Desarrollo de pensamientos matemáticos

The New Zealand mental health system was similarly shaped by the social and moral concerns of 1 8th century England, and the desire to provide more adequately for those most in need. Confusion surrounding the exact nature of mental illness did, however, cause some early problems, and the mentally ill were initially catered for within local jails. Although a number of hospitals made special provisions for mental health patients, the practice was uncommon. In some instances 'Boarding Out' or community placement was also offered, but again this option was not extensively used.25

In contrast to the colonial hospitals, the Lunatics Ordinance of 1 846 did not restrict patient entry according to status or financial position and reflected a somewhat progressive attitude toward mental health care. Further humanitarian concerns also meant that provisions within local jails were short lived, and by the 1 850s alternative modes of care were being explored. Discussions were mostly confined to the perceived merits of a regional network or centrally administered single asylum, but by 1 872 the

decision to construct a network of provincial lunatic asylums had been made.26

The asylums were typically located on the outskirts of the settlements they served. Although the rationale behind this was partly due to public attitudes, fear, and discrimination, the locations also provided a more therapeutic environment, where various forms of milieu could also be applied. These settings also meant that many facilities became somewhat self-supporting, utilising these rural locations for horticulture, and the patients as a cheap and available source of labour, rationalised as motivational therapy. The treatment was generally administered by medical professionals, though uniquely lay keepers and superintendents were often used in a supporting role.

The asylums came under central Government control in 1 876, a move designed to facilitate a more consistent approach to care and management. An inspector was also appointed, and in 1 880 the role was expanded to include hospitals and charitable institutions.27 The inspector's powers were wide ranging;28 however, the monitoring

function was dictated by the extent to which the asylums were able to provide care. As the majority of patients were considered incurable, and unlikely to be released, the psychiatrist was often required to do little more than manage patient care or prescribe restraints where necessary.

A generous admission policy meant that overcrowding within the asylums became a problem and necessitated the construction of additional facilities. With improvements in communication, roading, and rail systems, it was also possible to situate these asylums in even more remote locations. This enabled large facilities to be constructed and beneficial therapies, associated with farming and physical activity, could also be designed. A disadvantage of establishing remote facilities, however, was that patients were further distanced from the wider community, their families and social networks. Moreover, many of facilities were far from purpose built and failed to address the problems of overcrowding or the need to create a therapeutic environment. Other problems also

arose:

The asylums, which had been humane and effective alternatives for the care of the mentally ill, became large, physically isolated institutions which were little more than great crowded warehouses of despair.29

Treatment objectives were also compromised as patients with a wide range of conditions, abilities and behaviours, were managed within the same type of dormitory environment. As well as making it difficult to apply treatment, of more concern was the fact that the progress of some was being adversely affected by the behaviour of others. Later, as 1 08

improved opportunities for the sub-classification of patients was presented, more individualised settings were utilised, such as small cottages or villas. The limited availability of these units, however, inevitably diminished the extent to which they were utilised. 30

The First World War had a dramatic effect on the way in which mental health was perceived. Many of the returning soldiers were being diagnosed with a relatively new condition known as ' shell shock' . The idea that those who had fought so bravely for their country should be cared for within existing institutions was abhorrent to many friends and relatives. The end result was a further reconsideration of the institutionally-based model of psychiatric care. Subsequently, a range of additional services (outside the large institutions) were constructed. Although initially designed to treat soldiers, the method was later expanded to include general patients and those diagnosed as having 'less acute' mental health disorders. More importantly, these were annexed from the larger institutions and in this regard they went someway to reducing the stigma attached to mental health:

By the end of the last century [ 1 9th] state mental hospital admissions showed a greater use by persons of the upper and middle class and, consequently, lunacy gradually became mental illness .. .'Mental hospital ' and ' inmate' therefore replaced ' lunatic' and 'asylum' in an attempt to restore the acute treatment function of institutions upon the hospital model . . . The recognition of ' shell shock' as a legitimate psychiatric condition during the First World War tended to confirm a growing awareness that mental illness was not a disease of the lower social classes alone. The area of the new madness was veiled behind reference to the 'borderlands', 'nerves' and 'neurasthenia' . Treatment for such cases required 'half-way houses' . From 1 906 a variety of

peripheral services was tacked on to existing institutions so as to cater for the m entally ill of

. . I I 31

supenor SOCla c asses.

In 1925 further reforms to the mental health sector were made. A stocktake of psychiatric services found that initial moves toward deinstitutionalisation had provided

many benefits including an improved standard of care. As a result, smaller services (linked to larger institutions) were developed within the community. Although the public

impression of mental illness remained tolerable at best, these types of services did at least raise public awareness. For the first time, outpatient clinics were attached to general

hospitals, and provided useful alternatives for patients requiring less intensive treatment. Although confined initially to Auckland and Wellington, the success of the approach led to the development of similar services throughout the country. Later, more intensive

inpatient services were provided, and while activities were limited by the availability of psychiatric professionals, these services did provide a more accessible and often less

distressful alternative to the larger institutions. Moreover, these hospitals provided a

much needed buffer, particularly as the larger facilities were struggling because of

overcrowding.32

Into the 1 950s, and with the development of new psychoactive drugs, a new era in psychiatric treatment and care emerged. It was no longer assumed that the more severe psychotic conditions were untreatable or that a lifetime of supervised care was required in

every instance. Clinicians began to explore the possibility of managing the care of long- term patients outside the established institutional settings. It was part of a world-wide

trend. The development of specific hostels or community homes for the intellectually

disabled reinforced these moves,33 as did the construction of old peoples homes and improved arrangements for the care of geriatric patients away from large hospital settings:

The recognition of the detrimental effects of hospitalisation and developments In psychopharmaceutical, psychotherapeutic and social treatments gave impetus to deinstitutionalisation and opened doors to new approaches now associated with community psychiatry and community care. Treating the patient in the least restrictive environment and consumer empowerment have made social functioning and social performance important concepts, not only for patients, practitioners and researchers, but certainly also for family members and close relatives of patients. 34

By the 1 970s and 80s various non-Government organisations were providing residential care facilities. Promoted through the use of Government subsidies, most maintained a direct relationship with their regional psychiatric hospitals and were used to provide an­ alternative form of rehabilitation and complemented the process of deinstitutionalisation. Unfortunately, these arrangements developed unevenly across the country, and consequently reflected the type of regional diversity that had historically characterised the larger mental health facilities. Despite this, deinstitutionalisation was well underway and became the preferred Government alternative to institutionally-based care.35 Not everyone agreed with the trend. Community care had not been organised in a systematic way and concerns about inadequate supervision and care were often heard when readmission was declined or incidents of abuse arose. The deinstitutionalisation movement was overdue, and necessary, but it had been poorly managed. Hospital boards

were generally unprepared for the task and lacked both the expertise and planning capacity. Therefore, when the Department of Health formally disestablished the Division of Maori Hygiene in 1 972 and responsibility for psychiatric hospitals passed from central Government to hospital board control, the gaps and unevenness in the system were all too apparent. Thirty years later, concerns about community care, and the inability to gain access to inpatient care were still being voiced.36

Changing attitudes and an improved understanding about the nature of mental illness, meant that the philosophies of the previous few decades were beginning to change. Many of the larger psychiatric facilities had been constructed in an era when policies were developed with the dual aims of treatment and asylum, with architectural designs often based on the need for security. Although these hospitals provided centralised locations for the treatment of all types of mental disorders, too often they were located in remote locations and isolated individuals from their families and social networks. As the relevance of social factors became more accepted, deinstitutionalisation presented the opportunity to adopt alternative forms of treatment and rehabilitation. For those patients accustomed to institutionalised care, this process was mostly a welcome alternative. However, issues of co-ordination and consistency of care were to be felt for many years:

Deinstitutionalisation was partly a response to the big, ugly, prison-like mental institutions in which people even with the mildest forms of mental illness were treated for the first fifty years of this century. Isolated from their communities, supervised and dis-empowered, people leaving

psychiatric institutions frequently saw themselves as escaping. In a broader sense,

deinstitutionalisation became a metaphor for escaping from closed attitudes and limited thinking.

But deinstitutionalised care was also decentralised care. With decentralisation came problems of integration, and co-ordination. The success of deinstitutionalisation often came to be measured by reduced rates of hospitalisation rather than improved rates of access to treatment or support.37

Though highly touted, deinstitutionalised care did not replace nor reduce the need for the more specialised mental health institutions, initially at least. The larger facilities were to maintain their profile and all but monopolised the available clinical and professional expertise. However, changes to the manner in which mental health care was administered appeared inevitable, and while masked by the notion that deinstitutionalisation was a much more effective/humane means of treatment, there was little doubt that the drive toward greater efficiencies within the health sector was a significant motivating factor.

By the 1 990s, the mental health sector appeared willing to explore the opportunities offered by the health reforms and to further refine the deinstitutionalised approach to mental health care. A mental health strategy, Looking Forward, captured the new mood

and set out two major goals: decreasing the prevalence of mental health problems within the community; and increasing the health status and reducing the impact of mental disorders on consumers, their families, caregivers, and the general community.38 A sequel document, Moving Forward, identified a series of objectives and targets, including

the introduction of cultural assessment procedures for Maori consumers and increased Maori involvement in the design and purchasing of services appropriate to Maori needs.39