Theses on Mental Health Reform in Australia

 

The Federal Government of Australia commissioned a detailed review of the country’s mental health system. (It subsequently tried to suppress the review for 12 months, and has since abandoned some of its recommendations). Now, as Australia recovers from a Federal election cempaign, discourse of mental health policy has been dominated by a small, recurring number of self-proclaimed advocates, as well as their respective research institutes. The proposal that the present Government is implementing is to expand the bureaucratic structure of GP’s Primary Health Networks (PHNs) to allow for a division between ‘complex’ and ‘low-intensity’ treatments. The former will have treatments administered and rationed by the PHNs; the latter will be diverted to self-management apps. The Headspace model, which, other than isolated, localised successes, has been a miserable and costly failure, will be retained, albeit with some minor trimming down of administrative functions. The advocates – and the most prominent are Patrick McGorry, Ian Hickie, and John Mendoza – want the app approach to be expanded at the direct expense of the existing Medicare system, which they say needs ‘reform’ (i.e. severe cuts or abolition). Meanwhile, the advocates are silent on the perilous and worsening state of public mental health systems, and the $11 billion per year that the Government spends on subsidised ‘private’ health insurance. The aim of the theses here is to provide an alternative to the dominant discourses and speakers which purport to speak for the mental health system and those who use it.

 

The patient is not the ‘client’. An elementary principle of psychotherapeutic practice is the notion that the entity or person funding the assessment and treatment is the client. This may not be the same as the person undergoing the treatment, and at times, the interests of the client and actual patient may be directly opposed. In Australia, the Government is the main ‘client’ of mental health services insofar as it is footing the bill for this or that service; in effect, the patients are the indirect objects of the service.

It is important to keep this in mind when evaluating the heartfelt claims of political parties and mental health advocates. There is no evidence of any sort that the Government is particularly concerned with mental health policy. It has systematically underfunded mental health services for decades. The factors correlated with mental health outcomes tend to relate to structural economic problems, and neither of the major parties show any sign of being willing to address these. The present Coalition Government will almost certainly worsen suicide rates and mental health outcomes by doing the contrary (i.e. exacerbating existing housing problems, cutting education and health spending, taking $2.5 billion from welfare and making the welfare system more punitive, etc). Examining the evidence, one can only conclude that mental health is a very low priority, and possibly even viewed as a fiscal black hole.

Naturally, no politician can articulate this directly. This is where the advocates above do a service for their client, the Government. Namely, they sell cheap programs to Governments that can then use them for nice soundbites, and to give the appearance that they are doing something about mental health. The advocates are selling covers stories, and alibis. Even McGorry has hinted that this is the case: whilst services are systematically dismantled and degraded, ‘awareness’ campaigns are at an all-time high. (The ABC has served as a de facto propaganda wing of the Government in this regard, with some particularly cringe-worthy and facile attempts at ‘awareness’).   In the strictest sense, the needs of patients are incidental to this transaction. That having a bureaucrat assign ‘low intensity’ apps to potentially psychotic or suicidal patients may be very likely to increase the rates of death and suffering is beside the point, since the point is not addressing problems as such but to give the appearance of doing so. In this paradigm, cost-effectiveness and standardisation are an added bonus.

Both major parties regard mental health in the narrowest of technocratic terms, and through the prism of neoliberal economic ideology. The essential idea of what constitutes a mental health treatment is understood, by both the Government and self-proclaimed experts to be something exclusively didactic and autocratic. (Some have even warned that if too much unstructured talking therapy is available, patients may become ‘dependent’). The ‘treatments’ on offer under the neoliberal paradigm tend to be ‘techniques’ of dubious ethical provenance, such as those found in behaviourism, cognitive therapy, and McMindfulness and ‘wellness’ kitsch. Without exception, they are relentlessly reduced to quantitative outcomes and variables, with an accordingly distorted and narrow conception of ‘evidence’. The emphasis is generally on inculcating the individual with ideals of independence, compliance with normative regulations, ‘self-management’ and pacification. (I have critiqued these approaches at length elsewhere, such as here and here).

Without getting into a lengthy discussion of economics, it is important to grasp that neoliberalism is not laissez-faire. Rather, neoliberal economic ideology tends to have a preoccupation with cuts and austerity not so much because this might lead to excessive government expenditure, but because of its alleged effects of market distortion and uncompetitiveness. Moreover, austerity tends to be combined with strong elements of coercion. Australia’s Centrelink system is a great example of this. From a purely economic point of view, it may be better to pay the unemployed to study and gain qualifications, or to provide them with proper employment on state projects. Ideologically, however, this goes against the grain of the individualistic, ‘self-management, marketised ideals of neoliberalism, so instead Centrelink is organised around a system of punitive surveillance and disciplinary measures, even though this is wasteful in economic (not to mention human) terms. Likewise, Headpsace is grossly inefficient when compared with the Medicare system – an appointment with a Headspace general psychologist costs $339 compared to $84 under Medicare – but Headspace allows for more micromanagement of treatment at the level of policy, and more administration of ‘techniques’ designed to inculcate self-management, rather than promote a properly therapeutic relationship. (About 45% of Headspace clients do not bother returning after 1-2 sessions, an abject failure of ‘engagement’, whatever the ‘youth-friendly’ pretensions held by the service).

In any case, there is ample evidence from around the world that neoliberal economic policies worsen both general and mental health, and the ‘treatments’ that emerge under this ideology are intended to perpetuate rather than challenge it. Thus, when ‘advocates’ like Hickie come out in support of a brutally neoliberal Government, whilst minimising fears about privatisation, we know that it is a matter of ideology rather than ‘evidence’.

In case it needs saying, the ALP is no better than the Coalition on mental health, alhough it is slightly better on healthcare overall. Where the Coalition prefers the outright barbarism of neoliberal policy, the ALP imagines it can run a government along technocratic lines, with each policy portfolio outsourced to ‘experts’ in order to avoid politics. Until the evidence proves otherwise, none of the major parties ought to be presumed to have a shred of sincerity on matters of mental health.

The self-proclaimed experts and advocates in fact promote fringe or partisan positions, with personal interests at stake. Their claims of being ‘evidence-based’ are unequivocally false. Beyond Blue has as its CEO former Coalition politician Jeff Kennett, best known for implementing a ruthless version of ‘economic rationalism’ in Victoria. The Black Dog Institute in Sydney has for its treasurer a director of Transfield (now Broadspectrum), an organisation given millions in Government funding. In exchange for this, the corporation operates concentration camps for asylum seekers of Nauru and Manus Island. These facilities have been condemned by the UN and, in psychiatric terms, are practically suicide factories. With ‘friends’ like these, mental health service users certainly don’t need enemies.

McGorry, a former Australian of the Year, is perhaps the least-bad of the bunch, but even he has demonstrated an unwavering commitment to bioreductionism and the now-discredited DSM system. Previously, he proposed a bizarre and coercive set of protocols for early intervention into ‘attenuated psychosis’, which Dr Allen Frances described as ‘the largest and most reckless public health experiment ever attempted’.   Hickie was a co-founder of the failed Headspace program. To try and fail at a mental health program may not be so bad, perhaps, except that Hickie aggressively pursued this program at the direct expense of others, such as the relatively successful (and universal) Medicare scheme. Hickie was given ample warning that his proposals were evidence-free; he pursued them nonetheless, at the expense of hundreds of millions of taxpayer dollars, and an unknown quantum of human suffering through untreated mental health. Hickie now distances himself from the program, whilst still advocating for its continued existence. Without the presence of some powerful friends, it is inconceivable that Headspace would have survived years of organisational dysfunction and poor outcomes. After the mess to which he contributed, one might think that Hickie might have the decency to give himself a probationary period before any more of his reverse-Midas ‘advocacy’.

Mendoza is militantly opposed to Medicare provisions for mental health treatment. He has looked at data showing which suburbs use Medicare mental health services the most, and since the wealthiest suburbs participate most in this universal service, he believes that the data self-evidently demands the abolition of Medicare services, to be replaced by a monopoly provider. What he fails to tell the victims of his screeching is that this pattern – of highest Medicare uptake in metropolitan centres rather than rural and remote Australia – is consistent across all Medicare services, and not just mental health. He also fails to mention that the evidence demonstrates that Medicare services do more heavy lifting for the disadvantaged than any other service. There is no mention of the vast mass of data supporting the proposition that Better Access is both more effective and more efficient than Headspace. It’s also more accessible than Headspace, despite the latter’s ‘youth-friendly’ schtick. Consistent with this pattern of puzzling omissions, Mendoza the Mendacious neglects to emphasise his personal connections with app manufacturers of the sort spruiked by charlatans like he and Hickie, and which he hopes to use to secure monopoly provider status in lieu of Medicare face-to-face services. (This is the basic template by which Medicare is privatised by stealth. See this press release on dementia as representative example).

Contrary to what these ‘advocates’ aver, the evidence for apps and eCBT is not good. If it is being championed in Australia at present, then it certainly isn’t for reasons of efficacy. As some have pointed out, the ubiquitous surveillance of apps can actually be itself a factor in mental health pathology. That apps and eCBT are poor substitutes for mental health treatment is no surprise, since one of the most evidence-based findings in the history of mental health evidence is that the most critical factor in determining a treatment’s success is the quality of the therapeutic relationship. And, after all, one uses rather than has a relationship with one’s apps. What they are advocating for is a purely technocratic, recipe-book application of treatment principles of the sort that died a much-deserved death some 2 or 3 decades ago.  Moreover, given the well-established (and worsening) vagaries in mental health assessment and diagnosis, it is to be expected that having a bureaucrat arbitrarily assign patients to ‘mild’ and ‘complex’ categories, on the basis of a cursory assessment, is tantamount to gambling with people’s lives. One would expect these policies to increase the loss of life and limb through poor-assessment, and delays or obstacles to treatment by way of bureaucratic hurdles. The claims of empiricism are intended to give this the thinnest veneer of plausible deniability when the inevitable hits the fan. None of these advocates would get a pass in an undergraduate course on psychology or public policy based on their shambolic treatment of evidence. They are to empirical science what KFC is to high gastronomy. KFC is, however, less of a risk to health. Mendoza in particular repeatedly calls for an end to debate, an end to thinking, in order for his preferred policies to be implemented immediately. And whilst another review or Royal Commission would indeed be a waste of time, the demand for immediate, uncritical action cannot but remind us that we are in the company of fascists or professional bullshitters, especially when the ‘action’ in question is a profitable transaction between them and the Government. And whilst the perspective of the present author is decidedly to the left on economic matters, even the most dry of right-wing libertarians will be able to recognise the advocates’ – peddling their substandard wares to the Government –  as exemplars of the most shameless form of rent-seeking and attempted monopolisation by executive fiat.

The so-called private health system is disgraceful when it comes to mental health. The system in total inhales $11 billion of taxpayer funding each year, yet does almost nothing for outpatient mental health services. Curiously, the experts and advocates are totally silent on this point, preferring instead to emphasise the need to cut Medicare. In the private system, taxpayer dollars fund exorbitant and often useless inpatients stays to the tune of around $1,000 a day. When an inpatient’s insurance expires, or moves to a lesser degree of funding, that patient very rapidly becomes an outpatient. Again, the problem here is not so much economic but ideological. There is already clear evidence that the private health insurance system is founded upon ‘junk policies’; there is little to suggest that anybody in power wishes to change this arrangement regarding mental health.

 

Mental health treatment is not a standardised, one-size-fits-all exercise. Each individual is different, and must be treated accordingly. Complex problems must be dealt with in the context of a patient’s entire life and history, and in the security of an ongoing therapeutic relationship. The refusal to recognise this is one of the most repugnant failures of policy of our advocates and their Government. Psychological treatment is not a production-line function. Where there is high clinician turnover and standardisation – Headpsace is a good example – the result is abject therapeutic failure. Again, there is ample evidence on this point that our evidence-mongers have failed to heed. The patient who is traumatised, or paranoid, or besieged with crippling anxiety, needs more than a series of fixed protocols and productivity measures. A treatment must allow room for specifically non-productive elements, such as trust-development, silences, and repetitions.  Above all, it needs time, not technocracy. This was the recommendation of the Royal Commission into sexual abuse, who encouraged an expansion of Medicare services, and greater ease in accessing them. The reader who has persisted through this piece will not be surprised to learn that the evidence-based, innovative Government and its agile mental health advocates have said nothing of this particular recommendation, based on the evidence of hours of testimony and countless tears.

The cookie-cutter, falsely-construed ‘evidence-based’ approach to mental health has been tested. It was implemented some years ago in Sweden, in an attempt to curb the number of individuals suffering psychological disability. Specifically, the government of the time rolled out CBT as per the (distorted) evidence-base. It should be said that the Swedish model was superior to the proposed Australian model, since it relied on actual clinicians rather than the outsourcing of clinical functions to software. In any case, the result was clear – Sweden finished up with more disability than before, and the program had to be scrapped. In the UK , the cheap, brief and one-size-fits-all approach to mental health, similar to that Australia’s experts are clamouring for, was implemented by way of a program called IAPT. Not only has this program been widely derided by patients and clinicians alike, about 50% of the psychologists involved in delivering services under IAPT have themselves become depressed as a result of the program. These are the outcomes for which Hickie and co are earnestly striving in Australia. ’Disruption’, indeed.

 

 

‘Multidisciplinary’ care is fine in theory, but largely mythical in mental health. The PHN system being implemented by the Government is one which will see patients allocated a maximum of 18 sessions, with the idea that these will be divided across a number of specialists (such as a psychologist, housing worker, drug and alcohol worker, etc). Since most people have multiple problems, this appears reasonable, at first. The underlying presumption, however, is again, a ham-fisted misapplication of the worst elements of the medical model, in that each patient needs a series of narrow ‘specialists’ who treat discreet problems which are neatly isolable from other elements of a patient’s life. There is no single ‘good enough’ professional to take care and responsibility. On paper, of course, a GP or psychiatrist will take this role, but in practice, it is virtually inconceivable that time-pressured GPs and psychiatrists will act as case managers and care coordinators. In other words, it’s a model of mental health care resembling a Ceaușescu orphanage, in which isolated care functions are officially the responsibility various professionals, but there is not one generalist professional to take overall care and responsibility.

The Government and reform advocates are creating a two-tier mental health system by stealth. The Medicare system for mental health treatment has numerous bureaucratic hurdles of a pointless nature (i.e. mandatory, arbitrary reviews, reports, etc, which constitute about 50% of the program’s cost), but ultimately allows patients, clinicians and GPs a modicum of freedom in terms of choice of treatment and provider. The opponents of Medicare want to outlaw this self-determination in favour of a more micro-managed, PHN system, with even more pointless checks and balances than Medicare. That neoliberals want to cut Medicare is hardly a new phenomenon, but what is particularly galling is that Hickie and Mendoza (among others) wish to present these cuts to universal services (for which money will be diverted to their research institutes, their programs, and their apps) as egalitarianism.

We should be clear about the sort of egalitarianism that the advocates have in mind. They object to Medicare on the basis that its mental health programs are used most often in the inner-city. From this, they conclude that the system is unfair and should be ‘reformed’ (i.e. cut or abolished). The advocates forget that the inner-city of Melbourne, for instance, houses tens of thousands of economically disadvantaged people. Moreover, they ignore the evidence that the entire Medicare system has greatest uptake in the inner-city, but that it is nevertheless the best system for reaching the broadest range of disadvantaged Australians. That Mendoza and others systematically ignore this piece of evidence suggests some rather unpleasant combination of either deception or gross incompetence. This isn’t to say that Medicare does not require supplementary programs and services, especially in remote and rural areas, or differential rebates, or a substantially improved hospital system. But consider what Hickie and Mendoza propose as an alternative: a quasi-market tender process in which the poorest quality of generic services are available through a monopoly provider. (These transparent stooges themselves have links to the would-be providers). If this is egalitarianism, it is an egalitarianism of the breadline. The former patients and clinicians of Headpsace report a pattern in which neither has much choice in how a treatment proceeds. Treatment, as I have repeatedly been told, is reducible to SSRIs, and the administration of professionally-embarrassing ‘techniques’ (i.e. for breathing, ‘sleep hygiene’ and the like).

The obvious outcome of all of this is that, if Hickie and Mendoza have their way, patients will be left with no Medicare, and a diminishing public health system, a near-useless health insurance system, and a surfeit of apps and expensive, dysfunctional bureaucracies who have been gifted monopoly tenders, rather like the private prison system of the US. Since the only prospect of a high-quality, outpatient treatment under those arrangements would be private, Hickie and co are effectively promoting a two-tier health system, in which the poor receive nothing that resembles a competent or ethical treatment. We should recall that McGorry, Hickie, Mendoza and Tanti, the former CEO of Headspace did not campaign for government-funded programs plus Medicare, but always one at the expense of the other. This style of competitive advocacy has been as aggressive in its outlook as it is impervious to evidence. Those with most to lose from their victories – namely, Australia’s poorest citizens – also happen to be the least able to have their concerns taken seriously by politicians and policy-makers.

 

Technology does not hold to solutions for Australia’s mental health problems, but then neither does a Luddite approach. That Australia’s most distinguished mental health promoters even support the use of self-administered apps is rather horrifying for what it reveals about their degraded conception of mental health treatment, and the individuals who receive it. The apps, as well as the pseudo-empirical psychotherapies upon which they are based are, essentially, treatments for moral failure, and they are on the increase throughout the Anglophone world. The links between these treatments and neoliberal economic ideology are absolutely clear, and we should have no illusions when it comes to Australia’s mental health system being an enthusiastic participant in this mental health-destroying ideology. Ian Hickie in particular is fond of speaking of ‘mental wealth’, in which the treatment of mental suffering is to be prized primarily for the gains in economic productivity that ensues. Little wonder that he and the Liberal Party can engage in a few rounds of mutual backslapping and bonhomie.

The apps that are born of this marriage of neoliberalism and psychology are therefore not ideologically neutral. The apps attempt to displace the disciplinary and surveillance functions of the cognitive or behavioural ‘therapist’ and isolate them into algorithms. It remains to be seen what the effects of this will be, but as already discussed, the evidence suggests little is therapeutic about them. Obviously, a device has no empathy of the sort that may lubricate a face-to-face CBT relation; on the other hand, self-administration may possibly enhance the function of interiorisation of the algorithms. The type of human being presupposed by these interventions is not one to be found in the textbooks on philosophy or psychology so much as it is homo economicus.

In any case, the underlying assumptions here are that treatment is and should itself be a formulaic technology, whether it is delivered in person or by the web. Consequently, there is little sense in blaming apps per se, since the technology beloved of neoliberal psychologists is merely an embodiment of existing ideological and political preoccupations. And, to make a rather old-fashioned (but vital) point, both clinicians and service users in this system become part of the technology, cogs in the machine. This is apparent in the Headspace model, which enthusiastically embraced formulaic treatment (albeit of a face-to-face form, though now, increasingly, online), and who failed, catastrophically, to retain the majority of its service users beyond a therapeutically trivial time frame. The organisation itself is in the midst of an industrial dispute with its own workers, and appears committed to a range of dubious workplace practices. The very same industry doyens who purport to be supporting mental health in Australia now rank alongside of Grill’d and 7-11 when it comes to industrial-level exploitation, and far from being an anomaly, is precisely the sort of outcome one would expect in view of the underlying ideological assumptions at issue. The use of technology as a supposed mental health treatment is therefore not the problem per se, but the symptom of another problem. The solution to this latter problem will neither be found in Luddite opposition to technology nor in fancier tech, but in altering the assumptions, and economic and social relations which give rise to the technology in the first place.

Existing mental health advocates are an obstruction to improving the system. They – I am referring to the aforementioned advocates – are unelected vandals of public health in Australia. They have been given enormous power to influence policy, and in the case of Headspace and other areas, they have demonstrably failed. Their bellicose campaigns for private interests and pet projects come at the direct expense of functional elements of the health system, and their plans can reliably be expected to increase suicide and suffering in Australia. They are, in effect, peddling policies which aim at the dismantlement of Medicare and universal health care. In this, they are colluding with a conservative government which is also hostile to Medicare, and they have the stunning audacity to present their fringe, partisan positions as ‘evidence based’ and equitable. Without exception, the advocates should be removed from all positions of influence as far as policy is concerned, and ignored by any political party concerned about public policy. One can take the gurus seriously, or take mental health seriously, but not both. And those who care about quality outpatient treatment of mental health in Australia can support the campaign to protect and extend existing Medicare services.

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