Feature Article - Mental health services
Contributed by Mary Blackwood, former State Manager, Mental Health
At the turn of the last century, mental illness was regarded as a fortunately rare problem to be managed in an institutional rather than a societal way. Public mental health care revolved almost entirely around treatment in residential complexes unashamedly termed lunatic asylums. Society’s concern was only that these asylums be managed in a humanitarian, responsible and kindly way, with proper attention to the physical needs of the unfortunate inmates. Although the early part of this century saw the flourishing of profoundly influential schools of thought in psychiatry and psychology and these (such as Freudian theory) relied on the individual psyche as the guide to disorder, the public provision of service was overwhelmingly institutional.
In Tasmania, the Hospital for the Insane at New Norfolk had been established as a Lunatic Asylum, an attachment to the Invalid Hospital for convicts, by 1834.
In the first half of this century and a little beyond, the reality and desirability of institutional life was, it seems, simply unquestioned. The imperatives were about improvements and expansion, staffing, humanitarian treatment, and resident comfort. Overcrowding and increasing demand were constant issues; numbers were high (522 in 1916; over 600 in the 1940s), and the solutions were to provide the same kind of service, but to provide it better.
In the 1940s a Parliamentary Standing Committee considered the development of a new hospital to replace the old; new wards were constructed and occupied in 1957 and 1959, with a nurses home and library soon to follow.
By the early 1960s the institutional complex was an almost complete community within its local community, New Norfolk. Tailoring, laundry, bootmaking, hairdressing, day activity and industrial therapy, mortuary, pharmacy, catering, radiology, recreation and occupation were all provided on site.
Yet the germs of modern service philosophies are to be found even in the very early days of the asylum and in the subsequent developments. Segregation of people with intellectual disability from those with mental illness was always sought and was underlined by legislation in 1922; the idea of recovery, and integration back to the community was embodied in the establishment of Millbrook Rise in 1934 as a convalescent hospital for mentally disturbed ex-service men and women. Millbrook acted also as a ‘halfway house’, a much later concept, for people in transition from the mental hospital itself.
The landmark date for the establishment of modern services, however, is 1968, when the Mental Health Services Commission was set up in response to perceived inadequacies in psychiatric services throughout the State. The focus began to shift almost immediately. In its very first annual report, the Commission recorded the creation of a Board of Management for the mental hospital (by now called the Royal Derwent Hospital), the establishment of a Chair in Psychiatry, and of a Professional Psychiatric Unit, the creation of acute psychiatric units across the State in general hospitals, and the establishment of a Combined Childrens Centre.
The Commission sowed the seeds of modern service: early detection, extended hours services, general practitioner liaison and involvement of non-government organisations are all included as part of the 1968 directions for mental health. Yet in 1968 of the Commission’s budget allocation of $2,434,500 the Royal Derwent component was 89%, and there were 930 patients accommodated there.
The task, clearly, was to shift the balance and the resources in favour of the new community directions, and there were only two ways to do this, given the perennial public sector axiom that new State funding was never to be expected. The first way was to reduce admissions. From 1974, when the Commonwealth Government funded community mental health teams, reliance on the institution reduced and admissions dropped; to the present day admissions to the institution are regarded as a last resort. The second way was to provide specific alternative facilities and ensure direct transfer of residents and ward closure.
This occurred with the opening of rehabilitation and psychogeriatric services in Hobart in 1987 and the transfer of residents; Subsequently the Howard Hill Centre in Longford and Curraghmore in Devonport opened; nursing homes began to take elderly patients, and community centred psychiatric services expanded. The twin strategies have seen the institutional population now dropped to 90, from 573 in 1970.
In the new century there will be no institution as such; but there will be a range of small scale residential services to meet the needs the institution once met.
In 1989 the Mental Health Services Commission was integrated into the Department of Health Services as part of a national trend towards ‘mainstreaming’, the alignment of mental health with health generally. Mental Health, it is claimed, has outgrown its need for special attention because its place is so firmly assured. Intellectual disability services were formally structurally separated to become part of the wider disability framework, as first recommended in 1962 and progressively implemented by the Mental Health Services Commission.
In 1992 the State’s directions towards mainstream care, community integration and legislation reform were given huge impetus by the National Mental Health Strategy. In the recognisable sequence of outrage, enquiry and reform which has often characterised major change (for example in Tasmania in 1883), the Human Rights and Equal Opportunity Commission inquired into mental health services across Australia, and the Commonwealth Government established reform and incentive funding ($1.2m annually for Tasmania by 1997-98) as well as substantial national project funding in areas such as community awareness. Tasmania has participated fully in all these developments, with a strategic plan resting on the key components of promotion, prevention, reduction of the impact of mental illness, consumer rights, quality and partnerships.
In parallel, the State’s own reform agenda has seen the establishment of local residential and community facilities in a network of care across the State, and 70,000 Tasmanians have accessed those services in the last decade.
These changes, though gradually implemented, represent a radical change in mental health care, from custodial to community, from containment to participation and from congregate asylum care to specialised individual treatment.
The changes rest on two foundations: a growing knowledge base and massive social change. The certainty is that both will continue into the next century.