Human Rights and Mental Illness 

Report of the National Inquiry 
into the Human Rights 
of People with Mental Illness 


Part III 


People with 
Particular Vulnerabilities 




Chapter 17 

ELDERLY PEOPLE 

Introduction 

Psychiatric disorder is at least as prevalent among the aged as among the 
young, but elderly people also have special needs. Old age can bring economic, 
social, physical health and accommodation problems which make coping with 
a mental illness doubly difficult. Compounding these factors, evidence to the 
Inquiry clearly established that the elderly are often victims of discrimination 
in health services, either through abuse or neglect. The worst images associated 
with the old mental institutions — for example patients being physically 
restrained or sedated — are still the reality for many confused and sick elderly 
people. Their mental illness frequently goes unrecognised and untreated, or 
inappropriately treated. All these problems are becoming more urgent as the 
proportion of older people in our population rapidly increases. 

The most serious mental illnesses, such as schizophrenia and manic depression, 
are found among the elderly. But two disorders afflict them particularly 
frequently: dementia and depression. 

Dementia 

'Dementia' means a loss or impairment of mental powers. The term is used to 
refer to a group of conditions (including Alzheimer's disease) where the most 
prominent symptoms are memory loss and confusion. It is the most common 
mental health problem among people over 80. Among the younger elderly (65-80) 
other disorders are more common (especially depression), but dementia is 
probably still the most troublesome. 

It has been called the living death. And this is really what happens. The person 
in later stages is there in body but their personality has gone. It is not the 
same person.1 

Most dementia (about 70 percent of cases) is due to Alzheimer's disease, and 
the term 'Alzheimer's' is often used (inappropriately) to refer to dementia 
generally. The precise cause of Alzheimer's disease is unknown. The second 
major cause of dementia is stroke, which damages patches of the brain and 
produces 'multi-infarct' dementia. Dementia can also result from diseases such 
as AIDS, Huntington's Chorea or Parkinson's disease, or from alcohol-induced 
brain damage. 

Human Rights and Equal Opportunity Commission Page 509 



Whatever its origin, the prominent manifestations of dementia are usually the 
same: confusion and loss of memory (especially short-term memory), often 
accompanied by delusions or depression. It is usually progressive and 
irreversible. 

There is some disagreement about whether dementia is a mental illness or 
simply a physical disease affecting the brain. NSW is the only State which has 
a detailed operational definition of mental illness incorporated in legislation,2
 and that definition does not include dementia. So for certain important legal 
purposes (such as involuntary admission to a psychiatric hospital) dementia is not 
classed as a mental illness in our most populous State. But expert witnesses to 
the Inquiry were virtually unanimous that for medical purposes — and in terms of 
social impacts — it should be treated as a mental illness.3 

Incidence: the Ageing Population 

The number of older people in the world is increasing rapidly. The proportion 
of the population which is elderly is also rising in industrialised countries, 
due to lower birth rates and greater longevity. 

In Australia, the number of people over 80 years old is expected to grow from 
260,000 in 1981 to 560,000 in 2001 and 790,000 in 2021. The number over 65 
will be 2.26 million, or 12 percent of the population, by 2001; and 3.48 
million, or nearly 16 percent of the population, by 2021. Some European 
countries already have more than 16 percent of their population over 65. 

The rise in the elderly population will bring a corresponding increase in the 
mental disorders of the aged. In most industrialised countries dementia 
currently affects about 5 percent of people over 65. However, the incidence 
rises sharply as age increases: 20 percent of those over 80 are afflicted.4 At 
present, 100-140,000 Australians have moderate to severe dementia — but this 
number is expected to exceed 200,000 within 10 years.5 

Dementia is not restricted to the elderly: 10 percent of sufferers are under 65. 
However, there are no services designed specifically for these thousands of 
younger sufferers.6 

Where are the Dementia Sufferers? 

Approximately half of Australia's dementia sufferers live at home, alone or 
with relatives. A substantial number live in residential facilities (hostels and 
nursing homes).7 Many, however, are homeless or live in boarding houses or 
refuges, where they frequently receive no formal treatment for their mental 

Page 510 Mental Illness Inquiry 

illness. They also miss out on support from family and friends which is vital 
to so many dementia sufferers living in the community.8 Expert witnesses told 
the Inquiry that 60-80 percent of nursing home residents have dementia, and 30 
percent suffer from depression.9 But some are in residential care primarily 
because they are physically ill or frail. If they were physically well, a 
significant number could live at home.10 

About 3000 dementia sufferers are patients in psychiatric hospitals.11 Some are 
there primarily because they have another mental illness, and some because 
their dementia produces severely disruptive behaviour. However, a number are 
still so confined because our society has provided no alternative. 

Depression 

According to expert opinion, depression among the elderly often goes undiagnosed 
— but it may be twice as common as dementia.12 About 50 percent of 
elderly people have at least one symptom of depression.13 Estimates vary, but 
one Australian study found major depression in 10.2 percent of those over 65.14
 (Even on a conservative estimate, this would mean over 100,000 older 
Australians suffer this painful condition.) 

One measure of depression is the suicide rate, which is higher among people 
over 65 than in any other age group.15 The rate for men 70-79 is the highest 
for all males.16 

Depression frequently accompanies other health problems. It often occurs 
alongside dementia, and the symptoms of the two conditions are sometimes 
confused.17 It is associated with chronic physical illness, which is itself more 
prevalent as people get older. Depressive symptoms are also a common side 
effect of prescription medications, including hypertension drugs — and the 
elderly take far more medications than the young. 

Ironically, depression is one of the most curable mental illnesses. However, the 
evidence indicated that among the elderly, it is often — unnecessarily — left 
completely untreated. All too often it is not even diagnosed. 

Treatment of the Elderly Mentally III 

Evidence to the Inquiry established that our health system often ignores elderly 
people who are mentally ill, or assigns them the lowest priority. The elderly are
 more likely to get drugs, less likely to receive psychotherapy, and less likely 
to use outpatient services than younger patients.18 They may also miss out on 

Human Rights and Equal Opportunity Commission Page 511 

the medical care they need, for example an operation or physiotherapy which 
could improve the quality of their lives.19 

People are often denied treatment or assessment because they are old and because 
they are dementing. Why operate on an old person's painful joint — they haven't 
got long to go. Or a person with dementia doesn't get treatment for their peptic 
ulcer because, after all, what do they know?20 

Neglecting the physical health needs of old people is a form of elder abuse. It 
is also self-perpetuating: elderly people in poor health are three to four times 
more likely to become victims of abuse than those in good health.21 

Inappropriate treatment is not only unhelpful; it can also distract attention from 
other health problems needing attention. For example, the Inquiry heard 
evidence concerning an elderly woman in Queensland who was given ECT as 
a treatment for disturbed behaviour which was assumed to be caused by a 
mental illness. In fact the behaviour was due to an undiagnosed bowel irritation 
which, in a younger patient, might not have escaped detection for so long.22 

When an elderly person's mental illness requires hospitalisation or residential 
care, it is hard to find a bed available. And if one is found, it is quite likely to
 be inappropriate. If elderly people with mental illness remain in the community, the
 services they need are often not provided. 

In the competition for scarce mental health resources, the elderly take low 
priority. For example, in hospital redevelopment, the elderly are at the bottom 
of the list: 

The acute care wards are being rebuilt first and the drug and alcohol wards, and then
 eventually they plan to rebuild the psychiatric wards for the elderly. That may be 
seven years down the track, it may be ten years. But it is going to be last, there is 
no doubt of that, and of course, by then I expect the money will have run out.23 

Some witnesses told the Inquiry of a shortage of psychogeriatric beds in 
hospitals; others said the problem is not so much an overall shortage as an 
inappropriate distribution of beds between hospitals and other residential 
facilities.24 When places are available, they are not always appropriate. Little 
attention is paid to the need to separate the demented elderly from the 
psychiatrically disturbed but non-demented elderly, from psychiatrically 
disturbed younger people and (in nursing homes and hostels) from patients 
whose disability is solely physical.25 

Page 512 Mental Illness Inquiry 

Treatment of Dementia 

We may still not know what causes the major dementing illnesses and we have no cure but 
we do know how to treat them. I should say that we know how to treat the people who suffer
 from them because there is a difference between treating the disease and treating the 
sufferer... Let the researchers carry on their work. We all hope that science will provide
 the answer and that one day there will be a prevention and a cure. But in the meantime we
 must spread the word that dementia is manageable, that people with dementia need not 
suffer because of the illness.26 

Managing dementia essentially consists of providing safe living arrangements 
where sufferers can maintain their remaining mental and social skills and 
protected, as far as possible, from events that make them anxious, confuse 
angry or frustrated. 'Such feelings go badly with dementia because the suffer 
is unable to deal with the reason and can only respond to the feeling itself. 
This means that, at least in the later stages of dementia, treatment is closely 
linked with accommodation. In the early stages it is more dependent on support 
services in the community.28 

Evidence to the Inquiry consistently indicated that people with dementia in 
institutional care should be separated from people who are not cognitively 
impaired. For people without dementia, it can be very distressing to be around 
someone who 

doesn't know what day it is, where she is, who you are, what you just said, what 
happened 30 seconds ago, what is happening now and what will happen to her in the next 
30 seconds.29 

The evidence also clearly indicated that one important distinction frequently 
overlooked by health planners is between dementia sufferers who are bedbound 
and those who are ambulant, ie physically well and inclined to wander. The 
behavioural changes that come with dementia can be extremely disruptive to 
other patients. For example, the right to personal privacy is recognised in 
Federal law and the Federal Government's Charter of Nursing Home Rights and 
Responsibilities,30 but it is extremely difficult to enforce against a wandering 
co-resident with dementia: 

In a nursing home situation someone with dementia can go in and rummage in somebody else's 
locker or dressing table. They can get into the wrong bed. And the normal aged get very 
upset by this sort of behaviour and lack understanding, because that bed and that dressing 
table is their only private space left in that time of their life. And so they need to be 
kept contented and happy as well as the person with dementia, who does not deserve to be 
yelled at for going into the wrong room or rummaging. Rummaging and wandering is a symptom 
of Alzheimer's disease.31 

Human Rights and Equal Opportunity Commission Page 513 

People with dementia are also a continual disconcerting reminder to other residents of what
 may await them as they grow older. (And since the majority of 
our elderly will not develop dementia, this fear is often needlessly induced.) 

The needs of dementia sufferers themselves are also very different to those of 
many other elderly people: 

They do not need stimulation, they do not need occupational therapy. They need a quiet
 environment where they can do duties or participate in activities they are familiar with.
 Simple things like light housework, raking the garden. And they need to be in small groups. 
Large groups can confuse them more. It would be like going into a room and not recognising 
anybody there. And every time they go into a gathering that is how it feels to them because 
their short-term memory is very, very short.32 

Contrary to the approach advocated by many witnesses to the Inquiry, the 
Federal Government's current policy on institutional care for dementia sufferers 
is to integrate them in ordinary hostels and nursing homes.33 Recently it 
modified its hostel funding formula — apparently to allow a higher subsidy for 
residents suffering from dementia. But it has shown little support for the idea 
of dedicated dementia hostels or nursing homes.34 

Residential Treatment 

Hospitals 

The psychogeriatric wards of public hospitals were criticised by a number of 
witnesses to the Inquiry. The large institutional setting is intimidating and 
depressing for patients and their families, lacking in privacy and expensive to 
run. For example in Sydney: 

I would emphasise the very inappropriate nature of the long-term ward... it is 
a barn. It is very institutional, quite inappropriate for long-term care, for 
people to live in for the rest of their lives... And you should see the toilets 
and the bathing facilities. It is horrible.35 

And in Newcastle: 

Some examples I find unsatisfactory are the persistence of dormitory style 
accommodation for elderly patients, the absence of facilities in many wards for
visitors' rooms and also the isolation of wards in which such patients are kept. 
For instance at Morisset Hospital, which is the site of most of our long stay beds,
 there is no public transport access. The railway station is some miles away and the 
taxi services there charge a country rate, which means that the relatives have to pay 
there and back for a trip. In general the standard of 
accommodation is very old and requires much renovation.36 

Page 514 Mental Illness Inquiry 

Similarly in Tasmania, the major psychiatric institution is 40km outside Hobart 
and public transport access is described as 'terrible'. Not surprisingly, patients 
there rarely receive visitors (one-tenth the number received by patients in a smaller 
facility in town).37 The isolation this imposes is cruel — and especially difficult 
for elderly people and their spouses to overcome. 

A particular problem for elderly people in psychiatric hospitals is that their 
physical health needs tend not to be adequately met. The elderly have far more 
health problems than younger patients, but psychiatric facilities are not 
equipped to deal with chronic physical ailments. This means elderly psychiatric 
patients do not receive the level of care they should be getting from medical 
specialists, physiotherapists and other health professionals.38 

There was a general consensus in the expert evidence presented that people 
with dementia should only be hospitalised as a last resort. But some 3000 
dementia sufferers live in mental hospitals,39 usually because there are no 
vacancies at smaller facilities. Some are people who were admitted years ago 
with schizophrenia or another mental illness, who have grown old and 
developed dementia in hospital. Others have been admitted more recently, 
specifically for disruptive behaviour caused by dementia. 

Some people currently in hospital with dementia would be unable to cope with 
life anywhere else. But many patients admitted to specialist psychiatric facilities 
mprove over time, to the point where they could very well be placed in purpose designed 
dementia facilities (of which there are still very few), nursing homes or hostels, making 
room in the psychiatric facility for more disturbed people. The Inquiry was told, for 
example, that Hobart's Royal Derwent 
Hospital has some 70 patients in this category. Unfortunately, the waiting list 
for a place in a nursing home in southern Tasmania is 100-120 names long; and 
as vacancies arise, they go first to people still in the community rather than 
those who are already in institutions. No new dementia patients are being 
admitted to Royal Derwent, but those already there remain in hospital because 
'there is nowhere else to go.'40 As one expert said: 

I have always been convinced that this is almost a crime to send elderly people to such a 
situation. It is always counter-productive, always makes for more disturbance, and the only
 possible way that the mental hospital can cope with this is either to drug them down, tie 
them down, or lock them in and let them pace around.41 

Discriminatory funding arrangements have also been a significant problem. 
Before the Inquiry commenced, Federal Government rules denied admission to 
a nursing home to anyone who had been a patient in a psychiatric hospital for 
12 months.42 The reason for the rule appeared to be cost-saving for the 

Human Rights and Equal Opportunity Commission Page 515 

Commonwealth (which funds nursing homes), by keeping patients in the 
hospitals (which are funded by the States).43 

Discrimination by nursing homes against the mentally ill also prevents transfers 
out of hospital. An elderly person known to have schizophrenia would very 
likely be rejected, even if the condition were well controlled with medication.
44 A psychogeriatrician at the Selby Lodge psychiatric unit in Western 
Australia told the Inquiry: 

We have had the situation where relatives have approached a prominent nursing home, told 
them that their relative was in Selby Lodge, and have been told: we do not accept patients 
from Selby Lodge. That same nursing home, on the other hand, will ask us for help when they
 have difficult patients.45 

Nursing Homes and Hostels 

For many elderly people, involuntary admission to an aged institution can be the ultimate 
denial of human rights. The level of dependency and corresponding loss of power experienced 
is often without parallel. Lives have to be adjusted to accommodate a set of routines imposed
 by a hierarchical structure in which the patient is at the bottom of the heap. The loss of 
freedom and corresponding quality of life is devastating for many elderly people.46 

Nursing homes and aged hostels are an important form of accommodation for 
elderly people who can no longer manage living at home. The two categories 
overlap, but generally hostels are for those who are physically well and without 
significant behavioural disorders, but who need some help with eating, bathing 
and dressing. They have fewer staff than nursing homes, and usually no nursing 
or medical staff. 

Nursing homes generally cater for people who need substantial daily assistance 
and continuing nursing care. These facilities are often associated with hospitals, and most
 patients are seen regularly by their general practitioners. However, most nursing homes have 
little or no contact with psychiatric services.47 

Most nursing homes and hostels are run by charities or private operators. They 
are funded by a Federal Government subsidy and by the residents, who pay 8590 
percent of their pensions to live there. In some cases State governments also 
contribute top-up funding. 

Apart from these 'Commonwealth-funded' homes, there are a number of State 
nursing homes (run by State governments and funded from State health budgets) 
and some completely private facilities. 

Page 516 Mental Illness Inquiry 

Nursing homes and hostels are intended to serve different clienteles, but they 
share common problems of long waiting lists and, at least from the perspective 
of dementia sufferers, poor design.48 

Waiting lists for admission to both hostels and nursing homes are long — partly 
because of a shortage of places, but more because the shortage of support 
services in the community causes families to see residential care as their only 
option. Family carers often go to a great deal of trouble to research the best 
place for their demented relative to go, only to find that in reality they have 
very little choice. If a vacancy comes up they are forced to take it, regardless 
of whether they consider it appropriate. 

The design of nursing homes and hostels poses a major problem for managing 
ambulant dementia. About 10,000 dementia sufferers in Australia who live in 
nursing homes have serious behavioural disorders.49 Nursing homes, like other 
old age services, are usually designed to cater for frail elderly people who are 
often bedbound or at least chairbound. These homes often face onto main 
roads, and fire regulations require that the doors be kept open. But ambulant 
dementia patients tend to stray from the premises, or disrupt other residents if 
forced to remain inside. Staff cannot be expected to chase after them constantly,
 so instead: 

they get zonked out with medication or tied to their chairs. Not the nursing home's
fault, except they shouldn't have admitted them there in the first place. They admit 
them there because there is nowhere else for them to go.50 

Poor architectural design has been exacerbated in the past by the Federal 
Government's formula for funding staff in nursing homes and hostels. The 
formula is based on a Resident Classification Instrument (RCI) (or in hostels 
the Personal Care Assessment Instrument), which measures the needs of every 
person admitted to a nursing home. The RCI weights physical disability far 
more heavily than mental disturbance. Someone with dementia who is 
physically well rates much lower for funding than a bedbound stroke victim. 
This means ambulant dementia sufferers are seriously underfunded — given the 
staff time they actually require. As one expert witness told the Inquiry: 

A 70-year-old, fit as a Mallee bull, strong ex-farmer, say, who is wandering around 
trying to get out, potentially aggressive if he is frustrated, doubly incontinent, 
gets very significantly less nursing staff than somebody who is immobilised in bed...
it is incongruous and grossly iniquitous.51 

Since the cost of caring for people with ambulant dementia is so high, some 
nursing homes refuse to take them. More disturbingly, according to one expert: 

Human Rights and Equal Opportunity Commission Page 517 

every nursing home around the country that is trying to put in a special care unit 
for ambulant people with behavioural disturbance with dementia is going broke.52 

After the Inquiry had heard the evidence referred to above, the Federal 
Government (on 1 April 1992) introduced a revised RCI which gives more 
weight to behavioural disturbance as a factor in funding nursing home and 
hostel residents.53 However, it is not clear that this formula will significantly
 address the chronic problem of underfunding for dementia.54 

Standards of Care and the Charter of Rights 

The Commonwealth has set care standards for its nursing homes and hostels 
which constitute conditions for funding.55 In 1990 it also introduced a Charter 
of Rights and Responsibilities for nursing homes and a similar one for 
hostels.56 Whereas the standards are basically regulatory, the Charter informs 
consumers of their rights. The rights prescribed reflect international human 
rights instruments; they include the right to quality care, to full information, 
to personal privacy, to move freely without undue restriction, to maintain control 
over one's personal and financial affairs, 'to be treated with dignity and respect, 
and to live without exploitation, abuse or neglect'. 

While witnesses expressed strong support for the Charter, evidence to the 
Inquiry indicated that for many nursing home residents these rights are not 
translating into reality: 

[People] with dementia [aren't] fed, even though they can't feed themselves — 
the food is plonked down in front of them and they're left. Or the lack of dignity —
 they pull the clothes off themselves, and they're left naked. Or the lack of 
appreciation of personal values, so that an elderly man always had his shower in 
the evening, and he's forced to have it at five in the morning because that's the way
 the institution is structured. And of course he doesn't want the young female nurse
 showering him, because it degrades him, it humiliates him. And he lashes out and 
becomes angry when they try to do that, and so he is restrained or he is sedated.57 

Even in the best nursing homes, people with dementia are frequently unable to 
understand or exercise their rights — for example the right to information about 
their treatment or the right to control their own affairs. In such cases it is up
to family members or guardians to understand the Charter and protect these 
rights. The Charter does not mention dementia, but the Alzheimer's Association 
has asked the Government to consider the role of family carers in relation to 
the Charter, to strengthen and legitimise their involvement.58 

The Charter also specifies responsibilities, including that of respecting the 
rights and needs of other residents in nursing homes or hostels. As previously 
mentioned, the presence of a person with ambulant dementia can seriously 

Page 518 Mental Illness Inquiry 

infringe the rights of other residents who have their mental faculties intact.
 This places staff in the invidious position of having to decide whether to curtail 
the rights of one resident (eg by sedation) to preserve the rights of others (eg 
to privacy).59 This is not a deficiency in the Charter, but rather a result of 
current nursing home design and the established — but quite inappropriate — policy 
of forcing many mentally ill elderly to live with the mentally well. 

The Charter has the significant limitation that it applies only to Commonwealth 
facilities, and not to State government homes. Nor does it apply to psychiatric 
hospitals, boarding houses or private nursing homes which do not receive 
federal funding.60 Since, according to the evidence, most people admitted to 
residential care have little choice and less knowledge of the type of funding 
arrangements applying to the facility they are going into, it is basically 
happenstance whether or not they get the benefits of the Charter: 

We do not think, whether a service is State-run with the mental health system or 
Commonwealth funded in the nursing home or hostel, that people should have different
 rights. [In either type of institution] the needs of the person with dementia...
are exactly the same.61 

The Charter may not be delivering all that it promises, but the effects of 
excluding non-Commonwealth homes from its operation are substantial. The 
Charter is reinforced by a standards monitoring scheme which provides some 
level of control, through the potential threat to withdraw funding if standards 
are not met.62 Residents of private or State government institutions are denied 
not only their rights being clearly defined, but also the protection that this 
monitoring affords.63 

The States have their own regulations setting conditions for licensing of nursing 
homes, but evidence from several States (Queensland and Western Australia in
 particular) highlighted some disturbing practices in State nursing homes. 

Queensland has a regulation requiring the Director-General of Health to be 
notified if any resident has had to be coerced or restrained for long periods. 
The Inquiry heard evidence that this has been contravened by State nursing 
homes.64 Some nursing homes make their own judgment on whether a person 
with dementia has a mental illness or an intellectual disability, and then 
'process' the patient according to what is most convenient. Outright violent 
abuse also occurs: for example, in June 1992 a coroner in Victoria found that 
an elderly woman who died in a private nursing home in 1989 had been beaten 
by a nurse the night before.65 

Denial of basic medical care is a more common form of elder abuse: 

Human Rights and Equal Opportunity Commission Page 519 

The daughter of an elderly lady in a nursing home...complained to the Senior Medical 
Officer of the facility that her mother's prescribed pain relief was not being 
dministered by nursing staff...the SMO retorted: 'demented people don't feel pain.'66 

Evidence to the Inquiry also suggests the general standard of living in some 
State nursing homes requires investigation: 

For instance, six people live in a room and the food that is presented bears no 
resemblance to the menus on the walls.67 

Overmedication 

Elderly people with a mental illness are more likely to be given drugs than 
younger patients — and less likely to be offered alternative forms of treatment 
such as psychotherapy.68 

In the case of people with dementia, the tendency to administer drugs 
frequently turns into overmedication. Dementia sufferers are often alert and 
active at night, especially if they have not been fully occupied all day. To cope
 with the inconvenience this creates, staff in nursing homes often resort to the 
'chemical straitjacket' of sedatives. For example, the Inquiry was told 60-70 percent
of elderly patients in Tasmanian nursing homes are routinely prescribed night-time 
sedatives. Whether the drugs are actually administered depends merely on whether staff
are available to supervise wakeful patients.69 

Overmedication was also referred to by witnesses in other States,70 and there 
is no reason to assume that Tasmania is worse than other jurisdictions in this 
respect. 

Apart from being medically unnecessary, the sleeping tablets used are mostly 
benzodiazepines — drugs such as Valium, Mogadon and Serepax which are 
dependency-forming. The effects were described by an expert witness to the 
Inquiry in the following exchange: 

Chairman: Is there any adverse effect that occurs from people taking sleeping 
tablets when they do not need them, or is it just completely neutral? 

Dr Mathew: Definitely...if you sedate them they will be sleepy during the daytime
 and [have] hangovers and also they will get used to it and they will not 
be able to sleep without them. They will get habituated, most of these drugs do. 
Chairman: Sorry, did you say they become habituated? 
Dr Mathew: Habituated. 

Page 520 Mental Illness Inquiry 

Chairman: So is there an element of addiction or habituation? 
Dr Mathew: There is, yes.71 

To make matters worse, psychiatric drugs can have effects which actually 
resemble the symptoms of mental illness, especially of depression. This can 
confuse the diagnosis and treatment, so that patients end up taking more drugs 
to 'cure' them of the effects of the drugs themselves. 

Solutions: Special Dementia Care Facilities 

Many of the behavioural problems associated with dementia can be ameliorated 
by designing residential facilities specifically for dementia sufferers. Special 
dementia hostels are similar to standard hostels or nursing homes, but with a 
secure environment and with staff who have received training in dementia 
care.72 These two factors virtually do away with the need for sedation as a 
'management' (rather than a medical) practice.73 From a practical point of 
view, one major design requirement is simply a garden for patients to walk in, 
with a secure fence around it to prevent them wandering away. The design 
should also minimise confusion for people who are apt to forget where they 
are. 

In spite of the large and growing number of elderly people affected, Australia 
has only a handful of purpose-built dementia facilities. One which impressed 
the Inquiry is the Flagstaff Gully nursing home, opened recently in Hobart 
after an 8-year planning process. Operated by the Alzheimer's Association, it 
provides a series of small 'home-like' units in a secure environment, 

but it does not appear or feel or look like a locked environment. There is
enough outside wandering area and enough doors leading to other wandering places,
 so that theydo not feel that they are in a locked environment. And neither do the
 staff or family who visit. And that is a very important part.74 

Flagstaff Gully accommodates 32 people with ambulant dementia and significant 
additional problems — for example, double incontinence and behavioural 
disturbances like aggression or 'trying-to-get-out sort of behaviours'.75 A 
research project is under way to compare its effectiveness with that of a normal 
mental hospital ward. The research to date is encouraging: 

They are all so happy and relaxed... When you go there you will see people who 
you will say: these people are not behaviourally disturbed, they should not be 
here. I can assure you they were very behaviourally disturbed when they went there, 
and it is the environment and the staffing that has improved the situation.76 

Human Rights and Equal Opportunity Commission Page 521 

Flagstaff Gully's designers hope to demonstrate that their model is more cost-
effective than a hospital ward, being cheaper to build and using staff more 
efficiently. They estimate staff time savings will pay for the building costs in 
two years.77 

Another special dementia facility visited by the Inquiry is the Lefroy Hostel 
run by Anglican Homes in Perth. This hostel is also secure, with extensive 
grounds where the 36 patients can wander safely. The building itself is designed 
to allow residents to walk around without encountering long corridors or dead 
ends, and to end up back where they started. 

Rooms at Lefroy Hostel are furnished with the residents' own familiar 
possessions to give them a sense of belonging, of ownership and self esteem. 
The dining areas are small, so that even though they may not recognise people's 
names, they can recognise and retain the feeling and emotions and also retain 
some recognition of faces, so they can form friendships.78 

Apart from the design of physical facilities, the success of residential dementia 
care depends critically on the quality of staff: 

Good staff can partially retrieve a poor environment. The most marvellous environment
cannot retrieve the situation produced by poor or untrained staff.79 

The staff at Lefroy Hostel have had specific dementia training but they are not 
nurses. They are chosen 'more [for their] attitude to elderly people than 
qualifications'.80 The hostel tries to keep its residents active, emphasising 
activities that they find rewarding and which maintain their skills as long as 
possible. 

The operators of the Lefroy Hostel have estimated the relative cost of 
maintaining dementia sufferers in a standard hostel, an ordinary nursing home 
or a special dementia hostel like theirs: 

standard hostel special hostel nursing home (Cth)

cost per resident 17,000 26,400 34,000 
($/year) 

subsidy from Commonwealth 
5,400 10,900 24,000 

Page 522 Mental Illness Inquiry 

The cost of running a dementia hostel is more than a standard hostel, but 
substantially less than a nursing home. The subsidy from the Federal 
Government is also lower — so low, in fact, that Lefroy Hostel loses $250,000 
per year. The Western Australian Government has been contributing approximately 
$150,000 per year to make up part of the shortfall, but Anglican Homes 
told the Inquiry it cannot continue to operate at such a low level of 
Commonwealth funding. It has asked for the subsidy to be lifted to $15,000 per 
year per resident. This subsidy would make Lefroy and future special dementia 
hostels viable, and allow a significant number of dementia sufferers currently 
in nursing homes to be cared for more humanely — and more cheaply.81 

The NSW version of special dementia accommodation is the CADE unit (the 
acronym stands for Confused and Disturbed Elderly). There are 6 of these 16bed 
units, all outside Sydney. They are purpose-built facilities designed on 
similar principles to Flagstaff Gully and Lefroy: a secure environment with a 
locked garden, catering for small numbers of ambulant residents, with 
behavioural disturbance, but who are not in need of nursing care. The 
bedrooms in CADE units are grouped around the kitchen and residents are 
encouraged to take part in cooking and other normal activities as much as 
possible. Witnesses who have observed CADE units praised them as excellent 
dementia accommodation, while lamenting the fact that there are so few (a total 
of 96 units for a State with at least 35,000 dementia sufferers).82 

On the evidence presented to the Inquiry it is quite clear that the few special 
dementia facilities operating in Australia are far more successful than 
conventional methods of dealing with dementia — despite the financial and 
bureaucratic obstacles they face. 

The demand for places in special dementia hostels is difficult to measure, 
because the paucity of special facilities means geriatricians and social workers 
generally do not consider them an option. However, one study of people with 
dementia found 77 percent of those admitted to nursing homes would have been 
appropriately placed in a special dementia hostel if one was available; only 23 
percent actually needed the nursing care provided in nursing homes.83 As 
special facilities are also much cheaper to operate, it is obvious that they are 
a far more economical and humane investment for dementia care than nursing 
homes. 

Ironically, Federal Government policy is to keep down the number of nursing 
homes and expand the hostel sector: between 1981 and 1985 the hostel bed 
ratio per 1000 people over 65 has increased from 14.0 to 21.9.84 But under 
the policy of integration, it is only standard hostels which are being encouraged.
85 Since standard hostels cannot cope with severely demented, behaviour-

Human Rights and Equal Opportunity Commission Page 523 

ally disturbed people, they end up being placed in nursing homes — the very option
 the Government is trying to discourage. 

According to one group of aged care agencies, the National Anglican Caring 
Organisations Network (NACON), the Government's refusal to support special 
dementia hostels is adversely affecting four groups of people: dementia 
sufferers in nursing homes (who are unnecessarily sedated or restrained); 
mentally well residents (who are subjected to the disturbing behaviour of their 
dementing neighbours); staff (who must constantly be policing dementia 
sufferers; and relatives (who can see that their loved ones are inappropriately 
placed). NACON believes this policy could constitute a breach of the 
Government's own standards and the Charter of Rights.86 

Community Care 

A large number of dementia sufferers live at home, on their own or with 
relatives.87 This is partly because it is so difficult to get into a nursing home
 or hostel; but it is also because many elderly people and their carers would prefer
 to 'keep the family together'— at least for as long as this is possible. 

Dementia sufferers who live at home are said to be living in the community, 
or receiving community care. In fact 'community care' is a misnomer which 
obscures the reality of who is doing the 'caring'. It does not mean care by the 
community or even by the family, but most frequently by wives, daughters and 
daughters-in-law. Seventy three percent of dementia carers are female. The 
increasing participation of women in the paid workforce may well mean that the 
pool of women available for this unpaid work will shrink.88 

Another effect of the ageing population is that carers are also getting older. 
Whether they are the wives, husbands or daughters of dementia sufferers, they 
are frequently elderly themselves.89 

The whole demographic situation in Australia is changing, as in other Western 
societies. Because people had children later it means the carers are now getting 
older themselves and... If you're 60 years old looking after an 84-year-old mother 
and you've got bad arthritis, it might be difficult for you to lift her out of bed 
and shower her and things like that.90 

As with other mental illnesses, the Federal Government's policy on dementia 
now aims to encourage community care instead of residential care. This policy 
reflects clinical opinion that residential care should be the last resort. In 
principle, dementia sufferers should be able to live in the community unless 
they are physically unwell or have serious behavioural problems such as a 

Page 524 Mental Illness Inquiry 

tendency to run away.91 Evidence presented to the Inquiry clearly indicates 
that providing such services would still cost the government significantly less 
than residential care.92 But this policy can only respect the rights of the 
mentally ill if carers have the support services they need. 

Burden on Carers 

Dementia places a great burden on family carers. Caring for a dementia 
sufferer is itself a psychological and physical health hazard.93 Carers have 
high rates of depression, anxiety and other psychiatric problems. 

The best way to support a person with dementia is to support his or her carer 

— because a dementia sufferer's quality of life is linked directly to the carer's
 ability to cope. The single most significant cause of institutionalisation is 
family carer breakdown.94 One witness accurately reflected a great deal of evidence 
presented to the Inquiry: 


I wanted to care for her at home, but in the end her mental state meant that I 
became so distressed and finally found it too difficult to cope with her. It was
24-hour care for the whole family.95 

At its worst, inadequate support for carers can lead to elder abuse or 'granny 
bashing'. The United States has witnessed the emergence of a practice known 
as 'granny dumping', in which relatives unable to cope with the expense and 
strain of caring for their dementing elders simply abandon them in a public 
place.96 Elder abuse ranges from neglect and manipulation to violence or 
exploitation: 

It mostly occurs in families...because the families are under such stress that 
they don't know how to cope, and they lash out in frustration.97 

Economics for Carers 

Caring for a person with dementia can be a full-time job. Apart from the 
economic sacrifice carers make by dedicating themselves to this task, they also 
save the community the cost of institutional care and accommodation. The cost 
of keeping someone in a nursing home is over $500 per week.98 As an 
incentive for home care, the Federal Government offers carers the Domiciliary 
Nursing Care Benefit (DNCB). The 1992 Budget raised this benefit to a very 
modest $52 per fortnight — indexed annually. For the previous 11 years it had 
remained at $42 per fortnight.99 

Many carers told the Inquiry that the DNCB eligibility criteria discriminate 
against dementia sufferers. The criteria are extremely narrow. They require that 

Human Rights and Equal Opportunity Commission Page 525 

the carer live full-time with the patient, and that the patient be specifically 
in need of nursing care. Dementia sufferers need many hours of care and 
supervision which is not strictly nursing — so they frequently fail to qualify. 
This is another facet of the problem which has traditionally undermined funding 
for dementia sufferers in nursing homes. 

Our taxation system discriminates against dementia sufferers who have paid 
carers living with them: 

There is no allowance within the taxation [legislation] for payments made to a
 live-in carer. However, a person who looks after someone who is blind or confined
 to a wheelchair — that is, someone who has a physical disability — the person who 
is paying for that live-in carer can claim those expenses as a taxation 
deduction.100 

The system also discriminates between dementia sufferers at home and those 
in residential care: 

If someone with dementia is living in a nursing home, fees paid over $1000 are 
claimable as a taxation deduction, versus no fees allowable if that person is 
still living at home. Indeed, that actually encourages people to move their family
 member into an institution.101 

Services for People with Dementia and Their Carers 

Community care for people with dementia should start from the premise that 
there is an invisible army of health workers out there who are doing most of this
 anyway. There are families, friends, neighbours who are doing a lot of this, and 
there is no way our country could afford to replace all that — nor should we try to. 
What we should try to do is harness it and fill in the gaps.102 

The support carers ask for is hardly extravagant — indeed, in the Inquiry's 
view it is extremely modest: 

Most carers of dementia sufferers agree that they can cope as long as they can get
 a good night's sleep, and some daily respite.103 

The services that exist for dementia sufferers and their carers were described 
to the Inquiry by several expert witnesses as 'a hotch-potch, without any 
thought of a strategy',104 'a bureaucratic nightmare'.105 This is largely 
because, historically, our aged services were developed with the physically frail
in mind and dementia services were grafted on, often inappropriately. The most 
successful services overseas (eg in the UK) are based on integrated dementia teams
 comprising doctors, social workers and psychiatric nurses. The teams have contact 
with the hospitals, visit people in hostels and nursing homes, and 

Page 526 Mental Illness Inquiry 

also support carers in the community.106 Such an integrated approach is rare 
in Australia for any mental illness — including dementia. 

As with other mental health services, dementia services, such as they are, are 
concentrated in the major cities. This creates serious inequities for elderly 
people and their carers in regional centres and rural areas, where services are 
often non-existent.107 (See also Chapter 22 — People in Rural and Isolated 
Areas.) 

The community mental health services that do exist are under strain due to lack 
of resources. This can be potentially dangerous. For example, a HACC worker 
in Tasmania told the Inquiry of an elderly immigrant man who was visited by 
a community nurse every day: 

[The nurse] prepared a box of medicine for him — several pills three times a day. 
He would take the box in one go, unsupervised at home.108 

Practical support services are important in enabling family carers to look after 
their elderly relatives, yet still maintain their own lives. For dementia sufferers 
who live on their own, these services are all that allows them to remain in the 
community. The services range from counselling and medical treatment to temporary 
residential care. They may also include assistance with housework or gardening, 
daycare to give the carer occasional time off, or technical solutions like changing 
all the locks over to one key to minimise confusion. 

The services required will vary with individual dementia sufferers and 
individual carers. They will also change as the dementia progresses. So a 
primary requirement for dementia services is flexibility. 

Daycare 

Some communities have daycare centres where severely demented, behaviourally 
disturbed patients are looked after by nursing staff. Daycare helps 
maintain the dementia sufferers' social abilities.109 But more importantly, it 
gives family carers the occasional respite they need to continue to do the job 
of caring. One such centre in Hobart is estimated to keep 30-35 people in the 
community and off the waiting list for residential facilities.110 The Inquiry 
was told more dementia-specific daycare centres are 'desperately needed'.111 

Dementia daycare should be programmed around clients — rather than around 
standard tasks or bureaucratic requirements. That means being flexible, 
allowing people with dementia to choose whether to be involved in group 
activities or not, acknowledging individuality and encouraging independence. 

Human Rights and Equal Opportunity Commission Page 527 

Successful daycare is culturally appropriate. This may mean furnishing facilities 
in an old-fashioned style that makes elderly people feel at ease, or in a centre
 with Italian-speaking clients, providing an interpreter and Italian shortbread 
at morning tea.112 

The limited daycare available does not in itself substantially alleviate the 
pressure on home carers. Scarce resources only allow individual dementia 
sufferers a few hours of daycare each week, still leaving family carers to bear 
the overwhelming responsibility. One witness pointed out that dementia daycare 
does not even approach the service that is generally expected of childcare, ie 
8.30-5.30 on weekdays.113 Another suggested that daycare centres should 
ideally function as night-care centres as well, because people with Alzheimer's 
disease commonly have interrupted sleep patterns and are often especially alert 
and active at night.114 

Respite Care at Home 

One of the most valued support services is respite care in the home. Various 
organisations and departments provide services such as Meals on Wheels, home 
help and domiciliary nursing. Home services are usually funded through the 
Home and Community Care Program (HACC). Some use volunteer labour; 
others have paid staff. These mainstream services offer valuable assistance to 
aged people and their carers. However, most are designed for clients who are 
physically infirm but mentally competent. People with dementia have special 
needs. They need services which are flexible enough to accommodate their 
erratic life patterns, with staff specifically trained to cope with confused 
behaviour. 

The Alzheimer's Association (WA) respite service 

One apparently successful respite service is run by the Alzheimer's Association 
in Western Australia. It has 30 paid carers and 22 volunteers who provide help 
to about 100 people each week. In its three years of operation it has helped 
over 500 dementia sufferers, including 165 'hard cases' who were referred on 
by other agencies because they did not fit their criteria. 

Clients can be referred to the service by any source: relatives, a GP or another 
health worker or agency. The only criterion for acceptance is a diagnosis of 
irreversible dementia. Staff assess the elderly person 'in the most unthreatening 
way possible': obtaining details from a family member over the telephone and then
 visiting the family at home. The service then matches the family with a carer who
 is judged most appropriate for that client. Carers are matched on the 

Page 528 Mental Illness Inquiry 

basis of personality and past experience, rather than on an arbitrary basis such 
as living in the same locality. 

The scheme's strong point is that it is tailored to meet the individual needs of 
each person. This contrasts with most mainstream programs, which require 
their clients to fit into fixed schedules. Clients in the respite scheme receive 
six hours of care a week, which can be during the week or weekend, during the 
daytime or at night. If the family carer wants to go out, the respite carer stays 
with the demented person at home. If the family carer needs some quiet time at home, 
the respite carer takes the client out for the day. 

Each client is assigned to his or her respite carer for as long as the service is 
needed. This minimises the confusion that could result from having to develop 
more than one new relationship. Carers receive intensive training initially and 
then continuing training, support and weekly debriefings. This is essential 
because the work is stressful: 

I have sat with a sufferer for six hours...it is a long time when you are with 
omebody who is forgetful, who repeats the same story over and over again, and 
does not let you out of their sight.115 

The success of the training is demonstrated by the low staff turnover of 13 
percent. This compares with a turnover rate of 60 percent in respite care 
services run by other organisations.116 

The Association believes six hours a week is not enough respite care for a 
person with dementia. However, their resources are stretched to the limit and: 

Unfortunately, at the moment, because of funding we have a waiting list of 30 
families needing help. And these people are in desperate situations. Every one
 of them is a deserving case but they cannot be helped at this stage."7 

Respite Care Away from Home 

People with dementia who are living in the community also need access to 
occasional respite care away from home. In the event of a family crisis or the 
family carer becoming ill, dementia sufferers often have nowhere to go except 
a hospital acute ward. This, the Inquiry was told, is absolutely inappropriate.
Staff in public hospitals and acute hospitals do not know how to handle somebody
 with dementia and because the behaviour is so paradoxical they often think the 
person with dementia is just being difficult.118 

Human Rights and Equal Opportunity Commission Page 529 

Lack of flexibility in the services available can have serious consequences for 
dementia sufferers. For example, a family carer who had to go away for 
several months was placed in a very difficult situation: with no temporary 
respite care available, her only option was to commit her mother permanently 
to a nursing home or hostel.119 

Country people are especially disadvantaged in this regard — as in so many 
areas of mental health.120 

Information for Carers 

Family carers also need information and education: 

That's information about the diagnosis and likely process of the disease, so they
 can understand what's going on and know what to expect. They need to handle 
difficult behaviours, [and to know] how to communicate with a confused person, 
how to prevent or defuse difficult situations, how to organise respite care, 
how to make necessary legal arrangements, how to use the system which is a very 
confusing thing — ultimately how to find appropriate residential care when the 
need arises.121 

Information about support services, like the services themselves, is generally 
inadequate, and in many areas non existent and poorly coordinated. There is 
usually no central point of contact and carers must fight their way through a 
maze trying to find out what services are available and how to use them: 

Knowledge is usually restricted to the knowledge of the person you go to, so if
 they are a Federal government employee they will know about Federal services 
and they will not necessarily tell you about State services or local services 
and vice versa.122 

One solution recently developed is a brokerage model, a one-stop shop for 
information, referrals and services.123 Brokerage offices, funded by HACC, 
purchase and coordinate whatever services are needed to prevent individual 
dementia sufferers from having to be institutionalised for as long as possible. 

[The service] needs to be accessible... It needs to be user-friendly so that 
people don't feel intimidated from getting help. It needs to be flexible so that
 for one person the critical point about keeping them in their own home is if 
they can get meals. [In another case a person might need] someone to do some
maintenance on their home so they can get up and down the steps.124 

Alzheimer's Association 

The Alzheimer's Association is the main support group representing carers and 
families of people with dementia. It has a national office and state branches 
which provide public education programs, library resources, information and 

Page 530 Mental Illness Inquiry 

counselling for sufferers. It runs support groups for carers and in one State, 
Western Australia, provides an in-home respite service. The Queensland Branch 
provides respite by operating two daycare centres. The Tasmanian Branch 
operates the Flagstaff Gully nursing home. (The Association also organises 
events such as national conferences on Alzheimer's disease.) 

One of the Association's main functions is as an advocacy and lobby group on 
behalf of families of dementia sufferers. Because of the effects of the illness, 
the vast majority of people with dementia cannot be their own advocates; but 
their families are so exhausted by caring for them that they rarely have time or 
energy left over to perform this role.125 

The Association claims an expertise in dementia management which is rare 
even in government health and aged services departments. This means the 
Association makes an extremely important contribution by helping to develop 
policies on dementia.126 

Like other mental illness support groups, the Association relies on volunteers, 
but in most States it also receives government funding toward the cost of 
administration and provision of direct services. Like other groups, it faces a 
heavy demand for its services. Unlike other groups, however, the Association's 
clientele is growing rapidly, because the ageing of the population means the 
incidence of dementia is increasing much more rapidly than most other mental 
illnesses. 

Ironically, just when demand for its services is surging, the Alzheimer's 
Association may lose part of its already modest funding. The Association's 
national office received $300,000 as a four-year seeding grant under the Federal 
Government's Community Organisations Support Program. However, the 
Inquiry was told that grant would cease in mid 1993, and the Government had 
decided not to provide ongoing funding after that date. Unless an alternative 
source of funding is found, this will mean the end of the Association as an 
effective national voice on behalf of many people with dementia and their 
carers. 

Policy Issues Emerging from the Evidence 

Inconsistent and Contradictory Provisions 

The lack of uniform mental health legislation (see Chapters 3,4 and 29) or of 
portable services between the States is especially relevant for dementia sufferers 
because elderly people frequently live interstate from their relatives. Provisions 
for guardianship, power of attorney, testamentary capacity and even the 

Human Rights and Equal Opportunity Commission Page 531 

definitions of mental illness vary from state to state. Relatives trying to cope 
with this face enormous difficulty, frustration and expense. 

The former Department of Health, Housing, and Community Services recently 
conducted the second stage of its Mid Term Review of the Aged Care Reform 
Strategy. This stage aims to develop 'integrated approaches to dementia 
care'.128 Under this strategy, a five-year National Action Plan for Dementia 
Care was announced in 1992.129 This Plan aims to make all aged care 
services more responsive to the needs of dementia sufferers and their carers. 
It should bring about improvements in terms of broad policy and planning. 
However, the Alzheimer's Association believes that implementing changes at 
a practical level requires an independent, well-resourced national task force on 
dementia, analogous to the National Task Force on AIDS.130 Proponents of 
the task force point out that dementia is an incurable disease affecting 
numerically far more people than AIDS. An independent task force might prove 
more amenable to the proposition that dementia sufferers in residential care 
should be separated from non-dementing elderly people. Such a task force 
would also be less likely to overlook the 10 percent of dementia sufferers who 
are not elderly.131 

People who are elderly and also mentally ill are particularly vulnerable. As is 
common — but inexcusable — for people with dual 'disabilities', they tend to 
fall between government departments: in this case between health (usually 
State) and aged care (Federal). One psychogeriatrician working in a State 
psychiatric hospital and attempting to get a community care program off the 
ground told the Inquiry: 

The State really would like us to perhaps be entirely Federally funded, and Federal 
funded departments do not want to know us either: they say we are State, so which 
side do we go to?... HACC simply do not want to know us because we are seen as a 
State government department even though our particular projects...are entirely 
community based.132 

Dividing responsibility for aged health services between the Commonwealth and 
the States has led to excessively rigid and complex guidelines and arbitrary 
distinctions. For example, whether a dementia sufferer ends up in a State or 
Commonwealth nursing home is purely a matter of luck. Yet their rights and 
the standard of care they receive may be quite different, because 
Commonwealth protections do not apply to State facilities.133 

The conceptual and formal division between health and aged services also 
creates difficulties in the admission process for nursing homes. The gatekeeper 
to Commonwealth nursing homes in most areas is the Geriatric Assessment 
Team (GAT) from the Department of Health, Housing, Local Government and 

Page 532 Mental Illness Inquiry 

Community Services. One problem, already noted, has been the policy of 
refusing nursing home admission to former psychiatric patients; this has 
recently changed. Another problem is that psychogeriatricians are not allowed 
to authorise the transfer of their own patients from hospital into a nursing home 
without approval from a GAT or a geriatrician.134 To get this approval, 
psychogeriatricians often feel compelled to overemphasise their patients' 
physical problems, since GATs, like the Resident Classification Instrument, 
tend not to attach enough weight to dementia as a criterion for admission to 
residential care.135 

Witnesses to the Inquiry suggested that placing psychogeriatrics and all other 
aged services under one budget would allow more comprehensive and equitable 
services.136 At the very least, coordination between services would be improved! 

Confusion about definitions can result in services being denied to the people 
who need them most. In one part of Sydney, nurses funded by HACC were 
assigned to provide services for the confused and disturbed elderly, but told 
they were not to see anyone with a mental illness, eg depression or paranoid 
states. Since many people with dementia also suffer from those other conditions, 
the nurses were in a quandary as to whether they were allowed to assist 
or even see these elderly people.137 

Policy-making in the field of mental illness is frequently characterised by a 
failure to consult and inform interested groups and individuals when changes 
are proposed. In this respect, dementia appears to have recently fared better 
than other areas of mental illness. The Federal Government has consulted 
psychogeriatricians and the Alzheimer's Association on recent initiatives in aged
 care, such as the Mid Term Aged Care Review and the nursing home Charter 
of Rights and Responsibilities.138 However, at a State level it appears that lack 
of consultation is still a major problem. In Western Australia, for example, there
 is no mechanism for the State's two psychogeriatricians to put their views to anyone
 involved with policy or service planning.139 In NSW extensive consultation preceded 
the decision to place dementia sufferers under the Guardianship Act rather than the
 Mental Health Act. Even so, this has resulted in some perceived shortcomings: 

We find, for example, people who are dementing and aggressive may be harmful to their
 family and.. .they're not a mentally ill person as defined by the act. So that if they 
haven't got a single hallucination or delusion the Mental Health Act can't be used.140 

Human Rights and Equal Opportunity Commission Page 533 

Funding 

In the competition for scarce mental health resources, the elderly mentally ill 
take low priority. There is an acute shortage of services for treatment, 
accommodation and support for family carers. Unless we rapidly develop 
effective planning to take account of the ageing population, the shortage will 
become much worse. 

Throughout the mental health system, resources are overwhelmingly concentrated 
in institutions instead of in the community. As noted elsewhere in this 
report, 80 percent of mental health monies are still tied up in hospitals and 
other institutions, even though 95 percent of the mentally ill now live in the 
community.141 The distribution of the aged care budget similarly focusses on 
institutions. Yet at least half of all dementia sufferers live at home, and more 
would if the support services were there to allow it.142 

The Federal Government spent $1.5 billion in 1990-91 on nursing homes, 
where (according to expert evidence cited earlier) at least 60 percent of 
residents have some degree of dementia. This represents $21,400 per resident. 
Expenditure on aged hostels was $351 million. About 25 percent of residents 
in these hostels have dementia, which represents $7,970 per capita.143 

Expenditure on HACC programs, which allow people to continue living in the 
community, was only $279 million. The number of people using HACC was 
about 200,000, of whom an unknown proportion have dementia. The per capita 
expenditure for people living at home and using those services was therefore 
only $1394.144 

Evidence to the Inquiry strongly suggests that many dementia sufferers are 
having to make do without any assistance from government services at all. 
Roughly four out of five personal services to the elderly are provided by family 
or others in the community without cash exchange — in the private economy 
which is not reflected in the national accounts.145 In South Australia, for 
example, there are an estimated 11-12,000 people with dementia. Some 4000 
are in residential facilities; but of the 8000 who are not, only 2000 are on the 
records as using dementia services. What is happening to the other 6000, 
apparently no one knows.146 

Providing more resources for dementia sufferers in the community cannot come 
about merely by redistribution. The nursing homes and hostels do not appear 
to have funds to spare; in fact, some of the practices which are most unacceptable 
from a human rights perspective stem directly from insufficient funds. So the total 
funding for dementia and other mental illnesses in the elderly must be 

Page 534 Mental Illness Inquiry 

increased. At present there is some disagreement on how much money is 
actually spent on dementia care: the Federal Government cites a figure of 
$1,045 billion in 1990-91,147 but one expert witness called this 'outrageous 
sleight of hand': 

They have used the figure of 60 percent of residents having dementia...to say that 
60 percent of the total nursing home budget is therefore being applied to dementia 
services. And they have done the same for hostels. The fact that most of these residents
 were admitted for reasons other than dementia...appears to be irrelevant. The Department 
can say that $1,045 billion is being allocated to dementia services whereas in fact the
bulk of this sum is spent on the treatment and management of physical conditions.148 

Home and Community Care (HACC) Funds 

Dementia services, like other aged care services, are mainly funded by the 
Federal Government — through nursing homes and hostel subsidies and through 
the HACC program. The Alzheimer's Association expressed concern to the 
Inquiry about two aspects of HACC: the distribution of funds through State 
governments, and the possibility of HACC devolving entirely to State control 
in the future. 

HACC provides funds to match contributions from each State on a dollar-fordollar 
basis. This means federally-funded services for the elderly are only 
provided if a State government is prepared to allocate an equal amount. 
Depending on the priorities of different governments, this produces gaps, 
duplications and inequities between States.149 The Alzheimer's Association 
maintains that aged services are a Commonwealth responsibility which should 
be funded directly by the Commonwealth to ensure, as far as possible, that all 
elderly Australians receive the standard of service to which they are 
entitled.150 

The possibility of HACC being handed over entirely to the States is viewed 
with similar misgiving by dementia support groups, which believe that the 
uneven record of State governments in using HACC funds casts doubt on their 
commitment to adequate dementia services in the future. If HACC is devolved 
to the States, state legislation will be needed to safeguard the rights of those 
affected by dementia.151 

The Need for Specific Aged Psychiatric Services 

Australia has very few designated psychogeriatric services. Elderly people with 
mental illness are dealt with by the general adult psychiatry services, which 
sometimes do not adequately understand that problems can present differently 

Human Rights and Equal Opportunity Commission Page 535 

in the elderly. This can result in treatable conditions like depression remaining 
undiagnosed and untreated due to ignorance. 

The Inquiry was told that elderly people of non-English speaking backgrounds 
are particularly at risk of their mental illness going undiagnosed. This means 
no attempt is made to manage their condition until it reaches crisis point. A 
community worker from the Migrant Resource Centre in Hobart gave this 
example of a 74-year-old man of Eastern European background: 

I was contacted by [his] landlord... I tried to go and find the gentleman; we could 
not find him. The landlord let me inside so I [found out] his name and nationality,
 contacted the ethnic group, all possible services. The gentleman was found seven days
 later in a local park, probably [had been] there for the last seven days. He was 
totally unable to find his way home, [after] not eating for definitely several days...
These examples are happening 
too often. It is very difficult for me to believe that nobody could recognise [the
 problem] earlier. I do not know how often examples like this happen in the Australian
 community, but they are happening much too often in [the] non-English speaking one. It
 is just that nobody is prepared to sit and spend enough time to recognise how deeply
disturbed these people are.152 

Staff may also find younger patients more interesting to work with: 

they would much prefer a person with a personality disorder or an acute schizophrenia 
to some elderly person who may be frail and have physical problems who also is acutely 
depressed or anxious.153 

Many elderly people have physical problems which make it difficult for them 
to visit doctors, outpatient clinics or community health centres. They need 
home visits, which they often do not get — either because of staff shortages or 
because their GPs do not recognise the problem.154 

These problems all highlight the need for special psychogeriatric services. 
Witnesses to the Inquiry favoured a model based on integrated multidisciplinary 
teams working in the community and also with patients in hospitals, nursing 
homes and hostels. The teams- should link in with aged medical services, 
including geriatric services but especially GPs, who are the main providers of 
health care to the elderly. One community team would be needed to cater for 
each 20-25,000 aged people in a particular area. The team would coordinate a 
range of facilities including outpatient services, acute, rehabilitation and long-stay 
hospital beds, as well as assessment and care in patients' homes.155 A 
few integrated psychogeriatric services have recently been established in capital cities:
 on Sydney's North Shore and in St George in the south; in Melbourne and in Adelaide. 
But the Inquiry was told they are 'very embryonic and resisted by a lot of people'.156 

Page 536 Mental Illness Inquiry 

Research, Training and Staffing for Mental Illness in the Elderly 

Considering the magnitude of the challenge posed by dementia, Australia is 
disastrously deficient in training and research to meet it.157 For a disease 
which has the potential to cripple the health budget, the funding for research 
on preventing dementia is woefully inadequate: in 1991-2 the total expended by 
the National Health & Medical Research Council for research on dementia was 
less than $600,000. This compares with $10 million spent on cardiovascular 
disease, $10 million on AIDS and $11.8 million on cancer research.158 One 
leading dementia researcher in 1989 said he spent one-third of his time trying 
to raise money instead of working on his research.159 

One limitation on research and also on the development of special psycho-
geriatric services is a shortage of health professionals trained in psychogeriatric care. 
Expert evidence to the Inquiry indicated that the entire country has fewer than a dozen 
practising psychogeriatricians, whereas Britain, for example, has about 200. 160 At its 
Tasmanian hearings the Inquiry was told that State had only one psychogeriatrician, whose
 responsibilities covered the southern part of the State. There is not one psychogeriatrician 
in Queensland.161 Western Australia has only two — the same number it had in 1980.162 

Psychogeriatrics is not a particularly attractive area for doctors, being 
one of the most personally demanding and difficult areas of medical practice. It is low tech,
 depending on the good nature and skills of dozens of workers, and hence does not attract the
 headlines and photo opportunities of other areas of clinical practice.163 

For most old people their only contact with the health system is the local GP. 
But doctors receive virtually no training in psychogeriatrics. Many doctors 
simply do not know how to detect mental disorders in the elderly, much less 
how to treat them.164 

This evidence from experts was reinforced by a 1990 study of general 
practitioners' ability to detect dementia and depression in elderly patients.165 
The doctors correctly diagnosed dementia in the majority of patients affected, 
but only managed to detect 20 percent of patients affected by depression. This 
failure is extremely important. Depression is almost always treatable — but 
only if it is recognised. 

Doctors themselves say they feel frustrated when faced with dementia — given 
their lack of training. Many are concerned about the difficulty of making a 
clear diagnosis or of managing a progressively deteriorating condition. Equally 

Human Rights and Equal Opportunity Commission Page 537 

difficult is knowing how to help families cope with a dementing relative. GPs 
need training in all these areas.166 

Ignorance among government policy-makers helps perpetuate the poor state of 
knowledge among GPs: 

Recently there was a paper put out by the National Health and Medical Research Council titled 
General Guidelines for Medical Practitioners on Providing Information to Patients. We noted that 
there was not one reference in those guidelines as to how to deal with someone with dementia. Again,
 [in] a recent publication — admittedly it is only at draft stage — which is titled Patients' Rights
 and Responsibilities, which is something being undertaken by the WA Government, there was also no
 mention in the document as to how people with dementia could be dealt with. In other words, there 
as no provision for people who need advocates.167 

Similarly, the Federal Government's guidelines for nursing homes (published 
in 1987) contain not one express reference to dementia.168 This is extraordinary, given the numbers 
affected. The more recent guidelines on standards for aged care hostels do mention dementia.169 

According to the Royal Australian and New Zealand College of Psychiatrists170 
more psychiatric nurses skilled in dealing with the elderly are urgently required. Education about
 mental illness in the elderly is also needed 
for other workers, especially staff of nursing homes, hostels, daycare centres 
and also boarding houses and retirement villages. Thousands of people, 
including many volunteers, provide direct care in those facilities with very little education or 
information about dementia or the other conditions affecting their clients. Aged care work is poorly
 paid, highly stressful, physically taxing and accorded little prestige.171 Not surprisingly, the people
 who do it have a high burn-out and attrition rate caused by overwork, low morale, frustration, anxiety, 
anger and guilt.172 Maltreatment of nursing homes patients may be at least partly attributable to the high 
stress on staff.173 Financial remuneration is one factor, but in the absence of resources to raise salaries,
 administrators should recognise staff contributions, and meet their needs for training, information, 
counselling and adequate staff levels.174 

Human Rights 

Apart from ignorance, there is another reason why the mental health needs of 
the elderly are constantly neglected. It is prejudice — the idea that old people 
are disposable items, no longer useful and not worth spending money or energy 
on. It is the attitude that old people are not entitled to quality of life, because getting sick,
 feeling depressed and losing one's memory are just natural parts 

Page 538 Mental Illness Inquiry 

of getting old which must be expected; because they are old and going to die 
anyway; or because they are not assertive enough to complain:175 

Visiting one day I found her in a wheelchair being pushed along a long draughty corridor, her hospital
 gown hitched above the pubic area and the blanket which was meant to cover her flung in a haphazard manner
 around her neck... Another time I arrived to find my mother tied in a chair, alone in a large room, again 
uncovered and she was hallucinating. I thought she was dying and tried to get help but nobody took any notice
... She was treated like this because she was a person of no account.176 

In contrast, the same person was later cared for by staff who respect their 
elderly patients: 

Eventually I found an excellent nursing home... She was well cared for without any sedation, managed with
 kindness and firmness and a lot of attention and care. The example of an excellent matron who was active
 in supervising and helping and a small team of experienced senior sisters who liked old people and had
 been there many years, seemed to influence all the other members of the staff.177 


The successful Lefroy Hostel for dementia sufferers in Perth maintains that 
attitudes are more important than formal qualifications in selecting the right 
staff.178 

Older people are generally vulnerable to neglect and abuse, whether physical, 
psychological or economic. Australian and overseas studies indicate that 3-5 
percent of the elderly become victims of abuse.179 

The elderly mentally ill are entitled to the same human rights as other people 
who are vulnerable and in need of protection. Those who come from Aboriginal 
or non-English speaking backgrounds are especially disadvantaged.180 (See 
Chapters 23 and 24 respectively for evidence relating specifically to the needs 
of Aboriginal and Torres Strait Islander people and of people from non-English 
speaking backgrounds.) 

Recognising the particular vulnerability of elderly people in residential care, 
Australia has at least addressed their basic rights in standards and the nursing 
home Charter. However, evidence to the Inquiry clearly established that for 
many elderly mentally ill people, especially those with dementia and depression, 
those rights are being consistently violated. 

Many elderly people rely on family members to be their advocates, but these 
carers already have their hands full trying to meet all the immediate needs — 
partly because the support services are so inadequate. Concern for the human 
rights of the elderly mentally ill must also, therefore, extend to the basic 
rights of their carers
 — if protection of their rights is to be effective. 

Human Rights and Equal Opportunity Commission Page 539 

The Inquiry has deliberately sought to identify the most positive models of 
caring for people with dementia, either in residential facilities or living at 
home. Those models show that dementia, like other mental illnesses, can be 
managed successfully without compromising protection of human rights. 
Facilities such as those we have identified in this chapter are encouraging — 
but pathetically few in number.181 They must be replicated, with adaptations 
where necessary, so that all dementia sufferers can be treated with the respect 
our older Australians deserve. 

Page 540 Mental Illness Inquiry 

1. Roberta Gripton, Alzheimers Association (Western Australia). Oral evidence, 
Perth 12.2.92, p347. 
2. See Chapter 3 — Definitions and Conceptions of Mental Illness. 
3. Prof Henry Brodaty, psychogeriatrician and Alzheimers Association Federal
 President. Oral evidence,
 Sydney 19.6.91, p263. 
4. ibid, p262. 
5. Dr Jacob Mathew, psychogeriatrician. Oral evidence, Hobart 13.11.91, p266. 
6. Brodaty, op cit, p264. Also Lynette Chester, President, Alzheimer's
Association (Western Australia). 
Oral evidence, Perth 12.2.92, p346. 
7. Brodaty, op cit, p263. 
8. Raphael Chapman, Community Accommodation Support Service (Adelaide). 
Submission, Fritz and White Bread,
 Appendix 3, p4. 
9. Prof John Snowdon, psychogeriatrician. Oral evidence, Sydney 20.6.91, p511. 
Also Dr Stephen Tycehurst,
 psychogeriatrician. Oral evidence, Newcastle 9.7.91, p831. 
10. Dr John Tooth, psychiatrist and President, Alzheimers Association (Tasmania). 
Oral evidence, Hobart
 11.11.91, p41. 
11. Brodaty, op cit, p263. 
12. J Snowdon, 'Psychiatric services for the elderly,' Australian and New Zealand 
Journal of Psychiatry v21,
 1987, pi32. 
13. H Brodaty, 'Psychiatric co-morbidity in Alzheimer's Disease', Proceedings of 
the Second National Conference,
 Alzheimer's Association Australia, Adelaide 1992, ppll-13, atpl3. 
14. Snowdon, op cit (ANZJP), pl32. 
15. AS Henderson and S J Rosenman, 'Psychogeriatrics (Part 1: Psychiatric illness
 in late life)', in P Beumont and R Hampshire (eds), Textbook of Psychiatry,
 Blackwell Scientific Publications, Melbourne 1989, p222. 
16. Snowdon, op cit (oral evidence), p511. 
17. Henderson and Rosenman, op cit. 
18. Brodaty, op cit (oral evidence), p264. 
19. id. 
20. ibid, p265. 
21. M Pinkerton-James, The Elderly as Victims of Crime, Abuse and Neglect 
(Trends & Issues No37), Australian Institute of Criminology, Canberra 1992, p4. 
Pinkerton-James cites K Pillemer and D Finkelhor,
 'The prevalence of elder abuse: A random sample survey,' The Gerontologist, 
v28 Nol, pp51-57. 
22. Advocacy for the Aged, Queensland. Evidence provided to the Inquiry. 
23. Snowdon, op cit, p516. 
24. Brodaty, op cit, p276; Snowdon, op cit, p514. 
25. Mathew, op cit (oral evidence), p264. 
26. B Price, 'Education for caring — no longer a privilege', Proceedings
 of the Second National Conference, Alzheimer's Association Australia, Adelaide 1992, p6. 
27. id. 
28. An innovative, much more active approach has been taken by a group in
 Christchurch, New Zealand, where a mutual support group for people in the
 early stages of Alzheimer's disease has operated for two years. The group
 meets to talk about the difficulties faced by 

Human Rights and Equal Opportunity Commission Page 541 

dementia sufferers, including problems they feel unable to discuss with their 
family members. They share ideas for coping with failing memories, and encourage 
each other to accept help or even make the transition into residential care. 
The group cannot arrest the progress of the disease, but it has been successful in 
enhancing the members' self esteem and ability to cope with their condition. 
E Peach and G Duff, 'Mutual support groups: A response to the early and often
 forgotten stage of dementia', Proceedings of the Second National Conference, 
Alzheimer's Association Australia, Adelaide 1992, pp61-62. 

29. Price, op cit, p7. 
30. Department of Community Services and Health, Charter of Residents' Rights 
and Responsibilities in 
Approved Nursing Homes, AGPS, Canberra 1991. 
31. Gripton, op cit, p352. 
32. ibid, p349. 
33. R Lefroy, 'The special hostel for care of people with dementia', Medical 
Journal of Australia, v55 No3, 5 Aug 1991, pl41. See also J Callum, 'Quality 
of survival in an ageing society', Proceedings of the Second National Conference,
 Alzheimer's Association Australia, 1992, pl6. The Commonwealth Government's 
policy of integrating the demented elderly with the cognitively well is not 
explicitly stated; rather the issue of separating these two groups of patients 
is consistently not addressed. See for example Department of Health, Housing 
and Community Services, Aged and Community Care Budget Initiative 1A, 1991; 
or the Department's Aged Care Reform Strategy, Mid Term Review 1990-91, AGPS, 
Canberra 1991, pi77. 
34. Paul Wilmot, Anglican Homes (Western Australia), Presentation to the then 
Minister for Aged, Family and Health Services, 24 May 1991. 
35. Snowdon, op cit, p517, referring to Rozelle Hospital. 
36. Tycehurst, op cit, p819. 
37. Mathew, op cit, p266. 
38. Prof John Snowdon. Evidence to the Inquiry subsequent to the formal hearings. 
39. Brodaty, op cit, p263. 
40. Mathew, op cit, p265. 
41. Tooth, op cit, p42. 
42. Tycehurst, op cit, p819. 
43. Mathew, op cit, p265. 
44. ibid, p271. 
45. Dr Neville Hills, psychogeriatrician. Oral evidence, Perth 12.2.92, p367. 
46. Pinkerton-James, op cit, p4. 
47. Snowdon, op cit, p511. 
48. Mathew, op cit, p272. 
49. Tooth, op cit, p45. 
50. Snowdon, op cit, p511. 
51. Tooth, op cit, pp42,48. 
52. id; and Mathew, op cit, p267. 
53. The old RCI provided 12 criteria for measuring the level of nursing assistance 
needed by a patient, and only one of the 12 referred to 'behaviour'. In the new 
instrument, three of 

Page 542 Mental Illness Inquiry 

the 14 criteria refer to behavioural difficulties: physical aggression, verbal
 aggression and other behavioural problems. 

54. The owner of one nursing home that meets all the Commonwealth's outcome 
standards has been quoted in the press saying the funding formula means he 
cannot afford to take dementing or psychogeriatric patients. J Chandler, 
'Standards high, but income of home isn't,' The Age 1 June 1992, pl5. 
55. The nursing home standards, introduced in 1987, are contained in the
 National Health Act, s45D. They are interpreted in a longer document used 
by monitoring officers as a reference: Living in a nursing home - Outcome 
standards for Australian nursing homes, AGPS, Canberra 1987. Hostel 
standards, formulated in 1990 under slOF(l) of the Aged or Disabled Persons 
Homes Act, are set out in Keeping the Quality in Hostel Life, AGPS, Canberra 1990. 
56. Department of Community Services and Health, Charter of Residents' 
Rights and Responsibilities in Approved Nursing Homes, and Charter of 
Residents' Rights and Responsibilities in Approved Hostels. 
57. Brodaty, op cit, p266. 
58. Pat Jones, Alzheimer's Association. Oral evidence, Sydney 19.6.91, p268. 
59. Lefroy, op cit, pl41. 
60. Brodaty, op cit, p265. 
61. Jones, op cit, p269. 
62. The monitoring scheme appears to be successful in compelling homes to 
raise their standards. Dr John Braithwaite and his colleagues at the 
Australian National University have been studying the effectiveness of 
Commonwealth regulation of nursing homes for five years. Their interim 
report says facilities identified as poor performers in a 1987 survey have
 since mainly improved their service. Braithwaite et al, The Contribution 
of the Standards onitoring Process to the Quality of Nursing home Life: 
A Preliminary Report, Department of Community Services and Health, Canberra 
1990. According to press reports, the Commonwealth has threatened 22 Victorian 
nursing homes with funding cuts over the past two years as a result of monitoring 
teams observing sub-standard conditions. J Chandler and D Wilson, 'Threats 
improve nursing home care,' The Age 1 June 1992, pi. 
63. Chester, op cit, p350. 
64. Advocacy for the Aged, Queensland. Submission, pi. 
65. 'Beating "was part of cause of death"', Canberra Times, 3 June 1992. 
66. Advocacy for the Aged, op cit, p2. 
67. Chester, op cit, p350. 
68. Brodaty, op cit, p264. 
69. Mathew, op cit, p269. 
70. For example Snowdon, op cit, p511. 
71. Mathew, op cit, p269. 
72. R Lefroy et al, 'The care of people with dementia: Is there a need for a 
special hostel?', Australian Journal on Ageing, v9 No4, 1990, p26. 
73. Dr John Tooth. Evidence submitted to the Inquiry after the close of formal hearings. 
74. Anne Kelly, Flagstaff Gully nursing home. Oral evidence, Hobart 12.11.91, p226. 
75. Tooth, op cit (oral evidence), p46. 

Human Rights and Equal Opportunity Commission Page 543 

76. ibid, pp43,46. 
77. id. 
78. Peter McHale, Lefroy Hostel. Oral evidence, Perth 12.2.92, p360. 
79. J Tooth, 'Design for residential care', Proceedings of the Second National Conference,
 Alzheimer's Association Australia, Adelaide 1992, p23. 
80. McHale, op cit, p269. 
81. Paul Wilmot, Anglican Homes. Letter, 16 April 1992. 
82. Tycehurst, op cit, p828; Snowdon, op cit, p511. Formal evaluation of CADE's 
operations also shows the system significantly improves elderly residents' health 
and quality of life: R Fleming and J Bowles, 'Successful ageing in long-term care 
for the dementing,' Proceedings of the 25th Annual Conference of the Australian 
Association of Gerontology, Canberra 1990, pp81-84. 
83. Lefroy et al, op cit, p28. 
84. Department of Community Services, Nursing Homes and Hostels Review, AGPS, 
Canberra 1986. Cited in J Snowdon and S Mackintosh, 'Depression and dementia
 in three Sydney hostels', Australian Journal on Ageing v8 No4, 1989, p24. 
85. Lefroy et al, op cit, p28. 
86. National Anglican Caring Organisations Network, 'Resolution of Concern'. 
Submitted to HREOC 8 May 1992. 
87. Brodaty, op cit, p263, and in evidence to the Inquiry subsequent to the formal hearings. 
88. Dr Anthony Jorm, Social Psychiatry Research Unit, Australian National University.
 Oral evidence, Canberra 18.3.92, pl8. 
89. id. 
90. Brodaty, op cit, p276. 
91. Tooth, op cit (oral evidence), p41. 
92. The Alzheimers Association in WA estimates the cost of providing a home care 
service to one dementia sufferer one day per week at $5000 per year. Ideally 
each sufferer should receive two or three services per week, which would 
cost $10-15,000 per year. The cost of ordinary nursing home care is $27,000 per
 year; and even in special dementia hostels it is $23,000 per year. A very large 
number of dementia sufferers use no services at all, which keeps the present 
overall cost of services to people living at home low. The Alzheimers Association
 says this non-use is unmet need: the Government is keeping costs down by failing
 to provide the services people need. Similarly, the cost of an intensive domiciliary
 service provided to dementia sufferers in Adelaide was estimated in 1989 at $115 per week,
or just under $6000 per year. L J Mykyta and G Lovell, ' Community care for dementia 
sufferers', Australian Journal on Ageing v8 No3, 1989, p19 
93. Jorm, op cit, pl4. 
94. Brodaty, op cit, p267. 
95. Lorraine Beard, carer (NSW). Letter, 8 July 1991. 
96. T Egan, 'Dad got old, so they dumped him,' Sydney Morning Herald 27 March 1992, p4. 
Egan quotes an American estimate of up to 70,000 elderly parents abandoned in 1991. 
97. Brodaty, op cit, p265. This is also supported by Pinkerton-James, op cit, p4. 
98. Brodaty, op cit, p282; Lynette Chester, letter, 15 April 1992; Paul Wilmot, 
letter, 16 April 1992. 
99. Jones, op cit, p267. 

Page 544 Mental Illness Inquiry 

100. Chester, op cit, p345. 
101. id. 
102. Brodaty, op cit, p279. 
103. M Hueke, 'A model for the management of people with diagnosed dementia in country 
areas', Australian Journal 
on Ageing v9 No4, 1990, p34. 
104. Tooth, op cit, p39. 
105. Brodaty, op cit, p277. 
106. Tooth, op cit, p40. 
107. Even the provision of nursing home and hostel beds is problematic — for example, the 
New England Health Region of NSW has a nursing home and hostel deficit of 277 places, 
based on the Commonwealth's recommended ratios of 40 nursing home and 60 hostel beds 
per 1000 people over age 70. Hueke, op cit, p34. 
108. Zophia Pakulski, Migrant Resource Centre. Oral evidence, Hobart 13.11.91, p285. 
109. F Jordan et al, 'Quality care and best practice for people with dementia', 
Proceedings of the Second National Conference, Alzheimer's Association Australia, 
Adelaide 1992, p3. 
110. Mathew, op cit, p273. 
111. id; and Gripton, op cit, p349. 
112. Jordan et al, op cit, p5. 
113. Jorm, op cit, pl8. 
114. Gripton, op cit, p350. 
115. ibid, p353. 
116. P O'Connor and E Kingsley, 'When all else fails: In home respite may be the answer',
 Proceedings of the Second
 National Conference, Alzheimer's Association Australia, Adelaide 1992, pp31-33. 
117. Gripton, op cit, p348. 
118. ibid, p349. 
119. ibid, p355. 
120. Chester, op cit, pp346,350. 
121. Brodaty, op cit, p267. 
122. Jones, op cit, p269. 
123. id. 
124. Brodaty, op cit, p278. 
125. ibid, p264. 
126. Dr John Tooth. Letter to the Chairman of the Inquiry, 5 March 1992. 
127. Chester, op cit, p350; Franceska Jordan, letter, 13 February 1992. 
128. Department of Health, Housing and Community Services, Mid-Term Review of the Aged
 Care Reform Strategy - Stage 2, 1991-92. Background Paper, 30 Sept 1991. 
129. Health Care for All Australians: 1992-93 Reforms (Budget Related Paper No8), p29. 
130. Brodaty, op cit, p264. 
131. Prof Henry Brodaty for the Alzheimer's Association. Submission, p2. 
132. Hills, op cit, pp377-378. 
133. Brodaty. Oral evidence, Sydney 19.6.91, p265; Jones, op cit, p269; Chester, op cit, p350. 

Human Rights and Equal Opportunity Commission Page 545 

134. Hills, op cit, p366. 
135. Prof Henry Brodaty. Evidence to the Inquiry subsequent to the formal hearings. 
136. Snowdon, op cit, p516. 
137. ibid, p515. 
138. Brodaty, op cit, p274. 
139. Hills, op cit, p372. 
140. Brodaty, op cit, p274. 
141. Dr John Hoult, psychiatrist. Oral evidence, Sydney 20.6.91, p408. Magdi El Hag,
 Victorian Community Managed Mental Health Services. Oral evidence, Melbourne 8.4.91, pl25. 
Lisa Brophy, Association of Mental Health Workers. Oral evidence, Melbourne 9.4.91, p227 
142. Brodaty, op cit, p263; Jones, op cit, pp266-267. 
143. Wilmot, op cit. This is roughly consistent with figures provided by Dr John McCallum
 at the National Centre for Epidemiology (Australian National University): he estimates 
that HACC accounts for 12.4c in each long-term aged care dollar, while residential care
takes 69c. J McCallum, 'Quality of survival in an ageing society', Proceedings of the 
Second National Conference, Alzheimer's Association Australia, Adelaide 1992, p16. 
144. Wilmot, op cit. 
145. McCallum, op cit, pl5. 
146. Alzheimer's Association (SA). Evidence to the Inquiry subsequent to the formal hearings. 
147. A Howe, 'Putting the pieces together — towards a National Action Plan for dementia
 care', Proceedings of the Second National Conference, Alzheimer's Association Australia,
 Adelaide 1992, pl8. 
148. Tooth, op cit (letter to Chairman of the Inquiry, 5 March 1992). 
149. Alzheimers Association (South Australia). Evidence to the Inquiry after the close
of formal hearings. 
150. Brodaty, op cit, p277. 
151. Jones, op cit, p269. 
152. Pakulski, op cit, p285. 
153. Snowdon, op cit, p510. 
154. id. 
155. ibid, p511. 
156. id. 
157. 'Alzheimer's cure key to reducing nursing home patients,' Hospital and Healthcare
Australia v21 No7,
 July 1990, pp 14-15. 
158. Franceska Jordan, Alzheimer's Association. Submission. 
159. Dr John Currie, Mental Health Research Institute of Victoria, quoted in Alan Attwood, 
'Scourge of the aged,' Time Australia, 25 September 1989, p67. 
160. Snowdon, op cit, p509. The number of geriatricians in Australia is half the 
recommended level of the British Geriatric Society, with only ten geriatricians in
 training around the country in 1990: 'Alzheimer's cure key to reducing nursing home 
patients', op cit, pl4. 
161. Mathew, op cit, pp264,275. 

Page 546 Mental Illness Inquiry 

162. Hills, op cit, p367. In November 1992 the Western Australian Government announced 
it will fund a Chair in Psychiatry for the Elderly at the University of WA. 
163. ibid, p368. 
164. Brodaty, op cit, p263; RANZCP, Position Statement on Psychiatric Services 
for the Elderly, p2. 
165. J Bower, A Jorm, S Henderson and P Harris, 'General practitioners' detection of
 depression and dementia in elderly patients', Medical Journal of Australia v153, 
20 Aug 1990, ppl92-196. 
166. Brodaty et al, 'Dementia, doctors and carers', Proceedings of the Second National
 Conference, Alzheimer's Association Australia, Adelaide 1992, p67. 
167. Chester, op cit, p345. 
168. Department of Community Services and Health, Living in a Nursing Home Outcome 
standards for Australian Nursing Homes, AGPS, Canberra 1987. The document does refer
 to 'managing aggressive behaviour': 'The cause of the behaviour should be identified, 
steps taken to alleviate the problem, and the situation reviewed.' However, if the 
problem is dementia, an ordinary nursing home will have difficulty alleviating the problem. 
Similarly, the document mentions the use of restraint on residents' movements: 'Before 
use, all types of restraint, including chemical restraint, must be carefully considered
 and authorised by the resident's medical practitioner... When residents with diminished
 intellectual competence are restrained it is particularly important to involve their [family] 
representative in the decision.' Evidence to the Inquiry suggests the reality in many 
nursing homes falls far short of this considered approach to restraint of elderly patients. 
169. Department of Community Services and Health, Keeping the Quality in Hostel Life, 
AGPS, Canberra 1990. 
170. RANZCP, op cit, p3. 
171. Pinkerton-James, op cit, p5. 
172. Dr Michael Duke, RANZCP. Oral evidence, Melbourne 10.4.91, p347. Also see Bob Price,
 op cit, p6. 
173. Pinkerton-James, op cit, p5. 
174. Jordan et al, 'Quality Care and Best Practice for People with Dementia,'
 Proceedings of the Second National Conference, Alzheimer's Association Australia,
 Adelaide 1992, p4. 
175. Brodaty, op cit, p263. 
176. Thea Waddell, carer. Oral evidence, Sydney 19.6.91, p270. 
177. ibid, p271. 
178. McHale, op cit, p361. 
179. Brodaty, op cit, p265. See also Pinkerton-James, op cit, p4. She cites 
J McCallum, S Matiasz, and A Graycar, Abuse of the Elderly at Home: The Range of the Problem, 
National Centre for Epidemiology and Population Health, Canberra, 1990; also NSW Task
 Force on Abuse of Older People, Abuse of Older People in their Homes, Office on Ageing, 
Sydney 1992. 
180. Brodaty, op cit, p277. 
181. Apart from Flagstaff Gully and Lefroy facilities the Chairman of the Inquiry was also 
impressed by a specially designed home for dementia sufferers recently opened by the 
Salvation Army near Geelong — Kardinia Lodge. 

Human Rights and Equal Opportunity Commission Page 547 

Chapter 18 

HOMELESS PEOPLE 

Mental illness can happen to anyone...all those shuffling lost souls...were once 
somebody's bright-eyed son or daughter.1 

Definitions 

Homelessness among the mentally ill is a very visible and growing problem.2 
Formal definitions of homelessness vary, but the National Inquiry into 
Homeless Children defined it as a lack of shelter that is permanent, adequate 
and secure, together with the vulnerability that lack of shelter brings.3 The US 
Federal Task Force on Homelessness and Severe Mental Illness defined a 
homeless person as someone lacking a fixed, regular and adequate night-time 
residence, or someone whose primary night-time residence is a temporary 
shelter or a place not designed for people to sleep.4 

Some witnesses to the Inquiry considered homelessness to describe not only 
those who sleep the night outside, in refuges, night shelters and empty buildings
 or squats; but also the many thousands now living in sub-standard boarding houses 
and other inadequate, low-cost accommodation.5 

Many of the problems confronting the homeless are certainly faced by larger 
numbers of people who are variously described as 'disaffiliated', or lacking 
social roots in a community. These people may live in cheap single rooms or 
other marginal accommodation.6 

Who and How Many Are They? 

The size of the homeless population in Australia is difficult to estimate 
accurately.7 This is partly because definitions of homelessness vary, but also 
because the erratic lifestyle typical of many homeless people defies attempts at 
measurement. However, in 1985 the Federal Department of Housing and 
Construction estimated that 40,000 Australians slept outdoors, and 60,000 were 
housed inadequately without security of tenure or income.8 

The homeless are not one homogeneous group.9 They include the elderly, the 
young, individual women and men and families. Some may be relatively stable, 
staying for years in a refuge or shelter; others lead very transient lives.10 

Page 548 Mental Illness Inquiry 

However, they have one thing in common: they live in poverty, with little or 
no social support. 

Homeless people suffer a high rate of physical and mental health problems.11 
In a 1991 survey in Melbourne, 90 percent of agencies working with homeless 
adults reported psychiatric illness as a significant problem. Other major 
disabilities included drug and alcohol abuse and dependence, poor nutrition, 
dual disabilities and intellectual disabilities.12 

A recent profile of the homeless mentally ill indicates that 80 percent have been 
unemployed for over 10 years, and most would be regarded as unemployable. 
They are isolated: one-third report no living relatives, and half report no close
 friends. Over half have never married.13 

All receive some form of social security — be it one or a combination of 
sickness, invalid, age or unemployment benefits. However, which pension or 
benefit they receive appears to be unrelated to the severity of their illness.14 

Homeless people with mental illness tend to concentrate in the inner cities, but 
many come from the country or from outlying suburbs — where accommodation 
and services are even more scarce.15 Some 15 percent left school before 
age 12, and 75 percent left by the time they were 16.16 

About 90 percent of the homeless mentally ill are smokers.17 Homeless people 
not only have much higher rates of disease than the rest of the population, they 
have much higher rates of mortality as well.18 A witness from a St Vincent de 
Paul hostel for the homeless told the Inquiry: 

Personal hygiene is a constant concern... Just to encourage them to bathe regularly, 
to change their clothes and to wash their clothes always seems a problem. They are not 
able to cook and eat proper food, and hence why they come to us, I believe, [is] just 
for nutrition.19 

Most homeless mentally ill people fall into two broad groups.20 One group is 
the ageing, destitute, long-term mentally ill. The other comprises younger 
people who are transient — constantly shuttling between hostels, refuges and 
hospitals. 

Over the last 20 years the age profile among the homeless has shifted markedly 
toward the young.21 The Inquiry was told these younger people are more 
likely to be aggressive, less amenable to the rules of agencies or organisations, 
more likely to 'cause trouble' and provoke hostility, and to kill themselves: 
'they are the most distressing group to deal with.'22 

Human Rights and Equal Opportunity Commission Page 549 

It is in the evenings when you go to these centres that these young people come in.
 They have been out in the day wandering around and in many ways nobody can get a 
handle on them. They move up and down the coast of Australia between Sydney, Melbourne 
and Brisbane.23 

Alienation, Isolation, Victimisation and Violence 

Apart from the direct effects on the homeless sufferer, mental illness alienates 
other people. One worker from a Melbourne homeless agency told the Inquiry: 

Just the nature of psychiatric disability is that it is feared by many people. We, 
as workers, find it difficult to come to grips with; people in the community also 
have trouble trying to do that. What that means is that they are ostracised, they 
are alienated, they are isolated, and they are put back into other suburbs, for 
instance, like St Kilda...where, in fact, there's lots of other people there that 
are also vulnerable.24 

Suburbs like St Kilda25 (or Darlinghurst in Sydney or Fortitude Valley in 
Brisbane) thus become 'a big stewpot of all sorts of different people with all 
sorts of different vulnerabilities'.26 This phenomenon increases the pressures 
on each mentally ill person in the area — because it is not only the 'normal' 
community which shuns them: homeless people generally (ie those who are not 
mentally ill) do not understand psychiatric disability and are afraid of it: 

What that means is that the people react in two ways: they either use [the homeless 
mentally ill] as scapegoats, and heighten and feed into what a psychiatric disability 
sufferer is going through; or they actually shun them and turn away and they then become
 isolated. So certainly...having a psychiatric disability in the homeless field or 
scene can be a very scary [experience], a very isolated one.27 

One unfortunate consequence of this prejudice among the homeless population 
is that many mentally ill people prefer to stay on the streets rather than endure 
rejection in a refuge for the homeless.28 

Homeless people's isolation is such that they can get into severe difficulties 
for example, their welfare benefits being cut off) without anyone around them 
realising their plight.29 Witnesses to the Inquiry emphasised the vulnerability 
of homeless people to violence and exploitation: 

They can be preyed upon; some of the elderly people can be beaten up for their money;
 they are ostracised30... Many times they are robbed, assaulted, raped, you name it... 
They are systematically, almost continuously robbed.31 

They are one of the most vulnerable groups in our society, open to being robbed, 
violently treated, sexually abused and especially mistreated in business affairs. 
They are easy prey for anybody, especially those wanting to 'borrow' money or cigarettes.
 And they usually oblige, for their own safety or they're too trusting of people, or 
simply the need for attention and affection... They are confused about their possessions,
 what they own and 

Page 550 Mental Illness Inquiry 

where they've left them, or how much has been stolen from them or taken from them at one
 stage or another.32 

Transience 

Homeless people, especially the mentally ill, typically lead very transient lives. Many are
 caught in a revolving cycle of hospital admissions and discharges.33 

They move between States, from shelter to shelter: 

[They] wander the length and breadth of Australia without any consistent adequate support, 
virtually untouched by anyone (except maybe counter staff at CES, or Department of Family 
Services or Social Security), but [they] somehow have developed a link of homes, in inverted
 commas, throughout Australia...the Salvation Army hostels or St Vincent de Paul hostels, 
because they see them as the only place that really cares for them.34 

Witnesses from the Catherine House women's shelter in Adelaide said their 
clients never stay more than two months in one place:35 

[One] young woman...for a period of 2 1/2 years she'd come back to us on 12 occasions...
because she had nowhere else she could live... Another young woman of 25 who came to us
 was a transient and during five months she visited us seven times, and of the times she 
came to us on two occasions she'd been on the streets, another time living in a squat, 
another time she had come from the parks.36 

The homeless mentally ill frequently rotate between welfare agencies: 

I can remember when I started at Hanover...I went to visit another agency and standing outside
 was this gentleman who was - he had a psychiatric disability. He was very angry, he was yelling
 at a lamp post, playing with the cars. Everyone didn't know what to do. I mean, we were 
literally comatose. We couldn't communicate with this person and he certainly wasn't in a
 position to communicate with us. 

I thought at that stage, oh well, I don't work here, so that is okay. Except two days later
 of course he turned up at Hanover Centre, so I had to deal with it.37 

This restlessness (often caused by mental illness) is a convenient excuse not to 
provide services to homeless mentally ill people, since they are perceived as a 
problem from elsewhere.38 At the same time, transience is virtually imposed 
on some mentally ill people by government services — which send them to 
another area as a way of passing on responsibility.39 

Prevalence of Mental Illness 

If you ask any of the services dealing with homeless people about changes in the 
homeless population over the last ten years, they will talk about the growing numbers
 of homeless people with a psychiatric illness who arrive at their services without 
support or direction.40 

Human Rights and Equal Opportunity Commission Page 551 

The most common mental illness among the homeless is schizophrenia. This 
cruel disease is estimated to affect one in four residents in Sydney's inner city refuges 
for the homeless.41 While this figure is high, it is consistent with studies of inner city 
shelters overseas, which have indicated a prevalence of schizophrenia up to 36 percent.42 

In Brisbane the homeless shelters on any one night probably accommodate as many people 
with schizophrenia as do the psychiatric units of [the two main] hospitals. In Sydney, 
researchers have shown there are more people with schizophrenia using the shelters than
 are using the beds of the three inner city psychiatric units.43 

Homelessness itself is increasing,44 and mental illness is obviously increasing 
among the homeless. A study in Sydney in 1974 found 11 percent of homeless 
men had had at least four psychiatric hospital admissions45 — today that figure 
would be considered extremely low. The National Health and Medical Research 
Council reports that in Australia, the US and Britain between a quarter and half 
of all homeless adults are 'suffering severe and perhaps chronic mental 
disorder'.46 

According to evidence presented on behalf of the Royal Australian and New 
Zealand College of Psychiatrists, 50-75 percent of people in shelters for the 
homeless have histories of major mental illness.47 A 1988 study of homeless 
people in Melbourne indicated over 70 percent had experienced some period of 
mental disorder, and almost half of those had current disorders.48 This 
evidence is also consistent with studies overseas.49 

At the Ozanam House shelter in Melbourne, which accommodates up to 180 
men per night, a survey of long-term residents, who have been there five to ten 
years, found 25 percent have a current psychiatric illness.50 At the Catherine 
House shelter for women in Adelaide, 32 percent of residents have a history of 
mental health problems. (Overall, 75 percent have drug or alcohol problems 
and/or intellectual or psychiatric disabilities.)51 

At Matthew Talbot Hostel for homeless men in Sydney, the psychiatric illness 
rate is estimated at about 30 percent.52 At St Vincent's Hostel in South 
Brisbane the rate is 15-30 percent.53 The Salvation Army's Crossroads agency 
in Melbourne told the Inquiry that during 1990, one-third of the 24,000 people 
requesting help from Crossroads had a psychiatric illness or severe behavioural 
disorder.54 

The magnitude of the problem has been well documented in the past and should not 
require further detailed surveys... Issues now revolve around the adequacy, effectiveness
 and coordination of services for people with a mental illness. These are questions of 
political will rather than of further demonstration of need.55 

Page 552 Mental Illness Inquiry 

Treatment 

The right of these people to first rate treatment and rehabilitation is denied to them. 
I believe it is a disgrace which no caring community should tolerate, if not for 
compassionate reasons, then for selfish reasons.56 

Homeless people need accommodation, but if they have a serious mental illness 
they also need treatment. Many mentally ill people have difficulty obtaining 
treatment, or even recognising that they need it — and the homeless are 
especially disadvantaged in this regard because they have no family or friends 
to give them support.57 As a result: 

These people tend to move in and out of crisis situations, often resulting in them 
either being picked up by the criminal justice system or remaining on the peripheries
 of society. They rely on homeless and crisis agencies to cope until events escalate 
into what could have been an avoidable acute admission.58 

In theory, the policy of deinstitutionalisation means the homeless mentally ill 
should be receiving treatment through community mental health services, with 
hospital admissions for the occasional acute episode. (This approach to 
treatment is now the 'accepted norm', rather than prolonged institutionalisation 
in a psychiatric hospital.) However, as one submission to the Inquiry said: 

Despite their failings, institutions did at least provide food and shelter.59 

On the streets, the mentally ill find neither adequate food nor shelter. Nor are 
they likely to receive treatment for their mental illness. 

The most poverty-stricken group in our community, stricken and alone, lost, eke out 
their days in a monotonous way, often still tormented by the symptoms of florid mental 
illness.60 

Witnesses representing homeless agencies and hostels repeatedly told the 
Inquiry of the difficulties they experience in attempting to obtain or sustain 
treatment for their clients who are mentally ill. One problem which arises 
frequently is that mentally ill residents in hostels or refuges refuse to take their
 prescribed medication. Staff with no mental health training are then forced to confront 
a person who is becoming psychotic. A worker at the Ainsley Village homeless shelter in 
Canberra described a common scenario: 

They will lock themselves in...and when we go up there and they say, 'I do not want to
 see anybody'— in fact we have no powers. We would not force anyone to do anything they 
ould not do. But it gets to the stage.. .where we need some sort of power to — here we go,
 we are talking about human rights here — but to try and force people to take their 
medication.61 

Human Rights and Equal Opportunity Commission Page 553 

Sometimes 'if it is a real crisis', staff from the shelter take the mentally ill 
person to a hospital, only to find the hospital refuses to accept the person as a
 patient. An appalling shuttling process ensues: 

So what we are forced to do in many cases is to pin an eviction notice on their coat 
and leave them in the emergency centre. Well, this is very upsetting for us...to try 
nd force the hospital to take these people. We have done that and they send them back.
 They have sent them back in a taxi. One chap collapsed on the floor; we had to put him 
in hospital, send him back again.62 

In many cases, what I've had to do is put them in a taxi and send them up to hospital.
Many times they've sent them back to me.63 

Even when a hospital does accept a homeless mentally ill person, they have short-term 
[treatment] and the door swings back and we get them back again. 
They go off their medication and we are pleading with the hospital to take them back 
again, and so it goes on.64 

An experienced Melbourne psychiatrist described to the Inquiry the life pattern 
of the thousands of homeless Australians affected by mental illness: 

Most, sadly, cycle backwards and forwards from shelter to hospital back to shelter 
again like some endless game of musical chairs, competing for the few beds available 
and leaving often prematurely from hospital, and often inappropriately, before any 
response to treatment.65 

Despite the difficulty of obtaining treatment, however, many homeless people 
do end up in hospital — at least briefly. (A 1991 study in Western Australia 
found 10 percent of patients discharged from Gray lands psychiatric hospital had 
been homeless before admission; 46 percent had been homeless at some point, 
and 14 percent said they were frequently homeless.66) The disparity between 
the rhetoric and the reality is not so much what happens in our hospitals — but 
the pathetic paucity of services available after discharge. 

Medication 

Many mentally ill people have been prescribed medication to lessen the severity 
of their illness, but non-compliance in taking medication is common. Homeless-
ness increases the chance of non-compliance, because transience makes it 
virtually impossible to maintain a routine. The homeless mentally ill are also 
likely to have difficulty obtaining medication, and they have nowhere to store 
it. Since they lack the support and continuity of family and friends, homeless 
mentally ill people rarely have anyone monitoring whether they are taking their 
medication, or even whether any has been prescribed for them. They may 

Page 554 Mental Illness Inquiry 

wander from refuge to refuge without anyone knowing what treatment they are 
(or should be) receiving.67 

Why Are They Homeless? 

Why some people become homeless and others do not is poorly understood. 
Many factors contribute to the genesis of homelessness, including mental and 
physical health, institutionalisation as a child, socioeconomic status, intelligence, 
education, personality, family and social support, and the prevailing economic and 
social policy climate.68 

Witnesses to the Inquiry generally identified homelessness as the result of 
poverty,69 alienation and the housing crisis, the loss of boarding houses and 
other low-cost accommodation,70 and the inadequate provision and high cost 
of housing for those most in need:71 

For example, in Sydney in 1987 some 28 boarding houses, which had long provided cheap
accommodation in the inner city, were demolished and replaced with expensive units 
[to house] visitors to the Bicentenary. As far as we are aware, no provision was made
 for the occupants of the boarding houses.72 

Does Mental Illness Cause Homelessness? 

A major American study of the health of homeless people found that homelessness 
and mental illness are causally related.73 Mental illness can directly or 
indirectly lead to homelessness — either through deinstitutionalisation or simply
 because mentally ill people do not get the support they need to cope with 
normal life. Conversely, homelessness precipitates and exacerbates a wide 
range of health problems, including mental illness. Homelessness also makes 
treatment and management of mental illness more difficult, even if appropriate 
services are available. 

The policy of deinstitutionalisation, which began in the 1960s in some States 
and later in others, is widely believed to be the major cause of homelessness 
among the mentally ill. But the homeless mentally ill did not become visible in 
large numbers until years after the peak of that policy. Clearly, therefore, 
deinstitutionalisation was not the only cause. The loss of low-cost rental 
housing since the 1970s is another important factor:74 

It is our view that people with schizophrenia who once could afford a room or boarding 
house can no longer do so and must seek shelter in the refuges. In fact, it was only after
 1981 when low cost accommodation became scarce in Sydney that 20 out of the 22 schizophrenic
 men [in the study] began to use the refuge on a regular basis.75 

Human Rights and Equal Opportunity Commission Page 555 

In an era of affordable accommodation, our psychiatric hospitals were emptied 
with little or no thought apparently given to where the former patients would 
live. (If thought was given, then clearly grossly inadequate resources were 
allocated to translate policy into reality.) In the 1990s analogous and equally 
irresponsible practices continue. Mentally ill people are admitted to hospital in
 an acute state, then discharged without health authorities having any idea what becomes
 of them. 

Apart from the direct effects of deinstitutionalisation, evidence to the Inquiry 
clearly established that homelessness is a frequent consequence of mental 
illness. Expert witnesses referred to a 'social drift' of people with long-term 
disabilities down the socioeconomic scale, through unemployment and into 
homelessness.76 It is especially true of people with schizophrenia and those 
with drug and alcohol abuse problems (which frequently accompany mental 
illness among the homeless)77, who end up 'disadvantaged and destitute'.78 

The vulnerability of someone with a current disorder is considerable... As social and
 economic supports fall away, it becomes increasingly likely for a person to become homeless.79 

Does Homelessness Cause Mental Illness? 

A person who is homeless is susceptible to stress and hardship that most of us cannot
 even begin to imagine. Such pressures are likely to bring about mental illness.80 

For most homeless people with a mental disorder, the disorder occurs before 
homelessness.81 However, on the evidence presented to the Inquiry, it is clear 
that homelessness may contribute to mental disorders, to associated problems 
such as substance abuse, and to impeding appropriate treatment or responses. 
As one expert witness explained: 

It's certainly true that people become mentally disturbed [and] very depressed by their 
experience in this environment... You often see people talking to themselves or... sitting 
together talking and having what I call parallel conversations — so in other words nobody 
is listening. And I think that sense of isolation and lack of feedback does lead to mental 
disturbance, and certainly would contribute to pre-existing mental illness and...to drug-taking
 and alcohol abuse and, I think, would cause depression.82 

This view is strongly supported by recent overseas research.83 

Homelessness and poverty can also contribute to a perception of mental illness: 

If that person was well off, had supports, they may be labelled eccentric. If they are poor,
 without accommodation, homeless, they are labelled mad. And I think that is a big distinction 
we need to be aware of.84 

Page 556 Mental Illness Inquiry 

Particularly Vulnerable Groups 

The combination of homelessness and mental illness is a daunting burden. But 
among the homeless mentally ill there are groups with special needs who are 
even further disadvantaged.85 

One group frequently identified by witnesses was homeless women. 

Very little information is available on homeless women: most surveys of the 
homeless focus on single men.86 Few services exist for homeless women, or 
for homeless families.87 Boarding houses, being mixed accommodation, are 
often inappropriate for women who have been abused by men.88 For women 
with a mental illness, sometimes compounded by drug or alcohol dependency, 
there is almost nowhere to go — especially if they have children. In Adelaide, 
for example, Catherine House is the only shelter prepared to take women with 
psychiatric or substance abuse problems.89 But even that shelter cannot take 
children — so in Adelaide, as in a number of other cities, women with children 
who are homeless and mentally ill have no accommodation options at all. 

Children and young people with mental illness are also at particular risk if they become homeless.
 The deprivation, violence and exploitation associated with 
youth homelessness has been described in the Commission's report Our 
Homeless Children; mental illness makes a homeless young person even more 
susceptible to those risks.90 

People who live in rural communities are another group with special needs. 
Homelessness and mental illness are by no means confined to the cities: 

Almost all the new services which have been established to accommodate and assist homeless 
people in the country areas report that they have many clients who have been discharged from 
hospitals or who are mentally ill." 

Smaller population centres also lack the cheap accommodation which transient 
people can often find in cities. In Port Lincoln the Inquiry was told: 

There are no hostels, no boarding houses, there is no form of alternative accommodation 
in Port Lincoln, and I have known of young people sleeping on the oval because they suffer 
from schizophrenia and nobody wants to have them in their home.92 

Mental health services generally are woefully lacking in country areas, and any 
support for the homeless mentally ill is spread very thin indeed.93 

Human Rights and Equal Opportunity Commission Page 557 

Dual and multiple disabilities are common among the homeless.94 For 
example, many homeless people have a mental illness and an intellectual 
disability, or a mental illness and a substance abuse problem: 

We observe that these people in fact abuse a variety of substances to cope with their illnesses 
and their subsequent rejection by existing [mental health care] systems. [They often use] 
prescription pills and alcohol rather than hard illicit drugs.95 

People with dual disabilities have particular difficulty coping with daily life: 
they are possibly the most disadvantaged of all the mentally ill. Paradoxically 
— and inexcusably — they are often excluded from support services because 
they do not comply with formal guidelines designed for only one disability. For 
example: The staff of one inner urban non-medical detox [centre] cannot supply people with 
medication for mental illness because it is a non-medical detox! This leaves the person unfortunate
enough to be afflicted with a dual disability — alcohol dependence and mental illness — without 
access to treatment services. Similarly, many psychiatric services refuse to treat the mentally 
ill who have drug or alcohol related disorders.96 

The resistance from government psychiatric services is based on the assessment 
of problem behaviour as being 'drug induced' and therefore not appropriate to 
a mental health facility.97 The evidence from staff in one major Victorian 
agency typified reactions to this policy expressed by community groups: 

We recognise that the distinction between psychiatric illness and substance abuse can be murky, 
however... It is our belief that the [Victorian] Office of Psychiatric Services has to accept the 
reality of this client group, that they are likely to abuse substances (as 
opposed to being addicted to them), and that this is another symptom of the individual not coping,
 rather than the cause.98 

This process of exclusion 'borders on the systemic for homeless people with 
multiple disabilities'.99 

Conditions in Shelters and Refuges 

Many who would have been in previous times housed in hospitals...are now housed in accommodation which
 would never be tolerated in hospital.100 

A major form of accommodation for homeless people in cities is shelters or 
refuges. Many of these are run by religious charities, often with government 
support; others are funded directly by State governments. The biggest hostels, 
located in Sydney101, each provide a meal and a bed for up to 400 men per 
night. 

Page 558 Mental Illness Inquiry 

With the enormous size of the hostel there is little quality or quantity of care for the individual... 
Care facilities need to be small to build up decision-making ability and a sense of worth.102 

Three of the largest urban shelters for the homeless are run by the St Vincent 
de Paul Society. In a written submission to the Inquiry, the Society described 
these shelters as a dumping ground for men with a behavioural or mental illness problem. Police, hospitals
...ambulances etc just drop them off at the front door.'03 

Conditions in the refuges and shelters — even the most reputable — are clearly 
unsatisfactory:104 

There is one psychiatric nurse available and most of his/her effort is taken up with dispensing
medications. The men spend most of their time waiting for meals, a bed etc. There is a general 
feeling from the staff that we are letting men down — we offer food, shelter, but that's it. 
Loneliness and anonymity pervade the hostel.105 

Crowding is a major problem, especially for the mentally ill: 

People with schizophrenia and manic depression illness spend a great deal of time during the night
 walking. At present there is a lot of frustration experienced as some people are trying to sleep 
and others are in motion.106 

They need to stomp around at night, and there's just no place for them to stomp between mattresses 
on floors.107 

Residents are generally locked out of dormitories during the day,108 and: 

The lack of privacy is unbelievable, even your clothes are put in a wire basket, people can see all
 your everyday activity — it is a very public thing to happen to you.109 

Refuge life can also be stressful and distressing: 

During the day there [are] up to two or three hundred people on the premises. For anyone with a 
psychiatric disability that is quite frightening, to be in amongst people with psychiatric, 
intellectual, drug [addiction] and alcoholic dependency.110 

Security is also a major concern. At Catherine House in Adelaide: 

We have four staff.. .but because of the behavioural difficulties that we experience at times,
 we do need someone [on duty] 24 hours a day. We believe it is unsafe for the women generally 
and for individual women to be in that house without someone who can immediately get 
assistance... We have tertiary students sleeping over from midnight till 

7.30 in the morning, and their job is to contact a staff member if there's a problem. But 
it is a cause of anxiety...because there's not someone right on the spot.111

Human Rights and Equal Opportunity Commission Page 559 



Sometimes the difficulties caused by disturbed or sick people must be dealt with 
by calling the police: 

There's often violence in the house at 3am...[or] during the night from 10 or 11.
 Sometimes the police are asked to come in.112 

We can't always cope with the problems that arise and we do have to ask them to leave,
 and indeed at times we have to ask the police to assist us and move these women on.113 

Women's Refuges 

I am finding more and more that women are choosing to return to unsafe situations because 
accommodation is not available.114 

Homeless women and their children are frequently referred by welfare agencies 
to women's refuges, because no other alternatives are available. These refuges 
generally serve as a haven for women who have been victims of domestic 
violence. Bringing mentally ill women into a refuge, where they cannot receive 
any appropriate treatment, can have deleterious effects on others who are there 
attempting to recover from the experience of domestic violence:115 

It's a burden to other residents already in the shelter who are experiencing crises 
themselves, and when a woman is inappropriately referred she either contributes to
[the others'] crisis situation, or they will start to target her because they can't 
understand what's going on and they are frightened. And it also has issues for 
staff working in shelters, in terms of the amount of resources that you need to
 allocate to one person when there are several families experiencing distress.116 

Conditions in women's refuges (such as the necessary high level of security) 
may also aggravate a mental illness or disorder. One of a number of examples 
cited to the Inquiry concerned a woman who had paranoid schizophrenia and 
was fleeing a violent home: 

I referred her to one of the women's shelters and they were happy to assist her
 because she was on medication and it was controlling her situation. However,
as soon as [we] got to the women's shelter she saw the security screens on the 
windows and doors, and that immediately escalated her mood and she became paranoid.
 Within five minutes it became apparent that it wasn't appropriate for her to stay 
in any shelter accommodation... [Eventually] the woman was quite frustrated with 
the limited options she had and chose to return to an abusive relationship, stating 
that at least there she knew what was happening and...what she was dealing with.117 

It is inexcusable that women suffering a mental illness are forced to choose 
between homelessness and violent abuse. 

Page 560 Mental Illness Inquiry 

Homeless Service Agencies 

It's a wonderful feat that the financial cost and some of the odium of caring for
 this group has been shifted from health services to someone else.118 

The Inquiry heard evidence in every State from representatives of refuges, 
charities like St Vincent de Paul and the Salvation Army, and other agencies 
providing shelter or services to the homeless. Many of these witnesses believe 
they have shouldered responsibility for the homeless mentally ill as a result of 
deinstitutionalisation;119 but that government bodies have failed to recognise 
or support them in that role.120 

Professor Ian Webster, a doctor who cares for the homeless in Sydney, 
expressed the frustration of charitable organisations: 

Does anybody ask these organisations are they prepared to pick up the tab or pick
 up the load when a government makes a decision not to do something?... Nobody has 
asked the people at Matthew Talbot hostel, or me or the nurses who work with me, 
is this something that you have expected to do in that environment?121 

Many staff in non-government homeless agencies resent having to cope with 
people who were never intended to become their responsibility. The agencies 
work on the assumption that most homeless people are 'fairly ordinary people 
who will eventually be able to get back to a home or...return to a normal 
life.'122 But increasingly, the homeless consist of people who are so disabled 
that they need permanent support of many kinds, not just emergency accommodation 
for the night. Government mental health policies — either deliberately 
or negligently — have forced these people onto the doorsteps of charities which 
have neither the resources nor the skills to help them: 

No department will accept the responsibility so homeless persons agencies with
 open door policies become the only option.123 

The growing problem of mental illness among the homeless has prompted some 
agencies to form special bodies dedicated to this issue. For example, the 
Society of St Vincent de Paul, which has worked with homeless people for 
many years, has formed State and National Committees in Support of People 
with Mental Illness.124 However, no comparable response has come from 
governments to specifically address the needs of this very vulnerable and 
disadvantaged group. 

Accommodation is not the only area where agencies feel compelled to do the 
job of governments. Homeless people are entitled to income support, health and 
other services, but the government departments which should be providing 

Human Rights and Equal Opportunity Commission Page 561 

those services are reluctant to deal with the homeless mentally ill. The burden 
of advocating and obtaining these services for them invariably falls on the 
shoulders of the agencies. 

Access to Services 

Effective responses by psychiatric services to assist staff and people who are homeless
 with a mental disorder have been limited... Services have, in many cases, remained inflexible 
and inaccessible.125 

Homeless people are affected by a pincer movement: they are caught between 
increasing poverty and decreasing capacity of the system to respond to people 
in need. This means the homeless mentally ill are routinely denied the services 
and benefits they need most, and which other people reasonably expect to have: 
housing, employment, social security, medical care and other services.126 

Discrimination 

One reason for this deprivation is discrimination. 

Homeless people find themselves excluded from generic services. They may be 
considered undesirable  or too much trouble or inappropriate...or the way that 
0services are delivered is inappropriate for someone who is unable to keep an 
appointment or who feels too uncomfortable to hang around for long periods in
 crowded waiting rooms, to be viewed at best with curiosity and more usually as an object 
of distrust and suspicion.127 

The Inquiry was told government health services are reluctant to deal with the 
homeless, especially if they are mentally ill. For example, if a homeless person 
with mental illness needs medical treatment, even for major problems requiring 
an operation, staff of non-government agencies are forced to adopt 'extraordinary strategies' 
to get them accepted into a public hospital. And 
even when they got them into hospitals, of course, they came out as quickly as lightning because 
the hospitals] had great difficulty coping with them.128 

Bureaucratic Barriers 

Another reason homeless people are denied access to the services they need is 
the rigid division of responsibilities among government departments: 

Increasingly barriers are being set [up].. .and people are saying 'this is not my problem but 
somebody else's problem. This doesn't belong to the mental health system, it belongs to the
social welfare system; it doesn't belong to the social welfare system, it belongs to the
 judicial system,' as the case may be.129 

Page 562 Mental Illness Inquiry 

Government departments tend to see their functions as meeting only certain 
specified needs. As one expert witness commented, they prefer only to deal 
with 'clean-skins', and not with people who have complex problems with every 
aspect of their lives.130 

As already noted, people who have multiple disabilities — and thus do not fit 
neatly within the guidelines of any one service — often miss out altogether. A 
homeless person with a mental illness typically has many overlapping needs, 

and whilst departments argue about [who should take] the responsibility for that person, no
 support is provided in the meantime by the statutory authorities.131 

If no department accepts responsibility, the homeless agencies with open-door 
policies become the only source of assistance.132 However, even some of the 
agencies prefer not to deal with mentally ill people, based on past difficulties 
with individual clients.133 

Identification Requirements 

Another obstacle is the increasingly strict requirement for proof of identity and entitlement. 
When governments have, in the past, decided to tighten eligibility for people claiming health 
or welfare services, little consideration appears to have been accorded to the consequences for
 the homeless mentally ill — all of whom depend on the welfare system.134 

The national health system has in many ways improved homeless people's 
access to health care, but on the other hand, there is an incessant problem, particularly amongst
 those who are confused and disorientated, of losing their Medicare cards, not being able to prove
 who they are, and not being able to gain free medical treatment.135 

Homeless people lose their Medicare cards not only because they are personally 
disorganised, but also because lack of secure shelter means their belongings are 
frequently stolen. 

The same problem applies to the Pharmaceutical Benefits Scheme (PBS). As 
one experienced doctor said: 

They cannot find their pension number and we have to go through all sorts of ruses to try and get
just reasonable supplies of pharmaceuticals to treat their medical conditions.136 

The Inquiry was told recent changes to the PBS have made it even more 
inaccessible to this destitute group of people. In response, some of the homeless 

Human Rights and Equal Opportunity Commission Page 553 

hostels in Sydney have entered into a complex arrangement with the Federal 
government, to rand a local pharmacist to provide the drugs needed by hostel 
residents.137 

The Department of Social Security also has stringent requirements as a 
deterrent to fraud: 

The onus is on the client to provide certain things such as identity, proof of residence, birth 
certificates and all that sort of thing. [For the homeless mentally ill], that is a monumental 
and totally unrealistic task. You have to remember that most of these people are at best very
 confused. Some of them don't know who they are, where they are, let alone...dealing with Social 
Security or the Ministry of Housing.138 

Most homeless people do not know how to deal with the Department of Social 
Security.139 People who lose their identification but who know they are 
entitled to benefits sometimes become infuriated at 'being given the runaround'. 
Social Security staff may feel threatened by this and be even less helpful, which only makes the
homeless person more upset. According to one expert witness: 

While Social Security might believe it is doing the right thing by checking up against fraud — 
and my personal view is that there is an absolute obsession with fraud — I think it operates 
against the interest of these people who have quite genuine need... And it leads to quite a lot of
conflict and disharmony in Social Security offices as these people quite reasonably get agitated 
about what is happening to them.140 Even if homeless mentally ill people manage to get on Social 
Security benefits, they are often cut off because they do not understand the rules. This happens
 particularly when a person has been classified in the wrong category of benefits: 

For example, someone who does have a slight disability which may have not been 
diagnosed by the system, may well be on unemployment benefit, on sickness benefit or on a benefit
 which requires that person to do certain things like putting in a medical certificate or fortnightly 
application for unemployment benefits; they do not do that (for whatever reason), and very soon the
 income security is gone because the benefit has been cutoff.141 

The Inquiry heard that some mentally ill individuals actually become homeless 
because their welfare benefits are cut off: 

This has usually been because of their incapacity to negotiate the Social Security system 
effectively. It may be the result of frank psychosis, such as paranoid delusions, but more often 
it seems to be a simple matter such as failure to notify a change of address.142 

In this situation it is once again the non-government agencies which assume 
responsibility for helping these people to obtain the benefits which are their 

Page 564 Mental Illness Inquiry 
right. The agencies which are less preoccupied with bureaucratic formalities than government
 departments are: 

The great virtue of some of these organisations is there is no need to produce a ticket. 
You don't have to define who you are to get in.143 

Sometimes homeless people are not aware that their benefits have been cut off, 
or they are reluctant to seek help. One Melbourne agency described a typical 
experience with one client: 

We found that three months ago in fact his sickness benefits were cut off. He didn't tell anybody; 
he doesn't particularly like using the money from the government. It only came to our attention 
because the rooming house rang us up and said that his rent wasn't being paid. For this gentleman
 to be able to go and fill out a Social Security sickness benefits form again, which meant that he 
could then be put back onto sickness benefits, was an awesome ordeal. What we were able to do, 
because of the relationship that was there, was simply get him to sign a form; tell him that, yes, 
we will fill out the rest of the details and 
take it through to Social Security.144 

Helping people to regain their welfare benefits is a daily task which is 
frustrating and 'very, very time-consuming' for agency staff.145 

Inadequate or Inappropriate Services 

Most homeless mentally ill persons are willing to accept offers of help, but their perceptions of 
needs and service priorities often do not coincide with those of providers146.

When homeless people with a mental illness do gain access to mainstream 
services, they frequently find the services are inadequate for their needs. A 
mundane example is that there is no public provision of podiatry or physiotherapy, which are considered 
optional luxuries by our health system.147 But for people who sleep rough, are frequently injured and 
wear ill-fitting shoes or none at all, those services can bring significant improvements in health. 

As already indicated, health and welfare services generally define their ambit 
of operation in a limited and inflexible manner. But the homeless mentally ill 
have many interrelated problems: 

People who are long-term mentally ill have a greater rate of physical health problems and unmet health 
needs. Conversely, the people with a long-term disability have a higher rate of mental illness.148 

Human Rights and Equal Opportunity Commission Page 565 

In fact, medical treatment may be the least difficult need to meet: 

A lot of the time people's medical needs are looked after: you can get services for the medical side 
of psychiatric illnesses. [The problem] is the non-recognition that people with psychiatric illnesses
 are just like the rest of us. They have a personality before they got the psychiatric illness, they 
will have it afterwards and they will have it during it... 

They have housing needs, they have personal needs, friendship needs, to be able to be understood, 
to be in a situation where they are not judged just because they have a psychiatric disability... 
[But] the concentration of psychiatric services on their medical illness often alienates the people
 from that service.149 

Mentally ill people have difficulty using hospital outpatient services: 

These people who go to outpatient clinics, they're waiting two and three hours in some places to be 
attended to... People who are kind of mentally unstable at that time, they don't have that kind of
time to sit around because they're very agitated, and they're needing direct care now.150 

Not surprisingly, these obstacles are enough to dissuade many homeless 
mentally ill individuals from even attempting to obtain the help they need to 
survive. One witness cited the public housing waiting list as an example, but 
his comments apply equally to other services: 

Waiting time is of such a nature that most people don't even bother to apply; and that 
applies for homeless people in particular because they are very suspicious and wary of 
the way — of their experiences with authorities and...well, their perception that they
 have been given a raw deal, which most of the time is absolutely true.151 

The alarming result of all these factors is that thousands of homeless mentally 
ill Australians go without the treatment and support they need — not for any 
reason connected with their illness, but because the systems which are supposed 
to help them simply do not do so. 

Resistance to Services Being Established 

Evidence to the Inquiry demonstrated a general recognition that the services 
available for the homeless mentally ill are inadequate. Yet any efforts to 
establish more appropriate services must confront formidable obstacles: not 
only bureaucratic and financial limitations, but also community resistance from 
residents who object to seeing mentally ill people in their neighbourhoods. 

For example, the St Vincent de Paul Society planned to open a hostel for the 
homeless mentally ill in the Sydney suburb of Lewisham; local opposition 
forced the agency to abandon the plan.152 One objective of the Lewisham 
project was to allow careful consideration of the best housing models for the 

Page 566 Mental Illness Inquiry 

homeless mentally ill. Very little is known on this subject, because so little has
 been attempted: 

We need to pay more attention to what are appropriate kinds of accommodation for people
 with mental illness, in which environment they could be protected, at the same time be 
independent and yet gain access to services.153 

The Inquiry heard extremely disturbing evidence of active discrimination, 
outright harassment and vandalism directed at a charity which attempted to set 
up a rural home for people recovering from mental illness on the South Coast 
of NSW. Local residents, allegedly with the support of the local council, 
obstructed the project's development, threatened its members and vandalised the 
property. Finally the project was abandoned: 

The nervous and physical sufferings which we have received on this property as a result
 of this consistent harassment makes it impossible for our St Francis 'family' to continue
 there. The stress we have been under is amplified in one person, John Holt, who, because 
of the pervading anxiety decided he would 'prefer to go back to prison'.15* 

Primary Health Care 

Homeless people who are mentally ill have difficulty using the ordinary health 
services, for reasons already mentioned — including loss of Medicare cards, 
inability to keep appointments and discrimination. Some cities have free clinics 
for the homeless. In Sydney several were established after the Henderson 
Poverty Inquiry in 1974.155 Apart from providing health care, these clinics 
must often act as mediators between this very disadvantaged group and the 
bureaucracies of the health, mental health, welfare and guardianship systems. 

Evidence to the Inquiry clearly indicated that the concentration of mental health resources 
in large hospitals seriously disadvantages people who are transient and have little contact 
with the health system. This can be improved: training is improving for doctors and nurses, 
with more emphasis being placed on 
community medicine and community mental health;156 additional responsibility 
appropriately conferred on local area health services can also contribute.157 

One widely available but under-used 'mental health resource' identified by 
several expert witnesses is general practitioners. Although only a small 
proportion of the homeless mentally ill have any contact with formal mental 
health services, 95 percent have contact with a GP.158 GPs thus 'offer a great 
potential as agents of care and support' for homeless people with a mental 
illness: 

Human Rights and Equal Opportunity Commission Page 567 

They accept [GPs] as a reasonable way of making contact with the care system. They in fact value 
that because this person is not a psychiatrist, not part of the formal mental health system and...
they look towards that person as being on their side and reasonable.159 

One expert witness pointed out a danger to the homeless mentally ill in the 
ethical debate over the allocation of health resources. The question being asked 
is: who deserves health care? If the answer is framed in terms of personal 
characteristics and behaviour patterns, it will be easy for the homeless mentally ill to be 
systematically excluded from levels of health care which other people receive as a matter of 
course: 

For example...at public hospitals where people talk about how they would decide who should be 
admitted for heart transplantation... The criteria that people use.. .might include things 
such as smoking or some other attribute of that kind. 

Now there may be reasonable reasons for using that as a point of discrimination, but taking
this class of people [the homeless]...most of them are smokers. And that has been a product 
of not so much their wantonness or inclination to self-abuse...but it has been a part of 
the undervaluing that they have experienced in their life.160 

Agency Staff 

The Inquiry repeatedly heard evidence that the homeless agencies are 
understaffed, and their workers are undertrained to deal with the range of 
problems they are required to confront. Homeless people with a mental illness 
need substantial and continuing support. But as one Melbourne worker said: 

We are a team of three social workers, basically working with up to 250 people, we are stretched 
very thinly... Professionals, generally speaking, don't have the time to spend with these people
 because they are just too thinly spread.161 

Working with homeless people is emotionally taxing for staff who see injustice 
being done on a daily basis: 

It's very heart-breaking from a human point of view, it's very frustrating for workers.162 

At some shelters (especially women's refuges) mentally ill people are often 
turned away in the interest of protecting the other residents. A worker at a 
South Australian women's refuge told the Inquiry: 

As for myself and the staff at the shelter, this doesn't help our mental wellbeing at all, 
because we're there to help women and to work with them — and having to see women turned out
 on the streets mentally ill or disturbed, nowhere to go, at risk to themselves and to the 
community, doesn't help us at all.163 

Page 568 Mental Illness Inquiry 

Because most agencies are intended to serve people who are homeless but not 
mentally ill, their staff rarely possess the expertise needed to help individuals affected 
by mental illness. 

The hostel is becoming an extension of the psych hospital but without the expertise to provide
 a therapeutic environment.164 

Training is needed in hostels and refuges, where staff are expected to dispense 
medication to people who are mentally ill.165 One expert witness called for 
an integrated scheme of accommodation and medication, to take adequate 
account of the fact that many homeless people are mentally ill.166 

Even the few experts working with agencies told the Inquiry there are big gaps 
in their understanding of mental illness and mentally ill people. One witness, 
referring to younger, transient homeless people with a mental illness, said: 

There is so much uncertainty...in my mind about even getting a handle on what they are like. 
Perhaps the most I can say is...when you look at this group they are often dressed outlandishly,
with tattoos or hair grown in particular ways, unusual garb on. And most citizens would be 
offended by them and yet they are very mentally ill young people who need help, and they are 
sometimes quite aggressive... What [we] need more than anything else is a way of identifying
 with them and being their advocate.167 

One submission to the Inquiry suggested that governments should consider 
directly funding the employment within non-government agencies of mental 
health professionals: 

Many of the staff in the agencies already have excellent skills through years of practical
 work with the mentally ill. However, specific professionals, such as psychiatric nurses, 
could help shoulder the burden and quickly teach other staff new skills.168 

Relations Between the Health System and Agencies Assisting the Homeless 

The following statement summarised a great deal of evidence to the Inquiry 
presented by staff at homeless agencies: 

Aside from finding appropriate accommodation [for their homeless clients] they will say 
that they are unable to access services to provide support and assistance to people with 
psychiatric disability, or to secure support for themselves as workers in situations which 
they are often not confident in dealing with.169 

Human Rights and Equal Opportunity Commission Page 569 



Hospitals 

Witnesses in all States repeatedly stressed the failure by psychiatric hospitals 
to communicate with agencies or anyone else when a homeless person is 
admitted or discharged. For example, on admission: 

One woman was taken to hospital from a rooming house. She did need to go to hospital — 
there wasn't any question of that. I actually was visiting someone else in the hospital 
a week later, [and] saw her there...she had been there for one week in a hospital gown, 
fresh gowns daily; nobody in that hospital had contacted where she had come from (and she 
did have an address) to say could someone bring out her personal belongings. So there she was
 without any underclothing in the hospital, just stuck there; and it just happened that 
I was passing and was able to go back and get it. But that is not the way things should work.170 

Hospital monitoring of patients on release is also deficient. The Inquiry heard 
of a number of incidents such as the following: 

[A] gentleman was brought in by two elderly people...he had walked from Ballarat to Melbourne. 
He had a.. .psychiatric history, he had been in institutions for most of his life. Unbeknownst
 to him we did ring the institute he had just left, the psych hospital that he had just come 
from. They did not realise he had left — he wasn't certified.171 Even when mentally ill people
 recognise that they need treatment, agency staff have great difficulty in obtaining assistance.
 A worker at the Ozanam House shelter in Melbourne recounted a typical incident: 

A gentleman came into my office one day asking for protection, that he wanted to go to 
one of the major psych hospitals near us to be put in. I rang the hospital nearby asking 
could I send him over. Because of the red tape and the bureaucracy we had to go through, 
it took up quite a few hours of time... In the end I had to take the gentleman...to the 
doctors on the premises — who are not psychiatric trained — to get medication, and he 
ended up staying at Ozanam House.172 

Agency and refuge staff are often confused by hospitals' refusal to take people 
who obviously need help, but who do not fit the definition of mental illness. 
For example, at the Crossroads crisis centre in Melbourne: 

We constantly have problems with the medical system saying that these people don't fit 
the criteria for psychiatric hospitals for their care, and yet if you look at the DSM-III-R, 
which is the Americans' diagnostic manual for psychiatric illnesses, [the symptom] appears. 
So there seems to be some discrepancy there.173 

The evidence presented to the Inquiry clearly established that while we have 
relegated large numbers of Australians who are severely disturbed or mentally 

Page 570 Mental Illness Inquiry 

ill to an existence centred around shelters for the homeless, such refuges cannot provide
 effective access to our health care system. 

Access to treatment services should not be premised on primary care givers in homeless 
services distinguishing between conditions such as alcohol-related brain injury, behavioural 
disorder, psychiatric illness, intellectual disability or drug-induced psychosis, 
particularly as they may all manifest in similar behaviour. In the past staff from 
shelters have been criticised for not making these distinctions when making referrals 
to mental health Indeed, the health care system throws up barriers to treatment for people in 
urgent need by relying on clinical distinctions which frustrate the efforts of 
those working in shelters and refuges. 

Glenside and Hillcrest [psychiatric hospitals] are not prepared to offer accommodation to women 
who are classified as having either a behavioural disorder or personality disorder...[but only those]
 who have treatable illness. And a lot of the women I see are classified as having personality 
disorders'75... It is confusing to a lot of women working in women's shelters exactly how they 
define a personality disorder and why that is not considered a mental illness176... Some of 
the behavioural traits that have been described to me for women suffering from personality 
disorders [include] talking to themselves, having hallucinations, having [a] fascination with 
knives ... paranoia, lighting fires and isolating themselves from their supports and the 
women around them.177 

(The problems created by the diagnosis of 'personality disorder' are discussed 
further in Chapter 25.) 

Women escaping violent abuse may be assessed as [having] a personality disorder simply because 
[hospital staff] have got the information about their social background — that background being
 that they have experienced several years of abuse. So therefore their mental problem is because 
of their social environment and not a medical issue.178 

On the basis of all the evidence, one of the most serious problems is many 
hospitals simply 'passing the buck' to the shelters on discharge: 

• Many are discharged from the psych services to Ozanam House as their home, as their permanent
 accommodation and with no follow-up or no services to those people — and also no phone call 
to Ozanam House to inform us that they are being placed there. We are not a special service 
and we are not funded for special services... We have no drug and alcohol service and we have 
no psychiatric service.179 
• The patients from the hospital usually end up in the St Vincent de Paul hostel, Mt Isa.180 

Human Rights and Equal Opportunity Commission Page 571 

• I can't think of an example when we received follow-up phone calls from anyone at the hospital 
about how the person was going, or to offer us any suggestions about how we might manage 
that person.181 

Hospitals justify the policy of discharging patients directly to homeless shelters on 
the basis that there is nowhere else for them to go. Since the agencies generally have 
no psychiatric skills, this policy not only puts a great strain on their resources — but
 it is also detrimental to the patients' recovery, perpetuating and in many cases exacerbating
 the downward social spiral associated with mental illness.182 Shelters have all the disadvantages 
and none of the advantages of hospitals: 

[A] crisis accommodation centre isn't a good place for someone to be sent straight from 
hospital. For one...it's still a semi-institutional sort of environment where the person 
doesn't have a lot of privacy and certainly is surrounded by other people who have their 
own difficulties. But...it also has the disadvantages of not having the structure that 
the hospital has, so they're being thrown into a fairly...chaotic situation which wouldn't
 seem to be the one that would help a person stabilise when they're just recently leaving 
hospital.183 

While the evidence clearly established that this practice by hospitals is 
widespread, the Inquiry heard of at least one hospital which does co-operate 
with the shelters and agencies. Staff at Catherine House women's shelter told 
the Adelaide hearings: 

We have a very good relationship with Glenside Mental Health Hospital. We ring and consult
 and they're always very helpful.184 

If we get a referral from a hospital, if we have support from social workers and doctors
 we can manage. We have meetings with workers from Glenside to discuss how to handle 
[mentally ill residents], how to protect ourselves. But at the end of the day we get 
very stressed out.185 

Crisis and Outreach Services 

Witnesses from homeless agencies told the Inquiry that even outreach or crisis 
services are difficult for them to use. Crisis teams are notoriously short-staffed and 
frequently non-existent. In St Kilda, which has the highest per capita psychiatric 
admission rate in Victoria, there is no after-hours psychiatric crisis service.186
 Even in the daytime, workers in the homeless agencies have an enormously difficult
 time getting assistance from the psychiatric hospitals. For example, staff at the 
Crossroads Centre in Melbourne recounted their efforts to get help for a man who was 
having a psychotic episode, and was dripping wet and screaming: 

Page 572 Mental Illness Inquiry 

The [Crossroads] worker phoned St Kilda Community Health Centre, who were unable 
to attend and suggested calling Albert Park Clinic. They also were unable to attend 
and suggested calling Royal Park. Royal Park also said they were unable to attend 
and advised contacting Albert Park! Another call to Albert Park Clinic led to the 
Community Policing Squad being recommended. However, Prahran Community Policing Squad 
were not available at the time and were only able to attend after a new shift began.187 

Where crisis teams do exist, the logic of their operation can be frustrating: 


We've had several instances where [a] woman with, for example, a history of manic 
depression recognises that her symptoms are escalating and is asking for help, and 
shelters will ring for an outreach service from a psychiatric institution and they 

won't come — or they only come when there's a crisis. They actually say 'We'll come
 when there's a crisis.' And this woman is trying to manage her problem; and it seems
 to me that the respect [she deserves] to be accorded for trying to do that...is just 
not there. 

Or what will happen is that they won't come out and you've actually got to get the police 
to take them into the institution. I mean, that must be enormously traumatic for the 
person on top of everything else that is happening to them. 

We just don't know when the outreach service actually works. And I mean if we can't 
demystify when the service works ourselves, how could you expect somebody else to do it?188 

Relations between Government Departments and Agencies 

The Inquiry heard disturbing evidence about the lengths to which some 
government services and agencies will go in an attempt to pass on responsibility 
for the growing number of homeless people affected by mental illness. 

One tactic is to refer the person on to an agency without mentioning to staff 
there that the person is mentally ill. For example, a women's refuge worker 
told the Inquiry: 

It concerns me that the information we receive from other service providers is either 
deliberately misleading or they underplay behaviours so that you don't get the total picture... 
We had a Family and Community Services worker ring us with a referral for a woman and four
 children who was of a non-English-speaking background. And basically what this person said
 was that it was straight domestic violence and that the children were dirty — they had nits 
because of travelling. When we started to look at the issue a bit more, because we try to get
 as much information as we can about a particular family, this 
worker then acknowledged that they were long-term clients...that she has a very long record of
 mental illness. He would not have said anything unless we pressed... He recognised that this
 person was going to be difficult to place, so he would withhold information in order to 
improve her chances of being placed, without perhaps recognising the consequences of 
inappropriate referral.189 

Human Rights and Equal Opportunity Commission Page 573 

When a mentally ill person is placed inappropriately in a shelter, this can 
produce problems between agencies: 

[I]t soon becomes apparent to staff at the shelter that this is not going to work. And then...
what happens is that you become part of a co-abuse. You again have got to move that woman on, 
so you prolong her crisis situation, her distress — and...you are placed in the situation of: 
where are you going to move her on to? Because basically there isn't anywhere. And you are 
facing the questions that this FACS worker had to face when he was giving us information. 
ow much are you going to actually share with someone about the person you are trying to refer?'90 

The end result is depressingly predictable: 

Often, on the grapevine, we will hear that this woman has gone back to her partner or is
 out on the street where men who prey on such women will target them, and so that their 
abuse is perpetuated and that their transient lifestyle and their issues are never
 addressed by anyone.'91 

Another appalling practice revealed by evidence to the Inquiry is known as 'bus 
therapy'.192 It consists of mental health or welfare agencies putting a homeless 
mentally ill person on a bus (or train) with a ticket to another town, in the hope that 
someone there will take responsibility. A psychiatrist in Orange, NSW 
explained: 

Some [patients]...will even tell you that, you know, professionals will give them money out 
of their own pockets and say, 'Look, you are to go up to the bush, conditions are better up there."93 

In the new town the mentally ill person rings the police or FACS or a crisis 
line, if there is one, and the whole process begins again. A refuge worker in 
Cairns told the Inquiry: 

The train ticket to the next stop occurs a lot in northern regions because of that 
enviable winter we have...to the point a few years ago that we were so swamped that we had
 to send out a form letter to other shelters and agencies nationwide to please be a bit more
 considerate because we simply could not cope. And also they were under quite a lot of 
assumptions about what was available up here and what the lifestyle was like.194 

Poverty and Trustees 

The physical and psychological problems of the homeless mentally ill are 
generally compounded by extreme poverty. 

In order to be able to pay for something you have to have money. Now most homeless people 
with a psychiatric illness do not work... Basically, 99 percent of the people are on benefits 
— if they are on benefits at all. Many of them do not have any income for the 

Page 574 Mental Illness Inquiry 

same reason that they are not confident and skilled enough to deal with what is really a very
 complex and intimidating sort of a structure.195 

Some people with a mental illness do have money which is administered by 
legally appointed trustees. However, it was clear from evidence to the Inquiry 
that there are serious problems in many relationships between trustees and 
beneficiaries. For example, the Inquiry was told trustees are frequently 
neglectful or obstructive toward the people whose money they are managing. 
In the case of a mentally ill person on the verge of homelessness, an unresponsive attitude
 by trustees, or even some unnecessary delay, can have serious consequences. 

There was one fellow who had a long history of mental illness, finally got stable accommodation;
 his rent was to be paid by the State Trustees. The rent went up. Numerous letters had gone 
to the State Trustees; it was not taken note of. In the end, that man could have been evicted 
for rent arrears. It happened that the landlord was okay, so he wasn't — but how many cases 
does this happen, I think to myself, when you know of only one?196 

Trustees' judgments about the best interests of a mentally ill person may be 
based on well-meaning but ignorant assumptions. For example, a homeless 
agency worker told the Melbourne hearing: 

A woman who has accumulated $900 worth of debts... She does have that amount of 
money with the State Trustees. I rang on her behalf asking could we negotiate some way of paying 
off her debts to free her from this, because -1 was talking about the dignity of being able to 
pay your debts, which is something I know a bit about personally. 

But the [State Trustees' officer] would not entertain it. She said [the homeless person] has to 
learn to budget — which I never have, and I am sure a lot of the people in [this] room never 
have learnt how to do. She must negotiate - all of the people on this woman's list had to write 
to the State Trustees to get their $4 back, their $80 back. The woman had no say in her money."7 

Many people feel so intimidated and misunderstood by their trustees that they 
avoid dealing with them altogether. This forces them to live in even greater 
poverty — principally as a result of die trustees' attitude, or perceived 
inaccessibility. 

For example, an agency worker told the Inquiry of a homeless mentally ill 
woman who needed a warm jacket as the Melbourne winter approached: 

I said, how about getting one? And she said, 'Oh, I will go to the op shop.' I said, what about 
your money in the State Trustees? [She replied,] 'Oh no, I don't want to go in there and talk 
to them, I will go to the op shop."98 

Human Rights and Equal Opportunity Commission Page 575 

For the homeless mentally ill, the poorest people in our society, this inaccessibility, 
insensitivity or even intimidation denies them access to their own money just as effectively 
as deliberate discrimination would. It is obviously a serious form of neglect, and should not 
be allowed to continue. The homeless mentally ill must be accorded their economic rights as far
 as is possible and reasonable. 

They get the feeling that it is not their service. They have to feel that they can walk in and
maybe [be] a pest sometimes and say, I want some of my money now. I mean, you have got to put 
checks and balances and things...[but] people have to feel the services are theirs, because 
it is their money.199 

What the Services Should be Like 

The homeless mentally ill must be able to feel that it is their right rather than a privilege 
to obtain the services they need. 

Witnesses to the Inquiry repeatedly emphasised that services — whether they 
are night shelters, community health centres or home care — must be designed 
for the people they are trying to help. This means a service should acknowledge 
and accommodate clients' mental illness — but it must also recognise they have 
other needs beyond their psychiatric disability.200 Services should be multidisciplinary, 
and not dominated by psychiatrists.201 

Continuity of relationships is one of the most important factors — yet it is 
precisely what is missing from government health services. When it is 
provided, it can contribute significantly to the mental health of a homeless 
person. For example, the man who four years ago was severely disturbed, 
yelling at lamp posts and playing in the traffic: 

We couldn't communicate with this person and he certainly wasn't in a position to communicate with us... 
4 1/2 years down the track, this gentleman (although he doesn't comply with medication, [and] he does 
have alcohol and drug problems), I believe through...continuity of relationships with him he has a 
bigger and better insight into some of his own behaviour.202 

He feels welcome when he comes to the day centre. The insights to his own behaviour about what is 
acceptable and what is not acceptable, I believe, through the channels of communication and friendship
 that he has found at the centre has meant that, for instance, he gets locked up by the police less 
than he did 4 1/2 years ago; that he can come into the centre and he has got some idea...that if 
he is angry what he might be able to do is go for a walk around the block, or he can talk about it.203 

Page 576 Mental Illness Inquiry 

Other important requirements are that services be more flexible and accessible. 
At present a homeless mentally ill person seeking support 'finds it a difficult 
and confusing process, because service provision and methods of service 
delivery can vary so much from area to area. '204 

These features — continuity, flexibility, accessibility — can only be achieved 
if adequate resources are allocated: 

As far as support goes, I believe it is the quality of support that is given to these people [that 
matters]. It is time-consuming to give good quality of support; I guess if it is time-consuming 
therefore it is costly.205 

However, on the basis of evidence presented in every State and Territory, 
homeless people with mental illness are clearly among the most vulnerable and 
abused in our society. The cost of protecting their rights is not, therefore, an 
optional extra; it must be accorded an urgent and effective response. 

Human Rights and Equal Opportunity Commission Page 577 



1. Dr David Leonard, representing the Royal Australian and New Zealand College of Psychiatrists.
 Also Director of Clinical Services at Royal Park Hospital. Oral evidence, Melbourne 10.4.91, p346. 
2. Rehabilitation Advisory Group (Western Australia), Community Based Rehabilitation and Support
Services for People with Long-term Mental Illness, 1991, p8. 
3. Human Rights and Equal Opportunity Commission, Our Homeless Children, AGPS, 
Canberra 1989, p43. 
4. US Task Force on Homelessness and Severe Mental Illness, Outcasts on Main Street, Department
 of Health and Human Services, Washington DC 1992, p7. 
5. These witnesses not only included advocacy groups, but also experts such as Dr N Buhrich, 
Acting Director of the Department of Psychiatry, St Vincents Hospital. Oral evidence, 
Sydney 18.6.91, p135. 
6. H Hermann, P McGorry, P Bennett, R van Riel, D McKenzie and B Singh, 'Prevalence of severe mental
 disorders in disaffiliated and homeless people in inner Melbourne', American Journal of Psychiatry 
vl46, 1989, pi 179. 
7. This is not a problem peculiar to Australia. In the US, where efforts to measure the homeless 
opulation have been going on for considerably longer, estimates vary between 200,000 and over 
wo million. Even the US Government's own estimates vary by over 300 percent. National Institute of 
Medicine, Homelessness, Health and Human Needs, National Academy Press, Washington DC 1988, p3. 
8. National Health and Medical Research Council (NHMRC), Homelessness and Severe 
Mental Disorders (Report of the Health Care Committee Expert Panel on Mental Health), 
AGPS, Canberra 1991, p4. 
9. Netty Horton, Coordinator, Victorian Council of Homeless Persons. Oral evidence, 
Melbourne 10.4.91, p401. 
10. id. 
11. Homelessness, Health and Human Needs, op cit, pp39-75. 
12. H Clough, Somewhere That's Home... A Report on Adult Homelessness in the Inner East 
of Melbourne, Compass Accommodation Support Service, 1991, p7. 
13. Buhrich, op cit, pl35. 
14. id. 
15. Prof Ian Webster, Professor of Public Health at the University of NSW and visiting medical 
practitioner at Matthew Talbot Hostel, Sydney. Oral evidence, Sydney 20.6.91, p459. 
16. Buhrich, op cit, pl37. 
17. ibid, pl35. 
18. Webster, op cit, p450. 
19. Sister Kay O'Neill, St Vincent de Paul. Oral evidence, Cairns 9.8.91, pl050. 
20. Webster, op cit, p461. 
21. NHMRC, op cit, p5; Our Homeless Children, op cit, p65. 
22. Webster, op cit, p461. 
23. id. 
24. Megan Campbell, Health and Welfare Coordinator, Hanover Day Centre. Oral evidence, 
Melbourne 10.4.91, p403. 

Page 578 Mental Illness Inquiry 

25. St Kilda has the highest psychiatric admission rate in Victoria: 76.4 admissions per 
10,000 people per year. David Eldridge, Director of Crossroads Supported Housing Network. 
Oral evidence, Melbourne 8.4.91, plOO. 
26. Campbell, op cit, p403. 
27. id. 
28. id. 
29. ibid, p405. 
30. ibid, p403. 
31. Ben Hagedorn, Hanover Access Centre. Oral evidence, Melbourne 10.4.91, p411. 
32. O'Neill, op cit, pl050. 
33. Webster, op cit, p451. 
34. O'Neill, op cit, pl050. 
35. Sister Anne Gregory, Catherine House shelter for homeless women. Oral evidence, 
Adelaide 22.10.91, p233 
36. Sister Margaret Tulley, Catherine House shelter for homeless women. Oral evidence, 
Adelaide 22.10.91, p236
37. Campbell, op cit, p404. 
38. Homeless Mentally 111 Advocacy Group, No Fixed Abode. Homeless, Mentally III and 
Desolate -A Call for Action, Brisbane 1992, p4. 
39. Paul Fanning, Chief Executive Officer, Orange Health Service and Director of
 Psychiatric Services for the Central Western Health Region. Oral evidence, Orange 12.7.91, p904. 
40. Horton, op cit, p400. 
41. M Teesson and N Buhrich, 'Prevalence of schizophrenia in a refuge for homeless men: 
A five year follow-up', (Australian) Psychiatric Bulletin Nol4, 1990, pp597-600. 
42. Buhrich, op cit, pl36. 
43. Homeless Mentally 111 Advocacy Group, op cit, p3. 
44. 'The increasing trend towards homelessness is frightening. As unemployment rises and agencies report
 an alarming increase in new people coming on to the scene, the too hard fall even lower to the bottom of 
the ladder and there are more people to join them.' Horton, op cit, p402. 
45. Webster, op cit, p449. 
46. NHMRC, op cit, p4. 
47. Leonard, op cit, p345. 
48. H Hermann, P McGorry, P Bennett, Pamela, R van Riel, P Wellington, D McKenzie, 
and B Singh, Homeless People with Severe Mental Disorders in Inner Melbourne, Council of 
Homeless Persons, Melbourne 1988. 
49. The US Task Force on Homelessness and Severe Mental Illness cited one in three as
 the rate of severe mental illness generally among the homeless (Outcasts on Main Street, p7).
 This figure is lower than might be expected, given that the rate of schizophrenia alone 
is up to 36 percent in shelters. But it reflects the relative weakness of the welfare 
safety net in America, which forces homelessness on many people who are poor but not 
mentally ill. In Australia those people are more likely to remain housed, however precariously. 
50. Cathy Meese, assessments and referral team at Ozanam House. Oral evidence, Melbourne 10.4.91, p408. 


Human Rights and Equal Opportunity Commission Page 579 


51. Sister Anne Gregory, Catherine House shelter for homeless women. Oral evidence, 
Adelaide 22.10.91, p233. 
52. St Vincent de Paul Society, NSW. Submission, p8. 
53. ibid, p9. 
54. Crossroads, Victoria. Submission, p4. 
55. Ozanam Community. Submission, p4. 
56. Leonard, op cit, p346. 
57. John Quinn, mental health nurse, Brisbane. Submission, p2. 
58. Crossroads, op cit, p5. 
59. Quinn, op cit, p2. 
60. Leonard, op cit, p345. 
61. Bill Aldcroft, Ainslie Village. Oral evidence, Canberra 18.3.92, pi 17. 
62. id. 
63. Moira Shannon, Port Lincoln Women's Shelter. Oral evidence, Port Lincoln 18.10.91, pl7. 
64. ibid, pi 16. 
65. Leonard, op cit, p345. 
66. M Harries, L Jayasuriya, A Wearne, and J Dickinson, Schizophrenia and Social Needs,
 Department of Social Work, University of WA, 1991. Cited by the Rehabilitation Advisory 
Group (Western Australia), op cit, ppll-12. 
67. David Eldridge, Director of Crossroads Supported Housing Network, Melbourne. 
Evidence given to the Inquiry subsequent to the formal hearings 
68. NHMRC, op cit, p8. 
69. Chris Allison, Coordinator, George Street Outreach Project. Oral evidence, Melbourne 10.4.91, p406. 
70. Webster, op cit, p451. 
71. Horton, op cit, p400; Buhrich, op cit, pl37. 
72. Our Homeless Children, op cit, p207. 
73. Homelessness, Health and Human Needs, op cit, pp39,50-51. 
74. NHMRC, op cit, p9; Teesson and Buhrich, op cit, p597. 
75. Teesson and Buhrich, op cit, p599. Other surveys of mentally ill people in homeless shelters 
indicate significant variations in the number that are former psychiatric patients, eg NHMRC, op cit, p9. 
76. Buhrich, op cit, pl37; Leonard, op cit, p345. 
77. Outcasts on Main Street, op cit, plO. 
78. Webster, op cit, p456. 
79. Horton, op cit, p402. 
80. id. 
81. NHMRC, op cit, plO. 
82. Webster, op cit, p456. 
83. Homelessness, Health and Human Needs, op cit, pp50-51,60-62. 
84. Allison, op cit, p406. 

Page 580 Mental Illness Inquiry 

85. See later chapters of this report for more detailed consideration of these special needs groups. 
86. Julie Felus, Irene Women's Shelter. Oral evidence, Adelaide 21.10.91, p295. Also NHMRC, op cit, p5. 
87. Horton, op cit, p402; Gregory, op cit, p239. 
88. Tracey Grime, Coordinator, Domestic Violence Outreach Service. Oral evidence, Adelaide 21.10.91, p283. 
89. Gregory, op cit, p233. 
90. Our Homeless Children, op cit, p238. 
91. Horton, op cit, p402. 
92. Vicki Gould, Department of Family and Community Services. Oral evidence, Port Lincoln 
18.10.91, pl5. 
93. Horton, op cit, p402. 
94. Tulley, op cit, p236. 
95. Crossroads, op cit, p5. 
96. Ozanam Community, op cit, p8. 
97. Crossroads, op cit, p6. 
98. id. 
99. Ozanam Community, op cit, p8. 
100. Leonard, op cit, p345. 
101. The large hostels in inner Sydney are the Matthew Talbot Hostel (operated by St Vincent 
de Paul), Edward Eagar Lodge (Wesley Central Mission), Foster House (Salvation Army), Swanton 
Lodge and Campbell House (Sydney City Mission). 
102. St Vincent de Paul Society, op cit, p8. 
103. Society of St Vincent de Paul, National Committee for the Care of the Mentally 111 
(since renamed the National Committee in Support of People with Mental Illness). Submission, p7. 
104. Recognising the problems associated with the large inner city hostels, one of 
the main agencies which run them has embarked on a redevelopment program aimed at redistributing
 beds away from the large hostels into smaller facilities. Funded by Federal and State governments
 through the Supported Accommodation Assistance Program, the redevelopment aims to reduce the 
size of the hostels and provide alternative accommodation in cottages in the suburbs. This
 'transitional' accommodation is less institutional and more likely to encourage long-term
 homeless people to develop the living skills they need. Outreach workers from the agency
 visit the cottages regularly, so the residents still get some of the support they had 
in the hostels — but without the loss of dignity and independence which hostel life entails.
 However, the redevelopment program is not directed specifically at people with a mental 
illness, who may need more support than this scheme — with its limited funding — can provide.
 Evidence concerning the redevelopment program was provided by Rosemary Kraegen, Redevelopment
 Officer, Matthew Talbot Hostel, Sydney, after the Inquiry's formal hearings. 
105. St Vincent de Paul Society, op cit, p8. 
106. Sister Catherine Hefferan, St Vincent de Paul Society, Queensland. Submission. 
107. Sister Catherine Hefferan, St Vincent de Paul Society, Queensland. Oral evidence,
 Brisbane 15.8.91, pl611. 

Human Rights and Equal Opportunity Commission Page 581 

108. Buhrich, op cit, pl35. 
109. Webster, op cit, p464. 
110. Meese, op cit, p407. 
111. Gregory, op cit, p235. 
112. Meese, op cit, p408. 
113. Gregory, op cit, p233. 
114. Grime, op cit, p284. 
115. Shannon, op cit, pl7. 
116. Felus, op cit, p287. 
117. Grime, op cit, p284. 
118. Leonard, op cit, p345. 
119. Eg Hefferan, op cit (submission), pi; Horton, op cit, p400. 
120. Horton, op cit, p400. 
121. Webster, op cit, p452. 
122. id. 
123. Horton, op cit, p402. 
124. Hefferan, op cit (submission). 
125. Horton, op cit, p400. 
126. Webster, op cit, p449. 
127. Horton, op cit, p401. 
128. Webster, op cit, p453. 
129. ibid, pp450-451. 
130. ibid, p453. 
131. Horton, op cit, p401. 
132. ibid, p402. 
133. Quinn, op cit, pi. 
134. Webster, op cit, p451. 
135. ibid, p453. 
136. id. 
137. ibid, p454. 
138. Hagedorn, op cit, p410. 
139. id. 
140. Webster, op cit, p454. 
141. Hagedorn, op cit, p410. 
142. Quinn, op cit, p2. 
143. Webster, op cit, p452. 
144. Campbell, op cit, p405. 
145. Hagedorn, op cit, p410. 
146. J P Morrisey and I Shifren Levine, 'Researchers discuss latest findings, examine needs 
of homeless mentally ill persons,' Hospital and Community Psychiatry v38 No8, 1987, p812. 

Page 582 Mental Illness Inquiry 

147. Webster, op cit, p453. 
148. id. 
149. Campbell, op cit, p404; Allison, op cit, p405. 
150. Hefferan, op cit (oral evidence), pl614. 
151. Hagedorn, op cit, p409. 
152. Webster, op cit, p451. 
153. ibid, p459. 
154. Hefferan, op cit (submission). 
155. Webster, op cit, p449. 
156. ibid, p463. 
157. ibid, p462. 
158. ibid, p458. 
159. id. 
160. ibid, p455. 
161. Hagedorn, op cit, p410. 
162. ibid, p411. 
163. Shannon, op cit, pl7. 
164. Society of St Vincent de Paul. Submission, p9. 
165. Buhrich, op cit, pi38. 
166. ibid, pl35. 
167. Webster, op cit, p461. 
168. Quinn, op cit, p2. 
169. Horton, op cit, p400. 
170. Allison, op cit, p406. 
171. Meese, op cit, p408. 
172. id. 
173. Hamley, op cit, pi03. 
174. Ozanam Community, op cit, p4. 
175. Grime, op cit, p283. 
176. ibid, p284. 
177. ibid, p283. Similar evidence was given by Sister Margaret Tulley from Catherine 
House in Adelaide (p236): 'We have women who self-mutilate, jump on chairs, shout out, 
do what the voices tell them to do, yet we're told that they have not a psychiatric 
disorder but a personality disorder. And we're at a loss to know where these women will
 be housed on a permanent basis.' 
178. ibid, p284. 
179. Meese, op cit, p407. 
180. Hefferan, op cit (submission). 
181. Hamley, op cit, pl02. 
182. Quinn, op cit, pi. 
183. Hamley, op cit, plOl. 

Human Rights and Equal Opportunity Commission Page 583 


184. Gregory, op cit, p234. 
185. ibid, p239. 
186. Paul McDonald, Program Director, Crossroads Crisis Contact Centre. Oral evidence, 
Melbourne 8.4.91, pl04. 
187. Crossroads, op cit, p21. 
188. Felus, op cit, p288. 
189. ibid, p286. 
190. id. 
191. ibid, p287. 
192. Ruth Breen, Accommodation Service, Excell Enterprises. Oral evidence, Port Lincoln 
18.10.91, pll3. 
193. Fanning, op cit, p904. 
194. Michelle Knight, Ruth Women's Shelter. Oral evidence, Cairns 9.8.91, pl058. 
195. Hagedorn, op cit, p410. 
196. Allison, op cit, p406. 
197. id. 
198. ibid, p407. 
199. id. 
200. Campbell, op cit, p404. 
201. Allison, op cit, p405. 
202. Campbell, op cit, p404. 
203. id. 
204. Horton, op cit, p401. 
205. Campbell, op cit, p404. 

Page 584 Mental Illness Inquiry 

Chapter 19 

WOMEN 

Women are the most frequent users of mental health services in Australia, yet these 
services and the legislation which governs them generally fail to recognise the special
 needs of women.1 

Any analysis of women and mental health must take account of the particular 
social pressures which affect women's lives — because sociodemographic 
factors 'may place women at a greater risk of mental health problems'.2 These 
factors include poverty, single parenthood, sex role stereotyping, and 
discrimination in employment. The burden placed on women as primary carers 
in the family, and particularly as carers for the mentally ill, is another 
important issue3 (See Chapter 15). Health policy-makers have acknowledged 
these areas as major factors in the provision of effective and equitable mental 
health services for women. The recent Report of the National Health and 
Medical Research Council's Expert Advisory Panel on Women and Mental 
Health concluded: 

Any attempt to improve women's mental health must take into account the importance 
of equity and social justice in improving the lot of women. Their [physical health]
 and psychological state will be powerfully influenced by these factors.4 

Evidence presented to the Inquiry focussed on four areas of particular concern 
to women: diagnosis and treatment of mental illness; post natal depression; the 
psychological effect of violence; and the absence of adequate shelter. 

Research and practical experience in Australia and overseas have continually 
identified differences in the types of mental illness experienced by men and 
women. A wide range of studies has demonstrated that women are more likely 
than men to experience depression and affective disorders. (A number of recent 
studies — both in Australia and overseas — indicate that women are twice as 
likely as men to report extreme levels of psychiatric distress and are also twice as
likely to report a history of affective or mood disorder.)5 In contrast, men have a
 higher risk of substance abuse and personality disorders.6 

Diagnosis and Treatment 

Available evidence suggests that sex role stereotypes influence the definition 
and diagnosis of mental illness, particularly depression, in women. A number 
of female witnesses also told the Inquiry they believed the traditional 'medical 

Human Rights and Equal Opportunity Commission Page 585 

model' is over-emphasised by many general practitioners and mental health 
professionals in diagnosing disorders.7 

Many women expressed concerns about what they perceived as a lack of understanding 
and specific knowledge about mental illness on the part of general 
practitioners.8 The local GP is frequently the first person women consult 
concerning depression and anxiety related illnesses. However, women 
complained they were not listened to or understood when they attempted to 
describe their experiences to doctors. This dismissive attitude was characterised by 
one witness as the 'it's all in your head syndrome'. 

Several women claimed GPs and psychiatrists generally focussed on symptoms 

— to the exclusion of environmental factors which the women believed 
contributed to the stress and anxiety they experienced. This over-reliance on 
symptomatology — without appropriate attention to more complex psychosocial 
factors — can make accurate diagnosis difficult. It can also (even if inadvertently) lead to
 the neglect of significant aspects of the patient's presentation. An excessive focus on 
symptomatology and a tendency to ascribe medical causes to stresses resulting from normal 
occurrences have been identified as significant issues in recent studies.9 

Conversely, research indicates that many women referred by GPs to psychologists, 
with diagnoses such as neurotic depression and anxiety and depression, 
may in fact be experiencing a normal reaction to stressful events in their lives. It has been 
suggested that this kind of misdiagnosis may be related to 'the relatively short consultations
 provided by doctors', which 'limit the chances of identifying the relationship between the 
stressful life events and physical illness, or between physical illness and a deterioration 
in someone's mental health'.10 

A number of women believe they are not receiving adequate information about 
alternatives to drug-based treatment for depressive illnesses. A female consumer 
who suffers from a bipolar disorder expressed her frustration about the limited 
approach taken by doctors who subscribe to the traditional medical model: 

There is no form of counselling for people to deal with emotional, relationship issues etc. 
Psychiatrists, in my experience, do not provide such counselling. They check mental health 
against a range of criteria by asking questions to elicit information relevant to those 
criteria, prescribe medication, sometimes provide some useful advice and that's it. The 
counselling they do give is severely limited by their rigid adherence to the medical model.11 

The over-use of benzodiazepines and other drug treatments for women was also 
raised in evidence to the Inquiry. Many women expressed concern at the 
apparent ease with which doctors prescribe tranquillisers and other medication 

Page 586 Mental Illness Inquiry 

for depression, without discussing alternative forms of treatment such as 
psychotherapy and stress management techniques. Other witnesses told the 
Inquiry that while they accepted some psychiatric disorders clearly had to be 
treated with psychotropic drugs, many anxiety related mental health problems 
could be effectively treated with alternative therapies or lifestyle changes — 
assisted by therapists or other professionals: 

I have found the attitude of psychiatrists and other staff in the mental health system to be
 a major obstacle in my search for changes in lifestyle to prevent the recurrence of mental illness.
 The attitude has invariably been, at best, 'it won't do you any harm, but it won't do you any good'. 
I have found this negativity distressing at times, but have learnt to ignore it as best I can.12 

This consumer's concerns were corroborated by a Sydney psychiatrist who 
regularly treats women, particularly women from non-English speaking backgrounds, who commented: 

One thing which would help a lot with all the women with panic disorder, anxieties, agoraphobia
 is the provision of healthy lifestyle type programs such as relaxation therapy, stress management,
 assertiveness skills... You can't find these facilities generally. If you want to refer someone...
they end up being on medication.13 

The importance of including women in decision making about types of 
treatment and alternatives to drug-based treatments has been emphasised in 
several government reports on women's health. A 1986 report by the Women 
and Prescribed Drugs Working Party to the then Premier of New South Wales 
recommended that women be provided with more information about drugs 
commonly prescribed for mental illness and alternative drug-free ways of 
dealing with stress and anxiety. Similar recommendations were reiterated in the 
National Health and Medical Research Council's 1991 report on Women's 
Mental Health: 

It is important that specific education programs be developed for undergraduate medical students
 and general practitioners aimed at increasing skills and knowledge about a range of management
 strategies including counselling and appropriate prescribing. Considerable care should be taken
 before prescribing psychotropic medication when other forms of treatment may be equally effective 
and synchronous with greater public interest in non-drug treatment.14 

A number of witnesses, identifying the negative effects of sex role stereotyping 
by psychiatrists and other mental health professionals, expressed concern at the 
lack of psychosocial assessment offered and the tendency of doctors to 'pigeonhole' women.15 

Human Rights and Equal Opportunity Commission Page 587 

It was suggested that women are indirectly discriminated against because the 
psychiatric profession itself is predominantly male, and is practised in a 
patriarchal social environment. Some women believed they had been labelled 
as 'dysfunctional' simply because they did not conform to a certain stereotype. 
Misgivings about this systemic discrimination are not confined to consumers: 

Women, as consumers of health care, have often felt poorly understood and managed by those 
providing it. Further research is required to see if women receive different treatment or if
 some aspects of health care [have] adverse consequences for their mental health. It has
 often been suggested that women may be more likely to be seen as in need of mental health 
care or identified as having mental health problems. There have been questions as to how 
appropriate this is or as to whether there have been discriminatory or other negative 
consequences, eg identifying non-acceptable behaviour as madness in women.16 

This may be because, in the words of one advocacy group: 

Psychiatry...reflects and maintains the values and practices of...society. [It] lays 
claim to being scientific: an objective, rationally based, value-free and universal system 
of knowledge and practices. However, [it is] located in the broader societal context... 
It [is] necessary to question how notions of gender influence the definition, diagnosis and 
consequent treatment of mental illness in women. '7 

The significance of sex role stereotypes in clinical judgements of mental health 
was, a generation ago, the subject of a major US study in which the researchers 
hypothesised that abstract notions of mental health would be influenced by 
social stereotypes of masculine and feminine characteristics.18 Clinicians were 
asked to characterise a healthy man, a healthy woman and a healthy adult (sex 
unspecified). The clinicians' concepts of a healthy man were similar to those 
of a healthy adult. However, concepts of a healthy woman were significantly 
different. The results of the study consistently demonstrated that clinicians were more 
likely to describe a healthy woman as being more submissive, less 
independent, less adventurous, less aggressive, more emotional and less 
objective than a healthy man. As the researchers commented, 'this constellation 
seems a most unusual way of describing any mature, healthy individual'.19 

The authors of this study concluded that women are often placed in the difficult 
position of having to decide whether to exhibit the qualities deemed 'normal' 
for men and healthy adults, thus leaving their femininity open to question; or 
to behave in 'the prescribed female manner, accept second class adult status, 
and possibly live a lie to boot'.20 These are clearly major issues which, a 
generation later, are still affecting women and their mental health. They are 
issues which urgently require further study and definition in Australia. 

Page 588 Mental Illness Inquiry 

Post-Natal Depression 

There are a number of mental illnesses women experience which are related to 
their role as mothers. One of the most common is post natal depression (PND), 
also known as post partum depression.21 It affects up to 1 in 7 women in mild, 
moderate or severe form.22 

Extensive evidence was provided to the Inquiry by the Post and Ante Natal 
Depression Association (PaNDa), a community support group for women who 
suffer post natal disorders and for their families. Post natal depression occurs 
in 12 to 14 percent of cases at up to three months after birth and in 22 to 24 
percent of cases within the first post natal year. However, PND has been 
known to occur as late as two years after birth. Expert opinion indicates that 
the aetiology of PND is best perceived within a multidimensional context — 
biological, psychological, social and cultural factors may all be relevant.23 

The Inquiry was told that the exact combination of factors affecting an 
individual woman's susceptibility to PND is unclear. However, contributing 
factors include stress during pregnancy or delivery, a previous history of 
depression, depressive symptoms during pregnancy, prolonged breast feeding 
and being older than 30 at the time of birth.24 The symptomatology for PND 
also varies, but there are four general characteristics: feelings of depression; 
a sense of loss; feelings of irritability, hostility and resentment; and changes in
 maternal feelings. Women with PND commonly experience long periods of 
depression, reduced appetite and libido, sleep disturbance and a low tolerance 
of partners and children.25 One woman described the sudden onset of PND: 

I had never confronted a life problem I hadn't coped with, nor experienced mood change
 or depression. I enjoyed my pregnancy and looked forward to having my baby... 
My experience of PND started suddenly. I [had] felt a deep feeling of inner contentment 
and happiness... But four days after the birth I also remember a most terrifying
 experience. During the night I woke up abruptly. I sat bolt upright in bed [thinking] 
'there is something terribly wrong with me'. I experienced sudden waves of panic attacks 
and heart palpitations. I was dripping in perspiration from hot and cold flushes.
 I was shaking involuntarily. My head felt strange. My thoughts and language were
 disjointed and my brain wasn't functioning normally.26 

This witness told the Inquiry of attempting to obtain assistance for her 
depression, but finding it difficult to locate a professional who could diagnose 
the problem. After visiting a number of general practitioners, psychologists and 
naturopaths who diagnosed stress and recommended rest and relaxation, all to 
no avail, she finally came across a psychiatrist who diagnosed her PND and 
treated it effectively with anti-depressant medication.27 

Human Rights and Equal Opportunity Commission Page 589 

Misdiagnosis is common28 and: 

Although some women are lucky in that their general practitioner, obstetrician, 
maternal and child health nurse happen to be familiar and knowledgeable [about] 
PND and either can well facilitate appropriate support themselves or can refer 
on to professionals who can, many women and their families find themselves 
experiencing what we refer to as 'a professional merry-go-round' looking for help.29 

For those women who do not get assistance, PND can pose a major risk — not 
only to their own lives but to their child and others around them: 

If they do not receive the help they need, the known effects of PND are: marital 
stress or breakdown; loss of quality of life for the woman, husband and children; 
deterioration of the woman's health which can lead to chronic illness — 
and in the most acute situations — the loss of life of the mother or infanticide.30 

Representatives of PaNDa told the Inquiry that the lack of knowledge 
concerning PND among psychiatrists and other medical professionals is one of 
the major impediments to improving its diagnosis and treatment. Two major 
reasons for this ignorance were advanced. First, the aetiology of post natal 
depression is not yet clearly understood and more research into the illness is 
essential. Second, there is still considerable ignorance and stigma associated 
with PND. This was described to the Inquiry as 'the old 'pull yourself together, 
you've got a lovely baby, what more could you want' approach'.31 

Early recognition and appropriate management of PND is crucial, and can often 
mean the difference between an excellent prognosis and immense personal 
distress and family breakdown. Evidence presented to the Inquiry indicated that 
effective diagnosis and treatment should include social and practical support
 for the mother. This may comprise medical care on an inpatient, outpatient or 
community care basis for both mother and baby (possibly including psychotherapy 
for the mother) or, if appropriate, psychotropic medication for the 
mother.32 

One psychiatrist who specialises in treating PND told the Inquiry that 
medication can be extremely helpful in assisting women to recover from 
depression: 

For those people who decide upon treatment, I find the use of medication very
 useful. I've seen people use osteopathy, homoeopathy, naturopathy and 
acupuncture. I'm not knocking these treatments as treatment programs, 
I want to make that quite clear. All of these treatments make a valuable 
contribution to health care...[but] I have not seen these treatments being 
successful in curing PND. Some people are reluctant to take medication and I
respect that. But the problem is that you may have to keep the [depression] 
corrected for one to two years... If you take away the medication too soon, 
the depression returns." 

Page 590 Mental Illness Inquiry 

Evidence presented to the Inquiry suggested that confusion and ignorance 
concerning the type of treatment appropriate for PND is common: 

Every woman who develops PND fears if she tries to get help her baby will
 be taken from her, and these fears are real... Women with severe PND are
 frequently admitted to general psychiatric wards, surgical wards, midwifery
 wards, gynaecological wards. Sometimes staff try to help but often the staff
 tell us they don't know what to do, others tell of less kindness and comments
 like, 'you don't belong here, go to a psychiatric hospital or go home, we don't
 want you here'.34 

The Inquiry was also told that while medication and other therapies are an 
important part of the treatment for PND, 'the maternal infant relationship is 
fifty percent of the therapy' and if this relationship is not supported, it 
can be lost for a lifetime.35 One of the difficulties raised in evidence was the
 lack of hospital facilities for women who may need inpatient psychiatric care,
 but who also need close contact with their babies. Appropriate inpatient support 
services are needed to ensure this is provided. 

The Post and Ante Natal Depression Association submitted that maternity 
hospitals should have PND clinics attached to them — for three major reasons. 
First, they would enable women to be with their babies during treatment. 
Second, they would facilitate professional interest in the disorder and third, 
they would provide a focal point in the community for people who are not sure 
where to obtain assistance.36 It was also suggested that similar units be 
provided in psychiatric hospitals so that women with acute PND are not 
separated from their babies during inpatient psychiatric treatment. 

The provision of adequate emotional support to the partners and families of 
women with PND is also an important part of the treatment process: 

[Partners] need to be involved too so that they are not separated from their 
wives and babies... This aspect is often overlooked or dismissed as not being 
important. What is the point of therapy and isolation for the woman to go home 
to hopefully pick up the [familial] relationships ad hoc. As one woman said, 
(and it is not the first time we have heard it), 'well, I'm over my PND now 
but I've lost my husband, my baby, my home'.37 

One health professional employed by a community agency assisting women with 
PND told the Inquiry that many of her clients receive no support from their 
partners or their families. However, with suitable housing and adequate support 
and supervision, the majority could cope quite well and go on to raise their 
children.38 As this witness noted: 

It would be more economical, and certainly more humanitarian, to provide such
 support, either as a wing of an existing service or as a separate service 
altogether, than to deal with the consequences of the otherwise almost
 inevitable breakdown of family units.39 

Human Rights and Equal Opportunity Commission Page 591 

Puerperal Psychosis 

Puerperal psychosis is a severe disorder which is less common than post natal 
depression. It affects between 300 and 700 women a year in Australia40 and 
usually occurs during the first six weeks after birth (generally between days 
three and fourteen). The symptoms of puerperal psychosis can be similar to 
those of schizophrenic-type illnesses and can include extreme mood swings, 
hallucinations, and delusions or thoughts of harming the baby or oneself.41 
Diagnosis may be difficult when symptoms first present because it may not be 
immediately clear whether the illness is depression or a schizophrenic-type 
illness.42 This condition may be treated in special mother-baby psychiatric 
units which only exist in a few of our major cities or, if the child is at 
risk, in an inpatient psychiatric setting. It responds well to treatment but 
even after recovery the woman may be at risk of a recurrence or continuing 
disorder.43 

Violence Against Women 

Domestic Violence 

A number of witnesses gave evidence concerning the relationship between 
domestic violence and the development of mental illness in some women. 
Research has consistently shown that women who have a history of violent and 
abusive relationships are more likely to be affected by a mental illness than 
women who do not. A recent New Zealand study found that approximately one 
third of women who had suffered domestic violence had also suffered mental 
ill health, including post traumatic stress disorder and depression.44 

The Queensland Domestic Violence Task Force, reporting in 1988, found that 
the effects of domestic violence included constant feelings of helplessness, 
terror and entrapment and that women who have experienced violence are much 
more likely to suffer psychiatric problems than other women in the 
community.45 Victims of domestic violence have higher stress levels and suffer 
more affective disorders than women from non-violent homes. They are also 
more likely to be substance abusers, to suffer from somatic complaints46 and 
to attempt suicide.47 

Much of the evidence presented came from community workers and the staff 
of women's shelters who regularly deal with women who have suffered 
domestic violence. They emphasised that the link between a history of domestic 
violence and mental illness is complex and requires some understanding of the 
psychological difficulties associated with surviving a violent situation: 

Page 592 Mental Illness Inquiry 

A woman in a violent relationship is rarely open about it. [She is most likely
 to] cover up the violence from outsiders and the [conflict] between her
 understanding of what is happening to her day to day and her pretence about
 her life to family members, neighbours, doctors and lawyers makes her doubt her 
own sanity. In many cases her reactions may appear irrational to others — yet 
they are the way in which she makes sense of her reality. It is sometimes a 
short step for her from this into treatment with antidepressants or other 
treatments which are ineffective because they do not help her come to terms 
with her real problem which is her partner's abuse. She may find herself in 
the mental health system where her presenting symptoms may include depression 
and/or attempted suicide. These are seen as the disease to be treated and the
 underlying cause, 
the violence and fear in her relationship with her partner, may not even be
 recognised.48 

The enduring psychological effects of domestic violence were described by a 
Melbourne minister of religion who told the Inquiry she regularly ministered 
to women who had been traumatised by living in violent situations: 

After being in an abusive relationship for many years, suffering emotional, 
physical, sexual, social and financial abuse...the women were able to leave 
the relationship with the help of women's refuges or other community support
 and move on to the independent living situation. It was during this period of 
independence when the [women were] faced with the sole responsibility of 
providing and caring for their children and also faced with the years of
 abuse to their... wellbeing and mental stability that they... experienced a
 mental and emotional breakdown. 

These women had no previous history of mental illness. During this breakdown 
hey were placed in a psychiatric hospital — separating them from their children.
 This placed the associated stigma on them [of having been] in a psychiatric unit.
 While the women were being treated in a psychiatric hospital their ex-husbands
 went to the Family Court and gained custody of the children on the basis that
 the mother was mentally unstable and unable to care for the children... 
We believe that this illness was a short-term, 'one-off occurrence directly
related to years of abuse.49 

The Inquiry was told that many women caught in such situations are labelled 
as 'mentally ill' when they are simply reacting — usually some time later — to 
a highly traumatic situation. It is important for clinicians and community 
workers to acknowledge the reality of their experiences, rather than trying to 
'fit them into the disease model'.50 

This process turns a woman in crisis into a patient within a mental health system
 which is ill-equipped to react appropriately. Labelling her as a patient; 
prescribing drugs to allay her symptoms; but not treating the cause of her 
problem reinforces her feelings of low self esteem, lack of confidence and 
guilt which have already been engendered by her abusive partner. The end is 
worse than when she sought help.51 

In this situation the woman once again becomes a 'victim' — this time of the 
mental health system. When early intervention fails and misdiagnosis occurs, 
women may become hospital inpatients. The Inquiry was told that one survey 
of women in a psychiatric hospital in the United States found that half the 

Human Rights and Equal Opportunity Commission Page 593 

patients had histories of physical and/or sexual abuse. It was suggested that 
'there is no reason to believe that the situation is any different' in 
Australia.52(Indeed other evidence presented suggested it may be similar or worse.)53 

Women are sometimes not safe from an abusive partner, even in hospital. The 
Inquiry heard that many women feel so frightened their partners will find them 
that they ask the hospital to keep details about their admission and date of 
discharge confidential. It was alleged that in some cases these requests had 
been ignored and the woman had been 'regarded as unco-operative at best and 
paranoid at worst'.54 

Open access visits from their abuser, frequently under the guise of care and 
concern for their welfare, can be terrifying and provide excellent opportunities 
for the message to be reinforced that there was no secure place, not even in
 hospital. They may even be required to undergo combined interviews with their
 abuser while the underlying fear and stress is not acknowledged and the reality
 of their danger is not accepted.55 

Sexual Assault of Women Inpatients 

The Inquiry heard disturbingly frequent allegations about sexual assault of 
women inpatients,56 who sometimes find themselves in non-segregated areas 
where they are particularly vulnerable. 

Women are subject to sexual harassment and abuse from male patients and staff
 within these [mixed] units. When they complain to staff women are ignored,
 blamed, not believed or told not to worry about it. For example, a young woman
 who had been sexually abused in the past complained to staff when a male patient 
continually masturbated in front of her. She was told to keep out of his way.57 

Several women suffering from manic depressive disorders told the Inquiry that 
they were particularly vulnerable to sexual assault during a manic episode, 
when normal decision making processes may be impaired: 

After he had sex with me I felt so ashamed. I felt this was the bottom of the barrel
 — in a psychiatric ward and just a thing to be used. I was so muzzy from the
 medication I couldn't resist and at the time I felt it was probably my fault
 I got raped.58 

Many female consumers expressed concern that while they knew that they had 
been assaulted and their rights abused, the fact that they had a psychiatric 
disability worked against them: 

I thought that if I complained they'd just say I was mad anyway and they wouldn't 
believe59 me.

Page 594 Mental Illness Inquiry 

A psychiatrist in private practice in Western Australia, after informing the 
Inquiry of several female patients who had been sexually abused as inpatients, 
said: 

In my opinion these women are the tip of the iceberg and demonstrate that not enough 
is being done to ensure the sexual safety of disturbed women. If a woman is locked up 
for her own safety it is ironic that she thereby suffers worse abuse in the place 
which is supposed to protect her.60 

These fundamental abuses of women's rights to a safe and secure environment 
cannot be allowed to continue. As one women's organisation stressed: 

It is the responsibility of all mental health service providers to ensure that women's 
personal safety is not under threat.6' 

Other Sexual Assault 

In addition to allegations concerning misdiagnosis and maltreatment of women 
inpatients, the Inquiry heard evidence concerning links between traumatic 
events such as domestic violence and sexual abuse and the development of 
affective disorders such as depression and post traumatic stress disorder. 

One Victorian expert provided the Inquiry with the results of a study which 
investigated the relationship between child sexual abuse and mental health in 
adult life. The research sought to establish whether there is a causal connection 
between child sexual abuse and adult mental disorders and how any such connection 
might be influenced by other aspects of individual background and development. 
While there is a general relationship between child sexual abuse and the development
 of mental illness in adulthood, the researchers found that other contributing factors 
include an individual's personal history and 
socioeconomic status. These findings, together with other evidence presented 
to the Inquiry,62 suggest that while child sexual assault cannot be identified as the 
single contributing variable in the development of some adult mental illness it often 
is a significant factor: 

The overlap between the possible effects of child sexual abuse (CSA) and the matrix 
of disadvantage from which it so often emerges [are] so considerable as to raise doubts 
about how often, in practice, CSA operates as an independent causal element... CSA 
correlated with an increased risk for a range of mental health problems, but in most 
cases its effects could only be understood in relationship to the context from which 
t emerged and within the victim's subsequent psychosocial development.63 

This research, however, represents a relatively conservative assessment of the 
long-term damage inflicted by child sexual abuse. Expert clinicians appearing 

Human Rights and Equal Opportunity Commission Page 595 

before the Inquiry presented more disturbing evidence, which is addressed in 
greater detail in Chapter 20 — Children and Adolescents. 

Apart from the effect of childhood experiences, the Inquiry also heard evidence 
concerning a link between experiences of sexual assault and the development 
of affective disorders such as depression and post traumatic stress disorder. 

A Melbourne psychologist provided several case histories of women who had 
experienced post traumatic stress disorder as a result of child and adult sexual 
abuse. In one case, a woman had been raped and suffered long-term psychiatric 
problems as a result. She undertook treatment for post traumatic stress disorder, 
but while she was receiving treatment her marriage broke down and her 
husband filed for custody of the children. In his decision, the judge found that 
the woman had been a good mother, but was unsuitable as a custodian for her 
children because of her psychiatric history. This judgement was despite 
representations and clinical histories from the woman's doctors stating that she 
had recovered from her mental illness. Her psychologist told the Inquiry, 'I 
believe that this blatant form of discrimination against people with post 
traumatic stress disorder goes on all the time'.64 

Shelter 

The Inquiry heard evidence in all States and Territories concerning the large 
number of women affected by mental illness living in refuges, shelters for the 
homeless and other places providing emergency accommodation. (This issue is 
also addressed in Chapter 10 — Accommodation and Chapter 18 — Homeless 
People.) 

A great majority of the women who stop [at the women's shelter] are from domestic
 violence situations. They are in crisis. Sometimes those women in crisis are not 
only showing signs of stress that accompany the crisis, but also evidence of 
psychiatric illness.65 

While refuge staff do their best to support women with psychiatric problems 
they are 'not trained to assess or assist women suffering from mental illness' 
and regularly find themselves in difficult situations — trying to balance the 
needs of the individual who is ill against the wellbeing of other women in the 
shelter.66 

The Inquiry heard there were several imperatives compelling many women with 
psychiatric problems to end up in refuges: 

An important observation made by refuge workers is that many of the mentally ill 
women who prefer to come to the refuge rather than seek private accommodation in the 

Page 596 Mental Illness Inquiry 

community, do so out of a need for support and for a safe place to stay with other
 women. [Furthermore] the income of women who are mentally ill is usually a social 
security benefit. This means that the only affordable accommodation is unsuitable 
and at times threatening. Women, particularly those living [on the street] have reported
 to refuge workers that they are subject to harassment and rape. Most of these women 
who have gained other accommodation are often unsuccessful in resettling and ultimately 
either become extremely distressed due to isolation and find themselves hospitalised, 
or turn to refuges for help.67 

In Adelaide, workers from Catherine House, a refuge for homeless women, 
reported that over thirty two percent of their clients had a history of mental 
illness.68 Evidence from women's shelters in Darwin69 and Port Lincoln70 
indicated that approximately ten percent of their clients were affected. 

Many of these woman first sought emergency accommodation after leaving 
violent relationships. Once it becomes apparent that they have a psychiatric 
problem, refuge staff are faced with the unenviable task of either having to care for
 someone in need of specialist mental health services which cannot be 
provided by the refuge, or refusing to accommodate the woman (and her 
children), knowing that she has nowhere else to go: 

In most instances, the women who come to [the shelter] who do suffer mental illness 
[present] three options for staff. One, they either refer them back to hospital or back 
to one of the referring agencies; two, the women go unsupported into accommodation on 
their own, and often end up back in hospital; or three, they are referred to [accommodation]
 which is primarily equipped to cater for single women, not women with children. 
Other than that there are no options available to women suffering mental illness.71 

Women with psychiatric disabilities are often referred to refuges by hospitals 
and other mental health services. In Darwin the Inquiry was told that the local 
women's shelter regularly receives referrals from the Royal Darwin Hospital, 
which sends women with behavioural and psychiatric problems to the shelter 
at the rate of approximately two per month. This is in spite of the fact that the 
women's shelter is not supposed to accommodate women with mental illness.72 

Agencies accept inappropriate referrals because they know that women would 
otherwise end up on the streets. However, in doing so they create difficulties 
for the woman in question and other clients.73 

The lack of appropriate accommodation services for women with psychiatric 
disabilities has now produced a completely unacceptable situation. It is clear 
from the evidence that staff working in emergency accommodation services are 
providing a variety of services for which they are either underqualified or 
completely unqualified. Several suggestions were made to the Inquiry 
concerning action needed to effectively redress this situation. 

Human Rights and Equal Opportunity Commission Page 597 

• Most of the research is about homeless men and men who live on the fringe — marginalised 
men with mental health problems. There's very little about women and women with children.74 
• There are no statistics or hard data... There is an urgent need for research into this 
area to be conducted across the whole community. This research needs to be consistent in all
 areas, well coordinated, evaluated and include consumers... This is of prime importance75.
• There is an urgent need for the provision of accommodation for women suffering 
domestic violence and mental illness. Both crisis accommodation...and long-term 
accommodation... If accommodation is set up, we need to employ qualified staff; staff that 
can provide appropriate supports, who will be able to administer medication when required; 
can be able to identify behaviour, and support women and children.76 

The evidence placed before the Inquiry clearly indicates that the human rights 
of women suffering mental illness are being both abused and neglected. Fear, 
ignorance, lack of self esteem and discrimination impair the ability of these 
women to effectively advocate for more appropriate services.77 Clearly, 
governments and others responsible for providing these services need to address 
these issues urgently - not only for the sake of the many thousands of women 
affected, but also for the protection of their children and the wellbeing of their families. 

The Need For More Research 

It is clear that each of the issues addressed in this chapter is sufficiently 
important to require an urgent response. It is equally clear that while several 
problems can and must be promptly addressed by appropriate programs, others 
require careful research to ensure an effective response. Indeed, it is not only 
the issues particularly affecting women which are mentioned above. There are 
other areas in which women confront problems which require special research 
and attention. The case for additional mental health research is presented in 
Chapter 26 of this report. In view of the evidence submitted to the Inquiry, 
research into women's mental health needs must be a priority. 

The most recent study of the incidence of Alzheimer's disease, for example, 
indicates it is almost twice as prevalent among women aged 40 to 64 as it is 
among men in the same age-group.78 The devastating effects of this disease 
on sufferers and their families highlight the urgent need for further research in this area.
 The impact of Alzheimer's disease is discussed in more detail in 
Chapter 17 — Elderly People. 

Page 598 Mental Illness Inquiry 

1. Robyn James, Western Region Women's Human Rights Commission Response Group, 
Victoria. Submission, p3. 
2. National Health and Medical Research Council (NHMRC), Women and Mental Health: Report
 of the Health Care Committee Expert Advisory Panel on Women and Mental 
Health, Monograph Series Nol, AGPS, Canberra 1991, pi. The Expert Panel is chaired 
by Professor Beverley Raphael — the former president of the Royal Australian and New 
Zealand College of Psychiatrists and current Professor of Psychiatry at the University of
 Queensland. Professor Raphael acted throughout the course of the Inquiry as its specialist adviser. 
3. ibid, p2. 
4. id. 
5. ibid, p5. 
6. id. The NHMRC report notes that '...for most disorders women show higher levels than men,
 particularly depression, anxiety states, somatisation disorders, whereas men show higher 
rates for substance abuse disorders and antisocial personality disorder.' 
7. This point was also raised by a number of women during community consultations conducted 
in capital cities and regional centres. 
8. id. 
9. NHMRC report, op cit, p48. 'Consumer groups as well as feminist organisations have
 suggested that there may be a tendency to prescribe psychotropic medication and medicalise
 normal life stresses.' 
10. Z Mullaly, 'Counselling Depressed Women', Healthright v8 No2, Feb 1989, ppl5-16. 
11. Jennifer Lane, consumer, Victoria. Submission, p3. 
12. ibid, p8. 
13. Dr Elsa Bernardi, representative, RANZCP, NSW Branch. Oral evidence, Sydney 
17.6.91, pll4. 
14. NHMRC report, op cit, p50. 
15. Several women used this term during the Inquiry's community consultations in Port Lincoln. 
16. NHMRC report, op cit, p48. 
17. Robyn James, op cit, p5. 
18. I K Broverman, D Broverman et al, 'Sex-Role Stereotypes and Clinical Judgements of Mental 
Health', Journal of Consulting and Clinical Psychology v34 Nol, 1970, pi. 
19. ibid, p5. 
20. ibid, p6. 
21. The Inquiry was told that post natal stress is not the same as post natal depression: 
'The confusion between post natal stress, which all mothers and fathers know about, and post
 natal depression as a clinical disorder is causing a lot of problems. Stress is a normal 
reaction. Post natal depression as a disorder involves a dysfunction... For example, a mother 
suffering stress reactions has a two week holiday or a rest and respite and then she 
returns to normal. A mother with PND would have a two week holiday and be the same or worse 
afterward'. Terry Smith, President, and Jo Rogers, Secretary, Post and Ante Natal Depression 
Association (PaNDa). Oral evidence, Melbourne 10.4.91, p430 

Human Rights and Equal Opportunity Commission Page 599 

22. Rogers, op cit, p431; and Professor Lorraine Dennerstein, Head of the Mercy Mother-Baby Unit
 and Post Partum Disorder Clinic, Melbourne, in information provided as part of PaNDa's submission
 to the Inquiry. 
23. NHMRC report, op cit, p8. 
24. id. There have been many studies undertaken in this area. For example, Boyce and Todd 
studied rates of post natal depression in women who had emergency caesarean sections rather
 than spontaneous vaginal births. The authors found that women having an emergency caesarean 
section were six times more likely than women having spontaneous vaginal delivery to develop 
post natal depression. The authors note that the identification of these additional risk 
factors is essential if early intervention and treatment of PND are to be successful. P Boyce
 and A Todd, 'Increased risk of post natal depression after emergency caesarean section', 
Medical Journal of Australia vl57, Aug 1992, ppl72-174. 
25. These characteristics were described by Dr L Marinovich, senior psychiatrist, Royal Women's
 Hospital, Melbourne, in a paper provided as part of PaNDa's submission to the Inquiry. 
26. Jo Rogers, 'When Motherhood Isn't Bliss — Post Natal Depression', address given at Mercy 
Maternal Hospital October 1991, ppl-4 This paper was included as part of PaNDa's submission to the Inquiry. 
27. ibid, p6. 
28. NHMRC report, op cit, p8. 
29. PaNDa Submission to the Australian Health Ministers Advisory Council, Mental Health Working
 Party, Mental Health Discussion Paper January 1990. Included as part of PaNDa's submission to 
this Inquiry, pl3. 
30. Rogers, (oral evidence) op cit, p431. 
31. ibid, p433. 
32. See PaNDa evidence and NHMRC report, op cit. 
33. Marinovich, op cit, p8. 
34. Rogers (oral evidence) op cit, p434. 
35. id. 
36. id. 
37. ibid, p435. 
38. Margaret MacPherson, social worker, Pregnancy Help, Western Australia. Submission, pi. 
39. ibid, p2. 
40. Based on a frequency of between one and two per thousand births, as suggested by the NHMRC. 
41. NHMRC report, op cit, plO. 
42. id. 
43. id. 
44. Cited in Mental Health in Australia, December 1990, p33. 
45. Queensland Domestic Violence Task Force, Beyond These Walls, Brisbane 1988, p67. 
46. NHMRC report, op cit, p36. 
47. id. 

Page 600 Mental Illness Inquiry 

48. Topsy Evans, member, Domestic Violence Action Group. Oral evidence, Hobart 
13.11.91, p313. 
49. Pastor Robbi Dawson, social worker, Port Melbourne Baptist Church. Submission, pi. 
50. id. 
51. id. 
52. id. 
53. See Chapter 20, Children and Adolescents. 
54. Evans, op cit, p314. 
55. id. 
56. These allegations are discussed in more detail in Chapter 8, Inpatient Care and Treatment. 
57. James, op cit, ppl2-13. 
58. Evidence presented in a written submission by Meg Smith, Secretary, Manic Depressive and 
Depressive Association of NSW, pp6-7. 
59. ibid, p6. 
60. Dr Lois Achimovich, psychiatrist, Fremantle Hospital, Western Australia. Submission, ppl-2. 
61. Thea Bates, Victorian Community Managed Mental Health Services Inc (VICSERV). Submission, pl7. 
62. Dr Aidene Urquhart, Director of Child Psychiatry, Mater Children's Hospital, South Brisbane. 
Oral evidence, Brisbane 16.8.91. 
63. P Mullen, J Martin, J Anderson, S Romans, and P Herbison, 'Child Sexual Abuse and Mental Health 
in Adult Life', The Lancet, 1988, p841. This paper was provided as a submission to the Inquiry 
by Prof P Mullen. 
64. Evelyn Field, Victorian Branch, Australian Psychological Society. Submission, pi. This is by 
no means an isolated case. As indicated earlier, the Inquiry was told that psychological and 
psychiatric reports written about women are regularly used against them in custody cases: Evans, 
op cit, p314. 
65. Desley Boyle, Deputy Mayor, Cairns City Council, psychologist and Chairperson of Cairns 
Regional Health Authority. Oral evidence, Cairns 9.8.91, ppl 109-1110. 
66. Creina Scally, Dawn House Women's Shelter. Oral evidence, Darwin 21.7.92, p59. Evidence 
was also provided by Suzanne Fogerty, Director of Dawn House, who told the Inquiry of one 
case where a woman staying at a refuge attacked another woman with a brick. The refuge worker 
rang the hospital and asked the staff to check the client's medication. It was revealed that 
he medication, which was an anti-inflammatory drug, was reacting with other medication the woman was 
taking. The woman was referred to a doctor who stabilised her medication and her behaviour returned to
normal. While this case was resolved satisfactorily, it illustrates the difficulties faced by services 
which are not equipped to deal with mentally ill women. 
67. Dawn House Women's Shelter, Darwin. Submission, op cit, p6. 
68. Sister Gregory, Catherine House. Oral evidence, Adelaide 22.10.91, p233. 
69. Dawn House Women's Shelter, op cit, Appendix 1. 
70. Irene Women's Shelter. Evidence presented by Tracey Grime, Coordinator, Domestic Violence Outreach
 Service. Oral evidence, Port Lincoln 21.10.91, p283. 
Scally, op cit, p60. 

Human Rights and Equal Opportunity Commission Page 601 

72. A requirement of the Supported Accommodation Assistance Program (S AAP).which funds the shelter.
 (See Chapter 10 of this report for further discussion of SAAP.) 
73. Julie Felus, Irene Women's Shelter. Oral evidence, Port Lincoln 21.10.91, p287. 
74. ibid, p295. 
75. Scally, op cit, p62. 
76. ibid, p63. 
77. James, op cit, pl4. 
78. G McGonigal and B Thomas, 'Alzheimer's in Scotland', British Medical Journal v30 No6879,
March 1993, p680. 

Page 602 Mental Illness Inquiry 

Chapter 20 

CHILDREN AND ADOLESCENTS 

We're looking at only around 30 [acute adolescent psychiatric] beds available in Victoria, a similar 
number in New South Wales, virtually none in Queensland, none in the public sector in South Australia, 
and [none] in Western Australia.' 

Incidence and Prevalence 

The diagnosis of children and adolescents with mental illness is not clear-cut. Often the developmental 
aspects of behaviour lead to unrealistic diagnostic labels that may vary between settings, such as school
 and home, and often over time. Thus...it is common practice...to restrict the diagnosis of mental illness
 to the most extreme cases. While this is understandable, it means that children and adolescents with
 severe emotional and behavioural disturbance are often not categorised as having a mental illness, 
although they may fulfil the diagnostic criteria.2 

Although very little epidemiological research has been conducted on the prevalence of mental illness 
among children and adolescents in Australia, there was substantial agreement about estimated levels 
of psychiatric disturbance in young people by experts presenting evidence to the Inquiry. 

Children 

One leading child psychiatrist told the Inquiry that rates of mental illness for 
children and young people are much the same all over the world. In any given 
year, approximately 10 percent of children show significant psychiatric disturbance and 1 percent
 are in urgent need of psychiatric treatment.3 

The Inquiry heard similar evidence in Melbourne: 

About 15 percent of children have some sort of emotional or behavioural problem during childhood 
which requires some assistance...and about 1-2 percent of children have psychiatric disorders of
 sufficient severity to warrant specialist services. I emphasise that I am not only relating to 
psychiatric specialist services, but...specialist input from psychologists and social workers... 
Of those 1-2 percent who require specialist resources, much less than half actually end up
 getting them.4 

In a major Australian study, Professor Helen Connell surveyed the prevalence 
of disorders among Queensland children aged ten and eleven, comparing a rural 
group with a Brisbane group of the same age. The study concluded that 23 
percent of the children had mental health problems, and 14 percent fitted a 
diagnosis of mental disorder.5 

Human Rights and Equal Opportunity Commission Page 603 

Adolescents 

The Royal Australian and New Zealand College of Psychiatrists has estimated 
that 15 percent of adolescents suffer from recognisable psychiatric disorders, 
and 5 percent suffer from serious disorders which 'warrant intervention'.6 
About 1 percent have a 'severe psychiatric disorder':7 

In schizophrenia, the peak age of onset is in late adolescence and young adulthood. 
We estimate that in NSW there will be 1000 new cases per year — and most of those 
will be adolescents.8 

These estimates conform with US data9 which indicate that 90 percent of all 
psychiatric disorders have their onset in adolescence or early adulthood. Fifty 
percent first affect young people between the ages of 16 and 18. (These figures 
are important in appreciating the serious deficiencies in our mental health 
system chronicled in this chapter.) 

The Number of Young Australians Affected 

Expert assessments of the number of adolescents in Australia affected by 
psychiatric problems are generally based on overseas epidemiological studies 
of prevalence, applied to Australian population estimates by age group. 

i In Australia, there are approximately 246,500 15-20 year olds who have disorders
 which warrant recognition [based on an estimated 15 percent in this age group]
 and 82,000 adolescents who would likely benefit from psychiatric intervention 
[based on an estimated 5 percent in this age group].10 

Expert evidence varied regarding the number of young people with illnesses 
severe enough to require specialist treatment, but all estimates were in the 
range of 1-5 percent.11 Even based on the lowest figure of 1 percent (ie 
including only adolescents with schizophrenia and other forms of psychosis), 
over 16,000 young Australians are affected. 

Witnesses stressed to the Inquiry that they were using overseas statistics 
because of the paucity of research in this area which has been conducted in 
Australia.12 This evidence emphasises the urgent need for local epidemiological 
studies to be undertaken, specifically in the area of child and adolescent 
mental health. Without sufficient accurate data, it is difficult to plan either 
effective intervention strategies or appropriate treatment services. 

Page 604 Mental Illness Inquiry 

Definitions and Terminology 

The definition of 'mental illness' in children and in adolescents — and its
 interrelationship with 'emotional disturbance' and 'behavioural disorder' — is a 
complex and contentious issue. The co-existence of these problems in young 
people makes diagnosis (and prevention, therapeutic intervention or treatment) 
particularly difficult — requiring specialist knowledge, not only on the part of 
mental health professionals, but also from a range of other individuals involved 
in the young person's life. (See later sections of this chapter dealing with 
interagency co-operation and the training needs of allied professionals.) 

The Inquiry was presented with a number of 'working definitions' by expert 
witnesses who emphasised that a range of contributing factors must be taken 
into consideration when diagnosing mental illness. These elements include 
environmental influences (parental conflict, family breakdown, abuse, and 
educational, social, or cultural factors); genetic pre-disposition (parental
 mental illness); and the developmental stage of psychological and emotional
 maturation of the young person. 

Mental illness in the young tends to differ from mental illness in adults,13 and 
where similar disorders exist in young people, different signs may occur — not 
only compared with adults, but also according to the different developmental 
stages of the young person. (These views are confirmed by recent overseas 
research.)14 

One clinical psychologist quoted this definition of mental illness in children: 

A persistent presence of disturbed behaviour and/or disturbed emotions and/or
 disturbed relationships considered abnormal in the context of the child's
 sociocultural background and stage of psychological development, accompanied
 by impairment in personal and social functioning.15 

Witnesses also referred to the very wide definition of 'psychiatric disorder' 
given in a definitive study assessing the levels of psychiatric morbidity in 
Australian children: 

An abnormality of behaviour, emotions, or relationships sufficiently marked and 
sufficiently prolonged to cause handicap to the child and/or distress or 
disturbance to the family or the community, and not synonymous with 'maladjustment'
 or 'illness'.16 

The Inquiry was told that far too little attention has been paid to the withdrawn,
 quiet, depressed child or adolescent, whose problems may not be recognised or
 defined as emotional disturbance, because these children attract so little attention.17 

Human Rights and Equal Opportunity Commission Page 605 

The terms 'behaviourally disturbed' and 'emotionally disturbed' tend to be used 
interchangeably, although they sometimes accrue localised meanings.18 

The Inquiry has concluded that in order to ensure effective provision of relevant
 services to young people it is essential to adopt a broad view of disturbance 
in childhood and adolescence (however 'untidy' this may be from a legal or 
clinical perspective). Indeed, the Head of Child Psychiatry at one major hospital
 recommended that children with non-psychotic disorders, (ie with emotional or 
behavioural problems) should be given access to services regardless of definitional
 distinctions. 

Behavioural problems in children...are essentially associated with children 
getting into trouble. When they exist in a serious form in early childhood, 
they are the most persistent disorders of childhood. They are also very prevalent. 
They are the disorders which lead to severe personality disorders and substance 
abuse in adulthood. They are extraordinarily difficult to manage. Because of
 their persistence and the multi-modal nature of intervention which is most 
likely to be effective... They should be included within the definitions to
 provide them with access...to acute care [and to] rehabilitation services 
required to turn their lives around.19 

Disturbed children and young people are frequently denied admission to 
psychiatric treatment services because they fall outside the narrow clinical 
definitions, admission criteria and legislative charters of the relevant 
departments or institutions.20 

An inclusive but simple classification of childhood psychiatric syndromes has 
been proposed: 

• Emotional disorders, characterised by a disturbance of expressed and felt emotion, 
predominantly anxiety, depression, or a mixture of both. 
• Behaviour disorders, characterised by extremes of normal behaviour 
(under-activity, over-activity, passivity, aggressiveness), or persistence
 of immature behaviour (wetting or soiling). 
• Somatoform disorders, in which physical and psychological factors are 
inextricably linked. Many were previously known as 'psychosomatic' disorders. 
• Educational or 'learning' disorders (including dyslexia). 
• Psychosis, characterised by loss of contact with reality and major deficits
 in personality development. 
• Organic brain disorders, when physical disturbance of the brain has led to 
psychological symptoms. 
• Abuse disorders, in which the child has been subjected to physical and/or 
sexual abuse.21 
In many cases, some of these symptoms and conditions overlap.22 

Page 606 Mental Illness Inquiry 

Assessment and Diagnosis 

Patients present to us because of emotional and/or behavioural symptoms. Our task 
is to understand those symptoms in the context of the individual's developmental level, 
both physical and emotional, [including] their physical health and social environment, 
which include home and school factors.23 

Frequently there is a failure to recognise that a child is suffering from a 
disorder. 

Children with problems often go unrecognised, especially in cases where the focus 
is on adult needs, such as in the case of marital discord, parental mental illness24
 or domestic violence, [which are] primary indicators of risk for children. When these
 situations aren't recognised, children's problems are rarely addressed.25 

Expert witnesses canvassed several factors which make diagnosis in children 
and adolescents particularly complex: 

Very few children with problems show signs that are the same as the major mental 
illnesses in adults... Normal adaptation and growth are fraught with difficulties 
that prove problematic for children, their families, school teachers and important 
others.26 

A number of witnesses raised the issue of reluctance — both by parents and 
mental health workers — to identify a child or adolescent as being 'mentally 
ill', with the consequence that the young person often remains untreated or is 
handed over to another agency which does not have the expertise to help. 

The reluctance to 'label' children [as having a mental illness] and thus to risk
 the many costs associated with it, is natural... In the absence of a label implying
 'illness', the mental health system is not engaged in the treatment of this group
...[so] the programs [to which they are referred] are managed by persons without 
the appropriate training and experience... Secondly, without being identified as...
requiring special services [by] the label 'mental illness', children and adolescents 
can be discriminated against with 
impunity.27 

The consequences of such unprofessional responses (reflecting either conscious 
or subconscious capitulation to the stigma and discrimination which still attach 
to mental illness) can be extremely serious. 

A large number of these youngsters are suffering major depression, sometimes of a
 primary nature...but because of other adolescent behavioural and developmental 
issues, it tends to be not seen because it is masked... Very often, this serious
 medical aspect of their condition is not recognised, [or] sometimes it is misdiagnosed
 as schizophrenia. If one diagnoses an adolescent as schizophrenic in the years 
15, 16, 17, it's a diagnosis of relative despair.28 

Human Rights and Equal Opportunity Commission Page 607 

Without an appropriate initial assessment and referral, many mentally ill adolescents
who also have behavioural problems can get into very serious difficulty. 

Generally speaking, perhaps two-fifths of those with serious psychological disorders
 are considered to suffer from behavioural disorders. They drift into all sorts of 
negative lifestyles, sometimes via drugs and other forms of substance abuse — 
a lifestyle which makes them at risk of running away from home, becoming homeless... 
And we have inadequate assessment and certainly inadequate hospitalisation for these
 youngsters. I am not suggesting we build more hospitals or provide more beds. 
The major issue today is providing adequate community treatment versus hospitalisation.29 

Past reluctance to acknowledge that children can and do have serious disorders 
has meant there is insufficient investigation to identify them and to provide 
appropriate treatment: 

There was a belief [on the part of clinicians] until a few years ago [that children did 
not develop conditions] which parallel those in adults, because they didn't talk to the 
children [in the course of diagnosis]; but now, once we look in detail using current 
research methods [including the child's self-reports of symptoms experienced], we find 
that children do have disorders like agoraphobia, depression, obsessive compulsive neurosis
 and so forth. These [may be] very young children — five, seven.30 

Depressive illness in children is particularly difficult to diagnose because the 
child cannot readily communicate the experience. An adult witness to the 
Inquiry described her experiences of depression as a child: 

The terms 'mental illness' and 'nervous breakdown' for me mean depression, which
 I have suffered from since my childhood. I can very clearly remember when I was 
five years old, sitting on top of the disused air-raid shelter at my school and cutting 
my knees with glass. I think that was the only way I could reach out to people to tell them 
how badly I felt inside. When I was 11,1 can remember being very profoundly depressed. Part
 of my delusion in that depression was that I believed that I had cancer and that I was going 
to die, and I stopped eating. I think that sort of response — to stop eating, to become 
depressed, all of those things — were the only ways I could communicate such deep black pain. 
I can communicate that pain better to you now, because I'm older, I've got a large 
vocabulary, I'm tertiary educated, which helps me to put forward these things.31 

Assessing Disturbed Children and Adolescents 

Expert witnesses in several States emphasised the necessity for more comprehensive, 
professional assessments of disturbed young people. One Sydney 
psychiatrist advocated an inter-sectoral assessment team established with an 
appropriately skilled coordinator: 

Certainly one needs educational input, one needs psychological input — probably the single 
most valuable profession would be a neuropsychologist who specialises in learning disability.
 In practical terms, that person could provide insight into the deficits the child 

Page 608 Mental Illness Inquiry 

or adolescent may have and what is required to make good those deficits. One also needs
 psychiatric input.32 

Contributing Factors 

While I support [the evidence] on the contribution of child psychiatric disorder to
 family breakdown, the converse also needs to be taken into consideration, namely, the 
role of severe family discord in the [development] of emotional and behavioural problems 
in children and adolescents.33 

While there is clearly a wide range of factors which can contribute to mental 
health problems in young people, these are not generally understood by the 
community and may even be overlooked by health professionals.34 

Professional and academic witnesses identified the following high risk 
factors:35 

• infant or childhood physical, psychological, sexual, or emotional abuse; 
• genetic predisposition; 
• dysfunctional family life and major domestic conflict; 
• parental mental illness; 
• other major trauma or disaster; 
• parental alcoholism or habitual substance abuse; 
• alcohol or substance abuse; 
• pre-natal, perinatal and post-natal disease, trauma or distress in mother or baby or both; 
• serious childhood physical illness, or physical or intellectual disability; 
• family poverty or unemployment; 
• homelessness; 
• membership of an Aboriginal or Torres Strait Islander community; 
• non-English speaking background or refugee status; 
• living in a rural or isolated area; 
• being held in protective or corrective custody

In addition, there are the serious mental illnesses which have their onset in 
adolescence and occasionally in childhood36 and which afflict a percentage of 
the population in all societies at similar rates. 

The Role of Interactive Processes 

Evidence to the Inquiry indicated that there is a range of significant factors 
which interact within the family and between the child and its wider social 
environment. The evidence also reflected a growing understanding of some of 
the contributing factors which interact to influence the development of 
psychological and emotional disturbance in children and adolescents. 

Human Rights and Equal Opportunity Commission Page 609 

The Inquiry was informed that it is particularly important for therapists and 
clinicians working with troubled families to take account of ways in which one 
or a number of factors in the family dynamics interact with others, building up 
a network of interactions.37 

One of these interactive processes is the connection between hyperactivity38 
in a child and resultant family breakdown: 

I think it works both ways; dysfunctional families do create psychopathology in the child, 
and a disturbed child does produce dysfunction in the family. For example, a very severely 
hyperactive child puts tremendous pressure on the family — on both the mother and the father 
— and that drains their resources. If they are well-adjusted and resourceful and have social 
supports, they may cope... If they do not, that may lead to family breakdown. In many cases, 
professionals may be able to support the family, to help them to learn 
strategies and ways of dealing with the disturbance in the child.39 

There is now more evidence coming up suggesting that hyperactivity is related to the 
development of antisocial personality in adulthood — it [appears that] it increases the 
risk quite substantially.40 

A number of child and adolescent mental health specialists pointed to the urgent 
need for research in Australia to gain information about these and other 
possible contributory factors. For example, the relationship between learning 
difficulties and mental health problems was mentioned repeatedly: 

So many child psychiatric problems [include] learning problems, language problems, other
 neuropsychological disabilities as an integral part of the problem. If numbers of young 
people are getting incomplete assessments, then it is likely they are not getting optimal 
treatment.41 

Of the recognised contributory factors, the one which the Inquiry was told has 
received far too little acknowledgment and emphasis is the significance of 
childhood neglect and abuse in the development of concurrent or later disorder. 
For this reason, the Inquiry has taken the view that special attention should be 
accorded these issues in this report. 

Child Abuse 

It seems to me that [one of] the big issues for the next decade [in child psychiatry] 
will be the damaging consequences of child abuse and neglect... Failure to develop a more
 appropriate response to these problems will keep our psychiatric facilities...fully
 occupied well into the next century.42 

Child abuse43 — one of society's most appalling phenomena — can lead to 
immense trauma and suffering. It is only relatively recently that health and 

Page 610 Mental Illness Inquiry 

welfare services and the courts have acknowledged that many adults seriously 
harm or neglect their babies, children and adolescents.44 

There is some evidence that adolescents suffer physical, verbal, psychological 
and sexual abuse — particularly physical abuse — much more than is commonly 
realised, and that it may be one significant reason why adolescents as young as 12 and 13
 run away from home. It is, however, still difficult to determine accurately the extent of
 the various forms of child abuse and increased research in this area must be a priority. 

Child abuse is hidden. It occurs mainly in the privacy of the child's own home, hence 
exact numbers are impossible to calculate.45 

The Inquiry was told repeatedly that unless agencies were able to intervene to 
assist the whole family, professionals saw little point in removing children to 
a temporary safe home — only to send them back to further abuse. Appropriate 
counselling and support for abusing parents is essential before a child is 
returned to them.46 However, the current dearth of resources means that in 
many cases this does not occur. 

Neglect 

Physical neglect of infants and children is a form of child abuse.47 Neglect is 
far more difficult to detect — even to estimate — than other forms of abuse.48 

One reason the extent of child neglect cannot easily be estimated is that it is 
usually hidden until it becomes extreme. One of the most reputable bodies in 
the US 49 estimates that there are five times as many neglecting families as 
abusing families and that, as these agencies see only the most severe forms of 
neglect, the problem is probably extensive.50 Both severe and moderate child 
neglect have been reported as potential causes of emotional and psychological 
damage,51 in addition to physical damage — for example, emotional dependency 
in childhood, adolescence and adulthood, and chronic depression in adulthood.52 

Effects of Abuse and Neglect 

The fact that childhood neglect and abuse can substantially contribute to the 
development of mental illness and behavioural and emotional disturbance was 
confirmed by many witnesses to the Inquiry, particularly clinicians working 
with children. The effects are appalling — and the gravity of the problem is not 
yet recognised by Australian society, or, indeed, by our governments. 

Human Rights and Equal Opportunity Commission Page 611 

The help needs to come when they are suffering in childhood... 40-60 percent of women 
in inpatient psychiatric care have experienced significant sexual abuse in childhood.
 Their adult diagnosis will be depression, phobias, obsessive compulsive disorder, 
personality disorders, or even schizophrenia if they have flashback memories of 
critical voices and shadowy figures." 

As one Queensland expert told the Inquiry: 

In my 25 years' experience working in the child psychiatry field, the greatest noxious 
influence on the mental health of children... is child physical and sexual abuse and 
neglect. I would estimate that in 75 percent of our current cases at the Mater 
[child psychiatry clinic] we would find physical and/or sexual abuse and/or neglect,
 in either this or the previous generation — in either the parental generation or in 
the current children.54 

The effects are not only tragic for the individuals concerned, but are massively 
compounded by the later effects on their families. 

The importance of damaging stress in childhood cannot be underestimated as an underlying
 factor in adult mental illness, because we see such a lot of it in the parents of 
children that present to our service. And that would include the serious mental 
illnesses... A person can be rendered vulnerable early in life through being exposed 
to very damaging sexual abuse, for example, as a young child — it can really ruin that 
person's mental health for the rest 
of their life... Many of the mothers I see (because we work with the whole family) have 
been depressed for years as a result of physical and sexual abuse in their childhoods. 
They've just been chronically depressed — full-blown depressive illnesses — never diagnosed
 and never treated.55 

This evidence was supported by a South Australian witness working in the 
Child Protection Service: 

The potentially damaging early effects that sexual abuse has on the mental health of 
children...include anxiety, depression, anger and sexualised behaviour. Among young 
children there may be sleeping problems, nightmares, fears and phobias, [bed-wetting,
 soiling,] school problems, and psychosomatic disturbances. Longer term effects can 
include.. .unsatisfactory interpersonal relationships, sexual dysfunction, depression, 
suicide, alcohol and drug abuse, delinquency and runaway behaviour.56 

One submission from a peak NSW non-government organisation also emphasised 
that a history of childhood abuse was common among women in 
psychiatric hospitals, but that little attention was paid to the long-term effects of 
such abuse in most hospitals — and no counselling had been offered to help them come to 
terms with its consequences.57 (Also see Chapter 27 — Prevention and Early Intervention.) 

Page 612 Mental Illness Inquiry 

Responses to Abuse and Neglect 

State and Territory governments have responded to the problems of child abuse 
and neglect with a range of mechanisms — including child protection services; 
orders providing for institutional care or temporary or long-term foster care; 
protective custody; and in three States — South Australia, NSW and Queensland — 
mandatory reporting by teachers, doctors, social workers and welfare officers of 
suspected cases of abuse.58 (Individuals may report the suspected abuse of a child 
in those States where reporting is mandatory for professional groups.) 

However, the mere fact of bringing a case to the attention of the authorities 
does not, in itself, constitute an effective response to this pervasive and 
pernicious problem. It may in fact be worse than useless if, after the report, 
nothing is done about intervention, counselling, treatment, and (where it is in 
the best interests of the child) removal from the care of the abusing adult.59 

Child and Adolescent Psychiatric Services 

We have heard people say [to the Inquiry] today that psychiatric services is the poor 
cousin of the health dollar — I would say that child and adolescent psychiatric services 
is the poor cousin of the poor cousin.60 

Range of Services 

There was general agreement among witnesses providing evidence to the 
Inquiry that the small number of child and adolescent services which do exist 
are of a high standard and are staffed by skilled and committed mental health 
professionals.61 The problems they face, however, are enormous. They include 
a desperate shortage of services — with none at all in many regions; grossly 
deficient funding; a lack of appropriately trained staff; poor understanding by 
administrators of what is required to organise a multidisciplinary, multi-agency 
approach to child and adolescent mental health care; and unsatisfactory or 
incomplete mechanisms for integration with related services. (These issues are 
dealt with in detail later in this chapter.) 

According to the evidence presented, those services which do exist can be 
divided into the following categories: 

• Community centre-based comprehensive services (these constitute the majority of
 programs for children, families and adolescents); 
• inpatient acute units for children up to 12-13 years; 
• inpatient acute units for adolescents; 
• inpatient behaviour disturbance services for children and families; 

Human Rights and Equal Opportunity Commission Page 613 

• inpatient behaviour disturbance services for adolescents; 
• children's day patient programs; 
• adolescent day patient programs; 
• outpatient assessment or treatment services for both age groups; 
• home-visiting (community) services; 
• crisis outreach and regular 'home-based' or community outreach services for 
families, children and adolescents. 

A South Australian witness described the approach taken in Adelaide: 

We believe that we have adopted a model of service that is flexible enough to meet
 the needs of the community but sophisticated enough to provide all levels of service.
 After much deliberation and significant disagreement...two decentralised Child and 
Adolescent Mental Health Services were established [in the northern and southern 
suburbs] with the aim of making the services more community-based... [We aimed to get]
 more child psychiatrists in the public sector and an agreement that multidisciplinary
 mental health teams were the best option.62 

The services, which are affiliated with Adelaide Children's Hospital and the 
Flinders Medical Centre respectively, operate 40 hours a week — although 
'sometimes after-hours clinic sessions are offered if it is difficult for family 
members to come [in working hours].'63 The teams consist of child psychiatrists, 
community mental health nurses, clinical psychologists, social workers, 
occupational therapists and, where possible, a speech pathologist. Both services 
work closely with the Education Department and operate day clinics for 
consultation and individual, group and family therapy. The hospitals to which 
the services are linked provide a 24-hour on-call crisis service. However, clinic 
staff consider there is still 'a gap there between what we provide and what could 
be provided.'64 

A witness at the Hobart hearings described a child and adolescent outreach 
service which visits community health centres — not mental health centres. 
Although they are based at the child and adolescent psychiatric clinic, one or 
two professional staff members see new referrals and regular patients in the less
 threatening environment of the community centre.65 

A Queensland expert66 told the Inquiry that a comprehensive children's 
psychiatric service, such as those attached to children's general hospitals in a 
number of major centres throughout Australia, would include inpatient, 
outpatient and day patient services and consultation-liaison.67 Both inpatient 
and non-residential child and family services would use a wide range of 
treatments and therapeutic approaches, including individual, family, parent, and 
group therapy, and such features as psychotherapy, stress management, play 
therapy, and therapy through creative expression. 

Page 614 Mental Illness Inquiry 

A Model Service 

One effective inpatient service for behaviourally disturbed adolescents was 
inspected by the Inquiry in Perth. Hillview Terrace Hospital is a residential 
facility which provides therapeutic programs for emotionally and behaviourally 
disturbed adolescents aged 13-18 and their families. It treats young people who 
are so disabled by their symptoms that outpatient treatment would not be 
satisfactory. (However, the hospital accepts only voluntary patients whose 
families are prepared to involve themselves actively in the treatment program.) 

This service provides an integrated program of three types of therapy — 
individual therapy, family therapy and milieu therapy (treating a disorder by 
making changes to a patient's circumstances and environment in order to 
enhance the effectiveness of other forms of therapy). The more severely 
disturbed or psychotic adolescents are not usually admitted, because they are 
considered unlikely to respond to any of these therapies. The young people who 
are admitted suffer from a range of conditions including depression, suicidal 
behaviour, anxiety, emotional or behavioural reactions to sexual abuse, 
obsessional disorders, reactions to dysfunctional family situations, anorexia and
 bulimia nervosa, and other psychogenic disorders. 

The hospital is located in a gracious old two-storey building surrounded by 
lawns and trees: 

It's a beautiful place — the bedrooms have a lovely outlook. It is so important
 to have this park-like atmosphere of peace and serenity.68 

It accommodates up to 15 young people who, wherever possible, continue to 
attend school or work during the day. The average length of stay is four 
months, although this varies considerably, depending on the individual and their 
progress. A program of individual goals is established and regularly reviewed 
by the client and the nurse case manager. 

Family therapy sessions help all members of the family work towards changing 
negative patterns of behaviour and interaction. The overall treatment approach 
emphasises the adolescents' basic normality and areas in which they are able 
to function effectively, rather than their difficulties. 

Troubled adolescents in this program learn to modify unsatisfactory emotional 
responses and to practise more productive ways of managing their lives in a 
safe and reassuring environment. Evidence to the Inquiry demonstrated the 
importance of this type of intervention — before young people end up in the 
youth drug culture or the juvenile justice system. 

Human Rights and Equal Opportunity Commission Page 615 

Hillview Terrace's adolescent residential service is supported by an adjacent 
non-residential child and family service, which provides a comprehensive range 
of family interventions and child and family therapy programs. The Inquiry also 
heard evidence of several similar non-residential services in other cities.69 

As previously indicated, at least 10 percent of adolescents are affected by the 
kind of disorders treated at Hillview Terrace Hospital (ie several thousand in 
Western Australia alone). This service, while excellent, is only available to a 
tiny fraction of those who need such assistance. 

Difficulty in Obtaining Treatment 

Access to treatment is one of the most important rights that children and adolescents 
have to have. For many years, until quite recently in fact, people did not think that
 children and adolescents had psychiatric problems — child psychiatry [itself] is a
 fairly new discipline... As a consequence, services for children and adolescents
 have been very scarce.70 

Difficulty of Access for Children 

There are problems with access to services. Children are mostly not able to seek help 
as effectively as adults. They rely on adults to firstly, recognise their needs, and 
then to seek help on their behalf.7' 

Children are relatively powerless in making decisions and accessing services in 
any field. Most do not have the knowledge or maturity to identify either the 
kind of problem they are having or the kind of assistance available. For a 
number of reasons, adults cannot or will not always respond appropriately: 

[Some children] are prevented from receiving services by their families, because their 
families may have a view that they shouldn't be visiting the doctor or the psychologist 
or the social worker... Child psychiatry services have no mandate...with those children.
 We can't make them come... Children aren't usually mentioned in Mental Health Acts... 
The people who ultimately deal with children like that are social welfare services under 
certain care and protection applications... For some of those children it leads to disruptions of 
attachment, to deprivation, to secondary consequences which magnify the psychiatric disorder.72 

Schools are potential points of referral to services for children, but (as 
discussed below) this system is far from satisfactory. Even when it works well, 
the summer break proves problematic: 

The long Christmas school holiday is a period when all support [from within the schools] is
 removed, and I would suggest that more than 90 percent of these children don't have the skills
 to tap into other community resources.73 

Page 616 Mental Illness Inquiry 

Difficulty of Access for Adolescents 

Many adolescents are also unlikely to acknowledge or identify an emerging 
mental health problem. 

For young people generally, mental health is something they don't even begin to 
conceptualise. [They] are only vaguely aware of how their state of mind affects their 
verall social interaction... Typically, they view psychiatrists as 'people that stuff 
around with your mind'.74 

Clinicians who gave evidence to the Inquiry emphasised that adolescents need 
to relate to their own age group. If they do accept the need for assistance, they frequently 
reject services which cater for children or adults — particularly if they are experiencing 
problems which already make them feel 'different'.75 

Witnesses also emphasised the importance of making facilities for adolescents 
relevant and appropriate for young people. 

Youth culture is a fact... Young people simply walk away from services that do not speak their
 language or share their outlook. Services which do not address adolescent needs separately are
...a waste of time and money.76 

A difficulty we have in young people accessing our service is the anti-authority stance of
 adolescents. A unit such as ours will be seen as part of the Government, perhaps wielding
 a big stick. Young people may access drop-in centres rather more freely.77 

Some services have recognised the benefits of reducing bureaucratic procedures 
to a minimum: 

To facilitate accessibility, no referral is necessary to our service — young people, 
or their families, can access us directly. A general practitioner, a specialist medical
 practitioner, guidance officer within a school, or a welfare officer from Community 
Services may approach us concerning a child that is known to them. We are quite happy 
to take up that referral, but we ask the family to contact us directly to make the arrangements. 
There is no charge for the service we offer.78 

Services also have to contend with the extreme reluctance, by both adolescents 
and their families, to be associated with anything identifiable as 'psychiatric' 
or 'mental health' — due to prejudice against people who have mental illnesses. 

The stigma of attending a psychiatric unit is one obstacle... The stigma is also
 [self] imposed in that individuals will be afraid of the idea of having a mental illness
... Another situation which can result in non-referral is the belief by some lay people
 and some professionals that referral of a child to a psychiatric service means that 
child will be hospitalised and/or medicated.79 

Human Rights and Equal Opportunity Commission Page 617 


One of the problems we hassle with is our name — Child and Adolescent Mental Health
 Service. The average adolescent takes one look at that and runs a mile. One of my 
colleagues recently quoted two families who said they had driven up to the door, 
taken one look at the label, and said: 'We can't go in there!'80 

This evidence highlights the need for adolescent services to include facilities 
such as youth drop-in centres — located, named, designed and equipped in a 
manner which appeals to adolescents and accords with the prevailing youth 
culture. Otherwise young people will avoid the facility and therefore not receive
 the treatment and support they need. 

Deficits in Service Provision 

There are very few child psychiatry services in Australia, and I can particularly
comment about Victoria... Children in the country miss out, because there are almost 
no psychiatric services in rural areas; ethnic groups miss out, because of access problems;
 Aboriginal groups miss out...and children in general miss out on services.81 

Although Australian society pays lip service to the notion that our children are 
valued and our young people are 'the hope of the future', the serious deficiencies 
in child and adolescent mental health services exposed throughout the Inquiry suggest
 the opposite. Without exception, every witness presenting 
evidence about child and adolescent mental health referred to the appalling lack 
of provision for training, staff, facilities and services to assist children and 
adolescents in need of special care. 

This serious inadequacy of services was quantified by several witnesses: 

Children and adolescents comprise almost a third of our population. We can estimate 
that there would be, at any one time, approximately 13-15,000 children and young people 
in the ACT suffering from psychiatric or behavioural problems. A tiny proportion of this
 large group is receiving support and treatment of any kind.82 

Because a comprehensive range of services is needed to meet the mental health 
needs of our most vulnerable children and adolescents — and because so few 
of these needs are being met — many witnesses identified particular areas in 
which they believed the need is most acute. 

Lack of Community Crisis Teams and Support Services 

Experts agreed that it is generally preferable to keep adolescents out of 
hospital-based care whenever possible and to provide them and their families 
with treatment and support in their own surroundings. In order to achieve this, 
it is necessary to be able to mobilise experienced mental health workers to go 
to where the young person in crisis is — first, to assess their condition; and 

Page 618 Mental Illness Inquiry 


second, to initiate treatment if appropriate, without having to physically remove
 the child or adolescent to a psychiatric ward. However, according to the 
evidence, there are very few areas in Australia where such services are 
available. The following evidence refers to South Australia, but similar 
accounts were presented to the Inquiry in every State and Territory. 

[There are] two conspicuous lacks in the field of child and adolescent mental health.
 The first is a lack of a crisis assessment and treatment team particularly aimed at
 home [visits] and an accessible form of treatment for adolescents in the community.
 The second is developmentally-appropriate inpatient beds, either within the general
 hospital or as a freestanding 
unit.83 

Lack of Inpatient Assessment Facilities 

Community or home-based care is not always appropriate for children or 
adolescents who become seriously disturbed or psychotic. A period of inpatient 
care may be required to carry out a full assessment of the young person's 
condition. However, suitable facilities for inpatient assessment are inadequate 
or non-existent in many parts of Australia — even in some of our major cities. 

There would be somewhere between 30-40 young people in Perth each year from the ages of,
 say 12-18, who suffer the onset of either schizophrenia or manic depressive psychosis.
 Currently there is not a suitable facility for inpatient assessment of these young people.84 

Lack of Inpatient Acute Beds 

Where acute inpatient admission is considered necessary, an adolescent in crisis 
often finds no suitable facilities exist, or else that a facility is full and no beds 
available. In every State witnesses deplored the lack of adolescent inpatient facilities. 

• There are several psychiatric facilities [for young people] within the Melbourne 
metropolitan area. [When a young person] requires removal from their home, however, 
most of these have limited bed capacity and, more often than not, are unable to assist
 because they are full... The bottom line in the whole spectrum of juvenile psychiatric 
and emotional disturbance is the lack of resources available... It's not unusual for us
 as a [Community Policing] Squad when we are presented with a child with problems to
 spend several hours on the phone trying to find some sort of help for that child.85 
• The two inpatient units [in metropolitan Brisbane] for children and for adolescents
 are often full and have waiting lists several weeks long. Officers of the Department 
of Family and Community Services are overwhelmed by child abuse referrals and only 
react to the most urgent cases.86 
• In NSW, there are only two inpatient services that can deal with suicidal young people,
 and in Victoria, we've only currently got three.87 They're always full. You have to wait
 about six to eight weeks to get a person into those services — if you're lucky.88 

Human Rights and Equal Opportunity Commission Page 619 

The Director of Psychiatry at a regional hospital decried the lack of acute 
inpatient facilities for either children or adolescents outside major city centres: 

There are no adolescent beds. There are no children's psychiatric beds. There is no 
hild psychiatrist. Last night at 8.30pm I went to the paediatric wards to see a child — 
a boy who had dived out of a window with his teddy bear screaming 'They are going to kill me'.
 I went to see him, but where can we send him? If we send him to the city to the adolescent 
unit, how will his family be able to be with him? And I'm sure we wouldn't get him in, anyway.
 My registrar spends up to three or four hours on the phone trying to find a bed for the
 people with serious mental illness who present — they come to our hospital and then we
 have to find a bed for them. Most of my registrars and resident's time is taken up in 
making phone calls.89 

Lack of Community Centre-Based Services 

The major part of service provision for troubled children, adolescents and their 
families is — and should be, wherever possible90 — through community-based 
child and adolescent mental health centres, which provide a range of services 
both mobile and centre-based, so that young people can stay in their homes and 
schools and take part in normal daily activities as far as possible, while still 
obtaining appropriate therapy. The added disruption and trauma of psychiatric 
hospitalisation is usually avoided, except where the young person is experiencing acute
 mental illness or extremes of emotional or behavioural 
disturbance. 

Fully staffed multidisciplinary child and adolescent teams are only found in our 
largest cities — and not even in all of these: 

The World Health Organisation estimates that you need one child and adolescent mental
 health team consisting of eight workers, for every 100,000 in the population. 
According to population ratios in 1986, Queensland required 26 teams; it had only 15. 
In 1991, I would reckon that we probably need 30 such teams. We still have 15. 
The whole 15 teams only cost $6 million, and I think it would be a small investment
 on the part of the government to double this, to bring us up to par.91 

Judging by the submissions received, and by inspections of child and adolescent 
clinics conducted by the Inquiry, a great deal can be achieved in adequately 
staffed, geographically accessible, community clinics for children and their 
families. But, the Inquiry was told, there are very few of them. A family whose 
members are desperate and a young person who is depressed, psychotic or 
seriously disturbed and needs the service urgently may have to wait months in 
some States: 

Health Department child mental health clinics in Brisbane have waiting lists, many of
 at least a month, and in working-class areas, at least three to six months long — 
and most of the private child psychiatrists have waiting lists.92 

Page 620 Mental Illness Inquiry 

The waiting list for young sufferers is appalling. Families are often told they have
 to wait three months before being seen. Usually a crisis occurs before this time, 
necessitating police intervention. To realise their child or adolescent is disturbed 
is traumatic enough to cope with, but to find that help for them is just not available 
in time of crisis is incomprehensible.93 

Lack of Day Treatment Programs 

Day treatment and outpatient services can often provide a disturbed child or 
adolescent with quite substantial care and treatment, without the dislocation of 
being admitted to an inpatient facility. (They are also much less costly to run 
than inpatient services — which require meals, cleaning staff, laundry and 
kitchen services and greater capital expenditure, in addition to the clinical 
services.) However, professional child and adolescent mental health workers 
presenting evidence identified major inadequacies in this area. 

There seem to be two major deficits in services — firstly, there is no day facility for 
children. This would require the co-operation of a number of inter-departmental agencies,
 and secondly, there are no separate facilities for older adolescents.94 

An integrated network is the best way of treating disturbed adolescents in the community,
 that network to include outpatient facilities, which are already in place.. .and an 
adolescent day service... There is a large gap between the few beds in a general hospital 
setting, and the community clinics. There is no kind of in-between step where people can 
have a more intensive program, either in their own home, or through a...day service.95 
Inpatient Planning Problems Caused by the Small Numbers 

The Inquiry heard differing professional views concerning bed requirements for 
inpatient care for disturbed adolescents. In the larger cities such as Sydney and Melbourne,
 clinicians and other service providers acknowledged the necessity 
for an extension of inpatient facilities for acutely mentally ill or disturbed 
adolescents. In some smaller cities, such as Canberra and Hobart, psychotic 
adolescents constitute a relatively small number of young people needing some 
kind of mental health treatment. Some specialists therefore regarded them as 
too few in number to warrant the construction and staffing of a specialist unit. 

I do not believe [Tasmania's] population warrants a residential facility. The need 
to admit young people for psychiatric assessment or care is small... Of the patients
 that come to our facility, I have only four adolescent patients with diagnosed schizophrenia.
 Two of them have required very short admission [to the adult psychiatric ward]...
 That number does not warrant a separate residential facility... There is actually 
a greater need for children to have permanent and ongoing placements within the community, 
whilst at the same time receiving psychiatric help on an outpatient basis.96 

Human Rights and Equal Opportunity Commission Page 621 

In centres where the population is relatively small, there is clearly a need to 
examine a range of possible alternative approaches. 

Deficits in Staffing 

It was common for witnesses to describe their own staff shortages, and the 
efforts their services make to cover the community's needs — because no other 
agency has the expertise in the field and because there are simply not enough 
trained staff anywhere in child and adolescent mental health. A witness from 
Clare House in Hobart told the Inquiry: 

We provide a range of child, adolescent and family mental health services [on an 
outpatient basis]. Our sister clinic in Launceston and another in Burnie are both much more
 poorly staffed than our unit. We provide some consultant back-up to the Burnie clinic, but
 there is very much more needed in other parts of the State... At Burnie, the district 
[they are servicing] is very wide-flung...and they currently have only one and a half 
to two clinical staff. That has been a problem of recruitment to that area.97 

Deficits in staffing sometimes mean that essential functions are not even 
attempted: 

South Australia is a long way behind...in the range of facilities available for child 
and adolescent psychiatry, despite the sympathetic approach of the government... 
The problem is that there just aren't sufficient people working in the area... 
We can't provide access to services because we don't have the services, and we don't 
have the people. We have very good outpatient services for children and adolescents, 
but they have waiting lists of three, four months. That means we can't even think about
 providing services to the juvenile justice system, the drug and alcohol system, to 
the people working in primary health care, working with street kids, working with 
children with chronic illnesses.98 

Lack of Child and Adolescent Psychiatrists 

A psychiatrist appearing on behalf of the Western Australian Branch of the 
RANZCP summarised the acute problem of staff shortages in child and 
adolescent psychiatry which the Inquiry heard about in every State and 
Territory: 

One of the main things that is holding us back...is the serious shortage of child 
psychiatrists... One of my prime concerns...is to increase the number we have — we 
currently have about half the recommended minimum number of child psychiatrists for
 our population in WA...and they are primarily concentrated in the metropolitan area.
 A reasonable estimate is that we should have about 25, by the most conservative estimates
 of what is reasonable. We currently have 12. I have three child psychiatrists in 
training...[but] a number of things put that in jeopardy too — there are no designated
 training jobs in child psychiatry; I would need to prevail on the good offices of other 
people to 'lend' me jobs to train child psychiatrists... It is also a problem in
 other States. It has recently become a serious problem in Queensland, that I am aware of — 

Page 622 Mental Illness Inquiry 

[psychiatrists who wish to train as child psychiatrists] have actually been leaving
 that State because they cannot get training." 

Lack of Specialist Mental Health and Allied Health Workers 

Specialist psychiatrists with training and experience in working with disturbed 
children and adolescents are essential to the provision of appropriate services. 
However, for every trained psychiatrist in this field, a larger number of mental 
health and allied professionals is required: child mental health nurses, adolescent
 mental health nurses, family therapists, social workers, counsellors, specialist 
clinical psychologists, remedial education teachers, occupational 
therapists, and sometimes speech therapists. 

Many services around Australia are juggling the time of too few workers in too 
few disciplines to attempt to provide an effective service. 

This is the case even in major metropolitan areas, but it is especially true in 
more sparsely populated areas where, in many instances, even if funds are 
available, qualified staff are not. In North Western Tasmania: 

The child and adolescent unit [provides] only 20 hours of clinical psychology and two
 social work positions, one of which has been unfilled for the last eight weeks 
because we are unable to get a suitably qualified person... A psychiatrist is available 
to the child and adolescent unit only one day per month and is therefore...available 
only to the staff [to provide case consultation] and not to the patients.100 

Inequitable Distribution of Scarce Resources 

Most workers attempt to fit as many children, families and adolescents into the 
daily schedule as they possibly can. Despite their efforts, however, they can 
often only respond to those in most urgent need. One reason is the maldistribution of
 the limited resources which are available. 

Brisbane has two children's hospitals, but with the advent of regionalisation, [one] 
now has 200,000 more people in its catchment area than does the other. Both hospitals'
departments of child psychiatry cater for approximately 500 new client families per year,
 with a similar number of problems and conditions. [One] hospital has a full-time staff
 of 36 people; [ours] has a full-time staff of four. This means that staff...are under 
constant stress, with huge caseloads, long hours, sub-standard working conditions and 
minimum resources. Because patient needs are paramount, few resources remain for teaching, 
research, staff training, and primary prevention work. In the long term, everyone — 
the staff, the children, the community as a whole — pays the price. There's no saving 
in the long term.101 

Human Rights and Equal Opportunity Commission Page 623 
Deficits in Training in Child and Adolescent Mental Health 

The general training needs of mental health professionals and others who work 
with those affected by mental illness are discussed in Chapter 6. However, the 
lack of training in child and adolescent mental health warrants special attention. 

Psychiatrists 

Child and adolescent psychiatry has been extremely slow to develop as a 
specialty area in Australia. 

Until recently, there's been very little support for academic positions — my Chair
 was the fourth in Australia,102 and that's a major problem.103 

The undersupply of specialists and the urgent need to encourage more psychiatrists to
 enter the field was raised by numerous witnesses: 

The training of people in the mental health area — whatever professional discipline they 
come from — has been dominated by a cross-sectoral adult-oriented view. Very few academic 
institutions or training programs have taken up a developmental [child and adolescent] 
line, [so] it's hard for the products of that system to envisage the need in the other areas.104 

Academic endeavour in the area is essential: 

There has always been a training program for child psychiatrists for the past decade or
 longer...[but] there is no academic child psychiatry department within this State —
there is a vacuum in leadership.105 

Because there are so few specific services for children and adolescents, the 
opportunities for specialist training are also extremely limited. In some States,
 such as Western Australia, they are non-existent. 

If you want people to work in.. .child and adolescent psychiatry, you have to provide
 good training experiences for them and good facilities through which they can provide
 the services. At the moment there is no service — no acute service for adolescents 
— so it is very difficult for anyone who wants to specialise in that area to be able 
to work.106 

Allied Professionals 

There are a number of professional groups whose members come into contact 
with young people in the course of normal school and community interaction. 
Members of all of these groups may be involved with children who are 
mentally ill or seriously disturbed. These professional groups include teachers, 
psychologists, counsellors, social and welfare workers, family therapists, 

Page 624 Mental Illness Inquiry 

Family Court counsellors, youth workers, police officers107 and court 
officers. The fact that members of all these professions need some special 
training108 was raised repeatedly in evidence to the Inquiry: 

Adequate training is required not only] in medical schools and post-graduate medical schools
 and in nursing schools, [but] for all professionals involved in mental health [so that there
 is] adequate assessment and adequate diagnosis.109 

Fortunately, there are exceptions: 

Our psychiatric unit has recently been accredited as a career child psychiatry training
 facility... Graduate psychologists and social workers-in-training come on placement and
...psychiatrists-in-training [for adult services] are [now] required to spend six months
of their training within a child and adolescent psychiatric unit. At undergraduate level,
 senior medical students come on placement with us as a mandatory part of their training...
 I would hope in future we will be able to offer such packages for, say, community welfare 
officers, guidance officers and so on, to increase their awareness of emotional and 
ehavioural problems in children and what our facility offers.110 

Inadequate Funding 

Witnesses in all jurisdictions drew the Inquiry's attention to the grossly 
inadequate funding provided for mental health services for young people: 

I really have one thing to say and that is that child and adolescent mental health services
 in this State get about 6 percent of the total mental health budget, and it is not enough.
 These services really need about twice that proportion just to get to first base.111 

Fluctuations in funding and lack of forward planning compound the problem: 

What is needed is stable core funding in an ongoing way — not uncertainty every six 
months about whether the service is going to get sufficient funding to keep going for the
 next six months.112 

Witnesses speaking from very different professional perspectives identified both 
State and Federal budget priorities among the most fundamental problems: 

The dramatic financial squeeze on the States by the Commonwealth Government, in 
combination with the low-spending policies of the Queensland Government, has meant that 
State government services to the mentally ill have been a low priority.113 

In the 1990-91 Victorian Budget, resources allocated to [child and adolescent] mental health 
services were reduced. One facility was actually closed, and it was the only facility in the 
State which provided an inpatient service to the late-adolescent group aged 16-20. Other 
facilities had staffing and general running-cost cuts. There was some expansion, which 
is most welcome — some...occurred in the country and [there was] the establishment of an 
adolescent inpatient unit at Monash Medical Centre, but this has been at the 

Human Rights and Equal Opportunity Commission Page 625 

expense of the Parkville Adolescent Unit. These cuts have been made worse by the 
reduction in other services for children and adolescents in general health, education,
 welfare. These have traditionally provided preventive mental health programs to support 
and augment work that's done by our own services, so that the pressure on us has become 
even greater.114 

In addition to the serious deficiencies in even basic services for young people, 
the Inquiry received evidence concerning shortfalls in related services which 
exacerbate the difficulties. These included suitable adolescent accommodation, 
both supported and independent; training and employment; education; and 
social and recreational activities for adolescents recovering from a mental 
illness. (These issues are addressed in several other chapters.) 

Inappropriate Placement 

I think it's appalling for 13 and 14-year-olds to be admitted to adult psychiatric wards... 
It's difficult enough when they're admitted to general medical wards, where there are not 
adequate psychiatric staff, but there is a real danger...in the psychiatric hospital that 
these children can be exploited where there are some very disturbed [adults] and levels of
 supervision may not be appropriate.115 

Because there are so few services for children and adolescents, the Inquiry was 
repeatedly told that young people in crisis are frequently placed in highly 
inappropriate facilities — sometimes at great personal risk. 

This evidence included instances of mentally ill or seriously disturbed children 
being placed in children's general medical wards; adolescent acute wards; adult 
psychiatric hospitals; and inappropriate temporary foster care. 

If we have a child who is traumatised in some way — who, for example, has attempted suicide — 
then we have to admit them to a public hospital before we can get them to Wynyard [an adult
 psychiatric clinic], which is the only facility which will receive children in these
 unfortunate situations. There was a case this year where a child had taken an overdose... 
It wasn't appropriate for her to stay at Wynyard because the other patients who were there 
on that particular night made it far more dangerous for her to stay in the institution than 
it was to put her back into a deplorable home situation, which is where she 
finished up... Often a referral does not take place, because the [available] places are seen
 to be inappropriate and, on the occasions when those waters have been tested, have been shown
 to be inappropriate.116 

Adolescents with serious psychiatric illnesses who require inpatient assessment 
and care face similar problems: 

• Young people can be admitted to the psychiatric units of adult general hospitals — Sir 
Charles Gairdner Hospital, Queen Elizabeth Medical Centre and Royal Perth Hospital. This
 is a less than optimal environment for treating psychotic illnesses, particularly with 
young teenagers — there is virtually no facility there for education... And there are 

Page 626 Mental Illness Inquiry 

problems...where young people are exploited emotionally or in other ways by adult patients... 
The other alternative is the adult psychiatric hospitals, which are...really quite unsuitable
 for similar reasons.117 

• Every year, a large number of young people unable to gain access to adolescent 
psychiatric services end up as inpatients at adult psychiatric services. Over the past eight 
years, on average around 15 young people per year aged 13-15 have been admitted into the 
adult psychiatric system. This figure jumps significantly...in the 16-18 year old bracket,
 with the average [per year] being around 166 admissions.118 
• The only place available for students requiring hospitalisation is essentially designed 
for adults and not for adolescents... The programs are not essentially therapeutic... 
Some young people have already been subjected to all forms of abuse and, depending on the 
ther people who have been admitted to the [adult psychiatric] clinic, it may not be safe 
for an adolescent girl to be admitted with a large number of older youths and young men.119

Another relatively common practice — placing adolescents in children's wards 
— is equally inappropriate: 

[There are] no specific inpatient facilities for adolescents... [They are] either admitted 
to Princess Margaret Hospital, which is the children's hospital and theoretically has an 
upper age limit for admission of 14. Very disturbed teenagers do not fit well into the 
children's hospital environment — we have an inpatient ward with eight beds, and some 
of the patients would be as young as three or four. It is not appropriate to put these
 young [children] with very disturbed teenagers. Children's hospitals have...problems 
with teenagers.120 

The Inquiry also heard damning evidence of children and adolescents entering 
the juvenile justice system by default — simply because no one had been able 
to provide assistance at an early stage and there were no mental health facilities 
available when the crisis occurred. 

Inevitably, many young people with psychiatric problems languish within the correctional
 system and within youth training centres, because the mental health system will not 
appropriately deal with them.121 

In many instances, the only care and protection society provides for these 
severely troubled young people is a remand centre, a lock-up, or a prison cell. 
Dr David Wells, the Director of the Office of Forensic Medicine in Victoria, 
told the Inquiry: 

Even this week, we have had to put young people into police cells for hours, waiting
 for the phone call back. That's an appalling situation.. .The impact on the individual 
— a person who has committed no offence is put into a cell. And then [there is] the impact 
on the family — a 16-year-old boy with his first schizophrenic manifestations is locked up
 while they try to find a bed. It is devastating!122 

Human Rights and Equal Opportunity Commission Page 627 

The police themselves are appalled by what they are forced to do with some 
young people who are in an extremely vulnerable state: 

A 15-year-old girl was so violent towards her family...that she had to be removed [and was]
 presented at court. Because there was no other placement available, she had to be remanded
 in custody for six weeks, pending her release to a child psychiatric centre for treatment
... These children and adolescents [do not] require removal to remand detention centres.
 The juvenile sufferer does not understand what is happening to him or herself when 
suffering psychiatric or emotional illness. Being incarcerated and appearing before a 
children's court can only add to their bewilderment... The hardest thing for me is to
 be there when a child says to me, 'What have I done wrong? Why am I going to court? Why 
have I got to be locked up?'... The placement of these children and adolescents in 
remand detention facilities because of incredibly inadequate resources can no longer be
 tolerated... Is it not the same as placing a mentally ill adult into Fairlea or Pentridge?123 

In another case brought to the attention of the Inquiry, a 12-year-old boy in 
Newcastle was 'locked up like a criminal, when his major sin is a mental 
illness that no-one has been able to help him with'.124 The boy, who was 
diagnosed as suffering from an obsessive-compulsive disorder, was charged 
with a minor stealing offence and given bail. When he breached bail conditions 
by refusing to take medication and became violent and destructive in his home, 
he was referred to the Worrimi Detention Centre — after both the Departments 
of Community Services and Health were unable to find anywhere else to place 
him. He was kept there for seven nights. After the second night, he was found 
hiding in a broom cupboard in the lock-up. 

The Children's Court Magistrate who heard the case said publicly that it 'highlighted
 the complete lack of facilities for mentally ill children in the area.' The Professor
 of Psychiatry at Newcastle University125 commented on the case, saying that a population
 the size of the Hunter region should have 'about eight to ten beds' for disturbed children 
and adolescents. (The publicity generated by this controversy achieved a breakthrough in this 
instance — a new team was formed in the Hunter area, with officers of the Community Services 
and Health Departments given responsibility for arranging the assessment and care of 
children with mental, emotional or behavioural problems not catered for by 
existing services.) 

It is appalling that a disturbed child had to be incarcerated in an ill-equipped 
facility, with no health or welfare staff to treat or care for him, before the 
implications of his situation were acknowledged and alternative arrangements 
made. However, it should be noted that the boy was eventually admitted to an 
adult psychiatric hospital (notwithstanding the unanimous view of experts that 
such placements are completely inappropriate) — because there is no inpatient 
adolescent facility in Newcastle. 

Page 628 Mental Illness Inquiry 

Prevention and Intervention 

A separate chapter of this report deals with prevention and intervention in 
detail. However, there was a considerable body of evidence from clinicians and 
service providers concerned about disturbed children and young people coming 
into their services too late or not at all. Numerous witnesses expressed their 
frustration and dismay that frequently nothing is done for seriously at-risk 
children or young people. 

It is not clearly recognised how important it is to deal with people with mental illness
 and to bring to light the potential for future problems, particularly in terms of the
 children. There is quite a lot of literature now recognising that women having problems
 during pregnancy and post-natally has an impact on the child's development... Obstetricians 
tend to focus on the problems of the woman, rather than on the implications for the health of
 the baby too, after it is delivered.126 

One peak community organisation maintained that it is important for all 
pregnancy services to aim at 'reducing anxiety and depression in prospective 
mothers' and at teaching expectant mothers about the development of beneficial 
mother-child relationships — on the basis that 'child mistreatment prevention 
[has] to start during pregnancy'.127 

A Sydney psychiatrist referred to the earliest possible preventive strategies — 
starting with informing expectant mothers of the services available; continuing 
with the provision of outreach obstetric follow-up; and most particularly, maintaining and
 promoting early childhood services, which she considered 'one of 
the most valuable preventive agencies this nation has' for early identification 
of children at risk, troubled children and dysfunctional families.128 

Another psychiatrist from a children's residential service expressed frustration 
that the necessary network of early detection and intervention strategies has not been developed: 

In many cases, children with problems can be identified at the age of two, three, or four
 years old, and help for them can be organised. It's also very clear that families at risk 
can be identified very early. [These categories would include] teenage parents, parents having
 severe financial difficulties, parents from broken homes and so on. [If] these were identified
 fairly early, some intervention could be organised for them.129 

Two Sydney psychiatrists informed the Inquiry about the long-term effects of 
poor childhood intervention services. 

The majority of the most disabled adults with severe mental illness show significant mental 
health problems prior to entry into adulthood, and yet children showing early problems —
 particularly those in which intervention may well have an important preventive role — are 

Human Rights and Equal Opportunity Commission Page 629 

often denied access to services through inadequate provision of services...or services which 
are either inappropriate or insufficient.130 

We [the psychiatric profession] have been concentrating on treating disorders when they are
 already fully developed — when they have already produced the handicap. Often, people are
 being treated when they have already had the disorder for ten years and then they are treated.
 But that is too late in most cases: most of the handicap takes place in the formative years of 
development — the years in which people develop their working skills... When they are treated in
 their thirties and forties, their lives have already been largely destroyed.131 

The effects of this paucity of appropriate services are, the evidence suggests, 
not confined to the individuals themselves — but have a major impact on their 
families and society generally. 

In the case of young people...with early-onset major psychiatric illness, there is some evidence
 which suggests that what you actually do to help these young people...does have an effect on 
the prognosis. Unless we can modify something in our management of these young people, 
they will go on to become long-term dependents on welfare, chronically unemployable; they 
do not fit back into the school system, and [place] great stress on their families and siblings.132 

Model Intervention Services 

Several excellent intervention initiatives are being undertaken in pockets around Australia.
 One example is the Warwick Child and Adolescent Clinic in Perth, which provides services in 
conjunction with the Education Ministry for children in school-years seven to eight (the
 transition period between primary school and high school). 'The New School' provides day
 programs for one or two terms for children who have difficulty adjusting to the transition,
 due to psychological, behavioural or psychiatric problems.133 

In Canberra there is a very successful program at Phillip (Secondary) College with a group 
of school children with problems from eight to twelve years old, brokering a supported 
involvement for them by volunteer senior students working with them, getting the kids to do
 things together in a group in a structured way, which is really a very important way of 
helping [troubled young people] to fit in.134 

Role of Schools 

Identification and Referral 

Clearly, our schools have an important role in identifying young people with 
mental health problems and referring them for assessment or counselling. 

Page 630 Mental Illness Inquiry 

It is quite often schools who are the first to see the beginnings of mental illness... For 
the last ten years in Tasmania we have seen an unheralded increase in the degree of disturbance
 amongst young people — perhaps in response to increased unemployment; certainly in response
 to a gradual breakdown of the family unit. That has been evidenced in increasing amounts of 
teenage depression, in homelessness and the associated trauma... With these children who are at
 risk, often schools have a chance to act far more pro-actively...because by anticipating the need, 
quite often we can act to remove the trauma... Schools [can] provide an enormous safety net for 
children through guidance and student 
support services135...picking up...children who need immediate psychiatric treatment [or] perhaps
 in the pre-psychiatric stage.136 

In instances where a school does have the benefit of child psychiatric assessment by a skilled
 professional, such as one Queensland 'special school' visited by a child psychiatrist who gave 
evidence to the Inquiry,137 the school principal can take steps to refer students who appear to 
be at risk. The witness told the Inquiry that, from the school population of 90 children and 
adolescents, he was asked to provide psychiatric help for 17.138 

In the opinion of Queensland teachers in one recent study,139 nearly 17 
percent of children and adolescents had significant problems and approximately 
4 percent were classified as having severe problems. (The majority of teachers 
felt that problems were increasing and over 80 percent believed inadequate 
levels of assistance were available to address the problem.) 

The failure of education authorities to implement policies which effectively 
address the rights of both school students in need of specialist intervention and of teachers 
and other students to conduct their schooling in an efficient and stress-free manner is a
 reflection of the same general ignorance, widespread 
confusion and denial of the existence of mental illness and serious disturbance 
among young people that exists in the wider community. 

This ignorance, confusion and denial of the problem at a policy level also 
results in the failure of teacher training courses to adequately train and equip 
teachers (who will all, at some stage, be faced with the stress of dealing with 
severely disturbed students), with some understanding, some techniques, and 
a realistic appreciation of likely levels of back-up support. 

Exclusion of 'Disturbed' Children from School 

School staff who are not trained in identifying and referring disturbed young 
people tend to respond by deflecting the problem to some other area. This 
situation was referred to frequently in evidence: 

We have got a problem with administrative boundaries... Children who are mentally ill are at
 the margin of responsibility. The central task of education is learning, so there is 

Human Rights and Equal Opportunity Commission Page 631 

often a lot of pressure to get kids with severe behaviour disorders 'out of my school'
 and somewhere else. A vast amount of time is wasted by schools dodging their 
responsibility for such tasks.140 

Some of these children end up homeless141 as well as deprived of their right 
to an education, after suspension or expulsion from school.142 

A witness from a child and adolescent mental health clinic told the Inquiry in 
our national capital that she 'increasingly [sees] six-year-olds who have been 
kicked out of school — kids who just cannot be contained within the school 
system': 

It's a much bigger problem than anyone is prepared to acknowledge... We get at least
 one referral a week of a kid who has been kicked out of school... We are not saying 
it's easy for the schools. But we need to be dealing with this problem differently, 
because if this child falls out of education, all the mental health systems in the world 
are not going to help — you cannot work with a kid who is not at school or at least 
in some daily program of activity. Mental health services cannot deal with deprivation, 
abuse, and lack of a system of care which emphasises the needs of the child — they can 
only deal with fall-outs 
from the system...and I'm talking about systems other than just mental health... Mental 
health services for children and adolescents depend entirely on the quality of services
 provided by education and family services.143 

Rather than excluding vulnerable children and adolescents who are seriously 
disturbed, our system should ensure that adequate resources are provided to 
assist them.144 

Professionals in Schools 

The lack of professional support staff in schools was frequently referred to in 
evidence. Such individuals include school psychologists, counsellors, child 
guidance officers, social workers, special education and remedial teachers. 
Some of these professionals are employees of departments other than education 
departments — such as community services or health. This creates one of the 
major blocks to providing appropriate and timely identification, assessment, 
intervention and referral services for disturbed children. 

A big problem we have is resources for children and adolescents with mild to moderate 
problems. We have a good deal less [resourcing for these] than we used to have. Up to 
20 years ago, there was widespread development of Child and Family Guidance clinics; 
there were specialist child health nurses, who undertook counselling; there was long-term 
involvement by Baby Health Centre sisters in supporting families. Now, the best setting 
to deliver such services is often school-based, in that it's a good place to have counselling 
services and to run parenting skills courses. But there are massive barriers, because 
the education administrators do not see that as part of their function and the Teachers' Unions, 
particularly in this Territory, utterly oppose the appointment of any staff [to positions within] 
the Education Department who do not have teaching qualifications, whereas in 

Page 632 Mental Illness Inquiry 

Victoria, for instance, you can appoint school psychologists and social workers. In Western 
Australia, there is a big role for nurses in schools. That cannot happen here. In [Canberra],
 we have a good example in the Catholic school system, where there is a service including 
mainly social workers and some psychologists, who are non-teachers, working in schools and 
having the option to see families as well... It is much easier for families to trust someone 
whom they perceive does not have the school principal 'breathing down their necks."45 

In schools where the teachers have the skills to know where referral is 
appropriate, however, trained professionals — and the services in which they 
operate — must be available to follow through. 

Now that Canberra no longer carries out universal checks of three-year-old children within the
 health system, the next opportunity...occurs in the school. Teachers and school counsellors
 have told mental health workers that they are able to identify certain children in grades one 
and two who have some particular difficulty, either with their school work or in terms of their 
behaviour. If assistance could be offered to those families at that point, it would help to
 ensure that these children's problems do not become compounded as they grow older... A much
 broader strategy is required for troubled children involving a range of services.146 

The role of school psychologists, school social workers, counsellors and 
guidance officers is crucial in two respects — they provide teachers with a 
resource to which they can refer individual young people whom they identify 
as needing attention, and they work directly with or refer those individuals to 
appropriate sources of assistance. 

An association of school psychologists in Victoria147 told the Inquiry their 
work includes counselling and assisting children at risk; helping students, 
teachers, and parents with problems in the school community; acting as 
behaviour consultants; assisting with strategies for management of aggression 
or lack of motivation among students; and providing professional support both 
to other school staff and to children experiencing emotional and psychological 
difficulties.148 

However, the association also told the Inquiry that 'the future of school 
psychology services in Victoria is uncertain, and the service is likely to 
disappear through natural attrition', due to cuts in numbers and restructuring 
of the service, coinciding with administrative changes to all the State's student support 
services in 1987.149 It also reported the results of a national survey which indicated
 school psychologists throughout Australia were finding it 
almost impossible to respond to the number of requests for their services made 
by teachers, due to a major increase in administrative duties and reductions in 
staff numbers.150 

Human Rights and Equal Opportunity Commission Page 633 

There have also been cutbacks in the number of individuals entering the profession, as 
indicated in evidence from NSW:151 

Across the State, [there are] 1513 students to every counsellor... [Because] Special
 Education schools and classes receive additional allocations, many counsellors in fact
 have over 1800 students in their district. There was a time when the Government asserted
 that a large number of students per school counsellor was unavoidable, [due to] a shortage 
of trained counsellors. In recent years the situation has changed. There is now an excess of
 unappointed new counsellors. The Government's response has been to reduce the numbers of 
counsellors in training... In 1990, there were 36 full-time and 18 part-time counsellors in
 training; in 1991, there were 34 full-time and 18 part-time; and in 1992, there were 29 
full-time and 13 part-time.152 

These cuts amount to a reduction, over two years, from 54 counsellors in 
training to 42. 

The Juvenile Justice System 

If you evaluate the juvenile detention centre populations...what you find is that young 
people in these facilities are about as badly off from a mental health perspective as the 
children who come to our mental health clinics — they are almost transposable. The major 
difference is that one group have committed some sort of offence for which they have been
 apprehended and the other group haven't.153 

Disturbed and mentally ill adolescents often end up in the juvenile justice 
system because no one has been able to recognise or deal with their underlying 
problems.154 This was starkly illustrated by a recent study conducted in the 
South Australian Youth Remand and Assessment Centre (SAYRAC).155 The 
study found that 17 percent of young people in the centre had been living on 
the streets prior to being remanded in custody, another 23 percent had been 
living with friends, and 18 percent had been in institutional care — ie, only one quarter
 of the remanded group (aged 11-17 years) had lived at home before 
being detained. The majority had left school between 13 and 16. According to 
one witness, they were 'unemployable, uneducated kids without any support, 
with multiple handicaps, [for whom] we have to shift the concepts away from 
discipline, to disability.'156 

Reluctance to identify young people as being mentally ill 'leads to them being 
treated in a default system'. Without assessment and an appropriate range of 
intervention services they just 'slip between the cracks of the various systems 
and end up in the juvenile justice system.'157 

The number of young people who have thus been consigned to incarceration 
rather than treatment is in the thousands. 

Page 634 Mental Illness Inquiry 

One would expect that 30-50 percent of the children in correctional facilities would have
a mental health problem — [that is,] young people for whom the separation diagnosis 
[ie the diagnosis made on discharge, release or referral] was a mental health diagnosis.
 We find that incarcerated young people have very similar backgrounds to those of young 
people in psychiatric care — family breakdown, poverty, parents with [problems which 
include] personality disorder, alcoholism, mental illness, or drug abuse.1S8 

Mental health services must also give priority to identifying and protecting 
those young people who have the less common but more serious mental 
illnesses and who are very likely to commit offences if untreated: 

It is important that [there is] a mental health service for these young people to
 provide a safety net for some of the rarer psychiatric conditions [of young people],
 such as schizophrenia, manic depression, or obsessive compulsive disorder, [all of 
which] can lead a young person to offend and which are often not detected in the 
juvenile population, or detected too late for [early] treatment.159 

Lack of Adequate Assessment, Management and Treatment 

At the present time...it costs over $1000 a week to keep a juvenile in custody,
 but most of that expense seems to be taken up with pure custody, rather than 
treatment or diagnosis... Very often, there's a lack of diagnosis when there are
 serious symptoms indicative of some sort of mental illness. ,6° 

The needs of disturbed young people in correctional institutions have largely 
been overlooked in this country161 and are only just beginning to be dealt with 
in some States.162 

With regard to adolescents in custody...a number of studies...have identified that 
approximately two-thirds can be identified as having soft neurological signs, and of 
that group, at least 40 percent have a serious learning disability. Early identification 
of these young people at their first point of entry into the juvenile justice system is
 a very substantial area of need which, if addressed, could provide...considerable 
cost-effectiveness and lessening of suffering, both human and economic.163 

It was clear from evidence presented to the Inquiry that, once a disturbed or 
mentally ill young person is in a correctional facility, or even in a care and 
protection residential centre, they have little chance of receiving assessment and treatment.
 In fact the services appear to be diminishing in some areas: 

Access to specialised mental health services is particularly critical [for] juvenile 
offenders. There has never been, in NSW, a comprehensive mental health service for 
juvenile offenders who are...in either detention facilities or affiliated residential 
facilities... A decade ago, there appeared to be more facilities available — they never 
came anywhere near meeting the need — but there has been a serious contraction in these 
services steadily over the last decade to the point where there are now almost no services;
 yet, at the same time, it is well established that there is an acute need for these mental 
health services.164 

Human Rights and Equal Opportunity Commission Page 635 

The custodial facilities and environment were also described in evidence as 
being potentially harmful, in themselves, to the mental and emotional state of 
the young people detained. 

When young people enter detention, the institution itself may give rise to significant
 mental health problems... Depressed delinquents are a case in point — they often try 
to counter their feelings of depression by seeking exciting, dangerous, daring, illegal 
activities in an attempt to relieve their restlessness and boredom. So it is hardly 
surprising that, when they are incarcerated...if it fosters hopelessness...[they are]
 vulnerable to suicidal depression. A psychologist...has referred to NSW detention centres
 as environments in which hope is crushed.165 

In South Australia, the Youth Remand and Assessment Centre was described 
by one psychiatrist as being 'diabolically designed for young people': 

There is no natural light, the bars are just terrible, and personally, I couldn't
 last more than 48 hours in there.166 

Questions raised during the Sydney hearings canvassed the suggestion that 
psychiatric treatment in correctional or detention facilities compromises the 
correction process: 

There has been a lot of debate about mental health services in detention centres — 
[one view is] that to incorporate mental health services is to cave in to a 'soft option' 
approach. The debate is, in some ways, another enactment of the 'mad versus bad' argument 
about the causes of juvenile delinquency. In my view, this is a total distraction. I don't
 think there is any mental health specialist these days who seriously suggests that the 
primary focus of mental health services in detention centres is to mitigate the offences 
of these young people, but I think they share my belief that juvenile offenders have a 
right to competent mental health care for legitimate mental health needs.167 

The Inquiry was told that young people with diagnosed mental illness who have 
committed offences may be dealt with in a range of different ways by the 
Courts, depending on a number of factors, including chance. If the young 
offender is found guilty of the offence, they may be committed to a juvenile 
institution, where they may or may not receive appropriate care and treatment.
168 Older adolescents may be committed to an adult jail.169 They may be found not guilty
 on account of a mental illness, with varying consequences for the individual's subsequent
 disposition and welfare: 

It depends on the luck of the person... If they are found guilty and directed into a 
humane and informed, competent and caring team, that guilty finding can be worked through.
 On the other hand, if they are found not guilty, [they may be] discharged into the great 
unknown to deteriorate psychologically.170 

Page 636 Mental Illness Inquiry 

The services that do exist vary greatly between States.171 In Western 
Australia: 

In relation to Children's Court services there is currently no equivalent to facilities 
like the Children's Court Clinic in Victoria to provide pre-sentence reports to Magistrates
... There is an inadequate structure for providing psychiatric back-up to the juvenile 
institutions. They do have a small number of psychologists, but there is no specific 
mechanism to allow for a group of psychiatrists and a formal child psychiatric treatment
 team to have regular input to these young people, whom we know are a group at increased 
risk of emotional and behavioural disturbances... Currently, once they are in institutions,
 all they can do is send them to the psychiatric hospital on certificate. And that is 
not an environment where their needs are best understood, or any plan of management 
can be evolved that will be integrated into what they have to go back to [in the 
institutions].172 

In South Australia, the Chairman of the Inquiry opened a unit in mid-1992 
which was developed as a result of growing concern that the psychiatric needs 
of young people in the juvenile justice system were not being adequately met. 
The Forensic Psychiatry Unit, established by the South Australian Child and 
Adolescent Mental Health Service, is a co-operative agreement (with joint 
funding) between that service and the Department of Family and Community 
Services. It provides assessment and treatment services for young people in 
residential facilities operated by the Department, as well as those in juvenile 
detention. 

Youth Suicide 

Statistics 

Adolescent suicide ranks.. .second to car accidents as the most frequent cause of
 adolescent death. The suicide rate for [young] males has tripled in the last ten years...
 The male rate for this age group is between three and five times the rate for females. 
The rate of attempted suicides for females is higher than that for males.173 

In recent years, there has been an alarming increase in the suicide rate among 
adolescents aged over 15. A psychiatrist who specialises in the area of youth 
suicide told the Inquiry: 

The problem of suicide among Australian youth has been rising steadily for 25 years. 
After traffic accidents, it is the greatest killer of Australian young people...
particularly males aged 15-19 and aged 20-24. The rate amongst 15-19 year old males has 
increased from 7.3 per 100,000 population to about 21 per 100,000 in 25 years.
The rate amongst girls has gone up about two-fold.174 

The rate of young people who unsuccessfully attempt suicide has also increased 
greatly: 

Human Rights and Equal Opportunity Commission Page 637 

The rate of attempted suicide has also doubled since 1965 to about 130 per 100,000
 in the 12-15 age group and about 350 per 100,000 in the 16-20 age group.175 

Risk Factors 

The Inquiry heard evidence from a number of child and adolescent psychiatric 
specialists who have been working on identifying factors contributing to the 
increase in youth suicide. One important risk factor is a prior suicide attempt: 

We know that once a young person has attempted suicide, the chance of them attempting 
it again is increased at least five-fold... The majority of young people who attempt 
suicide receive medical treatment only. They attend Accident and Emergency services 
and, because of limited resources and the reluctance of general hospitals to send young 
people to psychiatric hospitals.. .most of these young people are just sent home... 
And their cry for help which the suicide attempt represents goes unheard.176 

Other risk factors for suicide include mental illness or emotional disturbance 
(especially depression); those factors contributing to mental illness listed earlier
 in this chapter; risk-taking behaviour; pressure of societal role expectations 
(particularly in the case of young males); media coverage of other youth suicides; 
and poor education or leaving school early.177 

However, there is no reliable way to predict which individuals will commit 
suicide.178 

Rural Young People 

There is often a major problem of access by suicide attempters to counselling [after 
the attempt]...and the final point is there is no-one there to advocate for them — 
they are an invisible group, a marginalised group. Rural youth suicide victims are...
nearly always psychiatrically disturbed and sometimes identifiably mentally ill... 
Mental illness figures extremely prominently in the list of risk factors. Most of the 
young people who kill themselves are in fact suffering from a psychiatric disorder — 
usually a major depression or a conduct disorder or substance and alcohol abuse, 
and they have been exposed to suicide or have had suicide in their families.179 

The most alarming increase in male youth suicide rates has been in rural areas 
and small towns: 

The rural rates have gone up substantially, particularly in the smaller country towns
 and farming communities. They have gone up about four-fold, from about 1.4 per 100,000
 to about 5.7 per 100,000 in NSW — that's double the percentage of total suicides. 
[The rate in] 15-19 year old males in rural shires has increased five or six-fold over
 the same period.180 

Page 638 Mental Illness Inquiry 

Witnesses emphasised just how vulnerable rural young people are — at the 
same time as being affected by the same compounding factors as urban 
adolescents. 

Rural families have been affected by the economic downturn over the last 25 years,
 which has led to...the decline of small country towns. The problems...include 
chronic unemployment and poverty, lack of local tertiary opportunities, lack of transport
... There is a gap between idealised myths of the bush and the harsh reality of life 
on the land, so that young males really have problems coming to grips with expectations
 and their diminishing actual status.181 

Specific factors contributing to this tragic escalation in rural youth suicides 
include: 

exposure to higher levels of domestic violence and parental alcohol consumption and 
homicide, higher personal alcohol consumption, and ready access to firearms. They 
lack access to health services, including mental health resources, and they face a 
lack of confidentiality [due to the small size of the community] if help is sought.182 

There's tremendous stress on rural families... A key ingredient...is alcohol use... 
Just about everything harmful young people do to themselves they are much more likely
 to do in an intoxicated state.183 

The way the media reports youth suicides was cited as one significant factor: 

Several researchers have studied the effects of media reports on the potential rise
 in suicidal behaviour...and demonstrate a clear causal link. On the other hand, the media 
[could] play a positive role in changing community awareness through programs which provide
 informative material of a health promotional nature.184 

It is barely defensible for the media to continue handling suicide in an insensitive manner
 when there is evidence to suggest that this...may be functioning as a catalyst for other 
young people to suicide. On the other hand, there is little suggestion that carefully planned,
 responsible reporting...of the topic has the same likelihood of contagion.185 

In more general terms, one commentator has pointed to 

the possibility that, behind youth suicide...lies a profound and growing failure
 of the culture of Western industrial societies — a failure to provide a sense of meaning, 
belonging and purpose in our lives, and a framework of values... I believe we are witnessing 
the cultural abuse of an entire generation of young Australians [who are] being culturally
 dispossessed.186 

This perception is supported by much of the evidence presented to the 
Commission several years ago and analysed in the report Our Homeless 
Children.187 

Human Rights and Equal Opportunity Commission Page 639 

Gender Differentials 

There is a significant gender difference in the rates of male and female youth 
suicide, with a heavy predominance of young males committing suicide; while 
the reverse is true for attempted suicide, where young females predominate.
188 There has been insufficient research in Australia to draw informed 
conclusions from these differences. However, it has been suggested that the 
impact on girls and young women of known predisposing factors may be quite 
different from their impact on boys and young men. 

The role of alcohol may be one significant factor:189 

A study of two years of suicides in Western Australia showed that...males were more likely
 to be under the influence of alcohol [at the time of the suicide] than females. Just under
 half of the teenagers and people aged 20-24 years showed positive blood alcohol tests... 
Attempted suicides among youth have also been increasingly linked to alcohol intoxication.190 

However, it has been suggested that use of drugs or alcohol should not be 
viewed as a cause of youth suicide in itself — but rather as symptom of more 
serious underlying problems.191 

Strategies for Prevention, Intervention and 'Postvention' 

Prevention 

Prevention strategies which target youth in general include things like self esteem courses, 
provision of crisis counselling, training of health staff and education staff, setting up peer
 support systems... We need to identify high risk groups like attempters, those who have been 
exposed to suicide or suicidal behaviour, those with associated or cumulative risk factors.192 

Recommended prevention strategies covered a range of areas, including the 
development of media guidelines for reporting youth suicides; access to 
specialised adolescent mental health assessment and treatment services;193 
better liaison between officers of community services and health departments 
to ensure proper assessment of young people;194 data collection from hospitals, 
the police, employment services and other government and non-government 
agencies; and health education and promotion programs. 

Witnesses also advocated increasing rural youth mental health counselling 
services; consulting with general practitioners in rural areas and providing 
additional training for rural health professionals. 

Page 640 Mental Illness Inquiry 

Intervention 

It is hard to know how many of these young people made an attempt to get help. Some of the cases
 we've dealt with...were known to community health facilities, or had made a previous suicide 
attempt which had been registered with the local hospital. [Some] had been to their general
 practitioner, had made a number of contacts within the community. But appropriate help did 
not seem to have been forthcoming.195 


Intervention strategies include emergency hotlines, suicide crisis counselling 
and post-attempt counselling. Witnesses pointed out that people dealing with 
adolescents in crisis need special training in crisis intervention and there
would be benefit in developing hospital protocols, linked to accreditation, for
 the assessment and management of youth suicide attempters.196 

Specific at-risk groups — such as homeless youth,197 young people in 
custody, or those from minority groups — need to be assessed by individuals 
with specialist expertise. A small number of secure residential beds are also 
required for suicidal youth in both metropolitan and rural centres.198 

Critical Incident Counselling 

The term 'critical incident counselling' (or 'postvention') is used to describe 
various strategies employed following a suicide to deal with the aftermath of the death. 
They include supportive counselling for the bereaved, debriefing of 
health workers and members of the police, special debriefing and support for 
school staff and students199, provision of information about community mental 
health resources and, possibly, training in stress management and coping strategies.200 
(A school postvention research study submitted to the Inquiry is 
discussed in the following section on youth suicide research.) 

Responses to the Increase in Youth Suicides 

Concern about the seriousness of youth suicide as a social problem is reflected 
in the large number of reports and conferences on the subject in recent 
years.201 Specialist child and adolescent units have also conducted several 
important studies. 

The Western Australian Department of Health provided the Inquiry with the 
1988 report by the Youth Suicide Working Party.202 Recommendations 
included improvement and extension of treatment services, engaging schools 
and other agencies who deal with young people in preventive work, undertaking 
research and other primary prevention strategies and the implementation of a 
common policy for all hospitals in the management of suicidal young people. 

Human Rights and Equal Opportunity Commission Page 641 


A submission from the Mental Health Branch of the Queensland Department of 
Health dealt with the establishment of the Suicide Research and Prevention 
Program as a response to the problem of increasing youth suicide.203 

The Queensland Department of Health has also recently launched a major campaign204 
aimed at all potentially suicidal people, but specifically targeting 
young males aged 15-24. The rate of death by suicide in this group has for the 
first time exceeded road accident fatalities in Queensland. Strategies introduced 
include a departmental request to all hospital and community health centres to provide
 24-hour facilities for potential suicides and the review of hospital procedures to
 ensure rapid responses to telephone calls or arrivals of suicidal people at hospitals. 

Recent Youth Suicide Research 

The Inquiry received evidence concerning recent research studies covering risk 
factors and prevention;205 diagnostic instruments used to identify depression; 
data collection from coroners; the effects of youth suicide on school classmates,206
 and the possible 'cluster effect';207 as well as an examination of adolescent 
attempted suicides in a juvenile detention centre.208 

The study which examined imitation and the 'clustering' factor in suicides of 
school students found sufficient evidence to suggest there is a real possibility 
for effective prevention, intervention and postvention work. 

The researchers had been providing therapy to a number of friends of Adelaide 
teenagers who had attempted or committed suicide. They retraced connections 
and found 'compelling [indications] that teenagers do imitate their peers'. 
Nevertheless, the study revealed that 

Suicide is a personal affair...and the teenagers...were depressed and had suicidal
 thoughts... In most cases...[they had] a troubled home life with a particular crisis
 triggering the act. The suicide or suicide attempt does not come out of the blue.209 

However, the most sobering outcome of the team's work with young people 
was the finding that: 

Increasingly, teenagers believe that suicide is simply a reasonable option, to be
 chosen or not, when circumstance demands.210 

This research has demonstrated that in a closed school community, effective 
postvention work can be done to identify vulnerable adolescents, and to provide 
special care, counselling and therapy — necessary processes which the 

Page 642 Mental Illness Inquiry 

researchers conclude may 'help curb...the spread of a pseudo-normality — an 
apparent acceptance by adolescents of suicide as OK'. 

A national research study of youth suicide211 is expected to report in 1993. 

Appropriate Responses 

Priorities for Service Provision 

While it is difficult to establish service priorities when services are either 
inadequate or non-existent, a number of witnesses identified specific priority 
areas. 

Community centre-based services 

Many witnesses emphasised the need for intensive psychiatric care facilities or 
services for young people and their families: 

Many child and family mental health problems are best dealt with in...facilities
 in their local community. However, approximately 10 percent of children and 
families presenting for psychiatric assistance need intensive assessment and/or 
treatment, either as day patients or inpatients. Prevalence and incidence studies
 indicate that, for every million total population, there is a requirement for one
 intensive child psychiatry treatment facility offering 
approximately 10 inpatient and up to 20 day patient places.212 

Teenagers with major psychiatric illnesses like schizophrenia and manic depressive
 psychosis... [have] needs which are very special... Whilst I think the absolute
numbers for a population like Perth do not justify a specific unit, there is a need
 for some [special service] — perhaps a team — in one of the general hospitals that
 could have other input from educational authorities to help these young people.213 

Another proposal — to use existing adolescent psychiatric beds in the private 
sector — was advanced by an expert witness in Adelaide: 

There is a private hospital in South Australia for children and adolescents with 
about 30 beds. We at the Adelaide Children's Hospital have been trying for about 
two years to get the Government to rent four or five public beds there. We could 
provide the medical services, they could provide the hostel services [cooking, l
aundry, etc] because it's ridiculous to duplicate such things. That would be a 
good public-private mix. Unfortunately.. .no decision has been made. I believe that
 place will close within the next couple of months because, financially, it cannot 
exist. [Neither] the private or the public [facilities] can exist separately. A 
city of one million people just can't support a private system and a public system
 for adolescents — you have to bring them together in some sort of partnership — 
there's nothing wrong with that, it's perfectly reasonable. But I believe the private
 hospital will close, and we will lose that. What will happen then is that there 
won't be any private adolescent beds, so the [private] patients will come to the 
Adelaide Children's Hospital.214 

Human Rights and Equal Opportunity Commission Page 643 

In addition to acute admission facilities for young people with serious 
psychiatric disorders, the Inquiry was told that major centres also need 
medium-stay residential facilities for mentally ill or disturbed adolescents who 
need transitional treatment and accommodation between hospital and home. 

In Tasmania the Inquiry was told: 

[There is a need for] something that is specifically designed around adolescent needs
 that is seen by young people themselves as being therapeutic care for them specifically.
 I think that would remove a lot of the trauma associated with both the psychiatric 
visits to these clinics and also to the times when they have to be hospitalised... 
The ideal vehicle to drive that facility [would be] the Child and Adolescent Unit — 
it already deals with children on a day-to-day or visit-by-visit basis. It would seem
 a pretty natural extension for it also to take over responsibility for residential and
 therapeutic care as well.215 

The Need for Inter-Sectoral Collaboration 

Great improvements in the care and treatment of psychiatrically affected adolescents 
could be made by the joint management of cases by services such as schools, medical 
and welfare services. Currently, there appears to be buck-passing, to the detriment of
 the children.216 

We have no residential facilities with trained staff that offer therapeutic programs for 
dolescents... There would need to be collaboration, understanding and commitment from many 
departments, including Education, Community Services, Mental Health and Police departments.217 

The necessity for effective coordination and co-operation between the various 
agencies which are, or should be involved in the integrated care of children or 
adolescents' psychological, psychiatric or other disturbances was a consistent 
theme in evidence presented to the Inquiry. 

However, even where there is consensus that services must be coordinated, the 
Inquiry heard that many individual workers and agencies have repeatedly been 
frustrated in their efforts by the strength of traditional bureaucratic boundaries,
 and have found that achieving a functional model of coordinated service provision is
extremely difficult. When a coordinated approach was cited in evidence, so was the necessity
 to train staff from non-mental health agencies: 

One to 2 percent of children [would be] expected to be referred to child psychiatric 
facilities. Others receive help from a wide range of other facilities...which also cater
 for emotionally and behaviourally disturbed [children]... A number will be managed by 
the Department of Youth and Community Services, the Education Department, and services
provided by Anglicare, Centacare, and other community drop-in centres. One of our tasks
as a Child and Adolescent Psychiatry Unit is to find ways to make available our collective
 expertise so that it can be utilised by those other agencies. 

Page 644 Mental Illness Inquiry 

Our greatest difficulty has been to set up a formal process of secondary consultation with 
other Government departments such as the Department of Community Services and the Education
 Department. We have attempted to break down the barriers between agencies... But it seems 
that no sooner do we seem to be forging some links with workers in those departments than 
the structure changes — workers move on and we are back to square one again. There is a real 
need for liaison from administrators in the three departments to coordinate the process of 
secondary consultation.218 

One example of the difficulty government departments have in sharing 
important resources (even information) was given by a witness in Devonport: 

At a recent meeting we asked the Department of Youth and Community Services for a simple 
[list of] the people who worked in the Department in the Devonport area — their names and 
[their jobs] — because that gives us an avenue to tap into. [The answer was] that some
pamphlets would be provided in March or April of next year... Quite often, several agencies 
will be dealing with the same person. It is quite possible for a child to walk around until
 they find the agency that gives them the answers they want... On the very rarest of occasions 
do these agencies actually get together to work the case through and provide a...referral
 where one person is in charge of that person's treatment.219 

Such bureaucratic inefficiency and obstructionism is obviously unnecessary; 
when the lives and futures of children are involved it is inexcusable. 

Evidence to the Inquiry suggested that many existing services fit the individual 
into the area provided by their own programs, effectively disaggregating the 
child's problems into only those elements which they are equipped to deal with, 
but not viewing and treating clients as an integrated whole. 

Relatively few children are seen by child and adolescent facilities, compared to the number
 expected to be in need of assistance. There is very little cross-referral to more appropriate 
services — that is, inter-agency co-operation — which suggests that people are attending the 
appropriate service the first time; that services offer a sufficiently wide range of appropriate 
interventions; or that services fit people into the service they provide.220 

The deleterious effects of enforced bureaucratic segregation of professional 
functions were emphasised in evidence by a Perth child psychiatrist: 

There has recently been restriction on the capacity of psychologists within the education system
 to provide formal cognitive and other psychological assessments. This has thrown a tremendous 
burden on the health system, with people being referred to...Princess Margaret Hospital primarily 
for educational assessments... This throws an unreasonable [cost] burden on families, because 
there are not any Medicare rebates for psychological assessment... Unless these families go on
 expending substantial amounts of money, they get an incomplete assessment of complex interacting
 problems... Another anomalous situation regarding health care refunds [is that] there are rebates 
for general practitioners for doing family therapy, but not for psychiatrists to do family therapy.221 

Nor are there rebates for appropriately trained psychologists! 

Human Rights and Equal Opportunity Commission Page 645 

Examples of Successful Service Collaboration 

Evidence about inter-sectoral collaboration was not universally negative. 
Initiatives have been taken in some centres to facilitate the involvement and cooperation of
 relevant departments and agencies. 

The Inquiry was advised about several government initiatives, such as the South 
Australian interdepartmental program for dealing with suspected cases of child 
abuse222 and the Troubled Youth Support Service in Western Australia. This 
is a joint Commonwealth-State initiative in which the Health Department, the 
Drug and Alcohol Authority and several non-government agencies provide an 
integrated preventive health service to young people.223 (The Child Protection 
Council interagency guidelines in NSW have already been mentioned.)224 

Research 

There is a glaring lack of resources in the research area [for] child and adolescent psychiatry...
 In terms of the research budget, [it] receives even far less than does adult psychiatry.225 

In addition to research into youth suicide, important areas requiring research 
in child and adolescent mental illness include vulnerability to disturbance and treatment approaches.226 

Several witnesses also advocated research into service-level requirements for 
future resource planning: 

We need [to know] what are the minimum community service requirements in these 
areas... We work in the dark — we really have no idea of the base level requirements for our student
 population and no idea what provisioning of an adequate program for these children is either... 
I am arguing for a better and healthier framework in which the existing resources can be delivered.
 If we have to cut up the same cake, then I am suggesting that the youth portion of it should be 
better than 5 percent.227 

Another key area clearly justifying significant research resources concerns 
factors in the development of psychosis in mid to late adolescence. 
A Model Research Program 

The Early Psychosis Research Centre was recently established in Victoria228 
to research first-episode and recent-onset functional psychosis, particularly 
schizophrenia. The Centre will focus on prevention in high-risk groups; early 
case detection and intervention to minimise the severity of a disorder; and 

Page 646 Mental Illness Inquiry 

evaluation of the effectiveness of the Centre's prevention and intervention programs — 
particularly with patients experiencing their first psychotic episode. 

Conclusion 

Evidence to the Inquiry on the status of mental health services for children and 
adolescents demonstrated that there are few areas where adequate services exist, 
and access to them is limited. Several very promising programs have been 
initiated since the Inquiry began. However, the overwhelming picture is one of 
inadequate funding, inadequate provision of facilities, inadequate staffing, 
inadequate training of health and other workers, inadequate inpatient care, inadequate 
community and home-based care, inadequate coordination between agencies, inadequate knowledge,
 inadequate research, inadequate data collection and inadequate commitment to the establishment
 of prevention and intervention 
services. 

All these deficiencies are compounded in access and service provision for 
Aboriginal and Torres Strait Islander young people; for those living in rural and remote areas;
 for children and adolescents from non English speaking backgrounds; and for children and 
adolescents with dual or multiple disabilities. The human rights of disturbed and at-risk
 young Australians are being seriously denied by such glaring omissions, with often tragic 
consequences for the individuals and families involved and for our entire community. 

Human Rights and Equal Opportunity Commission Page 647 

1. Prof Bruce Tonge, Faculty of Child Psychiatry, Royal Australian and New Zealand College 
of Psychiatrists and Head of the Centre for Developmental Psychiatry, Monash University.
 Oral evidence, Melbourne 9.4.91, p242. 
2. John Gardiner, clinical psychologist, Warwick Child and Adolescent Clinic, Western Australia.
 Submission, pi. 
3. Dr Aidene Urquhart, Director of Child Psychiatry, Mater Children's Hospital, Brisbane.
 Oral evidence, Brisbane 16.8.91, pl683. 
4. Tonge, op cit, p235. 
5. H M Connell, L Irvine, and J Rodney, 'Psychiatric disorder in Queensland primary schoolchildren,'
 Australian Paediatric Journal vl8, 1982, ppl77-180. Two other child prevalence studies are: M Rutter
 and P Graham, 'Psychiatric disorders in ten and eleven-year-old children', Proceedings of the 
Royal Society of Medicine v59, 1966, pp382-7; and M Sawyer, A Sarris, P Baghurst, C Cornish, and
R Kalucy, 'The prevalence of emotional and behaviour disorders and patterns of service utilisation
 in children and adolescents', Australian and New Zealand Journal of Psychiatry v4, 1990, pp323-30. 
6. Royal Australian and New Zealand College of Psychiatrists, Psychiatric and Social Treatment 
Facilities for Adolescents, 1984, p4. 
7. Tonge, op cit p237. 
8. ibid, p238. 
9. The Epidemiological Catchment Area Study was undertaken by the National Institute of Mental Health 
in five US cities in 1981-1985. It measured prevalence in an identified 'catchment' area, 
administering Diagnostic Interview Surveys to the entire population of the area — thus removing 
the common problem of having to rely on people who come to the attention of service agencies and
 having no measure of those people who never seek attention for mental health problems. DA Regier,
 JK Myers, M Kramer et al, 'The NIMH Epidemiological Catchment Area Program: Historical context, 
major objectives and study 
population characteristics,' Archives of General Psychiatry v41, Oct 1984. 
10. M Sawyer, D Meldrum, B Tonge, and J Clark, Mental Health and Young People, (Report to the 
National Youth Affairs Research Scheme), Research and Evaluation Unit, Child and Adolescent
 Mental Health Service, Adelaide Children's Hospital, 1991, pl4. 
11. Tonge, op cit, p235. Professor Tonge put the number at between 1 and 2 percent. 
12. Eg Sawyer et al, op cit. 
13. Prof Robert Adler, Director, Child and Family Psychiatry, Royal Children's Hospital, Melbourne.
 Submission, pi: 'Very few children are affected by mental illnesses such as schizophrenia.. .
or manic depressive psychosis.' Also Rosemary Nairn, Phillip Clinic Child and Adolescent Service, ACT.
 Submission, pi: 'Developing a full-blown mental disorder under the age of 17 is relatively rare,
 whereas behavioural disturbance is more common and may or may not lead to or be symptomatic of 
a serious disorder.' 
14. See, for example, A E Kazdin, 'Childhood depression', Journal of Child Psychology and Psychiatry 
(UK) v31 Nol, 1990, pl35. 
15. Rosemary Laver, Australian Psychological Society. Oral evidence, Hobart 12.11.91, pl72. 
16. Connell et al, op cit. 
17. Prof Beverley Raphael, Professor of Psychiatry, University of Queensland. Information provided to the Inquiry. 
18. Nairn, op cit, p2. 

Page 648 Mental Illness Inquiry 

19. Prof Brent Waters, Head of the Department of Child and Adolescent Psychiatry, Prince of Wales 
Children's Hospital. Oral evidence, Sydney 17.6.91, p23. 
20. Parliament of Victoria, Social Development Committee, Young People at Risk, First Report upon 
the Inquiry into Mental Disturbance and Community Safety, 1991, pp63,4,6. 
21. B Waters and J Brennan, 'Child and Adolescent Psychiatry: Psychiatric Syndromes of Childhood'. 
In P Beumont and R Hampshire (eds), Textbook of Psychiatry, Blackwell 
Scientific Publications, Melbourne 1989, pl86. 
22. Kazdin, op cit, pi49: 'Increasingly [it is found] that children may meet criteria for more than 
one disorder, a phenomenon referred to as co-morbidity. For example, epidemiological studies have found that,
 among children and adolescents who meet criteria for a psychiatric diagnosis, approximately half also
 meet criteria for at least one other disorder as well. Many disorders are known to co-exist, including,
 for example, conduct disorder and attention deficit hyperactivity disorder... Studies have shown that
 depression and 
anxiety are often related and that children who have one of these disorders often meet the criteria
 for the other as well; even in cases where they don't meet the diagnostic criteria, they are likely 
to show symptoms [of] the other disorder.' 
23. Dr Stephen Morgan, psychiatrist, Clare House Child and Adolescent Psychiatric Service, Tasmania. 
Oral evidence, Hobart, 11.11.91, p96. 
24. See also Chapter 16. 
25. Laver, op cit, pi75. 
26. id. 
27. Gardiner, op cit, p2. 
28. Dr. Marie Bashir, psychiatrist and Director, Community Health Services, Central Sydney Area Health 
Service. Oral evidence, Sydney 20.6.91, p497. 
29. ibid, pp497,498,503. 
30. Assoc Prof Joseph Rey, Director, Rivendell Child, Adolescent and Family Services, Royal Prince Alfred
 Hospital, Sydney. Oral evidence, Sydney 18.6.91, p247. 
31. Anne Greener, consumer, NSW. Oral evidence, Sydney 20.6.91, p519. 
32. Bashir, op cit, p502. 
33. Adler, op cit, pi. 
34. Bashir, op cit, p497: 'Often, a serious medical aspect of their condition [adolescents with behaviour
 disturbance] is not recognised. On the other hand, sometimes it is misdiagnosed.' Stephen Pinkus, 
clinical psychologist, Clare House Child and Adolescent Psychiatric Service, Hobart. Oral evidence, 
Hobart 12.11.91, ppl75,6: 'The special problems of children in relation to mental illness involve, 
firstly recognition of children with difficulties... Children with problems often go unrecognised; 
[even] in situations in which there are primary indicators of risk factors, children's problems are 
rarely addressed.' 
35. These 'high risk factors' are matters of correlation, and are not necessarily causal. 
36. As mentioned earlier in this chapter, schizophrenia, major depressive illness and manic depression
 together affect at least 1 percent of young people. However, they account for approximately only one
 tenth of the mental health difficulties of young people warranting specialist professional treatment. 
37. Raphael, op cit. 
38. Sometimes now referred to by education and health professionals as 'attention deficit disorder' 
or 'attention deficit-hyperactive disorder' (ADD). 

Human Rights and Equal Opportunity Commission Page 649 

39. Rey, op cit, p249. 
40. ibid, pp247,248. 
41. Dr John Dingle, Assistant Director, Department of Psychiatry, Princess Margaret Hospital for Children.
 Oral evidence, Perth 10.2.92, p26. 
42. Urquhart, op cit, p2, and oral evidence, Brisbane 16.8.91, ppl688,89,91. 
43. J Mathias, 'Cycles of violence and abuse', in Breaking Out: Challenges in Adolescent Mental Health 
In Australia, National Health and Medical Research Council, Canberra 1992, pl08: 'There is no standard 
definition of abuse... Child abuse has been defined by the National Committee on Violence as the 
physical and psychological damage experienced by children and adolescents resulting from the abusive 
behaviour of a person in trust or authority. This definition therefore includes physical, emotional 
and sexual abuse, as well as neglect.' 
44. Australian Family Law Council, Child Sexual Abuse, AGPS, Sept 1988, pp7,8. The report cites a landmark 
1966 paper by US researchers Heifer and Kempe, 'The Battered Baby Syndrome', published in the American 
Medical Journal, claiming for the first time publicly that caregivers, including parents, harmed children 
in their care. These claims were 'greeted with shock and denial, which gradually gave way to acceptance 
of the reality of child physical abuse and neglect... The same shock and denial greeted reformists when 
they first began to say that adults, including caregivers, were also sexually abusive to their 
children... The community has been reluctant to acknowledge that child sexual abuse occurs, and not 
infrequently... It is no longer possible to deny this phenomenon... The taboo about acknowledging 
[it] has been broken down by sheer weight of evidence for its existence as...medical practitioners, 
social scientists and reports from adults molested as children began to reveal what they had found.
 The cost to society is only just being counted... Victims are over-represented in mental institutions,
 prisons, drug and alcohol programs and amongst 'street kids'. The effects of abuse are of short-term 
and long-term duration and are usually devastating for the child and family.' 
45. Abused Child Trust, Queensland. Submission, attachment A, pi. 
46. Nairn, op cit, pl58. 
47. Mathias, op cit. 
48. Raphael, op cit. 
49. L Young, Physical Child Neglect, National Committee for the Prevention of Child Abuse, Chicago, 1986, pi. 
50. id. 
51. KOates, Child Abuse and Neglect: What Happens Eventually ?, Brunner Mazel, New York 1986. This study 
includes case studies of Australian children and describes the effects of abuse or neglect. 
52. Young, op cit, ppl,3,7. '[Neglected] children are deprived of the physical care and protection that
 normal human growth requires. Because their plight is the result of inaction, they are easily overlooked
 until the severity of the neglect shocks adults around them into recognition... Children of severe neglect
 sometimes die as a result - of malnutrition, of accidents, of fire. Most of them survive; but they are
almost inevitably psychologically 'starved', since severe neglect is so often accompanied by emotional 
indifference that is nearly total... Even in the more moderately neglecting families, there is often not a 
dependable routine, so a baby cannot know exactly when he or she will be fed, it will not be soothed and 
comforted and will become apathetic. The apathy cloaks an anxiety that would otherwise be intolerable.
 
Page 650 Mental Illness Inquiry 

53. Dr Terry Heins, psychiatrist, Phillip Child and Adolescent Clinic, Canberra. Oral evidence, 
Canberra 18.3.92, pp37,44. 
54. Urquhart, op cit, p2, and oral evidence, Brisbane 16.8.91, ppl687-91. 
55. ibid, ppl689,90. 
56. P Mulhearn, social worker, Child Protection Service. Oral evidence, Adelaide 21.10.91, p43. 
The Child Protection Service is a multi-disciplinary service attached to the Child and Adolescent 
Mental Health Service in Adelaide. It comprises clinical psychologists, social workers, doctors and 
nurses who liaise with staff from Family and Community Services, the police, and therapists from the
 Child and Adolescent Mental Health Service. It assesses children and young people who are suspected 
of having been physically, emotionally or sexually abused, or victims of neglect. Where assessments 
confirm the existence of abuse, 
or therapy is recommended for the child, the appropriate referrals are made and parents are provided 
with the opportunity to get help to modify their abusive behaviours. This is particularly important, 
because many abusive parents who were abused themselves as children did not receive any acknowledgment
 or assistance to break the cycle. The client is listened to, supported and respected in the process of 
assessment — which may have a therapeutic function in itself for the young person. 
57. Christine Flynn, Policy/Administration Director, Mental Health Coordinating Council, New South Wales.
 Submission, plO. 
58. Mandatory reporting of suspected child abuse is also being considered in Victoria. 
59. NSW Child Protection Council, Interagency Guidelines for Child Protection, Sydney, 1991. 
The guidelines delineate the roles and responsibilities of agencies involved in protecting children 
who have been or are at risk of being abused, including the Departments of Health and Community Services,
 the Police, the Courts and relevant non-government agencies. The guidelines were developed by the Child 
Protection Council to facilitate case management by the agencies concerned. 
60. Patrick Marwick, senior social worker and Head of Clinical Services, Warwick Child and Adolescent
 Clinic, Perth. Oral evidence, Perth 10.2.92, p97. 
61. Prof Robert Kosky, Professor of Child Psychiatry, University of Adelaide at the Children's Hospital.
 Oral evidence, Adelaide 21.10.91, pl40. 
62. Cathy Caust, administrator, Southern Child and Adolescent Mental Health Service, Adelaide. 
Oral evidence, Adelaide 21.10.91, pp 15,16. 
63. Dr Stephen Allison, psychiatrist, Southern Child and Adolescent Mental Health Service, Adelaide.
 Oral evidence, Adelaide 21.10.91, p20. 
64. id. 
65. Morgan, op cit, p97. 
66. Prof Beverley Raphael, Professor of Psychiatry, University of Queensland. Information provided 
to the Inquiry. 
67. Liaison psychiatry is the term used to describe the practice by a consultant psychiatrist of 
providing psychiatric assessment and referral (where appropriate) of people with physical illnesses,
 injuries or conditions and who may have concurrent mental health needs. 
68. Kosky, op cit, pl41. 
69. For example, Clare House in Hobart; Phillip Clinic in Canberra; Avoca Clinic in Sydney; 
Arndell and Rivendell in Sydney, which both provide inpatient services for emotionally and 
behaviourally disturbed young people, as well as non-resident child and family therapy; child and 
family mental health services or departments affiliated with or attached 

Human Rights and Equal Opportunity Commission Page 651 

to children's general hospitals, such as those in Melbourne, Adelaide and Brisbane; and a number of 
others providing a range of child and family therapy services. 

70. Rey, op cit, p242. 
71. See, for example, Pinkus, op cit, pl75. 
72. Tonge, op cit, p237. 
73. M Brakey, Principal, Ulverstone High School, Tasmania. Oral evidence, Devonport 14.11.91, p452. 
74. Tony Blackwell, Coordinator, Link Youth Health Service, Hobart. Submission (attachment), pi. 
75. Pinkus, op cit, pi75. 
76. G Mason, Youth Suicide in Australia: Prevention Strategies, Report of a study commissioned by 
the Commonwealth Youth Bureau of the Department of Employment, Education and Training, conducted by 
the Australian Institute of Criminology. Canberra 1990, pl59. 
77. Morgan, op cit, p96. 
78. ibid, p97. 
79. ibid, pp96,97. 
80. Dr Graham Martin, Clinical Director, Southern Child and Adolescent Mental Health Service, Adelaide.
 Oral evidence, Adelaide 21.10.91, p58. 
81. Tonge, op cit, p236. 
82. Nairn, op cit, p(i). 
83. Allison, op cit, pl8. 
84. Dingle, op cit, pl9. 
85. Senior Constable Helen Adams, Community Policing Squad, Victoria Police. Oral evidence,
Melbourne 9.4.91, ppl89,193. 
86. Dr William Bor, RANZCP, Queensland Branch. Oral evidence, Brisbane 15.8.91, p 1599. 
87. This was the situation in April 1991. 
88. Tonge, op cit. 
89. Name withheld, psychiatrist. Oral evidence in private hearing. 
90. Raphael, op cit. 
91. Bor, op cit, pl598. 
92. ibid, pl597. 
93. Adams, op cit, ppl89,191,193. 
94. Pinkus, op cit, pl73. 
95. Allison, op cit, pi8. 
96. Morgan, op cit, p99,104. 
97. ibid, pp98,99. 
98. Kosky, op cit, pl40,148,149. 
99. Dingle, op cit, pp21,22. 
100. ibid, p451. 
101. Urquhart, op cit. pl683. 
102. A Chair in Child Psychiatry was established at the University of Western Australia at the end of 1992.
 See Chapter 7 — Developments Since the Inquiry Began. 

Page 652 Mental Illness Inquiry 

103. Tonge, op cit, p239. 
104. Kosky, op cit, pl45. 
105. Bor, op cit, pl597. 
106. Dr David Lord, RANZCP (Western Australian Branch). Oral evidence, Perth 11.2.92, pl48. 
107. R Hearn, Locked Up, Locked Out: The Denial and Criminalization of Young People's Mental 
Health Crisis, Victorian Community Managed Mental Health Services Inc, Melbourne March 1993, p41.
 This report refers to a survey conducted in co-operation with Victorian Police which found that: 
'Police do need more training in...working with this group... 83.5 percent of the [police] respondents
did not think they knew enough about mental health problems to work effectively with [young people]... 
Communication with the target group appears to be the major area of need... Training could [also] be 
useful in relation to working with aggressive behaviours.' 
108. B Raphael, 'Psychiatry at the coal-face', Presidential address to the 1986 Annual Congress 
of the RANZCP, in Australian and New Zealand Journal of Psychiatry v20 1986, p324. 
109. Bashir, op cit, pp497,8. 
110. Morgan, op cit, p98. 
111. Kosky, op cit, pl38. 
112. Dr Aidene Urquhart, Brisbane. Information provided to the Inquiry after the close of formal hearings. 
113. Bor, op cit, pl595. 
114. Jennifer Luntz, President, Coalition of Child and Adolescent Mental Health Professionals. 
Oral evidence, Melbourne 8.4.91, p38. 
115. Waters, op cit, p25. 
116. Brakey, op cit, p451,454. 
117. Dingle, op cit, ppl9,20. 
118. Hearn, op cit, p21. 
119. Jenny McCulloch, Secretary, School Crisis Intervention, Tasmania. Oral evidence, Devonport 
14.11.91, pp453,4. 
120. Dingle, op cit, pi9. 
121. Neil Rees, President, Mental Health Review Board, Victoria. Oral evidence, Melbourne 8.4.91, p25. 
122. Dr David Wells, Director, Office of Forensic Medicine, Victoria. Oral evidence, 
Ballarat 11.4.91, p603 
123. Adams, op cit, pl90,198. 
124. Newcastle Herald, 2 July 1992, pi, 'Mentally ill boy, 12, locked up like a criminal';
 and Newcastle Herald, 10 July 1992, p3, 'Hunter working team seeks to avoid repeat of 
anguish to mentally ill child.' 
125. Prof Vaughan Carr, who also gave evidence at the Newcastle hearings of the Inquiry. 
126. Dr J Cubis, psychiatrist. Oral evidence, Canberra 18.3.92, p47. 
127. J Krupinski and G Burrows, 'Mental Health Promotion: Policy Strategies for Australia'.
 Survey commissioned by the Australian National Association of Mental Health (ANAMH)
and the Mental Health Foundation. Included as an appendix to ANAMH's submission to the Inquiry. 

Human Rights and Equal Opportunity Commission Page 653 

128. Bashir, op cit, p501. 
129. Rey, op cit, pp243,6,7. 
130. Waters, op cit, ppl5-16. 
131. Rey, op cit, p249. 
132. Dingle, op cit, p20. 
133. Marwick, op cit, pp94,95. 
134. Heins, op cit, p37. 
135. See, for example, Jenny McCulloch, op cit. 
136. Brakey, op cit, p451,452. 
137. Bor, op cit, pl595. 
138. id. 
139. ibid, pl596, quoting survey undertaken by the Queensland Advisory Council on Special
 Education Needs Working Party. 
140. Heins, op cit, p39. 
141. Human Rights and Equal Opportunity Commission, Our Homeless Children: Report of the 
National Inquiry into Homeless Children, AGPS, Sydney 1989, p273. 
142. A Bain, 'Issues in the suspension and exclusion of disruptive students', Australasian 
Journal of Special Education vl2 No2, 1988, pp 19-24. 
143. Nairn, op cit, ppl57-60. 
144. Gardiner, op cit. The US has federal legislation (public law 94-142) specifying criteria
for categories of students who need special education and providing for special funding for this group. 
145. Heins, op cit, p38. 
146. Nairn, op cit (submission), pi 1. 
147. Gordon Walker, Ailsa Drent and Mardi Whitla, Australian Guidance and Counselling 
Association, Victoria. Submission. 
148. ibid, pi. 
149. ibid, Appendix C, ppl,2. 
150. ibid, pi. 
151. Lenore Grunsell, Secretary, School Psychologists Australia Inc, NSW. Submission, pi. 
152. id. 
153. Waters, op cit, p21. 
154. Bashir, op cit, p497. 
155. The Centre is for young offenders under 18 and is administered by the South Australian
 Department of Community Welfare. The study compared adolescents from two-parent families 
attending Adelaide child and adolescent psychiatric clinics with a group of 78 young offenders 
held in the remand centre. Reported in: RJ Kosky, MG Sawyer, and JC Gallant, 'Adolescents 
in custody: Hidden psychological morbidity', Medical Journal of Australia vl53, 2 July 1991, pp24-27. 
156. Kosky, op cit, pl43. 
157. Danny Sandor, youth worker. Oral evidence, Melbourne 9.4.91, ppl77,8. 
158. Waters, op cit, pp21,29. 
159. ibid, pp21,22. 
Page 654 Mental Illness Inquiry 

160. Peter Nordan, Brosnan Centre Youth Service, Catholic Prison Ministry. Oral evidence, 
Melbourne 9.4.91, pp288,9. 
161. R Kosky, 'Adolescents in custody: A disciplining or a disabling experience?' in
 Breaking Out: Challenges in Adolescent Mental Health In Australia', National Health and Medical
 Research Council, Canberra 1992, pl32. 
162. For example, the Victorian Department of Health and Community Services commenced 
a reorganised and upgraded range of psychiatric and psychological services to juvenile justice 
clients in February 1993. Also, see below regarding the Forensic Psychiatry Unit for Children
 and Adolescents opened in 1992, by the South Australian Government. 
163. Bashir, op cit, p501. 
164. Waters, op cit, p20. 
165. id. 
166. Kosky, op cit, pl44. Prof Kosky also states in 'Adolescents in custody' (op cit, endnote 160),
 pl33: 'Current youth detention centres are ugly, austere and psychologically brutalising... 
The opposite is needed: centres to provide pleasant, comfortable, warm and nurturing environments. 
167. Waters, op cit. 
168. Robin Gurr, President, NSW Council of Social Service. Submission, p2. 
169. Dr Yvonne Skinner, psychiatrist. Oral evidence, Sydney 8.7.91, p670 
170. Bashir, op cit, p506. 
171. In February 1993, the Victorian Department of Community Services and Health 
reorganised psychiatric and psychological services to juvenile justice clients, including 
assessment and treatment functions in youth training centres, and access to child and adolescent 
psychiatric services for those in juvenile justice facilities. These services are, it is claimed,
 to be integrated into a comprehensive health service, with specialist resources. The Children's 
Court Assessment Service will be restructured. 
172. Dingle, op cit, pp20,21,25. 
173. G Martin, M Clarke and C Pearce, 'Adolescent suicide: Music preference as an indicator 
of vulnerability', Unpublished paper, 1992, pi. 
174. Dr Michael Dudley, psychiatrist, Avoca Clinic Child and Adolescent Service, Prince of Wales
 Hospital, Sydney. Oral evidence, Sydney 18.6.91, pl98. 
175. Tonge, op cit, p238. 
176. id. 
177. M Dudley, B Waters, N Kelk, and J Howard, 'Youth Suicide in New South Wales: Urban-Rural Trends,
1964-1988,' in S McKillop, Preventing Youth Suicide, Conference Proceedings, Australian Institute of
 Criminology, Canberra 1990, ppl7-35. The study analyses official suicide statistics for young people 
aged 10-19 in NSW from 1964-88, noting increases in firearm suicides particularly in rural areas. 
Prof Waters and Dr Dudley both gave evidence at the Inquiry's hearings in Sydney. 
178. R Goldney, 'The prediction of suicide', in Preventing Youth Suicide, op cit, pp49,50. C Cantor,
 'Suicide and community psychiatric care', Paper presented to the 16th Annual Symposium, RANZCP — 
Social and Cultural Section, Townsville, 26-29.9.91, pp2,3. 
179. Dudley, op cit. 
180. id. 
181. A Patience, in Breaking Out: Challenges in Adolescent Mental Health in Australia, National
 Health and Medical Research Council, Canberra 1992, pp44-60. 

Human Rights and Equal Opportunity Commission Page 655 

182. Dudley, op cit, pl98. 
183. Waters, op cit, p28. 
184. Report of the Youth Suicide Working Party, op cit, ppl3,15. 
185. Mason, op cit, ppl44-147. This report suggests guidelines for responsible media reporting, 
some of which include references to suicide as 'an unnecessary and tragic means of resolving...
problems, emphasising that help is available...[including] where such assistance can be obtained.
' The report also makes reference to guidelines developed by the RANZCP in its 1989 submission to
 the Australian Broadcasting Tribunal, stating: 'Guidelines should discourage repeated or 
romanticised coverage of suicide... Depiction of the method [used] should also be discouraged.' 
186. R Eckersley, 'Failing a generation: The impact of culture on the health and wellbeing of 
youth', Paper presented to the Australian Rotary Health Research Fund Fifth International 
Conference, Adolescent Health Behaviour: Identifying Vulnerability and Resilience, Canberra, 11-14.11.92, pp3,6,18. 
187. Our Homeless Children, op cit. 
188. One possible explanation for the higher rate of attempted suicide by young females 
and completed suicides by young males is the effectiveness of the more direct and violent 
methods chosen by males. I Hayward, R Moyle, B Hart and V Gardner, 'Availability of method 
and suicide rates', Report of the Youth Suicide Working Party, op cit, Appendix 4.4, p63: 
'More males (approximately 45 percent Australia-wide) under 20 years and 2024 years use firearms. 
The under 20 year age group's next most preferred methods are hanging, poisoning by solid or 
liquid substances and carbon monoxide poisoning. Females in these two age groups used 
[poisonous substances]...most often.' 
189. Dudley, op cit, p202. 
190. Hayward et al, op cit, p67. 
191. Mason, op cit, p42. 
192. Dudley, op cit, pl99. 
193. Waters, pp20,22. 
194. Dr Dudley described this area as 'a shambles... We have to provide the workers with supports.
 Supervisory processes haven't been set up, or they've only been set up very piece-meal.' 
195. Waters, op cit, p28. 
196. Dudley, op cit, ppl99,202,3. 
197. The Homeless Children's Inquiry and other studies have clearly established that homeless 
young people are at very high risk. In a 1989 survey conducted by the Salvation Army, 34 percent
 of homeless young women and 17 percent of homeless young men had attempted suicide. 
198. ibid, p203. 
199. This aspect of postvention is particularly important. Young people close to the individual
 who has suicided need assistance to come to terms with their loss and to help them overcome any
 consequent guilt, anger or depression. 
200. Mason, op cit, pl34. 
201. eg Preventing Youth Suicide, op cit; St Michael's Uniting Church, Preventing Suicidal 
Behaviour in Young People, Melbourne 1992; Centre for Adolescent Health, Youth Suicide Prevention,
 Melbourne 1992; Australian Association for Adolescent Health, 1990 Biennial 

Page 656 Mental Illness Inquiry 

Conference, Future Shock into Future Health, Workshop: 'Teenage Suicide — What Can We Do?' Perth, 1990. 
202. Report of the Youth Suicide Working Party, op cit. 
203. Dr Christopher Cantor, Director, Suicide Research and Prevention Program, Queensland 
Department of Health, Mental Health Branch. Submission, ppl-4. 
204. 'Driven to Suicide', Sunday Mail, Brisbane, 8 Nov 1992. 
205. Report of the Ministerial Task Force to Review Child and Adolescent Psychiatric Services
 in Western Australia, Department of Health, Perth, 1993, p2; and G Martin and S Waite, 
Parental Bonding and Adolescent Suicide, Child and Adolescent Mental Health Service, Flinders
 Medical Centre, South Australia. Paper provided to the Inquiry by the authors. 
206. Two recent South Australian studies examined the effect on adolescents of the suicide 
of another student: One study looked at a school where two young people had suicided. It 
found that adolescents with pre-existing depression or a preoccupation with suicide may be 
at high risk of 'copy cat' suicide: G Martin, N Kuller and P Hazell, 'The effect on adolescents
 of the completed suicide of another student', Youth Studies Australia, Autumn 1992, pp20-22. 
The other study was conducted in an Adelaide school after the suicide of a teenage girl. 
In this study it was those who were already depressed and had suicidal thoughts, or those 
who had already attempted suicide, who were apparently influenced by 
the death to actively imitate. G Martin, 'Adolescent suicide: Postvention in a school', 
Youth Studies Australia, Autumn 1992, pp24-27. 
207. G Martin, 'Adolescent Suicide: Imitation and the Clustering Phenomenon', Youth Studies Australia,
 Autumn 1992, pp28-32. 
208. The study at the Longford Remand Centre in Perth examined the incidence and nature of serious
 suicide attempts made by adolescents. The 12 young attempters were all male and ranged in age 
from 11 to 17. Four were Aboriginal. The study found that in this group family breakdown had
 been chronically stressful: most of the subjects had either been in foster care or institutions. 
Seven had experienced physical violence from caregivers, but none reported sexual abuse. 
Nine of the twelve had been living with relatives or friends or on the streets. Few received 
visits from families while detained. Eleven of the twelve suicide attempters had histories of 
some level of alcohol and drug use. Eleven of the 
twelve had been charged with a violent offence, but only a quarter of non-suicidal detainees 
had been so charged. Three quarters of the group had made a previous suicide attempt. In five cases, 
the preceding circumstances were similar — occurring after an angry confrontation with staff, 
followed by isolation. 
209. Martin, op cit ('Adolescent Suicide: Imitation and the Clustering Phenomenon'), p32. 
210. ibid, p32. 
211. The National Health and Medical Research Council has established a task force, chaired 
by Dr Peter Baume, to examine issues related to youth suicide nationally. 
212. Urquhart, Submission, p2. 
213. Dingle, op cit, ppl8,19,20. 
214. Kosky, op cit, pl49. 
215. Brakey, op cit, p455. 
216. Libby Steeper, Convenor, ACT Council of Social Services. Submission, p2. 
217. McCulloch, op cit, pp453,456-7. 
218. Morgan, op cit, pp96-99. 
219. Brakey, op cit, p452. 

Human Rights and Equal Opportunity Commission Page 657 

220. Pinkus, op cit, ppl74-5. 
221. Dingle, op cit, p22. 
222. Peter Mulhearn, social worker, Child Protection Service, Southern Child and Adolescent Mental 
Health Service, Adelaide. Oral evidence, Adelaide, 21.10.91, p45. 
223. Western Australian Department of Health, Submission (including Report on the Troubled 
Youth Support Service, and Report of the Ministerial Task Force to Review Child and Adolescent
 Psychiatric Services in Western Australia), p3. 
224. See endnote 59. 
225. Tonge, op cit, p239. 
226. Rey, op cit, p249. 
227. Brakey, op cit, p452. 
228. The Early Psychosis Research Centre in Melbourne was opened by the Inquiry Chairman in July 1992. 

Page 658 Mental Illness Inquiry 

Chapter 21 

PEOPLE WITH DUAL AND MULTIPLE DISABILITIES 

There is a huge number of intellectually disabled people who receive no treatment for their
 psychiatric disorder because it is not available.1 

Many thousands of Australians who suffer from mental illness are also affected 
by some other disability. While there are many forms of 'dual disability', 
evidence presented to the Inquiry predominantly focussed on four areas — the 
difficulties confronting individuals with psychiatric problems in addition to an 
intellectual or sensory disability; the problems of people with mental illness 
compounded by a substance abuse disorder; the effect of brain injury on mental 
health; and HIV/AIDS related psychosis. 

Dual diagnosis is a really big problem area. It's not just a problem area with intellectual
 disability and mental illness. It is a problem with drugs and alcohol. It is a problem with 
people who have sensory disability. It is certainly a problem with people who have a physical
 disability. There are no services targeting [the needs of these people].2 

Mental Illness and Intellectual Disability 

Expert evidence from several psychiatrists emphasised the important but widely 
unrecognised phenomenon that people who are intellectually disabled3 are more 
likely than the non-disabled to experience mental illness:4 

Two percent of the population is intellectually handicapped and the prevalence of mental illness
 in that population is — depending on the study — between 30-50 percent, so one is looking at 
around 1 percent of the population.5 

This is an extremely large number of Australians — between 100,000 and 
170,000. 

One of the difficulties associated with treating people who have an intellectual 
disability and suffer from mental illness is that: 

[While] a number of psychiatric disorders in the intellectually disabled area are the same as
 [those in] general psychiatry, there are some special areas which do not fall easily into
 the normal classification system.6 

Mental ill health also often results from a variety of factors which particularly affect 
the intellectually disabled. These include 'lack of friends, not having a 

Human Rights and Equal Opportunity Commission Page 659 

valued social role, not having a job and not having a home'.7 The Intellectual 
Disability Services Council of South Australia told the Inquiry that: 

If significant emphasis were given to resolving these issues, we may see fewer people 
actually having to become riders on the mental health merry-go-round'.8 

Psychiatric difficulties confronting many intellectually disabled people are 
compounded by a scandalous shortage of appropriate psychiatric services. 

There are almost no mental health services for disturbed people with developmental
 disabilities. It is quite appalling... It is not because of a lack of will on behalf
 of the developmental disabilities people who desire these services. There has never
 been adequate provision of such services.9 

Evidence to the Inquiry by psychiatrists familiar with intellectually disabled 
patients established that their needs are often ignored because they fall between 
two areas of service delivery: non-psychiatric services which cater specifically 
for people with disabilities — and services which provide expert psychiatric care 
but are unfamiliar with the needs of the intellectually disabled. The Intellectual 
Disability Services Council of Victoria told the Inquiry that this division of services
 leads to further disadvantage10 because the client is treated as if the 'two 
conditions are mutually exclusive'.11 

Several psychiatrists presented evidence concerning the negative effects of this 
'compartmentalisation': 

The psychotic complications of the intellectually handicapped can usually be handled 
in a relatively straightforward way and can be managed. [However] the chronic problems 
relate more to intellectual [disability]... I will say, 'Yes, we will treat this person'
...but that is going to be a matter of two to three weeks. We then run into the problem 
of who is going to be responsible for the continued management when the family is no 
longer able to cope. That is where the arguments often get acrimonious... The problem 
is that we have ended up with carve-ups which have been done for administrative reasons
 and the patients, 
reasonably of course, refuse to fall into the pigeonholes that we use.12 

Since the Inquiry began the Commonwealth and the States have (in July 1991) 
entered into the Commonwealth-State Disability Services Agreement. This 
Agreement is aimed at improving service delivery to people with disabilities, 
and reducing the kind of administrative confusion and 'pigeonholing' referred 
to above.13 Under the Agreement, State and Territory governments assume 
responsibility for accommodation and all other support services for people with 
a disability. The Commonwealth government retains responsibility for employment under
 its Disability Services Program, and both levels of government retain responsibility 
for advocacy services.14 

Page 660 Mental Illness Inquiry 

In November 1991 the Commonwealth also introduced the Disability Reform 
Package, which is aimed at providing a more effective system of income 
support payments for people with disabilities and facilitating the involvement 
of disabled people in open employment.15 

However, several witnesses, in evidence concerning reforms to disability services
 and their impact on people with intellectual and psychiatric disabilities, 
claimed that the process disadvantages people with dual disabilities: 

The vocational programs administered under the Disability Services Act fail 
to recognise that many [intellectually disabled] persons also suffer mental disorders.
 Currently the vocational programs are only funding those persons who are employable
in open employment and withdrawing funding from other vocational programs who provide 
a more supportive environment. It is obvious to parents, workshop managers and 
professionals in the field...that persons with both developmental disability and 
mental disorders will not be able to achieve productivity in open employment... 
Many parents have shared with me their great anxiety of the threatened withdrawal 
of Commonwealth finance to work and activity facilities for disabled persons with 
extra support needs on account of [their] mental illness. A concept of the so-called 
least restrictive alternative must also consider the most advantageous alternative.16 

Similar concerns were also expressed by Australian Parent Advocacy, a non-government 
organisation advocating for the intellectually disabled: 

Persons with a joint intellectual/psychiatric disability are not being fairly treated
 in the process of implementation and devolution of the Disability Services Act (DS A)...
 evidence proves that the severely and multiply disabled are being left out of the 
process of empowerment being created by the DSA. There is a distinct gap in services
 and money for the multiply disabled — because the nature of their disability requires
 massive amounts of support — and this support costs dollars.17 

The Inquiry was told that dual or multiply disabled people can be disadvantaged 
in accessing appropriate disability services because of the criteria used to assess
 the level of their disability. The manager of a sheltered workshop for intellectually 
disabled people in Newcastle, for example, gave evidence that her clients had to be
 diagnosed as 'moderately to severely' disabled in order to obtain government assistance.
However, they are only assessed on the level of their intellectual disability and not for
 psychiatric disability. This poses difficulties for people who are mildly intellectually 
disabled but are also affected by a psychiatric disability. While the extent of their
 intellectual disability may not affect their ability to work in open employment, the
 psychiatric disability can make unsupported employment extremely difficult or impossible: 

[For example I had a client]...who was assessed as having mild intellectual disability but
 [he also] has very distinct psychiatric problems. He lived independently and was not coping.
 I tried to find some assistance through Disability Services...[but they said] he was 

Human Rights and Equal Opportunity Commission Page 661 
too high functioning...this young man eventually ended up being quite suicidal because 
I was unable to find criteria he fitted to get support.18 

I go home very frustrated and worried that I am encouraging people to utilise their 
rights but without the support systems to back that up... I feel that we are encouraging
 people to do wonderful things on the one hand but we are setting them up for failure on the other...19 

The lack of specialist services leads to what one psychiatrist described as errors of
 both 'omission' and 'commission'.20 Errors of omission occur because of a lack of 
specific services for people with mental illness and an intellectual disability.
 Errors of commission, on the other hand, include:21 

the inappropriate use and indiscriminate use of medication in an attempt to control 
[the patient's] behaviour because other people cannot manage it. [T]his is not to say
that intellectually disabled people should not receive medication: many of them should 
and do not. My view is that they are receiving medication inappropriately, not based on 
proper diagnosis and assessment.22 

Such inappropriate use of psychiatric medication was described by another 
psychiatrist as a 'chemical straitjacket'.23 

In addition to evidence about the misuse of medication, the Inquiry heard 
allegations that intellectually disabled women living in psychiatric hospitals 
were being sexually abused. (This evidence has subsequently been corroborated 
in Victoria by the Inquiry into Aradale hospital.) 

When the issue was raised among staff [the response] was that she is on Depo Provera
 so it is not a worry... [In other cases] women have been sexually abused by practitioners
 or other staff, or indeed male clients, and they have been labelled as manipulative or
 having personality disorders and therefore not to be believed.24 

This evidence illustrates the extreme vulnerability of intellectually disabled 
patients. The Intellectual Disability Services Council of South Australia 
presented evidence that more scrutiny is necessary to 'ensure that there are 
adequate ways in which people [can] have their conditions reviewed within 
psychiatric hospitals'.25 The Council suggested that organisations such as the 
Office of the Public Advocate have an important role to play in such a process. 
In addition, the involvement of carers and relatives is particularly important: 

We have found that in the area of intellectual disability the continued involvement of
 families, friends and advocates has been a powerful force to deal with many of the
 injustices that can otherwise creep into any service system.26 

It is clear from evidence presented to the Inquiry that the professional distinction
 between medically-based services and rehabilitation and support services 

Page 662 Mental Illness Inquiry 

must be effectively addressed if the needs of patients with both intellectual and 
psychiatric disabilities are to be met and their rights respected. Appropriate professional 
training is one critical area. 

[In addition] there has not been a program of training mental health professionals,
 or people with a mental health focus, to go into this kind of work. [We need to address]
 the huge problem of the lack of trained staff to specialise in this area.27 

The Inquiry was told that there is, at least in one State, a precedent for joint 
service provision to people with intellectual and psychiatric disabilities. Since October 1990: 

In NSW both health and welfare and disability services accept joint responsibility
 for people with both developmental disability and mental disorder... [A] number of
 responsibilities are delineated for each service. Although this does not solve the 
problems of inadequate expertise and inadequate service, it at least enables the first 
step to be taken and that is to go beyond the position of both services saying 
'it's not our problem'.28 

This policy was expressed in a directive by the Directors General of the 
Departments of Health and Community Services, in which staff were informed 
that 'persons with developmental disability who have a psychiatric disturbance 
are the joint responsibility of [both Departments] and priority in management 
in both Departments is given to persons with more serious conditions'. The 
policy sets out procedures for client management and specifies the particular 
responsibilities of each Department — as well as their joint responsibilities. 
The Inquiry was told that this new approach to service delivery is monitored by 
joint regional committees comprising representatives from each Department — 
and that it has been successful and could be easily implemented in other States 
and Territories.29 

Since the Inquiry began there have been several other developments aimed at 
improving training among psychiatrists in relation to the needs of people 
affected by mental illness and intellectual disability. The Royal Australian and 
New Zealand College of Psychiatrists has recently increased its requirements 
to ensure that prospective fellows have more adequate knowledge about this 
area. The College's examination process will also be changed to reflect this 
initiative. The NSW Institute of Psychiatry also advised the Inquiry that it will 
enhance programs to include intellectual disability and mental illness. 

Notwithstanding these developments and promises, evidence to the Inquiry 
established there is an urgent need for academic research, increased clinical 
expertise and substantially increased resources in this much neglected area of 
dual disability. In the United Kingdom there are seven full university chairs in 
the psychiatry of intellectual disability and 'a greater number of junior 

Human Rights and Equal Opportunity Commission Page 663 

positions.30 In Australia, by contrast, there are currently no academic positions 
'solely devoted' to this area of expertise.31 

Mental Illness and Substance Abuse 

The dual diagnosis of mental illness and substance abuse covers two overlapping 
but distinguishable groups of individuals: 

One subgroup has, [under] DSM-III-R, both a major substance abuse disorder and
 another major psychiatric illness. The other subgroup uses alcohol and/or other
 drugs in ways that affect the course and treatment of mental illness.32 

The Inquiry received little evidence from the individuals directly affected. 
However expert evidence and recent overseas research clearly indicate that 
mental illness compounded by substance abuse is a major problem. One of the 
largest studies of the causes and prevalence of mental illness and chemical 
addiction is the United States Epidemiological Catchment Area study.33 This 
survey of 20,000 Americans found that 47 percent of individuals with a drug 
or alcohol problem also reported that they suffered from some form of mental 
illness.34 Although no quantitative research of this kind has been undertaken 
in Australia, expert information available to the Inquiry suggests that the 
prevalence of mental illness and substance abuse in our population would be 
comparable to if not similar to that found in the United States.35 

Although diagnoses of substance abuse and mental illness may be related, they 
are also quite distinct and may require quite different types of treatment. 
Research undertaken both in the United States and Australia has established 
certain commonalities in relation to people with mental illness who also have 
substance abuse problems. Mental illness can, for example, lead to alcohol and 
drug dependence when clients resort to self-medication to control the symptoms 
of depression and other affective disorders. Conversely, psychiatric disorders 
can result from the abuse of alcohol and other substances.36 Psychiatric 
symptoms can thus contribute to the tendency to use drugs, while substance 
abuse can accentuate psychiatric symptoms.37 

Notwithstanding these recognised links, evidence to the Inquiry established that 
there are very few services available to effectively treat individuals affected
 by both mental illness and substance abuse disorders: 

Attention needs to be given to people with specific problems such as [dual diagnosis].
 There need to be specific services for people [with mental illness and chemical addiction]
 — with staff who are trained adequately to deal with people who have those dual problems.
 At present such patients fall between services with the mental health service saying, 
'well, look, really they have got an alcohol problem: it is not for us, it is more for you; 

Page 664 Mental Illness Inquiry 

and the alcohol services saying 'it is really a mental health problem, not their
 alcohol'. I think there ought to be a designated service.. .attached to the mental
 health services...[with staff who are] specially trained to deal with the unique
 problems of that particular group.38

The evidence also indicated a serious lack of communication and integration 
between the mental health system and substance abuse services. In both of our 
largest States the Inquiry was told that many people with a dual diagnosis 'fall 
through' the gaps in the health care system because mental health services are 
unwilling to admit them due to their chemical addiction, and detoxification 
centres and other organisations treating substance abuse are unable or unwilling 
to provide treatment for the mentally ill: 

If somebody with a psychiatric disability has a drug problem and is on medication,
to try and get them into a detoxification centre is impossible because detox centres 
will not take anyone on medication...[and] to try to get anyone with a drug problem
into an accommodation service designed for psychiatrically disabled people...is almost impossible.39 

The main problem in the area of dual diagnosis appears to be... the lack of communication
 between the mental health and drug and alcohol fields... As a result of this division, 
services in both fields are unclear as to who should take responsibility for dealing
 with the dual diagnosis patient.40 

Expert evidence to the Inquiry indicated that in the past, mental health 
professionals tended to avoid 'patients who show hazardous or harmful drug 
use'.41 Similarly, drug and alcohol services are often unaware that a client's 
disturbed and erratic behaviour may be due to mental illness, not just substance 
abuse. In fact, experts generally agreed that it can be extremely difficult to tell
 which symptoms are due to substance abuse, and which may be due to a 
psychiatric problem. 

Psychiatric services and services for alcoholism and drug addiction have 
different philosophies and approaches to treatment.42 For example, mental 
health workers generally aim for an assertive follow-up model, pursuing clients 
if they miss an appointment. In drug and alcohol services there is a greater 
reliance on self motivation, which can inadvertently — but seriously — 
disadvantage mentally ill clients.43 For many drug and alcohol services, 
helping a client abstain from any form of substance use is a primary goal. This 
can obviously create major difficulties for people with mental illness and 
substance abuse problems, who may depend on psychiatric medication for their 
mental health and stability.44 There are also fundamental differences of 
professional opinion, both within and between services, as to whether substance 
abuse is a cause or a symptom of psychopathology and how it should be 
treated.45 

Human Rights and Equal Opportunity Commission Page 665 

There is a clear correlation between substance abuse and the development of 
certain affective disorders and other mental illnesses, particularly among 
adolescents.46 To illustrate the complexities which sometimes characterise this 
connection, one psychiatrist presented the case history of a young man whose 
mother had manic depressive illness and had been hospitalised frequently over 
many years. The boy had started using, growing and selling marijuana during 
the first few years of high school. He continued to get into trouble at school 
and with the police and was sent for regular therapy sessions — to no avail. 
The psychiatrist told the Inquiry: 

We [the therapist and other professionals] believed that his use of marijuana on a 
daily basis, more than once a day, was in fact quite deleterious to his mental
 health and we believed that unless we could get him off the marijuana we did not
 have a fair chance of working with the boy or getting him to settle into any kind
 of therapeutic relationship... I believe he has major mental health problems and
 he probably has the early beginnings of the illness very similar to his mother, 
and he is attempting to deal with it in his own way by using marijuana.47 

The Inquiry also examined the preliminary results of a survey undertaken by 
the same psychiatrist, which indicate that adolescents who use drugs such as alcohol,
 marijuana, LSD and analgesics, are more likely to experience depression and suicidal thoughts. 

While the evidence presented to the Inquiry was often anecdotal, it is reinforced by 
recent research which indicates that mental illness and substance abuse are significant 
problems for many adolescents. Researchers have suggested two major reasons for this.
 First (as set out in Chapter 20), many of the major 
mental disorders have their onset in adolescence; and second, drug and alcohol 
use is generally high among adolescents.48 

Witnesses from non-government agencies gave evidence that many people with 
dual diagnosis are not receiving any assistance for their addiction or their 
mental illness: 

There has been considerable administrative confusion and 'buck passing' over service
 responsibility for people with alcohol/drug abuse and mental health problems. The end
 result is often that these people receive no treatment or service and often end up 
in the homeless population.49 

According to expert evidence such individuals are frequently 'severely disorganised people,
 usually extremely poor, [who] have disrupted or chaotic relationships, few social supports
 and are very unhealthy physically'.50 This may account for the high incidence of this
 particular dual disability in the homeless population. A recent study undertaken in the 
American city of Baltimore found 'a high prevalence' of mental illness and alcohol and 
substance abuse disorders 

Page 666 Mental Illness Inquiry 

among the homeless compared to the general population.51 The authors 
concluded that the comorbidity of mental health and substance abuse problems 
reflects the 'disaffiliation' of the homeless population. (As detailed in Chapter 18,
 the homeless are one of the groups least likely to obtain assistance for psychiatric
 and other problems.) 

Evidence to the Inquiry indicated that the high incidence of mental illness and 
substance abuse among the homeless is partly related to the fact that people are 
not able to obtain treatment because they are not in a stable enough environment 
to keep appointments or to detoxify. The chief executive officer of 
Hanover Welfare Services (an organisation which provides support services to 
homeless people in Melbourne) told the Inquiry that his organisation is not 
equipped to deal with people with dual diagnosis. Nevertheless, the organisation's 
workers regularly have to deal with difficult clients like 'James' who have nowhere else to go: 

'James' displays erratic and self destructive behaviour. He is socially isolated,
 withdrawn and therefore vulnerable to exploitation. He has had contact with a wide
 variety of health services and accommodation and welfare agencies. James has had
 multiple psychiatric admissions and treatments, multiple public hospital admissions 
and [has participated in] multiple drug and alcohol treatment programs. There has 
also been some police intervention.52 

The situations of people like James illustrate the dilemma faced by service 
providers who have to choose between providing accommodation to people with 
dual diagnosis who are disruptive to other clients, and protecting the rights of 
other residents to a safe, secure environment. 'The weight of this decision is 
enormous' and it is not appropriate for generalist services to be dealing with 
it.53 It was suggested to the Inquiry that these problems indicate the urgent 
need for a closer interaction between mental health and drug and alcohol 
services: 

Health and welfare agencies are not adequately equipped to assist people who suffer 
multiple problems, and whose behaviour is particularly disruptive. We have found that
 there is often a lack of service delivery coordination between agencies dealing with 
the one individual. This can be compounded by the failure of major health services to 
work in a way that enables them to reach the homeless person in their own environment...
 We believe that hospitals and clinics need to make a greater effort at tailoring more 
flexible service delivery methods that will meet the particular needs of psychiatrically
 disabled individuals who also suffer from significant alcohol or drug dependence.54 

A submission by the Western Australian Council of Social Service effectively 
summarised recommendations made by many witnesses who called for a more 
integrated approach to people with mental illness and substance addictions: 

Human Rights and Equal Opportunity Commission Page 667 

[There is] a need for the integration of services, including the designation of a
 'primary care' worker (regardless of discipline of agency) to be responsible for 
the complete care of a person. The coordination of services was seen as being achieved 
by establishing a single service based on consultative contact and closer liaison between 
the various agencies servicing the needs of the same clients. Emphasis was placed on the 
importance of adopting a holistic approach to treating people and that all agencies should
 consider themselves part of a team and accordingly coordinate all treatment.55 

Mental Illness and Deafness 

To be totally deaf is like having a thick panel of glass between oneself and the world.56 

There are no precise figures available on the number of Australians who are 
deaf. However, approximately 17,000 (0.1 percent of the population) are 
profoundly deaf57 and the most recent research available indicates that one in 
seven Australians is hearing-impaired.58 Definitions of deafness vary — but 
deafness is not the same as hearing impairment: 

It is best not to confuse hard of hearing or hearing impaired people with deaf and 
deafened people because the kind of communication problems the latter face are quite
 different from those of the hearing impaired.59 

Many in the deaf community have a distinct culture and language which differ 
from those of-the dominant hearing culture and people who experience marginal 
hearing loss.60 Evidence was presented that most people who are profoundly 
deaf can be described as 'prelingually deaf'61 (that is, individuals who suffered 
hearing loss at a very early stage of childhood development and whose hearing loss
 has precluded the acquisition of normal language skills). People who are prelingually
 deaf usually use sign language.62 

The Inquiry was told there are two major issues facing deaf people in relation 
to mental illness; both involve communication. First, deaf people are sometimes 
mistakenly perceived as being mentally ill by hearing relatives and professionals 
because of difficulties in communication. Evidence to the Inquiry established that 
hearing people sometimes perceive deaf people's behaviour as 'abnormal' or 'dysfunctional' 
because it is different.63 Second, evidence was presented that mental health staff 
sometimes fail to communicate effectively with deaf patients, which has resulted in
 mistaken diagnosis and inappropriate treatment. 

Deaf people may appear to be affected by mental disorder when in reality [they may] 
under severe stress and — unable to express themselves verbally — exhibit what is 
perceived by hearing people as being unusual or socially unacceptable behaviour.64 

Evidence presented to the Inquiry also indicated that during adolescence deaf 
young people may exhibit behaviour problems as they 'act out' their frustration 

Page 668 Mental Illness Inquiry 

and anger and seek to assert their independence from their hearing parents. 
This can lead to conflict in the family as parents attempt to assert their 
authority, and the deaf adolescent resists their control. Sometimes these 
difficulties lead to an act of violence on the part of the adolescent and subsequent 
intervention by community services and/or the police. The Inquiry was 
told that it is at this stage that 'young deaf people are particularly vulnerable to 
referral abuses':65 

Most youngsters remain in an unaltered domestic environment in which further infringements
 are inevitable. Re-offending leads either to police involvement as a deterrent, 
[or] the administering of tranquillisers or admission to a hospital psychiatric ward for
 observation.66 

[I am] aware of young deaf people who have been subjected to harrowing experiences of
 restraint, admission and periods of incarceration [in a psychiatric institution]
without fully understanding the events, without representation and being discharged 
believing themselves to be or believed by others to be, mentally unstable.67 

It is difficult to estimate the number of deaf people who may also suffer from 
a diagnosable mental illness. However, the Queensland Deaf Society told the 
Inquiry that there are approximately 6,500 prelingually deaf people in 
Queensland. The Deaf Society was aware of 14 clients in the Brisbane 
metropolitan area who were receiving services from mental health professionals.
68 The Victorian Deaf Society, which presented data on contacts with 
clients who required assistance with mental health problems, estimated that 
during the 1990-91 financial year a total of eight working weeks were spent 
dealing with deaf clients who were also experiencing mental illness.69 

Ignorance about deafness can have extremely serious consequences. 

One of the main reasons for admissions of deaf people to psychiatric hospitals was 
'impulsive, aggressive behaviour'... A large number of deaf patients in some hospitals 
were considered 'subnormal' until careful diagnostic review showed that there was no
 evidence to support this view. In fact it can be difficult, even for psychiatrists 
with an understanding of deaf people and an ability to communicate with them to make 
a diagnosis at times. The main factors for this difficulty include the combination of
 mental disorder, communication difficulty, lack of language sophistication, and the 
effects of hospitalisation.70 

Difficulties associated with treating deaf people who are also mentally ill were 
illustrated in a case study presented to the Inquiry by the parents of a deaf man
 who started exhibiting disordered and violent behaviour as an adolescent: 

[Our son] was born profoundly deaf, the victim of rubella... His early life was
 one of great frustration and suffering, but in spite of this, he was a loving 
and loved member of the family... In his late teens he became difficult to direct 
and advise. Attempts to control 

Human Rights and Equal Opportunity Commission Page 669 

him were met with physical response and life with him was now a strain on the family...
 He [also began exposing himself in public]. His breakdown mentally was to follow and
 was the beginning of the past 14 years in and out of hospital.71 

This man has spent many years in and out of the psychiatric system. He first 
received psychiatric treatment after attempting suicide and subsequently became 
increasingly disturbed and violent towards his family. While his parents 
recognised the need for their son to receive specialised inpatient care, they 
believed that his condition has deteriorated as a result of his experiences in 
psychiatric institutions. 

The Inquiry heard allegations concerning inappropriate treatment by medical 
staff, with serious consequences which could have been avoided if steps had 
been taken to communicate effectively with patients and understand their 
disability. In one instance a nurse entered a ward and told the patients to get 
out of bed. One man, unable to hear, kept sleeping. The nurse interpreted this 
as disobedience and struck him.72 This incident was not isolated. Evidence to 
the Inquiry indicated that hospital and medical staff frequently failed to consider
 the deaf man's disability in their interactions with him. Staff regularly talked to 
him even though they knew he was deaf and doctors did not explain the nature of the
 treatment and what was happening to him.73 

As the evidence presented throughout this report indicates, the experience of 
mental illness is often terrifying and isolating. This is certainly the case for deaf
 people whose sensory isolation compounds the problem. While there is no 
excuse for the kind of behaviour described above, the Inquiry was told many 
mental health professionals are unaware of the particular needs of deaf people: 

Ninety-nine percent of professionals, including mental health workers, are unaware of
 the differences between the deaf and the hearing. Their image of a deaf person is 
based on their contact with the post lingually deaf... who can comprehend English; 
can lipread, can communicate orally and do have [the same] cultures and norms as 
hearing people. [To them], a deaf person is no more than a hearing person with 
blocked ears. Significant cultural and language factors are regrettably not part of 
the diagnostic and intervention equations in mental health.74 

There is no doubt that involvement of interpreters for the deaf and other 
communication strategies can make a major difference to the quality of care and 
the prospects of recovery or rehabilitation. 

We believe many of these problems could have been alleviated had [our son] been given 
counselling by a psychiatrist or at least had an interpreter present to communicate 
for him. In spite [of our many representations] he has had no counselling, 
occupational therapy or an interpreter. Only once in the last six years has an 
interpreter been present at an interview between him and a doctor.75 

Page 670 Mental Illness Inquiry 

Clearly, the effective treatment of mental illness depends on effective communication
 between clinicians and patients: 

It is this very area of communication that causes so much anxiety and frustration for
 people who are deaf.76 

Equally clearly, improved communication and consultation are essential if the 
rights of deaf Australians to appropriate services are to be ensured. 

The issue is the provision of appropriate services that will enable the language 
and cultural differences of the deaf community to be taken into account when
 professionals are working with deaf clients who have a mental illness.77 

Mental Illness and HIV / AIDS 

Evidence presented to the Inquiry identified two general dimensions associated 
with mental illness and AIDS. First, serious mental illness can be precipitated 
or caused by infection with the Human Immunodeficiency Virus (HIV).78 
Second, people who have a pre-existing mental illness which impairs their 
judgement may be particularly vulnerable to HIV infection because they may 
be more likely to engage in high risk sexual or drug taking behaviour.79 

Recent research in Australia and overseas has identified a number of affective 
and organic mental disorders associated with AIDS. When diagnosed with 
AIDS, many individuals experience 'adjustment' disorders, including 
depression, changes in self esteem and suicidal ideation. These forms of illness 
are generally treated in the same way as other affective and mood disorders — 
using anti-depressants if necessary, and individual and group therapy.80 

The major organic disorder associated with AIDS is AIDS dementia complex 
(ADC). This 'complex' refers to a range of symptoms that can result from the 
later stages of the syndrome. These include progressive cognitive change and 
deficits in cognitive functioning, which are often accompanied by motor and 
behavioural disturbances.81 

The NSW Health Department has estimated that in that State, 20 percent of 
people with ADC/AIDS have significant neuropsychiatric impairment which 
diminishes their ability to perform activities of daily living.82 Dr Neil Buhrich,
 Coordinator of the Sydney Inner City Mental Health Service, presented several
 case studies of AIDS patients who had developed psychoses as a result of ADC,
 'with symptoms indistinguishable from those observed in the functional 
psychoses'.83 Individuals affected require psychiatric assessment and are 
sometimes prescribed psychotropic drugs to treat their psychotic symptoms.84 

Human Rights and Equal Opportunity Commission Page 671 

The Inquiry was also told that many people with a mental illness such as 
schizophrenia are at increased risk of developing AIDS: 

In persons with schizophrenia, social skills and social judgement are seriously
 impaired. Sexual contact and needle use may be quite chaotic. Education concerning
 safe sex practices and drug usage may be ignored or not be properly understood.
 One of the problems here is that the progression from HIV infection to full AIDS
 takes many years... During that time, the patient may have many unprotected sexual
 contacts and many dirty needle exchanges.85 

It is unclear how many people with mental illness are also infected with HIV, 
because no research has been undertaken in this area. However, the Inquiry 
heard evidence that between 1-5 percent of the inpatients at one major 
hospital's psychiatric clinic are, or are likely to be, HIV seropositive.86 This 
figure is much higher than the incidence in the general population. 

The evidence clearly indicated that people with a dual diagnosis of mental 
illness and AIDS can be difficult to care for because their psychiatric illness 
may impede their judgement, making them more likely to engage in risk taking 
behaviour.87 The Inquiry was also told that it is extremely difficult to find 
appropriate placements for mentally ill people who have AIDS and engage in 
high risk behaviour which puts other members of the community at risk of 
contracting HIV. There are currently four options available for placing these 
patients, none of which is 'a good solution'. First, they can be admitted to 
hospital. Second, they can be charged and brought before a magistrate. Third, 
they can be placed in a hostel. Finally, as Dr Buhrich put it, '[the] option is
 to ignore the problem. But at what cost?'88 

Each of these options is problematic. Many people with mental illness and 
AIDS may not need psychiatric care, but still require suitable accommodation 
in the community — an option which may put other residents in shared 
accommodation at risk because of erratic behaviour. Legal proceedings are also 
unlikely to benefit these individuals or achieve any change in their behaviour. 
Dr Buhrich suggested that one way of ensuring appropriate care and a stable 
environment for these clients is to provide special residential facilities with
 24hour medical and psychiatric care.89 The Inquiry would also support the use 
of liaison-consultation psychiatry for people undergoing treatment in specialised 
facilities for AIDS or AIDS-related illness. 

Head Injury 

The Inquiry also studied evidence concerning the incidence of mental illness 
among the many thousands of Australians affected by head injury. While there 
is little recent research in Australia, United States evidence suggests that up to 

Page 672 Mental Illness Inquiry 

60 percent of head injured individuals subsequently suffer serious depression 
or other significant mental health problems or emotional disorders — often as 
a result of cognitive impairment or dysfunction.90 

The Inquiry was told that while head injury is not confined to any particular 
group in the community, it is frequently young people who are affected: 

[Head injury] is complicated by the onset of adolescence, resulting in frustration, 
anger, withdrawal and acting-out behaviours. For the young adult, just beginning to 
establish him/herself as an individual, head injury means becoming dependent on family 
members, loss of employment, loss of friendships/relationships, loss of skills, 
loss of income. It means boredom, frustration, anger, confusion...91 

The confusion and frustration which often accompany head injury can result in 
emotional outbursts and violent behaviour towards family and friends. As the 
young person 'acts out' their frustration, family problems develop and the 
police sometimes become involved; this can aggravate the problem: 

These [domestic] incidents are usually inappropriately labelled and the young person
 subjected to police and psychiatric intervention that only serve to exacerbate the 
situation and lock the person into a system that cannot offer appropriate assistance.92 

Depression is also common after head injury. As individuals come to terms 
with the nature of the injury and its impact on their lives, they experience a 
profound sense of loss. In this context, anxiety and depression are understandable. 
However, research indicates that in some people this reaction develops into a depressive
 illness requiring treatment by a psychiatrist.93 

The Inquiry was told that one of the major difficulties associated with treating 
head injury patients is the lack of appropriate services for supported accommodation,
 crisis intervention, ongoing support and behaviour management 
programs for individuals suffering behaviour disorders, and counselling for 
family and friends.94 

Conclusion 

Clearly, Australians suffering dual or multiple disabilities are among the most 
vulnerable and disadvantaged in our community. It is a disgrace that for some 
of these groups there are pathetically few appropriate services available. 

Human Rights and Equal Opportunity Commission Page 673 

1. Professor Bruce Tonge, Faculty of Child Psychiatry, Royal Australian and New Zealand 
College of Psychiatrists. Oral evidence, Melbourne 9.4.91, p240. 
2. Robert Ramjam, coordinator of planning, Schizophrenia Fellowship of New South Wales,
 Oral evidence, Sydney 19.6.91, p323. 
3. Intellectual disability is often referred to as developmental disability. In using the
 term intellectual disability, the Inquiry has adopted the terminology used by most of its witnesses. 
4. Tonge, op cit, p239. Professor Tonge told the Inquiry that 'Psychiatric disorder is
 significantly more common in the intellectually disabled. At least 30 percent of 
intellectually disabled persons have an emotional or behavioural problem of major severity.' 
5. Dr Stewart Einfeld, New South Wales Branch, Royal Australian and New Zealand 
College of Psychiatrists. Oral evidence, Sydney 17.6.91, pl22. 
6. Tonge, op cit. 
7. Intellectual Disability Services Council, South Australia. Submission, p2. 
8. id. 
9. Professor Brent Waters, child psychiatrist. Oral evidence, Sydney 17.6.91, p25. 
10. Intellectual Disability Services Council, op cit. 
11. id. 
12. Dr S Rosenman, Director, Ward 15, Woden Valley Hospital. Oral evidence, Canberra 18.3.92, pl02. 
13. The Commonwealth-State Disability Services Agreement is a five year agreement between 
the State and Territory governments and the Commonwealth aimed at reforming the administration
 of services for people with disabilities by clarifying which level of government has 
responsibility for particular types of services. The Disability Support Program is discussed 
in detail in Chapter 9 — Community Care and Treatment. 
14. Under the Agreement, State and Territory Governments are required to introduce legislation 
complementary to the Commonwealth Disability Services Act 1986 before any transfer of 
responsibilities is effected. Victoria, Tasmania, the Australian Capital Territory, 
Queensland and Western Australia have passed complementary legislation. While they have not
 done so at the time of writing it is expected that New South Wales, South Australia and the
 Northern Territory will pass similar legislation in 1993. 
15. The Disability Reform Package involved reforms to a number of areas of government policy 
and service provision, including the provision of social security benefits and employment 
assistance. The cornerstone of the Package is the restructuring of the financial benefit 
system for people with disabilities. One of the main features of the new disability support
 system is that to qualify, a person must have a physical, intellectual or psychiatric 
impairment of 20 percent or more and a continuing inability to work for the next two years 
in order to qualify for a disability support pension. 
As discussed elsewhere in this report, the Commonwealth Rehabilitation Service's funding of 
1200 new placements nationally for vocational rehabilitation schemes is part of this reform strategy. 
The Inquiry was told that although these new places are a welcome initiative, considerable funding
 is needed to provide appropriate employment opportunities. 
16. Einfeld, op cit, pi 19. 
17. Mary Walsh, National President, Australian Parent Advocacy, Queensland. Submission p3. 
18. Lyn Mason, Manager, MATARA. Oral evidence, Newcastle 9.7.91, pp797-798. 

Page 674 Mental Illness Inquiry 

19. ibid, p797. 
20. Tonge, op cit, p240. 
21. id. 
22. id. 
23. Waters, op cit, p26. 
24. Trish Quinn, community worker and psychiatric nurse. Oral evidence, Melbourne 10.4.91, pp482-483. 
25. Intellectual Disability Services Council, op cit. 
26. id. 
27. Waters, op cit, p25. 
28. Einfeld, op cit, pl23. 
29. Further evidence from Dr Einfeld indicated that the joint approach to service delivery
 was operational at the time of drafting this report. Einfeld, op cit, pi 19. 

31. id. Information since made available to the Inquiry indicates that the University of Sydney
 has recently advertised a position of Senior Lecturer/Associate Professor of Developmental 
Disability in the Faculty of Medicine — a position which would involve teaching and research 
in mental health and intellectual disability. 
32. Western Australian Council of Social Service (WACOSS), Discussion Paper on Dual Diagnosis,
 forwarded as part of Submission, p3. 
33. Regier et al, op cit. The ECA study is also discussed by R G Pols, 'Psychiatric illness 
and substance abuse disorders: A case of neglect', paper presented at the World Federation for 
Mental Health, Pacific Regional Conference, Sydney 12-15 April 1992. 
34. About 34 percent of the survey population reported that they suffered from a diagnosable 
psychiatric disorder. Of that 34 percent, nearly 14 percent of people reported having a non-alcoholic
 substance abuse problem. 
35. Several expert articles, (see, for example, E C Penick, E J Nickel, et al, 'The Emerging 
Concept of Dual Diagnosis: An Overview and Implications', in O'Connell (ed), Managing the Dually
Diagnosed Patient: Current Issues and Clinical Approaches, Haworth Press, New York 1990) including
 that by Pols, refer to the ECA study as a 'benchmark' for the prevalence of mental illness 
and substance abuse disorders. 
36. Pols, op cit, p6. 
37. WACOSS Discussion Paper, op cit, p4. 
38. Dr John Hoult, Director, Clinical Psychiatry, Glebe Community Centre, Sydney. Oral evidence, 
Sydney 20.6.91, p411. 
39. Thea Bates, Director VICSERV. Oral evidence, Melbourne 8.4.91, pl47. Also see F McDermott
 and P Pyett, Not Welcome Anywhere, VICSERV, 1993. 
40. L Butt, 'Dual Diagnosis', Connexions vl2 No5, Sept/Oct 1992, p20. 
41. Pols, op cit, p7. 
42. WACOSS discussion paper, op cit, p5. 
43. Butt, op cit, p23. 
44. id. 

Human Rights and Equal Opportunity Commission Page 675 

45. WACOSS, op cit. 
46. The link between affective and other mental disorders and substance abuse has been well 
documented. C Penick, E Nickel et al, 'The merging concept of dual diagnosis: An overview
 and implications', in Managing the Dually Diagnosed Patient: Current Issues and Clinical
Approaches; and H Gregorius and T Smith, 'The adolescent chemical abuser: Special 
considerations in dual diagnosis', Journal of Adolescent Chemical Dependency vl No4, 1991. 
47. Dr Graham Martin, psychiatrist, Child and Adolescent Mental Health Services. 
Oral evidence, Adelaide 21.10.91, p53. 
48. Gregorius and Smith, op cit, p82. 
49. WACOSS Submission, p5. 
50. Pols, op cit, p9. 
51. Breakey et al, 'Health and mental health problems of homeless men and women in 
Baltimore', Journal of the American Medical Association v262 NolO, Sept 1989. 
52. Tony Nicholson, Chief Executive Officer, Hanover Welfare Services, Victoria. Submission, p2. 
53. id. 
54. id. 
55. WACOSS, Discussion Paper, op cit, pi. 
56. J W Flynn, Executive Director, The Victorian Deaf Society. Submission, pl6. 
57. id. 
58. This figure is taken from a study by the Environmental Health Service in Adelaide,
 published in The Australian Journal of Public Health in December, 1992. 
59. id. 
60. R Hilsdon, Community Services Coordinator, Queensland Deaf Society. Submission, p2. 
61. id. 
62. Hilsdon, op cit, told the Inquiry that the preferred language for deaf communication 
is the Australian sign language, Auslan: 'Auslan is a visual, manual language. Its syntax 
and semantics differ vastly to that of English. It has no written form.. .as a communication
 tool it is as effective as English is when it's used by a native speaker. Most deaf people 
acquire fluency in Auslan only after leaving school, when they elect to participate in the 
deaf cultural community.' The Victorian Deaf Society also said the use of sign language is one 
of the defining characteristics of the deaf community. Sign language is crucial not only 
for communication between deaf people but also as a 'minority language' which 'is used as
 much as a mark of group membership' within the deaf community. 
63. See Flynn, op cit and Hilsdon, op cit. 
64. Dr A J Blackmore, cited in Flynn, op cit, pl8. 
65. Hilsdon, op cit, p3. 
66. id. 
67. id. 
68. Hilsdon, op cit, p2. It was not stated whether the reference to mental health professionals 
related to private and public or outpatient/inpatient services. 
69. Flynn, op cit, p4. 

Page 676 Mental Illness Inquiry 


70. Dr A.J. Blackmore, cited in Flynn, op cit, pl9. 
71. Names withheld. Submission No 459, pi. 
72. ibid, p5. 
73. ibid, pp5-15. 
74. Hilsdon, op cit, p2. 
75. ibid, pl2. 
76. Anonymous Submission, Western Australia, pi. 
77. Hilsdon, op cit, p3. 
78. Dr Neil Buhrich, Clinical Director, Sydney Inner City Mental Health Service, 
Bill Davies, clinical nurse consultant and Susan Johnston, mental health coordinator. Joint Submission, pi. 
79. id. 
80. G Polk-Walker, 'Treatment of AIDS in a psychiatric setting', Perspectives in Psychiatric
 Care v25 No2, 1989, plO. 
81. id. 
82. NSW Health Department, Planning for HIV/AIDS Care and Treatment Services in New 
South Wales 1990-1994, prepared by the AIDS Bureau of NSW, September 1990, p8. 
83. N Buhrich, D Cooper, and E Freed, 'HIV infection associated with symptoms 
indistinguishable from functional psychosis', British Journal of Psychiatry vl52, 1988, p652. 
84. id. 
85. Buhrich, op cit, (submission), pi. 
86. id. 
87. ibid, p3. 
88. ibid, p4. 
89. This suggestion is consistent with recommendations made by the NSW Health Department,
 which noted: 'It is desirable for people with AIDS-related dementia and other neurological 
impairments to be managed in the least restrictive environment possible, taking into account
 the level of their impairment, available health and community resources and the need to 
ensure the safety of the individual.' NSW Department of Health, op cit, p8. 
90. Eg G Prigatano 'Psychiatric aspects of head injury: Problem areas and suggested 
guidelines for research', in H S Levin, J Grafman and H Eisenberg (eds), Neurobehavioural 
Recovery from Head Injury, Oxford University Press, NY 1987, pp224-229; I Grant and W Alves, 
'Psychiatric and psychosocial disturbances in head injury', in Levin et al, op cit, pp234-237; 
A H Van Zomeren and R J Saan, 'Psychological and social sequelae of severe head injury', 
in R Braakmaned, Handbook of Clinical Neurology, vl3, Elsevier Science Publishers, 1990; 
P Storey, 'Some psychological and emotional problems after head injury', paper provided
 to the Inquiry by HEADWAY, the National Head Injuries Association, Nottingham, England. 
91. Information obtained by the Inquiry from Margaret Santiago, Executive Director of the 
Head Injury Association of Victoria (HEADWAY). 
92. id. 
93. See Storey, op cit, plO. 
94. Santiago, op cit. 

Human Rights and Equal Opportunity Commission Page 677

Chapter 22 

PEOPLE IN RURAL AND ISOLATED AREAS 

The irony is that in many of the areas where the need is greatest the services are fewest. 
This is particularly the point in small country communities where mental health services—
 and certainly mental health services for children and adolescents — are almost entirely non-existent.' 

More than 5 million Australians live outside our major urban centres and more 
than half of these live in small rural towns or remote areas.2 These people have 
a number of special needs in relation to mental health. Isolation, social factors 
associated with small scale communities and the effects of recent, severe rural 
recession can all exacerbate mental health problems.3 Psychiatric services, however,
 as the Inquiry heard from witnesses all over Australia, are even more inadequate than
 other health services in rural areas. There appears to be a particular tension between 
effective recognition of the needs and rights of rural Australians affected by mental illness 
and the pressures of economic rationalism. 

Distribution of Services 

One of the major difficulties confronting country people was put clearly to the 
Inquiry by a representative of the Country Women's Association: 

Those who decide.. .mental health policies are city based administrators who make
adverse comparisons between city and rural hospitals, trying to make rural admissions conform 
to those of city hospitals. When services in the country do not get utilised to the required level 
because there is not the general population to sustain them and the population is decreasing, 
it is immediately questioned whether those services are needed and they are sometimes withdrawn.4 

In some States the reality of this perception was confirmed by witnesses 
representing the health administration: 

The population of the region that I 'look after' is around about 17,000. It is very sparsely 
spread over approximately 65 percent of the area of South Australia [including Oodnadatta, Coober
 Pedy, Roxby Downs and Woomera]. This of course means that...the incidence of mental illness is
 extremely sparsely spread over that area. This in itself causes a major problem when people 
require a given service. It is simply regarded as uneconomic to provide specialist services 
to those areas.5 

We are particularly poorly serviced in the country. A model that locks up resources 
in the hospitals means, because of economies of scale, in a place like South Australia where there 

Page 678 Mental Illness Inquiry 

are no cities of more than 30,000 outside of Adelaide, that [country people] are 
particularly disadvantaged...because none of them have the economies of scale even to have an inpatient unit.6 

'Regionalisation' of health administration has been implemented in most States 
and Territories. In theory, this policy promotes consideration of localised 
factors and places services in closer contact with communities. In practice, 
however, the policy often becomes the vehicle or rationale for excessive 
'economies of scale' — so that services are less likely to be provided, particularly in sub-specialty
 areas. The Inquiry repeatedly heard of the acute shortage or complete absence of services
 such as child or adolescent psychiatry,7 multicultural mental health8 and forensic psychiatry.9 

The contrast between rural and metropolitan mental health services was 
illustrated in a submission from the Queensland Country Psychiatrists' 
Association, comparing the actual staffing and resources at Toowoomba 
General Hospital (serving a population of 234,000) with recommendations made 
by the Royal Australian and New Zealand College of Psychiatrists:10 

It is considered appropriate that the General Hospital be staffed with: 

• five full-time psychiatrists — in the present service there is one; 
• six visiting psychiatrists — at present there are two; 
• ten full-time registrars — at present there is one; 
• five full-time residents — at present there is one; 
• five psychologists — at present there is one; 
• five psychologists — at present there is one; 
• three occupational therapists — at present there is one; 
• five social workers — at present there are none. 
The recommendation is for 80 beds. Space has been provided for 24 but the financial constraints 
only permit the staff allocations sufficient to provide 15 bed places. The nursing and 
organisational limitations are comparable. The unit itself, although better than the one it
 replaces, is far below the standard of that provided in metropolitan areas.11 

Similarly, a NSW witness described the sparse distribution of psychiatrists in 
major country health regions of our Premier State: 

In the Central West Health Region there are approximately three full-time equivalent
 psychiatrists in the public health system and less than one full-time equivalent in 
private practice. In Orana Region [north-west] there is one psychiatrist in private practice.
 In the Far West I believe there is one at Broken Hill. I also contacted South West 
New England and South Eastern Regions, each of which have about four psychiatrists, 
some in private practice and some in the general health system. Needless to say, most
 of these are based in the major cities and services in the more remote areas are 
generally conducted by psychiatric nurses who are embattled.12 

Human Rights and Equal Opportunity Commission Page 679 

Outside the capital cities and a few regional centres in our three most populous 
States (NSW, Victoria and Queensland), services are limited to local hospitals, 
general practitioners and periodic visits (often monthly or less frequently) 
from mental health professionals. In most cases these hospitals have no dedicated beds
 for country people affected by mental illness and no psychiatrists or nurses with
psychiatric training. The general practitioners, who seldom have much expertise in 
mental health, service much larger and more dispersed populations than general practitioners in the city.13 

The undesirable effects of this pattern of 'service delivery' were repeatedly 
drawn to the Inquiry's attention. Typical of the problems identified were those 
at one large regional centre in South Australia: 

There is no resident psychiatrist in Whyalla. Services are provided by four 
visiting psychiatrists who come on a monthly basis... Mentally ill patients have to 
wait several months to see a psychiatrist... There are incidents of clients being 
admitted to hospital in an attempt to obtain psychiatric services as visiting psychiatrists
 will try to see inpatients if their load permits. These attempts to access services
 mean that hospital beds can be occupied unnecessarily and at enormous expense to the hospital.14 

The Inquiry also heard that there is a serious lack of non-government rehabilitation
 and support services outside the metropolitan and provincial cities. (This issue is addressed
 in Chapter 5 — Mental Health Services.) 

Inpatient Treatment 

Few local hospitals serving rural areas have the resources to deal with people 
in acute phases of mental illness. Admission to a local hospital may nevertheless 
sometimes be preferred to the limited alternatives. One rural community health worker 
summarised the advantages and disadvantages of local hospital admission as follows: 

It doesn't have the stigmatisation of someone being admitted to a psychiatric hospital 
and, in some cases, it can be quite beneficial. But sometimes the hospital environment 
isn't suitable for someone who's not physically ill but rather depressed or agitated. 
For example, we don't have a secure area and staff are unable to spend the many hours 
demanded by someone who's anxious and depressed.15 

However, the inappropriateness of admitting people with mental illnesses to 
local hospitals, and the absence of facilities for such patients, was emphasised 
by witnesses in all States and the Northern Territory. 

• At Albany Hospital, there are no currently qualified nursing staff dedicated to nursing 
the psychiatrically ill. This creates difficulty for the young inexperienced general trained 
nurse who may be anxious or even afraid in the presence of a behaviourally disturbed 

Page 680 Mental illness Inquiry 

patient, or a patient who is at risk of self harm. The patient may be disadvantaged by 
lack of special psychiatric nursing skills.16 

• There is no major country facility in the mid north of this State [South Australia]
 that can adequately hospitalise a mentally ill person. Local hospitals are forced to 
admit a patient with a mental problem, are not equipped to handle these problems, and
 staff are not trained to care for such people. Because of ignorance, the patient
 becomes the brunt of jokes, is treated with derision and often victimised, a situation
 that would not be tolerated had the patient had a socially acceptable illness.17 
• The type of care and attention we get after hours [in the Alice Springs Hospital]
 is very much dependent on individual doctors. Some doctors have had experience in psychiatric
 wards in other hospitals in the country and are quite keen to respond to a crisis... 
Others clearly have had no experience, and were not aware that there was an expectation 
that they would provide services to us — which means we fluctuate from having a more or
 less immediate response from a medical officer to no response whatsoever for many hours.18 

Admission of individuals affected by mental illness to local hospitals not only 
creates immediate problems for patients and staff but also carries the risk of 
fostering prejudice in small local communities. A representative of GROW in 
South Australia depicted the problem from the consumer's perspective: 

It has been disconcerting at times when GROWers have been put into the local 
hospital and they have had to go into the geriatric ward and that's a bit hard for them...
 because when they're in a manic episode... They're too disturbing in the ordinary ward... 
I think there's more stigma with them being put into ordinary hospitals, in a small town...
because if they do go off or cause a disturbance... People never forget that in a little town. 
It's really hard to live it down.19 

Sometimes, the shortage of appropriate facilities means that a person in an 
acute phase of mental illness is detained in the local jail or police cells. 
Evidence that this occurs as a regular practice in parts of rural Queensland was 
given to the Inquiry by several witnesses.20 

The other option for treating those with acute conditions is hospitalisation in the city. 
This has many disadvantages. Forcible removal and transportation to the city, often over 
long distances, are likely to be traumatic and stigmatising — particularly where this is
 done by the police, as is frequently the case in several States.21 

If a person had a compound fracture in one of our outback centres they would be 
evacuated by a retrieval team. A team of experts would come up from a metropolitan area
 in a safe, comfortable aircraft; they would be stabilised and put into a safe condition 
before they were transported and then they would be transported under the care of 
professionals. It does seem somewhat unjust that because you happen to have a mental
 illness rather than a physical illness you are treated to a ride in the paddy wagon
 rather than being stabilised and given the care of a professional.22 

Human Rights and Equal Opportunity Commission Page 681 

The stigma never goes away when someone is taken off in the back of a police paddy wagon in this way.23 

Often no provision is made for the return journey — as illustrated by a case 
cited by the Medical Superintendent of Bloomfield Hospital in Orange: 

The Ambulance [service]...limit their responsibility to getting them here. 
So that we have recently had the distressing experience of a 15 year old Aboriginal
 boy coming from Brewarrina, left by the ambulance, discharged the next morning to 
find his way back to Brewarrina.24 

For a person from a rural or remote community, admission to a facility in the 
city means isolation from family, friends and other support networks.25 This 
may be devastating at a time when the individual is particularly vulnerable. 
Many witnesses referred to difficulties experienced by relatives and friends 
visiting those admitted to hospitals that are many hours drive from the patients' homes. 

To drop everything and drive four hours, find accommodation and then to return home 
can be out of the question for some people.26 

Depending on circumstances, there is sometimes also an element of 'culture 
shock' for rural patients transported to an alien urban environment.27 This 
dislocation has significant costs in both human and economic terms.28 Nevertheless,
 if a patient requires involuntary treatment, the mental health legislation in every 
jurisdiction limits the availability of such treatment to specifically designated facilities
 that have been approved for this purpose — and these exist only in a very small number
 of centres, particularly in Western Australia, South Australia and the Northern Territory. 

However, once a person is discharged from hospital there are further difficulties 
associated with obtaining appropriate follow-up treatment and support on their return
 home. The initial problems were summarised by one witness: 

Are they going to have continuity of care at some metropolitan hospital or where? 
There is limited information coming from the metropolitan area to the country, to GPs,
 mental health nurses and families of the patient re management plans, medications
 and after care. 29

In South Australia, patients returning to the country from inpatient units in 
Adelaide, unlike those in the city, are not able to receive free of charge the 
regular maintenance medication they require to remain in the community.30 
They do not even have access to the hospital by way of a toll free telephone 
number.31 The Coordinator of the Port Augusta Mental Health Service told the 

Page 682 Mental Illness Inquiry 

Inquiry that there was no system for regular blood testing of clients on Lithium 
or Modecate.32 The same witness also drew attention to the lack of day care 
or drop-in centres and the absence of supported accommodation.33 

These specific examples were indicative of widespread inadequacies in aftercare 
services in rural areas. The point was conceded, in general terms, by the 
Queensland Government in its submission to the Inquiry: 

Difficulties are experienced in providing adequate follow-up when people return 
to their home communities.34 

A recent report by the Health Department of Western Australia also emphasised 
these problems and conceded the need for change at both legislative and 
practical levels.35 

The recent concerns about the quality of care at Wilson's Patch36 raise the question 
of the adequacy of supervision for all patients on aftercare within the provisions of
 the current Mental Health Act... In recognition of the different arrangements required 
by people on aftercare, measures need to be implemented to ensure that roles and 
responsibilities are understood and accepted by all persons involved in the care of 
these patients. In addition, supervision arrangements with a nominated medical 
practitioner must be formalised before discharge and remain in place throughout the
 period of aftercare.37 

As is apparent from the evidence concerning the distribution of services in rural and 
remote areas, appropriate supervision by a medical practitioner can be 
extremely difficult to arrange in the country. In many cases, aftercare and 
follow up, like primary services, rely on visiting services — which are, at best, sporadic. 

Visiting Services 

In all States the Inquiry heard evidence concerning the outreach services to 
many rural areas conducted from hospital or community based services in major 
population centres. At best, these may involve multi-disciplinary teams with 
psychiatrists (including sub-specialists such as child or adolescent psychiatrists
 and psychogeriatricians), psychologists, mental health nurses and social workers.38 
However, such a range of expertise is available in very few places — and never at the
 same time or full-time. Team members visit country locations on a rotational basis
 (if at all), according to the availability of resources.
 
A large number of towns in rural areas receive no services of this nature at 
all.39 Services in South Australian regional cities and towns again typified the 
problems. 

Human Rights and Equal Opportunity Commission Page 683 

Of the four psychiatrists servicing Whyalla, one is in town for only half a day per
 month and works primarily, although not exclusively, as a psychogeriatrician. Of
 the remaining three, one offers two days per month and the others one day per month.40 

While the situation varies from town to town, the basic problems are the same. 
In Port Pirie: 

We have two psychiatrists who visit one day each, once a month. We have no psychologist. 
There is a long waiting list to see the psychiatrist. The psychiatrist is usually exhausted 
and doesn't finish until sometimes 10pm in an attempt to fit all patients in. Needless to say, 
psychiatrists do not extend their visiting rights when their time is up. There is no
 family counselling, there is no one to do it.41 

In these circumstances sick individuals may have to wait several months before 
they are able to see a psychiatrist.42 Cancellation of visits not only extends 
these delays43 but may jeopardise the therapeutic relationship or lead to the 
failure of a referral.44 

Lack of continuity in the relationship of care-giver to client and the sporadic 
nature inherent in visiting services are also significant in terms of the need for mental
 health workers to have — and to be accepted as having — an understanding of the lifestyle 
and environment of their rural clients.45 Awareness of and sensitivity to local values and 
concerns are important in the development of trust, particularly with clients in the mental
health field. The feelings of one resident of a remote area in the Northern Territory about 
health workers from the city were expressed succinctly: 

Do not send me any more glib, smart talking young health workers.46 

These problems are not insurmountable. The issues have been addressed by 
those responsible for the operation of one successful outreach program, the 
NSW Far West Mental Health Team. This Team, based in Broken Hill, services a population of 
approximately 33,000 (spread over a region of 150,000 square kilometres) by car and with the 
help of the Royal Flying Doctor Service. 

We have certainly found that integrating members of the mental health team into local communities 
increases the likelihood of their being contacted for assistance. We therefore have a firm 
practice and belief in individual team members taking responsibility for particular isolated 
communities in which, over time, they become well known and accepted. It takes a considerable
 amount of time and energy to build trust in isolated communities: all our primary therapists 
who visit the outlying towns in our region, routinely spend time at both the local hospital and 
school, to help support and listen to the 
nurses and teachers who bear the brunt of the psychosocial problems in the community.47 

Page 684 Mental Illness Inquiry 

However, in terms of the evidence presented to the Inquiry this program is 
exceptional — if not unique. 

Strains on Health Professionals 

At times we ply a fine line between exhaustion and unpopularity, and it's very difficult.48 

The demands on services in country areas far exceed supply — with the result 
that recruitment to such positions is notoriously difficult, vacancies remain 
unfilled for long periods and the strain on the small number of mental health 
professionals is enormous.49 

Evidence to the Inquiry from the Royal Australian and New Zealand College 
of Psychiatrists emphasised that this problem is compounded by the effects of 
isolation itself. 

Working in remote areas entails being professionally isolated, with greater demands placed
 on psychiatrists and lack of access to appropriate support services. Hence practising in remote
 areas is unattractive to psychiatrists and results in these areas being under-serviced.50 

This isolation may take various forms. A psychiatrist practising at a regional 
hospital is most unlikely to have the support of a registrar or relief by way of 
a locum.51 In the more remote areas, there may be a complete lack of contact 
with professional colleagues and information networks for extended periods. 
The most extreme example of this brought to the Inquiry's attention was a 
psychiatrist providing an outreach service in the Kimberley region of Western 
Australia from Derby Regional Hospital. He described his position as follows: 

To my knowledge, I am the most isolated psychiatrist in the world... When I arrived in 1987,
 I arranged to be on the circulating list for several journals, the first of which arrived 
in June 1989. It was accompanied by a letter saying that due to high costs, journals would no 
longer be circulated... Once or twice a year I can attend a conference somewhere but these trips 
are very expensive.52 

A subtler form of isolation can sometimes occur with regionalisation, a point 
illustrated by another Western Australian witness: 

Workers are [potentially placed] in very isolated positions in regionalised services which 
neither appreciate nor understand some of the issues associated with mental illness... We have
 a social worker in a region in WA who made a complaint, as she should have, about treatment 
that was being given to a person who was mentally ill... She took it up with the director of 
the service unit who told her to keep quiet. She brought it to the Ethics Committee of the 
AASW who said 'you have no right to keep it quiet...' It was then taken 

Human Rights and Equal Opportunity Commission Page 685 

to the administrator in the region whose preference was for the social worker not to stir 
the pot — there were enough troubles in the region as it was. Now her statement to me, and 
I am on the Ethics Committee of the AASW, was 'What the hell am I to do? I want my job but 
I also value the [client's] rights and I want to see these policies in place.' She ended up
 with spiders being put through her front door by other workers in the unit." 

Evidence from other witnesses indicated that the problems of professional 
isolation could be alleviated by networking among professionals. In the area 
serviced by outreach workers from Whyalla, South Australia, the Inquiry was 
told: 

Basically there is no networking at all...even amongst professionals. We feel that [networking]
 should be encouraged so that the professional working in these areas would not feel too 
isolated or uncared for by their colleagues working in the suburban areas. And through networking
 we feel they will be able to access professional help and advice... Now, of course, there are
 attempts being made in this area but the cost factors and distances required to travel make 
professional networking quite difficult to establish.54 

However, a more optimistic picture was given in areas where professional 
networking did occur. For example, in Kalgoorlie, as a result of visits by 
specialists from Perth: 

I think those of us who go to the country, just from the process of referrals, build up a sort
 of network of general practitioners that we get on well with and who know us... I find that GPs
 will ring me up just to chat about something and ask whether a referral is warranted or not... 
But there is not actually a formal structure...and of course there are a number of large country 
areas which do not have that resource.55 

Strains on Consumers and Families 

Factors such as inadequate services for acute treatment, follow-up or respite, 
distance from services and transport problems compound the pressures which 
are increasingly a part of rural life. Small scale communities are less likely to generate 
self help groups or other consumer or carer networks because of the 
relatively small number of people involved, concerns about confidentiality,56 
and because of financial and geographic limitations.57 Many witnesses pointed 
to the effects of the rural recession58 which has both reduced household 
incomes and further eroded limited employment opportunities, increasing 
existing strains and exacerbating stresses. Many country witnesses referred to 
a particular lack of understanding of mental illness in rural areas, lack of 
information about services, and need for education about mental health 
issues.59 These factors add to the strains on country consumers and their 
families or other carers. 

Page 686 Mental Illness Inquiry 

One of the most serious and prevalent problems in country areas is that the 
combination of lack of awareness on the part of carers and professionals or 
para-professionals, combined with the difficulties in accessing services, means 
that mental illness often goes untreated until it reaches the acute stage. As a 
psychiatrist in northern Queensland pointed out: 

Usually the people out there have little or no experience in the treatment of mental illness
 and they are often battling quite hard to deal with this situation adequately. Often times 
the person has to be ill enough to be regulatable [ie fit to be detained] before they can be 
brought into the hospital and adequately assessed and treatment started.60 

Pressures on Young People 

In the context of such disadvantage and deprivation, the disturbingly high rate 
of suicide in rural areas is, perhaps, not surprising.61 But the extent of this 
phenomenon is alarming — and it must be addressed. (The increased rates and 
possible causes of youth suicide in country areas are dealt with in more detail 
in Chapter 20 — Children and Adolescents.) 

The point that must be noted in this chapter is the evidence that adolescent 
males in larger country towns appear to be at substantially greater risk than 
those in our cities. Even more alarming is the fact that the suicide rate of young males in
 small country communities has increased by 600 percent in the space of one generation.62 

Possible Solutions 

Despite the enormity of the problems in rural areas, it is clear there are a 
number of possible solutions. At one level these involve incentives to general 
practitioners, psychiatric registrars, psychiatrists, psychiatric nurses and other mental
 health professionals to encourage them to practise or to continue 
practising in the country.63 As discussed in Chapter 5, the critical need for 
rehabilitation and support services also suggests that initiatives should be taken to 
encourage the establishment of non-government services for rural and 
isolated communities. 

There is also a model for provision of mental health services by one psychiatrist and 
several nurses trained in community psychiatry, acting in consultation with a network
 of other community nurses, GPs, schools, police and others. The founding psychiatrist
 of the Psychiatric Emergency Team (PET) in Perth outlined the possibility of adapting 
this concept to rural areas. 

Human Rights and Equal Opportunity Commission Page 687 

The Psychiatric Emergency Team was a community nursing service with psychiatric 
backup. My nurses...decided when a psychiatrist was needed. I or other psychiatrists 
would go in and do what we had to and then get out and the nurses would continue to manage
 the case which was quite revolutionary and quite threatening to senior members of my
 profession...that nurses should run a service... 

For the country regions one does not have to have psychiatrists in every region. 
I had a model in mind of community psychiatric nurses being trained by a minimum of six months
 placement with the PET and then to be placed as community nurse in each of the country 
regions... As one nurse covering a huge area she could not possibly attend to every patient's
 concerns but what she could do is make herself a valuable resource person who works with
 all other people involved in health care...other community nurses...local GPs, families, 
schools. So if someone were to become mentally ill she could make an assessment, get
 information over the phone perhaps from relatives and others involved, liaise with 
police, justices of the peace, the local country doctor to put in place referral, 
if indicated, to hospital.64 

For our most remote regions, there are also responses using recent advances in 
science and technology which could be used to offset the shortage of services. 

Some of these involve the use of 'Tele-medicine' or two-way interactive computers 
that allow client assessment and consultation from remote locations. This technique
 has been found to have features making it particularly applicable for psychiatric 
use65 and the Queensland Health Department has already pioneered 
a network of facilities in remote areas linked with major urban hospitals through 
Aussat.66 While this will clearly not replace face-to-face interaction 
entirely, it does provide another significant mechanism to address the widespread
 disadvantages of rural isolation. 

Whatever programs or practices are implemented, however, it is clear that the 
basic rights of rural Australians necessitate urgent action by governments — 
including initiatives in resource allocation which acknowledge the extent of 
increased vulnerability and disadvantage in many rural areas. 

Page 688 Mental Illness Inquiry 

1. Prof Brent Waters, Professor of Child and Adolescent Psychiatry, University of NSW. 
Oral evidence, Sydney 17.6.91, p22. 
2. From statistics compiled in 1990 by the Department of Community Services and Health,
 quoted in Appendix 1 of National Health Strategy Background Paper Noll: Improving Australia's
 Rural Health and Aged Care Services, Sept 1992. 
3. Evidence of the effects of such factors was given to the Inquiry by a number of witnesses,
 including Dr Michael Dudley, psychiatrist, Avoca Clinic, Prince of Wales Hospital. Oral evidence,
 Sydney 18.6.91, pl98; and M Brewster, GROW. Oral evidence, Port Lincoln 18.10.91, p31. 
Also see A Fahey, 'Just Like Us', Report of a consultation on psychiatric services in 
rural areas to the Lodden District Health Council, March 1991, given to the Inquiry by 
David Pugh, Coordinator, Community Support Scheme, Bendigo; and P Yellowlees, 'Rural 
mental health', Medical Journal of Australia, vl57, Aug 1992, pp152153. 
4. Elva Hansen, Country Women's Association. Oral evidence, Perth 11.2.92, p242. 
5. Lindsay Cheers, Director, Outback Services, Port Augusta Hospital. Oral evidence,
 Adelaide 23.10.91, p345. 
6. David Meldrum, Acting Chief Executive Officer, South Australian Mental Health Service. 
Oral evidence, Adelaide 21.10.91, p80. 
7. Cheers, op cit, p345; Patricia Mead, Southern Child and Adolescent Mental Health Service.
Oral evidence, Adelaide 21.10.91, p30; Dr J Dingle, Assistant Director, Department of Psychiatry,
 Princess Margaret Hospital for Children and Secretary, Faculty of Child Psychiatry, RANZCP. 
Oral evidence, Perth 10.2.92, p21; Prof Bruce Tonge, Centre for Developmental Psychiatry, 
Monash University. Oral evidence, Melbourne 9.4.91, p244; Dr Ian Shochet, clinical psychologist,
 Australian Psychological Society. Oral evidence, Orange 12.7.91, p944. 
8. Mead, op cit, p31. Also Marie Gibson, Coordinator, Migrant Resource Centre. Oral evidence, 
Townsville 12.8.91, pi 137. 
9. Vince O'Donnell, Roma and District Community Support Association, Queensland. 
Submission, pi. 
10. The recommendations originated with the Queensland Branch of the Royal Australian 
and New Zealand College of Psychiatrists. 
11. Dr Fabian Bryant, Chairman, Queensland Country Psychiatrists' Association. Submission, pi. 
12. Norman Rowlands, clinical psychologist. Oral evidence, Orange 12.7.91, p945. 
13. National Health Strategy Background Paper Noll, op cit, Table 2, pl9. 
14. Siva Pearce and others, South Australia. Submission, pl8. 
15. Ruth Kinslow, social worker, Central Clinic, Port Augusta. Oral evidence, 
Adelaide 18.10.91, pl08. 
16. Dr J A Lister, psychiatrist, Western Australia. Submission, p2. 
17. Judith Sherry, South Australia. Submission, p2. 
18. Sue Jefford, Director of Psychiatric Nursing, Mental Health Services, Alice Springs. 
Oral evidence, Alice Springs 23.7.92, p221. 
19. Brewster, op cit, p31. 
20. See for example V O'Donnell, Roma and District Community Support Association, Queensland. 
Submission, p2. P O'Brien, Brisbane Psychiatric Social Workers Group, Queensland. Submission, p2. 

Human Rights and Equal Opportunity Commission Page 689 


21. See for example Brewster, op cit, p31; Pearce, op cit, pl4; M Parsons, community mental 
health nurse, Colbrook House. Oral evidence, Port Lincoln 18.10.91, p42; M E Kilpatrick, 
Queensland. Submission, pi; D Wright, Central Clinic, Port Augusta, South Australia. 
Submission, pi; Sister Trainer, chaplain, Bloomfield Hospital. Oral evidence, Orange 12.7.91, p935. 
22. Cheers, op cit, p358. 
23. Sherry, op cit, p4. 
24. Dr John Hoskin, medical superintendent, Bloomfield Hospital. Oral evidence, Orange 12.7.91, p887. 
25. J Ross, consumer. Oral evidence, Melbourne 10.4.91, p445. O'Donnell, op cit, pi. 
26. O'Donnell, op cit, pi. Also see Queensland Government, submission, p38; Joyce Lawrence, 
carer, Queensland. Submission, pi; Private hearing, carer. Oral evidence, Newcastle 9.7.91, p776. 
27. Indeed, the Inquiry was told that for this reason, as well as the great difference 
in distances (45 minutes by plane, compared to more than three and a half hours by road),
 it would be preferable to transfer patients from the remote Kimberley region to Darwin
 rather than to Perth — but this was not possible because of the need to abide by State 
boundaries. Christine O'Farrell, Regional Director, Kimberley Health Region, Western
 Australia. Submission, p2. 
28. id. Also see O'Brien, op cit, p2. 
29. Sherry, op cit, p3. 
30. Kinslow, op cit, ppl07-108. Parsons, op cit, p67. 
31. Sherry, op cit, ppl-2. 
32. Wright, op cit, pi. 
33. id. 
34. Queensland Government, op cit, p38. 
35. WA Department of Health, Report to the Minister for Health into Investigation of Allegations
 Concerning Aboriginal People Discharged from Gray lands to Wilson's Patch, Dec 1992. 
36. These concerns, reported in the media in December 1992, related to the appropriateness of
 care provided to four former patients of Graylands Hospital at a private property in a bush 
setting. See Chapter 23 — Aboriginal and Torres Strait Islander People. 
37. id. 
38. For example, outreach services from the Central Clinic, a community mental health service
 based at Port Augusta Hospital: Kinslow, op cit, pplOl-103. 
39. id. Also Queensland Government, op cit, p38. 
40. Pearce, op cit, pl8. 
41. Sherry, op cit, p4. 
42. id. 
43. O'Donnell, op cit, pi. 
44. Cheers, op cit, p354. 
45. Hoskins, op cit, p889. 
46. Quoted in D Clarke, A Study of the Health and Welfare Needs of Women Living in Remote 
Areas of the Northern Territory, NT Women's Advisory Council, Aug 1991, p32. 

Page 690 Mental Illness Inquiry 

47. Yellowlees, 'Rural mental health', op cit, pl53. 
48. Kinslow, op cit, pi04. 
49. Sherry, op cit, p4. Also see Bryant, op cit, pp5-6; Caust, op cit, pl6. 
50. Dr Barrie Kenny, Honorary Secretary, RANZCP, Victoria. Submission, p8. 
51. Bryant, op cit, pp3-6; Dr C Alroe, psychiatrist. Oral evidence, Brisbane 15.8.91, pl642. 
52. Dr N McLaren, part of submission from RANZCP, WA Branch, pi. 
53. Maria Harries, President, WA Branch, Australian Association of Social Workers. Oral evidence, 
Perth 11.2.92, p263. 
54. Parsons, op cit, p48. 
55. Dingle, op cit, p29. 
56. Hansen, op cit, pp243-4; Fahey, op cit, pp32-3. These and other witnesses stressed the 
negative consequences of being labelled 'mentally unstable' in a small community. 
57. Pearce, op cit, pl4. 
58. Dudley, op cit, pl98; Mead, op cit, p31; Pearce, op cit, pp6-9. 
59. Wright, op cit, pi; Sherry, op cit, pi; Ross, op cit, p445. 
60. Dr James Woolridge, consultant psychiatrist, Cairns Community Health Services. 
Oral evidence, Cairns 9.8.91, pl044. 
61. Mead, op cit, p31; Dudley, op cit, ppl97-198; B Melvin, Director, Mental Health Services,
 Orana and Far West Region. Oral evidence, Orange 12.7.91, p910. 
62. Waters, op cit, p27. 
63. Bryant, op cit, pp5-6. Kenny, op cit, pp8-9. National Health Strategy 
Background Paper, op cit, p24. 
64. Dr Malcolm Roberts, psychiatrist. Oral evidence, Perth 12.2.92, p334. 
65. Jane Preston, 'Using telemedicine to improve health care in distant areas', 
Hospital and Community Psychiatry v43 Nol, 1992, pp5,25-27. 
66. David Watson, 'Telemedicine', Medical Journal of Australia vl51, July 1989, pp62-68. 

Human Rights and Equal Opportunity Commission Page 691 

Chapter 23 

ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE 

Introduction 

Mental health services are designed and controlled by the dominant society. The health system 
does not recognise or adapt programs to Aboriginal beliefs and law, causing a huge gap
 between service provider and user. As a result, mental distress in the Aboriginal 
community goes unnoticed, undiagnosed and untreated.1 

The Inquiry received evidence from Aboriginal and Torres Strait Islander 
people from urban, rural and remote communities throughout Australia. 
Aboriginal witnesses emphasised that mental illness among Australia's 
indigenous people cannot be understood in the same terms as mental illness 
among non-Aboriginal Australians, because of their unique culture and their 
experience as a dispossessed people. A complex range of social and cultural 
issues were presented to the Inquiry which were not directly related to mental 
illness. However, the Inquiry recognises the complexity and breadth of issues 
which contribute to the psychological wellbeing and mental ill-health of 
Aboriginal people and their significance in the development of culturally 
appropriate and effective treatment models and programs. In this context, the 
evidence discussed in this chapter reflects the needs and issues identified by 
Aboriginal people as being significant. 

The Historical Experience 

The underlying causes of the physical and emotional ill-health prevalent in Aboriginal 
communities lie in the continuing social, political and economic disadvantage that 
Aboriginal people experience.2 

Traditional Aboriginal societies were not homogeneous. Prior to white 
settlement the diversity of the physical environment led to the development of 
a variety of indigenous cultures and societies throughout the Australian 
continent. In traditional societies, Aboriginal people were totally dependent on 
the land. As a result, complex social systems evolved in which the land and the 
people were not only physically, but spiritually linked. 

The dominant non-Aboriginal cultures have very little understanding of Aboriginal
 culture as a rich and enduring culture which extends back over 40,000 years to the
 beginning of time. Aboriginal culture and society have their origin in the dreaming,
 when the Ancestral 

Page 692 Mental Illness Inquiry 

Beings created Aboriginal people and the earth simultaneously, breathing life and shape
 into the land, its life forms and the cyclic processes of nature... Aboriginal culture 
has been perpetuated by the Elders who have passed on the knowledge through stories, 
dance, song, rules for living, ceremonies and paintings [which] ensure the spiritual 
bond between the land, the Ancestral Beings, spirits and Aboriginal people in the cycle 
of life... Aboriginal culture still combines beliefs and law in relation to spiritual 
obligations, rituals and customs, men's and women's business, family obligations,
 kinship rules, various taboos and communication.3 

These traditional customs and life cycles were irrevocably affected by colonisation. 
As white settlement spread, Aboriginal people were forcibly removed from their 
traditional lands and their families. The Central Australian 
Aboriginal Congress told the Inquiry that for Aboriginal people, colonisation 
left a legacy of grief and loss that is still profoundly felt today: 

Our people were forced from their country, and into mission or government settlements.
 This loss involved economic, spiritual, and cultural disruption. There were massacres 
of our people as recently as the 1930s. Forced settlement came with handouts of food 
— white flour, sugar and tea. We were denied access to our natural sources of food. 
Then a policy of assimilation was imposed on us and our children were taken away
 and families split up.4 

Every Aboriginal witness discussed the long-term psychological effects that 
colonisation has had on Aboriginal people since 1788. As one witness said, 'the 
pain and bitterness of these memories are passed on from generation to 
generation and results in feelings of hate, anger, frustration, grief, depression 
and alienation'.5 These memories are reinforced by the continuing economic and social
 disadvantage experienced by Aboriginal people. For Aboriginal people, contact with
 European culture has been characterised by the denial of access to public 
facilities, to adequate housing, to education, to economic power or the resources 
needed to play a meaningful role in the new culture.6 

The Inquiry was told the denial of Aboriginal peoples' human rights has had 
a profound effect — not only on the mental health of individuals, but on the 
collective psyche of Aboriginal communities. 

The underlying causes of Aboriginal mental ill health flow from generations 
of cultural genocide, a dislocation and destruction of Aboriginal cultural ways 
of survival and a denial of the right to self-determination. This has its 
psychological [consequences]... Aboriginal people are subjected to blatant 
and subtle racism, and inevitably this racism is internalised and people 
feel bad about themselves and each other...7 

Human Rights and Equal Opportunity Commission Page 693 

Cross-Cultural Perspectives on Mental Illness 

Evidence from Aboriginal people and non-Aboriginal psychiatrists indicated a 
lack of knowledge and appreciation of Aboriginal society and culture by mental 
health professionals. Aboriginal witnesses expressed concern that the definitions 
of mental health which have been applied to Aboriginal people are ethnocentric and
 perpetuate stereotypes of Aborigines as deviant, rather than providing ways of 
understanding mental health from an Aboriginal point of view. 

An Aboriginal [perception] of mental health is holistic, there is no need to 
compartmentalise... Aboriginal mental health should not be viewed from a medical 
model of abnormality.8 

This is in direct contrast to the western psychiatric tradition which conceives 
the mind and its illnesses as generally distinct from those of the body or the 
spirit. Aboriginal culture sees the health of the mind, the body and the spirit
 as inextricably linked. In some traditional societies: 

The word most commonly applied to the 'behaviourally disturbed' is translated both 
as madness and deafness... The seat of reason is affected... Individuals with
 disturbed behaviour are often seen as not responsible for their actions. This
 perception of disturbed behaviour also implies a certain acceptance and lack 
of moral judgement about the actions of a 'mad' person.9 

Western psychiatry's emphasis on symptomatology often fails to appreciate the 
cultural and sociological framework in which the symptoms and the diagnosis 
take place. This is an issue of major concern to Aborigines, who perceive non-
Aboriginal diagnostic techniques as simplistic and frequently inaccurate in 
defining their experiences.10 

Aboriginal people view mental health in a very different way to non-Aboriginal people. 
Their traditional ways of dealing with mental illness would appear not to 
compartmentalise it to the same extent as modern western psychiatry.11 

For Aboriginal people, traditional concepts concerning the meaning of 'illness' 
and 'health' are quite unlike western ones. Health is not a purely physical state,
 it is related to the wellbeing and harmony of groups of people with their 
spiritual and physical universe. For Aboriginal people, perceptions of health 
were, and continue to be, closely related to quality of life. 

In Aboriginal society there was no word, term or expression for 'health' as it is
 understood in Western society. It would be difficult from the Aboriginal perception 
to conceptualise 'health' as one aspect of life. The word as it is used in Western society
 almost defies translation but the nearest translation in an Aboriginal context would 
probably be a term such as 'life is health is life'. 

Page 694 Mental Illness Inquiry 

Health to Aboriginal peoples is a matter of determining all aspects of their life, 
including control over their physical environment, of dignity, of community self esteem, 
and of justice. It is not merely a matter of the provision of doctors, hospitals, 
medicines or the absence of disease and incapacity.12 

Prevalence of Mental Illness 

The Inquiry was informed that 'hard data on the incidence of mental ill health 
within Aboriginal communities is scarce'.13 This makes any accurate estimation 
of psychiatric morbidity rates and the occurrence of specific psychiatric 
diseases extremely difficult. 

There [is no] adequate or comprehensive epidemiological survey of Aboriginal 
psychiatric morbidity in Australia. There has never been such a survey. Even 
if one looked at what information is available, for example in institutional 
catchments, [and] Aboriginal versus non-Aboriginal psychiatric morbidity with 
respect to hospital inpatients, it tells you very little because the whole question 
of how Aboriginality is [taken into account] is dubious.14 

Despite the absence of epidemiological data, evidence presented to the Inquiry 
by Aboriginal people indicated that 'mental illness amongst Aboriginal and Torres
 Strait Islander people is a common and crippling problem which goes 
undiagnosed, unnoticed and untreated'.15 

The Inquiry was told that there are two dimensions to Aboriginal mental illness: 
what was frequently referred to in the evidence as the 'mental distress' and 
poor self image caused by colonisation and perpetuated by the poor socioeconomic 
circumstances in which Aboriginal people live; and the range of diagnosable psychiatric
 disorders which are also prevalent in the non-Aboriginal community. Although these
 phenomena are frequently linked,, they are not the same. 

It is important in looking at mental health problems affecting the Aboriginal
 population to recognise that there are two overlapping areas of difficulty. 
One is a group of people who have mental disorders as we would usually understand them 
and then there is another very large group of people presenting with symptoms of
 distress, which really reflect in social issues [such as] depressive symptoms, 
substance abuse problems and suicidal behaviour. I think this clearly represents
 mental distress, but it has to be understood in a social context.16 

Social Context of Aboriginal Mental Illness 

Evidence from Aboriginal people demonstrated that environmental and social 
factors have had a lasting and significant impact on their psychological 
wellbeing. 

Human Rights and Equal Opportunity Commission Page 695 



If you talk to Aboriginal people, the themes [that] will come up again and again 
are the kidnapping of children, dispossession, economic discrimination, political
 discrimination. I have no doubt that these factors together have eroded the wellbeing
 of most Aboriginal individuals...such that they are more vulnerable to a variety of 
stresses and that would probably lead to high psychiatric morbidity.17 

A number of studies of Aboriginal mental health problems throughout Australia 
have identified factors associated with lifestyle stress as contributing significantly 
to emotional and psychological ill health. One study undertaken by the Tharawal 
Aboriginal Co-operative in New South Wales, found that 29 percent 
of the Aboriginal men and 38 percent of the Aboriginal women surveyed were 
suffering from stress levels which impaired their ability to cope with day-to-day 
problems and caused physical or social problems in their lives. These figures are 
more than double those cited in similar studies of non-Aboriginal men and women 
undertaken by the Heart Foundation.18 

In 1991, the New South Wales Aboriginal Mental Health Report found that 'the 
particular disadvantage that characterises Aboriginal people's position in 
Australian society today leads to an increased vulnerability to the development 
of some categories of mental health problems'. It also found that the likelihood 
of a person experiencing a mental health problem and/or a mental disorder was 
exacerbated by a childhood history of separation from biological parents, 
neglect or institutionalisation.19 

Similar findings have also been made in other States. A study conducted by the 
Victorian Aboriginal Health Service found that 54 percent of all respondents 
had a psychiatric disorder. Of these respondents, over 50 percent had been 
separated from both their parents and more than 25 percent had been brought 
up outside their Aboriginal communities in foster homes and institutions.20 

The Inquiry was told by many witnesses that the forced removal of Aboriginal 
children is a major factor in the mental distress experienced by Aboriginal 
people.21 This issue was also raised by psychiatrists: 

We are seeing trans-generational patterns occurring in Aboriginal society, in terms
 of the impact on people raised in institutions who then have to confront dilemmas 
of parenting down the line... [Clinical] interventions need to take account of that
 long-term cycle.22 

However, the grief, poor self-image and emotional distress experienced by 
Aboriginal people are rarely dealt with in a clinical setting: 

Aboriginal people grow up in communities and experience family dying around them 
all the time. There is no grief or crisis counselling available...23 

Page 696 Mental Illness Inquiry 

It was suggested by several witnesses that one of the phenomena which may 
obscure the extent of mental illness in Aboriginal communities is the fact that 
many individuals act out their behavioural and psychological problems through 
anti-social and self-destructive behaviour. 

[There is] a link between the socioeconomic conditions of Aboriginal people and
 their mental health... In many circumstances the links are [demonstrated] in
 domestic violence, alcohol abuse, child neglect and abuse and other forms of 
'anti-social behaviour', and these problems have their roots in the powerlessness
 of Aboriginal communities and the subsequent high levels of stress and tensions within them.24 
Many Aboriginal people told the Inquiry that much of this behaviour either 
goes undiagnosed or is treated as a police problem. This leads to contact with the 
criminal justice system, where Aboriginal people are labelled as socially 
deviant — and their psychological problems are exacerbated. 

Jails and children's institutions are full of Aborigines who have been branded 
anti-social and many have been diagnosed as having a behaviour disorder. So,
 since the coming of Cook we have been led to believe that Aborigines are a
 nation of sociopaths.25 

Many Aboriginal people have seen their brothers and sisters labelled as mentally ill
 (and hospitalised and incarcerated as a result) when they understand and know the
 problem as a social and political one. The diagnoses are always 'white' 
non-Aboriginal ones and the solutions are seen as another form of oppression.26 

Dr Ernest Hunter, a psychiatrist with the NSW Aboriginal Medical Service, 
told the Inquiry that non-Aboriginal professionals tend to treat symptoms of 
social distress as medical disorders.27 

The significance of these issues was also addressed in the report of the Royal 
Commission into Aboriginal Deaths in Custody, which found that there had 
been an extraordinary level of state intervention in the lives of all the 
Aboriginal people who had died in custody. In his final report, Commissioner 
Johnston observed: 

The most fundamental causes of the over-representation of Aboriginal people 
in custody are not to be found in the criminal justice system but in those factors
 which bring Aboriginal people into conflict with the criminal justice system in the 
first place... The most significant contributing factor is the disadvantaged and unequal
 position in which Aboriginal people find themselves in the society — socially, 
economically, and culturally.28 

As one Aboriginal mental health worker told the Inquiry. 

Human Rights and Equal Opportunity Commission Page 697 

We know that people that have a lot of mental health problems are picked up by the
 police and they usually end up in jail... We feel that's not good enough.29 

The Royal Commission concluded that the overwhelming majority of deaths in 
custody resulted from suicide. Evidence to this Inquiry indicated that Aboriginal 
offenders who are incarcerated often experience depressive symptoms and unresolved 
anger which sometimes leads them to attempt or commit suicide 
whilst in custody. Many young Aboriginal men and juveniles are in custody 
during their formative years. As a result they are permanently alienated from 
their communities. 

Alienation from the outside culture increases and the ability to cope normally — 
that is within Aboriginal culture or within mainstream culture — decreases. 
[When they are released from prison] the mental health consequences of this cycle 
[are] an accumulation of unresolved anger and the inwardly turning self-destructive
 behaviour... [such as] alcohol abuse. The high incidence on release of domestic 
and community violence and re-offending reflects this mental state.30 

Diagnosing Mental Illness 

While most academic surveys of hospitalisation rates and the extent of mental 
illness in Aboriginal communities have used data from urban populations, most 
of the evidence provided to the Inquiry about the experiences of Aboriginal
 people with a mental illness was given by individuals and community representatives 
from rural and remote areas. 

Although there is little epidemiological information available concerning 
Aboriginal people, the Inquiry received several statistical estimates of morbidity 
rates based on research studies and hospital separation figures in different 
Australian States. These statistics generally indicate that Aboriginal people 
who are hospitalised with a mental illness are most commonly diagnosed as having
 either an affective disorder, a mental disorder associated with alcohol abuse or 
some form of psychosis. 

The Western Australian Branch of the Royal Australian and New Zealand 
College of Psychiatrists presented evidence that Aboriginal people are massively 
over-represented in involuntary admissions to State psychiatric hospitals and 
within the corrective services system: 

Being Aboriginal carries a three-fold increase of involuntary psychiatric 
admission to State hospitals and being a metropolitan Aborigine carries a 
five-fold increased risk of compulsory admission. In comparison with non-Aboriginal
 patients, Aboriginal patients have a seven-fold greater chance of an alcohol 
and organic brain syndrome diagnosis being made.31 

Page 698 Mental Illness Inquiry 

Another Western Australian witness indicated that: 

47 percent of Aboriginal males suffer with mental disorders associated with 
alcohol dependence... 19 percent of Aboriginal women have depressive disorders
 and 21 percent of Aboriginal women have neurotic disorders.32 

In Queensland, a survey conducted in 1991 found that 70 percent of Aboriginal 
and Torres Strait Islander inpatients were diagnosed as having schizophrenia or 
substance abuse disorders, in comparison to 42 percent of non-Aboriginal 
patients. These apparent disparities between diagnoses may reflect culturally 
inappropriate methods of assessment. 

You could not confidently generalise about the [Aboriginal] population by looking 
at who is in an institution because.. .the validity of the diagnostic assessments
 that have been made with those people are problematic... At best you are catching 
one part of major psychiatric illness in terms of various psychoses; you would not
 be catching any sort of less debilitating symptoms of psychological distress and
 you certainly wouldn't be tapping widespread poor mental health...33 

One of the additional difficulties associated with determining the rate of mental 
illness among Aboriginal communities is that people who may be mentally ill are
 often cared for within their community and do not come into contact with 
mental health professionals. The Inquiry was told that unlike non-Aboriginal society, 
Aboriginal people are often very tolerant and supportive of people who 
are behaving anti-socially as a result of mental illness. One researcher working 
with the Aboriginal community in Western Australia observed that: 

The Aboriginal community has the capacity to hold its ranks and support someone
 who displays patterns of strange behaviour. And, though they are not described 
as mentally ill, they [may exhibit symptoms of mental illness]. [However], 
the community, rather than isolate that individual or sending them off to 
[a psychiatric institution], maintains them in the community with protection 
from their peers and families.34 

Witnesses to the Inquiry also emphasised the fact that disturbed people are 
often kept within their communities because their illness is perceived as a 
normal reaction to spiritual forces or a curse such as being 'sung'.35 
Rather than being physically ill, the person is considered to be spiritually ill. 

Signs from the Ancestral Beings and the power of the spirits are still 
culturally relevant for a significant number of Aboriginal people... 
For those who have retained their cultural ties and lifestyles...
[hallucinations and other phenomena associated with disorders] may not be 
fantasy but a reality within their cultural context.36 

In these cases, specific traditional treatments may be employed. 

Human Rights and Equal Opportunity Commission Page 699 

The sorts of traditional treatments which people still use today include the skills
 of ngangkari. Ngangkari can help when someone has something in their head. There are 
other Aboriginal ways of treating problems caused if someone has been sung, or if they
 walk into a special place or intrude on secret singing when they are not supposed to.
 These sort of problems can be cured by the person who sent someone mad in the first 
place. There are also bush medicines which help if someone has a headache, if they
 cannot hear properly, if they are angry, or their thoughts are confused.37 

There are, however, some situations where people who are ill pose problems 
which the community cannot manage. 

The important message communities gave us was that in traditional times they would
 have cared for slightly 'mad' people and that is what families still try to do 
today. However, for really bad problems in the past, people said that they would 
have had to leave the person behind or punish them. These are another sort of problem
 which communities now need help to deal with.38 

Looking after community members with mental illness can also be difficult 
because of an implicit assumption that the community is able to care for its 
own: 

There's a lot of mental health problems in the community and they're just mostly left
 for community people because everyone thinks that because you're Aboriginal that you 
can look after your own. But there's a lot of other illnesses to look after and often 
mental illnesses are just not understood and people are just left.39 

Substance Abuse and Mental Illness 

While not always related to the issue of mental illness, a number of witnesses 
emphasised that the physical and psychological effects of substance abuse are 
particularly worrying for Aboriginal people. These effects may be caused by 
the action of the drug itself or result from brain damage or other psychological 
deficits directly related to substance abuse. Whatever the cause, violent and 
disturbed behaviour creates extreme distress in communities. 

The Central Australian Aboriginal Congress told the Inquiry that 'alcohol abuse 
is a reflection of mental health problems in the community, and also in many 
ways exacerbates these problems':40 

It is hard for people to control drunks or [petrol] sniffers, and traditional ways 
of treating disturbed people often do not work with these modern problems. In addition, 
people told us about other cases where grog makes it harder for disturbed people. 
Maybe their families do not look after them if the family starts drinking; drunks 
are often least tolerant of disturbed people, and may beat them up or take their money.41 

Page 700 Mental Illness Inquiry 

However, there are few services to deal with this problem42 and inappropriate 
assessment and treatment is common.43 

Drug and alcohol consumption, when excessive, often accompany mental illness, 
and consideration of the one generally involves an assessment of the other. 
However, when the patient is Aboriginal, a proper evaluation and diagnosis 
may be impaired because medical information about Aboriginal drug and alcohol 
consumption can be [inappropriate, resulting in] poor doctor/patient communication 
and adverse treatment outcomes.44 

Misdiagnosis 

Evidence to the Inquiry highlighted two major issues associated with the 
misdiagnosis of mental illness in Aboriginal people: the diagnosis of a mental 
illness when the patient is exhibiting 'unusual' behaviour which is appropriate 
in Aboriginal terms; and making an inaccurate diagnosis when a patient is in 
fact mentally ill. 

The Inquiry was told that many psychiatrists are ill-equipped to distinguish 
between these phenomena. 

While it is now accepted that Aboriginal people do suffer from the same psychiatric
 afflictions as [non-Aboriginal] Australians, recognition, assessment and management
 of these illnesses in Aboriginal people is different because of their [social 
disadvantage] and the idiosyncratic and non-European styles in which psychiatric 
illnesses sometimes present.45 

The lack of special psychiatric services and professional expertise in cross-
cultural psychiatry makes Aboriginal people particularly vulnerable. Because 
most of the mental health workers responsible for assessing Aboriginal people 
are not Aboriginal themselves, the importance of cultural beliefs and practices 
and their relevance to the patient's symptomatology are often overlooked. This 
was particularly apparent in evidence presented to the Inquiry concerning 
people from remote Aboriginal communities where traditional cultures are 
strong. 

In Darwin, the Inquiry heard evidence concerning an Aboriginal man who was 
killed by police following a confrontation on Elcho Island in 1990. The Inquiry 
was told that the man had a long-standing psychiatric disorder. 

The person killed had suffered bouts of psychiatric illness for ten years. He had
 been generally managed by his own community. At the times when the episodes became 
acute and violent, given members of the community would restrain him and arrange for
 his medication and occasional hospitalisation... Taking him into custody was always
 done with patience and kindness.46 

Human Rights and Equal Opportunity Commission Page 701 

In 1990 the mentally ill man speared another Aboriginal man on Elcho Island. 
Following the spearing a search party was mounted by the police. The man was 
confronted and ran towards police with a broken fishing knife. The police 
called on him to stop and the man, who was disturbed and spoke little English, 
kept running. He was shot dead.47 

The Inquiry was told that the man had been misdiagnosed as having alcohol-
related brain damage when in fact he did not drink, and that one doctor had 
regarded him as being intellectually disabled because he could not speak 
English. Although these aspects of the patient's case history were not 
specifically related to the incident during which he was shot, it was alleged that
 if the man's case had been dealt with more carefully, and accurate diagnosis and 
appropriate case management had been undertaken, the fatal confrontation with the
 police may not have occurred.48 

Evidence to the Inquiry suggested that it can be extremely difficult to accurately 
diagnose mental illness in an Aboriginal person because of factors such as the 
person's traditional language and spiritual beliefs: 

The diversity of Aboriginal cultures creates a dilemma for psychiatrists and 
psychologists alike because what applies for a particular set of overt conditions
 (symptoms) in the case of a specific patient and the corresponding appropriate 
treatment may not be appropriate for an individual with similar problems from a 
different location and community because of differing cultural beliefs and practices.49 

Because of the geographical isolation of many Aboriginal and Torres Strait 
Islander communities, particularly in the Northern Territory, Western Australia 
and Queensland, people who are mentally ill are often sent to cities and large 
towns for assessment and treatment. This physical dislocation of individuals 
from their communities can be extremely destructive to their mental wellbeing. 

As an Aboriginal witness told the Inquiry in Queensland, mental health service 
providers need to be aware of the particular cultural needs of Aboriginal people 
who are mentally ill: 

Everything in the environment gives us cues as to our standing and place in the
 universe, our standing within the community, and within our own family groups. 
The situations and structures we've got today in our society, whether they be mental 
institutions...or wards attached to hospitals, they are a totally alien environment
[from what] we need to make us sane... Those people who have been diagnosed or actually 
put into a situation like that are not getting the necessary cues [so that they can] behave
 in the right manner — so that there can be some meaningful dialogue with...the people 
that are actually doing the therapeutic work...50 

Page 702 Mental Illness Inquiry 

These observations were reaffirmed from a clinical perspective by a psychiatrist 
who has worked with Aboriginal people: 

Most Aboriginal people of my acquaintance are very concerned with the quality of
 their relationships with other people [and] the quality of the relationships with
 their immediate country. The quality of the relationships are very important barometers
 of their individual wellbeing. If you have a western psychiatric intervention that 
just looks at an individual out of context — indeed you might be assessing an individual
 who is several thousand miles from their home without any of their family there and
 under heavy medication — I'm not sure that you would get much sense out of them in 
terms of their experience of distress because you have taken the individual out of 
their context and for them context is everything.51 

Cultural Bias in Psychological Tests 

The Inquiry was told that the psychological tests administered by non-
Aboriginal mental health workers to assess psychiatric illness can also 
contribute to misdiagnosis.52 Psychological tests are based on asking questions 
which are formulated to give a standard response. However, the standard is 
derived from a sample of the general population — a population which is not 
Aboriginal. Evidence indicated that there are no known Aboriginal norms for 
these tests and that they are based on concepts alien to Aboriginal culture. 

An example in the field of personality clinical testing and mental health is the CAQ, 
which is a well known personality test. This measures normality of functioning in 
different areas of personality as psychometrically derived from the mainstream 
population. So, they have already determined a number of traits and they measure 
people against that, so even the concept of [types of] personality such as extrovert 
and introvert are culturally biased. So, an abnormal score for a person from a very 
different culture may well be indicating cultural difference rather than abnormality. 
Attributing abnormality to cultural difference is an institutionalised abuse of human 
rights just as is the assumption that the concepts used in the field of mental health 
can be fairly assessed cross-culturally.53 

Aboriginal People with Special Needs 

Two particular groups within the Aboriginal community were identified by a 
number of witnesses as requiring special attention — the elderly and young 
people. 

Elderly People 

In Alice Springs the Inquiry heard disturbing evidence concerning misdiagnosis 
and inappropriate treatment of elderly Aboriginal people with mental illness. 
Evidence suggested that elderly people have been incorrectly diagnosed as 
having dementia, and removed from their traditional communities in remote 

Human Rights and Equal Opportunity Commission Page 703 

areas (often several hundred kilometres from any other settlement) to nursing 
homes in Alice Springs where they become isolated and institutionalised. 

The Inquiry was told that the use of the term 'elderly' when talking about 
Aboriginal people does not always relate to old age in chronological terms. 
Aboriginal people's greatly reduced life expectancy means that those regarded 
as elderly may be in their forties or fifties, an age not considered old in the 
non-Aboriginal community.54 

According to the evidence, two major reasons are advanced for removing elderly Aboriginal
 people to nursing homes: physical frailty and confusion; and the lack of facilities in 
remote areas to enable families and communities to care for old people who are physically 
or mentally ill.55 

[Not being able to cope] results in families and carers sending old people away to nursing 
homes. The lack of options for support for carers continues to go largely unaddressed by 
health clinics in the bush which assist in the process of removal of old people. The lack
 of respite care [is also a factor]. Support services which would provide basic physical
 and mental health assistance are either limited or basically they are just non-existent.56 

The Inquiry was told that while many of the old people resident in nursing 
homes may