Institutional care – was the baby thrown out with the bathwater?
By Dave Macpherson
Twenty years ago the Clark Government shepherded through the closure of the country’s grim old standalone mental health institutions – Tokanui, Lake Alice and Cherry Farm are names that come to mind.
The argument put forward was essentially that the Victorian era ‘loony bins’ were a discredited, inhumane, and even prison-like, means of caring for the severely mentally ill. The film One Flew Over the Cuckoo’s Nest, complete with the archetypical Nurse Ratchett and a lobotomised Jack Nicholson – along with a series of home-grown Lake Alice ‘electrotherapy’ horror stories – helped convince Governments and communities that isolated, rural ‘mental hospitals’ had to go.
The replacement was to place those who were not too severely mentally ill back into ‘the community’ where they could integrate and interact with the general community as part of the healing process, as well as the creation of small residential mental health units within main hospital precincts to cover patients with forensic/criminal issues, and those deemed in need of 24/7 ‘professional’ mental health care due to the severity of their illness.
The promise was that all the money spent on the old ‘mental hospitals’, and more, would be spent on providing the care, support and facilities required to meet these needs.
The truth, under successive Governments, has been that while there have been minor ‘cost-of-living’ type increases in spending, the resources allocated – including training, staff and community resiliency – has never met the actual needs, especially when you consider the growth of mental health and related issues in the community – poverty, drugs, unemployment, and family violence are all implicated in the stark figure that one in four kiwis will face mental health issues during their lifetime; but are by no means the only causes.
The contracting out of community mental health care to NGOs, some of whom had little or no experience in the field, became primarily based on cost, and acute residential support became a luxury that was never properly funded.
In my first month of election to the Hamilton City Council in 1998, we received a spate of complaints from residents of one street about the ‘inappropriate behaviour’ of residents of a mental health-funded ‘halfway house’. On investigation, we discovered 6 adult residents with mental health issues – some of them patients shifted from the closed Tokanui Hospital – living in one small 3-bedroom house with one support worker funded to come in for 8 hours a day (except not on weekends)!
Without support for 75% of the time, it was hardly surprising these residents were in trouble, and the surrounding community was upset. When we questioned Ministry of Health and Waikato Hospital officials, they freely admitted that the NGO ‘running’ the halfway house (along with others around the city) had put in the lowest tender.
The alternative to these services were the new hospital campus ‘mental health units’, like the Henry Bennett Centre in Hamilton, where forensic, acute and non-acute Wards were constructed alongside each other, in buildings next to (or part of in some regions) the main hospital, usually in the middle of the largest city in the region, and where professionals increasingly saw the best option as prescribing enough of the right sort of drug to keep the ‘inmates’ under control.
Bed numbers were always limited, as were educational, restorative and family/whanau support areas and resources within these units, leading to a prescription drug-led, prison-like atmosphere, without the work requirement. ‘Patients’ had little to do each day, other than smoking in secure courtyards provided, and then later denied when overzealous policy wonks got in on the act.
You were either shut up in a medium or high-security prison, or thrown out on the street (quite literally for many) – there was (and is) little support for patients transitioning back into the community.
In reaction to this, more and more are questioning the complete closure of standalone mental health institutions – including quite a few nurses, community care providers and other professionals working in the sector. This week a ‘friend’, who works in the related aged care sector, posted a comment about the Henry Bennett Centre on the ‘Nick Autumn Stevens’ Facebook page: “This dreadful place is not where people with an illness belong….its too noisy….and closed in….nothing to do…..this place should be in the country where people can work out in the garden…cook in the kitchen, do some crafts, woodwork ect…..heal in peace….”.
As part of the growing debate about the future of mental health services in this country, this sort of view is being expressed more and more often.
Did we throw out the baby with the bathwater when we decided to change course 20 years ago? Has the change just been used as a means of limiting public expenditure on mental healthcare? Should we be looking at combining the best aspects of both the old system and the current system? Should the resources be increased to match need rather than Treasury policy? Should Governments get off their collective arses and lead the debate, rather than being dragged into it kicking and screaming?
Dave Macpherson – Father of Nicky ‘Autumn’ Stevens and Waikato DHB member (from Dec 2016)
As an ex foster parent, I also feel that the concept of ‘orphanages’ or Health Camps should be revisited.
There are simply not enough suitable volunteers to care for all the children emerging from our broken homes and communities, especially for kids with deep rooted issues that require long term homes.
Of course my vision of a Utopian Orphanage doesn’t have a chance under our current abusive economic system.
But one can dream.
Agreed, Siobhan. And yet I have the feeling that if the issue was revisited, as you propose, the long term costs may well be less than continuing with the current system.
We see increasing numbers of alienated, zombified people with little left in the their lives other than eating and drinking in desolate urban environments. Dressed in black, overweight or obese, they stagger from oversized vehicles into eating establishments or supermarkets, seeking the little gratification this society offers them -overindulgence in addictive so-called food which is based on over-processed grains and which is loaded with sugars, glutamate and vegetable oils and factory-farmed animals. Some people do not even bother to get out of their vehicles and queue in fast-food drive-throughs for their doses of corporation-produced and corporation-marketed toxins which throw their biochemistry out of balance. And with drink-driving no longer in vogue, many people load up with alcohol at supermarkets and bottle-stores and seek the ‘comfortably numb’ feeling induced by intoxication at home. Such people are clearly mentally ill, but by the standards of this corrupt and dysfunctional society are designated ‘normal’. Good citizens even because of their mindless consumption.
At the other end of the scale we have toddlers and children growing up in a corporatized screen-addicted society that discourages them from participating in the very activities necessary for them to grow into what until recent times was regarded as normal adulthood. Such children -disconnected from nature- are clearly mentally ill but by the standards of this corrupt and dysfunctional society are also designated ‘normal’.
The descent into chaos is clearly accelerating, and is very much in line with ‘End Times’ prophesy: a curious coincidence or something more? I have not been a fan of the Bible since I reached the age of reason but must say what we are witnessing is clearly indicative of ‘End Times’. And everything is being made worse by the day.
It has to be that way, of course: we know that the key to good health (both physical and mental) is a strong, caring community and togetherness with nature, and those are the very opposite of what the corporations that control western societies want. More illness = more profit for companies specializing in making people ill and treating illness, as exemplified by the USA.
Some nice judgemental comments there about people in your community. Perhaps you should look at yourself.
Maybe it is the inconvenient truth? I notice daily how people live in their little own state of mind, that is somewhat detached from the reality around them. Many seem to be mentally and emotionally neutered.
I 100% agree. I worked at Porirua Hospital when it truly was an asylum. We were funded to work with our patients and their families to give the best care possible. Patients were transitioned back into the Community where the Community MH Nurses continued to support and monitor them Unfortunately it is only the bad news stories that get the publicity, not the majority of good news stories where people were rehabilitated and respected. I loved my job and looked forward to going to work each day. I wish it could be like that for people with Mental Health issues again.
Not under Helen Clark. Natz in Govt 1990-99, closed these “Hospitals” between 1992-1999!! according to references. Perhaps the same old story, Its Labours fault..
Not under Helen Clark. Natz in Govt 1990-99, closed these Hospitals”” between 1992-1999!! according to references. Perhaps the same old story,”its Labours fault”…
Dave….you are telling it exactly like it is.
I was working in the sector in the early eighties when Tokanui was being earmarked for permanent closure. We were a halfway house type place, but unlike the one you tell of we were staffed 24/7 with very strict supervision and structure. A few of our residents had to periodically return to Tok for stabilisation, and there was the odd one or two who preferred to be there.
Far from the madding crowd.
We were involved in the discussions around closure of the ‘institutions”, and even then we knew that unless properly resourced, community care could be disastrous for those who we knew needed a great deal of support.
The prevailing voices were those who demanded (quite rightly) that those with mental illness should be treated humanely and not shut away… ‘out of sight for the out of mind’…and not treated against their will.
Trouble was/is that many of these voices were from people who had experienced a mild degree of mental illness and assumed that their experience gave them the authority to speak for those for whom recovery to full community involvement (and safety) was not necessarily a given.
Despite many voices expressing concern, the Powers That Be bowed to ideology and threw the baby out with the bathwater.
And Dave, you know what pain that has caused for so many.
Everything you have written about mental health services can be said about disability support services.
Everything.
And interestingly, a few years ago there was an article posted on a disabled persons organisation’s facebook page about a group in Australia who had set up a rural residence for people with autism. There were trees and grass and farm animals. There was 24/7 care in a homely but safe environment. There were wide open spaces, peace and quiet.
One of the first people to post a comment was a hard core disability rights advocate….absolutely outraged at this retrograde step of pushing people with disabilities out of the community and back to being hidden in rural institutions.
The next person to comment was a young adult who was struggling to manage life on the spectrum. The ‘world was much with her’, and like many on the spectrum she found it nearly impossible to buffer the sensory overload that town living brought. Strong medication had been prescribed, and the side effects were devastating.
This rural residence sounded like paradise to her.
Its interesting that you asked if these ‘reforms’ were to do with limiting public expenditure on mental health (and disability supports), because I was involved in a discussion about this just that this morning.
In my darker moments I truly believe that the Misery of Health not only does not understand disability (and mental illness) but actually and actively hates those they perceive as being of weaker stock.
For both groups, the Miserly of Health has caused pain and stress and suffering and death. And they employ a shit load of petty bureaucrats to write policies and strategies and action plans…ostensibly after ‘consulting with the sector’. Then you go and find out exactly who is on these sector advisory panels and find they all have some financial arrangement with the Misery. The snouts in the trough are unlikely to risk losing their funding by telling their Miserly paymasters they have cocked it up.
The $$$ spent by ACC on a person who chooses risky activities and disables themselves would make those in mental health and disability support weep. So much more worthy of $$$ spent are the fit and active who fall, than those born with disabilities or those whose minds struggle in an increasingly stressful world.
You go for it Dave….kick their collectively arses until they scream.
(You may be interested in the post on Pundit from Brian Easton….http://pundit.co.nz/content/who-was-accountable-for-the-shambles )
“Actually Claudia is a ‘generic’ manager. That is, she knows nothing (or very little) about what she is managing and so is unable to take into consideration the particularities involved. She, like most of the other managers in the novel (and, in my experience, in practice), constantly stumbles against the realities of what they are managing. An example, not used in the novel, is that managers insisted that bed usage in wards be increased, without understanding that the more intensively they are used the more likely there will be cross-infection. Doctors tell me that people died as a result. I’ll leave you to read the novel for many other examples.
Yes, people died as a result of redisorganisation, many more experienced greater discomfort, and – as the novel details – resources were wasted. Managers rarely take into consideration the resources they are using in order to save resources.”
Not under Helen Clark’s term. Natz in Govt Nov1990-Nov1999. These “Hospitals” closed between 1992-Oct1999.
Same old story. “Ït’s Labours fault”..
20 years ago, the Clark government?
I thought Helen Clark got into power in 1999, not 20 years ago?!
No, it wasn’t the Clark government: the process was largely complete by the time they came to power.
In fairness all round, the rethinking of the role of the big institutions began in the 1960s. See this:
http://www.teara.govt.nz/en/mental-health-services/page-5
“Planning for new psychiatric hospitals ended in 1963 and no extra beds were provided from 1973. Instead, from the 1970s psychiatric services came to emphasise outpatient care, community-based treatment and more modern facilities.”
In the very early 90s, I attended a “Quality in Health” seminar, at which concerns were raised about the closure of psychopaedic hospitals (Templeton having been slated for closure at that stage), and fears that resources would not follow the people being relocated to the extent that would be needed.
At that same session, the same issue (resources) was raised regarding the closure of the big psychiatric hospitals. Views were expressed that closures were part of Rogernomics, and to save money. Officials at the seminar pointed out that the changes had begun long before Rogernomics – as noted in the Te Ara article – and weren’t about saving money. The public had been promised that the resources used to run such places would be diverted to community care. There was scepticism about whether that would happen. Which, of course, turned out to be well-founded, hence the issue having been raised at that seminar.
There’s no doubt that funding and resource shortages are much more serious now than they were, even in the early 1990s. I don’t know what the solutions might be. Even were there a change of government, there would need to be widescale agreement, both on the need for change, and what sort of change would bring better results.
Siobhan: “I also feel that the concept of ‘orphanages’ or Health Camps should be revisited.”
There are still some health camps extant, I believe; last I heard, the one at Otaki was still going strong, though about to relocate to Paraparaumu, I think. They certainly have their place, though that would be critically dependent on the quality of care they provide.
As to orphanages: crikey! I thought, remembering the institutions of my childhood, and the dreadful places we all heard about in eastern Europe 20-odd years ago. I’m certain it’s possible to do better than that: trouble is, we don’t seem to be either very good at designing such places, or willing to fund them to the extent necessary to provide a good quality environment.