I noho mātāmuri ngā whakaaro o te hunga hauā i te pūnaha hauora Pākehā - Western healthcare system was dominated by ableist views

14.    The Western health care system, within which Lake Alice operated, was based on the biomedical model of illness rather than te ao Māori perspectives of health or other holistic understandings. The Western model is based on ableist and disablist views of mental health and disability. Ableism is “a value system that considers certain typical characteristics of body and mind as essential for living a life of value”.^[28] Disablism is a by-product of ableism and involves discrimination and oppression against disabled people based on the prejudice that considers disabled people’s bodies and minds as ‘deviant’ from the norm.^[29]

15.     The Western health care system, with its focus on deficits, did little to incorporate the collective views and experiences of disabled people, including people experiencing mental distress. The views of non-disabled people and health professionals ruled over the views of disabled people on issues directly affecting their own lives. This is an example of ableism. From the beginning, the mental health survivor movement has prioritised healing by focusing on people’s strengths and on transforming the mental health system. Most people experiencing mental distress want to live in their communities with their whānau and friends, with support to make their own decisions. People with mental distress know better than anyone what they need for their own wellbeing. They need a minimum of safeguards and the opportunity to learn from their own mistakes. Real distress and emotional pain can be associated with mental health conditions, and there can also be growth. Most survivors believe they can recover their wellbeing.

16.    While institutionalisation became the common practice of the day, it was never a practice supported by disabled people and people experiencing mental distress. The term ‘asylum’ was a misleading term that was used to refer to large institutions. In fact, what some survivors want is occasional time out from life’s pressure, temporary asylum – in its original sense.

17.    Today, it is widely acknowledged that mental health and wellbeing must be seen within the broader social determinants of health – the political, economic, cultural and social environment in which people live.^[30] However, ableist and disablist views consider that people experiencing mental distress are disadvantaged, leading to stigma, discrimination and often exclusion. In particular, ableism and disablism see mental distress as something to be ‘fixed’ or ‘erased’.^[31] This is contrary to more recent views that see disability and mental health as an expression of diversity, dignity and strength^[32] and place the responsibility on society to remove disabling barriers.^[33]

Nā ngā ture whai āhuatanga pai me te hauora hinengaro i hua ake ai te whakarautanga kaitā - Eugenics and mental health legislation led to large-scale institutionalisation

18.    Lake Alice was established within a wider international and domestic context of large-scale institutionalisation of disabled people and people experiencing mental distress. As early as 1844, the Crown began building institutions for people experiencing mental distress.^[34] Over time, these were known as ‘lunatic asylums’, ‘mental hospitals’ or ‘psychiatric hospitals’.^[35] These mental health settings were managed separately from the rest of the health system and were the main form of mental health support until the mid-20th century.^[36]

19.    Institutionalisation further increased in the 20th century, largely due to the popularity of eugenics. Eugenics is an ableist and racist movement that views people with a disability, or non-European features and certain behaviours as genetically inferior and therefore seen as ‘socially inferior’ and undesirable.  This led some eugenics advocates to argue disabled people should be separated from the rest of society in ‘mental deficiency colonies’ to prevent the breeding of a ‘subnormal’ race.^[37] Over the early decades of the 20th century, governments introduced measures to identify, classify and segregate disabled people and people experiencing mental distress from the rest of society.  Post-World War II it also led to medical genetics a medical specialty including a wide range of health concerns from genetic screening and counselling to fetal gene manipulation and the treatment of children and adults with hereditary disorders.  

20.    Several institutions were opened to prevent ‘deviant’ behaviour and, ultimately, to prevent residents from having children. In 1953, a Department of Education report (the Aitken report)^[38] promoted large-scale residential institutions as providing the best model of care for children with a learning disability. Following the release of this report, many families were pressured to place their disabled children in institutions and the number of residents rose rapidly.^[39]

21.    Rates of admission to psychiatric hospitals peaked in Aotearoa New Zealand during the 1940s and 1950s, a time when rates of institutionalisation for mental illness were among the highest in the world.^[40] Voluntary admissions to mental hospitals were increasingly common from the 1950s. However, there is increasing evidence that many of these admissions were effectively compulsory.^[41] In the 1970s, the shift was towards community and outpatient mental health support, but it was not until the early 2000s that most hospitals with a sole psychiatric focus were closed. Today, support for wellbeing and community solutions for people experiencing mental distress continues to be inadequate.^[42]

22.    Throughout the period of institutionalisation, there was a lot of public trust in the medical profession, which continues today. Many families wished to keep their family members at home but placed disabled whānau members or those experiencing mental distress in institutions on medical advice that this would be best for them.^[43] However, ableist and disablist views dominant in the medical profession throughout this time likely underpinned much of this advice. These views and other prejudices also meant many people were placed in mental health settings for perceived behavioural or other reasons not related to their mental health.

23.    Successive pieces of mental health legislation, including the Mental Defectives Act 1911 and the Mental Health Act 1969, also reflected ableist and disablist attitudes. Both statutes had significant gaps in terms of rights and protections, including limited oversight and a lack of transparency and accountability for what went on in hospitals, particularly in relation to treatment. The Acts contained no specific provisions or protections for children and young people, who were essentially treated the same as adults. The 1969 Mental Health Act did not distinguish between mental disorder and intellectual disability, leading to the risk that disability and mental distress would be treated the same.

24.    Extreme experimental procedures have been practised on people in psychiatric and psychopaedic institutions other than Lake Alice. Lobotomies and other experiments involving brain surgery to influence mood and behaviour, electroconvulsive therapy (ECT) to affect memory, conversion practices of Rainbow community members, deep sleep therapy, experimentation with anti-psychotic drugs on children, long periods of solitary confinement, and the manufacture and use of instruments to give electric shocks to children for punishment. Articles on some experiments appeared in medical journals. Ethical oversight was minimal and little regard was had for truly informed consent. 

25.    The Royal Commission’s final report will share the experiences of survivors in other mental health settings across Aotearoa New Zealand.

Ngā wheako Māori i te taurimatanga mate hinengaro - Māori experiences of psychiatric care

26.    Initially, Māori contact with government mental health care was low. However, the numbers of Māori entering psychiatric institutions began to increase rapidly from the 1960s, until the rate was greater than that of non-Māori by the 1980s.  That disparity has continued to rise.^[44]

27.    Because of unemployment, institutional racism, lower incomes and a lack of connection to culture and traditional support networks because of urbanisation and colonisation, Māori were more likely to be placed in psychiatric care.^[45] During our scope period, tamariki Māori and rangatahi Māori were more likely to be brought to the attention of the State and criminalised than their Pākehā counterparts. Therefore, Māori were more likely to be committed to psychiatric care through the criminal justice system, rather than through medical referrals.

Ngā waiaro ki ngā hapori Āniwaniwa - Attitudes toward Rainbow communities

28.    In the mid-20th century, many medical professionals believed homosexuality was a form of mental illness that should be treated. From the late 1950s, mental health practitioners commonly used behaviour therapy to ‘treat’ homosexuality. The medicalisation of same-sex relations reached a peak among medical professionals, including psychiatrists, in the 1950s and 1960s in the United States and United Kingdom.^[46]

29.    By the 1970s, in response to gay rights movements in several countries, the psychiatric profession’s position on homosexuality as a mental illness began to shift. Psychiatric bodies in several countries removed homosexuality from their catalogues of ‘mental disorders’. Criticism among medical professionals and researchers towards ‘treatments’ for homosexuality grew, and the use of these practices declined over the 1970s and 1980s. It was not until 1986 that the Homosexual Law Reform Act decriminalised sex between males in Aotearoa New Zealand. Until then, men could face prosecution and imprisonment for crimes of sodomy and ‘indecent assault’, even if sex was consensual.

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