Submission 522 - Association of Counselling Psychologists ...€¦ · aspects, rather than mental health being addressed in isolation. Mental-health is about more than the absence

AssociationofCounsellingPsychologistscounsellingpsychologists@gmail.com

POBox1524,Subiaco6904www.counsellingpsychologists.org

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Submissionby:AssociationofCounsellingPsychologists(ACP)

Author:DuaneSmith

TheSocialandEconomicBenefitsofImprovingMentalHealth

ProductivityCommissionMentalHealthInquiry(April2019)

Contact:DuaneSmith

ExecutiveChair:AssociationofCounsellingPsychologists(ACP)

[email protected]



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TheSocialandEconomicBenefitsofImprovingMentalHealth

ProductivityCommissionMentalHealthInquiry

Theauthor,onbehalfoftheAssociationofCounsellingPsychologists(ACP),thankthe

ProductivityCommissionfortheopportunitytocontributetothecurrentMentalHealth

Inquiry.TheAssociationofCounsellingPsychologists(ACP)representsmembersacross

Australia,promotingandadvocatingcounsellingpsychologyasafieldofpsychological

practice.CounsellingpsychologistscanbefoundinarangeofsettingsofferingMedicare

rebatedtreatmentwithingovernmentandnon-governmentorganisations,hospitals,

educationalinstitutionsandprivatepractice.CounsellingPsychologistsprovideassessment,

formulation,diagnosis,treatmentandmanagementofpsychologicalproblemsacrossthe

wholespectrumofmentalhealthdisorders,includingprovidingservicestopeoplewith

permanent,complexandsignificantdisabilitiesatthemoderatetosevereendofthe

spectrum.Thefollowingsubmissiondoesnotaddressallthequestionsraisedinthe

ProductivityCommissionIssuesPaper.TheProductivityCommissioninquiryintoimproving

mentalhealthisbroadrangingandcoversanumberofareasimpactingonthementalhealth

oftheAustralianpopulation.Thissubmissionfocusesonlyonaddressingthosequestions

withinthescopeandexpertiseoftheprofessionofcounsellingpsychology.

CounsellingPsychology

Psychologyasadisciplineandprofessionhasafundamentalroletoplayinmentalhealth

services.PsychologyisaregulatedhealthprofessionundertheauthorityoftheAustralian

HealthPractitionerRegulationAgency(AHPRA)andthePsychologyBoardofAustralia(PsyBA).

RegistrationwiththePsyBAisessentialtopracticeasapsychologistinAustralia,and

psychologisttitlesareprotected.

Forgeneralregistrationasapsychologistafour-yearundergraduatedegreeinthescienceof

psychologypluseitheratwo-yearsupervisedinternship(knownasthe4+2pathway),ora



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furtherone-yearaccreditedMasterDegreeandoneyearofinternship(knownasthe5+1

pathway),isrequired.Psychologistswithhigherlevelsofeducationandtrainingbeyonda

one-yearMasterDegreecanbeendorsedinnineareasofspecialisationfollowingthe

completionofaregistrarprogram.

Counsellingpsychologyisanareaofpracticethatspecialisesintheassessment,diagnosis,

treatment,andmanagementofserious,chronic,andcomplexmentalhealthdisorders.The

ACPrepresentsthosecounsellingpsychologistswhoholdorareworkingtowards,the

minimumeducationandtrainingforendorsementasacounsellingpsychologistas

determinedthePsyBA.ieatleastanaccreditedtwo-yearMaster’sDegreeincounselling

psychology,followedbyatwo-yearregistrarprogram.ACPfullmembershavetherefore

completedaminimumofeightyearsofaccreditededucationandtraining.

AccreditationofpsychologyeducationandtrainingprogramsoccursviatheAustralian

PsychologyAccreditationCouncil(APAC)toensurecompliancewiththeAccreditation

StandardsforPsychologyPrograms(theStandards)(2019)

TheProductivityCommission’sMentalHealthInquiryprovidesanunprecedentedopportunity

foracomprehensivereviewofmentalhealthservicesinAustralia.Theinquiry’sbroad

approachtoreviewingtheprovisionofmentalhealthservicesandinclusionofother

psychosocialsectors,includingeducation,housing,employment,socialservicesandjustice,is

tobecommended.Thisapproachisconsistentwithaholisticphilosophywhich

provideswhole-personcarethatsupportsmentalhealthalongsideotherbiopsychosocial

aspects,ratherthanmentalhealthbeingaddressedinisolation.Mental-healthisaboutmore

thantheabsenceofmentalillness.Goodmental-healthisakeydeterminantofother

outcomes.Peoplearemorethanadiagnosisandeffectivementalhealthservicesrecognise

this.Thecurrentinquiryacknowledgesthewholepersonandprovidesthepotentialfora

much-neededparadigmaticshiftinmentalhealthcareinAustralia.



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Overview–SystemicIssues

Isaparadigmshiftneededinthewayweviewanddelivermentalhealthservicesin

general?

“Mentalhealthandmanycommonmentalhealthdisordersareshapedtoagreatextentby

social,economicandphysicalenvironmentsinwhichpeoplelive”.(WorldHealthOrganization

&CalousteGulbenkienFoundation,2014).Socialdeterminantsofmentalhealthinclude

education,employmentandworkingconditions,builtenvironment,physicalenvironment,

housing,gender,culture,ethnicity,safety,socialconnectedness,income,earlychildhood

development,healthandsocialservices.

TheProductivityCommissiondocumentclearlyoutlinestheeconomic,societalandpersonal

costsoftheunderdeliveryofappropriateperson-centredmentalhealthserviceson

Australiansociety.Italsohighlightsthatthecurrentsystemlackseffectiveoutcomesinpart

duetoacontinuationofdiagnosticspecificsiloedservices,limitedcontinuityofcareand

ultimatelyalackofresponsibility/accountabilityofserviceproviders.

Naylor,TaggartandCharles(2017)arguethatdevelopingmoreintegratedapproachesto

mentalhealthshouldbeakeyprioritygiventhecloselinksbetweenmentalhealthand

physicalhealthoutcomes,andtheimpactthesehaveonthequalityandcostsofcare.Itiswell

establishedthatwhenthementalhealthneedsofpeoplewithphysicalhealthconditionsare

notadequatelyaddressed,thisincreasescostsandunderminespatientoutcomes.

Thecurrentmental-healthcaresystemresultsinidentifiedgapsofsupport-whichourmost

vulnerablemembersofsocietyfallthroughregularly.Thatis,marginalisedpopulations,

LGBTQI+,AboriginalandTorresStraitIslanderpeoplesandpeoplefromCALDbackgrounds.In

addition,thosewithcomplexsystemicneedswhoareatriskofdevelopingmentalhealth



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concernsoftenstruggletoreceivethepsychologicalandholisticcaretheyneed,andpeople

withacutepresentationsareregularlydischargedfrominpatientcarewithoutadequate

supportsystemsinplace.TheburdenandcosttoAustraliansocietyandtheeconomyis

clearlyevident.

Naylor,TaggartandCharles(2017)statethatmentalhealthcareisoftendisconnectedfrom

thewiderhealthandsocialcaresystem–institutionally,professionally,clinicallyand

culturally.Artificialboundariesbetweenservicesmeanthatmanypeopledonotreceiveco-

ordinatedsupportfortheirphysicalhealth,mentalhealthandwidersocialneeds,andinstead

receivefragmentedcarethattreatsdifferentaspectsoftheirhealthandwellbeinginisolation.

Figure1illustratessomeofthegroupsofpeoplewhofrequentlysufferasaresult.

Figure1



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Therearewelldocumentedfundamentalproblemswiththeoversimplificationofthecurrent

medical/psychiatric/diseasemodelwhereanindividual’sdistressisseenasaformof

pathology,withunidentifiedbiologicalfactorsthatlinktosymptomclustersanddiagnosis.An

individualismuchmorethantheirdiagnosis.

Unfortunately,thebiomedicalprocessoftenresultsinalossofindividualagency,increased

stigmatizationandnegativeeffectsofmedications.Diagnosticinflationisawell-researched

phenomenon,wherebyalargepercentageofpresentationsformentalhealthconcernsto

frontlineGP’sresultinprescriptionsforpsychiatricmedicationwithlimitedassessment,

limitedoutcomesand/ornoremittanceofsymptoms.

Bystrictlyadheringtothebiomedicalmodelasaprimaryexplanationofaperson’sdistress,

weriskdismissingtheindividual’scircumstancesandpersonalstory.Thisapproachfocusses

onwhatiswrongwiththeperson,ratherthanwhathashappenedtothem.

Wehavelostsightofthemultiplefactorsthatmaycontributetoanindividual’sdistress.Many

ofthesefactorsarehighlightedinthePCreport.Addressingthisshortfallinourcurrent

systemrequiresaparadigmshiftinallareasofmentalhealthassessment,diagnosis

formulation,treatmentandevaluationtoaholisticandsystemicperson-centredapproach,

thatutilisesasteppedmodelofcarefocussingontheindividual’sneedsinrelationtotheir

ownuniquestory.

Steppedcareisaninherentlyrecoveryorientatedmodelthatidentifiesmentalhealthasa

continuumofpsychologicaldistressandrecognisesthatallofusmaymovethroughthese

timesofdistresstowellnessthroughoutthelifespan.

Whilethemedicalmodelneedstoremainthecentre-pieceofhealthandmental-healthcare

inAustralia,wealsoneedtotakeintoaccountothernon-symptomspecificsocialdeterminant

realitiesinanindividual’slifeandapplyamultifactorialapproachtomentalhealth.



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ThisisparticularlyevidentformarginalizedcommunitiesincludingourIndigenouspopulation.

“despitecontemporarydefinitionsof‘mentalhealth’incorporatingthenotionofbeing‘not

simplytheabsenceofmentalillness’andexistingalongaspectrumthatincludes‘positive

mentalhealth’currentlythedisciplineisstillpredominantlyfocussedonpsychopathologyand

mentalhealthdisorders,withthenotionofpositivementalwellbeingyettobereallywell

defined.WebelievethatsituatingmentalhealthwithinanAboriginalandTorresStrait

IslanderSEWBframeworkismoreconsistentwiththeviewthatAboriginalandTorresStrait

Islanderconceptsofhealthandwellbeingprioritiseandemphasisewellness,harmonyand

balanceratherthanillnessandsymptomreduction”.(Dudgeon,Milroy&Walker,2014,p.64).



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Weareproposingthefollowingmodelsasabetterwaytounderstandandtreattheperson

andtheirdistress/diagnosis:

Figure2:PTMF

PowerThreatMeaningFramework

• ThePowerThreatMeaningFramework(PTMF)(Johnstone&Boyle,2018)hasbeen

rigorouslyvalidatedthroughcollaborationwithpeoplewithlivedexperienceofmental

healthdisorders.“Insummary,thisframeworkfortheoriginsandmaintenanceof



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distressreplacesthequestionattheheartofmedicalisation,‘Whatiswrongwith

you?’withfourothers:Whathashappenedtoyou?(HowhasPoweroperatedinyour

life?).

• Howdiditaffectyou?(WhatkindofThreatsdoesthispose?).

• Whatsensedidyoumakeofit?(WhatistheMeaningofthesesituationsand

experiencestoyou?)

• Whatdidyouhavetodotosurvive?(WhatkindofThreatResponseareyouusing?)”

(Johnstone&Boyle,2018,p.190-191).

“AkeypurposeofthePTMFrameworkistoaidtheprovisionalidentificationofevidence-

basedpatternsindistress,unusualexperiencesandtroubledortroublingbehaviour. In

contrasttothespecificbiologicalcausalmechanismswhichsupportsomemedicaldisorder

categories,thesepatternsarehighlyprobabilistic,withinfluencesoperatingcontingentlyand

synergistically.However,thisdoesnotmeanthatnoregularitiesexist.Rather,itimpliesthat

theseregularitiesarenot,asinmedicine,fundamentallypatternsinbiology,butpatternsof

embodied,meaning-basedthreatresponsestothenegativeoperationofpower”(Johnstone&

Boyle,2018,p.191).

Furthermore,thefollowingisanarrativesummaryoftheFoundationalPowerThreatMeaning

Pattern:“Economic/socialinequalitiesandideologicalmeaningswhichsupportthenegative

operationofpowerresultinincreasedlevelsofinsecurity,lackofcohesion,fear,mistrust,

violenceandconflict,prejudice,discrimination,andsocialandrelationaladversitiesacross

wholesocieties.Thishasimplicationsforeveryone,andparticularlythosewithmarginalised

identities.Itlimitstheabilityofcaregiverstoprovidechildrenwithsecureearlyrelationships,

whichisnotonlydistressinginitselfforthedevelopingchild,butmaycompromisetheir

capacitytomanagetheimpactoffutureadversities.Adversitiesarecorrelated,suchthattheir

occurrenceinaperson’spastand/orpresentlifeincreasesthelikelihoodofexperiencing

subsequentones.Aspectssuchasintentionalharm,betrayal,powerlessness,entrapmentand



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unpredictabilityincreasetheimpactoftheseadversities,andthisimpactisnotjustcumulative

butsynergistic.Overtime,theoperationofcomplexinteractingadversitiesresultsinagreatly

increasedlikelihoodofexperiencingemotionaldistressandtroubledortroublingbehaviours.

Theformoftheseexpressionsofdistressisshapedbyavailableresources,socialdiscourses,

bodilycapacitiesandtheculturalenvironment,andtheircorefunctionistopromote

emotional,physicalandsocialsafetyandsurvival.Asadversitiesaccumulate,thenumberand

severityoftheseresponsesrisesintandem,alongwithotherundesirablehealth,behavioural

andsocialoutcomes.Intheabsenceofamelioratingfactorsorinterventions,thecycleisthen

setuptocontinuethroughfurthergenerations.”(Johnstone&Boyle,2018,p.195).Theabove

reinforcestheneedforpreventativemeasuresandearlyinterventionatasystemiclevelto

retardthedevelopmentofmentalhealthdisordersandprovidetimelytreatment–bothof

whicharekeyobjectivesofthisProductivityCommissioninquiry.

SystemicNeedsAssessment-SocialDeterminantsApproach

AdaptedfromSTREAM-SystemicTherapeuticRelationalEmpowermentandAdvocacyModel

(Smith,2016).

ASystemicNeedsAssessment(SNA)isaholisticandsystematicprocessfordeterminingand

addressingneeds,or"gaps"betweencurrentconditionsanddesiredconditionsforthe

individual.Thediscrepancybetweenthecurrentconditionandbestoutcomeconditionmust

bedefinedtoappropriatelyidentifytheneed(seefigure3).

Acomprehensivereportiscompletedthatcoversthefollowing8domainsoffunctioningand

definesandhighlightsareasofsupportneeded:



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Figure3

TheSNAprocessalsoenablesprioritizationofthesafety,psychological,physicalandmedical

healthneedsoftheindividual.

IndividualSupportPlanning(ISP)

PersoncentredcareisrealizedthroughthedevelopmentofIndividualSupportPlans(ISP)and

activelyfacilitatingconnectionsandengagement,navigating,advocating,mentoringand

supportingtheclienttosystemicallyre-connectwithallrequiredsupportnetworksthatmeet

theneedsoftheindividualinanintegratedprocess.

RegularreviewisvitaltorefiningandretuningtheISPtomeetthechangingsupportneedsof

theindividualovertimeovertimeandcanbeintegratedintothesteppedcaremodel.

Thecircularflowdiagrambelowhighlightsthedevelopment,implementationandreview

processoftheISP(figure4):



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Figure4

AnexampleofanISPandpotentialpathwaystosupportsolutionsonalldomainsisasfollows:

Figure5:IndividualSupportPlanningTemplate



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QUESTIONSBEINGADDRESSEDBYTHEPRODUCTIVITYCOMMISSIONISSUESPAPER

QUESTIONSONASSESSMENTAPPROACH:(p.10)

Q.Whatsuggestions,ifany,doyouhaveontheCommission’sproposedassessment

approachfortheinquiry?Pleaseprovideanydataorotherevidencethatcouldbeusedto

informtheassessment.

• TheProductivityCommission’sinquiryintomentalhealthcareinAustraliaistimely

andtobecommended.Theissuesraisedforconsiderationaresignificantandindicate

thatstructuralchangeisrequired.Thisimpliesbothaparadigmaticshiftinthe

approachtomentalhealthcareinAustralia,andarenewedapproachtotheprovision

ofservicestoincludeothersocialdeterminantsofmentalhealth.Therearecurrentlya

numberofeffectivementalhealthservicesinAustralia(e.g.theMedicareBetter

AccessProgram).However,establishedmentalhealthsystemsandservicesneedtobe

refinedandexpandedtoincludeabroaderunderstandingoftheunderlyingcausesof

mentalhealthdisordersandthevariousfactorsthatcontributetorecovery.Thereis

roomforimprovementandaneedtoensureefficienciesintermsofhealth,economic

andproductivityoutcomes.Pleaseseeprevioussection:“Overview–SystemicIssues”

forfurtherelaboration.

QUESTIONSONSTRUCTURALWEAKNESSESINHEALTHCARE:(p.13)

Q.Whyhavepastreformeffortsbygovernmentsovermanyyearshadlimitedeffectiveness

inremovingthestructuralweaknessesinhealthcareforpeoplewithamentalillness?How

wouldyouovercomethebarrierswhichgovernmentshavefacedinimplementingeffective

reforms?



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• Pleaseseeprevioussection:“Overview–SystemicIssues”above.

Q.What,ifany,structuralweaknessesinhealthcarearenotbeingtargetedbythemost

recentandforeshadowedreformsbygovernments?Howshouldtheybeaddressedand

whatwouldbetheimprovementsinpopulationmentalhealth,participationand

productivity?

• Themedicalmodelfailstoaccountforsocialdeterminantsofhealthandmentalhealth

andwellbeing.Longtermimprovementinpopulationmentalhealthrequiresa

paradigmaticshiftthatconsidersthebiopsychosocialaspectsofmentalillnessanda

healthsystembasedoncollaborativecare.Pleaseseeprevioussection:“Overview–

SystemicIssues”forfurtherelaboration.

QUESTIONSONSPECIFICHEALTHCONCERNS:(p.16)

Q.Shouldtherebeanychangestomentalillnesspreventionandearlyinterventionby

healthcareproviders?Ifso,whatchangesdoyouproposeandtowhatextentwouldthis

reducetheprevalenceand/orseverityofmentalillness?Whatisthesupportingevidence

andwhatwouldbesomeoftheotherbenefitsandcosts?

• Yesthereshouldbechangestomentalillnesspreventionandearlyinterventionby

healthcareproviders.

• WithregardtopsychologyservicesprovidedundertheMedicareBetterAccess

Program,currentlyunderscrutinyaspartoftheMBSReview,newitemnumbers

allowingforindividualsandgroupstoaccesspreventative/earlyintervention

psychologicalserviceswouldenablepeopletoseekappropriateandtimely



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community-basedpsychologicalservices,ratherthanhavingtowait,andrisk

becomingsignificantlyunwellanddistressed.

• Thereareanumberofresearchpaperspostulatingthebenefitsofearlyintervention

withregardtoreducingseverityanddurationofepisodesofmentalillnesswhere

theseissuestendtobeepisodicinnaturesuchasBipolarMoodDisorder(e.g.Berk,

Brnabic,Dodd,Kelin,Tohen,Malhi,Berk,Conus&McGorry,2011;Berk,Hallam,Malhi,

Henry,Hasty,Macneil,Yucel,Pantellis,Murphy,Vieta,Dodd&McGorry,2010;Berk,

Malhi,Hallam,Gama,Dodd,Andreazza,Frey&Kapczinski,2009;Conus,Macneil&

McGorry,2013;Muneer,2016;Taylor,Bressan,PanNeto&Brietzke,2011).

• Researchalsosuggeststhatearlyintervention–bothintermsofageandstageof

illness-mayleadtolowerratesofrecurrencefollowingrecoveryindepressive

disorders(Clarke,Rohde,Lewinsohn,Hops&Seeley,1999&Jarrett,etal,2001).

• Hetrick,Parker,Hickie,Purcell,YungandMcGorry(2008)arguethat“theidentification

ofthesubsyndromalandprodromalstageofdepressivedisordersprovidesthe

opportunityforearlyintervention”andthatstage-appropriatetreatment,“maydelay

orpreventonset,reduceseverity,orpreventprogressioninthecourseofthe

depressivedisorder.”Inaddition,itissuggestedthatbyidentifyingandtreating

depressivedisordersearly–othercomorbiddisorderssuchassubstanceabuseand

suicidality,maybereduced.

• Thereisalsoconsiderableevidenceforbetterlong-termprognosisforindividuals

whentreatmentisaccessedsoonafterinitialsymptompresentations(e.g.early

interventionforpsychosis).Inaddition,whendetectedandtreatedearly,treatment

options,otherthandrugtherapies(i.e.CBT),canbeeffective(Bechdolf,Wagner&

Klosterkotter,2006;Phillipsetal.,2009).Thereisanimpliedcostsavingassociated



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withearlyinterventionandtheuseofnon-drugtherapies.Accordingtothemost

recentwebreportfromMentalHealthServicesinAustralia(MHSA)lastupdatedon

22March2019,fourmillionpeoplereceivedmentalhealth-relatedprescriptionsin

2016-17.

• GPs,schoolpsychologistsandemployeeservicesarebestplacedtoundertakethe

earlyidentificationofdisorderssuchaspsychosis,BipolarDisorderandMajor

Depression.Adequatetrainingintheidentificationofsubsyndromalandprodromal

symptomsandappropriatereferralpathwaysforthesegroupsisessential.

• The“InvestingtoSave:TheEconomicBenefitsforAustraliaofInvestmentinMental

HealthReform”finalreportprovidesanoutlineofthecostsavingsofearly

interventionandrecommendsthreespecificareasofneed,namely:“peoplewith

physicalandmentalhealthco-morbidities”,“groupsatriskofprolongedmentalill-

health”and“e-mentalhealthinterventions”(MentalHealthAustraliaandKPMG,

2018,p.57).

• Thissamereportnotesthat“ROIformentalhealthisgreatestwheretheinterventions

areprovidedtothosewithmildoremergingmentalhealthconditions.”(Mental

HealthAustraliaandKPMG,2018,p.58).Psychologyservicesprovidedunderthe

MedicareBetterAccessProgramareprimarilyaimedatthiscohort–theimplication

beingthattheBetterAccessProgramhasthepotentialforthegreatestROIinmental

healthservicesinAustralia.Asstatedabove,reformofthisprogram,aspartofthe

MBSReview,iscurrentlyunderwayandaimstoimproveeconomicandoutcome

efficiencies.

• Inaddition,TheDepartmentofHealth(2010)paperon“EffectofBetterAccesson

interactionsbetweenGPsandpsychologists”reportsthattheBetterAccessProgram



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hasledtoimprovedpatientoutcomesbyencouragingcollaborativepracticebetween

GP’sandpsychologists.Theimplicationofthisbeingthatpeopleareabletoaccess

community-basedservicesthroughBetterAccessand,throughcollaborativecare

betweentheirGPandpsychologist,achievepositiveoutcomes–avoidingmoresevere

symptomologyandprotractedinpatienttreatment.

• Whileearlyinterventionsoonafterfirstepisode/diagnosis/returnofsymptomsis

essentialtoavoidmorecomplex,longtermmentalhealthdisorders,appropriate

interventionintheearlyyearsoflifealsohasthepotentialtoamelioratethe

developmentofmoreseveresymptomsandprovidebothhealthandeconomic

benefits.

• Currently,parentsandfamiliesofpatientswithamentalhealthdiagnosiscannot

accesssubsidisedinterventions.Thislimitationisproblematicforseveralreasons:(i)

parent-focusedinterventionsareacorefeatureofvariousevidence-basedtreatments

forchildhoodmentalhealthconditions(e.g.,David-Ferdon&Kaslow,2008;Evans,

Owens,&Bunford,2014;Eyberg,Nelson,&Boggs,2008;Keel&Haedt,2008;

Silverman,Pina,&Viswesvaran,2008);(ii)thecost-benefitpay-offishigherwith

parentandfamilyinclusioninchildandadolescenttreatments(Haine-Schlagel&

Walsh,2015;Karver,Handelsman,Fields,&Bickman,2006);and(iii)thereisclear

evidencethatearlyinterventionisoptimallyachievedwhenparentandfamily-based

interventionpackagesaredeliveredatdevelopmentallyappropriatetimes(Brittoet

al.,2017).Parentalparticipationinchildtreatmentsconsistentlyproduces

improvementsinchildhoodtreatmentoutcomes(Dowell&Ogles,2010).Moreover,

whenofferedincommunityandgroupsettings,parenting-basedinterventionsare

morecost-effectivethanchild-onlytreatmentssincetheyreducetheriskofrepeat

admissionsandreferrals(Duncan,MacGillivray,&Renfrew,2017;Lo,Das,&Horton,

2017;Mihalopoulosetal.,2015;Wrightetal.,2015).



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• TheinclusionofnewMBSitemnumbersenablingparentsandkinshipgroupstoaccess

psychologyservicescouldleadtoimprovedoutcomesforchildrenandfamilygroups.

Q.Whatchangesdoyourecommendtohealthcaretoaddressthespecificissuesofsuicides

andcomorbiditiesamongpeoplewithamentalillness?Whatevidenceistheretosupport

yoursuggestedactionsandwhattypesofimprovementswouldyouexpectintermsof

populationmentalhealth,participationandproductivity?

• ThereareseveralorganisationsacrossAustraliainvolvedinresearchingand

conductingpreventionandpostventionactivitiesrelatedtosuicideandmentalhealth.

• Suicidalideationandattemptscanoccurwithinthecontextofseveralmentalhealth

disorders(e.g.depression,BipolarDisorder,PTSD,substanceabuse,personality

disorders),andrisklevelscanchangequickly.Insuchsituations,removingbarriersto

accessingappropriatetreatmentiscentraltosavinglives.

• Twosuggestionsaremadeheretoassistwiththisissue:

o AllowphonesessionstobeincludedintheMBSlistofitemsforpsychological

servicesirrespectiveoftheresidentialaddressoftheclientandtheirtreating

psychologist(currently,phonesessionsareonlyavailableforclientsin

sufficientlyruralandremotelylocations).Acommoncomplaintsmadeby

clientsaboutusingsuicidephonelinesandwebsitesisthattheyhavetospeak

toastranger–thisisaconsiderablebarrieratpointintimewhenanindividual

alreadyfeelsutterlyoverwhelmed.Beingabletospeaktosomeonewithwhom

theyhaveapre-existingrelationshipmaymakeasignificantdifferenceto

whethertheyreachoutforhelp.



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o ImprovecollaborativecaremodelswithinmentalhealthservicesinAustralia,

(e.g.approveanMBSitemforpsychologiststobeinvolvedincase

conferencing).Thiswouldassistincomprehensivesupport,case

conceptualisationandtreatmentalignmentbetweenpsychologistsworkingina

privatepracticesettingandothermental/healthserviceswhentheyhavea

clientincommon.Increasedalignmentacrossservicesismorelikelytoresultin

collaborative,consistentandcohesivementalhealthcareandreducetherisk

ofclientsfallingthroughthe‘gaps’.Collaborativecaremodelsareconsistent

withcurrentpolicyrecommendationsfromanumberofdifferentsources

(InvestingtoSave–KPMGandMentalHealthAustraliareport,p.62,2018).

Q.Whathealthcarereformsdoyouproposetoaddressotherspecifichealthconcerns

relatedtomentalill-health?Whatisthesupportingevidenceandwhatwouldbesomeof

thebenefitsandcosts?

• Whilethemedicalmodeliscentraltoeffectivehealthcare,expandingthemodelto

includesocialdeterminantsofhealthandmentalhealthwouldleadtoamoreholistic

focusandapproachtohealthcare.Inaddition,particularlyinthecaseofmorecomplex

andseverehealthandmentalhealthdisorders–collaborativecaremodelsare

essentialtoovercomethesilosthatcurrentlyexistbetweenphysicalandmental

healthservices.Asimpleexampleofovercomingthisdistinctionwouldbethe

implementationofmentalhealth‘check-ups’withGP’salongwithphysicalhealth

‘check-ups’.GP’scouldregularlymonitortheirpatients’mentalhealththroughthe

standardapplicationofscreeningquestionnaires(e.g.onceeverysixto12months).

Forthosepatientsidentifiedas‘atrisk’,referraltopsychologiststhroughtheBetter

AccessProgramprovidesasimpleandaccessiblepathwayforpatientstoreceive

timelyinterventiontoavoidlongertermandmorecomplexpresentations.



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• SeealsoInvestingtoSave–KPMGandMentalHealthAustraliareport,2018.

Q.Whatoverseaspracticesforsupportingmentalhealthandreducingsuicideand

comorbiditiesshouldbeconsideredforAustralia?Why?Isthereformalevidenceofthe

successofthesepractices,suchasanindependentevaluation?

• TheUKImprovingAccesstoPsychologicalTherapies(IAPT)stepped-careprogramme

beganin2008,andhastransformedthetreatmentofadultanxietydisordersand

depressioninEngland.Over900,000peoplenowaccessIAPTserviceseachyear,and

theKing’sFundReport:AFiveYearForwardViewforMentalHealthcommittedto

expandingservicesfurther,alongsideimprovingquality(Naylor,TaggartandCharles,

2017;NationalCollaboratingCentreforMentalHealth,2018).

QUESTIONSONHEALTHWORKFORCEANDINFORMALCARERS:(p.17)

Q.Whatcouldbedonetoreducestressandturnoveramongmentalhealthworkers?

• Increasedleaveentitlements,financialincentives,supportedprofessional

developmentopportunities,self-careinitiatives(work-lifebalance,flexibleworking

hours),andaccesstoEmployeeAssistancePrograms.

Q.Howcouldtrainingandcontinuingprofessionaldevelopmentbeimprovedforhealth

professionalsandpeerworkerscaringforpeoplewithamentalillness?Whatcanbedoneto

increaseitstakeup?

• Trainingandprofessionaldevelopmentofferedasaconditionofemployment.

• Furthertrainingandprofessionaldevelopmentmandatoryforretainingregistration(as

isthecaseforpsychologistscurrently).



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• Accreditationoftrainingandprofessionaldevelopmentproviders.

• UtiliseEAP’sandthetrainingandprofessionaldevelopmenttheyoffer.

• Collaborativetrainingcoursesbetweenandfordifferentprofessionalgroups,e.g.GPs

trainingpsychologistsandviceversa;peoplewithlivedexperiencetraining

professionals.

Q.Whatchangesshouldbemadetohowinformalcarersaresupported(otherthan

financially)tocarryouttheirrole?Whatwouldbesomeofthebenefitsandcosts,including

intermsofthementalhealth,participationandproductivityofinformalcarersandthe

peopletheycarefor?

• EstablishanMBSitemforcarerstoaccesspsychologicaltherapy(individualand

group),ifneeded,inrecognitionoflong-term‘caring’asasignificantpsychosocial

stressor.

• Costswouldbeminimalagainstthebenefitsassociatedwithreducedratesofburn-

out,thedevelopmentofsupportnetworksandthereducedburdentothepublic

purseassociatedwiththeinformalcareofpeoplewithmentalhealthdisorders(as

opposedtoinpatientcareand/orformalisedcarethroughoutpatientprogramsor

paidcarers).

QUESTIONSONHOUSINGANDHOMELESSNESS:(P.19)

Q.Whatapproachescangovernmentsatalllevelsandnon-governmentorganisationsadopt

toimprove:

• supportforpeopleexperiencingmentalillnesstopreventandrespondto

homelessnessandaccommodationinstability?

• integrationbetweenservicesforhousing,homelessnessandmentalhealth?



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• housingsupportforpeopleexperiencingmentalillnesswhoaredischargedfrom

institutions,suchashospitalsorcorrectionalfacilities?

• flexibilityofsocialhousingtorespondtotheneedsofpeopleexperiencingmental

illness?

• otherareasofthehousingsystemtoimprovementalhealthoutcomes?

Q.Whatevidencecanwedrawontoassesstheefficiencyandeffectivenessofapproaches

tohousingandhomelessnessforthosewithmentalill-health?

Q.Whatoverseaspracticesforimprovingthehousingstabilityofthosewithmentalillness

shouldbeconsideredforAustralia?Why?Isthereformalevidenceofthesuccessofthese

practices,suchasanindependentevaluation?

QUESTIONSONSOCIALSERVICES:(p.21)

Q.Howcouldnon-clinicalmentalhealthsupportservicesbebettercoordinatedwithclinical

mentalhealthservices?

(Theabovequestionsareansweredbelow)

UnderlyingIssues:

• Theabsenceofsafeandsecureaccommodationcanhaveasevereandnegative

impactonaperson’sphysical,mental,socialandemotionalwellbeing.Shelterand

safetyarebasichumanrightsandintegraltothelowerlevelsofMaslow’sHierarchyof

Needs(Maslow,1943).



23

• AnecdotalreportssuggestthatthroughoutmanyregionsinAustralia,despitebeing

assessedaseligiblefor“prioritylisting”duetomentalhealthconcerns,peoplemaybe

waitlistedforseveralyearsbeforebeingofferedahome.Unfortunately,demand

outstripssupply.

• Thepublichousingsystemisoftendifficulttonavigateandlacksappropriateresources

intermsofbothadvocacyandstaffing.Theassessmentprocesscanbelengthyand

complex.Anecdotally,manypeoplegiveupasservicesare“toodifficulttonavigate”.

• Thisisparticularlydetrimentaltopeoplewithmentalhealthissuesfromvulnerable

sectorsofourcommunity,thatis,AboriginalandTorresStraitIslanders,peoplewho

aresociallyisolated,peoplewhoareunemployed,andatriskyouth.Centrallyco-

ordinatedhousingservicesthatmeetemergency,shorttermandlongertermneeds

arerequired,alongwithahighlevelofunderstandingandflexibilityforpeoplewith

mentalhealthdisorders-particularlywheninpatientcarecanjeopardizetheir

chancesofaccessingappropriatehousingsupport.

• Thereisasevereshortageofemergencyaccommodation.Inaddition,itappearsthat

peopleareregularlyreferredfromacutementalhealthcarefacilitiesdirectlyto



24

EmergencyAccommodationServices.Thisisinappropriateandrepresentsafracture

inthecontinuumofcareanddutyofcareprocess.Clientswhoarementallyunwell

andprematurelydischargedfromacutecarefacilitiesintoinappropriate

accommodationrepresentariskforcompletedsuicideormultiplepresentationsto

ED–placingfurtherpressureonemergencydepartmentsandthehealthbudget.

• Socialwelfareservicesremainsiloed.Theredoesnotseemtobeanyclearlinksor

accountability/responsibilitybetweentheDepartmentofHousing(DoH),Centrelink,

theHealthDepartment,specialistservices,non-governmentserviceprovidersand

privatesectorserviceswhosupportindividualsthroughtheMBS.Individualswith

complexmentalhealthneedsarerequiredtonavigatethesevariousdepartmentsand

servicesthemselves.Acentralisedsystemwithfacilitiestosupportthiscohortis

urgentlyneeded.

PossibleSolutions:

• ConsiderFinland’s“HousingFirstModel”.

• Sincethemid1980´stacklinghomelessnesshasalmostcontinuouslybeenafocusof

GovernmentprogramsinFinland.DuringrecentyearshomelessnessinFinlandhas

decreased(Pleace,Culhane,Granfelt,&Knutgard,2015).

• TheFinnishHousingFirstapproachwasintroducedtoaddresshomelessness.

Permanenthousingbasedonanormalleasewasseenasafundamentalsolutionfor

homelesspeople.Individuallytailoredsupportservices,increasingthesupplyof

affordablerentalhousingandpreventivemeasureswerealsopartoftheapproach.

Sincethen,hostelshavebeenconvertedintosupportedhousingunitswith

independentflatsforthetenants.Newsystemstosupportpeopleandtoimprove

integrationintheirneighbourhoodshavebeendeveloped.Homelesspolicieshave



25

beenbasedontheHousingFirstapproachsince2008.Thegovernment’sPAAVO

programs(2008-2015)targetedlong-termhomelesspeople(Pleace,Culhane,Granfelt,

&Knutgard,2015).

• “Asanoverallassessment,itcanbestatedthatthemaingoaloftheprogramme,the

permanentreductionoflong-termhomelessnessonanationallevel,hasbeenreached

withthehelpofacarefullyplanned,comprehensivecooperationstrategy.Programme

workinaccordancewiththeHousingFirstprincipleisproofofthefactthatwith

sufficientandcorrectlyallocatedsupport,permanenthousingcanbeguaranteedeven

forthelong-termhomelessinthemostdifficultposition.Thesignificantfinancial

investmentallocatedtotheprogrammebymunicipalities,organisationsandthestate

aswellastheextensive,long-termnationalandlocalcooperationhavemadeit

possibletointegratethedevelopmentofhousingandservicesbothonagenerallevel

andalsobytakingtheneedsofdifferenttargetgroupsintoaccount.”(Pleace,

Culhane,Granfelt,&Knutgard,2015,p.104).

• Shifttoanewsystemicneedsassessmentapproach(e.g.PowerThreatMeaning

Framework)toclearlyidentify“homelessnessandloneliness”aspartofthespectrum

ofpossibleriskfactors.

• Dramaticallyincreasepublichousingstock.Employbuildingcompaniesthatwill

undertakevocationaltrainingprogramsforlongtermunemployedandatriskgroups

withinthecommunity.

• UtiliseaPsychologicallyInformedEnvironments(PIE)approach.Basically:

”Weneedtoexpressthecomplexissuesunderpinningandmaintaininghomelessness

asaninteractionbetweenindividualsandtheirenvironment.Onewayinwhichthiscan

bedoneisthroughpsychologicallyinformedenvironments.”(Maguire2017,para.2).



26

“SowhatisaPIE?Well,atitsmostbasicitisanenvironmentthatmakesuseof

methods,whichareinformedbypsychologicaltheoriesandframeworks.Thiscouldbe

atanylevel,fromthewayinwhichhostelstaffmembersthinkabouttheproblemsthat

theirresidentsface,orhowriskprotocolsandpoliciesarewritten.Rightuptotheway

inwhichabuildingisconstructedandconfigured.”(Maguire2017,para.3)

“Psychologicaltheoriescanbeincrediblyusefulindescribinghowpeoplemaythink,

feelandbehavegivenasetofexperiencesandenvironmentalfactors.Forstaff,

understandinghowwethinkandfeelaboutthewayapersonisbehaving,mayenable

ustobemoreconsideredinourreaction.It’susefultounderstandgenerallyhow

trauma,e.g.inchildhood,warzonesoreverydaylife,canaffectthewaypeoplecope

withdifficultsituations,sothatwearelesslikelytomakejudgementsabout

behaviourswefinddifficultorchallenging.”(Maguire2017para.4)

Q.Aretheresignificantservicegapsforpeoplewithpsychosocialdisabilitywhodonot

qualifyfortheNDIS?Ifso,whatarethey?

• Therearecurrentlygapsforthosewhohavesignificantpsychosocial

difficulties/disabilitywhodonotqualifyfortheNDIS.Theydonotmeetpsychiatric

diagnosticspecificcriteriabuthavesignificantdeficitsinpsychosocialfunctioning.

Theseindividualshavedifficultyaccessingsupport,accessingfurtherandhigher

education,findinggainfulemployment,livingindependentlyandaccessingsustained

housing.

Q.WhatcontinuityofsupportareStateandTerritoryGovernmentsproviding(orplanto

provide)forpeoplewithapsychosocialdisabilitywhoareineligiblefortheNDIS?

• Currentlythereseemstobenocontinuityofcare.Thesystemisstillsiloeddueto

diagnosticspecificeligibilitycriteria.



27

Q.Arethedisabilitysupportpension,carerpaymentandcarerallowanceprovidingincome

supporttothosepeoplewithamentalillness,andtheircarers,whomostneedsupport?If

not,whatchangesareneeded?

• Disabilitysupportpensionsandcarerpaymentsareinadequate.Anecdotalreports

implythatitisdifficulttomeeteligibilitycriteriaformanyindividualswithmental

healthdisordersandtheircarers.Assessmentprocessesarenotpersoncentred.They

arelongwinded,requiremultipleappointments,arecomplextounderstandand

requirethatonlydepartmentalstaffareableto“deem”eligibilitybasedon

medical/psychiatricdiagnosticspecificcriteria.

• Thecurrentsystemdoesnotrecognizementalhealthonacontinuumandthatdeficits

infunctioning(includingcapacitytowork)canbeepisodicinnatureandfluctuateover

timeandinseverity.Itpreferencesthemedicalmodelofpsychiatricdiagnosis.Tobase

assessmentsonbiomedicalpsychiatricdiagnosticcriteriaisclearlyoutofstepwith

currentresearcharoundmentalhealthandevenatoddswiththecurrentholistic

functionalpsychosocialdisabilityassessmentthroughtheNDIS.“Mentalhealth

conditionsforwhichtheimpactoftheimpairmentvariesovertime(episodic)can

remainacrossaperson’slifetimeandcanbeconsideredlikelytobepermanent.”(NDIS,

2018,p.2).

• Therequiredpsychiatricdiagnosticlabellingalsoincreasesstigmatizationandreduces

thehopeandagencyoftheindividualinferring“Ihavethisillness/diagnosisforlife.”

• Thesystemisalsopunitiveinnature.Anecdotalreportssuggestthatmanyindividuals

arebeingdeniedpaymentsduetoaninabilitytomeetestablishedcriteriai.e.

attendingreviewappointmentsandcompletingpaperworkwithinrestrictivetime



28

constraints.Deficitsinfunctioningusuallyrelatedirectlytomentalhealthissues,for

example,anxiety,stress,poorindependentlivingskills,reducedcognitivefunctioning,

illiteracy,homelessness,povertyetc.

Q.Isthereevidencethatmentalillness-relatedincomesupportpaymentsreducethe

propensityofsomerecipientstoseekemployment?

• No.Itislikelythatreducedpropensitytoseekemploymentcouldbeexplainedbyan

absenceofhopeandsupporttoassisttheindividualtochangetheirsituation.

• Anindividual’scapacitytoseekandmaintainemploymentovertimeisimpactedbya

numberoffactors.Mentalillness-relatedincomesupportpaymentsareessentialfor

thosewhomostneedassistanceinourcommunity.Reducingorlimitingsupport

paymentsonlyincreasesfinancialstressanddetrimentallyaffectsfunctionalcapacities

onmanypsychologicalandwell-beingdomains.

Q.Howcouldmentalillness-relatedincomesupportpaymentsbettermeettheneedsof

peoplewhosecapacitytoworkfluctuatesovertime?

• Thecurrentsystemandreportingrequirementspenalizethoseindividualswhomaybe

makingprogresstowardsemploymentbutmayhavetoreducehoursintimesof

increaseddistress.Itisimportanttotailorpaymentstomakeallowancesforthis

phenomenonduringrecovery.Currentreportingprocessestendnottosupportthe

recoverymodelinmentalhealth.

• Paymentsbeing“earningsspecific”intheshorttermisproblematic.Thatis,support

paymentsshouldbeconsistentandpartofalongertermrecoveryplanthatsuitsthe

individual’sneeds.



29

QUESTIONSONSOCIALPARTICIPATIONANDINCLUSION:(p.22)

Q.Inwhatwaysaregovernments(atanylevel)seekingtoimprovementalhealthby

encouragingsocialparticipationandinclusion?Whatevidenceistherethatpublic

investmentsinsocialparticipationandinclusionaredeliveringbenefitsthatoutweighthe

costs?

• Governmentinitiatedsocialparticipationandinclusionprogramsvaryacrosslocations

andlevelsofgovernment.

• Somelocalgovernmentsprovidesocialparticipationandinclusionprogramsat

communityandrecreationcentres,e.g.LivingStrongerLivingLongerprogramsat

gymnasiums.

• AttheFederallevel,programssuchasFamilyMentalHealthSupportServicesare

offeredandprovideearlyinterventionsupporttochildrenandyoungpeopleuptoage

18yearswhoareshowingearlysignsof,orareatriskofdeveloping,mentalillness.

• TheMentalHealthStatementofRightsandResponsibilities(AustralianGovernment,

2012)setsoutavisionforthewaythoseexperiencingmentalhealthdisorderscanbe

assisted.PartII:Non-discriminationandsocialinclusionstates:

“(3)Non-discriminationandsocialinclusionarefundamentaltothementalhealthof

thewholecommunity.Thereisarecognisedcorrelationbetweenseveremental

illness,lowsocio-economicstatusandsocialexclusion.”

“(4)Mentalhealthconsumershavetherighttosocialinclusionandparticipationin

sociallifeonanequalbasiswithotherswithoutdiscriminationofanykind.”(Australian

Government,2012,p.7).



30

Q.Whatroledonon-governmentorganisationsplayinsupportingmentalhealththrough

socialinclusionandparticipation,andwhatmoreshouldtheydo?

• Act-Belong-Commit(MentallyHealthyWA)isanevidence-basedmentalhealth

programaimedatincreasingindividualandcommunitywellbeingbyfocussingon

increasingconnectionsbetweencommunitymembers

(https://www.actbelongcommit.org.au/).ItwasstartedinWesternAustraliaandhas

nowexpandedtootherstatesandfurther.Programsofthisnature–beingboth

promotionalandpreventiveandfocussingonincreasingcommunityengagementand

socialinclusion-areinlinewithMaslow’sHierarchyofNeeds(seeabove)and

reinforcethebenefitsofsuchendeavours.Socialconnectednessisabasichuman

need,and,byimplication,contributestopositivementalhealthoutcomes.

• TheRecoveryCollegeservicemodel,duetobetrialledinWesternAustraliain2019,

hasbeenshowntobeinclusive,toaddressthepowerdifferentialbetween

practitionersandclients,topromotesocialparticipationandreducepsychological

isolation,i.e.duetopeertopeerinteractions(Perkins,Meddings,Williams,&Repper,

2018).

Q.Arethereparticularpopulationsub-groupsthataremoreatriskofmentalill-healthdue

toinadequatesocialparticipationandinclusion?What,ifanything,shouldbedoneto

specificallytargetthosegroups?

• Therearecertainlysomegroupswithinthecommunitythatstrugglewithsocial

isolationandexclusion.Theseinclude:IndigenousAustralians,ruralandremote

communities(includingfarmers)newimmigrants,economicallydisadvantagedpeople,

refugeesandpeoplewithbothmentalandphysicaldisabilities.Appropriatelytrained

practitionersarerequiredtoworkwiththesecommunitiesandfacilitatesocial

participationandinclusion–alongwithreferralstospecificmentalhealthservicesas

needed.



31

Q.Whatindicatorsaremostusefultomonitorprogressinimprovingmentalhealth

outcomesthroughimprovedsocialparticipationandinclusion?

• Giventhatsocialparticipationandinclusionisaprimaryhumanneed,onewould

expectanumberofpositiveoutcomesfollowingimprovementinthisareaasindicated

bythefollowing:

- Lowerratesofhospitaladmissionsformentalhealthissues.

- Reducedsuiciderates.

- Decreasedutilisationofmentalhealthservicese.g.theBetterAccess

Program.

- Reductionintherateofprescriptionforpsychotropicmedication.

- Reducedhomelessness.

- ChangesinMedicarerefundsformentalhealthconsultations,and

improvementinotherdirectmeasuresofmentalhealthandwellbeing,

e.g.K10,MMPI,PAI.

QUESTIONSONJUSTICE(p.24)

Q.Whatmentalhealthsupportsearlierinlifearemosteffectiveinreducingcontactwith

thejusticesystem?

• Aholisticapproachwhichunderscoresthevaluesofsafety,basicneedsandwellbeing

ofcommunitiesandindividualsisanimportantfactorinreducingfuturecontactwith

thejusticesystem.Peoplefromlowsocioeconomicorminoritygroups(particularly

AustralianAboriginalandTorresStraitIslandergroups)arevulnerabletocominginto

contactwiththejusticesystem.Therehasbeenanoverrepresentationofsuchgroups

inthejusticesystem,likelybecauseofearlycontactwithantisocialrolemodelling,

substanceabuse,physicalandsexualabuseandothertrauma,povertyand



32

displacement.Supportsthatareculturallyappropriateandassistpeopleholistically,by

tendingtobasicneedssuchastheprovisionofadequatelivingconditions,are

requiredinadditiontocommunity-basedmentalhealthinterventions,suchas

parentingprogramsandsubstanceabuseinterventions.Manyindividualswhooffend

havehadparentswhocameintocontactwiththejusticesystemthemselvesorwho

havesubstanceuseissues,therefore,ahighlevelofsupporttopregnantmothers(and

theirimmediatesupports,suchaspartners)mayamelioratethestressthatislikelyto

leadtoacontinuationofthenegativefeedbackloopinthesefamilies.

• Duetothetransgenerationalnatureoftraumaandthehigherlevelofincidenceof

mentalillnessinchildrenofparentswithamentalillness,engagingneworwould-be

parentsinparentingprograms,traumacounsellingandothermentalhealthservices,

wouldincreasethelikelihoodofbetteradjustmenttoparenting,anddecrease

likelihoodofmentaldisorderssuchaspost-nataldepressionandhenceleadtolower

stresslevelsforthechildandparent/s.Itisoftenbestfortheyoungchildtoremain

withtheirmotherevenwhensheisincarceratedorexperiencespsychosocialor

mentalhealthproblems.

Therefore,thesemotherscanbeengagedinparentingprograms,psychological

treatmentandothersupportservicestoenhancetheirlife,aswellasbeprovidedwith

adequateplacementfollowingsentencing.Ideally,prisonsthatarestructuredto

accommodatemothersandtheirchildren,aswellasmimicdailylifeinthecommunity

providethebestenvironmentforsuchwomen.

• Childhoodtraumaisanothersignificantfactorunderpinninglateroffending(asa

juvenileandadult).Thereisahighnumberofchildrenwhoexperiencephysicaland

sexualabuseinAustralia.Ahighnumberofabusedchildrengrowuptodependon



33

drugsandalcoholasacopingmechanismfornumbingthemfromtheemotionaltoilof

trauma,hencepredisposingthemtoactinantisocialways.

• Supportingthesechildrenandprovidingthemwithageappropriatetreatment(suchas

playtherapyfortrauma)assoonaspracticablecanassistinrestoringthechildona

normaldevelopmentaltrajectoryanddecreasingtheriskofthechilddevelopinga

mentaldisorderorre-enactingthevictim/perpetratorrolebyvictimisingothersasan

adult.Theremayalsobeadiscrepancybetweencourtprovidedvictimsupportservices

andcommunityandpostcourtengagementservices.Aschildrenwhohaveatleast

onesupportivecaregiverorparentaremuchmorelikelytoovercomesymptoms

associatedwithsuchtrauma,itmaybebeneficialforthesupportingcaregiverstobe

engagedinpsychologicaltreatmenttoeducatethemabouttheseissuesandalso

providetreatmentiftheparentsarethemselvesexperiencingmentalhealthproblems.

• Familytreatmentmayalsobebeneficial.Forexample,familysystemicapproaches

withyoungoffendersappreciatethesocialcontextintowhichtheyouthreturns,with

theseinterventionsmorelikelytomaintainpositivechanges.Suchprogramsinthe

WesternAustralianjusticesystemwereabandonedduetoawithdrawaloffunds,

possiblyduetothedifficultiesofimplementation(e.g.attendingoffenders’homes).

Parenttrainingprogramsandprogramsaddressingparentabusehavehadsome

preliminaryimplementationinAustralia,buttherehasarequirementforfurther

researchintothisarea.(YouthJusticeReviewandStrategy–Meetingneedsand

reducingoffendingbyPArmitageandProfessorJOgloff2017,Victoria(publishedon

justice.vic.gov.au)



34

Q.Towhatextentdoesinadequateidentificationofmentalhealthandindividualneedsin

differentpartsofthejusticesystemincreasesthelikelihood,andextent,ofpeoples’future

interactionswiththatsystem?

• Thereisahighnumberofindividualssufferingfrommentalhealthproblemsand

mentalillnesswhocomeintocontactwiththejusticesystem.Manyofthese

individualsarenotdiagnosedadequatelyduetolimitedcontactbetweenmental

healthcareprovidersandthejusticesystem.WhiletheJusticeDepartmenthas

increasinglysoughttoassessmostoffenders,manyonlyundergosuchprocesseswhen

theirriskofreoffendingishigh,ortheiroffencesareofaseriousnature.

Therefore,forsomeofthosewhomayappeartobeatlowerrisk(butwithpersistent

mentalhealthissues)mayslipthroughthegaps,beleftuntreatedandreoffend.The

prioritisationofhigh-riskandhigh-needoffendershasledtootherswhoseriskand

needsmayremainunaddressed,particularlyinthecurrentclimateofprison

overpopulationandhighincarcerationrates.Further,similartothehigh-riskoffenders,

onlyhighlydistressedindividualswithalreadydiagnosedmentalillness(suchasdueto

privateclinic/GPdiagnosisorfollowingapsychiatricsentencingassessment)may

receiveimmediatepsychologicalandpsychiatrictreatment.

Thoseindividualswhoaredeemedtobecopingarelikelytobeoverlookedfor

individualintervention.Therefore,theirproblemsareleftunaddressedandthey

presentthesameriskofrecidivismastheyhaveuponinitialjusticesystemcontact.

• Inaddition,offendersmaybeassessedtoinformsentencing,however,these

assessmentsaretreatedconfidentiallyandfuturecaregiversortreatmentproviders

maynothaveaccesstosuchinformation.Thereisnospecialistpsychological

assessmentservicetoscreenalloffendersformentalhealthproblemsanddisorders.

Asaresult,theoffendingindividualmaynotreceiveappropriatetreatmentunlessthey

havehadanassessmentfordifferentreasons(e.g.forsentencing)andbeenidentified



35

andflaggedasrequiringspecificmentalhealthtreatment.Individualswhoreceive

shortersentencesareoftenoverlookedforoffenderspecificprogramsandother

treatment.Asaresult,theyarelikelytoreoffendinasimilarmanner.Evenifoffences

areconsideredtobeofageneralistandminornature(e.g.non-violentoffences),

repeatedoffendingpresentsconsiderablecoststosocietyandfuelsanantisocial

undercurrentinthecommunity;possiblybreedingthepropensityforfurther

offending.

Q.Wherearethegapsinmentalhealthservicesforpeopleinthejusticesystemincluding

whileincarcerated?

• Unfortunately,resourcesarelimitedandthenumberofpsychologicaltreatment

sessionsprovidedforindividualswithahistoryofseveretraumaisofteninadequate.

Thereisalsoalackofspecialistpsychologicalgroupstoprovideappropriatetreatment

topreventre-offending.

• Thefocusofthejusticesystemislargelytopreventrecidivismbyaddressinganumber

ofcriminogenicfactors,ofwhichmentalillnessisonesuchfactor.Asaresult,thereisa

prevalenceofoffenderspecificinterventionaimedtoprovideskillsand

psychoeducationtoreducereoffending,addresssubstanceabuseandaddressviolent

orsexuallyabusivebehaviourthroughcognitive-behaviouralbasedprograms.While

theseinterventionshavebeenfoundtobeeffective,mostofthestudiesconducted

followoffendersuptofiveyearspostsentence.Thereisariskthatunderlying

psychosocialfactors(e.g.pooraffectregulationduetochildhoodtrauma)remain

unresolved,leadingtoacyclicpatternofreoffending.

• Asearlytraumaexperiencesarecommonamongstoffendingindividualswithmental

healthproblemsanddisorders,itisparamountthatthisbeaddressed.Somestaffwho



36

providecounsellinginprisonsmaynotbeadequatelytrainedtoprovidesuch

interventions.Inaddition,counsellingservicesinprisonsareoftenlimitedduetoa

focusonsuicideandself-harmpreventionandothercrisisinterventions.Asnoted

previously,duetotheoverpopulationofprisons,crisisinterventionseemsto

predominatethePrisonCounsellingServices.

• Whileoffendingindividualsinthecommunitymaybeassessedasrequiringtrauma

specificpsychologicalintervention,therearefewsuchpsychologistsworkinginthe

justicesystem.Whileoffendingindividualsmayseekexternaltreatment,manyare

fromlowsocio-economicbackgroundsandcannotaffordtheservicesofaprivate

psychologistspecialisingintrauma.Evenwhenthepsychologistisabletobulkbillthe

client,10sessionsisinadequatetoaddressalifetimeoftraumaandmarginalisation

thatsomeoftheseindividualshaveexperienced.

Q.Whatinterventionsinthejusticesystemmosteffectivelyreducethelikelihoodofre-

offending,improvementalhealthandincreaseprospectsforre-establishingcontributing

lives?Whatevidenceisthereaboutthelong-termbenefitsandcostsoftheseinterventions.

• Thecurrentinterventionsinplaceaimedtoreducerecidivismrateslargelyinclude

programsbasedonthe‘WhatWorks’literatureincludingtheRisk-Need-Responsivity

modelwhichaddressidentifiedcriminogenicfactorsassociatedwithoffending.For

example,therehavebeenavarietyofprogramsaddressingsexualandviolent

offending,sometimesspecificallyaimedatvariousgroups,forexampleIndigenous

offendersorthosewithintellectualdisabilities.Therehavebeenprogramsaddressing

varioustypesofviolentbehaviours,suchasthosemorespecificallyaimedatmen

perpetratingspousal/partnerabuse.Althoughthereareprogramsforwomen,theyare

oftendevelopedbasedonmaleoffendingliteratureandlackculturalsensitivity.Asa

result,theseprogramsareconsistentlyinneedofmodification.Otherprograms,such



37

ascognitiveskillsandsubstanceabuseareaimedatgeneralistoffendersoradjunct

problems.Programsarealsoadministeredaccordingtotherisk-needmodel,with

higherriskoffendersbeingmorelikelytoaccesssuchprogramsthanlowrisk

offenders.Further,theprogramsprovidedvaryinintensity,withhighintensity

programsbeingmostappropriatetoaddresshighrisk-needs.Theprogramsthatarein

placetoaddressviolentandgeneralistoffendingdowelltoreducetheriskof

recidivism,atleastintheimmediateterm.However,evidenceisstillbuildinginregard

totheefficacyofcurrenttreatmentofoffenders,particularlythosesufferingfrom

mentalhealthproblems.Asaresult,continuousresearchanditsapplicationinthe

developmentofoffendertreatmentneedstocontinue.Offenderswhoexperiencea

holisticapproachtotreatment,byaddressingtherelevantcriminogenicneedswhile

beingresponsivetotheirmentalhealthproblems,mayhavebetteroveralloutcomes

andbecomeproductivemembersofsociety(Egan,2013).

• ApositiverolemodelofaprisonsystemcanbefoundinScandinaviancountrieswhere

imprisonmentsratesarelow,recidivismislowandprisonconditionsarethemost

humaneintheworld.Whileconsiderablefinancialinvestmentwasmadetoleadto

suchchanges,thepositiveoutcomesandlowprisonernumbersarelikelytobemost

costeffectiveduetosavingsinlegal,socialandhealth(includingmentalhealth)costs

associatedwithimprisoningoffenderswhoconsistentlyreoffend(Pratt,2008).

Q.Whatarethemainbarrierstoloweringtheover-representationofpeoplelivingwitha

mentalillnessinthejusticesystemandwhatstrategieswouldbestovercomethem?

• Thekeybarrierstodecreasingthenumberofindividualswithamentalillnessinthe

justiceservicesinclude;

-thelackofholisticapproachestoaddressoffendingbehavioursandmentalhealth

-thedifficultyofaddressingmentalhealthissueswithinregionalandremoteareas



38

-alackofmentalhealthtreatmentwithinthejusticesystem(includinginprisonand

thecommunity)

-insufficientavailabilityofsubstanceusetreatmentforoffendersinthecommunity

-alackofconnectednessbetweencommunity-basedsupportorganisations,mental

healthorganisationsandthejusticesystem

-ashortageoffamily,systemicandsocialapproachestotargetoffendingandmental

healthissues.

• Connectingjusticeandmentalhealthservicesandfocussingontreatmentratherthan

punitivemeasuresappearstobemosteffectiveinreducingmentalhealthproblems.

IncentivessuchastheSTART(MentalHealth)CourtinWesternAustraliaisanexample

ofaholisticsupportandinterventionprogramthatassiststhosesufferingfrommental

illnesswhohaveoffended.Serviceswithinthisprogramincludelegal,psychological,

socialandpractical,withindividualsexperiencingapositiverelationshipwiththe

professionalsinvolvedleadingtopositivepreliminaryoutcomes.Theextensionofsuch

programsislikelytoyieldpositiveresultsanddecreasethenumberofindividualswith

mentalillnesswhoalsooffend.

• Implementingregionalspecificservicesandincreasingpsychologicaltreatmentin

theseareaswouldalsobeofbenefit.Increasingincentivesforexperiencedand

endorsedpsychologiststotraveltoregionalareasmayleadtohigherqualityof

servicestotheseareas.

• Increasingspecialistpsychologistswhoarequalifiedtoworkwithcomplextraumaand

mentalhealthdisordersandwhohaveanunderstandingofsocial,developmentaland

culturalissues(specificallyforensic,clinicalandcounsellingpsychologists)islikelyto

increasethequalityofservicestargetingoffenderswithmentalhealthproblemsand

disorders.Therecouldbeaseparateservicewithinprisons(aswellasinthe



39

communityjusticeservices)thatemploysorcontractssuchprofessionalstosolely

addressthementalhealthdifficultiesandaddresstheimpactoftraumathatthe

offendermayhaveexperienced,ratherthanaprimaryfocusonrecidivismrisk,which

oftenleadsindividualstofeelmisunderstoodandstereotyped.Connectingand

identifyingexternalpsychologistswhomaybeabletoassistlowriskoffenderswith

mildermentalhealthproblemsmayalsobebeneficial.Further,theimplementationof

aMedicarebasedmodelforthetreatmentoftraumaspecificormentalhealthco-

morbiddisorders(forexampledepressionandsubstanceabuse)allowingforaccessto

agreaternumberofannualpsychologicaltreatmentsessionsislikelytobridgethegap

betweenmilderformsofmentalillnessandseverementalhealthissueswithco-

morbidproblemssuchasdruguseandoffending.

• Whilethereareanumberoforganisationstargetingsubstanceuseinthecommunity,

manyofthesearestrugglingtomeetthedemandsfortreatment,whichcanmeanthat

offendersseekingtoaddresssubstanceabuseinthecommunitymaybewaitlisted.

• Anotherapproachtoconsidercouldbegroupmindfulness/relaxationandmeditation

sessionsconductedinprisons(andeveninthecommunity)asanadjuncttooffender

relevanttreatmentandassistinaffectregulationandstressmanagement.

• Thejusticesystemcouldseektodevelopandreintroducefamilyandsystems-based

interventionsinordertoaddressgreatersystemicissuesandpreventlifetimesof

offendingbyjuvenileswhocomeintocontactwithjusticeservices,andwhoare

embeddedwithinantisocialnetworks.

Q.Towhatextentdoinconsistentapproachesacrossstatesandterritoriesleadto

inefficientineffectiveorinequitableoutcomesforoffendersandtheirfamilies?



40

• EachstateandterritoryinAustraliaimplementdifferentapproachesandservices

leadingtodifficultiesincomparingoutcomesofinterventionsacrossAustralia,limiting

furtherresearchandthedevelopmentofnewapproaches.

• Attimestherehasbeenalackofcommunicationbetweenstates,leadingtoalackof

knowledgeaboutproposedinterventionsanddelayingtheirimplementation.For

example,therehasbeenagreatdealofresearchconductedwithinthejusticesystem

inVictoria,butlesssoinotherstates.Otherstates,suchasWesternAustraliamayfind

itdifficulttoimplementcertainstrategiesdevelopedelsewhereduetoadifferent

populationgroupandthegeographyoftheregion.

• Approachesinonestate,forexamplefamilyandsystems-basedservices,maybe

experiencingdevelopmentandgrowth,butarenotrolledoutinotherstatesleadingto

alackofeffectivetreatmentoptionsonanationalbasis.

QUESTIONSONCHILDSAFETY(p.25)

Q.WhataspectsofthechildprotectionprogramsadministeredbytheAustralian,Stateand

TerritoryGovernmentsarethemosteffectiveinimprovingthementalhealthofpeoplein

contactwiththechildprotectionsystem?

• TheCommonwealthofAustralia(2009)releasedtheNationalFrameworkfor

ProtectingAustralia’sChildren2009–2020thatguidestheearlyinterventionandchild

protectionresponsesofeachstateandterritoryandprovidesindicatorsthroughwhich

outcomescanbemeasured.

• Earlyinterventionandfamilysupportservicesareprovidedbystateandfederal

organisations.However,eachstateandterritoryisresponsibleforthechildprotection



41

mattersoftheirresidents.Duetoallnational,stateandterritoryservicesbeingguided

bytheNationalFrameworkforProtectingAustralia’sChildren(Commonwealthof

Australia,2009),alloperationalframeworksandpoliciesemphasisethebestinterests

ofthechild,supportingfamiliesintheircommunities,earlyinterventionand

prevention,culturalsensitivity,multidisciplinaryteamsandinter-agencycooperation.

Thereisalotofscopeforpsychologiststoworkinallareaswithinthesefederaland

statesystemsasthephilosophyandcompetenciesofpsychologistsalignwiththeaims

andprinciplesoftheseservices.

• Resourcesforeachnational,stateandterritory’spoliciesandframeworks:

Federal

AustralianGovernmentDepartmentofSocialServices(2015)

ACT

ACTGovernmentDepartmentofCommunityServices(2017)

http://www.communityservices.act.gov.au/ocyfs/children/child-and-youth-protection-

services

NSW

NewSouthWalesGovernmentDepartmentofHealth(2013)

http://www.health.nsw.gov.au/parvan/childprotect/Pages/counselling.aspx

https://www.health.nsw.gov.au/parvan/childprotect/Pages/default.aspx

NT

NorthernTerritoryGovernmentDepartmentofChildrenandFamilies(n.d.)

https://territoryfamilies.nt.gov.au/about/publications-and-policies

QLD

QueenslandGovernmentDepartmentofCommunities,ChildSafety,andDisabilities

Services(2018)

https://www.csyw.qld.gov.au/childsafety/child-safety-practice-manual

SA



42

https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+intern

et/clinical+resources/clinical+topics/child+protection

https://www.childprotection.sa.gov.au/department

TAS

TasmanianGovernmentDepartmentofHealthandHumanServices(2016,2018)

VIC

VictorianGovernmentDepartmentofHumanServices(2007)

http://www.cpmanual.vic.gov.au/our-approach/best-interests-case-practice-model

WA

WesternAustraliaGovernmentDepartmentofCommunities(2018)

WesternAustralianGovernmentDepartmentofHealth(2015)

https://www.dcp.wa.gov.au/Organisation/Pages/PolicyFrameworks.aspx

• Whilethepolicies,proceduresandservicesinthefederaljurisdictionandwithineach

stateandterritoryappeartobeguidedbythesameprinciples(outlinedintheNational

Framework),thestructureoforganisationsandtheservicesprovidedareverydiverse.

TofullyanswerthisquestioninrelationtoallchildprotectionservicesinAustralia,

wouldbeanentiresubmissioninandofitself!Wedonotthinkitiswithinthescopeof

thecurrentinquirytogointothatmuchdetail.

Q.What,ifany,alternativeapproachestochildprotectionwouldachievebettermental

healthoutcomes?

• Parentalmentalhealthhasbeenshowntobeapredictorofchildrenbecoming

involvedinchildprotectionsystemsandofnegativechildmentalhealthoutcomes

(Darlington&Feeney,2008;Jeffreys,Rogers,&Hirte,2011;O’Donnelletal.,2015;

Sheehan,2005).ThisisrecognisedinsupportingoutcomethreeoftheNational

FrameworkforProtectingAustralia’sChildren(CommonwealthofAustralia,2009):



43

“riskfactorsforchildabuseandneglectareaddressed”.O’Donnelletal(2015)

considertheparentaldiagnosesthatarelinkedwiththegreatestriskofchild

protectioncontact.However,theNationalFrameworkforProtectingAustralia’s

Children’sIndicators(AustralianInstituteofHealthandWelfare[AIHW],2018)shows

thatthenumberofparentswithmentalhealthissueshasincreasedbetween2009and

2018.Noanalysisexistsastowhetherthisincreaseisgreaterthanpopulationgrowth.

Regardless,morecouldbedonetoimproveparentalmentalhealthtodecrease

contactwiththechildprotectionsystem,andpromotebetteroutcomeswhere

childrendobecomeinvolvedwiththesystem.

• ThefourthactionplanoftheNationalFrameworkforProtectingAustralia’sChildren

(CommonwealthofAustralia,2018)suggestsfourpriorityareas:

1)ImprovingoutcomesforAboriginalandTorresStraitIslanderchildrenatriskof

entering,orincontactwith,childprotectionsystems.

2)Improvingpreventionandearlyinterventionthroughjointserviceplanningand

investment.

3)Improvingoutcomesforchildreninout-of-homecarebyenhancingplacement

stabilitythroughreunificationandotherpermanentcareoptions.

(TheRoyalAustralianandNewZealandCollegeofPsychiatrics(2015)recommend

assessmentandtreatmentprinciplesforimprovingoutcomesforchildreninout-of-

homecare.Thesesuggestionsincludeworkinginmulti-disciplinaryteams.)

4)Improvingorganisations’andGovernments’abilitytokeepchildrenandyoung

peoplesafefromabuse.

• TheNationalFrameworkforProtectingAustralia’sChildrenIndicators(AIHW,2018)

onlypresentsnationaldata;eachstateandterritoryisresponsibleforstructuringand

implementingchildprotectionservicesindependently;so,itisdifficulttodetermine

whichservicesareachievingbetteroutcomes.



44

• Despitepolicyandproceduralguidelinesthataimforcontinuityofcareand

interagencyco-operation,oftenserviceprovisionbetweenearly

intervention/preventionservicesandchildprotectionagenciesarefragmentedand

notwellco-ordinated.Fragmentedservicesandlackoftrauma-informedservicescan

resultinre-traumatisationforfamilieswhohavealreadyexperiencedchronicand

complextrauma(Wall,Higgins,&Hunter,2016).Itisthereforesuggestedthat

continuityofcarethroughoutallstagesofcontactwiththechildprotectionsystembe

improvedtoachievebetteroutcomesforchildrenandtheirfamilies.(Clinicaland

counsellingpsychologistshavetrainingandskillsinworkingwithtraumaandcould

contributetodeliveringtrauma-informedservices.)

• VictorianAuditor-General’sOffice[VAGO](2018)foundthatstaffinthechild

protectionworkforceinVictoriasufferednegativementalhealthoutcomesimpacted

by:

a)longandunpredictableworkinghours,

b)repeatedexposuretotrauma,violenceand,onoccasion,death,

c)difficultinteractionswiththepublic,and;

d)highprofessionalexpectation.

Itislikelythatthisisthecaseinallchildprotectionworkforces,althoughthereislittle

research/evidencecurrentlyavailableinotherstatesorterritories.

Enhancingthementalhealthofthechildprotectionworkforceislikelytoincreasethe

abilityofworkers/servicestoworkcollaboratively,workwithcomplexneeds,and

achievebetteroutcomesforfamiliesandchildren.

VAGO(2018)suggestedthatthereneedstobemorechildprotectionemployeesto

reduceworkloadsandincreasedsupportforchildprotectionemployeestopromote

bettermentalhealthintheworkforce.Two(offour)recommendationstobetter

supportchildprotectionworkersare:



45

1)Mentalhealthtrainingforallchildprotectionworkers,and

2)Betteravenuestoreport/respondtomentalhealthconcerns;therearesixavenues

suggested,twoofwhichareaccesstopsychologicalcounselling(EAP)andimproving

responsestocriticalincidentsthatcausedistress.

QUESTIONSONEDUCATIONANDTRAINING(p.26)

Q.Whatarethekeybarrierstochildrenandyoungpeoplewithmentalill-health

participatingandengagingineducationandtraining,andachievinggoodeducation

outcomes?

• Therearemanypossiblefactorsthatseemtoactasbarrierstochildrenandyoung

peoplewithmentalill-healthparticipatingandengagingineducationandtraining,and

thatdisrupttheircapacitytoachievepositiveeducationaloutcomes.Theyinclude:

Withinprimaryandsecondaryschoolsettings-thecapacityandskillstheteacher

hastomanagesymptomaticbehavioursintheclassroom.Behavioursareoften

seen/labelledas‘disruptive’‘naughty’and‘oppositional’.Theselabelsmayleadto

stigmatization.Insomecases,‘acting-out’behaviourcanbeexplainedby

underlyingmental-healthcondition(s)thatneedtobeunderstoodandtakeninto

account.

Alackofsupportprovidedtotheparentsofchildrenwithmentalhealthdisorders.

Asaresult,familystressesincrease,siblingissuesincrease,maritalstresses

increaseandthetrickle-downeffectlikelyfurtherexacerbatesthechild’smental

healthsymptomologyandengagementwitheducation.



46

Socialandculturalfactors–ascitedintheTheMentalHealthofChildrenandAdolescents.

ReportonthesecondAustralianChildandAdolescentSurveyofMentalHealthandWellbeing

(2015).

Lackofmotivationtolearnwhichmayresultfromenvironmentalfactors,suchas

familyvalues.

Lackofintrinsicmotivationaffectedbyemotionalfactorssuchas:

§ Lackofconfidence

§ Negativeself-evaluation

§ Fearofinadequacy,failure

§ Shyness

§ Impulsivity

§ Boredom

§ Notrelatingtoteacher

Ormentalhealthfactorssuchas:

§ Emotionaldysregulation

§ Feelingunsafeintheclassroom,especiallyforchildrenwhohave

experiencedabuse

§ Childrenwhohaveexperiencedtraumaareunabletoconcentrateandstay

focused–oftenlabelledADHD

§ Depression

§ Insecureattachment–problemsconnectingtoothersorinseverecases

§ Anxiety

Youngpeopledonotnecessarilyunderstandthattheyneedhelp.Youngpeople’s

behaviourisanexpressionoftheirneurologicalneed,consequently,theyadaptand

developcopingbehaviourstodealwithsituationsintheleastpainfulway.Adolescents

inparticular,areoftennotmotivatedtoseekhelp.



47

Parentsareoftennotwillingtoacceptthattheirchildmayhaveamentalhealth

problemthatisinterferingwiththeirlearning.

Parentsmaynotbewillingtotaketheirchildoutsidetheschoolenvironmentfor

psychologicalhelp,orbehamperedbytimeconstraints,financialissues,oralackof

motivation.

Teachersnotwelltrainedinchilddevelopmentandemotionalhealthofchildren.

Teachersnottrainedintheimportanceofcreatinga“safeclassroom”forchildren.

TheeducationsysteminAustraliadoesnotadequatelyfocusonthementalhealthof

studentsasanintegralaspectoftheschoolcurriculum.Manystudentswhoare

underachievingwouldbenefitfrommoretimebeingspentonachievingemotional

wellbeingintheirprimaryschoolyears.Moreschoolpsychologistsareurgently

requiredAustralia-wide.Afocusonthepsychologicalwellbeingofprimary-aged

childrenasanintegralaspectoftheschoolcurriculumwouldnotonlyleadto

improvededucationaloutcomes,itwouldadditionallyprovidetheopportunityfora

preventativefocusinmentalhealthcareAustralia-wide.

Q.Isthereadequatesupportavailableforchildrenandyoungpeoplewithmentalill-health

tore-engagewitheducationandtraining?

• Unfortunately,not.

• Schoolpsychologists,whilehavingthemostappropriatetrainingandexperienceto

assistchildrenandyoungpeoplewithmentalill-healthtore-engagewitheducation



48

andtraining,unfortunatelyhaveanumberofcompetingdemandsontheirtimeand

areoftennotinapositiontoprovideadequatesupporttothiscohort.

• Moreschool-basedpsychologistsareurgentlyrequiredAustralia-wide.

• Psychologistscanassistteacherswithin-classbehaviourmanagementskillsandwith

understandingbehavioursrelatedtomentalhealthconditions.Increasedaccesstoin-

classassistanceforteachersbypsychologistscouldleadtomorepositiveeducational

outcomesforchildrenwithmentalhealthdisorders.

• Thesocialandemotionalwellbeingofprimaryandhighschoolstudentsneedstobe

viewedasapriority.Mentalill-healtheffectsallareasoflearning.

• Havingorganisationsexternaltoschoolssupportingyoungpeople,suchasHeadspace,

isineffectiveintheabsenceofacollaborativecaremodel.

• Giventhatprimaryandhighschoolagedchildrenspendapproximately6hoursperday

atschool,thereisanopportunitytoeducatechildrenaboutmentalhealth;toassess

andprovideearlyinterventiontreatments;andimproveeducationaloutcomesfor

childrenatriskofmentalhealthdisorders–butonlyifthereisamoreorganised

approachtodealingwithmentalhealthissueswithintheschoolenvironment.

Q.Dostudentsinalllevelsofeducationandtraininghaveaccesstoadequatemental

health-relatedsupportandeducation?Ifnot,whatarethegaps?

• No-thereissignificantinconsistencyinsupportprovidedbetweenschools–both

publicandprivate.Unfortunately,accesstopsychologicalsupportisoftenmostlimited



49

inlowsocioeconomicareasandforfamilieswithoutthemeanstofundprivate

support.

• Universitycounsellingservicesareinauniquepositiontoidentifyandrespondto

mentalhealthissuesanddisordersbeingexperiencedbytertiarylevelstudents.Thisis

particularlyrelevantforpreventionandearlyinterventionprograms(e.g.Early

EpisodePsychosis).However,theyareoftenshort-staffedandunabletoprovide

adequateservicestostudentsduetolimitedresourcesandalackoffunding.

Q.Howeffectivearementalhealth-relatedsupportsandprogramsinAustralianeducation

andtrainingsettingsinprovidingsupporttostudents?Howeffectiveareprogramsin

educatingstaff,studentsandfamilies,onmentalhealthandwellbeing?Whatinterventions

aremosteffective?Whatevidenceexiststosupportyourassessment?

• Mentalhealth-relatedsupportsandprogramsinAustralianeducationalandtraining

settingsarelimitedinthesupporttheyprovidetostudents.

• Socialandemotionallearningneedstobemadeapriority.Theeducationsystem

needstocreateaspaceinthecurriculumformentalhealthpromotionandprevention

programs.

• Mentalhealthinterventionsneedtobeprocessbasedanddelivereddifferentlyto

academicsubjects.

• Interventionsneedtobeattunedtotheyoungperson;toassesstheneedthattheir

behaviourismeetingandthenfindawayofsatisfyingthatneedinahealthierway(as

perthePTMF).



50

• Themosteffectiveinterventionsareevidence-basedwithresearchtosupporttheir

efficacy.Thishasbeenwelldocumented(Fox,Southwell,Stafford,Goodhue,Jackson,

andSmith,2015)

• AccordingtoFirthetal.(2008)whoconductedanevaluationofaBeyondbluethree

year,school-basedprojecttopromotestudentmentalhealthinthreeAustralian

states,successfulimplementationofaprogramdependsonbeingabletailorittothe

needsofeachschoolandadequateresourcing.

Q.Doteachersandotherstaffinschoolsandeducationfacilitiesreceivesufficienttraining

onstudentmentalhealth?Dotheyreceivesufficientsupportandadvice,includingonthe

qualityandsuitabilityofdifferentapproaches,toadequatelysupportstudentswithmental

ill-health?

• In2015Beyondblueconductedasurveyof600principalsandteachersinNSW.The

resultsweretelling.Basically,allthosesurveyedindicatedthattheyconsideredmental

healthasimportantasacademicachievement.However,nearlyaquarterdidnot

believeitwastheirresponsibilitytoaddressthementalhealthconcernsoftheir

studentsandnearlyhalfrespondedthattheydidnothavethetimetofocuson

assistingtheirstudentstoachievepositivementalhealthoutcomes.Inaddition,the

surveyidentifiedthatteachersdonotbelievetheyhavethenecessaryresourcesto

managethementalhealthconcernsoftheirstudentsandonlyathirdindicatedthat

theirschoolprovideprofessionaldevelopmentand/ortraininginthisarea

(Beyondblue,2015).

Q.Whatoverseaspracticesforsupportingmentalhealthineducationandtrainingshould

beconsideredforAustralia?Why?Isthereformalevidenceofthesuccessofthesepractices,

suchasanindependentevaluation?



51

• ProgramssuchastheUK-basedTalentedTeacherProgrammeseektoincrease

teachers’confidenceandskillsetinmanagingstudentswithmentalhealthissues

(Haywood,CartegenaFarias,Ahmed&Tanner,2016).

• Thecurrent“BeYou”programleadbyBeyondblueandlaunchedin2018,isan

excellentexampleofanevidenced-basedapproachtoimprovingthementalhealthof

school-agedchildren.However,itisanimperativetoensurethatsuchprogramsare

implementedacrossschoolsinafairandconsistentmanner.

• AsreportedbyFoxetal.(2015)theinternationalpictureisnotmuchbetterthan

Australia.Earlyinterventionhasnotbeensystematicallyadoptedinanycountry.Like

Australia,programsareimplementedandevaluatedasaoneoff;rarelyasawhole

schoolapproachandareoftendiscontinued.

QUESTIONSONGENERALEMPLOYMENTANDSUPPORT(p.28)

Q.Whatexamplesarethereofemployersusinggeneraldisabilitysupportmeasures

(throughsupportedwagesandassistancetoprovideworkplacemodifications)toemploy

peoplewithamentalillness?Howcouldsuchmeasuresbemademoreeffectiveto

encourageemployerstoemploypeoplewithamentalillness?

• DisabilityEmploymentServiceProvidersstatethatthereareanumberoflarge

organisations(e.g.largeretailcompanies,hospitals,universities)whoemploypeople

withdisabilities;however,informationrelatedtothesortsofgeneraldisabilitysupport

measuresthatwerebeingemployedforpeoplewithmentalillnesswasnotreadily

available.AconversationwithaUniversityEquityofficershowedthatinlarge

organisationsatleast,severalmeasureswereavailabletosupportemployeeswith

mentalhealthissues,includingcounsellingthroughanEAP,mentorsintheworkplace,



52

time-outwhererequired,modifiedjobrequirementsandamendedworkcontracts

wherenecessary.Itisnotedthatthesemeasuresaremoreeasilyimplementedby

largeorganisationsthathavetheinfrastructureandfinancialresourcestodealwith

generaldisabilitysupportmeasures–thesameisnotnecessarilytrueforsmaller

businesses.

• SupportmeasurescanonlybeeffectiveifBOTHemployersandpotentialemployees

areawareofthosemeasures.Aninternetsearchrevealsthattherearealargenumber

ofgovernmentbodies,government-fundedbodies,NGOsandself-fundedcommunity

groups(DSC,DCA,DisabilityEmploymentServices,Centrelink,NDIS,BeyondBlue,

BlackDog,etc)thatdirectlysupportorprovideinformationaboutdisability/mental

illness.Informationisscatteredandfragmentedandthismakesitextremelydifficult

forprospectiveemployersofpeoplewithmentalillness,tofindoutaboutavailable

supportmeasures.

• Muchoftheinformationrelatingtoworkplacementalhealthforemployersisvery

broadandusesvaguetermssuchas“providesupport.”Whilepolicyisveryspecific

aboutwhatemployersarenotallowedtodo(e.g.discriminate)itisnotparticularly

helpfulinprovidingspecificsaboutwhattodotoprovidesuchsupportforan

employeewithamentalillness.Moreover,ifasmallbusinessisinclinedtoemploy

someonewithamentalillness,isitnoteasytofindinformationaboutwhatthe

Governmentwilldotofacilitatethat,tooffsetthepotentialfinancialcostsof

employingsomeonewithanexistingmentalillness.

TheNationalInquiryonEmploymentandDisabilityInterimReport2004-bytheHumanRights

Commission,states:

• Oneofthemajorbarriersfacingemployersrelatestoperceptionsaboutthefinancial

coststhatmayaccompanytheemploymentofpeoplewithdisability.



53

• Aone-stop-information-shopshouldfulfilavarietyoffunctionsregardingthat

potentialfinancialburden.

• First,sometimesemployersassumethatthecostsaregreaterthantheyreallyare.In

theUnitedStates,asurveyofover700usersoftheJobAccommodationNetwork(JAN)

foundthatmorethan70percentofaccommodationscostlessthan$500.[32]Thusit

seemsthatwhileemployersmaybelievethatworkplaceaccommodationswillcost

thousandsofdollars,theyaremorelikelytocosthundreds.However,unlessthereisa

placeforemployerstogotoclarifytheactualcost,itwillbedifficulttoremovethe

perceptionthatagreatexpenseisinvolved.[33]

• Second,thereareavarietyofgovernmentassistancepackagesthatseektodefraythe

costoftakingonapersonwithdisability(seefurtherbelow).Ifanemployerisunaware

of:(a)theexistenceofthegovernmentpackage;(b)theextentofthatassistance;(c)

theeligibilitycriteriaforthatassistance;and(d)whatneedstobedonetoaccessthat

assistance;thentheimpactofthoseincentivesisgreatlyreduced.[34]

• TheDEWRJobAblewebsitehasaFactSheetonEmployerIncentivesinits'Employer'

portal,althoughitisnotveryobviouslydisplayed.[35]TheUnitedStatesEARNandJob

AccommodationNetwork(JAN)websitesprovideexamplesofalternativewaysto

displaytheinformation.[36].

Q.Arethereothersupportmeasuresthatwouldbeequallyormorecosteffective,or

improveoutcomes?

• Whilethereisalotofinformationabouthowto“support”peoplewithmentalillness

intheworkplace,mostofthisinformationrelatesto“monitoring”mentalhealthinthe

workplace(e.g.“AreyouOK?”andprovidingguidancetomanagementaboutwhatto

lookforandhowtomanagementalhealthissuesintheworkplace.)Theseinitiatives

relatetothementalhealth/illnessofcurrentemployees,andwhilehelpfulin



54

potentiallychangingculture,doesnotactivelyencouragetheemploymentofpeople

withanexistingmentalillness.Theincorporationofmentalhealthintoworkplace

cultureneedstobeextendedtotheactiveemploymentofpeoplewithmentalillness,

ifthenotionofworkplacediversityistobetrulymeaningful.Inshort,itis

recommendedthatasinglesourceofeasyaccessinformationbecreatedand

promotedtoensurethatlargeandsmallbusinessesalikeareawareofthesupport

measuresavailabletothem.

MostlargeorganisationshavepoliciescoveringmentalillnessaspartofOHS,however

mentalillnessisfrequentlydealtwithbyreferringsuffererstotheEmpoyeeAssistance

Program(EAP).ThisisproblematicsinceEAPsarefrequentlylimitedto3to4sessions,

whichmayhelpwithsuperficialproblems,butisnotsufficienttoprovideongoing

supporttopeoplewithongoingmentalhealthissues.Itisrecommendedthatfinancial

supportisprovidedtoemployerstoenablethemtoadequatelyprovidepsychological

supporttotheiremployeeswhenrequired.

• Someorganisationsnowincorporatetrainingtoeducatemanagementaboutmental

illnessandhowtobesthelpemployeeswhosufferfrommentalillnessinthe

workplace,andthereisabundantevidencetoshowthatthishasaneffect.This

trainingneedstobeencouragedtochangeworkplaceculture–thereisstillpervasive

stigma(includinginternalisedstigma)associatedwithmentalillness.Financial

incentivessuchassubsidisedworkshops,mightimprovetheuptakeofthisformof

training,whichwouldhavelong-termbenefitsintermsofproductivity(reduced

absenteeismandpresenteeism).

• Toassistemployeeswithmentalhealthissues,organisationcanmakeworkplace

modificationssuchasmentoring(similartothedigitalindustrymentoringprogramfor

youngpeopleprovidedbyHeadspace),amendedworkcontracts(additionalleave



55

duringtimesofmentalillness,reducedworkinghours,reducedKPIs)workplace

trainingformentalillness.However,thisrequiresbothadequateinfrastructureand

financialresources.Smallbusinessemploysroughly44%ofworkingAustralians.

Governmentmaygivefinancialincentives,suchastaxbreaks,fororganisations

(particularlysmallbusinesses)whoemploypeoplewithmentalillness,tooffsetthe

costofsupportingthemintheworkplace.Thecreationofacompetitive,highprofile

andwellpublicisedGovernmentawardfororganisationsthatsupportofpeoplewith

mentalillness,mayalsoencouragebothsmallandlargebusinessestoemploysuch

people.ThefactthatROIforemployerswhoestablishpositivementalhealthpractices

intheworkplaceisbetween2-11%(dependingonthesizeofthecompanyand

associatedvariable)needstobepromotedtobothbigandsmallbusiness,sincethis

affectstheirbottomline.

QUESTIONSONMENTALLYHEALTHYWORKPLACES(p.30)

Q.Whattypesofworkplaceinterventionsdoyourecommendthisinquiryexploreas

optionstofacilitatemorementallyhealthyworkplaces?Whataresomeoftheadvantages

anddisadvantagesoftheinterventions;howwouldthesebedistributedbetween

employees,workers,andthewidercommunity;andwhatevidenceexiststosupportyour

view?

• Harvey,Joyce,Tan,Johnson,Nguyen,Modini,&Groth,(2014)suggestthatstrategies

areneededattheindividual,team,andorganisationallevelandrecommendthe

following:

1. Designingandmanagingworktominimiseharm:improveflexibilityaround

workinghours,encourageemployeeparticipation,reduceriskfactors,ensure

safetyofworkenvironment.



56

2. Promotingprotectivefactorsatanorganisationalleveltomaximiseresilience:

buildapsychosocialhealthyclimate,enhanceorganisationaljustice,promoteteam

basedinterventions,providemanagerandleadershiptraining

3. Enhancingpersonalresilience:provideevidence-basedresilienceandstress

managementtraining.Incorporatecoachingandmentoringandworksitephysical

activity.

4. Promotingandfacilitatingearlyhelp-seeking:Wellbeingchecksthatinclude

detainedpost-screeningprocedures,andEAP.

5. Supportingworkersrecoveryfromamentalillness:providetrainingregarding

supervisingandsupport,facilitatepartialsicknessabsence,providereturn-to-work

programs,encourageindividualplacementsupportforthosewithaseveremental

illness.

6. Increasingawarenessofmentalillnessandreducingstigma:providementalhealth

educationandtrainingtoallstaff

• Fromtheemployee’sperspective:

Work-lifebalance.

Aworkplacewhichprovidesafavourableenvironmentcanbebeneficialfor

individualsoverallmentalhealth(Fossey&Harvey,2010;Barak,Travis,Pyun,&

Xie,2009).Workcanprovideasenseofpurpose,communityandacceptance,

andopportunitiesfordevelopment.

Thenegativepersonalconsequencesofhighstrainjobscanbemitigatedby

effectivesupportintheworkplace(Harveyetal.,2014).

• Fromtheemployer’sperspective:

Reduceabsenteeism,increasedpresenteeism,increasedemployee

engagementandproductivity(Harveyetal.,2014).



57

Wellbeingispositivelyrelatedtoworkperformance(Wright&Coropanzano,

2000)andjobsatisfaction(Wright,Cropanzano&Bonnet,2007).

Providingsupportthatincludeshighqualityfeedback,variety,andlearning

opportunitieshavebeenfoundtobepositivelyassociatedwithwork

engagement(vigour,dedication,andabsorption)(Halbesleben,2010).

• Harveyetal.(2014)recommendimplementingstrategiesinastaged,individualistic,

andregularlyreviewedmanner.

1. Establishcommitmentandleadershipsupport

2. Conductsituationalanalysis

3. Identifyandimplementappropriateinterventionstrategies

4. Reviewoutcomes

5. Adjustinterventionstrategies

Q.Whataresomepracticalwaysthatworkplacescouldbemoreflexibleforcarersof

peoplewithamentalillness?Whatexamplesarethereofbestpracticeandinnovationby

employers?

• Providetheoptionforflexibleworkinghours-chosenbytheemployee.

• Provideworkplaceeducationaroundmentalillnesstomanagementandstaff.

• Provideoptionsforcarersleave/sickleaveforpeoplecaringforsomeonewitha

mentalillness.

• Adjustworkdutiestomeettheneedsoftheemployeeandemployer.

Q.Howcanworkplaceinterventionsbeadaptedtoincreasetheirlikelihoodofhavinganet

benefitforsmallbusinesses?



58

• Mentalillnesshasbeennotedtoplayalargefactorinabsenteeism,sickleave,and

reduceworkcapacity(Harveyetal,2014).Therefore,amorementallyhealthywork

placemayincreaseproductivity,presenteeism,andjobsatisfaction.

• Avoidingworkrelatedburnoutmayreducestaffturn-over,thereforereducingtime

andresourcesspentontrainingandseverancepackages.

QUESTIONSONFUNDINGARRANGEMENTS(P.36)

Q.WhathavebeenthedriversofthegrowthinmentalhealthexpenditureinAustralia?Are

thesesameforceslikelytocontinuedrivingexpendituregrowthinthefuture?Whatnew

driversarelikelytoemergeinthefuture?

• Thefollowinghavecontributedtoincreaseddemand(andthereforeexpenditure)in

mentalhealthtreatment.

1) increasedawarenessofmentalhealth/illnessthroughinitiativessuchas

Beyondblue,

2) increasedaccessandavailabilitythroughBetterOutcomes,PHNcoordinatedcare

andBetterAccess,

3) initiativesthatreducestigmaandencouragesuffererstoseekmentalhealth

treatment,and

4) increasedawarenessofthebenefitsofmentalhealthtreatments.

• Oneofthemaindriversofgrowthonmentalhealthexpenditureinthepasthasbeen

expenditureonpsychiatricmedicinessubsidisedthroughthePBS.Thishasbeen

reducedthroughtheintroductionofMedicarefundedBetterAccesstoMentalHealth

Careinitiative.Increasedawarenessofmentalhealthissuesaswellassocialissues,for



59

example,domesticviolenceandfamilyabuse,whichhavesignificantimpactacrossall

levelsofsocietyandmentalhealthwillbedriversforfutureexpenditure.Funding

initiativeswillneedtobedrivenbysystemicprinciplesincorporatingtheimpactof

differentcontextsthatmaynotbedirectlyidentifiedbyfocusingpurelyoncategorical

diagnoses.Practitionersshouldbeskilledatbeingabletoidentifyaperson’s

uniquenessandthecontributingfactorstotheirsymptomatologyandthattwopeople

sharingthesamediagnosismaycomefromdifferentcontextsthatmightrequire

differentapproaches.Futurefundingshouldalsoincorporateresearchintoeffective

therapeuticapproachesforvariousmentalhealthissuesandmorecomplexand

seriousdisorders.Thecurrentfocusonalimitednumberofapproachesmaynot

necessarilymeettheneedsoftheconsumer.

• Otherdriverswillbetheinvestmentinelectroniccommunicationandinformation

technologyinthedeliveryofcertainservicesandstreamliningcommunication

betweenservicedeliveryprovidersandgovernmentdepartments.

• Fundingmentalhealthservicesthatfocusonprevention,educationandearly

interventionshouldbeapriority.

• Fundingshouldbedrivenonthebasisofincreasingaccessforconsumers.

Q.Howcouldfundingarrangementsbereformedtobetterincentiviseserviceprovidersto

delivergoodoutcomes,andfacilitatecoordinationbetweengovernmentagenciesand

acrosstiersofgovernment?

• OfferrebatestoserviceproviderswithintheMBSbasedonthetrainingtheyhave

completed(whetherthisistrainingtoregistration,endorsement,orotherprofessional



60

development).Itisassumedthathigher-leveltrainingincreasespractitioner

knowledge,skill-baseandcompetencyandwillthereforeleadtoimprovedtherapeutic

outcomes.

• Factorinthecomplexityofclient’spresentingissuesinrelationtotherebateoffered.

• Fundingcouldbeallocatedtoofferfreeorsubsidisedtraininginparticulartreatment

techniqueswhichwouldinturnleadtoimprovedoutcomes.

• Providefundingtoserviceprovidersforengagingincaseconsultationswithaclient’s

otherhealthcareproviders(GP,psychiatrist,psychologistetc...).Thiswouldencourage

amorecollaborativeapproachtomentalhealthcareandamoreinformedtreatment

approachfortheclient.

Q.Arethecurrentarrangementsforcommissioningandfundingmentalhealthservices—

suchasthroughgovernmentdepartments,PHNsornon-governmentbodies—delivering

thebestoutcomesforconsumers?Ifnot,howcantheybeimproved?

• WhilePHNsareviewedashavingthepotentialtoprovide“world-class,person-centred

healthcare”(Boothetal.,2016,p.4),theyareonlyoneaspectofafully-integrated

mental-healthcaresystem.AcuteandrecoveryservicesarebeyondthescopeofPHNs

andremaintheresponsibilityofgovernmentandprivateserviceproviders.In

addition,psychologyservicesdeliveredthroughtheMBSprovideanessentialoption

forbothGPsandconsumers–andtheopportunityforthosewhocanafforditto

subsidisetheirownmentalhealthcare.

• TheAustralianGovernment,DepartmentofHealth(2010),undertookanevaluationof

theBetterAccessinitiative.Theresultsshow“thatBetterAccessconsumers



61

experienceclinicallysignificantreductionsinlevelsofpsychologicaldistressand

symptomseverityuponcompletingtreatment.Consumersreportedadecreasefrom

highorveryhighlevelsofpsychologicaldistressatthestartoftreatmenttomore

moderatelevelsofpsychologicaldistressattheendoftreatment.”(Australian

Government,2010,para.2.6).

• “Thesameoutcomeswereachievedwhethertheconsumerwasmaleorfemale,

youngorold,orwealthyorfinanciallydisadvantaged.”(AustralianGovernment,2010,

para.2.6).

• Whileitwasreportedlydifficultfortheevaluationtodeterminethecost-effectiveness

oftheBetterAccessprogram,thetypicalcostofpsychologicalcarewassubstantially

lowerthancost-modellingforoptimaltreatmentforanxietyanddepression

(AustralianGovernment,2010).

• Inaddition:“Bulk-billinglevelsalsoincreasedasthelevelofrelativesocio-economic

disadvantageincreased.”(AustralianGovernment,2010,para.2.3).Thisimpliesthat

theinitiativeisreachingconsumersinlowersocio-economicareasandproviding

accesstopsychologicalservicesforpeopleinat-riskgroupswithinAustraliansociety.

• Obviouslyincreasedmentalhealthfundingimpliestheopportunitytobettermeet

need–particularlyinacutecareservicesandforthosemostatrisk,i.e.marginalised

groupsandresidentsinruralandremotecommunities.

• Inaddition,asmentionedabove(seeprevioussection:“Overview–SystemicIssues”),

thesiloednatureofmentalhealthcareinAustralianeedstobeaddressedthrough

theprovisionoffundingaimedatimprovingcommunicationandcollaboration

betweenservices.



62

Q.HowdoesthewaytheMedicareBenefitsSchemeoperateimpactonthedeliveryof

mentalhealthservices?Whatchangesmightdeliverimprovedmentalhealthoutcomes?

• SeetheReportfromtheMentalHealthReferenceGroupforrecommendations

regardingimprovingmentalhealthoutcomesaspartoftheMedicareBenefitsScheme

Review.

QUESTIONSONMONITORINGANDREPORTINGOUTCOMES:(P.37)

Q.DoesAustraliahaveadequatemonitoringandreportingprocessestoassurecompliance

withnationalstandardsandinternationalobligations?

• Allregisteredmentalhealthprofessionalsacrossbothprivateandpublicservice

settingshaveanethicalandprofessionalresponsibilitytobeadequatelytrainedand

competenttoappropriatelyselect,administer,evaluate,andreportonkeyoutcomes

relevanttothepersonorpersonsreceivingmentalhealthcare.Suchinformaland

formalassessmentprocessesaretypicallygovernedbytheregulatoryboardofthe

givenprofessionandanyrelevantCodesofEthics.

Q.Whichagencyoragenciesarebestplacedtoadministermeasurementandreportingof

outcomes?

• Typically,mostmeasurementandreportingoftherapeuticoutcomesremainthe

responsibilityoftheindividualmentalhealthserviceprovider.Assuch,itis

recommendedthatstandardizedmeasurementandreportingoccuracrossall

agencies,publicandprivate,toensurethatthemonitoringofconsumerprogressand

wellbeingisrepresentedacrossallsectorsofmentalhealthcare(fromlowtohigh

intensitycare).



63

Q.Whatdoesimprovedparticipation,productivityandeconomicgrowthmeanfor

consumersandcarers?Whatoutcomesshouldbemeasuredandreportedon?

• Therelationshipbetweenindividualmentalhealthand

participation/productivity/economicgrowthisbidirectionalandmutuallyreciprocal

suchthatmeasurablestabilityorprogressinoneisdirectlycorrelatedwithsubsequent

advancementsintheother.Accordingtobiopsychosocialandsystemsperspectives,

individualsbothinfluenceandareinfluencedbythebroadersystemschangesthat

occuraroundthem.Individualswithgoodmentalhealtharemorelikelytoactivein

theircommunityandsocialsurrounds,takecollectiveresponsibilityforpeopleand

tasksaroundthem,andmeasurablycontributetoAustraliansocietyanditseconomy.

Similarly,systemswhichpromotepositivepreventativementalhealthapproachesand

supportindividualandgroup-levelengagementinemployment,volunteering,and

leisureactivitiesaremorelikelytoimproveandstabilisethementalhealthof

individuals(consumersandcarers)whooperatewithinthatsystem.

• Outcomestobemeasuredandreportedonaroutinebasisshouldinclude:

o Ratesoftherapeuticretention(includingno-showsanddrop-outs).

o Numberofsessionsrequiredtoachievedesiredoutcomes(makingnoteof

baselinefunctioning/presentation,anyrelevantdiagnosesandpresenceof

comorbidities,andinterventionsutilised).

o Natureandeffectivenessofthetherapeuticalliance.

o Globalwellbeing(asopposedtosymptomspecificmeasures)-thisismore

consumerfocused.

Q.Whatapproachestomonitoringandreportingareimplementedinternationally?What

canAustralialearnfromdevelopmentsinothercountries?



64

• FeedbackInformedTreatment(FIT)originatedinthe1980sandsincethenhasbeen

recognisedandutilisedonaninternationalscaleasameansofgatheringconsumer

feedbackonthetherapeuticalliance,processoftherapy,andconsumer’soverall

wellbeingandprogress(Duncan,Miller&Sparks,2004;Prescott,Maeschalck,&Miller,

2017).DevelopedbyateamofresearchersincludingScottMillerandBarryDuncan,

thestandardisedOutcomeRatingScale(ORS)andSessionRatingScale(SRS)measures

facilitatethiscultureoffeedbackrecognisedascrucialforunderstandingwhether

desiredclientoutcomesarebeingattained(Duncan,Miller&Sparks,2004;Prescott,

Maeschalck,&Miller,2017).FIThasapositiveeffectonconsumerretention(including

no-showsanddrop-outs),numberofpsychologicalsessionsrequiredtoachieve

desiredoutcomes,andeffectivenessoftreatment(Duncan,Miller&Sparks,2004;

Prescott,Maeschalck,&Miller,2017).

• Althoughnotanationalmandateorrecommendation,anecdotalevidenceindicates

thattheFITmodeliscurrentlybeingadoptedbyanumberofpsychologistsacrossboth

privateandpublicsectorswhohaverecogniseditsutilityformonitoringandinviting

discussionsonvariouselementsofthetherapeuticalliance,clientsymptomatology,

andprogresstowardsclientgoals.Itisanticipatedthatacontinuedshifttowardssuch

internationally-recognised,evidence-informedmonitoringandreportingpracticeswill

improvetheeffectivenessofinterventionsattheindividuallevel,empowerclientsto

adoptamoreactiveroleinevaluatingandimprovingthementalhealthservices

availabletothem,aidfundingdecisionsdependentonthechronicityofmentalhealth

disordersandpresentations,andoffermorerichdataforinformingmentalhealth

policy.

Q.Towhatextentiscurrentlycollectedinformationusedtoimproveserviceefficiencyand

effectiveness?



65

• InformationcollectedbygovernmentagenciessuchasMentalHealthServicesin

Australia(MHSA)ispresumablyprovidingvaluableinsightsintotheprevalenceof

mentalhealthdisordersandestablishingdirectionsforpolicyandtreatmentpriorities.

• Atanindependentpracticelevel,dependingonthenatureoftheservice,the

collectionofinformationtoevaluatetheefficiencyandeffectivenessoftheservice

beingprovidedtoclientsmaynotbemandatory.However,evidenceindicatesthat

globalwellbeingmeasuresandFITscalescanimproveserviceprovisionandclient

outcomes(Duncan,Miller&Sparks,2004;Miller,Duncan,Brown,Sorrell,&Chalk,

2006;Prescott,Maeschalck,&Miller,2017).

• FITscalesproviderealtimefeedbackontheefficacyoftreatmentandcontinually

monitoranumberoftherapeuticfactorstoensurethatthepsychologicalservicebeing

providedisalignedwiththeclient’sowntherapeuticgoals(Duncan,Miller&Sparks,

2004;Prescott,Maeschalck,&Miller,2017).Whenindividualsareabletoaccess

treatmentsthataretailoredtotheirneedsthrough“formal,real-timefeedback”

improvementsarenoted“inbothretentionandoutcome”(Milleretal.,2006,p.5).

TheimplicationbeingthatutilisingFITscalestocontinuallymonitortheefficacyof

treatmentprovidesamethodbywhichthisinformationisbeingusedtoimprove

serviceefficiencyandeffectivenessatanindividualandoverallpracticelevel.



66

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