After years of neglect the federal government has shovelled billions of dollars into the mental healthcare system — but the debate on how best to spend it has just begun. In the second of a four-part joint investigation with Inside Story, health journalist and Croakey blogger Melissa Sweet examines the vitriol directed at mental health campaigners Ian Hickie and Pat McGorry …
It’s not only psychologists who have been tearing each other to shreds (as outlined in part one of this series). Considerable vitriol is also being directed at two of the country’s most prominent psychiatrists, Ian Hickie, executive director of the Brain and Mind Research Institute at the University of Sydney, and Pat McGorry, an Australian of the Year and executive director of Orygen Youth Health in Melbourne, a mental health service that includes the Early Psychosis Prevention and Intervention Centre.
For years, Hickie and McGorry have worked closely as prominent advocates, not only calling for more funds for mental health but also pushing for changes to the way funders, services and professionals operate. They have argued for new types of services to meet the needs of young people, who often fall through the gap between child and adult services despite being at a stage of life at which many mental health problems develop. They have also stressed the importance of issues like education, employment and social inclusion.
Hickie and McGorry were instrumental in developing headspace, also known as the National Youth Mental Health Foundation, and are directors of the not-for-profit organisation. Headspace aims to provide comprehensive care to those aged 12 to 25 by bringing together specialist and primary health services to provide general health and mental health services, alcohol and drug counselling, and education, employment and other assistance.
That there is now tri-partisan support for mental health reform is at least partly a reflection of the pair’s sustained engagement with the media and politicians of all persuasions. Yet since the budget they have come under fire from a wide range of critics. They have been accused of having undue influence on policy, of feathering their own nests, of being in the pockets of the drug industry, and of failing to bring the wider sector with them. (It’s worth noting that the expansion of headspace and early psychosis intervention services was recommended in the 2009 National Health and Hospitals Reform Commission report and by the Mental Health Council of Australia.)
At least some of the ill-will is explained by the fact the Better Access program, of which Hickie in particular has been a longstanding critic, was cut while headspace and early psychosis intervention services will be expanded. Some see this as a case of the government converting former critics into supporters. Others note that one motivation for the Better Access changes was to support an expansion of a more equitable system of access to psychological care via the Access to Allied Psychological Services program. The pity, as the Senate report pointed out, is that these were not rolled out before the cuts took effect.
The attacks on Hickie and McGorry can be viewed through multiple prisms. They are tall poppies whose strong advocacy is bound to create professional jealousies. “It’s the peril of being a public health advocate,” says Wayne Hall, a professor in the Centre for Clinical Research at the University of Queensland. “You do get a high profile and there will be plenty of people to shoot you down. The only thing that surprises me, having been in the drug and alcohol field, is it’s taken so long for Pat and Ian to cop the criticism they have.”
The backlash against the pair also reflects professional demarcation disputes. Creating a new type of service for youth means stepping on the toes of existing child and adult services and service providers, for example, and some child psychiatrists view Hickie and McGorry as intruding on their turf. And there are inevitably tensions between prevention and early intervention and treatment, and between those focused on the needs of the patient in front of them versus those considering the broader population’s needs — including people unable to get access to existing services.
Then there are the tensions between those professionals who deal with less common but more severe disorders like schizophrenia and those advocating for less severe but more common disorders like depression and anxiety. There is also competition for funds between services and professionals focused on different stages of the lifespan. One of the more astute observations in the Senate report came from the Australian Counselling Association, which commented that “the problem is the siloing of professions. Every profession wants the dollar for their profession and every peak body wants the money for their members … Shouldn’t it be based on consumer need?”
But Louise Newman, professor of developmental psychiatry at Monash University, says competition for funding in different areas is not so much about professional infighting as a result of historic underfunding of mental health. “It’s the starving dogs with their bone,” says Newman, who argues for far greater focus on early childhood and family support. Or as another senior psychiatrist puts it: “It’s all about dividing a cake. Everything is at the expense of somebody else.”
Some of the frustration also reflects wider disappointment with health reform. So much more was promised than has been delivered — we are still left with fragmented funding and services — and so much remains unclear, especially about the future of community services and how mental health will fare under casemix funding for hospitals. There are also real questions about the logistics of the national roll-out of headspace and the early psychosis intervention centres, and whether funding, workforce, bureaucratic and federal/state political processes are up to the task.
And while Hickie has been critiquing the Better Access program, others have been raising questions about the evidence base for headspace and the Early Psychosis Prevention and Intervention Centre (EPPIC). One of those is Jon Jureidini, a child psychiatrist in Adelaide and member of Healthy Skepticism, an organisation that monitors inappropriate pharmaceutical marketing and influence. He argues the evidence supporting the approach taken by headspace and EPPIC has been over-sold, and he also raises broader questions about whether a medical response is appropriate for the many problems affecting young people that have social origins.
“This is not to say that headspace and EPPIC” — early psychosis intervention — “are without merit,” he says. “Both of these models warrant further exploration and evaluation but they certainly aren’t of the quality that we should give over the vast majority of the new money.” One of the reasons for divisions within mental health, Jureidini adds, is the lack of firm evidence about the merits of various interventions. “We’re working in an area of uncertainty. There’s very little concrete evidence to separate one person’s idea from another in terms of their effectiveness.”
John Mendoza, whose high-profile resignation last year as chair of the National Advisory Council on Mental Health has consigned him to the political sin bin, has a different perspective, expressing frustration at the preoccupation with the news services and corresponding lack of scrutiny of existing services. “Total federal and state mental health funding will come in at just under $6 billion in one year. This year we will spend $60 million on early intervention through EPPIC and headspace,” he says.“Our state governments will spend over $500 million on stand-alone psychiatric institutions,” Mendoza points out, “and we still have 2100 beds in such institutions. We’ve had pathetic governance around national mental health plans for 20 years. Everyone agreed we were closing these institutions in 1992. At the moment we are still spending on our acute care beds and our stand-alone beds over 50% of our total resources. They’re not well-based interventions. The acute care beds in general hospitals should make up about 10% of our general mental health investment.” The critics of early intervention, he says, “should focus on where the big problems are”.
No doubt the backlash against Hickie and McGorry also reflects broader community suspicion about psychiatry, perhaps not surprising given the profession’s history of attracting royal commissions and other inquiries. There are also concerns about medicalisation of health problems more generally — the inappropriate use of psychiatric medications is a genuine concern, particularly in nursing homes — and about overly close ties between the psychiatry profession and the pharmaceutical industry.
“Our college of psychiatry, among other medical and surgical colleges in Australia and elsewhere, became addicted to drug company money — not just for running conferences, but to meet the bottom line,” says Alan Rosen, a psychiatrist who has been a strong advocate for community mental health and works with the Brain and Mind Research Institute at the University of Sydney and the University of Wollongong. “They are at different stages of painfully weaning themselves off this formerly bountiful teat.”
Rosen says he generally supports the work of Healthy Skepticism, but thinks the focus by some members on Hickie and McGorry is misplaced, given the pair’s emphasis on a psycho-social model of health care and focus on social justice rather than narrowly clinical approaches. “In this case, I think Juredini et al are criticising a movement [early intervention into psychosis] that is actually trying to persuade other clinicians to lower anti-psychosis medication use to often very small dose levels, only if and when it is necessary,” he says.
McGorry himself says he has much in common with the broader concerns of Healthy Skepticism, having devoted much of his career to trying to reduce the adverse impact of medications, and the impact of traumatic systems of care on young people. “My whole career has been trying to reduce reliance on antipsychotic medications,” he says. “I’ve done most of my research on psychosocial treatments.”
The backlash against Hickie and McGorry is also being fed by the extreme end of the anti-psychiatry lobby, including scientologists who have been lodging freedom of information requests targeting their research projects at the universities of Melbourne and Sydney. The Citizens Commission on Human Rights, founded by scientologists in 1969 as a “mental health watchdog”, includes amongst its work a museum in its Hollywood headquarters called “Psychiatry: An Industry of Death”. The CCHR website says “this state-of-the-art museum documents how psychiatry is an industry driven by profit, its pretended help often resulting in death”.
Powerful personalities are another factor. The pair may have different personal styles — McGorry being a quiet, restrained presence in contrast to the voluble, high-energy Hickie — but they share an absolute faith in the rightness of their causes. They are “true believers”, say some colleagues. Years ago, Hickie’s mother told me that her son can be argumentative. She said: “If he thinks he’s right, heaven help you.”
It’s not surprising that when Hickie and McGorry loudly describe the failings of existing services, those working in these services, often under difficult circumstances, take affront. Indeed, it seems that the major protagonists in recent debates all feel, to some extent, that they have been victims of personal criticisms or slurs. Wayne Hall observes: “There’s an even-handedness in the personal attacks.”
For John Mendoza, the divisions reflect a sector in crisis: “This infighting is typical of a bottom dweller, dog-eat-dog world where there are so few resources that it breeds this sorts of behaviour. The only other area where you see these sort of divisions is in indigenous affairs.” Indeed, a cynic might think the post-budget schisms represent a convenient outcome for a government previously facing an effective united lobby with massive public support fanned by the activist group GetUp.
As another mental health policy insider puts it: “As far as the sector goes, we always used to bitch and complain but we did it behind closed doors. Now we’re having an open civil war. That just allows government to say, ‘they don’t know what to do, what the priorities are, they can’t agree. And if the experts can’t agree, then why should we throw public money at mental health?’”
Jennifer Doggett also sees the division as destructive: “I wouldn’t have thought there are going to be any winners from trying to discredit what [Hickie and McGorry] have done. A more constructive approach would be to say that these initiatives can achieve some gains and this is what else needs to be done.” Doggett says when groups ask for funding political advisors want to anticipate the likely political fallout. “You can never give them everything they ask for,” she says. “You ask, if we give them 80%, are we going to get beaten up for the 20% we don’t give them? If that’s the case, we may as well give the money elsewhere.”
For those who have followed the longer history of mental health reform, the personalisation of the backlash is not unusual. Over the years, many of those associated with challenges to the status quo have come under bitter attack. On occasions, these have escalated into personal threats and acts of intimidation and violence.
Dawn O’Neil (whose background in mental health is profiled in part one of this series) sees the backlash against Hickie and McGorry as in part a reflection of their role as change agents. “I know them both very well,” she says. “I have found them to be incredibly passionate, committed, smart and … I would call them revolutionaries really.”
*Tomorrow: Competing claims and interests in mental health debates
**Declarations: The Croakey health blog, which Melissa Sweet moderates, has received funding from the Brain and Mind Research Institute and the Public Health Association of Australia. The author has also been paid for research (not related to mental health) through the University of Melbourne centre involved in the Better Access evaluation, and the lead author of the evaluation, Jane Pirkis, was interviewed for this article.