Where to for Australian mental health services? Promoting self-efficacy

I have deliberately interpreted the remit of this essay narrowly, choosing not to be diverted by current turf wars between biologically and psychosocially minded mental health professionals and debates about how little or how much biological advances have helped or hindered the care of individuals with mental illness (Bracken et al., 2012; Bullmore et al., 2009; Insel and Quirion, 2005; Kingdon and Young, 2007). Suffice to say that our biological treatments remain very helpful for some patients but much less helpful for many others, both in terms of efficacy and side effects. On the other hand, psychosocial care is very difficult to deliver to individuals who are too unwell, psychotic, disorganised and distressed by their symptoms. So, we obviously need to take the best mix of biological and psychosocial interventions and customise them in a coherent manner for the individual patient. We also need to have patients and carers explicitly involved in the planning and delivery of this package of care. And this needs the ‘system’ to enable a seamless multifaceted service encompassing all need areas (clinical, family, work, and so forth).

Pragmatically, I ask how we might realistically enhance outcomes for people with so-called ‘severe’ mental illnesses such as schizophrenia and psychotic mood disorders. I bring to this essay a perspective from the UK, where I trained; Western Australia, where I worked from 1994 to 2001; and Victoria, where I have been since 2001. I have had exposure to academia as well as public and private practice and have kept abreast of major developments in mental health service delivery in other countries. But, mostly, my reflections are based on the Victorian public mental health system, and are very much from the perspective of a psychiatrist. I restrict myself largely to adult services, albeit the fundamentals of my thesis have applicability for other age groups.

The Victorian system: positives and deficits

I believe that Victoria does have one of the most coherent, uniform and functional public mental health systems in the world, embracing a community-based model with a consistent set of services in each catchment area (Castle, 2011; Singh and Castle, 2007). Such services include inpatient beds co-located with general hospitals, step-up/step-down facilities in most catchments, continuing care and secure extended care facilities at a local or regional level and community teams with crisis and longer-term care capabilities. There are also a number of state-wide services including for dual disability, personality disorder and transcultural issues. The non-government organisation (NGO) sector is very strong and growing; linkages between mental health services and NGOs are getting better. We also have an enviable number of private sector beds and private psychiatrists, at least in the metropolitan area. The model is compatible with what Thornicroft and Tansella (2013) espouse for developed nations such as ours.

My belief is that we need to build on these foundations rather than effect a complete rebuild. But it is clear that some aspects of care remain suboptimal. In 2006, St Vincent’s Mental Health Service hosted a conference attended by representatives from the 21 urban and rural mental health services in Victoria, as well as the main NGO providers and consumers and carers (Gerrand et al., 2007). The aim was to assess the strengths and weaknesses of the Victorian mental health services as they were then operating. In brief, whilst most attendees believed that the overall direction of deinstitutionalisation was correct, a number of deficits and problems were noted, namely:

• There was seen to be a major ongoing problem with ‘cross-sector’ issues such as dual diagnosis (drug and alcohol), dual disability (intellectual disability) and forensic issues. People from culturally and linguistically diverse (CALD) backgrounds were also thought to be disadvantaged by the current system, due to language and cultural issues.

• Case management was considered to have many positives, but with generic models particular skills sets might have been lost and this was unsatisfactory for staff and patients. For example, little group work or family therapy is done in mainstream public sector services and many psychologists, in particular, have left for the private sector. Also, some caseloads remain unrealistic in some services.

• Emergency response had been enhanced through the evolution of crisis assessment teams, but emergency departments (EDs) are often used as a stop-gap and were not perceived as always ‘friendly’ to mental health patients, despite many services having 24-hour ED mental health presence. The relatively low number of acute beds in Victoria was seen as an ongoing problem for access, with daily pressures leading to early discharges and a very florid inpatient environment in which aggression and assaults are all too common and in which females, in particular, often feel very vulnerable. The ability to offer a therapeutic environment in the inpatient setting was seen as difficult and more often than not admissions were mostly about containment of acute risk.

• Linkages with other service providers, including general practitioners, private sector clinicians, NGOs, general health services, employment agencies, educational institutions and agencies providing disability support payments were thought to be suboptimal, and it was noted that the physical health issues faced by mental health patients were often neglected.

The lives of Australians with psychotic disorders

A more contemporary source of information is the report of the Survey of High Impact Psychoses (Morgan et al., 2012). This study provides a detailed cross-sectional account of the lives of 1825 Australians with a psychotic disorder. Clearly many have ongoing mental health problems: for example, according to the Diagnostic Interview for Psychoses (Castle et al., 2006), 41.3% of participants had current delusions, 37.5% suffered hallucinations and 11.5% experienced current suicidal ideation. There was substantial unmet need. Of particular concern was the physical health status of participants (Galletly et al., 2012), with a quarter being at high risk for cardiovascular disease. Worryingly, compared to the 1997 Survey (Jablensky et al., 2000), cigarette smoking remained highly prevalent at 66.1% (Cooper et al., 2012), and there had been a large increase in illicit substance use: for example, lifetime cannabis use was reported by 97.3% of respondents, and 49.3% had used in the previous year (Moore et al., 2012). Rates of work inclusion were little changed from the 1997 Survey, with only 21.5% being in paid employment.

Recovery

So, we need to think differently and shift to be in full step with the Recovery movement (Slade, 2009). ‘Recovery’ is in danger of becoming another piece of psychobabble, but the essence is important and needs to be embraced by all who work with the mentally ill. Broadly, it encapsulates the notion that the individual with a mental illness should be at the centre of his or her care package, be involved in driving it and in ensuring it has a holistic scope rather than a narrowly clinical focus. Psychiatrists should not be scared of this; we should work with it and use the Recovery ethos as a guide for a better strategic alliance between patients, carers and services. We need to ensure that we do not, as psychiatrists, either compromise or lose our professionalism or feel that we do not have an integral role to play in the comprehensive care of people with a mental illness: such a crisis of professional status has been clearly exhibited in the UK (Craddock et al., 2008). We need as a profession to effect better alliances with key other parties, such that we maintain the focus on the person with a mental illness rather than on supporting unhelpful system structures that more often than not put barriers in place so as to protect their proverbial turf. Lee and colleagues (2013) have usefully reviewed strategies that might enable this to occur, and provided recommendations in this regard.

But patients and carers also need to come to the party, also taking responsibility for their health. It is not good enough to have people stopping medications, using illicit substances, landing back in hospital for the umpteenth time and then blaming the ‘system’. Returning to Talcott Parsons’ (1975) notion of the sick role, people who are unwell should be able to expect support from society, but have certain societal responsibilities in return, notably to follow the path that is likely to help them get better (and stay better). Of course there will be times when control will need to be taken and the appropriate mental health legislation employed, but we should aim, collectively with patients and carers, to reduce to a minimum the use of compulsory detention, including community treatment orders.

Self-efficacy

To my mind, the only way all of this can be ensured is by empowering patients in taking better control of their own wellness. To do that, the role of health professionals is to support those with a mental illness and their carers (family members and others) and provide them with the necessary skills they will require to keep themselves well. There are various models that have been developed to deliver on these imperatives, including Wellness Recovery Action Planning (Cook et al., 2009), Strengths (Rapp, 1998) and Collaborative Recovery (Oades et al., 2005). One local Australian programme is called the ‘Optimal Health Programme’ (OHP; Gilbert et al., 2003, 2012). The explicit aim of this programme is to enhance self-efficacy by mapping vulnerabilities and strengths at an individual patient level, and building the individual’s skill set such that he or she can effectively negotiate the ‘system’ and keep well, in terms of mental and physical health. This is hardly rocket science, and there are many examples of this being effectively delivered for chronic physical health problems such as diabetes and asthma (Newman et al., 2004; Wagner et al., 2001).

A particular virtue of OHP is that it is generic rather than illness-specific, which means it is less stigmatising and allows multiple issues to be addressed and customised to the individual. For example, it does not merely target mental health symptoms, but looks broadly at the individual and his or her spiritual, emotional, social, intellectual, occupational and emotional functioning, and maps strategies to address these different parameters. It can be delivered by any health professional, with sufficient training, and has also been employed by peer workers, who bring to the equation their own ‘lived experience’. A further core component is mapping what are termed ‘collaborative partners’, be they a family member, general practitioner, psychiatrist, endocrinologist, psychiatric disability support worker, case manager, drug and alcohol worker, work placement support person, or whoever is willing to participate and who can assist in addressing any domain the individual wants to work on. This places the individual with the mental illness at the centre of his or her turning world, rather than focusing on different service agencies and trying to get them to align. The programme has been evaluated using a quasi-experimental design, with good uptake and acceptability and improvements in mental state and reductions in crisis assessments and hospitalisations; it is thus also cost effective (Gilbert et al., 2012).

This description of the OHP might be seen as somewhat self-serving, as I have been part of the development of it over many years. And of course there are other models that address many of the same needs. But what is clear is that these models are not being adopted broadly and across sectors, and are not consistently at the core of what we do in terms of service delivery. Psychiatry should take a lead here, partnering effectively with all stakeholders and shifting our thinking away from systems and barriers and towards a strategic alliance with patients and carers. Actually, rather than being scary, it is mostly refreshing, enriching and more rewarding for all involved.

A system response?

How can the system itself effectively respond to these ongoing challenges? Well, of course, more money is required, but, despite the political rhetoric, that isn’t likely to happen any time soon: the much lauded extra monies that have been provided by the Federal Government certainly haven’t trickled down in anything other than a very tiny trickle to mainstream services. And we have just recently witnessed how health generally (and mental health in particular) remains a political football to be kicked between Canberra and the States and Territories in the ongoing and incredibly unhelpful blame game about who is or isn’t delivering upon what, in terms of health. Of course, we should continue to lobby for more resources, and advocate for our staff and patients in this regard, but in the meantime we need to focus on what can be done with what we have.

To my mind, the reliance on one or two prominent individuals being the spokespeople for the profession is wrong on numerous counts, and this role needs to be adopted by our College, in consultation and liaison with other similar bodies representing cognate professional groups, as well as consumer and carer organisations. We should be advocating for a uniform, Recovery-based model being mandated and funding should be linked to individual patients, with incentives to work across sectors and diminish barriers to care. Substantial investment must be made into the process of ensuring collaboration amongst service providers, as well as educating staff across all stakeholder groups in the model of care. Ultimately, patients and carers must be empowered to effect their own care, supported rather than managed by the ‘system’.