Friday, October 21, 2016

Ross Bremner and the great mental health experiment

(First published in the Manawatu Standard and Nelson Mail, October 19).

The American economist Milton Friedman once said it was a great mistake to judge things by their intentions rather than their results. I was reminded of that quote when I read about the tragic series of murders perpetrated by the Waikato man Ross Bremner.

Bremner, you may recall, stabbed his mother to death and left his father critically wounded. He then drove to a remote settlement on Kawhia Harbour where he killed a harmless and helpless elderly couple, apparently at random, before taking his own life.

Obviously, Bremner was very seriously disturbed. He had been treated for schizophrenia at Waikato Hospital. His mother had called mental health services for help only two weeks before she died at his hands.

People who knew Bremner, including a neighbour who had worked in mental health, were worried about what he might do.

Presumably a coroner will investigate the circumstances of the four deaths.  If there was a failure of the system, as seems pretty clear, the people responsible must be held accountable.

In the meantime, we are entitled to ask some questions, such as: why was a man as disturbed as Bremner not in care, for his own wellbeing as well as the safety of others?

That brings me back to Friedman’s quote.  Until the 1980s, mentally ill people in New Zealand were mostly looked after in hospitals. Older readers will remember the names of these institutions: Tokanui, Sunnyside, Lake Alice, Porirua and Kingseat, to name a few.

They tended to be drab, depressing places where patients were managed rather than treated. I know this because my brother-in-law, who was schizophrenic, spent years in Porirua. I also once had an opportunity to observe things from the inside when mental health nurses went on strike and I responded to a call for volunteers to help.

It was an imperfect system, but patients had a roof over their heads, three meals a day and a warm bed to sleep in. They had companionship and nurses to ensure they took their medication. Their families didn’t have to fret constantly about whether they were okay.

Perhaps just as important, the mentally ill were sheltered from the stressful world outside the gates. The word asylum, after all, means a place of shelter and protection.

The nurses and orderlies seemed dedicated and caring and did the best they could in less than ideal circumstances. They were certainly not the stereotype sadists personified by the vindictive Nurse Ratched in One Flew Over the Cuckoo’s Nest.

But those hospitals no longer exist. Well-meaning reformers decided they were inhumane. Mentally ill people deserved to live independent lives in the community.

This suited the government bean-counters, because it relieved the state of the cost of maintaining all those big institutions with their expansive grounds and endless maintenance demands.

Closing them down and flogging them off also fitted the ideology of the time, which favoured cutting back the state sector. “Community care” was a convenient excuse to spend less on mental health – a perfect confluence of touchy-feely idealism and hard-headed fiscal management.

The transition happened with indecent haste and there were a lot of casualties. As in so many things, we lurched abruptly from one extreme to another. And we still haven’t got it right, as the recent events in the Waikato show.

The reforms worked for some patients, but many ended up living in squalid flats and boarding houses where they were left to fend for themselves. The least fortunate ended up on the streets.

In theory, someone was still supposed to make sure that those living on their own looked after themselves and took their medication. In practice, it doesn’t seem to have worked like that.

Bureaucrats and politicians love to waffle about providing “wrap-around support” for vulnerable people but it’s more preached than practised. Under the mantra of “community care”, the state was able to wash its hands of day-to-day responsibility for the mentally ill while maintaining the pretence that they were living more rewarding, fulfilling lives. 

I know that when my brother-in-law was living independently, he was essentially left to himself. When there was a problem, it was almost impossible to find anyone in “the system” who would take responsibility or even provide information to the family.

Mental health care became highly politicised. The Privacy Act was used not only to keep patients’ families in the dark, but as a shield to prevent scrutiny of the sector and to disguise its failings. 

I remember being angrily heckled by mental health professionals at a conference where I spoke as a journalist about the importance of transparency in the sector. At the time there had been several violent deaths caused by rigid adherence to privacy codes that prevented people from being told about potentially dangerous patients living in the community.

As recent events have reminded us, not all the casualties of the reforms were patients. They included ageing parents who felt forced to provide a home for unstable and often unmanageable adult children. It seems Ross Bremner’s hapless parents fell into this category.

What a dismal way to spend the last years of your life, desperately trying to care for unpredictable and potentially dangerous offspring and unable to get professional help when it was most needed.

Community care remains a good idea in principle. But if judged on its results rather than its intent, it has been, at best, a costly experiment in human terms. The people who died at Ross Bremner’s hands are the latest evidence of that. 


Nemesis said...

How right you are. I've worked as a psychiatrist in both the old asylums (including the huge ones near London, known locally as 'bins') and in what we loosely call 'the community'; we have truly thrown the baby out with the bath water. For sure, the institutionalisation of long-term patients, who were the passive recipients of a sheltered environment, was an evil in itself, but the ideologically driven, zealous reformers couldn't see any potential hazards in expelling these ill-equipped folk into the tough world outside. Those of us who expressed reservations were accused of paternalism, elitism, and any number of other -isms.The catch-phrase was 'community care', but it soon became evident that this really meant'community neglect'. No wonder that a large proportion of ex-patients (now redesignated 'health consumers') found themselves in jail, and the 'revolving door policy' became part of the social landscape.
Is there a solution? Perhaps. Two things are required: money, and a radical change in mindset. I'm not sure that there is the political will, or public motivation, or again, the practical resources, to achieve it.
For a start, proper mental health care is horrendously expensive; it probably needs as much funding as the whole of the physical health services collectively. Where will it come from? The glamour of surgery, the emotional pull of cancer and heart disease, and the 'lifestyle diseases' will all take precedence. Schizophrenia and dementia aren't sexy.
And then, despite the trendy chat about awareness of mental illness, there remains a huge stigma associated with it; this comes from fear derived from ignorance, and plain prejudice (both of which, I'm ashamed to say, I've encountered not infrequently amongst my former medical colleagues). Those working in the mental health sector suffer low professional status, and tend to earn considerably less than those in other areas: no wonder there's a chronic recruitment problem.
And further, for as long as we allow ourselves to be bamboozled by politically correct ideas such as 'cultural safety', and take the principles of privacy and rights to ridiculous extremes, the mess will remain insoluble. We need to once again provide shelter - places of care and safety - for those who, because of incapacitating mental illness, just can't cope in open society. That's not paternalistic, or demeaning: it's humane.

Unknown said...

Well said Karl.
You speak of mental health patients. The same - of course - is true for anyone previously institutionalized: the intellectually or severely physically disabled etc. I know of now very elderly parents caring for an adult who can scarcely move, with little practical help and little financial support. They are terrified as to what will happen when they simply are not here any longer, as is their fully compis mental adult child. As you allude, part of the move to wrap around community care (!) was to build on the stigma of how awful institutions were.

What should have happened is that residential care be made available in small settings with high staff numbers all of whom were professionally trained and well paid. It still needs to happen. Yeah, I know, dreams are free.

Ron said...

Karl for PM. Brilliant. Why doesn't Labour grab this with everything they have? They need something and this is something we can all grasp and is actually caring about the struggling end of NZ.