From the 1960s psychiatric patients were encouraged to take more active role in their own care and treatment. The general community also became more tolerant of the mentally ill. In this period many of the more manageable patients were discharged from hospital. Planning for new psychiatric hospitals ended in 1963 and no extra beds were provided from 1973. From the 1970s psychiatric services came to emphasise outpatient care, community-based treatment and more modern facilities. Every mental hospital patient was assessed in 1973, and 26% of psychiatric and 46% of intellectually handicapped patients were recommended for accommodation outside a major psychiatric or psychopaedic hospital.
Rise of community care
From the 1970s, under the umbrella term ‘community care’, most people with mental disorders received support from a range of non-governmental organisations (NGOs). These developed alternatives to institutional care, helped change public attitudes and built international links.
Community organisations included the Intellectually Handicapped Children's (now IHC) Parents' Association (1949), the Schizophrenia Fellowship (1977) and the Richmond New Zealand Trust (1978). The Mental Health Foundation, formed in 1977, concentrated on policy issues and advocacy to promote mental health and lower the rate of mental illness.
The risks of community care
Psychiatrist Fraser McDonald served as the medical superintendent at both Carrington and Kingseat hospitals in Auckland. He warned of the risks, as well as advantages, of phasing out psychiatric hospital services in place of community care.
‘Let there be no misunderstanding, if these social structures are to be established and are seen as utterly essential for the proper healthy development of community psychiatry they … will need to involve at least as much money and as many people as have been involved in creating and maintaining the old institutions. To do anything less will be false economy of the cruellest kind.’1
Problems of transition
In response to a mix of ideological and fiscal imperatives, almost all psychiatric hospitals were run down, closed, repurposed or sold off by the 1990s. This was a result of haphazard local schemes rather than a carefully managed national plan. In this final phase of deinstitutionalisation, very few psychiatric hospitals retained any services on their historic campuses. One exception was Hillmorton Hospital, formerly Sunnyside Hospital.
The transition to a system of community-based services became very complex and messy as it coincided with several waves of health sector restructuring in the 1980s and 1990s. The rapid growth and spread of multiple agencies – public, private and voluntary, local, regional, national, and culturally-based – funded under different contracts to provide aspects of care and support lacked coordination and certainty of outcomes.
Patients, families of patients, and carers were caught in the cracks, and there were harrowing and occasionally tragic tales of poor communication, missed opportunities, poor support, lack of continuity of care and unsuitable placements.
Such challenges, however, elicited for the first time the strong and influential voice of patients (or consumers as they were increasingly called), carers and families who shared their experiences and concerns. A number of former psychiatric hospital patients lodged legal claims alleging abuse by staff and doctors. Some received official apologies. Many more consumers contributed to the general inquiry into mental health services chaired by Judge Ken Mason (1995-6) and the Confidential Forum for Former In-Patients of Psychiatric Hospitals (2005-7). The inquiry's report cited many such stories about the inadequacy of services. The forum, the first of its kind in New Zealand, offered a constructive approach to dealing with historic matters that had deeply affected people. The many individual narratives revealed negative themes around institutional culture and treatment regimes. On the positive side, many participants told the forum of their recognition and lasting appreciation of care they had received from staff members or other patients.
The 1990s also saw a number of important advances in mental health services. These included the development of regionally based forensic psychiatry services, legislative revision, the detachment of intellectual handicap from mental health services, and more attention to the needs of Māori, who were over-represented in mental health statistics.
Public consultation by health agencies also encouraged action based on responses from the consumers of mental health services. The Mason Inquiry’s criticism of the Ministry of Health’s lack of leadership, influence and capacity to infuse the system with vision and purpose led to major organisational changes. The Mental Health Commission was set up in 1996 as a watchdog over the sector. It worked closely with the ministry to shape the future by advising the government on the needs of people experiencing mental illness, encouraging research and advocating improvements. The latter included appropriate services for Māori, the integration of drug and alcohol policy and services with those for mental health, better promotion of mental health, and the prevention of mental illness. The commission was always intended to be a temporary body. Its residual functions were moved to the Health and Disability Commission in 2012.