From the 1870s to the 1970s: the Changing Face of Public Psychiatry in South Australia

ASYLUMS

When the colony of South Australia was first established in 1836, there being no provision for lunatics, as those with a mental illness were then called, they became unwelcome cohabiters with the other inmates of the Adelaide Gaol, the felons apparently objecting to sharing their accommodation with the pauper insane, many of whom were often noisy, dirty, and difficult to control. In 1841 the Board of Pauper Lunatics was established to address this problem and suggest an appropriate alternative. However, because no one was prepared to be responsible, and because by 1841 the colony was close to bankruptcy, and the newly arrived Governor (Grey) had restricted public expenditure and brought a halt to public building, nothing was done.

In April 1846 a house with eight rooms and a small cottage was rented on the Eastern plains, the site on which Parkside Lunatic Asylum was later to be built, but because this house was not large enough to house all of the lunatics, many remained in gaol until 1855. In 1852 a new asylum, Adelaide Lunatic Asylum, was built on the parklands at the eastern end of North Terrace, on ground overlooking the Botanic Garden. However, within 10 years this had also become overcrowded and planning was begun for another asylum. Although Adelaide Lunatic Asylum was considered to be below standard, it remained in use until 1902, when its last patient was finally transferred to Parkside Lunatic Asylum, which had been opened in 1870 to house 700 patients.

In his book Lunacy in Many Lands, George Tucker describes what were believed to be the chief causes of insanity at the time. He had visited asylums all over the world, including Parkside and the Adelaide Asylum on North Terrace, and describes the prevailing opinions as follows. ²

But it was not only those who were considered insane who were admitted to the new Parkside Asylum, as is made clear in the annual report of the Resident Medical Officer, Dr Alex S. Paterson, in 1871. There had been an unusually high number of deaths, and by way of explanation he comments as follows. ³

In his book commemorating the centenary of Glenside Hospital, as Parkside Asylum was later to be called, Harry Kay quotes the text of an article published in the Observer on 29 January 1876, which describes in vivid detail a visit to the asylum and the conditions that prevailed. ⁴ Kay also describes the asylum's silkworm industry. Apparently, by 1876 over 2000 mulberry trees had been planted in the Parkside grounds to provide food for the silkworms, which were tended by some of the patients, and the silk from which was sent to Italy and France for weaving into cloth.

By 1909 it was clear that Parkside, now with 1051 patients, was overcrowded, and the 1909 Report of the Parkside Lunatic Asylum Management Inquiry recommended the purchase of land, approximately 800 acres, a few miles to the north of the city. ⁵ It was considered that a farm environment would be both therapeutic for the inmates, and profitable for the institution. Unfortunately, financial constraints were again to intervene in the expansion of facilities for the mentally ill, and in September 1916 the Mental Defectives Board decided that the building of a large mental hospital in the North should be postponed until the finances of the country were in a more ‘buoyant’ condition.

In 1913 the Mental Defectives Act was passed. ⁶ It marked the official change in nomenclature from lunatics to mental defectives. Although this change to our ears may sound less than enlightened, the intention was to create a more modern definition. But the umbrella term ‘mental defective’ still encompassed both mental illness and mental retardation, and it was not until the Act of 1964 that two types of mental defect were defined: mental deficiency, and mental illness. ⁷ It was also recognized that the term ‘mental hospital’ was more appropriate than ‘lunatic asylum’, with all its gothic images of horror, and so in 1913 the Parkside Lunatic Asylum changed its name to Parkside Mental Hospital. The Mental Defectives Act of 1913 also provided for the establishment of a receiving house, a place for the observation and temporary treatment of potential patients, which would avoid the sending of at least some of them under certification to the mental hospital. A moving account of the treatment of patients at Enfield Receiving House during the 1950s can be found in John Cawte's book, The Last of the Lunatics. ⁸ As early as 1908, Dr J. Cleland, the then head of the Parkside Asylum, had suggested the need for such a place, where voluntary patients could avoid the stigma of certification. He had observed the comparative brevity of stay of many patients (more than one-third remained within the hospital for less than 1 month, and more than half were discharged within 3 months), and considered that many of these people could have been spared the stigma of admission to a lunatic asylum, had there been some place connected with a general hospital where they could receive treatment as uncertified patients. ⁹ It seems that the preoccupation with providing a treatment environment, which would avoid the stigma of mental hospital admission, has a long history. Although the Act of 1913 provided for the establishment of receiving wards in country and public hospitals, these did not eventuate, and it was not until the 1960s that beds for psychiatric patients were provided in general hospitals, and not until the 1970s that psychiatric wards appeared. Prior to the 60s there had been psychiatric clinics in some of the hospitals but no beds were available for inpatient treatment.

In his annual report for the year 1913, Dr Cleland also suggests the following. ¹⁰

One wonders if the local medical practitioners would have responded favourably to this scenario. Fortunately, it did not eventuate.

Because of the state's financial situation, and the importance given to the receiving house concept, in 1922 Enfield Receiving House finally opened with 48 beds, but it was not until 1926 that work commenced on the nucleus of Northfield Mental Hospital. The first block to be built was Ward 5, to accommodate 25 ex-soldier mental patients. By 1927 a block for farm-working chronic patients was also under construction. Even before it was completed, the government of the day was being urged to provide accommodation for a further 200 patients (100 male and 100 female), although female patients were not admitted to Northfield until 1937. In 1929 Northfield Hospital (later to become Hillcrest) was officially opened. It was modelled along quite different lines from the previous institutions built in South Australia, and followed the ‘cottage plan’, an idea developed in Europe in the mid 1800s. Under this system, patients could be distributed into a number of smaller buildings, and segregated according to the nature and severity of their affliction rather than all housed together in one massive building. Unfortunately some of the potential advantages of this plan were lost because it was not until after 1962 that each building began to be used for a specific purpose. Whereas Parkside had its olive groves, cottage gardens, and mulberry trees for its silkworm industry, Northfield had its farm. In the report of the Inspector-General of Hospitals, Dr B. H. Morris, for 1929, the farming activities, and their therapeutic and commercial value, are described. ¹¹

Patients remained unpaid for these labours until 1966 when a token payment of 5 shillings was made per week. Conditions at Northfield between 1929 and 1960 are described in detail in Averil G. Holt's book Hillcrest Hospital: The First 50 Years, ¹² commemorating the golden jubilee of the hospital.

In 1940 all building at Northfield came to a halt and was not resumed until 17 years later, when Ward 8, Howard House, was opened to house the female tuberculosis patients from the three mental hospitals. The ward was built using Commonwealth funding made available under the conditions of the Tuberculosis Act of 1945, which specified that grants be provided to states for capital and maintenance expenditure on tuberculosis hospitals. The building of additional wards at Northfield did not alleviate the accommodation problem, which was further complicated by increasing numbers of admissions of mentally retarded children from Minda Incorporated, a training home at Brighton for intellectually retarded and epileptic children, which was involved only in the treatment of less severe cases. The more severe cases were sent either to Parkside or Northfield. In 1952 Minda redefined its policy to accept only children between 6 and 12, and admissions to the two psychiatric hospitals increased. At both Parkside and Northfield, female patients helped to care for the mentally retarded children who were often completely dependent, providing them with at least some mothering, in a situation where, without their help, the staff would simply have been unable to cope.

In 1943 Dr Bill Dibden, who was later to become the Director of Mental Health Services, had been asked to establish an outpatient psychiatric department at the Repatriation General Hospital. His other commitments were such that he was able to provide only a single session per week. This was increased to two in 1945. Alan Stoller, in his report on mental health facilities and needs of Australia, reported that in 1954 ‘A very wide range of psychotherapy was applied’. This contrasted markedly with his criticisms of the situation at the two mental hospitals. ¹³

In 1951, Dr Birch, who was then Superintendent of Mental Institutions, had submitted a recommendation for a new type of hospital specifically to cater for the care and training of the mentally retarded. He alludes to this in the Annual Report for that year. ¹⁴

This much-needed accommodation did not eventuate until Strathmont Centre was opened in 1971, nor was there an increase in Northfield's bed capacity, the addition of further wards at Northfield being dogged by considerable delays because government funding was spent on other priorities. This was lamented by Dr Birch in his last Annual Report in 1961. ¹⁵

In 1962 Dr Bill Salter became Superintendent of Northfield Hospital, having been Deputy Superintendent since 1946. He was particularly concerned that patients should be given increased freedom wherever that was possible, and paid tribute to the role that Russell Barton's book, Institutional Neurosis, ¹⁶ had played in his realizing that patients were being turned into ‘zombies’ due to the restrictive way that they were cared for. In 1957 a Patients’ Representative Committee was established in an attempt to encourage patients to take an interest in their own lives and the life of the hospital community. This committee consisted of both patients and staff, and met weekly to discuss and contribute ideas for the improvement of the patients’ welfare. Staff were encouraged to offer ideas and these were often implemented by Dr Salter, although it seems that it was so difficult for him to persuade Dr Birch (who was of a much more authoritarian disposition) that these more progressive methods should be implemented, that he finally took the simple expedient of taking action, and later advising Dr Birch what he had done; to paraphrase Dr Salter – sparing Dr Birch from making those awful negative decisions.

Although it seems that Dr Birch was in many ways authoritarian, and was generally considered parsimonious in his administration, nonetheless his concern for the welfare of his charges is evident in the annual reports he wrote during his time as superintendent of Parkside, and director of the mental health services. For example, although the introduction in the mid- 1950s of chlorpromazine and the ‘tranqillizing’ drugs meant that many long-term patients improved dramatically, he cautioned against regarding them as some sort of panacea. ¹⁷

With many long-term patients improved to the extent that they could contemplate survival in the outside world, the need for community and voluntary support grew. The Marjorie Black Club, the role of which was to facilitate the social rehabilitation of ex-patients, was sponsored by the South Australian Association for Mental Health in 1961, and in 1965 a property was purchased to house it. The premises were named after Miss Marjorie Black, a retired schoolteacher and hospital visitor who had established the club in 1956, and who had approached the Mental Health Association for support because she felt that it had reached a point – it had a membership of 132, most of whom lived in boarding houses – where it would benefit from being administered by a committee that she hoped would be sponsored by the Association.

The South Australian Association for Mental Health had been established in 1956. It counted many eminent South Australians among the members of its Council, which held its first meeting, chaired by its President, Sir Herbert Mayo, in November of that year. Dr Bill Dibden was actively involved in the formation of the Association, and was a member of its council. It was the Association that actually raised the money to pay for the establishment of a Chair in Psychiatry at the University of Adelaide. In 1958, when the need for a Chair was being discussed, Professor W. H. Trethowan, Professor of Psychiatry at the University of Sydney, was invited to address a public meeting in Adelaide. He also agreed to provide a report to the Mental Health Association on South Australia's requirements in the field of mental health. Professor Trethowan delivered the inaugural Barton Pope Lecture, ‘Man's progress towards the goal of mental health’, in June 1959. This was the first in what became an annual series named after Mr S. Barton Pope – later Sir Barton Pope – a member of Council, and Vice President of the Association, who had offered to donate £100 towards the cost of organizing the lecture, and who later made further donations to be invested to provide funds for the cost of future lectures. The Barton Pope lectures continue to be presented on an annual basis. Professor Trethowan also delivered his report to the South Austral- ian Association for Mental Health, and it was printed for circulation at their expense along with a second report by John Cawte.

From the quotes that follow here it can be seen that these reports would also have contributed to the impetus for change. ¹⁸

By July 1961 the South Australian Association for Mental Health had already raised sufficient funds to fund the Chair in Psychiatry for the first 3 years, and at the end of 1962 Dr Bill Cramond was invited to take the Chair in Mental Health at the University of Adelaide. The suggestion that it would be more appropriate to create a university chair in mental health rather than in psychiatry had been Bill Dib- den's, but it was strongly supported by Professor Trethowan in his report. ¹⁸

THE WALLS COME DOWN

The 1960s saw the acceleration of change and improvement in the lot of psychiatric patients. Dr Bill Cramond, a very different personality from Hugh Birch, became the Director of Mental Health in 1961 and, with the fortuitous combination of his strong commitment to change, a liberalizing shift in the social climate, and the impetus, provided by some rather stringent criticisms offered by Stoller in his report for the Government to provide long-needed increased funding, ¹³ the way in which people with mental illnesses were treated underwent a transfor- mation.

In October 1961 Dr Cramond submitted a report to the Chief Secretary and Minister for Health for South Australia, Sir A. L. McEwin, in which he outlined his recommendations for changes to the mental health services. ¹⁹ Included were the creation of a day hospital, a sort of halfway house for patients on the way in or out of hospital, the introduction of outpatient clinics at Parkside and Northfield, the decreasing of ward size from 90 to 100 patients to wards to accommodate 40–45 patients, the provision of decent clothing for long-term patients, instead of the stand- ard hospital clothing they had previously worn, the improvement of training for psychiatric nurses, an increase in the number of trained social workers, the appointment of trained occupational therapists, and improved training for medical staff. Dr Cramond also proposed that planning should begin at once for a new 800-bed facility for the intellectually subnormal.

Until this time, many of the wards at Parkside had been enclosed by stone walls and ha-has, 3.6 m-high 1 cm cyclone mesh or galvanized iron fences. Now high walls and bars on windows were removed and many hitherto locked wards became open wards, where patients could come and go as they pleased. But these were merely the obvious visible signs of the major changes taking place throughout the public psychiatric system. By 1962, patients were classified according to age, social behaviour, and whether they were mentally ill or intellectually retarded, and assigned to different wards on this basis. In the past they had been segregated not according to diagnosis but according to sex, and whether or not they were continent in their beds. The state was now zoned into north and south regions, with the dividing line being the River Torrens from the sea to Mount Pleasant, Northfield catering for the northern zone, and Parkside for the south. Newer therapeutic approaches were adopted, and the concept of the therapeutic community gained increasing momentum and support. Child psychiatric services became established on a statewide basis, having expanded from their early beginnings at the clinic at the Adelaide Chil- dren's Hospital in the 1930s. ¹⁹

Great strides were made in the training of psychiatric nurses. Previously, training had consisted of only 36 h of medical lectures over 3 years with the addition of another 12 h from a senior nursing sister. In 1963, the Nurses Registration Board of South Australia became responsible for setting the examinations and supervising the training and syllabuses, and the number of hours of lectures increased to more than 200. Schools of nursing were established at both Northfield and Parkside in 1966, at which time lecture hours increased again to over 350. Later, psychiatric nurse training in South Australia was to become a post-basic qualification that could be undertaken only by those who had completed their general nurse training.

There was a clear need for more social workers – at this time there was one qualified psychiatric social worker at the Child Guidance Clinic, a qualified social worker at Parkside and Enfield, and an unqualified and relatively inexperienced worker at North- field. By 1964 a cadet scheme for social work students had been established, but still it was difficult to attract social workers to the psychiatric hospitals. It was then that a Mental Health Visitors course was established under the direction of Barbara Franck (later Auld), the social worker at Parkside. It provided inservice training along social work lines to people who might have relevant experience, languages other than English, or particular skills that would be suited to this kind of work. Barbara published two papers on this highly successful programme. ²⁰ , ²¹

In the 1960s the South Australian training programme for psychiatrists became firmly established under the direction of Dr John Clayer, who was eventually to become the first Director of Post Graduate Training, Research and Development. It was he who established a series of trial examinations in the third and final year of their course to rehearse candidates for their membership exams. This strategy proved very successful, and South Australian pass rates were high.

In 1963 the first qualified occupational therapists were employed at Parkside. The 1960s also saw the development of industrial therapy in which patients, and ex-patients who were not yet able to compete in a normal employment environment, were paid to work in a sheltered industrial workshop. Although payments were small, it was felt that this experience would provide them with motivation and give them a sense of being part of the community workforce. This was already established in Victoria but it needed support from industry to establish facilities in South Australia. Industrial therapy began in an old store in 1964, but by 1969 Invicta Workshops had been established in a new building, built at a cost of $103 000.

Dr Cramond resigned as Director of Mental Health in 1965, having decided to give up the dual role of Director of Mental Health and Professor of Mental Health, and to concentrate on his academic responsi- bilities. Dr Brian Shea became Director of Mental Health, but was soon to be appointed as Director General of Medical Services. In 1967, Parkside Mental Hospital changed its name to Glenside Hospital and, for the first time, all mention of mental illness was expunged from its title. Northfield Mental Hospital had already changed its name to Hillcrest Hospital in 1964.

In 1968 Dr Bill Dibden became Director of Mental Health Services, a position he was to occupy until mid-1978, when he became Director General of Med- ical Services. He had worked as a resident medical officer at Parkside Mental Hospital from 1943 to 1946, during which time physical methods of treat- ment such as electroconvulsive therapy, full-coma insulin therapy and, later, prefrontal leucotomy were being used. In fact it was at Parkside that electrocon- vulsive therapy was administered for the first time in Australia. It was given by Dr Birch, using a machine that he had built himself, because there were no machines available in Australia at that time. These treatments seemed to offer the possibility of patients getting better, and doctors, lacking other means, administered them to patients who were often considered to be too incompetent to give consent, and who were therefore not asked. Such attitudes would not be tolerated today when paternalism, however well intentioned, is frowned upon. Later he was to reflect: ¹⁹

Dr Dibden became aware that many eminent professionals were very critical of psychiatric practice and theory. He had been influenced by the ideas of Thomas Szasz, ²² Barbara Wootton ²³ and William Sargant; ²⁴ and he describes in his book ¹⁹ the development of his involvement with the drafting and passing of a new Mental Health Act. He acknowledges that he was influenced in his thinking by a University of Adelaide law student, T. S. George, who in 1971 completed an honours thesis, the subject of which was a critical examination of the criteria for admission and discharge of patients under the South Australian Mental Health Act, 1935–1963. ²⁵ One of the major concerns of the new Act was the rights of patients, and the Act contained specific provisions to protect them from wrongful detention. ²⁶ It was an Act that also provided for the establishment of a Guardianship Board and a multidisciplinary Mental Health Review Tribunal, concepts new to the mental health area. He was later to say that his greatest satisfaction during his time as Director of Mental Health Services came from the elaboration of the education programme for psychiatrists in training and the evolution of the new mental health act. ¹⁹

During Dr Dibden's time as Director, Strathmont Centre for the intellectually disabled was completed and opened in 1971. Two centres had been proposed initially. Strathmont Centre was to be built on land adjoining Northfield Hospital and, later, Elanora Centre was to be built south of the River Torrens at O'Halloran Hill. However, the second centre was never built. Strathmont's design was very different from the two psychiatric hospitals. Originally it had been planned to build villa units that would house 24 people, the units being arranged to form blocks of 48 beds. However, Mr Joe Craig, the Public Buildings architect responsible for its design, attended a conference in Copenhagen in 1966 where he delivered a paper on the proposed design, only to discover that the prevailing thinking in Scandinavia was that it was critical that units should house no more then a maximum of 12 people, and that the design should be such that it was impossible to exceed this limit. He returned to Adelaide and redesigned the units. In the final design approved for construction, most villas contained four units of eight beds, or 32 per villa. In his travels in Europe he was repeatedly to hear that the design of such facilities should be primarily to create the sort of place one would like to live in oneself. In other words, the design should be for people; the fact that they were subnormal or retarded should not be the guiding principle. These principles were to be translated into the design of future psychiatric wards built at Hillcrest and Glenside.

In 1973, Northfield Security Hospital was opened to house the criminal mentally ill. ¹⁹ Prior to this, they had been kept in the notorious Z Ward at Parkside. The problems inherent in having a criminal maximum security unit within the grounds of a mental hospital had been compounded at Parkside by the fact that only a small section of Z Ward was actually gazetted as a hospital for criminal mental defectives. In 1987 the security hospital was replaced by James Nash House, built within the grounds of Hillcrest Hospital. It was the first purpose-built unit for the treatment of prisoners with a psychiatric illness within a psychiatric hospital in Australia. The devolution and consolidation of services from Hillcrest Hospital to Glenside and community-based services began in 1992, and the hospital has now closed, but James Nash House still operates as a forensic psychiatric facility.

By the 1970s, mental health staff included psych- iatrists and trainee psychiatrists, psychiatric nurses, psychologists, social workers, physiotherapists, occu- pational therapists, pharmacists, chaplains, and an art therapist. Later, a music therapist was appointed. Limited psychiatric services were provided to country areas, community clinics and hostels had been estab- lished, and psychiatric wards were being introduced in the general hospitals. While fully qualified allied health staff had tended to become an accepted part of the service in the 1960s, there had been some notable precursors. Ruth Bright, later to become world renowned for her work and publications as a music therapist, worked at Parkside in the 1950s. She was a musician who was interested in music therapy and she came to the hospital on a voluntary basis. At first, she started with singing sessions in the female admission ward but later, buoyed by her success in the admission ward, she started a choir in one of the female back wards. Apparently some of the patients who had been mute for years joined in and began to sing, although they still did not speak. There was also an artist, John Morley, who used to do art therapy in the back wards on Sunday mornings. He managed to get profoundly retarded people with no language, who were doubly incontinent and who had great difficulty in relating to people, to produce beautiful paintings on the glass windows. Morley himself filmed this and produced a documentary called Every Sunday Morning. Unfortunately, it appears that the film has not been preserved.

In 1973 a psychiatric library was established at Glenside. Its role was to provide a service to mental health staff throughout the state, a rather ambitious undertaking with one librarian, a few books and journals, no clerical staff and no money. Fortunately the situation was rapidly rectified and the library prospered. In 1996 the library's collection was merged with the Barr Smith Library at the University of Adelaide, and the service continues to be provided on a statewide basis. Utilizing the University Library's highly developed technological infrastructure, a mental health web site ²⁷ has been established to deliver information not only to the Government's mental health staff, but also to private practitioners and the general public. The University has also published on its web site Dr Dibden's Biography of Psychiatry, a biographical account of the history of psychiatry in this state from 1939 to 1989. ²⁸ After his retirement, Bill was persuaded by Professor Ross Kalucy, from Flinders University, to embark on the writing of this history. He conducted, and taped, interviews with a number of psychiatrists, and others, who had been involved with the development of the mental health services in South Australia, and from the material he gathered he produced the book. It is rare to have such an account of psychiatric history (the tapes are also preserved), and this perspective complements other documents which, of necessity, are devoted more to facts and figures and publicly available sources, and less to personal experience. It is rarer still to have such a personal account of the vicissitudes of the drafting and passage of new mental health legislation.

CONCLUSION

While the early days of public psychiatry in South Australia may seem isolationist and restrictive, this needs to be seen in the context of the history of psychiatry worldwide. Certainly from the outset, the mentally ill had their champions from within the asylum system, many of whom were only too aware of the limits of their treatment options, and were concerned to advance the progress of psychiatric care, to increase the freedom of their patients whenever the opportunity arose and, if possible, to spare them the stigma of detention in an asylum. Repeatedly, advancement in the provision of better facilities was baulked at by governments that either lacked the funds or simply gave higher priority to other causes but, as in other states, ²⁹ the ideas of ‘normalization’, of moving the treatment of mental disorders into the mainstream of health care, and of shifting treatment focus from hospital to community, were evident long before the deinstitutionalization movement made its official appearance.