Dear Minister,
Congratulations on your position Minister. You must be looking around for opportunities to make a big difference to Mental Health and wondering which aspect of this difficult portfolio to concentrate on.
Among the many aspects of mental illness such as workforce participation, increasing costs and lack of professionals could I perhaps beg for the most obvious. Please Minister keep more of us alive.
A 2001 report conducted in West Australia where health records are linked to enable this sort of finding, found that the life expectancy of users of mental health services in that state was in their 50s. This is commensurate with life expectancy in the indigenous community. The shorter life span for people with mental health issues is a world-wide problem.
The reasons for this limitation of life span is not, as most people would imagine, suicidality, but rather a complex series of health problems including failure to be screened as often as other people and also that once diagnosed, the mentally ill do not appear to receive the same standard of care as other people, possibly because of communication problems. The key issue here is one of “vulnerability”.
Having seen friends deteriorate rapidly despite having graduated from various “recovery based” programmes I would like to gratuitously suggest some possible ways in which you as Minister could possibly affect these alarming statistics.
TRIAGE people with mental illness in your mind. This is quite acceptable practice and it clarifies the situation. To my mind there are four main groups, the highly vulnerable, the sometimes vulnerable, the recovering and the “two-thirds”. The two-thirds are the majority of people with mental illness who don’t use mental health services. The highly vulnerable group includes in order of priority, those on guardianship or treatment orders, those with co-morbidity – more than one illness, disability or with addiction problems and those with medication resistance. This group could also include those with severe forms of Asperger’s and those with so-called Borderline Personality Disorder as both these groups can have real problems with communicating. The other groups of people listed above are coping in my view with present rates of services but the highly vulnerable are being neglected to the extent that some of them would have been better off in a pre-1970s institutional hell-hole.
FOCUS on the “vulnerability” factor. Presently in mental health services when “recovery” and “strengths” are paramount, a discussion of vulnerability is avoided to the point that some people are experiencing serious neglect. All the talk about “strengths”, “resilience”and “independence” can, in my view, cause the people with serious illnesses to feel that they shouldn’t ask for the extensive help they need. This becomes crucial if you combine it with other factors like many not having telephone access; finding it difficult to manage many appointments, memory problems arising from psychiatric drugs and having trouble affording GP visits and medications.
ALLOCATE as a matter of urgency a case manager for all persons falling in the highly vulnerable category. This might be costly but it is necessary. There is a lot of “fat”in the mental health industry and you need to wield the knife on other sectors and give the most seriously ill the attention they need. This highly vulnerable group needs to be contacted once a week either by home visit or by phone because their condition can deteriorate very quickly.
Now to look at some ways to cut costs and re-direct services:
SKIRT the Recovery Model/Strengths Perspective rabbit hole. The lack of any reasonable definition behind these two approaches makes trying to have a logical conversation about them hallucinatory. The use of these two models with the seriously mentally ill, although popular to the point of doctrine and dogma, is problematic. This is because the strengths of those with a serious mental illness are usually in a highly specialized area and are not generally able to be used to transform the entire persona. The problem can then arise that service providers will say: ”You wrote a fantastic book on the Triple Banded Pardalote therefore you must be recovered and won’t need any more services.” It just doesn’t work this way. If anyone tells you these two approaches are the “new paradigm” in mental health that you simply have to know about get out your dog-eared University copy of T.S Kuhn’s The Structures of Scientific Revolutions and wave it at them.
ENSURE that referral policies are not giving a false picture of the success of various recovery oriented programmes. Some of these programmes have specific requirements for prospective participants – in other words they only take those people who have a good chance of recovering well and avoiding hospitalisation in the first place. Consumers in these agencies can be “stepped down” or streamed into less challenging programmes if they become unwell during the programme. This is not socially inclusive; not supported by consumers (who lose their friends from the programme) and in my view gives a skewed picture of how well the programme is achieving “recovery”.
SUPPORT low-cost community based programmes that are supported by volunteers. These agencies are more successful in general because they have local support. The volunteers also provide an extended informal network of people the highly vulnerable can rely on and not being bound by corporate rules can generally do something about abuse and neglect if they should observe it occurring.
JUDGE programmes for the mentally ill on how willing these programmes are to include home visits and how readily they will pick up and transport people. The “highly vulnerable” generally either can’t or won’t access public transport. If this group is visited in their homes once a week by various people then they at least have a chance of asking for help before they get seriously ill.
Be AWARE that your constituency is an unusual one in that it mostly silent. The highly vulnerable mentally ill do not appear in many reviews, forums and tend not to participate in research, therefore their opinions are generally not known. You could however set up local focus groups for this highly vulnerable group if you provide transport, lunch and most of all an adequate space which provides comfortable seating and the ability for the person to leave the group and sit down slightly away from the group to recoup. I am stressing this because people with serious mental illnesses often have singular needs relating to space, sociability and comfort. In fact if you want to judge whether an organisation is going to deliver consumer-centred services to all groups of mentally ill people then look at their floor plan. If they have most of their space tied up in offices and restricted client spaces then they are not going to be able to adequately provide services to the seriously mentally ill.
USE already existing community infrastructure to deliver services for people with mental illness as they are likely to be central, easy to physically access and have the kind of space and activities that people with serious mental illness prefer. For example it is more sensible to use existing College, TAFE, University or Neighbourhood House spaces for delivering mental health education programmes rather than agencies and NGOs because these public facilities are socially inclusive; they have spaces like Libraries and Cafes and services such as low-cost gyms and free full-time computer access which predict favourable outcomes for people with serious mental illness. Not only that but they have teachers who are trained to teach adults in an interesting and stimulating way. Using existing facilities in this way would save a lot of money currently spent on NGOs that could be deployed towards increasing life expectancy.
FUND low cost activity and recreation programmes so that people in the highly vulnerable group have the opportunity to attend at least three of these a week. If you engage consumers in this type of programme as soon as they get out of the ward then they are less likely to develop long-term costly addiction problems. Programmes that should be looked at as a possible model include the Get Active programme ran by Tasmanian Women Sport and Recreation and the Richmond Fellowship Recreation Programmes.
Don’t HESITATE to look at the use of teleconferencing for psychiatric and psychological consultations where professionals are scarce. Many people with mental health problems don’t really want to meet mental health professionals in the flesh and would actually prefer teleconferencing.
Yours with high expectations,
Maggie Maguire
