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The mental health crisis

March 17th, 2004

Along with children’s welfare, mental health seems to be the chronic disaster area of our social services. It’s not hard to see why – the problems aren’t amenable to simple one-size-fits-all bureaucratic solutions (let alone the market solutions beloved of so many policymakers), and those most directly affected rarely get heard. Still, it’s one of the tests of a civilised society how well we respond to the needs of those who can’t voice their own demands, and it’s not a test we’re passing at present. Regular reader Graeme Bond has written the story of his own family’s tragedy and the policy failures that contributed to it. Well worth reading and thinking about.

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  1. James Farrell
    March 17th, 2004 at 15:08 | #1

    What a likeable-looking young man, and what a horrifying story. This Four Corners program of September 2002 told several similar stories from New South Wales. The program was shortly followed by the report of the NSW Legislative Council Select Committee on Mental Health. One source of frustration for the committee was apparently the difficulty of getting a handle on the dimensions of the problem. Paul Barry wrote this in the SMH in June 2003:

    Of course, we can’t prevent all of [these deaths] from happening,” says Dr Brian Pezzutti, a former Liberal upper house MP, who chaired the recent NSW parliamentary inquiry into mental health, “but if there are 15, 20, 50, 250 people a year who are self-harming or harming others whilst they are meant to be under care, we can’t have much faith in the system.”

    Pezzutti says the NSW Department of Health refuses to reveal the extent of the problem. “We asked for the number of people who harmed themselves or others whilst under care and we were denied that information,” he says.

  2. Louis Hissink
    March 17th, 2004 at 15:30 | #2

    John,

    Since health in general has become institutionalised along with its bureaucracy and the burdens of political and legislative requirements, yet based on humanity’ historical experience with such social systems, you remain surprised that such things happen?

    It is intrinsic to the system, John. When everyone is responsible, vis. the state, then no one is. And when no one is, then such tragedies become par for the course.

  3. Graeme Bond
    March 17th, 2004 at 16:02 | #3

    Thanks John for including this issue in your blog, it will extend the reach I hope.
    Hall Greenland wrote an excellent piece surveying the state of the Mental Health System across Australia in The Bulletin last October, ‘A Dying Shame’http://bulletin.ninemsn.com.au/bulletin/eddesk.nsf/6df5c28ed2c6c605ca256a1500059f03/937641a21b07f711ca256db1004a9ed7?OpenDocument
    He followed up with a shorter piece focussing on a particularly bad incident in Sydney earlier this year ‘Psychotic Reaction’ http://bulletin.ninemsn.com.au/bulletin/eddesk.nsf/6df5c28ed2c6c605ca256a1500059f03/dee5c3b5a23eea94ca256e1a00080f62?OpenDocument.
    The first in particular was followed by a large reader response and many letters published.
    For those who think it is all anecdotal and not systemic, I commend the report of the Victorian Auditor-General ‘Mental health services for people in crisis’ http://www.audit.vic.gov.au/reports_par/agp81cv.html

  4. Graeme Bond
    March 17th, 2004 at 16:03 | #4

    Thanks John for including this issue in your blog, it will extend the reach I hope.
    Hall Greenland wrote an excellent piece surveying the state of the Mental Health System across Australia in The Bulletin last October,A Dying Shame.
    He followed up with a shorter piece focussing on a particularly bad incident in Sydney earlier this yearPsychotic Reaction
    The first in particular was followed by a large reader response and many letters published.
    For those who think it is all anecdotal and not systemic, I commend the report of the Victorian Auditor-General Mental health services for people in crisis.

  5. March 17th, 2004 at 17:48 | #5

    And thanks to Graeme too.I know it is not the point, but it is an exquisite piece that captures so much and stays poised.

    Louis is wrong. The point is not that no-one takes responsibility. It is that the responsibility taken by ordinary people is not supported by the state. This is not an issue that can be seen in an ideological framework.

  6. Louis Hissink
    March 17th, 2004 at 19:22 | #6

    David,

    In such a health system, it is the state which is ultimately responsible, by definition. It’s agents then have no recourse but to implement the instructions of the state, or health system.

    If however, you assign responsibility to individual health professionals, then they need to make those decisions on the spot. In order to do that they need to be autonomous. As they are, however, part of the “system”, they cannot be given autonomy, because if that were permitted, the state becomes superfluous and we then find ourselves another situation.

    If that becomes the case, then who pays? And who is accountable to whom? And who decides which resources are allocated to where?

    However, having said that, you have not explained where I was wrong, or on what particular I am wrong.

  7. derrida derider
    March 17th, 2004 at 19:29 | #7

    It is very clear that Louis has never been close to anyone with a serious mental illness, or indeed had any like tragedies; he couldn’t be so callous otherwise. These things regularly wreck more than one life.

    Whenever libertarians rabbit on about how ‘personal responsibility’ should replace all state action I’m reminded of Lenin’s comment on his Anarchist allies-du-jour: “Fine people, but an ideology for children”.

  8. Jill Rush
    March 17th, 2004 at 21:20 | #8

    Part of the problem is that professionals are only responsible in a legal sense for limited parts of the whole and have no ability to affect other parts – the beating one’s head against a brick wall system where everyone is sympathetic but noone has the power to change things.

    There is also something of a religious fervour in the view that people with mental health problems are better in the community whilst ignoring that the community does not have facilities, supports or market power to do the work even if those who are truly troubled had the ability to access services.

    The other main problem we face is that action only ever occurs when there is a perceived crisis and as soon as that passes like a ripple in a pond then everything is back to normal.
    More reporting and recording is required which means we are less able to actually do anything, as it becomes a disincentive to actually look for solutions tailored to the individual.

    I don’t see this improving anytime soon as the decisions are made by people who “understand” problems intellectually but have no real idea of what the system does to individuals who may or may not come into contact with it, who feel powerless anyway and have no hope of having anyone who can affect change listen to their concerns as inevitably solutions will cost money.

  9. Brian Bahnisch
    March 18th, 2004 at 00:06 | #9

    dd is right. Your perspective changes when you have had personal involvement. I had such for about 25 years from 1960. Until 1980 there was no difficulty about access to psychiatric hospital facilities in Brisbane. In the early 1980s this appeared to be changing and there was the beginnings of rationing long term stays.

    I can’t comment with any authority on how things are now, but my impression is that there is a heavy reliance on drugs and repeated mild doses of ECT (electro-convulsive therapy). The GPs I know do seem to be much better informed on the issue than they were.

    David did what I thought was a powerful story on this issue recently entitled Letting the devil in… over at barista.

    I’m struggling with why mental health problems are endemic in our society and why the incidence seems to be increasing.

  10. Observa
    March 18th, 2004 at 12:25 | #10

    Jason’s problem and the policy failures that contributed to his death, speak for itself. This was failure, despite the obvious engagement of a caring family and friends.

    There is another way in which public welfare policy (ie the one size fits all approach), has also failed. Keith Windschuttle has pointed to this with his recent comments about certain remote aboriginal settlements. He has been howled down by the usual culprits, with their blind idealogical approach. In my state SA,the Rann Labor Govt has finally bitten the bullet and appointed an administrator to the Anangu Pitjantjatjara lands in the NW of the state. As well they have finally responded to the disgraceful lesbian agendists in FAYS in this state, after a recent inquiry came as close to saying this, as public-service speak can go.(FAYS is responsible for child welfare, foster care services, etc) Rann has signalled an end to this crap, by breaking up the Health and Human Services Commission into its components, with direct answerability to tough, new ministers. By all accounts they intend to kick lesbian, agendist arse. If Conservative govts were to do this, WWIII would break out(Rann has also made some strong statements to PS unions, who view Labor as a soft touch in recent wage pushes)

    What some people have to ask themselves honestly is- What have been the results of the continuos assault on what might be broadly defined as white picket fence, family values. The ALP in the states at least, is beginning to find the right answers. I’m not so sure Federal Labor is on the right track, if Latham’s back-down on male role models/mentors, is anything to go by. As for his equivalence of different relationships for the nurture of children, I think we can deduce the lesson there. The predicament, single mum and blogger, Gianna finds herself in now, with the natural father, should be a lesson to all, that having a child is not as simple as getting a new cat. The natural father, has some unwelcome, white picket fence values it seems. Bit of a change from the usual tale of dodgers of responsibility and child maintenance.

  11. TJW
    March 18th, 2004 at 23:39 | #11

    Im interested in how high level policy is actually translated into these outcomes.

    There appears to have been a policy of de-institutionalisation of the mentally ill over the past few decades, yet some pyschiatrists I have spoken to see this as being dangerous. Maybe they don’t represent the viewpoint of the majority of mental health practitioners.

    Why are governments (on both sides) so willing to adopt policies designed to keep individuals out of institutions? Won’t they just suffer more or end up getting shot by police or harming others? Is it just saving money or maybe they have been convinced by stories of abuse and believe that all institutions are bad?

    Does a government simply stop building facilities and therefore deprive psychiatrists of any option but to release individuals into the community?

    I wonder what most psychiatrists think. At least one I know thinks the problem is going to end up a massive disaster before action is taken.

  12. March 19th, 2004 at 01:06 | #12

    It is a massive disaster. McGorry says, in his NW Health Region in Melbourne alone, that two thousand people apply every year for crucial early treatment, and he has space for only 700. If we were talking about broken legs, we would say this was completely unacceptable.

    The article cites a letter he wrote which said “while mental illness constitutes 20 per cent of the illness burden, it attracts only 7 per cent of the health budget. He also noted that suicide now kills the same number of people as road accidents.”

    Think of the social energy we put into road accidents.

    My personal theory is that
    a) mentally ill people don’t look sick (mostly)
    b) mentally ill people are not infectious so they don’t have to be separated out to prevent a plague and
    c) the policy makers are regularly shown terrifying figures about the cost of providing hospital beds in the mental arena as easily as they are offered in the non-brain area.
    d) there is a strange conspiracy going on about the use of magic bullet medication. The talking cure is dead, we believe, and so is the need to communicate. New integrated therapies are not taken up (pace McGorry).,

  13. Brian Bahnisch
    March 19th, 2004 at 23:55 | #13

    Well said, David.

    David also mentioned in his post on the topic that with de-institutionalisation the mentally ill lose the advocacy of large institutions, hence the funds dry up over time.

    Every time this comes up on radio the incidence of homelessness amongst the mentally ill comes up.

    Last Sunday Terry Lane on Radio National’s “The National Interest” had a segment on ‘Postcodes and Poverty’ with Prof Tony Vinson who has done a report ‘Community Adversity and Resilience’ available from the Jesuit Social Services. This report points out that postcodes associated with the poor produce high proportions of prison inmates as well as the mentally ill as measured by admittance to public hospitals.

    As we have seen, this criterion falls far short of the reality. Vinson also said that the rich, or those with means, tended to have treatments that did not directly identify them as mentally ill.

  14. March 20th, 2004 at 13:51 | #14

    DD wrote “…Whenever libertarians rabbit on about how ‘personal responsibility’ should replace all state action…”

    I don’t think it’s necessary to be that unrealistic, and indeed treating things as either turn ‘em loose or run their lives makes a false (and harmful) dichotomy.

    To me, it seems a desirable ideal to have people turned loose AND able to look after themselves, and the only unrealistic part is to drop the caveat, a kind of externalising the costs. So, rather than keep running people (harmful in itself, and also tending to aggravate matters), we should treat the ideal as a reference point to steer by, if not directly at, and work towards making people truly enabled – promotion. Without that it would be as harmful as freeing slaves; when the British freed slaves there was at least a transitional arrangement of “tutelage”.

    I believe this has wider applicability, but it does fit the mental health area. This approach would not turn loose anyone who could be hurt, and not only would it allow gains to reach those who could benefit, it would allow resources to be freed up for the benefit of those who still needed them. There wouldn’t be the US approach of turning people out on the street because some untested theory aligned well with some gatekeeper’s self interest; the whole point would be to do any testing, in aggregate and for individuals.

  15. March 23rd, 2004 at 04:54 | #15

    I missed this last week, being preoccupied with other things, not the least of which is working in the NSW mental health system.

    It is just as hideous as is described. In fact even more so. The speed with which people *have* to be discharged (pressure of beds..) is positively scary and the way in which the inpatient units cover their legal asses by referring clients to understaffed underresourced community teams is nothing less than criminal (in my opinion of course).

    But until more money is put into both inpatient beds and community staffing, and the proper resourcing of both, the situation is going to get much much worse. The NSW government has no intention of doing this, it even pretty much told its own select committee “dont be bloody daft” when many of the points the committee raised involved committing much more funding to mental health.

    naturally, I cant say where I work, I’ll be sacked. I still want to do the best I can with the little I have available, as most of us do. Thats what successive managers rely upon.. the altruism of the workers. Alas there isnt enough to prevent tragedies like that which Graeme experienced.

    More money, more beds, more resources. No other “solution” will ever be right. Overall, the aussie mental health systems are the worst funded in the world, and NSW is the lowest funded in Oz. Pathetic, really.

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