Māori attitudes and approaches to health and disability

44.  Traditional Māori attitudes to hauora (health and wellness) had multiple dimensions, including hauora hinengaro (mental health and wellbeing), hauora tinana (physical health and wellbeing), hauora whānau (family health and wellbeing) and connection to whenua (land).

45.  Wellness required a state of balance in all spiritual aspects of a person, including their tapu, mana, mauri and wairua. Traditional Māori healing operated within this broader holistic context. Tohunga (expert, healer) addressed the root cause and the symptoms rather than trying to treat a single underlying cause.[10]

46.  The Western medical concept of disability had no equivalent within te ao Māori (the Māori world).[11] For example, Māori oral histories suggest that being kāpō (blind) was seen not as a disability but a source of greatness or special power to be shared with their hapū.[12] There is limited evidence about attitudes to disability and Deafness in te ao tawhito (the ancient Māori world).[13] Tāngata Turi likely experienced limited but functional participation in Māori society pre-colonisation.

47.  The arrival of European missionaries and settlers disrupted Māori systems of health and wellbeing.[14]

Pacific Peoples’ approaches to health and disability

48.  Before colonisation, Pacific cultures did not consider mental illness to come only from within a person. They viewed mental distress as ‘spiritual possession’ caused by the breach of a sacred covenant between people and their gods. [15]

49.  Since colonisation and Christianity, some Pacific attitudes towards mental distress have changed. Christian perspectives tended to see disability as a punishment for sin and this may have influenced Pacific Peoples’ views towards disabled people.[16] These beliefs express themselves in attitudes of cultural stigma and shame.[17]

50.  Pacific Peoples still see mental distress as not just a medical issue with a physical cause but as an inseparable part of overall wellbeing involving “body, soul and spirit”.[18]

Pākehā settler approaches to mental distress

51.  Before the mid-18th century in Britain, people who experienced mental distress were part of the community, cared for by a patchwork of family and Christian charity.[19] If they were thought to be a risk to themselves or others they might be cared for in a small hospital, or jailed. The State intervened sometimes in the case of landowners experiencing mental distress to protect the land title.[20]

52.  Disruption to social structures from population growth and urbanisation meant that in the 18th and 19th centuries families were sometimes unable to care for their loved ones. This carried over to Aotearoa New Zealand. By the end of the 19th century there were gaps in Pākehā extended family networks due to people having fewer extended family members living nearby. This led the Inspector of Lunatic Asylums to complain that many patients were in the asylums only because they had no one else to look after them.[21] The 19th century was also when mental distress began to define a person as an identity.[22]

53.  During the Inquiry period, ableism and disablism were strong societal attitudes. From the 19th century European settlers focused on the importance of physical and mental fitness. This drew attention to people whose bodies and minds were seen as different. These attitudes continued to influence views into the 20th century.[23]

Eugenics influenced attitudes to mental distress

54.  Eugenics was a social and political 19th and 20th century movement that believed unwanted genetic characteristics could be bred out of the human population. These characteristics included traits and behaviours considered undesirable, such as committing crimes, being poor, having sex outside of marriage and mental distress.[24]

55.  Over the early decades of the 20th century, the eugenics movement influenced State measures to identify, classify, group and segregate disabled people and people who experienced mental distress from the rest of society. [25] Eugenics was condemned after the Second World War following the horrors of the Nazi regime, but its ideas still influenced laws, policies and attitudes during the Inquiry period. For instance, discussion of problem families from poor areas, the use of birth control without consent in care settings and the segregation of disabled people away from their communities all echo eugenics thinking about inherited traits and fitness for reproducing.

56.  Society held a general fear of mental distress that was reinforced by the State, faiths and by widespread belief in the medical model of disability. The medical model of disability refers to disability being seen as “an individual’s problem, something wrong or broken that could be cured or contained”.[26]

People who experienced mental distress often experienced lifelong poverty

57.  During the Inquiry period, people who experienced mental distress often experienced lifelong poverty that impacted their care options. They were generally excluded from mainstream work. When work was available, it was often low paid, part time or temporary, with poor working conditions and few career opportunities.[27]

Changing attitudes during the Inquiry period

58.  During the 1960s and 1970s, several groups, including Māori, human rights, gay rights and disability rights activists, placed the State’s care and protection system under increased scrutiny and broadly challenged the status quo.

59.  During the 1960s and 1970s, the disability rights movement challenged the government’s policies and approach to the care of disabled people. Internationally, disabled people developed the social model of disability in response to the traditional medical model and attitudes.

60.  The social model of disability, with its emphasis on removing attitudinal and physical barriers to participation, led to policy shifts that enabled the closure of large institutions. Deinstitutionalisation was first proposed in the third report of the Royal Commission into Hospital and Related Services in 1973. This report was highly critical of putting people into institutions and recommended community-based care.[28]

61.  From 1974, the State stopped building new psychiatric hospitals.[29] Existing institutions remained open and continued to be used. Closing psychiatric institutions took more than 30 years.

62.  The Mental Health Foundation was established in 1977, at a time when mental distress was not generally spoken about openly. The Foundation had its roots in the belief that early developmental experiences are critical to people’s lifelong mental health and was formed to promote the mental health and wellbeing of all New Zealanders. [30]

63.  The public’s fear of mental distress continued throughout the 1980s and 1990s. The 1988 Mason Report stated that:

“The general population appears to have a very distorted image of psychiatric patients. This image is influenced by a lack of education and knowledge of the major psychiatric disorders and a misconception that psychiatric illness is inextricably linked with dangerousness.”[31]

64.  The 1980s and 1990s also featured increased recognition of the lack of appropriate care and resourcing for people who experienced mental distress. including inquiries into the mental health system in the mid-1980s and 1990s.[32]

65.  The Aotearoa Network of Psychiatric Survivors was created in 1990 to support users of mental health services and improve the mental health system. It lobbied for deinstitutionalisation of care and community-based housing for former patients.[33]

66.  In 1994 the State passed the Health and Disability Commissioner Act. As part of moves to ensure that consumers of health and disability services would have the right to be treated fairly, a Code of Health and Disability Consumer’s Rights was produced. An independent commissioner was appointed, assisted by a free, independent national advocacy service to support people to make complaints under the code.[34]

67.  The 1992 Mental Health Act established the Mental Health Review Tribunal, an independent body appointed by the Minister of Health to decide among other things, whether patients are fit to be released from compulsory status, investigate complaints about breaches of patient rights, and appoint second-opinion psychiatrists.[35]

Frameworks for State mental healthcare

68.  The Mental Defectives Act 1911 set out the conditions for admission into mental health settings until it was replaced by the Mental Health Act 1969. The Mental Defectives Act 1911 was the first legislation in Aotearoa New Zealand to categorise types of disability, long-term health conditions and mental distress. The Act arranged ‘mental defectives’ into six categories including persons of unsound mind.[36] This was extended by the Mental Defectives Amendment Act 1928 to include a seventh category: persons socially defective (defined as anti-social behaviour requiring supervision).[37]

69.  Decisions about how the mental healthcare system operated were usually made at a national level by the Minister of Health or the Director-General of Health or the Department of Health.[38] Ultimate accountability for the mental healthcare system sat with the Minister of Health, who provided overall direction, oversight and control over the system.[39]

70.  During the Inquiry period, decisions about what mental healthcare should look like and how it should be delivered and funded sat variously with the Department of Health (followed by the Ministry of Health from 1993 onwards) and Division of Mental Health / Mental Hygiene, the Director-General of Health and the Director of Mental Hygiene / Mental Health, and a range of devolved decision-makers including Hospital Boards, Area Health Boards and Crown Health Enterprises.[40]

71.  The Director-General of Health was the chief administrative officer of the department, and the Ministry of Health from 1993. Reporting to the Director-General was the Director of Mental Hygiene, later Director of Mental Health, who had specific legislative obligations relating to people in disability and mental healthcare.[41]

72.  Until 1983, hospital services were provided by District Health Offices and Hospital Boards. From 1983 to 1993 there was a decentralisation of purchasing and provision of healthcare away from the Department of Health to Area Health Boards, and with further reform this changed again to Regional Health Authorities and Crown Health Enterprises and the establishment of Needs Assessment and Service Coordination agencies. In 1998, further reform created the Health Funding Authority and Hospital and Health Services.[42]

73.  More localised decisions about how specific institutions or third-party providers should be run were made by individuals such as superintendents or medical officers, or devolved decision-makers such as Area Health Boards and Crown Health Enterprises.

74.  In 1992 the Needs Assessment and Service Coordination system was set up after a review of the existing disability support services.[43] The funding and delivery of existing support services were redistributed across the four Regional Health Authorities.[44]

75.  Under this system, disabled people (including people experiencing mental distress) needed to be assessed to see what funding they were eligible for. This funding then determined the support and resources they could access.[45]

Mental health settings

76.  By 1957, Aotearoa New Zealand had 11 psychiatric hospitals – Kingseat Hospital in Karaka, Carrington (later called Oakley) Hospital in Tāmaki Makaurau Auckland, Tokanui Hospital located south of Te Awamutu, Lake Alice Hospital in Rangitikei, Porirua Hospital in Te Whanganui-ā-Tara Wellington, Braemar Hospital in Whakatū Nelson, Sunnyside Hospital in Ōtautahi Christchurch, Seaview Hospital in Hokitika, and Seacliff, Wakari and Cherry Farm Hospitals in Ōtepoti Dunedin.

77.  These hospitals largely offered an inpatient service, where people stayed for treatment. They also took disabled people as patients, largely people with a learning disability. The experiences of disabled people are detailed in the Inquiry’s final report Whanaketia – through pain and trauma, from darkness to light, the case study on the Kimberley Centre, Out of Sight, Out of Mind, and the summary on disabled survivors' experiences of abuse and neglect in care.

78.  From the 1970s, psychiatric experts increasingly stressed the importance of community and outpatient care for people experiencing mental distress. As in the disability sector, the shift to the provision of community mental healthcare and services was slow.[46]

79.  By 1999, almost all the large-scale psychiatric institutions had closed their doors. Cherry Farm Hospital in Ōtepoti Dunedin closed in 1992, Tokanui Hospital located south of Te Awamutu closed in 1998 and Kingseat Hospital in Karaka closed in 1999.[47] Mental health services were largely devolved to inpatient care in local hospitals, outpatient hospital services and a range of smaller-scale community providers, including support services provided by non-government organisations, offering residential care or specialist programmes.[48]

80.  Inpatient teams, such as in psychiatric wards attached to general hospitals, made up a smaller part of the mental health system, undertaking close observation, intensive investigation or intervention.[49]

81.  Given the multidisciplinary nature of the mental health and addiction sectors over time, a range of teams (including community mental health teams) may have been involved in an individual's pathway through the mental healthcare system.

82.  While Māori mental health programmes and service providers began to emerge from the 1980s, [50] State mental health services were predominately Eurocentric and not culturally responsive to tāngata whaiora.[51]

83.  The monocultural nature of mental health services presented language and cultural barriers, [52] which meant that they were often not culturally safe for Pacific Peoples and their families. Cultural safety for Pacific Peoples could also include religious safety. One study published in 2000 on the experience of eight Pacific service users within a mental health setting found that religious safety was often not achieved, particularly in the context of inpatient services such as acute wards. Author Malo Vito described a cultural religious difference that contributed to incorrect interpretations:

“Any type of religious or cultural behaviour which might be deemed over the top, delusional or psychotic in a psychiatric service would be just eccentric, or extreme within Pacific Islands communities. Pacific Islanders' vocal praise and worship could be seen as ranting and raving within the confines of an acute ward.”[53]

Health professionals and other care workers

84. Day to day decisions about people in mental healthcare settings were made by medical professionals and other healthcare workers who made decisions about individual treatment, care and other daily activities. These decision-makers included doctors, psychiatrists, nurses and other healthcare workers.

How people entered mental health settings

85. The Mental Defectives Act 1911 set out the conditions for admission of people who experienced mental distress into mental healthcare settings until it was replaced by the Mental Health Act 1969. Both Acts provided the legal authority for admission to an institution, either compulsorily (against the person’s will) or voluntarily (by choice).[54]

86. For people who experienced mental distress, placement in mental healthcare settings was often compulsory. People were placed in mental healthcare settings by order of the court, on an emergency basis, or through the criminal justice system. Sometimes people entered voluntarily or on the advice of their family or clinician.[55]

87. The Mental Health (Compulsory Assessment and Treatment) Act 1992 led to substantial changes in New Zealand’s mental healthcare system. It put more importance on the rights of patients, recognising the role of cultural factors in diagnosis and treatment and the right to appeal treatment.[56]

88. The 1992 Act still enabled compulsory mental health assessment or treatment, if someone was judged to be a serious danger to themselves or others, or unable to take care of themselves.[57] Mentally distressed patients could also be compulsorily assessed and treated in the community.

89. The Director of Mental Health became responsible for administration of the Mental Health Compulsory Assessment and Treatment Act 1992.[58] The Director-General of Health could also appoint a director of area mental healthcare services for each region, to lead the mental health workforce for their area.[59]

Data

90. The Inquiry found little reliable data about people with disability and mental distress before or during the Inquiry period. The most recent substantial dataset prior to the Inquiry period was the 1916 Census results, which documented a much narrower range of impairments compared to modern standards.

91. Of the total population of Aotearoa New Zealand in 1916, 6,359 people were recorded as having one or more of the following impairments: 206 people were recorded as deaf-mutes, 566 people recorded as blind, 4,275 people recorded as lunatics, and 1,312 people recorded as feeble-minded.

92. By 1996 out of a total of population of 3,618,303 people, 517,212 (14 percent) indicated they or their dependents were disabled. Of this, 411,477 indicated they or their dependents had a long-term disability.

General rates of admission

93.  Rates of admissions into psychiatric hospitals increased rapidly during the 1940s and 1950s, reaching a peak in the 1960s and falling gradually over the 1970s:

• in 1953, approximately 9,700 people (478 per 100,000 of NZ population)[60]
• in 1966, approximately 10,600 people (397 per 100,000 of NZ population)[61]
• in 1971, approximately 10,100 people (355 per 100,000 of NZ population)[62]
• in 1976, approximately 8,500 people (270 per 100,000 of NZ population)[63]
• in 1981, approximately 8,000 people (257 per 100,000 of NZ population).[64]

94. The ethnic makeup of people who entered psychiatric hospitals fluctuated over this period.

Rates of Māori entering mental healthcare increased

95. As with disability care, whānau Māori have traditionally preferred to look after family members experiencing mental distress at home, rather than placing them in mental health settings.[65] In 1909, Māori made up just over 1 percent of psychiatric inpatients nationwide, rising to 1.8 percent in 1938. Ten years later, in 1948, this had increased to 2.6 percent. This figure represented 20.8 people per 10,000 population for Māori, while for non-Māori the figure was 51 people per 10,000.[66]

96. From the early 1960s, both Māori and non-Māori rates of admission to mental healthcare settings increased.[67] Non-Māori admission rates stabilised in the mid-1960s and then declined during the 1970s and 1980s, but Māori rates of admission increased throughout the 1960s, stabilised in the 1970s, and rose again throughout the 1980s.[68]

97. From 1970 to 1987, tamariki Māori (10 to 19 years old) and rangatahi Māori (20-29 years old) were admitted to mental healthcare at a rate approximately one and a half times higher than non-Māori. The rate of rangatahi Māori admission was approximately double the non-Māori admission rate in the mid-1980s.[69]

98. By the mid-1980s, Māori made up 14 percent of all psychiatric admissions despite making up only seven percent of the population.[70] From 1960 to 1990, while “non-Māori first-time admissions to mental health facilities had only slightly increased”, the Māori rate increased by more than 200 percent. [71] By the late 1990s, the high rates of mental distress and conditions among Māori were described as a crisis of “unprecedented proportions”.[72] In 1999, for example, 50 percent of forensic inpatient service users and 29 percent of community-based service users were Māori.[73]

99.  The increase in Māori admissions was partly attributed to the worsening state of mental health among Māori, and Māori accessing mental healthcare at a later stage of distress. Scholars attribute the worsening state to a range of factors, including alienation from traditional whānau and hapū support systems, poor access to primary healthcare, a lack of culturally appropriate services, racism and poverty.[74]

100. Studies from the 1990s found Māori adults were more likely to be admitted to psychiatric units through the justice system, after coming to the attention of law enforcement agencies; Māori were about two to three times more likely to receive referrals from law enforcement agencies than non-Māori.[75]

Numbers of Pacific Peoples in mental health settings unclear

101. During the Inquiry period there was limited data on the admission of Pacific fanau (children), tagata talavou (young people) and tagata matua (adults) to mental healthcare or the duration of their stay.

102. Data from 1984 showed that Pacific adults aged 15 years old and over were represented in psychiatric admissions at rates close to their proportion in the general population. Pacific tagata talavou and tagata matua comprised 2.3 percent of the national population but only two percent of admissions to psychiatric care.[76] However, research throughout the 1980s and 1990s found that Pacific patients who entered mental healthcare were more likely to be formally committed and were also more likely than non-Pacific people to be readmitted.[77] Leota Dr Lisi Petaia’s evidence to the Inquiry notes that one of the first interactions that Pacific Peoples usually have with mental health facilities is through the justice system.[78]

103. In 1999, seven percent of forensic inpatient users and five percent of community-based service users were Pacific Peoples. These figures indicate an overrepresentation in these mental health settings compared with the general population.[79]

Entries into forensic mental health settings

104. During the 1990s regionally based forensic psychiatric services were developed which existed at the interface of the mental health and criminal justice sectors.[80] This pathway was significant for survivors experiencing mental distress, and / or with learning disability and / or neurodiversity, where it was relevant to their offending.

105. Entry into forensic services involves an individual being charged with a criminal offence and subsequently being referred to this specialised mental health setting for assessment and treatment.[81] Sometimes individuals were transferred from prison to mental health settings, including forensic wards, because they were considered unwell and in need of treatment.[82]

106. A 1999 review of forensic services found that most service forensic users have offences that are classed as ‘serious’ (violent or sexual). The review also found that the most common referral pathway into this setting has been through the courts, with prison being the second highest referral source. [83]

107. While forensic service users can be inpatients or community-based, forensic services remain more institutionally focused compared to other adult mental health services.[84]

108. The 1999 review found all but one inpatient service user was ‘under legislation’, such as the Criminal Justice Act 1985 or the Mental Health (Compulsory Assessment and Treatment) Act 1992. [85] While 41 percent of outpatients had informal or voluntary legal status, many had previously been inpatients under one of these Acts. [86]

Footnotes