Week 6 – Deinstitutionalisation

Moving on from the Asylum

Through the Middle Ages and even up to the 18th century, the treatment of people with mental illness included public shaming, inquisition, banishment, incarceration, torture and execution. The false view that ‘madness’ was the result of demonic possession, immorality or a punishment by God played a part in this history.

The life of St John of God (1495–1550) provides an example. St John devoted his life to the care of the sick and destitute and himself experienced times of great mental and spiritual anguish. He was subjected to ‘the latest methods to try to bring him to his senses’:

The cures they used for such cases like his consisted of flogging and placing the afflicted person into a dismal dungeon. They used other similar methods as well, so that by means of inflicting pain and punishment, the patients might shed their madness and regain their sanity. So they stripped him naked and tying him up by the hands and feet, they flayed him with a doubly knotted whip.

In his ministry to people experiencing mental illness and destitution, St John established a hospital in Granada – the House of God – where people were treated instead with charity and love.

The development of the sciences of psychology and psychiatry in the 19th and 20th centuries recast the issue of mental health as a medical one. Asylums for the ‘insane’ were established to treat people in a secure environment away from the mainstream of society. Psychiatrists began to develop standards for the diagnosis of disorders. Psychological therapy and advancements in medications led to an approach in which the treatment of ill-health sought an end to long-term institutionalisation and promoted the release of patients back into society when they were well. But mental hospitals were often overcrowded, and patients were exposed to inhumane and abusive conditions, often indefinitely. Hence the asylum model gave way to less custodial and less segregating community-based care.

The program of ‘deinstitutionalisation’

In the late twentieth century, Australia began closing its mental health hospitals and reintegrating people into the community to receive medical and psychosocial support. This process reduced the number of acute psychiatric beds from 30,000 in the 1960s to around 6,000 by 2005. In the early 1980s, the New South Wales Inquiry into Health Services for the Psychiatrically Ill and Developmentally Disabled (‘The Richmond Report’) became the blueprint for the new model of care.

Integrated community services, backed up by specialist hospitals, were to ensure that people living with mental ill-health were cared for in a ‘normal community environment’. Early intervention, home-based care for people experiencing mental illness and adequate support for their families were stressed. The aim was to foster a supportive community, where mental illness was de-stigmatised and the rights of people with ill-health to social integration and opportunities for advancement were guaranteed.

But there was a catch. The program would only work if it was preceded by the redirection of funding from the closure of existing hospitals to the development of community services. A decade later, the National Inquiry into the Human Rights of People with Mental Illness (‘Burdekin Report’) found the policy had largely failed due to inadequate funding. Because of the inadequacy of community mental health services, charities and the community sector, together with families and carers, ended up carrying much of the load. Inquiry Chair and Human Rights Commissioner, Brian Burdekin, labelled the deprivation, discrimination and stigmatisation still suffered by Australians affected by mental illness ‘a national disgrace’.

Since then there have been many Federal and State inquiries, but they have not led to lasting reform. A National Mental Health Strategy has been established, and we now have the Fifth National Mental Health and Suicide Prevention Plan. The Productivity Commission has recently been conducting a national inquiry into Mental Health and Victoria is holding a Royal Commission into its mental health system.

The commitment of governments to the humanitarian principle of community integration was a great advance that is still to be fully realised. It is hoped that the current inquiries will ensure adequate funding for Australia’s mental health system. We need a nationally agreed, implemented and evaluated mental health service model.

Reference: Social Justice Statement 2020-21 Live Life to the Full: Mental Health in Australia. Pages 9-10.