Health

While Covid-19 lockdowns shone fresh light on mental health, deficiencies in psychiatric and psychological care have been critical for many years. By Ahona Guha.

The long road to real mental health

Clinical and forensic psychologist Dr Ahona Guha.
Clinical and forensic psychologist Dr Ahona Guha.
Credit: Rachael Michelle

I am a psychologist now, but first I was a patient. When I desperately needed mental-health help, I found a private psychologist and a general practitioner who walked with me on my recovery pathway. For the people who now turn to me, I’m fully aware how impossible this journey seems.

When health professionals hear of the mental-health crisis, we shrug wearily. We’ve lived with this emergency for years – the pandemic just gave it a new context. Patients and providers alike are trapped in the convergence of spiralling demand and dwindling supply. These forces are inextricably linked, thanks to more than a decade of political disregard for the resourcing needed to create a robust health system. Sustained attacks on the social foundations of psychological wellbeing have caused great distress. If fewer people can find decent housing, stable jobs or even feed themselves, more will experience mental trauma and more will need help. We have been forced to live in an economy, not a society, and the human costs of this paradigm shift are massive.

The failures of our system are due in large part to years of inadequate funding for training and the social infrastructure that prop up mental health, such as housing, drug rehabilitation programs and Centrelink. Add to this the systematic erosion of Medicare, exemplified by the freeze of rebates, the lack of specific concessions for longer mental-health appointments with GPs, and more recently the cuts in funding for telehealth access to rural psychiatry. Moreover, the 20 sessions that patients can currently claim with a psychologist under the Better Access scheme will likely revert at the end of this year to the 10 sessions that were available before the onset of Covid-19. That is nowhere near enough to treat any serious mental-health disorder.

The mental-health system was at its limit before the pandemic. The subsequent increase in demand stretched it beyond its capacity, leaving many people waiting for months to see professionals while their conditions deteriorated, ensuring that they would then need more intensive care. The Australian Institute of Health and Welfare  noted calls to both Lifeline and Kids Helpline were up in January this year, compared with one and two years ago. Lifeline received a record number in August/September 2021. Mental health-related prescriptions have spiked during the past two years. Sectors that were already poorly resourced were hit hardest, such as child and adolescent services.

“Most mental-health clinicians can’t safely discharge their current patient load, so they turn away dozens of referrals per week,” clinical and forensic psychiatrist Dr Jacqueline Rakov tells The Saturday Paper. “Access to publicly funded services remains mostly restricted to severe mental illness.”

The “mental-health system” is itself a misnomer – it is not a monolithic entity. Rather, it is a Frankenstein’s monster, a collection of disparate limbs lurching along in some semblance of cohesion. Each part has been added based on acute need, with little consideration as to the way they should function together.

The public system involves in-hospital care and outpatient community care providers, typically reserved only for cases of acute need, such as florid psychosis or intense suicidality. Public services operate under a model that assumes there are certain true disorders, while others – such as personality disorders and trauma – often do not meet the threshold for treatment, despite ample evidence of the debility they can cause. Certain interventions, such as assessments or treatment for adult ADHD, tend not to be provided by public services at all, leaving sufferers struggling to afford private practitioners’ fees.

Medicare rebates for mental health are insufficient and have remained frozen for many years, resulting in most practitioners charging a gap fee. Poor public funding for services such as assessments and report writing, which are essential for diagnoses of neurodevelopmental conditions, means identification and treatment can be delayed for years. By limiting access to affordable early diagnosis and intervention, we risk condemning patients to a lifetime of struggle to manage their condition.

The role of GPs is also underappreciated. They are the linchpin of the mental-health system and rebates for their services have also stagnated for years, with no specific funding for mental-health services beyond the plans they write for psychologists.

“GPs are completely inadequately funded by Medicare for appointments to meaningfully address mental illness at the primary care level, which simply cannot be achieved in six to 15 minutes,” Rakov says.

The private system is expected to handle the overflow of work the public system can’t accommodate, though it was designed to cater to those with less critical cases, including anxiety, depression, histories of trauma and lower-acuity eating disorders. Not all of these conditions are mild and many require ongoing multidisciplinary care as well as management of episodic crises that can’t be dealt with in the private system without great cost to the patient. In addition, the private system runs on a for-profit model and operates with poor workforce oversight, adherence to employment law, as well as limited standardisation of service and quality control. These difficulties can weigh heavily on new practitioners, who may be more vulnerable to exploitative business practices.

I became a psychologist partly because I wanted to effect the change I myself received. Sometimes, when I am making desperate phone calls trying to find a public service that will conduct an ADHD assessment for a young person in great need, or have a patient terminate prematurely because their funded sessions have run out, or have someone who’s suicidal tell me they were sent home with diazepam from the emergency room, I wonder whether it was all worth it. I hold the hope, because I must – otherwise I would burn out.

The culture in public mental-health services is poor. A survey of ACT health workers in 2019 found about 35 per cent of respondents had experienced bullying – most of which was staff-on-staff – while 12 per cent said they had been subjected to physical harm, sexual harassment or abuse at work. An earlier survey of mental-health staff in Victoria in 2016 found that 83 per cent of respondents had experienced occupational violence over the previous year.

Mental-health workers in Victoria’s system have had no increase in pay since mid-2019, as their enterprise bargaining agreement has taken more than two years to finalise. Public sector psychologists are already poorly paid relative to their extensive training. This undervaluation, on top of a demeaning workplace environment, may drive more clinicians to the relative flexibility, psychological safety and better remuneration of the private system. No one works in mental health for money alone, but it can help incentivise clinicians to stay in high-stress roles.

Meanwhile, little attention has been paid to developing training in psychiatry and psychology. These professions have demanding and expensive pathways to qualification, as they should, but funding has been increasingly skewed to one-size-fits-all approaches. We can’t expect high-quality care if we fund only those professions that are cheapest and quickest to train and hire.

The effort to keep up has been an “unprecedented” strain on practitioners, says clinical psychologist Dr Jon Finch. Most of his colleagues increased hours during the pandemic and are now trying to cut back to avoid burnout.

“Our clinic has had difficulty finding new clinicians, with what seems to be a lack of new graduates,” he tells The Saturday Paper.

Psychology postgraduate training programs have tiny intakes due to a lack of Commonwealth funding. And bungles in the examination system of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) mean that no new psychiatrists have been accredited for almost two years. For a small profession that absorbs a huge volume of community demand, this is a disaster. Moreover, Rakov cited a 2022 survey of early career psychiatrists presented at the RANZCP’s May conference showing that, once accredited, 65 per cent of the 238 respondents felt unprepared to work in private practice, a sector that absorbs huge need.

The task ahead of us is daunting.

An increase in Commonwealth-funded training places for psychiatry and postgraduate psychology is vital. A boost in funding for GPs providing mental-health care is long overdue. Telehealth access should be permanent, with increased Medicare funding for those treating clients in remote areas, to facilitate bulk-billing. Public services must focus not just on acute crises, but on managing a broader range of disorders. To retain existing staff, the high rates of bullying, harassment and occupational violence must be addressed, and flexibility and work-life balance need to be closer to what the private sector offers. The Victorian government’s bonuses of up to $3000 are a start – reliable pay increases commensurate with inflation would be better.  

That said, it is encouraging to see the large investments in mental health made by both Queensland and Victoria in their recent state budgets. Queensland has committed to spending $1.6 billion over a five-year period including funding new hospital beds, alcohol and drug services and outpatient treatment. Victoria has made similar commitments.

Of course, these plans also necessitate longer-term funding for training to ameliorate the current staff shortages; without appropriate staffing levels, there is no mental-health system.

Ten years ago, I would not have been able to speak about my own experiences without stigma. We have made great strides in how we see mental health and mental illness. This work must continue. 

All views are Ahona Guha’s own.

This article was first published in the print edition of The Saturday Paper on June 25, 2022 as "Long road to mental health".

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Ahona Guha is a doctor of clinical and forensic psychology and a writer from Melbourne.

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