6. To understand and report on the full spectrum of abuse and neglect that survivors told the Inquiry, an analysis of the different types of abuse and neglect survivors experienced was undertaken. The types of abuse and neglect were derived from the primary ways survivors told the Inquiry that harm was enacted, or caused, through abuse and neglect. The experiences of abuse in care that survivors shared with the Inquiry were unique, complex, and nuanced. Often, multiple types of abuse were experienced simultaneously and repeatedly.

7. The Inquiry’s Terms of Reference set out that abuse should be understood as “physical, sexual, and emotional or psychological abuse, and neglect”.[2] These are categories that are commonly used across international research literature on abuse and maltreatment.[3] The State has acknowledged these types of abuse occurred in State care settings during the Inquiry period, as well as neglect, including cultural neglect.[4]

8. However, survivors have told the Inquiry of forms of abuse and neglect with distinctive characteristics that have not yet been explicitly acknowledged by the State, including cultural, religious, spiritual, medical, educational, and financial. These forms of abuse and neglect are also discussed in emerging research literature from Aotearoa New Zealand and overseas.[5]

Nā te urunga ki te pūnaha taurima i hua mai ai te whakahapatanga
Entry into care caused trauma

9. Many children, young people and adults who were placed into State and faith-based care – particularly social welfare settings, faith homes and residences, psychopaedic and psychiatric institutions and hospital settings for people with physical disabilities – experienced profound trauma at the point of entry, regardless of the nature of their existing attachments and relationships. This was especially common for children, young people, adults and people with a learning disability who were involuntarily removed from their homes and placed into care.

10. Survivors who were involuntarily placed into social welfare settings shared that when they were entering care, they were not told or were lied to about why they were being taken and for how long, only adding to the trauma of being separated. In some cases, they were lied to about where they were going to avoid them ‘acting out’.[6]

11. Many survivors also recognised that they needed to be removed from whānau for various reasons, as discussed in Part 3 of this report. These reasons include that their parents could have been experiencing mental distress, poverty, and in some cases abuse at home, yet some survivors still suffered trauma or unjust treatment due to how they were taken into care.

Nā te whakahāweatanga i whakanoho ai ki ngā pūnaha taurima
Discrimination led to placement in care

12. For some groups, the premise behind and intention in which they were placed in care was discriminatory. These groups included Māori, Pacific Peoples, disabled people, people experiencing mental distress, Deaf and Takatāpui, Rainbow and MVPFAFF+, and girls and women. As discussed in earlier parts of this report, numerous social, political and structural prejudices within society – some with religious backing and some enforced through law – led to increased surveillance and intervention by State and faith-based organisations. These same prejudices then informed the nature of care settings and how those within them were treated.

13. The Inquiry heard that being taken into care was violent and abusive for some Māori and their whānau, hapū and iwi, and was an act of ongoing colonisation and racism.[7] Taking tamariki and rangatahi Māori into care removed them from their essential connections to their whānau, hapū, iwi and cultural identity. This occurred within a context of paternalistic and racist policies that sought to ‘domesticate’, ‘civilise’, and assimilate Māori into dominant Pākehā society.[8]

14. For Māori survivors, entry into care denied them the rights and responsibilities associated with their personal and tribal whakapapa, impacting on their ability to develop important kinship bonds and practice whanaungatanga. This was a transgression against whakapapa. Isolation from their whānau, hapū and iwi also prevented them from practising and connecting to their taha Māori, depriving them of access to their language, cultural customs, knowledge and traditions. As the Waitangi Tribunal found in 2021: “Since the 1850s, Crown policy has been dominated by efforts to assimilate Māori to the Pākehā ways of thinking and living, including Eurocentric conceptions of the ideal environments in which to raise children.”[9] For tāngata Turi Māori and tāngata whaikaha Māori this was further compounded by ableism, disablism, and policies of segregation. Dr Tristram Ingham (Ngāti Kahungunu, Ngāti Porou) described the segregation and removal of tāngata whaikaha Māori as “causing immeasurable damage”, and remarked on the issue in a broader context:

“The Crown's approach overall to disability has been reductionist and ablest. It has often employed the same strategies of segregation, suppression and paternalism that characterise the Crown's approach and actions towards Māori in general.”[10]

15. For Pacific Peoples, being taken into care followed on from, and reinforced, racist views that Pacific cultures were inferior to Pākehā culture and sought to assimilate Pacific individuals to Pākehā norms.[11] This was evidenced by increased surveillance on Pacific youths and families, particularly during the Dawn Raids / NZ Police taskforce era, which assumed Pacific youths were delinquent and their parents were unsuitable. It was reflected generally in the culture of most State and faith-based care settings, which mirrored an ignorance of Pacific cultures within wider Aotearoa New Zealand society and the official policy of ‘assimilating’ Pacific migrants.[12]

16. For Deaf people, disabled people, and those experiencing mental distress, the Inquiry heard how being placed into care was sometimes abusive, audist and disablist. Deaf people, disabled people, and people experiencing mental distress, were intentionally removed and segregated from society, to be hidden “beyond the sight and minds of their community”.[13] This involved being separated from essential connections to their families and cultures, including Deaf culture.

17. This process occurred within the structural context of State policies influenced by discrimination and eugenics. For example, in 1911, former Attorney-General John Findlay described those who were ‘defective’ as “a source of contamination and weakness” who needed to be isolated from society.[14] For Takatāpui, Rainbow and MVPFAFF+ survivors, the Inquiry heard how some were placed into both State (usually psychiatric) and faith-based care with the intent to ‘convert’ them to heterosexuality. This was due to religious values, reflected in legislation until 1986, which deemed homosexuality to be ‘sinful’ or ‘unnatural’.[15] Both psychiatric and religious conversion therapies were psychologically abusive and could be physically and medically abusive. This is illustrated in the following sections. Survivors entered both psychiatric and faith (often pastoral) care for these reasons, either because they were forced to, or voluntarily, due to their own or their family’s concerns about homosexuality. However, most did not expect the resulting treatment under conversion therapy.

18. The intent behind the placement of children and young people in social welfare residences and institutions generally, throughout the Inquiry period was that they were often seen as criminal, deviant and in need of punitive control. Children and young people who experienced law and transitional settings were similarly seen as criminals and deviants in most cases.

19. Views on gender and family life, influenced by faith-based beliefs on sin and redemption, also informed why some unmarried girls and women were encouraged or shamed into going to unmarried mothers’ homes.[16]

He aukati i te whanaungatanga
Disruption to forming attachments

20. The Inquiry heard that taking children away from their family or whānau, often at critical formative stages of their development, can have huge impacts on their existing attachment relationships, as well as their ability to form attachments thereafter.[17] Several experts told the Inquiry that the removal experience for children would be terrifying, incredibly traumatic, damaging and a type of loss and grief, even when removal was not abrupt. Dr Alayne Mikahere-Hall described removal as the ‘severing’ of a relationship[18] and Dr Tania Cargo noted that “as far as [the young children] know, their parents are dead”.[19]

21. Attachment is a core process of human development that usually takes place during the early years of childhood to create “a lasting psychological connectedness between human beings”.[20] More than simply ‘bonding’, attachment operates at a neurological level, shaping identity and behaviour, and establishing patterns for how an individual builds and maintains future relationships.[21] This process enables a person to form their sense of self (whether that is individual or collective) – an essential part of being human, belonging, and discovering self-confidence.[22]

22. Attachment is expressed and understood differently across cultures. A Eurocentric approach has a more individualised view, focused on the mother-to-child bond.[23]

23. Te ao Māori understandings of attachment are more collectivist. While parent-to-child attachments remain integral, these are only some of the crucial relationships essential to developing a sense of self, including connection to wider whānau, community, whenua, and wairuatanga. For Māori, tamariki are a taonga belonging to and living within a community that has a shared responsibility for them. This was reflected in traditional ways of raising tamariki.[24]

24. The Inquiry acknowledges that for many Māori survivors, their lived experience of being raised by whānau was not always reflective of this.

25. When children and young people are removed, all aspects of their development and wellbeing can be affected. Dr Sarah Calvert noted:

“We see ... the protest, the anger, but we also see the shut-down, the desire to take yourself inside yourself, the grief is so profound, and we can think with small children they don't have any language for this, all they can do is behave in some way, and hope that that will bring the attachment object back to them. But of course, in many cases that doesn’t happen.”[25]

Te wheako o ngā whakanohonga maha
Experience of multiple care placements

26. Trauma and disconnection are compounded when children and young people are shifted across different care settings multiple times. This was the case for many survivors in social welfare settings. As discussed more in Part 3 of this report, children and young people were often moved between placements due to overcrowding and resource constraints, and perceptions of challenging behaviour, leading to placements in more 'secure' care settings.

27. Experiencing multiple placements often meant disrupting attachments and making it difficult for children and young people to form and maintain connections to people and places[26], this equated to overwhelming neglect of the development of children who had entered care. Multiple placements could also lead to:

• Increased behavioural problems (both external and / or internalised), regardless of whether they had such problems when entering care.[27]
• Disruption in education and decreased academic performance for most survivors.[28]
• Increased levels of physical and mental health service use, as well as the ongoing economic cost associated with patterns of physical and mental health service use.
• Placement instability, leading to:

i. most survivors being robbed of the consistency necessary to rebuild attachments and trust in relationships [29]
ii. some survivors experiencing a reduced likelihood of reunification with parents, hapū, iwi or communities and / or reduced likelihood of exiting from care

• increased likelihood of returning to a care setting after reunification with parents, hapū, iwi or communities
• placements in costly and restrictive care settings for some survivors.

28. When children and young people experienced multiple placements, they were robbed of the consistency necessary to build attachments and rebuild trust in relationships. Instead, they experienced a pattern of further disruptions.

 Te whakawehe roa me te whakataratahi i te tuakiri ahurea, whānau, hāpori me te pāpori
Continued separation and isolation from cultural identity, whānau, community, and society

29. Being kept in care further cut-off many survivors from essential connections to their whānau, wider communities including hapū and iwi, society and culture.

30. Many care settings that separated children, young people and adults from their whānau and community did not allow them to maintain connection to their identity and those close to them. Dr Calvert explained:

“Residential care, by its very nature, cannot provide the opportunity for a child or young person to develop secure attachments with staff. That is a key feature of institutional care, there is no continuity of relationship and no formal sense of belonging.”[30]

31. Many survivors discussed feeling unloved and unwanted, and experienced difficulties in connecting to others. While some survivors did recall placements that had caring staff or foster parents,[31] care settings did not generally provide the kind of love, nurturing and emotional support that would be expected within a whānau or family. Separation from whānau and family contributed to this overall neglect. This is further discussed in the section on ‘Psychological and emotional abuse and neglect’.

32. The Inquiry heard of caregivers and staff not allowing survivors to visit or communicate with whānau members, including staff preventing survivors from receiving letters and gifts from their whānau. Many survivors were also told they were not wanted or loved by their whānau.[32] Some survivors were separated from their siblings while in care, often after they had entered a placement together. This was particularly traumatic as it was one of the only connections that they felt they could hang on to.[33] Many care institutions were geographically isolated which often made it more difficult to maintain social and familial connections.[34] The Inquiry recognises that the geographical isolation of some care settings was a form of State control over people in care and their relationships.

33. Separation from family, whānau, aiga and kāinga played a major role in the cultural disconnection of many Māori and Pacific survivors.

34. Some survivors told the Inquiry how their care setting isolated them from society, and how they had little knowledge of, or ability to interact with, the wider world because of this separation. Survivor Sir Robert Martin described how being in disability and mental institutions until he was 15 years old was like being “brought up on a different planet with different rules”, and that he had no knowledge about things such as the All Blacks, music or history.[35]

 Te tūkinotanga-ā-hinengaro, ā-kare-ā-roto, me te whakahapa i roto i te pūnaha taurima
Psychological and emotional abuse and neglect in care

35. The Inquiry defines psychological and emotional abuse as being any act which harms a person’s psychological and emotional wellbeing and safety, as well as their thoughts and outlook. This includes threats of harm, abandonment, humiliation, isolation, and other tactics and acts which result in the “systemic destruction of a person’s self-esteem and / or sense of safety”.[36] These forms of abuse are also often described using terms such as “emotional abuse, verbal abuse, mental cruelty, intimate terrorism and psychological aggression”.[37]

36. When understanding types of psychological and emotional abuse and neglect, context is important. No two people will experience these types of abuse and neglect the same, which is emphasised when considering different cultural worldviews.

37. In te reo Māori, it is possible to explain these forms of tūkino – abuse, harm and trauma – under the broad concept of whakaiti which is to belittle and humiliate someone in a way that is intended to directly impact on their wairua or spiritual and emotional state. Irrespective of the way in which the belittling takes place, the act of whakaiti is acknowledged by the intent to harm the subject of the humiliation and diminish them in some way.

38. The power of words to damage and inflict emotional pain on someone in a Māori worldview is illustrated in the saying: “He tao rākau e taea te karo, he tao kupu tē taea te karo” (a wooden spear can be dodged and avoided, but not the spear of words). Many sayings exist to warn of people to be cautious about words used because of the known impact on others, and the fact that once spoken, they could not be unsaid, such as “E kore te huare e hoki ki te waha” (the spittle will never return to the mouth).

39. In te ao Māori, the effects of psychological abuse are described by the way in which they impact the abused, for example:

• takahi mana is the trampling of a person’s mana
• patu wairua is an attack on their wairua or spiritual wellbeing
• patu hinengaro is an attack on their mental wellbeing, their self-esteem and inner thoughts
• patu manawa describes a deep psychological attack that impacts their feelings.

40. Most survivors spoke about experiencing emotional and psychological distress and abuse while in care. This included verbal abuse, acts or speech intended to humiliate or shame them or others, the use of manipulation, intimidation, threats of physical or sexual harm toward them or others, and isolation from whānau and communities (which was often a feature designed into the geographic isolation of institutions). The Inquiry frequently heard how survivors felt they were treated as objects and animals.[38] The Inquiry also heard experiences of being seen and treated with a ‘deficit lens’, which gave survivors’ a “bleak narrative about their future”.[39]

41. As will be explored throughout this section, psychological abuse has a strong and consistent co-occurrence with virtually every other form of abuse. Physical, sexual, spiritual and financial abuse, as well as other distinct forms, such as solitary confinement, all have psychological components and effects. Survivors did not always directly describe their experience using the words ‘psychologically’ or ‘emotionally abusive’. However, it is clear from their experiences that harm was experienced across the scope of their humanity, including their wairua and psyche.

42. Psychological abuse occurred with varying severity and was often cruel, inhumane, and degrading. Many survivors from across settings described how psychological abuse was often continuous and cumulative. With verbal shaming and humiliation, some said the abuse was so relentless, they began to believe what they heard. Māori survivor Ngatokorima Mauauri said, “I began to accept that this was who I was going to be”.[40]

43. Psychological abuse came to define some institutions, with many survivors describing settings as having cultures of fear and violence.[41]

44. Specific expressions of psychological abuse require closer description. These include:

• institutionalisation, depersonalisation, and severance from family, whānau, hapū, iwi, community and peers
• verbal abuse, shaming and humiliation
• manipulation and threats
• witnessing violence
• psychological neglect.

Te mauheretanga me te whakataratahitanga
Institutionalisation and depersonalisation

45. Institutionalisation is the process of removing someone from society and putting them in a place or situation designed to contain people with particular needs and embedding norms, values, and behaviours in the people in the institution. This involves removing individuals’ defining characteristics and replacing them with those desired by the institution or system they have been placed in. This could be a residential or institutional facility, or a general system that assumes control of individuals’ choices and movements.[42] Most survivors the Inquiry heard from experienced some form of institutionalisation while in care.

46. Institutionalisation is psychologically abusive in distinct ways, including regimentation, depersonalisation and forced separation from collectives. These heavily involve many of the dynamics already discussed, particularly the disruption of attachments (and further, the disruption of human development) and connections to family, whānau, hapū, iwi and wider society. Children, young people and adults exposed to institutional care did not receive the type of nurturing and stimulating environment needed for normal growth and healthy psychological development.

47. There have been many studies looking at institutionalised care and the common outcomes experienced by individuals. These include negative emotional, cognitive and physical development, and in some instances limited (if any) development, affected growth, and attachment challenges. [43] In 2006, a review showed that “optimal child development was not facilitated by institutional care”.[44]

48. Institutionalisation was a way that people who went into care were devalued. Differences and diversity were not respected but were used as criteria to devalue people. People were institutionalised not with intention to enable a good life in equity with the rest of society, but to avoid total neglect while minimising the ‘burden on society’ that care recipients were thought to represent. This was worsened by creating institutions and other settings in isolated places. Being isolated emphasised both the perception of difference and the idea that contact with the people being isolated was undesirable. Being isolated also enabled abuse and neglect due to the reduced potential for witnesses, and the difficulty of escaping. Many residential institutions focused on:

• embedding norms, values and behaviours onto those in their care, including using strict routines and dehumanising actions to ensure military-style compliance
• a ‘one-size-fits-all’ approach that provided the same service to all persons in that care setting irrespective of their age, gender, abilities, needs and reasons for being placed in the institution
• processing people in care in groups according to a fixed timetable without consideration for privacy or individuality – the result is that people in care are sleeping, eating, playing and sometimes going to the bathroom at the same time or in a set order, regardless of their individual needs
• limited, if any, encouragement or support to develop and enable children, young people and adults in care to show their personal preferences and individuality. Clothes, towels, and toys were often shared within the group and living space did not allow for privacy.

49. This constituted systemic abuse. Survivors from across settings described highly regimented lives, with harsh punishment for those who stepped out of line. Survivors who lived in faith-based orphanages and children’s homes told the Inquiry about strict daily routines for getting up, making beds, prayer or church, breakfast, school and jobs.[45]

50. In institutional settings such as psychopaedic and psychiatric hospitals, and hospital settings for people with physical disability, survivors and former staff described highly regimented daily routines that were dehumanising and disempowering. Staff could dictate everything from when and what residents ate, when and with whom they were showered, what spaces they occupied during the day, and when they went to sleep at night.[46]

51. In residential and institutional facilities, institutional care was also characterised by generally there being an inadequate ratio of carers to persons in care. This meant people in care experienced multiple caregivers throughout their stay. This insufficiency of carers deprived the person of the opportunity to form healthy attachments with a significant adult, which in turn may have contributed to attachment disorders and difficulty with a wide variety of social relationships later in life.

52. Caregivers typically received little training, and the training they did receive was more focused on health issues than on social interaction. They spent the vast majority of their hours feeding, changing, bathing, cleaning children, young people and adults and the sleeping facilities, and preparing food rather than interacting with the people in care.

53. When caregivers perform their caregiving duties, it came across at times as ‘cold’ with little warmth, sensitivity, or responsiveness to individual children, young people or adult’s emotional needs.

54. Residents had little say in their daily routines, which were often organised for staff convenience.[47] The Ministry of Health and Whaikaha – Ministry of Disabled People acknowledged that due to psychopaedic and psychiatric settings having large numbers of patients and often low staff numbers, they operated “a more regimented and standardised system of care than would be acceptable today. This meant that people often lost independence and individuality”.[48]

55. The regimented order and routine of an institution was prioritised over an individual’s needs or their sense of autonomy or freedom of choice.[49] Māori survivor Matthew Whiting, who was diagnosed with cerebral palsy when he was 9 months old and has spastic quadriplegia with a speech impairment, likened Pukeora Sanatorium in Waipukurau, in the mid-1970s to a prison: “It was an institution and you did what staff told you to do… It was like sending someone to prison at 11 years old.”[50]

56. Survivors also described depersonalisation through suppression of their identities in care homes. Some survivors of faith-based homes were assigned a number for personal items such as clothing, handkerchiefs, and the use of cubicle spaces.[51] One survivor told the Inquiry the nuns referred to them by numbers. They said:

“We had numbers at Nazareth House, and they used to call out our number. We had to line up outside the hallway from the bathroom, cos it was always in the bathroom at night, about six o’clock or so at night.”[52]

57. Another survivor explained that all children were given the same haircut.[53] A survivor of Star of the Sea Orphanage (Catholic) in Tāmaki Makaurau Auckland, described how all her personal items, including clothes, were removed from her upon entry. She said it was “traumatising just having your identity taken from you as a child”.[54] Similarly, gifts from whānau were confiscated or shared among everyone in faith-based homes.[55]

58. In disability and mental health institutions, rules about how people could look and what they could wear began from the moment individuals entered these settings. For example, a survivor and a former staff member each recalled all residents at an IHC hostel wearing the same clothes, with the same “bowl haircut”.[56] Most survivors did not have their own clothes or possessions while in disability and mental health settings, and would live in pyjamas or dressing gowns, or only have access to a communal pool of clothes that had to be shared with other residents.[57] People's names and personal milestones, such as birthdays, were often not acknowledged in these care settings.[58]

59. In his witness statement provided to the Inquiry, Paul Milner, a disability researcher involved in the deinstitutionalisation of the Kimberley Centre near Taitoko Levin, cited sociologist Erving Goffman’s 1961 work on institutions, stating “the loss of progressive personal identity through restrained and regulated circumstance represented the defining attribute of institutional life”.[59]

60. Institutionalisation cut off survivors from those they associated and identified with, including their families, whānau, hapū, iwi, community and peers. Survivors were continuously separated from their whānau and communities, and sometimes their siblings who also entered care. Within institutions, survivors were also frequently directed to stay away from their friends and peers, and isolated from any human contact through solitary confinement.

61. Socialisation is a core component of identity development for all humans. Socialisation is how a society perpetuates itself by passing on its cultural DNA to its members. This process begins from the moment a person is born and continues throughout their lives, influencing everything from language to how they might perceive right from wrong. Whānau, schooling and peers normally played critical roles in shaping a person. For Māori and Pacific peoples, broader collectives play a role in socialisation.

62. Institutionalisation created a unique form of depersonalisation for Māori and Pacific Peoples due to the role that collective identity plays in socialisation including identity development. The removal of individual and collective identity through institutionalisation was therefore culturally and spiritually abusive for many. This was also a collective abuse upon Māori collectives - hapū and iwi.

Te tūkino-ā-waha, te taunu me te whakaiti
Verbal abuse, shaming and humiliation

63. Psychological abuse often involved verbal abuse. This was perpetrated by both carers and peers, and seen across all care settings.

64. Verbal abuse was often used to shame people. Many survivors spoke about being constantly put down, being told they were ‘useless’,[60] a ‘worthless piece of shit’,[61] ‘stupid’, ‘unloved’, and ‘unwanted’.[62]

65. Survivors told the Inquiry how staff and caregivers would tell them they were “born criminals” and destined for a life in prison or psychiatric institutions.[63] In faith-based settings, survivors recalled being called ‘evil’,[64] ‘daughter of Satan’,[65] and sinners.[66] Women in unmarried mothers’ homes were told they were ‘filthy’, ‘dirty’ and called ‘whores’.[67]

66. The Inquiry repeatedly heard from survivors who experienced discriminatory abuse, including being called sexist, racist, ableist, disablist and homophobic names. Multiple Māori survivors recall being called racial slurs such as ‘nigger’[68] and ’black ass’,[69] and being told they were useless, lazy, thieves or “would never get anywhere in life” because they were Māori.[70] This was a form of whakaiti and a transgression against whakapapa, as Māori survivors were essentially being denigrated because of their whakapapa and societal conceptions about what it meant to be Māori.

67. In some faith-based settings, Māori survivors were regularly subjected to whakaiti through being told that their culture and whakapapa was ’dirty’ and satanic, which was a co-occurrence with spiritual abuse.[71]

68. Similarly, Pacific survivors report being called ‘coconuts’ and ‘niggers’.[72]

69. In disability and mental distress settings, survivors told the Inquiry they were called derogatory names by staff, including ‘bungeye’,[73] ‘egghead’,[74] and other slurs intended for disabled people.[75]

70. Survivors across care settings reported being humiliated. Humiliation often involved both verbal abuse such as being made fun of or embarrassed. It had a strong co-occurrence with physical abuse that was intended to degrade survivors and make them look physically weak or repulsive. This included being forced to perform meaningless and degrading tasks, such as moving around a residence by crawling,[76] clean toilets with toothbrushes then use them to brush their teeth,[77] or having their faces pushed into faeces and vomit.[78]

71. In some care settings, the use of shaming and humiliation was often justified by staff as a punishment. This was part of a wider process of dehumanisation, intended to reduce victims to ‘less than’ their peers and care staff.[79] Verbal abuse, humiliation and shaming often co-occurred with other forms of abuse, particularly physical, sexual, racial and spiritual abuse.

Te whakapakepake me te whakatumatuma
Manipulation and threats

72. Manipulation is the influencing of another person’s choices through unfair, abusive, coercive or deceptive means. Threats are a key tool used to manipulate others. Survivors described being manipulated and threatened, particularly when they were being physically, sexually and spiritually abused. In many instances, abusers used manipulation and threats to exploit, control and silence survivors.

73. Sonja Cooper and Amanda Hill explained that through their legal practice representing hundreds of survivors, they have heard how people in psychiatric settings were often threatened with medical treatment and procedures such as electric shocks and lobotomy, known to cause harm.[80] Restrictive measures within these care settings were also used as forms of punishment and to ensure compliance:

"Placement in seclusion and psychiatric criminal wards as a punishment or in order to induce compliance in patients who ‘misbehaved’.”[81]

74. The Inquiry heard from some survivors of faith-based settings who talked about the manipulation they experienced in the form of spiritual abuse, whereby religious leaders used religious authority and claims of closeness to God to dominate, control or coerce them. Examples included survivors believing the abuse was God’s will; that they were special because they were chosen by a religious leader; that it was their fault and they were a bad person, a sinner or evil.[82]

Te kitenga o te kaikokatanga
Witnessing violence

75. Witnessing violence, directly or indirectly, is a form of psychological abuse.[83] Research has demonstrated that seeing abuse or trauma as a child contributes to adverse adult outcomes, including psychiatric disorders.[84] Most, if not all, survivors told the Inquiry that they witnessed others being harmed and many described feeling distressed and upset because of this.

76. Many survivors described care settings as environments of fear and violence.[85] Repeated and ongoing exposure to maltreatment of themselves and others was felt cumulatively.

Te whakahapatanga-ā-hinengaro, ā-kare-ā-roto hoki
Psychological and emotional neglect

77. Survivors reported neglect of care, affection, respect, dignity, encouragement and emotional support which was closely associated with psychological and emotional abuse. This neglect was a failure to take into consideration and prioritise survivors’ psychological and emotional wellbeing, and the requirements in care institutions or foster homes to maintain this. This psychological and emotional neglect was an act of whakarere.

78. The Inquiry heard about multiple care settings that were characterised by a lack of care, affection, aroha and emotional support and connection. Survivors and witnesses, including former staff, repeatedly discussed how many care settings and staff were hostile, harsh, antagonistic and cold, again showing that this was a systemic issue.[86] Some survivors highlighted the harsh differences between the aroha they experienced at home, even in homes where they could have also experienced abuse and neglect, and the lack of aroha in care settings.[87]

79. Some survivors told the Inquiry about carers in State and faith-based institutions, and foster families, who had provided them with the care and affection that they required.[88] The Inquiry also heard how simple acts of kindness by a kitchen staff member or teacher in harsh care environments were etched in survivors‘ memories and were often the only acts of kindness they remembered.[89]

80. The Inquiry heard of instances where survivors reported, or attempted to report, the abuse they were suffering, only to be dismissed, ignored, silenced and not believed.[90] There were many instances where survivors said others (such as staff members and teachers) knew abuse was happening, but did nothing to stop it, and in some cases, encouraged it.[91] This complete disregard of survivors’ safety was a form of psychological neglect and put survivors in positions where they experienced further abuse, and felt increased fear and helplessness.

81. Most survivors told the Inquiry that their human dignity was trampled on, damaged and treated as though they did not need and deserve love, belonging, play, kindness or care. Survivors said they were not treated as people who should be nurtured and their aspirations for the future were not supported.

82. The Inquiry heard from survivors who explained that they were never hugged and had “no closeness”.[92] Survivor Victoria Marie Rutter Taylor, who was placed into faith-based care said: “We were not just animals, and we needed more than people feeding and showering us”.[93] Similar sentiments were shared from survivors who went through social welfare,[94] and disability and mental health settings.[95]

83. Disability and mental health settings were characterised as having an “absence of emotional connectedness and comfort”, including a lack of affection, aroha and emotional support.[96] Many survivors described feeling unloved and unwanted, particularly as children at psychopaedic institutions.[97] Sir Robert Martin described severe emotional neglect as being a feature of the ‘care’ he experienced at the Kimberley Centre near Taitoko Levin. He said: “As a toddler at Kimberley I was fed and changed and taken care of, but I do not remember being picked up, or loved and cuddled, because there were so many of us, we were just a number.”[98]

84. Some survivors in psychiatric care settings experienced emotional neglect by staff, even when they were visibly upset.[99] The Inquiry heard from a survivor of psychiatric institutions that when other residents were so distressed, to the point of thinking about or attempting self-harm or suicide, that staff would not respond with care and empathy.[100]

85. Institutionalisation included a strong component of general psychological neglect. Survivors were denied the opportunity to express themselves, including through clothing or hairstyle choices, and were unable to explore their unique skills and interests, contributing to erosion of their personal identities.

Te tūkinotanga ā-tinana me te whakahapa i roto i te pūnaha taurima
Physical abuse and neglect in care

86. Physical abuse is a broad term used to refer to any actions that cause harm to people’s bodies.[101] The Inquiry considers that physical abuse includes any actions that cause harm to people’s bodies, but also includes any physical violence or assault, bodily interference, and forced actions such as excessive exercise intended as punishment. Sexual assault is also a form of physical abuse, which is discussed in the following section.

87. Physical abuse was one of the most prevalent and pervasive forms of abuse that survivors told the Inquiry about, across all settings and groups, and often co-occurred with other forms of abuse. While physical abuse varied in severity, many reported ongoing extreme violence in care, including regular beatings at the hands of staff, foster parents, peers, and teachers. Survivor William Wilson reported that he almost died as the result of physical abuse in care.[102] The Inquiry heard of incidents where students died at Marylands School, and it is alleged that this was a result of physical abuse from staff.[103] As stated in the Inquiry’s interim report, Stolen Lives, Marked Souls, in the absence of coronial records, the Inquiry was unable to investigate allegations that boys died from abuse at Marylands.[104] From the limited information received, the Inquiry has concerns about the circumstances surrounding the deaths of students at Marylands.

88. Survivors shared how they experienced so much physical violence that they became ‘immune’ or ‘used’ to it.[105] The Inquiry heard that those in authority knew about this violence but did little to stop it.[106] The frequency and severity of violence in institutions contributed towards creating atmospheres of fear,[107] ensuring that physical violence was often a key part of wider psychological abuse of those in care.

89. Survivors told the Inquiry they were punched and slapped,[108] kicked,[109] pushed, shoved and grabbed,[110] dragged,[111] pushed into a wall,[112] knocked unconscious,[113] put in headlocks,[114] burned,[115] hosed down with high pressure water,[116] whipped and beaten with a variety of implements[117] and given electric shocks[118] by staff and caregivers. This happened across care settings. The Inquiry also heard about incidents where survivors had been suffocated or strangled,[119] including being choked with rope.[120] Some survivors described abuse which resembled waterboarding from foster parents[121] or residence staff.[122]

90. Survivors spoke about staff and caregivers interfering with their bodies or forcing them to undertake actions that were intended to cause physical or psychological harm, such as excessive and harsh physical training,[123] force-feeding (including their own vomit),[124] physical restraint,[125] humiliating or demeaning actions,[126] misuse of electro-convulsive therapy, and chemical or medicinal harm. Misuse of electro-convulsive therapy and chemical restraint are discussed in the Medical abuse and neglect section.

Te whiu-ā-ringa
Corporal punishment

91. Physical abuse was often used as punishment and to enforce the control of staff or other carers. This happened across all care settings. Almost all survivors who experienced physical abuse spoke about it being used as punishment, often for minor infractions or behaviours outside of their control, including bedwetting,[127] for behaviours considered deviant such as running away,[128] or for discriminatory reasons such as being Pacific,[129] Māori,[130] disabled[131] or Deaf.[132]

92. Corporal punishment occurred with other types of abuse and neglect, such as psychological abuse and physical neglect. For example, the Inquiry heard of caregivers and staff intentionally withholding food and shelter. This could be for extended periods or under further adverse circumstances, such as in rain or cold weather.

93. Corporal punishment in social welfare residences and institutions was permissible up until the 1980s. The Department of Social Welfare completely prohibited corporal punishment in 1986.[133] Corporal punishment in registered schools and early childhood centres, was banned in 1989.[134] During this period, proponents of corporal punishment justified its use as a means of correcting behaviour, shaping character and maintaining staff authority. However, sources show that some agencies advised against corporal punishment except as a last resort.[135]

94. The extremity of physical abuse under the guise of corporal punishment was recognised in many instances as going above and beyond what was societally acceptable at the time.[136] While some survivors described canings or physical training as punishment, many stories showed how staff members went to extremes with such actions to inflict as much pain as possible. Survivors discussed long-term health impacts from these instances, which are outlined in Part 6 of this report. Other instances of abuse frequently involved extended and severe beatings.

95. Māori survivors experienced corporal punishment that was perpetrated under the guise of a culturally specific practice. This occurred in Māori faith-based boarding schools and at providers such as Whakapakari on Aotea Great Barrier Island.[137] The Inquiry heard of an instance where a student attending Hato Pāora was made to waewae takahia (stamp / tap foot in kapa haka) for hours and then told to hold a tūturu stance (bend the knees) for periods of time which would cause the person’s legs to wobble and give out.[138] Those who fell over were hit with a paddle. Another survivor shared how he was knocked out by the paddle four times.[139]

96. Similarly, Pacific survivors discussed corporal punishment that was given with a cultural justification. Survivors from the Methodist Wesley College in Pukekohe such as William Wilson recalled violent punishments such as the ‘Samoan Slap’ and ‘Island Respect Hidings’.[140]

97. Instances of violence that occurred with a cultural framing contributed to the separation of survivors from their culture, as this abuse meant they wanted nothing to do with the practice or the abusers.

98. Disabled survivors discussed corporal punishment within various settings, including schools and residences. NZ European survivor Tony Ryder recalled that at a children’s home he was regularly punished by being made to sit in an electric chair that ‘zapped’ people.[141]

99. Blind survivors told the Inquiry they were punished by staff at blind schools for behaviours such as using echolocation to navigate spaces.[142] Blind people can use echolocation to help perceive their environment and can include using sounds such as mouth clicks, finger snaps, whistling and cane taps.[143] Blind survivors described their blindness as being a part of their cultural identity, so being punished for behaviours associated with that identity represented psychological and emotional abuse and cultural neglect.[144]

100. As discussed in the Inquiry’s case study on Van Asch College and Kelston School for the Deaf, Our Hands were Tied, Deaf survivors between the 1950s and 1980s experienced and witnessed corporal punishment at the hands of teachers, including being strapped, in response to their use of Sign Language.[145] As Sign Language is a fundamental element of Deaf culture, suffering corporal punishment in this context represented psychological and emotional abuse and cultural neglect.

Te tūkinotanga ā-tinana aropā
Peer-on-peer physical abuse

101. Peer-on-peer physical abuse among care residents is a complex form of abuse. It includes the same behaviours and actions identified above, although often with different motivations, and is influenced by several factors.

102. Cultures of violence within many settings encouraged and allowed violence between peers. In some settings, particularly in social welfare residences and institutions, staff instructed residents to assault other residents, seemingly for purposes of control or amusement, or wilfully ignored abuse. Survivors talked about receiving ‘beatings’ and ‘hidings’ from other residents, as well as being assaulted with makeshift weapons, such as books in socks, or sharpened objects.

103. In psychiatric and psychopaedic settings, survivors described being bullied, punched, bitten, stabbed, hit with objects and thrown down some stairs by their peers.[146] Sometimes peer-on-peer violence could be extreme. Survivor Danny Akula who was a patient at Porirua Hospital as a young man, told the Inquiry about a time he was held down by other patients and forcibly tattooed.[147]

104. The Inquiry heard from survivors of faith-based schools that peer violence was common in school settings. Some survivors described daily abusive and torturous attacks from seniors, who were often put in positions of authority by staff.[148] One survivor who attended St Patrick’s College (Catholic), Silverstream in the 1970s experienced older students taking part in ‘de-grutting’ where they would put their hands down the back of other students’ pants, yank their underpants out and lift them onto coat hooks which caused some students’ backsides to bleed.[149]

105. Within social welfare residences and institutions, ‘kingpin’ hierarchies or other formalised measures of peer-on-peer violence would see stronger residents perpetrate violence on younger or smaller residents. This happened “at the direction of staff members, who would use the kingpin as a form of discipline while providing the kingpin favours and privileges not afforded to other children”.[150]

106. Many care settings had initiation rituals whereby new residents were physically assaulted by their peers on entry. Staff members often knew about these beatings.[151] Hierarchies and initiation beatings of this sort existed in boys’ and girls’ residences, although some female residential survivors reported that rather than a kingpin, hierarchies were dominated by packs of girls.

107. Similarly, in faith-based children’s homes, a culture of violence among children and their peers was sometimes encouraged by staff. One survivor recalled an incident at Sunnybank Boys' Home (Catholic) where a nun ordered all the boys in the school to attack him.[152] Some faith-based residences, such as Hodderville Boys' Home (The Salvation Army), had similar cultures of violence to social welfare residences and institutions.[153]

108. While peer-on-peer violence was not always directly instructed or condoned by staff, it occurred, in part, because of staff negligence, flaws managing resident behaviour and disposition, and the typically punitive, harsh environments.

Te whakahapatanga-ā-tinana
Physical neglect

109. Physical neglect includes being deprived of basic needs such as adequate food, clothing, shelter, and hygiene products. Physical neglect encompasses being left unattended or lack of oversight by caregivers and staff.

110. Many survivors spoke about experiencing some form of physical neglect, such as being left cold and hungry, with inadequate or little to no food or shelter. The Inquiry heard about children having to sleep in sheds[154] or on floors,[155] being so starved they had to eat out of rubbish bins[156] and so dehydrated they had to drink dirty bath water[157] or from toilets.[158]

111. Some survivors with disabilities were physically neglected or abused during their personal care routines, including those who required assistance with toileting, showering, cleaning teeth or eating.[159] Staff aggressiveness or indifference to the challenges faced by people with disabilities could cause pain and injury. The Inquiry also heard about survivors being deprived of essential hygiene care.

112. Across all care settings, female survivors were often denied access to menstrual products, as well as information and support around menstruation.[160] In faith-based settings, this form of physical neglect often co-occurred with psychological and spiritual abuse – menstruating women and girls were shamed, humiliated and verbally abused. Male survivors also spoke about the lack of support for physical changes during puberty.[161]

113. Survivors also experienced lack of appropriate oversight and physical support. This was experienced most acutely by those who had daily personal care and support needs such as residents in disability and psychiatric settings. Survivors spoke about how residents in disability settings could be left for hours in soiled clothes.

114. The Inquiry heard that inadequate bathing and hygiene practices in some disability and mental health settings resulted in the spread of diseases such as glue ear, hepatitis, and intestinal infections.[162]

115. Survivors and residents were also physically neglected by being left unattended which could risk their physical safety. This could result in extreme or even fatal consequences, such as choking to death on food.

Read the next part of Chapter 2 here