Before the 1960s, in Quebec, the fate of people with mental health challenges was imprisonment, sometimes for life, in large psychiatric institutions. Religious orders managed the asylums and received assistance from the state in the almost total absence of health professionals.
The 1960s
In 1961, Jean-Charles Pagé, a former patient of the Saint-Jean-de-Dieu hospital, published the book Les fous crient au secours (The Madmen Cry for Help). In his book, he describes the poor living conditions, the use of electroshock therapy, straitjackets, and solitary confinement. Pagé denounces the nuns' administration of the facility and the difficulty of obtaining real therapeutic follow-up. The afterword was written by Dr. Camille Laurin, a psychiatrist and later politician, who echoed Pagé's testimony. The book caused an uproar upon its release, and a massive media campaign was launched to modernize psychiatric care in Quebec.
Indeed, less than a month after the book's publication, Jean Lesage's government set up the Commission on Psychiatric Hospitals headed by Dr. Bédard, which proposed a profound change in the asylum model.
The 1970s
The 1970s were marked by a first wave of deinstitutionalization, which involved moving a large number of patients from asylums to smaller facilities in the community. The goal was also to reduce hospitalization times and the number of beds in large psychiatric hospitals. The establishment of psychiatric departments in general hospitals was the main measure to decentralize services and bring them closer to citizens. The number and diversity of professionals trained to work in the psychiatric network was also increased. Psychiatric hospitals were purchased by the government from religious orders.
Between 1970 and 1975, the Castonguay-Nepveu reform, a reform of health and social services, took place. This reform brought recognition of the right to health, the adoption of the Mental Illness Protection Act (1972), and the creation of Local Community Psychosocial Service Centers (CLSCs) (1974). The 1972 Mental Illness Protection Act moved from exclusion to protection. It regulated involuntary hospitalization by limiting it to: "a person considered dangerous to themselves or to others." The imposition of a closed cure measure required a court order and two medical certificates, and this measure was made mandatory.
Despite these reforms, the situation for people living with mental health problems remains very difficult. Inside asylums, there are descriptions of "inhumane" practices, "ordinary atrocities," "cold electroshock," the use of restraints, drug overdoses, long periods of internment with little or no medical follow-up, and "great difficulties communicating with psychiatrists."
Recently established CLSCs are reluctant to provide front-line mental health services. With a few exceptions, it was not until the 2005 Mental Health Action Plan that the government mandated the creation of community mental health services.
The late 1970s and early 1980s
In the late 1970s, alternative resources, self-help and advocacy groups began to share experiences and come together, giving rise in 1983 to the Regroupement des ressources alternatives en santé mentale du Québec (RRASMQ). The mission of the RRASMQ (1983) has several objectives, including: promoting and defending the rights and interests of psychiatric patients and those experiencing emotional and psychological problems; encouraging changes in laws; denouncing the abuses of traditional psychiatry and any behavioral control techniques; fighting against prejudices about "madness" and for the right to be different; promoting the creation and maintenance of sufficient and adequate resources outside the traditional framework.
The 1980s
In the early 1980s, the aim was to impose the voices of psychiatric patients in public bodies where policies were developed "where decisions were made".
Community mental health organizations were very actively involved in the legislative reforms of the time, particularly the reform of the Civil Code. They aimed to protect the rights of people living with health problems and joined forces with other minority groups, including people living with physical disabilities. The priority was to harmonize the provisions of the Civil Code with the Quebec Charter of Rights and Freedoms and the Canadian Charter of Rights and Freedoms.
Mental health rights groups are pursuing several fronts: the right to consent to care, the limits and regulation of the use of involuntary institutional care and the use of isolation, control, physical and chemical restraint measures, and finally the rules governing the declaration of incapacity and public guardianship.
Advocacy groups play a central role in rigorously documenting abuses and the lack of recognition of rights in institutions. They initiate or support legal proceedings that lead to changes in laws protecting people living with mental health challenges.
Outrage over the living conditions in asylums, the deinstitutionalization project, and the desire to create accessible services in the community are shared by many civil servants and health professionals. Although there is significant resistance, the voices of psychiatric patients and a conception of rights and practices outside of asylums are finding support and strengthening. Those supporting changes from within the government rely on the work of rights groups and alternative resources.
At the Ministry of Health, some officials recognize the rigor of the critical work carried out by the alternative and advocacy movement. This makes it easier to secure funding for community initiatives.
Quebec's Mental Health Policy (1989)
In 1989, the Quebec Mental Health Policy was created. This policy places the individual at the center of mental health services and proposes a broader partnership between the individual, their loved ones, public mental health services, and community organizations. It recognizes and ensures funding for self-help groups, establishes advocacy organizations, and establishes beneficiary committees in psychiatric facilities.
The 1990s
Following the adoption of the Quebec Mental Health Policy (1989), regional groups for the promotion and defense of rights were established and, in 1990, the Association of Intervention Groups for the Defense of Mental Health Rights in Quebec (AGIDD-SMQ) was born. These groups provide individual support, training on the rights and recourse of people living with a mental health problem.
AGIDD-SMQ promotes shared fundamental values that underpin the practices of its member groups, including social justice and the principle of favorable bias, which involves giving credibility to individuals and their complaints to support them in defending their rights. A holistic view of the individual and the empowerment of power are among the core values of rights advocacy groups and alternative resources.
In 1996, Mr. Rochon, Minister of Health and Social Services, introduced Bill 39, initially titled An Act respecting the protection of persons suffering from mental illness, which amended the 1972 Act. The Minister thus aimed to establish a better balance between the rights of people living with a mental health problem and the rights of the community and public safety. Following mobilizations, it became the Act respecting the protection of persons whose mental state presents a danger to themselves or to others. These new legislative provisions prevent the confusion between dangerousness and mental illness. In other words, a person can be dangerous without having a mental illness.
The 1990s were marked by increased participation of people with mental health challenges in advocacy groups and alternative resources. They increasingly took a prominent role in symposiums and public consultations. Alternative resources trained and prepared them to participate in government committees and public commissions. Their experiences were valued: they were often hired as speakers or trainers.
The 2000s
Beginning in 2003, the Charest government, with a view to reducing the size of the state, proposed a major reform of the health and social services system. Among other things, the aim was to eliminate the Regional Health and Social Services Agencies, regional public planning bodies. Jean Charest's Liberal government abolished the Quebec Mental Health Committee (CSMQ), which had played a role in public reflection and consultation on deinstitutionalization and in developing proposals from the community movement. In 2004, 95 health and social services centers (CSSS) were established across the province, merging CHSLDs, hospitals, and CLSCs.
In 2005, the Charest government developed a new Action Plan for the period 2005-2010, entitled The Strength of Ties . This action plan maintains the principle of empowerment and introduces the participation of those directly affected at the heart of its orientations. In particular, it gives priority to the recovery of the whole person and recognizes the ability of people living with a mental health problem to make choices and actively participate in decisions that affect them.
The Action Plan establishes frontline mental health teams and community follow-up teams for people living with serious and persistent mental health problems. Community organizations contribute to achieving the Action Plan's objectives with a view to complementing services.
In 2007, the Porte-Voix du récupération (Voice of Recovery) was created by users Luc Vigneault, Nathalie Lagueux, and Véronique Bizier. The priorities of this national association were the integration of experiential knowledge into treatment teams, peer support, GAM (Medication Self-Management), the strengths-based approach, the recovery-oriented approach, and the fight against stigma.
Self-management of medication
The goal of Self-Management of Medication in Mental Health is to enable the person taking medication to move closer to a medication that suits them and that fits into a broader approach to improving their well-being and regaining control over their life.
The recovery-oriented approach
In the recovery-oriented approach, the rights of people with mental health problems are central. It emphasizes recognizing that each person has: 1) the right to have their own personal goals and make their own life choices; 2) the right to participate in the development of their individualized service plan; 3) the right to receive information about their illness and the side effects of medication; 4) the right to refuse treatment; and 5) the right to be treated with respect, dignity, and compassion.
Recovery-oriented services refer to services delivered directly in individuals' homes, determined by their personal goals and based on egalitarian and supportive relationships. By emphasizing individuals' rights and responsibilities, recovery transforms both their self-perception and the way services are delivered. Around the world, the concept of recovery and the importance of empowerment are increasingly recognized as guiding principles in the development of mental health care systems. By basing its action plan on these principles, Quebec is adopting an approach that respects individuals and encourages their participation in society.
The Mental Health Action Plan (PASM) 2015-2020
The Mental Health Action Plan, Doing Together and Differently, aims to enable continuous access to a variety of mental health services, particularly through the implementation of front-line services and the establishment of new modes of collaboration between establishments and the stakeholders concerned.
It is a continuation of the previous mental health action plan, The Strength of Ties. The PASM 2015-2020 is based on interdisciplinary and intersectoral collaboration. It also aims to promote mental health and prevent mental disorders and suicide. The PASM's orientations are: 1) to promote the primacy of the individual and the full exercise of their citizenship; 2) to ensure care and services adapted to young people, from birth to adulthood; to promote clinical and management practices that improve the care experience; and to ensure the performance and continuous improvement of mental health care and services.
Conclusion
Before the 1960s, in Quebec, the fate of people with mental health challenges was confinement in large psychiatric hospitals. The 1960s were marked by a profound questioning of the asylum model. The 1970s saw the beginning of deinstitutionalization and the era of the Castonguay-Nepveu reform. In the early 1980s, the goal was to impose the voice of psychiatric patients in public bodies where policies were developed. Towards the end of the 1980s, the Quebec Mental Health Policy was created, placing the individual at the center of mental health services.
The 1990s were marked by increased participation of people with mental health challenges in advocacy groups and alternative resources. During the 2000s, the Strength of Ties Action Plan was developed, followed by the Doing Together and Differently Action Plan . The 2000s were characterized by a recovery-oriented approach, in which the rights of people with mental health problems were central.
All in all, in nearly 60 years, in Quebec, people with mental health challenges have moved from a position of dependence on psychiatric hospitals to a reappropriation of power over their lives.