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PUBH1382 Australian Health Care System
Week 6 (Section B): Understanding mental illness
and social work, psychology and psychiatry
INSTRUCTORS: Mervyn Jackson & Amy Loughman
Learning objectives
1. Briefly describe the history and evolution of the mental health care system in
Australia.
2. Describe the features of service delivery that have arisen from the National Mental
Health Strategy – including:
a. Mainstreaming services
b. Development of community services
c. Privatization of care
3. Identify the health professionals who provide care to the mentally ill.
4. Describe a recovery approach to mental health care including:
a. Multidisciplinary teams
b. Case management frameworks.
5. Describe the broad frameworks of the approaches of the following disciplines to
mental illness and health:
a. social work
b. psychology
c. psychiatry
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Notes
1. The history and evolution of the mental health care system in Australia.
Mental health care in Australia was provided in institutions until 1955. A first wave of
deinstitutionalisation led to the development of community services for people with acute
mental health problems. A second wave of deinstitutionalisation from the 1980s focused
upon development of community services for people with chronic mental illness.
The National Mental Health Strategy was launched in 1992. The main goals of the National
Mental Health Strategy were to move service delivery from psychiatric hospitals to general
hospitals and the community, to create better links between government support services
and to foster uniform mental health legislation across the country.
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Mental health care systems are primarily funded and managed by state and territory
governments. In the past, it was common practice to manage people experiencing mental
illness through the law courts and incarcerate people with a mental illness in secure
asylums. The first asylum in Australia was built in 1811 in Castle Hill, Sydney. At this stage,
mental illness was not seen as a health condition; therefore doctors were not involved in
these asylums. They were mainly run by prison guards and the legal system.
In 1839, it became a requirement to have a medical diagnosis of a mental health condition
and certification from a doctor to be admitted to an asylum. However, it wasn’t until 1883
that asylums began to be run by medical practitioners instead of staff from the penal
system. These changes came about through inquiries into the living conditions of these
‘inmates’ that is, how people with a mental illness were managed in terms of their mental
health.
In 1953, there were 24 psychiatric hospitals in Australia. In the same year, the government
conducted an investigation into the living conditions within psychiatric hospitals. This
inquiry found that the hospitals were overcrowded and also housed patients who were
elderly and who had an intellectual disability. The inquiry concluded that more hospitals
should be constructed but non-psychiatric patients should be located and treated
elsewhere.
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Due to this report, the focus from institutionalising the mentally ill shifted to
deinstitutionalisation. That is, earlier discharge from these psychiatric hospitals. This came
about due to the findings that mental health issues were better treated with early
intervention strategies and that long-term stays in these psychiatric hospitals had a
detrimental effect on the overall mental health of these patients. To aid
deinstitutionalisation, community services had to be created to provide these early
intervention services. Day hospitals were formed to treat acute cases of mental illness and
those that had been newly diagnosed. The creation of aged care services, drug and alcohol
services, psychological services and services for the intellectually disabled occurred around
this period. These avenues were funded by the state and territory governments.
Original deinstitutionalisation involved the acutely ill, but in the late 1980s, the chronically
ill began to be discharged from psychiatric hospitals into community services. These
services enabled them to live outside the hospitals. Mental health wards in general
hospitals were created and the number of psychiatric hospitals declined and segregation of
people who were mentally unwell became less of a focus of mental health in Australia.
2. Features of service delivery that have arisen from the National Mental
Health Strategy
The term ‘mainstreaming services’ refers to the change from treatment of patients with a
mental illness in specialized psychiatric hospitals to mental health wards in general
hospitals. The aim of mainstreaming mental health services was to increase access of
health services for people with a mental illness and reduce the stigma of mental health (by
removing institutionalization and replacing it with specialized care within the community. It
should also be noted that an important element of mainstreaming services for the mentally
ill was to allow people experiencing mental illness to stay close to their community, their
family and their friends. Mainstreaming services decreased the need for separate
specialized psychiatric hospitals; however there was a related need for an increase in
psychiatric beds available in general hospitals.
The goals of community services was to promote mental health (as opposed to focusing on
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mental illness), to increase awareness of mental illness in the community, to allow the
patients to have individual care and also to help maintain their dignity in the light of a
challenging time in their lives. Community services include mental health teams and
residential services. Mental health teams assess and monitor people with mental health
conditions in the community to ensure they are coping with everyday life. Residential
services promote independence in people with a mental health condition and include
supported accommodation, social activities and job opportunity services. Community
services mainly support those with a chronic mental health illness. As a consequence, these
services sometimes failed to address youth mental health issues (preventing the
occurrence of future episodes of mental illness that would inevitably lead to a diagnosis of
a mental disorder.
In recent times, the privatisation of mental health care in Australia has become more
apparent. The increased role of private mental health services has reduced the burden on
government services and focussed more on a market model of health care. This has
allowed the person with the mental illness to choose treatments that are appropriate for
them. This shift has been driven through non-government organisations (NGOs). Currently,
most mental health issues are addressed via primary care providers [GPs] and allied health
services as opposed to inpatient stays on mental health wards in general hospitals. This
has also focused on increased care by family, friends and communities of people with a
mental health condition.
The role of GPs is continuing to expand and they are now seen as central in the primary
health care of people with mental health problems. GPs serve as the first place members of
the community will go when experiencing negative mental health conditions. GPs then
refer them to appropriate services and provide a continuing management role of patient as
they are treated for the various aspects of their mental illness
3. Professionals who provide mental health care
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Many different health professionals work in the field of mental health. GPs constantly
consult with people prior to obtaining an official diagnosis for a mental health condition,
and refer patients on to specialists for further treatment when required. GPs constantly
consult patients with anxiety and depression.
Primary mental health care has taken a multidisciplinary approach, having particular aim at
people aged 12-25, as this is the age period when people are most likely to experience their
first episode of mental illness. An example of this is an initiative created by the National
Youth Mental Health Foundation called Headspace. The shift to multidisciplinary care
increases cohesiveness between these teams and specialist services.
To increase accessibility of mental health services, mental health services were reformed
through the Better Outcomes in Mental Health Care (BOiMHC) initiative. This allowed GPs
to claim through Medicare for the provision of psychological services (including being able
to see psychologists and social workers). These referrals were mainly for patients
experiencing common mental health conditions such as anxiety and depression.
In 2006, the Better Access program was created to enable more health professionals to
claim services through the Medicare Benefit Scheme such as psychologists, social workers
and occupational therapists; however in 2010 this funding was revoked from social work
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and occupational therapy. Other key workers in mental health services include
psychiatrists, disability support workers and many other allied health professionals
whenever the need for their services is required. Allied health professionals see people
with mental illness for physical conditions too; however do not provide direct mental health
care services such as physiotherapists.
4. Recovery approach to mental health care
Multidisciplinary teams work collaboratively in mental health services to draw on the
expertise of other disciplines, but taking a multi-model focus and thus using both
biomedical and social models to guide their practice. The patient’s social environment is
vital in the recovery process, and multidisciplinary teams evaluate the patient’s access to
safety, food, shelter, education, employment, social support and money. Housing for
people with mental health is often one of the greatest challenges, followed by lack of job
opportunities. The job of multidisciplinary teams is to identify mental illness and then
manage the risks associated with the condition. Allied health professionals within the team
require a basic knowledge of common psychotropic drugs used in mental health services,
as well as the drug’s side effects. These teams educate clients on the medications in an
attempt to increase adherence, and encourage engagement in everyday activities
[including various therapies]. Some multidisciplinary team members [mainly psychologists,
psychiatrists and social workers] will have undergone specialised training to provide higher
level treatment [such as cognitive behavioural therapy (CBT)].
Finally, the person experiencing mental health problems should be perceived as being a
member of the multidisciplinary mental health team. Patients (or clients of mental health
services) should be and need to be involved decision making associated with their own
treatment. Providing a client centred approach in mental health care increases compliance
to therapy and medication, as well as empowering the individual to determine their own
recovery process and goals. Therefore, the multidisciplinary team members (especially
social workers) will often take on an advocacy role for the patient, ensuring their needs are
met and their recovery is facilitated adequately.
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There are three models of care that are commonly referred to as case management. These
are the brokerage model, the extended brokerage model and assertive case management.
The brokerage model is a market approach to mental health care. In this model, case
managers mainly oversee the budget for purchase of services for the patient. The extended
brokerage model involves selecting a ‘key worker’ who is responsible for coordinating the
care for the patient and ensuring everyone on the team is informed of decisions and
outcomes. All team members report back to the key worker. Assertive case management
uses proactive and specialised approaches to the patient, focussing on crisis response,
review, planned interventions and is goal directed.
5. Approaches to mental health and illness
It is important to understand that different healthcare professions have different
understandings of, and approaches to both mental health and mental illness.
Consequently, although they often work together in multidisciplinary teams, therapeutic
input from each of these professions will vary. The following three professions can be seen
broadly as focussing most heavily on one of the factors in the biopsychosocial model. The
biopsychosocial model considers mental health outcomes as a combination of factors,
including: biological (genetic, brain structure and function), psychological (personality,
thought processes, interpersonal style and skills) and social (socioeconomic, stress, life
events). Whilst the dominant view within all of these disciplines acknowledges this
contemporary model of mental health, each acts primarily on one more than the other
factors of the model.
a. Social work: Providing health care to people, families and communities
Social work is the discipline that works most closely with people, families and communities
to ensure holistic and comprehensive attention to the social aspects of health and illness.
Social workers address the person in the environment and context with which people live
and work. This includes their family and community and their cultural context, employment
sphere and country.
Social workers use the term ‘the person in the environment’ to shape how they treat their
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patients. This means that there is a constant focus on the physical, emotional and social
environments people live and work in. Social work encompasses culture, ethnicity, country
and job, has a focus on empowering the individual in social relationships, and works
collaboratively problem solving issues and encouraging change within the individual, the
family and the whole community.
Social work operates under a human rights and social justice framework, which has a
strong focus on the right and the needs of the person and their family. This can be
achieved through support services for the person and the family and any other required
services that ensure the patient and the family are working as a team towards recovery.
The focus of social workers is to commit to advocating for their client’s, supporting and
protecting their human rights.
Social determinants of health - a framework
The social determinants of health are the situations and environments which we live and
work in. These environments are heavily shaped by how money, power and resources are
distributed throughout the world. The social determinants of health perspective suggest
that our health is directly related to our social situation and that negative health outcomes
can arise from life situations that leave a person vulnerable to these outcomes. There is a
correlation between positive health outcomes and a higher socio-economic status.
Social determinants of health include things like gender, ethnicity, physical environment,
education level, social participation, access to health care, lifestyle factors, discrimination
and participating in early childhood care. The World Health Organisation (WHO) suggests
that to address health inequalities within and between countries, it is important to address
the distribution of money, power and resources within and between countries. To balance
these factors more evenly would mean increase positive health outcomes. Social workers
address these social determinants of health daily with their clients.
b. Psychology: Helping people to deal with their mental health, behaviour and social
environment at an individual level.
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Psychology is the study of human behaviour, and therapies are most commonly
psychological in nature (talking, behaviour modification, interpersonal skills training).
Because psychologists are not medical practitioners, they do not prescribe medications or
pharmaceutical treatments. As the name suggests, psychology acts mostly at the
psychological level of the biopsychosocial model, however psychological research
investigates the roles of all components of the biopsychosocial model.
c. Psychiatry: A specialty of the medical profession dedicated to the treatment of
mental illness
Psychiatry is a specialty of the medical profession, meaning that psychiatrists have first
trained as medical practitioners (5-6 years), completed general medical practice in a
hospital (1-2 years) and then a further fellowship in psychiatry (approx 5 years).
Psychiatrists learn and apply their knowledge of pharmaceutical as well as
behavioural/psychological therapies to treat mental illness, and often see relatively more
severe cases that psychologists for this reason.
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