History of Contemporary Mental Health Care Report by: Cathy Jones 2 Cathy Jones Cathy Jones is highly regarded in the mental health field, particularly through her role as the Manager of the Cambell House Psychiatric Disability Support Service (PDSS). After working in the general health system and a large metropolitan psychiatric hospital, Cathy developed a strong commitment to community based psychosocial rehabilitation. This report was produced by Cathy when she undertook further studies and describes the societal response to mental illness over time, including: 1. Early Western History of the Response to Mental Illness 2. Incarceration of People with Mental Illness in Australia during the early 1800s 3. Humanitarian Segregation during the Asylum Period 1850 – 1950 4. Medical Deinstutionalisation during the 1950s and 1960s 5. Community Mental Health Movement in the 1970s and 1980s 6. National Reform and the Development of Area Mental Health Services in Victoria during the 1990s 3 Early Western History Our understanding of the early history indicates that beliefs surrounding mental illness were closely connected with religion and spirituality. Mental illness was being considered to be a manifestation of the will of god or the devil, and at times sufferers were labelled as demons or witches. Although the penal laws against witchcraft in England were removed in 1736, a woman was tried as late as 1797 for crimes relating to witchcraft. Superstitious rites in relation to insanity which involved dunking in water were little different from the ‘cold bath’ and ‘bath of surprise’ that were favourite remedies for insanity used by early medical practitioners.1 The earliest ‘treatment’ model in the Western world may have begun in ancient Greece where the belief in humors was put forward by Hippocrates and other ancient Greeks to explain illness of the mind and body. Prior to the seventeenth century, communities throughout Europe would deliver people labelled as “mad” to sailors who would then abandon them in far off lands in a vessel referred to as a “ship of fools”. Banishment of people with a mental illness can be observed in a number of different cultures. 4 In seventeenth century England workhouses and poorhouses were created for the incarceration of vagrants, beggars, the unemployed and the ‘insane’. It was during this time that John Locke indicated that mental illness might not have its roots in religious explanations and that madness may be an affliction of the ‘mind’ not the ‘soul’. In the eighteenth century Pinel, the father of “moral treatment” paved the way for a more humanitarian approach to the care of people with mental illness in France. At this time in England the belief still persisted that lack of religious obedience led to immoral behaviours such as those exhibited by people with a mental illness. At the end of the eighteenth century in England the early foundation for the medical model of treating mental illness slowly began to take shape. The English Lunatics Act of 1845 provided for some regulation of hospitals and licensed houses and amending acts in 1853 provided for the establishment of county asylums, which were public institutions rather than the private licensed madhouses that predated them. These asylums, however, were large institutions where human rights abuses were common. It wasn’t until the end of the nineteenth century in England that the medical profession became interested in mental illness and a scientific model of mental illness replaced the “Old World” religious ideology.2 In England when the Lunacy Act of 1890 came into force it applied also to ‘mental defectives, with the term ‘lunatic’ meaning ‘idiot or person of unsound mind’. 5 Early 1800s: Incarceration of the Mentally Ill in Victoria, Australia From the 1830s to the late 1840s Victoria was known as the Port Phillip District of New South Wales and there was no provision for people with mental illness other than incarceration in ‘lock ups’, our early gaols. Poor houses did not exist in Australia as they did in England during the late eighteenth and early nineteenth centuries. In 1838 a gaol was built at the site of the West Melbourne Market. It was a small stone building with stock and leg irons prominently placed out the front. There was no separation of criminals and people with a mental illness at this lock up and stockade. Early in 1840 the Collins Street West Gaol was constructed and some provision was made to separate people with a mental illness with the building of the Lunacy Ward. In 1840 the Metropolitan Gaol (later called the Old Melbourne Gaol) was used as a hospital for the insane, with both men and women being detained there. The “most violent lunatics” at that time were transferred to Sydney. 6 1850s to 1950’s: Humanitarian Segregation - The Asylum Period Following a publicity campaign in the Port Phillip Gazette in 1841 under the title, “Lack of Asylums”, the New South Wales Council provided funds in 1845 for the building of an asylum, which opened in October 1848. Originally called the Merri Creek Lunatic Asylum and the Melbourne Lunatic Asylum, it was subsequently named the Yarra Bend Lunatic Asylum in 1851. In 1852 the Yarra Bend Asylum accommodated 72 people and, with the construction of additional accommodation, this grew to 300 in 1856. The Yarra Bend Asylum admitted people directly from police custody or gaol as well as receiving referrals for private care, which was provided at a charge of 1⁄4 penny a day. Private care was subsequently available at other facilities including Harcourt (Ascot Vale) and Cremorne (Richmond) which between 1869 and 1885 provided ‘care of the senile and wealthy inebriates, as well as reception of lunatics’. The original legislation that established the basis for the public response to mental illness was the Lunacy Statute of 1867, which was based on consolidation of the law of England as it applied at the time. 7 Many changes have occurred in the way we assist people with mental health problems. The types of care were reflective of the way different generations thought about illness and mental health. In the past century our society has moved away from segregated care, putting people away, into what we now recognise as societal discrimination, rejection and neglect. We may be moving towards an era where people are accepted, treated with dignity and respect and provided with equitable services. The asylum period started in the early nineteenth century and was the beginning of a major effort to change the care of people with long term mental illness. It came from the “moral” approach to understanding mental illness. Morrisey and Goldman3 note that the “core belief was that the new cases of insanity could be cured by segregating the distracted into small, pastoral asylums where they could receive humane care and instruction” The need for institutional care grew as our population became larger. The relatively simple government response to community pressure was to increase the size of the institutions. With practically no effective treatments available large congested facilities developed. The broad community view was that people with mental illness were incurable and required long-term asylum. Funding did not keep pace with the growing size of the asylums. By the mid-twentieth century the original therapeutic style community envisaged had in reality become primarily custodial care.4 8 This period of time contributed substantially to the marginalisation of mental health from both general health and other social and disability services. Asylums assumed almost total responsibility for the lives of their patients, including treatment, accommodation, clothing, food, social network, vocational and recreation experiences. Essentially they attempted to provide ‘whole of life care’. However, this was at a huge cost – people were excluded from mainstream community life and often confined with little regard paid to basic civil liberties. As the institutions became larger as the population grew they also became more substandard and overcrowded5 . It needs to be remembered that modern medications did not exist. Minimal community involvement occurred in these institutions and this intensified fear and stigmatisation of people with mental illness. During this era voices for institutional reform were raised. One notable mental health campaigner in America, Dorothy Dix, organised for questions to be asked in various parliamentary forums and achieved lasting fame. This humane segregation, but nevertheless custodial approach dominated in Australian institutional care from 1850 to the 1940s6 . 9 1950s to Medicated Deinstitutionalisation While there were many critics of asylums, no significant change occurred until after World War Two. A number of factors combined at this time to force change. What followed was a major deinstitutionalisation of the asylums in the 1950’s. This happened due to a large number of factors outlined by Mechanic and Aiken such as: • The effectiveness of the newer pharmacological agents in controlling the more severe manifestations and behavioural disturbance of mental illness. • Concern to extend the legal and civil rights of people with mental illness, (especially after people saw the way returned soldiers were being treated). • Concern about actual and perceived abuse in the essentially custodial approach to care with no real treatment being offered. • Under-stimulation, loss of valued roles and loss of independence of people who had respected roles in the community (eg. returned soldiers). • Increased awareness and value of personal autonomy and equality. • A philosophy that it is better to treat people in the community in which they live. • The increasing financial burden on governments of maintaining large institutions. 10 The first factor, the development of new, relatively effective medications, at first bought great hope and it was believed that people would be totally cured and be able to live useful lives in the mainstream community. This was not to be. The Medicated Deinstitutionalisation era had several facets: • the discharge of existing patients into the community; • reducing new admissions and treating people outside specialised psychiatric institutions; • creation of private ‘for profit’ hostels (special accommodation houses) that were often little better than the large institutions in regard to the quality of care; and • forcing families to be the primary carers with little support. During this period there was an 80% decline in psychiatric beds in the USA from 559,000 beds in 1955 (338 beds per 100,000 pop.), to 103,000 beds (41 beds per 100,000 pop.) today8 . In Victoria, the institutional population declined from 12,000 in the early 1950’s to 7,000 in the early 1960’s. Throughout Australia the population of the psychiatric hospitals declined from 29,500 in the early 1960s (281 beds per 100,000) to 6750 (40 beds per 100,000) in the early 1990’s. During this period some psychiatric hospitals developed outreach clinics or outreach services for patients discharged to their families, or into special accommodation houses or unsupervised boarding and rooming houses. 11 Outreach or clinic staff attempted to provide a range of services of both a maintenance and emergency type to people with chronic mental illness. They were often seen as critical in helping with readmission as required. These programs were funded through hospital budgets (which were funded through the state health systems) and were often seen as the ‘poor cousin’ to hospital based services. They usually continued the orientation toward providing some of the “whole of life” services, including renting, or even in some circumstances buying, houses for community based accommodation, and social and recreational programs. Little attempt was made to assist people to use mainstream services and these attempts usually failed when they did occur. The major criticism of the medicated deinstitutionalisation process was the failure of the hospital dollar to follow the ‘patients’ into the community. The lack of staff and accommodation in the community, before the withdrawal of access to the institutions, was of particular concern. The significant reduction of beds in psychiatric hospitals was not accompanied by a comparable reduction in the proportion of the mental health budget going to these institutions and an increase of money to community based services. 12 1970s and 1980s: Community Mental Health Movement As deinstitutionalisation took effect, the momentum began for better facilities for acute in-patient care and the development of community mental health program. The formal advent of this in Australia probably started with the funding of community mental health services by the 1972 Labour Government under Prime Minister Whitlam. Community based care was of course not new. This, and neglect, had been the only options open to communities before the asylum period. The roots of community care can be traced back to the fourteenth century when a system of home care for people with chronic mental illness was established in Belgium9 . The humanist movement in particular assisted many people in the seventeenth century. However, in Australia, it was not until the 1970s that community based mental health services increased significantly as an alternative to long term hospitalisation and asylum. Some of these programs grew out of the psychiatric hospital outreach and aftercare programs while others were established independently. 13 With the advent of the reformist Government in the 1970s, Commonwealth funding became available to develop and expand community health centres. Particularly in Victoria and NSW these centres often incorporated a mental health component. An example of this was the establishment of 50 Living Skills Centres in NSW from 1977 to the present. In Victoria the trends were for separate development of community clinical teams and separate, community managed rehabilitation agencies. In Queensland acute in-patient services were developed within the grounds of general hospitals. These changes continue in Australia today. The move to mainstream, or co-location of mental health services with general health services allows for services to be closer to where people live and to be provided in a less stigmatised environment. In Victoria this move was completed in the 1990’s. George Lipton10 listed some of the agreed objectives of the community movement: • to provide treatment in the community for the severely mentally ill • to provide different treatments from those available in overcrowded institutions • to reduce the number of new admissions by community intervention 14 • to provide continuity of care in the community which was thought to lead to better and more humanistic rehabilitation, and a more normal and satisfying life for the patient However, mostly due to the State based funding system, these changes were not implemented in a uniform or consistent manner. Community based services were often developed separately from the psychiatric hospitals and acute in-patient units of general hospitals. A major criticism of the period is that many community mental health programs ignored people with seriously mental illness in favour of more interesting issues or for people who could participate in the ’talking therapies’. This often resulted in resources being diverted from the people at the severe and chronic end of the mental health spectrum, placing them at risk of further marginalisation. Large numbers of people also became, technically, homeless and lived in unsatisfactory residential facilities in the community, or were inappropriately placed in nursing homes or, reportedly, in jails. In many areas significant competition appeared to occur between the hospital and community services sector for funds. The different sectors claimed the moral high ground for their service methods and distrusted each other. Close coordination or integration of the services occurred and important principals such as continuity of care failed to be achieved. 15 In NSW the Richmond Report provided a basis for reform of mental health. In Victoria, the Commonwealth’s Healthy Cities program provided the funding boost to the reform and transfer of beds to the general hospital system. 1990 onwards: National Reform and Development of Area Based Mental Health Services in Victoria Policy makers started to address the community and service systems concerns regarding lack of consistency and coordination in the 1990’s. The Commonwealth commenced major policy reform with the National Mental Health Strategy. New, coordinated models started to be developed and restructuring of health services into area/regional organisational models was viewed favourably. Overall, especially in Victoria and NSW, mental health services have now been integrated with general health services within discrete geographic catchments. In Victoria, Area Mental Health Services offer specialised clinical services providing a range of programs including assessment, crisis intervention, mobile support and treatment services, acute in-patient services and community outpatient clinics. The Psychiatric Disability Support Service sector through non government agencies provides a range of psychosocial rehabilitation services such day rehabilitation, in home support, residential rehabilitation, advocacy and self help / mutual help. 16 This is consistent with the National Mental Health Policy that requires mental health services to be mainstreamed with the general health sector, yet supposedly also maintaining integration of specialised services to ensure continuity in clinical management. In some regions, highly integrated community based services with strong gate-keeping rules for accessing beds were developed. Other areas maintained a more traditional hospital approach while trying to meet the need to promote continuity of management through close coordination with the community teams. In Victoria government funding practices protected mental health budgets and defined minimum proportional allocations to hospital and community based services. This ensured that community based, adult, child and adolescent and aged mental health services received specific percentage shares of regional population based mental health budgets. Implementation of models for case management and coordinated care and the National Standards for Mental Health Services (1996) dominated approaches to mental health care during the 1990s. During the early 2000s implementation of consumer outcome measures and the Victorian Standards for Psychiatric Disability Support Services and strengthening consumer and carer participation are key reform activities. 17 References 1 Jones K (1972) “A History of the Mental Health Services”, Routledge & Kegan Paul, London. 2 Longo DA & Peterson SM (2002) “The Role of Spirituality in Psychosocial Rehabilitation”, Psychosocial Rehabilitation Journal, 25(4), Spring, 333-340 3 Morissey JP, and Goldman HH (1984) “Cycles of Reform in the Care of the Chronic Mentally Ill”, Hospital and Community Psychiatry, 35(8):785793 4 Kosky R (1986) “From Morality to Madness: A Reappraisal of the Asylum Movement in Psychiatry 1800-1940”, Australian and New Zealand Journal of Psychiatry, 20:180-187 5 Garton S (1988) Medicine and Madness: A Social History of Insanity in New South Wales, 1880-1940, Modern History Series 5, NSW University Press, Kensington 6 Kosky ibid; and Wing JK (1990) “The Functions of Asylum”, British Journal of Psychiatry, 157:822-827 7 Mechanic D, and Aiken LH (1987) “Improving the Care of Patients with Chronic Mental Illness”, New England Journal of Medicine, 317(26): 1634-1638 8 Lamb RH (1992) “Is it Time for a Moratorium on Deinstitutionalization? (editorial)”, Hospital and Community Psychiatry, 43(7):669 9 Srole L (1977) “Gheel, Belgium: The Natural Therapeutic Community 1475-1975” in Serbin G (ed) New Trends of Psychiatry in the Community: Proceedings of the Fourth International Symposium of the Kittay Scientic Foundation, March 28-29,1976, New York, NY, Ballinger, Cambridge Krupkinski J, Mackenzie A and Carson N (1984) “Feasibility of Discharge of Chronic Psychiatric Patients”, Australian and New Zealand Journal of Psychiatry, 18:364-372 18 10 Lipton G L (1980) “Community Mental Health as a Reality”, Australian and New Zealand Journal of Psychiatry, 14:183-186