CHAPTER 1

Mental health care

in Australia
LEA RN IN G OBJE CTIVE S

This chapter will:

1.1 define the major terms and concepts used in the delivery of mental health care in Australia
1.2 describe the effects of stigma on people with mental health problems
1.3 discuss notions of ‘care’ and ‘caring’
1.4 explain the context of care in Australia
1.5 outline the prevalence and impact of mental illness in Australia
1.6 describe the most common mental health issues that health professionals in Australia will encounter.
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 Introduction
All health professionals in Australia, across the full range of health care settings, will encounter
people with mental health issues. This is because mental health and substance use disorders
account for 12 per cent of the total burden of disease in Australia, ranking third for morbidity
and mortality after cancer and cardiovascular disease (Australian Institute of Health and Welfare
[AIHW] 2016b). Around 45 per cent of Australians aged 16–85 years have or will experience a
mental health or substance use problem in their lifetime (AIHW 2015a). Moreover, mental health
and substance use disorders are the main causes of disease burden in younger people (AIHW 2016a).
It is therefore vital that all health professionals have an understanding of how to help the person
with a mental illness.
This text introduces health professionals to the specialty field of mental health, and describes how
mental health services are delivered in Australia today. The text provides a useful resource for health
professionals who work in general health settings and also for students of the health professions. It gives
an overview of the core skills and knowledge required by health professionals to support people who are
affected by mental illness, regardless of where they live in Australia. While there are many differences
between the states and territories in relation to mental health policy frameworks, legislation, practice
approaches, and use of terminology, there are also enough similarities to enable health professionals
nationwide to work together to improve mental health outcomes for all.
This chapter focuses specifically on the frameworks that guide the delivery of mental health services
in Australia. It commences with definitions of the terms ‘health professional’, ‘mental health’, ‘mental
ill‐health’, ‘mental illness’ and other key terms that are often used in the field of mental health. Also
considered is the power of language, together with the impact of stigma on people who are affected by
mental health problems. Another important focus is the notions of care and caring, including the context
of care in Australia — a discussion that sets the scene for an outline of the prevalence of mental illness
in Australia; together with descriptions of the most common mental health problems encountered by
health professionals in all settings.

UPON REFLECTION

Physical, social and emotional wellbeing

The close links between mental health, physical health, and social and emotional wellbeing support the
saying that ‘There is no health without mental health’.

QUESTIONS
1. What are three things you already know about mental health and mental illness?
2. What are three things you would like to learn about mental health and illness?
3. What are three things you would like to change in your professional practice to foster a more
comprehensive approach to delivering health care?

1.1 Definitions
LEARNING OBJECTIVE 1.1 Define the major terms and concepts used in the delivery of mental health
care in Australia.
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Health professionals often work in multidisciplinary teams. The multidisciplinary team in the health
context consists of a wide range of personnel, each with their own professional or regulatory standards
and requirements, who work together to deliver systematic and comprehensive treatment and care to those
in need (Moser, Monroe‐DeVita & Teague 2013). This systematic and comprehensive care encompasses
all aspects of personhood — for example, the behavioural, biological, cultural, educational, emotional,

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 environmental, financial, functional, mental, occupational, physical, recreational, sexual, spiritual and
social aspects of who we are. The range of disciplines or fields of health includes:
•• ambulance officers and paramedics
•• counsellors
•• dietitians and nutritionists
•• Indigenous health workers
•• medical practitioners
•• midwives
•• nurses, including enrolled and registered nurses, and nurse practitioners
•• occupational therapists
•• pastoral workers and chaplains
•• pharmacists
•• physiotherapists
•• psychologists
•• social workers.
Each of these disciplines has an important role to play in the delivery of health care.
For example, paramedics are frontline health professionals who provide emergency or life‐saving
health care, and other unscheduled care, out‐of‐hospital and in the community. This includes stabilising
a person’s health condition for or during transport to hospital. Paramedics often work with ambulance
officers and specialise in medical emergencies and the management of high acuity patients.
Another important group of health professionals is social workers, who are committed to pursuing
social justice, enhancing quality of life and developing the full potential of individuals, groups and com­
munities. In view of the importance of the social determinants of health in influencing the health out­
comes of people and communities, the role of social workers in the multidisciplinary team is essential.
Occupational therapists support the person to attend to their own everyday needs and preferences
(often referred to as ‘functional needs and preferences’) as well as participate in meaningful activities.
Enabling people to be independent and self‐sufficient is integral to supporting good health in our society.
Occupational therapists also work with families, groups and communities, and are becoming increas­
ingly involved in addressing the effects of social, political and environmental factors that contribute
to the exclusion of people from employment. This is in addition to facilitating the personal, social and
recreational activities in which a person would like to become involved.
Other health professionals include counsellors, dietitians or nutritionists, Indigenous health workers,
pastoral workers and chaplains, pharmacists and physiotherapists. Each of these health professionals
play a significant role in delivering health care to people with mental health issues. The roles of these
health professionals will vary according to the scope of practice of each profession, and can range from
crisis or emergency care, to brief consultation or ongoing support. Whatever their scope of practice,
all health professionals will require some understanding of what is required to help the person who is
affected by symptoms of mental illness.
In the field of mental health, there are a number of health professionals with quite specific roles, and
this can sometimes be confusing. For example, many people are uncertain about the difference between
a psychiatrist and psychologist. A psychiatrist is a medical practitioner who has undertaken additional
study and acquired a very high level of expertise in the diagnosis and treatment of mental illness.
A particular focus of the care and treatment provided by a psychiatrist — like all medical practitioners
— is the physical or biological aspects of a person’s illness. A psychiatrist can prescribe medications and
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admit a person to a hospital. Some psychiatrists have also been trained to provide psychotherapy or other
forms of psychological therapy.
In contrast, psychologists and clinical psychologists have been trained to provide psychological inter­
ventions or therapies for people. The focus of psychologists and clinical psychologists is the cognitive
and behavioural aspects of a person. While both the psychologist and clinical psychologist can pro­
vide therapy, the clinical psychologist holds a master’s degree in clinical psychology, which means that

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 they can provide interventions that are more complex than psychologists. Neither the psychologist nor
clinical psychologist, however, can prescribe medication or admit a person to a hospital.
The most common health professional in the field of mental health is the nurse. Some people are
confused by the different types or levels of nursing and para‐nursing roles, which include assistants
in nursing, enrolled nurses, registered nurses and nurse practitioners. Each of these categories has a
different educational requirement and scope of practice. Nurses who work in the field of mental health
are sometimes called psychiatric nurses, but ‘mental health nurse’ is the preferred terminology. This
is because ‘psychiatric’ has biomedical connotations and a nurse’s scope of practice is far wider than
biomedicine alone. Generally, nurses provide care to people, around the clock, to help address the many
different needs and preferences of the person. The approach of the nurse is defined by holism, encom­
passing all aspects of personhood, not just the physical needs.
The term ‘mental health nurse’ is often used to describe the nurse, enrolled or registered, who works
in a mental health‐related field. However, the Nurses and Midwifery Board of Australia (NMBA), the
regulatory authority for nurses and midwives that is part of the Australian Health Practitioner Regulation
Agency (AHPRA), has no special category for ‘mental health’ or ‘psychiatric’ nurse. The Australian
College of Mental Health Nurses — the national professional body for mental health nursing — admin­
isters a credential for registered nurses who hold a specialist postgraduate qualification and can demon­
strate substantial and current experience in the field of mental health, as well as ongoing professional
development. Credentialed mental health nurses are often leaders in public mental health services, as
well as the defence health and justice health systems; and can work as autonomous practitioners in the
primary health care context, providing care to people with complex symptoms of mental illness.
Just as important to the multidisciplinary team are the support workers, including peer workers, who
are employed by community managed organisations to provide counselling, social and recreational sup­
port, housing and accommodation support, assistance to obtain employment, and opportunities for edu­
cation. As explained later in this text, there are many different social determinants of mental health
and illness. Health professionals do not work in a vacuum. With one in five Australians experiencing
symptoms of mental illness at some stage in their lives, the delivery of high quality mental health and
support services has become an increasingly important focus for governments and communities alike.
There is a need, then, for health professionals, regardless of discipline or specialty, to develop a greater
understanding of mental health and illness, as well as the diverse members of the multidisciplinary team
who deliver services to people with mental illness, and thereby enable the best possible outcomes for
those in need.

Mental health and mental illness

The term ‘mental health’ has different meanings for different people in different contexts. In Australia,
the field of mental health describes an area of health care that focuses on the psychological, emotional
and behavioural wellbeing of the population. With the development and implementation of the National
Mental Health Strategy in the early 1990s, governments across Australia, at the national and state or
territory levels, joined together to define mental health as the capacity of individuals and groups to
interact with one another and their environment in ways that promote subjective wellbeing, optimal
development and use of mental abilities (cognitive, affective and relational); and to achieve individual
and collective goals consistent with justice (Australian Health Ministers 1991). This national definition
has remained unchanged over the years.
Mental ill‐health is most commonly referred to as mental illness or disorder in Australia. According
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to the Australian government, a mental illness is a health problem that significantly affects how a person
feels, thinks, behaves and interacts with other people (Australian Government 2013). Mental illness
is diagnosed according to standardised criteria, such as that provided by the DSM‐5 or ICD‐11 (the
chapter that looks at assessment in the mental health context has futher information). One reason the
term ‘mental illness’ is so commonly used to describe a mental health problem is because the Australian
health system continues to be dominated by the biomedical approach to treatment and care.

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 A mental health problem also interferes with how a person thinks, feels, and behaves, but to a lesser
extent than a mental illness (Australian Government 2014). Mental health problems are more common
and less severe than mental illnesses or disorders, and include the mental ill‐health that can be experi­
enced temporarily as a reaction to the stresses of life. A person with a mental health problem may
develop a more severe mental illness if they are not supported effectively (Australian Government 2014).

THE BIG PICTURE

The mental health of first responders

Many first responders (such as those who work
in ambulance and paramedicine services, fire
and rescue services, police forces and state
emergency services) are involved in or witness
traumatic events. Over time, this may affect
the mental health of the first responders. The
mental health issues experienced may include
depression, anxiety, post‐traumatic stress dis-
order, relationship difficulties, alcohol and/or
substance abuse, and suicidal thoughts.
Heads Up, or the Mentally Healthy Workplace
Alliance (www.headsup.org.au), is sponsored by
a range of organisations, including the Australian
government and beyondblue, to support the
development of mentally healthy workplaces, across Australia. This includes helping managers to develop
an action plan aimed at creating a workplace that supports the mental health of employees. It also in-
volves helping employees to take responsibility for their own and their colleagues mental health, and
educating employees on how to have a conversation with colleagues who they may be worried about.
The Good Practice Framework for Mental Health and Wellbeing in First Responder Organisations has
been developed by Heads Up to enable first responder organisations to support the mental health and
wellbeing of their employees. All health professionals are encouraged to read this handbook and consider
how they can better help first responders to manage their levels of stress.
Another set of guidelines for first responders has been developed by the Black Dog Institute
(www.blackdoginstitute.org.au), an Australian not‐for‐profit organisation, which has become a leader in
research related to the diagnosis, treatment and prevention of mood disorders such as depression and
bipolar disorder. The Black Dog Institute joined forces with a number of universities, as well as the Centre
for Posttraumatic Mental Health and St John of God Hospital, to develop Expert Guidelines in the Diag-
nosis and Treatment of Post‐Traumatic Stress Disorder in Emergency Service Workers. These guidelines
have been developed to improve the support given to emergency workers who report ongoing psycho-
logical consequences from exposure to trauma.
These guidelines provide good preliminary resources for health professionals who work with first re-
sponders. Health professionals are encouraged to familiarise themselves with the principles involved in
helping those who experience traumatic events in the course of their work.

Biomedical approaches to health care

The biomedical perspective evolved after the Age of Enlightenment, a period which began in the late
seventeenth century, ended in the late eighteenth century, and was characterised by the advancement of
Copyright © 2017. Wiley. All rights reserved.

scientific knowledge. The Age of Enlightenment saw the development of the ‘rational’ explanation of
health and illness. Supported by the theories of the French philosopher, René Descartes, the body was
viewed as a material object that could be understood only by scientific study and physical examination
(Berhouma 2013). In contrast, the mind was posited as part of a higher order, understood through intro­
spection. As such, the body and mind were separated into two distinct entities, with illness considered as
either somatic (physical) or psychic (mental) (Hamilton & Hamilton 2015). This philosophy paved the

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 way for the development of an area of science now known as biomedicine, which focuses on the somatic
or physical aspects of illness (Colborne & MacKinnon 2003).
Today, the biomedical approach to the treatment of illness is viewed by many as a paternalistic or
vertical approach to health care. It involves ‘expert’ health professionals assessing the symptoms of a
person, making a diagnosis and devising treatment based on their scientific knowledge of the disease
process. In turn, the unwell person follows the directions provided by the expert health professional to
achieve a reduction in the severity of their symptoms (Deacon 2013). The biomedical approach focuses
on cause (disease or condition), effect (illness or deficiency), treatment (pharmacological, surgical and
rehabilitative) and outcome (cure or disability) (Mehta 2011).
Psychiatry is the branch of biomedicine that specialises in the treatment of mental illness. A person
is diagnosed by a psychiatrist according to the way in which the symptoms, which are reported by the
person and/or observed by the psychiatrist, fit a set of predetermined criteria (e.g. DSM‐5 or ICD‐11).
Diagnoses range in type and degree of severity, and can include depression, anxiety, substance use dis­
order, psychosis, schizophrenia and dementia. Upon diagnosis, the person is prescribed medication and
often advised to participate in one or more of the psychological therapies. If appropriate, electroconvul­
sive therapy may also be recommended. Once the person responds to this treatment regimen, they are
discharged from care.
The dominance of the biomedical model in the field of mental health has given rise to terminology
that is likewise dominated by notions of disease or pathology. Consequently, the concepts of health and
wellness often take second place to those of ‘disorder’, ‘dysfunction’, ‘illness’, ‘deviancy’ or ‘abnor­
mality’. Language used in the mental health setting is also influenced by the legislative frameworks in
place across Australia. For example, the terms ‘mental illness’, ‘mental disorder’ and ‘mental dysfunction’
are defined in different ways, according to the mental health legislation of each of the states and territo­
ries across Australia. This language use creates a degree of tension for health professionals who are com­
mitted to working within a framework of health and wellness, as they find themselves moving between the
notions of health and illness or wellbeing and dysfunction. The contradictory language use also explains
a common misunderstanding, that is, that the term ‘mental health’ now replaces, or is sometimes synony­
mous with, the term ‘mental illness’. Frequent errors in using the term include the following.
•• ‘The person has mental health; she is hearing voices’, rather than the more appropriate ‘The person
may have a mental health problem; she is hearing voices’.
•• ‘The consumer has been diagnosed with mental health’, rather than the more appropriate ‘The con­
sumer has been diagnosed with a mental illness’.
To maintain their authenticity, health professionals are encouraged to familiarise themselves with the
most appropriate and current usage of relevant terms in the mental health sector. This is important in
light of the substantial power and influence of language in our society today.

The power of language

Various philosophers have discussed how language plays a crucial role in framing, informing, devel­
oping and maintaining social relations (e.g. Fairclough 1989; Foucault 1961; Goffman 1967). Language
shapes or interprets the way people see the world; it is also used to define or describe personal experi­
ences or situations. Language has the power to persuade, control and even manipulate the way people
think, act and react (Leventhal 2016).
For these reasons, language must be used carefully. When working within a health and wellness frame­
work, one of the core aims of the health professional is to inspire hope in others (Sælør et al. 2015). This
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includes helping a person to focus on their strengths and abilities, rather than their deficiencies or dis­
abilities. One way to inspire hope is to employ language that empowers rather than disempowers. This
often requires health professionals to make the conscious choice to use one word over another.
For example, it is generally understood that the word ‘patient’, in the health context, signifies a person
who is being attended to by a health professional. This is because the word has a long history of associa­
tion with medical practitioners and hospitals. Notions of ‘patient’ have also been connected with ideas of

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 passivity (i.e. a patient is a diseased or disabled person who is being treated by an active and expert health
professional). In this way, the word ‘patient’ sets up ideas of disempowerment, with health professionals
positioning themselves as authorities and the patients taking a more subordinate role. It is this unequal rela­
tionship that has led to the development of alternative terms, including ‘client’, ‘consumer’, ‘service user’ or,
quite simply, ‘person’, when referring to individuals who seek assistance from a health professional.
In this text, the word ‘person’ is the preferred signifier for someone who is being cared for by a health
professional. This choice was made because the word serves to normalise the process of giving and
receiving help or assistance. At other times, the terms ‘patient’, ‘consumer’, ‘service user’ or ‘client’ are
also used. This is because people in the clinical context who require assistance for physical or mental
health issues are referred to in a variety of ways, therefore use of the different terms in this text reflects
the clinical context.
Similarly, health professionals are referred to in a number of different ways throughout the text.
The term ‘health professional’ has already been defined. Other similar terms employed in this text
may include ‘clinician’, ‘health care professional’, ‘personnel’, ‘practitioner’, ‘staff member’ or, again,
‘person’. Use of a variety of names reflects the diversity in our health system. It also reflects a desire to
be inclusive and avoid labels.
Indeed, health professionals are encouraged to examine the way in which language can be utilised to
label or stereotype people. Such stereotypes are often derived from misperceptions or ‘myths’ about a
particular (often minority) group of people. For people with a mental illness, the most common myths
that health professionals will encounter in Australian society are outlined in table 1.1.

TABLE 1.1 Myths about mental illness

Myth: mental illness is a life sentence

Facts
• There are many different kinds of interventions available to support people with mental health problems.
Some of these interventions involve medications; others focus more on helping the person to address the
psychological and social issues they may be experiencing.
• The earlier a person receives help for a mental health problem, the better their outcomes.
• There is no reason why people with mental health problems cannot live full and productive lives.
• Many people experiencing mental health problems delay seeking help because they fear stigma and
discrimination. Reducing stigma will encourage more people to seek help early.
• Most people with mental health problems are treated in the community by their general practitioners (GPs).

Myth: mental illnesses are all the same

Facts
• There are many different mental health problems, each with different symptoms.
• Each mental illness has its own particular set of symptoms, but not every person will experience all of these
symptoms. For example, some people with schizophrenia may hear voices, but others may not.
• Simply knowing a person has a mental illness will not tell you about their own, unique experiences of that
illness.
• Mental health problems are not just ‘psychological’ or ‘all in the mind’. While a mental health problem may
affect a person’s thinking and emotions, it can also have physical effects such as insomnia, weight gain or
loss, increase or loss of energy, chest pain and nausea.

Myth: some cultural groups are more likely than others to experience mental illness

Facts
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• Anyone can develop a mental health problem; no one is immune to experiencing a mental illness.
• Many people from culturally and linguistically diverse and refugee backgrounds have experienced torture,
trauma and enormous loss before coming to Australia. These experiences can cause significant psychological
distress, which predisposes these people to develop mental health problems.
• Cultural background affects how people experience mental health problems and also how they understand
and interpret their symptoms.

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 TABLE 1.1 (continued)

Myth: people with a mental illness are violent

Facts
• Research indicates that people who receive treatment for a mental illness are no more violent or dangerous
than the general population.
• People living with a mental illness are more likely to be victims of violence (especially self‐harm). It has been
calculated that the lifetime risk of someone with an illness such as schizophrenia seriously harming or killing
another person is only 0.005 per cent, while the risk of that person harming themselves is nearly 10 per cent.
• There does seem to be a weak statistical association between mental illness and violence. This assertion is
concentrated in certain subgroups, for example, people not receiving treatment who already have a history
of violence, and people with substance abuse issues. However, the association between mental illness and
violence is still weaker than the association between violence and alcohol abuse in general, or between
violence and being a young male between 15 and 25 years of age.

Source: Adapted from Hunter Institute of Mental Health (2014)

In the field of mental health, stereotyping or labelling can have quite negative consequences. It is
important, then, to acknowledge that those who experience symptoms of mental illness are people
first, and their symptoms or conditions are of secondary importance. Outdated descriptors such as
‘schizophrenic’, ‘the mentally ill’, ‘mentally ill person’ or ‘mental institution’ are viewed as unhelpful,
even counterproductive. Instead, health professionals are encouraged to use language such as:
•• a person who is experiencing symptoms of schizophrenia
•• a person with schizophrenia or living with schizophrenia
•• a person who is receiving help for their mental health issue
•• a mental health facility or unit.
Fostering the use of constructive language is one way that health professionals can help to manage the
stigma that is experienced by people with mental health issues. Stigma and its outcomes are the focus of
the next section of this text.

1.2 Stigma
LEARNING OBJECTIVE 1.2 Describe the effects of stigma on people with mental health problems.
Seminal philosopher Goffman (1967) defined social stigma as the social disapproval, overt or covert, of per­
sonal characteristics, beliefs, behaviours, or conditions that are perceived by a society to be at odds with
social or cultural norms. Stigma is a social reality that works to discriminate between those who are accepted
as ‘insiders’ and those who are rejected as ‘outsiders’ (Webster 2012). Stigma makes a clear distinction
between ‘us’ as ‘normal’ and ‘them’ as ‘deviant’ — with the latter marginalised or ostracised accordingly.
There are many examples of groups that have experienced social stigma over the centuries. These
examples include those who belong to a minority cultural group or ethnicity, have diverse sexual prefer­
ences or expressions of gender, or have a mental illness or a disability (Carman, Corboz & Dowsett 2012).
Other examples of social difference that can lead to social marginalisation include contagious or trans­
mittable diseases (e.g. leprosy, HIV/AIDS), a criminal conviction, an unemployed status, an eating dis­
order or an addiction to alcohol or illicit drugs (Mannarini & Boffo 2015; Thomas & Staiger 2012).
There is evidence globally that some progress has been made to reduce stigma and change the ways
in which people who experience symptoms of mental illness are perceived (Meier et al. 2015). These
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changes are partly due to developments in pharmacology, together with other treatment interventions
that have brought about a marked improvement in outcomes for people who experience symptoms of
mental illness. Changed attitudes have been achieved through the progress made by the global human
rights movement and evolving socio‐cultural perceptions of how minority groups should be treated. In
Australia, improved community perceptions have resulted from work that has been undertaken by pri­
mary health care organisations such as beyondblue, SANE Australia, and the headspace National Youth

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 Mental Health Foundation. The roles of these community managed organisations include supporting
people with mental health issues to live in the community, while also educating the community about
mental illness. (The chapter that focuses on mental health service delivery has further information.)
Although such progress and associated community initiatives are to be commended, there is always
room for improvement. For example, Buys, Roberto, Miller, and Blieszner (2008) suggest that depression
caused by physical pain or illness is more socially acceptable in Australia than depression resulting from
emotional concerns. Similarly, depression is a more acceptable diagnosis than psychosis (Reavley & Jorm
2011). Questions also remain about the community perceptions of people who experience symptoms of psy­
chosis, especially when linked to the misuse of illicit drugs and alcohol. Questions to consider include: is
it more acceptable in Australia to be diagnosed with a psychosis of an unspecified origin or a drug‐induced
psychosis? Health professionals are wise to reflect upon such questions in light of their clinical practice.

Community attitudes
People with mental health problems continue to be stigmatised in and by the community through their
misrepresentation in the news and entertainment media (Whitley & Berry 2013). Perhaps most con­
cerning is the suggestion that people with a mental illness are the main perpetrators of violent crime in our
community. As already noted, this is a representation that is statistically inaccurate (Hodgins et al. 2011;
Short et al. 2013). Vendsborg, Nordentoft, and Lindhardt (2011) argue that the major determinants of
violence are socio‐demographic and economic, with substance abuse the most significant indicator. Yet,
people with a mental illness continue to be caricatured as, for example, a maniac on a killing spree, a
free‐spirited rebel, a narcissistic parasite, or victims of mind games played by psychopaths (e.g. Psycho,
One Flew Over the Cuckoo’s Nest, Silence of the Lambs, Shutter Island) (Ramchandani 2012; TNS
Research International 2010). Certainly there are exceptions to such representations. For example, in the
movie A Beautiful Mind, a man with a serious mental illness is portrayed quite sympathetically. Signif­
icantly however, a feature of this and similar movies is that the protagonists have genius‐like attributes
in addition to their mental illness, thereby suggesting that mental illness is acceptable only if the person
has other exceptional qualities to compensate for the mental illness.
Media representations reflect and also perpetuate community values and attitudes: journalists construct
the community in a particular way, and community members generally understand media representations
as ‘the way things are’ (Dale et al. 2014). This has significant ramifications for people with a mental ill­
ness. For example, misrepresentations work to dehumanise, marginalise and isolate people with mental
health issues. Although changes in community attitudes are evident, it would seem the fundamental
problem remains — people with mental health issues continue to be stigmatised by the community.

IN PRACTICE

Stigmawatch: keeping an eye on

the media
SANE Australia is a national charity working for
a better life for people affected by mental illness,
through campaigning, education and research.
SANE’s StigmaWatch program (www.sane.org/
stigmawatch) responds to community concern
about media stories, advertisements and other
representations that may stigmatise people with
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mental illness or inadvertently promote self‐harm or

suicide. StigmaWatch also provides positive feed-
back to the media where they have produced accu-
rate and responsible portrayals of mental illness
and suicide.

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 StigmaWatch follows up on reports submitted by hundreds of ‘StigmaWatchers’ — ordinary
Australians, people with mental health problems and their families, health professionals — who are con-
cerned about how the media depict mental illness and suicide.
StigmaWatch reviews these reports against the guidelines developed by the Australian Government’s
Mindframe National Media Initiative. Should StigmaWatch find that a media story is stigmatising, inac-
curate or irresponsible, it will raise these concerns with the media outlet or journalist responsible and
encourage them to revise or withdraw the article. StigmaWatch also provides advice on how to safe-
guard against future media coverage that may stigmatise mental illness and suicide. This is essential
in light of the changing media landscape, including online resource and entertainment, social media
channels.

QUESTIONS
1. The terms ‘fruitcake’, ‘nutter’ or ‘psycho’ are often used colloquially to describe people who experience
mental health problems. Discuss the effects of such labels on people with mental illness, their families,
and also on communities as a whole.
2. Over the next week, record the number of times that you hear family members, partners, friends,
colleagues, or people in the community, on television or in films use words with a negative connotation
to describe mental illness. As a health professional, what can you do to discourage this kind of
communication?

The impact of the stigma associated with mental illness is considerable — it includes reduced options
for employment, obtaining accommodation, and socialising, as well as personal distress and low self‐
esteem (Evans‐Lacko et al. 2013). Self‐stigma is also a problem. For example, people with mental health
issues may sometimes view themselves in a negative light. This results in diminished self‐esteem and
self‐efficacy (Thornicroft et al. 2012). Additionally, stigma may lead to people with symptoms of mental
illness feeling reluctant to disclose their symptoms and/or postponing seeking help.
As a means of supporting the reduction of stigmatising attitudes in our community, the Australian gov­
ernment has legislated to protect the rights of minority groups. When stigma is acted upon and a person
is treated differently because they have a mental illness or other disability, they are experiencing dis­
crimination. In Australia, such discrimination is unlawful under the Disability Discrimination Act 1992
(DDA). According to Webber et al. (2013), discrimination against people with a mental illness is one of
the biggest obstacles to people receiving effective care and treatment. Health professionals are encour­
aged to familiarise themselves with the DDA and model the principles it upholds. This is an important
means by which prevailing community attitudes can be challenged.
Indeed, health professionals are in a prime position to assist with the process of bringing about change.
This suggests the importance of health professionals understanding the impact of social stigma on the
life of a person, including their level of education, employment, income, housing, community involve­
ment and, ultimately, health. By speaking out against stigma, educating the community and advocating
for the person with mental health issues, health professionals can assist to break down the barriers.
These barriers include the stigma that is evident within the health professions themselves.

Attitudes of health professionals

Sadly, the negative attitudes towards people who experience symptoms of mental illness are also evident
Copyright © 2017. Wiley. All rights reserved.

within the health professions (Reavley et al. 2014). For example, notions of ‘guilt by association’ often
mean that mental health professionals experience stigma (Verhaeghe & Bracke 2012). Negative attitudes
are expressed by other health professionals through expressions such as ‘I could never work in mental
health!’, ‘Everyone who works in the field of mental health gets assaulted!’, ‘You have to be mad to
work in mental health’ or ‘Don’t go and work in mental health, you’ll lose your clinical skills!’ Such
comments are based on stereotypes rather than research evidence. Moreover, the comments provide one

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 possible reason for the difficulty experienced nationally in recruiting health professionals to work in the
field of mental health (Kopera et al. 2015).
Also alarming are the attitudes and behaviours of a small number of health professionals when inter­
acting directly with people with a mental illness. Some of these attitudes and behaviours have been
identified as:
•• talking about consumers rather than to consumers
•• putting down and ridiculing consumers
•• failing to provide information to consumers to enable them to make informed decisions
•• failing to provide appropriate or respectful services
•• failing to respect the information shared with the service by family members
•• perpetuating negative stereotypes (Hansson et al. 2013; Kopera et al. 2015).
Significantly, these attitudes and behaviours are not confined to the Australian context; they are evi­
dent in countries across the globe and encompass a range of health professions, including medical
practitioners, nurses, allied health professionals and students (Chien, Yeung & Chan 2012; Hansson
et al. 2013).
In light of this situation, it is essential that health professionals understand the issues involved, in
particular the way in which stigmatising attitudes and behaviours influence the empowerment and
disempowerment of people with mental illness (Ryan, Baumann & Griffiths 2012). Specifically, the
research evidence suggests that many health professionals feel threatened or challenged by notions of
empowerment for consumers (O’Reilly, Bell & Chen 2012). This includes health professionals taking
actions such as:
•• removing the personal freedoms of the person with a mental health problem
•• forcing people with a mental illness to take medication against their will
•• deciding which aspects of treatment and care will or will not be provided to the person without con­
sulting them
•• making decisions about a person’s ‘best interests’ without consulting them
•• using language and terminology that alienates or excludes the person who is experiencing symptoms
of mental illness (Barrenger, Stanhope & Atterbury 2015; Sweeney et al. 2015).
There is a need, then, for each and every health professional to take responsibility, self‐examine,
and identify their personal attitudes towards, or perceptions of, people with mental health problems.
This process of self‐examination or self‐reflection must include consideration of the value placed by
people with mental illness on health professionals who take non‐paternalistic, respectful and inclusive
approaches (Valenti et al. 2014). There is also a need to:
•• consider the unique situation of each consumer
•• be aware of the insidious, even seductive nature of the power that can be wielded by health pro­
fessionals over vulnerable people, including those who are unwell
•• adapt and adjust professional responses to people with a mental illness based on the insights gained.
Questions health professionals may ask themselves as they reflect could include, ‘How do I view
people with a mental illness?’ and ‘How do these attitudes and perceptions impact upon my professional
practice?’ Answering these questions honestly will assist the health professional to become a practitioner
with high levels of self‐awareness.
Indeed, fostering self‐awareness is necessary for all health professionals. It is only through self‐
awareness that health professionals can address issues that may impede their capacity to:
•• build and maintain an effective therapeutic alliance or relationship
Copyright © 2017. Wiley. All rights reserved.

•• collaborate with consumers and their carer or families

•• support the development of coping strategies for people with mental health issues
•• facilitate the Recovery journey and best possible long‐term outcomes for mental health consumers.
Acquiring the skills to self‐reflect and foster self‐awareness will, in turn, enable health pro­
fessionals to more effectively assist the many people in Australia who experience symptoms of
mental illness.

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 UPON REFLECTION

Reflective practice
Reflection is the examination of thoughts and actions. Health professionals can reflect on their practice
by focusing on how they interact with their colleagues and the environment in which they work. Reflec-
tive practice is a process by which health professionals can become more self‐aware, build on their
strengths, work on their weaknesses and take action to change the future. Health professionals from a
range of disciplines participate in reflective practice, including allied health, first responders, midwives
and nurses (Oelofsen 2012; Turner 2015).

QUESTIONS
1. Reflection‐in‐action involves considering events that have occurred in the past. Identify an event in
which you were involved where a person with a mental illness was stigmatised. What could you have
done differently?
2. Reflection‐in‐action involves considering events, including your own behaviour(s) and the behaviour
of others, as they occur. What techniques could you use, as a health professional, to develop
reflection‐in‐action?
3. Critical reflection involves uncovering our assumptions about ourselves, other people, and the
workplace. What techniques could you use to critically reflect on your assumptions and attitudes
towards people with a mental illness?

1.3 A focus on caring

LEARNING OBJECTIVE 1.3 Discuss notions of ‘care’ and ‘caring’.
In light of a context that is characterised by negative attitudes towards people with a mental illness, as a
health professional, what does it mean to ‘care’? With the many advancements that have been made in
science and technology, as well as research and evidence‐based practice, is ‘caring’ a construct that is
relevant to the delivery of health services today? These are important questions for health professionals
to consider, with the delivery of health care in Australia is driven by a demand to meet key performance
indicators (KPIs) and collect empirical data to inform evidence‐based practice (Nowak 2012; Shields
2012). In this context, ideas of care and caring can sometimes be forgotten.
Interestingly, precise definitions of the terms ‘care’ and ‘caring’ are lacking in the health context. For
example, care is both a noun and a verb — it is a feeling or attitude, such as concern; and it involves
action or activity, such as attending to a person (Ranheim, Kärner & Berterö 2012). Care can be under­
stood as a way of being and also a way of behaving (Leininger 2012a). Despite these differences, it is
often presumed that an understanding of the notion of caring ‘comes naturally’ to health professionals
(Alpers, Jarrell & Wotring 2013). For example, by virtue of choosing to work in the field of health,
a health professional may be described as a caring person. However, the nature of health care in the
twenty‐first century means that health professionals will practise, intervene, treat, manage, assist and
support, engage in therapy or deliver a service (Hogan & Cleary 2013). Efficiency and effectiveness are
the name of the game. This raises the question: where does care and caring fit? Answers to this question
in part lie with the history of caring.

History of caring
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Different disciplines have developed different knowledge bases to explain what it means to provide care.
For example, health professionals who work in the field of nursing have a long tradition of providing
care, developed from the work undertaken as far back as Florence Nightingale in the mid‐1800s. Caring
theorists Peplau (1952, 1991) and more recently Barker (2009) have built on this work, describing the
notion of caring as both a science and an art; that is, caring comprises a set of evidence-based technical
skills as well as personal qualities such as sensitivity, giving respect and accepting others.

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 From a multidisciplinary perspective, the seminal philosopher Heidegger (1962) described ‘caring’
as a universal phenomenon that influences the way people think, feel and behave in relation to one
another. Almost 20 years later, in the health context, commentators such as Ray (1981) identified four
ways of thinking about ‘caring’:
1. psychological care
2. practical care
3. interactional care
4. philosophical care.
In so doing, the notion of care is constructed as both a theoretical framework and an approach that is
taken by health professionals to improve the levels of a person’s physical and mental health, as well as
their ability to function on a day‐to‐day basis.
A decade later, Morse, Bottorff, Anderson, O’Brien and Solberg (1991) went on to suggest five cate­
gories of caring:
1. a human trait
2. a moral imperative
3. an effect or outcome
4. an interpersonal interaction
5. a therapeutic intervention.
This view of caring suggests much more than the demonstration of concern for a person or even
attending to that person. It is a view that also involves knowledge, thinking, planning, implementation
and evidence of effectiveness. At the same time, the categories of interpersonal interaction and thera­
peutic intervention suggest that caring has a very personal focus.
It is perhaps for this reason that Dyson (1996) linked caring to the personal qualities of knowing,
patience, honesty, trust, humility, hope and courage. Watson (1988) likewise conceptualised care and
caring as an interpersonal process between two people that protects, enhances and preserves the dignity
of the person; and enables the survival, development, and growth of all those involved. Caring, then, is a
construct that is both theoretical and practical, as well as procedural and personal.
Of particular importance is the difference noted by Leininger (1981) between general or generic
caring and professional caring. General or generic caring is learned as part of a person’s ongoing
growth and development, by way of upbringing, family background, cultural values and life experiences.
Professional caring has a more conscious and comprehensive focus, and encompasses each of the dif­
ferent dimensions of personhood. For example, health professionals care for a person’s physical and
mental health, as well as their social, spiritual and emotional wellbeing.
This view has been supported by other researchers across the years. Of particular importance are sugges­
tions that, while feelings of concern and the act of attending to a person hold a significant place in the delivery
of health services, they are unlikely to be therapeutic unless the person providing the care is competent or
proficient (Barker & Reynolds 1994; Leininger 2012b). For health professionals, then, health care and caring
involves specific knowledge and skills, as well as attitudes and action. This is because proficient and pro­
fessional care and caring has a context and purpose: supporting better health outcomes for all.

Aims of care and caring

In the broad sense, the aim of all health care is to improve health outcomes (World Health Organization
1986). More specifically, in Australia an important aim of delivering a mental health service is consumer
participation. This aim is in line with national strategic direction (Commonwealth of Australia 2005,
Copyright © 2017. Wiley. All rights reserved.

2009); and also with the growing influence of the consumer movement (Hunt & Resnick 2015; Adams &
O’Hagan 2012).
Care and caring in the professional sense will always be influenced by the aims of its delivery, and
these aims will depend upon the context of the care and caring. The health care context is complex
and comprises many relational and environmental factors (Dewar & Nolan 2013; Ranheim, Kärner &
Berterö 2012). This includes the structures and settings created by the organisation that is providing the

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 service, the type of service delivery, the knowledge base and approach of the health professional pro­
viding the service, together with the needs and preferences of the person(s) receiving the care (Wright &
Chokwe 2012).
In turn, each of these contextual aspects is multifaceted. For example, the context of the person who is
receiving care will comprise many aspects of personhood including the behavioural, biological, cultural,
educational, emotional, environmental, financial, functional, mental, occupational, physical, recreational,
sexual, spiritual and social. Consequently, health professionals must change or adapt their practice to
meet the very specific needs and preferences of each of the people they help. This suggests why there is
no one‐size‐fits‐all approach to the delivery of care. Rather, the type of care delivered must be flexible
enough to fit the needs and preferences of the person it serves.

Definitions of ‘care’ and ‘caring’

In light of the history, context and purposes of delivering health care, in this text the terms ‘care’ and
‘caring’ are understood as a collaborative process that occurs between health professionals and a person
or persons to achieve mutually agreed upon objectives. Care and caring are delivered in a systematic way
by health services to support people and improve health outcomes. Care and caring is also an attitude
and set of actions demonstrated by competent health professionals in the course of their work (Alpers
et al. 2013; Holttum 2015). The best health care and caring is consumer‐centred and person‐focused;
that is, it is delivered according to each person’s individual needs, preferences and choices.
Interestingly, research has identified a marked difference between the activities that consumers
identify as the most important to them when they receive care, and the activities that health professionals
identify as the most important for consumers (Leininger 2012a; Suserud et al. 2013). For example, con­
sumers often report that they remember the kindness exhibited by a health professional, while health
professionals tend to be more focused on providing effective clinical interventions as efficiently as poss­
ible. These differences suggest that consumers must always be given the opportunity by the health pro­
fessional to express their preferences and make their own choices. Further, and as much as is possible
within the health service framework, health professionals must work towards supporting these pref­
erences. This is why care is often described as a process that is negotiated between the consumer and
the health professional in a process that involves caring with as well as caring for the person (Hogan &
Cleary 2013).
In any definition of care, the related competencies of the health professional must also be identified.
When helping the person with a mental health problem, these competencies include specific knowledge,
clinical skills and communication skills to:
•• engage with the person
•• actively listen to the person
•• build a relationship with the person.
Further, care requires health professionals to demonstrate an attitude of compassion and sensitivity,
a giving of self, as well as honesty and sincerity (Coffey, Pryjmachuk & Duxbury 2015; Dewar &
Nolan 2013). While these attributes are very personal, it should also be noted that, for the health pro­
fessional, they do not necessarily ‘come naturally’ in the workplace. Rather, health professionals must
develop themselves professionally so that they can provide care regardless of their reactions to a person
or situation. More detailed information on how the health professional can manage their reactions and
emotions in challenging situations is provided in the chapters focusing on common reactions to stressful
conditions, and people displaying challenging behaviours.
Copyright © 2017. Wiley. All rights reserved.

Finally, while there is no doubt that technology is important to the delivery of health services in
Australia today, it is the health care itself that ensures the humanity of these health services. Essentially,
it is in the very nature of people to care for others in need. Perhaps most profoundly, when competent
care and caring is delivered and people connect to and with one another, the health outcomes will speak
for themselves (Leininger 2012b). These outcomes will include an improved social and emotional well­
being of the people involved.

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 Health professionals must display competency in engaging with the person, actively listening to the person and
building a relationship with the person.

UPON REFLECTION

Care and caring

Reconsider the sentence from the previous section: ‘There is a marked difference between the activities
that consumers identify as the most important to them when they receive care, and the activities that
health professionals identify as the most important for consumers.’

QUESTIONS
1. Why do so many health professionals think that they ‘know better’ than the person who receives the
care?
2. What is the difference between the knowledge gained through university study and the understanding
gained from the lived experience of a health condition?
3. How can health professionals bridge the perceived divide between theory and lived experience of a
mental health problem, to support the notions of individual choice and preference?

1.4 Caring in the health context

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LEARNING OBJECTIVE 1.4 Explain the context of care in Australia.

All health professionals can learn from the way in which mental health care has been provided over the
years. In particular, there are quite profound lessons to learn from the many errors that have been made
when delivering services, both past and present.

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 In early colonial times, people with a mental illness were locked away from the community in ‘lunatic’
asylums. The first ‘mental institution’ in Australia was located at Castle Hill, New South Wales, from
1811 to 1825 (Evans 2013). Prior to this, ‘the insane’ were housed at either Parramatta Gaol or, in some
cases, Bedlam Point at Gladesville. Other asylums were established in each of the new colonies, around
Australia, in the years that followed (Colborne & MacKinnon 2003).
At that time, endeavours were made to provide humane treatment and there were numerous com­
missions and inquiries into reported abuses. Even so, overcrowding in institutions across Australia
meant that a predominantly custodial approach was taken to provide care of those who were ‘com­
mitted’. As a result, treatment options were limited (Evans 2013). Moreover, the focus of the treat­
ment options was often physical in nature and included straitjackets and cold baths (Coleborne &
Mackinnon 2006).
It was only after the Second World War that scientific advancement gave rise to new pharmacological
interventions that enabled better outcomes for people with a mental illness (Beer 2009). In turn, with
improved knowledge and better outcomes, came changes in the way people and societies viewed mental
health and mental illness. This included recognition that people with mental health issues had the right
to live freely in the community, and that the previously common practice of locking people away from
mainstream society, with no right of reply, was unethical.
In response, governments across the Western world began to examine the way in which health care
was delivered to people with a mental illness. In Australia, the inquiries and reports that were most influ­
ential in questioning the ethics and practices of the day included the:
•• Richmond Report (1983)
•• Barclay Report (1988)
•• Burdekin, Guilfoyle, and Hall Report (1993).
Detailed information about these reports can be found on the websites of relevant state and territory
departments of health, or the University of Sydney Index of Australian Parliamentary Reports.
The implementation of recommendations made by these and similar reports and inquiries gave rise to
huge changes to the way mental health care was delivered in Australia. These changes have included:
•• the deinstitutionalisation of mental health services
•• a decrease in the size and number of psychiatric hospitals
•• the separation of developmental disability services from mental health services
•• support for consumers to live in the community
•• the development and expansion of integrated community services or networks, including health ser­
vices, accommodation services, and other social services
•• changes in funding arrangements to support the new era in mental health service delivery (Hillingdon
2011; Loi & Hassett 2011).
The profound impact of these changes continues to be felt by many health professionals and services
in all states and territories, across Australia.
The process of deinstitutionalisation also saw the development and implementation of new mental
health legislation in Australian states and territories. While there are clear differences in the way in
which this legislation is enacted in each of the states and territories, the fundamental principles are the
same. These include:
•• protecting the human rights of people with mental health problems
•• guarding the safety of people with mental health problems, and also the safety of the community
•• ensuring that people with mental health problems are treated in the least restrictive environment
Copyright © 2017. Wiley. All rights reserved.

•• promoting individual choice of lifestyle for consumers.

By upholding these principles, health professionals will effectively support the spirit of the legislation
regardless of location.
At this point it is also helpful to note that, in line with the development of mental health legis­
lation, each of the states and territories has also developed their own legal frameworks to protect
the rights of people with disabilities (McSherry & Wilson 2015). Although this legislation was and

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 continues to be distinct from mental health legislation, it reflects many of the same principles and
ethical principles. The various types of health services available for people with a mental illness and
intellectual disability are outlined in the chapter focusing on mental health service delivery. In addi­
tion, health professionals are encouraged to seek out information on this important aspect of health
service delivery, especially as people with a disability have a higher incidence of mental illness than
the general population.
The advent of deinstitutionalisation also saw the development and implementation of new models of
care and treatment for people with a mental illness. This included mainstreaming, which was intro­
duced as a means of reducing the health inequalities and stigma experienced by people with mental
health issues. Today, people who present to health services with symptoms of mental illness are no
longer sent to separate campuses at ‘other’ locations. Instead, mental health services have been inte­
grated into the general or mainstream health system (AIHW 2016b; Martens 2010).
Not only that, the traditional custodial function of those who treated or cared for people with mental
health issues has now been replaced by a therapeutic function. Today, it is the role of health profes­
sionals to enable consumers to live in the community and be contributing members of that community.
To do this, health professionals work with other government departments and agencies, such as social
and housing services, to facilitate care that is comprehensive and integrated, and encompasses all aspects
of the person’s life.

UPON REFLECTION

Deinstitutionalisation
Some people suggest that the widespread closure of the mental health asylums or institutions in
Australia created more problems than it solved. This is because many people who had previously lived
in institutions — where they were provided with food, clothes and a roof over their head — became
homeless when those institutions were closed. Also of concern are statistics that indicate almost half
of prison entrants (49 per cent) report that they have been told by a health professional that they have
a mental health disorder, and more than one in four (27 per cent) are currently on medication for a
mental health disorder (AIHW 2015b). Some commentators suggest prisons have becomes ‘the new
institutions’ of the twenty‐first century

QUESTIONS
1. What do you see as the benefits of deinstitutionalisation for people with mental illness, which
commenced in the 1980s?
2. What do you see are the challenges of deinstitutionalisation?
3. How would you respond to those who call prisons ‘the new institutions’ of the twenty‐first century
for people with a mental illness?

Current policy directions

Mental health policy in Australia today, at the national and state or territory levels, has developed over
time and in response to directives from the United Nations and the World Health Organization (WHO).
Also important has been the ongoing lobbying of governments by human rights groups and members of
the consumer movement.
In 1991, the United Nations (UN) established the Principles for the Protection of Persons with Mental
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Illness and the Improvement of Mental Health Care. This document commences with a statement
upholding the fundamental freedoms and basic rights of those who experience symptoms of mental
illness. The remaining 24 principles provide guidance on how these freedoms and rights are upheld.
They include enabling people with mental health problems to live in the community; and also ensuring
that care is readily accessible, has the least number of restrictions on the person’s freedom and rights,
and is appropriate for the particular needs and preferences of the person.

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 In 2009, Australia was reviewed by the UN Special Rapporteur for its human rights performance, as
part of a regular process that occurs for all member states of the UN. The Human Rights Council made
over a hundred recommendations to the Australian government for change, including those related to
the way in which people with mental illness were treated. For example, it was recommended that the
Australian government:
•• allocate adequate resources for mental health services and other support measures for persons with
mental health problems, in line with the United Nations Principles for the Protection of Persons with
Mental Illness and the Improvement of Mental Health Care
•• reduce the high rate of incarceration of people with mental illness
•• ensure that all prisoners receive an adequate and appropriate mental health treatment when needed
(Human Rights Law Centre 2011).
Today, many of these recommendations have been implemented, thereby ensuring that the way in
which Australia delivers mental health services is better aligned to the framework provided by the UN.
No less important is the guidance provided by WHO. Of particular importance is the recommendation
that all mental health policies be anchored by the four guiding principles of:
1. access
2. equity
3. effectiveness
4. efficiency (World Health Organization 2001).
Services that are accessible allow all people to seek treatment sooner rather than later. In Australia,
providing accessible as well as equitable services can be challenging when considered in light of the
cultural and linguistic diversity of the population, together with the vast distances between many rural
and remote communities (Veitch et al. 2012). Even so, access and equity remains two of a number of
cornerstones of mental health service delivery in Australia today. Indeed, Australians pride themselves
on the fact that quality mental health services are made available to all, regardless of distance, cultural
background, religion, or ability of the person to pay.
Likewise, the Australian government of today is committed to delivering appropriate, timely, effec­
tive and efficient mental health care that is in line with the best available, contemporary, evidence‐based
research (National Health and Hospitals Reform Committee 2009). Services must be comprehensive
and integrated; and facilitate the timely treatment of those who are in need of help (Petrakas et al. 2011;
Rosen & O’Halloran 2014). As with access and equity, effectiveness and efficiency are core tenets that
guide the delivery of all health services in Australia, including mental health services.
Since the early 1990s, the national and state or territory governments have developed a range of
mental health strategies, plans and policies to reflect UN and WHO principles and recommendations.
For example, the National Mental Health Strategy provides direction to state and territory governments
across Australia to enable improvement in the quality of life of people living with symptoms of mental
illness. This strategy was first endorsed in April 1992 by the Australian Health Ministers’ Conference
(1992a 1992b) as a framework to guide mental health reform.
According to the Department of Health website (www.health.gov.au), the National Mental Health
Strategy aims to:
•• promote the mental health of the Australian community
•• prevent the development of mental health problems
•• reduce the impact of mental health problems on individuals, families and the community
•• assure the rights of people with a mental illness.
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Milestones for the development of the National Mental Health Strategy are outlined in the various
documents that mark the evolution of the National Mental Health Strategy. These include the:
•• National Mental Health Policy (1992, 2008)
•• National Mental Health Plan(s) (1992–1997, 1998–2003, 2003–2008, 2009–2014)
•• National Mental Health Standards (2010)
•• Mental Health: Statements of Rights and Responsibilities (1991, 2012)

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 •• National Roadmap for National Mental Health Reform (2012–2022)
•• Establishment of the National Mental Health Commission (2012)
•• Contributing Lives, Thriving Communities — Report of the National Review of Mental Health Pro­
grammes and Services (2014)
•• Australian health care agreements.
The National Mental Health Strategy and ongoing developments have great significance for all health
professionals across Australia. Regardless of the location or context of their work, health professionals
have a responsibility to familiarise themselves with, and abide by, the principles and policies outlined
in the strategy. To support health professionals to familiarise themselves with these process, an A–Z
listing of mental health publications can be found at the Commonwealth Department of Health website
(www.health.gov.au).

Current service frameworks

It is important that health professionals understand the frameworks within which they provide health care.
Such understanding enables health professionals to see the ‘big picture’ of their everyday work. This sec­
tion provides a brief overview of the principles that guide the delivery of health care in Australia. This
information will help health professionals to contextualise the information provided throughout this text.
Significantly, the overarching framework within which health care is delivered to people with mental
health issues in Australia is the same as that which guides all health care and treatment. This framework
is called the public health framework or approach.
Public health framework
The ‘big picture’ framework for health service delivery in Australia is called ‘public health’. This term
is not to be confused with the public health care system, which includes Medicare and other health
funding that supports the universal health coverage provided to all Australians and permanent resi­
dents. Rather, by examining the health trends in populations, communities or groups, and recommending
or overseeing appropriate interventions, the public health framework in Australia aims to:
•• prevent disease
•• promote good health practices
•• prolong life.
Public health includes epidemiology, which is the study of patterns of health and illness in populations
or groups, and involves statistical analysis of data generated to provide an evidence base that shapes stra­
tegic direction (Putland et al. 2013). Some health professionals would know this approach as ‘population
health’, which identifies groups of people that are particularly vulnerable to health issues because of
their demographic characteristics (e.g. age or cultural background) or past experiences (e.g. exposure to
trauma or abuse) (Perkins et al. 2011). For example, the statistics cited earlier, in relation to the mental
health status of the Australian population, fall into the population health category, and provide a basis
upon which Australian governments develop strategic direction and shape services (e.g. National Health
and Hospital Reform Committee 2009). The public health framework also incorporates services such
as prevention and promotion, environmental health, occupational health and safety services, and other
services that enable self‐determination, self‐care and self‐help for all communities and people. These
services form an integral part of the Australian primary health care agenda.
Primary health care agenda
Primary health care is an integral part of the public health framework. Primary health care is currently
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defined by WHO as:

essential health care made universally accessible to individuals and families in the community by means
acceptable to them, through their full participation and at a cost that the community and country can
afford. It forms an integral part both of the country’s health system of which it is the nucleus and of the
overall social and economic development of the community (WHO 1978).

CHAPTER 1 Mental health care in Australia 19

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 Primary health care, then, is essential care because it is about supporting people, families and com­
munities (Cleary et al. 2014). It is holistic and comprehensive in approach, incorporating all aspects
of what it means to be human and achieve optimal levels of health (DoHA 2010). Primary health care
focuses on health rather than illness, prevention rather than cure, and communities rather than hospitals
(National Health and Hospitals Reform Committee 2009).
An important aspect of the various primary health care services in Australia is the delivery of resources
and information to promote healthy lifestyles within communities, by communities, and to support
communities (Gwynn et al. 2015). Other areas of focus include equity in health care; research‐based
methods; accessible, acceptable, and affordable technology; promotion of health; prevention of illness;
early intervention; and continuity of care. In short, primary health care is ‘community‐centric’.
Primary care — a subset of primary health care — is accessible, affordable, and enables people or
groups of people to participate individually and/or collectively in the planning and implementation of their
health care (Primary Health Care Working Group 2009). There has been a tendency in Australia to position
‘primary care’ within the biomedical model and the domain of general practitioners who operate out of
small businesses located in the community. Consequently, the term is often construed as meaning the ‘first
point of contact’ in the health care system. However, primary care is much bigger than this. All health pro­
fessionals can provide primary care, regardless of setting, because this type of care enables them to:
•• acknowledge diversity in the culture, values and belief systems of the person, while promoting their
dignity as a person and right to self‐determine
•• establish collaborative partnerships with the person, together with their family or significant others,
ensuring open channels of communication, and active participation in all aspects of their care
•• engage therapeutically with the person, together with their family or significant others, in a way that
is respectful of the person’s choices, experiences and circumstances; building on the strengths of the
person, enhancing the person’s resilience, and promoting health and wellness
•• collaboratively plan and provide a variety of health care options to the person (including the coordi­
nation of these options) and ascertain that these options are consistent with the person’s mental,
physical, spiritual, emotional, social, cultural, functional and other needs
•• actively value the contributions of other health professionals, health services, agencies and stake­
holders, ensuring the collaborative and coordinated delivery of holistic or comprehensive evidence‐
based health care
•• pursue opportunities to participate in health promotion and illness prevention activities with and for
the person, including health education and support of social inclusion and community participation
(DoHA 2010).
It is all too easy for health professionals to overlook the essential role played by primary health
care services, such as prevention and promotion services, because these services tend to be staffed by
the ‘unsung heroes’ who work behind the scenes (Roberts 2012). Similarly, health professionals who
work as first responders or in the very busy secondary health care and tertiary health care sectors
may underrate the important and ongoing health‐related work that is carried out by non‐government or
community managed organisations, or by small medical or allied health practices. This is because these
organisations do not ordinarily provide emergency or acute services. Yet primary health care services
provide an important means by which people, especially those with mental health issues, are supported
to live in the community. Indeed, in Australia, primary health care services play an essential role in
supporting the deinstitutionalisation of the mental health services. More information about the primary
health care agenda, primary care, and the primary health care services that are delivered in Australia, is
provided in the chapter that focuses on mental health service delivery.
Copyright © 2017. Wiley. All rights reserved.

Current service approaches

All health systems will take a particular approach to the way they deliver their services, with different
approaches taken at the different levels of health care. For example, one approach may be used when
providing a service to the individual and their family or carers, whereas a different approach may be

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 used when supporting communities as a whole. The choice as to which is the best approach to take will
depend on a range of factors, including infrastructure, service linkages, workforce and other resources
(Merkes, Lewis & Canaway 2010).
In Australia, the national government has identified person‐centred and family‐centred care as the first
principle for guiding the delivery of health care (National Health and Hospitals Reform Commission
2009; Australian Commission on Safety and Quality in Healthcare 2010). These approaches to care
are responsive to the individual differences and preferences of the people who receive the care. The
approaches involve health professionals focusing on the needs, preferences and aspirations of people as
individuals; together with the needs, preferences and aspirations of the families who support these indi­
viduals, in the process of planning and delivering care (McMillan, Kampers & Traynor 2010; Kitwood
1997; Rogers 1977). Person‐centred and family‐centred care is partly achieved by facilitating a range
of service options or health care choices. For health professionals, the principles for delivering person‐
centred and family‐centred care include being accessible and flexible, respecting the person and his/her
significant others as someone who shares in the decision making around the health services they utilise,
and ensuring health care is comprehensive and well‐coordinated (Clissett et al. 2013).
Another common approach to care is the strengths‐based approach. This approach focuses on the
strengths rather than deficiencies of the person and his/her family or significant others, and also the
community in which the person is located, with a view to building on the person’s and community’s
abilities, as well as developing their resilience (Campbell & Burgess 2012; Simmons & Lehmann 2013).
The main aim of the strengths‐based approach is to assist the person (or community) to develop their
strengths as a means of managing their own particular set of circumstances (Tedmanson & Guerin 2011).
It is important to note, however, that each of these approaches has been developed by health professionals,
and feature health professionals playing a central role in the way in which health services are accessed and
health care provided. It is the health professional who works to know the patient as a person; it is the health
professional who is accessible and flexible to meet the needs of the person; and it is the health professional
who empowers the person. Essentially, then, these approaches maintain the position of the health profes­
sional at the centre of the delivery of health services, and, as such, in the position of power.
In contrast, consumer‐centred approaches place the person with a health need at the centre of the care
they receive. Consumer‐centred care is becoming an increasingly common approach taken by health
service organisations located in Western countries such as Australia. The participation of consumers
and carers in the planning, development and delivery of mental health services is now an expectation of
Australian governments at national and state or territory levels (Commonwealth of Australia 2005, 2009;
DoHA 2009a). Consumer and carer participation in health service delivery is said to increase adher­
ence to, and the effectiveness of, treatment programs, facilitate consumer satisfaction and promote best‐­
evidence practice (Adams & O’Hagan 2012; Corrigan et al. 2012; Hungerford, Dowling & Doyle 2015).
Consumer‐centred approaches grew out of the ‘patients’ rights’ movement in the United States, which
was part of the wider civil rights movement of the late 1960s, that advocated for the rights of women,
African–Americans, homosexual people and other minority groups. This movement eventually gave
rise to postmodern notions of multiple realities, including the many and varied individually constructed
meanings of experiences of health and ill‐health (Collier 2010). As a consequence, there are now a
number of different consumer‐centred models of health care. At the heart of each of these models, how­
ever, lies the principles of consumer participation, with consumers involved with — even driving — the
development of health services and the models of care utilised, as well as the individual health care
they receive (Newman & Kulman 2011). As noted by Deegan (1996, p. 92), who is an internation­
Copyright © 2017. Wiley. All rights reserved.

ally renowned mental health consumer peer advocate, ‘those of us who have been diagnosed are not
objects to be acted upon. We are fully human subjects who can act and in acting, change our situation’.
Consumer‐centred approaches, then, position the consumer as the person who determines how he or she
responds to the challenges of their lives, not the health professional. Consumer‐centred approaches are
characterised by an active consumer rather than a passive patient, and health professionals act as co‐
workers in the process of identifying and addressing the health needs of a person.

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 Recovery
In the field of mental health, the notion of ‘Recovery’ first emerged over 30 years ago out of the con­
sumer movement and growth in advocacy for consumer rights and autonomy (Anthony 1993). Recovery
is a consumer‐centred approach to health care that is underpinned by the principles of hope, optimism,
health and wellness (Corrigan et al. 2012). Recovery approaches position consumers as the experts
in their own lived experience of mental illness who collaborate or work in partnership with health
professionals to make choices about the health care they receive (Slade, Adams & O’Hagan 2012).
Recovery for people with a mental illness involves a whole‐of‐life journey of transformation, as they
move from a position of disempowerment to one of self‐determination and autonomy (Hungerford et al.
2016).
The Australian government is firmly committed to Recovery‐oriented mental health services. This com­
mitment is demonstrated in a number of ways, and includes the government’s definition of Recovery as:

a personal process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It involves
the development of new meaning and purpose and a satisfying, hopeful and contributing life as
the person grows beyond the effects of psychiatric disability. The process of recovery must be
supported by individually‐identified essential services and resources (Commonwealth of Australia
2009, p. 31).

Other definitions of Recovery, or the Recovery model, can be found in the literature, and are all based
on the tenets of hope, optimism, individual strengths and wellness. Recovery approaches are described
as less about an absence of symptoms or illness and more about enabling consumers to move beyond
the negative consequences of their condition. This means that consumers work towards accepting that
they may continue to experience symptoms of mental illness without allowing this to affect their hope or
future. Recovery, then, is viewed as a process more than an outcome, a journey rather than a destination.
The Principles of Recovery focuses upon the concepts of:
•• hope, optimism, individual strengths and wellness
•• meaning, purpose and respect
•• equality, mutuality, collaboration and responsibility
•• community engagement
•• self‐confidence, empowerment and agency
•• personal growth
•• individual rather than universal solutions
•• social inclusion and connectedness
•• process rather than outcome orientation.
There has been some confusion about how to integrate Recovery as a model of care into the practice
of health professionals. One reason for this is the more traditional understanding of the term ‘Recovery’
in the context of the biomedical model of treatment and its focus on ‘cure’. Another reason is the chal­
lenge involved in fitting a truly consumer‐centred approach into health service organisations that are,
firstly, dominated by the biomedical model and, secondly, restricted by the demands of clinical gover­
nance (such as the publicly funded health system in Australia). It is perhaps for this reason that the
Australian government has recommended that health services are Recovery‐oriented, rather than defini­
tively consumer‐centred (Hungerford 2014).
According to Australia’s National Standards for Mental Health Services (Commonwealth of Australia
2010), which guide the way in which health professionals care for people with a mental illness, Recovery‐
Copyright © 2017. Wiley. All rights reserved.

oriented practice is guided by six principles:

1. the uniqueness of the individual
2. real choices
3. attitudes and rights
4. dignity and respect

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 5. partnership and communication
6. evaluating Recovery.
Each of these principles is now discussed in turn.
The uniqueness of the individual
The health professional recognises that Recovery is not necessarily about cure, but rather the opportunity
for people who experience symptoms of mental illness to live a meaningful, satisfying and purposeful
life, as a valued member of the community. The health professional also accepts that the outcomes
of Recovery‐oriented health care are personal and unique for each person, going beyond an exclusive
health focus to include an emphasis on quality of life and social inclusion. Finally, this principle involves
the health professional supporting empowerment of the person, with that person recognising that they
are at the centre of the care received (Mueser et al. 2015).
Real choices
The health professional supports and empowers consumers to make their own decisions about the way
they live, promoting choices that are meaningful to or for them. The health professional supports the
person to build on their strengths and to take as much responsibility as they can for the choices they
make. This includes the health professional balancing duty of care with supporting the person to take
positive risks and embrace new opportunities (Moran & Russo‐Netzer 2016).
Attitudes and rights
This principle promotes the health professional as someone who listens to, learns from and acts upon
communications received from the consumer and their partners, families or friends about what is impor­
tant to them. The health professional also respects each person’s legal, citizenship and human rights.
Finally, the health professional supports each person to ‘maintain and develop meaningful social, recrea­
tional, occupational and vocational activities’; and instil hope into the person’s future and ability to live
meaningfully (Hungerford, Dowling & Doyle 2015; Rosen & O’Halloran 2014).
Dignity and respect
The health professional is courteous, respectful and honest in all interactions with the consumer
and their partners, families or friends. This principle also requires health professionals to be sensi­
tive and respectful when dealing with values, beliefs and cultures that are different to their own.
Finally, the principle of dignity and respect involves the health professional challenging discrimi­
nation and stigma wherever it exists, whether in their own organisation or the broader community
(Chambers et al. 2014).
Partnership and communication
The health professional acknowledges that the person who experiences symptoms of mental illness is an
expert on their own life; and that Recovery involves working in partnership with the consumer, and also
their partner and/or family members, to provide support in a way that is meaningful to them as people.
In addition, health professionals value the importance of sharing relevant information; as well as the
need to communicate clearly and to work in positive and realistic ways to help people to realise their
hopes, goals and aspirations (Hungerford et al. 2016).
Evaluating Recovery
The health professional supports the continuous evaluation of Recovery‐oriented practice at all levels.
This includes supporting the person to track their own progress in their Recovery journey; as well as
reporting of key outcomes of Recovery that include (without being limited to) the social determinants of
Copyright © 2017. Wiley. All rights reserved.

health, such as education, employment, housing, and social and family relationships (Commonwealth of
Australia 2010; Hungerford et al. 2016).
When the care that is delivered to people with mental health problems, together with their partners,
family members and friends, is framed by these six principles, there is every chance that Recovery will
be achieved.

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 Working towards this end, however, is no easy task. As noted by Deegan (1996), health professionals
cannot force Recovery to happen — instead, they must work to create an environment in which the
Recovery process is nurtured. This is no easy task, especially when considered in light of the gap that
remains between Recovery‐in‐policy and Recovery‐in‐practice (Hungerford 2014; Newman & Kulman
2011). Some commentators say that this gap is the result of the confusion some health professionals
feel about the term ‘consumer‐centred Recovery’ (Collier 2010; Barker & Buchanan‐Barker 2011).
As already noted, consumer‐centred Recovery stands in contrast to the more traditional or biomedical
understandings of Recovery or ‘cure’. Even so, with time and effort, Recovery as a journey of hope and
optimism building on a person’s strengths can be achieved by people with mental illness when supported
by committed health professionals.

IN PRACTICE

Recovery‐in‐practice
Mental health Recovery focuses on inspiring hope
and optimism in the person with a mental illness. It
also involves health professionals forming partner-
ships and collaborating closely with the consumer,
to enable empowerment. Consumers are given
a range of options related to the health interven-
tions from which to choose. This approach takes
time and a commitment on the part of health pro-
fessionals to focus on developing and maintaining
the therapeutic relationship.
Mental health Recovery presents challenges
for first responders, such as paramedics, or
registered nurses who work in emergency
departments in hospitals. This is because first
responders interact with the person for only a
relatively short period of time. In addition, the situations in which these health professionals support the
consumer may have a high acuity and require decisions to be made very quickly.
Take, for example, Trish, who regularly rings 000 and/or presents to the emergency department of
hospitals after an episode of deliberate self‐harm. Trish states that she feels relief from her emotional
pain after cutting up — however, this self‐harming behaviour involves her using a sharp knife to place
deep cuts in her forearms, thereby placing her life at risk. First responders are required to take action,
quickly, to minimise blood loss. Also, the first responders cannot help but wonder why Trish is behaving
in this way and consuming valuable resources, including their time, when there are other people out
there in the community who need assistance because of an accident, cardiac event, or other emergency.
Another example is Brett, who has been reported to the first responders after a family member called
000 in a highly anxious state. The family member stated that Brett was 19 years old and had been
behaving ‘oddly’ in the last month or so, staying in his bedroom and talking to himself. Overnight, this
muttering had increased in volume to the point where he could be heard shouting at some unknown
person. When the family had tried to enter the bedroom, Brett had accused them of trying to ‘get’ him
and threatened to hurt them if they came near him. The family had no idea what was going on and were
desperate.
Implementing the principles of Recovery in these kinds of scenarios is difficult — but not impossible.
For this reason, it is important that health professionals consider the issues involved prior to experi-
encing such events.
Copyright © 2017. Wiley. All rights reserved.

QUESTIONS
1. What practical steps can be taken by health professionals, who practise in emergency settings, to
support the Recovery journey of people with a mental illness?
2. What choices can be given to the person with a mental illness who needs emergency care, regardless
of the urgency of the situation?

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 1.5 The prevalence of mental illness in Australia
LEARNING OBJECTIVE 1.5 Outline the prevalence and impact of mental illness in Australia.
As noted earlier in this text, mental illness is one of the leading contributors to the non‐fatal burden of
disease and injury in Australia (AIHW 2016b). It is associated with increased exposure to health risk
factors, greater rates of disability, poorer physical health and higher rates of death from many causes
(including suicide). It is of great concern, then, that approximately 45 per cent of Australians aged
between 16 and 85 will experience a mental illness at some point in their lives, and one in five Australian
adults will experience a mental illness in any given year (ABS 2015; AIHW 2016a). Figure 1.1 out­
lines the prevalence rates of anxiety, mood and substance use disorders across the lifespan in Australia.
In particular, there are concerning trends for those aged 25–54 years, who are most likely to be raising
families and working.

FIGURE 1.1 Prevalence rates of selected mental illness by age group

40 Males
Females
30

20
%

10

0
16–24 25–34 35–44 45–54 55–64 65–74 75–85
Age in years
Source: Australian Bureau of Statistics (ABS 2012)

These statistics suggest the widespread — even endemic — nature of mental illness across Australia.
The statistics are even more concerning when considered in light of the effect of mental health prob­
lems on a person’s ability to interact positively with their family members, friends, colleagues and/or
the broader community. For example, people with mental health problems may find it more difficult
to relate to others or maintain functional relationships. Further, mental illness has a financial cost. For
example, the economic cost of serious mental illness in Australia, including opioid dependence, has been
estimated at almost $100 billion annually, including losses in productivity and labour force participation
(Royal Australian and New Zealand College of Psychiatrists 2016). Additionally, the leading cause of
the loss of healthy years of life due to disability has been identified as mental illness (Franke, Paton &
Gassner 2010).
The prevalence of mental illness across Australia is an important motivating factor for health pro­
fessionals to learn about the issues involved, and to integrate quality mental health care into their
everyday practice (Rosen & O’Halloran 2014). This importance is underscored by the fact that many
people who are currently seeing health professionals for a physical health problem may also have mental
health issues that have not yet been identified.
Copyright © 2017. Wiley. All rights reserved.

Indeed, there has been an increase in the number of people in Australia with physical illnesses or inju­
ries who also have mental health problems. This means that more people who arrive at or are admitted
to a hospital to be treated for a physical health problem will also be experiencing symptoms of mental
illness (Ahire et al. 2013). Moreover, many people in hospital or who have been recently discharged
from hospital will develop mental health issues. Of particular concern are those with a chronic physical
illness (such as heart disease, stroke, cancer, diabetes, chronic pain) who are far more likely than those

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 who are physically well, to develop depression, anxiety or other forms of psychological distress (beyond-
blue 2014). Research suggests that many of these people receive no treatment or interventions for these
conditions (Glasper 2016). This is concerning as it indicates that many health professionals are either
not identifying mental health issues in the person with a chronic illness or they are unable to provide the
care required (Lawrence, Hancock & Kisely 2013).

Prevalence of suicide in Australia

Suicide and other self‐harming behaviours are discussed in detail in the chapter that looks at caring for
a person who has self‐harmed. In this text, the prevalence of suicide in Australia is briefly reviewed as a
means of introducing readers to this very significant public health issue and establishing a platform for
further reading.
In the 5‐year period from 2010 to 2014, the average number of suicide deaths per year was 2577,
accounting for 1.9 per cent of all deaths (Mindframe National Media Initiative 2016). Over three‐quarters
of these deaths were males, with men aged between 40 and 44, and over 85 years, of most concern (ABS
2016). Overall, the most common method of suicide was hanging (58.7 per cent), followed by poisoning
by drugs (10.8 per cent).
Common themes derived from the statistics related to suicide include the following.
•• There are more deaths by suicide each year in Australia than deaths by motor vehicle accidents.
•• People with a previous history of attempted suicide are at greatest risk of suicide.
•• Mental illnesses (such as major depression, psychotic illnesses and eating disorders) are associated
with an increased risk of suicide, especially after discharge from hospital and when a treatment reg­
imen changes or has been reduced.
•• People with alcohol and drug abuse problems have a higher risk of dying by suicide than the general
population (Mindframe National Media Initiative 2016).
It is also important to consider the suicide rate of Australia’s Indigenous peoples (5.2 per cent of all
deaths), which is much higher than that of non‐Indigenous Australians (1.9 per cent) (Mindframe National
Media Initiative 2016). For example, young Aboriginal and Torres Strait Islander males, aged 15–19
years, are 4.4 times more likely to die by suicide than non‐Indigenous Australian males of the same age.
Similarly, young Aboriginal and Torres Strait Islander females, aged 15–19 years, are 5.9 times more
likely to die by suicide than non‐Indigenous young females (Mindframe National Media Initiative 2016).
There is much that can be done by health professionals to help to reduce the rates of suicide in Australia
for Indigenous and non‐Indigenous groups. Preventative measures include early identification of risk factors;
together with the promotion of social, emotional and spiritual wellbeing, and improved quality of life for
individuals, families and communities (Hunter Institute of Mental Health 2015). Health professionals are
also in a prime position to help people to develop stronger protective factors so that they can better cope
with stress. This can be achieved by involving family members, friends and relevant support services; and
supporting people to develop high levels of personal resilience, community connectedness, and hope.

Issues for young people

Adolescence is a time of great physical, emotional and social change. It is a time of life that brings with
it new, adult‐like challenges, and associated stresses. The way a young person reacts to stress will affect
their ability to cope with life (Cave et al. 2015). This is why it is crucial to support young people to
develop personal coping skills and also become aware of how they may be affected by stress (McGorry,
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Bates & Birchwood 2013). Stress can be a positive factor because it can motivate people and groups
into action (see the chapter on common reactions to stressful situations for further information). Stress
can also have a negative impact on people, especially young people who are already feeling insecure,
confused or anxious. This, in turn, can give rise to a range of mental health issues for the young person.
According to Mission Australia’s latest Youth Survey, 1 in 5 young people living in Australia are likely
to be experiencing mental health problems, with less than 40 per cent of these young people feeling

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 comfortable enough to seek professional help (Ivancic et al. 2014). A national survey of the mental
health and wellbeing of young people conducted in 2013–14, found that almost 1 in 7 (14 per cent)
young people aged between 4–17 years — equating to 560  000 children and adolescents — had a mental
health disorder. Attention Deficit Hyperactivity Disorder (ADHD) was the highest proportion (just over
7 per cent), followed by anxiety disorders (just under 7 per cent), major depressive disorder (3 per cent)
and conduct disorder (2 per cent). Of those with a mental health disorder, almost 30 per cent (or 4 per
cent of all young people aged to 17 years) had experienced two or more disorders at some time in the
previous 12 months (AIHW 2015a).
While the prevalence of mental illness is relatively high in young people, they also have a relatively
low use of mental health services (Carlson et al. 2013). General practitioners are the service most fre­
quently accessed by young people with a mental disorder (15 per cent), followed by psychologists
(10 per cent). Young people with a substance use disorder are the least likely to use mental health ser­
vices (Zimmermann, Lubman & Cox 2012). The main reason for this lack of utilisation of services is
that most young people (85 per cent) did not feel the need to seek help (ABS 2010). Another reason is
that the current mental health system is not adequately resourced to deal with young people who have
mild‐to‐moderate mental health issues (headspace 2011). As a consequence, young people may have
difficulty finding a service that can meet their needs or preferences. This is concerning because it means
the young people are not receiving the support or health care they need.
For this reason, there is a pressing need for health professionals from across the disciplines to know
what services are available and how these services can be accessed. Advising young people and their
families of these services is crucial. Young people who experience mental health problems are more
likely to experience issues with their physical wellbeing and educational, psychological and social devel­
opment (Eather, Morgan & Lubans 2011; Glasper 2016). In contrast, when the early signs of mental
health issues are identified and addressed, outcomes for the young person are improved. More infor­
mation about the early intervention strategies currently used to help young people with mental health
problems, together with the services that are available for young people in Australia, are discussed in the
chapter that focuses on mental health service delivery.

UPON REFLECTION

Young people and suicide

Research suggests an upward trend in the rate of suicide in young people aged 15–19 years. Likewise,
despite the huge amount of focused work that has been undertaken to address the issues involved, the
overall rate of suicide among young people aged 20–24 has not declined (Metcalf & Blake 2014).

QUESTIONS
1. Identify at least three reasons why young people in Australia would consider suicide as an option.
2. As a health professional, what can you do to help address the high rates of suicide in young people in
Australia?
3. As a health professional, what can you do to encourage young people to seek help for mental health
issues?

1.6 Common mental health issues

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LEARNING OBJECTIVE 1.6 Describe the most common mental health issues that health professionals in
Australia will encounter.
The most common mental health issues in Australia are anxiety disorders, including generalised anxiety
disorder, post‐traumatic stress disorder, social phobia, panic disorder and obsessive‐compulsive dis­
order (14.4 per cent) (Mindframe National Media Initiative 2016). Affective or mood disorders, such as

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 depression or bipolar disorder, are the next most common issue (6.2 per cent). Substance use disorders
are also of concern (5.1 per cent), including the subgroup of alcohol use disorder (2.9 per cent). Other
mental health conditions that health professionals may face in the emergency context include suicide
attempts and self‐harming behaviours, and challenging behaviours due to psychosis or a mania. Health
professionals may also interact with those who exhibit psychologically based physical symptoms, often
called somatisation.
Statistics such as these suggest one reason why the National Mental Health Strategy prioritises an
improved understanding of mental health issues by all health professionals, not just mental health pro­
fessionals, and also by the general population. This prioritisation includes community education and the
delivery of mental health education to frontline workers in health, emergency, welfare and associated
sectors, ensuring coordination between these services (Green, Hunt & Stain 2012).
At the same time, these statistics present a challenge to health professionals who are committed to pro­
viding comprehensive care. Of particular concern are the potential consequences for people when mental
health issues go unrecognised. As noted in figure 1.2, these consequences can include a decrease in
quality of life for the person and reduced health outcomes. It is essential, then, that health professionals
recognise the signs and symptoms of mental illness; and that they also have knowledge that will enable
them to provide the most appropriate referral for, or treatment and care to, the person exhibiting these
symptoms.

FIGURE 1.2 Potential consequences of mental health issues going unrecognised

Consequences of unrecognised mental health issues

• Decrease in the quality of life of the person and possibly their relatives/carers
• Physical recovery impeded
• Unnecessary physical investigations undertaken in search of ‘answers’ to symptoms that have no
physical cause
• Increase in cost for health service providers
• A longer period off work and related financial problems
• Social isolation
• Early treatment not implemented, leading to an increase in symptoms of mental illness
• Higher risk of suicide

Source: Evans, Nizette & O’Brien (2017)

A list of the mental health issues that health professionals are more likely to encounter in a health
context is provided in table 1.2, together with a brief description of the way in which the person who
is experiencing these issues may present and the recommended intervention. This list provides a useful
summary for health professionals who are interested in familiarising themselves with the more common
mental illnesses. The information in this table has been drawn from a range of sources, including the
diagnostic manuals DSM‐5, ICD‐11; evidence‐based clinical practice guidelines produced by organ­
isations and institutions such as the Australian and New Zealand Academy for Eating Disorders
(2011); Australian Centre for Posttraumatic Mental Health; National Eating Disorders Collaboration
(2013); National Institute for Health and Clinical Excellence (NICE) (2013); the Royal Australian and
New Zealand College of Psychiatrists (2013); and the Royal Australian College of General Practitioners
(2013); alongside a range of textbooks, including Kaplan and Sadock (2014). For health professionals
Copyright © 2017. Wiley. All rights reserved.

working in the wider health context, the conditions outlined in table 1.2 may be experienced by the
person as a co‐occurring or co‐associated condition. This describes people with mental health issues
who have also developed physical conditions that require medical or other interventions; or people
with physical conditions who develop a mental health problem. More comprehensive descriptions of
these conditions are provided in other chapters, including those with the greatest burden of disease, for
example, bipolar disorder and schizophrenia, and substance use disorders.

28 Mental health care

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

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 Copyright © 2017. Wiley. All rights reserved.

TABLE 1.2 Summary of the more common mental health issues

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Mental health issue Typical presentation Recommended intervention

Acute stress reaction (ASR), also called acute stress disorder (ASD) (see also the chapter on common reactions to stressful situations)

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

A transient psychological condition that develops in Usually begins within minutes of the event and The condition is usually self‐limiting, with most
response to a traumatic event. It is not necessary disappears after hours or days. Symptoms can people recovering using their own internal
for the person to have been physically involved be severe and distressing for the person, and resources. In the short term, health professionals
in the trauma event to experience this reaction. may include (i) initial state of ‘daze’ or other must (i) ‘treat the symptoms’ (e.g. if a person is
Traumatic events include any experience that dissociative symptoms such as emotional shivering, provide them with a blanket); (ii) provide
threatens, or is perceived to threaten life or physical detachment or an apparently inward focus that verbal reassurance and normalise the experience
safety of the person or others around them and reduces attention to and awareness of the person’s for the person and their partner or family. This
arouses feelings of intense fear, helplessness or surroundings; (ii) memory loss — especially for includes providing explanations and information
horror. the traumatic event (‘dissociative amnesia’), and about the condition, and social support if
depersonalisation (a perceived loss of contact necessary.
with reality, feeling unreal); and (iii) altered levels of Structured psychological interventions such as
consciousness, agitation/overactivity or withdrawal, debriefing should not be offered routinely as they
symptoms of anxiety (e.g. sweating, increased heart are not ordinarily necessary.
rate or flushing).
After two weeks, a person for whom ASR
persists may be offered a comprehensive clinical
assessment. Dependent upon the findings of this
assessment, therapeutic interventions may include
trauma‐focused cognitive behavioural therapy
including exposure and/or cognitive techniques
and/or other relevant psychological or social
interventions.

Adjustment disorder (see also the chapter on common reactions to stressful situations)

A maladaptive emotional or behavioural reaction to Associated symptoms fall on a continuum, from Initially, interventions can include (i) reassurance;
an identifiable stressful life event or life change. The mild depression and/or anxiety, to traumatic stress, (ii) arousal reduction; (iii) addressing the cause
reaction generally occurs from one to three months distress and, at times, suicidality. of individual’s stress or feelings of conflict; and
after the initial stressor and tends to resolve within Impaired social or occupational functioning can (iv) skills and/or relaxation training.
six months. occur, ranging from withdrawal from social or In the longer term, similar strategies are used in the
occupational activity to an inability to cope with form of psychosocial support and psychological
these activities. interventions.
The reaction generally resolves when the identified
stressor(s) abates.

CHAPTER 1 Mental health care in Australia 29

 Copyright © 2017. Wiley. All rights reserved.

TABLE 1.2 (continued)

Mental health issue Typical presentation Recommended intervention

Anxiety (see also the chapter on depression, anxiety and perinatal mental health)

Characterised by feelings of tension, worried Subjective symptoms include feelings that range Initially, people with anxiety can be helped with

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thoughts and physical changes (including increased from apprehension, discomfort and dread, up to the reassurance and calming techniques such as using
blood pressure). There may be recurring intrusive fearful impression of impending doom and panic. a soft measured voice and moving the person to a
thoughts or concerns, avoidant behaviours and Objective symptoms include palpitations, chest quite space for de‐stimulation.

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

physical symptoms such as increased blood pain, diarrhoea, headache, nausea, urinary In the longer term, interventions include
pressure, sweating, trembling, dizziness or rapid frequency, increased rate of respirations and (i) psychological therapies such as cognitive
heartbeat. Six anxiety disorder subtypes are:

30 Mental health care

muscle spasm. behavioural therapy; or anxiety management
(i) panic; (ii) generalised anxiety; (iii) social anxiety; techniques, such as mindfulness or relaxation; and
(iv) specific phobias; (v) obsessive‐compulsive; and (ii) pharmacotherapy such as benzodiazepines and
(vi) post‐traumatic stress. antidepressant medications.
A combination of psychological therapy and
pharmacotherapy is also helpful.

Bipolar affective disorder (including manic/hypomanic and depressive phases)

A mood or ‘affective’ disorder that cycles between Lifetime misdiagnosis is not uncommon, with Initially (i) ensure safety from harm to self or
mania and depression. symptoms frequently ascribed to schizophrenia or others; (ii) exclude underlying organic conditions
For most people, bipolar affective disorder is a a personality disorder. (e.g. substance‐induced mania, delirium); (iii) treat
recurring and sometimes disabling condition. Mania and hypomania (i.e. mania of a lesser physical complications (e.g. dehydration); and
People often have difficulties in maintaining stable intensity) are characterised by episodes of (iv) keep the person safe.
relationships and employment. Bipolar affective (i) impaired insight and judgement; (ii) chaotic The main longer term interventions are
disorder accounts for 12 per cent of all Australian behaviour that can include irritability, aggression, (i) pharmacological (e.g. mood stabilisers);
suicides annually. disinhibition; (iii) disorganised cognition (ii) psychosocial support to help manage the
The major ongoing Recovery issue is non‐ (e.g. grandiosity, tangentiality); and (iv) psychosis symptoms; (iii) psychological interventions to
adherence to pharmacological treatment. This may (e.g. delusions, hallucinations). help manage stress and other symptoms; and
be a function of the symptoms, or due to difficulties For depressive symptoms, see the separate entry (iv) psychoeducation to help with levels of adherence
with self‐concept, self‐esteem, or the social stigma for depression. with pharmacotherapy, suicide prevention and family
attached to the disorder. therapy to manage the symptoms. Support groups
can also be helpful for some people.

Deliberate self‐harm (DSH) (see also the chapter on caring for a person who has self‐harmed)

An acute, deliberate, non‐fatal act that may or may Self‐injury includes a wide variety of behaviours: Initially, (i) ensure safety from further self‐harm;
not include suicidal intent. self‐mutilation (e.g. self‐cutting or self‐burning), (ii) if injuries require medical attention, transport
Often associated with other mental health jumping from heights, attempted hanging and to emergency department; (iii) refer to the mental
conditions such as depression, substance use, and deliberate car crashes. Self‐poisoning refers to health specialist team.
anxiety disorders. There is a particular association an overdose of medicines or other drugs or the Longer term, (i) cognitive behavioural therapy and
with some personality disorders, including ingestion of other substances. problem‐oriented approaches (especially dialectical
borderline personality disorder. behaviour therapy [DBT]); (ii) address underlying
Vulnerability to DSH may persist long term for mental disorders, and (iii) manage triggers/stress
some people. and enhance coping skills.
 Copyright © 2017. Wiley. All rights reserved.

Mental health issue Typical presentation Recommended intervention

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Delirium (see also the chapter on caring for an older person with mental illness)

Delirium is a medical emergency: if left untreated, There are three main signs: (i) acute or swift onset In the short term, the underlying cause of the
it can result in death. It is generally reversible and fluctuating course over hours to days, which delirium must be treated.

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

when the underlying cause is treated. Delirium can tends to be worse at night (‘Sundown syndrome’); Psychosocial support and reassurance must also
be difficult to detect and is often undiagnosed, (ii) inattention or erratic/disorganised thinking and be given to reduce any distress, to both the person
particularly in (i) older people with a co‐occurring behaviour (e.g. confusion, disorientation, paranoia, and their family members.
dementia and (ii) up to 20 per cent of younger hallucinations, memory impairment); and (iii) altered
In extreme cases, where the person is at risk of
hospitalised people, with many health professionals levels of consciousness, from comatose (unable to
further harm, pharmacological interventions may be
presuming only older people develop delirium. be aroused), to lethargic (drowsy), to hyper‐aroused
used.
Delirium is sometimes called acute brain syndrome, (agitated), to a mixed presentation.
acute confusioned state or acute organic Health professionals are advised to consider
psychosis. It is generally caused by an underlying delirium if at least one of the following ‘5 Ps’ are
illness, or metabolic or chemical disturbance. It can present:
also be caused by stress. • Pus — an infected lesion
• Pills — including misuse, adverse reactions and
drug interactions for over the counter medicines
and prescribed medicines, illicit drugs and
alcohol
• Pain — particularly in people whose ability to
communicate has been compromised
• Pee — urinary tract infections often go
undetected, particularly in older people who have
become dehydrated
• Poo — constipation or diarrhoea (gastrointestinal
problems)

Dementia (see also the chapter on caring for an older person with mental illness)

A cluster of symptoms that provide a label for Symptoms include: (i) slow cognitive decline In the short term, (i) reassure the person; and
a range of specific behavioural, psychological, exhibited through slowly increasing functional (ii) keep the person safe;
physical and social deficits. The incidence deficits such as memory loss, confusion, language In the longer term interventions include: (i) person‐
increases dramatically with age but tends to be disturbance, an increasing inability to self‐care, and centred approaches where health professionals
rare in the under‐55 age group. The most common often depression and anxiety; (ii) ‘challenging respond to the immediate needs and preferences
form of dementia is Alzheimer’s disease, which behaviours’ or behavioural and psychological of the person and their carer; (ii) pharmacological
accounts for 50–70 per cent of all cases. The symptoms of dementia, including wandering, pacing, treatments (e.g. anticholinesterases).
onset is insidious and irreversible. The disease hoarding, verbal and physical aggression, screaming,
progresses gradually but continuously and survival repetitive vocalisations, delusions and hallucinations,
is approximately 8–11 years from the onset of sexual disinhibition and faecal smearing. Typically
symptoms. dementia ends in permanent dependence in all

CHAPTER 1 Mental health care in Australia 31

aspects of care and, ultimately, death.
 Copyright © 2017. Wiley. All rights reserved.

TABLE 1.2 (continued)

Mental health issue Typical presentation Recommended intervention

Depression (see also the chapter on depression, anxiety and perinatal mental health)
Diagnosed when a person’s mood is consistently Symptoms include (i) feelings of worthlessness or Initially (i) reassure person; (ii) ensure person is safe;
sad or ‘low’, they lose interest and pleasure guilt, (ii) impaired concentration, (iii) loss of energy/ and (iii) refer person to mental health professional
in activities or events that ordinarily interest or fatigue, (iv) suicidal thoughts, (v) appetite/weight for a comprehensive health assessment,

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please the person, for at least two weeks. Also change, (vi) altered sleep pattern, (vii) tearfulness, Longer term, interventions include (i) medication
accompanied by four or more other symptoms from (viii) depressive body posture, (ix) agitation, (x) social (antidepressants); (ii) psychological therapies
those listed under ‘Typical presentation’. withdrawal, and (xi) inability to be ‘cheered up’. (e.g. cognitive behavioural therapy or interpersonal

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

Physical illnesses such as cancer, respiratory Symptoms of depression can be difficult to identify therapy); (iii) social support and physical care if
and cardiovascular disease, diabetes, stroke in people with a physically illness. This is because required; (iv) or a combination of (i), (ii) and (iii).

32 Mental health care

and neurological conditions increase the risk of the symptoms may be mistaken for the side‐effects
depression. of some treatments for physical illness, such as
Similarly, depression following a cerebral vascular medicines, and chemotherapy or radiotherapy
accident, myocardial infarction or prolonged (e.g. changes in sleep and appetite). It is therefore
physical illness is associated with increased important to provide a comprehensive assessment
mortality. to ensure appropriate diagnosis.

Eating disorders (anorexia nervosa, bulimia nervosa) (see also the chapter on caring for a person who has self‐harmed)
Eating disorders are a group of serious, complex Anorexia nervosa: Initially, address any life‐threatening symptoms
and potentially life‐threatening mental disorders Deliberate weight loss and a refusal to eat. (e.g. cardiac arrest, severe malnourishment).
with variable causes and a high rate of relapse that Hyperactivity is common. In the longer term, all eating disorders
require specialist, multidisciplinary care. About 50 per cent of people with this condition also require complex, specialist multifactorial and
A person with an eating disorder requires use purging and vomiting behaviours to lose weight. multidisciplinary care across a range of settings
appropriate therapeutic interventions as early A common symptom is a preoccupation with body including medical support, psychiatry, psychology,
as possible after diagnosis. Without this early shape and size, including delusions (e.g. seeing self mental health nursing, dietetics and social work.
intervention, the disorder is more likely to be as fat even when severely underweight). Depression People with eating disorders can be best
long‐term, lead to physical health conditions, and obsessions are often found in people with an supported with:
reduce the person’s quality of life and also their life eating disorder, particularly in those with anorexia • access to treatment and support
expectancy. nervosa. A range of medical complications can • improved workforce knowledge and skill
There are different types of eating disorders. The be experienced from both conditions. These can application of evidence‐based clinical practice
main diagnoses are anorexia nervosa and bulimia affect all of the body systems but amenorrhoea, guidelines and strong family support preventative
nervosa. osteoporosis and hypometabolic symptoms are strategies.
common in people with anorexia nervosa.
Bulimia nervosa:
People with this condition episodically binge on
food (repeatedly over‐eat to an extreme degree) and
then take measures to prevent weight gain such as
making themselves vomit, taking laxatives or starving
themselves. Low self‐esteem, impulsivity, problems
with intimacy and dependency, and difficulty
managing anger are common in people with bulimia
nervosa. Common medical conditions for those with
bulimia nervosa include gastrointestinal problems
and electrolyte imbalances.
 Copyright © 2017. Wiley. All rights reserved.

Mental health issue Typical presentation Recommended intervention

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Panic (see also the chapter on depression, anxiety and perinatal mental health)

Panic is an intense form of anxiety. When a person A panic disorder is diagnosed when the person In the short term, (i) treat physical symptoms
experiences a panic attack, the intense symptoms experiences recurrent and unexpected panic (e.g. hyperventilation); (ii) reassure person; and

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

develop abruptly and tend to peak within attacks and at least one of the attacks has (iii) keep the person safe.
ten minutes. been followed by (i) at least one month of either In the longer term, aims of interventions include
persistent concern about having additional attacks, (i) control and cessation of panic attacks; (ii) control
(ii) worry about the implications of the attack or its and cessation of fear‐driven avoidance; and
consequences, and/or (iii) a significant change in (iii) reduction in vulnerability to relapse.
behaviour related to the attacks.
Both psychological and pharmacological treatments
can achieve the first two goals but there is no
evidence that pharmacotherapy is able to reduce
vulnerability to relapse. Cognitive behavioural
therapy can help the person develop the skills to
deal with panic attacks and reduce the probability
of relapse.

Post‐traumatic stress disorder (PTSD)

Classified as an anxiety disorder, occurring as a Main signs and symptoms are evident for more than Initially, (i) keep person safe; (ii) reassure person
delayed psychological response (i.e. after 4 weeks) a month after the event and include (i) reliving the that the condition is relatively common and very
after an individual has been exposed to an extreme trauma — such as through nightmares and intrusive treatable; and (iii) refer person for comprehensive
traumatic stressor involving actual or threatened memories, with associated physical reactions as health assessment.
death or serious injury, or a threat to the physical anxiety and panic; (ii) hypervigilance including In the longer term, preferred interventions are
integrity of self or others. trouble sleeping, irritability, difficulty concentrating, (i) psychological therapies, including trauma‐
The individual will have experienced intense fear, hyperarousal; and (iii) avoidance of reminders of the focused cognitive behavioural therapy or eye
helplessness or horror. Most people exposed to trauma including people, places and activities, and movement desensitisation and reprocessing with
a traumatic event will adapt over time. For the also feelings of unreality or emotional numbness supervised, ‘real life’ exposure to the triggers.
5 per cent of people who develop PTSD after (up to and including dissociation).
Pharmacological interventions are not
experiencing a traumatic event, psychosocial generally regarded as a first‐line intervention
functioning can be seriously impaired. although antidepressants can usefully support
psychotherapy.
Prevention is supported by psychological screening
for vulnerability and the provision of information and
emotional support, as needed, immediately
post‐trauma.

CHAPTER 1 Mental health care in Australia 33

 Copyright © 2017. Wiley. All rights reserved.

TABLE 1.2 (continued)

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Mental health issue Typical presentation Recommended intervention

Psychosis

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

The causes of psychosis are not completely The most common symptoms are (i) confused In the short term, (i) reassure person; (ii) keep
understood. About three in every hundred people thinking (where thoughts are disorganised or person safe; (iii) reduce stimulation; and
will experience a psychotic episode at some point nonsensical); (ii) delusions (beliefs not shared (iv) transport person for comprehensive health

34 Mental health care

in their lives. with others of the same cultural background); and assessment.
Psychosis is generally understood to be the result (iii) hallucinations (visual, auditory — the most In the longer term, interventions are
of organic brain dysfunction. A person experiencing common), olfactory, tactile or taste sensations or pharmacological and psychosocial: (i) antipsychotic
psychosis has a reduced ability to distinguish what representations that are not objectively real. medication; (ii) stress reduction, including a
is real. reduced‐stimulus environment; (iii) support and
Psychosis is also associated with a number of reassurance; and (iv) lifestyle management.
organic conditions including delirium, dementia and
the use of alcohol or other drugs.
Not everyone who experiences a psychosis
will go on to be diagnosed with schizophrenia,
schizoaffective disorder, or bipolar affective
disorder. Some people only experience one or two
episodes of psychosis, while others experience
ongoing episodes and are diagnosed as having a
serious mental illness.

Schizophrenia

Schizophrenia is a long‐term and debilitating Symptoms of schizophrenia a similar to those of In the short term, (i) reassure person; (ii) keep
psychotic disorder that affects the way in which psychosis, however they are experienced in the person safe; (iii) reduce stimulation; and
a person thinks, feels and behaves. People are long‐term. In addition, people with schizophrenia (iv) transport person for comprehensive health
diagnosed with schizophrenia after they have been experience a range of ‘negative’ symptoms, such assessment.
unwell for six months or more, including at least as (i) a lack of emotional expression, (ii) a lack In the longer term, to achieve the best outcome,
one month during which they experience active of interest or enthusiasm in activities or life, and people who have been diagnosed with
symptoms of psychosis. Schizophrenia is also (iii) reduced ability to relate to others. schizophrenia are treated with a combination of
associated with a reduced capacity to function medication and community support. Interventions
as an active and contributing member of the most commonly include: (i) pharmacological,
community, leading to long‐term disability. including antipsychotics, (ii) psychological
therapies, including family interventions
and cognitive behavioural therapy, (iii) early
interventions, and (iv) community support programs.
 Copyright © 2017. Wiley. All rights reserved.

Mental health issue Typical presentation Recommended intervention

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Somatisation

The development of physical symptoms in response People who somatise symptoms are not feigning or In the short term, as for anyone in distress,
to psychosocial distress. There are three aspects: ‘putting on’ symptoms, but are genuinely convinced (i) reassure person; (ii) make sure person is safe;

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

(i) physical symptoms with no pathophysiological that they are physically unwell. The most common (iii) transport person for comprehensive health
cause; (ii) the person believes they are physically somatic complaints are (i) throat problems, assessment.
ill; and (iii) the person seeks the help of health (ii) pregnancy, (iii) chest pain and (iv) anxiety. Other Long‐term interventions are psychological, including
professionals (usually GPs). common somatic problems are (v) hypertension, cognitive behavioural therapies, interpersonal
In Western societies, somatisation is more (vi) depression and (vii) oesophageal problems. psychotherapies and the technique of reattribution,
common than depression and anxiety in general where people are encouraged to move away from
medical practices. Somatisation is found in around somatic concerns to consider their emotional
20 per cent of people who seek the help of a GP — issues.
and often people discovered to be depressed or
anxious will present first with somatic symptoms.
Women are twice as likely to present with somatic
complaints than men.

CHAPTER 1 Mental health care in Australia 35

 While the list of common mental health issues in table 1.2 provides health professionals with a con­
venient means of categorising the experiences of a person, it is important to acknowledge that informa­
tion about a diagnosis, signs and symptoms and interventions does not of itself lead to better outcomes
for the person. As noted in previous sections of this text, what is most important is the quality of the care
and caring a person receives.
High quality health service delivery is only ever achieved through high quality relationships between
the person affected by mental health problems and the health professionals. Indeed, the therapeutic
relationship has been identified as the most effective means of bringing about positive change in the
health outcomes of people with a mental illness (Browne, Cashin & Graham 2012; Royal Australian and
New Zealand College of Psychiatrists 2013; Theodoridou et al. 2012). Quality therapeutic relationships
assist with problem solving, medication adherence and improving quality of life (Klingaman et al. 2015).
They also promote positive personal growth and development, and increased levels of personal func­
tioning and coping. The therapeutic relationship is explored at length in the chapter focusing on assess­
ment in the mental health context.
Copyright © 2017. Wiley. All rights reserved.

36 Mental health care

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

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 SUMMARY
This text provided an overview of the frameworks that guide the delivery of mental health services in
Australia. It defined key terms, such as ‘mental health’ and ‘mental illness’, and explained the need for
health professionals to be careful about the way they use language in the mental health context. This
explanation led to a discussion about the effects of stigma upon people with mental health issues. There
was a particular focus on care and caring in the text, including ways and means health professionals
can foster a caring approach to helping people. Current policy directions and service frameworks and
approaches (including a discussion of the place of mental health Recovery) were also examined. This
was followed by an explanation of the prevalence of mental illness in Australia, with a focus on suicide
and mental health issues for young people. Finally, the text outlined the most common mental health
issues encountered by health professionals who work across a range of health settings.

KEY TERMS
biomedical approach the Western, scientific approach to the treatment of illness or disease. The
causes of illness are viewed as biological. The health professional’s role is to make a diagnosis,
prescribe treatment interventions and achieve measurable outcomes.
burden of disease the overall impact of disease or injury on a society, including that which is beyond the
immediate cost of treatment. Burden of disease incorporates individual, societal and economic costs.
competency a capability or standard, or level of practice comprising knowledge, skills and attitudes
that are measured by a set of valid and reliable items.
consumer‐centred care a model of care in which the health professional ‘works with’ the consumer
rather than ‘acts upon’ the patient; this includes advocating for the consumer and enabling them to
become active participants in their treatment and care
co‐occurring or co‐associated condition sometimes referred to as a comorbid condition, these terms
describe a disease, disorder or condition that occurs at the same time and/or is related to another
unrelated disease, disorder or condition
deinstitutionalisation the process of dismantling the asylum or mental institution network and
rethinking the social position of people with a mental illness.
discrimination the unfair treatment of a person or group of people based on categories such as gender,
age, class, ethnicity, culture, religion, health issue or disability
empirical data data gathered from observation or experiment, most often related to values that form
part of the scientific method
empowerment the process through which people become more able to influence the individuals and
organisations that affect their lives
evidence‐based practice relates to the health interventions or practices for which systematic research
has provided evidence of effectiveness; also known as ‘empirically supported treatment’
generic caring learned as part of a person’s ongoing growth and development, by way of upbringing,
family background and life experiences
health care a systematic and comprehensive service that is delivered in the health context; is
person‐centred, collaborative, supportive; and aims to improve health outcomes
health professional a person who delivers competent, appropriate and effective health care in a
Copyright © 2017. Wiley. All rights reserved.

systematic way
integrated community services services located in the community that have established links and
work in partnership or a coordinated way to improve outcomes for consumers
key performance indicators (KPIs) a set of quantifiable measures used by health services to gauge or
compare performance in meeting strategic and operational goals
mainstreaming the integration of mental health services with general health services

CHAPTER 1 Mental health care in Australia 37

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

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 mental health the capacity of individuals and groups to interact with one another and their
environment in ways that promote subjective wellbeing, optimal personal development, and use of
their abilities to achieve individual and collective goals
mental health problem a mental health issue that is less severe than a mental illness or disorder
which, if not dealt with, can develop into a mental illness or disorder
mental illness or disorder the term most commonly used in health care to describe the spectrum of
cognitive, emotional and behavioural conditions that interfere with social and emotional wellbeing
and the lives and productivity of people
moral imperative originally defined by the philosopher Kant, who described a principle of conscience
and reason that compels a person to act
morbidity the incidence of ill‐health or disease
mortality the incidence of death in a population
multidisciplinary team a group of health professionals from a variety of disciplines, with different
skills or areas of expertise, who work together to provide systematic and comprehensive care and
treatment to those in need
nurse a health professional with a holistic and comprehensive or ‘whole of person’ approach to health care
occupational therapist a health professional who supports and enables people to accomplish everyday
tasks to achieve a maximum level of independence and safety
one‐size‐fits‐all approach an approach or intervention that does not take into consideration
diversity or difference; rather it demands that the needs and preferences of all people are met by a
standardised approach or intervention
paramedic a frontline health professional who provides emergency or life‐saving, and other
unscheduled health care, out‐of‐hospital and in the community
primary care a subset of primary health care; it is accessible, affordable, and enables people or groups of
people to participate individually and/or collectively in the planning and implementation of their health care
primary health care health care that focuses on the multiple determinants of health and the need for
community control over health services
professional caring caring that is conscious, comprehensive, competent, context specific, and
encompasses the physical, psychological, social and spiritual aspects of a person
psychiatrist a medical practitioner who has specialised in the field of psychiatry; they focus largely on
the biological causes of illness and prescribing medication
psychiatry the branch of medicine that specialises in the treatment of mental illness
psychologist a health professional whose focus is the cognitive and behavioural aspects of a person
and their health. A clinical psychologist has a higher level of education and expertise in this area of
health delivery than a psychologist
public health care system universal health care funded and administered by the Commonwealth and
state/territory governments in Australia. This system is subsidised by these governments through
Medicare, and state and territory departments of health, and can be accessed by all Australian
citizens or permanent residents
public health framework the overarching approach to health service delivery in Australia that focuses
upon population trends, prevention of illness and promotion of health
Recovery model a consumer‐centred model of health care that focuses on hopes and goals for the
future, optimism, and living life to the full
secondary health care health care that is generally accessed after referral by a health professional; it
Copyright © 2017. Wiley. All rights reserved.

is typically delivered through hospitals or other related services funded by state or territory public
health services
social worker a health professional who intervenes to support those who are socially disadvantaged by
providing psychological counselling, guidance and assistance with social services
somatisation the experience of a person who feels, reports, or is preoccupied with physical symptoms
that have no biological cause and/or are disproportionate to any actual physical disturbance

38 Mental health care

Hungerford, C. (2017). Mental health care, 3rd edition. Wiley.

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 stigma an attribute, behaviour or reputation that is perceived, constructed and/or represented by a
group of people, society or culture in a negative way
tertiary health care health care that is delivered by highly specialised health professionals and
services, often located in larger service centres
universal health coverage a health care system that provides health care and financial protection to all
citizens of a country at little or no cost
universal phenomenon a factor, feature, event, situation or dynamic that is not confined to any
particular category, group, culture or population
World Health Organization (WHO) an agency of the United Nations that is an overarching authority
on international public health and coordinates international public health initiatives. Its headquarters
are in Geneva, Switzerland.

REVIEW QUESTIONS
1 Define ‘mental health’ and ‘mental illness’.
2 What role does the media play in perpetuating the stigma attached to people with a mental illness?
3 What is the difference between a psychologist and a psychiatrist?
4 Why is it important to know about de‐institutionalisation?
5 Define ‘care’ as both a noun and a verb.
6 What are the differences between person‐centred and consumer‐centred approaches to helping
people?
7 Identify the main principles of Recovery approaches to mental health service provision.
8 What is the mental illness that young people in Australia are most likely to experience?
9 What intervention is most effective for helping young people with mental health problems?
10 Identify and describe the four most common mental health problems in Australia.

DISCUSSION AND DEBATE

1 Consider the following scenario.
Elissa is studying nursing at university and is keen to work in the emergency department of a
tertiary referral hospital after she graduates. In her view, this will be an exciting and varied job
that will allow her to really make a difference for people who are acutely unwell. Mustafa is
studying paramedicine and is looking forward to using his knowledge and skills in emergency
situations that require quick thinking and fast action to save lives. Neither Elissa nor Mustafa can
see the relevance in learning about care and caring, mental health Recovery, consumer‐centred
approaches, or even the most common mental health disorders. In their view, all they needed to
know is how to ‘stop the bleeding’ while dealing with the occasional ‘drunk’ or ‘madman’ who
may cross their paths.
Consider the points of view of Elissa and Mustafa. How would you respond to their concerns
about the comprehensive approach to learning that they are required take as part of their courses?
2 ‘There is no way I would ever work in the field of mental health, I would lose my clinical skills.’
This attitude is evident in many health professionals. Discuss the statement, in light of the high
Copyright © 2017. Wiley. All rights reserved.

levels of people with a physical illness who also have a mental health problem; and people with a
mental illness who also have a physical illness.
3 Discuss the difference between primary health care and primary care. Why are these differences
important?
4 Why is it important for all health professionals to understand current national and state/territory
policy directions and the models of care utilised by mental health services?

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 5 Consider the alarming suicide rate of older men aged 85 years and over. What do you see as
the main contributors to this situation? What role does ‘ageism’ play? What more can all health
professionals do to address the issues involved?
6 How does knowing the most common mental health problems, the signs and symptoms of these
problems, and the main interventions to address the mental health problems, support health
professionals in their caring role?

PROJECT ACTIVITY
Choose one of the four myths about mental illness identified in table 1.1.
1 Review research and government databases for evidence that ‘de‐bunks’ the myth you have chosen.
2 From your reading, identify at least five additional facts that could be added to the list already
provided.
3 What practical steps can be taken by health professionals, in the course of their work, to help to
‘de‐bunk’ these myths?

WEBSITES
1 The Australian government’s Mental Health Commission was established in 2012 to provide
independent reports and advice to the community and government on what’s working and not
working in the field of mental health. The Mental Health Commission sees mental wellbeing as
important to the individual, their family, support people and the community; as well as employers
and co‐workers, health professionals, teachers and friends. The Mental Health Commission aims to
support all people and groups to work together to improve mental wellbeing and a sense of a life
well lived: www.mentalhealthcommission.gov.au
2 Emerging Minds actively promotes the mental health and wellbeing of infants, children, adolescents
and their families/carers. This website is dedicated to advocating for the development and
implementation of appropriate prevention, promotion and early mental health programs and services
for children and their families. The levels of mental health of infants, children and adolescents has
a significant impact on their future health and wellbeing. This website provides information on
the programs and services available for children with mental health problems, and their families:
www.emergingminds.com.au
3 The Australian government’s Mindframe National Media Initiative in Australia has a companion
website. The sections of this website have been created to provide access to accurate information
about suicide and mental illness and the portrayal of these issues in the news media, on stage and
on screen in Australia: www.mindframe‐media.info
4 The Australian Institute of Health and Welfare provides information about mental health and a
range of services offered. This includes the page: ‘Mental health services in Australia’, which
provides a picture of the national response of the health and welfare service system to the mental
health care needs of Australians: http://mhsa.aihw.gov.au/home
5 Mental Health Australia is the peak, national non‐government organisation representing and
promoting the interests of the Australian mental health sector. Mental Health Australia is committed
Copyright © 2017. Wiley. All rights reserved.

to achieving better mental health for all Australians. The organisation was established in 1997
as the first independent peak body in Australia to truly represent the full spectrum of mental
health stakeholders and issues. Mental Health Australia members include national organisations
representing consumers, carers, special needs groups, clinical service providers, public and private
mental health service providers, researchers and state/territory community mental health peak
bodies: https://mhaustralia.org

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 6 Australian Indigenous Health InfoNet is a web resource for people working, studying or interested
in addressing issues that influence the social and emotional wellbeing (including mental health)
of Aboriginal and Torres Strait Islander peoples. The resources provided on this website include
research evidence and other knowledge that supports the work of practitioners and policy makers
in the social and emotional wellbeing area: www.healthinfonet.ecu.edu.au/other‐health‐conditions/
mental‐health
7 The United Nations is an international organisation that works to develop friendly relations among
nations and promote social progress and human rights. It provides guidance on how people with
mental illness can expect to be treated in the health care system through its Principles for the
Protection of Persons with Mental Illness and the Improvement of Mental Health Care: www.un.org
8 The World Health Organization (WHO) is the public health arm of the United Nations. The primary
role of WHO is to direct and coordinate international health within the countries that are part of
the United Nations’ system. The main areas of work of WHO are health systems, promoting health
through the life‐course, noncommunicable diseases, communicable diseases, corporate services,
preparedness, surveillance and response. Information about mental health from a global point of
view is also available: www.who.int/about/en

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ACKNOWLEDGEMENTS
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Quote: © World Health Organization
Quote: © Commonwealth Government
Figure 1.1: © Australian Bureau of Statistics
Figure 1.2: © Evans K, Nizette D & O’Brien A (2017) Psychiatric and mental health nursing (4th ed.).
Chatswood: Mosby Elsevier.
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46 Mental health care

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