2019 Submission - Royal Commission into Victoria's Mental Health System Organisation Name N/A

Name Mr Guy Coffey

What are your suggestions to improve the Victorian communitys understanding of mentalillness and reduce stigma and discrimination? "I have not addressed this question in my submission and it is not something I have particularexpertise in. However I believe the following needs to be considered. - information provision andincreased understanding within the community is a necessary but not sufficient condition to reducestigma. Some very well informed people (including MH professionals) still possess stigmatisingattitudes. - Attempting to bring attitudes into alignment with views on physical health is useful upto a point however there are also important differences in the nature and experience of physicaland mental illness that need to be acknowledged. Often to a greater extent, mental illnesses canaffect how we see ourselves and who we are to others. - it is a reality that some people withsevere mental illnesses have a vastly reduced quality of life as a result. This needs to beacknowledged in educational campaigns but also needs to be a cause for compassion andgrounds for significant societal support, not a reason to marginalise and stigmatise. - theexperiences of mentally ill people need to be part of any public education campaign. Bringing thecommunity to understand the immense struggle and courage required to live with a severe mentalillness is an important part of encouraging empathy and compassion. - a human rightsperspective not just more information is needed. The goal is too increase empathy, compassionand a sense of community commitment and duty to promote the rights of mentally unwell people.- as with many pressing and complex human problems, we are not the first to try to find a solution.A thorough review of what has and hasn't worked internationally should be undertaken "

What is already working well and what can be done better to prevent mental illness and tosupport people to get early treatment and support? N/A

What is already working well and what can be done better to prevent suicide? N/A

What makes it hard for people to experience good mental health and what can be done toimprove this? This may include how people find, access and experience mental healthtreatment and support and how services link with each other. N/A

What are the drivers behind some communities in Victoria experiencing poorer mentalhealth outcomes and what needs to be done to address this? addressed in the submission

What are the needs of family members and carers and what can be done better to supportthem?

N/A

What can be done to attract, retain and better support the mental health workforce,including peer support workers? N/A

What are the opportunities in the Victorian community for people living with mental illnessto improve their social and economic participation, and what needs to be done to realisethese opportunities? N/A

Thinking about what Victorias mental health system should ideally look like, tell us whatareas and reform ideas you would like the Royal Commission to prioritise for change? addressed in the submission

What can be done now to prepare for changes to Victorias mental health system andsupport improvements to last? N/A

Is there anything else you would like to share with the Royal Commission? please see the submission

SubmissiontotheRoyalCommissionintoVictoria’sMentalHealthSystem

SubmissionDate:5July2019

GuyCoffey1

Introduction

ThankyoufortheopportunitytomakeasubmissiontotheRoyalCommission.In

accordancewithmyareaofexperienceafocusofthissubmissionismentalhealth

servicedeliverytorefugees.However,Ialsoaddressarangeofmattersfallingwithin

theRoyalCommission’stermsofreferencewhichrelatetomentalhealthservice

provisiontotheVictoriancommunitygenerally.Iwillcommentonthefollowingsubject

areas:

1. mentalhealthservicedeliverytoasylumseekersandrefugees;

2. thementalhealthcareofyoungasylumseekersandrefugeesinthecorrectional

system;

3. thementalhealthcareofpeoplewithpost-traumaticconditions;

4. accesstoprivatesectorpsychologicaltreatmentbypeopleofnon-English

speakingbackground;

5. thecapacityofpublicmentalhealthservicestodeliverevidencedbased

psychologicaltreatments;and

6. thequalityofrehabilitationservicesforpeoplewithchronicmentalillnesses.

Thissubmissionmakesanumberofpropositions.

1. Thepolicyenvironmentgoverningthelivesofasylumseekersisfundamentally

inimicaltotheirmentalhealthandmentalhealthservicesareunableto

adequatelymeettheirneeds.

2. Commonwealthmigrationlawinteractswiththejusticesysteminwaysthat

depriveyoungasylumseekerandrefugeeoffendersofmentalhealthtreatment

andopportunitiesforrehabilitation.

1 FoundationHouse,4GardinerStreetBrunswickVIC3056.Mob.0419322468email:

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3. Post-traumaticconditionsarenotadequatelytreatedwithinthepublicmental

healthsystem.Accesstospecialistposttraumaticmentalhealthservicesis

limited.

4. MigrantsandrefugeeswhoarenotfluentinEnglishhavefarlessaccessthan

Englishspeakerstopubliclyfundedprivatepsychologicalservicesowingtothe

limitedprovisionofinterpretersfortheseservices.Thisisanobjectively

discriminatorypracticeinmentalhealthservicedelivery.

5. Publicmentalhealthservicesdonotdelivertherangeofevidencebased

psychologicaltreatmentsrecommendedbyallmajorbestpracticetreatment

guidelines.Psychologicaltreatmentsareinadequatelyintegratedintotreatment

plansandserviceshaveinsufficientstaffpossessingtherequisite

psychotherapeuticskills.

6. Therearesignificantgapsinthedeliveryofrehabilitationservices.Twoexamples

areprovided:thereisalackoffocusonamelioratingcognitiveimpairments

whichhavepersistedbeyondtheremissionofacutesymptomsandvocational

trainingandplacementappearstobeineffectiveinmanyinstances.

Thissubmissiondrawsonmyexperienceofworkinginmentalhealthservices.Ihave

workedasaclinicalpsychologistfor30yearsinpublicmentalhealthandspecialist

psychologicaltraumaservicesincluding21yearswithinVeterans’Psychiatryandthe

PsychologicalTraumaRecoveryServiceattheAustinandRepatriationMedicalCentre.I

amcurrentlythepracticedevelopmentadvisorattheVictorianFoundationforSurvivors

ofTorture,apsychologicaltreatmentandsupportserviceforrefugees,whereIhave

workedparttimefor20years.Iactasaconsultanttoorganisationsonpsychological

andlegalissuesinrelationtorefugeesincludingtheUNHCRandtheDepartmentof

HomeAffairs.Iconductresearchandpublishinthefieldofrefugeementalhealth.I

provideforensicpsychologicalreportsforthecourtsinVictoriaandpsychological

assessmentsofapplicantsforrefugeestatus.Withrespecttomycommentsonrefugee

migrationlawandCommonwealthpolicyrelatingtoasylumseekers,thesearebasedon

myexperienceworkingasalawyeratVictoriaLegalAidprovidingassistancetoasylum

seekersandrefugees.

Theviewsexpressedhereinaremyownandarenotnecessarilythoseofthe

organisationsatwhichIamemployed.

Thissubmissionhasbeenwrittenwithinatighttimeframeandisnotafullyreferenced

scholarlypaperbutasetofpropositionsbasedoneitherdirectobservationderived

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fromclinicalpractice,researchorboth.Moredetailedandreferencedexplanationsof

aspectsofthesubmissioncanbeprovidedonrequest.

1.Mentalhealthservicedeliverytoasylumseekersandrefugees

Inordertodeliveramentalhealthservicethatmeetstheneedsofrefugees,the

determinantsoftheirneedsmustbeunderstood.Forthepurposeofthisdiscussion,I

willprovideaverybriefsummaryofwhatisknownaboutthevariablesaffectingrefugee

psychologicalwell-being.

Influencesonpsychologicalwell-being

PeoplewhoenteredAustraliaasrefugeesorhavesoughtasyluminAustraliaarealarge

andheterogeneouscommunitygrouprangingfromthenowveryelderlypostWW2

refugeestorecentlyarrivedasylumseekersandhumanitarianentrants.Whilethe

mentalwell-beingofrefugeesisasdiverseasthatwhichexistsinthegeneral

community,decadesofstudyofthementalhealthofrefugeeshavedemonstratedthat

atapopulationlevelanumberofgeneralisationscanbemade:

- amongmanycohortsofasylumseekersandrefugeesratesofmentalillnessare

manytimeshigherthanintheoverallAustralianpopulation2;

- themostcommonmentalhealthproblemsexperiencedarePosttraumatic

StressDisorder,depressionandanxietydisorders3;

- thereisevidencefrominternationalstudiesthatratesofseverementaldisorders

suchasschizophreniaareelevatedamongrefugees4;

- ratesofmentaldisorderarepredictedbytheextentofpre-arrivaltraumaand

loss,andbypost-arrivalstressors5;

2 Thereisalargenumberofstudiesofprevalenceofmentaldisorderamongrefugees;forexample,Fazel,

Metal.(2005)Prevalenceofseriousmentaldisorderin7000refugeesresettledinwesterncountries:a

systematicreview.Lancet365:1309-14.SteelZetal.AssociationofTortureandOtherPotentially

TraumaticEventsWithMentalHealthOutcomesAmongPopulationsExposedtoMassConflictand

Displacement.JournaloftheAmericanMedicalAssociation,August2009.TurriniGetal.Commonmental

disordersinasylumseekersandrefugees:umbrellareviewofprevalenceandinterventionstudiesIntJ

MentHealthSyst(2017)11:51.3Forexample,TurriniGetal.Commonmentaldisordersinasylumseekersandrefugees:umbrellareview

ofprevalenceandinterventionstudiesIntJMentHealthSyst(2017)11:51.

4Hollander,Anna-Claraetal.(2016)Refugeemigrationandriskofschizophreniaandothernon-affective

psychoses:cohortstudyof1.3millionpeopleinSweden.BMJ(2016)352.5Porter,M.,&Haslam,N.(2005).Predisplacementandpostdisplacementfactorsassociatedwithmental

healthofrefugeesandinternallydisplacedpersons:Ameta-analysis.JournaloftheAmericanMedical

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- whilethereisadearthofepidemiologicalstudiesofthementalhealthofasylum

seekers,theavailableevidenceisthatratesofPTSDanddepression6andratesof

selfharm7aremanytimeshigherthaninthegeneralcommunity.

- thepost-arrivalstressorsmostcommonlyassociatedwithpoormentalhealth

includeinsecureresidencystatus;destitution;experienceofdiscrimination;

concernsaboutfamilyoverseas;andprolongedimmigrationdetention8.

Anumberofthe‘postarrivalstressors’whichhavebeenfoundbothinAustraliaand

internationallytoadverselyaffectasylumseekerandrefugeementalhealtharedirectly

producedbyAustraliangovernmentlawandpolicy.Theseinclude:

- providingformandatoryandindefiniteimmigrationdetentionforallpeople

arrivinginAustraliawithoutvisas–theadversementalhealthconsequencesof

immigrationdetentionforasylumseekersisestablishedunequivocally9;

- causingasylumseekerswhoarrivedbyboattobeeligiblefortemporary

protectionvisasonly,ensuringongoinginsecureresidency;

- preventingtemporaryprotectionvisaholders(theresidencystatusofmany

thousandsofsuccessfulasylumseekerswhoarrivedbyboat)frombringing

familytoAustralia;

- inadequatematerialsupportforasylumseekersincludingremovalofworkrights

andanysourceofincomesupportforsomebridgingvisaholders(thereare

currentlyabout6,800asylumseekersinVictoriawhoarrivedbyboatwhohold

bridgingvisas10);

Association,294,602−612.FredrickLindencronaetal.2008,MentalHealthofrecentlyresettled refugeesfromthemiddleeastinSweden.SocPsychiatryandPsychiatricEpidemiology.43:121-1316AnunpublishedcurrentstudyofarepresentativesampleofasylumseekersinNSWfoundthatnearly

halfofthecohorthadprobabledepressionandoveraquartersufferedprobablePTSD:TheSydney

ReAssureStudy,SteelZetal.(UNSW).TurriniGetal.Commonmentaldisordersinasylumseekersand

refugees:umbrellareviewofprevalenceandinterventionstudiesIntJMentHealthSyst(2017)11:51.7SeeHedrick,Ketal(2019,underreview)SSM–PopulationHealth.Thisresearch,

basedonself-harmincidentsreportedtotheDepartmentofImmigrationandBorderProtectioninthe12-

monthsto31stJuly2015,foundthatself-harmepisoderatesamongasylumseekersincommunity-based

arrangementswerefourtimestheAustraliancommunityratesforhospital-treatedself-harmandself

harmratesforasylumseekerslivinginthecommunityundercommunitydetentionarrangementswere22

timestheAustraliancommunityrates.Ratesofself-harmforpeopleinimmigrationdetentionfacilities

weremanytimeshigheragain.8EdithMontgomery,(2008)LongtermeffectsoforganizedviolenceonyoungMiddleEasternrefugees’

mentalhealthSocialScienceandMedicine671596-1603;SteelJetal.ThePsychologicalConsequencesof

Pre-EmigrationTraumaandPost-MigrationStressinRefugeesandImmigrantsfromAfricaJImmigrant

MinorityHealth(2017)19:523–532.9Forarecentreview:vonWerthernMetal.Theimpactofimmigrationdetentiononmentalhealth:a

systematicreviewBMCPsychiatry(2018)18:382https://doi.org/10.1186/s12888-018-1945-y.

10DepartmentofHomeAffairs,IllegalMaritimeArrivalsonBridgingEVisa,31March2019.

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- thecreationovertwodecadesofadivisivepublicdebateoverasylumseeker

policywhichhascreatedantagonismtowardpeopleseekingasyluminsome

sectionsofthecommunity.

Theeffectofpoormentalhealthamongasylumseekershasimmediateandlongterm

consequences.Whenanasylumseekerismentallyunwell,thedemandsofthe

protectionvisaapplicationprocessaremadeevenmoredauntingandthelikelihoodof

anunfairoutcomeisincreasedbecausetheapplicant’sabilitytoarticulatetheirclaimsis

compromised11.Inthelongertermthecapacityofthesuccessfulapplicanttoadaptand

integrateintotheAustraliancommunityismadeconsiderablymorechallengingbya

lackofpsychologicalwell-being.Mentalhealthclinicianswhoworkwithrefugeesare

familiarwithpeoplewhoarrivedinAustraliatoseekasylum,whoweredetainedfor

extendedperiods,enduredaprotractedvisaapplicationprocess,livedinpovertyinthe

community,wereseparatedfromfamilyformanyyearsorlostcontactentirely,and

whonowsuffersevereandchronicposttraumaticorothermentalhealthconditions

thatrobthemofadecentqualityoflife.

Shortcomingsinmentalhealthservicedeliverytoasylumseekersandrefugees

Someasylumseekersandrefugeesreceiveexpertandcompassionatecareinthemental

healthsystem.Howeverinmyexperiencethestandardofcareisveryuneven.The

reasonsforthisfallintothreecategories:lackofknowledgeamongtreatingstaff;

difficultyalteringthecircumstancesadverselyaffectingmentalhealth;andlackof

accesstoservices.

Mostmentalhealthcliniciansdonothaveagoodunderstandingofthecircumstancesof

asylumseekersandrefugees.Manyareunawareofthestressorstheyareenduring.

Whileasylumseekersandrefugeessufferfromthesamerangeofmentaldisordersas

thegeneralpopulation,theirpresentationsareoftenshapedbyposttraumatic

symptomsandreactionstocurrentstressors;fewpublicmentalhealthclinicianshave

specifictrainingintreatingthesepresentations.

11 TheUNHCRhasbeenconcernedabouttheaffectofasylumseekers’mentalhealthonthefairnessof

theprotectionvisaapplicationprocessinthecontextofcurrentAustralianpractice.Asaconsequence

theyproducedguidelinestoassistrefugeestatusdecisionmakers:See

https://www.unhcr.org/publications/legal/5a127e907/guidance-note-on-the-psychologically-vulnerable-

applicant-in-the-protection.html

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Clinicianscanoften,understandably,feelhelplessinthefaceofrefugees’psychological

difficultiesbecausetheyareunabletoalterwhathasprecipitatedandmaintainsthem.

Sometimesthisresultsinminimisingandunder-diagnosingthedifficulties–thepatient

mightbeseenasprimarilypresentingwithavulnerablepersonalityorsufferingfroman

‘AdjustmentDisorder’-aconditionwhichissituationallydrivenandwhichmightbe

considerednotamenabletotreatment.Howeverclinicianswhoareexperiencedin

assistingrefugeesknowthatvaluablementalhealthassistancecanberenderedto

asylumseekersandrefugeesevenwhentheircircumstancesaredire.

Itcanbedauntinganddemoralisingnonethelessformentalhealthclinicianstowork

withclientswhosementalhealthisbeingdevastatedbytheircircumstances.Their

abilitytoprovideeffectivetreatmentisincreasediftheyworktogetherwithservices

advocatingforimprovementsintheclient’ssituation,whetherthatinvolvesmaterial

aid,resolutionofresidencystatus,assistingcontactwithfamilyoramelioratingoneof

themyriadotherpossiblesourcesofasylumseekers’distress.Currentlythe

coordinationbetweenpublicmentalhealthprovidersandrefugeelegal,advocacyand

supportgroupsisnotstrong.

Asylumseekersandrefugeescanlackaccesstomentalhealthservicesforarangeof

reasons.Posttraumaticconditions,evenwhencausingthesamelevelofdebilitationand

distressasotherseverementaldisorders,maynotbeseenasprimarilythe

responsibilityofthepublicmentalhealthsystem.Whenseveretraumahasbeen

experienceddevelopmentally,itmaymanifestasapersonalitydisorder,including

BorderlinePersonalityDisorder.Fewpublicmentalhealthfacilitieshavespecialist

programsandclinicianstrainedinthetreatmentofthiscondition.

Addingtothedifficultyingainingaccesstotreatmentisaviewthatpsychologically

basedtreatmentsareeithernotculturallyappropriateforpeopleofnon-western

backgroundornoteffectiveifdeliveredwiththeassistanceofaninterpreter.Itis

difficulttoascertainhowwidespreadsuchbeliefsare,buttheresearchevidenceand

clinicalexperiencestronglycontradictsthem12.

Withrespecttotheprovisionofpsychologicaltreatmenttoasylumseekersandrefugees

throughMedicare(‘BetterAccess’)orPrimaryHealthNetworkfundedservices,there

12Thereisalargeliterature;forexample,TurriniGetal(2019).Efficacyandacceptabilityofpsychosocial

interventionsinasylumseekersandrefugees:systematicreviewandmeta-analysis.Epidemiologyand

PsychiatricSciences1–13.https://doi.org/10.1017/S2045796019000027

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aretwobarrierstoaccess.Asubgroupofasylumseekersinthecommunityareineligible

forMedicareservicesandrelyonpublichospitalsandsomecommunityhealthcentres

formedicalservices.Secondly,underthesefundingarrangementsforpsychological

servicestherearelimitedornointerpretingservicesavailable(thisisdiscussedfurther

belowinrelationtonon-Englishspeakersgenerally).Anotherissueofaccessinthe

privatesectorinvolvesthecoordinationoftheservicesneededforpeoplewithcomplex

andmultipleneeds.Asylumseekersandrefugees,notdissimilartootherpopulations

withraisedprevalenceofposttraumaticconditions(forexampleveterans)oftenhave

otherconcurrentmentaldisorders,medicalconditionsaffectingmentalstate,family

andsocialproblems,andvocationaltrainingneeds.Atreatmentplaninvolvingan

individualpsychologistinprivatepracticewilloftennotprovidethecoverageof

treatmentandthesetofmedical,psychologicalandpsychosocialinterventionsrequired

foroptimumoutcomes.Furthermore,tenortwelveindividualsessionswillusuallynot

beanywherenearadequatetoprovidepsychologicaltreatmenttoarefugeewitha

chronicpost-traumaticcondition.

2.Thementalhealthcareofyoungasylumseekers,refugeesandnon-citizensinthecorrectionalsystem

Theobservationsmadeinthissectionarederivedfrommyexperienceinconducting

forensicpsychologicalassessmentsofasylumseekersandrefugeesforthecourtsand

providinglegalrepresentationforasylumseekersandrefugeeswhosevisashavebeen

cancelledduetotheiroffending.

ChildrenfromCALDbackgrounds,includingsomerefugeecommunities,are

substantiallyoverrepresentedintheyouthjusticecentrepopulation13.Forthosewho

arenon-citizens,theirpassagethroughthecriminaljusticesystemmaydiverge

markedlyfromthatofchildrenwhoarecitizenseventhoughthesamesentencing

principlesapplytothem.Theoverarchingprincipleinsentencingchildrenandyoung

peopleisrehabilitation;theapproachisenshrinedinlegislation14andhasbeen

unequivocallyendorsedbythejudiciary:

[T]heprimacyofrehabilitationinthesentencingofyoungoffendersiswellestablished,bothatcommon

lawandbytheprinciplesoftheCYFA…

…

13Arecentsurveyfoundthat39%oftheVictorianyouthjusticecentre(custodial)populationcomprised

childrenandyoungpeopleofCALDbackground:SentencingAdvisoryCouncil,June2019,‘CrossOver

Kids,VulnerableChildrenintheYouthJusticeSystem’,report1,p44.14Section362(1)oftheChildren,YouthandFamiliesAct(2005).

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[t]hestatutoryframeworkforjuvenilejusticecompelsthecourtsentencingayoungoffender(almost

alwaystheChildren’sCourt)toadopttheoffender-centred(or‘welfare’)approach,ratherthanthe

‘justice’or‘punishment’approach...justasimportantly,thisstronglegislativepolicyiswellsupportedby

theextensiveresearchintoadolescentdevelopmentconductedoverthepast30years15

Thesentencingofchildoffendersisconsequentlygovernedbyconsiderationsincluding

preservationoffamilyrelationships,furtheranceofeducationandminimisationofthe

stigmaassociatedwithacriminalsentence16.

Thefateofanasylumseekerorrefugeechildoryoungadultorindeedanynon-citizen

whoischargedwithacriminaloffenceisdetermined,however,bytheinteractionof

VictoriancriminallawandtheMigrationAct1958(the‘MigrationAct’).Theprovisions

oftheMigrationActthatcomeintoplayarethoseprovidingforthecancellationof

bridgingvisas17onthebasisofcriminalcharges(s116)andcancellationofsubstantive

visas(includingtemporaryandpermanentprotectionvisas)uponconvictionfora

criminaloffence(s501).TheinteractionofstatecriminalandCommonwealthmigration

lawleadstoarangeoftrajectoriesforyoungoffenderswhoarenon-citizens.Thereare

manypermutationsbutthefollowingexamplesareillustrative–allaredrawnfrom

casesIhaveworkedondirectlyorofwhichIamaware18.

Scenario1–anasylumseeker’sbridgingvisacancellationuponchargesbeinglaid,

immigrationdetention,chargesdroppedandreleaseintothecommunity

Amentallyunwellyoungadultasylumseekerischargedwithanoffence.Hisbridging

visaiscancelledandheisthereforebyoperationoflawplacedinimmigration

detention.Aftersomemonthsthechargesarewithdrawnontheapplicationofthe

policeinformantowingtodeficienciesintheevidence.Theasylumseekerremainsin

immigrationdetentionformoremonthsuntiltheMinisterforImmigrationgrantsa

bridgingvisa19andafternearlyayearofdetentionheagainlivesinthecommunity.

Whileheldinimmigrationdetentionhismentalhealthdeteriorates.Heisexposedto

violenceandwitnessessuicideattempts.Whiledetainedheisnotabletoobtain

treatmentfromthepublicmentalhealthfacilityhenormallyattends.Hesuffersfroma

15 BradleyWebster(apseudonym)vTheQueen[2016]VSCA66(MaxwellPandRedlichJA)at[9]and[28].16Section362(1)oftheChildren,YouthandFamiliesAct(2005)

17Bridgingvisasareheldbypeoplewhoarewaitingfortheoutcomeofavisaapplicationforasubstantive

visa(thatis,avisaallowingthepersontoremainforafixedperiodorpermanentlyinAustralia)andallow

themtolivelawfullyinthecommunitywhilethisoccurs.18Identifyingdetailshavebeenremoved;somefactshavebeenchangedinordertoanonymisethe

scenario.19TheMinisterforImmigrationhasadiscretionarypowerunders195AoftheMigrationActtogranta

visa.Thereisnotimeframeastowhenthevisagrantmayoccur.IftheasylumseekerarrivedinAustralia

withoutavisaheorshewillbeunabletoapplyforabridgingvisawhileinimmigrationdetention.

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complexposttraumaticconditionanddepressionandtherearenospecialisedtreatment

servicesavailablefortheseconditionswhileheisinimmigrationdetention.When

releasedhismentalhealthhasdeterioratedtothepointwherehisabilitytoengagewith

hislawyerandparticipateintheprotectionvisaapplicationprocessaresignificantly

compromised.

Scenario2–achildasylumseekerischarged,bridgingvisacancelled,remanded,

Children’sCourtcustodialsentence,uponcompletionofsentenceindefiniteimmigration

detention,refusalofprotectionvisaoncharactergrounds

AchildasylumseekerarrivesinAustraliawithhisfamily.Hehadlivedforyearsinthe

midstofacivilwarandwasprofoundlytraumatised.HesuffersfromcomplexPTSDthat

includesseveredissociativesymptoms,unstablemood,intenselabileemotionin

responsetostressorsandperiodicself-harmandsuicidality.When16yearsoldheis

chargedwithaseriousoffence.Hisbridgingvisaiscancelledandheisremandedina

youthjusticecentre.Anapplicationforbailisnotaviableoptionbecauseifsuccessfulit

wouldleadtohimbeingdetainedinimmigrationdetention–withoutabridgingvisahis

detentionismandatory.Whileremandedhereceivespsychologicalcounselling,

pharmacotherapyandpsychiatricreviewbutnospecialistservicesforhiscomplexneeds

areavailable.Duringremandheisphysicallyandsexuallyassaulted.TheChildren’s

Courtsentenceshimtoatermofdetentioninayouthjusticecentre.TheCourtfinds

thattheoffendingoccurredinthecontextofseverementalhealthproblemsandthata

rehabilitativedispositionincludingextendedspecialisedpsychologicaltreatmentis

appropriate.Heservesaterminayouthjusticecentreduringwhichhereceivesfurther

counselling,supportandpharmacotherapywhichhefindshelpfulbutwhicharenot

specialisedinterventionstailoredtohisspecificneeds.Upontheexpirationofhis

sentenceheisplacedinimmigrationdetention.Heisfoundtobearefugeebuta

protectionvisaisrefusedoncharactergrounds.Hisemotionallability,severe

dissociativesymptomsandperiodicself-harmaredifficultfortheimmigrationcentresto

manage.Heisalsovulnerabletomistreatmentbyolderdetainees.Heismoved

betweendetentioncentres,includingforanextendedperiodinanotherstateandaway

fromhisfamily.Onanumberofoccasionsheisheldinseclusionroomsasanattemptto

containhisagitatedanddisruptivebehaviour.Heisheldinprotectionunitstoremove

himfromotherdetaineeswhoposearisktohim.Hereceivespsychiatricreviewsand

someintermittentcounsellingwhileinimmigrationdetentionbutnotreatmentspecific

tohisneeds.Onanumberofoccasionsheallegesthathehasbeenphysicallyand

sexuallyassaulted.Hisprotectionvisaapplicationremainsonfoot.

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Heisnowayoungadultheldinindefiniteimmigrationdetention.Ofthenearlyfiveand

ahalfyearssincearrivinginAustraliaasatraumatisedchildasylumseekerhehasspent

fourandahalfyearsinimmigrationdetentionoryouthjusticecentredetention(the

majorityinimmigrationdetention)andoneyearinthecommunity.

Scenario3–childrefugeeresettledinAustraliawithapermanentvisa.Youthoffending

resultingincancellationofvisa,youthdetentionandthenadultprison

AlateprimaryschoolagedchildrefugeeresettlesinAustraliawithhisfamily.Heandhis

familyweredisplacedduetocivilwarandthenspentanumberofyearsinarefugee

camp.HehadreceivednoformaleducationpriortoarrivinginAustralia.Heacquires

Englishslowlyandseemsdistractibleinclass.Inmidsecondaryschoolhebecomes

disruptiveinclass;hisliteracyandnumeracyaretwotothreeyearsbeneathhisyear

level.Hereceivespsychologicalassessmentregardinghislearningabilitybutalthough

post-traumaticsymptomsandfamilyconflictarenotedtobecontributingtohislearning

difficultieshereceivesnoformalinterventions.Hebeginsusingsubstancesat14years

old.Fromtheageof15yearshebeginscommittingmultiplegangrelatedcrimes

involvingtheft,armedrobberyandhomeinvasion.

Heissentencedtohisfirsttermofyouthdetentionwhen16yearsold.Whenremanded

apsychologicalassessmentnotesthathesuffersproblemswithunstablemood,intense

labileaffect,identityconfusion,attentiondeficits,andstimulantrelatedsubstance

abuse.Hereceivescounsellingwhileremandedandsomemoodstabilisingmedication,

thefirsttreatmenthehasreceived.Heisrefusedbail.Whileinyouthdetentionheis

assaulted,ononeoccasioncausinghimtoloseconsciousness,andheassaultsothers.

Disruptivebehaviourwhileindetentionleadstohimbeingconfinedtohiscellfor23

hoursadayforthreeweeks.Furtherchargesarelaidand,havingturned18,heis

transferredtoanadultprison.Inadultprisonheisconfinedtohisroomfor23hoursa

dayforanumberofweeks,althoughhesaysheprefersnottoleavehiscellatall

becausehedoesn’tfeelsafe.Hedescribesadeteriorationinhismentalstatewhile

secludedincludingmoreintensememoriesoftraumaticeventsfromhischildhood.

Whileservinghissentenceinadultprisonheisnotreceivinganymentalhealthcare.

Owingtothegravityoftheoffendinghewillfacemandatoryvisacancellationand

indefiniteimmigrationdetentionuponthecompletionofhissentence.Theinstabilityin

hiscountryoforiginislikelytomakerepatriationimpossibleandthereforeavery

extendedperiodinimmigrationdetentionislikely.

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Scenario4Ayoungadultnon-citizen–achildmigrant,hearrivedinAustraliaasan

infant.Earlychildhoodneglectandabuse.Parentsseparatedwhenaninfantandleftin

careofseverelymentallyunwellmother.Placedinfostercarewhereabused.Offending

frommidadolescence.Mentallyunwellfromlateadolescence.Visacancellationinearly

adulthood.

Theyoungadulthasneverappliedforcitizenship.Heisdiagnosedwithschizophrenia

andborderlinepersonalitydisorderwhen19yearsoldbuthasonlyreceived

intermittenttreatmentforhisconditionatthetimeheisremandedwhen21yearsold.

Hereceivesamandatoryvisacancellationafterheisgivena14monthcustodial

sentence–hehadpreviouslyreceivedmanynon-custodialsentences.Heisnotgranted

parolebecausehecannotre-enterthecommunitywithoutavisa.Uponcompletionof

hissentencehefacesmanymonthsoryearsofimmigrationdetentionwhilelegal

appealsarefinalised.Herequirestreatmentforhiscomplexsetofmentaldisorders.In

prisonhehasreceivedmedicationforhispsychoticillnessbutnopsychological

treatment.Inimmigrationdetentionhistreatmentislikelytobelesscomprehensive

still.Forensicpsychologicalreportstenderedduringhissentencingindicatedaneedfor

thoroughongoingtreatmentinvolvingpharmacotherapyforhispsychosisandmood

instability;psychotherapyforcomplexdevelopmentaltraumaandtoassistthe

managementofrecurrentpsychoticsymptoms;treatmentforsubstanceaddiction;case

management;andvocationaltraining.

Thesescenariosareinmyopinionillustrativeofthepathwaysthroughthecorrections

andmigrationsystemsofnon-citizenandmentallyunwellyoungoffenders.The

consequenceoftheinteractionofCommonwealthmigrationlawandpolicyandState

criminallawisthatrehabilitativeobjectivesinthesentencingofchildrenandyoung

adultsaredefeated.Insteadofreceivingbail,paroleandthebenefitsofcommunity

correctionsorders,allofwhicharelikelytobeaccompaniedbymentalhealthtreatment

andrehabilitation,theyoungnon-citizenisheldinremand,custodywithoutparoleand

immigrationdetention.Forallyoungpeople,butparticularlyasylumseekers,refugees

andpeoplewithtraumatichistories,treatmentwithincustodyisinferiortowhatcanbe

achievedinthecommunityduetothenarrowerrangeofservicesavailableandthe

adversepsychologicaleffectsofthecustodialenvironment.Serviceprovidersworking

withyoungasylumseekersandrefugeesareawarethatcustodyoftencausesmental

healthdeteriorationratherthanrehabilitation.Experiencingphysicalassaultand

witnessingviolencetoothers,exposuretoanti-socialattitudesandtheuseofextended

seclusionasamanagementmeasureareconditionswhichprecludeatraumatisedyoung

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person’srecovery.When,followingacustodialsentence,ayoungpersonisheldin

immigrationdetentionratherthanthecommunityunderparoleoracommunity

correctionsorder,theyareplacedinasecondenvironmentwhichisantitheticalto

recovery.Anenvironmentwhichweknowisunequivocallyassociatedwithmental

healthdeteriorationovertime,takestheplaceofwhatacourtwouldnormallyenvisage

forayoungoffender-acommunitysettinginwhichtheyoungpersoncanstartto

regaintheirmentalequilibriumthroughcomprehensivementalhealthcare,education,

vocationaltrainingandthesupportoffamilyandfriends.

Insummary,themodernhumanesocietalapproachtoyoungoffenders,asenshrinedin

theChildren,YouthandFamiliesAct(2005),isfrustratedbyCommonwealthmigration

lawandpolicy.Therangeofnon-custodialandpreandpostcustodialrehabilitative

communitydispositionsavailabletotheCourtsareinpracticeoftenunabletobe

accessedbythenon-citizenoffender.Thesentencingobjectivesforyoungoffenders

directedto,totheextentpossible20,preservingfamilyrelations,avoiding

criminalisation,minimisingdisruptiontoeducation,improvingtheoffender’swell-being

andaddressingthecausesoftheoffendingarethwartedwhenmigrationlawpursuesits

owngroundsforimposingdetention.Forthementallyunwellnon-citizenchargedwith

orservingacriminalsentence,oneofmanyconsequencesisthattheyarelessliketo

receiveadequatetreatmentandcareandtheirconditionislikelytobeexacerbated.

3.Thementalhealthcareofpeoplewithpost-traumaticconditions

Post-traumaticconditionsareelevatedinpopulationsthathaveincreasedlevelsof

exposuretopotentiallytraumatisingevents–forinstancerefugees,veteransand

victimsofcrime.Violenceandsexualabuseinchildhoodandextendedtraumaduring

adulthoodcangiverisetocomplexpost-traumaticpresentationswhichthenew

diagnosticcategoryof‘ComplexPosttraumaticStressDisorder’intheyettobefinalised

ICD11(WorldHealthOrganisation)taxonomyofmentaldisordersaimstocapture.In

additiontothePTSDsymptomclusters,thediagnosisdescribesso-called‘disordersof

selforganisation’–negativeself-concept,disturbancesinrelationshipsandaffective

dysregulation.

20Therehabilitativedimensiontosentencing,particularlyinrelationtomoreseriousoffences,isbalanced

withtheneedforcommunityprotection:s362,Children,YouthandFamiliesAct(2005).

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ThemajorityofpeopleexperiencingPTSDexperienceconcurrentdisordersand

conditions–oneormoreofdepression,otheranxietydisorders21,substanceuse

22and

increasedratesofsuicidality23.RatesofPTSDhavebeenfoundtobeelevatedinpeople

sufferingbipolardisorder24andpsychoses

25.Thesecomorbidconditionscannotbe

separatedfromthepost-traumaticsymptomsandneedsimultaneoustreatment.The

sequencingofinterventionsandhoweachconditionmayposechallengesforthe

treatmentoftheother,isasubjectwhichiscurrentlygivenmuchresearchattention.

PTSDhadbeenfoundtobeacommondisorderexperiencedbypatientsinprimarycare

settings;forexampleaUSstudyfoundalmostone-quarterofpatientsmetthecriteria

forcurrentPTSDandone-thirdmetthecriteriaforlifetimePTSD,althoughonly11%

werediagnosedinmedicalrecords26.Asdescribed,ratesofPTSDaremarkedlyelevated

inmanycohortsofrefugeesandsomewhatelevatedamongpeoplewithmajormental

illnesses.Thereisreasontobelievethatpost-traumaticconditionsareunder-identified

andundertreatedinpublicmentalhealthfacilities27.Thereareanumberofreasonsfor

this.Psychosesandmajoraffectivedisorderstendtobethediagnosesreceivingthe

mostclinicalattention.Secondly,thesefacilitiesareorientedtowardpharmacotherapy

andcasemanagementasthefirstlineoftreatmentandcarewhereastheevidence

basedfirstlinetreatmentsforPTSDarevariousformsoftraumafocusedpsychological

treatments28.Fewmentalhealthcliniciansarespecificallytrainedinthesetreatments.

21Nickersonetal.ComorbidityofPosttraumaticStressDisorderandDepressioninTortured,Treatment-

SeekingRefugeesJournalofTraumaticStressAugust2017,30,409–415.Haagen,J.Fetal.(2016)

Predictingpost-traumaticstressdisordertreatmentresponseinrefugees:Multilevelanalysis.British

JournalofClinicalPsychology,56,69–83.https://doi.org/10.1111/bjc.12121.

22Berenz,Eatal.Posttraumaticstressdisorderandalcoholdependence:Epidemiologyandorderof

onset.PsychologicalTrauma:Theory,Research,Practice,andPolicy.Vol.9(4),2017,pp.485-492

23Afzali,Metal.Traumacharacteristics,post-traumaticsymptoms,psychiatricdisordersandsuicidal

behaviours:Resultsfromthe2007AustralianNationalSurveyofMentalHealthandWellbeing.Australian

andNewZealandJournalofPsychiatry.Vol.51(11),2017,pp.1142-1151.24Madhavi,Retal.BipolarIdisorderwithcomorbidPTSD:Demographicandclinicalcorrelatesinasample

ofhospitalizedpatients.ComprehensivePsychiatry.Vol.722017,pp.13-17.25GrubaughAetal.Traumaexposureandposttraumaticstressdisorderinadultswithseveremental

illness:Acriticalreview.ClinicalPsychologyReview31(2011)883–899.

26LiebschutzJ

elal.PTSDinurbanprimarycare:highprevalenceandlowphysicianrecognition.JGen

InternMed.2007Jun;22(6):719-26.Epub2007Mar10.

27Thishasbeenidentifiedasanissueinpublicmentalhealthservicesinternationally:seeGrubaughAet

al.Traumaexposureandposttraumaticstressdisorderinadultswithseverementalillness:Acritical

review.ClinicalPsychologyReview31(2011)883–899.28Forexample:TheAustralianGuidelinesfortheTreatmentofAcuteStressDisorderandPosttraumatic

StressDisorder.PhoenixAustralia–CentreforPosttraumaticMentalHealth2013.

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Withregardtocomplexpost-traumaticpresentations,wherethedisordermanifestsas

BorderlinePersonalityDisorder,thereisaspecialiststatewidepublicfacility29butthe

areamentalhealthserviceshavelittle,orareonlyjustnowbeginningtoacquire,the

capacitytodeliversystematicevidencebasedtreatmentsforthiscondition.

Currentlythereisaninequitabledistributionofspecialistservicesforthetreatmentof

post-traumaticmentalhealthdisordersinVictoria.Thereisonepublichospitalthat

treatsveterans,police,emergencyservicepersonnelandpeoplewhoseconditionsare

compensable(duetohavingbeenprecipitatedbyanevent,suchasaworkplaceinjury

orroadaccidentforwhichthereisstatutorycoverageofmedicalcosts)30.Thereare,to

myknowledge,asmallnumberofprivateclinicswhichprovideprogramsforsufferersof

PTSDwhichcanassistpeoplewithprivatemedicalinsurance31.Whentheconditionis

particularlycomplex,whenthepersonpresentsperiodicsignificantrisktothemselves,

orwherethereisacomorbidmajormentalillnessaprivatepractitionerisunlikelytobe

abletoprovidetherangeofservicesthattheclientneeds.Inmyviewpublicmental

healthfacilitiesshouldbeabletoprovideexpertmentalhealthcareforthisgroup.This

maybeachievedthroughmorethoroughscreeningforpost-traumaticconditions,

ensuringasubgroupofstaffwithineachareamentalhealthservicehasspecialist

traininginthetreatmentofPTSD,andestablishingformalprogramsinthenetworkof

mentalhealthserviceswithinwhichsufferersofPTSDwhodonothaveprivate

insuranceoreligibilityforcompensabletreatmentcanreceivecomprehensivecare.

Partofthesuiteofcareavailableshouldbeaninpatientfacilityspecificallydesignedto

treatpost-traumaticconditions.AsubgroupofpeoplewithseverePTSDrequiresasafe,

therapeuticinpatientenvironmentatcertainphasesoftheirtreatment;suchan

environmentisnotprovidedbyacutepsychiatricinpatientunitsandisnotcurrently

availableinanyothersetting32.

29SpectrumPersonalityDisorderService.

30ThePsychologicalTraumaRecoveryService,TheAustinHospital.

31Forexample,TheAlbertRoadClinic.

32 ThePsychologicalTraumaRecoveryService,TheAustinHospital,providesinpatientservicesforeligible

peoplebutnottothegeneralcommunity.

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4.Accesstoprivatesectorpsychologicaltreatmentbypeopleofnon-Englishspeakingbackground

PrivateprovidersdeliveringMedicare(betteraccess)andPrimaryHealthNetwork

fundedpsychologicaltreatmenthavelimitedornoaccesstointerpreters.Theseservices

areunavailableforpeople-primarilymigrantsandrefugeesbutalsosomeindigenous

people-whoarenotfluentinEnglish.Theonlywaytheservicemightbedeliveredto

thesegroupsisifthereisaproviderwhospeaksthelanguageoftheclient;accesstoa

providerwiththelinguisticandtherapeuticskillsmatchedtotheclient’sneedsisin

mostcasesunavailable.

Thisarrangement,involvingaverylargeallocationofpublicfundsforcommunity

healthcare,shouldberegardedasdiscriminatoryandunconscionable.

Ihavedescribedtheneedformorestronglycoordinatedmultidisciplinaryplansofcare

involvingarangeofpractitionerseachofwhomtakesresponsibilityforaspecificareaof

care.Howeveraccesstoonsiteinterpretersisapreconditionforassistingpeoplewho

arenotfluentinEnglish(orwhoprefertospeakintheirmothertonguewhenengaging

inpsychologicaltreatment).

Beyondbasicequitableprinciples,thereareanumberofconsiderationsthatshould

informpolicywithregardtoaccesstointerpretersbyprivatepractitioners.In

psychotherapyofanydepthaninterpreterbecomesintegraltothetherapeutic

relationshipandthesuccessofthetreatment.Itisoftenveryimportanttoengagethe

sameinterpreteroralimitednumberofinterpreterswhenworkingwithtrauma

survivorsorindeedwhenanyexploratorypsychologicalworkisbeingundertaken.

Employingaphoneinterpreterisanarrangementwhichisusuallyentirelyinadequateto

thetask.EvenforthosewhohaveacquiredreasonablefluencyinEnglish,Ihavefound

thatmanyclientsprefertospeakintheirmothertonguebecausetheyareableto

expressthemselveswithgreatereaseandnuanceandfeelthattheyarefullyincontact

withtheiremotionsratherthan,whenspeakinginEnglish,observingtheiremotions

‘fromtheoutside’.Theyfeel,inotherwords,evenwhenbilingual,thattheirmother

tongueremainsthelanguageoftheiremotionallifeandoftheirownself.

Itmaybethatthecurrentsituationcouldbeslightlyamelioratedbyencouragingmore

bilingualpractitionerswiththerequisitecommunitylanguagestobecomepartof

primaryhealthnetworksandforgeographicalbarrierstobeovercomebyincreaseduse

ofteleconferencingfacilities.Howeverthesearrangements,whileworthwhile,willnot

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addressthelargerissueofequitableaccess.InthisregardIshouldalsonotethatinmy

experiencethereisnotaninsignificantnumberofmigrantsandrefugees,especially

fromsmalleroremergingcommunities,who,forreasonsofperceivedconfidentiality,

wishtoreceivetreatmentfromaclinicianfromoutsidetheirowncommunity.

5.Thecapacityofpublicmentalhealthservicestodeliverevidencedbasedpsychologicaltreatments

Nationalguidelinesrequirethat‘[t]reatmentandsupportprovidedbytheMHS[mental

healthservice]reflectsbestavailableevidenceandemphasisesearlyinterventionand

positiveoutcomesforconsumersandtheircarer(s)’33.TheNationalMentalHealth

Strategyandcodesofprofessionalconductrequirepracticetobeevidencebased.

Cliniciansnowhaveavailabletothemanextensivesetoftreatmentguidelinesproduced

bothinAustraliaandinternationally.Theevidencefortheeffectivenessofparticular

treatmentsandinterventionsistypicallyorganisedaccordingtoahierarchyranging

fromhighgradeevidenceofferedbyasystematicreviewofrandomisedcontroltrialsto

lowgradeevidenceprovidedbyacaseserieswithpretest/posttestoutcomes.Highlevel

evidencefortheeffectivenessofatreatmentprovidestheclinicianwithsomeassurance

thatonapopulationleveltheinterventionwillassistclientswithaparticularmental

disorder.Howevergoodclinicalpracticeneverinvolvestheunreflectiveapplicationof

thetreatmenttothedisorder;theclient’sspecificpreferences,culturalbeliefs,

psychologicalcharacteristicsandcapacities,andsocialcircumstancesleadthe

competentcliniciantomakechoicesbetweendifferenteffectivetreatmentsandto

tailorthechosentreatmenttothespecificneedsoftheclient.

Likealltreatmentsforcomplexmentalhealthconditions,theprovisionofeffective

psychologicaltreatmentsrequiresconsiderabletrainingandexperience.Itisalsolabour

intensiveandtimeconsuming.Inrelationtopsychologicaltreatments,inmyexperience

publicmentalhealthserviceshaveneverhadstaffprofilesorfundingtoprovidewhat

evidencebasedtreatmentguidelinesindicateshouldbeprovided.Thereisinfacta

chasmbetweentreatmentguidelines’recommendationsandclinicalpracticewith

respecttopsychologicaltreatment.

Thispointcanbestbemadebyexample.Thetreatmentguidelinesfortreating

depressivedisordersproducedbytheAustralianPsychologicalSocietyandtheRoyal

33 Nationalstandardsformentalhealthservices2010;Standard10,DeliveryofCare.

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AustralianandNewZealandCollegeofPsychiatristsrecommendpsychological

treatmentsforthisdisorder.TheAPSguidelinesindicatethereislevel1evidencefora

numberoftreatmentsincludingCognitiveBehaviouralTherapyandInterpersonal

Therapy.Bothguidelinesindicatethatformoderatetoseveredepressioncombined

psychologicalandpharmacotherapyismoreeffectivethaneithertreatmentalone.The

RANZCPguidelinesstatethat‘[f]ormostpatientswithdepression,acombined

treatmentapproachismoreeffectivethaneitherpsychologicalorantidepressant

treatmentalone.Thisappliesparticularlytodepressionofmoderateorgreaterseverity

…andchronicdepression’34.Therecommendationsguidingtreatmentofdepressionin

theUKaresimilar:theNICEguidelineindicatesthathighintensitypsychological

interventions35combinedwithpharmacotherapyisthetreatmentofchoicefor

persistentsubthresholddepressivesymptoms,mildtomoderatedepressionwith

inadequateresponsetoinitialinterventions,andmoderateandseveredepression36.

Itisunlikelyinmyexperiencethatevenasizeableminorityofpeoplesufferingamajor

depressivedisorderwhoattendapublicmentalhealthservicearereceivinga

recommendedpsychotherapy.

Treatmentguidelinesallocatearoleforpsychologicaltreatmentsforallmental

disorderssufferedbypeopleattendingpublicmentalhealthservices.Therolewillvary

accordingtothementaldisorderandtheperson’sspecificneeds.Treatmentguidelines

indicatepsychologicalinterventionsasfirstlinetreatmentsforPTSD,someanxiety

disorders,mildtomoderatedepressivedisordersandborderlineandotherpersonality

disorders;asfirstlinetreatmentincombinationwithpharmacotherapyformoderate

andseveredepressivedisorders;asusefulinrelapsepreventionforbipolardisorders

andasanadjunctivetreatmentduringtheacutedepressivephaseoftheillness;andas

animportantelementinthetreatmentofschizophrenicdisordersinrelationto

treatmentresistantpositivesymptomsandinrehabilitationandrelapseprevention.

Ibelieveasurveyofpastandcurrentpracticewouldfindthatthedeliveryof

psychologicaltreatmentsinpublicmentalhealthfacilitiesisnotalignedwithbest

practicetreatmentapproachesandinfactfallsfarshortofthem.Psychological

treatmentsshouldbeanintegralandubiquitousfeatureofpublicmentalhealth

treatmentplansandthetreatmentsshouldbedeliveredbysuitablyqualifiedand

34RoyalAustralianandNewZealandCollegeofPsychiatristsclinicalpracticeguidelinesformood

disorders,AustralianandNewZealandJournalofPsychiatry2015,Vol.49(12)1-185,4135TheNICEguidelinedescribeshighintensitypsychologicalinterventionsasinvolving16to20sessions

over3or4monthswithfollow-upsessions.36NationalInstituteforClinicalandCareExcellence,Depressioninadults:recognitionandmanagement.

Clinicalguidelinepublished28October2009.

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experiencedclinicians.

6.Thequalityofrehabilitationservicesforpeoplewithchronicmentalillnesses

IdonothaveparticularexpertiseinthisareabutIwishtomakeafewcommentsbased

onanalltoofrequentobservation:thatpeoplerecoverfromtheacutephaseofsevere

mentalillnessbutarethenunabletorecoverpurposefulandsatisfyinglives.Thereare

manyreasonsforthis,Iwillfocusonjusttwo–thepersistenceofinadequatelytreated

cognitiveimpairmentsandtheinadequacyofvocationaltrainingandplacement.

Allmajormentalillnessescausecognitiveimpairment.Inmyexperiencepeople

sufferingfromarangeofdisorders,moodandanxietydisorders,PTSDandpsychotic

disorderswilloftenindicatethatattentionproblems,andimpairmentinrecollectionof

dailyeventsandretrievalofautobiographicalmemoriesareamongthemostdebilitating

experiencesassociatedwiththeirmentalillness.Evenwhenthedisorderisinremission,

indisorderssuchasschizophrenia,majordepressivedisorderandPTSD,thereis

evidencethatcognitiveimpairmentpersists37.Inmyexperiencecognitiveimpairmentis

rarelyafocusofclinicalattention.Mostmentalhealthclinicianshavelimitedskillsinthe

remediationofcognitiveimpairment.Neuropsychologistswhoareexpertsincognitive

disorders,areusuallynotemployedinpublicmentalhealthservicesnoratnon

governmentpsychiatricrehabilitationandsupportservicesandaregenerallydifficultto

access.Theirskillsarenotconfinedtoexplainingneuropsychologicalconsequencesof

braindisorders;theycanalsoprovideexpertassistanceinthemanagementand

rehabilitationofthecognitiveeffectsoffunctionaldisorders.Recoverygoalsforpeople

withchronicmentalillnessshouldincludespecificinterventionstoimprovecognitive

functioning;neuropsychologistsandotherclinicianswithrelevantskillssuchas

occupationaltherapistsshouldmakesubstantialcontributionstotheimplementation

anddeliveryofthisphaseoftreatment.Mentalhealthservicesshouldemployorhave

directaccesstoclinicianswithspecialistknowledgeoftheremediationofcognitive

abilitiesinpeoplewithmajormentalillnesses.

Anindispensableelementinrehabilitationistheperson’sideasabouthowtheywould

liketoimprovethequalityoftheirdailylivesandwhatsetofactivitieswouldhavevalue

37 Forexampledepressioninremission:BoraE,HarrisonBJ,YucelM,etal.(2013)Cognitiveimpairmentin

euthymicmajordepressivedisorder:Ameta-analysis.PsychologicalMedicine43:2017–2026.

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andmeaningtothem.Assistingthepersondefinewhatthislifelookslikeandwhatthe

barriersaretorealizingitshouldbeintegraltorehabilitation.Whentheperson’sgoals

aretofindpaidemploymentoravoluntaryactivitythatismeaningfultothem,

employmentservicesornon-governmentrehabilitationservicesareofteninvolvedin

assistingtheclient.Oftentheknowledgeaboutthepersonheldbythementalhealth

serviceandthevocationalassistanceprovidedbytheemploymentserviceorNGOisnot

wellintegrated.Itismyexperiencethatmanymentallyillpeoplewhohavespent

extendedperiodsoutoftheworkforcefindtheattempttoregainemploymenta

frustratinganddemoralizingexperience.Theyhavetoldmethattheywouldbenefit

frompre-vocationaltrainingbutthishasnotbeenavailable.Theyhavealsosaidthey

wouldbeassistedbyagraduatedre-entryintoemployment,commencingwithpart-

timeworkandongoingassistancefromapersonwhoseroleitistoprovidepractical

supportinthetransitionbacktowork,butthisdoesnothappen.

Manypeoplewhohavesufferedfromamentalillnessinmyexperiencefeelabandoned

atthepointwhentheyattempttomovebackintoafullerlifeinvolvingworkorstudy.

Howpeoplewithseverementalillnessesareassistedbackintotheworkforceandto

engageinthebroaderlifeoftheircommunityneedstoberethought.

7.Concludingremarks

Mentalhealthservicescanbeviewedfrommanyperspectives.Itistruetosaythat

withinthecurrentsystemgoodpracticesco-existwiththosethatareneglectfuland

inattentivetothementallyillperson’sneeds.Ihaveattemptedtodescribesomeofthe

latterpractises.

IftheCommissionwouldbeassistedbyfurthercommentonanyoftheareasoutlinedin

thissubmission,Iwouldwelcometheopportunitytodosobymeansoforalor

additionalwrittenevidence.

GuyCoffey

5July2019

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