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Nov 24, 2015

The Uber of Anxiety is not going to heal mental illness

There is not enough money for mental health services, leaving different approaches fighting for scraps.


To call the nation’s mental health system “fragmented” would do disservice to a dusty hard drive. Actually to call it a “system” is even a bit of a stretch. Everyone, from patients to the policy class, is agreed that Australia’s mental health services are in need of urgent reform. Well, everyone but Mark Latham, who is of the minority view that mental ill health is a fiction written by “worried well” lady writers he doesn’t like. Most other commentators, peak bodies and politicians accept the evidence: people are sick and services are scant. “Chin up” is no longer a recognised strategy.

There may be consensus that something significant needs to be done, but that doesn’t translate to the view that something needs to be spent. There are few signs from Health Minister Sussan Ley that funding to the sector is likely to increase. While the mental health envelope has been a little more generously stuffed in recent years, data sets show that relative to other OECD nations, our own spend on mental health relative to the health budget falls far behind.

There are probably no prominent mental health advocates who would say “no, we don’t need any more money”. But in our local climate of austerity-lite, such people are required to adapt to the prevailing tone of “agility” and accept the terms of lean spending, usually by arguing over which under-funded part of an under-funded sector gets most of it.

When the National Review of Mental Health Programmes was leaked earlier this year, the advice that funding be moved from hospital services and into preventive, community-based strategies was criticised by The Royal Australian and New Zealand College of Psychiatrists. When the Gillard government cut the scope of the Better Access program that permits Medicare subsidy to psychology services in favour of other programs, disagreement was widespread and public.

This week, the Australian Psychological Society (APS) revived that debate last heard in 2011 with its submission to the 2016-17 federal budget. The organisation is seeking to restore the pre-2011 Better Access sessions available to us to 16, instead of the currently available 10.

This morning by telephone, APS executive director Lyn Littlefield said that the perception, often reflected in media, that different organisations were fighting for different professional interests was false. “I’m really not fighting for psychology” she said. She is fighting for better outcomes that psychology, along with a range of other services, can deliver.

There is some evidence that the Better Access program, introduced by the Howard government in 2006, has improved health outcomes. Since its inception, a greater number of Australians are addressing their mental health concerns with a registered or clinical psychologist. But an unintended outcome of the scheme is that these subsidised sessions tend to be accessed by the most advantaged Australians. Ebullient critic and frequent policy adviser Professor Ian Hickie was unequivocal in his criticism. Better Access, he said, did not uphold the Medicare principle of universality.

Littlefield concedes that this is a problem, but she explains the unintended consequence is not down to a fundamental failure in Better Access policy but to uneven distribution of psychology services. Psychologists, unlike many other professionals in the business of doing social good, have no incentives and few programs to lead them into the regions that need them the most.

Professor Patrick McGorry, another prominent advocate known for his work with the ABC’s Mental As week and his collaboration with Hickie, told Crikey that he would like to see a scheme where “clinical psychologists are more incentivised and rewarded”. He does not support further cuts to the Better Access program, but like Hickie, he sees the value in a more integrated approach to mental health care. He consistently campaigns for “multidisciplinary teams rather than isolated office based practice or silos of either psychologists or psychiatrists, as is currently the case”.

The APS represents a slightly different view, which holds that there are many kinds of mental illness, particularly high-prevalence disorders like anxiety and depression, which can be meaningfully addressed in a “silo”. Sometimes 16 psychology sessions are alone enough to help a patient out. Sometimes that won’t even touch the sides and a more team-based approach that addresses the many causes and effects of a mental illness is truly needed.

Just how broad the social and medical contexts should be in considering treatment of mental illness is a really interesting question; it’s one we lay folk have often. But this era is not one in which lobbyists have the luxury of discussing different models of understanding. It’s one that demands statements about outcomes. Discussion of an integrated approach in such an atomised time is difficult.

In many sectors, not just mental health, it seems Ley and Turnbull are committed less to funding services than they are to speaking the language of Uber. We’re not going to spend our way into better health. We’re going to innovate!

This is not to suggest that abandoning red tape or unproven therapies in favour of genuinely clever solutions is a bad idea. It is, however, to say, as the Croakey blog often does, that different fragments of a very fragmented mental health system are left fighting for funds while Mal bangs on about innovative approaches. While professionals and patients wait for the Uber of Anxiety, divisions emerge to produce, in the words of John Mendoza, former chair of the National Advisory Council on Mental Health, a “dog-eat-dog world where there are so few resources that it breeds this sort of behaviour”.

Differences in theoretical positions on mental health are not just bred by schools of thought. They are also bred by hunger. Whatever divisions there are on the correct approach, these are enhanced by need. “The big problem,” said Littlefield “is that there is not enough money.”


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7 thoughts on “The Uber of Anxiety is not going to heal mental illness

  1. paddy

    Seriously good piece Helen.
    Well done and thanks for that excellent summary.

  2. JennyWren

    Telling it like it is. I saw the list of recommendations when the APS tweeted a link to it yesterday. They have increased it to include domestic violence victims and also Tele health. The scandal is that skype sessions are just as effective as face to face consults, yet medicare won’t rebate them. How cost effective would it be to simply fund them rather than trying to induce psychs to move to regional and remote regions? There is a lot of professional compliance needed to fulfill the registration requirements. How can you do that in bumf**k?

  3. Jeff Richards

    If governments want to sort out mental health the should shift their focus from pussy cat mental health programmes to acute mental care. Over the last two decades they have cut acute beds to fund mental health programmes promoted largely by NGOs and ‘star’ personalities who have caught the medias attention . Many of these programmes have dubious value. Now states are confronted with major problems finding acute beds for those who land in hospital emergency departments.

  4. AR

    Paddy & Jenny, whom I respect on the evidence of their past comments think this wodge of verbiage is worth reading.
    OK, I’ll try but, FFS!

  5. JMNO

    Re Jeff’s comments – read Madness a Memoir by Kate Richards for an insight into hospital and community mental health care. Both are needed. As one who pays for a psychologist sessions for a young mentally ill family member – sessions which have done her the world of good – it seems to me that 10 funded sessions a year are not enough. My family member really needs to go once a fortnight. She can’t afford to pay for the sessions though and if you don’t have family to help then you never get the chance to get better.

    Also I long for the time when there is proper case management of those with mental illness – a case worker who does a needs-based assessment and monitors care and progress; and also gives the mentally ill person a bit of a push from time to time when necessary to take a few steps forward.

    This would be money well-spent as it would get many mentally ill people back up on their feet and back into the workforce and participating in the community much faster; rather than leaving then to flail around stuck in their rut of illness.

    If they had a physical illness or injury, they would be entitled to all the follow care they needed, mainly covered by Medicare, or sometimes by private health insurance. This doesn’t happen for the mentally ill.

  6. Jeff Richards

    My criticism centers on the redirection of resources / funding of acute services to intermediate and long term care, partly because certain prominent mental health advocates have the ear of journalists. We surely need both, but not at the expense of acute care. Our hospital emergency departments are routinely full of mental health patients who wait for days to find an acute bed. In my view (and 25 years as a mental health nurse) good acute care gives mentally ill people a better shot at functioning normally in communities. There is a tendency to ‘overcare’ people with mental illness, a process -of handing them over to the management of all these agencies and NGOs- that often creates resentment among the chronically mentally ill, who prefer to have as much independence as possible without all these carers telling them (subtly or nor so subtly) what they should be doing with their lives.

  7. Helen Razer

    Thanks for your comments, Jeff.
    I’m aware of the dispute and I mentioned it here. I hope I made the point, as the Croakey blog and others have, that both approaches have been shown to be necessary and effective and representatives of each are forced by famine to fight each other.
    And, I would say something like Better Access which addresses more treatable and common prevalence disorders is a good idea as are multidisciplinary approaches in more complex and explicitly social cases as are actual beds for people who need them.
    Perhaps let’s urge for a bigger spend, rather than joining the call for priority. The advice from experts I have is clear: more money is needed. All ’round.


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