A.C.T. Disability, Aged and Carer Advocacy
Service (ADACAS) A.C.T. Disability, Aged and Carer Advocacy
Service (ADACAS)
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Letter to the Editor of the Canberra Times by Kym Duggan,
Chairperson
ADACAS
ADACAS paper on Crisis in ACT Mental Health Services
Dear Sir
I refer to the many recent articles on the alleged dysfunctional state of ACT’s mental health services. ADACAS, (ACT Disability Aged and Carer Advocacy Service Inc.) congratulates Jon Stanhope and Simon Corbell, for withstanding the pressure to build yet another institution. The issue is a complex one, and not well served by resorting to simplistic responses, such as a time-out facility.
ADACAS has had involvement with many of the people currently before the courts. Without exception, they ended up in court because of a lack of appropriate community based supports, which resulted in a deterioration of their mental health status. Another institution would not have solved the problem for them or the courts, because institutions need adequate numbers of suitable staff too!
Have we learned nothing from Gallop? People need individual solutions, not “one size fits all” institutions.
Yours sincerely
Kym Duggan
Chairperson
ADACAS
Ph 6242 5060
The purpose of this paper is to broaden the debate about the need for more institutions, of various types, for people with psychiatric disability , mental illness and mental dysfunction , and specifically to canvass alternatives to institutional care.
ADACAS is an advocacy agency which provides individual advocacy for people with disability, and those who are ageing. ADACAS is funded by both ACT and Commonwealth Governments for advocacy, which includes funding provided some years ago by the Commonwealth Government to provide advocacy specifically for people with psychiatric disability. ADACAS is the only independent advocacy agency in the ACT funded to provide advocacy for people with psychiatric disability, and has over 9 years experience in this form of advocacy.
At a more specific level, ADACAS provides advocacy for a number of people with psychiatric disability who, in the last 5 years or more, have been at the centre of a number of incidents which have received significant media attention, including the most recent events. Therefore, we are in a position to inform the debate, from the consumer’s perspective, about why the situation has deteriorated to its current impasse.
In addition, ADACAS has a staff member who is also a qualified psychotherapist, which is a form of psychological counselling specifically developed for the treatment and long-term management of people with mental dysfunction, especially borderline personality disorder . Whilst some of the issues affecting ACT MHS are related to people with a recognised mental illness, eg depression, schizophrenia etc, the people who are regularly in the media, and presenting the greatest challenge to ACT MHS, are people with borderline personality disorder.
The presenting issue is that there are some people in the ACT with a psychiatric disability whose interactions with MHS staff are no longer therapeutic, and are regularly reduced to allegations of (mutual) assault. As a result, MHS staff have refused to treat them.
The media coverage of the most recent case has resulted in calls for more institutions, including:
These calls have come from people with mental illness, their family, community based organisations, ACT government officials including statutory oversight agencies, Police and the courts. There are similar issues across all jurisdictions in Australia.
Based on the experience of ADACAS consumers, the fundamental need is for adequate levels of suitable staff, in ACT Government and community based agencies. Attached are case studies supporting this statement, (Attachment A).
ADACAS does not believe there is a need for more institutions. There are a number already in the ACT, including PSU, Calvary Hospital wards, Secure Care unit, respite houses etc, and we believe a review of their respective roles etc should be undertaken before committing the ACT community to the expense of the construction of another facility.
There are also some underlying questions with respect to the role of ACT MHS, community based MHS and the implementation of the National Mental Health Strategy. The confusion relates to inter-relationship between clinical management, case management, social support and acute health care.
Whether due to lack of resources, or other reasons, ACT MHS operates under a risk management approach. Thus only people who are in crisis receive attention from MHS. As a result, those people who are not in crisis receive very little support, eg case management. In fact we understand ACT MHS does not provide case management now, but “clinical management”.
ADACAS perception of what’s available for people living in the community with mental illness, is that their social and community living needs are not catered for. There is a prevalence of the medical model, even in important areas of people’s lives such as independent living skills.
When this is combined with the risk management approach discussed above, the consequence is that, over time, the overall mental health status of Canberrans with mental illness has deteriorated, and the pressure on the acute sector has increased almost beyond its capacity to cope.
However in our opinion, the situation would not be as critical, if ACT MHS and community sector staff were “suitable” and adequately trained and supported. In particular, in our experience, we are astounded at the lack of common sense that is sometimes displayed by staff working in the sector, see case studies 2b and 5e.
If this position is accepted by Government, then there are no “magic bullets” to solve this situation. An institution, of whatever form, will not address the issues. In fact it may well be that the situation could be exacerbated if the current staff approaches are continued into the new institution. In our opinion, and experience, the likely result of such an approach will be the increased use of physical and chemical restraint, and an increased risk of yet more “deaths in custody”.
However, ADACAS recognises that the situation calls for a response from the ACT Government.
The ACT Government must immediately take action to address the acute staffing situation, (ie not just numbers), as without that approach, any solution will be only a band-aid response. However, ADACAS makes the following suggestions to ease the situation mental health consumers are currently facing, which should operate in parallel with a longer-term workforce strategy.
ADACAS supports the concept of separating long term housing from support. That is, a person in need of support should be able to access it in their own home, rather than having to move from their home to access it. Whilst this concept has been acknowledged for people with disability for decades, (and soundly debated during the Gallop Inquiry etc), this concept has yet to gain acceptance in the mental health field.
Secondly, ADACAS does not support the concept of congregate care, eg group homes and other forms of institutions. This is especially the case where the people living in them have no say on where they will live, with whom they will live, and who comes into their home to provide them with support.
ADACAS’ interpretation of the National Mental Health Strategy and the National Mental Health Standards gives authority to our position as stated above, but we have not seen any evidence of this occurring in ACT MHS and community based service provision.
So, in the option presented above, ADACAS would see “generic” housing options as:
Other options should these not be suitable for one reason or another could include;
(However, given the description of the eligibility criteria for access to Warren I’Anson house, ADACAS has some concerns about the appropriateness of this option, if the people are not to be placed at further risk.)
This strategy also demonstrates the concept that the types, and levels of support change, as the needs of the person change. This removes the need for costly infrastructure/capital development: eg a step-down facility, and/or a series of community based group houses staffed at differing levels, eg 24 hr, 12 hr, drop in, on call etc. International and local experience has shown that these purpose built facilities frequently become “white elephants”, when the purpose is no longer relevant. Subsequent Programs are tailored to fit into the buildings etc available, rather than being tailored to the needs of the consumers, and are thus less effective than they might be.
ACT MHS base their management of people with borderline personality disorder on the text of Watson and Kravitz which essentially argues that:
ADACAS agrees with this approach. However we believe that ACT MHS have misinterpreted it in their management of people with borderline personality disorder.
Their implementation of this approach (in ADACAS experience with 4 different people), has been to deny access to PSU when they have sought admission because they believe they are at risk of harming themselves, or others, or damaging property. They are turned away with no alternatives made available for them, which often leads to action by them that has been described as “criminal activity”. The “immediate consequences” of this action is that ACT MHS has them charged eg with assault, damage to property etc. If the person is on bail, then they are charged with breach of bail etc. (See attached case studies.)
The ultimate conclusion to this approach is a custodial sentence. However, prisons are not treatment centres, and the likely outcome is the person is released back into their community even more disturbed and traumatised, effectively requiring increased support from MHS.
ADACAS recognises that, when stressed, people with personality disorders can be extremely difficult to manage, and very disruptive. However, if the role of PSU is to assist, treat and manage people who are at risk of harming themselves or others, then we believe that PSU needs to staffed with adequate numbers of “suitable” people, (see footnote 4) to respond to calls for support.
We are firmly of the opinion, (in the situations where we have been involved), that had PSU responded to the person appropriately, the breakdown in relations and communication between the person and ACT MHS would not have occurred, and the consequent injury to people, and damage to property could also have been avoided.
As mentioned in the introduction, the ACT is not the only jurisdiction experiencing these problems. There have been several media reports in the last 12 months, (NSW, Victoria etc) about similar events, some unfortunately ending in the death of the alleged offender.
The root cause, as is now widely acknowledged, is that the de-institutionalisation programs of the 70’s through to the 90’s, were not accompanied by equivalent development of community based support. Essentially people were “dumped”. Whilst the ACT had no institutions comparable to those found in other states, there is a local example of this, when Watson Hostel was closed down, see attached case studies.
However there are a number of examples from within Australia and overseas which
demonstrate successful outcomes for people with mental illness and dysfunction,
and which are founded on effective community based support.
The South Australian Government has implemented an approach which focuses on
establishing long-term case management for people with mental illness, who,
usually due to lack of adequate levels of appropriate support, become enmeshed
in the criminal justice system. They have also established a Mental Health Court,
to “apply the principles of therapeutic jurisprudence”, with a view
to addressing the health issue that lead to the criminal behaviour.
The UK has recently implemented a new strategy for the management and treatment of people with borderline personality disorder which, as in SA, focuses on an holistic approach, including recognising the importance of establishing an effective therapeutic and case management relationship with the consumer.
In the USA, Project Link was formed in Rochester, NY in 1995 to respond to
the criminalisation of people with mental illness. The model, which is based
on assertive community treatment and intensive case management, has reportedly
significantly reduced the number of mentally ill people in jails. An important
aspect of the model is the need to develop and maintain collaborations among
community systems.
In contrast, ACT MH community services, (eg CATT, Community Health Teams etc)
are so under-resourced that long-term involvement with someone, even if the
staff had the skills to establish a long-term relationship with the person (see
attached case studies), is not possible. The situation is compounded by the
fact that there are few psychiatrists offering psychotherapy under Medicare.
As the cost of psychotherapy is beyond the means of most people, the only option
is ACT MHS. This is not an option for many people, due to breakdown in communication,
trust etc, as result of the issues with lack of suitable staff, and dogmatic
(“zero tolerance”) approach to management of people with personality
disorder.
One of the significant developments of the SA, NY and UK examples above, is
the recognition of the importance of responding to the person in an holistic
manner, across “ideological divides” and in a timely manner. This
approach is critical to effective management of people with borderline personality
disorder and/or mental illness generally, especially where pharmacological interventions
are not an option. This is in stark contrast to the ACT experience, where the
medical model is paramount, and other paradigms are ridiculed and actively discouraged.
Unfortunately, in our view, the Management Assessment Panel, which was established to overcome boundary issues, has not been able to deliver outcomes for people in this situation, (see case studies).
ADACAS recognises the difficult situation facing the ACT Government and community, which we believe has, in part, arisen because of many years of under-resourcing of the ACT mental health system, both Government and community based. However, we do not believe that the construction of an institution, of whatever size or purpose, will resolve the problem.
The long-term investment in adequate numbers of suitable staff will go a long way to improving the quality of life for people with mental illness.
However, any response must be consistent with the directions set out in the National Mental Health Strategy, respond to identified needs of specific individuals, and be sustainable.
Knee-jerk reactions involving the establishment of institutions will not deliver the desired outcome for the Government, the ACT Community and, most importantly, for people with mental illness and their families.
Finally, ADACAS is concerned at the prevalence of the medical model across all forms of service provision for people with mental illness and/or dysfunction who are living in the community. We do not believe that ACT MHS and community based services overall, are in the “right relationship” with mental health consumers. Whilst we acknowledge the importance of the acute health system and longer term clinical management for people with mental illness and/or dysfunction, we believe that their role is to support someone to have a good life, not to control it.
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A.C.T. Disability, Aged and Carer Advocacy Service (ADACAS) Inc.
PO Box 144, Dickson ACT 2602
Office: Suite 207, Block C, Canberra Technology Park, Phillip Avenue,
Watson
Phone: (02) 6242 5060 Fax: (02) 6242 5063 TTY:
(02) 6242 5065.
Email us at adacas@adacas.org.au
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Last modified 12 February 2007