The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises that continuous improvement in psychiatry and mental health care requires recognition of harm caused by some practices in the past. This Position Statement, prepared by the RANZCP Community Collaboration Committee, a constituent committee of the RANZCP Practice, Policy and Partnerships Committee, acknowledges that psychiatrists have a critical role to play in acknowledging historical harmful practices and committing to learn from them. This includes being open to constructive questioning of current mental health practices which may have harmful consequences.
The RANZCP is committed to improving the lives of people with mental illness through the highest-possible standards of practice by psychiatrists and mental health services.
Many factors contribute to recovery from mental illness, including an understanding of recovery, the person and their supporters, clinical treatment, psychological therapies, psychosocial rehabilitation, and ongoing supports in the community (RANZCP, 2016),. A recognised barrier to accessing this treatment and support, however, is the stigma regarding mental illness which deters many people from seeking help. A significant aspect of this stigma is persistent, widespread misunderstanding in the general community about the nature of present day psychiatry, modern mental health care, and those who provide it. This perception is largely rooted in a ‘folk memory’ of past practices which caused fear and sometimes harm, but which have no part in modern psychiatric care.
The stigma and misunderstanding persist due to a number of factors. Public attitudes are significantly influenced by entertainment and news media which can give a sensationalised, highly misleading impression of psychiatry and mental health services. When people have been affected by harmful practices in the past, this understandably informs their attitudes today, which may then be shared with others. In order to effectively communicate the nature of modern psychiatry and promote improved mental health, therefore, the College has a responsibility to explicitly acknowledge any harm caused by past practices, and to learn from these in order to provide the most effective care now and in the future.
Practices now known to be harmful had a range of causes. They included both systemic approaches to care and individual practices. Some historical treatments may have been well-intentioned but were without an evidence base, ineffective, and distressing to experience. Treatments also may have been used inappropriately (for example, past administration of electroconvulsive therapy without anaesthetic, or even as a punishment rather than a therapy).
An entire model of care – the asylum system, which dominated mental health care for the nineteenth and much of the twentieth century – often disregarded the dignity of those it was intended to care for and protect. Until the development of antipsychotic medications in the mid-twentieth century, there was certainly an argument for such facilities which could provide genuine care and a place of ‘asylum’ for the residents. At the same time, they institutionalised inhumane practices which would have been unacceptable beyond their walls. In time they became feared by the public, with reputations for overcrowding, brutality, separation of children from parents, and permanent exclusion from society (Miller, 2012). A whole series of Royal Commissions in Australia and New Zealand (for example, into Callan Park and Claremont hospitals) confirmed that, for some, these fears were well-founded.
Adverse and harmful events have also occurred in general hospitals, specialist psychiatric facilities, and private hospitals (for example, at Lake Alice, Townsville General, and Chelmsford hospitals), and through unacceptable behaviour by individual psychiatrists towards their patients (such as sexual exploitation).
As well as contributing to stigma and misunderstanding about modern mental health care, these practices have led to persistent attitudes in the public mind towards psychiatry and a ‘fear’ of psychiatrists (Rubinstein and Rubinstein, 1996). In addition to improved, humane and evidence-based treatments, further systemic measures to counter these misperceptions have included the various Mental Health Acts in Australia and New Zealand, Official Visitors Programs, Mental Health Commissions, the RANZCP review of its governance structure, and mandatory reporting policies.
Others areas are acknowledged as needing improvement. For example, the College is committed to the minimisation, or elimination as much as possible, of seclusion and restraint (RANZCP, 2015). This Position Statement complements the College’s commitment to support all actions that deliver improved mental health care and outcomes for people affected by mental illness in a safe, effective way, regulated by formally-approved protocols and policies. This explicit commitment is required by the community, as well as to support psychiatrists and other professionals working in the mental health system.
Despite these changes, the legacy of past practices is still with us, and may be for some time to come (RANZCP, 2016). The asylum era not only affected those living with mental illness and their families, but those treating and caring for the mentally ill too. It also continues to affect attitudes towards people with mental illness, psychiatry, and mental health services, acting as a barrier to help-seeking by those who need diagnosis, treatment and support. Acknowledging and learning from this legacy is therefore essential to mental health care in Australia and New Zealand.
Mental health care refers to the broad range of treatment, psychosocial rehabilitation, and support options for those who experience symptoms of any form of mental illness or psychological disorder.
As well as evidence-based medical treatments and psychosocial rehabilitation, this care is also shaped by legal frameworks which are periodically updated and can vary between jurisdictions, although they are broadly in agreement. Because of the vulnerability of people when a power imbalance is present, such legislation defines certain aspects of mental health care, such as the circumstances regarding involuntary treatment and forensic care, for example, with safeguards to protect the person affected as well as the community. Psychiatrists and other mental health professionals are bound to follow these laws, in combination with guidance on values and practices from their professional bodies and the current literature.
In order to meet this challenge of addressing legacies of past practice in psychiatry which hinders effective mental health care, the College is reaching out to the wider community to encourage dialogue and partnerships. The RANZCP Community Collaboration Committee is one of the College’s principal avenues to do this. It facilitates and promotes understanding of the hardships, prejudices, and isolation experienced by people affected by mental illness, their families, whanau, and other carers, in order to drive a change of culture in psychiatry to make it more open and community-friendly. Through the work of this Committee, it has been confirmed that the impact of harmful practices in the past has led to an emotional legacy which is a barrier to development of a mutually respectful and trusting relationship with the psychiatric profession. Attitudes towards the mental health system and those who work in it, then, continue to be affected by past practices, especially those in the large psychiatric institutions, and by the professional attitudes which sometimes flourished in those environments (Miller, 2012).
This continuing impact is very real for many psychiatrists too. Careers and professional attitudes were shaped during this ‘institutional’ era when disrespectful or potentially harmful practices (intended or not) were more common. More recently-qualified psychiatrists and trainees may even see elements of such attitudes among their colleagues, and need to be ready to identify them as such.
There is an increasing evidence base regarding the complex interactions between the mind, brain, and environment, including the effects of highly stressful or traumatic experiences. It is imperative that the College and psychiatrists acknowledge the ongoing impact of past harmful practices in mental health care. Furthermore, while acknowledgement is necessary, it is insufficient on its own. We are also obliged to learn from understanding these past practices and events, and commit to using these lessons to improved current and future mental health care.
As the last standalone psychiatric institutions are closed or altered fundamentally from their role of ‘asylum,’ it is too easy to think these challenges are behind us, and that once acknowledged, the community simply needs to put aside outmoded perceptions and ‘catch up’ with modern psychiatry. It is not so simple however. Many of the root factors implicated in reviews of adverse events in mental health care are still in existence, and have the potential to cause harmful effects in the future.
Psychiatrists are under constant professional and ethical pressure when practising in circumstances and conditions that inadequately meet the needs of people with mental illness and their families, for example when resources in public mental health care are limited or systems are sub-optimal (Bloch et al, 1999). Ethical vigilance in such circumstances should be maintained while providing care and taking into consideration any adverse outcomes that may arise.
Learning from experience, including adverse events, is an integral aspect of improving healthcare outcomes (Canadian Medical Protective Association, 2009). Root cause analysis of these events emphasises the importance of looking beyond the immediate details of an event to find contextual and contributory factors that allowed the development of a situation where harm could occur. While most commonly applied to individual adverse events, systems and practices which cause harm can also be reviewed in this way.
In New Zealand, the Protected Disclosures Act (2001) was drafted to encourage people to report serious wrongdoing in their public or private workplace by providing protection for ‘whistleblowers,’ following the case of mental health nurse who was initially dismissed for revealing that a violent forensic patient was being inappropriately discharged into the community (New Zealand Parliament Hansard, 2007). Similar legislation exists within Australian state jurisdiction and within the Australian Public Interest Disclosure Act (2014).
Psychiatrists have a critical role to play in acknowledging historical harmful practices and committing to learn from them. This includes being open to constructive questioning of current mental health practices which may have harmful consequences.
- acknowledges the ongoing impact of past mental health practices, and commits to learning from them, with continued vigilance of current practices to prevent harm to people with a mental illness
- commits to including, in the core psychiatry training curriculum, relevant facts about past harmful practices and evidence of their ongoing impact
- commits to developing strategies to reach out to communities which may still feel the impact of past harmful practices, and continually improve them by establishing close relations, dialogue, and partnership
- commits to equipping psychiatrists to be sensitive when dealing with patients affected by harmful practices in the past, and to understand the consequences of traumatic memories in the present
- expects psychiatrists to show leadership, empathy, and understanding regarding past harmful practices, and to support any healing initiatives
- encourages people to openly discuss and acknowledge the past, without any thought of retribution or litigation (Miller, 2012).
The RANZCP acknowledges the valuable input, presentations and materials developed by all members of the Community Collaboration Committee, past and present, on this subject.