From Criminals to the Case for Community Care
Many of the 750 convicts who arrived on the First Fleet in 1788 were mentally ill (Parkinson 1981). The new settlement was governed as a military autocracy, whereby “the Governor’s authority was virtually absolute and it was the legal foundation on which lunacy administration rested”. The penal nature of the colony, steeped in a military and custodial regime influenced the model of care for these people. There was no distinction made between criminals, those with intellectual disability or mental illness. Anyone who was deemed a risk to society was imprisoned (Page 2).
Initially those designated criminals, idiots or lunatics were bundled together in the Town Gaol at Parramatta. They were held to be a nuisance and menace to the community at large. By 1811 a mental asylum was established at Castle Hill, New South Wales and an attempt was made to separate those who were criminal from those who were mentally ill. Untrained male attendants hired for their physical size and strength staffed it.
In 1838, Tarban Creek Asylum, Sydney (later Gladesville Hospital) became the first purpose built psychiatric facility in Australia. Inmates were drawn from both the Sydney and Melbourne settlements. The first superintendent appointed had gained experience at St Luke’s Hospital for the mentally ill in England. His role was twofold, the maintenance of discipline, restraint and order as well as financial oversight. Yet this was patently insufficient and a growing awareness of the need for medical involvement in the treatment of the mentally ill began to form.
A further 12 asylums were established in New South Wales during the 1800s housing up to 2000 inmates. In 1843 the Lunacy Act was introduced in Victoria. This piece of legislation heralded a shift in the conceptualisation of mental illness, an awareness of the need for medical treatment and the acceptance of responsibility by governments for care of the mentally ill. There was also growing recognition of the abuses being perpetrated against the mentally ill. Because of this recognition, in 1852 a government enquiry was formed to investigate reports of violence, corruption and general mismanagement of mental asylums. A direct result of the enquiry was that doctors slowly replaced lay superintendents as administrators of the asylums. This marked the beginning of the moral treatment era and humane conditions for inmates. The medical approach introduced notions of treatment and rehabilitation and moved away from a purely custodial framework.
However, the single most important development in the treatment of mental illness was the discovery of chlorpromazine in 1951, otherwise known by its trade name, Largactil, an antipsychotic medication that revolutionised the treatment of schizophrenia. Like most innovations, the discovery of chlorpromazine as a treatment for schizophrenia was serendipitous and resulted from researchers in France trying to find a cure for malaria. Instead, they found this newly synthesised drug had a sedating effect on patients. Chlorpromazine secured FDA approval in 1954 as the first psychiatric medication and provided a breakthrough in the treatment of mental illness. The pharmacological management of schizophrenia enabled patients to embark on programs of rehabilitation that included therapeutic, vocational and recreational activities.
Psychiatric institutions developed work schemes consisting of farming activities such as gardening, growing vegetables and tending to livestock. Male patients were encouraged to contribute to outdoor and more physical activities such as brickwork, woodwork, and farming. Female patients were engaged in food preparation in the kitchens, in the laundry and sewing rooms. These activities were seen as innovative, adaptive and a means for all inmates to make a positive contribution to the upkeep of the asylum (Brothers 1962).
Rapid change occurred following the Second World War, economically, politically and socially. The era between 1950 and 1970 introduced mepbromate in 1955 (otherwise known as happy pills), tricyclic antidepressants in the late 1950s, the first of the benzodiazepines in 1960, the first popular MAOI (monoamine oxidase inhibitor) in 1961, diazepam (Valium) in 1963, haloperidol in 1967 and cognitive therapy in the 1960s. These developments, among others, cemented the role of psychiatry in the care and treatment of mental illness. The ability to stabilise and manage the symptoms of psychosis and mood disorders, offered those with mental illness hope of discharge from the asylums.
A seminal paper, The Richmond Report, published in 1981 argued for the deinstitutionalisation of people with mental illness and uncovered the various abuses perpetrated against those individuals being held in institutions. It was identified with D.T. Richmond who was Chairperson of the NSW Inquiry into Health Services for the Psychiatrically Ill and Developmentally Disabled and who championed the rights of the mentally ill to live in the community. Following publication of the Richmond Report deinstitutionalisation in Australia commenced in 1992 but it was inadequately funded and poorly orchestrated.
Reports of mentally ill people living on the streets, unmedicated, hungry and dying prompted two inquiries by the Australian Health Ministers Advisory Council (AHMAC) Task Force convened in 1991 and the National Inquiry into the Human Rights of People with Mental Illness by the then Human Rights and Equal Opportunity Commissioner, Brian Burdekin, The Burdekin Report (1993). Both of these enquiries addressed justice, sociological, economic and epidemiological issues.
Following these inquiries, the preferred model of treatment for those with mental illness moved towards community care with brief hospitalisations in acute inpatient units (AIHW 2013). Managing those with mental illness in the community called for new models of care that introduced generic care co-ordinator positions staffed by nurses, occupational therapists, psychologists and social workers. This in turn has resulted in extended scopes of practice and blurred boundaries between these professional groups. Where once, mental health nurses did everything, today these activities are shared by the professional groups in mental health services.
References: Vrklevski, L., K. Eljiz, and D. Greenfield. (2017). The Evolution and Devolution of Mental Health Services in Australia. Inquiries Journal 9 (10). Pages 1 – 8. http://www.inquiriesjournal.com/a?id=1654