Monday, February 10, 2020

Guest post: Andy Espersen on the treatment of mental illness

Regular readers of this blog may recognise the name Andy Espersen. Not only is Andy an occasional commenter, but he was mentioned in a Dominion Post column of mine in February 2018, which was reproduced on this site. Now in his 80s, Andy (who emigrated to New Zealand from Denmark) spent 40 years working in psychiatric institutions and has campaigned tirelessly on the issue of care for people with a mental illness - more specifically, schizophrenics. A central thrust of his argument is that many schizophrenic people now living in the community would be much better off in institutional care - an option denied them by the Mental Health Act of 1992.  It's an issue I have some knowledge of, having had a brother-in-law with schizophrenia.

Last year, a parliamentary select committee "took note of" a petition presented by Andy seeking a royal commission into harm suffered by schizophrenia sufferers as a result of the closure of mental hospitals. The committee's essentially sympathetic report on his petition is reproduced HERE. But Andy is dissatisfied with the outcome of the government inquiry into mental health, whose report the committee repeatedly cites, and wants to keep the debate going. I'm very happy to provide him with this platform. 

Been and gone is the million-dollar, much-vaunted Inquiry into Mental Health and Addiction, chaired by Ron Paterson.  The Government has accepted most of its  recommendations, including its main recommendation, namely the repeal and replacement of the 1992 Mental Health Act.

It is odd that this has not engendered any  reaction from interested parties such as district health boards and the Mental Health Foundation. I remember very well the furore and debate when this Act came into being.  It replaced all previous mental health legislation which was based on our first such legislation (of 1846).  In the report's chapter 11 (p.191)  we read, “New Zealand needs a national level discussion to reconsider  beliefs, evidence and attitudes about mental health and risk (sic)”. So let me start the ball rolling   -  noticing that until now we have had only a deafening silence. The Inquiry report brazenly declares the 1992 Act  “out of date”  -  but it most certainly does not back this statement up with adequate reasons. Quite the opposite: the report displays total incomprehension as to why we need mental health legislation in the first place  -  namely, to be legally able to contain  and protect totally vulnerable, demented people.  Let me explain :

If you Google the question, “Why do we need mental health legislation?”, you get answers such as, “The legislation sets out special rights to protect you if you are being assessed or treated for mental illness without your consent, and your rights if you are under compulsory assessment or treatment”. In other words, the Act is there to protect you against excessive intrusion into your personal autonomy by authorities. But the reason for our original 1846 legislation was to protect you as an individual from the terrible effects of the illness  -  and to protect you from being held responsible for criminal actions committed by you while demented. 

There is a world of difference between these two paradigms. One puts the responsibility for applying the legislation in a particular case on a psychiatrist who must assess the degree and quality of the patient's volition to decide whether to apply the law or not.  The other makes it mandatory to apply the law, simply because the person is demented – and traditionally, this was never determined by psychiatrists (these being a very recent invention).  This was decided in a court of law  -  often by a jury.

The 1992 Act had  two consequences which represented a radical change in the philosophy governing the  treatment of mental illness that had prevailed since the European enlightenment.  Firstly, it removed a mentally ill person's  legal right to asylum for life.   Since 1846 a mentally ill person had a legal right to be admitted (or before the voluntary inpatient legislation in 1960, "committed"), to a mental hospital  - simply because of being mentally ill.  Secondly, it removed society's  right and duty to contain an obviously mentally ill person and place him (or her) in a mental hospital. This proviso, of course, was both to protect psychotic persons against their own actions, of which they are no longer in control,  and to protect innocent citizens from being harmed by them. My meaning of  “mentally ill”  extends only to people suffering from  either functional or organic dementias   -  mainly the senile dementias, the schizophrenias and the manic-depressive or other endogenous depressions and psychoses.

Our first legislation on these matters was a direct effect of the European Enlightenment  - that amazing wave of rational,  intellectual and humanistic understanding of our human condition which swept over Europe from the mid-18th century. Immanuel Kant wrote that it consists of humankind's emergence from its self-incurred immaturity, and its submission to the dogmas and formulae of religion or political authority.  And  its cornerstone was freedom of thought and speech.  Lunacy had always  been just a fact of human life, never to be questioned.  But Dorothea Dix, a young  Sunday School teacher in  early 19th century Massachusetts,  was not afraid to question the  way the sufferers  of this terrible mental condition were treated.  She laboured all her life to persuade states in the US and  other governments to establish asylums for these unfortunate people.

And so it happened in New Zealand  :  a benign, charitable government  in 1846 formulated and enacted the Lunatics Ordinance. To begin with, the sufferers  just became special inmates in prisons and hospitals; but the building of our huge asylums soon began,  and from then on schizophrenic sufferers no longer presented any great problem in our society.  

As always, the great majority of patients still lived  with their families. It is not generally known today that  “in a typical New Zealand mental hospital, 86% of those admitted in 1955, not suffering from congenital mental deficiency and under the age of 60, were discharged within 12 months of admission;  one third of these were discharged within one month of admission” (K. R. Stallworthy,1959).  And please note, this was 1955 – before the advent of powerful tranquillising medication which greatly shortened the average length of time spent in the hospitals by patients.

But the asylums were always there for the many who had no family, who were too afflicted by their illness to be able to leave, who had a recurrent, acute  psychotic episode (a common complication in probably half the chronic cases), those who needed respite care and those who were dangerous to themselves or others.

An interesting  debate went on in asylums in the latter part of the 19th century between the adherents of medical and  moral treatment of the insane. One faction, the medical profession, wanted to treat and cure schizophrenic people,  though they could not boast of much treatment other than blood-letting, whipping or forced labour. Then there was the other faction: lay people who from their experiences of living with the insane knew the futility of any treatment.  Very soon our medical doctors were persuaded of the superiority of the moral way of treating the patients  -  and in the 20th century they greatly improved on the moral treatment through such innovations as the villa system and occupational therapy.

Science, reason, humanism, progress  -  all were the bases of the Enlightenment. And the fruits of the Enlightenment were  the institutions of our modern world which we now take for granted: democratic governments, schools, hospitals, the  fourth estate (with its self-imposed code of ethics) and so forth.   But alas, over the past half-century all these institutions have come under increasing attack. People with small minds, incapable of seeing the wood for trees, are disdainful of their governments, critical of sound academic knowledge in any sphere (though quite ignorant themselves) and rejecting  reason and humanism as the only yardstick to measure things by.   Here in New Zealand  we now see people attacking the Treaty of Waitangi, or the understanding of it as it was always accepted.  In its time this was regarded as a crowning example of enlightened European civilisation. The amazing benefits from the enlightened institutions that  the colonisers brought with them to share with indigenous Maori count for nothing in the twisted minds of these backward-looking, self-proclaimed reformers.

Nowhere has this counter-Enlightenment been more evident than in the case of mental asylums.  From the 1960s onwards people slowly again began to “submit to dogmas and formulae” (as Kant astutely put it).  Instead of soberly observing disabled human individuals and intelligently accepting the evidence before their very eyes with realism and charity, it became the norm to follow the indoctrination preached by well-meaning ideologues.  It was felt very deeply by many that it was wrong for so many schizophrenic people to be institutionalised in mental asylums. The fact that mental hospitals were never prisons and that doctors tried their level best to discharge as many patients as possible  back to their families was not understood.  Likewise, after the enactment of the 1992 Act, the fact that the schizophrenic population as a whole became much worse off than when we had residential hospitals was deliberately ignored.

New mental health legislation  will now be written.  It is my fervent hope that this legislation will again oblige our society to grant lifelong protection and hospice care to all sufferers of functional and organic  dementias.  Yes, I agree that we must review the 1992 Act; but the Inquiry report's vague, wholly unrealistic reasons for doing so should not be heeded.

Footnote: Andy invites and welcomes comment.


Lindsay Mitchell said...

Thank you for the context. Many believe that correctional facilities have become de facto asylums. Within the prisons are 'at risk' wings staffed I presume by medical staff but these do not fulfill the pressing need among prisoners. I've heard a prisoner saying how after one spell there, it should be actively avoided and that advice gets shared. He endeavoured to hide symptoms.

Building support for the reintroduction of compassionate and long term care for the mentally ill might curry more political favour (unfortunately necessary to achieve change) when broached in these terms: A portion of prison funding should be re-allocated into residential care for the mentally ill.

More generally the 1990s goal of ailing individuals being 'supported in the community' has developed into them becoming isolated, lonely, more vulnerable and/or more dangerous in the community.

Lindsay Mitchell said...

I neglected to thank you for committed and continued advocacy after many decades of work in this area.

Trev1 said...

Well said Andy. Schizophrenics suffer enormously in today's unenlightened environment. First it is a real struggle to get them diagnosed before any treatment regime can begin. We had to travel to another district to get a younger relative properly diagnosed - the local DHB didn't want to know. Secondly I have observed that while treatment with drugs like Quetiapine can help control their symptoms, any upset (real or imagined) or pressure they may feel such as money worries can become rapidly destabilizing. A place of respite is desperately needed to protect them, and possibly others, from their actions. As for MSD, I have seen little but callous disregard for people with schizophrenia. Of all the sins of neo-liberalism in New Zealand, the 1992 Mental Health Act was perhaps the most cruel. Why does this government continue to sit on its hands while spraying money around like confetti elsewhere, eg the so-called "Provincial Growth Fund"?

Unknown said...

Definitely agree with you especially the final two sentences. Far too many distressed mentally ill people are living lives of misery without their basic as human beings being met - their human rights.

Unknown said...

Thanks Andy for your tireless efforts to bring the plight of those with psychotic illnesses to the attention of policy makers. Your campaign gives me hope that the present politically correct mental health system can be improved to provide better outcomes for both those individuals suffering the devastating effects of a psychotic illness, and their families.
My brother was one of the many people you speak in support of and was failed by our current mental health system. Living with a chronic psychotic illness for 30 odd years he was only too familiar with the "revolving door" basis of mental health treatment. Although the hospital care he received during periods of acute ill health was excellent, admission to hospital was in most instances only as a result of coming to the attention of the police after causing a public disturbance. Ongoing support from mental health services in the community was severely lacking and he spent the last few years of his life living in homeless squalor in a van, tent or car. He lost hope that anything would ever improve for him.