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Submissionby:AssociationofCounsellingPsychologists(ACP)
Author:DuaneSmith
TheSocialandEconomicBenefitsofImprovingMentalHealth
ProductivityCommissionMentalHealthInquiry(April2019)
Contact:DuaneSmith
ExecutiveChair:AssociationofCounsellingPsychologists(ACP)
counsellingpsychologists@gmail.com
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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).
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• 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
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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
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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).
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“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.
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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
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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.
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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).
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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.
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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
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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
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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)
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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
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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
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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
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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
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-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
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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?
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• 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
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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
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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):
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“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.
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• 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:
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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.
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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.
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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
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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
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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).
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• 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?
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• 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,
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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.
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• 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
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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
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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.
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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).
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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?
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• 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
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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
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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
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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.
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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).
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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?
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• 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?
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• 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.
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