - to a s s e s s the c o m p a r a t i v e c o s t - e f f e c t i v e n e s s of p r o v i d i n g mental h e a l t h s e r v i c e s to p a t i e n t s r e s i d i n g i n t h e i r own homes, r a t h e r than i n i n s t i t u t i o n s . The r e s u l t s were encouraging and, while the iss u e of c o s t - e f f e c t i v e n e s s was not c l a r i f i e d , the experiment i n d i c a t e d that home care programmes were a v i a b l e a l t e r n a t i v e to h o s p i t a l i z a t i o n i n some c a s e s (Goodacre & S c h i e l d r o p , 1973; Goodacre, et a l , 1975; Coates, et a l , 1976). By 1973, the Department of H e a l t h had i n i t i a t e d o t h e r , s i m i l a r p r o j e c t s . S e v e r a l experiments were conducted throughout the p r o v i n c e to d e t e r m i n e whether p a t i e n t s i n a c u t e c a r e h o s p i t a l s c o u l d be d i s c h a r g e d e a r l y to s u p p o r t i v e home c a r e s e r v i c e s . The r e s u l t s i n d i c a t e d that home care programmes were c o s t - e f f e c t i v e ; f o r example, the t o t a l cost of care i n a home care programme was approximately $12.00 per p a t i e n t day, f o r an average t o t a l c ost per p a t i e n t of $101.10. I t was es t i m a t e d t h a t t h i s r e p r e s e n t e d a s a v i n g of $630 per p a t i e n t who would otherwise have been admitted to, or r e t a i n e d i n , an acute care h o s p i t a l . Both p a t i e n t s and t h e i r f a m i l i e s were more s a t i s f i e d with home care and there was no r e d u c t i o n i n the q u a l i t y of care and t r e a t m e n t . 2 9 D e s p i t e the u n c e r t a i n t y i n r e l a t i o n to the P s y c h i a t r i c Home Care experiment, the general idea of p r o v i d i n g care to p a t i e n t s ( i n c l u d i n g mental h e a l t h p a t i e n t s ) i n t h e i r own homes, r a t h e r than h o s p i t a l s , was f i s c a l l y a t t r a c t i v e . By the end of the 1970's, i t was apparent that the process of d e - i n s t i t u t i o n a l i z a t i o n was approaching i t s z e n i t h . In the case of both Riverview H o s p i t a l and the g e r i a t r i c h o s p i t a l s , the 405 p a t i e n t s remaining i n r e s i d e n c e were i n d i v i d u a l s who r e q u i r e d an i n c r e a s i n g l e v e l of care and who could not, given the a v a i l a b l e community s e r v i c e s , be e a s i l y discharged. In a d d i t i o n , R i v e r -v i e w H o s p i t a l was a d m i t t i n g more, s e r i o u s l y d i s t u r b e d , i n v o l u n t a r y p a t i e n t s who c o u l d not be managed i n the com-m u n i t y , 3 0 d e s p i t e the i m p l e m e n t a t i o n of the r e m a i n i n g major component i n the T u c k e r Committee's s t r a t e g y ; namely, the e s t a b l i s h m e n t of p s y c h i a t r i c u n i t s i n general h o s p i t a l s . The development of p s y c h i a t r i c u n i t s i n general h o s p i t a l s was aimed at the p r o v i s i o n of treatment f o r acute cases. At the end of 1968, accommodation f o r 149 beds had been b u i l t , premises f o r 285 beds were under c o n s t r u c t i o n , and a f u r t h e r 397 beds were i n the p l a n n i n g stage. The H o s p i t a l Insurance Act R e g u l a t i o n s were amended so t h a t h o s p i t a l s , or p a r t s of h o s p i t a l s , c o u l d be d e s i g n a t e d as f a c i l i t i e s f o r p s y c h i a t r i c day-care and o u t - p a t i e n t s e r v i c e s (Mental Health Branch, 1970), and p a r t of R i v e r v i e w was d e c l a r e d an 'open h o s p i t a l ' to ease the burden on h o s p i t a l s i n Vancouver. This allowed " s u i t a b l y q u a l i f i e d p h y s i c i a n s to a d m it, t r e a t and b i l l t h e i r own p a t -i e n t s " : the normal p r a c t i c e i n general h o s p i t a l s . 3 1 By December 1970, the bed count had i n c r e a s e d to 382 (with a f u r t h e r 129 i n the p l a n n i n g s t a g e ) and the Deputy M i n i s t e r noted t h a t "these beds f a c i l i t a t e admission, shorten h o s p i t a l -i z a t i o n , and permit a r a p i d r e t u r n of the p a t i e n t to f a m i l y and work." The i n t e n t was to provide short-term, a c t i v e treatment f o r v o l u n t a r y p a t i e n t s r e f e r r e d by p s y c h i a t r i s t s o p e r a t i n g both 406 i n p r i v a t e p r a c t i c e and i n c o n j u n c t i o n w i t h the mental h e a l t h c e n t r e s . In a d d i t i o n , n i g h t and day c a r e , and o u t - p a t i e n t s e r v i c e s , had been e s t a b l i s h e d at f i v e h o s p i t a l s to f a c i l i t a t e p a r t i a l h o s p i t a l i z a t i o n . In the Deputy M i n i s t e r ' s view, "the t h e r a p e u t i c and economic" a d v a n t a g e s c o u l d n o t be " o v e r -emphasized". 3 2 A d d i t i o n a l p s y c h i a t r i c u n i t s were opened during the mid-1970's to keep pace w i t h the demand and, by 1980, 25 u n i t s c o n t a i n i n g a t o t a l of 682 beds had been e s t a b l i s h e d throughout the p r o v i n c e . 3 3 While the t a c t i c appeared to be s u c c e s s f u l , p s y c h i a t r i c u n i t s had t h e i r l i m i t a t i o n s . The u n i t s were unable to deal w i t h s e v e r e l y d i s t u r b e d i n d i v i d u a l s and, during the l a t e 1970's, the Superintendent at Riverview r e p o r t e d that he was r e c e i v i n g an i n c r e a s i n g number of urgent r e f e r r a l s from general h o s p i t a l s . 3 4 In a d d i t i o n , a n o t h e r p r o b l e m began to emerge; namely, an i n c r e a s e i n the l e n g t h of time spent by mental h e a l t h p a t i e n t s i n p s y c h i a t r i c u n i t s . In 1975, i n d i v i d u a l s s u f f e r i n g from mental d i s o r d e r s were s t a y i n g i n u n i t s f o r an average of 12.8 days, w h i l e the a verage l e n g t h of h o s p i t a l i z a t i o n f o r a l l c a t e g o r i e s of p a t i e n t was o n l y 8.9 days. By 1978, when the average l e n g t h of s t a y had d e c l i n e d to 8.5 days, those w i t h mental d i s o r d e r s were remaining longer than any other category (13.3 days) and, by 1980, t h i s had i n c r e a s e d to 13.8 days. The t r e n d was f o r mental h e a l t h p a t i e n t s to r e m a i n i n u n i t s f o r longer p e r i o d s of time and t h i s ran c o n t r a r y to the government's goal of reducing the use of acute care h o s p i t a l s ; a p o l i c y that was w o r k i n g i n the case of o t h e r consumers of h o s p i t a l 407 s e r v i c e s . The Impact of Economic Problems The p r o v i n c i a l s t r a t e g y f o r the management of the mentally d i s o r d e r e d that was c o n s t r u c t e d i n the mid-1960's was based upon the recommendations of the Ross Repo r t of 1961. The v a r i o u s t a c t i c s had t h e i r r o o t s i n the package of reforms s u p p l i e d by the C.M.H.A. d u r i n g the l a t e 1950's and e a r l y 1960's, and the As s o c i a t i o n ' s ideas f o r r e s o l v i n g the problems c o n f r o n t i n g the s t a t e at that time provided the i n i t i a l impetus. By the e a r l y 1970's, however, i m p l e m e n t a t i o n of the s t r a t e g y was b e i n g p r o p e l l e d by an a d d i t i o n a l f a c t o r ; namely, the e s c a l a t i n g c o s t s of h e a l t h care. The f i r s t i n d i c a t i o n of a s p e c i f i c concern f o r rendering the mental h e a l t h s e r v i c e c o s t - e f f e c t i v e appeared i n 1970. At the end of the y e a r , the Deputy M i n i s t e r of M e n t a l H e a l t h 3 7 wrote, ' The burgeoning c o s t of h e a l t h s e r v i c e s renders i t imp e r a t i v e that the most e f f e c t i v e d e l i v e r y system of care be designed and maintained. To t h i s end, an emphasis was to be placed upon the development and e v a l u a t i o n of community programmes, a r e - o r g a n i z a t i o n of e x i s t i n g programmes, and a redeployment of e s t a b l i s h e d resources and p e r s o n n e l . At t h i s p o i n t , the d e c i s i o n was made t o undertake s t u d i e s and experiments (e.g., the P s y c h i a t r i c Home Care P r o j e c t ) to determine whether i n s t i t u t i o n a l s e r v i c e s could be r e p l a c e d by l e s s expensive but e q u a l l y e f f e c t i v e community care and treatment a l t e r n a t i v e s . 408 By the end of 1972, community programmes had expanded i n the b e l i e f t h a t t h e s e would p r o v i d e an e f f e c t i v e s e r v i c e a t lower c o s t , and the government had commenced plann i n g a "compos-i t e community mental h e a l t h programme f o r Greater Vancouver" (i.e., the G.V.M.H.S.). These developments had been s t i m u l a t e d by, among other matters, the "mounting concern over the c o s t of h e a l t h c a r e " . 3 7 The Department of Health S e r v i c e s and H o s p i t a l Insurance was the l a r g e s t government department and consumed a lion's, share of the p r o v i n c i a l budget (Clague, et a l , 1984). The c o n c e r n f o r the e s c a l a t i n g c o s t s of h e a l t h c a r e d i d not d i m i n i s h w i t h the e l e c t i o n of an N.D.P. government i n 1972. The new government i n h e r i t e d an "incoherent" h e a l t h care system c h a r a c t e r i z e d by " p i e c e m e a l p l a n n i n g , f r a g m e n t e d s e r v i c e d e l i v e r y , and c a l l s f o r more co m p r e h e n s i v e s e r v i c e s " and i t i n i t i a t e d a review w i t h the goal of developing a more "e q u i t a b l e and e f f i c i e n t " system (op c i t : 119). Dr. R i c h a r d F o u l k e s was commissioned to undertake a comprehensive study and recommend improvements which would, among o t h e r m a t t e r s , "ensure f a r b e t t e r value f o r each h e a l t h d o l l a r spent" (op c i t : 132). 3 8 The F o u l k e s R e p o r t - ' H e a l t h S e c u r i t y F o r B r i t i s h C o lumbians' - was s u b m i t t e d to the government i n 1973 and proposed massive and sweeping changes which i n c l u d e d a r a d i c a l r e c o n s t r u c t i o n of the mental h e a l t h system (Foulkes, 1974). The Report advocated a r e j e c t i o n of the dominant ' m e d i c a l / p u n i t i v e model'; that i s , a r e a l change to community o r i e n t a t i o n by a t t a c k i n g p s y c h i a t r i c domination of the system and by d i s -mantling the l a r g e mental h o s p i t a l complexes subs-409 e q u e n t t o t h e d e v e l o p m e n t o f c o m m u n i t y services...and a new form of r e g i o n a l o r g a n i z a t i o n . (Foulkes, 1974a: 14). The i n s t i t u t i o n s had to be l i t e r a l l y demolished s i n c e t h i s would c o n s t i t u t e an i n v a l u a b l e , even e s s e n t i a l , s y m b o l i c a c t ; a "ceremonial s a l u t e to the beginning of the end of barbarism" (op c i t : 15). I t would a l s o reduce the c o s t s of mental i l l n e s s . For Foulkes, f i n d i n g a s o l u t i o n to the problem of mental h e a l t h i s more t h a n a q u e s t i o n o f i d e o l o g y o r e v e n humanity. I t i s becoming i n c r e a s i n g l y a p p a r e n t that our present methods of l o o k i n g at and d e a l i n g w i t h mental h e a l t h are i n c r e a s i n g l y expensive (op c i t : 23). Despite the concern f o r c o n t r o l l i n g c o s t s , expenditures on mental h e a l t h s e r v i c e s d u r i n g the N.D.P. e r a d i d not r e f l e c t r e s t r a i n t . In f i s c a l 1971/72, f o r example, t h i s component of the h e a l t h c a r e system consumed $37.4 m i l l i o n . In the l a s t f i s c a l y e a r o f t h e N.D.P. g o v e r n m e n t ( i . e . , 1 974/75), expenditures had r i s e n to $56.8 m i l l i o n . 3 9 While the i n c r e a s e was due, i n pa r t , to a r i s e i n the c o s t s of o p e r a t i n g the mental h e a l t h i n s t i t u t i o n s (e.g., Riverview H o s p i t a l ) , i t was a l s o an outcome of o t h e r i n i t i a t i v e s ; n o t a b l y , the deve l o p m e n t of community-based and d e - c e n t r a l i z e d mental h e a l t h resources. The N.D.P. government was i d e o l o g i c a l l y committed to the p r i n c i p l e of 'community c o n t r o l ' ( M o r e l y , e t a l , 1983; C l a g u e , e t a l , 1984) and, as a c o r o l l a r y , to the development of " l o c a l i n i t i a t i v e and c i t i z e n - c o n t r o l l e d primary h e a l t h care c e n t r e s " (Cumming, et a l , 1976: 20). These concerns were r e f l e c t e d i n the i n c r e a s e i n expenditures i n t h i s area. In f i s c a l 1971/72, only $1.09 m i l l i o n was expended on 'community s e r v i c e s ' (i.e., 410 mental h e a l t h c e n t r e s and o t h e r r e s o u r c e s ) but, by f i s c a l 1974/75, expenditures i n t h i s area had r i s e n to $5.7 m i l l i o n . 4 0 With the r e t u r n of a S o c i a l C r e d i t government i n 1975, the N.D.P. i n i t i a t i v e s i n the h e a l t h and s o c i a l s e r v i c e s f i e l d s were r e v i e w e d and many were abandoned (Clague, et a l , 1984). The Foulkes Report was c r i t i c i z e d f o r i t s " p o l i t i c a l " overtones, and the new M i n i s t e r of H e a l t h r e j e c t e d the p r o p o s a l s f o r a r e -c o n s t r u c t i o n of the h e a l t h care system. He opted i n s t e a d f o r ' m o d i f i c a t i o n ' , a l t h o u g h he d i d endorse F o u l k e s * g o a l of reducing the use of acute care h o s p i t a l s (op c i t ) . In a d d i t i o n , e s c a l a t i n g c o s t s became an i s s u e , i n p a r t because the S o c i a l C r e d i t r e - e l e c t i o n s t r a t e g y had i n c l u d e d an a t t a c k upon the N.D.P.'s a l l e g e d , poor f i n a n c i a l management and the c r e a t i o n of a budget d e f i c i t (Morely, et a l , 1983). By 1975, the N.D.P. government was f a c i n g economic problems. The gross p r o v i n c i a l product had f a l l e n two percent, i n f l a t i o n had a c c e l e r a t e d , and p u b l i c expenditures had r i s e n as the economy slowed and even reversed i t s growth (op c i t ) . While the t o t a l combined government expenditure i n 1971 had amounted to $1,397 b i l l i o n (13.4% of the g r o s s p r o v i n c i a l p r o d u c t ) , by 1975 t h i s had r i s e n t o $3,442 b i l l i o n (18% of the g r o s s p r o v i n c i a l p r oduct): $2,206 b i l l i o n i n constant, 1971 d o l l a r s . In f i s c a l 1974/75, the t o t a l p r o v i n c i a l combined a c t u a l expenditure exceeded the t o t a l gross revenue by $10 m i l l i o n and a budget d e f i c i t consequently appeared. By the end of f i s c a l 1975/76, the d e f i c i t had i n c r e a s e d to $410 m i l l i o n and, i n order 411 to be c o n s i s t e n t w i t h i t s e l e c t i o n p l a t f o r m , the new S o c i a l C r e d i t government began to i n t r o d u c e p u b l i c s e c t o r r e s t r a i n t measures designed to reduce the p r o v i n c i a l debt (op c i t ) . The measures were apparently s u c c e s s f u l s i n c e , by the end of f i s c a l 1976/77, government e x p e n d i t u r e s had f a l l e n to 15.8% of the gross p r o v i n c i a l product and a budget s u r p l u s of $94 m i l l i o n had been g e n e r a t e d (op c i t ) . The improved f i s c a l s i t u a t i o n was maintained and, by the end of f i s c a l 1979/80, the budget s u r p l u s had grown to $464 m i l l i o n (op c i t ) . While expenditures on h e a l t h care were lowered i n order to reduce the budget d e f i c i t , t h i s was only a temporary measure and the S o c i a l C r e d i t government g r a d u a l l y i n c r e a s e d i t s per c a p i t a e x p e n d i t u r e on h e a l t h c a r e i n r e a l ( c o n s t a n t d o l l a r ) terms (Evans, 1986). For example, while constant d o l l a r per c a p i t a e x p e n d i t u r e s t o o d a t $624.73 i n f i s c a l 1975/76, by f i s c a l 1979/80, t h i s had i n c r e a s e d to $719.57. T o t a l h e a l t h c a r e expenditures i n c r e a s e d from $892.3 m i l l i o n i n f i s c a l 1975/76 to $1,490 b i l l i o n i n f i s c a l 1979/80 and accounted f o r approximately 30% of the government's combined e x p e n d i t u r e . However, expenditures were s t a b i l i z e d so that they d i d not exceed seven per-cent of the p r o v i n c i a l domestic product (Health & Welfare: Canada, 1983; Evans, 1986) and t h i s was accomplished, i n p a r t , by the e s t a b l i s h m e n t of l o w - c o s t a l t e r n a t i v e s to c a r e and treatment i n h o s p i t a l s . As Evans p o i n t s out, between 1975/76 and 1979/80, per c a p i t a spending on care and treatment i n hosp-i t a l s rose "more or l e s s e x a c t l y at the r a t e of i n f l a t i o n ; there was no i n c r e a s e i n r e a l spending i n t h i s area" (1986: 185). 412 The t a c t i c of e x p a n d i n g the network of m e n t a l h e a l t h c e n t r e s and other community-based a l t e r n a t i v e s r e f l e c t e d the government's p o l i c y of s t a b i l i z i n g the c o s t s of h o s p i t a l s . W h ile t h e r e was an i n c r e a s e i n both the c u r r e n t and c o n s t a n t d o l l a r expenditures on, i n p a r t i c u l a r , mental h e a l t h c e n t r e s , t h i s component of the system was a more c o s t - e f f e c t i v e way of managing p a t i e n t s than i n s t i t u t i o n s . Despite the process of de-i n s t i t u t i o n a l i z a t i o n , b o t h the c u r r e n t and c o n s t a n t d o l l a r e x p e n d i t u r e s on t h e t r e a t m e n t o f h o s p i t a l i z e d p a t i e n t s ( e s p e c i a l l y at Riverview H o s p i t a l ) rose s t e a d i l y throughout the 1970's. F o r example, a t the end of f i s c a l 1970/71, the o p e r a t i n g c o s t s of the H o s p i t a l had amounted to $16.1 m i l l i o n and the i n s t i t u t i o n had t r e a t e d 5,431 p a t i e n t s ($8.16 per p a t i e n t t r e a t e d , per day). By the end of 1979, the H o s p i t a l o p e r a t i n g c o s t s f o r the year had r i s e n to $37.6 m i l l i o n (current d o l l a r s ) ; however, the H o s p i t a l had only t r e a t e d 2,473 p a t i e n t s and the per diem, per p a t i e n t t r e a t e d cost had soared to $41.65 (current d o l l a r s ) . I f i n c r e a s e s i n o p e r a t i n g c o s t s had merely k e p t p a c e w i t h t h e r a t e o f i n f l a t i o n o v e r t h e d e c a d e (approximately 67%) the o p e r a t i n g c o s t s would have only r i s e n to $26.8 m i l l i o n and the per diem t r e a t e d c o s t to $13.62. Expenditures on the treatment of p a t i e n t s i n the H o s p i t a l had i n c r e a s e d i n r e a l terms over the ten year p e r i o d , even though the number of p a t i e n t s being t r e a t e d had been h a l v e d . 4 1 While expenditures on mental h e a l t h c e n t r e s a l s o i n c r e a s e d i n r e a l terms, they managed a much l a r g e r and i n c r e a s i n g volume of p a t i e n t s . At the end of f i s c a l 1970/71, the c e n t r e s had 413 expended $1.5 m i l l i o n on the treatment of 9,923 cases (43 cents per p a t i e n t , per day). By the end of 1979, the annual o p e r a t i n g c o s t s of the ce n t r e s stood at $6.8 m i l l i o n (current d o l l a r s ) and they had t r e a t e d 17,519 c a s e s i n the y e a r : $1.06 per p a t i e n t , per day (current d o l l a r s ) . I f i n c r e a s e s i n expenditures had been pegged to the ra t e of i n f l a t i o n over the decade the op e r a t i n g c o s t s of the c e n t r e s i n 1979 would have amounted to $2.5 m i l l i o n and the per diem t r e a t e d cost would have r i s e n to only 71 cents. By the end of the decade, c u r r e n t d o l l a r e x p e n d i t u r e s on the cent r e s had i n c r e a s e d n e a r l y f i v e f o l d but the volume of p a t i e n t s had a l s o grown and i t was a p p a r e n t t h a t a l a r g e number of p a t i e n t s c o u l d be managed i n r e t u r n f o r a r e l a t i v e l y s m a l l o u t l a y . An enhancement of the r o l e of mental h e a l t h c e n t r e s , as w e l l as home treatment programmes and comprehensive community mental h e a l t h s e r v i c e s (e.g., the G.V.M.H.S.), was a s s i s t i n g the M i n i s t r y of Health i n i t s quest to provide e f f e c t i v e s e r v i c e s at minimum c o s t . 4 2 C e r t a i n l y , these comparative data are l i m i t e d measures of the r e l a t i v e c o s t - e f f e c t i v e n e s s of mental h e a l t h c e n t r e s ; f o r example, t h e y do not take a c c o u n t of the e x t e n t to which h o s p i t a l i z e d p a t i e n t s r e q u i r e d a more i n t e n s i v e (and, t h e r e f o r e , c o s t l y ) programme of t r e a t m e n t than those a t t e n d i n g mental h e a l t h c e n t r e s . E x p e n d i t u r e s on the b o a r d i n g home programme which, i n 1979, c o s t an a d d i t i o n a l $500,000 (60 c e n t s p e r r e s i d e n t per day), are excluded. S i m i l a r l y , no account i s taken of the M i n i s t r y of Human Resources expenditures on s e r v i c e s and b e n e f i t s f o r mental h e a l t h p a t i e n t s r e c e i v i n g c a r e and 414 t r e a t m e n t i n the community. By the end of the decade, the M i n i s t r y was c o n t r a c t i n g w i t h n o n - p r o f i t s o c i e t i e s f o r the p r o v i s i o n of community s e r v i c e s such as 'achievement c e n t r e s ' . 4 3 More i m p o r t a n t l y , the M i n i s t r y was p r o v i d i n g s o c i a l a s s i s t a n c e (e.g., G.A.I.N.) which ranged from $240 per month f o r a s i n g l e person, to $855 per month f o r a l a r g e f a m i l y , and there i s no doubt t h a t m e n t a l h e a l t h p a t i e n t s a t t e n d i n g m e n t a l h e a l t h c e n t r e s were among the 114,000 i n d i v i d u a l s who r e c e i v e d s o c i a l a s s i s t a n c e every month. 4 4 However, the c e n t r e s and o t h e r community s e r v i c e s were d e t e r r i n g new a d m i s s i o n s and r e - a d m i s s i o n s to R i v e r v i e w and o t h e r m e n t a l h e a l t h f a c i l i t i e s . The p o p u l a t i o n of t h e s e i n s t i t u t i o n s d e c l i n e d even though the p r o v i n c i a l p o p u l a t i o n i n c r e a s e d . In the absence of mental h e a l t h c e n t r e s and other s u p p o r t i v e r e s o u r c e s , t h e r e i s no doubt t h a t the i n - p a t i e n t p o p u l a t i o n would have r i s e n and the c o s t s of o p e r a t i n g the f a c i l i t i e s would have e s c a l a t e d . In a d d i t i o n , new i n s t i t u t i o n s would have been necessary and the c a p i t a l c o s t s of c o n s t r u c t i o n much higher than the c o s t s i n v o l v e d i n e i t h e r r e n o v a t i n g p a r t s of e x i s t i n g government b u i l d i n g s or c o n s t r u c t i n g new premises, to accommodate the mental h e a l t h c e n t r e s . There i s e v e r y i n d i c a t i o n t h a t , g e n e r a l l y , c a r e and treatment i n the community was seen as p o s s i b l y more e f f e c t i v e than care and treatment i n an i n s t i t u t i o n . I t was c e r t a i n l y no more e x p e n s i v e and may even have been cheaper, and t h e r e i s l i t t l e doubt t h a t , by the end of the 1970's, a l l of t h i s was 415 recognized by a government that was committed to a long-term p o l i c y of reducing the u t i l i z a t i o n of a l l h o s p i t a l s , not j u s t those c a t e r i n g to i n d i v i d u a l s s u f f e r i n g from mental i l l n e s s . The i n t r o d u c t i o n of t h i s p o l i c y was due, i n p a r t , to the c o s t - s t a b i l i z a t i o n measures introduced by the f e d e r a l government d u r i n g the 1970's. By the end of 1975, the l a t t e r had i n d i c a t e d t h a t i t wished to develop a new c o s t - s h a r i n g formula the purpose of which was to r e - d i s t r i b u t e the e s c a l a t i n g c o s t s of medicare (Guest, 1985). Ottawa had, f o r example, announced i t s i n t e n t i o n to introduce c e i l i n g s on the r a t e of i n c r e a s e i n the f e d e r a l p o r t i o n of the c o s t s of p h y s i c i a n s e r v i c e s . The p r o v i n c e s p r o t e s t e d s i n c e i t was b e l i e v e d that t h i s would r e s u l t i n an increase i n p r o v i n c i a l expenditures on h e a l t h care; they would have to a b s o r b i n c r e a s e s i f m e d i c a l and h o s p i t a l c o s t s r o s e f a s t e r than the growth of the economy and, i n B r i t i s h Columbia, i t was e s t i m a t e d that the new formula would cost the province an a d d i t i o n a l $170 m i l l i o n over a f i v e year p e r i o d . 4 5 By the end of 1976, a new p r o v i n c i a l - f e d e r a l agreement was s t i l l b e i n g n e g o t i a t e d but t h e r e was a consensus t h a t the e x i s t i n g c o s t - s h a r i n g formula would be abandoned. However, the s i t u a t i o n was c h a r a c t e r i z e d by an a i r of u n c e r t a i n t y and the p r o v i n c i a l government was f a c i n g "the economic p r e s s u r e s of r i s i n g h e a l t h c o s t s " . 4 6 A l l medical insurance r e s e r v e s had been depleted and the government was using c o n s o l i d a t e d revenue to f i n a n c e the system. In o r d e r to r e s o l v e t h i s p r o b l e m , the government announced a s u b s t a n t i a l i n c r e a s e i n medical insurance premiums. Monthly premiums rose 50% and the per diem charge f o r 416 h o s p i t a l care i n c r e a s e d from one d o l l a r to four d o l l a r s . The new f e d e r a l - p r o v i n c i a l agreement ( i . e . , b l o c k g r a n t funding) came i n t o e f f e c t i n 1977 and s t i m u l a t e d the search f o r " l o w - c o s t a l t e r n a t i v e s to h i g h - c o s t c a r e " i n the p r o v i n c e . 4 8 F e d e r a l f u n d i n g f o r h e a l t h c a r e became s e n s i t i v e to the ' b u s i n e s s c y c l e ' and t h i s f a c t o r was to have s i g n i f i c a n t consequences w i t h the onset of the r e c e s s i o n i n the e a r l y 1980's (Guest, 1985; Evans, 1986). At the same t i m e , the s o - c a l l e d ' E s t a b l i s h e d Programmes Financing' scheme d i d c o n t a i n advantages f o r the p r o v i n c e s . As Guest p o i n t s out, the p r o v i n c e s no l o n g e r had to match f e d e r a l g r a n t s w i t h p r o v -i n c i a l d o l l a r s but c o u l d a l l o c a t e b o t h f e d e r a l money and t h e i r own f o r any programme purpose w i t h i n the g e n e r a l a r e a of h e a l t h . I t was hoped t h a t t h i s i n c r e a s e d autonomy and f l e x i b i l i t y i n managing the h e a l t h c a r e system would r e s u l t i n g r e a t e r economies (op c i t : 225) The scheme e f f e c t i v e l y c l e a r e d the way f o r the p r o v i n c e s to do whatever they wished i n the f i e l d of h e a l t h c a r e , i n c l u d i n g encouraging the "growth of f r e e market concepts i n the h e a l t h c a r e s y s t e m " (op c i t ) . I t e n a b l e d the B r i t i s h C o l u m b i a government to i n t r o d u c e a 'long-term c a r e programme' which r e l i e d h e a v i l y upon the p r i v a t e s e c t o r , and to hunt f o r other l e s s e x p e n s i v e a l t e r n a t i v e s to i n - p a t i e n t c a r e i n h o s p i t a l s which would "contain the r i s i n g c o sts of h e a l t h c a r e " . 4 9 In sum, the measures introduced by the f e d e r a l government as p a r t of i t s s t r a t e g y f o r reproducing the c o n d i t i o n s necessary f o r continued c a p i t a l accumulation had a s i g n i f i c a n t impact upon the p r o v i n c i a l g o v e r n m e n t ' s g e n e r a l h e a l t h c a r e p o l i c y . 417 Adjustments had to be made and s t u d i e s of v a r i o u s aspects of the p r o v i n c i a l h e a l t h c a r e system were c o n s e q u e n t l y u n d e r t a k e n . These i n c l u d e d a mental h e a l t h planning survey. C o s t - S t a b i l i z a t i o n , The Cumming Repor t on P r o v i n c i a l M e n t a l Health Care, and the Rise of the New Legalism In 1978, the p r o v i n c i a l government e s t a b l i s h e d the ' H o s p i t a l F u n d i n g P r o j e c t ' , a p p o i n t e d a ' M e d i c a l Manpower Advisory Committee' and commissioned a mental h e a l t h planning survey. The c o s t of o p e r a t i n g h o s p i t a l s c o n s t i t u t e d the l a r g e s t s i n g l e item i n the p r o v i n c i a l budget and the M i n i s t e r of Health was eager to c r e a t e a system that a l l o c a t e d funds " e q u i t a b l y , f o r optimum p a t i e n t c a r e . " 5 0 The government had to develop a new, g e n e r a l , h e a l t h care s t r a t e g y ' t h a t w o u l d , 5 1 provide l e a d e r s h i p and d i r e c t i o n i n the promotion and safeguarding of an optimum s t a t e of h e a l t h f o r a l l residents...with due regard to f i n a n c i a l l i m i t -a t i o n s , by e n s u r i n g the p r o v i s i o n of s e r v i c e s t h r o u g h the e f f i c i e n t use of a v a i l a b l e r e s o u r c e s and by s t i m u l a t i n g p e r s o n a l , f a m i l y , and community r e s p o n s i b i l i t y and involvement. The o b j e c t i v e s included; the promotion of p r e v e n t i o n progammes and a l t e r n a t i v e s that would "contain the r i s i n g c o s t s of h e a l t h c a r e " ; a r e - o r g a n i z a t i o n w i t h i n the M i n i s t r y of H e a l t h to enhance i t s r o l e as f a c i l i t a t o r and c o - o r d i n a t o r (rather than d i r e c t p r o v i d e r ) of s e r v i c e s ; the 'education' of the p u b l i c i n r e g a r d to " f i n a n c i a l r e s p o n s i b i l i t y " and the " u t i l i z a t i o n of s e r v i c e s " ; and, u l t i m a t e l y , the p r o v i s i o n of a more e f f e c t i v e and e q u i t a b l e system of h e a l t h care. ^ I t was f e l t t h a t a new s t r a t e g y was ' t i m e l y ' because of the impact of changes i n the f e d e r a l - p r o v i n c i a l h o s p i t a l funding 418 a r r a n g e m e n t s which p l a c e d a h e a v i e r f i n a n c i a l burden on the shoulders of the p r o v i n c e s . 5 3 C o s t - s t a b i l i z a t i o n was a c r i t i c a l i s s ue and a l l h e a l t h s e r v i c e s were to be re - o r g a n i z e d to enhance and develop community-based a l t e r n a t i v e s to h o s p i t a l s . Indeed, i t was the " M i n i s t r y ' s i n t e n t i o n to de-emphasize i n - p a t i e n t care and place g r e a t e r emphasis on p r e v e n t i v e , ambulatory and home c a r e programs," s i n c e t h e r e was a " h i g h e r than n e c e s s a r y u t i l i z a t i o n of h o s p i t a l s . " There would be a " s h i f t i n emphasis from i n - p a t i e n t c a r e i n h o s p i t a l beds to day c a r e and home care," and t h i s was based "on the b e l i e f that such programs are both b e t t e r f o r the p a t i e n t and l e s s c o s t l y to the t a x p a y e r . " 5 4 The H o s p i t a l Funding P r o j e c t was to devise a b e t t e r system and t h i s e n t e r p r i s e evolved i n t o the 'Hospital Role Study' - a major a s s e s s m e n t of h o s p i t a l s e r v i c e s i n the p r o v i n c e ( M i n i s t r y of Health, 1981). The Medical Manpower Advisory Committee was a l s o appointed to help address f i n a n c i a l i s s u e s . The Committee was to make recommendations re g a r d i n g the geo g r a p h i c a l d i s t r i b u t i o n of p h y s i c i a n s and to " a d v i s e on r e l a t e d c o s t c o n t a i n m e n t i s s u e s " . 5 5 The m e n t a l h e a l t h p l a n n i n g s u r v e y was, t h e r e f o r e , i n i t i a t e d at a time when the p r o v i n c i a l government was concerned w i t h c o n t a i n i n g the co s t s of the e n t i r e h e a l t h care system, not j u s t the mental h e a l t h component. Dr. John Cumming was commissioned to assess the d e l i v e r y of mental h e a l t h s e r v i c e s i n the province and to make recommendations which would "improve the c o - o r d i n a t i o n and d e l i v e r y of these s e r v i c e s " , 5 6 and the 'Cumming Report' was presented to the M i n i s t e r of Health i n May 419 1979. The Report was the product of a 12 month study of a l l the f a c e t s o f m e n t a l h e a l t h c a r e and c o n t a i n e d a s e t o f recommendations r e g a r d i n g b o t h a f u t u r e s t r a t e g y f o r the management of the mentally d i s o r d e r e d and l e g i s l a t i v e changes t h a t would f a c i l i t a t e i m p l e m e n t a t i o n ( M i n i s t r y of H e a l t h , 1979 ) . 5 7 At the time the s u r v e y was c o n d u c t e d ( f i s c a l 1978/79), M i n i s t r y o f H e a l t h e x p e n d i t u r e s t o t a l l e d $1.3 b i l l i o n and c o n s t i t u t e d the l a r g e s t i t e m i n the p r o v i n c i a l b u d g e t . 5 8 H o s p i t a l Programmes had ab s o r b e d 48% ($631.3 m i l l i o n ) , and R i v e r v i e w H o s p i t a l and the p s y c h o g e r i a t r i c f a c i l i t i e s had consumed a f u r t h e r $47.7 m i l l i o n . Consequently, the combined c o s t of H o s p i t a l Programmes and mental h e a l t h f a c i l i t i e s accounted f o r 51% of the M i n i s t r y ' s budget. The t o t a l cost of op e r a t i n g the mental h e a l t h i n s t i t u t i o n s and a l l mental h e a l t h programmes (e.g., mental h e a l t h c e n t r e s ) amounted to $63.1 m i l l i o n (4.8% of the M i n i s t r y ' s budget) but mental h e a l t h p a t i e n t s were a l s o r e c e i v i n g treatment i n the p s y c h i a t r i c u n i t s of general h o s p i t a l s . In f i s c a l 1978/79, the approximate per p a t i e n t , per diem c o s t of h o s p i t a l c a r e was $170.6 and the average m e n t a l h e a l t h p a t i e n t (who s t a y e d 13.8 days) c o s t $2,354.28. G i v e n t h a t , i n 1978, some 9,913 m e n t a l h e a l t h p a t i e n t s were admitted to and t r e a t e d i n p s y c h i a t r i c u n i t s , t h i s category of p a t i e n t consumed approximately $23.3 m i l l i o n of the t o t a l cost of H o s p i t a l Programmes. In t o t a l , the p r o v i s i o n of care and treatment f o r mental h e a l t h p a t i e n t s i n 1978/79 cost an est i m a t e d $86.4 m i l l i o n (6.5% of the t o t a l h e a l t h budget). Not 420 a vast amount i n the context of the o v e r a l l budget but, never-t h e l e s s , worthy of a t t e n t i o n i f economies could be achieved. In t h i s regard, Dr. Cumming's r e p o r t endorsed the government's goal of enhancing community-based a l t e r n a t i v e s to i n s t i t u t i o n a l care; i n d e e d , i t c o n t a i n e d a s t r o n g recommendation t h a t the f u t u r e f o c u s be upon the development of adequate community s u p p o r t systems. Cumming c o n c u r r e d w i t h the view t h a t the m e n t a l l y d i s o r d e r e d were alr e a d y l i v i n g outside mental h o s p i t a l s and that a r e l i a n c e upon h o s p i t a l care would d i m i n i s h . The trend was to be supported s i n c e the c o s t s of h o s p i t a l i z a t i o n were too high, the human and c i v i l r i g h t s i s s u e s too complex, and the negative s i d e - e f f e c t s too great ( M i n i s t r y of Health, 1979: App. IV). Cumming f e l t t h e r e was a need to d e v e l o p new community s u p p o r t s y s t e m s , p r o p e r l y c o - o r d i n a t e e x i s t i n g community s e r v i c e s , and open more general h o s p i t a l p s y c h i a t r i c u n i t s to deal with short-term acute cases. Units should take r e f e r r a l s from community w o r k e r s and use p s y c h i a t r i s t s and g e n e r a l p r a c t i t i o n e r s on a s e s s i o n a l b a s i s , to both undertake admissions and s u p e r v i s e care. Personnel t r a i n i n g and standards should be improved t o en s u r e b e t t e r v a l u e f o r money s i n c e s a l a r i e s consumed the l a r g e s t p r o p o r t i o n of the mental h e a l t h budget. The s y s t e m was t o be c o n t i n u a l l y e v a l u a t e d t o e n s u r e ' p r o d u c t i v i t y ' and an emphasis was to be p l a c e d upon 'primary p r e v e n t i o n ' i n o r d e r to reduce the h i g h c o s t of c a r e and treatment. Mental h e a l t h s e r v i c e s needed to be r a t i o n a l i z e d and thereby rendered more c o s t - e f f e c t i v e (op c i t ) . Many of the recommendations flowed from Cumming's concerns 421 r e g a r d i n g e x i s t i n g community and i n s t i t u t i o n a l r esources. The concept of the mental h e a l t h centre was sound but many problems had emerged which r a i s e d q u e s t i o n s of e f f i c i e n c y . W h i l e the c e n t r e s were supposed to be based upon the p r i n c i p l e of the ' m u l t i - d i s c i p l i n a r y team', the bulk of the work was shouldered by s o c i a l w o r k e r s . O t h e r p r o f e s s i o n a l s ( n o t a b l y , n u r s e s and p s y c h o l o g i s t s ) were i n short supply, only four c e n t r e s enjoyed the s e r v i c e s of a f u l l - t i m e p s y c h i a t r i s t , and 13 c e n t r e s r e c e i v e d no i n p u t from p s y c h i a t r i s t s . There was a l a c k of c o h e s i o n among s t a f f ; i n d e e d , t h e y t e n d e d t o o p e r a t e independently because of c o n f l i c t s and r i v a l r y . 5 9 The c o n f l i c t was not c o n d u c i v e to the p r o v i s i o n of e f f e c t i v e c a r e and treatment and, i n Cumming's view, the c e n t r e s needed to be more c l o s e l y i n t e g r a t e d with other h e a l t h s e r v i c e s and h o s p i t a l s i n a r e g i o n , and r e - o r g a n i z e d as 'community support s e r v i c e s u n i t s ' . They should be s t a f f e d by p s y c h i a t r i c nurses, enjoy i n c r e a s e d budgets, and assume a b r o a d e r r e s p o n s i b i l i t y f o r p r o v i d i n g i n t e g r a t e d community care (op c i t ) . I n s o f a r as the mental h e a l t h c e n t r e s had t h e i r problems, so too d i d the i n s t i t u t i o n s , and Riverview H o s p i t a l was s i n g l e d out f o r severe c r i t i c i s m . Programming lac k e d c o - o r d i n a t i o n and the H o s p i t a l was o p e r a t i n g " i n the p i o u s hope t h a t i f each d i s c i p l i n e does that which i s a p p r o p r i a t e to i t the r e s u l t i n g whole w i l l be a t h e r a p e u t i c programme" (op c i t : 54). The s i t u a t i o n was not h e l p f u l to p a t i e n t s who r e q u i r e d and responded to "a s t r u c t u r e d e n v i r o n m e n t i n w hich they (had) a c l e a r cut r o l e w i t h r i g h t s and o b l i g a t i o n s and i n which the o n going 422 programme encourages and s u s t a i n s a sense of both membership and accomplishment" (op c i t ) . The H o s p i t a l ' s a c c o u n t i n g and b u d g e t i n g s y s t e m was d e f i c i e n t and c o n s e q u e n t l y was i n c a p a b l e of r e p o r t i n g on the c o s t s of v a r i o u s a s p e c t s of p a t i e n t c a r e and t r e a t m e n t . S i m i l a r l y , the system could not account f o r the high c o s t s and low q u a l i t y of f o o d s e r v i c e s ; a s i t u a t i o n t h a t s u g g e s t e d the p r e s e n c e of ' u n n o t i c e d t h e f t ' . In s h o r t , the H o s p i t a l " c o u l d not j u s t i f y i t s a c t i o n s i n f i s c a l terms" (op c i t : 55). The flow of p a t i e n t s was being a r t i f i c i a l l y r e s t r i c t e d 6 0 and, while t h i s p r a c t i c e had r e s u l t e d i n both a p o p u l a t i o n d e c r e a s e and the a v o i d a n c e of the ' r e v o l v i n g door' p r o b l e m , i t was c r e a t i n g d i f f i c u l t i e s f o r those areas i n the pro v i n c e where no general h o s p i t a l p s y c h i a t r i c u n i t s e x i s t e d . The D i r e c t o r of the f a c i l i t y had decided to l i m i t p a t i e n t intake to 13 p a t i e n t s per month f o r each p s y c h i a t r i s t on the a d m i s s i o n ward; the most clogged s e c t i o n of the H o s p i t a l (op c i t ) . Although i n t e g r a t e d , m u l t i - d i s c i p l i n a r y treatment teams were s u p p o s e d t o be d e v e l o p i n g a c o - o r d i n a t e d c l i n i c a l programme, there was no evidence that t h i s was o c c u r r i n g . The de f e c t was blamed on ' s t a f f shortages' but i t was a l s o due to an adherence to obs o l e t e work r u l e s and p r a c t i c e s which consumed an i n o r d i n a t e amount of c l i n i c a l time. There was no evidence of mistreatment although many par t s of the H o s p i t a l were d e s c r i b e d as ' d e p r e s s i n g ' and t h e r e was an o v e r a l l " l a c k of the v i g o r , morale and i n g e n u i t y necessary to achieve maximal t h e r a p e u t i c 423 p o t e n t i a l from ward s t a f f " (op c i t : 56 - 57). Q u e s t i o n s were a l s o r a i s e d i n r e l a t i o n to the l e v e l of care that was r e q u i r e d f o r the p a t i e n t p o p u l a t i o n . The p r o j e c t team s u r v e y e d the p a t i e n t p o p u l a t i o n on June 18th 1978, and d i s c o v e r e d t h a t 230 of the 1,102 p a t i e n t s (21.3%) d i d not r e q u i r e p s y c h i a t r i c c a r e of any k i n d ( e s p e c i a l l y , c a r e i n an a c u t e h o s p i t a l s e t t i n g ) and c o u l d have been d i s c h a r g e d i f v a r i o u s community s u p p o r t s had been i n p l a c e . The same was p o s s i b l y true of other p a t i e n t s who r e q u i r e d only r e h a b i l i t a t i v e and p r e - i n f i r m a r y c a r e . Indeed, o n l y h a l f of the p a t i e n t p o p u l a t i o n r e q u i r e d c o n t i n u i n g p s y c h i a t r i c c a r e and a c u t e p s y c h i a t r i c care. O v e r a l l , Cumming f e l t that the H o s p i t a l had to r a t i o n a l i z e i t s f i s c a l , a d m i n i s t r a t i v e , and programme o p e r a t i o n s and t h a t , r a t h e r than s i m p l y d e n y i n g a c c e s s and c r e a t i n g a w a i t i n g - l i s t , every e f f o r t had to be made to render the f a c i l i t y more c o s t - e f f e c t i v e . The survey team a l s o assessed the s i t u a t i o n i n the f i e l d of p r i v a t e s e c t o r care. Cumming f e l t that the i n i t i a t i v e s taken by the n o n - p r o f i t s e c t o r were laudable and l a u r e l s were handed to, i n p a r t i c u l a r , the v a r i o u s schemes which enabled p a t i e n t s to l i v e i n d e p e n d e n t l y i n the community. On the o t h e r hand, the p r i v a t e , f o r - p r o f i t s e c t o r , which was i n v o l v e d i n the p r o v i s i o n of boarding home care, l e f t much to be d e s i r e d . Since i t was not p o s s i b l e to v i s i t every boarding home i n the p r o v i n c e ( t h e r e were more than 300), the s u r v e y team s e l e c t e d a sample of 27 homes which provided care f o r a t o t a l of 424 462 p a t i e n t s . S i x t e e n homes were found to c o n t a i n l e s s than d e s i r e a b l e c o n d i t i o n s ; indeed, s i x should have been c l o s e d down. The homes were c h a r a c t e r i z e d by o v e r - c r o w d i n g , a l a c k of p r i v a c y , a l a c k of programmes, and i n f r a c t i o n s of l i c e n s i n g r e g u l a t i o n s . The other 10 were d e s c r i b e d as 'back-wards'. In Cumming's view, 31% of the p a t i e n t s seen were judged t o be l i v i n g i n c i r c u m s t a n c e s so sub-s t a n d a r d t h a t improvement c o u l d not be e x p e c t e d without r a d i c a l changes i n e i t h e r the p l a n t or the management, f o r t y one percent were l i v i n g i n unsat-i s f a c t o r y c i r c u m s t a n c e s , but i t was judged t h a t these could be improved (op c i t : 88). The s o c i a l workers s u p e r v i s i n g the programme were under pressure to p l a c e p a t i e n t s i n homes but p r i v a t e operators were concerned w i t h p r o f i t a b i l i t y and t h e r e f o r e wanted d o c i l e , e a s i l y managed r e s i d e n t s . In a d d i t i o n , the survey team heard p e r s i s t e n t and c o n s i s t e n t rumours of o p e r a t o r s who were o v e r - m e d i c a t i n g , p h y s i c a l l y abusing, and f a i l i n g to provide adequate food f o r , t h e i r r e s i d e n t s . I t was f e l t t h a t the f i n d i n g s of the s u r v e y p r o b a b l y r e f l e c t e d the s i t u a t i o n throughout the boarding home programme and that t h i s area of mental h e a l t h care c o n s t i t u t e d a problem. C o n s e q u e n t l y , t h e r e was a need, among o t h e r m a t t e r s , to make operato r s more accountable to t h e i r c o n t r a c t s , l i m i t the s i z e of homes, improve l i v i n g c o n d i t i o n s , and ensure that r e s i d e n t s were e n r o l l e d i n adequate day programmes. The Cumming Report a l s o addressed the i s s u e of law reform and i t was recommended that the Mental Health Act be completely r e c o n s t r u c t e d i n order to f a c i l i t a t e both a r a t i o n a l i z a t i o n of 425 the mental health, system and the d e s i r e d emphasis upon the use of community-based s e r v i c e s . W h i l e the s t a t u t e had been s u b j e c t e d to minor amendments s i n c e 1964, i n Cumming's view, " r e v i s i o n s have f a i l e d to keep pace with the r a p i d changes i n the s e r v i c e system" (op c i t : 111). In p a r t i c u l a r , reforms were needed i n the f o l l o w i n g a r e a s : the p r o c e s s of a d m i t t i n g i n v o l u n t a r y p a t i e n t s ; the p r o v i s i o n which allowed the d i r e c t o r s of mental h e a l t h f a c i l i t i e s to c r e a t e w a i t i n g l i s t s ; the f a i l u r e to make s p e c i f i c p r o v i s i o n f o r p s y c h i a t r i c u n i t s , o u t - p a t i e n t s e r v i c e s , community mental h e a l t h c e n t r e s , and other community s e r v i c e s ; the f a i l u r e to use R e g u l a t i o n s as a mechanism f o r t r a n s m i t t i n g p o l i c y ; and, p a t i e n t s ' r i g h t s . The mental h e a l t h s t a t u t e should be " e n t i r e l y r e w r i t t e n , modernized and expanded to cover those areas now d e a l t with inadequately" (op c i t : 112). In the area of i n v o l u n t a r y admission, Cumming f e l t that the grounds f o r c e r t i f i c a t i o n were too broad and at odds with "modern concepts of c i v i l l i b e r t i e s " . The procedure was u n c l e a r and probably r e s u l t e d i n p a t i e n t s being detained on the b a s i s of c e r t i f i c a t e s t h a t were " t e c h n i c a l l y imperfect". In a d d i t i o n , the p r o c e s s of r e v i e w i n g the need f o r c e r t i f i c a t i o n and c o n t i n u e d d e t e n t i o n was d i f f i c u l t and f a i l e d t o p r o t e c t p a t i e n t s ' r i g h t s . P a t i e n t s could 'appeal' to the review panel but there was "no way of knowing whether p a t i e n t s (were) always accorded t h i s r i g h t . " When reviews occurred, they seemed to be "perfunctory" and p a t i e n t s could not be adequately represented by counsel s i n c e the l a t t e r was not able to both see p a t i e n t s ' f i l e s and t e s t the evidence found i n them; that i s , a patient's 426 l a w y e r was n o t e n t i t l e d t o q u e s t i o n t h e m e n t a l h e a l t h p r o f e s s i o n a l s who had made e n t r i e s i n the f i l e s which were used by the r e v i e w p a n e l i n the d e c i s i o n - m a k i n g p r o c e s s . In Cumming's view, the "procedure l a c k s any of the safeguards of a f a i r hearing and i s p a t e n t l y open i f not to abuse, at l e a s t to negl e c t of the l e g i t i m a t e r i g h t s of the p a t i e n t " (op c i t : 111-112). Cumming recommended a n a r r o w i n g of the c r i t e r i a f o r i n v o l u n t a r y admission, a t i g h t e n i n g of admission procedures, and the i n t r o d u c t i o n of r e v i e w p r o c e d u r e s t h a t would make the p r o c e s s b o t h f a i r e r and more a c c e s s i b l e . The p r o c e s s o f ad m i t t i n g p a t i e n t s i n v o l u n t a r i l y would become more d i f f i c u l t , while the process of se c u r i n g a discharge would become e a s i e r . On the q u e s t i o n of o t h e r r i g h t s f o r p a t i e n t s , Cumming noted that the s t a t u t e f a i l e d to s p e c i f y the general r i g h t s of p a t i e n t s ; notably, the r i g h t to make c o n t r a c t s unless d e c l a r e d incompetent; the r i g h t to have access to f r e e communication; the r i g h t to i n f o r m a t i o n about treatment; and, the r i g h t to p r i v a c y and c o n f i d e n t i a l i t y . He a l s o f e l t that "the r i g h t to treatment and the r i g h t to ref u s e treatment must be con s i d e r e d and made e x p l i c i t " , a l o n g w i t h the " r i g h t to t r e a t m e n t i n the l e a s t r e s t r i c t i v e s e t t i n g p o s s i b l e " (op c i t : 112). Indeed, p h y s i c i a n s who s i g n e d c e r t i f i c a t e s f o r i n v o l u n t a r y a d m i s s i o n s h o u l d be r e q u i r e d to s t a t e that admission to an i n s t i t u t i o n c o n s t i t u t e d the use of the l e a s t r e s t r i c t i v e s e t t i n g . The i n t r o d u c t i o n of t r e a t m e n t - r e l a t e d r i g h t s was c o n s i s t e n t with h i s recommendation that the d i r e c t o r of a f a c i l i t y no longer be p e r m i t t e d to refuse a d m i s s i o n i f adequate c a r e and t r e a t m e n t was not a v a i l a b l e . 427 While the r e l e v a n t s e c t i o n of the Act (i.e., s. 21 (a)) had been o r i g i n a l l y i n troduced as a way of preventing over-crowding, i n p r a c t i c e i t was used to l i m i t s t a f f caseloads. A w a i t i n g l i s t c o u ld be crea t e d and used to r e g u l a t e the flow of admissions, and t h i s d e n i e d p a t i e n t s a c c e s s to t r e a t m e n t . In Cumming's view, i t was p r e f e r a b l e that the demand f o r s e r v i c e be met by r e - o r g a n i z i n g and r a t i o n a l i z i n g H o s p i t a l p r a c t i c e s . W h i l e the r e a c t i o n s to the Cumming R e p o r t were mixed ( M i l e s , 1982), immediate steps were taken to r e s o l v e some of the p r o b l e m s u n c o v e r e d i n the s u r v e y . 6 1 P e r s o n n e l from the M i n i s t r i e s of F i n a n c e and A t t o r n e y - G e n e r a l r e v i e w e d the s i t u a t i o n at Riverview H o s p i t a l and new f i s c a l c o n t r o l s were introduced. In keeping w i t h Cumming's recommendations, steps were taken to d i v i d e the H o s p i t a l i n t o three r e g i o n a l s e r v i c e s and e f f o r t s were made to b e t t e r meet the demand f o r u r g e n t a d m i s s i o n s by r e - o r g a n i z i n g the a v a i l a b l e r e s o u r c e s . In a d d i t i o n , i t was repo r t e d that o p e r a t i o n s i n a l l areas of the H o s p i t a l were b e i n g r a t i o n a l i z e d i n o r d e r to a c h i e v e c o s t -e f f e c t i v e n e s s . 6 2 By the end of 1979, the M i n i s t e r of Health had examined mental h e a l t h p o l i c i e s w i t h a view to i m p r o v i n g the c o s t -e f f e c t i v e n e s s of s e r v i c e s ; p a r t i c u l a r l y , those aimed a t c h r o n i c a l l y and a c u t e l y mentally i l l persons who were r e c e i v i n g , or who might r e q u i r e , t r e a t m e n t i n h o s p i t a l s . 6 3 S e r v i c e p r i o r i t i e s were r e d e f i n e d and the p r e v a i l i n g s t r a t e g y f o r the management of the men t a l l y d i s o r d e r e d was adjus t e d i n a way that underscored the importance of continued d e - i n s t i t u t i o n a l i z a t i o n 428 and n o n - i n s t i t u t i o n a l i z a t i o n . Every e f f o r t was to be made to improve the management of p a t i e n t s who evidenced m u l t i p l e h o s p i t a l admissions and gross d e f i c i e n c i e s , and who could not care f o r themselves or engage i n work. 6 4 M e d i c a t i o n and the p r o v i s i o n of s h e l t e r were seen as the ' c o r n e r s t o n e s ' of s e r v i c e s f o r t h i s group s i n c e both elements allowed p a t i e n t s to r e c e i v e care and treatment i n the community. 6 5 S h e l t e r was to be provided through the boarding home programme and, i n the l i g h t of Cumming's c r i t i c i s m s , e f f o r t s were made to upgrade the s t a n d a r d s of homes. The b o a r d i n g homes were amalgamated w i t h the l o n g - t e r m c a r e programme and an emphasis was placed upon r e h a b i l i t a t i o n r a t h e r than j u s t ' c u s t o d i a l ' c a r e . The need f o r more a n c i l l a r y s e r v i c e s was r e c o g n i z e d (e.g., a c t i v i t y c e n t r e s , s h e l t e r e d employment, and day a t t e n d a n c e c e n t r e s ) , as was the need f o r s m a l l , s p e c i a l i z e d resources f o r young, p s y c h i a t r i c a l l y d i s a b l e d people. The l a t t e r would prevent f u r t h e r c h r o n i c i t y ; the c o s t l y outcome of n e g l e c t i n g to t r e a t a mental d i s o r d e r i n i t s e a r l y s t a g e s . 6 6 The management of a c u t e l y i l l p a t i e n t s was a l s o given a high p r i o r i t y . The importance of e a r l y i n t e r v e n t i o n to prevent h o s p i t a l i z a t i o n was e m p h a s i z e d and the r e s p o n s i b i l i t y f o r s e r v i c e d e l i v e r y was to be p l a ced p r i m a r i l y upon the shoulders of the m e n t a l h e a l t h c e n t r e s . The dominant ' p h i l o s o p h y ' supported the p r i n c i p l e s of "community-oriented, comprehensive, mental h e a l t h s e r v i c e s , " and the need f o r more community resources was r e c o g n i z e d . 6 7 In a d d i t i o n , e f f o r t s were made to 429 improve the p r o c e d u r e s f o r emergency i n t e r v e n t i o n ; t h a t i s , e x p e d i t i n g the short-term h o s p i t a l i z a t i o n of s e r i o u s l y d i s t u r b e d and "more unmanageable" p a t i e n t s who r e q u i r e d h i g h l y s p e c i a l i z e d treatment but who were causing problems f o r general h o s p i t a l p s y c h i a t r i c u n i t s . To t h i s end, Riverview H o s p i t a l was to co-o r d i n a t e i t s a c t i v i t i e s with both the mental h e a l t h centres i n a r e a s t h a t d i d not have p s y c h i a t r i c u n i t s , and the e x i s t i n g u n i t s . In o r d e r to p r e v e n t c h r o n i c i t y , i t was n e c e s s a r y t o develop more s t r e a m l i n e d ways of both a d m i t t i n g and t r e a t i n g a c u t e l y i l l p a t i e n t s , and then q u i c k l y d i s c h a r g i n g them to community s e r v i c e s . 6 8 The p r o v i n c i a l government a l s o r e s p o n d e d t o one o f Cumming's recommendations i n the area of law reform. Within a y e a r , new R e g u l a t i o n s g o v e r n i n g the conduct of r e v i e w p a n e l h e a r i n g s were i n t r o d u c e d and t h e s e i m p r o v e d the r i g h t s of J p a t i e n t s i n a manner t h a t s u p p o r t e d the g o a l of r e d u c i n g the l e n g t h of time spent i n h o s p i t a l . The panels became more q u a s i -j u d i c i a l i n nature and t h i s assured p a t i e n t s (and the govern-ment) of a hearing at which the need f o r continued confinement would be thoroughly reviewed. The d i r e c t o r of a f a c i l i t y was r e q u i r e d to i n f o r m a p a t i e n t of h i s or her r i g h t to seek a hearing, w i t h i n seven days of a d m i s s i o n , and a copy of the r e l e v a n t p r o v i s i o n s of the Mental Health Act, and the new Regulations, had to be posted i n a conspicuous and a c c e s s i b l e p l a c e i n a f a c i l i t y . P a t i e n t s were e n t i t l e d to be r e p r e s e n t e d by c o u n s e l and the l a t t e r were 430 e n t i t l e d t o c a l l w i t n e s s e s , make s u b m i s s i o n on b e h a l f of p a t i e n t s , and chall e n g e the d e c i s i o n s of those r e s p o n s i b l e f o r confinement (a panel was empowered to o b t a i n a p a t i e n t ' s records and summon h i s or her at t e n d i n g p h y s i c i a n to a hearing). This p r o v i s i o n b u t t r e s s e d the work of a s p e c i a l l e g a l s e r v i c e - The Mental P a t i e n t s ' Advocate P r o j e c t - that had been e s t a b l i s h e d to a s s i s t p a t i e n t s with, among other matters, the review process. There was to be a minimum of delay i n se c u r i n g a hearing f o r a p a t i e n t (the panel chairman was r e q u i r e d to convene a meeting w i t h i n 28 days of an a p p l i c a t i o n ) and the panel had to reach a d e c i s i o n w i t h i n 24 hours. W r i t t e n reasons f o r the d e c i s i o n had t o be p r o v i d e d and, i f t h e p a n e l was o f t h e v i e w t h a t c o n f i n e m e n t was no l o n g e r j u s t i f i e d , the p a t i e n t had to be discharged i m m e d i a t e l y . 6 9 W h i l e the government's r e s p o n s e answered Cumming's c r i t i c i s m s of the review procedure, no e f f o r t was made (at that time) to r e c o n s t r u c t the Mental Health Act. In keeping w i t h one of Cumming's recommendations, the government chose to introduce changes through the medium of Regulations, r a t h e r than s t a t u t o r y reform. I t e s t a b l i s h e d a more e f f e c t i v e review procedure that s u p p o r t e d the u n d e r l y i n g s t r a t e g y f o r the management of the mentally d i s o r d e r e d , but without going through the complex and time-consuming process of d r a f t i n g and i n t r o d u c i n g new l e g i s -l a t i o n . Both the adjustment i n s t r a t e g y and the new, complementary review panel procedures were t i m e l y measures s i n c e , by the end of 1980, a nationwide economic r e c e s s i o n began to have an impact 431 i n the province. The gross domestic product began to d e c l i n e , the r a t e of i n f l a t i o n began to r i s e and, by the end of f i s c a l 1980/81, the S o c i a l C r e d i t government faced a budget d e f i c i t of $372 m i l l i o n (Morley, et a l , 1983; M i n i s t r y of Finance, 1982). The p r o p o r t i o n of the p r o v i n c i a l domestic product expended on he a l t h care had r i s e n to 7.33% and, by the end of 1981 t h i s had inc r e a s e d to 7.50% (Evans, 1986). The need f o r a programme of r e s t r a i n t , r a t h e r than j u s t ' s t a b i l i z a t i o n 1 , had appeared, s i n c e without such a programme any continued d e c l i n e i n the p r o v i n c i a l domestic product would r e s u l t i n an unacceptable e s c a l a t i o n of the p r o p o r t i o n expended on h e a l t h care (op c i t ) . Any economies which could be achieved i n the area of, i n p a r t i c u l a r , h o s p i t a l care and treatment were viewed as c r u c i a l and, by the end of 1980, t h i s a r e a had been s i n g l e d out f o r s p e c i a l a t t e n t i o n . The M i n i s t r y of Health introduced a number of measures to d e a l w i t h the " p r e s s u r e s of r i s i n g c o s t s , " i n c l u d i n g i n c r e a s e s i n d i r e c t c h a r g e s f o r h e a l t h s e r v i c e s , a p o l i c y of indexing charges to r e f l e c t changes i n the economy, i n c r e a s e s i n medical insurance premiums, and, i n c r e a s e s i n the per diem charge f o r i n - p a t i e n t care. Grants to h o s p i t a l s had exceeded one b i l l i o n d o l l a r s , "making the achievement of g r e a t e r op e r a t i n g e f f i c i e n c i e s more e s s e n t i a l than e v e r . " 7 0 Indeed, i n the view of the Deputy M i n i s t e r , 7 1 H o s p i t a l o p e r a t i n g e x p e n d i t u r e s r e m a i n a major o b s t a c l e to c o n t a i n i n g the upward s p i r a l of h e a l t h care c o s t s , e s p e c i a l l y s i n c e 80% of spending comp-r i s e s s t a f f wages and b e n e f i t s . In t h i s regard, the M i n i s t r y set an example by i n t r o d u c i n g i t s 432 own h i r i n g f r e e z e . As Evans (1986) has demonstrated, a programme of r e s t r a i n t was i n t r o d u c e d i n the e a r l y 1980's. In a d d i t i o n , by 1983, i t was apparent that the p r o v i n c i a l government had adopted elements of a monetarist economic s t r a t e g y and was consequently d e t e r -mined to reduce government spending by 'down-sizing* the p u b l i c s e c t o r and ' p r i v a t i z i n g ' p u b l i c e n t e r p r i s e s and s e r v i c e s ; p a r t i c u l a r l y , those which comprised the p r o v i n c i a l w e l f a r e s t a t e ( A l l e n & R o s e n b l u t h , 1986). W h i l e the h e a l t h c a r e s e c t o r d i d not e x p e r i e n c e the s e v e r e c u t b a c k s imposed e l s e w h e r e i n the p u b l i c s e c t o r , i t was not p e r m i t t e d to grow i n r e a l terms (Evans, 1986). In keeping w i t h ' r e s t r a i n t ' , the long-standing p o l i c y of reducing the use of h o s p i t a l s and i n t r o d u c i n g a l t e r n a t i v e s to i n - p a t i e n t c a r e , c o n t i n u e d t h r o u g h o u t the f i r s t h a l f of the 1980's. 7 2 As Evans (op c i t ) has p o i n t e d out, the p r o v i n c i a l government " s i g n i f i c a n t l y reduced per c a p i t a r a t e s of h o s p i t a l use" by a " c o m b i n a t i o n of e x p a n s i o n of a l t e r n a t i v e s and r e s t r i c t i o n of i n p a t i e n t c a p a c i t y " (op c i t : 188). The m e n t a l h e a l t h area was a f f e c t e d by t h i s process and the importance of d e - i n s t i t u t i o n a l i z a t i o n , n o n - i n s t i t u t i o n a l i z a t i o n , and the enhancement of n o n - p r o f i t and p r o p r i e t a r y involvement i n the p r o v i s i o n of care i n c r e a s e d , as the need f o r r e s t r a i n t i n t e n s -i f i e d . The M i n i s t e r of H e a l t h i mplemented the a d j u s t m e n t s i n s t r a t e g y which were planned i n 1979, and mental h e a l t h c e n t r e s 433 bore the b r u n t of s e r v i c e d e l i v e r y . At the end of 1981, the caseload of the 31 c e n t r e s and 20 s u b - o f f i c e s stood at 16,350 and, by A p r i l 1985, t h i s had i n c r e a s e d to 21,304. In a d d i t i o n , the c a s e l o a d of the G.V.M.H.S. grew from 3,011 c l i e n t s a t the end of 1980, to 3,500 c l i e n t s i n A p r i l 1985. 7 3 P r i v a t e s e c t o r involvement, p a r t i c u l a r l y i n the long-term care and home-care programmes, a l s o g r e w 7 4 and, by 1985, the ' C o n t i n u i n g Care D i v i s i o n ' of the M i n i s t r y of Health had been charged with the task of developing s o c i e t i e s and v o l u n t e e r groups to " i n i t i a t e and expand r e s o u r c e s " . 7 5 D e - i n s t i t u t i o n a l i z a t i o n c o n t i n u e d and, at Riverview H o s p i t a l , both the numbers of admissions and the p a t i e n t p o p u l a t i o n d e c l i n e d . In 1982, the H o s p i t a l admitted 1,034 p a t i e n t s and, at year end, the p o p u l a t i o n was e s t i m a t e d to be 1,000. By f i s c a l 1984/85, the a verage p o p u l a t i o n s t o o d a t 873 and only 987 p a t i e n t s had been admitted i n the y e a r . 7 6 In the area of p s y c h o g e r i a t r i c care, Skeenaview Lodge was c l o s e d i n 1984 and the r e s i d e n t s were e i t h e r r e - l o c a t e d w i t h t h e i r f a m i l i e s or t r a n s f e r r e d to long-term care f a c i l i t i e s i n t h e i r home communities. The process of d e - i n s t i t u t i o n a l i z a t i o n and f a c i l i t y c l o s u r e has a l s o a f f e c t e d those deemed to be mentally 7 7 • • retarded, ' and i t i s c l e a r t h a t , s i n c e 1986, the government has been c o n s t r u c t i n g a new 'mental h e a l t h plan' that i n v o l v e s the c l o s u r e of a l l remaining i n s t i t u t i o n s . In J u l y 1985, the M i n i s t e r of H e a l t h c a l l e d f o r sub-missions from those who wished to comment on the development of a new mental h e a l t h plan f o r the province and, i n January 1986, the M i n i s t e r announced that a review of mental h e a l t h s e r v i c e s 434 was t a k i n g p l a c e because of the need to r e p l a c e ' o u t - d a t e d 1 7 fi f a c i l i t i e s a t the R i v e r v i e w and V a l l e y v i e w H o s p i t a l s . ' 0 By A p r i l 1986, the l a s t of the s u b m i s s i o n s ( i . e . , a l i s t of r ecommendations c o m p i l e d by the B r i t i s h C o l u m b i a M e d i c a l A s s o c i a t i o n ) had been r e c e i v e d and the M i n i s t e r announced that the c onsensus a p p e a r e d to f a v o u r the i n t r o d u c t i o n of non-i n s t i t u t i o n a l s e r v i c e s . 7 9 A 'Mental Health C o n s u l t a t i o n Report' was r e l e a s e d i n the F a l l of 1987 and i t i s c l e a r from t h i s document that the plan i s to f i n a l i z e the process of d e - i n s t i t u t i o n a l i z a t i o n by c l o s i n g p u b l i c mental h o s p i t a l s ( p a r t i c u l a r l y , Riverview H o s p i t a l ) by 1992 ( M i n i s t r y of H e a l t h , 1987). I n s t i t u t i o n s are to be r e p l a c e d by enhanced community-based c a r e and t r e a t m e n t resources ( i n c l u d i n g those provided by the p r i v a t e s e c t o r ) 8 0 and s m a l l , i n - p a t i e n t p s y c h i a t r i c u n i t s d i s t r i b u t e d around the p r o v i n c e , but g r a d u a l i m p l e m e n t a t i o n i s p l a n n e d i n o r d e r to a v o i d t h e p r o b l e m s e x p e r i e n c e d i n o t h e r p l a c e s where a l t e r n a t i v e s were not d e v e l o p e d i n advance of i n s t i t u t i o n c l o s u r e (op c i t ) . In O n t a r i o , f o r example, the process of r a p i d d e - i n s t i t u t i o n a l i z a t i o n p r i o r to the development of adequate community s e r v i c e s has r e s u l t e d i n the emergence of urban 'ghettos' p o p u l a t e d by d i s c h a r g e d p a t i e n t s ( M a r s h a l l , 1982). T h i s has c r e a t e d p r o b l e m s of o r d e r maintenance as w e l l as a growing c r i t i c i s m of s t a t e p o l i c i e s , and i t i s evident that the B r i t i s h Columbia government wishes to avoid a s i m i l a r s i t u a t i o n . The new s t r a t e g y i s b e i n g p r o p e l l e d by the need to r e s t r a i n expenditure; indeed, the proposed 'mental h e a l t h plan' 435 i s "overshadowed by the awareness of e s c a l a t i n g o v e r a l l h e a l t h c a r e c o s t s " ( M i n i s t r y of H e a l t h , 1987: 19). One g o a l i s to d e r i v e "maximum e f f e c t i v e n e s s from e x i s t i n g resources" and, i n t h i s regard, the government proposes to make the "current l e v e l of f i n a n c i a l resources at Riverview H o s p i t a l " a v a i l a b l e f o r the development of a l t e r n a t i v e s (op c i t ) . However, while a d d i t i o n a l 'bridge f u n d i n g ' may be s u p p l i e d to d e v e l o p community-based a l t e r n a t i v e s as the H o s p i t a l i s 'scaled down', only the c u r r e n t l e v e l s of f u n d i n g w i l l be p r o v i d e d f o r the o p e r a t i o n of new s e r v i c e s . Arguably, t h i s w i l l amount to a r e d u c t i o n i n funding by the time the i n s t i t u t i o n s are closed, and t h i s i s c o n s i s t e n t with the government's r e s t r a i n t p o l i c y . I t i s c l e a r that the Cumming Report on p r o v i n c i a l mental h e a l t h s e r v i c e s was i n i t i a t e d at a time when the government was c o n f r o n t i n g problems w i t h the funding of the e n t i r e h e a l t h care component of the p r o v i n c i a l w e l f a r e s t a t e . Cumming recommended an adjustment i n the s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d w h i c h was c o n s i s t e n t w i t h the q u e s t f o r c o s t -s t a b i l i z a t i o n and, s u b s e q u e n t l y , r e s t r a i n t . The R e p o r t a l s o provided the grounds f o r implementing changes. D e - i n s t i t u t i o n -a l i z a t i o n and n o n - i n s t i t u t i o n a l i z a t i o n r e c e i v e d a strong endor-sement and were j u s t i f i e d i n the l i g h t of the p r o b l e m s a s s o c i a t e d with, i n p a r t i c u l a r , Riverview H o s p i t a l . The 'Cumming Report' a l s o recommended law r e f o r m s t h a t were c o n s i s t e n t w i t h a r e d u c t i o n i n t h e u t i l i z a t i o n o f h o s p i t a l s . In essence, Cumming recommended a s h i f t from a l e g a l 436 framework c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' which p e r m i t t e d the l i b e r a l use of mental h e a l t h f a c i l i t i e s , to one which r e f l e c t e d the 'new l e g a l i s m ' and the attendant emphasis upon r e s t r i c t i v e a d m i s s i o n c r i t e r i a , s t r e a m l i n e d and q u a s i -j u d i c i a l r e v i e w p r o c e d u r e s , p a t i e n t s ' l e g a l s e r v i c e s , and p a t i e n t s ' r i g h t s ( n o t a b l y , the r i g h t to c o u n s e l , the r i g h t t o r e f u s e t r e a t m e n t , and the r i g h t to t r e a t m e n t i n the l e a s t r e s t r i c t i v e s e t t i n g ) . While the government only i n t r o d u c e d one of the reforms proposed by Cumming (i.e., improving p a t i e n t s ' r i g h t s i n the context of post-admission review) t h i s supported the a d j u s t m e n t i n s t r a t e g y and, as we s h a l l see, the o t h e r proposed reforms are now being introduced as an i n t e g r a l p a r t of the new 'mental h e a l t h plan'. In o r d e r to r e s t r a i n e x p e n d i t u r e on h o s p i t a l c a r e and t r e a t m e n t i t i s n e c e s s a r y t o reduce u t i l i z a t i o n , and t h i s r e q u i r e s the i m p o s i t i o n of l i m i t a t i o n s upon both consumers and p h y s i c i a n s . In the co n v e n t i o n a l h o s p i t a l s e t t i n g t h i s can be a c c o m p l i s h e d t h r o u g h , among o t h e r m e a s u r e s , p u b l i c and p r o f e s s i o n a l 'education' r e g a r d i n g the u n d e s i r a b i l i t y of over-u t i l i z a t i o n , and the p r o v i s i o n of e q u a l l y e f f e c t i v e , but l e s s c o s t l y , a l t e r n a t i v e s which are a l s o more popular among consumers (e.g., home c a r e ) . By the end of the 1970's, the p r o v i n c i a l M i n i s t r y of Health had introduced these kinds of measures. In the m e n t a l h e a l t h c o n t e x t , however, l i m i t i n g the a c t i v i t i e s of consumers i s not as important as r e g u l a t i n g the p r a c t i c e s of p h y s i c i a n s . The l a t t e r are i n d i r e c t c o n t r o l of the process of admission and confinement ( p a r t i c u l a r l y , w i t h i n a 437 l e g a l framework c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' ) s i n c e t h e i r p a t i e n t s may be unable to make and e x e r c i s e informed d e c i s i o n s . Where p h y s i c i a n s f a i l to r e s p o n d to p o l i c i e s r e g a r d i n g a d m i s s i o n and c o n f i n e m e n t (e.g., i n f o r m a l r e q u e s t s that admission be sought only as a l a s t r e s o r t ) and consequently d e c l i n e to l i m i t t h e i r u t i l i z a t i o n of h o s p i t a l s , other measures which render the process of i n v o l u n t a r i l y a d m i t t i n g , t r e a t i n g and c o n f i n i n g p a t i e n t s more d i f f i c u l t , become necessary. New and s t r i c t c r i t e r i a f o r i n v o l u n t a r y admission (e.g., o b j e c t i v e evidence of dangerousness) may be introduced through the medium of m e n t al h e a l t h l e g i s l a t i o n , which may a l s o be used t o c o n s t r u c t other o b s t a c l e s to i n i t i a l and continued confinement. Key examples are the ' r i g h t to r e f u s e t r e a t m e n t ' which c o u l d p e r m i t a p a t i e n t to r e f u s e c o n s e n t to t r e a t m e n t s g i v e n i n h o s p i t a l s t h e r e b y r e n d e r i n g h o s p i t a l i z a t i o n p o i n t l e s s ; the 'r i g h t to the l e a s t r e s t r i c t i v e a l t e r n a t i v e ' which p r i o r i t i z e s the p r o v i s i o n of care and treatment i n the community r a t h e r than an i n s t i t u t i o n ; and, t h e r i g h t t o a p p e a l t h e n e e d f o r c o n f i n e m e n t to a q u a s i - j u d i c i a l r e v i e w p a n e l or c o u r t which prevents both the 'warehousing* of long-stay p a t i e n t s and the r e t e n t i o n of new p a t i e n t s beyond the p o i n t at which they need to be confined. However, the p l a c i n g of l i m i t a t i o n s upon the p r a c t i c e s of p h y s i c i a n s , the a s s o c i a t e d adjustment i n the s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d , and the u n d e r l y i n g economic r e s t r a i n t measures, could be p e r c e i v e d as an 'attack' upon the h e a l t h care component of the w e l f a r e s t a t e : hallowed 438 and p o l i t i c a l l y s e n s i t i v e ground f o r the s t a t e (Evans, 1986; Gold, e t a l , 1986; Toews, 1980; E l - G u e b a l y & P a p i n e a u , 1984; C a r r o l l , et a l , 1984). There i s widespread, p u b l i c support f o r the p r e s e r v a t i o n of a 'medicare' system and any overt attempt to reduce expenditures could r e s u l t i n a problem, i f not a c r i s i s , of l e g i t i m a t i o n f o r the government r e s p o n s i b l e . S u c c e s s i v e M i n i s t e r s of Health i n B r i t i s h Columbia have been w e l l aware of t h i s danger ( C a r r o l l , e t a l , 1984) and t h i s a c c o u n t s f o r the government's a t t e m p t s to m a i n t a i n p e r c a p i t a h e a l t h s p e n d i n g d e s p i t e growing budget d e f i c i t s (Evans, 1986). 8 1 This does not, however, preclude c o s t - c u t t i n g or r e s t r a i n t s that are c a r e f u l l y s c r e e n e d or o t h e r w i s e l e g i t i m a t e d and, i n the m e n t a l h e a l t h c o n t e x t , the n e c e s s a r y j u s t i f i c a t i o n can be found w i t h i n the mechanism used to impose l i m i t a t i o n s upon h o s p i t a l u t i l i z a t i o n ; namely, new and i n h e r e n t l y j u s t i f i a b l e mental h e a l t h l e g i s l a t i o n which enhances and p r o t e c t s fundamental human, c i v i l and l e g a l r i g h t s . Enter, the 'new l e g a l i s m ' and i t s p r i n c i p a l proponent, the mental h e a l t h p a t i e n t s ' r i g h t s movement. IV; THE CANADIAN PATIENTS' RIGHTS MOVEMENT AND THE RISE OF THE NEW LEGALISM The recommendations f o r law reform found i n the Cumming Report c o n s t i t u t e d the f i r s t formal statement of the need f o r changes c o n s i s t e n t w i t h the 'new l e g a l i s m ' i n B r i t i s h Columbia. The proposals r e f l e c t e d the views of two a l l i e d o r g a n i z a t i o n s t h a t had been c o n s u l t e d d u r i n g t h e s u r v e y ; n a m e l y , t h e p r o v i n c i a l branch of the Canadian Bar A s s o c i a t i o n (C.B.A.), and the M e n t a l P a t i e n t s ' A d v o c a t e P r o j e c t (M.P.A.P.). W h i l e 439 Cumming's team was a t work, t h e C.B.A.'s ' C o m m i t t e e on C o r r e c t i o n s and I n s t i t u t i o n s ' was d e v e l o p i n g i t s own recommendations f o r mental h e a l t h law r e f o r m and t h e s e were adopted by Cumming. S i m i l a r l y , the views of the M.P.A.P. formed the b a s i s f o r Cumming's recommendations i n regard to r e f o r m i n g the r e v i e w p a n e l p r o c e d u r e s . The M.P.A.P. had s t r o n g t i e s t o the Mental P a t i e n t s ' A s s o c i a t i o n ; an i n t e r e s t group c o n s i s t i n g of those who were e x p e r i e n c i n g or who had experienced c o n t a c t w i t h t h e m e n t a l h e a l t h s y s t e m ( C h a m b e r l i n , 1979). The recommendations of b o t h the C.B.A. and the M.P.A.P. r e f l e c t e d the g e n e r a l o b j e c t i v e s of the Canadian p a t i e n t s ' r i g h t s movement; a loose amalgam of l e g a l a i d lawyers, mental p a t i e n t s ' a s s o c i a t i o n s , and c i v i l l i b e r t a r i a n s that played a key r o l e i n the r i s e of the 'new l e g a l i s m ' . The f i r s t s i g n s of a Canadian, p a t i e n t s ' r i g h t s movement a p p e a r e d i n t h e e a r l y 1970's and t h i s d e v e l o p m e n t was s t i m u l a t e d by the emergence of a general, nationwide, human and c i v i l r i g h t s movement. The l a t t e r was the seedbed of many s o c i a l reforms and the p a t i e n t s ' r i g h t s movement was a s m a l l , but r e m a r k a b l y s u c c e s s f u l , component of t h i s l a r g e r r e f o r m movement (Hepburn, 1980). The g r o w i n g c o n c e r n f o r human and c i v i l r i g h t s was c a p t u r e d by, f o r example, the McRuer R o y a l Commission on C i v i l Rights i n O n t a r i o . During the l a t e 1960's, t h i s body reviewed a l l the p r o v i n c i a l laws which a f f e c t e d r i g h t s and l i b e r t i e s , i n c l u d i n g mental h e a l t h l e g i s l a t i o n (Main, 1970). The p r o v i n c e ' s M e n t a l H e a l t h Act (the epitome of 'enhanced m e d i c a l i z a t i o n ' ) had only j u s t been proclaimed at the time of 440 the Commission's i n q u i r y but t h i s d i d not impede c r i t i c i s m . Indeed, the Act was d e s c r i b e d as an o u t s t a n d i n g example of a s t a t u t e that undermined " a l l the safeguards which have been set up to p r o t e c t the r i g h t s of the i n d i v i d u a l " (op c i t : 14). Changes were suggested; notably, the p r o v i s i o n of more r i g h t s f o r those appearing before review boards; the i n t r o d u c t i o n of a r i g h t t o v o t e ; and, a c l a r i f i c a t i o n of p o l i c e powers to apprehend mentally i l l persons (op c i t ) . The g e n e r a l c o n c e r n f o r human and c i v i l r i g h t s was accompanied by an i n t e r e s t i n a l l e v i a t i n g 'poverty', and these f a c t o r s s t i m u l a t e d the d evelopment of l e g a l a i d schemes and 'community-based' l e g a l s e r v i c e s (e.g., n e i g h b o u r h o o d law c e n t r e s ) . The schemes and s e r v i c e s were aimed at p r o v i d i n g disadvantaged groups with both equal access to law and e q u a l i t y before the law, i n the somewhat q u i x o t i c b e l i e f t h a t once these groups obtained access to the power embodied in law they would be a b l e to both s e c u r e a more e q u i t a b l e s h a r e of w e a l t h and e n j o y t h e r i g h t s and b e n e f i t s h e l d by t h e b u l k o f t h e p o p u l a t i o n . As young, e n t h u s i a s t i c , l e g a l a i d lawyers expanded t h e i r i n t e r e s t s to encompass a wide range of d i s a d v a n t a g e d people, they d i s c o v e r e d the unmet l e g a l needs of those i n mental h e a l t h i n s t i t u t i o n s . The l a w y e r s were r e s p o n s i b l e f o r c o n t a c t i n g and p r o v i d i n g r e p r e s e n t a t i o n f o r p a t i e n t s and t h i s c o n t r i b u t e d to the development of a p a t i e n t s ' r i g h t s movement (Gordon, 1981; 1983). Various l e g a l a s s i s t a n c e programmes f o r p a t i e n t s began to appear i n the p r o v i n c e s d u r i n g the 1970's; however, bot h the 441 q u a l i t y of s e r v i c e and the l e v e l of commitment to p a t i e n t s ' r i g h t s i s s u e s v a r i e d c o n s i d e r a b l y . Some programmes focussed only upon c o n v e n t i o n a l l e g a l needs (e.g., f a m i l y law, consumer law and l a n d l o r d - t e n a n t m a t t e r s ) , w h i l e o t h e r s p r o v i d e d a g e n e r a l s e r v i c e t h a t a l s o d e a l t w i t h i s s u e s r e l a t e d t o confinement i n h o s p i t a l s . Some were s t a f f e d by v o l u n t e e r s who provided only advice and a s s i s t a n c e , while others were s t a f f e d by f u l l - t i m e lawyers, employed by p r o v i n c i a l l e g a l a i d schemes, who v i s i t e d h o s p i t a l s at r e g u l a r i n t e r v a l s . In some p r o v i n c e s , mental h e a l t h p a t i e n t s were t r e a t e d as merely another c l i e n t group f a l l i n g w i t h i n the general purview of l e g a l a i d s e r v i c e s w h i l e , i n o t h e r s ( n o t a b l y , O n t a r i o and B r i t i s h C o l u m b i a ) , e f f o r t s were made to determine both the extent to which they had s p e c i a l needs and the best way of meeting those needs. In 1973, an 'ombudsman' experiment aimed at r e s o l v i n g p a t i e n t / h o s p i t a l c o n f l i c t s t h r o u g h m e d i a t i o n was a t t e m p t e d a t L a k e s h o r e P s y c h i a t r i c H o s p i t a l i n T o r o n t o and, two y e a r s l a t e r , the Ont a r i o Legal A i d Plan funded a duty counsel scheme a f f e c t i n g 14 p r o v i n c i a l mental h e a l t h i n s t i t u t i o n s . The province a l s o hosted s p e c i a l , v o l u n t e e r l e g a l a s s i s t a n c e programmes organized by law s c h o o l s and community law c e n t r e s . In B r i t i s h C o l u m b i a , an o r g a n i z e d and s p e c i a l advocacy s e r v i c e (the M.P.A.P.) was c r e a t e d i n the mid-1970's from a p a t i e n t s ' l e g a l a s s i s t a n c e programme s t a f f e d by v o l u n t e e r s (op c i t ) . P a t i e n t s ' a s s o c i a t i o n s a l s o began to appear d u r i n g the 1970's; n o t a b l y , the M e n t a l P a t i e n t s ' A s s o c i a t i o n i n B r i t i s h Columbia, and the Onta r i o based o r g a n i z a t i o n s , 'Project Release' 442 and 'The P s y c h i a t r i c H o s p i t a l P a t i e n t s W e l f a r e A s s o c i a t i o n ' (Chamberlin, 1979; Hepburn, 1980). These groups expressed t h e i r c o l l e c t i v e d i s s a t i s f a c t i o n w i t h both the t r a d i t i o n a l medical approach adopted by p s y c h i a t r i s t s and the way i n w h i c h the l a t t e r t e n d e d to e x e r t p a t e r n a l i s t i c c o n t r o l s o v e r t h e i r p a t i e n t s . The groups sought b o t h b e t t e r a c c e s s to l e g a l s e r v i c e s and reforms to mental h e a l t h l e g i s l a t i o n which would erode 'enhanced m e d i c a l i z a t i o n ' , p a r t i c u l a r l y i n the areas of i n v o l u n t a r y admission, compulsory treatment, guardianship, and the c o m m i t t e e s h i p of e s t a t e s ( C r i c h t o n , 1975). P a t i e n t s ' o r g a n i z a t i o n s began to appear i n other p r o v i n c e s and, while they operated as autonomous agencies f o c u s s i n g upon l o c a l i s s u e s and needs, they c o n t r i b u t e d to the q u e s t f o r law r e f o r m t h r o u g h t h e i r a s s o c i a t i o n s w i t h s p e c i a l l e g a l s e r v i c e s and c i v i l l i b e r t i e s groups ( C h a m b e r l i n , 1979; Hepburn, 1980; Savage & McKague, 1987). 8 2 The work of t h o s e i n v o l v e d w i t h b o t h the l e g a l a i d movement and p a t i e n t s ' a s s o c i a t i o n s was s u p p o r t e d by c i v i l l i b e r t a r i a n s . While the l a t t e r had always shown an i n t e r e s t i n the r i g h t s of mental h e a l t h p a t i e n t s , by the e a r l y 1970's they had s t a r t e d to p r e s s more f o r c e f u l l y f o r the i n t r o d u c t i o n of m e n t a l h e a l t h law r e f o r m s a i m e d a t e r o d i n g 'enhanced m e d i c a l i z a t i o n ' (Page, 1976). Considerable headway was made i n On t a r i o where r e s e a r c h e r s a s s o c i a t e d with c i v i l l i b e r t i e s groups began to explore the marginal and o f t e n i l l e g a l a c t i v i t i e s of medical p r a c t i t i o n e r s i n v o l v e d i n the admission and treatment of p a t i e n t s . In p a r t i c u l a r , a s t u d y by Page and Y a t e s (1973; 443 1974), demonstrated that, d e s p i t e the l i b e r a l nature of mental h e a l t h l e g i s l a t i o n , p r a c t i t i o n e r s e i t h e r d i s r e g a r d e d or c i r c u m v e n t e d s t a t u t o r y p r o c e d u r e s and a d m i t t e d and c o n f i n e d p a t i e n t s as they thought f i t . The f i n d i n g s of the r e s e a r c h e r s b u t t r e s s e d the p r o v i n c i a l government's d e c i s i o n to review mental h e a l t h l e g i s l a t i o n and introduce changes which would complement i t s d e - i n s t i t u t i o n -a l i z a t i o n and n o n - i n s t i t u t i o n a l i z a t i o n p o l i c i e s (Manitoba Law Reform Commission, 1979; M a r t i n , 1985). The l e g a l counsel to the M i n i s t e r of Health - G i l b e r t Sharpe - was granted a mandate to examine the shortcomings of the e x i s t i n g l e g i s l a t i o n and make ap p r o p r i a t e recommendations. Sharpe was a c i v i l l i b e r t a r i a n s y m p a t h e t i c t o the g o a l s of the p a t i e n t s ' r i g h t s movement (Sharpe, 1978; 1979) and the l a t t e r had, t h e r e f o r e , a cquired a s t r o n g a l l y who o c c u p i e d an i m p o r t a n t p o s i t i o n w i t h i n the p r o v i n c i a l s t a t e apparatus. New l e g i s l a t i o n which r e f l e c t e d the t e n e t s of the 'new l e g a l i s m ' was p a s s e d i n 1978 ( i . e . , the Mental Health (Amendment) A c t ) 8 3 and t h i s c o n s t i t u t e d a v i c t o r y f o r the p a t i e n t s ' r i g h t s movement. 8 4 C i v i l l i b e r t i e s groups i n most p r o v i n c e s became i n v o l v e d i n both the process of lobbying f o r reform and the p r o v i s i o n of r e p r e s e n t a t i o n f o r p a t i e n t s a p p e a r i n g b e f o r e r e v i e w b o a r d s . C i v i l l i b e r t a r i a n s sympathetic to p a t i e n t s ' r i g h t s i s s u e s were a l s o to be found i n u n i v e r s i t i e s and, from the mid-1970's onwards, t h e s e i n d i v i d u a l s began to p u b l i s h c r i t i q u e s of p s y c h i a t r y and mental h e a l t h l e g i s l a t i o n , a t the same t i m e 444 e x t o l l i n g the v i r t u e s of developments i n the United S t a t e s . In one of the f i r s t a r t i c l e s on the is s u e of l e g a l r i g h t s , Caron (1972) argued that the use of compulsion i n admission and treatment had to be set aside i f progress was to be made i n the treatment of h o s p i t a l i z e d p a t i e n t s . Reitsma (1973), presented the f i r s t major statement of the c i v i l l i b e r t i e s p e r s p e c t i v e and argued t h a t the On t a r i o mental h e a l t h l e g i s l a t i o n (pre-1978) was untenable s i n c e i t d i d not guarantee the r i g h t s and l i b e r t i e s of p a t i e n t s . C e r t i f i c a t i o n p r a c t i c e s were i l l e g a l and r e v i e w boards were r a r e l y used. H i l l (1977) attacked the s i t u a t i o n i n Quebec by a r g u i n g t h a t the p r o v i n c e ' s l a w s were i n c o n s i s t e n t w i t h b o t h f u n d a m e n t a l human r i g h t s and t h e r a p e u t i c advances. In h i s view, there was a need f o r a p a t i e n t s ' ' B i l l of Rights', 'watchdog' c o m m i t t e e s to o v e r s e e p r a c t i c e s i n h o s p i t a l s , and other measures that would assure p a t i e n t s the " f u l l e x e r c i s e of t h e i r f u n d a m e n t a l r i g h t s " (op c i t : 529). In a s i m i l a r v e i n , Anand (1979) p u b l i s h e d a c r i t i q u e of both the process of c i v i l commitment and the abuses that were i n f l i c t e d upon p a t i e n t s by p s y c h i a t r i s t s i n Ontario. In h i s view, i n v o l u n t a r y p s y c h i a t r y had to be r e j e c t e d as "an u n r e a s o n a b l e i n c u r s i o n upon the autonomy of the i n d i v i d u a l " (op c i t : 251). Other s c h o l a r s p u b l i s h e d works which r e f l e c t e d a s i m i l a r c i v i l l i b e r t a r i a n and r e f o r m i s t theme (see, e.g., W e i s s t u b , 1977; 1980; M a r s h a l l & Hughes, 1974; Mazar, 1978; Shone, 1976; Draper, 1976). G e n e r a l l y , these three l o o s e l y bonded groups - l e g a l a i d l a w y e r s , p a t i e n t s * a s s o c i a t i o n s , and c i v i l l i b e r t a r i a n s -c o n s t i t u t e d (and continue to c o n s t i t u t e ) the Canadian p a t i e n t s ' 445 r i g h t s movement. While t h e i r a c t i v i t i e s were s t i m u l a t e d by the emergence of a general human and c i v i l r i g h t s movement i n Canada, t h e i r s p e c i f i c i d e o l o g i c a l r o o t s can be t r a c e d to developments i n the United States. In p a r t i c u l a r , the views of w r i t e r s s u c h as Thomas S z a s z and N i c h o l a s K i t t r i e , t h e p e r s p e c t i v e of A m e r i c a n c i v i l l i b e r t a r i a n s ( n o t a b l y , Bruce E n n i s ) , and t h e f i n d i n g s o f s o c i a l s c i e n t i s t s f r o m t h e ' l a b e l l i n g ' p e r s p e c t i v e ( n o t a b l y , S c h e f f and Rosenhan) were i n f l u e n t i a l . T h e s e c o n t r i b u t o r s were i n d i v i d u a l l y and c o l l e c t i v e l y r e s p o n s i b l e f o r r a i s i n g the s p e c t r e of the 'therapeutic state', proposing and implementing l e g a l s o l u t i o n s t h a t w o u l d p r o t e c t and p r e s e r v e f u n d a m e n t a l r i g h t s and l i b e r t i e s , and p r o v i d i n g t h e ' e v i d e n c e ' n e c e s s a r y f o r a s u s t a i n e d a t t a c k upon both the power and the s o c i a l c o n t r o l f u n c t i o n s of p s y c h i a t r i s t s . 8 6 M e n t a l p a t i e n t s ' a s s o c i a t i o n s began to emerge i n major c i t i e s across the United S t a t e s during the 1970's and l i n k s were f o r g e d w i t h c i v i l l i b e r t a r i a n l a w y e r s who began to i n i t i a t e l i t i g a t i o n on b e h a l f of p a t i e n t s ( C h a m b e r l i n , 1979; Savage & McKague, 1987). Cons i d e r a b l e headway was made i n e s t a b l i s h i n g p a t i e n t s ' r i g h t s through t e s t cases and s t a t u t o r y reform and, by the l a t e 1970's, both the c o u r t s and s t a t e l e g i s l a t u r e s had recognized and entrenched a v a r i e t y of r i g h t s i n c l u d i n g , a r i g h t to r e c e i v e t r e a t m e n t i f i n s t i t u t i o n a l i z e d ; a r i g h t to due process before c i v i l commitment occurred; a r i g h t to treatment i n the l e a s t r e s t r i c t i v e s e t t i n g ; and, a r i g h t to p e r i o d i c review while c o n f i n e d . Advocates had a l s o s t a r t e d to pursue the 446 e s t a b l i s h m e n t of a r i g h t to r e f u s e t r e a t m e n t ( B r a k e l , e t a l , 1985). In a d d i t i o n , s p e c i a l l e g a l s e r v i c e s f o r p a t i e n t s began to p r o l i f e r a t e from the mid-1970's onwards and, as was the case i n C anada, t h i s d e v e l o p m e n t was t i e d t o t h e g r o w t h and c o n s o l i d a t i o n of a broader l e g a l a i d movement (Brakel, 1981). E x p e r i m e n t a l p r o j e c t s were e s t a b l i s h e d i n m e n t a l h e a l t h f a c i l i t i e s and, s i n c e these proved to be e f f e c t i v e i n addressing the unmet l e g a l needs of p a t i e n t s , a network of s e r v i c e s was developed (op c i t ) . While these agencies provided c o n v e n t i o n a l l e g a l s e r v i c e s , they a l s o pursued t e s t cases which complemented the work of the c i v i l l i b e r t a r i a n lawyers. There i s l i t t l e doubt that the successes of advocates i n the U n i t e d S t a t e s i n s p i r e d the l a w y e r s a s s o c i a t e d w i t h the Canadian p a t i e n t s ' r i g h t s movement. Most of the l e g a l terms and c o n c e p t s employed by the l a t t e r (e.g., the r i g h t t o r e f u s e treatment, and the r i g h t to the l e a s t r e s t r i c t i v e a l t e r n a t i v e ) were drawn from the American mental h e a l t h law j u r i s p r u d e n c e of the 1970's and i t i s a p p a r e n t t h a t C a n a d i a n l a w y e r s were monitoring events c l o s e l y w i t h an eye to b u i l d i n g arguments f o r s i m i l a r reforms (i.e., the 'new legalism') i n Canada (Weisstub, 1980). The g e n e r a l o b j e c t i v e s of the Canadian p a t i e n t s ' r i g h t s movement were t w o f o l d ; namely, to c h a l l e n g e , erode and e v e n t u a l l y r e p l a c e m e d i c a l d o m i n a t i o n o v e r the c a r e and treatment of those deemed to be 'mentally i l l ' ; and, to engineer 447 complementary law r e f o r m s t h a t r e s t r a i n e d the i n v o l u n t a r y admission, confinement and treatment of p a t i e n t s (i.e., the 'new l e g a l i s m ' ) . B r i t i s h C o l u m b i a was the f i r s t p r o v i n c e to host b o t h a m e n t a l p a t i e n t s ' a s s o c i a t i o n and a s p e c i a l , p a t i e n t s ' l e g a l s e r v i c e . A d e t a i l e d e x p o s i t i o n o f t h e two main o b j e c t i v e s , as w e l l as the i n i t i a l response on the p a r t of the s t a t e , can be s e c u r e d t h r o u g h a b r i e f e x a m i n a t i o n of the emergence of these two p r i n c i p a l components of the movement i n the province. The Emergence of a P a t i e n t s ' Rights Movement i n B r i t i s h Columbia The p a t i e n t s ' r i g h t s movement f i r s t appeared i n B r i t i s h Columbia i n 1971 when a group of former mental h e a l t h p a t i e n t s met i n Vancouver to d i s c u s s t h e i r mutual d i s s a t i s f a c t i o n w i t h the system of mental h e a l t h c a r e . In t h e i r view, ' s e l f - h e l p ' was o f t e n b e t t e r than care and treatment i n h o s p i t a l s and the group wanted to d e v e l o p an i n f o r m a l , s u p p o r t i v e network f o r those a f f l i c t e d with mental d i s o r d e r s (Chamberlin, 1979). The f o u n d a t i o n s of Canada's f i r s t , f o r m a l , mental p a t i e n t s ' a s s o c i a t i o n had been l a i d and, w i t h i n a year, another important d e velopment o c c u r r e d ; namely, the e s t a b l i s h m e n t of a l e g a l a s s i s t a n c e programme at Riverview H o s p i t a l . The programme was i n i t i a t e d by H o s p i t a l s o c i a l w o r k e r s , law s t u d e n t s , and v o l u n t e e r lawyers who were i n v o l v e d with the nascent l e g a l a i d movement, and the p r o j e c t o p e r a t e d under the a u s p i c e s of the p r o v i n c i a l l e g a l a i d scheme. The resource was welcomed by the H o s p i t a l s i n c e i t was "of tremendous h e l p to many of the p a t i e n t s " and, f o l l o w i n g the f i r s t year of o p e r a t i o n , plans were 448 made f o r an e x t e n s i o n of the s e r v i c e . The e l e c t i o n of an N.D.P. government at the end of 1972 s t i m u l a t e d b o t h the p a t i e n t s ' a s s o c i a t i o n and the l e g a l a s s i s t a n c e programme. The new government was more committed to human r i g h t s i s s u e s than i t s predecessor (Clague, et a l , 1984) and was s y m p a t h e t i c to the p r i n c i p l e s and o b j e c t i v e s of the o r g a n i z a t i o n s . By the end of 1973, the l e g a l a s s i s t a n c e programme had grown, the government had improved the p r o v i s i o n of l e g a l a i d i n the p r o v i n c e , and r e s p o n s i b i l i t y f o r the resource was assumed by a newly formed, autonomous, community l e g a l s e r v i c e ; namely, the Vancouver Community Legal A s s i s t a n c e S o c i e t y (V.C.L.A.S.). 8 8 The S o c i e t y s p e c i a l i z e d i n b o t h the p r o v i s i o n of d i r e c t l e g a l a s s i s t a n c e to disadvantaged i n d i v i d -u a ls and the p u r s u i t of human, c i v i l , and l e g a l r i g h t s i s s u e s f o r v a r i o u s communities of i n t e r e s t (e.g., w e l f a r e r e c i p i e n t s ) , and i t promptly sought to e s t a b l i s h the Riverview programme as a f o r m a l , permanent agency s t a f f e d by f u l l - t i m e , s a l a r i e d personnel (Vancouver Community Legal A s s i s t a n c e S o c i e t y , 1973). By 1974, the i n t e r e s t i n p a t i e n t s ' r i g h t s i s s u e s was c o n s i d e r a b l e and, i n the May of t h a t y e a r , a c o n f e r e n c e on 'Mental D i s o r d e r and the Law' was h e l d at the U n i v e r s i t y of B r i t i s h Columbia. For the f i r s t time, a l l the i n d i v i d u a l s and o r g a n i z a t i o n s i n the p r o v i n c e who were concerned wi t h p a t i e n t s ' r i g h t s met to d i s c u s s key i s s u e s (Kerfoot, 1974). The l e v e l of concern was high and the g a t h e r i n g c o n s i t u t e d the f i r s t c l e a r and u n i f i e d e x p r e s s i o n of a quest f o r reforms that r e f l e c t e d the 'new l e g a l i s m ' . R e p r e s e n t a t i v e s from the M e n t a l P a t i e n t s ' 449 A s s o c i a t i o n (M.P.A.) sought improved r i g h t s f o r those i n h o s p i t a l ; n o t a b l y / open a c c e s s t o c o m m u n i c a t i o n (e.g., t e l e p h o n e s ) ; the abandonment of h o s p i t a l l a b o u r ; and, the outlawing of f o r c e d treatment. The C.M.H.A. made the case f o r the p r o t e c t i o n of r i g h t s o t h e r than those a s s o c i a t e d w i t h h o s p i t a l i z a t i o n ; n o t a b l y , the r i g h t to s e c u r e l i c e n c e s , the r i g h t t o v o t e , and t h e r i g h t t o s e c u r e e m p l o y m e n t . Rep r e s e n t a t i v e s from the ' C i t i z e n s Commission on Human Rights' -a body e s t a b l i s h e d by the Church of S c i e n t o l o g y - a rgued f o r more humane treatment and improved res p e c t f o r the fundamental human r i g h t s of p a t i e n t s . The c o - o r d i n a t o r of v o l u n t e e r s e r v i c e s at R i v e r v i e w H o s p i t a l a rgued f o r i mproved p a t i e n t access to l e g a l a i d that would a l l o w p a t i e n t s to make use of the r i g h t to seek j u d i c i a l review of the need f o r c o n f i n e m e n t . 8 9 The v a r i o u s o r g a n i z a t i o n s had t h e i r own p a r t i c u l a r o b j e c t i v e s but they were bonded by a common i n t e r e s t i n enhancing and p r o t e c t i n g the human, c i v i l and l e g a l r i g h t s of p a t i e n t s . Of a l l t h e o r g a n i z a t i o n s r e p r e s e n t e d , t h e p e r s p e c t i v e s advanced by both the M.P.A. and the Riverview Legal A s s i s t a n c e Programme p r o v e d to be the most i n f l u e n t i a l and shaped the views of o r g a n i z a t i o n s which subsequently supported the movement; n o t a b l y , the C a nadian Bar A s s o c i a t i o n and the B r i t i s h Columbia C i v i l L i b e r t i e s A s s o c i a t i o n . The p e r s p e c t i v e of the M.P.A. c o n s t i t u t e d a s t r i d e n t c r i t i q u e of both p s y c h i a t r y and the mental h e a l t h system and the o r g a n i z a t i o n a r t i c u l a t e d a number of c o n c e r n s : n o t a b l y , 450 u n j u s t i f i a b l e , i n v o l u n t a r y a d m i s s i o n and t r e a t m e n t ; the qu e s t i o n a b l e nature of 'voluntary' admission and treatment; the value-impregnated nature of d e f i n i t i o n s of mental i l l n e s s ; the judgmental c h a r a c t e r of the process of p s y c h i a t r i c d i a g n o s i s ; the use of d r u g s as ' c h e m i c a l s t r a i g h t - j a c k e t s ' ; and, the adverse s i d e - e f f e c t s of prolonged medication (Chamberlin, 1979). The A s s o c i a t i o n a l s o questioned the power of p s y c h i a t r i s t s and t h e i r f u n c t i o n as s o c i a l c o n t r o l a g e n t s f o r the ' t h e r a p e u t i c state'. P s y c h i a t r i s t s had an emotional and f i n a n c i a l i n t e r e s t i n r e t a i n i n g t h e e x i s t i n g s y s t e m e v e n t h o u g h , i n t h e o r g a n i z a t i o n ' s view, the dominant m e d i c a l model had to be r e j e c t e d i n favour of a system of s o c i a l work support networks and s m a l l , f r i e n d l y s h e l t e r s ; t h a t i s , t r u e 'asylums'. The A s s o c i a t i o n ' s c o n c e r n s a l s o e x t e n d e d to a c r i t i q u e of m e ntal h e a l t h l e g i s l a t i o n ( i . e . , t h a t c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' ) which compelled admission and treatment on the b a s i s of both the parens p a t r i a e and the p o l i c e powers of the s t a t e (op c i t ) . W h i l e the v i e w s of the M.P.A. posed a c h a l l e n g e to p s y c h i a t r y , they were e x p r e s s e d i n a p o l i t i c a l l y f a v o u r a b l e atmosphere. The 'Foulkes Report' on the p r o v i n c i a l h e a l t h care system had been r e l e a s e d and the s p e c i a l r e p o r t - 'Psychiatry at the Crossroads' - c o n s t i t u t e d an i n d i c t m e n t of both p s y c h i a t r y and the e x i s t i n g p r o v i n c i a l mental h e a l t h system. Foulkes drew a t t e n t i o n to a number of problems and f l a w s which supported the M.P.A.'s q u e s t f o r a l t e r n a t i v e s : t h e e x c e s s i v e use o f medication, e l e c t r o - s h o c k treatments and c u s t o d i a l care; the 451 f r a g i l e n a t u r e of the l i n e between the t r e a t m e n t of mental i l l n e s s and ' s o c i a l r e g u l a t i o n ' ; the j u d g m e n t a l powers of p s y c h i a t r i s t s ; the p s y c h i a t r i c domination of treatment; and, the f a i l u r e to focus upon change i n the s o c i a l and economic m i l i e u w i t h i n which i l l n e s s a r o s e and t r e a t m e n t was g i v e n . I t was necessary to r e s t o r e s o c i a l j u s t i c e to the mental h e a l t h system and t h i s r e q u i r e d a r e j e c t i o n of the 'medi c a l / p u n i t i v e ' model, the d e m o l i t i o n of mental h o s p i t a l s , and a m u l t i - d i s c i p l i n a r y approach to care and treatment (Foulkes, 1974). F o u l k e s ' p e r s p e c t i v e d i d not a t t r a c t the s u p p o r t of p s y c h i a t r i s t s , and the P s y c h i a t r i c S e c t i o n of the B r i t i s h Columbia Medical A s s o c i a t i o n (B.C.M.A.) denounced h i s recommend-a t i o n s as ' i r r e s p o n s i b l e ' (op c i t ) . I n s t e a d , the A s s o c i a t i o n presented i t s own set of recommendations which were compiled by a s p e c i a l 'Task Committee'. The l a t t e r agreed that there was a need f o r change i n the mental h e a l t h system and that i n n o v a t i o n s i n the a r e a of community c a r e and t r e a t m e n t were t o be encouraged. However, the Committee sought more resources f o r t h e e x i s t i n g s y s t e m (e.g., p s y c h i a t r i c u n i t s i n g e n e r a l h o s p i t a l s ) r a t h e r than the r a d i c a l r e c o n s t r u c t i o n proposed by Foulkes. The demise of the N.D.P. government i n 1975 r e s u l t e d i n a r e j e c t i o n of Foulkes' ' r a d i c a l ' ideas, but the new S o c i a l C r e d i t government d i d nothing to hamper the a c t i v i t i e s of the p a t i e n t s ' r i g h t s movement. By 1976, the M.P.A. had e s t a b l i s h e d a branch at Riverview H o s p i t a l with a view to c o n t a c t i n g the long- s t a y p a t i e n t s and the o r g a n i z a t i o n became a c t i v e l y i n v o l v e d i n 452 p u r s u i n g p a t i e n t s ' r i g h t s i s s u e s ( C h a m b e r l i n , 1979). The M i n i s t r y of H e a l t h began to e x p r e s s an i n t e r e s t i n p a t i e n t s ' r i g h t s and the D i r e c t o r of Government H e a l t h I n s t i t u t i o n s commenced d i s c u s s i o n s w i t h ' i n t e r e s t e d ' p e r s o n s and o r g a n i z a t i o n s "on the p r o t e c t i o n of p a t i e n t s ' r i g h t s and r e l a t e d m a t t e r s . " 9 0 By the end of 1978, H o s p i t a l a u t h o r i t i e s were holding r e g u l a r meetings with r e p r e s e n t a t i v e s of the M.P.A. to a s s i s t i n d e v e l o p i n g p a t i e n t c o u n c i l s f o r each of the major u n i t s i n the Riverview complex and, as a r e s u l t of the deaths of two p a t i e n t s , a panel of i n q u i r y i n t o a l l e g e d p a t i e n t abuse had been e s t a b l i s h e d . T h i s was "conceived as an independent, f a c t -f i n d i n g body" t h a t would i n v e s t i g a t e the c o n c e r n s of the M.P.A. 9 1 The A s s o c i a t i o n was a l s o a c t i v e o u t s i d e the H o s p i t a l . A ' d r o p - i n ' c e n t r e had been e s t a b l i s h e d f o r the b e n e f i t of - p a t i e n t s r e c e i v i n g care and treatment i n the community and, by 1978, t h i s was ope r a t i n g seven days a week wit h funding from a v a r i e t y o f g o v e r n m e n t and n o n - g o v e r n m e n t s o u r c e s . The A s s o c i a t i o n was a l s o o p e r a t i n g f i v e c o - o p e r a t i v e r e s i d e n c e s that provided a l t e r n a t i v e s to boarding-homes (Chamberlin, 1979). A f u r t h e r , o f f i c i a l endorsement of the o r g a n i z a t i o n came i n 1979 when the M i n i s t r y of Health provided funds f o r an A s s o c i a t i o n l i a i s o n worker. T h i s i n d i v i d u a l was to work i n c o - o p e r a t i o n w i t h the G r e a t e r Vancouver M e n t a l H e a l t h S e r v i c e i n o r d e r to " e s t a b l i s h an e f f e c t i v e working r e l a t i o n s h i p " and to ensure t h a t the two o r g a n i z a t i o n s operated harmoniously. Steps were being t a k e n t o p r e s e r v e the A s s o c i a t i o n and encourage, r a t h e r than 453 r e s t r a i n , i t s work. Inasmuch as the A s s o c i a t i o n f l o u r i s h e d , so too d i d the L e g a l A s s i s t a n c e Programme, at R i v e r v i e w H o s p i t a l . By 1977, V.C.L.A.S. had s e c u r e d f u n d i n g from the Donner F o u n d a t i o n f o r the e s t a b l i s h m e n t of a f o r m a l 'Mental P a t i e n t s Advocate P r o j e c t ' (M.P.A.P.) and, with the d i r e c t a s s i s t a n c e and encouragement of t h e M.P.A. t h i s r e s o u r c e began o p e r a t i o n s i n t h e F a l l (Himmelfarb & Lazar, 1981). The p r o j e c t , which was the f i r s t of i t s kind i n Canada, was s t a f f e d by f u l l - t i m e lawyers and housed i n ' s t o r e - f r o n t ' p r e m i s e s on the grounds of the H o s p i t a l (op c i t ) . S i n c e the p r o j e c t was a d m i n i s t e r e d by V.C.L.A.S. - an o r g a n i z a t i o n with o f f i c e s i n Vancouver - p a t i e n t s r e c e i v i n g care and treatment i n the community were a l s o able to gain access to s p e c i a l l e g a l s e r v i c e s . By the end of 1978, the r e s p o n s i b i l i t y f o r f u n d i n g the M.P.A.P. had been assumed by both the p r o v i n c i a l Law Foundation and the f e d e r a l Department of J u s t i c e . The p r o j e c t became a permanent f e a t u r e of the mental h e a l t h landscape even though i t was not s u p p o r t e d by a l l the s t a f f a t the H o s p i t a l (op c i t ) . Many d i s a p p r o v e d and the r e a s o n s can be d i s c e r n e d from the o b s e r v a t i o n s of the D i r e c t o r of Government H e a l t h I n s t i t u t -93 i o n s : 3 J i t p r o v i d e s easy p a t i e n t a c c e s s to i n d e p e n d e n t l e g a l s e r v i c e s t h a t e nsure p a t i e n t s ' r i g h t s a r e p r o t e c t e d , and e s t a b l i s h e s t h a t the l e g a l i t y of Mental Health Act committals i s c l o s e l y s c r u t i n -i z e d . The H o s p i t a l had a c q u i r e d an i n d e p e n d e n t 'watchdog' which 454 monitored the a c t i v i t i e s of s t a f f ( e s p e c i a l l y p s y c h i a t r i s t s ) , and e n s u r e d t h a t the h o s p i t a l f a c i l i t i e s were not 'over-u t i l i z e d ' . Both the nature and the degree of p s y c h i a t r i c o p p o s i t i o n were evident when an e v a l u a t i o n of the p r o j e c t was undertaken f o r the Department of J u s t i c e . The r e s e a r c h e r s canvassed the v i e w s of p s y c h i a t r i s t s and, w h i l e the M.P.A.P. was seen as a v a l u a b l e resource where a pati e n t ' s l e g a l problem f e l l w i t h i n the realm of c o n v e n t i o n a l l e g a l p r a c t i c e , there was o p p o s i t i o n to i t s i n v o l v e m e n t i n i s s u e s of a d m i s s i o n , t r e a t m e n t and c o n f i n e m e n t (op c i t ) . P s y c h i a t r i s t f e l t t h a t p a t i e n t s were u n a b l e to p r o v i d e p r o p e r i n s t r u c t i o n s to a d v o c a t e s and t h i s r e s u l t e d i n the p u r s u i t o f 'problems' which were e i t h e r f r i v o l o u s or n o n - e x i s t e n t and a r i s i n g from the p a t i e n t s ' d e l u s i o n s . A g g r e s s i v e a d v o c a t e s d i s r u p t e d the t h e r a p e u t i c r e l a t i o n s h i p and t h i s was not i n the best i n t e r e s t s of p a t i e n t s . The p r o j e c t introduced unnecessary 'legalism' i n t o the r e l a t i o n -s h i p between p s y c h i a t r i s t s and p a t i e n t s and, i n s o f a r as the former were working under the constant fear of l i t i g a t i o n , t h i s hampered the p r o v i s i o n of e f f e c t i v e treatment. In a d d i t i o n , i t was f e l t that the p r o j e c t ' s pre-occupation with f a c i l i t a t i n g the r e l e a s e of p a t i e n t s was d i s r u p t i v e and d e s t r u c t i v e s i n c e i t o f t e n r e s u l t e d i n p r e m a t u r e or u n w a r r a n t e d d i s c h a r g e s . 9 4 G e n e r a l l y , p s y c h i a t r i s t s sought a r e t u r n to a t i m e when the p r o j e c t was a l e g a l a s s i s t a n c e programme s t a f f e d by v o l u n t e e r s . Advocates had been forced, by the lack of time and resources, to n e g o t i a t e a r e s o l u t i o n of c o n f l i c t s between p a t i e n t s and s t a f f , 455 r a t h e r than pursue l i t i g a t i o n , and p s y c h i a t r i s t s p r e f e r r e d t h i s a p p r o a c h . In a d d i t i o n , the l e g a l a s s i s t a n c e programme had focussed i t s a t t e n t i o n upon c o n v e n t i o n a l l e g a l problems and the r e s o l u t i o n of s u c h p r o b l e m s was o f t e n h e l p f u l to a t r e a t m e n t team (op c i t ) . P r o j e c t s t a f f a dopted a number of p h i l o s o p h i c a l t e n e t s which were c o n s i s t e n t w i t h the p e r s p e c t i v e of the M.P.A. and r e f l e c t e d the 'new l e g a l i s m ' . No person should lose h i s or her l i b e r t y , even on t h e r a p e u t i c grounds, w i t h o u t due p r o c e s s . S i m i l a r l y , t h e r e s h o u l d be no i n v a s i o n of an i n d i v i d u a l ' s p h y s i c a l or m e n t a l i n t e g r i t y u n l e s s a need c o u l d be demon-s t r a t e d . The act of confinement i n a h o s p i t a l should not r e s u l t i n the l o s s of c i v i l and c i v i c r i g h t s . An i n d i v i d u a l i n h o s p i t a l was e n t i t l e d to both equal access to law and e q u a l i t y before the law, p a r t i c u l a r l y s i n c e p a t i e n t s ' r i g h t s would be of l i t t l e use without easy access to f r e e l e g a l s e r v i c e s . In t h i s regard, i t was f e l t that the best type of l e g a l s e r v i c e would be one t h a t p r o v i d e d a c c e s s i b l e , i n d e p e n d e n t , s p e c i a l i z e d , and a d v e r s a r i a l p a r t i s a n advocacy, r a t h e r than c o n f l i c t r e s o l u t i o n through mediation and n e g o t i a t i o n (op c i t ) . 9 5 G e n e r a l l y , t h e g o a l s o f t h e M.P.A.P. were t o ; (a) endeavour to make new law t h r o u g h t e s t c a s e s and to seek the r e f o r m of e x i s t i n g law t h r o u g h the p r o c e s s of community education and l o b b y i n g ; and, (b) to provide f r e e , uncompromised l e g a l advocacy (op c i t ) . The p r o j e c t o p e r a t e d on a r e a c t i v e , . 4 r a t h e r than p r o a c t i v e , b a s i s , and a s u b s t a n t i a l p r o p o r t i o n of i t s t i m e was s p e n t d e a l i n g w i t h c o n v e n t i o n a l l e g a l p r o b l e m s . 456 Nevertheless, p a t i e n t s ' r i g h t s i s s u e s were the dominant concern and l e g a l p r o b l e m s a r i s i n g from the p r o c e s s of a d m i s s i o n , treatment, confinement, case review, and discharge became the l a r g e s t s i n g l e component of the p r o j e c t ' s c a s e l o a d . In the f i r s t t h r e e y e a r s of o p e r a t i o n , the p r o j e c t d e a l t w i t h 465 cases, 60% of which i n v o l v e d i s s u e s r e l a t e d to h o s p i t a l i z a t i o n . Of these, 80% (223 cases) i n v o l v e d p a t i e n t s seeking r e l e a s e and the p r o j e c t was s u c c e s s f u l i n s e c u r i n g e i t h e r a f u l l o r c o n d i t i o n a l d ischarge f o r the m a j o r i t y of c l i e n t s (op c i t ) . In most c a s e s , r e l e a s e was s e c u r e d w i t h o u t r e c o u r s e to l i t i g a t i o n s i n c e the H o s p i t a l adopted a p o l i c y of d i s c h a r g i n g p a t i e n t s b e f o r e a s c h e d u l e d c o u r t appearance (op c i t ) . T h i s t a c t i c tended to f r u s t r a t e the process of using the c o u r t s to e s t a b l i s h p a t i e n t s ' r i g h t s through t e s t cases, but some cases were heard, and p r o j e c t s t a f f g r a d u a l l y b u i l t a s m a l l body of case law c o n s i s t e n t with the new l e g a l i s m . At the same time, however, these cases brought the p r o j e c t i n t o c o n f l i c t with the p r o v i n c i a l government and demonstrated the l i m i t s of the state's w i l l i n g n e s s to embrace the law r e f o r m o b j e c t i v e s of the p a t i e n t s ' r i g h t s movement. The P a t i e n t s ' Rights Movement and the State. B o t h t h e M.P.A. and t h e M.P.A.P. had become f i r m l y e s t a b l i s h e d i n B r i t i s h Columbia by the end of the 1970's and i t i s apparent that the p r o v i n c i a l government approved of most of t h e i r a c t i v i t i e s . The M.P.A.'s primary o b j e c t i v e - a d i m i n u t i o n of the medical model - was not embraced but the A s s o c i a t i o n ' s 457 work i n the p r o v i s i o n of community s e r v i c e s and resources was supported s i n c e t h i s was c o n s i s t e n t w i t h the s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d ; notably, the t a c t i c s of d e - i n s t i t u t i o n a l i z a t i o n and n o n - i n s t i t u t i o n a l i z a t i o n . The M.P.A.P. was a l s o of v a l u e i n s o f a r as i t m o n i t o r e d t h e a c t i v i t i e s of mental h e a l t h p r o f e s s i o n a l s , r e g u l a t e d the l e n g t h of t i m e p a t i e n t s s p e n t i n R i v e r v i e w H o s p i t a l , and g e n e r a l l y d i s c o u r a g e d o v e r - u t i l i z a t i o n of the f a c i l i t y . - P s y c h i a t r i s t s d i s l i k e d the p r o j e c t but t h e i r o b j e c t i o n s a p p e a r e d to have l i t t l e i m p a c t and the work of a d v o c a t e s was e n c o u r a g e d . In p a r t i c u l a r , the government adopted the M.P.A.P.'s proposals f o r changes to the p a t i e n t review process (as expressed through the Cumming Report) and introduced reforms c o n s i s t e n t with the new l e g a l i s m . I t i s apparent, t h e r e f o r e , that the p r o v i n c i a l government was l i s t e n i n g t o , and u t i l i z i n g , the i d e a s of a group of r eformers i n order to implement i t s s t r a t e g y f o r the management of the mentally d i s o r d e r e d . However, u n l i k e the s i t u a t i o n i n the 1950's and 1960's, when a s s i s t a n c e was o b t a i n e d from a p r o g r e s s i v e but r e s p e c t a b l e i n t e r e s t group with c l o s e t i e s to the s t a t e (i.e., the C.M.H.A.), the government had chosen a more r a d i c a l , d i s o r g a n i z e d , and autonomous ' a l l y ' . The p a t i e n t s ' r i g h t s movement i n B r i t i s h Columbia had no d i r e c t t i e s with, f o r example, p e r s o n n e l w i t h i n the s t a t e a p p a r a t u s and t h i s was a r e f l e c t i o n of the s i t u a t i o n g e n e r a l l y found i n other p r o v i n c e s . From i t s i n c e p t i o n i n the e a r l y 1970's, the C a n a d i a n p a t i e n t s ' r i g h t s movement was an autonomous i n t e r e s t group. 458 However, i t was f a r from being a cohesive, i n t e g r a t e d , and co-or d i n a t e d o r g a n i z a t i o n (Savage & McKague, 1987). Indeed, i n the mid-1970's, one commentator a s s o c i a t e d w i t h the movement a c c u r a t e l y d e s c r i b e d the area of p a t i e n t s ' r i g h t s as, a melange of c o n f u s i o n , v i r t u o u s p l a t i t u d e s and modest p r o g r e s s , i n which h o s p i t a l i z e d m e n t a l p a t i e n t s r e a l i s t i c a l l y p o s s e s s l i t t l e , i f any e f f e c t i v e power v i s - a - v i s t h a t of i n s t i t u t i o n a l p s y c h i a t r y and no-nonsense p r o v i n c i a l l e g i s l a t i o n (Page, 1976: 9). He continued with an important o b s e r v a t i o n ; namely, that • b r e a k t h r o u g h s ' i n t h e a r e a a r e t r a n s i t o r y , i d i o s y n c r a t i c and p r e c i p i t a t e d f a r l e s s o f t e n by the per s u a s i v e powers or successes of c i v i l l i b e r t -a r i a n s than by_ f o r c e s and e v e n t s e x t e r n a l t o the p a t i e n t s ' r i g h t s move ment (emphasis added) (op c i t ) . Since that time, progress i n the area of law reform has been s p e c t a c u l a r . P r o v i n c i a l governments have r e s p o n d e d f a v o u r a b l y t o the movement's q u e s t f o r r e f o r m and t h i s i s r e m a r k a b l e , p a r t i c u l a r l y i n the l i g h t of both the s i z e and composition of the i n t e r e s t group and the nature of the people whom i t r e p r e s e n t s . W hile the p a t i e n t s ' r i g h t s movement has become more organized and cohesive i n some pr o v i n c e s (notably, O n t a r i o and B r i t i s h Columbia) i t i s s t i l l a s m a l l , l o o s e l y -bonded and g e n e r a l l y d i s o r g a n i z e d amalgam (Savage & McKague, 1987). There i s , f o r example, no s i n g l e , o v e r a r c h i n g , n a t i o n a l body that c o - o r d i n a t e s a c t i v i t i e s . The movement has attempted to advance the i n t e r e s t s of a group of d i s e n f r a n c h i s e d , marginal, and s o c i a l l y r e j e c t e d i n d i v i d u a l s f o r whom there i s , g e n e r a l l y , l i t t l e p u b l i c sympathy. U n l i k e the s i t u a t i o n i n regard to other components of the general human and c i v i l r i g h t s 459 movement, governments have not been f a c e d w i t h w i d e s p r e a d , p u b l i c pressure to improve p a t i e n t s ' r i g h t s . Nevertheless, as the p r i n c i p a l proponent of law reforms c h a r a c t e r i z e d by the 'new l e g a l i s m ' the movement has been e x t r e m e l y s u c c e s s f u l i n a c h i e v i n g t h i s o b j e c t i v e (Savage & McKague, 1987). As Page (1976) has suggested, the success has been due to ' f o r c e s and e v e n t s ' e x t e r n a l to the movement; n o t a b l y , the s t r u c t u r a l c o n d i t i o n s under w h i c h the r e f o r m e r s have been p u r s u i n g t h e i r o b j e c t i v e s . C e r t a i n l y , the advent of the Canadian Charter of Rights and Freedoms i n the e a r l y 1980's has a s s i s t e d the p a t i e n t s ' r i g h t s movement. The i n t r o d u c t i o n of the C h a r t e r c r e a t e d a c o n s t i t u t i o n a l f o u n d a t i o n upon which c i v i l l i b e r t a r i a n lawyers could b u i l d reforms and, while t h i s has not o c c u r r e d to any great extent in the mental h e a l t h context, some p r o v i n c i a l governments have e i t h e r i n i t i a t e d reviews of mental h e a l t h l e g i s l a t i o n , or already amended t h e i r s t a t u t e s i n order to ensure compliance (Robertson, 1987; Gordon & Verdun-Jones, 1987). T h i s has r e s u l t e d i n the i n t r o d u c t i o n of r e f o r m s c o n s i s t e n t w i t h the new l e g a l i s m i n the past few years, but the emergence of the Charter does not e x p l a i n the r i s e of the 'new l e g a l i s m ' i n the 1970's, and the w i l l i n g n e s s of p r o v i n c i a l gov-ernments to embrace the law reform o b j e c t i v e s of the p a t i e n t s ' r i g h t s movement at that time. R a t h e r than the outcome of a new c o n s t i t u t i o n a l i n s t r -ument, the r i s e of the new l e g a l i s m i s a p r o d u c t of the s t r u c t u r a l c o n d i t i o n s which have a f f e c t e d the h e a l t h c a r e 460 component of the w e l f a r e s t a t e s i n c e the 1970's, and the congruence between the o b j e c t i v e s of the reformers and those of the s t a t e . New economic p o l i c i e s were introduced by the f e d e r a l government i n order to ensure a r e p r o d u c t i o n of the c o n d i t i o n s necessary f o r continued c a p i t a l accumulation, and these a f f e c t e d the p r o v i n c i a l l e v e l of the s t a t e . The l a t t e r was r e q u i r e d to a d j u s t i t s o r d e r m a i n t e n a n c e s t r a t e g y i n r e l a t i o n t o the m e n t a l l y d i s o r d e r e d , a t the same t i m e a d d r e s s i n g a p o t e n t i a l l e g i t i m a t i o n problem, and the e x e r c i s e and s y n c h r o n i z a t i o n of the s t a t e ' s p o t e n t i a l l y c o n t r a d i c t o r y c a r d i n a l f u n c t i o n s was a c c o m p l i s h e d t h r o u g h the use of law r e f o r m . S i n c e the new l e g a l i s m i n v o l v e s the i n t r o d u c t i o n of reforms which advance and p r o t e c t the fundamental r i g h t s and l i b e r t i e s of p a t i e n t s , i t i s an i n h e r e n t l y j u s t i f i a b l e way of imposing l i m i t a t i o n s upon the u t i l i z a t i o n of mental h o s p i t a l s . Consequently, i t supports the s t a t e ' s q u e s t f o r b o t h c o s t - s t a b i l i z a t i o n and r e s t r a i n t , and pr o v i d e s a l e g i t i m a t i o n of these p r a c t i c e s . I t i s the l a t t e r which have crea t e d the c o n d i t i o n s favourable to the o b j e c t i v e s of the p a t i e n t s ' r i g h t s movement and which a c c o u n t f o r the success of t h i s i n t e r e s t group. At the same time, the p a t i e n t s ' r i g h t s movement has not been able to achieve a l l i t s o b j e c t i v e s , even i n the area of law reform. The s t r u c t u r a l c o n d i t i o n s which favoured the e f f o r t s of t h i s group of reformers have a l s o determined the l i m i t s of s t a t e t o l e r a n c e and, w h i l e the l a t t e r has embraced the law r e f o r m o b j e c t i v e s of the movement i t has done so o n l y to the e x t e n t that they a s s i s t the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n 461 of i t s c a r d i n a l f u n c t i o n s (i.e., f a c i l i t a t i n g and l e g i t i m a t i n g the s t r a t e g y f o r the management of the m entally d i s o r d e r e d , and the a s s o c i a t e d economic r e s t r a i n t p o l i c i e s ) . W h i l e the p a t i e n t s ' r i g h t s movement i s an ' a l l y ' of the s t a t e , i t i s an autonomous i n t e r e s t group which i s d i f f i c u l t to c o n t r o l and i t i s a p p a r e n t t h a t the moment i t s a c t i v i t i e s have an a d v e r s e impact upon the s t a t e , l i m i t a t i o n s are imposed. The e x p r e s s i o n and i m p o s i t i o n of these l i m i t a t i o n s has been most apparent i n B r i t i s h Columbia where, i n the e a r l y 1980's, the a c t i v i t i e s of the M.P.A.P. began to exceed the bounds of the t o l e r a b l e . To the e x t e n t t h a t the M.P.A.P. o p e r a t e d i n a manner c o n s i s t e n t w i t h the p r o v i n c i a l government's s t r a t e g y f o r the management of the m entally d i s o r d e r e d , i t s presence was of value to the s t a t e . However, s i n c e i t was an autonomous agency the p r o j e c t c o u l d pose a t h r e a t to s t a t e o b j e c t i v e s . From the o u t s e t , s t a f f a d o p t e d a ' p a r t i s a n a d v o c a t e ' r o l e and d e m o n s t r a t e d t h a t the p r o j e c t would make f u l l use of a l l the weapons in the l e g a l a r s e n a l i n the p u r s u i t of the i n d i v i d u a l and c o l l e c t i v e i n t e r e s t s of p a t i e n t s (Himmelfarb & Lazar, 1981). Consequently, there was a high p r o b a b i l i t y that the p r o j e c t ' s a c t i v i t i e s would hinder, r a t h e r than a s s i s t , the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s , and t h i s was the r e s u l t as the p r o j e c t p u r s u e d t e s t c a s e s aimed at improving and e s t a b l i s h i n g p a t i e n t s ' r i g h t s . The p r o j e c t secured i t s f i r s t v i c t o r y i n 1 9 7 8 9 6 when, i n Rosandik v. Manning, 9 7 the Supreme Court confirmed that i n v o l -untary p a t i e n t s had a r i g h t to seek j u d i c i a l review of the need 462 f o r confinement even though they had been deemed 'incapable' of managing t h e i r a f f a i r s . A d e t e r m i n a t i o n of i n c a p a b i l i t y meant that the P u b l i c Trustee assumed c o n t r o l of a p a t i e n t ' s l i f e and, consequently, was r e s p o n s i b l e f o r i n i t i a t i n g l e g a l a c t i o n s on h i s or her b e h a l f . S i n c e t h e s e a c t i o n s i n c l u d e d m a t t e r s p e r t a i n i n g to r e l e a s e from a h o s p i t a l , a p a t i e n t c o u l d not i n s t r u c t the M.P.A.P. to commence l i t i g a t i o n , w i t h o u t f i r s t o b t a i n i n g the approval of the P u b l i c Trustee. This meant that 'incapable' p a t i e n t s were unable to make f u l l and e f f e c t i v e use of the p r o j e c t . The m a t t e r was r e s o l v e d i n f a v o u r of a p a t i e n t ' s r i g h t to apply f o r r e l e a s e i n h i s or her own name and w i t h o u t the p r i o r a p p r o v a l of the P u b l i c T r u s t e e or the p a t i e n t ' s committee. The case c l e a r e d the way f o r the p r o j e c t to represent a l l c l a s s e s of p a t i e n t i n matters p e r t a i n i n g to p r o v i n c i a l mental h e a l t h l e g i s l a t i o n and, by 1980, a number of t e s t cases had been launched. Some of these reached the c o u r t s , w hile others were r e s o l v e d by a change of p o l i c y p r i o r to a t r i a l of the matter. For example, p a t i e n t s seeking discharge were granted access to t h e i r h o s p i t a l f i l e s and records, and t h e i r r i g h t to appear at an a p p l i c a t i o n f o r r e l e a s e was e s t a b l i s h e d . The p r a c t i c e of making work assignments a p r e c o n d i t i o n f o r advancement to l e s s r e s t r i c t i v e forms of confinement and paying p a t i e n t s at a r a t e below the p r o v i n c i a l minimum wage, had been s u c c e s s f u l l y challenged. Other cases addressed such matters as, the p r a c t i c e of i n t e r c e p t i n g and o p e n i n g p a t i e n t s ' m a i l ; the p r a c t i c e of h o l d i n g p e r s o n s i n j a i l s u n t i l i n v o l u n t a r y a d m i s s i o n to a 463 / h o s p i t a l could be arranged; and, the extent to which those who were i n v o l u n t a r i l y admitted to a mental h e a l t h f a c i l i t y from a n o t h e r i n s t i t u t i o n , had a r i g h t of a c c e s s to both a r e v i e w panel and j u d i c i a l review (op c i t ) . By the e a r l y 1980's, the work of the p r o j e c t i n f a c i l i t -a t i n g the discharge of p a t i e n t s had r e c e i v e d d i r e c t government support i n the form of new Regulations a f f e c t i n g the conduct of review panel hearings. In keeping with the recommendations of the Cumming R e p o r t , p a t i e n t s ' r i g h t s were improved and t h e s e i n c l u d e d the r i g h t t o l e g a l c o u n s e l (as p r o v i d e d by, f o r example, the M.P.A.P.). At the same t i m e , however, i t became apparent that while the c o u r t s were i n c l i n e d to a s s i s t i n the e s t a b l i s h m e n t and c l a r i f i c a t i o n of some p a t i e n t s ' r i g h t s , they would not endorse r i g h t s which might r e s u l t i n the r e l e a s e of those who were u n a b l e to f u n c t i o n beyond the w a l l s of a h o s p i t a l . More i m p o r t a n t l y , i t became c l e a r that the p r o v i n c i a l government would not t o l e r a t e the e s t a b l i s h m e n t of r i g h t s and other e n t i t l e m e n t s that c o n f l i c t e d with the i m p e r a t i v e s of order m a i n t e n a n c e and economic r e s t r a i n t . Indeed, as the advocacy began to hinder the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s , l i m i t a t i o n s were imposed. The concerns of the j u d i c i a r y i n regard to the r e l e a s e of p a t i e n t s were r e f l e c t e d i n three t e s t cases which i n v o l v e d an attempt to c l a r i f y both the standard and the onus of proof i n j u d i c i a l reviews. In Re Robinson and H i s l o p , 9 8 a p r o j e c t lawyer a t t e m p t e d to p ersuade the Supreme C o u r t to adopt a s t r i c t standard of proof (namely, 'clear and c o n v i n c i n g evidence') when 464 d e a l i n g w i t h a p p l i c a t i o n s f o r r e l e a s e . The court r e j e c t e d the argument and h e l d t h a t , w h i l e the onus of p r o o f l a y upon the h o s p i t a l , the normal c i v i l standard (i.e., by a preponderance of the evidence) was a p p r o p r i a t e . Further, where p a t i e n t s were unable to care f o r (and neglected) themselves, unable to r e t a i n p r o p e r a c c o m m o d a t i o n i n t h e c o m m u n i t y , and i n n eed o f p s y c h i a t r i c n u r s i n g , the standard had been s a t i s f i e d . The r u l i n g was upheld i n two subsequent cases; namely, Re Hoskins and H i s l o p and Scherba v. H i s l o p . " While the Supreme C o u r t c o n f i r m e d t h a t i t would c o n t i n u e to s u p e r v i s e the management of m e n t a l h e a l t h p a t i e n t s , and p e r m i t c o n t i n u e d confinement only i f i t heard c l e a r and unequivocal evidence of both the p r e s e n c e of a m e n t a l d i s o r d e r and the need f o r treatment, i t would not a u t h o r i s e the discharge of p a t i e n t s who might d e t e r i o r a t e i n the community. 1 0 0 In Hoskins, f o r example, the p l a i n t i f f had e x h i b i t e d a p a s t p a t t e r n of d i s c o n t i n u i n g medication and r e l a p s i n g whenever she was r e l e a s e d , and, s i n c e she had i n d i c a t e d that she would not f o l l o w a p r e s c r i b e d course of t r e a t m e n t upon r e l e a s e from R i v e r v i e w H o s p i t a l , the c o u r t d e c l i n e d to order her d i s c h a r g e . A l t h o u g h the i s s u e was not s p e c i f i c a l l y a i r e d i n these cases, i t i s apparent that i f the Supreme Court had a u t h o r i z e d the r e l e a s e of the p a t i e n t s t h i s would have been tantamount to an i m p l i c i t endorsement of a r i g h t to r e f u s e t r e a t m e n t once di s c h a r g e d to the community. Insofar as t h i s may have r e s u l t e d i n r e l a p s e and r e - a d m i s s i o n , i t would have been i n c o n s i s t e n t 465 w i t h the t a c t i c s of d e - i n s t i t u t i o n a l i z a t i o n and n o n - i n s t i t u t i o n -a l i z a t i o n . In a d d i t i o n , an endorsement of a r i g h t to r e f u s e t r e a t m e n t f o r d i s c h a r g e d p a t i e n t s c o u l d have c r e a t e d d i f f i c u l t i e s f o r those r e s p o n s i b l e f o r t h e i r management and t h i s may have r e s u l t e d i n a p r o b l e m of o r d e r m a i n t e n a n c e i n the communities which were h o s t i n g such p a t i e n t s . The p r o v i n c i a l government was a l s o r e l u c t a n t to endorse any e f f o r t s which could have r e s u l t e d i n the e s t a b l i s h m e n t of a r i g h t to r e f u s e treatment. Indeed, i n the one i n s t a n c e where p r o j e c t lawyers launched and won a t e s t case i n p u r s u i t of t h i s r i g h t , the government responded by passing new l e g i s l a t i o n that negated the impact of the case. While the M.P.A.P. focussed most of i t s a t t e n t i o n upon the l e g a l p r o b l e m s e x p e r i e n c e d by t h o s e a d m i t t e d v i a c i v i l c o m m i t m e n t p r o c e d u r e s , i t a l s o t o o k an i n t e r e s t i n t h e commitment and treatment of mentally d i s o r d e r e d o f f e n d e r s . By 1980, i n t e r v e n t i o n i n t h i s a r e a had i n t e n s i f i e d 1 0 1 but the advocacy was g e n e r a l l y acceptable u n t i l the p r o j e c t launched a t e s t case t h a t undermined the power of p s y c h i a t r i s t s to t r e a t both d i s o r d e r e d o f f e n d e r s and persons admitted to h o s p i t a l under the c i v i l emergency admission procedures set out i n the Mental H e a l t h A c t . In H i l t o n v. D u f f y , 1 0 2 a case b e f o r e the Supreme C o u r t i n the F a l l of 1980, the c o u r t r u l e d t h a t p r i s o n e r s s e r v i n g s e n t e n c e s who became m e n t a l l y i l l c o u l d o n l y be t r a n s f e r r e d , r a t h e r than admitted, to a mental h e a l t h f a c i l i t y . However, s i n c e n e i t h e r the m e n t a l h e a l t h l e g i s l a t i o n nor the C r i m i n a l Code provided the a u t h o r i t y to t r e a t a p r i s o n e r who had 466 been t r a n s f e r r e d , the Commission faced the dilemma of having the s t a t u t o r y r e s p o n s i b i l i t y to t r e a t , but no a u t h o r i t y to do so without consent or s u b s t i t u t e c o n s e n t . 1 0 3 T h i s meant that there was no p o i n t i n p l a c i n g m e n t a l l y d i s o r d e r e d o f f e n d e r s i n a p s y c h i a t r i c f a c i l i t y i f they e i t h e r d e c l i n e d to give consent to treatment or were incapable of g i v i n g consent. The t e s t case c r e a t e d an order maintenance problem f o r the p r o v i n c i a l government s i n c e i t faced the sp e c t r e of c o r r e c t i o n a l f a c i l i t i e s housing untreated and u n t r e a t a b l e m e n t a l l y d i s o r d e r e d i n m a t e s . In a d d i t i o n , s i n c e the c o u r t ' s r u l i n g a f f e c t e d the p r o v i s i o n s of the mental h e a l t h s t a t u t e which p e r m i t t e d c i v i l , emergency a d m i s s i o n s , m e n t a l l y d i s o r d e r e d p e r s o n s who were admitted i n t h i s manner could not be t r e a t e d without consent. The government was not slow i n responding to t h i s s i t u a t i o n . W i t h i n a matter of months, amendments to the Mental Health A c t w h i c h n e g a t e d t h e i m p a c t o f H i _ l t o n v_^ Duf_f_y_ ( i . e . , p e r m i t t i n g t r e a t m e n t w i t h o u t c o n s e n t ) had been d r a f t e d and p r e s e n t e d to the L e g i s l a t i v e Assembly ( R i t c h i e , 1981). The amendments were p a s s e d w i t h o u t d e b a t e 1 0 4 and, w h i l e t h i s r e s u l t e d i n a b e l a t e d p r o t e s t on the p a r t of b o t h the N.D.P. Opp o s i t i o n and the M.P.A.P., t h e i r complaints were to no a v a i l (op c i t ) . 1 0 5 The p r o v i n c i a l government had demonstrated both the l i m i t s beyond which p a t i e n t s ' advocates would not be allowed to s t r a y , and the mechanism i t would employ to ensure t h a t t h e i r a c t i v i t i e s stayed w i t h i n the realm of the t o l e r a b l e . A l t h o u g h the p u r s u i t of a r i g h t to r e f u s e t r e a t m e n t 467 through the c o u r t s had proved to be a f u t i l e e x e r c i s e , p r o j e c t l a w y e r s were not d e t e r r e d from l a u n c h i n g t e s t c a s e s t h a t addressed other areas of concern. Indeed, i n 1983, the p r o j e c t s c o r e d a v i c t o r y i n a case t h a t t h r e a t e n e d s t a t e economic r e s t r a i n t p o l i c i e s i n the h e a l t h care s e c t o r , but which e l i c i t e d the same s t a t e response. In D i r e c t o r of Riverview H o s p i t a l v. A n d r z e j e w s k i , 1 0 6 the c o u n ty c o u r t h e l d t h a t , w h i l e the p r o v i s i o n s of the M e n t a l Health Act allowed the H o s p i t a l to sue f o r the payment of the c o s t s of c a r e , the s t a t u t e d i d not r e q u i r e an i n v o l u n t a r y p a t i e n t to pay d a i l y charges where the i n d i v i d u a l had not been deemed to be incapable of managing h i s or her a f f a i r s ; that i s , where the p a t i e n t ' s a f f a i r s had not been p l a c e d under the c o n t r o l of a c ommittee. A p r o j e c t l a w y e r argued t h a t , s i n c e a d m i s s i o n was i n v o l u n t a r y , and s i n c e t h e m e n t a l h e a l t h l e g i s l a t i o n d i d not make p r o v i s i o n f o r the payment of u s e r - f e e s under t h e s e c i r c u m s t a n c e s , the government c o u l d not demand payment. The c o u r t a g r e e d but the government took s t e p s to remedy the s i t u a t i o n . W i t h i n a matter of days, the government announced that i t would e i t h e r appeal the d e c i s i o n or change the Mental Health Act to p r e v e n t the d e c i s i o n from a f f e c t i n g o t h e r p a t i e n t s . The government was concerned that, as a r e s u l t of the case, those who had been i n v o l u n t a r y p a t i e n t s would c l a i m refunds and that c u r r e n t p a t i e n t s would be exempt from c h a r g e s . 1 0 7 Amendments to the A c t , which c l a r i f i e d the government's power to p r e s c r i b e 468 charges, were d r a f t e d and passed by the L e g i s l a t i v e Assembly. 1 U° Once again, the l i m i t s of s t a t e t o l e r a n c e had been t e s t e d and i t responded by passing l e g i s l a t i o n which n e u t r a l i z e d the e f f e c t s of a case that threatened i t s h e a l t h s e c t o r r e s t r a i n t p o l i c i e s . While the M.P.A.P. continued to provide a c c e s s i b l e l e g a l s e r v i c e s f o r mental h e a l t h p a t i e n t s i n the wake of H i l t o n and Andrzejewski, i t has not pursued other r e p o r t e d t e s t c a s e s . 1 0 9 Indeed, the two cases proved to be something of a high p o i n t i n the p r o j e c t ' s a c t i v i t i e s . D e s p i t e a f a v o u r a b l e e v a l u a t i o n (Himmelfarb & Lazar, 1981), the p r o j e c t l o s t both i t s f e d e r a l funding and i t s ' o f f i c i a l ' premises i n the grounds of Riverview H o s p i t a l . 1 1 0 A l t e r n a t i v e , p r o v i n c i a l government funding was not p r o v i d e d b u t , w i t h t h e s u p p o r t o f t h e M.P.A. and o t h e r o r g a n i z a t i o n s , the p r o j e c t has c o n t i n u e d t o p r o v i d e l e g a l s e r v i c e s , a r t i c u l a t e p a t i e n t s ' r i g h t s i s s u e s , and pursue mental h e a l t h law reform i n the p r o v i n c e . 1 1 1 The M.P.A.P. was u s e f u l to the government f o r a p e r i o d of time but i t both o u t l i v e d i t s u s e f u l n e s s and began to hinder the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . The p r o j e c t was of value i n s o f a r as i t supported the t a c t i c of d e - i n s t i t u t i o n a l i z a t i o n , r e g u l a t e d the len g t h of time new p a t i e n t s spent i n R i v e r v i e w H o s p i t a l , and g e n e r a l l y discouraged u t i l i z a t i o n of the f a c i l i t y . However, the e f f e c t i v e implementation of d e - i n s t i t u t i o n a l i z a t i o n and n o n - i n s t i t u t i o n -a l i z a t i o n p o l i c i e s r e d u c e d the need f o r the agency. More i m p o r t a n t l y , the a c t i v i t i e s of advocates began to c o n f l i c t with the state's economic r e s t r a i n t measures and order maintenance 469 f u n c t i o n , and the p r o j e c t had to be curbed. The use of s t a t e -i n i t i a t e d s t a t u t o r y amendment was e f f e c t i v e i n n e u t r a l i z i n g the impact of t e s t c a s e s ; however, t h i s was a l s o a cumbersome, v i s i b l e and p o t e n t i a l l y unstable way of r e s o l v i n g the problems c r e a t e d by the p r o j e c t , and i t was f a r e a s i e r to w i t h h o l d funding. T h i s i s not to s u g g e s t t h a t the p r o v i n c i a l government abandoned the idea of i n t r o d u c i n g the types of s t a t u t o r y reforms sought by the M.P.A.P. and o t h e r components of the p a t i e n t s ' r i g h t s movement. Wh i l e i t i s a p p a r e n t t h a t i n d e p e n d e n t , agg r e s s i v e p a r t i s a n advocacy on behalf of p a t i e n t s i s t o l e r a b l e o n l y to the e x t e n t t h a t i t does not h i n d e r the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s , t h i s a c t i v i t y can be separated from those aspects of the new l e g a l i s m which a s s i s t the s t a t e (e.g., the i n t r o d u c t i o n of s t r i c t c r i t e r i a f o r i n v o l u n t a r y admission and continued confinement, and the r i g h t to treatment i n the l e a s t r e s t r i c t i v e s e t t i n g ) . Indeed, even though i t c u r b e d the a c t i v i t i e s of the M.P.A.P., the p r o v i n c i a l government has i n d i c a t e d i t s i n t e n t i o n to embrace the new l e g a l i s m i n c o n j u n c t i o n w i t h i t s new 'mental h e a l t h plan'; a s t r a t e g y f o r the management of the mentally d i s o r d e r e d w h ich i s b e i n g c o n s t r u c t e d to s a t i s f y the s t a t e ' s g e n e r a l programme of r e s t r a i n t i n the h e a l t h c a r e component of the p r o v i n c i a l w e l f a r e s t a t e . The s t r a t e g y i s aimed at the c l o s u r e o f a l l m e n t a l h e a l t h i n s t i t u t i o n s and t h e new l e g a l i s m c o n s t i t u t e s the l e g a l framework necessary f o r i t s implementation and l e g i t i m a t i o n . 470 S t e p s have a l s o been taken to l i m i t the a c t i v i t i e s of p a t i e n t s ' advocates i n other p r o v i n c e s , and these have i n v o l v e d an a b s o r p t i o n of t h i s component of the p a t i e n t s ' r i g h t s movement i n t o the s t a t e a p p a r a t u s . In Saskatchewan, f o r example, p r o v i s i o n has been made f o r the a p p o i n t m e n t of ' o f f i c i a l r e p r e s e n t a t i v e s ' ; that i s , government employees charged with the task of a s s i s t i n g p a t i e n t s i n 'understanding' t h e i r r i g h t s . 1 1 2 Autonomous, p a r t i s a n l e g a l s e r v i c e s such as the M.P.A.P. are not to be u t i l i z e d and, s i n c e ' r e p r e s e n t a t i v e s ' a r e p a r t of the s t a t e a p p a r a t u s , they can be e a s i l y r e g u l a t e d to ens u r e t h a t they o p e r a t e w i t h i n a c c e p t a b l e bounds. In t h i s way, the a c t i v i t i e s of m e d i c a l p r a c t i t i o n e r s can be m o n i t o r e d and c o n t r o l l e d by the s t a t e w h i l e the l a t t e r can s i m u l t a n e o u s l y r e s t r a i n the a c t i v i t i e s of p a t i e n t s ' advocates. An advocacy scheme c o m p a t i b l e w i t h s t a t e i n t e r e s t s has been i n o p e r a t i o n i n O n t a r i o s i n c e the mid-1980's. In t h i s p r o v i n c e , the government e s t a b l i s h e d a m u l t i - d i s c i p l i n a r y advocacy s e r v i c e - the ' P s y c h i a t r i c P a t i e n t s Advocate Program' -t h a t i s s t r u c t u r a l l y i n c a p a b l e of p u r s u i n g t e s t c a s e s or otherwise i n t e r f e r i n g with s t a t e o b j e c t i v e s . Eleven advocates (only three of whom are lawyers) have been placed i n h o s p i t a l s throughout the province and these i n d i v i d u a l s are charged w i t h the task of r e s o l v i n g c o n f l i c t s between p a t i e n t s and h o s p i t a l personnel, i n a s w i f t and j u s t manner, by mediation and negot-i a t i o n r a t h e r than c o n f r o n t a t i o n (Turner, et a l , 1984). While the programme i s p o r t r a y e d as an i n d e p e n d e n t o r g a n i z a t i o n o p e r a t i n g at arms le n g t h from the government, i t i s funded by 471 the l a t t e r , and c r i t i c s have suggested that i t i s merely a co-opt e d b r a n c h of the M i n i s t r y of H e a l t h w h i c h i s i n c a p a b l e of advancing or p r o t e c t i n g p a t i e n t s ' r i g h t s (op c i t ) . The c r i t i c i s m i s v a l i d i n s o f a r as a d v o c a t e s are not p e r m i t t e d , o r g a n i z e d or t r a i n e d t o p u r s u e , f o r example, t e s t c a s e s or o t h e r c l a s s a c t i o n s on b e h a l f of p a t i e n t s ( K a i s e r , 1986a). Instead, they are to respond to p a t i e n t s ' requests f o r a s s i s t a n c e and focus t h e i r a t t e n t i o n upon i n d i v i d u a l cases or p r o b l e m s ( T u r n e r , e t a l , 1984). W h i l e p a t i e n t s may have recourse to other options and w h i l e advocates can r e f e r cases to, f o r example, l e g a l a i d lawyers, the goal of the programme i s to r e s o l v e c o n f l i c t s without using the l e g a l system. It defuses and f i l t e r s - o u t the kinds of i n d i v i d u a l problems from which t e s t c a s e s can be b u i l t and, c o n s e q u e n t l y , p r e v e n t s a g g r e s s i v e l a w y e r s from s t r a y i n g i n t o a r e a s t h a t might c h a l l e n g e , f o r example, s t a t e e c onomic p o l i c i e s . At the same t i m e , the presence of the programme e f f e c t i v e l y assuages the demand f o r p a t i e n t s ' l e g a l s e r v i c e s (Gordon, 1983). In s h o r t , w h i l e p a t i e n t advocacy i s a necessary f e a t u r e of the new l e g a l i s m f o r the s t a t e , advocacy s e r v i c e s are being absorbed i n t o the s t a t e apparatus and l i m i t a t i o n s are being placed upon the a c t i v i t i e s of a d v o c a t e s . 1 1 3 T h e i r p r i n c i p a l r o l e i s to f a c i l i t a t e l a r g e r s t a t e s t r a t e g i e s f o r the management of the m e n t a l l y d i s o r d e r e d and, t h e r e b y , a s s i s t t h e s t a t e i n t h e e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . In a d d i t i o n t o the p r o b l e m s p o s e d by t h e a d v o c a c y 472 component of the p a t i e n t s ' r i g h t s movement, the s t a t e has a l s o had t o c o n f r o n t and d e f u s e t h e o p p o s i t i o n m o unted by a c o n s e r v a t i v e i n t e r e s t group; namely, organized p s y c h i a t r y . The l a t t e r has o b j e c t e d to b o t h the law r e f o r m o b j e c t i v e s of the p a t i e n t s ' r i g h t s movement and s t a t e economic r e s t r a i n t p o l i c i e s , and the s t a t e has t a k e n s t e p s to a d d r e s s , i n p a r t i c u l a r , the attendant l e g i t i m a t i o n problems. THE CONFLICT WITH ORGANIZED PSYCHIATRY The success of the p a t i e n t s ' r i g h t s movement i n persuading p r o v i n c i a l governments to adopt the new l e g a l i s m i s p a r t i c u l a r l y r e m a r k a b l e i n the l i g h t of the o p p o s i t i o n mounted by an i n t e g r a t e d and p o t e n t i a l l y more powerful i n t e r e s t group; namely, organized p s y c h i a t r y and i t s a l l i e s (Savage & McKague, 1 9 8 7 ) . 1 1 4 As the p a t i e n t s ' r i g h t s movement began to emerge, p s y c h i a t r i s t s responded with c r i t i c i s m and a vigorous defence of both t h e i r r o l e i n the management of the mentally d i s o r d e r e d and the l e g a l framework e s t a b l i s h e d i n the 1960's ( i . e . , 'enhanced m e d i c a l -i z a t i o n ' ). v Although many i n d i v i d u a l p s y c h i a t r i s t s provided t h e i r own c r i t i c i s m s of the p a t i e n t s ' r i g h t s movement, the f o r e m o s t r e p r e s e n t a t i v e of the p s y c h i a t r i c p e r s p e c t i v e has been the Canadian P s y c h i a t r i c A s s o c i a t i o n (CP.A.). From the mid-1970's onwards, t h i s o r g a n i z a t i o n began to mount an attack upon both the new l e g a l i s m and s t a t e m e n t a l h e a l t h f u n d i n g p o l i c i e s . I n s p i r a t i o n was drawn from the arguments o f f e r e d by organized p s y c h i a t r y i n the United States (notably, the American Psych-i a t r i c A s s o c i a t i o n ) where p s y c h i a t r i s t s and mental h e a l t h law 473 advocates were engaged i n a b a t t l e over the 'best i n t e r e s t s ' of p a t i e n t s (Wexler, 1981; Warren, 1982; R a c h l i n , 1985), and t h i s c o n f l i c t spread i n t o Canada. New p a t i e n t s ' r i g h t s were c r i t i c -i z e d as too r e s t r i c t i v e and r e s u l t i n g i n the benign n e g l e c t of those s u f f e r i n g from mental i l l n e s s e s . I t was argued t h a t p a t i e n t s were b e i n g e i t h e r f o r c e d from the 'back wards' of h o s p i t a l s i n t o the 'back s t r e e t s ' of c i t i e s , or denied access to mental h e a l t h care and t h e r e f o r e f o r c e d to contend with l i v e s dominated by the misery of i l l n e s s . By the beginning of the 1980's, t h i s approach became fused w i t h c o n c e r n s r e g a r d i n g the i m p a c t of government economic r e s t r a i n t measures i n the h e a l t h care s e c t o r and the damage that t h e s e were c a u s i n g to the q u a l i t y of m e n t a l h e a l t h s e r v i c e s . The CP.A. began to l o b b y f o r i n c r e a s e d f u n d i n g and improved s e r v i c e s and, i n so doing, p u b l i c l y exposed and c h a l l e n g e d the s t a t e ' s p o l i c i e s and a c t i o n s . S i n c e the p r o v i s i o n of h e a l t h care was hallowed and p o l i t i c a l l y s e n s i t i v e ground, the C.P.A.'s a c t i v i t i e s posed a problem of l e g i t i m a t i o n f o r the s t a t e . One of the f i r s t attempts to w r e s t l e w i t h the i m p l i c a t i o n s of the growing concern f o r improving p a t i e n t s ' r i g h t s appeared i n the l a t e 1960's (Kreyes, 1969); however, the f i r s t response on the p a r t of o r g a n i z e d p s y c h i a t r y emerged i n 1972. In h i s a n n u a l a d d r e s s t o t h e members o f t h e R o y a l C o l l e g e of P s y c h i a t r i s t s , the p r e s i d e n t (Dr. M a r t i n Roth) l a u n c h e d a s p i r i t e d attack on the c r i t i c s of p s y c h i a t r y . The 'new s o c i a l determinism' embodied i n the work of s o c i a l s c i e n t i s t s and the s o - c a l l e d ' a n t i - p s y c h i a t r i s t s ' had i n v o l v e d an u n a c c e p t a b l e 474 p o r t r a y a l of p s y c h i a t r y as a hand-maiden of the ' t h e r a p e u t i c state'. P s y c h i a t r i s t s were seen as the s o c i a l c o n t r o l agents of a corrupt s o c i a l order and the p r a c t i c e of p s y c h i a t r y was merely a form of i n s t i t u t i o n a l v i o l e n c e . None of t h i s , Roth argued, was tenable although i t d i d r a i s e s i g n i f i c a n t c h a l l e n g e s f o r the p r o f e s s i o n ( P r e s i d e n t i a l Address, 1972). By 1978, the A s s o c i a t i o n had to contend w i t h more than an i n t e l l e c t u a l c r i t i q u e of p s y c h i a t r y s i n c e the p a t i e n t s ' r i g h t s movement had s c o r e d a s u c c e s s i n O n t a r i o . Indeed, the new p r o v i n c i a l m e n t a l h e a l t h l e g i s l a t i o n became the s u b j e c t of a l e n g t h y c r i t i q u e i n the a n n u a l p r e s i d e n t i a l a d d r e s s t o the Col l e g e . The growing concern with p a t i e n t s ' r i g h t s was noted and the new Ontario l e g i s l a t i o n was condemned as "misguided and misbegotten" ( P r e s i d e n t i a l Address, 1978: 517). Any r e s t r i c t -ions that were placed upon the process of i n v o l u n t a r y admission v i o l a t e d the r i g h t s of f a m i l i e s , the p u b l i c , and those p a t i e n t s who n e e d e d t r e a t m e n t , and were a " r e t r o g r e s s i v e s t e p " . P o l i t i c i a n s had become preoccupied with c i v i l r i g h t s and they had to be made aware of the adverse consequences of f o l l o w i n g t h i s path (op c i t ) . The new O n t a r i o l e g i s l a t i o n became something of a cause c e l e b r e f o r o r g a n i z e d p s y c h i a t r y and the d e v e l o p m e n t s were viewed w i t h alarm p a r t i c u l a r l y s i n c e , by the end of 1978, i t was apparent that other p r o v i n c e s were c o n s i d e r i n g s i m i l a r reforms (op c i t ) . Indeed, the advent of the new l e g a l i s m i n O n t a r i o seemed to add a new urgency to the c a l l s f o r p r e s e r v i n g 475 l e g i s l a t i o n c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' . M i l l e r (1979), f o r example, p u b l i s h e d an a t t a c k on the ' l e g a l i s t i c ' emphasis i n the new l e g i s l a t i o n and the r e s t r i c t i v e admission c r i t e r i a were s i n g l e d out f o r s p e c i a l a t t e n t i o n . In p r a c t i c e , t h e s e were not i n the b e s t i n t e r e s t s of p a t i e n t s s i n c e they impeded the p r o v i s i o n of e a r l y , and t h e r e f o r e more e f f e c t i v e , treatment. C e r t a i n l y , p a t i e n t s ' r i g h t s i s s u e s were of import-ance; however, i n M i l l e r ' s view, new s a f e g u a r d s were o n l y necessary i n the area of post-admission review. Within a matter of months, these i s s u e s r e c e i v e d an a i r i n g i n a v i g o r o u s debate i n the pages of the C a n a d i a n J o u r n a l of P s y c h i a t r y and the Canadian M e d i c a l A s s o c i a t i o n J o u r n a l , w i t h the m a j o r i t y of w r i t e r s e x h i b i t i n g l i t t l e sympathy f o r the p e r s p e c t i v e of the p a t i e n t s ' r i g h t s movement. Both Sher r i n g t o n (1981) and McCormick (1981) c r i t i c i z e d the O n t a r i o l e g i s l a t i o n f o r i t s o v e r l y r e s t r i c t i v e commitment c r i t e r i a , and McCormick suggested t h a t the s t a t u t e could not be i n t e r p r e t e d l i t e r a l l y s i n c e t h i s would r e s u l t i n p h y s i c i a n s being f o r c e d to act i n a manner c o n t r a r y t o the b e s t i n t e r e s t s of t h e i r p a t i e n t s . Consequently, there was a tendency f o r medical p r a c t i t i o n e r s to admit persons on the b a s i s of the c r i t e r i a which e x i s t e d p r i o r to the new s t a t u t e . The extent to which other p r a c t i t i o n e r s were i n c l i n e d to f o l l o w the same c o u r s e of a c t i o n became c l e a r as a r e s u l t of r e s e a r c h i n t o the admission p r a c t i c e s of p h y s i c i a n s . T h i s work demonstrated the presence of a 'quiet r e v o l u t i o n ' among medical p r a c t i t i o n e r s and there was evidence of a widespread tendency to 476 ignore, i n p a r t i c u l a r , the c r i t e r i a f o r commitment set out i n the new l e g i s l a t i o n (Page & F i r t h , 1979; Page, 1980, 1981; McCready & Merskey, 1982; R i c h e r t & Moyes, 1983; M a r t i n & Cheung, 1985; Bagby, et a l , 1 9 8 7 ) . 1 1 5 Other p s y c h i a t r i s t s began to attack the p e r s p e c t i v e of the p a t i e n t s ' r i g h t s movement by p o i n t i n g out t h a t t h e r e was p u b l i c a c c e p t a n c e of the f o r c e d confinement and treatment of those with communicable d i s e a s e s (Toews, e t a l , 1980). In a d d i t i o n , r e s e a r c h was c o n d u c t e d to d e m o n s t r a t e t h a t i n v o l u n t a r i l y a d m i t t e d p a t i e n t s were non-committal on the question of r i g h t s and showed l i t t l e i n t e r e s t i n launching appeals a g a i n s t admission d e c i s i o n s (Toews, et a l , 1981, 1984). A l l of t h i s c r i t i c i s m c o n s t i t u t e d a t h r e a t to the l e g i t i m a c y of the 'new l e g a l i s m ' . By the e a r l y 1980's, the concerns of organized p s y c h i a t r y began to focus upon s t a t e economic r e s t r a i n t p o l i c i e s as w e l l as the i s s u e of p a t i e n t s ' r i g h t s . In the 1981 a d d r e s s to the C o l l e g e , the p r e s i d e n t (Dr. E. L i p i n s k i ) launched an attack upon government h e a l t h c a r e f u n d i n g by a r g u i n g t h a t , d e s p i t e the sombre warnings of "runaway medical c o s t s " , the p r o p o r t i o n of the gross n a t i o n a l product absorbed by h e a l t h care had remained constant f o r a decade ( P r e s i d e n t i a l Address, 1981). Governments had, n e v e r t h e l e s s , i n t r o d u c e d r e s t r a i n t s which r e s u l t e d i n c h r o n i c under-funding, and had chosen to c o n t r o l the behaviour of p h y s i c i a n s r a t h e r than t h e i r p a t i e n t s . To have done otherwise would have been p o l i t i c a l l y untenable. P h y s i c i a n behaviour had been c o n t r o l l e d by c l o s i n g h o s p i t a l beds and the c o n s e q u e n t process of d e - i n s t i t u t i o n a l i z a t i o n had become a d i s a s t e r . Those 477 who needed mental h e a l t h s e r v i c e s were unable to secure them and they were consequently condemned to e i t h e r the back a l l e y s of c i t i e s or to j a i l s and p r i s o n s . While t h i s s i t u a t i o n had been created by government economic p o l i c i e s , i t was a l s o a product of the work of t h ose who sought to impose r e s t r i c t i o n s on p s y c h i a t r i s t s through mental h e a l t h l e g i s l a t i o n . The p a t i e n t s ' r i g h t s movement was w e l l i n t e n t i o n e d and i t s e f f o r t s were t r u l y humanitarian; however, i n L i p i n s k i ' s view, i t s a c t i v i t i e s were not i n best i n t e r e s t s of p a t i e n t s (op c i t ) . The i s s u e s of economic r e s t r a i n t , a r e d u c t i o n i n the 1 q u a l i t y and q u a n t i t y of mental h e a l t h s e r v i c e s , and p a t i e n t s ' r i g h t s had become f u s e d , and t h e r e was a s u g g e s t i o n t h a t the process of c o n t r o l l i n g the a c t i v i t i e s of medical p r a c t i t i o n e r s i n order to accomplish economic goals had been f a c i l i t a t e d by the work of the p a t i e n t s ' r i g h t s movement. S i n c e i t was apparent that governments would continue w i t h t h i s course of a c t i o n , d e s p i t e the v i e w s of o r g a n i z e d p s y c h i a t r y , a major chall e n g e had appeared and, by the end of 1981, the CP.A. had d e v e l o p e d a new p o s i t i o n on the q u e s t i o n of p a t i e n t s ' r i g h t s . Indeed, the o r g a n i z a t i o n prepared and endorsed a p a t i e n t s ' ' B i l l of R i g h t s ' which s u p p o r t e d some of the o b j e c t i v e s of the p a t i e n t s ' r i g h t s movement. The A s s o c i a t i o n d e p l o r e d any abuses of the commitment p r o c e s s but, s i n c e i n v o l u n t a r y a d m i s s i o n might be n e c e s s a r y before treatment could be given, the e x e r c i s e of p r o f e s s i o n a l d i s c r e t i o n i n t h i s area was to be preserved. Wherever p o s s i b l e , 478 treatment was not to be given without f r e e , f u l l , and informed consent and p a t i e n t s had a r i g h t to p a r t i c i p a t e i n a l l d e c i s i o n -making p r o c e s s e s ( i n c l u d i n g t h o se a f f e c t i n g t r e a t m e n t ) . A p a t i e n t s h o u l d not be r e q u i r e d to u n d e r t a k e ' h o s p i t a l l a b o u r ' without proper remuneration and d i s c r i m i n a t i o n on the b a s i s of mental handicap was to be p r o h i b i t e d . P a t i e n t s had a r i g h t to an humane p s y c h o l o g i c a l and p h y s i c a l environment and the CP.A. stood, f i r m l y behind one p a r t i c u l a r p a t i e n t s ' r i g h t ; namely, the r i g h t to r e c e i v e treatment when i l l (Watt & E l - G u e b a l l y , 1981). While many areas of disagreement e x i s t e d , i t was apparent that the A s s o c i a t i o n was attempting to e s t a b l i s h a compromise with the p a t i e n t s ' r i g h t s movement. The d e f i n i t i o n of 'mental i l l n e s s ' , the process of i n v o l u n t a r y admission, the r i g h t to r e f u s e t r e a t m e n t , and the r i g h t to r e c e i v e t r e a t m e n t were c o n t e n t i o u s a r e a s , and the l a s t of t h e s e i s of p a r t i c u l a r i m p o r t a n c e f o r an u n d e r s t a n d i n g of the o b j e c t i v e s w hich underpinned the C.P.A.'s apparent quest f o r rapprochement. The s t a t u t o r y entrenchment of a r i g h t to r e c e i v e treatment can form the b a s i s f o r l e g a l a c t i o n d e s i g n e d to compel a p r o v i n c i a l government to p r o v i d e the r e s o u r c e s n e c e s s a r y f o r t r e a t m e n t . 1 1 6 I t i s , t h e r e f o r e , a p a t i e n t s ' r i g h t which b e n e f i t s more than those deemed to be s u f f e r i n g from m e n t a l d i s o r d e r s . Those i n v o l v e d i n the o r g a n i z a t i o n , a d m i n i s t r a t i o n and d e l i v e r y of mental h e a l t h s e r v i c e s are a l s o l i k e l y t o be b e n e f i c i a r i e s s i n c e t h e i r b a i l i w i c k w i l l be e i t h e r preserved or, b e t t e r s t i l l , expanded. In the United St a t e s , f o r example, the r i g h t has been used to pressure s t a t e governments i n t o p r o v i d i n g 479 more mental h e a l t h resources and, i n many i n s t a n c e s , l i t i g a t i o n launched on behalf of p a t i e n t s was i n i t i a t e d by mental h e a l t h p r o f e s s i o n a l s (Brakel, et a l , 1985). T h i s has not e s c a p e d the n o t i c e of the p a t i e n t s ' r i g h t s movement and, as C h a m b e r l i n (1979) has p o i n t e d out, m e n t a l p a t i e n t s ' a s s o c i a t i o n s view the r i g h t to r e c e i v e treatment as a l e g a l c o n c e p t t h a t has more to do w i t h the w e l f a r e of mental he a l t h p r o f e s s i o n a l s than t h e i r p a t i e n t s . The e s t a b l i s h m e n t of such a r i g h t c h a l l e n g e s n e i t h e r the e x i s t i n g and j u d g m e n t a l process of d e f i n i n g 'mental i l l n e s s ' , nor the power of psych-i a t r i s t s to impose unwanted treatment. I t l e g i t i m i z e s the use of i n v o l u n t a r y admission and confinement and does not r e s u l t i n the e s t a b l i s h m e n t of 'treatment' a l t e r n a t i v e s that are both l e s s r e s t r i c t i v e than i n s t i t u t i o n s and w h i c h l i e o u t s i d e the c o n v e n t i o n a l mental h e a l t h system (i.e., ' r a d i c a l ' or a l t e r n a t e forms of mental h e a l t h care) (op c i t ) . In short, f o r p a t i e n t s ' a s s o c i a t i o n s , the r i g h t c o n f i r m s the dominance of the medical model and p r i m a r i l y s e r v e s the i n t e r e s t s of m e n t a l h e a l t h p r o f e s s i o n a l s . The r i g h t to r e c e i v e treatment and other r i g h t s endorsed by the CP.A. (e.g., the r i g h t to an humane, p s y c h o l o g i c a l and p h y s i c a l environment) were e i t h e r u n l i k e l y to reduce medical domination of the management of p a t i e n t s , or l i k e l y to r e s u l t i n d i r e c t b e n e f i t s f o r mental h e a l t h p r o f e s s i o n a l s . Some p a t i e n t s ' r i g h t s could be used to preserve the b a i l i w i c k of p s y c h i a t r i s t s i n the f a c e of s t a t e economic r e s t r a i n t p o l i c i e s , and the A s s o c i a t i o n had a d o pted a t a c t i c employed by an a l l y - the 480 C.M.H.A. - i n the 1950's and 1960's; namely, a d v o c a t i n g those p a t i e n t s ' r i g h t s which would b u t t r e s s p r o f e s s i o n a l i n t e r e s t s . In t h i s regard, the C.M.H.A. continued to support psych-i a t r i c i n t e r e s t s (Savage & McKague, 1987). F o l l o w i n g i t s success i n en g i n e e r i n g 'enhanced m e d i c a l i z a t i o n ' i n the 1960's, the A s s o c i a t i o n s w i t c h e d i t s f o c u s to the e s t a b l i s h m e n t and p r e s e r v a t i o n of c i v i l r i g h t s such as, the r i g h t to v o t e , the r i g h t to secure and r e t a i n v a r i o u s l i c e n s e s , and the r i g h t to a t t a i n and hold v a r i o u s forms of employment (Swadron & S u l l i v a n , 1973). The C.M.H.A. d i d not, however, abandon an i n t e r e s t i n mental h e a l t h l e g i s l a t i o n and, from the mid-1970's onwards, the o r g a n i z a t i o n began to pursue the r i g h t to r e c e i v e treatment. The A s s o c i a t i o n a l s o s t a r t e d t o l o b b y f o r improved mental h e a l t h resources and, with the emergence of s t a t e c o s t - s t a b i l i z a t i o n p o l i c i e s i n the 1970's, t h i s became a primary concern (Toews & Barnes, 1982 ). In 1981, the C.M.H.A. e s t a b l i s h e d a 'Mental Health S e r v i c e s Committee' which undertook a nationwide 'needs assessment* and t h i s demonstrated the extent to which, i n the A s s o c i a t i o n ' s v i e w , the h e a l t h needs of those a f f l i c t e d w i t h m e n t a l d i s o r d e r s were not b e i n g met (op c i t ) . One answer to t h i s p r o b l e m was to pursue the e s t a b l i s h m e n t of a p a t i e n t ' s r i g h t to r e c e i v e t r e a t m e n t , and the C.M.H.A. s u p p o r t e d the CP.A. i n i t s quest f o r the same goal. While some i n d i v i d u a l p s y c h i a t r i s t s continue to c r i t i c i z e b oth the new l e g a l i s m and the p a t i e n t s * r i g h t s movement ( M i l l i k e n , 1987; M i l l i k e n & Osinchuk, 1984; Hoaken, 1986), the 481 CP.A. has a p p a r e n t l y r e a l i z e d t h a t , w i t h the advent of the C h a r t e r , p s y c h i a t r y has l i t t l e c h o i c e but to adapt (Goldman, 1984; Hoffman, 1985). Nevertheless, organized p s y c h i a t r y and i t s a l l i e s ( n o t a b l y , the C.M.H.A.) have mounted a two-pronged a t t a c k upon the s t a t e . O r g a n i z e d p s y c h i a t r y has p u b l i c l y exposed and c h a l l e n g e d f e d e r a l and p r o v i n c i a l economic r e s t r a i n t p o l i c i e s i n the mental h e a l t h s e c t o r thereby posing a problem of l e g i t i m a t i o n . I t i n i t i a l l y c h a l l e n g e d the l e g i t i m a c y of the new l e g a l i s m but has subsequently used the p a t i e n t s * r i g h t s i s s u e (by advocating a r i g h t to r e c e i v e treatment) i n an attempt to stop any f u r t h e r e r o s i o n of mental h e a l t h s e r v i c e s . Since the p r o v i n c i a l l e v e l of the s t a t e was a l s o using p a t i e n t s ' r i g h t s i s s u e s to f a c i l i t a t e and l e g i t i m i z e i t s c o s t - s t a b i l i z a t i o n and r e s t r a i n t p o l i c i e s , t h e C.P.A.'s t a c t i c was p o t e n t i a l l y e f f e c t i v e . The S t a t e Response; Appeasement, L i m i t a t i o n , and the New Legalism D e s p i t e the l e g i t i m a t i o n p r o b l e m c r e a t e d by o r g a n i z e d p s y c h i a t r y , many p r o v i n c i a l governments have proceeded with the i n t r o d u c t i o n of economic r e s t r a i n t measures, new mental h e a l t h s t r a t e g i e s , and law reforms c o n s i s t e n t w i t h the new l e g a l i s m . Indeed, the l e g i t i m a t i o n problem has enhanced the value of the new l e g a l i s m f o r the s t a t e , and the i n h e r e n t l y j u s t i f i a b l e nature of such reforms has been r e i n f o r c e d by the t i m e l y advent of the C h a r t e r . One p r o v i n c e , however, has acknowledged the o b j e c t i o n s of organized p s y c h i a t r y and i n t r o d u c e d l e g i s l a t i o n which a p p a r e n t l y appeases t h i s i n t e r e s t group (thereby defusing a l e g i t i m a t i o n problem), but without r e l i n q u i s h i n g those aspects 482 of the new l e g a l i s m which b u t t r e s s economic r e s t r a i n t p o l i c i e s . In Saskatchewan, the government introduced the new l e g a l i s m , at the same t i m e r e c o g n i z i n g (but d i l u t i n g ) the demands of organized p s y c h i a t r y , p a r t i c u l a r l y i n r e l a t i o n to the p a t i e n t s ' r i g h t to r e c e i v e treatment. New mental h e a l t h l e g i s l a t i o n c o n s i s t e n t w i t h the new l e g a l i s m was passed i n Saskatchewan i n 1985 and the p r o v i n c i a l b r a n c h of the C.M.H.A. p l a y e d a dominant r o l e i n the r e f o r m p r o c e s s . 1 1 7 In 1980, the o r g a n i z a t i o n e s t a b l i s h e d a Task Force to examine the adequacy of the province's mental h e a l t h system -a system that was being subjected to severe economic r e s t r a i n t -and a co m p r e h e n s i v e r e p o r t was r e l e a s e d i n 1983 (Task F o r c e Committee, 1983). The document contained a l i s t of recommend-a t i o n s designed to improve mental h e a l t h care i n the province and these envisaged an expansion of mainstream mental h e a l t h s e r v i c e s . Among o t h e r m a t t e r s , the Task F o r c e wanted: a renewed commitment t o r e g i o n a l i z a t i o n ; an e x p a n s i o n i n the numbers of approved homes and group homes to en s u r e the p r o v i s i o n of adequate community care f o l l o w i n g d e - i n s t i t u t i o n -a l i z a t i o n ; new s p e c i a l s e r v i c e s f o r p a r t i c u l a r groups (e.g., the e l d e r l y ) ; and, t h e a l l o c a t i o n o f a l a r g e r s h a r e o f t h e government's h e a l t h care budget to mental h e a l t h s e r v i c e s . The Task F o r c e a l s o touched upon the i s s u e o f mental h e a l t h law r e f o r m by p r o p o s i n g a r e v i e w of p r o v i n c i a l l e g i s -l a t i o n . In the l i g h t of a t t a c k s by members of the p a t i e n t s ' r i g h t s movement (an i n t e r e s t group that was c l e a r l y not a l i g n e d 483 w i t h the A s s o c i a t i o n ) the Task F o r c e sought to c l a r i f y the powers of medical p r a c t i t i o n e r s to i n v o l u n t a r i l y admit, t r e a t , and c o n f i n e p a t i e n t s . I t was f e l t t h a t p s y c h i a t r i s t s were r e l u c t a n t to use i n v o l u n t a r y a d m i s s i o n p r o c e d u r e s s i n c e they feared the l e g a l consequences, and the C.M.H.A. wanted changes t h a t would e n s u r e p r a c t i t i o n e r s were not o p e r a t i n g i n an atmosphere of u n c e r t a i n t y (op c i t ) . W h ile the Task F o r c e was u n d e r t a k i n g i t s a n a l y s i s the A s s o c i a t i o n i n i t i a t e d an i n q u i r y i n t o the need f o r mental h e a l t h law r e f o r m and, i n 1984, a f u r t h e r r e p o r t was r e l e a s e d (Committee of Enquiry, 1984). This contained p r o p o s a l s f o r a 'Mental Health Care D e l i v e r y Act' that would provide the l e g a l framework necessary to support the A s s o c i a t i o n ' s p r o p o s a l s f o r improved mental h e a l t h s e r v i c e s . A r i g h t to r e c e i v e treatment was f i r m l y endorsed, along with procedures f o r admission and t r e a t m e n t which would b e t t e r c l a r i f y the powers of m e d i c a l p r a c t i t i o n e r s . In the i n t e r i m , the p o s s i b l e i m pact of the Charter had been assessed (notably, the ' l e g a l r i g h t s ' and the ' e q u a l i t y r i g h t s ' p r o v i s i o n s ) and i t was c l e a r that any reforms t o m e n t a l h e a l t h l e g i s l a t i o n had to take the C h a r t e r i n t o a c c o u n t . S i n c e the l a t t e r ( i . e . , the e q u a l i t y r i g h t s p r o v i s -ions) c o u l d be used to r e i n f o r c e the changes which were d i r e c t l y s u p p o r t i v e of improved and expanded mental h e a l t h s e r v i c e s , i t was a v a l u a b l e but two-edged sword. The Charter a l s o demanded improved safeguards f o r those who were deprived of t h e i r l i b e r t y (e.g., i n v o l u n t a r y p a t i e n t s ) , and t h i s meant an a c c e p t a n c e of the types of reforms sought by the p a t i e n t s ' r i g h t s movement. 484 The recommendations of the C.M.H.A. were p a r t l y r e f l e c t e d i n the new mental h e a l t h l e g i s l a t i o n , but these were m o d i f i e d by the government i n keeping with both r e s t r a i n t p o l i c i e s and the c o n t e n t of the C h a r t e r . P r o v i s i o n was made f o r a ' r i g h t t o r e c e i v e treatment 1 but i t s impact was l i m i t e d by the i n c l u s i o n of c o n d i t i o n a l terms. The new s t a t u t e p l a c e s a p a t i e n t ' s attending p h y s i c i a n under a duty to provide care and treatment that w i l l r e s u l t i n discharge to the community, but i t s p e c i f i e s that t h i s duty w i l l be l i m i t e d by the a v a i l a b i l i t y of resources. P h y s i c i a n s a r e o n l y r e q u i r e d to do t h e i r b e s t t o p r o v i d e adequate treatment, given the reso u r c e s at t h e i r d i s p o s a l , and the government i s not compelled to provide improved s e r v i c e s (Gordon & Verdun-Jones, 1987). The new s t a t u t e a l s o i n t r o d u c e s s t r i c t e r c r i t e r i a f o r i n v o l u n t a r y admission and the p r o v i s i o n of treatment without consent, p r o h i b i t s the use of psychosurgery, e s t a b l i s h e s q u a s i - j u d i c i a l r e v i e w p r o c e d u r e s , and, makes p r o v i s i o n f o r o t h e r p a t i e n t s ' r i g h t s (e.g., p a t i e n t s are e n t i t l e d to p a r t i c i p a t e i n treatment d e c i s i o n s ) which are both c o n s i s t e n t w i t h the Charter and sup p o r t i v e of the goals of the p a t i e n t s ' r i g h t s movement. In e f f e c t , the p r o v i n c i a l government c o n s t r u c t e d a s t a t u t e that a p p a r e n t l y appeases organized p s y c h i a t r y and i t s a l l i e s , at the same t i m e a v o i d i n g the e s t a b l i s h m e n t of p a t i e n t s ' r i g h t s which might compel an in c r e a s e i n expenditures on mental h e a l t h s e r v i c e s . I n s o f a r as the l e g i s l a t i o n imposes l i m i t a t i o n s upon the i n v o l u n t a r y a d m i s s i o n , t r e a t m e n t and c o n f i n e m e n t o f p a t i e n t s , i t a l s o r e f l e c t s those a s p e c t s of the new l e g a l i s m 485 which b e s t s e r v e s t a t e , economic i n t e r e s t s . I t i s a s t a t u t e that a s s i s t s the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s p o t e n t i a l l y c o n t r a d i c t o r y c a r d i n a l f u n c t i o n s , and i t i s a t t -r a c t i v e to, f o r example, the Government of B r i t i s h Columbia. Both an appeasement of o r g a n i z e d p s y c h i a t r y and the i m p o s i t i o n of l i m i t s upon the reform o b j e c t i v e s of the p a t i e n t s ' r i g h t s movement are c o n s i d e r a t i o n s which are shaping the content of mental h e a l t h s t a t u t e s . The extent to which t h i s i s the case i s evident from the c u r r e n t process of c o n s t r u c t i n g new mental h e a l t h l e g i s l a t i o n i n B r i t i s h C o l u m b i a . W h i l e the r e c e n t l y r e l e a s e d 'Mental H e a l t h C o n s u l t a t i o n R eport' s e t s out the government's new s t r a t e g y f o r the management of the mentally d i s o r d e r e d , i t does not address the is s u e of law reform i n depth ( M i n i s t r y o f H e a l t h , 1987). However, i t i s e v i d e n t t h a t implementation of the 'mental h e a l t h plan' w i l l be accompanied by changes to l e g i s l a t i o n , and that a r e c o g n i t i o n and enhance-ment of p a t i e n t s ' r i g h t s i s an i n t e g r a l p a r t of the s t r a t e g y . The mental h e a l t h s e r v i c e has adopted f i v e " p h i l o s o p h i c a l core v a l u e s " , the f i r s t of which e x p r e s s e s the t e n e t s of a 'new l e g a l i s m ' that r e f l e c t s an appeasement of orga n i z e d p s y c h i a r y and l i m i t s the o b j e c t i v e s of the p a t i e n t s * r i g h t s movement: Men t a l l y i l l people have the same pers o n a l r i g h t s enjoyed by the general p u b l i c : the r i g h t to q u a l i t y h e a l t h c a r e , to determine p e r s o n a l g o a l s , to access community s e r v i c e s , and the r i g h t to p r i v a c y ...Within t h e i r a b i l i t y to know and judge, p a t i e n t s have the r i g h t to r e f u s e t r e a t m e n t as w e l l as to have the l e a s t i n t r u s i v e treatment p o s s i b l e . They have the r i g h t to adequate and i n d i v i d u a l i z e d care, i n c l u d i n g d i r e c t i o n and management, when t h e i r own or p u b l i c s a f e t y i s at r i s k (op c i t : 2). I A ' r i g h t to r e c e i v e t r e a t m e n t ' i s e x p r e s s e d as a ' r i g h t to 486 q u a l i t y h e a l t h care' and t h i s i s l i m i t e d to 'adequate' care and c o n t r o l whenever a p a t i e n t ' s behaviour c o n s t i t u t e s a r i s k to the s a f e t y of e i t h e r the i n d i v i d u a l or the community. A ' r i g h t to refu s e treatment' i s a l s o acknowledged but, again, the impact i s l i m i t e d by the use of c o n d i t i o n a l terms ( i . e . , the p a t i e n t ' s a b i l i t y to 'know and judge'). A review of the Mental Health Act i s taking p l a c e w i t h i n t h i s ' p h i l o s o p h i c a l ' framework, but a major r e c o n s t r u c t i o n w i l l not be completed u n t i l the new mental h e a l t h s t r a t e g y i s ready f o r i m p l e m e n t a t i o n . As i s the case w i t h the u n d e r l y i n g s t r a t e g y , law reforms w i l l be int r o d u c e d i n c r e m e n t a l l y and t h i s p r o c e s s of g r a d u a l , s t a t u t o r y amendment has s t a r t e d . 1 1 8 In a d d i t i o n , one 'reform' c o n s i s t e n t w i t h the new l e g a l i s m has been adopted i n advance of l e g i s l a t i v e change. As a m a t t e r of p r a c t i c e , R i v e r v i e w H o s p i t a l w i l l o n l y admit 'dangerous' i n v o l u n t a r y p a t i e n t s who cannot be t r e a t e d i n p s y c h i a t r i c u n i t s , even though the M e n t a l H e a l t h A c t r e t a i n s a s e t of l i b e r a l , i n v o l u n t a r y admission c r i t e r i a (Goresky, 1982). I t i s a p p a r e n t t h a t a d e c i s i o n has been made to adandon the 'enhanced m e d i c a l i z a t i o n ' which c h a r a c t e r i z e s the bulk of i, the c u r r e n t s t a t u t e , i n favour of the new l e g a l i s m . However, some u n c e r t a i n t y s u r r o u n d s the a c t u a l c o n t e n t o f the new l e g i s l a t i o n and t h i s r e f l e c t s the c o n f l i c t between o r g a n i z e d p s y c h i a t r y and the p a t i e n t s ' r i g h t s movement, and the state's need t o appease the f o r m e r and r e s t r a i n the l a t t e r , w h i l e s i m u l t a n e o u s l y u t i l i z i n g those aspects of the new l e g a l i s m which 487 a s s i s t i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . The province has been p a r t i c i p a t i n g i n the Uniform Law Conference of Canada, Mental He a l t h Law P r o j e c t , and t h i s i s now completed. The goal has been to produce s t a n d a r d i z e d mental h e a l t h l e g i s l a t i o n which e p i t o m i z e s one form of new l e g a l i s m (i.e., the Uniform Mental Health Act) and the Deputy M i n i s t e r of Health has i n d i c a t e d t h a t he has been w a i t i n g f o r the outcome of the p r o j e c t before i n t r o d u c i n g a new mental h e a l t h s t a t u t e . 1 1 9 T h i s suggests that the pro v i n c e may adopt the 'model s t a t u t e ' but t h i s course of a c t i o n i s by no means c e r t a i n . The Uniform M e n t a l H e a l t h A c t r e f l e c t s the o b j e c t i v e s of the p a t i e n t s ' r i g h t s movement but i t i s seen as embodying the ' r i g i d l e g a l i s m ' of the Onta r i o mental h e a l t h l e g i s l a t i o n , and has been attacked v i g o r o u s l y by p s y c h i a t r y ( M i l l i k e n , 1987). In the l i g h t of both t h i s o p p o s i t i o n and the p r o b l e m s of o r d e r m a i n t e n a n c e and l e g i t i m a t i o n which have accompanied the d e - i n s t i t u t i o n a l i z a t i o n p r o c e s s i n O n t a r i o (a p r o c e s s a l l e g e d l y p r o p e l l e d by ' r i g i d l e g a l i s m ' ) , the model s t a t u t e may not be adopted i n i t s e n t i r e t y i n B r i t i s h C o l u m b i a . 1 2 0 An a l t e r n a t i v e i s a v a i l a b l e i n the form of the new Saskatchewan l e g i s l a t i o n and t h i s i s viewed more favourably by s e n i o r o f f i c i a l s w i t h i n the p r o v i n c i a l s t a t e a p p a r a t u s . 1 2 1 Saskatchewan d i d not take p a r t i n the Mental Health Law P r o j e c t and developed l e g i s l a t i o n which i s seen as both more 'treatment o r i e n t e d ' and more e f f e c t i v e i n b a l a n c i n g p a t i e n t s ' r i g h t s i s s u e s and h e a l t h care n e e d s . 1 2 2 I t provi d e s a more e f f e c t i v e way of appeasing organized p s y c h i a t r y , r e s t r a i n i n g the p a t i e n t s ' 488 r i g h t s movement, and f a c i l i t a t i n g and l e g i t i m a t i n g the new s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d . E l e m e n t s o f t h e S a s k a t c h e w a n 'model' ( n o t a b l y , an endorsement of a l i m i t e d r i g h t to r e c e i v e t r e a t m e n t ) appease organized p s y c h i a t r y without n e c e s s a r i l y i n t e r f e r i n g w i t h s t a t e r e s t r a i n t p o l i c i e s , and t h i s w i l l d e f u s e any l e g i t i m a t i o n problem. The P s y c h i a t r i c S e c t i o n of the B.C.M.A. has expressed i t s i n t e n t i o n to oppose changes which threaten i t s b a i l i w i c k and i t cannot, t h e r e f o r e , be d i s r e g a r d e d by the s t a t e . When the government announced i t s i n t e n t i o n to review both mental h e a l t h p o l i c i e s and mental h e a l t h l e g i s l a t i o n i n 1985, the B.C.M.A. advised i t s membership of the development and suggested that they o b j e c t to any changes which might i n t e r f e r e w i t h the p r o v i s i o n of c a r e and t r e a t m e n t ( V i c t o r i a F i l e , 1985). The P s y c h i a t r i c S e c t i o n has subsequently monitored developments and p a r t i c i p a t e d i n the c o n s u l t a t i o n process (Section of P s y c h i a t r y , 1985; B r i t i s h Columbia Medical A s s o c i a t i o n , 1986). In an echo of the views of the CP.A., the group has made i t c l e a r that i t w i l l oppose any new l e g i s l a t i o n which r e s t r a i n s the " e f f e c t i v e c l i n i c a l c a r e and management of p a t i e n t s w i t h d i s a b l i n g p s y c h i a t r i c d i s o r d e r s " ( B r i t i s h Columbia Medical A s s o c i a t i o n , 1986: 318). S i n c e the p e r c e i v e d ' r e s t r a i n t s ' c o u l d be those found i n the Uniform Mental Health Act the p r o v i n c i a l government must proceed with c a u t i o n . The i n t r o d u c t i o n of the p r o v i s i o n s of the model s t a t u t e may engender a r e a c t i o n that a f f e c t s the l e g i t i m a c y of not only the l e g i s l a t i o n but a l s o the a s s o c i a t e d s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d . 489 At the same time, i t i s necessary to in t r o d u c e s t a t u t o r y r e f o r m s w h i c h s i m u l t a n e o u s l y c u r b the a c t i v i t i e s of m e d i c a l p r a c t i t i o n e r s i n regard to h o s p i t a l u t i l i z a t i o n and l e g i t i m a t e such measures. The 'Mental Health C o n s u l t a t i o n Report' makes i t c l e a r t h a t the s t a t e v i e w s p h y s i c i a n s as the 'gatekeepers* of the mental h e a l t h system and i t i s , t h e r e f o r e , n e c e s s a r y to impose r e s t r a i n t s which ensure that both i n v o l u n t a r y admissions and the l e n g t h of confinement be kept to a minimum. In v o l u n t a r y admission i s viewed as only "sometimes" a p p r o p r i a t e i n the case of those judged t o be "dangerous", and c o n f i n e m e n t beyond 30 days i s seen as r a r e l y n e c e s s a r y ( M i n i s t r y of H e a l t h , 1987). Even though, as a matter of p r a c t i c e , admissions to Riverview H o s p i t a l w i l l o n l y o c c u r i n the case of dangerous p a t i e n t s , e x i s t i n g m e n t a l h e a l t h l e g i s l a t i o n r e t a i n s a s e t of l i b e r a l a d m i s s i o n and t r e a t m e n t c r i t e r i a which m i r r o r the e r a of 'enhanced m e d i c a l i z a t i o n ' . In t h i s regard, some aspects of the p r o v i s i o n s found i n the Uniform Mental Health Act are of value s i n c e they impose s t r i c t r e s t r a i n t s upon the i n v o l u n t a r y admission, treatment and confinement of p a t i e n t s , at the same ti m e j u s t i f y i n g t h e s e measures by r e f e r e n c e to f u n d a m e n t a l human, c i v i l and l e g a l r i g h t s , as b u t t r e s s e d by the Charter. T h i s i s not to s u g g e s t t h a t m e d i c a l p r a c t i t i o n e r s w i l l n e c e s s a r i l y adhere t o a new l e g a l framework t h a t r e d u c e s the medical domination of the management of p a t i e n t s enjoyed under enhanced m e d i c a l i z a t i o n . A ' q u i e t r e v o l u t i o n ' o c c u r r e d i n Ontar i o f o l l o w i n g the i n t r o d u c t i o n of the new l e g a l i s m and i t i s , t h e r e f o r e , a p p a r e n t t h a t m e d i c a l p r a c t i t i o n e r s r e q u i r e 490 m o n i t o r i n g and ' s u p e r v i s i o n ' i f new l e g i s l a t i o n i s to be respected i n p r a c t i c e . Some form of p a t i e n t advocacy w i l l be r e q u i r e d to enhance the s u p e r v i s o r y r o l e of q u a s i - j u d i c i a l r e v i e w b o a r d s , but w i t h o u t u s i n g an autonomous, a g g r e s s i v e , p a r t i s a n advocacy s e r v i c e ( i . e . , the M.P.A.P.). S i n c e the new Saskatchewan l e g i s l a t i o n makes p r o v i s i o n f o r a s t a t e c o n t r o l l e d advocacy system, the adoption of a s i m i l a r scheme, i n B r i t i s h C o l u m b i a , s e e m s . l i k e l y . T h i s may s e r v e to f u r t h e r appease p s y c h i a t r i s t s (the M.P.A.P. was not supported by t h i s group of men t a l h e a l t h p r o f e s s i o n a l s ) , a t the same t i m e e n s u r i n g t h a t t h e i r a c t i v i t i e s are c o n s i s t e n t w i t h the s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d . The form of new l e g a l i s m now being c o n s t r u c t e d i n B r i t i s h Columbia i s r e f l e c t e d i n the ' p h i l o s o p h i c a l core values' which u n d e r p i n the new s t a t e s t r a t e g y f o r the management of the menta l l y d i s o r d e r e d ; a s t r a t e g y devised to complement f e d e r a l and p r o v i n c i a l economic r e s t r a i n t measures i n the h e a l t h care component of the we l f a r e s t a t e . The l a t t e r have been int r o d u c e d as p a r t of a new economic s t r a t e g y aimed at ensuring continued c a p i t a l accumulation, and the new l e g a l i s m a s s i s t s the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s by f a c i l i t a t i n g and l e g i t i m a t i n g i t s a c t i o n s . In t h i s regard, the c o n t e n t of new l e g i s l a t i o n i s b e i n g shaped by two a d d i t i o n a l problems which a f f e c t the l e g i t i m a t i o n and order maintenance f u n c t i o n s of the s t a t e ; namely, the need to appease organized p s y c h i a t r y , and the need to c o n t r o l , i n p a r t i c u l a r , advocates a s s o c i a t e d w i t h the p a t i e n t s * r i g h t s movement. A p o s s i b l e 491 r e s o l u t i o n i s a v a i l a b l e i n the form of the new l e g a l i s m introduced i n Saskatchewan, and i t may be that the impending new l e g i s l a t i o n i n B r i t i s h Columbia w i l l c o n t a i n key elements of t h i s ' m o d e l ' . 1 2 3 Vj_ THE RISE OF THE NEW LEGALISM: AN EXPLANATION The p e r i o d of mental h e a l t h law reform c h a r a c t e r i z e d by the new l e g a l i s m i s the product of a s h i f t i n p r o v i n c i a l s t a t e s t r a t e g i e s f o r the management of the mentally d i s o r d e r e d . This s h i f t has o c c u r r e d i n order to both a s s i s t i n the r e s o l u t i o n of the economic problems c o n f r o n t i n g the f e d e r a l and p r o v i n c i a l l e v e l s of the s t a t e , and to complement a new economic s t r a t e g y designed to ensure the r e p r o d u c t i o n of the c o n d i t i o n s necessary f o r continued c a p i t a l accumulation. In the l a t e 1960's, i n c r e a s i n g expenditures on the h e a l t h care component of the Canadian w e l f a r e s t a t e became a cause f o r concern at the f e d e r a l government l e v e l . Steps were taken to r e duce the u t i l i z a t i o n of a l l h o s p i t a l s and d e v e l o p low c o s t a l t e r n a t i v e s , and Ottawa changed the f e d e r a l - p r o v i n c i a l c o s t -s h a r i n g agreements to ease a g r o w i n g f i s c a l b urden. These measures c o i n c i d e d w i t h an adjustment of the dominant Keynesian economic s t r a t e g y and the g r a d u a l i n t r o d u c t i o n of some monetarist p o l i c i e s ; a change congruent w i t h a r e s t r u c t u r i n g of the i n t e r n a t i o n a l c a p i t a l i s t economy and d e s i g n e d to t a c k l e domestic economic problems. By the l a t e 1970's, the f e d e r a l government had s t a r t e d to r e s t r a i n the growth of the Canadian w e l f a r e s t a t e i n accordance w i t h the new economic s t r a t e g y and 492 t h i s process had an impact i n the pr o v i n c e s . While steps were taken to preserve the h e a l t h care component of the w e l f a r e s t a t e (i.e., c o s t - s t a b i l i z a t i o n p o l i c i e s were int r o d u c e d ) , the onset o f an e c o n o m i c r e c e s s i o n and t h e c o n t i n u e d a d o p t i o n o f m o n e t a r i s t p o l i c i e s i n the e a r l y 1980's r e s u l t e d i n the i n t r o d u c t i o n of p u b l i c s e c t o r economic r e s t r a i n t measures which a f f e c t e d the p r o v i s i o n of h e a l t h care. Mental h e a l t h s e r v i c e s had become an i n t e g r a l part of the wel f a r e s t a t e and the general h e a l t h care c o s t - s t a b i l i z a t i o n and r e s t r a i n t measures consequently a f f e c t e d the s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d . The process of de-i n s t i t u t i o n a l i z a t i o n , which had s t a r t e d i n the mid-1950's, was a c c e l e r a t e d , w i t h a view to f i n a l l y c l o s i n g e x p e n s i v e mental h o s p i t a l s and, as the example of B r i t i s h Columbia demonstrates, t h i s g o a l i s b e i n g a c h i e v e d . D e - i n s t i t u t i o n a l i z a t i o n was accompanied by the t a c t i c of n o n - i n s t i t u t i o n a l i z a t i o n , and e f f o r t s were made to e s t a b l i s h more 'community-based' care and treatment a l t e r n a t i v e s such as mental h e a l t h c e n t r e s , home care programmes, community mental h e a l t h s e r v i c e s , and acute care p s y c h i a t r i c u n i t s i n g e n e r a l h o s p i t a l s . In a d d i t i o n , the process of m o b i l i z i n g n o n - p r o f i t and f o r - p r o f i t o r g a n i z a t i o n s to provide resources and f a c i l i t i e s f o r the care of mental h e a l t h p a t i e n t s (a process i n i t i a t e d i n the 1960's) was enhanced. Since c o s t - s t a b i l i z a t i o n and r e s t r a i n t measures and the a s s o c i a t e d s h i f t i n the s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d c o u l d be c o n s t r u e d as an a t t a c k upon the p r o v i s i o n of h e a l t h c a r e (a p o l i t i c a l l y v o l a t i l e a r e a ) , the 493 s t a t e has sought ways of l e g i t i m a t i n g i t s a c t i o n s . At the same time, i t has been necessary to reduce h o s p i t a l u t i l i z a t i o n and, in the mental h e a l t h area, t h i s has r e q u i r e d the placement of r e s t r a i n t s upon the a c t i v i t i e s of p h y s i c i a n s (the 'gatekeepers' of the mental h e a l t h system). An abandonment of mental h e a l t h l e g i s l a t i o n c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' , i n favour of the new l e g a l i s m , assures the accomplishment of these p o t e n t i a l l y c o n t r a d i c t o r y o b j e c t i v e s and, thereby, a s s i s t s the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . Enhanced m e d i c a l i z a t i o n - a l e g a l framework that supported medical domination of the management of p a t i e n t s - p e r m i t t e d a l i b e r a l use of mental h e a l t h f a c i l i t i e s . The new l e g a l i s m , however, imposes s t r i c t r e s t r a i n t s on h o s p i t a l u t i l i z a t i o n and r e d u c e s m e d i c a l d o m i n a t i o n . The a d m i s s i o n , t r e a t m e n t and confinement of p a t i e n t s ( p a r t i c u l a r l y , i n v o l u n t a r y p a t i e n t s ) i n h o s p i t a l s i s rendered more d i f f i c u l t as a consequence of both s t r i c t admission and confinement c r i t e r i a and the e s t a b l i s h m e n t of a c o l l e c t i o n of p a t i e n t s ' r i g h t s ; n o t a b l y , the r i g h t t o treatment i n the l e a s t r e s t r i c t i v e a l t e r n a t i v e , and the r i g h t to refuse treatment. In a d d i t i o n , the new l e g a l i s m makes p r o v i s i o n f o r q u a s i - j u d i c i a l review boards and p a t i e n t advocacy s e r v i c e s b o t h o f w h i c h s u p e r v i s e a nd m o n i t o r t h e p r a c t i c e s o f p s y c h i a t r i s t s to e n s u r e they comply w i t h new p r o c e d u r e s and respect p a t i e n t s ' r i g h t s . The adoption of the new l e g a l i s m i s i n h e r e n t l y j u s t i f i a b l e 494 s i n c e i t r e s t s upon t h e a d v a n c e m e n t and p r o t e c t i o n o f fundamental human r i g h t s and freedoms, and the l e g i t i m a c y of law reforms of t h i s nature was strengthened with the advent of the Charter. The new l e g a l i s m can, t h e r e f o r e , be used by the s t a t e to j u s t i f y a s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d which has been devised to address economic problems and complement economic changes, even i n the face of a l l e g a t i o n s that the s t r a t e g y amounts to an attack on, and an e r o s i o n of, the p r o v i s i o n of h e a l t h care. The p r i n c i p a l proponent of the new l e g a l i s m has been the p a t i e n t s ' r i g h t s movement; a s m a l l , autonomous, d i s o r g a n i z e d and l o o s e l y bonded amalgam of l e g a l a i d lawyers, mental p a t i e n t s ' a s s o c i a t i o n s , and c i v i l l i b e r t a r i a n s . T h i s i n t e r e s t group emerged i n the e a r l y 1970's and was i n s p i r e d by both the c r i t i c s of p s y c h i a t r y and mental h e a l t h systems i n the United States and the s u c c e s s e s of A m e r i c a n , m e n t a l h e a l t h law a d v o c a t e s i n e s t a b l i s h i n g a number of p a t i e n t s ' r i g h t s . The p a t i e n t s ' r i g h t s movement was not d i r e c t l y 'co-opted' or i n f i l t r a t e d by the s t a t e (a s i t u a t i o n t h a t may be c h a n g i n g i n the c o n t e x t of p a t i e n t a d v o c a c y ) , but i t s i d e a s ( p a r t i c u l a r l y i n r e g a r d to the new l e g a l i s m ) have been embraced. T h i s has o c c u r r e d d e s p i t e the o p p o s i t i o n mounted by a l a r g e r and i n t e g r a t e d i n t e r e s t group; namely, organized p s y c h i a t r y and i t s a l l i e s . A l t h o u g h the movement has not e x h i b i t e d the degree of i n t e g r a t i o n and o r g a n i z a t i o n which c h a r a c t e r i z e s i t s opponent (i.e., organized p s y c h i a t r y ) , i t has been remarkably s u c c e s s f u l , and t h i s r e f l e c t s the i m p o r t a n c e of the new l e g a l i s m f o r the 495 p r o v i n c i a l l e v e l of the s t a t e . The l a t t e r r e q u i r e d a mechanism t h a t would a s s i s t i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s (i.e., l e g i t i m a t e and f a c i l i t a t e i t s s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d ) , and the p a t i e n t s ' r i g h t s movement provided an op p o r t u n i t y f o r t h i s to be d e v e l o p e d t h r o u g h the medium of i n h e r e n t l y j u s t i f i a b l e law reforms. The need became more c r u c i a l as organized p s y c h i a t r y began to crea t e l e g i t i m a t i o n problems f o r the s t a t e by mounting an attack upon, not only the p a t i e n t s ' r i g h t s movement and the new l e g a l i s m , but a l s o f e d e r a l and p r o v i n c i a l c o s t - s t a b i l i z a t i o n and r e s t r a i n t p o l i c i e s . O r g a n i z e d p s y c h i a t r y r e c o g n i z e d t h a t p a t i e n t s ' r i g h t s i s s u e s and economic r e s t r a i n t p o l i c i e s were interwoven (i.e., t h a t the s t a t e was using the former to j u s t i f y and implement the l a t t e r ) and c o n s e q u e n t l y adopted a t a c t i c employed by the C.M.H.A. i n the 1950's and 1960's; t h a t i s , a d v o c a t i n g those p a t i e n t s ' r i g h t s which would a l s o p r o t e c t or advance p r o f e s s i o n -a l i n t e r e s t s . In c o n j u n c t i o n w i t h the C.M.H.A., o r g a n i z e d p s y c h i a t r y began t o p r e s s f o r t h e i n t r o d u c t i o n o f , i n p a r t i c u l a r , a p a t i e n t ' s r i g h t to r e c e i v e t r e a t m e n t ; a r i g h t viewed with s k e p t i c i s m by mental p a t i e n t s ' a s s o c i a t i o n s . Since the r i g h t helps to p r o t e c t mental h e a l t h s e r v i c e s from funding r e d u c t i o n s , i t threatens s t a t e economic r e s t r a i n t p o l i c i e s and, as the example of Saskatchewan demonstrates, the s t a t e can and w i l l introduce measures which s i m u l t a n e o u s l y appease p s y c h i a t r y (thereby d e f u s i n g a l e g i t i m a t i o n problem) and l i m i t the impact of the r i g h t to r e c e i v e treatment. 496 Inasmuch as the o b j e c t i v e s of o r g a n i z e d p s y c h i a t r y are being c o n t r o l l e d by the s t a t e , so too are the o b j e c t i v e s of the p a t i e n t s ' r i g h t s movement. As the case study of the a c t i v i t i e s of a p a t i e n t s ' advocacy group i n B r i t i s h Columbia has demonst-r a t e d , t h e r e a r e l i m i t s to the s t a t e ' s t o l e r a n c e of the movement. Once the a c t i v i t i e s of a d v o c a t e s b e g i n to h i n d e r , r a t h e r t h a n a s s i s t , t h e s t a t e i n t h e e x e r c i s e a n d s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s through, f o r example, the p u r s u i t of t e s t c a s e s , the s t a t e w i l l a c t to curb the movement. Ins o f a r as the s t a t e has l i m i t e d the r i g h t to r e c e i v e t r e a t m e n t (as s o u g h t by o r g a n i z e d p s y c h i a t r y ) so an u n c o n d i t i o n a l r i g h t to r e f u s e treatment and other r i g h t s sought by the p a t i e n t s ' r i g h t s movement have been e i t h e r r e j e c t e d or s t r i c t l y l i m i t e d , e s p e c i a l l y where they c o n f l i c t w i t h the need to maintain c o n t r o l over mental h e a l t h p a t i e n t s i n the community and with economic r e s t r a i n t measures. P a t i e n t advocacy s e r v i c e s are an important component of the new l e g a l i s m f o r the s t a t e s i n c e they monitor and s u p e r v i s e medical p r a c t i t i o n e r s i n c o n j u n c t i o n with q u a s i - j u d i c i a l review boards. However, i t i s c l e a r that autonomous, a g g r e s s i v e and p a r t i s a n advocacy does not meet w i t h a p p r o v a l . I n s t e a d , p r o v i n c i a l governments have developed an a l t e r n a t i v e i n the form of s t a t e c o n t r o l l e d and funded advocacy s e r v i c e s that monitor and s u p e r v i s e the management of p a t i e n t s but w hich i n v o l v e m e d i a t i o n and n e g o t i a t i o n between p s y c h i a t r i s t s and t h e i r p a t i e n t s , r a t h e r than c o n f r o n t a t i o n s and l e g a l a c t i o n s (e.g., t e s t cases) which might c o n f l i c t with l a r g e r s t a t e o b j e c t i v e s . 497 Indeed, t h e r e a r e i n d i c a t i o n s t h a t t h i s component of an otherwise autonomous p a t i e n t s ' r i g h t s movement i s being absorbed i n t o the p r o v i n c i a l s t a t e apparatus. In summary, the demise of 'enhanced m e d i c a l i z a t i o n ' and the r i s e of the 'new l e g a l i s m ' i n Canadian mental h e a l t h law i s t h e p r o d u c t o f a s h i f t i n t h e s t a t e ' s s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d . The s h i f t has been p r o p e l l e d by problems and changes which have a f f e c t e d one of the s t a t e ' s c a r d i n a l f u n c t i o n s - r e p r o d u c i n g t h e c o n d i t i o n s n e c e s s a r y f o r c o n t i n u e d c a p i t a l a c c u m u l a t i o n . (The r e l a t i v e autonomy of, and connections between, the f e d e r a l and p r o v i n c i a l l e v e l s of the s t a t e , and the two p r i n c i p a l i n t e r e s t groups i n v o l v e d i n reform, are i l l u s t r a t e d i n Figure 6.1). New f e d e r a l and p r o v i n c i a l economic p o l i c i e s have had an adverse impact upon the p o l i t i c a l l y s e n s i t i v e h e a l t h care component of the w e l f a r e s t a t e , and t h i s presents a p o t e n t i a l l e g i t i m a t i o n problem f o r the s t a t e . In order to both r e s o l v e t h i s problem and f a c i l i t a t e the s h i f t i n the s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d , the p r o v i n c i a l l e v e l of the s t a t e has adopted the law reforms sought by the p a t i e n t s ' r i g h t s movement. The new l e g a l i s m imposes l i m i t a t i o n s upon the a c t i v i t i e s of m e d i c a l p r a c t i t i o n e r s and these are necessary to b u t t r e s s both the s h i f t i n s t r a t e g y and the u n d e r l y i n g economic p o l i c i e s . In a d d i t i o n , s i n c e the new l e g a l i s m enhances and p r o t e c t s fundamental r i g h t s and l i b e r t i e s , i t i s an i n h e r e n t l y j u s t i f i a b l e type of law reform which defuses l e g i t i m a t i o n problems. The new l e g a l i s m , t h e r e f o r e , a s s i s t s the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n 498 FIGURE 6.1: THE RELATIVE AUTONOMY OF, AND CONNECTIONS BETWEEN, THE LEVELS OF THE STATE AND INTEREST GROUPS The spheres represent the relatively autonomous and interlocking federal and provincial levels of the state, and their relationship with the two principal interest groups. Both organized psychiatry and the patients' -rights-movement (a loose am alga m)lie outside the state,- but-the advocacy component of the movement i s being absorbed into the state apparatus. (1) Autonomy t o reproduce the conditions necessary for continued c a p i t a l accumulation. May influence provinces through cost-sharing and other arrangements, and over-arching legislation (e.g., the Charter). May confront and resolve legitimation problems. (2) Autonomy i n the management of the mentally disordered and t o resolve associated order maintenance and legitimation problems, but autonomy relative t o federal economic plans/strategies and, i n part, legislation. (3) Large, autonomous, organized, conservative interest group allied with other groups (e.g., C.M.H.A.). Creates legitimation problem f o r both levels of the state. May create order maintenance problem by encourag-ing members t o disregard legislation. Requires appeasement. (4) Small, autonomous, disorganized interest group. Law reform objectives f a c i l i t a t e and legitimate provincial strategies f o r the management of the mentally disordered and, therefore, resonate with federal and provincial state objectives. However, advocacy component creates order maintenance problem, hinders economic policies, and requires limitation. of i t s c a r d i n a l f u n c t i o n s . However, some a d d i t i o n a l l e g i t i m -a t i o n and order maintenance problems have been c r e a t e d by both o r g a n i z e d p s y c h i a t r y and the p a t i e n t s ' r i g h t s movement. The r e s o l u t i o n of these problems has a f f e c t e d (and i s a f f e c t i n g ) the content of new mental h e a l t h l e g i s l a t i o n as the s t a t e seeks to appease p s y c h i a t r y and r e s t r a i n p a t i e n t s ' a d v o c a t e s , w h i l e s i m u l t a n e o u s l y u t i l i z i n g those aspects of the new l e g a l i s m which b u t t r e s s s t a t e o b j e c t i v e s . 500 ENDNOTES: CHAPTER 6 Key to A b b r e v i a t i o n s D.B.S.: D o m i n i o n B u r e a u o f S t a t i s t i c s . M e n jta 1 H e a 1 th S t a t i s t i c s , Annual Report. Ottawa: Queen's P r i n t e r . D. of H.A.R.: P r o v i n c e of B r i t i s h C o l umbia. Department of Health: Annual Report. V i c t o r i a : Queen's P r i n t e r . D. of H.R.A.R.: P r o v i n c e of B r i t i s h C o l u m b i a . S e r v i c e s For People: Department of Human Resources, Annual Report. V i c t o r i a : Queen's P r i n t e r . J.L.A.: J o u r n a l s of the L e g i s l a t i v e Assembly of the Province of B r i t i s h Columbia. V i c t o r i a : Queen's P r i n t e r . M. of H.A.R.: P r o v i n c e of B r i t i s h C o l u m b i a . M i n i s t r y o f Health: Annual Report. V i c t o r i a : Queen's P r i n t e r . M. of H.R.A.R.: P r o v i n c e of B r i t i s h C o l umbia. S e r v i c e s For People: M i n i s t r y of Human Resources, Annual Report. V i c t o r i a : Queen's P r i n t e r . M.H.S.B.A.R.: Department of H e a l t h S e r v i c e s and H o s p i t a l Insurance. Mental Health S e r v i c e s Branch, Province of B r i t i s h Columbia, Annual Report. V i c t o r i a : Queen's P r i n t e r . StatsCan.: S t a t i s t i c s Canada. Mental Health S t a t i s t i c s . Ottawa: Queen's P r i n t e r . 1: While i t was f e l t that the centres would be c o s t - e f f e c t i v e (i.e., l e s s expensive than, but j u s t as e f f e c t i v e as, acute care h o s p i t a l s ) , t h i s c l a i m was not u n i v e r s a l l y endorsed (Freeman, 1973). 2: See, Vancouver Sun, A p r i l 1st 1987. B r i t i s h Columbia, f o r example, d i d not agree to abide by the p r o v i s i o n s of the f e d e r a l l e g i s l a t i o n u n t i l March 30th, 1987; two days b e f o r e the d e a d l i n e . 3: D.B.S. and StatsCan: 1965 to 1982. 4: StatsCan: 1971 to 1979. 5: M.H.S.B.A.R., 1967/68. 6: Comprehensive programmes f o r e m o t i o n a l l y d i s t u r b e d c h i l d r e n and f o r e n s i c c l i n i c s were a l s o to be developed. 7: M.H.S.B.A.R., 1967/68: 10. The p r o v i n c i a l government p u b l i c l y announced the new p l a n i n the Throne Speech a t the opening of the 1968 S e s s i o n . I t was e v i d e n t l y p l e a s e d to announce a major r e - o r g a n i z a t i o n of mental h e a l t h s e r v i c e s that 501 would meet the changing p a t t e r n s of care. The importance of the process of d e - c e n t r a l i z a t i o n was emphasized s i n c e t h i s would e n s u r e b e t t e r c a r e f o r a l l B r i t i s h C o l u m b i a n s , r e g a r d l e s s of t h e i r p l a c e of r e s i d e n c e . (J.L.A. 1968). The government saw f i t to p r o v i d e an up-date i n the Throne Speech i n 1969. The process of r e - o r g a n i z a t i o n and d e - c e n t r a l i z a t i o n was "proceeding w e l l " and the government i n d i c a t e d that i t intended to emphasize community care o p t i o n s . (J.L.A. 1969). 8: Bevan Lodge was a 70 bed i n t e r m e d i a t e c a r e f a c i l i t y c o n s t r u c t e d to meet the needs of the mentally r e t a r d e d and to ease the burden on T r a n q u i l l e and Woodlands. I t was b u i l t by the p r o v i n c i a l government but o p e r a t e d by the Bevan Lodge A s s o c i a t i o n : a b r a n c h of the C o u r t n e y M e n t a l H e a l t h S o c i e t y . The E r i c M a r t i n I n s t i t u t e was a 170 bed i n t e n s i v e treatment, i n -p a t i e n t and day c a r e p s y c h i a t r i c u n i t i n V i c t o r i a which was o p e r a t e d by the Board o f D i r e c t o r s of the Royal J u b i l e e H o s p i t a l . Glendale H o s p i t a l (Lodge) was a 300 bed f a c i l i t y f o r the mentally r e t a r d e d operated by the Glendale Lodge S o c i e t y . The government a l s o turned over the Smithers Experimental Farm to the A s s o c i a t i o n f o r Retarded C h i l d r e n ; the l a t t e r operated the f a c i l i t y as a 30 bed t r a i n i n g c e n t r e f o r the m e n t a l l y r e t a r d e d (M.H.S.B.A.R. 1967/68). 9: M.H.S.B.A.R., 1967/68. 10: The p r o v i n c i a l government a l s o d i s t r i b u t e d the c o s t s of c o n s t r u c t i n g f a c i l i t i e s by passing the Treatment Resources Act; a s t a t u t e t h a t e n a b l e d the government to p r o v i d e c a p i t a l c o n s t r u c t i o n grants to n o n - p r o f i t s o c i e t i e s p r o v i d i n g care f o r e m o t i o n a l l y d i s t u r b e d c h i l d r e n and the mentally r e t a r d e d . The government would provide one t h i r d of the c a p i t a l c o n s t r u c t i o n c o s t s , p r o v i d i n g a s o c i e t y s u p p l i e d an a d d i t i o n a l ten per-cent. The remaining c o s t s of c o n s t r u c t i o n could be acq u i r e d from other sources; notably, the C e n t r a l Mortgage and Housing C o r p o r a t i o n . By 1970, the p r o v i n c i a l government had made f i v e g r a n t s , t o t a l l i n g i n e x c e s s of $153,000 and, i n 1972, 13 n o n - p r o f i t s o c i e t i e s r e c e i v e d grants. Further a s s i s t a n c e a r r i v e d i n June, 1973, when the f e d e r a l government amended the N a t i o n a l Housing Act. The C e n t r a l Mortgage and Housing C o r p o r a t i o n i n t r o d u c e d a programme t o p r o v i d e 100% mortgage f i n a n c i n g to n o n - p r o f i t s o c i e t i e s that wished to provide f a c i l i t i e s f o r ' s p e c i a l needs' groups such as the mentally d i s a b l e d . In a d d i t i o n , the f e d e r a l government would p r o v i d e s t a r t - u p funds (M.H.S.B.A.R. 1969 -1973). 11: M. of H.R.A.R., 1977. 12: The reasons f o r the t r a n s f e r were t h r e e f o l d . F i r s t l y , s i n c e the Department of Human R e s o u r c e s was a l r e a d y s e r v i c i n g the needs of many m e n t a l l y r e t a r d e d p e r s o n s t h r o u g h a v a r i e t y of programmes and d i r e c t a s s i s t a n c e , i n t e g r a t i o n would r a t i o n a l i z e the system. S e c o n d l y , i n a c c o r d a n c e w i t h the U n i t e d N a t i o n s D e c l a r a t i o n , the government had committed i t s e l f to the p r i n c i p l e of 'n o r m a l i z a t i o n ' and the p r o v i s i o n of i n t e g r a t e d , 502 community-based s e r v i c e s . There was a growing p u b l i c awareness that r e t a r d a t i o n was not a mental i l l n e s s and that an emphasis should be p l a c e d upon t r a i n i n g m entally r e t a r d e d persons so that they c o u l d a c q u i r e the s o c i a l s k i l l s n e c e s s a r y t o l i v e as i n d e p e n d e n t l y and ' n o r m a l l y ' as p o s s i b l e . The Department of Human Resources, r a t h e r than the Department of Health, was seen as the " l o g i c a l c h o i c e " . F i n a l l y , by t r a n s f e r r i n g m e n t a l r e t a r d a t i o n s e r v i c e s to Human Resources, the pro v i n c e would be a b l e to r e c o v e r up to 50% of the c o s t s of s e r v i c e s from the f e d e r a l government under the Canada A s s i s t a n c e P l a n (D. of H.R.A.R., 1974/75). 13: Based on a r e v i e w of D. of H.R.A.R., and M. of H.R.A.R., 1974 - 1979. 14: M.H.S.B.A.R., 1967/68. 15: Data from M.H.S.B.A.R., D. of H.A.R., and M. of H.A.R., 1966 - 1979. 16: In 1969, the government passed the Community Care F a c i l i t i e s L i c e n s i n g Act which, among other matters, eased the process of l i c e n s i n g homes (operators could accept two boarders without a l i c e n c e ) . The boarding home programme was r e g i o n a l i z e d i n 1971 and s o c i a l workers were appointed to sup e r v i s e and develop new homes and s u p p o r t i n g r e s o u r c e s t h r o u g h o u t the p r o v i n c e . A Community Care F a c i l i t i e s L i c e n s i n g Board was e s t a b l i s h e d i n 1972 and the N.D.P. government encouraged the e s t a b l i s h m e n t of n o n - p r o f i t o r g a n i z a t i o n s t o a s s i s t w i t h the development of a d d i t i o n a l r e s o u r c e s such as the r e c r e a t i o n and a c t i v i t y programmes provided by The Coast Foundation S o c i e t y (Tomlinson & Cumming, 1976). The N.D.P. government a l s o i n t r o d u c e d changes t o s p e e d up t h e l i c e n s i n g p r o c e s s a nd e n c o u r a g e t h e est a b l i s h m e n t of new homes (e.g., b u i l d i n g standards were eased i n the case of homes wit h fewer than nine r e s i d e n t s and boarding home r a t e s were i n c r e a s e d ) . G r o u p - l i v i n g homes were e s t a b l i s h e d and an 'independent l i v i n g ' apartment p r o j e c t was i n i t i a t e d (op c i t ) i n the b e l i e f that these would provide a b e t t e r s e r v i c e at lo w e r c o s t . By the end of the 1970's, the b o a r d i n g home programme was both r e c e i v i n g and d i s c h a r g i n g a high volume of p a t i e n t s and r e c e i v i n g d i r e c t r e f e r r a l s from, f o r example, m e n t a l h e a l t h .centres. The programme r e d u c e d the use of h o s p i t a l s ( e s p e c i a l l y , expensive acute care beds) and b u t t r e s s e d the emerging p o l i c y of n o n - i n s t i t u t i o n a l i z a t i o n (M.H.S.B.A.R., D. of H.A.R., and M. of H.A.R. 1969 - 1978). 17: Data from M .H.S.B.A.R., D. of H.A.R., and M. of H.A.R.: 1969 - 1980. I t i s apparent that the government was proud of t h i s achievement. The r a p i d expansion i n mental h e a l t h c e n t e r s was mentioned i n glowing terms i n the Throne Speeches i n 1971 and 19 72 (J.L.A. 1971, 1972). 18: Based on an a n a l y s i s of M.H.S.B. A.R., D. of H.A.R., and M. of H.A.R.: 1968 - 1980. 503 19: D. of H.A.R., 1973: 17. See, a l s o , ' M i n i s t r y of H e a l t h Report', B r i t i s h Columbia Medical J o u r n a l , V o l . 19, 102 (1973). A s i m i l a r scheme was i n i t i a t e d i n Burnaby. 20: Data from D. of H.A.R., and M. of H.A.R.: 1974 - 1980. The e f f e c t i v e n e s s of the G.V.M.H.S. i n t r e a t i n g the m o d e r a t e l y to s e r i o u s l y i l l p a t i e n t i n the community was confirmed through i n -house e v a l u a t i o n . The community c a r e teams were w o r k i n g to c a p a c i t y with a case l o a d of 250-300 p a t i e n t s but were p r o v i d i n g a q u a l i t y s e r v i c e . I t was f e l t t h a t once a l l the s u p p o r t s e r v i c e s had been e s t a b l i s h e d , Vancouver would have a system of mental h e a l t h care unequalled i n Canada ( D. of H.A.R. 1976: 76; and, M. of H.A.R. 1978: 90). 21: M.H.S.B.A.R., 1967/68: 81. 22: I b i d . 23: This t a c t i c was intr o d u c e d and, i n 1968, the Superintendent of Riverview H o s p i t a l r e p o r t e d that a l i m i t had been placed on a d m i s s i o n s due to a r e d u c t i o n i n the number of p h y s i c i a n s on s t a f f (Report of the S u p e r i n t e n d e n t o f R i v e r v i e w H o s p i t a l . M.H.S.B.A.R. 1968). 24: There was only one i n t e r r u p t i o n . In A p r i l 1965, Essondale H o s p i t a l and the Cr e a s e C l i n i c were amalgamated to form R i v e r v i e w H o s p i t a l . At the time of the a m a l g a m a t i o n , 2,806 p a t i e n t s were r e s i d i n g i n Essondale and the p a t i e n t p o p u l a t i o n 'increased' w i t h the a d m i n i s t r a t i v e change. However, by 1967, the r e s i d e n t p o p u l a t i o n once again began to f a l l and, by the end of 1968, the p o p u l a t i o n had d e c r e a s e d t o 2,667 p a t i e n t s (M.H.S.B.A.R. 1964/65 - 1968). 25: Data from M.H.S.B.A.R., D. of H.A.R., and M. of H.A.R.: 1965/66 - 1981. 26: M.H.S.B.A.R. 1970, D. of H.A.R. 1975, M. of H.A.R. 1980. See a l s o , D. of H.R.A.R. 1975 and M. of H.R.A.R. 1980. 27: M.H.S.B.A.R., 1970. 28: M.H.S.B.A.R., 1972. 29: D. of H.A.R., 1973. 30: T h i s phenomenon f i r s t a p p e a r e d i n the mid-1970's (D. of H.A.R., 1974 - 1976). In 1967/68, 45% of p a t i e n t s were admitted on a v o l u n t a r y b a s i s and, by 1973 (the l a s t year i n which data were p u b l i c l y r e p o r t e d ) , t h i s p r o p o r t i o n had f a l l e n to 22%. At the end of 1976, the Superintendent of Riverview r e p o r t e d that the 'majority' of p a t i e n t s were s e r i o u s l y i l l i n d i v i d u a l s who had been a d m i t t e d i n v o l u n t a r i l y (M.H.S.B.A.R. and D. of H.A.R. 1965/66 - 1976). 31: M.H.S.B.A.R., 1967/68: 11. 504 32: M.H.S.B.A.R., 1970: 14. 33: StatsCan, 1978 - 1980. 34: Report of the Superintendent of Riverview H o s p i t a l , M. of H. A.R. 1977. 35: Data from D. of H.A.R., and M. of H.A.R.: 1975 - 1980. 36: M.H.S.B.A.R. 1970: 13. 37: M.H.S.B.A.R. 1972: 11. 38: See a l s o , D. of H.A.R. 1974. 39: Data from M.H.S.B.A.R. and D. of H.A.R.: 1971/72 - 1974/75. 40: I b i d . The N.D.P. government made a number of improvements i n both the h e a l t h and s o c i a l s e r v i c e s f i e l d s ; f o r example, mental h e a l t h s e r v i c e s became t o t a l l y i n t e g r a t e d w i t h i n a r e -named Department of Health. More i m p o r t a n t l y , by 1975, a r e -named Department of Human Resources had assumed r e s p o n s i b i l i t y f o r the m e n t a l l y r e t a r d e d . The c o s t s of th e s e s e r v i c e s t h e r e f o r e no longer appeared i n the p r o p o r t i o n of the Department of Health's budget a l l o c a t e d to mental h e a l t h s e r v i c e s . 41: Data from M.H.S.B.A.R., D. of H.A.R., and M. of H.A.R.: 1970/71 - 1979. 42: I b i d . 43: That i s , s h e l t e r e d workshops and other programmes designed to improve the q u a l i t y of l i f e of a l l handicapped persons. At the end of 1979, t h e r e were 75 a c h i e v e m e n t c e n t r e s i n the p r o v i n c e r e c e i v i n g g r a n t s t o t a l l i n g $2.8 m i l l i o n , and the m a j o r i t y were c a t e r i n g to the needs of e i t h e r mentally r e t a r d e d or mentally i l l a d u l t s and c h i l d r e n (M. of H.R.A.R. 1979). 44: M. of H.R.A.R., 1979. 45: D. of H.A.R.: 1975 and 1976. 46: D. of H.A.R. 1976: 15. 47: I b i d . 48: M. of H.A.R. 1977: 15. 49: M. of H.A.R. 1978: 15. See a l s o , M. of H.A.R. 1977. The long-term care programme was a new approach to meeting the needs of those who could not l i v e without help but who d i d not need care i n an expensive, acute care h o s p i t a l . The programme began i n J a n u a r y 1978 and was aimed a t a l l consumers of h e a l t h s e r v i c e s . I t r e l i e d h e a v i l y upon the o p e r a t o r s of the 539 505 p r o p r i e t a r y and n o n - p r o f i t l i c e n s e d community care f a c i l i t i e s i n the p r o v i n c e (13,631 of the 15,082 l o n g - t e r m c a r e beds were l o c a t e d i n p r i v a t e f a c i l i t i e s ) . In the mental h e a l t h area, i t was f e l t t h a t an i n t e g r a t i o n of the boarding home programme i n t o l o n g - t e r m c a r e would r e s u l t i n many b e n e f i t s ; i n c l u d i n g the p o s s i b i l i t y of an expanded c a p a c i t y w h i c h would a l l o w the remaining i n s t i t u t i o n a l i z e d p a t i e n t s to be discharged. Indeed, by the end of 1979, the government had announced a plan to c l o s e one p s y c h o g e r i a t r i c f a c i l i t y and discharge the p a t i e n t s to t h e i r home communities where p r i v a t e f a c i l i t i e s w i t h i n the long-term care programme would c a t e r to t h e i r needs (M. of H.A.R., 1979). 50: M. of H.A.R., 1978: 17. 51: I b i d : 15. 52: I b i d . 53: I b i d . 54: M. of H.A.R. 1979: x i i . 55: M. of H.A.R., 1978: 21. The p r o v i n c e had more p h y s i c i a n s per c a p i t a than the n a t i o n a l average and i t was f e l t t h at, as a consequence of the s u r p l u s , the pr o v i n c e was o v e r - s e r v i c e d . The s i t u a t i o n had to be remedied, p a r t i c u l a r l y s i n c e the per c a p i t a c o s t of medical care ($102.10) was consequently higher than the n a t i o n a l average ($83.55). 56: M. of H.A.R., 1978: 17. 57: The survey was undertaken by a team d i r e c t e d by Dr. Cumming. Numerous submissions were r e c e i v e d from p a t i e n t s ' groups and a s s o c i a t i o n s , a s w e l l a s s o c i a l w o r k e r s and m e d i c a l p r a c t i t i o n e r s , and the team v i s i t e d m e n t a l h e a l t h f a c i l i t i e s throughout the prov i n c e to canvass the views of those i n v o l v e d i n s e r v i c e d e l i v e r y . 58: A l l the data presented i n t h i s paragraph are drawn from M. of H.A.R. 1979. 59: There were i d e o l o g i c a l c o n f l i c t s between those f a v o u r i n g the 'medical model' and those f a v o u r i n g the 'behavioural' approach, and the process of p a t i e n t assignment i n v o l v e d a s t r u g g l e f o r the more ' d e s i r e a b l e ' type of c l i e n t . Those w o r k i n g w i t h c h r o n i c c a s e s e n j o y e d l o w e r p r e s t i g e w i t h i n the c e n t r e s than those working with acute cases. 60: S e c t i o n 21 (a) of the M e n t a l H e a l t h A c t g r a n t e d the d i r e c t o r s of f a c i l i t i e s c o n s i d e r a b l e d i s c r e t i o n in" the admission process. For example, they could refuse to admit a p a t i e n t i f adequate care and treatment was not a v a i l a b l e . T h i s s e c t i o n was used to r e s t r a i n the number of a d m i s s i o n s whenever s t a f f i n g l e v e l s f e l l . 506 61: On J u l y 19, 1979 the N.D.P o p p o s i t i o n quizzed the M i n i s t e r of Health of the content of the r e p o r t and demanded to know what he was g o i n g to do about the b o a r d i n g home s i t u a t i o n . The M i n i s t e r of Health defended government p o l i c y but i n d i c a t e d that the problem was being addressed (B.C. Hansard, J u l y 19, 1979). 62: In a d d i t i o n , a plan was devised to i n c o r p o r a t e a h o s p i t a l s o c i e t y f o r Riverview; that i s , to cr e a t e a n o n - p r o f i t , h o s p i t a l s o c i e t y w i t h a Board of D i r e c t o r s and an a d m i n i s t r a t i v e system i n k e e p i n g w i t h t h e s i t u a t i o n f o u n d i n g e n e r a l , p u b l i c h o s p i t a l s . R i v e r v i e w was t o c e a s e t o be a g o v e r n m e n t i n s t i t u t i o n under the d i r e c t c o n t r o l of the M i n i s t r y of Health (M. of H.A.R. 1979). The plan was not implemented at t h i s time. 63: M. of H.A.R. 1979, 117. 64: M. of H.A.R. 1980: 85. 65: I b i d . Many p a t i e n t s r e s i s t e d medication, but i t was f e l t t h a t the development of pharmacy s e r v i c e s i n mental h e a l t h c e n t r e s would help overcome the problems a s s o c i a t e d with t h i s " c r i t i c a l l i n k i n community maintenance of these i n d i v i d u a l s " (op c i t : 85). P a t i e n t s c o u l d be m a i n t a i n e d by an i n j e c t a b l e form of phenothiazine which would l a s t one week and ' i n j e c t i o n c l i n i c s ' were organized at mental h e a l t h centres. These were h e l d i n c o n j u n c t i o n w i t h s o c i a l a c t i v i t i e s s i n c e i t was f e l t t h a t t h i s would encourage p a t i e n t s to a t t e n d and r e c e i v e m edication. 66: M. of H.A.R., 1979. 67: M. of H.A.R., 1980: 90. 68: I b i d . 69: B r i t i s h Columbia Regulations, 118/80, D i v i s i o n 8, ( A p r i l 2, 1980); now, 145/84: Se c t i o n s 6 and 7. 70: M. of H.A.R. 1980: 8 - 9 . 71: I b i d . 72: A l t e r n a t i v e s to h o s p i t a l i z a t i o n ( i . e . , day c a r e and home care) were appa r e n t l y both b e t t e r and l e s s c o s t l y . A M i n i s t r y e v a l u a t i o n of the home c a r e programme i n 1980 i n d i c a t e d t h a t t h i s approach had kept 34% of p a t i e n t s out of f a c i l i t i e s . I t was e s t i m a t e d t h a t t h e s e p a t i e n t s would have consumed $35.3 m i l l i o n of the h o s p i t a l programmes budget while the t o t a l home care budget was only $11.1 m i l l i o n ( I b i d ) . 73: Data from M. of H.A.R.: 1980 - 1985. 74: In November 1980, the programmes r e l i e d upon 123 p r o p r i e t a r y and n o n - p r o f i t homemaker s e r v i c e s , 412 p r o p r i e t a r y and non-p r o f i t community care f a c i l i t i e s , 37 p r i v a t e h o s p i t a l s , 17 non-507 p r o f i t group homes, and 229 mental h e a l t h boarding homes, the bulk of which were p r o p r i e t a r y o p e r a t i o n s (M. of H.A.R., 1980). 75: The M i n i s t r y had e n d o r s e d a ' p h i l o s o p h y ' t h a t e m p h a s i z e d " i n v o l v i n g the f a m i l y wherever p o s s i b l e " and "p r o v i d i n g s e r v i c e s to ensure that the i n d i v i d u a l and h i s f a m i l y are able to cope w i t h i n t h e i r own r e s o u r c e s " (M. of H.A.R., 1983/84: 43). By 1985, the M i n i s t r y of Health had announced the c r e a t i o n of a new ' r e h a b i l i t a t i o n programme', o p e r a t e d by n o n - p r o f i t and p r o p r i e t a r y agencies, that would provide " t h e r a p e u t i c work and vol u n t e e r t r a i n i n g " to p s y c h i a t r i c a l l y d i s a b l e d a d u l t s (M. of H.A.R., 1984/85). The process of ' p r i v a t i z a t i o n ' a l s o a f f e c t e d a n c i l l a r y h o s p i t a l s e r v i c e s (e.g., l a u n d r y ) . 76: Data from M. of H.A.R.: 1982, and 1984-85. The m a j o r i t y of p a t i e n t s (approximately, 88%) stayed i n the h o s p i t a l f o r l e s s than 30 days. Riverview was, t h e r e f o r e , p r i m a r i l y a short-term acute care f a c i l i t y . 77: The process of d e - i n s t i t u t i o n a l i z a t i o n and f a c i l i t y c l o s u r e has a l s o a f f e c t e d the d e l i v e r y of s e r v i c e s to the m e n t a l l y r e t a r d e d . The em p t y i n g and c l o s u r e of i n s t i t u t i o n s began to a c c e l e r a t e i n the e a r l y 1980's when the M i n i s t r y o f Human Resources (now, S o c i a l S e r v i c e s and Housing) announced that the goals of the mental r e t a r d a t i o n s e r v i c e programme would be to e n a b l e c l i e n t s to l i v e i n the ' l e a s t r e s t r i c t i v e ' type of f a c i l i t y i n t h e i r own c o m m u n i t i e s . The p r o c e s s of em p t y i n g Woodlands School began and, by 1981, Cabinet had approved both the continued development of ' d e - c e n t r a l i z e d s e r v i c e s ' and an increase i n community s e r v i c e s (e.g., p r o p r i e t a r y r e s p i t e care homes and group homes (and o t h e r r e s o u r c e s ) o p e r a t e d by non-p r o f i t s o c i e t i e s ) that would al l o w the eventual 'phasing down' of the l a r g e r i n s t i t u t i o n s . The po p u l a t i o n s of Glendale Lodge, T r a n q u i l l e and Woodlands d e c l i n e d from 1,535 at the end of 1980 to 1,308 by the March 1984, and T r a n q u i l l e School was c l o s e d i n September 1984. There i s every i n d i c a t i o n that the remaining f a c i l i t i e s w i l l be c l o s e d by the end of the decade (M. of H.R.A.R., 1980 - 85/86. See, a l s o , J.L.A. 1981, and, B.C. Hansard, June 17, 1983). While the emptying and c l o s u r e of these i n s t i t u t i o n s i s not d i r e c t l y r e l a t e d to the government's r e s t r a i n t p o l i c i e s i n the h e a l t h c a r e s e c t o r , the p r o c e s s can be t r a c e d to the economic problems c o n f r o n t i n g the s t a t e (Redish, 1986). As the r e c e s s i o n began to have an impact on employment l e v e l s i n the p r o v i n c e , so more funds were r e q u i r e d t o m a i n t a i n income a s s i s t a n c e schemes. Between 1980 and 1982, approximately 50% of the M i n i s t r y ' s budget had been expended on income a s s i s t a n c e but, by the end of f i s c a l 1983/84, t h i s had r i s e n to 60.2%. Since the government was attempting to manage a budget d e f i c i t , i n c r e a s e d funds f o r income a s s i s t a n c e had to be c r e a t e d by r e d u c i n g e x p e n d i t u r e s i n o t h e r a r e a s w i t h i n the M i n i s t r y ' s budget. Among those t a r g e t t e d f o r r e d u c t i o n s were s e r v i c e s f o r the mentally r e t a r d e d (op c i t ) and, while 6.5% of the M i n i s t r y budget was c o n s i s t e n t l y a l l o c a t e d to these s e r v i c e s between 1980 508 and 1982, by 1984 the f u n d i n g a l l o c a t i o n had been r e d u c e d to 5.6% (M. of H.R.A.R., 1980 - 1984). 78: See, Vancouver Sun: Jan. 25th 1986. 79: See, R o y a l C i t y Record, June 28th 1986. Vancouver Sun, Jan. 31st 1986; A p r i l 30th 1986; August 8th 1986; November 29th 1986; February 27th 1987. 80: While the i s s u e of ' p r i v a t i z a t i o n 1 i s not a dominant f e a t u r e of the p r o p o s e d 'mental h e a l t h p l a n ' , i t i s a p p a r e n t t h a t t h e l o n g - s t a n d i n g i n v o l v e m e n t o f n o n - p r o f i t and p r o p r i e t a r y o r g a n i z a t i o n s i n the p r o v i s i o n of c a r e i s to continue. In a d d i t i o n , a renewed emphasis i s to be placed upon ' f a m i l y - b a s e d ' and v o l u n t e e r s e r v i c e s ( e x t r e m e l y i n e x p e n s i v e forms of ' p r i v a t i z a t i o n ' ) . Riverview H o s p i t a l i s to be handed ove r to a n o n - p r o f i t h o s p i t a l s o c i e t y (a c o u r s e of a c t i o n c o n t e m p l a t e d s i n c e a t l e a s t 1979) b r i n g i n g the f a c i l i t y i n t o l i n e w i t h other p u b l i c h o s p i t a l s i n the p r o v i n c e . 81: I t i s noteworthy that the i s s u e of h e a l t h care funding was r a i s e d i n the Throne Speeches of 1983 and 1985. On' b o t h occasions i t was s t r e s s e d t h a t , d e s p i t e the ' d i f f i c u l t f i s c a l s i t u a t i o n ' , the government's commitment to m a i n t a i n i n g f i r s t c l a s s h e a l t h care was absolute. (J.L.A. 1983 and 1985). 82: For example, the M i n i s t e r i a l Task Force that reviewed the M e n t a l H e a l t h Act i n A l b e r t a i n 1983 (The Drewry Rep o r t ) r e c e i v e d submissions from a wide range of groups i n c l u d i n g two p a t i e n t s ' a s s o c i a t i o n s . In Saskatchewan, the e n q u i r i e s i n t o the p r o v i n c i a l mental h e a l t h system conducted i n the e a r l y 1980's by the C.M.H.A., r e c e i v e d submissions from two ' s e l f - h e l p ' groups; namely, the Saskatoon Crocus Co-coperative and 'By Ourselves: Regina' (Committee of Enquiry, 1984). The views of the groups were supported by submissions from the School of Human J u s t i c e a t the U n i v e r s i t y of R e g i n a , and l a w y e r s from the p r o v i n c i a l Legal A i d S e r v i c e . 83: S.O. 1978, c. 50. 84: While the movement was s u c c e s s f u l i n s e c u r i n g law reforms, t h i s d i d not n e c e s s a r i l y mean t h a t p a t i e n t s ' r i g h t s would be r e s p e c t e d i n p r a c t i c e . Subsequent s t u d i e s f o r the C a n a d i a n C i v i l L i b e r t i e s Union by Page and others (Page, 1980, 1981; Page & F i r t h , 1979) demonstrated that many medical p r a c t i t i o n e r s were i g n o r i n g the l e g i s l a t i o n . 85: The Church of S c i e n t o l o g y i s a l s o i n v o l v e d i n the p a t i e n t s ' r i g h t s movement t h r o u g h i t s ' C i t i z e n s Commission on Human Rights'. However, t h i s i s a m a r g i n a l i z e d and extremely s e c r e t -iv e group that i s an embarrassment to the other o r g a n i z a t i o n s . 86: T h i s i s b a s e d upon a r e v i e w o f t h e c o n t e n t and b i b l i o g r a p h i e s of the p u b l i c a t i o n s of those i n v o l v e d i n the p a t i e n t s ' r i g h t s movement. In a d d i t i o n , i n her comprehensive 509 study of mental p a t i e n t s ' a s s o c i a t i o n s , Chamberlin (1979) has demonstrated that the ideas and b e l i e f s of t h e i r l e a d i n g members can be t r a c e d to the works of S z a s z , S c h e f f , Goffman, L a i n g , Ennis and other American c i v i l l i b e r t a r i a n s . 87: R e p o r t o f S u p e r i n t e n d e n t o f R i v e r v i e w H o s p i t a l , M.H.S.B.A.R., 1972: 65. 88: R e p o r t o f S u p e r i n t e n d e n t o f R i v e r v i e w H o s p i t a l , M.H.S.B.A.R., 1973: 77. 89: While the r i g h t had been e s t a b l i s h e d i n the mental h e a l t h l e g i s l a t i o n p a s s e d i n 1964, i t was not e x e r c i s e d s i n c e few p a t i e n t s (and lawyers) knew that i t e x i s t e d . In a d d i t i o n , the case was made f o r improved review panel r i g h t s . In keeping with i t s general philosophy of i n c r e a s i n g community involvement i n the o p e r a t i o n of a wide range of government s e r v i c e s and a c t i v i t i e s (Clague, e t a l , 1984), the N.D.P. government had changed the membership of the panel (Mental Health Amendment Act, S.B.C. 1973, c. 127. See, a l s o , B.C. Hansard, November 7, 1973). P s y c h i a t r i c involvement was reduced and the panel was to comprise a c h a i r p e r s o n of no s p e c i f i e d p r o f e s s i o n a l background, a p h y s i c i a n , and one other person appointed by the p a t i e n t . I t was f e l t t h a t t h i s would e n s u r e t h a t p a t i e n t s were " a s s e s s e d r a p i d l y , c a r e f u l l y and with some degree of community approach" (D. of H.A.R. 1974: 78). The newly c o n s t i t u t e d panel came i n t o e f f e c t i n January, 1974 and, during i t s f i r s t year of op e r a t i o n , o n e - t h i r d of the seventy p a t i e n t s reviewed were recommended f o r d i s c h a r g e . D e s p i t e t h e s e changes, members of the c o n f e r e n c e f e l t t h a t p a t i e n t s s h o u l d have a r i g h t t o i n d e p e n d e n t r e p r e s e n t a t i o n at hearings, i n a d d i t i o n to a r i g h t to nominate a member of the panel. 90: D. of H.A.R. 1976: 135. 91: D. of H.A.R. 1976: 151. The de a t h s of the p a t i e n t s were r a i s e d i n the L e g i s l a t i v e Assembly on J u l y 14, 1977. One p a t i e n t had d i e d from burns a f t e r being p l a c e d i n a hot bath, while the other committed s u i c i d e s h o r t l y a f t e r d i s c harge from the h o s p i t a l . The O p p o s i t i o n q u i z z e d the government on t h e i r i n t e n d e d c o u r s e of a c t i o n and c l a i m e d t h a t p a t i e n t s ' r i g h t s were being f r e q u e n t l y abused at the h o s p i t a l . I t was apparent that the i n f o r m a t i o n held by the Op p o s i t i o n had been s u p p l i e d by the M.P.A. The M i n i s t e r of Health responded by s t a t i n g that the s t a f f member r e s p o n s i b l e f o r the burning of the p a t i e n t had been d i s m i s s e d and that the complicated circumstances surrounding the s u i c i d e had been examined. He a l s o s t a t e d that steps had been taken to e s t a b l i s h a system of in-house i n v e s t i g a t i o n of a l l e g e d abuses. This proved to be the panel of i n q u i r y (B.C. Hansard, J u l y 14, 1977: 3666-3667). 92: M. of H.A.R. 1979: 133. The M.P.A. was s t r o n g l y supported by the N.D.P. In 1976, when the A s s o c i a t i o n was running short of f u n d s , i t s p l i g h t was r a i s e d and de b a t e d a t l e n g t h i n the L e g i s l a t i v e Assembly (B.C. Hansard, May 26, 1977: 2041-2444). 510 The i s s u e was r a i s e d again one year l a t e r when the Op p o s i t i o n questioned the M i n i s t e r of Health on the p r o v i s i o n of funds to the o r g a n i z a t i o n . The M i n i s t e r s t a t e d t h a t f u n d i n g had been i n c r e a s e d c o n s i d e r a b l y and that the government would continue to s u p p o r t the agency (B.C. Hansard, March 14, 1977: 3667-3669). On May 23, 1978, the O p p o s i t i o n again badgered the government on the q u e s t i o n of funding s i n c e the A s s o c i a t i o n ' s 'drop-in' centre had been f o r c e d to 'beg' f o r money from the M i n i s t r y of Health (B.C. Hansard, May 23, 1978). 93: M. of H.A.R. 1978: 151. 94: I t should be noted t h a t other mental h e a l t h p r o f e s s i o n a l s ( n o t a b l y , p s y c h i a t r i c s o c i a l w o r kers) d i d not oppose the es t a b l i s h m e n t and p r o t e c t i o n of p a t i e n t s ' r i g h t s s i n c e i t was f e l t that t h i s might improve the e f f e c t i v e n e s s of treatment and thereby b e n e f i t p a t i e n t s . Indeed, an experiment was conducted a t R i v e r v i e w i n 1978 to a s c e r t a i n the p o s s i b l e i m p a c t of one r i g h t sought by the p a t i e n t s ' r i g h t s movement; namely, the p a t i e n t ' s r i g h t t o see h i s / h e r h o s p i t a l and m e d i c a l r e c o r d s . The H o s p i t a l adopted a p o l i c y of a l l o w i n g access to records f o r a p e r i o d of s i x months and, during t h i s time, 39% of p a t i e n t s took advantage of the opp o r t u n i t y . The e v a l u a t o r s r e p o r t e d that no problems arose and that s t a f f g e n e r a l l y f e l t that a l l o w i n g access might a c t u a l l y be t h e r a p e u t i c (McFarlane, et a l , 1980). The value of endorsing at l e a s t one p a t i e n t s ' r i g h t t h e r e f o r e had some e m p i r i c a l support. 95: The p r o j e c t d i d not r e j e c t the ' p h i l o s o p h y ' of s u p p o r t i n g t r e a t m e n t teams. Indeed, s i n c e the o n s e t of i l l n e s s and a d m i s s i o n to h o s p i t a l o f t e n a r o s e from 'problems i n l i v i n g ' , every e f f o r t had to be made to r e s o l v e the l e g a l aspects of such problems. These e i t h e r preceded or occurred as a consequence of the process of i n s t i t u t i o n a l i z a t i o n , and t h e i r r e s o l u t i o n could a s s i s t care and treatment. 96: The f i r s t , reported, case presented by mental h e a l t h law a d v o c a t e s -Ex P a r t e D e a r i n g (( 1976) 64 D.L.R. (3d) 382) - came b e f o r e the p r o v i n c i a l Supreme C o u r t i n 1975 and p r i o r t o the est a b l i s h m e n t of the p r o j e c t as a formal agency. Dearing had been i n v o l u n t a r i l y a d m i t t e d t o R i v e r v i e w on the b a s i s of d e f e c t i v e medical c e r t i f i c a t e s and h i s counsel argued that h i s c l i e n t should, consequently, be r e l e a s e d . In the i n t e r i m , the H o s p i t a l a r r a n g e d f o r the c o m p l e t i o n of new documents and c e r t i f i c a t e s and the Court h e l d that, s i n c e the d e f e c t s had been r e m e d i e d , the H o s p i t a l c o u l d c o n t i n u e to c o n f i n e D e a r i n g f o r treatment. 97: (1978) 5 B.C.L.R. 347 (B.C.S.C.). 9 8: (1980) 114 D.L.R. (3d) 620 (B.C.S.C.). 99: ( 1981) 12 1 D.L.R. (3d) 337 (B.C.S.C.). [1981] B.C.D. C i v . 2668-02 June 22, 1981 (B.C.S.C.). In Scherba, the Supreme Court u p h e l d i t s p r e v i o u s d e c i s i o n s r e g a r d i n g the onus of p r o o f . 511 However, i f i t was proved that a p a t i e n t e x h i b i t e d d e l u s i o n s , h a b i t s , and a c t i o n s , t h a t w o u l d r e s u l t i n a s u c c e s s f u l i n v o l u n t a r y admission, t h i s was s u f f i c i e n t to s a t i s f y the burden and standard of proof. 100: The Court held t h a t , s i n c e the consequences of confinement were g r e a t (an i n d i v i d u a l not o n l y l o s t h i s / h e r l i b e r t y but c o u l d a l s o be s u b j e c t e d to any form of t r e a t m e n t ) , i t would p e r m i t c o n t i n u e d d e t e n t i o n o n l y i f i t h e a r d c l e a r and unequivocal evidence of both the presence of a mental d i s o r d e r and the need f o r treatment. The Court a l s o confirmed that i t would c o n t i n u e to p l a y a r o l e i n the s u p e r v i s i o n of mental h e a l t h p r o f e s s i o n a l s . C o u n s e l f o r R i v e r v i e w H o s p i t a l a rgued that, s i n c e p a t i e n t s had access to a review panel, the opt i o n of j u d i c i a l review was unnecessary and should be abandoned. The Court d i d not agree. 101: M. of H.A.R. 1980. 102: [1980] B.C.D. Crim. Conv. 575201, A802065, September 18, 1980, (B.C.S.C.). 103: See, M. of H.A.R. 1980. The r u l i n g i n H i l t o n d i d not n e c e s s a r i l y r e p r e s e n t a change of h e a r t on the p a r t of the j u d i c i a r y i n r e l a t i o n t o the r i g h t to r e f u s e t r e a t m e n t . P a t i e n t s ' advocates a p p l i e d the p r i n c i p l e s of l e g a l formalism by arguing that the l e g i s l a t i o n c l e a r l y d i d not permit treatment without consent. Since t h i s was the case, the Court had l i t t l e c h o i c e but to agree. 104: M i s c e l l a n e o u s S t a t u t e s Amendment Act, S.B.C. 1981, c. 31. Despite the impact of the amendments upon fundamental r i g h t s and freedoms, the government chose to make the changes by way of a g e n e r a l , 'housekeeping' s t a t u t e c o n t a i n i n g l a r g e numbers of sm a l l and u s u a l l y cosmetic adjustments to v a r i o u s Acts which i t u s u a l l y presents and passes r o u t i n e l y i n the c l o s i n g days of a S e s s i o n . The motive f o r t h i s u n u s u a l c o u r s e of a c t i o n i s unclear but i t may have r e f l e c t e d an attempt to prevent debate. I f t h i s was the case, the government was s u c c e s s f u l . 105: See, a l s o , Vancouver Sun, Aug. 13th 1981. 106: (1983) 150 D.L.R. (3d) 535 (B.C. Co. Ct.). 107: See, a l s o , The Province, August 7th, 1983. 108: Per, the Regulations Act, S.B.C. 1983, c. 10: s. 21. See, a l s o M e n t a l H e a l t h Amendment A c t , S.B.C. 1985, c. 12, and B.C. Hansard, February 12, 1985. 109: I t was s u c c e s s f u l i n an a c t i o n f o r m a l i c i o u s p r o s e c u t i o n and f a l s e i m p r i s o n m e n t where a p a t i e n t had been i m p r o p e r l y admitted, i n v o l u n t a r i l y confined, and f o r c i b l y i n j e c t e d with drugs, but the damages awarded were minimal ($500). See, Ketchum li. H i s l o p (1984) 54 B.C.L.R. 327 (B.C.S.C.). 512 110: The p r o j e c t c o n t i n u e d t o o p e r a t e from the M.P.A. 's premises i n the H o s p i t a l . One of the pr o j e c t ' s key advocates -Gerald Green - has r e c e n t l y accepted a p o s i t i o n i n Ontar i o and the l o s s of one of i t s most experienced lawyers has not helped the M.P.A.P. i n the p u r s u i t of i t s goals. I l l : The Committee on C o r r e c t i o n s and I n s t i t u t i o n s of the p r o v i n c i a l branch of the Canadian Bar A s s o c i a t i o n has l o b b i e d a c t i v e l y f o r mental h e a l t h law reforms and i t s membership has i n c l u d e d l a w y e r s from the M.P.A.P. S u p p o r t has a l s o been provided by the B r i t i s h Columbia C i v i l L i b e r t i e s A s s o c i a t i o n , an o r g a n i z a t i o n t h a t has provided r e p r e s e n t a t i o n f o r p a t i e n t s at review panel hearings. 112: Committees r e v i e w i n g mental h e a l t h l e g i s l a t i o n i n other p r o v i n c e s (notably, A l b e r t a and Manitoba) have recommended the appointment of a 'patients' r e p r e s e n t a t i v e / a d v o c a t e ' . F u r t h e r , the Uniform Mental Health Act makes p r o v i s i o n f o r a 'patient's a d v i s o r *. 113: In a d d i t i o n to the c o n s t r a i n t s a r i s i n g from the s t r u c t u r e and o r g a n i z a t i o n of l e g a l a i d and advocacy s e r v i c e s , l a w y e r s have to con t e n d w i t h v a r i o u s s t a t u t o r y i m p e d i m e n t s ; such as, l i m i t a t i o n s on the e x t e n t t o which a c t i o n s can be l a u n c h e d a g a i n s t mental h e a l t h p r o f e s s i o n a l s without the approval of a court or a province's s e n i o r law o f f i c e r (see, Gordon & Verdun-Jones, 1986). These l i m i t a t i o n s are the l a s t remaining v e s t i g e s of 19th century lunacy law. 114: A l l i e d groups i n c l u d e the C.M.H.A. and o r g a n i z a t i o n s r e p r e s e n t i n g the f a m i l i e s of p e r s o n s s u f f e r i n g from m e n t a l d i s o r d e r s ; n o t a b l y , C a n a d i a n F r i e n d s of S c h i z o p h r e n i c s , an a s s o c i a t i o n that c o n s i s t e n t l y l o b b i e s i n support of p s y c h i a t r y (Savage & McKague, 1987). The s t a n d i n g of the C.M.H.A. as an o r g a n i z a t i o n o u t s i d e the p a t i e n t s ' r i g h t s movement i s confirmed by Savage & McKague (1987); two a r d e n t p a t i e n t s ' r i g h t s advocates. The A s s o c i a t i o n i s d e s c r i b e d as a " w e l l - i n t e n t i o n e d " but "middle-of-the-road" o r g a n i z a t i o n and i s c r i t i c i z e d s t r o n g l y f o r i t s apparent support of the 'medical model'. The authors do note, however, that s i n c e 1983 the A s s o c i a t i o n (at the n a t i o n a l l e v e l ) has e x h i b i t e d a s h i f t towards a more r a d i c a l p a t i e n t s ' r i g h t s p e r s p e c t i v e . 115: I t was a l s o apparent, however, that some p h y s i c i a n s d i d not d i s l i k e the new l e g i s l a t i o n and t h a t many were c h o o s i n g to comply with the new law (Menuck & Littmann, 1982). Savage & McKague (1987) have r e c e n t l y r e p o r t e d a f u r t h e r ' r e v o l t ' by medical p r a c t i t i o n e r s i n Ontario . In January 1986, a number of p h y s i c i a n s employed i n p r o v i n c i a l p s y c h i a t r i c f a c i l i t i e s began to apply to review boards, on behalf of every i n v o l u n t a r i l y a d m i t t e d p a t i e n t , f o r a r e v i e w of the need f o r admission. The p h y s i c i a n s were angered by the i n t r o d u c t i o n of a p a t i e n t a d v o c a t e programme, and p r o t e s t e d by a t t e m p t i n g t o 513 overload the boards w i t h hearings. 116: The argument a s s o c i a t e d with the r i g h t may be summarized as f o l l o w s : where the s t a t e d e p r i v e s an i n d i v i d u a l of h i s or her l i b e r t y on the b a s i s of i t s parens p a t r i a e power and duty, i t has an e q u a l l y c o m p e l l i n g duty to p r o v i d e the r e s o u r c e s n e c e s s a r y to e n s u r e t h a t the p e r s o n w i l l be g i v e n whatever t r e a t m e n t he or she may need i n o r d e r to a c h i e v e a s t a t e of h e a l t h s u f f i c i e n t to a l l o w a r e s t o r a t i o n of l i b e r t y . Treatment i s t h e q j J i _ d p r o guo f o r i n v o l u n t a r y a d m i s s i o n t o , and confinement i n , a mental h e a l t h f a c i l i t y and, where a government f a i l s to provide the resources necessary f o r adequate treatment, i t has n e g l e c t e d to completely f u l f i l i t s parens p a t r i a e duty. Consequently, i t has no r i g h t to d eprive a person of h i s or her l i b e r t y (see, e.g., B r a k e l , et a l , 1985). 117: Mental Health S e r v i c e s Act, S.S. 1984-85, c. M-13.1. The p e r s i s t e n c e of the A s s o c i a t i o n Tn t h i s p r ovince i s probably due to the f a c t t h a t Saskatchewan was the f i r s t to e s t a b l i s h a b r a n c h of the 'new ' o r g a n i z a t i o n i n the 1950's. Key, e a r l y f i g u r e s i n the C.M.H.A. (notably, Drs. Lawson and MacKerracher) were l o c a t e d i n the p r o v i n c e . 118: M e n t a l H e a l t h Amendment A c t , S.B.C. 1985, c. 12. Among other matters, t h i s s t a t u t e c l a r F f i e d a p a t i e n t ' s r i g h t to apply f o r review a f t e r the f i r s t 30 days of d e t e n t i o n , and then every 90 days t h e r e a f t e r , unless the Chairman of the review panel i s of the o p i n i o n that a review should occur at an e a r l i e r time. The Act a l s o ensures that the review procedures are a p p l i c a b l e to b o t h a l l mental h e a l t h f a c i l i t i e s and to the p s y c h i a t r i c u n i t s of g e n e r a l h o s p i t a l s . In a d d i t i o n , the r i g h t to seek j u d i c i a l r e v i e w of the need f o r d e t e n t i o n i n a mental h e a l t h f a c i l i t y has been extended to a d u l t s and youths t r a n s f e r r e d from c o r r e c t i o n a l i n s t i t u t i o n s . (B.C. Hansard, F e b r u a r y 12, 1985, pp. 4922-4925). F u r t h e r amendments were i n t r o d u c e d per the H e a l t h S t a t u t e s Amendment A c t S.B.C. 1986, c. 6, and the M i s c e l l a n e o u s S t a t u t e s Amendment Act (No. 1) S.B.C. 1987, c. 42. These s t a t u t e s s h o r t e n the p e r i o d s of time d u r i n g which a p a t i e n t may be c o n f i n e d without re-examination and a l l o w more frequent a p p l i c a t i o n s f o r review (see, a l s o , Order i n C o u n c i l 1882/87 (Sept. 17th 1987) amending the M e n t a l H e a l t h Act R e g u l a t i o n s ) . The D e p u t y M i n i s t e r o f H e a l t h has s t a t e d t h a t t h e p r o v i n c i a l mental h e a l t h l e g i s l a t i o n i s under review and that i t w i l l be amended i n keeping w i t h the new p r o v i n c i a l mental h e a l t h p o l i c y (Royal C i t y Record, June 28th 1986). T h i s i s confirmed by p e r s o n a l communications w i t h s e n i o r o f f i c i a l s i n a p r o v i n c i a l government M i n i s t r y . In t h e i r view, the government p r e f e r s to i n t r o d u c e s t a t u t o r y changes i n c r e m e n t a l l y s i n c e t h i s i s p o l i t i c a l l y e x p e d i e n t and a l l o w s t i m e f o r the i m p a c t to be assessed. 119: See, R o y a l C i t y Record, June 28th 1986. C o n f i r m e d by p e r s o n a l communications with s e n i o r o f f i c i a l s i n a p r o v i n c i a l 514 government M i n i s t r y . 120: P e r s o n a l c o m m u n i c a t i o n s w i t h s e n i o r o f f i c i a l s i n a p r o v i n c i a l government M i n i s t r y . 121: I b i d . 122: I b i d . Saskatchewan d i d not take p a r t i n the Mental Health Law P r o j e c t because the p r o v i n c e ' s l e g i s l a t i o n was b e i n g su b j e c t e d to a comprehensive review that was near completion at the time the p r o j e c t was i n i t i a t e d . 123: The a d o p t i o n of the Saskatchewan 'model' may, however, encounter r e s i s t a n c e from the p a t i e n t s ' r i g h t s movement. Two independent p a t i e n t s ' advocates i n O n t a r i o have r e c e n t l y c l a i m e d that the new Saskatchewan l e g i s l a t i o n v i o l a t e s the p r o v i s i o n s of the Charter and i t i s apparent that they do not view the s t a t u t e i n a favourable l i g h t (Savage & McKague, 1987). It i s l i k e l y , however, that governments w i l l ignore the p r o t e s t s of advocates unless a Charter cha l l e n g e i s s u c c e s s f u l . 515 CHAPTER 7. MENTAL DISORDER, LAW AND STATE: THE GENERAL THEORETICAL IMPLICATIONS I t i s not w e l l to sneer at the p o l i t i c a l economy i n i t s r e l a t i o n to the insane poor. Whether we think i t r i g h t o r not, the q u e s t i o n of c o s t has d e t e r -mined and w i l l continue to determine t h e i r f a t e f o r weal or woe. O l i v e r Wendell Holmes, 1891. I: INTRODUCTION In Canada, s t a t e s t r a t e g y and the l e g i s l a t i o n a f f e c t i n g the management of the mentally d i s o r d e r e d have been subjected to changes s i n c e 1900. At the t u r n of the c e n t u r y , s t a t e s t r a t e g y f o c u s s e d upon s e g r e g a t e d c o n f i n e m e n t i n p u b l i c and p r i v a t e a s y l u m s and the r e l e v a n t p r o v i n c i a l and t e r r i t o r i a l l e g i s l a t i o n was c h a r a c t e r i z e d by ' l i m i t e d l e g a l i s m " . The a c t i v i t i e s of medical p r a c t i t i o n e r s i n regard to the commitment and c o n f i n e m e n t of i n s a n e p e r s o n s were s u b j e c t e d to forms of j u d i c i a l and q u a s i - j u d i c i a l s u p e r v i s i o n , and the j u d i c i a r y dominated the process of a p p o i n t i n g committees or guardians to manage the a f f a i r s of those deemed to be ' l u n a t i c s ' . By the 1930's, the s t r a t e g y had s h i f t e d to a combination of short-term and long-term i n s t i t u t i o n a l i z a t i o n f o r care and medical treatment. New f a c i l i t i e s and resources f o r the s h o r t -term, i n t e n s i v e , m e d i c a l t r e a t m e n t of 'mental d i s e a s e s ' were g r a d u a l l y i ntroduced (e.g., psychopathic h o s p i t a l s ) and, while the o l d p l a c e s of s e g r e g a t e d c o n f i n e m e n t were r e t a i n e d , they were to be used p r i m a r i l y f o r p a t i e n t s who d i d not respond to 516 e a r l y , a c t i v e treatment. The s h i f t i n s t r a t e g y was accompanied by law reforms c h a r a c t e r i z e d by ' m e d i c a l i z a t i o n 1 . The j u d i c i a r y c o n t i n u e d to c o n t r o l the a p p o i n t m e n t of c o m m i t t e e s and some j u d i c i a l and q u a s i - j u d i c i a l s u p e r v i s i o n of long-term confinement was r e t a i n e d ; however, medical p r a c t i t i o n e r s began to dominate the a d m i s s i o n , t r e a t m e n t and c o n f i n e m e n t of v o l u n t a r y and i n v o l u n t a r y p a t i e n t s , e s p e c i a l l y i n r e g a r d t o p s y c h o p a t h i c h o s p i t a l s and other a c t i v e treatment f a c i l i t i e s . D u r i n g the 1950's and 1960's, s t a t e s t r a t e g y s h i f t e d to d e - i n s t i t u t i o n a l i z a t i o n and, w h i l e the t a c t i c of s h o r t - t e r m h o s p i t a l i z a t i o n f o r e a r l y , a c t i v e t r e a t m e n t was r e t a i n e d , e f f o r t s were made to provide community-based care and treatment r e s o u r c e s f o r b o t h d i s c h a r g e d and new m e n t a l l y d i s o r d e r e d persons. Mental h e a l t h l e g i s l a t i o n c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' was introduced and t h i s i n v o l v e d the removal of the l a s t v e s t i g e s of ' l i m i t e d l e g a l i s m ' . The j u d i c i a r y r e t a i n e d c o n t r o l over the appointment of permanent committees but t h e i r involvement i n other aspects of the management of the mentally d i s o r d e r e d was r e d u c e d to a p o i n t where i t became a l m o s t n e g l i g i b l e . W h i l e t h e i r d e c i s i o n s c o u l d be s u b j e c t e d to a d m i n i s t r a t i v e r e v i e w , m e d i c a l p r a c t i t i o n e r s d o m i n a t e d a l l aspects of the admission, treatment and confinement of p a t i e n t s and they were empowered to examine and c e r t i f y p a t i e n t s as incapable of managing t h e i r a f f a i r s . A n o t h e r s h i f t i n s t r a t e g y began i n the 1970's and was accompanied by changes i n mental h e a l t h l e g i s l a t i o n which have 517 e r o d e d m e d i c a l d o m i n a t i o n of the management of the m e n t a l l y d i s o r d e r e d . The p r o c e s s of d e - i n s t i t u t i o n a l i z a t i o n has a c c e l e r a t e d w i t h a view to c l o s i n g a l l p u b l i c m e n t a l h e a l t h i n s t i t u t i o n s , a t a c t i c of n o n - i n s t i t u t i o n a l i z a t i o n has been introduced, and mental h e a l t h p a t i e n t s are to be housed by the p r i v a t e s e c t o r w h i l e r e c e i v i n g t r e a t m e n t i n community-based res o u r c e s . S t a t u t o r y reforms c h a r a c t e r i z e d by the 'new l e g a l i s m ' have been int r o d u c e d and these impose c o n t r o l s on the extent to which medical p r a c t i t i o n e r s can u t i l i z e h o s p i t a l s . S t r i c t c r i t e r i a f o r i n v o l u n t a r y admission and confinement have been e s t a b l i s h e d , together with a v a r i e t y of p a t i e n t s ' r i g h t s , and the a c t i v i t i e s of m e d i c a l p r a c t i t i o n e r s are m o n i t o r e d and s u p e r v i s e d by advocacy s e r v i c e s and p r o a c t i v e , q u a s i - j u d i c i a l review boards. The j u d i c i a r y play a r o l e i n the e s t a b l i s h m e n t and p r o t e c t i o n of p a t i e n t s ' r i g h t s and the combination of advocacy, q u a s i - j u d i c i a l review and j u d i c i a l involvement d i m i n i s h e s the extent to which m e d i c a l p r a c t i t i o n e r s dominate the management of p a t i e n t s . Canadian mental h e a l t h law c u r r e n t l y resembles some aspects of the ' l i m i t e d l e g a l i s m ' which were i n pla c e at the turn of the century (i.e., forms of q u a s i - j u d i c i a l s u p e r v i s i o n ) . However, s t r i c t e r l i m i t s have been imposed upon the admission, treatment and confinement of mental h e a l t h p a t i e n t s and the post-admission a c t i v i t i e s of medical p r a c t i t i o n e r s are more c l o s e l y supervised; i t i s i n t h i s sense that the c u r r e n t era of law reform may be d e s c r i b e d as a new form of l e g a l i s m . The a s s o c i a t i o n between the s h i f t s i n s t r a t e g y and the 518 p e r i o d s of mental h e a l t h law reform (i.e., the tendency f o r the s t a t e to a l t e r n a t e l y impose, ease, and then re-impose forms of j u d i c i a l and q u a s i - j u d i c i a l s u p e r v i s i o n ) has been e x p l o r e d t h r o u g h an a n a l y s i s of the emergence of 'enhanced m e d i c a l i z -a t i o n * , the demise of t h i s form of mental h e a l t h l e g i s l a t i o n , and the r i s e of the 'new l e g a l i s m ' . W h i l e the n a t i o n a l s i t u a t i o n has been examined, the primary focus has been upon the events i n one pr o v i n c e (i.e., B r i t i s h Columbia) and a p a r t i c u l a r t h e o r e t i c a l p e r s p e c t i v e w i t h i n a s o c i o l o g y of the s t a t e and law - s t r u c t u r a l i s t Marxism coupled w i t h an examination of the r o l e and impact of human agency - has been employed to e x p l a i n the s h i f t s i n s t r a t e g y and the corresponding s t a t u t o r y reforms. Both the d e s c r i p t i o n and the a n a l y s i s of the changes i n s t r a t e g y and l e g i s l a t i o n have c o n t r i b u t e d to an understanding of the p e r i o d s of mental h e a l t h p o l i c y and law reform which have emerged i n Canada s i n c e the t u r n of the c e n t u r y ( e s p e c i a l l y , s i n c e the 1940's) and t h i s i n f o r m s , i n p a r t i c u l a r , the debate s u r r o u n d i n g the r i s e of the new l e g a l i s m (see, e.g., G o s t i n , 1983c, 1983d; Gordon & Verdun-Jones, 1986; J o n e s , 1980; Rose, 1985). In Canada, the new l e g a l i s m i s a mechanism employed by p r o v i n c i a l governments p r i m a r i l y to r e s t r i c t the use of mental h e a l t h i n s t i t u t i o n s and does n o t , as G o s t i n (1983c, 1983d) c o n t e n d s , c o n s t i t u t e p o s i t i v e ' l e g a l a c t i v i s m ' aimed a t p r o v i d i n g more e f f e c t i v e s e r v i c e s f o r p a t i e n t s w h i l e s i m u l t a n e o u s l y p r o t e c t i n g fundamental r i g h t s and freedoms. For example, a r i g h t to r e c e i v e treatment has not been endorsed by governments whereas other p a t i e n t s ' r i g h t s which l i m i t h o s p i t a l 519 u t i l i z a t i o n have ( w i t h i n l i m i t s ) been embraced. The e n t r e n c h m e n t of the new l e g a l i s m i s a p r o d u c t of changing economic c o n d i t i o n s which have a f f e c t e d the p r o v i s i o n of m e n t a l h e a l t h c a r e and t r e a t m e n t , and the law r e f o r m s s i m u l t a n e o u s l y f a c i l i t a t e and j u s t i f y government economic r e s t r a i n t measures i n the p o l i t i c a l l y s e n s i t i v e h e a l t h c a r e component of the w e l f a r e s t a t e . As Rose (1985) suggests, the language of p a t i e n t s ' r i g h t s has been used to d i s g u i s e a ' p o l i t i c a l s t r a t e g y ' intended to reduce the r o l e of i n s t i t u t i o n s i n the p r o v i s i o n of mental h e a l t h care, and l e g a l r h e t o r i c has ' d e - p o l i t i c i z e d ' the debate over p r i o r i t i e s i n the a l l o c a t i o n of r e s o u r c e s . Since the new l e g a l i s m i n v o l v e s the enhancement and p r o t e c t i o n of c h e r i s h e d , fundamental r i g h t s and freedoms i t i s i n h e r e n t l y j u s t i f i a b l e , and i t removes the need f o r the b a s i s and i m p l i c a t i o n s of the u n d e r l y i n g s t r a t e g y to be p u b l i c l y d e b a t e d . Two c o m p e t i n g i n t e r e s t g r o u p s w i t h d i f f e r e n t p e r c e p t i o n s of the 'best i n t e r e s t s ' of p a t i e n t s - the p a t i e n t s ' r i g h t s movement and organized p s y c h i a t r y - have been i n v o l v e d i n the reform process, and the former has been more s u c c e s s f u l than the l a t t e r . However, the r e c o g n i t i o n and e n t r e n c h m e n t of p a t i e n t s ' r i g h t s i s p r i m a r i l y a p r o d u c t of the congruence between the g o a l s of the movement and government economic r e s t r a i n t p o l i c i e s , r a t h e r than humanitarian or other c o n s i d e r -a t i o n s . While the f i n d i n g s are of value, i n p a r t i c u l a r , to those i n t e r e s t e d i n the f i e l d of law and p s y c h i a t r y , the a n a l y s i s has 520 more important t h e o r e t i c a l i m p l i c a t i o n s f o r the s o c i o l o g y of s o c i a l c o n t r o l , a s o c i o l o g y of law informed by s t a t e theory, and a convergence of the two r e s e a r c h programmes. I I ; THEORETICAL IMPLICATIONS FOR THE SOCIOLOGY OF SOCIAL CONTROL The a n a l y s i s of the two p e r i o d s of mental h e a l t h law reform s i n c e the 1940's (i.e., 'enhanced m e d i c a l i z a t i o n ' and the 'new l e g a l i s m ' ) has i n v o l v e d an e x p o s i t i o n o f b o t h t h e u n d e r l y i n g s h i f t s i n s o c i a l c o n t r o l s t r a t e g i e s p e r t a i n i n g to the mentally d i s o r d e r e d and the reasons f o r these changes. While the primary focus has been upon the i m p l i c a t i o n s f o r a s o c i o l o g y of the s t a t e and law, the a n a l y s i s a l s o c o n t r i b u t e s to the r e s e a r c h programme w i t h i n the s o c i o l o g y of s o c i a l c o n t r o l by d e s c r i b i n g and e x p l o r i n g t h e c h a n g e s i n s o c i a l c o n t r o l s t r a t e g i e s i n Canada; notably, the emergence of d e - i n s t i t u t i o n -a l i z a t i o n (or 'decarceration'); n o n - i n s t i t u t i o n a l i z a t i o n ; and, p r i v a t i z a t i o n ( S c u l l , 1984; Lerman, 1982; Warren, 1981; Cohen, 1985). In p a r t i c u l a r , the a n a l y s i s v e r i f i e s key a s p e c t s of S c u l l ' s (1984) account of the d e c a r c e r a t i o n process and, with some m o d i f i c a t i o n , i t s a p p l i c a b i l i t y i n the Canadian context. D e - i n s t i t u t i o n a l i z a t i o n began i n Canada i n the 1950's as a response to three primary problems: s e r i o u s over-crowding i n the i n s t i t u t i o n s f o r segregated confinement; the p r o j e c t e d cost of b u i l d i n g new (but i n e f f e c t i v e ) f a c i l i t i e s to r e s o l v e the problem; and, the growing c r i t i c i s m of these p l a c e s . A s t r a t e g y of care and treatment through e f f e c t i v e but l e s s c o s t l y (both to c o n s t r u c t and o p e r a t e ) community-based a l t e r n a t i v e s such as mental h e a l t h c e n t r e s was developed, and a concerted e f f o r t was 521 made to r e - a c t i v a t e and discharge i n s t i t u t i o n a l i z e d , 'long-stay' p a t i e n t s and l i m i t the confinement of new p a t i e n t s . These kinds of measures had been p r o p o s e d d u r i n g the 1920's and 1930's by the C a n a d i a n N a t i o n a l Committee f o r M e n t a l Hygiene but the ideas remained dormant i n most p r o v i n c e s u n t i l the problem of o v e r - c r o w d i n g r e a c h e d unmanageable p r o p o r t i o n s and l a r g e r s t r u c t u r a l changes a f f e c t e d the p r o v i s i o n of p u b l i c h e a l t h and s o c i a l w e l f a r e s e r v i c e s . In the l a t e 1940's, the f e d e r a l government adopted a plan f o r p o s t - w a r s o c i a l r e c o n s t r u c t i o n b u i l t upon a K e y n e s i a n economic s t r a t e g y and t h i s i n v o l v e d the i n t r o d u c t i o n of a v a r i e t y of p u b l i c , s o c i a l w e l f a r e measures. By the 1950's, a ' w e l f a r e s t a t e ' was e s t a b l i s h e d i n Canada and b o t h t h e a v a i l a b i l i t y of s o c i a l a s s i s t a n c e b e n e f i t s and an i n c r e a s e i n the numbers of s o c i a l workers provided the c o n d i t i o n s necessary f o r d e - i n s t i t u t i o n a l i z a t i o n to o c c u r . The a ppearance of new drug treatments i n the mid-1950's f a c i l i t a t e d the p r o v i s i o n of treatment i n the community r a t h e r than i n s t i t u t i o n s , but t h i s t e c h n o l o g i c a l advance merely served to b u t t r e s s a s t r a t e g y that had a l r e a d y been implemented. The s t r a t e g y of d e - i n s t i t u t i o n a l i z a t i o n (and the attendant preference f o r community-based care and treatment) was f i r m l y entrenched by the 1960's and mental h e a l t h s e r v i c e s became an i n t e g r a l p a r t of the h e a l t h c a r e component of an e x p a n d i n g w e l f a r e s t a t e . The p r o b l e m s of o v e r - c r o w d i n g were r e s o l v e d w i t h o u t e x p e n d i t u r e on new i n s t i t u t i o n s and the m e n t a l l y 522 d i s o r d e r e d were managed e f f e c t i v e l y and j o i n t l y by the h e a l t h and s o c i a l w e l f a r e s y s t e m s . In a d d i t i o n , p r i v a t e n o n - p r o f i t s o c i e t i e s and f o r - p r o f i t o p e r a t o r s became i n v o l v e d i n the p r o v i s i o n of s u p p l e m e n t a r y community-based s e r v i c e s and resou r c e s such as board and care homes. By the e a r l y 1970's, however, the c o s t s of the e n t i r e h e a l t h care component of the w e l f a r e s t a t e became a cause f o r c o n c e r n and s t e p s were taken t o s t a b i l i z e e x p e n d i t u r e s . H o s p i t a l u t i l i z a t i o n was s i n g l e d out f o r s p e c i a l a t t e n t i o n and e f f o r t s were made to develop low cost a l t e r n a t i v e s . Domestic and i n t e r n a t i o n a l economic problems r e s u l t e d i n an adjustment of the Keynesian economic s t r a t e g y and the gradual i n t r o d u c t i o n of elements of a monetarist economic p o l i c y . The new economic s t r a t e g y i n v o l v e d a r e d u c t i o n i n the s i z e of (and expenditures upon) the p u b l i c s e c t o r and these measures had an impact upon t h e w e l f a r e s t a t e . E f f o r t s were made t o p r o t e c t the p o l i t i c a l l y s e n s i t i v e h e a l t h care component (and, t h e r e f o r e , the mental h e a l t h f i e l d ) but the onset of an economic r e c e s s i o n i n the e a r l y 1980's and the g r a d u a l a d o p t i o n of a d d i t i o n a l monetarist p o l i c i e s r e s u l t e d i n the i n t r o d u c t i o n of r e s t r a i n t , r a t h e r than s t a b i l i z a t i o n , measures. The i m p o s i t i o n of c o s t - s t a b i l i z a t i o n and r e s t r a i n t measures provided an a d d i t i o n a l impetus to both the process of d e - i n s t i t u t i o n a l i z a t i o n and the development of e f f e c t i v e but l e s s expensive community-based care and treatment a l t e r n a t i v e s . A t a c t i c of n o n - i n s t i t u t i o n a l i z a t i o n was introduced, p r i v a t e s e c t o r involvement i n the p r o v i s i o n of care was enhanced, and, 523 by the e a r l y 1980's, the l a t t e r was p r o p e l l e d by a g e n e r a l p o l i c y of ' p r i v a t i z i n g ' p u b l i c s e c t o r e n t e r p r i s e s and s e r v i c e s . L a r g e , p u b l i c mental h o s p i t a l s are now b e i n g c l o s e d and the mentally d i s o r d e r e d are being managed through a combination of p u b l i c and p r i v a t e community-based f a c i l i t i e s and resources. It i s evident, t h e r e f o r e , that a s h i f t away from the use of p l a c e s of s e g r e g a t e d c o n f i n e m e n t ( i . e . , d e - i n s t i t u t i o n -a l i z a t i o n ) f i r s t emerged i n Canada during the 1950's and t h a t , by the 1960's, t h i s p r o c e s s had been j o i n e d by what i s now r e f e r r e d to as ' p r i v a t i z a t i o n ' ; t h a t i s , a change i n the o w n e r s h i p of f a c i l i t i e s and r e s o u r c e s . The changes d i d not occur i n i t i a l l y as a r e s u l t of f i s c a l d i f f i c u l t i e s but, r a t h e r , through the combined e f f e c t of other problems c o n f r o n t i n g the s t a t e (e.g., s e r i o u s o v e r - c r o w d i n g i n d i s c r e d i t e d m e n t a l h o s p i t a l s ) and the emergence of s t r u c t u r a l c o n d i t i o n s which were favourable to the implementation of ideas which would r e s o l v e t h e s e p r o b l e m s ; n a m e l y , a w e l f a r e s t a t e b u i l t upon t h e i n f r a s t r u c t u r e of K e y n e s i a n e c o n o m i c s . The p r o c e s s of de-i n s t i t u t i o n a l i z a t i o n and a form of ' p r i v a t i z a t i o n ' were a l r e a d y i n p l a c e when f i s c a l problems began to emerge i n the mid-1970's and the r e s o l u t i o n of these problems, coupled with the adoption of p u b l i c s e c t o r r e s t r a i n t p o l i c i e s i n the e a r l y 1980's, has r e s u l t e d i n a c c e l e r a t e d d e - i n s t i t u t i o n a l i z a t i o n aimed a t h o s p i t a l c l o s u r e ; a t a c t i c of n o n - i n s t i t u t i o n a l i z a t i o n ; and, enhanced p r i v a t e s e c t o r involvement. In t h e i r analyses of d e c a r c e r a t i o n i n the mental h e a l t h 524 f i e l d i n the U n i t e d S t a t e s and B r i t a i n , both S c u l l (1984) and Sedgwick ( 1982) have s u g g e s t e d t h a t the p r o c e s s has been supported by l i b e r a l reformers who have been u n w i t t i n g l y co-o pted by the s t a t e . In t h e i r view, the r h e t o r i c of l i b e r a l reform and c i v i l r i g h t s provided the s t a t e w i t h a screen that e f f e c t i v e l y d i s g u i s e d an e c o n o m i c a l l y m o t i v a t e d s h i f t i n s t r a t e g y and t h i s c l a i m has been p a r t l y c o n f i r m e d by the a n a l y s i s of the r i s e of the new l e g a l i s m i n Canada. However, i t i s a l s o e v i d e n t t h a t , i n Canada, " l i b e r a l r e f o r m e r s ' (namely, the C.M.H.A.) were i n v o l v e d i n the c o n s t r u c t i o n of a s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d p r i o r to the emergence of economic problems and changes (i.e., the era of 'enhanced m e d i c a l i z a t i o n ' i n the 1950's and 1960's), and t h a t t h e s e r e f o r m e r s are to be d i s t i n g u i s h e d from the p a t i e n t s ' r i g h t s movement: a group of reformers favoured by the s t a t e at a t i m e when a s h i f t i n s t r a t e g y was p r o p e l l e d by economic c o n s i d e r a t i o n s ( i . e . , the e r a of the 'new l e g a l i s m ' i n the 1970's and 1980's). In a d d i t i o n , the e r a of the new l e g a l i s m has been c h a r a c t e r i z e d by c o n f l i c t between the p a t i e n t s ' r i g h t s movement, organized p s y c h i a t r y , and the s t a t e . T h i s c o n f l i c t i s shaping the content of new mental h e a l t h l e g i s l a t i o n and both groups have been r e s t r a i n e d by the s t a t e i n k e e p i n g w i t h i t s economic, order maintenance, and l e g i t i m a t i o n goals. The r o l e played by reformers and t h e i r r e l a t i o n s h i p with the s t a t e i s , t h e r e f o r e , a more complex is s u e which goes beyond the ' c o - o p t a t i o n ' t h e s i s o f f e r e d by S c u l l and S e d g w i c k . C e r t a i n l y , s t a t e policy-makers have supported the i n t r o d u c t i o n 525 of p a t i e n t s ' r i g h t s because they are both c o n s i s t e n t w i t h s t a t e g o a l s (e.g., d e c r e a s i n g h o s p i t a l p o p u l a t i o n s ) and p r o v i d e an humanitarian j u s t i f i c a t i o n f o r e c o n o m i c a l l y motivated s h i f t s i n p o l i c y ; however, t h i s does n o t mean t h a t t h o s e a d v o c a t i n g p a t i e n t s ' r i g h t s have been b l i n d to t h i s apparent abuse of t h e i r e f f o r t s to a c h i e v e a measure of j u s t i c e f o r m e n t a l h e a l t h p a t i e n t s . As Brown (1982) and Rubenstein (1986) p o i n t out, i n the United States ' s e r v i c e - o r i e n t e d ' advocates and l i b e r t a r i a n a d v o c a t e s are c o n v e r g i n g around the common g o a l of a t t a c k i n g s t a t e mental h e a l t h funding p o l i c i e s . S i m i l a r l y , i n Canada, those who oppose both the new l e g a l i s m and s t a t e economic r e s t r a i n t p o l i c i e s i n the h e a l t h c a r e s e c t o r ( i . e . , o r g a n i z e d p s y c h i a t r y and i t s a l l i e s ) have p r o t e s t e d the changes and a t t e m p t e d t o use t h e p a t i e n t s ' r i g h t s i s s u e t o p r o t e c t p r o f e s s i o n a l i n t e r e s t s ; notably, by pursuing a r i g h t to r e c e i v e t r e a t m e n t . In a d d i t i o n , the p a t i e n t s ' r i g h t s movement - an i n t e r e s t group with o b j e c t i v e s which are, c u r r e n t l y , g e n e r a l l y c o n s i s t e n t w i t h those of the s t a t e - has a t t e m p t e d to pursue reforms which are i n c o n s i s t e n t w i t h s t a t e goals; namely, the r i g h t to r e f u s e treatment. The s t a t e has consequently imposed r e s t r a i n t s and, while the ideas of the movement i n the area of law reform may have been 'co-opted' to achieve the s t a t e g o a l s of f a c i l i t a t i n g and l e g i t i m a t i n g a s h i f t i n the s t r a t e g y f o r the management of the mentally d i s o r d e r e d , the movement i t s e l f has g e n e r a l l y m a i n t a i n e d i t s autonomy. A l t h o u g h t h e r e a r e i n d i c a t i o n s t h a t one component of the movement - advocacy s e r v i c e s - may be a b s o r b e d i n t o the s t a t e a p p a r a t u s , o t h e r components (e.g., p a t i e n t s ' a s s o c i a t i o n s ) r e m a i n o u t s i d e the 526 s t a t e a p p a r a t u s . In a d d i t i o n , the a p p a r e n t ' c o - o p t a t i o n ' of a dvocacy s e r v i c e s i s a r e c e n t development and d i d not o c c u r during the r i s e of the new l e g a l i s m . The ' c o - o p t a t i o n ' t h e s i s i s , t h e r e f o r e , an i n a d e q u a t e a c c o u n t of the r e l a t i o n s h i p between the s t a t e and autonomous groups of r e f o r m e r s i n Canada, and t h i s f l a w a r i s e s from a weakness common to much of the work w i t h i n the s o c i o l o g y of s o c i a l c o n t r o l ; namely, a f a i l u r e to examine the nature and r o l e of the e n t i t y which c o n s t r u c t s and implements s o c i a l c o n t r o l s t r a t e g i e s - the c a p i t a l i s t s t a t e . A n a l y s t s such as S c u l l (1984) and Sedgwick (1982) have n e g l e c t e d to forge a strong l i n k w i t h the s o c i o l o g y of the s t a t e (see, a l s o , Warren, 1981; Cohen, 1985), d e s p i t e the connections between the two areas of a n a l y s i s (Ratner & McMullan, 1987), and t h i s r e s u l t s i n a neglect, of the complex d i a l e c t i c a l i n t e r p l a y between the development of s o c i a l c o n t r o l s t r a t e g i e s and other s t a t e i m p e r a t i v e s , as w e l l as the way i n which the s t a t e uses the human agency embodied i n reform movements i n order to f a c i l i t a t e and l e g i t i m a t e i t s p r a c t i c e s . I l l ; THE CONTRIBUTION TO AND IMPLICATIONS FOR NEO-MARXIST THEORY IN THE SOCIOLOGY OF THE STATE AND LAW The a n a l y s i s of the emergence of mental h e a l t h l e g i s l a t i o n c h a r a c t e r i z e d by 'enhanced m e d i c a l i z a t i o n ' , the subsequent r i s e of the 'new l e g a l i s m ' , and the r e l a t i o n s h i p between t h e s e r e f o r m s , c h a n g i n g s t a t e s o c i a l c o n t r o l s t r a t e g i e s , and the f a c t o r s underpinning these s h i f t s i n s t r a t e g y c o n t r i b u t e s to the growing body of theory and r e s e a r c h p e r t a i n i n g to the nature and r o l e o f t h e s t a t e i n Canada ( s e e , e.g., P a n i t c h , 1979; 527 Stevenson, 1983; Ratner & McMullan, 1987). The a n a l y s i s i s of p a r t i c u l a r i m p o r t a n c e f o r an u n d e r s t a n d i n g of the l a w - s t a t e r e l a t i o n and, t h e r e f o r e , a Canadian s o c i o l o g y of law informed by s t a t e t h e o r y . In a d d i t i o n , i t f o r g e s a l i n k between, and thereby c o n t r i b u t e s to a convergence of, the neo-Marxist s t a t e -law r e s e a r c h programme and the s o c i o l o g y of s o c i a l c o n t r o l . W h i l e a n a l y s t s r e c o g n i z e t h a t the C a n a d i a n s t a t e i s a m u l t i - d i m e n s i o n a l e n t i t y comprised of the two main l e v e l s of government - f e d e r a l and p r o v i n c i a l - and the a s s o c i a t e d government a p p a r a t u s (e.g., the b u r e a u c r a c y ) , i t may a l s o i n c l u d e other, l e s s obvious, components. Autonomous i n t e r e s t groups which l i e o u t s i d e the f o r m a l s t a t e a p p a r a t u s may be e i t h e r a b s o r b e d or h a r n e s s e d ( w h o l l y or p a r t l y ) where t h e i r r e f o r m o b j e c t i v e s r e s o n a t e w i t h t hose of the s t a t e . The b o u n d a r i e s of the s t a t e are f l e x i b l e and, w h i l e the c o r e ' i n s t i t u t i o n s ' may be permanent, o t h e r ' i n s t i t u t i o n s ' can be t e m p o r a r i l y added. An expansion of the boundaries of the s t a t e to encompass autonomous i n t e r e s t groups i s determined by the nature of the problems c o n f r o n t i n g the s t a t e at any given juncture. Both the f e d e r a l and the p r o v i n c i a l l e v e l s of the s t a t e are r e l a t i v e l y autonomous e n t i t i e s which occupy key p o s i t i o n s w i t h i n the s t r u c t u r e of c a p i t a l i s m . The autonomy of the f e d e r a l l e v e l of the s t a t e i s r e l a t i v e to the requirements of an i n t e r n a t i o n a l , c a p i t a l i s t economy as w e l l as the c o n s t i t u t i o n a l l y p r e s c r i b e d zones of r e s p o n s i b i l i t y awarded to the p r o v i n c e s ; f o r example, 528 the c o n s t r u c t i o n and o p e r a t i o n of a system f o r the management of the, m e n t a l l y d i s o r d e r e d . C o n v e r s e l y , the autonomy of the p r o v i n c i a l l e v e l of the s t a t e i s r e l a t i v e to the power of the f e d e r a l l e v e l of the s t a t e to d i c t a t e , f o r example, economic s t r a t e g y and to r e g u l a t e p r o v i n c i a l p r a c t i c e s t h r o u g h , i n p a r t i c u l a r , f i s c a l c o n t r o l s such as c o s t - s h a r i n g agreements i n t h e h e a l t h c a r e s e c t o r w h i c h a f f e c t s t r a t e g i e s f o r t h e management of the m e n t a l l y d i s o r d e r e d . In a d d i t i o n , the autonomy of b o t h l e v e l s of the s t a t e i s r e l a t i v e to (and necessary f o r the conduct of) t h e i r three, p o t e n t i a l l y c o n t r a -d i c t o r y , i m p e r a t i v e s or ' c a r d i n a l f u n c t i o n s ' w i t h i n the s t r u c t u r e of c a p i t a l i s m ; namely, r e p r o d u c i n g the c o n d i t i o n s n e c e s s a r y f o r c a p i t a l a c c u m u l a t i o n ; l e g i t i m a t i o n ; and, o r d e r maintenance, i n the i n t e r e s t s of c a p i t a l i s m as a whole (Ratner & McMullan, 1987). The l a s t of these ' c a r d i n a l f u n c t i o n s ' - order maintenance - i n v o l v e s the development and implementation of s o c i a l c o n t r o l s t r a t e g i e s f o r the management of ' s o c i a l d e v i a n t s ' (e.g., the m e n t a l l y d i s o r d e r e d ) and r e p r e s e n t s the p o i n t a t which a s o c i o l o g y of s o c i a l c o n t r o l i n t e r s e c t s with the s o c i o l o g y of the s t a t e . S o c i a l c o n t r o l s t r a t e g i e s should complement (i.e., not c o n t r a d i c t ) the other c a r d i n a l f u n c t i o n s and problems a r i s e f o r the s t a t e where s y n c h r o n i z a t i o n i s absent; f o r example, where a s o c i a l c o n t r o l s t r a t e g y begins to c o l l a p s e thereby a f f e c t i n g the other c a r d i n a l f u n c t i o n s . S i m i l a r l y , a l e g i t i m a t i o n problem or a problem w i t h the p r o d u c t i o n of the c o n d i t i o n s necessary f o r c a p i t a l accumulation may n e c e s s i t a t e a change i n s o c i a l c o n t r o l 529 s t r a t e g y ; f o r example, a s h i f t away from the use of d i s c r e d i t e d and over-crowded i n s t i t u t i o n s f o r segregated confinement, or a c c e l e r a t e d d e - i n s t i t u t i o n a l i z a t i o n and enhanced p r i v a t i z a t i o n i n order to c l o s e expensive, p u b l i c mental h o s p i t a l s . Where p r o b l e m s a r i s e i n s y n c h r o n i z i n g the c a r d i n a l f u n c t i o n s , the s t a t e w i l l employ a l l the means at i t s d i s p o s a l i n o r d e r to a c h i e v e an e f f e c t i v e b a l a n c e . S t a t e a c t i o n can i n v o l v e the use of autonomous i n t e r e s t groups which seek reforms c o n s i s t e n t w i t h s t a t e o b j e c t i v e s as w e l l as the use of law and components of the l e g a l a p p a r a t u s . As the a n a l y s i s of the management of the m e n t a l l y d i s o r d e r e d has d e m o n s t r a t e d , the s t a t e can use a l l three; that i s , i n t e r e s t groups, the law, and components of the l e g a l apparatus. The C.M.H.A. and t h e p a t i e n t s ' r i g h t s movement a r e examples of i n t e r e s t groups which have been used, p r i m a r i l y by the p r o v i n c i a l l e v e l of the s t a t e , i n order to f a c i l i t a t e and l e g i t i m a t e s h i f t s i n s o c i a l c o n t r o l s t r a t e g i e s a r i s i n g from s y n c h r o n i z a t i o n p r o b l e m s . In the case of the C.M.H.A., the o r g a n i z a t i o n was u t i l i z e d at a time when a s h i f t i n s t r a t e g y was necessary to r e s o l v e problems w i t h the e x i s t i n g system f o r the management of the mentally d i s o r d e r e d . The s t a t e faced not only a p r o b l e m of o r d e r maintenance ( i n r e l a t i o n to the m e n t a l l y disordered) but a l s o a problem of l e g i t i m a t i n g the p r e v a i l i n g s y s t e m , and the C.M.H.A. d e v e l o p e d a new s t r a t e g y (and new, supporting l e g i s l a t i o n ) which would r e s o l v e the problems. Since the s t r a t e g y was c o n s i s t e n t w i t h (and enhanced) b o t h the development of a welfare s t a t e , and the un d e r l y i n g , Keynesian 530 s t r a t e g y f o r the continued r e p r o d u c t i o n of c a p i t a l i s m , i t was adopted. By the 1970's, however, the s t a t e c o n f r o n t e d a p r o b l e m w i t h the p r o d u c t i o n of the c o n d i t i o n s n e c e s s a r y f o r c a p i t a l accumulation. The r e s o l u t i o n of t h i s problem - f i s c a l r e s t r a i n t and the adoption of a new economic s t r a t e g y - had an impact upon the p o l i t i c a l l y s e n s i t i v e h e a l t h care component of the w e l f a r e s t a t e and, t h e r e f o r e , the s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d , and a d i f f e r e n t i n t e r e s t group was u t i l i z e d i n o r d e r to b o t h f a c i l i t a t e and, e q u a l l y i m p o r t a n t l y , to l e g i t i m a t e a s h i f t i n s t r a t e g y . T h i s i n t e r e s t group - the p a t i e n t s ' r i g h t s movement - c o n s i s t e d of an amalgam of p a t i e n t s ' a s s o c i a t i o n s , l e g a l a i d lawyers, and c i v i l l i b e r t a r i a n s , and i t was one minor component of a g e n e r a l human r i g h t s and c i v i l l i b e r t i e s movement. The group sought to advance the i n t e r e s t s of d i s e n f r a n c h i s e d , m a r g i n a l , and s o c i a l l y - r e j e c t e d p e o p l e (i.e., mental h e a l t h p a t i e n t s ) and, d e s p i t e i t s d i s o r g a n i z e d and l o o s e l y - b o n d e d n a t u r e , i t was r e m a r k a b l y s u c c e s s f u l i n a c c o m p l i s h i n g many of i t s goals. The movement's o b j e c t i v e s i n the area of mental h e a l t h care and treatment (i.e., a d i m i n u t i o n of the 'medical model') were not embraced but i t s a s s o c i a t e d q u e s t f o r law r e f o r m s which e s t a b l i s h e d and p r o t e c t e d the fundamental r i g h t s and freedoms of p a t i e n t s were adopted, even though there was no widespread p u b l i c pressure f o r the s t a t e to do so. However, law reforms c h a r a c t e r i z e d by the new l e g a l i s m a r e i n h e r e n t l y j u s t i f i a b l e and they s e r v e d to f a c i l i t a t e and l e g i t i m a t e s t a t e p r a c t i c e s ( n o t a b l y , a r e d u c t i o n i n the 531 u t i l i z a t i o n of e x p e n s i v e h o s p i t a l s ) , d e f u s e the o p p o s i t i o n mounted by other i n t e r e s t groups which c h a l l e n g e d the l e g i t i m a c y of s t a t e a c t i o n s (notably, organized p s y c h i a t r y ) , and, thereby, a s s i s t e d the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . Autonomous i n t e r e s t groups may, t h e r e f o r e , be wholly or p a r t l y a b s o r b e d i n t o t h e f a b r i c o f t h e s t a t e ; t h a t i s , i n c o r p o r a t e d as an a u x i l i a r y p a r t of the s t a t e a p p a r a t u s or t e m p o r a r i l y embraced as " a l l i e s ' . Once t h i s o c c u r s , the i n t e r e s t g r o u p s may l o s e t h e i r i n d e p e n d e n c e and become r e l a t i v e l y autonomous components of the r e l a t i v e l y autonomous s t a t e . The success of a reform movement i s dependent l e s s upon i t s s t r e n g t h r e l a t i v e to o t h e r , o p p o s i n g i n t e r e s t groups and more upon the congruence between the o b j e c t i v e s of reformers and t h o s e of the s t a t e . Indeed, as the example of the p a t i e n t s ' r i g h t s movement demonstrates, even a s m a l l , d i s o r g a n i z e d , and l o o s e l y bonded amalgam of r e f o r m e r s who are opposed by a s t r o n g e r and more o r g a n i z e d i n t e r e s t group can a c h i e v e i t s o b j e c t i v e s . The extent to which t h i s occurs i s dependent upon the w i l l i n g n e s s of the s t a t e to embrace p r o p o s e d changes and t h i s w i l l i n g n e s s i s determined by the value of such reforms f o r the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . P a r a d o x i c a l l y , when reforms are of value an i n t e r e s t group w i l l be s u c c e s s f u l but, s i n c e i t w i l l be drawn t e m p o r a r i l y i n t o the s t a t e a p p a r a t u s , i t w i l l a l s o l o s e i t s a b s o l u t e autonomy. 532 W h i l e t h i s may appear to amount to ' c o - o p t a t i o n ' , i t i s e v i d e n t t h a t r e f o r m e r s are a b l e to s e c u r e some of t h e i r o b j e c t i v e s where these support, or do not i n t e r f e r e with, those of the s t a t e . A l i b e r a l democratic s t a t e that responds to the e f f o r t s of autonomous r e f o r m e r s i n a c o n c r e t e and o b s e r v a b l e manner w i l l enhance i t s l e g i t i m a c y , and the human agency embodied i n reform movements may be u t i l i z e d by the s t a t e i n o r d e r to a c c o m p l i s h t h i s and o t h e r o b j e c t i v e s . At the same time, reformers can engineer changes and the successes of the C.M.H.A. p r o v i d e an e x a m p l e o f t h e e x t e n t t o w h i c h an o r g a n i z a t i o n ' s o b j e c t i v e s can be accomplished. The A s s o c i a t i o n was a b l e to advance the i n t e r e s t s of p s y c h i a t r y (and mental h e a l t h p a t i e n t s ) d u r i n g the 1950's and 1960's by r e s u r r e c t i n g c h e r i s h e d but dormant ideas, s e c u r i n g i n t e g r a t i o n w i t h the r e s t of the h e a l t h care system, and entrenching medical domination over the management of the mentally d i s o r d e r e d . S i m i l a r l y , the p a t i e n t s ' r i g h t s movement has been s u c c e s s f u l i n the p u r s u i t of law reforms which e s t a b l i s h fundamental r i g h t s and freedoms f o r p a t i e n t s and erode medical domination. Some of the o b j e c t i v e s of an i n t e r e s t group may a l s o be accomplished where i t i s comprised of i n d i v i d u a l s w i t h i n , or on the p e r i p h e r y of, the s t a t e apparatus, who play a c r i t i c a l r o l e i n the implementation of s t a t e p o l i c i e s ; f o r example, a s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d . By v i r t u e of t h e i r s t r a t e g i c p o s i t i o n , these i n d i v i d u a l s can c r e a t e problems f o r the s t a t e . For example, c o n s e r v a t i v e , s t a t e mental h e a l t h personnel may ' r e v o l t ' a g a i n s t new l e g i s l a t i o n which both l i m i t s 533 the use of f a c i l i t i e s and e r o d e s the e x t e n t to which they dominate the management of p a t i e n t s , and t h i s may threaten the p r a c t i c a l a p p l i c a t i o n o f s t a t e p o l i c i e s . S i m i l a r l y , a p r o f e s s i o n a l body r e p r e s e n t i n g key personnel (e.g., organized p s y c h i a t r y ) can p u b l i c l y c h a l l e n g e s t a t e economic r e s t r a i n t p o l i c i e s i n the h e a l t h care s e c t o r , thereby r a i s i n g l e g i t i m a t i o n problems. In both i n s t a n c e s , goals may be secured as the s t a t e appeases the i n t e r e s t groups i n order to a v o i d problems of order maintenance and l e g i t i m a t i o n . Although reformers and c o n s e r v a t i v e i n t e r e s t groups may achieve some of t h e i r o b j e c t i v e s i t i s , n e v e r t h e l e s s , apparent that the s t a t e w i l l make every e f f o r t to ensure that these do not h i n d e r the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . O b j e c t i v e s may be e i t h e r embraced e n t h u s i a s t i c a l l y or accepted as t o l e r a b l e , and reformers may be enabled by the s t a t e t o t h e e x t e n t t h a t t h e i r g o a l s s u p p o r t o r do n o t c o n t r a d i c t those of the s t a t e . On the other hand, o b j e c t i v e s may be i g n o r e d and r e j e c t e d and the s t a t e may a t t e m p t to r e s t r a i n the a c t i v i t i e s of reformers or opposing i n t e r e s t groups once they exceed the bounds of the t o l e r a b l e . The p a t i e n t s ' r i g h t s movement, f o r example, has not been allowed to achieve a l l i t s o b j e c t i v e s i n the area of law reform (e.g., the r i g h t to r e f u s e t r e a t m e n t ) and, once the p u r s u i t of r e f o r m s c r e a t e d problems f o r economic r e s t r a i n t p o l i c i e s and order maintenance t h e s t a t e c u r b e d i t s a c t i v i t i e s . S i m i l a r l y , o r g a n i z e d p s y c h i a t r y has been r e s t r a i n e d by the s t a t e i n i t s p u r s u i t of a r i g h t to r e c e i v e t r e a t m e n t f o r p a t i e n t s and t h i s measure was 534 necessary i n order to p r o t e c t economic r e s t r a i n t p o l i c i e s . At the same time, the s t a t e must take care to ensure that l i m i t i n g measures do not c r e a t e , f o r example, a problem of l e g i t i m a t i o n and, as d i f f i c u l t i e s emerge, the s t a t e may j u s t i f y i t s a c t i o n s by r e f e r e n c e to the c o n c e r n s of a n o t h e r i n t e r e s t group. For example, t h e . l i m i t s placed upon p a t i e n t s ' r i g h t s advocates can be j u s t i f i e d by r e f e r e n c e t o t h e c o n c e r n s o f o r g a n i z e d p s y c h i a t r y f o r the p r o v i s i o n of c a r e and t r e a t m e n t t h a t w i l l r e s t o r e a p a t i e n t ' s m e n t a l h e a l t h . The p a r a m e t e r s o f a c c e p t a b i l i t y are d e t e r m i n e d by the s t a t e ' s o v e r - a r c h i n g o b j e c t i v e s i n regard to the e x e r c i s e and s y n c h r o n i z a t i o n of i t s s t r u c t u r a l l y determined, c a r d i n a l f u n c t i o n s and i t i s the l a t t e r which w i l l d i c t a t e the extent to which r e f o r m e r s e i t h e r succeed or f a i l . It i s i n t h i s sense that the human agency embodied i n the a c t i v i t i e s of reformers and c o n s e r v a t i v e i n t e r e s t groups i s l i m i t e d by s t r u c t u r a l c o n s i d e r a t i o n s . The s t a t e w i l l a l s o u t i l i z e law and components of the l e g a l a p p a r a t u s i n o r d e r to e x e r c i s e and s y n c h r o n i z e i t s c a r d i n a l f u n c t i o n s and new l a w s o r l a w r e f o r m s may, consequently, emerge; f o r example, mental h e a l t h l e g i s l a t i o n c h a r a c t e r i z e d by enhanced m e d i c a l i z a t i o n or the new l e g a l i s m . Law i s the medium through which'fstate p o l i c i e s and p r a c t i c e s are t r a n s m i t t e d , enforced and mediated, and i t i s used to organize and r e g u l a t e a c t i v i t i e s w i t h i n the s t a t e a p p a r a t u s (e.g., a mental h e a l t h system). Components of the l e g a l apparatus such as advocates, q u a s i - j u d i c i a l bodies, and the j u d i c i a r y , e x e r c i s e an autonomy r e l a t i v e to the l e g i s l a t i o n c o n s t r u c t e d by the s t a t e 535 i n order to achieve i t s o b j e c t i v e s at a given juncture; that i s , the i n v o l v e m e n t and a c t i v i t i e s of components of the l e g a l apparatus are s u b j e c t to, and may be c r e a t e d by, an o v e r r i d i n g body of law c o n s t r u c t e d by the s t a t e . The s t a t e used the medium of law reform d u r i n g the 1960's in order to f a c i l i t a t e a new s t r a t e g y f o r the management of the mentally d i s o r d e r e d , and there was a corresponding r e d u c t i o n i n the use of components of the l e g a l a p p a r a t u s ( i . e . , the j u d i c i a r y ) t o r e g u l a t e t h e p r a c t i c e s o f p h y s i c i a n s . A s u b s e q uent s h i f t i n s t r a t e g y was accompanied by law r e f o r m s which r e s t o r e d a s u p e r v i s o r y r o l e f o r components of the l e g a l a p p a r a t u s , and c r e a t e d new components f o r t h i s p u r pose ( i . e . , advocacy s e r v i c e s and q u a s i - j u d i c i a l review boards), and t h i s was accomplished through the u t i l i z a t i o n of a key l e g a l concept; namely, f u n d a m e n t a l human, c i v i l and l e g a l r i g h t s . P a t i e n t s were r e - d e f i n e d as ' j u r i d i c a l s u b j e c t s ' and, w h i l e t h i s a c t i o n may be v i e w e d as an e x t e n s i o n of the s u b s i d i a r y r e f o r m s i n t r o d u c e d i n the 1960's when p a t i e n t s were i n v e s t e d w i t h ' r i g h t s ' i n regard to the management of t h e i r e s t a t e s i n order to b u t t r e s s the g o a l of i n t e g r a t i o n , p a t i e n t s ' r i g h t s were employed f o r d i f f e r e n t purposes i n the 1970's and 1980's. The a n a l y s i s of the use of p a t i e n t s ' r i g h t s to implement and l e g i t i m a t e a s t a t e s o c i a l c o n t r o l s t r a t e g y p r o p e l l e d by economic c o n s i d e r a t i o n s i n t e r s e c t s with a s i g n i f i c a n t debate w i t h i n the s o c i o l o g y of law. As Sumner (1981) has p o i n t e d out, the i s s u e s of reformism and r i g h t s have a t t r a c t e d the a t t e n t i o n of two opposing f a c t i o n s . For some a n a l y s t s (e.g., A l t h u s s e r , 536 P o u l a n t z a s , Di'amond, and Bankowski & Mungham), ' r i g h t s ' a r e merely bourgeois l e g a l concepts which always serve to support the s t a t e and c a p i t a l i s m . They a t o m i z e a s o c i e t y and t h i s m e r e l y r e i n f o r c e s b o u r g e o i s i n d i v i d u a l i s m w h ich, i n t u r n , undermines c l a s s s t r u g g l e . According to t h i s view, r i g h t s are m e r e l y i d e o l o g i c a l f i c t i o n s w h ich do l i t t l e to a f f e c t the p e r s i s t e n t s o c i a l i n e q u a l i t i e s embodied i n c a p i t a l i s m ; indeed, they p r o t e c t the s t a t u s quo by c h a n n e l l i n g c l a s s c o n f l i c t s along 'acceptable' l e g a l avenues. Reformism and the p u r s u i t of r i g h t s m e r e l y smooth out c o n f l i c t s and, s i n c e t h o se s e e k i n g r e f o r m through and w i t h i n the e x i s t i n g l e g a l framework are o f t e n co-o p t e d by t h e s t a t e , t h e y do l i t t l e t o c h a n g e b o t h th e e s s e n t i a l l y bourgeois l e g a l form and the c a p i t a l i s t s o c i a l and economic order. Sumner (1981) notes that t h i s p e r s p e c t i v e i s c r i t i c i z e d by other a n a l y s t s (e.g., Thompson, H i r s t , Cain & Hunt, Trubek, and Young) who argue that both r i g h t s and the p u r s u i t of reform are a s p e c t s of a c o n t r a d i c t o r y , r e l a t i v e l y autonomous l e g a l form which can be u s e f u l l y employed i n s t r u g g l e s w i t h the c a p i t a l i s t s t a t e . A l t h o u g h r e f o r m e r s a l w a y s s t a n d i n the shadow of c o -o p t a t i o n , c o n t r a d i c t i o n s can be e x p l o i t e d and reforms can r e s u l t i n genuine m a t e r i a l gains, e s p e c i a l l y f o r the ' r i g h t - l e s s ' . The p u r s u i t of r i g h t s and o t h e r r e f o r m s can a l l e v i a t e s u f f e r i n g , a m p l i f y c l a s s s t r u g g l e s , and c o n f r o n t and expose the l i m i t s of s t a t e power; indeed, reform i s viewed as an i n t e g r a l p a r t of the p o l i t i c a l s t r u g g l e of a c l a s s or c l a s s f a c t i o n which can pave the way f o r g e n uine s o c i a l and economic t r a n s f o r m a t i o n s . 537 C e r t a i n l y , the a c t i v i t i e s of reformers can be undermined and, s i n c e c a p i t a l i s m i s adaptive, those who pursue " r i g h t s ' must be both v i g i l a n t and c o n s t a n t l y aware of the need to ensure that t r a n s f o r m a t i o n s a c t u a l l y o c c u r (e.g., changes i n the s o c i a l r e l a t i o n s of c a p i t a l i s m ) , o n c e l e g a l r e f o r m s have been accomplished. The a n a l y s i s of the changes i n C a n adian m ental h e a l t h l e g i s l a t i o n demonstrates that the concept of r i g h t s i s an aspect of the l e g a l form which i s employed by the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . As De Sousa Santos (1980) has argued, the s t a t e uses t h i s type of law reform i n order to r e s o l v e f i s c a l , l e g i t i m a t i o n or order c r i s e s . The s t a t e i s s e l e c t i v e i n i t s adoption and entrenchment of r i g h t s (e.g., an u n l i m i t e d r i g h t to r e c e i v e / r e f u s e treatment has not been endorsed) and i t i s apparent that only those r i g h t s which e i t h e r complement or do not h i n d e r s t a t e o b j e c t i v e s , w i l l be deemed acceptable. At the same t i m e , however, law embodies c o n t r a d i c t i o n s which can f r u s t r a t e s t a t e p r a c t i c e s and t h i s i s the case where the concept of r i g h t s i s u t i l i z e d . While the autonomy of law i s r e l a t i v e to the i n t e r e s t s of the e n t i t y which c r e a t e s i t (i.e., the s tate) an image of absolute autonomy must be maintained i n order to ensure l e g i t i m a t i o n , and t h i s i s accomplished through the n o t i o n s of, i n p a r t i c u l a r , the r u l e of law, l e g a l f o r m a l i s m , and fundamental r i g h t s and freedoms b u t t r e s s e d by c o n s t i t u t i o n a l instruments such as the Canadian Charter of Rights and Freedoms. 538 Law i s p o r t r a y e d as a r e i f i e d and u n i v e r s a l l y a p p l i c a b l e body of r u l e s and, i n order to maintain l e g i t i m a c y , the s t a t e i s o b l i g e d to comply w i t h the ' r u l e s ' i t c r e a t e s ; f o r example, i t must re s p e c t r i g h t s which p r o t e c t j u r i d i c a l s u b j e c t s from the s t a t e . W h i l e the r u l e s may be changed by the s t a t e a c c o r d i n g to i t s i n t e r e s t s (e.g., the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s ) , t h i s r e q u i r e s j u s t i f i c a t i o n and, once the s t a t e has chosen to i n t r o d u c e laws w h i c h e n t r e n c h i n h e r e n t l y j u s t i f i a b l e , fundamental r i g h t s and freedoms, both changes to and breaches of these laws w i l l be d i f f i c u l t to j u s t i f y ; indeed, a c t i o n s of t h i s kind could p r e c i p i t a t e a l e g i t i m a t i o n c r i s i s . The state's use of r i g h t s as the mechanism wit h which to r e s o l v e p r o b l e m s a s s o c i a t e d w i t h t h e e x e r c i s e a n d s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s i n v o l v e s , t h e r e f o r e , a c o n t r a d i c t o r y l e g a l e n t i t y which can, and has, c r e a t e d f u r t h e r d i f f i c u l t i e s . The s t a t e i s o b l i g e d to observe the r i g h t s i t has e s t a b l i s h e d ( p a r t i c u l a r l y , s i n c e the advent of the Charter) and, while these are necessary i n order to r e g u l a t e a c t i v i t i e s w i t h i n i t s own a p p a r a t u s i n a c c o r d a n c e w i t h , f o r example, economic goals, they a l s o p l a c e the s t a t e i n a v u l n e r a b l e p o s i t i o n . As t h e e x a m p l e o f o r g a n i z e d p s y c h i a t r y (and i t s a l l i e s ) d e m o n s t r a t e s , a s h r e w d i n t e r e s t g r o u p c a n u t i l i z e t h e c o n t r a d i c t i o n s embodied i n the n o t i o n of r i g h t s by expressing i t s o b j e c t i v e s i n terms of r i g h t s which are i n c o n s i s t e n t w i t h s t a t e g o a l s ; n o t a b l y , t h e r i g h t t o r e c e i v e t r e a t m e n t . S i m i l a r l y , the p a t i e n t s ' r i g h t s movement has p u r s u e d a n o t h e r ' i n c o n s i s t e n t ' r i g h t ; namely, the r i g h t to r e f u s e treatment. 539 Both s i t u a t i o n s have i m p e l l e d the s t a t e to i n t r o d u c e a m e l i o r a t i v e counter measures which l i m i t r i g h t s , puncture the l i b e r t a r i a n and humanitarian screen which conceals the economic c o n s i d e r a t i o n s u n d e r l y i n g the s t a t e ' s a c t i ons, and t h e r e b y cre a t e p o t e n t i a l l e g i t i m a t i o n problems. The counter measures a l s o demonstrate the steps which w i l l be taken by the s t a t e to deal w i t h c o n t r a d i c t i o n s . The law may be c o n s t r u c t e d or changed i n a way t h a t l i m i t s or n e g a t e s the i m p a c t of i n c o n s i s t e n t r i g h t s , and e f f o r t s may be made to c o n t r o l troublesome groups (e.g., a g g r e s s i v e , p a r t i s a n a d v o c a t e s ) by a b s o r b i n g them i n t o the s t a t e apparatus. The measures may be s u c c e s s f u l i n curbing the a c t i v i t i e s of those who pose c h a l l e n g e s on the b a s i s of r i g h t s and may even enhance the l e g i t i m a c y of the s t a t e ; f o r example, the c r e a t i o n of s t a t e - c o n t r o l l e d p a t i e n t s ' a dvocacy a p p e a r s to s u p p o r t , r a t h e r than r e s t r a i n , the p r o t e c t i o n and advancement of r i g h t s . However, the s i t u a t i o n i s unstable and h i g h l i g h t s both the l i m i t s of law reform f o r the s t a t e and the p o t e n t i a l which e x i s t s f o r reformism that i n v o l v e s the p u r s u i t of r i g h t s . In summary, the r e l a t i v e l y autonomous s t a t e ( p a r t i c u l a r l y , at the p r o v i n c i a l l e v e l ) w i l l expand i t s boundaries to encompass o s t e n s i b l y autonomous i n t e r e s t g roups i n o r d e r to r e s o l v e problems a r i s i n g from the e x e r c i s e and s y n c h r o n i z a t i o n of i t s s t r u c t u r a l l y determined and p o t e n t i a l l y c o n t r a d i c t o r y , c a r d i n a l f u n c t i o n s . The o b j e c t i v e s of i n t e r e s t groups may i n c l u d e the p u r s u i t of law reforms and, i f these reforms f a c i l i t a t e and/or l e g i t i m a t e s t a t e o b j e c t i v e s , they w i l l be i n t r o d u c e d . The 540 s t a t e w i l l u t i l i z e a r e l a t i v e l y autonomous a s p e c t of i t s own apparatus (i.e., law and components of the l e g a l apparatus) i n order to e x e r c i s e and synchronize i t s c a r d i n a l f u n c t i o n s but, s i n c e t h i s embodies a f u r t h e r s e t of c o n t r a d i c t i o n s , new d i f f i c u l t i e s may be created which r e q u i r e a m e l i o r a t i v e a c t i o n . This i s the case p a r t i c u l a r l y where favoured law reforms i n v o l v e a r e c o g n i t i o n and e n t r e n c h m e n t of i n h e r e n t l y j u s t i f i a b l e , fundamental r i g h t s and freedoms; a l e g a l concept which embodies a d d i t i o n a l c o n t r a d i c t i o n s . The n o t i o n of r i g h t s may be employed by i n t e r e s t groups opposed to s t a t e a c t i o n s and t h i s c r e a t e s a complex and u n s t a b l e s i t u a t i o n f o r the s t a t e as i t seeks to e x e r c i s e and synchronize i t s c a r d i n a l f u n c t i o n s , i n the i n t e r e s t of c a p i t a l i s m as a whole. W h i l e the f o r e g o i n g a n a l y s i s of s t a t e s t r a t e g i e s and l e g i s l a t i o n a f f e c t i n g the management of the m entally d i s o r d e r e d i s an i n s t a n c e study which c o n t r i b u t e s to neo-Marxist t h e o r i z i n g i n the s o c i o l o g y of the s t a t e and law i n Canada, i t has i m p l i c a t i o n s f o r the n e o - M a r x i s t r e s e a r c h programme. The emergence of laws a f f e c t i n g the management of s o c i a l d e v i a n t s cannot be u n d e r s t o o d w i t h o u t an a n a l y s i s of the a s s o c i a t e d s h i f t s i n s o c i a l c o n t r o l s t r a t e g i e s and the reasons f o r these s h i f t s . S o c i a l c o n t r o l s t r a t e g i e s cannot be f u l l y understood w i t h o u t r e f e r e n c e t o t h e s t a t e and i t s p o t e n t i a l l y c o n t r a d i c t o r y , c a r d i n a l f u n c t i o n s w i t h i n the s t r u c t u r e of c a p i t a l i s m . At the same time, s t a t e p r a c t i c e s i n the f i e l d of order maintenance extend beyond the narrow c o n f i n e s of c r i m i n a l j u s t i c e and cannot be understood without a f u l l a p p r e c i a t i o n of 541 the complete and d i v e r s e spectrum of s o c i a l c o n t r o l . Indeed, the a n a l y s i s p o i n t s to the importance of a convergence of three s o c i o l o g i e s ( s t a t e , law, and s o c i a l c o n t r o l ) , the value of an i n t e g r a t i o n of the a s s o c i a t e d bodies of research, and, the need to extend the neo-Marxist t h e o r e t i c a l t r a j e c t o r y i n t o new f i e l d s i n o r d e r to s e c u r e a f u l l u n d e r s t a n d i n g of the s t a t e and the s t a t e - l a w r e l a t i o n . A convergence w i l l , however, have i m p l i c a t i o n s f o r the n e o - M a r x i s t programme. On the one hand, the f i n d i n g s of r e s e a r c h i n s o c i a l c o n t r o l w i l l provide new e m p i r i c a l m a t e r i a l f o r t h e o r i s t s . The s o c i o l o g y of s o c i a l c o n t r o l has produced, and i s p r o d u c i n g , a r i c h and d i v e r s e h a r v e s t t h a t i n c l u d e s : r e v i s i o n i s t h i s t o r i e s w hich l i n k m a t e r i a l , i d e a t i o n a l and p o l i t i c a l f a c t o r s to changing s o c i a l c o n t r o l systems (see, e.g., S c u l l , 1979; Rothman, 1971; I g n a t i e f f , 1978); F o u c a u l d i a n analyses of changing s o c i a l c o n t r o l systems and s t r a t e g i e s (see, e.g., Cohen, 1985); e x p l o r a t i o n s of c o n t e m p o r a r y s h i f t s i n s o c i a l c o n t r o l p r a c t i c e s (see, e.g., S c u l l , 1984; Warren, 1981; Lerman, 1982); and, examinations of the a c t i v i t i e s of those who manage d e v i a n t s (see, e.g., T e p l i n , 1984). On the other hand, n e o - M a r x i s t t h e o r i s t s w i l l have to e x p l o r e new f i e l d s and a c c o u n t f o r the complex and c o n t r a d i c t o r y p r a c t i c e s i n the e n t i r e area of order maintenance. As t h i s a n a l y s i s of the mental h e a l t h area demonstrates, at l e a s t three consequences can be i d e n t i f i e d . F i r s t l y , i t w i l l be n e c e s s a r y f o r n e o - M a r x i s t t h e o r i s t s to adopt a b r o a d e r conception of s o c i a l c o n t r o l systems and networks, and explore 542 and e x p l a i n t h e ' m a s t e r p a t t e r n s ' a f f e c t i n g t h e f i e l d . S e c o n d l y , t h e o r i s t s w i l l be r e q u i r e d to a c c o u n t f o r one p a r t i c u l a r aspect of the contemporary master p a t t e r n ; namely, the c h a n g i n g o w n e r s h i p o f the s o c i a l c o n t r o l a p p a r a t u s . T h i r d l y , a broader conception of s o c i a l c o n t r o l w i l l r e q u i r e a wider and i n t e g r a t e d a n a l y s i s of the r o l e of law and components of the l e g a l apparatus i n f a c i l i t a t i n g and/or l e g i t i m a t i n g a l l s o c i a l c o n t r o l s t r a t e g i e s . One of the v i r t u e s of the s o c i o l o g y of s o c i a l c o n t r o l l i e s i n i t s s i n g u l a r focus upon the order maintenance f u n c t i o n of the s t a t e and, w h i l e a n a l y s t s have g e n e r a l l y n e g l e c t e d to forge a s t r o n g l i n k w i t h the work of s t a t e t h e o r i s t s , they have generated an h i s t o r i c a l l y informed image of s t a t e s o c i a l c o n t r o l s y s tems as c o m p r e h e n s i v e and i n t e g r a t e d s e t s of r e l a t i v e l y autonomous sub-systems, each with a primary r e s p o n s i b i l i t y f o r the management of d i f f e r e n t c a t e g o r i e s of ' s o c i a l dynamite' and ' s o c i a l junk'. As Cohen (1985) suggests, these sub-systems can be v i e w e d as p a r t s of a s o c i a l c o n t r o l 'net' w hich has become wider and denser, and assumed a d i f f e r e n t form, as a r e s u l t of both the e x i g e n c i e s of domestic p a c i f i c a t i o n and the unexpected consequences of ' d e - s t r u c t u r i n g ' r e f o r m s . W h i l e n e o - M a r x i s t t h e o r i s t s have analysed the order maintenance f u n c t i o n of the s t a t e , the p r i m a r y f o c u s has been upon the q u i n t e s s e n t i a l component of the s o c i a l c o n t r o l net and a s s o c i a t e d s t r a t e g i e s ; namely, c r i m i n a l j u s t i c e . I t i s evident, however, that order maintenance encompasses much more. There are other components and s t r a t e g i e s f o r the management of ' s o c i a l d e v i a n t s ' that are 543 c o n s t r u c t e d and i m p l e m e n t e d by the s t a t e and which, l i k e c r i m i n a l j u s t i c e , cannot be a n a l y s e d i n i s o l a t i o n . F u r t h e r , some of these components d i s p l a y a benign, r a t h e r than c o e r c i v e , face and play a dual and p o t e n t i a l l y c o n t r a d i c t o r y r o l e i n the management process. The s o c i a l c o n t r o l net i s c o m p r i s e d of a t l e a s t t h r e e components - c r i m i n a l j u s t i c e , mental h e a l t h , and s o c i a l w e l f a r e - a n d t h e s e i n v o l v e b o t h o v e r t l y c o e r c i v e and more s u b t l e methods of s o c i a l c o n t r o l . 1 The m e n t a l h e a l t h and s o c i a l w e l f a r e components d i s p l a y a predominantly benign face and r e l y p r i m a r i l y upon n o n - c o e r c i v e means; n o t a b l y , the c a r e and treatment of those who are ' i l l ' , and f i n a n c i a l and other forms of mediation and p a c i f i c a t i o n , r e s p e c t i v e l y . They play a dual and p o t e n t i a l l y c o n t r a d i c t o r y r o l e ; f o r example, the m e n t al h e a l t h component i n v o l v e s apprehension and confinement f o r 'care and treatment', r a t h e r than containment and punishment, but the l i n e between the two a c t i v i t i e s i s both f i n e and the o b j e c t of p u b l i c c o n troversy. S i m i l a r l y , the s o c i a l w e l f a r e component i n v o l v e s t h e p r o v i s i o n o f d i r e c t a s s i s t a n c e f o r t h e d i s a d v a n t a g e d but i s a l s o a means whereby s u r p l u s l a b o u r and o t h e r p o t e n t i a l l y t r o u b l e s o m e groups can be r e g u l a t e d and p a c i f i e d (see, e.g., Gough, 1979). S o c i o l o g i s t s of s o c i a l c o n t r o l have d e s c r i b e d and analysed the contemporary t r a n s f o r m a t i o n s a f f e c t i n g these components, d e m o n s t r a t e d the ways i n which the components exchange, and s h a r e i n the management o f , ' c l i e n t s ' , and, i d e n t i f i e d the 544 s h i f t s i n emphasis which o c c u r at d i f f e r e n t j u n c t u r e s (see, e.g., T e p l i n , 1984; Lerman, 1982; Cohen, 1985). The s t a t e appears to e x h i b i t a p r e f e r e n c e f o r the use of one component of the net at c e r t a i n times and t h i s then c o n s t i t u t e s the core of an o r d e r m a i n t e n a n c e s t r a t e g y , w i t h the o t h e r components a s s u m i n g a l e s s dominant r o l e . As Cohen (1985) a r g u e s , t r a n s f o r m a t i o n s i n s o c i a l c o n t r o l s y s t e m s and s t r a t e g i e s transcend the boundaries of the components of the net and can be a r r a n g e d i n t o 'master p a t t e r n s ' , and the p r o c e s s e s of s o c i a l c o n t r o l can o n l y be f u l l y u n d e r s t o o d by r e f e r e n c e to t h e s e p a t t e r n s . Evidence of s h i f t i n g p r e f e r e n c e s and master p a t t e r n s has been uncovered i n the a n a l y s i s of the management of the m e n t a l l y d i s o r d e r e d i n Canada. The r e s p o n s i b i l i t y f o r the management of those deemed to be mentally i l l has g r a d u a l l y s h i f t e d from the mental h e a l t h component to the s o c i a l w e l f a r e component and t h i s process began i n the l a t e 1950's when d e - i n s t i t u t i o n a l i z a t i o n and community care and treatment were adopted as the p r e f e r r e d c o n t r o l s t r a t e g y . Personnel from both components shared i n the management of p a t i e n t s , and the t r a n s f e r of r e s p o n s i b i l i t y has been o c c u r r i n g s t e a d i l y s i n c e t h a t t i m e ; i n d e e d , i t may be argued t h a t the c l o s u r e of p u b l i c m e n t a l h o s p i t a l s s i g n a l s a completion of the process. R e s p o n s i b i l i t y f o r the management of those deemed t o be m e n t a l l y r e t a r d e d was a l s o g r a d u a l l y t r a n s f e r r e d to the s o c i a l w e l f a r e component and t h i s process was c o m p l e t e d d u r i n g the 1970's. O v e r a l l , the m e n t al h e a l t h component of the s o c i a l c o n t r o l net may be s h r i n k i n g i n s i z e and 545 i m p o r t a n c e b u t t h i s c l a i m r e q u i r e s f u r t h e r e m p i r i c a l o i n v e s t i g a t i o n . In short, f o r neo-Marxist t h e o r i s t s , a convergence with the s o c i o l o g y of s o c i a l c o n t r o l w i l l r e q u i r e an examination of the system of order maintenance as a comprehensive, i n t e g r a t e d , complex, and c h a n g i n g ' s o c i a l c o n t r o l net' c o m p r i s e d of b o t h o v e r t l y c o e r c i v e and o s t e n s i b l y b e n i g n but c o n t r a d i c t o r y components. State p r a c t i c e s i n the s o c i a l c o n t r o l f i e l d f o l l o w 'master p a t t e r n s ' and t h e o r i s t s w i l l be r e q u i r e d to explore the r e l a t i o n s h i p between the emergence of these p a t t e r n s and, f o r example, the c h a n g i n g c o n d i t i o n s which a f f e c t the s t a t e ' s e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . Order m a i n t e n a n c e i s o n l y one c a r d i n a l f u n c t i o n and cannot be understood without r e f e r e n c e to the o t h e r s , and the l a t t e r may e x p l a i n master p a t t e r n s which i n v o l v e , f o r example, the adoption of a s t r a t e g y i n which the o s t e n s i b l y b e n i g n s o c i a l w e l f a r e component dominates. One a s p e c t of the c o n t e m p o r a r y m a s t e r p a t t e r n - the changing ownership of resources and f a c i l i t i e s w i t h i n the s o c i a l c o n t r o l n e t - p r e s e n t s a p a r t i c u l a r l y i n t e r e s t i n g and p o t e n t i a l l y f r u i t f u l f i e l d o f a n a l y s i s f o r n e o - M a r x i s t t h e o r i z i n g . As the t h e s i s has demonstrated, both the process of ' p r i v a t i z a t i o n ' and a ' c o m m o d i f i c a t i o n ' o f t h e m e n t a l l y d i s o r d e r e d are not new phenomena; p r i v a t e asylums e x i s t e d at the t u r n of the c e n t u r y and p r i v a t e s e c t o r i n v o l v e m e n t i n the p r o v i s i o n of community based resources began i n the l a t e 1950's. However, t h e i r c u r r e n t enhancement i n the form of a 'new trade 546 i n lunacy', dominated by ' s o c i a l c o n t r o l entrepreneurs' ( S c u l l , 1981), and f a c i l i t a t e d by the s t a t e , has to be e x p l o r e d and e x p l a i n e d . P r i v a t i z a t i o n and c ommodification are p o t e n t i a l l y c o n t r a -d i c t o r y t a c t i c s f o r the s t a t e s i n c e they i n v o l v e the t r a n s f e r of r e s p o n s i b i l i t y f o r the management of s o c i a l d e v i a n t s to the p r i v a t e s e c t o r . The s t a t e appears, t h e r e f o r e , to be r e l i n q u i s h -i n g c o n t r o l and c e a s i n g to take a d i r e c t i n t e r e s t i n o r d e r m aintenance. D e s p i t e b o t h the p o s s i b i l i t y t h a t t h i s p r o c e s s could c r e a t e a c r i s i s of order (e.g., p r i v a t e systems may not be as e f f e c t i v e as p u b l i c systems), and the emergence of o p p o s i t i o n which c h a l l e n g e s s t a t e l e g i t i m a t i o n , the t r a n s f e r of ownership i s c o n t i n u i n g . Indeed, i t i s a f f e c t i n g the q u i n t e s s e n t i a l c o n t r o l system - c r i m i n a l j u s t i c e (Cohen, 1985). These i s s u e s r a i s e q u e s t i o n s about the adequacy of a s t r u c t u r a l i s t i n t e r p r e t -a t i o n which v i e w s each of the s t a t e ' s c a r d i n a l f u n c t i o n s as e q u a l l y i m p o r t a n t and r e q u i r i n g s y n c h r o n i z a t i o n . I t may be argued, f o r example, t h a t the a c c u m u l a t i o n f u n c t i o n i s the dominant c o n s i d e r a t i o n and t h a t the m aintenance of o r d e r and l e g i t i m a t i o n are important but s u b s i d i a r y f a c t o r s f o r the s t a t e . P r i v a t i z a t i o n and c o m m e r c i a l i z a t i o n a i d accumulation by c r e a t i n g a new i n d u s t r y , markets, and commodities from which a p r o f i t can be e x t r a c t e d and the process may be b e t t e r e x p l a i n e d through a s t r u c t u r a l i s t a n a l y s i s t h a t e m p h a s i z e s and e x p l o r e s the c o n t r a d i c t i o n s and problems i n the c a p i t a l i s t economy which have had an adverse impact upon the process and r a t e of accumulation. 547 In t h i s r e g a r d , p r i v a t i z a t i o n may be e x p l a i n e d by the c a p i t a l - l o g i c p e r s p e c t i v e w i t h i n s t r u c t u r a l Marxism. In b r i e f , these t h e o r i s t s argue that the c a p i t a l i s t s t a t e i s an i n t e g r a l p a r t of the process of accumulation and that the form, f u n c t i o n and a c t i v i t i e s of the s t a t e r e f l e c t and reproduce both the l o g i c and the c o n t r a d i c t i o n s of c a p i t a l i s m . The s t a t e s e c u r e s the c o n d i t i o n s necessary f o r c a p i t a l accumulation a c c o r d i n g to the c h a n g i n g l o g i c of the p r e v a i l i n g p o l i t i c a l economy, and the 'contemporary moment' - monopoly c a p i t a l i s m - has experienced a d e c l i n i n g r a t e of p r o f i t and a c r i s i s of a c c u m u l a t i o n which r e q u i r e s s t a t e i n t e r v e n t i o n (Ratner & McMullan, 1987). I t may w e l l be argued that s t a t e a c t i o n s to deal with t h i s problem have i n v o l v e d the e s t a b l i s h m e n t of new f i e l d s of i n v e s t m e n t , new markets, and new commodities which c r e a t e new sources of p r o f i t , by d e - s o c i a l i z i n g s e r v i c e s provided by the s t a t e ; i n c l u d i n g , the s o c i a l c o n t r o l apparatus. Reduced revenue demands enable the r e t e n t i o n of s u r p l u s i n the hands of c a p i t a l and the l a t t e r may e x t r a c t f u r t h e r p r o f i t t h r o u g h i t s i n v o l v e m e n t i n a new 'industry' c r e a t e d by the s t a t e . P r i v a t i z a t i o n may, t h e r e f o r e , be a m a n i f e s t a t i o n of s t a t e a c t i o n s designed to r e s o l v e a c r i s i s of a c c u m u l a t i o n embodied i n the l o g i c and c o n t r a d i c t i o n s of monopoly c a p i t a l i s m , and t h i s p o s s i b i l i t y opens a new avenue of e m p i r i c a l i n q u i r y f o r c a p i t a l - l o g i c t h e o r i s t s . F i n a l l y , an examination of both s o c i a l c o n t r o l systems as c o m p r e h e n s i v e and i n t e g r a t e d e n t i t i e s and. the emergence of a s s o c i a t e d master p a t t e r n s , w i l l r e q u i r e an e q u a l l y comp-rehensive examination of the state's use of law and components 548 of the l e g a l apparatus i n order to f a c i l i t a t e and/or l e g i t i m a t e i t s p r a c t i c e s . An e x p l o r a t i o n of the master p a t t e r n s might w e l l d e m o n s t r a t e uses of the law and the l e g a l a p p a r a t u s w hich transcend the boundaries of the components of the s o c i a l c o n t r o l n e t . For example, i t i s e v i d e n t t h a t the i s s u e of r i g h t s c u r r e n t l y extends beyond the c o n f i n e s of mental h e a l t h law and t h a t i t has a f f e c t e d b o t h the c r i m i n a l j u s t i c e and s o c i a l w e l f a r e f i e l d s . The notio n s of p r i s o n e r s ' r i g h t s and r i g h t s f o r the c l i e n t s o f t h e s o c i a l w e l f a r e c o m p o n e n t e m e r g e d a t approximately the same time as the new l e g a l i s m and, i n s o f a r as the s t a t e has d e f i n e d the m e n t a l l y d i s o r d e r e d as ' j u r i d i c a l s u b j e c t s ' and provided them with a means whereby r i g h t s can be p r o t e c t e d and e n f o r c e d (e.g., advocacy s e r v i c e s ) , so o t h e r groups have been s i m i l a r l y bestowed. In so d o i n g , the s t a t e has, p a r a d o x i c a l l y , empowered the very groups that i t seeks to c o n t r o l and some questions consequently a r i s e f o r neo-Marxist t h e o r i s t s ; n o t a b l y , t o what e x t e n t have the ' c l i e n t s ' of the e n t i r e s o c i a l c o n t r o l system been granted r i g h t s ; why has t h i s o c c u r r e d ; and, how do e s t h e s t a t e manage t h i s g l a r i n g c o n t r a d i c t i o n ? The f o r e g o i n g d i s c u s s i o n has i d e n t i f i e d and b r i e f l y d i s c u s s e d three primary consequences f o r neo-Marxist t h e o r i z i n g which w i l l be generated by an i n t e g r a t e d s o c i o l o g y of s t a t e , law and s o c i a l c o n t r o l . Further r e s e a r c h must be conducted with a comprehensive v i s i o n of s o c i a l c o n t r o l i n mind and wit h the goal of e x p l o r i n g , i n p a r t i c u l a r , the nature and emergence of 'master p a t t e r n s ' i n Canada. Research should be undertaken i n order to 549 d e t e r m i n e , f o r example, the e x t e n t t o which (and the r e a s o n s why) a s h i f t away from the use of s e g r e g a t e d c o n f i n e m e n t , a c c e l e r a t e d d e - i n s t i t u t i o n a l i z a t i o n , and p r i v a t i z a t i o n have a f f e c t e d a l l the components of the s o c i a l c o n t r o l n e t . An a n a l y s i s of s t a t e s t r a t e g i e s and l e g i s l a t i o n a f f e c t i n g the mentally d i s o r d e r e d a l s o c a l l s f o r more re s e a r c h and the next s e c t i o n c o n t a i n s a b r i e f d i s c u s s i o n of the a r e a s i n which f u r t h e r work i s r e q u i r e d . IV: FURTHER RESEARCH The a n a l y s i s provided i n t h i s r e s e a r c h on the changes i n Canadian m e n t a l h e a l t h law and the a s s o c i a t e d s h i f t s i n the s t a t e s t r a t e g y f o r the management of the men t a l l y d i s o r d e r e d , has been r e s t r i c t e d to e v e n t s s i n c e 1945. The emergence of ' l i m i t e d l e g a l i s m ' d u r i n g the 19th century, the subsequent r i s e of ' m e d i c a l i z a t i o n ' , and the attendant changes i n s o c i a l c o n t r o l s t r a t e g i e s , have been reviewed but not explored i n depth, and resear c h aimed at the l a t t e r should be undertaken i n order to secure a f u l l understanding of the h i s t o r y of mental h e a l t h law and the management of the mentally d i s o r d e r e d i n Canada, as w e l l as the i m p l i c a t i o n s f o r a Canadian s o c i o l o g y of s t a t e , law and s o c i a l c o n t r o l . S i m i l a r l y , the d e t a i l e d a n a l y s i s of the emergence of enhanced m e d i c a l i z a t i o n , i t s subsequent demise, and the r i s e of the new l e g a l i s m has f o c u s s e d upon e v e n t s i n the p r o v i n c e of B r i t i s h Columbia. Developments i n the r e s t of Canada have been examined and the c i r c u m s t a n c e s under which law r e f o r m s and s h i f t s i n s t r a t e g y have occurred i n other p r o v i n c e s (notably, 550 Saskatchewan and O n t a r i o ) have been e x p l o r e d ; however, the a n a l y s i s has been l i m i t e d and g e n e r a l i z a t i o n s s h o u l d be undertaken with c a u t i o n . F u r t h e r res e a r c h aimed at a d e t a i l e d a n a l y s i s of developments in other p r o v i n c e s and the T e r r i t o r i e s i s , t h e r e f o r e , r e q u i r e d . 3 T h i r d l y , the r e s e a r c h c o m p r i s e s a ' m a c r o - s o c i o l o g i c a l ' a n a l y s i s of changes i n l e g i s l a t i o n and s t a t e s o c i a l c o n t r o l s t r a t e g i e s , and the primary focus has been upon the r e l a t i o n s h i p between s h i f t s i n s t r a t e g y , law reforms, and changing s t r u c t u r a l c o n d i t i o n s . While the a c t i v i t i e s of s t a t e personnel and groups of r e f o r m e r s have been e x p l o r e d i n o r d e r to d e t e r m i n e , i n p a r t i c u l a r , the r o l e and impact of human agency, t h i s has i n v o l v e d an a n a l y s i s of i n f o r m a t i o n d e r i v e d , i n p a r t , from the u s e f u l but sparse r e s e a r c h conducted by others. The study has not p e n e t r a t e d the r e a l m of e v e r y d a y p r a c t i c e s and f u r t h e r r e s e a r c h i s r e q u i r e d i n order to e s t a b l i s h both the i n t r i c a c i e s of the r e l a t i o n s h i p between autonomous i n t e r e s t groups and the s t a t e (e.g., the r e c o g n i t i o n and e x p l o i t a t i o n of c o n t r a d i c t i o n s ) and the p r a c t i c e s of t h o se i n v o l v e d i n the i m p l e m e n t a t i o n of s t a t e p o l i c i e s and laws, p a r t i c u l a r l y where they are opposed to s t a t e a c t i o n s (e.g., p s y c h i a t r i s t s ) . It i s necessary to examine any d i s c r e p a n c i e s t h a t may e x i s t between s t a t e p o l i c i e s and laws and the r o u t i n e p r a c t i c e s of, f o r example, mental h e a l t h p r o f e s s i o n a l s , p a t i e n t s ' advocates, and review boards, and t h i s can only be accomplished through ' m i c r o - s o c i o l o g i c a l ' a n a l y s i s . F i n a l l y , s i n c e i t i s e v i d e n t t h a t the new l e g a l i s m i s 551 a f f e c t i n g c o u n t r i e s o t h e r than Canada ( n o t a b l y , B r i t a i n , the U n i t e d S t a t e s , and A u s t r a l i a ) an a n a l y s i s of the f a c t o r s u n d e r p i n n i n g the r e f o r m s i n these n a t i o n s i s w a r r a n t e d . In p a r t i c u l a r , comparative r e s e a r c h could generate i n s i g h t s i n t o the c o n n e c t i o n s between s o c i a l c o n t r o l s t r a t e g i e s , law, the s t a t e , and g l o b a l economic problems and s h i f t s which would be of i m p o r t a n c e to the g e n e r a l n e o - M a r x i s t r e s e a r c h programme. Further, an e x p l o r a t i o n of the extent to which the cu r r e n t era of m e n t al h e a l t h law r e f o r m i s a deve l o p m e n t p e c u l i a r to advanced c a p i t a l i s t c o u n t r i e s with a common l e g a l c u l t u r e and s i m i l a r l e g a l systems would be of value. I t i s a l s o important to examine whether the new l e g a l i s m i s an i n t e r n a t i o n a l phenomenon that transcends d i f f e r e n t l e g a l systems, c u l t u r e s and p o l i t i c a l systems (e.g., has i t emerged i n s o c i a l i s t c o u n t r i e s ? ) and, i f t h i s i s so, why governments have chosen to adopt t h i s form of l e g a l r e g u l a t i o n . Are the r e f o r m s a p r o d u c t o f , f o r example, u n i v e r s a l p r o b l e m s or s h i f t s i n the g l o b a l economy which are h a v i n g a g e n e r a l i m p act upon s t r a t e g i e s f o r the management of the men t a l l y d i s o r d e r e d ? Comparative r e s e a r c h c o u l d a l s o encompass an e x a m i n a t i o n of the ways i n which the 'mental health' laws and s t r a t e g i e s of d i f f e r e n t c o u n t r i e s are a f f e c t e d by c u l t u r a l and i d e o l o g i c a l d i f f e r e n c e s (e.g., p e r c e p t i o n s of both 'mental i l l n e s s ' and the p r e f e r r e d method of managing the ' m e n t a l l y d i s o r d e r e d ' ) and the e x t e n t to wh i c h t h e s e f a c t o r s i n f l u e n c e t h e d e c i s i o n s a nd p r a c t i c e s o f governments f a c i n g common economic problems. 552 Vi_ THE LAW AND THE CONTROL OF THE MENTALLY DISORDERED: FUTURE DIRECTIONS The a n a l y s i s of the changes which have a f f e c t e d both mental h e a l t h law and the un d e r l y i n g s t a t e s t r a t e g i e s f o r the management of the men t a l l y d i s o r d e r e d i n Canada, demonstrates t h a t t h e s e i n t e r l o c k i n g phenomena a r e f a r f r o m s t a t i c . Consequently, i t i s p o s s i b l e to p r e d i c t that the new l e g a l i s m and the c u r r e n t s t a t e s t r a t e g y w i l l e v e n t u a l l y be subjected to f u r t h e r changes. F o l l o w i n g the p a t t e r n s of past p e r i o d s of law r e f o r m , the next e r a might be c h a r a c t e r i z e d by e i t h e r a 'new m e d i c a l i z a t i o n ' (i.e., a r e s t o r a t i o n of medical domination), or •enhanced l e g a l i s m ' ( i . e . , a f u r t h e r d i m i n u t i o n of m e d i c a l c o n t r o l and an e n t r e n c h m e n t of j u d i c i a l and q u a s i - j u d i c i a l domination). Whatever the t r a j e c t o r y , the c h a r a c t e r i s t i c s of l e g i s l a t i o n w i l l be determined s i g n i f i c a n t l y by the un d e r l y i n g s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d and the nature of the problems c o n f r o n t i n g the s t a t e i n the e x e r c i s e and s y n c h r o n i z a t i o n of i t s c a r d i n a l f u n c t i o n s . D i f f i c u l t i e s p e r i o d i c a l l y a r i s e w i t h r e s p e c t to the v i a b i l i t y of c o n t r o l s t r a t e g i e s , l e g i t i m a t i o n s o l u t i o n s , and i n attempts to reproduce the c o n d i t i o n s necessary f o r c a p i t a l accumulation. While the exact nature of fu t u r e problems and c r i s e s which might be encountered by the s t a t e i s d i f f i c u l t to p r e d i c t , some s p e c u l a t i v e comments on the p o s s i b l e d i r e c t i o n of mental h e a l t h law and s t a t e s t r a t e g y d u r i n g the next two decades can be o f f e r e d . I t seems p r o b a b l e t h a t the c l o s u r e o f l a r g e , d i s c r e d i t e d mental h o s p i t a l s and the concomitant emphasis upon the use of community-based c a r e and t r e a t m e n t methods w i l l 553 c o n t i n u e , but i t i s l i k e l y t h a t t h i s s t r a t e g y w i l l e n c o u n t e r d i f f i c u l t i e s and that the s t a t e w i l l be r e q u i r e d to d e a l with an a s s o c i a t e d p r o b l e m of o r d e r m aintenance and l e g i t i m a t i o n . There i s a l r e a d y some evidence of a growing problem i n t h i s area i n the United S t a t e s where the p l i g h t of the 'homeless mentally i l l ' (i.e., the a p p a r e n t l y i n c r e a s i n g numbers of d e - i n s t i t u t i o n -a l i z e d mental h e a l t h p a t i e n t s l i v i n g on the s t r e e t s of c i t i e s ) i s becoming a p r e s s i n g s o c i a l i s s u e ( E l p e r s , 1987). A r e l i a n c e upon the p r o t o t y p i c a l c o n t r o l system - c r i m i n a l j u s t i c e - has p r o v e d to be i n e f f e c t i v e and one r e c e n t r e s p o n s e has been to r e s t o r e some medical c o n t r o l over the management of p a t i e n t s by i n t r o d u c i n g new l e g i s l a t i o n w h i c h e a s e s s t r i c t i n v o l u n t a r y a d m i s s i o n c r i t e r i a and p e r m i t s i n v o l u n t a r y ' o u t - p a t i e n t ' commitment; that i s , a requirement that d e - i n s t i t u t i o n a l i z e d and n o n - i n s t i t u t i o n a l i z e d p a t i e n t s attend mental h e a l t h c e n t r e s to r e c e i v e t r e a t m e n t (see, e.g., E l p e r s , 1987; Durham & La Fond, 1987). I f a major p r o b l e m of h o m e l e s s n e s s a r i s e s i n Canada, p r o v i n c i a l governments may w e l l respond by i n t r o d u c i n g s i m i l a r l e g i s l a t i o n , and the next era of mental h e a l t h law reform might, t h e r e f o r e , be c h a r a c t e r i z e d by a 'new m e d i c a l i z a t i o n ' . However, i n s o f a r as a r e s t o r a t i o n of m e d i c a l d o m i n a t i o n c o u l d i n v o l v e i n c r e a s e d e x p e n d i t u r e s on m e n t a l h e a l t h r e s o u r c e s , d e c i s i o n -m a k i n g w i l l l i k e l y be a f f e c t e d by p r e v a i l i n g e c o n o m i c c o n d i t i o n s . I f t h e r e i s no i m p r o v e m e n t i n t h e economy s u f f i c i e n t to a l l o w the easing of r e s t r a i n t s upon p u b l i c s e c t o r e x p e n d i t u r e s ( e s p e c i a l l y i n the h e a l t h c a r e component of the w e l f a r e state) i t seems u n l i k e l y that the new l e g a l i s m w i l l be 554 eroded s i g n i f i c a n t l y , but t h i s i s contingent upon the absence of an o t h e r w i s e u n r e s o l v a b l e c r i s i s w i t h the management of the m e n t a l l y d i s o r d e r e d i n the community. A f a i l u r e to secure a long-term improvement i n the economy through an adjustment of Keynesian p o l i c i e s , and the p o s s i b l e entrenchment of an a l t e r n a t i v e m o n etarist economic s t r a t e g y , might r e s u l t i n f u r t h e r p u b l i c s e c t o r r e s t r a i n t measures and the c o n c o m i t a n t a d o p t i o n o f , f o r example, a s t r a t e g y of t o t a l p r i v a t i z a t i o n i n the mental h e a l t h area. T h i s might i n v o l v e the r e - e s t a b l i s h m e n t of i n s t i t u t i o n s owned and o p e r a t e d by the p r i v a t e s e c t o r , the c r e a t i o n of new, p r i v a t e community-based r e s o u r c e s f o r the management of p a t i e n t s , and a p p r o p r i a t e s t a t u t o r y changes aimed at b o t h f a c i l i t a t i n g a p r i v a t e , f o r -p r o f i t system of s o c i a l c o n t r o l and r e g u l a t i n g the i n d u s t r y i n order to prevent problems of order maintenance and l e g i t i m a t i o n . In t h i s regard, the growth of a Canadian, p r i v a t e n u r s i n g home i n d u s t r y suggests that one element of a f u l l y p r i v a t i z e d system i s a l r e a d y e m e r g i n g , and t h i s development i s b e i n g p r o p e l l e d by the p r o s p e c t of economic p r o b l e m s a r i s i n g from s i g n i f i c a n t d e m o g r a p h i c changes. Demographic p r o j e c t i o n s i n d i c a t e t h a t , over the next two decades, a growing p r o p o r t i o n of the p o p u l a t i o n w i l l be comprised of e l d e r l y people and that many w i l l be s u f f e r i n g from d i s e a s e s of a g i n g which have an a d v e r s e i m p a c t upon t h e i r m e n t a l h e a l t h . The n e e d f o r a p p r o p r i a t e h e a l t h and w e l f a r e s e r v i c e s w i l l i n c r e a s e , the c o s t s of c a r i n g f o r the e l d e r l y w i l l consequently r i s e , and the s t a t e w i l l a l s o be r e q u i r e d to address the problem of the s o - c a l l e d 555 'pension burden' (see, e.g, Gordon & Verdun - J o n e s , 1986a). I n d e e d , t h e p r o c e s s o f ' p o p u l a t i o n a g i n g ' m i g h t a l o n e p r e c i p i t a t e a f i s c a l c r i s i s f o r t h e s t a t e w h i c h has a s i g n i f i c a n t impact upon the s t r a t e g y f o r the management of the mentally d i s o r d e r e d . An i n c r e a s e i n the numbers of p r i v a t e i n s t i t u t i o n s f o r the care of the e l d e r l y w i l l probably continue and i t i s noteworthy that p r o v i n c i a l governments are rev i e w i n g the adequacy of the l e g i s l a t i o n governing these 'new asylums' i n order to address a gr o w i n g p r o b l e m of l e g i t i m a t i o n ( S o c i a l P l a n n i n g C o u n c i l of M e t r o p o l i t a n Toronto, 1984). In a d d i t i o n , the c u r r e n t i n t e r e s t i n r e f o r m i n g the l e g i s l a t i o n a f f e c t i n g mental incompetency and committeeship, and the c o n s t r u c t i o n of new a d u l t guardianship laws and systems, w i l l l i k e l y continue, and t h i s development complements the es t a b l i s h m e n t of a f u l l y p r i v a t i z e d system f o r the management of the m e n t a l l y d i s o r d e r e d . P r o p o s e d a d u l t guardianship laws entrench j u d i c i a l domination over the process of a p p o i n t i n g an i n d i v i d u a l to guard and manage a m e n t a l l y i n c a p a b l e p e r s o n l i v i n g i n the community and i n v o l v e new p r o c e d u r e s which a r e s t r e a m l i n e d , i n e x p e n s i v e , and r e d u c e medical involvement i n the decision-making process (see, e.g., Gordon, e t a l , 1986). W h i l e p r o v i s i o n i s made f o r s t a t e p e r s o n n e l (e.g., p u b l i c g u a r d i a n s and s o c i a l w o r kers) t o undertake guardianship d u t i e s , the preference i s f o r the use of p r i v a t e guardians (e.g., a r e l a t i v e or f r i e n d ) and i t i s i n t h i s sense that new gua r d i a n s h i p laws and systems i n v o l v e an element o f ' p r i v a t i z a t i o n ' . S i n c e p r i v a t e g u a r d i a n s h i p c o u l d a l s o be 556 p r o v i d e d by e i t h e r g u a r d i a n s h i p a g e n c i e s o r i n d i v i d u a l g u a r d i a n s , on a f o r - p r o f i t b a s i s , the p r i v a t i z a t i o n p r o c e s s could expand r a p i d l y . The new a d u l t g u a r d i a n s h i p l a w s and s y s t e m s are e a s i l y j u s t i f i e d as humanitarian a l t e r n a t i v e s to i n s t i t u t i o n a l i z a t i o n and p a t e r n a l i s t i c s t a t e i n t e r v e n t i o n , and they are c o n s i s t e n t with both p r e v a i l i n g economic r e s t r a i n t p o l i c i e s and the need to ensure the d i r e c t and e f f e c t i v e c o n t r o l of the p h y s i c a l person and a s s e t s of the mentally d i s o r d e r e d . Indeed, i t i s p r e d i c t e d that t h i s area of mental h e a l t h law w i l l i n c r e a s e i n importance over the next decade as p r o v i n c i a l governments r e a l i z e that t h i s method of c o n t r o l l i n g the m e n t a l l y d i s o r d e r e d i s e f f e c t i v e , j u s t i f i a b l e , c o n s i s t e n t w i t h economic r e s t r a i n t g o a l s , and l i k e l y to a s s i s t i n the r e s o l u t i o n of p r o j e c t e d economic p r o b l e m s a r i s i n g from, i n p a r t i c u l a r , an i n c r e a s e i n the p r o p o r t i o n of e l d e r l y persons i n the po p u l a t i o n . Insofar as new guardianship laws make p r o v i s i o n f o r the appointment of i n d i v i d u a l 'supervisors' and s u b s t i t u t e d e c i s i o n -makers, c h a r g e d w i t h the tas k of managing a l l a s p e c t s of a mentally d i s o r d e r e d person's l i f e , they e f f e c t i v e l y d i s p l a c e the b u l k of c u r r e n t m e n t a l h e a l t h s t a t u t e s . The l a t t e r make extensive p r o v i s i o n f o r the p r o t e c t i o n of p a t i e n t s ' r i g h t s and p r e s c r i b e complex procedures f o r the management of p a t i e n t s , a l l of which c o u l d be removed where the c o n t r o l of a m e n t a l l y d i s o r d e r e d p e r s o n i s p l a c e d i n t h e hands o f a g u a r d i a n a u t h o r i z e d to make s u b s t i t u t e d e c i s i o n s . Indeed, mental h e a l t h 557 s t a t u t e s could become as o b s o l e t e as l a r g e mental h o s p i t a l s and, to the e x t e n t t h a t new g u a r d i a n s h i p laws e n t r e n c h j u d i c i a l domination over the management of the mentally d i s o r d e r e d , t h e i r widespread adoption w i l l perhaps h e r a l d the emergence of an era of 'enhanced l e g a l i s m ' i n C a n a d i a n m e n t a l h e a l t h law. The l a t t e r w i l l serve to f a c i l i t a t e and l e g i t i m a t e a new s t r a t e g y f o r the management of the mentally d i s o r d e r e d t h a t i s b u i l t upon a f u l l y p r i v a t i z e d system of s m a l l i n s t i t u t i o n s and community resou r c e s housing and t r e a t i n g m entally d i s o r d e r e d persons who are s u b j e c t to the d i r e c t c o n t r o l of p r i v a t e guardians. The e x t e n t to w hich t h i s d e velopment c o n s t i t u t e s an accurate p i c t u r e of both mental h e a l t h law and s t a t e s t r a t e g y i n , f o r example, 2008 i s i m p o s s i b l e to d e t e r m i n e . However, c u r r e n t trends i n both the process of p r i v a t i z a t i o n and a d u l t g u a r d i a n s h i p law serve to r e i n f o r c e t h i s v i s i o n of the f u t u r e s t a t e s t r a t e g y f o r the management of the mentally d i s o r d e r e d and the next p e r i o d of mental h e a l t h law reform i n Canada. 558 ENDNOTES: CHAPTER 7 1: These are a l s o components which are d e s i g n e d to manage t h o s e who have e i t h e r r e s i s t e d o r n o t been e f f e c t i v e l y i n f l u e n c e d by, o t h e r s o c i a l c o n t r o l p r o c e s s e s and who have, consequently, been d e c l a r e d to be ' s o c i a l deviants'. The s o c i a l c o n t r o l net must be viewed as a l s o encompassing the formal and i n f o r m a l n e t w o r k s , i n s t i t u t i o n s , and s y stems which p l a y an important r o l e i n the genesis of s o c i a l c o n t r o l ; n o t ably, the f a m i l y , the workplace, and the education system. The l a t t e r may be d e s c r i b e d as the 'soft' components of the s o c i a l c o n t r o l net and those who r e s i s t or f a i l i n t h i s area may be e v e n t u a l l y managed by the 'hard' components; namely, c r i m i n a l j u s t i c e , mental h e a l t h , or s o c i a l w e l f a r e . 2: T h i s c l a i m i s b a s e d s o l e l y upon t h e s h i f t i n r e s p o n s i b i l i t y f o r m e n t a l l y i l l and m e n t a l l y r e t a r d e d (developmentally d i s a b l e d ) persons, at the a d m i n i s t r a t i v e l e v e l ( i . e . , from the b a i l i w i c k of m i n i s t r i e s of h e a l t h to the b a i l i w i c k of m i n i s t r i e s of s o c i a l w e l f a r e ) , p a r t i c u l a r l y i n B r i t i s h C o l u m b i a . Developments i n o t h e r p r o v i n c e s and o t h e r c o u n t r i e s might w e l l be d i f f e r e n t . 3: The l i m i t e d a n a l y s i s n e v e r t h e l e s s p o i n t s to the h i g h p r o b a b i l i t y t h a t the f i n d i n g s of t h i s t h e s i s w i l l be confirmed. Some minor v a r i a t i o n s may be d i s c o v e r e d and the r a t e at which the law r e f o r m s and s h i f t s i n s t r a t e g y have o c c u r r e d may be d i f f e r e n t . However, t h e s e w i l l l i k e l y be due to l o c a l i z e d f a c t o r s such as, the r e l a t i v e s t r e n g t h of the v a r i o u s i n t e r e s t groups, the s i z e of a province's p o p u l a t i o n , the s i z e and s t a t e of the mental h e a l t h system, p a r t i c u l a r p o l i t i c a l events, and, the s t a t e of a p r o v i n c i a l or r e g i o n a l economy. 559 APPENDIX I METHODOLOGY In t r o d u c t i o n T h i s t h e s i s i s an h i s t o r i c a l , m a c r o - s o c i o l o g i c a l a n a l y s i s w i t h i n the domain of the s o c i o l o g y of law. It i s an 'emergence study' (Sugarman, 1981); t h a t i s , an a n a l y s i s of s o c i a l , p o l i t i c a l and economic events and c o n d i t i o n s a f f e c t i n g both the c o n s t r u c t i o n and passage of laws, and the a p p l i c a t i o n s of these laws, at given h i s t o r i c a l j u n c t u r e s . The g e n e s i s of the t h e s i s can be t r a c e d to t h r e e main f a c t o r s . F i r s t l y , t h e a u t h o r ' s l o n g - s t a n d i n g i n t e r e s t ( i n i t i a l l y k i n d l e d while working f o r a community law centre) i n both the p l i g h t of mentally i l l persons i n i n s t i t u t i o n s and the use (and l i m i t s ) of law as a mechanism f o r s e c u r i n g a p p r o p r i a t e r e f o r m s . S e c o n d l y , a d e s i r e to answer a number of q u e s t i o n s r e g a r d i n g the e v o l u t i o n of mental h e a l t h law i n Canada which emerged during e a r l i e r r e s e a r c h f o r a Masters t h e s i s : why have p a t i e n t s ' r i g h t s been embraced by governments; what i s the l i n k between r i g h t s , the c h a n g i n g use of i n s t i t u t i o n s , and the economics of mental h e a l t h ; why d i d the p e r i o d of reform occur d u r i n g the 1960's; and, what o t h e r p e r i o d s of r e f o r m have a f f e c t e d C a n a d i a n m ental h e a l t h law and why d i d they o c c u r ? F i n a l l y , a d e s i r e to c o n t r i b u t e to the body of knowledge i n a Canadian s o c i o l o g y of law, e s p e c i a l l y the knowledge b e i n g generated by the neo-Marxist r e s e a r c h programme. The a u t h o r wanted t o u n d e r t a k e an i n s t a n c e s t u d y t h a t 560 would ex p l o r e s o c i a l c o n t r o l i s s u e s but without f o c u s s i n g upon the p r o t o t y p i c a l c o n t r o l system, i t s personnel and " c l i e n t s ' ; namely, c r i m i n a l j u s t i c e . The l a t t e r has been (and i s being) analysed by others (see, e.g., Ratner & McMullan, 1987) and i t was f e l t t h a t an u n d e r s t a n d i n g of the e n t i r e s t a t e s o c i a l c o n t r o l system would be enhanced by a study which explored the management of a n o t h e r group of ' s o c i a l d e v i a n t s ' ( i . e . , the m e n t a l l y d i s o r d e r e d ) . An h i s t o r i c a l , m a c r o - s o c i o l o g i c a l a p p r o a c h was adopted s i n c e t h i s would not o n l y s e c u r e a d e s c r i p t i o n of the e v o l u t i o n of a n e g l e c t e d area of Canadian law, but a l s o ensure a f u l l understanding of the changes which have o c c u r r e d . An u n t a n g l i n g of the complex, d i a l e c t i c a l i n t e r p l a y between the s t a t e , s o c i a l c o n t r o l s t r a t e g i e s , law, s t r u c t u r a l c o n d i t i o n s , and human agency can only be accomplished through a r e t r o s p e c t i v e a n a l y s i s s i n c e the nature and s i g n i f -icance of events and r e l a t i o n s h i p s between events are u s u a l l y best understood some time a f t e r they have occurred. The design and implementation of the r e s e a r c h was guided by the methodology of a s e r i e s of exemplary s t u d i e s which e i t h e r f o c u s d i r e c t l y upon the same s u b j e c t m a t t e r ( i . e . , m e n t a l h e a l t h law) or are concerned with the general t o p i c area (i.e., s t a t e s o c i a l c o n t r o l s t r a t e g i e s ) . H i s t o r i c a l l y i n f o r m e d s o c i o l o g i c a l s t u d i e s of mental h e a l t h law have been undertaken i n B r i t a i n by Bean (1980), B u t l e r (1985), Jones (1955, 1960, 1972) and Unsworth (1979), and the methods employed by thes e a n a l y s t s ( i . e . , documentary and a r c h i v a l a n a l y s i s of the c i r c u m s t a n c e s s u r r o u n d i n g v a r i o u s p e r i o d s of r e f o r m ) were 561 adopted. The c o n t r i b u t i o n s of the ' r e v i s i o n i s t ' h i s t o r i a n s of s o c i a l c o n t r o l (e.g., S c u l l (1979, 1984)) were a l s o i n f l u e n t i a l p r i m a r i l y because these a n a l y s t s have produced t h e o r e t i c a l l y i n f o r m e d t r e a t i s e s w hich l i n k h i s t o r i c a l and s o c i o l o g i c a l c o n c e r n s and i n t e r p r e t h i s t o r i c a l e v e n t s t h r o u g h a c r i t i c a l l e n s . One p a r t i c u l a r v i r t u e l a y with the h i s t o r i a n s ' c a p a c i t i e s to p e n e t r a t e epiphenomena and a n a l y s e the impact of b r o a d e r s t r u c t u r a l c o n d i t i o n s p r e v a i l i n g a t p a r t i c u l a r t i m e s , but without s a c r i f i c i n g i s s u e s of human agency. Sugarman's (1981) g e n e r a l c r i t i q u e of r e s e a r c h i n the s o c i o l o g y of law a l s o i n f l u e n c e d the design and implementation of the research. In h i s d i s c u s s i o n of the work of both l e g a l h i s t o r i a n s and s o c i o l o g i s t s of law a number of key problems have been h i g h l i g h t e d ; notably, an e x c e s s i v e focus upon case law and l e g i s l a t i o n as the o n l y s o u r c e of d a t a , and a c o n c o m i t a n t f a i l u r e to i n t e g r a t e data p e r t a i n i n g to other r e l e v a n t phenomena (e.g., economic developments). Lawyers undertaking h i s t o r i c a l and s o c i o l o g i c a l a n a l y s e s of law have a tendency to r e s t r a i n t h e i r e x p l a n a t i o n s w i t h i n the b o u n d a r i e s of l e g a l t h e o r y and j u r i s p r u d e n c e ; they f a i l t o pose l a r g e r 'why?' q u e s t i o n s and n e g l e c t to examine data from which v a l i d answers might w e l l be d e r i v e d . S o c i o l o g i s t s undertaking analyses of law d i s p l a y other s h o r t c o m i n g s which are a l s o a p r o d u c t of t h e i r d i s c i p l i n a r y b a ckgrounds; n o t a b l y , a f a i l u r e to take f u l l a c c o u n t of the complex r e l a t i o n s h i p between s t a t u t e s , cases, and l e g a l theory. In Sugarman's view, both the 'new' l e g a l h i s t o r i a n s and s o c i o l o g i s t s of law s h o u l d examine not o n l y l e g i s l a t i o n and 562 cases but a l s o a v a r i e t y of other data such as a r c h i v a l records, company r e p o r t s , and government documents. As f a r as i s p o s s i b l e , they should analyse the complete spectrum of m a t e r i a l s p e r t a i n i n g to the c o n s t r u c t i o n of any g i v e n law or l a w s. To t h i s might be added the requirement that a n a l y s t s seek out and i n t e r v i e w both those r e s p o n s i b l e f o r and those a s s o c i a t e d with the c r e a t i o n of the law/s under examination. In a d d i t i o n , Sugarman argues t h a t e m p i r i c a l r e s e a r c h should not proceed i n an a t h e o r e t i c a l manner. The work must be h a r n e s s e d t o a r e l e v a n t t h e o r e t i c a l framework w h i c h , f o r Sugarman, i s e x e m p l i f i e d by the Gramscian p e r s p e c t i v e ; that i s , ' e x p e r i e n t i a l ' h i s t o r i e s which focus upon the hegemonic f u n c t i o n of law. The works of the Warwick S c h o o l of S o c i a l H i s t o r y (i.e., Albion's F a t a l Tree and Whigs and Hunters) are viewed as exemplars which embody a number of v i r t u e s . The c o n t r i b u t i o n s r e f l e c t a t h r e e d i m e n s i o n a l a p p r o a c h t o l a w ( i . e . , an e x a m i n a t i o n of the s o c i a l , economic and p o l i t i c a l f a c t o r s a s s o c i a t e d with the c r e a t i o n and a p p l i c a t i o n of laws), a concern w i t h the complex impact of s o c i a l r e l a t i o n s on law f o r m a t i o n , and, a c o n c e r n f o r e x a m i n i n g the i m p l i c a t i o n s of r e s e a r c h i n t h e o r e t i c a l terms. The S p e c i f i c M e t h o d o l o g i c a l G u i d e l i n e s The t r a n s l a t i o n of Sugarman's g e n e r a l d i r e c t i v e s i n t o p r a c t i c e r e q u i r e d a more s p e c i f i c s e t of m e t h o d o l o g i c a l g u i d e l i n e s and, while t h i s study of Canadian mental h e a l t h law focussed p r i m a r i l y upon a p e r i o d that might w e l l be d e s c r i b e d as 563 'modern h i s t o r y ' (i.e., the 1940's onwards), E.P. Thompson's s i x general p r i n c i p l e s f o r u n d e r t a k i n g s o c i o - h i s t o r i c a l a n a l y s i s were adopted (Thompson, 1978). Thompson i s one h i s t o r i a n who has forged a l i n k between h i s t o r y and s o c i a l theory (Skocpol, 1984), and h i s g e n e r a l p r i n c i p l e s o r ' r u l e s ' f o r t h e ' i n t e r r o g a t i o n ' of d i s c r e t e f a c t s or evidence uncovered i n the course of r e s e a r c h , may be summarized as f o l l o w s : ( i ) I n i t i a l l y , s c r u t i n i z e the e v i d e n c e to e n s u r e t h a t i t i s ' h i s t o r i c a l f a c t ' and to determine the circumstances under which i t was recorded (a t e s t of v a l i d i t y and r e l i a b i l i t y ) . ( i i ) Analyse the ' f a c t s ' at the l e v e l of t h e i r 'own appearance', or 'apparent s e l f - d i s c l o s u r e ' , i n o r d e r to e x t r a c t ' v a l u e -bearing evidence', such as a t t i t u d e s and i d e o l o g i e s . ( i i i ) Analyse the ' f a c t s ' as 'value-free evidences' r e l e v a n t to the i n q u i r y a t hand (e.g., s t a t i s t i c a l i n d i c e s of v a r i o u s k i n d s ) . ( i v ) A n a l y s e ' f a c t s ' as l i n k s i n a l i n e a r s e r i e s of o c c u r -rences, or 'contingent events' in order to set out a n a r r a t i v e account of 'the way t h i n g s happened'. (v) A n a l y s e ' f a c t s ' as l i n k s i n a l a t e r a l s e r i e s of ' s o c i a l / i d e o l o g i c a l / e c o n o m i c / p o l i t i c a l r e l a t i o n s ' i n order to determine the nature of a s e c t i o n of a given s o c i e t y i n the past and, by i m p l i c a t i o n , the r o l e of t h i s s e c t i o n i n , f o r example, the c r e a t i o n of law. (vi) Analyse ' f a c t s ' f o r ' s t r u c t u r e - b e a r i n g evidence'; that i s , i n f o r m a t i o n p e r t a i n i n g to the g e n e r a l s t r u c t u r a l c o n d i t i o n s under which events occurred. With the e x c e p t i o n of p r i n c i p l e ( v i ) , the f o r e g o i n g r e f l e c t the general p r a c t i c e s of h i s t o r i a n s . The i n c l u s i o n of the s i x t h p r i n c i p l e i s a p r o d u c t of Thompson's i n t e r e s t i n l i n k i n g i s s u e s of human agency with s t r u c t u r a l c o n s i d e r a t i o n s ; that i s , examining the d i a l e c t i c a l r e l a t i o n s h i p between human a c t i o n and the c o n s t r a i n i n g and e n a b l i n g e f f e c t s of the s t r u c t u r e s c r e a t e d by humans ( T r i m b e r g e r , 1984). T h i s 564 p a r t i c u l a r c o n s i d e r a t i o n was deemed e s s e n t i a l f o r a complete understanding of the process of mental h e a l t h law reform (i.e., an a c c o u n t t h a t d i d not i g n o r e s t r u c t u r e but which would not c o l l a p s e i n t o economic or other forms of determinism). I t should be noted that the p r i n c i p l e s were not intended s o l e l y f o r use i n h i s t o r i c a l s t u d i e s of law. While Thompson's own work r e f l e c t s a keen i n t e r e s t i n the area (see, e.g., Whigs and Hunters), the p r i n c i p l e s have a more general a p p l i c a t i o n and can be used to guide and f a c i l i t a t e r e s e a r c h i n the r e - v i t a l i z e d area of h i s t o r i c a l s o c i o l o g y (see, e.g., Skocpol, 1984). Thompson's s i x p r i n c i p l e s were adopted and u t i l i z e d i n the c o u r s e of the r e s e a r c h f o r t h i s t h e s i s . The e x t r a c t i o n of ' v a l u e - b e a r i n g e v i d e n c e ' i n v o l v e d an a n a l y s i s of government documents, as w e l l as the documents and w r i t i n g s generated by i n t e r e s t groups (e.g., the Canadian Mental Health A s s o c i a t i o n ) . I n f o r m a t i o n was e x t r a c t e d from v a r i o u s , o f f i c i a l s o u r c e s of s t a t i s t i c a l data; f o r example, p r o v i n c i a l mental h e a l t h s e r v i c e r e p o r t s . I n s o f a r as the c h r o n o l o g i c a l stages of the process of mental h e a l t h law reform were i d e n t i f i e d and d e s c r i b e d , ' f a c t s ' were a n a l y s e d as l i n k s i n a l i n e a r s e r i e s of o c c u r r e n c e s ; i n s h o r t , a n a r r a t i v e a c c o u n t of the 'way t h i n g s happened' i s s u p p l i e d . The l i n k s i n a l a t e r a l s e r i e s of s o c i a l , i d e o l o g i c a l , economic and p o l i t i c a l r e l a t i o n s were a l s o analysed. The key i n d i v i d u a l s and groups a s s o c i a t e d with the reform process were i d e n t i f i e d and the r e l a t i o n s h i p s between them were analysed. F i n a l l y , ' s t r u c t u r e - b e a r i n g evidence' was sought and secured. 565 The n a t u r e of the b r o a d e r c o n t e x t w i t h i n which the r e f o r m process was o c c u r r i n g , at d i f f e r e n t j u n c t u r e s , was i d e n t i f i e d and the impact upon reform i s d e s c r i b e d . While t h e s e m e t h o d o l o g i c a l p r i n c i p l e s s e r v e to impose r i g o r and o r d e r upon h i s t o r i c a l l y i n f o r m e d s o c i o l o g i c a l r e s e a r c h (or s o c i o l o g i c a l l y informed h i s t o r i c a l research) t h e i r adequacy can be d i s p u t e d . While the r i g o r w i t h which res e a r c h i s conducted can be a s c e r t a i n e d from the q u a n t i t y , q u a l i t y and scope of the m a t e r i a l s which c o n s t i t u t e the data, t h i s does not a d d r e s s t h e p r o b l e m o f i n t e r p r e t a t i o n . ' F a c t s ' can be 'interrogated' but both the e x t r a c t i o n of meaning and i t s f u s i o n w i t h the meanings d e r i v e d from o t h e r ' i n t e r r o g a t i o n s ' are i n e v i t a b l y i n f l u e n c e d by t h e o r e t i c a l and i d e o l o g i c a l b i a s e s . These i n f l u e n c e s shape the f i n a l product and a reader must, at the o u t s e t , be aware of the c o l o u r of the i n t e r p r e t i v e l e n s employed by an a n a l y s t . The p r o b l e m s o f i n t e r p r e t i n g t h e p a s t i n o r d e r t o e s t a b l i s h p a t t e r n and,meaning i n h i s t o r y were f i r s t d i s c u s s e d by the n i n e t e e n t h c e n t u r y German h i s t o r i a n , W i l h e l m D i l t h e y ( D i l t h e y , 1961). These problems are, t h e r e f o r e , f a r from new but no l e s s c r u c i a l . Indeed, they become m a g n i f i e d where an h i s t o r i c a l s o c i o l o g i s t seeks to move beyond d e s c r i p t i o n to a t h e o r e t i c a l l y informed account of events. The r e s e a r c h e r must attempt to immerse h i m / h e r s e l f i n the s i t u a t i o n at any given time and i n t e r p e t events through the eyes of those who have l e f t p h y s i c a l t r a c e s ( i . e . , r e c o r d s of v a r i o u s k i n d s ) . T h i s may be d i f f i c u l t s i n c e an h i s t o r i a n can never r e a l l y know 'what i t was 566 l i k e ' and can never r e a l l y be sure that he or she has overcome the d i s t o r t i o n s created by both the p o s i t i o n occupied by those r e c o r d i n g events at the time and the researcher's 'modern' view of the world. At the same t i m e , the h i s t o r i a n has the advantage of h i n d s i g h t and can, t h e r e f o r e , analyse a l a r g e r p i c t u r e which was i n a c c e s s i b l e to a c t o r s a t the t i m e . The s i g n i f i c a n c e of and r e l a t i o n s h i p between s i m u l t a n e o u s l y o c c u r r i n g events only comes to l i g h t some time afterwards and the a b i l i t y to both analyse the ' t o t a l p i c t u r e ' and then e x p l a i n e v e n t s by r e f e r e n c e to a body of theory c o n s t i t u t e s one of the s t r e n g t h s of h i s t o r i c a l l y informed s o c i o l o g i c a l r e s e a r c h . Of course, i f the r e s e a r c h a l s o i n v o l v e s an a n a l y s i s of c u r r e n t e v e n t s ( i . e . , i f a r e s e a r c h e r seeks to examine a p e r i o d of 'modern h i s t o r y ' ) then the c l o s e r he or she comes to the present day, the more d i f f i c u l t i t i s to see the l a r g e r p i c t u r e . The problem of i n t e r p r e t a t i o n i s , t h e r e f o r e , a p o t e n t i a l f l a w i n any h i s t o r i c a l r e s e a r c h which seeks to do more than m e r e l y d e s c r i b e e v e n t s (e.g., b a t t l e A between B and C took p l a c e at D and s t a r t e d a t E time on F d a t e ) . In the f i n a l a n a l y s i s , s e v e r a l i n t e r p r e t a t i o n s can be (and are) p r e s e n t e d from which the ' t r u t h ' may be d i s t i l l e d . At the same t i m e , those o f f e r i n g i n t e r p r e t a t i o n s cannot engage i n f l i g h t s of fancy and the v a l i d i t y and r e l i a b i l i t y of t h e i r work has to be assessed i n some way. T h i s can be accomplished by examining, i n p a r t i c u l a r , the q u a n t i t y , q u a l i t y and scope of the m a t e r i a l s 567 underpinning t h e i r analyses, the r i g o r with which the r e s e a r c h and a n a l y s i s has been c a r r i e d out, and the p r e d i l e c t i o n s of the r e s e a r c h e r / s . The S p e c i f i c Methodology and A s s o c i a t e d Problems The r e s e a r c h f o r t h i s t h e s i s was c o n d u c t e d w i t h the f o r e g o i n g i s s u e s and p r o b l e m s i n mind, and the c o l o u r of the i n t e r p r e t i v e l e n s has been s p e c i f i e d i n Chapter 4. The r e s e a r c h was undertaken i n stages, w i t h d i f f e r e n t methods being a p p l i e d a c cording to the task at hand. The stages and methods were as f o l l o w s : (1) A c o m p r e h e n s i v e r e v i e w and a n a l y s i s of the C a n a d i a n l i t e r a t u r e p e r t a i n i n g to mental h e a l t h law and mental h e a l t h systems from the mid-19th century to the present day. (2) A comprehensive a n a l y s i s of the dependent v a r i a b l e ; namely, C a n a d i a n mental h e a l t h law. The l a t t e r was d e f i n e d as the s t a t u t e s and o r d i n a n c e s of the p r o v i n c e s and t e r r i t o r i e s of Canada from 1900 to 1987, and the colony of Newfoundland from 1900 t o 1947, p e r t a i n i n g to l u n a c y , i n s a n e asylums and h o s p i t a l s , m e n t a l h y g i e n e , mental h o s p i t a l s , m e n t a l h e a l t h , mental incompetency and committeeship, adult guardianship, and p u b l i c t r u s t e e s h i p , as w e l l as the a s s o c i a t e d c a s e s . In a d d i t i o n , s t a t u t e s and ordinances p r i o r to 1900 were reviewed to ensure that important l e g a l developments or s p e c i a l events were not overlooked. C o n v e n t i o n a l l e g a l r e s e a r c h methods were employed and i n v o l v e d a manual t r a c i n g of the o r i g i n s o f , and r e f o r m s t o , 568 l e g i s l a t i o n t h r o u g h s t a t u t e c i t a t o r s , i n d i c e s , a nd an examination of each s t a t u t e . The process of reform s i n c e 1900 was then mapped and the connections between l e g i s l a t i o n (e.g., mental h e a l t h , incompetency, and p u b l i c t r u s t e e s t a t u t e s ) were determined. The process was accompanied by a manual t r a c i n g of cases p e r t a i n i n g to the d i f f e r e n t s t a t u t e s . Again, c o n v e n t i o n a l l e g a l r e s e a r c h methods were employed and i n v o l v e d the use of d i g e s t s , c i t a t o r s , r e p o r t i n g s e r v i c e i n d i c e s and, where these were not a v a i l a b l e f o r c e r t a i n j u r i s d i c t i o n s , a s e a r c h of r e l e v a n t r e p o r t i n g s e r v i c e s . In a d d i t i o n , a s e a r c h was conducted through the 'Quicklaw 1 computerized r e p o r t i n g s e r v i c e i n order to i d e n t i f y recent cases. Information p e r t a i n i n g to the lunacy/mental h e a l t h laws of B r i t a i n , other Commonwealth j u r i s d i c t i o n s , and the United S t a t e s was at hand when the r e s e a r c h commenced. Changes i n t h e s e j u r i s d i c t i o n s were monitored as the r e s e a r c h proceeded. The s t a t u t e s and cases were then analysed with a view to d e t e r m i n i n g t h e i r c h a n g i n g c o n t e n t and the p e r i o d s of r e f o r m d u r i n g the chosen t i m e f r a m e . In the c o u r s e of the c o n t e n t a n a l y s i s , s t a t u t e s were read with s i x s p e c i f i c goals i n mind: ( i ) I d e n t i f y i n g the p r o v i n c e / s which s p e a r h e a d e d the process of reform at d i f f e r e n t times. ( i i ) D e s c r i b i n g the c h a n g i n g p r o c e d u r e s a f f e c t i n g the management of those deemed to be l u n a t i c s / m e n t a l l y d i s e a s e d / mentally i l l ; ( i i i ) Determining the goals, i n t e n t i o n s and mood of the 569 l e g i s l a t o r s by i n t e r p r e t i n g the general v o i c e of the s t a t u t e s , as r e f l e c t e d i n words, terms, phrases and p r o v i s i o n s ; (iv) Deciphering the i n f l u e n c e s i n the s t a t u t e s ; that i s , the presence or otherwise of terms, phrases and p r o v i s i o n s drawn from other j u r i s d i c t i o n s w i t h i n and beyond Canada; (v) Deciphering the i d e o l o g i c a l underpinnings by a n a l y s i n g any preambles, statements of p r i n c i p l e s , or general i n t e r p r e t -a t i o n clauses; and, ( v i ) D e t e r m i n i n g the p r e s e n c e or o t h e r w i s e of economic im p e r a t i v e s , as r e f l e c t e d i n the p r o v i s i o n s of s t a t u t e s . The case law was r e a d w i t h the same s p e c i f i c g o a l s i n mind. In a d d i t i o n , the a n a l y s i s was d i r e c t e d by three f u r t h e r o b j e c t i v e s ; namely, to a s c e r t a i n the presence or otherwise of any d o c t r i n e s or p r i n c i p l e s e s t a b l i s h e d by the c o u r t s ; to d e t e r m i n e the c o n c e r n s of the j u d i c i a r y and any r e l a t e d i d e o l o g i c a l underpinnings; and, to e s t a b l i s h the presence of any p r o c e d u r a l and/or i n t e r p r e t i v e d i r e c t i v e s o f f e r e d by the c o u r t s which had a b e a r i n g upon the body of s t a t u t e s . The bulk of t h i s r e s e a r c h was conducted i n the law l i b r a r y at the U n i v e r s i t y of B r i t i s h Columbia. Supplementary analyses were c o n d u c t e d at the U n i v e r s i t y of Regina and i n the law l i b r a r i e s at the U n i v e r s i t y of A l b e r t a , U n i v e r s i t y of Manitoba, U n i v e r s i t y of Toronto, M c G i l l U n i v e r s i t y , Dalhousie U n i v e r s i t y , and Memorial U n i v e r s i t y . The chance to p ursue s u p p l e m e n t a r y a n a l y s i s a r o s e as a consequence of a r a r e o p portunity. While the l e g a l r e s e a r c h was 570 b e i n g c o n d u c t e d , the a u t h o r was i n v i t e d to take p a r t i n the m e n t a l h e a l t h law r e f o r m p r o c e s s . E x t e n s i v e r e s e a r c h was conducted f o r the Government of the Yukon T e r r i t o r y w i t h a view to p r e p a r i n g a r e p o r t on the s t a t e of the T e r r i t o r y ' s m e n t a l h e a l t h and a d u l t g u a r d i a n s h i p law. The mandate i n c l u d e d the p r e s e n t a t i o n of recommendations f o r reform and a s u b s t a n t i a l r e p o r t was p r e p a r e d (Verdun-Jones & Gordon, 1985). T h i s was f o l l o w e d by the d r a f t i n g of two new s t a t u t e s . The author was thus a f f o r d e d a chance to o b s e r v e and p a r t i c i p a t e i n the law reform process which was the s u b j e c t of the t h e s i s . In a d d i t i o n , the a u t h o r undertook a n a t i o n a l s t u d y of a d u l t guardianship law, w i t h s u b s t a n t i a l funding from the S o c i a l S c i e n c e s and H u m a n i t i e s R e s e a r c h C o u n c i l . T h i s p r o v i d e d an a d d i t i o n a l o p p o r t u n i t y to observe the reform process s i n c e the r e s e a r c h i n v o l v e d t r a v e l throughout Canada with a view to, among other matters, holding d i s c u s s i o n s with p r o v i n c i a l government and other b o d i e s / i n d i v i d u a l s on the need f o r a d u l t g u a r d i a n s h i p / mental h e a l t h law reforms (see, Gordon, et a l , 1986).. 3) An i d e n t i f i c a t i o n and c o m p r e h e n s i v e a n a l y s i s o f t h e d i a l e t i c a l i n t e r p l a y between a l l the independent v a r i a b l e s which might account f o r the p e r i o d s of mental h e a l t h law reform. T h i s process occurred i n three stages. (i) A comprehensive review and a n a l y s i s of p r o v i n c i a l and f e d e r a l government documents (e.g., r e p o r t s ) and s t a t i s t i c s p e r t a i n i n g to mental h e a l t h law, m e n t a l h e a l t h s e r v i c e s , and h e a l t h c a r e s y s t e m s d u r i n g the p e r i o d chosen f o r d e t a i l e d a n a l y s i s ; namely, 1945 to 1987. The documents were a n a l y s e d 571 with a view to a s c e r t a i n i n g : (a) The avowed reasons f o r pursuing reform. (b) The impact of l a r g e r , s t r u c t u r a l c o n d i t i o n s (e.g., r e f e r -ences to changes i n economic s t r a t e g i e s ) . (c) The impact of p a r t i c u l a r i n t e r e s t groups and i n d i v i d u a l s both w i t h i n and beyond the s t a t e apparatus. (d) The i m p a c t of d e v e l o p m e n t s o u t s i d e Canada, i n the m e n t a l h e a l t h care/mental h e a l t h law f i e l d s . (e) N a t i o n a l and p r o v i n c i a l t r e n d s and i s s u e s i n the m e n t a l h e a l t h care f i e l d . T h i s content a n a l y s i s generated a p i c t u r e of the ' o f f i c i a l s t o r y * a n d an i n i t i a l i m a g e o f b o t h t h e i n t e r e s t g r o u p s / i n d i v i d u a l s at work and the s t r u c t u r a l context w i t h i n which they operated. ( i i ) A comprehensive review and a n a l y s i s of the documents and w r i t i n g s of the i n t e r e s t g r o u p s / i n d i v i d u a l s i n v o l v e d i n the m e n t a l h e a l t h law r e f o r m p r o c e s s (e.g., the C a n adian M e n t a l Health A s s o c i a t i o n , the Canadian P s y c h i a t r i c A s s o c i a t i o n , mental p a t i e n t s ' a s s o c i a t i o n s , the C a n a d i a n Bar A s s o c i a t i o n , and p r o v i n c i a l government personnel). The m a t e r i a l s , which i n c l u d e d p u b l i s h e d a u t o b i o g r a p h i e s and memoirs, were analysed w i t h a view to e s t a b l i s h i n g : (a) The s p e c i f i c goals of reformers. (b) The p r o f e s s i o n a l involvements and i d e o l o g i c a l commitments of the i n t e r e s t g r o u p s / i n d i v i d u a l s . (c) The r e l a t i o n s h i p between the reformers and the f e d e r a l and 572 p r o v i n c i a l governments. (d) Any apparent c o n f l i c t s with other reformers. (e) The impact of s t r u c t u r a l c o n d i t i o n s , i n c l u d i n g the emergence of the g e n e r a l human r i g h t s movement i n the l a t e 1960's and e a r l y 1970's. ( i i i ) A c o m p r e h e n s i v e r e v i e w and a n a l y s i s of s e c o n d a r y sources d e s c r i b i n g and a n a l y s i n g the economic developments i n Canada during the p e r i o d under examination, with a p a r t i c u l a r emphasis upon the emergence and subsequent a t t e n u a t i o n of the ' w e l f a r e state'. Stage (3) i n v o l v e d a comprehensive search of the hol d i n g s i n the l i b r a r i e s a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a , supplemented by an a n a l y s i s of documents i n the l i b r a r i e s at the i n s t i t u t i o n s i t e m i z e d i n (2) above. In a d d i t i o n , a l l the l e g a l and the major medical j o u r n a l s were reviewed f o r the p e r i o d i n q u e s t i o n ; the l a t t e r i n c l u d e d , Canada's M e n t a l H e a l t h , The Canadian Medical A s s o c i a t i o n J o u r n a l , and The Canadian J o u r n a l of P s y c h i a t r y . (4) An a n a l y s i s of the process of mental h e a l t h law reform i n one province i n order to explore, i n d e t a i l , the r e l a t i o n s h i p between s h i f t s i n s t r a t e g y , law reform, s t r u c t u r a l c o n d i t i o n s , and human agency. A d e t a i l e d a n a l y s i s of the r e l a t i o n s h i p i n every pr o v i n c e and t e r r i t o r y would have been p r e f e r a b l e . However, s i n c e t h i s would have i n v o l v e d a t l e a s t a decade of r e s e a r c h , i t was necessary to focus upon a s i n g l e case study. B r i t i s h Columbia 573 was chosen f o r a number of reasons: (i) The general p a t t e r n of mental h e a l t h law reforms found i n Canada as a whole w a s / i s r e p l i c a t e d i n the p r o v i n c e . In a d d i t i o n , the p r o v i n c e was at the l e a d i n g edge of reform i n the 1960's, was i n v o l v e d i n the r i s e of the new l e g a l i s m at an e a r l y s t a g e , and was one p l a c e where the p a t i e n t s ' r i g h t s movement f l o u r i s h e d . Consequently, there was a p o s s i b i l i t y that reforms i n the p r o v i n c e may have i n f l u e n c e d events elsewhere i n Canada. ( i i ) The c h a n g i n g s t r u c t u r a l c o n d i t i o n s a f f e c t i n g the whole of Canada were and are being experienced i n the p r o v i n c e . ( i i i ) The g e n e r a l h e a l t h and w e l f a r e (and e s p e c i a l l y , mental health) p o l i c i e s of the p r o v i n c i a l government have been and are a m i r r o r of p o l i c i e s elsewhere i n the country. ( i v ) C o n v e n i e n c e ; t h a t i s , the a v a i l a b i l i t y of d e t a i l e d data, i n f o r m a t i o n , and access to key i n d i v i d u a l s and agencies. (v) An o p p o r t u n i t y to o b s e r v e the impact ( i f any) of d i f f e r e n t p r o v i n c i a l p o l i t i c a l p a r t i e s and t h e i r a s s o c i a t e d i d e o l o g i e s , upon the reform process. The choice of B r i t i s h Columbia d i d , however, i n v o l v e some d i f f i c u l t y o r i g i n a t i n g w i t h the ambitious nature of the p r o j e c t . The r e s e a r c h sought to examine two phases of reform which had emerged over a p e r i o d of 40 years, so the f o r e g o i n g b e n e f i t s had to be weighed a g a i n s t s e v e r a l d i s a d v a n t a g e s . W h i l e the p r o v i n c e was an e a r l y c o n t r i b u t o r to the reforms of the 1960's, the emergence of c o m p r e h e n s i v e r e f o r m s to m e n t a l h e a l t h l e g i s l a t i o n , i n keeping w i t h the new l e g a l i s m , has been slower. 574 Indeed, i t may be argued that Ontario would have been a b e t t e r choice. However, Ont a r i o was not at the l e a d i n g edge of reform i n the 1960's and, u n l i k e B r i t i s h C o l u m b i a , d i d not h o s t the emergence of the p a t i e n t s ' r i g h t s movement. Moreover, i t was f e l t t h a t a d e t a i l e d account of events over the 40 year p e r i o d r e q u i r e d a measure of c o n t i n u i t y . T h i s would e n s u r e a f u l l understanding of the development of the mental h e a l t h p o l i c i e s and s t r a t e g i e s w hich u n d e r p i n n e d l e g i s l a t i v e changes. On balance, then, the advantages of s e l e c t i n g B r i t i s h Columbia as a case study outweighed the disadvantages. The focus on developments i n B r i t i s h Columbia was guided by two key q u e s t i o n s ; namely, what form d i d m e n t a l h e a l t h p o l i c y / l a w reform take, and why d i d i t occur? These q u e s t i o n s were answered by f o l l o w i n g a s e r i e s of steps during which every u s e f u l i t e m of i n f o r m a t i o n was e x t r a c t e d , c r o s s - c h e c k e d and v a l i d a t e d by r e f e r e n c e to i n f o r m a t i o n g l e a n e d from the o t h e r s t e p s , and then mapped and i n t e r p r e t e d . The s t e p s were as f o l l o w s : ( i ) A r e v i e w and a n a l y s i s of a r c h i v a l s o u r c e s ; n o t a b l y , the a n n u a l r e p o r t s of a l l the p r o v i n c i a l M i n i s t r i e s i n v o l v e d w i t h mental h e a l t h matters from 1935 to 1987. Foremost among th e s e were the r e p o r t s of the mental h e a l t h s e r v i c e , w h i c h p r o v e d to be an immense and r i c h s o u r c e of q u a n t i t a t i v e and q u a l i t a t i v e data. ( i i ) A r e v i e w and a n a l y s i s o f t h e J o u r n a l s o f t h e L e g i s l a t i v e Assembly of B r i t i s h C o l u m b i a from 1944 to 1987, i n c l u d i n g (from 1971 onwards) Hansard. 575 ( i i i ) A d e t a i l e d r e v i e w and a n a l y s i s of a l l p u b l i c l y a v a i l a b l e government and other documents p e r t a i n i n g to mental h e a l t h p o l i c y and law reform during the p e r i o d , i n c l u d i n g those r e f e r r e d to i n the a r c h i v a l sources examined i n step ( i ) . (iv) A review and a n a l y s i s of p r o v i n c i a l newspapers f o r the p e r i o d s 1960 to 1966, and 1979 onwards. (v) A r e v i e w and a n a l y s i s of the j o u r n a l s p u b l i s h e d by p r o f e s s i o n a l bodies a s s o c i a t e d i n any way wit h mental h e a l t h care and treatment i n the pro v i n c e during the p e r i o d i n qu e s t i o n (e.g., the B r i t i s h Columbia Medical J o u r n a l ) . (vi) D i s c u s s i o n s w i t h key i n d i v i d u a l s working w i t h i n both t h e p a t i e n t s ' r i g h t s movement and r e l e v a n t p r o v i n c i a l M i n i s t r i e s . S i n c e the g o a l of the case s t u d y was a d e t a i l e d a n a l y s i s of s t a t e p r a c t i c e s , i t was f e l t that i n f o r m a t i o n should be o b t a i n e d r e g a r d i n g the c o n s t r u c t i o n of s t r a t e g i e s a t the highest p o s s i b l e l e v e l w i t h i n the s t a t e apparatus. The s t a t e personnel who were c o n s u l t e d are s e n i o r members of the p u b l i c s e r v i c e r e s p o n s i b l e f o r the development of s t a t e p o l i c y i n the area under study and t h e i r a s s i s t a n c e was secured i n order to ob t a i n i n f o r m a t i o n p e r t a i n i n g to both the changes i n s t r a t e g y and l e g i s l a t i o n s i n c e the l a t e 1970's and the government's plans in r e l a t i o n to, (a) the management of the mentally d i s o r d e r e d ; (b) f u r t h e r changes to mental h e a l t h l e g i s l a t i o n ; and, (c) the f a c t o r s a f f e c t i n g d e c i s i o n - m a k i n g . At the r e q u e s t of t h e s e personnel, t h e i r i d e n t i t i e s are known only to the author and h i s s u p e r v i s o r y committee. Of a l l the stages i n the rese a r c h , the case study was the 576 o n l y one to p r e s e n t s i g n i f i c a n t d i f f i c u l t i e s . Three p r i m a r y problems were encountered. F i r s t l y , a v a s t amount o f m a t e r i a l p e r t a i n i n g t o p r o v i n c i a l mental h e a l t h p o l i c i e s and p r a c t i c e s was obtained but, s i n c e the primary goal was to d e s c r i b e and analyse the main s h i f t s i n the s t r a t e g y f o r the management of the m e n t a l l y d i s o r d e r e d ( r a t h e r than p r o v i d e a d e t a i l e d h i s t o r y of the p r o v i n c i a l mental h e a l t h s e r v i c e ) , the data had to be compressed i n t o a r e l a t i v e l y b a s i c o v e r v i e w . F i n e d e t a i l s had to be e x c l u d e d w h i l e s i m u l t a n e o u s l y p r e s e r v i n g a c c u r a c y , and t h i s process r e q u i r e d a c a r e f u l , s e l f - c r i t i c a l reading and a n a l y s i s of i n f o r m a t i o n . E v e r y e f f o r t was made to e n s u r e t h a t the e v e n t s , p r a c t i c e s and t r e n d s which have been d e s c r i b e d and analysed c o n s t i t u t e a comprehensive and accurate account of the a c t i v i t i e s and changes a f f e c t i n g the m e n t a l h e a l t h f i e l d . However, o t h e r a n a l y s t s may o b j e c t to e i t h e r the l a c k of s p e c i f i c d e t a i l or the way i n which some d e t a i l e d i n f o r m a t i o n has been i n c l u d e d f o r the purposes of i l l u s t r a t i o n . Secondly, w h i l e a vast amount of m a t e r i a l was uncovered f o r the p e r i o d between 1945 and the l a t e 1970's, the q u a n t i t y and q u a l i t y of, i n p a r t i c u l a r , o f f i c i a l data sources began to d w i n d l e a f t e r t h a t t i m e . The a n n u a l r e p o r t s of the r e l e v a n t m i n i s t r i e s f o r the 1950's and 1960's can o n l y be d e s c r i b e d as 'immense' and c o n t a i n e d v a s t q u a n t i t i e s of b o t h d e t a i l e d s t a t i s t i c s and r i c h commentary. S i n c e the documents were ' o f f i c i a l ' accounts of events they were i n i t i a l l y approached (and read) wi t h s k e p t i c i s m . I t was assumed, f o r example, that 577 government p e r s o n n e l would p r o v i d e r o u t i n e , r e p e t i t i v e and p r o b a b l y s a n i t i z e d a c c o u n t s o f t h e a c t i v i t i e s o f t h e i r agencies/departments from year to year. However, t h i s was not the case and the documents were found to c o n t a i n a p p a r e n t l y balanced and f r e q u e n t l y candid r e p o r t s of events. By the e a r l y 1980's, however, the documents had been reduced to comparatively meagre p r o d u c t i o n s . The r e a s o n f o r t h i s i s u n c l e a r . I t may have been r e l a t e d to government economic r e s t r a i n t p o l i c i e s which n e c e s s i t a t e d a r e d u c t i o n i n the c o s t of c o m p i l i n g and p r i n t i n g r e p o r t s ; on the o t h e r hand, i t may have been the o u t c o m e o f a g o v e r n m e n t p o l i c y o f l i m i t i n g t h e p u b l i c d i s s e m i n a t i o n of d e t a i l e d i n f o r m a t i o n r e g a r d i n g p o l i c i e s , problems and funding. In a d d i t i o n , the p r o c e s s of r e p o r t i n g , r e c o r d i n g and p r e s e n t i n g s t a t i s t i c s underwent changes duri n g the 1970's and 1980's. In p a r t i c u l a r , the ' r e p o r t i n g y e a r ' f o r p a t i e n t p o p u l a t i o n movement (e.g., the numbers of a d m i s s i o n s and discharges) s h i f t e d from a f i s c a l year to a September-September r e p o r t i n g s y s t e m , w h i l e o p e r a t i n g c o s t s and o t h e r economic i n f o r m a t i o n were s u p p l i e d f o r the f i s c a l year. T h i s complicated (but d i d not d i s t o r t ) the a n a l y s i s of general trends i n the use of (and the c o s t s of operating) i n s t i t u t i o n s . T h i r d l y , the process of r e s e a r c h i n g the c u r r e n t p e r i o d of r e f o r m ( i . e . , from the e a r l y 1980's onwards) e n c o u n t e r e d some d i f f i c u l t i e s . The s i g n i f i c a n c e of, and r e l a t i o n s h i p between, events i s not a b s o l u t e l y c l e a r due to t h e i r temporal p r o x i m i t y . 578 As n o t e d above, o f f i c i a l d a t a s o u r c e s became s p a r s e and the p r o c e s s of s e c u r i n g s u p p l e m e n t a r y i n f o r m a t i o n r e g a r d i n g the i n t e n t i o n s of the p r o v i n c i a l government was impeded by s e v e r a l f a c t o r s : the stormy p o l i t i c a l c l i m a t e i n the province (e.g., the c o n f l i c t between the government and a major p u b l i c s e c t o r union o v e r the d e - i n s t i t u t i o n a l i z a t i o n p r o c e s s ) ; the a c t i v e and c o n t i n u i n g process of p u b l i c c o n s u l t a t i o n i n r e l a t i o n to a new m e n t a l h e a l t h p l a n and a s s o c i a t e d law r e f o r m s ; and, the r e s e a r c h e r ' s a d v o c a c y on b e h a l f o f t h e p a t i e n t s ' r i g h t s movement, h i s p r e s s u r e f o r r e f o r m i n the f i e l d of a d u l t g u a r d i a n s h i p law, and h i s involvement i n the Yukon government p r o j e c t . S e v e r a l w e l l - p l a c e d 'informants' w i t h i n the p r o v i n c i a l bureaucracy were c o n s u l t e d about p o l i t i c a l agendas u n d e r l y i n g p r o s p e c t i v e r e f o r m s , but, w h i l e they p r o v i d e d i n v a l u a b l e i n f o r m a t i o n r e g a r d i n g the general d i r e c t i o n of, i n p a r t i c u l a r , changes to mental h e a l t h l e g i s l a t i o n , they were e i t h e r unable or u n w i l l i n g to d i s c u s s the d e t a i l s of c u r r e n t d e c i s i o n - m a k i n g p r o c e s s e s . The f o r e g o i n g s p e c i f i c methodology, guided by Thompson's s i x g e n e r a l p r i n c i p l e s , g e n e r a t e d the d a t a upon which t h i s t h e s i s r e s t s . The p r i n c i p a l i s s u e s and p r o b l e m s have been i d e n t i f i e d along with both the researcher's p r e d i l e c t i o n s (i.e., an a s s o c i a t i o n w i t h the p a t i e n t s ' r i g h t s movement) and the t h e o r e t i c a l t r a j e c t o r y employed d u r i n g the a n a l y s i s ( i . e . , s t r u c t u r a l M a r xism). A l l the d a t a are p u b l i c l y a v a i l a b l e ; t h e r e f o r e , the f i n d i n g s of the t h e s i s are open to s c r u t i n y and p o s s i b l e r e v i s i o n . 579 BIBLIOGRAPHY A b e l - S m i t h , B. (1964). The H o s p i t a l s : A Study i n S o c i a l Adm i n i s t r a t i o n i n E n g l a n d and Wales. Cambridge: H a r v a r d U n i v e r s i t y P r e s s . A b e l l a , R.S. (1983). Access to Legal S e r v i c e s by the Disa b l e d . Toronto: Queen's P r i n t e r . A l brow, M. (1981). 'Law... i d e o l o g y , s o c i o l o g y ? ' , B r i t i s h J o u r n a l of S o c i o l o g y , 32, 127 - 136. A l f o r d , R. (1975). H e a l t h Cafe P o l i t i c s : I d e o l o g i c a l and I n t e r e s t Group B a r r i e r s t o Reform. C h i c a g o : U n i v e r s i t y of Chicago P r e s s . A l l e n , R.C. & R o s e n b l u t h , G. (Eds.) (1986) R e s t r a i n i n g the Economy. Vancouver: New Star Books. Am e r i c a n P s y c h i a t r i c A s s o c i a t i o n . (1951). S t a n d a r d s F o r P s y c h i a t r i c H o s p i t a l s and C l i n i c s . Washington, D.C.: American P s y c h i a t r i c A s s o c i a t i o n . Anand, R. (1979). 'Involuntary Commitment i n On t a r i o : The Need to C u r t a i l the Abuses of Psychiatry'. Canadian Bar Review, 57, 250 - 267. A p o l l o n i , T. & Cooke, T.P. (Eds). (1984). A New Look a t Guardianship. B a l t i m o r e : Brookes. A p p l e t o n , V.E. (1967). ' P s y c h i a t r y i n Canada a C e n t u r y Ago'. Canadian P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 12, 345 - 361. Armour, P.K. (1981). The Cycles of S o c i a l Reform: Mental Health P o l i c y - M a k i n g i n the U n i t e d S t a t e s , E n g l a n d and Sweden. Washington, D.C.: U n i v e r s i t y Press of America. Balbus, I.D. (1977). The D i a l e c t i c s of Legal Repression. New Je r s e y : T r a n s a c t i o n . Balbus, I.D. (1977a). 'Commodity Form and Legal Form: An Essay on the R e l a t i v e Autonomy of Law', Law and S o c i e t y Review, 11, 571 - 588. Bankowski, Z. & Mungham, G. (1976). Images of Law. London: Routledge & Kegan P a u l . Bankowski, Z. & Mungham, G. (Eds.) (1980). Essays i n Law and S o c i e t y . London: Routledge & Kegan P a u l . B a r t o n , W. & Sanborn, C. (Eds). (1978). Law and the M e n t a l H e a l t h P r o f e s s i o n s : F r i c t i o n a t the I n t e r f a c e . New York: I n t e r n a t i o n a l U n i v e r s i t y Press. 580 Bean, P. (19 80). Compulsory A d m i s s i o n to M e n t a l H o s p i t a l s . C h i c h e s t e r , J. Wiley & Sons. Bean, P. (Ed). (1983). M e n t a l I l l n e s s : Changes and T r e n d s . London: J.Wiley & Sons. B e i r n e , P. (1977). F a i r Rent and L e g a l F i c t i o n . London: MacMillan. Beirne, P. (1979). 'Empiricism and the C r i t i q u e of Marxism on Law and Crime', S o c i a l Problems, 26, 373- 385. Beirne, P. & Quinney, R. (Eds). (1982). Marxism and Law. New York: J . Wiley & Sons. Beirne, P. & S h a r l e t t , R. (Eds.) (1980). Pashukanis: S e l e c t e d W r i t i n g s on Marxism and Law. London: Academic P r e s s . Beis, E.B. (1984). Mental Health and the Law. R o c k v i l l e : Aspen P u b l i c a t i o n s . B l a i r , W.R.N. (1968). Mental Health i n A l b e r t a . A Report on the A l b e r t a Mental Health Study. Edmonton: M i n i s t r y of Health. Bloom, B.L. (1984). Community M e n t a l H e a l t h . Monterey: Brooks/Coles P u b l i s h i n g . B o l g e r , S., C o r r i g a n , R., D o c k i n g , J . & F r o s t , N. (1981). Towards S o c i a l i s t Welfare Work. London: MacMillan. Boyd, N. (Ed.) (1986). The S o c i a l D i m e n s i o n s o f Law. Scarborough: P r e n t i c e - H a l l . B r a d l e y , V. & C l a r k e , G. (1976). Paper V i c t o r i e s and Hard R e a l i t i e s . Washington, D.C.: Georgetown U n i v e r s i t y Press. B r a k e l , S.J., (1981). ' L e g a l A i d i n M e n t a l H o s p i t a l s ' . American Bar Foundation Research J o u r n a l , 21:1, 22 - 93. B r a k e l , S.J., P a r r y , J . & Weiner, B.A. (1985). The M e n t a l l y D i s a b l e d and the Law. 3rd E d i t i o n . C h i c a g o : A m e r i c a n Bar Foundation. B r i t i s h Columbia Medical A s s o c i a t i o n . (1959). 'B r i e f on Mental Health S i t u a t i o n i n B r i t i s h Columbia'. B r i t i s h Columbia M e d i c a l J o u r n a l , 1, 667 - 668. B r i t i s h Columbia M e d i c a l A s s o c i a t i o n . (1964). 'Medical A c t i o n f o r Mental Health'. B r i t i s h Columbia Medical J o u r n a l , 6, 155 -163. B r i t i s h C o l u m b i a M e d i c a l A s s o c i a t i o n . (1986). 'To The Community With Care'. B r i t i s h Columbia Medical J o u r n a l , 28, 315 - 318. 581 Brown, P. (1982). ' P u b l i c P o l i c y and the R i g h t s of M e n t a l P a t i e n t s ' , Mental D i s a b i l i t y Law Reporter, 6:1, 55 - 58. B u r g e s s , T.J.W. ( 1898). 'A H i s t o r i c a l S k e t c h of Our Canadian I n s t i t u t i o n s f o r the Insane'. T r a n s a c t i o n s of the Royal S o c i e t y of Canada, S e c t i o n IV, 3 - 117. B u t l e r , T. (19 85). M e n t a l H e a l t h , S o c i a l P o l i c y and the Law. London: MacMillan. C a l v e r t , J . (1984). Government, L i m i t e d : The C o r p o r a t e Takeover of the P u b l i c Sector i n Canada. Ottawa: Canadian Centre f o r P o l i c y A l t e r n a t i v e s . C a m p b e l l , CM. & W i l e s , P. (Eds.) (1979). Law and S o c i e t y . London: Martin Robertson. Campbell, I.G. (1983). 'Proposed Changes to the Mental Health and C r i m i n a l J u s t i c e Systems i n Queensland'. C r i m i n a l Law J o u r n a l , 7, 179 - 206. Canada's M e n t a l H e a l t h . (1961). 'New M e n t a l H e a l t h Act f o r Saskatchewan'. Canada's Mental Health, 9:10, 4 - 6 . Canada's Mental Health. (1968). 'Ontario's New Mental Health Act', Canada's Mental Health, 16: 3 & 4, 26 - 37. Canada's M e n t a l H e a l t h : E d i t o r i a l . ( 1970). 'Dr. D.G. MacKerracher and Dr. F.S. Lawson', Canada's Mental Health, 18, 31. C a n a d i a n M e d i c a l A s s o c i a t i o n . (1984). H e a l t h : A Need f o r Re- D i r e c t i o n : A Task Force Report on the A l l o c a t i o n of Health Care Resources. Ottawa: Canadian Medical A s s o c i a t i o n . C a n a d i a n M e n t a l H e a l t h A s s o c i a t i o n . (1958). M i l e s t o n e s i n Mental Health. Toronto: Canadian Mental Health A s s o c i a t i o n . C a n a d i a n M e n t a l H e a l t h A s s o c i a t i o n . (1961). M e n t a l H e a l t h S e r v i c e s i n Canada: In t e r i m Reports, 1_ - 6.. Toronto: Canadian Mental Health A s s o c i a t i o n . Caron, P. (1972). 'Obstacles to Reform: Compulsion i n Mental H o s p i t a l s ' , Canada's Mental Health, 22: 3 & 4, 28 - 31. C a r r o l l , W.K., Doyle, C. & Schachter, N. (1984). 'Medicare at Risk', i n Magnusson, W., C a r r o l l , W.K., Doyle, C , Langer, M. & Walker, R.B.J. The New R e a l i t y . Vancouver: New Star Books. C a r s o n , D. (1983). 'Mental P r o c e s s : The M e n t a l H e a l t h A c t , 1983'. J o u r n a l of S o c i a l Welfare Law, 1983, 196 - 211. C a t t e l l , R.B. ( 1 9 8 3 ) . ' L e t ' s End t h e D u e l ' , A m e r i c a n P s y c h o l o g i s t , 38, 769 - 776. 582 C h a l k e , F.C.R. (1962). ' C l a r e n c e M e r e d i t h H i n c k s , M.D.'. Canada's Mental Health, 10:4, 1 - 2. C h a l k e , F.C.R., Swadron, B.B., & G r i f f i n , J.D. (1964). The Law and Mental D i s o r d e r , Volumes 1 & 2. Toronto, Canadian Mental Health A s s o c i a t i o n . C h a l k e , F.C.R., Swadron, B.B., & G r i f f i n , J.D., (1967). The Law and M e n t a l D i s o r d e r , Volume 3. T o r o n t o , C a n a d i a n M e n t a l Health A s s o c i a t i o n . C h a l k e , F.C.R. (1973). 'The Law - A Mousetrap?', C a n a d i a n P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 18, 338 - 339. C h a m b e r l i n , J . (1979). On Our Own: P a t i e n t C o n t r o l l e d A l t e r n a t i v e s to the Mental Health System. New York: McGraw-H i l l . C h a m b l i s s , W. & Seidman, R. (1971). Law, Or d e r and Power. Reading: Addison-Wesley. C h a m b l i s s , W. & Seidman, R. (1982). Law, Or d e r and Power. (2nd E d i t i o n ) Reading: Addison-Wesley. Chan, J . & E r i c s o n , R. (1981). D e c a r c e r a t i o n and the Economy of Penal Reform. Toronto: U n i v e r s i t y of Toronto Research Report. C h r i s t i e , J . (1983). 'Guardianship: The A l b e r t a Experience: A Model For Change'. Health Law i n Canada, 3, 58 - 66. C h r i s t i e , J . (1984). ' G u a r d i a n s h i p i n A l b e r t a : Canada', i n A p o l l o n i , T. & Cooke, T. (Eds.) A New Look a t G u a r d i a n s h i p . Ba l t i m o r e : Brookes. C l a r e , A. (1976). P s y c h i a t r y i n D i s s e n t . London: T a v i s t o c k . C l a g u e , M., D i l l , R., S e e b a r a n , R. & Wharf, B. ( 1 9 8 4 ) . R e f o r m i n g Human S e r v i c e s : The E x p e r i e n c e o f the Community R e s o u r c e s Boards i n B.C.. Vancouver: U n i v e r s i t y o f " B r i t i s h Columbia Press. C l a r k , R.J. (1947). Care of_ the M e n t a l l y 111 i n B r i t i s h C o l u m b i a . U n p u b l i s h e d M.S.W. T h e s i s: S c h o o l of S o c i a l Work, U n i v e r s i t y of B r i t i s h Columbia. Clarkson, J.C. (1973). Mental Health and Re t a r d a t i o n S e r v i c e s i n Manitoba. Winnipeg: Department of Health and S o c i a l S e r v i c e s . C l ement, W. ( 1975). The C a n a d i a n C o r p o r a t e E l i t e . T o r o n t o : M c C l e l l a n d & Stewart. Clement, W. (1977). C o n t i n e n t a l C o r p o r a t e Power. T o r o n t o : M c C l e l l a n d & Stewart. 583 C o a t e s , D.B., K e n d a l l , L.M., McCurdy, E.A., & Goodacre, R.H. (1976). 'Evaluating H o s p i t a l and Home Treatment f o r P s y c h i a t r i c P a t i e n t s : A One-Year Follow-Up', Canada's Mental Health, 24, 28 - 32. Cohen, S. (1985). V i s i o n s of S o c i a l C o n t r o l . Cambridge: P o l i t y P ress. Cohen, S. & S c u l l , A.T. (Eds.) (1983). S o c i a l C o n t r o l and the State. Oxford: M a r t i n Robertson. C o l e s , E.M. (1982). C l i n j ^ c a l P£Y_c h££a__t ho lo gy_. L o n d o n : Routledge & Kegan Paul. Commission D'Enquete s u r l a Sante et l e B i e n E t r e S o c i a l . (1970). C o n t r i b u t i o n a un Pro j e t de L o i - Cadre en Matiere de Maladie Mentale. Annexe 5. Quebec. Committee of E n q u i r y . (1984). The L e g i s l a t i o n o f Concern: Proposals f o r a New Mental Health Care D e l i v e r y Act. Regina, Mental Health A s s o c i a t i o n i n Saskatchewan. Committee on Mental Health S e r v i c e s i n Ontario. (1979). Legal Task Force Report. Toronto: O n t a r i o C o u n c i l of Health. Conrad, P. & Schneider, J.W. (1980). Deviance: From Badness to S i c k n e s s . S t . L o u i s : C V . Mosley. Cooper, D. (1967). P s y c h i a t r y and A n t i - P s y c h i a t r y . London: T a v i s t o c k . Cooper, D. (1971). The Death of the Family. New York: V i n t a g e . C o t t e r r e l l , R. (1981). 'The Development of C a p i t a l i s m and the F o r m a l i z a t i o n of Contract', i n , F r y e r , B., Hunt, A., McBarnet, D. & Moorhouse, B. (Eds.) La w, S t a t e and S o c i e t y . London: Croom Helm. Couburn, D. (1978). 'Patients' Rights - What i s i t they Want?' Health Care i n Canada, 20, 45 - 46. C o u l t e r , J . (1973). Approaches to I n s a n i t y . London: M a r t i n Robertson. C o u l t e r , J . (1979). The S o c i a l C o n s t r u c t i o n of Mind. London: MacMillan. Crane, D. (1981). Beyond The M o n e t a r i s t s . T o r o n t o : James Lorimer. C r i c h t o n , A. (1975). 'Mental H e a l t h and S o c i a l P o l i c i e s : An Overview', Canada's Mental Health, 23: 4 (Supp.). 584 Cumming, J., C o a t e s , D. & Bunton, P. (1976). 'Community Care S e r v i c e s i n Vancouver: I n i t i a l P l a n n i n g and I m p l e m e n t a t i o n ' . Canada's Mental Health, 24:1, 19 - 23. Cuneo, C. (1979). 'State, C l a s s and Reserve Labour: The Case of the 1941 Canadian Unemployment I n s u r a n c e Act', C a n a d i a n Review of S o c i o l o g y and Anthropology. 16, 148 - 159. Cuneo, C. (1980). 'State Mediation of C l a s s C o n t r a d i c t i o n s i n C a n a d i a n Unemployment I n s u r a n c e , 1930 - lgSS'', S t u d i e s i n P o l i t i c a l Economy, 3, 37 - 65. Curran, W.J. & Harding, T.W. (1978). The Law and Mental Health: Harmonizing O b j e c t i v e s . Geneva: World Health O r g a n i z a t i o n . De Sousa S a n t o s , B. (1980). 'Law and Community: The Changing Nature of State Power i n Late C a p i t a l i s m ' , I n t e r n a t i o n a l J o u r n a l of The S o c i o l o g y of Law, 8, 379 - 397. Deaton, R. (1973). 'The F i s c a l C r i s i s of the State i n Canada', i n , R o u s s o p o u l u s , D.I. (Ed.) The P o l i t i c a l Economy o f the S t a t e . M ontreal: Black Rose. Demay, M. (1973). 'The B e g i n n i n g s o f P s y c h i a t r y i n Saskatchewan'. Canada's Mental Health, 21 (Jan), 18 - 24. D e u t s c h , A. (1948). The Shame of the S t a t e s . New York: Harcourt, Brace & Coy. Deutsch, A. (1949). The M e n t a l l y 111 i n America, 2nd E d i t i o n . New York: Columbia U n i v e r s i t y P r e s s . Department of H e a l t h : New South Wales. (1983). I n q u i r y I n t o He a l__t h S e r v i c e s F o r The Psy_c h i a t r i_ca I_l_l_ and The Developmentally D i s a b l e d . Sydney: Department of Health. Department of N a t i o n a l H e a l t h and W e l f a r e . (1954). M e n t a l Health S e r v i c e s i n Canada. Ottawa: Department of N a t i o n a l Health and Welfare. Dickson, I. (1980). 'The CP.A., 1951 - 1958'. Canadian J o u r n a l of P s y c h i a t r y , 25, 86 - 97. D i l t h e y , W. (1961). P a t t e r n and Meaning i n H i s t o r y : Thoughts on H i s t o r y and S o c i e t y . New York: Harper. Domhoff, W. (1967). Who R u l e s A m e r i c a ? . Englewood C l i f f s : P r e n t i c e - H a l l . D o m i n i o n - P r o v i n c i a l C o n f e r e n c e on R e - C o n s t r u c t i o n . (1945). Reference Book: Health, Welfare and Labour. Ottawa: Dominion-P r o v i n c i a l Conference on Re-Construction. D o n z e l o t , J . (1979). The P o l i c i n g of Fam i l i e s . New York: Pantheon Books. 585 Draper, G. (1976). 'Due P r o c e s s and C o n f i n e m e n t f o r M e n t a l Disorder'. A l b e r t a Law Review, 14, 266 - 281. Draper, G. (1976a). The Law and M e n t a l H e a l t h . Edmonton: A l b e r t a Law Foundation. Draper, G. & W i l l i a m s o n , C. (19 76). Lunacy i n L e g i s l a t i o n . Edmonton: A l b e r t a Law Foundation. D r o v e r , G. (1983). 'Beyond the W e l f a r e S t a t e ' , The S o c i a l Worker/Le T r a v a i l l e u r S o c i a l , 51, 141 - 144. Dun l o p , B.D. (1979). The G r o w t h o f N u r s i n g Home C a r e . Lexington: D.C. Heath. Durham, M.L. & La Fond, J.Q. (1987). 'Back to the Asylum: The Future of Mental Health Law i n the United States'. Unpublished paper presented at the 13th I n t e r n a t i o n a l Congress on Law and P s y c h i a t r y , Amsterdam, June 17th - 20th, 1987. Edelman, B. (19 79). O w n e r s h i p of the Image: E l e m e n t s f o r a M a r x i s t Theory of Law. London: Routledge & Kegan P a u l . E d i t o r i a l . (1958). ' R o y a l C o m m i s s i o n (U.K.) on M e n t a l I l l n e s s ' , Canadian P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 3, 18 - 20. E d i t o r i a l . (1960). 'The B r i t i s h M e n t a l H e a l t h A c t , 1959'. Canadian P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 5, 30 - 32. E d i t o r i a l . (1961). ' P a r l i a m e n t and P s y c h i a t r y ' . C a n a d i a n P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 6, 52 - 58. E d i t o r i a l . (1980). ' P a t i e n t ' s R i g h t s ' . B r i t i s h C o l u m b i a Medical J o u r n a l , 22, 335. E d i t o r i a l . (1982). 'Responsible P a t i e n t s ' . B r i t i s h Columbia Medical J o u r n a l , 24, 200. E l - G u e b a l y , N. & P a p i n e a u , D. (1984). 'Economic C o n s t r a i n t s and Q u a l i t y A s s u r a n c e i n M e n t a l H e a l t h S e r v i c e s : S e n s i t i v e I n d i c a t o r s * . Canadian J o u r n a l of P s y c h i a t r y , 29, 115 - 120. E l k i n s , J.R. (1979). 'Legal R e p r e s e n t a t i o n of the M e n t a l l y 111'. West V i r g i n i a Law Review, 82, 157 - 250. E l l i o t , G.R.F. (1 9 5 2 ) . S u r v e y o f H e a l t h S e r v i c e s and F a c i l i t i e s i n B r i t i s h C o l u m b i a i n E x i s t e n c e on December 31st 194 8. V i c t o r i a : Department o f H e a l t h and W e l f a r e , B r i t i s h Columbia. E l p e r s , J.R. (1987). 'Are We L e g i s l a t i n g R e - i n s t i t u t i o n -a l i z a t i o n ? ' . American J o u r n a l of O r t h o p s y c h i a t r y , 57, 441 - 446. 586 Emerson, R. (1981). 'Economics and E n t e r p r i s e i n Board and C a r e Homes f o r t h e M e n t a l l y 111', A m e r i c a n l . £ E ^ v u r a 1_ S c i e n t i s t , 24, 771 - 785. E n n i s , B.J. (19 72). P r i s o n e r s of P s y c h i a t r y . New York: Harcourt Brace. E s p i n g - A n d e r s e n , G., F r i e d l a n d , R. & W r i g h t , E. (1976). 'Modes o f C l a s s S t r u g g l e and t h e C a p i t a l i s t S t a t e ' , K a p i t a l s t a t e , 4-5, 186 - 197. E s t e s , C. & H a r r i n g t o n , C.A. (1981). ' F i s c a l C r i s i s , D e i n s t i t u t i o n a l i z a t i o n , and the E l d e r l y ' , American B e h a v i o u r a l S c i e n t i s t , 24, 811 - 826. E s t r o f f , S. (1981). ' P s y c h i a t r i c D e i n s t i t u t i o n a l i z a t i o n : A S o c i o c u l t u r a l A n a l y s i s ' , J o u r n a l of S o c i a l Issues, 37, 116 -132. Evans, R.G. (1984). S t r a i n e d Mercy: The Economics of Canadian Health Care. Toronto: Butterworths. Evans, R.G. (1986). 'Re s t r a i n i n g Health Care: New R e a l i t i e s and O l d V e r i t i e s ' , i n , A l l e n , R.C. & R o s e n b l u t h , G. (Eds.) R e s t r a i n i n g The Economy. Vancouver: New Star Books. F a c u l t y of Law. (1959). A Report on Mental Health L e g i s l a t i o n i n B r i t i s h Columbia. Vancouver: F a c u l t y of Law, U n i v e r s i t y of B r i t i s h Columbia. Feeley, M.M. (1976). 'The Concept of Laws i n S o c i a l Science: A C r i t i q u e and Notes on an Expanded View', Law and S o c i e t y Review, 10, 497 - 523. F e l t o n , B.J. & S h i n n , M. (1981). ' I d e o l o g y and P r a c t i c e of D e i n s t i t u t i o n a l i z a t i o n ' , J o u r n a l of S o c i a l I s s u e s , 37, 158 -172. Fenton, F.R., T e s s i e r , L., Struening, E.L., Smith, F.A., Benoit, C , Contandriopoulos, A.- P., & Hung, N.Y. (1984). 'A Two-Year Follow-Up of a Comparative T r i a l of the C o s t - E f f e c t i v e n e s s of Home and H o s p i t a l P s y c h i a t r i c Treatment', Canadian J o u r n a l of P s y c h i a t r y , 29, 205 - 210. F i n d l a y , P.C. (1978). 'Theories of the State and S o c i a l Welfare i n Canada', Canadian J o u r n a l of S o c i a l Work, 4, 109 - 128. F i n e , B., K i n s e y , R., Lea, J . , P i c c i o t t o , S. & Young, J . (1979). C a p i t a l i s m and the Rule of Law. London: Hutchinson. F i n k e l , A. (1979). ' O r i g i n s of the W e l f a r e S t a t e i n Canada', i n P a n i t c h , L. (Ed). The Canadian S t a t e : P o l i t i c a l Economy and P o l i t i c a l Power. Toronto: U n i v e r s i t y of Toronto P r e s s . 587 F l e m i n g , T. (Ed.) (1985). The New C r i m i n o l o g i e s i n Canada: St a t e , Crime and C o n t r o l . Toronto: Oxford U n i v e r s i t y P r e s s . F l o r a , P. & H e i d e n h e i m e r , A.J. (Eds.) (1981). The Development of W e l f a r e S t a t e s i n Europe and A m e r i c a . London: T r a n s a c t i o n Books. F o l e y , H.A. (1975). Community Mental Health L e g i s l a t i o n : The Formative Process. Lexington: Lexington Books. F o u c a u l t , M. (1965). Madness and C i v i l i z a t i o n : A H i s t o r y of I n s a n i t y i n the Age of Reason. New York: Vintage Books. F o u l k e s , R.G. ( 1 9 6 1 ) . ' B r i t i s h C o l u m b i a M e n t a l H e a l t h S e r v i c e s : H i s t o r i c a l P e r s p e c t i v e to 1961', C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l , 85, 649 - 655. Foulkes, R. G. (1974). Health S e c u r i t y f o r B r i t i s h Columbians, S p e c i a l R e p o r t , P s y c h i a t r y at the C r o s s r o a d s : A Review. V i c t o r i a , M i n i s t r y of Health: B r i t i s h Columbia. Foulkes, R.G. (1974a). Health S e c u r i t y f o r B r i t i s h Columbians. V i c t o r i a : M i n i s t r y of Health: B r i t i s h Columbia. F r a n c i s , D. (1977). 'The Development of the L u n a t i c Asylum i n the Maritime Provinces', A c a d i e n s i s , Spring, 23 - 28. F r a s e r , A. (1978). 'The Legal Theory We Need Now', S o c i a l i s t Review, 8, 147 - 187. Freeman, S.J.J. (1973). 'Mental H e a l t h and the H a s t i n g s Report', Canada's Mental Health, 21: May/Aug., 3 - 5 . F r e i b e r g , A. (1976). 'Out o f M i n d , Out o f S i g h t ' : The D i s p o s i t i o n of M e n t a l l y Disordered Persons Involved i n C r i m i n a l Proceedings'. Monash U n i v e r s i t y Law Review, 3, 134 - 172. F r i e d m a n , P.R. ( E d ) . ( 1 9 7 9 ) . L e g a l R ^ g h t s of M e n t a l l y Di s o r d e r e d Persons. New York: P r a c t i s i n g Law I n s t i t u t e . Fryer, B. (1981). 'State, Redundancy and the Law', i n Fryer, B., Hunt, A., McBarnet, D. & Moorhouse, B. (Eds.) La w, S t a t e and S o c i e t y . London: Croom Helm. F r y e r , B., Hunt, A., McBarnet, D. & Moorhouse, B. (E d s ) . (1981). Law, State and S o c i e t y . London: Croom Helm. G a b e l , P. (1977). ' I n t e n t i o n and S t r u c t u r e i n C o n t r a c t u a l C o n d i t i o n s : O u t l i n e of a Method f o r C r i t i c a l L e g a l Theory', Minnesota Law Review, 61, 601 - 643. Gagne, R. (Ed). (1973). M e n t a l P a t i e n t s P r o t e c t i o n A c t and J u r i d i c a l Aspects of Mental Diseases. Montreal: Les E d i t i o n s Intermonde. 588 Gee, A.M. (1953). ' D i r e c t o r ' s Report', i n , Department of P r o v i n c i a l S e c r e t a r y , M e n t a l H e a l t h S e r v i c e s , P r o v i n c e of B r i t i s h C o l u m b i a , Annual R e p o r t ; 1952/53. V i c t o r i a : Queen's P r i n t e r . G i l b e r t , N. (1983). C a p i t a l i s m and the W e l f a r e S t a t e . New Haven: Yale U n i v e r s i t y Press. G l e n d a y , D., G u i d o n , H., & T u r o w e t z , A. (Eds.) ( 1 9 7 8 ) . Modernization and the Canadian S t a t e . Toronto: MacMillan. Goffman, E. (1961). Asylums: Essays on the S o c i a l S i t u a t i o n of Mental P a t i e n t s and Other Inmates. Harmondsworth: Penguin. Gold, J.H., Hector, R.I. & Grunberg, F. (1986). 'An Overview of the Canadian Health Care Experience*. H o s p i t a l and Community P s y c h i a t r y , 37, 1115 - 1119. Goldman, B. (1984). 'Can Treatment Be Compulsory?' Canadian Medical A s s o c i a t i o n J o u r n a l , 130, 451 - 453. Goodacre, R.H. & S c h i e l d r o p , P. (1973). ' P s y c h i a t r i c Home Treatment as an A l t e r n a t i v e to Mental H o s p i t a l Care', Canada's Mental Health 21:6, 6 - 7 . Goodacre, R.H., C o l e s , E.M., MaCurdy, E.A., Co a t e s , D.B., & K e n d a l l , L.M. (1975). ' H o s p i t a l i z a t i o n and H o s p i t a l Bed Replacement', Canadian P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 20, 7 -14. Goresky, W.V. (1982). ' R i v e r v i e w Role'. B r i t i s h C o l u m b i a Medical J o u r n a l , 24, 316 - 317. Gordon, R.M. (1981). 'Legal S e r v i c e s f o r M e n t a l H e a l t h P a t i e n t s : Some Commonwealth Developments'. I n t e r n a t i o n a l J o u r n a l of Law & P s y c h i a t r y , 4, 171 - 180. Gordon, R.M. (1981a). L e g a l S e r v i c e s F o r M e n t a l H e a l t h P a t i e n t s , Burnaby: Unpublished M.Al (Crim.) T h e s i s , Simon Fr a s e r U n i v e r s i t y . G o r d o n , R.M. (1 9 8 3 ) . ' L e g a l S e r v i c e s f o r M e n t a l H e a l t h P a t i e n t s : Some O b s e r v a t i o n s on C a n a d i a n and A u s t r a l i a n Developments'. Canadian Community Law J o u r n a l , 6, 17 - 35. Gordon, R.M. & Verdun-Jones, S.N. (1983). 'The Right to Refuse Treatment: Commonwealth Developments and Issues'. I n t e r n a t i o n a l J o u r n a l of Law £ P s y c h i a t r y , 6, 57 - 73. Gordon, R.M. & Verdun-Jones, S.N. (1986). 'Mental H e a l t h Law and Law Reform i n the Commonwealth: The R i s e of the New L e g a l i s m ? ' , i n W e i s s t u b , D. (Ed), M e n t a l H e a l t h and Law: I n t e r n a t i o n a l P e r s p e c t i v e s Volume 2. Toronto: Pergamon Press. 589 Gordon, R.M. & Verdun-Jones, S.N. (1986a). ' P r i v a t i z a t i o n and P r o t e c t i v e S e r v i c e s For the E l d e r l y : Some Observations on the Economics of the Aging Process', I n t e r n a t i o n a l J o u r n a l of Law £ P s y c h i a t r y , 8, 311 - 325. Gordon, R.M. & Verdun-Jones, S.N. (1987). 'The Impact of the Cana d i a n C h a r t e r of R i g h t s and Freedoms on C a n a d i a n M e n t a l Health Law: The Dawn of a New Era or Business as Usual?', Law, Medicine and Health Care, 14, 190 - 197. Gordon, R.M. & Verdun-Jones, S.N. (1987a). 'The I m p l i c a t i o n s of the Can a d i a n C h a r t e r o f R i g h t s and Freedoms For the Law R e l a t i n g t o G u a r d i a n s h i p and T r u s t e e s h i p ' , I n t e r n a t i o n a l J o u r n a l of Law ji Psychiaty. 10, 21 - 34. Gordon, R.M., Verdun-Jones, S.N. & M a c D o u g a l l , D. (1986). S t a n d i n g i n T h e i r Shoes: G u a r d i a n s h i p , T r u s t e e s h i p and the E l d e r l y i n Canada. Ottawa: S o c i a l S c i e n c e s and H u m a n i t i e s Research C o u n c i l . G o s t i n , L.O. (1977). A Human Condi t i o n (2 Volumes). London: MIND. G o s t i n , L.O. (1979). 'The M e r g e r o f I n c o m p e t e n c y and C e r t i f i c a t i o n : The I l l u s t r a t i o n of Unauthorized Medical Contact i n the P s y c h i a t r i c Context'. I n t e r n a t i o n a l J o u r n a l qf_ Law P s y c h i a t r y , 2, 127 - 139. G o s t i n , L.O. (1982). 'Human R i g h t s , J u d i c i a l Review and the Me n t a l l y Disordered Offender', C r i m i n a l Law Review, 1982, 779 -793. G o s t i n , L.O. (1983a). A P r a c t i c a l Guide to Mental Health Law: The Mental Health Act, 1983. London: MIND. Go s t i n , L.O. (1983b). The Court of P r o t e c t i o n . London: MIND. G o s t i n , L.O. ( 1 9 8 3 c ) . ' C o n t e m p o r a r y S o c i a l H i s t o r i c a l P e r s p e c t i v e s on Mental Health Reform'. J o u r n a l of Law S o c i e t y , 10, 47 - 70. G o s t i n , L.O. (19 8 3 d ) . 'The I d e o l o g y o f E n t i t l e m e n t : The A p p l i c a t i o n of Contemporary Legal Approaches to Psychiatry', i n Bean, P. (Ed). M e n t a l I l l n e s s : Changes and Tr e n d s . London: J.Wiley & Sons. Gough, I. (19 79). The P o l i t i c a l Economy of the Welfare State. London: MacMillan. Gove, W. (19 75). The L a b e l l i n g of_ D e v i a n c e : E v a l u a t i n g a P e r s p e c t i v e . New York: Sage. Grace, C. & W i l k i n s o n , P. (1978). S o c i o l o g i c a l I n q u i r y and Legal Phenomena. London: C o l l i e r M a c M i l l a n . 590 Gray, B.H. (Ed.) (1983). The New H e a l t h Care F o r P r o f i t ; Doctors and H o s p i t a l s i n a_ Competitive Environment. Washington: N a t i o n a l Academy Press. Gray, K.C. (1960). ' L e g i s l a t i o n and Mental I l l n e s s ' . Canadian H o s p i t a l , 37:3, 51 - 55. Greenaway, W.K. & B r i c k e y , S.L. (Eds.) (1978). Law and S o c i a l C o n t r o l i n Canada. Scarborough: P r e n t i c e - H a l l . Gregory, J. (1979). 'Sex D i s c r i m i n a t i o n , Work and the Law', i n F i n e , B., K i n s e y , R., Lea, J., P i c c i o t t o , S. & Young, J . (Eds.) C a p i t a l i s m and the Rule of Law. London: Hutchinson. G r i f f i n , J.D. ( 1 9 6 7 ) . ' P l a n n i n g P s y c h i a t r i c S e r v i c e s : H i s t o r i c a l Perspective', Medical S e r v i c e s J o u r n a l of Canada, 23, 1245 - 1260. Grob, G.N. (1973). M e n t a l H e a l t h I n s t i t u t i o n s i n A m e r i c a : S o c i a l P o l i c y to 1875. New York: Free P r e s s . Grob, G.N. (1983). Mental I l l n e s s and American S o c i e t y : 1875 -1940. P r i n c e t o n : P r i n c e t o n U n i v e r s i t y P r e s s . Guest, D. (1985). The Emergence of S o c i a l S e c u r i t y i n Canada. 2nd E d i t i o n . Vancouver: U n i v e r s i t y of B r i t i s h Columbia Press. Gunn, M.J. (1983). ' L e g i s l a t i o n : M e n t a l H e a l t h (Amendment) Act, 1982', The Modern Law Review, 46, 318 - 329. Gunningham, N. (1974). P o l l u t i o n , S o c i a l I n t e r e s t and the Law. London: Ma r t i n Robertson. Hadden, T. (1975). Company Law and C a p i t a l i s m . London: Weidenfeld & N i c h o l s o n . H a l l , Hon. E.M., (1980). Canada's N a t i o n a l - P r o v i n c i a l Health Program For The 1980. Ottawa: Health and Welfare, Canada. H a l l , S., C r i t c h e r , C , J e f f e r s o n , T., C l a r k e , J. & Roberts, B. (19 7 8). P o l i c i n g the C r i s i s : Mugging, S t a t e , and the Law. London: MacMillan. Handler, J.F. (1978). S o c i a l Movements and the Legal System: A Theory of Law Reform and S o c i a l Change. New York: Academic Pr e s s . H a s t i n g s , J . (1972). The Communi t y H e a l t h C e n t r e i n Canada. Ottawa: Information Canada. Hay, D., L i n e b a u g h , P., Rule, J., Thompson, E.P. & Winslow, C. (1975). A l b i o n ' s F a t a l Tree. New York: Pantheon. H e a l t h & W e l f a r e : Canada. (1982). M e n t a l H e a l t h S e r v i c e s i n Canada. Ottawa: Health & Welfare: Canada. 591 Health & Welfare: Canada. (1983). N a t i o n a l Health Expenditures i n Canada, 1970 - 1982. Ottawa: Health & Welfare: Canada. Hell o n , CP. (1973). *A L e g i s l a t i v e Approach to Mental Health Programs: M e n t a l H e a l t h L e g i s l a t i o n i n A l b e r t a ' . C a nadian P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 18, 335 - 337. H e n d e r s o n , H.W. (1 9 7 1 ) . ' M e n t a l H e a l t h D e v e l o p m e n t s i n Ontario'. Canada's Mental Health, 19: March & May, 13 - 16, 7 -10. H e p b u r n , A.W. (1 9 8 0 ) . ' P a t i e n t s R i g h t s and t h e D u t c h Clientenbond', Canada's Mental Health, 28:3, 16 - 18. Heydon, J.D. (1980). ' R e s t r i c t i v e Trade P r a c t i c e s and U n f a i r Competition', i n Kamenka, E. & Ehr-Soon Tay, A. Law and S o c i a l C o n t r o l . London: Edward A r n o l d . H i d a y , V.A. (1983). ' S o c i o l o g y o f M e n t a l H e a l t h Law', So c i o l o g y and S o c i a l Research, 67, 111 - 128. H i l l , B.P. (1977). ' C i v i l Rights of The P s y c h i a t r i c P a t i e n t i n Quebec'. Revue J u r i d i q u e Themis, 12, 503 - 529. H i m m e l f a r b , A. & L a z a r , A. (1981). L e g a l A i d For M e n t a l P a t i e n t s : An E v a l u a t i o n Report. Ottawa: Department of J u s t i c e . H i n c k s , CM. (1962). 'Our H e r i t a g e 1 . Canada's M e n t a l H e a l t h , 10:4, 2 - 5 . H i r s t , P. (1979). On Law and Ideology. London: MacMillan. Hoaken, P.C.S. (1986). ' P s y c h i a t r y , C i v i l L i b e r t y , and Invo l u n t a r y Treatment'. Canadian J o u r n a l of P s y c h i a t r y , 31, 222 - 226. Hoffman, B.F. (1985). 'The Impact of New E t h i c s and Laws on E l e c t r o c o n v u l s i v e Therapy', C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l , 132, 1366 - 1368. Hoggett, B. (1984). Mental Health Law. London: Sweet & Maxwell. H o l l o w a y , J . & P i c c i o t t o , S. (1978). S t a t e and C a p i t a l . London: Edward A r n o l d . Horowitz, A.V. (1982). The S o c i a l C o n t r o l of Mental I l l n e s s . New York: Academic P r e s s . Hunt, A. (1978). The S o c i o l o £ i c a l Movement^ i n Law. P h i l a d e l p h i a : Temple U n i v e r s i t y P r e s s . Hunt, A. (1980). 'The R a d i c a l C r i t i q u e of Law: An Assessment', I n t e r n a t i o n a l J o u r n a l of the S o c i o l o g y of Law, 8, 33 - 46. 592 Hunt, A. (1981). 'Dichotomy and C o n t r a d i c t i o n i n the S o c i o l o g y of Law', B r i t i s h J o u r n a l of Law and S o c i e t y , 8, 47 - 77. Hunt, A. (1981a). 'Marxism and the A n a l y s i s of Law', in,. P o d g o r e c k i , A. & Whelan, C. (Eds.) S o c i o l o g i c a l Approaches to Law. London: Croom Helm. Hurd, H.M. (Ed). (1917). The I n s t i t u t i o n a l Care o f the Insane i n the United S t a t e s and Canada. B a l t i m o r e . Hutchison, J.A. (1981). 'College Reports'. B r i t i s h Columbia Medical J o u r n a l , 23, 579. I g n a t i e f f , M. (1978). A J u s t Measure of Pain: The P e n i t e n t i a r y i n the I n d u s t r i a l R e v o l u t i o n , 1750 - 1850. London: MacMillan. I l l i c h , I. (1975). Medical Nemesis. New York: Pantheon. Ingleby, D. (Ed). (1981). C r i t i c a l P s y c h i a t r y : The P o l i t i c s of Mental Health. Harmondsworth: Penguin. J a c o b s , D. (1980). 'Marxism and the C r i t i q u e of E m p i r i c i s m : A Comment on Beirne', S o c i a l Problems, 27, 467 - 469. J e s s o p , B. (1980). 'On Recent M a r x i s t T h e o r i e s of Law, the St a t e , and J u r i d i c o - P o l i t i c a l Ideology'. I n t e r n a t i o n a l J o u r n a l of S o c i o l o g y of Law, 8, 339 - 356. J e s s o p , B. (1982). The C a p i t a l i s t S t a t e . O x f o r d : M a r t i n Robertson. J o n e s , D.P. & De V i l l a r s , A.S. ( 1985 ). P r i n c i g l e s of A d m i n i s t r a t i v e Law. Toronto: C a r s w e l l . Jones, K. (1955). Lunacy Law and C o n s c i e n c e 174 4 - 1845: The S o c i a l Hi s t o r y of the Care of the Insane. London: R o u t l e d g e & Kegan Paul. Jones, K. (1960). Mental Health and S o c i a l P o l i c y 1845 - 1959. London: Routledge & Kegan Paul. Jones, K. (1972). A H i s t o r y of the M e n t a l H e a l t h S e r v i c e . London: Routledge & Kegan Paul. Jones, K. (1980). 'The L i m i t a t i o n s of the L e g a l Approach to Mental Health'. I n t e r n a t i o n a l J o u r n a l of Law & P s y c h i a t r y , 3, 1 - 7. K a i s e r , H.A. (1986). ' I n v o l u n t a r y P s y c h i a t r y i n Nova S c o t i a ' . Dalhousie Law J o u r n a l , 10, 211 - 224. K a i s e r , H.A. (1986a). ' L e g a l S e r v i c e s f o r the M e n t a l l y 111: A Polemic and a Plea'. U n i v e r s i t y of New Brunswick Law J o u r n a l , 35, 89 - 110. 593 Katz, A. & Larsen, N. (1975). "Guide to the Mental Health Act of Manitoba" . Legal Aid Manitoba News, August, 1975, 2 - 14. K e r f o o t , C. (Ed.) (1974). M e n t a l D i s o r d e r and t h e Law. Vancouver: U.B.C. Centre f o r Continuing E d u c a t i o n . Kirby, M. (1981). "Mental Health Law Reform: The "Second Wave". Medical J o u r n a l of A u s t r a l i a , 1, 421 - 424. K i t t r i e , N. (1971). The R i g h t to be D i f f e r e n t : D e v i a n c e and Enforced Therapy. B a l t i m o r e : PenguTh. Kla r e , K.E. (1982). ' J u d i c i a l D e - r a d i c a l i z a t i o n of the Wagner Act and the O r i g i n s of Modern Legal Consciousness*, i n Beirne, P. & Quinney, R. (Eds.) Marxism and Law. New York: J.Wiley. Kopolow, L. (1979). 'Consumer Demands i n Mental Health Care', I n t e r n a t i o n a l J o u r n a l of Law £ P s y c h i a t r y , 2, 263 - 278. Kopolow, L. & Bloom, H. (Eds). (1977). Mental Health Advocacy: An Emerging Force i n Consumers' Rights. Washington, D.C.: United S t a t e s Department of Health, Education & Welfare. Krause, E. (19 77). Power and I l l n e s s : P o l i t i c a l S o c i o l o g y of Health and Medical Care. New York: E l s e v i e r - N o r t h H o l l a nd. K r e y e s , W. (1969). 'Human Freedom and M e n t a l I l l n e s s 1 . Canadian P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 14, 409 - 412. La F r a n c e , A.B. (1982). I m p r o v i n g P r o t e c t i v e S e r v i c e s f o r Older Americans: Legal Role. P o r t l a n d : Center f o r Research and Advanced Study, U n i v e r s i t y of Southern Maine. Laing, R.D. (1961). The D i v i d e d S e l f . London: T a v i s t o c k . Laing, R.D. (1967). The P o l i t i c s of Experience. Harmondsworth: Penguin. L a i n g , R.D. & E s t e r s o n , A. ( 1970). S a n i t y , Madness and the Family. Harmondsworth: Penguin. Lane, J.G. (1984). Compliance of Saskatchewan Laws with the Canadian Charter of Rights and Freedoms. Regina, M i n i s t r y of J u s t i c e : Saskatchewan. Langdon, F.J. (1980). R e p o r t on the Death of Thomas Hagan. St. John's: Department of J u s t i c e : Newfoundland & Labrador. L a n g l o i s , L. (1976). 'The E v o l u t i o n of the L e g a l S t a t u s of Mental P a t i e n t s i n Quebec and O n t a r i o : A Comparison'. Canada's Mental Health, 24:3, 5 - 9 . Law Reform Commission of Saskatchewan. (1981). T e n t a t i v e P r o p o s a l s f o r a G u a r d i a n s h i p A c t . S a s k a t o o n : Law Reform Commission. 594 Law Reform Commission of Saskatchewan. (1981a). T e n t a t i v e Proposals f o r a Compulsory Mental Health Care Act. Saskatoon, Law Reform Commission. Lawson, F.S. (1958). 'Mental H o s p i t a l s : T h e i r S i z e and Fu n c t i o n ' , Canadian J o u r n a l of P u b l i c Health, 49, 187 - 195. Le Grand, J . & Robinson, R. (Eds.) (1984). P r i v a t i s a t i o n and the Welfare State. London: A l l e n & Unwin. L e i g h t o n , A.H. (1982). C a r i n g F o r M e n t a l l y 111 P e o p l e . Cambridge: Cambridge U n i v e r s i t y P r e s s . Lerman, P. (1982). D e - i n s t i t u t i o n a l i z a t i o n and the W e l f a r e S t a t e . New J e r s e y : Rutgers U n i v e r s i t y P r e s s . Lightman, E.S. (1986). 'The Impact of Government Economic R e s t r a i n t On Mental Health S e r v i c e s i n Canada, Canada's Mental Health, 34, 24 - 28. Lindman, F.T. & Mclntyre, D.M. (1961). The M e n t a l l y D i s a b l e d and the Law. Washington: American Bar Foundation. Lowman, J . , M e n z i e s , R. & P a l y s , ' T. (Eds.) (1988). T r a n s - c a r c e r a t i o n . A l d e r s h o t : Gower P u b l i s h i n g . McCormick, W.O. (1981). ' I n v o l u n t a r y Commitment i n O n t a r i o : Some B a r r i e r s t o the P r o v i s i o n o f P r o p e r C a r e 1 . C a n a d i a n Medical A s s o c i a t i o n J o u r n a l , 124, 665 - 667. McCready, J . & Merskey, H. (1982). 'On the Recording of Mental I l l n e s s f o r C i v i l Commitment'. Canadian J o u r n a l of P s y c h i a t r y , 27, 140 - 143. McDonald, L. (1976). The So c i o l o g y of Law and Order. London: Faber & Faber. M c F a r l a n e , W.J.G., Bowman, R.G. & M a c l n n e s , M. (1 9 8 0 ) . 'Patient Access to H o s p i t a l Records: A P i l o t P r o j e c t ' , Canadian J o u r n a l of P s y c h i a t r y , 25, 497 - 502. McLaughlin, P. (1979). Guardianship of the Person. Downsview: N a t i o n a l I n s t i t u t e on Mental R e t a r d a t i o n . M c M u l l a n , J.L. & Ratner, R.S. (1983). ' S t a t e , Labour, and J u s t i c e i n B r i t i s h Columbia', i n F l e m i n g , T. & V i s a n o , L.A. (Eds.) Deviant D e s i g n a t i o n s : Crime, Law and Deviance i n Canada. Toronto: Butterworths. McNeel, B.H. & L e w i s , C.H. (1960). 'Care of the M e n t a l l y 111 i n O n t a r i o ' , C a n a d i a n H o s p i t a l , 37:2, 34 - (102), 37:3, 48 -(106) . MacKeen, H.P. (1970). R e p o r t of the Ro y a l Commission on the H a l i f a x County H o s p i t a l . H a l i f a x : Department of Health. 595 M a c K e r r a c h e r , D.G. (1964). T r e n d s i n P s y c h i a t r i c Care. Ottawa: Queen's P r i n t e r . Maddison, J . (1978). 'Mindless M i l i t a n t s ? P s y c h i a t r y and the U n i v e r s i t y ' , i n Greenaway, W.K. & B r i c k e y , S.L. (Eds.) Law and S o c i a l C o n t r o l i n Canada. Scarborough: P r e n t i c e H a l l . Mahar, A.L. (1980). ' G u a r d i a n s h i p of Low Income E l d e r l y : One Community's A l t e r n a t i v e t o I n s t i t u t i o n a l i z a t i o n ' . The G e r o n t o l o g i s t , 20, 154 - 170. Main, W. (1970). 'Mental Health and the Royal Commission on C i v i l Rights'. Canada's Mental Health, 18, 13 - 17. Manitoba Law Reform Commission. (1979). Report on Emergency A p p r e h e n s i o n , A d m i s s i o n s , and R i g h t s of P a t i e n t s Under 'The Mental Health Act'. Winnipeg: Manitoba Law Reform Commission. Marchak, M.P. (1981). I d e o l o g i c a l P e r s p e c t i v e s on Canada. (2nd E d i t i o n ) Toronto: McGraw H i l l - R y e r s o n . M a r l e t t , N. (1980). I s s u e s of Competence and the Dependent Adults Act. Edmonton: O f f i c e of the P u b l i c Guardian: A l b e r t a . M a r s h a l l , C. (1962). 'The Nova S c o t i a M e n t a l H e a l t h Plan', Canada's Mental Health, 10, Supp. 28. M a r s h a l l , C. (1973). 'A L e g i s l a t i v e Approval to Mental Health Programs', Canadian P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 18, 340 -343. M a r s h a l l , J . (1982). Madness: An I n d i c t m e n t of the M e n t a l Health Care System i n O n t a r i o . Toronto: O n t a r i o P u b l i c S e r v i c e Employees Union. M a r s h a l l , V. & Hughes, D. (1974). 'Nothing E l s e But Mad: C a n a d i a n L e g i s l a t i v e T rends i n the L i g h t of Modes of M e n t a l I l l n e s s and T h e i r I m p l i c a t i o n s f o r C i v i l L i b e r t i e s , ' i n , Haas, J . & S h a f f i r , B. (Eds.) D e c e n c y and D e v i a n c e . T o r o n t o : M c C l e l l a n d & Stewart. M a r t i n , B.A. (1985). ' C r i t e r i a f o r C i v i l C o m m i t m e n t : Me d i c o l e g a l Impasse 1, i n Webster, CD., Ben-Aron M.H. & Hucker, S.J. (Eds). Dangerousness. Cambridge: Cambridge U n i v e r s i t y P r e s s . M a r t i n , B.A. & Cheung, K.D. (1985). ' C i v i l Commitment Trends i n O n t a r i o : The E f f e c t of L e g i s l a t i o n on C l i n i c a l P r a c t i c e ' . Canadian J o u r n a l of P s y c h i a t r y , 30, 259 - 264. M a r t i n , B.A., Kedward, H.B., & E a s t w o o d , M.R., ( 1 9 7 6 ) . ' H o s p i t a l i z a t i o n f o r M e n t a l I l l n e s s : E v a l u a t i o n of A d m i s s i o n T r e n d s from 1941 t o 1971'. C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l , 115, 322 - 325. 596 Massad, P. & S a l e s , B. (1981). " G u a r d i a n s h i p : An A c c e p t a b l e A l t e r n a t i v e t o I n s t i t u t i o n a l i z a t i o n ? ' . A m e r i c a n B e h a v i o u r a l S c i e n t i s t , 24, 755 - 767. Matthews, R. (1979). " D e c a r c e r a t i o n ' and the F i s c a l C r i s i s ' , i n F i n e , B., K i n s e y , R., Lea, J . , P i c c i o t t o , S. & Young, J . (Eds.) C a p i t a l i s m and the Rule of Law. London: Hutchinson. Mazar, D. (1978). 'Mental I l l n e s s and the Law', i n , Greenaway, W.K. & B r i c k e y , S.L. (Eds.) Law and S o c i a l C o n t r o l i n Canada. Scarborough: P r e n t i c e - H a l l . Mechanic, D. (1969). Mental Health P o l i c y and S o c i a l P o l i c y . Englewood C l i f f s : P r e n t i c e - H a l l . M e n t a l H e a l t h Branch. (1970). A Summary of the Growth and Development of Mental Health F a c i l l t i e s and S e r v i c e s i n B r i t i s h Columbia, 1850 - 1970. V i c t o r i a : Department of Health S e r v i c e s and H o s p i t a l Insurance. Menuck, M. & L i t t m a n , S.K. (1982). ' I n v o l u n t a r y A d m i s s i o n to H o s p i t a l and Treatment i n O n t a r i o : Is Pessimism Among P h y s i c i a n s Warranted?' Canadian Medical A s s o c i a t i o n J o u r n a l , 126, 1168 -1171. M i l e s , A. (1981). The M e n t a l l y 111 i n Contemporary S o c i e t y . Oxford: Martin Robertson. M i l e s , J . (1982). ' S i x t y Y e a r s of P r o g r e s s ? A C r i t i c a l Comparison of the B.C. Mental Health Planning Reports of 1919 and 1979'. B r i t i s h Columbia Medical J o u r n a l , 24, 24 - 26. M i l i b a n d , R. (1969). The State i n C a p i t a l i s t S o c i e t y . London: Weindenfeld & N i c h o l s o n . M i l i b a n d , R. (1983). C l a s s Power and S t a t e Power. London: Verso. M i l l e r , A. (1979). 'The O n t a r i o M e n t a l H e a l t h A c t , 1978: A Comment on i t s A p p l i c a t i o n ' , Canadian J o u r n a l of P s y c h i a t r y , 24, 515 - 516. M i l l i k e n , A.D. (1983). "Medical C e r t i f i c a t i o n of the M e n t a l l y 111: A P r o t e c t i o n f o r the I n d i v i d u a l ' s R i g h t s ' . Canadian J o u r n a l of P s y c h i a t r y , 28, 137 - 143. M i l l i k e n , A.D. (1987). 'The U n i f o r m M e n t a l H e a l t h A c t : A C l i n i c i a n ' s Questions'. Health Law i n Canada, 7:3, 76 - 85. M i l l i k e n , A.D. & O s i n c h u k , J.W. (1 9 8 4 ) . ' M e d i c a l C e r t i f i c a t i o n , C i v i l Commitment and the P r o t e c t i o n of Rights'. Canadian Medical A s s o c i a t i o n J o u r n a l , 130, 1271 - 1272. MIND, (1981). A l t e r n a t i v e s to Mental H o s p i t a l s : Report of the European Workshop. London: MIND. 597 M i n i s t e r ' s Committee (The). (1982). R e p o r t on R i g h t s and P r o t e c t i v e L e g i s l a t i o n f o r I n t e l l e c t u a l l y Handicapped Persons. Melbourne: M i n i s t r y of Health: V i c t o r i a . M i n i s t r y of F i n a n c e : B r i t i s h C o l u m b i a . (1982). Economic Review: 1982. V i c t o r i a : M i n i s t r y of Finance. M i n i s t r y of H e a l t h : B r i t i s h C o l u m b i a . (1979). M e n t a l H e a l t h Planning Survey: Report. V i c t o r i a : M i n i s t r y of Health. M i n i s t r y of Health: B r i t i s h Columbia. (1981). H o s p i t a l Role Study: A D i s c u s s i o n Paper on H o s p i t a l S e r v i c e s i n B r i t i s h Columbia. V i c t o r i a : M i n i s t r y of H e a l t h . M i n i s t r y of H e a l t h : B r i t i s h C o l u m b i a . (1987). M e n t a l H e a l t h C o n s u l t a t i o n Report: A D r a f t Plan to Replace Riverview H o s p i t a l . V i c t o r i a : M i n i s t r y of Health. M i n i s t r y of H e a l t h : Newfoundland. (1983). R e p o r t o f the M i n i s t e r ' s A d v i s o r y Com m i t t e e on the M e n t a l H e a l t h A c t . S t . John's: M i n i s t r y of Health. M i n i s t r y of Health: O n t a r i o . (1979). Rights and Responsib- i l i t i e s : The M e n t a l H e a l t h A c t , 1978. T o r o n t o : M i n i s t r y of Health, O n t a r i o . M i n i s t r y of S o c i a l S e r v i c e s and Community H e a l t h : A l b e r t a . (1983). R e p o r t of the Task F o r c e on the M e n t a l H e a l t h A c t . Edmonton: M i n i s t r y of S o c i a l S e r v i c e s and Community Health. M i s h r a , R. (1984). The W e l f a r e S t a t e i n C r i s i s . B r i g h t o n : Wheatsheaf Books. M o r l e y , J.T., R u f f , N.J., Swainson, N.A., W i l s o n , R.J. & Young, W.D. (1983). The Reins of Power: Governing B r i t i s h Columbia. Vancouver, Douglas & M c l n t y r e . M o r r i s , G.H. (1978). ' C o n s e r v a t o r s h i p f o r the ' G r a v e l y D i s a b l e d ' : C a l i f o r n i a ' s N o n d e c l a r a t i o n of Non-independence'. I n t e r n a t i o n a l J o u r n a l of Law £ P s y c h i a t r y , 1, 395 - 426. M o r r i s , G.H. (1980). 'The Use of Guardianships to Achieve - or to A v o i d - the L e a s t R e s t r i c t i v e A l t e r n a t i v e ' . I n t e r n a t i o n a l J o u r n a l of Law £ P s y c h i a t r y , 3, 97 - 117. M o s c o v i t c h , A. & A l b e r t , J . (Eds.) (1987). The 'Benevolent' S t a t e : The Growth of Welfare i n Canada. Toronto: Garamond P r e s s . Moscovitch, A. & Drover, G. (Eds.) (1981). I n e q u a l i t y : Essays on the P o l i t i a l Economy o f the S o c i a l W e l f a r e . T o r o n t o : U n i v e r s i t y of Toronto P r e s s . Murphy, H.B.M. (1972). ' F o s t e r Homes: The New Backwards?' Canada's Mental Health, 22, Supp. 71. 598 Myers, D., F i t z g e r a l d , D. & B a l l , J . (1981). R e p o r t of the C o n s u l t a t i v e C o u n c i l of Review of M e n t a l H e a l t h L e g i s l a t i o n . Melbourne: M i n i s t r y of Health: V i c t o r i e u N a y l o r , T. (1975). The H i s t o r y of C a n a d i a n B u s i n e s s : 1867 j-1914. Volumes I & I I . Toronto: James Lorimer. N i o s i , J . (1981). Canadian C a p i t a l i s m . Toronto: James Lorimer. Noble, P. (1981). 'Mental H e a l t h S e r v i c e s and L e g i s l a t i o n : An H i s t o r i c a l Review'. Medical Science and the Law, 21, 16 - 21. O'Connor, J. (1973). The F i s c a l C r i s i s of the State. New York: S t . M a r t i n ' s P r e s s. O' S u l l i v a n , J . (1981). Mental Health and the Law. Sydney: Law Book Company. O l s e n , D. (1980). The S t a t e E l i t e . T o r o n t o : M c C l e l l a n d & Stewart. Ontario A s s o c i a t i o n of S o c i a l Workers. (1979). Mental Health S e r v i c e s i n O n t a r i o . T o r o n t o : O n t a r i o A s s o c i a t i o n of S o c i a l Workers. O r g a n i z a t i o n f o r Economic Co-operation and Development. (1981). The Welfare State i n C r i s i s . Geneva: O.E.C.D. Page, S. (1976). 'Towards E v a l u a t i n g the M e a n i n g f u l n e s s of Legal Counsel f o r P s y c h i a t r i c P a t i e n t s ' , Canada's Mental Health, 24: 3, 6 - 11. Page, S. (1980). 'New C i v i l Commitment L e g i s l a t i o n : The R e l e v a n c e of Commitment ' C r i t e r i a " . C a n a d i a n J o u r n a l of P s y c h i a t r y , 25, 646 - 650. Page, S. (1981). ' C i v i l Commitment: O p e r a t i o n a l D e f i n i t i o n of New C r i t e r i a ' , Canadian J o u r n a l of P s y c h i a t r y , 26, 419 - 420. Page, S. & F i r t h , J . (1979). ' C i v i l Commitment P r a c t i s e s i n 1977: T r o u b l e d S e m a n t i c s or T r o u b l e d P s y c h i a t r y ' . C a n a d i a n J o u r n a l of P s y c h i a t r y , 24, 329 - 335. Page, S. & Yates, E. (1973). ' C i v i l Commitment and the Danger Mandate'. Canadian P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 18, 267 -271. Page, S. & Yates, E. (1974). 'Semantics and C i v i l Commitment', Canadian P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 19, 413 - 414. P a n i t c h , L. (Ed.) (1979). The C a n a d i a n S t a t e : P o l i t i c a l Economy and P o l i t i c a l Power. T o r o n t o : U n i v e r s i t y of T o r o n t o P r e s s . 599 Parry, J . (1984). 'Right to Refuse P s y c h o t r o p i c Medication'. Mental and P h y s i c a l D i s a b i l i t y Law Reporter, 8, 82 - 85. P a r t i n g t o n , M. (1980). ' L a n d l o r d and T e n a n t : The B r i t i s h E x p e r i e n c e ' , i n Kamenka, E. & Ehr Soon Tay, A. (Eds.) Law and S o c i a l C o n t r o l . London: Edward A r n o l d . P e r r e t z , E.A. (1960). 'The Volunteer i n P s y c h i a t r i c Service', Canadian H o s p i t a l , 37:3, 109 - 111. P f o h l , S.J. (1978). P r e d i c t i n g D a ngerousness: The S o c i a l C o n s t r u c t i o n of P s y c h i a t r i c R e a l i t y . Lexington: Lexington Books. P i n c o c k , T.A. (1970). 'A H a l f C e n t u r y o f P s y c h i a t r y i n Manitoba'. Canada's Mental Health, 18:3, 4 - 10. P i v e n , F.F. & C l o w a r d , R.A. (1982). The New C l a s s War. New York: Pantheon. P i a t t , A. ( 1 9 6 9 ) . The C h i l d - S a v e r s : The I n v e n t i o n o f Delinquency. Chicago: U n i v e r s i t y of Chicago P r e s s . P i a t t , A. ( 1 9 7 7 ) . The C h i l d - S a v e r s : The I n v e n t i o n of D e l i n q u e n c y . (2nd E d i t i o n ) . C h i c a g o : U n i v e r s i t y of C h i c a g o P r e s s . P l o t k i n , R. (1977). ' L i m i t i n g the T h e r a p e u t i c Orgy: M e n t a l P a t i e n t s ' Right to Refuse Treatment'. Northwestern U n i v e r s i t y Law Review, 27, 461 - 525. P o u l a n t z a s , N. (1973). P o l i t i c a l Power and S o c i a l C l a s s e s . London: New L e f t Books. P r e s i d e n t i a l A d d r e s s . (1972). ' P s y c h i a t r y and i t s C r i t i c s ' , Canadian P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 17, 343 - 347. P r e s i d e n t i a l A d d r e s s . (1978). ' R i g h t s , R i t u a l s and the P o l i t i c a l Process', Canadian J o u r n a l of P s y c h i a t r y , 23, 513 -518. P r e s i d e n t i a l Address. (1981). 'Canadian P s y c h i a t r y of the 80's: Gateway or G o a l ? 1 , C a n a d i a n J o u r n a l of P s y c h i a t r y , 26, 112 -119. R a c h l i n , S. (Ed.) (19 85). L e g a l Encroachment on P s y c h i a t r i c P r a c t i c e . San F r a n s i s c o : Jossey-Bass Inc. Ralph, D. (1983). Work and Madness: The R i s e of Com muni t y P s y c h i a t r y , M ontreal: Black Rose. Ratner, R.S. & McMullan, J.L. (1987). State C o n t r o l : C r i m i n a l J u s t i c e P o l i t i c s i n Canada. Vancouver: U n i v e r s i t y of B r i t i s h Columbia P r e s s . 600 Reasons, C.E. & R i c h , R.M. (1978). A S o c i o l o g y o f Law: A C o n f l i c t P e r s p e c t i v e . Toronto: Butterworths. R e d i s h , A. (1986). ' S o c i a l P o l i c y and ' R e s t r a i n t * i n B r i t i s h Columbia' i n , A l l e n , R.C. & Rosenbluth, G. (Eds.) R e s t r a i n i n g the Economy. Vancouver: New S t a r Books. Reich, C. (1964). 'The New Property'. Yale Law J o u r n a l , 73, 733 - 787. R e i t s m a , M. (1973). ' C i v i l L i b e r t i e s and the M e n t a l l y 111', Canada's Mental Health, 21: 6, 10 - 11. R e n d e l , M. (1976). 'Law as an I n s t r u m e n t of O p p r e s s i o n or Reform: Race R e l a t i o n s and Sex D i s c r i m i n a t i o n ' , i n C a r l e n , P. (Ed.) The S o c i o l o g y of Law. Keele: U n i v e r s i t y of Keele P r e s s . R e s n i c k , P. (1984). 'The I d e o l o g y of N e o - C o n s e r v a t i s m ' , i n Magnusson, W., C a r r o l l , W.K., Doyle, C., Langer, M. & Walker, R.B.J. (Eds.) The New R e a l i t y : The P o l i t i c s o f R e s t r a i n t i n B r i t i s h Columbia. Vancouver: New S t a r Books. Richards, J . & P r a t t , L. (1979). P r a i r i e C a p i t a l i s m : Power and Influence i n the New West. Toronto: M c C l e l l a n d & Stewart. R i c h e r t , R.A. & Moyes, A.H. (1983). 'Reasons f o r I n v o l u n t a r y Commitment i n M a n i t o b a and O n t a r i o ' . C a n a d i a n J o u r n a l o f P s y c h i a t r y , 28, 358 - 361. Richman, A. (1964). P s y c h i a t r i c Care i n Canada: E x t e n t and R e s u l t s . Ottawa: Queen's P r i n t e r . R i l e y , R. & Richman, A. (1983). 'Involuntary H o s p i t a l i z a t i o n i n C a n a d i a n P s y c h i a t r i c I n p a t i e n t F a c i l i t i e s . 1970 - 1978'. Canadian J o u r n a l of P s y c h i a t r y , 28, 536 - 541. R i t c h i e , G. (1981). ' V i c t o r i a F i l e ' . B r i t i s h Columbia Medical J o u r n a l , 23, 572. R o b i t s c h e r , J . (1978). 'The L i m i t s of P s y c h i a t r i c Authority', I n t e r n a t i o n a l J o u r n a l of Law £ P s y c h i a t r y , 1, 183 - 204. R o b e r t s o n , G.B. (1987). M e n t a l D i s a b i 1 i t y and The Law in Canada. Vancouver: C a r s w e l l . R o e s c h , R. & G o l d i n g , S. ( 1 9 8 5 ) . 'The I m p a c t o f D e i n s t i t u t i o n a l i z a t i o n ' , i n F a r r i n g t o n , D. & Gunn, J . (Eds.) Aggression and Dangerousness. New York: J . Wiley. Rohn, G. (1961). 'White C r o s s C e n t r e s i n Canada'. Canada's Mental Health, 9:1, Supplement. Rose, N. (1985). 'Unreasonable R i g h t s : M e n t a l I l l n e s s and the L i m i t s of the Law'. J o u r n a l of Law & S o c i e t y , 12, 199 - 218. 601 Rose, S.M. (1979). ' D e c i p h e r i n g D e i n s t i t u t i o n a l i z a t i o n : C o m p l e x i t i e s i n P o l i c y and Program A n a l y s i s ' , Milbank Memorial Fund Q u a r t e r l y , 57, 429 - 460. Rosenhan, D.L. (1973). 'On B e i n g Sane i n Insane P l a c e s ' , Science, 179, 250 - 258. Rosenhan, D.L. (1975). 'The Contextual Nature of P s y c h i a t r i c D i s o r d e r s ' , J o u r n a l of Abnormal Psychology, 84, 462 - 469. Ross, M. (1961). Survey of Mental Health Needs and Resources of B r i t i s h Columbia. V i c t o r i a : Queen's P r i n t e r . Roth, L. ( 1979). 'A Commitment Law f o r P a t i e n t s , D o c t o r s and Lawyers'. American J o u r n a l of P s y c h i a t r y , 136, 1121 - 1127. Roth, L. (1980). 'Mental Health Commitment: The State of the Debate, 1980'. H o s p i t a l and Community P s y c h i a t r y , 31, 387 -Rothman, D.J. (1971). The P i s c o v e r y of the Asylum: Soc i a l Order and D i s o r d e r i n the New R e p u b l i c . Boston: L i t t l e , Brown. Rothman, D.J. (1980). C o n s c i e n c e and C o n v e n i e n c e . B o s t o n : L i t t l e , Brown. Roy, R.G. (1971). 'Admission of P s y c h i a t r i c P a t i e n t s on Medical C e r t i f i c a t e s i n Canada'. Canada's Mental Health, 19:6, 17 - 19. Royal Commission on Health S e r v i c e s . (1964). Report. Ottawa: Queen's P r i n t e r . R o y a l Commission on the Law R e l a t i n g to M e n t a l I l l n e s s and M e n t a l D e f i c i e n c y , 1954 - 57. (1957). R e p o r t . London: H i s Majesty's S t a t i o n e r y O f f i c e . R o z o v s k y , L. (1979). 'New D e v e l o p m e n t s i n Nova S c o t i a P s y c h i a t r i c L e g i s l a t i o n ' . Dalhousie Law J o u r n a l , 5, 505 - 517. Rubenstein, L.S. (1986). 'Treatment of the M e n t a l l y 111: Legal Advocacy E n t e r s the Second G e n e r a t i o n ' . A m e r i c a n J o u r n a l of P s y c h i a t r y , 143, 1264 - 1269. Rubin, J . (19 78). E c o n o m i c s , M e n t a l H e a l t h and the Law. Toronto: Heath & Co. Savage, H. & McKague, C. (1987). M e n t a l H e a l t h Law i n Canada. Toronto: Butterworths. S e c t i o n of P s y c h i a t r y . (1985). 'Report 1. B r i t i s h C o l u m b i a Medical J o u r n a l , 27, 252 - 255. Scheff, T. (1966). Being M e n t a l l y 111: A S o c i o l o g i c a l Theory. Chicago: A l d i n e . 602 Scheff, T. (Ed.) (1975). L a b e l l i n g Madness Englewood C l i f f s : P r e n t i c e H a l l . Schmidt, W. S., M i l l e r , , K., B e l l , W., & New, E. (1981). P u b l i c Guardianship and the E l d e r l y . Cambridge: B a l l i n g e r P u b l i s h i n g . Schur, E. (1968). Law and S o c i e t y : A S o c i o l o g i c a l View. New York: Random House. S c u l l , A.T. (19 79). Museums of Madness: The S o c i a l C o n t r o l of I n s a n i t y i n Nineteenth Century England. New York: St. Martin's Press. S c u l l , A.T. ( 1 9 8 1 ) . ' A New T r a d e i n L u n a c y : T h e Recommodification of the Mental Patient'. American B e h a v i o u r a l S c i e n t i s t , 24, 741 - 754. S c u l l , A.T. (1981a). ' D e i n s t i t u t i o n a l i z a t i o n and the Rights of the Deviant', J o u r n a l of S o c i a l Issues, 37, 6 - 20. S c u l l , A.T. (1984). D e c a r c e r a t i o n : Community Treatment and the D e v i a n t - A R a d i c a l View. (2nd E d i t i o n ) . Englewood C l i f f s : P r e n t i c e - H a l l . Sedgwick, P. (1982). P s y c h o - P o l i t i c s . Cambridge: Harper & Row. Shapland, J . & W i l l i a m s , T. (Eds). (1983). M e n t a l D i s o r d e r and the New L e g i s l a t i o n . L e i c e s t e r : B r i t i s h P s y c h o l o g i c a l A s s o c i a t i o n . Sharpe, G. (1978). 'The O n t a r i o M e n t a l H e a l t h A c t , 1978. A Legal Perspective'. Canadian J o u r n a l of P s y c h i a t r y , 24, 517 -519. Sharpe, G. (1979). 'Trends i n Mental Health L e g i s l a t i o n ' . Law S o c i e t y of Upper Canada Gazette, 12, 134 - 143. Sheppard, D.R. (1966). 'The O f f i c e of the P u b l i c T r u s t e e i n B r i t i s h Columbia'. U n i v e r s i t y of B r i t i s h Columbia Law Review, 1966, 2, 422 - 439. S h e r r i n g t o n , A. (1981). ' D i f f i c u l t i e s i n Commitment of the M e n t a l l y 111'. Canadian Medical A s s o c i a t i o n J o u r n a l , 124, 223 -224. Shone, M. (1976). C o n f l u e n c e of the M e n t a l H e a l t h and L e g a l Systems i n the P r o c e s s f o r Compulsory C i v i l Commitment i n A l b e r t a . Unpublished LLM T h e s i s : U n i v e r s i t y of A l b e r t a . S k o c p o l , T. (Ed.) (1984). V i s i o n and Method i n H i s t o r i c a l S o c i o l o g y . Cambridge: Cambridge U n i v e r s i t y P r e s s . Skultans, V. (1979). E n g l i s h Madness: Ideas on I n s a n i t y , 1580 _2 1890. London: Routledge & Kegan P a u l . 603 Smandych, R. (1982). 'The R i s e of Asylum i n Upper Canada: An A p p l i c a t i o n of S c u l l ' s ' M a c r o - S o c i o l o g i c a l ' P e r s p e c t i v e ' . Canadian C r i m i n o l o g y Forum, 4, 142 - 148. Smandych, R. & Verdun-Jones, S.N. (1986). 'The Emergence of the Asylum i n 19th Century O n t a r i o : A Study i n the H i s t o r y of Segregative Con t r o l ' , i n , Boyd, N. (Ed.) The S o c i a l Dimensions of Law. Scarborough: P r e n t i c e H a l l . S m i t h , C M . (1970). ' M e n t a l H e a l t h D e v e l o p m e n t s i n Saskatchewan', Canada's Mental Health, 18:5, 15 - 20. S m i t h , C M . ( 1 9 7 1 ) . ' C r i s i s and A f t e r m a t h : Community P s y c h i a t r y i n Saskatchewan, 1963 - 69', C a n a d i a n P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 16, 65 - 75. S m i t h , CM. (1979). 'From H o s p i t a l t o Community: A System Changes', Canadian J o u r n a l of P s y c h i a t r y , 24, 113 - 120. Snider, L. & West, G.W. (1980). 'A C r i t i c a l P e r s p e c t i v e on Law i n the C a n a d i a n S t a t e : D e l i n q u e n c y and C o r p o r a t e Crime', i n Ossenberg, R.J. (Ed.) Power and Change i n Canada. T o r o n t o : M c C l e l l a n d & Stewart. S o c i a l Development Committee. (1978). P r o c e e d i n g s of the E n q u i r y i n t o B i l l 19, The M e n t a l H e a l t h Amendment A c t , 19 78. M i n i s t r y of Health: O n t a r i o , unpublished t r a n s c r i p t s . S o c i a l P l a n n i n g C o u n c i l o f M e t r o p o l i t a n T o r o n t o . (1984). C a r i n g For P r o f i t : The C o m m e r c i a l i z a t i o n o f Human S e r v i c e s . Toronto: S o c i a l Planning C o u n c i l . S p i c e r , R. (1981). Conspiracy: Law, C l a s s and S o c i e t y . London: Lawrence & Wishart. S p i t z e r , S. (1975). 'Toward a M a r x i a n Theory of Deviance', S o c i a l Problems, 22, 638 - 651. S p i t z e r , S. & Denzin, N. (1968). The Mental P a t i e n t : S t u d i e s i n the S o c i o l o g y of Deviance. New York: McGraw H i l l . S t e i n , S.D. (1980). 'The S o c i o l o g y of Law', B r i t i s h J o u r n a l of Criminology, 20, 99 - 122. S t e v e n s o n , P. (1983). 'The S t a t e i n E n g l i s h Canada: The P o l i t i c a l Economy of P r o d u c t i o n and Reproduction', i n , S o c i a l i s t S t u d i e s : A Canadian Annual. Toronto: S o c i a l i s t S t u d i e s . S t o e s z , D. (1981). 'A Wake f o r the W e l f a r e S t a t e s S o c i a l W e l f a r e and the N e o c o n s e r v a t i v e C h a l l e n g e ' , S o c i a l S e r v i c e Review, 1981, 398 - 410. Stone, A. A. ( 19 76). M e n t a l H e a l t h and Law: A System i n T r a n s i t i o n . R o c k v i l l e : N a t i o n a l I n s t i t u t e on Mental Health. 604 Stone, A. A. (1979). 'The Myth of Advocacy', H o s p i t a l and Community P s y c h i a t r y , 30, 819 - 822. Strong, H.R. (1983). ' C i v i l Commitment: A Review of T r a d i t i o n a l Arrangements i n the P r o v i s i o n of Involuntary H o s p i t a l i z a t i o n of the M e n t a l l y 111'. C a n a d i a n J o u r n a l of P s y c h i a t r y , 28, 307 -Strong, M.K. (1930). P u b l i c Welfare A d m i n i s t r a t i o n i n Canada. Chicago: U n i v e r s i t y of Chicago Press. Sugarman, D. (1981). 'Theory and P r a c t i c e i n Law and H i s t o r y : A P r o l o g u e to the Study of the R e l a t i o n s h i p Between Law and Economy from a S o c i o - H i s t o r i c a l P e r s p e c t i v e ' , i n , F r y e r , B., Hunt, A., McBarnett, D. & Moorhouse, B. Law, State and S o c i e t y . London: Croom Helm. Sumner, C. (1979). Reading I d e o l o g i e s . London: Academic P r e s s . Sumner, C. (1981). 'The Rule of Law and C i v i l R i g h t s i n Contemporary Ma r x i s t Theory', K a p i t a l i s t a t e , 9, 63 - 92. Swadron, B. (1964). D e t e n t i o n o f the M e n t a l l y D i s o r d e r e d , Toronto: Butterworths. Swadron, B. (1966). 'Recent Mental Health L e g i s l a t i o n ' , Canada's Mental Health, 14, 10 - 13. Swadron, B. & S u l l i v a n , D. (1972). Mental R e t a r d a t i o n - The Law - G u a r d i a n s h i p . Downsview: N a t i o n a l I n s t i t u t e o f M e n t a l R e t a r d a t i o n . Swadron, B. & S u l l i v a n , D. (1973). The Law and Mental D i s o r d e r . Toronto: Canadian Mental Health A s s o c i a t i o n . S w a r t z , D. (1979). 'The P o l i t i c s of Reform: C o n f l i c t and Accommodation i n Canadian Health P o l i c y ' , i n , P a n i t c h , L. (Ed). The C a n a d i a n S t a t e : P o l i t i c a l Economy and P o l l t i c a l Power. Toronto: U n i v e r s i t y of Toronto P r e s s . Swazey, J.P. (1974). Chlorpromazine i n P s y c h i a t r y . Cambridge: M.I.T. P r e s s . S y k e s , P. (1970). ' M e n t a l H e a l t h D e v e l o p m e n t s i n New Brunswick', Canada's Mental Health, 18:6, 16 - 20. Szasz, T. (1961). The Myth of Mental I l l n e s s : Foundations of a Theory of Personal Conduct. New York: D e l t a . S z a s z , T. (1963). Law, L i b e r t y and P s y c h i a t r y . New York: C o l l i e r . Szasz. T. (1970). Ideology and I n s a n i t y . Garden C i t y : Doubleday Anchor. 605 S z a s z , T. (1970a). The M a n u f a c t u r e of Madness. New York: Harper & Row. S z a s z . T. (1974). The Second S i n . London: R o u t l e d g e & Kegan P a u l . S z a s z . T. (1975). The Age of Madness. London: R o u t l e d g e & Kegan P a u l . S z a s z . T. ( 1 9 7 6 ) . S c h i z o p h r e n i a : The S a c r e d S y m b o l o f P s y c h i a t r y . New York: Basic Books. Szasz. T. (1977). P s y c h i a t r i c S l a v e r y . New York: Free Press. S z a s z , T. (1977a). The T h e o l o g y of M e d i c i n e . Baton Rouge: L o u i s i a n a S t a t e U n i v e r s i t y P r e s s . Szasz. T. (1978). The Myth of Psychotherapy: Mental Healing as R e l i g i o n , R h e t o r i c and R e p r e s s i o n . Garden C i t y : Doubleday Anchor. T a l b o t , J. (1978). The Death of the Asylum. New York: Grune & S t r a t t o n . T a r s h i s , L. (1984). World Economy i n C r i s i s . T o r o n t o : James Lorimer. Task F o r c e C o m m i t t e e on t h e M e n t a l H e a l t h S e r v i c e s i n Saskatchewan. (1983). The F o r g o t t e n C o n s t i t u e n t s . R e g i n a : Mental Health A s s o c i a t i o n i n Saskatchewan. Task F o r c e R e p o r t . (1970). The C o s t of H e a l t h S e r v i c e s i n Canada. Ottawa: Information Canada. T a y l o r , I. (1983). ' J u s t i c e Expenditure, Welfare Expenditure and the R e s t r u c t u r i n g of the C a n a d i a n S t a t e ' , i n Crime, C a p i t a l i s m and Community. Toronto: Butterworths. T a y l o r , J.A. & D a v i d s o n , A.E. (1964). 'Mental H e a l t h A c t , 1964'. B r i t i s h Columbia Medical J o u r n a l , 6, 51 - 52. T a y l o r - G o o b y , P. (1985). P u b l i c O p i n i o n , I d e o l o g y and S t a t e Welfare. London: Routledge & Kegan P a u l . T e p l i n , L.A. (Ed.) (1984). M e n t a l H e a l t h and C r i m i n a l J u s t i c e . B e v e r ly H i l l s : Sage P u b l i c a t i o n s . Therborn, G. & Roebroek, J. (1986). 'The I r r e v e r s i b l e Welfare S t a t e : I t s Recent M a t u r a t i o n , I t s E n c o u n t e r w i t h Economic C r i s i s , and i t s F u t u r e P r o s p e c t s ' , I n t e r n a t i o n a l J o u r n a l o f Health S e r v i c e s , 16, 319 - 337. Thompson, E.P. (1977). Whigs and H u n t e r s . Harmondsworth: Penguin. 606 Thompson, E.P. (1978). The Poverty of Theory. London: M e r l i n P r e s s . Toews, J . (1980). 'Mental H e a l t h S e r v i c e s i n a Time of R e s t r a i n t ' . Canada's Mental Health, 28:4, 2 - 4 . Toews, J . & Barnes, G. (1982). C h r o n i c M e n t a l P i s o r d e r s i n Canada. Ottawa: Health & Welfare: Canada. Toews, J. & Barnes, G. (1986). 'The Chronic Mental P a t i e n t and Community P s y c h i a t r y : A System i n T r o u b l e ' , Canada's M e n t a l Health, 34, 2 - 7 . Toews, J . , E l - G u e b a l y , N. & L e c k i e , A. (1981). ' P a t i e n t s ' Reactions to T h e i r Commitment'. Canadian J o u r n a l of P s y c h i a t r y , 26, 251 - 254. Toews, J., E l - G u e b a l y , N., L e c k i e , A. & Harper, D. (1984). 'Patients' A t t i t u d e s at the Time of T h e i r Commitment'. Canadian J o u r n a l of P s y c h i a t r y , 29, 590 - 595. Toews, J., Prabhu, V. & El-Guebaly, N. (1980). 'Commitment of the M e n t a l l y 111'. C a n a d i a n J o u r n a l of P s y c h i a t r y , 25, 611 -T o m l i n s o n , P.B. & Cumming, J . (1976). 'Coast F o u n d a t i o n Apartment P r o j e c t ' . Canada 1s Mental Health, 24: 1, 23 - 28. Townsend, F.R. (1972). 'Mental H e a l t h P e v e l o p m e n t s i n Nova S c o t i a ' . Canada's Mental Health, 20, 21 - 27. T r i m b e r g e r , E.K. (1984). 'E.P. Thompson: U n d e r s t a n d i n g the Process of H i s t o r y 1 , i n Skocpol, T. (Ed.) V i s i o n and Method i n H i s t o r i c a l S o c i o l o g y . Cambridge: Cambridge U n i v e r s i t y P r e s s . Trubek, P.M. (1977). ' C o m p l e x i t y and C o n t r a d i c t i o n i n the Legal Order: Balbus and the Challenge of C r i t i c a l S o c i a l Thought about Law', Law and S o c i e t y Review, 11, 529 - 569. T u r n e r , T., M e d i l l , M.F. & S o l b e r g , P. (1984). ' P a t i e n t Advocacy: The Ontario Experience 1. I n t e r n a t i o n a l J o u r n a l of Law & P s y c h i a t r y , 7, 329 - 350. T y h u r s t , J.S., C h a l k e , F.C.R, Lawson, F.S., McNeel, B.A., Roberts, C.A., T a y l o r , G.C., Weil, R.J. & G r i f f i n , J.P. (1963). More For The Mind. Toronto: Canadian Mental Health A s s o c i a t i o n . Unsworth, C. (1979). 'The Balance of Medicine, Law and S o c i a l Work i n Mental Health L e g i s l a t i o n , 1889 - 1959', i n , Parry, N., Rusti n , M. & Satyamurti, C. (Eds). S o c i a l Work, Welfare and the State. London: Edward Arnold. Vancouver Community L e g a l A s s i s t a n c e S o c i e t y . (1973). L e g a l P r o b l e m s A f f e c t i n g the S i c k , Aged, and I n f i r m . Vancouver: Vancouver Community Legal A s s i s t a n c e S o c i e t y . 607 Verdun-Jones, S.N. (1985). 'The Dawn of a New L e g a l i s m i n A u s t r a l i a ? The New South Wales M e n t a l H e a l t h A c t , 1983, and Related L e g i s l a t i o n ' . I n t e r n a t i o n a l J o u r n a l of Law & P s y c h i a t r y , 8, 95 - 118. Verdun-Jones, S.N. & Gordon, R.M. (1985). M e n t a l H e a l t h and A d u l t G u a r d i a n s h i p Law i n the Yukon T e r r i t o r y . W h i t e h o r s e : Department of Health and Human Resources: Yukon. Verdun- J o n e s , S.N. & Smandych, R. (1982). 'Catch-22 i n the Nineteenth Century: The E v o l u t i o n of T h e r a p e u t i c Confinement f o r the C r i m i n a l l y Insane i n Canada, 1840 - 1900', i n C r i m i n a l J u s t i c e H i s t o r y : An I n t e r n a t i o n a l Annual. New York: John Jay Press. V i c t o r i a F i l e . (1985). 'Mental Health Act, Changes'. B r i t i s h Columbia Medical J o u r n a l , 27, 191. Wald, P. & Friedman, P. (1978). 'The P o l i t i c s of Mental Health Advocacy i n the United States'. I n t e r n a t i o n a l J o u r n a l of Law £ P s y c h i a t r y , 1, 137 - 153. W a l k e r , M. (Ed.) ( 1 9 8 8 ) . P r i v a t i z a t i o n : T a c t i c s and Techniques. Vancouver: The F r a s e r I n s t i t u t e . Ward, M. (1946). Snake P i t . New York: Random House. Warren, C.A.B. (1981). 'New Forms of S o c i a l C o n t r o l : The Myth of D e i n s t i t u t i o n a l i z a t i o n ' . American B e h a v i o u r a l S c i e n t i s t , 24, 724 - 740. Warren, C.A.B. (1982). The Court of Last Resort: Mental I l l n e s s and the Law. Chicago: U n i v e r s i t y of Chicago Press. Watt, J.A. & E l - G u e b a l y , N. (1981). 'CP.A. P o s i t i o n Paper: The Chronic Mental Patient'. Canadian J o u r n a l of P s y c h i a t r y , 26, 494 - 501. W a t t i e , B. (1977). 'What's Happening i n Tunney's P a s t u r e ? Reports, Developments and Future Plans', Canada's Mental Health, 25:1, 2 - 1 9 . W e i s s t u b , D. (1977). ' I n v o l u n t a r y Commitment*. C a n a d i a n P s y c h i a t r i c A s s o c i a t i o n J o u r n a l , 22, 177 - 180. W e i s s t u b , D. (Ed.) (1980). Law and P s y c h i a t r y i n the C a n a d i a n Context. Toronto: Pergamon Press. Weller, G.R. & Manga, P. (1983). 'The Push For R e p r i v a t i z a t i o n of H e a l t h Care S e r v i c e s i n Canada, B r i t a i n , and the U n i t e d S t a t e s ' , J o u r n a l o f H e a l t h P o l i t i c s , P o l i c y and Law, 8, 495 -518. 608 Wellsch, T. (1983). 'The Right of the C i v i l l y Committed Mental P a t i e n t to Refuse Treatment'. Saskatchewan Law Review, 48, 269 -291. West, G.W. (1984). Young O f f e n d e r s and the S t a t e . T o r o n t o : Butterworths. Wexler, D. B. (1981). M e n t a l H e a l t h Lawj_ Major I s s u e s . New York: Plenum Press. Whitehead, T. (1982). Mental I l l n e s s and the Law. Oxford: B a s i l B l a c k w e l l . W i l e n s k y , H.L. (1975). The W e l f a r e S t a t e and E q u a l i t y . Berkeley: U n i v e r s i t y of C a l i f o r n i a P r e s s . W i l l i a m s , J . I . & L u t e r b a c h , E.J. 'The Changing B o u n d a r i e s of P s y c h i a t r y i n Canada 1, S o c i a l Science and Medicine, 10, 15 - 22. Wing, J.K. (Ed.) (1975). S c h i z o p h r e n i a From Withi n . London: N a t i o n a l S c h i z o p h r e n i a Foundation. Wing, J.K. (1978). R e a s o n i n g About Madness. London: O x f o r d U n i v e r s i t y Press. Wolfe, D.A. (1979). 'The State and Economic P o l i c y i n Canada, 1968 - 75', i n P a n i t c h , L. (Ed.) The Canadian S t a t e : P o l i t i c a l Economy and P o l i t i c a l Power. T o r o n t o ! U n i v e r s i t y of T o r o n t o P r e s s . Wolfe, D.A. (1984). 'The Rise and Demise of the Keynesian Era i n Canada: Economic P o l i c y , 1930 - 1982', i n C r o s s , M.C. & K e a l e y , G.S. (Eds.) Modern Canada: 1930 - 1980's. T o r o n t o : M c C l e l l a n d & Stewart. Wolfensberger, W. (1974). ' R e f l e c t i o n s on Reading Old Annual Government R e p o r t s on the L u n a t i c and I d i o t Asylums of the Province of Ontario'. Canada's Mental Health, 22:3, 21 - 23. 609
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Mental disorders, law, and state : a sociological analysis of the periods of reform in Canadian mental health law
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