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Unpacking The Royal Commission

In February 2019, with advice from the Victorian Government, the Governor of the State of Victoria formally established the Royal Commission into Victoria’s Mental Health System. But a 3195-page report is a bloody long read, so I’ve done my best to condense it here.

The Background

The current system has catastrophically failed to support the diverse needs of people living with mental health challenges or psychological distress, let alone to deal with unexpected demands that may arise. The severe bushfire season and COVID-19 pandemic not only amplified, but also brought to light the pressures on our mental health system.

The system largely operates in crisis mode, taking a reactive approach to crises as opposed to proactively preventing them. Anna, a GP from Hobart, shared her challenges:

“The system is overstretched and mostly only able to deal with crises. Also, staff within the system are burnt out, which affects their capacity to provide consistent care. Absence and turnover rates within the sector are high. Unfortunately people get sicker because of lack of access to specialist support, it takes a crisis to get seen, and once the crisis is past, there is little capacity for ongoing treatment.”

The limitations of our system can be traced back to its origins in the 19th and 20th centuries, where people with psychological distress were isolated from their communities and housed in institutions. While there has been social change since then, including promotion of human rights, our mental health system has been left behind.

‘Power imbalances’ still pervade people’s experiences when seeking support, marginalising them and preventing them from having their needs and preferences respected. Human rights are still breached through compulsory treatment – where a person is medicated or committed to hospital against their will.

Lucy Barker, a witness before the Royal Commission, with significant trauma from compulsory treatment, said the measures taken were extreme:

“You wouldn’t treat anyone else that way, but because you are perceived to have a mental illness, you can be restrained to a bed for hours or thrown in a seclusion room or chucked in the back of a divvy van or jabbed in the butt, and then knocked unconscious for a day.”

Examples of marginalisation like these are reflected in the structural issues of the mental health system, which include inaccessibility of services, over-reliance on medication, overlooking the perspectives of people with psychological distress and ineffective investment. These problems arise because of the existing stigma and discrimination surrounding mental health – consumer attitudes deter governments from proper investment in good mental health and wellbeing.

Insights from Consumers

The Royal Commission received more than 12,500 contributions from the Victorian community to better understand the existing strengths and weaknesses of the system, in conjunction with future needs and expectations.

The Commission engaged with people living with mental health challenges, carers and supporters, mental health workers, researchers and service providers and explored the needs of our diverse communities, including those from Aboriginal communities, LGBTIQ+ people, and people from culturally diverse backgrounds.

Some of the most meaningful contributions, which have helped shape the Commission’s recommendations, came from people with a lived experience of mental health challenges. These people bravely stepped forward to share their personal experiences of how the system failed and sometimes even harmed them.

Getting support early is difficult. People living with mental health challenges wait long periods and become ‘sicker’ before they can gain access to suitable services. One person told the Commission:

“I personally have asked for help from all the promoted channels and been turned away as I was not suicidal enough … Surely if someone has the courage to ask for help, Australia has the resources to help.”

Younger people are adversely affected. Younger people face mental health challenges as they start to participate in higher education and employment, form relationships and begin their journey into adulthood. A study from the United States estimated that 75% of all lifetime cases of anxiety, mood, impulse control and substance use disorders emerge by the age of 24 years.

The ‘missing middle’. There is a substantial and constantly growing number of people with too “complex”, too “severe” and/or too “enduring” needs to be supported through primary care alone, but not “severe” enough to meet the strict criteria for specialist support. Kathryn, a carer from Melbourne, shared her story:

“At the height of Covid lockdown, my son became actively suicidal and incredibly distressed. We called an ambulance. He was taken to hospital… We were there for five hours when they said he wasn’t bad enough to hospitalise.”’

Inequitable access to services. Poverty and financial hardship make it incredibly difficult for people to access services. The Mental Health Coalition of ACT have even said:

“You don’t have to be mentally ill for long, before you can’t afford basic health care.”

A stronger focus on personal recovery is needed. The current system mainly focuses on the goal of ‘clinical recovery’, to address symptoms. However, the concept of ‘personal recovery’, which has been advocated for by the consumer movement, is what’s needed to create a meaningful life, with or without mental health challenges. As Ms Erandathie Jayakody, a witness before the Commission, explained:

“At the heart of a recovery-oriented approach is a recognition of the most basic human desire to have control of one’s own life and future, and the belief that people with mental health challenges have the ability and autonomy to achieve that.”

Communities and places do not adequately support good mental health and wellbeing. The focus is largely on the ‘mental health system’, with little consideration for the social factors at play which determine one’s own mental wellbeing. This focus understates the value of communities, workplaces and education settings in shaping good mental health.

Some groups face additional barriers to support. Certain groups, including Aboriginal people, LGBTIQ+ people, refugees, asylum seekers, people from culturally and linguistically diverse backgrounds and people living with disability face a range of additional barriers when seeking support. The existing system does not currently ensure that people from these groups receive the safe and inclusive care they deserve.

Mental health challenges are aggravated by housing instability. The irregularity of mental health can lead to increased housing instability for many, meaning people may be forced to move accommodation or deal with the uncertainty of the shelter above their heads. Solid foundations for a longer-term housing reform and expansion of recent investments are set out in the recommendations, but an ongoing government-wide effort will be required to abate Victoria’s housing crisis.

Inadequate investment. Victoria’s financial investment in mental health per capita is low compared with other states and quite poor in comparison with physical health. The Honourable Professor Kevin Bell AM QC, Director of The Castan Centre for Human Rights Law, Monash University, emphasised how unacceptable this is:

“In human rights terms, this is a matter of obligation, not policy. Victoria is not like a developing nation where lack of resources is an explanation for under-investment in health.”

The value of lived experience work is starting to be recognised, but faces challenges. There is a great opportunity to expand and bolster workforces built on lived experience. However, these workforces experience challenges such as stigma and discrimination, along with a lack of infrastructure and professional support. In order to unlock the potential of these workforces, services will need to be ready to promote and empower them.

Recommendations for a new system

In order to address these challenges, the Commission has made 65 recommendations, in addition to nine in an interim report, based on engagement with people with lived experience. 

These recommendations outline system-wide changes to create a mental health and wellbeing system that is both contemporary and adaptable – a system that ensures people have access to services that are empathetic, responsive to their needs and based on their own rights and preferences.

Premier Daniel Andrews has committed to implementing all of the recommendations made in the report, which include:

  • Establish dozens of local adult, youth and child mental health services in various locations, making it easier for people to access support
  • Create new “safe spaces” for adults and young people, designed with the help of people with lived experience 
  • Set up a new non-government agency led by people with a lived experience of mental illness and psychological distress
  • Do away with the old Mental Health Act and enact a new one by the end of 2021, with the sole focus of achieving the highest attainable standard of mental health and wellbeing for all Victorians
  • Immediately reduce the use of seclusion and restraint in mental health, with the aim of eliminating the practices within 10 years and ensuring compulsory treatment is only used as a last resort

There are four key themes that emerged from the recommendations, which represent cohesive visions for the future of the mental health and wellbeing system:

An integrated system led by the community

Victoria’s new mental health and wellbeing system will be restructured with community at its heart, consisting of two parallel systems – one for infants, children and young people and the other for adults and the elderly.

Instead of applying labels to service use, which can be stigmatising and discriminatory, the Commission has focused on the provision of services based upon people’s strengths and needs.

The service system will be structured into six tiers, from community and primary care support all the way through to ongoing intensive treatment, care and support at a statewide level. Service providers become increasingly specialised in each subsequent tier and collaborate in an integrated and meaningful way.

Consumers will be able to access services through Local Mental Health and Wellbeing services close to their support networks – either directly or via referral. When someone has a higher level of need, a general practitioner will be able to refer them directly to an Area Mental Health and Wellbeing service, which operates with extended hours and responds to crisis calls from anyone 24/7.

Perinatal mental health teams will support prospective and new parents whilst a new youth mental health and wellbeing stream will be set up, so Victoria’s young people can feel mentally well as they grow into adulthood.

A holistic approach to mental health requires going beyond the mental health and wellbeing system to bring together service streams productively. An example is providing supported housing for people with mental illness or living in unstable housing, as part of the Victorian Government’s 10-year social and affordable housing strategy. Stable housing is genuinely life-changing, fostering a sense of community, purpose and hope for the future.

A responsive mental health crisis system will be established so that police, ambulance callouts and visits to ED will no longer be the only options. New “safe spaces”, led by consumers, will be easily accessible for people experiencing varying levels of distress.

People with a lived experience will lead the establishment of a new agency to prop up and develop organisations and services that are led by and made for people with a lived experience of mental illness or psychological distress.

A responsive system that promotes inclusion and tackles inequity

Some of the most significant issues which underpin our health and wellbeing are the social and economic conditions in which people are born, grow, work, live and age, as well as the systems that shape our personal experience. These conditions are referred to as the social determinants of health and numerous studies suggest they account for about 30-55% of health outcomes.

The future of the mental health and wellbeing system will provide safe, personalised and accessible services while adapting to variable inequities, supporting those who may be experiencing disadvantage. 

This reform looks beyond the system to examine varied factors affecting mental health, through activities designed to uphold human rights and reduce imbalances in mental health outcomes. In the reformed system, stigma and discrimination will be confronted through the development and implementation of anti-stigma programs and improved access to legal protection from mental health discrimination.

Victoria’s diverse communities will be acknowledged and responded to appropriately and effectively. For instance, support for LGBTIQ+ people to navigate and access the system will be bolstered, and all Victorians will be able to obtain information and resources regardless of their language, hearing, literacy or cognitive abilities. Healing centres will also be established by Aboriginal community-controlled health organisations to improve the social and emotional wellbeing of Aboriginal children.

Strengthened confidence through prioritisation and collaboration

In order for the reformed system to sustain itself, effective leadership and governance with collaboration across governments and communities must form the foundation. The new system will ensure that people with lived experience are leading and partnering with others in reform efforts. It’s not about ‘giving a greater voice’ to people with lived experience; but rather, to revolutionise the system from within so that these voices are not only heard but are central to the decision-making about issues affecting their lives.

The Victorian Government will be held accountable for the performance of the mental health and wellbeing system by a new independent Mental Health and Wellbeing Commission. This new Commission will be able to freely initiate its own inquiries into matters supporting its objectives and will take on the responsibility for responding to complaints.

System-level governance will be strengthened through the appointment of a Chief Officer for Mental Health and Wellbeing, elevating mental health as a government priority. The Commission’s redefined system will be enshrined in legislation with a new Mental Health and Wellbeing Act, designed to reflect the vision for this future system.

Services will be commissioned in new ways to respond to the diverse needs of people and investment will be prioritised through the implementation of a new levy to fund mental health services. This special levy, similar to the state’s fire services levy, is thought to be unprecedented and is expected to raise ‘hundreds of millions of dollars’.

Different factors shape people’s health and wellbeing, such as education and justice settings, workplaces and social networks. As such, collaboration across different sectors and governments will be crucial in responding to these factors; this is especially important for suicide prevention and response, as varied factors are associated with suicide.

A new system with contemporary and adaptable services

The new system will need to be flexible in adapting to variable expectations and emerging challenges in order to improve the experiences of people, families, carers and supporters for generations to come.

This starts with the implementation of workforce reforms, establishing a diverse workforce with the capability and experience to deliver effective support in the future mental health and wellbeing system.

In this contemporary system, consumers are supported in shared decision-making processes which respect their personal goals and human rights every step of the way. This includes the eventual elimination of practices such as seclusion and restraint and substantial reduction of the use of compulsory treatment, so it’s used only as a last resort.

This system will be supported to adapt and change with new approaches to digital technology, research and innovation. Service providers will be required to provide minimum digital functionality to improve system access, navigation and continuity of care. New strategies for information management will be established in collaboration with consumers, to help collect, use and share information across the system safely and effectively.

A dedicated mental health and wellbeing innovation fund will be set up to promote innovation in treatment, care and support and to test new approaches to service provision. Translational research to apply new models of care in service delivery environments will be led and co-created with people with lived experience. The system will be dynamic, continually evolving and adapting to respond to the changing needs of people living with mental illness or psychological distress, families, carers and supporters.

Closing Thoughts

All of us are touched by mental health challenges, in one way or another. But not everyone openly talks about or understands them in the same way. Many from culturally diverse backgrounds still experience a great deal of stigma and even shame around the topic, especially when it comes to sharing one’s own struggles. These diverse communities do experience a higher prevalence of mental health challenges and if they don’t talk about it (to perhaps avoid appearing vulnerable), this perpetuates the stigma. 

The fact that the report acknowledged everyday experiences affecting mental health like discrimination was truly empowering, since the more frequently people experience racism, harrassment and bullying, the more likely they are to be psychologically distressed. The Royal Commission was a powerful platform where the stories of migrants, refugees and First Nations people were acknowledged and shone a light on the distinct lack of culturally safe services in the system.

In my darkest hour, what helped me was hearing from others that were just like me – understanding that I wasn’t alone in what I was experiencing was really transformative. While conventional therapies supported me to an end, finding others who genuinely understood what I was going through was the real catalyst in my recovery, since they too had lived through those challenges.

Recommendations in the report called for the establishment of a new agency led by people with lived experience. This reform will be incredibly fruitful for the advancement of the mental health and wellbeing sector – a community of experts in their own lived experience is what’s needed to cultivate empathetic relationships with people who are struggling, promoting empowerment and self-determination in their road to recovery.

The reality is that lived experience work is still met with some challenges, including stigma from others about peer supporters having mental health challenges and their input not holding as much value compared to clinicians. It’s promising to see that the report recognises the current system’s inadequate efforts in valuing the expertise of people with lived experience, however more work is required to develop appropriate policies and frameworks moving forward. That being said, the Royal Commission’s vision to put lived experience at the heart of our mental health and wellbeing system is a great start. I look forward to both witnessing this once-in-a-lifetime report unfold and contributing to making its vision a reality for future generations to come.

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