L’Institut universitaire en santé mentale de Québec – All

Mental illnesses have not always been treated the way they are today. Even with scientific progress, we still know little about what causes a number of illnesses. Contrarily, treatments to improve patients’ quality of life have improved remarkably over the years. But if we go back a few centuries, the situation was quite different and people had different values and ideas about life.In the 17th and 18th centuries, little or nothing was known about the causes of madness; it was often confused with criminality. Scientists at the time did not agree on whether mad people were possessed by the devil, causing them to have intermittent fits of madness, or if there were physical causes of these states of mind. Whatever the case, there were three choices in those days for the confinement of mad people: a hospital, a prison, or a lodge, which only existed in Quebec. But the purpose of each was the same: to hide from view the undesirable elements in the Quebec City area and eliminate begging in its streets. It was to decrease begging that the Hôpital Général de Québec was founded in 1629, and institutions of the same kind were built in Montreal and Trois‑Rivières.1 It was only in 1714 that there were places for confinement of women, the “maisons de force”, and in 1721 “lodges” were created for men. These forms of confinement offered patients neither cure nor treatment. Their primary function was to control dangerous mentally ill people and to help families that could not afford to look after these patients. It was in 1801 that the first legislation concerning funding for confinement of the mentally ill appeared. Now that there was government funding, confinement in the lodges burgeoned and they were filled to capacity. In these lodges, the only method used at the time to treat patients in crisis was restraint, with the patient’s limbs being completely immobilized.In Europe, those who attributed madness to purely physical causes developed other techniques whose effectiveness was more than doubtful. For example, spinning machines were a method used to “cure” madness. The patient was tied to a chair and was spun about for hours, even days. This technique was used to cause the blood to go to the brain and cause nausea, which it was said had beneficial effects. The surprise bath was another treatment of this kind, as was the iron cage, which isolated the patient during an acute attack and controlled his or her movements.2Things began to change for these unfortunates in about 1793. A French doctor named Philippe Pinel developed a new theory that rejected the ideas about madness that existed in society. Pinel advocated giving up violent therapeutic treatments such as the iron cage or spinning chair in favour of calmer, more humane methods, such as moral treatment. Classification of mental illnesses began at that time. Pinel’s classification of mental illnesses, which he developed in the early 19th century, divided mental illnesses into four categories: melancholia, mania, idiocy and dementia. For a long time, this categorization of illnesses was the only reference used in the field of psychiatry.But in the late 19th century, three types of mental disorders replaced Pinel’s classifications: general paralysis, which included all complications of tertiary syphilis, alcoholism (withdrawal, psychoses, intoxication, alcoholic dementia), and schizophrenia. This was the infancy of the science of mental health: psychiatry.In 1824, a report on the mentally ill in Lower Canada was presented to the Government as part of a movement towards removing the responsibility for the mentally ill from the Church and the religious orders.3 Doctor James Douglas, a well-known doctor in the Quebec area, gave a talk at this time on the causes of madness, which he attributed not only to heredity, but also to the socio-economic and socio-cultural aspects of the times. This view of madness led to a new idea: it could strike anyone, and being placed in a respectable establishment, in addition to providing more control over the patient’s bad habits, could have positive consequences for the individual. The Government accordingly asked Doctor Douglas to found an asylum in Quebec, which would be publicly funded. But Doctor Douglas worked towards a goal different from “confinement” of the mentally ill – moral reform of patients. His view was that isolation and locked, passive incarceration could only make the madness worse and, in some cases, lead to suicide. Isolation then gave way to community life; violence to calm and gentleness; bread and water diets to good meals; and so forth, all with the aim of moral education of the patient.4Thus, on September 15, 1845, the Asile provisoire de Beauport (today l’Institut universitaire en santé mentale de Québec) was founded by Doctor James Douglas, with the assistance of doctors Charles-Jacques Frémont and Joseph Morrin. It was located in the former manor house of Sieur Robert Giffard, Seigneur de Beauport, pioneer and first doctor in New France.  When it opened, 95 “lunatics” – the term used at the time for the mentally ill – were removed from hospitals and prisons in Quebec City, Montreal and Trois-Rivières and housed in the asylum. This was the first time it was considered that lunatics had an illness and were therefore curable.5 The humaneness of Doctor Douglas’s new therapies also led to some changes being made in certain shock treatments that people believed in at the time. This was the case with shower baths, where patients would be placed in a tank for about fifteen minutes and have cold water poured over them, and also with blood-letting from the head, the use of leeches, mercury, and so forth. They were still attempting at that time to cure patients with dizziness and vomiting. Confinement and isolation were still used for violent cases.6 These treatments were gradually abandoned, thanks to Doctor Douglas’s gentler treatments.This era was therefore characterized by the fact that the authorities of the time became aware that the treatment of mad people was outdated and barbaric, and the first asylum in the Province was created in 1845 in Quebec. Change could be seen in the treatments given to the mentally ill, but especially in people’s ideas about mental illness, with Pinel’s theory, which would be applied at the Asile provisoire de Beauport from the time it was founded – moral treatment.It is also of note that in 1885, medical control of institutions in the field moved into the hands of the Government.

1. Since its beginnings, l’Institut universitaire en santé mentale de Québec has had several different names: 1845-1850: Asile provisoire de Beauport; 1850-1865: Quebec Lunatic Asylum; 1865-1912: Asile des aliénés de Québec; 1912-1923: Asile Saint-Michel-Archange; 1923-1976: Hôpital Saint-Michel-Archange; 1976-2009: Centre hospitalier Robert-Giffard.
2. Normand Séguin, s.d., L’institution médicale. Les presses de l’Université Laval, Québec, 1998. p. 37
3. Archival collection, Galerie Historique Lucienne-Maheux, l’Institut universitaire en santé mentale de Québec.
4. Hubert A. Wallot. Entre la compassion et l’oubli: La danse autour du fou, Survol de l’histoire organisationnelle de la prise en charge de la folie au Québec depuis les origines jusqu’à nos jours, I- La chorégraphie globale. Éditions MNH, Beauport, 1998, p. 30.
5. Ibid.
6. Louisa Blair. Les Anglos : La face cachée de Québec, Tome I : 1608-1850. Commission de la Capitale nationale du Québec and Éditions Sylvain Harvey, s.l., 2005, p. 88.

According to some authors, at the outset moral treatment, which includes any therapy related to reason and the mind, such as recreation or work, was only a front to hide the real purpose of asylums – shutting away all undesirables to tidy up the landscape of society.1 However, the benefits of moral treatment were quickly realized and it was used more frequently. After Pinel’s theory was published, a report by Doctor William Hackett, a doctor at the Hôpital Général de Québec, was presented in 1810. The report said that activity, cheerfulness and regular exercise lead to health and are beneficial to body and mind, and that total lack of stimulation was suitable only for the violent mad.2

1. Peter Keating. La Science du Mal : L’institution de la psychiatrie au Québec, 1800-1914. Éditions Boréal, Montréal, 1993, p. 146.
2. H. A. Wallot. op. cit., p. 38.

In 1893, the Sisters of Charity of Quebec signed a contract with the Quebec government to care for and maintain the patients in the Asile des Aliénés de Québec, which was later to become the Hôpital Saint-Michel-Archange. (B1) They immediately started on landscaping the grounds, creating parks and gardens around the buildings to make the patients’ stay more pleasant. They also began to use recreational therapy. More than once a month, the sisters organized musical evenings for the patients. In summer, they had a great many picnics. (B2) Later, other activities were increasingly introduced for treatment of patients: checkers, reading, music, dancing, and so on. (B3) Dancing was seen by doctors as very therapeutic, because it channelled the patients’ excitement, somaticization and touching and consequently helped them to recover their strength and make up their need for sleep.1 There was even a band formed in 1900, (B5) which the patients enjoyed very much. Dances were also organized for patients and employees, with more than 200 attending each month. Holidays were greatly anticipated – Christmas, when patients received a small gift, New Year’s Eve, Saint Catherine’s Day, Mid-Lent, maple sugar season, birthdays, etc. (B6-B8) A pilgrimage to Sainte-Anne-de-Beaupré was provided every year by the Québec-Montmorency-Charlevoix railway company.2 (B9) This kind of therapy was successful because it interrupted the monotony of most of life for confined patients. (B10) Many of them enjoyed complete freedom on the grounds, which helped them take responsibility for themselves. In 1937, the first radio station was inaugurated at the hospital. News and music were broadcast, along with religious services and prayers. Patients were both entertained and kept informed of what was happening in the hospital. (B12-B13)

1. Normand Séguin. op. cit., p. 43.
2. Hubert A. Wallot. op. cit., p. 105.

Occupational therapy was being developed at the same time and was equally beneficial for patients. In 1900, crafts began to take an increasingly greater place in therapeutic activities. Patients worked on a number of activities that required working with their hands – painting, ceramics, basketwork, knitting, embroidery, and woodworking. Exhibits of the products they created were organized so that the public could see what the confined patients were doing. In 1922, the Château Frontenac organized an exhibition and the following day the newspaper Le Soleil said in an article that 430 patients from the Hôpital Saint-Michel-Archange were working with their hands and that what they were producing could easily be sold commercially.1 In 1930, the hospital had more than ten different craft shops used regularly by patients.Over time, occupational methods increased and improved. In 1968, physical education was added to the list of pastimes, and doctors spoke enthusiastically about its many benefits. (B-13a) Physical activity helped to channel unconscious needs such as aggression, identification, affectivity and creativity. It was particularly recommended for patients who were aggressive or agitated, or who had poor muscle tone.2 Occupational therapy was thus very popular at Hôpital Saint-Michel-Archange; not only did the patients enjoy it, but it was very beneficial for them. (B14)

1. Jules Lambert. Fiches documentaires lors de la réalisation du livre : Mille fenêtres. Galerie Lucienne-Maheux, l’Institut universitaire en santé mentale de Québec. Fiche no 2.
2. Wilfrid Pilon et Pierre Audet. Activités thérapeutiques de groupe. Men’s Unit B. Hôpital Saint-Michel-Archange, Galerie Lucienne-Maheux, Centre hospitalier l’Institut universitaire en santé mentale de Québec, 1968, p. 2.

While leisure pursuits were seen as therapeutic because they interrupted the monotony of life and distracted patients from frenzied ideas, many doctors recommended that patients also work, because it would have the identical effect and be equally good for the patients’ minds.1 Doctors believed that work was the first step in a patient’s recovery. It was advised because it fostered the individual’s disalienation and resocialization and made him or her feel like a useful member of society. It got patients accustomed to regular hours, and work loads were increased gradually, helping them adapt to the world they would be going back to.But in spite of the proliferation of the kinds of work patients did and the benefits obtained, work therapy also had some problems. In the 1870s, work therapy decreased at the Asile des Aliénés de Québec because of a lack of supervisory staff. At this time, the asylum was also directed to be a money-making institution, and moral treatment was very costly. To cut costs, the owners reintroduced treatments that had for the most part been abandoned – isolation and restraint – in spite of the plans to create a broad-scale moral treatment project in 1874-75. This project included a work component: gardening, a knitting workshop, sewing, woodworking, shoemaking, a bakery, maintaining the slaughterhouse, the pig farm and the stables, and a leisure component: dancing, walks, picnics, theatre, concerts, public entertainments, circuses, illustrated lectures, parlour games and singing. In spite of this, it appears that the plan was never implemented, because an 1880 report from the inspectors states that only about twenty patients were doing activities that could be considered moral treatment. But a moral treatment plan was implemented in the early 1880s because they could actually see the benefits.2Starting in 1845, patients were set to work hoeing, gardening, and cutting and splitting wood. In winter, they cleared snow and broke rocks. In 1894, Doctor Arthur Vallée, (B15-B-15a) the medical superintendent at the Asile des aliénés de Québec from 1893 to 1903, stated that over 75% of the men in the hospital were working on repairs to the hospital’s buildings. The women were making new clothing, sewing, weaving and knitting. (B16-B17-B18-B19-B19-a) In 1897, the hospital had two workshops for making brushes, in which a great many patients worked. These workshops were very productive and, in that same year, outside businesses complained of unfair competition, although their merchandise was sold for the going market price.3 This was also the period when they began to make extensive use of workshops at the Asile des Aliénés de Québec. (B20-B21)The benefits of moral treatment are so significant that this kind of treatment is still used today, in spite of changes and developments made over time.4 The appearance of drugs did not completely eliminate recreation and work; new programs were put in place. With regard to recreational therapy, in 1968 a graphic expression project was set up to help subjects arrive at a better understanding of their problems through what they did in the workshop, discover unsuspected personal skills, and express themselves more spontaneously. The Émile-Nelligan centre was created in the 1970s for the purpose of teaching socially acceptable behaviour and helping patients get in touch with reality through form, concrete materials, objects and the environment. Occupational therapy and the crafts program were used along with graphic expression.5Animal therapy was introduced at Hôpital Saint-Michel-Archange at this time, and used for physical and psychogeriatric care. Small animals and birds were kept in an area called Le Bosquet, the grove.6 Work therapy also developed over time and the kinds of work increased. Some of the types of work done in the 1970s were for industrial contracts for manufacture of sheds and dish and floor mops; shampoo bottling; preparation of vegetables and culinary preparation; activities related to printing; manufacture of envelopes; assembly, folding and binding of documents; message services; laundry; and reception of merchandise. With this great diversity, they were able to attract and satisfy more patients.The goals of moral treatment, which has proved its worth many times since 1845, have with time been defined and clarified. In about 1960 the aims of moral therapy (which had become milieu therapy) were confirmed: to bring patients close to nature and away from their pathological environment; turn their minds away from morbid thoughts; give them an ordered, structured environment; encourage contact with “intelligent” people to improve their social skills; and give them the latitude to express their individual tastes.7 In short, this therapy was intended to restore a social and occupational life to patients, without making them aim for a perfect re-entry into society, which it was believed would put too much pressure on them.We can see then that moral treatment, which was used right from the foundation of psychiatric hospitals, has evolved over the years. Doctors immediately understood its beneficial effects and it was developed and improved over time. This moral treatment was part of a process of institutionalization of psychiatry and it had a vital role to play, since even with the arrival of drugs, which seemed revolutionary at the time, moral treatment would continue to be used in all hospitals. The era of treating mental illness in the same way as any other physical disease began.

1. Hubert A. Wallot. op.cit., p. 108.
2. Normand Séguin. op.cit., p. 48.
3. Jules Lambert. Mille fenêtres. Éditions Centre hospitalier Robert-Giffard, Beauport, 1995, p. 34.
4. Today, recreation and work are still considered to be beneficial, both for those with mental illness and for the rest of society.
5. Jules Lambert. Mille fenêtres. op.cit., p. 129.
6. Ibid., p. 147.
7. Hubert A. Wallot. op.cit., p. 115.

Early in the 20th century, new treatments were discovered and applied. While some of them seem “barbaric” to us at first glance, they were considered revolutionary at the time. New medical treatments such as malaria therapy, insulin therapy, lobotomy and the sleep cure were added to the moral treatment already extensively used since the institution of asylums in Quebec, but did not replace it. With strong recommendations for their being used simultaneously, cures, or at least improvements in patients’ conditions, seemed to increase remarkably.Malaria therapy, (C1) discovered in 1917 by Julius Wagner Von Jauregg (1857‑1940) in Vienna, was developed and introduced in Quebec in about 1925 and used starting in 1927 as a treatment for syphilitic dementia (general paralysis) at the Hôpital Saint-Michel-Archange. This treatment consisted in inoculating a patient who had general paralysis with the malaria organism. The aim was to bring about enough hyperthermic crises (paludal fever) to cure the disease. Jauregg thought that, since the disease was caused by an outside agent (the syphilis microbe), increasing a patient’s temperature could kill this external agent and bring about a cure. Doctor Charles-Saluste Roy, (C2) superintendent of the Hôpital Saint-Michel-Archange from 1923 to 1946, said in 1929 that results to that point were unexpected but that the treatment was still a high-risk one.1 There were statistics to back up this statement: of ten patients treated with malaria therapy, one had full remission, two cases were unchanged, three improved, and four died. His success was thus limited, in spite of expectations. A completely outdated treatment today, it was replaced in the 1940s with penicillin, which proved to be more effective and reduced the risks related to the treatment.Insulin therapy (C3-C4) was discovered in 1933 by psychiatrist Manfred Sakel (1900-1957). In the beginning, as today, insulin was mainly used to treat diabetes, but it was soon realized that it had beneficial effects when used to treat schizophrenia in particular. Insulin therapy was also the first treatment to have a positive effect on this illness, and it was used starting in 1934.2 This treatment was introduced at Hôpital Saint-Michel-Archange around 1937, but it was definitely used most in the 1950s. Schizophrenics are the patients who respond best to this medical treatment, but not the only ones; cases of paranoia and depression were also treated. On the other hand, insulin therapy causes problems for women. According to Doctor Armand Thibault of Hôpital Saint-Michel-Archange, they were more difficult to treat with this medication because their reactions to the drug were more violent than with men. This problem was dealt with by treating women in separate rooms.3 This medical therapy was used until the 1970s at Saint-Michel-Archange, and was then completely replaced by antidepressants.Other forms of treatment were developed at the same time, including convulsion therapy, also called chemically induced convulsions, developed by Ladislas Von Meduna (1896-1964). Meduna first used injections of camphor dissolved in olive oil to bring about convulsions in catatonic patients. Shortly after, he gave up this treatment and used metrazol (Cardiozolâ). (C5-C5a) Introduced to Quebec in 1934, this medication, which proved to be more effective than camphor, was first used as a diagnostic test for epilepsy, since it caused a series of convulsive crises in patients, and epileptics react strongly to convulsions. It had an effect on behavioural and character problems and its effects on all various psychoses, including manic depression, anxiety and schizophrenia, were soon recognized. While it did not completely cure the illness, metrazol brought about such an improvement that following treatment it was possible to take the patient to a common room and to ask him or her to perform small tasks. In a paper on shock treatment published in 1943, Doctor Charles-Saluste Roy said that metrazol was on the way to becoming the most popular drug for treatment of all kinds of psychoses.4However, there were some problems with convulsion therapy using metrazol. Firstly, some patients could not be treated with this medication – people with heart conditions, febrile disorders, and people who had suffered serious head trauma and had memory loss.5 In addition, convulsions sometimes caused patients to suffer numerous fractures, which can also cause problems. Thus, a few years after the discovery of metrazol for convulsion therapy, it was replaced by electroshock therapy, developed by Ugo Cerletti (1877-1963) and Lucino Bini (1908- ).The principle of electroshock therapy is to bring about loss of consciousness, followed by convulsions, by passing an alternating current through the brain. The result was a spectacular decrease in the duration of mental illnesses, usually terrible for the patient, which previously lasted from six to nine months.6 In 1955, a study published on electroshock showed that the results of this medical treatment were at least as good as those for insulin therapy. But it could not replace metrazol as a diagnostic test for epilepsy, which is one of the negative aspects of this treatment. The other is the view of the anti-psychiatry movement of the 1970s, which spoke out against this method, saying that it was a barbaric procedure. This stand caused skepticism about electroshock therapy among the public. This treatment is still used today, but in less dangerous and more humane conditions. Curare is used to avoid convulsions and general anaesthesia prevents the patient from suffering. Moreover, the main indication for electroshock today is major depression that is resistant to other treatments and puts the patient in a life-threatening condition, so it is used as the treatment of last resort.Lobotomy, (C6) invented in Portugal in 1935 by Egas Moniz (1874-1955) and introduced to Quebec in about 1946, was considered revolutionary at the time. It involved severing the nerves that link the frontal lobe to the rest of the brain to cut off any interchange of signals. The first lobotomy carried out in Quebec was in 1946 at the Verdun hospital; it was later introduced at Saint-Michel-Archange. It was used to treat anxiety and pathological agitation, among other disorders. In spite of its spectacular successes, which astounded all the doctors, lobotomy had its drawbacks. In fact, it was very risky. Neurological science at the time was not well developed, and knowledge about the brain was minimal. There were sometimes incidents where the wrong nerves were mistakenly severed, causing the patient to fall into a vegetative state. Lobotomy could also have negative effects such as loss of affect and relapses.7 While patients appeared to improve, there were sometimes problems that did not show on the surface. While the tormented seemed to be soothed and the agitated appeared to be calm, they were sometimes left without moral judgment and social skills. The arrival of psychopharmacology (C7) in the 1950s meant the end of this practice, which did not reappear until a number of years later. In spite of everything, this medical treatment seems to have an appeal for the medical world, because it is still practised today in isolated cases. But lobotomy has had a name change, the word seeming to be too pejorative; the treatment is now stereotaxis. It is used these days on people suffering from chronic depression or serious compulsive disorders and has a response rate of 60% to 70% among patients who have undergone this surgery.8Finally, the sleep cure was also a medical treatment much used early in the second half of the 20th century. It consisted simply of systematically putting the patient to sleep for several days in bed in a room reserved for this purpose. This therapy was used to treat several types of illness – patients who were very depressed and both physically and mentally exhausted, patients with manic excitement or acute delirium, and those exhausted by overstress, sleeplessness and lack of nourishment.9When they appeared, people both admired and were repelled by the medical treatments mentioned above. While they were revolutionary at the time, when psychopharmacology arrived they were relegated to memory. (C8-C9-C10-C11-C12-C13-C17-C18)

1. Jules Lambert. Mille Fenêtres, op.cit., p. 60
2. Lambert Tremblay. Évolution des traitements en psychiatrie depuis la fondation de l’asile jusqu’à l’ère du Prozac dans la société moderne, p. 18.
3. Armand Thibault. Notes relatives à l’insulinothérapie, traitement en vigueur au cours des années 1950. Galerie historique Lucienne-Maheux, l’Institut universitaire en santé mentale de Québec, p. 1. 21 Lambert Tremblay. op. cit., p. 26.
4. Charles-Saluste Roy. La malaria thérapie et la thérapeutique par les chocs à l’Hôpital Saint-Michel-Archange. Auspices du Ministre de la Santé et du Bien-être Social, l’Honorable Henri Groulx, Québec, Galerie Lucienne-Maheux, l’Institut universitaire en santé mentale de Québec, 1943, p. 63.
5. Ibid.
6. Hubert A. Wallot. op. cit., p. 135.
7. Mario Girard. “L’émotion sectionnée”, in La Presse,January 9, 2005, p. 13.
8. Ibid.
9. Hubert A. Wallot. op.cit., p. 108.

Psychopharmacology, which has been around for a long time, only really developed recently and, with its quite phenomenal ability to control mental illness, effectively puts the medical treatments in vogue in the mid-20th century on the scrapheap. With its diversity and multiple areas of action, it is a major element in the development of treatments for mental illnesses and changes our perceptions. As soon as mental illness began to be treated like any physical illness – with medication – the public at large became more tolerant of people with mental illness.Sedatives and hypnotics used to treat mental disorders were put on the market towards the end of the 19th century in Germany. Morphine, a derivative of opium, was discovered as early as 1806. Opium was often prescribed at that time for its tranquilizing, sedative properties. However, it was abandoned in the late 19th century because patients became addicted. Bromides, calming medications used to treat nervous disorders and insomnia, were discovered in 1826, but were only used in asylums towards 1880, for their sedative properties, to relieve addiction to morphine and cocaine, and to calm agitated patients so that they did not exhaust themselves. They brought about a prolonged sleep cure for very excited patients. Bromides were used up to the 20th century.1Chloral hydrate, discovered in 1832, began to be used in psychiatric hospitals in 1869. This medication was very popular for a long time because of its soporific properties. Scopolamine, or hyoscine, was discovered around 1880 and used as late as 1950 to calm patients with anxiety. In 1903, barbiturates, strong sleeping drugs, made their appearance. Since then, approximately fifty derivatives have been put on the market.2 Meprobamate, a chemical tranquilizer, was the first to become wildly popular, to the point that in 1956, one American in 20 used it. But its harmful effects were discovered and it was scrapped.3Psychopharmacology was developing more and more in the 1940s. The same medications were used, but some, like hyoscine and morphine, were combined to achieve better results. Because of the overcrowding in psychiatric hospitals at the time, it is understandable that arguments among patients and noise were common. The development of psychopharmacology brought calm to the crowded wings.4 But true modern psychopharmacology began in the 1950s with the arrival of antidepressants and neuroleptics, whose antipsychotic effects were discovered by Jean Delay (1907-1987) and Pierre Deniker (1917-1998). Among antidepressants, chlorpromazine (Largactil), used mainly in the 1960s in the “Laborit cocktail” (a mixture of Demerol, Phenargan and Largactil), revolutionized psychopharmacology by calming agitated, excited patients. Largactil was the first truly effective medication for psychoses. It was used a great deal at that time. In 1953, in Hôpital Saint-Michel-Archange alone, 230 patients were treated with this medication. Neuroleptics were also active on patients’ agitation and on psychoses. Great hope was put in these medications and results were promising. They were also used to control disordered thoughts, affect and behaviour.5 Since the discovery of all these medications, a whole array of antidepressants and antipsychotics has been put on the market, replacing all other treatments used in the history of madness since doctors began to search for a medical solution to this problem.The 1960s also saw the marketing of new products that would revolutionize psychopharmacology: benzodiazepines, which are still used today. They replaced the barbiturates discovered some decades earlier. Recognized for their anxiety relieving and hypnotic properties, they would become the most prescribed medications around the world. The best known control anxiety: diazepam (Valium), flurazepam (Dalmane), alprazolam (Xanax) and lorazepam (Ativan). Lithium was also discovered at this time (1954) by Mogen Chou, and was used to treat bipolar disease. In 1987, fluoxetine (Prozac) appeared. Still very popular today, it is used to treat anxiety, depression, bulimia, obsessions, panic and malaise.6The arrival on the market of all these medications greatly changed the treatment of mental illnesses. A revolution in the science of psychiatry and a new conception of mental illness followed. The new wave advocated deinstitutionalization, which was to take place en masse in the following years, so that today we have treatment provided in the community and much more extensive research at the Institut universitaire en santé mentale de Québec.In the 21st century, new debates are arising regarding ethics and the law. Specialists today question the administration of medications: Should we give a medication to a patient who cannot understand the importance of side effects? In the same vein: Can a person who is completely removed from reality truly make an intelligent choice that has been well considered and will be beneficial for him or her? Many people are pondering these issues today because the invention and administration of medications continues to bring up questions of this kind. (D1-D3-D4-D5)

1. Lambert Tremblay. op.cit.,p. 25.
2. Ibid., p. 26
3. Hubert A. Wallot. op.cit. p. 126.
4. Jules Lambert. Mille Fenêtres, op.cit., p. 81.
5. Ibid., p. 74.
6. Lambert Tremblay. op.cit.,p. 34.

With the development of psychopharmacology in the 1950s came a great wave of deinstitutionalization. The change in the way people thought about mental illness led once again to a new view of the treatments that should be given to those who suffered from it. The human rights movement gave an air of respectability to psychiatric institutions and the aim henceforth was to humanize mental health treatment, first by abandoning confinement in asylums as a means of dealing with mental illness and then by limiting the number and duration of hospital stays. Efforts were made to avoid having patients lose their jobs and their homes. People were only hospitalized if it was absolutely necessary, and people who could do so returned to society.While the true deinstitutionalization movement did not start until about 1960, the early 20th century had its school of thought concerning this issue. Doctor Delphis Brochu, the medical superintendent at Hôpital Saint-Michel-Archange from 1903 to 1923, said that he thought that the mentally ill in hospitals should be prepared for an eventual return to society and accordingly increased the number of discharges of the most lucid patients. With some, he also attempted treatment in their family environment and, if this failed, in families in isolated or very rural areas.1 We can see in this that the first indications of a move towards deinstitutionalization appeared in the early part of the century. (E1)Deinstitutionalization began in 1950 with the implementation of the “open doors” program, which broke up hospital stays with outings such as walks in the park or weekends spent at home. This was also the period when hostels affiliated with the Hôpital Saint-Michel-Archange were recognized; they were mainly used to relieve overcrowding of the health system. However, there was a certain amount of delay in deinstitutionalization in Quebec because this movement required a reorganization of the way mentally ill people are cared for. The emphasis had to shift from the individual patient to his or her family, social and cultural environment.2It was therefore during the 1960s that the real change took place. In 1965, the nuns gave up management of the hospital following the revolution in psychiatry and the beginnings of deinstitutionalization. The hospital became a government-run institution. This was the first phase of deinstitutionalization, instigated in part by the Bédard report. In 1961 the Liberal government formed a commission to study psychiatric hospitals and on March 9, 1962, its report was presented. One of the recommendations in the Bédard report was deinstitutionalization. The report stated: “The Commission is convinced that hundreds of patients continue to live in our mental hospitals when their mental state does not require hospitalization. The Commission concludes its comments with these main recommendations (…):

1. Mentally ill patients must be treated in a location close to their residences to avoid social uprooting;
2. Smaller hospitals (fewer than 500 beds) attached to regional general hospitals providing more adequate services (…);
3. Apart from hospitalization, each psychiatric hospital must provide a range of services: outpatient clinics, day and night centres, emergency teams, etc, with the resulting reduction in number of beds (…).” 3

This first phase had three objectives: regionalization, diversification and a greater number of services in the community.The second phase began about 1975 and, again, mainly changed the way society looked at mental illness. When it was considered in the same light as any other disease, services for the mentally ill began to be integrated into already existing institutions such as general hospitals and medical clinics.The third and final wave of deinstitutionalization started with the 1989 mental health policy. This policy contained five directives for treatment of mental illness:

1. make the individual the prime consideration;
2. enhance the quality of services;
3. distribute resources equitably, based on needs;
4. look for solutions in the patient’s customary environment;
5. form a strong partnership between the individual, public resources and resources in his or her environment.4

Subsequent to the 1989 policy, a system of services in the community (outside of hospitals) was put in place in order to avoid hospitalizations in a psychiatric environment. These community treatment centres were set up in locations that were not set apart from the rest of society. A multidisciplinary team provided services day and night. The specific characteristics of the patients, based on their diagnoses, and the specialization of the employees, who were trained in a particular approach, made these centres locations for treatment that were super specialized in psychiatry.5 Various services were provided at these centres, such as psychiatric day care, a service for centre workers to accompany patients, an emergency intervention service, and home visits.Treatment in the community has changed a great deal since it first appeared. In the 21st century, l’Institut universitaire en santé mentale de Québec (E2) has split up its services into a number of specialized centres in the community. Since the institution reorganized its care and services, these centres are attached to client programs. hypertextlink: http://www.rgiffard.qc.ca/soins_services/soins_psychiatriques/programmes_clienteles.asp The hospital’s guidelines explain that this type of organization consists of a series of interrelated actions taken to arrive at specific objectives, which require human, material, financial and knowledge resources to be achieved, in order to meet the major needs of a particular client group.6 In these client programs, patients are grouped based on the different categories of psychiatric diagnoses. The aims are better needs assessment, greater accessibility of services in the community and better distribution of resources.7 Thus, depending on patients’ diagnoses, they are not hospitalized but treated outside a hospital in a centre that specializes in their type of illness. For example, one of the client programs includes persons with severe personality disorders. These patients receive care at the Faubourg Saint-Jean treatment centre. This client program treats the most severely affected persons in the Quebec City area, who have serious symptoms and require an interdisciplinary approach to improve their mental health. People suffering from emotional problems go to the day hospital to consult the multidisciplinary team and receive treatment. These services are provided to people in a crisis condition who do not present any danger to themselves or others. It is intensive, short-term treatment enabling hospitalization to be avoided. People are most often referred there by the psychiatric emergency department at the Hôpital de l’Enfant-Jésus.8 A number of centres that treat a particular family of diagnoses have been created in the community. We are seeing the results of deinstitutionalization today – greater accessibility of appropriate services for patients to promote better treatment in the community, and the maximum reintegration into society possible. A number of other residential resources in the community of l’Institut universitaire en santé mentale de Québec, such as family resources, have been transferred to the Quebec region’s local community service centre (CLSC). Services and professionals are also following this trend and moving out into the community.

1. Hubert A. Wallot. op.cit., p. 92.
2. Ibid., p. 182.
3. Hubert A. Wallot, op.cit., p. 211.
4. Ibid., p. 391.
5. Ibid., p. 374.
6. l’Institut universitaire en santé mentale de Québec. Guide d’élaboration d’un programme clientèle, mars 2003, p. 10.
7. http://www.institutsmq.qc.ca/index.php?id=25
8. http://www.institutsmq.qc.ca/index.php?id=110

Specialization of services provided developed along with the move towards deinstitutionalization. From the early 1920s, the Hôpital Saint-Michel-Archange obtained its own physiotherapy service, which provided diathermy and ultra-violet treatments. It was immediately very popular and its use increased over the years. In 1956, 1,035 patients used the physiotherapy service, which had also improved its methods; in addition to diathermy and ultra-violet treatments, they added treatments such as ultrasound, wax baths, and massage.1 Physiotherapy marked the start of a great shift towards specialization, which was also to increase in the 1960s. A number of medical specialties started at Hôpital Saint-Michel-Archange.In 1944, the social sciences school at Laval founded its first psychiatric social service. This was used in tandem with the Hôpital Saint-Michel-Archange, which founded its psychiatric social service clinic in 1947. Specialists from this university attended patients when they first entered the hospital, during their hospitalization, and at their discharge. The psychology service was founded in 1953, when a psychologist was hired to join the team of specialists.In 1966 we saw a turning point in specialization at the Hôpital Saint-Michel-Archange. An inhalation therapy service was developed and along with patient care provided in this area, hospital staff was trained in cardio-respiratory resuscitation.2 In that same year, Hôpital Saint-Michel-Archange expressed a wish to create gerontology services, and services for children and adolescents, alcoholics, and so forth. They also said they wanted to develop areas related to psychiatry, such as psychology, social work and occupational therapy, as well as hire instructors, educators and patient attendants.3 All these services were to be created in the years that followed.In about 1973-74, Hôpital Saint-Michel-Archange created an intake centre in its establishment. It was intended for patients who did not need ongoing psychiatric, medical or nursing care, but who did need to use the educational, learning, recreational and motivational services in order to return to society. It was closed in the 1980s to become a long-term care hospital (CHLSD).Today, the movement to super-specialization has led l’Institut universitaire en santé mentale de Québec to include a full range of specialized professional services, such as those for “functional” rehabilitation (occupational therapy and physiotherapy), pharmacy, psychology, sex therapy, social services, specialized education, gerontopsychiatry, neurology, and so forth.

1. Jules Lambert. Mille fenêtres, op.cit., p. 77.
2. Ibid., p. 144.
3. Jules Lambert. L’Hôpital psychiatrique, Centre actif de traitement et de réhabilitation. Commission Bonneau – Dr, Jules Lambert, 1966, p. 11.

The Institut universitaire en santé mentale de Québec has long been concerned about the training of its personnel. In 1915, Sister Saint-Calixte, who was then superior and director of the Hôpital Saint-Michel-Archange, founded the first school of nursing in the district of Quebec, which in 1924 became affiliated with Université Laval. In 1949, in response to a request from the health ministry and Université Laval, Sister Saint-Ferdinand founded the school of neuropsychiatry for graduate nurses. The school trained heads of care units for clinical teaching and prepared students to be assistants to psychiatric specialists in the general hospitals. At the request of the Quebec nurses’ association, Université Laval made a session in psychiatry mandatory for a diploma starting with the 1960 exams. Some years later, the nursing course was integrated into the CEGEP programs and courses in auxiliary patient care were provided at the comprehensive schools.1In 1952, the university’s rector asked the hospital to become a teaching hospital so that he could send his medical technology students there. One aspect of its mission was to “foster the emergence, maintenance and development of a teaching culture focused on knowledge of psychiatry and mental health.”2 The Institut universitaire en santé mentale de Québec joined as part of its mission at Université Laval. University students could then take internships in several fields – psychiatry, psychology, social services, nursing, and so forth.Today, the Institut universitaire en santé mentale de Québec has a very well developed teaching component.The second half of the 20th century was therefore synonymous with changes in the way psychiatric care was organized in Quebec. With treatment in the community, people with mental illness could better integrate that community. Teaching and specialization made it possible for patients to receive care that was better suited to their needs. At the end of the 20th century, treatment of mental illnesses at the Institut universitaire en santé mentale de Québec had reached great heights, particularly with respect to research and creation of innovative programs.

1. France Saint-Hilaire. “Hôpital Saint-Michel-Archange: Berceau de la profession infirmière à Québec”, Le P’tit Robert, no. 245, May 2005, p. 3.
2. http://www.institutsmq.qc.ca/index.php?id=59

(F1) One element at L’Institut universitaire en santé mentale de Québec – research – has been developing more and more over the last several decades. Since the 1950s, we have seen rapid development of laboratories. In 1954, another laboratory was added to the biology laboratory for the purpose of furthering research. In 1958, this biology laboratory already had two doctors of science working there.1 In 1966, the Hôpital Saint-Michel-Archange officially became a research and teaching centre and promoted training for its team members at both the undergraduate and postgraduate levels.2 A broad-scale project was carried out in 1987. In partnership with Université Laval and the Hôtel-Dieu du Sacré-Cœur-de-Jésus, L’Institut universitaire en santé mentale de Québeccreated the Centre de recherche Université Laval Robert-Giffard (CRULRG). Its principal mission was to advance science with respect to neuropsychiatric illness in adults and children, as well as the brain and behaviour. Pioneering fields such as neuroscience and genetics are studied and taught at the Centre. Research at CRULRG mainly focuses on four distinct areas:

1. evaluative and clinical research,
2. systemic neurobiology,
3. genetic epidemiology,
4. cellular neurobiology.3

Neuroscience has developed in the last 25 years. It attempts to understand how the brain functions and to connect its different areas to specific functions. For example, this science has determined that language is connected to the frontal lobe. Through neuroscience we may find the origin of mental illnesses so that they can be effectively treated. Many advances have been made in this field – over the years more than a hundred neurotransmitters have been discovered, such as serotonin in 1952 and dopamine in 1957.CRULRG is recognized by the Fonds de Recherche en Santé du Québec, and its research on illnesses such as schizophrenia, autism, Alzheimer’s disease, Parkinson’s disease and a number of others have earned the Centre an excellent reputation both nationally and internationally.4

1. Jules Lambert, Mille fenêtres, op.cit., p. 77.
2. Jules Lambert, L’Hôpital psychiatrique…, op. cit., p. 12.
3. http://www.institutsmq.qc.ca/index.php?id=accueil
4. http://www.institutsmq.qc.ca/index.php?id=59/

Madame France St-Hilaire, professional archivist and head of the communications service at the Galerie historique Lucienne-Maheux. Supervision, text editing and caption writing.Madame Catherine Lessard, head of the communications service at l’Institut universitaire en santé mentale de Québec. Text editing.Monsieur Gilles Barbeau, Professor Emeritus, pharmacy faculty, Université Laval. Editing text on medical and psychoparmacological treatments.Madame Lucie Ouellet, programming officer in the care and clinical services division at l’Institut universitaire en santé mentale de Québec. Text editing.Monsieur Simon Lecomte, technicien en audiovisuel, audiovisual technician in the teaching division of l’Institut universitaire en santé mentale de Québec. Photographing documents from the archives and processing photographs.Thanks as well, for their valuable advice, to:

• Monsieur Alain Rioux, co-ordinator of programming and client service evaluation in the care and clinical services division of l’Institut universitaire en santé mentale de Québec.
• Docteur Hubert Wallot, psychiatrist at l’Institut universitaire en santé mentale de Québec.
• Patricia Solomon, for having supplied the French-to-English translation.