Blog authors:
Dr Richard Schweizer, Policy Advisor & Research Officer richard.schweizer@onedoor.org.au.
Dr Djuna Hallsworth, Support Group Peer Leader at One Door Mental Health djuna.hallsworth@onedoor.org.au.
A Brief Overview of Deinstitutionalisation in Australia
Mental health policy in Australia has long been a field of considerable controversy and change.
Perhaps the most significant change to the mental health sector made in Australia in the past half-century has been the deinstitutionalisation of mental health asylums and hospitals. Deinstitutionalisation, which gained momentum in the 1960s, refers to the transition of people with severe and/or long-term mental health concerns from being housed for long times in psychiatric hospitals to being treated within and by the community. In the background of the movement towards deinstitutionalisation lie memories of asylums as “total institutions” (as they were branded by Erving Goffman in his book Asylums1) where almost the entirety of patients’ lives were regulated, or where hospital wards were the loci of social control more generally (such as illustrated in Ken Kesey’s One Flew Over the Cuckoo’s Nest2). There is considerable evidence that community-based treatment is superior to hospital-centred care for many people with acute or long-term mental illness,3 although deinstitutionalisation also brought with it the need to integrate previously marginalised individuals into the housing and job markets: an endeavour that was generally ineffective due to under-resourcing and social stigma.4
The movement towards deinstitutionalisation in mental health found its roots in the Consumer Rights Movements in the US, UK and Italy, before spreading internationally. The US is known for the development of a coalition of stakeholders supporting mental health policy reform, while, in Italy, the psychiatrist Franco Basaglia is recognised for having contributed to the progressive Trieste Model of mental health support. Developments towards community treatment of people with mental illness has now been made in many contexts, though its effectiveness varies based on quality of care and structural support provided in the community.5
By the 1970s in Australia, a small but growing number of psychiatrists, psychologists, social workers, volunteers, and consumer advocates formed alliances and coalitions with the goal of influencing politicians and health bureaucrats for change. Prominent members included artist and mental health activist Simon Champ, consumer and psychologist Meg Smith, and consumer advocate Janet Meagher.6 This movement supported the development and release of the Richmond Report in 1983 by the NSW government, chaired by David Richmond.7 This report advocated, inter alia, the closure of a number of mental health institutions and concomitant funding of community-focused care. The Report met significant controversy, especially as it proposed significant reform to prior institutions, behaviours and interests in the mental health sector.
As a result of the report, and the broader mental health civil rights movement, governments across Australia (predominately state governments) closed a number of medium-to-large clinics and asylums. With this change came the need for policy and social change to address the rights of mental health consumers. Over time, there was a gradual shift in the language describing people with mental health concerns – they became “service users” or “consumers”, rather than the less empowering “mental patients” or “inpatients”, or simply being labelled according to their diagnosis.
Part of the reason why deinstitutionalisation was achievable was the development of medications addressing mental illness, which aimed to reduce symptoms to allow people to live outside of the highly controlled hospital setting. This included the development of the first anti-psychotic, chlorpromazine, in 1951, the first anti-depressants in the 1950s, and, perhaps more significantly, the development of fluoxetine (Prozac) for depression in 1987.
With that said, the history of mental health reform in Australia certainly did not end with the closure of many hospitals and asylums. The Richmond Report and mental health activists’ demands included increased financial support for mental health services in the community. As a result, contemporary community care may involve Assertive Community Treatment, mobile mental health caseworkers, support groups and supported housing and job placement programs. Even the Schizophrenia Fellowship (now One Door Mental Health) emerged out of this sustained advocacy for people with severe mental illness. Unfortunately, Australian State and Federal governments have, as yet, failed in many ways to support adequate community services for people who have been deinstitutionalised.8 This is a substantial ongoing point of criticism for mental health policy in Australia.
So, wither mental health reform?
Some have observed that “neoliberal” patterns of governance have become more pronounced in Australian politics.9 This entails a focus on individual responsibility, a privatised market for services (such as in the NDIS) and a goal of smaller public sector with less public spending. Such changes do not bode well for people with mental health challenges or in crisis, needing sustained public support.
Indeed, in the current environment the spirit of those activists who fought for themselves, their loved ones and those they cared for to bring on deinstitutionalisation must not die. We must continue to advocate for this: the civil rights, respect and the provision of sufficient, well-placed services for all those with mental health conditions.
1 Goffman, E., 2017. Asylums: Essays on the social situation of mental patients and other inmates. Routledge.
2 Kesey, K., 1992. One Flew over the Cuckoo’s Nest. Penguin Classics S. New York, NY: Penguin Putnam.
3 Rosen, A., Newton, L., & Barfoot, K., Clinical Perspectives: Evidence based Community Alternatives to Institutional Psychiatric Care. Medicine Today, vol 4, no. 9 (September 2003), p. 90.
Young, L. and Ashman, A.F., 2004. Deinstitutionalisation in Australia part I: Historical perspective. The British Journal of Development Disabilities, 50(98), pp.21-28.
Dean, C., Phillips, J., Gadd, E.M., Joseph, M. and England, S., 1993. Comparison of community based service with hospital based service for people with acute, severe psychiatric illness. British Medical Journal, 307(6902), pp.473-476.
4 Arboleda-Flórez, J., 2017. What Has Not Been Effective in Reducing Stigma. In Gaebel, W., Rössler, W., Sartorius, N. (Ed.), The Stigma of Mental Illness - End of the Story? (pp. 515-530): Springer.
5 Bredewold, F., Hermus, M., & Trappenburg, M., 2020. ‘Living in the community’ the pros and cons: A systematic literature review of the impact of deinstitutionalisation on people with intellectual and psychiatric disabilities. Journal of social work. 20(1), pp. 83-116.
6 Dunlop, R. and Pols, H., 2022. Deinstitutionalisation and mental health activism in Australia; : emerging voices of individuals with lived experience of severe mental distress, 1975–1985. History Australia, 19(1), pp.92-114.
7 https://www.nswmentalhealthcommission.com.au/content/richmond-report
8 Savy, P. and Richmond, K., 2005. In sight, in mind: mental health policy in the era of deinstitutionalisation. Health Sociology Review: The Journal of the Health Section of the Australian Sociological Association, 14(3).
Rosenberg, S., Salvador-Carulla, L. and Rosen, A., 2023. Mental health reform in Australia–unfinished business. BJPsych International, 20(4), pp.99-101.
Cf. Montenegro, C., Dominguez, M.I., Moller, J.G., Thomas, F. and Ortiz, J.U., 2023. Moving psychiatric deinstitutionalization forward: A scoping review of barriers and facilitators. Cambridge Prisms: Global Mental Health, 10, p.e29.
9 Gooding, P., 2016. From deinstitutionalisation to consumer empowerment: Mental health policy, neoliberal restructuring and the closure of the ‘Big bins’ in Victoria. Health Sociology Review, 25(1), pp.33-47.
Scull, A., 2021. "Community Care": Historical Perspective on Deinstitutionalization. Perspectives in Biology and Medicine, 64(1), pp.70-81.