Whakatakinga - Introduction

628.    The concept of institutional or systemic abuse describes how violence and abuse is not only experienced by individuals but can be “violence inherent in a system”.^[1254] The system in which the unit functioned was one where keeping the order of the unit was most important. There was an imbalance of power.  The children and young people there were not valued.  Abusive practices and punishments were normal and relied on Western models of medical treatment.  The wider social system placed these children and young people away from the rest of the community at Lake Alice.

629.    During our inquiry, the Ministry of Health acknowledged the growing body of literature suggesting an “inherent likelihood of deviation from acceptable social norms in the psychiatric institutions and other institutions as they previously operated”.^[1255] In relation to Lake Alice, the ministry acknowledged the State’s clear systemic failure that contributed to the abuse at Lake Alice and that anyone under the age of 17 who had been at the unit should be treated as a survivor for the purpose of seeking redress.^[1256]

630.    We similarly find that abuse was inherent in the institutional system of Lake Alice. Several factors contributed to this environment, including the power imbalance between children and young people and the staff at Lake Alice, the normalisation of abusive practices and punishments and reliance on exclusively western models of medical treatment.

“I hua ake ngā mahi tūkino i te horopaki o te tōrite o te mana” “Abuse occurred in the context of power inequities”^[1257]

631.    The admission of children and young people to Lake Alice was often because of the trust placed in medical professionals, including Dr Leeks. In addition to those placed there by the Department of Social Welfare, we heard the whānau of children and young people agreed to their being admitted to Lake Alice on the basis of medical advice. We have described the inherent power imbalance in health care settings, particularly for Māori, Pacific peoples and disabled people. We heard about the many barriers these groups and their whānau faced when reporting or objecting to abuse, including not wanting to challenge people in positions of authority and ableist attitudes.

632.    Children and young people admitted to Lake Alice then faced more disadvantages. The imbalance in power relations between these children and young people and the staff and doctors was huge. They were children and young people, not adults. They were held in the unit against their will, they were separated and isolated from families both legally and geographically. They were experiencing mental distress and were labelled and discriminated against for being seen to be mentally ill. Research shows an increased risk of abuse in relationships where others have power over a person and are the decision makers about the way relationships are conducted and managed.^[1258]

633.    The power imbalance existed not only between the medical professionals and the children and young people, but also between the medical professionals and parents, guardians and responsible agencies. Because of this authority held over the children and young people, doctors and clinical staff would only rarely seek consent from the children and young people or their guardians.

634.    Children and young people at Lake Alice were subject to many negative beliefs that devalued their self-worth and potential. They had little self-determination and largely depended on the staff to provide care. Their voices were often ignored at Lake Alice. They were not involved in decision making on their admission to the unit or treatment while there. Barriers to communication were not appreciated, including for those with English as a second language, cultural barriers or disabilities. Whānau were largely kept in the dark about what was happening at the unit and their views about the appropriateness of treatments were often not sought or generally dismissed.

635.    The inequitable dynamic between the medical staff and the children and young people created an environment where abusive practices and punishments could happen, often without question. We also heard about a perception among some staff that the children and young people in the unit were dangerous or out of control and had to be disciplined.

636.    Retired child psychiatrist, Mr Alan Mawdsley, described the exercise of power as reflecting prison conditions.

“ECT should never be used as a punishment or to modify behaviour. Its alleged use at Lake Alice Child and Adolescent Unit seems to me to be symptomatic of a prison guard mentality. It portrays a kind of power imbalance which is not appropriate for therapy. One where you have a position of power and you have some means of exerting power over the people that are under your control. You’re exerting that power not because it’s beneficial to the patient, but because it enhances your power and authority. It’s not even appropriate, in my opinion, within the prison system. The health care system shouldn’t have anything to do with coercive practices.”^[1259]

637.    The power imbalance at Lake Alice meant children and young people making disclosures of abuse, especially by doctors or other medical staff, were not believed and the responsible agencies took no action. This was especially the case for Māori, Pacific peoples and disabled people.

638.    One clinical psychologist working at the unit said, “I recall that the nurses generally thought of the psychiatrists as gods. It was not normal for the nurses to question the psychiatrists’ instructions.”^[1260] Mr Hollis, a social worker who worked with children and young people in the unit said:

“I believe Dr Leeks was in the unique position of being the only qualified child and adolescent psychiatrist at the time. Therefore, I don’t think anyone wanted to question him too much. He was a very powerful figure.”^[1261]

Te taiao ā-tinana ki Lake Alice - The physical environment at Lake Alice

639.    Lake Alice was a secure psychiatric institution in an isolated location. Security measures made it difficult for people to visit or for patients to leave. The unit’s remote location meant it was often difficult for Māori to maintain links with whanau.  It was also difficult for tamariki Māori and Rangatahi Māori to maintain a connection with their culture and language.

640.    Academic, Ms Kate Prebble, noted in her study of psychiatric nursing in Aotearoa New Zealand during this period the staff at rural psychiatric hospitals formed close-knit communities – since staff lived, worked and socialised together in a remote, self-contained setting.^[1262] She suggested these tight social and professional links could have deterred staff from reporting the poor practice of their co-workers.^[1263]

641.    Several survivors described the facilities at Lake Alice as intimidating and prison-like (as discussed in section 2.1.5). Some staff members shared this view. For example, Ms Anna Natusch, a teacher, said the hospital focused on the block that housed the criminally insane, which, “was grey concrete, clanging doors and iron bars. Cameras watched every move of the person. The most they saw of the outside world was the sky above in the concrete surrounded exercise yard. It was dehumanising.”^[1264] She said she “could feel the vibrations of fear” as she entered one of the villas where young girls were housed with adults.^[1265]

642.    Facilities were known to be inadequate. For instance, the superintendent of Lake Alice described general overcrowding and cramped conditions in villa 7 (which housed the boys in the unit) as numbers being admitted to the unit increased.^[1266] A 1977 clinical services report said  admissions tended to exceed transfers, discharges and deaths. “Consequently, there is some overcrowding and some of the facilities are not being used for the purpose for which they were designed.”^[1267] The report also noted that one villa, which accommodated patients aged 14 to over 65,  who were considered particularly very difficult to manage, was “grossly overcrowded and is unsuited for the purpose for which it is being used”.^[1268]

643.    Mr Craig McDonald, who worked as a hospital aid in the wider hospital while he was training as a psychologist, told us the unit was isolated from the rest of the hospital and secretive:

“As I was still learning at the time, I was interested to learn what therapies were used in the unit. In 1977, I decided to visit the Unit to ask about their treatments. Upon entering I was confronted by the charge nurse, and told I was trespassing by being in the unit. He warned me that if I entered the Unit again a formal trespass notice would be put on my personnel file."^[1269]

Te āhua noho ā-whakarau ki Lake Alice - The institutional culture at Lake Alice

644.    The institutional culture at Lake Alice enabled abuse to occur. Institutional culture is much better understood now than it was in the 1970s,^[1270] but even allowing for the benefit of hindsight problematic aspects of the culture at Lake Alice could have been identified and addressed at the time.

645.    Commentators writing about the workplace culture of psychiatric institutions in the 1960s and 1970s frequently described the atmosphere as overtly masculine. Lake Alice, which was exclusively male until 1966, had this masculine culture, and male staff generally opposed the introduction of female nurses in that same year.^[1271]

646.    In the 1970s, hospitals were run as a strict hierarchy as stipulated in the Department of Health’s 1972 document Ethics and Rules of Conduct for Staff:

“All members of the staff are expected to carry out the legal orders of their superior officer without question. If they consider that these orders are unreasonable, they may, having given reasons for their objections and done what they have been told to do, present their objection to the next higher authority.”^[1272]

647.    Lake Alice was no exception. In May 1976, the medical superintendent, Dr Pugmire, circulated a paper to staff that described the administrative structure of Lake Alice as “a rigidly defined, hierarchical dictatorship”.^[1273] He went on to say:

“Orders coming down the line from senior officers to lower ranks are not optional. Even if a senior officer gives an order in a polite manner or even if the senior officer gives the order in the form of a request, it still has to be obeyed first and argued about afterwards. Anyone who attempts to prevent an officer carrying out a legitimate order commits an offence.”^[1274]

648.    This hierarchy was recognised by clinical and educational staff, who mirrored the deference shown to the medical profession by the staff from external agencies such as social workers. Educational professionals who spoke to the inquiry largely felt senior medical staff in the unit were unapproachable and did not take the advice of those outside psychiatric or clinical psychological disciplines.

649.    We earlier referred to two examples of threats made by Dr Leeks to staff who expressed concern about his actions. On one occasion, Mr Terrence Conlan, a nurse, expressed concern that electric shocks given to Mr Paul Zentveld had caused muscle spasms, which he said was not meant to happen. On a different occasion, Mr Brian Stabb, a nurse, expressed concern about the administration of shocks. Dr Leeks responded by referring to the hospital housing the nurses lived in, implying their accommodation would be at risk if they continued to express concern.

I māori noa iho ngā mahi tūkino - Abusive practices accepted as the norm

650.    As the children and young people were housed in a unit which was part of a psychiatric hospital, the medication, medical equipment and language of that setting became available and was able to be misused.

651.    Medical status, paternalism and medical language were used to validate the existence of the unit and the practices used there. Language such as ‘treatment’, ‘discipline’, ‘timeout’, ‘electro-convulsive therapy’ and ‘aversion therapy’ disguised what was happening in practice. This language gave professional legitimacy and respectability to practices that were abusive. Children and young people experienced violence justified as therapy and harsh discipline rationalised as a legitimate form of behavioural control.

652.    Painful medical techniques such as electric shocks and injections of paraldehyde were routinely misused in the unit and physical and emotional abuse occurred in the open (as discussed in chapter 2.1). Solitary confinement was also routinely used. These were accepted means of maintaining control within the unit and staff, including Dr Leeks, appear to have become desensitised to the pain they were inflicting.

653.    Charge nurse, Dempsey Corkran, told us that, in hindsight, he considered ECT and paraldehyde were probably overused in the unit, but he said paraldehyde was prescribed and ECT was probably overused in all psychiatric hospitals as it was the treatment of choice at the time.^[1275]  He said he would like to think neither was used as means of punishment but he could understand why patients who were “seriously out of control or were doing something very wrong” may have seen it as such. ^[1276]  He said paraldehyde was a form of control in very difficult circumstances and that “it helped to restore control where other means weren’t possible”. ^[1277] 

654.    This demonstrates how the availability and acceptance of these practices led to their frequent misuse by unit staff. Coupled with the view that the tamariki were out of control and undisciplined, a culture of abuse developed in the unit. As we have noted, tamariki were often sent to the unit because of their apparent behavioural problems. When complaints were first made to responsible agencies, some of their agents were more concerned with whether the methods were effective at modifying behaviour than whether they amounted to abuse,^[1278] which contributed to abuse continuing within the unit (discussed in chapter 2.1).

Te korenga o ngā mahi whakangungu kaimahi me ngā rawa - Inadequate staff training and resourcing

655.    The power dynamics and abusive practices at Lake Alice can be, in part, attributed to issues relating to the care workforce. We heard about staff shortages and poor staff training at Lake Alice and more widely within psychiatric care throughout the country. Because of this, many staff practices were to maintain control over patients such as extended periods in secure or use of restraint. We also know the workforce was not trained in matauranga Māori or te reo Māori, despite the large numbers of Māori in the unit.

656.    During the 1970s, there was a worldwide shortage of qualified child psychiatrists. This was particularly serious in New Zealand.^[1279] Dr Leeks was one of very few child psychiatrists in the country at the time, and his services were divided among the Manawaroa health clinic at Palmerston North Hospital, various child health clinics and the unit, where he worked about one day each week.

657.    It is clear from the Lake Alice annual reports for 1971 to 1977 that the hospital had difficulty recruiting and retaining qualified staff.^[1280]

658.    Various factors contributed to the shortage. Quite apart from the difficulty of the job, there may have been concerns about workload, with a report that staff levels were not being increased despite the opening of more villas at Lake Alice.^[1281] Poor working conditions in the institutions were reported generally.

659.    In addition, the stigma associated with mental illness meant psychiatric nursing was largely seen as ‘dirty work’.^[1282] Staff said it was a tough working environment. One former psychiatric nurse who worked at the unit from 1974 to 1976 said staff members would come and go. “It did not appear to me that the Adolescent Unit was a popular place to work. I believe there was a general feeling in the hospital that the residents were out of control and undisciplined.”^[1283]  He also said the unit had built a reputation of being “set apart and clandestine”.^[1284] He told us, “The staff who worked there were ostracised, and none of the local staff wanted to work there.”^[1285]

660.    The hospital reported that staff selection policies were effective: “A rigorous selection system is adopted for all staff at Lake Alice.”^[1286]  But with the difficulties of recruiting and retaining staff and adequately resourcing the unit, a lack of effective vetting procedures was apparent at this time. There is no indication the hospital recognised a need to recruit staff that reflected the diversity of the children and young people in the unit.

Te whakangungutanga o ngā kaimahi ki Lake Alice - Training of staff at Lake Alice

661.    A charge nurse at the unit confirmed that in the 1950s and 1960s most staff at Lake Alice were ‘self-trained’.^[1287] This was echoed by a nurse aide who worked in Lake Alice for about three years. He said there was no formalised training and no formalised supervision for nurse aides and while he was at Lake Alice^[1288] all his training was on the job.^[1289] Staff with training in or knowledge of tikanga Māori could have provided an opportunity for Māori tamariki at the unit to maintain some contact with their culture. As one survivor noted, “Lake Alice totally disregarded my Māori culture. I did not have access to any Māori cultural learning as a patient there.”^[1290]

662.    The inexperience and lack of formalised specialist training meant junior nurses and nurse aides relied on the mentorship and on-the-job training provided by senior nurses and psychiatrists at Lake Alice. This would have made it difficult for them to challenge clinical decisions and treatment choices by more senior colleagues.

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