People with mental illness falling through the cracks

Concerns are growing about the number of mentally unwell people spending repeated time in prison and then falling through the cracks when they return to the community, sometimes with tragic results. Bruce Munro looks at the statistics and talks to those affected and those calling for change.

Prisons are New Zealand's largest mental-health institutions.

The streets are our second largest.

Once upon a time we locked up everyone who was not "normal" and "good".

They were the "mad", the "bad", the "sick" and the "disabled". And we had a different place for each of them - asylums, prisons, hospitals and infirmaries.

But then we closed most of our mental hospitals and sent the vast majority of the residents on their way. The cracks in care yawned wide, people with mental illness got into trouble or did terrible things, and we often put them in the only place left - prison.

Today, mental illness is rife among the more than 8600 men and women in our country's 19 prisons. More than half have lifetime psychotic, mood or anxiety disorders. Twenty percent are "thinking a lot about suicide", and nearly 60% have mild to severe personality disorders. The vast majority of prisoners with mental illness have the added complication of long-term substance abuse.

And when they have done their time, we send them out again.

Vincent [surname withheld] was released from prison for the eighth time earlier this year.

Of Ngati Porou descent but raised by a Pakeha family in Otago, he has been incarcerated for 17 of his 39 years. That does not include two years in Cherry Farm psychiatric hospital, north of Dunedin, where he was diagnosed with paranoid schizophrenia at the age of 15.

Nor the year spent at Dunedin's Wakari psychiatric hospital after Cherry Farm was closed in 1992. Nor a year at Hillmorton Hospital in Christchurch ...

With nowhere to live when he was released from Milburn's Otago Corrections Facility in February, Vincent slept under bridges and in Dunedin car parks for about a month and a-half, until he got into trouble again.

"There were meds in prison, but I stopped taking them," he said.

"I suppose I was fighting the system. I was angry, not sleeping, not taking my meds.

"I thought I could be well but I wasn't ... I came out a mess."

After several weeks living rough, and in an agitated state, Vincent wanted to be admitted to Wakari Hospital but was told there was no room. He was given some medication and told to come back the next day. He took all the pills at once and then, sometime after 5pm, entered the yard behind the South Community Mental Health premises and used rocks and a chair to do $50,000 worth of damage to vehicles parked there.

"Whenever I do my crime, I've always showed remorse and done my time," he said.

"I'm just really pleased those cars weren't people that day."

The judge ordered Vincent to pay $3000 reparation and gave him a six-month home detention sentence so he could continue a community drug treatment programme.

Since then he has been living in a boarding house off High St, in Dunedin, with about 13 other tenants who are former prisoners, former mental-health patients or both.

In the late 1800s this part of town was known as the Devil's Half-Acre, a notorious triangle formed by Princes, Maclaggan and Maitland Sts where slumming, sweated labour, prostitution and drugs were commonplace.

More than a century later its legacy continues in the form of sometimes squalid rental properties housing dozens of ex-inmates and former psychiatric patients.

It is where community worker Carol Frost witnesses poverty and despair on a daily basis.

"It gets you down. The hopelessness of it is soul-destroying," she said.

"We see the same people over and over, and try to help them.

"If they have family support it's difficult but not impossible.

But if you have no-one to support you and make sure you take your medication and pay your rent, you deteriorate.

"If you are living in a dive and all the people around you are drunks and drug addicts, what chance do you have?

" It was a catch-22 situation, she said. They find it hard to get accommodation, and at least the landlords give them a roof over their heads. Some of the houses are run down, but if they were spruced up their present tenants would have nowhere to stay.

New Zealand "threw out the baby with the bathwater" when it closed most of its mental hospitals during the 1990s, Mrs Frost said.

She lists the problems her clients face. There is not enough support and care in the community for people with mental illness, Wakari Hospital's emergency psychiatric beds are almost always full, and the wait for help from the Community Alcohol and Drug Service can take weeks, she says.

Add to that discrimination by prospective employers and you truly have "a vicious cycle".

The cases she knows of, involving people with mental illness who have been in prison, are as plentiful as they are sad: someone living under bushes near Dunedin's Otago Settlers Museum during the past winter until the bushes were removed; a man presently living under trees in the city's Town Belt; another recently returned to prison for parole breaches ...

"When he takes his medication he feels good," she says of the man sent back to prison.

"So then he feels he shouldn't have to take it and so he gets in trouble.

"A number of mental-health people are thrown in jail because there is nowhere else to keep them and others safe.

"At another time they would have been in a secure place, where they would feel secure." Mrs Frost thinks an effective solution would require "lots of money and a change of attitude from government and society".

"But that won't happen. We've become too selfish," she adds.

Dr Warwick Brunton, of the University of Otago's department of social and preventive medicine, said that for more than 100 years we locked up an increasingly wide variety of people who threatened or concerned us.

But by the 1970s there was a growing realisation that a proportion of those in mental hospitals did not need to be there.

"A 1974 survey showed a quarter of all patients with a psychiatric diagnosis, and 45% of those with an intellectual handicap diagnosis, were capable of independent living," Dr Brunton, who is a mental-health policy researcher, said.

This late-blooming tolerance did not result in much change at the time, but was used by those promoting fiscal austerity in the 1980s to help justify the wholesale closures of the 1990s.

In the course of a few decades New Zealand went from 10,000 state psychiatric hospital beds to fewer than 1000.

The aim, since the mid-1990s, has been for the Ministry of Health's specialised mental-health services to care for the 3% of the population with the most severe mental illness, while primary health services cater to the remaining 17% with mild to severe mental illness.

It is often community organisations, such as the New Zealand Prisoners Aid and Rehabilitation Society and churches, who end up having the most regular contact with the more unwell component of this larger cohort.

The Rev David Brown, of Church of Christ Community, says "mental-health difficulties" are common among the 40 to 70 people who turn up to the Dunedin church's St Andrew St drop-in centre on Friday evenings. Some of the regulars have been in and out of prison several times.

"You often see them function well for a while and then go downhill and get in trouble and go to Wakari [hospital] or prison, and then it all starts again."

They have become the detritus of 21st-century life, he says.

People with mental illness living in the community used to be able to find work, often low-skilled, which gave them something useful to do and a group of people to keep an eye on them.

"But now there is no place where they fit and no sense of dignity. How do you feel hope?" Mr Brown asked.

"Society runs on this super-efficient model. But it means we leave a whole lot of people behind. We need to provide them not just with benefits but also a place in society."