Life, Death and Deliverance at Callan Park Hospital for the Insane, 1877-1920: A Public Policy Message

How can my thesis on this historical topic inform current debates about mental health care policy in Australia? Before I answer this question, I need to first give a summary of the current outcomes of recent policy developments in, and debates on, mental health care and the most salient factors behind these outcomes, focussing on mortality. Having given this context, I will suggest how the results of my research might contribute to these discourses. I hasten to add that my research is far from complete as yet.

The following graph by Darrel Doessel and colleagues depicts the trend in all causes mortality of the mentally ill from 1916 to 2004.[1] Of particular interest is their expression of mortality in terms of PYLL – Potential Years of Life Lost. That is, the possible years of life the deceased might have lived had they not died before the expected age of death for a person in the general population. This measure gives greater weight to premature deaths and is therefore useful in assessing and comparing the effects of illnesses and treatments, hence I intend to use it in my thesis.[2] Doessel et al note that mortality rates have worsened since 1916, while death rates from circulatory diseases have declined. I should point out that data beyond 1996 should be disregarded, because as Doessel et al explain, the post 1996 results significantly understate suicide rates.[3] Unfortunately, I have not found a more up-to-date Australian longitudinal study as yet, although more recent official data strongly suggests that mental health related mortality has continued to rise since 1996.[4] At the same time, government expenditure on mental health increased by 178 per cent in real terms between 1992-93 and 2010-11.[5] I find it concerning, therefore, that mortality and life expectancy are not to be found among the Key Perfomance Indicators (KPIs) of the National Mental Health Reports,[6] while at the same time it has been recognised as a leading cause of morbidity, as the 2013 Report recognises.[7]

What are the causes of this unhappy situation? In the 1950 and 1960s, there was a nation wide but unsystematic move to deinstitutionalisation, which became official policy by the late 1970s and early 1980s. Alan Rosen writes that by 1984, 90 per cent of severely mentally ill people in NSW were living in the community. Unfortunately, expenditure did not follow the patients. [8] For many years, the money saved by deinstitutionalisation was not directed to mental health services in the community. It is only since the exposure of the numerous failings of ‘community care’ by the 1993 Burdekin Report that Federal and State governments have attempted to address the expenditure gap.[9] While deinstitutionalisation  and ‘community care’ continued to be officially justified by emphasis on the human rights of patients, the end result of years of underfunding and neglect was a net loss of both rights and health, as the Burdekin Report suggested.

In another 2010 paper, Doessel and colleagues point out that about 1.5 million Australians affected by mental disorders fall into the ‘unmet need’ category.[10] Most of these persons live in the community. While Burdekin recognised that ‘community care’ imposes heavy costs on carers, families, neighbours and the justice system, these costs have not, to my knowledge, been estimated. As of 2014, we still know little about the true cost of mental health provision and the cost-effectiveness of programs. [11] One end result is that about 50 per cent of prisoners have identifiable mental health issues, not to mention mentally ill persons in the court system or coming into contact with police.[12] The rights of these persons are firmly limited. Gabrielle Drake, in her 2010 study of licensed boarding houses in  Sydney, found that the quality of life of residents with mental illness was very poor. The human rights of these residents were not upheld.[13] Guy Johnston and Chris Chamberlain estimated that fifteen per cent of homeless people in Melbourne for the years 2005-2006 were mentally ill before becoming homeless and sixteen per cent became mentally ill subsequently.[14] It is perhaps encouraging that the Summary of the 2014 National Review of Mental Health Services recommends a more evidence based approach, with more resources and better targeting.

But with respect to deinstitutionalisation, there is no debate, despite the well recognised problems of diminished rights for large numbers of mentally ill, unknown costs and poor outcomes of mental health programs. Indeed, one declared goal of the 2014 Review is to further reduce inpatient services. Where the authors claim to ‘learn from history’,[15] their history starts in 1991. Why have decision makers set their faces against the more distant past? I think it implausible that they, as the general public, are not affected by 150 years of negative stereotyping, from the asylum literature of Edgar Allan Poe to films such as One Flew over the Cuckoo’s Nest and the Terminator series, where staff are portrayed as sadists, bullies and rapists and physical conditions are miserable. But Stephen Garton and others have claimed that these abuses are not intrinsic to institutional care, but were rather the product of the severe financial stringencies of the post World War I period and the Depression, which persisted until the deinstitutionaliation era, as Stephen Garton points out in his paper on ‘Seeking Refuge’.[16] But he also maintains that asylums ‘in their colonial heyday’ were ‘well resourced, well maintained institutions that had an excellent record of success’.[17] Why can we not also learn from this history?

The evidence cited by Garton is insufficient to support his claims because of a lack of detailed and targeted analysis and over reliance on broad aggregate numbers for a heterogeneous patient population. He does not mention issues of gender, family or class. My current research on Callan Park in New South Wales and earlier work on Claremont in Western Australia has already established that asylums in late colonial and early Federation periods catered for several types of patients. Many of these patients, such as alcoholics, might not be considered mentally ill now.[18] Therefore Garton’s claims with respect to the mentally ill may not be valid. I am currently analysing mortality and discharges, using more modern techniques, such as PYLL, and taking into account the issues just mentioned. Should my research confirm Garton’s contentions, what then? Given the long history of steadily increasing mortality despite increased expenditure, I think it is morally imperative to bring this evidence to the attention of decision makers. It is impossible, as Garton points out, to return to the old asylum system. But for certain classes of the mentally ill, some measure of well resourced and targeted institutionalisation might at long last begin to address premature mortality. As Gerald Grob writes, ‘The issue, therefore, is not whether historical knowledge will be employed to influence decision-making and public policies, but what kind of history will be used’.[19]

Reading List

Australian Institute of Health and Welfare, The Health of Australia’s Prisoners 2015, Australian Institute of Health and Welfare, Canberra, 2015, Part II ‘Mental Health’.

Australia Institute of Health and Welfare, ‘Mortality over the Twentieth Century in Australia’, Mortality Surveillance Series, no. 4, Canberra, 2006.

Burdekin, B, National Inquiry into he Human Rights of People with Mental Illness, Canberra, 2013.

Burnet, NG, et al, ‘Years of Life Lost (YLL) From Cancer is an Important Measure of Population Burden – and should be considered when allocating research funds’, British Journal of Cancer, vol. 92, no. 2, 2005, pp. 241-245.

Commonwealth Department of Health and Ageing, National Mental Health Report 2013, Commonwealth of Australia, Canberra, 2013.

Doessel, DP,  Williams, RG & Whitford, H, ‘Structural Imbalance and Resource Shortage in the Australian Mental Health Sector’, Journal of Mental Health Policy and Economics, vol. 13, no. 1, 2010, pp. 3-12.

Doessel, DP, Williams, RG & Whitford, H,  ‘The Trend in Mental-Health Related Mortality Rates in Australia 1916-2004: Implications for Policy’, Australia and New Zealand Health Policy, vol. 7, no. 3, 2010, pp. 1-10.

Drake, G, ‘The Privatisation of the Back Wards: The Accommodation of People with Intellectual Disabilty and People with Mental Illnes in Licensed Boarding Houses in Sydney’, PhD Thesis, Curtin University, 2010, Conclusion.

Garton, S, ‘Seeking Refuge: Why Asylum Facilities Might Still be Relevant for Mental Health Care Services Today’, Health and History, vol. 11, no. 1, 2009, pp. 24-45.

Grob, GN, ‘Abuse in American Mental Hospitals in Historical Perspective: Myth and Reality’, International Journal of Law and Psychiatry, vol. 3, 1980, pp. 295-310.

Johnston, G & Chamberlain, C,  ‘Are the Homeless Mentally Ill?’, Australian Journal of Social Issues, vol. 46, no. 1, 2011, pp. 29-48.

Paper 1: Learning From History, National Review of Mental Health Programmed Services 30 November 2014, vol. 4.

Rosen, A, ‘The Australian Experience of Deinstitutionalisation: Interaction of Australian Culture with the Development and Reform of its Mental Health Services’, Acta Psychiatrica Scandinavica, vol. 113 (Supp. 429), 2006, pp. 81-89.

Roth, DT,  ‘“Died Today”. The Brief Lives of Patients at Claremont Hospital for the Insane 1909-1919’, MA Thesis, Australian National University, 2015.

Citation: David Roth. Life, Death and Deliverance at Callan Park Hospital for the Insane, 1877 to 1920: A Public Policy Message. Australian Policy and History. December 2016.

Endnotes