Newsletters

December 2014

Newsletter No. 46

From bad to worse Prevention of mental disorders (2) History Corner 1814 Mental Health News – Headspace

FROM BAD TO WORSE

Every year hundreds of children are placed in out-of-home care on Child Protection applications alleging abuse and neglect. Judges of the Children’s Court hear the evidence, which is tested by adversarial cross- examination and counter-argument, and they reach conclusions in the best interests of the child.
Generally there is a defined period of out-of- home care during which the case worker has the responsibility of doing everything possible to help the family resolve its dysfunction in anticipation of the child’s return to its care. Everybody is happy when this is successful. Unfortunately, this does not always work, and the child may return to protective custody. The Judge again reviews the old and the new evidence.
Returning the child to its family with appropriate support has potentially the greatest probability of success, as compared to the success rates of alternative placements.
Placing a child in temporary out-of-home care provides safety and nurturance but does not provide the healthy attachments that are necessary for long term social and emotional and cognitive development. Whatever degree of attachment that does occur is disrupted when the temporary placement ends, which adds to the child’s emotional burden. Placing a child in permanent out-of-home care has the possibility of providing for its needs but is fraught with difficulties.
The difficulty of establishing healthy attachment in substitute families, particularly for older children, is so great that many such placements fail. Even younger children who have successful attachment still have residual emotional dissonance regarding their families of origin. Experience of past adoption practices showed that no matter how loving the adoptive family may be, there is frequently a traumatic longing for reconciliation with the birth family, which can be destructive of the adoption. For this very reason adoption law reform made it so difficult for adoptions to occur that they are now relatively rare.
On the child protection side, however, it must be acknowledged that a small number of children come from families that are so dysfunctional that they will never be able to provide the care necessary for healthy development. The earlier this conclusion is reached the greater the chance of adoption into a substitute family before damage is too great for success.
The Children’s Court judge, then, is in the invidious position of having to decide what is in the child’s best interests. Temporary care will be damaging if prolonged. Premature return to a dysfunctional family will be damaging. Permanent out-of-home care may work or may fail. It would be a justifiable risk if there was certainty that the family of origin was definitely going to damage the child. Who can assist in providing appropriate assessment information? Also, who is in a position to say whether the dysfunctional family has been given appropriate treatment to address the dysfunction, and whether there is any likelihood of capacity to respond? These are significant clinical issues, not to mention the human rights issues concurrently involved.
Now, that said, there has been an unheralded legislative event. After consultation that was so limited that pertinent legal bodies and others did not know about it until just days before, the Human Services Minister introduced a Bill into Parliament that will very significantly affect children and families. While called the Children, Youth and Families Amendment (Permanent Care and other Matters) Bill 2014, it represents in fact a substantial change to the Act and its ethos. It reduces the powers of the Children’s Court and greatly increases the powers of the DHS.
The powers of the Children’s Court to oversee DHS involvement have been curtailed. DHS will instead be self-monitoring. The ability of the court to order access for a child with a parent has been curtailed. DHS will no longer be required to arrange or provide remedial input to families and a prime permanency objective is to be adoption.
This is particularly alarming. Whilst wishing to support DHS in its thankless task of child
protection intervention, the reality is that most protective caseworkers are junior and relatively inexperienced social workers. Not only do they not have the knowledge, experience and expertise to assess and monitor the treatment needs and progress of their clients, the new arrangements will absolve them of the responsibility to do so and give them the powers to make life-changing decisions for children without recourse to judicial oversight.
This spate of changes is due to come into operation in 2016 if not accelerated to an earlier date. Under this new regime, over time the likelihood is greatly increased for there to be many children from circumstances of poverty and disadvantage needlessly being removed from home permanently, through the very fact that early help for the family, the retention of access and oversight by the Children’s Court will have been lacking.
The Bill has been passed in both houses of Parliament. There was a haste to get it through the Parliament before the election since it has the endorsement of the current government.
The Law Institute, the Bar Council and Liberty Victoria have begun to remonstrate. You may wish to read what is on the Law Institute Website about the Bill. MHYFVic is of the opinion that these crucial decisions need judicial oversight and greater professional input than previously, not less!
Allan Mawdsley

PREVENTION OF MENTAL DISORDERS

This is the second of the five-part series of newsletter articles devoted to Prevention of Mental Disprders. The MHYFVic Projects aim to define the best practice approaches to prevention of mental disorders, and invite any interested members to join the project groups working on any one or more of these tasks.
The universal services thought most important in preventing mental disorders form a hierarchy like Maslow’s Hierarchy of Needs in which a foundation of the most basic needs must be met before the more subtle factors can contribute. The proposed hierarchy for children and families means programs that :
 Ensure adequate safety, housing, food and general health, welfare and educational services.
 Promote social stability, family functioning and adequate parenting skills.
 Enhance social cohesiveness and pro- social participation
 Encourage every child’s educational progress to reach his/her potential
 Provide processes to identify and deal with toxic events
Our October newsletter considered the challenge of how we might ensure adequate safety, housing, food and general health, welfare and educational services. This newsletter ponders the second question. How do we promote social stability, family functioning and adequate parenting skills?
The definition of social stability in the political
context means conservatism and the maintenance of the status quo. However, in the context of mental health it has more to do with the resolving of instability that would undermine family functioning.
Research, such as that quoted by Kristi Openshaw, has produced clear evidence that family resilience is a predictor of quality of life and that parent-child relationships, social support, family conflict, and family type are variables that impact quality of life.
Problems with parenting skills may be assisted by interventions such as the Triple P program used as a Public Health measure available to whole populations. This has been undertaken in Western Australia where clear benefit has been shown for the parenting skills of participants. Although it is more effective with milder degrees of dysfunction and less so with serious dysfunction, and requires a voluntary decision for participation, the availability of such assistance is a major contribution.
Steve Zubrick, in a Commonwealth Department of FACS report in 2000, ‘Indicators of Social and Family Functioning’ said, “(The use of…) indicators of social and family functioning… identifies opportunities to modify risks which have been associated with increases and decreases in the prevalence of problems of developmental health and wellbeing. This allows the development of prevention strategies and better intervention”. He went on to recommend the use of some measures, one of which was the “psychological capital” of the family.
Psychological capital is a term arising from the field of organizational psychology, and much of the literature relates to increasing employee job satisfaction through improving workplace arrangements. However, the factors comprising psychological capital are of significant relevance. These are : self-efficacy, optimism, hope and resiliency.
Taking up Zubrick’s point, what intervention strategies for families will improve self- efficacy, optimism, hope and resilience?
Approaching this task from a different point of view would be Nathan Epstein’s structural concept of family functioning. Using his model, one would ask, “What can be done to improve ‘Affective Involvement’ (belongingness)”? “What can be done to improve ‘Affective Expression’ (capacity to love and hate, approve and dissent)”? “What can be done to improve interpersonal communication”? What can be done to improve problem-solving”? “What can be done to ensure appropriate controls (internal and external)”? “What can be done to support and strengthen family roles”?
This preliminary consideration of issues related to family functioning has raised a number of questions for which there are some answers at an individual level but very little at a public health level. Further literature review, proposing appropriate mechanisms to achieve changes, and identification of best practice models, will be Task Two of this Project on Prevention of Mental Disorders.
Offers of collaboration in this, or any other task in the Project, will be gratefully accepted.
References:
Openshaw, Kristi P. “The relationship between family functioning, family resilience, and quality of life among vocational rehabilitation clients” Dissertation, Utah State University 2011.
Zubrick, SR et al. “”Indicators of Social and Family Functioning”, Commonwealth Department of Family and Community Services, 2000.
Project Coordinator : Dr Allan Mawdsley Members welcome
Contact Allan Mawdsley on 0419 77 00 66 or mawdsley@melbpc.org.au

HISTORY CORNER 1814

Mental health services were first buildings for housing disturbed people. We begin a series that will document the first such institutions in Australia. From the outset there was a problem in how to assess patients as in need for the special accommodation that the asylum offered.
The idea of the asylum as a safe haven for the insane arrived in Australia with the Governorship of Macquarie, as did the problem of who should have access to the facilities and services of the asylum, as articulated by the second superintendent, Bennett (Neil, 1992). Macquarie knew of the contemporary English social reforms when he became Governor of New South Wales in 1808, but there had always been a clause in the commission of all New South Wales Governors, as follows:
And whereas it belongeth to us in right of our Royal Prerogative to have the custody of ideots and their estates and to take the profits thereof to provide for the custody of lunaticks and their estates without taking the profits thereof to our own use. (Phillip’s Commission, 1787; cited in Neil, 1992)
Macquarie established the asylum at Castle Hill, within the grounds and buildings of the first Government farm in New South Wales. Castle Hill asylum opened in 1814 and closed in 1826, and from the outset was a care facility with medical support, rather than a Tukean (York Retreat) moral treatment facility.
Some of the problems of hospital administration encountered at Castle Hill remain features of mental health services today. Neil (1992) has commented in particular, on admission criteria, the tensions between administration and medical officers, and the roles and training of the direct carers. Admission of inmates at Castle Hill was a constant source of difficulty for the superintendent, who would receive referrals upon the recommendations of magistrates, doctors, and concerned others. Sometimes referral was made based on the level of violence displayed by a person, construed as an indicator of their implicit insanity. But in
MHYF Vic: promote mental health, reduce stigma, advocate, resource, and collaborate 4
1821, on several occasions, three physically violent and disruptive ex-policemen were received by the superintendent under a magistrate’s recommendation, and then discharged by the medical officer (Assistant Surgeon) because they were not considered mad.
It is clear that mentally ill people were indeed sometimes referred, as indicated in the superintendent’s report of 3 May, 1821 (Neil, 1992).
I am wholly at a loss how to fill the columns [on a special form] accounting for their present and former employment. Mr Bowman [Principal Surgeon, NSW] knows full well that they do nothing here but Eat, Drink, Sleep and Wrangle – and whoever sends them here, give me no information whatever, and if I make enquiry of themselves one tells me he is the Emperor of Germany, another calls himself Buonaparte, with other high-sounding titles on the part of the Males, and of the females we have Queens, Princesses, Duchesses and Countesses with other first rate characters
(Superintendent William Bennett, Castle Hill Lunatic Asylum).
Processes were needed to decide who to admit, and what to do with them once admitted. Treatment was not an active component of confinement. However, following Tuke (Neil), occupation was considered to be encouraging of the recovery a person’s mind.
Staff at Castle Hill, including medical officers, were often recruited from among the convicts or former convicts of Sydney (Neil, 1992). A clear criterion for employment as a keeper or attendant was physical strength (Neil). This was much the case elsewhere in Australia, for example, at the Adelaide asylum mid- nineteenth century (Shlomowitz, 1994) and was still a feature of employment as an
attendant in Western Australia in the 1960s (Martyr, 1999).
References
Martyr, P. (1999). Setting the Standard: A history of the Australian and New Zealand College of Mental Health Nursing Incorporated. Sydney: ANZCMHNI.
Neil, W. (1992). The lunatic asylum at Castle Hill: Australia’s first psychiatric hospital, 1811-1826. Castle Hill, NSW: Dryas.
Shlomowitz, E. (1994). Nurse attendants in South Australian lunatic asylums, 1858-1884. Australian Social Work, 47, 43-51.
Jolyon Grimwade

MH News HEADSPACE

The Headspace Program is now several years old and papers are emerging to answer some of the controversial questions that have been raised about it.
The program is a Commonwealth Government initiative in the mental health of adolescents. It is delivered at a number of specific centres in capital cities of all States and in some major rural cities, and also online through a dedicated internet website. It consists of self- referred consultations with psychologists, psychiatrists and appropriately trained youth welfare workers, followed by counselling or referral to centres for therapy, or by internet interventions.
When it was launched there were concerns about its cost-effectiveness, whether the expenditure would cannibalise funding that should be devoted to other mental health projects, whether it would address real needs
MHYF Vic: promote mental health, reduce stigma, advocate, resource, and collaborate 5
or the “worried well”, and whether it would be therapeutically effective (especially the relatively untried internet assessment and treatment components).
Although there has not yet been sufficient time to fully address the outcome issues, there has been preliminary data to indicate that outcomes are fairly much in line with traditional treatment pathways. What is quite striking, however, is the hugely better access compared to traditional services. Community-based prevalence studies have shown that about half of the cohort with responses in the clinical range never see any professional helpers and that only about 5% see mental health professionals. The rates are worst in the disadvantaged and rural areas. The Headspace data shows considerably greater accessibility, including for the rural and disadvantaged subgroups.
In answer to the question of whether these clients are representative of morbidity in the community or merely the ‘worried well” the following abstract of a paper from the Medical Journal of Australia gives an impressive account of an important new initiative in the spectrum of mental health services.
Objectives: To provide the first national profile of the characteristics of young people (aged 12-25 years) accessing headspace centre services – the Australian Government’s innovation in youth mental health service delivery — and investigate whether headspace is providing early service access for adolescents and young adults with emerging mental health problems.
Design and participants: Census of all young people accessing a headspace centre across the national network of 55 centres comprising a total of 21 274 headspace clients between 1 January and 30 June 2013.
Main outcome measures: Reason for presentation, Kessler Psychological Distress Scale, stage of illness, diagnosis, functioning.
Results: Young people were most likely to present with mood and anxiety symptoms and disorders, self-reporting their reason for attendance as problems with how they felt. Client demographic characteristics tended to reflect population-level distributions, although clients from regional areas and of Aboriginal and Torres Strait Islander background were particularly well represented, whereas those who were born outside Australia were underrepresented.
Conclusion: headspace centres are providing a point of service access for young Australians with high levels of psychological distress and need for care in the early stages of the development of mental disorder.
Reference : Debra J Rickwood et al. “headspace — Australia’s innovation in youth mental health: who are the clients and why are they presenting?” MJA 200(2)· 3 Feb 2014

OUR UPDATED WEBSITE

After much thought our website has been significantly revised to give casual visitors immediate information about what we do and what we stand for, whilst at the same time allowing members to go straight to specific sections such as Projects or Newsletters or Events, without having to navigate past reams of information.
Now that the main revision has been implemented we are working on tasks of development of Projects to give us the evidence base for our advocacy. There are quite a few items under development at the present time which are not yet reflected in the website but over the next few months we expect to see a burgeoning of activity.
Visit us on mhyfvic.org

2014 MHYF Vic Committee

* President, Jo Grimwade
* Vice-President, Jenny Luntz
* Past President: Allan Mawdsley
* Secretary, Celia Godfrey
* Treasurer, Anne Booth
* Membership Secretary, Kaye Geoghegan * Projects Coordinator, Kylie Cassar
* WebMaster, Ron Ingram
* Newsletter Editor, Allan Mawdsley
* Youth Consumer Representative, vacant * Members without portfolio:
Suzie Dean, Miriam Tisher, Zoe Vinen, Sarina Smale

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