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Guest Editorial

Outcry and Silence: Social implications of asylum closure in Australia

Pauline Savy
School of Social Sciences, La Trobe University, Albury-Wodonga Campus, VIC

Article Text

This issue of HSR is dedicated to sociological discussion of the social impact of mental health reform, particularly the closure of many publicly funded Australian stand-alone psychiatric hospitals over the last two decades. A recent Australian publication is highly significant to this collection of articles. Entitled Not for Service: Experiences of Injustice and Despair in Mental Health Care in Australia, (Mental Health Council of Australia and the Brain and Mind Research Institute in association with the Human Rights an Equal Opportunity Commission, 2005), this report concludes that government promises to establish adequate, networked, community-based services to replace institutional care have not materialised. Reverberating through this report are the voices of consumers, advocates, families, workers and politicians who give accounts of homelessness, lack of inpatient and community services, over-reliance on pharmaceutical treatment, undue confinement, imprisonment in gaols, and suicide.

Sociologists' voices are not among those included in the Not for Service report; their silence is both symptom and cause of sociology's lack of profile in regard to important social problems such as the treatment and everyday lives of individuals who suffer debilitating mental illness. With few exceptions, it is claimed, sociologists have been silent on even the most publicly debated of changes to the structure and delivery of mental health services - the closure of many large asylums across Australia (Willis and Broom 2004). In contrast, other provocative matters of the last two decades - HIV/AIDS, the human genome project and complementary or alternate medicine - have caught the imagination of a significant number of sociologists (Willis & Broom 2004).

This special issue of HSR constitutes a deliberate move to redress this silence. The first step took place at The Australian Sociological Association (TASA) Health Sociology Day at the annual conference in Beechworth, Victoria in December 2004. The theme of the day's proceedings 'Has Deinstitutionalisation Worked?' was energised by stimulating presentations and by the physical location of the conference. The site, now a campus of La Trobe University, was opened in 1967 as the 'Ovens Lunatic Asylum'. In its heyday in the 1960s, the asylum then renamed Mayday Hills Hospital, housed one thousand inmates. The papers in this issue, some authored by presenters at the 2004 Health Sociology Day, contribute to a much-needed revival of sociological interest in mental illness. They take up issues central to the Not for Service report: the need for reform and closure of asylums or stand-alone psychiatric hospitals, the political orientations and social impact of Australia's deinstitutionalisation program, human rights and the quality of everyday life for individuals diagnosed with mental illness, the provision of psycho-social treatments and community based support services, and the centrality of risk discourse within psychiatric services.

As guest editor, I see a threefold purpose in writing this introductory article. Firstly, the release of the Not for Service report begs an overview of the rise of the asylum as a humane model of care and its fall from grace as a total institution (Goffman 1961), an ungovernable form of publicly-funded care (see Gerrand this issue). For this reason, I will begin by sketching the history of asylums in Australia, noting that many calls and reform measures, all arguing for humane, dignified and therapeutic mental health care, run through and beyond this history. Secondly, having highlighted sociologists' relative silence on the social consequences of deinstitutionalisation, it is important to acknowledge the inspiring work that has been produced by Australian social scientists. I will refer to three publications that stand out in terms of their analyses of particular aspects of deinstitutionalisation, as well as the direction they provide for future research questions pertinent to the structural, therapeutic and lived-experience dimensions of mental illness in our times. Thirdly, I conclude with the principal and pleasing task of introducing the papers that constitute this issue, and add to the existing body of work.

The rise and fall of asylums in Australia

Debate over the necessity for and operation of stand-alone psychiatric institutions has been a perennial feature of societal responses to mental illness in the western world. It seems that abandonment of some of the most vulnerable individuals in our society continues to happen, whether they are in or out of asylums. Gostin notes that:

Countless promises have been made to right the wrongs, but new forms of neglect have always emerged. The mentally disabled have ended up in prison, in equally deplorable adult homes, or on the streets, homeless and destitute, while the wider society has averted its eyes (Gostin 2004: 11).

Gostin's words allude to the numerous political pledges and undertakings to provide humane and therapeutic modes of care for citizens afflicted with disabling mental illness, to protect such vulnerable individuals from abandonment, poverty, and abuse. The most enduring and notorious of these efforts, the establishment of 'lunatic asylums', resulted from humane intent to remove the many 'lunatics' incarcerated in gaols across Australia in convict times. Early colonial officials, such as Governor Macquarie of New South Wales, intended that these places would live up to the meanings inherent in the word asylum (Lewis 1988: 21-26). That is, they would provide shelter and protection from harsh treatment and exploitation; they would be havens characterised by the prevailing ideas of cure and moral treatment[1]. Indeed, asylums were regarded by some as a gift for those who could not survive in the 'harsh, demanding and critical world outside' (Cade 1979: 89). Sociologically, the relocation of 'lunatics' from gaols to asylums rhetorically drew a line between the moral categories of criminal insanity and lunacy, or between badness and madness (Conrad and Schneider 1985). At the same time, the social purpose of the asylum was to delineate the 'normal' from the 'mad' and to carve out a milieu in which the otherness of the insane could be managed (Porter 2002: 122).

As the Australian population grew, so too diagnostic categories expanded to accommodate the stresses of advancing civilisation, alcoholism, and criminal activity linked to mental deficiency (Lewis 1988: 21-26). Soon after opening, the asylums were faced with the problems of overcrowding, under-staffing, lack of staff skill and aptitude for caring, and bureaucratic apathy. Before the end of the nineteenth century, unsanitary, harsh living conditions, the parsimonious approach to governing the institutions, and the crude methods utilised to maintain order inside the institutions were detailed in several critical governmental reports (Lewis 1988). As in earlier times, beatings, shackling and seclusion were routine methods for controlling 'obstinate' and 'defiant' behaviours such as absconding, violence, self harm, incontinence, and faecal smearing[2] (Lewis 1988: 12).

Over the lifetime of the Australian asylums, inmates were subjected to the same experimental treatments as those in other western countries[3] (see Cade 1979; Porter 2002; Scull 1981, 1993, 2005). Reports, press tirades and activist outcries continued throughout the nineteenth and twentieth centuries (Lewis 1988). In the 1950s, the introduction of the phenothiazine drugs, the result of experimentation by French surgeon Henri Laborit, proved to be a significant catalyst in changing psychiatry (Shorter 1997: 248), and the therapeutic and organisational climate of asylums. These drugs toned down the experience of psychotic symptoms such as hallucinations and delusions and lessened feelings of anxiety so that patients were regarded as more 'accessible' or amenable to psycho-social forms of treatment. From this time on, short-term stays gradually replaced long term admission as the norm. It should be noted that while the phenothiazines are usually hailed as the most significant pharmaceutical breakthrough in the history of treating psychosis, Australian psychiatrist John Cade's discovery of the potential of lithium salts for the treatment of mania, preceded this in 1948[4].

By the 1970s, group therapies and re-socialisation programs, along with the appointment of social workers, psychologists and occupational therapists, increasingly contributed to what was professionally considered to be progressive, therapeutic milieux. For those who took leading roles in the innovations, the concept of total institution had been laid to rest. John Cade (1979), president of the Australian and New Zealand College of Psychiatrists in 1969-1970 and a distinguished Fellow of the American Psychiatric Association (Walter 1999: 969) had, over decades of dedicated practice, championed improvements in the lives of inpatients of large psychiatric hospitals. In his history of Australian psychiatry, Cade (1979) describes the pleasant ambience of the modern psychiatric hospital in the 1970s, its carefully organised therapeutic programs, and the appeal of free treatment. In his view, for the patients there was in fact an over-supply of comfort and freedom from responsibility that worked against their rehabilitation:

It is hardly to be wondered at that some people...are resistant to the thought of discharge from such an environment, reluctant to face the responsibilities of an independent life in the community again. Herein there is a trap for conscientious and tender-hearted staff. Some tend to foster dependency reactions in their patients, quite unwittingly, and fail to encourage positive roles and independence (Cade 1979: 101).

Clearly for Cade, familiar with the harsh regimes of earlier times, the improvements were significant. However, a variety of testaments - anecdotes, consumer advocacy reports, academic studies, and media scandals - contradict his rosy view, arguing that life inside asylums during and after the 1970s retained many dehumanising features (see, for example Gardner 1976; Gardner & Veno 1979; McGuiness & Wadsworth, 1991; Human Rights and Equal Opportunity Commission 1993; Pierce & Mildenhall 1994; Human Rights and Equal Opportunity Commission 1995; Keating 1999). Perhaps the most far-reaching of these critical accounts is the Richmond report released in March 1983 (Department of Health, New South Wales 1983). Its key recommendations included the establishment of networked community based services, assessment teams, supported housing, rehabilitation facilities and mobile crisis care. Overall, the Richmond report provided a framework to close stand-alone psychiatric hospital care, and to integrate mental health services within mainstream health facilities.

Australia-wide government support for these recommendations came in the form of the National Mental Health Strategy policy documents which started to be developed in the late 1980s. In 1993 a major report, the Burdekin Report of the National Inquiry into the Human Rights of People with Mental Illness (Human Rights and Equal Opportunity Commission 1993), argued that the rights of mentally ill people were being violated as they were accommodated in cramped, grotty, boarding houses and similar undesirable places. The one thousand page Burdekin report claimed that tens of thousands of mentally ill people were being denied basic human rights in hospitals, prisons and the community. This report raised concern that promises of appropriate, accessible, community-based services, explicit in the rhetoric of deinstitutionalisation policies, had not materialised to meet the rights and needs of mentally ill individuals and their immediate social networks. Moreover, it concluded that Australia's treatment of the mentally ill breached United Nations standards, and called on the federal government to get tough on state governments, which administer most public mental health services.

Ten years later, a consumer report produced by the Mental Health Council of Australia entitled Out of Hospital, Out of Mind! expressed similar concerns about the deficiencies of care (Groom et al 2003). It called for a range of actions, including early intervention services, training of workers, innovative alcohol and substance abuse services, national standards, more genuine consumer participation, and enhancement of services in rural and poorly resourced areas. Yet two years later, the Mental Health Council of Australia's Not for Service report argues that national progress towards meeting these needs at a local service level is minimal. It claims that while some positive government initiatives have taken place in the last decade, these are insufficient to address the deep-seated problems associated with the closure of many stand-alone psychiatric hospitals. In short, the report concludes that we now have reached a point of serious and systemic neglect.

What social science can offer

Although there is relatively little social science work on mental health issues, there are several examples of particularly useful empirical research that deserve detailed attention here. Of course, other worthy examples exist but space constraints do not permit discussing these. Two of the three Australian social science research publications which I outline here are ethnographic studies of deinstitutionalisation. The third, Barrett's (1996), deals with psychiatric practice within a stand-alone psychiatric hospital at a time when some of this facility's beds had been closed. Though similar in some broad respects, these studies individually pursue different questions and exemplify quite distinctive theoretical and methodological approaches. I describe these studies to demonstrate their value as exemplary scholarly contributions that should excite and encourage academics and students at a time when more work, from a variety of approaches, is needed.

In The Psychiatric Team and the Social Definition of Schizophrenia: An Anthropological Study of Person Illness, Robert Barrett (1996) provides insights into the work of a multi-disciplinary team located in an Australian psychiatric hospital. At the time of his study, in the early 1990s, short stays and innovative care approaches to care were high on this hospital's organisational agenda. As psychiatrist and anthropologist, Barrett provides a particularly valuable analysis because he is both insider and outsider in this hospital.

Barrett explores the everyday practices and language of team members as they constitute 'schizophrenia', 'the schizophrenic', and the 'person with schizophrenia' as objects of their highly specialised practice. Barrett's empirical material, the basic tools of clinical work, writing and talking, shows the transformation of spoken word to written case notes, and the ways in which 'cases' are constructed. Practically, this discursive transformation locates a patient into a clinical world where a therapeutic trajectory is determined. As 'cases' constituted through the team's definitions and within the prevailing cultural and professional discourses of 'progress', some individuals are deemed 'recoverable', worthy of therapeutic investment and others not so.

Theoretically counterposing Schutz's social phenomenology and Foucault's archaeological location of cultural knowledge, Barrett sets out the ways that the team accomplishes definitions of schizophrenia to show the roots of these definitions in eighteenth century categorisations. Biological, negative ideas of chronicity, degeneration and disintegration of self, he argues, persist in what we regard as progressive times, and in the definitional work of treatment coalitions. Barrett shows how staff oscillate between biological and psychosocial perspectives of schizophrenia and how these definitional exercises ultimately underscore the idea of a disintegrated self, a marginal, anomalous category of person.

The challenge Barrett throws out is to psychiatric practitioners as well as to social scientists. The task is to seek and grasp the empirical cultural and local interpretive materials through which schizophrenia is constituted, for example, as subjective experience, as medical explanation, as madness, and as myth. All definitions are significant in their social, personal and therapeutic consequences. For example, for staff, gaining insight into their taken-for-granted ways of defining schizophrenia and determining treatment pathways may allow for a process that includes clients' own definitions of illness, and plans for ways for putting themselves 'together' again (Barrett 306).

Kelley Johnson's ethnography, Deinstitutionalising Women: An Ethnographic Study of Institutional Closure, describes the transfer of twenty-one women from a locked unit within a large Australian institution for people with intellectual disabilities. Although this population is not categorised as having mental illness, Johnson's study is worthy of note here because it is one of the few that offers a detailed sociological analysis of the organisational processes and experiences of staff and patients during the time of closing an institution. The process of deinstitutionalising this facility was similar to the processes undertaken at Willsmere and other stand-alone psychiatric hospitals in terms of its efforts to locate and consult the women and their relatives about new housing arrangements.

Of particular merit in the study is Johnson's participant role in a marginal world, the kind of place most of us avoid, a place she describes as a total institution (Goffman 1961). Here, the patients had little to do outside of the regimental schedule of the day. They were frequently aggressive towards staff and each other and often harmed themselves. During the course of her research Johnson witnessed rough handling of patients as staff carried out their daily tasks. At times she found herself taking up the 'hard line' attitudes of staff to achieve some semblance of order to help staff in their efforts to get patients bathed, toileted and fed.

Johnson was already engaged in her participant-observer role when the decision was made to close the institution. She was thus well positioned to observe responses to the decision by staff, patients and family members. These included industrial disputation and the resistance of some families. Johnson observed the process of reconstructing the identities of the twenty-one women from their clinically formed reputations as disabled trouble-makers to become people with disabilities and with rights.

Johnson's ethnography contributes to social science in several ways. Firstly, it addresses a gap in the literature on institutionalised women with disabilities. Secondly, it contributes to knowledge of the process of deinstitutionalisation as it affected the lives of individuals who had, for years, been locked away from ordinary life. Thirdly, Johnson's narrative analysis of interview material allows for the meanings of living with intellectual disabilities, life inside the institution and, later, release from it, to be expressed through the voices of the women themselves.

In Self and illness: Changing Relationships in Response to Life in the Community Following Prolonged Institutionalisation, anthropologist Liz Newton's (2001) lengthy fieldwork study examines the experiences of a group of individuals discharged from long-term stays in an old, decaying Victorian style institution. Newton follows anthropological and sociological traditions of being with marginal people and taking readers to their daily worlds and to their plights. Prior to their discharge, Newton kept company with them over a period of six months and then, following their discharge, for two years as these ex-psychiatric patients adapted to living in 24 hour supported accommodation in the general community.

Newton's conceptual interest lies in the selfhood of her informants, in particular their changing self-concept and presentation as they adapt to life outside. She shows this adjustment occurring as a slow, sometimes up-and-down progress and, in doing so, takes us to the subjective nature of psychotic illness - its bouts, peaks, torments and residual symptoms - and the implications of this for interacting with others. Newton considers the problem of selfhood for her group of mentally ill people as a problem of their 'fit' into society. This problem is ultimately one of 'humanness', or what becomes of selfhood as it merges with illness. Identification of self with chronic mental illness may make it difficult for individuals to establish new social roles after being hospitalised for many years. Still, as Newton's informants show, this experience of an ill self does not necessarily preclude people from getting on with life and developing agency.

From Newton's compelling, ethnographic descriptions and analysis of interviews with her informants we see how these individuals strive for social standing and sustained supportive, emotional relations with others. Remarkably, we learn that as inpatients, they were regarded as lacking volition and having no future. Newton's analysis shows that ex-asylum patients may still be relatively marginalised and may need occasional supervision, and even occasional inpatient care. Importantly also, it shows the necessity for setting up and maintaining supported accommodation projects such as the one that gave Newton's informants the chance of independence and dignity.

The value of these three studies for directing further social science work lies not only in their scholarly thoroughness but in their capacity to take us into the everyday, out-of-sight worlds of seriously mentally ill individuals and those charged with caring for them. Sensitivity, empathy and courage are necessary traits for researching, spending time with, and advocating for the rights and needs of people who are not only removed from ordinary constructs of reality by the nature of their illness but are also socially marginalised by stigmatising societal structures and processes (Estroff 1984). In demonstrating these traits, the authors exemplify the unresolvable contradiction at the heart of all 'experience-near' work (Geertz 1984): they make the plight of mental illness more familiar to readers whilst preserving 'otherness' in terms of the 'unreality' and strangeness of their informants' experiences (Crapanzano 1986). 'Othering', as the companion of advocacy, is necessary for showing sufferers' needs for social support and inclusion.

Contributions to this issue and to future sociological research

The topics across the following eight papers in this issue of HSR resonate with the range of concerns raised in the recent Not for Service report. In distinct theoretical and methodological ways, the papers elaborate themes and issues concerning the social and economic pressures leading to closure of stand-alone psychiatric hospitals and the ensuing social consequences. Invariably, they refer to the problem of insufficient community-based services and the related implications for mentally ill persons and concerned others. Importantly, for the discipline of sociology, the papers represent a substantial response to the need for more research into mental health and illness phenomena as these are shaped by political decision-making, societal attitudes and by small-scale, local and personal experience.

The paper by Katy Richmond and Pauline Savy entitled 'In sight, in mind: mental health policy in the era of deinstitutionalisation' provides a broad overview of the post-deinstitutionalisation period. The paper argues that in times gone by psychiatric patients were 'out of sight, out of mind'. But with the first National Mental Health Plan in 1992 Australian state governments were urged to downsize (and preferably close) stand-alone psychiatric hospitals and to provide a much more diverse set of health care choices. An innovative set of options have now been put in place, ranging from clinical care in psychiatric wards of acute hospitals to mobile mental health support teams, small supervised residential care institutions and community mental health centres. The process of deinstitutionalisation in Australia is, at most, only half complete and there are many critics. Nevertheless sufferers from mental illnesses are now in a very real sense 'in sight' and 'in mind'. The paper concludes with suggestions for new sociological research in the mental health field.

Michael Hazelton's paper, 'Mental health reform, citizenship and human rights', alerts us to the global nature of deinstitutionalisation and the impact of political ideologies on the provision of services for the mentally ill. Hazelton employs an international comparative approach to analyse the mental health reforms elaborated in governmental policy documents of four countries - United Kingdom, Italy, Brazil and Australia. His discussion is anchored in the concepts of citizenship and human rights and the degree of their realisation in each country through the distribution of scarce resources and social membership. In his comparison of the performances of the four countries in this regard, Hazelton highlights strategies that have improved the social circumstances of the mentally ill.

Julie Henderson, in her paper 'Neo-liberalism, community care and Australian mental health policy', subjects key policy documents associated with the National Mental Health Strategy to discourse analysis. Henderson shows the linguistic changes to these documents over time, particularly the incorporation of new language that frames the social problem of mental illness and constructs the meaning of community care within neo-liberal ideology. Henderson equates the policy language with that of the early consumer movement concerned for the autonomy, freedom and choice of mentally ill persons in regard to their treatment. However, she argues that the prescriptive and regulatory nature of the mental health bureaucracy established by policies undermines these ideals and shifts care responsibility to individuals and families.

In her paper, 'Can deinstitutionalisation work? Transforming mental health services from 1993 to 1998 in Victoria, Australia', Valerie Gerrand takes us inside the process of the Victorian government's mental health reform during 1993-1998. Gerrand worked on policy development in the Victorian state mental health branch from 1993 to 2000. She had previously managed community mental health services set up following closure of a psychiatric institution, and had practised as a social worker in psychiatric institutional and community-based settings. From these experiences, and as a sociologist, Gerrand outlines the problems with an institution-based mental health service system. Acknowledging criticisms frequently levelled at deinstitutionalisation, Gerrand argues that Victoria's mental health reforms have largely avoided the known pitfalls, providing a solid basis for further development as well as a blueprint for similar reforms in other states.

Janice Chesters' article, 'Deinstitutionalisation: an unrealised desire', focuses on mental health services in Victoria and argues that deinstitutionalization, in its most humane and therapeutic sense, has not been achieved. Chesters draws significantly from published historical materials and her own archival research to show that cyclic reforms to overhaul institutional forms and to establish community-based services have resulted in the establishment of a variety of settings, all of which are underpinned by institutionalised models of medical care and control. A key part of Chesters' critique is the assertion that the anti-psychiatrists' protests about the reality of mental illness and the horrors of life inside the asylums have not contributed to the development of alternative, humane models of care.

In her paper, 'From therapy to administration: deinstitutionalisation and the ascendancy of risk thinking', Anne-Maree Sawyer shifts the focus to the level of psychiatric practice within a Crisis Assessment and Treatment (CAT) team. As a social work practitioner on one such Victorian team, Sawyer is well placed to sociologically analyse the team members' discursive means and practices as they assess and direct treatment for acutely and seriously mentally ill individuals. Sawyer examines the linguistic shift in assessment documentation, specifically, the change from the therapeutic orientation inherent in crisis assessment to the current centrality of risk assessment. She locates risk consciousness within neo-liberal discourses and, through the inclusion of case material, links risk thinking with a narrowing of services and professional clinical roles.

In the final paper in this collection Clare Hocking, Janet Phare and Jan Wilson provide insights into the daily lives of eight individuals who had spent more than four years in New Zealand psychiatric hospitals. In 'Everyday life following long-term psychiatric hospitalisation', these authors employ narrative analysis to describe the quality of their informants' daily lives in terms of social contacts and activities. Inactivity, isolation and loneliness characterise their worlds. Hocking and her colleagues argue that programs for deinstitutionalised people need to be long-term, even life-long, for individuals whose illness and long-term inpatient experience have left them with limited capacity to engage in friendships and meaningful activities. In turn, health care workers need to direct their therapeutic approach towards engendering social opportunities to achieve such involvement.

In an epilogue to this special issue, Daphne Habibis reviews the current situation of people living with a mental illness and places it in the context of current policy and public discourse, including the findings and responses to the recent Not for Service report. Habibis points to the considerable potential, and need, for sociological research into mental health, building on the excellent work already being undertaken. As an experienced Australian sociologist and researcher in the field of mental illness and service provision her analysis and advice conclude this issue on an encouraging note.

Directly and indirectly, the papers in this issue highlight a range of areas for further research: accommodation and homelessness, including the problem of governing the standards of boarding houses and other forms of private accommodation that house large numbers of mentally ill persons[5]; substance use and co-morbidity[6]; the high rate of mental illness among gaol populations[7]; fear of speaking out against service inadequacies[8]; the specialisation of some facilities that places patients on a service 'merry-go-round'[9]; the dominance of pharmaceutical treatments and increasing security and loss of freedom within inpatient facilities[10]; police control of profoundly distressed individuals[11]; and the rising incidence of depressive and anxiety disorders along with the high number of prescriptions for neuroleptic medication[12]. Indeed, as personal troubles and social issues (Mills 1959), the social constitution and experience of mental illness in our times presents a compelling and rewarding field for further sociological study.

Acknowledgements

For their advice and support in the writing of this paper I thank Katy Richmond, Ann-Maree Sawyer and Carolyn Tozer.

[1] Moral therapy is a term coined by French psychiatrist Phillipe Pinel who, in 1793, unchained the wretched and long hobbled prisoners at the asylum in Bicêtre, France. He halted beatings and other forms of abuse and improved inmates' diet. Pinel and followers of his moral therapy laid 'the foundations of rational and humane treatment of the insane' and the beginnings of modern psychiatry (Ingleby 1985: 145).

[2] Untrained attendants held considerable control over the management of patients as few doctors and psychiatrists were willing to work in this unglamorous field (Lewis 1988: 18). Lewis (1988: 14) reports that at the Kew asylum in Victoria in the mid-1880s, the medical team consisted of one doctor and one assistant to care for nine hundred patients. In any case, many of the medical treatments of the day - emetics, purgatives, cold showers, blistering, electric shock, mercury, paraldehyde, bromides and barbiturates (Lewis 1988: 12-13) - were so crude and cruel in their effects that the line between therapy and punishment was indistinguishable.

[3] The asylum provided an 'almost exclusive arena in which the new profession plied its trade' (Scull 1981: 19). Procedures that now seem cruel and illogical, such as the surgical removal of tonsils, teeth and abdominal organs, insulin coma therapy, and leucotomy, were adopted, often enthusiastically by psychiatrists searching for cures and professional legitimacy through adoption of the bio-medical model. By 1958, one hundred and two leucotomies had been performed at Melbourne's Mont Park psycho-surgery unit alone (Cade 1979: 58). Leucotomies and other similar surgical procedures were still being conducted at Mont Park in the 1970s.

[4] Working from the hypothesis that mania is caused by the toxic effects of normal body products, Cade's experiments led him to focus on lithium urate. Encouraged by the calming effect of this element on his laboratory guinea pigs, Cade injected himself to ascertain its safety in use on humans. Convinced, he trialled lithium salts on ten patients with mania with staggering results (see Cade 1979: 69-74; Shorter 1997: 256). However it was not until the 1960s that lithium was widely prescribed for treatment of manic states, especially those associated with bipolar illness.

[5] On 19/09/05, ABC TV's 'Four Corners' showed a grim portrayal of the impoverishment, homelessness, and exploitation of many seriously mentally ill individuals in New South Wales. These conditions have been central criticisms in early reports such as the Richmond Report (1983) and the Burdekin Report (1993).

[6] The increasing incidence of co-morbidity, or the correlation between substance use and relation to mental illness, is a principal concern of psychiatry today (see, for example, Australian Government Department of Health and Ageing 2003; Hamilton, King & Ritter 2005). The use of illicit drugs may precipitate or exacerbate psychiatric symptoms. The social implications for an individual are often very serious. For example, when rent money is spent on drugs the individual may be evicted and become homeless.

[7] The incidence of mental illness within Australia's prison population is said to be high. Presumably, this incidence will include many individuals who are categorised as having what is referred to by the psychiatric professions as dual diagnosis, that is, their mental illness is complicated by illicit substance use. One report suggests that 12% of prisoners in Australian jails have psychotic symptoms and that around 40% suffer a mental health disorder (Kearney & Cresswell: http://www.indymedia.org.uk/en/2005/07/318331.html).

[8] A 'climate of fear' has been referred to in a number of significant reports. Individuals and spokespersons for peak bodies and advocacy groups admit that they are reticent to complain about services. In the case of advocacy groups and peak bodies, representatives are reluctant to speak out and contribute to public debate as this, they consider, may jeopardise recurrent public funding (see, for example, Human Rights and Equal Opportunity Commission 1995).

[9] As agencies specialise in particular mental health problems, for example, drug and alcohol abuse, patients are more likely to be passed on from one agency to another when they don't entirely fit the diagnostic classifications that underpin that specialty. Sociologically, this 'merry-go-round' ride in which the individual is variously classified and re-classified resonates with Goffman's concept of 'agency circuit' I'd put those words in normal font but inside single apostrophes (1961). The report of the Human Rights and Equal Opportunity Commission (1995: 42-43) reports on research a study that shows this passing of patients from one kind of service to another, specifically, from psychiatric hospital to general hospital to jail.

[10] See Richmond and Savy, and Hazelton this issue.

[11] The Not for Service report shows that, to some extent, the police force has become a de facto mental health service. See Sawyer, this issue, for reference to issues concerning police involvement in acute psychiatric episodes.

[12] In a recent essay, pharmacist Gail Bell claims that 'More people than ever before in the history of Australia are taking anti-depressants. Five million PBS scripts in 1990, 8.2 million in 1998, twelve million last year, 250000 of which were written for patients under twenty years old' (Bell 2005: 3).

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