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Out of sight, out of mind

April 5th, 2005

Reader Graeme Bond pointed me to this ABC radio Ockham’s razor special on the way Australia deals with mental illness, especially the Cornelia Rau case, also dealt with on last night’s Four Corners. The Rau case brought into focus how awful it is that places like Baxter detention centre exist, but far more mentally ill people end up in prison. An obvious question is whether the closure of mental hospitals in the 1970s was a bad idea, or a good idea taken too far. Graeme writes

Instead of updating psychiatric institutions, as is done with hospitals, schools etc, we have replaced them with ‘community based neglect’ and another institution, prison.

No one suggests ‘community care’ for other serious illnesses requiring hospitalisation. It is sometimes akin to suggesting open heart surgery on the kitchen table.

Not all mentally ill require a high level of expensive care, many, such as the homeless on the streets would have their lives vastly improved by little more than hostels with a low level of supervision and assistance with Centrelink forms so they were not reduced to begging. It is preferable to jail and probably cheaper.

Others simply need occasional brief periods of hospitalisation during a crisis and otherwise live relatively normal lives with their families.

and this seems pretty convincing to me. We’ve had a string of inquiries into this issue, without, it seems, making much progress.

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  1. Paul Watson
    April 5th, 2005 at 08:53 | #1

    “[M]any [mentally ill], such as the homeless on the streets would have their lives vastly improved by little more than hostels with a low level of supervision and assistance with Centrelink forms so they were not reduced to begging”.

    Graeme Bond seems to be confusing being intellectually slow with diseases such as schizophrenia. Most sufferers of the latter, I suggest, would be perfectly capable of regularly filling out Centrelink forms.

    What many would not be capable of, however, is living on a Centrelink budget. There is a high correlation between schizophrenia and drug addiction/self-medication. Hostels are therefore just not a practical answer.

  2. harry clarke
    April 5th, 2005 at 09:14 | #2

    There are important ideas in this posting. In the 1970s I read Szasz’s ‘Myth of Mental Illness’ and ‘The Manufacture of Madness’ and got very negative impressions of psychiatry and psychiatrists. The basic message seemed to be that individuals needed to take individual responsibility for their problems and get their act together. But mental illness is real, can destroy lives and families and does in some cases require treatment. Asking people to accept responsibility can amount to not caring.

    The same issue arises with respect to the illegal drugs debate and indeed alcoholism. Writers like Stanton Peele vehemently deny that addictions are an illness that requires treatment. They criticise the medicalisation of behavioural problems. Indeed they argue that recognising addictions as an illness can be countertherapeutic since individuals have low incentives to change their behaviour.

    Its a difficult issue. On the one hand we seek to assert people’s individual rights and then, if they should act in ways that harm themselves, seek to intervene (in same cases using force) to help them.

    I think we should be cautious about taking away people’s rights and in general take people’s claims about themselves seriously. But also on occasions some intervention is necessary.

  3. mctavish
    April 5th, 2005 at 09:53 | #3

    Having worked in the field of disabilities I have seen the terrible effects of institutionalisation on people. Community based support is the way to go for most people.

    The problem as I see it is that the process of deinstituationalisation was never implemented properly. The government was being advised that they would save money by closing them down and providing community based services, but they realised they could save even *more* money by doing the former and going cheap on the latter. Shame.

  4. April 5th, 2005 at 10:30 | #4

    Backing up Mactavish, in the late 1970s there was a wave of reform of services for people with mental retardation (re-badged as intellectual handicap). Around the world “normalisation” became the over-riding imperative and most of the Australian states did studies of their services and implemented normalisation to a greater or lesser extent. I spend two years with a colleague in the NSW Anti-Discrimination Board on discrimination and intellectual handicap: this report appeared in 1982 and was closely followed by the Richmond reforms that practically emptied the major public institutions, although nobody would claim that our report was the catalyst, that was just the way every progressive person was thinking at the time.
    It was always assumed that support services would be provided to maintain the quality of life of people in group homes or hostels but it does appear that something went wrong in the implementation, unless we are prepare to rethink the rationale of the whole process.

  5. R J Stove
    April 5th, 2005 at 10:38 | #5

    There’s a certain mentality in Australia which advocates reinstitutionalising all the mentally ill as a panacea. This overlooks (and I speak as one with some experience on the wrong end of hospitalisation) one crucial fact. Namely this: the reason deinstitutionalising took off during the late 1970s and the 1980s – not only in Australia but through most of the Western world – was precisely because the old mental institutions (private or public) were, to be blunt about it, so bloody awful.

    Anyone who doubts this should read Janet Fife-Yeomans’ Deep Sleep (this about a private rather than a public asylum, namely Sydney’s Chelmsford), or Albert Deutsch’s The Shame of the States, or Robert Whitaker’s Mad In America. Standards of safety were nonexistent. In Guatemala City during 1960, a fire at one such institution claimed 225 lives. That’s an extreme instance. But until recently you could be forced to undergo the most murderous physical maltreatment in such places; and it was entirely legal.

    So I, for one, most certainly do not get sentimental about the old pre-community-care methods. Any more than I get sentimental about community care itself. Undiscriminating advocates of the latter have to explain away why the results have been so persistently disappointing. Undiscriminating advocates of the former have to explain away why the results were so persistently disgusting.

  6. Graeme Bond
    April 5th, 2005 at 11:16 | #6

    No, Paul Watson, I am not “confusing being intellectually slow with diseases such as schizophrenia.”
    Recently when beggars on the streets was made an issue by our glorious state Leader of the Opposition, wanting them removed, both the police and organisations such as the Salvation Army were quick to respond that most were mentally ill and I think it was a Salvation Army spokesperson I heard make the point about the complexities of Centrelink being just too much, thus leaving them with no income.
    Supported hostel accomodation, partly funded by a deduction from Centrelink payments would at least see them sheltered, fed, medicated etc and provide a measure of observation of their condition.

  7. April 5th, 2005 at 12:50 | #7

    Reducing stress and supporting self respect are key tools in helping people to recover/adapt/stabilise.

    Hard to see how homelessness and grotesque poverty is useful.

    I too had a bit to do with deinstitutionalisation in the 1980’s, which provided an object lesson in the value of freedom and autonomy. And it was only in the 1960’s that the dungeons under Willsmere in Melbourne were closed; night staff were known to rape patients; the country asylums in particular were clones of Bedlam.

    But I did have a wise political advocate say two things to me about the process that resonated and were prophetic. He said that the big asylums were useful partly because they were cheap, and that community care would cost more – but the argument was always that they would cost less. And he said that the main defence of mental hospital spending came from the institutional structure. That is, doctors and unions.

    Right on both counts I reckon. Resources follow power, and the mentally ill are almost the most depowered people in our society.

  8. April 5th, 2005 at 14:21 | #8

    Following the report on Discrimination and Intellectual Handicap I wrote a thesis on the evolution of the services and the flow of funds from state and commonwealth agencies. Part of the story is the amazing rise of the voluntary sector when handicapped children began to survive to adulthood in large numbers post 1945 (the post penicillin era). Parts of the theses are now on line at this address.

  9. April 5th, 2005 at 15:03 | #9

    The vast majority of illnesses have moved from “hospitalization” to community care. And the consumers would not have it any other way. Procedures that once would have had a 5 day stay in hospital now are performed in day surgery.

    Those who pine for “the good old days” of institutions for the handicaped, (aged, intellectally, mentally or physical) must never have worked or looked inside those institutions where human rights violations, depravity, abuse (sexual, financial, mental and physical), lack of care and no accountability were rife.

    In most cases the worst of the “de-institutionalisation” is better than the best of the “good old days”

    I don’t hear anyone saying its all ok or good enough now. More money is needed, more care is needed but we don’t need a return to big bluestone bins up on a hill.

  10. Paul Watson
    April 5th, 2005 at 15:49 | #10


    The Salvation Army spokesperson, who referred to the complexities of Centrelink being just too much for the mentally ill, was *not* (if s/he knew what they were talking about) referring to form filling-in difficulties (= basic literacy).

    Drug-addicts (mentally ill or otherwise) indeed find Centrelink often intolerable and useless, because it pays (i) a sum which must be strung out over a fortnight and (ii) not on demand (almost never, anyway). In both these respects, begging/windscreen-washing are quite unlike Centrelink – they provide quick money for a hit.

    I don’t know what the answer is, but I get the feeling that loss of public amenity caused by begging etc is not being costed in to the overall equation.

    As for your suggestion: “Supported hostel accomodation, partly funded by a deduction from Centrelink payments would at least see them sheltered, fed, medicated etc”, does the medication part include free access to drugs like heroin?

  11. April 5th, 2005 at 15:56 | #11

    What is crazy in relation to Cornelia’s case is that the assessment of the psychiatrist, suggesting the liklihood of schizophrenia was ignored, and that it took so long to get that assessment, and that there was no follow up in terms of treatment.

    Even though Baxter is evidently a barbarous place, at least for some, I hope the whitewash set in place by the government, does not preclude charges of misconduct, and any breaches of human rights and law. But then the enquiry is set to defect responsibility (so much for the preaching). The real responsibility lies with those who conceived, designed and run such a hellhole. They should feel guilty and ashamed. Perhaps the problem here is that they have a mental disorder that precludes such emotions.

    Deinstitutionalization for the sufferers of mental illness appears to me to make sense, in the best interest of the patient, provided they have constant access to accommodation, drug treatment, medical support and so forth. I quess the key breakthrogh were the drugs that make mental illness manageable. Drugs alone are not enough as Cornelia’s case demonstrates.

    What interests me is her antipathy to receiving treatment. I would have thought that would have that would have brought relief from suffering. I suppose the timing of treatment must be made by another person, and Cornelia was endeavouring to be a free spirit.

    Nothing though can justify her cruel treatment. It should not happen in a decent society. But I suspect David is right, mentally ill people are depowered.

  12. Andrew Reynolds
    April 5th, 2005 at 16:00 | #12

    How should it be tackled? How should society be dealing with the drug addicted as opposed to the mentally ill? Should the addicts be housed in some form of detention to dry them out?
    It is a problem I have never really been able to think of an entirely satisfactory course for.

  13. April 5th, 2005 at 16:22 | #13

    I take this as a rather large special case of a widespread general problem. Here, it’s clearly “good” to release most of these people into a supportive community. Only, what community? Result: people falling between the cracks.

    The wider issue has been a long time developing, and it’s a result of the cumulative interaction first of muddle headed left-wingery, then ditto right-wingery. First paternalist government provide services and, so to speak, crowded out old approaches more than was actually needed, largely via the burdens flowing from the funding. Then, based on wishful thinking harking back and hard headed looking forward, the services (but not proportionately the taxes, and not in the same places as before).

    Result: both from the wealth transfers compared with the distant past, and from a complete lack of adequate transition in many respects (both in the revenue raising and the service provision) we get the worst of both worlds. That’s in privatising, defence, mental health, and you name it. But the remedy isn’t to revert to more government provision, any more than it was to revert to less government provision.

  14. Geoff Honnor
    April 5th, 2005 at 16:26 | #14

    “Deinstitutionalization for the sufferers of mental illness appears to me to make sense, in the best interest of the patient, provided they have constant access to accommodation, drug treatment, medical support and so forth.”

    I guess that’s the problem in a nutshell: they don’t. I think it’s important to factor in an understanding that traditional ‘community care’ – by it’s very nature – can never provide a 24/7 care continuum and that psychotic episodes won’t necessarily occur within the care-support timeframe available .

    “What interests me is her antipathy to receiving treatment. I would have thought that would have that would have brought relief from suffering. I suppose the timing of treatment must be made by another person, and Cornelia was endeavouring to be a free spirit.”

    Anti-psychotic drugs can have fairly dire side-effects, not least of which can be significant weight-gain. They can also (reportedly) induce a kind of disengaged state that many patients find problematic. Maintaining adherence to dosing regimens and script renewal can also obviously be problematic for some psychosocially dysfunctional people.

  15. April 5th, 2005 at 16:31 | #15

    There are paradoxes within paradoxes, wmmbb. One of the ways in which some mentally ill people are mentally ill is that they think they are not mentally ill.

    Besides, mental illness is so painful on an existential level, people desperately want to feel they have beaten it, and are restored to normality. The drugs mean they are not normal.

    What is more, the drugs make you feel pretty dreadful. The list of “side effects” is horrifying, from constipation to the shakes to chronic obesity to memory and concentration problems.. I understand the situation is improving steadily, but I imagine taking a huge amount of psychoactive chemicals will make you feel like crap.

    Apparently one of the big issues with bipolar disorder is that the highs are fun. On the drugs, people complain that everything is flattened out, that their emotional integrity is stolen.

    So “compliance” is a major issue in the treatment of people with a mentally illness. And for anyone interested in social justice and freedom issues, the question of power is really difficult here.

  16. R J Stove
    April 5th, 2005 at 17:04 | #16

    David Tiley writes: “I understand the situation is improving steadily, but I imagine taking a huge amount of psychoactive chemicals will make you feel like crap.”

    No disagreement there from me. It’s a case of “damned if you do, damned if you don’t” as far as many users of such chemicals are concerned. Anyone who doubts the worst effects of psychoactive drugs should witness the so-called “Thorazine shuffle”: a hideous horror-movie-style incessant spasmody, characterising millions of patients who were prescribed Thorazine during the 1960s and 1970s. I was lucky enough to escape that, merely because of having been born too late to have been given it.

    Then there are the joys of frontal lobotomy (best-known victim: JFK’s sister Rosemary, who died just a few months ago). And let no-one say that frontal lobotomy couldn’t make a comeback. Or, if it comes to that, let no-one say that sexually voracious night-nurses (also mentioned by Mr Tiley) couldn’t make a comeback. After all, ECT did. In the 1950s ECT was all the rage. In the 1980s it greatly slipped from fashion. Now, it’s more and more often used, although with rather more discrimination than it was fifty years back.

  17. April 5th, 2005 at 18:21 | #17

    However if you have a family member experiencing the delusions of a psychotic episode, as I have had, and being told that there are only 7 beds free in Perth that night then you might take another look at the problem. Apparently 3 or 4 years ago there were 2000 psychiatric beds available in Perth. Now there are 1200 with further cuts being made. What would have happened to my family member if I was told that there are no beds available – what would I have done???

    The family member is OK now as it was temporary as most of these episodes are – the drugs worked in this case.

    The mere fact that I am saying, the family member, summerises the feelings about the mentally ill. You really do not want to mention them at all. Visiting him in the locked ward was an experience to say the least and gave our other children a view on a life that most people do not see.

    I don’t think that in this fast paced world of with easy access to drugs that we can afford to neglect the mentally ill. It may be you or a loved one next. Maybe you will not be as lucky as I was. I found a bed for my family member and he is OK now. Maybe you will not. What are your kids doing now??? If they are smoking pot then they stand a good chance of having a psychotic episode as this is on the rise.

    Depression can happen to anyone – just look at Paul Hester. To anyone he was a happy person – yet he was really deeply depressed – where was the help for him???

    Mental illness is not a problem of street people or deros it is you and me and anyone.

  18. still working it out
    April 5th, 2005 at 22:02 | #18

    I have had the unfortunate experience of having a close family member suffer mental illness.

    Institutionalisation would complete overkill in her case. Community based care is without doubt a much better option than institutionalisation. It is much better suited to the up and down nature of most mental illness sufferers. Usually they only need ongoing supervision with acute care readily available when or if they have serious attack. The problem is that the resources that go into it are far too small. Its is very difficult to get quality ongoing help and getting help during an acute attack is often quite difficult.

    As bad as the resources are in Perth they’re a lot better than they are in inner Sydney. I have actually had the chance to directly compare and was very pleasantly surprised at the great attitude of the mental health professionals and the seemingly very good resources available in Perth.

    And if you are living in Western Sydney with mental illness? Well you wondered what you would have done if you were told there are no beds available when a close family member has a psychotic episode. I have actually had the chance to find out. Its hard to describe how helpless you feel after waiting 6 hours in an emergency room to see a doctor and to then be told the on call psychiatrist will not see you and to go home.

  19. still working it out
    April 5th, 2005 at 22:09 | #19

    The anti-psychotic drugs do have a lot of quite horrible side-effects. Having seen what they can do to a person I can quite understand why it would not be easy to stay on them. Its hard to keep taking medication which makes you feel like crap all day, enery day possibly for the rest of your life.

  20. April 6th, 2005 at 09:49 | #20

    still working it out
    True I have not had to cope with inner western Sydney and don’t want to. I moved to Perth for many reasons and it is still a fantastic place to live.
    I can understand you despair. I waited for 6 hours and got a bed for my son. I cannot imagine what would have happened if there were none available.
    More needs to be done to improve the service so no-one needing care is turned away.

  21. John Quiggin
    April 6th, 2005 at 19:57 | #21


  22. Stephen Ziguras
    April 7th, 2005 at 16:03 | #22

    Part of the problem is that policy makers have taken succesful community care models such as ‘assertive community care’ designed in the USA, and then implemented them here without the resources they need to be effective. As part of my previous job, I did a systematic review of evidence for the effectiveness of community care. The results suggested that it can work, but caseloads in succsesful programs vary from 15-25 clients per staff member. In Australia, most programs have caseloads at least double this. Its nto really surprising that its less effective!
    Add to that, the lack of affordable housing and the more precarious job market.

    I suspect the (increased) preacriousness and stress associated with many jobs has a more adverse impact on people with mental illnesses as they are much more liable to relapse when under stress.
    I dont think the answer is reinstitutionalisation since as well as denying someones legal and civil rights, institutions also contribute to psychological problems.

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