Dr Michael Bassett

Dr Michael Bassett

Newspaper Columns


Problems with Psychiatric Care

06/12/2005

Last week's rampage by a psychiatric patient in Henderson is a reminder that in recent years many innocent people have suffered at their hands. Every time another attack takes place there is public bewilderment and outrage. Ministers and staff promptly assure us they will be more careful. Then it happens again. What most worries the public is why so many clearly insane people aren't in secure care. The answer is that psychiatrists and politicians pay more heed to patients' rights than to public safety.

Before the early 1980s, there were several old, large mental hospitals dotted around the country. Oakley, Kingseat, Tokanui, Porirua, Seacliffe and the dreaded Lake Alice spring to memory. They were isolated institutions housing thousands of patients under varying degrees of security. The public adopted an "out of sight, out of mind" approach to their inhabitants. As Labour's then spokesman on health, I can attest they were horrible places to visit. Dank and cheerless, they smacked of Dickensian workhouses. A variety of treatments (and mistreatments) involving shock therapy and smelly drugs like paraldehyde, subdued or treated patients. There were regular inquiries into patient abuse, and a major outcry over the death of an Oakley inmate in 1982. Psychiatric services were dysfunctional; something had to be done.

Enter the crusaders. Much talk was heard about psychiatric problems being an ordinary illness (correct), and patients having rights to "community care", rather than institutionalisation. With breathtaking speed after 1980, patients were emptied out of psychiatric hospitals. The argument advanced was that "community care" would advance patients' rights and save money. Half-way houses were constructed, and by the late 1980s there were specialist Maori psychiatric units as well. Several problems quickly showed up. First, while the new system did improve the quality of some patients' lives, it alarmed many families, and was labour-intensive, and therefore not cheap. Secondly, it seemed impossible adequately to supervise psychiatric patients enjoying their new freedom. It has often been difficult to identify which group of carers is responsible for a particular patient. In June 1987 someone who had been in secure institutions all his life, but whom the professionals had returned to the community and left responsible for his own medication, killed people at an Auckland bus stop. The inquiry I set up produced the first report by Judge Ken Mason Later killings produced more. The frenzied attack in Henderson is just the most recent outrage. The public has long since worked out that in practice "community care" puts patients' rights ahead of public safety.

In-house reports have recommended more money and better patient management. However, no "expert", so far as I recall, has seriously questioned whether the policy change has tipped too far towards patients' rights. There have been many horrendous rapes, sexual assaults and stabbings by patients playing hide and seek with their care-givers. The cause is always the same: someone who in former times would have been locked up has been let out, yet was beyond the capacity of family, friends or support services to control.

One obvious point must be made: a shortage of money is NOT the main problem. What is done with it is. Huge sums have been wasted in the psychiatric sector over the last twenty years. Buildings like Oakley were expensively renovated, then closed and sold. Villa by villa, Kingseat near Auckland received a make-over, and was then sold. There have been as many fancy theories driving psychiatric policy as there are psychiatrists - the only reason we can be grateful for their shortage! Even greatly increased levels of community care can never provide the degree of security the public reasonably demands.

It's another crusade where the balance has tipped too far. In this case, away from institutionalisation. Nobody wants a return to the conditions of the 1970s. But higher levels of detention there must be. When in doubt, detain. Never rely on unsupervised self-medication. It's high time politicians enforced these simple rules. Patients themselves, their families, and the wider community, would all sleep more easily if the pendulum that swung so violently against psychiatric hospitals twenty years ago, returned nearer to equilibrium. If we began holding the crusaders personally responsible for the results of their excessive zeal, they might play safer. There's a problem, however: hospitals will have to be rebuilt. Earlier crusaders sold most of them in the hope of making their new orthodoxy irrevocable. Another high price for listening to the politically correct with no pause button.