Larvatus Prodeo

With Mark’s blessing, I thought I’d check the view from on top too. Two weeks out from the provision of the Palmer Inquiry to Minister Vanstone — which is set to uncover, amongst other things, that Cornelia Rau didn’t receive psychiatric treatment for some 3 months — I wanted to give a very brief history of changes to mental health provision in New South Wales. I suppose it’s also a follow up to Naomi’s post on homelessness and, also, gives some political background to Kate’s wonderful piece on disability.

Halfway through the dilapidated sprawl of North Ryde, on my last trip to Macquarie University as an undergraduate, my bus pulls up to lights. Across the other side of a waist-high iron fence is a nondescript red brick house — probably some kind of community housing. A man with a navy jumper and worn brown pants is awkwardly holding a rake as he makes a slow, stunted shuffle across a leaf strewn lawn. He has awful posture. He pauses after just a few steps and looks up. I wonder when a carer visited last.

A few months before I was born, in 1982, then N.S.W. Minister for Health Laurie Brereton, announced the establishment of an inquiry into health services for the psychiatrically ill and developmentally disabled. Submissions were called for, a call-in was organised, sites were visited and eight months later, The Richmond Report, was published.

With the walls around the infamous Callan Park Hospital knocked down some two decades earlier, a plan of action for deinstitutionalisation was long overdue. The 1961 McClemens Royal Commission into that institution which led to this symbolic recognition of patients’ rights found overcrowding, inadequately skilled staff, and appalling conditions for patients and staff. Erving Goffman coined the term ‘total institutions’ in his classic work on Asylums (published that same year) to critique these microcosms of authoritarian, rationalised bureaucracy — bifurcated between patient and staff worlds. Moreover, the very basis of institutionalisation was coming under scrutiny alongside criticism of practical administration. Szasz weighed in, wrestling with Cartesian dualism to the point where psychiatric diagnoses were no longer medical but behavioural pathologies; a point also expressed in Foucault’s genealogical works on normality and madness. In their own ways, these critiques exposed a vicious cycle of institutionalisation: highly bureaucratised structures of contemporary patient life fostered the dependence on routine and pathological behaviours on which the legitimacy of institutions hinged.

Libertarian advocacy groups for sufferers of mental illness began exploring patients rights by suing doctors and hospitals in the 1970s. The movement for deinstitutionalisation also led to the articulation rights of the mentally retarded (uttered in 1971 included the right to work) as well as seeking greater transparency in admission and treatment. In 1970, the landmark ruling by the Supreme Court in Allen v Superintendent of Callan Park required hospitals to have cases of involuntary admission brought before a magistrate for approval as soon as feasible. During this time, it was all too common for patients to be discovered suffering conditions normally thought of being ‘outside the current orthodox definitions of mental illness.’ In other words, whether their vulnerability and dependence was a result of mental illness, the effects of long term institutionalisation, or cognitive incapacity was often unknown or somehow lost to the staff.

However, the oil price shocks precipitated a crisis in the welfare state throughout the 1970s; and the lacerations of stagflation would eventually be operated on during various Wran budgets. The health care rationalisation under that government followed Fraser’s carving up of Medibank which begs the question - why David Richmond wasn’t called upon 5 years earlier?

The 15 years to 1991 would see the national ratio of the population in psychiatric institutions fall by more than two thirds; whilst the ratio of disability hostel accommodation would more than triple during that time. However, 1991 also marked a new recognition for patients’ rights which the Richmond Report had articulated, but never really saw the light of day. It was a vision of community based psychiatric health service delivery during the major structural economic reforms, and there was industrial relations turmoil. Remaining mental institutions were destined for underfunding and understaffing and would languish as fiscal priorities at least until the election of the Greiner Government.

I don’t want to go into the details of the Richmond Inquiry here. David Richmond spells out the major changes here (pdf). I suppose two things really stand out for me in terms of our responsibilities to provide services to the mentally ill and, also, the developmentally disabled since his recommendations were largely adopted two decades ago.

Firstly, despite the Richmond Report making strange bedfellows of economic reformists, fiscal rationalists, and libertarian social movements, were the recommendations just a bit too convenient? The coming of the Post-Industrial Society, as the brilliant sociologist Daniel Bell labelled it a decade earlier, would see enormous pressure on the marketplace being able to support unskilled/low literacy positions in affluent liberal democracies across the globe. Moreover, the leap of the Sydney Olympic Committee members after Juan Antonio’s fatefully uttered ‘the winner is Sydeney’ would, I believe, mark a new fin-de-siecle spirit in this town; the worst manifestation being the growing conspicuousness of latte sipping inner city glitterati. Richmond’s colleagues arguably couldn’t have foreseen changes to the stratification of the city which have developed. Perhaps the overcrowding of homeless shelters and unintentional delegation of treatment to staff there — tasks previously carried out under the authoritarian gaze of qualified men behind closed doors — are the ugliest credentials for membership into the club of elite knowledge-based cities with the likes of New York and Tokyo.

Secondly, mentally ill and developmentally disabled persons are overrepresented in the state’s jails. How many cases like Cornelia Rau’s interstate wandering will it take for us to seriously re-evaluate how the ethic of ‘least restrictive’ service provision intersects with a tough on Laura Norder rhetoric which has seen the total N.S.W. prison population rise by 50% in the last 10 years? I say seriously evaluate because it faces two formidable opponents: fiscal rationality ($50 000 per prisoner per annum vs. $200 000 per mental health bed in a public hospital per annum) and great soundbites (’keeping more criminals off the streets’). As long as it must compete with handing down less taxing balance budgets and being able to stay ‘tough on crime’ for headlines and 6pm news time, I suppose it’s never really going to happen.