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Chapter 2: Research
2.1 Research 2.2 History of care 2.3 Evolving models of care 2.4 Specific youth needs 2.5 Navigating complexities
Key findings
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The model of care is changing, but buildings are not changing with it
Many existing mental health services do not address the specific needs of adolescents and young adults
Services that are available to young people are complex and difficult to access.
2.1 Research
How is mental health care being delivered? How can we remove the barriers to accessing care?
The history of mental health care in New South Wales provides significant insight into changing approaches and perceptions of mental illness in the modern era. In the late 19th century, there was a shift towards a moral and humane approach for those suffering from mental illness. This new approach to care was focused on dignity, compassion, and comfort. However, declining investment over the years led to neglect, mistreatment, and abuse, well documented in a series of reports and royal commissions. Renewed investment in mental health care and social awareness led to rapidly evolving approaches to treatment. A person-centred, recovery-focused model has led to a significant reduction in acute lengths of stay, with a higher focus on outpatient care and improved selfmanagement of care in the community. In recent years, a trauma-informed perspective is being integrated into care models, requiring more individualised treatment approaches. However, there is a need for the physical environment to be adapted to meet diverse populations and reduce the risk of re-traumatisation. Existing buildings which are institutional, de-humanising and impersonal are not appropriate for effective trauma-informed care. The physical environment has a part to play in the way care is delivered, and a positive therapeutic environment can have a significant impact on recovery.
Recent investment into mental health services has focused on counselling and emergency support, often provided in the form of a digital or telehealth method such as free hotlines or websites. While this may be effective in supporting early diagnosis or access to treatment, the wide range of services supporting different needs may be seen as complex and confusing, leading to a delay in accurate diagnosis and a lack of personal care. There are opportunities to provide a more streamlined and integrated approach to initial diagnosis and interventions, reducing the overall long-term impacts of mental illness on an individual, and their family and friends. Health buildings which are high quality, public and accessible can help in reducing the barriers to care by minimising stigma, raising the profile of mental health treatment, reflecting the needs of a diverse community, and supporting trauma-informed approaches to care. A trauma-informed approach to mental health care for young people presents a significant opportunity for early intervention before mental disorders can compound into adulthood. This will reduce the overall burden of disease on society into the future, as well as minimising the stigma of mental illness and delay in diagnosis and treatment in the future.
2.2 History of care
The history of mental health care in Sydney reveals the cyclical nature of changing approaches to care.
Convicts, Criminals and Lunatics
Bethlem Asylum in London opened in 1247 and is one of the oldest asylums in the world. Practices there, as in similar institutions at the time, were very traumatic for patients. ‘Treatments’ included bleeding, vomiting and purging, in the hope of restoring balance to the bodily systems based on the concept of the balance of the four humors. Those with mental illness were considered to be possessed and, when they became confined to such institutions, their capacity to re-enter society was limited. Alternatively, they were locked away at home, separate from their family, or left to wander the streets.
When the First Fleet arrived in Australia in 1788, discourse surrounding mental health treatment was beginning to change. In 1793, French physician Philippe Pinel ordered that chains be removed from mental patients at the Biçetre Hospital, Paris; Pinel published the first description of schizophrenia in 1809. This described how a new understanding of mental illness as a medical condition may inform treatment practices. However, in Sydney, convicts with mental illness were not distinguished from criminals until around 1838 when Tarban Creek Lunatic Asylum opened in Gladesville. Here, ‘lunatics’ were separated from convicts and housed in cramped, poorly ventilated buildings, many of which were not purpose-built but rather old convict factories.
Moral Responsibility and Treatment
The Dangerous Lunatics Act of 1843 heralded a shift in the perception of mental illness in the Colony of New South Wales. It detailed a new awareness of the need for medical treatment and the acceptance of responsibility by governments for care of the mentally ill. This marked the beginning of the moral treatment era in Australia.
Prominent moral reformers and medical practitioners such as politician Henry Parkes and Dr Francis Campbell (superintendent of the Tarban Creek Asylum) condemned the antiquated buildings that housed ‘lunatics’, and advocated for purpose-built institutions designed along the lines of the latest theories of moral therapy.
Compassion and Care
In 1884, with the help of Colonial Architect James Barnet, Dr Norton Manning opened Callan Park, the first asylum in the colony to be designed and built according to moral therapy principles. Moral therapy was a form of psychotherapy based on the belief that a person with a mental disorder could be helped by being treated with compassion in a clean, comfortable environment that provides freedom of movement, opportunities for occupational and social activity, and care from physicians and attendants. This approach to mental health was a stark departure from the previous concept of mental health and treatment, and a significant step forward towards humane mental health care.
Manning’s extensive travel and research into the latest treatments according to moral therapy principles led to
significant reforms in treatment. Views of nature and access to fresh air, sunlight and exercise were considered critical for a therapeutic environment. Ha-ha walls provided security without reducing views, and minimised the negative feelings of restriction and control. This was further supported by thoughtful separation of cohorts, understanding that differences in genders and patient acuity can reduce the effectiveness of treatment. A calm setting with quiet environments was believed necessary to reduce distraction, foster introspection, and support active therapy. This was balanced with active engagement and opportunities for creativity, learning, and fun.
Moral therapy spatial design elements
The architectural response to moral therapy was to create a soothing environment for patients through external views, a serene location, and a quiet atmosphere, coupled with key spatial design elements.
Exercise and airing courtyards Separation of genders
Central building with pavillions housing different patients Quiet atmosphere Natural daylight
Ha-Ha walls
Serene setting Natural ventilation Views to nature
Decline and Drug Therapies
The establishment of Callan Park signified a revolutionised mental health care system in NSW. At the time, asylums were well funded and political discourse was encouraging, with Henry Parkes remarking that the colony’s asylums were now ‘palaces’ under Manning’s directorship. However, moral therapy asylums should not be romanticised. Although conditions had improved and the model of care had changed to favour medical and therapeutic approaches, asylums were overcrowded, institutional, and custodial in operation. The lack of effective treatments for chronic patients led to a build-up of patients in care, causing overcrowding. In the 1880s, there were 200 patients in Callan Park without a bed; this ballooned to 1500 patients in the 1930s. As a result of this overcrowding, the quality of care declined drastically. Funding in the interwar periods reduced resources for asylums, leading them to become mismanaged with high staff turnover. A similar pattern of decline followed globally. Journalist and social historian Albert Deutsch noted in the 1940s that overcrowding and a build up of chronic patients shifted asylums from places of active treatment to custodial care. Callan Park had become a revolving door for patients, with readmission rates at 60% in the 1970s, rising from just 10% in 1880. Conditions had become so bad that the public sentiment about mental health care began to change. The discovery of psychotropic drugs in the 1950s offered hope that medical therapies may enable chronic patients to live outside wards, initiating the shift to community care models. The 1983 Richmond report meant that Australia officially moved away from custodial treatment to community care. However, as early as 1989, the Burdekin report found that community mental health programs were drastically underfunded. This pattern has continued for the past 40 years to the present day.
Restoring Dignity and Reducing Stigma
There are significant overlaps between the historic principles of moral therapy and contemporary care models. Reflecting on the physical environment provided in the original Callan Park Asylum provides inspiration for new mental health services.
Throughout 2020-2021, many young people around the world have experienced negative mental health impacts when deprived of their freedoms. Destigmatising mental illness is critical to ensuring that they get the care and support they need. Increased investment in mental health creates opportunities for new buildings that engage the community, are a positive contribution to the built environment, and welcome young people into a supportive space.
APA Dictionary of Psychology. Dictionary.apa.org. (2021). Retrieved 13 May 2021, from https://dictionary.apa.org/ moral-therapy.
A Victorian Mental Asylum | Science Museum. Science Museum. (2021). Retrieved 13 May 2021, from https:// www.sciencemuseum.org.uk/objects-and-stories/medicine/victorian-mental-asylum#:~:text=The%20word%20 asylum%20came%20from,in%20the%20City%20of%20London.
Carron, M., & Saad, H. (2012). Treatment of the Mentally Ill in the Pre-Moral and Moral Era: A Brief Report. Jefferson Journal Of Psychiatry, 24(1). https://doi.org/10.29046/jjp.024.1.001
Greenfield, D., Eljiz, K., & Vrklevski, L. (2017). The Evolution and Devolution of Mental Health Services in Australia. Retrieved 13 May 2021, from http://www.inquiriesjournal.com/articles/1654/the-evolution-and-devolution-ofmental-health-services-in-australia.
Garton, S. (2009). Seeking Refuge: Why Asylum Facilities Might Still Be Relevant for Mental Health Care Services Today. Health and History, 11(1), 25–45.
2.3 Evolving models of care
Trauma-informed Care and Practice. Blue Knot Foundation. Retrieved 13 May 2021, from https://www.blueknot.org. au/Workers-Practitioners/For-HealthProfessionals/Resources-for-HealthProfessionals/Trauma-Informed-Careand-practice.
McClellan, P. (2014). Interim report. Royal Commission into Institutional Responses to Child Sexual Abuse.
Department of Health. (2017). The Fifth National Mental Health and Suicide Prevention Plan (p. 31). Canberra: Commonwealth of Australia.
Cathy Kezelman on trauma-informed care
According to the Blue Knot Foundation, “frameworks of care and treatment are changing from purely bio-medical (medicine and psychiatry) and/or purely psychoanalytical (psychology) to include the psycho-social (trauma-informed) and a recovery focus (recovery-oriented)”. Based on recent evidence highlighting the lasting impacts of childhood trauma on a person’s mental health, the Fifth National Mental Health and Suicide Prevention Plan recommended that mental health staff in all service settings should be trained in the delivery of recovery-oriented and traumainformed care. The need for a comprehensive and consistent approach to providing care in mental health services, based on trauma-informed principles, is vital to ensure people have the greatest opportunity of recovery.
Understanding psychological safety
Trauma often affects the way people approach potentially helpful relationships, stemming from a lack of safety and trust. By supporting people to feel safe, both physically and psychologically, a traumainformed approach to care aids the recovery process. Previous methods of seclusion and restraint only account for the physical safety of a consumer and those around them, and disregard psychological safety. A higher consideration of both physical and psychological safety lessens the need for physical interventions that are confronting and potentially traumatising to the consumer. Provision of safety, both physical and psychological, is fundamental in promoting a better recovery.
Trauma affects us all, whether directly or indirectly. A trauma-informed approach to care recognises this and considers its impacts on the wellbeing of people and communities. This shift in the model of care has become more widely recognised and implemented. However, while models of care are evidently
Institutional and impersonal buildings
changing to reflect a consideration of these impacts, buildings have yet to do so. Instead of purpose-built health services designed to respond to trauma-informed care, buildings are being retrofitted to adapt. As such, they do not reflect a trauma-informed approach to care and often result in aged, cramped, and institutional spaces.
Safety is important to consider for a consumer’s general wellbeing and is critical to the healing and recovery process. Consumers, who may already feel unsafe in their daily lives, need to feel safe in receiving care. A move away from traditional mental health spaces such as seclusion and restraint rooms, which exacerbate feelings of unsafety in inpatient settings, can promote safety in treatment. A purpose-built healthcare environment can positively contribute to the recovery process and reduce the need to rely on outdated approaches to care.
Creating safe environments for care
2.4 Specific youth needs
Black Dog Institute and Mission Australia. (2017). Youth mental health report. Randwick: Black Dog Institute and Mission Australia. NSW Government. (2018). Supporting Young People During Transition to Adult Mental Health Services. Guideline: NSW Government Mental Health Branch. Retrieved from: https://www1.health. nsw.gov.au/pds/ ActivePDSDocuments/ GL2018_022.pdf
Mental health disorders experienced in adolescence have the potential to be extremely disruptive to an individual’s wellbeing, functioning, and development, in both the short and long term.
As a natural process of growing up, adolescents are frequently exposed to new experiences. While most experiences can be positive, there may be compounding stresses or instances of trauma that are detrimental to a young person’s mental health. The potential severity of the long-lasting impacts of mental health disorders poses a significant danger to the healthy development of an individual, which can be exacerbated by the risk-taking behaviours associated with adolescence. As such, it is critical to have effective interventions and services in place that are accessible and address the specific needs of young people, as well as those who care for and support them.
Building Healthy Relationships
Childhood trauma can be defined as “the experience of an event by a child that is emotionally painful or distressful, which often results in lasting mental and physical effects” and can occur as a result of interpersonal trauma or traumatic events. When it occurs in adolescence, interpersonal trauma can impede a young person’s ability to build healthy relationships with people, creating relational insecurity. This can be particularly detrimental when it comes to seeking help.Young people who lack relational security are less likely to seek help from adults, preventing the formation of potentially beneficial relationships. This can impose an additional barrier to care and exacerbate feelings of being unsafe.
Discontinuity of Care
The risk of serious mental illness increases as adolescents age, becoming most prevalent in the older teen years. This could be due to the difficulties in transitioning from child to adult service structures. Discontinuity in care at this age can lead to the disruption of crucial milestones and have adverse impacts on an individual’s health, social, educational and vocational outcomes. Currently, there are no adolescent and young adult specific services to aid in this transition. This inevitably means that many young people fall into gaps in care, disrupting the development of mature health behaviours.
Breaking the cycle of trauma and disadvantage
75% of lifelong mental disorders are diagnosable before the age of 25. Early intervention improves knowledge around mental health and encourages the development of mature health behaviours. This prevention through early intervention could reduce or remove both the short-term negative impacts of mental health disorders, and the longer-term impacts which contribute to an ongoing cycle of disadvantage that may result from mental health disorders going untreated into adulthood.
In the current mental health environment, services are inadequate to meet the demands of youth mental health, clearly demonstrated by the high prevalence and significant disease burden within the youth demographic. There is a significant gap in the delivery of mental health services. Youth-specific services must be prioritised.
2.5 Navigating complexities
Young Minds Matter: Use of services by young people with mental disorders. Child Family Community Australia. (2021). Retrieved 13 May 2021, from https://aifs.gov. au/cfca/2016/08/22/ young-minds-matteruse-services-youngpeople-mentaldisorders.
McCrindle Research. (2020). The Future of Education 2020. Norwest: McCrindle Research. Retrieved from https://mccrindle. com.au/wp-content/ uploads/reports/ Education-FutureReport-2020.pdf
Limited independence
Young people are often dependent on adults and caregivers in their lives to support them. Current adolescent and young adult services do not consider the potential barriers to care that young people may face. Young people without sufficient support may have limited ability to seek help. Youth-specific design should consider that most young people are studying full-time, have little financial means or access to Medicare, and are travelling via public transport. Young people may have difficulty navigating through health networks, and understanding the process of referrals. There is a significant reform required to ensure that young people can easily access the help they need, regardless of their level of independence, mobility and family support.
Social Stigma
Most young people will struggle in silence when experiencing difficulty and are reluctant to seek help. This reflects the deep-rooted social stigma attached to mental health. Social stigma has long been a significant barrier in accessing care, heightened by a lack of mental health knowledge and the negative perceptions associated with seeking help. Complex systems of care reinforce the notion that mental health services should be hidden away from the public eye. As a result, while stigma surrounding mental health has seen significant reduction in recent years, it is still a barrier to accessing services. On top of this stigma, young people fear that their confidentiality will not be maintained when seeking help, especially from caregivers. Feeling unsafe when seeking help indicates a lack of security which adds an additional barrier to treatment and recovery.
Navigating the System
Mental health services are often difficult to navigate and access as they are often networked and disaggregated, or disjointed and independent. Specialised services may not be operating within the same networks, or may not be clearly available to the consumer.
The pathway to referral for individualised services is unclear for young people and may rely in part on some self-awareness and self-diagnosis by the consumer. Many young people are unable to direct themselves towards relevant services and, as such, are unable to access the help that they may need. Young people under the legal care of parents/ guardians are reliant on their primary caregivers. As a result, they may not have the resources to independently seek help, which may be necessary where there is a lack of support from the household.
