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2019 Submission - Royal Commission into Victoria's Mental Health System Organisation Name N/A
Name Mr Guy Coffey
What are your suggestions to improve the Victorian communitys understanding of mentalillness and reduce stigma and discrimination? "I have not addressed this question in my submission and it is not something I have particularexpertise in. However I believe the following needs to be considered. - information provision andincreased understanding within the community is a necessary but not sufficient condition to reducestigma. Some very well informed people (including MH professionals) still possess stigmatisingattitudes. - Attempting to bring attitudes into alignment with views on physical health is useful upto a point however there are also important differences in the nature and experience of physicaland mental illness that need to be acknowledged. Often to a greater extent, mental illnesses canaffect how we see ourselves and who we are to others. - it is a reality that some people withsevere mental illnesses have a vastly reduced quality of life as a result. This needs to beacknowledged in educational campaigns but also needs to be a cause for compassion andgrounds for significant societal support, not a reason to marginalise and stigmatise. - theexperiences of mentally ill people need to be part of any public education campaign. Bringing thecommunity to understand the immense struggle and courage required to live with a severe mentalillness is an important part of encouraging empathy and compassion. - a human rightsperspective not just more information is needed. The goal is too increase empathy, compassionand a sense of community commitment and duty to promote the rights of mentally unwell people.- as with many pressing and complex human problems, we are not the first to try to find a solution.A thorough review of what has and hasn't worked internationally should be undertaken "
What is already working well and what can be done better to prevent mental illness and tosupport people to get early treatment and support? N/A
What is already working well and what can be done better to prevent suicide? N/A
What makes it hard for people to experience good mental health and what can be done toimprove this? This may include how people find, access and experience mental healthtreatment and support and how services link with each other. N/A
What are the drivers behind some communities in Victoria experiencing poorer mentalhealth outcomes and what needs to be done to address this? addressed in the submission
What are the needs of family members and carers and what can be done better to supportthem?
N/A
What can be done to attract, retain and better support the mental health workforce,including peer support workers? N/A
What are the opportunities in the Victorian community for people living with mental illnessto improve their social and economic participation, and what needs to be done to realisethese opportunities? N/A
Thinking about what Victorias mental health system should ideally look like, tell us whatareas and reform ideas you would like the Royal Commission to prioritise for change? addressed in the submission
What can be done now to prepare for changes to Victorias mental health system andsupport improvements to last? N/A
Is there anything else you would like to share with the Royal Commission? please see the submission
SubmissiontotheRoyalCommissionintoVictoria’sMentalHealthSystem
SubmissionDate:5July2019
GuyCoffey1
Introduction
ThankyoufortheopportunitytomakeasubmissiontotheRoyalCommission.In
accordancewithmyareaofexperienceafocusofthissubmissionismentalhealth
servicedeliverytorefugees.However,Ialsoaddressarangeofmattersfallingwithin
theRoyalCommission’stermsofreferencewhichrelatetomentalhealthservice
provisiontotheVictoriancommunitygenerally.Iwillcommentonthefollowingsubject
areas:
1. mentalhealthservicedeliverytoasylumseekersandrefugees;
2. thementalhealthcareofyoungasylumseekersandrefugeesinthecorrectional
system;
3. thementalhealthcareofpeoplewithpost-traumaticconditions;
4. accesstoprivatesectorpsychologicaltreatmentbypeopleofnon-English
speakingbackground;
5. thecapacityofpublicmentalhealthservicestodeliverevidencedbased
psychologicaltreatments;and
6. thequalityofrehabilitationservicesforpeoplewithchronicmentalillnesses.
Thissubmissionmakesanumberofpropositions.
1. Thepolicyenvironmentgoverningthelivesofasylumseekersisfundamentally
inimicaltotheirmentalhealthandmentalhealthservicesareunableto
adequatelymeettheirneeds.
2. Commonwealthmigrationlawinteractswiththejusticesysteminwaysthat
depriveyoungasylumseekerandrefugeeoffendersofmentalhealthtreatment
andopportunitiesforrehabilitation.
1 FoundationHouse,4GardinerStreetBrunswickVIC3056.Mob.0419322468email:
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3. Post-traumaticconditionsarenotadequatelytreatedwithinthepublicmental
healthsystem.Accesstospecialistposttraumaticmentalhealthservicesis
limited.
4. MigrantsandrefugeeswhoarenotfluentinEnglishhavefarlessaccessthan
Englishspeakerstopubliclyfundedprivatepsychologicalservicesowingtothe
limitedprovisionofinterpretersfortheseservices.Thisisanobjectively
discriminatorypracticeinmentalhealthservicedelivery.
5. Publicmentalhealthservicesdonotdelivertherangeofevidencebased
psychologicaltreatmentsrecommendedbyallmajorbestpracticetreatment
guidelines.Psychologicaltreatmentsareinadequatelyintegratedintotreatment
plansandserviceshaveinsufficientstaffpossessingtherequisite
psychotherapeuticskills.
6. Therearesignificantgapsinthedeliveryofrehabilitationservices.Twoexamples
areprovided:thereisalackoffocusonamelioratingcognitiveimpairments
whichhavepersistedbeyondtheremissionofacutesymptomsandvocational
trainingandplacementappearstobeineffectiveinmanyinstances.
Thissubmissiondrawsonmyexperienceofworkinginmentalhealthservices.Ihave
workedasaclinicalpsychologistfor30yearsinpublicmentalhealthandspecialist
psychologicaltraumaservicesincluding21yearswithinVeterans’Psychiatryandthe
PsychologicalTraumaRecoveryServiceattheAustinandRepatriationMedicalCentre.I
amcurrentlythepracticedevelopmentadvisorattheVictorianFoundationforSurvivors
ofTorture,apsychologicaltreatmentandsupportserviceforrefugees,whereIhave
workedparttimefor20years.Iactasaconsultanttoorganisationsonpsychological
andlegalissuesinrelationtorefugeesincludingtheUNHCRandtheDepartmentof
HomeAffairs.Iconductresearchandpublishinthefieldofrefugeementalhealth.I
provideforensicpsychologicalreportsforthecourtsinVictoriaandpsychological
assessmentsofapplicantsforrefugeestatus.Withrespecttomycommentsonrefugee
migrationlawandCommonwealthpolicyrelatingtoasylumseekers,thesearebasedon
myexperienceworkingasalawyeratVictoriaLegalAidprovidingassistancetoasylum
seekersandrefugees.
Theviewsexpressedhereinaremyownandarenotnecessarilythoseofthe
organisationsatwhichIamemployed.
Thissubmissionhasbeenwrittenwithinatighttimeframeandisnotafullyreferenced
scholarlypaperbutasetofpropositionsbasedoneitherdirectobservationderived
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fromclinicalpractice,researchorboth.Moredetailedandreferencedexplanationsof
aspectsofthesubmissioncanbeprovidedonrequest.
1.Mentalhealthservicedeliverytoasylumseekersandrefugees
Inordertodeliveramentalhealthservicethatmeetstheneedsofrefugees,the
determinantsoftheirneedsmustbeunderstood.Forthepurposeofthisdiscussion,I
willprovideaverybriefsummaryofwhatisknownaboutthevariablesaffectingrefugee
psychologicalwell-being.
Influencesonpsychologicalwell-being
PeoplewhoenteredAustraliaasrefugeesorhavesoughtasyluminAustraliaarealarge
andheterogeneouscommunitygrouprangingfromthenowveryelderlypostWW2
refugeestorecentlyarrivedasylumseekersandhumanitarianentrants.Whilethe
mentalwell-beingofrefugeesisasdiverseasthatwhichexistsinthegeneral
community,decadesofstudyofthementalhealthofrefugeeshavedemonstratedthat
atapopulationlevelanumberofgeneralisationscanbemade:
- amongmanycohortsofasylumseekersandrefugeesratesofmentalillnessare
manytimeshigherthanintheoverallAustralianpopulation2;
- themostcommonmentalhealthproblemsexperiencedarePosttraumatic
StressDisorder,depressionandanxietydisorders3;
- thereisevidencefrominternationalstudiesthatratesofseverementaldisorders
suchasschizophreniaareelevatedamongrefugees4;
- ratesofmentaldisorderarepredictedbytheextentofpre-arrivaltraumaand
loss,andbypost-arrivalstressors5;
2 Thereisalargenumberofstudiesofprevalenceofmentaldisorderamongrefugees;forexample,Fazel,
Metal.(2005)Prevalenceofseriousmentaldisorderin7000refugeesresettledinwesterncountries:a
systematicreview.Lancet365:1309-14.SteelZetal.AssociationofTortureandOtherPotentially
TraumaticEventsWithMentalHealthOutcomesAmongPopulationsExposedtoMassConflictand
Displacement.JournaloftheAmericanMedicalAssociation,August2009.TurriniGetal.Commonmental
disordersinasylumseekersandrefugees:umbrellareviewofprevalenceandinterventionstudiesIntJ
MentHealthSyst(2017)11:51.3Forexample,TurriniGetal.Commonmentaldisordersinasylumseekersandrefugees:umbrellareview
ofprevalenceandinterventionstudiesIntJMentHealthSyst(2017)11:51.
4Hollander,Anna-Claraetal.(2016)Refugeemigrationandriskofschizophreniaandothernon-affective
psychoses:cohortstudyof1.3millionpeopleinSweden.BMJ(2016)352.5Porter,M.,&Haslam,N.(2005).Predisplacementandpostdisplacementfactorsassociatedwithmental
healthofrefugeesandinternallydisplacedpersons:Ameta-analysis.JournaloftheAmericanMedical
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- whilethereisadearthofepidemiologicalstudiesofthementalhealthofasylum
seekers,theavailableevidenceisthatratesofPTSDanddepression6andratesof
selfharm7aremanytimeshigherthaninthegeneralcommunity.
- thepost-arrivalstressorsmostcommonlyassociatedwithpoormentalhealth
includeinsecureresidencystatus;destitution;experienceofdiscrimination;
concernsaboutfamilyoverseas;andprolongedimmigrationdetention8.
Anumberofthe‘postarrivalstressors’whichhavebeenfoundbothinAustraliaand
internationallytoadverselyaffectasylumseekerandrefugeementalhealtharedirectly
producedbyAustraliangovernmentlawandpolicy.Theseinclude:
- providingformandatoryandindefiniteimmigrationdetentionforallpeople
arrivinginAustraliawithoutvisas–theadversementalhealthconsequencesof
immigrationdetentionforasylumseekersisestablishedunequivocally9;
- causingasylumseekerswhoarrivedbyboattobeeligiblefortemporary
protectionvisasonly,ensuringongoinginsecureresidency;
- preventingtemporaryprotectionvisaholders(theresidencystatusofmany
thousandsofsuccessfulasylumseekerswhoarrivedbyboat)frombringing
familytoAustralia;
- inadequatematerialsupportforasylumseekersincludingremovalofworkrights
andanysourceofincomesupportforsomebridgingvisaholders(thereare
currentlyabout6,800asylumseekersinVictoriawhoarrivedbyboatwhohold
bridgingvisas10);
Association,294,602−612.FredrickLindencronaetal.2008,MentalHealthofrecentlyresettled refugeesfromthemiddleeastinSweden.SocPsychiatryandPsychiatricEpidemiology.43:121-1316AnunpublishedcurrentstudyofarepresentativesampleofasylumseekersinNSWfoundthatnearly
halfofthecohorthadprobabledepressionandoveraquartersufferedprobablePTSD:TheSydney
ReAssureStudy,SteelZetal.(UNSW).TurriniGetal.Commonmentaldisordersinasylumseekersand
refugees:umbrellareviewofprevalenceandinterventionstudiesIntJMentHealthSyst(2017)11:51.7SeeHedrick,Ketal(2019,underreview)SSM–PopulationHealth.Thisresearch,
basedonself-harmincidentsreportedtotheDepartmentofImmigrationandBorderProtectioninthe12-
monthsto31stJuly2015,foundthatself-harmepisoderatesamongasylumseekersincommunity-based
arrangementswerefourtimestheAustraliancommunityratesforhospital-treatedself-harmandself
harmratesforasylumseekerslivinginthecommunityundercommunitydetentionarrangementswere22
timestheAustraliancommunityrates.Ratesofself-harmforpeopleinimmigrationdetentionfacilities
weremanytimeshigheragain.8EdithMontgomery,(2008)LongtermeffectsoforganizedviolenceonyoungMiddleEasternrefugees’
mentalhealthSocialScienceandMedicine671596-1603;SteelJetal.ThePsychologicalConsequencesof
Pre-EmigrationTraumaandPost-MigrationStressinRefugeesandImmigrantsfromAfricaJImmigrant
MinorityHealth(2017)19:523–532.9Forarecentreview:vonWerthernMetal.Theimpactofimmigrationdetentiononmentalhealth:a
systematicreviewBMCPsychiatry(2018)18:382https://doi.org/10.1186/s12888-018-1945-y.
10DepartmentofHomeAffairs,IllegalMaritimeArrivalsonBridgingEVisa,31March2019.
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- thecreationovertwodecadesofadivisivepublicdebateoverasylumseeker
policywhichhascreatedantagonismtowardpeopleseekingasyluminsome
sectionsofthecommunity.
Theeffectofpoormentalhealthamongasylumseekershasimmediateandlongterm
consequences.Whenanasylumseekerismentallyunwell,thedemandsofthe
protectionvisaapplicationprocessaremadeevenmoredauntingandthelikelihoodof
anunfairoutcomeisincreasedbecausetheapplicant’sabilitytoarticulatetheirclaimsis
compromised11.Inthelongertermthecapacityofthesuccessfulapplicanttoadaptand
integrateintotheAustraliancommunityismadeconsiderablymorechallengingbya
lackofpsychologicalwell-being.Mentalhealthclinicianswhoworkwithrefugeesare
familiarwithpeoplewhoarrivedinAustraliatoseekasylum,whoweredetainedfor
extendedperiods,enduredaprotractedvisaapplicationprocess,livedinpovertyinthe
community,wereseparatedfromfamilyformanyyearsorlostcontactentirely,and
whonowsuffersevereandchronicposttraumaticorothermentalhealthconditions
thatrobthemofadecentqualityoflife.
Shortcomingsinmentalhealthservicedeliverytoasylumseekersandrefugees
Someasylumseekersandrefugeesreceiveexpertandcompassionatecareinthemental
healthsystem.Howeverinmyexperiencethestandardofcareisveryuneven.The
reasonsforthisfallintothreecategories:lackofknowledgeamongtreatingstaff;
difficultyalteringthecircumstancesadverselyaffectingmentalhealth;andlackof
accesstoservices.
Mostmentalhealthcliniciansdonothaveagoodunderstandingofthecircumstancesof
asylumseekersandrefugees.Manyareunawareofthestressorstheyareenduring.
Whileasylumseekersandrefugeessufferfromthesamerangeofmentaldisordersas
thegeneralpopulation,theirpresentationsareoftenshapedbyposttraumatic
symptomsandreactionstocurrentstressors;fewpublicmentalhealthclinicianshave
specifictrainingintreatingthesepresentations.
11 TheUNHCRhasbeenconcernedabouttheaffectofasylumseekers’mentalhealthonthefairnessof
theprotectionvisaapplicationprocessinthecontextofcurrentAustralianpractice.Asaconsequence
theyproducedguidelinestoassistrefugeestatusdecisionmakers:See
https://www.unhcr.org/publications/legal/5a127e907/guidance-note-on-the-psychologically-vulnerable-
applicant-in-the-protection.html
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Clinicianscanoften,understandably,feelhelplessinthefaceofrefugees’psychological
difficultiesbecausetheyareunabletoalterwhathasprecipitatedandmaintainsthem.
Sometimesthisresultsinminimisingandunder-diagnosingthedifficulties–thepatient
mightbeseenasprimarilypresentingwithavulnerablepersonalityorsufferingfroman
‘AdjustmentDisorder’-aconditionwhichissituationallydrivenandwhichmightbe
considerednotamenabletotreatment.Howeverclinicianswhoareexperiencedin
assistingrefugeesknowthatvaluablementalhealthassistancecanberenderedto
asylumseekersandrefugeesevenwhentheircircumstancesaredire.
Itcanbedauntinganddemoralisingnonethelessformentalhealthclinicianstowork
withclientswhosementalhealthisbeingdevastatedbytheircircumstances.Their
abilitytoprovideeffectivetreatmentisincreasediftheyworktogetherwithservices
advocatingforimprovementsintheclient’ssituation,whetherthatinvolvesmaterial
aid,resolutionofresidencystatus,assistingcontactwithfamilyoramelioratingoneof
themyriadotherpossiblesourcesofasylumseekers’distress.Currentlythe
coordinationbetweenpublicmentalhealthprovidersandrefugeelegal,advocacyand
supportgroupsisnotstrong.
Asylumseekersandrefugeescanlackaccesstomentalhealthservicesforarangeof
reasons.Posttraumaticconditions,evenwhencausingthesamelevelofdebilitationand
distressasotherseverementaldisorders,maynotbeseenasprimarilythe
responsibilityofthepublicmentalhealthsystem.Whenseveretraumahasbeen
experienceddevelopmentally,itmaymanifestasapersonalitydisorder,including
BorderlinePersonalityDisorder.Fewpublicmentalhealthfacilitieshavespecialist
programsandclinicianstrainedinthetreatmentofthiscondition.
Addingtothedifficultyingainingaccesstotreatmentisaviewthatpsychologically
basedtreatmentsareeithernotculturallyappropriateforpeopleofnon-western
backgroundornoteffectiveifdeliveredwiththeassistanceofaninterpreter.Itis
difficulttoascertainhowwidespreadsuchbeliefsare,buttheresearchevidenceand
clinicalexperiencestronglycontradictsthem12.
Withrespecttotheprovisionofpsychologicaltreatmenttoasylumseekersandrefugees
throughMedicare(‘BetterAccess’)orPrimaryHealthNetworkfundedservices,there
12Thereisalargeliterature;forexample,TurriniGetal(2019).Efficacyandacceptabilityofpsychosocial
interventionsinasylumseekersandrefugees:systematicreviewandmeta-analysis.Epidemiologyand
PsychiatricSciences1–13.https://doi.org/10.1017/S2045796019000027
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aretwobarrierstoaccess.Asubgroupofasylumseekersinthecommunityareineligible
forMedicareservicesandrelyonpublichospitalsandsomecommunityhealthcentres
formedicalservices.Secondly,underthesefundingarrangementsforpsychological
servicestherearelimitedornointerpretingservicesavailable(thisisdiscussedfurther
belowinrelationtonon-Englishspeakersgenerally).Anotherissueofaccessinthe
privatesectorinvolvesthecoordinationoftheservicesneededforpeoplewithcomplex
andmultipleneeds.Asylumseekersandrefugees,notdissimilartootherpopulations
withraisedprevalenceofposttraumaticconditions(forexampleveterans)oftenhave
otherconcurrentmentaldisorders,medicalconditionsaffectingmentalstate,family
andsocialproblems,andvocationaltrainingneeds.Atreatmentplaninvolvingan
individualpsychologistinprivatepracticewilloftennotprovidethecoverageof
treatmentandthesetofmedical,psychologicalandpsychosocialinterventionsrequired
foroptimumoutcomes.Furthermore,tenortwelveindividualsessionswillusuallynot
beanywherenearadequatetoprovidepsychologicaltreatmenttoarefugeewitha
chronicpost-traumaticcondition.
2.Thementalhealthcareofyoungasylumseekers,refugeesandnon-citizensinthecorrectionalsystem
Theobservationsmadeinthissectionarederivedfrommyexperienceinconducting
forensicpsychologicalassessmentsofasylumseekersandrefugeesforthecourtsand
providinglegalrepresentationforasylumseekersandrefugeeswhosevisashavebeen
cancelledduetotheiroffending.
ChildrenfromCALDbackgrounds,includingsomerefugeecommunities,are
substantiallyoverrepresentedintheyouthjusticecentrepopulation13.Forthosewho
arenon-citizens,theirpassagethroughthecriminaljusticesystemmaydiverge
markedlyfromthatofchildrenwhoarecitizenseventhoughthesamesentencing
principlesapplytothem.Theoverarchingprincipleinsentencingchildrenandyoung
peopleisrehabilitation;theapproachisenshrinedinlegislation14andhasbeen
unequivocallyendorsedbythejudiciary:
[T]heprimacyofrehabilitationinthesentencingofyoungoffendersiswellestablished,bothatcommon
lawandbytheprinciplesoftheCYFA…
…
13Arecentsurveyfoundthat39%oftheVictorianyouthjusticecentre(custodial)populationcomprised
childrenandyoungpeopleofCALDbackground:SentencingAdvisoryCouncil,June2019,‘CrossOver
Kids,VulnerableChildrenintheYouthJusticeSystem’,report1,p44.14Section362(1)oftheChildren,YouthandFamiliesAct(2005).
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[t]hestatutoryframeworkforjuvenilejusticecompelsthecourtsentencingayoungoffender(almost
alwaystheChildren’sCourt)toadopttheoffender-centred(or‘welfare’)approach,ratherthanthe
‘justice’or‘punishment’approach...justasimportantly,thisstronglegislativepolicyiswellsupportedby
theextensiveresearchintoadolescentdevelopmentconductedoverthepast30years15
Thesentencingofchildoffendersisconsequentlygovernedbyconsiderationsincluding
preservationoffamilyrelationships,furtheranceofeducationandminimisationofthe
stigmaassociatedwithacriminalsentence16.
Thefateofanasylumseekerorrefugeechildoryoungadultorindeedanynon-citizen
whoischargedwithacriminaloffenceisdetermined,however,bytheinteractionof
VictoriancriminallawandtheMigrationAct1958(the‘MigrationAct’).Theprovisions
oftheMigrationActthatcomeintoplayarethoseprovidingforthecancellationof
bridgingvisas17onthebasisofcriminalcharges(s116)andcancellationofsubstantive
visas(includingtemporaryandpermanentprotectionvisas)uponconvictionfora
criminaloffence(s501).TheinteractionofstatecriminalandCommonwealthmigration
lawleadstoarangeoftrajectoriesforyoungoffenderswhoarenon-citizens.Thereare
manypermutationsbutthefollowingexamplesareillustrative–allaredrawnfrom
casesIhaveworkedondirectlyorofwhichIamaware18.
Scenario1–anasylumseeker’sbridgingvisacancellationuponchargesbeinglaid,
immigrationdetention,chargesdroppedandreleaseintothecommunity
Amentallyunwellyoungadultasylumseekerischargedwithanoffence.Hisbridging
visaiscancelledandheisthereforebyoperationoflawplacedinimmigration
detention.Aftersomemonthsthechargesarewithdrawnontheapplicationofthe
policeinformantowingtodeficienciesintheevidence.Theasylumseekerremainsin
immigrationdetentionformoremonthsuntiltheMinisterforImmigrationgrantsa
bridgingvisa19andafternearlyayearofdetentionheagainlivesinthecommunity.
Whileheldinimmigrationdetentionhismentalhealthdeteriorates.Heisexposedto
violenceandwitnessessuicideattempts.Whiledetainedheisnotabletoobtain
treatmentfromthepublicmentalhealthfacilityhenormallyattends.Hesuffersfroma
15 BradleyWebster(apseudonym)vTheQueen[2016]VSCA66(MaxwellPandRedlichJA)at[9]and[28].16Section362(1)oftheChildren,YouthandFamiliesAct(2005)
17Bridgingvisasareheldbypeoplewhoarewaitingfortheoutcomeofavisaapplicationforasubstantive
visa(thatis,avisaallowingthepersontoremainforafixedperiodorpermanentlyinAustralia)andallow
themtolivelawfullyinthecommunitywhilethisoccurs.18Identifyingdetailshavebeenremoved;somefactshavebeenchangedinordertoanonymisethe
scenario.19TheMinisterforImmigrationhasadiscretionarypowerunders195AoftheMigrationActtogranta
visa.Thereisnotimeframeastowhenthevisagrantmayoccur.IftheasylumseekerarrivedinAustralia
withoutavisaheorshewillbeunabletoapplyforabridgingvisawhileinimmigrationdetention.
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complexposttraumaticconditionanddepressionandtherearenospecialisedtreatment
servicesavailablefortheseconditionswhileheisinimmigrationdetention.When
releasedhismentalhealthhasdeterioratedtothepointwherehisabilitytoengagewith
hislawyerandparticipateintheprotectionvisaapplicationprocessaresignificantly
compromised.
Scenario2–achildasylumseekerischarged,bridgingvisacancelled,remanded,
Children’sCourtcustodialsentence,uponcompletionofsentenceindefiniteimmigration
detention,refusalofprotectionvisaoncharactergrounds
AchildasylumseekerarrivesinAustraliawithhisfamily.Hehadlivedforyearsinthe
midstofacivilwarandwasprofoundlytraumatised.HesuffersfromcomplexPTSDthat
includesseveredissociativesymptoms,unstablemood,intenselabileemotionin
responsetostressorsandperiodicself-harmandsuicidality.When16yearsoldheis
chargedwithaseriousoffence.Hisbridgingvisaiscancelledandheisremandedina
youthjusticecentre.Anapplicationforbailisnotaviableoptionbecauseifsuccessfulit
wouldleadtohimbeingdetainedinimmigrationdetention–withoutabridgingvisahis
detentionismandatory.Whileremandedhereceivespsychologicalcounselling,
pharmacotherapyandpsychiatricreviewbutnospecialistservicesforhiscomplexneeds
areavailable.Duringremandheisphysicallyandsexuallyassaulted.TheChildren’s
Courtsentenceshimtoatermofdetentioninayouthjusticecentre.TheCourtfinds
thattheoffendingoccurredinthecontextofseverementalhealthproblemsandthata
rehabilitativedispositionincludingextendedspecialisedpsychologicaltreatmentis
appropriate.Heservesaterminayouthjusticecentreduringwhichhereceivesfurther
counselling,supportandpharmacotherapywhichhefindshelpfulbutwhicharenot
specialisedinterventionstailoredtohisspecificneeds.Upontheexpirationofhis
sentenceheisplacedinimmigrationdetention.Heisfoundtobearefugeebuta
protectionvisaisrefusedoncharactergrounds.Hisemotionallability,severe
dissociativesymptomsandperiodicself-harmaredifficultfortheimmigrationcentresto
manage.Heisalsovulnerabletomistreatmentbyolderdetainees.Heismoved
betweendetentioncentres,includingforanextendedperiodinanotherstateandaway
fromhisfamily.Onanumberofoccasionsheisheldinseclusionroomsasanattemptto
containhisagitatedanddisruptivebehaviour.Heisheldinprotectionunitstoremove
himfromotherdetaineeswhoposearisktohim.Hereceivespsychiatricreviewsand
someintermittentcounsellingwhileinimmigrationdetentionbutnotreatmentspecific
tohisneeds.Onanumberofoccasionsheallegesthathehasbeenphysicallyand
sexuallyassaulted.Hisprotectionvisaapplicationremainsonfoot.
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Heisnowayoungadultheldinindefiniteimmigrationdetention.Ofthenearlyfiveand
ahalfyearssincearrivinginAustraliaasatraumatisedchildasylumseekerhehasspent
fourandahalfyearsinimmigrationdetentionoryouthjusticecentredetention(the
majorityinimmigrationdetention)andoneyearinthecommunity.
Scenario3–childrefugeeresettledinAustraliawithapermanentvisa.Youthoffending
resultingincancellationofvisa,youthdetentionandthenadultprison
AlateprimaryschoolagedchildrefugeeresettlesinAustraliawithhisfamily.Heandhis
familyweredisplacedduetocivilwarandthenspentanumberofyearsinarefugee
camp.HehadreceivednoformaleducationpriortoarrivinginAustralia.Heacquires
Englishslowlyandseemsdistractibleinclass.Inmidsecondaryschoolhebecomes
disruptiveinclass;hisliteracyandnumeracyaretwotothreeyearsbeneathhisyear
level.Hereceivespsychologicalassessmentregardinghislearningabilitybutalthough
post-traumaticsymptomsandfamilyconflictarenotedtobecontributingtohislearning
difficultieshereceivesnoformalinterventions.Hebeginsusingsubstancesat14years
old.Fromtheageof15yearshebeginscommittingmultiplegangrelatedcrimes
involvingtheft,armedrobberyandhomeinvasion.
Heissentencedtohisfirsttermofyouthdetentionwhen16yearsold.Whenremanded
apsychologicalassessmentnotesthathesuffersproblemswithunstablemood,intense
labileaffect,identityconfusion,attentiondeficits,andstimulantrelatedsubstance
abuse.Hereceivescounsellingwhileremandedandsomemoodstabilisingmedication,
thefirsttreatmenthehasreceived.Heisrefusedbail.Whileinyouthdetentionheis
assaulted,ononeoccasioncausinghimtoloseconsciousness,andheassaultsothers.
Disruptivebehaviourwhileindetentionleadstohimbeingconfinedtohiscellfor23
hoursadayforthreeweeks.Furtherchargesarelaidand,havingturned18,heis
transferredtoanadultprison.Inadultprisonheisconfinedtohisroomfor23hoursa
dayforanumberofweeks,althoughhesaysheprefersnottoleavehiscellatall
becausehedoesn’tfeelsafe.Hedescribesadeteriorationinhismentalstatewhile
secludedincludingmoreintensememoriesoftraumaticeventsfromhischildhood.
Whileservinghissentenceinadultprisonheisnotreceivinganymentalhealthcare.
Owingtothegravityoftheoffendinghewillfacemandatoryvisacancellationand
indefiniteimmigrationdetentionuponthecompletionofhissentence.Theinstabilityin
hiscountryoforiginislikelytomakerepatriationimpossibleandthereforeavery
extendedperiodinimmigrationdetentionislikely.
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Scenario4Ayoungadultnon-citizen–achildmigrant,hearrivedinAustraliaasan
infant.Earlychildhoodneglectandabuse.Parentsseparatedwhenaninfantandleftin
careofseverelymentallyunwellmother.Placedinfostercarewhereabused.Offending
frommidadolescence.Mentallyunwellfromlateadolescence.Visacancellationinearly
adulthood.
Theyoungadulthasneverappliedforcitizenship.Heisdiagnosedwithschizophrenia
andborderlinepersonalitydisorderwhen19yearsoldbuthasonlyreceived
intermittenttreatmentforhisconditionatthetimeheisremandedwhen21yearsold.
Hereceivesamandatoryvisacancellationafterheisgivena14monthcustodial
sentence–hehadpreviouslyreceivedmanynon-custodialsentences.Heisnotgranted
parolebecausehecannotre-enterthecommunitywithoutavisa.Uponcompletionof
hissentencehefacesmanymonthsoryearsofimmigrationdetentionwhilelegal
appealsarefinalised.Herequirestreatmentforhiscomplexsetofmentaldisorders.In
prisonhehasreceivedmedicationforhispsychoticillnessbutnopsychological
treatment.Inimmigrationdetentionhistreatmentislikelytobelesscomprehensive
still.Forensicpsychologicalreportstenderedduringhissentencingindicatedaneedfor
thoroughongoingtreatmentinvolvingpharmacotherapyforhispsychosisandmood
instability;psychotherapyforcomplexdevelopmentaltraumaandtoassistthe
managementofrecurrentpsychoticsymptoms;treatmentforsubstanceaddiction;case
management;andvocationaltraining.
Thesescenariosareinmyopinionillustrativeofthepathwaysthroughthecorrections
andmigrationsystemsofnon-citizenandmentallyunwellyoungoffenders.The
consequenceoftheinteractionofCommonwealthmigrationlawandpolicyandState
criminallawisthatrehabilitativeobjectivesinthesentencingofchildrenandyoung
adultsaredefeated.Insteadofreceivingbail,paroleandthebenefitsofcommunity
correctionsorders,allofwhicharelikelytobeaccompaniedbymentalhealthtreatment
andrehabilitation,theyoungnon-citizenisheldinremand,custodywithoutparoleand
immigrationdetention.Forallyoungpeople,butparticularlyasylumseekers,refugees
andpeoplewithtraumatichistories,treatmentwithincustodyisinferiortowhatcanbe
achievedinthecommunityduetothenarrowerrangeofservicesavailableandthe
adversepsychologicaleffectsofthecustodialenvironment.Serviceprovidersworking
withyoungasylumseekersandrefugeesareawarethatcustodyoftencausesmental
healthdeteriorationratherthanrehabilitation.Experiencingphysicalassaultand
witnessingviolencetoothers,exposuretoanti-socialattitudesandtheuseofextended
seclusionasamanagementmeasureareconditionswhichprecludeatraumatisedyoung
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person’srecovery.When,followingacustodialsentence,ayoungpersonisheldin
immigrationdetentionratherthanthecommunityunderparoleoracommunity
correctionsorder,theyareplacedinasecondenvironmentwhichisantitheticalto
recovery.Anenvironmentwhichweknowisunequivocallyassociatedwithmental
healthdeteriorationovertime,takestheplaceofwhatacourtwouldnormallyenvisage
forayoungoffender-acommunitysettinginwhichtheyoungpersoncanstartto
regaintheirmentalequilibriumthroughcomprehensivementalhealthcare,education,
vocationaltrainingandthesupportoffamilyandfriends.
Insummary,themodernhumanesocietalapproachtoyoungoffenders,asenshrinedin
theChildren,YouthandFamiliesAct(2005),isfrustratedbyCommonwealthmigration
lawandpolicy.Therangeofnon-custodialandpreandpostcustodialrehabilitative
communitydispositionsavailabletotheCourtsareinpracticeoftenunabletobe
accessedbythenon-citizenoffender.Thesentencingobjectivesforyoungoffenders
directedto,totheextentpossible20,preservingfamilyrelations,avoiding
criminalisation,minimisingdisruptiontoeducation,improvingtheoffender’swell-being
andaddressingthecausesoftheoffendingarethwartedwhenmigrationlawpursuesits
owngroundsforimposingdetention.Forthementallyunwellnon-citizenchargedwith
orservingacriminalsentence,oneofmanyconsequencesisthattheyarelessliketo
receiveadequatetreatmentandcareandtheirconditionislikelytobeexacerbated.
3.Thementalhealthcareofpeoplewithpost-traumaticconditions
Post-traumaticconditionsareelevatedinpopulationsthathaveincreasedlevelsof
exposuretopotentiallytraumatisingevents–forinstancerefugees,veteransand
victimsofcrime.Violenceandsexualabuseinchildhoodandextendedtraumaduring
adulthoodcangiverisetocomplexpost-traumaticpresentationswhichthenew
diagnosticcategoryof‘ComplexPosttraumaticStressDisorder’intheyettobefinalised
ICD11(WorldHealthOrganisation)taxonomyofmentaldisordersaimstocapture.In
additiontothePTSDsymptomclusters,thediagnosisdescribesso-called‘disordersof
selforganisation’–negativeself-concept,disturbancesinrelationshipsandaffective
dysregulation.
20Therehabilitativedimensiontosentencing,particularlyinrelationtomoreseriousoffences,isbalanced
withtheneedforcommunityprotection:s362,Children,YouthandFamiliesAct(2005).
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ThemajorityofpeopleexperiencingPTSDexperienceconcurrentdisordersand
conditions–oneormoreofdepression,otheranxietydisorders21,substanceuse
22and
increasedratesofsuicidality23.RatesofPTSDhavebeenfoundtobeelevatedinpeople
sufferingbipolardisorder24andpsychoses
25.Thesecomorbidconditionscannotbe
separatedfromthepost-traumaticsymptomsandneedsimultaneoustreatment.The
sequencingofinterventionsandhoweachconditionmayposechallengesforthe
treatmentoftheother,isasubjectwhichiscurrentlygivenmuchresearchattention.
PTSDhadbeenfoundtobeacommondisorderexperiencedbypatientsinprimarycare
settings;forexampleaUSstudyfoundalmostone-quarterofpatientsmetthecriteria
forcurrentPTSDandone-thirdmetthecriteriaforlifetimePTSD,althoughonly11%
werediagnosedinmedicalrecords26.Asdescribed,ratesofPTSDaremarkedlyelevated
inmanycohortsofrefugeesandsomewhatelevatedamongpeoplewithmajormental
illnesses.Thereisreasontobelievethatpost-traumaticconditionsareunder-identified
andundertreatedinpublicmentalhealthfacilities27.Thereareanumberofreasonsfor
this.Psychosesandmajoraffectivedisorderstendtobethediagnosesreceivingthe
mostclinicalattention.Secondly,thesefacilitiesareorientedtowardpharmacotherapy
andcasemanagementasthefirstlineoftreatmentandcarewhereastheevidence
basedfirstlinetreatmentsforPTSDarevariousformsoftraumafocusedpsychological
treatments28.Fewmentalhealthcliniciansarespecificallytrainedinthesetreatments.
21Nickersonetal.ComorbidityofPosttraumaticStressDisorderandDepressioninTortured,Treatment-
SeekingRefugeesJournalofTraumaticStressAugust2017,30,409–415.Haagen,J.Fetal.(2016)
Predictingpost-traumaticstressdisordertreatmentresponseinrefugees:Multilevelanalysis.British
JournalofClinicalPsychology,56,69–83.https://doi.org/10.1111/bjc.12121.
22Berenz,Eatal.Posttraumaticstressdisorderandalcoholdependence:Epidemiologyandorderof
onset.PsychologicalTrauma:Theory,Research,Practice,andPolicy.Vol.9(4),2017,pp.485-492
23Afzali,Metal.Traumacharacteristics,post-traumaticsymptoms,psychiatricdisordersandsuicidal
behaviours:Resultsfromthe2007AustralianNationalSurveyofMentalHealthandWellbeing.Australian
andNewZealandJournalofPsychiatry.Vol.51(11),2017,pp.1142-1151.24Madhavi,Retal.BipolarIdisorderwithcomorbidPTSD:Demographicandclinicalcorrelatesinasample
ofhospitalizedpatients.ComprehensivePsychiatry.Vol.722017,pp.13-17.25GrubaughAetal.Traumaexposureandposttraumaticstressdisorderinadultswithseveremental
illness:Acriticalreview.ClinicalPsychologyReview31(2011)883–899.
26LiebschutzJ
elal.PTSDinurbanprimarycare:highprevalenceandlowphysicianrecognition.JGen
InternMed.2007Jun;22(6):719-26.Epub2007Mar10.
27Thishasbeenidentifiedasanissueinpublicmentalhealthservicesinternationally:seeGrubaughAet
al.Traumaexposureandposttraumaticstressdisorderinadultswithseverementalillness:Acritical
review.ClinicalPsychologyReview31(2011)883–899.28Forexample:TheAustralianGuidelinesfortheTreatmentofAcuteStressDisorderandPosttraumatic
StressDisorder.PhoenixAustralia–CentreforPosttraumaticMentalHealth2013.
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Withregardtocomplexpost-traumaticpresentations,wherethedisordermanifestsas
BorderlinePersonalityDisorder,thereisaspecialiststatewidepublicfacility29butthe
areamentalhealthserviceshavelittle,orareonlyjustnowbeginningtoacquire,the
capacitytodeliversystematicevidencebasedtreatmentsforthiscondition.
Currentlythereisaninequitabledistributionofspecialistservicesforthetreatmentof
post-traumaticmentalhealthdisordersinVictoria.Thereisonepublichospitalthat
treatsveterans,police,emergencyservicepersonnelandpeoplewhoseconditionsare
compensable(duetohavingbeenprecipitatedbyanevent,suchasaworkplaceinjury
orroadaccidentforwhichthereisstatutorycoverageofmedicalcosts)30.Thereare,to
myknowledge,asmallnumberofprivateclinicswhichprovideprogramsforsufferersof
PTSDwhichcanassistpeoplewithprivatemedicalinsurance31.Whentheconditionis
particularlycomplex,whenthepersonpresentsperiodicsignificantrisktothemselves,
orwherethereisacomorbidmajormentalillnessaprivatepractitionerisunlikelytobe
abletoprovidetherangeofservicesthattheclientneeds.Inmyviewpublicmental
healthfacilitiesshouldbeabletoprovideexpertmentalhealthcareforthisgroup.This
maybeachievedthroughmorethoroughscreeningforpost-traumaticconditions,
ensuringasubgroupofstaffwithineachareamentalhealthservicehasspecialist
traininginthetreatmentofPTSD,andestablishingformalprogramsinthenetworkof
mentalhealthserviceswithinwhichsufferersofPTSDwhodonothaveprivate
insuranceoreligibilityforcompensabletreatmentcanreceivecomprehensivecare.
Partofthesuiteofcareavailableshouldbeaninpatientfacilityspecificallydesignedto
treatpost-traumaticconditions.AsubgroupofpeoplewithseverePTSDrequiresasafe,
therapeuticinpatientenvironmentatcertainphasesoftheirtreatment;suchan
environmentisnotprovidedbyacutepsychiatricinpatientunitsandisnotcurrently
availableinanyothersetting32.
29SpectrumPersonalityDisorderService.
30ThePsychologicalTraumaRecoveryService,TheAustinHospital.
31Forexample,TheAlbertRoadClinic.
32 ThePsychologicalTraumaRecoveryService,TheAustinHospital,providesinpatientservicesforeligible
peoplebutnottothegeneralcommunity.
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4.Accesstoprivatesectorpsychologicaltreatmentbypeopleofnon-Englishspeakingbackground
PrivateprovidersdeliveringMedicare(betteraccess)andPrimaryHealthNetwork
fundedpsychologicaltreatmenthavelimitedornoaccesstointerpreters.Theseservices
areunavailableforpeople-primarilymigrantsandrefugeesbutalsosomeindigenous
people-whoarenotfluentinEnglish.Theonlywaytheservicemightbedeliveredto
thesegroupsisifthereisaproviderwhospeaksthelanguageoftheclient;accesstoa
providerwiththelinguisticandtherapeuticskillsmatchedtotheclient’sneedsisin
mostcasesunavailable.
Thisarrangement,involvingaverylargeallocationofpublicfundsforcommunity
healthcare,shouldberegardedasdiscriminatoryandunconscionable.
Ihavedescribedtheneedformorestronglycoordinatedmultidisciplinaryplansofcare
involvingarangeofpractitionerseachofwhomtakesresponsibilityforaspecificareaof
care.Howeveraccesstoonsiteinterpretersisapreconditionforassistingpeoplewho
arenotfluentinEnglish(orwhoprefertospeakintheirmothertonguewhenengaging
inpsychologicaltreatment).
Beyondbasicequitableprinciples,thereareanumberofconsiderationsthatshould
informpolicywithregardtoaccesstointerpretersbyprivatepractitioners.In
psychotherapyofanydepthaninterpreterbecomesintegraltothetherapeutic
relationshipandthesuccessofthetreatment.Itisoftenveryimportanttoengagethe
sameinterpreteroralimitednumberofinterpreterswhenworkingwithtrauma
survivorsorindeedwhenanyexploratorypsychologicalworkisbeingundertaken.
Employingaphoneinterpreterisanarrangementwhichisusuallyentirelyinadequateto
thetask.EvenforthosewhohaveacquiredreasonablefluencyinEnglish,Ihavefound
thatmanyclientsprefertospeakintheirmothertonguebecausetheyareableto
expressthemselveswithgreatereaseandnuanceandfeelthattheyarefullyincontact
withtheiremotionsratherthan,whenspeakinginEnglish,observingtheiremotions
‘fromtheoutside’.Theyfeel,inotherwords,evenwhenbilingual,thattheirmother
tongueremainsthelanguageoftheiremotionallifeandoftheirownself.
Itmaybethatthecurrentsituationcouldbeslightlyamelioratedbyencouragingmore
bilingualpractitionerswiththerequisitecommunitylanguagestobecomepartof
primaryhealthnetworksandforgeographicalbarrierstobeovercomebyincreaseduse
ofteleconferencingfacilities.Howeverthesearrangements,whileworthwhile,willnot
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addressthelargerissueofequitableaccess.InthisregardIshouldalsonotethatinmy
experiencethereisnotaninsignificantnumberofmigrantsandrefugees,especially
fromsmalleroremergingcommunities,who,forreasonsofperceivedconfidentiality,
wishtoreceivetreatmentfromaclinicianfromoutsidetheirowncommunity.
5.Thecapacityofpublicmentalhealthservicestodeliverevidencedbasedpsychologicaltreatments
Nationalguidelinesrequirethat‘[t]reatmentandsupportprovidedbytheMHS[mental
healthservice]reflectsbestavailableevidenceandemphasisesearlyinterventionand
positiveoutcomesforconsumersandtheircarer(s)’33.TheNationalMentalHealth
Strategyandcodesofprofessionalconductrequirepracticetobeevidencebased.
Cliniciansnowhaveavailabletothemanextensivesetoftreatmentguidelinesproduced
bothinAustraliaandinternationally.Theevidencefortheeffectivenessofparticular
treatmentsandinterventionsistypicallyorganisedaccordingtoahierarchyranging
fromhighgradeevidenceofferedbyasystematicreviewofrandomisedcontroltrialsto
lowgradeevidenceprovidedbyacaseserieswithpretest/posttestoutcomes.Highlevel
evidencefortheeffectivenessofatreatmentprovidestheclinicianwithsomeassurance
thatonapopulationleveltheinterventionwillassistclientswithaparticularmental
disorder.Howevergoodclinicalpracticeneverinvolvestheunreflectiveapplicationof
thetreatmenttothedisorder;theclient’sspecificpreferences,culturalbeliefs,
psychologicalcharacteristicsandcapacities,andsocialcircumstancesleadthe
competentcliniciantomakechoicesbetweendifferenteffectivetreatmentsandto
tailorthechosentreatmenttothespecificneedsoftheclient.
Likealltreatmentsforcomplexmentalhealthconditions,theprovisionofeffective
psychologicaltreatmentsrequiresconsiderabletrainingandexperience.Itisalsolabour
intensiveandtimeconsuming.Inrelationtopsychologicaltreatments,inmyexperience
publicmentalhealthserviceshaveneverhadstaffprofilesorfundingtoprovidewhat
evidencebasedtreatmentguidelinesindicateshouldbeprovided.Thereisinfacta
chasmbetweentreatmentguidelines’recommendationsandclinicalpracticewith
respecttopsychologicaltreatment.
Thispointcanbestbemadebyexample.Thetreatmentguidelinesfortreating
depressivedisordersproducedbytheAustralianPsychologicalSocietyandtheRoyal
33 Nationalstandardsformentalhealthservices2010;Standard10,DeliveryofCare.
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AustralianandNewZealandCollegeofPsychiatristsrecommendpsychological
treatmentsforthisdisorder.TheAPSguidelinesindicatethereislevel1evidencefora
numberoftreatmentsincludingCognitiveBehaviouralTherapyandInterpersonal
Therapy.Bothguidelinesindicatethatformoderatetoseveredepressioncombined
psychologicalandpharmacotherapyismoreeffectivethaneithertreatmentalone.The
RANZCPguidelinesstatethat‘[f]ormostpatientswithdepression,acombined
treatmentapproachismoreeffectivethaneitherpsychologicalorantidepressant
treatmentalone.Thisappliesparticularlytodepressionofmoderateorgreaterseverity
…andchronicdepression’34.Therecommendationsguidingtreatmentofdepressionin
theUKaresimilar:theNICEguidelineindicatesthathighintensitypsychological
interventions35combinedwithpharmacotherapyisthetreatmentofchoicefor
persistentsubthresholddepressivesymptoms,mildtomoderatedepressionwith
inadequateresponsetoinitialinterventions,andmoderateandseveredepression36.
Itisunlikelyinmyexperiencethatevenasizeableminorityofpeoplesufferingamajor
depressivedisorderwhoattendapublicmentalhealthservicearereceivinga
recommendedpsychotherapy.
Treatmentguidelinesallocatearoleforpsychologicaltreatmentsforallmental
disorderssufferedbypeopleattendingpublicmentalhealthservices.Therolewillvary
accordingtothementaldisorderandtheperson’sspecificneeds.Treatmentguidelines
indicatepsychologicalinterventionsasfirstlinetreatmentsforPTSD,someanxiety
disorders,mildtomoderatedepressivedisordersandborderlineandotherpersonality
disorders;asfirstlinetreatmentincombinationwithpharmacotherapyformoderate
andseveredepressivedisorders;asusefulinrelapsepreventionforbipolardisorders
andasanadjunctivetreatmentduringtheacutedepressivephaseoftheillness;andas
animportantelementinthetreatmentofschizophrenicdisordersinrelationto
treatmentresistantpositivesymptomsandinrehabilitationandrelapseprevention.
Ibelieveasurveyofpastandcurrentpracticewouldfindthatthedeliveryof
psychologicaltreatmentsinpublicmentalhealthfacilitiesisnotalignedwithbest
practicetreatmentapproachesandinfactfallsfarshortofthem.Psychological
treatmentsshouldbeanintegralandubiquitousfeatureofpublicmentalhealth
treatmentplansandthetreatmentsshouldbedeliveredbysuitablyqualifiedand
34RoyalAustralianandNewZealandCollegeofPsychiatristsclinicalpracticeguidelinesformood
disorders,AustralianandNewZealandJournalofPsychiatry2015,Vol.49(12)1-185,4135TheNICEguidelinedescribeshighintensitypsychologicalinterventionsasinvolving16to20sessions
over3or4monthswithfollow-upsessions.36NationalInstituteforClinicalandCareExcellence,Depressioninadults:recognitionandmanagement.
Clinicalguidelinepublished28October2009.
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experiencedclinicians.
6.Thequalityofrehabilitationservicesforpeoplewithchronicmentalillnesses
IdonothaveparticularexpertiseinthisareabutIwishtomakeafewcommentsbased
onanalltoofrequentobservation:thatpeoplerecoverfromtheacutephaseofsevere
mentalillnessbutarethenunabletorecoverpurposefulandsatisfyinglives.Thereare
manyreasonsforthis,Iwillfocusonjusttwo–thepersistenceofinadequatelytreated
cognitiveimpairmentsandtheinadequacyofvocationaltrainingandplacement.
Allmajormentalillnessescausecognitiveimpairment.Inmyexperiencepeople
sufferingfromarangeofdisorders,moodandanxietydisorders,PTSDandpsychotic
disorderswilloftenindicatethatattentionproblems,andimpairmentinrecollectionof
dailyeventsandretrievalofautobiographicalmemoriesareamongthemostdebilitating
experiencesassociatedwiththeirmentalillness.Evenwhenthedisorderisinremission,
indisorderssuchasschizophrenia,majordepressivedisorderandPTSD,thereis
evidencethatcognitiveimpairmentpersists37.Inmyexperiencecognitiveimpairmentis
rarelyafocusofclinicalattention.Mostmentalhealthclinicianshavelimitedskillsinthe
remediationofcognitiveimpairment.Neuropsychologistswhoareexpertsincognitive
disorders,areusuallynotemployedinpublicmentalhealthservicesnoratnon
governmentpsychiatricrehabilitationandsupportservicesandaregenerallydifficultto
access.Theirskillsarenotconfinedtoexplainingneuropsychologicalconsequencesof
braindisorders;theycanalsoprovideexpertassistanceinthemanagementand
rehabilitationofthecognitiveeffectsoffunctionaldisorders.Recoverygoalsforpeople
withchronicmentalillnessshouldincludespecificinterventionstoimprovecognitive
functioning;neuropsychologistsandotherclinicianswithrelevantskillssuchas
occupationaltherapistsshouldmakesubstantialcontributionstotheimplementation
anddeliveryofthisphaseoftreatment.Mentalhealthservicesshouldemployorhave
directaccesstoclinicianswithspecialistknowledgeoftheremediationofcognitive
abilitiesinpeoplewithmajormentalillnesses.
Anindispensableelementinrehabilitationistheperson’sideasabouthowtheywould
liketoimprovethequalityoftheirdailylivesandwhatsetofactivitieswouldhavevalue
37 Forexampledepressioninremission:BoraE,HarrisonBJ,YucelM,etal.(2013)Cognitiveimpairmentin
euthymicmajordepressivedisorder:Ameta-analysis.PsychologicalMedicine43:2017–2026.
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andmeaningtothem.Assistingthepersondefinewhatthislifelookslikeandwhatthe
barriersaretorealizingitshouldbeintegraltorehabilitation.Whentheperson’sgoals
aretofindpaidemploymentoravoluntaryactivitythatismeaningfultothem,
employmentservicesornon-governmentrehabilitationservicesareofteninvolvedin
assistingtheclient.Oftentheknowledgeaboutthepersonheldbythementalhealth
serviceandthevocationalassistanceprovidedbytheemploymentserviceorNGOisnot
wellintegrated.Itismyexperiencethatmanymentallyillpeoplewhohavespent
extendedperiodsoutoftheworkforcefindtheattempttoregainemploymenta
frustratinganddemoralizingexperience.Theyhavetoldmethattheywouldbenefit
frompre-vocationaltrainingbutthishasnotbeenavailable.Theyhavealsosaidthey
wouldbeassistedbyagraduatedre-entryintoemployment,commencingwithpart-
timeworkandongoingassistancefromapersonwhoseroleitistoprovidepractical
supportinthetransitionbacktowork,butthisdoesnothappen.
Manypeoplewhohavesufferedfromamentalillnessinmyexperiencefeelabandoned
atthepointwhentheyattempttomovebackintoafullerlifeinvolvingworkorstudy.
Howpeoplewithseverementalillnessesareassistedbackintotheworkforceandto
engageinthebroaderlifeoftheircommunityneedstoberethought.
7.Concludingremarks
Mentalhealthservicescanbeviewedfrommanyperspectives.Itistruetosaythat
withinthecurrentsystemgoodpracticesco-existwiththosethatareneglectfuland
inattentivetothementallyillperson’sneeds.Ihaveattemptedtodescribesomeofthe
latterpractises.
IftheCommissionwouldbeassistedbyfurthercommentonanyoftheareasoutlinedin
thissubmission,Iwouldwelcometheopportunitytodosobymeansoforalor
additionalwrittenevidence.
GuyCoffey
5July2019
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