Deinstitutionalisation: an unrealised desire.

ABSTRACT

The mental illness reform movement of the 1960s and 1970s or 'anti-psychiatry' produced a rich critique of institutional responses to mental illness. One consequence of this movement was a powerful commitment from across the political spectrum for the closure of specialist mental hospitals and a move to community care--deinstitutionalisation. This paper briefly explores the reform movement's impact on mental illness services, but it also examines the much less well known and less influential counter critique mounted by archivists, historians, clinicians and philosophers. This counter critique showed that while place was important, no one location guaranteed humane and effective mental illness care. Good, poor and horrific treatment occurred in the community as well as in a range of institutional settings. This paper explores the complexity, interconnectedness and cyclical nature of mental illness services in Victoria, Australia. A regional case study from Gippsland, Victoria, and the story of Cornelia Rau help support the contention that deinstitutionalisation in its most humane and therapeutic sense is an unrealised desire.

KEY WORDS

mental illness; deinstitutionalisation; asylums; anti-psychiatry; sociology; Gippsland, Victoria.

Introduction

In the 1960s and 1970s, the work of sociologists, psychiatrists, writers, filmmakers and other anti-psychiatrists helped build a social movement for mental illness reform. While their critique was important, an unhelpful consequence of their work was the adoption by lay and academic communities of a series of powerful myths. These myths included the belief that mental illness did not exist or was created in asylums; that psychiatric treatments were little more than exercises in brutal social control; and that people, especially women and girls, were regularly confined for life in mental hospitals without appropriate reasons (Sedgwick 1982; Barham 1992; Busfield 1996). These myths influenced community understandings of mental illness and of the appropriate location of care and treatment (Shorter 1997). If mental illness was created in psychiatric hospitals then it would seem logical that patients needed liberation and community acceptance rather than a hospital bed and treatment. These powerful myths gelled with the cost-saving agendas of neo-liberal, economically conservative politicians promoting individualised, medicalised and often privatised mental illness care delivered in less costly general hospital and community settings. The opportunity to deinstitutionalise, that is, to close ageing, costly psychiatric hospitals that were a target of constant criticism, while winning community acclaim, was a powerful incentive to action for all sides of politics (Sedgwick 1982).

The myths, ideologies or discourses popularised by the mental health reform movement and the acceptance of deinstitutionalisation as a panacea was challenged by medical historians, archivists and some practitioners (Allderidge 1985; Shorter 1997). Medical historians asserted that nineteenth century asylums, or stand-alone mental hospitals, were built in response to the lack of appropriate mental health care in prisons, police cells and the community (Bostock 1968; Allderidge 1979; Hyslop 1987; Lewis 1988; Fead 1994). Asylums, they pointed out, were expensive to build and operate and so they were therefore selective about who they admitted and how long they were allowed to stay (Lewis 1988; Chesters 1996). Asylums varied in size, and regimes of medical and nursing care, as well as admission policy, changed over time (Allderidge 1979). Although acutely aware of the failures of the specialist mental hospitals, these commentators did not think that deinstitutionalisation would necessarily result in better treatment and care (Jodelet 1991).